4?^^ \i 5 ^J-tlpRARV/?^ I "% ^ ......:5? .^ MIBRARY<:k, ojnvD'io^ ufCAUFOMf^ ^(?Aiivaanj^ ^miVNyi^"^ ^OFCAIIFO/?^ < ^OF-CAIIFO% ,\WEUNIVERS/A 5= ^•lOSANCflfj-^ \^i 112^1 irrti ^/sm^ '^/SWu < &\ Bij, ^OFCAllFOff^^ ':ja3AiNn3V^^ 15^ %iaMNniV«^ lis so. -M-UBRARY<9' Hi ^OPCAUF0«^ ^OFCAUFOft^ -^t^AHvaani^ AMEIIN(VERS/a %umyiv^ Wjt vS i 3tf fe^ ^OFCAllFOff^^ ^5X\MJNIVERJ/^ ^lOSANCtl^T^ ^^lUBKARYQc ^aojnvDior' ^OFCAllFOffyfe, IMS! V LECTURES ON THE PRINCIPLES AND PRACTICE OF MEDICINE, DELIVERED AT KING'S COLLEGE, LONDON. ON SLIGHT AILMENTS, AND ON TREATING DISEASE. BY LIONEL S. BEALE, M.B., F.R.S.. FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS AND OF KING'S COLLFGE. LONDON ; JOINT PROFESSOR OF THE PRINCIPLES AND PRACTICE CF MEDICINE IN THE COLLEGE, AND PHYSICIAN TO THE HOSPITAL; GOVERNMENT MEDICAL REFEREE FOR ENGLAND. FOURTH EDITION. London : J. & A. CHURCHILL. iMDCCCXCVI. [AI/ liights Reserved. ] HARRISON AND SONS, PRINTERS IN ORDINARY TO HER MAJESTY, ST. martin's lane. TABLE OF CONTENTS. INTRODUCTORY. ^ PACK Introductory .. i Sliglit ailments and civilization I Derangements and discomfurt 3 Slight ailments 5 Interest in the patient 6 Doctors should he in good health ... 9 Attention and knidness ID Slight ailments treated on same principles as serious diseases 11 G'cok and Roman medicine 14 Quackery, credulity suspicion 17 In fmitesimal doses 18 Decillionths of a grain 19 Ilomruopathy — conversion 20 Legal estimate of science 21 Chemistr)', microscope, homa^opatliy 22 Evidence of action of medicines 23 Scepticism, credulity imposture ... 24 Want of confidence in us 26 PACE I'rinciples of conduct 27 Law, medicine, and medical methods 28 New legislation 29 Legal and medical views 30 Luna'y Acts Amendments 32 Legal overruling med cal differences 33 Medical and scientific evidence 34 Medical work and thought 35 Antivivisection petition 37 Political opposition to science 38 Opposition to research.. 39 i\nticurative legislation 39 Opposition to vaccinal ion 41 Dr. Creigiton's article 43 John Bright and Oladstone 44 (ierman vaccination law 47 Se ni-conhdence in medicine 48 Life insuran"e (juestions 49 Medical life insurance reports 49 MEDICAL CHARITY ORGANIZATION. Out-patients and slight ailments 54 Self-supporting dis[)ensar'es 55 New organization of I harity 56 Gratuitous tnedical help 59 I'ay-wards in public hospitals 60 What is given by doctors 61 Organization of out-patients f>3 New relief organizations 64 Obje tions to the new system 65 Provident dispensary system 66 MINUTE INVESTIGATION. Importance of knowledge deri\ed fr im careful microscopical investi- gation 67 Elementary parts or cells 67 Inter-molecular c rculation 68 Action cif skin, kidneys, and bowels 70 Eibroid changes 71 Communicable diseases 73 Action of certain poisons 74 Nature of contagia 7'^ Bacilli microbes, m'crococci 78 Fungi and decay of lenves 79 The ever-present bacterium S'^ P)acteria swallowed by all 81 Dust and disease 82 Bacteria iii our tissues 82 .\ccess of disease germs 84 Conditions of bacterial growth 85 Specificity ^6 Origin and change of species 87 Giowth and multiplicat'on of bac- teria 90 Poisonous animal alkaloids 92 Plonnines and leuromat'nes 92 Contagion originating in organism. . 04 Disea.se germs frc m bioplasm 96 On pus formation 97 Antiscfitics 98 Opposition to antiseptics 99 Accusation of diffusing c.:ntagia loo i rf-)7749 VI CONTENTS. THE TONGUE IN HEALTH AND DISFASE — CHANGES IN MOUTH AND FAUCFS. PAGE Characters of torgue in health io6 The dorsum of the tongue I03 Fungiform and filiform papillK and their covering 107 Epithelial cells 108 Fungi and low organisms in mouth loS Bacteria 109 Changes in the mucous membrane of mouth and tongue HO Tongue in various derangements ... Ill Importance of secretion 112 Dry and moist states of the tongue 1 13 Exciting the flow of saliva 115 Sialagogues ... I15 White moist furred tongue 117 PAGE Pale tongue ) 18 Tongue in chronic rheumatism 118 Bright red tongue II9 Dry brown tongue 119 fiiemorrhage 121 Cracks and fissures ... 121 Inhalers, bronchitis kettle 124 Of the use of spray 124 Metallic and other tastes in the mouth 125 Aphthse, thrush, sores and ulcers ... 126 Treatment of aphthte 127 Offensive breath i?8 Use of purgatives 130 Use of mercury 131 APPETITE— FASTING CELEBRITIES— NAUSEA— THIRST— OEESnY— EMACIATION. Impaired appetite ; loss of appetite 132 Fasting celelirities 133 Voracious appetite, bulimia 134 Nausea 136 Sea-sickness 138 1 reatment of nausea .:. ij9 Objections to alcohol ,.... i^o Acquirnig intempeiate habits 140 Thirst 141 Importance of liquid I42 Obesity 143 Emaciation 148 INDIGESTION : ITS NA'lUKE AND TREATMENT. Indigestion — dyspepsia 150 Strong and weak stomachs 152 Nerve-fibres 01 intestinal canal 153 Nerve gang ia and plexuses 155 Pain-conducting nerve-fibres 156 Gastrodynia — pain in ston ach 157 Heartburn, pyrosis, or waterb' ash... 1=8 Flatulence, wind in the sttmach ., 160 Treatment of ordinary indigestion ... 162 Of condiments and alcohol 166 Influence of cold Ifc7 Indigestion from failing glands, as in old age 168 Of pepsine and its uses 171 Method of preparing pepsine 173 Value of pepsine in fevers 177 OF CONSI IPATION. Importance of regular action of bowels 181 Craftsmen subject to constipation ... 183 Typical aches and pans 184 Literaty persons often suffer 185 Impaction of fa;cal matter in large intestine 185 Influence of the reabsorption of fluid in causing constipation i8^ AlteraL on m blood 187 Constipation and the healing process 1S9 Fever after oiierations 189 Ilajiiion holds or pi'es 191 ( 'f the action of enemata 103 Hygienic and dietetic treatment 195 Exercise, cold bath, rubbing, moist applications, &c 195 Diet 198 French prunes and Normandy pip- pins 199 Veg' tarianism 200 Of taking fluid 201 Smoking tobacco 203 Of purgatives in constipation 203 Ord nary purgatives 207 Purgatives for children 2H Conserve of currants ?I2 Saline purgatives 215 Friedrichshall and other waters 2 '8 Effervescing salines ... 219 DI-VRRHCEA— COMMON INTESTINAL WORMS- GIDDINESS— AUFcAL VERTIGO. Ordinary diarrhoer, 220 BiUous diarrhoea 227 Treatment 01 diarrhoea 228 Thread worms 230 Large round worm — treatment ..... 231 Tapeworm 232 \'ertigo, swimming in the head 232 Aural vertigo ... 234 CONTENTS. Vll nil.IOUSNESS— SICK HEADACHE — NERVOUSNF.SS. Biliousness ► 236 D'-rangc-ment of the livt-r 239 Treatment of i)ilii)usiicss 240 Action of east wind 242 faundice 243 \'cllo\v atrophy 246 Treatment of temjiorary jaundice ... 247 Sick lieadache 247 llemicrania 24S Nausea and vomiti g 24S Nature of the disease 250 Sick headache and epilepsy 255 Treatment of sick headache 256 „ ,, ,, during the attack 258 Starving 259 Treatment of sick lieadache in the in'ervals between the atticl»s 263 Of the managemenl o'" sick headache when the patient continues at work 267 Drowsiness 269 Wakefulness and restlessness 269 Nervousness 271 Americans 273 NEURALGIA — RHEUMATISM — RHEUMATOID ARTHRITIS — (;OUT. Curative stage of chronic maladies... 276 No rheumatism or govit in North West Provinces of India 279 Ne.iralgia 2S0 Treatment of neuralgic affections ... 282 Rheumatic pa'ns 2S5 Nature of rheumatic pains 2S8 Tieatment of rheumatism 289 Diet in rheumatism 295 Rheumatoid or osteo-arthritis 296 Management of mild cases of rheu- matoitl arthritis 300 •Slight gout and gouty tendencies ... 305 1 1 iuts on treatment 305 ON I"EVER AND INFLAMMATION'. The feveiish and inflammatory state 308 Of catching cold 309 Preliminary changes 31I Body beat of warm-blooded animals, fixed 312 Ri^e of body heat in all fevers and inflammations 313 Is there increased oxidation in fever ant! in ham (nation ? 3'5 Of ascertaining the tenperature 315 Essential changes in fever and in- flammation 316 Fever in cholera 317 Of free .secretion which leads to recovery 319 Treatment of a C' >ld 3^1 " Only a cold " ^>^ Changes in tissues 325 OF THE ACTUAL CHANGES IN FEVKli AND INFLAMMATION. Of fever and inflammation 328 Alterations ot calii.re of vessels 329 Inflammation of web of frog's foot 329 The fever of over-exertiin 331 Inflammation a local fever 331 Exudation of fluid and bioplasts ... 333 The formation of piS in and near capillaries: inflammation and fever 334 The passage of blood and living par- ticles through the walls of capillary vessels — Diajiedesis 33; Capillary hivmorrhage 336 '^^ohnhoaB's re>earches 338 Spontaneous movement 340 Vital jihenomeiia ",40 Changes in Bi'iplasm : Pus 341 COMMON FORMS OK SLIGHT INFLAMMATION Formation of mucus — mucus cor- puscle 345 Bioplasm of mucus 346 Amcfba 3.6 Impaired sensibility 347 Dryness of the mucous membrane... 347 Nerve-fibrt-s concerned in pain 347 Diminish ed sensitiveness of mucous membrane 348 Cuuntei-action —counlei -irritation .. 349 Cracks and fl.ssures about the lii« ... 350 (■"rinc iples of treatment 351 Alcohol and astringer ts 352 Conjunctiva, i'iHammation of 353 Treatment of inflamed eyes 355 S re throat . . ;- 56 Treatment of sore throat 358 (^'■'■^■■gles 359 Inflammation of mucous m mbrane of the air pas.^ages 360 Vlll CONTENTS. COMMON FORMS OF SLIGHT INFLAMMATION — Continued. Running from the ear> j6i Inflammation of stomach and in- testinal canal 361 Treatment ot congestion and inflam- mation 362 Slight Hysentery 364 Chilblains 365 PAGE . 366 . 367 3^9 Treatment Boiis Carbuncle Changes preparatory to the occur rence of disease „ 369 On preventing serious disease ... ^70 Escape from disease 373 INDEX 375 ON SLIGHT AILMENTS, THEIR NATURE TREATMENT. INTRODUCTORY. Each one of us has, no doubt, suffered at times from slight derange- ments of the health — derangements which are not dependent upon or likely to determine structural change in any tissue or organ of the body, but due rather to temporary disturbance — to an alteration in the ordinary activity of tissues and organs, which soon may be succeeded by a return to the healthy state. In many instances the derangement is, in fact, an alteration in the rate at which normal phenomena are performed. Perhaps, in consequence of changes in the blood itself or in the tissues outside the vessels, the blood may flow too slowly or too quickly through the capillaries. These tubes often become unduly distended or relaxed, and disturbed action in the adjacent nerve-fibres being thereby occa- sioned, pain or discomfort is experienced. Among civilised nations a perfectly healthy individual seems to be the exception rather than the rule. I do not remember having seen more than two or three men in the course of my life who had never experienced any form of illness and did not know what it was to feel out of sorts. It is indeed very rarely one meets with a person who has reached the age of thirty who will not admit that at various times he has suffered from many different, though slight, derangements of health. We are indeed often told by those whose prospects of longevity are nevertheless good, that they have scarcely passed a week without the occurrence of some very decided departure from the perfectly healthy state. Some complain of frequently feeling fatigued, others tell you they are uncomfortable, or complain of being irritable and annoyed at 2 SLIGHT AILMENTS AND CIVILIZATION. slight troubles which would not ruffle them in the least if they were in ordinary health. How few of those who take a very active part in the work of the world know what it is to enjoy uninterrupted health ! Most have to work on in spite of lassitude, or headache, or muscular or nerve pains, or indigestion, or some other discomfort, which frequently, perhaps continually, troubles them. How many of us experience a confused feeling, an indisposition to mental exertion, a distinct sense of fatigue after what we cannot but regard as very moderate mental application ! Many people take dismal so-called constitutional walks, not because they enjoy the exercise, or from necessity, but because they have heard that this sort of penal servitude— walking for walking's sake is necessary to keep themselves in a condition which some call health. Many a man thus imposes upon himself the regular perform- ance of the most dreary form of taskwork, and forces himself to go through his monotonous labours when his inclination would lead him to take rest and probably to go to sleep. In not a few instances the inclination would have the support of the reason. Some, again, who are considered to be in perfect health, scarcely know what it is to sleep soundly and rise refreshed, with spirits buoyant and energetic, with a desire for work. Men and women there are, and in every class of society, poor as well as rich, hardworking as well as idle, who scarcely ever eat without discomfort, and suffer still more if they do not take their usual meal at the accustomed hour. Few, indeed, of those who live in cities pass through life without being troubled with various derangements connected with the action of the stomach and intestinal canal. You will, of course, desire to know whether all these slight derange- ments are necessary consequences of our civilisation — of our somewhat artificial mode of living— or whether by altering our habits we should certainly acquire and maintain a state of perfect health. The improved health of the people in this country during the last fifty years is due, not only to greatly improved sanitary conditions, but to a number of circumstances, among which better clothes and lodging, excellent but very cheap food in abundance, have largely contributed to bring down the death-rate to its present low average, and to greatly increase the vigour and happiness of the population. Unquestionably not a few of us suffer from slight ailments because we are ignorant of the proper way of managing ourselves in order that we may work most advantageously, or because we give way to habits of self-indulgence as regards the quantity and character of our food and drink. The quantity of food required relatively to the body weight is large in childhood, more moderate in middle life, and small as we approach old age. The amount will also vary somewhat according to the amount and character of the work done, and in even greater degree according to individual DERANGEMENTS AND DISCOMFORT. 3 peculiarities, some requiring very much more food than others placed under precisely similar conditions as regards temperature, work, exercise, sleep, &c. Many, from inherited weakness of various organs, must suffer more or less under any circumstances, and it is our duty to study the many ordinary slight ailments, in order that we may be able to mitigate the sufferings of our patients, if we cannot make them strong and vigorous. In this direction there is much to be done, and I cannot help thinking that of late years in our zeal for pathological discovery we have devoted less attention to functional disturbance without organic disease than for the interests of the community might reasonably be looked for from us, and for the interests of true medicine might be expected. What is the meaning of these slight, but perhaps very frequent, disturbances or derangements of the changes which take place in an organism whose tissues are in a perfectly normal state ? When any departure from the healthy state occurs it is obvious that the processes by which the equilibrium of physiological action is preserved are tempo- rarily deranged and out of order. An unusual or exceptional change — increased or diminished ordinary action, results. In many instances some time must elapse before the exceptional gives place to the ordinary activity, and slight excess or diminution of action in a different situation re-establishes the balance of health. A little too much food, or food of a wrong kind, or badly cooked, or food eaten at the wrong time, or too quickly — a glass of bad wine, bad milk, or bad water, to say nothing of a dry east wind, or a cold damp atmosphere, often occasions such disturbance in the normal changes in the body, as to cause even the strongest and exceptionally healthy to feel for a time far from well. Every generation has thus suffered, and we have not yet discovered exactly how a healthy person should proceed so as to keep every organ and every tissue in his body in a perfectly healthy state under the necessarily varying conditions to which he is exposed, so that each may continue to act for the longest possible time, until all gradually fail together in old age, and action at last ceases in natural and inevitable death. The fact that the age of every living thing is fixed and definite within certain limits is very remarkable, and is opposed to the views of those who tell us that the average age of man may be extended to one hundred and twenty years or more in time to come. Persons who accept this view cannot be aware of the minute changes in all tissues and organs as age advances, which changes ensure failure in action at a certain time. Unfortunately it is not possible to lay down positively the minimum quantity of food required for an individual to keep him in good health without change in weight, and even as regards the proper amount of water there is great difference in individuals, some taking twice or even r. 2 4 GENERAL REMARKS. three times the quantity required by others under similar circumstances, and enjoying equally good health. As it is our particular work in life to prevent or cure disease and relieve suffering, it is undoubtedly our duty to carefully study and investigate, as far as we are able to do so, the nature of such slight aches, pains, discomforts, and derangements as nearly all suffer from. Not a few people magnify slight ailments, but, on the other hand, some persons are no doubt inclined to under- estimate the importance of, or to ignore altogether, aches, pains, and disturbances, the early recognition of which might be of great advantage by enabling the doctor to interfere at once, and perhaps prevent long and serious illness. By a " slight ailment " is meant a departure from the healthy condi- tion which, although it may be accompanied by discomfort or actual pain, is seldom associated with permanent damage to the organ or tissue affected. Some slight disturbances of the normal condition may, however, last for a considerable time. Some soon give way to treatment, and the return to the healthy state is complete. Some, slight in them- selves, result in more or less serious changes, and may be but the first stage of important and perhaps fatal acute or chronic maladies. What is called an " ordinary cold " is an example of this, for no one can feel sure, until a few days have passed, whether the " cold " is but the slight derangement which almost everyone has many times experienced, or is the beginning of disturbance far too important to be included among " slight ailments." You will be very frequently called upon to prescribe for slight ailments, and you will often be asked how this and that bodily derange- ment or discomfort may be avoided, upon what it depends, and whether it is not indicative of some change more serious than mere temporary disturbance of ordinary action. You will be expected to fully explain how many a slight ache or pain is caused, though the problem is so complex that in the present state of our knowledge it cannot be solved. You will often be asked to lay down rules of health, by the practice of which all troubles may be avoided in the future. Very disappointed will the sufferer feel if you make light of his suffering, and dismiss him with the suggestion that, being only functional derangement, it is of no consequence. A little study and intelligent observation among sick people teaches us to be considerate and not too off-hand in giving advice, and you will soon be impressed by the fact that grave symptoms and excruciating pain may, in the long run, result from temporary derangements of no real consequence, while on the other hand, you must not forget that the most terrible morbid changes in important organs may exist for years, and run their course without the patient being cognizant of any unusual symptoms, or conscious that anything in his organism had been going wrong. ON SLKillT AILMKNTS. 5 I propose, then, that the first twelve lectures of my course on the Principles and Practice of Medicine should be devoted to the considera- tion of the nature and treatment of slight ailments. Could we examine the tissues ever so minutely, it is doubtful whether in such cases we should discover any very obvious departure from the healthy state. The enlargement of a few " nuclei," a little more or less fluid than ordinarily traverses the "intercellular" spaces in the tissues is probably all that would be demonstrated. No structural change would as yet have been induced, and even in cases in which there is decided departure from the normal physiological action, and where considerable pain and distress may be experienced, the accumulation in the blood of some product that should be quickly eliminated, or a slight alteration in the chemical composition of the fluid that transudes through the capillary walls and bathes the tissue elements, is probably all that could be detected, though this would indeed be quite sufficient to account for the symptoms. In the course of our inquiry questions of the greatest interest will present themselves, and although the present state of our knowledge does not enable us to give a full and satisfactory explanation of all the phenomena, say, of an Ordinary Cold or a Sick Headache, I feel sure that a more full consideration of the slight disturbances of physiological action which are continually occurring even in the healthiest among us, will assist us in understanding those more complex phenomena which constitute actual disease. The plan I propose to adopt will not only enable me to bring under your notice thus early in my course some of the simplest and most common derangements you will be called upon to correct, but I shall be able to direct your attention to practical matters of great importance with regard to the action of remedies and to refer to methods of prescribing and administering many ordinary medicines — matters of great importance in these days, when so few among you enjoy the advantages formerly gained by apprenticeship. I shall make use of very few learned terms, and when obliged to employ hard words shall endeavour to give their derivation and meaning at the present time — for meaning changes. I shall try to describe the derangements I have to consider in the simplest manner possible. In case any of you should think I am too outspoken as regards the confessions I shall have to make of ignorance concerning the real nature and causes of some of the simplest and most common of the slight ailments, I would only remark that, as there is so much real knowledge in medicine, and as the labours of our predecessors have established so many great truths and principles, we may surely freely admit that there are many things which we do not know, without fear of losing the confidence of the intelligent. Surely it is the very worst thing for the best interests of true medicine if any of 6 INTEREST IN THE PATIENT. her followers act in such a way as to lead those who are completely ignorant of our work to imagine that anyone has somehow acquired, in a mysterious way, knowledge that cannot be communicated to others, or that we have means of investigating disease which is not pursued or understood by ordinary mortals. It has been said that we used to put drugs of which we knew little into a body of which we knew less, and it is to be feared that even in these enlightened times, substances are sometimes prescribed the precise action of which has been very imperfectly studied. The prescribers, I fear, relying lather upon the statements and high encomiums of others than upon the facts of medical experience. We have no remedies of a secret nature, no occult arts of preparing or triturating medicines so as to increase their virtues. All that we know can be learnt by anyone who chooses to spend the time and take the trouble requisite for mastering the facts of medicine and the branches of science upon which it is based. There is, I fear, still manifest a tendency here and there to credit some of us with the possession of some mysterious power to control disease, but there is no excuse for this. Whenever naturally self- reliant enthusiasts act as if they were really the fortunate and favoured possessors of a power of detecting and controlling morbid processes that was not to be acquired by other men, the advance of medical truth will be retarded. I have been told that a physician recently assured an important person that he lived " in miracle," and boasted that he could eiifect a change in an important organ in a very short time, which is, and must ever be, impossible. In every age self-confidence and boastful pretension in many departments of human endeavour have commanded the faith and devotion of the simple and superstitious, and with the aid of these the evolution of the extraordinary and marvellous from the ordinary and intelligible is not difficult. I should feel sorry, and almost culpable, if in after days I should discover that one of my pupils had strayed from the right path, as some who have studied medicine have somehow been induced to do, and had tried to make people believe he was able to make use of some mysterious powers and agencies, and thus had obtained an influence over disease which not one of his brother practitioners would think of claiming. There is no mystery or miracle in modern medicine, and it is our duty to say so in all cases. If you go into practice fresh from the wards and the pathological department, and at once undertake the treatment of sick people, — if you pass from the investigation of important structural changes to the practical consideration of functional disturbance, and especially if you look too exclusively from a purely scientific standpoint, you will meet with many things that will puzzle you. The patients you SLICllT AILMENTS. 7 treat will not be satisfied, and you will be disappointed because they are not contented with the advice you give. Perhaps you will feel, in consequence, out of heart, or more or less disgusted with practical professional work. It has been said that the physician should be a consolation to the patient, but many a student fresh from the study of severe forms of disease would, I fear, afford poor comfort to a dyspeptic, or to a person suffering, say, from functional nervous disturbance, perhaps accompanied with liver derangement, and would hardly know \vhat to say to a patient in whose body he could discover no decided degeneration or disease of tissues or organs. The patient might describe many unpleasant and even alarming sensations and symptoms, which to him appeared of grave consequence, and all the comfort that he would get from such a medical adviser would be that, as there was no organic disease, he might go away and bear his complaints as best he could. Medical advisers of purely anatomical and pathological habits of mind are certainly apt to disappoint or even offend unscientific patients, and, without deserving it, may gain for themselves the unenviable reputation of being thoughtless and unkind, of being regardless of others' suffering, and, if not objectionable, very far from agreeable ministers of relief You must, therefore, learn how to study and investigate the nature of slight ailments and endeavour to relieve them, and should the conditions which give rise to them be beyond our means of control, we must try to reduce the severity of the patient's sufferings. If the patient's malady is, unfortunately, ever so intractable or incurable, and far removed from the category of slight ailments, he will be much more grateful to you for your attention, and for doing what you can to relieve him, than he would be if you favoured him with the most learned and elaborate disquisition concerning his case, even though it were accompanied with the demonstration that his illness was profoundly interesting and afforded an exceptionally perfect illustra- tion of some very remarkable pathological phenomena in which you were particularly interested. You will generally find that if a man has pain in his stomach, especially if accompanied with excruciating spasm, he will not be satisfied with the assurance that he will be better when the wind is dispersed. However interested we may be in studying the natural history of disease, the patient desires our assist ance, and wants remedies which will relieve his sufferings as soon as possible. I think you will agree in the opinion that such a patient is not more unreasonable than most doctors themselves would be under similar circumstances. If from ignorance of the use of simple remedies you tell the patient that nothing can be done, he will go to some intelligent person, professional or perhaps non-professional, who 8 SIMPLE MEDICINES. may give him a dose of Bicarbonate of Potash, or some Essence of Ginger (lo drops) and Sal Volatile (30 drops) in two tablespoonfuls of water. He will be at once relieved, and will get well in the course of a few hours, and loudly praise the adviser of the successful treatment. On the other hand, anything but praise would fall to your share. The patient would give you a bad character, and speak of you as an ignorant person and incompetent practitioner. Nevertheless though, perhaps, not acquainted with the great value of such commonplace things as Bicarbonate of Potash, and Ginger, and Sal Volatile, and many other simple medicines which are efficacious in curing various unpleasant aches and pains, you might be well informed as regards the manage- ment of serious cases, and, in fact, a good practitioner. In the treatment of most chronic ailments, slight and severe, it is most important to impress the patient with the necessity of allowing time for improvement and recovery. The impatience to get well quickly often leads the sufferer to go from one authority to another, and to adopt a number of expedients without much chance of gaining benefit from anyone. It too often happens that patients change one climate for another, low places for high places, cold for heat, or heat for cold, without gaining the end required. " Cure " after " cure," bath after bath, water drinking— alkaline water, still and effervescing— waters con- taining arsenic, iron, iodine, bromine, sulphur, and others of great renown — to say nothing of numbers of medicines, the potency of which is vouched for by experienced doctors in every part of the world ; many of which remedies, though positively pronounced infallible, and con- fidently recommended by the expenditure of thousands of pounds to call the attention of suffering humanity to their surpassing virtues, are, nevertheless, forgotten in a short time, and give place to other medicines of equal but undemonstrable perfection. To anyone who thinks, it must seem obvious that derangement of organs of such complex structure as the lungs, heart, liver, kidneys, brain and nerves, and many others, change for the better will proceed slowly, and this change in favourable cases will continue for a consider- able time, if only the right conditions can be steadily maintained. Even obstinate maladies, some being regarded as incurable, may be kept from getting worse, and caused to continue for a considerable period in a quiescent stage, during the persistence of which improvement may occur at any time, and recovery may follow — if only the patient can be persuaded to steadily persevere with the measures recommended. The knowledge hitherto attained with regard to the nature and course of pathological phenomena, renders it very improbable that any remedial measures, which act like a charm in some mysterious way, will ever be discovered— while, on the other hand, our advancing knowledge and practical experience point to the importance of good management, wic SHOULD r.K in cood !ii;ai,tii. 9 steadily pursued for many weeks or months, as being the course which is most likely to be followed by improvement and recovery. Those of you who are going to take part in a country practice ought to be especially careful to try to do all you can to please, as well as to help your patients. There may be no other medical adviser within many miles, and it will be unfortunate if any of the people in your neighbourhood should be prejudiced against you. You must, indeed, think over people's individual peculiarities, be ready to pardon their susceptibilities, and try not to offend them. The most painful (iifferenceshave been occasioned from want of care on this head; and many a coolness between patient and practitioner, which has lasted for years, and has caused much suffering and misery, might have been altogether avoided, had the practitioner exhibited a little amiability, and exercised ordinary caution and self-control, early in his acquaint- anceship. Not a few differences with patients may sometimes be traced to the practitioner's ignorance of common things he ought to know, or to an attempt upon his part to introduce new customs in dealing with his patients with which they are not familiar. You will find some useful hints to guide you in country practice and much information on conducting different branches of practice in a very useful little book to those about to enter upon the practical duties of professional life, written by Dr. Diver. It is entitled " The Young Doctor's Future ; or, What shall be my Practice ? " and is published by Smith, Elder, and Co. But, further, the study of slight ailments is of no small importance to medical practitioners, for it is of the greatest consequence that we ourselves should be in good health. Attendants of the sick should themselves be well, and each one of us should recognise the importance of keeping himself in a healthy state, that he may be cheerful and hopeful in the presence of the sick. It never does for a doctor, while listening to the sorrows of his patients, to be continually reminded of his own discomforts, and constantly thinking, if he does not actually declare, that he is far worse than his patient, and more worthy of attention, sympathy, and commiseration. The sufferer suffers less if he has healthy, cheerful, hopeful people about him. Dwelling on the fact of pain, and talking about it, seems to increase it. Many patients suffering from temporary derangements are in a low, despondent state. Such a frame of mind is more commonly due to temporary deranged action of the stomach and liver than to any other circumstance. Though you may be equally or even more dyspeptic and may feel very wretched, you must be careful not to add to the general depression by discoursing about your own ailments. You must encourage and cheer the patient, and speak as hopefully as in sincerity is i)ossible. All this is not very easy to do if we are not well. The doctor who is suffering aches and twinges is to be pitied, for he must not allow himself to complain. An 10 ATTENTION AND KINDNESS. ailing, demonstratively nervous, or hypochondriacal doctor, will be of little use, will get into discredit with patients, and will be disappointed ; and it will probably happen that some, it may be, ill-informed but more worldly-minded medical authority in his neighbourhood will get the patients who ought to be in his more deserving hands. This, may be, not unfrequently the secret of some undeserved failures in practice. Those of you who, like many excellent men who have preceded you, feel inclined to condemn the delicate attention, the excessive care, the extreme solicitude for minute perturbations of sensation or emotion of the invalid, characteristic of some very popular and very successful doctors, should pause, and try to look a little from the patient's point of view. Even a philosopher who feels ill, though he may be sure that there is not much the matter with him, may nevertheless desire some skilled and experienced medical adviser who will appreciate his aches and pains, who will consider his complaint, and listen patiently to the story of his woes, who will take a cheerful view of his case, and express himself accordingly, instead of suggesting possibilities of pathological degeneration in the gloomiest phraseology. You may be able to relieve many a sufferer by suggesting some very simple remedy. A dose of Bicarbonate of Potash or Soda (from lo to 20 grains) in water, or Lime water after meals may be all that is required. Little may be needed, but still that little assistance is necessary. Do not be too hasty in giving an opinion concerning the import of uncertain and indefinite symptoms. Many of the apparently slight disturbances or ailments may be due to some grave pathological change, which would be entirely passed over by one who had had little expe- rience in medical observation, but would be full of significance to the well-informed practitioner. That very formidable and rapidly fatal disease of the lungs, acute tuberculosis, usually begins as an ordinary catarrhal affection, and for some days the very serious nature of the malady may not be suspected. If the practitioner had not seen cases of this terrible disease, he might err in taking a hopeful view of the malady till a few days before death actually occurred. Certain forms of blood poisoning from the introduction of septic poison are associated with such slight general disturbance that for several days the patient seems to be suffering only from a slight febrile attack, the temperature being only a degree or so above the normal, and the restlessness and excitement being attributed, especially in the case of females, to " nervousness," and perhaps a cause is found in one or two consecutive sleepless nights. In a few days without any great or sudden change occurring, the patient sinks into a state of collapse and dies, the serious nature of the case not having been suspected till shortly before death. On the other hand, we often find that apparently serious illness is really due to temporary rUINCII'LES OF TRKATMENT. II and functional derangement only. You should remember that the most perfect machines sometimes go wrong without a flaw being discoverable just before the occurrence, it may be, of a complete break down. To say nothing of the living matter or bioplasts, the tissues and organs and the marvellously minute and delicate structures of a living being may fail in many ways without giving any notice even to their owner. The complex conditions under which living matter lives, and grows, and moves, and dies, may be changed in one or two seconds without the individual being in the least degree aware of it. The most careful scrutiny and minute examination may fail to demonstrate any fault or flaw. Nay, after the body has ceased to work — after its death, the changes which have resulted in its destruction may elude the most careiul investigation. We know that, for example, Hydrocyanic Acid, by its action on the living matter, the bioplasm, of the nervous system, will kill a living organism in a few seconds, but, nevertheless, as to the exact changes which the acid works in the bioplasm of nerve structures we know nothing. The same is true of many other modes of death. The flaws existing in tissues in disease are not always to be demonstrated, though possibly not a few would be demonstrated, if only we knew exactly how to render them evident and distinct. Slight Ailments Treated on the Same Principles a.s Serious Diseases. — There is also this very cogent reason which impels me to direct your attention thus early in my course to the consideration of slight ailments. Many of the principles upon which the treatment of even trivial derangements is conducted obtain in the management of graver maladies, and in not a few instances you will find that attention to the relief of slight ailments will afford you great assistance in determming the proper course to pursue in the treatment of very serious forms of acute disease. For example, I shall be able to show you that the treatment of a grave disorder like acute rheumatism is based upon facts and reasoning which apply equally to slight affections of a rheumatic character. Fevers and inflammations of the very slightest degree afford lessons of the greatest value concerning the management of almost every disease of this class. By carefully observing the action of remedies in slight ailments, we may gain most valuable knowledge. And especially in the treatment of slight derangements of our own health may we hope to acquire definite infomiation concerning the precise action of some of the most important of the medicines we employ. I am sure that anyone who has experienced the change in his sensations which occurs after taking a few doses of ammonia (Sal ^^olatile, 30 drops in two tablespoonfuls of water) in the course of an ordinary cold, or has noticed the pleasant alteration which takes place during an attack of quinsy as soon as diuretic and sudorific remedies have begun to act, or is practically acquainted with the relief 12 PRESCRIBING. afforded in biliousness, certain forms of indigestion, and sick headache by half or even a quarter of a grain of gray powder or calomel, will not only be convinced of the usefulness of the drugs, but will not altogether despise the views and practice of fifty years ago. Nor will he succumb to the nonsense of giving coloured water to his suffering contemporaries, or suggest that a number of cases of different forms of disease should be left without any medical treatment whatever, in order that what has been naively termed the " natural history of disease " may be studied — the patient, of course, being persuaded not to complicate the interesting inquiry by longing for the relief of his suffering or for convalescence, too quickly for leisurely observation of the changes in the symptoms. There are many valuable points connected with prescribing which are of the utmost consequence, and which are to be learned from the practitioner who is well acquainted with the management of slight ailments. I have often heard the remark that our predecessors knew more about the management of ordinary diseases than we of this generation do. There is some truth in this, and I am sure that many old practitioners now living have been very successful in relieving the aches and pains of their patients, perhaps more so than some of the young ones, who possibly may, nevertheless, have a far more intimate knowledge of the diagnosis of obscure forms of disease and of the minute changes which have damaged tissues and organs, but are apt to forget that all unpleasant aches and pains are not due to structural change and serious degeneration or disorganization. Those of you who have worked under country practitioners enjoy a great advantage in this respect, and will be aware of many things connected with the art of prescribing for symptoms, of which even men who have highly distinguished themselves in our medical classes and medical examina- tions may be in ignorance. Nor do I see how this very desirable practicable information can be gained in any other way. I may try to convey to you some of the wrinkles I have learned long ago from my own masters, but shall only very imperfectly succeed. To offer remarks on the details of treatment when sick people are actually being treated in the country surgery is very advantageous, but to attempt to give in lectures or at the bedside of serious cases of disease, detailed information as to the combination of remedies in pills and mixtures, and a number of thmgs practically of considerable importance, would be tedious, and would take so long a time that one could not expect a class to listen with attention. I shall, therefore, only venture to trouble you now and then with details as regards prescribing, but it will be well for you to take note of particular prescriptions, which I have frequently found of great value in the management of cases of deranged health — a most important class, always requiring our attention. TACT AND TKKATMENT. I3 On Tael ami on liaiiiiii;; l>aticiit<<' Contldciicc. — Practitioners who will not endeavour to help their patients who are suffering from slight ailments had better not attempt to practise medicine at all, because they will almost certainly fail, seeing that a large percentage of our sick of all classes, fortunately for themselves, do not suffer from grave pathological changes, though they may require intelligent medical assistance. There is not one amongst us who gives his attention to those patients only who are suffering from very serious forms of disease. You must therefore understand the nature of slight derangements, and you must know how to relieve them. You must not treat the complaining patient with contempt, and tell him there is nothing of any conseciuence the matter, and that he may go about his business. If we behave in this manner the public will naturally be offended, and some people will be led to seek and accept advice perhaps from mere pretenders, or from wiseacres who profess to discover the most wonderful and exceptional phenomena in very ordinary cases, or who, while thus trying to gain the ear of the patient, make the most of every opportunity of casting a slur on those who have honestly studied and practised. Knowing little or nothing of morbid changes, and of the sciences upon which the investigation and treatment of disease rests, many of these professing healers are, in a way, extremely clever, and not a few have the advantage of a marvellous development of that peculiar mental endowment called " tact " — a most desirable possession for every one who has to treat and take care of sick people, if, in addition, he is honest and good. I would have you take note, however, that this word " tact " has a very comprehensive and elastic meaning, and is in these days equally applied to an honest desire on the part of anyone to avoid wounding the feelings of a sensitive person, or to avoid needlessly vexing any one when it is necessary to communicate unpleasant things, and to the successful exercise of glaring imposture and pitiless humbug. One now and then gets, in a sense, an instructive, though a very painful if profitless lesson, as to the means by which the good opinion of people unlearned in medical and other matters may be gained by a practitioner who is sadly deficient in knowledge and in experience, and who is perfectly conscious of his defects, but knows well how to make up for them. A master of tact, and determined to avail himself of the advantage he thus possesses in the struggle for existence, he convinces, he persuades, and perhaps flourishes where many a good man would fail, and, perhaps, where many such have already failed. Nevertheless, do not let me lead you to conclude that tact is another name for humbug, any more than that kindness and politeness imply insincerity ; but it is only too true that some makers of fortunes have been indebted for their success to cunning, cuteness, and tact, rather than to hard work, goodness, or intellectual power ; and he who thinks very highly of tact, and acts upon his opinion, must be very 14 QUACKERY AND TACT. careful lest he slide too far down the incline, which may lead him on from the display of tact to the habitual exercise of humbug, and at last to give way to utter heartlessness and selfishness of the lowest order. But, it is to be feared, there are persons who would be easily influenced by what the quack says, who would be dissatisfied with the view taken by the well-informed medical practitioner, and alas, some- times with the conviction that the latter knew nothing about his business, and was ignorant of the nature of the changes taking place in the organism, and of the method by which these changes might be modified when they were not properly performed. This is unfortunate, but there is no help for it. Every upright practitioner has found himself occasionally in this unfortunate position. So situated, the best thing is to say very little, be as patient as possible, and leave matters to set themselves right if this may be. At the same time, while doing our best to preserve and extend the high repute of our profession, we must be careful not to play into the hands of pretenders, and this we shall certainly do if we needlessly offend fanciful and crotchety patients. There are few matters of greater interest and consequence to us than the manner by which we may succeed in gaining the confidence of our patients, without making promises which cannot be fulfilled, and, indeed, without saying or admitting anything of which an upright, intelligent, and high-minded gentleman of education, kindness, and consideration could in the least degree feel ashamed. Some men have a natural gift of inspiring confidence at once, just as others have unfortunately to contend with natural defects resulting in exciting in the minds of others anything but confidence. He who is to afford real help to people as a medical adviser must be trusted and believed in by his patients. It is, therefore, his duty to study and train himself so that confidence may be inspired in those who may place themselves under his care. In this endeavour, we are, however, often heavily weighted. To gain the esteem of some people unlearned in matters medical, it may, indeed, be necessary to promise more in the way of cure than a man of sound judgment and repute would be able to do. :werticiiie in Circece and Rome — Quackery. — To those of us who have passed many years working and thinking among sick people, and having studied, with the help of the teaching of our predecessors and the aid of new and accurate scientific instruments, the nature of the actual phenomena occurring in the tissue elements, and in the fluids of the body in health and the departures from the healthy state, it seems as extraordinary as it is disappointing, that men of undoubted intelli- (^ence and well acquainted with the ways of the world, should sometimes select for their medical advisers, not perhaps actual ignoramuses, but medical pretenders — impudent fellows who act up to the conviction that if they only talk nonsense with sufficient audacity they will prevail GREKK AM) ROMAN MKDICINK. I5 and convince. Even among highly educated people, it is very excep- tional to meet with one who is sufficiently acquainted with anatomy, physiology, and chemistry to detect the true character of medical nonsense. But this is not new or peculiar to our time. Galen (" Meth. Med.," 1. i) tells us that in the time of the Roman Empire that what gave vogue to a physician was not science, but skill in flattery. To him who was the best sycophant, everything became easy. " To him every door was open. In a short time he became rich and power- ful." " The asses of Thessalus had parcelled out the art of healing into the most minute subdivisions of practice." In the time of Cicero Rome swarmed with special curers, who rapidly gained a reputation, and made large sums of money. Some, for instance, confined their practice to the treatment of the uvula, the eyes, the ears, or the eye- lashes, or certain kinds of cutaneous eruptions. " Some restricted their attention to the treatment of aged men, others to that of the strong and robust. Some would cure only with herbs, others by means of gymnastic exercises." " Some took their title to practice from almost every malady, from each period of life, from every kind of medicament, from each smallest part of the human body," There were corn doctors ; and women practised as well as men. The profession appears to have been open to the most unscrupulous. " Not a few professed to be guided in their treatment by the course of the stars," some by the nature of the dreams of the patient himself, some perhaps by " suggestion." Long before law was constituted in Rome medicine appears to have been carefully studied in Greece. At a time when Romans sacrificed to the Goddess of Fever, and raised temples in the hope of conciliating her, the God of Healing was worshipped in Greece. There, too. flourished thought, contemplation, and reasoning. Two hundred and fifty years before Christ a Greek physician practised in Rome, and still earlier the statue of Esculapius had been placed on an island of the Tiber, and menaced the Roman Gods of Fever and their altars. This Greek physician practised medicine and surgery, and compounded his own medicines. He was highly honoured, was provided with a house in the best part of Rome at the public expense, and the title of Roman Citizen was conferred upon him. Greece was the birthplace and the nursery of medicine, and there was a time when the Greek physician was consecrated to science and virtue by the noble vow to Hippocrates, was pledged to honour his profession, and to independence. Three centuries before the Christian Era medicine flourished in Greece, and for many years continued to advance, almost keeping pace with the wonderful progress of art and many branches of learning which about this period reached a very high degree of excellence. All this was checked by the Roman conquerors, and the enslavement of the exponents of art and culture 1 6 ]\IEDICINE IN IMPERIAL ROME. soon followed. Medicine thus introduced into Rome suffered terrible degradation. Anyone could then practise as a physician or surgeon, and the most ignorant seem to have enjoyed equal rights with the clever and well educated. The faults and crimes of the most wicked and depraved were soon regarded as characteristic of all. Pliny informs us that rapacious bargains were made and taxes laid on suffering ; many of those who treated the sick were mere sycophants, who cringed to the corrupt rich and ministered to every caprice, flattered the base, and were the obsequious apologists of the most detestable habits and crimes. Some were as cruel as they were reck- less. Galen, indeed, went so far as to declare that the only difference between the physicians who practised in Rome and the robbers on the highway was that the latter plundered mankind in the mountains, and the former in the city. In Imperial Rome many of the medical practitioners were slaves, who had been bought and sold. A slave acquainted with the practice of medicine sold for three times as much as an ordinary slave. Some of these slaves, or bondsmen of physicians, or slave physicians were engaged in dark and mysterious intrigues, open to bribes to bring false accusations, and even committed murder by poisoning and in other ways. One referred to by Cicero appears to have been guilty of burglary, robbery, and murder while he was still a physician. A public slave who knew nothing of medicine could educate himself in his leisure hours and thus become a physician ; he might perhaps gain a high reputation in the practice of some special department, and by the money earned, could after a time purchase his freedom. At one time Julius Csesar appears to have made all who practised medicine in Rome citizens. Many distinguished patients who recovered from an illness attributed their cure to the physician. Imperial favours and other great advantages were bestowed upon the fortunate practitioner. Immense fortunes were thus made by mere quacks, who had little knowledge or experience, but who were trusted and gained the confidence of others by boasting of their powers, or by good luck. One would have thought that in our days of intelligence and culture every one would have preferred as his medical adviser one whose history and position alone showed that he could not be a quack or an ignoramus, and that at least they would take the very little trouble required to find among the hundreds of practitioners, whose work and repute are known, or among the thousands whose training and character are recognised, an adviser who would not only treat them with judgment and intelligence, but would satisfy them in other ways. But instead of this, even in the largest cities and even seats of learning how often do we find the recommendation of some sanguine person who declares he has been cured of the most serious and extraordinary COM' IDI'.XCK I\ KRROR. I7 maladies after the most distinguished members of the profession had completely failed, taken and acted upon without a shadow of doubt or misgiving. It is quite extraordinary what large practices have been made in a short time by the puffing of inlluential people, not one of whom has perhaps taken the trouble to ascertain whether the fortunate practitioner is really deserving or not of the high praise and recom- mendation he has had the good luck to enjoy. A bone setter, who has never known the anatomy of bones, ligaments, or muscles, has been encouraged to twist and torture delicate joints without let or hindrance, perhaps after a distinguished surgeon had strongly advised that they should be kept perfectly still for a considerable time. Sometimes it would appear that a certain extreme confidence of manner, backed by an approach to vulgarity on the part of the fortunate pretender, had been set down as indicating originality of mind, experi- ence, and even genius. On the other hand, the art of looking wise and saying nothing seems to be the secret of success in some instances. Not unfrequently fluency in small talk, and a bustling manner, indicative of overwhelming business, ensures quick success ; while, occasionally peculiarity or perfection of dress appears to have won the respect and confidence of patients, and secured to the elegant doctor a considerable income. You will not, however, feel astonished at all this if you consider how very ignorant of all subjects bearing in any way upon physiology and medicine are the generahty even of so-called well- informed people. Among politicians, the intellectual classes, the leaders of thought, among classical people and mathematicians, lawyers, public speakers and writers, are many who do not take the slightest interest in any department of natural knowledge, and are so incapable of entering into scientific modes of thought and work, that they can be deceived and cheated by the most commonplace pretender. The ignorance and prejudice fostered by the teaching and advice of persons wholly ignorant of science, and by nature strongly opposed to the scientific method, as well as to all attempts to inquire into the nature of things, have constituted the chief obstacles to improvement, and have en- couraged the maintenance of conditions adverse to health and favour- able to the perpetuation of diseases still annually destroying thousands, but which ought long ago to have become unknown in England. It is easy for those who make light of the facts of medical and sani- tary science, and who profess to believe in the virtue of decillionths of a grain to retort by accusing scientific men of attempting to constitute themselves into a sort of trade union, condemning all who do not fall in with their views. The writers in our public journals, however, ought to be able to see through such false charges and commonplace cries, and expose them. To condemn as a trade union a body of men engaged in the furtherance of the greatest of all blessings, the 5i l8 DECEIVING INTELLIGENT PEOPLE. health of the community, is unjust. The profession encourages an<3 rewards individual merit, and sanctions individual success, — permits the freest competition between its members, limits neither hours of work nor freedom of thought, — encourages all to aspire to equal, and, if it may be, to excel the greatest of those whose lives and works are recorded in its annals, — endeavours to protect the unlearned and uninstructed from imposition and wrong, and refuses to sanction on the part of its members any secret method of healing, however useful it may be, or the use of any medicine, the ingredients, composition, and method of producing which, are not published to the world for the advantage of all. There is not the faintest justification for urging a complaint of the kind against the medical profession. Anything like what is called trade unionism amongst us, if possible, is one of the most improbable of improbable eventualities. We only desire that the real knowledge which has been handed down to us, and which is still being added to by the work of thousands of practitioners and scientific physicians and surgeons in all parts of the world, shall not be considered in any way comparable with or related to any of the followers of certain so-called medical systems, which are based upon the assumption that any effects result from the exhibition of quantities of various medicines supposed to amount to less than the millionth of a grain, or that any increased potency is conferred by methods of division, tritura- tion, agitation, or dilution. We maintain that the dicta upon these and other medical matters, received as true by sections of the public, are opposed to facts of anatomy, physiology, chemistry, and physics, to observation and experiment, while, on the other hand, the principles upon which medicine is based, we contend, are continually being tested and verified, or modified. inflnitesimai Doses. — To ascertain whether such a quantity as the decillionth of anything acts in any way is impossible. Any attempt to do so would be foolish, since no one can be sure that one-decillionth of a grain of anything in the world can be obtained. Such supposed fractional part is beyond the Hmits of physiological, chemical, or other known method of investigation. It is invisible, intangible, undemon- strable, and as a medicine exists only in imagination, and can be proved by assertion only. In fact it is not possible even to imagine particles of a degree of minuteness considerably less extreme than these, and it is- useless to attempt to reason on such things. I am ready to admit that there are persons who believe that the decillionth of a grain of opium will produce an effect upon man's organism, just as there are people who hold that the earth is flat, that living things are machines, that spontaneous generation from the non-living occurs, that vaccina- tion is detrimental, and a number of things which may have been conclusively proved or disproved, as the case may be, or concerning DECILLIONTIIS OF A GRAIN. I9 which there can be no evidence one way or the other, or which are altogether beyond the reach of thought. In this country we are proud of what is called liberty of opinion, and we cannot i)revent our friends and neighbours from holding and propagating beliefs, views, and doctrines which from the standpoint of fact and reason may be inadmissible. Many medical questions upon which there is wide difference are really open to further investigation and discussion, and upon these all ought to keep their minds open to conviction, if new evidence should be adduced. But, at the same time, many assertions which are commonly and frequently advanced, as if they had been proved true, are not reasonable, — not open to discussion. The assertion, for instance, that the decillionth of a grain of opium produces an effect on the human organism is one of these. IVIany years ago I saw in a hospital in the south of Europe a poor woman who was dying of cholera — was, indeed, obviously within an hour or two of death. The attending physician examined her and pre- scribed " Opium." I asked him what quantity of the drug he had ordered the patient to take, and, after some calculation, he said, " The decillionth of a grain." Now, I shall no doubt be considered by some who prescribe millionths and decillionths a very narrow- minded and prejudiced person, but I decline to discuss with anyone who believes, or professes to believe, either that he had actually given this quantity of opium, or that such an amount of that drug would, if it could be introduced into the body, produce any effect whatever upon any living thing. It is useless to argue about the possible action of such infinitesimal quantities of drugs — even in the case of the most active substances; for the idea that the decillionth of a grain of any thing can produce any change whatever in a living body is absurd. The assurance that it does act rests on no evidence whatever, and is at this time a nonsensical assertion. Is there any process known by which a single decillionth of a grain can be obtained, or ten or twenty or a hundred decillionths? Of course there are people who firmly believe in the potency of decillionths — but this is not the question. We have to inquire whether there is any reliable evidence in favour of any action whatever being produced by such quantity, and the answer must be that there is absolutely none. The absurdity of the whole pretension wnll be rendered evident to most minds by work- ing out a sum in arithmetic : — if a person began to take a decillionth of a grain of opium the moment after birth and continued to take one decillionth each succeeding minute, to what age must he live before he had swallowed one single grain ? It would not be reasonable to expect that the public generally should be sufficiendy informed concerning medical and scientific 20 IIOMCEOPATHIC CONVERSION. questions to enable them to form a judgment as to the relative merits of different systems of medical treatment, any more than they should be expected to investigate such questions as spiritualism, or to determine the nature of, and right method of dealing with, certain forms of contagious disease. All thoughtful and reasonable professional men have, however, strong cause of complaint when they find that persons of intelligence, holding positions of authority — law-makers, ministers, and distinguished political chiefs — so express themselves as to lead people as ignorant or more ignorant than themselves to repose confidence in any one who prescribes the millionth of a grain of charcoal or the decillionth of a grain of opium, and declares that he has as good ground for his practice as the one who orders ten or twenty grains of the first or a tenth or more of a grain of the last. It is remarkable how very few persons seem to realise the tremendous difference between such fractional parts as tenth.s, hundredths, and thousandths — and miUionths, billionths, and decillionths. Probably the most striking and, I believe, exceptionally rapid cases of homceopathic conversion and conviction on record was that of a great legal authority and profound controversialist and critic, who during the greater part of a long and active life had been engaged in endeavouring to extract the truth from all sorts of people, frequently under circumstances not very favourable to his aim. Con- stant familiarity with the ingenious devices adopted by those whose interest it is to conceal, or distort, or misrepresent the truth may possibly have had the effect of fostering a suspicious habit of mind, which in after years seems in certain cases to have resulted at the same time in general doubt and mistrust, and a curious infatuation to believe the incredible and love the impossible. Not a few among us doubtless carry trust and confidence in others to almost ridiculous lengths, and at last believe in the virtue of everything which is main- tained to be an infallible cure, or the beneficial action of which is asserted by people who have taken it, and fancy they have experienced benefit therefrom. Such simple folk in all ages of the world have unknowingly done their best to encourage nonsense and spread sham reputations. But it is passing strange to find the acute lawyer among people as innocent of law as of investigating what purports to be evidence, and incapable of confirming their faith or of increasing their doubt by inquiry and cross-examination, soothing his troubled spirit and assuaging his irritated intellect with simple beliefs in the virtue of a millionth of a grain of charcoal, and the evolution therein of new potencies by trituration and division, by dilution and agitation. But not less wonderful would it be if any such gifted legal mind arrived at the conviction that simple and easily provable medical facts were false, and LEGAL ESTIMATE OF SCIENCE. 21 the prodigious assumptions of some charlatans literally true, or if further, by cross-examination he successfully dissected the many doubts and uncertainties included in scientific truth, and thus having clearly established the uncertainty of some things in medicine, had then triumphantly denounced all medical knowledge as imperfect, defective, pretentious, unsound. Eut very wonderful convictions are evolved daily and published for the instruction or the warning of the world. With respect to medical and purely scientific questions, investiga- tion by legal cross-examination often results in confusion and doubt, and the effort to formulate a very definite view of the import of scientific facts may increase the confusion, and result in the spread of error. Lawyers often complain that our medical evidence is vague, uncertain, contradictory, and worthless, and in consequence form or profess to have formed a low estimate of medical and scientific methods. While we may be endeavouring to get as near to the truth as possible at great trouble and cost to ourselves, law arrives at a decision at the cost of others, by methods different in character and promise from those pursued by us. No doubt there is little in medicine which from a legal standpoint could be called true. But I fear we should cut a very sorry figure if in the sick-room we resorted to legal processes and attempted by them to investigate the purport of the facts of a case of illness. Even if the patient were himself a lawyer he would not be soothed by being minutely cross-examined as to the real character of the pain he expe- rienced, or the particular mental twistings in the wrong direction from which he suffered, nor would he like to be very minutely cross-questioned as to the manner in which he had lived for months or years before his seizure. What would be the effect if the doctor examined him as he examines the doctor I will not venture to enquire. Is it credible that a highly-trained reasoner, whose judgment on some questions must be good, and who, of course, would be exceptionally quick in discerning goodness and uprightness, intelligence and con- scientiousness in his fellow creatures, who had been in close relationship with some of the best medical and scientific teachers of his time, and who might have had constantly for years under his observation, and studied in all its details medical work as conducted in our best medical hospitals and schools, — who might have watched for a generation the career of many a man as he passed from school to college, from the state of student to that of teacher, professor, physician or surgeon, should have failed to discover in any of the individuals in question sufficient intelligence, judgment, honour, or goodness to gain his esteem or inspire him with confidence in their knowledge, belief, intelligence, and integrity ? For a mind in such an environment to commit itself to dogmas about the potency of infinitesimal division 22 CHEMISTRY, MICROSCOrE AND HOMCEOPATHY. and trituration would seem to be scarcely possible. To persuade itself, to be satisfied with the evidence adduced by advocates of the impossible is certainly not to be explained upon any rational theory that can be proposed. Is it possible that under certain mental con- ditions some of the arguments in favour of dilutions, triturations, and division into decillionths could temporarily enthral the reasoning powers, or act as an anaesthetic on the legal understanding ? Of late some zealots have appealed to chemistry, the microscope, the spectroscope, in the hope of finding facts in some way confirma- tory of their extraordinary contention concerning the potency of a millionth, decillionth, &c., of a grain. It has been urged as confir- matory of homoeopathic doctrine that since a Hve bacterium, weighing perhaps much less than the millionth of a grain, is capable of exciting fatal morbid changes if introduced into a healthy organism, it is not unreasonable to infer that a like very minute quantity of some potent inanimate drug might be capable of giving rise to very wonderful phenomena. But it is not the one living bacterium that works all the mischief. This minute organism soon grows, and divides and subdivides until at length millions have resulted, and have by their growth and by the organic changes effected during their growth brought about such changes in the blood, in the interstitial fluid, in the tissues, and in the living matter of all these as to cause very important symptoms, and perhaps even in a short time death. The homoeopathic non-living infinitesimal has no such power of prodigious increase except in the homoeopathic imagination. The question is one of fact and demonstration. It can be proved, and has been proved again and again, that the bacteria really cause the ■changes which are so important, while it has not been proved, and cannot be proved, that the millionth of a grain of Nux or Kali, or Iron, Lead, Calomel, Chalk, or Carbon, has ever produced, or is capable of producing, any change whatever in any part of the organism of anything living. Anyone can prove easily enough that a distinct effect will result from taking a quarter of a grain of Calomel or Opium. The effect produced, it is true, will not be in all respects exactly the same in every individual, and the degree and rate of the action will vary somewhat €ven in the same individual at different times, but the influence of the drugs will be so similar in case after case, that a general conclusion will be arrived at, and the remedy ordered in appropriate cases almost with the certainty of producing the required effect. Indeed, if the experi- ment be tried in twenty or thirty or more individuals, the effects will be repeated with general uniformity, and the physician will be able from his experience to form general conclusions concerning the action of the remedy upon the organisms, and the proper doses to be given in different cases. In fact the substances may be given ten or ten thousand ACTIONS OF MEDICINES. 23 times, and the conclusions already arrived at will be confirmed. ■Generally if the doses be increased, an increased action will result, as any one who chooses to do so may prove in the case of his own organ- ism. On the other hand, if the dose be reduced to the hundredth or thousandth of a grain, no perceptible effect will result, and if the experi- ment be repeated hundreds of times in many persons, the conclusion already arrived at will not have to be modified. These very small doses are useless. They produce no definite discoverable effect. How then can we expect to prove anything concerning the action of the thousandth, the hundred thousandth, the millionth of a grain ? Again, from ten to twenty grains of Bicarbonate of Potash or Bicar- bonate of Soda will often produce an advantageous effect in cases of flatulence or heartburn, as well as in other forms of functional disturb- ance of the stomach. If people found that half a grain or the tenth of .a grain had an effect, is it likely they would repeatedly take the larger •dose ? The thousandth, ten thousandth, or hundredth thousandth of a grain would be taken in preference to the larger quantity if we found that It had any effect at all. When an alkali acts by neutralising free acid it need scarcely be said that the amount required is to some extent determined by the amount of free acid present, which varies much in different cases. To attempt to neutralise the acid present by giving the one hundred thousandth of a grain would be ridiculous. I shall of course be assured that the evidence of the action of a millionth of a grain or less of the very same drugs is quite conclusive, although the hundredth or the thousandth of a grain may be impotent ; but what is called evidence, is of a kind very different from that adduced in favour of the action of a quarter or half a grain, and is, in fact, no evidence at all. But to prove the point it is not needful that people should try the remedies upon themselves. The drugs in question and many others are being used daily in ordinary doses, and have been used over a period of many years in hundreds of institutions for treating the sick in Europe and in America. By regular attendance for a week or two at any one of these, a person of ordinary intelligence would be convinced that in discovering the nature of disease and in treating it practitioners were acting upon, and were guided by well-ascertained facts and principles. There are persons who know nothing of science, and who have never seen anything of sick people, who nevertheless talk as if they were thoroughly experienced in the science and practice of medicine. Such authorities sometimes condemn us because we decline to " consult " with men who practise according to conjectural principles based neither on experiment, observation, or experience. Certain rich, influential, and fashionable persons having patronised and embraced some absurd conceit, profess to be grievously offended with a practitioner, who 24 SCEPTICISM AND CREDULITY. perhaps has been studying and teaching medicine for half a hfetime^ because he decHnes to adopt useless measures which it is desired out of mere caprice should be carried out. It has been my lot to study, on more than one occasion, the well- turned phrases and persuasive sentences by w^hich a popular prescriber of decillionths, brimful of tact, manages to bring conviction to the minds of people of intelligence, and at the same time to impress them with his profound knowledge, though all the time he may have been talking nonsense, but was perhaps not aware that he was doing so. But, as is well known, cleverly expressed nonsense often hits the mark, and will continue to do so for many a long day. Men^ high among the most intelligent and most learned, nay, men who have been looked up to as men of the world, have often been misled in matters medical, and profound lawyers have failed to distinguish medical nonsense from medical sense, and sham science from real scientific knowledge. Of those who are always gauging the value of ordinary evidence, and devoting themselves to the extraction of truth, some seem to be specially susceptible to medical and scientific imposition. But there is hardly a department of human endeavour in these days in which you will not find audacious pretenders influencing opinion, and gaining short-lived notoriety and renown at the hands of their dupes. Excellence as regards one department of knowledge is often asso- ciated with extraordinary ignorance and credulity concerning other branches ; nay, the same individual sometimes manifests the extreme of scepticism as regards certain things, while in others he is unsurpassed for his credulity. You will find persons sceptical concerning demon- strable and demonstrated facts, and faithful and believing in respect of fictions of the imagination and the most nonsensical dicta. A profound knowledge of logic, mathematics, law, classics, or metaphysics will not protect a man from imposition and quackery as regards the nature and management of the ailments of his body, and there are not a few persons having great intellectual capacity who have been duped by quacks while they mistrusted the true statements of an honest, straightforward medical practitioner. There is nothing more extraordinary than the confidence often reposed in what is false, and the doubt, disbelief, and suspicion exhibited concerning that which is true. In the matter of medical advice, at all periods of history, humbug has sometimes reigned supreme. Character, experience, unremitting work often go for nothing. In England and in America great success is often attained by persons almost ignorant of their calling. There still lurks belief in mysterious and inexplicable actions as regards certain medicines and compounds, as well as in the wonder-working powers of some who prescribe them. This it is, possibly, which enables the self- asserting empiric to exert a favourable impression upon certain of those nn'osTur^K and nonsense. 25 who, though really great in some departments, are al best but very ill- informed concerning matters of health and disease. Some even of our very simplest prescriptions are supposed to possess wonder-working power, which, I fear, would vanish in a moment if they were translated into English. But we may hope that the time is not far distant when we may order Bicarbonate of Soda, Hydrochloric Acid, and such- like simple medicines, which may often afford great relief, without enveloping them in a cloak of mystery. People would be much astonished if they knew what cheap and common drugs were sometimes bought at extravagant prices in the form of various highly-puffed patent medicines of secret composition, not a few being compounds of simple remedies which have been prescribed by medical practitioners day by day for a century or longer. Simple well-known medicines, some consisting of substances which have been used by nearly every member of the profession over more than a century, are made into pills, or introduced into mixtures, said to cure all sorts of ills, and called by some new name, as if a new discovery had been made. A patent or proprietary medicine is the result, the virtues of which are declared by numerous persons, all of whom bear witness in language of the strongest kind to the virtues and never- failing success of the extraordinary newly discovered cure. The owner is protected by the Legislature, which receives a large sum for the privilege granted by the imposition of a stamp on every box or bottle sold, and allows the monopoly of a trade mark, which is registered. Thousands upon thousands of pounds are spent in proclaiming to the world the enormous advantage to be derived from the nostrums. The proprietors of newspapers and of other journals are glad, and their reputation adds to the sale, and ensures the popularity of the newly invented wares. The medical journals are not behindhand in spreading the fame of the curative materials, and find it necessary to provide hundreds of pages for advertisements, while for bringing under notice the titles of the books written by foreign and British scientific men, teachers, and the members of the medical profession — a very few pages only are required. The sale of many of these medicines must be enor- mous, for, as is well known, many thousands of pounds are annually spent by their owners in advertising ; while the expense of purchasing the ingredients, and the preparation and packing of the mysterious bodies, which are shipped to every part of the world for the relief of the suffering public, is very moderate. The composition of these healing wonder-workers is a secret, which, of course, adds greatly to their potency in the eyes of some people. In some countries there are no secret remedies, and the composition of every pill or potion compounded and sold for the public good has to be notified, so that the great advantage derived from the mystery of the unknown is lost. 26 WANT OF CONFIDENCE IN US. But though, in this case, the pubHc gains the advantage of cheaper remedies, miUions may be lost to the State, to the journals, and the happy owners by this English form of " protection," and the people are deprived of the use of hundreds of secret nostrums warranted to cure every disease, pain, discomfort, or health disturbance present and to come. Want of Confldcnce in Medical Practitioners. — If we raise our voice ever so gently against nonsense and imposture, some of the writers belonging to the organs of public opinion hold up to reprobation what they denominate the proverbial jealousy, the intolerance, the illiberality, and the narrow-mindedness of the profession. The comments in the supposed interests of the public, and the strictures passed upon us are sometimes most comical, but you will now and then find, I fear, that your work is rendered very difificult in consequence. If you attend through a very long and serious illness a patient who, from the badness of the times, is perhaps unable to afford you remuneration for your services, and you hear that as soon as he is able to get about he has placed himself under the care of a distinguished quack, who found it necessary to see him every day, and received a handsome fee each time, you are fortunate in belonging to a liberal profession, and you are too considerate to be jealous of the quack, who is well paid perhaps for doing nothing, or to feel hurt or angry if he happens to have made any mistakes in diagnosis. If, after having ridden over hundreds of miles of ground of rough country in rough weather to attend the sick poor around you, finding not only medicine for all, but food and medical comforts for not a few, you one day discover that the only people within ten miles of you enjoymg a moderate income have, out of the purest kindness, invited a celebrated homceopath to visit them, and he, also out of kindness, has seen and prescribed for a number of your patients at half the fee he usually condescends to receive, you are to feel thankful that you live in a free country, where opportunity is afforded to all. You will think it hard that unqualified and only partly qualified persons are not prevented by law from imposing upon innocent people, as is the case in some countries which have not reached the high degree of civilization attained by us, but you should also feel thankful that the Government does not pass laws which would conduce to the further impoverishment and degradation of legally qualified medical men who enjoy the privilege of attending the poor for little or nothing in the several districts of the United Kingdom. A few highly influential law-making persons agree with certain eclectics, who consider that it is degrading for animal magnetisers, hydro-, homoeo-, and other " paths," and for a genius, a conjurer, or a " certain cure " to submit to the ordeal of examinations on elementary anatomy, physiology, medicine, and surgery, conducted by unpractical theorisers, and pre- sided over by the narrow-minded supporters of " medical trade unions ! " I'UINCn'LES OF CONDUCT. 2/ But after all, it must be conceded that the successful quack seldom enjoys more than a short reputation. He has to make hay while the sun shines, for he may soon have to give place to a quack more lucky and more celebrated than himself, and pass into obscurity. On the other hand, although we may receive far less than our due, we belong to a body proud of its history, and confident as regards its future. Resting on ever-advancing science, medicine must pro- gress as knowledge advances ; and as information extends, respect for real work will gradually increase. The regard for the medical practitioner will be higher in the future than it has been in the past, and ere long the numbers of those who appreciate our work and put trust in us will include as many as the most enthusiastic among us could desire. Nor can we now feel surprised that people who know little or nothing about us or about the subjects we have been taught and teach, and the methods of investigation and treatment we pursue, are more or less prejudiced against us and our work. The whole profession is sometimes attacked as if the majority of its members were ignorant, prejudiced, and not worthy of public confidence. We are, as I have remarked, occasionally placed in a position of great difficulty, and are much perplexed as to the course we ought to take. Regard for the honour of the profession and self-respect may sometimes seem to require a course of action opposed to the real interests of the patient and not quite in accordance with that ■ consideration and kindness which, under all circumstances, has to be extended to all sick and suffering. If, however, we carefully bear in niind the high importance of the credit and honour of all — if we make ■people understand that we have no methods to keep secret, no prerogatives, or mysterious agencies to protect or preserve : that on the contrary we desire that the knowledge we possess should spread, and that all possible means of relief and all methods of preventing disease should be widely diffused ; that we court enquiry into the principles upon which our methods of investigation and treatment are based, and desire that our reasonings thereupon should be examined and criticised ; we shall seldom, I think, experience difficulty in deciding how we ought to act in almost any case that may arise. In short, we must do all for the honour of the profession without ever wounding the feelings or sacrificing the interests of the patient or his friends. Fac rede nil time. It is desirable that we should think over the circumstances which have led many to form an incorrect estimate of medical method and work, in the hope that by so doing we may be able to obtain a verdict more in accordance with our deserts, and thus be enabled to increase our usefulness to the public. Prejudice from time to time not only 28 MISTRUST OF MEDICAL METHODS. operates against us, and diminishes our influence, but prevents the introduction of many reforms which would be of great advantage to the community. Indeed it would be more in accordance with the public interests if the influence of the medical profession were much greater than it is at this time. What is very serious for us is that ignorance of our methods and even prejudice against doctors sometimes exist in high quarters, and too often find expression in remarks unreasonable and undeserved on the part of men holding high and responsible pubhc positions. In many cases I am convinced that observations to our disparagement would never have been uttered if the speaker had made himself acquainted with the actual facts. There is unfortunately great and widely spread ignorance concerning us and our aims and works, and it is most important that better knowledge should prevail. Medical methods are by some regarded with doubt and mistrust, and some of our enquiries into the facts of living beings have been so successfully opposed of late years that they have even been stopped by the passing of prohibitory laws, enforcing heavy fines for disobedience. Investigations- upon the lower animals are now practically forbidden in England, and those who advocate experiments even upon frogs are denounced as- cruel and worthy of severe punishment. But with glaring inconsistency the interests of the frog in its tadpole state are still uncared for. Some aspirant to political renown might, perhaps, soon rise to popularity and win power by eloquent appeals to the people in favour of the- protection of tadpoles, and compel the Commons to pass a short tadpole rights protection bill. For the present we must submit as best we may to the unpleasant- ness of not being a very popular or a very influential body. We are tolerated and by some considered as a sort of necessary evil, and it is no doubt generally admitted we are sometimes useful in relieving pain and suffering, and occasionally, especially in serious cases, we may even be regarded as a comfort. Politically the profession has little power,, and in this respect our interests rank considerably below those of cotton, iron, beer, spirit, and many other industries. Legal and itiedicai Metiioiis. — Legislation has been introduced with reference to the examination and certifying of lunatics, which seems to show how little is thought of our action and judgment^ and which certainly is not considerate to the unfortunate patients. The new laws imply a doubt on the part of those who framed them, whether the majority of practitioners ought to be trusted to place under restraint those persons who according to medical judgment, based upon well ascertained facts, are insane. The reasoning by which the conclusion in favour of the new procedure has been. reached seems to be very curious. It looks as if it had been concluded that honest, intelligent, straightforward medical practitioners were largely NKW LECilSLATIOxV. 29 outnumbered by a class of persons that could not be so characterised, and that therefore it was necessary for authority to act on the supposi- tion that doctors generally are not to be thoroughly trusted to act rightly towards either sane or insane. A shorter and probably more satisfactory way to have protected the general interests of the sane and insane would have been to have enacted that special persons should be appointed by law to decide as to sanity and insanity. Further it seems to have been argued that, upon the whole, if the decision was left as heretofore in the hands of the profession, although the risk of dangerous lunatics being free was slight, the risk of sane persons being treated as lunatics would be serious. The change in question seems to have been suggested after very limited observation, while its adoption could only be justified by the occurrence of very numerous errors of medical judgment, or by the demonstration of the wilful perversion of truth in a considerable number of cases. There ought surely to have been over- whelming evidence of its necessity or desirability before a course so injurious to the reputation of the medical profession was decided upon. Many a lunatic has been sheltered by injudicious friends, and has thus escaped being medically examined. Families have been ruined, individuals ill-treated, disfigured, injured, and even killed, by lunatics at large, simply because persons who knew nothing about the disease con- sidered the patient was not bad enough to render it necessary to restrict his liberty in any way. It is certain that in the gre.at majority of cases mental disease can be detected and treated, to the great advantage of the patient as well as of the community, but it is not reasonable to expect practitioners will take the responsibility of advocating that a patient should be confined, if they may be proceeded against by the alleged lunatic, and perhaps mulcted in damages and expenses so heavy as to ruin them ; in addition to which there will be the loss of professional reputation necessarily caused from the remarks made with respect to possible motive for the treatment. The detection of early signs of mental disease will, I think, be rendered still more difficult under the new system than it was under the old one. No doubt the doctor and the lawyer look upon the question of insanity from very different points of view. The first endeavours to prevent the individual from injuring himself or others, while the lawyer is careful to regard every person as sane, innocent, and free, until it has been positively proved that he has committed a mad or b^id act. In the one case action is intercessory and preventive, in the other detective and punitive. We say •' save and prevent the sick and insane person from acting wrongly." The law says "consider him well and sane until he has committed wrong, when he must be judged and acquitted or convicted and punished or pardoned, or be prevented from doin*^ more wrong without punishment, as the case may be." 30 LECxAL AND MEDICAL VIEWS. It has been discovered that in medical interference for the purpose- of preventing mental disease or relieving it in its early stages there is great danger. The liberty of the subject is threatened and restrained. The law seems to prefer to act on the principle that until the patient has done actual harm to himself or others his liberty should be respected, and he is to be regarded as a sane and free man, and in all respects fully entitled to exercise and enjoy all the rights and liberties of a healthy citizen. In other words the law allows a patient to do, and indeed insists that he shall be permitted to do the very thing we deem- it to be of the highest consequence that he should be prevented from doing. We regard him as already out of health, and not responsible for all he may say and do, and we can give full and sufficient reasons for our opinion. But the law seems to feel certain, and insists that there is nothing whatever the matter with him, that the doctors are mistaken and prejudiced or something worse, and that therefore the patient is to be protected by law from medical interference. But from, whichever side we look, it must surely be admitted that the practical conclusion arrived at and acted upon is very curious, for it involves the proposition that any danger likely to result from lunatics being abroad will be small as compared with the danger to society resulting from the profession having the power to deprive people whom they consider mad of their liberty. And it has, therefore, been decided that though risk of attacks by lunatics may be incurred, it is above all things necessary that means should be taken to prevent the possibility of sane persons being placed in confinement by practitioners who may be stupid, prejudiced, or dishonest. This danger to the sane seems to have been considered so formidable as to render it necessary that a new law should be passed to protect the public. The consent of a magistrate or justice of the peace must be obtained before a patient can be legally placed under restraint. But surely this want of confidence in the judgment or integrity, or both, of medical practitioners in general, thus displayed and proclaimed in a public manner, is calculated to diminish the respect entertained for the members of the profession, while the imputation is unjust. The medical authorities have not even been asked to consider whether it would not have been better that members of the profession should have been relieved of all responsibility than that their advice should be required under restrictions so severe and unsatisfactory as regards the relations between doctor and patient. The courts have their own views as to what constitutes sanity and insanity, and they have the power to carry them into effect. Although they may listen to what we have to say, they often decline to be guided by medical opinion, and may regard an unfortunate, imitative, irrespon- sible creature as a vicious criminal. Why, therefore, should they not act entirely without any reference to us, instead of asking our opinion and LE(;Ar. AND MKDICAL DIKl'^KRENCKS. 3I then throwing it aside in cases in which we find distinct evidence of defective mental power, due perhaps to imperfect development of an organ ? Indeed, many a criminal held responsible in a legal sense is unquestionably irresponsible if the case be considered from the medical side. Who could have supposed that in England in 1S89 it would have been necessary to petition Parliament* not to insist that the sanction of a magistrate shall be required when it is desirable to send a patient at once to an asylum, because if, as suggested, the magistrate or justice was to " visit the alleged lunatic, summon and examine witnesses, administer oaths, and otherwise enquire concerning him," the early treatment of the patient, so very important, must be hindered or postponed ? Perhaps when at last it is commenced, the disease will be more confirmed, and the prospect of improvement much reduced. It is well to record the proposal whether it be acted upon or not. It must have emanated from high legal authority, and from its terms some idea of the view entertained concerning the action of the profession in a very difficult and responsible situation may be formed. In the new Lunacy Acts Amendment Bill the magistrate seems to be empow^ered to sanction or object to the decision arrived at by medical advisers as to sending patients to an asylum, and thus prevent what may be of the utmost consequence, the early treatment of the case. The patient seems to have the right to be taken before or to be visited by a judge, magistrate, or justice, if he has not been seen by one before being admitted to the asylum. In short, it would appear that the physician may be called upon by the patient to justify the course he has pursued or proposes to pursue with regard to him before a legal authority. The magistrate or justice necessarily becomes the patient's friend to protect him against his enemy the doctor. Is not this legis- lation in the wrong direction and based upon wrong principles ? Why should the legal authorities not undertake the whole responsibility and decide for themselves whether a patient is sane or insane, and if insane, how, when, and where he' should be treated ? Unless the proposed new system be modified, the physician is not only altogether subordinate to the representative of the law, but he is superfluous, because the question may be decided from the law side, and medical opinion overruled. But what if the consequence of the reasoning upon which the new system is based becomes apparent in the increase in the number of lunatic depredations, and the irresponsible but sometimes dangerous acts of persons who have for a long time required care, and whose illness has been increasing until it culminates in some terrible crime ; * See "The Humble Petition of the Royal College of Physicians of London," May 25th, 1889. 32 LUNACY ACTS AMENDMENTS. will the legal authority be held responsible for the wrong medical diagnosis, and neglect of the proper treatment ? On the other hand, let us suppose the very worst case that could possibly occur had actually happened — a sane person being wrongly confined by medical authority. Might not this contingency be easily provided against by a law enacting that everyone placed under restraint should within a definite period of time (twenty-four or forty-eight hours) be visited by two or more skilled officials, who should report upon his case, and order his release if they consider it right so to do ? If members of the profession, after a prolonged medical education, are not to be trusted, the best persons to decide upon these sometimes very difficult cases can hardly be magistrates and justices, who may have had no medical training whatever. After being recognized as qualified to practise, it seems curious to allow an official to contest in a court of law action which was suggested by a practitioner as being for the patient's benefit? A Lunacy Department of the State might be established with authority to define the degree of departure from the sane condition which constitutes insanity, to detect and treat all cases ■of lunacy, rich and poor, and to provide for the proper care and manage- ment of all lunatics and persons of weak intellect. While there can be no doubt that in fact and spirit the law is just and even kind towards certain classes of offenders, it seems curiously sensitive and suspicious concerning the acts and motives of medical practitioners. Nothing but the strong general suspicion of wrong-doing very widely spread would justify the new proceedings with reference to the treatment of lunacy, and some other matters in which medical practitioners are necessarily concerned. It is taking from the profes- sion authority to act which had been conferred at a time when its members were as a body less well-informed and less responsible than they are at this time. And is it not almost telling the public in so many words that the authority we have had has not been exercised with discre- tion and care, judgment and disinterestedness, and therefore must be taken away ? There is no doubt that in some other respects our methods and acts are not approved, though this conclusion cannot be justified by an appeal to facts. Many of the cases in question are really medical and not legal at all. There is no better reason for a lawyer deciding as to the nature and treatment of disease of the brain than of heart, lungs, liver, or kidneys. Surely the time has arrived for considering this highly important question for the purpose of ascertaining whether some change cannot advantageously be made with reference to legal and medical advice as to the proper management of persons supposed to be insane. Some will say that we have brought the change upon ourselves by our vague and uncertain statements in the witness-box. Lawyers some- MEDICAL EVIDENCE. 33 times complain that they cannot get us to give " yes " or " no " answers to questions impossible to be answered in this easy way without the sacrifice of fact and truth, and their remarks sometimes tend to discredit us. But they ought to know, and it is certain that many of them do know, that it is not possible to give unqualified statements with reference to many medical and scientific questions. The utmost we can attain to in many instances is probability, approaching in some cases to something near certainty. But this is not enough for law. Law must have certainty — from witnesses. It is surely the legal method, not ours, which is at fault. Much scientific evidence is of the greatest consequence, although it cannot be put in such a way as to please a court without perhaps wide departure from the truth. If then lawyers form a low estimate of us and our work it cannot be helped, and although some members of the legal profession, taking their cue from superior authority, translate the view into their own homely language, by asserting that doctors can be got to swear anything, the imputation, though neither pleasant or deserved, must be borne until the law relating to scientific witnesses, and the practice of cross-examin- ation to which they are subjected, be changed, as ought in justice to have been done long ago. Judges often expect too much from the skilled medical and scientific witness. The legal mind is constantly contemplating clear distinct issues — guilty or not guilty— was the act done or not — yes or no? Did the poison or the wound cause death? The necessity of decision as regards law, one way or the other, is paramount ; a decision, too, which, as regards the particular case, may be finals and held to be based on principles that are fixed and definite, until it is found by better law to be bad law, and is overruled upon another principle in another court. All this arbitrariness and this necessity for positive decision are far removed from the paths of science. The scientific mind scarcely ever attains to absolute certainty, and seldom desires it ; dogmatic enuncia- tions are not compatible with the scientific spirit, and final settlement unknown. Probability, the "maybe," the "might be," " possibility," " tendency of thought," are often the nearest approach to the positively certain that certain departments of science can as yet attain. It is true that the " high degree of probability " does now and then appear to approximate to truth, but as time advances the distance may increase. Some engaged in science feel that the law is often very hard upon them ; they are asked for their opinion, and then to give their reasons, and these reasons are then analysed and dissected by the legal mind, which sometimes attaches its own legal meaning to the words employed, and probably condemns scientific men for daring to ground any conclusions upon the "vague" knowledge they possess, and straightway proceeds to seek out other scientific witnesses whose opinions are adverse to the D 34 VALUE OF SCIENTIFIC EVIDENCE. first, and whose reasons after analysis and dissection may be found to accord better with legaHty, or may possibly be found still less satisfactory in a legal sense than those they were expected to replace. Then comes harmonious condemnation of science from all sides. The judge can discover no legal use or truth in the science advanced, and other members of the profession declare roundly they can always get scientific people to swear as strongly for the defendant's cause as the witnesses their friends have put in the box, have sworn for the plaintiff's. In condemning us, lawyers tacitly admit imperfections in their own methods for deciding upon questions raised, and may seem vexed because a prisoner cannot be proved to be guilty or innocent by scientific evidence only. But medical, like other evidence, is sometimes conclusive, some- times doubtful, sometimes altogether useless. Why not then, in cases in which scientific evidence is of such great importance, refer the question for decision to a court of three or four scientific witnesses upon whom judicial authority had been temporarily conferred, and whose award, as far as the scientific part of the case was concerned, should be final, or at any rate should be allowed to stand until new scientific discoveries have been made? Much scientific evidence, though of the most conclusive character, cannot be made clear to persons who have not been long familiar with the particular branches of scientific enquiry involved, and facts which to us are really quite decisive, may appear to one to whom the details are unknown, as of the most shadowy and inconclusive character. I much doubt whether, for instance, a jury of intelligent and well-educated men, but with a general knowledge only of the physics and chemistry taught when they were students, would be satisfied that the evidence that might be brought before them of the presence of a particular metal in the sun was convincing. If they endeavoured to follow the description of the process of examination, but were not acquainted with the prin- ciples upon which much of the new work rested, they would probably soon feel confused by the numerous details that were described, and it is doubtful whether they would understand the reasoning on the facts ; while, on the other hand, to the trained intellect, acquainted with the facts, the evidence would appear as conclusive as if a portion of the matter of the sun had been actually obtained and handled, and examined by chemical tests in the laboratory. So is it with regard to many facts of medical technical evidence, which in certain cases have to be brought before the courts. In consequence of our not being able to represent the facts so that the same high degree of importance may be assigned to them as they have assumed in our own mind, we are in disgrace and an erroneous estimate is formed of the value of our evidence, our work, and our methods. In some cases, instead of helping the court,, our evidence seems to add to the difficulty of arriving at any decision WANT OF TRUST. 35 whatever. It is not surprising that we are not held in high favour in the legal atmosphere, but at the same time it is certain that the profes- sion does not deserve the treatment it has occasionally received at the hands of some politicians and lawyers, and, as a consequence, from the public. Let any one fairly consider what medical knowledge has done for the world in recent times, and I am sure he will not form a low estimate of the usefulness of medical work and thought. Consider, for instance, the steadily falling death-rate, sometimes under fourteen per thousand, notwithstanding the increased density of population — the rapidly improving general health and vigour of a considerable and increasing percentage of the people — the better management of and the lower death-rate among, young children — the improved laws and continually improving practices relating to the health and management of the sick poor, the inmates of prisons, lunatic asylums, workhouses, hospitals, and other places in which a number of persons are received, the improved dwellings, better clothing, better food and water, and a hundred beneficial changes carried into practice during the last fifty years, mainly in consequence of the repeated advocacy of the profession, and the progressive work, thought, and careful observation of successive generations of medical practitioners. The more our work is understood the better for us. If only people were better trained in scientific and medical knowledge, so that they might be able to judge for themselves on many of the questions in which we are concerned, our position would be far higher than it is at this time. Want of trust in us may have encouraged cruel proceedings against medical practitioners in cases in which they had unquestionably acted in the best interests of the patient and the public. Though in several painful cases the practitioner has been completely exonerated and has been dismissed " without a stain upon his character," he would have been far better off, not merely for financial reasons, if he could have kept clear of law altogether. You cannot then be too careful to avoid being needlessly forced or drawn into any position in which it is at all likely you may have to appear and defend your character or acts in courts. There can indeed be little question that the want of trust in us, as well as the prejudice against the profession, on the part of the public and of lawyers, is kept alive and increased by the extraordinary system for taking scientific medical evidence and the plan of cross-examining scientific witnesses prevalent in the courts. As long as certain medical practitioners are summoned to testify in favour of the particular view adopted by one side, and practitioners of equal eminence summoned by the opposite side to controvert the evidence of the plaintiffs medical friends and explain away the facts and arguments that have been advanced by the other side, so long will there seem to be something worse than uncertainty as regards medical and scientific n 2 36 PREJUDICE AGAINST SCIENCE. statements and inferences, and many persons will come to the con- clusion that the contentions on both sides are equally unsatisfactory- Instead of being credited with the desire of giving technical informa- tion for the assistance of those who have the great responsibility of arriving at a decision on the merits of a complex and difficult case, practitioners by one side or the other are accused of want of candour, a desire for hair-splitting, and entering upon various medico-scientific refinements calculated to confuse ordinary intelligences^ and are some- times even suspected of hiding or misrepresenting the truth. Again, by the wonderful ingenuity of counsel, any difference of opinion as regards the import and bearing of a fact is sometimes accentuated or grievously exaggerated to our detriment. Occasionally every bit of truth gets squeezed out of scientific evidence by the merciless comments in the course of a long and exhaustive adverse cross-examination, sometimes conducted in a manner apparently designed to throw a witness off his guard, or to irritate him in the hope of getting an admission which he would not have made as long as he had command of his temper. The system is not suited to the requirements of modern knowledge, and is as much out of date in the world of to-day as would be battering-rams and bows and arrows. The great importance of the matter to the public and to all of us is my excuse for having troubled you with these somewhat lengthy remarks. Opposition to Scientific Investigation. — But of all the prejudices against medical methods aroused during recent years the most far reaching is that which essays to put a stop to all scientific enquiry and investigation concerning the nature of physiological and pathological phenomena, and the effects of medical treatment by observation and experiment upon the lower animals. The activity of societies opposed to experiment and investigations for ascertaining new facts concerning the actions of living beings not only retards progress in many ways and encourages the feeling already too strong against new work and knowledge, but tends to humiliate scientific workers before the public by classing them amongst people who are vicious as well as ignorant. On every occasion which affords the least excuse for directing public attention to the cruelties supposed to be endured by the lower animals at the hands of physiologists, the most garbled and grossly exaggerated statements have been made about the torture inflicted. At a meeting held at the Mansion House in support of the Pasteur Institute in June, 1889, the Lord Mayor explained the manner in which a petition against vivisection had been got up and signed. The case is a good illustration of the way in which " evidence " may be obtained to influence those who legislate and the public generally, and how easily and cheaply a very few energetic but prejudiced persons may succeed in making themselves famous and move the opinion of numbers in favour ANTI-VI\'ISECTION I'KTITION. IJ of perfectly needless and very arbitrary legislation opposed to the principles by which legislators in this country have hitherto been guided : — The Lord Mayor, in his opening speech, said : — " That since he had consented to the holding of that meeting in the Egyptian Hall, he had been deluged with a very great amount of literature. A large number of the letters he had received were anonymous, and a very large proportion of them scurrilous. When he entered upon the movement he was prepared for a considerable amount of opposition ; but he felt that it was one that so affected his fellow-countrymen that he would have been altogether unworthy of his position had he neglected to take it up because of unreasoning opposition to it. A prominent and active part against the movement had been taken by what was called the London Anti-Vivisection Society. From them he had received a petition, bearing only 2,100 names, although it was 27 yards long, and had evidently been circulated all over England. Those who got it up were evidently well up in the petition dodge, if he might use that phrase, as a few important names had been cut out of their places in the respective districts and had been pasted together on the top. Two-thirds of those who signed the petition were women. He would go further, and say that three-fourths were women and children. In numerous instances the lady of the household, after signing her own name, had induced her domestic servant to sign it also. In one instance the petition had, he thought, been signed by a number of boys and girls in a mixed school. The writing indicated the greatest possible ignorance ; spelling was clearly not a strong point with the signatories, some of whom were too modest to begin their signature with a capital letter. Others had thought well to place on record the prefix of Mr., Mrs., or Miss. Over and over again there was more than one signature in the same handwriting. One gentleman, a crab and lobster seller, who boiled his victims alive, petitioned as an anti-vivisectionist."— " Daily News." The object of this meeting was simply to help to save life in the case of persons who were likely to suffer from one of the most subtle and terrible diseases known, and to encourage efforts to carry out a method by which the ravages of hydrophobia have been checked and reduced ; never was a new process more unfairly criticised or more foolishly opposed, and indeed with an intensity of feeling quite inexplicable, as this discovery by Pasteur of a means of saving the life of the patient although the virulent poison may be already growing and multiplying in his blood and may be about to make itself evident — and within a short time — by disastrous and fatal effects on his fluids and tissues. Deaths among those bitten but protected by Pasteur's treatment numbered I "5 per cent., and among those not protected, 15 per cent. It was clear that whether the evidence advanced was uncertain or conclusive, poor or weak, every reason existed for encouraging instead 38 POLITICAL OPPOSITION TO SCIENCE. of opposing further observation and experiment. The question at issue is not political, and, therefore, ought not to be treated by political process. Petitions to Parliament are not the means to take either to forward or to prevent scientific inquiry. It is not right that petitions should be got up to prejudice public opinion against scientific men, and those who advocate them and present them are not doing their best for progress, or for their country. It would be far better for us to forego all advan- tage .of grants and pohtical countenance and support, than to incur the risk of public opposition on political lines. It is, indeed, hard that non-political scientific thought and work should be exposed to attack for political purposes from a purely political standpoint. Art, literature, and science are far removed from politics, and, by common consent, ought, like religion, to be thoroughly protected from every kind of political attack. If some people can only get a few friends to sign a petition for or against some act, views, or opinions of members of some profession or calling, and move public attention to the undiscovered rights or the unrighted wrongs, they and their party soon gain power, attention, and notoriety, and if the cards are played with tact, it may be, at any rate for a short time, considerable political power. In this country, the freedom of which we are so proud seeuis to include the freedom of the ignorant, prejudiced, and opponents of progress by political manoeuvres to acquire power to oppress and hamper those engaged in discovering new facts, and thus to check the spread of new knowledge. Sensible persons will feel grateful to the Lord Mayor for putting in their true light the facts of the case. Too frequently have scientific men who cannot defend themselves been unjusdy condemned by irre- sponsible persons, who, no doubt, at least in many cases, quite uninten- tionally, have been encouraging unfair attacks, and spreading un- deserved reports to their detriment and injury. The following extract from a letter of Professor Huxley's to the Lord Mayor puts the question at issue very plainly, though perhaps not quite judicially : — " Oppo- •sition to the proposals which your lordship sanctions would be equally inconceivable if it arose out of nothing but the facts of the case thus presented. But the opposition which, as I see from the English papers, is threatened has really for the most part nothing on earth to do either with M. Pasteur's merits or with the efficacy of his method of treating hydrophobia. It proceeds partly from the fanatics of laissez faire, who think it better to rot and die than be kept whole and lively by State interference (!) : partly from the blind opponents of properly conducted physiological experimentation, who prefer that men should suffer rather than rabbits or dogs, and partly from those who, for other but not less powerful motives, hate everything which contributes to prove the value of strictly scientific methods of inquiry in all those questions which affect the welfare of society. I sincerely trust that the good sense of OPPOSITION TO RESEARCH. 39 the meeting over which your lordship will preside will preserve it from being influenced by these unworthy antagonisms; and that the just and benevolent enterprise you have undertaken may have a happy issue." Anti-curativc i.eKiMiation. — In the management of one class of diseases anti-curative legislation has been carried in direct opposition to the very first principles of medicine. It is obvious that the true interests of society render it desirable that all diseases should be sought out, detected, and submitted to treatment as soon as possible. To relieve suffering and to cure disease that is curable are the aim of the medical profession ; but, from the legislation in force, it seems to have been held that the evil of a very serious disease spreading far and wide was considerably less than the evil of subjecting it to treatment, and that the objections to discovering cases and curing them are even greater than the objection of allowing them to spread. It is well known, and there is actual and positive proof, that the class of diseases referred to is one of the most serious and far reaching known. Its prevalence is associated with dreadful misery, shortened life, and incapacity for work, while its baneful action and the consequences of its ravages may be transmitted to descendants in succeeding generations. Laws have been framed and passed in spite of the strongest reasons urged against them by professional men who were thoroughly acquainted with the whole subject. I venture to think that the course taken in this and some other instances by legislators in the teeth of the strongest evidence could not possibly have been carried if legislation had been independent of political exigencies. It certainly is most remarkable that in these days a dozen or more people with little or no knowledge of the subject they support or protest against, but eminently skilled in the arts of the advocate, constituting themselves into a society or association or institution or league, should quickly acquire political influence, and by agitation, succeed in forcing legislation opposed to the experience, knowledge, and judgment of a profession destitute of political power, but numbering twenty thousand or more, and many of whose members are well known to the legislators. Even the broad lines upon which the profession has acted in all countries for centuries are assailed and called in question by persons who appear to have considered the questions so superficially that they are not aware of the grave objections to their injudicious proposals which as it were lie on the very surface. But it is not only on account of the paramount importance of political necessity that our practice and principles are set at naught. The very first duty of every one connected with tl:e management of the healthy and sick is to prolong life to the utmost, ar.d this duty is to be carried out without any qualification under any circumstances. Of course we are to relieve the pain and 40 PREJUDICES AGAINST KNOWLEDGE. suffering, but under no circumstances can the principle of prolonging life to the last moment be called in question. Nevertheless, from time to time, cleverly written articles appear, in which it is not obscurely hinted that we are wrong in prolonging life if we prolong suffering and pain and misery. Also it is held by some to be unreasonable as well as cruel to save very weak children. In doing so it is affirmed that we are acting against the highest interests of the community, and are actively contributing to impair the vigour of the race. Nay, some very confident but irrational persons, ill-informed on important facts, suggest that if the weak among us were destroyed at a very early period of life the coming race would be greatly benefited. In the near future we may expect to see advocated an association for the relief and release of the suffering and aged, and for the removal of organisms not fitted to survive in the struggle for existence. New lights are emerging from the philosophical fog, who will without unnecessary delay proceed to carry into practice the new ideas, culminating in that wonderful modern discovery that "the weakest go to the wall." The new advocates of the revival of this most ancient and supposed philosophical necessity show us how every one who goes to the wall must be weaker than those who do not reach that destination, and further that the proof of being the weakest is the fact of proceeding to the wall. But, alas ! in the first place, as is very well known, very weak children, animals, and plants not only often survive, but become strong and active as growth pro- ceeds. Some live to be old, and some of those who ought clearly to have died in very early youth reach extreme old age. In the case of weakly children, many of the diseases which cause further deterioration may themselves be prevented and average health acquired. Many a contagious malady fatal to some among the best and wisest of our fore- fathers is now extinct, and not a few of those which are now sometimes very fatal will be unknown to our descendants. There can be no doubt that, if scientific men are permitted quietly to pursue their investigations without efforts being constantly made to incense the public against them, many new discoveries will be made which will result in the estab- lishment of means to combat disease, and to prevent the deleterious action of many of the most potent of contagious poisons. No one ought to side against us, or to sign petitions against suggested scientific enquiry, until he has mastered the precise object and the details, and has convinced himself that the investigation is calculated to result in more harm than good. Surely in the particular matter of Pasteur's researches the lives, positions, and characters of the supporters of the investigation ought to be more than sirfificient to convince any reasoning being that the inquiries were called for and ought to be continued and encouraged. Nor is it only that many of the diseases of man have been eradicated, or their dangerous influences mitigated or prevented by OPPOSITION TO VACCINATION. 4' scientific investigation and careful study and observation. It seems probable that by timely interference and by judicious expenditure many very serious and fatal diseases from which cattle and many domestic animals suffer may be got rid of, and thus the loss of millions of money prevented. x\s regards these and other medical and scientific ciues- tions equally important, all that is required to gain further advantages in the future is public trust and confidence in scientific investigation, and the protection of those engnged in the work from being picketed, boycotted, misrepresented, and otherwise ill-used by anti-scientific and anti-progressive opponents, ambitious of notoriety or of political power and distinction, and careless at whose expense their object is gained. But further there is evidence that by preventing the spread of contagious disease in the case of some of the lower animals we are also protecting ourselves from being attacked by many serious conditions — it being probable, indeed in some instances certain, that the same poison acts deleteriously on animals as well as on man, while some of the contagious germs which have such disastrous actions upon man seem to be generated in one or more of the lower animals. UiipoKitioii to Vaociiiation. — It is wonderful how very slowly the most certain and unassailable medical facts are accepted, appreciated, and practically acted upon in any way approaching the degree of their importance. Some, after having been proved over and over again and in different ways to be based upon true principles, are assailed, con- demned, and neglected, year after year, possibly because some of our legislators appear to have been led to consider that the choice lay between disease and revolution. Parents are allowed to disobey the law and risk the lives of their children, or their injury and disfigurement for life, on the absurd plea that they are opposed to vaccination. Thus is preserved and spread among us a loathsome but preventable disease of the most serious character. It is in medical and scientific matters only that people are allowed and encouraged to act against the laws passed for the benefit of all, and to form and act upon their own opinions, apparently not because they have studied the matter, but because they enjoy some political influence. Concurrence in their opposition to vaccination may gain a few votes for a candidate for Parliament. It is scarcely credible that an enlightened community should permit the persistence and spread of a disease so easily preventable as small pox. Only think of the absurdity of having to provide at enormous expense accommodation for thousands of cases of small pox, not one of which need occur. Year after year people are permitted and even encouraged to break the law and are fined for the privilege of allowing their children to be in a condition favourable for con- tracting small pox, rather than have them vaccinated, and thus rendered 42 VACCINATION AND SMALL POX. incapable of taking the disease. Every few years it seems to be neces- sary to appoint a commission of distinguished persons to institute an official enquiry into the efficacy of vaccination, simply because a certain number of well-known people for one reason or another announce that they have made up their minds to oppose this very unobjectionable operation, which ought to be universally performed ; notwithstanding that it is practically certain that unvaccinated persons if exposed to the contagion will sooner or later take small pox, while vaccinated persons escape, even if they are surrounded by the poison germs. Some very odd thinkers attribute our improved condition as regards the prevalence and severity of small pox in recent years not to vaccina- tion but to the improved health of the people. That the population is more healthy and better able to resist the damaging effect of many febrile diseases is certainly true, and the advantage in this respect which we enjoy is unquestionably, in some degree, the result of improved food, clothing, and hygiene. But I am not aware of any facts which indicate that the contagion of small pox is more than perhaps in a slight degree less virulent or less certain in its effects than it was twenty or fifty or a hundred years ago. Nor do I believe that immunity from the assaults of this disease can be obtained by the most perfect sanitation, by the best food, or by the introduction of any chemically active substance or medicine into the body. Indeed, so far as I am able to judge, no such contention is to be justified, and for anyone having authority to publicly represent such a view as if it were to be trusted and practically acted upon, is really cruel and wrong, because it necessarily leads people to conclude that vaccination is a needless precaution to take. If vaccination were abandoned at this time we should certainly lose in a few years hundreds and thousands of the population from an easily and certainly preventable disease. The contagium of small pox is one of the most virulent and certain in its action of all contagious poisons, and it is very doubtful whether, even with the greatest care that could be taken, the isolation of those suffering could be carried out so eff'ectually as to certainly prevent the escape of some of the poison particles, and their reception by persons in a state favourable for attack, living in the neighbourhood of the sick. Small pox and cattle-plague are among the most terribly contagious of all contagious diseases, and these contagia are among the most certain to produce their effects. As regards cattle-plague, probably not one animal in a thousand would be found to be proof against this most powerful contagious virus. That some individuals among men and animals are more prone to take contagious diseases is certain, just as some are more likely than others to suffer from the febrile state, but resisting power seldom approaches completeness in the case of small pox and cattle-plague. DR. CKEIGHTON'S ARTICLE. 