THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES SAN FRANCISCO COUNTY MEDICAL SOCIETY 1905 THE RENEWAL OF LIFE. LECTURES, CHIEFLY CLINICAL BY THOMAS KING CHAMBERS, M.D., HONORARY PHYSICIAN TO H.B.H. THE PRINCE OF WALES, CONSULTING PHYSICIAN AND LECTUEER ON THE PRACTICE OP MEDICINE AT ST. MARY'S HOSPITAL, CONSULTING PHYSICIAN TO THE LOCK HOSPITiL. FROM THE FOURTH LONDON EDITION. PHILADELPHIA: LINDSAY & BLAKISTON. 18G6. HENliY B. AStlMEAD, PRINTER, 1102 and 1101 Sansom Street. BioroediuJ Umry m 100 tzssr PREFACE FOURTH EDITION In the first two editions I named the selection of clini- cal observations laid before the public " The Renewal of Life," meaning thereby to intimate what is more fully stated early in the volume, that the main point for the physician's consideration in disease is the deficiency of vital action, and that all successful medical treatment is a renewal of that vital action. To my annoyance the words were found strangely "open to misrepresentation" by several of the literary men engaged in reviewing the work. Such a risk seemed to outweigh the advantage of ex- pressing in an epigrammatic form the principles advocated, and led me to take the unusual course in the third edition last year of leaving out a great part of the title. I tried to justify the change of name by large additions to the original matter, dovetailing into the text comments made before my class on recent passing cases, and inserting twenty three new lectures, three given at the College of Physicians, and the rest in the theater of St. Mary's Hospital School. 624156 vi PREFACE TO THE FOURTH EDITION. While that edition was in the press, I was struck down by a dangerous illness, and have been out of work nearly eighteen months. On my return, by God's grace, to health and labor, I find it sold off, and a new one called for before I have again occupied the teacher's chair. I have, therefore, no fresh matter to offer, and must content myself with a thorough revision, and the addition of an index unavoidably omitted last year. It will be seen that many of the " Lectures," as set before the reader, combine materials orally delivered at several, and often at distant, times. These are short clini- cal commentaries on cases, made still shorter by the omis- sion of much elementary instruction on diagnosis, only suited to students. The fragments are here united under subjects, and to avoid chronological confusion the date of its viva voce production is placed at the head of each portion. I trust the disjointed aspect thus given will be pardoned, as we pardon roughnesses, inexcusable to the finished works of the studio, in a portfolio of sketches made on the spot, out of consideration for the vividness which drawing from nature only can give. T. K. C. 22b, Brook Street, Grosvexor Square ; October, 1865. SUBJECTS OF LECTURES. PAGE I. Death and Life . . . . .13 II. Disease and Cure 30 III. Formation of Mucus and Pus , 54 IV. Ditto .... 62 V. Ditto . . . ' . 72 VI. Typh-Fever 86 VII. Ditto . 106 VIIL Ditto . 111 IX. Ditto . 117 X. Smallpox 132 XI. Rheumatic Fever 144 XII. Ditto . 156 XIII. Ditto .... 164 XIV. GONORRHCEAL RHEUMATISM 168 XV. Pericarditis . 181 XVI. Pleurisy . . 194 XVII. Hydrothorax . 203 XVIII. Acute Laryngitis . 221 XIX. Capillary Catarrh . 230 XX. Pneumonia . 238 XXI. Ditto . . 251 XXII. Emphysema op the Lungs 274 XXIII. Pulmonary Consumption . 288 XXIV. Thoracic Aneurism . 309- VUl SUBJECTS OF LECTURES. XXV. Disease of the Heart . XXVI. Purpura . * . XXVII. Anvemia . XXVIII. Prominence op Eyeballs XXIX. Atrophy of Muscles XXX. Chorea . XXXI. Epilepsy . XXXII. Hysteria . XXXIII. Spinal Paralysis XXXIV. Sciatica . XXXA^. Albuminuria XXXVI. Ditto . XXXVII. Ascites . XXXVIII. Diabetes . XXXIX. Mortification XL. Importance of the Digestive Organs rapeutics XLL Indigestion in General . XLII. Slow Digestion and Acidity XLIII. Pain in the Stomach XLIV. Eructation and Vomiting XLV. Diarrh(ea XL VI. COSTIVENESS AND CONSTIPATION XLVII. Dietetics . XLVIII. Corpulence XLIX. On Pepsine L. On Alcohol LI. On Bloodletting LII. Review L'Envoi IN The- CHAMBERS' LECTURES. LECTURE I. DEATH AND LIFE. Reasons for introductory lectures — Decay of dead bodies^ or Death — Decay of living bodies, or Life — Life cannot be in excess — Health, death, and disease, contrasted — Partial death as exhibited in disease, viz., in degenerations, in hypertrophies, in malignant tumors, in catarrh, in boil and abscess, in fever and zymotic diseases, in ansemia, in tuberculosis — Classification of diseases — The restorative direction of modern medicine. {Introductory Clinical Lectures at St. Mary's Hospital, delivered October 4, 18G1, and October 2, 1862.) Before I enter, as a teacher of clinical medicine, upon my duty of showing you how to read the lessons which are spread out before your eyes in the hospital wards, it is my custom to give you an introductory lecture. I think this saves time in the end, for '•''claudus in vid antevertit cursorem extra viaiii," as Bacon tells us, and my object is to show you the way. Doubt- less all your past professional studies have been in a manner in- troductory to this crowning study; your anatomy, and chemistry, and physiology, and the systematic principles of medicine learnt under me and my colleagues, have led up to this end. But I wish shortly to recall to your memory what points in those studies of life and death have the most special bearing on the 2 14 DEATH AND LIFE. matter in hand, and to show how a consistent theory of thera- peutics may be built up from them. It is true that there are, and always have been, practitioners who declaim against theories altogether, who even boast that they can do without them, and think them useless, not consider- ing that to express such scorn is as if we should be proud of not knowing what we do when we act, or what we say when we talk. To reason at all is to theorize; no one without theorizing can direct a method of cure to a sick person except at haphazard. As a matter of fact, none of these objectors ever do prescribe without theorizing about either the individual suJBferer or the class to Avhich they refer his sickness, though not always able to put their theory into words. In short, the want of a guiding principle to connect the loose facts of daily experience has at all times been felt. From this practical need have been bred the many systems of therapeutics stamping their mark from time to time on the his- tory of our art. They have sprung from the brains of working men at the bedside, not from philosophers in their closets. Their adopters have not necessarily any strong faith in their truth or universal applicability; but the heart wearies for a chain to link together the scattered fragments of knowledge — a string for its pearls; it must have an idea on which to codify the laws of action. It would be a long task to quote the curious systems founded on imperfect data, but numbering their hosts of followers in former ages, which have been given up as false and dangerous ; I do not wish twice to slay the slain. I shall content myself with putting before you that which influences me in my prac- tice, to which I now proceed. Man's body may be likened to a stately mansion, made of beauteous but very perishable materials, all of which are always needing repairs to keep up the shapeliness and usefulness of the building. But not all in equal degrees; some of the walls may stand unaided for years, while other parts may want almost hourly looking after. When the owner leaves the dwelling the repairs cease, and then we see, not all at once, but one after DEATH AND LIFE. 15 another, the materials falling into ruin. It will serve a purpose in my argument to think over the several steps of this ruin for a few minutes. Already while the soul is withdrawing we know that changes begin, very obvious to even the most superficial observer. These changes are mostly due to the loss of water by evaporation. The eyeball loses its brilliancy and gets dry and flat, the features shrink, the gloss leaves the hair and skin. All this goes on all the more rapidly after decease, and then we hide our dead out of our sight, and the future fate of the body is less familiar to us; we must search for exceptional cases or special observations if we want to know what happens. These we may cull from sundry independent sources. Here is one which old barbarous manners afford us. "Rizpah the daughter of Aiah, the concu- bine of Saul," watched for the six summer months, from "the beginning of barley-harvest" in April, to the rainy season in October, " till water dropped upon them out of heaven," to guard the corpses of her murdered kinsmen from the beasts of prey. So long under the sky of Palestine did they hold out a quarry for the wild dogs and vultures. In a moister air decay is quicker, but still not so quick as is often supposed. Here is another observation redolent of the refinements of modern science. The notes made by M. Devergie* on the bodies at the Morgue at Paris, show that for two months and*a half after decease the muscular structures still keep their natural forms and hues. Up to three months and a half, the scalp, eyelids, and nose so far retain their ordinary feature that the age of the person may be told.. It is four months and a half before complete destruction of the face occurs, or the bones become brittle, and the bulky muscles of the neck and thighs are converted into adipocere. So that we may call three months and a half a short time to be occupied by the decomposition of a human body. So long does flesh last as flesh, and tissue tissue, and is not melted into its mother earth. Let us come forth quickly from these ghastly scenes of the charnel-house to the joyous bustle of brimming life, and ask how * Devergie, "Medecine Legale," t. ii, chap. v. 16 DEATH AND LIFE. long it takes not a dead but a living body to decay? "A living body decay?" Yes, in truth; but Avhereas in the former case it was a thing to make men shudder, the fading of a long-loved image, the tearing up of a fair garment, the fall of a darling home, the violation of a worshipped shrine, the forcible divorce from our nearest and dearest — it is all this and more — in the latter it is associated with the fullest fruition of all that is joyous in existence, the bounding pulse, the free-drawn breath, the swelling chest, the thrilling feel of health, the highest uses of mind and body. Decay is more truly a part of life than it is of death ; for it goes on unstayed through the whole of corporeal being; whereas, after dissolution, it gradually ceases, and ends its work with the reconversion of the organic particles into eternally changeless elements. The most living body is the most active in decay; the more bodily and mental vigor are dis- played, the more quickly do the various tissues melt down into substances which are without delay removed by the excreting organs. The more the blacksmith toils with his arms and the more the statesman with his brain, the heavier bulk of carbon, nitrogen, oxygen, and hydrogen is thrown out by lungs, liver, skin, and kidneys. Do they then wear out by this constant use, friction, and drain? No, no — the more bricks are removed from the old wall, the more new bricks will a good builder put in ; and so, provided that the supply is suflScient, and that the builder is a good one — the more rapid the drain — the newer and stronger and fitter for its uses will the body become. But I will leave generalities and try to represent in figures how long it takes by living decay for the living body to drain away, and to have its substance renewed. In the grim details which I recalled to your memory at the beginning of this lec- ture, the nitrogenous or fleshy parts were most accounted of and especially named as giving shape and the general look of a man to the melting corpse. So of the nitrogenous parts we will now speak — How long are they in being removed by vital decom- position? We may reckon with Drs. Bidder and Schmidt* that the body * '-Die Verdauungssiifte und der Stoffwechsel," p. 400. DEATH AND LIFE. 17 of w apt we have been to reduce the vitalitj' in our aims at cure. I need hardly allude to ulcerations and rugged con- ditions of the stomach, of the throat, of the vagina, and neck of the womb, which have been treated to their great injury by de- pressing medicines. 5. We are very much inclined from ancient prejudices to take congestion for a proof of active life, and the red, black, or other dark-coloured relics of congestion, as post-mortal evidences of activity in the organ so discolored. It appears to indicate the direct contrary. 6. So also with livid and reddish discolorations of the living skin. How often do you hear it remarked that a red, bloated- faced man wants "bringing down," when, in fact, what is re- quired is a more vitalized blood, and a more vigorous action of the heart and arteries. How often is a patient drenched with mercurials and purgatives because he is "black under the eyes," when tonics and better diet are the true specifics. Blueness and blackness of the sclerotic, again, is a safe indication for tonics, and the finger-nails may also be used as a guide to the same treatment. 7. The regularity with which death results on the loss of a certain amount of weight should lead us to make more use than we do of the balance, that easily applied aid to diagnosis, prog- DISEASE AND CURE. 37 nosis, and treatment. It is a direct measure of the success of our medicines, or of the progress of disease. 8. Hectic fever is an obscure subject. But I think some ap- proach to an elucidation of it may be made from the direction ■ of those singuhir nycthemeral osciUations of temperature which take phice in health. In full vigor, the normal production of animal heat rises gradually up to its maximum at noon, and falls to its minimum at midnight. In health this variation is slight, but in the simple debility produced by deficient food it is more than quadrupled. In M. Chossat's experiments it rose from 0-7-1:° to o*28°. The extreme of heat was so much more, and the extreme of cold was so much more than in health ; and not onl}'' was this change observed, but also that the periods of the accession and diminution became irregular, and were not governed by the diurnal time. Do not these observations distinctly associate periodic fevers, and through them perhaps the periodicities of disease, with direct debility? 9. The liability to be injuriously aifected by external .agents, especially by cold, is a sure proof of deficient vitality. This is not always accompanied by sensitiveness to the changed tempera- ture, but is made evident by catarrhs, bilious attacks, local in- flammations, congestions, &c., and is often popularly rated as characteristic of "an inflammatory subject." 10. M. Chossat's observations of the alvine evacuations are very valuable. Let us never forget that not only constipation, but also diarrhoea, and an exceedingly foul condition of the ex- cretions, may, and in fact generally do, arise from mere inanition. This is an important lesson for routine adherents of blue pill and black dose. The commonest instance we have of fetid evacuations from inanition is that of unfortunate babies who have been starved by hand-feeding, or by the imperfect condition of their mother's milk. Perhaps mercury may make the stools less disagreeable for a time, for it throws into the bowels a quantity of bile, which prevents their decomposition, but that is done at the expense of the poor infant's body, and must contribute to further the debility. 38 DISEASE AND CURE. 11. The weaker the life the quicker the heart beats, and the readier it is excited. This phenomenon is particularly well marked in zymotic fevers, Avhere the rapidity of the pulse is a good guide to the degree in which the poison of the fever has affected the system, and what force the system has to bear u^i against the poison. In pneumonia too, the rapidity of the pulse is usually in a direct ratio to the danger, and to the necessity for opiates and stimulants. In pulmonary consumption, starving, depressants, expectorants, salines, and all that is usually classed as antiphlogistic treatment, makes the pulse quicker and quicker, and nothing reduces it so steadily as oil and other restoratives. 12. The knowledge that convulsion arises when there is a deficient supply of blood to the brain, has been a long time in forcing upon the profession the conviction that it is a disease of inanition. Perhaps the impediment has been the finding in post- mortem examinations black blood, rendering abnormally con- spicuous the smaller vessels and capillaries, when, in certain diseases, convulsions have preceded death. The blood is too visible, and so the fallacy has been jumped to that it is too abundant. The real fact is, that it is too stagnant, that it is too arterial, too little renewed. Perhaps the great show that convulsions make, the natural awe which they excite among the bystanders, and the active help they seem to call for, impress us with an idea of activity of life in the sufferer. Chorea, epilepsy, teething fits, convulsive apoplexy, delirium tremens, hysteria, and some forms of mania, are familiar instances. But in all of these every experimental improvement made from year to year in the treatment is in the direction of replacing lost nervous power, not of restraining its excess. 13. The difficulty which the nervous tissue exhibits in parting with its substance by vital decay, explains the difficulty of its renewal. There are no patients so slow in recovering health as those whose nervous system is exhausted. They are months or years in getting ill perhaps, and they are months or years in getting well. Let our recollection of the slow growth of this tissue comfort us under such circumstances. The time and com- pulsory idleness needful for its restoration make it the most ex- DISEASE AND CURE. 39 pensive of tissues to get worn out, and rightly enough its higher manifestations are most highly paid for. Among diseases of deficient construction may also be included the tissue diseases of degeneration, where instead of highly vitalized elastic material a brittle, or a soft, or a formless mass is deposited. It is alive, but imperfectly alive, easily dies, and is useless while it lives. Tubercle is a substance of this sort. It appears strange at first glance that some organic matters which are referable to this class should carry out of the sj^stem with them a spark of half independent vitality. Cancer, for example, multiplies itself conspicuously, and so does pus in a more hidden manner, so long as they can get their food from the body. But this multiplication is the lowest (one might say the most diluted) form of life, and certainly indicates no re- dundancy in the parent system. M. Chossat remarks, "Bichat and the physiologists who have been occupied on the same subject before and after him have thrown the greatest light upon the causes of death, by classify- ing them according to the functions which help to bring them on. In dividing death into death by the brain, death by the lungs, and death by the heart, they run through the series of vital functions, and suppose that they have thus exhausted the subject. However, on coming to facts, it is certain that we thus explain but a small number of the cases of death, and that the great majority of those brought under our observation escape this classification. This is so even in the cases Avhich seem easiest to lend themselves to this division. In pulmonary consumption, for instance, who can say that usually death supervenes by asphyxia ? for the lung on the day of decease is not, as a rule, more disorganized than it was the day before; and yet the day before it sufficed for the aeration of the blood. On the other hand, who has not witnessed autopsies in a number of febrile maladies, in which there is no morbid change found, except lesions, often very insignificant, in the intestinal canal ? One cannot, without doing violence to the judgment, consider these as sufficient to account for the death. The fact is, the classifi- cation of Bichat does not explain all, and to the three modes of 40 DISEASE AND CURE. death which he points out we must needs add at least a fourth — death by the digestive apparatus, or inanition."* M. Chossat is quite right; indeed he rather underrates his case: very much more than half the patients we lose die from imperfect nutrition, and very much more than half of those who recover gain that end by chanced or designed restoration of their digestive functions. Exactly the same means that prevent death, prevent or cure disease. This may seem a platitude, but- it is a very important one, and must not be allowed to "lie bed-ridden in the dormitory of the soul" because it is so true. All are ready enough to admit that when a patient is in danger, the first thing to be done is to keep him alive. Act in the same way when he is not in danger; cure him by sustaining the partially or locally failing life; post- pone partial death, as you would postpone total death. (II.) Disease of destruction, or deficient moulting, commences when the functions whose business it is to remove efiete products from the tissues are inefficient. I say " functions" designedly instead of organs, in order to include the whole process from the period when the tissue becomes eifete to the expulsion of the products of its decay from the body. For in whatever part of the pro- cess a check takes place, the result on the whole health is iden- tical, and the principles, though not perhaps all the details, of the treatment must be the same. And in whatever part a check takes place, the main injury is the stoppage of vital metamor- phosis at its origin. This is the case even in mere mechanical obstruction. Take for instance the impaction of a gall-stone in the common duct; first the intestines are in want of bile — that is a deficiency they can easily bear ; then the gall-bladder and the ducts get dis- tended — which does not interfere very much with the patient's comfort ; but the real serious injury is the non-removal frqm the blood and tissues of what forms the biliary secretion. And the injury is of exactly the same nature, whether the jaundice * Page 194. DISEASE AND CURE. 41 arises in the mechanical way alluded to, or whether it arises in the ultimate tissues themselves, as jaundice from mental impres- sion for example. It might seem at first sight as if diseases of deficient moulting were exceedingly easy to detect, and to reduce to classification. We are in a position to measure accurately the quantity and quality of the most important excretions, and can approximate to a knowledge of those not so readily reckoned. We can know hy experiment the daily excretion of urea, phosphoric acid, sulphuric acid, and water by the kidneys ; of carbonic acid by the lungs ; of faeces by the bowels ; of water and salts by the skin, and we can find out with a fair approach to accuracy when these are diminished. But in the great majority of cases this diminution is in reality the consequence of deficient supply ; vital decay does not remove the tissues, because there is no new material to take their place. To call these cases instances of deficient moulting is a misappropriation of terms, and to treat them as such most pernicious. The most familiar example is the amenorrhoea of weakly females. To what purpose are emmenagogues ? Why should we wish to force the ovaries or uterus to bleed, when the reason why they do not bleed is that there is not enough blood formed ? The custom of administering purgatives, whenever the bowels are not open so often as those of robust persons, is another too familiar instance of mistaking the true nature of the deficiency. The only diseases we can safely refer to the class now con- sidered are those where the effete product is obviously retained in excess in the system, and where the impediment to its ex- cretion is usually the imperfect action of the secerning organ, such as urj»mia or the excess of urea in the blood from degene- rated kidneys, asphyxia or retention of carbonic acid from non- aeration, jaundice from mechanical impediment, or incomplete development of hepatic cells, and perhaps certain cases of the lithic acid diathesis. In most of the patients we have to do with, both classes of morbid phenomena are united ; there is a general deficiency of life, and both nutrition and destruction are below par, often in 42 DISEASE AND CURE. equal, more often in unequal proportions. The instance T have just given of urseniia is in point ; one marked change in the blood is the retention in it of urea, the product of destructive metamorphosis, which acts as a poison ; but another change, certainly more Avorthy of consideration as being more under our control, is the absence of red blood-discs by reason of defective nutrition. Hence we have mixed phenomena from the union of the two. I would say incidentally that there are few cases in which the defective nutrition is not at the same time the most important in a pathological sense as explaining natural phenomena, and at the same time the most important in a therapeutical sense, as being the most easily compensated. Be it remarked also that mixed phenomena, requiring mixed treatment, arise sometimes from the deficiency in one part of the chain of vital acts overthrowing the balance of functions found in health. An apparent excess of certain functions or constituents arises from the absence of those which normally are in correspondence with them. Thus Dr. Prout, to whom the pathology of urinary diseases owes so much, speaks of a "phos- phatic diathesis," and we not uncommonly hear medical men speak of "phosphatic urine" as if the ailment were an excess of the salts of phosphorus ; although in reality in such cases those constituents of the excretion are usually less copious than in health, and are deposited only from deficiency of the acid which should hold them in solution. The object of medical treatment is cure. The end of the physician's labor and care is accomplished by the patient get- ting well. What is this cure of getting well ? It is a restora- tion of the disordered body to its natural state of ease or health. This restoration we often see come to pass independent of any interference from without, by what is allegorically called an " efl'ort of nature." Wounds heal, diseases cease, in men and animals wdio have none to help them. The event comes about, not in consequence of the driving out of any materies morhi, but DISEASE AND CURE. 43 on the resumption of their normal functions by the diseased organs : the full vital force regains its influence in them, and they recover. The social disease of "a strike" is cured by the hands going on work again. Now diseased organs must necessarily have less power in them than healthy ones; and it is obvious therefore that the curative vitality must mainly be due to, and proceed from, those which remain healthy. It is to their having some sound action to spare that the sick man owes his recovery. The vital force at the same time removes the retained products from the tissues, and replaces them by new material. This is the true teaching of nature's cure. Cures by art are effected in exactly the same way. Every artificial appliance which does not aid this one only mode of re- covery is an impediment to it, or simply a nullity. A drug m itself effects nothing by its mere chemical or neutralizing influ- ence ; it is the vital power which this drug calls forth, or frees from a burden, that is the true healer. Quinine, for instance, will not neutralize malarious poison ; Peruvian marshes are not less deadly for cinchona trees falling into them ; but the drug's vital action on that which remains healthy of the body cuts short the fever which is the consequence of that malarious poison. The action of a remedy by which a sick body becomes sound must be looked upon as a vital act of the body itself and not a simple act, but a series of vital acts, which grow out of one another in regular succession as the branches grow from a tree. They are not dependent upon the continuous presence of the remedy, but persist long after it is removed from the system, just as a railway train goes on " of itself" (as we conventionally say) when disconnected from the locomotive. The true art of healing consists in the establishment of vital acts tending towards the renewal of the body, towards a new birth of diseased tissue, and in the encouragement and aiding of those vital acts after the removal of their original excitant. Since there are two parts in the chain of life, " construction" and "destruction," and since external agencies may act upon these in two ways by increasing them or diminishing them, a 44 DISEASE AND CURE. primary fourfold classification of curative agents naturally arises; and this will be the most handy classification for a prac- tical man. We have — (1.) CoNSTRTJCTiVES (^laroTpofiKa) OT aids to formative nutrition. (2.) Destructives ['icToivrtKa) or augraenters of destructive assimilation. (3.) Arresters or construction {pioihafihTiKa). (4.) Arresters of destruction {fiiocpviaKTiKa). Among Constructives we have the following classes: — 1st. The materials of which the body is built up : albumen, fibrine, gelatine, fat, oil, water, iron, lime, phosphatic salts, soda, ammonia, sulphur, oxygen, ^c, which are generally taken in the form of food. 2nd. Medicines which appear to act by replacing necessary constituents of the body. — This is as yet a very dimly understood class ; but we may hope something from the progress of physio- logical chemistry to explain the action of sundry medicines, which we cannot doubt will be proved restoratives, though we cannot at present see by what steps. Quina and other vegetable alka- loids may be taken as an example, whose cure of ague may be best explained by supposing them to replace some constituents of the body destroyed by malaria. 3rd. Digestive solvents. — Water, which must be in excess of that required in the structure of tissues, and without which the said materials cannot be absorbed. Cai'bonic acid — required to be present in the water for the easier solution of bone, earth, carbonate of lime, and albuminous food which contains them. Pepsine, to replace deficient gastric juice. Lactic acid — re- quired in the stomach to acidify the mass and enable the albu- men to be acted upon by the gastric juice. This may be replaced by other acids, such as hydrochloric, or acetic, or malic, for ex- ample, in some cases. Bile, in the form of inspissated ox-gall, or liquid ox-gall in capsules, to supply the place of that which is arrested in its passage or in its formation by disease. Pancre- atine, similar to pepsine. DISEASE AND CURE. 45 4th. Excitants of digestive solvents. — Mineral acids mixed with the food increases the flow of bile ; indeed all acid sub- stances have the power of exciting alkaline secretions. Thus they are useful, not only in jaundice from suppression, but in many cases of indigestion where this solvent is too sparingl}'- formed. In many cases, too, of flatulence from fermentation of the ingesta, mineral acids are beneficial, by causing the pouring out into the intestinal canal of bile which arrests putrefaction. Alkalies, on the other hand, will also increase the flow of bile. Perhaps it is that they supply one of its constituents ; perhaps (as Dr. Harley explains it) they stimulate a secretion of gastric juice, according to a converse law to that quoted in respect of mineral acids, and this gastric juice excites the bile-flow. It is obvious that to accomplish this object, alkalies must be taken on an empty stomach, otherwise they are wasted, or rather do harm, by neutralizing the acid already mixing with the ingesta. Sugar, peppers, mustard^ spices, and other condiments, act in a mode- rate degree in the same way, as may be seen by the effects on the saliva; but their influence is limited. Ease of mind, or cheerful conversation, excite the gastric juice ; or, I should rather say, they prevent the opposite state of mind which retards the secretion. Oxygen has a direct effect in exciting the flow of all the digestive solvents from the saliva downwards. Water in- creases their quantity in the same way that it adds to the solid bulk as well as to the liquid bulk of all secretions. 5th. Artificial replacement of wanting vital functions. — The normal animal warmth is a great element in promoting normal reconstructive growth. We know how much more readily inter- nal wounds heal than external wounds ; how much more quickly, when they have been carefully covered up and kept at an even temperature, than when they have been laid open to the vary- ing influences of the variable air. Disease lowers the power of producing heat in the diseased tissue, or it causes heat to be produced in a fitful irregular way. An even artificial lieat is therefore a strong means of renewing life. Where vitality is deficient throughout the whole body, we can economize it by clothing impervious to atmospheric changes, as woolen, silk, 4 46 DISEASE AND CURE. &c., and by avoiding linen, as in albuminuria among chronic diseases, and in acute rheumatism among acute. Where there is a local deficiency of vitality, as in pneumonia, pleurisy, peri- carditis, peritonitis, ulcerated bowels, &c., none of our cura- tive appliances are so important as a continuous poultice. Warm baths supply a large quantity of assimilable heat, which lasts for a considerable time, and hence, in certain cases, they are felt as a tonic. But they will only suit patients who are bene- fited, or at least not injured, by the absorption of a great deal of water. Electricity supplies the contractile muscular fibers with a stimu- lus to action which is wanting in cases of deficient nerve-force. Hence it keeps up the habit of motion in paralytic limbs, pre- vents their getting atrophied, and sustains them in a state of possible activity till such time as the injured nerve-force recover itself. Artificial motion and rubbing act much in the same way. Mechanical aids to sight, sound, hearing, and movements, rightly employed, may come under the same category. 6th. A temjyorary revival of deficient functions. — For example, the deepening of sluggish breathing by ammonia, valerian ethers, and essential oils. This stimulation, though it may be only tem- porary upon the organ directly acted upon, and is therefore fol- lowed by a reactionary collapse; yet indirectly it contributes to life by the influence of the organ's functions upon other parts. Thus the deepening of the breathing, instanced just now, aerates the blood and strengthens the circulation, and so makes to the capital of life an addition which lasts long after the passing stimulus has lapsed into a corresponding degree of deficiency. Perhaps the permanent benefit of warm bathing, often so much greater than can be accounted for by the short increase of warmth, may be explained in the same way. Alcohol often acts beneficially in full doses at long intervals, in cases where its con- tinued influence in smaller doses would be hurtful, probably on this same principle. But as a general rule, those stimulants are to be preferred for the purpose whose effect is more transient. 7th. Increasers of absorption are constructive medicines. Vegetable bitters brace up and harden the mucous membranes. DISEASE AND CURE. 47 aa may be easily tried by their effect on the mouth. Hence exosmosis is lessened, and endosmosis increased. Digestion is made more rapid and effectual, nutriment is taken up more copiously and quicker. Even in a healthy person the remains of the List meal are sooner disposed of, and the appetite for the next sharpened by a bitter. This is the pure action of a vege- table tonic; but a good many of the plants we use as such con- tain various matters which otherwise unfit them for our purposes in certain cases. Perhaps none exercise so few of these noxious influences and are more generally applicable than the products of the inimitable cinchona. Astringents also may reasonably have some of their beneficial influence on the digestive canal explained by their restraining the formation of mucus. When mucus is in excess, it doubtless interferes much with the taking up of nutriment by membranes, and the checking its growth is an indirectly constructive act. Many of the vegetable bitters contain tannin or other astringent constituents, and are thus peculiarly suited to the leucophlegmatic (or mucogenous) dia- thesis. These drugs are suitable not only for the digestive canal, but to other internal tegumentary membranes. Thus the renewal of life in the uterus and ovaria is very much aided by checking leucorrhoea with astringent injections. The absent catamenia will often reappear while the weakening discharge is being thus arrested; and stagnant ulcers will form fresh healthy tissue, wounds will close, and abscesses heal after, nay, during the application to them of astringents. Sulphate of copper and nitrate of silver are most active in this waj ; but, as you know well from your experience as dressers, heed must be taken lest when destroying the mucus and pus-formation you also destroy the life of the adjoining tissues whose preservation is your care. Sulphate of copper is a most powerful internal medicine, as a reviver of health in ulcerated parts of the intestinal canal, and it also seems to act as a tonic generally to the digestive tract. Nitrate of silver would probably be equally useful, but unhappily it is too soon converted into the inert chloride by the salt of the secretions. 8th. Excitajits of the involuntary muscles which subserve ab- 48 DISEASE AND CURE. sorption are also constructives. Thus strychnia and aloes in- crease the appetite by hastening the passage of the alimentary mass, and this joined to their bitterness makes them tonics. But they both are better Avhen aided by other tonics. Suc- cussion stimulates these muscles, and so very gentle exercise promotes digestion, but violent muscular exertions arrest it, because they engage the nervous energy elsewhere. There are certain reagents which, in a manner as yet quite unexplained by physiology, appear to alter towards health par- ticular tissues. They are not constituents of the body, nor do they seem suited to take the place of constituents of the body, nor do they cause any evacuation of retained eflFeta, nor do they apparently act on any of the healthy organs. Iodine and bro- mine, for example, have this effect on the white fibrous tissues, and as they originate renewal, I can hardly help classing them among constructives. With Destructives our forefathers have left us well ac- quainted. Time out of mind the Avorld has had long lists of articles of materia medica, classified according to the organs through whose gates they disgorge the products of metamor- phosis. "Sudorifics," "purgatives," "diuretics," "expecto- rants," &c., are familiar to both doctors and the unlearned; while others, as mercury for examj^le, are known as general "liquefacients," promoting destructive metamorphosis univer- sally, and a consequent increase of solid evacuation from all quarters. And other expedients again, such as bleeding, are a direct mechanical abstraction of a part of the living body. The uses of Destructives are the following : 1st. To remove from the system effete matters lohich are toxi- cally noxious to healthy life. Nothing does this so universally as water. The biliverdin which we see staining the skin in jaundice, and which indicates also the presence of the more injurious biliary acids, may be removed by mercurials^ by podo- jphyllin, by soda^ and, according to Dr. Harley, by benzoic acid, provided always care be taken that the passage for their exit is DISEASE AND CURE. 49 free, that the bile ducts are not obstructed. So also uric acid may be eliminated from the blood by nitre and by some other neutral salts, when the kidneys are healthy and neither degene- rated nor congested. In applying these remedies it is necessary to see clearly what is the effete matter we wish to get rid of, and to use the appropriate agent. No laborers in the present field of practical medicine deserve so well of the world as those who make it their business to inquire into the real intimate working of our tools. The chemists' shops are quite full enough, and it adds much more to true useful knowledge to make a single step towards explaining the action of one established remedy than to add a hundred articles to the pharmacopoeia. One would be glad to know in the case of each eliminating drug which of the efi'ete constituents it most readily acts upon. Thus much milder medicines might often be employed, which would go straight to the point, instead of exercising in addition some violent but un- necessary action. Do not let us rest satisfied with the nomencla- ture of "purgatives," "diuretics," "sudorifics," if it is possible to discover what it is they purge out, what constituent is specially removed through the kidneys and what through the skin by the augmented secretion. 2d. To remove inechanical impediments to normal excretio7i. The proviso which I made just now in the case of the liver and kidneys, namely, that their should be nothing in their structural state which can impede the flow of bile or the urinary constituents, reminds us of another use for destructives. For example, leeches on the right hypochondrium will often restore a flow of bile, in diminishing a congestion of the hepatic tissue by which its for- mation may be stayed. Cupping the loins will act as a diuretic by relieving congestion of the kidneys after scarlatina or other cause. Leeches to the anus, or artificial hsemorrhoids, will empty the stagnant portal circulation, resuscitate its activity, and by this means enable medicines to be absorbed and food to be digested. General bleeding will at a great expense to the system, and not perhaps more readily, effect all these objects at once. The advantage of venesection to our forefathers was that 50 DISEASE AND CURE. it did not require any accuracy of diagnosis of the organ to be attacked, but made a general assault on all together. 3d. The removal of impediment to absorption is another good reason for the administration of sundry destructive medicines. This is often merely a question of mechanics, and if we could apply mechanical means to the required locality, they often would do better. Such for example is the removal from the stomach and intestinal canal of mucus, Avhether peopled with parasitic worms or not. Mucus is in itself peculiarly insoluble, and therefore indigestible, and it also firmly resists diosmose: thus its presence stands in the way of the absorption of nutri- ment by the digestive membranes. It is not easy to rid the patient of these incumbrances without abnormally augmenting destructive excretion, but if it can be done we should be glad to do it. 4th. The removal of systemic poisons which are the cause of disease by destructives seems shown to be possible by the effect of mercury on the syphilitic virus. The body is endowed with power to gradually eliminate this virus, and after a course of diseased states of long, perhaps years long duration, to return again to health. Indeed if it had not this power, remedies would be useless; for drugs, though they can arouse sluggish capabilities, can bostow none not originally inherent in the nature. The natural elimination, tedious always and perhaps sometimes otherwise impossible, is, according to Mr. Lee and other experienced syphilographers of late years, much quickened by mercury. Mercury does not, like sarsaparilla, bark, iodide of potassium, and other constructives, benefit by curing the diseases caused by the virus ; it aids the system to destroy the virus itself. That it should do so is not surprising when we see its wonderful destructive action on animal tissues; how they become softened and blanched and dwindled in decay when the system is saturated with the metal. Were there any other chronic diseases so indubitably kept up by the obstinate adhesion in the system of a morbid poison, it might be worth while to destroy the poison in the same way. It might be worth while to submit to having the healthy parts DISEASE AND CURE. 51 of the body scotched, for the sake of prematurely killing its baleful guest ; but I do not think we can find another instance among maladies common enough for us to be well acquainted with their pathology. In acute fevers dependent on organic poison the system casts it forth so quickly that sometimes danger is born of its very haste and effervescence. We should be at no pains to hurry the process, although we might possess the capability of doing so. Under the same restrictions as morbid poisons comes the removal of inde- pendent parasites, such as lice, itch acari, the fungi of favus and pityriasis versicolor, of dead or incurable parts of the body which react upon and become the causes of diseases, and of foreign matters generally. We must balance the injury Ave may be obliged to inflict in removing them against the good done by such removal. A free review of the rational reasons for using destructive treatments in the cases I have given as examples, will confirm the universal rule that they are never to be employed for their own sake, but only to either make room for, or to give play to constructive growth. Arresters of constructive life, as such, can scarcely come under the denomination of medicines; physicians never wish to stop growth in human patients. As poisons we do use them on animals for certain purposes of our own: alcohol is given to puppies to keep them small dogs; and it is stated that dwarf- like jockeys have been produced by the same treatment. We have thus a warning of what the effect of the agent is. The same article of diet, however, appears in another light as an arrester of destruction. We not selaom wish to stay the process of vital decay in our patients, and are provided with a means of doing so in alcohol. In a lecture published some time ago* I explained the reasons for thus viewing alcohol, entering * See Lectures XLVII and L of this edition. I take this opportunity of say- ing that the lectures are not placed in the order in which they were delivered. Clinical instruction is of course given as the cases occur ; so that the student 52 DISEASE AND CURE. into details of the circumstances -which should guide and govern its administration; and I have not time to repeat them now. I have there classed it as an anaesthetic, whose primary action is on the nervous system, and attributed to that action its eiFect in staying destructive metamorphosis. Our other more generally acknowledged anaesthetics have a similar action; they prevent the wearing out of the body by the painful and destructive functioning of the nervous system during disease. Why is the functioning of the nervous system during disease painful and destructive ? It seems to me that M. Chossat's experiments throw some light on this obscure subject. The nervous system is the ^'- ultimum moriens" — the member of the body the least affected by vital decay, that upon which starva- tion, deficiency of life, disease, have least decomposing influence. It remains therefore energetic, sensitive, and motive, whilst the others become deadened and sluggish. Thus the due balance of the functions is overthrown. By a restriction placed upon the normal but inconvenient force of the nervous system we get a state more like to health, by reason of its nearer approach to balance, and guard the tissues against the disorganizing tendency of its abnormal disturbance. The same aim of restoring the balance may be effected by raising the depressed vitality of the non-nervous deficient functions. And where this can be done, of course it is the best treatment. Where means of accomplishing such a desirable object are wanting, anaesthetics are the next best resource. Just as in machinery when a wheel has got worn and inefficient, it is best to put in a new one, if possible ; but where we cannot, we slacken the steam power — quod opibus deest, arte sareimus. may come fresh from the bedside observation of the patient to the deductions made therefrom. Introductories, however, at the opening of each session, aflford a legitimate opportunity for a systematic statement of principles, for going back to the abstract truths which are the result of previous practice and experience. To the reader it is convenient that these should come together at the beginning of the volume; and the sequence of time being thus disturbed, I have preferred to set the rest in a sort of natural order, putting together those which seemed to have most bearing on one another, rather than to arrange them chronologically. DISEASE AND CURE. 53 Is pain the expression of the want of balance I have spoken of, or is it only a co-ordinate phenomenon? Certain it is that pure pain, such as neuralgia, is relieved either on raising the vital functions with food, tonics, &c., or on blunting the nerves with anaesthetics. Remark now that destructives and arresters are not in any case final treatment; the end is in every in<*tance reconstruction or renewal — an aim which must be kept in view in all the phy- sician does or counsels. These principles of therapeutics I make it the business of my clinical lectures to enforce and illustrate by the examples of dis- ease which are at the moment passing under your eyes. Do not suppose these examples to be picked examples — cases selected to prove my points: no — each one of my patients in the wards teaches the same lessons to all, at least to all those who are will- ing to be taught by nature rather than by books. Let me en- treat of you not to neglect the opportunity which is afforded by our liberal public charities and the independence of your pupil- age to learn truth, and then you will not fail in after years to practice it. LECTURE III. THE FORMATION OF MUCUS AND PUS. Offiee of mucous membranes — The identity of mucous globules and nascent ejnthclium — Self-supported growth of mucous globules — Similar to organic groivth of a imrasite — Is this form of life an excess or a deficiency of normal life? {First Lumleian Lecture at the College of Physicians, Lent, 1863.) The subject which I have chosen for these Lumleian Lectures is one which must be interesting to physicians above all other observers of nature, for in very few indeed of the cases minis- tered to by us has not either the cause of the death acted on the body through these integumentary coverings, or manifested its action by a perversion of their functions. The majority of our medicines are intended to act on mucous membrane, and all are introduced into the body through it. We cannot therefore but be grateful to those who have endeavored to add to our knowl- edge of its nature and habits. The term by which it is conventionally designated is apt to lead the most thoughtful of us into a fallacy. Active members of society are named after the work which is their most import- ant occupation. The industry of the lawyer is the administra- tion of the "law;" the doctor is most efficient when he is most "learned;" the duty of bishops and overseers is kmaKontiv, "to oversee" each their several departments. But the office of mucous membrane is not to secrete mucus. It is most active Avhen it is not doing so, and its activity is decreased just in pro- portion to the copiousness of the mucus. Typical health cer- tainly consists in its absence; many robust people pass weeks without expectorating; many find their handkerchiefs clean and THE FORMATION OF MUCUS AND PUS. 55, unrumpled after being clays in their pockets, in spite of all the artificial and accidental irritants to which the Schneiderian mem- brane is subject; and the urinary and intestinal canals contribute only an infinitesimal quantity, which may fairly be attributed to a temporary departure from health of some fraction of their large area. The business of mucous membrane is to offer a passage for oxygen, "water, fat, albumen, and other useful substances, and to defend the less easily renewed tissues beneath it from the de- leterious action of external agents. These functions it best ful- fills when it is bedewed with a moderate exhalation, and not with mucus. This exhalation is transparent and aqueous, exhibiting nought of that stringy adherent character by which we ordinarily recog- nize the substance known as mucus. It carries out with it the epithelium scales shed or moulted from the surface; and these scales are consequently found in the excretions ; but it is itself absorbed again as quickly as it is exhaled, and docs not con- tribute to the substance of any of the ejecta of the body. The typical healthy condition of a mucous membrane may be con- sidered to be a constant dampness without visible fluid, and a moderate and gradual shedding of epithelium. Shed epithelia in a complete form are found also in mucus, but not so as to modify its physical properties. Its most obvious characteristic is the presence of transparent bodies, apparently of a gelatinous consistence, of a more or less rounded or oval form, and with one or more nuclei, seemingly of a less trans- parent consistence, in their interior. But its physical properties of consistence and adhesiveness, which so peculiarly distinguish it from all other transparent fluids, seem to be derived from the medium in which these globules are placed. This origin may be inferred because similar globules, quite undistinguishable in appearance and behavior, constitute also the bulk of pus, a fluid of quite distinct attributes and properties. There are probably no observations more suggestive and luci- ferous to rational medicine than those contained in the paper of Henle, published about a quarter of a century ago in Hufeland's ;3G THE FORMATION OF MUCUS AND PUS. Journal. It is an excellent example of physiological reasoning, and later observation seems to set the matters of which it deals beyond reasonable doubt. Professor Henle's argument aims, successfully I think, at tracing the globules which are seen in mucus under the micro- scope to that substance which in the normal state of typical per- fection would form epithelium. They appear to be young epi- thelium arrested in its growth, and prematurely moulted oif from the body. The condition which produces them is an arrest of development. To feel the full force of the experiments and observations which confirm this view, it is necessary to see the connecting links of resemblance which run through the course of the integu- mentary membranes. We must pass over for the nonce the dif- ferences which fit for their various uses the external skin, the coverino; of the tongue and mouth, the secretinoj lining of the stomach, the absorbing lining of the intestines, the defensive coats of the bladder, urethra, rectum, &c. We must look upon them as one whole. Just as the skin clothes the muscular frame- work of the body, moulded on the form of the skeleton, so the mucous membrane lines the internal canals, pits, and galleries, following their intricate windings throughout. And for exactly the same purpose — namely, to be a defensive medium of com- munication between the individual being and the outer world, between the microcosm and the megalocosm, in all their chemical and mechanical relations to one another. For the fulfillment of this common duty they have a common structure. Strip off a piece of epidermis, and you find that its outermost layer consists of flat polygonal scales pressed close together and united both by the edges and surfaces so as to form a continuous leathery tissue. They are welded into one fabric like the exposed part of an old macadamized road. But just as, when you pick up the surface of this road, you expose a deeper layer of stones loose and separate, so beneath the scarf skin you find what Malpighi, Avith philosophical prescience, called the rete mucoHum. This consists, like the scarf skin, of separate corpuscles, which, like the stones of the macadamized road, be- THE FORMATION OF MUCUS AND PUS. 57 come looser in structure, less adherent, and less similar to tlie upper layers as you go deeper. The superior corpuscles are, indeed, flattened, and exhibit a flattened nucleus inclosed in a clear cell as an epidermoid scale. But as you get nearer the cutis the nuclei are rounder and rounder, and the transparent area of the cell is less and less visible; until at last, on the cutis, the corpuscles are seen to consist of only granular masses. These granular masses are identical with those seen in mucus. Just in the same Avay the mucous membranes arc clothed with epithelium, loosely scaly in some parts, Avoided together like a macadamized pavement in another, columnar in another. And when this is stripped off or injured, there are brought into view floating granular masses of various sizes, Avhich constitute what are familiarly known as "mucous globules." They are exactly identical with the inner strata of the epidermis, the rete mucosuiu of Malpighi. What are these globules? Are they something special, be- longing to special tissues, and appearing only under special cir- cumstances? Or are they a form of organic matter common to other parts also? Are we to apply here the Baconian myth of Proteus, and look for their natura naturcms as exhibited else- where in various shapes? It think it is philosophical to do so. The appearance they have is that of all matter when it first puts on life. The telescope and the microscope equally reveal to us these nebulae as the earliest indication of vitality, drawing the surrounding chaos towards a central point, then exhibiting that central point as a kernel or nucleus. And then this kernel becomes the parent of new centers, individual and separate, and these again starting places of new action. The dawn of vitality is exhibited in the coalescence of molecules of organic matter so as to form nuclei, which, under favorable circumstances, develop either separate cells or tissues. Up to this point each focus of life seems to be a separate in- dividual. It takes in nourishment by its innate power from without; it increases in size and alters in shape. And this alteration in shape seems principally to take place from within. It is not merely an aggregation outside of ncAV molecules, but a 58 THE FORMATION OF MUCUS AND PUS. plastic change of internal appearance. Nay more, it possesses the faculty of giving birth to an individual, and so to a succession of individuals, like itself. No better evidence of automatic exist- ence can probably be given. These phenomena can be seen without much difficulty in the globules of mucus. That which answers best is what we often expectorate in little semi-transparent gelatinous lumps from the bronchi in the morning after exposure to night air. This must not be mixed with water, or be allowed to cool, but kept at the temperature of the body, and put immediately under a lens of as high a power as you can command. Dr. Beale showed me the phenomena first under a 24th, but I have seen them very well under an 8th inch in an old-fashioned Powel's microscope. Keep your eye fixed on one nuclear mass, and you will often see a gradual change in its appearance. First a clearer nucleus ap- pears in it; then, as you gaze, two, three, or more smaller nuclei. Then the fine granular sj^ecks in its sides coalesce into a nucleus. Then you see that it has a bulge in its side, and that a nucleus forms a bud, and then has a constricted neck or stalk. And then, perhaps, if you are lucky enough to get the mucus in motion without losing sight of your object, the bud may float oif as a separate globule. Or the -■■»"''''°^^!t?^ .-."*»'« ^'i5i^ ^f'-'^^^A whole globule may divide into ^y'^^iiW 0§i{^ "|iV^'"v^ two, each with a separate nucleus, "<^^ as i have tried to represent m this drawino; from life of five globules in this state of tran- sition. A temperature below that of the body seems to check this de- velopment, but you may often keep it on by means of a spirit- lamp. The globules in which I have seen it take place are those from the trachea, from the os uteri, and from warm freshly- passed urine in cases of inflamed bladder. When the fluid has got dried up by the heat thus constantly applied, you may in some degree restore its activity by moisten- ing it with a viscid animal fluid, such as saliva. The greater part, indeed, is broken up into molecules, and these show no THE FORMATION OF MUCUS AND TUS. 59 disposition to unite into globules, but among them will remain some globules unbroken, and these will again form new nuclei, and bud as they did at first. Is this organic growth? Or is it the aggregation intovislble masses of particles already existing, like that which Mr. Rainey has described as taking place in mineral matters? Is it a mere coalescence, or something more? I must say that to my mind the production of an individual like itself, capable again of re- producing another individual still resembling the grandmother globule, is identical with organization. And I think, too, that the multiplication of the nuclei inside is quite unlike any sort of coalescence, which would add matter to the outside, like an urinary calculus or an avalanche. It seems to me that each of the globules contains a center of life, into which the pabulum passes from the outside, nourishing them and giving them means to increase in number. This would account for the enormously rapid collection of mucus filled with globules on inflamed membranes, even on membranes which in the healthy state shed very little epithelium, or have but one layer of it, as in the bronchi, and therefore cannot be supposed naturally to form much young epithelium. The first parent globules may be aborted young epithelium cells, and these may be the ancestors of others which form the bulk of the mucus, begetting them with the extreme rapidity characteristic of gene- ration in low organic life. If this be true, mucus may be viewed as a parasite, receiving from the body its nutriment indeed, but not its form nor its claim to vitality. Doubtless the growth of mucus is most rapid where there is normally a thick layer of epithelium, and where a large growth of young epithelium is constantly being formed to replace the rapid moulting. But still it is much quicker on localities with a thin layer than could be accounted for by each globule being an aborted scale ; there could not be enough aborted scales to furnish so much mucus so full of globules. I believe, therefore, that it grows on the surface by their budding and splitting in continuous succession. eO THE FORMATION OF MUCUS AND PUS. If you compare pus which has been some time accumulating on the surface of a mucous membrane with that which is being freshly formed, you will remark a decided difference in the globules they contain. Take some accessible mucous surface — the eye, or the vagina, for example — thickly covered with opaque secretion, and you will find the globules nearly all of a size, even and spherical. Then wash it clean with cold water, and examine the first-formed secretion: the globules are of all sizes and of irregular shapes, oval, bulging, budding, with or without nuclei. This seems to indicate a general change of form by time — a certain completion of creation in that which has been longest farmed. When we see, as I have described, the globules of mucus bud- ding, dividing, and subdividing in active haste — new foci of in- dependent vitality generated and multiplying even when separated from the body — it might appear that a local increase of life was being exhibited. Certainly a greater bulk of living substance is formed by a membrane secreting mucus or pus, than is the case in the healthy state; for the secretion outweighs by a hundred- fold the daily quantity of epithelium which its original material was destined to make. But what sort of degree of life is ex- hibited by this secretion? Is rapidity of multiplication to be looked upon as evidence for or against force of vitality? Against it, I think. The lower we go in the scale of creation, the more quickly and the more copiously do the living forms representing the various classes reproduce their kind. The less functions and force and intensity of existence they have, the more prominent becomes reproduction as the main object of their being created. This seems to be the universal rule, to be traced all through living beings till we get down to the Amoeba and the mould, in which no trace of a function can be detected beyond the multi- plication of their simple substance. Here, indeed, it becomes difficult to draw the line between organic and inorganic. Instead of being in contrast and in con- flict with the physical force of inanimate nature, vitality seems to obey laws which closely resemble them. The main point of distinction seems to be the growing from a center outward of THE FORMATION OF MUCUS AND PUS. 61 organic, and the ao;orres;ation towards the center of inororanic, individuals. When organic matter destined to form part of an animal has attained the end of so becoming a member of a consistent whole, it ceases to multiply itself. Cells do not normally go on splitting up and producing cells similar to themselves in situ. The highest development of their vitality is ceasing to exist as growing matter. A fully-formed epithelium scale does not produce another scale, nor the nucleus of a muscular fiber another nucleus. The reten- tion of reproductive force is an expression of the lower and an exclusion from the higher functions of life. In the mucous globule, then, we find organic matter, whose destination was the formation of epithelium, arrested in its development when it has attained only the lowest degree of life — that lowest degree of life being the function of repro- duction. LECTURE IV. THE FORMAT I ox OF MUCUS AND PUS. Mucous globules not cells, hut nuclear matter — The representative of the cell is the medium in lohich they float — It is therefore not likely to retrograde into globules — Formation of pus from mucus — How does pus appear on the surface? — Observations of several observers — Passage of globules through ejjithelium — Pus-globules not descendants of epithelial cells, but jyarasitia formations inside t.h,em — Epithelium semi-fluid — Breach of epithelium in some cases — Grroivth of pus. [Second Lumleian Lecture at the College of Physicians, Lent, 1863.) I DESCRIBED in my last lecture the mucous globules forming nuclei in its center, and these nuclei splitting up into two or more, subdividing and separating the Avhole globule into several. From this it has been inferred that it is in this way that the globules grow — tliat they are, in fact, cells which multiply by subdivision. But I described also the formation of buds at the side of the globules. These buds commence by the granules of which the mass of the globules consists becoming gradually more visible and distinct, and forming centers of growth distinct and separated by a conspicuous interval from the central nuclei. They are not derivatives from the central nuclei, but new start- ing-points of growth. This is important, because it takes the globules put of the category of cells. In a fully-formed cell it is only the nucleus, and not the transparent area of formed matter, which grows ; whereas here the whole substance grows and origin- ates growth. The globules are, in fact, nuclei. Or we may more properly call them "nuclear matter;" for a nucleus must THE FORMATION OF MUCUS AND PUS. 63 be a necleus of something, whereas these are nuclei of nothing. Nuclear matter is that which is fitted to be the nucleus of some- thing, unless arrested in its development — in other words, organic living matter in a condition to grow and multiply. A confirm- ation of this occurs in a drawing by Dr. Beale. When tissues are steeped in a weak solution of carmine, the only parts which receive a permanent stain are the nuclei, or young growing matter in them. Now, of the mucous globules the whole sub- stance receives a permanent stain, as is shown in the drawing here exhibited. It appears therefore to be wholly formed of nuclear or growing matter. It may be remarked that the mucin, or transparent fluid medium in which the globules float, does not receive so marked and so permanent a stain from the carmine; and this appears a very fair argument for considering it as the formed substance of which the globules are the nuclei — a sort of common trans- parent area, a common cell-wall to numerous nuclei ; just as coral is the common skeleton to millions of coral insects. Each perfect epithelial scale, each nucleus, has its own formed sub- stance constituting its own cell-wall ; in the lower grade of life represented by mucus there is a less perfect common formed substance, constituting a common cell-wall. Now, if the mucin, or transparent medium in Avhich the globules and granules float, stand in the place of fully-formed organic substance or cell, it will not retrograde into the con- dition of growing substance. Such a retrogression does not happen in cells. In an epithelial scale, for instance, the trans- parent area does not become nuclear matter. But it transmits the nutriment to the necleus inward through its substance with- out being destroyed. On this supposition the formation of mucin will be the highest development of the life of the globule, for it answers to the formation of tissue from nuclear matter. And in that case we should expect to find that the nearer its normal condition the morbid secretion can be collected, the more of this higher state of life it would exhibit, and that the further from its normal condition it is, the less there would be of the formed matter. Such is the fact. The fluid which first forms on an 64 THE FORMATION OF MUCUS AND PUS. inflamed f^urface contains few globules and much stringy trans- parent medium. Its nuclear matter has so far departed from life that it cannot form separate cells, but only an imperfect common area. But as the inflammation goes on, this power is still more and more lost; the nuclear matter cannot form the mucin, it can only multiply ; and hence the stringiness of the mucus disappears, and it becomes what Ave know by the name of " pus." As far as the morbid matter itself is concerned, pus indicates in it a further deficiency of vitality than mucus — a deficiency of vitality shown first in its internal self-multiplica- tion, and secondly in its non-production of mucin. The question naturally arises as to how these products of arrested vitality make their way to the surface of the mucous membrane where we find them. The pabulum whence they are developed lies on the inner side of the epithelium, whereas we find them quite uncovered. The first explanation that occurs •would be that the epithelium is destroyed, and that they are in the first place the debris of the dissolution, united to that which would normally go to form it. This would, in fact, be a modification of the old idea, that pyogenesis was a kind of ulceration, and involved a certain solution of continuity in a tissue. Indeed, it would amplify the idea, for it would extend its application to mucus as well. To this idea Professor Virchow seems to incline in the edition of his "Cellular Pathology" pub- lished in 1858 (p. 395), where he represents the formation indeed of the mucus and pus-globules to take place in the lower layers of the epithelium, but to be mixed with and to have their bulk added to by the outer layers which they push off". Since then, however, several observers have found that the most intense catarrhal condition of mucous membranes may exist without any loss of the superficial epithelium. Even in that most destructive state commonly known as diphtheritic inflammation, where fibrin is thrown out with the pus, the epithelium may be perfect. Dr. Sanderson has kindly lent me some notes he made of the autopsy of a child who died at St. Mary's Hospital of diphtheric angina, in whose larynx this fact THE FORMATION OF MUCUS AND PUS. 65 was very clearly seen. The Avliole interior of the organ was lined with a firm, closely adherent false membrane. When that was detached, portions of flabby concretion still remained, which could be washed oifwith a stream of water. "On examining the surface," says Dr. Sanderson, "after much wasliing, it was found to be entire. It exhibits to the naked eye, indeed, marked inequalities of appearance, as if eroded; but these must be de- pendent on the adhesion of minute particles of concretion; for, on makir)g snips of the surface with sharp scissors at those parts where the eroded appearance was most obvious — viz., on the upper surface of the epiglottis, the epithelium was found to be entire. The only exception was at the upper margin of the ventricles, where the epithelium was adherent only here and there ; but there was no trace of thickening or alteration of the basis-membrane, which exhibited its normal appearance."* Forsterj" has also carefully examined, by both horizontal and perpendicular section, the epithelium of mucous membranes in a state of purulent catarrh, and has found in it either no change or very unimportant change from the normal state. The globules, then, or the material of the globules, must some- how be passed through the epithelium. Dr. Buhl, of Munich, has lately detected it in transitu, and drawn figures of it on the road. The case on which his observations were made was one particularly well suited for the purpose. The patient had died of pyemic inflammation of the portal vein and of the bile- ducts of the liver. Now, the epithelium of the bile-ducts pre- sents a very marked character; its cylindrical bodies exhibit an unmistakable shape. So obvious is this shape that it can be detected even when considerably distorted ; and therefore he was able to trace the epithelium scale, modified by what he ration- ally enough concludes to be the presence in it of pus-globules. This is clearly exhibited in his sketches of the various forms or stages of altered epithelium as he saw it floating loose in the fluid pus or massed into clots. First, he shows the normal * Private notes of Dr. Sanderson. f Communication from the Wiizhurg Institute of Pliysiology and Anatomy. ' Wiiizburger Med. Zeitechrift," bd. i, j)art 2. 6Q THE FORMATION OF MUCUS AND PUS. epithelium cylinder, as a medium of comparison, and of these there were great quantities. Then come a number of bodies ■which we can recognize, when they are here placed in a row, as perversions of the cylinder, gradually increasing in rotundity and receding in likeness ; but Avhich in their extreme of dis- similarity would not be seen to have any connection with it except by a previous knowledge of the fact. M (After Buhl.) The majority of the enlarged cells were filled with oil-granules. Others, in which the fat was accumulated to a smaller amount, contained from two to ten rounded bodies exactly like the free pus-globules surrounding them — so like, that hardly any doubt could be entertained that they were cells pregnant with pus- globules. As a rule, the group of pus globules lay close to the thick end of the cylinder; but often between the thick end and the groups of pus-globules there was to be seen a degree of con- striction, making the cell bottle-shaped. Sometimes the tail of the cell was obliterated or torn oft", when it was almost globular, but even then capable of recognition. In cells where there were only two or three globules the nucleus remained distinctly visible and perfect. In others the granular globules seemed to be dividing and splitting up into four or six, the original nucleus of the cylinder still remaining visible. So that pus-globules evidently do not of necessity take their rise in the degeneration of nuclei of existing tissue. In other examples, again, the cell-contents seem entirely to THE FORMATION OF MUCUS AND PUS. 67 have degenerated into fatty molecules, whether from the growth of the globules just described or from other causes, and in them the nucleus had degenerated along with the rest of the cell. I have noticed in the epithelial scales from the vagina, in cases of purulent discharge, a somewhat similar repletion with granular matter without alteration of the nucleus. And mixed with them there were also large round granular corpuscles, which had the appearance of containing pus-globules, and which might have been degenerated epithelial scales. But scaly epithelium has not such a definitely marked form as the cylindrical variety, and it is difficult to identify it in a state of transmutation. Remak* has also found in the pus from inflamed bladder large cells which he thought he identified as the epithelium from the fundus vesicae. These contained from six to fifteen globules, entirely filling up the interior, and in every respect like mucus- corpuscles. But he does not trace a series of transitional forms. It will be seen by these observations that the pus-corpuscles are not so much descendants of the epithelial cells as what may be called parasitic formations within them. They are parasites inside the epithelial cells, capable of increase by propagation within the tissue, just as on the surface the mucous globules were shown as parasites capable of increase by propagation without the tissue. And they grow quite independent of the true nucleus of the cell, and are not derived from it. Thus the nuclear material may pass through the substance of the epithelial coat of mucous membrane without destroying it, and not only be itself unaltered, but may increase in quantity during the progress. This is one way in which the pus-material may reach the surface, and explains those cases in which the epithelium is quite uninjured. We find these fluid or semi-fluid properties exhibited by epi- thelial cells in their daily duty of absorption. Fat, from its highly refractive powers, can easily be traced, though a fluid, by the microscope ; and fat in globules can be seen passing through the substance of the epithelial cells of the intestines * Virchow, " Archiv," bd. xx, p. 198. 