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 SIX LECTURES, V 
 
 DELIVERED 
 
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 TO THE STUDENTS OF ST. BARTHOLOMEW'S HOSPITAL, 1866. 
 
 BY 
 
 
 F. C. KEY, F.R.S., ^ 
 
 Late Pres. of, and Mem. of the Council and of the Court of Examiners of the Royal 
 
 ColL of Surgeons of England ; late President of the Royal Med. and Chir. 
 
 Soc. of London ; Consulting Surgeon to St. Bartholomew's and Great 
 
 Northern Hospitals, and to the Charter House; Hon. Fellow 
 
 of the Imperial Medico-Chirurg. Academy of St. 
 
 Petersburgh ; Chairman of the Government 
 
 Commission on Syphilis, etc., etc. 
 
 |)ork : 
 
 & CO.. 
 
 1867.
 
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 NEW YORK: 
 
 AOATHYKIAN PEKBS, CO DfANE Si. 
 
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 PREFACE. 
 
 THE following Lectures were delivered to the Students 
 of St. Bartholomew's Hospital, and they are now 
 published at their request and for their instruction. 
 
 If any Members of older growth fail in knowledge of 
 matters so essential as those I have discussed, however 
 unskilfully I may have treated them, the sooner they enter 
 on the path of inquiry the better. 
 
 It is in the nature of scientific inquiry to intermingle 
 error with truth. Our faculties, however cultivated, 
 cannot penetrate the recesses in which are concealed the 
 more precious gems of perfect knowledge, the value and 
 even the nature of which are variously appreciated by 
 different observers. Hence opposite deductions and 
 contradictory opinions. 
 
 The majority of our profession are biassed in favor of 
 depletive measures. They consider diseases to originate in 
 excess of vitality, and to be the product of undue force, I 
 have endeavored to show that they far more commonly 
 arise from reduced or exhausted power. A weak condition 
 of the animal body is intelligible enough, but an abnormal 
 condition warranting a reduction of vital power by artificial 
 agency I cannot understand.
 
 Ti A PREFACE. 
 
 We talk of " increased heat," of " increased action," of 
 " excitement," and so 'on, as demanding a reduction or a 
 lowering of tfce^ vital powers ; while it is notorious that 
 intense heat of skin is the frequent attendant on the last 
 hours of life, and who will venture to treat the " excite- 
 ment" of delirium tremens by any agent less potent than 
 Alcohol or Opium? 
 
 The great machine of Medical knowledge, however, is 
 moving onwards in the direction of truth. 
 
 On a line between the antagonistic principles of the 
 schools of Cullen and of Brown the Profession will 
 eventually take its stand at a point, I suspect, far nearer 
 to Brown than to Cullen. This is the natural reaction 
 following on years of error. 
 
 The palpable confusion between diseases of the vascular 
 and of the nervous systems which has so long prevailed is 
 but evidence of the same error. 
 
 Whether the sketch I have drawn be overcharged for 
 it does not affect the pretension of a finished picture I 
 leave to be determined by others.
 
 CONTENTS: 
 
 LECTURE I. 
 
 PAGE 
 
 Congestion not Inflammation Treatment of Congestion Cases of Con- 
 gestion Tonic Treatment exemplified in abscess Evils of depletive 
 treatment Tonic treatment -Bark, wine, &c., the quantity deter- 
 mined by the pulse Employment of wine in the London Hospitals I 
 
 LECTURE II. 
 
 Remote causes of Disease Causes definite and traceable General causes of 
 disease The aperient system Treatment by increasing the quantity 
 of healthy blood Stimulants in debility reduce the frequency of the 
 pulse Alcoholic stimulants essential Cases Diseases of animal and 
 organic life Cases in illustration of the two varieties of disease. 1% 
 
 LECTURE III. 
 
 Imitations of real disease The study of, much neglected by the profession 
 Indicated by local pain and muscular spasm Distinct from inflam- 
 matory diseases The term " Hysteria" objectionable Nature and 
 source of Hysteria Errors in diagnosis Critical examination of 
 cases Hysteric affection of joints Hysteric contraction of fingers. 36 
 
 LECTURE IV. 
 