43 It is idle to argue that because some contagious diseases have disappeared, or their intensity has been reduced, the same is happening or will happen as regards small pox. There is no evidence whatever in favour of such a conclusion. Small pox seems to belong to a category quite distinct from that which would include most of the contagious fevers. Some have died out, some are dying out, but small pox is as certain and almost as virulent as ever. No person properly protected by vaccination takes the disease, but almost every person who has never had it, or has never been vaccinated, suffers if he be well exposed to the influence of the poison. I consider, therefore, the statement that "better hygiene of the person, better ventilation, and more spacious residential quarters " have in any way lessened the liability to take small pox quite unjustifiable, and think that Dr. Creighton ought to withdraw this and many other intimations in the same direction, in his article. A medical society, or a small committee of medical men, seems to be the body in which in the first instance minute details connected with the question should have been discussed if it was thought needful to reconsider it at this time. It seems scarcely fair to say anything in a work of general information which may have the effect of making people doubt the advantage of vaccination as long as it remains likely that persons not vaccinated will take small pox, and if over middle age will almost certainly die if they are attacked. Within the last few years I have seen some of the very worst cases of small pox that have ever come under my observation. Unvaccinated adults were the victims, and death took place. Again, some contend, and there is much truth in the contention, that at least in the young at certain times and in certain conditions of health there is an undue susceptibility, varying in intensity in different individuals, to the influence of different forms of contagion, and that whether a child contracts any particular form depends simply upon the particular disease that may be prevalent at the time. If protected from all disease germs the individual would, of course, retain his good health, but if exposed to the contagium of measles, or whooping cough, or scarlatina, or other contagious fever, such an individual would be attacked, while possibly many exposed to the same poison would escape, and the patient himself at another time would have escaped though fully exposed to the contagium. But the chance of a child escaping any of the above contagious fevers, though surrounded by the poison, is, I conceive, greater than the chance of his escaping small pox, no matter what might be the state of his general health at the time ; or, in other words, the probability of the spread of small pox among unprotected children is enormously greater than that of any other febrile disease. It is curious how easily some of our greatest law makers and most knowing politicians, even very old Parliamentary hands, are led to make 44 JOHN BRIGHT ON VACCINATION. injudicious if not entirely unjustifiable observations on medical ques- tions. Both Mr. Gladstone and Mr. Bright have shown more political ingenuity than knowledge and candour in dealing with this particular question. Neither has affirmed or denied the efficacy of vaccination, but for some reason both have been most careful to avoid offending the susceptibility of voters having anti-vaccination proclivities. In 1883 Mr. Bright said: — "The facts appear to me to be in favour of vaccination, but that it often (!) fails of any good effect, and sometimes causes much evil, and even death (!), is admitted even by its warmest supporters." Mr. Bright thought that persuasion and example " would have been more effective than compulsion." The penalties and imprisonment of parents " for refusing to subject their children to an operation which is not un- frequently i?iJiirious and sometimes fatal (!), seems to me a needless and monstrous violation of the freedom of our homes and of the rights of parents." In one part of the speech it is said that vaccination causes even death, in another that it is sometimes fatal, and therefore to fine and imprison parents who object to their children running such a risk becomes a monstrous violation of the freedom of their homes and their rights. Mr. Gladstone, if I remember rightly, some time since suggested to some of the opponents of vaccination that he could conceive circum- stances which might render it not undesirable to inquire further con- cerning the advantage of subjecting all persons under all conditions to the operation of vaccination. But, as I have before remarked, this is one of the many scientific and practical questions, the truth concerning which will not be discovered and disclosed by political methods. In the near future we may expect that representatives will be required by constituencies who will engage to vote for the protection and spread of small pox and other contagious diseases — representatives who will vote for the suppression of scientific investigation and for the encourage- ment of human suffering — representatives who will engage to encourage the protection of all forms of disease germs and further the preservation of bad health — representatives who will agitate in the interests of typhoid and cholera and other maladies of advantage in reducing our numbers. On occasions, well organised bodies of representatives might unite and combine to support resolutions proposed in the interests of class sections, possibly for the general disintegration of empire, for the spread of nihilistic philosophy, for the change of laws, and for a new interpretation of the rights of capital and labour, or for the annihilation of modern civilization. J'rom time to time some over-zealous members of the profession are anxious that the public should not only know the exact truth as regards the advantages of vaccination, but should also be well-informed as to any objections real or supposed against the operation. Every pariicular instance in which, owing to some very exceptional circumstance, the AXTI-VACCINATION. 45 operation was not successful, or which perhaps from some unfortunate and purely accidental circumstance was followed by serious illness, is to be recorded in detail, although such untoward cases are very rarely met with — so rarely that the fact of their occurrence no more justifies the condemnation of vaccination than the very rare fatality caused by an anesthetic can be held to demand the abandonment of that invaluable means of relief from suffering. The objections to vaccination, having been enormously exaggerated and repeated over and over again by opponents, have acquired a purely artificial and very unjustifiable notoriety. Thus may hundreds or thousands of persons have received a very wrong impression about the efficacy of vaccination and its dangers, and have been led to join the ranks of the opponents before they had informed themselves of the truth or real importance of the objections. One of the most recent exponents of the supposed facts and argu- ments against vaccination, and one who I venture to think will not soon have a successor, is Dr. Charles Creighton, the writer of the article " Vaccination " in the new edition of the "Encyclopedia Britannica." In this large work there are very few articles which it can be said have been written in the very critical spirit here apparent, and I can- not but think that if subjects generally had been treated according to Dr. Creighton's method, the usefulness of the work as a repository of the knowledge of our time would not be considerable. Dr. Creighton has remarked that " the profession as a whole has been com- mitted before now to erroneous doctrines and injurious practices, which have been upheld by its solid authority for generations (!). Le Sage's satire upon bloodletting, in Gil Bias, which appeared in 1715, ought of itself to have made that practice ludicrous in the eyes of the world ; but bloodletting survived a hundred years after that in all countries." It would be difficult I think to find a more unfair comparison. There is not the faintest analogy between the proofs of the %'alue of bloodletting and the proofs of the value of vaccination. The evidence in favour of the one belongs to a category very different from that in which evidence in favour of the other would be placed. A patient might live or die after bloodletting, and it might be impossible to decide how far the loss of the blood in that particular instance caused or affected the result ; and many cases might be very carefully studied one after the other by acute and accurate observers without a definite decision either in favour of or against bloodletting in certain morbid conditions being arrived at. But the evidence in favour of vaccination is conclusive — absolutely conclu- sive. Let the vaccinated child be exposed to the contagion of small pox and he will not take the disease, but where is to be found the man who would allow his unvaccinated self or child to be exposed to the same contagion ? Dr. Creighton must be well aware that bleeding is 46 DR. creighton's views. still of great use in a few cases, and that if the subject were discussed among us many facts and arguments would be adduced in favour of removing blood in certain conditions. There is, then, no analogy between the " opinion," past or present, as regards the efficacy of bleeding and that of vaccination. And if, as Dr. Creighton seems to think, it must be admitted that bleeding as a form of treatment has been utterly abandoned, what could be more unjustifiable than to insinuate that in the near future vaccination, like bloodletting, will also be aban- doned ? Dr. Creighton has to prove by experiment, either that unvac- cinated persons exposed to the contagion of small pox will be in little or no danger of contracting the disease, or that our country is and will be everywhere and at all times so free from the virus of small pox that it is not worth our while to protect ourselves against the possibility of suffering from the consequences of the entrance of the poison in our unprotected bodies. A reader of the " Encyclopaedia Britannica " expects to find in such a work a fair and accurate account of the views generally enter- tained at the time ; and (in doubtful questions), a summary of the facts and arguments on both sides. But this article " Vaccination " and one or two other articles seem to be written for the purpose of presenting what it is not unfair to call a party academic view, a course surely out of harmony with the general aim and spirit of the work. The admission of an article which is in any degree calculated to make people doubt the need of vaccination, or to prejudice them in the slightest degree against it, is so serious a responsibility that I venture to think some step ought to be taken to show the public that the article in question does not accurately represent the conclusions arrived at from a careful consideration of facts derived from scientific investigation, or from a course of enquiry or observation extending over a few weeks in any small pox hospital, or of the opinions of those who have been long engaged in the management of small pox hospitals and the treatment of the sick ; while as regards the practice it is desirable to adopt, in order to protect the rising generation from the chances of suffering from small pox, Dr. Creighton's article, as far as I can under- stand it, is thoroughly opposed to the views long held and acted upon by the whole profession here and abroad. I am sure that almost every member of the profession and many who are not doctors will cordially agree with Mr. Preston Thomas's obser- vations on the vaccination question ("The National Review" for June, 1889), and it is to be hoped that his criticisms on Dr. Creighton's memoir will be as widely read as the memoir itself. It is painful to think that a practice so unquestionably advantageous to the community, and which has been tested on the largest scale and in many countries, should be called in question to the certain injury and perhaps death of GERMAN VACCINATION LAW. 47 not a few, and to the danger of all. As long as there remains the slightest chance of the occurrence of a case of small pox, every infant born in this empire ought to be vaccinated, and every child ought to be re-vaccinated before he attains the age of twelve. The conclusions on this question arrived at in Germany after careful enquiry in 1S84, and adopted by the Reichstag, were : — that an attack of small pox conferred immunity against subsequent attacks, that vacci- nation was similarly protective, but if performed in infancy it must be repeated at puberty ; and that since the introduction of vaccination no increase of any particular disease or of the general mortality had occurred which could be regarded as a consequence of vaccination. Mr. Preston Thomas concludes his article from which the above remarks have been taken, with the following valuable summary : — " The Germans now actually enforce rc-vaccination as well as prh/iary vacci- nation by law, and it remains to be seen whether by this measure they will not eventually extinguish small pox throughout the Empire. This example, set by one of the wisest nations of the world, is one that England might very well follow. There is no more violation of the sacred rights of man in compelling a parent to secure the re-vaccination of his child of twelve years than in requiring the vaccination of an infant of three months. Probably, however, another epidemic of small pox will be necessary to secure this extension of the vaccination law. Meantime we have to confront an agitation, much stimulated by Dr. Creighton's article, for the absolute repeal of compulsory vaccina- tion. It is the poor who would be affected by such a change, since the educated classes are noiu both vaccinated and re-vaccinated, and ivould doubtless be so whether compulsion existed or not. To repeal the vaccina- tion Acts would, if the experience of the past is to be trusted, involve the future sacrifice of thousands of lives, ana a terrible responsibility attaches to any politician who dares to advocate a step which will have this result." The italics in the above extract are mine. ("Vaccination and the ' Encyclopaedia Britannica,' " by H. Preston Thomas, " National Review" for June, 1SS9.) We are told that there are now some thousands of unvaccinated children in Leicester alone. It is very difficult to believe that the number of parents who have refused to allow their children to be protected against an attack of small pox in the future, perhaps when they may be over forty years of age, in which case the chances of recovery will be very small, have been impelled to take this course after full investigation of the pros and cons. Have they yielded to that irresistible pleasure derived from the contemplation of bravely defending the freedom of the home, and the rights of parents so dear to English- men, and acting in opposition to laws which they have been told are unjust ? In all legislation affecting ever so indirectly what has been 48 SEMI-CONFIDENCE IN MEDICINE. called the liberty of the subject, it is necessary to form a careful estimate of the relative advantage of slowly spreading persuasion, and teaching, — and legislation certain to excite opposition and to arouse the instinct of defiance still strong, and apparently very deeply rooted in many of the worthy descendants of the free lances and independent freebooters of earlier if not happier times. The time may come when vaccination shall be superfluous, but it is not yet ; nor can anyone in reason look so far forward into the future as to point to a period when small pox shall for so long a time have been extinct that no longer can any fear be entertained of its recur- rence and spread among an unprotected people. Doubt Concerning Medical Work and Judgment. — The unreason- able doubt as regards medical and scientific methods is not unfrequently associated with what has been called a general impression that the doubts and difficulties connected with medical investigation are so con- siderable, while the changes in medical views are unquestionably so frequent, that Uttle reliance is to be placed on the medico-scientific doctrines of the time, however strongly they may be supported by what some consider proof. Nevertheless, it may be said that we are at least as much crusted as any other body of men in these times. Such an admission does not however go very far, seeing that to be of real service to people, to reduce the anxiety suffered by friends in cases of severe illness, and to get patients as quickly as possible restored to health we require the full confidence not only of the patient but of those about him. But such implicit trust must clearly be of slow growth and can only be enjoyed in cases in which doctor and patient, and the friends of the patient have been acquainted for years. In many instances it is to be feared the confidence bestowed is not complete and is so easily shaken that often the persuasion of a perfect stranger will result in a change of front, and before long, doctrines, principles, and views, the very opposite of those that only recently prevailed, will engage the attention and perhaps be acted upon. Mfe Insurance.^ — Among the confidential duties which nearly all of us are called upon to undertake is the medical examination of candidates for life insurance, and candidates for certain offices and for various posts for the proper discharge of the duties of which good health is necessary. It is of advantage to know and be known by some of the staff of the office or department in the interests of which you are asked to advise. Unfortunately in this as well as in some other cases a sort of semi- confidence gradually shading into doubt sometimes takes the place of that confidence in our powers of investigation and judgment which we hope to enjoy, and in the absence of which it may be hard to act to the best advantage. Insufficient confidence in medical judgment is sometimes indicated WANT OF CONFinENCE IN US, 49 by the great number and very detailed and searching character of the questions you are requested to answer, as well as by the somewhat abrupt and almost dictatorial style in which some of them are framed. You are not only asked for your opinion but you are in a way cross- questioned and cross-examined as if those who addressed you doubted whether you had the will to afford the information required or the knowledge which would enable you to obtain it, or to form a correct estimate of the bearing and importance of the facts recorded. Some- times the questions would almost suggest that he who was requested to answer them was almost suspected of a desire to keep something back that ought to be told, or was likely to slightly misrepresent the truth. It is not very uncommon to be asked by a confiding patient or friend for one's really candid opinion, and to be assured that the answer given shall be kept a profound secret, implying that there are doctors who do not give their candid opinion, who do not say what they know, and are therefore not to be thoroughly trusted. But a very curious and rather Unpleasant example of want of con- fidence is shown by the questions asked in some of the forms we have to fill up concerning a person's health, powers of work, and probable length of life, — and many of the questions are put in such a way as to imply doubt as to the degree of confidence to be reposed in the answers. The detailed examination we are expected to make is really quite extraordinary. Sometimes we are asked to describe the condition of the cavities of the body and of the viscera contained in them and their functions — alone a sufficiently comprehensive and extensive demand. But this is only one out of perhaps twenty complex questions, some of which are to the point, while some are almost irrelevant. To adequately reply to many of these questions would take a very long time without in the least degree aiding anyone to arrive at a correct judgment concerning the particular case. By some offices the medical examiner, instead of being regarded as a responsible adviser concerning the value of the life he has seen and examined, seems to be looked upon as a sort of clinical reporter or clerk who cannot be trusted to make the needful examination, or to draw conclusiona from the facts he has observed. Some other aspects of this matter appear in the course of a summing up of a case before the Lord Chief Justice, and the observations of his lordship will be read with interest : " Anything more full of pitfalls for the unwary than these two documents he could not imagine. It was perfectly true that the answers were to be made by the assured. It was true also that the terms of the contract were printed, that persons should read them, and that they must be held to the letter of them. But the company was dealing with a class of persons, sensible, perhaps, but uninstructed and unlearned persons who were not accustomed to examining with critical eyes the contents of legal documents ; and one E 50 LIFE INSURANCE QUESTIONS. could not help seeing that these two documents were full of pitfalls. Now the application form was made a part of the contract, a part of the bargain between the assured and the company. The medical officer was made the agent of the assured, and, by the terms of the contract, if any statement in the certificate of the medical examination was wrong, the policy was forfeited. One of the questions asked was, ' Has the applicant ever had severe headache, or any nervous or muscular trouble ? ' Why, good heavens, was there anybody who in his life had not had some nervous or muscular trouble ? In the case of the form before his lordship, the agent had answered ' No ' to this question, so that if at the age of fifteen or twenty the assured had overworked himself and become nervous for a few weeks, so that the doctor had advised a holiday, the policy failed. Another question was, ' Has the applicant ever been, or is he now, predisposed to cough, difficulty of breathing, expectoration, or palpitation ? ' How in the name of sense was a man to know if he was predisposed to cough ? There were other questions of a similar character, and yet it was a condition of the policy that if any of the answers to these enquiries were not true, full, and complete, the policy was gone. The medical officer, as his lordship had already said, was made, by the terms of the contract, the agent of the assured for answering medical questions, and if any statement was wrong, the policy was vitiated. They were things for the doctor himself to ascer- tain. But even if he (the Chief Justice) was wrong about the doctor being the assured's agent for such questions, there was the statement the applicant himself had to make. One of the questions the appHcant had to answer was, ' Age and cause of death of father's mother and father ; age and cause of death of mother's mother and father ? ' Here also if any mistake was made in the answers given the policy was void ; so that if the applicant made a statement which was untrue about the age or cause of death of his mother's father, there was an end of the contract. Another question was, ' Do you suffer from, or have you ever had, bronchitis ' — which he once heard Lord Campbell describe as a bad cold — ' colic ' — which they used to call stomach-ache — ' or any form of trouble referable to the lungs, difficulty in swallowing, or any symptoms indicating disease of the heart or neighbouring vessels, disease of the stomach or bowels, disease of the kidneys, or dyspepsia, excessive or scanty secretion of urine ? ' The secretion of urine, for instance, must be neither excessive nor scanty but exactly right, and if the applicant made any mistake as to what was exactly right, the policy was void. Then, again, the applicant was asked, ' Have you ever had any illness, disease, or injury within the last five years ? ' How was a man to be sure what an insurance company meant by illness or injury? Yet strict accuracy in the replies to all these questions, and many more of a like character, was made a condition of the contract. Some of the QUESTIONS AS TO LIFE INSURANCE. 5 1 questions were, no doubt, very right and proper, but the incjuiries seemed to embrace every kind of slight or temporary trouble that the human frame was subject to; and if there was the least slip in answering the questions, either by the assured person himself, or by the medical man, the policy could be repudiated. It was perfectly true to say that all these questions and conditions were printed, that a bargain was a bargain, and that those who signed the form must be bound by its terms. It was quite true that persons did this with their eyes open, and that no one in his senses would enter into such a contract as that in use by the plaintiffs." — From "The Review," November 6th, 1889. The questions in some of the official documents can hardly have emanated from a medical mind, or be published with medical concurrence. They seem to have been framed rather by those who had more con- fidence in numerical than in medical and scientific methods. Some even consider our medical examination superfluous. Nevertheless our statistical friends, for the time, yield to popular prejudice, and allow the medical reports still to have some little weight in their decisions. The occasional detection by the physician of facts proving serious disease of heart, lungs, kidneys, liver, or other organ, which could only be dis- covered by careful medical examination, and may perhaps render the life uninsurable, does not happen in a sufficient number of cases to disturb the calculated results when large numbers are dealt with, though careful medical examination in individual cases may be the means of saving a heavy loss. On the other hand, it may be said, and, perhaps, with some degree of truth, that the care exercised in the medical selection may easily be carried too far, and thus lead to the rejection or loading of lives which might have been assured at or near the ordinary premium to yield profit. It is really doubtful whether there is now the same need for detailed questions as existed formerly. It should be borne in mind that sound medical knowledge is more widely diffused, and the average practitioner far better informed. Not only the medical, but the general, education of the members of the medical profession is far better than it was when many of the forms issued for our guidance were compiled by the offices. The great majority of middle-aged practitioners, even in outlying districts, are now well qualified to examine lives for assurance, and their care and judgment are to be relied upon. It must not, however, be supposed that objection is made to the plan of printed questions and written replies. Indeed it is quite right to ask us to give any information we may be able to gain even on points which may not be medical, but which, nevertheless, may be of office or actuarial interest and importance. It is, however, obvious that questions may be so needlessly multiplied and so detailed and minute as to absorb the whole attention of the physician ; and very E 2 D^ MEDICAL LIFE INSURANCE REPORTS. considerable time may be required for completing the answers to the series required. In this way there will be risk of the medical mind being diverted from the consideration of broad facts, and important, medical enquiries of grave consequence may be omitted. It is even possible that the real object of the medical enquiry may in this manner be overlooked, and the report be of considerably less value than it would have been if the whole time and attention of the examiner had been concentrated upon the purely medical aspect of the case. How far the examiner is expected to exercise his judgment and advise the directors, how far he is expected merely to act as a reporter to furnish facts upon which their judgment is to be based, has not been deter- mined, and perhaps cannot be determined with perfect accuracy, and probably different views are entertained on these matters in different ofifices. Whether it is to the advantage of the office to place implicit trust in the medical examiner's recommendation, or only to be guided by it in a moderate degree, is a question which will be differently answered in different cases ; but it is certain that the reporter cannot be too careful in trying to express as clearly as possible the facts he is able to ascertain which in any degree distinguish the life he is examining from an average one of the same age, and particularly as respects tlie habits of the proposer and their probable effects upon his organism at a later period of his life. Some of the commands given to us are very curious and almost humiliating in the details and explanations deemed necessary for our guidance. Peremptory directions are given as to the precise way in which we are to put the questions to a proposer. We are enjoined to give full and "unambiguous" answers to certain questions, the qualifi- cation almost suggesting the suspicion that ambiguous answers are fre- quently given. Then, although we may be asked to form an opinion sometimes, we are not allowed the freedom of expressing it in our own words. Our views are to be stated according to the terms laid down, which may include many things of comparatively little consequence and may compass the omission of matters of importance which would certainly have been represented if we had been allowed to express our views in our own way. Many certificates which we have to give include some things which, from the medical standpoint, will hardly be con- sidered of much use, while certain facts of some consequence may not have a place. If we consult an authority about a piece of land, or a house, or the points of an animal, we request him to give us his opinion, or we ask him to send us a " report," and generally take his advice without any- thing approaching an enquiry into the several facts upon which his advice is based. We conclude that he has carefully enquired into the details necessary for arriving at a correct conclusion, and trust to his honour. MEDICAL EXAMINATION. 53 But, in forming an estimate of a person's health and the probable duration of his life, we may be asked for written answers to a number of questions which might be answered by the person liimself, by a friend, or by a clerk. So minute are some of the instructions given to us that we are told to emphasize the questions and to pmise after each answer ! The authority framing the questions appears to have been strongly imbued with the idea that unless duly instructed, and warned to be very careful and particular, the practitioner would perhaps scamp the examination, although he had undertaken to conduct it to the best of his power, and it has been deemed necessary to tell us that we are to give the applicant plenty of time for considering his answers to our questions, — and so forth, as if we were students about to enter on the duties of clinical clerk, and somewhat lazy, untrustworthy students too, inclined to shirk work, or to go through the formality without entering into the spirit of the examina tion. Sometimes we are asked to follow instructions for nothing ; in some cases a fee of a guinea is paid ; in some half a guinea is proposed As before remarked, there is nothing unreasonable or objectionable in requesting us to answer questions ; indeed, the plan well carried out will save time and trouble, and contribute to the formation of a just conclusion. But to needlessly multiply questions, to request answers to many that could be asked and answered without troubling us at all, and to instruct us where we ought to pause, what we ought to emphasize, — is not treating medical practitioners as considerately as they deserve. According to a less formally but 'perhaps better arranged scheme, we might be asked simply whether we considered the applicant fit for assurance or for the post he is trying for as regards health, strength, and enduring power, and whether in our opinion it is probable he will live as long as most persons of his age. Should our opinion not be favour- able, we should be requested to state the general grounds upon which our adverse conclusion had been based, and whether, if the proposer was considered to be older than his real age by a certain number of years, he might be insured. But further, not only is our medical examination and opinion some- times received with reserve approaching to a want of confidence, but some of our non-medical friends, with a certainty that is quite astonish- ing, form a decided opinion, and seem to have a positive conviction that their view is correct in cases in which we feel the greatest difficulty in deciding what is the right course. It is very remarkable that some having no knowledge whatever of anatomy, physiology, pathology, or medicine, as these subjects are known to us, should feel confident that they can form a perfectly accurate estimate of almost any man's health and his prospects of living. Some of these confident judges go so far as to set their opinion against our own, and, laughing at our doubts 54 MEDICAL CHARITY ORGANIZATION. and cautiously formed opinion, do not hesitate to declare that many of the imperfections in organs and faults in their action which we detect — many of the diseases we discover in heart, lungs, kidneys, liver, brain, or spinal cord — are little more than the creations of our morbid imaginations, although not one of these same confident authorities as to human life values, would think of putting his judgment to the test in the case of an animal to work, or to fat, or to admire, without first con- sulting with the veterinary authority. Hospital Out-Patients and Slight Ailments. — Great principles as regards the treatment of disease may, without doubt, be learnt and taught, and the influence of important remedies illustrated in slight ailments as well as in grave disorders. The circumstance that little attention, comparatively speaking, has been paid to this part of medicine, even in the best of modern systematic works, makes me particularly desirous of bringing it under special notice. But among the cases of slight ailments you must always bear in mind that you will occasionally discover some very serious malady, and therefore arrangements made for treating slight troubles must comprehend the detection and proper management of the most serious maladies. No one must practise on the idea that, as slight ailments constitute the great majority of the cases he will see, he need not be qualified to deal with grave cases. You may learn a good deal about man's slight derangements if you study in the out-patient department of the hospital, or in public dispensaries, and I strongly advise you to take advantage of every opportunity that may offer of seeing practice. Do not be deterred from spending time — much time — in the out-patient department, although in some quarters disparaging observations may be made concerning out- patient medical work both by professional and by non-professional people. Up to this time the out-patient departments of our hospitals have been of the greatest service to the poor, as well as of great advantage to those who are studying medicine. It is there we learn to understand and interpret the curious descriptions given by people in so many different ways concerning the aches and pains they experience. There we learn to recognise the difference between apparent and actual suffering. There we are taught to quickly discern different forms of disease, and to acquire that ready method of investigation which is so valuable in after life. Although complaints have been made of the rate at which people are gratuitously seen and dismissed, it will be found in practice that the out-patient hospital physician seldom misses an important case of actual disease, while of his real use to the poor there can be no question what- OUT-1'ATIEXTS AND SLIGHT AILMENTS. 55 ever. Of late years there lias been quite a considerable party of charitable people whose chief work has been to bring telling indictments against hospital management. Their fault-finding with our existing system curiously corresponds with an intense desire on their part to establish a different one, which is not to grow from small beginnings and succeed in due time ; but a new plan which under their confident but inexperienced management is at once to burst into full bloom. In our out-patient departments slight ailments arc prescribed for and relieved at once, while serious cases of disease are detected and immediately transferred to the wards for thorough investigation and treatment, without that inquisitorial investigation which forms a very important factor in the new model sick-poor relief and centralization and general organization association. It is doubtful whether, by any system that can be inaugurated, a poor patient will be more quickly relieved and cared for than by the one which has been gradually con- structed mainly by members of our profession, and has been supported by the friendly and generous help of those who have confidence in our voluntary and well-tried system of hospital management, and is now in useful operation in every part of the empire. To teach providence and thrift to all classes is laudable, but there is no good reason why this desirable lesson should be taught at the expense of ruining the most useful institutions in the world. The whole question of medical charity is of course very important, but by many very active and energetic people is altogether misunderstood. I shall venture to consider how the questions which have been raised by some enthusiastic non- professional people appear when viewed from the medical side. seif-suiiiiorting System. — It is now the fashion to condemn the system upon which our best hospitals have long been successfully administered. And to those unacquainted with the facts there seems to be something plausible in the objections raised. It will perhaps be found that the desire on the part of some enthusiasts in charity organization to improve the several departments of hospitals is supple- mented by a much stronger desire to encourage a so-called self-supporting system, based on the fanciful hypothesis that working men and others are degraded whenever they receive relief from their sufferings without payment. The tendency, and the value of the facts and arguments advanced, and the principle of computation adopted, may be judged by the oft-repeated assertion that a fourth of the population of London receives gratuitous medical treatment annually. It is a dictum of certain philanthropists — would that it were the practice as well — that everyone ought to pay for medical advice. If the patient cannot pay enough to remunerate the doctor, he is to be made to combine with others placed in a similar position, and so a sort of club, to which a salaried medical officer is appointed, is formed; or funds are to be 56 SELF-SUPrORTING SYSTEM. raised by subscription to be added to the subscribers' payments, just sufficient to provide a minimum payment to the doctor. This plan, often advantageous, is not in many instances " self-supporting." Anyone who knows much of the working classes knows that the demand for medical help, sick diet, and medical comforts does not always corre- spond with the time when good wage is being earned. In the universal extension of a partially successful plan thousands of pounds are to be collected for starting "self-supporting" dispensaries, which are "self-supporting" only in name. People are to give in order that certain members of the population may be doctored at half, or a quarter the usual cost, or something less than that, and doctors are to accept a miserable remuneration, although nearly all would prefer to give their services. I have seen a great deal of the poor and of out-patient hospital practice in my time, and, as I have not met with the recently discovered gigantic evils of the system, I cannot advocate the proposed changes. With regard to medical charities generally, it may be remarked that of late years it has become fashionable to find all sorts of faults with those who are responsible for their administration, and to bring against them accusations and charges, most of which are unjustifiable, while not a few are nonsensical. Then there is an anti-charitable relief party amongst us which, like some other revolutionary parties, is destructive rather than constructive. Of the power of this party there is no doubt, for practically it supplies an excellent excuse for not help- ing charitable medical institutions. If, says the person about to give, there is doubt as regards the advantage of this charity, I had better con- sider. Consideration soon leads to an instinctive buttoning up of the pocket, and the new views concerning the pauperization of the poor, by helping them when they are ill, take the place of pity for the helpless or nearly helpless sick. But though the withholding of help is undoubtedly the practical outcome of the opposition to voluntary contri butions, the advocates of the new system altogether deny that this is the eifect of their ill-judged remonstrance against what they call " indis- criminate" almsgiving. If it is difficult or impossible for an opponent to bring facts against a practice to which he objects, he calls it " indiscriminate," a term, certainly in this case, more correct as applied to the fault-finding than to the thing to which objection is made. What our benevolent opposition desires is "organization." And so confident are the new organizers as regards their own powers in this direction that they do not hesitate to intimate that if only the funds of the old institutions which were raised by others were but administered by them instead of by the originators, or by the old or new friends of the charities who provided them, both those who give and those who receive would indeed be blest ! NEW ORCANIZATION. 57 It is very remarkable that tliis strong opposition to giving medical help, medicine, and comforts to the poor during illness should coincide with efforts to give clothes and dinners to the children of the poor. It is certain that if the latter plan is not to be objected to on the ground of its pauperizing tendencies, neither can the former. Organizing philanthropists claim to have specially trained themselves for expend- ing and managing the funds given and to be given by the philanthro- pists who have not the good fortune to be gifted with the organizing faculty, and the new organizers are perfectly confident that all charitable people, institutions, friends, and others anxious to do good to the poor in general and the sick poor especially, should be committed to them for proper organization. The originators, the present supporters, the working staffs of hospitals, who have done and are doing, the work, are to be instructed by these specially qualified persons and to be placed under their immediate superinten- dence. If the process is objected to, managers, servants, all must be turned adrift, and the institution started afresh on new lines by the self- constituted organizing authority, who will modify, as may be desirable, and remodel the plan of the founders, and carry on the work for the future on the new and improved principles. Our unendowed hospitals seem to be the institutions to be first selected for the immediate application of the new views. Many of them are but poorly supported, and some persons who help them are, it is feared, persuaded to reduce or withdraw their support in order that the institutions may be "organized" and administered according to new doctrines. In short, certain persons, who know little or nothing of medical work, are essaying to completely alter the relations which have for long subsisted between those who supply the funds, those who administer them, and the sick poor. They would regulate the condi tions under which we doctors are to be allowed to treat the sick in accordance with their own theories of medical charity and organization. They are thoroughly satisfied that we have been deceived and misled, in short, humbugged right and left, and compelled to waste our time as well as spend the money of our friends, in seeing great and wealthy people who, poorly clad for the occasion, wait their turns in the waiting rooms, in order that they may cheat us of our due and use up money given to the poor. Our new organizers pity us, and are fully convinced that if only they were allowed to organize, this evil, as well as many others, con- nected with the present system, would soon disappear. Our confident friends of the new organization never having been imposed upon, and never having once failed to detect imposition of every kind, are naturally very desirous to organize anew our hospitals, our patients, and ourselves. Before a poor patient is to be permitted to see the doctor he is ordered, according to the new system, to give a full account of himself, his means. 58 OF MEDICAL CHARITY. and his family affairs. Account is to be taken of his dress and general appearance, in order that it may be correctly ascertained whether he is really poor and wretched and destitute enough to have given to him a little medical advice and just a dose or two of medicine which possibly may, and at once and completely, relieve him, at a cost of perhaps a fraction of a farthing ! All sorts of wild accusations are made as regards the flagrant mismanagement in general hospitals. Then it is said Special Hospitals divert funds from the somewhat better managed General Hospitals, and not a few plausible suggestions are made with the view of inducing those who work in hospitals, and those who subscribe to them, to support the new effort. But it is to be feared that the com- plaints about bad administration of funds, indiscriminate charity, anxiety to pay the hardly used doctor, and the like, are but means to an end, and belong to the same category as that to which much modern political reasoning (?) belongs. The real reason of this extraordinary interference with other people's business is not clearly expressed, but there are more than dreams and hopes of a Central Board controlling all the hospitals and appointing all the officers — a perfectly organized universal hospital system, in which the medical officers will be the paid servants of the managers. For years past there has been much fidgety and worse than useless interference with medical work, and it is time the ill-placed activity should cease, or find new spheres better suited for its disturbing, destructive, and worse than useless operations. That we are perfectly able to manage our own affairs is evident enough from the work already done and the work now doing all over the world. We have been, and shall always be, obliged to give our services in many cases. With the very best intentions to assist, improve, and correct, organizers will increase our troubles, and in more ways than they can be aware of. That many of us, like members of another profession, have much work and little pay is too true ; but most of the proposed new arrangements would have an effect the direct contrary of that desired and intended. The benevolent proposal to establish pay or self-supporting institutions right and left is open to very serious objections, and where one or a few practitioners would be benefited, a number would find themselves worse off than before ; for some patients who once paid the doctor will no doubt get their medical help for a little less, while those who have no means at all must still be attended free ; as there will be many sufferers whom the practitioner cannot send to the hospital or the workhouse medical officer, because he may be miles away, and practically, the doctor on the spot wall be obliged to do what he can to help them — pay or no pay. To send a working man a long distance who is suffering from some slight ailment, perhaps to be at once relieved by a dose of Sal Volatile or Bicarbonate of Potash, would be as hard as it would be absurd. But unless all cases — very slight as well as very severe — are provided for, the new ORCAMZATIUX OF ClIAKITN'. 59 organizing principles will not work as well as the voluntary support arrangement. The old plan, if less systematic, is thoroughly efficient, and very practical. To extend any provident system to the unendowed hospitals, and no doubt the effort to do so will be made in some form or other, will be disastrous. It is obvious that the hospitals will at once lose their old friends who liberally support them, while their new friends will no doubt bring them the best organization, but little money. They will then have to appeal for State help, and the best hospital system in the world, which originated with us, and has been growing for centuries, and has gradually established itself in every j)art of the country, gaining in usefulness and strength as the nation progresses in wealth, will be destroyed without good reason and against the wish and judgment of those most interested and best qualified to continue the work. Members of the profession, and particularly the working staff, ought to have far more direct influence in the management of medical charit- able institutions than has hitherto been generally accorded to them. It must be borne in mind that many of our most useful and most wealthy medical charities would not have existed but for medical men. Not a few were first established and supported by the doctors, who themselves took part in the actual work. None can be carried on with- out the cordial support of professional men. It is, therefore, clearly right that the wishes and views of those who do the principal part of the work should be considered and acted upon. The staff should always have a voice in the management of the charity, and no radical change ought to be thought of without their concurrence. So far, therefore, from our influence being reduced — in wisdom and justice it should be greatly increased. For the lust eighteen years — of the twenty-four elected members of the Committee of Management of King's College Hospital, from six to eight have been members of the medical staff. This direct influence of the physicians and surgeons upon the management of the hospital has benefited the institution in many ways, and has assisted the lay members of the committee. The philanthropists who seem to fancy they have a sort of right to regard us as mere tools to use, or pawns to move about as they think fit, can easily find fields better suited for the exercise of their talent, and in which their labour would be more productive than in attempting the impossible, in endeavouring to organize the unfortunate, and regulating and drilling the sick and suffer- ing, until they fall into order under their arbitrary hard-and-fast rules and regulations. Illness, disease, suffering can only be regulated within certain moderate limits, and these are best known to those who have been for years working among the sick. We doctors take the rough with the smooth. Practically, we all do much work for nothing, and some amonust us are so situated that for the greater amount of work 6o PAY-WARDS AND PAY-PATIENTS. done they get no remuneration whatever — they and their patients, nevertheless, hving and working usefully in distant parts, far away from the influence of disturbing organizers and organizations. The Question of Pay-Wards ana Pay-Patients in Public Hospitals. — There is much difference of opinion concerning the admission of pay- patients into hospitals which are designed for the treatment of the poor — and the funds of which are provided for this purpose only. In these days it is not easy to clearly define what should be understood by " poor," as regards those who need gratuitous, or nearly gratuitous, medical help and nursing during illness. Many a bank clerk, small tradesman, shop assistant, or schoolmaster, is undoubtedly poor, though he may wear a black coat and hat. How many of the clergy are also poor in these days ! There are thousands of persons who would not be included among the poor, and who by some would not be regarded as proper recipients of gratuitous medical help, but who certainly cannot afford the expense of a long illness, and are as worthy recipients of medical or surgical treatment in public hospitals as could be found. By some the question is supposed to be solved by requiring those who are not considered to be among the very poor, to contribute according to their means. In some hospitals a small number of beds are allowed to be thus occupied. In others a ward is set apart for the purpose. Some medical practitioners consider that such a plan is open to abuse, and that unless the greatest care is exercised by hospital authorities, persons who are not proper objects of charity will take unfair advantage of the system. In actual practice, however, one does not find that many applications for admission as pay patients are made, and as far as I am aware, not the slightest interference with the interests of the very poor has occurred. In many instances the medical attendant of the patient begs for his admission. In the Great Northern Central Hospital a few pay-wards have been arranged in which patients pay sums according to their means, up to two guineas a week, as may be determined by the House Committee of the hospital, who make a careful investigation into the status of the applicant; the latter must also obtain a certificate from a registered medical practitioner, stating that the case is a fit and proper one for treatment in such wards. Each patient is treated by the honorary staff of the hospital just as the ordinary in-patients in the other wards. Of Gratuitous Medical Help to the Poor. — In discussing the question whether the profession ought or ought not to give gratuitous medical help to the lower classes of labourers and the so-called really poor, it must be borne in mind that what we give has nothing to do with money or property, but must be placed in a category by itself. It is not like giving a dole that might teach a man to whine and grumble and sue for more. It is very different from giving him free WHAT IS (;ivi:x nv doctors. 6i breakfast and dinner, or free education for his children. We do not present him with anything he had not before, or add to his worldly goods, or provide him with that which he can sell or hoard, or make profit by. Neither do we aspire to procure for him ease, or, to add to his luxury, reduce the hours of his work, or make it less hard. What we give does not tend to make him idle or more selfish, but rather the contrary. All we aim at, and are able to do, is to put him in the way of getting back as soon as possible the health and strength he has lost, and with these his power of earning his livelihood ; and if he is suffering pain we do our utmost to relieve it. After all, the medical help given only restores him to his natural state, and it really seems to me unreasonable to contend, that by help of the kind we are sometimes able to afford, any recipient by any possibility can be degraded in the very slightest degree. \Ve are often asked to help in a great emergency, and under circumstances and at a time when it is unlikely the question of remuneration would occur to the mind. Sometimes, no doubt, advantage is taken of us, but, in certain cases, are we not bound to help and do all that we can, whether we gain or lose ? The doctor, like every other worker, it is truly said, must live, but, unlike most other workers, he is often called upon to help people in a strait — in an exceptional condition — in a great difficulty, and perhaps from no fault of their own, possibly from sheer accident, or bodily weakness acquired or inherited. If, at the time of trouble, they are without or almost without means, we cannot suggest that they must wait for help until better times, but must do all we can to assist them to get well as quickly as possible. If, in the case of a workman, illness is unfortunately associated with impecuniosity ; if, as not uncommonly happens, he has spent all his money, are we to decline to try to relieve him, and to send him, it may be many miles, to hospital, or dispensary, or workhouse, when a little of our time, and perhaps some com- paratively inexpensive drug judiciously prescribed, and which we may have ready, will afford almost immediate relief? Or, to take a still worse case, in which a few hours' delay might possibly greatly increase the danger to life, is it not wholly inconsistent with our feelings and prin- ciples to discuss about the man's means, and waste time in endeavour- ing to decide whether he is or is not a proper object for gratuitous medical help ? Nay, is not the mind occupied with other matters, and ought we not to permit ourselves to be guided by the strong natural desire to do the best we can without delay ? It must also be borne in mind that, although at the time of illness people may not be able to afford to pay anything to the doctor, a time comes later on when they are better off, and are glad to be able to do what is right. In many cases of the kind, the interference of third persons, however highly organized, and however good their intention may be towards us, might 62 GRATUITOUS MEDICAL HELP. completely destroy long-established friendships, and interfere with the relationship between doctor and patient to the injury of both. And is ii not passing strange that, at the very time there is such an outcry a<^ainst giving gratuitous medical help and medicine, great efforts are being made to introduce a system for giving food and clothes ? Surely the last are more likely to discourage self-help and thrift among the wage-earning classes than our medical advice and physic. At any rate, it seems certain that if the giving of food and clothes is to be justified, there can be no doubt whatever as to the propriety of giving advice, medicine, and medical comforts in very many cases. Depend upon it, your own judgment, good feeling, and common sense will enable you to settle these questions as they ought to be settled, and without doubt or difficulty, and far more quickly than the interesting organizers, who are so very anxious to help you to get your due, would be able to effect. If our friends would allow honorarium questions to be settled by ourselves, and would kindly let our real or supposed interests, unorganized as they are, alone, we should be content. They do not perceive that their perfect and much-desired cheap medical institutions for encouraging thrift and all good, will soon bring forth cheaper ones, from which still more economical health and thrift-pro- moting concerns will in due order be evolved — damaging in many ways to the profession which was to have been assisted, not elevating or advan- tageous to the poor, not providing them with the good medical attend- ance desired, not tending in any way to increase the respect of the public for the medical calling. In any other craft but medicine, such persistent interference would be strongly resented. Suppose an association constituted itself to pro- vide law, or any other form of intellectual labour, at a cheap rate for the benefit of the working classes who were not considered to be able to pay the regular fees, would not the lawyers at least insist that they should be considered, and that the terms and conditions should not be determined by outside interference without proper consultation with themselves? And, as regards medical attendance on the working classes, this outside interference is the less justifiable, because in the past as well as at the present time the practical necessity of giving medical aid in some cases has been and is fully recognized and provided for by the profession in every part of the world, fc'ome of these new associations seem to think that we are to work just in the way and on the terms they dictate. In short, they would deprive us of the right we enjoy with others — of giving our services when, where, and how we may consider right or proper or desirable. On the plea that they have satisfied themselves that they are better organized than we are, and know more about the facts than we do, though we have been at the work for years while they know very little of the matter from our medical ORGANIZATION OF OUT-l'ATIENTS. 63 side — they would oust us altogethei except as obedient paid officers bound to execute their orders. It would be far wiser on the part of the public to request us who do the work among the poor to use for the benefit of the sick the money they subscribe, than to establish associations to dicate to us and to select the particular persons wc are to help. The OrsJuii'/.atloii of Out- Patients. — A very favourite suggestion of self-constituted organizing philanthropists is that the number of out- patients attending hospitals should be limited. Now it must be borne in mind that a public institution gradually gets very widely known, and poor patients come to it for help from very long distances, and it seems scarcely fair to tell a patient that he must come again because he is one over the number admitted for the day, and especially when the real cost of helping him is so very small. Again, among a great number of out-patients will be found some suffering from grave disease. Such by the present system are at once admitted into the wards and properly treated and nursed. To send away such cases, especially if they have come many miles, would be wrong, and it is obvious that the porter is not the proper official to be allowed the responsibility of distinguishing the fit from the unfit. Nor is there if the work increases the least difficulty in finding highly-qualified medical practitioners to attend the poor who come in increased numbers to the out-patient departments of hospitals. The staff can always be increased, and the increase is to the public advantage by the larger experience afforded to an increasing number of medical officers and by the prompt action taken in getting poor working people well as quickly as possible. Moreover, in case of the occurrence of any serious epidemic, we have the means and machinery of combating it ready, in thorough working order, available at any moment, and capable of immediate expansion and at excessively small cost to the community. No matter how bad the times might be, our present medical charities are fully competent and, with a little temporary addi- tional help, ready organized for almost any amount of work. Several ot our hospitals in a week could be arranged to receive tvvice the ordinary number of patients, and considerable increase of funds would be immediately supplied by the committee and friends of each institu- tion. Instead of this some would set in work the cumbrous and slowly- responding machinery of municipal or imperial taxation, possibly at a time when all classes were overtaxed and an expensive foreign war on our hands. In short, on all grounds it is better to leave these expenses to be provided as heretofore by the highly successful and practically unobjectionable voluntary system. Surely it is better to continue to utilize well-known and long-established institutions, which form centres of medical assistance conveniently placed here and there amongst our 64 NEW RELIEF ORGANIZATIONS. increasing millions, than to trust to the chances of establishing new ones equally good, and rearranging all upon new principles of cen- tralization and organization, however perfect the untried scheme may appear on paper. Is it right that wealthy or powerful and energetic enthusiasts in perfection that might be, having perhaps little practical experience, should interfere and try to stop or change all the tried and steadily flowing current of work and support, proceeding in many cases gently, usefully, and without interruption ? Is it right to stop the work of an institution which has been useful in many ways for centuries unless there be evidence of bad management, gross extravagance, or something worse ? I wonder whether those who want to manufacture wholesale out of existing institutions new ones for providing the poor with cheap medical treatment are aware that in some neighbourhoods advice and medicme may be obtained for a fee of 6d., that teeth may be extracted for 6d., and that fully-qualified medical practitioners are the advisers and operators. Already in some poor neighbourhoods dispensaries have been started as speculative concerns, and it may well be asked — why should not an enterprising company finance new hospitals on a remunerative basis ? The staff might be persuaded to pay large sums annually for the privilege of being connected with institutions so important. The scheme might be launched under some such title as the " Universal Diagnosis and Hospital and Dispensary Relief Asbociation." New Provident Dispensary System. — The last new efforts differ from all others in being backed by capitalists, and instead of being worked by the givers themselves or their representatives, are to be managed by organizers, who will have immense power to give or refuse help, and from whose decision there can be no appeal. Refusal at one institution would mean refusal at all, and hard would be the lot of many an unfortunate person suffering from serious illness. But I regard it as certain that if from any cause the old system of medical help supported by voluntary subscription should be ousted by some new movement, it will after a time again revive, and even be more popular and more useful than ever. Up to this time, the medical management of the sick in our hospitals and public institutions has been committed to officers who hold their posts for years, and who gradually become well known. Reputation acquired by years of steady work brings credit to the insti- tution, which again helps forward the next generation of practitioners. In the great majority of cases the finances are devoted entirely to the requirements of the patients. There is no self-supporting question in any form, and it is difficult to see how any really self-supporting system can be established which will work with fairness. Consider the expense OBJECTIONS TO THE NEW SYSTEM. 65 of a single case of typhoid. Half or more than half the amount of wages earned by many a workman in a year will be required for proper nursing, and day and night attention during the illness, to say nothing of the expense of change of air and suitable diet during a long convalescence. In some of the new institutions springing up especially in poor neighbourhoods there is no certainty that the best i)ractitioners will be appointed. In the dispensaries backed by the subscriptions of the wealthy and in the dispensaries started on a commercial basis the officers will probably be young practitioners receiving a fixed salary, the amount of which it is to be feared will be reduced as the number of applicants for the posts increases. These officers will have nothing to do with the general management, and will in fact be the servants of the managers by whom they are appointed. In many neighbourhoods the dispensary patients would no doubt soon discover that the advice of the practitioners in the neighbourhood was as good as that to be obtained at the dispensary, and the cost little or no more. In this way the new evils may slowly be righted, but the loss to many individuals who have been working hard for many years and whose clientele has been invaded by the new interests laying hands on all the patients they can find, will, it is to be feared, be as serious as it is undeserved. Some of the subscribers to the dispensary would probably have remunerated the doctor to the same and perhaps to a greater extent as private patients, and, from the closer relationship, have more highly esteemed him. But, according to the new plan, will he not have to attend many of the poorer class for nothing, and practi- cally will he not have to do so, whatever new rules, regulations, or organizations m.ay be invented ? Upon the whole, while the new system is established with the view of helping the doctor and adding to his too small income — like some other panaceas for the cure of existing defects as well as old faults and imperfections, it has had and will continue to have an exactly contrary effect. In exceptional cases in the country and in towns where there are not too many doctors, no doubt the Provident Dispensary system has been of service both to patients and practitioners. It has worked well, and will continue to work well, especially if the management remains in judicious hands. But the success of the new effort to extinguish voluntary systems in England, long ago established for helping the poor in sickness, and that have been in active work for years, will be fraught with disastrous results. I think it probable that in the course of time in many places the new plan will be found wanting, and will give place to the re-introduction and revival of the sounder and more sensible method. In conclusion then, I would venture to remark that, like some other modern movements, the Provident Dispensary system, though started in F 66 PROVIDENT DISPENSARY SYSTEM. full confidence that it was to be of very great benefit to poor people as well as to the medical practitioners who attend them, and that it was to effectually overcome all the objections of the present system, will increase some of our present troubles and cause the introduction of new ones from which the existing system is free. The fact publicly known that such and such practitioner receives a few pence for his attendance on dispensary patients, will not raise us much in the estimation of persons who might be private patients, while if some who could not command his services were gratuitously assisted by him it would redound to his credit, though it would not help him to live. There is yet another way in which the Provident Dispensary system is likely to damage the profession. Those interested in its success will of course endeavour to get the institutions as widely known as possible, and will oftentimes unknowingly persuade patients of neighbouring practitioners to leave them and go to the dispensary or to be attended by the same practitioner through the dispensary. Considering the great number of well educated practitioners in every part of London and other large cities, and the very severe competition that exists already, it seems scarcely kind or wise on the part of persons having command of large means to use their capital in such a way as to lower the very low scale of remuneration which in some parts exists at present. Not only must provident dispensaries have this effect, but they will bring about a new and far more disastrous kind of competition, inasmuch as their success is certain to be followed by the establishment of cheaper dis- pensaries on a similar plan but still more effectually conducing to thrift and self-reliance among the subscribers, and still further reducing the pay of the unfortunate doctors who do the work of the dispensary, as well as giving more work and less pay to the practitioners near who do not belong to the institution. It is therefore on the highest grounds to be hoped that the rage for the new thrift and provident medical organizations will cease in populous cities where doctors abound. In small towns and villages where there are only a few practitioners, this ^nd some other forms of medical attendance clubs, carefully managed and moderate in ambition, will work well and be helpful to the people. In such cases the medical dispensary or club can be established by the doctors themselves with the help of friends, or by the would-be patients, without the assistance or interference of any great central organizing power or authority. The capital some would expend in establishing new provident dispensaries would be far more usefully employed in helping already existing medical institutions, clubs, hospitals, and other medical charities, than in starting new dispensaries and appoint- ing new staffs pledged to make their work and themselves as popular as possible irrespective of the ruin that may be wrought as regards other interests. MINUTE INVESTIGATION. Tmportaiiro of Kiu»vloil;?c cicrlvcil from [tlicrosfopfcal Enquiry. — In all healthy changes, in all derangements, in all forms of disease, thousands of minute particles, each of complex arrangement and com- position, the action of which does not etiiirely depend upon their structure, physical characters, or chemical composition, are implicated. It is by the increased action or want of action on the part of millions of these minute particles that are alive that the broad phenomena evident to us as disturbed actions, and derangements and morbid changes, are occasioned. Do not, therefore, cast a slur on the consideration of microscopic details; do not neglect the facts arrived at by microscopical investigation. Rather, on the other hand, try to acquire the power of seeing in imagination the very particles which are involved, and of contemplating the phenomena proceeding in connection with them. Bear in mind, too, that around and in the interstices between the particles of matter composing each elementary part of a living organism changes are constantly taking place. Remember that of the matter of the elementary part it is the bioplasm only that lives and is the seat of the vital action. The formed material which results from the death of particles of the bioplasm is the seat of physical and chemical changes only. These elementary parts or cells are so small that more than a thousand thousand of them might not occupy more than a cubic inch. Each during life is the seat of incessant change. Towards the bioplasm of each elementary part streams of fluid, holding various substances in solution, continually tend, and, having reached it, part with certain constituents, which are taken up by the living matter, and while in its substance are converted into living matter having the same properties and powers as the already existing bioplasm. The fluid, deprived of some constituents and having received products of disintegration, again traverses the formed material, and is taken up by the blood or is other- wise disposed of. Thus the formed material or tissue of every organ of the body is the seat of the passage to and fro of streams of fluid, and each part is being contmually bathed by fresh portions of fluid, which brings and takes away dissolved in it things required for use, or things which must be got rid of. This continual movement of fluid characterizes everything living that exists or ever has existed from the lowest to the highest. In every form of plant and animal it is present and is essential. When the flow is impeded, derangement results, and degeneration and decay may commence ; fat oil globules, earthy phosphates, and other substances interfere with normal action ; when the flow stops death of bioplasm takes place, and the portion of tissue thus losing the preserva- tive influence exerted by the never-ceasing currents of fresh portions of F 2 68 MICROSCOPICAL INVESTIGATIOXS. fluid through its most minute interstices undergoes chemical decom- position, just as a portion of tissue taken from a dead animal would do if kept artificially at a temperature of loo". If the change stops in a single elementary part or in a few elementary parts, the products resulting must be gradually removed, or adjacent elementary parts will die and more poisonous products result. The deleterious gases and other poisonous substances thus formed, if there is no vent by which they can escape altogether, may pass into the blood, and contaminate or actually poison every drop of the nutrient fluid, or may, by transudation into adjacent tissue, destroy considerable portions of it by killing its living matter. In this way a large portion of tissue may soon be involved, and the death of the individual must shortly follow from poisonous materials generated in his own body. There is, in fact, during life a constant circulation through every tissue and everj- elementary part — a constant interchange of gases and certain solid matters dissolved in fluid, some of which are appro- priated as nutrient material, while others are removed as products of decay. This never-ceasing circulation goes on around and amongst the smallest particles of all tissues and organs. Slo\v-moving tiny streamlets bathe the very molecules of the cells or elementary parts, and penetrate into the substance of every molecule, living and non - living, thus ministering not only to the growth and increase of the bioplasm, but the formed material of the different tissues can be preserved in a healthy and active state only by aid of these currents. What may be correctly termed an active inter-molecular circulation is one essential condition of a healthy stale of tissues of all living things, and it will be well for us to occupy a few minutes' time in its consideration. This interstitial circulation is absolutely necessary for the free action and for the preservation of the structure of every part of every living thing. Its complete or partial cessation is very soon followed by actual degeneration or by the deposition of substances calculated to produce a deleterious action. The interstitial inter-molecular circulation requires in most persons, and in all those who live too well or even moderately well, a little assistance from time to time. Especially is this necessary in the case of those who consume much nutrient material in proportion to the muscular and ner\'e work they discharge. Free action of skin, kidneys, and bowels is the principal means by which the activity of the interstitial flow may be increased. Water drinking and free perspiration are, therefore, beneficial by promoting the removal of matter from the blood, for thus the interstitial flow in the tissues and to and from all the capillary vessels will be promoted. In plants the inter-molecular circulation is equally essential, and the constant removal of fluid from the surface of the leaves and flowers is one of the most important of the operations concerned in establishing ELEMKNTARV I'ARTS OR CELLS. 6g and maintaining a very free circulation of fluid around and in and out of every "cell " of the living plant. Even in the lowest, simplest, and most minute of living forms, inter-molecular circulation begins with existence and never ceases until death takes place. It is one of the phenomena constant in and characteristic of every form of life, but it is peculiar to living things. There is nothing like it in any non-living matter, and the perfect manner in which it is carried out cannot be approached by artificial arrangements. The importance of the continual flow of fresh portions of fluid through all the formed material or tissue of every part of the organism cannot be over-estimated. It has much to do with health and longevity. The rate of flow changes from time to time, and though sometimes it goes on very slowly, the movement never stops as long as life lasts. You must try to picture to yourselves these never-ceasing movements of fluids simultaneously proceeding in every part of every elementary part constituting every tissue of the organism, though it may be considerably less than the one-thousandth of an inch in diameter. It is obvious that the activity of these movements will in some measure depend upon the quantity of fluid taken up by the blood, the rate of its flow, and the relaxed or contracted state of the arterioles. If the nutrient fluid is habitually deficient in water, more especially if it be surcharged with only slightly soluble materials, there will be slow molecular circulation and a tendency to the deposition of some of the least soluble matters in tissues where the circulation is slowest. It is in this way urates and phosphates may be deposited in organs and tissues where ordinarily the circulation is slow, as happens in cases of gout. When we treat such a malady we promote the introduction of substances from time to time into the blood which have the property of exerting a solvent action on these slightly soluble compounds, but the water in which these are dissolved is most potent. By water alone, in many instances, deposition may be prevented, or, if deposited, the resolution of these substances, and their reintroduction into the blood, and at last their excretion from the body, may be effected. The knowledge of the phenomena proceeding in the interstices of tissues enables us to understand precisely how many of our remedial measures act. The careful consideration of such minute changes enables us to suggest methods of treatment in various cases, of great importance and value, and the frequent contemplation of the phenomena may and probably will result in the suggestion of new and improved procedures. We may act upon the formed material itself, rendering it more soft or more firm — help or interfere with the deposition of insoluble matters in its substance — influence the growth of bioplasm (living matter) — assist the removal of products of its death, and bring about many changes of the greatest consequence as regards treatment. Many of "JO INTER-MOLECULAR CIRCULATION. the diseases we have to diagnose and treat are due to a disturbed state of this inter-molecular circulation, and not a few of the most serious morbid changes result from diminished activity of the flow. Many matters which ought to be washed away as fast as they are formed accumulate in the interstices of the tissues and impede, and perhaps destroy, their structure and action. When we can restore this molecular circulation to its normal state derangements of various kinds are at once relieved. In treating many forms of established disease our principal object is to increase the activity of the inter-molecular currents in the interstices of the tissues involved. This object may be fulfilled in several ways. As already explained, free perspiration and indraughts of water will effect it ; sometimes the administration of frequently repeated doses of alkali promotes increased activity of the inter-molecular flow, and assists the solution of imper- fectly soluble matters which have been deposited or are in course of deposition. Looking from the point of view I have indicated it will be well to consider, for instance, what is the precise action of such a substance as quinine when it cures in a few hours certain forms of obstinate nerve and, as it is sometimes called, muscular pain, and what happens when local thickening of the subcutaneous areolar tissue, and inflammation of many structures that may have lasted for months, subside in a fortnight or less under the influence of biniodide or other preparation of mercury. In cases in which too much nutrient material has been day by day introduced into the blood for considerable periods of time, slow circula- tion or stagnation of some of the molecular currents in various tissues and organs of the body will occur. Diminishing to some extent the quantity of blood in the body, as may be effected by partial starvation, or rather by a moderate diet for several weeks, will again promote the flow. Free perspiration will have the same effect. The imbibition daily of several tumblers of water will, by favouring the free action of the kidneys and transudation of fluid from the blood, also benefit the patient. Water containing alkalies or salts of vegetable acids, particularly the citrates and tartrates, will, by exciting cutaneous and renal action, help to re-establish currents in the several tissues and organs in which the molecular circulation has become unduly slow or may even have ceased for a time. By promoting purgation and sweating and the free action of the kidneys we favour the circulation of interstitial fluid in all the tissues and organs of the body. It is in this way that any imper- fectly soluble substances deposited are dissolved and removed in solution. By exciting these processes from time to time, the deposition of any insoluble matters in the case of persons predisposed is prevented. And the greater the excess of nutrient matter over the exact amount required, the more important is it to encourage these processes of FIBROID CHANGES. /I elimination. In other words, he who lives well requires free action of the skin, kidneys, and bowels far more than does the person who lives abstemiously. Further, when we consider the close proximity to the very thin walls of these tubes, of the nerve-fibres distributed to the 'capillaries, we shall not feel surprised that nerve changes are among the prominent and constant phenomena of disturbed molecular circulation. Any change occurring in the composition of the blood, which results in a diminished tendency on the part of the fluid constituents to permeate the vascular walls, will give rise to disturbance of the nerve-fibres just outside the capillary vessels. If the capillary vessels are over-distended or insufti- ciently filled with blood, these nerve-fibres will also be disturbed and will transmit impressions to the nerve-centre, which will react upon the efferent nerves leaving the centre and at length distributed to the muscular fibres of the small arteries. This change results in dilatation or contraction, as the case may be, and may perhaps lead to a more serious and more widely distributed nervous disturbance. But this part of a very complex question will be more conveniently discussed when we have to consider the vascular phenomena of Inflammation and Fever. Fibroid tiiaiiges. — Of late years the formation of fibroid tissue, that is a structure much resembling irregular forms of white fibrous tissue, has been regarded by some as a disease. In point of fact this is a change which affects healthy tissues as they become old. The irreg- ularly arranged delicate fibres may be detected in all adult tissues and organs wherever capillaries, arterioles, and vesicles or nerve-fibres exist. It is probably the irremovable remains of textures which have performed their functions and are wasting. In all cases where consider- able and quick change occurs, this fibroid tissue accumulates, and to such an extent that more delicate but important textures are obscured or completely hidden by it. The finer ramifications of peripheral nerve- fibres are surrounded by fine fibre-like tissue, and the latter represents the remains of a previous generation of nerves which has ceased to be active but has been succeeded by multitudes of new nerve-fibres. The so called fibroid-degeneration may occur in any organ the normal structures of which have deteriorated. Thus, in gradual shrinking of the liver which occurs in cirrhosis, the remains of the whole organ in extreme cases appears as a mass of fibrous tissue embedded in which, however, may be found the remains of the secreting structure which in its healthy state is almost free from any fibre-like material. This fibroid tissue is also a very common result of inflammation. The lymph which is deposited on serous membranes and in the inter- stices of tissues undergoes gradual change in the course of which water 72 FIBROID CHANGES. and some substances are absorbed, and a fibre-like texture remains which never undergoes absorption. It seems hardly correct to regard this as a fibroid degeneration or a fibroid deposit. It is but the unabsorbable, irre- movable remains of prior pathological processes. In many forms of disease the small arteries undergo this change, and the fibroid material which accumulates in sufficient amount to make the arteries, which can be felt, thick and rigid to the touch, may result almost entirely from degene- rative changes, particularly of the nerve fibres and the muscular fibres to which the alteration of the calibre of the small arteries is mainly due. It seems to me hardly correct to speak of this change as hypertrophy of the muscular coat of the vessel, seeing that the contiactile material of the muscular coat is destroyed and the alterations of the calibre of the vessel under the influence of nerve changes no longer take place. Equally incorrect is it, as far as I can judge from observation, to call it " fibrosis " and regard it as dependent upon a special pathological process. DISEASE GERMS OF MORE THAN ONE KIND— POISONS- NATURE OF CONTAGIA — BACTERIA AND ALLIED ORGANISMS— DUST AND DISEASE— ACCESS OF DISEASE GERMS— SPECIFICITY— MULTIPLICATION OF BACTERIA WITHIN THE ORGANISM— POISONOUS ALKALOIDS- CONTAGIOUS LIVING MATTER ORI(}INATING WITHIN THE ORGANISM— PRECAUTIONS AGAINST THE SPREAD OF DISEASE GERMS. From vague ideas about subtle poisons and imponderable or scarcely ponderable entities v/e have gradually progressed to actual fact-know- ledge. We have been slowly learning more and more during the last twenty or thirty years, and the researches of Pasteur have taught how in certain cases we might see and study, isolate, and grow, and experi- ment with the actual material that established the destructive morbid changes which may take place in the organism of the sufferer. During recent years numbers of highly skilled observers have been conducting the most elaborate researches and with such success in every direction that multitudes of new facts of the highest importance have been dis- covered, and every few months some important demonstration is added to the volume of knowledge. To give a correct idea of what is now known and the precise bearing of many of the established facts in a few pages is not possible, and many observers are unable to accept as general propositions some of the broad conclusions which have been embraced by not a few of those who are rightly regarded as high authorities. Action of Certain Poisons. — Before concentrating our attention on the question of the nature of the material which is concerned in the propagation and spread of communicable diseases, I shall offer a few remarks concerning the action on the system of one or two of the many classes of poisons which may be introduced into the blood. It is remarkable that our knowledge of the actual changes which occur in cases of quick death from ordinary non-living poisons is still very imperfect. Even in the case of a potent agent like hydrocyanic acid, the broad effects of which are so very obvious, sudden, certain, and constant, we are still unable to give an account of the actual phenomena 74 ACTION OF CERTAIN POISONS. so quickly following one another, and involving disastrous and irre- parable damage to the delicate and ever active elements of the nervous system, and which so soon result in the cessation of all living action. The action of poisonous matters which immediately stop or seriously disturb the respiratory process, or which paralyse the heart, is more obvious, at any rate up to a certain point of the destructive change ; but of the exact nature of the phenomena which occur in the working elements of the organs, we are still ignorant. Then there is that wonderful class of death-producing substances to which the poison of the rattlesnake and of other venomous snakes belongs, and which may be dried, or boiled, or frozen, or acted upon by strong alcohols, and kept for any length of time in a dry state without loss of potency. This remarkable substance, according to the researches of Weir Mitchell and Reichert, seems to be allied to peptones which result from peptic or tryptic digestion. The action of certain matters in a state of putrefaction may belong to the same category, but, at least, many of these have been proved to be due to, or to be complicated by, the action of the living bacteria they contain, or the presence of sub- stances secreted by them or products resulting from their death. Nay, there are substances which appear to be formed under certain circum- stances by these organisms, which not only cause the death of the living matter (bioplasm) of the textures among which they grow and multiply, but ensure their own death. As we are unable to adequately explain how such poisonous sub- stances as opium or hydrocyanic acid bring about the changes in living matter which result in its death, we shall not feel surprised that the exact action upon living particles so minute as those of various kinds of con- tagium has yet to be ascertained. In the action of such substances as the poison of venomous snakes, putrid substances, hydrocyanic acid, strych- nine, certain forms of pus, and certain bacilli, we have examples of so many essentially different destructive agents, all capable of causing death. But each acts in a different way, though all may kill the living matter, if not directly, by bringing about a state or condition which quickly has this effect. We are not able to give a rational account of the actual changes effected by any one of them from the time of its entrance into the body to the time when the death of the living matter upon whicl'i its influence is brought to bear is occasioned. Nor are we at present able to say what is the nature of the alteration which first occurs when the living matter enters upon that series of changes which soon ends in its death. Broad w^ell-marked phenomena characterize the action of many of these poisonous substances, and are so well marked and distinctive that from symptoms alone we can sometimes point to the particular poison at work. The actual disturbances taking place in the ultimate particles MATERIAL OF CONTACIION. 75 of nerves, or nerve-cells, or in the constituent molecules of the living matter of the anatomical elements, have so far eluded our grasp. We cannot even conjecture how any one of these poisonous substances pro- duces the disturbance, or stops the vital processes in the living bioplasm. The instant the poisonous matter comes into contact with the moving, growing, living matter, what striking changes must occur ! Is the por- tion acted upon actually destroyed and cast away from the rest ? Are chemical changes that were proceeding interfered with ? Are the mole- cules merely disturbed in their relations to one another ; the living matter jarred or shaken, so that the normal changes steadily pro- ceeding are brought to a standstill, or is the relation between the elements to one another in the living particle disturbed and entirely altered ? It is certain that the changes occurring in the living matter of the organism are not the same in every kind of death; and decompositions, which in some cases seem to begin before death has actually occurred, in other instances are postponed till long after death has taken place. It may be fairly asked whether the sudden death of multitudes of masses of living matter as contradistinguished from the death of one after the other, particle by particle, will account for the difference. In the case of bites of some venomous serpents decomposition is said to begin in the neighbourhood of the inoculation of the venom within a few minutes of its introduction. This looks as if all the living matter in the im- mediate neighbourhood of the affected tissues died instantly, and the circulation of the interstitial fluid suddenly stopped, so that putrefac- tive decomposition occurred and spread very rapidly. The venom of poisonous snakes upon being directly mixed with the blood prevents coagulation, but decomposition soon follows; while hydrocyanic acid produces what we call a sedative action on the nervous system, paralysing its action, and stopping the vital movements of the bioplasm, but it is said that it arrests fermentation and putrefaction. When certain quickly acting poisonous materials are introduced into the blood, the bioplasm not only of the blood itself, but of the capillaries and of the nerve-fibres lying close to their walls, is very soon killed. The amount of products of rapid decomposition from a considerable area being thus quickly introduced into the blood would soon cause the death of any bioplasm that might have escaped the action of the poison m the first instance, and being quickly diffused through the tissues in the neighbourhood, the death of further particles of bioplasm must soon follow. ]>iateriai of Contagion. — With reference to the material concerned in the spread of communicable diseases, our knowledge up to this time has rendered it certain that, at least in a great number of cases, the communicable matter is in a living state, that is, capable of growing and 76 NATURE OF CONTAGIA. multiplying under certain favourable conditions, though perhaps of lying dormant, for a considerable time, but retaining its vitality. If it dies its potency ceases, and can never be regained. At the same time it is conceivable that there may be disease-carrying particles passing from the infected to the uninfected, which, although not in a living state, may nevertheless cause the production in the body of the sick person of substances which by coming into immediate relation with the blood and fluids in a certain condition may start chemical and other changes similar to those in the course of which the original particles were formed. While it is true that the communicated material is in a great number of instances composed of matter in a living state, the nature of the living matter is very different, absolutely different in certain different forms of disease. The conclusion which by some is believed to be established, that contagia generally consist of one class of substance only, is, I think, untenable at this time. The contagia of small pox and of the vaccine disease belong to a category distinct from that which would include those of anthrax, septicaemia, or relapsing fever. These differ in their nature, the mode of their action, and in their origin. Cancer, and leprosy, and tubercle are not contagious in the same sense that scarlatina, measles, and typhus are contagious, though the contagious material of all is no doubt in a living state. The contagia which are the active agents in transmitting disease all consist of matter in a state of division so minute that the active particles will pass readily through the walls of capillary vessels without the occur- rence of any visible rupture or opening, and may then travel for a considerable distance, suspended in fluid, in the interstices between epithelial cells, and even through the substance of the cells themselves. We know indeed that particles many times greater will traverse great distances, and will pass through most of the tissues of the body, and ultimately reach an organ, at a considerable distance from the point at which they entered, and where they may have grown and developed very rapidly. That the minute particles of contagium, many of which are less than the i-ioo,oooth of an inch in diameter, consist of living matter was distinctly proved by the fact of their wonderful increase and multiplica- tion in the body, and in suitable media in the laboratory. Every one entering the body is soon represented perhaps by a million or more, of which many leave it when the attack is over, and by the agency of which the disease may spread far and wide in all directions. Many disease-producing living particles retain their vitality for a considerable time after they have left the seat of their production, and some under very adverse circumstances. Certain forms may remain in a dormant but nevertheless living state for a very considerable period, NATURE OF COXTACIA. 77 in some cases perhaps to be measured even by centuries. A single minute living particle gaining access to or being carried into a position in which the surroundings are favourable, and the proper pabulum abundant, will soon grow. And it multiplies exceedingly — for each one of the thousands of resulting particles undergoes the same process till countless millions, each one having the same properties or powers possessed by the parent particle, result. The demonstration of minute organisms, bacteria, bacilli, micro- cocci, and the like in all the tissues and fluids in many contagious diseases of man and animals from the highest to the lowest, and in plants from the most complex to the very simplest kinds, and the discovery of numerous well-characterized species of these with most marked individual specific characters, necessarily led many to accept the conclusion that the causation of all contagious diseases had been suc- cessfully elucidated, and that the true cause of every form of every communicable disease was the bacterium, and that every form of con- tagium was a species of bacterium. But, alas ! many who have been following with the greatest interest and care the truly wonderful dis- coveries in this practically new department of knowledge have felt quite convinced that the inference that all contagious poisons were of the same nature was a mistake, and that to attribute all communicable diseases to bacteria and allied organisms was not at any time to be justified by facts and observations. Now it would seem that we are again approaching the road by which we may eventually reach the con- clusion that contagious poisons are not all of the same nature. That some are bacteria is certain, but some, as I have said, are undoubtedly derived from the living matter of the body itself. Under this last head we must admit the possibility of the origin from time to time of some new disease-producing germ. Again, it is possible that some contagia may partake of the nature of peptones, which without being living, setup chemical changes, which, having once commenced, spread from particle to particle, by virtue of some contact action, the exact nature of which has still to be ascertained ; while it seems possible that certain com- plex chemical organic substances, which, though incapable of multipli- cation, may nevertheless initiate changes in an unaffected organism and establish phenomena like those which occurred in the one in which these chemically active substances were formed. Even if all contagia agree in being composed of living matter, they do not all belong to the same class or category. Some are themselves organisms that live like parasites in other beings, some possibly chang- ing their characters at different periods of developmental progress towards a form of life very different in character from them. Some contagious disease-producing particles consist of a form of livino- matter very nearly related to, and indeed emanating from, that of the 78 BACILLI, MICROBES, MICROCOCCL organism and result, in fact, from abnormal growth and multiplication of certain forms of living matter of the tissues or fluids of the body. In this process of descent from the bioplasm of a high to that of a low degraded form, the living particles lose some of the most striking of their original powers and acquire new ones, different from any possessed by the higher bioplasm from which they came. The most important of the livmg disease germs which are instru- mental in spreading contagious diseases are the following : — i. Bacteria, micrococci, and the still more minute buds and germs of these and allied organisms. 2. The germs of microscopic and other fungi. 3. Minute particles of living matter originating in the living matter of the organism itself. Of Bacteria, Bacilli, Microbes, Micrococci, and Allied Organisms. — Although there is much yet to be learned before we shall be able to give a full and accurate account of the exact way in which these, perhaps the lowest of the low forms of life in the world, are connected with disease and death in man, and in all animals and plants, so much has been demonstrated of late years towards proving that, at least, in many instances, there is a true causal connection, and it is therefore necessary that our attention should be directed to the consideration of a question of such great interest and consequence. While actual proof that the bacteria really cause the disease is in some cases wanting, the evidence in many is so strong that it is im- possible to avoid the conclusion that the connection is direct and intimate. On the one hand many, perhaps hundreds of species of bacteria are as harmless as their presence is universal, and, on the other, the entrance of certain forms into the organism is so soon followed by characteristic symptoms exactly repeated in case after case, that we cannot doubt for a moment that the minute living particle by its growth and multiplication in the blood and fluids of the organism, and by the changes it causes during its growth, is the direct cause of disease and death. Of examples of harmless bacteria you may find millions in and amongst the epithelial particles of the mouth and tongue of every one. Of the death-causing bacterium I cannot give a better instance than that of anthrax. So certain is its influence that if but a living particle less than the one hundred thousandth of an inch in diameter be introduced into the blood of certain animals, they will almost certainly have the characteristic symptoms in a short time, and will almost as certainly die. Wherever organic matter is undergomg change and disintegration in an organism, or outside it, at the temperature of man's body, or some deforces lower or higher than this, and in some cases at a much lower temperature, such organisms will be found in countless multitudes. They grow and multiply at the expense of the disintegrating organic FUNGI AND DECAY OK LEAVES. 79 matter. At this time of the year (October) there is not a leaf in which you will not find millions of low vegetable organisms in various stages of development and growth. As the organic matter of the dying leaf or plant undergoes change, and the decomposition of its more unstable compounds commences, the circumstances specially favourable for the growth and multiplication of many of the microscopic fungi will be established. Fungus germs exist in the air at every part of the earth's surface at all times. Though by no means constantly present in pre- cisely the same amount, some are always to be detected in appreciable numbers, if the air is properly examined. Many, coming into contact with the moist surface of the leaf about to decay, find there the con- ditions favourable for their development. The spores germinate, and from the surface of the tissues of the plant the growth easily makes its way into the intercellular spaces and into the cells themselves. But are we to believe, on the one hand, that the decay of the leaves is due to the fungi, or, on the other, that this decay is the cause of the development, growth, and multiplication of the minute organisms? All that can be proved by facts and observation is that as cells of the leaf grow old, substances are formed which are easily appropriated by the fungi. The germs of fungi are present and are ready to develop just at the time when the pabulum appropriate for each species is produced. The fungus does not spring from the leaf, neither is the leaf caused to grow old by the fungus, for its deterioration begins before the growth of the fungus commences. The fungus is probably in no sense either the cause or the consequence of the decay. And in the case of the higher animals and man, at least in many instances in which low organisms are associated with morbid processes, these last are neither the cause of disease nor are they produced by it. Fungus germs and micrococci of various kinds, being present, will grow and multiply whenever the surrounding conditions may be favourable for the life of each particular kind. If, however, the conditions remain for a considerable time unfavourable, the germs if present will remain quiescent, and may at last die, though probably many such germs retain their vitality in a quiescent state for many years — some possibly for centuries. Of these organisms there are undoubtedly vast multi- tudes of species, each having a life history of its own. In the case of every plant and animal there are probably several species peculiar to it. Nor are bacteria and micrococci found only at this period of the year (autumn) in connection with dead and decaying vegetable tissue. At all times millions are discovered in every particle of earth near the surface, and upon all bodies near it, in it, and upon it, in the bark and among the tissues of every tree and plant. In the vegetables and fruit we eat are countless millions of such living growing organisms. Look, for instance, at the cells of a piece of lettuce or of the leaf of the water- 80 THE EVER-PRESENT BACTERIUM. cress, nay, even those in the leaf and stem of the young and rapidly growing mustard and cress. There you will find, if you examine thin sections or the separated cells under a magnifying power of three hundred diameters or more, millions of little bodies, each of which is capable of giving rise to countless multitudes in a very short time. If you carefully study the revolving living matter of the cell of the leaf of the Vallisneria, you will have no difficulty in discerning some of these low organisms in close proximity to, indeed apparently in, the substance of the living moving matter of the plant itself. So very close is the lowest living particle to the highest during its life, that no wonder the material of the latter falls a prey to it at last. The instant the higher living matter ceases to live it is invaded and appropriated by the ever- growing bacterium — the most constant, the most unchanging and universal of all kinds of living things, and, if I mistake not, of all the survivor ; of all the most fit to survive as long as all forms must continue to die. Certain species of this minute organism are the best friends of posterity, if indeed they are not the only organisms that render continuity of the higher organisms possible. As with regard to deteriorating vegetable tissue, so it is with decay- ing animal tissue. Whether the body be in a state of health or disease, wherever tissue or any form of organic matter is about to undergo dis- integrating chemical change, wherever decomposition is taking place, or is approaching, the conditions will be favourable for the growth and multiplication of these low organisms, the germs of which are present. But long before any changes akin to deterioration and decay are ordinarily supposed to commence, even from the very earliest period of construction and growth, bacterial germs are ever present, ready to grow and multiply should the death and disintegration of a living particle occur, or even if the interstitial circulation of fluid should cease. No wonder, then, that we find so many low organisms growing in connec- tion with the old decaying epithelium of the mouth and of the tongue, of the oesophagus, stomach, intestines, and other parts. Under certain circumstances, bacteria and fungi grow and multiply to a vast extent in the lower part of the alimentary canal, as I shall presently explain. We cannot suppose that such organisms do harm ; for patients suffering from maladies in which the alimentary canal seems to be almost filled with bacterial growth of a certain kind recover, and without damage to any textures having been occasioned. I have not studied the epithelium from the mouth of a savage who has never been in contact with civilised man, but, without having actually looked, I feel pretty confident that similar low vegetable organisms, and some of the same species, would be found growing in the cells just as they grow in those of our own mucous membrane. In the lower animals, organisms of the same general character BACTKRIA SWALLOWED BY ALL ANIMALS. 8l abound. If you examine the tongue of the dog or of the cat, of the sheep or of the ox, you will find that the same sort of changes are con- stantly going on. Everywhere the old epithelial cells are being invaded by these organisms, which grow and multiply as they do in the epithelial cells of man himself. Multitudes, of course, pass down into the stomach, and, under ordinary circumstances, many are probably de- stroyed during digestion by the action of the gastric juice and bile, and other fluids, which are poured into the alimentary canal. Those that are not destroyed certainly do no harm. In the healthy state they either do not grow and multiply at all during digestion and assimilation, or comparatively to a very slight extent only. In the case of animals the introduction into the stomach of fungi of very many species, and other low organisms in countless numbers, constantly proceeds upon an enormous scale. Every mouthful of water consumed by sheep, oxen, and other animals constantly teems with myriads of low vegetable and animal organisms in various stages of development ; and in the food taken bacteria and many species of fungi in various stages of development are present, as well as the minute sporules of many different species. But although millions are always entering the alimentary canal of man and animals without doing harm, and probably without growing and multiplying there to any great extent, there are circumstances under which a different state of things is met with. If the stomach is out of order, if the bile and other secretions are deranged, or if on account of some temporary or permanent impedi- ment to their passage they are not poured into the alimentary canal in proper quantity, phenomena totally unlike those characteristic of the healthy state are induced. Many an infant has suffered from the extraordinary development of bacteria in its alimentary canal, and some children die from the state of things thereby induced. But the bacteria cannot correctly be regarded as the cause of the departure from the normal state. That is to be sought in the secretions and in the action of the glands prior to the multiplication of the organisms. I have seen every part of the cavity of the stomach, and of the small and large intestines of an infant filled with curdled milk which had not undergone the slightest digestion, and every particle of which, when under the microscope, almost seemed .to be composed of bacteria, so abundant were these bodies. Sometimes, however, bacteria grow and multiply in the milk of the mother before it has escaped from the breast, and the changes effected in the milk by the growth and multiplication of these organisms, it need scarcely be said, render it quite unfit for the sustenance of the infant ; and such milk, were it taken, would, except perhaps in the very strongest children, give rise to serious derangement of the digestive organs. In such a case the maternal secretion must have been out of order at the time G 82 DUST AND DISEASE. of its production, or the bacteria would not have grown and multiplied in it. It is certain that in such secretions and in the glands that pro- duce them ordinary bacteria-germs are invariably present, but they do not generally increase and multiply until long after the secretion has been discharged from the gland. Dust and Disease. — Erroneous notions have been spread far and wide by sensational phrases like " Dust and Disease." The " dust " which causes disease is of a most exceptional kind. It has been said that the air of the Swiss mountains is devoid of bacteria. But is the health and vigour of the inhabitants of the Alps to be compared with that of the workers on the Paddington Dust Heaps ? Bacteria in us. — There is not a part of the body of any one of us half an inch in diameter where bacteria germs are not present. Certainly every time we eat, myriads are carried into our alimentary organs ; and every time we breathe, except in the very purest atmosphere, multitudes pass into the air-passages. So small are these bacterial germs, that they would pass without the slightest difficulty through thin membrane and through the interstices of any of the tissues of the organism in all directions ; and yet the public has been taught to beheve that there is some intimate connection between bacteria and dust, and morbid phenomena. Dust may be dangerous or perfectly harmless. Ordinary bacteria are indeed harmless enough ; they exist in us without disturbing us in any way, but they only grow and multiply in great numbers when circumstances become favourable. I can give you positive proof that bacteria germs exist not only upon the surface of the skin and mucous membranes, but in all internal organs, in the inter- stices of healthy tissues, and in the blood itself. The view, therefore, that when these organisms are found in the tissues and internal parts they have entered from without shortly before their presence was de- tected, is incorrect. Some years ago I examined the layers of a fibrinous clot which had been slowly formed from the blood in the in- terior of a large aneurismal sac of the aorta of a man who died of the disease. The body was examined six or eight hours after death. The aneurism had existed for many years ; and probably some of the layers of fibrm which had been dei)Osited were almost as old as the aneurism itself. Now I found that in all parts of the firm, laminated, leather- like material, which served to greatly increase the thickness of the wall of the aneurismal sac, there were indications of disintegrating changes having taken place. Upon carefully examining minute pieces of the fibrin under high powers, multitudes of bacteria and their germs were discovered without difiiculty. But the older layers in the outer part were here and there softened, and portions of the fibrinous matter ?eemea eroded, many small masses of soft and broken-down material r.ACTERIA WITHIN THl': VESSELS. 83 being present. All these teemed with bacteria, moving, growing, and multiplying. Now these bacteria, like the fibrin in which they were growing and multiplying, were within the vascular system and very close to the blood, internal to the several tissues constituting the wall of the vessel, which was dilated to form the aneurismal sac. From their im- mense number and from the eroded state of the layers of fibrin, the bacteria must have been growing and multiplying in the lifetime of the patient, and for many months before death. They could not have got into the position in which they were discovered from the outside, for it is hardly conceivable that a bacterium could find out, while yet out- side the body, that within the vascular system of a particular individual there was material very suitable for its growth and multiplication. Neither in this case was it possible that the bacteria could have made their way from without to the situation in which they were found, nor could they have effected in the course of a few hours the extensive erosions and softening of the fibrin observed. Hypotheses such as these could not be suggested with any show of reason. The only con- clusion, therefore, in accordance with the facts of the case and with common sense, is that which I have adverted to : — viz., that bacteria germs e.xist at all times in all parts of the body, even in the blood itself during the healthy state. As long as the normal state of things exists, the ordinary living bacteria germs in all parts of the organism do not grow and multiply, but when any change occurs of such a character as may result in chemical decomposition, the germs multiply. The multiplication proceeds in decaying tissue-elements although we are alive, just as it takes place in dead animal and vegetable matter out of the body. Under certain circumstances bacteria grow and multiply in the capillaries of a tissue or organ, causing local obstruction or stoppage of the cir- culation. And the process will occur in every part of every one of us a very few hours after death has taken place, and in some cases even before death. In face of such facts, it is not reasonable to accept the doctrine that bacteria, fungi, and such-like organisms are invariably morbific^ or disease-producing, or are of themselves, at least under ordinary circum- stances, productive of harm to the organism into which they pass. The theory that such organisms, or closely allied organisms, or their patho- logically modified descendants, constitute the actual poison of most of the contagious diseases from which we suffer has been taught and accepted far and wide, and is now by many regarded as a true general principle. There are, however, many contagious diseases which are not due to bacteria, and it has been shown that many bacteria do not cause any disease at all. If, then, bacteria germs constitute the actual, material living particles by which specific contagious disease is propagated, they G 2 84 ACCESS OF DISEASE GERMS. must be special or peculiar bacteria, totally different from the ordinary bacteria germs which exist, and have existed everywhere. The ordinary bacteria may certainly grow and multiply enormously on the mucous membranes of the body, in follicles of the mucous surfaces and in viscera — intestinal canal, bladder, and passages therefrom — nay, even amongst the elements of healthy growing tissues, without causing any disease whatever. Bacteria germs, low fungi, and perhaps some low algae may exist in the tissues and fluids of the human organism. As you may convince yourselves at any time, millions of such living bodies are unquestionably present during every moment of existence in health on the surface of the dorsum of the tongue. Multitudes, as I have said, pass down the alimentary canal every time we swallow food or fluid. But putrid fluids laden with bacteria may not be innocuous. Organic matter in a state of putrefactive decomposition when introduced into the alimentary canal may give rise to pathological phenomena irrespective of the bacteria it may contain, and from the bacteria present bacterial growth may spread to the destruction of tissues and most important organs. Bacteria may pass into the capillaries, multiply withm them, stop the circulation or contaminate the blood, and the poisoning of the whole organism may be brought about in a very short time. Access of disease germs. — Bacteria are so very minute that they would easily pass through the thin delicate tissue which constitutes the wall of the capillary vessels, especially in the case of the lungs, where the membrane by which the blood in the vessels is separated from the air in the air cells is of extreme tenuity. Contagia gain access to the organism in different ways ; some suspended in the air we breathe, as those concerned in the production of Influenza, Whooping Cough, Measles, and other diseases, if, indeed, these affections are bacterial in their nature ; some, floating in the water and liquids we drink, some mixed with our food. For the passage of some into the blood an open wound is necessary. Vaccinia (?), Rabies, Syphilis, Glanders (?), Ery- sipelas, Pyaemia ; though whether all these conditions are actually due to bacteria is still an open question. For others, long exposure to the frequent or constant presence of the minute living organism seems to be an essential condition. In this last case it may be that the organism, retained possibly for a long time as in a fold of skin, at last begins to grow ; and diverticula from it, or possibly spores considerably smaller than itself, gradually insinuate their way into the body, move about till they find favourable situations, and then grow. Or possibly, in the case of persons not influenced by the wide-spread belief in the great impor- tance of cleanliness, these organisms or their germs may long retain their active living state in the mixture of secretion from within and dirt from without which collects in folds of skin and even on parts of the surface somewhat exposed to friction. Only by very slow degrees do the CONDITIONS OF BACTERIAL (;RO^VT^. 85 living germs at last gain an entrance and establish themselves in the tissues, but when this happens, changes characteristic of certain kinds and terrible enough, may soon result. For the successful and rapid growth and multiplication of most of the bacteria, outside as well as within the organism, rest seems a favourable, if not an essential, circumstance. A calm state of the air, more especially if associated with a considerable degree of moisture, still water, or other fluid, the surface of decomposing organic matters unruffled by air currents or internal movements, slow circulation or actual stagnation of the fluids within the body, are the conditions most favourable to the rapid growtli and multiplication of the organisms. On the other hand, the opposite state of things is inimical. It is therefore that which we endeavour to establish in order to prevent bacterial growth and accomplish the destruction of bacteria. Frequent cleaning of rooms, moving things in all the corners, brushing, sweeping, scrubbing, airing every part of rooms and passages and clothes and coverings, warming air, opening windows and doors so as to create air currents ; causing water to flow freely and frequently through all pipes and water courses — interferes with the multiplication of bac- teria. Whether by these or any other means the destruction of all or nearly all the organisms present is achieved is, indeed, doubtful, but that their numbers are greatly reduced, and many caused to pass into a dormant, inactive state, in which though they live they cease to multiply is pretty certain. Many contagia enter the body freely suspended in the air, or supported on dust particles floating therein ; not a few are directly introduced with water and different kinds of food. Some require to remain in contact with a certain part of the surface for a considerable time before they gain an entrance, and some can only get in through a wound or abrasion, but may of course be introduced by direct intentional inoculation with the aid of a sharp instrument pene- trating through the cuticle. That many disease-causing bacteria germs are air-borne, there can be little doubt. The poison of mumps, of whooping cough, and many more gain access to the organism by being carried into the lungs, possibly injuring the delicate nerve fibres lying just outside the capillar)' vessels and exciting reflex nerve actions in their course through the dehcate membrane into the blood. Some think that the tubercle bacillus gains access to the walls of the pulmonary air cells by being carried in this direct manner in the air during inspiration. Adhering to the wall of the air cell it would grow and multiply and gradually give rise to inflam- mation, leading to other changes, which result may favour the formation of what we know as tubercle. Whether we should regard tubercular disease as due alone to the presence, growth, multiplication, and effects of the tubercle bacillus is, however, questionable. Of its constant pres- 86 SPECIFICITY. ence there can be no question, but whether it be causal, concomitant, or sequential has to be determined. What, however, is not at all doubtful, is that at least many persons may be freely exposed, and for years, to the influence of the organism without contracting the disease. Some authorities teach that tubercular disease is contagious, but I cannot help feeling surprised, considering the evidence adduced so far, that this view should have been accepted. To me it seems very incon- clusive, and it is not generally acted upon in practice. From what I have been able to learn, there is no reason for a person in ordinary health to fear this contagium, if the individual exposed be in good health and be not of a pronounced tubercular tendency. Nor, in the existing state of our knowledge, should I consider it my duty, for example, except under special circumstances, to advise a wife not to nurse a husband who was dying of tubercular disease. If this were the usual way in which the disease spread, it would have been demon- strated long ago by the numerous instances in which those about the patient suffered from the disease. Specificity. — Of the existence of specific and peculiar properties and powers in bacterial organisms, so marked and so constant as to entitle different kinds to be regarded as distinct species, no doubt can be entertained. The evidential differences are almost as marked as those which distinguish a penicillium from a sugar fungus, or a mushroom from a puff ball. Moreover, the more carefully the several kinds of bacteria are studied, the more marked and more numerous are the differential characteristics discovered. The very numerous bacteroid bodies which infest different plants and different kinds of organic matter in a state of decay are probably distinct from one another, but whether they should be regarded as species I am not competent to decide. In some instances the specific differences are indeed remark- able. The bacillus of anthrax, for instance, differs from every other known bacillus in many well-marked characteristics. But while we note specific differences, it must be allowed that by growing and multiplying under conditions differing in certain respects from those present in the natural state, the characters of bacteria become modified, as was shown by Pasteur, and in some cases entirely new properties may be acquired. And to such a degree is this differ- ence sometimes carried that, as in the modified anthrax bacillus for instance, if the modified organism be introduced, the animal, instead of being destroyed by anthrax, will live, and such changes will be effected in its fluids that for the future the creature will resist the destructive action of the normal anthrax bacillus. In other words, the animal is afterwards protected from anthrax, though not in the same way as the human organism is protected from small pox, by the growth and multiplication of the living particles of the vaccine ORIGIN OF SPECIES AND VARIETIES. 87 lymph inoculated in the operation of vaccination. But because by growth and multiplication under artificial conditions, which are not supposablc in nature, new properties are somehow acquired by some organisms, it must not be assumed that it is in some such way that all species result. The argument from artificial to natural selection seems almost as unjustifiable as the argument from non-living to living. There is what I would term a natural inherent specificity and there is an acquired artificial specificity. In the first case reversion is slow, if not exceptional. In the last, the early death of the organism alone prevents reversion to the original form. In not a few cases the new specificity is associated with a tendency to weakness, exhaustion, and early death of the particular organism. Some have attempted to surmount the difiiculty of accounting for the origin of such a multitude of bacterial species or varieties, each having the power or property of causing a definite disease, by the conjecture that ordinary bacteria, like higher organisms, are themselves the subjects of rapid pathologic evolutional change. It is surmised that an ordinary bacterium living under particular but at present unknown conditions, might give origin to pathologic bacteria of the vilest nature, and these might further change, and give rise to absolutely new disease-producing organisms. But in this way, conjecture is added to conjecture, and the evolution of one hypothesis prepares for the evolution of many more. New forms of being are assumed, and pathological prodigies are added to the already multitudinous new creations of the evolutional imagina- tion. As a fact, we find that the pathological phenomena occurring in man and the higher animals become less specific as w-e descend in the scale of created beings, and it is doubtful w^hether in the lower simpler forms of life any phenomena occur to which the term pathological or morbid is strictly applicable. That an Actinia or a Hydra may suffer from pathological change, is certain, but that organisms very much lower in the scale and simpler in organization than the above should be capable of undergoing change which could De properly regarded as morbid or pathological, is very improbable. The suggestion of bacteria naturally taking upon themselves a sort of pathological transformation, and developing by degradational evolution a bacterium of vileness and virulence potent to produce, it may be, new and fatal forms of disease, is a wonderful conjecture. The broad facts of nature are entirely opposed to it, though, as above remarked, by growth and multiplication under certain artificial conditions, new and often extra- ordinary properties may undoubtedly be acquired ; but for how many generations these may be retained is not decided. Conditions varying within the limits of nature which in high and complex organisms would result in pathological phenomena, in these low forms merely determine an alteration in the rate of growth and multipli- 88 CHANGE IN SPECIES. cation. The change in such an organism as the yeast plant, which seems to correspond to the process of formation of pus in man and the higher animals, is more rapid multiplication by the division and subdivision of the living matter (bioplasm). The bacterium would appear to be much lower and simpler as regards the varied conditions under which it will live and grow, than the yeast plant. Indeed, under ordinary natural conditions the bacterium seems to be one of the most constant and unchangeable of all forms of life, and if by artificial methods adopted by us, artificial forms are caused to spring from it, these if left alone would die or revert to the primi- tive constant form. Still, it is possible that great change in sur- rounding conditions might cause the development of bacteria with new disease-causing powers, from pre-existing harmless varieties or species. But the ordinary bacterium growing and multiplying under natural con- ditions is among the least varying of all living forms. The organism that grew and multiplied in dead bodies at the time of the Pharaohs is probably identical with that which is associated with the decomposition of the organic matter of the human body in our own time, and possibly germs may have lain dormant in the mummy for ten centuries and produce descendants now. Nor is there any reason to suppose that, should the world last as long, any alteration will take place in the characters, mode of growth, and disintegrating capacity of the bacterium some thousands of years hence. Moreover there is no good reason for concluding that the bacterium of very ancient geological epochs was different from the form flourishing everywhere to-day. Looking broadly then, one most striking fact in connection with bacteria is, that countless millions of similar forms in endless repetition have been produced with- out change in power through past ages, and will be produced through the ages yet to come. We must, therefore, be very careful as regards the acceptance of so-called evidence of change in property and power of living organisms of this low class so long as they are freely left to grow and multiply in their natural way. I would sum up thus : — In spite of the facts which incline one to doubt whether the views here criticised can be accepted, it must be admitted that some low organisms by being placed undei altered conditions do in multiplying acquire new properties, or at least properties far removed from those which the bacteria from which they have been derived possessed. i\nd wonderful to relate, certain very low and simple living organisms, though differing but very slightly from the original and as far as we know ordinary forms, if introduced into the body will not destroy life, but will grow and multiply and establish changes which, though harmless, protect the host from the dire consequences of invasion by the original virulent form. Such results established by Pasteur lead us to hope that further research will show us how by the attenuation of the virus of many contagious diseases, CHANGE IN SPECIES. 89 by protective inoculation, our successors may succeed in effectually escaping maladies which are fatal to not a few of this generation. The apparently new forms constituting the attenuated virus arc perhaps but temporary modifications, the descendants of which would soon resume the old type. Divergence and reversion in a limited and very moderate degree, and in forms of life much higher than the bacterium, occur, and may be frequently repeated, without ever leading to or resulting in any lasting change of type. Cases in which the specificity of a contagium is very strongly marked exhibit such great variation as to the intensity of the symptoms produced, that it has been said that the type of the particular disease varies from time to time. And what is still more remarkable, an epidemic which appears at the outset to be slight may become a very severe one, or vice versa. In some cases the contagium continues to gain in virulence during a certain period, and then the intensity of action of the poison seems to be gradually reduced until the epidemic completely ceases. One of the most remarkable facts discovered in connection with bacilli is that certain virulent organisms are destroyed by certain other forms. Even the anthrax bacillus, one of the most inveterate, is destroyed by the pyocyanic bacillus ("Chassin La Maladie Pyocyanique," Paris, 1889). In this way the living virus of one contagious disease may be destroyed by the introduction of another. Most bacilli lose their power of growth and multiplication after remaining for a time in a dead body buried in earth. The period varies much, some bacilli dying or more probably becoming dormant in a few days after death, while some retain their activity for several weeks. The spores in many cases resist the influence of adverse con- ditions for a much longer period than the bacilli themselves. The spores often survive under conditions which are fatal to the bacilli. According to E. Von Esmarch, pathogenic microbes disappear quickly after death {" Zeitschrift fiir Hygiene," Bd. VII, Seite i, 1889; "British Medical Journal," December 28th, 1889, p. 1465). Vignal has shown that the nature of the food has an influence upon the quantity and quality of the ferment formed by the common micro- organism (Bacillus Mesentericus Vulgatus, the Kartoffel Bacillus of Koch, "British Medical Journal," December 28th, 1889, p. 1465). There is no doubt that in wards in which numbers of patients have been received and treated over considerable periods of time, infective germs may increase in virulence as well as in number. The fact is proved by the frequency with which wounds become septic. The intensity of the disease, as well as the certainty of infection, increases according to the reduction of ventilation and room space and the increased number of sick. Is this an example of the formation of a pathological infective 90 INFECTIVE BACTERIA GERMS. bacterium from a common, universally distributed harmless one? On the other hand, by thoroughly cleansing the walls, floor, and ceiling of a thoroughly infected apartment, and leaving all the windows open for a considerable time, the infective tendency will disappear, at any rate for a time, and recent wounds will heal satisfactorily. 