68 THE FORMATION OF MUCUS AND PUS. during their active state. This is well shown in some recent drawings, made by Balogh,* of intestinal epithelium during the ingestion of fat ; the whole thickness, not a central tube, but the whole thickness of the cell, is seen permeated by it, and allow- ing it free passage. The physiological passage of fat globules inwards may reconcile us to the idea of the pathological passage of pus outwards. But Professor Henle well says : "If they are sometimes formed in the interior of a cell saturated with their material, this fact does not exclude the possibility that just in the same way they may sometimes be developed from the same plasma beneath the cells." In such case they would be projected on to the surface between the separated epithelium cells. This other mode of growth and attaining the surface is strikingly shown in a drawing by Dr. Edward Rindfleisch, of Breslau,t which exhibits in section the nictitating membrane of a frog affected with a partial catarrh of the eyes. Fig. 3 is the normal state, where the me'iuhrana propria (as Professor Henle calls it) is seen as a moderately transparent layer, with Fig. 3. Fig. 4. @ After Rindfleisch. its delicate areolar-tissue-corpuscles, and the epithelium as two parallel rows of equal-sized cells. In Fig. 4 the pathological condition is represented ; the pavement of epithelium is thrown up and separted by nucleated pus or mucus-globules, which are seen to proceed from the membrane beneath. And the substance of this membrane appears to be saturated and ren- dered opaque by what must be an earlier condition of the same bodies. * Moleschott, " UntfTsuchungeii zur Naturlelire, " bd. vii, 6tes heft, f Virchovv, " Arcbiv," bd. xxi, plate viii. THE FORMATION OF MUCUS AND PUS. 69 These observations seem to show that the pus- or mucus- globule on mucous membranes is the material of young or re- novated epithelial cells, arrested in its development at the earliest dawn of life, before it has assumed the form of a cell, when it is almost as unlike its destined final form as an egg is to a chicken. They seem to show that in this state it may be thrown directly off by the epithelium being broken, or it may pass into the substance of the epithelium. In either case it does not part with the low degree of life it has acquired ; but neither does it acquire a higher degree; it goes on propagating, but nothing more. Both Buhl's and Rindfleisch's observations seem also to prove that pus-globules are not produced, or at least not produced only, by the degeneration of existing cells; they are not tissue retrograding into a lower form of life like fatty, amyloid, and similar morbid matter. Buhl's drawings especially exhibit the nucleus of the epithelial cell intact along with the newly- formed pus-globule. They differ, however, in one particular, that whereas according to Buhl the first pus-globule produced free in the cell increases itself by division, Rindfleisch assumes a splitting up of the whole contents of the cell according to the analogy of the egg-3^elk. As Buhl's observations are made upon epithelium alone and Rindfleisch's upon areolar tissue also, and in one case the epithelium remained perfect and in the other was broken up, I can see no inconsistency in allowing both to be correct, and to represent the different behaviour of growing matter under different circumstances. A very ingenious locality has been selected by Junge* for the investigation of the growth of pus — viz., the tunic of the aque- ous humor in the eye. He caused inflammation by the appli- cation of a hot wire to the cornea of an animal, and was thus able to see what went on in the deeper parts of the eye without exposing the affected tissue to the air or any other extraneous agency. He was thus able to see the activ'e growth of globules * " Uber Eiterbildung," &c.: " Archiv fiir Path. Anatomic und Pliysiologie," bd. jxii, heft 1, 2, p. 193. 70 THE FORMATION OF MUCUS AND PUS. by division and subdivision so far as the formation of large masses. As tlio secretion on the surface of mucous membranes becomes more opaque or "purulent," so the globules are more and more regular in size, rounder, and more like one another. In trans- parent mucus most of them are oval, with nuclei indistinct and various in number, -while there are often lumps on their sides distorting the form. In creamy pus they are nearly all of a size, and present two or three well-marked nuclei. This is easily accounted for, if we admit that they are multiplied on the surface of the membrane. When first formed, they appear under violent and varying circumstances, diiferent in degree every moment, and therefore are different in form; but when once separated they may go on multiplying under favor of nutriment and heat for several generations. Thus, like wild races of animals, they lose individual differences, and become more and more similar and uniform in characteristics. The formation of pus in deep seated parts is, of course, not so easy to trace as on surfaces, and experimenters seem deterred by the difficvilty of the subject. In all tissues where pus is found, its optical characteristics are the same as the fully formed pus of mucous membranes: it presents globules all nearly of the same size, and with a pretty even amount of nuclei. This is its complete condition ; but what it is like immediately on its sepa- ration Ave do not know. We cannot trace it throuorh a stao;e analo- gous to mucus. Of its previous condition, however, we may form a shrewd conjecture. The same elementary substance which appears on, or rather in, integumentary tissues as the common material of the various kinds of epithelium, appears also as granular nuclei in other tissues — in the ganglia of nerves, in the brain, in the parenchyma of the liver, in the spleen, thyroid and thymus, &c. The same bodies occur also in the blood, where they have been termed "chyle-corpuscles" and "white cells." They are found in largest quantities in the most recently formed, most quickly growing, and most actively renewed component parts of the animal frame. In short, the most rational interpretation of this THE FORMATION OF MUCUS AND PUS. 71 form of organic matter is that which represents it as the common material of all tissues in its earliest state of elementary life. And as that which was to have formed epithelium is cast off as the basis of the mucus and pus-globule, so that which was to have formed hepatic parenchyma, nerve, or areolar tissue becomes pus, perhaps through some unsuspected transitional stage. In this account of organic forms in pus and mucus I have endeavored to harmonize the contributions of several observers. I have done this mainly by omitting points of observation and deductions in which they differ from one another, and putting together those on which they agree. Their harmony has also been much assisted by translating into a common language the various terms in which they express the laws of life which their observations appear to exhibit. LECTURE V. THE FORMATION OF MUCUS AND PUS. Mucus and pus compared — Grades of loss of vitality in mucous membranes — Exemplification of these grades in smalljjox pus- tules — Practical deductions from the various points commented on in the three lectiires. ( Third Lumleian Lecture at the College of Physicians, Lent, 1863.) In respect of the vitalized forms which they exhibit, we may consider pus and mucus as identical ; the pus globule being merely the descendant more or less remote of the mucus-globule, and both retaining only that low degree of life which they originally ■derived from the body. The physical differences between the two depend seemingly upon the medium in which these vitalized forms are suspended. Neither in pus nor mucus are the con- tents of this medium constant in their proportion to one another; no two analyses of pus or mucus are ever the same. Indubitable pus and indubitable mucus may be clearly defined ;as the two ends of a scale, between which there are innumerable gradations. The most transparent, stringiest, and least globular mucus consists principally of a peculiar animal matter, which is not albumen, though it closely resembles it. It is not coagulable by heat, and it contains more oxygen on ultimate analysis than albumen does. Sulphur also appears not to be one of its con- stituents. Until it can be found reducible to be considered a compound of some known intermediate substances, it is tempo- rarily called "mucin." This word simply means mucus divested •of those contents which are capable of another nomenclature and physical separation — as, for instance, epithelium-scales, blood, the ammonia of decomposition, &c. The analyses are well known, THE FORMATION OF MUCUS AND PUS. 73 being reprinted in every work of physiological chemistry, but shed little light, for the obvious reason that the substance ana- lyzed is hardly ever twice the same. Pus, on the other hand, contains a large quantity of albumen, and a large quantity of fat. A modification in the mode of the loss of health is characterized by the presence of fibrin, and cer- tain forms of defective vitality by casein being also found. The inorganic constituents of both see?n to be the same as those of blood-serum with some of its water lost. Our diagnosis, then, of the morbid secretions of the mucous membranes should be noc absolute — not that such and such a specimen is pus or is mucus — but comparative, that it is more or less purulent, according as it exhibits a greater or smaller quantity of albumen ; a fact easily ascertained by the degree of its coagulation by heat when diluted with water. And this is thoroughly practical and important, for it indicates the degree of loss of local vitality in the secreting membrane. Equally practical also and important is the obser- vation of the presence of fibrin and its amount. In large and overwhelming quantities we are familiar with it as occurring in the most serious deficiency of life consistent with life at all which we find in mucous membranes; and there appears even in minor cases a closer connection between its amount and the degree of deficient vitality or inflammation. During a severe cold in the head minute clots of spontaneously coagulating fibrin may be found in the secretion of the Schneiderian membrane, which, existing in large quantities, foim the false membranes indicative of the serious poisoning of the system in diphtheria and croup. The phenomena we see on the mucous membranes are a ques- tion of degree rather than of essential difi"erence. Loss of vitality, as shown in mucous membranes, seems to be exhibited in the following degrees: First there is an arrest of function. For example, from the impression of cold the Schneiderian membrane is temporarily deprived of its endosmotic force; it ceases to absorb the water which is condensed on its surface from the breath, and that water drips from the nostrils. Or the stomach or intestines, from mental or physical causes, are deprived of their power of absorb- 74 THE FORMATION OF MUCUS AND PUS. ing and digesting the fluid matters presented to them, and par- tially first excreted from them ; and these fluids may pass away by diarrhoea. Or the skin is chilled, and shows its deficient vitality chiefly in the deficiency of its most prominent function ; though it feels painfully, it cannot feel so delicately as it ought. In a vigorous person full life is soon regained: the nose recovers its natural degree of dryness ; the intestines absorb again before the fluids have passed from the body, and the temporary indi- gestion does not arrive at diarrhoea : the skin recovers its feeling after a temporary painfulness. But we know that our invalid patients, whose vitality is low, are not so easily reinstated. Catarrh of various parts quickly and readily follows the action of physical agents. It is probable that in this least degree of injury the capillaries are contracted in area, and consequently the rapidity of their stream increased, by the action of the nerves. This phenomenon is wanting where the injury is greater; in experiments upon animals the microscope does not detect it, if the reagent applied is powerful. 2. A greater degree of injury is accompanied by a loss of elas- ticity in the capillaries. Their dilatation, and the consequent retention and stagnation of the blood in them, is familiar to us all, in both the living and dead subject, as '•'■ inflammatory con- gestion.'' 3. This stagnation may be in isolated spots complete; the blood-disks adhere together in rolls, as when removed from the body,* and block up the passage. Thus the arterial wave is obstructed in its course, and like an ocean swell shattered against a shore of rocks, becomes more evident to the senses as the well- known '■'■ throbbing .'' It is shortened and sharpened, but there is no evidence that it is strengthened; indeed, the analogy I have cited, and the general fact of weakness being accompanied by quickened pulse, would seem to show that it is diminished in propelling force. * It is not necessary here to go into the question, so abl_y treated by Mr. Lister, as to the first origin of this evidence of death; whether the blood-disks adhere in consequenfe of their own idiopathic death, or in consequence of the withdrawal of the influence of the tissues, which normally keep them from ad- hering:. THE FORMATION OF MUCUS AND PUS. 75 In the meantime there is an accumulation of that constituent of the blood which most resembles in appearance the element of young growing tissue — the colorless hlood-corpuscles. The blood is dark, indeed, to the naked eye, but under the microscope is seen to be made dark by being filled with these pale bodies, pos- sessing a high refractive power. The loss of elasticity in the coats of the capillaries renders them more easily permeable by the contained fluid. Serum is poured out into the neighboring parenchyma, and joins with the swollen capillaries in producing ^'■stveUing.'" The loss of vitality in the blood-disks maybe so complete that their hiematin is dis- solved in the serum, and we get the surrounding parts stained with it — as for a short time in typhus fever, and for a long time in syphilitic eruptions. Or the blood-vessels may completely lose their cohesion and be ruptured, allowing of haemorrhage. But in all this there is no new process, nothing which is not a direct deficiency of function. In solid structures this effusion is followed by an endosraotie current of the watery part back again into the circulation, leav- ing behind it the more solid and coagulable constituents. On free surfaces, covered only by soft open epithelium, the water and salts therein dissolved escape, forming the fluid of the mucus. The elements of new tissue, being there very copious to supply the constant demand for growth, ooze out copiously with the serum, and constitute the mucous globules. They are wasted elements of new growth, not themselves a new creation, or evi- dences of superadded life. How do these matters get through the coats of the capillaries? There cannot be holes for their escape, or else the blood-disks, which are the smaller of the two, would escape also. Doubtless this is one of the great riddles of physiology. But the art of drawing is in a certain degree responsible for some of the difii- culty which it presents to our minds. When Ave have no means of correctirg' by our other senses impressions made on the eye, we are too apt to consider everything with an outline as equally solid. The necessarily hard outlines of the engraver express to us forms which may, for all the paper shows, be spheres of cast 76 THE FORMATION OF MUCUS AND PUS. iron, whereas in truth they are as delicate as aerial clouds. "Why may they not pass through tissues, mutually dissolving and dis- solved by the materials of those tissues ? Just as we see a stratum of fleecy cloud among mountains, or in Turner's pictures, disap- pear when it comes to a stratum of warm air, and reappear in the same form when it emerges on the other side. To get just ideas of nature, we must look upon solidity as a comparative, not as an absolute, quality. 4. In a higher degree of deficient vitality the serum contains albumen and fat also exuded with it; and this mixed with the multiplied globules constitute the fluid we call "pus." The albumen and fat not only escape on free surfaces, but saturate also the tissues they escape through, making them more reten- tive of water than would otherwise be the case. Inflamed cuticle takes a much longer period to dry than normal cuticle. Lan- ghans* found that a piece of healthy rabbit-skin was crisp in three hours, but a piece of the same skin which had been in- flamed during life took twenty hours to part with its moisture to the same extent. It appears to be saturated with the nutri- ment which it has lost the power of employing aright. 5. Pus, formed as I have described, is a soft and greasy sem.i- liquid, capable of shielding from foreign influences the part with which it lies in contact. It is more bland and less liable to de- composition than any artificial application; for perfectly "laud- able" pus laid on the healthy skin causes less irritation than even water. But under certain circumstances it becomes what we term ichorous; and then it is corrosive, poisonous, and de- structive to the neighboring tissues. Now, this cannot arise simply by the chemical decomposition of the pus itself in conse- quence of retention ; because in a good many cases (as in cancrura oris, for example) it has not been retained so long as usual, but is thrown off" ichorous and irritating as it is formed. But you may observe that in all these instances of ichorous pus there is necrosis, mortification, ulceration, or some other form of actual loss of tissue. Tissue may be formed, as in granulations, but it is being destroyed at the same time with abnormal rapidity. I * "Zeitschrift fur Rat Med.," R. iii, bd. xii, heft 2. THE FORMATION OF MUCUS AND PUS. 77 cannot but think, therefore, that the ichorous nature of such pus may be clue to its saturation with the organic acids which are the results of the decomposition, not of the pus itself, but of the melting tissues. Wash away this irritating pus, clean the sore, and that which is then formed often is quite bland and benignant. As pus differs from mucus, so ichor differs from pus in the nature of its accidental fluid constituents. The formation of ichorous pus exhibits a further stage of loss of vitality. The poisonous part of it seems to be peculiarly soluble, and capable of uniting with, and destroying animal tis- sues. Absorbed into the blood, it naturally destroys the vitality of the constituents of that fluid, causes it to coagulate in localized spots, and thus to give rise to the congestions and abscesses of pyiTeraia. When we reflect how easily ulcerations may arise in mucous membranes, and what an active surface they offer for absorption, we cannot be surprised at the frequency with which pysemic abscesses follow slight injuries, such as operations on the bladder, crushing of calculi, typhous iniammation of the bowels — cases which seem of minor moment, but which certainly involve solutions of continuity, Avith consequent decomposition of tissue and the formation of ichor, in a situation very open to absorption. 6. The formation of fibrinous coats on mucous membranes I have already shown not necessarily to involve destruction of the epithelium. Is the loss of vitality which causes it to exos- mose through tlie capillaries in the fibrin itself or in the walls of those vessels? Whichever it may be, such an exudation cer- tainly is evidence of a great deficiency of life; and, moreover, by the mechanical impediment it throws in the way of the func- tions, usually leads to further deficiency. These facts, so familiar to us all in our daily work, viewed thus in connection with one another, cannot fail to impress us with the feeling that the seeming activity of mucous membranes in diseases is in truth a descending scale of loss of vitality. And this feeling must, I think, have great weight in our therapeutical dealings with those diseases; indeed, I cannot imagine anything of more practical importance to physicians and their patients. 6 78 THE FORMATION OF MUCUS AND PUS. The influence of physical agents on mucous membranes which are throwing off mucus or pus, or are disposed to do so, is very different from what it is during their health. A degree of cold, which is borne with ease by them when in full vigor, causes a further arrest in their functions, and heat is equally badly borne. The action of oxygen, as contained in atmospheric air, is to the healthy tegumentary tissues invigorating and beneficial; but when their vitality is lowered, exposure to it kills them still further, and may even alone prove fatal to the patient, as we see in the instance of extensive burns. I was lately much struck with the noxious influence of atmos- pheric air on the pyogenic skin in a case of confluent smallpox. At the period of the maturation of the pocks, when just pre- paring to begin drying up, they presented three grades, dis- tinguishable by the following microscopic differences in their contents. In one sort the matter was of the consistence of thin lard, white and opaque. Examined under the microscope, it w;is seen to consist of epidermic scales, many of normal aspect, but some filled w^ith granular matter hiding from view the central nucleus. In another sort the normal scales were few, the granu- lar scales equalling them in number ; but more numerous than either were pus-globules of various sizes and of irregular shapes, as if budding on several sides. In a third sort, taken from the very confluent parts of the eruption, there was nothing to be seen in general but regularly formed pus-globules of even size, and a number of highly refractive globules (of fat) among them. The fully formed pus was so copious that it overpowered the debris of epidermis, which was barely visible. These three classes of microscopic phenomena represented three grades of destruction which the skin had undergone from the effect of the variolous poison. In the first the epidermis was merely de- stroyed, and the materials for renewal were available for a new one. In the second to a slight degree, and in the third com- pletely, these were converted into pus to a great depth. Con- sequently there was great risk of permanent destruction of the skin, or a scar. Now I found that the grade of destruction bore a direct ratio to the exposure of the various parts to the air. THE FORMATION OF MUCUS AND PUS. 79 The most favored situations Avere the thiglis, abdomen, and tongue, where the pocks of the first or less injurious kind were very numerous. Next came the legs and back, and tiien the hands and forearms. The face was the most purulentlj affected of all. The back (where the eruption was conlluent) maintained its comparative immunity in spite of the cuticle being much chafed by the movements of the sufferer. You will notice that the most affected situations are those which are most exposed to oxygen and evaporation, which are life to the healthy skin, but death to it when diseased. On rational grounds, tlien, I think the practice of painting over the pocks in prominent and important situations with col- lodion, caoutchouc, or gutta percha may be fairly defended. In this way we do all we can to secure a local atmosphere of car- bonic acid — the normal atmosphere of intei-nal tissues, — and to prevent the loss of vitality in the covered parts. More than this, I think we should be led to consider whether we do not sometimes err in applying too rigidly the theory of the universal wholesomeness of fresh air. Fatal cases teach us that it is bad for inflamed skins ; is it good for wounds ? is it good for abscesses? is it good for inflamed lungs? As physi- cians we have most to do with the latter case ; and I must say I find that few things contribute to the ease and recovery of my patients so much as limiting the supply of oxygen in the atmos- pheric air by saturating it with w'atery vapor. I refer here not only to pneumonia, but to all catarrhal affections of the breath- ing apparatus. The stomach, again, is much benefited by carbonic acid. It naturally contains that gas, and some cases of deficient diges- tion appear to arise from its absence. Atmospheric air swal- lowed with the food, or by a pernicious habit, produces dyspepsia ; and nothing benefits that dyspepsia so much as solution of car- bonic acid in water. Soda water, potash water, and lithia water derive their main virtue from the fl'xed air contained in them. I believe that the only way in which carbonic acid is employed in surgery is under the form of yeast poultices, which certainly 80 THE FORMATION OF MUCUS AND PUS. stay the progress of death in the skin quicker than most appli- cations. Were I a surgeon, I should like to try the use of the gas in a purer form as a healing agent for wounds, operative or accidental. Such an atmosphere of carbonic acid is to a certain extent secured to sore places by a layer of pus or mucus, Avhicli is satu- rated with that gas, and not very pervious to oxygen. It is a great defence against noxious agencies, and I think we are wrong to clear it away more than is necessary to comparative cleanli- ness and the patients' comfort. We know how much lighter gonorrhoea is in the female than in the male, and one reason appears to be that the secretion is not constantly washed off the mucous membrane by the passage of the urine. Dirty people seem hardly to notice the existence of these discharges from the mucous membrane — they come and go of their own accord with- out causing any illness ; while, on the other hand, cleanly pa- tients are martyrs to their minor virtue and to their sensitiveness, protracting and aggravating disease by constantly removing the defence which pus or mucus presents against oxygen and cold. Of course an exception must be made of cases where the pus is ichorous and poisonous in its quality, for then the sooner it is removed the better for the patient. On the principle of not too frequently cleansing away mucous secretions, I should attribute greater advantages than we are in the habit of attributing to opiates and other sedatives in those pulmonary affections, where there is a copious bronchial dis- charge. Their obvious and immediate effect is to ease the cough; and some medical men are in the habit of speaking of that alle- viation as if it were merely a convenient mask to conceal the morbid action proceeding on uninterruptedly. This easing of the cough, doubtless, takes place through the pneumo-gastric nerve being rendered less sensitive to the presence of the abnor- mal secretion, and so allowing it to collect in larger quantity before it is expectorated. So that I cannot but think this col- lection in larger quantities before expectoration is beneficial as a defence and as a curative measure. The idea which I have tried here to inculcate, that an increase THE FORMATION OF MUCUS AND PUS. 81 in the quantity of living tissues is by no means an evidence of an increase of their life or of their powers of life — nay, further, that it is rather an evidence of deficient life, cannot but have an important bearing on both pathology and practical physic. It is not a question of words, but of deeds. Were inflammation an abnormal increase of the vital powers of the tissues affected, then we cannot do better than employ the many agents which have a direct power of weakening life, a power which Boerhaave and Van Swieten believed was the only one the art of medicine could give.* Were inflammation an increase of vital powers, we should value our bleeding, our blistering, and our evacu- ants in accordance with the degree in which they reduce the strength. If, on the other hand, the phenomena of inflamma- tion indicate direct deficiency of vitality, not only in the general system, but in the part affected, then we must make the chief end to be kept in view in our treatment the retention and in- crease of vitality. And when we employ the means I have named, we must look upon their debilitating action as an ugly fault unfortunately joined to some other virtue which they possess, and must try to counteract the evil while we retain the good. Take for example the remedy bloodletting. Experience shows it to be beneficial in certain cases, so let us use it by all means. But all its benefits can be rationally traced to its me- chanical hydrostatic action — to the taking away of so much fluid pressure which the weakened part is unable to bear. Let us, then, so apply the remedy that these mechanical phenomena should have most play, by making it as local and as sudden as we can, and by using it with a reference to what we want it to do. And all its evils can be also rationally traced to its physio- logical action — to its detraction of so much material of tissue from the circulation. Let us, then, when we use it for its me- chanical advantage, counteract its physiological disadvantages by replacing to the best of our ability these materials of tissue. Instead of designedly starving our patients when we bleed, or leaving the matter to chance, let us designedly feed them. * "All that art can do is to weaken life."— Van Swieten's " Commentary ou Boerhaave," vol. i, § 106. 82 THE FORMATION OF MUCUS AND PUS. We may reckon in the same way with other remedies less directly destructive than bloodletting. We should value them, not in proportion to their special cvacuant power, for which they severally are classified as purgatives, expectorants, sudorifics, &c., but in proportion to the renewed growth of healthy tissue which accompanies their action. For example, epsom salts and aloes are both purgatives; but take a case of ansemic intestinal costiveness, and Ave know well that the more epsom salts the patient is dosed with the worse she is, but that aloes will restore a healthy condition to the mucous membrane of the bowels, and gradually reinstate its powers. It is not in proportion to their purgative powers that purgatives are beneficial, and we can hardly therefore consider that it is because of these purgative powers that they are beneficial. The action of cantharides upon the skin as a curative agent has been established by the common consent of many genera- tions. Is it the blisterinoj and destruction and drain of organic matter set up by the epispastic which does the good, or is some other part of its action ? Now in eczema and herpes, and in smallpox above all, we have an enormous amount of blistering and destruction of skin and drain of organic matter ; but instead of distant inflammation being arrested by them, or distant gene- ration of pus prevented, we often see it produced. In smallpox, the more pustules there are on the body the more likely the patient is to have bronchial catarrh and pneumonia. Burns bear a still closer resemblance to the morbid process set on foot by cantharides ; but the greater the extent of burn the more risk there is of internal inflammation. Then remark the stage of their action when blisters do good : their benefits are experienced, not when the destruction of epidermis is at its height, not Avhen there is most serum and mucus and pus evacuated, but as the healing begins. Observe, for instance, a case of water in the chest under treatment : the level of the pleuritic fluid does not decline most rapidly when the blister on the surface is filled with serum, but when it is drying up and healing. Is it not, then, the growth of new cuticle which restores our patient ? In reckoning the beneficial actions of blisters as evidence for THE FORMATION OF MUCUS AND PUS. 83 tlie counter-irritant theory of therapeutics, we are apt to forget the cantharidin which is absorbed by the skin, and the direct action of which absorbed drug on the mucous membranes is to bring them to a more healthy state. It appears, when taken in a fluid form, for instance in chronic bronchitis and sometimes in gonorrhoea, to be a direct stimuhmt of the vitality of these mem- branes. Blisters may be beneficial in this way quite independ- ent of their more obvious effect. Perhaps the most powerful for good of all the agents added to the Pharmacopoeia of late years is oil. During the internal use of oil the pus-secreting tissues dry up and become healthy, and their congested state is diminished. And the more readily assimilated is the form of oil, so much the more marked is this improvement ; that is to say, the more we saturate the system with a basis of growth, with a material capable of being built up into new tissue, the less likely it is to throw off the material of tissue in a half-formed state. The easy digestibility of cod- liver oil to my mind more than accounts for its wonderful ef- fects, and makes superfluous the chemist's aims to find iodine or anything else as a constant constituent in it. The good we do by administering it is in direct proportion to the largeness of the supply of nutriment thus presented to the tissues, and bears no relation to any pathogenetic results. In investigating the action of drugs, we are sometimes apt to look too far, and in our search for the mysterious to pass over the obvious. We are apt to bestow too little thought on the immediate action of these agents on the mucous membranes with which they come in contact. Quinine, for example, inasmuch as it passes through the blood so far as to reappear in the urine, doubtless influences most tissues of the body ; but still nine patients out of ten receive the greater part of the benefit accruing from the use of quinine by means of the augmented appetite and digestion which results from its presence on the mucous membrane of the stomach, not in the blood. It seems probable that the improvement in the vitality of pus-secreting parts which accompanies a course of quinine is due to the greater 84 THE FORMATION OF MUCUS AND PUS. quantity of nutriment which it causes the mucous tract of the intestines to absorb. The influence of heat upon mucus is a suggestive fact. If al- lowed to get cold, the globules cease to develop the little life they have ; but if kept at the temperature of the body, they con- tinue to grow into pus in spite of the unnatural circumstances in which they are placed under the microscope. This seems to explain how hot fomentations and poultices "favor suppura- tion," as surgeons say, in boils and abscesses. It explains also why suppuration is usually more rapid in deeply seated, well- covered parts than in exposed situations. But is it wise thus to " favor suppuration ?" Yes, tndy ; for while we are aiding the vitality of the pus-forming material, we are also aiding the vital- ity of the surrounding tissue — we are enabling it to recover that perfect state in which it need no longer waste its nutriment by throwing it off in a semi-vitalized stage ; while at the same time the pus formed is the most natural, the warmest, the softest, and the least injurious substance we can apply to a sore tissue. The recognized benefit of moist warmth may, I think, sug- gest to us something more. When an animal submits to the periodical latency of the higher functions which takes place during sleep, it instinctively seeks the warmest berth it can find ; it is instinctively careless about the supply of oxygen so that it can get heat. Beasts hide themselves in unventilated dens and burrows ; man surrounds himself with blankets and curtains in a close bedroom, and not all the questionable argu- ments of busy philanthropists can persuade him to open his window at night. I suppose that instinct is hereditary ex- perience transmitted by generation from sire to son, and con- tinuously increased through countless ages. It is not surprising, therefore, that its silent voice should beat out of the field the voice of argument, however loquacious. But I doubt if we physicians listen for it carefully enough. In that state of de- ficient vitality which constitutes disease, we are sadly apt to leave to accident the duty of cherishing the weak life by warmth. In every hospital I enter, the Avards are a great deal too cold. Because their forefathers tried to keep the sick warm by unwise THE FORMATION OF MUCUS AND PUS. 85 methods, the public in the present day zealously oppose the better means of healthy warmth which new inventions provide. Can we be surprised at rheumatic patients falling into peri- carditis, at fever patients having pneumonia, when house-visitors, vigorous and well-fed, walk in from the park, and finding the wards smell of mutton-broth and poultices, order the Avindows open without compunction ? Such things are; but they might be prevented if physicians would first convince themselves, and then the public, that an atmosphere and a temperature which is agreeable and wholesome to the healthy need not be either agree- able or wholesome to the sick. I have endeavored in these three lectures to point out with as little dogmatism as I could, for dogmatism before such an audience would be ridiculously misplaced, the practical bearings of a limited though an important part of the phenomena of life. The formation of mucus and pus is not indeed even the whole of that pathological state which we conveniently call inflammation. But I think no harm is done by pressing to results deductions from even the most limited observations, so long as we remember that they are limited, and so long as we do not forcibly bend other observations into coincidence with them. LECTURE yi. T YPH-FEVER. Case related — Cause of fever — Why it affects some and not all — Case shoivitig the progress of fever-poison cheeked by an emetic — Action of fever-poison on living organistn — Devitalizing potver on blood — The first symptom of partial death, a rigor — J^ext symptom, pain — Loss of appetite, diarrhoea, hemor- rhage, and increased heat, all are evidences that disease is something less than life — The object of treatment is not the 7nere typh-poiso7i, but the interstitial death of the tissues — The touchstone of restorative medicine is its application — Use of emetics — Tepid sponging — Cold affusion — Supply of food — Hydrochloric acid — Alcohol — L ocal bloodletting — Princi' pal difference between patients lies in the stomach — Two in- stances — De duction. (^Clinical Lecture, given at St. Mary's Hospital, October 18, 18G1.) You saw a case of continued low-fever (or as I shall call it for shortness Typh-fever) admitted four days ago, which presents a good many points valuable for instruction. Charles P., a-ged 15, a shop-messenger, who has grown rapidly lately, and has been worked perhaps rather beyond his strength, stated on admission that he had felt ill, languid, and unfit for exertion during the last six weeks. The past fortnight he had come home every evening without any appetite for his supper, and had sat cowerinji; and shiverin"; over the fire. For three days he vomited all food taken, had diarrhoea, and pain in the belly. Cough also had come on with a stitch in the right side TYPII-FEVER. 87 y during inspiration, and he had expectorated transparent mucus with sooty specks in it. There Avere to be seen on the surface of the abdomen and chest upAvard of a dozen dingy fever-spots in several stages, some entirely disappearing on pressure, some not. You found no pain or gurgling on pressure of the belly, and the diarrhoea was stated to have ceased. You saw the patient prostrate from great muscular languor and inability to stand, and a very weary, dull look in his eyes. His tongue was thickly coated with yellow fur; his skin was hot and dry; his pulse 104, small and sharp. His urine was high-colored, and deposited a copious yellow sedi- ment, soluble by heat. The quantity passed during the next twenty-four hours after admission was fifteen ounces, of the specific gravity 1-020. Then you noticed that the right cheek was flushed. The lower part of the right lung you heaid was dull on percussion, and to the listening ear there were moist cracklings coarse and fine in it, and dry whistling sounds scat- tered about the rest of the lungs. The boy's mother stated that they lived in a healthy attic, dry and free from foul odors, and could in nowise account for the illness. Here is a sporadic case of one of the low continued fevers common in this metropolis, and which have received a great variety of names according to variations impressed upon them by the epidemic temporary constitution of the air or the pecu- liarities of the individual. The two best-marked and best- known varieties are called "typhus" and "typhoid," dis- tinguished by peculiarities of eruption, and Ave hardly ever get a case in London which may not either be classed as one or the other, or be represented as a transition between the two. In registration at St. Mary's Ave make the distinction, and often also in speaking pathologically of the cases. But in treating them I do not do so; and therefore in lecturing about treatment, which is the business of a clinical teacher, I have adopted a name which would include both, from its likeness would be gen- erally understood, Avould not involve adhesion to any theory of identity or difference, and have in addition the merit of short- 88 TYPII-FEVER. ness. When I speak of continued low zymotic fever I shall call it "typh-fever." The present case has been a good one for study, for it has presented all the most important symptoms without the patient being so ill as to be unable to tell his story, or to make the repetition of it and the examination by pupils dangerous to him. I will call your attention to what you may learn from it. There is every reason to believe that one of the chief exciting causes of these fevers is a poison generated by decomposing organic matter and received into the body from without. To judge by its effects it seems to be widely diifused through the air, especially in the neighborhood of its origin in the air of sewers, putrid marshes, and crowded human habitations. If you are readers of popular sanitary literature, you are probably crop-full of the accumulated and deeies repetita evidence of this fact. You are tempted to ask how it is, if the poison is spread so broadcast, that everybody does not get poisoned? You will wonder why it should get into the body of this boy, whilst you, really much more exposed to it, escape. But remember there are two things necessary to poisoning; not only the poison, but a person apt to be poisoned. And, in point of fact, the latter is the most important element in the transaction. It is only on a predisposed body that a morbid poison acts. Most likely we are all constantly taking in minute doses of the poison which is the exciting cause of these continued fevers, and can digest, oxydize it, or otherwise render it harmless under ordinary circumstances. But should some epidemic influence or exceptional deficiency of vitality rob us of the power of doing so, then we suffer the effects and have typhus or typhoid fever, as the case may happen to be. There was reason enough for this boy being the victim, while others escaped, siiown in his recent rapid growth and in his strength being overtasked by his work. The exhaustion of vitality allowed the poison to do its work. Besides this purely foreign mode of generation of the poison, it would appear capable of being produced within the body itself — out of its own substance — idiopathically. At least such a closely similar train of phenomena follow, where an external TYPH-FEVER. 89 origin would seem a forced interpretation of nature, that we can hardly help coming to the conclusion I have stated in the last sentence. Thus a tjphous state follows severe and disorgan- izing wounds, where all noxious foreign influences have been cautiously shut out; and mere climatic agencies, such as the unwonted heat of the sun, overwork, chills, damps, and espe- cially a combination of these circumstances, will bring on the well-known "febricula," perhaps of only a few days' duration, perhaps protracted into or (as some word it) "changing into" a regular typhus. I speak of the exciting cause of fever as of a material ponder- able substance for the sake of convenience. But I do not wish to exclude the possibility of its being an immaterial power or force, like light, heat, electricity, or sound, are held to be. If it be so, it is like them associated wuth ponderable matter, and becomes known to us only by means of such association. We speak of a thunder-cloud causing certain phenomena, although we know it is the electricity of the cloud which does so ; of the sun burning us when we mean the heat of the sun ; of a cannon deafening us when we refer to the vibrations of the air acting on our ears. And so we may speak of the poisoning power as a part of that modification of matter to which it is joined, in spite of that modification of matter possibly existing in a similar form (chemically speaking) without being joined to it. Observe how slowly the power acts in some cases. Our patient is upward of five weeks ailing before any of the distinctive features of his fever show themselves, and then they creep out one by one. The time is not usually so long, especially during epidemics, but you may detect it in the history of almost every case. And you ought to notice it, because from some systematic works you might be led to thinking that a continued fever was easily to be meas- ured by days and hours from the very moment of invasion. This is impossible in practice, and would be of little use were it pos- sible. I rather incline to think that the most usual path by which the virus enters is the digestive canal, in cases Avhere it is begot- ten of decomposing organic matters foreign to the body. It is 90 TYPII-FEVER probably mixed with the saliva and carried down to tbe stomach, where it possibly may increase and multiply in the gastric mucus. During severe epidemics it has been observed that those who smoke or chew, especially if they spit out the saliva instead of swallowing it, are less liable to be attacked.* And at an early stage, even after the virus has begun to act upon the system, the fever may be stayed by emptying the stomacli, and thus prevent- ing the whole dose being taken up. Those who have watched my practice will have witnessed several instances of the success of this treatment; they will have seen the fever cut short, and convalescence entered upon immediately, with its charncteristics of painless weakness and emaciation gradually passing away. One case last autumn gives me the opportunity of putting on record that the influence of the remedy is not merely apparent or accidental, but that it really removes an essential part of the disease. W. S., a robust lad, aged 15, came into the hospital September 5, 1860, w4th hot skin, rigors, excessive muscular languor, pain in the back, limbs, and head of four days' dura- tion, gurgling in the right iliac fossa, and rose-spots. For the first twenty-four hours he had no medicine, and the urine was kept and analyzed. The result exhibited the following quan- tities of its various constituents daily excreted: — Grammes. __^--- — -— -^ m ^ '>.oE a >-• !3 « S o o Date. 111 5 < 'i^ 3 -^ 5-< => s — .S 33 3 ^ <3 Z O CO '"' September 6, 1860, . . . 1000 1.027 50.63 •43 •25 3-48 3^24 Then an emetic was administered, and coincident Avith a uni- versal remission of all the symptoms, the urine exhibited the following remarkable change in tbe amount passed during the next five periods of twenty-four hours : — * Mr. Catlin, of American Indian celebritj', attributes the comparative free- dom of his wild friends from malarious influences totbeir being tauglit as infants to sleep with their mouths shut, and to their being prevented by etiquette in after life from ever opening them, except for eating or speaking. TYPII-FEYER. 91 Grammes. Date. a m 111 a a a g 5 ? 5 ■d '3 o 5 ■r ^ o 3tJ 3 O _; September 7, Sept. 8 and 9 ; mean of two days' urine mixed September 10, September 11, 530 770 1200 1320 1-028 1-016 1-011 1-006 29-37 14-79 18-42 16-71 a trace 0-037 0-090 a trace 0-79 2-68 4-20 4-02 1-97 1-008 1-34 0-96 1-14 0-72 0-32 0-71 Now, the contrast between these specimens of urine is exactly that which is found between the urine during typh-fever and the urine during convalescence. In the first there is evidence of destructive metamorphosis going on with extreme rapidity ; in the latter the destruction is overtopped by renewal. And this change into convalescence was most strikingly marked as due to the operation of the emetic. When we see so often the immediate consequence of one dose of so simple a remedy, it is difficult to avoid the conclusion that its benefit is purely me- chanical, and that it acts by removing from the mucous mem- brane of the stomach a poison only partially absorbed and still adherent to it. Another reason for guessing that the gastric mucous membrane is an early if not the earliest recipient, is that it early exhibits such special phenomena as usually accom- pany the ingestion of an unwholesome material. Spontaneous vomiting is very generally found in the first stage of the attack (as you have observed in the patient under consideration), and seems to offer a presumption that the part which is then most feeling the effects of the poison is that organ which most resents it — the gastric mucous membrane. Such is the evidence by which I have been led to believe that the exciting cause of typh- fever enters usually by the digestive canal — valeat quayitum. When the poison has once gained admission and is diffused by means of the circulation through the system, its effect is to destroy the vitality of a considerable amount of the organic living matter with which it comes in contact. The destruction is interstitial, not local — I mean, it does not kill wholly a cer- tain spot which it touches, like sulphuric acid, but it kills only 92 TYPII-FEVER. certain constituents of the tissues. The destruction is also partial, not entire — the organic matter is by no means utterly disorganized, but only brought down to a less vital, less organic condition. It may be traced easiest in the changes found in the medium by which it is diffused. The blood, the common thoroughfare for distribution of good and evil to the tissues, is seriously changed. If you examine it under the microscope you will find that the normally shaped red disks are diminished in numbers as compared with what pathologists call "melanosed" corpuscles, that is to say, dying or dead disks, shrivelled and small, of a dark color, with black specks in them, and with gimped edges. In bad cases these are unable to range them- selves in rolls, as healthy blood does when it coagulates; they seem to have scarce any attraction for one another and lie in amorphous heaps. They dissolve early in the serum and form with it a red fluid. You may trace this dissolution in the dusky stain which the blood communicates to the skin in typh-fever. The poisoning apparently goes on very gradually in some cases, and quicker in others. You heard from this boy that he was five weeks ailing before he gave up work. There was an imperfect renewal of the body, shown by languor after exertion and by loss of appetite or deficient demand for new material. But destructive assimilation was not checked, there was no im- pediment to the carrying off of the effete tissues by excretion. It may be that in a great many cases the disease, the partial death, stops here, the destroyed tissues and their destroyer together are disorganized, are reduced to their elements and pass away. The idea is incapable of proof, but it would account for a vast number of those mysterious languors, unclassified, unnamed, and often unpitied, which distress patients and puzzle doctors. It is a characteristic of this sort of virus to poison mainly the nervous system. The fevers it produces get their name from then.ce — ricpoc = a smoke or mist overclouding the instrument of connection between body and mind. In no other diseases of equal curability is it so much affected. When therefore the poisoning has reached a certain pitch, and that not a very high TYPII-FEVER. 93 pitch, early in the disease, the nervous system takes notice thereof, and expresses itself in its most common mode of taking notice of partial death, namely, by a shivering fit. Any severe injury to the bod}^, a stretching of fibrous tissues, an operation, the fear of an operation, the absorption of destructive drugs, such as antimony for example, will cause more or less of a rigor in proportion to the sensitiveness of the individual. And thus also in zymotic fevers, when the interstitial death of the neural constituents of the body arrives at a certain degree, there fol- lows a rigor. This rigor recurs from time to time at uncertain intervals, but generally about once a day, and most commonly in the evening, as the mother remarked in the case which forms the text of my lecture. Then commences another symptom of partial death — pain. This boy described his head, his limbs, and his back as aching all at once. That is to say, wherever there was most tissue with sensitive nerves in it, there was found pain, indicating the dis- eased state of that tissue. Now this aching is a symptom of the earlier rather than of the more advanced stages of typh- fever; not because there is in the latter less death, but because then the nervous system becomes partially dead too, and does not feel so acutely; while in the former it retains most of its normal sensibility. Observe that our patient tells us of nausea and loss of appe- tite, which diminished the food eaten — of vomiting, which re- jected the greater part of that diminished food — and of diarrhoea, which carried off the remainder scarce digested at all. Yet in spite of all, the amount of solid matter passed from the kidneys is fair; the specific gravity of the fifteen ounces of urine passed in the twenty-four hours is 1-020, which is a good deal for a person not in strong health. The metamorphosis, therefore, of the worn-out tissues into urea and salts is active; there is a con- tinuous destruction of them in spite of the defective supply. This goes on so long as the poison lasts in the body; but when it is got rid of, the destruction ceases ; no more of the tissue is metamorphosed than is required to make room for new material, and the specific gravity of the urine falls during convalescence. 94 TYPII-FEVER. This may take place very suddenly, as in the instance I gave you of a fever cut short by an emetic; but in general the altera- tion is more gradual. I have mentioned the amount of urea, large in proportion to the nutrition, contained in the urine of typh-fever, which is rendered evident by its high specific gravity. There is also an increase very evident to the naked eye in another constituent of some importance, the colored organic material, -which gives the secretion its ordinary hue. You saw how dark this boy's water was, and how deeply it stained the vessel from which I poured it on a piece of white linen. We have great reason to think that there is a close alliance between this substance and whatever it is which gives the red tint to the blood-disks, and that its excess depends on excessive destruction of those im- portant little living particles. The sulphuric and phosphoric acids combined with bases, which form a necessary part of urine, do not in fevers follow the lead of the urea; their amount is less than in health. Whether this is due to the destructive metamorphosis taking less eflfect on the chief tissues containing sulphur and phosphorus, than it does on the blood ami muscles, is doubtful. Dr. Parke suggests that perhaps a third of the normal sulphates and phos[)hates of the urine are derived directly from the food, and not from the metamorphosis of tissue; and therefore that their diminution in typh-fever may be owing to the starvation, while the amount which still remains represents a fair proportion of destruction.* The chlorine, in the shape of chloride of sodium, is also in small quantity, but not so deficient as to lead us to suppose that the metamorphosis of the chlorinated materials of the body does not go on, or that there is retention of them in the fluids. The great quantity of chloride of sodium taken as food, and directly mixing with all the fluids, again brings in difliculty. And an- other is throAvn in our way by the frequency of intercurrent pneumonia, which itself causes a retention of the chlorides naturally excreted from the kidneys. This youth, for example, has a little pneumonia, and we could not, therefore, say if ab- * Parkes"On the Urine,'' B. ii, part iii, sect. 4. TYPH-FEVER. 95 sence of chlorides in his case were due to that inflammation or to typh-fever. In other cases our impediments to knowledge are diarrhoea or colliquative sweating, which carry off chloride of sodium. The diarrhoea so frequent a companion of continued fever is a further evidence of death in the blood. Let the fluid fever stools be set aside in a tall glass, and you will see them shortly sepa- rate into two parts; the higher one a half-transparent serum, in which float epithelial scales and crystals of ammonio-magnesian phosphate; the lower stratum a greenish-black flocculent pre- cipitate. This last has no smell of bile, nor is bile to be found in it by chemical tests; but it contains broken-up blood-disks and a great quantity of dark, granular coloring matter — it is just like blood altered by the secretions of the bowels. And very often when you let the stools separate in this way, and look at them by transmitted light, you Avill see a visible sanguineous tinge in them, and blood mixed with mucus is visibly passed from the bowels. Blood, too, is not unfrequently spat up with the mucus from the lungs, and drips from the nose; and in bad cases the dried-up mucous membrane of the mouth cracks, and exudes the sanguineous serum on the surface of the tongue, pro- ducing the "dry, brown tongue" characteristic of severe fever. All these prominent symptoms call your attention to the inter- stitial death, the lessened life of the body. The increased heat in fever is to the careless observer rather adverse to the doctrine which I have advanced, that all disease is an evidence of diminished vitality. And in truth it requires some thought to see why it is not a conclusive objection. But an answer to the idea of an augmentation of heat being neces- sarily an augmentation of life is afforded by the fact of many recorded instances of the increase of corporeal warmth having taken place in corpses actually after full death; so that, dis- carding at once the notion of its being a proof of vitality, we may try and trace what causes, really rather to be associated with death, may give rise to it in the cases under our eye. In the first place, in fever you have a diminution of the evaporation which takes place from a healthy skin, and which acts as a 96 TYPII-FEVER. powerful refrigerator, as any physiologist who has perspired knows full well. The dormant dry skin does not do its cooling office. Then in the second place, there is a much larger quan- tity of dead matter to be evacuated, and the destructive meta- morphosis of this dead matter, the semi-vital chemical destruction, raises the temperature, as all chemical solutions do. Wherever metamorphosis is rapid, the temperature is raised. But this metamorphosis alone, this passage of living into inorganic mat- ter, cannot be called an increase of life, inasmuch as it indicates an advance of death. It is necessary, may be, to the removal from the body of poisoned ingredients, and is so far an advan- tage, but still it is an indication of the quantity that is poisoned. Such are some of the most prominent consequences of the typh-poison in the human body. You may call to mind, very likely, warnings 1 have given you against the old humoral pathologist's doctrine of a materies morbi, which was looked upon as the disease, and which he thought he has done his duty by endeavoring to eliminate. "Surely," you will say, "this which you have been describing is a most typical materies morbi; if I evacuate this, I cure the disease." Not so fast — the bullet Avhich enters the soldier's ribs is a materies morbi — have you cured the disease when you have extracted it? Nay, more — suppose the bullet passed right through the chest and went out on the other side, would you consider the disease gone? No — the typh-poison is not the dis- ease, any more than a bullet, or sulphuric acid, or opium is a disease, though each may be a material cause of disease. The partial death which these agents cause is the disease, — is that which requires to be treated^ and must be the chief point for the physician's consideration. Here let us bring our doctrines to their touchstone — bedside application. The physician should ask himself — What vitality is wanting, and where is it wanting? And then — How shall I easiest supply it? In the first place, if he sees the case early, almost the only thing he notices is the lowered vitality of the stomach — how badly it digests its food, and how it loathes its usual work. He TYPH-FEVER. 97 reasons that the functions are arrested by the presence of some poison, and he empties the stomach Avith an emetic. In manj cases brought under treatment early in the disease, this treat- ment cuts it short at once, as I tokl you in a former part of the lecture, and as you have had opportunities of observing in the wards. Secondly, supposing he is too late for his coup de main, he remarks that the skin is hot and dry, in a great measure from deficient perspiration and evaporation on the surface of the body. He undertakes to supply that want by an artificial moisture. He sponges the whole person over three or four times a day with tepid water, to which the nurses here generally add some distilled vinegar to make it more agreeable. The relief given is most sensible and immediate ; but of course it soon passes away, in- asmuch as changes of temperature are in their very nature tem- porary. The sponging must therefore be frequently repeated. Cold effusion is sometimes spoken of, both by opponents and advocates, as "checking" or "arresting" the febrile heat. This is apt to give you a wrong notion. If it really arrested the me- tamorphosis which is the cause of that heat, it would be obnox- ious to all that could be said against it. But in fact it no more "arrests" or "checks" the heat than emptying the bladder " arrests" the secretion of urine. A few moments' thought will show you that what it does is to remove the heat from the ex- ternal surface ; and if it affects the cause of heat at all, it would rather encourage it by making room for more. If the attendants have sufficient leisure to attend to an opera- tion which consumes a good deal of time, it adds very much to the comfort derived from the sponging to anoint the body with some softly scented olive oil. This supplies the place of the ar- rested sebaceous follicles, and softens the skin for the absorption and exhalation of Avater. It is a mistake to suppose that oil and water are at all inconsistent, or incapable of mixing in the sub- stance of living tissues. Where there is pneumonia in fever, or where the patient has recently had acute rheumatism, I confess I am somewhat cau- tious about the employment of aqueous affusion. It sometimes 98 TYPH-FEVER. chills the chest and causes an attack of pleurisy on the inflamed side, or pericarditis. Besides which, in the case of pneumonia, it interferes with a plan I have of keeping a large poultice outside the affected part, and which I find so heneficial that I do not like to omit it. For this reason sponging was not ordered for the present patient. Tltirdhj, the physician sees that a large supply of nitrogenous material must he wanting. The nitrogenous tissues are devital- ized, are drained away dead in a disproportionate excretion of urea and other organic compounds, and nothing is taking their place. Shall he act antagonistically, and try to stop the pas- sage of urea hy the kidneys ? I do not know exactly how he would set about it : but I do know that if he succeeded, he would do positive harm ; for the very worst cases of fever are those in which metamorphosis is active (as shown by the heat), while the excretion of urea is arrested (as shown by the lightness of the urine) ; they resemble cases of ursemic poisoning from dis- eased kidneys. The other principles of treatment which I have noticed in my introductory lectures would not perhaps be so directly injurious, but common sense would still allot the palm to restoration here. Let it be your chief aim to supply that which you clearly see is passing away — nitrogenous tissue. But how will vou supply it ? Solid food would in all proba- bility be vomited, from the unbearable loathing it excites. If not vomited, it would lie for some time a mere foreign matter outside the mucous membrane of the digestive canal, and then pass away by diarrhoea, with much flatus and fetor and much disengagement of gas during putrefaction. Your beef-stake might as well have been originally thrown down its final destination, the water-closet ; to which it passes putrid though undigested. Neither is it wise to fill the stomach with large quantities of victuals, for the same result follows. No "meals" must, there- fore, be allowed; and prudence sugests the giving in their place very small doses of nitrogenous aliment very frequently. These pass over the irritated stomach unconsciously, and are taken up gradually by the intestines, requiring but very little to make them fit for absorption. The suitablest food is that which is TYPH-FEVER. 99 naturally supplied to the weakest stomach. The feeble diges- tive organs of babies can assimilate milk, and milk forms the most appropriate nourishment for the debilitated viscera of the fever patient. Bj giving two or three ounces every hour you may get down a quart and a half per diem. But in ordinary in- stances every two hours is often enough, and that period is adopted for the boy before us. If there is sufficient acid left in the stomach to coagulate the casein into clots, and cheesy lumps are rejected by vomiting, as happens sometimes in milder cases, you may guard against this by adding liquor calcis or soda-water to the milk, or you may supply its place by beef-tea. But it is the lumping of the cheese into solid masses that it is desirable to avoid, not the acidification, which is beneficial. If the patient takes thus a good supply of milk and beef-tea, not only is the imminent danger of death by starvation avoided, but the emaci- ation which follows during convalescence is much less extreme, and the dano-ers in its wake less formidable. Eggs are highly nutritious food , if taken raw, and diluted with milk or water, they are quickly absorbed. But should they be delayed and putrefy, the products of their decomposition are peculiarly injurious : the sulphuretted hydrogen and ammonia evolved are poisons to the intestines. I should recommend you to avoid eggs till convalescence has restored the gastric pow- ers. The same objection does not lie against milk, the lactic acid arising from whose decomposition assists in the solution of the casein. Sour buttermilk is by no means to be despised as a food. Fourtlily^ the physician should turn his attention to the phar- macopoeia, and consider what he can cull from thence which will be of service. You have been taught in the systematic course on medical pathology, that ammonia, which is always being formed and given off from the animal body, is found much more abundant in certain conditions than in others, and that these conditions are those in which nutritive metamorphosis or growth was defi- cient as compared with destructive metamorphosis, or those in which there is retention in the blood of the products of that de- 100 TYPII-FEVER. structive metamorphosis. Thus, more ammonia is found in the breath after toil tlian after rest ; more than usual in those who hurt their digestion bj smoking tobacco ; a great deal in urremia, "vvhere the urea cannot escape by the kidneys ; but above all in typh-fever is this exhalation of decay noticeable, as you will find in Dr. Richardson's valuable "work on the coagulation of the blood,* Avhcre the phrase "super-alkalinity of the blood" is ap- plied to this condition. Dr. Richardson goes so far as to attribute to this super-alkalinity the special tj^phoid symptoms, and to suggest that the absorption of ammonia in excess may intensify fever in those who contract it from exposure to decaying organic matter or human exhalations. He supports his hypothesis on the experiment of inducing the symptoms, or something resembling them, by the injection of ammonia into the veins of an animal. The word " super alkalinity" is expressive, and quite unob- jectionable, so long as it is understood that the superabundance is not absolute, but comparative. For it is not shown that there is more alkali in the body than there ought to be, but more than there is acid to neutralize. " Sub-acidity" would be a synony- mous term, and Avould be more sujzgestive of the means we have at our disposal for remedying the defect. Very difficult indeed would it be for the eliminator to get this alkali out, but it is easy for the restoratist to get acid in. The acid I have always given is hydrochloric, and you conse- quently see on this lad's card — "R. Acidi hych'ocldorici diliiti '\X\xx, syriqn 5j, aquse .3J, altcrvd qudque liord sumat." Rich patients like a little more sugar, but I have not found them approve of the syrup of mulberries and barley-water, in which more elegant vehicle the late Dr. Maton used to give mu- riatic acid in fever. They say this is mawkish, and prefer the cheaper form, even on the score of taste. But it is still more approved of for its beneficial effects. This boy said to-day of his own accord, he hoped I should continue the draughts, they made him " feel so much stronger," meaning to express a sensation of relief to the wearisome languor of fever. In mild cases the tongue * Richiirdsoti on the •' Cause of the coagulatiou of the blood," Appendix I. (Edit. 1858) TYPII-FEVER. 101 begins to clean immediately, the thirst and diarrhoea much abate, and the repugnance to food is diminished. In a clinical lecture at this hospital in January, j 858,* I gave the details of the first dozen cases treated on this plan, and as you are a different audience from that which heard me at that time, perhaps I may be allowed to repeat the sentences in which I then tried to interpret the beneficial consequences: — "What blood, when analyzed, comes nearest in its altered proportions to the blood in low fever? Is it not that of scurvy and pur- pura ? There is the same excess of blackened (melanosed) blood-disks, the same deficiency of neutral salts and organizable (coagulable) lymph. Everybody treats these chronic affections "with acids, and why not also an acute affection which corres- ponds with them in one point at any rate ? As to the particu- lar acid employed, muriatic certainly deserves to be tried before others — first, because it is such a large constituent of the body that it might almost be called a food instead of Jf medicine ; and secondly, because it is such a powerful arrester of the decompo- sition of animal matters. Pour it into a sewer, and you destroy the miasma. May it not in the body stop that miasma from poisoning the tissues?" The allusion in the last sentence is to chlorine as a disinfec- tant. But I now doubt if there is sufiicient evidence of the benefit derived from the hydrochloric acid being due to this property. About sixteen years ago, I employed chlorine water as a medicine in fever at the Chelsea Dispensary ; yet I was not encouraged to carry on the treatment by tracing any benefit to it. Whether the chlorine which can be introduced in this way is not sufficient in amount (for it must be very dilute, or else it will induce choking), or whether it is really useless, I do not know ; but the inconvenience caused me to leave off its employ- ment. Dr. Pereira in his " Materia medica" speaks slightingly of the use of hydrochloric acid in putrid fevers, and implies that it rests solely on exploded theoretical propositions. He should have * Printed in the " Lancet,"' January 30 and February C, 1858, and partly re- printed in the next lecture but one. 102 TYril-FEVER. noticed that Boerhaave and Van Swieten recommend it, and that Sydenham used sulphuric acid in these forms of disease as an antiseptic drug. And these were men not easily led into erro- neous practice by a prevalent theory. To their experience I can add my testimony, for I have employed the plan above described in every case of typh-fevgr since the summer of 1857, and have had yearly more and more reason to speak well of it.* Dr. Pereira, in afterwards speaking of its use in dyspepsia, gives a I'eason for its employment therein, that first, " it is a con- stituent of the healthy gastric juice ; and, secondly, when mixed with mucus, it has a solvent or digestive power in the case of various articles of diet." Is not this as much a reason for giving it in acute cases as in chronic? Whether tlien, as Sydenham seems to have thought, any other acid would do as well as the hydrochloric, I cannot say, but it forms so large a constituent of the body combined with alkali in the blood and tissues, and free in the solvent juices, that it appears peculiarly suited to the purpose on restorative principles. As to the use of alcohol in fevers, I am guided almost entirely by the condition of the nervous system. If there is very com- plete prostration and delirium of a low muttering character, it is required. A tremulous state of the muscles, marked especially by a quivering of the hands and fingers, is a good test of the necessity for it ; and so is a sharp, weak, unequal beat of the heart. All these indicate that the nervous system is feeling very sensitively the destructive metamorphosis going on, and has its power lowered by its sensitiveness. Then is the oppor- tunity for the powerful ana3sthetic alcohol, w^iich in severe cases you see me order without scruple, but which I do not rank as part of the necessary methodus medendi of fever, and have not yet ordered for the lad we have been prescribing for. Above all, I would caution you against employing it as a substitute for the treatment which I have been describing. Wine may be * This yearly growing experience is put into numbers in a subsequent lecture. TYPII-FEVEU. 