 Symptoms of common paroxysmal Hysteria Constitutional liability 
 Nerve and nervous system Effect of railway accidents Influence of 
 the mind Effects of an unstrung nervous system on the actions of 
 daily life Imitative or contagious Hysteria Surgical cases of Dis- 
 tinct from Neuralgia Relation between Hysteria and the brain or 
 spinal cord Hysteria combined with real disease . . . 5 I
 
 viii CONTENTS. 
 
 LECTURE V. 
 
 Distinctions between nervous and vascular diseases recapitulated General 
 localities of Hysteria Case of Hysteria of the muscles of the larynx 
 Hysteric affection of the mammary gland Value of exercise Rela- 
 tive value of foot and horse exercise General and local treatment 
 Hysteria of hypochondriac regions Spinal affections Cases Effi- 
 cacy or inefficacy of issues Cases Railway actions and extortions 
 Cases Hysteric joints, treatment of Cases .... 65 
 
 LECTURE VI. 
 
 Hysteric affection of the (Esophagus Hysteric affection of the stomach; 
 gastrodynia of the Ovary Hysteric contraction of muscles Wry 
 Neck Contraction of ringers Contraction of elbow-joint Hysteric 
 contraction of the muscles of the leg and foot Hysteric paraplegia 
 Hemiplegia . . . . . . . . . 85
 
 SIX LECTURES ON HYSTERIA. 
 
 ON THE REMOTE CAUSES OF DISEASE, AND ON 
 ITS TREATMENT BY TONIC AGENCY. 
 
 FIRST LECTURE. 
 
 Congestion not Inflammation Treatment of Congestion Cases of Con- 
 gestion Tonic Treatment exemplified in Abscess Evils of Depletive 
 Treatment Tonic Treatment Bark, Wine, &c., the quantity deter- 
 mined by the Pulse Employment of Wine in the London Hospitals. 
 
 GENTLEMEN, Circumstances have limited my oppor- 
 tunities of instruction. I purpose, in the few lectures I 
 shall deliver, to discuss such principles of Medicine as 
 may prove useful to you, which involve the essence, if I 
 may so term it, of Medical and Surgical practice, and 
 the assent to and adoption of which appear to my judgment 
 indispensable to success in the treatment of disease. If 
 these principles are based on error, you will readily detect 
 it, and they will present themselves as so many rocks and 
 shoals in your future career to be avoided as dangerous. If 
 sound you will approve and adopt them. I adopt them 
 because I am satisfied, theoretically, they are based on 
 sound views of the animal economy ; and practically I find 
 them in a pre-eminent degree more successful in the treat-
 
 2 FIRST LECTURE. 
 
 ment of disease than those which refer so large a proportion 
 of diseases to what is termed inflammation and its supposed 
 consequences. 
 
 It is a prevailing error among the unthinking members 
 of our profession which refers all examples of redness of 
 vessels to inflammation. No term can be more inappropri- 
 ate. The ancient definition of inflammation is founded on 
 truth, and will hold true to the end of time ; but it is ren- 
 dered absurd by the practice of the modern school. In the 
 too frequent employment of the name we forget the con- 
 ditions essential to it. The arterial and capillary systems 
 perform their healthy functions so long only as they retain 
 the normal influence of the nerves supplying them, whether 
 locally or generally. If the supply of nervous influence 
 fails, the capillary system of a part loses its healthy tone, 
 and the vessels locally dilate. At the same time they lose 
 the power of propulsion, and there arises of necessity a 
 local rernora or arrest of the circulation, and, as a matter of 
 course, the part becomes red. Is this inflammation ? Yes > 
 in the judgment of many, it is termed a form or variety of 
 inflammation, not strict or positive, but inflammation of an 
 asthenic type, although it fails in three of the four conditions 
 essential to true inflammation, and exhibits redness only, 
 wanting pain, heat, and swelling. 
 