3IultipIicatioii of Bacteria in the Organism. — One or a few living particles soon after gaining access to the blood or lymph or interstitial fluids begins to grow and multiply. The multiplication may proceed until the number formed exceeds perhaps by many million-fold the actual number originally introduced. While this is going on there may be no observable disturbance of tissues, organs, or functions. The period during which multiplication proceeds is different in the case of different specific disease-producing particles, and may be a few hours only or it may extend to many days. This quiescent time is called the period of incubation. Some of the contagia increase and multiply out of the body as well as within it, and may thus increase as the condition caused by their presence spreads. Some, perhaps, pass part of their existence outside and attain another phase of development in the fluids in the interior of the body. The complete life-history of many species of bacteria has yet to be discovered, and it will probably be found that not a few- exhibit very different characters in different stages of their development, and possibly one organism in different phases has been mistaken for several distinct specific forms. Some bacteria live and grow for a time in the ground or in water, reaching another stage and becoming free in the air, and perhaps at last attain their latest and fully-developed form in our bodies, should we be so unfortunate as to be doomed to act , the part of host and provide for them the necessary conditions required for their free multiplication and still wider distribution. One of the most typical effects of the multiplication of bacteria within the circulating system is seen in weak frogs towards the end of winter. The course of some of the capillary vessels may even be as easily seen in the microscope as if they had been injected, in conse- quence of being completely choked with collections of bacteroid bodies. Whether such collections are to be found in all frogs towards the end of the hibernating period I cannot say, but I have found them in several. If not very numerous the collections might break up, and after being propelled for a time with the blood, many of the organisms probably die and the products resulting from their death are soon eliminated. Of the younger and more vigorous organisms some perhaps are retained in the splenic vessels and in other parts of the vascular system where the circulation is slow, to increase and multiply again whenever the surrounding conditions become favourable. There cannot be any doubt that local congestions or stagnations of GROWTH AND MULTIPLICATION IN THE BODY. 9I blood in the capillaries of certain tissues of man and the higher animals are due in the same manner to the presence, growth, and multiplication of bacteria. It is also almost certain that the fibrin around them and the substances resulting during their growth and multiplication, being gradually disintegrated, pass little by little into the blood current. They then get gradually oxidised and are thus slowly removed from the system. But some of the living germs still remain in the vascular system, not a few being embedded in the matter of the colourless blood cor- imscles, while probably some continue to freely circulate in the blood current. Under certain alterations in the composition of the circulating fluid these would rapidly increase and soon lead to that condition being established which is known as septicaemia, a form of blood poisoning, which may soon end fatally, or occasion serious illness of many weeks' duration, terminating at last in recovery. The conclusion, then, is now pretty widely accepted that the con- tagious matter, the contagium instrumental in the production of communicable diseases, is a bacterium of some kind or other, a living organism of very simple form, occupying a low position in the scale of life and far removed from the organism in which it produces dire results. But as bacteria germs are always present in a quiet or dormant state in the tissues and fluids of the higher animals, a great change must ensue before they can grow and multiply. For instance, from some disturbance in the capillary circulation a portion of tissue may be destroyed, and pass into a state of putrefaction. The blood itself is poisoned, and this preliminary change seems to be necessary to the growth of the bacteria. An exceptional state of things, widely differing from the normal condition, is, in fact, in the first instance necessary. The phenomena, which in man and the higher organisms ordinarily interfere with the growth and multiplication of the ever-present bacteria, give place to something very exceptional, and the cause of this, not the bacteria alone, seems to be the real cause of the morbid condition which may result in death. In controlling certain forms of contagious disease besides the presence of the bacterium or other form of disease germ, there must also be a particular state of the fluids of the body before the person can become infected — multitudes of germs may be present and obtain en- trance into the body and yet the individual may continue in perfect health and completely escape attack. It is therefore of more importance that we should all endeavour to keep ourselves in good health than that we should be ever struggling to shun places and persons supposed to be infected. Were it not for this knowledge our medical duties would be attended with far greater risk to life than is really the case. Some per- sons seem to be almost proof against invasion and may have been sur- rounded with contagion, and of a virulent kind, and nevertheless escape. 92 POISONOUS ALKALOIDS. Poisonous Alkaloids, Ptomaines and Leuconiaines. — Pfonidines. — In the putrefactive decomposition of albuminous matters which ordinarily begins soon after death, and in which bacteria probably play a very important part, certain alkaloids are formed. The bodies in question are known as Ptomaines, and some are highly poisonous. Several have been isolated and their properties investigated. The substances in question have recently been investigated by Gautier and have been divided into two classes. I, those which contain no oxygen : — Parvo- line, Hydro-collidine, CoUidine, Neuridine, Cadaverine, Putrescine, My- daleine ; and II, those which contain oxygen : — Neurine, Choline, Muscarine, Gadinine. Some are highly poisonous, and some inert. The so-called " Fever of fatigue " is thought to depend upon the ac- cumulation of certain ptomaines in the blood. The composition of several has been accurately determined by different distinguished chemists, and the result of their researches will be found in Dr. Brown's work on Ptomaines and Leucomaines. Leucomdines. — During the disintegration of some of the albuminous matters in the physiological changes in the living organism, several substances allied to organic alkaloids are being constantly formed. The chemical composition of some of these has been determined and their poisonous action proved. In health they are removed, but if from any circumstance they accumulate in the blood, deleterious action is pro- duced. The bodies in question have been called Leucomaines. Among them the following are enumerated by Pouchet and Gautier, and are thus arranged by Dr. Brown in his work : — Group I. The Betaines, or Uric leucomaine group ; Betaine, Karnine, Adenine, Guanine, Sarkine or Hypoxanthine, Xanthine, Pseudoxanthme ; Group II. Kreatinine, Xanthrokreatinine, Crusokreatinine, Amphikreatinine, Pseudoxanthine ; Group III not yet well defined, found in urine, in blood, intestines, saliva. Leucomaines in the healthy state are continually being produced during physiological changes, and are no doubt removed with a number of excrementitious matters as fast as they are form.ed. Probably many slight and temporary departures from the normal state of health are due to the accumulation in the blood of these substances, or to the temporary derangement of the organs whose duty it is to eliminate them ("Animal alkaloids; cadaveric and vital; or the Ptomaines and Leucomaines chemically, physiologically, and pathologically con- sidered in relation to scientific medicine, with an introduction by Prof. Armand Gautier." By Dr. A. M. Brown. Hirshfeld Brothers, Bream's Buildings, Fetter Lane, London, E.G.). Many general disturbances which have never been adequately accounted for may result in an indirect manner through the action of these substances. First, there may be an accumulation of excrementi- PTOMAINES. LKUCOMAINES. 93 tious and toxic substances in the blood ; and, secondly, in consequence of the action of these upon branches of afferent nerves distributed to the capillaries of different parts, — would be caused, — thirdly, disturbance in nerve centres immediately followed by changes in parts supplied by efferent nerves starting from the nerve centres thus influenced. In the production of some of these animal alkaloids, bacterial organisms are no doubt concerned. The bacteria may live their life and die without any harm resulting to the organism, but after their death the soluble toxic alkaloids which result may soon occasion serious changes by poisoning the living matter of important tissues and organs, and indeed cause rapid death. Or, during their life bacterial organisms may give rise to ferments which cause chemical changes in the course of which animal alkaloids among other products will be formed. The activity of these ferments in some cases does not appear to commence until the microbes themselves are dead. The toxic effects of the alkaloids and other poisonous substances is no doubt dependent upon the state of the processes connected with elimination. If the substances in question be very quickly excreted no harm will result, but if the excreting organs act imperfectly, an accumulation in the blood will take place, and in certain cases to an extent sufficient to cause death. It is possible that beneficial effects may result from the production of these ferments, or from the chemical compounds resulting from their action, in consequence of the establishment of a state of the fluids unfavourable to the support of bacteria. In this way a protective influ- ence from future attack may be brought about. "Attenuated virus" may be capable of effecting the necessary changes required for the pro- duction of the compounds which exert a protective influence without giving rise to a quantity sufficient to damage tissues and organs or to endanger the life of the organism. Although we have long been aware of the serious consequences which result from the accumulation and retention of excrementitious matters in the blood, and the class of substances known as extractive matters, recent researches have shown the existence of a number of chemical compounds quite new, many of which are crystaUine and have well-defined characters. This is an extremely interesting section of the very large subject of Bacteria and their effects upon the higher organ- isms but it cannot be further considered here. The reader is referred to Dr. Brown's work, of which a second edition has been recently pub- lished and in which full references will be found to the memoirs of some of the most recent distinguished investigators, also to Dr. Lauder Brun- ton's researches, " Gulstonian Lectures," 1889 ; and to a small work lately published : " On the animal Alkaloids, the Ptomaines, Leucomaines, and extractives in their pathological relations," by Sir William Aitken, 94 CONTAGIOUS LIVING MATTER ORIGINATING IN THE Ivnt., M.D., LL.D., F.R.S. Second edition. H. K. Lewis, Gower Street. Contagious Living Matter Originating in the Organism of Man or .vniniai!^. — While the contagium of some diseases undoubtedly consists of bacterial or allied organisms, it has not been proved that all or nearly all contagia are of this nature. The evidence that some contagia are produced in the organism they damage or destroy, seems to me con- clusive. Such contagia consist of living particles derived by direct descent from the living matter of the tissues and fluids of the body, which living matter being supplied with an increased amount of nutrient material, grows and multiplies very rapidly, and soon gives rise to multi- tudes of particles of living matter, having new powers and capable of living and multiplying under new conditions. It has been objected that the materies morbi of contagious diseases cannot consist of the modified living matter of the body itself, because the healthy living matter rapidly undergoes change when removed from the seat of its growth, and very soon dies. But he who accepts this apparent objection ignores most important facts, and seems to forget that, for example, among many other bioplasts, those of healthy ciliated cells retain their vitahty for many days after the death of the body ; the bioplasm at the base of the hair, and that in the deep layers of the cuticle, also resists for a considerable time the destructive influences which quickly destroy the living matter of many of the higher tissues of the healthy body. Then from how many of the tissues may small portions be taken and transferred to another organism in which they will live and grow, perhaps long after the organism from which they were taken has ceased to exist ! Many " disease germs " which invade man and animals are com- posed of living matter formed in and belonging to the organism, and are not in any way related to bacterial bodies. The virus of small pox and that of vaccine lymph are of this nature. The micrococci which have been seen in vaccine lymph and figured, are not, I believe, the particles which possess the potency. In lymph, in chyle, in blood, and probably in most of the interstitial fluids, very minute particles of bioplasm, much less than the i-ioo,oooth of an inch in diameter, exist in countless numbers. Particles of morbid bioplasm introduced into the fluid would mix with these, and could not be identified or distinguished. But although like them in appearance, the vital changes of the living particles in question are different, and it is probable that after growing and multiplying for a time many of the morbid particles resulting from the multiplication of those introduced may escape from the body, while those left in the tissues and suspended in the fluids die, and the products resulting from their death may render the fluids incapable of supporting any new particles of the same kind that may be or(;anism of man or animals. 95 introduced, and tlius " protect " the organism. In this way may be estabUshed tliat wonderful state known as protective influence, such as is brought about with respect to small-pox virus by the influence of that of vaccinia, and which may last for years, though its influence is of limited duration. It is the knowledge of this fact which has led to second vaccination being enjoined. Some of the above and many more cogent and striking facts are feebly alluded to or wholly ignored by some of the bacterial enthusiasts. General views have been founded on highly partial considerations, and the judgment of some seems to have been warped from the first by the confident assertions and extraordinary delineations of speculative authorities like Hallier. In spite of all that has been urged in favour of a general bacterium hypothesis, it must at this time be admitted that in many cases the specific bacterium of par- ticular diseases has not yet been identified. So far I feel unable to accept the idea that bacteria are instrumental in the production of pus corpuscles. That bacteria and pus corpuscles are often associated is perfectly true, but I cannot admit that it has been proved or even rendered in slight degree probable that the bac- teria have had anything to do with the production of the pus corpuscles. This at least is the conclusion forced upon the mind by microscopical investigation. In some of the drawings in which the bacteria and pus corpuscles are shown, certain pus corpuscles are seen here and there with no bacteria near them. When ordinary pus corpuscles are rapidly growing and multiplying very few bacteria or none are to be found, while when the pus corpuscles have ceased to move and are dead, and after death while they are undergoing disintegration and decomposition, multitudes of bacteria are invariably present. And these increase in numbers as the process of disintegration goes on, until the pus corpus- cles are wholly disintegrated. Just as many of the lower forms of life by growing and multiplying under certain altered conditions lose some of their old properties and acquire new ones, or their old properties undergo such modification that they produce effects totally different from any of their predecessors, so the bioplasm of the tissues and blood of man and animals acquires in process of multiplication under altered conditions, new properties and characteristics. But while the bacteria germs may in their further growth revert to their former type, the morbid bioplasm never produces descendants having the formative power of the bioplasm which gave them origin. As the bioplasm of man's body acquires increased power of growth, it also acquires increased power of resisting the destructive influence of external conditions. The movements of the morbid bio- plasm of the pus corpuscle, showing that it is alive, will continue long after those of the healthy bioplasm of the tissues and the white blood corpuscles have ceased, and it is certain that other forms of morbid g6 DISEASE GERMS. bioplasm originating in man's body exhibit far greater resisting power than that manifested by pus. In my work on "Disease Germs," p. 256, I endeavoured tjD show how a highly virulent contagious germ might result from the gradually increasing rapid growth of normal living matter. The evidence ad- duced and which was afforded by careful microscopical examination was strongly in favour of the conclusion that the virulent germ was derived by direct descent from normal bioplasm, and that it was not in any way related to bacteria or to any particles derived from without. And, as regards this particular contagious matter it has to be observed that when it is most virulent very few or no bacteroid bodies are to be found, while as the latter increase in number the degree of virulence is reduced and at length departs. The virulent contagious bioplasm just referred' to is closely related to pus, and it is well known that certain forms of pus possess the most active septic properties. These I think are inherent in the particles themselves and are not to be attributed to the fluid in which they grow, or to the bacteria which may be present in large or small numbers about them and in their substance. The process of pus formation may be studied from very different points of view. Suppuration may be considered as it occurs in a large abscess or in a pustule containing a small quantity of pus, and the changes occurring in an individual cell or elementary part in which pus formation is proceeding may be carefully studied by microscopical investigation. The genesis of pus-like particles of bioplasm may be investigated in epithelial cells, and particularly in those of the vagina and in some of the forms of bladder and urethral epithelium, as well as in the bioplasm of the lacunae of bone, in that of muscle, nerve, and other tissues. Pus formation may also be followed in some cuticular epithelial cells which have been exposed to the action of a blister. It is well known that healthy cuticular cells will live and grow if removed with certain precautions and grafted on a surface of the body of another person properly prepared for their reception. But the pus- like particles of bioplasm resulting from the rapid growth of that of normal epithelial cells, have during their formation gained the power of rapid growth and of growing under altered conditions. If a few pus corpuscles thus produced be transferred to the moist conjunctiva of the eye, they will take up nutrient matter, grow, and multiply at such a rate that the surface of that delicate mucous membrane is either damaged or completely destroyed. The evidence advanced in favour of the view that the formation of pus is due to bacteria seems to me altogether inconclusive, while it is evident that those who support the bacterial hypothesis of pus- production are not familiar with the changes which occur in the GROWTH OF rUS BIOPLASM. 97 bioplasm of many elementary parts in the early stages of inflammation. Under some circumstances, bioplasm originating in that belonging to normal tissues may attain such a rate of growth and acquire such power of living and growing under altered conditions and on different surfaces or in different tissues and fluids, and even in other species of organisms, that the most important physiological actions in the body invaded become seriously deranged; indeed, the pus may act as a virulent conta- gious poison which may, and in a very short time, destroy life. The intensity of the virulence really seems to increase with the increased rate of the production of the bioplasm. It looks as if free access of nutrient material to normal living matter and its appropriation, resulting in rapid multiplication and in exaggerated growth, might give rise to the development of a morbid bioplasm of the most destructive character. The growth and multiplication of pus-bioplasm may be studied under the microscope. Movements of the matter of the bioplasm very like those of leucocytes may be watched. Diverticula of the perfectly clear structureless living matter forming the basis of the living corpuscle are seen to make their appearance and project and move away from the surface of the mass. These are from time to time detached. Each little particle soon grows, and in this way rapid multiplication takes place. One is thus able to give a reasonable explanation of the origin of living pus-corpuscles in the living bioplasm of a tissue without the aid of bacteria, and it seems probable that those organisms follow instead of precede the early pathological changes. But admitting for the moment that bacteria are the true cause of suppuration, what are the stages which may be noticed from the first introduction of the bacteria, onwards, to the development of the fully-formed pus corpuscle, and how are the organisms supposed to act? What in fact is the pus corpuscle from a bacteriological point of view ? In the same way we may fairly ask how the bacillus of tubercle acts towards the bioplasm of the pulmonary tissues, and what is its relation to the so-called tubercle corpuscles and the other anatomical elements with which it is associated and which seem to perform a far more active part in the disintegration of the lung tissue and in the destruction of the patient's health and life than the minute and slow-growing bacillus itself. But pus formation can hardly be considered apart from inflammation — a vexed subject concerning which very diverse doctrines are taught, which cannot be further discussed here. The views above advanced are based upon observation of inflamed tissues of different kinds and at different periods of the process. I am sorry to say that in some very recent memoirs on the subject I find a number of words and phrases introduced the meaning of which is most obscure. Those who call to H 98 ANTISErXICS. their aid processes or conditions under such terms as " damage," " suspended vitahty," " lowered vitahty," " weakened vitahty," and speak of "weak tissue," "irritation," and the Hke, should at least define what they mean by them. Such phrases ought to have been buried long ago, but they are still employed as if everyone could define them and understood what was meant by the authors who use them. This revival of what I cannot but regard as mediceval pathology and of antiquated methods of explanation seems to me most unfortunate. Until it gives place to views more reasonable and more in accordance with what can be observed it is almost impossible, if not perfectly useless, to attempt to discuss the nature of the actual changes occurring. Precautions to be taken against the Spread of Disease Germs. — Unquestionably the liability to take contagious diseases varies con- siderably in different individuals exposed to the same influences and in the same individual at different times. While children are as a general rule much more susceptible than adults, we do not know precisely upon what the difference depends, but we should perhaps look for some variation in composition of the interstitial fluid of the tissues or of the blood itself to explain the facts. Stagnation and slow movement of the fluids — slow and but moderate interchange of nutrient materials — the slow and incomplete removal of excrementitious matters in all parts of the organism, must be regarded at least as circumstances favourable to the entrance, growth, and multiplication of the living contagium. Sa too, in the case of allied low organisms which pass their existence out of our bodies, are stillness, and very slight disturbance of humid air or still water favourable to their growth and multiplication. As it has proved impossible to utterly destroy many forms of contagium, our efforts have for long been directed to the discovery of means by which we may protect ourselves and others from invasion, and prevent the growth and multiplication of the germs which may have gained admittance to our fluids and tissues. The researches of Lister have clearly proved that the disastrous changes liable to occur in wounds may be prevented by dressing them in such a way that the access of living germs from without would be prevented. There are many ways of obtaining this desirable result, but in all that can be relied upon it would appear that bacteria are destroyed or conditions are established which have been experimentally proved to be hostile to their activity as well as to their growth and multiplication. But in spite of scientific and practical evidence accepted, con- firmed, and acted upon by hundreds of hospital surgeons in all parts of the world, in favour of the use of antiseptics for the purpose of destroying and preventing the growth and multiplication of bacteria, it is positively affirmed by some surgeons that many if not all the precautions taken to prevent the access of germs to wounds are super- OI'F'OSITIOX TO ANTISFJ'TICS. 99 Huous and useless. Nothinj:; can exceed the confidence and decision with which views opposed to those recently ado[)ted have been announced and acted upon. Not only are no antiseptics employed, but their use is condemned. In operations for ovariotomy Dr. Bantock employs no antiseptic whatever. In the fourth hundred of the cases operated upon by him with the use of plain water, the mortality was only four. Following the practice of Mr. Lawson Tait, Ur. Bantock washes out the peritoneal cavity with warm water, using a pint or a quart jug, a clean Higginson's syringe or Mr. Lawson Tait's apparatus. He says : " I have never known any evil result follow its use, but I have several times regretted that I did not resort to it. Nor am I at all particular in getting all the water away. ... I have washed out the peritoneum in more than one-half of the last hundred cases in the table." Again, " Once more let me say that for my hands, instruments, and sponges I use plain water ; that I take no precautions to sterilize it, as it is called, by boiling ; that I regard water that is fit for drinking and household purposes generally as suitable for the purpose of any opera- tion ; that while the water is heated — but not necessarily boiled — I have no hesitation in cooling it down, if too hot for my hands, with cold water drawn fresh from the tap, as, for instance, when washing out the peri- toneum, and that I pay the greatest attention to cleanliness and see that all utensils are as clean as water can make them. I wash my hands very carefully before commencing an operation, making them as clean as soap and water and a nail-brush can make them, and I frequently cleanse them during the operation. As a covering to the wound I employ simple absorbent gauze, perfectly innocent of any germicide or foreign substance. And such is my belief in the hurtfulness of 'germs,' that, were it not for other considerations, I would leave all my wounds exposed to the air — as, for example, I have sometimes done in amputa- tion of the breast, and always do in the operation for restoring a ruptured perineum." Appendix to a paper on " Hyperpyrexia after Listerian Ovariotomy," Royal Medical and Chirurgical Society, De- cember, 1880. See "Provincial Medical Journal," December 2, 18S9, p. 721. But to assertions that operation cases do perfectly well without any antiseptic treatment whatever, it may be replied that at least in con- taminated wards or rooms the antiseptic treatment will save many cases that would otherwise very soon become septic — that even under still more favourable circumstances wounds heal more slowly and less equably than where antiseptics have been used in every case. Eye operations seem to be a delicate test of septic poisons. Can such be performed in ordinary wards in which no antiseptic precautions have been taken? Has the knee-joint been opened with success without antiseptic precautions ? Dr. Bantock says he would do so without lOO DOCTORS ACCUSED OF DIFFUSING CONTAGIA. hesitation, for he can see no difference between the synovial membrane and the peritoneum. This, however, is not proof that it may be done. If operations can be successfully conducted in air contaminated with septic germs which would infallibly produce a deleterious influence if no such steps were taken, there is an unanswerable case in favour of anti- septics from the practical side. This, as far as 1 am able to learn, is undoubtedly the fact. In other words, operations may now be performed in general wards with safety which could not have been undertaken years ago without the most serious risk to life, while by the antiseptic S3'stem results as satisfactory may be obtained in densely populated places as can be looked for in the purest country air. It is incumbent upon those who maintain that the favourable results attributed to antiseptics are really due to cleanliness and water only, to show what the cleanliness really does, and exactly what is the nature of the deleterious matters that are removed by the frequent hand-washings and extreme care in the thoroughly cleaning everything that is to come into contact with the wound. Is the substance in their opinion of a chemical nature, or is it a lifeless ferment or a living germ ? If the last the advantageous influence of antiseptics has been conclusively proved experimentally. If the former, it is for the opponents of anti- septics to show how these act so favourably as they do in general wards in which, before their use, many operation cases went wrong, This remark particularly applies to ovariotomy, and I regret to say the evidence in the past was only too conclusive. If the opponents of antiseptics are constrained by the facts to admit their utility only in the very slightest degree, the case for their general employment is established. In spite of all the care that we have taken to restrict, as far as possible, contagious fever and other germs to the space and things immediately around the individual patient suffering from their presence, as well as to prevent their being carried about through the carelessness of attendants, complaints of the most serious kind have been made by persons who know little about us and our methods, but who appear to find consolation in the condemnation andmistrust of medical knowledge and action. We are accused of being the culpable germ-carriers from the sick to the healthy, and the distributors of contagious diseases to the people. Never was a charge more gratuitously made, or more groundless. Surely it is well known to the public that we, and our predecessors, have always done our utmost everywhere to destroy dis- ease and to prevent its spread. The observations of the Registrar- General conclusively prove that our efibrts have been attended with success. But it is curious to note that as soon as any ingenious person reports the discovery made in the recesses of his own imagination of something connected with medical matters, the cause is at once taken DOCTORS WRONGLY CHARGED. lOI up by the newspapers, and medical wrongs and evils out of number are discovered, reported far and wide, and commented upon for the public benefit. Parties are formed, strong letters written, addresses delivered, deputations appointed ; the peccant germs are to be brought before Parliament, and all members of the profession to be subjected to new laws, in order that the supposed wrongs may be righted. The artificial excitement after having been kept at a white heat for a week or two, gradually gives place to some other and equally artificial and uncalled- for suggestion. In this way people are needlessly alarmed about the propagation and spread of vile contagious germs, and sick people made to fear that the doctor treating them for one malady is perhaps bringing to them the germs of another, and is the bearer of more contagion than consolation. One of the last terrible disclosures published far and wide was that cases of contagious disease were sometimes treated in the general wards. We are, therefore, to be ordered to at once send every suspected case of contagious disease to the Fever Hospital or to an Asylum Board Hospital, perhaps four or five miles away. If such ad- vice were generally acted upon, it would sometimes happen that patients suspected to be suffering from contagious disease, but really free from any form, would be put into an infected place, and there infected, and have to pass through a serious disease which but for fussy ofificiousness they would have altogether escaped. If only the public were well informed upon these matters they would thoroughly trust us and protect us from the continual interference of restless people who, under the guise of philanthropic effort, are damaging the reputation of useful institutions, and assisting to destroy public confidence in hos- pitals and hospital ofificers. Instead of helping us to do all we can for the helpless sick poor, the real effect of injudicious fault finding and spreading terror of contagion, is to render it more difficult for us to act for the best, and to obtain the necessary means to provide for the sick who are suffering from serious disease. It is very curious how many amateur half-medical people, with extraordinary self-confidence, seem to consider themselves specially licensed to attack the profession of medicine. There is no other calling so constantly and so cruelly assailed. Now and then it is true we are patronised a bit in a half-apologetic manner, and it is reluctantly admitted that, under certain circumstances, we may be of some little temporary use. Every opportunity of fault finding with unendowed hospitals, deserving very different treatment, seems to be taken — in- stitutions which have been admirably officered by generation after generation of physicians and surgeons, and warmly supported by the generosity of friends, and the self-imposed labours cheerfully performed by enthusiastic committees. The public should protect us from the continual carping of people who desire to get power over institutions 102 DOCTORS ACCUSED and funds not belonging to them. Hardly a session passes without Parliament being moved to institute enquiries into some hospital ques- tion, magnified by fervid imaginations into an abuse, in order that the fault finders may have the chance of convincing the world how much better the work would be done and the money spent if they were requested to take the place of the committees and the doctors, and administer the affairs of all the institutions, according to the principles they had been good enough to lay down. If practitioners really were the carriers of contagion, would not the fact have been long ago proved by the circumstance of their own families being the first to suffer? The gloomy forebodings of bacterio- logical pessimists are surely but the offspring of their own morbid imaginations. How many of us have attended general hospitals for years, as well as cases of contagious disease in the homes of the poor, and have escaped ? Now and then it is true a disease is contracted in the course of our work, but with the precautions taken such an event is rare indeed. I have been in hospital wards, and formerly for hours at a time, and many times in the week during the last fifty years. I have lived in an ancient workhouse converted into a hospital for months in succession, in years gone by, not only without having contracted con- tagion but without having been laid up for a week during a period of more than fifty years. Nor have I reason to accuse myself of having acted as a carrier of germs more than once, and this was most doubtful. On two occasions I have been day and night, for two or three weeks at a time, among cholera patients. Undoubtedly I have always exercised reasonable prudence as to diet, and have taken hygienic precautions, particularly as regards getting plenty of fresh air in all weathers, clothing warmly, and making up as soon as possible for reduced sleeping time. I have no reason to think that my fortunate experience is very exceptional, and believe there are hundreds of practitioners, and probably thousands of nurses, who have not suffered from or carried about contagious disease germs, and have retained good health during a long working life. In short there is no justification for the outburst of bacteriological fright or for the proposed institution of bacteria proof dresses. The public may depend upon the profession for taking all necessary precautions, but neither doctors nor nurses are inclined to make themselves ridiculous as regards germ protection, or offensive to their patients, as unquestionably some of the proposed vestments would make them. Decades have passed since the surgeons of hospitals deemed it necessary to wear a peculiar dress while at work, and may it indeed be long before there is a return to a custom so offensive and so needless. At the same time, there is no doubt that f new means of protection are discovered, the members of the profession will at once carry into practice every avail- OF SPREADING CONTACIA. IO3 able process which bids fair to reduce the chance of spreading contagi- ous disease. But the suggestions alluded to are of doubtful advantage. In addition to the employment of germicidal solutions diffused through the air mixed with water — spread over wounds and around the patient — some of the most enthusiastic of the fair instructors of medical practi- tioners want to force us into germ-proof garments, which are to be washed and rubbed down after each visit to the germ-ridden patient. Our skin and hair are to be properly disinfected with carbolic spray or vapours of potency, so that any germ about us may be paralysed or destroyed. These directions will soon be followed by new and more stringent rules for our guidance and instructions that must be obeyed. The time during which we are to be in quarantine, and for compulsory abstinence from visiting patients who are not suffering from contagious disease, will have to be fixed by new laws. Every germ without us, near us, within us, will be hunted to death. But after enduring the suggested disfigurement and discomfort, what would be gained ? We should not spread contagion. We do not spread contagion now. By having the clothes saturated with carbolic acid or camphor, or other highly odoriferous germicide, particularly now that cases of con tagious disease are to be notified, we might excite a panic in a populous healthy neighbourhood, for we should thus, by odours and vestments, proclaim that we were attending cases of contagious disease, and were perhaps carrying and diffusing poison germs which had resisted our efforts to destroy or paralyse them. Not a few of the new suggestions for destroying the bacteria, and for preventing their being carried from the sick to the healthy, appear to be founded upon purely theoretical considerations, and are not in the least degree justified by facts. The contention in letters published in the " Times " was supported by a strong article, leading the public to think that we doctors are so often the agents of carrying infectious disease, that special precautions of a very stringent character ought to be enforced. But the public, having practical evidence of the care taken by us, as well as of our thorough candour in pointing out danger as soon as discovered, and of the efforts made, and generally with success, to prevent all risk, was satisfied. The evidence afforded by the gradual decrease of the already low death rate (from over 21 per toco to under 18 per 1000 in '88, and in London, now and then under 14 per 1000) rendered it unnecessary to write letters in defence. The public no doubt sees clearly enough that we need not return to the antiquated pest-house accommodation or revert to pest-house prin- ciples of doctoring and other systems and principles of a mediaeval character. We think we deserve, and feel pretty confident that we shall receive, the support of the public in these matters. The writers in the greatest of great journals are now and then liable to fits of nervous 104 CARRYING AND DIFFUSING CONTAGIA. excitement, and apt to be a little emotionally indignant about nothing, and big gooseberries, frog and toad storms, the blue-bottle with millions of many species of life-destroying contagious germs, carried long distances on his toes, and other terrifying "facts," are now and then apt to receive more serious consideration than they really deserve. Now and then nothing very stirring will happen. What is to be done? The columns must be written. Why not offer suggestions concerning nets and traps and other means of catching the germ-laden blue-bottle, and propose different methods of destroying him when caught ? The debate may be followed by a serious discussion on the thickness of coffins, the advantage of very rapid disintegration of our remains, and the quickest way of converting the products into food for vegetables, to be in turn converted into nourishment for the rising generation, which will thus be saved from destruction by the inhalation of the emanations from its dead progenitors. The demand for far-fetched sensations and forcible descriptions of grimy horrors seems to recur periodically, and should be provided for without attacking the profession and inventing imaginary wrongs, in order that the fancied perpetrators may be punished for their fancied crimes by being incarcerated in white mackintoshes and suffocated by cottonwool respirators. The isolation of the sick, and the means of preventing the spread of contagious disease, and all other sanitary arrangements necessary in the case of those suffering from contagious disease, are so fully considered in works on sanitary science that I shall not enter into the matter here. The reader will find much information on this part of the subject, brought u]D to the present time, in the lucid and well-arranged treatise on " Hygiene and Public Health," by Dr. Louis C. Parkes, published by H. K. Lewis, Gower Street. THE TONGUE IN HEALTH AND DISEASE— OF THE: PAPILLAE AND THE EPITHELIUM— OF FUNGI, BAC- TERIA, AND OTHER LOW ORGANISMS— OF CHANGES- IN THE MUCOUS MEMBRANE OF THE MOUTH AND TONGUE— OF THE SALIVA— VARIOUS STATES OF THE TONGUE— CRACKS AND FISSURES— MUCOUS MEM- BRANE OF THE MOUTH AND FAUCES— OF THE USE OF SPRAY— THRUSH, APHTH/E-TREATMENT— OFFEN- SIVE BREATH. In the first place, let me speak of the characters of the tongue. Few- things it used to be supposed were of greater consequence than the- recognition of the varied character which the dorsal surface of the tongue assumes in various cases of actual disease, and of slight derange- ments of health. That the importance of the changes of the surface of the tongue as an indication of internal disease has been exaggerated by some physicians is undoubtedly true, but that it is altogether useless as an indication is certainly incorrect. Anyone who is at the pains to- notice the alterations in his own tongue under varying conditions of health will convince himself that something is to be gained by noting the changes of the tongue in disease. To form a correct estimate of the value of the changes, you must be well acquainted with the appear- ance of the surface of the healthy organ and with the nature of the structures which exist upon its dorsal surface. I daresay that many who tell each patient to put out his tongue- sometimes do it as a matter of routine. I have known a rather absent doctor tell the patient to put out his tongue more than once in the course of a few minutes' conversation. Patients are sometimes a little prosy, and if there is not much the matter with them, you may not attend to their story as diligently as you ought to do. You lose the- thread of the discourse, and while your wits are wandering you may cry out quite unconsciously, almost as if your request was the result of some reflex and habitual action, "Put out your tongue," the organ having been already more than once displayed for your examination. If a small piece of the soft matter from the surface of the dorsun^ I06 GENERAL CHARACTERS OF THE SURFACE. of the tongue be scraped off and placed on a glass slide, and a drop of water be added, and covered with a piece of thin glass ^if this be examined under a quarter of an inch object-glass, you will find, though the tongue be in a perfectly healthy state, a great many objects of interest, of which I shall have to speak presently. General Characters of the Surface. — The character of the tongue undoubtedly is influenced by the state of the stomach. The mucous membrane which lines every part of the alimentary canal is, as you know, continuous with that which lines the mouth and covers the tongue. Whenever there is a little gastric disturbance the tongue may participate in the change. The relation between the two phenomena is, however, a complex one, and not very easily explained. Of the fact, in very many cases, there is no doubt, as we may easily prove by observa- tions upon ourselves. The appearance of the tongue, as I shall explain more in detail further on, is also in some measure affected by the state of the circula- tion, by the character of the blood itself, as well as by the rate at which the epithelium (tV/, upon, and t/^^^u, to place) on its surface grows, arrives at maturity, and decays and falls off. Sometimes the superficial epithelial cells remain intimately adherent to the tissue beneath, upon which they are placed, and from which they seem to grow. On the other hand, a layer of the epithelium is frequently very easily detached. The removal of a certain amount of the superficial layer of epithelium with millions of bacteria and fungi, which grow and multiply in and amongst it, invariably occurs during eating and drinking. When, there- fore, little food or only liquid food is taken for a time, the epithelium adheres in thick layers to the surface, and makes the tongue look white. In health the general colour of the dorsal surface inclines to pale red, but in certain forms of disease it becomes of a bright colour, almost like raw beef, and it is in consequence sometimes spoken of as " beefy." This seemingly raw condition depends partly upon the desquamation and falling off of a good deal of epithelium, so that the layer covering the subjacent structures is much reduced in thickness, and partly upon the capillaries being unduly distended with blood. You can see the deep red colour of the blood through the epithelial layer. The vessels of the mucous membrane of the stomach and of other parts of the intestinal canal may participate in this change. As regards the general appearance of the tongue then, it may be remarked that if the epithelial layer on the organ is thin, the tongue will be red ; if very thick, it will be white ; if rather dr)', of a dull brown or dark brown colour ; and if there is an abundant accumulation of soft and moist epithelium upon its surface, of a very opaque dirty white. If you look at the under surface and sides of the tongue in a look- ing glass you will observe that these parts have a deep red appearance. HAIR-LIKK PROCESSES OF FILIFORM rAl'ILL.E. IO7 The epithelium upon the sides, and the deep aspect of the tongue, con- sist of a layer so thin that the colour of the blood is seen through the epithelial tissue. The degree of redness varies according to the quantity of blood in the vessels, and changes in the colour are due to varying degrees of vascular distension, as in the case of redness and pallor of the skin. In blushing the small vessels of the skin of the cheeks are suddenly distended in consequence of an inrush of blood, permitted by the sudden yielding and dilatation of the little arteries in continuity with them, and the same phenomenon under certain circum- stances occurs in the vessels of the lips and tongue. Oil the Fimslforni ami Filiform l»a|»ill5U, anil of their Epithelial Covering.— In health there are to be seen here and there over the dorsal surface little spots, which are of a bright red colour. Upon more careful examination, it will be found that the red spots are really small papilla; with a constricted neck, in shape resembling that of a mushroom, and known as the Fungiform (fungus, mushroom-shaped) PapilliB. The epithelial investment of the fungiform papillae is thin, and the blood-vessels and terminal nerve networks lie just beneath. The papillre in question are, therefore, always red, and can easily be detected here and there amongst the filiform or conical papillae which are pretty uniformly spread over the dorsal surface of the tongue. The epithelium covering the surface of the filiform papillae is so thick that we cannot suppose sapid substances would quickly pass through it, or between the edges of the overlapping cells, and then come in contact with the nerves beneath. These filiform {filum, a thread, 2iXiA forma, likeness) papillae have probably nothing to do with the sense of taste, but are important organs of touch, much concerned, it may be, in the process of feeling the food so that the proper mus- cular movements may be made in order to place it in the right position for mastication and deglutition. It is the fungiform papillae and the soft red nmcous membrane at the sides and back of the tongue, as well as that of the palate and fauces, which are mainly concerned in laste. Epithelial Hair-like Processes of the Filiform I'apllUc. — In the central part of the dorsum of the tongue the epithelial sheaths of the filiform papilltE are very long, and indeed form elongated thread-like filaments, closely resembling hairs in structure. You may snip off a few of these hair-like bodies from your own tongue, or scrape portions of them from the central part of the back of the surface with a knife. The specimen may then be placed in a watch-glass in a little weak glycerine. After the processes have soaked for a time they may be removed to a glass slide, covered in the usual way with thin glass, and examined under the microscope, first under an inch power, and then under a quarter of an inch object-glass. You will find these long hair- I08 FUNGI AND LOW ORGANISMS. like processes are composed of layers of scaly epithelium imbricated and superimposed one upon the other. The longest of the epithelial filaments project from the surface of the tongue, perhaps, for more than the twentieth part of an inch. In furred tongues these sheaths of the papillae grow considerably in length and in some cases make up the greater part of the white fur. Small particles of food often become entangled amongst these ragged epithelial extensions of the filiform papillae. If you scrape the central part of the back of the tongue a short time after you have taken a meal, and examine the matter in the way described, you will almost invariably find a number of oil globules^ and very frequently starch globules, portions of muscular fibres, and other things, according to the nature of the last food taken, as well as an infinite number of low vegetable organisms, and legions of bacteria. Of the Epithelial Cells. — The epithelial layer on all the papillae of the tongue varies in thickness from time to time. The several epi- thelial cells composing the layer necessarily differ in age. The oldest of these cells are those which are outermost, and situated at the greatest distance from the surface on which they grow, and the youngest are those which are nearest the vessels. Passing outwards we meet with cells gradually advancing in age. The oldest are constantly decaying and falling off. These mix with the food, and, no doubt, during every meal we swallow them in thousands. But the old epithelial cells upon the tongue and mucous membrane of the mouth undergo other changes, with the general nature of which it is important that you should be acquainted. The changes in and about the epithelium should there- fore be carefully studied as opportunities of making the examination occur. Of Fiin^i and Low Organisms in and amongst the Epithelium of the Tongue and Mouth.— If you carefully examine under high magnify- ing powers (from three to twelve hundred diameters) the old epithelial cells detached from the mucous membrane of the mouth, from the inside of the cheek or the tongue, you will find that the cells contain a number of very minute spherical or oval particles, and multitudes of delicate filaments are often seen amongst them. (" Microscope in Medicine," pi. XXXVIII, fig. i, p. 272.) Now these minute spherical and oval particles, situated in the formed material of the cell, and most numerous in its outer, that is, in its oldest part, which is undergoing disintegration, are very low and simple organisms in an early phase of development. They have been called micrococci (fUKpd^, little, and KOkko^, a grain), and have received other names. In this state they have not reached their full development. They are of many species, and some are probably the living germs of organisms which exhibit different characters in their fully developed state. Each is capable of FUNGI ON TONGUE. IO9 producing millions of descendants, under favourable conditions, in a few hours. Some of them, probably under certain circumstances, become elongated, and thus bacteria of various forms are evolved; others may form the long threads which used to be called Leptothrix buccalis. (" Micro- scope in Medicine," pi. LXXXI, p. 492.) Some, perhaps, may be the germs of O'idiiim albicans, which under certain altered conditions grow and form the mycelium, which spreads and grows amongst the moist epithelial cells, and other fungi. It is probable, indeed, that many different species of fungi are represented by the spherical or oval germ- particles, existing in connection with the older epithelial cells on the surface of the mucous membrane of the mouth ; and the germ-particles themselves, although they closely resemble one another in appearance, may have been derived from different species of organisms. The various species of germs grow and multiply under different circumstances. In 1879 Mr. Butlin expressed the opinion that the fur of the tongue consisted principally of vegetable organisms, but in all the specimens I have examined, I should have said that the major part was composed of epithelium and epithelial debris^ with particles of food and oil globules. It has been stated by more than one observer that Sarcina ventriculi is often present in the fur of the tongue, but I have never found it in this situation, though I have examined the fur in very many cases during the past fifty years. In cases in which sarcinte were found in the stomach, I did not find them on the tongue or in other situations. I am afraid that many mistakes have been made with regard to the identification of Sarcina ventriculi. Old epithelial cells, like other old and formed tissues and dead organic animal or vegetable matter, are very soon invaded by the germs of low vegetable organisms, always very numerous in their vicinity, which grow at their expense, and live upon their substance. Not only on the surface of the cells, but in their substance, the fungus germs are found, and frequently project from them, forming little collections, which may be detached from time to time. Amongst the hair-like epithelial processes projecting from the free extremities of the filiform papilke, are often found masses which have a granular appearance under low magnifying powers. When examined under objectives magnifying more than three hundred diameters, these masses will be found to consist of millions of spherical and oval fungi or miciococci, grouped together, each little mass of bioplasm being surrounded by, and sepa- rated from, its neighbours by clear structureless material, which probably has been formed by it. Amongst the epithelial cells in every part of the mouth you will often find some very long, extremely delicate filaments, which, if ex- amined under high powers, will be found to exhibit a number of trans- verse markings. They grow and freely multiply in the fluids of the no CHANGES IN MOUTH, TONGUE, AND SALIVA. mouth at the usual temperature of that cavity. Many are found between the teeth. In the tartar you will meet with numbers of vegetable organisms. Indeed, it is probable that the deposition of the tartar is intimately connected with changes occasioned by the living organisms in question. Many of the filaments, long and short, exhibit peculiar undulating movements, some vibrating to and fro, others taking a spiral direction. In many cases you will find whole forests of vegetable organisms consisting of many different species, and of the same species at different periods of growth, upon the dorsal surface of the tongue. The growth and multiplication of these low organisms at the very entrance of our bodies, and so placed that they must pass in immense numbers into the stomach whenever we swallow anything, is a fact of great significance in connection with certain conclusions respecting the action of these low organisms upon the solids and fluids of man's body. The first question you will ask will probably be this : — Do these micro- cocci, bacteria, and allied organisms perform any distinct office or function in connection with the solution of food or digestion, effecting changes directly or producing ferments which induce changes, or do they merely live and grow upon the old epithelial cells and the debris of the food which must needs undergo change in such a situation, and at the temperature of the inside of the mouth ? "We find such bodies in animals as well as man, and though they are found in greatest number in certain derangements, multitudes are constantly present in the most healthy individuals. They have no doubt grown and multiplied under similar conditions and without varying in character for thousands of years. Changes in the Mucous :ilembrane of the :tIouth and Tongue : and of the Saliva. — It has been already suggested that changes in the mouth and tongue are frequently associated with somewhat similar changes occurring in other parts of the ver)- extensive system of mucous membrane concerned in the preparation, digestion, and absorption of food. One part of the mucous tract may participate in phenomena occurring in another part at a considerable distance. This participation is due to the circumstance that the nerve-centres presiding over actions occurring in different parts of the mucous membrane of the alimentary canal are connected together by commissural fibres. In certain forms of disease a local affection of limited extent may provoke an altered and pathological action of many feet of intestine, and may affect the character of the secretions from gastric and intestinal glands, though situated at a great distance from the seat of actual lesion. Very slight changes as regards diet will lead to reduction of the secreting action of the stomach glands. The mucous membrane often becomes less moist than it should be, and the secretion from every DERANGED ACTION OF STOMACH. Ill part is reduced, though it would be incorrect to say that the membrane became dry. The mucous membrane of the mouth and the glands connected therewith may partici[)ate in any altered action going on in the stomach. In practice we invariably find that in fevers, and indeed in any slight attack of feverishness, when the temperature of the body has risen only two or three degrees, — in short in the common patholo gical change which everybody has experienced when he has taken cold, — there is imperfect action and deranged secretion in the stomach. The saliva has much to do with the maintenance of a moist healthy state of the tongue and mucous membrane of the mouth, and even in very slight derangements, dryness of tongue may be due to these circumstances. In febrile conditions the tongue often becomes much furred, a change arising partly from the mere accumulation of epi thelium and debris, owing to the surface not being cleansed by the passage of food and liquid over it, partly to changes in the circulation in the capillary vessels and in the composition of the blood, consequent upon the febrile condition. For several hours, it may be for two or three days at a time, there is in many persons defective formation of the substances which form the all-essential constituents of saliva, the gastric juice, and other secretions poured into the intestinal canal. One consequence is that the ordinary desire for eating is not present, and if the person eat well in spite of his disinclination to do so, further derangement, perhaps severe pain and indigestion, may add to his troubles if he has not the good fortune to escape by free vomiting or by the occurrence of diarrhcea, or both. Under such circumstances it is, therefore, the best plan to starve, or, if the person is weak and feeble, he might take milk, beef tea, or strong soup in very small quantities, at short intervals of time (an hour or two hours) until healthy action returns. In fevers, and even in slightly feverish conditions, those complex compounds from which the cells of the salivary glands form saliva, and those out of which the gland cells of other parts of the alimentary canal develop the marvellous and peculiar substances which play so important a part in digestion and ultimately in nutrition, are not drawn from the blood through the walls of the vessels. This deranged action of an extensive system of glandular apparatus necessarily affects the compo- sition of the blood (which also suffers in other ways), and thus the action of every tissue and organ in the body may for a time become more or less deranged. When we come to consider the nature of the changes occurring in feverishness, we shall see that in all fevers, and in every febrile condition, digestion and the action of the alimentary canal are invariably disturbed, and often to an alarming extent. Every intelligent mother knows that in infants and in young children the febrile state often commences with derangement of the stomach, and may be oc- 112 TONGUE IN AN ORDINARY COLD. •casioned by improper food, as, for example, hard unripe apples. In this way important alterations in the blood and general derangement of the system may result from pathological actions which start from local disturbance. In such cases it is very important that the organ or portion of mucous membrane, the action of which is disturbed, should be per- mitted to rest for awhile, for you will find that after a rest for a time there will be good evidence of returning action, possibly of undue action. But if a greater amount of action than occurs in health should be noticed, the change will soon be followed by reduced activity, and at length by the normal degree of action. By degrees the state of health will be re-established without any permanent lesion or structural change of any kind having been induced. In such derangements, if by any means we can promote the return of secreting action — if we can get the various glands to act freely, the abnormal condition will be relieved, and the normal or healthy state restored, sooner than if matters are left to right themselves. In this way the patient gains an important advantage. I think I shall be able to convince you that in many cases we can be of use not only by effecting the expulsion of the irritating matters from the stomach or bowels, but also by diminishing the febrile condition set up. It will be well for me, however, before further discussing this part of the matter, to draw your attention to one or two points of general interest in connection with the febrile state. In an ordinary cold, the mouth is often more or less uncomfortable or clammy. The throat, as you know, feels dry and rough, and the appetite becomes impaired. But little saliva and little gastric juice are formed under these circumstances, and probably the quantity of intes- tinal fluid that ought to be secreted is much less than usual, and you will also notice, if you pay careful attention to the matter, that the kidneys do not secrete in the normal degree, while the bowels are often constipated. You will find, when you are suffering in this manner, that if you take a warm bath or a hot-air or vapour bath, by which the free action of the skin will be excited, the unpleasant sensations will cease, and at least for a time you will feel very much better. You may even experience complete relief. If you take a few doses of Nitrate of Potash, or Bicarhmate of Potash, or Citrate of Potash^ or Liquor AmmotticB Acetatis, or Liquor Aftunonia: Citratis, or some other saline which acts on the skin and kidneys, you will be greatly relieved. This relief is, I think, consequent upon the removal of certain sub- stances from the blood which had been accumulating in that fluid to its detriment, and which as they circulated caused derangement of action in many tissues and organs of the body. I shall have frequently to direct your attention to the general and often widespread changes which DRY AND MOIST TONGUE. II3 result from deranged actions confined to very limited areas of tissue or organ, and shall show that at least, in a number of cases, this may be explained by the alterations induced, directly or indirectly, in the cha- racter and composition of the blood. Hardly any of the ordinary physiological changes of the body can be deranged without some alteration taking place in the composition of the blood. The action of the digestive organs will be disturbed at once, and of this we shall soon have indications in the loss of appetite and various unpleasant sensations in the stomach, as well as by the altered state of the tongue. Of i»ry iiiiii Moist States of the Tongruc. — One of the commonest changes observed in the tongue is undue dryness — a condition which may depend upon a variety of circumstances. The moisture of the parts within the mouth varies greatly, and even, in most persons, the mouth is not equally moist at all periods of the day and night. The activity of the process of secretion varies much at different times ; the quantity of fluid in the interstices of a thick tissue like the skin or the dorsal surface of the tongue is by no means always the same, and varies with every change in the tension of the walls of the capillaries, the pressure of the circulation, the activity of the lymphatics, and a number of other circumstances. Lastly, it is obvious that the varying rate of evaporation from the mouth and nasal passages will alone cause altera- tions in the tongue as regards its moisture. The tongue is often dry in cases of Diabetes mellitus, though moist in the so-called Diabetes insipidus. The dryness of the dorsal surface of the tongue, a change which is not uncommon in many forms of disease, cannot be attributed to changes taking place upon the surface of the mucous membrane only, for the secretion of fluid by the glands beneath might entirely com- pensate, or more than compensate, for the loss of fluid by evaporation. In many cases the dryness seems to be due to alterations which occur beneath the mucous membrane, affecting the nutrition of the deep cells of the cuticular coverings of the papillae, and in part to the change in the composition of the blood itself and an altered state of the blood dis- tribution, as determined by dilatation of the litde arteries, consequent upon relaxation of the circular ijiuscular fibres occasioned by changes peripheral or central, of the nerve apparatus which governs their calibre. In ordinary health the moist condition of the tongue is due pardy to the transudation of fluid through the walls of the vessels towards the epithelial and other tissues, and partly to the presence of fluids secreted in varying quantities and poured into the cavity of the mouth, particularly the saliva. The surface of the tongue and inside of the mouth are thus kept moist. The moisture of the tongue and interior of the mouth will, however, be very much favoured if the air we breathe is moist, while in the opposite state of things the tongue will I 114 DRYNESS OF MOUTH. become more or less dry from evaporation, and obviously a greater amount of fluid will be required to maintain the mouth in a moist state in dry than in damp weather. The quantity of vapour communicated to the expired air which traverses the cavity of the mouth is liable to variations according to changes which occur in the lungs and air passages. The blood, as it traverses the capillaries of the lungs at different times, contains very different quantities of fluid, and therefore during some periods much more vapour will be given off from the blood to the air about to be expired than at other periods. Not only so, but the rate of exhalation of watery vapour from the blood is influenced by a number of complex conditions which are continually undergoing change. Every time we expire through the open mouth, the air laden with moisture is driven over the mucous membrane of the mouth and tongue. How- ever dry the inspired air may be, it becomes, if the individual is in good health, nearly saturated with moisture as it leaves the air-cells of the lungs. This damp air playing over the surfaces it traverses assists in keeping them moist. The mouth and tongue, however, may readily become dry, and a very unpleasant state of things will be experienced. Those who have acquired the bad habit of sleeping with the mouth wide open frequently suffer from the derangement in question. We should close the mouth before falling asleep, and during sleep we should breathe freely through the nose. In cold weather it is important that the cold air which is inhaled should pass over the surface of the mucous membrane of the nasal passages in order that it may be warmed before it reaches the wind-pipe and lungs. There is good reason to think that many attacks of bronchitis, pneumonia, and congestion of the lungs have been occasioned by breathing through the mouth instead of the nose in very cold weather. The air which receives a supply of moisture is better adapted for the further complex chemical changes effected by respira- tion, which changes, as many of you are no doubt aware, are most actively carried on during the period of sleep. Always advise your patients to acquire the habit of keeping the mouth closed and breathing through the nose, not only during sleep, but generally ; for, especially in cold weather, it is important upon many grounds that the inflowing air should take this circuitous route rather than the more direct one by the mouth. As soon as the mucous membrane of the mouth or adjacent passages gets dry, a desire for fluid will be experienced. The person longs for a little water, and when he gets it he moves it about in all parts of the mouth, so as to thoroughly moisten the mucous membrane ; but th.s operation requires to be very frequently repeated, as the surface when moistened with water gets dry sooner than when bathed with the natural fluids of the mouth. In many cases you will find glycerine EXCITING FLOW OF SALIVA. II 5 and water, in the proportion of one part to five or six, more effective than pure water. A Httle lemon-juice may be added to make the mixture more palatable, and sometimes you will find that linseed tea with glycerine and a little lemon-juice will be most efficient. If the mouth becomes very dry, articulation will be difficult or impossible. No one can speak properly if his mouth and tongue lose their ordinary moist condition, and you may have noticed that many orators who are accustomed to address audiences for a considerable period of time are obliged to sip water every now and then. But a man in good health ought to be able to talk for two hours without requiring a drop of liquid. In perfect health the ([uantity of saliva that flows into the mouth varies remarkably at different times, and the proportion is diminished in any little derangement of the system. The free flow of saliva has much to do with the moist healthy state of the tongue. In some cases the dry state of the mucous membrane results from the habit over a long period of time of taking into the system too much alcohol or too much solid food and too little water, practices which soon cause most important changes in the blood, and eventually may lead to impaired action of many of the secreting glands. Of Exciting the Flow of Saliva. — In many cases in which the secretion of saliva is deficient, the increased action of the salivary glands may be excited in a very simple manner. Anything which promotes the flow of saliva and induces the glands of the mouth to secrete more freely will, to some extent, relieve a dry state of the mouth and tongue. Comm.only, the mere irritation, stimulation, or excitation of the sensitive nerve-fibres spread out beneath the epithelium of the mucous membrane of the mouth, brought about by the contact of some pungent or acid material, is sufficient to cause a very free salivary secretion. A small piece of lemon just placed in the mouth will often give rise to a very free flow of saliva ; and there are various pungent materials which are introduced into the mouth for the very purpose. The mere moving about in the mouth of some solid body such as a smooth pebble will, through reflex action, promote the secre- tion of the saliva. The pebble acts upon the afferent nerves, and an increased flow follows. This is owing not only to the expulsion of the secretion already formed, but to increased secretion of salivary fluid by the gland-cells. siaiago^ucs. — We have many remedies which belong to the class of Sialagogues ((ti'xXoi', saliva, and a'/w, I expel). Horse-radish, — Mezereum, — Ginger, — Fyret/irum, the root of Anacycltis Fyrethrnm, the old Pelle- tory of Spain, — are examples of well-known sialagogues. But there is one better known to most of you, though its use as a sialagogue is in these days almost limited to some of the nautical people — I mean tobacco, which if used at all should be smoked, not chewed, and Il6 VARIOUS STATES OF THE TONGUE. smoked only in moderation, and in the open air. Certain salts also excite the secretion of the salivary glands. Chlorate of Potash {Dose, twenty grains in water) and Nitrate of Potash {Dose, five to ten grains dissolved in a wineglassful of water) are among the best. '$,\ickmg fused nitre (nitre balls) is an old and very favourite treatment for many slight ailments. You may now get Nitrate of Potash, generally known as Nitre, Chlorate of Potash, BicarboJiate of Potash and Soda, and a number of other useful saline remedies, compressed into small lozenges or tabloids containing five grains each. One or two may be allowed to slowly dissolve in the mouth three or four times a day, half an hour or more after a meal, and you will find they will cause a very free flow of saliva. When the mouth becomes very dry at night it is a good plan for the sufferer to sip now and then a little cold Barley water or Linseed tea (one tablespoonful of Linseed infused with a pint of boiling water; when cold, the seeds may be strained off and a little sugar added, or the viscid fluid may be flavoured with lemon-juice, and sweetened with glycerine in cases in which it is not desirable to give sugar). But the most important and most potent of all our medicines used for increasing the action of the salivary and most if not all other glands in the body, is Mercury. You will find when you have to prescribe for a dry uncomfortable state of the mouth, that if you give only half a grain of calomel, or even considerably less than this, within five or six hours a free secretion of the saliva into the mouth will occur, and the mucous membrane of the mouth, fauces, and neighbouring parts will become moist and more comfortable. All the little labial and buccal glands will secrete more freely. Instead of Calomel, you may give a grain or less of blue pill or gray powder. The last {Hydrargyrum cum Creta) is the mildest and perhaps the best of all the mercurial prepara- tions we use. In children's ailments it is one of the most efficient remedies handed down to us. In the days of my apprenticeship, we used to keep equal parts of powdered Rhubarb and Hydrargyrum cum Creta already mixed, and we ordered from one to six grains of the mixed powder to children, according to age. I continue to use this most useful prescription. The only objection is its nastiness, even in jam ; but for older children and adults the powder may be made into pills with a little Extract of Henbane, or it may be placed in one of the little capsules made of pastry-cooks' paper and swallowed. Various States of the Toiisne. — I will now proceed to consider a little more in detail the peculiar characters assumed by the tongue in- different states of health. The subject has received great attention from the very earliest ages, and not only from medical practitioners. It is in all respects worthy of your most attentive consideration. To many WIIITK FURRED TONGUE. 11/ persons the state of the tongue is a matter of grave anxiety through hfe, and men have been known to use the looking-glass every day for half a century or more for the pur])ose of observing the daily changes which occur. Especially does the tongue excite the greatest attention and interest among the members of that large section of civilised man, which knows not what it is to feel perfectly well — to be free from discomfort of every kind, and not to ail anything. One of the latest memoirs on the tongue is the excellent work of Dr. Dickinson, of St. George's Hospital — " The Tongue as an indication of Disease." The Lumleian lectures, delivered at the Royal College of Physicians in 1888. IVhite Moist Furred Tongue. — In some conditions the tongue pre- sents a very peculiar appearance, being very white in consequence of the accumulation of a quantity of soft moist epithelium on its surface, with mucus and secretions from some small glands, with multitudes of bacteria, fungi, and the debris of food. This state of tongue is seen in its most remarkable degree of manifestation in acute rheumatism. You may indeed often be led to suspect that a patient is suffering from acute rheumatism from the character of the tongue only. Unfortunately we have many opportunities of studying the tongue in this serious malady in the wards of our hospitals, which often contain several well- marked cases of the disease. The tongue in cholera is moist during the stage of collapse, dry in that of secondary fever. I do not know anything you can do in the hospital tolerably early in your student days, that will l)e of more real use to you in practice, than observe the characters of the tongue in different forms of disease. I strongly advise you, with the permission of the house physician, to go into the wards when he makes his visits, and institute a careful ex- amination of the tongue in several well-marked cases. Describe what you see, and repeat the ol?servations on each case every day or every other day. It is better not to undertake more than two or three cases at one time. Make microscopic examinations of the fur every now and then, and keep careful records and drawings of the results. From time to time you will notice how frequently improvement in the state of the patient coincides with, or is just preceded by, satisfactory changes in the state of the tongue. Of course you will meet with exceptions, and you will easily find cases which might be adduced in favour of the opinion that the appearances of the tongue are so variable and so uncertain that nothing of importance clinically is to be gained by taking note of the state of the organ. In fact occasionally we find a person who enjoys excellent health but whose tongue is almost invariably covered with a white fur especially in the morning, while others who are always complaining and are seldom free from pain and discomfort con- nected with digestion, whose tongue is invariably clean and healthy. Il8 AN^.MIC PALLID TONGUE. To rely exclusively on changes in the tongue would undoubtedly be misleading, but I think not more so than it would be to observe exclu- sively other individual signs and symptoms of disease. We do gain impor- tant information from the tongue, but, as regards diagnosis and treat- ment, never forget that we rely not on one or two facts, but always endeavour to learn all we can and think over the several points before we give an opinion. Fa/e Tongtie, Aiicemia {a without nZ/io, blood, literally bloodlessness). In anaemia the blood is poor and defective in red blood corpuscles. In ancemic persons, and in those suffering from various forms of disturbed digestion, the tongue is flabby, the vessels being imperfectly filled with blood and the blood itself poor in red corpuscles. The dorsum of the tongue appears flabby, and a quantity of moist epithelium adheres to its surface. The tongue itself is sometimes visibly larger, — swollen or sodden, oedematous (olcij/na, from olSew, to swell), as well as soft and flabby. The edges are much indented and marked with impressions of the teeth. This state of tongue improves under the influence of quinine and other tonics, and remedies which improve the digestive power of the stomach and the tone of the body. In some cases the capillaries and veins of the tongue are much dilated and distended with dark blood. In Slight Chrofiic Rheumatism (Rheuma, i>iw, to flow) the tongue is frequently white, covered with what we call a blankety fur. The white furred tongue is more moist than is the organ in the normal healthy state ; its epithelium is abundant and sodden, and everywhere invaded by fungi. Numerous low organisms are actually growing and multiplying very rapidly in the moist, soft, imperfectly-formed epithelium which continues to be developed and to accumulate while the rheuma- tic state lasts. Various organic matters also collect, and decomposition may take place in the whitish spongy layer which is formed in such abundance. The different fluids of the mouth and mucus and epi- thelium also contribute to increase the thickness of the white fur so characteristic of the condition. In many temporary derangements of the stomach and bowels we also find this moist furred condition of the tongue, and it may last for a few days at a time. The tongue of inveterate smokers is generally white and dirty, and a constantly dirty tongue, like some other departures from the normal state, is not incompatible with considerable vigour, good working power, and longevity. A moist tongue may change its characters during a malady and become dry. In a case of Diabetes insipidus, in which the patient passed a pint of urine per hour, Dr. Dickinson observed that the tongue was very moist, but after a time the case passed into Diabetes mellitus, when the tongue became dry. " The tongue as an Indication in Disease," p. 97. BRIGHT RED TONGUE, BROWN TONGUE. I I9 Bright Red Tongue. — in striking contrast with the white furred or " blankety " tongue is the red tongue, which is met with in certain forms of fever, the surface being smooth, of a bright red colour, some- limes appearing raw, and not unfrequently being dry and glazed. The red tongue is often seen in scarlet fever. In the early stage of the disease the tongue is often furred, and the red fungiform papillae are seen to project through the adherent epithelium, and appear as bright red spots. These papillae are swollen and the vessels much distended. The surface of the tongue is more or less uneven, and we have the appearance somewhat resembling that of a strawberry — hence, the straivbcrry totigue. But in a few days the superficial layers of epithelium of the tongue and of the lining membrane of the mouth and fauces are detached, desquamate {de., from, squama., a scale), and then the whole surface of the tongue is red. The smoothness and redness of the tongue last for some time, for the old cells of epithelium having been completely detached, some time must elapse before the new cells have sufficiently accumulated to prevent the red colour of the blood being so distinctly seen in the vessels beneath. The raw beefy character of the tongue is also observed towards the close of many exhausting diseases, as phthisis {({iOivw, to corrupt), and some forms of pyemia. Aphthous sores also form sometimes in conjunction with this state of the tongue, and must be treated as described on p. 127. • The Dry Brozun Tongue. — Strictly speaking, the dry brown tongue is hardly ever seen in slight ailments, and I shall only say a few words about it here. This state of tongue is often preceded by a moist white furred condition. Do not forget that a state of tongue somewhat resembling the dry brown tongue may result from sucking liquorice, black currants, or black cherries ; and other dark fruits may produce temporary staining of the tongue. But such give to the tongue a very peculiar appearance which you ought to be able to recognize at once. It is well also to bear in mind that the juices of some fruits, and other fluids having the property of staining the tongue or skin, are sometimes used by patients for the purpose of puzzling us. The dry brown or black tongue was common in many diseases of old time, and was well known to Hippocrates. In typhus and typhoid fever, and many other low conditions, the tongue may become brown or more or less black, owing in part to changes occurring in the epithelium, which, with mucus and secretions from various glands, has accumulated upon its surface and has got dry. If the feverish condition reaches any considerable degree of intensity, the moist surfaces about the mouth soon become dry and the little glands of the mucous membrane cease to secrete. The secretion of the salivary and other glands is diminished to such an extent as to render the process of deglutition (the swallowing of the food) extremely difficult. This is one of the reasons why we I20 GLYCERINE AND WATER. give to patients suffering from fever, milk and beef-tea and order nutrient matter dissolved in fluid. Indeed everything required should be intro- duced in actual solution, or in a very moist state, as in the form of pap. Or finely divided solid matter may be suspended in beef-tea, soup, or milk, and thus nourishment in a state easily absorbed may be given in cases in which it is absolutely required to support life. In many cases great relief will be afforded if the nurse will occa- sionally paint, as it were, the dry mucous membrane of the tongue and mouth with a little weak glycerine and water (one part to nine or ten of water) Avith a camel-hair brush. This is very necessary in some severe forms of fever in which the tongue and mouth become very dry and painful. After the tongue has been dry for several days, it is not un- usual for deep fissures to form upon its surface, and these fissures sometimes extend quite through the mucous membrane, and even reach the vessels and nerve-fibres in its substance. Escape of blood (hsemorr- hage) frequently occurs, and the blood accumulates and helps to form the dry brown matter which adheres to the tongue. Sometimes much of the hemoglobin of the blood is disintegrated while the blood circulates, and may make its way through the thin capillary walls; but more generally blood itself escapes from the capillaries in the usual manner, in consequence of their over distension and the formation of longitudinal rents or fissures in their walls. The blood from the vessels and the viscid niucus which collects upon the tongue and lips, together form dark brown or black flaky masses {sordes, from the Latin, sordes, dirt, filth), which accumulate about the mouth and often firmly adhere to the surface of the teeth. Sordes may sometimes be pulled off, but generally leave a raw and sore surface beneath. The dry brown tongue passes by gradations into the black tongue, characteristic of some of the very worst forms of fevers which occurred in former days, and which are even now occasionally met with in the East. As the severity of the feverish state passes off, the tongue begins to clean, usually at the edges first. This " cleaning" results from the growth of new epithelium on the deep surface, and the detachment of the old cells with mucus, fungous growths, particles of food, and probably a little blood — which have been accumulating and have adhered to the surface during the illness. As convalescence ap- proaches all this is cast off. To prevent the altered and partly decomposed organic matter, debris, &c., being swallowed, the mouth should be frequently rinsed out with Condfs fluid and water (half-a- teaspoonful to a tumbler of water), or a very weak Solution of Sul- phurous acid (one part of the Sulphurous acid, Acidum Sulphurosiim of the Pharmacopoeia, to five or six parts of water) or of Hyposulphite of Soda (five grains to an ounce of water). Hiemurriiage. — Just now I used the word hemorrhage, and as this H^EMORRHACE. 121 was, I think, tlie first time I have had to employ the term, it is desirable that I should explain its meaning and tell you exactly what happens when Juoiiorrha^^e takes place. The word is derived from two Greek words, man, blood, and (xYivufn, to break forth. Haemorrhage means, therefore, a breaking forth of blood. In former days we used to be told that there was such a thing as the passage of blood corpuscles through closed membrane, through the walls of vessels, in some mysterious manner without any rupture or solution of continuity. This was called /ncmorrkage by exhalation, and in my student days the opinion was still entertained that red blood corpuscles might traverse a capillary wall by " exhalation." At an earlier period, the capillaries used to be spoken of as e.xhalant vessels, and their function was regarded by some as opposed to that of the absorbents. Under certain circumstances blood corpuscles may pass through the thin walls of capillary vessels without the vessels being destroyed or even damaged. In all cases, however, an opening, it may be temporary only, in the vascular wall does exist. The capillary is not actually torn across, but when it becomes much distended by the accumulation of blood within it, the thin vascular walls are stretched and rendered very thin. Longitudinal rents or fissures result, through which the blood corpuscles, a few at a time, easily escape edgeways. When the pressure is relieved, the elastic wall of the vessel will contract, and the fissures close up, the capillary transmitting the blood as freely as it did before. The term Hceinorrhage, then, is strictly correct, and always means the breaking forth of blood from a vessel, large or small. Chronic Cracks and Fissures of the Tonerue. — This state of tongue is very common in persons who have long suffered from weak digestion. The tongue is generally rather pale, quite moist, and from time to time becomes covered with white fur, which is often distributed in patches. The cracks are usually rather deep, very irregular in arrangement, and differ much in number in different cases. For the most part they are permanent, but occasionally new ones form and the older ones increase in depth. The papillae at the edges of the fissures occasionally become sore. Aphthous patches of irregular shape may appear and increase in size, extending often to the bottom of the fissures, and sometimes the tongue becomes so sore that eating solid food is a painful process. The cracks may go on separating until a raw surface is exposed at the bottom. This is often exquisitely painful ; and if any alcohol, pepper, or salt substance is taken, the almost bare nerve-fibres exposed in the fissures are instantly affected. Not unfrequently in such cases the pain and discomfort are so great that the patient is deterred from eating, and in consequence suffers in health and strength. A moderate degree of this condition of tongue is extremely common. It does not usually inter- fere with longevity or predispose to any more serious derangements. 122 FISSURES OF TONGUE — TREATMENT. Those who suffer are obhged to be careful in diet and ought to live very moderately. If they exceed in any way digestion becomes deranged, the tongue gets foul and very sore, and some days must pass before the usual state of health returns. In such cases the bowels are sluggish, but you will generally find that mild purgatives only in small doses can be borne. Three or four grains of compoimd rhubarb pill, two or three nights in succession, with perhaps a little effervescing citrate of ammonia, soda, or potash, or some such simple saline, three or four times daily, will be of use, and expedite the return of the normal state. CarboHc acid lotion (one part to one hundred of water) is also a good application, especially if the fissures are associated with the presence of aphthous spots with vegetable growths on the surface, but the lotion is not a pleasant one to use. See also p. 127. There is, however, another form of cracked tongue common enough and very chronic, which is not to be cured in this simple manner. There are cracks and fissures here and there, but in some situations the surface is too smooth. The appearance is such as to lead one to think that, in the course of very slow pathological changes, many of the papilla have undergone change, and have at last wasted and disappeared, just as the villi of the small intestines do in certain forms of disease. The state of tongue which I am considering may last for years, getting better and worse many times. It is usually reUeved, and in not a few cases cured, by Iodide of Potassium. The remedy must be taken for two or three or more weeks at a time, then stopped for a short period, and resumed again. You may begin with two grains, and gradually increase the dose to five or six grains three times daily, and it is a point to give each dose dissolved in as much as half a pint of water. Some cases improve rapidly on Iodide of Mercury. You may order from the thirty-second to the sixteenth of a grain of the Perchloride of Mercury, that is, from thirty to sixty drops of the liquor Hydrargyri Perchloridi with five grains of Iodide of Potassium, and a little Syrup of Ginger, and perhaps twenty minims of De Fry's Liquor Cinchonas in four ounces of water an hour after food, twice or three times a day for two or three weeks at a time. These cases, and especially if they are cured by the medicine I have recommended, are generally considered to result from syphilis, but I feel confident that all are not of this nature. It is a grave mistake to suppose that everything cured by mercury and iodide of potassium, or some other iodide, must be syphilitic in its nature and origin. These remedies are most useful in the treatment of many conditions which have nothing whatever to do with the disease in question. Some who read these words will, how- ever, assert that I am mistaken, and that in cases in which the patient had never had an attack of syphilis the poison must have been intro- duced into the organism in some obscure and unknown manner, or that CHANGES IN MUCOUS MK.MDRANE. I23 it was derived from predecessors one or more generations back. This is a mere dictum. It cannot be disproved, but it rests on no adequate foundation of fact or observation; and we attach httle importance to such assertions when they rest on authority only. Changes In the Mucous Membrane of the .Mouth and Fauces. — Associated with the changes taking place in the epithelial surface of the back of the tongue, we have in many cases, also, corresponding changes in the mucous membrane of the mouth, the palate, the fauces, and the throat. The mucous membrane of all these parts is continuous, and no wonder that different sections are sometimes affected in the same manner. The action, also, not uncommonly extends downward through the narrow chink of the Glottis (-/Aa-TTf/, the tongue) into the Larynx (Xdpvy^, the larynx) the wind-pipe, or trachea (t/j«;^(';s-, rough). The voice may become hoarse, in consequence of the mucous membrane being swollen, dry, and otherwise altered. Not unfrequently this dryness extends to t\\Q posterior nares and affects the mucous membrane at the back of the nose, giving rise to a very painful sensation, a slight degree of which most have experienced when an ordinary cold is about to come on. If you look in the looking-glass at the back part of the widely opened mouth, when a cold is coming on, you may see the mucous membrane of a darker red than usual, and here and there it may appear glazed and dry. Not only so, but if you try a simple experiment you will discover that an important change has taken place in the sensitive- ness of the surface of the delicate mucous membrane of the soft palate. In health the slightest touch will excite movements of deglutition by reflex action, but when the membrane is dry and sore there is no such sudden response, the contraction of the pharyngeal muscles (0a/Ji/7f, the throat) follows very slowly or does not occur at all. You may touch the palate firmly without any effort to swallow being excited. This benumbed state of the highly sensitive surface generally is only temporary, and consequent upon the changes which have occurred just beneath the epithelium, where extremely delicate afferent nerve fibrils are distributed in immense numbers, but the condition may recur frequently, and some persons are hardly ever free from some slight derangement of the mucous membrane of the soft palate, fauces, and upper part of the Pharynx (0"/H'7f, the throat). In the treatment of this state of things, inhatation of steam, simple, or with a little am- monia or camphor is often of use. Inhalers are now largely used. Many are made of china, and are so arranged, that various volatile substances may be very easily inhaled with the steam of warm water The latter alone often affords great relief in irritable states of the mu- cous membrane of the throat and air passages. A very good form of inhaler is made by Messrs. Bullock and Co., 3, Hanover Street, \V. 124 BRONCHITIS KETTLE — SPRAY. Brouciiitis Kettle. — The air of the sick room may be rendered moist by arranging an ordinary kettle in such a manner that the steam comes direct from the kettle mouth into the room instead of going up the chimney. The spout of the kettle may be lengthened by adding a foot or more of tin tube, or the special bronchitis kettle made by Mr. Allen, of High Street, Marylebone, may be used. In derangements of the kind, the application of astringent substances to the palate and fauces often affords relief. You may apply with a large camel-hair brush a little of the Glycerine of Tannic Acid, the Glycerinum Acidi Tannici, or a solution of Nitrate of Silver (five to ten grains to the ounce of distilled 7vaier), three or four times daily. A few minutes after application the mouth should be gargled out with cold water or salt and water (one teaspoonful or more to half a pint) ; but the best plan of treating such affections, especially if they are chronic, is the direct application of the astringent or other solution, in the form of spray, as I will now describe. Of the use of Spray. — Of late years very many remedies have been applied to parts about the mouth in the form of spray, and great advan- tage has resulted. The practice was first employed in the treatment of diseases of the larynx, and many very ingenious instruments have been invented for the purpose of obtaining a cloud of watery vapour in a state of very minute division. Spray producers have of late been very much simplified in structure, as well as rendered more perfect. There are two principal forms of apparatus. One in which the " spray " con- sists of high pressure steam, a stream of water with the required sub- stances dissolved in it, being by the steam minutely divided into spray as it issues from a tube communicating with a reservoir. The steam is obtained by boiling water in a strong copper boiler specially made for the purpose and heated by a spirit-lamp. In the other, the requisite degree of pressure required for sufficiently comminuting the liquid to be converted into spray is obtained by a little india-rubber ball bellows. Both forms may be obtained of the surgical instrument makers for a few shillings, and are well adapted for use in the treatment of affections of the mucous membrane of the mouth, throat, nose, and larynx. The solution containing the material to be projected against the mucous membrane may be much stronger if the steam spray producer be used than if the air instrument be selected, because, in the first case, the solution converted into spray is diluted in strength by the steam which is used. Some of the best spray producers are those formerly used by Sir Joseph Lister, in surgical operations, and very efficient ones are now made by Messrs. Matthews Brothers, of High Holborn. In cases of dryness of the mouth, tongue, and throat, water alone may be used in the form of spray, or water with the addition of one- tenth part of pure glycerine. Alum spray solution is a powerful astring- METALLIC TASTES L\ THE MOUTH. 1 25 cnt. Ten grains of AIudi to the ounce of water is a good proportion. The same quantity of Tainiic Acid may also be tried. The spray solu- tion of Carbolic Acid may contain two grains to the ounce of water. Of CJiloride of Sodiitiii, that is, common salt, from two to twenty grains or more to the ounce of water. Chlorate of Potash five to fifteen grains to the ounce. Nitrate of Potash solution may be used of the same strength. The spray solution of Nitrate of Silver should contain a grain to the ounce of distilled water. You must be careful to filter the spray solution before you use it, and you must prevent dust from getting into it, as the fine tube of the spray producer is very easily obstructed by any small solid particle, and is cleaned with difficulty. I find it a good plan to cover the end of the tube which dips into the solution with a piece of muslin, which may be tied round it. In this way any solid particles which may be suspended in the fluid will be entirely prevented from entering the spray-tube at all. The spray instruments, the tubes of which are made of vulcanite, and which are worked by the hand, answer very well for ordinary purposes when five minutes' application two or three times a day is sufficient, but for more prolonged use a good steam apparatus is the best. Simple spray producers worked by the hand may be obtained at Mr. Hawksley's, 357, Oxford Street. We shall find that the spray method is well adapted for the treatment of certain forms of skin disease, and some other cases. There is no difficulty whatever in the use of the spray producer, and the patient can easily be taught to use the apparatus himself. For some time past I have had a large spray producer, of the form used by Sir Joseph Lister, in constant use. It answers perfectly for many purposes, and it may be employed for disinfecting persons, clothes, or rooms. When attending any case of contagious disease, any- one can expose every part of his clothes as well as his hair and hands to the action of a ten or fifteen per cent, solution of carbolic action. So quickly can the steam be generated that the whole process does not take more than ten minutes or a quarter of an hour. Metallic and other Tastes in the Mouth. — Patients not unfrequently complain of very peculiar tastes in the mouth described as metallic, salt, acid, sweet, bitter, and even fsecal (Fasx, dregs). The odorous matter of some putrid smells is unqu-estionably sometimes absorbed into the blood from the inspired air, and afterwards exhaled, the smell and taste of the breath remaining for many hours after the individual has left the neighbourhood of the odoriferous matter. In various derange- ments of the stomach the most peculiar tastes are experienced, and by patients are compared to the flavour of rancid butter, valerian, vinegar, and many other things.. Generally speaking the symptoms complained of may be relieved by exciting the excreting organs. Purgatives, espe- sially small doses of Calomel or Gray Powder (one to three grains) 126 APHTH/E — SORES AND ULCERS. repeated every third or fourth night for a fortnight or longer, usually afford relief. Exercise, free perspiration in a warm bath, Diuretics, and Stidorifics, are also useful. Thrush, Aphthae, — Sores and Ulcers in the Month. — Sores of the mucous membrane of the mouth are exceedingly common. These superficial sores are spoken of as AphthcE, from the Greek aTmo, I inflame. The derivation is not a very good one, for although no doubt the aphthous spots are associated with inflammation, they are not caused by this process. The meaning of this, like those of many other scien- tific terms, has changed as knowledge has advanced. Aphthae are little superficial ulcer-like depressions, sometimes with infiltration and con- sequent thickening of the tissues around, which form upon the surface of the mucous membrane. Sometimes the epithelium only seems to be affected, but more often the sore extends deeper, and damages the structure of the mucous membrane itself. Aphthae are extremely common in weak, ill-nourished infants, but are not unfrequently met with at all ages. In advanced age the disease occurs especially in those who have suffered from prolonged exhausting maladies. In various forms of chronic phthisis, and in some forms of pyaemia, they are present, and may cause great discomfort to the patient. It is difficult to explain precisely the changes which initiate the formation of aphthous sores, as, for example, those which are so frequently formed on the side of the tongue, just where the organ comes into contact with some tooth which is undergoing decay. The formation of a little pain- ful ulcer follows. Such ulcers very often affect the mucous membrane lining the lower lip just where the orifice of a labial gland is situated. Upon examination we find upon the aphthous spot a quantity of soft, moist material, which consists largely of epithelial debris, embedded in and everywhere invaded by fungi, especially a form of Oidium albicans, in various stages of development. Now it has been supposed that the fungi are the cause of the aphthae. The spores of the fungi, it is said, grow and multiply on the surface of the mucous membrane, and thereby cause inflammation and ulceration of the surface. Secretion takes place and the epithelium becomes soft and spongy, and thus the growth and spread of the fungus are favoured. The constituents of all organic secretions at the temperature of the body very soon undergo decomposition, and the germs being already present, fungi would soon develop, and would grow there and multiply. So that, instead of the fungi causing the disease, it is more probable that morbid actions on the surface of the mucous membrane give rise to changes favouring the development and the growth of the vegetable organisms, and that in these prior changes the true origin of the disease is to be sought. Fungi and their spores are, as I have said, invariably present, and their mere presence cannot possibly explain the TREATMENT OF AI'IITH/E. 1 27 development of the obstinate little ulcers which are now and then found in persons who apparently are in good health. I say in good health, but have little doubt that I use the term incorrectly ; and though I cannot tell you the precise particulars in which the normal condition is departed from, the fact of the development of aphthse is, I consider, proof that the person affected is not in perfect health. The affection is not purely local, and it is most probable that the occurrence of the spots in the mouth is preceded by, and intimately connected with, an altered state of the blood. These little aphthous ulcers are sometimes very difficult to get rid of, and of course a great number of " infallible cures " have been discovered. Artificial teeth often give rise to much trouble and discomfort owing to the same change, and sometimes when these are worn con- stantly without the mouth being frequently cleansed, very obstinate and sometimes even serious sores are produced and kept open. The patient who suffers in this way must exercise great care and for a time pay the greatest attention from day to day in keeping his mouth and teeth thoroughly clean. He must also consent to live on a simple diet and avoid all excess. Artificial teeth should be removed at night, and placed in a tumbler containing about twenty drops of red Condy's fluid to half a pint of water. Trcatniciit of Aphtiise. — Honey and borax, the Mel Boracis of the Pharmacopoeia, is a well-known old remedy for aphthae, and is equally efficacious in children, adults, and old people. Chlorate of potash also seems to exert some influence. In the case of adults the best remedies are those which are known to chemically change the fluids upon the surface of the spots which favour the development of fungi, and upon which they live. Tincture of Perchloride of Jron, or the Liquor Ferri Perchloridi of the British Pharmacopoeia, is a very potent local remedy. It may be applied to the surface of the ulcer with a camel-hair brush. Dip the brush into the Tincture of Perchloride of Iron, and just touch the surface of the ulcer ; leave it for a moment or two, and then the patient should wash out his mouth with water. But it is better to mix the iron with glycerine. Equal parts of pure Glycerine and Tincture or Solution of Perchloride of Iron make a very valuable application. This may be applied, as I have recommended, with a camel-hair brush, or one teaspoonful may be mixed with half a tumbler of water or more, and the mixture used frequently (every two or three hours) as a gargle or as a wash for the mouth. The patient should rinse the mouth with a little tepid water afterwards, for the frequent application of iron with- out due care causes temporary discoloration of the teeth. The glyce- rine assists the adhesive properties of the solution, and the morbid changes taking place are interfered with, the low vegetable organisms destroyed, and healthy action is soon re-established. A few grains of 128 OFFENSIVE BREATH. calomel added to half an ounce of lime water and an equal quantity of glycerine may also be applied locally with a camel-hair brush. Another very useful local remedy is Nitrate of Silver. The stick of fused nitrate of silver is lightly applied to the spots, or a strong solution (ten grains to an ounce of distilled water) may be applied with a brush every day until the cure is effected. The Thrush of infants usually yields to increased care in feeding. A very mild laxative is sometimes required, and oftentimes a little lime- water mixed with the milk is of great use. A little of the Mel Boracis may be put into the infant's mouth from time to time. But my friend the Professor of the Diseases of Women and Children will give you better advice on these matters than I can. Offensive Breath.~I will now briefly refer to a derangement which occurs sometimes in connection with disturbed gland action, and which gives people extreme annoyance. This is the emission of a very offen- sive odorous compound in the breath. It comes partly from the glands connected with the upper part of the respiratory and alimentary mucous membrane of the mouth and throat, and partly probably from the blood itself as it traverses the pulmonary capillaries. Even the individual himself is greatly annoyed by the smell which he exhales. The odour is not by any means the same in all cases, though I cannot tell whether chemical substances of different kinds are really produced. The odor- ous material is, I believe, formed in a great many cases by the glands of the mucous membrane of the air passages of the throat and of the mouth. I think these glands secrete the material which ought to be removed in another form by excretory glands, in other parts of the body, the action of which is much lessened or stopped in these cases. As offensive breath depends upon the secretion of a peculiar organic matter from the system, in order to effectually get rid of the tendency you must try to render more active the processes of secretion elsewhere. The offensive material may thus be got rid of by another and its more natural channel. In fact we must endeavour to get it or the material which yields it separated from the blood by other glands, and particu- larly by those which discharge their secretion into a convenient emunc- tory. You will generally find that if you excite the action of the ordin- ary glands whose office it is to separate odoriferous compounds from the blood, and discharge them into the bowel, the disagreeable smell of the breath will soon cease. In short, if you can only excite the more free action of the liver, the largest gland in the body, and of the kidneys and the solitary and other excreting glands of the small and large intestines, and keep up the increased action for a time, the patient will cease to be annoyed with the derangement. Sometimes he is afraid to go into society or be much in the company of other people for fear of OFFENSIVE BKEATIT. 1 29 annoying them as much as he is himself annoyed by the smell and even the taste of the air he expires. Acting u])on this view, the first remedies to be tried in such cases will be purgatives, diuretics, sudorifics, if the trouble is not relieved by keeping the mouth clean. In all cases antiseptic substances may be used to wash out the mouth frequently. The wash should have a little hot water mixed with it and be used tepid — not cold. Charcoal Poivder mixed with water is a wash for the mouth. A teaspoonful of Tincture of Myrrh in half a tumbler of water is also a good wash. Carbolic Acid is useful in such cases. A weak solution of carbolic acid (one part to two hundred of water) may be taken internally, and the mouth may be rinsed out frequently with such a solution. Weak carbolic acid spray may also be tried {see p. 1 24). Condy's fluid is another useful remedy. The mouth may be washed out several times daily with a solution consisting of half a teaspoonful of the red Condy in a tumbler of water. But to effect any lasting relief, you must be particularly careful to regulate the patient's diet. Many of those who suffer from trouble of this kind are too fond of rich sapid substances, and perhaps take too much beer or porter, and upon enquiry you will find perhaps that they habitually eat more than a not very vigorous stomach can properly digest. The excess of all the good things taken is imperfectly oxidised, and the chemical compounds formed clog the emunctories, and are in too considerable proportion to be got rid of by the various glands whose business it is to remove them from the body. Certain materials remain in the blood, and instead of being discharged from the bowels are eliminated in a crude form by the skin, by the glands of the mucous membrane, and in part by the lungs. Thus the expired air becomes contaminated. It is most important that people who suffer in this way should not overeat, should not take more of anything than is required for nutrition and the work of the body. As a matter of fact, almost everyone does eat more, and many eat very much more, than is required to keep the body in health. In some people, perhaps, in consequence of the liver being less active than it should be, the excess of food instead of being excreted in an altered form in the usual way by the solitary and other glands of the bowels, undergoes exceptional chemical change, and odoriferous compounds are formed in large amount, and persistently, to the patient's great distress. As I have suggested, the way to remedy this great annoyance is to encourage the more free action of the glands whose ordinary office it is to separate this class of substances from the organism. Try and transfer the action from the surface of the gastric and respiratory mucous membrane to that of the large bowel. For persons who have long suffered, besides giving occasional doses of one or two grains of calomel, blue pill, or gray powder, you must prescribe some mild harmless purgative, and of this K I30 OF THE USE OF PURGATIVES. frequent doses may be taken. Ycu must in fact take care that the bowels act freely, and that the excreting glands do their work efficiently, and you must explain to the patient that the improvement will only be gradual, and he must persist for some time in steadily pursumg the treatment you advise. Almost any purgative will have a good effect in many of these cases : — Different preparations of Colocynth, Aloes, Podophyllin, Scani- mony, Rhubarb, Jalap, Senna, Cascara, have all been prescribed with benefit. Several other purgatives have been recommended by different authorities. As a general rule it is better not to give large doses, as it is necessary not only to excite the action of the intestinal glands, but to keep it up — to help the glands from day to day to do their work — to give them just a little artificial stimulus and no more. From three to five grains of the Pilula Colocynthidis et Hyoscyaini, or the same amount of Pilula Rliei Composita may be ordered, or you may add half a grain or less of the Extractum Aloes Barbadensis, or one-fifth or less of a grain of Podophyllin to half the quantity of either of the pills mentioned. At first the pill should be taken every night, or just before dinner ; and when it begins to act, every other day, or once in every three or four days. Our object is to so regulate the bowels as to cause a daily action. With some persons Scanimojiy answers admirably. One or two grains of Resin of Scammony, Sca7nvionicB Resina, may be added to two or three of the Compound Colocynth Pill, which as you know contains a certain proportion. A patient of mine who died at the age of ninety-five had taken Scammony two or three times a week for many years with the greatest benefit ; but neither this nor Podophyllin, nor any purgative that I know of, acts equally well upon all. You must be well acquainted with a number of purgatives, and must be able to com- bine them in many ways. With this knowledge you will often be able to hit upon the right thing for particular patients. Our predecessors were more skilled in prescribing combinations of remedies than we are, and there is not the smallest doubt that we often succeed with a com- bination, although we may fail to effect the desired object with a single drug. Although I must not tire you with mentioning a multitude of remedies for a condition which sometimes resists all our efforts to relieve, there is yet one thing which as already stated is of the greatest service if given with judgment and due care. This is mercury, which, as you know, has the credit, and deservedly, of acting specially on the liver, but which also causes increased action of most of the glands connected with the alimentary, and probably also the ab- sorbent, system. Mercury is one of the remedies upon which our fore- fathers relied more implicity than we do. I think they often gave it too frequently and in unnecessarily large doses, but no\v-a-days I think we OF TIIK USE OK MKRCURV. 131 err in an opposite direction, and some .practitioners not only do not prescribe mercury in cases where immediate relief v;ould follow its administration, hut refuse to prescribe it altogether, and encourage the prejudice needlessly excited in the minds of patients against its use. Many a mother, who seems to be shocked at the very name of calomel, nevertheless frequently gives it to her darlings in some patent powder which she has used for years, and wliich she will tell you is a most excellent remedy for every complaint of infancy and childhood. In many instances in which the patient suffers from offensive breath, with a dirty tongue and a disagreeable taste in the mouth, and defective secretion of saliva, with perhaps slight nausea, and fulness or dis- comfort about the pit of the stomach, you may effect a cure and earn the gratitude of your patient by prescribing a few small doses of blue pill, gray powder, or calomel. The medicine should be given with a little rhubarb, compound colocynth pill, or some other purgative, every third or fourth night, three or four doses in all being ordered, though often one or two only will be required. With some persons, however, no compound of mercury will agree, and you must bear in mind that if you overdo mercurial treatment you will do harm. Indeed offensive breath is often caused by the regular administration of mercury, and the trouble often continues until long after the mercury has been given up. In these very exceptional cases you must employ other pur- gatives, and give various salines to act on the bowels, the liver, and kidneys, especially the Nitrate of Potash— Potassce iVitras, and the Chloride of Avunonium — Ammonii Chloridutn ; five to ten grains of the first, and twenty grains of the last, dissolved in two or three ounces of water, on rising and on going to bed. Podophylliu (a quarter of a grain), Cascara (the extract two grains, or a two grain tabloid, sugar coated), and Eiiouvniin may be tried at night or immediately after dinner, while the patient also takes the saline in the morning. IMPAIRED APPETITE— LOSS OF APPETITE— FASTING CELEB- RITIES — VORACIOUS APPETITE — NAUSEA — ALCOHOL — HABITS OF INTEMPERANCE — THIRST— OBESITY — EMACIATION NOT DUE TO STRUCTURAL DISEASE. Impaired apiietite. — Let me now say a few words about loss of appe- tite, a grievous complaint in the opinion of many people, who will tell you with dismay and astonishment that they have ceased to enjoy their food. They never feel hungry, and never eat with appetite. Some- times this lack of inclination for food is due to the circumstance that the complainants ordinarily eat too frequently, and possibly also eat too much. There is, however, unquestionably a form of loss of appetite, or impaired appetite, concerning which you will be consulted from time to time. This sometimes most obstinate ailment is learnedly known as Anorexia, the scientific term for loss of appetite, the word being derived from the Greek «, priv., o/je^i'-; appetite. Loss of appetite in some cases is rather advantageous and conserva- tive. Many a man who boasts of always enjoying an excellent appetite, would be more fortunate if from time to time his appetite was very moderate, though the fact might make him feel anxious. It is in truth a misfortune to have too good an appetite unless you have great self- command ; for the temptation to satisfy it is considerable, particularly in the case of those who are well off, and are unhappily obliged, owing to their social position, to keep good cooks. Many such persons are doomed to suffer as they get older from having eaten too much at an earlier period of life. He who wants to keep himself in a state of health must learn to care little about eating, and must not only sit down to his meals with an appetite, but take care that he leaves off eating before he is satisfied, and this is particularly important after middle life, and in tropical climates at all ages. Loss of appetite sometimes depends upon a state of the mucous membrane of the stomach bordering on inflammation. After a con- gested state or slight chronic inflammation has existed for a considerable time, degeneration of the gastric glands and other tissues may take place,, as occurs commonly in old age. After prolonged exhausting diseases, digestion may become permanently weak, and in such cases there is loss of appetite. In treating many of these, it is necessary to help digestion artificially, as I shall explain more fully in another lecture. But in persons whose stomach is fairly healthy, you will observe that FASTING CELEBRITIES. I 33 anything which induces a state of the system in which the nerves become weak, — great fatigue, excessive and long sustained brain-work, anxiety, mental emotion, fear, or joy, may give rise to impaired appetite. In cases in which the loss of appetite depends merely upon some temporary derangement of the mucous membrane of the stomach, many of the remedies useful in weak digestion will afford relief. Often a change of diet for a few days will effect a cure. Advise the patient to take nothing but milk and beef tea, with a little stale bread, or corn flour or lentil flour properly cooked. But where the loss of appetite depends upon undue wear and tear of the nervous system and is associated with mental depression, general weakness, inability to exert body or mind, a thorough change may be needed — a complete alteration in the general habits of life, an abandonment for a time of the general daily routine whatever it may be. Some of the cases in which the appetite becomes gradually reduced, or completely lost, are very curious and difficult to relieve. They occur commonly in the so-called hysterical or neurotic condition or diathesis (disposition, constitution, from cui and t/^;//<(, I place, I dispose). In many instances there certainly is no structural lesion either in the stomach or in any part of the nervous system. The affection is no doubt due to some deranged nerve action which lasts for a time and then passes off without leaving any actual pathological change. Hysterical (Itnepa, the uterus, because the con- dition is often associated with uterine derangement which was formerly regarded as its cause) girls and women are very apt to lose their appetite for a time. At first having little desire to eat they yield to the impulse and may gradually bring themselves to refuse all ordinary food. If pampered and pitied and regarded as interesting objects, they become worse and soon glory in refusing to eat. Occasionally we do meet with people in a state almost of starvation in consequence of having given way to this feeling of want of appetite. From there being no desire for food there is soon acquired an actual distaste, dislike, aversion. The mere smell of food at once causes all desire for it to disappear. There may be danger of actual starvation if the patient is not managed with judg- ment, but in such cases, when a fatal result occurs, death more com- monly depends, not upon actual inanition, but upon the development of some intercurrent malady when the body is in an excessively weak and exhausted state. Fasting celebrities. — Some of those remarkable " fasting " celebrities have commenced by degrees as above suggested. The fasting disposi- tion has developed itself after loss of appetite, perhaps occasioned by a feeble state of the digestive process, due to imperfect action of the secreting glands of the mucous membrane of the stomach, or of the nerves which excite these glands to form and discharge their secretion, and which has existed for some time. Fasting becomes a passion — a 134 VORACIOUS APPETITE. mania. The patients are pitied and patronised by the people about them, who humour them in every conceivable way, and encourage them in the belief that they are peculiar beings, who, unlike common folk, can actually live without eating. This gradually leads on to deceiving They systematically refuse everything that is brought to them, and are soon looked upon as mysterious persons. They surreptitiously obtain a little, and in this way may live in a weak, emaciated state for a great length of time. They lose weight very slowly, and then become station- ary, which fact of itself is proof that nourishment is somehow introduced into the body. An excellent account of one of the most remarkable of these cases, together with much matter of importance in connection with the general subject of starvation, has been recorded by my old friend, the late Dr. Robert Fowler, who investigated the evidence in the most thorough manner. I strongly recommend all who are interested in the physiological, moral, and legal aspects of fasting cases to study " A Complete History of the Case of the Welsh Fasting Girl (Sarah Jacob), with Comments thereon ; and Observations on Death from Starvation," by Robert Fowler, M.D. — Renshaw, 356, Strand, 187 1. Voracious Apiietitc. — Occasionally we are consulted about an in- ordinate appetite. The patient is never satisfied. He eats a pound of beefsteak or more, and still feels hungry. In some persons this great desire for food can hardly be considered as a disease or even an ailment. Children are occasionally the subjects of it. No doubt the condition is often encouraged or induced by injudicious management. Remarkable voracity is, however, not uncommonly associated with actual disease. In certain forms of mental disease it is a prominent symptom, and in Diabetes (rid, through, and [iaivw, I pass), a condition characterised by the formation and elimination of, it may be, a large quantity of sugar from the system, the appetite is very frequently, but by no means constantly, enormous. Many a diabetic can consume one pound, or even two pounds of rump steak at a sitting, and what is more remarkable, thoroughly digest it. Children and adults who suffer from worms have often a very large appetite, and it will be well for you to bear in mind this circumstance. Get rid of the worms and the child again eats moderately. Inordinate appetite used to be spoken of as Bulimia. This word, like many others I have referred to, is derived from the Greek. You must have remarked that a great number of medical terms, and particu- larly the names of diseases, are Greek. Those among you who have been taught Greek at school enjoy an advantage over those who are ignorant of it, inasmuch as the meaning of a vast number of words will be at once understood. It is somewhat unfortunate for many who are going into the profession that there should have been a dead set against EVILS OF OVER-FEEDING. 