103 useful as an adjunct, but never must it take the place of tlic true restoratives. There is, though, another of the exceptional methods of treat- ment, which has been employed with utility in this case— the local abstraction of blood. The boy had congestive pneumonia of the lower part of one lung, and I did not hesitate to cup him beneath the scapula on that side. And not unfrequently when there is pain in the right iliac fossa, with diarrhoea and tenesmus, I put leeches on the belly at the seat of pain. You. watched the dullness on percussion rapidly pass away from the lower lobe in our patient here ; and you will often see an equ-il relief to the abdominal congestion by the same agency. But you Avill cry out that I am sadly inconsistent. I am feeding up the patient with one hand and taking his pabulum vitae with another. The reproach is just in a certain sense, but that a very limited one ; and, in fact, may be levelled against half the operations of daily life. We are constantly suffering a small loss for the sake of greater gain. And I think the loss of a little blood is practically of no moment at all compared with the advantage of securing a freer circulation through the lungs or a diminution of congestion in the intestinal canal. Do not be led away by the superficial notion that blood is blood, and blood is life. Tiiat is not true, for blood varies immensely in its composition, some being very valuable, and some worthless. To lose a portion of the half-dead circulating fluid of fever is but little loss, and that little loss is amply repaid by the addi- tional nutriment which a small bloodletting will enable to be absorbed. The deficiency is soon made up again under a re- storative system of treatment. In the sequelae of low fevers, more than in any other diseases, the great difference between one patient and another as respects their poAver of recoveiy, lies in their stomach. There is a girl of four years old now in Victoria Ward, who was admitted on the 2d of September for rose-spotted fever, which had come out during the concluding week of August. She passed through the fever pretty favorably, but for the last seven weeks has had a succession of most formidable abscesses in the back, the cervical 104 TYPII-FEVEK. glands, the internal ears, and the parotid glands; yet, in spite of the exhausting effect of the large discharge of pus from these spots, she has continued advancing in convalescence, she has gained flesh and muscular power, so that now she can sit up. For this happy result she has to thank a most wonderful appe- tite, which never seems satisfied, even with an amount of food which is large for an adult, and which she deliirhts to wash down with wine and porter. No tonics seem of so much use to her as an extra snack at physic time. The most striking recovery from these py?emic abscesses after fever you Avitnessed last year in a girl of sixteen (E. A., admitted September 28, 186U). She had very putrid fever, accompanied by hgemoptysis, epistaxis, and bloody discharge per vaginam. She got well of her fever by the help of hydrochloric acid and wine. But as she became convalescent in the third week of October, she began to have large boils in the head; these were followed by abscesses running on into sloughing sores on the back. Durinn;; the first week in November inflammation and swelling of the left leg began. This quickly passed into puru- lent infiltration of the whole of the left thigh, an opening in which on November 28 discharged two pints of pus in twenty- four hours, and smaller quantities daily for several successive weeks. On December 12, there was a large abscess in the axilla, which was lanced and discharged several ounces. Her state of debility was such that she could not in the least help to feed herself. Yet all this time her stomach was in a state that a glutton would look up to as a seventh heaven. She was literally always hungry. As she swallowed her last hit of beef- steak she would feebly ask when she was to have some more, and what would be her next meal; and the way her eager eyes followed any article of food that passed her bed was quite affect- ing. "We allowed her wolfish appetite its full liberty, and fed the punv maid like a i:ii2;antic Kh^diator. The end of the tale r •/ COG is, that she recovered from an amount of purulent disease which it would have seemed impossible for the human frame to bear — and recovered perfectly, for I saw her in the April of the next TYPII-FEVER. 105 year, looking as healthy and walking as briskly as if she had never been ill. The moral of these cases is to do all you can to increase the appetite, and strengthen the digestive powers. Reckon the value of this drug and that drug, one tonic and another tonic, solely by the effect they have on the desire for food. If any remedy lessen this desire, insist upon leaving it off, whatever authorities may have recommended it ; and form your judgment, not from tradition or prescription, but from its effect in the particular case before you. LECTURE VII. TYPH-FEVER. THERAPEUTICAL STATISTICS.* {Clinical, St. Marys, October 17, 1863.) I HAVE often spoken with confidence of the advantage of the treatment you see me pursue in fever, and I am going to-day to lay before you the reasons why this confidence has been grow- ing yearly stronger and stronger. Since the opening of the hospital in the summer of 1851, to the time of my leaving London for the vacation last August, there have been registered as under my care 230 examples of continued fever. Of these, 109 have been treated on what may be termed "general principles;" that is to say, they took neu- tral salines three or four times a day, with small doses once or twice a day of hydrargyrum cum creta, at first, and later in the disease, bark, ammonia, ether, and wine, when these remedies seemed required by the symptoms. Leeches and cupping were employed to the exterior of the inflamed viscera as occasion called, and food was administered at the ordinary four daily meal-times. The other 121 have been treated on a uniform plan of continuous nutrition ; animal food, in a liquid form, has been given every two hours, day and night, while the patients were awake, and between every dose of nutriment a dose of hydro- chloric acid. They have been sponged two or three times daily with tepid water, when the skin Avas hot and dry; and, in a few * The substfince of this lecture was brought before the MeJical and Chi- rurgical Socieiy in April, 1863, but a few additional cases occurring between that time and August have altered the figures a Utile. TYPII-FEVER. 107 instances, leeches or cupping h.ave been used to tlie exterior of inflamed localities in tlie abdomen or cliest. These two classes of patients offer a fair basis for a statistical comparison of the therapeutical agencies brought into play : it is fair for the following reasons: 1. In the first place, each series is very nearly continuous; all the first-named 109 (with five purely accidental exceptions,*) occurred in the six years before September, 1857, and all the latter 121 in the six years since. No fallacy cun, therefore, arise from a selection for special treatment having been made intentionally or unintentionally. 2. They are spread over a considerable number of years ; thus both sets include sporadic cases, as well as the produce of epidemics. '6. They Avere all treated by the same physician in the same wards of a general hospital (where the cases are usually more severe than in special fever hospitals), and they nearly all come from the same group of districts of which our hospital is the center. 4. The diagnoses have been made and the records kept by registrars who have nothing to do with the treatment, and are independent of the physician in attendance. The only opening for error that I can discern is the bare possibility of a change of type in fevers having taken place at the very time when I changed the treatment, and of its having lasted for six years — possibilities which the records of other me- tropolitan hospitals during the same period reduce to nothing. That the severity of the disease in the two classes differed but little may be shown by the near equality of the periods of con- valescence. The mean time of stay in the hospital of the sick who recovered was, in the first series, 29-2 days ; in the second, 26-7 days; being a difference of but 2|- days. The ages, also, * Three of these exceptions were treated on general principles by a colleague taking my duty during my absence, and unaware of the experiment I was try- ing ; in one case I made a wrong diagnosis, having mistaken typh-fever for acute hydrocephalus, and treated it with iodide of potassium till too late; of the fifth I have no record, the patient having died within two daj's, and the clerk's notes being imperfect, except as to the fact of its being a case of fever. 108 TYPII-FEVEll. of the two series differed but little, the mean ago of each being between 22 and 23 years. These averages are cited merely to show the general similarity of the two series, and not to demonstrate any pathological fact. Of the first series (viz., those treated on general principles), 9 are entered as Typhus, and of these there died 4 44 " Typhoid " " 16 56 " Of doubtful or unrecorded type 3 Total 109 Total 23 Of the second series: 25 are entered as Typhus, and of these there died 52 " Typhoid " " 2 44 " Of doubtful or unrecorded type 2 Total 121 Total 4 For purposes of comparison in a therapeutical inquiry, it will probably be considered right to exclude from the first t;ible two deaths, and from the second table one death, which occurred within two days of admission ; for the exhaustion caused by the journey to the hospital in severe fevers allows but little scope for judging of the action of treatment during that period. This leaves the average mortality under general treatment 21 in 107 = 19| per cent., or nearly 1 in 5 ;* under the second method of treatment, by continuous nutriment and hydrochloric acid, 3 in 121 = 2| per cent., or only 1 in 40. I cannot, therefore, avoid the conclusion that the means em- ployed in the cases on the second list are very efficient in pre- serving life; and that out of every 100 persons attacked by con- tinued fever, from 16 to 17 more may be saved thus than by treating them on general principles. The continuous liquid nutriment given every two hours con- sisted of strong beef-tea and milk, of which together about six pints were administered in the twenty four hours. The hydro- chloric acid was given every two hours in doses of twenty minims * This mortality is higher than is usual at special fever hospitals, being about the same as at the other general hospitals in London. TYPII-FEVER. 109 of the Pharmacopoeal dilute acid in water or eau sucr^e. Both food and drugs were seen by the nurses to be swallowed, and not left to the discretion of patients, who, from nausea and occasional delirium, cannot be trusted to help themselves. The most immediate result of the hydrochloric acid is the more natural condition of the digestive mucous membrane, as shown at its two extremities, by the clearing of the tongue at the one end and the cessation of diarrhoea at the other. The more natural condition of the mucous membrane enables the greatest possible quantity of nutriment to be absorbed to take the place of the tissues poisoned and interstitially destroyed by the virus which is the cause of the fever. That the acid is in any sense a specific, or that it in any chemical way neutralizes, counteracts, or evacuates the virus is, 1 think, unlikely. For the mean period of convalcf^cence in these cases was shortened by only 2| days ; and certainly it would have been shortened more than that were the virus removed or rendered inert. That the convalescence is not more shortened, cannot of course be judged of in individual cases, and I state the fact from the statistics of the average stay of the patients in hospital, which I before quoted. Whether the treatment I advise would be equally useful in all climates, I cannot say, but in Shanghai, a climate as different as possible from England, Dr. Henderson* states that its employ- ment diminished the mortality of continued fever from 28 per cent, to 7 per cent., a very marked decrease. The action of wine and of emetics in continued fevers is not attempted to be tested in this inquiry. In both classes of cases they were given; the wine, as usual, in accordance with the patient's age and the condition of the nervous system, and emetics whenever the history we could elicit made us conjecture that the fever was in its first week. My impression is that a vomit, when given within the first four days, materially lessened * "Medical Times," March 21st, 1863. I found also, during a late visit to Italy last spring, Dr. Bishop of Naples equally convinced by experience of iis value in the low fevers in that climate, though their usual type is very different from ours (Note to fourth edition, October, 1865). 110 TYPII-FEVER. the severity of the fever ; and in some instances, seemed to cut it short. But I do not know how to obtain numerical evidence on the subject. I have never found an emetic do harm, unless there were antimony in it, when it sometimes caused or increased diarrhoea, and failed of the intended purpose. For this reason I prefer plain ipecacuanha. LECTURE VIII TYPH-FEVER. Cases with running commentary — Instance of a relapse of rose- spots — Contagion from patients to a nurse — Leeches and mercury — Blulberry-rash — Intermittent pulse — Rose-spots or mulberry-spots, which most dangerous? — Wine in fevers — Retarded emaciation — Subcuticular eruption — Contagion — Artificial cuticle in bed-sores — Sudamina — Loio condition in convalescence, its symptoms. , [It may be remarked that the date attached to the ensuing matter is earlier by more than five years than that which precedes it here. The cases are taken from the hvtter half of a clinical lecture published in the "Lancet" of February 6th, 1858, where, after nine others in which general treatment was employed, are de- tailed the particulars of the first twelve instances of the use of the method de- scribed a few pages back. It was not necessary again to allude to these patients- but some of them illustrating points of pathological interest, and some of them, besides the common treatment of the disease, having required that which was specially suited to each case, they are here reproduced.] {Clinical, St. Mary's, January 2.^, 1858.) [Nine cases of general treatment omitted.] Case 10.— William W. (Case Book 103, p. 52). This was the deputy coachman from the infected house I spoke of in Case 8. He had equal muscular prostration but not nearly so much mental affection as the housemaid. On the skin there were rosy spots, coming out slowly and in consecutive crops. One peculiarity in this case is, that during convalescence, when walk- ing about and eating meat, he had a relapse, and the rosy spots came out again, with delirium, prostration, &c., nearly as bad as 112 TYPII-FEA'ER. at first. It is very rare to have a relapse of rosy petechias, but you see it is not impossible. Case 11.— Mary Ann B. (C. B. 103, p. G4), a nurse in the hospital, had mihl delirious fever without any eruption. I am aiVaid Ave must allow that she caught it from the patients, for certainly there is no bad drainage here to generate it. There occurs one case now and then, to show you that low fever is con- tagious, and but one to show you that it is very slightly so. Case 12.— Fanny A. (C. B. 103, p. 66). This girl com plained a good deal of pain in the right iliac fossa several times recurring, which at last was treated by leeches and mercury with immediate relief. You may often hesitate about these remedies, for fear of lowering the patient's strength by depletion ; but if the pain is made a subject of complaint, you may feel safe ; for the very fact of the sensitiveness of the body shows that it is not too low to bear them. Those who are so much prostrated as to make a few leeches dangerous, are insensible to slight pain, and do not complain unless pressed. Case 13. — Emma B, (C. B. 103, p. 82). I never saw a skin more thickly covered with a mulberry-rash than in this fine stout brunette ef eighteen ; yet few have recovered so quickly. She came in on October 5th, having been ill eight days, with a pulse of 120 and great prostration; on the 6th her pulse was "80, and intermittent;" on the 7tli, "70, and intermittent;" on the 8th, "natural;" after which medicines w^ere left off, as she was convalescent. I am inclined to think that the natural tendency to develop coloring matter exliibitcd in the skin of dark persons causes them also to develop more freely than others the colored eruptions. You will read in many old books (and sound books too) state- ments to the effect that dark livid spots in fever are an evidence of more danger than rosy spots, and that the danger is greatest when this dark rash is most abundant. You will have ample opportunities during your student life of seeing that neither of these rules is applicable to facts as they come before you. There are most deaths among the rose-spotted, and you will see many cases of unusually rapid recovery among those with a very TYPH-FEVER. 113 copious eruption. Yet for all that I believe the ancients re- ported right. I believe that the difference is made by our more rational mode of treating our patients — successful in both sorts of cases, but most especially in those "whei'e the livid rash shows the chief force of the poison to have fallen on the blood. With- out wine, the most fatal cases would be among the livid-spotted; with wine, the most are among the rosy.* Emaciation did not commence in this patient till she was so far convalescent as to be up and dressed, and then with great rapidity she lost flesh. From the Avay in which she withstood and passed through the disease at its height, you would not hnve supposed her to have been so severely ill as she really was. But the quick destruction of all the tissues, and their necessary renewal before the full functions of life can be per- formed, show" how pi'ofoundly the typhous poison affects them. Emaciation may be rather called part of the cure than part of the disease; it is nature's mode of getting rid of injured tissue. Case 14.— William W. (C. B. 103, p. 112). Pink spots ; ab- dominal pain relieved by leeches ; quite en regie. Case 15.— Edward P. (C. B. 108, p. 114). This robust man was again one of a set where the fever was traceable to a poison- ous locality. You may remember that he made so much noise by yelling " Dust-ho !" that he was obliged to be removed to the noisy ward. He turned out to be a workman at a neighboring dust-contractor's, and the foreman of the yard was brought in a few days afterward, in Dr. Alderson's week ; and a third dustman came from close by, and will appear as Case 19. All these were very muscular men and very noisy. The first and second had rosy raised spots, which were peculiarly distinct and characteristic in Dr. Alderson's patient ; but the third had a livid rash ; and in the first, Avho is at present under review, there were livid mixed with rose spots. * Let me not be supposed to say that the use of wine in ferer is a modern discovery. All good authorities of all ages allow it in exceptional cases ; but till the present generation modes of diagnosis have not been accurate enough to separate entirely idiopathic fever and acute inflammations ; and therefore an adherence to Galen's condemnation of wine was really prudent in them as a rule. 114 TYPH-FEVER. Remark the nature of this man's occupation. Typhous mias- mata are perhaps generated more rapidly when the substances whence they arise are wet, because moisture aids decomposition. But when once they are produced, there is much greater danger of their diffusion in poisonous amount from dry matters. Work- ers in sewers sometimes get poisoned by sulphuretted hydrogen, but they do not catch fever ; nor do the men who cart night- soil into the country for manure. But when this is spread out on the fields, and exposed to the sun and air, it often causes a limited epidemic. So too, when drains are dried up by the sum- mer heat, the disease is more rife than in seasons when they are full. A dried marsh, and the banks of tidal rivers exposed at low water, are made more pestiferous. So you see sanitary im- provements require judgment as well as zeal. I believe the safest mode of treating dust would be to wet it. You will observe that hearty people, when they do get low fever, generally have it very badly, as was the case here. I sup- pose their system is able to resist small doses of the poison, and when it absorbs large doses they are the more completely pros- trated. Be careful not to give a favorable prognosis because your patient is a strong man : the muscular and the corpulent are of all the population those who run most risk. Case 16.— Caroline H. (C. B. 103, p. 214). This woman had great pain on pressing the abdomen, and fever stools. So she ought, by rule, to have exhibited a rosy rash ; but instead of that, there was a dusky subcuticular eruption, which is generally held to be of the mulberry sort. Van Swieten describes it as " lying very deep under the skin, as if nature, overpowered by the vio- lence of the disease, could not complete the critical translation which she had be";un."* He considers it a danrjerous siern, and I think he is right, as a general rule ; for, though this woman recovered, she was very ill. Case 17.— Charles N. (C. B. 103, p. 228). This boy, again, had livid spots accompanying abdominal complications, which were relieved by leeches. Case 1^.— Mary D. (C. B. 103, p. 228). A washerwoman, * " Commentaries on Boeiliaave," vol. vi, sect. T'J.'J. TYPII-FEVER. 115 who became affected immediately after receiving the dirty linen from a house where there had been fever patients. It seems to me difficult to avoid a conclusion, that low fever may become contagious when the poison is concentrated. It is certainly wise to act upon this opinion. Here again I made you remark the intcrmlttence of the pulse from debility during fever; and I also called your attention to the natural appearance of the stools during the height of the disease, and to their becoming liquid and fetid as the febrile symptoms declined and she' began to emaciate. A diarrhoea of fsuch a sort at such a time is a very favorable occurrence ; it is a critical discharge of the peccant humors. Case 19.— John G. (C. B. 103, p. 232). This was the third dustman. His pulse was also intermittent, as in three former cases, but not till he was getting better. At first it was not above 80, though he was very noisily delirious, and had a brown tongue. You may observe this abnormal slowness of fever pulses to be particularly prevalent in certain seasons. They have been slower than is quite consistent with the severity of other symp- toms this winter. Case 20.— Stephen F. (C. B. 103, p. 246). I hear from Mr. Sanders, of Chigwell, who attends this boy's family, that they had fever with "mulberry-rash" in the house, and that a bro- ther had died of it. Stephen was sent to London to be out of the w^ay, but sickened on the day of his arrival, and had rose spots in several crops. It is difficult to imagine the probability of two brothers contracting different miasmatic diseases in the same house, at the same time, and from the same cause ; and the rational conclusion would seem to be, that both were of the same nature. It would only be the most overwhelming evidence which could lead us to think otherwise. Stephen was very nearly following his brotlier to the grave. The more propitious hygienic circumstances under which he was placed, in an airy hospital, instead of an ill-drained cottage, weighted the scale in his favor. I do not see anything fresh to remark in the pathology of this case, except that the patient got a superficial sore on the back by obstinately saturating his sheets with urine and faeces, and continuously rubbing the sacrum 116 TYPII-FEVER. against them. You must distinguish these superficial sores from sloughs, because the same treatment will not prevent them. They will be produced by friction in spite of a water-pillow and all possible cleanliness, as in this lad's case. The best way of managing them is to paint the parts directly they get red with gutta percha softened in chloroform, of the consistence of paint, so as to dry immediately on application. You thus obtain an artificial new cuticle, and can renew it as many times a day £^s you like. Case 21.— Henry G. (C. B. 103, p. 2C)2). Instead of colored petechise, the eruption in this very low case consisted of miliary vesicles scattered like fine seeds all over the chest and abdomen. They are called in the case-book "sudamina." The word is de- rived from their often accompanying excessive perspiration;* but remark that the association is not a necessary one ; this man's skin Avas quite dry till he became convalescent. Case 22.t— John B. (C. B. 103, p. 106). I have taken him out of chronological order, because he was not treated by muri- atic acid. In fact, the fever had passed away, and he might be called convalescent; yet you saw him very ill, unable to raise himself in bed, and with a brown crust in the center of his tongue. On inquiry I found that this low condition, remaining after the special symptoms of the fever had passed away, arose from inanition. Beef-tea, wine, and bark, set him up directly. You will see a good many such cases in dispensary practice; they die, though convalescent, from sheer starvation. It is of some importance to recognize this fact, and you will find the most pathognomonic sign is the coincidence of the brown tongue with a perfectly clear mind and cool skin. These latter show that the typh-poison has passed aAvay, and that the condition of the mouth is tlie result of want of nutriment. * Or perhnps from their likeness to beads of sweat scattered over the skin. They are very common in Italy, appearing on the skin of persons with acute rheumatism, and, in short, all febrile diseases so generally, that "miliary fever" is considered by some to be a peculiar disease sui generis. f The numbers refer to the cases as they stood in the lecture originally pub- lished in the "Lancet" newspaper. LECTURE IX. TYPH-FEVER. Part I. — Three fatal cases since October, 1861 — One hrouglit in moribund, one treated with liydroeldoric acid, cj-c, one not — Four cases in hospital related, tvith comments — Danger of giving solid food too early in convalescence — Absence of enteric symptoms best guide to administration of solids — Dose of hy- drochloric acid for children — Connection of tyidhfever and 'pneumonia — Smallpox caught during convalescence from typh- fever. Part II. — Additional case, illustrative of the connection betiveen the two forms of typhfever eruptions — Precautions in case of threatened pneumonia — Caution against moving patients in fevers. Part III. — Four additional cases, with comments. Case 1. — Difficulty of distinguishing typhus and e7iteric fever — Relief of eutopic pain — Dry, glazed, cracked tongue in enteric cases — Arrest of diarrhoea by hydrochloric acid, by Dover's poivdery ^c. Case 2. — Fever spots and flea-bites — Fever cut short by an emetic — Emaciation during convalescence not prevented hy the cutting short of the fever. Case 3. — Fever cut short hy an etnetic — When not arrestive, this treatment is palliative. Case 4. — Fever contracted in the hospital aggravated nearly to a fatal extent by inflammation of previously diseased genital organs and bladder, and by a slough on the sacrum. — Treat- ment. Part IV. — Case of typh-fever contracted in the hospital by a patient admitted for acute rheumatism — Emetic only partially successful — Administration of solid food and ivine. [Clinical, St. Mary's, January 10, 1863.) Since October, 1861, when I last discoursed to you on con- tinued fever, it has been more than usually prevalent in both 118 TYPII-FEVER. its enteric and typhus forms, especially in the latter form during the present session. I have persisted in the employment of the same treatment I then commended to your notice, and with the same encouragement to proceed. There have been two deaths among those so treated. One was in the case of a little boy, age unknown, who was carried into the ward, December 17, 1861, quite unconscious, cold, pulse- less, with livid lips and colliquative diarrhoea. I scarcely can tell hoAV much of the nourishment given him was swallowed, and he did not survive the morroAV of his entering the hospital. I should have liked to know in what state this child Avas before he was brought away from home. It is not at all impossible that he might then have been in a condition admitting of recovery; for children very rarely die of typh-fever, however severely they may have it. At all events, it is certain that the exhaustion of the journey hither was the immediate cause of the fatal result. The patient was, to all practical purposes of restoration, dead before he came inside the doors. If your future pursuits should place under your charge poor people at their own houses, I do hope that events such as these (and they are sadly common), will make an impression upon you. Pray do not send bad cases of typh-fever out of their beds to be dragged in an exhausted state to a hospital. None of the advantages to be obtained there can compensate for the chances of life so thrown away. Another death occurred in a girl of eighteen. I was away for my holiday at the time of her decease, and no post-mortem examination of the body was permitted by the friends; nor are the clerk's notes very explicit — they seldom are in vacation time — but as far as I can judge from the history given me by the ward-sister, she seems to have yielded to a very rapidly con- gestive pneumonia. I am very sorry to have no further informa- tion about her, as nothing is so instructive as the investigation of the causes of failure of treatment usually successful. Another case of death from the inflamed and ulcerated bowels which so often accompany typh-fever, occurred in November last. But she was unfortunately not treated in my usual way, TYPH-FEVER. 119 for a reason which I will take the opportunity of telling you as a warning, as I trust the same reason is likely to be rare. The patient, Elizabeth T , was a girl of eleven years old, who was brought here October 24, with intense headache, deafness, delirium, vomiting, picking at the nose, and other symptoms, which the mother attributed to a blow on the back of the head. This led to a wrong diagnosis, and the child was, by my orders, treated with iodide of potassium, and blisters on the vertex, as for inflammation of the brain ijiydroceplialus acutus). I was absent from London at the time of her death also, but a post- mortem examination was made. The brain was confrested and wet, as it usually is in those that succumb to acute fevers, and have blood more fluid than natural. There was, however, nothing like the appearance caused by acute hydrocephalus, nor any trace of injury. On opening the abdomen, the cause of death was at once referred to the ilia, which were extensively inflamed and ulcerated in the manner usual in typh-fever. I wish people would more frequently put on record mistakes made in diagnosis; they are full of interest and instruction for themselves and others. The rest of the fever patients which have passed through the wards have done well, and I have no record of anything note- worthy in their cases beyond circumstances to which I have called your attention in former lectures apropos of former in- stances. I do not lecture to you about by-gone patients, except they have presented phenomena unlikely to occur again, pre- ferring to wait patiently till I can illustrate my words from the life. I will confine my remarks, then, to the four cases now remain- ing under your eyes, two in the male, and two in the female wards. Elizabeth T — , aged twenty-two, was made my patient De- cember 9, 1862, with rose-spotted fever of five days' duration since the introductory rigor, with very thickly coated tongue, diarrhoea, and severe pain on pressure of the abdomen. Every- thing went on well, no fresh spots came out after the 13th. On the 18th the appetite returned, and she was allowed fish diet at 120 TYPIIFEYER. her urgent request, although some tenderness remained in the abdomen, and on the 20th meat and beer. On the 25th it seems her appetite had failed again and she had a rigor and some vomiting. When I saw her on the 26th she was unable to stand ; her whole aspect denoted a relapse, and I sent her to bed with a return to my usual treatment of fever, dietetic and medicinal. It was a short attack, and no spots were seen on the skin. So that on January the 7th she was convalescent, and is now eating solid meat. The remark I have to make on this case is to warn you against too early yielding to the request of patients for solid food. They have a fallacious notion that it is more nutritious than the con- tinuous liquid diet which is given them, and in order to get it will pretend to feel more appetite than they really do feel. They will also often conceal that tenderness of the abdomen which is the sign of the yet unhealed congestion of the mucous membrane of the ilia. I should tell you, too, that when the patient takes hydrochloric acid, you are more frequently tempted to the error in judgment against which I am warning you than when they have other medicines. The acid causes a more rapid renewal of the lingual, and I suppose, at the same time, of the intestinal, epithelium : the dead, dirty coat is cleared away, and you have a clean tongue earlier than would otherwise happen. I was talked over by the patient too easily in this case, and ought to have been deterred, by the abdominal tenderness, from giving her meat so soon. The consequence was, the slight relapse which you have witnessed. William W — , a dirty, dissipated looking person of thirty-six years old, was sent to bed on the 30th ult., in a state of weak- ness and constant delirium, which entirely prevented his giving any account of himself; and now that he is getting well, his memory of recent events seems very dim. He was said, how- ever, to have been ill a week, his body was covered with livid spots, his tongue was brown and dry, and his tremulous hands kept picking at fancied objects before his eyes and on the bed- clothes. There was no diarrhoea or pain in the abdomen. He was treated in the usual way, and had ten ounces of port wine daily, with the usual result. TYPIIFEVER. 121 It is noted in the diary that he had some evacuation of liquid motions soon after admission, but that the stool was "natural" in appearance. What is meant is that it was such as is naturally caused by a purgative, and not the dark fetid excretion of fever, and in fact was traceable to an emetic draught which was ad- ministered on admission, and which did not cause vomiting and therefore went off by the bowels. Be careful to distinguish phe- nomena arising in the course of disease which are caused by art from those which are morbid and part of its essence. This man had no real diarrhoea and no pain on pressure of the abdomen, and therefore I did not hesitate on January 7th to order him meat diet on his expressing himself desirous of it, although he was not sufficiently recovered of his fever to be able to raise himself in bed; and I feel confident he will continue, as heretofore, to do justice to his treatment. Edward C — , a boy of seven years old, was seized on Decem- ber 28th with rigors, nausea, loss of appetite, nocturnal delirium, and febrile depression, so tbat he could not lift up his head. He Avas brought under my care on December 31st, by which time there were numerous dusky fever spots on the belly. He was put upon the usual treatment, and is now convalescent. I have to remark about the orders on the medicine card, that he took the same quantity of hydrochloric acid which is administered to adults, namely, twenty minims every two hours, without any inconvenience following. I have not generally given such large doses to children, but shall know now that it may be done with propriety. It is remarkable that a few days before this boy was attacked by typh-fever, without any local complication whatever, his father fell ill and was brought into the hospital on December 29th, with pneumonia affecting between one-third and half of the left lung. The father has had no delirium, nor more nerv- ous depression than is accounted for by the condensation of the lung, no eruption on the skin, nor diarrhoea, nor anything Avh'.ch would lead one to set down his complaint as due to the same cause as his son's. Yet the coincidence, joined to the fact of their residence being an ill-drained, ill-ventilated house, where 122 TYPII-FEVER. almost everj one lias been ill, is too striking to be passcl over in silence. Did the exposure to cold and wet during his daily labor predispose the hard-worked father's lung to be affected by the same cause, the typh-poison, as absorbed into the boy's blood acted principally on the nervous system? Was his more robust frame, and the dura messorum ilia able to pass un- scathed a dose of the typh sufficient to poison the more delicate tissues of the younger subject, while at the same time his lung, devitalized by wearing toil and exposure, yielded to its influ- ence? Is, in short, the pneumonia the expression of a quantity of poison enough to injure a failing part but not enough to aifect his whole body? I do not like to answer these questions ex cathedrd, but I cannot help seeing some connection between typh-fever and inflammation of the lung. The different way in which the same morbid agent afiects different individuals should guard you against considering it as the disease, against looking upon illness as something to be evacuated or neutralized. The disease, that against Avhich you have to struggle, is the partial deficiency of life caused by this morbid agent, and your struggles must take different forms ac- cording to the different forms of the deficiency. The fourth case of typh-fever still in the hospital is that of Sarah H — . She is a married woman, aged twenty-eight, of slim figure, and not muscularly strong. She was admitted De- cember 5, having rose-spotted fever of three days' duration since the rigor, and accompanied by delirium. As is usually the case with delicately framed susceptible females, the nervous system was especially affected : we were forced, in addition to the usual fever treatment, to give her a great deal of port wine ; the belly became tympanitic, and I was at one time seriously alarmed about her. However, on December 18 she was in her right mind and convalescent, though unable to raise herself from the lying posture for her natural evacuations. I mention the fact of her being quite confined to bed for a special reason. On the last-named date there was in the ward for a few hours, a patient who was discovered to have variola, and was sent off to the Smallpox Hospital. Now, Sarah H — TYPII-FEVER. 123 was the only unvaccinated person in the ward, and the con- sequence was that she received the infection, and has since gone through a severe attack of the confluent form of smallpox. In spite, however, of having thus imbibed a new poison, she con- tinued to increase in health and strength till the 30th. On the morning of the 31st she had a decided rigor, she became fever- ish, lost her appetite, and had nausea. The pulse rose to 110. Thinking she was about to have a relapse, like the first patient to whom I drew your attention, I put her back on the usual fever treatment, which she has continued to have ever since. One piece of information you may gain from the accident of this unfortunate patient having the two diseases so close upon one another, is the fact that typh- fever does not prevent a per- son receiving the infection of smallpox. A second is, that the presence, in a latent state, of the morbid poison which gives rise to the latter disease, does not retard the progress of convalescence from the former; and is in reality dormant as well as latent. A third is, that on the whole, the sufferings from smallpox are more severe than those from typh-fever. Our patient declared, at first, that the fever was the worst of the two, but by the time the pustules had completely maturated, and she was sore all over, she frankly confessed to me her error. {Clinical, St. Marys, February 13, 1863.) On Ellen D — , a servant girl, aged sixteen, who came under your observation three days ago with typh-fever of a week's duration, you have seen an instance of the two most common forms of eruption in this disease. The bosom and abdomen were thickly covered with dark livid spots, many of them as deep purple as those of purpura hcemorrhagica. She was in a very low state, the blood being very venous. Yesterday, in ad- dition to the purple spots, I observed on the abdomen several spots slightly raised above the surface of the skin, and of a much more pinkish hue. Her hair, and probably, therefore, her skin are naturally dark, so the maculae are not so pink as they would be in a blonde complexion; but still, no one would hesitate to 124 TYPII-FEVER. call tliem "typlioid" spots. This shoAvs jou the great difficulty that lies in the question of whether there are two distinct animal poisons causing "typhoid" and "typhus" fever. Doubtless, it is not impossible that both may exist in the body at the same time, and give rise to two distinct fevers at the same time ; just as a person might be poisoned by a mixture of strychnine and antimony, and exhibit the effects of both drugs together. But in the case of morbid poisons which increase in the body, such a joint progress shows at least a very close relation between the two. There are also other instances where the eruption seems to exhibit a transitional character, or wliere there is not a sufficiently distinctive eruption. In our register these cases are not distinguished, but are entered simply as "fever." If then there are two poisons which cause typh-fever, a point I consider not proved, they must be much nearer allied to one another than those which originate the usual eruptive fevers, such as scarlatina, smallpox, &c. You may have observed that I am loose in my nomenclature of this class of diseases, speaking sometimes of "common con- tinued fever," sometimes of "continued fever," sometimes of "low fever," sometimes of "typh-fever," sometimes of "fever" simply, when I mean the same thing. This is not from careless- ness, but to show you my opinion that for therapeutics, to which the greater part of my clinical lectures refer, the name is unim- portant; and also because the terms "typhoid" and "typhus," having acquired a special limited meaning, and when used by me, being used in that special limited meaning, are unsuited to my general purpose. Their employment would seem to prejudge a question upon which I am not engaged in this chair. I should advise you also not dogmatically to prejudge the question. Use, if you like, the popular nomenclature, but do not be skeptical of the possibility of the eruptions being pheno- mena of one morbid poison, varied by varying circumstances, any more than you are skeptical about their being indications of two poisons. There is no necessity for being in a hurry to decide, for it is not a matter of any importance to yourself or your patient. TYPII-FEYER. 125 Both forms of disease are infectious to a certain extent, as occasional instances in the wards show you. Typhus is said to be most so, perhaps from its following a larger dose of the poison ; but neither are very infectious, and do not require the extraordinary precautions proper for smallpox, measles, or scar- latina. And both call for the same treatment, and are accom- panied, though in varying proportions, by the same local in- flammations. AVhile on the subject of typh eruptions, I may take the oppor- tunity of warning you uot to limit your observations solely to the surface of the chest or abdomen, as is very commonly done. The flanks and buttocks are often the seat of them, and I have sometimes found spots very marked and indubitable in these situations, when their presence elsewhere was doubtful. In females especially it is convenient to find them liere, as it obviates the necessity for baring the front of the person, a pro- ceeding naturally repugnant to a delicate mind. Of course if they are not there you must examine the more usual habitat. In this girl there was great general congestion of the lungs; the respirations were much hurried, amounting to thirty in the minute; there were sibilant rtxles all over the chest, most intense at the back part ; but there was no localized dullnes on percus- sion. In consequence, I believe, of this congestion, the pulse was quicker than usual, beating 140 in the minute; for you will rarely find it above 120 when the pulmonary tissue is in a healthy state. When there is such an amount of congestion as to produce marked dyspnoea, it is better to omit the usual sponging of the surface of the body, or you run the risk of pneumonia. This had been done in the present instance, and the chest has been enveloped in a "jacket poultice." She now breathes easier, has less cough, and the pulse has sunk to 110, getting stronger at the same time. The even temperature of a poultice is by far the most powerful means of restoring the deficient vitality of the lungs, where that deficient vitality is general; I mean when the pneumonia is not circumscribed. You may observe that very many patients say on the first 9 126 TYPII-FEVER. visit, that they are "worse than before they left home to come into the hospital. Sometimes even deaths occur within the first thirty-six hours, of which I related you an instance in a former lecture,* the patients being, in fact, death-struck from the moment of admission. This arises from the exhaustion induced by the journey hither, of which you may always see traces, however short it may be. Removal even from the next street does harm, and the harm increases in a mathematical ratio to the time and distance required. Bringing patients in from a great way is most murderous; no excellence of nursing or superior comforts can atone for the risk run. As far as we possibly can, we limit our reception of typh-fever to the neigh- boring parishes, and prevent persons from a distance being admitted, if we hear beforehand of their coming. And once within the walls, they are spared every unnecessary movement; they are sent upstairs to bed in the lift, not allowed to raise their heads from the pillow to drink, and are supplied with a bed-pan for the other calls of nature. In typh fever everything depends on sparing most avariciously the little vital force that remains. You will have reason to re- gret every muscular exertion that you allow patients to make. I was called lately to Hertford to see what seemed to have been, and to be, a very moderate case of fever with intestinal affection. None of the distinctive bad symptoms peculiar to the disease had showed themselves. But unfortunately the patient had been at Brighton Avhen taken ill ; she pined for home, was allowed to move thither, and never rose from the prostration caused by the journey. I have heard of cases where the permission to sit up in a chair, instead of lying in bed, has resulted in fatal prostration. You will find of course more obstinacy on this point among the upper classes than the lower, and you will sometimes have great difficulty in overcoming it. But it is your duty to try and do so; and should patients persist in disobeying orders to keep quiet, I advise you rather to cease your attendance than to give way. You niust not allow people to sacrifice your good fame as well as their own lives. * January lOlh. See page 117. TYPII-FEVER. 127 [Clinical, St. Marys, March 6, 1863.) Eliza C — , a stout muscular girl of eighteen, was received February 27, with the usual symptoms of continued fever. The eruption was at first of a doubtful character; nobody could have decided accurately whether the spots were a pale example of those usually called typhus, or whether they were fading typhoid spots. This difficulty is one of the many which beset the investi- gation of the question of their identity or non-identity. Inas- much, however, as from the same house her sister was at the time under my care, and an aunt had just died with indubitable typhus, I thought it very likely her eruption would exhibit the same variety of appearance. But no — it proved not so, for since then many rosy spots, slightly elevated above the surface of the skin, have come out in successive crops. I mention this, be- cause these rosy spots are a warning to the physician that he may expect inflammation of the intestines. And the warning has been justified in this case; for the patient's principal com- plaint during the last few days has been pain in the abdomen, aggravated by pressure of the right iliac fossa, and much light- ened by a linseed meal poultice. There is nothing does patients with enteric symptoms so much harm as moving about and the impression of dry cold, and nothing does them so much good as lying quite still on the back and applying moist warmth. A poultice accomplishes both objects, it keeps the patient im- movable, and acts as a sort of perpetual Avarm bath to the ab- domen. It entails of course abstinence from the sponging treatment. Another warning of enteric inflammation was seen in her dry tongue, without much coating of epithelium, and with transverse cracks from side to side. It is seldom that you see a tongue like this Avithout the intestines being inflamed. This girl has had scarcely any diarrhoea. The fact is, that the hydrochloric acid treatment always prevents the diarrhoea of fever from attaining any prominence as a symptom. There is usually just about enough to show what it would be if not stayed. Should the hydrochloric acid alone be not sufficient, 128 TYPII-FEYEK. the diarrhoea is best treated by Dover's powder, both the opium and the ipecacuanha in that preparation being good for dysen- teric inflammation. Kino powder is also apphcable to such cases; but chalk is of course out of the question while you are administering hydrochloric acid. Thomas W — , a robust boy of sixteen, was brought here February 28, with symptoms of low continued fever of three days' duration. There was xerj great depression when the resident medical ofiScer, Dr. Rhodes, saw him then, and he fully expected it was going to be a very bad case. He ordered an emetic immediately, and the consequence was the vomiting of a quantity of blackish matter like semi-digested blood. "When I saw the lad the next day, he was so brisk-looking in the face, and exhibited so little febrile depression, that at first sight I was disposed to question Dr. Rhodes' diagnosis. But then I was shown the abdomen and chest covered with small purple spots. Even then I was not convinced, and put the spots to the test of examination by the microseope. I thought they might be flea- bites. Now, fleas cannot leave their marks without a puncture, and in all flea-bites you may, with a lens of very moderate power, if not with the naked eye, delect this puncture as a very minute dark-crimson point. The spots stood this test, there was no puncture, and they were certainly purpuric typhus spots, which have since faded away. But how is it that he had and, indeed has had since, so little febrile depression? The fact is, this is one of those fortunate cases of a fever cut short by an emetic. He is now emaciating, and emaciating extensively, and conva- lescent. In the last sentence I laid some stress on the word "emaciat- ing." The emaciation is a phenomenon of great interest; it shows how large an amount of tissue is interstitially poisoned in typh-fever ; how large an amount requires to be carried off by destructive metamorphosis during the renewal of life. In such cases as this, when the fever is cut short, it by no means follows that the emaciation should be cut short, and in point of fact it TYPII-FEVER. 129 is not so. The removal of the destroyed tissue is a necessary part of the case. Strokes of good fortune are sometimes equally gregarious with the proverbially "seldom single" misfortunes. Next bed to the boy lies a young man whose fever has been in the same way cut short by an emetic. Thomas B — , aged nineteen, ex- hibited on the 3d of March the usual symptoms of continued fever of three days' duration. There have been all along but few spots, and those of obscure indeterminate character on the abdomen. But he had the aspect of being very ill, and his tongue was thickly coated with yellow fur, and showed a ten- dency to get dry. He was treated in the same way as the last patient, with an emetic and hydrochloric acid, and has entered fortluvith upon convalescence. It is now nearly two years since I have had a case of fever so decidedly cut short by an emetic ; so do not expect it often. But nearly all have. the violence of the disease alleviated by that remedy; so that it is never out of place during the first week of the fever. Emily H — , aged twenty-six, married, was entered to the ward assigned to uterine diseases, for irritability of the bladder arising from antiversion of the womb, in middle of last month. On the 2d instant she was taken with feverishness, loss of appe- tite, and pains in the head and back. She had a rigor that night; she was transferred to me yesterday, and then there were obscure livid spots on the abdomen, and pain on pressure. She has been put on the usual treatment, and it appears likely to prove a mild case of typhus fever. I only mention it here as having been apparently contracted in the hospital, which I am glad to say is not a common occurrence. {Clinical, St. Marys, March 20, 1863.) Emily H — , about Avhom I said a few words on the day after her coming under my care, has given us more anxiety than I looked for. Iler antiversion of the uterus had been treated by a pessary, and her delirious, semi-conscious state, caused by the 130 TYPII-FEVER. fever, prevented her making this known to the nurse. The in- strument was removed immediately that it was discovered, and was followed by an excessively fetid discharge from the vagina, which lasted some days. A vaginitis had, in fact, been produced by the pressure, easily enough borne by a healthy vagina, but acting destructively on that part when its vitality Avas lowered by general disease. I was fearful that the patient was going to have internal sloughing, but she has escaped by good fortune and the use of an injection of decoction of cincliona and chlori- nated soda. She has escaped so far as her generative organs are concerned, but not altogether; the vaginitis and fever united entirely paralyzed the sphincters of the bladder and of the rec- tum, and it was impossible to prevent the pillow on which her sacrum lay from being soaked with the excretions. Her constant delirium also made her very unmanageable at first. We could not prevent the pressure on the sacrum, and the consequence is that a rather deep slough has formed there. This woman afforded an example of how the mental qualities, as well as the corporeal, suffer degradation in illness. During her raving she was constantly attempting to practice masturba- tion, and was uncurbed by shame, so that the nurse was obliged to be constantly on the watch to withhold her. I have no reason to suppose her generally a vicious person, and in recovering her reason she has recovered her modesty and self-restraint. When the human mind loses some of the divine powers bestowed by its Creator, it becomes as the mind of a brute. Madness is not something added to it, but something taken away; those powers are taken away by virtue of which it is said to be made "in the image of God," and by virtue of which it resists degrading in- fluences. The degrees or forms of madness are degrees of loss of free-will and self-control. I am happy to say she has now become rational, and also re- gained control over her sphincters, so that she is on the road towards convalescence. But if any more accidents happen, I will bring the case before you again. You saw that till the inflamed, or dying portion of skin gave way and broke, I kept it carefully painted over with gutta TYPII-FEVER. 131 perclia dissolved in chloroform; she has also had a water-pillow. The treatment w^as unsuccessful indeed in this instance, but still it is the best. 'After the skin was broken, a cinchona cataplasm was applied, which, by-the-bye, I may tell you how to prepare most economically. Do not make it entirely of bark, but sprinkle the powder thickly over a common bread or linseed poultice; you thus save an expensive drug, and also keep it moister. Now that the sloughy cellular tissue has separated and been cast off, I shall treat the sore by touching it alternately with nitrate of silver and applying tincture of benzoin, whenever the edges look livid and unhealthy. These low inflammations in continued fever are almost always a reason for giving alcohol to sustain the nervous system. Emily H — had at first six ounces of port wine daily, but I was soon obliged to increase her allowance to half a bottle, and she will probably continue that during a great part of her convalescence. There is danger in suddenly leaving off stimulants which have been beirun in fever. {Clinical^ St. Mary's^ January 24, 1863.) Elizabeth J — , aged nineteen, came in on January 16, with rheumatic fever, affecting principally the feet, knees, and hands. There was one day considerable pain on pressure of the cardiac region, such as is caused by rheumatism of the intercostal muscles; but that was immediately relieved by the application of half a dozen leeches, and there were no symptoms or signs of the disease spreading to the heart or pericardium. The pains were quite gone on the 21st; and on Sunday the 25th she was up and dressed, though still on the low diet, which seems best to suit convalescents from acute rheumatism. On that day she was taken with rigors, sudden loss of appetite, severe pains in the head, in the back and limbs, and complete prostration of strength. When the house-surgeon saw her in the evening, the tongue was exceedingly clammy, and covered with a whity-brown coat, as if getting dry; she was delirious; the pulse was 120; 132 TYPII-FEVER. and the skin hot, and of a dusky mottled color. Now, these symptoms were certainly not caused by the alkaline treatment of the rheumatic fever, for she took the bicarbonate of potash only five days, was not prostrated by it, and had left it off for four days; but as there had been a constant succession of bad cases of typhus fever in the ward, and the patient had all the symptoms of that complaint, Dr. Rhodes wisely decided that she must have caught it; and wisely also, acted in a decided manner. He immediately ordered her an emetic, and after its action, the usual diet and hydrochloric acid every two hours, with tepid sponging three times a day. I have told you that emetics will sometimes extinguish a typh- fever by a kind of conp-de-main. But really the cases in which this fortunate result follows are so rare, that you might hesitate whether it was worth aiming at, if no other good was to be gained by such bold treatment. It did not follow to the patient now Tinder consideration ; she remained delirious, quietly talking nonsense about various things; during Monday and part of Tuesday her tongue got dry, although cleared by the treatment, and the pulse kept quick. The prostration and tremor of hands were very great. It was impossible not to conclude that she was under the influence of a powerful poison. The cause of the disease was not removed, or the disease extinguished. Yet, though not extinguished, it was certainly shortened, for on Wednesday you saw her with her tongue clean and moist, the skin much cooler, and the pulse, though still 120, much firmer. Now, the normal duration of such a severe typh-fever, as she gave every promise of having to go through, is at least three weeks; and she would have had, in the course of nature, to be much worse before she was better. But here you see her in three days enter upon a convalescence which I do not doubt will be permanent; and I cannot help attributing this abbrevia- tion of the malady to the emetic. She was so much better on Wednesday, that I was asked if she should leave off the acid and be put upon the bark treatment of convalescence, and also whether she should have wine. I have never made the alteration of medicine so early in the dis- TYPII-FEVER. 133 ease as this; but I have occasionally been induced by the clean- ness of the tongue to do so only a few days later. And I must say, I have usually seen reason to regret it. The too early ad- ministration of cinchona, as well as tlie too early administration of solid food, have appeared to me to have been the causes of relapse in several cases. It is better not to give cinchona at all, and to postpone solid food till the patient is quite strong again, tlian to give them imprudently soon, and so to run the risk of relapse. As to wine, seeing that she is a young girl not habituated to alcohol, and has got over her delirium without it, I think it a superfluous expense. LECTURE X. SMALLPOX. Part I. — Case of smallpox watched from first infection — Se- quence of phenomena — Memoria technica by which to remem- ber their order — Use of observing the order — Action of oxygen on tlie general health of the patient and on the skin contrasted — 3Iicroscopical examination of the contents of the pocks., ivith practical deductions therefrom — Depth of injury to skin in smallpox — Reasons for cutting the hair. Part II. — Sj^read of smcdlpox in the hospital from the above case — Example of the use of vaccination in modifying the dis- ease — Action of vaccinia not homceopathic or counter-irritant — Infectiousness of smallpox compared zvith other diseases — Dif- ferent degrees of infectiousness demand different precautions. [Cliiiiccd, St. Mary's, January 16, 1863.) You have had a chance, such as falls to the lot of only lucky medical students, of watching the whole progress of a case of smallpox, from the first introduction of the poison into the body up to the completion of its work, in a young woman about whom I lectured last week apropos of her previous attack of typh-fever.* On December 18, Sarah II — was confined to her bed in the long ward, when a patient with variolous eruption fully developed was brought in, the law excluding such cases having been broken by an oversight consequent on the occupation of the officials at a hospital election. This person remained scarce two hours in the ward, and was never nearer to Sarah H — than thirty-six feet. But an extra nurse, who was then engaged, may very likely have been in attendance on both, and have carried the * See page 122. SMALLPOX. 135 infection in her clothes, not having been reserved, as she ought to have been, to the dangerous patient. That such a mode of transfer may have taken place is rendered probable by this nurse having communicated smallpox to her own child, with whom she slept, without taking it herself. The nurse, however, and all in the ward except Sarah H — , had been fully vaccinated; and it shows the powerful protection thus afforded, that all escaped personal harm except Sarah H — . On her, indeed, vaccination had been performed, but it had failed. Here you have been enabled to fix the exact time when the poison was received, and to trace the history of the resulting disease, unmodified by any protecting or disturbing causes. The pathology of smallpox, as we are taught it in books of syste- matic medicine, is derived from such examples as these, occur- ring in the olden time before it was neutralized by Jenner's immortal discovery. And it should give us confidence in our forefathers' powers of observation that cases of unmodified small- pox, then the rule, now happily the rare exception, are rightly described. You have seen a sequence of phenomena punctual to the due times laid down by them, and which I teach you in my systematic lectures on their authority. Twelve days did the seed lie dormant ; then its presence w^as declared by a three days, a more properly two days and a half, fever (counting from the first rigor) ; then for two days it bore a crop of papules ; after that, a vesicle growing gradually opaque for three days more, and then for two days encircled by a halo of rosy inflammation ; the next night brought the evidence of the complete filling of most of the pustules, by the rupture of the little band of epider- mis which had hitherto fastened their centers to the cutis. When the vesicles were two days old, the face swelled and there was considerable salivary secretion ; and the distention of the pustule was accompanied by swelled extremities. Since then the erup- tion has been gradually drying up. This normal order of the phenomena of variola is important to remember, not merely because it is a matter of scientific inter- est, but that you may be able to satisfy yourselves and your patients that all is going on right, and that the very disagree- 136 SMALLPOX. nble and painful appearances which they present are not signs of overhanging danger. I refer especially to tlie swelling of the face and hands occurring in proper succession, and Avhich would be alarming if unexpected ; whereas if you are enabled to forsee them, they are rather good omens than the contrary, and a source of justifiable consolation. To assist my memory as a pupil, I put the facts into some doggrel Latin verses : Bis sex celatur virus, tres febre notatur, Fertque duos soles papulam. tres postea opaquam Vesicam, roseuraque duos perfectior orbem ; Vincla cutis niedii dissolvit postera luna. Bidua vultum inflat vesica, movetque salivara. Pustula fert distenta manumque pedumque tumorem. Rough and bad as they are, they served my purpose. You may easily fix them in your minds by taking the trouble to make im- provements in the versification, for which there is ample room. There will be a real clinical use in such an exertion of school-boy knack. The unvarying sequence of the symptoms in smallpox may also serve in doubtful cases as a means of diagnosis, not only from other eruptive fevers, but even from chronic diseases. I have known, for instance, a case of eruption in a baby at the breast, Avhere it was impossible to decide, by the appearance, whether it was variolus or syphilitic, and where the counting of the days alone enabled a conclusion, afterwards proved correct, to be come to. I think I see you smile at the idea of two such different diseases as syphilis and smallpox being confounded. But your smile is one of imperfect experience. Syphilis, child of sin, shows its kinship to the father of lies by imposing upon us with imitations of many an innocent morbid state ; and among the rest it will often, in the infant, assume the exact aspect of smallpox, with central depression, red halo, and other usual diag- nostic marks. The reckoning of the days of latency and the history of the progress of eruption will alone save you frcfm fall- injr into our forefathers' error of confounding the "small" and the "great" pocks in babies, as the nomenclature shows that they did in early days. SMALLPOX. 137 You may have observed that this woman was placed in a large room by herself, with a blazing fire and two windows open night and day. To this access of fresh air to the lungs a great part of her freedom from the unfavorable symptoms so often accom- panying confluent smallpox is doubtless to be attributed. She has enjoyed her liquid food all along, and has several times prompted the addition of eggs, pudding, ale, &c., to her diet card, and I have no doubt will ask for solid meat as soon as the sore pustules in her throat will allow her to swallow it. But though the copious access of oxygen to the lungs is so highly desirable, I question very much whether it is equally de- sirable to the skin. I am led to this doubt by the following ob- servation. When the pocks were filled out, I opened a good many with a lancet, and examined under a microscope the con- tained matter. This was divisible into three classes : 1. That taken from pocks of small size and with slight inflam- matory halo. It was of the consistency of thin lard, white and opaque. Microscopically examined, it was seen to consist en- tirely of epidermic scales, the majority among them of normal aspect, but some filled with granular matter hiding from view the usual nucleus. 2. That taken from distinct and non-confluent pocks, with a broad halo, but not the largest or most humid of their kind. Here the normal scales Avere few, the granular scales equalling them in number, but more numerous than either were pus-glo- bules of various sizes and of irregular shapes, as if budding on several sides. 3. That taken from the worst of the distinct pocks and from the confluent parts. This consisted in several specimens entirely of equal sized pus-globules, with many dark specks and highly refractive fat-globules among them. There were hardly any epile — Arises from exposure to cold air during a catarrh — Danger much increased by imperfection of lung. [Clinical, St. Mary's, January 23, 1864.) The late weather, frosty, dry, and dusty, has borne its usual crop of severe bronchial catarrhs. Three of these came under my care last week, and I shall take the opportunity of making a few remarks upon the nature of the disease and the treatment required by the patient. What you see before you is a disease consisting of a rapidly occurring congestion of the mucous membrane of large and small air-passages, resulting in the pouring out of mucus and pus, and tending to destroy life by dyspnoea. In its slighter forms, and when affecting the trachea princi- pally, it constitutes the well-known "cold on the chest" or CAPILLARY CATARRH. 231 "bronchitis"* of the public in general. And when it is preva- lent on an epidemic scale, it is called "influenza." In these cases it appears to affect almost entirely the trachea and larger air-passages, and the oxidization of the blood is hardly at all interfered with. When the smaller or capillary bronchi suffer, then a serious interference with the aeration takes place, and the catarrh becomes, what is well called in old writers, "suffo- cative," or in more anatomical phraseology, "capillary catarrh." These cases differ from other bronchial catarrhs in the extreme sense of suffocation or dyspnoea, quite out of proportion to the physical signs elicited by auscultation, or to the cough and amount of expectoration. Important as the slighter cases are on the score of frequency, I cannot find suitable examples for clinical lecturing, for they usually are so much better after the seventh day, if there is no other disease in the chest, that they seldom appear in the wards. I can, however, exemplify by the more severe cases the treat- ment; the principles of which, and most of the details of which, are applicable equally to all. The first patient to which I ask your attention is Ellen C, a married Avoraan, aged twenty-two, eight months pregnant with her second child, who was admitted on the 8th instant, during the frost. She is robust and sturdy, and has not suffered any inconvenience from her pregnancy She had a cough for a fort- night, but it gave her so little inconvenience that she had not laid up till New-year's day, when it got much worse, and was accompanied by such shortness of breath that she was obliged to keep her bed, and w^as conveyed from thence to the hospital. You see that the dyspnoea was excessive, her face was congested and the lips livid, and she brought up by frequent coughing a small quantity of tenacious sputa, partly frothy with large bub- bles, Jind partly consisting of small, round lumps of tough mucus. * This word is vaguely applied, both by patients and by the profession when talking to patients, to any cough with expectoration. I believe peojile Hive much better to hear tliat they have "bronchitis," than to hear that they are coughing and spitting; but I think among ourselves we ought to give up the term as the name of a definite ailment; for it has been so much misused that it is too late to make it scientifically distinctive. 232 CAPILLARY CATARRH. The pulse was 120. Auscultation of the chest showed the lungs resonant, but filled with whistling, cooing, and all kinds of dry rales throughout, so loud, that the few moist sounds were seldom audible. She appeared in imminent danger. The whole chest was immediately enveloped in a jacket poul- tice of linseed meal, and she was directed to breathe entirely through a Mudge's inhaler, kept supplied with hot water. On the next day, the 9th, the dyspnoea was much relieved, and the pulse had sunk to 100. The same treatment was per- sisted in. On the 13th the pulse was 88, and she left off the inhalation ; on the 16th it was 72 ; the sputa were more opaque, and she breathed easily. The poultice was then discontinued, and a blister was applied to the chest. An ounce of decoction of bark was also ordered to be taken three times a day. This is a case of generally diffused acute bronchial catarrh without tendency to pneumonic condensation. The second case is that of Edward C, aged twenty-four, a bricklayer, now in Albert ward. He said he had been first seized by a cough and pain across the front of the chest on Christmas eve. This took him off Work immediately, but his breath did not get short, as it was when we first saw him, till a fortnight had elapsed, and the frost had commenced. Before admission he had been attending a few times as an out-patient, and it was on the last occasion of his so attending, viz., on the 13th instant, that Dr. Markham sent him up stairs to bed, as too ill to be allowed to leave our doors. The dyspnoea and lividity of face were not so great as in the last patient, but there was the same general diffusion of sibilant rales without dullness on percussion marked in any region. I say the dullness was not marked in any part; but after examination by the stethoscope had shown some fine crepitation beneath the right clavicle I percussed again, and then some of the bystanders thought that the upper lobe was not quite so resonant as the other. The tongue was white and furred, the sputa copious and frothy, and reported to have sometimes a yellow stain. CAPILLARY CATARRH. 233 He wanted to go home to fetch "his things," but his request was not complied with. He was ordered to be put to bed immediately, and to be cupped to the extent of six ounces beneath the right clavicle, the chest to be enveloped in a jacket poultice, and the vapor of hot water to be inhaled. On the 16th there was no fine crepitation or dullness on per- cussion. On the 20th the sputa had become purulent, and the cough alleviated during the day, though troublesome at night. He was then ordered two grains of quinine thrice a day, and to leave off the poultice, and has continued to convalesce. This is a case of acute bronchial catarrh arrested just on the verge of resulting in bronchial or catarrhal pneumonia. You may observe that the treatment of both these cases has been essentially the same as regards the most seriously injured part, the bronchial mucous membrane. Moist warmth has been kept continuously applied to both the inside and the outside of the chest. Moist warmth is the most powerful restorer of arrested circulation and vital action that we possess, the safest therapeutical engine we know of, because the most direct renewer of life. Perhaps you may exclaim that this mode of inhalation limits the supply of oxygen, which is so much needed for the aeration of the blood. I frankly grant that there is less free oxygen in warm steam than in cold air, and that therefore certainly less oxygen goes into the trachea; but I am not sure that less oxygen is absorbed by the pulmonary membrane. For this dilution with warm steam softens the tissue, and makes it more apt for endos- mose; and even in its immediate action it may cause more oxygen to be digested (if I may so say) from the weak, than from the strong supply. But oxygen (as I have often pointed out to you) is exceed- ingly injurious to tissues in the state of partial death which we call inflammation, and therefore the limiting its supply, to such extent as is consistent with safety, is not a thing to be avoided. You may ask whether this mode of treatment be applicable to 234 CAPILLARY CATARRH. the milder cases, such as you will have more to do with in privats practice than in a hospital. Yes — there is nothing like the in- haler for a cold on the chest, for which, indeed, it Avas first in- troduced by Mudge.