 Now these examples of local congestion or plethora of 
 vessels are yet in the present day confounded with true in- 
 flammation, and are treated by what we term antiphlogistic 
 agents viz., general and local bleeding, purgatives, diapho- 
 retics, and the suspension of food. True inflammation is 
 not so commonly seen as you may imagine ; and inasmuch
 
 FIRST LECTURE. J 
 
 as local redness does not involve all the required signs of 
 heat, redness, pain and swelling, which that state requires, 
 it cannot be true inflammation, and there is no difficulty in 
 proving that the treatment usually adopted in true inflam- 
 matory diseases is especially objectionable and injurious 
 in this. 
 
 There is another variety of so-called inflammation, in 
 the mouths of a large number of us called chronic; what it 
 means is somewhat difficult to define, but we employ it 
 rather to conceal a difficulty, than to expound it. 
 
 There are two principles on which this congested con- 
 dition of the blood-vessels may be treated 
 
 1. Blood may be taken locally; the system may be 
 lowered by salines, as they are termed, by purgatives and 
 diaphoretics. This treatment by local depletion would lead 
 to the inference that the blood is at fault and should be 
 removed. 
 
 2. The blood in these vessels may be forced onwards by 
 giving increased action to the heart, by the resort to agents 
 that tend to restore the healthy tonic condition of, or, at 
 all events, to give force to, the capillary system of the 
 affected part. 
 
 This latter is termed the tonic treatment of disease a 
 principle, I consider, based on a sound view of the functions 
 of the animal economy, and which formed the staple of my 
 treatment during the period in which I was attached to this 
 Hospital as Surgeon, and for many years prior. If this 
 principle be sound, treatment by depletion in any form must 
 be an error, and therefore injurious, and that it is injurious 
 I have not a doubt. I can speak with some confidence, for
 
 4 FIRST LECTURE. 
 
 I have tried both. In the history of the human mind there 
 is no operation more difficult than that of divesting it of 
 early impressions inculcated by authority and confirmed and 
 established by time. Convictions increase in strength as 
 we get older, for the habit of examining the one side of 
 a question only, and of conforming to all its requirements, 
 has assumed a settled, permanent form, and with the multi- 
 tude engaged in the practice of our profession there is no 
 adequate motive to enter on a path of inquiry which may 
 tend to unsettle the convictions of their past lives. Some 
 fifteen years since I had a succession of cases of severe 
 congestion that is, redness, not inflammation accompany- 
 ing wounds caused by operations, cases of mammary cancer 
 or other tumors removed by the knife, amputations, 
 hernia, &c. These cases exhibited on the third or fourth 
 day congestion of the vessels around the wound, which 
 often extended and led to abcesses, and occasionally to death 
 It was called in common hospital parlance erysipelas, 
 having the feature of redness only in common with that 
 disease ; but it was not erysipelas : in truth, it was a far 
 more formidable condition. I ordered every patient, after 
 undergoing any serious operation, treatment by stimulants. 
 I gave two tablespoonfuls of brandy and two of water every 
 four hours, to be continued for one, two, or more days. 
 From that date I never lost a patient from this cause, and 
 rarely did any unhealthy condition of the affected region 
 present itself. 
 
 Now observe this feature in the treatment by stimulants. 
 If these examples of local congestion of the blood-vessels 
 partook of the nature of inflammation, you, I am sure, will
 
 FIRST LECTURE. ^ 
 
 concur with me in considering this treatment a blunder. If 
 stimulants be inadmissible in the treatment of inflammation, 
 the treatment should have proved injurious. This it did not 
 prove, but, on the contrary, effected early and curative re- 
 sults ; therefore the disease was not that of inflammation. 
 What is true of the local is equally true of the general. 
 