135 (ireek, for no one can really learn Medicine without at the same time finding out the meaning of a numl)er of Greek words. The word Bulimia I learn comes from /io^)^-, an ox, or /^o/", the augmentative particle, and Avco's hunger. Bulimia, or voracious appetite, is a condition which I suppose may be due to an irritable state of the nerves of the stomach. Not unfrequently the affection is asso- ciated with vomiting, the stomach rejecting its contents as soon as they have accumulated to a certain extent. The voracious appetite, as we see it existing in children and young people, usually comes from undue encouragement. The greater the desire for food the more food the individual eats, and so he goes on until he succeeds in con- suming several times as much food as his system requires. Thus is thrown upon important organs the difficult task of eliminating a large excess of material not required by the organism, and which ought not to have been taken. Sad mistakes are frequently made by parents in this matter. A child perhaps is rather thin, and therefore encouraged to stuiT. By degrees the habit of taking enormous quantities of food is acquired, with the not uncommon result to the patient that he gets thinner and thinner, instead of gaining in weight. By reducing the quantity of food, you may succeed in increasing the child's weight. ]\Iany of the railway navigators, and very strong labourers who have heavy work to perform, suffer from this affection, partly in consequence of yielding to desire which their high wage enables them to gratify, and partly because they act upon the generally received theory propounded by certain popular philosophers, that the more you consume in the way of food the more work will your machinery perform — a principle which may to some extent apply to machines, but is quite inapplicable to any form of living organism, and altogether inaccurate as regards man, for oftentimes the man who works the hardest and does the most eats very little. The railway navigators are fine, strong men, many from 5 feet ID to 6 feet high, and some of them certainly do consume an enormous amount of animal food, probably three times as much as is required for the performance even of the great amount of work they do. The excess, of course, must be somehow excreted, and before it can be excreted must be acted upon by the secretions of various organs, espe- cially the liver. This and many other glands in the body are thus called upon to discharge an excess of work, and, as a general rule, they are damaged by over-action before the man reaches the age of forty. And in not a few cases the organs completely break down from overstrain, passing into various forms of disease which may result in early death. Indeed we do not often see one of these men doing a good day's work who is much more than forty. The great majority break down before that age is attained. The model navvy has unquestionably to work very hard indeed. His wages depend upon the amount he can lilt 136 NAUSEA.. and the rapidity with which he can move heavy weights, so that he is encouraged to exert himself to the utmost. The more work he can do in the time, the more money he earns. He has been assured that the more he eats the more work he will be able to do, and squanders his money in beef and beer and thus strains his organs of digestion, assimi- lation, and secretion, — ruins his health and shortens his life. There is no one to teach him better, so he adopts the prejudices of his order and follows his own inclinations, curiously enough at the same time acting upon dogmas sometime ago supposed to be scientific. If these men had common sense, and consumed about one-fourth of the food and beer many of them indulge in, they would have a chance of living to the ordinary period of life ; and if they did not do quite so much work in the time, they would continue able to work for many years longer. Many men who belong to the middle and upper working classes, and who have lived moderately, are often very strong and vigorous, and able to endure a considerable amount of bodily fatigue at the age of sixty-five or seventy, and there are some who, like the great statesman who felled trees, pass the last age, and are nevertheless strong in muscle and nerve. It need scarcely be said that, as regards the treatment of cases of inordinate appetite, it is a matter of the first importance to carefully regulate the diet. Small doses (three to five minims) of Dilute Hydro- cyanic or Prussic Acid, Aciduin Hydrocyaniaim dilutuin, and fifteen or twenty grains of Bicarbonate of Soda in an ounce of water, half an hour before meals, 'are often useful. Liquor Potassse, Bismuth, Tinc- ture of Hop, Tincture of Henbane, and preparations of Opium given with caution in small doses, with some other medicines, may be pre- scribed to soothe the stomach and allay the feeling of hunger in cases in which it depends upon unusual irritability of the nerves. Nausea. — Some persons frequently suffer from nausea, and a most unpleasant sensation it is to experience. You must, however, take care to distinguish between nausea and vomiting — actual sickness. People often tell you they are sick, although they never reject the contents of the stomach. This feeling of nausea is a very common one, and is met with in various degrees ; sometimes being very slight, just a little squeam- ishness, which as often as not passes off soon after food is taken ; sometimes so severe that the patient feels as if he must vomit. The nausea perhaps comes on as soon as he wakes, and lasts for some hours, and possibly may not entirely disappear for many days at a time. Nausea prevents people from eating, or at any rate makes them care- less whether they eat or not, and entirely takes away a pleasure highly appreciated by some, that of tasting, masticating, and swallowing food. There are, however, persons who hardly know what it is to feel hungry. They eat as a duty, but would quite as soon go without food. The feel- TREATMENT OF NAUSEA. I 3/ ing of being moderately hungry, — looking forward to and desiring food, undoubtedly is a pleasant sensation, especially if there is a prospect of its being gratified within a reasonable time. Nausea may be brought on by very many circumstances. If you were to take but a i-4th or even the i-6th of a grain of Tartar Einetic, Antwioniuin Jhriaratiun, a drug much in vogue fifty years ago, but now seldom prescribed, you would soon learn what the feeling of nausea is like, if you had not already experienced nausea otherwise caused. Those who go a short journey by sea often suffer from nausea, or some- thing worse. The ver}- few among you who have never learned to smoke may easily study the phenomena of nausea if you smoke a portion of a cigar for the first time. If the feeling should be so unpleasant as to make you determine not to repeat the experiment, perhaps, upon the whole it will be so much the better, for smoking wastes a great deal of time which might be better employed. In cases of inordinate appetite nausea is an advantage, as it prevents the patient from eating more than is good for him. Slight nausea is no doubt dependent in the ordinary way upon a somewhat disturbed state of the mucous membrane of the stomach or a deranged condition of the liver, or upon both. The sensation may be relieved in many ways. Some forms of nausea are at once relieved if food be taken. Pepper and various pungent substances, which excite the secretion of the stomach, are often useful. Cayenne pepper and Curry powder are well-known remedies. Ten or fifteen drops of Tinc- ture of Ginger in an ounce of water often relieves. But nausea seems to be due in some cases to some slightly impeded circulation in the vessels of the mucous membrane of the stomach, and those of the liver. The latter gland is sometimes much enlarged in consequence of the large quantity of blood which accumulates in it. After a few days, especially if the patient rests and takes very little food, it regains its usual volume without having undergone any permanent change, and without being in any way damaged. Nausea, dependent upon temporary vascular congestion, may be removed by promoting a more free flow of blood through the vessels of the Hver, stomach, and bowels, by giving a purge, such as Sulphate of Soda, or Epsom Salts. A warm bath, or a Turkish bath, will very often effect a cure, particularly in the case of those whose habits are too sedentary. Plent}' of fresh air, and but little food for a day or two, without resort to any other treatment, will sometimes cause the discomfort to cease. If these means fail, a mercurial purgative should be tried, see p. 1 30. But in order to cure some forms of nausea the patient has to go a step further, and induce sickness, as by a mustard emetic, by tickling the fauces, or by drinking two or three tumblers of luke-warm water. The distressing nausea that ])recedes, and is indeed sometimes substi- 138 SEA-SICKNESS. tuted for actual vomiting, in ordinary cases of sea-sickness, may last for a considerable time. This is often relieved as soon as vomiting occurs, but unfortunately, the vomiting may continue until the patient is really ill from exhaustion. The pathology of ordinary sea-sickness is still doubtful. Dr. Irwin published an interesting memoir, founded on four thousand cases (" Preliminary Observations on the Pathology of Sea -Sickness," Lancet, November 25th, 1881), in which the various theories entertained are carefully considered. Disturbance in the semi- circular canals seems to be connected with this motion sickness. " Motion produces sickness by disturbing {a) the endolymph in the semi-circular canals, {b) the viscera in the abdomen, and possibly {c) the brain and the subarachnoid fluid at its base " (Irwin). After the motion has been experienced for some time an " irritative hyperaemia of the semi-circular canals is set up," which, according to Dr. Irwin, is the true primary pathology of ordinary sea-sickness. The particu- lar part of the central nervous system involved in the reflex action of vomiting is situated in the Medulla Oblongata, near the Re- spiratory Centre. Vomiting may be caused by various poisons in the blood, and is sometimes one of the first evidences of the occur- rence of acute febrile disease, due to the action upon the nerve centre of poisonous matters formed within the body or introduced from without. Vomiting may also be caused by various forms of irritation, in or at a distance from the stomach, and may be due to slight or serious disturbance in the brain. Tickling the fauces, or, as people often say, " putting the finger down the throat," is generally soon fol- lowed by vomiting. So easily is this act produced that occasionally one meets with a person who can cause his stomach to reject its contents by a purely voluntary effort, without any direct irritation of any kind. Many healthy persons who suffer from time to time from nausea and vomiting, depending upon over-sensitiveness of the stomach, liver, and other glands, discover not only how to cure themselves in a very simple way, but also how to keep themselves well. They find it necessary from time to time to give their stomachs rest for from twelve to twenty- four hours, and then they get well, and remain well perhaps for a considerable time. The prejudice that exists against going without one's dinner now and then is really most curious. An occasional fast is almost necessary for many who live even but moderately well, and some, especially ladies who are little out of doors, and take little exercise, would be in much better health and would feel in better spirits, stronger and more capable of exercise, if they would not dine quite every day, as well as take a good lunch. It is also advantageous to take fish and no meat twice a week. As regards medicines for the relief of vomiting you will find that EVIL EFFECTS OF ALCOHOL. 1 39 from one to three or four drops of Hydrocyanic acid, Acidiini Hydro- cyaniciiin dilutum, in two tablcspoonfuls of water, with a little Jiicar- bonatc of Soda or Potash, in half a tumhlcr uf Soda or Potash water taken in sips before food will be useful. In some cases three or four drops of Solution of Ammonia, Lit/nor A/nmo/iite, with or without five or ten drops of Essence of Ginger, in a wine-glassful of water, may cure the ailment. A small dose of blue pill or calomel will often relieve very obstinate nausea, although many other remedies may have failed. In not a few instances counter-irritation is also of use. A mustard poultice may be applied over the region of the stomach and liver for twenty minutes every third or fourth day. Or a wet rag, covered with oiled silk, or a piece of Spongio-piline, wetted with warm water and worn for an hour or two, will frequently be found efficacious. See also tlie treatment of Indigestion, p. 165. Alcoliol and Habits of Iiiteiiiitvraiiee. — People who suffer from nausea or biliousness and want of appetite, — and there are not a few who are habitually ailing in this way, who seldom indeed during a long life have felt really well, — often find out for themselves, or they are told by too officious friends, that a little alcohol just before a meal will give relief. Brandy, gin, bitters of various forms, pick-me-ups, &c., are taken for this purpose, and a worse system has never been invented or acted upon. That bad habit of taking now and then ginger brandy, cherry brandy, or the worse one of frequently imbibing strong sherry for relieving nausea, a sensation of hollowness, or faintness, or fulness, or all-overishness, or what not has been the ruin of thousands. Having once acquired it, as is only too well known, the majority may find it far more difficult to give up this vicious practice than they supposed. Bad indeed is the fashion of taking just before dinner a small dose of brandy or ginger brandy, or dry sherry, or some other strong alcoholic stimulant, just to excite the appetite in order that justice may be done (!) to the repast, that is, that people may swallow more than is good for them, and more than they can easily digest. If a man cannot eat his dinner without first taking a stimulant, he had better go without it. He might wait a few hours, and then he would probably be able to take simple food without the help of condiments or stimulants. The habit of taking alcohol too frequently and too regularly often comes from this most objectionable practice of taking a little stimulant before dinner. The unfortunate person who is regarded as the " life of the party " cannot help himself, for he must be sprightly and entertaining from the beginning to the end of the feast, no matter what the penalty may be, — and illness and early death have been the result in many cases. Indeed there is little doubt that good dinners have slain and continue to slay more than all the wars, sicknesses, head-work, exposure, bad trades, and accidents added together. 140 ACQUIRING INTEMTERATE HABITS. Doctors are often accused of teaching and encouraging people to " tipple," because in certain morbid conditions they have found it necessary to prescribe stimulating doses of alcohol. For one person, however, recommended to take alcohol by us, how many thousands who have never consulted a doctor in their lives, take it on other grounds,— take it because they like it, or because they see others take it, or because they like the sensation it produces? Many will admit that they began when they suffered from a " sinking sensation," or from nausea, or uneasiness about the stomach, and after having been troubled from time to time, discovered that the unpleasant feeling was invariably relieved if they swallowed a little brandy. The little brandy generally increases in amount. Nausea and other unpleasant sensations instead of occurring once or twice in the day, occur a great many times, and the victim will tell you that, after a time, he was obliged to resort to the remedy in order to get through his work. Of those who allow them- selves to act thus not a few become slaves to alcohol, and then a more deplorable phase is soon reached. They cannot abstain, self-command is lost, and the unfortunate persons are no longer able to control them- selves in any way, while few will submit to be influenced and controlled by others. This state may last for a time, and then a new and very re- markable phenomenon is occasionally manifested — would it were always so ! The intemperate individual abstains entirely, and hates alcohol even more than he loved it before. He despises himself, is overwhelmed with remorse. In a little time he gives up the role of sinner and adopts that of saint, and saint of a despotic and uncompromising kind. For a long time he cculd not govern himself, but now he is determined to govern others, and in a very decided manner. He expresses virtuous indignation against all who take or sell or produce alcohol, and thinks it very hard that he is not able to punish every one who prefers wine to water, and who dares even to look at a stimulant. We have the curious spectacle of a very small minority who, by their own confession, for some time could not keep themselves within the bounds of reason, now seeking to impose their arbitrary veto upon the very large majority who have never had the slightest difficulty in either taking a little, much, or abstaining altogether, as seemed to be the best for their organisms at the time. With as much reason might power be given to convalescent lunatics to put the sane in straight waistcoats, or shut them up in padded rooms. All persons who lose control over themselves as to taking any form of alcohol should be placed under care as soon as possible. There is no doubt that the great majority can be cured if treatment be com- menced early in the disease. It is to be hoped that ere long our great legal authorities will permit us to act in the matter, and trust us instead of suspecting us of interfering or desiring to interfere in some way not THIRST. 141 to the interest of the patient or of society. As regards the treatment of inebriety, especially those terrible and most difficult cases which are met with from time to time in women belonging to the cultured classes, some excellent observations have been made by Mrs. L'Oste, who has been very successful in treating some most obstinate cases ("The Treatment of Female Inebriety in the Cultured Classes, resume of twenty-seven years' Experience," H. K. Lewis, Gower Street, 1SS9). Unfortunate persons who cannot taste a certain fluid without making themselves worse than animals, will, before they reach the incorrigible stage, sometimes come to you and crave medical advice. If you think sufficient self-control is left to them, you may be of some use by ordering certain medicines which will act, to some extent, like alcohol, but which are not open to the objections pertaining to that substance. Ammonia is often of great use. You may order half a teaspoonful of Salvolatile, Spiritus Avimonia Aromaticus, with twice as much Compound Tincture of Cardamoms, Tinctura Cardamo7ni Composita, in a wine-glassful of water every three or four hours for a few days or a week. Tincture of Hop, Tinctura Lupuli, Tincture of Orange, Tinctura Aurantii, or Syrup of Orange, Synipus Aurantii, are good additions to improve the flavour of the dose. Thirst. — It is probable that thirst is less dependent on the state ot the stomach than is the feeling of hunger, though it is quite true that thirst may be excited by Cayenne pepper, and irritating matters intro- duced into the stomach. It often occurs in connection with certain forms of indigestion, and is almost always experienced an hour or two after a good meal, during which little fluid has been taken. The fact that thirst is relieved by injecting fluid into the blood and by the absorp- tion of fluid from the general surface, — that it is present in all febrile states, and comes on after diarrhoea, after the action of ordinary purga- tives, and after free perspiration, however excited, would seem to indicate that the feeling is somehow due to the reduction of water in the blood. The sensation of thirst seems to be experienced principally in the back of the mouth and fauces. Considering this part of the mucous membrane very readily gets dry even in health, it is probable that very fine afferent nerve-fibres, close to the capillary network of wide capillaries having an unusual number of bioplasts in their walls, take part in the initiation of the phenomena which constitute what we call thirst. The capillaries and nerve-fibres referred to in that part of the mucous membrane which covers the convex surface of the epiglottis, and which is admirably situated for the detection and registration of varying degrees of moisture of the mucous membrane, are represented in pi. XCIII of " How to Work with the Microscope," 5th edition. No rigid rules can be laid down as to the exact quantity of fluid that should be taken per diem, for the proper amount varies in indi- 142 IMPORTANCE OF FLUID. vidual cases. It should undoubtedly bear a certain relation to the solids taken, but in practice it is in:ipossible to say, in any given case, precisely what this relation should be, for some persons generally feel thirsty, while others scarcely ever experience this sensation. One man finds he digests better and feels better if he takes from two or three pints of fluid daily. Another taking about the same amount of solid food or more, finds that half as much fluid suits' him best. Some forms of indigestion and many cases of inactive liver may be completely cured by taking a quart of water, hot or cold, flavoured with lemon-juice during the twenty-four hours ; or weak tea will answer equally well in some cases. When in practice, you will find that some people habi- tually take too much to drink, and some too little. The great majority of well-to-do people take far too little liquid, pass too little urine, perspire too little, and eat too much to be in health. You will occasionally, however, meet with cases of impaired digestion, general weakness, and feeble health, which are due to the habitual introduction of too much liquid with the food, the patients nevertheless feeling thirsty. On the other hand, not a few persons complaining of muscular and nerve pains in various parts of the body, and who are evidently suffering from a tendency to gouty or rheumatic affections, may be completely cured by a course of water-drinking, two or three pints or more of water being taken in small quantities at a time during the twenty-four hours. By ordering this plan to be continued for two or three weeks, three or four times in the year, we may succeed in washing out the tissues thoroughly, and keeping their owners in a healthy condition. People are needlessly prejudiced against warm water, because it has long had the reputation of exciting nausea and also on account of the possibility of the water containing disease germs of some kind. The latter objection is quite removed if the water is boiled for a quarter of an hour before being taken. In all cases not more than half a pint of water should be taken at a time, and this in mouthfuls, and not swallowed all at once. The extra quantity should be taken between meals and the first thing in the morning and the last at night. The most opposite advice is given, and by very confident authorities, as regards the taking of fluids at meal-times. However much the direc- tions to the patient may differ, they are expressed not only in plain but sometimes in needlessly positive and forcible language ; and though one adviser gives directions directly contradictory to those given by another, each proves to the entire satisfaction of the patient that his advice is justified by the most irrefragable arguments, and is conclusively sup- ported by the newest facts and theories as well as by the very latest results of the most carefully performed experiments. Many a patient has been told that he should drink little fluid with his meals, but it is an un- doubted fact that some of us not only digest far better but quicker if we OBESITY. 143 take a fair quantity. Increased fluid economises food — a small quantity of solid food higlily diluted going as far or farther than a large amount moistened with only a little. Very strong stomachs only can bear the ingestion of half a pint of cold fluid in a draught just before dining or after a meal, and it is undoubtedly a good general rule to take only a mouthful or less at once, and then wait a time and repeat the process, and as I have already remarked, warm or tepid water will generaUy suit better than cold. Especially in cold weather many who suffer from weak digestion, who come shivering to lunch or dinner, require warm liquid of some kind. Hot soup suits many, hot water, hot lemon-juice and water, hot coffee agrees with some : many prefer hot spirits and water — but spirics at least as a regular drink should be eschewed by all. Occasionally such a dose at meal-times does good, but it must not be daily, or even I should add, nighdy repeated as a rule. Taken regularly spirits are not only useless, but they may do serious harm to the digestive power, to the liver, and to many tissues and organs of the body. Few will be prepared to accept the suggestion that warm, of course not too strong, tea is excellent for some stomachs at meal times, but there is no question about the fact. I-ong experience has proved that half a pint of weak tea with or without milk or with a little lemon-juice or a small slice of lemon instead of milk, may be taken three times daily at meals not only without doing harm, but with the result of sometimes curing dyspeptic and other stomach discomforts. I know that this plan, which nearly all my medical friends would condemn, has worked well for upwards of forty years, and frequently succeeds admirably in old age. The tea should not be coarse flavoured and surcharged with tannin, and should not be infused for more than two or three minutes. Chinese tea seldom disagrees with any one, but the strong rough tasting teas now so fashionable are certainly objectionable, and if taken by any but the strongest should be made very weak. Nor is there in many cases any objection to the proper allowance of sugar. Indeed I should say that much needless cruelty has been exercised by some members of the profession who cut off" every bit of sugar a person habitually takes, because perhaps he may confess to have had a few twinges about his own joints or other symptoms due to accumulation of uric acid and other things in his blood. To forbid sugar and allow plenty of meat, soup, fish, and particularly the abominations called entrees, is unreason- able. A dozen lumps of sugar are harmless indeed compared with many of the complex delicacies which help to make up a " nice simple little dinner." Obesity. — The small or large amount of food taken does not alone account for the foct that some persons remain thin while others get moderately or very fat. Some have laid it down that more than a mod- erate decree of fatness is indicative of bad health, of a tendency to 144 OBESITY. disease of certain organs, and especially of the heart, and of degenera- tions in which fatty matter is found in tissues which are free from it in a state of health. It must however be borne in mind that various forms of fatty degeneration occurring in muscle, nerve and other tissues are met with in persons who have never been fat, and indeed, although the accumulation of adipose tissue and fatty degeneration of tissue may occur in the same individual, there is probably no pathological connection between the two conditions. In arrangement, in mode of deposition and absorption, in chemical composition, in relation to the normal tissues of the body, the fat of adipose tissue differs entirely from the fat of fatty degeneration, and there is really no analogy between the two processes. Though undoubtedly certain kinds of food do favour or interfere with the increase of ordinary adipose tissue, the getting fat or being thin is not a mere question of diet. Some get stout although they live upon a diet whicli contains very Httle fat-producing substance, and it is certain that fat is formed in many of the lower animals out of substances containing no actual fat, though of course all the elements necessary to form fat are present in every kind of food and even in the atmosphere only. Amongst us there are persons who get fat very easily, persons who are moderately fat or well nourished, and persons who cannot be made fat. But all may by food and treatment be made to vary in weight within certain moderate limits and at different times. Alterations in diet of a decided character should only be made with the utmost care, as, particularly after middle age, illness sometimes results from increas- ing or reducing in any considerable degree the quantity, and changing the kind, of food to which a person has been accustomed for some years ; and any change regarded as desirable either for improving nutrition or for reducing the amount of redundant adipose tissue should be made very gradually, and the effect of the altered diet should be carefully watched by the practitioner. Every well educated medical practitioner, and all have now to spend five years in medical training, is well qualified, particularly if he has long been acquainted with the patient's habits, peculiarities, and constitution, to explain and superintend the treatment necessary in these cases, — and I cannot help thinking that of late years, the system of looking for " specialists " and " experts " who are credited with extraordinary powers and knowledge concerning the means whereby fat people and lean people may be brought to the usual condition as rec^ards nutrition, is not in accordance with the best interests of the patient, or to the credit of the profession. Large fees are sometimes exacted for the treatment of cases which every well-informed prac- titioner would advise in the ordinary course of practice, while mysterious remedies are sometimes supposed to be employed, although the real treatment consists in a moderate and better regulated diet. The deposition of fat in the form of adipose tissue, and its removal OBESITY. 145 in cases in which there is a redundance, arc comi)lcx processes and well worthy of being thought over by the physician who is appealed to for the purpose of improving the nutrition of a thin person or of removing an inconvenient accumulation of fat. The quantity of redundant adipose tissue is sometimes enormous, often amounting to more than fifty or even a hundred pounds, and the increase is occasionally very rapid. The tendency appears at different periods of life from infancy to past middle life, and is observed in persons of very different types. Very frequently, however, those who get very fat are of an amiable, easy-going and perhaps, though by no means generally, of an indolent disposition, while the irritable, highly nervous people are more frequently thin, but to this there are also exceptions. Every particle of fatty matter in every form of adipose tissue results from a long series of complex chemical changes as the matter passes several times through the state of bioplasm or living matter. That is, certain substances are taken up by living matter, their atoms rearranged while in the living state, new substances being at last formed which in their turn are again appropriated by other living matter until at last the particular form of fat results. In other words matter lives and dies several times between the form in which it passes into the stomach as food and the production of the fat as it is found in adipose tissue in various parts of the body. Of all the tissues of the body, the adipose is the seat of the greatest changes in volume during life, for it may increase and diminish in a re- markable degree many times in the course of a few years. In many of the lower animals it increases annually towards autumn, and the fat is slowly taken up and consumed during the winter months. In this absorption of the fat and its ultimate oxidation and removal from the body the same sort of changes occur as in the deposition and removal of fat generally. It may be of interest to consider very briefly the order in which the changes occur when food is converted into lat. After being macerated for a time in the stomach and mixed with certain secretions added as the contents pass down the small intestine, the substances already altered are taken up by the living matter or bioplasm of the cells of the villi. In this state the elements are rearranged and the resulting sub- stances are taken up partly by the bioplasm of the walls of the capillaries and partly by that of the lacteals. The substances thus formed pass into the blood current w-here no doubt further change is effected, and either in actual solution or in a state of excessively minute division the matter traverses the capillary walls of the adipose tissue, and is at length appro- priated by the bioplasm of the large fat vesicles. At last the fatty matter takes the form of a small globule which gradually increases by the addition of more fat formed in the same way, and at length the L 146 TREATMENT OF OBESITY. well known appearance of the vesicle characteristic of adipose tissue results. The process is not one of simple aggregation as assumed by some, for the fat has different characters and is of a different chemical composition in different animals, and in the different organs of the same animal in certain instances. As is well known some individuals and some varieties of a species, — certain breeds " fatten " more readily than others, — that is under certain favourable conditions as to the supply and character of the food and general management adopted, fat is produced in a very short period of time, and therefore with the consumption of a comparatively moderate quantity of food and at small cost to the farmer. Nutrition is favoured by the nutrient material being dissolved or suspended in a considerable quantity of fluid. The same amount of nutritious matter goes farther and is more quickly appropriated if mixed with a fair amount of fluid than if little be introduced. The same remark holds good for the reverse process — the removal of fat for example from the system. In the treatment of obesity a fair quantity of water must be allowed or relief will be retarded. There is a general idea that because fluid in good proportion helps the appropriation and economises nutritious matters, it should be reduced to the greatest possible extent if we desire to reduce the weight ; but dilution favours the absorption of fatty matter and facilitates its removal from the system. Fat people who desire to reduce their weight should of course eat as little fatty matter as possible. Little or no sugar should be taken, and crust of bread only or toasted bread, which may be soaked in tea or coffee or in soup made from lean meat, should be allowed. Gluten bread, brown bread, biscuits or cakes, dry rusks made without sugar, thin biscuits that have been well baked may help to vary the diet. A good allowance of lean meat (from one to two pounds), white fish cooked in various ways but not fried, soups and broth made without fat. With a little ingenuity the diet may be varied very much. This really is of great importance, for many persons would lose appetite altogether and get weak and out of health if they had to sit down to meals of precisely the same character day after day, and few would be able to submit to the restrictions recommended, for a sufficient time to effect the absorption of a great part of the redundant fat without risk of injury to the health. Some vegetable matters and the infusions made from certain plants have somehow been supposed to reduce obesity, but as far as has been ascertained little or no influence upon the condition has been thus produced. Nor is it likely that any medicine or chemical substance will be of use, with the excei)tion of those substances which increase the action of the excreting organs, and tonic remedies such as quinine, which is required in the long course of treatment necessary in many cases — especially those in which the circulation is weak. You must carefully impress upon patients the great importance of not attempting TREAT .Mi: NT OF Ol'.KSITV. 1 47 to get considerable reduction in weiglit in a sliort time. A steady reduction of from one to two pounds in each succeeding week is sufficient, and any quick reduction is dangerous and should not be encouraged. I'eople should also understand that many very fat i)eople enjoy excellent health, and although they must suffer some incon- venience, every care should be taken not to damage the health by severe and sudden changes in the mode of living. In the management of cases of obesity you must be careful to ascertain whether the liver and kidneys are in a healthy condition. The liver is often somewhat enlarged, perhaps from mere congestion only, but in some cases the enlargement is due to changes which are succeeded by contraction — cirrhosis — resulting in deterioration and extreme wasting of the secreting structure. The kidneys are also often affected especially if the obesity is associated with a gouty state. The urine must from time to time l)e carefully tested for albumen, and also for sugar. In all cases of obesity, the heart should be carefully examined and during treatment, at intervals of two or three months. The action is sometimes very weak and tonic remedies ought to be given, with Digitalis or Strophanthus, but all these matters would of course be carefully considered by the practitioner who was regularly watching the case. The patient should be seen from time to time — in fact he should be kept under careful medical observation while under treatment. The public imagine that there are secret cures for this condition, and as in the case of other affections, suppose that there are specialists who know more concerning the treatment than their usual medical attendant who is the proper person to carry out the necessary treatment. In this way the patient will run little risk of the occurrence of changes likely to retard his recovery, and should any unforeseen derangement appear, it will be at once properly treated. It not unfrequently happens that large cjuantities of uric acid and urates are passed in the urine, particularly in the case of persons having a gouty tendency. Far too much importance has been attributed to the formation and elimination of uric acid. Where much meat is taken the urine often deposits uric acid and urates in considerable quantity, but if the quantity of fluid taken is sufficient, much may escape without any deposit being formed. At the same time when urates are deposited in the tissues, and in gouty states generally, we must be careful to reduce from time to time the nitrogenous constituents of the diet, and do what we can to favour the solution and elimination of the urates. Those who take large quantities of milk often pass abundance of uric acid or urates or of both, and for this reason whey, which may be given in some, may not be suitable in the treatment of all cases of obesity and in cases where there is a marked tendency to a gouty state of system, — a condition which is not unfrequently associated I. 2 I4S EMACIATION NOT DUE TO DISEASE. wilh obesity. If uric acid is very frequently present in unusual quantity in the urine either in solution, as a deposit, or in the form of urates, alkalies should be given after two meals daily for a time and an increased amount of water (two pints daily) should be taken. As a general rule in cases in which an increase of water is required daily to be kept up for a considerable period of time, the patient should be advised to acquire the habit of taking warm water. Some find this very difficult and assure you that the attempt or even the thought provokes nausea. A few drops of lemon juice, or a very small quantity of tea added to the water will sometimes get over the difficulty. In summer, effervescing citrate of magnesia may be allowed or any table water not containing a large excess of alkali, or Salutaris water — but upon the whole warm or tepid water answers better than perfectly cold water in cases in which the treatment has to be continued for some time, and really in the management of cases such as we are now considering little advantage can be gained unless the patient will steadily persevere for a sufficient time. The progress is often slow, but the greatest benefit results where gradual change is persistently promoted, in preference to more active treatment in the hope of expediting the return to a healthy condition —a course which usually ends in failure and disappointment and perhaps damage to the general health. Emaciation not due to disease. — Young persons of both sexes may become remarkably thin without any indications of actual disease. I'he emaciation may last for a year or longer and may steadily increase after it has once commenced, notwithstanding the greatest care. Hence, he friends are often most anxious and consider it necessary that the patient should be examined by some physician who is well known, and considered to be exceptionally skilful. Not unfrequently the favourable view taken by the practitioner who has watched the case for many months is regarded as incorrect, and a serious and gloomy opinion is given. Probably the patient is strongly advised to spend the winter abroad, and if the emaciation is associated with cough or short breath the friends are further alarmed by the suggestion that the condition may soon become serious if the greatest care is not taken. In the case of girls, the anxiety of a long engagement not unfrequently causes emaciation often accompanied by disturbed stomach and great weak- ness and perhaps wakefulness. The wedding is sometimes forbidden and much needless misery occasioned — while if the contrary advice had been given marriage would be soon followed by improved health and nutrition. In such cases the utmost care must be taken to form a correct judgment, and especially when the patient and friends are poor, and cannot find the means for residence abroad or for carrying out some expensive form of treatment necessita- ting residence in a home, massage and careful nursing attention. It EMACIATION NOT DUl-: TO DISEASE. 1 49 is indeed often dit'lu ult to decide wliat is the best course to pur- sue in cases of the kind whieli perhaps have l)een diagnosed as com- mencing phthisis, possibly by more than one authority. Sometimes we learn much from the fact that the advice to change the climate cannot possibly be followed for want of money. A young governess who was engaged to a schoolmaster had been getting thinner and thinner for three years or more and had caused the greatest anxiety to her friends. The medical attendants had decided that marriage was out of the cjuestion, while there were no means to carry out the usual advice. Careful examination revealed no evidence of lung mischief, and there was no family history of tubercular disease of any kind. Under the circumstances the right course seemed to be to advocate marriage. The advice was taken and in six months great improvement had occurred. The lady became the mother of a large family and from under six stone had increased to ten by middle life, and enjoyed excel- lent health. INDIGESTION : DYSPEPSIA— OF PAIN AND OF THE ARRANGEMENT OF THE FINEST NERVE-FIBRES IN THE STOMACH AND INTESTINES— PAIN-CONDUCTING NERVE-FIBRES— PAIN IN THE STOMACH— HEARTBURN, PYROSIS OR WATERBRASH— FLATULENCE : WIND IN THE STOMACH— GENERAL OBSERVATIONS ON THE TREATMENT OF ORDINARY FORMS OF INDIGESTION —CONDIMENTS AND ALCOHOL IN INDIGESTION- WARM CLOTHING IN INDIGESTION— INDIGESTION FROM FAILING GLANDS, AS IN OLD AGE— OF PEP- SINE AND ITS USES— VALUE OF PEPSINE IN FEBRILE CONDITIONS. Indigestion : Dyspepsia. — Many lectures might be devoted to the consideration of dyspepsia, but I shall only attempt here to give an imperfect outline of the subject, and offer a few suggestions concerning points of treatment which are of importance. The process of diges- tion, when it occurs naturally, goes on without the slightest disturbance^ and without our being aware of what is taking place. Those who are in perfect health probably do not know from any feelings experienced, that they possess such an organ as a stomach with five and twenty feet or more of small intestine beyond it. Many come to study medicine without knowing what a stomach is like until they see one in the dissect- ing room, so little can we learn concerning the structure and action of our own organs from sensations experienced, or from the contemplation of what is going on in our bodies. But there are some unfortunate persons, who, without being actually ill, hardly swallow anything without soon afterwards being made painfully conscious of the existence of the stomach, and its exact whereabouts. They cannot define its precise limits, but they very frequently suffer from uneasiness or actual pain which is referred to the neighbourhood of the stomach, and really seems to be situated in structures some distance beneath the surface of the skin. This discomfort usually comes on after taking food, but in certain forms of indigestion the pain precedes the introduction of solids or fluids, and when this is the case it may be relieved by food. When pain or un- easiness comes on some time after food has been taken, it may continue as long as the process of digestion lasts, but then the pain subsides, and does not usually return until after the next meal has been taken. Indigestion is learnedly spoken of as dyspepsia, which comes from DIl'l'ICUI/l' DKiESTIOX. 15I two Greek words, c/'v, with difficulty, and TrtTTf/c, to concoct, or digest. The pain or discomfort consequent upon slow or imperfect digestion, or indigestion, may be induced by many different circumstances. There may be some deranged action of the mucous membrane of the stomach, and hyper-sensitiveness (i'Trvp, over, or above) ; or severe pain may be occasioned by an altered state of the circulation caused directly or in- directly (by reflex action) influencing the nerves of the stomach. Not unfrequently one comes across cases of what may be called ordinary indigestion, where there is no actual disease, but still where a trouble- some and almost constant fixed pain, aching, heaviness, or sense of weight, of fulness or of pressure is complained of, so wearying to the patient that it deters him from tailing food. In consequence he gets thin and pale, and perhaps loses heart and becomes weak and despondent, and much out of health. We find in some cases a tendency to redundant formation of mucus and epithelium on the mucous membrane of the nose and air tubes. A corresponding state of the mucous membrane of the stomach, small and large intestines, bladder, and other mucous membrane is not infrequent. In fact the stomach, like other mucous membranes, and especially the mucous membranes which consist mainly of glandular organs, is liable to catarrhal inflammation, in which an undue quantity of mucus differing from that of health is secreted by the glands and modified epi- thelium is formed on the surface. These changes greatly interfere with the healthy action of the glands, and while they continue, little healthy gastric juice is formed. The function is much deranged and for a time it is necessary to let the organ rest by giving liquid food, — milk, beef tea, peptonised broths or soups in small quantities at a time for a few days, until the condition passes off. If the catarrhal affection is chronic, careful and perhaps prolonged good management will be required. Occa- sionally a considerable amount of viscid mucus, not unlike that from the nose and bronchial tubes in catarrh is brought up. This is generally followed by relief. If we could see the mucous membrane in some cases of indigestion we should no doubt find the vessels unduly distended with blood. There would be a state approaching to inflammation over a limited area only, possibly over a portion of mucous membrane not larger than a sixpence. Here the vessels would be seen distended, the blood moving very slowly along the capillary tubes, and some exudation from the vessels would very likely be found in the surrounding tissue. The nerves dis- tributed to the mucous membrane would have undergone those changes which result in their being unduly excitable. Their bioplasts and those of all the tissues in the neighbourhood would be found enlarged. Partly from this last circumstance, and partly from the pressure upon them exerted by the undue distension of the vessels, the sensitive nerve-fibres 152 STRONG STOMACHS. transmit impressions known to the patient as pain. The state of the mucous membrane I have just referred to may soon give place to the normal condition, or it may persist and lead on to a state of things which may result in the formation of an ulcer. Ulcer of the stomach is a serious disease, the nature and symptoms of which I shall have to refer to in another part of my course. Amongst healthy people who are capable of a fair amount of work, who have average or more than average powers of enduring hard work, mental and bodily, of bearing fatigue, and who now and then are capable of over-working for a time without suffering much, one often finds diges- tive derangements of two very different kinds — arising from different causes and requiring very different kinds of treatment. There is the person with excellent digestive power— always feeding with appetite, eating and perhaps drinking freely, and in fact finding out and being thoroughly convinced that plenty of food is requisite to keep himself m ordinary health. A good strong stomach is liable from time to time to get deranged, and its very activity is almost sure to result in illness unless its owner has really very hard work to do from day to day. Even in this case he probably digests and absorbs twice as much food as he requires, and fails to eliminate as much of the excess as he should do if he is to keep himself in health. This is the type of person who requires from time to time really active purgation. For him Dr. Cham- bers' blue pill and black draught every now and then would be excellent. A good dose of sulphate of magnesia, with or without infusion of senna, in warm water twice or three times a week would help to keep him right and greatly retard the commencement of the almost inevitable tissue- degenerations. But organisms of this class if they lead exceptionally vigorous, active lives, do often live to be old. On the other hand, of *hose whose hard, active, daily work consists of the expedition by rail or oy carriage from the home to the counting house and from the counting house to the good dinner, a considerable percentage will become patients suffering from dyspepsia, gout, rheumatic pains, asthma, weakness; malaise or the more serious subtle changes proved to occur in important organs after the age of 45 or 50 and resulting after a few years in actual disease of capillaries, arteries, muscular and nerve tissue, liver or kidney. The tendency can no doubt be checked if the patient will change his habits early enough, before tissue changes have proceeded to any great extent. But the difficulty is great. What will the cook say, what will the family, the friends say if the excellent dinners are abandoned and the social enjoyment of the evening repast stopped ? The patient himself will no doubt yield so far as to live rationally for a month or so at Homburg or other celebrated water cure ; during this short time the accumulation of noxious matters will be washed out without any inordinate intake, but how could the patient bear such wretchedness during the gloomy winter STRONCJ AND WEAK STOMACHS. 153 months? Practically I fear most will find extreme difficuUies in the way, though these are really not insuperable, and the improved health ought to give encouragement to keep up the change of system, and enable the patient and his family and friends to bear with fortitude the awful sacrifice. The other state of stomach belongs to a different order. Perhaps from the very first tender, highly sensitive, easily disturbed, and in some instances hardly ever going perfectly right for a single week at a time. The mucous membrane is probably often pale, the vessels containing little blood and the action of the glands slow and imperfect, the gastric juice less potent than it should be. Instead of enjoying his meal the owner of such a stomach is in constant disgrace. As a child he causes anxiety to his parents on account of the little food he takes and from the frequent attacks of illness, particularly feverishness. He always looks somewhat thin and ill-nourished, and is probably querulous, low- spirited, and unlike other children. By the time he is grown up he is fastidious, perhaps preferring bread and butter, apples and oranges, a little cold meat or cold fish, to the dainties set before him. He "cannot " take wine or beer, having learnt by bitter experience that both disagree, and he is perhaps continually fearful of getting ill. He dreads severe pain if he attempts to live like other people. Probably from 30 to 40 he is generally regarded by those he knows as a fidgety hypochondriac, of no interest to anyone, as incapable of enjoying himself as of helping others to enjoy themselves. But now his time is coming, for gradually his stomach behaves itself better. To his surprise he sometimes finds that he is able to digest an ordinary meal without discomfort. Slowly he becomes bold. He eats more, he gains in weight, his bowels act more freely. He loses the feeling of fatigue after slight exercise. He feels contented — nay, begins to enjoy life : laughs, cracks jokes, feels a little jolly on occasions. He looks so much healthier and better that some of his friends hardly know him, and as he approaches old age he feels like a different being. Such a dyspeptic not unfrequently reaches 80 or more, and may retain his health and working powers to the last. The hypersensitiveness of stomach, upon which all the early discomfort was due, is no doubt in the long run conservative, and perhaps through this weakness the individual not only gains strength and vigour as life advances, but is preserved from many ailments possibly involving structural changes, from which, but for his weak stomach he would have suffered. Of pain and of the arraiigcineiit of tlic iiiiest iicrvc-llbre.s in the stomach and intestines. — The whole question of pain is one of great interest and importance, and as the pain in indigestion and other derangements of the digestive organs is experienced through the instru- mentality of nerves which m the normal state transmit only impressions of 154 NERVES Ox^ THE INTESTINES. which we ate not cognizant, it will be worth while to consider the arrange- ment of the nerve-fibres concerned, and discuss their probable action. Nor can disorders of the intestinal canal be understood, without the knowledge of the way in which healthy action is governed and carried out. Although the bowels in every part are very freely supplied with nerve-fibres, so long as the functions are properly discharged we remain quite unconscious of the existence of any exquisitely sensitive tissues in connection with the alimentary canal. Fortunate are they who pass through life without discovering that sensitive nerves are distributed to the intestines. We know little of the changes taking place in the stomach and bowels unless something interferes with their due performance. Then indeed we become aware of the contrast between ease and certain forms of disease as it affects these wonderful structures. You will find in some of the older anatomical books, descriptions given which would give you a very imperfect notion either of the number or arrangement of the nerve-fibres of the gastric and intestinal tissues. In fact the most important and most extensive portion of these nerve- fibres is known to few anatomists even now, and only a few years ago it would have been impossible for us to form an accurate conception of the true arrangement of the nerve-fibres of the digestive tract, or of the actual phenomena going on during life in any part of it. As a fact all the tissues are most abundantly supplied with very fine nerve-fibres, although you might read much that would lead you to infer that the mucous membrane and muscular coat of the stomach and intestines received but very few nerves. It used to be supposed that the con- traction of involuntary muscular tissue resulted from direct irritation or stimulation. And even now little attention is given to the highly im- portant part played by the nerves and nerve-centres which influence every action and every movement connected with every part of the digestive process. In every part of the digestive apparatus from the mouth to the anus, the secreting and absorbing, as well as the muscular apparatus, receives an abundant supply of nerve-fibres. The muscular fibres which are distributed around the stomach and intestine as well as those situated just beneath the mucous membrane are frequently though not constantly in active movement, each fibre alternately shortening and lengthening — undergoing contraction and relaxation, — actions which occur at different times in different parts of the alimentary canal, and in all alternate probably with comparatively long periods of rest or quiescence. But invariably the movements of the muscular tissue, like that of every form of voluntary and involuntary muscle, take place under the influence of the nerves. Besides the nerves distributed in networks and plexuses to the mucous membrane and muscles in great number, there is a highly com- plex system of ganglia or nerve-centres little appreciated and indeed m;k\i:-(;a\(;lia and tliixuses. 153 hardly known to more than a few observers. You all know, of course, what multitudes of ganglia help to constitute the sympathetic system. Many of the large ones you see in the course of your work in the dis- secting room, and the more skilfully you dissect, the more ganglia will you find. \'c)U are also well aware of the complex interlacement of coarse nerve-fibres and trunks in many parts of the abdominal sympa- thetic system, but from the most perfect ordinary dissection that can be made, you will form but a very imperfect idea of the vast number of minute ganglia and ganglion cells connected with what seem to be excessively fine nerve threads. If, now, from a i)iece of small intestine of any small animal pinned out upon a strip of wood or cork, you will detach carefully the mucous membrane from the muscular coat, and soak it for a few days in equal parts of glycerine and water, replacing the solution from time to time with fresh fluid, and then gradually add stronger glycerine, you will find the tissue will assume a state favourable for the demonstration of the ganglia. Small pieces of the submucous tissue are to be sni]jped off, placed on a glass slide, and after being gently teased out with pins or needle points, and moistened with fresh glycerine, covered with thin glass. If you examine such a specimen under an inch object-glass, you will have no difficulty in demonstrating a vast network of ganglia and nerve-fibres. You will observe hundreds of little microscopic ganglia on different planes, and these you will discover are all connected with one another by numerous inter-communicating bundles of nerve-fibres constituting quite a network or plexus of fibres and ganglia. The ganglia in question were discovered some years ago by Meissner ; Auerbach had some years previously described plexuses and ganglia close to the muscular coat. But of course these observations were contradicted by some and ignored by others, and long papers were written by great authorities to prove that the nerves, ganglia, and plexuses were really vessels, the points of divergence of which, in their opinion, had been mistaken for ganglia. There is, however, no difficulty in demonstrating these ganglia most conclusively. I have many times shown in connection with the course of physiological anatomy which I used to give in this college, the cells composing them, with the bioplasm of the nerve-cells and fibres artificially stained with carmine, and I can assure you, with the greatest confidence, that the cells are true nerve- cells, and that fine nerve-fibres pass from them to supply with nerve- fibres the tissues of the mucous membrane, as well as the thick layers of muscular tissue which encircle the intestinal canal. So numerous are the fine nerve-fibres that there is not a portion of tissue the one five-hundredth of an inch in width which does not receive an abundant supply. Every villus of the intestinal canal is supplied with nerve-fibres> and the action of each of its several component tissues is presided over 156 DISTRir.UTION OF NERVE-FIBRES. by nerve-cells. Every gastric gland as well as every intestinal follicle is also abundantly supplied. In structural connection with the nerve- fibres is a nerve-centre, or rather a group of ganglia by which nerve action is determined, the changes resulting in the secretion of gastric juice and intestinal fluid regulated, and actions emanating from other nerve-centres or groups harmonised. The nerves have also much to do with the simultaneous discharge of the secretion upon the surface of the mucous membrane from thousands of microscopic glands. But in spite of this marvellous nerve-supply, so long as things go on rightly, you are not cognizant of any of the changes which are taking place. The intestinal tube is sometimes full and distended, sometimes relaxed, sometimes contracted, and yet all these alterations in volume, all this stretching and contraction, take place for the most part without our knowing anything about it. If, however, these same phenomena occur in an exaggerated way, or if anything interferes with their due performance, we very soon become conscious that things are not as they should be. We cannot always say exactly what part of the intestine is in fault, or what sets of ganglia are disturbed in their action, but we experience discomfort if not actual pain, and almost instinctively we so act as to give the whole digestive system little to do. We let it rest for a time. We take no food or confine ourselves to small quantities of easily digested slops, and in the course of a short time things generally right themselves. But surely it is very remarkable, seeing how unconscious we are in the healthy state, at least as far as feeling is concerned, of the existence of the intestinal canal, that when its action is much deranged, the pain experienced should be so very severe, and so difficult to bear, as is the particular pain which is developed at the peripheral distribution of the sympathetic nerve-fibres, the ordinary actions of which go on quietly and almost incessantly, but quite unconsciously. The peritoneum (~cpt', around, and th'i'w, to extend) or thin mem- brane external to the muscular coat of the intestine, which is supplied with nerves from these same ganglia, and which in the healthy state is always sliding smoothly in contact with the moistened surface of another layer of the same delicate tissue, becomes exquisitely sensitive in inflam- mation. The pain oi peritonitis (jrepl^ around, -cn/w, to extend, and ("t>/9, rash, the suffix itis denoting inflammation) is one of the most terrible forms of pain that any human being can have to bear, and yet these same nerve-fibres which are concerned in the most horrible suffering, act as a general rule quite unconsciously, do their work without our knowing anything of them, or of the action of the apparatus they govern. Pain.coniiuctiiig Xerve-flbres. — The nerve-fibres concerned in the transmission of the sensations we call pain, are not, I think, those which I'AIX-(()NI)UCTIN(; XKRVF.-FIIIRKS. I 57 have been regarded as special sensitive nerves, but the line nerve-fibres which were first demonstrated by me close to the capillary vessels, and so situated that any change in vascular turgescence would affect them. As is well known, the pain of a bad sore throat is much less severe than the pain experienced in pleurisy, pericarditis, or peritonitis, and yet the number of sensitive nerve-fibres distributed over a given area of tissue is many times greater in the mucous than in the serous membrane. When the tonsil is inflamed the pain is very great, but it depends less upon the tension of the mucous membrane covering it than upon stretching of the vessels and nerve-fibres in its substance. Again, the pain we suffer from in rheumatism originates in tissues which are not rich either in nerves or vessels, and yet it is more severe than many kinds of pain the seat of which is in parts more higb.ly vascular. The pain ia the lungs when pulmonary capillaries are congested, even if they be seriously damaged, is slight as compared with that which results when the capillaries of the pleura are involved. Nerve-fibres of the same kind are not only distributed close to the capillaries, but in many tissues, as for instance the cornea, are situated at some distance from any vessel ; but these nerve-fibres belong to the same order as those distributed to capillaries, and act as afferent nerves to centres, the efferent nerves of which are distributed to the muscular fibres of the little arteries. It is, 1 believe, when these afferent fibres are made to act violently, that pain is experienced. The pain associated with circumscribed inflammation of various kinds is due partly to the stretching and pressure to which the fibres of these nerves are subjected, and partly to the increased nutrition which proceeds in the nerve bioplasts, in consequence of the increased amount of nutrient pabulum which bathes them, and which has transuded through the stretched vascular wall. i»aiii ill the stoniacta. — If the vessels of even a small part of the mucous membrane of the stomach become unduly distended from any cause, discomfort results. If there is too much action of the glands or insufficient action, pain in the stomach, learnedly called Gastrodynia (700--/)/), the stomach, and or (';'*/, pain), or Gastrah^ia {a\'/o^, pain), is occasioned. If the food we take does not digest, that is, if it does not gradually dissolve after it reaches the stomach as it should do, but remains there, being moved round and round by the muscular action of the organ, we experience pain — and sometimes extreme pain. If you take rich, improper food, and drink a quantity say, of bad champagne, more especially if your dinner comprises tough beef and concludes with a good supply of heavy pudding or pastry, you will probably learn what is meant by an attack of gastrodynia unless you happen to have an unusually vigorous digestion. You will at the same time be thoroughly convinced of the existence of a vast number of extremely sensitive 158 PAIN IN THE STOMACH. nerves in connection with the walls of your stomach. Not only so, but in all probability the action of the whole intestinal canal will soon be violently disturbed, and you will be fortunate if you get off with a sharp attack of vomiting and acute diarrhoea : for in this way you may perhaps find a short cut to returning health. But thousands who eat moderately, and some even who eat immoderately, go on from year to year without the slightest discomfort of any kind in any part of the intestinal canal, and without discovering from any sensations they experience that they possess one. Indigestion may be due to altered gastric juice, Or to the secretion being too acid or not sufficiently acid ; or the active dissolving substance, the pepsin, may be in insufficient quantity or imperfectly formed ; or, on the other hand, the derangement may depend upon the pouring into the stomach of a considerable quantity of alkaline fluid, which neutralises the action of the gastric juice, and in other ways impedes digestion and interferes with the changes taking place in the stomach. Strange to say, two fluids of opposite qualities are secreted by glands in different parts of the stomach. Indigestion may also be caused by too much or too little liquid being taken with the food, or by a draught of cold fluid. Warm water, on the other hand, taken with the food, often gives relief, and weak tea agrees well with many stomachs, and even helps digestion. Heartburn, Pyrosis, or Waterbrash. — -There are certain glands at the cardiac extremity, near the point where the CEsophagus opens into the stomach, and called by some the Cardiac Glands, the secretion of which possesses an alkaline reaction. It seems that these glands in certain cases secrete a great quantity of a clear somewhat viscid alkaline fluid. Few of us are aware of the existence of the secretion of these cardiac glands in our own organisms, nor have we any actual experience of the formation of a fluid of the characters just mentioned. As is well known the contents of the stomach, under ordinary circumstances, are extremely acid. Many persons suffer from the regurgitation from time to time of a small quantity of highly acid fluid into the pharynx, when its distinctly acid taste is experienced. Chalk or Magnesia is taken for the relief of the Heartlmrn which, when physicians thought very much of hard words, was known as Ardor Ventriculi, or Cardialgia {Kapcin, dx^^o^-, pain). The acid fluid will effervesce freely if bicarbonate of potash or soda be added to it. A similar action occurs if chalk is mixed with it, but as it is more slow the effervescence is not so easily observed. Some of the out-patients of the Hospital will tell you that they frequently reject from the stomach a large quantity of clear liquid which you will find will cause the blue colour of reddened litmus to return. It is therefore of alkaline, not acid, reaction. This alkaline fluid is vomited or rejected in certain cases, which are termed JVater- brash or Pyrosis {Trvpwats; burning, from irdp, fire, Fer Chaud in French). WATERBRASII: TREATMENT. 1 59 The affection is very common in Scotland, and in England there are many old women who suffer from it. Patients sometimes bring us a few ounces or even half a i)int or more of alkaline fluid. Sometimes they tell us that the fluid burns them as it comes u]). In other cases it is described as slightly salt, or mawkish, or tasteless. The secretion when very alkaline neutralises the acid of the gastric juice if it is not rejected soon after its secretion, and greatly impairs the digestron of alljuminous matters. With regard to the acid which gives its reaction to the gastric juice. Although this consists juincipally of Hydrochloric acid, it must be borne in mind that it is by no means the only substance present having an acid reaction. We may divide the acids found in the stomach into two classes : — i. The acids formed or, at any rate, secreted there; the acids of the gastric juice, probably hydrochloric acid, phosphoric acid, and lactic acid : — and, 2. Acids which are formed, and sometimes in large quantity too, in the contents of the stomach, and which are detrimental to the process of ordinary digestion, and interfere with the conversion of albuminous matters into peptones. Valerianic and Acetic acid, Formic acid, Butyric acid, and a number of other organic acids seem to be produced in cases in which digestion is much deranged, and it is aston- ishing, when once these chemical changes have been initiated, with what persistence they continue, in spite of alterations in diet and various remedial measures. Waterbrash is often difficult to cure. The diet must be carefully regulated, so that the work of the stomach may be uniformly the same for each meal. Purgatives, and especially preparations of Rhubarb, are often useful. Magnesia, Bismuth, and Ginger, and small doses of Opium have also been advocated. The old Gregory's Powder, which consists of Rhubarb, magnesia and powdered ginger, is very useful in these cases. Astringents, such as Catechu and Kino, sometimes do good, and bitter infusions, particularly Calumba, have been given with advantage. Valerian, Assafoetida, and Galbanum are in the catalogue of medicines that may be prescribed in pyrosis, bat I shall presently have to refer to the treatment of dyspepsia, and shall bring these and some other medicines under your notice. In many of the cases of persistent Heartburn and Indigestion too much food has been taken and has been allowed to accumulate in the stomach. As it is not possible to neutralise organic acids which are formed by the decomposition of the food, without at the same time neutrahsing the acid of the gastric juice, it is often useless to give alkalies. Sometimes, it is true, benefit does result from the use of this class of medicines. By more than neutralising all the acids present, an increased secretion of gastric juice may be excited, but in many cases the pathological state persists, and in consequence of the continuance of l6o OF THE USE OF EMETICS. the processes of fermentation and decomposition, fresh quantities of the organic acids referred to are set free. The patient gets thin, because the greater part of what he eats is resolved into compounds which fail to nourish him, many of which indeed cannot be absorbed. In the manage- ment of these cases an almost forgotten proceeding is obviously the right one. First, clear out the stomach. Give an emetic. Vomiting is the natural way of curing many cases, where a quantity of organic acids resulting from chemical decomposition of some of the constituents of the food is formed. In such cases some wash out the stomach with warm water, but the operation is not a pleasant one. The normal action of the stomach may be completely suspended for a time, by the decomposition of every form of fresh nutrient matter introduced by the decomposing substances already present. People may suffer for months from a state of things which in former days would have been cured in a week or two by the aid of emetics and purgatives. Remember then, that a patient may actually increase in weight if you cause him to reject the contents of his stomach once or twice a week. Clear out the stomach from time to time, put him on a carefully regulated diet for a week or two, and his sufferings will very soon cease. Next, as to the emetic you should employ. JFcirm tvater will answer in many cases. You tell the patient to take two or three or more glasses of luke-warm water one after the other. The stomach gets distended, nausea follows, and in a few minutes the greatest relief is afforded by vomiting an amount of acid fermenting matter which astonishes the patient and convinces him that the proper treat- ment has been adopted. Some persons can vomit without even taking warm water, by a simple effort of the will ; others have to tickle the fauces and the soft palate with the finger. Mustard also may be used to excite vomiting. A dessert spoonful of the ordinary flour of mustard, mixed with half a pint of water, will make most persons sick in a very few minutes. Ipecacuanha is one of the least disagreeable of emetics. You suspend 20 grains of powdered Ipecacuanha in half a tumbler of water, and direct the patient to drink freely of luke-warm water after taking it. In the course of twenty minutes free vomiting will occur, and the whole of the contents of the stomach will be rejected without pain or discomfort. For a few hours after the emetic, the stomach may be allowed to rest. Perhaps some desire for food will be experienced, and then it will be found that the mucous membrane has resumed its normal condition, and that a supply of healthy gastric juice has been formed by the stomach glands. Flatulence, Wind in the Stoniaoli. — I must say a few words about flatulence or wind in the stomach — a somewhat disagreeable digestive derangement which depends in some cases upon unusual decomposition going on in the food after it has reached the stomach, and in some ADVANTACK OF I'UKCATION. l6l cases probably upon the actual separation of gases from the blood, or their secretion into the stomach or other part of the alimentary canal by some of the glands of the mucous membrane. Some unfortunate persons seem to have a baneful predisposition to inflation, and are habitually troubled with an enormous quantity of gas in the stomach. The organ is invariably greatly distended, and I am sure in some of the cases that have come under my notice the stomach must have frequently contained two or three quarts of gas besides more solid contents, — not only now and then, but constantly for weeks or months ; this state of distension l)eing in fact the general condition. It has been supposed that the peculiar knocks and taps characteristic of certain spiritual manifestations may be due to the movement of gas from one part of the stomach to another, or from the stomach into the intestines. But if in few instances these flatulent croakings are under the influence of spirits or take place in obedience to the will, there is no doubt that in the great majority of instances they occur in spite of the strongest voluntary efforts to restrain them. The gas is moved about in the stomach and intestinal canal by the action of the muscular fibres, and in the most capricious manner. Borborygmi {jiopiiojiv'C^w, I make a dull noise) are a serious annoyance, and on occasions a misfortune, as, for instance, when they trouble the sufferer in a select company during a pause in the general conversation. You must, therefore, pay attention to the matter, and study the circumstances favourable to the development of the unpleasant phenomenon, and the methods by the help of which you may be able to give relief. Sometimes by setting right the process of digestion, you may cure the patient. Pepsine alone continued for a week or two sometimes has the desired effect. In very obstinate cases, occurring in people who live too freely, it may be necessary to begin with an emetic, followed up by a restricted diet for some weeks. Some- times a single emetic followed by one or two tumblerfuls of warm water will effect a complete cure. Another very valuable remedial measure consists in purgation. You give a smart purge, say a three-grain Calomel pill, at night, and on the following morning a black draught or some purgative water or castor oil or some Sulphate and Carbonate of Magnesia in Pepperiidnt 7vatcr with a little ginger. In this way the contents of the alimentary canal are got rid of. After careful dieting for a time the patient completely recovers. In not a few cases you may relieve these symptoms by mitigated starvation only. Of course, if a patient came to you and you advised him to starve himself, you would never see him again. But there are many ways of inculcating good advice without shocking the nerves of sensitive people who suppose that abstinence from food for a few hours means death. Tell your patient not to take any solid food for a week. Order him a little beef tea three times a day. Towards evening he may take with it a M l62 TREATMENT OF INDIGESTION. biscuit, or a little dry toast. If very hungry you may permit him to have a little bread and butter, but a cup of lentil gruel will be better for him, and will be found more satisfying. By a little exercise of ingenuity you may suggest various things to take that will satisfy him, but which altogether will not amount to much. In this way, in the course of a few days, the effect desired will be accomplished. You permit as little matter as possible to pass into the alimentary canal for a time. Some prefer to be ordered to have nothing but oatmeal or lentil gruel well prepared and boiled for a quarter of an hour or more. The patient may take this for a time twice or three times a day. Lentil gruel is a really valuable thing. It is nutritious, satisfying, and acts as a sort of soothing poultice to the stomach and intestinal canal. Tell the patient to live on this or on Revalenta Arabica if he prefers it, for three or four days, and in this way you will probably get the action of the stomach and bowels right, and completely relicTe all dyspeptic symptoms. The flatus from which the patient has long been suffering will be generated no longer. General Observations on the Treatment of Ordinary Forms of In- digestion. — I shall not pretend to discuss this large subject exhaustively, but endeavour rather to direct your attention to some general remedial measures which you will find useful in practice. Oftentimes the indi- gestion is caused by taking too much food at a time and by insufficient mastication and insalivation. And it may be relieved by taking very little solid matter or by drinking half a pint of warm water or warm weak tea with the meals. Sometimes there is actual discomfort when the stomach does not digest the food as rapidly as it ought to do. The patient feels full and uneasy for several hours after a meal has been taken. Very commonly under these circumstances sleep is disturbed, or perhaps cannot be obtained. Those who dine too late in the even- ing often find that the stomach does not work well. The food, particularly some kinds of meat, long remains in the organ undigested. The contents are continually moved about and worked up and churned by the unceasing contraction and relaxation in different parts of the muscular coat of the stomach, but still its volume is but little changed, and the stomach remains much distended. A feeling of general discomfort is caused, which interferes with sleep. This, in fact, is a very common cause of wakefulness. The patient in consequence soon becomes weak, feels fagged, and unable to work. The sense of lassitude, and failure, and sometimes extreme despondency, suggests to him the need of " support." Friends advise him to partake more freely of nutritious food. Port wine, turtle, and oxtail soup, and other highly rmtritious delicacies are wasted upon him ; for instead of improving he gets worse, and feels more ill and unfit for business than ever. Know- ing the importance of rest he injudiciously flies to certain popular MEDICINES OF USE IX INDIGESTION. 163 soporifics, — lakes Ch/orodytie, Nepenthe, or Chloral, and thus possibly in addition to his many troubles experiences a terrible headache, tremor of muscles, dread of impending failure of health, and general " nervous- ness " which never before troubled him. He tells you that he really feels very ill indeed. But a few enquiries and a little consideration on your part enable you to afford speedy relief. A mercurial purge, followed by a few doses of some gentle laxative, will soon cause all the more serious symptoms to disappear, and then you must carefully attend to the digestive process. Diet the patient, only allowing easily digestible substances, and in very moderate quantity at a time for a week. A single purgative dose may not suffice. You must bear in mind that in many of these cases the muscular action of the stomach and small intestines, or the sensitive surface which plays an important part in the reflex action is at fault, and medicines which encourage the muscular contraction and the driving down of the intestinal contents may be required. Castor oil, Rhubarb in powder or in pills, Colocynth, Podophyllin, are often of great use in some of these cases ; but as I shall have to consider their action under the head of purgatives, I need not say more here. Advise the patient to take small doses of Dilute Hydrochloric acid (ten or fifteen drops in two table-spoonfuls of water), half an hour before food, and his digestion will soon be restored. Hydrochloric acid is, as you know, the natural acid of the gastric juice, and if you con- tinue to give it for some time, you will often find great improvement not only in the digestive power of the stomach, but in the performance of their function by other parts of the alimentary canal. You must not forget that from ten to twenty drops of this acid in water before meals, is also of great use in treating very many cases of weak digestion. Adds of various kinds are valuable in many forms of dyspepsia. The dilute Hydrochloric acid, Acidzan Hydrochloricum diliitum, and the Nitro-hydrochloric acid, Acidiun Nitrohydrochloricu7n dilutum, are most useful, and by their aid you may cure many a patient. There was more than one distinguished physician in London whose reputation, it might almost be said, had been gained by ordering acids. There can be no doubt of the efficacy of these medicines. Phosphoric acid, the Aciduiii Phosphoricum dilutum, in doses of twenty drops in water, seems to suit some people better than the other mineral acids. Lactic acid has also been prescribed ; but upon the whole the acids first mentioned are most efficacious. If you give from fifteen to twenty minims of the dilute Nitre-hydrochloric acid with half a drachm of Tincture of Orange, Tindura Aurantii, ten drops of Tincture of Ginger, Tindura Zingiberis, a drachm of the Syrup of Lemon, Syrupus Limonis, and perhaps ten drops of Chloric Ether, Spiritiis Chloroformi, with an ounce or an ounce and a half of water, — you will prescribe a dose which will be of great l64 INDIGESTION : TREATMENT. service to the patient, and please him. The mixture should be taken twenty minutes or half an hour before food twice or three times a day. I have known people continue a mixture of this sort for six or seven months at a time, and wdth great benefit. It is well to encourage them to give it up now and then for a week or so, but if they persist it can do no harm, and may possibly deter some from indulging in alcohol. Lemon juice, Citric Acid, Acidum Citricum, the Acid Tartrate of Potash, PotasscB Tartras Adda, and other organic acids and acid salts have also been found of use in the treatment of these cases. If decomposition take place in some of the constituents of the food after they have been some time in the stomach, instead of the ordinary solvent action proceeding until complete solution is effected, a large quantity of fetid gas may be generated. In these cases you will some- times find benefit resulting from an opposite plan of treatment : — from alkalies instead of acids. The alkali is usually given after food, but I have found that in some instances where gas is generated in quantity soon after food is taken, it is better to give it about ten minutes before food. Alkalies given before meals in certain conditions increase the quantity of gastric juice. You may order twenty drops of Liquor FotassfB and ten drops of Tincture of Ginger in water. Sometimes you will find that five minims of Liquor Ammonia will answer better than the Liquor Potasses. It is probable that the alkali acts by exciting the secretion of an excess of acid which at once exerts a solvent action upon the meat and allied substances. The condition we are speaking of may sometimes be relieved by taking a stimulant remedy which excites a free secretion of gastric juice, such as a little brandy, or ginger, or pepper, without giving alkali at all. The value of alkaline and antacid remedies has been known and acted upon for centuries, although better reasons can now be given in favour of prescribing them in certain cases and for the times when they should be taken, than was possible formerly. Unfortunately some may act very disadvantageously if continued for too long a time or taken in excessive doses. Care should be exercised in regulating the doses, and they should not be taken regularly for more than a day or two at a time, except under advice. Chalk, particularly the precipitated chalk, Crefa precipitata, is one of the most harmless of antacid remedies. Ten grains may be taken suspended in a little gum-water, or chalk lozenges of various kinds may be obtained. In some obstinate cases the plan of giving Hydrochloric acid before meals, and Carbonate of Soda, or Potash, or Liquor Potassce, or Liquor Ammonice after meals, has succeeded after many other modes of treat- ment had completely failed. If I want to give an ordinary alkali, I often prescribe twenty grains or more of Bicarbonate of Soda, Sod(z Picarbofias, in an ounce of water. You may order Peppermint, or FLATULENT CROAKINGS. 165 Pimento, or Cinnamon water, A<]ua Menthce. Piperita;^ Aqua Piinenta', Aqua Cinnamoiiii, as you may think best, and you will find that two or three drops of Dilute Hydrocyanic Acid, Aciduin Hydrocyanicum dilutuni, and a few drops of Tincture of Ginger, Tinctura Zingiberis, will improve the dose. Some physicians prefer Bicarbonate of Potash, but Liquor Potasscc may suit better and Liquor A)ntnotiice, five drops in water, may be tried if other alkaline remedies do not agree. Preparations of Bismuth, too, are often very useful. You may order from five to twenty grains of the old Nitrate of Bismuth, Bismuthi Subnitras of our Pharmacopoeia, or about the same quantity of the Carbonate of Bismuth, Bismuthi Carbonas, suspended in an ounce of water by the help of a little mucilage, and flavoured with Ginger, J'ep- permint, or some such substance. Or you may choose one of the more elegant preparations of Bismuth, of which so many are now made. We have a solution of Citrate of Bismuth and Ammonia, Liquor Bismuthi et Ammoniac Citratis, in the Pharmacopoeia, which contains three grains of Oxide of Bismuth in a drachm, and of which a dose of from half a drachm to a drachm may be given in a diluted state. Many other solutions of Bismuth supposed to be improvements upon this have been recommended. Bismuth lozenges, TrochiscHjpoxo'^-, awheel) Bismuthi, are also a convenient form in which to give this remedy. Preparations of Iron, Arsenic, and Zinc in small doses are of value in some instances, and when the mucous membrane is unduly sensitive and irritable, you will find that small doses of Tincture of Conium, or Hyoscyamus, or a small dose of Morphia or Opium will do more good than anything ; but of these I shall have again to speak in another place. External applications are sometimes beneficial. Stimulating lini- ments may be gently rubbed on the skin over the region of the stomach. Sedative applications externally are also often recommended. A Bella- donna or Opium plaster will cure some persons, while others derive more benefit from ordinary counter-irritants. A mustard plaster, a poultice consisting of equal parts of mustard flour and linseed meal, or a mustard leaf, a piece of wet writing paper being interposed between the mustard and the skin, is often tried with advantage. And you must not forget the very simple and efficacious measure of applying wet rag covered with oil silk, a towel folded into four and wetted on one side with warm water, or a piece of Spongio-piline, six or eight inches by ten or twelve inches, moistened and worn over the upper part of the abdo- men for two or three hours daily. This is pleasant to wear, soothing, and often useful. In cases of very obstinate flatulent indigestion accompanied by unpleasant explosions and croakings (Borborygmi), advantage may result from the use of pungent substances, like Horseradish, Peppers of l66 DIET IN HOT CLIMATES. various kinds, as well as Ginger. The Compound Spirits of Horse- radish, the Spiritus Arjiwracics Compositus of the Pharmacopceia, is not so much used now as it used to be ; but it is well to bear it in mind, for it is a useful preparation. You may order half a drachm or more in an alkaline or acid mixture, or with one of the preparations of bismuth above mentioned. Condiments and Alcohol in Indigestion. — I would remark that if taken with judgment, and only occasionally, condiments do no harm. Most persons as they advance in years indulge in them more or less, but it is bad in many ways for a patient to get into the habit of taking very strong peppers, for after a time the stomach fails to work without this artificial stimulus, and may become very weak indeed. Unquestionably as regards children and young people, we may be quite sure that " Opti- mum condimentum est fames ; " but as we get older and gradually become more dominated by the customs mdulged in by the more fortunate of our friends and approved by the rest, our appetite becomes less, and perhaps we almost forget what it is to feel hungry. We begin to appreciate delicate flavours, and to learn to like sauces. Sapid materials are desired, and often too freely indulged in, until we arrive at that high pitch of degradation, liking and longing for delicate viands, — desirous of dining daily, and giving our hearts to friends who are rich enough to have a skilful cook, and possess an extensive larder. Few men are more injudicious in the management of their digestive organs than well-to-do Englishmen. Not a few who go to India and other hot climates, actually live in defiance of reason as they have been accustomed to live here. They tell you they must daily have their good meat meal, or would certainly lose strength. They cannot digest as much meat as they like to swallow, so they get into the way of taking large quantities of pepper. Curry, which is a mixture of pungent seeds and peppers ground very fine, is popular. No doubt it is appetising, and the flavour of a well-made curry is certainly pleasant to the palates of most persons — even to those who have no pretension to be considered epicures, or good judges of delicacies. But this mixture, curry, has become a very favourite dish with Europeans who Hve in India and other hot climates on account of its stimulating action, and because it helps the stomach to digest a greater quantity of meat than could be properly dissolved and absorbed without its aid. Our system of dining off a number of rich meats as many do day after day is bad enough, and damaging to the organism even in this cold, damp, change- able climate, but in the hot parts of the world the practice is disastrous. There, diet should be light, and should consist principaUy of vegetable foods. Too many consider that if they do not take much meat they must take much beer, and not a few will insist on damaging their stomachs with liqueurs or brandy, and brandied wines. Derangement INSUFFICIENT CLOTIIINC; AND INDKiESTION. 167 is soon followed by serious illness. The liver, kidneys, and all parts of the alimentary canal become highly congested, and weeks or months of rest and carefully regulated very moderate diet are necessary to gain for the patient a valetudinarian existence. Every one going to a hot climate should sufliciently study physiology to understand the import- ance of living according to reason, and the penalties that may have to be paid for indulgence. Let him draw conclusions from what he observes concerning the food of the people around him. He may take fruits and vegetables, farinaceous matter of various kinds, milk and eggs, and just enough of tender meat or fish to satisfy his prejudices in favour of that kind of food. But he will be very unwise if he allow himself to get into the way of constantly stimulating the gastric and other glands by strong peppers in order that the undue action required for the diges- tion of considerable quantities of meat may be established. Those who come from a hot to a temperate or cold climate will do well to modify their diet. They should consume more butter, or cream, and milk than they would desire or find agreeable in a warm climate ; the quantity of meat may be increased, and possibly some will find benefit from taking a little alcohol. Alcohol, though apparently desirable in the case of some persons living in cold climates, is very deleterious in hot ones. It is a remedy which is often employed in certain forms of dyspepsia, but it is a dangerous one. Drinking habits are easily acquired, and although a little alcohol will often remove dis- comfort and assist digestion, many find that after a time they cannot digest without it, and not only so, but gradually increasing doses are taken as the small ones fail to have the desired effect. It is far better to suffer slight indigestion and discomfort than by imbibing too much alcohol to run the risk of bringing on a worse form of dyspepsia due to structural changes in the stomach and liver, which ultimately may lead to far more widely distributed, as well as more serious morbid changes in various tissues. Warm ciotiiiiis iu iiuiiseistioii. — Although in winter digestion may be very good, and weak stomachs generally work better in cold than they do in hot weather, there can be no doubt that some of the most obsti- nate forms of indigestion arise from the body not being sufficiently pro- tected. Those who adopt light clothing in an ungenial climate are very likely to suffer, and I feel pretty confident that next to injudicious eating and drinking, injudicious clothing is the commonest cause ot various disorders, among which are some of the most serious we have to treat. The fear people express of being too thickly clad in this climate would be ludicrous if the consequences were not often so serious, The young of both sexes are the chief offenders in this particular, and many an attack of rheumatic fever, of bronchitis, of pneumonia, and of other serious maladies have been due to light clothing. Now, although I l6S INDIGESTION IN OLD AGE. admit that woollen material of the thickness suitable for those who live in such a climate as this is sometimes uncomfortable, nay, disagreeable, for perhaps a fortnight or three weeks in some summers, I have never known any illness brought on by the practice of wearing it. To be bathed in perspiration from morning to night and from night to morning is not pleasant, but neither is it dangerous, and it is better to endure such discomfort during our short summer than run the risk of taking cold in consequence of a change in the vyeather finding us insufificiently protected. Depend upon it, people had better clothe very warmly in winter and not change their clothing in the summer, than be insufifi- ciently protected during the chilly days which occur even during the hottest period of our year. I should say woollen should be always worn next the skin by allj though in the hottest weather it may be somewhat thinner than in the winter. In strongly recommending a very decided additional protection to the delicate nerves and vessels of the skin to that afforded by our thin epidermis (eV/, upon, cepjua, the skin), which forms a very essential and absolutely necessary part of us, I confess to one considerable difificulty, and this is to name the material which may be worn by everyone without discomfort. It is curious that with all the ingenuity exhibited in the woollen manufacture, no texture has yet been invented to wear next the skin which is wholly satisfactory and cheap, and is not soon spoiled by shrinking to an inconvenient extent in wash- ing. Nothing I believe is yet to be obtained better than good flannel, but it is practically difiScult to get flannel garments made to fit comfort- ably ; and unless great care be taken to shrink the flannel thoroughly before it is used, uncomfortable diminution in some directions will soon be manifest, and will progress to a degree which is most unpleasant. Nevertheless, you must advise your patients of both sexes to wear wool- len of some kind next the skin. For the weak and sensitive this pro- tection, day and night, is absolutely necessary, and the strong and healthy will, by adopting this course, escape many small derangements. Wash leather has been recommended. It is comfortable, but too warm during the greater part of the year. Like silk, it is very expensive, and there are other objections to its use which I need not describe. Those who wear woollen under-clothes may go out in all weathers^ and will not require the very heavy and oppressive overcoats, which are such an encumbrance in walking. Iniligcstion from Failing Glands, as in Old Age. — But there are cases in which the stomach loses its power. Its action becomes weak. The glands require some artificial stimulus to excite them to discharge the proper amount of work. As we get older we become more particular as regards the flavour and other characters of what we eat and drink, and many cease to feel that desire for food, that pleasant feehng of hunger, which is worth more than perfection in cibo-critical DEl'KCTIVE MASTICATION. 169 powers. A boy or a young man in perfect health and vigour digests without knowing thjit he possesses digestive organs, but if the stomach becomes weak its owner gets particular, and the food he eats must be nicer as well as more digestible. And so it comes about that increased interest is taken in cookery, and the cook becomes a person of the highest consequence. In old age the stomach often becomes so weak that only certain well-cooked and very delicate things can be digested. Sometimes the stomach fails altogether, and we have to adopt various expedients in feeding, if we are to succeed in keeping old patients alive. You must also bear in mind that a very common cause of indiges- tion in advanced age, and in but too many instances long before, is the failure to perform their office on the part of the natural comminutors of the food. The teeth, from defective formation and growth during the early period of life, have nearly worn away, or they have decayed, or perchance the gum has altered in structure and the teeth have dropped out. The consequence is that practically there is no proper mastica- tion, the food is very imperfectly subdivided, and far too little saliva is mixed with it. Often it is bolted and the large hard masses which reach the stomach cannot be properly acted upon. It is often necessary to ask a patient whether he is able to bite. If, as sometimes happens, the food passes into the stomach in boluses of considerable size, but a small portion, in fact, only the surface of each mass can be subject to the action of the gastric juice, and if the meal is a large one, a very small portion only will be properly digested. Do not forget that many cases of imperfect digestion depend upon the bad state of the teeth. If you do not find this out you may go on pre- scribing a number of useless remedies, to the disappointment of your patient and to the loss of your credit. There are people even under thirty w^ho are incompetent, from a dental point of view. A patient may be provided with artificial teeth which will work better than his own, though he may have to suffer some unpleasant twinges before his mouth is set right for mastication under the new circumstances. When, therefore, you are consulted about difificult or weak digestion, or indi- gestion, it is very necessary to examine the mouth with the view of ascertaining the general state of the teeth, and of determ.ining whether the patient can or cannot properly masticate. And now let me revert to those cases where the digestive power of the stomach becomes weak because the gastric glands have gradually wasted, and are perhaps shrivelled and incapable of secreting gastric juice either good in quality or sufficient in quantity. When one con- siders the immense quantity, amounting perhaps to ten or more pounds, of gastric juice, formed during every period of twenty-four hours, one cannot wonder that the secretion should diminish as the vigour of life lyo IMPROVING THE DIGESTION. becomes impaired and reduced. As age advances the action of the gland-cells gets more feeble and the secretion is more slowly formed. The glands participate in the general shrinking and wasting and change into connective tissue, which goes on in other organs and interferes with the due discharge of their functions. If digestion is impaired, the proper amount of nourishment absorbed will be less than is required, and persons who suffer for some time gradually become weak. The muscles lose their vigour and the tissues change. Much of their substance is absorbed, and in some cases there is considerable wasting. Patients frequently get perceptibly thinner, and become unable to properly discharge their usual duties. In too many instances, in consequence of such phenomena going on for a considerable time, the organism loses its power of resistance to adverse circumstances, and the patient becomes liable to special morbid changes, affecting heart, lungs, liver, or kidneys, and may be attacked by some intercurrent malady, which may cut short life. The blood may coagulate in capillary vessels and small veins. In the changes resulting from the stagnation, substances are formed which, re-entering the blood, may poison or otherwise damage the system. In short, the most complex changes, and serious forms of disease, may be dependent upon long- continued imperfect action of the stomach and upper part of the bowels. You may often improve digestion by giving those acids which I have before referred to. Even where there is a gouty tendency, and you would be disposed to prefer alkaline to acid remedies, you will not un- frequently find in practice that mineral acids before meals will greatly benefit the patient. In some of these gouty cases, in which many different plans of treatment have entirely failed, I have found advantage from giving mineral acids be/ore, and a dose of alkali after meals. You will also discover, in the course of your practice, that half a grain or a grain of Calomel, or two grains or less of Gray Powder {Hydrargyrum cum Creta) with three or four grains of compound Colocynth Pill {Pilula Colocynthidis Compositd) once or twice a week, will be of immense service in many cases, with or without a gouty tendency, where the liver is congested or sluggish, and the stomach out of order. The following mixture half an hour after breakfast, lunch, and dinner is often of great use to those who have any tendency to the state of system which precedes the development of gout. Fifteen or twenty minims of Liquor Fotassce, five grains oi Nitrate of Potash {Potassa Nitratis), ten minims of Tincture of Ginger {Ti/ictura Zingiberis), a drachm of Tincture of Hop {Tijictura Lupuli), and one ounce of water. There is, however, one remedy which often succeeds, particularly in the case of old people, although other plans of treatment have completely failed. The remedy to which I refer is Pepsine. PEPSINE THE DIGESTIVE SUP.STANCE. I/I Of Pepsine and its Uses. — Pepsine has been introduced into medi- cine for some tliirty years or more, but a certain number of medical advisers during this time have confidently pronounced it a worthless remedy, and one which, if it acts at all, acts only by pleasing the fancy of the patient. If pepsine were really useless, like hundreds of other things which have been from time to time introduced, advertised until fashionable, and then have fallen into disrepute, it would have been before this time entirely discarded, if not forgotten. But what is the fact? In spite of many adverse circumstances, pepsine is probably more used than ever, and is now made and prescribed in every part of the world. Many different preparations of pepsine are sold to the public. At this time there is not only a vast number of different kinds to be had, but you may obtain the remedy in many different forms. There is pepsine in powder, pepsine in pills, pepsine in lozenges, pilules of pepsine, pepsine wine, and pepsine in glycerine. It is certain that a great number of people have found pepsine of use to them. The demand thus created for a really valuable remedy has led to the supply, not only of the real thing, but to the production of a number of cheap and worthless substitutes. Some preparations indeed exist which have been proved to possess little or no solvent action. He who recom- mends pepsine, or takes it, ought to be quite sure that the material is really what it purports to be. Although it is very easy to adulterate this substance or to pass off something else in its stead, it is fortunately also very easy to ascertain whether the pepsine possesses the proper degree of digestive efficacy. One grain of good pepsine ought to thoroughly digest one hundred grains of boiled white of egg in three or four hours at a temperature of ioo° F. In order to test the value of any particular specimen of pepsine you may proceed as follows : — One hundred grains of hard boiled white of egg cut into thin slices may be placed in a wide-mouthed bottle or flask with one ounce of water, and twenty drops of dilute hydrochloric acid i^Acidum Hydrochloricum dilution). One grain of pepsine powder is to be added, and the mixture placed before a fire, at a temperature of about 1 00° F. The flask is to be shaken from time to time. In about an hour the white of egg begins to look transparent at the edges, and in about four hours it will be completely dissolved if the pepsine is good. Pepsine will dissolve white of egg at ordinary temperatures if a longer time (from twelve to twenty-four hours) be allowed for the action. Now, since less than one single grain of good pepsine will digest 100 grains of white of egg, two or three grains ought to digest as much meat as would be found in the " eye " of a small mutton-chop. Three or four grains, therefore, of good pepsine is a sufficient dose, and will IJZ PROPERTIES AND USES OF PEPSINE. enable a patient to digest a small meal of meat even if the stomach secretes hardly any of the active substance. As a general rule, however, pepsine is only required to set the digestive process going, and probably , much more than the amount of meat which an invalid would require would be dissolved by the dose of pepsine taken. You may not only easily ascertain whether the pepsine you purchase is good or not, but if you choose to take a little trouble you may make your own pepsine. There is no difificulty or uncertainty in the process if a httle care is taken. When I held the Professorship of Physiology and of General and Morbid Anatomy, in King's College, I used to show to the class, as my predecessors had taught me to do, the action of the gastric juice upon different kinds of food. But we always found it most difificult to prepare a satisfactory digestive solution. We used to make an infusion by soaking for a time in tepid water pieces of the fourth or true digestive stomach of the calf. A little hydrochloric acid was then added, and the viscid mixture was strained through muslin. But it was often difficult to strain it properly, and at best we had a thick ropy mass which was by no means clear and transparent, and could not be made so by filtration. Many of the students of those days were sceptical and probably concluded that I had carefully rounded off the edges of the albumen so as to make it appear as if digestion had commenced, and some were not satisfied that the viscid opalescent mixture really possessed the solvent action attributed to it. I was therefore induced to try whether I could not obtain a digestive solution as clear as water, in which every stage of change occurring in substances placed in it could be watched from first to last. In my first attempts I followed the in- structions given by scientific chemists, and after conducting a number of complex chemical operations, I invariably lost, from chemical decom- position, the greater part or the whole of the pepsine I was in search of. Finding that the processes for isolating the pepsine turned out so very unfortunately, I determined to try to find some new method of getting a clear solution possessing active digestive properties. I taught myself to prepare an artificial digestive fluid by a process so simple and obvious that one wonders no one had employed it before, though up to the time I put it into practice, 1856-7, no one seems to have thought of the process. While considering the digestive process as carried out in different animals, it occurred to me that there was one domestic animal whose diet coincided more nearly with that of the human race than any other. The sheep and the ox were evidently less likely to possess a potent digestive material adapted for dissolving albuminous and allied substances than the pig. There is, I believe, no kind of animal food that the pig will not easily digest, and very quickly too. A pig's diet contaii^ animal as well as vegetable matter, and I need not tell you of the extraordinary quantity of nutritious substances PREPARATION OF PEPSINK. 173 of all kinds that a i)ig will consume and digest without difficulty. It seemed, therefore, not improbable thnt the best and strongest gastric juice would be found in the gastric glands of the stomach of the pig. I procured some fresh pigs' sloniachs and, after having slit them open, removed the contents, and carefully cleared away all particles of food, &c., from the surface, I dissected the mucous membrane away from the muscular coat. This must be done, because the mucous membrane of the stomach of this animal will be found to be thrown up into a number of thick folds, and it is required to be laid out smoothly on a fiat board. When the thick mucous membrane is thus spread out, a little water is allowed to run over it so as to remove dirty mucus and the remains of the food — pigs' food as you well know not being of the nicest character. You have then before you a soft, tolerably clean, smooth mucous membrane, which, in its entire thickness, consists of hundreds of thousands of pepsine-producing glands. But these gland-tubes are very minute. How are we to get the modicum of secretion which each contains ? The mouths of the little glands, as is well-known, open on the free surface of the mucous membrane. It occurred to me that, if I could only squeeze these glands, I might be able to press from the tube the active digestive substance which each contains, before any chemical change of the nature of decomposition could even have commenced in it. I took a paper-knife, and by firmly scraping the surface in one direction, I succeeded in squeezing out the little drops of mucus from the gastric glands, without any difficulty. In this way I sometimes obtained as much as three or four tea-spoonfuls of thick viscid mucus from a single stomach. But this substance is not a very manageable material for experiment. It will not dissolve in water, though it may be diffused through it. The mixture will be very viscid, and will not pass through filtering paper, while it very quickly passes into a state of decomposition. Few things could be less suitable for delicate experiments. Having then obtained the potent material in the active state in which it exists as formed in the body of the animal, I thought that, in order to prevent decomposition, the plan would be to dry it as soon as possible. I therefore spread the mucus in a very thin layer over the surface of a piece of clean glass about a foot square. The glass with the mucus was next quickly dried, at a temperature of 100°, before the fire, a current of air being allowed to play freely over it. In from twenty minutes to half an hour the mucus became perfectly dry, and could then be easily scraped off the glass in the form of scales. Being powdered in a mortar it formed a fine powder, which had scarcely any smell, but tasted a little salt. If I took a pinch of this dry mucus and mixed it with a little tepid water, I no longer got a ropy mass, but a mixture which, by filtration, yielded a perfectly clear fluid. You may, indeed without 174 DIGESTIVE rOWDER. difficulty, thus make a clear acid infusion of the mucus from the pig's stomach. To the dried mucus and water a few drops of dilute hydro- chloric acid are to be added. You will then have a very potent diges- tive fluid which, after standing for an hour or so with occasional stirring, will be found to readily pass through the pores of the filter. If all the operations have been successfully performed the filtrate will be as clear as the purest water ; indeed, you would not from its appearance know it from water. If you now perform the experiment with white of egg, as described in page 171, and place the flask at a temperature of 100°, you will find that the clear solution possesses active digestive properties. You may try various experiments, for the fluid being so clear you can watch the changes which take place, and study the process of digestion with ease. Having obtained this dried powder from the mucus secreted by the gastric glands of the pig's stomach, and found that such excellent arti- ficial digestive fluids could be easily prepared with its aid, it seemed desirable to try it medicinally as an aid to digestion, as it was evidently more efficient than many of the preparations of pepsine at that time in vogue. So I put it to the test in my own body and swallowed some of the dried powder. It did me no harm. Then I made some into three grain pills, and took one before each meal for several successive days. Infusions were prepared, which 1 drank, and no inconvenience resulted from their use. After a time I prescribed the medicine for others, and soon found that it was really useful in assisting digestion. It relieved the uneasiness accompanying the process in many cases, slightly encouraged the action of the bowels, and prevented the develop- ment of flatus in many instances in which inconvenience and suffering had resulted from this circumstance. Indeed, there could be no doubt that this would be a useful remedy in many cases where the digestive power of the stomach was impaired. Mixed with the food of infants, the powder assists digestion in many cases, and, in old age, it is in- valuable. Many old people whose digestion is greatly impaired may, indeed, prolong their lives if the process of digestion be assisted by mixing with the food, or by administering just before meals a little of the powdered mucus from the pig's stomach. By careful microscopic examination of many specimens of the powder I satisfied myself that there were no substances present likely to do harm, and though I have examined the mucus from the pig's stomach in very many cases, I never once discovered an entozoon of of any kind, or an ovum of an entozoon. The passage of food through the stomach of the pig is so quick that there is hardly time for anything to accumulate ; and when one considers how quickly the epithelial surface is formed and cast off in the discharge of function, one is not surprised that the surface of the mucous membrane is clean. Indeed, ON OSTRICH PEPSINE. 1/5 though of course the possibility of objectionable bodies being present in the mucus occurred to me, and has doubtless suggested itself to others, the facts of the case render it most improbable, and any objections under this head to the method of preparing pepsine powder rest on no foundation in fact. I therefore had no hesitation in taking and recommending the remedy. The next thing to do seemed to be to try and get some one to prepare this pepsine in quantity so that the profession might prescribe it, and patients have the advantage of its use. I therefore spoke to Mr. BuUock, of the firm of Bullock and Co., of Hanover Street, Hanover Square, whom I had known for many years as a scientific chemist of the highest character, and begged him to try my plan of preparation, and see if he could arrange for a sufficient supply of pigs' stomachs to make the powder in quantity. This was more than thirty-five years ago, and the remedy is still made in large amounts here and in America, particularly in Chicago, where sometimes thousands of pigs are killed day by day, and the pepsine is used in every part of the world. The process I adopted for making it was first described in the first volume of the "Archives of Medicine," page 269. Mr. Bullock has, I believe, made some improvements in the details of the process of preparing the material, and by great care and quick drying at a low temperature the proper degree of activity of the solvent matter has been ensured, and maintained at a given standard in every specimen that is made. Any of you can test the action of the Pepsma Porci in the simple manner I have described in page 171. You will find that a single grain, in point of fact, 8-ioths of a grain, will completely digest one hundred grains of the white of egg cut into thin pieces. It is interesting to watch, in a common bottle before an ordinary fire, the opaque albumen becoming gradually translucent, and then the trans- parent albumen gradually breaking down until a complete solution, a peptone, is formed. In this way you may get what is known as albumen peptone.* Mr. J. R. James, of the firm of Bullock and Co., carefully studied the properties of the so-called "Ostrich Pepsine" ("Pharmaceutical Journal," February 20th, 18S0). This substance, of which there is a * The only objection made to the process I have recommended is the strange one, urged by Mr. Squire, who remarks that the pepsine made according to the plan above described contains epithelium, and that if exposed to a damp atmosphere "it becomes putrid more or less, and acquires a most repulsive odour." But who would think of placing pepsine or other organic substances of any kind in a damp atmo- sphere, and what possible harm can the epithelium do ? Does Mr. Squire mean to suggest that any pepsine in the world will not putrejy ami acquire a most repulsive oduur if placed in a damp alinosphere? The substance that does not change under these circumstances cannot be pepsine. I regret to have to comment upon such a criticism. The test of pepsine is, of course, its solvent power, and 8-ioths of a gr;iin ought to dissolve 100 grains of coagulated white of egg. 176 PEPSIN E OF VARIOUS KINDS. specimen in the Museum of the Pharmaceutical Society, is thus described ("Medical Times and Gazette") by M. Ebelot:— "The stomach of the ostrich is celebrated for its incredible power of digestion. The abundance of pepsine to which it owes this faculty has created amono' the Indians a curious commercial fraud. They dry it, and sell it literally for its weight in gold. It is used for the purpose of restoring worn-out stomachs." A correspondent to the " Pharmaceutical Journal " says : " In the Argentine Republic ostrich pepsine is prescribed by medical men, and known by the public as ' pepsina nostra.' A good wine is made by digesting the stomachs in wine. I consider this a useful article ; but being a rough preparation our pepsine is preferable." Beyond these loose statements no definite experimental results have been pubUshed, so far as I know. A fair and impartial trial should, of course, be given to the substance by those who have the means at their disposal of testing it, but care ought to be taken that a worthless prepa- ration should not receive credit for performing a service which it is incapable of rendering. I wonder how much pepsine is obtained from one ostrich and how many of the birds are killed in the whole world in a year ? Mr. James says : — " Whilst conducting my experiments upon ostrich pepsine my attention was drawn to another preparation, called ' Ingluvin,' thus described in the ' Medical Times and Gazette ' for May 10, 1879 : ' This is a new remedy, prepared by Warner and Co. from the ventriailiis callosus gallinaceus. It is said to be superior to pepsine as a remedy for feeble, painful, and imperfect digestion, and may be prescribed in the same manner, dose, and combinations. . . . Ingluvin prepared from the gizzard of the chicken is the nearest approach to ostrich pepsine that can be obtained in Europe, we suppose. Naturally, I felt a little curious to test this preparation, and applied for some to the at^ents, who most readily supplied me. Below I have tabulated the results obtained. Fresh eggs were kept in boiling water for one hour and then allowed to get quite cold ; after depriving them of their shells the whites were cut into the thinnest possible slices — not minced, as it is easier to observe the progress of the digestion of albumen if it be sliced than if it be minced — and care was taken to reject any portion of yolk. Fifty grains of coagulated albumen thus prepared was placed in each wide-mouthed bottle and covered with five drachms of dis- tilled water containing i per cent, of hydrochloric acid, specific gravity i-i6. The quantity of pepsine was then weighed out and added to the mixture of albumen and dilute hydiochloric acid. The bottles and their contents were then placed in a water-bath and kept at a temperature of 98° to to2° F. for four hours, when digestion was regarded as complete.' PErSINE OF OSTRICH AND OTIIKK DIKDS. 1/7 Kind of pcpsinc Weight of pcpsinc Kl-suU employed. employed. Fig Pcpsine ^3 grain Digested. Ostrich Pepsine ... 2^. grains Not Digested. )) )> • • ■ D )' " )J 51 ••• 'O ') " Ingluviii 2)2 „ „ )> 5 " " 10 ,, ,, " From the results detailed in the foregoing tables and illustrated in the bottles shown, it will be seen that the albumen is scarcely acted upon at all, and thai both ostrich pepsine and ingluvin are destitute of the potver of digestion.'" Much larger quantities of " Ostrich pepsine " and " Ingluvin " might have been taken witli i)robably no difference in results. " In the stomach of the river crayfish is found a plentiful supply of a yellowish-brown, feeble acid juice, which possesses an energetic fermenting power and rapidly dissolves fibrin, but the addition of a few drops of a dilute hydrochloric acid solution stops the action. Also a somewhat similar ferment to pepsine, discovered by Fick and Murisier, in the stomachs of frogs, pikes, and trout, differs from it (pepsine) in being more active at a low temperature, as at 26^ F., while it loses its digestive power at the temperature of the blood (96° to 98" F.)." Value of l>e|i!!iiiie in Febrile Conditions. — Besides indigestion and weak digestion, there is another class of cases in which pepsine is of the greatest service. In fever the action of the stomach is more or less disturbed. Indeed, in all fevers the process of digestion seems to be greatly deranged. One of the first points noticed is loss of appetite. The feverish patient does not feel the ordinary desire for food. If a patient has been suffering from fever for many weeks, especially if emaciation is extreme, and the strength almost exhausted, it will be well to adopt the practice I have long acted upon, and add pepsine to the milk and beef tea in the proportion of three or four grains to a pint. Milk will be coagulated at first, but soon afterwards it will become partially digested and the curd may be easily broken up into very small pieces. Both the whey and curd will be in a state favourable for digestion, and for rapid absorption and appropriation by the bioplasm or living matter of the blood. If the feverish attack is of a kind which may continue severe for a considerable period of time, the body may lose very much in weight, the patient becoming excessively weak and his life bcmg perhaps for some time in jeopardy. Under such circumstances it is of the first importance to support the strength to the utmost. By mixing a little pepsine with the nitrogenous food you will greatly assist the digestive process. It may be during a very critical period of the malady, that 178 ON FEEDING BAD CASES OF FEVER. the nutriment is given in the form of a peptone and in a state fit to be immediately taken up by the vessels, and converted into blood con- stituents, and thus, by this expedient, life may be actually saved. In 1878 I had under my care a poor girl who became excessively emaciated in a prolonged attack of typhoid, the temperature varying from 102° to 105" during a period of six weeks. During the first week distension of the stomach and bowels by gas was considerable, and added much to the distress. I gave six grains of pepsine daily with a little hydrochloric acid in the beef tea, and kept this up during the whole period of the illness. The distension diminished after a few days, and I think that this simple plan had much to do with recovery in this instance. I have adopted the same plan in many cases. In the case of beef tea you may with advantage add a little hydrochloric acid, and place the mixture before the fire at a temperature of 100^ for an hour or two before the patient takes it. He will not dislike it, and to some the acid beef tea seems even pleasant. But generally when patients are as ill from fever as I am supposing, the taste is very much impaired, and practically there is no difificulty in getting persons to swallow the easily digestible peptones in the form of beef tea. Peptonised fluid meat was first made in quantity some years ago by Mr. Darby. Many excellent preparations of peptonised meat juice may now be obtained, but in places at a distance from large cities, the practitioner can easily give instructions how an excellent and readily digested peptone may be quickly prepared in the manner I have described. Another plan based on the same principle may be adopted. Instead of giving strong beef tea or soup containing pepsine, you may make a sort of meat jam. Underdone or perfectly raw mutton or tender beef may be cut up into small pieces, put into a mortar and well beaten with the pestle until it forms a small pulpy mass. A small quantity of salt may be added to make it palatable. Pepsine in the proportion of ten grains of the powder to an ounce of meat is then to be beaten up with it, when a drachm or more of dilute hydrochloric acid is to be poured in and the whole thoroughly mixed together. If you choose you may further add a little sugar to the mass. This panada or paste may be spread upon bread and butter, or it may be diffused through beef tea or soup. Children and many invalids will often take a compound of this sort when it is difticult to persuade them to take ordinary meat food at all. In some cases of illness we are unable to feed the patient by the mouth, and in fevers it sometimes happens that everything that touches the mucous membrane of the stomach immediately excites the most violent vomiting, and occasionally this state lasts for so long a time that there is danger of the {)atient perishing from inanition. In these, as ON FEKDIiNG HAD CASES OF FEVER. 1/9 well as in those bad cases where there is a physical impedient to the entrance of food into the stomach, or to its escape from the organ into the duodenum, we may keep the patient alive for many months by injecting nutrient substances in small (juantities (an ounce to three or four ounces) at a time, into the lower part of the bowel. The nutritious matter dissolved, or suspended in some mucilaginous substance like boiled starch, is introduced into a small elastic syringe made for the purpose and slowly injected into the rectum, the operation being repeated every three or four hours. To the beef tea employed for this purpose it is well to add two grains of pepsine to the ounce. The rate of its absorption is increased, and it is more easily assimilated and taken u') by the vessels of the mucous membrane. Nutrient supposi- tories of various kinds are now prepared and constitute a very con- venient and effective means of feeding by the rectum. N 2 CONSTIPATION— INSUFFICIENT ACTION OF THE BOWELS— IMPACTION OF F^CAL MATTER IN THE LARGE BOWEL — REABSORPTION OF FLUID— ALTERATION IN THE BLOOD— FEVER FROM FATIGUE AND AFTER SURGICAL OPERATIONS — PILES OR HEMORRHOIDS —OF THE ACTION OF ENEMATA — PURGATIVE ENEMATA — HYGIENIC AND DIETETIC TREATMENT OF CONSTIPA- TION — EXERCISE — COLD BATH : RUBBING — MOIST APPLICATIONS TO THE ABDOMEN — GALVANISM — FRENCH PLUMS AND NORMANDY PIPPINS — APPLES DRIED AND FIGS— VEGETARIANISM— OF TAKING FLUID —SMOKING TOBACCO — MEDICINAL TREATMENT OF CONSTIPATION— PURGATIVES— PURGATIVES FOR CHIL- DREN AND FOR AGED PEOPLE— CONSERVES— SULPHUR — ALOES— PODOPHYLLIN — DRASTIC PURGATIVES — SALINE PURGATIVES AND PURGATIVE WATERS. We may now consider a very important and almost universal accompaniment of the most common forms of deranged digestion and indigestion, and of which the majority of persons at some time or other have to complain. Constipation, a condition which varies greatly in degree, would, perhaps, be more correctly described as imperfect or insufficient action of the bowels. Probably nearly every one of us has suffered more or less from this trouble. And those who are accustomed to sedentary pursuits and intellectual work, have usually a more extended experience of sluggish action of the bowels than those who take plenty of exercise, and those who have to live by bodily labour. But I suppose there is hardly one who follows any walk of life whatever, or who does nothing at all in the way of real work, who has entirely escaped this derangement. The most idle, as well as the most industrious, often have to complain of constipation, and the condition may afflict people of all ages and of all classes, and in all climates. It is probably one of the most common of the slight derangements to which civilised man is subject. Whether savages suffer from it I do not know, but unques- tionably the majority of those belonging to a civilised community experience the discomfort. OF CONSTIPATION. l8l The word '■'■ constipation'' comes from the Latin 'Uvnstipare, to crowd together." Generally speaking, people attribute constipation to the accumulation of fceces in the large bowel, and infer that it is invariably to be relieved by purgatives. But in treating constipation a number of points have to be considered, some cases so far from being relieved by the frequent administration of purgatives are aggravated by that pro- ceeding. Most persons empty the lower part of the large intestine, or at any rate, partially empty it once during each period of twenty-four hours. But some persons' bowels have a habit of not being relieved oftener than every other day ; others have an evacuation once in two or three or four days, and a few females maintain that once a week is enough. Nay, I have heard it asserted that an action once in a fortnight was sufficient, and am bound to admit that there are instances in which habitual constipation is not associated with derangement of the health, although, as a general rule, a sluggish state of the bowels brings about general disturbance of the health, and sometimes leads to disastrous consequences. Of course, in cases in which fiscal accumulation goes on for many days, the lower part of the large bowel gradually attains enormous dimensions, and considerable increase in its capacity and stretching of its walls must ensue before it is sufficiently large to hold the excrementi- tious matter formed, as well as all the refuse material of the food which accumulates during the considerable periods of time just mentioned. I need scarcely say that this is a very unsatisfactory state of things, and if allowed to persist for years, must lead to serious trouble as age advances. There is no doubt, that if the large bowel, and indeed the intestinal canal generally, is to retain its healthy state and to be pre- served in good working order for sixty or seventy years, or more, the greater part of its contents ought to be expelled, as I have before stated, once in every period of twenty-four hours. Many of the physiological processes of the body, like this one, occur periodically and uniformly at about the same time during each period of twenty-four hours. Regularity as regards time much assists the daily evacuation of the bowels, and it is desirable that every one should do all he can to acquire this habit. I do not think it matters much whether the bowels act the first thing in the morning, after break- fast, or the last thing at night, so that the habit is acquired and a fixed time kept. Even in the case of animals, at least domestic ones, this operation is usually performed with the greatest regularity at a particular hour. If you have a pet cat or dog, you will find it convenient to teach it to evacuate its bowels at a given time, and it will be more than inconvenient if the creature should prove unteachable in this respect. An unmanageable disposition or disobedience renders an otherwise valuable animal almost worthless. Having referred to the desirability of regular action, I must now try 1 82 COINIPLETE EMPTYING OF BOWELS. to impress upon you the equal importance of complete, or nearly com- plete evacuation of the lower bowel, for what is called regular action may be associated with very imperfect removal of the contents. Although a small quantity of fsecal matter is daily discharged, this may bear so small a proportion to the total amount formed, that there is a constantly increasing residue, which goes on accumulating, to the great discomfort of the patient and the derangement of his health. In not a few cases this is no doubt due to the weak muscular contraction and imperfect action of the parts above, so that too small a quantity is forced down to the rectum to excite that part of the tube to sufficiently vigorous contractile action. As regards efficient action, a good deal usually depends upon the rectal contents. If a person lives upon highly nutri- tious diet, such as very strong soup or potted meat, he may find that his bowels will soon get obstinately constipated. If now he adds to this highly nutritive diet a quantity of amylaceous and soft fibro-cellular vegetable matter, which in itself possesses very little nutritive value, and of which comparatively little may be absorbed, he will find that the bulk of excrementitious material will be augmented and the action of the bowels will become more satisfactory. In fact, to be in good health, we have to take a certain quantity of material with the food which is not of use to the nutritive processes. The proportion of nutriment in bread and potatoes is small as compared with that existing in fat meat. To obtain an equal amount of nutritious matter a comparatively large quantity of bread must be taken, and of potatoes many pounds daily must be swallowed, if this is the only article of diet. Up to a certain point the admixture wath the really nutritive materials of a large amount of innutritions dross is advantageous, and even in the case of vegetable feeders this matter has to be considered. A horse does not do so well upon pure corn as upon corn and hay. Chaff is of far more value than we should be led to suppose from its chemical constituents. Most of us indeed require a certain amount of chaff to keep ourselves in fair health. Brown bread is very dear, because it contains so much valueless material, and is a rougher kind of bread than white bread. If you microscopically examine brown bread, you will find in it a large percentage of the testa of the wheat, which is quite indigestible. Oat- meal is useful in the same way. AH these things help to increase the bulk of the evacuation, and in this respect are of service. Unless there is a certain bulk to excite the fine nerve network of the mucous membrane of the intestine, the reflex action upon which the expelling force of the muscular fibres entirely depends is not brought about, or is only very feebly and inadequately performed. You will find that people who suffer from this condition, though they may have a regular action, complain of certain unpleasant sensa- tions. There is no organic disease. Indeed, if you examined every CRAFTSMEN SUBJECT TO CONSTIl>ATIOX. 