* But you will not persuade persons with a will of their own to submit to a jacket poultice, unless thej are nearly as ill as our present patients. If there is much thirst, effervescing draughts of citrate of am- monia seem to be liked ; but when the illness is a serious one there is some danger in advising treatment by drugs, because sick persons are so prejudiced by habit in its favor, and it is so convenient to them, that there is a risk of their neglecting the other and more important parts of the advice. As soon as the mucus became opaque, you will observe that I ordered quinine. Begin your tonics always as soon as you can, for they enable more food to be digested, and thus they shorten the convalescence. In the second case, bloodletting by cupping glasses was ordered beneath the right clavicle. This was done, because pneumonia seemed to be just commencing in the upper lobe of the lung — a very dangerous situation for it to commence in, much more dangerous than in the lower lobe, and demanding prompt measures as much as the more generally diffused bron- chial affection. The third case I shall commence by the post-mortem dissec- tion. On Wednesday some of you saw the examination of the body of a woman aged about forty, externally in good condition and not emaciated or presenting any aspect of chronic ailment. The removal of the ribs disclosed the right lung contracted very much, and clothed as to its lower part with a smooth white leathery coat, not adherent to the walls of the chest, and but slightly to the lung, though it had bound the lobe together in its contraction, and had caused atrophic degeneration of its tissue. It was probably the remains of old hydrothorax, for * " Radical cure for a recent catarrhous cough, with a chapter on the vis vitte, &c." Second edition. 1779. CAPILLARY CATARRH. 235 which she was in St. Mary's about three years ago. The upper lobe of the same lung was not much better fitted for receiving air, for it contained old and contracting chalky tubercle, and a vomica of ancient date as big as a chestnut. In the left lung there was no tubercle or consolidation or signs of pleuritic disease ; but the whole substance was doughy, retaining the marks of the five fingers when the hand was pressed upon it. The tissue was not nearly so crepitant as it should be, and it was black with venous blood. Some parts seemed more decidedly emphysematous. The trachea and bronchi were deeply reddened and dry, no pus exuding, as it so often does, from their orifices when cut across. Heart and abdominal viscera were of quite normal appearance. This woman was in the hospital but four days, and was too ill for us to learn much from her during life. She was a quiet gentleman's cook, and, though habitually subject to cough and short-winded, had been able to do her moderate work somehow till the arrival of our late severe weather. That laid her up, and in a week reduced her to the condition in which she was on admission, namely, hardly able to breathe even when propped up in bed, with the face livid, and the pui'ple blood-shot eyes starting out of their sockets. I do not think she had any ex- pectoration. Dry cupping and poultices did no good, and she was unable to foment the bronchi with Mudge's inhaler. As from the resonance on percussion over the cardiac region, I had suspected there was a good deal of emphysema, I gave her some lobelia and ether, but I could not perceive that it brought any relief. There is more instruction to be gained from the appearances after death. I dare say some of you can call to mind that terrible February during the Crimean war, when the apparently tough sovereign of our tough enemies was suddenly death-struck, while actively engaged in his patriotic duties. Few can forget the ghastly satire, too bitter for us even at that time, with which "Punch's" artist hailed the event; and medical men remember how the public was puzzled by the bulletin of the German physicians, who announced the death as due to "para- 236 CAPILLARY CATARRH. lysis of the lungs." By this unusual, but not inapt term they intended to designate that complete obliteration of function •which we see in such lungs as these ; and the emperor's illness was of the same nature as I am quoting three examples of to- day, namely, inflammation — a partial death — of the bronchial mucous membrane resulting in obliteration of function. It arose too under the same circumstances of exposure to severe dry frost during a catarrh. People were surprised at the rapid sinking of a man so re- markably muscular and strong as our gallant enemy. But I happened at that very time to be called to see a country clergy- man of large frame and great height, who sank in the same way from fatal bronchial catarrh, brought on by exposure during a cold on the chest. So that I felt less surprise than others. And I am rather disposed to think that big burly people, once severely smitten, yield to the disease with more than ordinary rapidity. I have noticed in the second case, how anxious I was to pre- vent the man from going out in the cold after we had once got him up into the ward. My reason was a feeling of the extreme danger not only of the extension of the catarrhal state which is brought about by cold air, but also of the penetration of the inflammation to the tissue of the lung (lobular or catarrhal broncho-pneumonia). Of the two ways by which inflammation penetrates to the lungs, from the inside or the outside, the former is much the worst. I have no doubt but what it was the unfortunate independence of control, which is a necessary part of sovereignty, that destroyed the emperor. He was determined to go on with his duties, come what might, and nobody's will was strong enough to say, "We will not let you." Any disease which has previously limited the area of available lung increases very much the danger of capillary catarrh. In the patient who is my present text the atrophied state of the lower right lobe, the ancient tuberculosis of the upper, and the possibly prevenient emphysema of parts of the left lung took away her chances of renewed life. Had I been aware of them all, I should have given a still more unfavorable prognosis than even the symptoms made me give. CAPILLARY CATARRH. 237 I applied the epithet "possibly prevenient" to the emphyse- matous state of the pulmonary tissue. I did this because the patient had given us during life some broken history of short- ness of breath affecting her for a considerable period, and it would be difficult to say that this degenerated condition of the lung membrane had not existed as its cause. But I said "pos- sibly," because in fatal cases of capillary catarrh emphysema is so often found, even in patients previously healthy, that it cer- tainly must be a consequence, and not the origin, of the com- plaint. This is especially the case in infants, whose lungs, when they die of bronchial catarrh or of broncho-pneumonia, are almost invariably highly emphysematous; a state of things which their age and previous good health show to be capable of very apid development. 16 LECTURE XX. PNEUMONIA. Three cases of pneumonia — 1. Frank uncomplicated double pneu- monia in a temperate man, with excessive dyspnoea — Cured ivith venesection, jacket poultice, continuous feeding and wine. 2. Pneumonia of upper and lower lobes of one lung, very slight in the other lung, in a broken-down old man — Cured with cupping, jacket poultice, continuous feeding and wine. 3. Co7igestive pneumonia of lower lobe in typh fever — Cured witli half-jacket poultice, cutting beneath scapula, continuous feeding, tvine and bark. Commentary — Pathology of pneu7nonia — Importance in propor- tion to qiumtity of tissue involved, not to stage of progress — Hence the value of a ready and quick means of checking its progress — Bloodletting — Action of it — Grcneral and local compared — III effects of loss of blood — 3Iode of judging of the necessity for it — Compensation for it — Poultices — their Action — Especially adapted for infants — Hoiv to make theyn — Alco- hol, when recpiiired — Effect of position in the pneumonia of typh fever — Bloodletting — Purgatives — Blisters — Antimony and mercury. {Clinical, St. Marys, May 10, 1862.) There have been three patients under my care in the Albert Ward this week to whom I have drawn your attention, as illus- trative of the most common phases under which we have to treat pneumonia in the adult. No. 1 is a case of frank uncomplicated inflammation of the pulmonary tissue. R. G., aged twenty-one, a very steady and temperate police- PNEUMONIA. 239 man, well made, robust, and never previously ill, was on April 12, taken with severe rigors, followed by a dull pain in the side, and cough. He got worse under treatment from day to day, and on the 18th was so alarmingly ill that his friends car- ried him to the hospital. I saw him shortly after he was put to bed, and certainly felt that they were justified in their alarm. The respirations were abdominal and were thirty-six in the min- ute ; he struggled and gasped for breath, his lips and tongue were livid ; the pulse was very quick and small, but the heart beat strongly in spite of its great rapidity. The expectoration was copious and glairy, of a deep tawny color, and with a few small striffi of blood in it. The whole of the ribs on the right side were motionless du- ring inspiration, while the movement of those on the left front was very visible. In the upper half of the upper right lobe, and in the lower right front, there was fine crepitation and compara- tive dullness on percussion. Beneath the right shoulder-blade the dullness was more absolute and there were coarse rales. Be- neath the left there was fine crepitation. It was obvious that active inflammation raged throughout nearly the whole (if not quite the whole) of the right lung, and in the lower lobe of the left, and that it was most advanced in the back part of the right side. At most a third of the pulmonary tissue was in working condition, so no wonder that exaggerated puerile breathing was heard in that third, and the ribs were heaved in an extraordinary manner, where heaved at all. The patient was bled to three-quarters of a pint from the arm, took eight ounces of port wine during the twenty-four hours, and beef-tea every two hours, and had his chest completely enveloped in a thick hot linseed-meal poultice. He was ordered also three efi"ervescing draughts of citrate of ammonia daily. I am told that relief began immediately after the venesection. At all events, next morning there was a great improvement, the breathing being much easier, the patient expressing himself as "stronger," and the sputum being but slightly tinged with brown. On the succeeding day there was a further step gained, and the pneumonic hue had disappeared altogether from the 240 PNEUMONIA. mucus expectorated. However, in the parts of the right chest in front whence I raised the poultice temporarily for examina- tion, viz., an inch beneath the collar-bone and an inch beneath the nipple, the dullness on percussion seemed very decided. But I will not allow myself the enticing task of describing a patient's daily progress towards health : suffice it to say, that on the 26th, eight days after admission, the effervescing draughts were ex- changed for decoction of bark, and that to-day. May 10, he goes out well. The respiration is quite natural, percussion and expansion normal in the upper lobe and back part of the lower lobe recently inflamed; but there still remained yesterday some little crepitation mixed with the healthy breathing, and slight comparative dullness below the mamma. I dare say it is gone now. No. 2. — Hugh J., aged sixty-three, hall-porter at a charitable institution, a respectable man, but not quite free from a suspicion of petty tipling, had an attack of pneumonia of the lower half of the left lung under my care about this time last year, from which he entirely recovered so far as the local symptoms were concerned, but he has looked older since. At the beginning of last week, April 28, he was again taken ill. I saw him at his home on the 2d of May, and sent him up to this hospital. On the right side the whole lower lobes and the greater part of the upper lobe were consolidated. In the upper lobe, fine crepita- tions were heard throughout. There was also some fine crepi- tation in the back part of the left lung. His tongue was thickly furred and clammy, his hands tremulous, and his manner ex- cited. There was also occasional delirium. The pulse was large, short, and empty — such as is usually found with the inelastic arteries of old age. He was cupped that day to six ounces on the cardiac region, and on the morrow to the same amount beneath the right clavicle. The chest was completely enveloped in a jacket of linseed poultice. He was ordered eight ounces of port wine, food every two hours, and three efiervescing draughts daily of carbonate of ammonia and tartaric acid. May 5. — Pulse 128. On the 4th there was considerable di- arrhoea, which ceased on the following day-break, after a small compound ipecacuanha powder. PNEUMONIA. 241 May 6. — Less crepitation in left upper lobe, but dullness on percussion, and coarse mixed with fine crepitation in right upper lobe. Sputa have been for the last three days very abundant, and of a deep rusty color. No change in the symptoms, except the gradual diminution in quickness of the pulse, is noticed till to-day (the 10th), when the sputa are darker and more like prune-juice, but showing signs of improvement by having some specks of opaque purulent mat- ter in them. The tongue is also a little moist, and only gets quite dry after sleep. He may be considered to have turned the corner in his progress toAvards recovery, and I have no hesi- tation now in pronouncing a favorable prognosis. No change has been made in the treatment. [On May 16 he began to take bark and ammonia. On the morrow the expectoration is noticed to consist of clear mucus for the first time since his admission, and he left the hospital to return to his place on May 30. Case-book, 161, p. 187.] No. 3. — John L., aged seventeen, w'as brouglit here from a house where his mother and sister have just died of "typhus fever," according to the account of an aunt who came to see him. He was taken ill on April 20, and when admitted on April 23, was as unfavorable a subject to look at as I ever saw at that early period of low continued fever. There was complete pros- tration and constant delirium, the tongue was clammy and tremu- lously protruded with great difficulty from the dry lips, the pulse 120 and small, the skin hot and dry. The eyes were bloodshot, and on the front of the body Avere from thirty to forty fever spots of various hues, some slightly raised and inclining to rose color, some livid, some completely purpuric and not changed by pressure. I mention these details because it is such cases of typh-fever, where the haematine of the blood is apparently so much poisoned, that are aptest to be accompanied by inflamma- tion of the lungs. He was treated in my usual way with hydro- chloric and tepid sponging, and was going on as usual very well till May 3, when some fine crepitation and dullness on percus- sion were found in the lower lobe of the right lung, accompanied by slight cough, but without expectoration. On the 4th he was 242 PNEUMONIA. cupped beneath the right scapula to four ounces, a poultice was applied over that part, and he was directed to be kept turned over on the left side. On the 7th the breath-sounds were healthy except a little coarse crackling mixed with vesicular breathing, such as is generally found in typhous patients ; the percussion was normal. The tongue and other muscles were scarcely, if at all, tremulous. He is now going through a rapid convalescence under bark and wine, and in a few days will doubt- less be able to stand on his legs. Whilst speaking of this case, and before I enter upon the treatment of pneumonia, I will make one observation to you on the importance of the diagnosis of the cause of dullness on per- cussion in acute fevers. In this instance there was no doubt about the prognosis of the rapid termination of the congestive inflammation. But you must not say the same on every occa- sion of finding the pulmonary tissue condensed in fever. A man will leave the hospital for a distant home in a few days, who has recovered very slowly from an attack of spotted fever rendered severe by dysenteric diarrhoea. He has had at the same time primary syphilitic sores and a bubo, and had been taking mer- cury ;* so that his tedious convalescence was quite accounted for by his previous history. Besides this, during the time he was laid on his back, I had found a considerable amount of con- solidation about the middle of the right lung, and at the apex crepitations. As at that time he was not well able to give an account of himself, I was inclined at first to set this down to pneumonia, to treat it as such, and anticipate its disappearance. You saw, however, that this morbid state remained unaltered when I examined him for his discharge, and it seemed to me by his tale of former winter cough and haemoptysis to be due to chronic tubercle. He will probably become consumptive some day. Learn from this case to take good heed before you hail a consolidation of the lung in fever as merely congestive. * I would remark in passing that this man's dysenteric diarrhoea (i. e. pain in the bowels with fever and blood-stained stools) came on very early in the ill ness, namely, on the third day, although the usual tendency of continued fever this year is by no means dysenteric. He was under the influence of mercury at the time. The action therefore of that drug is at least not preventive of bowel affection. Is it curative ? PNEUMONIA. 243 Now to return to the text of to-day's lecture. In pneumonia a most truly vital organ is smitten ; and so far as the disease extends, the destruction is total. A consolidated or even congested piece of pulmonary tissue is absolutely power- less to filfiU its duties, and yet that those duties should be fulfilled is essential to animal life. It is easy therefore to un- derstand that the gravity of the pneumonia is in direct propor- tion to the quantity of lung involved. The degree or form of the inflammation or condensation is of much less weight, so far as immediate danger is concerned, than the extent of tissue over which it is spread. Hence comes the importance of having some ready and effectual means at hand to check the march of the inflammation into fresh parts. If we can do this, we contribute more certainly to renew the patient's life than if we regulated, however favorably, the progress of it in already aff'ected places. No means is so readily applied, so immediate in its operation, as bloodletting. Its action has not to be waited for, like that of medicines in medi- cinal doses, but begins at the moment of application. That is a great point where time is so valuable. I believe also that it is the most active of the agents at our disposal, and that rightly used it is the saving of many a life in pneumonia. But at the same time I would have you clearly understand that "this is not a bow for every man's drawing" at every time, that though it is most rapid and active for good, it may be also most rapid and active for evil, and that foolishly and thoughtlessly used it has caused many a death. The good done l)y bloodletting in pneumonia is mechanical. The pathological state which asks its aid may be drawn as fol- lows: — by the temporary death of a portion of the lungs the blood cannot be -quickly enough passed onwards through their tissue; it can run freely as far as the right side of the heart, but there it is stopped ; the throng pressing onward from behind makes matters worse, and thus the balance between the venous and arterial heart is destroyed. You can feel the apex of the organ beating strongly against the ribs, the muscular action being excited by the presence of an unwonted amount of venous 244 PNEUMONIA. blood; yet the artery at the wrist is at the same time striking your finger with a weakened force. Take away some of the blood from the veins, and the balance is restored; the pulse becomes in technical phrase "freer;" that is to say, the heart being relieved of the undue crowd in the right side, is not checked in its contraction, but is able to clench upon its con- tents, and supply them steadily to the arteries. Judge then of the fitness of this treatment by the balance between the heart and the arteries. If the apex of the former organ strikes strong, while the pulse at the wrist is oppressed, act freely and confidently. If, on the contrary, the ventricles are weak, while the pulse is large and rapping, be cautious in what ycu do, and if you draw blood at all, let it be by cupping the chest. The advantages of general and local bloodletting are of essen- tially the same nature, though the operations differ somewhat in degree, and are diversely applicable. Where the patient, pre- vious to his current illness, was in vigorous health, actively digesting his food and actively renewing his tissues, he Avill bear and easily repair the abstraction of a good large quantity of blood. And a good large quantity of blood is most conveniently drawn from the arm. To get the full advantage of the remedy you would practice venesection. But if the pneumonia has come on a person previously an invalid, or in weak health, you fear for the possible bad consequence of your treatment, and you cast about for some means of getting the greatest advantage out of the least loss of blood. This is obtained by cupping on the region of the heart. Your four or five ounces taken from thence in a delicate invalid seem to produce as much correspond- ino; effect as the loss of twelve or fourteen let from a vigorous man's arm. Or, if it be more convenient, you may put on leeches. As a rule, however, I prefer cupping, for you can easily graduate the depth of the cuts so as to be able to stop them with ease : whereas, leech-bites will sometimes go on oozing for a long time unper- ceived into the poultice, which (as I will instruct you presently) is to be put round the chest. PNEUMONIA. 245 Another advantage of local bloodletting is the relief it gives to pleurisy. There are few cases of pneumonia where there is not some amount of inflammation of the serous coat of the lunss or ribs; and though the feeling of oppression in the chest over- tops and deadens the stitch in the side, which would otherwise be felt, yet there is no doubt but that the pleurisy adds to the distress, and the relief of it is no mean matter. Local blood- letting is for this purpose more effectual in proportion to its quantity than general. You will find some authors try to ground rules about blood- letting in pneumonia on the supposed degree of consolidation of the pulmonary tissue. These rules are practically inapplicable. They say you should bleed so long as you know that the lung is in its first stage of condensation {i. e. congestion) as proved by fine crepitation and incomplete dullness; and that you should not bleed after it has once become completely consolidated so as to admit no air into the finer bronchi, a state declared by the sound of coarse crepitation and complete dullness. Such a rule is quite useless at the bedside, and will often prevent your em- ploying active practice in cases where it is urgently called for. In the first place, in a majority of cases fine crepitation is masked by the mixture of coarse crepitation, produced by the presence of catarrhal mucus in the larger bronchi, especially in the catar- rhal pneumonia of the young. If you wait till you can distinctly hear fine crackles, you will wait too long. Moreover, the dull- ness of congestion is not necessarily incomplete; as you may satisfy yourselves by examining recent congestion in continued fever, Avhich is often very absolute, though so transitory that a mere change of position may remove it in twenty-four hours. Then again, a slight collection of scrum in the pleura may make the loAver lobe dull at the very outset, and prevent your bleeding at a very early stage, if you were to folloAv the rule I quoted. But the most serious objection to the rule is, that you may have all stages of partial tissue-death going on at the same time; one lobe, or one part of a lobe may have advanced even to yellow hepatization, while another part is just beginning to enter into red hepatization, that is to say, into a condition which by general consent is most capable of benefit from bloodletting. 246 PNEUMONIA. Your best guide to the necessity Avill be the dyspnoea. If your patient is inhaling laboriously from twenty to thirty times a minute, straining convulsively the muscles of inspiration, you may know that the congestion is recent and is spreading to new spots; and you will act wisely by endeavoring to stop it. And your best check against excess will be the balance of the heart and arteries. Remember that in letting blood you are wielding a dangerous weapon. While from a mechanical point of view nothing can equal the aid it gives, at the same time its more remote or phy- siological action is baneful. If you gain the inestimable boon of a restoration of balance in the circulation, and a consequent relief of dyspnoea and renewal of life in the lungs, you must not complain if some evils attend the process. The mere loss of so much "liquid flesh" is in itself an evil, but a minor one; of greater import is the increased proportion of effete fibrin and water Avhich it induces, the diminution of solid haematine, and the consequently diminished power to bear up against the de- struction, however temporary, of so much pulmonary substance. Remember also now what I told you about bleeding in a former* lecture on anaemia and bloodletting — be careful to sup- ply material in the place of that which you are taking away. Let the patient be fed with beef-tea or milk every two hours, just as if he had typh-fever. This is to be done in all severe cases irre- spective of other treatment; but I mention it next to the bleed- ing, to remind you of the close connection which there is between the two, between exhaustion and supply. It contributes as much to your success, whether you elect to bleed, or whether you do not. I come next to another direct restorative about the use of which also anywhen and anywhere you need have no manner of hesitation. You can always, without any exception of age, sex, condition, cause, or complication, follow a treatment to which I attribute more power of saving the lives of pneumonic patients than to any other, and which you see me apply in all cases; — I mean the wrapping up the chest in a large bath-like poultice. * ''Former" in respect of time of delivery. It comes later in this volume. PNEUMONIA. 247 The action of warmth and moisture on animal tissues tends directly to increase their vitality. You may see with the naked eye a healthy surface of skin under their application renew its life; it empties itself quicker of its pale, livid, venous blood, and glows with a fresh access of the bright arterial stream ; it swells up elastically with fresh juices; it is more delicately sensitive when used for the purposes of touch ; at the same time it feels no pain, but on the contrary an exquisitely pleasurable calm. You cannot see with your eyes this renewal of life in internal organs, but you may infer that what takes place in one tissue takes place also in another, with modifications of course depen- dent on distance and other difficulties of application. And you may infer it also in pneumonia from the results; for you find the dyspnoea diminished, the breath being easily drawn in spite of the weight of the poultice; the hot fevered skin becomes moist and active, and soon the ribs begin to move again, and air is re- admitted into the hitherto paralyzed lung-tissue. These eflFects are the most strikingly shown in the case of infants, whose thin- chested walls are rapidly and efficiently penetrated by the influ- ences of the poultice, and in whom also this remedy is the only one really safe and invariably necessary; for they cannot afford much loss of blood. I cannot speak too strongly of the import- ance of your adopting it, and letting all other treatment be passed over rather than this. The poultice is best made of linseed meal, because that keeps moist the longest. It should be spread half an inch thick on a cloth or flannel as broad as the circumference of the thorax. If any portion of the upper lobes be inflamed it is essential, and even if one of the lower lobes are inflamed it is prudent, that the poultice should be deep enough to cover the whole chest from the collar-bones to the hypochondria. Lay the patient in it on his back, and fold it across the front till it meets. In adults it will usually keep in place of its own accord; but in children you should have a tape stitched on in front and a tape behind which you can tie over each shoulder in the manner of a shoulder- strap ; otherwise the little prisoners wriggle out of their soft breastplates. When once you have got this jacket poultice m 24S PNEUMONIA. situ, keep it there, and desire the nurse, on pain of dismissal, never to take it off till another hot one is ready to go on. In low fever the continuous poultice somewhat stands in the way of the cool sponging. But in practice this last part of the treatment of fever becomes /less necessary at the period -whien congestion and pneumonia occur ; the skin has then become cooler and more active. Besides, the poultice often takes the place of sponging by softening and suffusing with a gentle perspiration the whole body. I have often heard pneumonic patients complain of the amount to which the moist warmth makes them sweat. Alcohol, especially in the form of port wine, is very useful in treating pneumonia. Even to hearty temperate persons, when you are going to bleed, it is desirable to give a little, as was done in Case 1. A glass of hot negus before the operation, makes it safer. And whenever you observe the nervous system becoming prostrate by the extent of the disease, as indicated by tremor of the hands, quivering of the tongue, delirium, or dry tongue, throw in a little wine from time to time. Check these symp- toms on their first threatening, and do not wait for the tremor to be excessive, the delirium complete, or the tongue brown as well as dry, or you may be too late. Old persons, especially in the upper classes, who have been used to good living, and per- sons of all ages who have indulged freely in alcoholic liquids (as Case 2), may begin wine immediately ; you need not wait for the symptoms above described. Children, on the other hand, get well quicker without it. In the administration of alcohol under any form, a rule di- xectly opposite to that which governs the giving nutritious food should be observed. The quantity considered necessary in pro- portion to the previous habits of the patient, should be given in one, or at most two doses during the twenty-four hours. The frequent repetition of small doses has appeared to me more injurious, or at all events less beneficial than the same quantity in a few larger doses.* In the pneumonia of low fever position is of great importance. * For reasons see Lecture XLIX. " On the use of alcohol." PNEUMONIA. 249 So Ion Of as the walls of blood-vessels retain their natural clasti- city, they are able to bear up against the gravitating force acting on the blood as on all matter : but when their life is lowered in disease, the elasticity is the first vital property that suifers, and the blood then is drawn down towards the lowest part of the viscus. This is especially the case in low fever. Lay the patient, therefore, on the side opposite to that affected (as was done in Case 3), or even on his face for a time, if both sides are affected ; and thus the very force of gravitation which you feared as a foe, becomes a friend, by withdrawing the conges- tion from the weaker point. This boy was cupped on the side. You need not shrink from taking a little blood in low fever, where an important viscus requires the operation. A large portion of the vital fluid you take away is poisoned and dead already, and unfit for the pur- poses of life, so that you are not robbing the patient to the full extent of the quantity drawn. You saw the lad much more lively after his cupping than before. It is better to bleed locally than generally, because local benefit is expected from it and not general, and the dyspnoea is seldom very urgent in these cases. I always avoid purgatives in pneumonia. My reason is because I have observed that patients who have diarrhoea at the same time generally do very badly. And if natural diarrhoea does harm, I infer that artificial diarrhoea does harm also. I prefer to produce constipation by opiates, where it does not already exist. If the rectum gets blocked up with faeces, it is easy to wash it out with warm enemata. Blisters have seemed to me to do harm where I have known them to have been employed before the patients came under ray care. It is usually non-medical persons who put them on, under the general idea that they are good for a cough with pain in the chest. I am afraid I must equally condemn antimony and mercury, medicines formerly often administered in pneumonia. When I used them I was often and often driven to leave them off on account of bad symptoms due to their agency, and in prosperous 250 PNEUMONIA. cases I always felt doubtful if the success could be fairly traced to them. Looking now at nature by the light of the theory of cure which I have set before you, this failure is rationally ex- plained. The agents named are pure "destructives;" the dis- ease is also one of pure destruction ; there are in it fewer of the phenomena of retention than in any other, and none of tTie in- sertion of a morbid poison in the system. The gain then which they can bring is infinitesimal, and the risk infinite ; they do more harm than bleeding by their physiological action, without any of the mechanical recommendations of that remedy ; they merely abet the worst effects of the disease. LECTURE XXI. PNEUMONIA. Record of six cases wJiich had occurred during the recess — {1st Case) Caution about bloodletting — {2d Case) Pneumonia of upper lobe in the stage of abscess — Relapse of pneumonia during convalescence, fatal to this patient — Post-mortem ex- mnination — Remarks on treatment — Cause of second attack — {2>d Case) Pneumonia in Brighfs disease cured — State of lung afterwards — {'ith Case) Pneumonia in measles — Catarr- hal pneumonia — {bth Case) Pneumonia treated ivith opium — When opium is desirable — Reduplicating pulse — {Qth Case) Pneumonia in a pregnant woman treated with opium — Re- marks on vomiting in pregnancy. Cases in hospital at the time of lecture — (Jth Case) Early occur- rence of pneumonia in typh fever — {Sth Case) Pouble pneu- monia in a fatal case of delirium tremens — {^th Case) Dou- ble pneumonia slowly progressing from one lung to another — Pleurisy also on one side — Food in convalescence — Mode of recovery of consolidated lung — {\Qth Case) Catarrhal p)7ieu- monia — Severity of symptoms at first, and rapid relief — Treatment by poultices and local bloodletting — [llth Case) Pouble pneumonia in a man of drunken habits — This p7i£U- monia also catarrhal, and distinguished by the severity of the early symptoms — Treatment with opium, poultices, and cupping — Delirium — Wine — {V2th Case) Pneumonia morien- tum in death from other causes. — Recapitulation of comments on the eases. {Clinical, St. Marys, May 2, 1863.) I HAVE heard complaints made against clinical lecturers, that thej do not sufficiently interest their audience by presenting for 252 PNEUMONIA. consideration strange and rare cases. 1 shall be deeply grieved if my exertions cease to arouse your attention ; but I must at once say that it is a matter of conscience with me to set before you as subjects for instruction in the lecture theater*, and '^ for bedside teaching, most commonly those forms of disease which you will most commonly have to treat in after-life. The time I shall allot to each will be proportioned as closely as pos- sible to the frequency of its occurrence. I believe that to be the most accurate measure of its importance to the public, and there- fore to medical men. To-day I take a very common disease — pneumonia. Since I last addressed you before the Easter vacation there have been six cases under my care in the hospital, which are sufficiently ordinary examples to offer several points of practical instruction. I. Caroline D., though a sexagenarian, has never been seri- ously ill before, and was quite well till the 3d of April, when she suddenly lost her appetite and felt ill all over. She had a bad cough, but no local sensation of pain in the chest or else- where. She was admitted April 10. Her pulse was 104, empty, sharp, and weak. The inspirations were thirty-six in a minute. There was dullness on percussion and fine crepitation of the lower right lobe, and some fine crepitation mixed with healthy breath- ing in the lower left lobe. She was ordered — I^ Ammonia ses- quicarbonatis gr. iv. u3^theris lT[xv. Misturde Camphorse 5J ; alternd qudque hord. Hirudines xii infra scapulam dextram, et postea cataplasm da lini assidue applicentur. The signs of inflammation did not further spread, but the right lower lobe became consolidated, so that on the 18th bronchial breathing and dullness on percussion are noted in that situation. On the 22d the pulmonary tissue began to become pervious again, and there was the well-known " crepitation of return" in the place before consolidated. The draught was changed for a mixture of squill and senega, but she complained that this nauseated her, and it was left ofi", and no medicines civen at all. PNEUMONIA. 253 You may perhaps be surprised that in treating a patient so okl as three-score, and where the pulse was empty, sharp, and weak, I shouhi have ventured upon taking blood. But I had calculated here upon receiving valuable aid from the digestive organs. Like most persons who have lost appetite from severe febrile disorder, she had eaten scarcely anything for several days. I calculated therefore that a continuous animalized diet, such as beef-tea and milk every two hours, would more than re- place a moderate loss of blood, and I should have been sorry to miss the advantage which its local application confers by stayino-, as it does, the progress of congestion towards condensation in the pulmonary tissue. It is quite true that in old age the detraction of blood does more harm than in 3'outh or middle age, simply because there is less strength to spare ; but at the same time it does more good than in youth or middle age, because of the tendency in later life which congestions have to increase, and to increase so very insidiously, and to recur when checked. So you must not for- get what a powerful weapon you are wielding, and how double must be your caution when dealing with elderly people. The second case of also an aged woman, is practically inter- esting, although it proved a fatal one in the end. II. Mary McK., admitted February 27, did not know the date of her birth, but looked upwards of sixty. She had been quite well of late years till three weeks previously, when she had slept in a damp bed after being exposed to much heat as a washer-woman. This was immediately followed by rigors, feel- ing of complete prostration, and loss of appetite. I fear she had but little care taken of her during the height of the inflamma- tion, for she seemed on admission to be almost moribund, and absolutely refused food. On examination of the chest the upper lobe of the right lung was found completely condensed, absolutely dull on percussion, with tubular breathing and coarse mucous rales, and in some places coarse bubbling. There was little cough, but copious green expectoration. From the localization in the stethoscopic examination of the 17 254 PNEUxMONIA. part affected, it was very doubtful whether this were not a case of senile tuberculosis. But the suddenness and recency of the invasion Avere against that diagnosis, and I inclined to think it the third stage of inflammation of the upper lobe. The diagnosis made but little difference in the treatment; for I gave her quinine and cod-liver oil much as I should have done had it been determined to be tubercular phthisis. We had great difficulty about the patient's food ; she said, on admission, she could eat notliing, and at first she persisted in eating nothing voluntarily, the nurse having to use actual force in giving her the beef-tea and milk which I had insisted upon her swallowing. She improved considerably under this treat- ment by three weeks after admission. On the l^th of March I found there was not the same extent of dullness below the right collar-bone, but there was still very considerable dullness and very coarse low-toned bubbling rales. She was recovering also her flesh and strength, and was capable of being entrusted so far Avith her diet that she was allowed to be dressed and have ordinary diet and porter with the other patients. She seems to have freely used her permission to get up, and to have fatigued herself very much on the 19th and 20th. On the morning of the 21st she had a rigor, lost her appetite, became feverish, and had severe pain in the head. There was then a good deal of typh-fever in the wards, and it seemed very much as if she had caught that disease. So she was ordered a couple of emetics, continuous food, wine, and hydrochloric acid. But on the 26tli my attention was drawn to her lungs by the expectoration of orange-colored sputa in considerable quantity. Her tongue had become dry and brown in spite of the wine, and yet there was none of the nervous symptoms (such as obtuseness of sense, de- lirium, or tremor of the muscles) which one looks for in cases of typh-fever. An examination of the chest detected the serious fact that the diagnosis had been too hasty, and that the symp- toms really were due to pneumonia. The whole of the right lower lobe Avas already impervious to air from recent consolida- tion, and there Avas fine crepitation also in the left loAver lobe. Half a dozen leeches were put on the latter side, and a jacket PNEUMONIA. 255 poultice over the whole chest: bark and wine were freely given: but little hope could be entertained of preserving life. She sur- vived just long enough for the expectoration to become purulent, but died on the Gtli of April. At the post-mortem examination we found the right upper lobe of the lungs was in many parts consolidated and of a gray color, and of a fine granular appearance, shading off in the natural red color in the parts pervious to air. There were in that lobe several small abscesses, and one as large as two wal- nuts. The right lower lobe, and to a less extent the left lower lobe, were consolidated and of a red color, leaving on the whole about six inches square of the whole pulmonary tissue permeable to air. The ventricular parietes of the heart were pale in patches, and the mitral valves white and thickened. The kidneys ex- hibited an atrophied appearance, the cortical structure being diminished in quantity and containing many small cysts. The liver had a thickened opaque capsule and a granular (nutmeg) appearance when cut into. In this case are displayed two pneumonias in one patient. The first attack in the upper lobe slie had rendered much more serious in its consequences than it otherwise would have been by starving herself. It had absolutely condensed the pulmonary tissue, and was already running on to abscess on her admission. And she was reduced to an extreme state of emaciation and weakness. So that a condition was present closely resembling tubercular consumption, and distinguishable from it only by the history. Yet the doubtful diagnosis gave me no regret, for it made not the slightest difference in the treatment of the case, whose prescription-card made some of you set it down as an ordinary case of phthisis, though I had determined in my own mind that it was of a different nature. I cannot forbear here leaving for a few minutes the considera- tion of the cases immediately before us, in order to make a few remarks which possibly at some future time may cheer your hearts under chilling anxiety. I know of nothing more fearful than the feeling that upon your knowledge or ignorance depends 256 PNEUMONIA. the life of a fellow-man. This feeling runs through, and ought to run through, your whole professional career; for the good of vour patients jour consciences cannot be too tender. But it is necessarily experienced in very different degrees in different cases, and in the present age you will find your anxiety generally turns upon diagnosis. The patients who make you dream and ]-oll about in your bed of nights, and who spoil your appetite, are oftener those with whom you cannot find out what is the matter, than those with whom you do not know what to do. Now, it is often a great comfort to reflect, and I am sure it is true, that where pathological conditions closely resemble one another in the symptoms they produce, the treatment they re- quire is probably exactly the same. I should be sorry to "lay a flattering unction to your souls," but this is simply justice to Yourselves. IIow often is it impossible to ascertain, without questions which it is impossible to press, whether certain diseases are due to previous syphilitic infection or not ! Fortunately the same tilings are curative in both circumstances. How often do we reasonably fear to alarm a timid mind by inquiries into here- ditary tendencies to lunacy or consumption! The cases are ex- ceptional where these inquiries are absolutely necessary. And in this instance it made no difference in the performance of my chief duty, that of prescribing for the patient, whether those Avere riglit who thought the consolidation was tubercular, or those who thought it pneumonic. The second attack of pneumonia happening under our eyes in the hospital, though hid from notice at first by its insidious manner of invasion, I cannot but attribute to the patient having got up and overworked her weak muscular powers. You may all be aware, from experience, how even in healthy persons un- wonted exertion will cause temporary congestion of the respi- ratory tract. The stitch in the side and shortness of breath after running are well known. If we take violent exercise during catarrh, the mucus is often stained yellow some hours afterwards. I remember once having haemoptysis on the morrow of a hard day's skating, though my lungs are quite healthy. In an injured liing this tendency is still more marked and hurtful. Consump- PNEUMONIA. -257 tive persons often spit blood after unusual exertion ; not as is sometimes represented, at the time of the exertion, and from the strain caused by it, but next day, as a consequence of the con- gestion. There was, then, nothing more likely, than that this aged woman should get congestion from the same cause, and nothing more likely than that it should run on rapidly to con- solidation in her weak state, and with her antecedent tendency to degeneration. It is a warning to us to be more careful in watching over patients, and in avoiding everything which tends to exhaust the failing life. The degenerative tendencies made evident by the state of the kidneys, liver, and heart, rendered the renewal of life very un- likely in this case. But that is nothing against doing our best. Patients as much degenerated as that often go about for years, and with extreme care may sometimes be brought round from apparently fatal illnesses. IIL William W,, aged thirty-seven, a post-boy, was admitted April 15, with extensive anasarca and some fluid in the pleura, arising from Bright's degeneration of the kidneys. He Avae treated with sesquichloride of iron and hot-air baths. The dropsy diminished a little. On the 23d he got chilled by an open window, and on the 24th the dyspnoea increased very much, his previously sero-mucous expectoration acquired rusty brown color, and there was extensive fine crepitation in the lower lobes of both lungs. He was cupped between the shoulders, and a small quantity (six ounces) of blood taken. A jacket poultice was kept round his chest, and he took 5ss of ether, and ITjx of chloric ether every three hours, and four ounces of gin daily. The dyspnoea was somewhat alleviated by these means, and on the 27th the sputa became gradually purulent, instead of rusty. On the 29th it was still more purulent and copious. With the increased dyspnoea, induced by the attack of pneumonia, the anasarca of the arms, chest, and upper part of the body gene- rally had very much increased. In this man's case the imminent danger arising from the pneumonia has indeed almost passed away, and the increased drops}^ of the upper extremities, arising from the extra impedi- 258 PNEUMONIA. ment to the passaoje of blood through the lungs, is alleviated ; but I fear that his broken state of health forbids our hoping for his final recovery. You may remark, however, that alcoholic stimulants, which certainly do not benefit albuminariacs in gene- ral, are here well borne and decidedly beneficial while the pneu- monia is acute, and that they have sustained the patient while ready to perish. They have also not produced any tendency to coma (which is so much to be dreaded in these circumstances), but have aided restorative action. This person had hardly a spark of life to spare, so as to allow of blood-letting to any extent, and it was only the imminent danger of death by congestion that induced me to employ the cupping. [The man died towards the end of May of gradually increas- ing dropsy in all the serous sacs and anasarca. The pulmonary tissue at the back part of both lungs was scarcely crepitant. But it was not dark and congested, as is usual in cases of dropsy. It was mottled with yellow, as if it had been solidified by the pneumonia and were recovering. The kidneys were mot- tled and granular, not shrunken. His case is again alluded to a few pages on.] IV. George P., aged twenty-seven, a coachman, was warded on April 14. He had had a cough for four days. On the loth he felt very ill, and in the evening of the same day an erup- tion of measles came out. His nose had been bleeding a little. His tongue was pretty natural ; the pulse 88 ; the respiration 32 in a minute. There was fine crepitation without dullness on percussion beneath the right scapula. He was ordered ten leeches beneath the right scapula that day, and ten the next, and a half-jacket poultice. He drew his breath much more easily after each application of the leeches. Dullness on per- cussion in the aifected part, which Avas noticed on the 16th, had disappeared on the 18th, and he took quinine till he left us on the oOth, the dullness gradually merging into moist crepitation of return. His cervical glands swelled as the eruption went off, and he had half a dozen leeches and hot fomentations to that part. PNEUMONIA. 259 Here, contrary to what I remarked in the hist case, there was plenty of life and vigor. Very probahly the man would have got over his pneumonia well under any circumstances, but the leeching certainly relieved his deep pain in the side (the stitch of congestion) and I think it made things more safe. For in measles the pneumonia is the variety conventionally named " catarrhal pneumonia," that is to say beginning with and ari- sing from bronchial catarrh, and is very apt to go on spread- ing. It does not come on as it were with a^gush, and involve at once at the pulmonary tissue it is going to involve, but creeps onwards from lobule to lobule in a troublesome manner unless checked. This is familiar enough to those who have much to do with measles, but I do not think I had an opportunity of remarking it to you before, because we so seldom have a example of that disease in our wards. Occurring mostly in children, and being in them a malady of small moment unless complicated with pneu- monia, it is rarely admitted into a general hospital. The swelling of the cervical glands is common in all zymotic diseases, and had nothing to do with the pneumonia. V. Samuel F., aged twenty-eight, a laborer, was seized on April 11, with a stitch in the right side and dyspnoea. I saw liim on the 14th. There Avas fine crepitation and comparative, but far from absolute, dullness on percussion in the lower half of the right lung. The expectoration contained some streaks of blood, and was a little yellowish. He had previously had six leeches on his side. I ordered him sixteen more and a jacket poultice. On the 16th the expectoration was rusty, and his nose had been bleeding. His bowels were open for the first time since his illness. His pulse was lO-l, and soft. He had had de- lirium on the previous night. His tongue and hands were tremu- lous, and the tongue had a yellowish tinge like that produced by chewing tobacco, which however he had not been doing. He was ordered ll^x of laudanum every four hours, six ounces of port wine daily, and a teacup of beef-tea hourly. By the 22d the crepitation of return was heard, though the expectoration continued to exhibit a yellowish tinge mixed with 260 PXEUMOXIA. the pus of wliicb its bulk consisted. lie was ordered quinine, mutton chop and porter in place of the laudanum and teacup diet. I On the 29th, cough and expectoration had ceased. Here the opiate treatment of pneumonia vras adopted. I think it especiall}^ suited to cases Avhere there is evidence of de- ficient power in the nervous system, where there is great pros- tration or tremor of the hands and tongue. Where also the tongue has a smooth whitey-brown-pnper colored coat. I give it also where there is diarihoea, or even any tendency to diarrhoea, such as two fluid motions daily, in pneumonia : for of all unfor- tunate complications there is none so bad as looseness of bowels: those patients alw;iys do best who are constipated either natu- rally or artificially. When in consultation you are obliged to defer to the opinion of others, and give either mercury or antimony, especially the latter, in pneumonia, always make a proviso that a good dose of laudanum shall be joined; it prevents a great deal of the harm which normally results from the use of those minerals. It is remarked several times in the note-book that no drowsi- ness was produced, although opium was given to the extent of three grains daily. This is characteristic of its action in acute inflammations, when it proves beneficial. Where the soporific efi"ect is fully manifested, I have not found that it has agreed so well. You will find it recorded in the case-book on the 18th that the pulse was "reduplicating." This is rather an awkward at- tempt to translate Galen's term 6iKpoTog, a character of arterial beat graphically compared by him to the stroke of a hammer brought down loosely on an anvil, which rebounds and so gives a second little stroke afterwards. It seems he often found it in the malarious fevers of southern Europe, and observed that it indicated an approaching crisis. I should think that very prob- able, for it seems to me to arise from the renewal of the natural course and force of the circulation, when that return to health is associated with weakness of the cerebro-spinal system — when the PNEDMONIA. 261 restored strength of the muscular tissue is not supported by a corresponding renovation of nervous function. It is an indica- tion for the use of alcohol and opium, I think, although I have not observed it often enough to be sure. VI. Jane W., a joung "vvife, mother of one child, and six months pregnant Avith her second, was admitted April 12. She had been quite well on the morning of the previous day, till she was taken with sickness and cold shivers at 9 A.M. Be- tween 12 and 1 p.m. pain came on in the left side accompanied by dyspnoea. She Avas treated with sixteen leeches, in two de- tachments, to the left side, jacket poultice and hydrochloric acid. On the 14th the case was identified as one of pneu- monia by fine crepitation in the whole lower half of the left lung with very slight comparative dullness on percussion, and a grain of opium every three hours was prescribed. The next day no sleepiness having been induced, and the tongue being yellowish, w^iite and pasty, she was ordered wine, but it seemed to cause vomiting, and was left off next day. The pulmonary crepitation was succeeded by absence of breath-sounds and increased dullness. On the 21st crepitation (of return) Avas heard, the appetite came back, and quinine was prescribed in- stead of the opium. She was discharged cured on the 22d. The vomiting, due probably in part to her pregnancy, did not recur. There is nothing to be remarked in this case respecting the pneumonia and its opiate treatment, beyond the fact of the advanced pregnancy, which seems to have off'ered no impediment to its success. You may observe that wine in a young person unused to stimulants produced vomiting, which ceased on its omission after the trial of a few glasses. Vomiting in preg- nancy is very often the consequence of persistence in taking alcoholic drinks. Alcohol is familiarly known to be an emetic when swallowed in excess, and in the sensitive state of the ab- dominal and thoracic nervous system which accompanies preg- nancy, a very small quantity is in fact an excess, so far as this effect is concerned. Foolish women, feeling Avhat they term 202 PNEUMONIA. "weak" from the extra weight of the body they have to carry during pregnancy, and perhaps also glad of an excuse for in- dulgence, sometimes take an additional quantity of wine or beer at this time, and are punished by troublesome vomiting. This can often be checked at once by making them leave off the stimulant, and take only light digestible food in frequent small quantities. You may remark that she was put upon hydrochloric acid for a couple of days. This was on her first admission, when the prostration, more than usual in single pneumonia, and caused probably by her journey to the hospital, made us suspect typh- fever. However, absence of delirium, of cutaneous eruption, and of any other signs of that fever, set the question at rest very soon, and fine crepitation in the pulmonary tissue pointed out the true disease. {Clinical, St. Manjs, May 30, 1863.) I shall resume the subject of pneumonia with a few additional cases. VII. Elizabeth M., a girl of sixteen, was taken ill on May 23, with drowsiness, nausea, vomiting, pain in her back and limbs, and in short the usual symptoms of typh-fever. On her admis- sion, two days afterwards, these were more decided, and the tongue was dry and brown in the center. But there were no fever spots, nor have any appeared since. She had some diarrhoea on admission, and there was pain on pressure of the left iliac fossa. On examination of the chest we found fine crepi- tation and slight comparative dullness in the left lower lobe, and this has since extended in a minor deg-ree to the risiht lower lobe. On further examination we found also a valvular murmur with the first sound of the heart on the left side of the apex, very local and scarcely heard at the center of the heart, probably due to valvular disease from an attack of acute rheumatism two years ago. The only additions made to the usual treatment of typh-fever were six leeches beneath the shoulder-blade, a jacket poultice, PXEUMONIA. 263 and ten grains of compound kino powder three times during the first day. The case is distinguished by the very early occurrence of pneumonia in typh-fever. It is not a mere congestion from the long gravitation of poisoned blood in the sluggish tissue, accord- ing to the commoner history of such accidents; but it began the first day or the second day of the disorder. The probable ex- planation of this is the imperfection of the girl's heart, by which the circulation was more than ordinarily retarded. Observe how laten the lung symptoms are : they came on quite unawares to the patient or her friends, and the lesion Avas made evident only by auscultation. It is usually so in typhous pneumonia; for the normal sensitiveness of the system is blunted by the poi- son, which by its effects might almost be called a narcotic poison, only that it does not produce true sleep. This is a warning to be very industrious in not neglecting the use of your ears in all cases of typh-fever. The compound kino powder was ordered for the purpose of putting an immediate stop to the diarrhoea. The hydrochloric acid would have done that gradually in twelve or twenty-four hours, but a purged state of the bowels is such a pernicious circumstance in pneumonia, that I was in a greater hurry than usual to arrest it. VIII. Timothy MacC, is a burly hard-drinking brickmaker, aged about twenty-seven, whom ^ye saw first in bed May 27. He was too ill to tell a consistent tale, but he stated that he had been quite well till the 22d, Avhen, on getting up in the morn- ing, he was seized with a trembling so severe that he could hardly dress himself, and was nearly two hours trying to do so. These "trembles" continued on admission; he could not hold his hand out straight, and said that when alone he saw flocks of sheep scampering past and shadows of persons not really present. He had a hard bad cough, and his sputa was rusty and copious, with pus in it. On the right side of the chest, both in front and behind, there was a diminution of vocal resonance, dullness on percussion, a3gophony, and coarse bronchial breathing. On 264 PNEUMONIA. the left side tlicre was dullness on percussion in the lower lobe behind, bronchophony and coarse rales. In the front of the same side tiiere was puerile respiration. There was also stitch under the ribs and pleuritic friction on both sides. The respi- rations were twenty-four, the pulse 112 in a minute. He was ordered ten drops of laudanum in effervescing am- monia draughts three times a day, jacket poultice, teacup diet, and eight ounces of port wine daily. On the 28th the pulse was 120, the respirations forty-two. He was very delirious. A pint of bottled stout was ordered in addition to the wine. He died early on the 29th — two days after admission. No post-mortem examination was allowed by the friends, who carried off the corpse directly. This is that severe form of pneumonia which not uncommonly supervenes on delirium tremens in hard drinkers much exposed to the weather. The nervous symptoms are, in proportion to their prominence, an unmistakable warning to avoid depressants and to keep up the patient's strength by^ all the means in your power. Bleeding such a man would probably kill him in raving mania, and I would not venture even to cup or leech him, useful as it would probably be to such a state of lung in a temperate strong person. Alcohol must be given Avithout stint ; but yet I fear that however active and unsparing your hand may be you will still lose the greater number of your patients wdiose pneu- monia comes on in the course of delirium tremens. IX. George F., aged twenty-three, was attacked on the 3d of May with rigors, and about four hours afterwards felt a severe lancinating pain in the right side, much increased by inspiration. He was sent up to bed as an urgent case in the evening, with great dyspnoea, a short sharp pulse, and dullness on percussion in the lower part of the right thorax. It seemed to be a case of pleurisy, and the house-surgeon ordered him mer- curials and salines, and applied leeches to the painful part. On the 6th, when I first saw him, the sputa had become tawny and speckled with blood. At that date, although the dullness on percussion was less marked than on admission, it was still pres- PNEUMONIxV. 265 ent, but all over the infra-scapular region on the right side and partially on the left, there was fine crepitation. He was then enveloped in a jacket poultice, and given seven minims of lauda- num every three hours. On the 0th the sputa was still more bloody, and he was ordered, in addition to the opium, tincture of bark and ammonia and port wine. Two or three days after we found the respiration quite absent in the lower lobes, though there was large bronchial breathing. But on the 16th crepita- tion began to return on the right side, and on the 18th some on left side too — a joyful sound ! By the 20th it was well marked and clear on both sides, and I thought myself justified in allow- ing him ordinary diet and porter, though the sputa was still partially tawny and purulent. Since then he has been steadily improving, with the assistance of a blister to the right side, where some pain was felt, and yes- terday he got up and partially dressed himself. There are two directions from which pneumonia attacks the lungs ; it begins either from the inside, that is to say from the bronchial mucous membrane, in which event it constitutes catarrhal pneumonia, or the "suffocative catarrh" of our fore- fathers ; or from the outside, when it may be fairly named pleuropneumonia. The latter is exemplified by the present case. I should say that, as a rule, the chief danger of catarrhal pneu- monia was at the first onset of the illness, when it sometimes ends very rapidly ; while pleuropneumonia causes about an equal degree of danger throughout, till convalescence begins. And convalescence is generally in such cases very slow, the destroyed pleura not allowing the restored lung to expand freely so as to dilate the air-cells. The tissue, therefore, is apt to remain condensed. I dare say you wondered to see me order for a man, whose lungs were in such a state as to cause dullness on percussion and crepitation, beef and porter like a laborer at work. But I reckoned that where there was vitality enough in the system to cause so quickly the returning sound of expansion, there was vitality enough to digest normal victuals. I do not say you can always succeed in getting solid meat digested thus early, but where you can, it shortens the convalescence very much. 2G6 PNEUMONIA. The mention of returning crepitation after pneumonia induces me to recall to your memory a post-mortem examination which took place a fortnight ago on a patient about whom I lectured on May 2 (William W.)* admitted for anasarca from diseased heart and kidneys, who died in the course of recovery from intercurrent pneumonia. I say " in the course of recovery," because the pulmonary tissue had again become partially per- vious to air, and the sanguineous expectoration had ceased. After death we were able to see what pathological condition these signs indicated during life. The tissue of the back part of each lung was barely crepitant, but it floated in water and admitted some air. It was mottled, as if measle-spotted, with yellow and red : on pressing it hard a small quantity of thick fibro-purulent stuff could be squeezed out from the yellower portions, but the others seemed quite empty. It was consoli- dated luno; recovering. I have no doubt in my own mind, that the way in which con- solidated lung recovers, is by the exudated fibrin breaking down into pus and being expectorated, while the obstructed air-vesicles regain their elasticity and capacity for performing their func- tions. This is a strong argument for an ample supply of nutri- ment during the regenerative process. You may have remarked, both from the progress of this pati- ent, who is slowly recovering, and from the post-mortal appear- ance of the lungs in the one who died from other causes during convalescence, that pneumonia is not a sudden attack, which strikes at once all the pulmonary tissue that is going to be affect- ed. Its onward march is gradual ; it creeps on from- spot to spot, and from lung to lung. And its backward march is gradual too ; the parts first paralyzed in their functions recover first, and those last wounded recover last. This too they do, in spite of the latter being perhaps the least affected. It is from observations like these that the great advantage of our post-mortem examinations is derived. The chief cause of death is often the least noteworthy fact about them. In nine cases out of ten it is some utterly irremediable organic lesion, * See page 257. PNEUMOXIA. 267 the siglit of which merely flatters your vanity by verifying your diagnosis. But the lesions which do not kill, and which are curable, are those you are concerned with, and to understand which makes you good practitioners. {Clinical, St. Marijs, July 11, 1868.) George F., about Avhom I lectured to you six weeks ago, has justified by the slowness of his convalescence the distinction I pointed out to you, between pneumonia commencing from the interior of the lung and from the outside. The lower right lobe still remains dull on percussion, and air is very sparingly admitted into it. Some parts of the puhnonary tissue has also broken down into a small abscess in the front part of the lower lobe. He has fortunately no hectic, and is getting strong and stout slowly upon iodide of iron and cod-liver oil. The ribs will probably fall in on that side just as they do after empyema, but we shall not be able to keep him in the hospital long enough for you to see the result. Two other cases of pneumonia were taken in yesterday week. X. Mary P., a child just at the age of puberty, was admitted July 2. She had had cough and cold for a short time, but did not give up her work as a domestic servant till the morning of her admission, when she was taken very ill, with shortness of breath. On admission the breathing was very labored, and she raised the alae nasi in inspiration. The respirations were 44 in the minute ; the pulse 144. There was bronchial breathing and whistlinfj riiles all over the chest. The wdiole of the v\^\\t lower lobe was dull on percussion. No stitch in the side, or pain on pressure. She was cupped to oiv between the shoulders, eight leeches were applied beneath the shoulder-blades, and the chest was enveloped in a jacket poultice. I also ordered her TT|x of laudanum every three hours and tea-cup diet. On the 4th, when I came round, she was asleep, and the respiration was evidently so much relieved that I did not care to waken her. She had expectorated some blood-stained mucus. On the 5th the pulse was 130; the respirations 30. 268 PNEUMONIA. On the 8tli the pulse was 120 ; the respirations 26. The dull- ness, on percussion, extended half way up the right lung, and coarse crepitation had succeeded to the whistling rales. The tongue was brown ; but that did not seem caused by any aggra- vation of the symptoms. On inquiry, I found she had been sleeping that night and morning much more than usual, and suspected that the brown coat of epithelium was caused by the oj)ium. I left off all medicine, and trusted to the poultice only. On the 9th her tongue was clean. To-day (the 11th), the respirations are natural, and the air enters freely to the base of the lung, which is resonant on per- cussion. Only on a full inspiration can you hear a little crack- ling in the pulmonary tissue. The sputa is purulent, with a slight orange tinge in some parts. She says her bowels have not been opened the last six days. She makes so much account of this, that I have given her a dose of castor-oil, to quiet her mind ; though really the constipation is a good thin.g in pneu- monia. Remark in this girl how severe the symptoms were at first, how dangerous indeed to life, yet how soon the alarming part of them passed away. This would not have been tlie case if she had had pleuritic pneumonia, instead of the catarrhal or bron- chitic form of the disease. The opium agreed with her very well, but ten drops every three hours is a large dose for a child ; and, therefore, when it did not seem to be demanded by the symptoms, I was glad to leave it off. You will usually find that the time for doing so is marked by tolerance ceasing, and increased drowsiness coming on. XI. George L., a muscular laborer, aged thirty-two, came under my care July 3. He confessed to being a hard drinker, and to having had several attacks of delirium tremens. After ailing for a few days to such an extent only as allowed him to go on with his work, he was taken on June 30 with rigors and dyspnoea, so as completely to prostrate him. When I saw him the respirations were 60 ; the pulse small, 140 ; his tongue thickly PNEUMONIA. 2G9 coated. The skin w.as hot and diy, and there was an eruption of herpes on the lips. There was dullness on percussion, with bronchial breathing, in the whole of the right lower lobe, and dullness less decided in the lower part of the left lower lobe, Avith fine crepitation at the upper level of the dullness. He was cupped to .jviij beneath the shoulder-blades, put in a jacket poul- tice, and ordered twenty minims of laudanum everj four hours, and tea-cup diet every two hours. On the 4th the pulse was 130, larger and fuller; the respira- tion 44. On the 5th the pulse was 120, the respiration 40. I found him raised in bed and reading a newspaper. On the 6th the pulse was 132 ; the respirations 36. He had been noisy and delirious the night before. Four ounces of port were ordered to be added to the treatment, to be taken at night. On the 7th tawny expectoration commenced. On the 8th pulse 108 ; respirations 36. To-day (the 11th), his pulse is 100; the respirations 26; the air enters freely into the right lower lobe, with only a certain coarseness on full inspiration. That part is also resonant on percussion. In the left lower lobe a slight comparative dullness remains, and there are the crackles of returning breath sounds. The lung tissue you see has returned to its allegiance in the order in which it ceased to work. First the right lower lobe, which was the most condensed on admission, and was the first affected ; then the left lower lobe, which was the last to suffer, and is, therefore the last to get well. Pneumonia does not strike like a thunderbolt the whole that is going to be injured, but creeps on from one spot to another, and creeps away in the same order. The remark which I made apropos of the last case as to the form of pneumonia, and the alarming earliness of its severe symptoms, applies equally to this man. Though his breathing was so short, and his pulse so quick on the 4th, yet on the 5th he had strength enough to be reading his Sunday newspaper. But the exertion was as bad for his body as the politics doubtless 18 270 PNEUMONIA. were for his mind, and in the evening he got delirious, and was inconveniently violent during the night. I had hoped to spare our wine, but was forced by this delirium to order him a couple of glasses of port to be taken every evening. You may learn by this instance how important quiet is in pneumonia both for mind and body. Nearly all our dangerous and fatal cases are made dangerous and fatal by neglect of this ; and though this patient is not seriously injured by his imprudent obstinacy, yet I have no doubt his convalescence will be the longer for it, and we have had to give him stimulants which might possibly have been spared. If the stimulancs had not been given, he would very likely have had delirium tremens ; the lungs Avould have become more congested, and he might have died like a man I lectured about on a late occasion. (See Case VIIL) When I say this, however, I ought to guard my words. For in reality he would not have been in anything like the danger of that poor fellow. Truly enough the two diseases are a most perilous combination ; but it makes a great deal of difference whether the pneumonia is a consequence of an antecedent deli- rium tremens, or, whether the delirium tremens is a consequence of the pneumonia coming on a predisposed subject. In the former case a fatal result almost invariably happens, but not so in the latter. So that though he might have died, yet he would not have been so certain to die as our former patient. XII. A little boy, four years old, was conveyed here on the 3d instant, just at his last gasp, and died about a quarter of an hour after I had seen him, while the ward-sister was putting him into a poultice, and giving him some wnne and beef-tea. It was entered in the "urgent admission book," as a case of pneumonia; and so there was pneumonia, but it had nothing to do with his death, which in reality arose from the impaction of a calculus in the right ureter and inflammation of the kidney following thereon. The pneumonia w^as a consequence, not a cause, being of the sort fairly designated " pneumonia morien- tum.'