 The late Mr. Jones, of Jersey, was a remarkably successful 
 operator, and in reference to his cases of operation for the ex- 
 cision of joints (considered to be diseased) he operated on 
 a succession of more than twenty-five without the loss of 
 a single case, while in England at the same date the mor- 
 tality was always great, recovery being rather the exception, 
 and not the rule. What was the secret of this ? Was it 
 fresher air, or different management ? I made the inquiry, 
 and learned that Mr. Jones invariably gave every patient on 
 whom he operated at least a pint of port wine on each of 
 the two days following the operation, and he acknowledged 
 to me that he owed the treatment which had been attended 
 with such remarkable results, to his observation of the suc- 
 cess that had attended my treatment in St. Bartholomew's 
 Hospital. The vital powers of the system are always de- 
 pressed by a large operation, whether much blood has been 
 lost or not. I have found this combined tonic and stimula- 
 ting treatment eminently successful, and so convinced am I 
 of its value that, if I were told it had been less successful 
 in the hands of others, I should feel assured it had never 
 been fairly tried. 
 
 In no disease is the application of this principle more val- 
 uable than in every variety of abscess, whether chronic or 
 acute, and especially perhaps the latter. Let us take a com-
 
 6 FIRST LECTURE. 
 
 mon example. In two or three weeks after her confine- 
 ment a lady has a milk abscess. You are called to attend 
 her, and on examination you find a firm lump in the sub- 
 stance of the breast, involving perhaps one-third of its cir- 
 cumference. It is painful and heavy. The diagnosis is 
 clear enough ; it is the deposit of an incipient abscess. 
 What is your treatment ? I will tell you. You think you 
 can disperse it. Impossible. You order two or three grains 
 of calomel with some colocynth or other purgative ; you fol- 
 low this up with salines, a class of drug that I consider 
 more than any other displays the vacillation and uncertainty 
 of the practitioner ; and you order leeches, about eight or ten 
 Jn number, and warm fomentations and poultices to be ap- 
 plied to the breast. All these remedies are resorted to under 
 the impression that 'you can obtain absorption of this solid 
 mass. But the attempt fails : it always has failed ; it always 
 must fail; and yet it is nearly always attempted. Doubtless 
 the leeches relieve the pain of distension, and that is all ; 
 but this good does not counterbalance the injurious effects 
 consequent on the loss of blood required in the body for 
 the most important of purposes. At the Examination 
 Board of the College of Surgeons, this question as to the 
 treatment of the early stage of a mammary abscess has been 
 for years a critical question of mine. The reply has been 
 invariably " leeches, fomentations, poultices, purgatives, 
 salines." Does this reply indicate more of the knowledge 
 or of ignorance ? Such is our profession among the multi- 
 tude, deny it who can. 
 
 Now, before I tell you what is right to be done, let me 
 make a remark or two in passing. This lady's condition is
 
 FIRST LECTURE. J 
 
 marked by great debility. You will find on inquiry either 
 that she had a " hard time," as it is called, that she lost 
 blood largely during the birth of her child, or that subse- 
 quently to her confinement she has been the subject of some 
 debilitating cause, such as diarrhoea, loss of food, or fatigue 
 of body or mind, or some other depressing influence has 
 drawn largely on her physical strength. It is owing to this 
 depressing influence that she is the subject of this painful 
 disease. Had the weakness not existed^ she would have escaped 
 milk abcess. 
 
 You do not find milk abscess or any other form of abscess 
 in a person of vigorous circulation. It is the product of 
 weakness, whether inherent in the constitution or the result 
 of accident. For evidence of the truth of this fact, examine 
 her pulse. Is it firm ? Will it bear the pressure of the 
 finger without stopping it ? Is it moderate in the number 
 of its beats ? Is it at or under 70 ? No ; it is at 80, or 
 90, or more ; it is weak, and easily compressed by the finger ; 
 it may be large, and full, and rounded, or it may be small ; 
 but be it one or the other, it is stopped by slight additional 
 pressure of the finger. Either the blood is deficient in 
 quantity, or the heart fails in power probably both. And 
 in this condition of the system, with indications of debility 
 perfectly palpable before you, you appeal to the great British 
 panacea for four-fifths of all diseases, and you prescribe for 
 your patient calomel and colocynth, leeches, salines, and 
 fomentations ! Then, in my capacity of examiner, I gen- 
 erally proceed thus Very well ; and now tell me on what 
 principle and for what purpose you administer these agents. 
 Let us begin with the calomel. What object have you in
 
 8 FIRST LECTURE. 
 
 view ? To regulate the secretions. What secretions ? 
 The liver. What has the secretion of the liver to do with 
 an abscess of the breast ? Do you necessarily infer disor- 
 dered liver because the mammary gland is the seat of 
 abcess ? Can any opinion be more irrational ? 
 