183 part of such person you would not find the least indication of the slightest structural change. Nevertheless, the almost constant discom- fort many of these people have to endure is really great ; and not only so, but various more or less serious conditions may result from this state of things. It is in this way that the unpleasant condition known as Hypochondriasis in the male, and as a form of Hysteria in the female, very often commences. There is even the possibility that a condition of disease bordering upon insanity may be brought about by long-continued defective formation of f^ces and im[)roper action of the bowels. Patients tell you they feel more or less oppressed, and heavy and overwhelmed. Some complain of an unpleasant sensation all over the surface of the abdomen. Instead of the food which they have taken gradually disappearing, it seems as if it went on accumulating and distending the stomach ; the patient is blown up with wind ; and the distress is great. Many persons who suffer in this way soon lose their healthy complexion and become more or less sallow and pasty. Indeed, it is quite extraordinary how many different derangements of the health may result from imperfect action or a torpid state of the secreting and expelling structures of the large bowel. There may be violent and persistent nerve pains referred to the back, or hips, or groins, and certain other symptoms which lead pessimist practitioners excelling in the discovery of extraordinary " neurotic " ailments to diag- nose structural changes in some part of the spinal cord, or the antecedent state which is supposed to lead to them. Certain remediable forms of Sciatica are undoubtedly due to this cause and violent lumbar pain, often called Lumbago, is not unfrequently occasioned by imperfect action of the expelling function of the lower part of the alimentary canal. There are many craftsmen peculiarly subject to constipation ; shoe- makers and tailors, for example, suffer greatly. Undoubtedly many of them live to be old, and most of them are extremely intelligent, thought- ful people, but, nevertheless, they do not pay sufficient attention to the action of the colon. Literary men, — teachers, male and female, — pro- fessional men generally, who take little exercise, more especially if they live and work in small, ill ventilated rooms, are great sufferers. You seldom see a shoemaker or a tailor with a good colour ; and the same remark applies to many others whose habits are too sedentary. Never- theless, it will be remarked that pasty, sallow complexions often characterise men having high mental endowments. Shoemakers are renowned for intelligence, energy, patience, endurance, determination, and cogitative power. Organisms of this clas^^, moreover, frequ.-ndy have great resisting capacity, and often liv^e to be old. Many are excellent lives to insure. Such persons may suffer much, and, in con- sequence, may be neither happy nor contented. They are, perhaps, l84 ACHES AND PAINS. despondent, or excessively irritable, and are not always very pleasant companions. Some of them who are so unfortunate as not to have to work for their living spend too much time in thinking of themselves, their aches and pains. Sufferers often complain of slight nausea, and of som.e discomfort about the stomach, with a sense of fulness of the head. Many of them consider themselves illused as w^ell as un- fortunate, and not a few, though they live, are always telling their friends that life is not worth living. An indescribable feeling of depression is sometimes said to be so severe that the patient is almost unable to control his actions. Persons, particularly females, who suffer from con- stipation get very tired after slight exertion, or feel tired without having exerted themselves at all. They tell you they are unable to walk ; or, if they walk a little way, they get so exhausted that they are obliged to return and lie down. Indeed almost invariably in this disorder there is a feeling of lassitude, an indescribable malaise, a dis- inclination to exertion of every kind. Among the multitude of aches and pains, discomforts, and miseries, mental and bodily, complained of by persons who have long suffered from sluggish bowels and the resulting disturbances, the following are often present :— an almost constant feeling of prostration — indisposition to take exercise — exhaustion after the least muscular effort — dulness — sleepiness — dreamy non-refreshing sleep — pain in the loins and back of the thighs and legs — pains in many joints. The patient feels faint — tired —giddy — feels stupid — may have palpitation of the heart — short breath — cough, and there is sometimes expectoration of mucus from the stomach, weight over the stomach, or a sense of fulness and pressure sometimes over the upper, sometimes over the lower part of the abdomen. His cheeks sometimes burn and the skin of the face is flushed, hot and dry — throat dry and often sore — tongue sore at the tip — slimy thick mucus in the mouth — eyes sunken — dark band of skin round eyes — conjunctivae more or less yellow — a general feeling of chilliness — the hands and feet cold, clammy, damp. Some complain of a dull pain in head which is almost constant of being irritable, nervous and despondent — having a dread of some impending evil — terribly low- spirited. The bowels act interruptedly and very imperfectly — the motions being often pale and scanty. The urine is secreted in small amount and is often high-coloured, malodorous— of high specific gravity with an abundant deposit of urate of soda, and not unfrequently uric acid. It is generally highly acid. Not a few experience a feeling of giddiness arid mental uncertainty, at times amounting almost to fright. There are noises in one ear accompanied with deafness, and at times a crack- ing noise in the ear — a feeling as if fluid was floating about at the top of the head — trembling and twitching of the right eyelid — coldness over lower part of l)ack — a feeling at times as though something in the IMl'ACTIOX OF I'/KCAL MATTKK. 185 inside had dropped lower down. The above are indeed but a few of the complaints made and [he feelings experienced by patients. The catalogue might easily be much extended, but in every instance I have adduced, the absence of any organic disease was proved and the sufferers had lived for years after the complaints made. In many cases complete recovery had taken place with forgetfulncss of having suffered. In some, the same symptoms persisted with varying degrees of severity, and in one case lasted to the age of eighty-live or six. Frequently the i)aticnt is discontented with the position in which he happens to be placed, though the discontent is shown rather by frequent grumbling than by any active attempts to change his surroundings. He is not inclined to make any effort to place himself elsewhere, in order that he may be better pleased and happier. The only way to help such l)eo])le is to allow them to growl, and then try to relieve the troubles from which they suffer, and in this effort you will generally meet with at least partial success. You may meet with individuals belonging to this class who seem inclined to pick small quarrels with almost anyone, and cannot, or will not, control their discontent. Successful critics are often of this sort, and many a severe article would never have seen the light if his liver and the glands of the critic's large bowel had been in good order at the time. This troublesome ailment then has its advantages. It brings profit to editors, proprietors, and that important section of a civilised community which delights in finding fault, and flourishes according to the skill it can display in reviling. Any of you who desire to excel in this department of literature cannot do better than cultivate indigestion and imperfect action of the bowels, and a condition to which I shall presently have to refer, under the head of biliousness. A con- stipated bilious dyspeptic is the sort of person soon to become a first class critic, and his articles will command high remuneration, and be read by everyone who is dissatisfied with his environment. luipaction of Faecal Matter in the Large Intestine. — .Vs our tissues get old their action becomes less vigorous, and peripheral nerves respond more and more slowly and less readily to their wonted stimulus. The muscular fibres of the intestines become weak and lose much of their contractile power. Particularly the muscular tissue of the large bowel, like that of the bladder, gets feeble, and the viscus may be at times unable to completely expel its contents. The collection of faeces therein gives rise to serious trouble. In old age some artificial stimulus is rec^uired from time to time to excite the weakened muscular fibres to contract with sufificient vigour to cause the bowel to empty itself, and f?ecal matter may go on accumulating for a long period. The collection is so gradual that the patient may not be conscious of it. By putting your hand over the belly, and particularly over the course of the large bowel, 5'ou may often feel the colon for a consider- 1 86 RE-ABSORPTION OF FLUID FROM INTESTINES. able portion of its extent much distended by an accumulation of hard fgecal matter. At the same time you may ascertain whether there is also wind in the large bowel. If you place one or two fingers of the left hand over the surface and strike the back of one finger sharply with the tip of the finger of the right hand, you will be able to decide at once according to the note elicited by percussion. A dull sound as you know indicates solid matter, while a hollow drum-like note (tympanitic) indi- cates air in the bowel beneath. Constipation has caused death. I recollect seeing an old lady who had been bed-ridden for years, and was in fact dying when she came under my observation, whose abdomen had increased to an enormous size. To my great astonishment, when I came to examine it I found the swelling due to an enormous accumulation of hard frecal matter. There was no fluid, and very little gas ; but the whole abdomen seemed occupied by a huge mass of hardened fsces — I should think amounting in weight to 30 or 40 pounds. Unfortunately I only saw the patient a few hours before death, when she was reduced to the last state of exhaustion, and when it was impossible to interfere. In this case fseces had probably been gradually accumulating in the intestines for many months without attracting notice. The patient being bed- ridden, the circumstance seems to have escaped observation. Probably if a medical practitioner had been allowed to interfere some six months before, the patient might have been saved. Injections might have been given, and the contents of the bowel thus gradually removed before any harm to it had resulted. Re-absoriition of Fluid by tlie Intestinal Surface as a cause of Con- .stipation. — In many cases of constipation you find that the fsecal matter is too hard and dry to pass easily along its wonted channel. If the vessels of the large bowel take up too much of the fluid which is associated with the fascal matter, the bulk may be so much reduced that the peristaltic action of the bowels cannot be readily excited, and it may be insufficient to drive on the contents fast enough. The consistence of the excrement is no doubt a matter of some impor- tance as regards the action of the large bowel and the process of defecation. In different animals the character of the faeces varies greatly, and we meet with every degree of difference from the extreme of dryness and firmness to the very opposite condition. For example, the faeces of the rabbit are hard, and are almost dry before they are expelled from the bowel. The same, too, is the case with the sheep. But in many other vegetable feeders the contents of the large intestine, instead of becoming inspissated before their expulsion, are very largely diluted with water. The faeces of oxen contain much fluid, while those of the horse contain comparatively little. Such facts, like many others, wait for an adequate ALTERATION IN TlIK I'-LOOD. 1 8/ explanation by the evolutionists of the coming age, who will discover new laws of evolution, and correlations of secretion, excretion, and growth. The too rapid absori)tion of the fluid should doubtless be regarded as one of the circumstances concerned in the causation of constipation. The quantity of liquid swallowed may be defective, and the undue inspissation dependent upon actual deficiency of fluid in the organism rather than upon re-absorption. Some persons, small eaters, habitually take too much licjuid, — others, perhaps large eaters, far too little. In the last the fluid part of the blood is constantly too highly concen- trated for the quick removal of many of its constituents by the secreting cells engaged in the process. The various chemical changes under such circumstances are interfered with, or cannot tdke place with due rapidity. The secretions of the body are often formed in too great a degree of concentration, and cannot therefore be thoroughly dissolved and washed away by the comparatively small amount of water present. Alteration in the Bluotl. — After constipation has lasted for some time, as I have already remarked, various constituents, out of which faecal and other excrementitious matters are ordinarily formed, unduly accumulate in the blood, and cause disturbance in many of the physio- logical actions. Derangement of the general health of the organism follows. There may also be suppression as regards the formation of excrementitious matters, or of the substances out of which these are elaborated by gland-bioplasm agency, as well as the retention or accu- mulation of these after they have been produced. When a person has been living for a long time in close rooms, too much indoors, taking too little exercise, and especially if he should have acquired the habit of eating too much, it is probable that his blood will be as a rule only imperfecdy aerated ; and the chemical changes which result in the production of compounds to be separated by various glands, and are at last about to be removed altogether from the organism, will not have taken place at the proper rate or to the full extent that is desirable. It is probable that in certain cases in which acute disease, particu- larly of the respiratory organs, proves fatal after a few days' illness, the probable explanation is as follows : — Imperfect action of excrementitious organs has perhaps existed for a long time before the patient is seized with the acute illness. The blood already laden with excretory matters cannot bear a further accumulation without exerting a paralysing influence on the nerve-centres which belong to the system regulating the degree of contraction of the organic or unstriped muscular fibre. This, I believe, is the reason why so many cases of influenza ran their course to a fatal termination in a few days, and an explanation of the very 1 88 CONSTIPATION AND THE HEALING PROCESS. favourable change for the better that has often immediately followed a small dose of gray powder or calomel administered during the early period of the attack, if, at the same time, the heart's action has been kept up by giving ammonia or alcohol in small doses at short intervals. In the reduced action of the excreting apparatus the intestinal glands participate. Too little faecal matter is formed, and of the amount formed, as already explained, only a portion is expelled on account of the sluggish state of the nerves and muscles of the bowel. Moreover, in chronic ailments re-absorption of soluble matters from the large intestine proceeds, and the materials taken up add to the accumulation of excrementitious matters in the blood, the serum of which is in consequence often actually changed in colour as well as in composition. The general health suffers, the clear ruddy complexion of health disappears, and the patient becomes constantly sallow. The colour of the skin generally is more or less dusky, the capillary circulation through the tissues will be miserably sluggish, and the intellect dull. There is an indisposition to exertion of every kind, and the nervous and muscular systems do not act or respond to stimuli as vigorously and as quickly as they used to do. People suffering thus may go on with their work, and as a fact numbers do so — but their work is performed, as it were, against the grain, and as though the workers were heavily weighted. If, now, for a time the conditions under which existence is carried on be modified, it is wonderful how soon and how great a change will take place. Perhaps for the first few days, even in the best of climates and amid the most beautiful scenery, the interest will not be excited or the despondency shaken off. Sleep may not be sound and the patient on rising in the morning does not feel refreshed. The muscles of many parts of the body ache ; some, and particularly those in the front of the leg, may feel sore, and after much walking become actually painful. The patient is conscious of a certain stiffness in his movements, and generally the elasticity both of mind and body seems to be for the time impaired. But, before long, a change takes place. The appetite improves and the sensation of hunger returns. Towards evening a tired feeling is experienced and is soon succeeded by a desire for rest. Many hours of sound refreshing sleep succeed and the patient gets up a different man. His spirits rise, he is seized with a desire to see, to do, to walk. He is thoroughly interested in things about him. The mental and bodily lassitude no longer troubles him. The complexion becomes ruddy, the skin smooth, and moist, and healthy. The bowels begin to act freely and in three or four days the excretory glands sepa- rate from the blood, and the excretory channels discharge in twenty- four hours more than had been previously removed in a week. In this way the blood is soon depurated and changed for the better, and I have FEVER FRO>r FATIGUE AND AFTER OPERATIONS. 1 89 no doul)t that, at least in many cases, tlie improvement in mental action is consequent upon the restoration of the blood to its normal healthy state. There is another fact which may be adduced in favour of the conclusion that in constipation, or imperfect action of the bowels, the blood becomes altered in character. If you happen to have any little inflamed abrasion on any part of the body, it will be more or less inflamed if the excretory processes should not be going on freely, and wounds will not heal. A slight wound or scratch will look red and angry, and will feel hot and painful. Instead of healing in the course of twenty-four hours, an abrasion may discharge altered and sometimes irritating liquor sanguinis from its surface. Healing under these circum- stances goes on very slowly, if, indeed, the process is not altogether entirely interfered with for a time. If you happen to be troubled with any litde cracks about the margin of the mouth or nose, you will find that they will gape and give you pain. They may remain open for several days, until free action of the bowels occurs, and then they soon improve. This angry state of scratches, or wounds, or little cracks or sores on the lips or margin of the tongue, depends, I think, upon an altered state of the blood which is gradually brought about by con- stipation. If the stools from being scanty increase in amount, and the urine from being scanty and of high specific gravity increases con- siderably, and becomes pale and of low specific gravity, all is soon changed. The suffusion in the derma disappears, the fluid poured out in the interstices being absorbed, and the healing process is soon established. Fever from fatipriie. and after Surgical Operation!*. — There is yet another point to which I must direct attention, because it is of the greatest importance in connection from constipation with the views I have advanced concerning the altered state of the blood. You will often meet with cases in which, a few hours after a surgical operation, the temperature rises three or four degrees, and the patient becomes feverish. The pulse increases in frequency. There may be some wandering at night or actual delirium, with a hot dry skin, and indeed the patient's state may be such as to cause his attendant considerable anxiety. The surgeon examines the wound and finds that instead of progressing favourably, it looks more or less angry, and the discharge on its surface is changed in character, losing its viscidity and becoming thin and watery, with perhaps a little softened and discoloured broken down blood clot mixed with it. Now, if when things are in this state you give a purgative which will act freely upon the bowels, you will perhaps find within four hours after the purgative has been taken, and even before it begins to act, the grave symptoms are mitigated, and the patient from that moment will progress favourably, I have many times watched with interest the fall in temperature in such cases ipo THE BLOOD IN CONSTIPATION. — a fall of some three or four degrees of Fahrenheit's scale in the course of a few hours — from the action of a purgative. If we apply what we have learnt by the careful study of the pathological phenomena on the surface of the skin to the consideration of the changes which go on in boils, carbuncles, abscesses, and in internal parts and many organs, in inflammation, not only will a flood of light be thrown upon the essential nature of the changes in such diseases as gout, rheumatic fever, pneumonia, and many more, but upon the mode of operation of our remedial measures discovered by experiment and observation or proved by experience to have been of value. Probably the febrile state which sometimes follows great fatigue is allied to that which is occasionally consequent upon a surgical operation. Rest, saline remedies such as Citrate of Potash (Potassae Citras), a small teaspoonful dissolved in half a tumbler of water once in three or four hours, broth, or beef tea and light farinaceous puddings for a few days will usually be all that is required to ensure the return to health. Complete rest in bed is of the utmost importance in all such cases. Many troublesome ailments occurring in childhood are due solely to the imperfect action of the bowels. When you get into practice, oftentimes you will be called to see a child who seems extremely ill, is irritable, sleepless and feverish, perhaps wanders somewhat and screams at night, perhaps is even delirious. Such symptoms necessarily cause grave anxiety to the parents. x\nd yet, serious as they appear, these untoward symptoms will very probably be completely relieved as soon as the bowels have been made to act freely. The facts briefly reviewed prove conclusively that the imperfect action of the large bowel may derange some of the most important physiological changes going on in the system, and disturb some of the most important organic actions. By affecting the composition of the blood, constipation may occasion derangement in the action of many secreting organs and seriously interfere with the due performance of many of the most important nervous actions, and impair for the time the intellectual powers, as well as disturb the temper. Moreover you will find that the particular remedies which act most advantageously in these cases of derangement, depending upon constipation or im- perfect muscular and excretory action of the bowels, are those which possess the special property of exciting various secreting organs to in- creased action. Among these perhaps the most useful are preparations of mercury, though sudorifics and diuretics not unfrequently exert a beneficial effect without any purgation whatever being produced. And I am sure that you will not fail to acknowledge that this fact also lends support to the view that the composition of the blood is modified by persistent constipation, and that excrementitious matters which ought ox THE NATURE Ol' I'lI.KS. IQI to be quickly excreted accumulate in it, nutritive and niiuiy other opera- tions being in consequence deranged. Lastly, you must bear in mind that the blood can be brought back to its normal state, and health restored by the action of those remedies which have the property of exciting the excreting action of the glands of the intestine and other parts, thus effecting the removal from the blood of deleterious ex- crementitious matters which have been accumulating. iMics or iiJKnn»rrii(»ias. — In many instances constii)ation is asso- ciated w'lih />i/es ox ]ucinorrhoids {nTfta, blood, pew, to flow) as they are termed, which consist of troublesome little nodules about the orifice of, the anus. Sometimes pendulous papillre form on the mucous mem- brane, half an inch or more above the orifice. These internal piles gradually enlarge and occasion pain and inconvenience. Each in- cludes one or more loops of vein, with a number of dilated capillaries. They frequently bleed, and sometimes a considerable quantity of blood may be lost in this way. An ordinary pile or hsemorrhoid is a small growth, which may vary much in shape, but which depends from the general surface. The subcutaneous or submucous areolar tissue is thickened, and often oedematous. Litde irregular varicose dila- tions of the veins can be seen in well-prepared sections, and the outer coat of the vein is more or less thickened from successive attacks of inflammation. Dilated veins of the mucous membrane or skin near or above the anus often exist around and between the actual hsemorrhoidal swellings. Sometimes the pile consists of spongy tissue, almost like that of the placenta, and undergoes great alteration in volume, like erectile tissue. There may be a number of small haemorrhoids around or within the anus, each gradually increasing in size until it is as large as the top of the finger, when great inconvenience results. Walking is accompanied by much suffering, and every now and then the vessels become more congested and the swelling increases in size. The tissues around the dilated vein become inflamed ; cracks and little ulcers form, and severe pain, necessitating complete rest in the re- cumbent posture for a time, is the result. Gradually this inflammation ceases. The swelling subsides again to its usual dimensions, and perhaps some time may pass before another acute attack comes on. Not unfrequently, clots form in the little venous pouches and irregu- lar cavities. The fibrin of the clot gradually contracts, and thus very hard nodules result. These remain for weeks without undergoing much change, but gradually the coagula are absorbed and the patient considers himself cured, or nearly so. But soon another attack occurs. Coagula again form and he is as bad as before. A pile or htemorrhoid which attains the size of a pea is seldom cured without removal. A little surgical operation is necessary, and then the patient goes on perhaps perfectly well for the rest of his life. In many instances there 192 ON THE NATURE OF PILES. is reason to think the development of piles might be prevented if the bowels had been made to act pretty freely and the intestinal canal kept in a healthy state from an early period of life. It is, however, some- times impossible to do this, owing to hereditary tendency to constipa- tion, or to structural changes in glands occurring at a very early age. You may prevent piles from enlarging rapidly and giving trouble, by making the patient frequently take moderate laxatives and attend care- fully to his diet, especially as regards animal food, of which only a small portion should be taken. Primarily the condition is probably due partly to original weakness of vessels and to a relaxed state of tissues, to the so-called scrofulous diathesis, in which there has been too rapid formation and imperfect hardening and condensation of tissue, and in part to an altered state of blood which interferes with the formation of healthy texture having its due property of resistance. The dilatation and other changes in the coats of the veins are in many cases general, and not restricted to the hcemorrhoidal veins. Want of exercise, defective oxygenation, and generally that state of blood which favours the development of the gouty and certain forms of the rheumatic state, seem to predispose to the formation of " piles " in various parts of the superficial venous system. Not a few cases of " phlebitis " belong to this category. In constipa- tion or imperfect action of the bowels, the vessels of the walls of the intestinal canal generally are somewhat distended, the capillaries almost constantly unduly distended with blood, and the capillary circulation slow and impeded. The blood accumulates in the veins which unite to form the large portal vein. The flow of blood through the liver is affected, and the portal capillaries in the lobules become habitually distended, and the action of the liver itself is of course much dis- turbed. The undue tension of the walls of the portal vessels is often- times temporarily relieved by the flow of fluid from the capillaries into the intestinal canal, as occurs in diarrhoea, or after the administra- tion of certain purgatives ; and if at the same time very little food is taken, so as to allow the organs loaded with inspissated blood to rest for a while, complete recovery may take place. If the diet be regulated and the general mode of living be corrected m cases in which it has been injudicious, the blood, and through the blood the various tissues and organs, may soon regain their normal state. Sometimes, as I have said, relief is afforded by actual heemorrhage from the distended veins, and occasionally the capillaries of the surface of the mucous membrane give way, and thus the tension is relieved. Among many proximate causes of haemorrhoids I believe conges- tion or impeded circulation of the blood in the portal capillaries of the liver is perhaps the most frequent. In many persons the liver often seems to act sluggishly, and for days together the circulation through it THE ACTION OF ENEMATA. 193 is much imixdcd. The whole organ temporarily increases in size in consequence of its vessels being unduly distended with blood. The practitioner under these circumstances directs his attention to relieving the congestion and increasing the action of this important organ, as I shall refer to later. An astringent ointment, like the old Compound (lall Ointment, Unguenium Galhc Compositum, applied at night, is certainly useful in the early stage when the haemorrhoids are small, but in many cases it requires to be diluted with an equal quantity of lard or pure vaseline. Attacks of congestion and the accumulation of blood in the vessels, which are productive of pain, may often be prevented, or if not very severe, at once relieved by proper treatment, particularly by paying attention to the action of the liver and bowels. Careful washing wich plain water twice a day is necessary. For the sore state of the skin and mucous membrane between or over the haemorrhoids, as well as for promoting the healing of the fissures that so commonly form, there is no remedy like Vaseline, but you must be careful to recommend your patients to ask for \kvt pure colourless or white Vaseline, without the slightest tinge of yellow, for the ordinary substance contains irritating matters which do harm, and some- times interfere with the healing process. Of the Action of Eiiemata. — You must not forget that, as was shown by Marshall Hall, defecation is a reflex action and is mainly dependent upon the contraction of the muscular fibres of the bowel caused by a current transmitted along efferent nerve-fibres emerging from the nerve- centre which receives the sensitive or afferent branches. The excitation beginning in the peripheral nerves of the mucous membrane of the large bowel being carried to the nerve-centre by the afferent fibres, changes are produced in the centre w^hich result in the transmission of an impulse to movement being conducted along efferent fibres, and which results in the contraction of the muscular fibres. The afferent nerves in the mucous membrane, like many special fibres in other parts, seem to be generally in a quiescent state. They do not instantly respond to any very slight stimulus, like certain other nerve-fibres, as for example those spread out on the conjunctiva, but decided and somewhat pro- longed pressure or other form of irritation seems to be necessary to throw them into full action. In many cases of constipation, the ordinary stimulus of the fscal matter present is not sufficient, and if contraction is to be produced, additional excitation must be brought about. It is upon this principle that the practice of introducing purgative enemata into the rectum is founded. Ordinary water may be gradually injected, and in this way the contents of the lower part of the bowel are much increased, until, having reached a certain volume, powerful reflex action occurs, and foeces and injection are forcibly expelled together. Do not, however, suppose that the response takes place 194 PURGATIVE EN EM ATA. immediately. A certain interval, perhaps five or ten minutes or a quarter of an hour, may elapse before the bowel contracts, and generally it is better that the contraction should not occur too quickly, for then only partial expulsion of the contents may be effected. In administering an injection you should direct that the fluid should be introduced very slowly, the operator stopping for a time whenever the patient feels contraction coming on. If the bowel is only gradually distended, you will often find that a i)int and a half of fluid or more may be introduced before reflex action is excited. This simple opera- tion, which is known as giving a Clyster^ or Injection, or Lavenie?it, is a practice which is very commonly adopted, and some people are in the habit of resorting to it very frequently. Some of the French ladies, I am told, never get an action without injecting water into the bowel, and have to carry out the practice daily or every other day. The lavement is an efficient but rather troublesome measure to resort to daily, and probably few English people could be persuaded to adopt the plan of treatment. Of enema syringes there are numbers constructed upon difi'erent principles and made of different forms. The simplest are made of vulcanised indiarubber, and can be obtained for three or four shillings. Higginson's is one of the best, and this simple instrument has been of the greatest service both to practitioners and patients. Purgative Eiieiiiata. — Instead of injecting ordinary water, you ma) employ water containing various purgative medicines, such as Colocynt/i, Aloes, Olive Oil, Castor Oil, or other purgative dissolved or suspended in weak gruel or in Soap and Jf'ater. In making a purgative enema you may use from a half to an ounce of ordinary yellow soap to a pint and a half of warm water ; with this two ounces of castor oil or three or four ounces of olive oil, with or without half an ounce of turpentine, may be mixed. Gruel is also used as an enema. If you require to give an aloes or colocynth enema, half a drachm of the first, or the same quantity or a drachm of the compound extract of colocynth may be well rubbed down in a mortar with a little water or syrup, and then mixed with a pint of gruel. The old pre- paration. Confection of Rue, in the proportion of three drachms to a pint, is a good addition in cases where there is much accumulation of flatus in the large bowel. Sometimes the accumulation of faecal matter in the large intestine is so considerable that the bowel becomes almost paralysed, and the individual cannot expel anything by the strongest efforts he can make. Under these circumstances you may inject some gruel, or plain water or soap and w^ater, or castor oil and soap and water, into the bowel, and in considerable quantity, without succeeding in exciting reflex action. The faeces remain as it were impacted, and cannot be dislodged by such TRp:ATMr:NT OF CONSTIPATION. 195 means. This contlition is sometimes spoken of as impaction. Vou may occasionally find tlie lower [)art of the large bowel of an old person so full and choked by impacted faecal matter that it overflows as it were, although there is not the slightest eflbrt on the part of the bowel to empty itself. In some of these cases you have to pass up a long tube, and to inject warm water with one-fifth or sixth part of glycerine, day after day, and so bring away the matter piecemeal. If the bowel does not contract, or has nearly lost its contractile power, the faical accumulation must be removed. A sort of scoop, or the handle of a spoon, or any other convenient instrument of the proper shape and with rounded edges so as not to cut the parts, may be used to remove the hard faecal matter. The operation is always a disagreeable one, and sometimes it is very difficult to perform, but it must be undertaken, and we must be prepared to interfere in this way many times in the course of our practice. Those of you who may by-and-by be engaged in country practice are sure to meet with such cases from time to time, particularly among the inmates of asylums for the aged, and in poor-houses, and you must be ready to afford the only relief that is possible. A little glycerine (half-a-teaspconful or a teaspoonful) injected into the rectum will often cause its contractions. In children, and sometimes in adults, the gentle introduction into the orifice of the bowel, and imme- diate withdrawal of a piece of firm soap, cut so as to form a slight cone about the thickness of the finger, will cause the rectum to expel its contents. The Hygienic and Dietetic Treatment of Constipation. There are certain methods of preventing and treating ordinary con- stipation with which everyone ought to be acquainted. By having recourse to some of them persons, who have suffered may not only obtain relief, but may succeed in preventing the recurrence of the trouble. Exercise, we are often told, is a great preventive of constipation, and sometimes will cure it when established. Many practitioners are very confident on this point, and invariably assure those who suffer that if only they will take sufficient exercise, they will be cured. Some obedient patients at once adopt the system of a regular constitutional. But here and there the plan completely fails. A man regularly walks his six or seven miles or more daily, but so far from his constipation being cured he may perhaps find it even worse than before. Exercise, it is perfectly true, is advantageous within certain limits. But if a person takes more exercise than is good for him he may actually encourage and increase this derangement instead of curing it. Nor is walking exercise so necessary or advantageous to all as is generally supposed. Individuals o 2 196 EXERCISE. differ from one another extremely in this respect. One cannot keep himself in health without his long dreary daily constitutional, while another enjoys excellent health though he may not walk a mile a week. Not only so, but it is a fact that many persons, particularly women, who have taken little active exercise at any period of life, have nevertheless enjoyed excellent health and have lived to be very old. In advocating exercise in constipation and in other slight ailments, you must be careful in the case of those who have not been accustomed to long walks to recommend moderate distances, at a quiet pace, or your means of cure may do harm. Two or three miles a day will probably be enough for most persons. The man who is engaged in hard intellectual work will, as a rule, require moderate exercise. During a holiday you may engage in a greater amount of muscular labour than you could advantageously perform if you were studying hard. And I have knovvn several instances of persons getting thoroughly out of health in con- sequence of acting upon the mistaken notion that hard exercise is required at the same time that intellectual work is carried on. When you are working for an examination, and reading several hours day after day, you will find that a gentle walk for an hour or so in the afternoon, or the plan of spending one or two hours in the open air sitting still or driving or " mooning about," will be more conducive to your progress than a long quick walk. Fast walking, running, and all violent athletic exercises should, like dinners and high living generally, be avoided by those who are preparing themselves for examination. Perhaps of all kinds of exercise which have the effect of calling into play the most important muscles of the body without producing fatigue cycling is the best, and now that the "safety bicycle" has come into general use, we shall probably find this kind of exercise will become very general. The only objection is that for cycling we require fine weather. Cycling has been strongly recommended as having advan- tages over walking exercise, and I think rightly so. And although, no doubt, there are troubles incidental to the saddle, these, I believe, never affect those in fair health who are moderate as regards the ■distance they travel. Ten to twenty miles is not too far even for men who have reached fifty, and there are many examples of riders of seventy who often cover more than twice the distance without getting over fatigued. According to the Right Honourable the Speaker of the House of Commons, who is a strong advocate of cycling, there are about 500,000 cyclists in the United Kingdom. (Midland Counties Meet, "Globe," June nth, 1889.) The number increases annually, and there is no doubt whatever that cycling is one of the most healthy modes of exercise, and far less tiring than walking. The worst of it is that during the winter months cycling is difficult, but possibly as time goes on, we may have a strip of asphalte on the broad roads provided THE COLD liATil. RUr-lIIXC. I97 for cyclists, just as is in many places provided for pedestrians, rails for tramcars, and tracks for heavy, slowly moving wagons. The Cold itatii is commonly said to be of use in the treatment of constipation. reople tell us that if we indulge in cold tub every morning or plunge into cold water, the l)0vvels will act properly and without artificial help of any kind. The system again is excellent for some, but the daily use of cold water will not suit all equally well. With some persons it disagrees and causes them to feel chilly and uncomfortable. On cold foggy mornings at this time of the year (November) it re(]uires some strength of mind to cover oneself with cold water just after turning out of a warm bed. Still many Englishmen declare that it not only suits them but affords them delight and keen enjoyment. Those with whom the cold bath agrees experience a pleasant glow all over the body, and feel warm and in good spirits for some time afterwards. When this is the case you may advise that the cold bath should be continued. But if, on the other hand, the patient feels chilly, miserable, and uncomfortable, with slight headache and chilliness of hands and feet, and especially if his skin should get cold and bluish, and he comes down to breakfast without an appetite, you should tell him that cold tub in the early morning is not suitable for him, and suggest that he should take his bath tepid or even warm. As a general rule people over forty or forty-five should use tepid or warm water, at any rate during the winter months. Riibbingr. — Another good general remedy, and one that is not open to any objection is rubbing. I believe this method is very little employed, and that its value is much underrated. There are many who, if instead of taking a cold bath would simply rub themselves well with a rough towel, using strong muscular efforts in doing so, would find a gentle glow come over the skin, and experience a far more comfortable sensation than is afforded by a cold bath, while an equal amount of old epithelium would be removed from the cuticular surface. The beneficial effects of rubbing the surface, are probably due to movement of the blood in the cutaneous capillaries, caused by the pressure exerted. This movement of the blood in cases where there is a tendency to its slow circulation in the capillaries of the tissues and organs is of the greatest consequence, and must be recorded as an important principle which must not be lost sight of in the treatment of many derangements and diseases. Of late years a particular kind of rubbing has been exalted under the name of massage, and much has been written as to the precise method of carrying out the system in order to get the most beneficial results. Massage, however, has for its object to promote changes in the muscles as well as in the skin, while ordinary rubbing with rough towel or glove affects the circulation of the blood in the capillaries and iqB moist application to the abdomen. the lymph in the lymphatics of the skin and subjacent tissues. In this way the general circulation is promoted, and often the healthy action of the intestinal canal. Of Kiieaiiing tlie Bowels.— Another very simple way of assisting the action of the large bowel is to press or knead the abdomen with the hands. Anyone can do this for himself. The two hands should be evenly moved upwards and downwards over the surface of the belly, and the large bowel gently pressed backwards in different places. Those who have studied anatomy know the course taken by the colon round the abdomen, and should press or knead it in a direction from its commencement in the caecum in the right ihac region, upwards, and across the upper part of the belly to the left, and then downwards, following the ascending, transverse, and descenditig colon towards its termination, in the rectum. This kneading encourages the contraction of the large bowel, and is certainly in many cases useful. Moist Application to the Abdomen. — Persons who suffer from torpid bowels are often much relieved by the application of a wet compress over the stomach. This is a very old remedy. You may apply a moist rag or towel, folded into four, to the surface of the belly, and cover it with oiled silk or a piece of mackintosh ; or a piece of moistened spongio-piline may be used. It matters not whether the water be cold, tepid, or warm. If applied cold it soon becomes warm, and I am not aware that any benefit results from the, to many persons, very un- pleasant application of a cold rag to the warm skin. Care must be taken that the compress or other application is not too wet when applied. All that is required is that it should be moist — not dripping wet. It may be worn for two or three hours daily, and in this way relief is often obtained, without the use of any medicine whatever. Galvanism. — Successive slight shocks sometimes have the effect of exciting the large bowel to contract. An ordinary magneto-electric apparatus may be used, care being taken to begin with a weak current and increase the strength gradually. Diet. — There can be no doubt that diet has very much to do with the regular and efficient action of the bowels. A liberal allowance of meat and a too highly nutritious diet favour constipation. On the other hand, various kinds of fruit and many vegetables cooked and un- cooked, as lettuces, water cresses, and mustard and cress, tend to prevent and relieve constipation. Bread. — The bread that we eat should not be made of very fine white flour from which all the bran has been carefully separated, and to which a certain proportion of alum — itself possessing astringent and constipating properties— has been added, to make it appear perfectly white. The best bread for keeping us in health is not the whitest. As regards pleasant taste and nutritive qualities, the sort of bread FKKNCIl I'KUNIiS AND NORMANDY I'll'l'INS. I99 you eat at farm-houses, and which is by no means vv'.iite, is much to be preferred. Brinvn bread, such as we get in London, is good, but it ought to be made of flour from which the branny particles have not been separated before being finely ground. I fancy that a good deal of brown bread is made by adding coarse particles of bran to ordinary flour. Brown bread taken from time to time will certainly help to excite the action of the bowels. "Whole-meal" bread is advan- tageous to many who suffer from constipation, and " Triticumina," entire wheat-meal bread, and " Hovis " bread, which have been recently introduced, are useful. Indian corn floiii' is one of the most wholesome and nutritious forms of food, but it is at present far too dear to be used as staple food ; it is much to be desired that this substance should be brought into ordinary use. Oatmeal, -igain, is another good and very desirable kind of food. It is taken by many, particularly by Scotch people, who well understand how to live cheaply. The best oatmeal is the Scotch, made into •' stirabout.'" The coarse ground makes the best porridge. Milk may be added, or it may be formed into thin cakes, which can be dried. These may be toasted when required, and eaten with butter. Oatmeal sometimes proves a good remedy in certain forms of constipation. In it all matters required to form the staple of ordinary diet are found, and it is a good substitute for bread. Some persons, however, dislike it, and with some it disagrees. Coffee. — A small cup of sweetened black coffee {Cafe noir) before rising sometimes acts as a purgative. Some persons gain the same advantage by drinking a cup of tea, or half-a-pint of warm water. Fruit. — There can be no doubt that fruit is a very useful article of diet. This will be freely acknowledged, but many are unable to indulge in fruit in the winter season. In a climate like ours, except for a very short period in the height of summer, fruit is a rather expensive luxury. However, though few can afford to obtain as much fresh fruit as they could eat, very good substitutes are within the reach of all, even of the poor, though few English people take advantage of the opportunity they enjoy of being able to purchase excellent dried and preserved fruit, apples, plums, and other kinds of fruit, at a very cheap rate. Oranges and lemons are also to be had during the greater part of the year. French Prunes and >ornianUj IMpplns. —Prunes may be bought for fourpence a pound, and a i)Ound of prunes will last many days. If properly prepared, cooked prunes are very good. The French and the Germans use prunes very generally. They stew them and add some syrup, and eat them with the meat at dinner almost daily. If you determine to try them, you may have to turn cook for a time, for you 200 VEGETARIANISM. will find few British cooks disposed to follow your directions. Should the cook be exceptionally amiable and willing to learn, you may suggest to her some such plan of proceeding as the following : — The prunes may be soaked in cold water for several hours, perhaps twelve hours or longer. When they are found to have swelled up, and to have become quite soft, in consequence of imbibing much cold water, they may be stewed in the ordinary way, and sugar added. If properly- cooked, they will be perfectly soft and of a very pleasant flavour. In this way you can all provide yourselves with perfectly good fruit all the winter. You may recommend French plums, which are nicer than ordinary prunes, but a little more expensive ; the so-called Bosnian plums are very good, and about the same price as ordinary prunes. Apples, dried. Figs. — Another fruit you can always get is dried apples. Normandy pippins are ordinarily sold now at all the grocers for a few pence a pound. These you will find an agreeable change, and may take the place of prunes. They must be soaked in water for a few hours, and then stev.ed in the ordinary way. A pound of these Normandy pippins will be sufficient for several dishes. Of late apples have been introduced in a new form. Thin shavings of apples dried in the sun retain their flavour so thoroughly that when moistened and cooked you could not distinguish them from fresh apples. These are imported from Canada and America under the name of " Apple rings," and are sold for sixpence or eightpence a pound. Excellent apples, peaches and other fruits are now tinned in California, and imported in large quantities. Another dried fruit, which is now very cheap and to be obtained in good order all the winter, is the dried fig. Figs are now brought over in immense numbers, and are very cheap. The purgative action is in- creased by soaking in water over night. The figs, in a state of soft pulp,, may be eaten on the following morning. Vegetariaitism. — While I regard it as proved beyond all doubt that a mixed diet is required for the majority, and that in childhood and youth a diet containing a rather liberal allowance of meat is necessary,, especially if the usual amount of exercise considered requisite in most public schools is taken, I am sure that many men about middle age and older take far too much meat, and of food belonging to the meat class. An ordinary good dinner as indulged in day after day by many well-to-do middle-aged men who take little or no exercise is absurd, and a considerable percentage of those who live thus, get gout and suffer in many other Avays just as we should expect. But a rigid vegetable diet is not what is required. Probably meat in small quantity three or four times in the week would be sufficient, while in the majority of instances an egg and a little bacon for breakfast, and a small shoe of meat daily with dinner would be a proper and healthy allowance. The OF TAKIN(; SUFFICIENT FLUID. 20r gouty may often be kept without meat for a week or two at a time with great advantage to their healtli, and many cases of incipient gout and certain forms of rheumatism may really be cured by judicious vegetable diet with eggs and milk puddings continued for a few weeks at a time. Of takhiK riiiiii.— The cjuantity of fluid taken has some influence upon the action of the bowels. Many people are seldom thirsty, and more object, some with good reason, to drinking water. Tea is often discarded on the supposition that it causes indigestion. If tea and coffee and alkaline and effervescing waters, and all forms of alcohol, are objected to by the medical adviser, as not uncommonly happens, the unfortunate patient will, in his efforts to comply with unreasonable advice, probably take too little fluid in the twenty-four hours, and many of the chemical changes going on in his body under these circumstances will be much deranged. One cup of tea or milk and water, at breakfast, half-a-pint of beer in the middle of the day, and perhaps another half-a-pint of beer, or wine and water at dinner, will scarcely amount to a sufficient quantity of fluid to keep the body in health, especially if the appetite is good, and a fair amount of solid food is consumed. People who are never thirsty will occasionally suffer from constipation, as well as from other derangements. When you have reason to think that a patient is suffering in health from taking too little fluid, and this is a very common fault, you may suggest to him the propriety of taking a certain quantity of water at fixed times. You recommend him to drink a glass of ordinary water on rising, another about eleven o'clock, and another at bed-time. Or you may suggest that at dinner he should take hock and seltzer water, and an hour after dinner, or at bed-time, another glass of seltzer, or some other effervescing water. In some cases you may recommend cider or perry to be taken at dinner. You may advise that broth should fornt part of the most important meal of the day, and generally, you suggest various things — milk, whey, more tea, linseed tea, or barley water, (S:c. — with the object of getting more fluid into the body. Warm water at meals, and in some cases before a meal is to be recommended. Within the last few years warm water has been spoken of as a new dis- covery. I know it was commonly taken by many persons more than fifty years ago, and I daresay it is more than a century since the plan was adopted. A large quantity of cold water (a tumblerful or more) at or before meals is not to be recommended, for in the case of persons with weak stomachs it might stop the digestive process altogether. In some forms of heart disease it is desirable not to increase the amount of blood in the heart and vessels, especially if the muscular contraction be feeble, and in certain forms of aniemia too much fluid is not desirable. 202 MEDICINAL WATERS. In general it does not do to advise the patient to take ordinarv' water, for, in the first place, few will adopt your prescription, and, secondly, there is the real and serious objection that ordinary water may be bad, and, though not disagreeable to the taste, may contain typhoid fever or other disease germs. All objections to ordinary water are, however, removed, if it be boiled. Some do not dislike taking warm tea or warm water with their meals. Either suits the stomach far better than cold fluid, which sometimes checks digestion. In cold weather I have long been in the habit of taking warm water, and have recommended the practice to others, but many object and prefer to let the water get quite cold before they drink it. Householders should make a rule that every morning a kettle of water that has been boiled for ten minutes or longer should be allowed to cool, and then poured on the filter. The boiling renders the water perfectly safe, for it destroys every living organism as well as any animal poisons that may be suspended in it. We recommend our patients to drink special aerated waters, and there is no doubt that some of these are more pleasant to the taste than is ordinary water ; but the rapidity with which waters of particular kinds come into favour and are forgotten, and give place to others, is sufficient to show that the water is, after all, the active and perhaps the most efficient ingredient. The patient who goes to some celebrated spa is no sceptic, and according to the instruction he has received from his teacher, attributes the beneficial effects he experiences, not to the ingredients dissolved in the water, but to some mysterious properties which these substances are supposed to have somehow acquired as they were dissolved, or while the solution was being forced upwards through certain strata to the surface of the ground. The potash and soda, &c., accordingly are not ordinary potash and soda, with the ordinary proper- ties of the molecules, but are imbued with some very remarkable powers somehow communicated to them in the bowels of the earth. Fashion and caprice sanction and encourage the universal healing powers of this or that spring, and then a new fashion decrees its impo- tence and transfers infallible potencies to some newly-discovered water. The self-denying supplicant who determines to devote himself for a few weeks to the worshi]) of Hygeia must turn out at about five a.m., and according to the established rites of the place, has to walk a certain distance, and drink a definite quantity of water before he is permitted to enjoy the frugal breakfast, at which even butter is often proscribed. More water drinking and more walking follow in due course, in obedi- ence to well-defined rules. The simple midday meal is succeeded by more walking, more air, and more water. Improvement is soon mani- fested. The bowels act, the appetite returns, the spirits rise, and due credit is given to the mysterious agencies supposed to be communicated TKKATMENT OF CONSTIPATION. 2O3 to some of the chemical ingredients of the water during their solution or afterwards. The air, the simple, wholesome, and restricted diet, the substitution of water for alcohol, the exercise, the rest enjoyed, and peace of mind are the mere accidents attending the curative action of the wonderful mineral constituents of the water. But those who drink good water m London, and live according to reason, may work hard and enjoy all the year round the advantages which some go so far, and at great expense and inconvenience, to try to find during what they call their holiday. Smokiii;; Tobacco. — Other unfortunate individuals, slaves to a bad liabit, tell you they never can get their bowels to act without smoking the accustomed cigar or pipe. Whether it be the force of habit, or whether the nicotine, the active principle of the tobacco, actually gets into the blood and excites the bowel to act through the nerve-centres I do not know, but we are often assured that smoking does exert a pur- gative influence. Tobacco smoking in moderation certainly does no harm whatever, and he who finds that it is followed by the desirable consequences referred to, will be wise to smoke ; but tobacco in excess may cause intermittent pulse, though we must not forget that inter- mittent pulse is often associated with stomach derangement, and even in smokers may not be due to the tobacco. Without being able to explain why, there is no doubt that we some- times get into a not very easily definable state of health, during which we feel unable to do many things as well as usual. To write a letter is an effort. To add uj) a string of figures becomes for the time a very serious task. We forget many things that ought to be carried out, and have an ill-defined fear that something that ought to have been done has been neglected. In some persons there is consciousness of impaired memory, and in many instances, patients about middle age get a settled conviction that they are about to suffer from some serious nerve-attack. They are haunted by visions of apoplexy and paralysis, permanent blindness, deafness, and other terribly depressing possibilities of failure and tissue degeneration. The condition may last for weeks, or even months. Sometimes this state of system may be but the prelude to some slight departure from the normal condition, but occasionally such an altered state of mental and bodily health exists for a week or two before the accession of some definite disease. The Medicinal Treat Dient of Constipation . Of Purgatives. — Although purgatives are among the most valuable of the medicines we possess, if they are given with care and judgment, you will do well to discourage their too frequent use. It is, indeed, one of the most important of our duties to teach people how to keep them- 204 :,IEDICIx\AL TREAT.MLINT. selves in health without physic, aud especially how to keep up free action of the bowels without having continual recourse to purgative remedies. Undoubtedly it is not possible to lay down precise rules by which this desirable result may with certainty be obtained, but I shall venture to offer a few general remarks likely to be of use to you in practice. I believe many cases of constipation are due, as I have before said, to the general habit of taking too little vegetable food. General opinion in this country would certainly pronounce in favour of the meat eating propensities of all classes of Englishmen, and the greater number of those who do take what I believe to be nearer to the correct proportion of vegetable food, do so, I fear, from necessity, in fact, because they have not the means to buy the quantity of meat they consider would be advantageous if only they could obtain it. Intelligent persons generally ought not to err in this direction, more especially as the greater number of the middle and upper classes do little muscular work, and really require but a very small quantity of meat to keep them strong and well. In these days there is less excuse for injudicious diet than there was formerly, for even when fresh fruit and vegetables are very scarce we can provide ourselves with excellent substitutes, in the shape of preserved vegetables and fruit, and jams of various kinds. It is curious how many people who think nothing of eating a shillingsworth of meat consider sixpence spent in fruit and vegetables, fresh or pre- served, an extravagance. The fact is, not only the cheapest but the most wholesome diet is that in which bread, fruit, and vegetables con- stitute the chief articles. I advise you to suggest to your patients during autumn, winter, and spring, to take advantage of the large quantities of fresh apples and other fruits dried or preserved now im- ported from Canada. Many persons might eat two or three good apples a day with advantage to their health. It has been often observed that on days when much food is taken, the amount of fcecal matter expelled is not considerable, while perhaps after taking very small quantities of food for several days it may be an unusually large quantity of excrementilious matter is got rid of. The large bowel seems in the case of some to act most freely when little food is taken. As regards the action of the stomach, small and large intes- tine, and of the liver, and, indeed, of all the glands that discharge their secretion into the alimentary canal, it is to be observed that great difference in degree of activity exist at different times. In the same period, twice or three times as much gland secretion may be discharged at one time as at another. Possibly the very different action of similar doses of the same purgatives on different occasions may be connected with the varying desire for food and the varying capacity for its diges- tion and assimilation. In cases of prolonged insufficient action of the bowels the general Mi;i)ici\AL treatmi;nt. 205 health is impaired and the blood becomes altered in composition. Many substances remain in it, and circulate with it through the vessels, which ought to have been eliminated, and the action of many secreting and other organs is, in consecjuence, more or less disturbed. The defect after a time may lead to important structural change, and may result in long-standing disease. It may be necessary to advise the patient who has been suffering from deranged health, depending upon a prolonged state of constipation, to submit to systematic medical treatment. In some instances the condition may be relieved by attending to the state of the patient's secreting organs without giving him any medicines having purgative properties. Deposits of considerable quantities of urates are formed, and the urine may be of very high specific gravity, owing to the presence of much urea in proportion to the w^ater in which it is dissolved, and in other respects may have departed, more or less, from the healthy state. In such cases a few doses of Bicarbonate of Potash {J\>/ass(e Bicarbojias), or Bicarbonate of Soda {SodcB Bicarbo7ias) will perhaps set everything to rights in a day or two, without any purgation. In many cases of constipation in which any little wounds or scratches do not (juickly heal, an ordinary purgative that acts on the alimentary canal may not suffice. You may have to select a medicine which acts upon the secreting glands, particularly those which discharge their secretions at once into the alimentary canal. It will be noticed many hours before any purgative effect is experienced by a small dose (a grain) of calomel or blue pill, the red and angry appearance of the wounds and scratches will subside, and the healing process will proceed satisfactorily within twelve hours after the dose has been swallowed. Where constipation has existed for a considerable period of time, and the general health has in consequence become considerably de- ranged, you must not expect that the patient is to be at once cured. Very free purgation is often followed by constipation, and the patient instead of being permanently benefited, is only relieved for a very few days. You will often find it necessary to give moderate doses of certain ether purgative medicines at short intervals for a time, taking care, how- ever, not to carry this system too far, so as to worry and irritate the ali- mentary canal, and cause the patient much pain and discomfort. Again, it not unfrequently happens that an ordinary purgative will not properly act, or it acts only very slightly, without affording the relief which is desired. In such a case it may be advisable to repeat the medicine two or three days running, but sometimes it is better to wait for a few days, and then give another dose. The same observation has been made as regards many other medicines. Bicarbonate of Soda or Potash often fails to relieve if given in single doses though they be large, while if fifteen or twenty grains be taken three times a day, and continued 206 SLUGGISH BOWELS. for three or four days or a week, a very distinct and satisfactory effect is produced. The same medicine administered to a person in precisely the same dose will sometimes act freely and sometimes will not act at all. The state of the bowel varies greatly as regards secretion, and its response to stimulants to secretion and muscular contractility. No doubt this depends to some extent on the appetite, and the kind and amount of food taken, but not entirely so, for sometimes after a person has lived sparingly for a time, a moderate purge will produce a very free action. The action of the intestinal, like that of other glands, is not uniform within corresponding periods of time, but sometimes it is very free, sometimes sluggish or almost suspended for a while. If we can just hit upon the time for the administration of the purgative, when the glands are about to act freely, the effect will be exactly what is desired. Most glands form and discharge their secretions, and then rest for a while. It is, therefore, wrong in principle to be continually trying to excite them to action by giving remedies day after day, for a considerable period. This injudicious and unreasonable piactice, which was much in favour fifty years ago, did weak people a good deal of harm, and to it we are indebted for the present unreasonable opposition to the employment of one of the most valuable medicines (mercury) known to us. When the constipation depends upon sluggish action of the large bowel only, the daily or almost daily administration for a time of a mild purge, containing Rhubarb, Magnesia, Aloes, Senna, Colocynth, or Podophyllin (a quarter of a grain) is unobjectionable, and by adopting this practice, which, however, has been solemnly condemned by some authorities, you will perhaps enable a patient to get through a great deal of work which otherwise he could not perform, and you will now and then succeed in transforming a thoroughly miserable and discontented person into a happy one. See also the remarks on the use of mercury under the " Treatment of Sick-headache." One is often assured by a patient in answer to enquiries that his bowels are "regular" — that is, that an action occurs every day, and he will perhaps tell you that he is quite confident no purgative medicine is required, and perhaps that he has been warned by some great authority that purgatives are dangerous. Although from the first you suspect that he requires a purge, according to his wish you try various remedies to relieve the symptoms of which he complains, but without effect. Being dissatisfied with you, he may go from doctor to doctor, seeking relief and finding none, until at last he is ordered to take a purgative, and is soon well. Oftentimes it is necessary to order a mild purgative pill to be taken daily before dinner, for a week or longer, and the patient is not unfrequently quite astonished at the effect. Up to the time of adopting this plan he had felt convinced that his colon was sLi(i(iisii r.o\vi::i.s. 207 clear, although, in fact, fajcal malltr had been very graduall)' accumu- lating in it for many weeks. You will often find small doses of purgatives given just after food for several days in succession, of great use in imperfect action of the bowels, from which many persons engaged in sedentary pursuits in towns very commonly suffer. From three to ten grains of Rhubari), with or without Carbonate of Soda, or five grains of Compound Rhubarlj pill, will be sufficient. \'ou must teacii people to experiment a little on themselves in order that they may find (Jut the least (quantity required to produce the effect desired. As before remarked, fruit taken daily is of use in such cases, but many persons do not try the plan long enough to obtain success. The digestive organs which act sluggishly require a good deal of humouring so to say. Violent purgatives are worse than useless, and not unfrequently a moderate purge is often followed by a headache and general upset, lasting perhaps for many days, and succeeded by the sluggish, torpid, imperfectly acting state. In general there is no difficulty in managing those who eat well and take plenty of exercise, but those who live very moderately, and whose work is intellectual rather than muscular, will require some thought and the e.xercise of a little ingenuity on your part to get them right, and to regain for them the much desired feeling of contentment dependent upon healthy intestinal action. As regards the dose of purgatives, you must be very careful, for you may order a patient a dose that will certainly clear out the whole intestinal canal, but which will also gripe him very severely, and make him for a time very weak and miserable ; while a dose which you might perhaps hardly believe would have any purgative action at all, would have been quite sufficient to effect the desired end, and without pro- ducing the slightest pain or discomfort. You must vary the doses of the drugs you prescribe, according to the state of the patient, and according to the sort of organism you have to treat. If you are pre- scribing for a gentle, sensitive, highly nervous, anxious, excitable person, who thinks he has got all sorts of ailments of a serious character, you must not give violent purgatives, for if you do, you may bring on great pain and sickness, and thereby much increase the intensity of the suffering you have been asked to alleviate. On the other hand, if you are treating a robust labouring man, accustomed to work hard and feed well, and in the habit of drinking three or four pints of beer a-day, and more when he can get it, who has a florid complexion and great muscular vigour, it would be foolish to order him a gentle pill or mild draught. To such a person two or three grains of Colocynth pill would be per- fectly useless, and ten grains might be required to act at all, and if you were to add to these two or three grains of Calomel, the patient would probably feel the more grateful to you. Many of the chemists, in town 20S CALOMEL AND COLOCYNTH. and country, sell good strong pills, which they call " Cabmen's Pills " or *' Navvy's Pills," and which are most useful for those for whom they are prepared. The necessity of varying the doses of medicines according to the individual patient should convince each student and practitioner of the importance of learning how to prescribe, and mix, and combine medi- cines, instead of exclusively relying upon the pills and mixtures prepared for the profession in enormous quantities by large firms, to be purchased by the gross and by the gallon, but which cannot be altered to suit individual persons or combined so as to suit peculiar temperaments. Moreover, there is no doubt that many extracts and pill-constituents iose something of their virtue by being kept for a considerable time. Practitioners have discovered certain combinations of things which are very valuable, and the receipt for many a useful pill or mixture has been handed down from generation to generation. In these days, not only do we neglect to use many excellent old prescriptions, but we no Jonger suggest new ones, and many combinations of drugs of tried value and in frequent use in former days will soon be altogether forgotten. The old system of teaching such elementary but practically important matters has been entirely abandoned, and many a wrinkle of the greatest importance in practice, instead of being preserved and transmitted as formerly from master to pupil, has been lost. Let me advise you never to neglect an opportunity of picking up from old practi- tioners any receipts for medicines they are willing to give you, nor to despise their teaching, especially as regards the treatment of many slight ailments difficult to manage and to cure. Do not receive with contemp- tuous indifference their suggestions for the treatment of functional dis- orders, although they may not be able adequately to explain according to the latest doctrines the exact nature of the pathological changes upon which the symptoms depend. Olive-Oil will with some act as a purgative, and may be taken as salad dressing. For infants, young children, and weak adults, olive-oil is a good purgative. Castor-Oil^ Oleum Ricini, which is the oily sub- stance expressed from the seeds of the Ricinus coin/nioiis, is one of the ibest and most frequently used of purgative medicines, and were it not for its nauseous flavour, not so perceptible, however, in the best Castor- oil of recent manufacture, would be yet more popular. It is, at the same time, one of the mildest and most certain of purgatives, and is suitable to persons of all ages. You may give it to the infant as well as to the most infirm and delicate. It is usually given by the mouth But Castor-oil may also be employed in enemata. It is one of the few purgatives that act upon every part of the intestinal canal, from the CASTOR-OIL AND RlIUIiARI!. 209 stomach downwards, but its action commences in the upper part, and it is efficient in driving down imperfectly digested and other matters that may be irritating the mucous membrane and causing pain. The dose varies from a few drops to half an ounce or more, but most persons take a larger dose of Castor-oil than is really necessary to produce the desired effect. One teaspoonful is often sufficient for an adult, and sometimes acts as well as a larger dose. Not the least advantage of prescribing the smallest dose that will be useful is that it is much easier to take. There are many receipts for taking Castor-oil so as to avoid tasting it. Upon the whole I think you will find the following one of the most efficient plans: — You direct that a teaspoonful or more of "black coffee," that is, coffee without milk, be poured into a wine glass, the whole of the interior of which, including the lip, has been well wetted with the coffee. A teaspoonful or a little more of the oil is then to be steadily poured on the surface of the coffee, when it will form a large globule lying perfectly free and not in actual contact with any part of the glass, because the latter has been well wetted with the adhering coffee. The patient then opens his mouth wide and pours the oil and coffee down his throat, swallowing the whole in one gulp. If the operation has been successfully conducted, he will not have tasted the oil in the slightest degree. Tea, a little Ginger or Orange Wine and water, or Peppermint, Camphor or Orange-flower water, or Brandy and water, or plain water may be used instead. Strong spirit being lighter than the oil will not do. Some strongly recommend that the dose of Castor-oil should be well shaken up in a bottle with twice its quantity of milk, and when well incorporated poured into a cup or glass and quickly swallowed. Rhubarb, Rhei Radix, Pulvis Rhei, is one of the best of purgatives, and its virtues are widely known. It has been a popular remedy for more than two centuries, and is one of the best purgatives for children. Mixed with Carbonate of Soda, Soda Bicarbonas, it is very useful in derangements of digestion. From five to twenty grains of Rhubarb with half as much Bicarbonate of Soda, will often give great relief. The dose may be repeated once every other day after food for a week or two in cases of constipation or imperfect action of the bowels. See also pp. 206, 207. Pulvis Rlici Conipositus, formerly known as Gregorys Fotvder, con- sists of Rhubarb, 2, Light ^Magnesia, 6, and powdered Ginger, i. It is an excellent and safe remedy and may be given in doses of from ten grains to a drachm in water. Ordinary Compound Rhubarb Pill, Pilula Rhei Composiia, and CotJipound Colocynth Pill, Pilula Colocynthidis Composita, suit most persons very w^ell. Three or four grains of either of the above with a grain of Extract of Henbane, Exlractum Ilyoscyami, may be made into 2IO COMPOUND RFIUBARB PILL. a pill, and one or two may be taken every night or every other night for a week or two, in many cases with great advantage. In this way the bowels may be thoroughly relieved and got into the way of working regularly. One of the great advantages of giving purgative medicines in the form of pills is that the particles of the drug are thoroughly comminuted aid diluted, as it were, by less active ingredients. The importance of the minute division of active substances was known even to the ancients. A smaller quantity of the active material is sufificient, and it is far less likely to do harm, while its action is sure to be more moderate and equable, if intimately mixed with a quantity of inert or slightly active material, than if administered in a pure state. Many pills and powders have been compounded on this principle. Compound Ipecacuanha powder, Pulvis IpecacuanhcE Composiiits, Compound Jalap powder, Pulvis JalapcE. Composihcs, and Compound Rhubarb powder, Pulvis Rhei Compositus, are examples. If there be much flatulence, or if ycu desire to give a little stimulus to the secretion of the gastric juice, you may add to the pill or pills half a grain or a grain of Capsicum, Capsici Fructus, or ordinary Cayenne Pepper, with advantage. Pills may be coated with silver leaf or covered with gelatine, sugar, or other material, in order that they may be swallowed more easily. Among the best are Wiley's coated pills made in Coventry. You must recollect in administering pills not to order more than five, or at the most six grains in one pill, or you will astonish your |)atient by the size of the bolus you have ordered him to take. Five grains form a moderate-sized pill, but if blue pill or calomel should be one of the ingredients, the pill will be small, because a grain of these mercurial preparations occupies very little space. This matter of the size of pills must be borne in mind, for some people think it an insult to receive a large pill, and many will tell you they cannot swallow one of even moderate size. The professed inability to swallow a pill is often mere affectation or determination on the part of the patient not to attempt to do so ; but some persons have a real difficulty. For them the pill may be silvered or gilt, or covered with a tasteless gelatine or starch coating, and if neither of these plans will please, tell them to pack the pill up in a small piece of moistened " pastry-cooks' paper," when the whole will slip down even if the patient makes no effort to swallow it. This pastry-cooks' paper can now be obtained at many of the large chemists, and is an excellent thing in which to give powders to children. Little capsules of this material have been prepared and made in separate halves. The powder or pill is placed in one and the cover applied, the edges, being slightly moistened, the two halves adhere, and the little parcel with the included medicine can be swallowed without any d'fficulty. COMPOUND LIQUORICE POWDER. 211 Nux Vomica may be given by itself or combined with a purgative, in cases of imperfect action of the bowels. It is useful by giving tone to the bowel and stimulating, probably through its action on the nerves, the muscular coat of the intestine. It is now frequently prescribed. It comes from the plant which yields Strychnine, Strychnos Nux Vomica. You may give of the I'^xtract of Nux Vomica, Extractum Niicis Vomica;, from a quarter of a grain to half a grain. If added to a mild purgative pill, it helps the action very decidedly. The Tincture of Nux Vomica, Tinctura Nitcis Vomic(c, may be prescribed in doses of from five to fifteen minims with some Compound Tincture of Bark or other tonic. Decoction of Aloes, Decoctum Aloes Composiium, Tincture of Senna, Tincture of Rhubarb, are simple remedies, which are often prescribed in doses of from a drachm to half an ounce. Scammony, Scammopium^ a gum resin from the root of Convolvulus Scammonia, is a component of many purgative pills, and is a very active purgative. For children suffering from intestinal worms Scammony is one of the best remedies. It may be given in doses of one or two grains, or from three to five grains of the Compound Scammony Powder, Pulvis Scammonice Compositiis, which consists of Scammony, 4, Jalap, 3, and Ginger, i, may be ordered instead of the pure drug. It may be taken in a little milk. Probably many patent purgative medicines con- tain Scammony. It is a raiher searching purgative, which clears out the bowel well, expelling any hardened freces and wind that may have collected. Of Scammony there are several kinds in the market, some worthless. The uncertainty of getting a good specimen has caused many not to prescribe the remedy, but when good, Scammony is one of the most useful purgatives. Purgatives suitable for children, delicate and aged persons. — Compound Liquorice Poivder is now in the Pharmacopoeia. This preparation is much used in Germany and Russia, and is certainly one of the best and safest of ordinary purgative medicines. The Pulvis Glycyrrhizce Composifus of the British Pharmacopoeia contains two ounces of finely powdered Senna and the same quantity of Powdered Liquorice root, with six ounces of powdered sugar ; but the German preparation is made as follows .• — " Powdered Senna, powdered Liquorice, of each 2 ; powdered Fennel, Sulphur, of each i ; white sugar, 6 : mix." — Squire's Companion to the British Pharmacopoeia. The dose of the powder is a teaspoonful, carefully mixed in a little water. Lenitive Electuary {Confectio Sennce composita) contains prunes. Although this is a very good purgative, you will find that some people do not like it. Children will often take stewed prunes, although it may be a difficult matter to give them any form of medicine. You may increase the purgative jjroperties of stewed prunes in a very simple way —and the hint I shall give you is a useful one to bear in mind in the p 2 212 SULPHUR. management of children. Suggest that a teaspoonful of Senna leaves be tied up in a small muslin bag and soaked for an hour in the water in which a pound of prunes is stewed. In this way you add a little infusion of Senna to the prunes, and although you hardly alter their taste, you considerably increase their purgative action. Conserve of currants, Senna a?id Glycerine. — My friend, Ivlr. G. Farr-White, of Surbiton, has found the following confection of the greatest service in the constipation of old people. He tells me that it does not lose its active properties by repetition : — Currants well beaten into a soft pulp in a mortar... 4 oz. Powdered Sugar ... ... ... ••■ ••• 402. Powdered Senna •■■ 2 oz. Powdered Ginger ... ... ... ... ... 5^ oz. Glycerine ... ... ... ••• ... ••• i oz. The whole is to be well incorporated and rubbed together to form a smooth confection. — Dose, half a teaspoonful daily when required. Sulphur. — Sir Alfred Garrod has lately been advocating a very old remedy, sulphur, which he recommends to be taken in the form of lozenges, but unfortunately for many persons the dose is too small. Brimstone and treacle used to be commonly prescribed more than fifty years ago. At that time sulphur was a remedy commonly in use among the poor, and considerable quantities were used medicinally. Like many other old fashioned things it has long been almost discarded. Whether it really deserves to be held in very high repute as a purgative I doubt. It is, however, probable, like many medicines belonging to the laxative class, it will act advantageously on some weak persons and particularly on children. It may be noticed that it is an ingredient of The German Lupiorice Poivder which has been in high favour of late years. Sulphur may now be obtained in lozenges, of which one or more may be taken when required. Aloes is a purgative which has the property of acting upon the large bowel. It probably excites the mucous membrane and its glands to secrete ; but by reflex nervous action, it stimulates the action of the muscular coat of the intestine, and excites vigorous con- traction both of the circular and longitudinal muscular fibres. It is a very good purgative to give in cases of torpid bowels, but it is important for you to bear in mind that aloes has the effect in some cases ot encouraging the formation or increase of haemorrhoids or piles, see^^. 191. It seems to act upon the mucous membrane of the lower bowel, and those who suffer from an irritable state of this part sometimes find their sufferings much increased if they take any of the ordinary preparations of Aloes. There are the Socotrine Aloes, Aloe Socotrina, and Barbadoes Aloes, Aloe Barbadensis. The Compound Decoction of Aloes, Dccoduni 01" THE USE OF ALOES. 213 Ahes Co/iiposiium, is ordered to be made of Socotrine Aloes, and contains besides, Myrrh, Saffron, Carbonate of l*otash, Liquorice, Compound Tincture of Cardamoms, and Distilled Water. This is a very valuable preparation, and enters into the composition of many favourite draughts which used to be prescribed in former days, and which brought gain to the apothecaries of old. That once very fashion- able but rather nasty dose called a Black Draught was composed of Decoction of Aloes, with Sulphate of Magnesia, Senna, and Liquorice. Its composition was modified by different authorities, and some im- provements, more nasty still, were made by ingenious physicmongers ; but the reputation of the black draught is gone, and though an excel- lent purgative, it is seldom prescribed in these days. Fifty years ago Dr. Chambers, who was then the fashionable physician in London, and other physicians only a little less fashionable, prescribed blue pills and black draughts for most ailments. Now it would not be easy to persuade people to swallow a black draught. However, with a little ingenuity you may suggest something less nauseous and equally efficacious. The Decoction itself may be taken in doses of from two drachms to an ounce and a half or more. Probably the best preparation of Aloes, to prescribe in the form of pills, is the Watery Extract of Aloes {Extractnm Aloes Socotrind). This watery extract does not irritate the bowels, and acts very effectually. It may be given in doses varying from the one-sixth of a grain up to a grain or more, but it is better not to order a larger dose than is abso- lutely requisite, and in prescribing, it is well to bear in mind that Aloes, as well as many other drugs, have their purgative action much improved by being reduced to a state of very minute sub-division, and mixed with other things. If small pieces of Aloes should stick in the mucous membrane of the large bowel, that particular part might be severely irritated, and in consequence the patient would experience great pain and discomfort ; while, if the medicine was very minutely divided and mixed with a quantity of inactive or less active material, there would be no danger of any such deleterious action. When )0u prescribe Aloes, you should always order it to be intimately mixed with other and less active substances. Let the pill contain, say, a quarter of a grain of the Extractum Aloes Atptosuiu with two or three grains of common Extract of Colocynth {^Extractum Colocynthidis Coitipositinn), and a grain of extract of Henbane {Extractum Hyoscyami). Although in these days it is the fashion to prescribe one remedy only, and I believe some distinguished physicians consider it improper to order more than two drugs in one pill or mixture, there is not the least doubt that, as far as regards the action of the medicine upon the organism, considerable advantage is gained by mixing several remedies together. Medicines, like foods, affect different people in a different 214 OF THE USE OF PODOPHYLLIN. way. If you preicribe several different things together, you may influence different idiosyncrasies, while it would be almost impossible to determine the particular purgative suitable for each individual patient. I much prefer a pill consisting of a little Compound Colocynth, a little Nux Vomica, a little Henbane, a small quantity of Podophyllin, and perhaps a little of the Watery Extract of Aloes, to a full purgative dose of any one of these preparations by itself. By mixing these things together, there is no doubt that you get a less painful and more efficient action than you do from a large dose of either of them separately. If you desire to test the truth of this obser- vation, you may carry out a very instructive experiment on your own organisms. Take, for example, one grain of Podophyllin and see how it affects you, and the next time you require a purgative take three grains of the Watery Extract of Aloes alone. On anotlier occasion try a very small dose (a quarter or the third of a grain) of Podophyllin or Aloes, mixed with three grains of Compound Colocynth pill, and notice whether, upon the whole, you do not get a better result with less griping pain than when you took the larger doses of the simple drugs. Podophyllin has been much used during the last twenty years, and was first employed in America. But it is a purgative of somewhat uncertain action, and those who order it should take care how they prescribe it. I remember the case of a child who was almost killed by half a grain of Podophyllin, incautiously ordered by the practitioner, who perhaps up to that time had been employing some weak and inferior preparation ; but this last prescription, being made up by a chemist who used good medicines, a much too powerful dose was administered. The drug varies much in quality, and it is, moreover, one of those things which acts very differently upon different people. I have patients who have been taking a small quantity of Podophyllin for many years, and who say they have never taken anything that acts more satisfactorily. On the other hand, one every now and then gets into disgrace for ordering the same thing to other persons, and I am sure the medicine is prescribed less frequently than it used to be. The drug sometimes gripes the patient so much that he does not wish to try }he remedy again. You should always order it first in small doses (a quarter or the third of a grain), mixed with compound Rhubarb or compound Colocynth pill, and if it causes no discomfort, you can easily increase the dose. Drastic and llydrasosiie Purgatives can hardly be included among the remedies for slight ailments, but a few of them may be prescribed in small doses for ordinary maladies. Thus Jalap,ycr/rt/«, is a very old and useful purgative, which may be taken in doses varying from five to fifteen grains. It excites the flow of fluid from the blood into the DRASTIC PUR(iATIVES. 21 5 intestine, and wlien prescribed should be mixed with an equal cjuantity of Bitartrate, Potassce Tartnu Acida, or Sulphate of Potash, Fotasste Su/p/ias. Jalapiiic is obtained from ordinary jala[) by rectified spirit. It is the resin, in fact, Raiiia /a/apw, deprived of its colouring matter by animal charcoal. A small dose of from one to three grains will be found to act freely. It may be prescribed in a pill or as a powder, mixed with a few grains of sugar. Elaterium, Croton Oil, Gamboge, are all violent purgatives : the two first, although useful in the treatment of some diseases, are not required in the management of slight ailments ; the last is prone to give great pain, and is now seldom given. Such purgatives as these should be prescribed in very small doses to begin with. In fact the practidoner who uses these drugs should ascertain whether the patient will bear them, by ordering in the first instance a very small dose. Drastic cathartics all excite the pouring out of a large quantity of fluid from the blood through the walls of the capillaries into the bowel. saline Purgatives are valuable in many cases of imperfect action of the bowels. Many of the salts used as purgatives act not only by pro- moting osmose of fluid from the blood by reason of the higher specific gravity of the saline solution in the intestine than that of the liquor sanguinis, but also by direct influence on the nerves of the mucous membrane. The beneficial action of some salines also depends upon their being first of all absorbed into the blood, and then excreted by the glands and follicles of the mucous membrane of the colon ; at the same time, many other substances are removed from the blood with the salt, and in this way the circulating fluid may be freed from certain deleterious constituents which have accumulated in it, and which if they had remained might seriously have interfered with the action and nutrition of various tissues and organs. Most salines act partly as pur- gatives and partly as diuretics, and not a few of them have the effect ot increasing the secretion of many, if not of all, the glands of the diges- tive system. There are many salts in the Pharmacopoeia which you wfll find useful. Of these some are very ancient remedies and well known in all countries. First of all, there is Epsom Salts, Sulphate of Magnesia, MagnesiiC Sulphas, and a capital remedy it is. It probably forms the basis of a great many fashionable medicines, and many people fre- quently take it without knowing from what a common drug they derive relief. It is one of the cheapest of medicines, for a pound of it only costs a few pence. It may be given in doses varying from half a drachm to half an ounce or more, in solution in water. The small dose, especially if dissolved in warm or lukewarm water, will sometimes 2l6 SULPHATES OF MAGNESIA AND SODA. purge freely and quickly. As a medical author has metaphorically remarked concerning a much advertised water, it is " speedy, sure, and gentle " ! Sulphate of Magnesia is a rather unpleasant thing to take, unless you mix it with about one-fourth of its weight of common salt and twenty drops of Aromatic Sulphuric Acid {Aciduin SulpJniriciim Aroiiia- ticufii), the whole being dissolved in an ounce and a half of lukewarm water. I often order ten minims of dilute Hydrochloric Acid, Acidum Hydrochloride m dihttuin, and two drachms of Sulphate of Magnesia, to be dissolved in an ounce and a half of Cinnamon Water, Orange Flower Water, Aqua Aurantii Fioris, common Water, or Infusion of Roses, Iiifusum Rosce Acidum. The last gives rather a pleasant taste and agreeable colour to the draught, which should be taken in the morning before breakfast, or about two hours after that meal. If you consider it desirable to act upon the kidneys at the same time as the bowels, and ■often it is very important so to do, you may add a few grains of Nitre, Pulvis Potassce Nitratis, and in this way you make a saline draught which many of your patients will find useful. It may be taken day after day for three or four days^ or twice or three times a week ; but its daily use should not be continued for longer than a fortnight at a time. Sulphate of Soda or Glauber's Salt, Sodct Sulphas of the Pharma- copoeia is not so strong in its purgative action as the Sulphate of Magnesia, but it is not quite so disagreeable in taste. You may give two or more drachms of Sulphate of Soda dissolved in an ounce and a half •of water. Or you may prescribe two or three drachms of the Sulphate of Soda with a somewhat less quantity of the Sulphate of Magnesia with five or ten grains of Nitre and a drachm or more of common salt. The addition of common salt you will find advantageous, as it certainly much diminishes the nauseous taste of the Sulphate of Magnesia. Sulphate of Soda, one of the constituents of Carlsbad water, acts powerfully on the liver, especially if dissolved in a considerable quantity of tepid water. By its use uric acid and other excrementitious matters are washed out of the tissues. In this way is no doubt to be explained the beneficial action of Carlsbad water in the gouty condition, and in states of system in which there is a marked gouty tendency. The real and lasting benefit which frequently results from even a short course of washing out, with judicious attention to diet, and the importance of free exposure to good air and properly regulated gentle exercise, suggests the general plan to be followed in the case of those who are precluded from enjoying the advantages of a course of treatment at Carlsbad or other place where suitable waters may be taken at their source. If, on the one hand, we study the rationale of the health course, and on the other observe -the results attending the same p'an of treatment at home, we need not despair of SALiN'i-: ruK(;ATivi:s. 217 being of some use to patients who are compelled to remain in this country, and are unable to give up their work even for a week. The use of Glauber and many other salts was perhaps better understood by a former generation of practitioners than it is by us. In such cases, the old fashion of prescribing two or more teaspoonfuls of Glauber's salts in tepid water once or twice a day was without doubt of great use, and I think that remedies of this class are in these days too seldom prescribed. It is not only persons who are actually suffering from diseases who arc benefited, but I have no doubt that many who are as it were preparing themselves by injudicious living for chronic liver disease, would escape if, before actual morbid change had resulted, they had been enjoined to take frequent doses of saline medicines. Carlsbad water, natural and arti- ficial Carlsbad salts, may now be obtained without difficulty in London. Many salts which have a diuretic and sliglitly purgative action are very valuable in the treatment of enlarged liver, at least, during the early periods of the disease, and a mixture of three or four salts will often be found more useful than Sulphate of Soda or Sulphate of Magnesia alone. In treating those who prefer to remain at home or are too poor to profit by a visit to Carlsbad, the following mixture of salts may be prescribed with advantage : — Sulphate of Soda, well dried ... ... 4 oz. Sulphate of Magnesia, dried ... ... 1 oz. Chloride of Ammonium... ... ... j{ of a.n oz. Nitrate of Potash i-j^ of an oz. Chloride of Sodium (Common Salt) ... i oz. To be dried, powdered and well mixed together, and kept in a wide- mouthed, well corked or stoppered bottle. Dose — a teaspoonful, more or less, in half a tumbler of tepid water, twice or three times daily (an hour after breakfast, about 4 o'clock, and an hour before going to bed) for a week or ten days at a time. Salines generally, like many other medicines, act more powerfully if they are combined than if taken separately, and, as I have already said, their action is expedited and increased if they are taken in a diluted state dissolved in warm or luke-warm water. Phosphate of Soda, Sodce Phosphas, is another salt which acts well as a mild purgative in doses of from one drachm to an ounce dissolved in water. It is not disagreeable, and has long been known as " Tasteless Saline Aperient." It is a good saline for children, and may be given dissolved in weak beef tea or other form of broth or soup. Soda Tariarata, a Tartrate of Soda and Potash, commonly called Rochelle Salt, used to be a very favourite saline purgative. It also acts on the kidneys. The acid of this salt, like Citric and many other 2l8 FRIEDRICHSHALL WATER. vegetable acids, becomes changed in the system, alkaline carbonates being formed, which render the urine alkaline. The dose is from one drachm to half an ounce or more dissolved in water. You may order a mixture containing half a dozen doses, and direct the patient to take an ounce, that is, two tablespoonfuls, with one tablespoonful of hot water. If the dose is taken before breakfast it will generally act in the course of two or three hours, and many a patient will have good reason to thank you for the advice you have given him. Seidlitz powders are another popular saline remedy. Many saline mixtures may be used instead of purgative mineral waters. Their action is much the same, but you will find that not a few of the most pros- perous of your patients will decline to take such salines as you can pre- scribe. They require a more fashionable form of saline in the shape of a purgative mineral water from some wonderful spring warranted to cure all diseases and patronised by the nobility of Europe. In these days there are indeed a number of potent natural mineral waters having purgative properties from which to choose. A few years since, almost every person was advised to take Pullna water. This after a time, like the once famous Epsom and Cheltenham waters, gave place to others. For years Fried ric/ishall has been credited with virtues of surpassing excellence, but now I suppose opinion is divided between this and the unpronounceable Hunyadi Janos bitter water. The latter contains much more of the purgative sulphates than Pullna,. Seidlitz, Kissengen, or Friedrichshall, and therefore acts more freely. Friedrichshall 7vaier is a mild purgative saline. Its composition is shown in the following analysis, for which I am indebted to Mr. C H. Piesse, Public Analyst for the Strand District : — ANALYSIS OF FRIEDRICHSHALL HITTER WATER. Cirains per gallon. Sodium 657-5 Potassium o'l Magnesium roo'8 Calcium i^'7 Silica 17 Chlorine fco3-i Bromine °'I3 Sulphuric acid (SO4) 739'2 Carbonic acid not estimateil. It seems to contain Sulphate of Magnesia and Chloride of Sodium. Mr. Piesse remarks that if the " Chlorine " be calculated into " Chloride of Sodium," and the " Magnesium " into " Sulphate of ^Magnesia," and the amounts of the salts thus indicated be dissolved in one gallon of ordinary drinking water, we shall have a solution very like the natural i:FKi;Rvi;s(i\(i salines. 219 Friedrichshall water, especially if the mixture be well charged with carbonic acid. You may tell the patient to take a wine-glass of Friedrichshall or Hunyadi Janos water with as much warm water every morning before breakfast, and in many cases it may with advantage be prescribed with twice as much Carlsbad water made warm, or hot water added. For patients who object to the expense of mineral waters you may easily prescribe a substitute according to the principles already mentioned, page 217. Whether the Sulphate of Magnesia and Sulphate of Soda in the water obtained from a spring are in a state in any way molecularly different from the salts as sold by chemists has not been determined, but certainly the less wealthy seem to derive as much benefit from solu- tions of ordinary Sulphates of Magnesia and Soda as the rich do from purgative mineral waters. Sulphate of Potash, Potassce Sulphas, is a very old saline aperient. It may be taken in doses of from ten grains to three scruples, dissolved in water. It enters into the composition of many of our remedies in the Pharmacopoeia. Effervescing Saline Purgative.— V,\i\. perhaps the pleasantest saline purgative is an effervescing draught. We have an excellent mild pur- gative in what is now called Granular Citrate of Magnesia. I believe that much of what is sold under this name is really Citrate of Potash or Soda. The ingredients are mixed, and the water of crystallisation in part driven off by heat ; but the preparation is a difficult one to make well. The dose is from one to two teaspoonfuls thrown into a tumbler two-thirds full of water, and the mixture is to be taken during efter- vescence. The granulated salts must be carefully excluded from damp, but if this be done they keep for a long period of time. Such effer vescing draughts are very agreeable in hot climates. It is of course only a very mild form of purgative, but useful in a great many cases when a cooling saline is required. The urine may be rendered alkaline by the salts. To those subject to deposits of uric acid and urates, to those who suffer from "biliousness " and "sick head.iche," the citrates, tartrates, and other salts of vegetable acids are useful. Many different forms of granulated effervescing salts are now largely used which con tain Quinine, Iron, Bismuth, Strychnine, Pepsine, Bismuth, Lithia, Caffeine, Salicine, and many other substances. These and many others are made by Bishop and Co. Granulated Effervescing Salts also con- stitute a very agreeable vehicle for many different kinds of medicine. Generally, in giving purgatives, do not forget that it is a great point to hit the exact time, for a moderate dose will often produce a full and sufficient effect, although at another time, in the case of the very same person, a larger dose will have little or no effect, save causing 220 EFFECT OF PURGATIVES. severe pain. If the right time can be selected, a mild purgative will be of the greatest use, and may possibly have the effect of preventing an attack of illness. This variability in the action of the same medicine is very remarkable in the case of mercury, an extremely small quantity of which has sometimes the most beneficial effect in dissipating symp- toms which for several days may have indicated serious general dis- turbance and the derangement of more than one important organ of the body. DIARRHCEA — SUMMER DIARRHCKA — TREATMENT OF DIARRHCEA— COMMON INTESTINAL WORMS— OXYURIS VERMICULARIS — ASCARIS LUMBRICOIDES — TAPE WORM— VERTIGO, GIDDINESS -AURAL VERTIGO. iiiarriioea. — I pass now to the consideration of a condition the very- opposite of constipation. Diarrhoea (ru'i, through, fjcw, I flow), though a common ailment, is less frequent than constipation, and is seldom habitual and persistent, lasting perhaps for the greater part of a lifetime, like the tendency to constipation. Now and then, however, you do meet with people who seem to suffer very frequently from a condition to which the term diarrhoea would be generally applied. To your inquiry if the bowels are open, the patient will perhaps reply '• Toa much so." On further questioning, you find that the bowels act three or four times every day. I have known highly nervous persons v>'ha habitually during a long life have had two or three liquid or almost liquid actions daily, not only without suffering any derangement of the health, but really enjoying good health. If we knew precisely how tO' bring about a moderate degree of this condition, we should much increase the comfort and add to the health of many, for it is surprising how very many suffer through life from constipation. With not a few, east wind means troublesome, imperfect action of the bowels or actual constipation, for which medicine must from time to time be taken. Whether looseness of the bowels depends upon a highly irritable state of the nerves of the mucous membrane, or is due to weak vascular walls, or to an altered state of the blood, or to a highly nervous dis- position, it is often difficult to decide. In some cases the condition results from a peculiar habit of body, and undoubtedly there are types of constitution which are remarkable for the great activity of various secreting glands, just as there are others as remarkable for slow and imperfect action. In neither case is there any structural alteration ; but one class is characterised by rapid, the other by sluggish, change. That diarrhoea may be produced through nerve influence only, is proved by a number of circumstances. Many nervous people are very subject to it. Fright, anxiety, and sudden joy may be immediately 222 SUMMER DIARRHCEA. followed by diarrhoea. Many students who have been exceedingly anxious concerning examinations have experienced the influence of the mind acting through nerve-fibres and nerve ganglia upon the secreting glands which discharge their contents into the intestinal canal. The action is due mainly to a relaxation of the muscular fibres of the small vessels, permitting dilatation and a free discharge of fluid from the blood directly into the bowels, as well as indirectly into the secreting glands. To those who suffer from constipation, an occasional attack of diarrhcea is very advantageous, and is not to be regretted. Probably diarrhoea carries off many noxious materials that have accumulated in the blood, and provided it only occurs now and then, and does not last for too long a time, and is not allowed to become very severe at a time when there happens to be an epidemic, may be beneficial. But you must not forget that an attack of typhoid fever is often ushered in by slio'ht and sometimes by severe diarrhoea. There is, however, usually a decided rise in temperature, which in many cases will enable you to form an opinion as to the nature of the malady. There are times when diarrhoea must be guarded against, and, if it occurs, must not be allowed to persist. During an epidemic of cholera, a person suffering from diarrhoea must be carefully watched, for if the condition continue unchecked for even a short time, the diarrhoea may become choleraic. Indeed in cholera times what appears to be ordi- nary diarrhoea may be succeeded in the course of a few hours by the collapse stage of cholera. The disease often begins with slight purga- tion, and you cannot tell whether a person is about to have a mild attack of ordinary diarrhcea or actual cholera. It therefore behoves us to be on our guard, and during the prevalence of a cholera epidemic, it is important to at once check all cases of diarrhcea. Suniinei* Diarrhcea. — The commonest form of diarrhoea is that which we meet with in hot summers, and often prevails to a great extent in autumn. This is called summer diarrhcea, and it is hard to say exactly what occasions it. Certain it is that it is more prevalent in hot, dry summers than it is in cold, wet ones. Some would explain the fact by the superabundance and cheapness of fruit in the former, and its scarcity and high price in the latter. Plums usually get the credit of exciting diarrhoea, but the condition frequently shows itself before plums are obtainable. No doubt bad, unripe fruit and decaying fruit are very liable to irritate the bowels, and may excite diarrhoea. Neither is there any doubt that decomposing vegetable or animal matter will bring on an attack of diarrhoea ; but what the particular organic material may be which exerts the deleterious influence I do not know. In all decompo- sition of animal and vegetable matter toxic substances are generated. On the other hand, it is quite certain that many of us can eat very considerable quantities of any ordinary fruit without suffering in any TRRITATIM-: DIARRIK ICA. 223 way, and even without the ordinary half-constipated habit being relieved. In summer the intestinal canal of many persons seems to be in an unusually sensitive or irritable state, so that very slight errors in diet are apt to derange its action for a time. Even a little beer that is out of order, or sour milk, will sometimes set up a troublesome attack of diarrhoea, which may last for days, and require careful treatment to check it. There are certain forms of diarrhoea which occur in persons who have been in tropical climates, which appear to be due to inaction or imperfect action of the liver. The condition may continue for months without being very severe — preventing the patient from gaining in nutrition, but not producing actual emaciation. In cases of the kind the motions are p.ile, not excessive in amount, and do not perhaps number more than two or three daily — never of the proper colour — and perhaps for a period extending over many months the digestion has been deranged, and the stools of a pale, dirty, light-brown colour, and sometimes even whitish. It will be found that relief is often afforded by very small daily doses of a mercurial^from half to the sixth of a grain of grey powder or blue pill, or a small dose of calomel, continued for a few days at a time. During treatment no meat should be allowed, but the diet should consist principally of farinaceous food — loread, milk, and a small quantity of strong, freshly made beef-tea. Concerning the precise changes which occur in severe diarrhoea, little is positively known. It is generally supposed, as I have already remarked, that nmch of the fluid escapes from the capillary vessels ; but at least, in some cases, it is more probable that the condition depends upon increased activity of many of the glands which discharge their contents into the intestinal canal. In sudden diarrhoea, depend- ing upon the presence of some irritating material, I suppose transuda- tion of fluid takes place from the vessels, as well as increased secretion from the glands. In many cases, for some time before the attack, it is probable that the blood has been in an unhealthy state, in which case the free discharge of watery matter will be of advantage to the patient, inasmuch as various noxious materials (ptomaines) will be eliminated, which would do harm if they were retained in it in a state of solution. Thus by the attack of diarrhoea is the blood at once depurated, and, in this way, may be soon restored to its normal healthy state. Un- questionably, therefore, in such a case, diarrhoea may be regarded as conservative and advantageous. Suppose a child has been eating a quantity of unripe fruit — and it is nothing very unusual for an English boy to eat half a dozen unripe and very uninviting looking apples : this will very soon produce an effect, the stomach and bowels will be irritated, and a sudden, and, it may be, violent derangement will follow, often accompanied by feverish- 224 CASTOR-OIL IN DIARRIiCF.A. ness, the temperature in such cases not unfrequently rising to 103° or 104'', with perhaps violent abdominal pain; and these symptoms may be sufficiently severe to excite alarm. If vomiting occurs, relief is at once experienced ; but more commonly purgation is excited, and may perhaps have existed for a few days before you are called in to see the patient. You must not expect the diarrhoea to cease until the whole of the irritating matter which excited it has been removed, and the sooner this result can be effected, the sooner will relief be afforded. All the particles of half-masticated apples, containing immature acids and other irritating organic compounds, must be removed from the ali- mentary canal before the diarrhoea will cease. In such cases, therefore, it is bad practice to attempt to check the diarrhoea unless you feel sure that the irritating substances have been entirely got rid of. You will often have to administer a mild purgative to expedite the removal of the matter which excited the purgation. Of all the purgatives that are known to remove irritating matters from the intestinal canal, oily purga- tives are the most suitable. Common olive oil, Okwn OUvcc, the best Lucca oil, will act in this way, and for very young children is quite sufficient, but as a general rule you will find it expedient to give Castor- oil, Oleum Ricini, the purgative action of which is more decided. There is an active principle in the Castor-oil, which affects the action of the stomach as well as the intestinal glands and vessels of the greater part of the alimentary canal. In this way, Castor-oil in its action contrasts with Aloes, Colocynth, and Sulphate of Magnesia, which act mainly upon the lower part of the small intestines and the colon. I suppose Castor-oil excites increased secretion in the stomach, the duodenum, the jejunum, and ileum, causing a quantity of fluid to be quickly poured out from the vessels and glands of the mucous membrane. Thus the alimentary canal is thoroughly flushed in every part ; and the action takes place from above downwards. Any irritating matters that may be present are thus swept away. Particularly in the diarrhoea of infants and young children is Olive-oil or Castor-oil a safe remedy. As a general rule, you will find a much smaller dose of Castor-oil will act than is usually administered. To a child of ten years old you may- give half a teaspoonful or a teaspoonful ; to an adult, two teaspoonfuls but a single teaspoonful of Castor-oil will be sufficient for many people. The objection to Castor-oil is its nauseating disagreeable flavour. I have already referred to the best way of taking it, and have offered some suggestions for disguising the taste. After diarrhoea has continued for some time, there may be a good deal of severe griping pain all over the stomach, or at least in its upper part. At the same time the patient feels chilly or very cold, and may actually shiver ; very generally there is more or less flatulence, with acid eructation, loss of appetite, and occasionally distressing nausea. TREATMENT OF DIARRHd.A. 225 The tongue is usually furred, and there may be a nasty taste in the mouth, or the mouth may feel clammy and disagreeable. In all cases of diarrhoea, particularly in the young, we must bear in mind the possibility of the symptom being due to an attack of Typhoid fever, in which case no purgative must be thought of. If the patient has been ailing for a time and looks weak and ill, and especially if the tem- perature for some days has been above the normal, care must be taken not to mistake the malady for a slight passing ailment. Purgatives may do great harm if given, especially to weak persons suffering from Typhoid. Acid eructations and the rising of acid fluid into the mouth will be relieved by the administration of alkalies and other so-called antacid remedies. You may give alkalies, such as Potash, Liquor Fofassce, twenty drops in a wine-glass full of water once in three or four hours, or the Bicarbonate of Potash or Soda, Ammouia, Carbonate of Ammonia, or Carbonate of Lithia. Preparations of Bismuth are also useful, as the Carbonate of Bismuth {Bismuthi Carbonas), or the Nitrate, the old Trisnitrate of Bismuth {Bismuthi Nitras), from ten to twenty grains to a dose, suspended in water with the help of a little mucilage ; or pre- pared chalk {Creta prcEparata), or precipitated chalk {Calcis Carbojias precipitata). Anything of an irritating character will very soon disorder the delicate mucous membrane of the intestinal canal of an infant, and a very simple remedy administered at the proper time will stop it, but if the purging be severe, and it be allowed to continue for a few hours, extreme exhaustion may ensue, and be soon followed by death. In these cases, mothers often make the unfortunate mistake of feeding the child too much. Fearing lest it should be starved, they keep pouring in milk. The secretions, already out of order, get worse, and the milk in- stead of being properly digested and assimilated, is either rejected in the form of curd, or the curd formed is passed onwards into the small intestine, where it excites irritation without being taken up and absorbed. Thus, the intestinal canal, in every part of its course, may become filled with firm white coagula, which, it will be noticed, constitute the greater part of every evacuation. After death from violent diarrhoea it is not uncommon to find the intestines even distended with coagulated and undigested curd. Cases of diarrhoea in infants may often be relieved at the outset b)- small doses of Lime Water {Liquor Calcis). A little may be mixed with the milk, in the proportion of a tablespoonful or less of lime water to half a pint of milk or sweetened Lime water {Liquor Calcis Sacchara- tus), may be given. Sometimes Potash Water answers better, and I have used Liquor Potassoe, in the proportion of fifteen drops to half a pint of milk. You must not allow the child to take as much milk as it likes. For a day or two, half a pint of milk in the twenty-four hours will be sufficient. It must be obvious that, as long as the disturbed Q 226 CHARACTERS OF THE STOOLS. state of the bowels continues, it will be worse than useless to push food. Time must be allowed for the alimentary canal to become partially emptied of its irritating contents before fresh nourishment is introduced. If the child is at all low, it must be supported with small doses of brandy — from ten to twenty drops in a teaspoonful of water or milk and a little sugar, once in two hours. You cannot be too careful in watching cases of infantile diarrhoea, especially in weak children, for it sometimes happens that serious exhaustion comes on quite unexpectedly, and if you do not visit the patient every few hours, a sudden change may occur and the case be hopeless before you come to its assistance. I have already drawn your attention to the fact that in these cases of diarrhoea, bacteria often grow and multiply to an enormous extent in the casein clots. In many cases every part of the intestinal canal is per- vaded by millions of these organisms, which grow and multiply in the altered secretions and food which are continually being poured into the stomach. The food given to the child merely serves to encourage the growth of bacteria, and it actually undergoes changes which interfere with its digestion and absorption. If just at the right time you with- hold food perhaps for a few hours only, everything may right itself; the irritating matters may themselves act a little on the bowels, and be pushed onwards by the contraction of the muscular coat of the intestine. Diarrhoea may come on and last for a few hours, or even for a day or two, and then the secretions return to their natural state. The child will be out of danger and soon be well again. In treating diarrhoea in children, particularly infants, you must take care that the child is kept warm. One of the principal causes of diarrhoea is cold : bathing in cold water, and exposure to cold and wet, will sometimes bring on diarrhoea even in adults. You should be aware of the different characters of the stools in different forms of diarrhoea. If they are of the natural colour and odour, you may let the diarrhoea go on for a while, for it will probably do no harm, and will most likely stop without medicinal treatment. But if the stools should become much altered — if they should emit a sour smell, and the secretion should have the appearance of rice water, it will probably be necessary to check the discharge. For such evacua- tions, as well as those which are colourless or almost colourless, consist wholly or in great part of secretions poured out from the glands and from the vessels of the mucous membrane of the lower part of the small and of the large intestine. You will find in such evacuations much altered mucus, with numerous small cells (bioplasts) from the follicles as well as from the surface of the mucous membrane, chiefly of the colon. Not unfrequently you will find a little blood, but there may be more albumen than the quantity of blood will account for. If the increased formation of mucus contmue for a considerable period of isiLKH's I)Iarrii(i:a. 227 time, it is often associated with a serious change in the tissues of the mucous membrane itself. After such excessive action has gone on for several days or weeks, there may ensue an excoriated and almost lacerated state of a small portion of the surface of the mucous mem- brane. A sort of superficial ulcer results, from the surface of which perhaps blood will from time to time escape. Not unfrequently, however, in this climate the colon is the seat of great uneasiness, often amounting to actual pain. In many of these cases it is unquestionably the mucous membrane which is affected. The capillaries of a limited area become congested. The congestion not unfrocpicntly passes into ulceration, and we have an approach to that state of things which may under certain circumstances be soon followed by dysenteric symptoms. More commonly, if proper precau- tions be taken, the patient gets better before actual ulceration occurs. If we could see the mucous membrane in some of these cases, I have no doubt we should find it in the immediate situation of the painful spot, swollen, red, and exceedingly sensitive. Every time the muscular coat contracts, the dull pain changes in character and becomes severe. The affection may occur in any part of the colon, but I think the sigmoid flexure, the caecum, and one or other end of the transverse colon are the situations to which the pain is usually referred ; and, as regards frequency, — in the order in which I have named them. If small pieces of hardened faeces or the debris of food happen to be forced into contact with the spot, sudden attacks of exquisite pain, of a cutting or tearing character, may be experienced. The state of mucous mem- brane I have described may last for weeks, or even months, just as a portion of skin may be deranged by congested vessels, and chronic changes induced in the epithelium, and continue for a long period. In the case of the colon, it is of the first importance not to allow any- thing of an irritating nature to pass along it — to restrain its action as far as possible — and to prevent the formation of wind, and the consequent irregular contraction of the muscular coat. In some forms of diarrhoea, which are often spoken of as '• bilious," you will notice a very peculiar alteration in the character of the stools, which are very dark coloured and not unfrequently maybe fairly spoken of as black. Sometimes the colour is such as to suggest the idea that bile has passed down the intestine without undergoing the usual changes, and forms the chief constituent of the fteces. In some of these cases it is probable that bile accumulates for a considerable period in the gall bladder, until at last this viscus, having become considerably distended, suddenly expels its contents, which are discharged in such quantity that much passes almost unchanged. You must be careful not to mistake the colour of the motions which is produced by many preparations of iron for that caused by blood. If Q 2 228 DIET IN DIARRIKEA. a person takes iron, his motions will become almost black, owing to the action of the sulphuretted hydrogen of the alimentary canal producing a dark black compound with iron. Salts of bismuth and lead also impart lo discharges from the bowel a peculiar dark colour. The diet is of the greatest importance in the management of all forms of diarrhoea. Little liquid should be swallowed while the purga- tion continues, and everything taken should for the time be tepid or cold, for hot things, and particularly hot liquids, seem to keep up the diarrhoea. Ordinary diet must be withheld for a time. The patient may live upon milk, thickened or not with flour, Indian corn, or lentil flour, arrowroot, sago, tapioca, or other bland, non-irritating starchy matter. Cream, pudding made with eggs, such as boiled batter, may be allowed, but anything containing hard particles that might get embedded in the mucous membrane or irritate any tender spot that may exist, must be avoided. Treatment of Diarrhoea. — In all forms of diarrhoea, particularly where there is much abdominal pain, it will greatly contribute to the comfort and relief of the patient if you at once apply warmth to the external surface and recommend that he be kept in a warm room. He should lie down and rest, and if the attack be severe he should remain in bed. Cold unquestionably tends to keep up diarrhoea, and may in fact cause it. Cold also increases the sufferings of the patient. Hot fomentations to the stomach have been strongly recommended, and certainly afford relief Various plans may be adopted. One of the simplest is to wring out flannels in very hot water, and have them quickly applied ; or two or three thicknesses of dry flannel, held before a good fire until quite hot, may be preferred. The wet or dry flannels should be covered with a piece of oiled silk or mackintosh, which will prevent rapid cooling ; or a large piece of spongio-piline, made moist with hot water, may be applied. A better plan is to procure at one of the shops where india-rubber things are sold a hot water bottle, made of good strong vulcanised india-rubber. It should be eight or nine inches by fifteen and covered with woollen material. In cases even of very severe griping pains, great relief will be aff'orded if the bottle containing hot water be placed close to the skin of the abdomen while the patient is lying on his side, and kept there for an hour or more. Those who are subject to troublesome attacks of diar- rhoea should wear during winter and summer a good thick flannel belt made for the purpose. There are many potent remedies for checking diarrhoea. We have alkalies, the action of which I have already referred to ; then there are many astringents, certain metallic salts, acids, and sedatives. Astring- ents {asfringo, I bind) are often given in diarrhoea, and unquestionably check it. Amongst these may be mentioned ^'- Krameria" ^^ Kino,^ ASTRINGENTS — OPIUM. 229 ''Catechu" '' Zo^cood ;" and several others are in general use. The value of many astringent remedies used in diarrhcjea is perhaps, in great measure, due to tlie Tannin they contain, and this substance itself may be prescribed. It is a powerful astringent, and lessens transudation of fluid through the walls of the vessels. The precise action of the Tannin is not fully understood. It may act directly upon the tissues them- selves, and perhaps also alter the permeable or diffusible property of the fluids. At the same time no doubt it acts upon the afferent nerves distributed to tlie capillaries, and through the efferent nerves causes contraction of the muscular fibres of the small arteries. Thus their calibre is reduced, and the quantity of blood flowing to the capillaries lessened. Logwood, Hamatoxyloii, is much used in the treatment of ordinary diarrhoea. You may order the Infusion of Logwood, Infusuiu Hicinatoxyli, in doses varying according to the severity of the illness. You may begin with small doses, say from two drachms to half an ounce of the infusion once in three hours, and if the diarrhoea continues the dose should be increased to an ounce, and the remedy given more frequently. Of astringent tinctures like the Tincture of Catechu, Tinc- tura Catechu, the Tincture of Kino, Tinctura Kino, and the Tincture of Rhatany, Tinctura Kramerice, you may prescribe from half a drachm or a drachm to three drachms of either tincture in a mixture, and you may give this once in three hours, or if the diarrhoea is severe, once in two hours. Many practitioners order one of these astringent tinctures with chalk. Chalk mixture, Mistura Cretce, and the Aromatic Powder of Chalk, Pulvis Cretce Aromaticus, are valuable remedies in ordinary cases of slight diarrhoea. If there is anything irritating the bowels, it must be removed, or the diarrhoea will continue. As I have already explained p. 224, a purgative is necessary to expel the irritating matters before the diarrhoea will cease. Next, with regard to the use of Opium. — If the diarrhoea has lasted for a considerable period of time, and the patient is becoming weak and exhausted, and you have reason to believe that instead of the bowels being filled with irritating matter, they are empty or nearly empty, the mucous membrane irritable and sore, with constant and irregular con- tractions of the muscular coat, giving rise to severe griping and excru- ciating pain, you will find Opium a valuable remedy. In such cases small doses frequently repeated answer best. You may give five or ten drops of Laudanum in each dose of a mixture for an adult, half as much in the case of young people, but bear in mind tliat Opium must not be given in any form to young children. I prefer to give Opium in severe cases of diarrhoea in the solid form. A quarter of a grain of solid Opium, or half as much of the extract, Extractum Opii, for a dose. The composition of Dover's powder is known to most of you. Two grains will contain one-fifth of a grain of Opium. This 230 INTESTINAI- WORMS. quantity or more of Dover's powder, the compound Ipecacuanha powder, Piilvis IpccacHa7ih(E. Compositiis, may be given in the form of a pill once in three or four hours if the diarrhoea persists. Or you may give the patent medicine Chlorodyne, which is so well known — perhaps too well known — to non-professional persons. Chlorodyne is a mixture of many things, but it undoubtedly acts beneficially, and agrees with some persons who cannot take ordinary preparations of Opium. Many other remedies are frequently ordered, but I cannot refer to them in this place. Coniinon Intestinal Worms. — I will now offer a few remarks upon the important subject of intestinal worms, for some of these parasites are often the cause of slight ailments, and at many different periods of life. It is, however, during childhood that illnesses depending upon the irritation of certain intestinal worms are most commonly met with. The ailment may vary from a slight but almost constant uneasiness or pain in the stomach, occasioning or accompanied by irritability of temper, to a very serious disturbance of the nervous system characterised by attacks of convulsions and even unconsciousness — in fact, by the epileptic condition, a form of illness which cannot be regarded as slight, though generally followed by recovery. Oxyurls vernilcularis. — The little Thread Worms are sometimes found in immense number in the fseces of children, and occasionally they trouble adults. The worms are male and female, the former being the smaller of the two. The female is seldom more than half-an-inch in length. They inhabit the lower part of the large bowel, and breed in immense numbers in the rectum. The eggs are oval, and are not more than the one five-hundredth of an inch in length in their longest dimen- sions. They are produced in countless multitudes, and can generally be demonstrated easily enough by microscopical examination of the matter passed by the bowel in cases in which thread worms have been observed. Children suffering from thread worms are often fidgety, fractious, and excitable. They generally complain of itching about the anus, and not unfrequently the mucous membrane of the nose and of the lips is in an irritable condition. Sometimes there is diarrhoea and discomfort referred to the lower part of the abdomen. In order to get rid of these minute pests you may begin with pur- gatives. A few doses of Castor-oil will often bring away hundreds of worms. Compound Jalap Powder, Pulvisjalapcs Compost tus, in doses of from five to twenty grains, according to age. Compound Scammony Powder, Pulvis Scammonii Co/iipositus, is still more efficacious, but must be given with caution in the case of weak children in doses of from two to ten grains. But of all the remedies for the destruction of thread worms, bitter infusions are the most potent, and Quassia is, I think, the best. An infusion of Quassia may be made by placing a TREATMENT OE WORMS. 