* It was the consolidation of scarce a half of the right lower lobe by this congestion of gravitation which caused the PNEUMONIA. 271 patient to be entered as I have said, and placed in the medical wards. Had that been the only anatomical change, this child might easily have recovered ; and I mention the case only to guard you against crediting the death purely to pneumonia. The dozen cases of pneumonia which I have made the subject of a considerable portion of three clinical lectures since Easter,* may be held to be a fair representation of an average four months' hospital experience of the disease. There have been specimens of its most ordinary forms very much in the propor- tions in which they will occur to you in practice. They have included 2 cases of pleuropneumonia, one fatal, one not ; (VIII, IX). 1 case of pneumonia in measles ; (IV). 1 case of pneumonia in typh-fever ; (VII). 1 case of pneumonia in Bright's disease; (III). 1 fatal case of pneumonia relapsing on a previously consoli- dated and broken-down lung; (II). 5 cases occurring in previously healthy persons ; (I, V, VI, X, XI). 1 case occurring as a complication of the death-agony from another disease ; (XII). In the fatal cases the death Avas caused in one by the pneu- monia coming on a previously consolidated lung (II), in the other on a severe attack of delirium tremens (VIII). In the third the pneumonia was caused by the death (XII). And as to treatment, I have taken current opportunities of impressing upon you the following rules : — I. Take blood locally, cautiously, in the early stage only, and with a distinct reference to the power of each patient. II. Keep the chest from first to last enveloped in a jacket poultice, and allow of as little movement as possible. III. Administer food frequently, largely, and in a liquid form. IV. Where the nervous system is deeply smitten, as indicated * Viz., on May 2, May 30, and July 11. They are here massed together into one lecture. 272 PNEUMONIA. by tremulous muscles, mental excitement, delirium. tawny tongue at an early stage, great depression, &c., give opium ; and in some cases give alcohol, but not in small repeated doses. V. Where there is diarrhoea, stop it immediately with opium or kino. Vr. Consider antimony, mercury, and purgatives as poisons in pneumonia. I have heard the plans of treatment which I recommend you to adopt described as "trusting to nature;" and sometimes a deprecatory "merely" is added — "merely trusting to nature." In one sense this is true, for all methods of cure, at least all suc- cessful methods of cure, must depend on the regaining of natural vital forces ; and the agencies brought into action by our inter- ference must be the natural vital forces of the body acted upon. The heat and moisture, for example, which we employ in pneu- monia, are an imitation of and compensation for the deficient steadiness of the vital warmth ; the current of blood which we cause to flow with our cupping-glasses is a replacement of the natural current ; we give opium to bring the condition of the nervous system into harmony with the functions arrested by the disease. There is no successful method of cure but what is suc- cessful by virtue of thus restoring vitality. But in the sense intended by those who slightingly use them, the words are synonymous with doing nothing, or leaving the patient to him- self, with la medechie expectcmte, with the contemplatio mortis of the satirist, with a hardened skepticism. It is a saying like those clever sneers of Job's adversary, which, under the guise of a truism, hide a lie. Doing nothing or leaving the patient to himself, would indeed be dishonest; but do we do so? Is it doing nothing to keep up constant relays of poultices night and day for a week or ten days? Is the enforcement of continuous nutrition no labor? Is there no anxiety and thought spent in hourly watching the need of variation in our doses of opium and wine for serious cases? Is the moistening and warming the air to an even temperature not enough to occupy our time ? Is it so much easier to sup- PNEUMONIA. 273 port the waning life than to weaken it, that the former should be condemned as idleness, the latter praised as activity? If the pneumonic patient were left to himself would he — could he — adopt any of the means suitable for his recovery? Would he not very likely be taking colocynth, senna, calomel, antimony, ipecacuanha, salines, senega, squill, hydrocyanic acid, colchicum, be rubbing in mercury, applying mustard poultices, and blisters, be bled coup sur coup, or have brandy every half hour? Is it nothing to stand sentry against the fatal seductions of poly- pharmacy? LECTURE XXII. EMPHYSEMA OF THE LUNGS. Illustration of the morbid anatomy of emphysema — -Fatty de- generation of the 'pulmonary membrane — Degeneration some- times fibroid — Cause of the pr oneness of children s lungs to become emphysematous — Question whether inspiration or expi- ration most tends to produce emphysema — Action of the lungs in breathing illustrated by an example of a man without a sternum — Expiration more powerful than inspiration — Ap- plication of the morbid anatomy of emphysema to clinical questions — Case of emphysema in an albuminuriac — Case of emphysema depressing the heart — Treatment and its objects — Iron — Tobacco — Lobelia — Stramonium — Mercury — Alcohol — Expectorants — Ttvo cases of emphysema in young women exposed to adverse circumstances — Treatment hy iron — Trial of expectorants. {Clinical, St. Marys, March 13, 1863.) The following case, of which you now see the post-mortem examination, is a fair illustration of the morbid anatomy of pul- monary emphysema. Of the diseases which the diseased had suifered from depen- dent on this condition, the history was given by him as follows: — George W., aged forty-two, a temperate laborer, much ex- posed by his work to cold and wet, had always "a good wind" till three years ago. Since that time he has been what he terms "asthmatic," that is to say, he has been habitually short of breath and liable to contract catarrh accompanied by dyspnoea on moderate exposure. He was still always able to do an average day's work till last Christmas, since which time he has been too EMPHYSEMA OF THE LUNGS. 275 short of breath. He cannot assign any cause for his illness except exposure to cold. When jou first examined him, March 2, he was breathing spasmodically and with extreme difficulty; his lips and face were dark purple, but without any of the bloated appearance you so commonly see in cases of dyspnoea from enlarged heart. On examining the chest we found the cardiac region, as well as the whole lower part of the thorax, preternaturally resonant, and the ribs were bowed and raised, so as to make the bony frame- work of the upper half of the trunk more globular than natural, and to throw backwards the lower angle of the scapula. The intercostal spaces were not protuberant. The number of respi- rations was thirty-four in a minute, the pulse 104. In the cardiac region, and in several other of the lower parts of the chest, I drew your attention to a peculiar crumpling sound in inspiration, not unlike that produced by squeezing up fine paper in the hand. He experienced a certain degree of relief from the rest in bed, and a draught three times a day containing lobelia and chloric ether ; so that on the 4th his respirations were reduced to twenty-eight in a minute. But he soon fell back again, and sank exhausted and breath- less on the 11th, and we have now to make the post-mortem ex- amination. On opening the chest the heart is seen completely overlapped and hidden by a layer of lung about two inches thick, consisting of lobular masses of pulmonary tissue, pale in tint, dilated into vesicles, and looking more like flesh-colored soapsuds than any- thing else. These masses of vesicles are firm and elastic from retained air; but when that is let off by a puncture, they sink down into a flabby non-crepitant substance. The same appear- ance is seen in the greater part of the lower left lobe, and at the apex of the upper lobe; and the lower right lobe is partly in a similar condition. The flesh of the heart is pale, and its cavities are large. The wall of the left ventricle is thinner perhaps than natural, but the whole organ is not so much dilated as to render 270 EMPHYSEMA OF THE LUNGS. the valves inefficient; and thcj are healthy in appearance. The kidneys and other viscera are quite normal. On the whole you are perhaps rather surprised at the small extent of obvious organic change, considering the violence and fatality of the symptoms. But now examine again the portions of lung not aifected with these bullae of emphysema. They are doughy, flabby, and non-elastic. They keep the mark of a finger pressed upon them. There are very slightly crepitant when squeezed. You nuiy reasonably feel dou-ljtful whether such pul- monary tissue can perform the functions which require elasticity and firmness. Now let us make a section, and cut out with a pair of curved scissors a few snips as fine as we can, tease them out with a needle, and place them under the microscope with a lens of one- quarter inch focus. You thus get a sight of the pulmonary membrane. You know it oun-ht to be a continuous skin-like membrane, transparent, and distinguished principally by bundles of fibers gently curled and interlaced. In a healthy lung it does not exhibit any cells or corpuscles. But here you see scattered about it numerous fine dark specks, and somewheres there are round bright globules with a dark outline, and somewheres the globules and specks are collected together into masses, denser towards the center — so o*l** *t y<'^'^''° — iust like the masses of fatty degeneration which you often witness in the muscular structure of atrophied hearts. This is in fact an example of the same morbid state in another tissue, the fatty degeneration of pulmonary instead of cardiac tissue. It is easy to understand how emphysematous bulliie arise. Melt one side of an India rubber ball in a candle and squeeze it; you see it bulge out into a bubble just in the same way; and just from the same cause, loss of elasticity. What the melting is to the India rubber ball that to the pulmonary branch of vesi- cles is the wasting of its elastic web into fat. When any dilating force is exerted upon the walls of the vesicles they give way and do not contract again. It is not always fatty degeneration which is found in emphy- EMPHYSEMA OF THE LUNGS. 277 seraatous lungs; sometimes it is fibroid degeneration, and Dr. Jenner has in his experience found this latter the most common.* Either sort of partial interstitial death involves a loss of the functions of elasticity and contractility in the tissue — fatty de- generation probably the most loss, and therefore it is that you find it in the most rapidly fatal and most marked cases, such as the one under our eyes. The same softness and proneness to give way may also be supposed to exist in the lungs of children; for the younger the tissue the softer it is; and thus children's lungs are very prone to become emphysematous without there being any interstitial change to be detected in the pulmonary tissue. The anatomical or predisposing cause of the disease we are considering may then be held to be a too great softness of tissue, from the lung either not having yet acquired its full power of resistance or from having lost it by morbid change. And now let us look for the external or determining cause, quite as important an element in the production of disease. It is the fact of breathing of course, and the act of breathing forcibly, that breaks down the over-soft tissue. But is it inspi- ration or expiration that is most to blame, or both equally ? The question rests on the point of which causes most pressure of air on the pulmonary membrane of the air-cells. And because inspiration fills these air-cells, it has appeared to some to cause most pressure on their walls. Doubtless in inflating a bladder you increase the atmospheric pressure on the inside, and I sup- pose it must be this analogy which has led physiologists astray. But the cases are quite difi'erent; the lungs are not inflated by blowing air into them, but by the expansion of their walls draw- ing air into them, in fact by the atmospheric pressure on the interior being forcibly lessened through the action of the diaphragm and other respiratory muscles. A fairer analogy would be a pair of bellows, the leathern sides of which are certainly not bulged outwards by the filling of the instrument. And if that leather were softened it would swell and stretch during the blowing of the fire, not during the drawing in of the air. * "Medico-Chirurgical Transactions," vol. xl, p. 26. 278 EMPHYSEMA OF THE LUNGS. Not inspiration, but expiration, must be the most efficient determining cause of the dilatation of the air-vesicles in emphy- sema. The difficulty which people feel in understanding this arises from their thinking of the thoracic walls as a contracting ball or box, of equal contractile force throughout, and which therefore in its contraction during expiration would equally diminish the area of all the pulmonary vesicles at once. And diminishing the area, say they, is certainly inconsistent with dilitation. But this idea of the chest is an erroneous one. The thoracic walls, from their irregular shape and from their vary- ing solidity in various parts, press with a very unequal degree of force on different parts of the lungs. The apices of the upper lobes, for example, from the deficiency of the bony frame- work above them, and the edges of the lower lobes from being in an angle, escape the compression of the ribs and diaphragm to a nYQat extent. When then the air by the action of the respiratory muscles is squeezed out of the more readily com- pressed parts, it is driven into or at least is driven towards these less compressed parts. Two or three years ago some of you were shown in this theater the action of respiration upon the less compressed parts of the lungs by a M. Groux, a poor gentleman with congenital de- ficiency of the sternum and a consequent fissure in the thoracic walls, which fissure was covered only by skin and cellular tissue. Of course the portions of lung behind this fissure were less com- pressed than any part of the pulmonary substance; and during expiration you saw therii bulge out, just like the leathern sides of a bellows during a corresponding movement. Those who witnessed the curious sight admired the toughness of pulmonary tissue Avhich could resist injury from such an abnormal state of things. And they could not fail to understand that if M. Groux's lungs had been Avanting in elasticity, they would never have been able to resist the dilating power exerted by expiration on this undefended part of the tissue. The same condition which M. Groux's deficiency of sternum exhibited in an exaggerated way, the normal partial deficiency of bony framework presents in a less degree to the apices of the lungs, and their peculiar angular EMPHYSEMA OF THE LUNGS. 279 position to the bases. It is in these parts that expiration causes the atmospheric pressure to be greatest, and it is in these parts that emphysema most commonly appears, as exemplified in the instance before us. It is at the apices and anterior edges of the lungs indubitably that we most often find this morbid state when the degeneration is generally diffused. When emphysema appears elsewhere in the lungs, the apices and edges being free from it, it is due to the degeneration being local, and to those peculiarly liable parts at apices and bases being shielded from injury by their healthy elasticity. Another reason for thinking that expiration rather than in- spiration is the main cause of the final injury to the vesicles in emphysema, is that it is much the most powerful of the two muscular efforts. If a man can draw in the air through his nostrils* with sufficient force to raise a column of mercury (say) two inches, he can by expelling it steadily raise the level 2|- inches: if he is strong enough to lift the fluid by inspiration 2^ inches, his expiratory power will mark 3|. Thus, even though it is possible that both inspiration and expiration may tend to rupture or dilate the pulmonary membrane, inasmuch as all motion must endanger an abnormally friable tissue, yet expira- tion tends to do so much the most. This is the real practical point ; as I will show you presently, when I come to apply our knowledge to its true end, the relief of distress. This fatal case then has shown you the true nature of the anatomical injury you have to deal with in emphysema of the lung. It is an interstitial partial death, or degeneration of the pulmonary membrane. This membrane, which forms the frame- work of the vesicles, thus loses its elasticity and is determined to dilatation by the action of forced expiration. It may be asked whether the degeneration is not rather the result instead of the cause of the dilatation. It may be sug- gested that bronchitis and violent cough originate the rupture * The uostrils must be used in the experiment, because the action of the tongue and cheeks in suction and puffing introduce a fallacy, bringing into use muscles which are not muscles of respiration. See Dr. Hutchinson's paper in " Medico-Chirurgical Transactions," vol. xxix, p. 199. 280 EMPHYSEMA OF THE LUNGS. of the vesicles, and that the ruptured vesicles, being unused, fall like all unused tissues, into fatty decay. I Avill not deny the possibility of such a sequence of events in some instances, be- cause in point of fact we do not find emphysema of unaltered pulmonary tissue in children. But it was not so in the case before us, because the patient had not been subject to bronchial catarrh, had no mucous secretion before he got short of breath, and indeed had very little even up to the fatal termination. And the case before us is a well-marked type of uncomplicated em- • physema in the adult. Do not rest satisfied with having learnt the pathology of a disease without applying the pathology to its treatment. If it were not capable of such an application I should not make it a subject for clinical lecturing. The pathology of emphysema shows us a gradually increasing loss of vitality in the pulmonary membrane. We must so treat the patient as to increase the vitality. A constant supply of nutritious food and long courses of food give the best chance of doing this. I should have adopted it for our patient had he lived long enough. The pathology may teach something more. Expiration is the dangerous and injurious part of breathing, and especially forced and arrested expiration. Let your patient carefully avoid all such employments as strain the respiratory muscles — all such labors as make a man hold in his breath and then puff it out with a jerk — such as lifting and carrying heavy weights, dig- ging, pitching, rowing, &c. I do not think you need trouble yourselves about wind instruments or singing ; persons with em- physematous lungs are not likely to be addicted to them, and as a matter of fact those who use the chest freely, such as public singers, do not get emphysema from the exercise of their profes- sion. Of this latter fact I am certain — it is not the due use, not the "straining" of the pulmonary membrane which causes it to degenerate, but rather the want of use. In this respect it resembles all other livino; animal tissues. EMPHYSEMA OF THE LUNGS. 281 - {Clinical, St. Marys, March 21, 1863.) I will t^ke the opportunity of having admitted, a week ago, two cases of pulmonary emphysema, to recur to our subject of a recent lecture. John D. is a poor street-sweeper now, and nearly seventy years old, but has been a gentleman's servant, has had "his beer regular," and taken it freely. This confession is corroborated by the shaking of his hands when he puts them up. lie says he has been "queer and wheezy" and subject to frequent coughs for six years, and five years ago was under my care for asthenic gout. The cough is of a violent spasmodic character, and does not bring up much mucus. His chest is resonant and rounded, and moves very little on inspiration. The cardiac dullness com- mences at a low level at the base of the heart, and the pulsations of the organ are felt in the epigastrium. His corpulence pre- vents us from getting the auscultatory signs of emphysema so clearly marked as one would wish. There is not now, nor does there ever appear to have been, any anasarca. The urine is albuminous, of the specific gravity 1-012 In this case I think there is a generally distributed deficiency of elasticity in the pulmonary tissue, which has arisen from the same diathesis as the morbid state of his kidneys (shown by the albumen in the urine) and perhaps of other organs as well. But his general weak health, graphically described by him as "queer," has prevented his working hard, though I dare say he has lived hard and drunk hard ; and in consequence the deter- mining cause which I explained to you fully in my lecture a fortnight ago, of forced and impeded expiration, has not been present. Thus local spots of very marked emphysema are not found. The defective vitality of the renal tissue, which makes him an albuminuriac, is doubtless of the same nature as that in the lungs ; and it causes a tendency in the blood to throw out its serum and thus to saturate the lungs with fluid, which assists also in concealing from our ears the signs of the emphysema present. 282 EMPHYSEMA OF THE LUNGS. The prognosis is certainly favorable as far as his chest is concerned, but I fear we cannot make a young man of him. The other case I will read from the case-book. " George H., aged fifty-three, a plasterer, first became asth- matic two years and a half ago. After suffering a few weeks and expectorating a little mucus streaked with blood, he was admitted into the hospital under Dr. Sibson, and remained six weeks, having during that period had a carbuncle on his neck and an abscess in the left axilla. He Avent out relieved, and has been able to work ever since, in spite of his asthma, till a month before last Christmas, Avhen he again was obliged to give up. On his coming under my charge, March 20, he presented the usual marked signs of extensive emphysema of the lungs. His chest is rounded, and the lower angles of the scapula are thrown upwards and onwards. The left side of the thorax is larger and more rounded than the right. There is very marked resonance all over it, including the cardiac region, and the heart is pressed downwards, pulsating regularly in the epigastrium ; the valve sounds are healthy. The breathing is abdominal ; the respirations are twenty-eight in a minute. The face is livid, and the lips blue, but without any of that bloated appearance so common in asthma from diseased heart. There is a good deal of frothy expectoration, but no blood streaks in it. The urine is healthy." While examining before you this and some other emphyse- matous chests, I have been asked by pupils how it is that iliere is no bulging of the intercostal spaces, and I have been ^iven to understand that bulging of the intercostal spaces is taught as a sign of emphysema. This is an error — the intercostal spaces do not "bulge," like as when the pleurae are full of fluid, a fact which you may ascertain for yourselves now. But of c^mrse from the chest being always in a state of fullness, the ribs are widely separated from one another. This, however, is a very different thing from intercostal bulging, as you may see in both the dead and living body. I have ascertained, by a reference to Dr. Sibson's case-book, that the signs and symptoms exhibited by this patient were EMPHYSEMA OF THE LUNGS. 283 much the same on his former admission as they are now. He is not essentially worse, and indeed his trade is not one which with ordinary care and prudence would be an injurious one. The prognosis therefore may be considered favorable. I will view as one the treatment of these two persons, inasmuch as I have ordered them both the same draughts, viz. : — I^ Tinct. ferri sesquichloridi 11\xx, Tinct. lohelise setherese "rtlxv, e Mist, campliorse .^j, ter die. The object of the iron is to try and restore its full vital powers to the creative arterial blood, so that it may renew the pulmonary membrane, that it may form healthy elastic tissue, instead of the degenerated and imperfectly elastic tissue. That places where the walls of the air-vesicles are broken away, and Avhere bullae exist instead of vesicles, should be filled up again with a new growth, may be considered beyond hope ; but that where the form of the lung substance remains perfect, where to the naked eye it is intact, and only under the microscope ex- hibits its incipient death, there I believe we need not despair of our restorative agent having a fair chance of success. The best restorative medicine is the healthy blood of the patient's own body, and to make that blood healthy is the most rational aim we can have. To the iron I shall at a future day add, in the case of George H., cod-liver oil, as a means of affording a molecular base to the growth of new tissue. He is thin, as you see, and it will be readily absorbed by the intestines, and probably agree well with him. I feel more doubtful about oil in the case of John D., as he is so flabbily corpulent ; but I shall try cautiously how he beirs it. You may have remarked that I refused the very urgent request of John D. for beer, which he said habit had made a necessary for him. I hope, if possible, to break him of the habit, for nothing is so injurious to degenerative tendencies as alcohol, and no form of alcoholic liquid so bad as beer. 284 EMPHYSEMA OF THE LUNGS. No — I must make one exception to the bad pre-eminence of alcohol, that is, mercury. Avoid mercury in these cases as you would a poison. Avoid also purgatives. The lobelia is ordered as a substitute for a more powerful medicinal agent, tobacco. Nothing calms the distressing asthma so well as a few whiffs of strong Virginia. But to allow smoking in the hospital would lead to breaches of discipline ; so I order that which is apparently the next best thing. Like tobacco, lobelia is a very variable article ; there seems to be as much difference between one specimen and another, as between the mildest cigarette and the strongest shag. This accounts for Avhat we read of enormous doses being sometimes perfectly inert, and of much less quantities having acted as a poison. A further safety to those who have taken large doses lies in the fact of its being like tobacco, an emetic, and so freeing the stomach of its presence in excess. I should advise you to use the strongest sort, paying the best price at the best shop, so that you may give it in moderate and graduated doses. Lobelia does not disagree with the digestion like opium, and you need not on that score abstain from its use. Another agent of the same character as tobacco is stramo- nium. It also is best administered in a pipe, but here again the hospital discipline interferes, and I am obliged to give it him in pills made Avith the extract, which you may see are not so effi- cient in this instance as the lobelia, though in the form of smoke it is often more useful. Perhaps some of you may doubt whether it is quite wise to diminish by calmatives the action of the respiratory function, and may think the asthma an effort of nature, ordained to accompany emphysema for a beneficial purpose. This is a case in point very subversive of the theory of disease being an " effort of nature." The forced breathing, nay, even the natural breath- ing, tends to dilate the vesicles, and if it were designed to ben- efit the patient, we should have to conclude that the design was erroneous — a conclusion repugnant to instinctive reverence. When there is an unhealthy condition of the mucous mem- brane of the trachea and laige bronchi, evinced by copious EMPHYSEMA OF THE LUNGS. 285 expectoration, 3^011 will find benefit from cantliarides or turpen- tine, either administered by the mouth, or applied to the surface of the chest in the form of blisters and rubefacient embrocations. These drugs often act very powerfully as restoratives of healthy action to diseased mucous membranes. They indirectly in this way benefit the emphysematous lung, by preventing the neces- sity for so much coughing ; but they are not directly useful to the tissue mainly at fault. I do not approve of the use of squill or ipecacuanha, and still less of antimony. Even if they appear to relieve for the moment, which is by no means generally the case, yet they lower the appetite and the powers of digestion, and thus stand in the way of active restorative treatment in emphysema. {Clinical, St. Marys, October 31, 1864.) There have been under your eyes during the month, two cases very graphically illustrative of the pathology of emphysema. On October 7 there was received from the Servant's Home (where she had been living, while attending as an out-patient), Annie C, aged seventeen, a fat but stunted maid-of-all-work. She was in the hospital during the summer of last year, and I find that her illness then was a typh-fever, slight in itself, but which had come on during a wet and cold foot-journey from Norfolk, and which had, under the adverse circumstances of its supervention, caused pneumonia of the lower lobes. She recovered perfectly to all appearance both the use of her lungs and her flesh at that time. But yet she says she has never quite ceased to suffer from shortness of breath. This shortness of breath has been gradually growing upon her, and prevents her keeping any place as a domestic servant. On admission she was very blue in the lips and face, and was suffering great dys- pnoea ; the respirations being forty in the minute. She said she had not been able to lie down in bed for two months. There were loud snoring and cooing rales throughout the lungs, inter- spersed with occasional cracklings in various parts, a roundness 19 286 EMPHYSEMA OF THE LUNGS. of the thoracic walls, abdominal and heaving i-espiration, and resonance on percussion noore extensive in every direction than it ought to be. The heart, however, is not entirely overlapped by the lung, so that this evidence of local emphysema in the left lung is not complete. The cardiac sounds are healthy. Emphysema is not usual in girls of seventeen, and we are able therefore the more distinctly to refer this case to the peculiar adverse circumstances in which she had been placed. Conges- tive inflammation of the pulmonary substance had been induced by exposure in a person previously disposed to it by the typhous state. The congestion had been relieved by treatment, but there was left behind the weakened life of the tissue unable completely to recover itself. This has resulted in gradual local degenera- tion ; in spite of the patient's generally well nourished condition, her lungs are starved and emaciated. This is the reason why I have treated her with iron and qui- nine, in addition to the gethereal tincture of lobelia, which was given to alleviate the special symptoms at first. She is now able to breathe easier and to lie down in bed, but I am afraid she must be turned adrift on the cold world next week, for one can hardly expect to fit her for domestic service, and more pressing cases demand the use of our beds. Bridget G., an unmarried Irish servant-girl, aged twenty-five, was admitted on the 19th. She has the same sturdy build and bloated look as the last patient, and I cannot help thinking that most probably the pathological history of her case is the same. It is true that we cannot draw from her any account of pneu- monia ; but she is impenetrably stupid and ignorant, and hardly understands the English language, so that I do not reckon her answers to cross-questions as of much worth. She might easily have had slight pneumonia without recording in her memory any- thing which could lead us to a knowledge of it. Even in the former case, I doubt if the clinical clerk would have made out the occurrence of pneumonia and typh-fever from the girl's tale without the aid of our former notes. Bridget's symptoms have been coming on three years, and in consequence the lungs occupy a larger space than Annie C.'s, EMPHYSEMA OF THE LUNGS. 287 overlapping the heart and rendering the cardiac region resonant. Her degree of dyspnoea, however, is not so great, nor is the impediment to lying down flat so marked. I have often re- marked that the asthmatic symptoms of emphysema are by no means proportioned to the large extent of the parts affected ; their severity rather depends on the rapidity with which the de- generation is advancing. 1 have put her on a course of iron, for which I have already to-day told you my reasons. I have also had her cupped between the shoulders, as an ex- pedient of immediate, though temporary, relief; and an expedient Avhich the prominence of the venous crasis amply justifies in her case ; — she Avill soon recover the blood lost. She had been taking, by somebody's orders, some pills of squill and ipecacuanha every night. I continued them, in order to ob- serve their influence. On leaving them off she slept quite as easy as when taking them (she said "easier"), and I could detect no change in the quantity or quality of the sputa. So that expec- torants are evidently of no use, an observation I have often had occasion to make in cases of emphysema. You have fairly exhibited in the history of these two girls the slow and gradual march of a degenerative lesion as a local affection in a sanguine and otherwise healthy person. You see it caused by privations and injuries, rather than by any violent special exertion of the part. And you see how these causes act even in persons not constitutionally liable to such degeneration, namely, with great slowness and without threatening any immi- nent danger. It is different with leuco-phlegmatic persons. In their case the advance of degeneration is repaid and acute, and, if not checked by active tonic treatment, proceeds soon to its fatal termination. You will say this is a great advantage for persons of sanguine temperament. So it is. But it has its counter-balance. De- generation in them is much less amenable to treatment, especially to treatment by iron, which is the most valuable, than it is in the leuco-phlegmatic. Though rarer and slower, its march in them is unfortunately sjircr, when it has once begun. LECTURE XXIII. PULMONARY CONSUMPTION. Pathological data concerniny phtJdsis — TJie disease localized by morbid anatomy and auscultation — Pitfalls incident to this knowledge — Not the presence, but the increase, of tubercle, is the chief imint — Innocuousness of non-2)rogressive tubercle — Object' of treatment should be the organs of nutrition, not those of respiration — Food — Cough medicines — Ajjpetite — Iron — Cod-liver oil — Alcohol — Remedies for diarrhoea — Cachetic phthisis — Chlorate of potash — Delirium hi the last stage of phthisis, hoiv caused, and how to be treated — Specifics. {Clinical, St. Mary's, December 13, 1861.) I SHALL not to-day detail any particular instance's of pulmo- nary consumption. For there always are several in the wards, to which I have called your attention on points of diagnosis ; and it would he wasting the valuable time of a clinical lec- ture to recite their familiar, phenomena ; which, so far as they affect the treatment, are very uniform, and perfectly familiar to you. I take it for granted also that in the systematic course of lec- tures on medicine you have assented to the following propositions, which seem to me to comprise the chief points contributed by pathology towards the treatment of the disease, and in proving which a great deal of time and thought have been worthily spent. I shall assume — 1. That the cause of the symptoms, of the disease, of its fatal- ity in fatal cases, is the occupation by tubercle of vital organs, especially the lungs ; — PULMONARY CONSUMPTION. 289 2. That the tendency to the formation of tubercle resides in the constitution of the individual; — 3. That this tendency may be either hereditary or acquired, or both hereditary and acquired at once ; — 4. That the circumstances which quickest develop this ten- dency are the same as contribute to anaemia, namely, starvation, bad air, deprivation of light, exposure to cold without power of resistance, fatigue, previous illness, in short, all depressants of the powers of life by want of supply to the formation of tissue. Anatomy and auscultation have rendered us the enormous service of tracing out truly in death and life the organs chiefly injured in pulmonary consumption, and the nature of the injury done. What an incalculable advantage we have over our grand- fathers in this respect ! What a contrast between the dangerous confusion of various diseases under one head, the distinctions without differences spoken of in the writings of the bygone age. and the almost pedantic precision of our diagnosis ! But do not stop here; pathology must carry you on further, or you will have gained so little from science, that I doubt if your practice will be any better than your grandfathers', in spite of the treasure of additional knowledge you possess. Often, during our talks up stairs, I perceive signs of your considering the tubercle as "the disease" against which you have to direct the energies of your minds, and from which the patient has to be rescued. You want to do something to "stop" it, to "absorb" it, to "counter-irritate" or "evacuate" it; you seem to imagine that if you could take away that mass of cheesy matter which auscultation puts almost as clearly before your mind as if the ribs were transparent, your treatment would be perfect. And I fear that in this you might be upheld very often by the tone of medical literature, even of modern date. For exam- ple, I read in the "Cyclopsedia of Practical Medicine" that emetics are useful in the early stages of phthisis, by displacing and evacuating the tubercles from the lungs. Can the writer ever have really tried with a scalpel to pick out a tubercle from the pulmonary tissue, when he thus suggests the possibility of the gentle pressure of vomiting effecting such a feat? And I 290 PULMONARY CONSUMPTION. find the effects of cod-liver oil sometimes attributed, not with obvious common sense to its being an easily digestible oil, but to the minute traces of iodine which it contains. Yea, iodine itself has been given in long courses with the idea of bringing about the removal of the tubercles. I wish to put these notions out of your heads. What the patient has to fear, is not the remaining of the tubercle in the body, but its increase. That which is once there has done its mischief, its path of ruin is past, the portion of lung which it has occupied is gone for ever, and cannot grow again any more than an amputated leg. The dissections of consumptives almost always show the cause of death to be a fresh formation of tuber- cle at no distant period, which has abridged the remaining organ to a degree inconsistent with life. A single deposit of tubercle to a moderate extent can almost always be recovered from. It is the continuous repetition of the morbid process which is so fatal. I cannot, therefore, too strongly impress upon you, that riot so much the tubercle as the tendency to form tubercle, not the morbid matter but the diathesis, is that which should occupy your thoughts. When tubercle first takes its place in the pulmonary tissue, the lung feels a good deal inconvenienced by its presence; there is cough, inflammation round the foreign body, and condensation of the neighboring substance ; and this is accompanied by general ill health, arising from the sudden loss of part of the respiratory function, to which loss the system has not had time to become accustomed. These consequences are directly proportioned to the quantity of lung spoilt. They may be so severe as to cause death by what is called "tuberculous pneumonia," or by "gal- loping consumption," "when a large extent of lung is very quickly rendered unserviceable. Or, when the injury is more gradual and slighter, they may be so insignificant as not to have attracted notice at all. The other day in a patient of mine who died of chorea dependent on a tubercle in the spinal cord, you saw at the post-mortem examination scattered tubercles in both lungs which had caused no symptoms at all during life, though they PULMONARY CONSUMPTION. 291 probably had been there much longer than the tubercle in the less usual situation which proved fatal. And very often in per- sons killed by accident, apparently in the prime of activity and with no history of any serious illness, you find crude tubercles, scars of former tubercles, and the chalk-like debris of tubercular matter.* Passing on to more agreeable evidence — we find people with a very large quantity of tubercle in the lungs, so large as to have almost proved fatal, who yet recover to a great extent from the mischief which it has caused. When once the lung has got over the shock produced by the presence of the first load of dead matter, the health recovers, and the patient (though imperfect in body of course) has only to fear a fresh crop. It is astonishing what enormous ravages may be made in the lung, and yet with the help of what remains how people will recover the health that has been lost. I dare say you may remember last summer a poor old woman sent to the hospital to die. There was in the left upper . lobe a vomica, so large that there was "metallic tinkling" in it; and for some weeks I took the oppor- tunity thus afforded of teaching you this sound. You know from my lectures on diagnosis that it hardly ever occurs except in pneumothorax with perforation, and not always there; that it is very rare in vomicse, and when present indicates a cavity bigger than your fist at least. So weakened was the patient by tl>e loss of so much lung, that she was at first unable even to feed herself, and quite soaked the bed with colliquative perspirations. Yet, contrary to all our expectations, she lost her night sweats, gained flesh, walked about the ward, and finally walked off home during my absence from London, so that I cannot say what was the exact state of her chest on leaving. But I will take for granted that the cavity remained unclosed, and probably will remain unclosed for the rest of her life. * In 566 autopsies of tubercular persons, which I found recorded in the poat- morlem books of St. George's Hospitul during ten years, there was seen the so- called "cretaceous" matter in the pulmonar}' tissue in 65. See " Decennium Pathologicum/' cliap. v, sect. 7, where statistical arguments are assigned for considering this solid substance to be really of tubercular character. 292 PULMONARY CONSUMPTION. I say I take for granted that the cavity Avill remain unclosed for the rest of her life, from my experience of post-mortem ex- {iminations, which lead to the conclusion, that in cases of cured phthisis pulmonalis vomicas rarely heal up, hut that they hecome dormant and comparatively innocent, lined with a thick mem- hrane, and thus separated from the healthy lung around them.* I can give also other and living evidence. — For example, R. S., a wine merchant, aged forty-two, was, in 1846, under the care of several of the most experienced in chest complaints of the London physicians. He had a large vomica in the left apex, was excessively debilitated by it, and was sent home with the information that he could not live a month. Well, he picked up strength and flesh, was enabled to return to his business, and, when I saw him in 1858, twelve years afterwards, he was in fair health, and as able to do a moderate day's work as anybody I know; but auscultation left no doubt that the vomica was still open in the lung, and that the small quantity of pus he expecto- rated came from it. In 1855, I advised a young man, with softening tubercles in the left lung, to accept a chance which he had of settling in the West Indies. Six and a half years afterwards, he returned to England for a temporary purpose, and came to me about some sjmptoms not connected with his chest. I found that his vomica Tifas still there, and secreting pus; but that he had never per- manently lost again the flesh which a course of iron and cod-oil had put upon him. He had even had an attack of haemoptysis, and gone through yellow fever, without serious injury. As a contrast to such cases — and the way in which we lose sight of our patients prevents our multiplying them — as a con- trast to these where vomicas have become innocuous, compare those in which chronic consumption proves fatal. In the latter, a dissection always (accidental cases excepted) reveals, either in the lungs themselves or in other vital organs, a formation of * Reasons are given in the chapter cited in the last note from my " Decenniura Pathologicum," in the Medico-Chirurgical library, for believing that "chalky masses'' in the pulmonary tissue are not the remains of Tomici« but of hard tubercle, which has dried up without softening. PULMONARY CONSUMPTION. 293 fresh hard tubercle as the cause of death, besides the established vomica or the old masses of morbid matter. It is clear, therefore, that it is the tendency to tubercle, and not the existing tubercle, which we have to fear and to guard against; and that for the successful treatment of consumption we must withdraw our minds from the morbid anatomy of the locality to the fatal propensity of the constitution. To my mind, it is a great relief and rest to be able to map out by auscultation the exact extent of the mischief done, and to know that there is enough of the morbid change discovered to account for the severity of the symptoms. I feel then like a general who is acquainted with the exact position and whole force of his enemies, and is sure that the country will suffer no further loss if they can only be kept from advancing. In the case of chronic consumption hope should never be en- tirely lost. If the remaining portion of lung has retained life so long, it can retain life longer, and the whole attention can be applied to its conservation. There is no question about the future conduct of the war, if only reinforcements for the enemy can be stopped in their march. To what quarter must we look for aid in this conservation ? I know you are disposed to turn first to the lungs. But if we inquire into the histories of those who have lived long with vomicae or tubercles, they are by no means found to have taken special care of their chests — they have not coddled or lived in- doors in even temperatures, hanging their lives on to their ther- mometers for fear of coughs : they have gone on with their professions or business or work : they have not " laid a knife to their throat," but have eaten and drunk like other people, and have enjoyed the gratification of their appetites. A patient of mine, over fifty, with copious pyoptysis and condensed lungs (of probably a tubercular nature) from his youth, has kept hounds, broken his bones like other Nimrods, contested county elections, sat in parliament, enjoyed his champagne and other good things, but 7iever allows any doctering of his chest. Nor is it only when tubercle is established that it may be arrested hj exposure of the body to active change; even the 294 PULMONARY CONSUMPTION. tendency may be averted. I examined for insurance, a few weeks back, a gentleman aged fifty-five, the second of a family of eleven in whom phthisis was hereditary. Circumstances have caused the three eldest to rough it in the world: they have traveled and worked for their bread, and now, when wealthy, they are healthy, active sportsmen. The seven youngest were coddled and petted, and all died of consumption under twenty- five. The statistics of death by phthisis in the two sexes corrobo- rate this deduction. Although males arc more liable to tuber- culosis than females, yet they are less liable to have that tuberculosis exhibited in the lungs. (See " Decennium Patho- logicum," chap, iv.) Now in all classes of social life, women are the least disposed to exert and expose their lungs ; they are more ready to invalid themselves ; and in the lower classes, whence these statistics are taken, they do not wear low dresses or tight stays (to which habits some have attributed consump- tion). Yet we find that tubercle with them takes the direction of the spared organ. You may perhaps say, "This spared organ is a most import- ant one : I will sacrifice the others to the possible chance of saving it." But consider — what is this tubercular matter? It is not anything peculiar to the lungs, but may arise from degene- rated nutrition — the inferior development of life — of any part, and may occur in any part. Now, excepting my glands, many of which I could easily spare, I should prefer having it in my lungs to any other part of my body ; for I know that I can live with a good deal less pulmonary tissue than nature has given me. But I cannot live with an equal amount of deficiency in my brain, or my heart, or my alimentary canal, of which I have onlv one. So that if tubercle is to exist at all, I really do not know that we should look upon it as a misfortune when it oc- curs in the chest, as it is safer there than in most parts of the body. If then care bestowed upon the lungs and special coddling of them increases the danger of tubercular tendencies, as the above arguments clearly show ; and if, supposing that special medica- PULMONARY CONSUMPTION. 295 tion could keep tubercle out of the lungs in particular, no ad- vantage is thus gained — to what Avould I have 3'ou turn? Leave the respiratory organs alone, and direct your thoughts to the organs of nutrition, the stomach and bowels, which will receive with thankfulness, and return with interest any care you bestoAV upon them. It is truly by aid of the digestive viscera alone that consump- tion can be curable. Medicines addressed to other parts may be indirectly useful sometimes, but they more commonly impede the recovery ; whereas aid judiciously given in this quarter is always beneficial and usually successful. The chest is the battle-field of past conflict, the stomach the ripening ground for new levies of life. Your aim should be to get the greatest possible amount of albuminous food fully digested and applied to the purpose of the renewal of the body, at the same time that the renewing agencies are brought to their highest state of efficiency. In this way a healthy cell-renewal takes the place of that morbid imperfect cell-renewal which appears in the shape of tubercular matter. With this view I shun, as far as I can, all those "potent herbs and baneful drugs" which may be classed together as "cough medicines," meaning antimony, ipecacuanha, and squill espe- cially. I avoid also merjcury, purgatives, and neutral salts, Avhich are debilitants. Where the heart is thin and weak, digitalis is sometimes useful, by regulating and calming its action; but as a rule it is injurious, by reason of the nausea and loss of appetite which it causes. The appetite should be the great object of your care. You will often find it sadly wanting ; and where that happens, the mucous membrane of the stomach and bowels should be braced up by quinine and strychnine. The latter acts quickly, and maybe added to the other medicines from time to time; but the former is most permanent in its effects, and should be begun at once, and continued through the whole process of medication, till the appetite equals or exceeds that of a healthy person. Iron, again, you will find a most powerful ally. The increase 296 PULMONARY CONSUMPTION. in the hajmatine of the blood which follows its use is all-im- portant ; for thus you supply to the tissues the true life-giving medicine — red blood. Begin iron in small doses, and gradually increase it till you have found the full quantity the patient can take, and then continue to administer rather less than that, so as to leave room for an occasional augmentation according to circumstances. Where you give digitalis, make it a rule to add iron and sometimes strychnine to the dose, as you thus get the full advantage of the digitalis, and shirk some of its possible evils. Iron prevents nausea, and strychnine co-operates in strengthening and regulating the action of the weakened heart. When the repugnance to eating is extreme, adopt the plan you so often see used in these wards with success, of giving milk in small and very frequently repeated doses. Nutrition has a habit like that of arguinfj in a circle; food creates the desire for food — of course, by strengthening the digestive organs; and thus, after a few days of milk diet, the patients will voluntarily ask for meat, and enjoy as a luxury that which a short time before excited the greatest disgust. If you find the milk lie long in the stomach and produce heartburn or acid eructations, add lime-water or soda-water to it. The first is the cheapest, the latter the pleasantest. Cod-liver oil will also often, like milk, create an appetite. But as a rule, especially in private practice, it is well not to commence it too soon ;• for the nastiness of the taste and feel is hard to get over at first, and it is much easier to take it when the appetite has begun to be renewed. Then it is not felt as a hardship even to begin, and in a short time patients will get really to like it. And they Avill like it, not merely as reasonable men like that which does them good, but irrespectively of such knowledge th^y will find it nice to the palate. Thus children, who always hate being done good to, will still often take to their oil with gusto. And as a proof that exalted reason has nothing to do Avith the preference, the same thing has been observed in brutes. A clerical friend of mine had a consumptive Skye terrier, which he treated secundem artem with cod-liver oil. At first the poor beastie abhorred it, and looked sad before and after each dose ; PULMONARY CONSUMPTIOX. 297 but in a short time he began to lick his lips after it, and if he Avas forgotten, would go and beg more canino at the door of the cupboard where it was kept. The best sort of cod-oil is the most agreeable, the clearest, the sweetest, and the most scentless — that, in fact, which is tho- roughly free from extraneous dirt. The oil from the same fish, formerly used by curriers, was sold for their use cheap and foul, and no doubt was quite good enough for manufacturing pur- poses; but it must excite a very natural disgust in any one but an Esquimaux or a whaler, I should think, for it stinks like old train-oil. Its low price wholesale. allows of certain firms spending large sums in widely advertising as a superior form of drug; but I strongly advise you never to prescribe the "brown oil" (as the name runs); it is never beneficial where the pure oil fails, and it often and often makes the patient protest he will on no consider- ation take it again. The mode of manufacture which causes the difference of the "brown" and "pale" oil is described in an article of the "Medico-Chirurgical Review" for January, 1856, and is quite enough to prevent any reader of delicate perceptions ever ordering or taking it again. The best plan is to give at first a teaspoonful, and afterwards two teaspoonfuls thrice a day, floating on the quinine or iron mixture to which the patient has already become habituated. I think an ounce a day is enough to administer as the full dose, and need not be exceeded. If the patient absorbs all that, you may be quite satisfied ; and more will be apt to turn rancid, and cause indigestion, the worst foe of the phthisical. The best time to take it is at the greatest distance from meals, as thus a sort of additional meal is gained, and food and physic are not confused ; but if your patient likes any other time better, on account of taste or business, do not stand in the way of his fancy. The effects of cod-liver oil become less and less a marvel the more we know of physiology. The instinctive desire shown by all nations for an oleaginous diet, and their association of sub- stances of this nature with proverbial ideas of happiness in all ages, show the value of a certain amount of it to man's comfort. The "butter and honey" of the prophet, used as a phrase for 298 PULMONARY CONSUMPTION. royal food, and the constant reference in the Bible to oil as a luxury (though it could have been no rarity in "a land of oil- olive") — these are sufficient to prove its estimation among the Hebrews. The Hindoo laborer, when he devours his gallon of rice for a meal, will spend all the pice he can get on the clarified butter of the country; and "as good as ghee!" is his expression of unqualified admiration. It was a mistake in Baron Liebig to state that oily foods are disgustful to natives of hot climates. All races of men require them and seek after them ; and the taste of the Esquimaux, so often quoted, depends mainly on the abundant supply of the article which the sea places at his disposal, coupled with a scantiness of other provisions. Throughout mankind there is an instinctive appreciation of the importance of this aliment, independent of accidental difi"erences of nation or locality. It seems felt to be, as science shows that it really is, a necessary material for the renewal of the tissues, and the desire for it be- comes synonymous with a desire for augmented life. An easily assimilated oil comes, in fact, into the short list of directly life-giving articles in the pharmacopoeia; for it is itself the material by which life is manifested. Hence, under its use, beneficial influences are exerted throughout the whole body ; old Avounds and sores heal up; the harsh wrinkled skin regains the beauty of youth; debilitating discharges cease, at the same time that the normal secretions are more copious; the mucous mem- branes become clear and moist, and are no longer loaded with sticky epithelium; the pulse, too, becomes firmer and slower — that is to say, more powerful, for abnormal quickness here is always a proof of deficient vitality. Such are the eifects, per- fectly consistent with physiology, of supplying a sufficiency of molecular base for interstitial growth. The addition of a small quantity of alcohol will often enable the oil to be absorbed more readily. This is a principle well understood by growers of live stock for prizes at agricultural shows, who, by the addition of fermenting grains or spirits to the animal's food, often fatten it more quickly. The addition therefore of Avine, whisky, tincture of orange-peel, or of any other harmless bitter to the medicine, is rational, and may be PULMONARY CONSUMPTION. 299 freely conceded, if the patient finds it agreeable. But the true use of it as a remedy or preventive for tuberculosis is a diiferent question. In my opinion alcohol is not only useless but injurious to the consumptive, excepting for its beneficial action upon the mucous membranes. It arrests and obstructs the vigor of vital action ; by it growth is checked, as we see in animals artificially kept small by dosing with alcohol in youth without a sufficient supply of food, and in men who have early in life habitually indulged in ardent spirits. Under its use renewal goes on slower, as we know by the diminished excretion of urea, water, bile, &c. (see Dr. Booker's "Experiments," and Lecture L. in this volume), and we can hardly therefore expect it to be advantageous where the continued renewal of vital powers is our primary object. But you may fairly ask how are to be explained cases like the following, in which to all appearance alcohol seems the pre- servative of life. J. P., a butcher, remarkably strong and stout, was first at- tended by me for delirium tremens, which he had suffered from several times before, and was always well in the interval; an attempt to become a teetotaller was immediately followed by galloping consumption. J. A., a brewer, came to me last year about indigestion and pimples (acne rosacea) on his nose and face; I urged him to give up brandy-drinking before breakfast and between meals; and I find now a developed vomica in his lungs, of which pre- viously there was no evidence. You may cite instances such as these, and attribute the vomicae to the omission of alcohol, which therefore you may represent as a direct preservative. I think you would be wrong. I confess I do not take such cases as mere coincidences, but I explain them in a way by no means corroborative of the idea that spirit-drinking keeps off" consumption. I think that alcohol acts as an anaesthetic, and prevents the system from resenting the presence of the tubercles; then, when it is left off", they act with doubly deleterious effect on the body, which is unprepared 300 PULMONARY CONSUMPTION. by their gradual increase to bear them as it Avere by habit. The quondam tippler is then in the same relative position as one in whom there is a large sudden development of the morbid matter; for the existence of the morbid matter unexpectedly becomes appreciated by the system, and its ravages suddenl}' taken notice of. Thus instead of really checking tubercular disease, the alcohol has acted merely as a mask, behind which the evil has gone on unawares. AVhat should you do in such cases as those above related ? Should you advise a return to drinking habits? I think not; for though the symptoms are somewhat lightened thereby, this is merely a misty cloud of anaesthesia which stands between the patient and his pain, and I doubt if life is prolonged. More- over it is possible to adopt measures as immediately effectual, while certainly offering moxe prospective advantages. In the last case which I quoted, after a certain struggle with bron- chitis, night-sweats, and emaciation, weight and strength are being gained under cod-liver oil and quinine, although the allowance of alcohol is reduced to that of a temperate man.* So to such remedies I advise you to trust in all like cases. Here, as ever, the appetite must be your index; the stomach must be the viscus whose health is to be your care. In advising foreign travel, again, take the stomach for a guide. At the dreary time of the English year, when your patients cannot get enough light and exercise to give them an appetite, let them seek those sunny climes where the winters are the holidays, the joyous seasons for out-of-door employment. Madeira is the best. The next is that lovely Mediterranean shore recently annexed to France, from Cannes to Mentone; and after that comes a long list of localities highly praised by their inhabitants, but with a more uncertain climate. Instead of naming one place after another and thus risking offence to a large number accidentally omitted, I prefer to give you a simple common sense rule by which you may help your patients to make the best use of the winter season. In choosing a home for your consumptive, do not mind the * He is now alive, and able to resume active business (Sept. 18G5). PULMONARY CONSUMPTION. 301 average height of the thermometer or its variations; do not trouble yourself about the mean rainfall; do not be scientific at all, but find out from somebody's journal how many days were fine enough to go out forenoon and afternoon; that is the test you require, and by that you may be confidently guided. Do not suppose all is done when you have chosen a climate. Your responsibility is by no means ended ; you must be care- ful in enforcing a right use of the climate. If your patients from distaste of foreign habits, from pining after home, or other causes, take to moping in-doors, or find themselves overwearied on going out, the sooner they return to England the better. They are getting no good, and they are running the risk of diarrhoea, low spirits, hysteria — or still worse, of failing so much, that they cannot return home, and must remain to die, "by strangers honored, and by strangers mourned." But if they write you word that they are boating, riding, swimming, sketching, catching lions in Algeria, or butterflies in Madeira, you may congratulate yourself on having added per- haps months, perhaps years, perhaps luster, to their lives. Next to the stomach, the bowels claim your main care. During this course of lectures, in which I am impressing upon you the principles of restorative medicine, it is almost needless to say that in pulmonary consumption you are to shun artificial purga- tives. But I had better remind you of the importance of being on your guard against natural diarrhoea. Do not allow it to go on an hour longer than you can help. The best remedies are sulphate of copper, hsematoxylum, and opium. Chalk mixture will sometimes act well ; but, if it fail, you have lost valuable time; so, if you follow custom in beginning with it, do not be obstinate in the continuance of your remedy. The sulphate of copper may be begun in doses of one-fourth of a grain, and increased up to two grains, if required to be persisted in. The haematoxylum may be given as an extract in dose from four grains up to any amount required, but should not be mixed with the copper, or you produce an ink. If you give both, let there be three hours' interval between them. 20 302 PULMONARY CONSUMPTION. You see almost daily cases of consumptive diarrhoea checked sometimes for a season, sometimes even permanently in patients whose disease is too extensive for recovery. This is doubtless a great point gained, and some time added to life. But more than this, I believe that the tendency to deposit tubercle also is some- times arrested by arresting the bowel complaint. Just after Lady-day, 1861, Miss Harriet B., aged thirty, whose "father and mother had both died of decline," was placed under ray care by Dr. Buckell, of Chichester. She had evidence of a small focus of tubercle in the apex of the left lung, producing pain, dullness, and crepitation (from the partial condensation of the lung round it), but no marked pulmonary ailment. I thought that the quan- tity of tubercle was slowly increasing from week to week. What she complained of, however, was emaciation and diarrhoea, accom- panied by the passage of pus, and sometimes streaks of blood in the mucous faeces. She was soon relieved of this by appropriate remedies; and with a store of hrematoxylum and copper was able to ffo on a long summer visit to some friends. I heard of her as going on well, and did not expect to see her again, or to make her case available for science. But as she returned through London in September, proclaiming herself quite well and stout, I had an opportunity of examining her chest again ; and much to my delight was it that I did so. Greatly to my surprise, I could detect no disease at all in the lung ; so that, instead of increasing, as I had feared, the pulmonary tubercle had become dormant, solely by the cure of the bowel complaint. Not all cases do as well as this, but still what has once befallen may befall again, and it is the surest road to success to hope and try for it. {Clmical, St. Marys, June 7, 1862.) In some cases of consumption there is a considerable amount of cachexia, the gums become spongy, or whitlows form on the fingers, or there are various kinds of skin diseases. This hap- pens usually in consequence of low living, damp, and depression of mind. PULMONARY CONSUMPTION. 303 There is now in Victoria ward a girl of sixteen, who was trans- ferred from a surgical ward. She was at first in a deplorable condition; she had been admitted for impetigo,* with which her cheeks and nose were covered, while the pads of her finger-tips and nails were sore and purulent from the same eruption. Yet the impetigo did not account for colliquative night-sweats, extreme emaciation, and weakness so great that she could not raise her- self in bed : these symptoms were explained by dullness at the apices of the lungs and localized rales, indicative of tubercular condensation. Some thought there was a vomica at one apex, on account of the cracked-pot sound on percussion, but it was a doubtful point — the cracked-pot sound is a very fallacious sign. She did not behave as if there was a vomica, for she has been gaining strength and flesh daily up to this time. My reason for recalling this case to you is to notice that, in spite of tonics and high feeding, before she came under my care she had been getting weaker and weaker. The only change I made was to give with her tonic mixture half a drachm of chlorate of potash daily in some cod-liver oil — I confess with but little hope that she should revive. I was never so struck before by the directly vitalizing force of this salt upon connective tissue. In a fortnight her "flesh came again like unto the flesh of a little child," as the Hebrew historian beautifully expresses it; the clear doll-like complexion of face and the pink babyish finger-tips are very pretty. And I have no doubt that a like quickening has gone on in the skins of the inside — the mucous membranes — so much strength and appetite has she gained. This case shows you when to give chlorate of potash in con- sumption with hope of profit. And I am glad you have the opportunity of seeing this, because a short time ago chlorate of potash blazed forth as a cure for phthisis in general ; and if you have tried and found it wanting in some ordinary instance, you * Impetigoz=.^'- ?i superficial formation, consisting mainly of jo^m from the de- nuded connective tissue of the corium, without external exciting causes." Eczeviazzz'-'- the same of serum." I do not propose these as dogmatical definitions, for dermatologists are a difiB- cult race to please, but simply to explain what I myself mean by the words. 304 PULMOXARY CONSUMPTIOX. might be tempted to treat with undeserved contempt a medicine of really great service in proper cases. [Clinical, St. Mary», February 6, 1864.) On my last admission day, January 29, there were received under my care two very distressing cases of consumption. Both were in the extremest state of emaciation and exhaustion from suppurating vomicae in the lungs, and so far presented a spect:icle which is sadly familiar to the medical man. In addition, the woman was purple in the lips and face from intercurrent pneu- monia, the man was in a cold sweat, and had diarrhoea. But the symptom exhibited by both in common, which leads me to mention the cases to-day, is one not quite so usual as these, yet sufficiently usual to make it of practical importance. I allude to delirium. The man got temporarily somewhat better of it after a few days' residence in the hospital, so that his mind wandered only at night, but the woman has been disturbing the ward with her continuous ravintrs, has been verv violent, exerting her small remains of strength to throw the beef-tea at the nurse. She uses such abominable language that it has become necessary to place her in a room by herself. Delirium at the latter end of exhaustive diseases is a sign of the participation of the nervous tissue in the destruction which is going on among all the tissues of the body. It answers to the convulsions and obtuseness of sense, which M. Chossat observed in animals starved to death.* The nervous system being the ultimum moriens of the body, suffers last, but does suffer in the end. This delirium is commonly accompanied by deafness, and is so accompanied in the two cases before us. I cannot say I have been able to trace a corresponding deficiency in the organs of sight, but certainly the taste and general sensation are deficient. The pain in the chest and suffocation, which the poor woman com- plained of on admission, are denied now that the raving is worse, and she does not appear to know food from medicine. * See before, pages 30 — 40 of ibis volume. PULMONARY CONSUMPTIOX. 305 The immediate cause, to which I have most usually seen occa- sion to attribute it, has been unwonted and excessive bodily exer- tion, at a time when extreme rest constitutes the only possible means of economizing the vital power. I have no doubt but what it was the being brought out of their beds to the hospital which made these patients so much worse directly on their arri- val, and which threatens to shorten their lives. In those who die no morbid change in the nerve substance is visible after death, though the symptoms during life generally cause it to be carefully looked for. This fact is familiar enough to those who have the inestimable pathological privileges of n public institution ; but I think it is often unknown to others; and, consequently, the natural connection in their minds between the increase of symptoms and the spread of tubercle in consumptive cases is apt to lead to their assigning the delirium we are con- sidering to a development of tubercle in the brain. Two months ago an old gentleman in the last stage of senile phthisis was brought up from the country by his family, contrary to the excel- lent advice of their own medical man, to obtain " a London opinion." I believe they had already taken him to one physician previously, when he arrived excited in mind and worn out in body, in my study. I felt much relieved when a glass of Madeira enabled him to be got back to the carriage, for I should not have been much surprised at his dying in my house ; and you may easily imagine that I rebuked the folly of his friends in strong language. However, he did get home. But very soon he became delirious and raving, as I learned by letter ; and I found that this delirium was attributed by those who attended him in the country to tuberculosis of the brain. The idea is a natural one, but it might have injured the patient had it influenced the treatment. His death in delirium was indubitably due to the almost superstitious folly of his friends in bringing him up to London. As to treatment, opium, wine, and continuous nutriment seem indicated, and to be of some use; but such cases of extreme dis- ease are not usefully illustrative of medical regimen. The man has been better since he began cod-liver oil and quinine, and 306 PULMONARY CONSUMPTION. perhaps the nourisliing thus the nervous tissue, if the food can be assimihited, is the best application of restorative principles. {CKnical, St. Marys, May 10, 1862.) ******** I am induced to add a few words about so-called specifics for consumption. Some years age, Dr. John Hastings proclaimed "naphtha" as an unerring cure. Some people tried it, and soon learnt that it was applicable at all only in cases where alcohol was beneficial, and even to such patients they found that the purer and wholesomer forms of spirit in daily use were both more useful and more acceptable. All the advantages of the remedy had been in the hands of the public in a pleasanter form centuries ago. Determined at last to try a virgin sub- stance — — "integros accedere fontes Atque baurire" — the same gentleman has recently discovered that serpents' dung now succeeds to the throne where once naphtha reigned. Our rude forefathers in art administered many curious things; the ashes of toads, the urine of boars, live spiders, human liver, human ordure, the skull of a murdered man, the blood of the patient's father, and other gatherings from witches' caldrons, are in their lengthy pharmacopoeias, and are many of them stored in that interesting collection of ancient articles of materia medica at the College of Physicians. Their intention was to drive out the devil by digusting him. But I do not think that they ever hit upon the bright thought of using the very dung of the accursed type of evil, that as he indignantly "goes out," he may say, " That eagle's fate and mine are one, Who in the shaft that made him die Beheld a feather of his own Wherewith he wont to soar so high." I really believe this expansion of the idea to be quite original. Good coprologists tell us that the excreta of snakes, foeces PULMONARY CONSUMPTION. 