 I often marvel at the wonderful faith exhibited by medical 
 men in the influence of these " secretions," as though the 
 liver, the most inoffensive organ in the whole body, was 
 the centre or focus of all its maladies. Well ! the calomel 
 and the other depressing agents do their work, and what are 
 the consequences ? The patient is weaker ; whatever nour- 
 ishment remained in the body is taken from it. The supply 
 of food is arrested. Salines follow, and draw on the circu- 
 lation yet more positively, and there remains the tumor as 
 at first. The pulse is now 90 or 100, weaker, and yet more 
 easily compressed. The appetite for food is gone, and in 
 order to obtain sleep, which is incompatible with her present 
 condition of weakness, you are compelled to resort to seda- 
 tives at night. Against these troubles which have interrupted 
 the natural progress of the malady the constitution strug- 
 gles, and in due course of time the mass suppurates, but 
 not healthily. It softens in the centre only, and points, and 
 you puncture it. The quantity of matter that escapes is 
 small in proportion to the solid mass it leaves behind, and 
 weeks elapse before this patient is restored to health. 
 
 Such is briefly the history of an ordinary case of mam- 
 mary abscess ; the practice adopted is general, though hap- 
 pily for humanity not invariable, and I protest, as a Hospital 
 Surgeon whose opportunities of observation have not been 
 inconsiderable, against such principles of treatment, as
 
 FIRST LECTURE. 9 
 
 irrational and preposterous, which arrest the functions of 
 Nature in her attempt to bring this disease to an early and 
 curative crisis, by the adoption of a false and radically un- 
 sound doctrine of the old school of medicine, that all diseases 
 partake of the character of inflammation, and are controlled 
 by depletive agents. 
 
 Now let us take another view of this subject ; examine 
 the evidence closely and think for yourselves. Your first 
 object is to look for the cause of disease. If you find by 
 inquiry and observation that mammary abscess prevails only 
 in weakly persons, as I have stated, that the subjects have 
 been ill-fed or are in impaired health, that they have a weak 
 pulse and bad appetite for food, what treatment would you 
 select, supposing that in such a weakly condition of the 
 health no abscess existed ? Would you not adopt a tonic 
 treatment ? Would you not administer wine and bark and 
 nutritious food, even though, true to your early impressions, 
 you threw in an occasional aperient under the title of an al- 
 terative ? Well, then, can the presence of incipient ab- 
 scess of the breast, itself a mere symptom with many others, 
 and which owes its existence to debility and debility alone, 
 as the primary cause can the presence of mere abscess 
 justify you in the adoption of remedies which tend to in- 
 crease the very evil you are endeavoring to counteract? 
 You want to give strength, and you add to the weakness. 
 You would not prescribe calomel without the abscess ; why 
 do you prescribe it with abscess ? You may reply that you 
 hope to carry off the abscess by purgation. But this is a 
 delusion. What ground have you for hoping to carry off 
 the abscess by purgation ? Have you observed one single
 
 IO FIRST LECTURE. 
 
 example in the course of years in which the employment of 
 calomel, &c., has cured, or even reduced in size, an ab- 
 scess of the breast ? No ! You have not seen it, nor will 
 you see it until Nature abandons her own laws to oblige 
 you. Now, gentlemen, if you could see this picture as I 
 have sketched it, you would shrink from the folly that pre- 
 vails so largely in the profession on this matter. You may 
 argue in justification that you have attended lectures on the 
 practice of surgery, and that you have been tanght it. 
 Very probably you have ; but who taught the lecturers ? 
 Believe me, the sooner you unlearn these errors the better 
 both for your patients and your own credit, and for the 
 honor of our profession. 
 