23 1 tablespoonful of Quassia wood chips or shavings in a jug and pourmg upon them about a pint of Cold Water. In an hour it may be strained. A child may take an ounce or more of the clear bitter infusion twice or three times a day. But it is more efficacious to inject the infusion of Quassia into the rectum, and if common salt be added in the propor- tion of about a tablespoonful to a pint of the infusion it will act more efficiently. In bad cases about a (juarter of a pint or more may be injected daily into the bowel with the aid of a little india-rubber ball syringe. If the worms are not very numerous, once or twice will be sufficient. Some cases will resist for a long time all the remedies that you may try, hut if you continue to use the injections steadily the case will at length yield to treatment, though the patient may long have to exercise great care as regards diet if he would continue free from the troublesome parasites. The tendency manifested by the large bowel of some persons to favour the growth and multiplication of these little Ascarids is very remarkable and cannot be easily explained. I feel sure that in some cases which have been completely cured by treatment, a fresh importation of parasites into the intestines has taken place months afterwards. Other persons, and even members of the same family, eating the same food and living under similar conditions, pass througii life without being once troubled by worms. Ascari.s Luinbricoides. — The large round v/orm is occasionally met with. The female is much larger than the male, and sometimes attains the length of twelve inches. It is of a pale brownish colour, round, about a quarter of an inch or more in thickness, and tapering off at each end to a thin rounded extremity. The male is only five inches long. These worms are seldom numerous, and usually not more than from two to four exist in one individual. They live in the small in- testine, but often pass downwards and escape when the bowels act. Occasionally they make their way into the stomach, and are vomited or pass into the mouth or nose to the annoyance and perhaps terror of the patient. Hundreds of thousands of eggs are formed and discharged by a single parasite. The eggs are oval, and about one three hundred and fiftieth of an inch in the longest diameter, and multitudes are sometimes found in the matter passed from the bowel by the patient, when sub- jected to microscopical examination. They may be seen by an inch or a half-inch object-glass. One of the most potent remedies for the round worm (Ascaris Lumbricoides) is Santonin, the active principle of San- tonica, which consists of the unexpanded flowers of some species ot Artemisia or Wormwood. The dose of Santonin is two or three grains for a child, and double the quantity may be taken by an adult. San- tonica is the unexpanded flower heads as imported from Russia, from which the active principle Santonin, Saiitonitium, is obtained. The dose of the flower heads is from ten to fifty grains. 232 VERTIGO, GIDDINESS. Tape worm. — Three kinds of tape worm are met with in England, the commonest of which is the Taenia Solium. Years ago many patients suffering from the presence of this worm used to come to the Hospital, but now we see very few cases. Of all the remedies I used to try, the ethereal Oil of Male Fern was the most efficacious in expelling the whole of the worm, including the head. Out of about thirty cases which I carefully watched in 185 1, when I was house physician to King's College Hospital, the head was expelled in six or seven. Some of the patients had been treated with kousso, and others with the oil of male fern. All the successful cases had been treated with the latter ; indeed, although I have seen many treated with kousso, I never was successful in finding the head ; the greater part of the worm, however, was invariably expelled. The oil of male fern is to be administered as follows : — two drachms to half an ounce, according to the age and strength of the patient, are suspended in eight ounces of water, with the aid of mucilage. After fasting for twenty-four hours (only a little water, or, at most, milk being allowed), the patient is made to take the draught early in the morning, and an hour or an hour and a half afterwards, a dose of castor oil is to be given. The worm is usually expelled in the course of the day. The fasting appears to be a very important part of the treatment, and it seems essential that the oil should be suspended in a large quantity of water. I have obtained many entire worms in this manner. Vertiso, swimming in the head or giddiness, is an indication some- times of disturbed action of the stomach and liver, and sometimes of deranged circulation and disturbed heart's action. But this symptom may also be due to affections of parts of the nerve structure of the brain or the small arteries which supply it. The exact seat of the lesion may vary, but in animals injury to the crus cerebri, as well as certain injuries to the cerebellum, are followed by vertigo, and at least in man the condition may be due to disease of the ear. For one case, however, of vertigo which is due to disease of the brain or its vessels, or of the ear, we shall meet with ten or more which depend upon temporary derangement of the digestive organs. Vertigo often comes from ex- haustion, over-fatigue, going too long without any food ; sitting up too late at night may occasion an attack. The giddy feeling after waltzing for too long a time, or turning round many times on one leg, is within the experience of most of us, and is a form of vertigo. You will find in some works on brain affections that vertigo is said to be one of the indications of serious cerebral disease. If, however, a patient comes to you complaining of vertigo, do not at once shake your head and look grave, even if you have read records of cases in which it undoubtedly preceded some terrible organic disease of the brain or cerebellum, or was discovered to be due to some tumour or other incurable morbid vi:uth;o. 233 growth ; for you may afterwards discover that you have given a wrong opinion. You ought to know that this, Hke many other symptoms, may be due to a mere transient disturbance in connection with the circulation or of the nerves presiding over the cahbre of vessels distributed to a very limited area of brain tissue. Temporary derange- ment of the stomach or liver, and probably very slight changes affecting both, will, as I have said, account for vertigo as it occurs in many cases which will come under your notice. There is a form of vertigo which is due to mere fancy or imagination. Having experienced the feeling of giddiness on one or two occasions, patients often fancy it is continu- ally coming on. Violent attacks of coughing, especially in the case of weak persons, may occasion severe attacks of vertigo. Patients who have been ailing for some time, though not suffering from any definite malady, and those who have long been troubled with loss of appetite or impaired digestion, are frequently subject to vertigo, and may often be cured by judicious management as regards diet and allowing a small quantity of wine or other stimulant, without any medicine. A little good soup at intervals of a few hours, and two or three glasses of Bur- gundy or port wine daily for a short time, may be ordered in such cases, and will often cure the giddiness and restore the general health in a week or two. In not a few instances vertigo is due to excessive nervousness. I have known highly nervous people of both sexes suffer from the most severe vertigo, preventing them from walking for many days, and even for a time liable to come on if the head was only slightly raised from the pillow. Sometimes disturbed co-ordinating power of the muscles of the eyeball is accompanied by giddiness. Vertigo occurs in many cases of blood-poisoning and in some forms of fever. It may be brought on by sudden loss of a considerable quantity of blood, as from haemorrhage, and it often occurs in anaemia. In some forms of epilepsy vertigo is a prominent symptom. The whole subject of vertigo has been discussed by Dr. T. Grainger Stewart in three clinical lectures, which have been published in a separate form (Bell and Bradfute, 21, Bank Street, Edinburgh, 1884). In these lectures (p. 43) giddiness is considered as arising from : — a. External conditions. I). Changes in sensory structures, c. Changes in conducting fibres, d. Changes in central nervous system, e. Dyspepsia. / Toxic causes, g. Causes of uncertain seat. h. Peripheral irritation. /. Menial causes. The word vertigo comes from vertex or vortex, a whirlwind, which is derived from verto, I turn. The sensation is sometimes described as a swimming in the head. Objects seem to be moving in a strange and irregular manner. Many cannot look from a great height down- wards without feeling giddy. Vertigo may be brought on by taking certain substances. Opium will cause it, also Belladonna ; alcohol 2 34 AURAL VERTIGO. causes it commonly. Tobacco will also give rise lo a form of vertigo. A slight temporary failure in the force of the heart's action may cause marked giddiness, and the attacks may recur from time to time, causing much anxiety to the patient and his friends. A few doses of Sal Volatile or brandy will frequently relieve this form of vertigo. Only a teaspoonful or less of the stimulant is required, diluted with not more than double the quantity of water. It must be taken in sips. Peculiar disturbances in vision occur in many cases of vertigo. Things look crooked. Some see only a portion of an object. They can see the upper half without being able to see the lower half of a person, and so on. These disturbances of vision do not necessarily imply anything more severe than temporary functional disturbance. Such symptoms may mean, it is true, something seriouS; but in many cases they certainly depend upon no more grave or important changes than may be determined by taking a little more wine than is good. " Swimming in the head " is by many considered a form of vertigo. Persons who have been for some time over anxious, or who have been overtaxing the mind or body, may suffer in this way. In the last case the unpleasant symptoms will sometimes disappear ten minutes after taking a dose of Sal Volatile or a little alcohol. If, however, they do not do so, they will pro- bably be relieved by a little attention to diet, and by a dose or two of Calomel or Blue Pill. The general health may afterwards be improved by taking a tonic containing acid and bark for a week or two. Aural Vertigo. — Disease and injury to the semicircular canals of the ear may cause a feeling of giddiness and a tendency to fall, as well as vertiginous movements, the direction of which, forwards, backwards, or from side to side, is determined by the particular semicircular canal which is affected. Meniere, as long ago as 1861, directed attention to a class of cases in which noise in one ear — humming, buzzing, whistling, puffing — often associated with pallor, headache, faintness, giddiness, nausea and vomiting, occurred in connection with disease of the semicircular canals, or of other parts of the ear. The attacks at first are slight and occa- sional, but gradually the noises in the head increase in intensity and are almost constant. At last absolute deafness of the affected ear ensues, and in consequence of the nerve-structures being destroyed, the giddiness and other symptoms cease. You will, however, meet with the symptoms above enumerated in cases in which there is no reason to suppose that organic disease of the ear or any other organ exists. The attacks, after recurring several times at intervals during many years, will at last cease, leaving the patient perfectly well. Some of these cases seem to belong to the category of sick headache, and the attacks will be relieved by a small dose of Calomel, Blue Pill, or Grey Powder, Hydrargyrum cum Creta. In such instances it is very probable that there is temporary disturbance AURAL VERTUiO. 235 of the circulation in the internal ear, as well as in other parts. Moreover, very nervous fanciful j^eople will sometimes complain of the symptoms of Meniere's disease, but as they quite recover under the influence of tonics, good living, and change of air, it is more likely that the symp- toms were due to slight and temporary nerve disturbance, rather than to definite morbid change affecting nerve or other tissue. BILIOUSNESS— TREATMENT OF BILIOUSNESS— JAUNDICE- TREATMENT OF TEMPORARY JAUNDICE— SICK HEAD- ACHE— HEMICRANIA— NAUSEA, VOMITING AND OTHER DISTURBANCE — SICK-HEADACHE AND EPILEPSY — TREATMENT OF SICK-HEADACHE — i. TREATMENT DURING AN ATTACK— 2. TREATMENT IN THE INTER- VALS BETWEEN THE ATTACKS— 3. OF THE MANAGE- MENT OF SICK-HEADACHE WHEN THE PATIENT CONTINUES AT WORK — DROWSINESS— WAKEFULNESS AND RESTLESSNESS— NERVOUSNESS. Biliousness. — It is difficult to adequately explain the various phe- nomena which constitute what is known as biliousness, although very many persons are well acquainted with the symptoms of the bilious condition, and have frequently experienced them. Whether there is congestion of the liver in all cases, I cannot tell, for I am glad to say that I never saw di post-mortem of anyone who had died during an attack of biliousness. Whatever may be the essential nature of the malady, it is not fatal. Nay, bilious people are for the most part long-lived. Some physicians who have experiences in connection with life insurance business, so far from objecting to take bilious people, are desirous of insuring them. In this opinion I fully concur. There is no doubt that a tendency to biliousness compels people to be careful as to their mode of living. They know that if they exceed they will suffer. Bilious persons are often very fidgety about their diet, for if they eat too much a bilious attack usually comes on, and for a time they are completely unfit for ordinary work. Although biliousness is anything but an agree- able malady, nevertheless you may generally recommend bilious patients with confidence for various occupations in which endurance is required. The capacity for steadily going on for a long period of time is in truth often associated with a bilious habit of body. I fancy a very large share of the best work of the world has been performed by the bilious. Such a tendency is frequently characterised by much energy and determination to work in spite of the derangement, and although there may be also some irritability of temper or despondency, there is PATHOLOGICAL CHANGES. 237 frequently a very remarkable degree of patience, persistence, and resisting power. Although I cannot give an accurate description of the pathological phenomena of biliousness, I may hel{) you to form an idea of the sort of unpleasant sensations experienced by bilious people, if I describe in his own words the sufferings of a gentleman who had been bilious all his life, but who nevertheless managed to live to a very advanced age. My friend was a man who might have done great things and left his mark ; but I fear he lost much, and perhaps the world more, in consequence of his not being obliged to work. As in some other cases a fortune is after all a misfortune. He was, moreover, unwise enough to allow him- self to get into that habit of thinking too much about slight physiological derangements which occurred in his own organism, and he gradually got into the bad habit of frequently talking to his friends about his aches and pains. Being rich, he was listened to, and further was spoilt by the sympathy and pity foolishly lavished upon him. As age ad- vanced, the interest of his environment seemed to him to diminish, while the growls and grumblings, excited by sensations within himself, became so loud that at length he determined to seek professional con- solation. He consulted the most celebrated physicians, but no one succeeded in curing his biliousness, or in teaching him to bear it patiently. He grievously troubled his fomily by his reiterated com- plaints, and by his persistent anxiety about himself. Though on occa- sions he felt pretty well for a day or two, during many years he failed to make himself contented or happy. Every kind of treatment was tried, but nothing cured the derangement, or averted the attacks. Blue Pill afforded some relief, and was the only remedy persisted in from first to last. All his tissues were probably sound, and I doubt whether there was any serious morbid change in any organs after more than ninety years of work. This gentleman was seen by me many times, and wrote down for me a description of his sufferings. Here it is : — " Flatulence, distension of the bowels, and painful sensations between the shoulders, coldness of the feet, twinging pains occasionally under the right shoulder blade, nausea after eating. Muscular pain about the head and neck, — particularly the muscles at the back of the neck." The last is a very common symptom, and a very painful one in many cases of bilious- ness, and recurs in almost every attack. This old gentleman ate too much, and no wonder he was disturbed at night and had to complain of " harassing and long distressing dreams." He also suffered, as very many old people do, from " irritation of the skin of the body generally, but of his legs principally, and from soreness and eruptions about the mouth, affecting chiefly the upper lip." Such was the long catalogue of recorded symptoms, —and the list by no means exhausts all this old gentleman's complaints. In nine cases out of ten many of the discom- 238 PATHOLOGICAL CHANGES. forts comprised in the phrase " biUous " are due to more food being taken than the organism requires in the time. One is often astonished at the very small quantity of food necessary to keep many persons of middle age and older in good health, and this small quantity of food is not incompatible with the discharge of a considerable amount of mus- cular work. Many such economical organisms, though they eat little, require an exceptional amount of sleep. Indeed there seems to be some connection between the proportion of food taken and the sleep required. And certainly many who have been noted for requiring little sleep have strong stomachs, and amongst such there have been some enormous eaters. In many " bilious " people the liver acts sluggishly, and more time is required for the blood to traverse the hepatic capillaries and to become properly depurated than they are inclined to allow. The consequence is slight derangement of hepatic action with the develop- ment of those disagreeable sensations they call " bilious." If too free living is persisted in, the condition gets worse and the chronic func- tional disturbance may gradually lead to the development of organic disease, which may, however, not become manifest in the shape of well- marked tissue degeneration for many years. Some who suffer from biliousness differ from my old friend to whose case I have just adverted, and seem to alternate between a state of misery and despair and a state of comparative ease and comfort and even sanguine hopefulness. You will sometimes find a patient bilious and irritable and out of temper, and very indisposed to do what you may wish, unless indeed he may have sufficient self-command to overcome his natural bent. Another time you will find the same person in excellent spirits, ready to do anything for you, and as agreeable as possible. We often have very contradictory accounts of the same individual ; one person tells us that he is a most disagreeable, cantankerous person, while another affirms him to be a most pleasant and excellent man. The conflict of testimony is explained by the circumstance that one informant happened to see him when he was bilious, while the other came in contact with him just after he had recovered from an attack. It seems curious that we should not be able to adequately explain such very prominent and persistent functional derangements as affect important organs in cases of biliousness, more especially as the con- dition is a common one, and has been often experienced by well-trained scientific and thoughtful members of our profession. But I have never been able to get, from any physicians with whom I have conversed or from any books I have read, what seems to me to be a clear and satis- factory account of the disturbance which occurs in an attack of bilious- ness, or of the actual changes which affect the action of the peccant organs during the prevalence of tlie attack. There is, however, no doubt that before and during the attack there is actual disturbance in DERAXCKMKNT OF THE LIVER. 239 the liver, and that wlienevcr biHousness is experienced, the changes taking place in this organ, as well as in the stomach, differ in important particulars from those which occur under ordinary circumstances. The liver is not concerned merely in the secretion of that fluid which we know as the bile, but it has to do with many other changes in the sys- tem. Among the most remarkable phenomena are its sugar and fat- producing powers. It also effects great changes in albuminous matters and peptones, which have just been taken up by the vessels of the intes- tines and carried to it dissolved in the portal blood. Concerning any slight derangements which the sugar-forming func- tions of the liver undergo from time to time we know comparatively little, but we do know that these functions may be so disturbed as to result in the establishment of a most serious change in the action of the organ, which, when once started, usually but not invariably persists. In Diabetes, particularly as it occurs in the young, many ounces of sugar, or perhaps, more accurately speaking, of a substance easily convertible into sugar, are formed during each period of twenty-four hours. The kidneys are chiefly concerned in the removal of this sugar from the blood, although the tears and other secretions contain sugar when the diabetic state has been established. This formation of sugar, although varying in activity from time to time, and under the influence of remedies, cannot certainly be stopped. It continues in the great majority of well-marked cases and gradually exhausts the patient, until, at least in the case of the young, after a period varying from a few months to two or three years, death results. On the other hand, it may be confidently stated that, under certain conditions the liver may be seriously deranged as regards its sugar-forming functions, not only with- out causing death, but even without apparently deranging the general health or nutrition of the patient. In old age it is not an uncommon thing to find a certain amount, and, occasionally, a considerable quantity, of sugar in the urine. It would seem that the sugar-forming action of the liver may be greatly in excess of what it is in the normal state, and although the sugar pervades the blood and is carried by it to the various tissues and organs of the body, it scarcely seems to disturb their action. At any rate it may con- tinue uninterruptedly for more than twenty years, and the patient may die at an advanced age of some other malady. Not only so, but any healthy person may for a time form considerable quantities of diabetic sugar, if he takes more than a moderate quantity of cane-sugar. A man who took a dose of a quarter of a pound of ordinary sugar passed dia- betic sugar in his water for two or three days afterwards, but this temporary diabetic state is not to be induced so easily in every person. The liver is the organ by which the change is effected, and if you think over these facts you will, I think, agree with me in the conclusion that 240 ON THE TREATMENT OF BILIOUSNESS. in many slight derangements of the health, some other functions of the Hver, instead of or as well as its bile-forming office, are at fault. The action of the liver-cells, in connection with their influence on the forma- tion and transformation of fatty, albuminous, and amyloid matters must, therefore, not be lost sight of in our efforts to determine the causation of many slight derangements of the health which seem referable to the liver. But as regards " biliousness," it seems to me that the yellow tinge of the conjunctiva so commonly observed, the alteration in the colour of the skin and its dryness, the disturbed action of the sebaceous glands, the sense of weight in the right side, the derangement of digestion — all point to the fat- and bile-forming operations of the liver-cells as being mainly at fault. This view is confirmed by the fact that medicines which correct the changes just referred to are those which unquestionably act upon the bile-forming process, and as soon as the action begins the patient who suffers from what is known as a bilious attack experiences relief. Some cases of severe biliousness approach so nearly to those cases of temporary jaundice which I shall presently speak of, that I am almost inclined to regard them as related to that condition. Possibly, it mav be correct to consider biliousness a condition which initiates certain forms of jaundice. BiUousness may possibly depend upon an inactive state of the liver-cells, in consequence of which substances remain in the blood which ought to be separated from that fluid and converted into bile. The sluggish state of the circulation, the tendency to the accumulation of the blood in the capillaries and veins, as shown by the distension of the capillaries of the papilla of the skin and the bleeding which takes place if they are divided, the formation or increase of haemorrhoids, the turgid state of capillaries near slight scratches or wounds, and the indisposition of the latter to heal, indicate such dis- turbance of the capillary circulation generally, as would result from the accumulation in the blood of substances which ought to be thoroughly eliminated from the circulating fluid. The Treatment of Biliousness. — The only medicine that relieves many bilious people is a small dose of some mercurial preparation. The old gentleman to whose case I have already referred, discovered that blue pill alone gave him ease, and dissipated for a tune the unpleasant sensations from which he suffered, and which made him at times perfectly wretched. He took blue pill of his own accord, whether the doctors allowed it or not. For forty years he seldom went four days without the remedy. He tried over and over again to get out of the habit, and many advisers strongly recommended him to give up taking mercurials. He made many attempts, but in a short time his sufferings became so great, that at last he was obliged to return to his favourite remedy. He seldom, however, took more than a grain once in four or ON THE TREATMENT OF BILIOUSNESS. 24I five days, but when he was very bad would take the same dose regularly tor three or four consecutive days. I do not mean to imply that you will cure every case of biliousnes-; if you give mercurials, but certainly the great majority that come undt r your notice will be benefited. Many cases resist every effort to cure them, but it is the exception to meet with a sufferer who cannot be in some degree relieved by treatment. The bilious habit seems to be due to an unusually sensitive, irritable stomach and liver, which fairly dis- charge their functions in a moderate degree, but which cannot be made to perform more than this moderate amount of work, without getting much out of order ; so that where you have to treat patients suffering from biliousness, you must be careful to give directions concerning diet, which should be very moderate. Most of the organs taking part in the digestion and assimilation of the food seem to strike work when a decided bilious attack comes on. If food be taken, the suffering becomes greater. Moderate starvation is what is required in many cases. Bilious people often find advantage from giving their digestive organs partial rest for several days. In this way, time is allowed for the return of the organs deranged to their normal state. The fact seems to be that the digestive organs require rest for a time, and if when an attack comes on this rest is given, the bilious state passes off, and then the patient not only feels extremely well, but the change perhaps lasts for a considerable time. In general, you will find that those who are liable to bilious attacks require very little meat. Free meat eating will often bring on an attack. Generally, rich foods do not agree. Fatty matters in certain forms and in moderate proportion must be taken, but cooked and half-cooked fatty materials, as in many sauces, soups, fried fish and meats, are not suitable. Cream or much milk sometimes precipitates an attack. Most forms of alcohol, and any form in quantity, will generally disagree with the patient. Vegetables and many fruits, particulady bananas, on the other hand, agree well. Vegetable acids seem to help the action of the liver and stomach. From half an ounce to an ounce of lemon juice with water or in linseed tea daily for a time is undoubtedly useful in many instances. Cider and perry in moderation, that is, one or at most two tumblers daily, can be taken by some bilious persons. Citrates, Tartrates, Acetates may also be given. Light puddings composed of starchy matters of various kinds, such as rice, Indian corn, Sago, or Tapioca, made with milk and eggs in small quantity, and plenty of bread, may be enumerated among the articles of diet for the bilious. Generally, such persons are of necessity small eaters. Their organs rebel before it is possible to damage them by overwork, and so they seldom die of those diseases which cut short the life of so many who enjoy good living, and who possess strong digestive organs. Hence, as I have already remarked, the bilious often 242 ON THE TREATMENT OF BILIOUSNESS. live to be old. When an attack comes on, benefit often results from the use of mild purgatives. Effervescing Citrates of Potash, Lithia, Ammonio-citrate of Bismuth (Bishop's), and Tartrates also do good. Liquor Ammonite Acetatis and Muriate of Ammonia have been also prescribed with advantage in many cases. I have often recommended grapes, in quantities of half a pound a day, when they can be obtained. Many persons have been relieved by taking from six to ten tumblers of fiuid in the course of twenty-four hours, for two or three days at a time. Ordinary soda water, or Brighton seltzer, or Apollinaris water, or dis- tilled water with free carbonic acid in it, Salutaris water, may be ordered. The kidneys are in this way made to act very freely, and relief soon follows. Of the deleterious action of the east wind upon the functional action of the liver there can be no doubt, but it is not easy to explain precisely how this results. That the dryness of the air and the constant wind are potent in interfering with the due action of the skin there can be no question, but these effects do not afford an adequate explanation of the facts, since persons shut up in rooms artificially heated and with the air suppHed with watery vapour, nay people who have kept their beds, are often aware when the wind blows from the east. Northerly and westerly winds may be as cold and I think as dry as the east winds, without giving rise to those very unpleasant sensations experienced by the majority of the population who have passed their fourth decade, whenever the wind is in the east. As long as the wind blows from this quarter people suffer, but a few hours after a change has taken place they feel perfectly well both in body and mind, for, as is well known, the temper is often terribly ruffled by a dry east wind. The seaside has the reputation of seriously impeding the action of the liver, and de- servedly so, for we are assured by many persons that whenever they go to the sea for a week or more, and especially if the wind at the time is east, the motions are invariably scanty and of a very pale yellow or of a gray colour. But what is very remarkable is this : — that for some time after their return from the sea the hepatic action of the same persons is unusually free. Although they may consume much less food than when they were away, the motions are more abundant and the fascal matter properly formed. In these cases there is no doubt that there is in- creased formation of faecal matter — that materials which had been accumulating for perhaps a fortnight previously are at length separated from the blood, and eliminated, and the patient in consequence feels greatly relieved and appears to be much improved in health. Where the bilious state is very severe, — and in some cases it is so severe as to incapacitate people from performing any kind of work for the time, — you will often afford relief, and in a very short time, if you give a grain or two of blue pill or Calomel. Some who suffer from JAUNDICE. 243 biliousness also experience violent headache at the time, and this symptom is also relieved by the blue pill or Calomel, and frequently in the course of a very few hours after the medicine has been taken. Indeed, some who suffer much, and who are, generally speaking, in any- thing but a good state of health, may yet be able to get through their work with the help of an occasional dose of a mercurial — from one to three grains of gray powder once in five or six days. I am not aware that any deleterious effects are produced by this practice in persons who suffer much from biliousness. Of course, it is not desirable for anyone to be continually taking mercurials, or any other drugs for that matter, but it is better to take mercurials now and then, than to be utterly incapacitated for one or two days out of every ten or twelve, as is the case with many who suffer from this most unpleasant ailment. From some experiments performed by Prof. William Rutherford on the dog, it appears that several vegetable substances act as stimulants to the secretion of bile, and it has been inferred that they act upon man as well as upon the dog. Among the most important of these cholagogues, are Iridin, Baptistin, Juglandin, of each of which from two to four grains may be prescribed for a dose, Euonymin in doses of from one grain to two grains, and Phytolaccin, of which the dose is from one- eighth of a grain to a grain. These remedies are made by John Richardson and Co., of Leicester, who prepare them in the form of pills, " pearl-coated," and of several different strengths. Prof. Rutherford's observations will be found in the " British Medical Journal," Feb. 8th, 1879. Jaundice is rather a common affection, particularly in sunu-ner. It may be due to many different causes, some of which are unimportant and transient, while others are serious and irremediable. The par- ticular form of jaundice to which 1 am about to refer may with pro- priety be included under the head of " slight ailments." It is known as ordinary jaundice, and I dare say that perhaps twenty per cent, of you have suffered from an attack of jaundice, or will do so before the age of twenty-five is passed. The physiological changes in the system must needs be very much modified if for a time the bile which is formed in such considerable quan- tity, instead of being poured into the intestines, is retained in the gall- bladder. It is probable that in every form of Jaundice the bile is formed by the liver but does not escape by its usual channel. Most commonly the Common Gall-Duct, Ductus Communis Choledochus, is plugged up ; and the bile, which has been formed by the cells of the liver, and has passed into the gall-ducts, is obstructed in its further course towards the intestine. After accumulating to some extent in the ducts and in the gall-bladder, it would appear that it gradually makes its way through their coats and gains entrance to the lymphatics and veins which lie outside them, passing into and circulating with the R 2 244 EXCRETION OF BILIARY COLOURING MATTER. blood. Tissues in all parts of the body become stained, and in some cases take a deep yellow colour. Textures both at the surface and in the interior of the body are thus tinted more or less intensely in cases of jaundice. Not only so, but the excretion of the yellow colouring matter origin- ally formed in the liver, and absorbed into the blood, is effected to some extent by the kidneys. Mucus, epithelial cells, casts, and even some crystals passed in the urine are tinged of a bright yellow colour, while the urine itself contains a good deal of yellow matter. Sometimes it appears of a dark green colour, owing to the quantity of bile it con- tains. So quickly in many instances is the bile removed from the blood by the kidneys that the urine is often stained with the characteristic yellow colour for some days before the skin acquires the slightest yellow tint. On the other hand, the secretions from the bowels will be found to lose the ordinary colour, and after the jaundice has lasted a short time they will be clay-coloured or colourless, Whether the impediment which interferes with the passage of the bile into the intestine in these cases of temporary jaundice is due to firm spasmodic contraction of the muscular fibres which surround the lower part of the common gall-duct near its opening in the duodenum, or to the accumulation of mucus and epithelium in the same situation, thus plugging the duct, is not quite certain ; but there can be no doubt that there is in all these cases an impediment to the onward flow of the bile consequent upon some temporary obstruction, which after a period varying from a week to three months or even longer, gives way without any permanent change of derangement being induced. Patients suffer- ing from temporary jaundice completely recover. Now I desire to ask your careful attention to the fact that in these cases the jaundice is due not to the accumulation in the blood of sub- stances out of which bile might be formed by the action of the liver- cells, but to the passage into the blood of bile which has been already formed by the action of these hepatic elements, and has passed into the ducts. As I have already said, the stools appear more or less like clay, or of very light brown colour, in consequence of the biliary matter not having passed into the intestines, where ordinarily it undergoes those complicated changes which take place in its resinous acids and colour- ing matter, and which end at last in the development of the peculiar chemical compounds which are constantly found in normal feecal matter. Even in slight cases of jaundice the bowels are usually some- what confined. The patient perhaps experiences slight nausea, with indisposition to take food. He gets thin. The nutrient matters he does take do not nourish him properly, and he feels weak and out of health. Some people suffering from jaundice are, however, able to do their work ; and students have passed through a difficult examination SKVIlkl'. J ATX DICK. 245 although they were deeply jauiidiced, but the proceeding was not a wise one. You see, therefore, th.it a very large and important organ like the liver may be seriously deranged without the ordinary functions of the other organs of the body being very seriously disturbed. For a time at least we can get on not only without bile flowing into the intestine, but in spite of its distribution to all parts of the body. 'I'he patient may, notwithstanding this great change, be able to i)erform a certain consider- able amount of work, and may be able to use his mind efificiently, although the whole of the blood distributed to his brain is contaminated with a certain amount of biliary matter. But, as I have remarked, you must bear in mind that from time to time cases of jaundice are met with which end, and very quickly too, most disastrously. It is a fact w-hich must not be forgotten that some cases which may run on to a fatal termination in the course of two or three weeks, and cases occurring in the young cannot at their com- mencement be distinguished from that almost trivial form of jaundice of which I have spoken. Ordinary jaundice may last for a period varying from one week to three months. Probably the average time will be from two to three weeks. When it persists for more than a month, even though there be no grave symptoms, we feel some degree of anxiety lest the case should be due to more than a temporary obstruction of the duct. The longest case of ordinary temporary jaundice which has come under my own notice lasted for upwards of twelve weeks. For the whole of this time the patient, a young man of eighteen, was deeply jaundiced, and no decided improvement began to take place until three months had passed. In cases where the malady is so considerably prolonged beyond the average time, we may suppose that the plug of mucus or modified epithelium in the common duct is firmer than usual. At last, however, the mass, having become softened, slowly escapes bit by bit from the orifice of the duct, and the organ gradually returns to its normal state. That form of jaundice which is very fatal, and which may end quickly in death, is dependent upon serious damage to the secreting and other structures of the liver ; indeed the liver-cells are often completely disin tegrated and destroyed. As I said before, I do not know how we can distinguish the terribly serious, from the slight ailment when the patient first becomes jaundiced. In the fatal form of jaundice, however, very grave symptoms are usually developed after a few days, and we then become aware of the terrible disease with which we have to deal. But during the first few days of the attack it is, I believe, not possible in many instances to distinguish a case which will end fatally from a case which will terminate in recovery. I allude to this matter because it is really most important not to be over confident and off hand in forminga prognosis in this, and indeed in many other forms of disease. You may 246 YELLOW ATROPHY OF THE LIVER. perhaps be called to see one of these fatal forms of jaundice, at its commencement, due to what has been called acute yellow atrophy of the liver, and if not aware of the existence of such cases, you might make a very sad mistake in informing the friends confidently that a necessarily fatal disease was only a slight ailment. We ought never to allow our- selves to make too light of a malady which may turn out to be very serious indeed. Under such circumstances w^e might be deservedly accused of want of care, experience, and knowledge, and regarded as advisers lacking discretion and wisdom, and wanting in power of dis- cerning a most serious disorder, which may destroy life in a short time. On the other hand, you must be careful not to needlessly frighten people by detailing all the possibilities of disaster in any given case. Happily these serious forms of jaundice are not common. In the course of a year we seldom see in the hospital more than one or two of them, and several years may pass without a single case being admitted. Ordinary temporary jaundice may occur at any period of life, but it is most common between the ages of fifteen and twenty-four ; and it is more frequently met with in males than in females. Whether it is that we are apt to exceed in diet more than the other sex at this period of life, or whether the way we live has anything to do with it, I cannot tell ; possibly we may be more anxious and nervous about our work and examinations than female students ; but it is certain that about adolescence, jaundice in men is not at all uncommon. Jaundice occurring in middle life and old age is not very likely to be of the kind referred to. More probably it will depend upon some more serious change than catarrh of the gall-ducts and the obstruction of the common duct by a plug of mucus. A very common cause of jaundice in middle life is a gallstone impacted in the duct. Jaundice of this kind is usually associated with great, and not uncommonly sudden excruciating pain, and its nature can often be at once detected. This form of disease can, however, hardly be included under the head of " slight ailments" ; neither can the jaundice which depends upon hydatids, or that due to cancerous or other tumours pressing on the duct. You should be aware that jaundice may occur in very young children, and I have known cases in which it existed in intra-uterine life. It is not an uncommon thing for the child at birth to be com- pletely jaundiced, but this usually is due to temporary change and soon passes off. I have seen one case in which life was destroyed at or about the eighth month of intra-uterine life by jaundice, caused by the impaction of a gall-stone in the common gall-duct. What is the earliest period of development at which the embryo may become affected I cannot say, but it is certain that a few months before birth biliary calculi may be formed. Urinary calculi also may be produced even before the development of the kidney, in which they are formed, is perfected. TREATMENT OF JAUNDICE. 247 Treatment of temporary Jaundice. — With regard to the treatment of ordinary jaundice, there is Uttle to be said. The main point to be borne in mind is that the patient should Hve on a h'ght diet. Do not let him feed heavily, or he will get worse, and may suffer much. Keep the bowels gently acting by giving small doses of blue pill or gray powder at intervals of a few days. You may also, or instead, occasion- ally give a dose of some saline purgative. A drachm or two of Sulphate of Magnesia, Magnesice Sulphas, with a little Hydrochloric or Sulphuric Acid (p. 216), before breakfast, is of service in this condition, just to promote the action of the bowels. Do not, however, give violent purgatives or attempt to cure the disease oft'hand by any course of special treatment. A mustard poultice may be placed over the region of the liver every day, or every other day, for twenty minutes. Another local application which seems to be of use, and which I learnt from Dr. Blakiston, is Hydrochloric Acid applied on rags. A little of the strong acid is diluted with twice or three times its bulk of water. A rag is carefully wetted with the lotion, placed over the liver, and then covered with some useless rags, pieces of flannel, or an old towel. This application may be used each alternate day, care being taken that the acid is not allowed to spoil any linen or the clothes of the patient. It produces only a little tingling. The skin should be wiped with a soft wet sponge when the rag is removed. I come now to another malady, reference to which may perhaps raise a smile. It is, however, an extremely disagreeable ailment to endure and it may entirely prevent, or seriously mar, the execution of mental and bodily work. SICK HEADACHE. MIGRAINE. This is, perhaps, one of the most severe of the maladies I have included under the head of slight ailments. The affection is common, and used to be known as Migraine. Some, who in other respects are perfectly healthy persons, with apparently sound constitutions, and whose tissues generally would seem to be not only healthy but of an enduring character, suffer from very frequent attacks, and may be for many years hardly ever free from the malady. Nevertheless, sick head- ache is to be regarded as a very troublesome and inconvenient rather than as a dangerous derangement. This curious disorder may affect people at every period of life. Some authorities assert with confidence that, as we grow older, we overcome the tendency to sick headache, but I am sorry to say I know some who have grown old, and many who are growing old, who still suffer. One sees cases of sick headache occasionally in very young children, fre- quently in young people and adults, and not uncommonly in old age. I know persons of seventy-five and upwards who continue to suffer 248 HEMICRANIA. from well-marked forms of this intractable malady. However, there is no doubt that the tendency of sick headache is to diminish in severity as age advances, so that many who are martyrs to frequent and severe attacks up to the age of twenty-five or thirty begin to improve after that period, and towards forty become troubled less frequently, or recover altogether. Sick headache is a disease not dependent upon any actual patho- logical change, as far as can be at present ascertained. It seems to be due to some temporary but widely extended derangement, influencing a number of different tissues and organs situated at a distance from one another, through the influence of nerve-distribution and connections. Hemicraiiia. — I shall endeavour to lay before you the several phenomena of which this malady is composed, and shall try to point out in what respects there is a departure from the normal and health)' action of the several organs and tissues involved. In the first place, as to the headache. This is peculiar, for it is sometimes confined to one- half or less of the head, Hemicra?iia (ijuiat'^; half, kpai>i'ou, the head). A part of one lateral half of the upper part of the head is the seat of very severe pain, which is occasionally described as of a boring or penetrating character, and may be so circumscribed that the painful spot could be covered by the top of the thumb. Sometimes the pain is situated immediately over one brow, the sensation experienced being like that which would be produced if a sharp and strong instrument was being forced into the head at that particular spot. The pain, varying much in intensity and somewhat in character from time to time, may last for a period of from twelve to twenty-four hours, or even longer. It may then shift to the opposite side, and after lasting there for about twelve hours more, may gradually subside, until the patient becomes perfectly free from pain. In a short time he feels well and in good spirits, and perhaps, for some days after the attack has subsided, is exceptionally vigorous. From the frequency of the occurrence of cases in which the pain is confined to the region above one or other brow, the condition has been called Bro7v Ague. The term ague is, however, unfortunate, for some of the cases are far removed from maladies belonging to that class. IWausea, vomiting and otlier disturbance. — Next, as regards nausea and vomiting, which frequently accompany this headache. The stomach derangement in sick headache is often very marked and very distressing ; but these symptoms are often preceded by an almost irrepressible tendency to yawn at frequent intervals. There is 3 sensation apparently situated in the soft palate which almost makes the person yield, but as soon as he has yawned once, the desire returns, and this often lasts for some hours, or until voniiting occurs or sleep is induced. There is, as I have said, almost always more or less nausea. NAUSEA AND VOMITING. 249 and not unfrequently absolute vomiting, the depression accompanying the sickness being sometimes of the most distressing character. It is often as bad as severe sea-sickness. I have known people to vomit fifteen or twenty times in the course of tlie day, although they were merely suffering from what is called sick headache. In this condition, then, we have temporary, but very decided and sometimes violent, dis- turbance of the digestive organs, inability to take food, nausea, and severe vomiting, associated with pain, more or less acute, on one side of, or it may be all over, the head. The vomiting is remarkable, for there is not merely straining and contraction of the stomach, followed by the rejection of its contents, but a great deal of secretion is poured into the stomach from the blood or from the glands, and after this has accumu- lated so as to distend the organ, it is suddenly expelled. It is in this way that many of those who suffer from sick headache get relief. After the removal of the contents of the stomach, which are often of an intensely acid reaction, the distressing nausea and sense of oppression and exhaustion becom.e relieved for a time, but recur if more acid fluid is poured out. What is very remarkable in many of these cases is this : that food may be digested shortly before the vomiting is excited, when an enormous quantity of acid fluid from the stomach is brought up. There can be no doubt that in these cases much acid is formed in the stomach, or secreted by the glands. Indeed, at the very time food is being digested and passed onwards to the duodenum, there is evidence of the formation and accumulation in the stomach of other acids besides the ordinary acid of the gastric juice. Oxalic, butyric, acetic, valerianic, are among the organic acids which are developed, owing to some unusual chemical changes taking place in the contents of the stomach. It is the accumulation of this acid mixture which causes the nausea and painful sinking experienced at the pit of the stomach. The nausea remains until the contents of the stomach have been expelled. Vomiting may, of course, be encouraged by the administration of a medicinal emetic, by drinking several tumblers of warm water, or by tickling the back of the fauces. The act of vomiting may be attended with instant relief. I have known cases in which the moment after the stomach had rejected its contents the pains ceased, and for a time at least the patient will be in comparative ease, or may feel perfectly well. In slight sick headache, as well as in more serious head affections, there is evidence of remarkable sympathy and association between the action of the brain and the stomach. The pain that we suffer in sick headache is not due merely to some affection of the cutaneous nerves of the skin of the head and face, as has been held by some, but there is clearly a temporary disturbance in the brain itself, probably in connec- tion with the vessels at least of the surface of the gray matter of the 250 DERANGEMENT OF THE STOMACH. convolutions, for not only does the pain seem to be situated in the brain, but the action of the cerebral elements is unmistakably disturbed. The memory is for the time impaired. Attention cannot be given without conscious and even painful effort. Sustained thought is impossible for the time, and there is a decided longing for mental rest, which, being yielded to. soon results in dozing, or in actual sleep. It might be thought that cerebral disturbance generally, at least when ushered in by functional or organic disease of the digestive organs, would be due to deranged action of the upper part of the alimentary canal only. The most remarkable phenomena undoubtedly point to stomach and duo- denal disturbance, and we know that in many diseases of the brain the action of the stomach especially is disturbed — frequent and sudden vomiting being often present. The action of the stomach as every one has experienced is much influenced by the brain, and the latter by the stomach. Digestion may seriously derange cerebral action, and may in its turn be modified or completely interfered with by mental or emotional disturbance. This indeed is admitted, but in many forms of sick head- ache, the derangement is certainly more general than the consideration of the subject thus far would have perhaps led you to suppose, and it is doubtful whether the lower as well as the upper part, and in some cases exclusively the lower part, of the alimentary canal is not implicated in the attack. I shall presently refer to this point more particularly. The disturbance of the nervous system in sick headache is so striking and widespread that some pathologists have been induced to place sick headache among nervous diseases, and to support the con- clusion that the derangement not only begins in the nervous system, but that the affection is exclusively nervous. To me, however, it seems more probable, and the conclusion is partly grounded upon personal experience, that the nerve phenomena are second in the order of their occurrence, and that the starting point of the malady is abnormal functional disturbance of the liver, stomach, and large bowel, or of one of them, and next to them, of the blood itself. That the blood is deranged in cases of sick headache is shown by several circumstances. It has been noticed that any slight wound or scratch on the surface of the skin looks angry, in consequence of the adjacent capillaries being distended with blood. The processes of healing and repair and the nourishment of tissues do not proceed as in perfect health. Another reason for concluding that the blood is more or less out of order, is that when the sick headache disappears very free action of excretory glands sets in. A considerable quantity of urine, often rich in urea and urates, and of high specific gravity, is voided, and this is succeeded by the free secretion of large quantities of pale urine containing a small proportion of solid matter. Gradually the ordinary NATURE OF THE DISEASE. 25 1 actions in the several tissues and organs are resumed. Any patclies of congestion on the surface disappear, and the capillary vessels are no longer distended. Could we see the viscera we should find tliat the veins which had been highly congested were no longer distended with blood, 'rhe composition of the blood is also much altered during the attack by the free discharge of certain substances from it into the stomach. The gastric glands, instead of pouring out ordinary gastric juice to digest the food, secrete, and in considerable quantity, a fluid which instead ot quietly acting upon the food, irritates the nerves distributed to the mucous membrane, and this results in vomiting. The fluid in the stomach is freciuently highly acid, but as I have remarked, the acidity is due not to the normal acid but to a number of organic acids which are not to be found in health. Under these circumstances it is of course quite useless to introduce food into the stomach, for little or no diges- tion will take place. The stomach must be allowed to rest for a while until its contents are rejected, or have been by degrees driven down- wards into the small intestine. It seems, then, probable that certain substances which yield these unusual chemical compounds discharged into the stomach have been accumulating in the blood for some time before the attack of sick headache commenced. Possibly the malady may be due to this accumulation of various matters in the blood, the " attack " being occasioned by their discharge into the stomach. The salivary glands, the little labial and buccal glands, are also affected at the time of sick headache. Saliva is very sparingly secreted, and the mouth is often in a dry or clammy and uncomfortable state ; the mucous membrane dries very quickly ; there is often a very un- pleasant taste, and instead of the mucous surface being soft and moist it seems to be besmeared with viscid mucus, and the patient will tell you his mouth is quite out of order. In many cases the action of the salivary glands is certainly suspended for a time, and when the attack is passing off, one of the first points noticed is the pouring out from the glands of a quantity of saliva into the mouth. With the return of salivary secretion, the unpleasant sensations about the mouth, the dry- ness, the disagreeable taste, and the clamminess disappear. The liver is ahvays out of order in " sick headache." Its action in many cases seems indeed to be almost suspended for a time. The excrements are sometimes, but not invariably, pale and altered in con- sistence, and are sometimes very offensive. The intestine is not stimu- lated to perform its ordinary contractions, and in many cases flatus collects. Moreover the surface of the liver is sometimes tender to the touch. Not unfrequently there is a feeling of fulness or actual pain in the right side ; and often there is a distinct yellowness of the skin and the conjunctiva. The liver is one of those glands which act irregu- larly : at least as regards the passage of its secretion into the intestinal 252 NATURE OF THE DISEASE. canal, the greatest differences are observed. In some animals probably days pass without a flow of bile, and after a large meal the gall bladder and ducts may be completely and suddenly emptied. Tn man this variation in the secretion and discharge of bile exists, but as compared with carnivora to a moderate extent only. In some persons, however, it entails much, almost constant, discomfort, and even suffering, affecting not only the spirits, but being constantly associated with, if not actually causing, a particular, and to its possessor most undesirable, temperament. This was well known to the ancients. Those who suffer from exceptional irregularity of hepatic action may, however, mitigate their misery by regulating their diet so as to suit their unfortunate condition. They must eat irregularly to be in accordance with their hepatic requirements, and they will find that to keep them- selves in health, and out of that mental morbid state which renders life a burden and contentment an impossibility, they must acquire the habit of taking little meat, and that little not every day, while the amount of fluid (water) introduced in proportion to the solids taken must be con- siderable. Many of these unfortunates do not require more than two or three ounces of meat three times a week, while they may drink from one to three or four pints of fluid (good water) daily. After trying this diet experiment for a month such persons will be astonished at its success. They will be surprised to jfind they have gained in weight, although they may have reduced by one-half or more the quantity of food they have taken ; and they will find this economy of no less advantage to their working powers and feelings, than to their pocket. Such people are among the most economical of " machines,"' and unlike any other form of machine, though they consume less, more work is to be got out of them ! In sick headache the action of the alimentary canal is partially sus- pended, or the intestine may scarcely act at all. Its contents, in many instances, seem to remain almost still for a time during the attack, or are but very slowly urged towards the lower bowel. The action of the colon is suspended. No accumulation of faecal matter goes on during the attack, for at the time fteces jirobably are not being formed. In some cases of sick headache, I think, the derangement actually begins in the large intestine, and sometimes there is evidence of moderate, but not excessive, faecal accumulation, with a passive state of the mucous mem- brane and its glands, and sluggishness of its muscular coat. The caecum and ascending colon are very commonly at fault, and I have succeeded in feeling the accumulation at this part of the bowel. The patient himself is frequently aware of some discomfort or unpleasant sensation in the ri-jht iliac fossa. By palpation you may detect the fulness, and by the tympanitic percussion over this part of the bowel you demonstrate the presence of gas, much of which probably arises from decomposition DKRANOKMENT OK THE LAKliE liUWKL. 253 of materials which ought to have been expelled long before. It does not follow that actual constipation has prevailed, but the bowel has not completely emptied itself. For some time, perhaps for weeks or months, it has not driven down the fnecal matter towards the rectum as fast as it was formed. The lower part of the ileum, as well as the caecum, is at fault in some instances. Probably Peyer's patches and the solitary glands do not act freely, and oftentimes their action is further disturbed l)y the constant [)resence of fauUy secretion, and possibly of the products of fermentation and unusual chemical action, in the slowly moving and sometimes almost putrefying mass. The action of the glands themselves is then interfered with and the uneasiness and pain which are sometimes experienced may be due to this cause. You must not forget these points, for they are of interest in connection with the causation of many derangements of the healthy some of which are by no means slight. I be- lieve that a prolonged, and perhaps almost constantly disturbed, action of this part of the alimentary canal may lead to important changes in the blood, and thus establish a state of system favourable to the develop- ment of important diseases of different kinds. Neither must it be forgotten that when materials remain for some time in contact with the mucous membrane of the large bowel, reabsorption occurs, and thus many noxious matters which ought to be discharged from the system very likely find their way in an objectionable form into the blood. You see, then, in sick headache there is evidence of very widespread i)ut, at the same time, slight derangement in many organs and tissues of the body. There is general disturbance of the intestinal canal, altera- tions in the composition of the blood, and disturbed action of many parts of the nervous system. There are derangements of touch, per- verted taste and smell, often disturbance connected with vision, and not unfrequently singing in the ears, giddiness, tremors, and other departures from the normal state as regards the action of the organ of hearing. The action of the heart is depressed. The capillary circulation is de- ranged, there being too little blood in some parts — congestion in others. Digestion is much deranged, and the action of the liver and other secreting organs is seriously impaired for the time. The muscles do not work as they should do. Delicate movements cannot be executed with the usual precision, and sustained muscular effort is difficult or impossible. The body is fatigued. The memory is more or less affected for a time, and in many instances the temper becomes " bilious." To attempt brain work when you suffer from sick headache would be useless, for the mind will seldom work to any advantage. Sometimes there is a very distressing faintness and a feeling of terrible exhaustion ; the heart's action being often very feeble for a time, and sometimes so very weak as to cause alarm. Rest in the recumbent posture for a few hours may be necessary, but generally the heart soon regains its usual 254 MEMORY AND TEMPER. power if let alone. Stimulants sometimes increase the stomach disturb- ance, and prolong the attack ; but if the heart's action is very depressed, it may be desirable to administer ammonia or brandy in very small quantities at short intervals until the organ regains its natural strength, as indicated by the character and intensity of the heart's sounds. When the attack of sick headache begins to pass off, urine, often loaded with deposits of Urates of Soda, Ammonia, and Lime, and of high specific gravity, is excreted. Then the kidneys begin to act freely, and the urine is of low density ard pale, the bowels also act slowly, and in a few hours more the patient will feel well. It is remarkable that after all this disturbance in the system, the individual who has suffered should be for a time in better health than usual, and he may feel exceptionally well and vigorous. Indeed, you will find that many of the victims of this derangement have considerable powers of endurance, enabling them in a great many instances to work on energetically far into old age. Many who suffer severely, though not fit to work, by great effort may get through their duties, and perhaps during a long lifetime may not have been forced to absent themselves for a single day. As far as I know, no harm results from working on through a sick head- ache in cases in which this can be done, but, of course, certain kinds of work cannot possibly be executed under the circumstances. Attacks of sick headache may occur once a week and oftener, or the affection may recur not oftener than once in a fortnight, or once a month, or still less frequently. You will sometimes find that the suffering returns almost to the day, after a week or a fortnight, or other interval. In spite of this almost continual disorder, the general phenomena of the system, essential to the continuance of life, proceed as usual. I think that some of those who suffer, and who take moderate care of themselves, really enjoy certain advantages as regards the prospect of longevity. Their tissues do not seem to grow old as fast as those of many of their more vigorous contemporaries. Periodical sick headaches may after all be conservative in their action, and may protect the organism from more serious pathological derangements, thus perhaps enabling persons to live long who might under other circumstances die early. Although the digestive organs may be seriously wrong for a certain time, they get the advantage of resting from time to time for periods varying from twelve to twenty-four hours, or longer. If in the affected organism anything happens to be wrong in connection with the alimentary canal, the illness ensures time being allowed for the derange- ment to right itself, instead of actual morbid change being induced by the repetition and persistence of the disturbance. There appears to be hyper-sensitiveness in connection with the nerves of the digestive organs in many who suffer from sick headache, which, by favouring severe temporary disturbance of a functional character, may prevent damage SICK ni:Ai)A(iii'; and I'.i'I1,i;i's\. 255 and permanent structural changes in important tissues. Possibly this may be the reason why many people who suffer from sick headache not only live to be old, but often retain their vigour in old age. sick lleaiiarlie and iCitilepsy. — Some physicians have thought that an intimate rclationsliip existed between sick headache and the epileptic state, but we meet with so many instances of each condition without the slightest indication of tendency to the other, that 1 cannot, without some further evidence, accept this opinion as correct. Undoubtedly you will now and then meet with a case which might seem to justify such an inference, but you will also come across cases which, considered alone, might suggest a relationship between epilepsy and many other forms of disease usually considered quite distinct. Indeed, there are few morbid conditions in which nerve derangement exists which might not be adduced as supporting the view of their affinity to the epileptic state. Hysteria, nightmare, waking up suddenly in the night and calling out, unconscious or partially unconscious, nocturnal expulsion of urine, twitchings occurring in the muscles, may all be regarded as belonging to the category of epileptic affections. But if I admitted this view to be probably correct, I should still be disposed to doubt whether any connection between sick headache and any form of the epileptic state had been proved. Some cases that come under our notice would seem to justify the notion that, in certain instances attacks of sick headache take the place of attacks of gout, or rheumatism or neuralgia, and that the affections are related. But it must be admitted that there are so many persons vvho suffer from sick headache who have no tendency to the conditions enumerated, while many who have one of these, hardly know what it is to suffer from headache of any kind. Nevertheless, there is reason to think that in all affections the blood is deranged, and possibly by the accumulation in it of nitrogenous materials which ought to be eliminated. All come on at intervals, and often suddenly. All may be relieved by the same general treatment. All may be aggravated by a full meat diet, and mitigated by a diet largely composed of vegetables and fruit. In all there is derangement of the stomach and liver, and Calomel and other remedies which act upon that and other excreting organs relieve those who suffer from these complaints, as well as those who suffer from sick headache. We cannot, I think, accept the generalization that all cases of sick headache belong to the class of neuralgic affections ; for those who suffer from severe forms of neuralgia do not seem to be more susceptible of sick headache than other persons ; nor, on the other hand, are the victims of sick headache invariably prone to the ordinary neuralgic pains. Nor do I see what we gain by calling this, and many diseases in which nerves are affected, a " neurosis," or by referring any of them to " nerve storms," for no one knows precisely what he means by the 256 NEUROSES AND NERVE STORMS. phrase " nerve storm." Nor has the supposed connection between sick headache and ague, and maladies of that class been proved. There seems to be an alliance between many different diseases, but it is most difficult to do more than point out the connection in general terms. As time goes on 1 have no doubt that many affections which have received different names, and are now regarded as distinct diseases, will be shown to be much more closely related to one another than we should be led to suppose from the accounts at present given in our systematic works on medicine. For reasons to which I have already adverted for the present, I should rather place ordinary sick headache under the head of derangements of the digestive organs than include it in the disorders of the nervous system. This question of the nature of the malady has an important practical bearing, for it must influence our views upon treatment. Now I think I may go so far as to commit myself to the opinion, that if the digestive system and the most import- ant organs of excretion could be made to work properly, and could be kept working properly, the subjects of sick headache would be cured, and from the time when these results had been obtained would be free from attacks. It appears to be probable, for reasons which I have set forth, that some material gradually accumulates in the blood, and by its deleterious action, first upon the nerve-fibres and centres of the vessels, and then on the nerve-cells of the brain, occasions the headache, and causes the inability to think, or at any rate renders it impossible to sustain connected thought for many minutes at a time. This inability to think is probably caused by an indirect action leading to dilatation of the capillaries of the pia mater and those of the superficial part of the gray matter of the convolutions, while the fluid effused from these vessels laden with noxious matters which ought to have been eliminated bathes the nerve-cells, and exerts a deleterious influence upon them. A small dose of Calomel within two hours, or even less time, sometimes completely alters the state of things — for the nausea, the headache, the misty confusion of intellect, all disappear. The kidneys soon begin to secrete actively, and in this way the blood is depurated. The stomach and the intestinal canal participate, and then the peccant matter which has accumulated is removed and the healthy function restored. Treatment of Sick Headache. — I believe we may often succeed by judicious management in reducing the number and severity of the attacks of this disorder. You must, in the first place, enquire very minutely into the general habits of the patient, and of course advise him to correct any irregularities he may have committed as regards quantity and quality of food and the times of taking it. To lay down a strict dietary is, however, useless — nay, it might be mischievous, and more harm than good result. Many doctors make themselves conspicuous TRKATMIiNT OF SICK IIKADA( 1 1 1",. 25? and their patients miserable, by the absurd importance they attach to severe restrictions as regards particular articles of diet. The victim of sick headache will not gain anything by feeding as if he were in jjrison, and exercising as if he were under sentence of penal servitude, or undergoing the " cure " at some strict bathing establishment, Vou may cut off his beer, wine, and all things containing sugar ; you may order him to take so many pieces of dry toast at breakfu'^t without a particle of I)utter, and only allow him skimmed milk and lime-water to drink. You may limit him to a biscuit for lunch, and allow a small chop, with bread pudding, made without any sugar, for dinner, and a cup of water arrowroot for supper, or no sapper at all. You may make him walk so many measured miles, rise at a certain hour, and retire at a time when most people consider the hour for a little quiet reading or other harmless enjoyment has arrived — and all to no purpose. Nay, instead of getting better, he may have to tell you that he is worse, and feels less happy and contented than before, and less able to bear his suffering. Your advice as regards living should be considerate, but not too strict, for, in the first place, we do not know enough about the real nature of the malady to justify us in accurately and arbitrarily laying down the law as to exact diet systems : and secondly, experience has incontestably proved that persons who suffer from sick headache get on better upon the whole if they live fairly well, in the intervals, and starve for the short period during which they have to suffer. As regards wine it will be generally found that light wines, such as hock, suit the sufferers if they require stimulants at all ; but many who suffer from the malady do not need any form of alcohol. There are many cases of sick headache that have resisted every attempt to cure them ; indeed, it must be confessed that, up to this time, no certain method of *' cure " has been discovered. While the headache lasts, and the action of the stomach and liver, and indeed of the secreting organs generally is suspended, even the most easily digestible substances do harm, and I know of no medicine that invariably affords relief to the patient, while some that give temporary relief do real harm if persisted in. Some of those who suffer from this unpleasant affection can tell some days before the derangement begins, that they are about to have an attack. There is an unpleasant taste in the mouth with a degree of dryness, particularly at the tip of the tongue, a feeling of distension or fulness over the stomach, sluggishness or inaction of the bowels, lassi- tude, and an indisposition to take active exercise, slight or considerable depression of spirits, and an inclination to sleep. The appetite may still be good, but there is often some degree of discomfort after taking food, an act frequently succeeded by a feeling of regret. Now if the patient, by whom the import of these premonitory symptoms is under- stood, takes two or three grains, or even a grain or less of Gray Powder, s 258 TREATMENT OF SICK HEADACHE. with a little Colocynth, and perhaps a saline draught the following morning, he may escape the impending attack. He may feel more or less out of sorts for a day or two, but he does not get the severe headache, and perhaps, also, escapes the sickness, though very likely he experiences a slight degree of nausea. This surely indicates that matters which had accumulated in the blood have been removed by the purgative, and have thus been prevented from exerting a deleterious influence on the nervous system culminating in headache, and causing other symptoms. But what should be done in these cases ? What methods of treat- ment afford the best chance of relieving the patient who actually suffers? If 3 ou cannot always cure him, you may do something to prolong the interval between the attacks, and to mitigate the severity of the symptoms when they occur. If the sick headache is not severe, persuade the patient to think as little about it as possible. Recommend him to go about his ordinary work, and tell him to try by his manner to prevent people from discovering that he is ill, for too much sympathy and kind inquiry may concentrate his attention upon the malady, and make him feel worse. If anything happens to annoy him he should keep quiet, and restrain himself from expressing any decided opinion until he is well, otherwise he may get the character of being a very ill- tempered or cantankerous person, when, in truth, he is nothing of the sort. It is his headache, not himself, that does the wrong. I. Treatmetit during an attack of Sick Headache. Rest. — During a severe attack of sick headache the patient, if this be possible, must have complete rest, so that the organs which are deranged may be allowed to gradually right themselves, and it must be borne in mind that the mind and the nervous system need repose as well as stomach, liver, and other organs. When the suffering is very great, and particularly in cases in which there is that distressing feeling of nausea, and frequent or occasional attacks of actual vomiting, the patient must lie down. But one meets with many instances in which if tolerably courageous he may continue his usual avocation in spite of the headache, and I am not aware that any one has discovered that by this plan the suffering was actually greater or lasted longer than when the opposite plan is followed and the patient gives way as soon as the headache begins, and lies down in a darkened room until the attack passes off. In bad cases, however, and especially if patients are weak and in other respects out of health, absolute rest in the recumbent posture must be recommended from the commencement of each attack. There are not a few sufferers who are so very ill that they are obliged to lie quietly in bed for two or three days. Starving in Sick Headache.— ThQ patient who is suffering from an STARVATION FOR A DAY OR TWO. 259 attack ought to starve for the time and thus rest the stomach. It is very remarkable, as already observed, that many who suffer from this trouble- some disorder are able to discharge even active duties without taking any food at all for perhaps twenty-four hours or longer, although if in ordinary health the same person fasted he would soon get faint if he attempted to do a very moderate amount of work. A person may rise with a sick headache and be quite unable to eat any breakfast, and yet may perform the ordinary duties of the day, and perhaps continue work- ing up to nine or ten o'clock at night without having taken a particle of food, and yet without suffering, while the same man in his ordinary health might not be able to postpone breakfast for an hour without becoming faint and exhausted. This peculiar state in which abstinence from food does not occasion exhaustion may last for forty-eight hours, during which period not an ounce of solid matter may be taken, and yet it does not follow that the nutrition of the body will be in any way impaired, or the health damaged for any length of time. The patieni will not lose in weight, because the organs soon resume their natural functions. When the appetite returns and the victim is able to eat again, nutrient material will be poured into the system and be rapidly appropriated. Abstention from food for twenty-four hours is usually long enough to allow the organs which are deranged to right themselves. But in any case during an attack of sick headache, it is not of the slightest use to attempt to force the patient to eat. Even bread and butter may disagree. The starchy matter of the bread instead of being digested may undergo other changes, and butter as well as other fats suffer chemical change, various organic acids being formed, which after a time irritate the stomach and cause it to reject its contents. Even meat is not digested, but if the patient feel exhausted a little cold beef tea may be absorbed, or beef tea which has been artificially half digested with the aid of pepsine, p. 173. If patients object to starve from the fear that they will get very weak, you may tell them to try a little mutton broth or beef tea, which should be entirely free from fat, and should be sipped. Of course, as far as any real advantage is concerned they might just as well take nothing, for the little that is introduced under these circumstances cannot in any way help nutrition, although it may, on the other hand, somewhat interfere with the return of the stomach to its normal state. The fact is, that temporary abstinence from food, as above suggested, can do no harm whatever, and this course is necessary if the patient desires to gain his normal state of health in the shortest time possible, and with the least degree of suffering. In considering the cogency of the ordinary scientific physiological objections that may be offered to starving for a day or two and to living on very little food (bread and butter, with perhaps a little cheese, or anchovy paste (with water, lemon juice and water, or weak tea for drink), s 2 26o INFLUENCE OF WARMTH. one must carefully bear in mind the condition of system which follows a long illness. Perhaps for weeks a patient, always thin, has been living on beef tea or milk and stimulants, and during his convalescence his stomach being sensitive will only bear liquid food. In many of such cases no doubt the heart's action is endangered from living too low for a consider- able time, but the ordinary precautions against fainting and failure are usually effective, for in practice one very seldom meets with cases illus- trating the failure in question, and though the patient is weak he steadily if slowly regains his former strength. It is not therefore likely that the degree of abstinence recommended will be productive of anything but good to those for whom it is recommended. Warmth. — Exposure to cold often precipitates an attack of sick headache if one is about to come on. Indeed, many sufferers attribute the illness to the direct influence of cold. I have thought on some occasions that instead of catching an ordinary cold from undue exposure, I had contracted the greater, if less lasting suffering — sick headache. Sick headache is certainly relieved by warmth. A warm bath sometimes removes the headache and almost always gives relief for the time. In slight attacks of sick headache complete relief may be obtained by putting the feet into hot water, or even by simply well warming them before a good fire. An ordinary hot-water bottle, or better, a vulcanised india-rubber bottle filled with hot water and applied to the stomach, sometimes appear to be of use, and is at any rate very pleasant under the circumstances. Counter-Irritatio7i. — There is no doubt whatever that considerable temporary relief is afforded during an attack of sick headache by the errjployment of counter-irritants. A mustard plaster (half mustard and half linseed) to the back of the neck or to the pit of the stomach will relieve the pain, or half of one of Rigollot's mustard leaves, a piece of writing paper intervening between the mustard and the skin, may be applied in one or both situations : but one of the best applications to be used in these cases is described on p. 247. In recommending the external application of strong Hydrochloric Acid, you must, however, always be very careful to give explicit directions, or you will get into disgrace in consequence of the destruction of bed clothes and the serious damage to wearing apparel. Acids. — It is curious that in many cases in which acids are produced in undue proportion by decomposition of various materials in the stomach, there should be a natural desire for things having an acid taste. Many persons certainly experience a distinct longing for acid drinks, which undoubtedly afford relief in some cases. Lemon or Lime juice and water iced, and taken in sips at a time, is very grateful to some, and often allays the distressing nausea present. Tea Drinking in Sick Headache. — Some persons sustain themselves ADVANTAGE OF TEA-DRINKING. 261 during an attack of sick headache by drinking several cups of moderately strong Chinese tea in the course of the day. The tea, which, however, should not be infused for more than three or four minutes, seems to keep them up, to mitigate the severity of the headache, and to relieve the nausea. Tea is condemned in the most emphatic manner by many members of the profession, but I cannot hell) thinking that the public form a more coirect estimate concerning the value of this celebrated infusion. I doubt whether it would be possible to persuade old women or old men, or even young men, as a class, to give up tea. The majority of people do not believe that tea does half the harm attributed to it, and with this opinion I am inclined to agree. If, however, you were ailing and were to consult many of the most distinguished mem- bers of the profession on the matter, you would almost certainly be enjoined to give up tea, whether the malady was dyspepsia, constipation, or sick headache, and indeed, for many slight ailments the most important curative measure would seem to be to abstain from tea. Some practitioners express this opinion with amazing confidence and absolutism. Milk and water, or wine and water, are suggested as substitutes— substitutes for tea ! Your medical adviser fairly argues that something or other must be wrong, and infers that you take some- thing that you ought not to take, that this something must be at the root of the evil, and then concludes, but not in my opinion with good reason, that the particular peccant matter is nothing less than tea. Now, It is almost hopeless to attempt to alter the views of those whose minds are " made up " upon such a matter as this, and, as regards the dele- terious effects of tea, not a few medical minds will be found in this happy state. No one is to be allowed to say a good word for tea. Tea is held to be the almost universal cause of dyspepsia, and there is an end of the matter. But in spite of its condemnation, tea is at this time more largely drunk than ever. Probably more than two hundred million pounds of tea per annum are consumed in the United Kingdom alone, and if its influence is as bad as some assert it to be, it is wonder- ful how few people discover its deleterious qualities. Seldom, I believe, does tea do the harm that has been attributed to it. In many cases of sick headache, four or five cups of good tea, at intervals during the day, will unquestionably mitigate the severity of a bad attack, and, perhaps, enable the sufferer to pursue his ordinary avocations in a way that he could not otherwise carry out. Strong coffee seems to suit some persons who cannot take tea. Vomitijv; sometimes goes on for four and twenty hours, and some- times for a longer period. The patient may be much exhausted, and the stomach become weak and very tender. Three or four days often pass before the patient regains his normal state of health and is again able to digest food. 262 VOMITING. My old friend Dr. Spender, of Bath, who for many years was himself a sufferer from this malady, made the following remarks in the British Medical Joi/rnal {or ]nne 14th, 1864: — "I always felt particularly well on the day before an attack, and this generally warned me for an approach of the enemy. At bed-time, I took a very mild aperient of aloes and myrrh. It was most fatal to have a good night, i.e., a long and deep slumber ; and so my first preparation was to put off going to bed as long as possible, and if that ghostly thing rang, called the night-bell, I welcomed the peal as my truest friend. My invariable rule was to keep sleep at bay as much as possible, however tired I might be ; an almost sleepless night would dash aside the coming headache. Only milk and porridge should be taken for supper ; soup or meat is simply poison." " When the sufferer awakes and feels that his misery is upon him, Dr. Beale's advice to starve should be absolutely obeyed. It is of no use to attempt to eat, for there is no appetite, and nothing would be digested. But that neurotic food named tea may be taken hot and strong, and at frequent intervals ; strong coffee is sometimes better still, but it never did me so much good as tea. An amelioration of the headache and a return of the appetite were generally simultaneous. Another remedy, usually of great service, is the fomentation of the head with the hottest water that can be borne, and continued for at least ten minutes. I do not think that Dr. Latham's suggestion of cold applica- tions to the head can be safe or useful. Rest and darkness are grand therapeutic means ; but how can either be enjoyed by a professional man who has to work whether his head aches or not ?" " A few words about medicines. Dr. Latham esteems guarana more highly than Dr. Beale. On the morning of a headache, I prescribe half a drachm of powdered guarana to be taken with hot water every two hours for three doses ; but if these do not afford almost immediate relief, it is useless to give more. Citrate of caffeine may do good when guarana fails. But I wish to lay special stress en the prophylactic treatment of migraine. Before the days of chloral and the bromine salts, Indian hemp was much more in fashion than it is now ; and I often recommended a dose of Indian hemp and of quinine to be taken every night during the intervals of the neuralgic attacks. It is doubtful whether any combination of more modern drugs promises better success ; and we must remember that our aim is gradual alleviation rather than sudden cure. In several cases I have thought that hypophosphite of soda contributed to a patient's benefit." Recovery after one of these headaches is almost like beginning a new life. From having been plunged into the depths of misery and despair, without the slightest alterations in any external conditions, the whole outlook seems changed. Not only hope but ambition rises in the mind, TREATMENT BETWEEN THE ATTACKS. 263 which is more active than usual. New ideas and new schemes take possession of it. There is not only a feeling of content, but a longing to enter upon more work than usual, and often the patient will find that he can work with more effect than usual after a sick he?dache. Indeed, were it not for the conviction that more attacks of headache were in store, all sorts of ambitious projects would be started soon after recovery. How differently would the same suggestions be received, and the same circumstances be viewed, by the individual during an attack ! Surely there can be no doubt that here we must look for the cause of the change in the individual himself, and not in the environment. The most opposite methods of treatment have been recommended for " bilious attacks," for although the symptoms may not be very dis- similar, one class of cases is relieved by purgatives and remedies which increase excretion, another by wine, iron, and tonic remedies; and although authorities have given us very positive advice as to dis- tinguishing the different classes of cases, in practice this will sometimes be found difficult, and now and then a mistake will be made. In most cases of sick headache no doubt a poison is generated in the system and causes the disturbance, while its oxidation and elimination by certain organs, particularly the kidneys and bowels, are followed by a return to the normal state of health. 2. Treat inetit in the Intervals bettveen the Attacks. Now, as to the treatment in the intervals between the attacks. After having tried many different systems of diet with the view of preventing attacks of sick headaches, as I have already mentioned, I have come to the conclusion that, upon the whole, the best plan is to live pretty well, and not to be too fidgety as regards food. In one or two days after the attack has passed off, the stomach begins to digest, and in most cases it will readily digest the ordinary things taken in health. I do not think that a restrictive diet, of any kind, is of much advantage, and if the plan adopted lowers the general health, there is no doubt that the attacks of sick headache will not only come on more frequently, but will be more severe. I should say to those who suffer from this troublesome ailment : — " Live fairly well while you can, and when the sick headache comes on, entirely abstain from food for a time. As soon as the attack has passed off, live as usual, and think as little as possible of the malady." A great many persons are certainly too careful as regards diet, in sick headache as well as in many other slight ailments. I fear, too, it must be confessed that many doctors encourage this, and give minute directions as to food which are as unpractical and unscientific as they are meaningless and useless. A parcel of very absolute rules are laid down for patients' guidance, many of which rest upon no principles 264 TRKATMENT IN THE INTERVALS whatever, and are mere arbitrary enactments. If they were called upon to give their reasons for the rules they have made, arbitrary practitioners would find themselves in a very serious difficulty. Many of the very- precise directions that have been given to people suffering from slight and not only slight ailments really seem ridiculous. Even if some patients are a little silly; it is certainly not our duty to treat them as if they were utterly devoid of sense. Give reasonable and necessary directions as to diet by all means, and see that patients do not exceed in any way, but to write minute directions concerning the precise thickness of the bread and the exact quantity of butter, and to give written orders as ta whether the toast is to be taken hot or cold, buttered on one side or on both, is nonsensical. Such trumpery fussiness v/ill be condemned by all sensible patients. If people, who are merely dyspeptic or bilious or inclined to headache, are allowed to be too particular as to what they may or may not eat, they get very fidgety, and perhaps at last loathe almost all food. They soon lose considerably in weight, simply because tney do not get food enough to sustain them. Such persons often get into a low hypochondriacal state, during which some real, and perhaps serious, illness may come on. Many who suffer from sick headache discover, if they will only try the experiment, that they can eat pretty much as other people do, in the intervals between the attacks ; and if they can manage to eat fairly well, they will find that, instead of having a greater number of attacks, they escape with few. Most who suffer from sick headache require and can take but very little stimulant. Many are better without any stimu- lants whatever. Beer will often precipitate an attack, and wine generally disagrees. A teaspoonful of sherry, taken between meals, is sufficient to bring on an attack in one predisposed to the ailment. There are, however, exceptions to this, for I know some who find that a little sherry or beer, but at meals only, helps them in the intervals, and does not bring on an attack unless one happens to be imminent. Sufferers from sick headache should do all they can to avoid worry. Peace of mind and freedom from anxiety are of course to be desired for every one, but those prone to the malady we are considering should be doubly careful, and should avoid undertaking responsibilities likely to make them anxious. So also they should exercise as much self- control as possible, and endeavour not to give way to a feeling of rest- lessness and fussiness, which only increases the severity of the attacks which they have to suffer. Many saline medicines, which increase secretion, seem to be useful to those who suffer from sick headache. Small doses of Nitrate of Potash, Potassce. Nitras, Bicarbonate of Potash, Potassce. £karbo?ias, the so-called effervescing Citrate of Magnesia, or Lupior Amnionic^ Acciatis, or Liquor Potassce Citratis, may be ordered to be taken in a BETWEEN THE ATTACKS. 265 largely diluted state early in the morning before the breakfast, and tiie last thing at night for a week or two at a time. Or you may give half a tumbler of Vic/iy JFa/er, or Lithia Water, or German Seltzer Water at the same times of the day, now and then, in the intervals between the attacks of sick headache. Some bitter preparations also seem to be of use. You may give Infusion of Orange, Infitsuni Aurantii, or Infusion of Quassia, Infusian Quassias, or Quinine ; or, as I have suggested before, you may try the effect of tea or coffee in somewhat larger quantities than they are usually taken. A good deal has been said about Ciuarana. It is prescribed in powder, in doses of from ten to thirty grains twice or three times a day. Its active principle has also been extracted, and may be prescribed in doses of from one to three or four grains. I am indebted to Messrs. Savory and Moore for a specimen of Guaranine. It looks something like quinine, but is more fiocculent. The taste, though bitter, is very unlike the taste of that substance. Messrs. Corbyn and Messrs. Probyn have prepared a Liquid Extract of Guarana, Extractum Gnarance liquidum, the dose of which is from twenty to thirty minims. I am sorry to say that although benefit seems to have been derived by some, many have tried this remedy without gaining the hoped-for advantage from its use. As regards Antipyriti, Antifebrin, and that class of remedies, the utmost caution should be exercised, for some persons finding the head- ache relieved, fly to the remedy whenever they get the slightest threat- ening, and thus acquire the bad habit of taking far too much of such substances, which have the property of destroying red blood corpuscles, and making the patient excessively weak — I have more than once seen real danger to life result from giving way to this practice. General treatment in the intervals of comparative good health must not be forgotten. Tonics of various kinds are often useful. You may give Quinine in one- or two-grain doses twice daily, about eleven and four o'clock, or Quinine Wine, or Tincture of Quinine. Various other bitter tonics and the mineral acids may be prescribed in many cases with advantage. The above remedies must, however, be withheld as soon as the headache begins and while it lasts. When you desire to give powders, such as quinine or guaiacum, you should recommend your patients to procure cachets, which are little gelatine boxes made in two pieces, in which the powder may be enclosed and easily swallowed. I'hese may be obtained in four sizes of most chemists, and by using them the most nauseous powders may be taken as easily as pills. If the patient suffers from constipated bowels, you must give mild purgatives, and if the various excreting glands do not sufficiently freely 266 EFFECTS OF CALOMEL. perform their work, you must prescribe those remedies which act upon the h'ver, kidneys, or other organs at fault. Whether Calomel should be given now and then is a point upon which there is much difference of opinion. Some patients undoubtedly derive the greatest benefit from small doses of this drug. From the sixth of a grain to two or three grains, taken at intervals of three or four days, is, as I have before remarked, treatment which really deserves in certain cases to be called •curative. There are, however, a few persons who cannot take Calomel. If you give half a grain or even less, the salivary glands will begin to act within three or four hours, and will soon secrete violently. The saliva flows from the mouth, the tongue and cheeks swell, the teeth become loose, and the patient is in too much pain t') take food, and is too ill to digest it properly if he could take it. You must be aware of this extra- ordinary susceptibility to the action of Mercury, and do not order it if the patient or friends assure you that invariably it has this effect. Sometimes Calomel seems to weaken patients terribly. Even small doses may purge too much, and harm, instead of good, may result from the drug. On the other hand, I can assure you that the confident unqualified condemnation of mercurials that has lately been so fashion- able rests on no foundation of fact. It is one of those fads or fancies which, being acted upon, are ever interfering with our usefulness to the sick. Here and there you find a person who cannot take Calomel, but it is easy to bring forward instances where persons having found out for themselves the value of mercury, have taken it almost daily for thirty or forty years, not only without suffering, but, from their own account, with great benefit. Indeed, some will tell you that they cannot get on without an occasional small dose. Many Mercury-takers have lived to be very old. I have given an instance of life being prolonged beyond eighty-four years, althou;,^h one or two grains of Blue Pill had been taken every fourth or fifth day for forty years. I have been told by people that they had been distinctly warned by their medical adviser upon no account to take Calomel, on the ground that if they did take the drug, it would almost kill them, or would at least provoke some serious and lasting injury to tissues and organs, and damage the consti- tution. Such assertions belong to the class of arbitrary utterances to which so many patients bow. It is a fact, as I have told you before, that Calomel enters into the composition of many powders which have a great reputation for exerting a soothing effect upon irritable children, and which are given even to young infants for the sake of improving the temper. It is wrong for practitioners to lay down the law ngainbt the use of such a remedy as Mercury. The public are sufficiently capricious to make it difficult to advise them for the best, and it is injudicious on the part of the skilled practitioner to encourage fancies and prejudices. Calomel, by helping the action of the stomach and liver, re-.tores diges- MANAGEMKXT OF SICK HEADACHE. 267 tion, and an irritable infant will soon regain its composure and good humour after a small dose. Adults experience a pleasant sensation if digestion goes on quietly and effectually ; while, on the other hand, if the digestive process is interfered with, the most amiable persons will sometimes find it difficult to keep themselves in that desirable state. If they do not feel out of temper, they probably feel melancholy and despondent, and even utterly out of heart, a mental state which may last for a considerable time if nothing is done, but which in many cases may be cured by half a grain of Gray Powder. So far the reputed substitutes for mercurials which I have tried have not succeeded as I could wish, but I have perhaps not tried them in a sufficient number of cases of sick headache and other maladies in which the liver is at fault to form a definite conclusion. 3. Of the Management of Sick Headache lohen the Patient continues to lUOfk. The following plan has been found to answer in several instances in mitigating the severity of the attack while the patient continued his usual avocation. The victim may become conscious of the attack as soon as he wakes in the morning, and instead of attempting to eat any breakfast, he should take only a cup of rather strong tea. There may be a feeling of weakness and lassitude, often accompanied by giddiness, but the patient can nevertheless walk about, and so far from feeling exhausted, as he certainly would do if under ordinary cir- cumstances he was deprived of the first and, with some, most important meal in the day, he will very probably not feel the slightest desire for food. In an hour or two he may take another cup of tea, and the dose may be repeated at intervals through the day. A little milk and sugar may be allowed, but probably the simple infusion of a good tea. taken warm, would be best. In this way the patient may get through his work, with difficulty no doubt, and perhaps he may feel somewhat miserable ; but the time passes more quickly than if he were lying down and contemplating his pain. Towards evening in many cases the discomfort becomes less, a sensation of emptiness, not difficult to bear, is experienced, and this is gradually followed by an actual desire for food. But the most striking change which sets in about this lime, and which is an invariable indica- tion of a favourable turn in the progress of the malady, is the free secretion of urine, after the action of the kidneys has been nearly suspended for fourand-twcnty or forty-eight hours or more. At first a small quantity of very acid urine, of high specific gravity, makes its appearance, but this is soon followed by a very free secretion of pale urine of low density, and great relief of all the distressing symptoms is 268 MANAGEMENT OF SICK HEADACHE. at once experienced. The stomach will now bear a little light food. The large bowel begins to resume its function, and next morning the patient will probably v/ake up, feeling nearly well. If, however, the head- ache still troubles him when he rises, it usually passes quite away during the day. It is true that in many cases the attack is often more severe and its duration longer than I have indicated, but the general plan of treatment suggested should be the same — complete abstinence from solid food, the administration of tea, coffee, or even plain water, at intervals of two or three hours, until the headache nearly ceases and the nausea disappears. Some people like warm water flavoured with lemon-juice, and you may add with advantage Supertartrate, or Nitrate, or Citrate of Potash, or some other salt known to act as a diuretic. Bishop's granular effervescing Citrate of Caffeine is useful in some cases of sick headache. It would appear that during the attack of headache most of the secreting organs of the body, and notably the liver, strike work. It is useless to try to violently and immediately excite them to action, for you would do harm by such attempts. You must wait for a few hours, and as soon as you see the slightest tendency of a return to activity, I believe you may be of use in hastening the return to convalescence and thus save time. A free flow of urine I am sure is advantageous. Purgatives- do harm if given too soon, and I have not been satisfied as to the advantage derived from many other remedies that have been warmly recommended during the attack. Neither warm baths nor cold baths seem to be of use ; and with the exception of tea or water flavoured with lemon-juice, with perhaps some simple saline diuretic, the less introduced into the stomach during the twenty-four or thirty hours of suffering the better. Let me press upon your notice the inference that sick headache is not an unmixed evil. The condition has its advantageous side, for he who is subject to the malady generally finds no difficulty in keeping temperate, and the delicacies of the table are to him scarcely a tempta- tion. Thus he is less likely to suffer from early failure and degenera- tion of important organs than many apparently healthy persons who may overwork them and subject them to undue strain. Lastly, we must bear in mind that in certain cases, although the symptoms generally may lead the practitioner to conclude that he has to treat a case of sick headache due to functional disturbance only, the con- dition may be much more serious, and be caused by organic disease. Moreover, the sickness so common in sick headache is a prominent symptom in very grave cases of cerebral disease, but I must not attempt to treat of the diagnosis of different forms of headache, and must now content myself with pressing upon your attention the necessity for care in diagnosis, so as to reduce as far as possible the chance of mistaking for a slight ailment a case of very serious disease of the brain or its membranes. DROWSINESS. 269 Drowsiness. — Patients sometimes come to consult us in consequence of a persistent sleepy state. They will tell you that they feel as if they could sleep all day as well as all night. If they sit on a chair for a few minutes, they begin to nod and soon drop off to sleep ; if they take up a book or a paper, it soon falls from their hands in consecjuence of an irresistible drowsiness. If they go out for a walk, they soon begin to experience a strong inclination to lie down and yield themselves up to sleep. Patients who suffer in this way sometimes come for help to their medical adviser. They may feel pretty well, and in good health, with the exception of this irrepressible drowsy feeling, and they ask you what they can do to get rid of a tendency so very troublesome and inconvenient. In many cases the drowsy state seems to depend upon some imperfect action of the digestive organs. Sometimes it may be traced to overfeeding. Sometimes to taking too large a meal in the middle of the day. Sometimes beer or a too liberal allowance of wine seems to be the cause of it. If you give mild purgatives and mineral acids before meals, and saline medicines which act upon the intestinal canal, you will often succeed in curing the patient. When the liver is in fault, as is not unfrequently the case, you will find the advantage of giving a small dose of Calomel, Blue Pill, or Gray Powder (from one to two grains will be sufficient) every third or fourth night for three or four courses. Cold bathing is often useful. As soon as the patient rises in the morning he may have a cold shower-bath. There is no need of a large quantity of water. A shower-bath of two or three pints will be sufficient. If the drowsiness is very troublesome, two moderate shower- baths a day may be tried — one at about eleven, the other at four o'clock — cold or tepid, according to the time of year. In some cases, in addition to the cold bathing, a mild purgative every night for a week will be found useful. TVakefulnes.s and Restlessness. — A condition the very opposite of drowsiness afflicts some patients. They come to you complaining that they cannot sit still or quietly rest for a time. They experience a strong desire to be continually walking about. They cannot stay for long in one place, and do not feel satisfied unless they get constant change of scene. You inquire if there is any cause for this restlessness, and, as a rule, the invalid assures you that, although everything is going on in its usual way, he cannot feel satisfied, quiescent, or composed. Sometimes vague frights harass the patient. When he goes to bed at night, instead of dropping off to sleep in a natural way, he lies tossing about. The pillow seems uncomfortable, and soon gets too warm for the head. A very miserable night is passed, and the patient only gets a little sleep towards morning, and perhaps wakes up feeling tired, exhausted, and unrefreshed. The mental disturbance in these cases depends upon some temporary derangement which cannot be accurately defined. If 270 WAKEFULNESS AND RESTLESSNESS. upon inquiry you learn that the restless state has existed for a consider- able period, you must induce the patient to thoroughly change his mode of life. If he is in business, recommend him to get away and take a holiday for a time. Send him to some place where he will get complete change of scene for a month or more. The diet must at the same time be carefully regulated, and in all probability the patient will return home well, and able to go on with his daily round of duty just as steadily as he did before the illness commenced. Persons who suffer from wakefulness are often ordered to take Chloral, and after finding out the efficacy of the remedy, some very imprudently continue its use without consulting their medical adviser. In a short time they discover that they cannot sleep at all without the drug, and at last they become complete slaves to its use. It has happened that from want of due care an overdose' has been taken and death has resulted. It is important to caution all persons for whom you prescribe Chloral, never to take this drug unless it is specially ordered for them. Sulphonal is safer than Chloral— you will sometimes find that two drachms of Tincture of Hop, Tinctura Lupuli, one drachm of Sal Volatile, Spiritus Amrnonioi compositus, half an ounce of camphor water. Aqua Camphorce, and an ounce of common water, make an efficient sleeping draught which is quite harmless and may be taken twice in the course of the night. More dangerous even than Chloral-taking is the hypodermic injection of narcotics, and it seems to me that this method ought never to be employed in cases of occasional wakefulness, and I think that in all cases the rule should be observed of never leaving the syringe and morphia solution in the patient's custody, nor should anyone be allowed to perform the operation for you. In those cases only in which owing to chronic incurable disease, accompanied by constant severe pain, the unfortunate patient can get no sleep or peace without the aid of morphia, and only very exceptionally, should this rule be relaxed, and non- professional persons permitted to inject the narcotic. Patients oftentimes complain of feeling tired and exhausted as well as restless, and sometimes they will tell you that they cannot walk half a mile in consequence of being muscularly weak. You must carefully inquire into the state of the various , organs of the body, and suggest what you can to rectify the action of any which may not be work- ing properly. Generally, you will do well to send such patients for a moderate tour in a pleasant part of the country, where they can see a good deal without walking very far. You must particularly caution them against over-fatigue. Many persons suffering from this or other conditions requiring change, are advised to take a walking tour in Switzerland or the Tyrol. So they go with all despatch, and having arrived at their destination, begin their pedestrian cure. Not having NERVOUSNESS. 2/1 been accustomed to much exertion for many years, they set to work and, perhaps, walk twenty miles or more a day. Instead of feeling better, and gaining scrength, they soon feel terribly tired and exhausted, and return home in every respect worse than when they set out. Such an expedition, under the circumstances, is a mistake. You must strongly impress upon such patients that they are not to walk more than a mile at first, and if they are tired, they are to sit down ; or better lie down on the sofa and read a novel, or otherwise amuse themselves. They should, as we say, moon about, or potter about in the open air several hours daily, without taking any active exercise. In this way, most sufferers will soon begin to improve, and when this is the case they may by degrees extend their daily walk until they are restored to health. Nervousness. — There is another condition, which is usually called " nervousness." In this state there can be no doubt that the mind is in some degree temporarily affected. There may be undue emotional excitement. The least thing may arouse fear or dread, but instead of the nervous excited state impelling the patient to be more active in his work, he finds it almost impossible for him to discharge his ordinary duties. A large proportion of the population seems never to have "experienced anything approaching to nervousness, but some people suffer from it in a terrible degree. I have been told by patients, that for some time they had been conscious of an indescribable anxiety, for which they could not account, and from which by no reasoning with themselves, could they get relief. They know and acknowledge that there is no reason for anxiety ; but nevertheless a sort of ill-defined dread seems to hang over them. They fear that something or other is about to happen, and this most painful state of mental disturbance sometimes lasts for a considerable time, causing the patient great suffering. With this state is frequently associated considerable depression of spirits. The subject of it feels as if everything was going wrong with him. He may be getting on just as well and making quite as much or even more money than usual, but nevertheless feels discontented and depressed, as if something terrible had happened. Such patients often make themselves needlessly wretched by fancying they have received slights at the hands of friends. A quite unintentional oversight is magnified by them until it appears to them a studied insult. People who suffer in this way some- times tell you that they are certainly going to the workhouse, and all this sort of thing, although they know themselves to be prospering. If a patient in this state of health should happen to lose a few shillings, he will feel quite convinced that everything is going to the dogs, and nothing will persuade him to give up the despairing views of life which have somehow arisen in his mind. Some who suffer from nervousness, and experience a restless, un- settled state of mind, occasionally do very curious things. A man may 272 NERVOUSNESS. wake up occasionally in the middle of the night and with the conviction he smells fire. He jumps out of bed, strikes a light, goes over the house, finds nothing the matter, and goes to bed again. In another hour or two, perhaps, he wakes up a second time, and goes through the same proceedings as before. Many people whose nervous system is a little overwrought wake up at night, jump up, and perhaps light a candle before they are quite aware of what they are doing. A further de- velopment of the same tendency may lead to sleep-walking, of which con- dition again there are many different degrees. Children of highly nervous temperament are likely to suffer from attacks of chorea. These and many more severe functional disturbances of the nervous system seem to depend upon a highly sensitive or excitable state of certain parts of the central nerve organs — perhaps inherited, but at any rate not due to structural change. The nervous state is often associated with a special type of organism, and frequently it will be found that cardiac disease, affecting either the mitral or aortic orifice, or both, also exists, or if not is likely to be developed before the period of adolescence. Sometimes an unusually restless and excitable state of the nervous system temporarily seizes upon people, and may come on at almost any period of life. But all the trouble experienced by the unfortunate patient may be due merely to disturbed action of the liver. The circu- lation becomes slov/ in the vessels of the gland, and many of the impurities which ought to have been separated from the blood remain and cause disturbance in the action of the brain. The patient who has suffered for long should be advised to visit friends, or take a holiday abroad. You should urge him to leave for a time his ordinary avocations, and very likely in a few weeks he will recover from his nervousness, and his digestive organs and liver will act better. Upon careful inquiry, you will find that many who suffer in this way have been long in the habit of taking too little sleep. There is hardly anything in which individuals more widely differ from one another than in the time required for sleep. Some can do with six or seven hours, but it is quite certain that many require nine hours. Nervous people, as a rule, are benefited by a long night's rest now and then, and ordinarily require an average of eight or nine hours. Of late years, very much has been written on the subject of nervous- ness, and attempts have been made to show that we are much more " nervous " than our fathers were. It seems to me that the evidence adduced in favour of the statement is, to say the least, very far-fetched. The so-called brainworkers are supposed to be great sufferers. It is said that people are more sensitive to heat and cold, and require to live in rooms more highly heated than was the case even a few years ago. It must, however, be borne in mind, that a far greater number of the existing population are able to have the advantage of warm rooms in NERVOUSNESS. 2/3 cold weather than formerly, and in consequence the majority enjoy better health, and live to be older. That large incomes engender a good deal of fussiness, and little aches and pains which are made too much of is, I dare say, true, and if this is " nervousness," an increase no doubt exists, and such *' nervousness " will increase as prosperity increases. I cannot help thinking that if our fathers had been as pros- perous as we are, as large a percentage would have suffered from " nervousness." However this may be, it is quite certain that if our modern habits and systems are productive of increased nervousness, they are at the same time upon the whole conducive to health and longevity. There is no doubt whatever that the general health of the population has improved, and is improving, that the average duration of life is on the increase, and, if the sum of human happiness is not much greater every succeeding decade, it ought to be so, and the fault lies in the circumstance that individual evil inclinations are capable of counteracting the natural influence of highly advantageous external conditions. Upon the whole, I doubt very much whether there is anything to justify many of the statements made about the increase of nervous disorders. Whenever money is made rapidly, luxury and folly will increase, but the silly. rich constitute but a very small, and after all a comparatively unimportant part of the popu- lation — so that in the life of a country like England their existence is hardly noted, except by themselves and the few whose interest leads them to minister to their requirements, and to pander to their caprices. Dr. G. M. Beard, of New York, has lately called attention to the increase of nervousness in the United States, but I think his remarks can only apply to a small fraction of the population of some of the large cities. This author seems to think very much of pork as a food, and to have formed a low estimate of those whose stomachs are not strong enough to digest it. The dethronement of pork, says Dr. Beard, is having a disastrous effect upon the American people — ■" Pork, like the Indian, flies before civilization." Really it seems very hard that people who cannot digest pork should be put down as unduly nervous, over-sensitive, and the like, and be accused of under- going deterioration and decay. I have no doubt that the American nation will survive and increase in numbers and in vigour, "the •dethronement of pork"' notwithstanding. Dr. Beard also tells us ■that there is increased sensitiveness to cold and heat among the people in these days, but he forgets that many who indulge in very warm rooms bear extreme cold better than those who cannot enjoy well warmed houses. As regards the effects of overworking the brain in the case of the young, while it may be admitted that, now and then, instances T 74 NERVOUSNESS. of mental strain are met with, such cases are rare, even in these days, as compared with the number of persons, young and old, who are suffering from the very opposite condition — from too little mental exertion. Speaking generally, I incline to the opinion that, upon the whole, far more disease results from too little brain work than from too much. THE EARLY STAGE OF CERTAIN OBSTINATE CHRONIC MALADIES— NEURALGIA— TREATMENT OF NEURALGIC AFFECTIONS— RHEUMATIC PAINS— MEASURES TO BE ADOPTED IN THE TREATMENT OF RHEUMATISM— THE DIET IN RHEUMATISM— RHEUMATOID OSTEO-ARTHRI- TIS— THE MANAGEMENT OF MILD CASES OF RHEUMA- TOID ARTHRITIS— OF SLIGHT GOUT AND GOUTY TEN- DENCIES—HINTS ON TREATMENT. The curable early stage of cerfam obstinate Chronic Maladies — Certain forms of Neuralgia, Chronic Rheumatism, Rheumatoid Arthritis and Gouty tendencies. We may learn much as regards the nature of disease and che principles upon which the management of certain serious morbid conditions should be conducted, by the careful study of the changes which occur during the early period of the departure from health — at a time when in fact they may fairly be considered as slight ailments, and in many instances as capable of bemg relieved or even cured, especially when the conditions are not complicated with certain peripheral tissue de- generations or central nerve-changes — -many forms of neuralgia, rheu- matism, rheumatoid arthritis, gouty states of various forms, with certain vague ailments depending upon chronic changes, and commencing degener^ftions of peripheral nerve-trunks or their finer or ultimate ramifications. In their fully developed state these ailments may be often diagnosed without difficulty, but in their early stages they have many points in common. Indeed at this early period they may be easily mistaken, but this may not be of much practical importance, because the same general principles of management may be applicable. Indeed as time goes on the ailment may exhibit certain symptoms characteristic of one or more, and various forms of rheumatism, rheumatoid arthritis, and gout, are often accompanied with neuralgic symptoms which are sometimes severe. As many physicians have pointed out we often meet with apparently mixed and doulitful cases which though easily identified, and are fully entitled to the different names which have been applied to them, cannot be distinguished at T 2 276 CHRONIC MALADIES. first. As this early stage may last for some years, it is no uncommon thing for the trouble to be pronounced to be a different disease by different authorities, and even by the same authority at different times, — and possibly very different forms of treatment advocated. In their early stages these conditions are characterised by patho- logical changes which though not identical can seldom be positively identified. In another respect too there is a resemblance. The pain which of course may vary greatly in intensity is of the same general character, and is always increased for the time by the movement of the tissues involved, or by pressure upon them which necessarily causes movement of the tissues, rendered tender. In all there is local disturbance of the circulation, effusion of fluid from the blood into the interstices of the affected tissues, and thus is produced a certain degree of swelling, but this swelling may last for a very short time, or its duration may be constant for many weeks or months, and nevertheless subside without any permanent structural change having been established. As a general rule, however, the longer the swelling persists the less likely will the patient be to escape struc- tural changes which m.ay persist, and which as time goes on may involve the formation of fibrous tissue or bone, or the replacement of muscle or nerve or a portion of an organ by a low form of passive fibroid material which at least after middle life can never be replaced by normal healthy active structure resembling the original. The aim of medicine is to prevent the occurrence of these last phenomena, and in every decade that passes, new facts are added to our knowledge and the pov/er of the physician to effect this long desired end becomes greater. The early stages of these conditions often yield to treatment steadily per- sisted in for a sufficient time, and even a degree of ataxia due to disease of the spinal cord may pass off without any recurrence. The absence of knee-jerk, though marked for a time, is often followed by a return to the normal state. Among the main troubles following slight or severe attacks of Typhoid fever, Diphtheria, Influenza or blood-poisoning, the morbid conditions we are considering must be included. Persons about or past middle age who had been perfectly free, and as they say had never had a day's illness, became subject to rheumatic or gouty troubles some time after the Influenza had entirely passed off". Even in the young an attack of Influenza often appeared to have been the disturbing cause which determined the commencement of some chronic constitutional malady of which there had before been no indication, and to which there had been no hereditary tendency. There are few questions more important or interesting than these general or local systemic changes which commence some time after an attack of some febrile affection from which however the patient seemed to have completely recovered. The CHRONIC MALADIES. 