307 and urine in one, consist mainly of lithate of ammonia — an un- attractive substance, which persons familiar with physiology believe to be harmless, and valuable only as manure. I rested content with that belief till I heard Dr. Hastings, when arraigned before a public court of justice for the avaricious raalpraxis of knowingly giving inert remedies, depose positively on oath that he held what he administered to be a powerful physiological agent. His powerful physiological agent was made by dissolv- ing {i.e. destroying) sixteen grains of boa constrictor's ejecta in a gallon of water by the addition of bromine, of which the dose is half an ounce. Such a solemn affirmation was not to be lightly, treated, and after that I did not feel justified in asserting dung to bo a useless drug till I had tried it. I procured forthvfith a sample from the secretary of the Zoological Society, and caused to be made a quantity of the so-called "solution" under the name of "mistura pythonis," and you have seen me order it pretty often since in cases where, no physic being required for a time, I felt myself justified in so doing. But instead of half an ounce, which was said by the witness to be so active, I have given two ounces three times a day. You have seen that its efi'ects are exactly the same as those of so much ditch water. Such is the fate of specifics for phthisis — ex uno disce omnes — and lucky is the public if all specifics are as innocent as snakes' dung. But do not let us part without a moral, or be satisfied with merely laughing at a delusion, liemember, you are acting no better than the vaunters of vain specifics when you vaguely pre- scribe one thing or another, even of known and acknowledged power, because you have heard of its being "good for consump- tion." The time which is lost in trying this and trying that remedy is lost for ever. You have no warrant for supposing that there can be any specific for that complex morbid state which causes phthisis; you have no warrant for substituting a vague search after such specifics for rational treatment; nor can you justify yourself for standing in the way of the patient get- ting his chance of a renewal of his waning life by the unsparing use of restorative agents. 308 PULMONARY CONSUMPTION. The proper persons upon whom to try the effects of new reme- dies in the first instance are not the sick, but the healthy or nearly healthy. If no obvious results follow the use of full doses by yourself or another free from present illness, you may be pretty certain the same will be the case with your patients. There are always to be found in hospitals specimens of malin- gerers and "old soldiers," and convalescents, upon whom it is quite safe to try these experiments under proper supervision, so as to satisfy any doubts you may have. Or if you have no doubts to begin with, you will thus gain a right to make the shortest and most telling answer to inquiries of "How does such and such a cure succeed?" "I've tried it and it is useless." You should make it a rule absolute, that objective phenomena rather than subjective are to be taken as tests, and that all things are to be "delivered in number and weight," according to the sage advice of the Son of Sirach. For instance, if you were examining the action of quinine, the changes of tempera- ture must be estimated by the thermometer, the changes of urine in the laboratory, the action on the skin from the amount of perspiration. And you must not waste time by performing ex- periments which do not admit of objective proof. LECTURE XXIV. THORACIC ANEURISM. First case — Aneurism, probably of the arteria innominata — Reasons for that diagnosis — Aortic valvular murmur ac- counted for — Probable abnormal position of artery — Prognosis unfavorable — Second ease — Aneurism of aorta and its treat- ment — Bloodletting and low diet — Pathology of aneurism — Object of treatment — Favorable prognosis — Two cases of favor- able result of treatment — Fatal case of aortic aneurism — Rupture of sac into the pleura in a healthy working man — ' Length of time a patient may live with a ruptured aorta an encouragement to treatment — Case of aneurism compressing the trachea, producing congestion of the lungs, and so fatal — Actions of bleeding, leeching, and digitalis — Action of digitalis on other involuntary fibers, as on the uterus in menorrhagia, and on the bladder in incontinence of urine. [Clinical, St. Mary's, January 5, 1861.) I TAKE the opportunity of having two patients in the wards afflicted with aneurism of that -sort which alone comes under a physician's care, viz., thoracic aneurism, to call your attention to the medical aspects of the lesion. The board admitted, yesterday, into Victoria ward a young woman of twenty-two, who has been a patient of mine in the Lock Hospital. She has had syphilis on and oflF ever since the age of fourteen; and though the eruptions and sores are now healed, her health is much broken, and she is stunted and weakly. She applies at St. Mary's not for her old complaint, but on account of palpitations, and pain across the front of the chest, which she states that she has felt for three years, but 310 THORACIC ANEURISM. which lately had got much worse. She also frequently suflfers from giddiness and fainting; and last Sunday was carried out of chapel in a dead swoon. A message has just come to say that on account of one of these attacks she is unable to come down to the theater, as I bade her. She often has a difficulty in swallowing food, especially solid food. She states that she has very partial use of the left arm ; and, on examination, it is smaller in girth to a marked degree, and the muscles are flabbier than on the right side. No pulse can be felt at the left wrist, nor at the bend of the elbow, nor on the inner side of the biceps. The axillary artery can be felt beating very feebly above the collar-bone. In a marked contrast to this stands the right side. The pulse at the wrist is natural, and above the collar-bone may be per- ceived a strong pulsation, and at the origin of and for an inch or more along the carotid artery a very distinct thrill. In the hollow above the sternum the same pulsation is even stronger, and throws forward the trachea, when you press upon it with your finger. With a stethoscope a purring whiz is heard in the same situ- ation as the pulsation is felt. A murmur is heard also at the upper part of the sternum, and is particularly loud on the level of the fourth costal cartilage, where it sometimes has a musical tone. There is no dullness on percussion beneath the clavicle. My diagnosis of this case is, that she has an aneurism of the ascending aorta at the part where the innominata is given off, and that this lesion involves the innominata and the origin of the carotid artery. I do not think it an enlargement of the in- nominata alone, because of its being situated so much at the back of the trachea as to throw the tube forward by its pulsations and also to press upon the oesophagus, and interfere with deglutition. Besides, in the only case I have seen during life of pure aneurism of the innominata, proved to be so after death, the tumor was smaller and rounder, and pointed more distinctly in the supra- clavicular hollow. THORACIC ANEURISM. 311 You have here nearly all the signs of aneurism of the aorta — (1) pulsation ; (2) whiz ; (3) impaired deglutition ; and (4) im- peded circulation. But you may say there is the same whiz at the aortic valves. What is the cause of that ? It is not, I think, produced directly by aortic aneurism, but it is produced by the same original cause. Aneurism forms because there is a friability or loss of elasticity in the coats of the vessel, due generally to a deposit of white opaque matter and to a partial degeneration of them. "What is more likely than the existence of the same disease in the aortic valves ? Now I come to the puzzling part of the case. You will ob- serve that the right axillary artery is quite free ; there is quite an open passage through it to supply the radial at the right wrist. Yet it is in this supraclavicular space that we have the pulsation and whiz ; whereas the left axillary, though it has nor- mally nothing to do with the innominata, is not supplied with blood, and the left arm is atrophied. I can account for this in one way, which I might as well de- tail, though it is more a matter of curiosity than of business. (I do not bind you to accept the interpretation ; and if any of you fresh from the anatomy school can suggest a better, I shall receive it with pleasure.) In many beasts, in the ruminants and solidungula, and in some pachydermata — as for instance, the hog — the aorta divides into two branches, the ascending giving off the two subclavians and the two carotids, while the other turns backward and becomes the descending aorta. On this has been founded, by the earlier anatomists, the popular division of the aorta into "ascending" and "descending," a division un- intelligible in the human species, but exceedingly applicable to the domestic animals whence the ancient men of science learnt their anatomy. It is by no means impossible that the patient before us may have a malformation, which is an approach to this lower condition of animal life — a malformation, of which specimens may be seen in many museums : namely, where the left subclavian, as well as the right, is given off by the innomi- nata, and has to cross over the arch of the aorta to get to its 312 THORACIC ANEURISM. work ; and in this crossing it would be interfered with by the tumor of the top of the arch. I cannot otherwise unravel the enigma, as the tumor is not large enough to obstruct a normal left subclavian. As an argument in support of the explanation, I may mention that the patient has a congenital deficiency of the reproductive organs, curious in a social point of view to find in a person of her degrading habits, for she is a common prosti- tute. She has no uterus, the vagina ending in a short cul-de- sac. A malformation in one part is a probable argument for it in another. This aneurism presents several points which lead me to pro- nounce an unfavorable prognosis. First. It is in the ascending part of the aorta. Now, you will find that almost all aneurisms of the ascending aorta are rather dilatations than aneurismal sacs. They have no sharp edge opening out suddenly into a dis- tinct bag. And these dilatations are more difficult of cure than the sharp-edged sacs, because there is a. clear stream through, and no back current, so that you cannot get clots to form in them. Secondly. The absence of clots is confirmed by the strength of the thrill. Thirdly. The supply of blood to the brain is seriously diminished, as is shown by her fainting fits. Fourthly. The impeded deglutition and the suspected malformation are dis- couraging. Fifthly. She is a poor anaemic woman, reduced by poverty, syphilis and mercury to a very low state, and she will not bear lowering treatment, I am sure. Sixthly. She is said to have, like most of her unhappy class, a violent temper ; so it will be difficult to detain her in the hospital, or to keep her circula- tion quiet while there.* It is doubtful how far we shall be able to apply the treatment suitable for the disease, and how far it will prosper, if applied. What that treatment is, I shall best tell you after the next case. Henry E., a negro, aged twenty-one, came under my care two months ago — viz., on November 9. Though now a com- mercial traveler, during the Crimean war he was a sailor in a transport, and during that time he got a severe blow on the * Very soon afterwards it was necessary to tura her out of the hospital for gross misconduct, and I have not been able to find what became of her. THORACIC ANEURISM. 313 back of the neck from a "derrick." He says he never had cough or shortness of breath, and was always " strong in the chest," till he began to feel a pain there in August last, especially between the left nipple and the collar-bone. This pain increased gradually, though intermittingly, through the autumn. Three days before we saw him, while he was at his tea in Windsor, it suddenly increased very much, and he says he felt " as if some- thing was going up and down from his heart to his arm." He fell down, was struck dumb, and found that he had lost the use of the left arm. On his admission, it was found that the pulse in that wrist was much weaker than in the right, and tliere was loss of power, though not absolute paralysis, throughout the limb. The throat was externally swelled on the left side, and the carotid could scarcely be felt. There was considerable swel- ling of the whole mammary and infraclavicular regions, in which latter also there could be distinctly made out comparative dull- ness on percussion. This dullness was more distinct on the third rib than immediately beneath the collar-bone. On ap- plying the stethoscope to the third rib, a distant whizzing mur- mur could be heard, which increased in intensity in nearing the shoulder, and was less loud towards the sternum. There was no pulsating tumor, and the lung-sounds were natural, except perhaps rather more bronchial on the left side than on the right. There was a breathing pulsation in the left jugular vein. The signs of aneurism were not so distinct as in the last case, because it did not come so near the surface. 1 am inclined to think it is towards the back of the descending part of the arch ; but wherever its exact locality may be, it evidently interfered with both arteries, veins, and nerves, which supply the arm, in- tercepting the pulse-wave and the nervous current, and causing anasarcous tumefaction from its obstruction to the return of blood by the veins. Local treatment was desirable, and leeches were applied seve- ral times beneath the clavicle. He would have been bled also; but five days after admission he fortunately caught scarlet fever from a neighboring patient, and it struck me that this might prove a substitute for venesection ; for it gave us a plea for keep- 314 THORACIC ANEURISM. ing him a close prisoner in bed, and putting him on very low diet. This plan was the easier carried out from his being, like most civilized Africans, of a mild tractable disposition, and it has been pursued steadily up to the present time. On December 1, it is noted by the clinical clerk that he had recovered power over the arm, and that the pulses appeared nearly equal. He has con- tinued the complete rest, and has taken prussic acid and digitalis. There is now no difference to be detected between the radials, and he has regained complete use of the arm ; he describes him- self as quite well enough to be an out-patient, and finds a band- age which he wears across the chest sufficient to relieve the occasional pains. There is a murmur still in the infraclavicular region ; but all impediment to circulation occasioned by the aneurism has ceased. The treatment which has been adopted here is an exemplifi- cation of the principles which I have taught in the systematic lectures on the principles of medicine, and I must refer you to those lectures for an historical account of the adoption of this practice in the seventeenth century by Valsalva. It is a strict following up of that which nature adopts in all aneurisms that heal spontaneously. In them you find a fibrinous clot formed, and the sac shrunken up from lack of stream passing through it. Here we have tried to make the blood likewise form fibrin- ous clots, by bringing it into that fibrinous state which loss of blood, angemia, and low diet induce ; and we have tried to keep the blood-stream as calm as possible by rest in the horizontal posture. The pathology of aneurism shows it to us as a local deficiency of life in a hollow organ, a deficiency of vital elasticity, which has let this hollow organ yield to the continuous pressure of the blood-stream. Doubtless if we could at first have renewed this vital elasticity, such would have been the legitimate aim of treatment, and such would be the course pursued by a rational physician. But here the mischief is already done, the vessel has dilated into an uncontractile sac and is beyond the reach of any of the poAvers of life. The object now must be to restore as much as possible the original area of the vessel, and to reinforce THORACIC ANEURISM. 315 the weakened walls bj an artificial clot ; so that though we cannot have a complete artery, we may have as good a substi- tute for it as circumstances will allow. There was much in favor of this patient from the outset : the aneurism was in the descending aorta ; there was no thrill ; his general health was good ; and he is an obedient quiet creature, very different from the ill-conditioned little woman last dis- cussed. At all events he has done very well ; and I should urge upon you to make the carrying out of this principle of treatment the goal of your wishes in thoracic aneurism. You will find patients very often rebel ; but do your best, and if you attain not success, you will at any rate deserve it. I like in general to bleed the patients ajQfected with aneurisms from time to time, and should have employed that mode of treatment if this man had not had the scarlet fever. A former patient of Dr. Sibson's, now an out-patient, testifies from his own observation to the superiority of venesection over leeches in its calmative influence over an aoritic aneurism which he has long had, and on which he is very observant to the effect of remedies. But I have heard an opposite opinion given by patients. I said you will deserve success, and sometimes you will get it. I kept a stone-mason in this hospital under the bleeding and starving treatment for five weeks. He had como in with a pul- sating tumor and aneurismal whiz under the left scapula, with severe pain in the floating ribs, which some thought were being absorbed. At the end of the five weeks he rebelled, and our relation as physician and patient was at an end; but the pulsa- tion had disappeared, and the whiz was scarcely to be heard ; and I had reason, therefore, to think the aneurism in a fair way to be cured. Even in cases where the treatment cannot be carried out a Voutrance, good may be done by an approach to it. In 1851, a lady was sent to me by a surgeon in the country, to consult me about increasing corpulence and dyspnoea. In investigating the cause of dyspnoea, I found a pulsation and an obscure whiz under the left clavicle, accompanied by deficiency of pulse in 316 THORACIC ANEURISM. the left wrist. I was satisfied that there was aneurism either of the subclavian or of the aorta at the origin of that branch. But bleeding was undesirable, because she was so fat. I have often told you how badlj obese people bear bleeding. Moreover she was sixty years of age. But, as she was a sensible woman, I managed to gain her confidence, and starved her for several weeks, giving her at the same time drachm doses of liquor potassse three times a day. The effect was a reduction of her corpulence, a diminution of the pulsation in the tumor, and greater freedom of breathing. I did not see her from 1851 till 1856, when, being in London, she called to show herself, saying how well she was. The pulse in the radial artery had not re- turned; but there was no beating in the tumor, and only a sort of roughness in the sound of the artery. She felt confident her- self of the good effect of the starving treatment. I have taken the opportunity of your having two patients together under your eye to bring the subject of aneurism before you, because of late the objections urged against venesection in excess and in improper cases have produced a fashion of decry- ing its use altogether, and especially in thoracic aneurism. Bleeding and starving, it is urged, induce debility and aneemia ; that is to say, in physiological language, they lower the force of the heart, and they cause a comparative excess of fibrine over blood-disks in the blood. These are both steps towards the mode adopted in nature to effect a cure of aneurism, and perhaps of some other diseases also. So, that, I contend, not merely is it the best mode, but the only honest mode, of treat- ing aneurism of the trunk-vessels ; because it is the only one we at present know consonant to reason and experience. {Clinical, St. Mary's, February 20, 1863.) Thomas "W., aged thirty-nine, a decorative painter, had always enjoyed robust health till the 4th of this month, when he was standing on a ladder graining a shop-front. Without any warning or previous feeling of illness he suddenly lost his THORACIC ANEURISM. 317 senses and fell down. On coming to himself after a few minutes he found he was not paralyzed in any part, but had severe pain in the side. This he attributed to the fall, and thouo'ht that he had broken a rib. No fracture of the bones however could be found, and the pain in the side appears to have been treated as pleurisy caused by the injury, the most natural diagnosis under the circumstances. On his admission to the hospital on the 11th, a week after the accident, the whole of the left side of the chest was dull on percussion before and behind, and there was entire absence of breathing except in the two upper inches next the collar-bone, where it was bronchial, the sough of expiration being very prolonged. There was no pulsation or heart sounds perceptible in the cardiac region, the organ being pushed over to the right side beyond the median line. The diagnosis of the medical man who had previously seen him was adhered to by us, a blister was applied to the left side, and on the 14th the heart was much nearer to its natural place than before, and the breathing in the upper lobe of the left lung more normal. He said he had less difficulty in respiration, and no pain in the side. I still continued to hold the original opinion, and supposed the pleuritic fluid to be in course of absorption. He continued going on well till the night of the 15th, when he suddenly jumped up exclaiming that he was dying, put his hand to his side, fell back deadly pale, and soon ceased to breathe. The post-mortem examination which has just now taken place, has exphdned the mystery. You see here in the descending portion of the thoracic aorta just above the diaphragm, the sac of an aneurism large enough to hold a man's fist, out of the left side of which a smaller sac about as big as a chestnut protrudes towards the left pleura. And in this smaller sac there is a rent a quarter of an inch long, which allowed the blood to flow freely out into the cavity of the pleura, and to fill it up with between five and six pints of blood. The blood had so far separated into serum and coagulum that the fluid which first issued on opening the chest was about as clear as that which you find in a bleed- ing cup carefully put by ; it was hardly at all stained red. The 21 318 THORACIC ANEURISM. heart was not at all injured by its dislocation, though lying entirely to the right of the cardiac region. The left lung was very little pervious to air, being sodden and inelastic in tissue. The pleura was quite natural, showing no signs of inflammatory action. I need hardly say that no suspicion of the true state of things crossed anybody's mind during the patient's life. The mode of death is so rare, that if an exactly similar case appeared to- morrow while this one was fresh in my mind, I think I should make the diagnosis I did here, of a collection of pleuritic fluid from injury to the pleura or lung. During the autopsy a pupil present, with a juvenile objection to being wrong in a diagnosis, upheld the idea of its having been originally a case of serous efiusion, into which the aneurismal sac had burst at the time of death. Tempting as it is to prove oneself right after all, I was compelled to diifer ; for had such been really the case the bleed suddenly mixed with the previously collected fluid would have stained it all deeply, and not have been seen separated into serum and crassamentum, as it was, on opening the pleura. I feel sure that the aneurism first burst at the time of the man's accident. Then that the prone posture and the fainting allowed a fibrinous plug to stay further mischief for a time; and that the giving way of the plug was the immediate cause of death. This case shows how imperceptible and with how little injury to health may be the growth of a large aortic aneurism — even one extensive enough to have eroded the vertebral column as this has done. The patient did not know w^at illness was till the rupture took place. And perhaps that was a consequence of the fall in a fainting fit. Do not let this discourage or terrify us with the fear of carrying, without being aware of it, such a dread- ful inmate in our chest. Let us rather comfort ourselves with the assurance, that if it has wrought so little harm when not known of, it may be prevented from doing harm when it is known of, if prudence is used to avoid accidents. A clot inside this sac would have completely restored the form and functions of the aorta. Even with a rent a quarter of an inch long in it, you see it THORACIC ANEURISM. • 319 was not necessarily fatal. The patient lived nearly a fortnight, the blood first poured out was beginning to be absorbed, the heart was returning to its place, and the lung to its breathing. If we could have seen what was going on inside, there would have been nothing extravagant in the hope that a permanent stoppage of the hole might have taken place; though, of course, the risk of the fatal accident which has really happened would have been equally clear to us. {Clinical, St. Marys, December 12, 1863.) Alfred D., a carpenter, aged thirty-three, enjoyed general good health till three months ago, when he became an out-patient for a constant distressing cough and shortness of breath. This state of things became worse and worse, and he was sent to bed under my care, November 11 It was then found that the pulse in the right wrist was very much smaller than in the left, an abnormal degree of pulsation was felt in the hollow above the collar-bone, and a characteristic whiz, as of an aneurism, could be heara where the pulsation was strongest. I believe all who examined him came to the same conclusion, that there was an aneurism of the arteria innominata, or at all events involving the arteria innominata, and pressing upon the trachea. The diagnosis was too clear to be of much interest. The lungs were very much congested, coarse and fine crepitations being heard in various parts, and the finer crepitations especially in the lower lobes, of which the right, on percussion beneath the scapula, was duller than the left. The patient was harassed by constant dyspnoea and frequent cough, especially at night, and had severe pain, sometimes spasmodically aggravated, in the neck behind the right collar-bone. There was copious muco- purulent expectoration. To relieve the afore-mentioned pain, general bleeding from the left arm was once resorted to, and several times leeches were applied above the clavicle. The patient said that the leeches gave the most relief; an assertion different from what I 320 THORACIC ANEURISM. have lioard made in otlicr cases of aneurism of the trunk vessels, and I am sorry to say I cannot explain the discrepancy. Digitalis and lobelia were also administered internally, and blisters and mustard poultices Avere applied externally; but I cannot say that either gave any relief to the cough or dyspnoea; and indeed a week before his death they were left off as appa- rently inefficient remedies. Morphia alone, and the afore-men- tioned leeches, seemed of any advantage. A week ago he had an attack of haemoptysis; but that was arrested by leeches, and he went on without much change, vary- ing in his fortune from time to time, now better, now worse, till yesterday In the morning he told the sister of the ward he thought he was really improved in health, and that he could lie down easier in bed. But after dinner he experienced great dif- ficulty in breathing, said he felt he was dying, sent for his wife and mother, and became livid and insensible almost before they arrived. To-day you are going to see the post mortem exami- nation. [Extract from record of post-mortevi examination by Mr. Nayler, curator to St. Mary's Hospital Museum: — "The aorta in its ascending and transverse portions was greatly dilated, and involved the origin of the innominata artery. Its coats felt also somewhat hard and brittle. In consequence of its increased size, the aorta rose much higher than natural in the chest, and obscured the root of the innominata. On laying open the trachea, its upper part was found to be healthy, but in its lower half the mucous membrane was much congested, and its rings flattened, and at this point they appeared to have undergone partial ab- sorption. The heart was soft and thin. The lungs were very full of blood, and at the back part were not universally crepi- tant."] The cause of death doubtless was a sudden increase of the congestion of the lungs from the interference of the dilated artery with the pneumogastric nerve, perhaps especially with the recurrent branch. Probably the only chance of relief for him would have been a recurrence of the hemoptysis which was of use a week ago. I should have practised bleeding and leech- THORACIC ANEURISM. 321 ing more assiduously, had not the weakly pulsation of the heart given a warning against it, and made one doubt if life would be prolonged by that expedient, while complete renewal or cure was out of the question. Do not set down loss of blood as a mere destructive agency, pure and simple. The more perfect and accurately graduated form of it exhibited in haemoptysis, and our rough imitations with lancets and leeches, by relieving the congested lungs of a burden that impedes their functions, cause more new blood to be made than heretofore, and so are an indirect renewal of life. You may observe that this man has had a considerable amount of digitalis, and that no beneficial result has been apparently produced by it. I must therefore say something justificatory of myself for administering it. My reason is, that digitalis seems to me to exert a special influence over involuntary muscular fiber, causing its contraction to be more firm and powerful; and that it exerts this influence most especially when the muscular fiber is abnormally lax, or when it is degenerated. Cats killed during the action of digitalis were found by Dr. Handfield Jones, in experiments he made some years ago, to have the heart strongly'- contracted. In the human subject I have, ever since I have been physician to St. Mary's hardly ever omitted to give digitalis to cases of thin dilated heart, with irregular failing pulse ; and the general result you have often seen to be, that the pulse grows firm and regular. Digitalis acts also upon the in- voluntary fibers of the uterus, renewing their tone, bracing them up, and stopping the monorrhagia of relaxation. You have several times had an opportunity of seeing monorrhagia stayed in this way, and notably one case admitted under my care rather more than a fortnight ago, which I especially mention now because other involuntary fibers besides those of the uterus were influenced. Emily T., a quadroon nursery-maid, aged seventeen, was ad- mitted November 27, suff"ering from monorrhagia, which iiad been almost constant for about three months, and had forced her to give up her situation. The quantity of blood lost was not large at any one time, but there was a continuous drain which had weakened her very much and rendered her very anoemic. Her 322 THORACIC ANEURISM. mother, a tall and stout mulatto, stated that the disease was hereditary, she having herself been often laid up in the same way when a young woman. The girl's uterus comes down very low in the vagina, almost to the hymen, and the os uteri is soft, tumid, and painful. There is also pain on pressing the region of the ovaries. She stated in addition, and the statement was confirmed by her mother, that from childhood she had been afflicted with incontinence of urine, and never remembered to have passed a night without wetting her bed. Infusion of digi- talis was prescribed for the menorrhagia, and the dose gradually increased up to two ounces every three hours. At this point the medicine was left off, for nausea and faintness with loss of appe- tite were induced, and the sanguineous discharge ceased. It has since returned once for a few hours, but was immediately checked by a resumption of the digitalis. So far the course of events was the usual and expected course; but the next observed phe- nomena is to me at least new; the patient states that the incon- tinence of urine has quite disappeared since the night before the arrest of the menorrhagia, that for the first time within her memory she has been able to hold her water during sleep, and now has not wetted her bed for ten nights. The beneficial action of digitalis over the sphincter of the bladder is of a piece with its action over the uterus, and is truly not surprising. I was not aware of it before, but shall certainly test it again, both in this girl in case of a return, and in other instances of that most unmanageable disease, incontinence of urine in the female. This digression is for the purpose of excusing my hope that digitalis might prove of use to the dilated and relaxed muscular fibers of arteries. The hope may be grounded on imperfect knowledge, and was disappointed in this instance ; but it is not an utterly irrational one, not a mere excursion into the realms of empiricism. [I feel it a duty to add a few sentences in this edition as to the future conduct of those who have suffered from external aneurism, and in whom, of course, a recurrence of the disease in more important parts is to be feared. It is obvious that the THORACIC ANEURISM. 323 case is here quite different from that of curing aueurism. The method of starvation and bleeding recommended in the lecture would be most injurious, as tending to induce further debility and degeneration. It should be used for the purpose of inducing the formation of clot only. The prevention of further degenera- tion of the arteries must be conducted on quite an opposite principle. Iron, nutritious food, and everything that promotes vigorous vitality, should be perseveringly given for the rest of the patient's life. I would strongly urge also a change from the climate of England, where degenerative disease is the rule and acute disease the exception, to Italy, where degenerative disease is the exception and acute disease the rule — a change, if not for life, at all events for long enough to alter the constitu- tion. It may be remarked that it is especially in the absence of aneurism that this peculiarity of the Italian climate is shown. In the statistics of Milan Hospital {Rendiconto della Benificenza delV Ospetale Maggiore, Sj-c, 1862), I find but 4 cases of thoracic aneurism in 61,761 patients, or 1 in 15,440 ; whereas at St. Mary's Hospital, London, I find 29 cases in 7319 patients, or 1 in 252. Again, at Genoa I find the last published bills of mortality (for 1860, printed by Dr. Giovanni du Jardin) with- out any deaths by aneurism. The last published for London contains 103.] LECTURE XXV. DISEASE OF HEART. Part 1. — Comparison of injury io life from the two sets of valves, severally — Deductions from autopsies — Case in point — Treat- metit calmative and restorative. Second case — Diseased mitral and aortic valves with dilated parietes — Treatment similar to last case, with certain additions. Part 2. — Degree of importance to he attached to the different points ascertainable by auscultatory diagnosis — Consequences of valvular disease different in different classes of life — Cases in illustration of its effects in tlie upper classes as distinguished from hospital patients — Causes of difference — Treatment of patients ivith disorganized valves — Avoidance of dangers — Iron — Chloride of Sodium — Hydrochloric Acid — Abuse of alcohol — Danger of rupture of valves — Case — Angina pectoris — Pathology of dilatation — Explanations to patients — All diseases of heart to he viewed practically as one. {Clinical, St. Marys, December 20, 1861.) In speaking of diseases of the cardiac valves I practically in- tend what is said to apply only to those of the left side of the heart; for the tricuspid and pulmonary are seldom affected alone with such severity as to produce either symptoms during life, or lesions recognizable after death ; so that physicians know very little about them. It is the mitral and aortic valves whose alter- ations we are best able to recognize by physical signs, and whose defects cause injury to the muscular walls of the heart. They are a source of anxiety to us in our daily duty, whereas the others are rather a matter of curiosity. Comparing the different valvular lesions of the left heart, DISEASE OF HEART. 325 with regard to the injury they inflict, and the consequent pro- portionate goodness or badness of the prognosis to be formed, I find that the worst cases, that is, the most liable to have serious consequences, are those in which both the aortic and mitral valves are simultaneously imperfect; the next worst are those in which the aortic have suffered ; and the most favorable are those where the mitral alone are inefficient. Thus I find that in 115 cases recorded in the "post-mortem book" at St. George's Hospital from 1840 to 1850, wliere dis- ease of one set of valves was accompanied by alteration in the cardiac walls, the aortic valves alone were diseased in G4, the mitral valves alone in 51. And in the former case also the alteration had assumed a more marked character ; for in cases where the aortic valves alone were diseased, the size of the cavi- ties was disproportionally large in comparison with the enlarged walls in 36; whereas when the mitral valves alone were diseased, the disproportionate enlargement occurred in only 18. And this diff'erence, it is to be observed, is not dependent on the greater frequency of lesions of the aortic valves alone, for in point of fact they are not more frequent. Thus in hearts whose walls were still normal, there was more or less lesion of the mitral valve in 34, of the aortic in 30. The powerful influence of the double lesion (/. e. of both valves at once) is shown by its being found with healthy heart- walls in only 6. Now this diseased state of the heart's walls is so very much the most important, and so very much the most frequent of the evil consequences of disorganized valves, that practically speak- ing it may be taken to represent the whole of those consequences. All our calculations of prognosis in cases of valvular injury need have reference to it alone. I have been hitherto quoting from my systematic lectures on the practice of medicine, apropos of a prognosis I have given of a case now under your eyes, and which I have selected as one promising enough to use as an illustration of treatment. A, J., aged thirteen, had rheumatic fever three years ago at Brighton, of which illness she has not much recollection, but 326 DISEASE OF HEART. she shows marks on the cardiac region of leeches, probably applied at that time for inflammation of the heart. She has since then always suffered from palpitation on the slightest exertion, or on any emotion ; and she has dyspnoea on attempt- ing to go up stairs or up hill, or walk above her usual pace. She had an attack of spitting of blood eighteen months ago, but otherwise her health has been good. Her complexion and ap- pearance fully bear out this statement; she is fresh-colored, muscular, bright-eyed, and plump; her mind is active and intel- ligent, and though the mammae are infantile and the catamenia have not appeared, she has the air and appearance of a girl two years older than her real age. I may remark in passing that such a backward development of the reproductive organs as you here see is a very common effect of cardiac disease in both sexes. The growth of the other organs or functions, mental or bodily, does not seem to be retarded. The palpitations have lately been rather more troublesome than usual, and on examination of the chest they are explained by a vibrating tremor, sensible to the finger, at the apex of the heart, and at the same point a very loud systolic murmur. The second sound is loud and sharp. The interval is clear. The systolic murmur is heard only very indistinctly at the base of the heart. On admission the pulse and heart-stroke were uneven in strength, but have by rest in bed become nearly natural. On percussion the dullness of the cardiac region does not appear to extend beyond the breadth and height which is usual in the normal state. This girl appears to labor under lesion of the mitral, with healthy aortic valve, one of the varieties of cardiac injury the least likely to cause enlargement, and therefore the least inju- rious of any; and since I cannot find that the heart is as yet enlarged, let us give her the benefit of the doubt, and hope that it may not become so. In the treatment, the first object is to restore regularity and calmness to the affected organ. With that view she has been kept lying down for a week ; she has had once two leeches and once one leech applied beneath the left breast, and has taken five DISEASE OF HEART. 327 minims of tincture of digitalis three times a day. This has been so far effectual, and will be continued only a short time longer. The next object is to keep the blood in as rich and nutritious a state as possible. The child has a critical period of her life to go through sooner or later, the time of puberty, when there is a call upon all the powers of growth. If she gets anaemic then, the heart will but too surely enlarge by dilatation. I have begun therefore giving her iron from the first, and shall urge its con- tinuance as long as I can keep sight of her. The richness of the blood instead of increasing the chance of haemoptysis, as you might have imagined, diminishes it. Thin watery blood easier oozes out ; and besides, the more nutritive the circulating fluids, the more active is the heart, the better it empties itself, and the less is the blood kept back in the lungs. Another case in the same ward is not quite such a hopeful one. Mary K., aged twenty-two, single, has been here since Novem- ber 25. She says that she has had rheumatic fever once this time seven years. She had no pain in the chest then, and per- fectly recovered, remaining well till an attack of what she calls "bronchitis," three years ago. After this again she was quite well till two years since, when she began to sufier from severe pain in the cardiac region, and had frequent colds. She also frequently had bleeding at the nose, and spitting of blood, even when keeping quiet, and when she moved about experienced much dyspnoea and palpitation of the heart. She however continued in service, and did her work. Six weeks before admis- sion she observed that she got blue in the face, and suffered more than usual from dyspnoea, so that three weeks before she was obliged to give up work. When you first saw her she was very blue in the face, and could hardly get her breath ; she was spitting blood, and there were loud sibilant and crepitant rales all over the lungs, without any localized dullness on percussion in the pulmonary regions. The pulse was very irregular and intermittent. The cardiac region was dull on percussion up to the interval above the third rib, and as far as the sternum towards the right side. The second sound of the heart was scarcely to be heard at all, but was re- 328 DISEASE OF HEART. placed by no murmur. There was a loud systolic murmur, loudest at the apex, and followed by a peculiar chirping sound, ratlier anterior to the time of the second sound. The intervals were imperfectly marked. In Mary K. there is probably regurgitation through both aortic and mitral valves. What she has suffered from is obstruc- tion to the passage of blood through the lungs, and consequently non-aeration and venosity. She had some haemoptysis, which gave relief, so I took the hint, and cupped her, and put on some leeches several times, which have also given relief. The irregu- larity and excitabilit}^ of the pulse have been successfully treated by digitalis. The venosity of the blood is in great danger of being suc- ceeded by ancemia, especially as her appetite is very deficient. The heart is already enlarged, and I fear it is improbable that she will ever be able to get her own living again ; still I think it right to give her iron, and purpose to continue it as long as pos- sible, that at all events she may obtain all the advantage she is capable of receiving. The most unhappy event for her would be degeneration of the muscular walls of the affected viscus, so that they should fail from debility duly to circulate its contents ; and I believe the best chance of avoiding this degeneration lies in keeping up the supply of a really nutritious blood. You may observe that the digitalis was left off several times. This was not on account of its failing in its object of calming and reducing to regularity the irregular heart, for that it effects well ; but, because when given in larger doses than five minims of the tincture, it produced nausea, and prevented her taking her meals. Now the physic we order on the diet card is at least equally important with that on the medicine card, and you must be careful where you want to renew life not to diminish the means of that renewal. The production of nausea and loss of appetite Avould do more harm than any action of the medicine could do good. DISEASE OF HEART. 329 (Clinical, St. Mary's, December 6, 1861, with additions in sub- sequent years.) There are always in our wards a few chronically diseased hearts, and I very weldora walk round without calling your attention to one or two as studies of diagnosis. I notice that when you begin the physical examination of the patient whom you know to have a cardiac complaint, you search first and foremost for endocardial murmurs, and then you often rest from your labor, and say what you have found. You seem to consider that sign as the most essential part of the diagnosis. You are partly right and partly wrong. This knowledge doubles the value of other future observations about the heart ; but standing alone, it is of less importance than any of them. While, then, I willingly receive this report first, I always beg you to go on without delay to further observations. The importance of the existence or non-existence of valvular disease lies not in the injui-y it inflicts itself, as in the likelihood of the induction of the other lesions of the heart. If the mus- cular structure remains healthy, injured valves do not appear capable of causing death. But very surely are they fatal when they are folloAved by dilatation or thickening or degeneration of the cardiac walls, with their sad train of dropsies, apoplexy, pulmonary hemorrhage, &;c. In the 2a.61 post mortem examinations at St. George's Hos- pital in ten years, the cardiac valves were diseased Avithout the walls of the heart being affected 113 times; but in every case there were other lesions amply sufficient to account for death quite independent of the valves, such as accidents, surgical com- plaints, cancer, low fever, &c. In one alone, where anasarca from granular kidneys was the immediate cause of death, could any symptom be debited to diseased valves with healthy heart, and that symptom was pulmonary hemorrhage.* In the classes of people represented by hospital patients, the probability that valvular disease will be followed by its unhappy * " Decennium Pathologicum," chap, x, sect. i. 330 DISEASE OF HEART. consequences is very great. When a patient thus affected leaves the wards, you may expect to see him again shortly, and on each fresh admission with a more severe complaint. Hence the more attentive students you are the worst prognosis do you justifiably form. But you must not apply the same rule to the different grade of society among whom you hope your private practice will lie. AVith persons in easy circumstances valvular lesions exist for years and years, perhaps through the greater part of a long life, and not only not prove fatal, but may fail even to cause symptoms bad enough to make them consult a medical practitioner. To prove to you this fact, I will quote from my private notes some cases of persons in easy circumstances in whom the stetho- scope or the history, or both, gave every indication of injury to the valves of long standing, but in whom no inconvenience suflfi- cient to be called illness by themselves has followed. Defective valves of 57 years' standing. — Col. R. S., at eight years old, had a bad attack of rheumatic fever, which laid him up for eleven months, and from which his heart has never wholly recovered. At sixty-five years of age he had a very loud mur- mur with the first sound. The year before he had had an attack of inflammation (congestion ?) of the lungs, which had left a con- siderable portion of the pulmonary tissue impervious, for his vital capacity, tested by the spirometer, was only 150 cubic inches, his height being 5 feet 10^ inches. Defective valves of 50 years' standing. — Archdeacon B., at six years of age, had an attack of inflammation of the heart, and since that time has been subject to irregular action of the organ, often followed by fainting fits. He has for some years lived more generously than he used to do, and suffers much less inconve- nience. The action of the heart is irregular and uneven, and there is a murmur with the first sound. He is now fifty-six, well, and moderately active. (Dec. 1861.) Defective valves of ^^y ears standing. — C. B., at twenty-eight, had rheumatic fever from sleeping in a damp bed. At sixty- three years old (in 1852) he had marked systolic murmur at the apex of the heart, but considered himself quite well, and is DISEASE OF HEART. 331 alive now (1861) when he must have long passed his threescore years and ten. Defective valves of 27 years' standing. — T. H. G., at six years old, had rheumatic fever. Since then he has had no illness of any kind. In June, 1860, when he was thirty-two, I detected a loud whizzing murmur with the first sound; in July, 1861, the same murmur remained. He is alive and I believe well now. (Dec. 1861.) Defective valves of about 21 years' standing. — C. S., aged thirty-six, in 1855 had a low blowing mitral murmur. He used to have severe palpitations when an under-graduate at Cam- bridge ; he has enjoyed average health since, with the exception of what he calls " colds," that is, a feeling of general malaise, for which he takes tonics, and is always better for the practice. He is alive and well now in 1862. Defective valves of 15 years' standing. — E, G., in 1846 had inflammation of the chest, accompanied by severe pain in the heart. I saw him first in June, 1848, when there was a loud musical murmur with the first sound. In December, 1848, and in January, 1850, the same murmur remained. He is still alive in 1862, aged seventy-two. Defective valves of at least 11 years' standing. — R. H., who in 1861 was still alive and forty-two years of age, had in 1850 a blowing systolic mitral murmur. Defective valves of at least 7 years' standing. — R. A. A., in 1862 still alive, aged fifty-three, had a blowing systolic murmur when I saw him in 1854. He is a robust muscular man, in the habit when young of pulling in boat races, to which he attributes the palpitations he now occasionally suffers from. Defective valves of 7 years' standing — T. J., aged twenty-three in 1854, had undergone scarlatina at sixteen years old, and never any other illness. I could hear a blowing systolic murmur at the apex of the heart, and he had pain in the cardiac region after exertion, but was not otherwise ill. His subsequent history is unknown to me. Defective valves of 7 years' standing. — D. F., aged twenty- nine in 1852, also had scarlatina at twenty -two years of age, 332 DISEASE OF HEART. accompanied by pain in the heart, and followed by palpitations of six weeks' duration. There was with some beats a systolic murmur loudest at the apex at that period, which was seven years after the reported cardiac affection. His subsequent his- tory is also unknown to me. Defective valves of 7 years' standing. — Miss S. had rheumatic fever from sleeping in a damp bed, accompanied by pain in the cardiac region, in 1856, when she was twenty-three years old. There is a distinct very localized systolic murmur at the level of the aortic valves. She has attacks of angina pectoris from ex- posure to cold, but with care is able to live like other people. Between April, 1862, and July, 1863, she lost no ground, and had only two slight attacks of angina pectoris. Defective valves of at least b years' standing. — F. J,, aged thirty in 1856, had then an irregular pulse and a systolic mur- mur, without any dyspnoea or general symptoms arising from the imperfection of the heart. He is alive now (Dec. 1862). Defective valves of 18 months' standing. — A. D., aged forty- three in 1850, had had rheumatic fever eighteen months pre- viously. The heart's action was irregular, and there was a systolic murmur, but no general symptoms at all referable to cardiac dis- ease, nor any suspicion that cardiac disease existed. Defective valves of a years standing. — W. II. C, aged thirty- one in 1850, had had rheumatic fever a year before, with inflam- mation of the heart, but considered that he had quite recovered ; and he really seemed to have done so, for his vital capacity was 220 cubic inches, his height being 5 feet 9 inches, so that there was no pulmonary obstruction. There was a systolic murmur, loudest at the level of the aortic valves. Defective valves of unknotvn duration, but at the date of exami- nation without any deleterious effect on the general health. — J. P., aged thirty in 1854, had an intermittent pulse, with a systolic murmur loudest at the base and middle of the heart. Unusual exposure affected his chest so as to lay him up Avith cough, but his general health was good. G. P., aged twenty-six in 1856, had a very irregular, unequal, and intermittent pulse, accompanied by a systolic murmur. He never suff"ered from palpitation, cough, or any illness at all. DISEASE OF HEART. 833 F. D., aged forty-nine in 1857, had a sawing systolic murmur, but had never had any illness or inconvenience referable to the heart. J. B., aged forty-eight in 1856, had an intermittent pulse, and a blowing murmur with first sound most distinct at the base of heart. He never suffered from palpitations. The subsequent history of these last six cases, having been only examined for insurance and not further traced, is unknown to me. Irregular pulse of long standing ivithout date. — Lord , aged seventy-four in 1862, and alive now, with a soft systolic murmur to be heard at the apex of the heart, has a distinct re- collection of having an irregular pulse as long as he can remem- ber anything. And other old people have told me the same, though I have not kept a note of their cases. Injure/ to heart from rheumatic fever of 10 years' standing. — T. A. 0., aged fifty-one in 1855, had had rheumatic fever ten years previously, and since then frequent " fainting fits" and palpitations. The action of the heart is jarring, and there is extended dullness on percussion, but no evidence of valvular dis- ease. He does not get worse. You know very well that cases like these are not to be met with in hospital practice, or among the paupers in a woi-khouse. Wherein lies the difference ? It is discoverable generally from the histories which these poor people tell of the final breakdown. The tale usuallj runs, " I was pretty well, or only a little short- winded, till I was thrown out of work and had to live low; then my heart got to beat worse, and my feet swelled." Or, " 1 could always earn my living till I was over-worked last summer;" or, " till I caught a bad cold last winter ;" or, " till I had sit up with my mother who died," and so on. And from this breakdown they never get quite up again, they never regain lost ground. In short, you will see that injured valves are slow to lead to fur- ther cardiac lesion in the w^ell-nourished, and quick to lead to further lesion in the ill-nourished ; and that the motive cause of their evil effects is anaemia, exhaustion, debility. Do not look upon this disadvantage of the poor in respect of 22 334 DISEASE OF HEART. cardiac disease as merely a universal rule in all diseases. In a good many cases the poor recover easier than the wealthy, and the good prognosis which you have habitually attached to certain morbid states in hospital practice will not be justified in private. Continued fever, to wit, is less fatal in the lower classes, although more common; consumption is less frequently "galloping," it is more chronic, and more rapidly benefited in their case ; again, anaemia is more often found dependent on removable causes, and therefore quicker cured in cofttagcs than in palaces. The peculiarly fatal nature of valvular disease of the heart, among those who live by bodily labor, arises from the fact just mentioned of lost ground being never recovered from. The heart is (physiologically speaking) a single organ with the single me- chanical function of forwarding the blood, and consisting of a number of unique parts mutually dependent on one another. If the left ventricular valves are injured, the right cannot take their office, nor the aortic replace the pulmonary. It is a chain, proverbially never stronger than its weakest link. Therefore no relief can be given to a failing part by another part taking its duty ; no rest for the purposes of recovery can be taken. The Designer of our frames has been here peculiarly sparing of re- serve function. Such is not the case in other organs ; if one kidney is destroyed, the other supplies its place, and as much urea is excreted as before ; large portions of lung may be im- pervious from tubercle, yet the blood be aerated normally by the remainder, and the patient recover of consumption. But in the heart each successive little injury can never be compensated for, and is added in turn to the previous list. The wealthier classes can avoid all the many circumstances which produce these suc- cessive little injuries — cold, want of food, over-exertion, mental worry ; and so under good advice can keep their imperfect valves from getting worse ; but those who depend upon daily toil for •daily bread run the risk and suffer the unhappy results. I said early in the lecture that I did not blame you for begin- ning your investigation with listening for cardiac murmurs, but I do blame you very much if you stop there. The evil import of valvular injury lies in its probable consequence, namely, en- DISEASE OF HEART. 335 largement of the muscular walls ; and it makes all the difference in the world to you and to the patient to ascertain if this already exists. Percussion and palpation are a much more necessary part of the examination than mere listening with a stethoscope. If the heart is dilated or thickened, or dilated and thickened, your ascertaining the fact makes all the difference in the world to your prognosis, and to the hopes which you have that your treatment may be successful. It is obvious that in the treatment of the disorganized valves themselves, restorative medicine in the strictest sense must be quite at fault. The renewal of the destroyed tissues is impos- sible, and equally so is any compensation for the arrested func- tion. But indirectly it is almost as effective in prolonging life, as if it could put in a new valve, or make another muscle do duty for the resting ventricle. It may repair those reparable conditions which are so injurious, and which by bringing on en- largement constitute the real danger in cardiac cases. In this, as in all diseases, try and cure what is curable, and trouble your- selves as little as possible about bygone injuries. Learn from the histories you hear in the wards what are the external causes which have brought on the first affection of the health, and you will thus learn the perils which 3'our patient with valvular injury has to fear. These are placed roughly in the order of prominence — fresh attacks of rheumatism; insufficient food; ") mentiil anxiety; drinking; overwork ; temporary violent exertions. Tlie first danger is to be avoided by warm clothing, dry air — especially in the sleeping room, and a residence in such a climate as does not naturally induce rheumatism. As a rule, in the cli- mate of England, moderately high ground is to be preferred to low, and an inland to a seaside or island abode. A town life, as being more healthily sedentary and avoiding changes of tem- perature, is rather to be chosen than rural occupations. >■ producing anaemia. 336 DISEASE OF HEART. DurinfT the attacks, if unfortunately thej come on, you cannot do better than adopt the full trea tment of rheumatic fever, namely, potash and opium, and especially blanketing, as more largely set forth in my lecture on rheumatic fever. And you must leech or cup the cardiac region, if there is any pain there indicating the probable presence of fresh endocarditis or pericarditis. But do not let the license you give yourself of local blood- letting to a moderate extent for the relief of an acute condition, which you fear may aggravate existing evils, — let not, I say, this license lead to your adopting the old "heroic" practice of thinking to cure established valvular injuries by continuous bleeding, like our forefathers Albertini and Valsalva. They fell into the mistake thus: they first supposed every enlarged part was over-nourished, or hypertrophied; then they thought that the best thing to prevent its over-nourishment was to under- nourish it; and then finding that bleeding in moderation some- times lightened a few symptonas, they determined that it did so by under-nourishing the heart, and that of course the more the patient got of it the better. Under the idea of producing its full influence, they bled frequently in small quantities — the most effectual way of accomplishing the end they had in view, the im- poverishment of the blood. With bleeding for such an end it was strictly reasonable to join starvation, as certainly the most direct way of diminishing nutrition. What the results would be of thus deliberately inducing anaemia we can easily guess, for daily experience shows that in none do the hearts so rapidly become enlarged, and on none does that enlargement have more baneful effects than on those people who are subjected to all or any of the causes of anaemia which I have named. Had the Sangrado treatment really been in vogue now in England, I should have certainly ranked it in the first class of the origins of disease in patients with lesed valves. I have spoken of the poor as without doubt the most exposed to the effects of those agencies which produce or aggravate val- vular lesion; but the rich are by no means exempt, and often require the protection of sound medical advice. Even "insuflS- cient food" is not an unknown cause of illness among them; the DISEASE OF HEART. 337 power to buy it does not always imply the power to eat it. They not uncommonly become anaemic from loss of vigor in the diges- tive organs. To counteract the risk of this anaemia I usually recommend that persons with affected valves, should three or four times»a year take a fortnight's course of iron under the eye of their ordinary medical man, whose watchfulness is needed to prevent excess. The insoluble forms of the metal, such as the sesquioxide, or the finely pulverized metallic iron made by French chemists, or the mistura ferri composita are the fittest for the purpose. Chlorine also in the form of hydrochloric-acid baths is a tonic not contraindicated by any circumstances in this case, and is a good accompaniment to the iron. The habitual use of a large quantity of chloride of sodium with food is another way of guarding against anaemia, which can readily be adopted by the patient. When there is reason to fear that dilatation has already begun, I often join with the iron small doses (from ^'g-th to j'^th of a grain) of strychnine. If the pulse intermits, this remedy some- times exerts its tonic power over muscular fiber by restoring regularity of beat, and thus gives you the satisfaction of feeling the good you do with it. When there is much palpitation on occasion of slight nervous excitement, especially if that is joined with irregularity and intermittence of pulse, a few small doses of digitalis are useful. Strange it is that this vegetable, which makes a healthy heart first intermit and then stop altogether, should bring back to order the organ when it is weak and beat- ing unevenly ! We can only account for the seeming anomaly by supposing it to act as an anaesthetic upon the cardiac nerves, withdrawing them from normal and needful stimulation in the first case, and from abnormal and hurtful stimulation in the second. The worst aspect of digitalis is, tiiat its benumbing in- fluence extends not to the heart alone, where it is wanted in proper cases, but to the whole tract of the pneumogastric nerve; it reduces the appetite and produces nausea; so I pray you to be cautious, and not to continue it longer than necessary. While you bid your patients live generously, you must take care to disabuse them of the notion that the advice includes 338 DISEASE OF HEART. excess in alcohol. Alcohol is really the most ungenerous diet that there is. It impoverishes the blood, and there is no surer road to that degeneration of the muscular fiber which is so much to be feared. And in heart-disease it is more especially hurtful, by quickening the -beat, causing capillary congestioi* and irre- gular circulation, and thus mechanically inducing dilatation of the cavities. Let the alcoholic drink be limited to that qyantity which increases the appetite. In a great many instances this quantity may be very shortly -written down — 0. To mental anxieties perhaps their social relations expose the rich quite as much as the poor, and their education makes them more sensitive. Both joys and sorrows affect them more deeply, and instead of balancing one another do equal harm. Happiness is as hurtful as misery. For example, I have a patient whose first attack of dilatation arose from grief at his first wife's death, and his second during the honeymoon of her successor. But alas! ungrateful discontented man seldom lets the blessings he is daily receiving affect his emotions so deeply as his occasional misfortunes, and so ill luck is more commonly productive of cardiac disease than good. By overwork as a cause of angemia, I mean too long-continued wearying toil, either intellectual or bodily. I would have you distinguish from it short extraordinary exertions, to which we can sometimes, though not very commonly, trace injury of the valves, but not direct degeneration of the heart-walls. Now and then a case occurs showing the possibility of a valve being ruptured by its own forced action. Thus I remember seeing one of Tattersall's stablemen, under Dr. Nairne's care at St. George's Hospital, who distinctly traced his first cardiac symptoms to a sudden pang which he felt when running a fast horse down tlie yard a year before. After death two of the pouches of the aortic valve were found torn, and from the re- gurgitation thus arising the ventricles had become enormously dilated during the year that he had lived. But the torn portions were not of normal structure ; the tissue was thickened and opaque, and therefore wanting in elasticity or power of resist- ance. And I believe this always is found to be the case in DISEASE OF HEART. 339 valves ruptured by violent strains ; I am not aware of any instance of healthy valves having been found broken. Where the tissue has become bony and brittle, rupture is more common; but then of course it will have been preceded by a long course of ill-health, for such an advanced lesion as ossification could not exist without seriously incommoding the individual. You would not be long diligent students in the dead-house without seeing in the dead body the cords of a mitral valve thus broken, rather from the quantity of lesion than from any external strain or violence. More common still are cases that you see during life of sudden pangs from exertion — such as race-rowing, jumping, fighting, — sudden pangs followed by increased palpitation, and other signs of aggravated enlargement of the heart. Yet the aggravation is not such as must surely accompany a broken valve, nor is the path to death so straight as it was in the case which I have related to you. Moreover, in some instances where an autopsy reveals that the valves are whole, you had previously heard a history of such pangs, and sometimes had seen them in the wards. What is going on in the heart during these fits of angina pectoris no one precisely knows, but it seems to me very probable that its state is one of temporary dilatation. The pain has the same tearing and paroxysmal character that you find accompanying the distention of hollow fibrous organs usually insensitive, such as the stomach, the colon, the bladder. The pain is of the same nature as that felt in over-strained tendons, or muscles wearied out by sustained efforts ; it appears associated with the stretching of usually insensitive fibers, and is sometimes the most dreadful agony the body can bear, as the inventors of racks and other instruments of torture well know. And the con- sequences too are similar, as well as the pain ; that is to say, like the bladder or the stomach, the heart may in one case completely recover; or, in a second, it may be completely para- lyzed and cause death ; in a third, it may remain partially powerless and dilated. As in the bladder, so in the heart, any one of these results may follow. Having said so much about the nature of injury by sudden 340 DISEASE OF HEART. strain, it is needless to remark that it is to be avoided bj all the expedients that lie in the patient's power ; and perhaps the best way of strongly impressing upon him (if he is a sensible man) the importance of your advice, is to explain, that is put into plain words the pathology of the case. I cannot agree with those who would make a mystery of our science. I am sure that we are never called upon to pervert the truth, seldom even to be passively reticent, and that the most thorough openness is always the best policy. To this end a complete explanation is gene- rally necessary. The patient must be told how erroneous are the vulgar notions derived from popular fiction about the extreme deadliness of organic disease ; the true facts of the case must be stripped of their picturesque hangings, and he must be led to look upon his condition with the same business-like reckoning of results as a physician. Unless this is done, your half truth will act as a lie. I should strongly advise you to get a habit of giving these clinical lecturettes in clear untechnical words. Let your patho- logy shape itself within your own minds in such language as all educated people can enter into ; and not only vfUl you be able to explain matters more easily to your patient, but you will un- derstand them better yourself. For this last statement "experto crede." In practical lectures it is always wisest to take chronic diseases ef the heart as one individual subject, for this is the way in which you have to think of them at the bedside. You should not treat patients with spoilt valves on one principle, those with dilated ventricles on another, those with thickened ventricles on a third ; but, as I have tried to make you think, each and all with a reference to the same function impeded in the same manner. Division leads to unnecessary repetition, and you may observe that I am careful to avoid it both in the way in which I class the patients in the wards for instruction, and in the ex- tracts I make from case-books for the lecture-room. I do this with a design of impressing upon you what I consider the main points in the management of diseased hearts, viz. — 1. The importance of valvular lesions consists in their liability to cause enlargement of the heart. DISEASE OF HEART. 341 2. In auscultation we should strive more to find out the state of the heart-walls than of the valves. 3. The danger of enlargement is greatest where the muscular fiber is weakest. 4. The muscular fiber is weakest where the blood is most anaemic. 5. The principal object, therefore, of treatment is to avoid anaemia. {Clinical, St. Mary's, January 30, 1863.) Eliza M., an unmarried woman, aged twenty-six, has been in the hospital four times during the last three years with attacks of haemoptysis and dyspnoea, arising from valvular disease of the heart. She was last admitted January 16, with dyspnoea ac- companied by excessive lividness of the face. She was soon relieved by the recumbent posture and half a dozen leeches to the cardiac region. My reason for mentioning the case to-day is to draw your attention to the dyspeptic symptoms which seem dependent upon the disease of the heart. On admission she said that she vomited up all her food, and although she only did that once after coming into the hospital, still she suffered from constant nausea after eating, and tympanitic distension of the intestines. I have often found this form of indigestion in cases of heart affection. There is nausea, vomiting, sometimes a great collection of mucus in the stomach, and intestinal flatulence. I attribute the nausea and vomiting partly to the constant jar communicated to the walls of the stomach by the palpitating heart, and which acts somewhat as the rocking of a ship pro- duces sea-sickness. Partly also I think it may be due to the general venous congestion which I have no doubt exists equally in the mucous membrane and in the external skin. The flatus in the digestive canal I think arises from the deficiency of ab- sorption, produced by congestion of the portal system. You must not look upon wind as a purely abnormal denizen of the alimentary canal. It would be a very abnormal state 342 DISEASE OF HEART. of things indeed if there were none found there. The greater part of it is carbonic acid and atmospheric air, derived from and swallowed with the food. But in health its quantity is limited and kept from inconvenient excess bj its continuous passage by endosmosis into the portal and venous blood. Now it is a familiar law of osmosis that the ratio of the rapidity of its current bears a direct relation to the motion of the fluid towards which it sets. Obviously, then, obstructions to the circulation, by diminishing the quickness of the moving blood, must impede absorption, and so allow the flatus to accumulate. It must be viewed as a col- lection not as an eff"usion. As regards remedies for this flatulent dyspepsia of cardiac patients, I have found hydrocyanic acid have a beneficial eff'ect. And in this case especially to give it is to accomplish two indicata with the same agent ; for by its general astion upon the pneumogastric nerve it alleviates the dyspnoea, at the same time that it deadens the over sensibility of the gastric plexus in special. LECTURE XXVI. PURPURA. Descriptive defiriition of purpura — Case 1. Young man affected with fatal hemorrhage and purpura without previous disease — Case 2. Menorrhagia and purp)ura in a girl othertvise healthy — Case 3. Purpura in a fatal case of diseased heart and kidneys — Pathology of purpura — Its connection ivith lesions of the circulating system — Its treatment based on its pathology — Caiitions respecting the administration of digitalis. — Case 4. Purpura fatal by hemorrhage into the brain. {Clinical, St. Mary's, February 6, 1864.) I WISH to call your attention to-day to three examples of pur- pura under my care this week, which illustrate the phenomenon under several different aspects. Purpura, or "the purples," consists of a diseased state of the capillaries, which causes them to rupture idiopathically or of their own accord, just as they would do in consequence of local violence. On soft or loosely constructed surfaces, such as mucous membranes, the escaped blood flows away in a fluid state ; where a tougher structure prevents this escape, us in the external skin for example, it forms purplish black spots of rounded shape and various sizes; in parenchymatous or semi- parenchymatous tissues, such as the brain or lungs, it may col- lect into masses which lacerate their substance and obstruct their functions. Case 1. John K., a laborer, aged thirty-five, previously quite well, was taken ill at tea-time on January 29, with bleeding from the mouth. This hemorrhage rapidly increased, and be- came very profuse ; so that by the evening of the 1st instant. 