 Presuming these principles to be unsound, however gen- 
 erally adopted, for that is no conclusive evidence in their 
 favor, let us now consider the subject from an opposite 
 point of view. 
 
 I assume a state of debility at starting. If you doubt 
 my title to do so, observe and inquire. Inquire of men 
 largely engaged in the practice of midwifery. Are strong 
 and healthy, or are weakly women more liable to mammary 
 abscess during lactation ? You will receive but one reply. 
 If, then, weakness prevail in the system so universally be- 
 fore the occurrence of the abscess, there is no escaping the 
 inference that the weakness is the cause of the abscess, for 
 you do not meet with cases of abscess in strong healthy 
 women, but it selects for its victims the poor, ill-fed, and 
 impoverished. One of the worst cases I ever saw was 
 that of a young woman in St. Bartholomew's Hospital, whose 
 husband struggled to support a family of seven persons on
 
 FIRST LECTURE. II 
 
 about as many shillings a week. This woman was confined 
 with twins, which she half nourished on a daily allowance 
 of bad beer, and for which misery the funds of St. Barthol- 
 omew's Hospital did ample penance. 
 
 You see, then, distinctly enough both cause and effect. 
 The cause is debility the effect is abscess, commencing 
 in a deposit of a large mass of coagulated fibrin. Now, 
 which do you select for treatment, the cause of the disease, 
 or the effect ? If the effect, you leave the cause untouched 
 for the production of another abscess. It is quite true that 
 under some exceptional circumstances, by reason of an 
 urgent necessity, we are compelled to direct our remedial 
 powers against effects which imperil important structures, 
 and even life itself; but that necessity does not hold in the 
 case of a mammary abscess, which is an evil on a smaller 
 scale. Should we not consider the abscess as a mere symp- 
 tom of debility in common with other symptoms, such as a 
 weak pulse, a hot skin, loss of appetite and sleep, consti- 
 pated bowels, headache, if it exist, &c? And would you 
 for a moment think of treating these symptoms individually ? 
 No ! Then why thus treat the abscess, itself a mere symp- 
 tom, and most especially when such treatment itself essen- 
 tially and radically false to the principles of sound pathology, 
 drives you to resort to remedies which, while they aggra- 
 vate the evil of the cause by reducing the strength to a yet 
 lower level, leave the effect untouched ? Is this wisdom or 
 folly ? 
 
 Now let me ask this important question Can any evil 
 result to the constitution from leaving the abscess alone ? I 
 mean, as a local affection, can it do harm? I do not refer
 
 12 FIRST LECTURE. 
 
 to it as a source of constitutional irritation that is an evil 
 which calls for aid but is it probable that the health can 
 suffer from its absorption, supposing such a local change 
 possible ? Assuredly not. Then it is obvious that the 
 local affection, which cannot be got rid of by the means 
 suggested, or by any other means that the ingenuity of man 
 has yet discovered, should be let alone, and that the influence 
 of the curative art should be directed to the constitutional 
 health as the primary cause of the derangement. 
 
 And here, in all humility, and in the candid acknowl- 
 edgment of our impotence to deal with disease excepting 
 through the hand of Nature, let us look to the real philos- 
 ophy of our art, and throw ourselves on her ample resour- 
 ces for such aid as man cannot command, but which Nature 
 is always willing to afford. Let us endeavor to restore the 
 constitution to that condition of health and vigor it pos- 
 sessed before the crisis occurred which led to all this mis- 
 chief, and, depend upon it, in obedience to a great law of 
 Nature, which takes cognizance of all disease with a view to 
 remove it when removable, you will find your tumor gradually 
 disappear, or, what is more probable, it will pass quickly 
 through those local changes essential to recovery, whether by 
 gradual absorption, or by rapidly formed but limited suppura- 
 tion, the one or the other alternative depending on the early 
 or late resort to rational treatment. 
 