2/7 fact shows how careful we should be to advise the patient not to return to work for some time after apparent recovery. Particularly after an attack of Influenza, Typhoid, or Pneumonia, is prolonged rest reciuired, and even though the attack may have been slight there is liability to subsequent complications. There has long been an opinion that these and some allied derange- ments are in a measure due to disturbance of digestive organs, particularly to the altered action of the stomach, and some of the processes occurring in the duodenum and upper part of the small intestine, and there is often evidence of the increased generation of acid substances not present in normal digestion, rendering for a time desirable a diet almost limited to vegetable matters. Very little alcohol should be taken, and certainly many cases do better without any, while the daily imbibition of a considerable quantity of water is advantageous. The tendency to sick headache, and particularly that form associated with the production of a large quantity of acid fluid in the stomach is developed in some, or on the other hand, as the patient gets older he may be relieved of this unpleasant malady which perhaps has tormented him from time to time from childhood. The tendency to sick headache may unfortunately be replaced by some gouty, rheumatic, or neuralgic symptom. Sometimes attacks of sciatica or lumbago mark the change — sometimes well marked rheumatoid arthritis in several joints supervenes, or a form of neuralgia from which the patient has never before suflered, torments him. But gouty troubles are perhaps the most common of all, and particularly in those instances in which the patient has long acquired the habit of living too well in proportion to the exercise he takes. The urine will often be found highly acid, perhaps containing excess of urea and depositing urates or uric acid, and of high specific gravity — 1030 or higher. The circumstances which determine the early or late coming on of degenerative changes in certain tissues, which occur sooner or later in all who live to the ordinary period of life, are highly complex and very different in different constitutions, in different modes of living and positions in life. Generally, the conclusion is forced upon us that too Httle work is as bad as excess of work as regards various important organs and tissues, in promoting the occurrence of degenerative changes. But it is as impossible to accurately define the amount of exercise which is bene- ficial to various tissues and organs, as it is to fix the exact quantity of food required to keep the body in health. And it must not be supposed that there is a fixed relation between work and food applicable to each individual. Some organisms are economical and some extravagant, but undoubtedly degenerative changes more frequendy prove to be the consequence of too free living than of the opposite, and this obtains in all classes. It is probably during the early periods of life, from birth to 2^8 CHRONIC MALADIES. adolescence, that there is the greatest danger of serious damage to tissues and organs from too httle food being taken, or from improper food and drink. Our increased knowledge of the structure of the tissues and organs, and of the phenomena which occur in them during their action, give us an enormous advantage over our predecessors in this respect, and it is possible to form, as I venture to think, a not inaccurate conception of the broad changes which are proceeding. In many cases of local neuralgia there may be merely distension and engorgement of the capillaries of a nerve-trunk or of a number of small nerve-fibres extending over a limited area. In this way the fine nerve-fibres amongst the capillary vessels and those close to them may be stretched or pressed upon, or disturbed in action by the fluid exuding through their walls, by the action of leucocytes growing and multiplying around them, or by the rapid growth and multiplication of bacteria which follows the congestion and much slower circulation of the blood through the vessels, as well as of the fluids in the interstices of the tissues. Just as various disturbances of nutrition may be induced by a departure from normal nerve action as illustrated by certain forms of skin eruption— some of them involving the tissues of the true skin as well as of the cuticle— so we find that there is not a tissue or organ of the body of man and the higher animals in which we do not meet with corresponding local changes not unfiequently resulting in the degenera- tion of important textures and small parts of organs in every part of the body. There is good reason to think that the initiatory changes in many cases are really due to disturbed nervous action commencing far away in the nerve-centres which regulate and govern the calibre of the arterioles and even in the higher nerve-centres which produce only an indirect influence. After the local capillary circulation has been rendered slow for a time, the escape of a greater or less quantity of fluid takes place through the stretched capillary wall. This effusion (exuda- tion) is intimately concerned in the production of the pain experienced by the patient in the early stages of neuralgia, rheumatism, gout and allied conditions as well as in some other departures from the healthy state in certain tissues and organs. Many pathological states are associated with, if not actually de- pendent upon, a considerable increase of the living particles (leucocytes) in the blood. Of these, nitrogen is an essential constituent, and in serious acute forms of the conditions we are considering ; the increase of these particles of living matter in the blood and also amongst the elementary parts of the tissues constitutes a danger to life. In vigorous health the excretion of matters rich in nitrogen is remarkable, and it is probable that the early stage of these conditions— the first departure from the normal health is dependent upon an unusual number of CHRONIC MALADIES. 2/9 leucocytes which grow and multiply in the affected tissues. These bodies themselves are mainly composed of nitrogenous substances which have probably been accumulating for a considerable time, and which ought to have been freely oxidised and converted into substances like urea, which would have been quickly removed from the system, without derangement of the health. As I have before remarked the great difliculty in the management of these and many other chronic cases after the middle period of life is to persuade the patient to steadily pursue a rational plan of treatment for a sufficient length of time. If for example you advise that the daily proportion of meat should be much reduced or none at all taken, you may be sure that many advisers far more confident, and in their own opinion more clever than yourself, will do all they can to persuade the patient that he is making a great mistake, and assure him that he will lose strength, that new and unsuspected maladies will come on, that you are on the wrong tack altogether, and that persistence in the plan of treatment you are pursuing will lead to most disastrous results. The patient may, however, sometimes be reassured if you draw his attention to the fact that immense populations live without meat on a kind of vegetable food which certainly would not answer in this country, or suit the constitution of many of our countrymen. So too with the considerable quantity of water you advocate, exception will be taken : but you may direct attention to the great benefit many invalids receive during the short time they spend drinking waters in various distant health resorts, to few of whom it seems to occur that possibly the same plan persisted in after their return home might be of the greatest service and cause the improvement already established to persist, and to increase. Few persons in this country seem to be aware of the fact that multitudes of our fellow creatures live in good health and are very strong and able to do a full amount of nervous and muscular work on a diet without meat and containing but a very small amount of any nitrogenous constituents of food. My old friend Dr. W. J. Palmer, retired Deputy- Surgeon-General, and formerly Professor of Anatomy and of Surgery, Medical College and Hospital, Calcutta, who has had large experience in India, has kindly sent me the following notes, which are, I thmk, of great importance in this consideration: — " Durmg 22 years' residence (1855 to 1879) 16 were spent in Bengal proper and 6 in the North- Western Provinces of the Bengal presidency — very large fields of medical work, and superintendence of the work of others, in both these countries. The population may be said to be Hindoo in both, so few are the exceptions, and this means that they never eat meat of any kind, except perhaps twice a year when they consume a part of that killed by their priest and offered in sacrifice. The two countries, and peoples, 28o NEURALGIA. differ greatly in all other respects. Those of Bengal proper numbered in iS8i — 66|- millions; they reside within 200 or 300 miles of the northern shore of the Bay of Bengal ; they live almost exclusively on rice, supplemented, according to the means of the consumer, by small quantities of vegetables, chiefly pumpkins, of milk, of fresh-water fish, and of lentils. Fish, however, is by no means a regular article of diet, and milk is not taken in large quantities. In fact ' food ' and ' rice ' are in the Bengali language synonymous and interchangeable terms. These people have a tendency to become inactive, flabby, and fat, with keen intellects but weak bodies. During my 16 years' incessant medical work amongst them I never saw (nor ever heard of any other European having seen) a single case of rheumatism or gout in any of these Bengalee people, neither the acute nor chronic forms of those diseases. On the eve of my departure from India an assistant informed me that a case of acute rheumatism had recently occurred in a well-to-do friend of his. This gentleman who informed me was a highly intelligent, as well as a thoroughly educated medical man ; his knowledge of rheumatism must, however, have been obtained from books ; he had not previously seen a case. If, however, it were a case of actual rheumatism, it would rather confirm the supposed intimate connection of rheumatism and diet, for he, the patient, had adopted the European diet some years before the attack. The influence of climate must not, however, be entirely dis- regarded, for Europeans who are members of rheumatic families, suffer much less from that disease in India than they would here, whether they live in the damp heat of Bengal or the dr}- scorching heat of the N.W. Provinces. These provinces lie immediately on the N.W. of Bengal, are never nearer the sea than 300 miles, and may be as far away as 900. This hot dry district will not grow rice but cereals and lentils flourish .and grow abundantly. The staple food here is wheat flour made into unleavened cakes with water and baked. Small quantities of milk, fish, and lentils are also consumed, but ' bread ' and ' food ' are synonymous words in this country. The people are taller, stronger, and physically a much finer race than the Bengalee ; they are in fact as fine a race with very few exceptions as can be met with anywhere, muscular, wiry, and bold with a tendency to become as upright in morals as they are straight in their physical configuration. In 1881 these people were entered as numbering 44^ millions. In all my medical experience amongst them no single case of rheumatism or gout ever came under notice, nor did I ever hear of others who had seen any." TVcuraigia. — Every one of you must have heard something about iVeitt-algia and Neiiralgic pains, though no one has yet been able to give an adequate explanation of their causation in many cases. Some- times these pains are no doubt due to a temporary change induced in the nerve centre or in the nerve-trunk. Perhaps the capillaries NEURALGIA. 28 1 distributed to the nerve-fibres constituting the trunk of a large nerve may be unusually distended with blood. Possibly the circular muscular fibres of the litde arteries ramifying amongst the bundles of nerve-fibres may be temporarily relaxed through nerve influence ; and thus the capillaries distributed to the particular nerve or particular part of the nerve may become much dilated, and by the pressure exerted upon the adjacent nerve tubules, severe pain may be occasioned. That the trunk of the nerve is the seat of attack in many forms of neuralgia is certain, and pain like that of neuralgia may indeed be pro- duced by temporary pressing, stretching, or squeezing a nerve-fibre. If a sensitive nerve-fibre be pressed upon by a growth of any kind, or be stretched over a tumour, great pain often results, and it may continue perhaps for months if the circumstances causing the alteration in the nerve persist. In certain cases, no doubt, the precise seat of the affection is in the peripheral distribution of the nerve where it breaks up into expansions, plexuses, or networks of extremely delicate fibres. Neuralgic pains, then, are generally associated with branches known to consist principally of sensitive nerve-fibres. Perhaps the fifth nerve is the greatest offender in these cases. You may have neuralgic pain closely resembling that of toothache and affecting the very same nerve- fibres, the tooth itself being free from disease. The pain may be so acute as to lead both the patient and his adviser to conclude that some morbid change is going on in the pulp of the tooth. The dentist is consulted, and unless he is thoroughly up to his work, the tooth may be injudiciously extracted, and upon examination found to be in perfect health. The patient, however, goes away with the conviction that, although he is minus a sound tooth, he has at any rate experienced the last twinge of pain. But, alas ! before many hours have passed the suffering returns as bad as ever. Torture as severe in all respects as that from which he had previously suffered is again experienced, though ]3erhaps to the sufferer the pain may seem to be situated in an adjacent tooth. The patient might have one tooth extracted after another without the neuralgic pain being cured. Extraction is not the proper expedient in these cases. In some instances it is probable that the attack depends upon change taking place in the circulation, and that in consequence partly of the pressure exerted by the distended capillary vessels, and partly in consequence of changes produced by exudation of fluid and the growth of leucocytes among the ultimate ramifications of the nerve-fibres, or around their bioplasm, pain is caused, and may persist until the effused substances are absorbed. In some cases the lymph which is present after a time contracts, and phenomena resembling those occurring in cirrhosis of liver, kidney, and central organs of the nervous system follow, 282 TREATMENT OF NEURALGIC AFFPXTIONS. and may result not only in stretching or pressure upon the nerve-fibres or both, but in their complete atrophy, followed by peripheral paralysis, partial or complete, of motion in certain muscular fibres, and of sensation over certain limited areas of skin. In a few very intractable forms of neuralgic pain originating in the tooth-pulp, it is probable that the nerve-centre is the seat of disturbance, and that this is due to vascular congestion, brought about by reflex action. In cases in which the pain depends merely upon some temporary disturbance in the branch of the fifth nerve which supplies the tooth, or in the tooth papilla itself, the probability is that it will yield to simple treatment. Certain forms of skin disease, particularly Herpes, Urticaria, as well as congested areas, ulcerations, sloughing, painful spots, numbness or anaesthesia, hypersethesia, twitchings, pains in many organs, heart, lungs, liver, kidneys, intestines, uterus, ovaries, mammae, as well as many parts of the brain, and ganglia may be due to nerve change. Treatment of Xeuralgic Aftections. — Sometimes a good sharp purga- tive will cure the i)atient at once, but more frequently it is necessary to follow up the purgative with tonics, and especially preparations of bark, or Quinine itself, a mild purgative being also given every few days. In this way you very often cure obstinate neuralgic pains. You must bear in mind that if Quinine is given by itself it may, under some conditions of the system, increase the pain, even for some time; while if you give a pui-gative in the first instance, or combine purgative medicine, such as Sulphate of Soda or Sulphate of Magnesia, with it, the Quinine will often act perfectly well and cure the patient. When the pain is intense, and is decidedly a neuralgic pain, coming on at about the same time of the day, and lasting about the same length of time, you must order a considerable dose of Quinine at once — five or ten grains, — and then from three to five grains twice or three times a day, taking care that the bowels act pretty freely at the same time. Some people can take as much as ten grains of Quinine twice or three times daily for several days with great relief to various nerve ailments. Quinine may be given in the form of pills, or you may place the bitter powder on the tongue, or it may be diffused through water, or dissolved m water containing a few drops of free Hydrochloric, Sulphuric, Nitric, or Phosphoric acid. The usual way of giving Quinine is the last. We order a six-ounce mixture as follows : — Aromatic Sulphuric acid, three drachms ; Quinine, thirty-six grains ; Syrup of Lemon, half an ounce or more, and water to six ounces. The dose will be half an ounce, or one tablespoonful, with an equal quantity of water, three times a day, between meals, for a fortnight. The old Muriate of Ammonia, Chloride of Ammoiiiian, Ammotiii Chloridum, is a very valuable remedy in certain cases of neuralgia which are not relieved by Quinine. Some consider it as a specific, and say that it seldom fails. The remedy should be given in good doses, and it HYPODERMIC INJECTION. 283 is often useless to order less than twenty grains or half a drachm, twice or three times daily between the meals. It is not pleasant to take, as it has a peculiar salt taste which is disagreeable to most palates. How- ever, those who have suffered much from neuralgia are usually ready to try anything that affords them prospect of relief. Salicine is sometimes of use, and may be given in doses of from five to eight grains every three or four hours for one or two days. Salicylate of Soda has been largely prescribed in the treatment of both slight and severe forms of rheumatic pains, and has been given for neuralgia. It is not much used in slight forms of either disease, but occasionally it does good. In many cases of acute rheumatism it acts admirably in lowering the quick pulse and high temperature. It must be given with care, and the patient taking it must be well looked after, as in a few individuals it lowers the pulse and depresses the heart's action to a greater degree than is desirable. Iron. Arsenic. — Many preparations of iron may be ordered in cases of neuralgia, particularly if there is reason to think that the state of the blood is at fault. Arsenic in small doses, and given with due care, will sometimes cure severe neuralgic pain. It is not well to continue arsenic for more than a month at a time. You may order from three to five minims of Fowler's solution of arsenic, Liquor Arsenicalis, with a little syrup of ginger and an ounce of water, three times daily, soon after food has been taken. Opium. — There are several forms in which opium may be given. A small dose of Dover's powder, Pulvis Ipecacuhance Compositiis (from two to five grains), at bedtime, followed in the morning by a mild saline purgative, if persisted in for a few days or a week, will relieve and some- times cure certain forms of neuralgic pain. Hypodermic Injection. — You may, too, inject a solution of Morphia under the skin if the pains are very severe. The sixth of a grain, or less, of this drug is sufficient for subcutaneous injection. The operation is performed with the aid of a little injecting syringe made for the purpose, one of many forms of which I show you. In this way, for the time being, you may relieve the most exquisite nerve pain ; but too often it happens that, as soon as the effects of the Morphia have worn off, the pain returns. You must know that people are nowadays too apt to get into the way of prescribing sedatives for themselves after they have found relief, and thus they may do themselves great harm. You must, therefore, always exercise caution in prescribing and recommending this class of remedies, and be careful to tell patients they ought never to prescribe them for themselves. More particularly as regards hypodermic injection it is my duty to impress upon you the importance of not allowing the patient, under any circumstances, to get into the way of operating upon himself. There is really great danger in this, for the 284 CHLORAL-HYDRATE. process is very simple and easily performed ; and as the relief is great, patients are very apt to assist themselves without waiting for the doctor. Of those who take this injudicious course, not a few get into the habit of narcotising themselves on the slightest excuse. Whenever they suffer slight pain they at once resort to hypodermic injection. As soon as the effects begin to wear off the pain recurs, and the dose is repeated. A vicious habit is soon acquired, and it is difficult indeed to prevent many of those foolish persons from going to extremes and making themselves slaves of the remedy. Very painful cases of the kind come under our notice from time to time, and every now and then death results from an overdose. Patients who have contracted this habit of self-injection not uncommonly lose all control over themselves and introduce narcotics hypodermically, just as other weak-minded individuals become a prey to drink or indulge in other vices. It is remarkable that some of the most active and highly trained intellects should have fallen victims to this most silly system ; and it is hardly credible that the most strong-minded persons are not unfrequently among those who lose all control of them- selves. Some think that we ought to have societies for the entire sup- pression of hypodermic injection. Dr. Sansom's Disks. — Of late years some excellent little disks of gelatine have been prepared, each of which contains a given quantity of the drug we may desire to inject. All that is necessary is to dissolve the gelatine disk in a few drops of warm water at the time when it is required. The solution may then be taken up by the syringe and injected into the subcutaneous areolar tissue of the patient. My friend, Dr. Sansom, was the first to suggest the employment of these disks, which are also used when it is required to apply atropine and other remedies to the conjunctiva. They are prepared by Messrs. Savory and Moore, of New Bond Street. Permanent neutral solutions for hypo- dermic injection are prepared by Messrs. Gerrard and Tanner, of Aldersgate Street, and little tabloids, which readily dissolve in a few drops of water, are now in general use. Chloral- Hydrate and Croton Chloral-Hydrate. — Chloral is of great use in procuring sleep in many cases of severe neuralgia, especially when the patient has been kept awake night after night, but you must give it with the greatest caution, — and only order one, or at most two, doses on the prescription. Take care also to write full directions how and when the draught is to be taken. The dose of Chloral is from ten to twenty grains, with a little syrup, and Peppermint or other water. The most convenient form is the syrup of Chloral-Hydrate, one drachm of which contains ten grains of the drug. Peppermint or Ginger covers the taste of the Chloral better than anything else. In cases of old catarrh and emphysema it should not be given. I have seen it do harm in several instances in which the heart was weak and the right ventricle dilated, RHEUMATIC PAINS. 285 and you must remember that there are chloral victims as well as alcohol victims, and every year some deaths occur from an overdose of this drug. Croto7i-Chloral or Butyl Chloral-Hydrate, which was much used a few years ago, when it was first discovered, has not been heard of so much lately. It is prescribed in doses of one or two grains, to be taken every two or three hours. In the " Lancet " for Jan. 31, 1874, my colleague, Dr. Burney Yeo, reported some cases in which the remedy had been of service in relieving severe neuralgic pain ; and in the same journal for Dec. 2, 1876, you will find some cases recorded by Dr. Skerritt, of Bristol, in which the remedy relieved bilious headache, facial neuralgia, and giddiness. Five grains were given twice a day. Messrs. Corbyn, Stacey, and Co., prepare a Syrup of Croton Chloral-Hydrate, — pills con- taining two, three, and four grains each, — and a Liquor Croton-Chloral, which contains one grain in ten minims. In very severe cases, the external use of Aconite may be tried, and acupuncture and stretching and division of the nerve are justifiable in extreme cases, but some of the results are such as to render it desirable not to recommend surgical interference until every other means have been tried and have failed. Massage. — Of late years, among many new plans of treatment of obstinate nervous affections, perhaps the most popular has been massage. This process, which has been called by some the rubbing cure, is said to require great skill, and to be useless or worse than useless if not practised by skilled hands. Like many other popular plans of treating chronic ailments, massage is reputed to be a certain cure in some very intractable diseases. Among the affections said to be relieved or cured by massage are, congestion of the brain, constipation, enlarged liver, oedema, dyspepsia, pain in the heart, catarrh, neuralgia, scriveners' palsy, distortions, chronic arthritis, rheumatism. Labour pains may be excited, the position of the child altered, the detachment of the placenta effected, menorrhagia caused to cease. Even the ear and the eye may be massaged, cloudy swellings of the cornea, and conjunctivitis cured ! In short, there is hardly a disease in which treatment by massage has not been advocated. And many of its advocates entertain no doubt whatever as to its curative effects, even in conditions caused by changes of the most opposite and, perhaps, conflicting kind, such as morbid changes relieved by rest, and morbid changes to be relieved or cured by movement. Rheumatic Pains. — I must now say a few words about another kind of pain which is very common. It is, perhaps, not so severe as bad forms of neuralgia, but it nevertheless occasions much suffering, and in some cases is so severe and so constant as to prevent the patient from following his work. I allude to the so-called Rheumatic Pains, which affect certain tissues and occur in many different parts of the body. The character of the pain differs somewhat in different cases, 286 MUSCULAR RHEUMATISM. sometimes beinc^ sharp evanescent twinges, which either flit about, as it were, from place to place, or seem to be obstinately fixed in certain joints, the severity of the suffering altering only in degree. A good many old men and old women living in cold damp country places will tell you they have been martyrs to rheumatism for more than half their lives. When the blood is in a state favourable to the development of those changes which result in rheumatic pains, you may be exposed to cold damp air for a short time towards sundown, and conscious of a slight chilly feeling ; but in two or three hours you may feel very decided aching of the muscles of the forearm, or upper arm, or of the leg, back, or other part of the body. Perhaps some of the tendinous structures about the wrists or ankles are the seat of fixed continuous pain, which becomes worse on exertion, and makes it a matter of great difficulty to lift anything or to perform the ordinary movements. A^ery commonly the muscles at the back of the neck, from their insertion in the occipital bone down- wards, are so painful that you cannot turn or bend the head. Partly from the pain and discomfort experienced, partly from the effect of the altered blood on sensitive nerves of the body generally, you feel quite ill and must lie down. You soon find out that external warmth gives great relief. Sit before a good fire, wrap yourself up in a railway rug, take a • warm bath or hot-air bath or a Turkish bath, and the pains may soon disappear. If you go to bed and freely perspire, you will feel better within an hour. But, perhaps, after a few hours more you have evidence that the pain temporarily allayed has not really gone, and that the changes which caused it are dependent upon phenomena which deter- mine a more lasting departure from the normal state. Rheumatic pains are often preceded by or are associated with flatulence, heart-burn, and other symptoms mdicative of deranged digestion. Some suppose that the peccant matter which causes the pain is actually secreted by the stomach, while others consider that it results from the occurrence of unusual chemical changes taking place in the recently absorbed constituents of the food. In favour of this latter view may be adduced the fact that the subjects of rheumatism are almost invariably made worse by beer, while rheumatics who can be persuaded to give up this popular beverage, almost invariably improve. The rheumatism, however, returns whenever the beer is resumed. Rheumatic pain in many cases seems to be seated in muscles and in fibrous tissues, while neuralgic pain is generally seated in a nerve- trunk or its ramifications. The dental nerve and its branches, or the superior maxillary or frontal, or certain cutaneous branches in various parts of the body, are more frequently affected than other nerves. Rheumatic pains, on the other hand, generally seem to be situated deeper, and to be more widely dispersed apparently in the substance of NATURE OF RHEUMATIC PAINS. 28/ tissues, as if emanating from many ultimate ramifications of nerves distributed in tendons, or fascia, or in the muscles themselves. Lum- bago is a form, and a very unpleasant one, of muscular or fibro-muscular rheumatism. Sometimes it is very obstinate and very difficult to cure. The patient is obliged to rest in bed, and it may be a fortnight or more before he is able to bend his back without great suffering. Care must be taken not to mistake pain in the back arising from other and more serious conditions for rheumatic muscular pain or lumbago. Rheumatic pain seems in many cases to arise very near the insertion of a muscle where there is much white fibrous tissue in connection with the periosteum. The point of attachment of the deltoid to the humerus is a favourite spot for the development of rheumatic pain, which may be so severe as to interfere with the raising of the arm, and to render the putting on of a coat without assistance a very difficult proceeding. Sometimes the pain persists in this situation for several weeks or months. The intercostal muscles are not unfrequently the seat of very severe rheumatic pain which is sometimes mistaken for pleurisy. The muscles of the side and of the hip are also frequently affected. Rheumatic pain in some of the fibres of the diaphragm and of the abdominal muscles has on occasions unfortunately led the practitioner to hastily express the opinion that the patient was suffering from peritonitis ; and some days perhaps will have elapsed before this unfortunate and erroneous diagnosis has been corrected. The nerve-fibres distributed to the muscular fibre cells (organic muscle) may be the seat of rheumatic pains as well as those distributed to voluntary muscle. It is to be remarked with reference to the latter, that those parts of the muscle situated nearest to the tendon are most frequently the seat of the pain. Here, of course, the circulation through the vessels is slowest, and there would be the greater chance of any exudations poured out from the blood producing a deleterious influence upon the finer branches of any nerve-fibres with which they may come into contact. In various forms of rheumatism then, we infer that it is certain of the fibrous tissues that are the seat of pathological change. Exudation is probably poured out from the blood as the circulating fluid slowly traverses the sparsely scattered capillaries of the tissues. The nerve- fibres close to the capillaries are those which are affected. The exudation poured out probably coagulates, and part of it is at length converted into fibrous tissue, so that the affected textures become thickened and the movements of the joints and of the tendons and muscles in their neighbourhood seriously impaired. In many old cases of chronic rheumatism the patient is seriously crippled, and the movements of some of his joints are greatly impeded or altogether stopped. It would almost seem as if in bad cases of rheumatism the 288 ^^\TURE of rheumatic pains. fibrous tissues were the seat of a sort of slow inflammation ; and that the exudation poured out in the interstices of the bundles of the fibrous tissue gradually increased in amount as the disease advanced, and that the resulting fibrous tissue underwent condensation and contraction, greatly interfering with the action of the tissues in question. The movements of the large joints at last cease altogether; this change being partly due to the pathological phenomena I have described, and in part to the circumstance that the pain accompanying every effort to move has gradually discouraged the patient from making any attempts. The limbs become quite stiff, and the unfortunate victim is entirely dependent upon others, even for every mouthful of food he swallows. We often see extreme cases of the kind in country workhouses. If you visit some of these institutions, you will almost certainly discover several persons who, for many years, have been complete cripples from rheumatism, and are bedridden and incapable of moving any one joint in the body. The inquiry as to the actual state of things at the seat of pain during the early stages of the disease in ordinary rheumatic affection is an interesting one, but I am sorry to say I cannot tell you what are the essential differences between a slightly rheumatic and a perfectly healthy tissue. The facts of the case justify the conclusion that certain materials, probably soluble, are formed in undue quantity in the blood that the solution transudes through the walls of the capillaries in situations where the vessels are few and the circulation is slow, that the contact of the fluid with the fine ramifications of the nerves and the growth and multiplication of leucocytes close to the capillaries causes pain, that in consequence of the formation of more fluid of the same character in the blood, that which has been already poured out cannot at once be absorbed. The accumulation thus brought about, accounts for the persistent character of the pain. "Whether the pain is caused by the direct influence of the eff'used fluid on the fine nerve-fibres, or upon the bioplasm or living matter connected with them, is a question which is open to discussion. There can be no doubt that stretching of the terminal ramifications of nerve-fibres or pressure upon them will give rise to pain, and it is not unreasonable to infer that fluid differing in its composition from that which bathes them in health would cause pain as well as disturbance of nerve action. The mere stretching and pressure to which the nerves are subjected are not, it may be fairly objected, an adequate explanation in many cases, as, for instance, in those where there is persistent rheumatic pain, not associated with any tension or swelling of the tissues. The views above suggested, however, receive support from the fact that in many cases after very free secretion has gone on for some time from skin, kidneys, and bowels, the re-absorption ■of any exuded fluid does take place and the rheumatic pain ceases. 1 KJLAl MliiN 1 Uf KllU-UAiA 1 ISM. -oy With regard to the muscles there is ahnost invariably imperfect action, and some muscles during an attack pass into a state of complete inaction. The muscular tissue, which has been many times affected by the rheumatic state, gradually wastes, and the muscle itself after becoming very weak soon exhibits structural degeneration. Near the tendon the contractile tissue undergoes condensation and slowly degenerates into fibrous tissue, while in the adjacent fleshy parts fatty degeneration often occurs. Shrinking, wasting, thickening, and contrac- tion proceed until fibre after fibre has deteriorated, when the limbs fail to execute their ordinary movements. I need hardly say more concern- ing the very serious results consecjuent upon the long continuance or frequent recurrence of the rheumatic state. Every one must see the importance of doing all he can to check the pathological changes, or failing this, to cause them to progress as slowly as possible, and to retard the development of that dreadful state of helplessness and in- capacity which are too often the consequences of frequent separate attacks of rheumatism or the continuous very chronic form of the malady. measures to be Adoiitejl for tlie Treatiuent of Hlieuinatism. — The very quick cessation of some forms of even severe rheumatic pain is very remarkable. A dose of Sal Volatile, a small glass of wine, a teaspoonful of spirits, twenty grains of Bicarbonate of Potash or Soda, a grain or two of Quinine, have severally in different cases had the effect of removing slight and even rather persistent pains of the rheumatic class within half an hour. Equally surprising is the effect of a warm bath or careful rubbing. It may be regarded as certain that pains of the rheu- matic as well as of the neuralgic order may be quickly alleviated by effect- ing changes in the alimentary canal, or on the external surface of the skin — a fact of the utmost importance in considering the treatment necessary for severe forms of the malady. The change so desired is brought about through the influence of nerves, and is, at least in many cases, reflex. By the remedies and by external rubbing the capillary circulation is affected, and there can be little doubt that the particular nerve fibres favourably influenced are those which run with the capillary vessels. No doubt the relief of the pain under the remedial influences referred to is but temporary, but by repetition of the same methods at certain intervals, the relief may be maintained, and after a time the con- ditions associated with the occurrence of the pain being removed, a cure may be effected. The repetition day by day for two or three weeks of free perspiration may have a most beneficial effect, and if only the patient can be persuaded to continue in a milder form for a much longer time the method of treatment recommended, he may not only keep himself well, but may prevent the occurrence of morbid changes which otherwise would slowly progress, and at last result in the de- 2gO TREATMENT OF RIIEUMATIPM. generation of muscular and nerve tissues of a very important and, it may be, irremediable kind. General hi/its concerning the prevention and relief of chronic rheumatic affections. — All who suffer from rheumatic pains, should, therefore, be made to understand that by acting in a certain way they may greatly diminish the tendency to rheumatism if they cannot completely check it ; while by acting in a different manner they may greatly encourage and expedite the progress of the morbid change. All rheumatics should he instructed concerning the great importance of promoting the free action of the secreting organs generally. The medical adviser should particularly direct the patient's attention to the great importance of frequent and free action of the skin, kidneys, and bowels, in order that the materials which tend to accumulate in the blood and which are concerned in the causation of the rheumatic state shall be removed as fast as tliey are formed, and as soon as possible expelled from the system, so that there may be no danger of their accumulation. It is remarkable how inveterate is the tendency in many to the formation and accumulation in the system of compounds of the class in question, and if the patient is to remain free from their deleterious effects, he must compass their removal day by day. In our climate a tendency to slight rheumatism is so common that I should say at least half the population suffer more or less. It is noticed, too, at every period of life. The so-called nervous^ neuralgic, and muscular pains are very often of a rheumatic nature. These may get well of themselves or be relieved or removed by a purgative, by a i&v^ doses of Bicarbonate of Soda or Potash, or by one of those effer- vescing salines now so commonly sold, or by frequent ordinary warm baths, or, in the case of the young, by active exercise followed by free perspiration, the diet being, of course, carefully regulated at the same time. A somewhat more decidedly developed rheumatic condition often brings patients to us for advice, and here and there, I am sorry to say, we find this to be but the state precursory to a severe attack. In the great majority of cases, however, the morbid condition yields, in a few days or a week or two, to remedial measures based on the principles already referred to. The first thing to bear in mind in the treatment, I might say of every form of rheumatism, is that free action of the skin should be encouraged. Warm baths of various kinds, and in many parts of the world, have been held in great repute for their curative properties. The Turkish bath is often of great use to those who are troubled with severe rheumatic pains. It is, however, a rather long business, and the patient who adopts it must have two hours or more at his disposal. I know people who take a Turkish bath twice every week with advantage, and consider that they <;()uld not get on without it. iUKKiSii Jj.\ lilb — Al.KAUlt..^. ^yi Those who cannot or will not adopt the advice given them to take Turkish baths may, perhaps, not object to an ordinary warm bath, twice or three times a week, staying in the water from twenty minutes to half an hour, or until they perspire freely. I think the action of the ordinary warm bath in rheumatism is improved if the water be made alkaline. This may be done by dissolving in it a quarter of a pound of washing soda. The vapour bath is also of great use, and so is the hot air bath. Very simple arrangements for vapour or hot air may now be obtained. Among the most etilicient is the portable apparatus sold by Hawksley, 357, Oxford Street, London. By free perspiration the removal from the blood of a large quantity of water, holding various substances in solution, is effected. Then thirst is excited, and the patient, to allay his thirst, drinks freely of aerated or other water. In this way the noxious materials which would otherwise accumulate in the tissues are gradually removed from the system, and the patient may escape much suffering. Small doses of Mercury. — Cases of rheumatism which have lasted for weeks or months, in which there has been pain in many muscles and in the fibrous tissues about the joints, and even a moderate amount of effusion into more than one joint, but without febrile disturbance, have been cured by two or three small doses of Mercury. The bowels, you win be told, are regular and have acted daily — but even in small eaters the dose you give will be followed by such free action that you will feel surprised. In these cases excrementitious matters have gradually accumulated in the blood and tissues, and by proper treatment the accumulation may be got rid of— not often by one dose, but after several given at intervals of a few days at a time. You need only give less than a grain in each dose, and probably three or four doses will be sufficient to cure the patient. This is one of the very few instances in which the word " cure " is, I think, correctly used. Many old doctors adopted this plan and some carried the system too far, but few of the rising generation are aware of its great value, and if they were, perhaps they would not adopt it until they had taken courage to try the experi- ment in their own organisms, or in the case of medical friends who are able to form a judgment of the effects of a remedy. Alkalies may be given in all forms of rheumatism. It is very im- portant for the free action of the muscles that the fluid which bathes the contractile tissue, and which undergoes alteration during the action of the muscle, should be frequently changed. If some portions of the fluid remain in contact with individual fibres, the materials resulting from the decomposition taking place during the action of those fibres will accumulate and necessarily interfere with their free action, probably also affecting the action of the nerves, and thus occasioning rheumatic pains. You will find that generally muscular pains may be relieved by U 2 292 REMEDIES EoK RHEUMATISM. exciting the action of trie skin, the bowels and the kidneys. Alkaline remedies have a very beneficial effect, and are invariably useful to those who suffer, possibly because in this condition there is an invariable tendency to the development in the system of organic acids, particularly lactic. You may order Bicarbonate of Fotjsh, or Liquor Fo/assce, or Bicarbonate of Soda. These are very old remedies, and concerning their influence in relieving rheumatic pains there cannot be the slightest doul)t. In many slight cases of pain, twenty or thirty grains of Bicar- bonate of Potash, dissolved in two ounces of water, will be found to relieve in three or four hours, and sometimes in half an hour. Sal Volatile helps the action, and also stimulates the heart a little. Thus the blood is driven more quickly through the capillary vessels, and in this way absorption is promoted. You may order the alkali to be taken about half an hour after meals, for a week or a fortnight at a time. But you must take care not to let a patient go on taking Liquor Potashes or Bicarbonate of Potash from one year's end to another, or you will probably be consulted on account of the appearance of phosphates in the urine, with perhaps irritable bladder. Retention of urine may follow, and considerable quantities of pus may be formed. Sometimes the patient becomes v«ry low and weak, and I am not sure that serious changes in the blood, and even purulent inflammation of joints, have not resulted from the too long continued use of alkalies. You must not forget to explain to patients how long you wish them to continue taking any medicine you prescribe, or you will sometimes be astonished, if not alarmed, to find that an obedient patient, for whom you have prescribed a pill, has been daily taking it for years. If a patient suffering from rheumatism finds that alkalies disagree with him, and disturb his digestion, you may try salts of vegetable acids, particularly the Citrates and Tartrates, for these become converted into alkalies in the system, and the urine may even be rendered alkaline by them as well as by the ordinary alkalies. Lemon and orange juice, and many fruits, also act beneficially in some cases. Among diuretics, the ordinary Nitrate of Potash or Common Nitre — dose from five to ten grains, in water, three or four times a day ; the Acetate of Potash, in doses of from ten to fifty grains, in two ounces of water, three or four times daily ; the Bitartrate of Potash {Fotassce Tartras Acida), in doses of twenty to sixty grains or more, in two or three ounces of witcr, three or four times in the twenty-four hours (sometimes also acts as a purgative) ; and the Citrate of Potash, in the same doses as the Acetate, — are the most generally u'-eful. Guaiacum. — In former days Guaiacum was much in favour in the treatment of chronic rheumatism, and I have found benefit result from its use. You may prescribe the resin, Guaiaci Pesina, in doses of ten grains made into pills or finely powdered and mixed with milk, three or BROMIDE OK POTASSIUM. 293 four times a day, or the Mistura Guaiaci, an ounce of which may be ordered twice or three times daily. Perhaps the least unpleasint form in which to take Guaiacum is as the Ammoniated Tincture, Tinctiira Guaiaci Ammoniata, in a mixture with some bitter tincture or infusion. Mucilage and a few drops of Spiritus Chloroformi, with water ; or peppermint, mint, or other water, may be used to cover the taste. Iodide of Potassium. — You will often find that severe lumbago pain, fixed pains in the muscles and fibrous tissues in many parts of the body, and severe chronic aching about various joints, which have troubled people for months, will be relieved by a few doses of Iodide of Potas- sium {Fofassii lodidiiui). You may begin with three grains, three or four times a day, and gradually increase the dose to five, six, eight, or ten grains. The Iodide should be dissolved in a considerable quantity of water, and should be taken about an hour or more after meals. You may also give with it half a drachm of Liquor Cinchoncd (De Vry's), and a few drops of Tincture of Ginger. Although I cannot justify the practice, on scientific grounds, I often give with the Iodide, Nitrate of Potash (five grains). The Iodide probably acts upon the painfcl textures, partly by promoting the absorp;ion of exudation, out I think chiefly by taking the place of Chloride of Sodium, driving this out and thus^ perhaps, promoting free circulation of fluids and saline matters through the interstices of the textures. Do not accept the conclusion, implicitly received by many, that the beneficial action of Iodide of Potassium is evidence of the syphilitic origin of the malady. This is one of the new delusions. Some authorities attribute half the ills we suffer from co syphilis, and even think that a syphilitic taint accounts for the majority of ailments they cannot otherwise explain or account for. If neither you nor your father nor your grandfather had syphilis, the origin of the disease is to be discovered further back in your ancestral line. Some authorities seem to think that no one exists who is entirely free from syphilitic taint. Both Iodide of Potassium and Bichloride of Mercury iieiit of .Mild Cases «f Itlicuiuatoid Arthritis. — Up to the time when the swellings connected with the tendons or periosteum become condensed, and probably till much adventitious fibrous tissue has been formed, and has accumulated and undergone contraction and condensation, the morbid condition ought to be remediable ; and as this state sometimes exists for three years or more there is i)lenty of time to carry out methods of treatment adapted to particular cases, which vary in constitution, age, and surroundings, and require somewhat different management. One would naturally conclude, therefore, that certain MILD CASES OK RIIKL'.MATOI 1 ) AKTIIKITIS. 3OI broad questions, such as the proper diet, the amount of h'quid to be taken in the twenty four hours, and other general points of first con- sequence would hy this lime have JK'cn conclusively determined, and that general jjrinciples of treatment would have been established. But, as in many other chronic and obstinate diseases, there is great difficully in persuading patients to steadily persevere in any course for a suffi' ient lime to inlluence the morbid processes and tendencies which lie at ihe root of the malady, and which undoubtedly in many cases are not easily overcome. If in these days a sufferer does not find evident improvement in a short time he desires to try another plan of treatment, and looks about for some new curative process, which perhaps to his mind a{)i)ears more likely to be efficient. Sometimes a patient will conclude that the greater the distance he has to travel in otder to place himself under the influence of some particular plan of treatment, or take the advice of some far distant authority, high in public estimation, the better will be his chance of recovery. A large number of curative medicines, the wonderful properties of which are extolled in the strongest terms by those who claim to have experienced their potency, are at our disposal. But nevertheless, we meet with cases th.at have resisted every kind of treatment that had been suggested — cases which improve a little from time to time, but fall back again, and at length pass into a condition in which structural alterations of tissues occur, and we are practically restricted to employing means of alleviating pain and taking measures to render the rate of pro- gress of the malady as slow as possible. In such a disease as chronic rheumatoid arthritis we should endeavour to decide as to the general method which seems most likely to modify the course of the patho- logical changes upon which the disease depends. The first general question of the greatest importance in the management of all cases of rheumatism, rheumatoid arthritis, gout, and some forms of neuralgia, is diet. This has been felt by all practitioners from very early days, and the results of practice confirm the conclusions arrived at from the microscopical and chemical investigation of the minute changes oc- curring in the tissues affected, as well as the conclusions of physio- logical research concerning the influence of different kinds of diet upon the general health. In not a few morbid processes, in the origin and progress of which nitrogenous articles of diet play a neces- sary and very important part, it is of the first consequence to consider whether these ought not to be much reduced, or altogether withheld for a time. There are often indications that during a long period, sub- stances of this class, or compounds resulting from their chemical change, have been accumulating in the system, and that some of the excess, instead of being thrown off as in health, has been appropriated by the living matter of certain tissues or organs, the particles formed 302 MILD CASES OF RHEUMATOID ARTHRITIS. seriously interfering witli their proper action, eventually resulting in the establishment of certain morbid processes, from which complete re- covery, after a certain time, is improbable or almost impossible. In the pathological changes already referred to as occurring in rheu- matoid arthritis it is certain that albuminous substances take an active part. Clearly, therefore, the patient should reduce the quantity of this class of foods. Little meat must be allowed, and gradually the patient may be induced to live without meat of any kind. I have found that no inconvenience or discomfort results from entirely withholding meat for many months, at any rate in the case of those about or past middle age. The patient soon gets into the habit of living upon vegetable food, but an egg or two as well as a fair quantity of milk may be allowed. After this course has been adopted for a month or two evidence of improvement will probably be afforded. The swellings on superficial tendons, which can be easily watched, and the oedema around will be perceptibly less. All pain may perhaps have ceased, and the patient v/ill feel encouraged to persist in the course suggested. In old age an almost exclusively vegetable diet with milk will be found gener- ally conducive to health. It does not cause old people to feel weak, and certainly in the majority of cases it perfectly agrees. Much has been said against the use of sugar in many departures from the healthy state, and very strong opinions have been given of the ill effects of this substance in gout, many forms of rheumatism, in indi- gestion, and many other ailments. Even in the healthy, sugar does not suit every stomach, and when this is the case certainly it should be avoided altogether, or only very sparingly taken. But with many sugar agrees admirably ; and in many forms, especially in the young, it seems to be a useful article of diet, and is certainly very much liked, and even longed for. Sweet fruits agree with most people, though one here and there cannot eat a single strawberry without suffering pain and stomach derangement. Ever since I began practice I have been an advocate for sugar, except in those rare cases in which it disagrees with the stomach and gives rise to heartburn or other trouble. In the case of young persons there is no doubt whatever that sugar is advan- tageous—not when taken frequently between the meals, of course, but with some kind of food at each meal, or with one or two of the meals. Very interesting are the recent observations of Dr. Vaughan Harley, who has shown, and I think conclusively, that sugar when taken as a food is " an active generator of muscular energy," a " promoter of mus- cular power " — that it retards the approach of muscular fatigue, and increases the day's muscular work. Now in rheumatoid arthritis I have put this j:ugar question to the test. On days when the swelling and pain had somewhat increased, sugar in various forms was taken to the amount of three ounces or MILD CASKS Ol- RHEUMATOID ARTHRITIS. 303 more daily without once procliicinjf'^ny change for worse, or giving rise to increase of pain. The experiment has been repeated again and again without deleterious consequences. But some patients undoubtedly find sugar does not suit them, in which case it must of course be given up. But to make objections to a moderate quantity of sugar in various forms of gout, rheumatism, arthritis, and neuralgia, and some other maladies, and to allow much, more of the meat class of foods than the system requires in good health, is, I venture to think, not in accordance with what we are taught b)' practical experience, or with what is sug- gested by reason. Of the general advantage of easily digestible fats in rheumatoid arthritis I have no doubt. Cod-liver oil has been strongly recom- mended by nearly all physicians who have had much experience in the treatment of this intractable disease. Milk, cream, and most fats may be given with advantage, particularly if the patient is thin and has been gradually losing weight for some time. Marrow seems to be one of the most easily assimilated of fats, and is borne well in rheumatoid arthritis. It may be lightly cooked and spread en toast. It is possible, too, that it may exert an influence upon the blood, and favour the in- crease of red blood-corpuscles, as Dr. Frazer, of Edinburgh, has shown to be the case in serious forms of anaemia ('' On the Effects of Bone Marrow in Pernicious Anaemia," Eleventh International Medical Con- gress at Rome, 1894, " Lancet," April 7th, 1894). Clotted cream, butter, milk, and milk puddings daily, generally suit patients suffering from rheumatoid arthritis. The quantity of liquid taken in proportion to the amount of solid or semi-solid food, especially after middle life, is generally too small to dissolve all that is required, and to effect that free circulation in the interstices of the tissues by which alone their healthy state and activity can be maintained, — too small for the chemical change of the excess of nutritious matters into compounds readily soluble in water and easily removed by the various excreting organs. In this way the undue accumulation of various substances in the tissues occasions impairment of activity, and degeneration of structure is brought about, and many im portant morbid changes, which often considerably shorten life, may ensue. Hundreds of popular baths and health resorts in every part of the world bear testimony to the healing powers of fresh air and various kinds of water, taken regularly and in quantities more considerable than the patients would think of imbibing at home. Of the benefit resulting there can be no doubt, and year after year the same persons return for treatment to the same springs, often with repeated good effects. But many who suffer from chronic maladies requiring this treatment are unable to change their surroundings, and it is therefore our duty to consider whether they cannot be treated on somewhat the same plan at 304 MILD CASES OF RHEUMATOID ARTHRITIS. liome. CertainI}' as ree:ards the increase of fluid this can be done easily enough, and at small expense. Patients may be instructed to take half a pint of water before breakfast, a like quantity between break- fast and the midday meal, and the glass repeated in the afternoon and the last thing at night. Water that has been well boiled may be taken w^arm in winter, tepid or cold in the warmer parts of the year. Distilled water, aerated if desired, may now be obtained without difficulty, and is well adapted for dissolving various substances which require to be removed from tissues if healthy action is to be retained or restored. Cases of chronic rheumatoid arthritis not complicated with renal disease certainly get on better when there is free diuresis than when there is free sweating. Indeed, in many cases the malady increases when there is much night perspiration, which may often be checked by quinine, nux vomica, or salicin. The two processes, diuresis and diapho- resis, have been encouraged alternately, and always with the results above mentioned, — reduction of the pain and swelling nearly always following the first, and increase of both resulting from the last. Free diuresis as promoted by three or four pints of water in the twenty-four hours has been steadily kept up for more than two years without any harm result- ing, and almost invariably with improvement. All forms of alcohol have been withheld, and even in cases where only a very moderate diet destitute of meat was allowed there was no e\"idence of loss of strength or weight. Now if in well-marked cases of a chronic malady, such as estab- lished rheumatoid arthritis, one finds a method of treatment may be persisted in for a considerable time with mitigation of the symptoms and steady improvement in the swelhngs and accompanying oedema, it is reasonable to conclude that if the same plan had been adopted at an earlier period, the disease might have been actually cured, especially in the case of those who are attacked at a comparatively early period of life. I have seen great benefit result in cases where the plan has been carefully and steadily pursued in old age. The pain has ceased, and the swellings in almost every situation have been much reduced. The patient, however, must be carefully watched in case the treatment should not suit ; but generally with a little management, and by in- creasing the quantity of liquid by degrees instead of placing the patient on the full quantity at once, the regimen will he well borne, and in many cases it is liked and persisted in for a year or longer without in any way disagreeing or causing inconvenience. As before remarked, many do well and progress steadily without any stimulant ; but if patients will not submit to this recommendation, a tablespoonful of whisky or brandy with water may be allowed at two meals daily. The value of alkalies, and of nitrate of potash, of salicin, salicylate of soda, and other remedies is unquestionable. I have found quinine in doses GOUT AND GOUTY TENDENCIES. 305 of from three to six grains, daily persisted in for some months, of great use, and have given with it small doses of nux vomica with benefit. Iron and arsenic are undoubtedly useful. In many instances half a grain of calomel twice a week has been of great service, especially in those cases, by no means uncommon, in which the action of the liver is disturbed and the motions scanty and pale, perhaps for weeks at a time. Ordinary mild purgatives are occasionally required, and among the most useful are magnesia, the calcined or the carbonate, alone or combined with the sulphate in small doses ; — or cascara or compound rhubarb or colocynth pills may be given twice or three times a week. Of !*ili^Iit iioiit anil of Gouty Tenilcncies — Hints on Treatment. — Ordinary gout will hardly be considered to be a slight ailment by any one who has had personal experience of the pain and other symptoms, but many slight twinges and various symptoms occurring in persons of a gouty tendency may fairly be included in the category of slight ail- ments. An attack of gouty trouble usually comes on suddenly with some degree of local swelling and pain— probably in one or more of the small joints and in the adjacent tissues. The swelling remains for a time and then gradually subsides. The same sudden invasion is observed even in very slight attacks, whether the pathological change affects the tissues of joints or muscles and fibrous tissue only. Uric acid and urates are often present in the urine in considerable proportion in many of these cases, especially as the attack subsides, or just after it has passed off; but we must also bear in mind that these deposits are found in many cases in which there is no indication of a gouty tendency. The interstitial fluid is not sufficiently alkaline to keep the urates in solution, and when this gouty condition has existed for many months or years, not unfrequently a very slightly soluble urate, urate of soda, is deposited in some of the tissues in needle-like crystals, which sometimes increase in number till a soft pultaceous mass is formed which seriously impedes movement of the parts. As this be- comes dry, it assumes a chalk-like appearance and the collections are known as " chalk-stones." Tissue degeneration often commences early and proceeds imper- ceptibly without the patient's knowledge until considerable structural change has occurred and the affected tissue can no longer perform its normal functions. It is therefore necessary that we should always care- fully examine a patient who has had even slight evidence of a gouty tendency. In the early stages of the affection I have no doubt many a patient can be cured, but after the disease has existed for a consider- able time and many attacks have occurred, serious tissue-changes take place. Between fifty and sixty-five, those who have been for years suffering more or less from gouty symptoms not uncommonly exhibit evidence of commencing disease of liver, kidneys, heart, lungs, o»- X 3o6 GOUT AND GOUTY TENDENCIES. brain, and some forms of organic disease, long suspected, for the first time become unmistakably manifest. Chronic nephritis often accompanies other changes in the gouty, and, perhaps for the first time after years of gouty troubles, albumen is detected in the urine. One often regrets that the renal degeneration was not discovered at an earlier period of the gouty condition, when perhaps the patient might have been persuaded to radically change his mode of living, and degenerative changes might have been prevented, or at any rate post- poned for a time, and caused to progress very slowly. The tendency to the occurrence of various ailments at this period of life should be well considered, as it is of the greatest consequence to detect the changes as soon as they commence, particularly in gout complicated with different forms of rheumatoid arthritis, and any enlargement of joints or thicken- ing of tissues in the neighbourhood, and the limiting of freedom of movement, and pain, though slight, should be noted. Even in cases which have been treated for some time by alkalies given freely from day to day for several weeks at a time I have remarked that the tendency to the formation of an undue quantity of acid still persisted. Acid eructations were frequent, the urine still remained acid, and a considerable deposit of uric acid or urates was generally present. It is a question whether taking from three to four pints of distilled water daily for a fortnight or longer does not get rid of this acid-forming tendency more effectually than the persistent use of alkalies, and there is no doubt that the long continuance of a very decidedly alkaline treat- ment is sometimes ineffectual and sometimes injurious. The practi- tioner must, however, be prepared for comparatively slow improvement in many of these chronic and intractable cases, though some persons undoubtedly do completely recover after having suffered for many years, although deposits or thickening may have occurred in connection with joints, tendons, periosteum and other fibrous tissues in many parts of the body. Purgatives are of use in the ailments under our notice and in some cases are absolutely necessary. The better the appetite, the more freely people live, the greater is the importance of this class of remedies. In general, violent purgatives are not needed, and may do harm. Moderate doses of colocynth or cascara extract daily or every other day after dinner and persevered in for some little time frequently give the patient great relief. A compound colocynth pill with a grain of gray powder or half a grain of calomel every other day after dinner is often of great use. But in slight cases of gout small doses (a teaspoonful in water) of calcined magnesia or carbonate of magnesia twice or three times daily -between meals for a week or so, usually is of great service. Persons with any gouty tendencies should take litde or no meat at least on alternate days, especially if they have reached or passed middle GOUT AND GOUTY TENDENCIES. 307 life. Vegetables, particularly mustard and cress, watercresses, and lettuces, cooked fruit, and farinaceous puddings. Two tumblers of water with two moderate meals daily, as well as a glass of warm water on rising or going to bed should be allowed. If, however, the gout is acute or accompanied with deposits of urates in the tissues, or with actual disease of the kidneys, other means must be adopted and the patient must place himself under careful medical treatment. Such cases cannot be considered to be slight ailments. X 2 ON FEVER AND INFLAMMATION— OF CATCHING COLD- PRELIMINARY CHANGES AND ^ATTENDANT PHENO- MENA—THE BODY-HEAT OF MAN AND WARM-BLOODED ANIMALS— RISE OF THE BODY-HEAT IN ALL FEVERS AND INFLAMMATIONS— IS THERE INCREASED OXIDA- TION IN FEVER AND INFLAMMATION ?— METHOD OF ASCERTAINING THE TEMPERATURE OF THE BODY- ESSENTIAL PHENOMENA OF FEVER AND INFLAMMA- TION—OF FREE SECRETION LEADING TO RECOVERY— THE PRINCIPLES UPON WHICH THE TREATMENT OF A COLD SHOULD BE CONDUCTED— OF FEVER WHICH BEGINS LIKE AN ORDINARY COLD— SLIGHT FEBRILE ATTACKS. On the Feverish ami inflanimatory State. — A departure from the healthy state of the blood may originate in the blood itself, or may be determined by changes in the tissues and organs which it nourishes. The change in the blood may, in its turn, react upon and influence the action of some, and, indeed, almost all the tissues and organs in the body. When thij is the case, the phenomena are said to be " general," to distinguish them from phenomena of the same kind, but which are restricted in area, and are therefore termed "local." We may speak of general tissue changes, general fever, general injlanwiatton, as contrasted with similar actions, but which are local, and affect only a very small portion of the tissues. Among the most important and most common general changes are those departures from healthy action known diS fevers and general inflammatiofis. So common is febrile and inflammatory disturbance that it is doubtful whether a single example of a mammalian organism could be adduced which had reached maturity without having suffered more or less. Few of us pass a month without experiencing, in our own bodies, some slight degree of febrile or inflammatory disturbance, and many are seldom entirely free for many weeks at a time from phenomena of the kind. Of Catching Cold. — Before bringing under your notice the actual phenomena which characterise all fevers and inflammations, I propose to direct attention to that most common of all febrile disorders, and the best known of all slight ailments — an ordinary cold — in the course OF CATCHING COLD. 309 of which a certain degree of febrile and inflammatory action invariably occurs. Most people have "caught cold " probably many times in the course of their lives, and though they may have suffered on some occasions severely, there is no reason to suppose that any tissue in the body has been damaged in the slightest degree. Whenever you are unfortunate enough to take cold, you should make the most of the opportunity and carefully study the changes as they go on in your own organism. When the cold is coming on, you may perhaps shiver a little, or you may experience a creeping sensation, apparently in the skin of different parts of the body. Although you may feel quite chilly, if you place a clinical thermometer in your arm-pit, you will be surprised to discover that it indicates a rise of three or four degrees above the normal in the temperature of your body, and the very striking and important fact will be impressed upon you that, although you feel extremely chilly and inclined to shiver and desire warm clothing, or to sit by the fire, with a good blanket over you, the temperature of your body is decidedly higher than it ought to be, and in fact may have risen from a little under 98" Fahrenheit, the point at which it stands in health, to 100°, 101°, or 102°. You need not be very much disturbed or frightened if you should find that it marks 103°. You will also notice that, as soon as you get into a free perspiration, all the uncom- fortable sensations which you have experienced during perhaps several hours, will disappear. As soon as you feel warm, and especially if you have perspired, you will find that the temperature has fallen a degree or two. After you have perspired very freely, it will fall lower still, and probably stand at the normal. I shall endeavour to show not only that a cold is a form of " fever," but that in many colds there is evidence of a certain, and, in some, a considerable degree of " inflammatory action." The mucous membrane of the nasal passages, of the larynx, trachea, and bronchial tubes, of the pharynx, and many of the small glands connected with these surfaces, are red and "inflamed." The capillary circulation in them is impeded, and if a minute examination be made we shall find evidence of undue growth of the bioplasm of the epithelium and adjacent structures. Many of the symptoms which usher in an ordinary cold precisely resemble those which occur when some special form of fever, or it may be, general or extending inflammation, is about to attack the patient. In the last case the shivering and other phenomena may be more severe, but the difference is one in degree ; in fact, a cold must be included among the Febrile Diseases. Let us now go further back in our inquiry as to the real nature of the malady, and try to discover the change w^hich, so to say, constitutes the first departure from the normal state in the case of a common cold 3IO IMPORTANCE OF EXCRETION. or other slight febrile attack. The change in question usually precedes by hours, and it may be days, the manifestion of any symptoms. The actual process of taking cold is never immediately followed by any phenomena which disturb the health or which indicate to the patient himself that he has passed, or is about to pass, from the healthy into an abnormal state. This fact alone — the existence of an interval between the commencement of the operation of the disturbing cause and the development of distinct derangement in the physiological actions of the body — is, I think, sufficient to show that the symptoms are not due to nervous disturbance alone, — and conclusively points to the conclusion that the change excited is of such a nature that it does not result in immediate consequences. The condition of the organism which is favourable to " taking cold " is not one of perfect health. The circulation at the time is feeble, and the blood itself not in a perfectly healthy state. Instead of passing quickly through the cutaneous capillaries, the circulation is retarded in the surface vessels, partly on account, as above suggested, of feeble heart's action, but mainly, I think, owing to the muscular fibres of the smallest arteries being relaxed, and the consequent dilatation of the tube of the vessel. The blood, very slowly traversing the cutaneous capil- laries, being far too long a time exposed to the cooling influences perhaps of a draught of cold air, becomes the seat of chemical changes which differ from those ordinarily taking place in the blood constituents. The particular chemical compounds formed under these circumstances are not readily excreted. Remaining in the blood, they accumulate, and minute bioplasts grow and multiply. At length an influence .upon the nerves is exerted, and then ensue the chilliness and other symptoms due to the deranged action of many tissues and organs of the body which mark the invasion of the illness. After a time the materials in question begin to be eliminated, and the patient gets well. If we promote the action of the excreting organs, we follow the " suggestions of nature " and expedite recovery. No\v some may think all this a rather fanciful ex])lanation ; but if we consider what happens in slight rheumatism, we shall, I think, be convinced that the conclusions arrived at are supported by facts. When the rheumatic state comes on, the patient experiences pain in the muscles and fibrous tissues in many parts of the body distant from one another, which pains are relieved in a very short time if free action of the skin, kidneys, and bowels is established. There is no doubt whatever that certain alkaline, diuretic, and purgative medicines excite the desired action, and thus the morbid condition is relieved or cured. The increased flow of urine, caused by- giving diuretics, is followed by thirst, to quench which the patient resorts to cooling drinks. Thus the tissues get well washed out, and the peccant materials which, by their action on the nerves, cause the i:)ain, are by SYMPTOMS OF A COLD. 3II degrees highly diluted and dissolved away, or if in the blood after " reacdon " has occurred, are converted into materials readily removed from the body by different emunctories. We are thus able to account for the formation of morbid materials in the body, and to explain how these derange many physiological actions and occasion pathological phenomena. Further, it has been shown how these noxious substances may be removed and by what means their removal is assisted, or, in other words, the recovery of the patient hastened. Preliminary Ciiaii^es and Attendant Plicnoinena. — As regards the accession of a cold, or other febrile or inflammatory attack, the first indications of derangement in the ordinary physiological processes are much the same, but the intensity of the changes varies greatly in different fevers and inflammations. For some little time before you " catch cold " you are conscious of not being in the ordinary state of health. Without feeling very weak or low there is an indisposition to move about, you are inclined to lie down, and perhaps if you followed your own inclination you would go to bed, and in this way try to obtain relief from the discomfort and sense of oppression and general uneasi- ness. In a short time some degree of soreness about the nose is usually experienced, and this is often associated with dryness of the nasal cavity and of the throat. The tongue feels more or less dry and uncom- fortable. Little or no saliva is secreted ; the skin too, often feels hot and dry. ^Vhen the skin is perfectly healthy, it is smooth and supple, but when a cold or any general fever or inflammation is coming on, a change usually takes place. It becomes more or less harsh, and even rough, small particles of the outer layer of the cuticle being partially detached. The surface, in consequence, feels dry and rough, and when rubbed, bran-like particles, consisting of the scales of old cuticle, are removed. Very frequently the patient experiences slight uneasiness about the head, perhaps not amounting to actual headache, but a little pain, it may be, over the brow, or heaviness there or at the back of the head, or in the back of the neck, or in all these situations. The pain in the neck is probably caused by some derangement affecting the nerves distributed to those muscles by the action of which the head is raised and drawn backwards. This pain just below the occiput often lasts for several days and is very troublesome; the slightest movement of the head being difificult in consequence of the pain which results. When a cold or fever is imminent, you may feel weak, disinclined to take exercise. If it is necessary to walk, you have, as it were, to force yourself to do so. You may feel low-spirited and out of heart, perhaps more inclined for bed than for work. There is little appetite, and perhaps no desire to eat an ordinary meal. Rather than solid food, you feel inclined to take a cup of warm soup or strong beef tea, or ordinary 312 BODY-HEAT OF MAN. tea or coffee, or gruel, or hot wine and water. There is very generally indeed a demand for fluid when a cold is coming on. You feel dry and thirsty, and almost instinctively seek for water, iced water or lemonade. It is unquestionably advantageous to take fluids when these sensations, which usher in a cold in the head or other febrile attack, are experi- enced. For although, as Dr. J. C. B. Williams long ago showed, by resisting the longing for fluid and bearing with the thirst for two or three days, the catarrhal symptoms, may be lessened at least for a time, — the discomfort and distress are often so great that the patient prefers the inconvenience incidental to the cold to the suffering which results from carrying out this dry system of treatment for its relief or cure, and it is doubtful whether the duration of the illness is by that plan in any way shortened. Indeed I have thought that in many cases the cold has been cut short by taking plenty of fluid and thereby exciting free action of the skin and kidneys. The premonitory symptoms of a cold are unques- tionably often much relieved by a basin of hot soup, or even warm tea or coffee. As you are probably aware, the treatment everywhere most popular is a glass of hot wine or spirits and water. You will hear in every part of the country of cases of various terrible forms of disease which have been at once stopped or cut short by a stiff glass of hot brandy, whiskey, or gin and water. It is certain that general relief of the discomfort and unpleasant symptoms may be obtained by drinking freely of fluids which excite the action of the skin and kidneys, and thus wash out of the system various deleterious matters which have accumu- lated in the blood. The Body-lieat of Man and Warni-bloortetl Animals, Fixed and Definite. — The temperature of man and the higher animals in a state of health is fixed within a very limited range, and as I mentioned, in one of my early lectures, it is worthy of note that this fixed and definite temperature of the blood in the case of warm-blooded animals is main- tained at the uniform standard, although the temperature of the medium in which the animal lives may vary greatly from time to time. The temperature of the body is the same in summer and winter, or at the most varies little more than a degree of Fahrenheit's scale. A man in the Polar regions will have the same internal temperature as one living at the Equator. In the cold climate there is very little sensible perspira- tion. In the hot one perspiration never ceases, and the cuticle is always wet and soddened. By constant changes in the rate at which heat is evolved in and carried off from the body, the internal temperature of the blood is kept very nearly uniform. It is remarkable that the limit of variation in health is so slight, for we may regard it as proved that the blood cannot vary to a greater extent than is represented by two degrees of Fahrenheit, without a departure from the normal state of health. Whether the air be cold or hot — whether a person in health HEAT IN FEVER AND INFLAMMATION. 313 take violent exercise or lie quietly in a warm bed— whether food l^e taken frequently or withheld for many hours, the temperature will not exhibit more than a very slight temporary disturbance, and if a change does occur the temperature will very soon return to the normal point. Rise of the Budy-licat in all Fevers anil Inflammatiuni!;. — On the Other hand, in every form of fever, and in every kind of inflammation, the temperature of the body or of the affected part, and therefore of the blood, rises. You must not forget that although, as I have said, the patient may feel excessively chilly, nay, though he be seized with decided rigors, and is pallid, the features pinched, and the face almost destitute of colour, or actually livid, and cold to the touch, the limbs trembling and teeth chattering, — the temperature of his blood will be higher than in the ordinary condition of health. So far from the blood being entirely or only affected, it is more probable that in many cases the rise in temperature begins in the tissues outside the vessels. The blood-corpuscles, as they pass through the capillaries, take heat from one place and distribute it to other parts, so that a considerable rise in one spot may soon be reduced and the heat diffused over a wide area, and thus cause only a slight rise in the temperature of the body generally. Even in the flea-bite, if it were possible to place an instru- ment among the distended capillaries and tissues of the affected part, the temperature, I venture to say, would be found higher than in the tissues just beyond the affected area. In extensive inflammations, as was shown by Mr. Simon, the temperature of the blood which leaves the infiamed part is always decidedly higher than when it entered the vessels leading to it. There is not a fever known to us in which the temperature does not rise above the normal ; neither is there any inflammation which is not characterised by phenomena which occasion the development of an increased degree of heat in the inflamed part. This generalisation is to be extended to all the higher animals. Every creature capable of suffering inflammation or the feverish condition exhibits, during the attack, elevation of temperature. There is, in fact, a very intimate con- nection between the increased development of heat and the states Fever and Inflamviation, and we may go so far as to affirm that the existence of either of these pathological processes without a rise in the tempera- ture is not possible. In both fever and inflammation it would seem that the circumstances which determine the maintenance of the equable body-heat of health are deranged, either generally, as in the fever, or locally, as in the inflammation. Heat is developed faster than it can be carried off, or the processes by which it is carried off are for the time interfered with, or both circumstances are concerned in determining the rapid rise of temperature which is often observed in various fevers and inflammations of marked intensity. 314 INCREASED OXIDATION. Is there Increased Oxidation in Fever and Inflammation ? — This question is one of much importance in reference to the consideration of the real nature of the febrile condition. It would be answered directly and most positively in the afifirmative by most pathologists, but, as we shall find, the facts known by no means justify an offhand and confident answer. The secretion from the kidneys of a person suffering from fever- ishness is usually concentrated and of high specific gravity. You will frequently find it loaded with urates, and often there will be Excess of Urea. Deposits of uric acid are common. The Excess of Urea is shown in a very simple way. To about half a teaspoonful of the urine in a test-tube you add an equal bulk of strong nitric acid, and plunge the lower part of the tube at once into cold water, shaking it from time to time. In the course of a few minutes crystals of Nitrate of Urea will begin to form, and if the specific gravity of the urine is 1030 or higher, it may become almost solid from the quantity of crystals produced. The circulation of the blood and the action of the various organs in the body are greatly disturbed, and there is departure from the normal state in many respects, both as regards the chemical processes proceeding in the blood, and the presence and accumulation in quantity of substances which ought to be removed from it in a very dilute state as fast as they are formed and carried into it. Many of the excrementitious matters are in such a high degree of concentration that they readily separate from the fluid in which they are dissolved, and in the case of the urine some are deposited soon after the secretion has become cool. These and many other phenomena, which are undoubtedly due to exceptional chemical change, are often set down to excessive oxidation, although a careful consideration of the facts would lead us to entertain the opposite conclusion, that oxidation was deficient, instead of being in excess. In many books you are told that body-heat is invariably the result of the combination of carbon and other elements with oxygen, and that the increase of temperature in all fevers is due to increased oxidation. There is, however, evidence of a most striking kind that in various morbid conditions in which the temperature of the body considerably exceeds the normal standard, the process of oxidation is much inter- fered with. If, for instance, a man has one lung solid from the air-cells being plugged up with lymph poured out from the blood, as occurs in pneumonia, is it not unreasonable to maintain that oxidation is going on to a greater extent, or is more complete, than in health ? In this case are not the affected air-cells filled with solid matter, which renders the entrance of air less constant and its renewal quite impossible ? And yet we are assured that the elevation of temperature in pneumonia, and in ASCERTAINING THE TEMrERATURK. 315 all Other febrile and inflammatory states, is due to increased oxidation, and to that alone. Again, the body of a person who has died from a terribly severe attack of acute rheumatism can hardly be considered to be in a state favourable to free oxidation. Nevertheless, the tempera- ture, which at the time of death may be as high as 107° or ioS°, often rises three or four degrees of Fahrenheit during the first hour or two after death. How, then, can we reasonably attribute this rise of tem- perature to increased oxidation ? Consider not only tho.t the rise con- tinues for some time after the lungs have ceased to act at all, and the heart can no longer propel a drop of blood along the vessels, but that for many hours or even days before death, the conditions of the body had been most unfavourable to the introduction of air and its free distribution to distant parts, as also to its absorption by the tissues and fluids. We can show that in all probability the high temperature is due to the increased growth of bioplasm, not to increased oxidation. The generalisation that the elevation of temperature in fever and inflammation is due to increased oxidation is, I think, a grave mistake. It is more probable that the phenomenon is occasioned by changes in the bioplasm or living matter of the blood and tissues, of a nature far removed from the process of oxidation. I shall have again to refer to this very interesting subject, and hope to consider it more in detail. Metlioil of ascertaining the Temperature of the Body. — The actual temperature as indicated by the thermometer is found to vary slightly according to the part of the body which is selected for observation. If, for example, you place the thermometer under the tongue, you will find, as you would anticipate, that it will mark a degree or so higher than if the same instrument is placed in the arm-pit. In medical observations on the body-heat we restrict ourselves to observations in two places — the mouth underneath the tongue, and the arm-pit. But if you try the mouth in the case of children you will not unfrequently have the bulb of your instrument bitten off. Such an accident is serious, for good clinical thermometers cost from six to twelve shillings each. It is, therefore, upon the whole, better to take the temperature in the arm-pit only. In order that you may be able to compare the records of different cases, you must take care to work in precisely the same way, and to place the thermometer in the arm- pit for at least two minutes if the bulb is a very small one, and for double that time if it is not of the smallest size. You will have little difficulty in using the small thermometer even in the case of the most irritable and violent children. For you can always put it in the arm-pit and keep the child's arm nearly still for the length of time required. Thermometers for medical observation, clinical thermometers as they are called, may be obtained of all the instrument makers. Those with the smallest bulbs respond very quickly and the index comes to a stand 3l6 COLD, HOT AND SWEATING STAGE. in two minutes, or even in less time ; but the degrees are small, and more difficult to read off than those of larger dimensions, which require to be inserted in the arm-pit for four or more minutes before you can feel sure that the mercury has come to a standstill. Of late great improvements have been made in the construction of the very small thermometers. The bore is so fine that observers whose eyesight is not the most perfect, often find it difficult to see the index. By grinding the glass away somewhat at the sides and making the front of a greater convexity, the effect of an elongated lens is produced, and the almost invisible mer- curial thread is made to appear as a broad band of mercury, which can be seen without the slightest difficulty. These instruments may be obtained of Mr. Hawksley, 357, Oxford Street; Messrs. Matthews, Holborn, and other instrument makers. Further consideration of the Essential Phenomena of Fever and Inflammation — Rigors, and Cold Stage — Hot Stage — Sweating Stage. — When a severe form of fever or inflammation is about to attack a patient, instead of mere chilliness and a sensation of creeping or tingling of the surface skin, an actual rigor is experienced. This is often so intense that the patient trembles in every limb, his teeth chatter, and he feels dreadfully ill. The very bed on which he lies may be perceptibly shaken, so violent and so general is the nerve and muscular disturbance. Among severe inflammatory maladies, a sharp attack of inflammation of the lungs. Pneumonia, and among fevers, small-pox, Variola, and scarlet fever, Scarlatina, are ushered in thus. If you were called to the patient as soon as he was taken ill, you would see his limbs trembling violently, his face pale and anxious, the patient considerably depressed in spirits, and perhaps suffering from nausea, and now and then violent retching adds to his distress. If you put your hand on his pulse you find it quick, feeble, and small. The temperature will be higher than normal, perhaps by four or five degrees. It would seem that in this condition the blood is diverted from the general surface of the body, and is driven in greater proportion to internal parts, — to the lungs, to the intestines, to the liver, and to other internal organs. These preliminary symptoms, with the shivering which is developed in a remarkable degree, represent what is known as the " cold stage " of an " intermittent fever." Agiie is a very remarkable form of feverish attack, inasmuch as the several special stages which are to be traced with more or less distinctness in all fevers and inflammations are very manifest, and are well defined and sharply marked off from one another. In the cold stage, blood not only leaves the surface, but temporarily parts with much of its water, which then occupies the interstices of the tissues. After a time it again enters the blood, or passes off by the intestines, in which case it may be altogether removed from the body as in Diarrhoea, or in Cholera, in which disease the blood becomes of a thick and tarry consistence, and stagnates in FEVER IN CHOLERA. 317 many of the vessels, scarcely moving at all in some of the capillaries which are distributed to very important organs of the body. The shivering and other symptoms which constitute the first indica- tions of derangement in febrile diseases are referable to conditions favouring the formation of deleterious matters in the blood itself. In some cases these are due to changes originating in the organism, in others to the introduction of a poison from without. The phenomena which mark the accession of a common cold correspond to the cold stage of the ague-fit. I think it probable that the so-called collapse stage of cholera is also analogous to the first stage of the ague-fit, and consider that it represents, only in the most severe form, the general phenomena which usher in every form of febrile and inflam- matory malady. In a sudden and very severe form of this terrible disease, we see the cold stage of a fever in its highest conceivable degree of development ; for, in fact, the collapse is so severe and so widely spread, so manifestly deranging the action of every tissue and organ in the body, that in too many instances death results in a very short time during this stage. But Cholera, like other febrile affections, has not only its cold stage. If the patient lives, the state of collapse at length gives place to great heat and dryness of skin, and this hot stage in turn is followed by a crisis or critical change, when the kidneys and skin again resume action. The blood regains its colour and begins to freely flow along its accustomed channels, and the various glands and tissues gradually recover from the shock they have sufl"ered, and return to their normal state. The patient, in fact, soon becomes convalescent. The feverish condition which, in cholera, follows the stage of collapse after a varying interval of time is called Secondary Fever. Happily few of you have seen either a case of ordinary cholera or the secondary fever, which was not so common, but not a few of your teachers have seen and have done their utmost to save many a case. In most epidemics the disease was very fatal during the cold stage, and where very much water had been already drained off from the blood into the intestinal canal, the patient died in collapse. In some of the cases which recovered the secondary fever was so slight that it attracted little or no attention ; but occasionally I have seen it very marked indeed, and have lost patients from secondary fever, who, some days before, had passed through severe collapse and were con- sidered to be recovering. I believe that this febrile stage of cholera corresponds very closely to the prolonged feverish condition character- istic of typhus or typhoid for example, and to the so-called hot or febrile stage of an intermittent. In an ordinary cold the feverish state usually lasts but a very short time, perhaps not longer than from ten to twenty- four hours. In typhoid fever, however, it may last for six weeks or more ; and in acute rheumatism sometimes extends over two months. During 3l8 STATE OF NERVOUS SYSTEM. the whole of this long period the temperature of the patient's blood may not once, even for a single hour, fall to the normal standard ; though in many cases it falls and rises several times in the course of the attack, passing three or four degrees above the normal, and then perhaps going down to that point when the temperature is above the normal, again rising, and so on. In an ordinary cold or catarrh the chilly stage is usually followed in the course of five or six hours by free perspiration, which immediately causes the temperature to fall and brings relief. In many instances the patient steadily recovers from the time the tem- perature fell. In fevers and extensive inflammations the nervous system generally is affected. In some forms the action of the brain is very much dis- turbed. Soon after the preliminary phenomena of the common cold have occurred, the pulse increases in frequency, and there is, possibly, severe headache, the whole of the head perhaps feeling full, almost to bursting, as if it had been forcibly distended. The mind is affected. No one at this time can perform much intellectual work. Tlie memory suffers, and to think at all is a painful effort. The patient probably feels much more inclined to lie down and do nothing. If he goes to bed, instead of falling asleep he tosses about from one side to the other in an uncomfortable way ; perhaps he dreams of horrible things, and wakes up suddenly, finding his mouth, fauces, and tongue dry and uncomfortable. The blood returns in volumes to the surface of the body. The little arteries dilate, the capillaries are distended, the colour is intensified, and the skin becomes hot to the feel, but it remains dry. This hot stage may be soon followed by the last or sweating stage. The skin is now bathed with perspiration, which continues it may be for several hours, so that the cuticle becomes completely soddened and softened. In this way a quantity of water with certain organic matters dissolved in it, often amounting to several pounds in weight, is very quickly removed from the blood. But at first there will be still more or less feeling of fulness and distension about the head. The patient again tries to go to sleep, the muscles seem to be fatigued, and there is a general feeling of lassitude. These phenomena mdicate a wide- spread disturbance of the nervous system, cerebral, spinal, and gan- glionic, caused probably by the action upon the nerves and nerve-centres of certain materials which ought to have been eliminated, but which have unduly accumulated in the blood. Such are some of the broad phenomena which almost everyone has experienced, who has taken a bad cold or has suffered from any form of fever. In severe and specific fevers and general inflammations, all the nerve phenomena are most strikingly developed, and trouble the patient for a longer period of time. In any well-developed fever, for FREE SECRETION IN FEVER. 319 instance, patients may pass many sleepless nights. They may be troubled with headache for a fortnight or three weeks, or even longer, and may be restless and wakeful during the whole of the time. Of Free Secretion which leads to Recovery. — The action of the skin and other excreting organs of the body, which had been partially suspended during the accession of the attack, and in many cases for some days before, is a general fact of great importance, and marks the temporary abatement or actual cessation of all febrile and inflammatory disorders. Now if these phenomena can be caused to come on some- what earlier than in the natural course of events, the duration of the febrile or inflammatory attack is to that extent reduced. As soon as the sweating comes on the patient may feel relieved, but until it has occurred he may experience much discomfort. Till then you may have felt very anxious about the case. We are unfortunately unable to ascer- tain at the commencement of the attack how bad the patient is likely to be; we never know to what extent any grave symptoms may continue to increase, or for ho ' long a time the patient will continue to get worse. Until sweating and free secretion have occurred we can seldom judge m severe febrile conditions as to the probability of recovery, or the duration of the time of illness. Recovery from every febrile illness is associated with the gradual removal from the organism of substances which probably have been accumulating for some time in the blood and nutrient fluids. These substances are slowly removed by the agency of the kidneys, skin, bowels, and other emunctories. When the skin acts pretty freely, you become thirsty and imbibe a quantity of fluid, which is again quickly removed by the kidneys. For some time before the illness and during part of the attack the bowels may have been confined, or have only acted imperfectly, especially when the febrile action was most intense. The glands of the mucous membrane of the intestinal canal, like other glands, do not act as freely in the early period of a cold as they should do. When, however, the patient returns to the normal condition these glands resume work, and the tendency to constipation and defective excretory action passes off. Moreover, as the feverishness abates, there will be exaggerated action of several glands as compared with their activity in the ordinary state of health. Not only do the kidneys and the cutaneous glands act in an unusual way for some time after recovery, but the glands of the mucous membrane of the nose and those of the mucous membrane of the air tubes also continue to secrete freely for some time. Many of us while in perfect health might leave our pocket- handkerchiefs behind without experiencing inconvenience, but when suffering from a cold it is well not to be neglectful. A quantity of secretion is poured out from the mucous membrane of the nose, and in many cases also from that of the wind-pipe and bronchial tubes, and 320 TREATMENT OF A COLD. this exaggerated secretion often continues for some time after we seem to be pretty well. The " secretion " I am speaking of is modified mucus with much fluid associated with it. In the healthy state the mucus which is formed is extremely small in amount and very tenacious. This mucus is princi- pally produced in minute glands connected with the mucous membrane and which open upon its free surface. The same glands, when the fever of an ordinary cold is passing off, secrete an undue quantity of a diluted and sometimes fluid mucus. Exaggerated action proceeds in connection with all the mucous surfaces, and persists for a certain period of time, varying from twelve or twenty-four hours to many days. The patient then usually gets better, and everything slowly returns to its normal rate of action. Now this very free secretion in certain cases is a matter of serious importance. There are certain forms of inflammation of the mucous membrane of the air-tubes, including the nasal passages, in which there may be an undue secretion of altered mucus, amounting to six or eight ounces in the twenty-four hours. In some sad cases, happily not very common, an excessive quantity of secretion is so quickly poured out, that it accumulates in the smaller air-tubes and death may be caused by suffocation in the course of a few hours. The mucous membrane of some persons' air-tubes is constantly in so sensitive and irritable a state, that whenever the weather is either cold or damp they suffer 'more or less. Such patients ought to spend their winter in a warmer climate, where they can be out in the open air almost daily, for if they remain in London they generally have to be shut up in warm rooms for a great part of the winter — a course very detrimental to the general health, and likely to render the mucous membrane still more irritable, and of course more sensitive to adverse atmospheric changes as life advances. Coryza is the scientific name for a cold associated with the secretion and removal of a considerable quantity of fluid secretion and viscid mucus from the secreting follicles and surface of that part of the mucous membrane which lines the nasal passages and adjoining cavities. Catarrh and Gravedo are terms applied to a cold in the head. The word Coryza, Aro/Ji-^a, is supposed to be derived from Kopo'^ or icapn, the head, and ^eV-, to boil. I am not, however, sure whether this deriva- tion is perfectly accurate. The condition was, perhaps, so called because some people, suffering from a very bad cold, said that they felt as if the blood in the head was in a boiling state. The Principles upon nliicit the Treatment of a Cold should be conducted. — As regards treatment, I suppose many would say " let a cold alone," "it will get well of itself," " do nothing." I am quite ready to admit that an ordinary cold will get well without any active treatment. Nevertheless, a bad cold is a very unpleasant affection in many ways. I TREATMENT OF A COLD. 321 and it is desirable to mitigate its severity, and shorten the attack, if we can do so. Besides, as I shall have to explain, many serious maladies in their early stage may be easily mistaken for an ordinary cold, and in many cases real advantage does result from the early adoption of judi- cious treatment. We will therefore endeavour to decide as to the principles according to which the treatment of a cold and allied derangements should be conducted. The phenomena characteristic of an ordinary cold, as I have just remarked, are present during the period of accession of many forms of fever, and sometimes in a greatly intensified state. You ought, therefore, to know whether, and by what means, these symptoms may be modified, or the changes which usher in convalescence encouraged, so that the latter be made to occur somewhat earlier than they would do if the malady ran its ordinary course. Obviously the thing to try to do, in the treatment of maladies of the class we are considering, is to bring on the period of perspiration as early as possible, and to excite the action of the various glands of the body. The blood has been diverted from the surface to the internal organs of the body, and we want, if we can, to determine its flow towards the skin, in order that much of its water and some of its organic constituents may be removed by the glands and discharged in the form of perspiration. External warmth will relieve the feeling experienced when a cold is coming on, and I think that sometimes the malady, and possibly some severe acute affections, may be cut short in this way. The patient is told to get into a warm bed, or to take a warm bath. But the application of cold externally has been as strongly recommended as warmth, and for the very same purpose in the same case ; and you might be led to suppose that here, as in some other instances, opposite and conflicting practices had been advised and adopted for the relief of the very same malady. But this is not really so, for whether you wrap a patient in a sheet dipped in warm water or in cold water, it makes very little difference, except that a cold sheet is somewhat more disagreeable to the patient than a warm one. Cold wet packing will bring about JLSt the same action as warm packing or a warm bath. For the chilly feeling produced by the first contact of the cold wet sheet is soon followed by reaction, and is replaced by a gentle glow succeeded by free perspiration. Did. — In treating a severe cold it is necessary to bear in mind that the regulation of the diet is a matter of importance. The patient for a few days should be kept on liquid food, good strong beef tea or ox tail soup, or milk or bread and milk only being allowed, and in small quan- tities at a time at short intervals, the patient not going for more than three hours without nourishment. In severe cases wine, brandy, or whiskey, in doses of one or two teaspoonfuls, should be given at about Y 322 PURGATIVES. the same intervals, the quantity being increased if the patient gets worse and becomes weaker, and if the temperature of the body rises. Diuretics. — But besides trying to excite perspiration, you may en- deavour to cause various ehminating organs to act freely. You should give unirritating diuretic remedies, such as Liquor AmmonicB Acetafis, Citrate of Ammonia, Citrate of Potash, Nitrate of Potash, or Chlorate of Potash. These all act more or less upon the kidneys, and increase the flow of urine ; some of them act upon the skin, and in other ways promote the removal from the blood of noxious substances which have accumulated in it. They and many other remedies are thus of use in the treatment of an ordinary cold as well as allied ailments. I often suggest the following prescription : — Spirit of Mindererus {Liquor AvifiioniiB Acetatis), two ounces ; Spirit of Chloroform {Spiritus Chloro- formi), from one to two drachms ; Nitrate of Potash {Potassce Nitras), sixty grains ; or Chlorate of Potash {Potassm Chloras), from one hundred to a hundred and fifty grains ; Syrup of Orange, of Squill, or of Tolu, half an ounce, and water to six ounces. The dose is half an ounce, or a tablespoonful, with as much water, once in two hours, or less frequently, for three or four days. Purgatives. — And lastly, the elimination of noxious matters which have accumulated in the blood may be further promoted by exciting to a moderate extent the action of the intestinal canal. In a cold the bowels are generally more or less confined, and in many cases there has been but imperfect action, perhaps, for some time previous to the attack. I therefore recommend you to make full inquiry upon this point, and if necessary order for the patient some mild laxative that will act upon the bowels and favour excretion. Thus you may perhaps shorten by a day or two the period of the duration of the cold. In the feverish condition which sometimes comes on soon after a surgical operation, relief may be afforded in the course of a few hours, by the administra- tion of purgatives, sudorifics, and diuretics. One or two grains of Calomel or gray powder will be found to act admirably in many of the most serious of these cases. The temperature falls soon after the dose has been taken, and the patient often experiences great relief long before the medicine begins to act on the bowels. The fact of improvement so immediately following the use of reme- dies which increase the action of the skin, kidneys, and bowels, favours the conclusion that the fever is due to the accumulation of certain materials in the blood, the elimination of which is followed by relief, and, as we say, the resolution of the fever. It is important to consider these matters, the more so just nov/, because there is too great a tendency to altogether discard the use of many medicines which are of great value m the treatment of disease. If the disease you are called upon to treat should be only a common ONLY A COLD. 323 cold, you will, nevertheless, find in practice that many persons who experience suffering, discomfort, or even mere inconvenience, strongly desire to be relieved of their troubles, and as quickly as possible. Of the sick who send for you a considerable proportion will certainly expect that you will do something for them. If you were in the same condition yourself you might be inclined to leave the case to nature and not to take any medicine nor desire to follow any course more unusual than indulging in a little more rest than when in good health ; but your patient will expect you to prescribe something that will relieve him or help him to get well, and I have known distinguished practitioners when ailing as anxious as the most unlearned patients "to have some- thing done for them." Unquestionably you may help persons suffering from a severe cold if you give sudorifics, diuretics, and a gentle purgative, and perhaps a little ammonia or mild alcoholic stimulant. Of Fever which begins like an Ordinary Cold. — Some cases, which at the outset seem to be nothing more than an ordinary cold or catarrh, do not prove to be of this nature, but issue in some form of serious acute disease. Those terrible fevers which occur in all the large cities of Europe, and which carry off so many thousands every year, may come on just as an ordinary cold does. During the period of accession the symptoms are much the same, and both the patient and his doctor may for some days think there is not much the matter. The patient feels so strongly convinced that he is suffering only from an ordinary cold, that he goes about just as usual. When, however, he gets worse from day to day, and feels decidedly weaker, he begins to be alarmed. At length he is obliged to take to his bed, and his temperature is found 10 be and to remain above the normal, perhaps rising to 102° and 103". By this time the practitioner is able to determine the nature of the case. Instead of the attack being as the patient himself supposed, an ordinary cold, it perhaps turns out to be a specific fever of a kind which not unfrequently destroys life. It may be that under the most favourable ciicumstances, and with the best nursing and medical treatment, the rate of mortality will not be less than one out of every fifteen or twenty attacked by the disease. It is a fact that many serious attacks of fever begin just like an ordinary cold. Now if you happen to be called, in just when the fever is coming on, and you thoughtlessly remark that " this is only an ordinary cold, I need not do anything," — think of the dilemma in which you may be placed. When the severe nature of the disease becomes apparent, you will be, as it were, convicted of having made a very serious mistake. Very likely neither the patient nor his friends will have any further confidence in you, and you may be pro- nounced to be an ignorant person who knows very little about his pro- fession. You may in consequence get out of heart and feel altogether dissatisfied with yourself Possibly even the most sagacious and Y 2 324 CHANGES IN TISSUES. experienced practitioner would have known no better, but he would not have committed himself to a definite opinion. As a fact it may have been impossible for any one to diagnose the case at the vjry early period of the attack, and the right course would have been to wait until the premonitory symptoms had passed off, or until some definite character- istics of a special malady had manifested themselves. You should always carefully inquire into all the facts of any given case, listen attentively to what the patient has to say concerning the symptoms which disturb him, and do all you can to relieve them, but postpone any decided expression of opinion as to the precise nature of the disease until the facts of the case enable you to speak with definiteness and decision. Especially in the case of children is it necessary to be very cautious before committing oneself to a positive opinion at an early period of a febrile attack. You may mistake a serious case for a slight one, or the reverse. You will be astonished at the very serious aspect sometimes presented by many a case of mere stomach disturbance. A child who has partaken of unripe fruit may be very ill indeed a few hours after- wards, with a temperature of 104°, flushed face, quick pulse and respira- tion, with a suffering, anxious look. An inexperienced practitioner would perhaps tell the friends that some severe fever or other acute disease was certainly about to appear, when perhaps a few hours after- wards the bowels act, the temperature falls to the normal, and when he next visits his patient he finds him well, and the friends laughing about his gloomy prognostications. In children suffering from slight ailments, I have observed the temperature rise from the normal to 104°, or even higher, and descend to the normal, within twenty-four hours — so rapidly may considerable changes in the body heat of children occur. Such cases, I need scarcely say, require simple treatment. A purgative dose of castor oil is sometimes needed, and the patient is well again as soon as it operates. The child, as often happens, is very thirsty, and you may allow it to drink water. Plenty of toast and zvater may be given, or plain water if the patient likes it better, provided it has been well boiled. Water, or milk and water, will help the skin and kidneys and bowels to act freely, and in consequence the feverishness will subside, and the patient regain the usual state of health. Sometimes, however, a feverish attack, instead of subsiding, continues for several days. Sometimes, after a feverish attack, a child may be ill for a week or two, and require careful management, although there may be no fresh fever. Again, although neither scarlet fever nor typhus fever, nor any other specific disease may be manifested, a general feverish state may be established and may continue for several days, and then gradually subside, leaving the patient thin and weak and for some time out of health. RELIEF OF TAIN. 325 It must be admitted, that in former days many doctors gave too much physic, and were somewhat too fussy. In these days, however, I fear there is a tendency, or more than a tendency, to err in an opposite direction. Some practitioners, having convinced themselves, seem to be most anxious to convince the pubhc and the profession that the chief duty of a medical adviser is to study, note, and carefully watch the progress of a malady, — to observe, if he is qualified to do so, the minute changes taking place in the tissues of the sick man, in order that he may discover facts which will increase our knowledge of the nature of the pathological processes, and possibly lead to the enuncia- tion of new principles of treatment for the benefit of sufferers in the next and succeeding generations. But this view of medical aspiration is not always appreciated by the patient, especially if the doctor's visits are not purely of an honorary character, and even then it will be found that there are some few patients so peculiar in their notions as to object to their bodies being used for observation, or their sufferings studied and noted as interesting pathological phenomena, which may be further elucidated as the case proceeds. You must really bear in mind that patients want to be relieved as well as watched, and unless you can be of some use to them, unless you can advise and help them, they may regard you as a nuisance instead of discovering in you a consolation. But further, we really ought to do all we can not only to remove bodily aches and pains, but also to relieve our patients' minds. You will not reduce the mental anxiety of a sick man if you tell him you can do nothing to relieve his pain, nothing to expedite his recovery, nothing to avert impending morbid change, or to mitigate the severity of the disease. I find that some doctors, if they get ill, even though the illness is obviously not a serious one, become very anxious, and of all sick people they are oftentimes the most difificult to manage. They usually think themselves worse than they are, and almost invariably desirous that something practical should be done. I have sometimes ventured to discuss with a medical friend the actual nature and import of the symptoms from which he was suffering, but I generally find that my friend is sadly disappointed if I do not propose to " do something " for him or suggest some operation to relieve him. If I remark to a medical patient that the malady will probably get well of itselt, he perhaps feel hurt, but if it is proposed that he should take a few doses of the Liquor Ammonise Acetatis, Nitrate or Chlorate of Potash, and Sal Volatile, a practitioner of even a philosophical turn of mind will feel quite happy, and take the medicine ordered with regularity, and bear his ailment with cheerfulness. Bear in mind then the principles upon which the treatment of an ordinary febrile attack is to be conducted, and be careful not to commit yourselves too hastily to a positive opinion as to the exact nature of feverish- 326 CHANGES IN TISSUES. ness which has only lately come on. It is important not to make too light of it on the one hand, or on the other to cause needless alarm by suggesting to anxious friends that what is probably only a most trifling and unimportant temporary derangement may turn out to be a grave disorder. Now it is probable that some of the attacks we meet with, severe though they be. but which are not followed by serious illness, are due to ptomaines or other poisonous matters which are formed in the blood and very soon excreted. A patient feels suddenly ill ; there are nausea^ chilliness, and even very decided rigors. In many such cases there is actual pain in most of the muscles concerned in walking, as well as in most of the joints, sometimes so distinct and severe as to raise in the patient's mind, especially if he is a doctor, visions of an attack of acute rheumatism or rheumatic fever, or the breath may be quick with or without sharp pain in the side, and he thinks he is in for an attack of pleuro-pneumonia or pleurisy. He cannot take food, he totters if he attempts to walk, his hands tremble, his teeth chatter, and he feels altogether prostrate. The condition must not be mistaken for the effects of drink. Naturally a patient in such a state looks for a warm bed at once. In an hour or two of this first, and most sensible of all remedial measures he gets into a profuse sweat, and continues to perspire freely perhaps for several hours. In the morning he feels almost well, though perhaps a little weak, but this feeling passes off in the course of the day, and within twenty-four hours he returns to his usual state of health, and is able to work as hard as before. Whether the sudden attack ends within twenty-four hours in com- plete recovery or ushers in an illness, which may extend over several weeks, requiring good nursing and careful management, and in which there may be danger to life, seems to depend, at least in many cases, upon the general state of the patient when attacked. If he happen to be a person who has lived freely, eating and drinking largely in propor- tion to the hard work he performs, there will soon accumulate in his organism an amount of noxious matters too considerable to be excreted at once, and illness soon follows. If he be a small feeder and his excreting organs in good order, he gets well at once. If in either case he have exceptionally active eliminating apparatus, — he is perhaps seized with sudden diarrhcea, perspires very freely, and passes a large quantity of water, but is not even threatened with any definite derangement in any tissues or organs whatever. If we think over these points we shall see why the treatment recom- mended is so successful in bringing about the return of the natural state of health. We also see why a full blooded, freely eating and drink- ing man should have an active, quickly acting, purgative — two or three grains of calomel, to be followed by a senna draught or a dose of castor CUTTING SHORT DISEASE. 32/ oil. In this way the old doctor would say " we cut short" many an attack of acute disease, and I think he was right. Then we give diuretics — Effervescing Citrate of Magnesia or other saline, or plenty of linseed tea, or two or three pints or more of plain water, or soda water, if the patient prefer it, in the course of twenty-four hours. If the patient is, and has been, a small eater and a water drinker, he will be all right after a night's perspiration. If the attack occurs in winter, a good lire, a hot bath, putting the feet in hot water, a glass of hot brandy and water will excite the desired perspiration. In addition, sudorific and diuretic remedies, w'ith plenty of water, may be given. THE CHANGES IN FEVERS AND INFLAMMATIONS— THE FEVER OF OVER-EXERTION— OF SOME FORMS OF SLIGHT FEVERS AND OF THEIR TREATMENT— FEVERS OR INFLAMMATIONS— ON THE FORMATION OF PUS IN AND NEAR THE CAPILLARIES IN INFLAMMATION AND FEVER— OF THE PASSAGE OF BLOOD AND LIVING PARTICLES THROUGH THE WALLS OF CAPILLARY VESSELS — CAPILLARY H/EMORRHAGE — DIAPEDESIS — VITAL PHENOMENA— CHANGES IN BIOPLASM : PUS. The >ature of the Changes in Fever and Inflammation. — Although we have much to learn concerning the causation of many slight patho- logical changes, several highly interesting facts have been recently added to our knowledge as regards the origin of the febrile state. While fever is undoubtedly caused in many cases by the introduction from without of some poisonous material which enters the blood, and then multiplies a thousand-fold, it is quite certain that a feverish state may be engen- dered by the accumulation in the blood of certain excrementitious substances which are ordinarily excreted as fast, or nearly as fast, as they are produced, and perhaps also of certain chemical compounds which have not reached the full degree of oxidation they would have obtained in a perfectly healthy state of the system and normal condition of the circulating fluid. Again, exceptionally hot weather will give rise to a feverish state in many persons, especially if at the time they have subjected themselves to over-exertion. The fever established under these circumstances is not unfrequently of a very severe form, and sometimes it is fatal. Excellent accounts have been given of it by writers on tropical diseases. I will now consider more particularly the actual phenomena of Fevers and Inflammations, and the general nature of the minute changes upon which they depend. I have already pressed upon your attention the important fact that in all fevers and inflammations there is an ele- vation of temperature. Whether the rise begins in the blood or in the tissues outside the capillaries, is a question concerning which some difference of opinion may be entertained. In some cases, it is certain that the tissue elements exhibit the earliest departure from the normal state, and in all probability it is there that the rise in temperature begins. FEVER AND INFLAMMATION. 329 But the blood is soon aftected, for in all cases the blood in the adjacent capillaries becomes hotter, and the heat is distributed during the move- ments of the blood, the red blood corpuscles being the principal agents in this distribution of heat. On the other hand there is reason to think that in some fevers and inflammations the change in the blood itself constitutes the first departure. In every form of marked inflammation and fever, the vessels of the affected part contain more blood than they do in the normal state. The capillary vessels and the small veins are distended. If you watch the phenomena of local inflammation in one of the lower animals, as for example that form which may be excited in the web of the frog's foot by the application to one spot of a small portion of mustard for a few minutes, and carefully observe the alteration in the circulation thereby induced, you will gain much important information concerning the nature of the vascular part of the phenomena. You will notice in the first place that the vessels have become much dilated, while the move- ment of the blood along them gets slower and slower. At last the cir- culation completely stops. If at this stage of pathological change the mustard be removed and the web be kept perfectly moist, it will be found that the movement of the blood will begin again, and that much of it will find its way on to the small veins. The vascular distension passes off, and the capillaries resume their normal calibre. In fact the normal state of the circulation will be restored, and without any damage whatever to vessels, nerves, or other tissues having taken place. In fever there can be no doubt that the same sort of change occurs in the capillaries as in inflammation, but the degree of change, though widely spread, is so slight in any one spot that it is not in all cases to be demonstrated. You may look upon an ordinary cold as a slight fever, while a chilblain may be adduced as an example of a slight in- flammation. Some authorities conside that febrile disorders should be classed among nerve disorders, and the arguments advanced in favour of this view also apply to the case of inflammations. But would it not be un- reasonable to include flea-bites, and boils, and abscesses, scarlatina, typhus, and measles in the class of nervous disorders ? Nerves and nerve-centres are invariably affected in all fevers and inflammations, however slight, and indeed no changes involving alterations in the diameter of the arterioles can take place in the body without nerves being concerned. The essential phenomena both of fever and inflammation are intimately connected with disturbed arterial and capillary action. The pathological action does not begin in nerve structures, and the nerves and nerve-centres, so far from being the points of departure of the morbid change, are only affected in consequence of preliminary changes in the blood or textures, or in both. 330 THE ACTION OF EXTERNAL COLD. The phenomena of some fevers and general inflammations are due to changes which have taken place in the blood, and there is, as I have remarked, undoubted evidence of the blood being, as it were, the starting point of all the phenomena. The disease begins in the blood. A poison, or inateries morhi, may infect the blood in the first instance, and through the blood various tissues and organs may suffer. It is very probable, I think, that the afferent nerve-fibres distributed to the capillary vessels are disturbed either by the action upon them of the altered fluid which transudes tlirough the vascular walls, or, in certain cases, by the growth and multiplication around them of minute particles of bioplasm, which, leaving the blood in countless numbers, traverse the thin walls of the capillaries, and pass into the interstices of the surrounding textures. In Scarlet Yqm^x {Scarlatina) the "rash" depends upon the capillaries of the surface of the skin being dilated to such an extent that the redness of the affected parts is as intense as that of the skin of the lips in the ordinary state. The bright red colour of the skin of the lips is due, as you are probably aware, to the number and considerable diameter of the capillaries of the skin of tlie part, and to the circumstance that these vessels are covered by a thin layer of epithelium only. In scarlet fever the redness is due to a dilatation of the vessels, somewhat like that which occurs in those of the skin of the cheek when we blush. In the fever, however, the blush lasts for a much longer time. The period of vascular congestion of the cutaneous capillaries is, in most febrile diseases, fixed and definite, but it varies considerably in duration as well as in the course which it takes in dif- ferent kinds of fever. The " eruption " or " rash "' is caused by the dilatation of the capillary vessels, which in some forms of disease lasts for a definite time. I do not say that the redness of the skin is due to increased supply of blood, for probably a less proportion of blood goes to and leaves the part than in the normal state. In a given time less blood passes along the vessels, but they are distended, and more blood remains in them ; their walls, being stretched, will be thinner and more permeable than in the normal state. The blood is not usually stagnant, but it circulates very slowly. Slight exposure of a part of the body to cold may cause a severe febrjle attack. In considering how cold operates, I think we shall find the following explanation in accordance with the broad facts of the case: — The heart's action being at the time feeble, blood will be flowing but slowly through the capillaries of the skin. The blood will therefore, for a much longer time than usual, be exposed to the detri- mental influence of cold. No wonder that under such circumstances chemical changes of an unusual kind are induced. Substances are formed which injuriously affect the tissues and interfere with the proper performance of many of the normal phenomena of secretion ERUPTIVE FEVERS. 