344 PURPURA. wlicn he came up by railway to St. Mary's, he reckons that he lost a gallon. And indeed it was very copious, for on each of the first two days of his being here there was very nearly a pint of fluid, exactly like pure blood, with a vermilion froth on the top, in the porringers by his bedside. But a good deal of saliva ■was mixed with it, so much at least as to prevent its coagulation, except in very small broken clots. On admission his mouth was full of clotted blood, which adhered to the gums ; on the tongue w^ere half a dozen black vesicles of the size and shape of split peas, and blood was oozing from their edges. On the lips and face, on the hands, arms, and various other parts of the front of the body, were numerous black spots of about the same diameter as those on the tongue, but not raised above the surface. His urine contained blood and, of course, albumen; but I could not find that blood had been passed from the bowels. He said he felt weak and tremulous; but he had walked to the hospital, and he sat upright, waiting for a bed to be prepared for him, for some time without faintness. There was color also in his cheeks and lips, and altogether much less exhaustion than one would have looked for after such severe hemorrhage. His ap- petite was not afi"ected, and the bowels were opened naturally "without medicine. He was ordered ice, sulphuric acid and turpentine draughts, and "tea-cup diet" of milk and beef-tea, with a wash of log- wood, catechu, and sulphuric acid, for the mouth. On the 3d there was little if any improvement in the local symptom, but his color and pulse had not failed. He was bid- den, in addition to the previous treatment, to keep in his mouth a lump of ice smeared M'ith powdered tannin. On the 4th the hemorrhage from the mouth was not lessened much; there was about three-quarters of a pint of froth-covered blood. It was stained brown by the local applications — in fact tanned. The pulse was quicker and weaker, about 108 in the minute and uneven. An ounce and a half of infusion of digi- talis was ordered to be taken every third hour, and the sulphuric acid and turpentine were left ofi". On the 5th (yesterday) the pulse was 120 in the morning, PURPURA. 345 110 in the afternoon, regular, even, and narrower than on the previous afternoon. The hemorrhage •was not diminished. Sore throat, faintness, and nausea were complained of. After he had taken six doses the digitalis draughts were given every four hours only. Late last night the breathing became short and difficult, and he died early this morning. Our secretary telegraphed to the poor man's wife at the village where they lived. The telegraph- clerk was unable at first to deliver the message, there being several people of the same name in the place; but hearing that a few days before a man bleeding much from the mouth had gone by train to London, he tracked him backwards from the station to his cottage by the blood which had been spat upon walls and stones by the way-side. This shows that the account of the excessive hemorrhage before admission was not exaggerated. [A post-mortem examination was made on the 8th, two daj's and a half after death. The whole front of the body was covered with spots of purpura, of which those on the chest had pale-yellow centers. The rest of the skin was very pale and there were very few spots on the back. There were numerous spots of pur- pura on the pleura, pericardium, small intestines, bladder, bronchi, trachea, and larynx. In the upper part of the latter organ they became more numerous, and in the fauces and tongue formed a continuous discoloration. On the tongue they were black and swollen as before death, and from the pillars of the fauces blood oozed on their being handled. There was no purpura on the oesophagus. The left auricle contained a firm non-adherent clot of fibrin, and there was an- other similar clot loose in the aorta. The heart was hard and firmly contracted. The ventricles are preserved unopened. The other viscera were quite normal in appearance.] Case 2. Jane N., aged nineteen, spinster, came in on January 29. She has a transparent ivory complexion, firm large limbs and muscles, and an aspect of strength. She has always enjoyed good health, but during the last three months the catamenia have been very profuse, and have gone on lasting longer and longer each period, till now she has hardly a week's interval. During the week before admission she several times found blood in her m.outh, and on the 26th purple spots came out on the face, arms, bosom, and legs, and continued to increase in numbers daily. They were of sundry sizes, from that of a mustard seed up to that of a pea, the smaller being far the most numerous. They 346 PURPURA. were of an intense purple color, and presented a singular appear- ance from their striking contrast with her clear waxy complexion, the hue being perfectly' complimentary. Their surface was not raised above the neighboring skin. I saw none on the mucous membranes of the mouth, but her gums looked a little red at the edges. Her bowels were regular. The urine could not be examined on account of the presence of the catamenia. She had lust her appetite, but I think that was accounted for by her sorrow at parting Avith her mother and coming into a hospital, as she has eaten fairly since she has found it to be not such a terrible place as she fancied. She was ordered the following: — ^i Dilute sulphuric acid, min. xxx, Tincture of digitalis, min. xv. Camphor water, fl. oz. j, every 4 hours. A tea-cup of milk or beef -tea every 2 hours. On the morrow I found her appetite was not so entirely lost as she said; so I ordered her broth and meat, potatoes and a lemon, and on February 3 ordinary meat diet. Twenty-four hours after commencing the draughts I pointed out to you that the center of each spot was lighter than the cir- cumference. It became distinctly yellow to the naked eye, and the dark color gradually faded away altogether by February 4. The sanguineous discharge ceased at the same time. She is quite convalescent, but I observed that after an interview with her mother yesterday she was paler in the lips and depressed in spirits; so I shall keep her in a little bit to watch against a re- lapse and give iier a good rest. Case 3. William 11,, a butler, aged forty-five, was admitted on January 29 sinking with emaciation, anaemia, and pain in the cardiac region. The anatomical lesions found at the post-mortem examination on February 3 were a dilated heart, with its mitral valve degenerated into wart-like growths, and kidneys atrophied PURPURA. 347 through the occupation of their substance by many curiously large cysts. The imperfection of the mitral valve had been known before death, but that did not explain the disease; and the circum- stances prevented any further diagnosis, or much association of the symptoms during life with the appearances on dissection. The chief causes of death do not therefore offer a profitable opportunity of clinical instruction, and I cite the case to-day to notice a secondary phenomenon. Two days before death there appeared a large blotch of purpura on the nose, occupying the greater part of the feature, and another spot on the left hand, which was slightly oedematous. The discoloration remained in the dead body. The blood was fluid. These three cases present to you three aspects of purpura. In the first two the disease was due to a marked loss of func- tion in the capillary vessels, so that their coats v,-ere ruptured, and the contained fluid oozed out. In the fii-st danger arose from the accidental location of this oozing in a loose surface, so that tlie hemorrhage was excessive. In the second there was no danger at all. In the third the deficiency of the capillaries was at a minimum, and would not alone have given rise to ex- travasation; but it was supplemented by the impediment to the circulation in the heart, and probably by the retention of urea in the blood. It was in itself unimportant. Like all diseases of the peripheral circulating system, pur- pura is most common in the parts most distant from the center. Such is the rule, though its want of universality is exemplified by the instances before us. But it is not most common in the most dependent parts, and in the legs it appears as often on the front as the back, on the body almost always on the front. This seems to remove its etiology from the category of being primarily traceable to lesion of the central organ of circulation or of the mass of the circulated fluid. Were such its origin, it would appear in cases where the first is most afi"ected, and in places where the latter is most abundant and most unhealthy. You must not fall into the old-fashioned error, inculcated when 348 PURPURA. I was a pupil, of lazily attributing all illnesses where the blood is abnormal in composition to "diseases of the blood," and there ending it. The blood is like a pond or reservoir attached to some great manufactories: the refuse of the manufacture flows into it, and the engine boilers are fed from it; waste products and latent power are mingled in its streams. If there is anything unusually foul in the water, the master does not lay the blame of that foul- ness on the innocent element, but traces it to defects in the pro- cesses drained and fed. So in purpura, the circulating fluid is probably always abnormal ; but it is surely unwise to stop our explanation at this point, and to search no further. For the hemorrhage, whether free or into the cutis, makes it abnormal, and the degeneration of the red disks, discernible by the micro- scope, is just what is found in cases where there is no purpura. It is surely going backwards, when the function we see to be deficient (namely, the retention of the blood) is a function of the capillary vessels, to say that their diseased contents are a cause of that deficiency. On this pathology is based the treatment. The less severe cases will recover under the use of cool unirritating, but nutri- tious, diet with vegetable and mineral acids, which astringe the capillaries. I think very possibly the young woman Jane N. would have done so; though not so quickly as she has now re- covered, because mineral acids alone are slow to stop menor- rhagia, Avith which, as well as with purpura, you will remember her to have been affected. But you saw that this treatment had no influence over the dangerous purpura of the first patient, although supplemented by other very powerful astringents. The most powerful remedy taken in both instances has been digitalis, whose agency in diminishing the area of the circulating system (probably through the functions of the involuntary nerves) I have often pointed out to you. Under its use the artery becomes smaller, the pulse-wave is narrowed and hemorrhage ceases, equally when it is on the loose surface of a mucous membrane, as when it is subcutaneous. You saw the purple blotches on the young woman fade away at a marvellously quick rate ; and you saw them fade away from PURPURA. 349 the center, not from the circumference, exhibiting yellow spots in the middle while the rim was still dark, thus proving that the action is not merely peripheral, but internal. At the same time you heard that the vaginal hemorrhage was also ceasing, as it usually does in simple menorrhagia under the action of digitalis. In the first related case there is no evidence of curative action, except the yellow centers to some of the blotches seen in the dead body. In the third case the purpura was such an unimport- ant part of the patient's illness, that it had no treatment at all. The chief caution which I think it necessary to give you about the administration of this remedy, is that you should provide against the danger accruing from the sudden uprising of the patient. From the diminution of the area of the vessels so much less blood is sent up into the brain, that fatal fainting may ensue if the usual hasty demand entailed by this change of posture is made. The symptoms of deleterious action, and which warn us to suspend the employment of digitalis, are giddiness and nausea, accompanied sometimes by irregularity of pulse. Dilata- tion of the pupils, cold sweats, and complete syncope, alluded to in your books of materia medica, are later phenomena, which I have not had an opportunity of witnessing, and before the supervention of which you ought to have left off your treatment. Digitalis seldom, if ever, begins to do harm till it has ceased to do good, and till therefore the necessity for it has passed. When the condition for which it may be wisely prescribed has passed away, then, and rarely before then, its poisonous power is exerted. And the more and more the original morbid con- dition is departed from, so is the novel morbid condition, the poisoning by the vegetable, developed. Hence its action appears to increase. Metaphorically it may be called " cumulative ;" but the use of that word must not lead you to suppose that soluble alkaloids, such as those in foxglove, are likely to accumulate in substance in the blood. The stricter explanation would be that its action is permanent, and therefore that each new dose adds to it. This account of the action of digitalis affords a reason for the 23 350 PURPURA. plan, which you see me adopt, of diminishing forthwith the dose, directly that a beneficial effect has begun to be produced. [Clinical^ St. Marys^ February 25, 1864.) Having so very lately lectured on the subject of purpura, I shall bring before you, as an appendix to that lecture, another case; though, as a fatal one and not seen by you or me during life, it is but little instructive taken singly. Two days ago a man, apparently of about thirty, was brought in evidently moribund, who was stated to have had "typhus fever." He died an hour and a half afterwards, without having manifested any diagnostic symptoms. At the post-mortem ex- amination yesterday we observed on the dorsum of one foot a small spot of purpura, another at the side of the leg, and a good many more on the back. The largest were about one-eighth of an inch in diameter. The skin in many parts of the person was mottled, like that of a corpse when decomposition is commencing, the face was purple, and the scrotum was reddish purple as if bruised. The body was well proportioned, and there was a healthy quantity of firm adipose tissue in the walls of the belly. The heart was hard and large, weighing with the pericardium one pound ten ounces. The pericardium was universally adherent, as if from long past inflammation, no connecting fibrin being visible. The valves were healthy, and in the cavities were con- tained the usual fibrinous coagula; there was none in the arteries or veins. No trace of chronic organic lesion was detected in any other organ. I show you here specimens removed from several of the viscera, which present a singular and uniform appearance, the differences being assignable generally to their different anatomical struc- ture. Here are pieces of the brain, of the liver, and of the small intestines, the kidneys, and the heart. You see scattered over them, inside and out, dark spots of purpura, such as I have described on the skin. This gives a very strange aspect to the kidneys, which look like the speckled belly of a trout. In a few PURPURA. 351 of the spots the fibrin seems to have separated itself, forming a vellow center to the effused blood. There is no halo of inflam- mation around any of them. Many of the spots in the liver are more yellow than red. In the brain the spots are large, and branch out along the course of the vessels on the surface. In the right anterior lobe the nervous substance is broken up by a large black gelatinous clot of blood. It is evidently, as you may feel, of considerable size, at least twice as big as a chestnut, but I wish to harden it in spirit before I make a section. There are two more clots about the size of small peas at the back part of the hemispheres. No other abnormal appearances were observed, and this clot in the brain is enough to account for death. The history of the case, which I have since obtained, is as follows: — The patient had previously suffered twice from acute rheumatism, and since November last had been badly off, living principally upon potatoes and bacon, but was in his usual health and spirits on the 18th instant. In the evening of that day he was attacked with sickness, pains in the joints, pains in the side, thirst and feverishness, which symptoms went on from bad to worse. On the 21st he was seen by Dr. Asprey, the resident medical officer at the Western General Dispensary, and found to have excessive pain in the joints and a brown tongue. In the evening he became delirious. On the 22d Dr. Asprey found him in a state of partial coma, but capable of being roused by effort, and certainly not anywhere paralytic. The tongue was dry and brown, and the pupils dilated. On the same evening he was brought to the hospital, as I have related, just before he breathed his last. This case shows how serious may be the consequences of purpura, a condition which, judging from the more ordinary examples seen by us, we are in the habit of rating low down in the scale of causes of mortality. In a case of cerebral hemorrhage like this paralysis and apoplexy were not to be expected, because the central parts of the brain were not pressed upon, the sanguinecus effusions taking their orifrin from and beinor confined to the surface. I remem- 352 PURPURA. ber the case of a young woman who, after a mental affliction, died with typh-like symptoms not very dissimilar to this man's. There was found in the brain a clot of blood so large as to con- ceal the greater part of one hemisphere, but it was thin and lay quite on the surface ; so that I suppose it did not compress the inner portions of the cerebral substance ; for there had been no paralysis. It is not so much the size, as the shape, and still more the situation of clots which make them apoplectic or not. A clot, one-tenth of the size of this, in the fornix or hippocampi would certainly have been apoplectic. LECTURE XXVII. ANEMIA. Part 1. — History of a case of ansemia — Objections to the nomen- clature of the disease — Its pathology — It consists of a func- tional deficiency of life in the blood-making organs — Applica- tion to this case — The defective morbid anatomy does not im- pede our treatment — Transitory curable states usually depend- ent on the mucous membranes, which have little post-mortal anatomy — Sketch of the active life of mucous membranes — Their importance in disease — Effect on health of their dimin- ished vitality — Application of this pathology to practice — In- tention of treatment to introduce nitrogenous food, iro7i, and chlorine — Mode of doing this, its effects, and reflections thereon. Part II. — Effect of ansemia on the mental faculties — Practical deductions. Part III. — Ansemia, when the result of permanent organic lesion, amenable to the same treatment as when functional. (Part I. — Clinical, St. Mary's, November 5, 1861.) I AM about to make a common and typical case of ansemia the text on which to hang a few practical observations on that disease. You will all remember the corpse-like paleness, made the more striking by red hair, of a girl we first visited this day fortnight, named Margaret C. She smiled courteously, though quite unable to raise herself from the bed, and in answer to cross-examination gave her history as follows : Her age is twenty, and she seems to have enjoyed generally very good health, as is* shown by her remembering that she had 354 ANAEMIA. such an unimportant discomfort as a pain in the right side when she was a school-girl of seven. She was carefully brought up by a step-father in a higher class of life ; but three years ago she lost him, and had to go into service as a housemaid at the age of seventeen. For that work she was scarcely strong enough, and had been too tenderly nurtured ; so after eighteen months' trial she gave it up, and was apprenticed to a Berlin-wool shop. There her mental superiority was recognized, for she quickly became forewoman, with three girls under her, in a shop at Maidstone. She felt the responsibility a good deal, and also thought the closeness of the shop did not suit her, although it did not make the others ill. However she retained in her face a high color, for which she seems to be somewhat admired, till nine months ago, when she began to lose it, and in a few weeks became as wax-like in hue as she is now. In the first stage of her ailing the appetite Avas large, so that she always felt in want of food ; but after three months it failed, then ceased entirely, and she took a disgust to all nutritious articles of diet. She had a good deal of pain in the epigastrium, and to the left side of it, and also suffered from palpitations and pain at the heart. A quarter of a year ago she spat up some blood, and had a little cough, which frightened her much. Thrice durino; the nine months she has had attacks of low spirits, with crying, which is usually set down to hysterics ; yet there is nothing abnormal in a girl being sad when she is out of health, or in her crying when she is sad, and Margaret C. does not appear at all hysterical now. The catamenia had always been quite regular and sufficient till the commencement of the angemia nine months ago, when they began to get scantier and scantier, and at last ceased entirely. The urine is pale and watery, the stools are scanty and steadily rare ; but there is never any sudden gush of bulky motions, no diar- rhoea alternating with constipation, or other indications of accu- mulation of fiBces in the intestines. The patient expands her chest perfectly, and there are no signs in the lungs to give rise to a suspicion of tubercle, or at all events of tubercle in such a quantity as to account for the antBraia. Tliere was at first a soft systolic murmur in the heart ANEMIA. 355 when she was agitated, which went away after she had rested in bed five days. First, for the name by which I have ah-eady designated this girl's disease. Anoeraia, or " bloodlessness," means in scientific language a want of red disks in the blood. The word has been objected to, because it has been supposed to imply etymologically that there is a deficiency in tlie actual quantity of circulating fluid, of which deficiency in quantity there is truly no proof. And "spangemia," or "thinness of blood," has been proposed in its stead. Such accuracy would be highly praisewortiiy, if it were only accurate ; but really the mere fact of thinness does not hit the essential feature of the disease ; for the specific gravity of the blood might be raised as high as you like, but if you did not restore the red blood-disks nothing would be gained; the morbid state would still exist. In truth there is no occasion for fault-finding. " Anseraia," by the analogy of Greek etymo- logy, does not mean deficient quantity of blood, but deficient quality, just as in Aristophanes aTzpoaijno^ does not mean a man "without a face," but "with an ugly face," avapidnog means "dif- ficult to count," and so on in numerous instances of the use of the a privative. I shall therefore contentedly use the term anaemia to include all cases in which the amount of blood- disks is below the normal proportion. Anaemia has existed during life in a great number of the patients from whose bodies has been taken the organically changed tissues which you see preserved in museums and shown in lectures on morbid anatomy, and which may also be found out by diagnosis. In other cases of equal import and prominence, anaemia is wanting. Again, very frequently you find it in a high degree in cases where there can be discovered no organic changes of the solids at all, and where, from the transitory nature of the bloodlessness, there is reason to conclude that such organic changes do not exist. Under this last category comes the patient who is the occasion of to-day's lecture. To understand how it is that so many causes are followed by the same effect, and by an effect not at all proportioned to the general importance or want of importance of the cause, you must 356 AN/EMIA. reflect upon the true relation which the blood bears to the rest of the organism. It may be compared to a chief thoroughfare in a great city. Very few trades, still fewer manufactures, are carried on out of doors or in the street it?elf, yet from the nature, the number, the pace, and other characteristics of the passing vehicles and people, a pretty shrewd notion of the commercial activity of the population may be formed. An observant for- eigner standing in Cornhill and viewing the quick steady pace and careful yet healthy faces of the many classed wayfarers, the well-packed loads of the vehicles, and their varied contents, could not fail to know that he was in the center of a prosperous trading nation. But it would not be, or ought not to be, the mere numbers of the people collected together that suggests to him the observation. On last Saturday he would have seen a greater crush than usual at the same place, but on inquiry he would have found that it was only in consequence of all business being suspended for Lord-Mayor's day. And at Naples, till lately, the lazzaroni and pickpockets who blocked up the pave- ments in the main thoroughfares, were evidences of trade beinoj not only suspended, but made impossible by a swarm of villians. So that it is not the mere fact of crowding which should give the idea of wealth. In the blood the physician traces proof of constructive meta- morphosis (the city's manufacturing industry), destructive meta- morphosis (its consumption), and effective life (its social happi- ness) being carried on. But as our intelligent traveler, in estimating the wealth of a community, must not be deceived by an idle crowd at one spot, so the medical philosopher must not set down mere local congestion as proof of wealthy blood. In both cases experience finds strong presumptive evidence of some- thing amiss. Neither must a mere bustling throng be reckoned as industri- ous citizens. There are cases were a larcje amount of solid matter, even where a large amount of red disks in active motion, adds no more to the usefulness of the circulating fluid than the lazzaroni to Naples, and which therefore, as far as treatment is concerned, are really in the same category as obvious an?emia. Of these I shall take a future opportunity of speaking. AN.EMIA. 357 But though crowds are no evidence of sound political health, yet it is certain that deserted streets prove political disease. So anaemia, or deficient redness in the blood, shows a deficiency of life in the ministers to that redness ; either the supply of food is too small, or its assimilation is defective ; in either case the supply of red disks, either absolutely or relatively, is not com- mensurate with the existing demand. In many instances of anasmia it is easy enough to lay the finger upon the instrument of life which is to blame. We detect without difficulty causes at work to produce it — starvation, which anybody can understand leads to an absence of the organic matters made out of food ; degenerated stomach, in which the aliments are not prepared for assimilation ; degenerated liver and duodenum, producing the same result ; lesions of intestines or their glands checking the imbibition of adipose matter, and so preventing cell growth ; changes in the spleen or lungs — organs which our physiological experiments, independent even of our observations of morbid phenomena, show to be answerable for the formation of new blood-disks in a way yet unknown ; mental derangement, care, disappointment — which so readily arrests the activity of the assimilating viscera ; these agencies, and many more, are readily comprehended as causes of anjBmia. But there are many cases where nothing obvious of this sort is to be made out, yet where the paleness of the blood seen in the face, lips, tongue, or in a drop taken from a pricked finger, and where evi- dences of it in fainting, weakness, palpitation, anasarca, amen- horrhgea, &c., are even more marked than Avhere demonstrable lesion is to be found. So it is in the present instance. The young woman's history gives no reason to suspect any organic disease of the lungs or other organs, and the functions of life were fairly performed till she began to get pale and languid nine months ago. The want of red blood, which we look upon as the important feature in her case, also attracted her own attention particularly, as she had previously had an ornamental fresh color. Then, after an interval amply sufficient to enable us to separate cause and effect, come the symptoms which I wish to notice as the consequences of antemia. Causes, no doubt, 358 ANEMIA. they are in some instances, but here consequences. I mean the loss of appetite, impeded circuhition, amenorrlisea, and hemor- rhage from the respiratory organs in a person previously unaf- fected in that way, which are noticed in the case book. The only explanation she can give of her loss of health is her having been employed in a shop less perfectly ventilated than she had been used to, and having the main responsibility of the concern thrown upon her. Alone neither would have been suf- ficient, as the shopwomen under her do not appear to have suf- fered from the air ; while, on the other hand, women engaged in retail business are not as a rule ansemic. But still I think that both together may perhaps be fairly charged with the blame, for while the increased mental labor was increasing metamorphosis, the greater demand was not responded to by greater supply, but on the contrary assimilation was checked by the comparative unwholesomencss of the respired air. The not being able to trace deeper the anatomical cause arises from the imperfection of our knowledge, but it does not arise from neglecting to apply such knowledge as we possess to practical medicine. If we were to make an autopsy of this patient instead of curing her, we should in all likelihood see no more solid lesions capable of accounting for her disease than we already know of, we should probably find nothing abnormal in any part. So that you need not lament the opacity of your patients' bodies, or suppose yourselves likely to learn how to treat them better if you could see their insides. Anaemia without obvious organic lesion of the solids, when properly managed, is a very curable condition, and this should still further reassure you that you miss nothing by not being able to study its post-mortal pathology. For passing and cura- ble states leave but faint footprints behind them for anatomists. In a great majority of cases they depend upon morbid changes of the mucous membrane, of all the tissues in the body the one most speedily affected by decomposition after death, and then presenting the worst possible picture of its condition during life. The intestines, as the anatomist sees them, are about as much ANEMIA. 359 like the intestines in health as the crumpled folds of dank parchment Avhich surround the mouth of a corpse resemble the same lips swelling with joy and expression. Let the picture which is painted on our minds be taken, not from the dead house, but from the familiar view of our own mouths in a looking-glass ; for one sketch drawn from the life is worth ten fiom the museum. Turn down the lower lip, and observe the infinite life going on. There is evidently as much blood as vessel ; and seeing that blood, from the quantity of solid matter visible in it, has a right to be called a semi-solid, this membrane has an equal right to be thought of as a semi- fluid. And when we think of it as semi-fluid, let not the idea of a stagnant marsh be presented to us, but of a headlong rapid. It is a useful way of keeping lively our feelings about the circulation, to examine through the microscope occasionally the toe-web of the slow-blooded frog. The action and ceaseless whirl of the living stream we see there quite drives us dizzy. What then must it be in our own Avarm selves ! If in a mem- brane so little animated as the frog's toe, or the bat's wing, which by the naked eye we should judge to be entirely devoid of blood, we are still enabled by our microscopes to see such a network of tubes conveying it — if, in a creature, the greater part of whose blood is driven from the extremities to the center by the tempoi'ary flight Ave cause in putting him under a micro- scope, we find such a busy scene of circulation — what must be going on in a tissue glowing with red life and health ! To the fault of the mucous membranes I am disposed to lay the condition in which we find our present patient. The t.vo circumstances to which I have traced the illness both act directly or iudiiectly on this tissue. The mental exertion involved in an unwonted responsibility thrown on a conscientious person would lessen the life of the involuntary muscles which carry along the mass of food through the alimentary canal. You know well how long your food is in leaving the stomach if you are called to an important midwifery case just after a hearty meal; and several commercial and literary men have complained 360 ANiEMIA. to- me of attacks of vomiting (that is, temporary paralysis of the stomach) when they took dinner alone, and so were apt to let the mind dwell deeply on some interesting subject ; and they have told me in wonder that they could dine out and eat and drink all sorts of rich things with impunity. They did not seem aware of the preservative value of frivolous con- versation. At the same time that the moral causes thus impeded diges- tion, the unwholesomeness of the air in the close shop where our patient was employed poisoned the mucous membranes, diminishing the vitality of their epithelium, and causing them to be abnormally covered with a thick layer of mucus. By this tenacious coating the entrance of alimentary substances into the veins and absorbents was impeded, and the owner pined in the midst of plenty. So all the usual signs of starvation followed. First, hunger, — by no means a constant companion of chronic deprivation of food, yet sometimes present as here ; then loss of appetite, a much more frequent phenomenon ; then paleness, languor, weariness, and pain in the stomach ; then anasarcous oedema, and, in short, the other more marked symptoms of anaemia. You may observe that the loss in those constituents of the body which are of a nitrogenous chemical composition, is more marked than that in the hydro-carbonaceous fat. The reason is partly that the destruction of adipose vesicles is somewhat shrouded by the saturation of the tissue with serum, which gives it a false plumpness — partly that fat, being absorbable without much (if any) alteration, is easier taken up into the system than fibrin or albumen, which require a chemical solution before they can be absorbed. So that, though starved, Margaret looks but little emaciated. All that I have now said must have of course for its moral some hints on the treatment. My aim in ansemia is to introduce as quickly as I can the largest possible amount of (1) nitrogenous food,- (2) iron, (3) chlorine. When I say "introduce," I do not mean " throw in," or get swallowed, but cause to be assimilated in the system. ANiEMIA. 361 As regards the first, it is obvious that if I had written down ever so many "ordinary diets," one to whom the very sight of food was an abomination would have gained nothing by it ; she would simply have gone without. I directed no meals at all to be taken, and no solid food ; but a cup of milk with a third part of lime-water in it to be given as medicine every two hours, and a pint of beef-tea in divided doses during the day. After two days she managed to eat an egg also daily, and after twelve days of gradual additions of this sort, you will find her on full allow- ance of mutton-chops, porter, beef-tea and milk. Iron is required to supply the anticipated new growth of red disks with their metallic constituent. You cannot force into the system in any way so certainly as by the " mistura ferri com- posita" of the pharmacopoeia. Large doses of the more soluble salts of iron have an action on the mucous membranes which not only prevents their being taken up, but only checks the digestion of other food. Evidence of the last-named effect is found in loss of appetite and feverishness, and in the rejection of iron and undigested food among the blackened stools much sooner than when the metal is given in the form named. In spite of the elegance of preparations constantly put before us, and recommended for their solubility, such as the chloride, acetate, citrate, phosphate, and other salts of iron, I often pre- fer the unchemical mixture. It seems as if the carbonate which is preserved from decomposition by the sugar, and the finely divided oxides diffused through the thick liquid, were peculiarly easy of solution in the water saturated with salts and carbonic acid, the solvent with which we have to do, not only in the stomach, but throughout the whole body. In reckoning the solubility of medicines, physiological phar- maceutists are apt to count the fluids of the body as distilled water, and because a substance is not soluble in that medium, to call it insoluble altogether ; whereas, if it be soluble in water saturated with carbonic acid and salts, it is sufficiently soluble for the purposes of life. I have found that some cases which did not get on so fast as I could wish under the above treatment, made a sudden start 362 ANEMIA. of improvement when to it there was added the administration of clilorine in the form of warm hydrochloric acid baths. More iron is taken up, the blackening of the faeces ceases, and it may be that the presence of more acid in the system retains more of the metal. In a few cases I tried for experiment's sake the hydrochloric acid baths alone ; and even then it was beneficial, seeming to confer muscular strength in the same way as the articles of materia medica which are commonly called tonic. On these grounds I cannot but think that hydrochloric acid supplies a distinct want in the system, that it is a directly restorative medicine in anaemia. It is not difficult to make this empirical observation accord with rational pathology. In anaemia the blood is more watery than natural ; the proportion not only of organic matters but of salts is deficient. Chloride of sodium is the most important of these salts, and the supply of one of the constituents of this ma- terial may be without fancifulness conjectured to be an aid to that renewal of life, which is the end of all medication. Besides the above-named medicines, you see that I have pre- scribed Pil. aloes cum myrrlid gr. iv. omni node sumenda. Do not suppose that this is ordered merely as a purgative, or that any other purgative would do as well. On the contrary, most purgatives are injurious in anaemia. Gamboge, sulphate of magnesia, colocynth, mercury, and several others which prodjice elimination of serum and increase secretion generally, do harm just in proportion to their activity. It seems established, by the experiment of making them act as purgatives when injected into the circulation, that their soluble principles have a destruc- tive iigency upon the blood; whereas the soluble alkaloid in aloes (aloine) is, in fact, a bitter tonic, and the purgative power of the vegetable resides in its insoluble resin.* Its action is very moderately eliminative — in small doses it slightly adds to the solid excreta of the colonic glands, and elicits faeces feculent in smell and of consistent form— while at the same time it retains by its bracing bitter the formation of mucus. See its action on * See Headland on the " Action of Medicines,"' p. 331 ; ani Robifiuet, in the "Journal de Pbarmacie" for April, 185G, quoted by Dr. Headland. ANAEMIA. 363 moist piles, how it dries them up and makes them smart ! And judge from this what its action on tlie gastro- intestinal raucous membrane is likely to be. At the same time by the more vigorous peristaltic action and by the solid mass passed along the gut, the already existing mucus is cleared away. Aloes is employed strictly as a clearer of the intestinal, especially of the colonic, membrane, and it is joined with myrrh, partly to divide it minutely and make a small dose go further, and partly to get the advantage of the extra resin. (Part II. — Clinical, St. Marys, January 23, 1863.) In a young unmarried woman, who leaves the hospital to-day, you may see an example of an occasional effect of anaemia to which I have not hitherto called your attention, I mean its effect on the mental faculties. Margaret H., aged nineteen, a stout and well-made, but small- boned, girl from the city of Cork, was admitted at Christmas with pallor, palpitation of heart, oedema of ankles, loss of appetite, amenorrhoea, and some other of the usual s^^mptoms of anoemia without organic disease. She was not at all hysterical. She stated that she had been eight months in London engaged as a maid-of-all-Avork, and attributed her present illness to the hard labor entailed by that situation. She was ordered food every two hours and Griffiths' steel mixture thrice daily, and has been taking the latter up to the present time with the usual improve- ment to her health. So far she exactly resembles a class of cases, of which we admit two or three every week. The only peculiarity Avas her excessive sluggishness of body and mind. She would lie or sit for hours without moving in the posture she was placed in ; and if desired to walk dragged herself along like a sloth. If questioned she did not answer, or confined her reply to rigid monosyllables. This slowness of ner- vous and intellectual power remained even after she had begun to regain color in her lips and cheeks ; so that the sister and nurses set her down as naturally half-witted, and doubted the 364 ANEMIA. possibility of her gaining her livelihood as a servant even in the hun^blest capacity. As she possesses more than ordinary perso- nal attractions, I dreaded sending out such a simple-minded creature defenceless into the wicked world of London. But during the last week some accident has set her to work at crot- chet, and I found her fingers nimbly twinkling at this occupation, which it seems she had been accustomed to in Ireland. She was encouraged to proceed, and to our surprise the manual operation, monotonous and mechanical as it seems to us, acted like magic ; in a few days she became cheerful, laughs and talks to the pa- tients, and has turned out a brisk girl of more than average in- telligence. In consequence one of our hospital visitors has proposed to get her a place as lady's maid. Doubtless the way was prepared, by the action of the iron in curing the anaemia, for a very slight extra restorative agent to enable her to regain her mental powers. Still I cannot but at- tribute very considerable influence to the habitual occupation, associated as it is with memories of her former happier life, taking her thoughts away from the dark back-kitchen of a Lon- don shop to the old merry days in county Cork. There were here two deficiencies to be restored; — first, that of red globules in the blood, which was effected by food and iron in the manner I have so often explained to you; — and secondly, that of the mental faculties; some new and brighter associations were required to excite her voluntary nervous system to action and to break the dull chain of her daily routine. Acci- dent supplied this in the present patient's case, and with such good effect, and so strikingly, that I trust you may be led to make your reason in other cases take example, and do inten- tionally what was here done by a lucky chance. Occupation, and that not merely of an amusing character, but of suflBcient interest and importance to require constant attention, is often a most valuable aid to treatment. I have known the little house- hold duties which are a woman's functon, even needle-work which must be done by a certain time, such as making a pair of slippers for their doctor, have a most beneficial effect upon the weakened mind. AN.^MIA. 365 (Part III. — Clinical, St. Marys, February 6, 1864.) The cases entered as ansemia in the register are usually such as do not display signs of any organic lesion to account for the deficient supply of red blood to the tissues. And the knowledge that these patients are readily cured by iron is so familiar to you that it seems almost like a truism. I am not sure if you equally entertain the fact that the same treatment is not less applicable to those whose defect is explained, either mechanic- ally or physiologically, by some discovered structural change of a permanent nature. You are too apt to look upon this struc- tural change as the main point to be considered, and in conse- quence, where it happens to be irremovable, you do not pay sufficient attention to such results of it as are really quite sus- ceptible of cure. To illustrate my words I will call to your recollection a young woman who has just left the hospital. On January 8, Louisa 0., an unmarried servant, aged twenty-five, was obliged to be sent up to bed with ansemia of very marked character. There was not a trace of red in her cheeks or lips even under the influence of excitement. She was hardly able to stand upright, and the attempt to do so brought on great faintness and giddiness. The catamenia which last flowed, though at the regular time, were of a greenish color. She had palpitation of the heart, and had been getting paler for several weeks, but the inability to stand was only of a fortnight's duration. There was pain complained of in the cardiac region, and a loud blowing murmur was to be heard with the first sound. This blowing murmur was very audible all over the cardiac region, and up the large vessels into the neck, but loudest and of a harsher character than elsewhere just at the level of the aortic valves. She could give no history of rheumatism, but had scarlatina some years ago. She was treated with iron mixture every three hours, and beef-tea and milk every t\vo hours. On the 13th she was able to eat a mutton chop. On the 16th the lips were getting rosy, and she was able to color up when spoken to. By the 27th she had gained a very 24 366 AN.EMIA. fair color, even when not blushing, and she was discharged on the 29th. But the cardiac murmur remained as loud, if not louder, and was equally ringing in its tone at the level of the aortic valves. She went home registered as "cured" (for it had been indexed as a case of " anaemia,") was supplied with a large bottle of her mixture, and was advised every two or three months to take a ten days' course of iron in some form. She was warned also that mercury, purgatives, antimony, and all debilitating medicines were very bad for her constitution, and that she must request any medical man whom she might consult, not to give them to her. I have no doubt in my own mind that this patient's central organ of circulation is in an imperfect condition ; and the special auscultatory signs induce me to think that the imperfect con- dition consists of a narrowness of the aortic orifice. It is true that she has never had any of the illnesses which usually cause cardiac lesion, and therefore I do not suppose the lesion to be of a degenerative kind. I should conjecture it to have more of the nature of an arrest of development. She is a puny, incom- plete person, of slim figure, with narrow hips and hardly any bust, with fine soft hair and a delicate skin. Though turned of twenty-five, she has the aspect of seventeen. I think it very likely that the aorta and its valves have not grown with her growth, but still retain the caliber suitable for a young girl. She is consequently unable to do woman's work ; and even the usual monthly discharge from the uterus, which is a relief to the fully formed female body, is too much for her. For the supply of blood to support work is limited by the limitation of area through which it has to pass. Whether the aorta will ever make up for lost time, and, though late, accommodate itself to the body, I cannot tell. But I can tell by the results of this and similar cases that the watery blood is capable of renewal, though it be watery in consequence of a still existing cause. And if any agent ever removes that still existing cause, by renewing its imperfect life, I am sure that agent will be healthy human blood, the best medicine ever de- vised. ANiEMIA. 367 The warnino; I o-ave her was directed ajjainst an unfortunate tendency, common to both the public and our profession, towards commencing treatment habitually with destructive remedies. They call this "clearing the decks for action;" in a majority of instances they throw overboard much of the best tackling in the ship and loosen her armor-plates. A so-called "sluggishness of the liver" is a frequent pretext. In a half-nourished person with pale blood of course the faeces are apt to be light-colored and scanty. Blue pill gives them immediately a darker color and increases their quantity, sadly at the cost of the patient's strength, and the temporary change soon passes off. Meat and iron produce the same result, by giving them more to be made out of, and the improvement is a real and permanent one. LECTURE XXVII I. PROMINENCE OF EYEBALLS. Cases with commentaries — Tlie 'pathology of the disease associ- ated u'ith that of ansemia, and (he requisite treatment tlience deduced. {Clinical, St. Marys, May 2, 1863.) A YOUNG woman who left the hospital yesterday exhibits one of the occasional accompaniments of anoemia in a marked degree. She is a subject of that state of the eyes called (somewhat bar- barously) Exophthalmia or Exophthalmos. Emily M., aged twenty-three, spinster, had been in since April the 10th. She is a leucophlegmatic flaxen-haired girl, but tall and well-grown, "with great marble limbs." Her com- plaint was menorrhagia, which had begun a month before by a slight attack of hasmoptysis. Of this she was soon relieved by an ounce of infusion of digitalis three times a day, a grain of opium every night, and complete rest in bed; and I am not going to lecture on that subject now. She has had two attacks of rheumatic fever, the first when a child, the last two years ago. Four years ago she had measles rather severely, and since that date her eyes have gradually got very prominent. The promi- nence vaiies somewhat with her state of health, and on her ad- mission was worse than usual. The left eye squinted disagreeably outwards, as is usually the case when she is in her worst state of health. On gently applying firm pressure with the fingers to the eyeballs, they may be got back to their natural place in the sockets, and at the same time the cellular tissue beneath the lower eyelid swells out. There is slight dullness on percussion, accompanied by bron- PROMINENCE OF EYEBALLS. 369 chial breathing, below the right clavicle. There is a loud sys- tolic murmur in the heart, much most marked at the level of the aortic valves, and not affected by change of posture. This prominence of the eyeballs is a patholgical problem not yet at all satisfactorily solved. There are four ways in which it has been accounted for — first, by describing it as an enlarge- ment of the eyeball itself, a view advocated by Drs. Begbie and Stokes; — second, by its protrusion in consequence of hyper- trophy of the tissues at the back of the orbit, as is maintained by Dr. Basedow; — third, by a congestion and dropsical swelling of the same tissues, accompanied by want of tone in the ocular muscles, to which Mr. Cooper ascribes it; — fourth, by an in- crease of the fat which forms the padding of the globe, which Dr. Ileusinger has found in two post-mortem examinations. These different views are described and enlarged upon in the "Edinburgh Medical and Surgical Journal" for 1854, page 426, where you will find full references to the literature of the subject. The first explanation certainly can apply only to exceptional cases. In three at present under my care no enlargement of the prominent organ can be detected; nor in two patients I saw cursorily several years ago, do I remember to have observed it. Indeed, in the girl whose history I have just related, the globes are both rather small for one of her height and size. I can hardly imagine a tough, leathery sac, like the eyeball, swelling without a local disease of its coats, such as cancerous degenera- tion for example ; and that would produce a disease of quite another class, and not to be confounded with the subject of this lecture. " Hypertrophy " of the tissues at the base of the orbit, suggested by Dr. Basedow, would imply a persistent and ir- remediable condition ; whereas I am sure that the eyes are at some times more prominent than at others, and that consider- able improvement may take place. My own impression is that the slighter and incipient cases may be quite accounted for by relaxation of the muscles, and that would soon be increased by a consequent filling up of the tissue by fluid and congested vessels. I incline therefore to the 370 PROMINENCE OF EYEBALLS. opinion given hj Messrs. Cooper and Dalrjmple, who attribute the disease to this cause. At the same time it must be observed that Dr. Heusinger supports his opinion as to its dependence on an increase of fat in the post-ocukir space by two post-mortem examinations, in which he found that condition of things. And I do not see any inconsistency in supposing that while the lighter cases are ex- plicable in the way I have first advocated, the fatal and more protracted should exhibit a more permanent morbid change. The deposit of fat in the tissue is quite analogous to what takes place in parts which have been stretched or temporarily enlarged, sueh as in the mammse or abdominal parietes after frequent pregnancies, in old hernial sacs, in the scrotum after long con- tinued varicosity of the veins, in the ear and lips after they have been unnaturally stretched in accordance with savage ideas of ornament. I mentioned having two other cases now under my care. As it is rather a rare disease, I shall take the liberty of breaking my usual law for clinical lectures and of relating their histories, though I cannot enable you to verify them for yourselves, Mary B., a surgeon's daughter now aged thirty, first came to me in June last year. She had been for several years the un- remitting nurse of an invalid mother, and restricted from the enjoyments almost essential to the health of her age and sex. For three years the catamenia had been irregular, and some- times absent for several months at a time. Her face and lips were pale, and her skin fair and delicate, easily flushing with excitement. Six months previously she had a severe pain in the region of the heart, and her doctor told her it was "rheumatism of the heart," and she had also suffered from palpitations. About that time she began to perceive a prominence of the eyeballs, and this had gradually become so marked as to make her uncomfortable by the observations it excited among her acquaintance. Examination of the chest showed the lungs to be quite healthy. The action of the heart was sharp, and there was a short harsh PROMINENCE OF EYEBALLS. 371 scrape audible towards the end of the first sound at the level of the aortic valves. I ordered her to take an ounce of the following mixture twice a day : I^ Tincturse ferri sesquichloridi 5'j, Stryclinix liydrochlorath gr. J, Tincturse digitalis 5j, Mistui'se camphorse 5x, Fiat mistiira, cujus swnantur cochlearia ij maxima his die. I kept her in London a few weeks as a rest, and since then she has taken every two months a three weeks' course of the medicine. She sends me word that now with the improvement of her general health the eyes have become much less prominent, and that she is by no means remarkable in her appearance. The other case is that of a puny woman of about fifty, who says she has been always ailing all her life, but never quite ill. She is the subject of a goitre of the central part and right lateral lobe of the thyroid gland. There is also a good deal of palpi- tation of the heart, but I cannot satisfy myself of the existence of any decided mui'mur. She is a very timid nervous person, and has some sort of fits, probably of an hysterical nature. I gave her iodide of potassium, and applied iodine externally to the tumor of the throat. But after three weeks it was but little, if at all, reduced, and she felt sure that her general health was the worse for the treatment. So then I gave her iron in full doses, and she seemed stronger again. She was at this con- juncture much thrown back by the alarm occasioned by a fire in her house. Her eyes are no better, but she is an unsatisfactory patient, and I question whether she perseveres in her medicine. Another case came under my care in the hospital during the first week of 1859 :* Charlotte B., aged thirty-nine, a dressmaker, had been in poor health for more than three years, and had always been a •weakly creature^ of pale leucophlegmatic aspect. At the period named a swelling about as big as an egg came in the front of the * See Case Book XIX, p. 95. 372 PROMINENCE OF EYEBALLS. throat. It was hard and had increased in size gradually to that of nearly three eggs at the time of admission. Latterly there had been strong pulsation in it, and it had caused occasional dyspnoea, for which leeches had been applied a week previously, with temporary relief. She was hysterical and had a nervous cough of a spasmodic, noisy character. Both eyes were ex- cessively prominent, and this prominence she said had first been observed a year before, and had increased up to admission. I cannot tell you much more about this case, as I was just then obliged to go abroad, but she is shown by the register to have left the hospital at Lady-day, and has not been again ad- mitted. She has attended from time to time, however, as an out-patient, and finds the occasional course of steel she gets beneficial, or she would not come for more. I have seen her about in the neighborhood, and her eyes seem no worse. All these cases, and indeed all the cases recorded by various authors, so ably collected by Dr. Begbie,* however much they may diifer in minor details, agree in connecting the disease with ansemia, and especially with those tendencies in ansemia to dis- order the heart and the growth of the thyroid gland. Experi- ence seems to refer the goitre, the weakened heart, and the pro- trusion of the eyeballs, to the same motive causes. They may not be connected with one another, but they are all connected with ansemia. Although, therefore, the direct mechanism by which the eye- ball is pushed outwards may be obscure, it seems to me that we know enough about the ailment to be quite satisfied as to the right treatment, the most important point for both the patient and ourselves. Courses of steel and restorative diet, rest of body and ease of mind, are the most effectual means of recovery, and seem to have been adopted by all those who have mentioned their treatment in the histories they put on record. In addition to this I should direct the patient to gently press back the eyeballs, and to wear a bandage over them at night. We know enough about the ailment also not to be alarmed at * Begbie's "Contributions to Practical Meditine," 1862. PROMINENCE OF EYEBALLS. 373 it, and to assure our clients that it is not of a nature in itself fatal to either life or sight. {Clinical, St. Marys, May 30, 1863.) Elizabeth M., aged sixteen, about whom I have been lecturing as having pneumonia and typh-fever, is worth observation also on account of the singular expression given to her face by eye- prominence. It seems she has always been a delicate child, and she has had several acute illnesses of which the last was rheu- matic fever, accompanied by pain in the heart, two years ago. There are clear signs of regurgitation through the mitral valve now heard by auscultation, but no other evidence of cardiac disease. She is now flushed with the fever and pneumonia, but- is generally pale, and is thin and weak looking. Though she is of full age, yet her mother says she has not yet been monthly, and her bust is quite child-like. This unnaturally protracted childhood is a frequent accom- paniment of valvular disease of the heart ; so common is the association, that it has not rarely been the very phenomenon which has drawn my attention to the heart ; and led to my finding out cardiac lesions before unguessed at. It continues often till after twenty years of age. I take the explanation of the facts to be, that from obstruction or regurgitation in the central organ blood enough is not spread over the body to carry out the func- tional development fitted to the time of life. Here you see a striking instance of it. In marked contrast to the undeveloped mammae is the throat of this girl. It has the full round form, swelling out in the mid- dle and sides, characteristic of plump and perfect womanhood. On examination by the hand this is found due to a soft enlarge- ment of the thyroid gland — an enlargement which I told you in my last lecture on this point is very commonly associated with the eye-prominence of which our patient is the subject. Like the last instance Ave had of this disfigurement it is stated to be worst when the patient is ill, and indeed it has become 374 PROMINENCE OF EYEBALLS. more remarkable since she has been in the hospital ; as has also the goitrous swelling, which at first was scarcely perceptible. I mentioned to you before the same thing as occurring in the case of a surgeon's daughter, whose eye-prominence is aggravated by severe dancing, long walks, and the like. Couple with this the fact that it entirely disappears after death, the eyes receding completely into their sockets, and I think you have evidence enough that however long and obstinate it is still a temporary curable disease ; and moreover, what is of more consequence, evidence enough to lead you to the means of cure, namely, those remedies which cure ansemia. This swelling of the thyroid is of a sort which will be more benefitted by iron than by iodine. LECTURE XXIX. ATROPHY OF MUSCLES. Part I. — Cases — Pathology — Treatment — Questions respecting hypertrophy. Part II. — Case of dropped hand from tJie poison of lead — Patho- logy of this form of paralysis and its connection with colic — Reasons for not considering its localization as dependent on the immediate absorption of lead — Treatment with iodide of potas- sium, sulphur baths, splints, electricity, quinine, oil, and blis- ters — which beneficial, which hurtful. (Part l.—ainical, St. Marys, June 13, 1863.) Nathaniel B., is a thin ascetic-looking man, of a faded-leaf complexion, aged forty-five. His expression recalls some stern " Bind-tlieir-kings-in-chains " of the Great Rebellion, or those faces one sees in old Spanish monasteries, not in the flesh, but looking out of the grim canvas of a Zurbaran or a Ribrera. Nathaniel B. is a top-sawer by trade, and Avas ahvays a hearty fellow, able to do a good day's work, till ten months ago ; when after violent exertion in turning over a mass of timber, he got what he calls "a wrench" in the pit of the stomach, and "has never been the same man since." The appetite failed and there- with the strength; the muscles wasted, and the whole body grew emaciated. The loss of appetite then became entire, and then in- creased to an utter loathing of food. He went into Guy's Hos- pital three months ago, but left apparently dissatisfied and ungrateful. On gaining admission to St. Mary's, May 22, he seemed much cast down, expecting never to get any better. He was able to walk about, and the chief loss of power seemed in the shoulder-muscles, the deltoid and biceps ; and when he tries to 376 ATROPHY OF MUSCLES. "put np" the latter, tliat is to throw into it the contractile ner- vous force, it feels quite soft, without any of the corky elasticity which distinguishes a sawer's arm. He is the father of thir- teen children, but since the commencement of his present illness, he has entirely lost virile power. He states himself to be a per- fectly sober moderate man, and has a good character on that ■score from his employer. It is scarcely necessary to say that the epigastrium and hepatic region were carefully examined for evidences of cancerous de- generation, and none was found. The lungs also were well aus- cultated, and nothing abnormal was detected, beyond a suspicion of slight comparative dullness in the right apex. He had not suffered from habitual cough or had any diarrhoea. He was at first kept in bed and given milk and beef-tea every two hours, with ten grains of Boudault's pepsine powders three times daily. In a few days his excessive nausea and lowness of spirits had abated, and he was ordered six grains of quinine and three drachms of cod-liver oil daily in addition. In a few days more he was tried Avith half a mutton chop, digested it well, and on the sixth of June was able to take our whole ordinary diet, a pint of milk, and a pint of beef-tea, and a pint of porter. On the 12th (yesterday) he was so much better, that I thought it was scarcely justifiable to let him occupy a place in the hospital any longer, and I trust he will be able to get on as an out-patient. As he was confined to his bed at first, it was not convenient to put him in the scales, but on May the 24th we found his weight 8 stone 5| pounds ; on the 30th, 8 stone 7| pounds ; on June 6, 8 stone 10 pounds ; on June 12, 8 stone lOJ pounds ; his height being 5 feet 6 inches. The only day on which he did not take the pepsine was May 29, when the stock was accidentally exhausted. He then com- plained of pain at the epigastrium and attributed that to the omission of the pepsine. This is a specimen of disease not quite so common as those I usually make the subject of my clinical lectures, and on that score not quite so interesting or important. Nevertheless it has this importance, that if you do not understand its true nature, ATROPHY OF MUSCLES. 377 you will be very apt to treat badly the patients afflicted, and to make them worse. I have often told you that neglect of the powers our Creator has dowered us with is punished by their withdrawal ; the intel- lectual sluggard becomes year by year more and more wanting in memory and judgment ; the arm of the Hindoo fakecr, tied upwards for a few months, withers away ; and the calf of the Chinese belle or of the stiff- booted clodhopper is flabby and wasted. It is very important that you should know that the same penalty which is thus inflicted on willful underwork, is also exacted sometimes from overwork, voluntary or involuntary. If a muscle is used so as to be worn out to a degree beyond that which the supply of nutriment is able to repair, or if it is so continuously used that there is no time for repair, it becomes de- generated, just in the same way as if it had not been used at all. And I am not sure but what incautious intellectual work pro- duces analogous results. How many men do we meet burdened, like little David would have been in Saul's armor, with more knowledge than they can wield ! Their minds seem day by day weakened by the stores they cannot use, so that they become less and less able to apply them. To how many of our profes- sion does the increase of practice bring the diminished, rather than the increased results of experience, if they do not stern^ and conscientiously reserve to themselves time for "the sessions of sweet silent thought." But I will confine iny observations now to degeneration of the body, not of the mind. We had in the Cambridge ward two months ago a blacksmith's apprentice, of slight frame and with an imperfect aortic valve, whose arms, especially the right, had become atrophied from wielding too heavy a hammer. A few years ago I had in the same ward a patient whose chief employment was turning over large rolls of lead ; and the exten- sors of his right forearm had become paralyzed. About the same time a hard-drinking and hard-smoking, but hard-working, cobbler was under my care, who was unable to raise the arms from atrophy of the triceps and deltoids, muscles absolutely needed in giving the artistic jerk to the thread which 378 ATROPHY OF MUSCLES. these ivorkmen affect. But his legs, which he had rested, were strong enough. The following cases, exhibiting the same agencies in action under different circumstances, are from my private note-book. E. C, aged fifty, had always been used to the regular habits proper for a London lawyer's wife, and not being fond of needle- work, had generally amused her leisure with reading. At that time her eyes somewhat failed, and she was advised not to read so much, especially in the evening. As an employment she sek herself the task of netting., first some strong- nets, and then a set of drawing-room curtains. She worked several hours a day, fastening the work to her foot secundum artem, and drawing the thread upwards. After a time she felt a weakness in the right shoulder, then a pain and stiffness ; being a very deter- mined kind of person she tried to work it off, rubbed and dowsed and shampooed her arm ; but the more she did so, the worse it got, and she was alarmed at last by the joint becoming exqui- sitely painful to the touch. Then her arm was put in a sling and tied up, she took steel and wine and nutritious diet and quite recovered. M., aged fifty-four, has lived an active literary life, writing much and well. Her vigor of constitution is shown by the menses only lately beginning to grow scanty and irregular. But she has a theory of corporeal discipline not reconcilable with rational physiology; she has thought to compensate for the ex- haustion of mental labor by violent bodily exertion, and has been in the habit of occupying her leisure by furiously digging her garden with a masculine s])ade, and mowing her lawns, not with one of the elegant new machines, but an old-fashioned scythe. The consequence is that her good right hand has lost its cunning, and a letter she sent to seek my advice was scrawled with the left. The principal atrophy is in the deltoid and biceps muscles (those used in mowing), which are painful when moved, but not when pressed. She cannot raise her arm by independent efforts above the level of her waist, and it "feels out of joint if she tries to force it." Friction, brandy and salt, mustard, &c., have only made her worse. Her arm is now by my advice tied ATROPHY OF MUSCLES. 379 up, and she is taking quinine and steel and cod-liver oil in small doses. You may easily recognize in all these cases the same evil in action under corresponding circumstances — atrophy produced by local overwork of voluntary muscle. And if you think, and examine closely the relations of the muscle to the rest of the organism, you will see that this overworked tissue, is in a position not very different from the underworked tissue, whose degeneration is so generally made the subject of remark by physiologists. The defect is in both instances a want of renewal. In underwork no demand is made for a renewal, and in over- work the demand is made, but is not eflBciently supplied. In the one the nerve-force, which should guide and govern the metamorphosis, is let lie asleep, and in the other has been so used up by unwonted toil, that it is exhausted, and for a time does not exist. So that the last effect on the muscular fiber is the same. No new store of muscular substance is laid in, and the whole degenerates into inelastic fiber, and finally into a pale fatty tissue of still lower vitality. What is called "over-training" in the prize ring has a similar pathology. The power of nerve over muscular fiber is capable of increase by education, so that it continues to brace it up more and more ; and to make the muscles harder and harder daily, till the ^'- gladiatoria totius corporis firmitas'' is attained, probably in as great perfection in our days as in Cicero's. But the muscular fibers themselves are not capable of proportionate augmentation, and when the nerves have learned to exercise them up to their full force, are incapable of further improvement. If then the training is continued, the nerve-force expends itself in exciting the continuous functioning of the muscles, destruc- tive assimilation exceeds the constructive; the body "eats into itself for lack of something else to hew and hack," and loses weight beyond the mere loss of fat.* Nerve-force is capable, as * A moderate allowance of alcohol during training, by acting as an an;esthetic to the nervous system, tends to prevent this result. Modern trainers are apt to enforce too great abstinence, with immediate selfish advantage probably, but to the final injury of their pupils. 330 ATROPHY OF MUSCLES. far as we know, of indefinite improvement ; but the instrument it plays upon cannot be made stronger than it was originally intended to be, and Avhen it is overstrained it degenerates. Hence premature decay is not rare among pugilists, boat-racers, runners, &c., whose ambition is greater than their powers, and those who live by extraordinary exertions of physical strength have a short average of life. The pathology is the same of that impotence of the generative and muscular functions which sometimes follows an active life in a tropical climate, and which cuts short the useful career of many of our countrymen in the East, and which is often unjustly attributed to lechery and drunkenness. But the most common examples of the disease are where it occurs in one set of muscles from special and partial over use, such as we see in turners, carvers of ivory and hard woods, and similar handicraftsmen. Muscles affected with atrophy are in an unnaturally soft and friable condition ; they are pale colored, and look as if they had been macerated in warm water. They become like the muscles of a very aged person, and in fact the change is not much differ- ent from a premature local old age. The change is usually first discovered by the patient in a much more sudden manner than you would have expected from its pa- thology. The ''wrench" which our sawer felt in his waist was not the real beginning of his ailment, but the last straw which broke the horse's back. And often painters will tell you that they went on earning full wages till a certain day, when they became utterly unable to raise their hand. Pain is a variable symptom. When one or a few muscles only are affected, it is a pretty constant accompaniment, and is usually set down as rheumatism, or as stiffness, the result of cold. In our present patient, where many muscles were more or less acted upon, it was absent, or so generally diffused as to produce rather a feeling of mental depression and malaise than of local distress. Muscular atrophy and local paralysis will sometimes follow chronic poisoning by malaria. I have a strong impression that ATROPHY OF MUSCLES. 