 This treatment is essentially tonic in its character. Its 
 object, as I have above stated, is the employment of such 
 medicinal and dietetic agents as tend to restore the consti- 
 tution to a condition of health and vigor. This is all we 
 can pretend to do, and, rely upon it, Nature will do the
 
 FIRST LECTURE. IJ 
 
 rest. I do not say, exclude all local treatment. Doubtless 
 a few leeches may relieve the pain, and fomentations or 
 poultices may in some slight degree contribute to the same 
 end ; but these agents are not, critically speaking, curative 
 they palliate symptoms only and, as pain is an evil, and 
 itself, when severe, a source of prostration, the Surgeon 
 may justly combat it by such remedies as draw as lightly as 
 possible on the circulation and do not reduce the vital powers 
 of the body. 
 
 There are two agents, in addition to good nourishment, 
 especially applicable to the treatment of a case of this kind 
 bark and wine. There is an inferior class of remedies, 
 but of the same character, such as bitter infusions casca- 
 rilla, gentian, and the like, and the varieties of infusions of 
 malt. There is no comparison between the virtues of the 
 two classes, but as pcor persons cannot afford wine, they 
 may afford good beer, of which the strongest is the most 
 efficient ; but among medicaments cinchona bark has no 
 rival. In all cases of abscess bark is invaluable. It pro- 
 motes suppuration when suppuration is inevitable, and it 
 checks suppuration in the exhausting action of chronic 
 abscess. It promotes appetite, and gives vigor to the sys- 
 tem beyond any other known tonic, and it is only on this 
 principle that it carries our patients rapidly through the 
 different stages of disease. I prefer the simple tincture of 
 bark, and I recommend you to administer it in full doses of 
 from one to three drachms twice a day. For adults I gener- 
 ally recommend a dessert-spoonful, and not less, and I have 
 not observed that its employment in such doses demands 
 the corrective influence of either purgative or alterative
 
 14 FIRST LECTURE. 
 
 medicine ; but, on the contrary, as I refer any temporary 
 torpidity of the actions of the alimentary canal to the want 
 of that vigor of system, and to that only, which the bark is 
 capable of correcting, so, as a rule, subject of course to 
 occasional exceptions, I leave the bowels alone. I have a 
 very limited faith in the cathartic system. In this I know 
 I am un-English ; but I am content to live under the oblo- 
 quy. On the subject of wine I have no intention of enter- 
 ing on the question how far alcohol is a source of strength 
 or of nutrition. As an ingredient in the diet scale of the 
 invalid, it is indispensable; and there is a very important 
 rule of conduct as regards its administration, the knowledge 
 of which I am most anxious to impress on your minds, and 
 which involves a principle that cannot fail to obtain your 
 concurrence on a closer observation of the nature of dis- 
 ease and the remedies pertinent to it. The prominent rule 
 I allude to is this : Administer wine or alcohol in quantity 
 regulated by its effects on the system, and not in any fixed 
 quantity determined by usage. A gentleman with a weak 
 pulse is told by his physician to take wine freely, and he 
 indulges in a bottle of claret at and after dinner, and by so 
 doing he considers himself to have obeyed the injunction of 
 his medical adviser. Now I shall select port wine as the 
 standard by which I regulate the advice I give under the 
 above circumstances ; and I am of opinion that for the 
 purposes of health three or four glasses of wine is the maxi- 
 mum quantity that, taken at any one time, can be serviceable. 
 All beyond this, answers the purpose of luxury and nothing 
 more, and is more or less injurious. Suppose a person of 
 abstemious habits takes a glass of wine, being much
 
 FIRST LECTURE. I. 
 
 fatigued from exercise, how long will he continue to feel 
 the benefit of it ? Possibly, at the outside, two hours or 
 less. The wine did good service at the time ; but the 
 effect has passed entirely away. If this person be subject 
 to a renewal of the fatigue, he can take a second glass at 
 the expiration of two hours on the same conditions, and so 
 on. He has in his fatigue the equivalent to disease, and 
 he takes the restorative with this result, that, having 
 consumed five or six glasses of wine, he is not conscious, 
 judging from his sensations, that he has taken any. 
 