33 1 and nutrition. The noxious materials dissol\-ed in the fluid, transuding with it through the walls of the capillaries, would come into contact with the delicate nerve-fibres, and disturb their action. As long as such matters remain in the blood, there must be in many ways a departure from the healthy state, but as soon as these compounds have been eliminated, the organism will be restored to its normal condition. For these reasons the free action of organs concerned in excretion is, as I have already stated, of the first importance, and is associated with the subsidence of the fever, and the discomfort which accompanies the attack. The Fever of Over-exertiou ami Fatigue. — Over-exertion, violent and long-continued muscular action, and exposure to intense heat may be followed by a state of high fever lasting, perhaps, for many days, and this may happen in the case of persons who have been in perfect health up to the time of the attack. " The Fever of over-exertion," by Dr. Knott, "Transactions of the Royal Academy of Medicine in Ire- land, 1888." A form of "Fatigue fever" is said to be induced by excessive brain work. This is one of the conditions which is said to result from over-pressure in schools. M. Peter has described the symptoms as observed by him in some children attending French schools. I have not myself seen instances of this and many of the other disturbances of the health attributed to over-pressure in schools in England. No doubt such cases are occasionally met with, but as far as I can judge, there is no conclusive evidence of health disturbance being frequently caused by undue mental exertion in more than a very few exceptional cases — indeed, my own opinion is that there is more suffering from too little than from too much brain work. Some Forms of Sligltt Fever and their Treatment. — Of the occurrence of fever from over-exertion there can, however, be no doubt. I have seen well marked cases in which the febrile state lasted several days, the temperature rising to 104° or a little higher for a short time. The patient must go to bed and rest till health is completely restored. As regards treatment all that is required is the usual liquid diet, small quantities of stimulant if the patient is very low, and a little saline such as citrate of potash — ^ Bishop's effervescing citrate of magnesia is a pleasant form to take. Eruptive Fevers. — Not only are slight attacks of feverish disturbance common, but some of these are characterised by a curious disturbance of the circulation of the blood in the capillaries of the skin, causing the appearance of " eruptions." Of eruptive fevers some are serious and dangerous to life, but a large number though accompanied by unpleasant phenomena, among which, a burning sensation and terrible itching are prominent, are not dangerous or liable to cause any severe changes dangerous to life. You must, however, bear in mind that the diagnosis 33- FEVERS OR INFLAMMATIONS. of many of these eruptions is by no means easy, and no one ought to think of giving an opinion until he has seen many cases, and studied the matter carefully. Some very unimportant looking eruptions may be indicative of grave febrile disease, while very distinct and formidable looking eruptions may be unaccompanied by any constitutional dis- turbance and of comparatively little consequence. Many are connected with some obscure nervoualis of a vessel does not really do so, and is, in fact, either in front of the capillary or behind it, and has not come out of the vessel at all. There is, however, no doubt that this migration of colourless blood- corpuscles does occur, but I believe it to be an exception rather than a common or ordinary phenomenon, while I feel sure that, in many cases, the process of inflammation may run its course entirely, without the escape of a single blood-corpuscle. The corpuscles found outside the capillaries in great numbers in cases of inflammation are produced not by the passage of colourless cor- puscles from the blood, but by the growth of very minute particles which have escaped with the transuded fluid. These particles do not consist of colourless blood-corpuscles, which, as such, have traversed the walls as has been supposed. So far from having been colourless blood-corpuscles, it is doubtful whether at any time one of them ever circulated in the blood as such. What, then, are these bodies, and how did they attain the position in which we find them ? Some years before the above views were published and popularised in this country, I had described another process of migration, or rather pouring out, from the blood, suspended in liquor sanguinis, of minute particles of living matter or bioplasm, which no doubt play a very important part in the complex phenomenon of inflammation. I showed that, if a very thin layer of healthy blood was examined by a high magnifying power, a number of corpuscles, infinitely smaller than either red or colourless corpuscles, were to be detected ; and not only so, but I proved that these minute corpuscles, varying from the one hundred- thousandth to the one ten-thousandth of an inch in diameter, and probably corpuscles still more minute, consisted of bioplasm, or living matter. The blood of man and the higher animals, while circulating in the living body, ought to be regarded as a fluid holding in suspension countless multitudes of minute particles of living matter which, at death, undergo a great change, and become converted into several different substances, among the most important of which is the matter we call fibrin. Similar minute particles of living matter are held in suspension in the circulating and nutrient fluids of every living organism, and are present even in the nutrient juices of plants. In the large cells of Vallisneria spiralis, which you may easily grow in a glass jar in your sitting room, you may see the rotation of the so-called " cell-contents." The most important of the contents being the apparently clear homo- geneous fluid which passes round and round the cell, as long as the very minute particles of bioplasm suspended in it, but to be demon- strated only by the aid of very high powers, continue alive. No one has succeeded in accounting for these movements by physical and chemical change, though many have attempted to do so. Many more z 2 340 SPONTANEOUS MOVEMENTS. have affirmed that it can be so explained, and with the confidence and satisfaction characteristic of the new philosophy, have affirmed that, even if the explanation they have given is not quite adequate and satisfactory at this time, it will certainly be found to be so at some future period. The power of moving resides not only in the minute particles of bioplasm, but also in the colourless substance in which they occur. As long as the matter of which these consist lives each particle may move, but when it dies the moving power is completely lost. This remarkable spontaneous niovemenf, which cannot be explained, which we may see in the pus-corpuscle, in the colourless blood-corpuscle, and in other forms of bioplasm belonging to man, to animals, and to plants, has Deen attributed to certain reactions between the particles themselves and things in their environment ; but if you will only look for yourselves and ponder over what you observe, you will soon be convinced of the incorrectness of the hypothesis. At no period of history have such ridiculous statements been made concerning the nature and actions of living things as in our own time. So far from being in advance of old doctrines, the ancients would have ridiculed much that now passes for philosophy. Untenable views concerning many things have been received as true simply because they have been repeatedly urged in strong language. The confidence with which physical explanations of purely vital phenomena are insisted upon and taught is most extraordinary. On the one side there is audacity and something approaching arrogance, on the other meek acquiescence, and an almost incredible credulity. Some teachers claiming to be scientific do not hesitate to tell the public that they know many things which have never been and cannot be proved. They are, we are assured, peculiarly strong diud "privileged" to prophesy, and to do other out of the way things. Some affirm that they discern all sorts of wonderful things, but they cannot tell us how to discern, nor do they explain by what means they have been able to discern. They are " gifted spirits," and do not belong to the class of ordinary mortals. Some prophetic philosophers, without having earnestly studied the phenomena of any living thing in nature, nay, without being even practically skilled in the ordinary methods of investigating the structure of any living organism, assault the whole world of life, and recklessly declare that all living things are produced and built up and worked according to the very same principles and laws by which the non-living world is fettered and confined in eternal helplessness. Vital iiiienomena. — Let me persuade you to observe what happens as the simplest of living things grows. Take, for instance, ordinary mildew, which can be obtained easily enough, or which each can grow for himself, for its germs are always present in the air. You may grow CHANGES IN BIOPLASM : PUS. 34I it in a little acid urine if you like. By carefully watching it, you will be convinced that it grows by taking up nutrient matter, which is not deposited upon its surface, but taken into its very substance, where it becomes converted into living matter, from every particle of which new particles may result. Ask the physicist to explain, if he can by any physical laws, the phenomena which have occurred while the organism has been under your observation. Up to this time instead of telling us what is going on — instead of describing by what means matter is changed in composition and acquires new properties whenever it is caused to assume the living state, confident physicists assert, and with an air of superiority, what according to their power of prevision is certainly to be achieved by physicists in the far-off future. Perhaps the materialist gifted with prophetic powers enlarges on the subject of chemical affinity and its possibilities, perhaps he will tell you about properties and attractions, tendencies, molecular forces, potentialities, and evolutions and laws, and discoveries concerning things that may be, or according to him must be, and which he, but no one else, can discern in imagin- ation. He will not, however, tell you what happens whenever lifeless matter is made to live, or when living matter dies. All the assertions made during the last ten years or more on the identity of vital and physical processes and properties have but retarded real advance in biological and medical science. No adequate explanation as regards the nature of the change from non-living to living, and from living to dead, has been discovered. The materialist view of living things is an absurdity, based on fancies and dicta instead of on facts. The vital phenomena observed in the case of the mildew or any other simple organism, closely resemble those which are observed in the case of living particles belonging to man and the higher animals, both in health and disease, and can be accounted for only by attributing them to the influence of a peculiar power or agency associated with the matter while it is alive, and which is absolutely distinct from any of the known properties or forces of ordinary matter. Changes in Bioplasm : Pus. — The minute particles of bioplasm or living matter which pass through the walls of the capillary vessels in cases of ordinary inflammation soon begin to undergo alteration. As long as they were being rapidly moved about in the blood stream these particles w^ould undergo little or no active change ; but as soon as they become stiU and quiescent, by their own inherent power of movement some begin to make their way through the walls of the vessels (diape- desis, p. 338), and soon take up and appropriate certain constituents of the nutrient material which surrounds them. While in the blood, probably in those organs where the circulation of the blood goes on very slowly, these minute particles grow and slowly undergo conversion into the bodies known as the colourless blood-corpuscles. When outside 342 CHANGES IN BIOPLASM. the vessels, as in inflammation, the particles grow more quickly and soon assume the form of the colourless corpuscles which we see in such immense numbers in the interstices of various tissues and just outside the walls of the vessels in inflammation. 1. Under certam circumstances the bioplasts in question soon die, and the products resulting from their death are quickly re-absorbed. 2. Under other conditions they develop a delicate fibrous material. 3. If supplied with plenty of pabulum they may continue to grow and multiply very rapidly until the form of living matter known as pus results. Pus-corpuscles are particles of living matter or bioplasm, which have been developed by direct descent, but with modification in power, from the minute living particles under consideration, or more directly from colourless blood-corpuscles, or from the bioplasm of some tissue. From such particles of bioplasm every form of adventitious fibrous tissue which we find outside the walls of the capillaries and in the interstices of the tissues, in various forms both of acute and chronic inflammation, is produced. The delicate fibrous tissue at first formed loses water, contracts, and gradually becomes condensed. The " thick- ening " and condensation which you often meet with in tissues which have been inflamed is thus brought about. As I have already remarked, the minute particles of living matter, or bioplasm, outside the walls of the capillaries may also grow and multiply until multitudes of "pus-corpuscles " result. Even at this time the fact that pus-corpuscles grow and multiply of themselves by the formation of little offsets, outgrowths, or diverticula, which are from time to time detached, is not generally recognised. You may remember, in a former lecture I described how the bioplasm of a cell might increase in size, and might give off diverticula, which being detached, form separate portions of bioplasm, each of which may grow and give off more processes, until by the growth and multiplication of a few particles millions of the masses of bioplasm known as pus-corpuscles are formed, every one of wnich may be regarded as the descendant of the bioplasm or nucleus c an epithelial cell. The pus-corpuscle cannot, therefore, be looked upon as an individual colourless blood-corpuscle, which has simply migrated from the blood by traversing the walls of the vessel. The idea that the formation of pus is in any way dependent upon bacteria or other forms of so-called micro-organisms is negatived by what may be easily seen in the production of pus-corpuscles in epithelial ceUs. The growth of the bioplasm and its division and subdivision under conditions which involve increased nutrition will convince any one who observes the phenomenon how pus may be produced in epithelium ; and, as exactly corresponding facts are to be demonstrated CHANGES IN BIOPLASM. 343 by the examination of bioplasm in otlier tissues, cartilage, fibrous tissue, muscle, nerve, &c., when exposed to the influence of an unusual supply of nutrient pabulum, no room is left for doubt as to the exact nature of the pathological process of pus-production. I cannot agree with my colleague, Professor Lister, in considering that bacteria may be the cause of suppuration, nor can I admit that this process can be properly attributed to chemical substances or to nervous disturbance. A state of things may be brought about by bacteria by nerve action or by chemical change which may indirectly occasion the more free distribution of nutrient matter to bioplasm to which the production of pus is directly attributable. SOME COMMON FORMS OF SLIGHT INFLAMMATION AND OF THEIR TREATMENT — FORMATION OF MUCUS — MUCUS CORPUSCLE— COUNTER-ACTION, COUNTER-IRRI- TATION—SORE LIPS— ALCOHOL, NITRATE OF SILVER AND OTHER ASTRINGENTS — CONJUNCTIVA— LOTIONS AND EYE-WATERS— SORE THROAT— THE TREATMENT OF SORE THROAT — GARGLES — INFLAMMATION OF MUCOUS MEMBRANE OF THE AIR-PASSAGES— RUNNING FROM THE EARS— INFLAMMATION OF MUCOUS MEM- BRANE OF STOMACH AND INTESTINAL CANAL— CON- GESTION OF SMALL INTESTINES— SLIGHT DYSENTERY —CHILBLAINS— TREATMENT— BOILS— TREATMENT— ON PREVENTING SERIOUS DISEASE. We will now endeavour to determine what are the essential changes which occur in epithelium and in some other tissue elements in ordinary slight inflammations. These changes do not necessarily lead to any structural alterations ; but if the inflammatory process continues for a certain period of time, it may be followed by tissue degeneration and other pathological phenomena, from which complete recovery — return to the normal state— cannot be looked for. Not a few of the slight inflammations are superficial, involving a very thin layer of the surface tissue only, and although most of them are by no means serious, some are very troublesome and many excessively painful. It is desirable, therefore, not only that you should know how to detect and distinguish them, but you ought to be fully conversant with the exact nature of the minute changes taking place, and the methods by which a return to the normal state may be promoted. The treatment of some of the inflammations in question has been already considered, but it seems to me very important that I should do my best to press upon your consideration the character of the changes effected by simple remedies in the vital actions which are proceeding in the inflamed tissue, the results of some of which have been rendered evident to us by careful microscopical lesearch. He will be most successful in the management of disease, who most nearly succeeds in picturing to himself the wonderful changes which proceed in such marvellous minuteness and detail, and which can only be revealed to FORMATION OF MUCUS. 345 those who have long and earnestly studied, and have taken full advan- tage of the elaborate means of minute investigation now at their disposal. The mucous membrane of the nose, and its many passages, as has been already stated (p. 311), is very liable to slight inflammation. In the changes which occur during an ordinary cold we have an illustration of the very gradual passage of physiological into pathological actions. There is a particular point in these changes when it would be impossible to decide whether it would be more correct to say that the membrane still remained in a healthy state or had just passed from this into a morbid condition. The difference between certain normal and inflam- matory states uncpestionably depends only upon an exaggeration of the activity with which normal changes are performed. In suppuration there is no depression or reduction in intensity of vital processes, but there is too much vital action, too much growth of a weak temporary character, and too rapid multiplication of living particles. It is by the careful study of inflammatory changes only moderate in degree that we shall be able to answer the question why in one case the healing, and in another, apparently similar in all general respects, the opposite and destructive process occurs. A slight wound suppurates, which we desire should heal, — an ulcer forms and increases in spite of all our efforts to stop its ravages. The observations made on p. 350 bear upon this most important question, and while one set of enquirers would attribute the want of repair to some derangement of the nervous system, another set to some chemical poison in the air, — another to the presence of bacteria of a malignant type, — I would refer it solely to the state of the patient's blood — to the presence in the circulating fluid of an abnormal quantity of material easily appropriated by low forms of bioplasm or living matter, and to the presence of multitudes of minute particles of these — of bioplasm particles which, passing through the capillary walls, grow and multiply and actually prevent the slower changes which ordinarily result in the formation of formed material, and which con- stitute an essential part of the healing process. If the matter upon which these particles live could be removed from the blood, we should stop the growth and multiplication of the bioplasm particles and cause their death. Hence in cases in which the patient's strength is good, free purgation favours the healing process, and in the case of those who sufter from prostration, alcohol in the blood and the application of alcohol and things which act like alcohol to the wound, acts in the same beneficial manner ; for this substance interferes with the growth of living matter, and alters the pabulum in such a manner as to render it unfit for the nutrition of the living particles. Formation of Mucus. — Mucus, as you know, is formed in small quantity in the follicles and glands in connection with the mucous membrane of the nose, even in perfect health. When we suffer from 346 BIOPLASM OF MUCUS. a common " cold in the head," these particles of bioplasm which take part in the formation of the tenacious mucus around them, grow and multiply more quickly than they do in the perfectly healthy state. The viscid material (mucus) formed by them is in greater proportion, softer in consistence, perhaps disintegrated and broken down, or actually de- composed, and in it bacteria and low forms of life find materials favour- able for their development, and eminently suitable for their nutrition. Mucus Corpuscle. — I have many times spoken of the bioplasm which constitutes the so-called Mucus-corpuscle, but I have not told you how you should proceed to observe the wonderful vital movements which occur during its life, and especially at the commencement of a slight cold, when the activity of the movement is considerably increased. Having obtained, by coughing or sneezing, a small piece of the trans- parent mucus, about the size of a pin's head, place it on an ordinary microscope plate-glass slide. Next cover it with a piece of the thinnest covering glass you can obtain, without adding water or any other sub- stance. Gently press down the thin glass cover with the aid of a pin or needle, and place the slide under the microscope, using first of all a quarter of an inch object glass, and then a twelfth or higher power, if you are fortunate enough to possess one. If not, you can gain the requisite degree of amplifying power in another way, and at the cost of a shilling or two. A piece of brass tubing, of the same diameter as that of the tube of the microscope, and arranged to carry the eye-piece, is fitted to it, sliding in just as the eye-piece does. The total length of the tube, to one end of which the object-glass, and to the other the eye- piece, is attached, is in this way increased to about eighteen inches. The intensity of the illumination being somewhat increased, you will find the little particles of mucus so highly magnified that you will be able to see the slightest changes which take place in their form and contour from moment to moment. The minute oval particles in the thin layer of transparent mucus, and which consist of living matter or bioplasm, may be said to repre- sent, and indeed correspond to, the " nucleus " of an ordinary epithelial cell, while the mucus — that viscid material which surrounds them — corresponds to the " wall " of the cell. If the epithelium of other mucous membranes grows unusually fast, a material which not only corresponds to, but resembles, mucus will be formed. If now you select one of the oval corpuscles, the living matter of the mucus, and examine it intently, you will soon observe changes in its out- line. Here and there protrusions will occur, portions of the mass moving away from the remainder, and then being withdrawn and incor- porated. The movements indeed very closely resemble those seen in an ordinary amoeba, and are vital movements of the same nature. They continue for a considerable period of time — perhaps for twelve hours, or NERVE-FIBRES OF CAPILLARIES. 347 longer, if you keep the mucus in a moist atmosphere, and so pre- vent it from drying up. Changes of the same kind occur in bioplasm generall)', but it is only here and there that we are able to demonstrate them so satisfactorily as in the case of the living Mucus-corpuscle, Pus- corpuscle, and colourless Blood-corpuscle. In these living particles any one can study, and at any time he desires to do so, the vital movements of bioplasm or living matter. In an inflamed mucous membrane, besides those prominent derange- ments, increased redness caused by congestion of the capillaries, and increased dryness consequent upon the defective pouring out of the fluid from the blood to take the place of that which has been quickly removed from the surface by evaporation, we have to notice important changes in connection with the action of the nerves. Every one who has had a cold knows that the sensation of the part is affected. The mucous membrane is sore and painful, so that his attention is being frequently directed to it. He fancies something is adhering to it which requires to be removed, and is constantly making efforts to get rid of it. In some cases a certain quantity of mucus collects upon the surface and dries, in others the sensation experienced seems rather to be due to the tissues being infiltrated with fluid. Sometimes the mucous membrane, particularly at the margin of the nose, becomes excoriated, or a super- ficial ulcer may form. In the last case it will be found that the ordi- nary protective hardened epithelial covering has been here and there removed, and a raw and highly sensitive fissure formed, at the bottom of which are capillaries and nerve-fibres. From the capillaries fluid escapes holding in suspension numerous minute particles of bioplasm, and not unfrequently small quantities of blood itself are poured out. The pain experienced is due to the exposure or incomplete exposure of delicate nerve-fibres. The particular nerves affected are those which are distributed close to the capillary vessels, and which have been already described. But other nerve-fibres may be involved, for as I have already mentioned, there are tissues in which nerve-fibres are dis- tributed, although no capillaries exist, which nerve-fibres are concerned in the pain experienced when the tissue is inflamed. At the same time it is probable that the nerves in question belong to the same system as those distributed to capillaries, while there is no doubt that the latter are concerned in transmitting to us the impressions which we call pain. I have already remarked that as regards many tissues to which numbers of nerve-fibres are distributed, we are quite unconscious of their exist- ence so long as the normal or healthy state lasts, but as soon as this gives place to inflammation, pain, it may be of the most exquisite kind, results. The nerves concerned are, I think, those of the capillary vessels which belong to that self-regulating system of nerves before referred to. These very delicate nerve-fibres become, as I have said, stretched or 348 PAINFUL SENSATIONS. pressed upon by the distended capillary vessels, and perhaps otherwise affected by the exudation which takes place. And in consequence of these derangements, this departure from the normal state, as respects the nerve-fibre, and the bioplasm which is connected with it, that dis- turbance of the nerve-current which we term pain results. The extreme pain accompanying pleurisy, that caused in the condi- tion we recognise as a rheumatic state of the nerves disturbed to the intercostal muscles, and the pain excited during inflammation even of very small portions of the subcutaneous tissues, as in the formation of a boil or even in the case of a chilblain, are illustrations of the exquisite sensitiveness of nerves in textures, of the existence of which in the normal state we are perfectly unconscious. In all these cases the actual nerve-fibres involved are probably those which run very close to the capillary vessels of the respective tissues. Eruptions, particularly of a vesicular character, often occur in the course of sensitive nerves, and particularly in the course of nerves which are very commonly the seat of neuralgic pain. Whether the sensitive nerve trunk is directly involved, or whether the fibres distributed to the capillary vessels of the nerve trunk and of the skin situated over the nerve only are affected, it is not possible to say. What, however, seems quite certain is that the vesicles of an eruption, which generally is herpetic in its character, follow the course of the nerve. The patho- logical disturbance resulting in the formation of the vesicles may be of a most complex nature, in which reflex nervo-vascular action plays a highly important part. There must be increased nutrition, with pouring out of fluid from the capillary vessels, and this phenomenon is probably due to the relaxation of the muscular fibre-cells of the small arteries and consequent enlargement of their calibre, a change which may be caused by disturbance in the nerve-centre governing the contraction and dilatation of the arterioles. The central disturbance may itself be due to impulses emanating from the sensitive nerve itself, or originating in the skin situated over its course and transmitted thence by afferent fibres connected with the centre. In this manner it is very probable that various peculiar eruptions and other disturbances connected with the nutrition of the skin and subjacent structures are occasioned. But besides the alteration in the sensibility of the mucous membrane in sore throat, important changes take place in connection with reflex nervo-muscular action. You are all no doubt aware that if the fauces be tickled ever so slightly, convulsive movements of swallowing wiU instantly follow if the mucous membrane be in a healthy state. In slight " sore throat " it will be found that the response to slight irritation is slow and imperfect, while in severe forms of inflammation no efforts of deglutition can be excited even by severe irritation. The changes in question are due to an alteration in the sensitiveness of the mucous membrane, and COUNTER-IRRITATION. 349 probably depend upon pressure or stretching of the delicate nerve-fibres, in consequence of which they cease to conduct impressions from the periphery to the nerve-centres. The dry state of the surface which is induced by slight inflammation of the mucous membrane may last for a short time, and then gradually subside without any further pathological action. If however the dryness and diminished secretion should persist for some weeks, restoration to the ordinary condition takes place very slowly, and before the healthy state can be resumed, a condition opposite to that of dryness supervenes. Secretion is poured out, it may be in very considerable quantity. This tendency to secretion, being once established, may persist for days or weeks, and then begin to diminish in amount. By degrees the glands return to their normal state of slight activity, secreting only a very small amount of transparent viscid mucus. Counter-action, Counter-irritation. — But we may reduce the secre- tion consequent upon exaggerated and abnormal action occurring upon a mucous surface by causing increased action elsewhere. Instead of trying to act directly upon the membrane which is the seat of the increased action, we may endeavour to establish increased action of surfaces or organs at a distance, situated in different parts of the body. In this way, for example, the inflammation and undue action which are going on in the surface of the nose in many cases of catarrhal inflamma- tion may be reduced. This is, indeed, a very important principle connected with the treatment of disease, and it has been acted upon for years, or even centuries, but we are much better informed concerning the rationale of the process than our predecessors were. That we can reduce the rate or degree of action in one part of the body by increasint^ it in another, may be proved by a simple experiment. When a cold is coming on, you feel great discomfort about the nose, the mucous membrane of which cavity is so swollen that the nasal passages arc obstructed, so that if you try to draw air down one nostril, you fail or only a little air can be drawn through if a great effort be made. You are obliged under these circumstances to breathe entirely through the mouth. The discomfort caused by the swollen state of the mucous membrane, depending partly upon exudation into the submucous tissue and partly upon increased nutrition going on in the epithelial covering may be ameliorated in a very short period of time, and in a very simple way. Let the feet be put into water, as hot as it can be borne without severe pain. In the course of a quarter of an hour, the disagreeable feeling of fulness and obstruction in the nose will cease. The air will pass throuo-h the nasal passages quite freely. By increasing the flow of blood in the ves- sels of the skin of the lower extremities, much of the circulating fluid will be diverted, for the time being, from the mucous membrane of the nose. Many cases of headache are also relieved by putting the feet into hot 350 CHANGES TAKING PLACE. water. If, instead of this, a mustard poultice be applied to the back of the neck, a similar effect will follow. As soon as the mustard poultice begins to act, the nerve-fibres distributed to the capillaries ramifying just beneath the epithelium, after being first irritated and then partly poisoned by the oil of the mustard, take part in initiating changes which result in the vessels becoming red and turgid from the increased quantity of blood which is driven into them. The blood in these vessels circulates more slowly, and gradually accumulates in them, the surface becoming red and exceedingly painful. Corresponding with this increased action in the healthy part we have reduced action at the seat of the morbid change. In this way we are able to effect alterations which are of immense importance in the treatment of many different forms of disease. In cases where the morbid action is chronic, we keep up the counter- irritation to a moderate extent, or we repeat the application of the counter-irritant from time to time. Even in very chronic diseases, there is good reason for adopting this principle of treatment. In some cases of phthisis, where there was reason to infer that tubercle was limited to a very small extent of pulmonary tissue, benefit seems to have resulted from keeping a small open sore on the skin of the upper part of the chest on the same side of the body. This is a form of " issue." In these days, however, this system of treatment is now rarely, perhaps too seldom, employed. Sore Lips.— Slight pathological derangements of the skin and mucous membrane of the lips are common. The surface becomes more or less dry, and the epithelium of the red part of the lip, which resembles that covering the skin, only forming a thinner layer, as well as the soft, moist epithelium lining the cavity of the mouth, may be deranged in its growth. The surface, instead of remaining quite smooth, becomes more or less harsh. Under these circumstances the patient often attempts to make the surface even, by rubbing it so as to remove the little projecting pieces of ragged cuticle. In this way the derangement is kept up or intensified. The cuticle tends to peel off in thin laminae, and many people cannot resist the temptation to catch at the pieces, and tear them away. But then the surface becomes raw, and often bleeds. In consequence of the air coming into contact with itj the moisture soon disappears, and the soft imperfectly-formed cuticle gets dry, the surface becomes corrugated, and the tissue is more painful than ever. By the irregular growth of epithelium the arrangement of the finest nerve-fibres is disturbed, and constant irritation gives rise to irregular stretching or pressure. The sensations thus caused, and rapidly succeeding one another, excite the patient's constant attention, and in consequence he continually rubs the affected part or keeps constantly picking at any loose portion of cuticle. Immediately around the irritated nerve-fibres multitudes of particles of living bioplasm actively PRINCIPLES OF TREATMENT. 35 1 grow and multiply, forming a mass of soft, very moist, spongy matter, the constituent particles of which are always changing in position. The drying that is proceeding on the surface necessarily disturbs the nerve- fibres, as well as other structures beneath. School-boys are very prone to pick their lips when in this state, and make them extremely sore, particularly at the line where the thin skin of the lip joins the ordinary skin, and at the angles of the mouth, where little cracks or fissures often form, which may remain for days or weeks, sometimes giving rise to ugly and troublesome sores. It is very desirable to prevent the irrita- tion which so disturbs the patient and causes him to make the sore worse, and retard the healing. Principles of Treatnunt.- — It is by taking the hint afforded by slight departures from the normal state that you may be of the greatest use in preventing more serious changes, or in being led to anticipate their occurrence, and by adopting measures known to interfere with the ex- pected pathological phenomena they may be prevented or modified. Half a grain of calomel or less given daily for four or five days will often be found to be more useful than one or two purgative doses. By the former plan you excite a series of moderate changes likely to have the desired effect, and oftentimes you will find that health is completely restored by the very free action of the organs of elimination throughout the body, an effect that might not have been produced either by violent treatment or by change of air, or by transference to high altitudes, or by drinking special waters. Upon what principles should the local treatment of simple ex- coriations and slight superficial ulcerations be based ? Our main object should be to reduce the growth and multiplication of the particles of bioplasm which are instrumental in keeping the fissure moist and open. This cannot be effected by causing them to dry up, because in that case a little crust would soon form which, in con- sequence of the contraction produced by desiccation, would afterwards be drawn away from the subjacent parts. In this manner a raw surface again appears, and is perhaps larger than the preceding one. We must at the same time try to prevent this drying up, and endeavour to reduce the growth of bioplasm, and the pouring out from the blood of fresh plasma containing more bioplasm particles. By effecting these objects certain celebrated lotions and other local applications promote healing. Some of them lead to the quick formation of a dry scab, but so thin that it does not become detached. Other applications are em- ;)loyed for the purpose of reducing the rate of growth of the masses of bioplasm on the surface of the sore, which is at the same time kept moist. The formation of the more permanent tissue slowly proceeds beneath this temporary protective covering. The latter process requires a considerable time for its completion, for much formed material has to 352 ALCOHOL — NITRATE OF SILVER. be slowly produced by the bioplasts of the several tissues, and time must be allowed for it not only to be slowly formed, but to become properly condensed. Alcohol. — One of the most potent applications for healing such slight sores as I have referred to, is alcohol. The sore place is to be painted over once in an hour or so, with pretty strong spirit, a camel-hair brus h being used for the purpose. Of course there is a sharp pain at th e moment the alcohol comes into contact with the delicate nerve-fibres, but it soon passes off. In many cases it is well to dilute the alcohol with an equal quantity of water or rose-water. It matters little whether you use any^of the ordinary spirits, or Eau de Cologne, but pure spirits of wine, diluted with one-third part of pure water, is the best application. By this treatment the thin skin on the surface of the fissure or ulcer will become hardened, and the soft, new epithelium that is being formed beneath will become condensed, and the new cuticle will gradually assume the usual character of that tissue. Let us consider how alcohol acts advantageously under these circumstances: — By its property of coagulating albuminous matters, alcohol tends to retard rapid growth, and to interfere with the multiplication of those particles of bioplasm which are growing so rapidly just outside the capillaries. The bioplasm, as I have mentioned, is growing so very fast that there is not time for the development and consolidation of that firm, healthy formed material which, with the living matter or bioplasm within, con- stitutes a cuticle cell. By applying alcohol then, you favour the formation of cuticular cells. Wherever the cuticle is thin, by painting it frequently with alcohol, you promote the formation of firm cuticular formed material (the outer part of the so-called cuticle cell) and thus the condensation and increase in thickness of the new tissue is effected. If there should be sores in the mouth, or if the mucous membrane of the gum should be soft and spongy from the infiltration of fluid in the substance of the mucous membrame, the surface of which may be very red and tender, the morbid action may also be quickly counter- acted by painting the part three or four times a day with spirits of wine, Spiritiis Vini Redificatus, or some other form of alcohol, or with spirits of Camphor, Spiritus CamphorcE. Solution of Nitrate of Silver. — Many lotions composed of metallic salts are employed in the treatment of sores. Most of them act by virtue of their property of coagulating and precipitating and forming compounds with albuminous matters. Among these salts is Nitrate of Silver, Argenti Nitras^ which causes some sores to heal very quickly. With a small camel-hair brush you paint the fissure with a little solution of Nitrate of Silver, consisting of from five to ten grains of the Nitrate in an ounce of Distilled water. This will give pain for the moment, but the soreness soon passes off. The growth and multipHcation of the INFLAMMATION OF THE CONJUNCTIVA. 353 masses of bioplasm are prevented, Time is allowed for the young cells to harden. Gradually, new cuticle is formed, the growth of healthy epithelium is favoured, and before long the healing process is completed. Not only is new cuticle encouraged to form, but when a portion of the true skin is removed, the various tissues are represented as well as the epithelial covering. Conjunctiva. — -A good illustration of the pathological changes which occur when a complex tissue becomes inflamed is afforded by the mucous membrane which covers the front of the eye and lines the eye- lids, the Cotijunctiva, — when in a state of inflammation. This moist mucous membrane is very highly sensitive, and as all have occasionally experienced, readily becomes inflamed. If you go out in foggy weather, and afterwards examine the conjunctiva, you will often find many of its vessels distended, and you will observe that it is much redder than it was before it was exposed to the deleterious effects of the irritating substances suspended in the air. The pathological change in question is due to the poisonous action of the irritating matter on the peripheral ramifications of the sensitive afferent nerves, whereby is occasioned a disturbance in the nerve-centres resulting in a paralysing influence upon the nerves of the little arteries. In the case of persons who are in a low state of health, who have lived badly for some time, and especially in those who belong to scrofulous families, there is increased liability to inflammation of the conjunctiva, as well as the glands and other structures which are connected with it. When the mucous membrane is inflamed the little glands participate, and from them is poured out an abundant secretion containing numerous particles of bioplasm. The vessels are distended, and that part of the mucous membrane which lines the eyelids and covers the white part (sclerotic) of the eye is reddened and, as I have remarked, assumes an appearance which well illustrates the changes taking place in inflammation. The condition is called Ophthalmia or Conjunctivitis, and is of great scientific interest, because the transition from the normal or ordinary state of health to the abnormal and temporary state of inflammation may be studied in its gradations. It is easy to examine the membrane from time to time with a lens, and without causing the slightest pain or inconvenience to the patient. The conjunctiva, especially in ill-fed, ill-nourished, and in scrofulous children, not only readily takes upon itself this exaggerated action, but passes into a state of inflammation which, though slight for a time, may soon become severe and be accompanied with an abundant formation of a yellowish secretion. If a little of the discharge is examined in the microscope, it will be found to consist of multitudes of particles of living matter, well known as pus-corpuscles. Such is the virulence of som.e of these living particles that if no more of ttie discharge than 2 A 354 INFLAMMATION OF THE CONJUNCTIVA. can be carried on the point of a needle, be transferred to the surface of the eye of another person, a similar pathological state is quickly esta- blished upon it. Serious inflammation is excited, and the same series of phenomena occurs. From this case the poison may be transferred to a third, and so on. Now, if many children in weak health who for some time previously have been badly managed as regards food, air, exercise, and cleanliness, are allowed to congregate, and especially if they are confined in close, ill-ventilated rooms, the disease may not only arise but soon acquire an extraordinary degree of virulence. It may spread so quickly in such a community of children, that in a short time, out of four or five hundred, one-third or even a larger proportion may be suffering from the disease. Of the number affected many will suffer severely, and serious structural changes in the membrane and in subjacent tissues will result. The transparent part of the eye in front, known as the cornea, may ulcerate, nd when after some time it heals, the tissue will be so altered that the very transparent texture will become opaque, or the eye itself may be destroyed, blindness of course resulting in either case. This very virulent poison of purulent ophthalmia may, as I have remarked, be evolved de novo without contagion. The contagious material may in fact originate upon the membrane which during its formation passes from the normal into the pathological condition. A highly contagious poison is also developed in the organism of a person suffering from peritonitis and some other inflammatory and febrile diseases. In this case it is to be remarked that the surfaces upon which the changes occur which result in the development of the living contagious poison are not and never have been exposed to the air. The contagious matter once developed, however, may spread far and wide, and with a rapidity which is quite remarkable. You see, therefore, that a living animal poison of a highly contagious kind may be developed direct from normal bioplasm, the most minute portion of which might estal)lish a similar series of pathological phenomena in a comparatively healthy tissue if transferred to it. Probably many of the pus-corpuscles found on the surface of the conjunctiva in a case of purulent ophthalmia do not result from the particle inoculated. Some, no doubt, are formed from the young bioplasts of conjunctival epithelium. There are, therefore, in such cases, two kinds of bioplasm growing and multiplying at the same time, but so intermingled that it would not be possible to obtain particles of each kind separately. In inflammation of the conjunctiva, not the least important of the phenomena is the dilatation of the vessels. Of the httle arteries many are dilated to three times their ordinary diameter, and the capillaries are also distended and choked with blood. Capillary vessels so small that hardly a single row of red blood-corpuscles would lie in them, and EYE-LOTIONS. 355 quite invisible in the ordinary state, become so large in inflammation and are so filled with blood that through an ordinary lens they can be seen as distinct dark-red lines. The injection of the vessels may con- tinue for many days and then pass off, or it may become chronic, when other pathological changes take place in consequence. The influence of the nerves and nerve-centre in these vascular changes has been already considered. Ti-eatment. — Inflammation of the conjunctiva requires to be care- fully treated. It is undesirable to allow this inflammation to go on, especially in children, because it may reach a stage in which there is danger of damage, not only to that very important structure of the eye, the cornea, the clearness of which is essential to distinct vision, but, as before remarked, to the whole organ. Good hygienic conditions are essential in the treatment of the disease as it occurs in children ; and it is very important to look for and relieve that preliminary state of in- flammation and enlargement of the glands in the membrane which almost invariably precedes an attack of purulent ophthalmia. Many astringent substances are of use in the treatment of inflamma- tion of the conjunctiva. These may be applied in various ways. In former days it was the practice to project a small quantity of some astringent powder on the surface of the inflamed conjunctiva, by placing a little of the powder in a quill or piece of straw, and blowing it sud- denly upon the eye, which was kept open for the moment. These powders were usually made of sugar and the potent substance, in the proportion of from ten parts or more of the former to one part of the latter, the whole being very finely powdered and carefully mixed. Oxide of Zinc, Nitrate of Potash, Abim, Sulphate of Copper, Nitrate of Silver, and other substances have been used in this way ; but the prac- tice is a bad one, and has been almost entirely abandoned in favour of solutions, which may be applied as drops, or by using an eye-glass or an eye-fountain. Strong astringent applications should never be used except under proper advice, or serious damage to the eye may result. Of Lotions and Eye Waters. — One of the best is a weak solution of Sulphate of Zinc, Zinci Sulphas, in water, or, if you wish to order a more elegant lotion, in Rose Water, Aqua Rosce. As regards the quantity, you may prescribe from a quarter of a grain to a grain, to the ounce of water. A very dilute solution will often produce a favourable change in cases of mild inflammation of the conjunctiva in a few hours. Sugar of Lead, Plumb i Acetas, or Sulphate of Copper, Cupri Sulphas, may be used 'in the same proportion as Sulphate of Zinc ; but the latter and Nitrate of Silver, Argenti Nitras, are probably the most efificacious. Of the last, half a grain or less to an ounce of distilled water. If the eye is very painful, a quarter of a grain of morphia or two or three 2 \ 2 356 SORE THROAT. drops of Laudanum, Tinctura Opii, to the ounce of distilled water, may be prescribed. In all cases the solution should be carefully filtered before it is applied. A lotion consisting of Spirits of Wine, Spirittis Vini Rectificatus^ or good Brandy, Spiritus Vini Gallici, in the proportion of one part to thirty or more parts of water, has also been recommended ; and where the vessels are dilated without any production of pus. the careful application of a weak spirit solution may be useful. Lotions may be applied to the surface of the eye in two or three different ways. One of the best methods is to seat the patient in a chair, and make him throw his head back. You then take a good-sized camel-hair brush, which will take up two or three drops of the lotion, which may thus be caused to flow into the inner corner of the affected eye. Of course the patient will instinctively close the eye at the moment, but he must be encouraged to open the lids a little, so that some of the solution may pass in, and the surface of the conjunctiva be thoroughly moistened by it in every part. Another plan is to bathe the eye with an ordinary sponge or rag, but you must always be most careful that the particular sponge or rag is used for no other purpose whatever. Where there are several patients each must have his own sponge, towel, &c., kept exclusively for his own use. Another way of applying lotions to the conjunctiva is with the aid of an Eye-glass. This is a little glass made something like a small wine-glass, the free edge being shaped so as to fit within the margin of the orbit. The eye-glass is half filled with the lotion, and the patient is directed to hold the glass steadily against the eye, while the head is to be moved about in such a "way as to cause the fluid to splash against the surface of the mucous membrane. Lastly, there is the little Eye-douche or Fountain, by the aid of which a jet of lotion can be thrown against the eye. These instru- ments may be obtained of surgical instrument makers. Astringent lotions generally by their indirect action upon the nerves of the part, and by their direct action upon the particles of bioplasm which are growing and multiplying, favour the formation of the firm material upon which the consistence and the protective character of the epithelium depends. Thus a " raw," or nearly raw, surface gradually becomes again protected with a layer of ordinary slow-growing epithelial tissue. Sore Throat. — Li an early lecture I have adverted to some of the changes which occur in sore throat, but in this place I shall consider one or two questions in connection with the subject which were then passed by. Most of us have suffered more or less from this affection. In the case of those who are susceptible, there frequently occurs a certain amount of congestion and inflammation in the mucous membrane of the fauces, and of the back of the pharynx. If you look at the palate in such a case, you will find it in very much the same state as I described SORE THROAT. 357 when referring to the mucous membrane of the nose in an ordinary cold. INIany of you will have opportunities of making the observation in your own persons. You may easily examine the fauces with the aid of an ordinary looking-glass. Instead of the membrane appearing moist, you will find it nearly dry, and perhaps you may see a piece of half-dry viscid mucus intimately adhering to it. The sensibility of the membrane is also affected. Although it feels sore, you will, however, find that it is less sensitive than in the normal state, while certain of its nerves do not respond so readily to a stimulus as they do in health. If the throat is perfectly healthy, the process of swallowing, or deglu- tition, is easily performed, and almost unconsciously — at least without any great effort ; but if the throat is sore, deglutition becomes difficult, and you have to make a very decided effort, perhaps more than one, before the morsel of food can be successfully swallowed. Then there is another fact of some importance with regard to the action of the mucous membrane. Not only are the nerves which are connected with the capillary vessels, and which are concerned in the sensation of pain and discomfort, obviously affected, but those which are instrumental in exciting by reflex action the contraction of the pharyngeal muscles. If, in the normal state of health, you tickle the soft palate ever so slightly with a feather, if the mucous membrane enjoys its proper sensitiveness, movements of deglutition almost in- standy succeed. But if the throat is " sore," the mucous membrane red, and perhaps dry, you may tickle it very decidedly, and only feeble contraction will follow after an interval of time, or no contraction of the muscles will occur. In this action the muscular fibres fail to contract, because the nerve-fibres which carry impressions from the surface of the mucous membrane to the nerve-centre are deranged. Their action for the time being is prevented. There is, as it were, a peripheral paralysis. The motor nerve-fibres, the nerve-centre, and even the afferent trunks themselves, may be all right : but the fine ramifications of the afferent fibres in the mucous membrane are so affected by the effusion in its substance and other changes, that they do not receive and transmit impressions. In many cases of sore throat you will see the little glands, w^iich exist in great number in the mucous membrane of the pharynx and fauces much enlarged, the orifices of the ducts standing out pro- minently. The little glands participate in the inflammation, and not unfrequently the change is chronic, and lasts for a considerable time. When sore throat attacks persons who have for some time been in a low state of health, or exposed to adverse influences, as sometimes happens in the case of those resident m workhouses, hospitals, jails, and other places, it may run on very quickly to extensive superficial ulcera- tion, which may affect the substance of the tonsil, and progress for 358 TREATMENT OF SORE THROAT. several days. The fetid products resulting from the decomposition of the secretion taking place upon or near the ulcerated surface are some- times absorbed into the blood and occasion a form of blood-poisoning. If swallowed, the discharges give rise to much disturbance of digestion. It is, therefore, most important in the treatment of such cases to apply substances to the surface which have the effect of completely changing the organic matters and destroying the infecting material. If Diphtheria exist in the neighbourhood, persons in a low state of health, and those already suffering from sore throat, are very likely to take the disease, which sometimes runs its course so very quickly that life is in jeopardy in a few hours after the malady has declareil itself, or even before there has been time for the formation of a false membrane, or for the development of any characteristic phenomena of the disease. It is, therefore, of the utmost consequence to very carefully watch cases of sore throat, especially when of an epidemic character. You should see the patient at intervals of a few hours, and you should give quinine and stimulants early, instead of waiting till the patient is very low. In some cases of what is called "hospital sore throat," as well as in Diphtheria, you will be surprised to find that persons may take in twenty-four hours from ten to thirty grains of quinine and eight or ten ounces of brandy, divided into doses given every two hours, without any indication of the quantity of either remedy being excessive ; and it may be necessary to continue this treatment for many days, giving at the same time plenty of beef-tea or milk. The Treatment of Sore Throat. — We are often consulted by patients who complain that they are almost constantly suffering from soreness of the throat. It is sometimes better, sometimes worse, but they will tell you the throat always feels rough and uncomfortable. Many local appli- cations are of great use. With the aid of a camel-hair brush you may paint the fauces with a solution of Nitrate of Silver, Argenti JVitras, but a stronger solution may be employed than was recommended for applying to the conjunctiva. A solution consisting of from five to ten grains to the ounce of distilled water answers well, or you may paint the fauces with a mixture of solution of Perchloride of Iron, Liquor Ferri Ferchloridi, and an equal quantity of Glycerine, Glyccrimim. This application is very useful in the treatment of sore throat, whether it be mild or severe. The Glycerine causes the Perchloride of Iron to adhers to the surface for a little time, and in that way increases its beneficial effects. The application allays the irritation, and not un- frequently the enlarged glands of the mucous membrane return to their healthy condition. In forms of sore throat in which there is a quantity of viscid mucus, accompanied with excoriations, or ulcers on the palate or tonsils, the mixture of Iron and Glycerine may be applied every two hours, or oftener. The solution is a potent antiseptic, and destroys any GARGLES. 359 deleterious properties the secretion may possess. By its application efforts of vomiting are often excited, and thus much of the secretion is got rid of. I have successfully treated in this way many bad forms of sore throat, which by some would have been called " diph/keritic." The condition is associated with great depression of strength, and as I have- before said, it is necessary to give quinine and wine or brandy in very decided doses. Any of the foul secretion swallowed by accident is rendered innocuous by the action of the iron. In this way stomach disturbance, so apt to ensue in these cases, and which so much increases the risk to life when it does occur, may be prevented. Tannin dissolved in Glycerine, Glycerinum Acidi Tan?tici, is also a good application. In applying such local remedies, whether a solution of Nitrate of Silver, or Glycerine and Perchloride of Iron, or the Tannin, perhaps the following will prove to be the best plan. 1 ake a good large camel-hair brush, which must be carefully lied to the end of a stick. This latter point is important, because if the l)rush is simply placed on the stick, it may unfortunately fall off at a critical moment, and be swallowed by the patient. The possibility of the occurrence of so awkward an accident may be thus prevented. The brush is to be thoroughly wetted with the application, and a few drops being taken up in it, the wet brush is to be well smeared over the surface of the affected mucous membrane. If there are any small ulcers, each is to be carefully touched with the application. After a quarter of a minute the patient may be allowed to gargle with a little cold or tepid water. Although severe forms of sore throat cannot certainly be included among " slight ailments," it is important that your attention should be directed to the general treatment of the patient. I have no doubt that by judicious management many cases are prevented from assuming a severe form. If the patient gets low, with a quick, weak pulse, especially if ulceration which may be present should be extending, and there is infiltration of the tissues around the tonsils, it is necessary to give wine or brandy and tonics such as iron and quinine. One is often surprised at the large amount of supporting remedies required in some of these cases. In what used to be called " hospital sore throat " we often find it necessary to give in severe cases six or eight five-grain doses of quinine in the four-and-twenty hours, and as much as twelve or more ounces of brandy during the same period, and this treatment may have to be maintained during several days. Garbles. — Various gargles are used in the treatment of sore throat, and an inflamed or aphthous state of the mucous membrane of the mouth. The influence of some of these is due to the presence of matter having astringent properties, while others depend for their eflicacy upon some form of alcohol. Fort wine is an excellent gargle in cases of ordinary relaxed sore throat, but some people do not like port, or any 360 INFLAMMATION OF THE AIR-TUB £S. Other kind of wine, and in that case you may order a gargle consisting of one part of spirits of wine to four or five parts of water. Alum used to be a favourite remedy, dissolved in a little water in the proportion of one drachm to six ounces. A good gargle may be made by dissolving a drachm of Nitrate of Potash, Foiassce Niiras, or Chlorate of Potash, FoiasscB Chloras, in six or eight ounces of water. An ounce of glycerine or honey may be added. Some like gargles made acid ; for this purpose you may order a drachm of Dilute Acetic, Phosphoric, or Hydrochloric Acid, to six or eight ounces of water. Many persons derive benefit from the use of a stimulating gargle, which may be made by adding a little Cayenne pepper, or Tincture of Capsicum, Thictiira Capsici, in the proportion of half a drachm or less to six ounces of gargle, but this is not suitable in the case of a very sensitive irritable mucous membrane, and indeed may do harm instead of good. A solu- tion of connnon salt is valuable as a gargle. A weak brine may be made by adding two tea-spoonfuls of salt or less to half a pint of water. The threat may be gargled with this solution once in two or three hours. In ordering gargles it is necessary to tell the patient to use the gargle frequently, for it is useless to gargle once or twice in the four-and-twenty hours. If the sore throat is at all severe, the gargle should be used once or twice in the hour. Of exciting increased action in distant parts. — You may sometimes relieve a sore throat as well as other forms of local inflammation and congestion by causing increased action in other organs and tissues. The action of a purgative is often followed by the relief of the throat affec- tion. Diuretics and sudorifics may be prescribed with the same object, and counter-irritation may be applied in some other part of the body. A mustard poultice to the neck, by establishing increased action on the cutaneous surface, often reduces the congestion of the mucous mem- brane of the throat. When slight, and not depending upon a general low state of the system, or altered blood, a sore throat may sometimes be cured in this way in a couple of hours. Iiiflaniinatioii of the :»Iucous Membrane of the Air Passages. — Inflam- mation, as has been already remarked, very commonly affects the mucous membrane of the nose and the cavities which open into it. There is increased secretion from all the glands and follicles opening upon the surface, increased formation of soft, moist, and imperfectly formed epithelium, taking the form of mucus, and undue turgescence of all the vessels. In consequence there is what is ordinarily called "running from the nose." When the mucous membrane of the large bronchial tubes is inflamed, and there is an increased formation of mucus on the surface, we have an ordinary catarrh, — the phenomena of which have been already referred to. There is in these cases also congestion of the INFLAMMATION OF THE STOMACH. 361 fauces, increased formation of mucus, and increased action of the glands. The transition from the ordinary epitheHal cell to the viscid material known as mucus, and from the mucus-corpuscle to the pus-corpuscle, may be observed and studied. In cases in which the inflammation continues for a considerable time, instead of viscid transparent mucus being formed, we meet with ordinary pus, or pus mixed with mucus, which is known as Miico-J>i/s, the microscopical characters of which must be carefully studied, as well as those of other kinds of sputum formed in different cases of disease. What is termed false membrane, or croupous exudation, is fre- quently formed in cases of inflammation of the mucous membrane of the larynx, trachea, and bronchial tubes. I have seen cases m which a complete and firm membranous cast of these passages was formed on the surface of the mucous membrane, antl was expelled entire after much suffering. The firm material consisted entirely of viscid mucus. Casts of the smaller bronchial tubes are also sometimes formed of mucus, but more commonly they consist of fibiinous material which has been poured out from the blood and has coagulated in the air-tubes. Running from the Ears is common among children of what is called " a scrofulous habit of body." The epithelium of the meatus undergoes change, and becomes soft, — the new epithelium being imperfectly formed, and superabundant. The vessels of the skin are also congested. After the disturbance has existed for some time, the discharge resembles that from an ulcerated surface. Not unfrequently the discharge dries up and forms a crust, which in consequence of the itching and irritation excited, is often picked off by the patient. A raw and very sore surface is exposed, and from this fresh discharge escapes, which in turn dries, and then follows a repetition of the process. The condition is very often obsti- nate and difficult to cure. In most instances constitutional treatment by iron and other tonics and cod-liver oil is requisite. As the health improves, the discharge begins to diminish and at last ceases altogether. Inflainination of the Mucous i^Ieiiibraue of the Stomach and Intestinal Canal. — The mucous membrane of the stomach is very liable to congestion and inflammation, much more so, I think, than is generally supposed. From time to time these pathological changes probably affect small patches of mucous membrane, last for a time, and then pass off if the mucous membrane is soothed and allowed to rest from active work for a few days. In all our best works on Medicine, the subject of ulcer of the stomach is fully treated of, but there is a state of things allied to ulcer, and leading to it, to which reference is seldom made. The state of mucous membrane to which I allude is not so serious as ulcer, but it is much more common, and if not relieved, may be succeeded by the 362 CONGESTION OP^ SMALL INTESTLNES. formation of an ulcer. The mucous membrane of the stomach, Hke the nasal and bronchial mucous membrane, "takes cold." It becomes red and less moist than in the normal state. There is often great discomfort and very frequently severe pain. The glands are more or less affected, and the functions of the stomach are very seriously disturbed. The secretion of gastric juice is interfered with and its qualities changed. Digestion is of course deranged, and sometimes completely checked. There may be much flatulence, which adds to the distress. Many patients, instead of allowing the stomach to rest for a while, are too prone to call for food when they experience any uneasiness. They feel exhausted and think a good meat meal will certainly relieve their dis- comfort. This they take, and very soon find they have made a mistake, for the pain is increased. If they are fortunate, vomiting will be excited, and all that has been taken, with perhaps other matters already in the stomach, will be rejected, when considerable relief will be expe- rienced. When you have reason to think that a patient is suffering from this slight inflammation, it is desirable to at once carry out measures for his relief, and effect a return to the healthy state as soon as possible, for the stomach is an organ whose work cannot be suspended for long at a time without the whole organism suffering. You order, therefore, nutri- tious but unirritating soft or liquid food for a while, and then take care that for the next few weeks only food of a soothing character, and which will be very easily digested, passes into the stomach. The patient must on no account be allowed to take ordinary diet, and you must tell him not to touch beer, and advise him not to take very cold or very hot liquids of any kind. Every form of alcohol should, as a rule, be with- held, because in a great many instances alcohol only irritates, and some- times greatly increases the pain. It may do much harm, though it must be admitted that not unfrequently it relieves for the moment the discomfort and sinking feeling which sometimes distress the patient. But if it relieves there is risk of the patient getting into the habit of taking it, and for this reason it is imperative to be cautious in permit- ting its use in such cases. We must never help people to find an excuse for permanently damaging their tissues and acquiring disease by indulging in alcohol. The digestion of meat, as you well know, almost entirely depends upon the secretion formed by the stomach glands. When this secretion is temporarily deranged, it is better to allow the mucous membrane of the stomach to do as little work as possible. Meat and fish should, therefore, be withheld for a time. The patients should be put on a milk diet. You may order them to take bread and milk, or arrowroot and milk, or rice, sago, tapioca, maccaroni, vermicelli, — and these should be cooked in such a way as to make a very soft moist food. By adopting this course the patient applies something like a poultice to the disturbed TREATMENT OF CONGESTION AND INFLAMMATION. 363 mucous membrane of his stomacli, and in many other cases, with great and immediate benefit. It does no one any harm to Hve on soft food of a farinaceous kind for a few days or a week. Indeed, not a few would gain in health if they systematically adopted such a diet for a week or two once in every two or three months. A very good substance to recommend patients to eat under these circumstances, only you will find many will refuse to eat it, is lentil flour, well boiled and made thick like gruel. Any part of the mucous membrane of the small or large intestine may be afilected by congestion and catarrhal inflammation. 'Vhere are many cases in which the iiatient complains of severe pain " in the stomach," the pain being really due to derangement of some part of the small or large intestine. The mucous membrane may be congested in patches, in which case the action of the follicles and of the villi for a time becomes seriously disturbed. By taking care that only bland substances, and as little as possible of these, pass along the small intes- tine for a time, the mucous membrane will soon be restored to its normal state, and it is important to do all you can to relieve such disturbances as soon as possible, for though, according to the patient himself, he may be suffering only from "pain in the stomach," if he does not submit to take complete rest, what is only a slight ailment may soon become a grave malady. In such cases, diet is of more conse- quence than medicine, but if the pain is very severe, it may be necessary to give small doses of sedatives. Advantage also results from employing mild counter-irritants over the situation of the stomach. The best counter-irritant perhaps is a poultice made of half mustard and half linseed-meal. This may be applied to the surface, near the seat of pain, and it unquestionably relieves. A mustard leaf is more easily prepared, but a piece of writing paper should intervene between it and the skin, or the action will be too strong, and the patient wall remove it before there has been time for the counter-irritant to have done good. The external application of warmth greatly relieves pain which results from a congested or inflamed state of the mucous membrane ot the intestinal canal. A linseed poultice, or flannels wrung out in hot water, will be of service. If, however, this does not soon afford relief, the surface of the poultice or the flannel may be sprinkled with turpen- tine. The thick india-rubber bottle for hot water should find a place in every traveller's trunk. It is most useful in the treatment of abdominal and other pain. I have already referred to it on p. 2 28. Stimulating liniments are, as a general rule, not advisable. You do not want to cause the bowels to move about in the least degree, or to disturb the parts at all. If you allow people to rub things in, the chances are they add to the sufferings of the patient, and do harm to tissues already tender and irritable, and perhaps in a state verging upon actual 364 SLIGHT DYSENTERY. disease. This rubbing in of liniments is often adopted most injudiciously for every kind of pain, and you sometimes even find a self-constituted and most self-confident but unqualified medical adviser "rubbing away ! " the pain of an inflamed joint. Many nurses and ladies having a turn for doctoring require to be cautioned on this head, for many conditions are made worse by rubbing, and in some instances very serious inflammation may be excited by the operation. Large bowel. — Congestion and inflammation of a portion of the mucous membrane of the large bowel is not uncommon. There is in such cases severe pain, and the action of the bowel is much deranged. The condition may pass on to ulceration, which may endanger life. Ulcers frequently form in the lower part of the small intestines in cases of Typhoid fever, the healing of which is always a very slow process. Every case of Typhoid fever requires the most careful management and constant attention, not only at the time ulcers are forming and the sloughs separating, but during the healing process. Though this disease cannot be included among "slight ailments," it is very desirable that you should know that health is only slowly restored, and that three months sometimes pass before a patient suffering from Typhoid can with safety be allowed to resume his usual diet and habits of life. All attempts to hasten convalescence are unwise, and every now and then a patient is lost m consequence. Full time must always be allowed for the healing of ulcers in any part of the alimentary canal. Slight Dysentery. — There happens to be just now a case of mild dysentery under my care in the Hospital. The man suffers much pain, and from the usual symptoms. He passes liquid motions with a good deal of mucus. In this case we are adopting, with the greatest benefit, a mode of treatment which may be considered "empirical" {e^nrcipu,, experience); for, although the remedy employed is undoubtedly useful, we do not know precisely how it acts. Ipecacuanha powder is of the greatest value in many such cases— not only where there is actual ulceration of the mucous membrane of the colon, but where there is an approach or tendency to this condition. In India this drug is used in the treatment of dysenteric affections. You may begin with doses of two or three grains of Ipecacuanha, in the form of a powder or pill, and you may increase the dose up to twenty grains or more, twice or three times a day ; or five or ten grains may be given with a half a grain or less of opium, which will prevent its emetic action. Some persons cannot take opium, and iu this case the Ipecacuanha must be given at first m small doses. The medicine may be continued until the symptoms are gready relieved. In many cases the patient is completely cured in a month or six weeks. It is remarkable how soon tolerance of Ipecacu- anha is acquired, for a dose which a patient may take two or three CHILBLAINS. 365 times daily without discomfort would act as a powerful emetic upon any of us. Indeed, if you desire to study the mode of action of an emetic in your own organism there will be no harm in trying the experiment with this drug. You may take twenty grains of Ipecacu- anha powder, Piilvis Ipecacuanha, (not Pitlvis Ipecacuanha. Coinpositus), suspended in half a tumbler of warm or lukewarm water. The dose may be followed by one or two tumblers of warm water, and in the course often minutes or a quarter of an hour, you will have an oppor- tunity of studying the violent contractions of the muscular coat of the stomach which will be excited by reflex action consequent upon the irritating effect of the Ipecacuanha upon the afferent nerve-fibres of the mucous membrane of the organ. Ipecacuanha is one of the most potent, and in action one of the least disagreeable, of emetic remedies. Congestion and inflammation occur in connection with other mucous membranes, as well as those to which I have specially drawn your attention. Thus, the gall-bladder and gall-ducts may suffer congestion ; and inflammation of the mucous membrane of the urinary bladder, of the ureters, and of the pelvis of the kidney are unfortunately frequently met with, but these cannot, I regret to say, be classed among slight ailments, and they will come under our consideration in another part of the course. rbiiDiaiiis. — This troublesome and often very painful affection is due to local changes in the vessels of the skin of parts of the body most distant from the large vessels, — notably the fingers and toes, and occasionally the ears and nose. These parts are more exposed to cold than the rest of the body, and to them the blood will be driven through the ramifications of the arteries with less force than elsewhere. Any- thing that retards the return of the blood towards the heart, such as the pressure on the superficial veins by tight gloves or shoes or garters increases the tendency to chilblains. On the other hand, anything that promotes the circulation either by increasing the force of the heart's action or by favouring the flow in the smaller vessels, as the use of large and easy boots and gloves lined with wash-leather or other warm material, will prevent their occurrence in persons predisposed to the malady. Chilblains seldom occur in the adult, and tiiey are far more common among ill-fed weak children than among strong and healthy ones. Insufficient exercise, especially in the case of those — and in towns such are very numerous — who suffer from weak heart's action. Sitting in cold rooms and sleeping in chilly bedrooms favour the development of chilblains, which are also encouraged by insufificient clothing. Warm woollen under -garments down to the wrists and ankles often prevent the occurrence of chilblains in those who have been subject to them. Exposure to cold, more especially when the vessels of the skin have 365 TREATMENT OF CHILBLAINS. been for some time previously subjected to pressure, is usually the immediate cause of an attack. In the capillaries of the affected skin the blood flows slowly and remains too long in the vessels. The composition of the stagnant blood is probably altered by being too long exposed to the influence of cold, and in consequence does not flow onwards towards the veins. Soluble matters transude through the walls of the vessels, and the skin and subjacent textures in consequence become swollen. The afferent nerve-fibres running with the capillaries are necessarily affected, and their action becomes sluggish, and the muscular fibres encircling the minute arteries soon undergo relaxation. AVhen the force of the heart's action becomes greater, and the activity of the circulation is temporarily increased, as occurs after meals or when the patient gets warm in the evening or in bed, a rush of blood occurs to the extremities. The relaxed arteries and their capillaries become greatly distended, the tem- perature of the part rising several degrees, the sensitive nerves at the same time being disturbed in such a way as to occasion the intense itching and discomfort experienced by the patient. In some cases there is little or no itching, but, nevertheless, the con- gested state of the vessels and consequent soddening of the tissues may result in damage to the cuticle, which may be raised in bullae, which soon rupture, and in the formation of troublesome sores, which heal very slowly, and add to the patient's suffering. In bad cases the skin around the vesicles becomes dark and soddened, and sloughs of considerable size may be formed, whicli often leave deep and bad ulcers, requiring a considerable time for healing. Treatineiit. — Chilblains often give rise to very severe suffering, and are difficult to cure. Appearing to be a local affection, the disease is too often treated by purely local measures only, In a great many instances it will, however, be found that improvement in the general health and strength is followed by a cessation of the painful inflammation. Tonics, especially preparations of Bark and of Iron, should be given. One or two tablespoonfuls of wine daily often effect great improvement without any local treatment whatever, and if this plan is adopted early in the winter season, the subjects of chilblains will sometimes escape an attack. Great care should be taken to clothe in woollen next the skin all children who are tortured with chilblains. The rooms in which they live should be well warmed in winter, and everything done to assist the weak, and in many cases slow, circulation. The gradual cooling down experienced in chilly weather, sitting still in cold rooms, does more harm in the case of those subjecc to chilblains than sudden exposure to cold for a short time only. Local Treatment of Chilblains. — If the skin is not very tender it may liOILS. 367 be painted with Tincture of Iodine, or very gently smeared with a liniment composed of equal parts of Soap liniment, Linimentitin Saponis, and Tincture of Iodine, Tindura lodi. Smearing the inflamed skin with a little Turpentine, Okjon Tere/>ifithince, or Acetic Acid, Acidum Aceticutn, or the hiniment of Turpentine and Acetic Acid, LinvnenUim Terebinthimc Aceikum, or Camphorated Spirit, Spiritus Catnphorce, undoubtedly much relieves the itching ; but if the cuticle is tender or sore, such remedies do harm instead of good. In this case the tender part is to be painted over with several layers of Collodion, or the Collodion flexile, made of Collodion, Canada Balsam, and Castor Oil. In this way a sort of artificial cuticle is made by which the tender parts beneath are protected until they recover their healthy condition, and time has been allowed for the formation of new cuticular cells beneath, and for the hardening process to be carried out by which the protective property of the cuticle is established. If the skin is actually broken a small poultice is to be applied with or without some stimulating substance, such as Resin Ointment, Unguentuni Resinie, or Peruvian Balsam, Balsainum Periivianuin. The health must at the same time be well sustained by good food, wine, Quinine, and Cod Liver Oil. When the sloughing process has ceased a stimulating Zinc lotion, one or two grains to an ounce of water, or Carbolic Acid lotion, or one part of absolute Phenol to forty parts of water, may be used, or antiseptic dressing may be applied. Boils, although brought about by very different circumstances, some unimportant, others indicative of grave disease, may be fairly included among "slight ailments." The old name for boil is Furiinciilus. This affection played a more formidable part during and anterior to the middle ages than since that period. In former days many very serious and fatal febrile conditions were characterised by the formation of boils. Although at this time boils may be associated with certain forms of blood poisoning usually fatal, they are nmch more common in states of the system in which there is temporary derange- ment of the blood than they are in serious blood diseases which soon destroy life. Pathologically the boil is of great interest, as the inflamma- tion begins in one spot and quickly involves a number of tissues, including nerves, blood vessels, and lymphatics, as well as all the textures forming the true skin. A small portion of the complex tissue is destroyed, in fact all its living elements die. The local inflammation thus ending in mortification and removal of a portion of the skin and subjacent structures starts from within, but it is difficult to decide whether the local change begins in a capillary or lymphatic vessel. In most cases, however, I think the capillary is the seat of the changes which result in the formation of the boil. Particles, probably of living matter, adhere to the wall of the capillary, and grow 368 ■ BOILS. and multiply until the vessel is occluded partly by accumulation of matter caused by the growth and multiplication of these tiny particles, and partly by fibrin from the blood The capillary being thus plugged exudation takes place from the adjacent capillary vessels, and with the fluid poured out, minute particles of living matter also escape, and these multiply in the surrounding tissue. In this way the ordinary nutrition of the part suffers, and the usual flow of fluid to and from the living matter of the several tissues which takes place in health is stopped. The nerves of the capillaries and other parts are stretched and pressed upon in consequence, and considerable pain is experienced. The rapid growth and multiplication of living matter which occurs in every part of the affected region as usual is associated with the increased development of heat. The inflamed tissues constituting the boil are sensibly warmer than the surrounding healthy tissues. The tissues which were supplied by the plugged capillaiy vessels soon change. The interstitial circulation ceases, the particles of bioplasm die, and soon a mass of decomposing tissue results, which is by the tension of subjacent vessels and the growth of bioplasm gradually forced towards the surface in the direction of least resistance. The pressure of the mass upon the tissues of the skin and the products of decomposition cause more destruction, and at last an opening results through which the mass of dead and decomposing tissue, the core of the boil, escapes. A certain amount of pus is formed between the core of dead tissue and amongst its elements, and the surrounding healthy structures. By this process the disintegration of the affected tissues is promoted, and the separation of the slough of dead tissue from the surrounding healthy part is ensured. As soon as the separation of the decomposing tissue mass is completed, repair and healing begin, and if all goes on well these processes uninterruptedly proceed. There are cases, however, in which gradual disintegration and death proceed until a very large mass of tissue is destroyed. In such cases there is great danger to life, and the patient requires to be thoroughly sustained with strong soups and wine or brandy. Boils may be caused by a poison developed within the system or introduced into the blood from without. The inhalation of infected air, eating diseased meat, over-eating, insufficient and bad food, too much animal food, may establish a state of health favourable to the formation of boils. An actual alteration no doubt takes place in the blood, although it is not possible to determme its exact nature. Boils are liable to occur after recovery or partial recovery from fevers, and are very common in cases of diabetes, but the precise influence exerted by the diabetic state upon the tissue which results in the development of the boil has not yet been ascertained. The bites of Mosquitos if numerous may occasion blood poisoning and considerable derangement r'R^:LI.MI^AR^■ ciiAXCiKs. 369 of the health, lasting for a considerable time and ending in the formation of boils of an obstinate kind in different parts of the body. Carbuncle is very closely allied to boils, but is more serious from the much larger area and depth of the inflamed tissue, and from the more serious constitutional disturbance. The inflammation is more diffused ; the slough formed is often so very large that the patient's strength is exhausted before its separation is effected, and the reparative process can begin. This affection cannot properly be included among Slight Ailments, and I therefore only refer to it as a farther development of the boil. Treatment. — As regards the treatment of boils, the best advice I can give you is to leave them alone. Incisions are not needed, and any attempt to expedite the removal of the slough does harm by breaking •down the temporary separation between the slough and the healthy tissue, thus causing some of the irritating discharge to pass into the surrounding areolar tissue, starting therein a similar inflammatory action leading to sloughing over a wider area. It is important, however, to prevent the boil from being rubbed or pressed upon by the clothes. A small piece of thick Amadou plaster like felt may be taken and a hole cut large enough to receive the boil, the summit of which may be partially covered by a piece of ordinary plaster. In this way the boil is protected. Veast has been highly recommended internally, but its efficacy is doul)t- ful. Quinine, mineral acids, and tonics of various kinds seem to be useful_ Wine may be given in the case of patients whose strength has been worn out by prolonged exhausting disease, but in ordinary cases of boils more harm than good results from stimulants. In carbuncle large doses of quinine, or quinine and iron, and a liberal allowance of wine or other stimulants are required, — but this affection is more than a slight ail- ment. It has been remarked several times, in these introductory lectures on Slight Ailments, that illnesses which apparently come on suddenly are themselves but the consequence of prior changes which have been going on for some time previous to the attack. These preliminary changes are a necessary and essential part of the illness ; but for them, the attack could not have occurred. The invasion, it is true, seems to be sudden, but the apparently rapid passage from coniparative health to decided illness is deceptive, for derangement even of a serious character may have existed for some time, though the patient may not have been aware of it. In many cases very grave disturbance may give rise to mere discomfort only, the patient himself having no conception of the serious changes which have been going on in his blood and tissues. In not a few instances, especially in persons about or past the middle period of life, the nerves are more or less numbed owing to degener- 2 B 370 1>REVENTIN(] SE! with various slight derangements of health lias been frequently noticed. Perhaps it is to be explained by the existence in particular individuals of a highly sensitive and exceptionally active state of those nerve-fibres and that part of the nerve system which is intimately connected with the healthy action of the circulating and digestive systems. In some persons these nerves respond to the slightest stimulus, and the least departure from the ordinary state at once occasions inconvenience or discomfort ; while in others, considerable variation, as regards temperature, quality and quantity of food, will make little or no im- pression, and will occasion no immediate disturbance or derangement. But, in the latter case, pathological changes may take place, and may result in grave structural change, without the patient having experienced the least discomfort, or even being made aware that any departure from the healthy condition had occurred in his system before the supervention of the serious illness which you are asked to investigate and treat. Per- haps, in some such manner, we may account for the fact that certain individuals are suddenly struck down by terrible disease while they seem to be in good health, and others, who never feel well, or look well, reach old age without experiencing one single attack of any illness sufificiently serious to endanger life. Such persons, it must be noted, are often obliged to be very careful, as regards diet, and the feeling of tiredness after great exertion is in them so severe that it must be yielded to. Thus they are forced to take rest before any damage whatever has been done to their organs. Is it not probable that careful attention to the process of excretion, as well as to the quality and quantity of food that is taken, brings about and preserves a state of blood in which disease germs, instead of growing and multiplying, would die? How many ailments may be prevented by judicious starving, or by living for a day or two now and then on low diet ? How thoroughly may not the blood be depurated by a sharp purge given, perhaps, just before blood or liquor sanguinis was about to escape from the vessels, to be poured, perhaps, into the air-cells of the lung ? Might not the purgation be fairly considered to have prevented an impending attack of acute Pneumonia or Inflam- mation of the Lungs, and thus to have really " cut short " the disease ? May not moderate doses of Bicarbonate of Potash or Soda, taken in solu- tion twice or three times daily for a week or two, avert an attack of acute rheumatism ? Will not a small dose of certain preparations of Mercury, now and then, prevent attacks of gout or rheumatism or sick headache or dyspepsia or biliousness ? Is it not reasonable to conclude that certain salts by their action on the bowels and kidneys, by promoting free elimination, establish a general state of the tissues which may for the time prevent the occurrence of certain morbid changes of serious con- sequence ? 374 CONCLUSION. I have endeavoured, in these few lectures, to show you why we should not fail to give careful attention to the study of those slight departures from the normal state which possibly, in these days, are sometimes too lightly passed over by the student and the practitioner, although, on the other hand, it must be admitted that the import of some very slight ailments has been strangely exaggerated by practitioners of a different mental tendency. As I have tried to impress upon you many times, slight derangements occasionally afford the first and only indications of commencing disease. There is good reason for thinking that by judicious management, not only may some troublesome though slight ailments be entirely relieved, but further and progressive morbid changes sometimes prevented or retarded. The principles upon which the treatment of many slight ailments may be successfully conducted are the same as those upon which the management of more marked developments of morbid phenomena is based. I have given illustrations of the simplest and slightest ailments, and have endeavoured to show how their treatment may be most simply and successfully carried out, and I have attempted to lead you on by degrees to consider more highly complex pathological changes, and have tried to make clear the principles upon which more complex methods of treatment are conducted. In no way, I believe, will you so quickly acquire that sound knowledge of pathological processes, and of the means of checking or modifying them, which is daily required in practice, as by adopting the course I have advocated. Let me, therefore, conclude by again impressing upon you the importance of not neglecting the study of the nature and treatment of " Slight Ailments," now, or indeed at any period of your professional career. INDEX Absorption of fluid in constipation, 187. Abs inence in sick headache, 259. Access of disease germs, 84. Acici appHcation to Hver, 247. ,, drinks in sick headache, 260. ,, of theVsomach, 159. Acids in indigestion, 163. Actinia, pathological changes in, 87. Action, increased, its effect in treatment, 349-. . ,, of medicines, 23. ,, of certain poison =, 73. ,, skin, kidneys, and bowels, 70. Acute Jaundice, 246. ,, tuberculosis, lo. Aerated waters, 202. Afferent nerves of capillaries, 332. Age of every living thing fixed, 3. Ague fir, 316. ,, brow, 248. Ailments beginning like a eld, 323. Air, bacteria in, 85. Air-passages, inflnnmatinn of, 360. AlTKEN, Sir 'William, on Ptomanies and Leucomaines, 93. Albuminous matters, effects of alcohol on, 352- Alcohol, bad effects of, 139. ,, causing vertigo, 233. ,, in dyspepsia, 166. ,, its use in the treatment of fis- sures and ulceration^, 352. Alkalies in indigestion, I&4. ,, in rheumatism, 291. Alkaloids, poisonous, 93. Aloes in cases of offensive breath, 130. ,. preparations of, in constipation, 212. Alum as a gargle, 360. ,, spray in sore throat, 125. Ammonium, chloride of, 282. Amceba movements, 346. Anoemia, state of tongue in, 118. Animal alkaloids, 93. Anorexia. 132. Anthrax bacillus, 86. Antifebrin, antipyrin, 265. Antiseptics, 98. ,, opposition to, 99. Ar.tivivisection, 37. ,, society, 44. Appetite, impaired, 132. „ voracious, 134. Apples in constipation, 200. ,, irritating !^tomacll and causing fever, 223. AphthK, 126. ,, treatment of, 127. Ardor ventriculi, 158. Arsenic, in neuralgia, 283. Arterioles, 278. Artificial teeth, attention to, 127. ,, ,, value in dyspepsia, 169. Arthritis, rheumatoid, 296. Ascarides, 230. Ascaris lumbricoides, 231. Astringents in ophthalmia, 355. ,, in diirrhcea, 228. ,, in the treatment of piles, 193- Atrophy of liver, yellow, 246. Attention, importance ot, 10. Auerbach, nerve plexuses intestine, 155 Aural Vertigo, 234. Average age of man fixed, 3. Bacilli, 78. ,, growth in body, 91. ,, pyocyanic, 89. Bacteria, 78. „ in blood in health, 82, 90. ,, in all foods, 81. ,, as a cause of oisease, 83. ,, dormant, 91. ,, everywhere, 80. ,, not homoeopathic, 22. ,, in intestine of infant, 81. ,, in stomach and bowels of infants, Si. ,, in tissues, 85. ,, on tongues of animals, 81. Balsam, Peruvian, 367. Bantock, Dr., agamst antiseptics, 98. Baptistin, 243. Baths in rheumatism, 304. Beard, Dr., on nervousness, 273. Beef-tea, peptonised, 178. B-lladonna, vertiiio from, 233. Bicycling in constipation, 196. Biliary colouring matter, excretion of 244. Bilious diarrhrea, 227. Biliousness, 236. INDEX. Biliousness, treatment of, 240. Bioplasm, action of poisons on, 74. ,, changes in outside capillaries, 339- ,, giving origin to pus, 341. „ growth of, in ipflammation, 333- ,, minute changes in, 339. ,, jTiinute particles in blood, 335, 341- ,, vital movements of, 346. Bismuth in indigestion, 165 Black draught and blue pill, 152. ,, tongue, 119. Blood changed by action of gbnds, 113. ,, in fever and inflammation, 314. ,, in constipation, 1S7, 189. „ passing through vtssels in fever, 332- . . ,, state of, in sick headache, 251. Blue pill, 152, 242. Body-heat in fever, 315. ,, in man, 312. Boiling potable water, 193. Boils, 367. , treatment, 369. Bone setters, 17. Borax and honey for thrush, 128. Borborygmi, 161. Bowels, c&mplettr emptying, 182. ,, ulcer of, 363. Brain disturbance in sick headache, 249. ,, treatment, 165. „ overworking, 273. ., and stomach, 249. Bread in constipation, 198. Breath, odour of, 128. Bright, John, on vaccination, 44. "Bright red tongue, 119. Bromide of potassium in rheumatism, 293- Bronchitis kettle, 124. Brow ague, 248. Brown tongue, 119. Bulimia, 134. Bullock's pepsine, 175. liUTLiN, Mr., on fur of tongue, 109. Butyl-chloral hydrate, 284. Cabmen's pills, 208. Caffeine, citrate in sick headache, 268. Crecum affected in sick headache, 285. Calomel in dyspepsia, 170. ,, in a cold, 322. ,, effect on secretion of saliva, 116. ,, after surgical operations, 189. ,, in sick headache, 266. Camphorated spirits in the treatment of chilblains, 366. Cancer, leprosy, tubercle, 76. Capillaries in inflammation, 335. ,, passage of corpuscles tlirough walls of, 338. Capillary haemorrhage, 336. ,, vessels, nerves of, 157. Carbolic acid as a gargle, 129. „ in cases of offensive breath, 129. Carbuncle, 369. Cardialgia, 158. Carlsbad water, 217. Cascara, 131. Castor-oil for constipation, 209. ,, for dianhoea, 224. Catarrh, 320. ,, of gall ducts, 244. Catarrhal inflammation of stomach, 151, 362. Catching cold, 308. Catechu in diarrhtea, 229. Cattle plague, 42. Caution in giving opinion, 10. Cayenne pepper in nausea, 137. Cells, flow of fluid in, 69. ,, or elementary parts, 67. ,, vital movements in, 339. Chaff, 182. Chalk mixture, 229. ,, stones in gout, 305. Chambers, Dr., black draught, 152. Changes from disease to health slow, 8. ,, in mouth and fauces, 123. ,, in species, 89. ,, in fever and inflammation, 320. Charcoal powder in cases of offensive breath, 129. Charity, medical, 58. Cheltenham water, 218. Chemistry, microscope and homoeopathy, 22. Chilblains, 365. ,, treatment, 366. Children, constipation in, 190. ,, high temperature in slight ail- ments, 324. Chloral hydrate, 284. ,, its dangers, 270. Chlorate of potash in sore throat, 125. ,, ,, as a gargle, 359. Chloride of ammonium, 282. ,, of sodium in sore throat, 125. Chlorodyne, 163. Cholagogues, 243. Cholera, fever in, 317. ,, homosopathic treatment of, 19. Chronic rheumatism, treatment of, 289. C CERO, quackery in time of, 15. Circulation, intermolecular, 69, 70. Cirrhosis, capillary haemorrhage in, 337- Citrate of magnesia, 219. Citrates in rheumatism, 292. Civilisation, slight ailments, I. Cleaning of tongue, 120. Clinical thermometer, 315. Clothing, warm, importance of, 167. Clyster." 1 93. Coffee in constipation. 199. COHNHEIM, on migration of blood cor- puscles, 3 38. Cold, action of, causing fever, 3 ",o. ,, bath in constipation, 197. INDEX. 377 Cold bath, in drowsiness, 269. ,, catchinj^, 308. ,, causing a febrile attack, 309. ,, its influence in diarrhcta, 228. ,, stage in fever, 316. ,, treated by counter-irritalian, 349. ,, tongue in an oidinary, 112. Collapse stage in cholera, 317. Collodion, 357. Colon, tenderness of, 227. „ derangement in sick headache, ,, impaction of fKces, 185. Colour of the tongue, 106. Committees, Hospital, advantage of, 59. Communicable diseases, 76. Complexion in those who suffer from constipation, 183. Compound jalap powder, 230. ,, rhubarb pill, 209. Condiments in indigestion, 166. Conduct, principles of, 27. Condy's fluid, gargle of, 120, 129. ,, ,, in offensive breath, 129. Confidence, on gaining, 13. ,, in error, 17. ,, want of, in us, 49. Congestion and Inflammation, treatment of, 363- . Conjunctiva, inflammation of, 353- Connective-tissue formed by bioplasm, 342. Conserve of currants, senna and glycerme in constipation, 212. Constipation, 180. ,, in domestic animals, 18 1. ,, moist applications to abdo- men, 198. ,, in jaundice, 244. ,, oatmeal in, 199. „ in sick headache, 252. ,, reabsorption of fluid in, 186. ,, treatment of, 192. Contagion, 75. ,, nature of, 76, 91. ,, doctors diffusing, 102. ,, of purulent ophthalmia, 354. Contagious disease, 42. ,, ,, living matter, 94. Contractile power of bowel, loss of, 185. Conversion, homoeopathic, 20. Co-ordinating power in vertigo, 334. Coin doctors in Rome, 15. Corpuscles, mucus, 346. ,, blood, passage through vas- cular walls, 335. ,, outside capillaries in inflam- mation, 342 Coryza, 320. Counter-irritation, 349. ,, in indigestion, 165. ,, in sick headache, 260. ,, in affection of stomach and bowels, 363. Country practice, 9. Courts, views of, in medical matters, 30. Cracks and fissures of tongue, 121. ,, treatment, 122. ,, on lips, 350. Credulity, 24. Ckei(;hton, Dr., on vaccination, 43. Critics subject to constipation, 183. Croakings, flatulent, Ibl. Cross-examination, investigation by, 21. Croton-chloral-hydrate, 284. ,, oil in constipation, 215. Croupous memljiane, 361. Curable stage of obstinate maladies, 275. Cures, 8. Curry powder in nausea, I37' ' ,, in dyspepsia, 166. Cuticular cells, 96. Cycling in constipation, 196. Darby, peptonised meat, 178. Death-carrying bacteria, 89. ,, rate, London, 103. Decay, part played in by fungi, 79. Deception, 17. Deciilionths of grains, 17, 19. Defective mastication, 169. Degeneration, muscles in rheumatism, 2S9. ,, fibroid, "J I. Degenerative changes, 277. Deglutition, 357. Depression in illness, 9. Deranged action of glandular organs, 158. ,, ,, large bowel, 253. „ liver, 239. , , „ stomach, in. Derangements of health, 1,3. ,, simple, 5. Despondency, 9. ' Diabetes, 133. ,, causing boils, 368. ,, hunger in, 134. „ tongue in, 113. Diagnosis, importance of being cautious in making, 323. Diapedesis, 338. Diarrhoea, 221. ,, treatment of, 224, 229. Diathesis, 132. Diet in constipation, 195, 198. „ in a cold, 321. ,, in diarrhoea, 228. ,, in hot or cold climates, 166. ,, in indigestion, 162. „ in rheumatism, 295. ,, in sick headache, 257. Digestion, artificial, 172. „ external applications in, 165. ,, improving, 170. „ influence on cerebral action, 253- . „ in jaundice, 244. ,, non-nutriiious matters in, lS,t. ,, in rheumaiism, 292. „ in sick headnche, 252. „ fluid, artificial, 1 74. 2 B ? 378 INDEX. Digestive powder, 174. Dilatation of capillary vessels in fever and inflammation, 329, 335. Diluents in a cold, 324. Dinners, disadvantage of late, 162. Diphtheria, 358. Disease germs, 73, 04. ,, mode of access, 84. . , natural history of, 7. ,, preventing, 370. Diseases communicable, 72. Disks for hypodermic injection, 284. Dispensaries, self-supporting, 55, 66. Dissection of nerves of intestines, 155. Diuretics, 360. ,, in a cold, 322. ,, in rheumatism, 292. Diver, Dr., the young doctor's future, 9. Divergence and reversion, 89. Doctors accused of spreading contagion, 102. ,, ,, causing intemperance, 140. Doses, infinitesimal, 18. Douche, eye, 356. Dorsum of tongue, 106. Dover's powder, 230. Drastic purgatives, 214. Drowsiness, 269. Dry moutli and fauces, 1 14. ,, tongue, 113. ,, brown tongue, 1 19. Dust and disease, 82. Dysentery, 217, 364. Dyspepsia, 150. ,, from bad teeth, 169. „ despondency in, 153. ,, treatment of, 162. East wind causing biliousness, 242. Eau de Cologne in treatment of cracks and fissures of lips, 350. Economical organisms, 277. Effervescing citrate of magnesia, 219. ,, saline purgatives, 219. Effusion in rheumatoid arthritis, 298. Elaterium in constipation, 215. Elementary parts or cells, 67. ,, ,, ,, currents in, 69. Emaciation not due to disease, 149. Emetics, 137, 160. Empirical treatment, 364. Endurance, powers of, in sufferers from biliousness, 236. Enemata, action of, 193. Epilepsy and sick headache, 255. Epithelium of tongue, ic8. ,, irregular growth of, 342. Epsom salts, 216, 218. Eructations, 165. Eruption in fever, 33 1. Eruptions, 348. Erysipelas, a fever or inflammation, 334. Escape of blood corpuscles from capil- laries, 335. „ from disease, 373. Euonymin, 243. Ever-present bacterium, 80. Evidence of actions of medicines, 23. ,, medical and legal, 33. Examination, medical, for insurance, 50- 53-. . Examining mucus-corpuscle, 346. Excess of urea, 314. Exciting flow of saliva, 1 15. Excoriations, treatment of, 35 1. Excretion, importance of, 310, 326. Exercise in constipation, 195. Exhalation, hsemorrhage by, 338. External applications in indigestion, 165. Extravagant organisms, 277. Exudation, 335. ,, in fever and inflammation, 333- ,, in rheumatism, 287. Eye-glass, 356. Eye waters, 355. FAECAL matter, impaction of, 185. False membrane, 361. Fasting girls, 133. Fat, formation of, 145. Fatigue fever, 189. Fauces, dryness of, 1 14. Febrile conditions, pepsine in, 177. ,, diseases, 308. Feeding bad cases of fever, 178. Fever, derangement of stomach in, ill. „ local, 333. ,, and inflammation, 328, 334. ,, of over-exertion, 189, 331. ,, after surgical operations, 189. ,, treatment, 331. Feverish and inflammatory state, 308. Feverishness in children, 333. ,, produced by irritation of stomach, 222. ,, secretion in, 292. Fevers, formation of pus in, 334. Fibrin, bacteria in, 83. Fibroid changes, 71. Fibrosis, 72. Fibrous matter, formed by bioplasts, 342. ,, tissue in rheumatism, 287. ,, ,, rheumatic pains in, 287. Figs in constipation, 200. Filiform papilLe, 107. Fissures and cracks of tongue, 121. Flannel for warm clothing, 168. Flatulence, 160. Fluid, quantity of to be taken, 142. ,, importance of taking, in consti- pation, 201. ,, in rheumatism, 303. ,, in rheumatoid arthritis, 298. ,. in treating a cold, 324. Flushes, 299. Fog, its effect on the conjunctiva, 356. Food, abstention from, in sick headache, 259. ,, containing bacteria, 84. INDEX. 379 P'ood, importance of not taking too much, 3, '34- Fountain, eye, 356. Fowler, Dr., iiis case of the fasting girl, 134- Fra/.ER, Dr., on jiernicious amtmia, 303. French plums in constipation, 199. Friedrichshall water, 218. Frogs, bacteria in vessels of, 90. Fruit causing diarrhoea, 224. ,, ,, fever, 324. ,, in constipation, 200. Fungi, germs of, io8. ,, ,, and decay, 79. ,, growth and multiplication of, 90. ,, on tongue and mouth, 108. ,, ,, ,, in rheumatism, 1 18. Fungiform papilln;, 107. Furred tongue, 108. ,, ,, moist, 117. Furunculus, 367. Gai.EX, on quackery in Rome, 15. Gall stones, 246. Galvanism in constipation, 198. Ganglia, 155. ,, regulating calibre of small ar- teries, 332. Gargles, 359. Gastralgia, 157- Gastric glands, nerves of, 151. ,, juice, variation in quantity of, III. (Jastrodynia, 157. General practitioners in Rome, 15. Genesis of pus, 9f>. Germans, on vaccination. 47. Germs, disease, 73. ,, fungi, tongue, 108. ,, ,, in every p?rt of body, 80. (iiddiness, 232. Gladstone on vaccination, 44. Glands of conjunctiva, inflamed, 353. ,, exciting action of, in offensive breath, 129. ,, gastric, wasting of, 169. Glauber salts, 216. Glycerine and water, for dry mouth, 120. Gout and gouty tendencies, 305. „ and kidney disease, 306. ,, treatment of. 306. ,, vegetables in, 307. ,, and sick headache, 255- God of fever, Goddess of healing, 15. Granulated effervescing salines, 219. Gratuitous medical help, 61. Gravedo, 320. Greece, medicine in, 14. Gregory's powder, 209. Grey powder, 116. Growth of bacteria, 91. ,, of pus bioplasm, 97. Guaiacum in rheumatism, 292. (iuarana in sick headache, 265. Gums, bleeding from the, 337. 1 1 Aims, intemperate, 139. Hii-'morrhage, 121. ,, capillary, 3^7. ,, by exhalation, 338. ,, from nose, 337. Ilccmorrhoids or piles, 191. Ilair-like processes of papilKv of tongue, 107. IIallier on fungi, 95. IIarley, Dr. Vaughan, on sugar, 302.' Headache, trtatment ot, 256, 349. ,, sick, 256. ,, in a cold, 31 1. Healing process disturbed in constipa- tion, 188. Health seldom perfect, i. ,, of doctors should be good, 9. ,, habits, affecting, 2. Heartburn, 159. Heat of body, 309, 312. „ _ in fever, 313. Help, patients desire from us, 7. ,, medical, to poor, 60. Hemicrania, 248. Herpes, 348. Hippocrates, 15. 1 lomoeopaths, 20. Homoeopathy, 20. Honesty and tact, 13. Honey and borax in aphtha, 127. Hospital, out-patients, 54- Hot climates, diet in, 167. Hot stage in fever, 317. Hot water, India-rubber bottle for, 228. Humbug, medical, 14. Hunyadi Janos water, 219. Huxley, letter to Lord Mayor, 38. Hydragogue purgatives, 214. Hydrochloric acid, external applicatio)> of, to liver, 247. Hydrocyanic acid in nausea, 139. „ its effects, 137. ,, no structural change in death from, 1 1. ,, poisonous action, 13. Hygienic treatment of constipation, 195. Hyper-sensitiveness of stomach, 1 84. Hypochondriacs, 183. Hypochondriasis in the male, 183. Hypodermic injection, 283. Hyposulphite of soda, 120. Hysterical loss of appetite, 133. Immunity to severe disease of those suffering from slight ailments, 373. Impaction of fiscal matter, 185. Impaired appetite, 132. Imposture and nonsense, 25. Increased action in air tubes, 361. Indian corn, 199. India-rubber bottle for hot water, 328. Indigestion, 150. ,, alkalies, 164. ,, in old age, 16S. ,, resulting from loss of teeth, 169. 38o INDEX. Indigestion, treatment of, 162-170. ,, warm clothing m, 167. Inebriety, 139. Infant, growtli of fungi in intestine of, 81. ,, thrush, 128. Infantile diarrhoea, treatment of, 225. Infective germs in hospitals, 89. Infinitesimal doses, 18. Inflammation, 308. ,, heat of blood in, 309, 313. ,, colon, 364. „ lungs, 371. ,, minute particles of bio- plasm passing through vessels, 338. slight, 345. ,, ct stomach, 1 51, 361. ,, of throat, 345. Inhalers, 123. Injection, 194. ,, hy]iodermic, 283. In.surance, Life, reports on, 52. Intemperance, 139. ., treatment, 141. Intercellular spaces, 5. Intercostal muscles, pain in, 287. Interference with medical work, 62. Intermolecular circulation, 70. Interstitial changes, 70. Intestinal canal, ganglia and nerves of, '55- ,, ,, nerves of, 156. „ „ inflammation of, 361. ,, ulcers, 363 ,, worms, 230. Investigation by cro.is-examination, 21. „ minute, 67. Iodide of potassium in cracks of tongue, 122. ), ., in rheumatism, 293. Iodine in chilblains, 367. Ipecacuanha as an emetic, 160. ,, in ulcers of colon, 364. Iridin, 243. Iron, darkening the motions, 228. ,, in neuralgia, 283. ,, tincture of, in sore throat, 358. ,, munated tincture of, in thrush, 127. Irritability in biliousness, 237. ., of dyspeptic persons, 185. Irrilation of mucous membrane, 345. ,, of stomach causing diarrhea, 223. Issue, 349. Itching in chilblains, 366. Jalai' in constipation, 210. Jalapine, 215. Jam, meat 178. Jamfs, Mr., on pepsinc, 175. Jaundice, 243. ,, severe, 245. Joints, state of, in rheumatism, 287. Judges and medical and scientific evi- dence, 33. Juglandin, 243. Kktti.e, bronchitis, 124. King's College Hospital management, Kidney disease in gout, 306. Kino, in diarrhcea, 229. Kneading the bowels, J 98. Knee joint, operations on, 99. Knott, Dr., on fatigue fever, 331. Knowledge, opposition to, 40. Krameria, in diarrhoea, 229. Large intestine deranged in sick head- ache, 253. ,, f?ecal matter impacted in, 185. Lavement, 104. Laws and medicine, 29. ,, German vaccination, 47. ,, new, 29. ,, vaccination, opposition to, 43. Lawyer's estimate of medicine, 21. Leaves, fungi in, 79. Legal estimate of science, 29. ,, method, 28. ,, processes not suited in medicine, 21. Legislation aniicurative, 39. Leicester, opposition to vaccination, 47. Lemon-juice when mouth dry, 115. Lenitive electuary, 211. Lentil gruel, 162. Leptothrix buccalis, 109. Leucomaines, 92. Liberty of opinion, 19. Life insurance question, 48, 49. , ,, questions, Lord Chief Justice on. 49. Lime-water in diarrhcea, 225. Liniments not always useful in pain, .363- Lips, eruption upon, 350. Liquid required in rheumatoid arthritis, 301. ,, taken, influence on action of bowels, 187. Liquor pctassre in indigestion, 164. ,, ,, in diarrhoea, 225. ,, sanguinis, 335. Liquorice powder, compound, 211. Literary men, constipation of, 183. Liver, deranged action in biliousness, 239. ,, exciting action of, in offensive breath, 128. ,, in sick headache, 251. Living bioplasm as a disease germ, 94. ,, matter, changes in. J41. ,, particles, passage of, through vessels, 338. I^ocal fever, 3 \2. Logwood, in diarrhcea, 229. Loss of appetite, 132. Lotion for eyes, 355. Lozenges, bismuth, in d\spepsia, 165. Lumbago, 287. Lunacy Acts Amendments, 30. IXDKX. ?8l Lungs, capillary, lutmorrhagc fioiii the, 337- ,, inflammntion of, 371. Magnesia carbonate, 215. ,, sulphate, 215. Management of patients, 9. Massage, 285. ,, in constipation, 197. Mastication, defects of, 169. Material of contagion 75. Materies morbi, 75, 78, 94. ,, ,, in fever, 328. Meaf, abstinence from, 279. ,, jam, 178. „ in inflamed mucous membrane of stomach, 362. ,. little required by bilious people, 241. Mechanism for governing calibre of arte- ries, 332. ,, for regulating capillary circu- lation, 330. Medical charity organisation, 58. „ evidence in insanity, j^. ,, difficulty of, 35. ,, humhug, 13. ,, life insurance examination, 53. Medicinal waters, 202. Medicine from legal standpoint, 21. ,, in Greece and Rome, 14. ,, and surgery in Rome, 14. Medicines, simple, 8. Meissner, nerve plexuses, 155. Mel-Boracis, 127. Meii-ory in sick headache, 254. Meniere's disease, 234. Mental disease, legislation. 29. Mercury in sick headache, 266. ,, in rheumatism, 291. ,, its use in oflensive breath, 130. Metallic taste in mouth, 125. Method, medical and legal, 28. Microbes, 78. Micrococci, 78. Microscope and homceopathy, 22. Microscopic ganglia, 155. ,, observation, 67. Migraine, 247. Migraiion of corpuscles through capillary walls, 338. Mildew, vital phenomena of, 340. INIilk ami lime-water, 225. Mind in s ck headache, 253. Mindereru*, 322. Minute changes in fever, 328. ,, investigation, 67. Mi-acle, none in modern medi;ine, 6. Misery and despair in biliousness, 337. Mistrust of medicine, 28. Moist application to bowels in constipa- tion, 198. ,, tongue, 113, 117. Molecular circulation, 70. Mortification following boils, 368. Movements of mucus corpuscle, 346. M(ncments, vital, 340. Mouth, ajihthie in, 126. ,, dryness of, 1 14. Muco-pus, 361. Mucous membrane, inflamed, 361. ,, ,, of nose inflamed, 345. ,, ,, of stomach inflamed, 361. „ ,, f)f throat inflamed, 356. Mucus, 345. ,, corpuscle, 346. ,, evacuations, 226. ,, formation of, 347. ,, of pig's stomach as pepsine, I73- ,, secreted in a cold, 361. Mum]is, poison of, 85. Muscles in rheumatism, 2S9. Muscular fibre cells of intestine, 156. „ rheumatism, 286. Mustard as an emetic, 137. , , leaf, mode of using, 260, 363. Myrrh, tincture of, in cases of offensive breath, 129. M)stery, no, in medicine, 6. Nares, dryness of, 123. Natural history of cisease, 7. Nature of contagia, 76, 91. Nausea, 136. ,, hydrocyanic acitl, 139. ,, in iaundice 244. „ in sick headache, 248. Navigators, shortlived, 135. Nepenthe, 163. Nerve, action of, determining calibre of arteries, 332. ,, cells and fibres governing capil- lary circulation, 347. ,, derangement in sick headache, 253- ,, disorders, relation of fever 10, 318. ,, disturbance in chilblains, 365. ,, eruption in course of, 348. ,, fibres concerned when pain is felt, 156, 347- ,, ,, of stomach and intestine, 153- ,, ,, pressure on in rheumatic pain, 288. ,, in inflammation, 347. ,, storms, 256. Nerves afTected in fcver, 318. ,, of digestive system, 155. ,, to capillary vessels, 157. ,, and ganglia, stomach and bowels, 156. ,, of intesfnal canal, 154. Nervous exciiement producing diarrhcea. 222. Nervousness, 10, 271. Nettle rash, 332. Neuralgia, 280. ,, and rheumatoid arthritis, 301. „ treatment of, 2S2. INDEX. Neuralgic and gouty affections, and sick headache, 255. Neuroses and nerve-storms, 255. Nitrate of potash in rheumatism, 292. ,, of silver in sore throat, 124. „ ,, in treating sores on lips, 352. Nonsense, 25. Normandy pippins in constipation, 199. Nose, haemorrhage from, 337. „ running from, 360. Nuclei, enlargement of, 333. Nucleus of a cell, 67. Nux, 22. ,, vomica in constipation, 211. Oatmeal in constipation, 199. Obesity, 143. ,, treatment of, 146. Odour of the breath, 128. (Edema, in osteo-arthritis, 297. ,, of tongue, 118. Offensive breath, 128. Oidium albicans, 126. Oil of male fern, 232. Old age, accumulation of fsecal matter in, 185. ,, indigestion in, 168. Olive oil as a purgative, 208. Oozing of blood from capillaries, 336. Operation, fever after, treatment of, 189. Ophthalmia, 353. ,, poison of, 371. Opium, decillionth of grain, 19. ,, in diarrhoea, 229. ,, in neuralgia, 283. ,, in homceopathic doses, 18. Opposition to antiseptics, 98. ,, research, ■59. ,, science, 36. ,, vaccination, 41. Organization, charity, 58. Origin of species and varieties of bacilli, 87. Osteo-arthritis, 296. Ostrich-pepsine, 175. Outgrowths from bioplasm, 346. Out-patient department of hospitals, 54. ,. and slight ailments, 55. ,, organization of, 63. Ovariotomy, 90. Overfeeding, evils of, 135. Over-sensitiveness in sick headache, 255. Oxidation not increased in fever and in- flammation, 314. Oxyuris vermicularis, 230. Pain, 153. ,, muscular, 290. „ conducting nerve-fibres, 156, 1 57. „ nerve-fibres concerned in, 153,347- ,, neuralgic, 280. ,, pleuritic, 348. ,, in the stomach, 153, 157. ,, rheumatic, 348. Palate, soft, dryness of, 123. Pale tongue. 118. Palmer, Dr., on natives of North- western provinces of Bengal, 279. Papilla of tongue, filiform, and fungi- form, 107. Paralysing action of nerve-centres and fibres, 319. Pasteur, opposition to, 38. Pasteur's views on specificity, 86. Patent medicines, 25. Pathological transformation, 87. Patient, interest in, 6. Pauperization, supposed, 58. Pay patients in Hospitals, 60. ,, wards ,, ,, 60. Peculiarity of dress, 13. Penicillium and sugar fungus, 86. Pepsine and its uses, 171. ,, ,, beef-tea, 179. ,, method of making, 173. ,, of the pig, 173. ,, value in febrile conditions, 177. Peptones, 178. Perfect health rare, i. Pericarditis, pain in, 157. Periodical processes, 181. ,, sick headaches, 248. Peripheral paralysis, 357. Peritonitis, 156. ,, contagium of, 354. Perspiration, free, in rheumatism, 291. ,, influence on interstitial cir- culation, 70. Peruvian balsam. 367. Peter, M. , on fever from over-pressure,. 331- Petition, 37. ,, antivivisection, 37. ,, to Parliament, lunacy laws, 3°- Pharynx, changes m mucous membrane of, 123, 357. Phlebitis, 191. Phosphate of soda, 217. Physical views of vital action, 340. Physiology, importance of study of, 167. Phytolaccin, 243. PiESSE, Mr., on Friedrichshall water, 218. Pig, pepsine of, 175. Piles or haemorrhoids, 191. ,, ,, treatment, 192. Pills, coated, 210. Pleurisy, pain in, 157, Plexuses, nerve, 155. Pneumonia, 371. ,, increased oxidation in, 314, Podophyllin in constipation, 214. Poison of disease, 83, 371. Poisons, action of, 74, 75. Political opposition to science, 38. Poor, medical help for, 60. Pork, its dethronement in America, 273, Port wine as a gargle, 359. Potash and soda in rheumatism, 291. ,, sulphate, 219. INDKX. Poultice, its use in truatmcnt of ulcer of stomach, 363. ,, in dyspepsia, 165. Powder, dit;estivc, 174. Practitioners, country, 9, 69. Prejudice against kno\vledj;e, 40. ,, „ science. 17, 36. Preliminary changes in febrile attacks, 311- ,, ,, various diseases, 369- Preparation of pepsine, 173. Prcscrdiing, 12, 67. Pressure in causint; chilblains, 366. Pretenders, medical, 6. 13, 17. Preventing mental disease, 30. Principles nf conduct, 27. ,, of treatment of slight and severe ailments, 11. Protection from contagious diseases, 95. Provident dispensaries, 64. 66. ,, ,, objections to, 65, 66. Prunes in constipation, 199. Prussic acid in nausea, 139. Ptomaines, 92, 223. Public want of trust, 35. PiUlna water, 21 S. Purgative enemata, 194. Purgation, influence on interatitial circu- laiion, 70. advantage of, 161. Purgatives, in offensive breath, 130. ., in a cold, 322. ,, in constipation, 203. ,, in indigestion, 163. ,, saline, 215. Purulent ophthalmia. 353. Pus-bioplasm, growth of, 97. Pus formation not due to bacteria, 96, .342. ,, corpuscles, format itin of, 342. ,, and bacteria, 95. ,, in boils, 36S. ,, in and near capillaries, 334. ,, on conjunctiva, ^53. ,. not altered blood -corpuscles, 338. ,, formation of, in and near capillaries, 34.1- Putrid fluids, bacteria in, 78. Pyocyanic bacillus, 89. Pyrethrum, 115. Pyrosis, 159. Quackery, 14. •Questions, life insurance, 51. Quinine, action of, 70. ,, in neuralgia, 282. ,, in sick headache, 265. Rash in fever, 330. Reabsorption of fluids from intestine, 186. Rectum, bleeding from the, 337. l\.ed tongue, 1 10. Redness of skin in fever, 332. Reflex action of throat disturbed in in- flammation, 357. Regularity of action, im[n)rtance of, 181. Relief organization, 64. Reports on life insurance, 52. Reputation of (|uacks, 14. Research, opposition to, 39. Resisting power to contagion, 42. Rest, importance of, 1 1 2. ,, in sick headache, 258. ,, importance of in treatment, 362. Restlessness, 269. Revalenta arabica, 162. Reversion. 90. Rheumatic i)ains, 286. Rheumatism, absence in parts of India, 279. ,, alkalies in, 291. ,, diet in, 295. ,, tongue in, 1 17. ,, causes of, 371. ,, pains, 285. ,, ,, nature of, 287. ,, treatment of, 290. Rheumatoid arthritis, 296. ,, ,, management of, 300. Rhubarb in constipation, 206, 209. Rigoli.ot's mustard leaves, 363. Rigors, 311. Rochelle salts 217. Rome, quacks in, 14. Rotation of cell-contents, 339. Round worm, 231. Rubbing in constipation, 197. ,, in liniments, 363. Running from the ear, 361. ,, ,, nose, 360. RUTIIERI'OKD, Prof., on Ii\er, 243. Salicine, 283. Salicylates, 283. Saline purgatives in constipation, 215. Salines, action of, 116. ., in sick headache, 264. Saliva, III. ,, exciting flow of, 115. Salivary glands in sick headache, 251. Salivation, 266. Salt as a gargle, 360. Sansom, Dr., his disks, 284. Santonin, 231. Sarcina ventriculi, icg. Scammony in constipation, 211. ,, in offensive breath, 130. Scarlet fever, rash in, 330. Scepticism and credulity, 24. Science, legal estimate of, 21. ,, prejudice against, 36. Scientific evidence, 34. Scratches not healing in constipation, 189. Scrofulous children, oiihthalmia, 354. Sea-side causing biliousness, 242. Sea sickness, 138. Secret medicines, 27. 384 INDEX. Secrets in medicine, 6. Secretion, free, a^'ter inflammation, 319. ,. in fever, 319. ,, importance of, in preventing illness, 37c. ,, in sore throat, 360. Sedatives in indigestion, 165. Seidlitz powders, 218. Self-supporting system, 55. ,, dispensaries, 64, 66. Semi-confidence in medicine, 48. Senses disturbed in sick headache, 253. Sensitiveness of inflamed mucous mem- Ivrane, 347. ,, of peritoneum, 156. Serious illness may be functional. Ii. Serous membranes, pain in, when in- flamed, 156. Shampooing in rheumatism, 285. Shivering and rigors, 31 1. Shrinking of muscles in rheumatism, 289. Sialagogues, 115. Sick headache, 247. ,, counter-irritation in, 260. ,, and epilepsy, 255. ,, tea drinking in, 259. ,, treatment of, 256. ,, during an at- tack, 258. „ between the attacks, 263. ^j ,, work being continued, 267. Simple medicines, 25. Skin, free action of, in rheumatism, 294. Slaves, medical, 16. Slight ailments, 4. ,, and out patients, 55. ,, treated on same prin- ciples as serious mala- dies, II. Slight inflammation. 345. Sluggish bowels, 207. Small pox and vaccination, 42. ,, virus of, 94. Smokers, tongue of, 118. Smoking as a remedy for constipation, 203. Soda bicarbonate in constipation, 205. ,, phosphate, 217. Sordes, 120. Sore on lips, 350. ,, mouth, 126. ,, throat, 356. ,, ,, state of mucous membrane, in. 358. Si'ENDER, Dr., on sick headache, 262. ,, on rheumatoid arthritis, 296. Specialists and quacks in Rome, 1 5. Species of bacteria, origin of, 87. Specificity, 86. ,, of contagium, 89. Spirit of Mindererus, 322. Spiritual manifestations, 161. Spontaneous movements of bioplasm, 346. .Spray producers, 124. ,, in treating sore throat, 125. Spread of disease germs, precautions against, 103. Squire, Mr., on pepsine. 175. Starving in sick headache, 259. ,, in biliousness, 241. Steel, tincture of, 127. Stewart, Dr. Grainger, on vertigo, 233- Stiffness of limbs, 287. Stimulants in sick headache, 257. Stomach, derangement of, in sick head- ache, 249, 251. ,, poulticing the, 363. ,, acids of, 159. , , capillary hemorrhage from the, 337; ,, fungi in, 8t. ,, inflammation of, 361. ,, irritation of, producing fever,, 223. of pig, 173. ,, strong and weak, 153. ,, ulcer of, 144, 364. „ wind in the, 161. Storms, nerve, 256. Strawberry tongue, 119. Sudden illness, 371. Sudorifics in a cold, 310. Sugar fungus, 86. ,, in rheumatoid arthritis, 302. ,, in urine, 239. .Sulphate of m.agnesia and soda, 216. Sulphonal, 270. Sulphur in constipation, 212. .Sulphurous acid gargle, 120. Support. 162. Surgical operations, fever after, 189. Suspicion, 15. .Swallowing, 357. Sweating in rheumatism, 290. ,. stage in fever, 31S. Swellings in rheumatism, 288. ,, rheumatoid arthritis, 298. ,, M J 7 changes in, 299. Swimming in the head, 232. Sycophants, 15. Sympathetic system, nerves of, 154. Sympt ms of a cold, 311. ,, explaining, 4. Syringes for injections, 194. Tact and treatment, 13. Tait, Lawso.N', operations for ovario- tomy, without ar tiseptics, 99. Tannic acid, glycerine of, sore throat,.. 359- Tape worm, 232. Tartar emetic, 137. Tartrate of soda and potash, 217. Taste, metallic, in the mouth, 125. INDEX. 3^S Tasicless salt, 217. Tea-resence of Morbid Growths- Albumen in the Urine irom Stone m the Kidney, Ureter, or Bladder— Albumen in the Urine from acute or chronic functional or Structural Changes in the Kidnev itself- On the Nature of Structural Kenal Changes— Acute Inilammation of the Kidney- Chrome Intlanmiation ot the Kidney with Enlargement- Chronic Wasting of the Kidney with Contradicn— Cirrhosis of the Liver and Kidney — Syphilitic Eenal Disease — On the Treatment of Diseases of the Kidney —Catheter Fever — Treatment of Acute Renal Disease- Diet in Acute Renal Disease — (Edema — Anasarca — Uraemia— Ascites^Clironic Renal Disease — Warm Clothing — Air aad Exercise — Sea-air in Chronic Renal Disease — Diet in Chronic Renal Disease — Pepsin in Chronic Renal Disease — Stimidants in Chronic Renal Disease— Iron— Digitalis— Treatment of Albuminuria of Advancing Age — Further hints on the Treatment of Clu-onic Albuminuria — Mdk Treatment — Treatment of Albuminuria dependent upon Syphilis — Bile — Jaundice from Obstruction and from Suppression — Treatment of Cases of Jaundice —Diabetes : (1) In the Young ; (2) In the Middle-Aged ; In the Old— Nervous Lesions in Diabetes — Coma in Diabetes^Sugar in the Ux-ine in Pneumonia, Brou- uhitis, and Phthisis — Impaired Sight and Cataract in Diabetes — Large Quantity of Urea in the Urine in Diabetes — Treatment — Grlycerine in Diabetes — Vegetables that may be Eaten — Bran Cakes: Formula for makinj — Almond Cake — Glycerine Sponge Cake — Skim-milk — Rennet and Pepsine in Diabetes —AlkaUne Remedies — Purgatives — Opium and Codeia — Ciuchonine, Quinine, and Strychnine. ON URINARY CALCULI AND CALCULOUS DISORDERS. Substances of which Calculi are formed — Ci-ystallisation in Viscid Matter Concentric Layers of Calcidi— Different Classes of Urinary Calculi — Uric Acid Calcuh— Calculi composed of Urates - Cystic Oxide: Cystine— Blood Calculi — Fatty Concretions — Oxalate of Lime Calcuh — Large Calcuh witliout any Symptoms — Calculus with long Spines projecting from it — Calculi in Patients who have had Cholera — Passage of Oxalate of Lime Calculi from the Kidney — Phosphate Calculi passed in large number — Prostatic Calcuh— Sir Henry Thompson's Observations-- On the Origin and Formation of Urinary Calcuh — The Formation of Microscopic Calculi — Dumb-bell Crystals form the Neuciei of many Calculi — Collections of Dumb-bells in the Uriniferous Tubes— Frequency of tlie occurrence of different kinds of Calcuh— Of the Influence of Considerable Quantities of Fluid in Pre- venting and Relieving Calculous Disorders — Importance of continuing Remedial Measures for some time — On dissolving Urinary Calculi — Of Injectiijg Solvent Fluids into the Bladder — Dr. Roberts' Experiments with Alkaline Carbonate — Treatment of Renal Calculus— Eehef of Pain by Sedatives— Treatment by Complete Rest— Catheterism — On Washing out the Bladder — Inscrument for Washuig out the Bladder as suggested by Mr. Job CoUins, and Improved by Mr. Buckstone Browne — Lithotomy — Lithotritj — Litholapaxy — Dr. Freyer's Operations — The Spontaneous Fracture of Calculi"^ in the Bladder — Nephrotomy and Nephrectomy. Now Ready, Second Edition, price 5*. 100 URINARY DEPOSITS, with Directions for the Clinical Examination of Urine : for Practitioners and Students. Plate I. Mucous — Bacteria — Fungi — Spermatozoa — Epithelium. Plate II. Spermatozoa — Epithelium — F'ungi — Leucine— Tyrosine. Plate III. Casts of the Uriniferous Tubes— Cholesterine— Granular— Epi- thelial. Plate IV. Casts of the Uriniferous Tubes, Large —Small— Waxy— Fatty- Blanket hah*. Plate V. Earthy Phosphate— A^irious forms of Urate— Pus and Phosphate. Plate VI. Fifteen different Forms of Uric Acid Crystals. Plate VII. Ten different Forms of Uric Acid Crystals— Triple Phosphate— Oxalate of Lime — Cystine. Plate VIII. Dumb-bell and Octahedra of Oxalate of Lime— Microscopic Calculi — Cancer Cells — Ova — Extraneous Matters. LONDON: J. AND A. CHUliCHILL. Now Ready, Fourth Edition, nearly 400 pages, prico Ss. SLIGHT AILMENTS: and on Treating Disease. Intrcjtluctory— Slight ailments and civilisation — Derangements and discomfort — No secret remedies — Quackery and tact — -Credulity, susj^icion — -Decillicjnths of grains — Homoeopathy — conversion — Legal estimate of science — Evidence of action of medicines — Principles of conduct — Law, metlicine, and medical methods — Legal and medical differences — Lunacy Acts Amendments — Legal overruling medical opinion — Medical and scientific evidence — Medical work and thought — Opposi- tion to research — Opposition to vaccination — Dr. Creighton's article— John Bright and Gladstone — German vaccination law — Medical life insurance reports. Medical charity organisation — Out-patients and slight ailments— New organisation of charity— Gratuitous medical help — What is given by doctors — Objections to the new system — Provident dispensary system. Minute investigation — Elementary parts or cells — Inter-molecular circulation — Action of skin, kidneys, and bowels Communicable diseases — Nature of contagia — Bacilli, microbes, micrococci — Fungi and decay of leaves — The ever-present bacterium — Dust and disease — Access of disease germs — Specificity — Origin and change of species — Poisonous animal alkaloids — Ptomaines and leucomaines — Contagion originating in organism — Disease germs from bioplasm — On pus formation — Antiseptics— Carrying and diffusing contagia. Of the tongue in health and in slight ailments — The dorsum of the tongue — Fungi- form and filiform papilLe and their covering — Tongue in various derangements — White moist furred tongue — Pale tongue — Tongue in chronic rheumatism — 'Bright red tongue — Dry brown tongue — Hemorrhage — Cracks and fissures — Inhalers, bronchitis kettle — Of the use of spray — Aphthoe, thrush, sores and ulcers in the mouth — Qflensive breath — Use of mercury. Appetite — Nausea — Thirst — Hunger — Loss of appetite — Voracious appetite — Nausea — Ac(|uiring intemperate haljits — Thirst. Indigestion : its nature and treatment — Indigestion — Dyspepsia — Strong and weak stomachs — Pain-conduciing nerve-fibres — Heartburn, pyrosis, or waterbrash — Flatulence, wind in the stomach — Influence of cokl — Indigestion from failing glands, as in old age — Method of preparing pepsine. Of constipation — Craftsmen subject to constipation — Literary persons — Impaction of faecal matter — Constipation and the healing process — Haemorrhoids or piles. Diarrhcea— Ordinary Diarrhoea — Treatment. Intestinal worms — Thread worms — Large round worm — Tape worm. Vertigo — Giddiness — Aural vertigo. Biliousness — Sick headache — Derangement of the liver — Treatment — Action of east wind — Jaundice— Yellow atrophy — Treatment of temporary jaundice — Treatment of sick headache. Neuralgia — Rheumatism — NeiTousness — Rheumatoid or osteo-arthritis — Treatment — Free sweating — Diet — Warm clothing. On the feverish and inflammatory stale — Of catching cold— Preliminary changes — Increase of the body heat in all fevers and inflammations — Is there increased oxidation in fever and inflammation ? — Method of ascertaining the temperature — Fever — rigors — hot stage — sweating stage — Management of affections beginning like a cold. Of the actual changes ir. faver and inflammation — Fevers and inflammations — The formation of pus — Diapedesis-tltemorrhage- Spontaneous movement — Vital phenomena. Common forms of slight inflammation — Formation of mucus — Bioplasm — Dryness of the mucous membrane — Counter-action — counter-irritation — Cracks and fissures — Principles oi treatment — Conjunctiva — Treatment of inflamed eyes — Sore throat — Running from the ears — Inflammation of stomach antl intestinal canal — Chilblains — Boils — Carbuncle — Changes preparatory to the occurrence of disease — Concluding remarks. LONDO M : J. AND A. CHUBCHILL. Notv read!/, demij Sco, fp. 230, with 86 illustrations, many of which are coloured. — Price, 5.9. THE LIVEE Uniform with " Urinari./ and Renal Berangements and Calculous Disorders" "The Microscope in Medicine," ''How to Work loith the Microscope," and " Slight Ailments." Introduction— Conflicting views on the structure of the liver— Anatomical description — General Structure— Clinical examination. — Changes in shape and size. The constant element^ the liver ' cell ' or elementary part present in all animals. Minute anatomy of the human liver — Portal canals — Hepatic venous canals— The lobules of the hver — Distribution of vessels— Portal vein— Hepatic arterv — Hepatic duct — Vasa aberrantia — Lymphatics — Nerves— Vessels of gall bladder— Glisson's capsule — The intimate structure of the lobules — Capillaries— CeU-containing network — The liver 'cJl/> ,5!flEUKIVERS/A, .^U)SANCEl£r.>. x..OfCAUF0« ^ _ I ^lOSANCfier^ o r /I c: CO %a3AlNfl-3V«^ ^5S\EUNIVERy/^ ^•lOSANCfUr^ .o ^lUBRARYO^ ^•UBRARYQ^, ..!CI\EUNIVERS/A. .sS:lOSAKCFl£nA xOFCAllFOek. ^OF-CAUFOfito