381 those are riglit who locate in the nerves the chief injury inflicted by such agencies as cause ague and its allied disorders of inter- mittent type. I am not therefore surprised at finding loss of nervous function, either in the form of neuralgia or paralysis, which can be attributed only to the poison above named. The only thing which distinguishes the paralysis from the other forms of aguish disorder, and consequently obscures the diagnosis, is that it is not intermittent. The treatment follows as a matter of course from the pathology. It consists, in the first place, in enforcing complete rest on the diseased parts, in not allowing them to have even the labor of supporting the members they belong to. The dropped hand we fasten on a splint; the paralyzed humerus we put in a sling, taking care that the elbow is well supported and does not drag upon the shoulder ; this patient, who is the text of my lecture, we put to bed and kept him there a few days. Then we admin- istered animal food in a form by which the patient takes as much as the stomach can possibly digest. In this instance there was utter anorexia; so beef-tea and milk were swallowed in medicinal form every two hours. To aid in digesting it pepsine was ordered three times a day. To supply a basis for molecular growth, cod- liver oil was given, as soon as the nausea was beginning to abate. And quinine was added to brace the mucous membrane up to its duty of absorption. I have not prescribed iron, but it would be quite rational to do so now that the intestines have begun to re- cover tone. Where the pains are severe, cold douche baths and cold water compresses give more relief than anything else. Warmth and stimulating embrocations seem to do harm. Where malaria has been to blame, you must be careful in de- siring your patients to avoid the dew-times — "when the mists arise that have strength to kill." A Roman proverb warns the native against the hour before and the hour after both sunset and sunrise, and many a stranger has suffered in that climate from a neglect of popular experience. In England the healthy population is not debarred from the sweet influences of these romantic hours, but those who have once suffered from malaria 25 382 ATROPHY OF MUSCLES. must remember that they are more than ordinarily liable to a fresh reception of the poison. You may be tempted to inquire, if over-use of voluntary muscle causes atrophy, and under-use also, while moderate use leaves our frames well-proportioned, what sort of use it is which induces hypertrophy ? I confess that in spite of the decies rejjetita state- ments of physiologists, Avho have been copying one another from the time of Galen, I do not know that any kind of use at all does so, in the sense of making the substance of the muscle larger when measured in a state of rest. Doubtless an actively em- ployed biceps or gastrocnemius will more readily be acted upon by the voluntary nerves, will contract more strongly, and be harder and more prominent when contracted; but I cannot find that it grows at all bigger. I do not absolutely deny the exist- ence of the physiological hypertrophy of muscle ; I only say that at all events it is very rare, for I cannot find any instance of it. The most notable example of muscular hypertrophy ought to be an active, well-made, one-legged or lame man; seeing he uses one leg instead of two, it ought surely to be enlarged. Yet in measurino; in several instances the remainino- \cs in a state of rest, 1 cannot find that the proportion which it bears to the arms is at all diiferent from the proportion in ordinary persons of the same build. And I cannot find that as a rule blacksmiths' arms are out of proportion to their legs. Both are muscular, for none but a muscular man can work at such a trade, and when excited, the brachial muscles contract firmer than those of the lower ex- tremity, and are more marked; but they are not disproportion- ately large when relaxed. Of course you will find employed in occupations where excel- lence may be attained by the special exercise of one set of mus- cles, men who have those parts well developed; but they are so developed originally, and not by the trade. Big-armed men become pugilists, big-legged men acrobats; but they do not become big-armed or big-legged because they are pugilists and acrobats. Sometimes the development is strangely out of accord with the occupation; the wrong man gets into the wrong place. I ATROPHY OF MUSCLES. 383 give you the measurements of the upper extremities of Cordon- nier, an horticulturist at Lisle, who has a most extraordinary development of the muscular and bony structure. He is not fat, but hard and firm, weighing in his clothes but sixteen stone, yet the circumference of the neck .... is 18 inches. of the breast .... is 44J inches. of the forearm . . . is 13 inches. of the wrist .... is 8J inches. of the palm of hand . is 11^ inches. How were these Herculean thews bred ? In strangling dragons, stunning wild bulls, cleansing Augean stables ? Did their owner — "Tear the lion as the lion tears the kid, Run on embattled armies clad in iron, And weaponless himself Make arms ridiculous?'' No — they are employed in tying up ladies' bouquets, for his skill in which accomplishment Cordonnier is famed. I have never heard of an hypertrophy like that being due to over-use. Where the hypertrophy exists in voluntary muscles, I suspect it is due to a cogenital peculiarity, and not to occupation. (Part II.— Clinical, St. 3Iarys, October 31, 1863.) In Benjamin Franklin you have an example of a disease you will very often have to treat, if your practice lies among artisans, the "dropped hand" of painters and glaziers. He has been employed in the carriage building department of the Great Western Railway, and is an old-looking man, though only forty- five. He has been a spirit drinker, but never gets actually drunk. He has had gout ofi" and on for the last ten winters, and used to take a great deal of colchicum. He found however that vegetable to produce symptoms resembling those of delirium tremens, and has given up the use of it in favor of iodide of po- tassium, which agrees with him well.* On September 28 he * His plan is this — when the gout comes on, he buys four pennyworth, or a drachm, of iodide of potassium, dissolves it in a pint of water, and takes it in the twenty-four hours. 384 ATROPHY OF MUSCLES. gave us the following history. He had heen first taken ill three Aveeks previously with crampy pains in the belly, •which got worse in spite of castor-oil, till the 28th. About the same time his hands began to droop, and when we took him in hand, at that date, he could not raise them on the wrist at all. There were also severe pains in the calves and thighs. The gums had a livid line, characteristic of saturnine poisoning, to the breadth of an eighth of an inch round the teeth, and the description he gives of his employment shows that he is much exposed to the influence of white lead. Besides using white lead to form what is technically called the "body" of the color laid on, he has also employed mercurial colors in the fine work required. And this addition of mercurial to saturnine poisoning, or perhaps his bad habit of spirit-drinking, caused a little peculiarity in the case, which was observed on his first admission: his arms were noticed to tremble when he held them out, as if afilicted with paralysis agitans. This peculiarity soon passed away, and there is nothing else to take the case out of the category of typical and ordinary instances of disease, such as I endeavor to select for my clinical illustrations. I am disposed to explain a great part of the pathology of painter's dropped hand on the same principle which I stated to you on a former occasion apropos of simple muscular atrophy. The white lead is slowly absorbed by its gradual and sparing solution in the fluids of the body, which are rendered capable of dissolving it by their saturation with carbonic acid. In the blood it destroys the red globules, and carried to the muscles, removes their red color also, and renders them incapable of contracting except under extraordinary nervous influence. This paralyzing effect is most commonly shown on the involuntary fibers of the intestines, producing the well-known painter's colic. There are two reasons why it should be exhibited soonest on these intesti- nal fibers; first, they are the nearest to the usual portal by which the poison enters the path of the food ; secondly, they are weak muscles, and yet have constant, almost unintermitting work to do so, so that they can have but little repose during which recovery from exhaustion might be possible. Hence colic and ATROPHY OF MUSCLES. 385 constipation from arrested vitality in the intestines is the com- monest result of lead poisoning. The same principles apply to the muscles of voluntary motion in the trunk and limbs, and most especially in the latter. Those muscles become most paralytic which are most exhausted by the peculiar employment of the individual. I had a patient a few years ago whose work lay in a sheet-lead warehouse, and con- sisted of moving very heavy masses of that weighty metal. He became gradually paralytic in the right forearm, and weak in the loins, parts extraordinarily exhausted by his labor. Painters, especially fine painters, such as those employed upon carriages, do not use the biceps, or the shoulder, or the dorsal muscles more than other people ; but they do use excessively the extensors of the hand. Try for yourselves the drawing of fine lines on a wall with the arm free, and you will find how painfully tired the out- side of the forearm soon gets. Artists usually rest the wrist on a mahlstick, with the result of saving these muscles, and artists seldom get paralysis. But for some reason or other artisans generally adopt another plan of gaining the requisite fulcrum for steadying the line ; they fix the hand by means of the fourth and little finger on the plain surface, calling the support thus obtained their " compass," and then wield the brush with the thumb and forefinger. This throws a terrible strain on the ex- tensors of the wrist, and they suffer accordingly. The over exhausted fibers become atrophied, pale, and paralytic ; while other muscles escape, although equally exposed to the baneful influence of the lead, but not so much used. I am not certain whether the neighborhood to the paint has much to do with the hand becoming paralytic. At first sight one would be disposed to think it had. But then on reflection you will observe that other muscles which are equally near, such as the flexors, do not become aftected ; and others which are still nearer also escape. A dropped hand can often twiddle its fingers with their interossei and lumbricales, bend in its tluimb with its adductor pollicis, and even exhibit the delicate action of the palmaris brevis. Now, the fibers of these muscles have but a layer of skin and dirt between them and the paint during the 386 ATROPHY OF MUSCLES. whole of working hours, whereas the forearm is scarcely even directly exposed to it ; for it is very unusual to see fine painters tuck up their shirt sleeves, and the majority even work in their fustian jackets ; yet it is the forearm that becomes affected, and not the more directly exposed muscles. A very similar kind of palsy is apt sometimes to effect clerks and others engaged in writing, who wield their pens in a stiff way without properly resting their elbows ; it may be called paralysis scriptorum. The man who is the text of the present lecture, was treated with iodide of potassium, to bring the lead remaining in him into a soluble form capable of being removed by the fluid excre- tions. He had also hydro-sulphurous baths thrice a week to test the progress of this removal of the poison. For ten days the secretion of his skin in the delicate places (such as the axilla) was stained blackish with each bath from the sulphuret of lead formed. But after ten days the stain was no longer visible ; and at the same time the livid line round the gums began to vanish. He was losing his lead — the cause of the disease was being removed. Yet though the cause was being removed, the disease remained, and indeed still remains to a considerable extent. The treat- ment applied to it has been first — Rest ; the hands are placed on splints for the greater part of the day and night, so that their weight may not drag upon the muscles. Secondly — Intermittent motion ; electric shocks are passed through the muscles for a short time daily. Thus the atrophy of over-exertion and the atrophy of disease are both guarded against by imitating the most healthy natural circumstances of rest and motion. He is also taking quinine and cod-liver oil, to furnish a basis of molecular growth for renewed muscvilar fiber ; and Avith this he has decidedly improved in general health, and is able to raise the wrists much better. While I tell you what has benefited him, I should also call your attention to one thing which in both his own and my opinion has done harm. As an experiment I treated the fore- arms for three days with small flying blisters, never allowing ATROPHY OF MUSCLES. 387 them actually to produce vesication, but to be moved onwards when the skin became reddened. The paralysis was certainly worse during this application, and for several days afterwards ; so of course I shall not repeat it. What I have previously described in this lecture to you constitutes the ordinary and typical treatment of dropped hand ; and, though I mention it as part of the established medication in my systematic lectures, I have always felt doubtful in what sort of cases blistering is bene- ficial, if any ; for I have never been able in my own experience to assign any good influence to it independent of other treatment. LECTURE XXX. CHOREA. Part I. — Case treated without medicine — This case a recent one — Principle of treatment. Part II. — Four long-continued hut curable cases treated with arsenic — Quoted as specimens of the disease as usually seen — Effect of forcible control over the movements. Part III. — Records of three fatal cases and two unaffected by treatment — Connection of chorea and rheumatism and dis- ease of heart statistically deduced from the records of thirty- three cases. (Part I. — Clinical, St. Marys, February 20, 1863.) A LAD of nine years old, Henry G., was taken in on the 19th of last month for chorea. His parents stated that the attack had come on suddenly a week previously without any assignable cause, and while he was sitting at dinner. It began by convul- sive movements of the arms and facial muscles, and very soon the whole body became affected. As he lay in bed I think I never saw more violent and uncontrollable motions of the limbs and body. He was never still, but speaking to him or touching the bed excited convulsions in the same electric manner as in hydrophobia, and judging by his wailing they seemed to be very painful. He was unable to retain his foeces or his urine. He was stated to have been subject to worms, as is the case with half the children of our laboring classes ; so I gave him once and again a stout jalap, aloes, and calomel purge to ascertain the fact; but no worms or mucus appeared, nor had there been any col- lection of old foeces in the colon. Beyond that he has had no medicine, except on one occasion a little catechu to solidify the CHOREA, 389 stools, which were passed involuntary, and prevent them dirty- ing the sheets so much. Yet you have seen the disease pass away entirely, so that on the llth instant the case-book records that he carried the inkstand steadily round the ward for us, handing it with one hand, and he has been making himself use- ful to the ward-sister by serving out patient's dinners. I have kept him in the hospital till to-day, solely to see if any relapse would occur. I said he had no medicine, but I did not say he had no treat- ment. He was surrounded as he lay in bed with toys, and he was induced to make every eiFort to retain them in his hands. In two days he began to get quieter, but not much more advance was made, till his regaining some power over the sphincters enabled us to have him dressed and to set him to walk in measured step about the ward. Then we imperilled our crock- ery in a good cause by letting him carry it about and clean it, till he rapidly acquired the steadiness you saw him exhibit a week ago. The object aimed at was to draw off his attention from his miserable state, to concentrate the mental forces in the endeavor to acquire power over voluntary muscle, and thus to renew their lost control. This is obviously not a disease which must necessarily go on from bad to worse if unarrested by art. The long list of varied remedial agents employed, many of them repugnant to one another, is enough to make us suspect this. Dr. Reeves, in his statistics of eighty-four cases occurring in the Norwich hospital, states that the shortest duration of the disease under pharma- ceutical treatment was two weeks ; the longest eight months ; and the common average seven weeks.* I suspect, though I have no statistics to show it, that the common average of dura- tion of recent cases where no medicines are taken, would be very similar. The pathology, or explanation of the immediate internal cause of chorea, is quite unknown. Sydenham ascribes it to a "hu- mor thrown upon the nerves." Yet in three fatal cases I have * "Edinburgh Med. and Surgical Journal," vol. viii, p. 314. 390 CHOREA. found the nervous system perfectly healthy, in a fourth there were tubercles in the spinal cord. Dr. Cullen thought that the malady depended on "a state of mobility" of the system ; that is to say, that the limbs move about too much because they are too movable. Dr. Marshall Hall attributed it to " reflex action ;" but talking of "reflex action" is merely to class the phenomena of convulsions under a common name, for nobody has yet dis- sected out the "reflex" nerves. So I do not think the learned have contributed much to our knowledge of the subject. You may observe that in chorea the principal muscle in any intended motion is pretty fairly obedient to the will ; this lad, when he was bidden to put out his arm, put it out ; but those muscles whose motions are normally associated with the princi- pal one, did not act ; he did not put it out straight, and twisted it in every direction but the correct one. Hence Darwin shrewdly classes it among " diseases (defects) of association," that is to say, cases where the necessary connection between certain vital acts is overthrown. The existing or external causes are sometimes easier to dis- cover. You have cases where the patient is anaemic, is teething, has mucous intestines and disordered alvine secretions impeding digestion, skin eruptions, retarded catamenia, pregnancy, dis- eased bladder or uterus, perineal fistulse, tubercles in spinal cord. (In these three latter cases I am recalling to my mind examples of fatal termination.) Many other patients again at- tribute the disease to fright. In such instances you find that the disease obstinately remains till the exciting cause is removed, and then begins gradually to decline. Under such circumstances the plan of treatment is obvious enough ; you must turn your efforts to the exciting cause, if it is removable, and then expect with confidence that the chorea will disappear in about a fort- night. If the exciting cause is permanent, or if (as is the case of pregnancy) it is too valuable to be got rid of, I cannot find that the specifics do any good. But in a very large number of cases you can discover no ex- citing cause. Perhaps it has passed away ; perhaps even if you had watched the patient all along, you would not have discovered CHOREA. 391 it on account of its secret nature. In such cases I have usually been in the habit of administering arsenic ; but really I cannot say that any patients under arsenic have ever passed from a severe state to one of complete voluntary control more quickly than this boy without arsenic. You may say truly that chorea exhibits sometimes a tendency to become chronic in cases where the general health only has been attended to. But I do not think that proves anything against my idea of its nature being to get well of its own accord. I believe that in these protracted cases there is a continual renewal of the cause of the disease ; that it is in fact kept up by injudicious management. One of the most common forms of injudicious management is the fixing of the patient's attention upon the deficiency of voluntary control. They are told, and wondering bystanders are told, often with exaggeration, how bad they are ; the malady is painted in heightened colors ; pitying friends off"er unnecessary help ; cruel companions ridicule their infirmities ; till, like the subjects of electro-biology, or mesmer- ism, they lose control more and more from being told that it is lost. You may see this mental cause of the aggravation of the disease most clearly shown if two or three patients chance to be put together in the same ward. It is impossible to avoid it sometimes, but you will observe that they always make one another worse, especially if females. If one is getting better, she will be immediately thrown back again by the introduction of a new companion similarly affected ; and not rarely a patient previously free will catch it by the contagion of the eyes. The influence for you to exercise for the cure is the very reverse of that which makes the disease worse ; you must en- courage the patients to make every exertion to direct the move- ments of the limbs and let them perceive as little as possible their deficiencies in this respect. Above all, let them avoid looking-glasses or the depressing sight of other unfortunates in the same condition. Poor persons are best treated as in-pa- tients of a hospital, for the advantage of getting them away from their injudicious friends outweighs the risk of possibly coming in contact v.ith other choreics. If the patients are not 392 CHOREA. in a position of life to make this resource available, at all events get them away from home as soon as possible. Sent under the care of a judicious governess to the seaside, or anywhere else for an excuse, many children recover rapidly who at home would have gone on relapsing and relapsing again every week. Slow walking in timed step is excellent practice for regaining directing power, and I dare say slow music and solemn minuets would be equally efficacious; you may remember that the Taran- tella was so called from beino- used to relieve a nervous affection falsely attributed to a poisonous spider ;* carrying trays and crockery, and other things that demand care, assists the cure. In short, using the will contributes more than anything else to its renewal, and is the only real "specific" for chorea, when once the original exciting cause has been removed. (Part IL— Clinical, St. Marys, May 30, 1863.) Maria S., aged thirteen, was received May 1, with very severe chorea of six weeks' duration. No cause could be assigned by her mother, nor could any worms be found in the fieces, but from her dirty and neglected appearance and the unnatural smell and color of the alvine excretion, I have no doubt she has been fed on diet very unsuitable to a growing girl. The muscu- lar movements were so excessive as entirely to prevent her speaking intelligibly, but she was quite quiet when asleep. She is a thin but healthy looking child, and the only abnormal phe- nomenon is the fetidity of the stools. She was kept for six days without medicine in order to observe the case, and no im- provement was found from the better food and discipline of the hospital. She was then put upon four minims thrice a day of liquor potassse arsenitis, and immediately began to get better. * la Kircher's specimens of Tarantella tunes the first are merry jigs, but the last is like a funeral march, and must have been composed, as one would guess, for some church dignitary affected with the curious contagious chorea of the fifteenth century. See Hecker's " Epidemics of the Middle Ages." — Dancing Mania, p. 172. CHOREA. 393 On the 9th she could walk up and down the ward and feed her- self, and is now able to assist in washing up the crockerj, and will leave the hospital shortly. Along with the last patient I also took in Richard B., aged nineteen, a chairmaker. Three months previously he had been obliged to walk home four miles in the dark, of which he had from childhood been much afraid. He was overwhelmed with fright, but concealed his fears out of shame. After this he be- came very nervous, and chorea gradually supervened. The in- voluntary movements increased so much, that for six weeks he had been unable to work at his trade. He is very thin and pale, with blue cornea to his eyes. He was put upon misturse ferri .^j ter die, to which has been added since 5j of cod oil. And he has also now a shower-bath every morning. On the 9th he was steadier than on admission, but then the improvement be- came stationary, so that I resolved to treat him also with arsenic. The quantity has been gradually increased up to TT|xvi of the liquor potassse arsenitis three times a day, and he has been slowly but steadily improving. A third patient, Emma B., aged fifteen, has been under my care only eight days. The catamenia had occurred for the first time two months previously, and about the period when they ought to have been again present she was observed to get rest- less and fidgety. In a fortnight's time this restlessness became complete chorea, which was the prominent disease on admission. The movements were then almost entirely confined to the right side of the body. Two nights before admission she went ofi" into an hysterical fit, but this had not before been observed, nor has it since occurred. After she had been in hospital a few days we found that the chorea came on in paroxysms of about two hours' duration, during which it was very violent over the whole person. In the intervals she was comparatively quiet, and could speak easily, though not extend the right arm straight. I ordered at first valerian, which seemed to do no good, and now she is taking arsenic like the others. She has also in addition a warm hip-bath nightly. 394 CHOREA. These are interesting cases for you to watch, for they present examples of the disease when it has already assumed a chronic form, and when the mere fact of its existence makes it reproduce itself, if I may so express myself. I mean that the constant movement and annoyance still further Aveaken the already weakened and predisposed body, and so instead of tending to recovery naturally tend to a prjolongation of the malady. In this stage it will not get well without some strong measures in the way of medicine. You saw that the child, Maria S., got no better during the week that she was treated by diet and discipline alone ; so we must have recourse to the pharmacopoeia. One very powerful aid is iron, and a great many cases may be cured with that remedy, either in the form of the red rust or of Griffith's mixture. But you saw that iron was beneficial only during the first two or three days to the boy Richard B. And the disease may come on even while a patient is taking iron. It did so a few years ago in a boy in this hospital, for whom I had prescribed that mineral for tubercular consumption (No. in Register, 8626, November 13, 1857). Nevertheless he got well of it without any change in the treatment. Perhaps he caught it by imitation of some other patient in the Avard, but the clerk has made no note of the fact. If so, both the supervention of the malady and its cure are easiest explained. Valerian is sometimes useful in chorea which arises in girls about and soon after the time of puberty, when it is apt to assume a paroxysmal form. This paroxysmal form we observed in Emma B., but still the valerian did not cure her. In all forms, however, you have seen a very decided improve- ment under the use of arsenic. I should not have called upon you to notice this, had they been recent cases, or if they had been cases in Avhich a turn towards recovery had already been taken. Under such circum- stances you may easily deceive yourselves as to the action of medicines, which do not cause, but are merely given along with the cure. About arsenic, however, I do not think you can have any doubt, observing these and similar patients, that it really acts as a special tonic to the nervous system, — curing the chorea CHOREA. 395 irrespectively of the cause whence it has originated. As arsenic is not a normal constituent of any part of the body, and cannot be imagined to replace any normal constituent; while at the same time patients increase in strength and weight during the course of taking it, I suppose it must be an indirect constructive, acting powerfully on the nervous system. (^Clinical, St. Marys., June 13, 1863.) Of the three patients about whom I lectured a fortnight ago Maria S. has gone home Avell, Emma B. is at work washing up cups and saucers, and Richard B. has improved as to his arms and legs, being able to walk straight and hold out an inkstand for me to write prescriptions. But his organs of speech have not improved at all. He stammers, and chews, and gnashes his teeth most painfully, whenever he struggles to talk. Impediments to articulation are usually the most difficult part of the malady to cure. Many who have had it only in childhood will stammer all their lives. So delicate are the muscular motions required for the rapid modifications of form which make the sounds of the different letters in speaking, and so decided and firm must they be for intelligible enunciation, that the slightest deficiency becomes immediately apparent. A muscular con- traction which might be well enough directed to guide the fingers in writing, may be very incompetent to shape tongue and lips in pronouncing. A tremor not noticed in the former is dis- agreeably prominent in the latter. The annoyance to the patient caused by this difficulty still further increases it, so that it reproduces itself and becomes chronic. More than that, the glottis is irregularly acted upon, and closed when it ought to be opened, so that speech, and sometimes the breath, is absolutely arrested. Nobody stammers in singing, when the glottis is kept open to form the musical tone. Stuttering and stammering; are in fact a local chorea. There is a deficiency of voluntary control over the muscles of speech. 396 CHOREA. In a recent case, such as this, very likely the arsenic will be of use, but I do not know whether it would be available where the defect has become habitual. The best way under that cir- cumstance is for the person to humble himself to the infant state, and be taught to speak all over again. He can get instruction from those ingenious tutors who teach the deaf and dumb, and systematically learn to shape slowly and deliberately his mouth into the form requisite for enunciating each letter separately. By practising this at his leisure and before a looking-glass he may gain great control over the articulating muscles. I shall in this case continue the arsenic, and not recede from the large dose (HX-'^vi of the liquor potassse arsenitis) unless there is perceived some poisonous action, such as sore throat, inflam- mation of the eyes, severe griping. I have also directed him to recite frequently in front of a mirror sundry choice scraps of literature relating to Peter Piper and his practices, which are popular practice in p's. \_JVote added July 3. This boy improved slowly, the arsenic having been increased up to lT[xviii of Fowler's solution three times a day. He went out cured and able to go to work to- day.] I have begun arsenic with another patient taken in yesterday, June 12, Ann W., whose case presents some analogy to the present condition of this boy, in that the disease is limited almost entirely to one part. The said Ann W., a fine tall girl of thirteen only, though she looks older, has been subject to occasional chorea since she was five years of age. Latterly she has had an attack annually, and last year two attacks. The jactitation is almost always confined, as now, to one arm ; with one exception to the left arm. But that once she had it in the right arm only, and last year in the left leg and left arm only. The catamenia have not yet been established. There is no abnormal murmur in the heart, and she has never been subject to rheumatism in any form. I have ordered her arsenic and shower baths. It will be interesting to watch this case and see whether the very local affection is benefited by arsenic as decidedly as the more general. CHOREA. 397 \_Note added July 3. The dose of liquor potassge arsenitis was gradually increased to TTLxiv. The patient was able to wash up crockery after she had been in hospital ten days, and was dis- charged cured this morning.] For three days I tried the experiment of controlling the spasmodic movement by fastening the affected arm against the side. The effect was to make it decidedly much worse. This observation is quite in accordance with the theory I hazarded in an earlier part of this lecture that the voluntary nervous force is deficient from want of use, and that the exercise of the direct- ing will is an important element in the cure. For that which is cured by the exercise of voluntary effort you would expect to be made worse by forcible involuntary control, and vice versd.~\ (Part III. — Continuation of the same lecture.) I must not let you suppose from the usually fortunate result of treatment, of which you are sure to see repeated examples, that a favorable prognosis can be always given as a matter of course in chorea. It is true that during the time in which you, my present class, have been pupils, there have been no deaths among my patients so affected, nor indeed any discharged as incurable. But in my case-books there are several of both sad sorts, and I will briefly extract them to damp any too cheerful ideas you might have acquired. John D,, (No. in Reg. 442) aged sixteen, was transferred to me from Mr. Coulson, February 13, 1852. He had been operated upon for stricture by the perineal section, and had accidentally been placed in a bed opposite to one occupied by a boy with St. Vitus' dance. He soon began to imitate the movements of his neighbor, and though removed to another ward he got worse and worse, and lost all control over his limbs. When trans- ferred he was found to have pericarditis, but the time of its supervention had not been noticed. He continued to get worse and worse, abrasions and sloughs and abscesses formed in various 26 398 CHOREA. external parts, and he died delirious Feb. 28. It is possible that the pericarditis and abscesses may have been due to pyaemia. Sophia G., (No. in Reg. 5003) aged eighteen, came to St, Mary's on June 15, 1855, Avith debility and pericarditis. The only illness she was aware of having had was chorea at four years old, which had not since recurred. Her pericarditis relapsed and got worse, and the chorea, so long absent, returned again. She died worn out on July 21. Hannah M., (No. in Reg. 746) a needlewoman aged twenty- three, was admitted November 1, 1861. Her sister told me she had been deserted by a lover the previous year, and had gradu- ally faded away ever since. Her skin had got brown and harsh, her body emaciated, and her mind sluggish. She became feverish, and a fortnight before admission exhibited the usual symptoms of chorea. On admission the jactitations were so bad that she could hardly be kept on the bed. No remedies were of any avail, she grew delirious, and then raving, and then com- atose, and died on the 9th. At the autopsy we found — (first), some old dry tubercles in the lungs and mesentery, dating probably from her first pining ; — (secondly), degenerated supra- renal capsules, connected, it may be jiresumed, with the bronze- tinted skin; — (thirdly), a scrofulous tumor as big as a filbert in the lumbar enlargement of the spinal cord, which probably was recent, and was the cause of the recent chorea. Two other cases were not fatal, but were not at all benefited by anything they received from the hospital. Sarah C, (No. in Reg. 24) aged twenty-three, married and full six months pregnant for the first time, was attacked on June 20, 1851, with acute rheumatism of left elbow and right foot, and at the same time her right arm became affected with chorea. She was free from pericarditis on her admission, June 27, but got it on the morrow. Her rheumatic and cardiac symptoms subsided, yet the chorea was as bad as ever when she went out on July 21. It continued till her child was born two months afterwards, and then was cured. Had this young woman been in any danger, it would have been worth while to have in- duced premature labor ; I have no doubt it would have stopped the chorea, but the remedy would have been worse than the disease. CHOREA. 399 Robert F., (No. in Reg. 804) aged eighteen, son of a medical man, was transferred here from a mad-house, Nov. 30, 1860. He had practiced masturbation from the age of seven, but does not appear to have suffered in his health till he was sixteen, when he became affected with chorea for six weeks. He then remained well till the end of 1859, when the disease Avas brought back again by the same filthy practice I have spoken of. It was of a peculiar description, coming on in paroxysms, princi- pally affecting the muscles of the neck, and twisting his head so far round sometimes as to cause him to tumble down, scream- ing and barking. He had been in a lunatic asylum, for which of course he was not a fit patient, and he had subcutaneous in- jections of morphia at St. George's hospital without benefit. Morphia was also tried here Avithout permanent benefit, and also cauterization of the urethra. He was discharged incurable after a month's trial of various expedients. So you see St. Vitus' dance is not always of so little moment as would appear from the bulk of cases, and perhaps from all the cases you may Avitness during your novitiate. You must not give an off-hand favorable prognosis, because you do not happen to have seen a bad result. I will also use the hospital records to point out to you a curious fact in the history of chorea, which happens to be illustrated by none of the four patients at present under your eyes, nor in truth by any admitted under my care this session. I mean the connection between it and acute rheumatism. Out of thirty- three cases which I have looked over in my old case-books, in the following six the nervous affection either began during rheu- matic fever, or followed immediately after it before convalescence was complete, or else rheumatic fever succeeded to the chorea. Sarah C, (No. in Register 24) aged eighteen, mentioned just now as an instance of the disease being unaffected by remedies, had both ailments at the same time, but Avithout cardiac lesion. John J., (No. in Register 291) aged sixteen, had chorea im- mediately after rheumatic fever. But was also infested with intestinal worms which might have been the cause. There was no cardiac lesion. 400 CHOREA. Sophia G., (No. in Register 5003) aged eighteen, died of pericarditis, very probably rheumatic, and chorea. I have men- tioned this case before among the fatal ones. Sophia M., (No. in Register 6425) aged seventeen, had chorea come on in the hospital during an attack of acute rheumatism, free from any cardiac complication. Eliza B., (No. in Register C437) aged seventeen, had chorea come on in the hospital during an attack of rheumatic fever, but she had no recent affection of the heart detected then. When again admitted for chorea in the succeeding year, there was a soft murmur, systolic and probably angemic. Martha C, (No. in Register for 1861, 346) aged twelve, was admitted with chorea. She denied having had rheumatic fever, though she said she had had rheumatic pains. The heart proved healthy. Next year she was under Dr. Sibson's care for rheu- matic fever, and then again the heart was examined and found healthy. You will observe, that though the association with rheumatism is evident, there is none made out with previous lesion of the heart. For, though Sophia G. had pericarditis, yet the others had no cardiac affection. Considering how very common inflam- mation of the central organ of circulation is in rheumatic chil- dren,* and that it is at this age that chorea usually occurs, on the mere doctrine of chances they would often coincide ; but the cases I have last referred to show that the constitutional connec- tion is really with the rheumatism, and not with the valvular or pericardial injury. Indeed, when you come to consider that the red contractile tissue in the majority of cases of acute rheumatism is seriously affected in its functions, and in some cases (muscular rheumatism) is the only tissue affected, and that chorea is manifested by a want of control of the muscular nerves over the muscles, a con- siderable light is thrown upon the relation of two diseases at * It is dependent partly on the natural activity and excitability of muscular fiber in young persons, partly on their intolerance of pain and warmth, and the difficulty of keeping them from throwing off the bed-clothes, and exposing their chest to cold air. CHOREA, 401 first sight so dissimilar. They are defects of vital function in the same part. In one case the sensitive ; in the other the motor function is injured. I am sorry to say no practical assistance in their cure has been afforded by the observation of the connection between the two diseases. I have, in a few cases, applied to chorea the same treatment I should have applied to rheumatism, namely, warmth and alkalies, and it seemed to me rather injurious than beneficial. LECTURE XXXI. EPILEPSY. Cases illustrative of the use of iodide or bromide of potassium — Suggested explanation of the benefit so derived — Accessory treatment. (Olinical, St. Mary's, June 20, 1863.) The following are the cases of epilepsy which have been in the hospital under my care since January 1. Richard L,, aged forty-four, a married groom, had never any serious illness before February 20. On that day, soon after going to his work at seven in the morning, he felt giddy, and in two or three minutes afterwards he became insensible and fell on the stable floor in a state of insensibility, during which, as his companions told him, he was convulsed. A similar access occurred the night after, and a third the next day. This was followed by a succession of fits for twelve hours, with intervals of from four minutes to a quarter of an hour. After that he had about three during each day. But during the nights they were more frequent, coming on whenever he tried to go to sleep. On the 27th of February he applied for admission, and had an epileptic attack in our board room. This one was seen to last about five minutes, being accompanied by casting up and twitch- ing of the eyes and slight convulsions. His urine was natural, the genital organs normal in function, and no blow on the head or any other possible cause for the fits detected. He had the air of a sober respectable man. EPILEPSY. 403 He was immediately put upon the following treatment: — ^i Potassii iodidi, gr. iv, Tincturse eantharidiim, ^xv, Mist, camphor 86, Sj, ter die. A small blister of an inch circumference behind each ear. The epilepsy never recurred, and he entirely lost the feeling of giddiness and general malaise which had been experienced during its continuance. As his home was in the neighborhood, he was discharged as cured on March 6, with a determination to come back if he felt any likelihood of a relapse, to guard against which he was provided with medicine for a fortnight. [He has not since made his appearance. February, 1864.] A. M., a boy of twelve, had a cut on the head by a fall in fighting at ten years old. After it had healed he was quite well till last November. At that date he began to have epileptic fits. At first they resembled faintings, and occurred with various fre- quency, sometimes as often as seven or eight times a day. Since then they have become of a convulsive character and have occurred mostly at night. "When they are coming on it seems to him as if the room were on fire, this is succeeded by sudden darkness, and he knows no more. His mother states that he almost always goes to sleep immediately after. His appearance is healthy, and there are no worms to be found in his stools, though his mother had given him strong purgatives and carefully examined the re- sults. There was ordered for him on March 20 the following prescription: I^ Potassii iodidi, gr. iv, Tinctwse cantharidum, lt]y, Mist, camphor 86, .5j, ter die Up to March 25 he had an attack each day. His eyes were fixed, and the pupils much contracted during them, and he fell down, but did not bite his tongue. 404 EPILEPSY. On April 1 at dinner time there occurred a short fit, and after that no more. He was discharged cured on the 11th, having taken no remedies beyond that named dnd two doses of castor-oil. Eliza D., an unmarried nurse-maid, twenty-four years of age, was admitted by governor's order, May 1, for epilepsy. She had her first fit sixteen months previously, when she was at the Cape with her mistress. At first she was not completely insen- sible, and had no convulsions, but soon the illness took on a more decided epileptic character, and latterly she has been attacked more frequently, sometimes as often as two or three times a day. The catamenia have never been quite regular to time, but otherwise she has been a healthy woman, except for the epilepsy. She is spare, brown, and intelligent, without any signs of hysteria. She was put upon the treatment by ^ Potassii bromidi, gr. xv, Mist, campliorse, .5J, ter die. During the night of May 5 she had two decidedly epileptic paroxysms, in which she bit her tongue. The bromide of potas- sium was increased to gr. xx, and she had no more. Thomas K., a G. W. R. porter, was admitted on April 11, during an epileptic fit, which he had in going to his work at four in the morning. He was treated with a turpentine enema and a blister at the back of neck, but as he did not wish to be kept from his work I lost sight of him. However, I have reason to believe that had he been ill again, he would have returned to the hospital. s I bring to your notice these last four cases of epilepsy which have been under my care, because in most of them a similar remedy has been used with apparently great success. Two have taken the iodide and one the bromide of potassium, and it certainly seems to have controlled the disease in an extraordi- nary way. Remark that all these three epilepsies are comparatively EPILEPSY. 405 recent. I have, as a rule, refused to admit long standing cases, as causing a great deal of trouble and expending in vain the funds of the hospital. And I think that trials of all remedies should be made on recent cases, for confirmed epilepsy has become such a habit in the system that it may be looked upon as incurable. Even there iodide and bromide of potassium will alleviate the evil. In one case due to an old sabre cut on the skull so long ago as the Greek war of independence, and accompanied by partial paralysis, I gave, in consultation wdth Dr. Watson, iodide of potassium, and the fits became not only less frequent but milder. Another case of fourteen years' duration and used to recur every three weeks, has now been nearly six months with- out at attack under the use of fifteen grains of bromide of potassium three times a day. This latter case had tried to take the iodide, but even in small doses it so soon produced its poisonous efi'ects, sore throats, irri- tative fever, &c., that it was never fairly tested. Sometimes we fail. I gave the iodide last winter to a young clergyman for epilepsy of not above a year's duration. During three weeks' stay in London he was indeed free from fits, but on returning home they recurred as ibad as ever. Singularly enough I had a few years before given this man large doses of iodide of potassium for non-syphilitic periosteal rheumatism, and it had acted like a charm. Is it possible that the medicine can have lost its effect over one disease by having been previously used for another in the same patient ? At all events he left it off, and when I last heard he was taking, under advice, mercurial alteratives to act on the liver and so on, not apparently with any advantage. This class of neutral salts seem to have a peculiar restorative action over the white fibrous tissues. They were first brought under the notice of the profession by the effect of iodine in scrofulous diseases of the glands, and then by their cure of syphilitic periostitis. A notion got into the profession that they had some antagonistic, or controlling, or evacuating power ovor syphilitic virus ; but the more recent surgical writers, such as Mr. Lee, think there is evidence against that idea, and that they 406 EPILEPSY. benefit by curing the disease arising out of the presence of the virus and not by removing the virus itself. They cure the patient's tissues, without specially affecting the Jiiateries morhi, if we may apply that misused, term to the poison which is the foreign cause of disease. You may see proof of this opinion in the fact of the equal benefit which they confer in rheumatic and other non-venerial cases of periosteal disease. When recently affected, these patients are restored to health as readily as the subjects of secondary syphilis ; and the apparent resistance in some cases to the remedy is due to the protracted nature of the ailments ; just as syphilitic periostitis, when it has lasted a long time without medical aid, is very obstinate also. On the ground, that iodide of potassium has a special restorative power over the white fibrous tissues, I should expect most direct benefit from it in epilepsy to those cases where epilepsy is due to some lesion of the membranes of the cerebral or other masses of nerve sub- stances, whether that lesion be temporary or permanent. But at the same time I have no data by which to doubt of its curative influence, where the disease arises from lesed nutrition or visible tumors of nervous matter. It may not improbably restore also that tissue to healthy vitality. Neither should I be disposed to be skeptical of its virtue where a peripheral cause exists for the convulsions. That peripheral cause may be an altered state of some fibrous tissue, and it can hardly act otherwise than through an altered nutrition of the nerve or its envelopes. It is also something to say that no permanent injury to health, and scarcely any even temporary inconvenience is ever wrought by iodide of potassium. Some persons, misled by an accidental instance or two of lunatics having previous to their lunacy taken this salt, have disseminated a notion that it weakens the mental powers. At the Lock Hospital for syphilis we administer annu- ally some hundred-weights of it, but have never found such a result follow. So that there are no patients affected with epilepsy on whom Ave are justified in not fairly trying the experiment of its use. I need hardly tell you how important hygiene is in the treat- EPILEPSY. 407 nient of epilepsy. The measures most to be insisted upon are those specially connected with the etiology of the disease in the particular case. Should mental causes, such as fright, anxiety, disappointment, lie at the bottom of the evil, a complete change of habits must be enforced ; and that is easiest carried out by a complete change of residence and of companions. The same expedient will also powerfully aid dietetic improvements in instances w^here the digestive track is at fault. In such cases a mild soluble animal dietary, which feeds the tissues by frequent nourishment, without overloading the stomach by copious meals, such as the diets of our hospitals, is of the greatest importance. — of so much indeed, that some even hesitate to accept hospital experience of the action of medicines in this disease as conclu- sive of their real value. All ambitious intellectual exertion, especially rapid and dis- cursive reading and writing against time, should be absolutely prohibited. But moderate employment of the thoughts, espe- cially on familiar and interesting hobbies, is useful in preventing that stagnation or concentration of the mind upon itself which is so hurtful in all chronic complaints. LECTURE XXXII. HYSTERIA. Part I. — Hysteria not fatal, but not therefore unimportant — JS^ot a uterine disorder — Its pathology lies between mind and body — Its forms to be divided according as it approaches one or the other — Such a division has a direct bearing on the treatment — 3Iental liysteria — Treatment, restoration of volun- tary mental force, of cutaneous circulation, and of emotional control — Corporeal cause for hysteria — Treatment, tonic to mucous membranes — Effects of tea-drinking — Treatment dietetic. Part II. — Hysterical vomiting — Three cases in hospital com- jjared ivith some private patients — It is not in strictness vomit- ing — Diagnosis and treatment — Tlieir difficulties — Hysterical cough — Contagiousness of hysteria. Part III. — Connection between hysteria and insanity illustrated — Medical curiosity about private history of patients — A p)hy- sician not a co7ifessor. Part IV. — Periods of life pirone to hysteria — Blighted affec- tions, lotvering diseases, and climate, as causes — Two cases of hystericcd loss of voice treated by valerian and shower-baths — Spasmodic cough and spitting of blood in one patient — Ad- vantages of auscultatioyi in the diagnosis of the latter. Part V. — Treatment by ice — Treatment by bloodletting Creneral conclusions. (Part 1.— Clinical, St. Mary's, November 8, 1861.) Those who rate the importance of diseases solely by the space they fill up in the Registrar-general's report of deaths, will care very little about the subject of the present lecture. Hysteria HYSTERIA. 40y does not show its face at all in that book. The reason is, that whenever it leads to a fatal result, it qualifies itself to be classed either as insanity, epilepsy, or some organic lesion ; and thus our registering friends who pay attention only to what people die, of, are apt to ignore it altogether. But this is not a practical way of viewing the human misery you are learning to lighten. The sum total of suffering from hysteria to patients and their friends is very great, and probably equal to that included under most of the names followed by high numbers in the lists of mortality. The chief thing that should make disease interesting to you is the amount of misery which it inflicts, and the likelihood there is of your exertions alleviating this misery ; not the grati- fication of your vanity by observing how the phenomena during life are explained by the post-mortem appearances. I hope you will not be led by the excellent opportunities for the study of morbid anatomy which student life affords to rate that science as the only glass through which you should look at disease. It is very rarely anything which can be put up in a bottle or made into an interesting preparation, that patients feel, and that it is the business of your life to help them to feel less. The true use of morbid anatomy is to teach the consequences of disease, not the art of healing it, and it is the art of healing which must be the prime object of your work in the hospital wards, and the business of your lives. You must not get a habit of classi- fying ailments according to parts affected only, or a great many will escape altogether from your nosology, and some you will not believe in at all perhaps. Of others, again, the names will give you altogether wrong notions ; and of these hysteria is an instance. It is seldom I ask you to erase anything from your memory, but — will you please to try and forget for the nonce that hysteria is derived from the Greek work 'varepa ? * That is the readiest way of avoiding the trap which the name sets open for the edu- cated student. In reality it has no more to do with the organ * Hysteria, with the second syllable long, as usually pronounced, means " a festival at which swine were immolated" {Donnegan), but I suspect the original designers intended the e to be short. 410 HYSTERIA. of reproduction than it has with any other part of the female body ; and it is no truer to say that women are hysterical be- cause they have wombs, than that men are gouty because they have beards. You may see daily in the ward appropriated to uterine cases all sorts of pathological changes of the part in question, without any greater tendency to hysteria than in other women ; and on the other hand, hysterical women are all around you, among both in and out-patients, whose uterine functions are perfectly healthy. Of two women I have examined who were born without any uterus at all, one was hysterical. Our forefathers, who invented the term still used, seem to have fallen in with a popular notion that the womb really danced about into all the strange places where discomfort is felt. They allowed their patients to think of that mysterious organ as now starting up under the left ribs and causing lumps and pain in the side, and properly enough therefore called "spleen" by classical writers of the Addisonian period, now jumping right up into the throat as a " globus," and now intruding itself into the brain, appearing like a nail driven in — a " clavus" — over the brow and disturbing the senses and passions. You may easily con- ceive that the believers in such superstitions were not trustwor- thy practitioners ; but you will be equally bad if you fall into the error of treating hysteria as a disease originating in the womb. Observe impartially the phenomena in those cases which come before you, and you will not fail to be convinced that the defi- cient vitality of which hysteria is a manifestation is in that puz- zling part of the circle of life which lies between spirit and matter. We know so little about the chain which connects the two, that its links are reckoned by us as few and short, and we have no names for any of them. ■ Yet when we see the varied phenomena produced by breaches or impediments to the connec- tion, we are led to feel the depth of our ignorance on the sub- ject, and to conjecture that these abysses of incertitude veil a long list of vital functions. In default of names for even the healthy functions of this part of life, we must not expect an accurate nomenclature for HYSTERIA. 411 their aberrations from health ; and the most we can do in trying to dassify forms of hysteria, is to trace how near their origin lies to one or other extremity of the series of vital actions which are interfered with ; what relation their phenomena hear on the one hand to mind, and what on the other to body. We shall thus have set in a natural series the varieties of the disease, with pure insanity at the one end, and epilepsy traceable to or- ganic lesion at the other. Such a nosology has a directly useful bearing on our treatment of the patient, which I cannot affirm of any other attempt at classification of hysteria that I have ^''et seen. I say it has a direct bearing on our treatment of the pa- tient to observe in each individual case whether the disease is most related to deviation from mental or bodily health ; for I feel convinced that it is only by this observation that Ave can avoid such disappointment as leads many in our profession to look upon hysteria as an opprobrium medicinse, which makes them feel the same sort of anger against it that is roused by moral guiltiness, and disposes them rather to punish than to cure the patient who has thwarted them. After this unusually long introduction I proceed to the busi- ness of the day, by calling your attention to three cases we have visited during the last week in the larger female ward. The first couch we come to is tenanted by E. J., a nursery- maid aged seventeen, who was brought here from her bed in her night-dress and wrapped up in blankets, as an " urgency" dur- ing the week. She complained of dreadful pain and absolute loss of power in the legs, so as to be quite incapable of standing. She said that five days previously her legs had been red and swollen, and that they had been rolled up in " bandages twenty yards in length ;" though in the same breath she declared that they were so painful that she could not bear them to be handled, and that it made her faint to have them touched. This illness she attributed to having caught cold, accompanied by diarrhoea, when with her mistress at the seaside, whence she has just come back. She complained also of stiffness and severe pain in the muscles of the neck and of pain in the heart, and of excessive perspirations. In short, she gave a fair description of the symp- 412 HYSTERIA. toms of an attack of rheumatic fever, and in truth she was sent to bed as a case of rheumatic fever, and so entered in the " Urgency admission book." But my eyesight did not let me concur in this diagnosis. The legs and feet were evenly smooth and white, and she did not cry out when any part was handled except the calves, to which she said the pain had retreated. Now the pain of rheumatic fever retreats to the joints, and not the calves. Moreover, there was no swelling of the neck, which she said was so painful ; and on diverting her attention, the car- diac region bore pressure without her flinching. And the flush- injr of her face seemed not due to fever, but rather to mental excitement. Then we noticed that the inside of her lips and her tongue were pale, and that the latter was indented by the teeth ; while there was a soft, soughing murmur, such as you find in anaemic persons, synchronous with the first sound of the heart. But what mainly led me to the diagnosis which I formed of hysteria was the expression of her countenance. She has an easily flushed skin, delicate features, quickly answering to the movements of the mind, and in the eyes a peculiar appearance which requires a separate sentence to itself. The balls are large, and the sclerotic of a transparent sky-blue ; the pupil is much dilated, giving a general dark hue to a naturally light eye, and the conjunctiva is smooth and bright from being overspread with tears on every emotion. The eyelids are large, full towards the outer canthus, giving a drooping, appealing expression to the face. I believe this is what ladies technically call " a sweet ex- pression." Of these several hysterical marks, the puffiness of the eyelid and the dilatation of the pupil are the most constant — indeed are seldom absent — and seldom deceive you. Her history has oozed out in driblets during the four days she has been here, and has been made up partly by a motherly old woman in the next bed ; for it excites her too much to attempt much cross-questioning. I would commend to your imitation this mode of piecing up a history by what can be extracted from the patient by those who can listen at leisure. Excitable persons are prone to exaggerate, to invent, to forget, and to appear to you impostors when cross-questioned by a stranger. HYSTERIA. 413 It seems that E. J. lias been in service since she was twelve years old, and enjoyed capital health till sixteen months ago, when she had a sad shock. She went home for a holiday, having heard of no illness in her family, and found her father in his coffin. This completely upset her. She has shifted about from service to service, and has always been obliged to leave from inability to get through her duties. The first bodily symp- toms she perceived were languor and palpitation of the heart on exertion; she then became subject to "fits" as she calls them ; if anybody made her laugh, she could not stop, soon began to cry and to scream, and fell into very low spirits afterwards. During this period the catamenia flowed for the first time last December, and appeared again in January : she says that she was neither better nor worse for the change of constitution. Since January they have been absent. This is a case of hysteria arising from a distinctly mental cause, and showing itself in mental symptoms. The organs first affected are those which are especially obedient to the emotions of both pain and pleasure. First, the heart ; then the risory, lachrymatory, and expiratory muscles. In health, we know how these are affected by changes in the mind, but are still under its control. When then we find in a patient that control deficient, and when we can trace the deficiency to a cause purely mental, it is rational to conclude that the broken link is nearer to mind than to matter, and it is rational to let this conclusion govern us in our treatment. I would here again warn you, as I did at the beginning of the lecture, against associating hysteria with the reproductive organs or functions. To read some male authors on this subject one would suppose that it was only a euphemism for lust. A signal injustice is thus done to the weaker sex, and they might well ask, as -^sop's lion did of the natural historian, if women wrote books on the diseases of men how would the creatures be de- scribed ? If you study in an unprejudiced spirit the histories of the numerous cases of hysteria which fall under your notice you will learn that the sexual instincts are not oftener the moral cause of the disease than any other social circumstances, and 27 414 HYSTERIA. that physically the dijfferential organs are less frequently at fault than any of the important viscera. Neither are lustful desires the consequence of hysteria any more than they are the conse- quence of all that weakens the mental powers, of all that lowers our species in the scale of creation and brings us nearer to other animals. Emotional hysteria is a primary disease of the mind as much as lunacy is. As in lunacy, so also in hysteria, there follow morbid pheno- mena connected with the manufacturing viscera. The stomach loses its power of digesting food enough to supply the waste, and the person becomes anaemic. Then the destructive meta- morphosis is checked too, the urea is excreted in diminishing quantities, and the unrenewed blood supplies no coloring mat- ter, so that the urine is pale and watery. In short, the pa- tient becomes anaemic ; and with ansemia, of course, there is a deficiency in the sanguineous excretions especially. Thus in this girl, as you have heard, puberty truly began in spite of the illness ; but power was wanting to carry on its periodical evacu- ation of effete blood. The catamenia flowed twice, and then ceased. Next to the stomach probably ranks the uterus in its liability to be affected by the mind — a fright may suspend the catamenia or cause miscarriage in a perfectly healthy woman ; and in female lunatics the courses are scarcely ever regular — so that it is quite in accord with analogy that the same defect should occur in the half-mental affections which we reckon as hysterical. Next notice the treatment. First. She was taken into the hosjntal as an in-patient. You will find in practice that, however good your theory of the treat- ment of hysteria may be, it is much more difficult to carry out and much less effective when the patients are at home than when you can remove them for a time from their ordinary habits and associations. It is not merely that unprofessional nurses fail to obey implicitly your orders, from misplaced tenderness or ignorance ; but that the patient's mind, by running in its habit- ual groove, and being perpetually subjected perhaps to the influ- ences which engendered the disease, less readily takes a turn HYSTERIA. 415 towards health. If you expect in private practice to be as suc- cessful as hospital physicians, you must try to imitate the cir- cumstances they have in their favor. This is most easy in the poorest and in the richest classes. The first can be sent into an hospital : and with the latter a thorough change of scene, under the charge of some judicious friend, is not difiicult to arrange. But this is often next to impossible for the families of farmers, retail shopkeepers, curates, village doctors, and the like, from the union of a light purse with a weighty feeling of independence. One good plan that can sometimes be adopted to the saving of pride and pocket together, is to negotiate an exchange of patients, where two families of about the same social standing are simul- taneously afflicted with an hysterical member. The relatives of A can take charge of B, and the friends of B repay the debt by their care of A. Mere kindness even may induce people to re- ceive on a visit such inmates, if it is pointed out how very valu- able the kindness really is, and what a high office of Christian charity is thus fulfilled, when a sick person, incurable at home, is rendered curable by removal. In the wealthier classes the complete renewal of mental asso- ciations involved in foreign travel is a mighty engine of cure. But yet if an hysterical patient be sent abroad during conval- escence, you must not be quite careless where you send her to. Some places enjoy a bad pre-eminence for producing relapses. These are generally low-lying places of even temperature ; and I suspect there is some connection between malaria and the in- duction of the disorder. Rome is an instance in point. I was much struck, when residing there a few years ago, by the fre- quency with which all diseases are modified by hysterical phe- nomena. And one case I saw of well-marked catalepsy, which strongly impressed me. It occurred in an English lady who never had hysteria before in any form, and who was excessively frightened by the unfamiliar symptoms. It came on within twelve hours of her arrival on a muggy spring evening, when she was fatigued by her journey, and open to all the injurious aerial influences of the Campagna Romana. During her stay she was from time to time threatened with a recurrence and feared she 416 HYSTERIA. was a destined victim of nervous invalidism ; but on leaving Rome the symptoms vnnished, have never recurred, and were thus proved to be wholly due to the peculiar climate. Be care- ful that your hysterical patients keep clear of the Eternal City.* Much harm is often done by sending them to travel in Italy with- out a warning on this point. Whatever be the scheme adopted for securing the change in habitual trains of thought, the principle of treatment will be the same. You must aim at bringing back the control of the mind over tlie body. A link has been dropped, is becoming paralyzed for want of use, and must be renewed. Let the patient be ex- ercised in voluntarily obe^nng specific orders for the direction of the will ; moving the limbs to time, at first slowly, and after- wards with more liveliness, till at last the culminating point of dancing can be arrived at. This is the crisis of the cure ; and when a girl can be induced to join a quadrille in the evening, you need not fear a relapse into hysterical paralysis. In the hospital we are obliged to substitute "dull mechanic pacings to and fro," assisting in the work of the ward, &c. ; but these are much better than nothing. The same strong effort requisite for these exertions is to be used to restrain the tendency to hyste- rical fits. The truth is to be forced upon the patient that she can learn to repress these manifestations of weakness ; and with the learning will come the power, and with the power the absence of occasions for exercising it. What you have to aim at is exactly the converse of the arts of the electro-biologists, mesmerists, and medium-showmen. These persons, with devil-like ingenuity, find means to induce a form of artificial hysteria in subjects with a tendency to mental disease ; that is to say, they partially destroy the control which the mind has over the body, and subject it to the suggestions of their own will. Let it be your happier task to restore this con- * A reviewer of the second edition of this volume, throws a doubt on this accusation against Rome. I was not aware that it was new ; but if so I am glad to find it confirmed by Dr. Scoresbj Jackson in his recent excellent work " On Climatology." He describes the climate as productive of a " morbid nervous sensibility," and afterwards advises that all cases "of perverted nervous sensi- bility" * * * '^ should avoid Rome." HYSTERIA, 417 trol by inducing the patients to exercise it for themselves. Above all things, never be led by curiosity or idleness to repeat the experiments alluded to. Each time that poor creatures are so practiced upon, they become more and more enslaved to the morbid impressions, till they lapse into permanent hysteria or even insanity. You might just as well give a man pneumonia- or break his leg, for the purpose of studying the consequence. Secondly. Shower-baths were ordered to he given every morn- ing. The making up the mind to the shock of a cold shower- bath is a capital exercise of the will. In summer it is most suitable ; and I dare say you remember in July, 1860, a farmer's daughter, whom our late house-surgeon, Mr. Ash, sent up from Cornwall with absolute paraplegia of both legs. This case ex- cited much amusement at the time, because it had been attri- buted by the girl's neighbors to witchcraft. It was due to hysteria; and she was ordered a shower-bath twice a day, with the effect of enabling her to walk several miles per diem, one day to the Pantheon, and another round the Serpentine, before she went home cured. I say "cured," partly because I have lately heard from Mr. Ash of her really being so, and partly also because I should anticipate the best results from the slow progress of her improve- ment. It is sometimes possible by a strong mental emotion to overcome suddenly nervous paralj^sis, but these sudden recoveries are apt to be followed, time after time, by relapses, and are seldom lasting. You have all, I dare say, read at school Hero- dotus' story of the dumb child of Croesus, who in a battle re- gained his speech, and stayed the soldier's uplifted sw^ord by crying out " Spare my father." Well, there was nothing mira- culous in this ; it was an ordinary instance of nervous dumbness cured by strong emotion ; but I should have been surprised if it had been stated that he continued able to talk. I know a case of permanent hysterical paralysis which was several times sud- denly cured ; once by the house catching fire, once by the patient's maid being struck down by cholera, once by an obsti- nate physician desiring her to rise up and walk. After each trial she was able to move about for a few days, but she relapsed again 418 HYSTERIA. as bad as ever, and remained paralytic till her death from other causes. Gradual cures, on the other hand, seldonj* relapse, and ^ are indubitably the most trustworthy. In winter a shower-bath twice a day, as ordered for the Cornish girl, would be rather a strong measure ; and it is better to prepare the patients for it by the use of a tonic warm bath, such as the following, which you often see me order: — I^ Acidi hydrochlorici Siss, aquse cahfactse ad 95° Fahr. congios xxx, M. Fiat balneum. Independently of their effect on the mind, shower-baths have also a good influence by arterializing the cutaneous circulation. Their immediate action is to drive the venous blood home to the heart and lungs ; and that which takes its place is arterial, as every one knows who has reflected on the pink cheerful glow of his person while drying himself after this morning luxury. Thirdly. Valerian was ordered to be taken three times a day. There are several substances dowered with a special action on those nervous functions which minister to the emotions. They come fiom different kingdoms of nature, and agree in no one poijit except in having all a very strong smell. The essential oils of sundry plants which are the pride and profit of the per- fumer, the rose, bergamotte, tuberose, violet, hyacinth, fresh hay, and some others of the few sweet scents that exist in this world, are poisons to all with a tendency to hysteria, and are proscribed by universal consent of fashion in all places where the disease is endemic. In Rome, you ought as soon think of going to an evening party with a drawn sword as with a strong-scented nosegay, in any hope of its acceptance. Tea is equally baneful, and the bad effect seems to dwell rather in the essential oil than in the alkaloids which it holds ; for coffee, which is as rich in theine, is by no means so hurtful. On the other hand, the bracers-up of the nerves would seem to have this good gift in recompense for their peculiar offensiveness in their raw state to the healthy nose — valerian, assafoetida, garlic, castor, musk, and I believe some others Avhose disagreeable virtues are not familiar with me. The first two are the best ; as, though musk is very beneficial, its high price and the unbearable permanence of its HYSTERIA. 419 odor, renders its use inexpedient. In hospital, you will gene- rally see me ring the changes upon the following prescrip- tions: — I^ Tincturde valerianse compositae 5ji Infusi Valerianae ad 5j- M. et fiat haustus ter vel quater die semendus. I^ Assafoetidse gr. x in pilulis ter die sumenda. I^ SpiritHs ammonise foetidas 5j