 If this law be founded in truth, I say, administer wine 
 frequently in moderate quantities, or in immoderate quanti- 
 ties if they are required. You can judge for your patient 
 what quantity he can take and what he requires, and I say 
 unhesitatingly, when required, the more he takes the 
 better and the sooner he will be well, which, I presume, is 
 the object to be attained. Judge the quantity of wine then 
 required by its effects, and do not administer it in given 
 quantities. 
 
 I consider wine indispensable in the tonic treatment of 
 disease. It should be administered in moderate quantities 
 at short intervals. If too short the effect of the wine will 
 prove cumulative, and reaction will follow. The art of 
 administering alcohol, whether in the form , of wine or 
 brandy, is learnt by observation of its effects on each 
 individual ; and be assured of this, that the quantity con- 
 sumed with impunity, be it large or small, is the guage of its 
 want by the system of that person. 
 
 During the last forty years the treatment of disease has 
 undergone great and important changes, and up to a later
 
 l6 FIRST LECTURE. 
 
 date the use of wine was very exceptional. I do not over- 
 state the case when I affirm that within the period I have 
 mentioned, the consumption of wine and brandy in the 
 London Hospitals has increased at least fourfold ; and I 
 may here relate an anecdote which confirms the above 
 statement. It has, I believe, been before published, but I 
 deem it right to bring it again under your notice. In the 
 year 1848 the Treasurer of the Hospital commented on 
 the quantity of wine I ordered for my patients. He said 
 the Hospital could not warrant the large expense. I 
 inquired the number of patients 550 ; and the wine 
 consumed was three pipes per annum. I told the worthy 
 Treasurer that the consumption of wine quite surprised 
 me; that I could not understand how my colleagues could 
 manage their cases, for that I could not treat Hospital cases 
 without wine ; and I assured the Treasurer I would do my 
 best, for the credit of the Hospital, to raise the consump- 
 tion of port wine from three pipes a year to thirteen, and 
 that nothing less would satisfy me, or my convictions. 
 Twelve years elapsed, when I was again addressed by the 
 successor of the then Treasurer on some matters connected 
 with thr diet scale of the Hospital. On inquiry into the 
 consumption ui port wine, he appealed to the Apothecary, 
 who, referring to his wine-book, announced the quantity 
 annually consumed to be thirteen pipes ! I was on the 
 previous occasion the great delinquent, but now, as the 
 Treasurer declared, " You are all nearly equally bad, 
 although you still head the list." And the same change in 
 the treatment prevails more or less in every Hospital in 
 London. Although this employment of stimulants and
 
 FIRST LECTURE. IJ 
 
 tonics at the expense of depletive agents has become so 
 prominent a feature in modern practice, it does not appear 
 to have exercised much influence on the theory of disease 
 as taught in the schools, nor on the practice of the 
 profession among the community. 
 2
 
 SECOND LECTURE. 
 
 Remote causes of disease Causes definite and traceable General causes of 
 disease The aperient system Treatment by increasing the quantity of 
 healthy blood Stimulants in debility reduce the frequency of the pulse 
 Alcoholic stimulants essential Cases Diseases of animal and organic life 
 Cases in illustration of the two varieties of disease. 
 
 I NOW claim your especial attention to the subject which 
 relates to the remote or primary causes of disease, 
 than which none connected with the practice of our pro- 
 fession can be more critical or more interesting. If you 
 inquire into the recent history of a person suffering from 
 disease or illness, whatever form almost it may assume, you 
 will learn of some event or circumstance of recent occur- 
 rence that has drawn more or less suddenly, whether on his 
 circulating or nervous system, by which the vital powers 
 of his body have been reduced. This condition is com- 
 monly known under the term exhaustion, and is the result 
 of a sudden draught on the powers of the constitution, by 
 which the relations hitherto existing between the physical 
 frame and the powers of life inhabiting it, are for the time 
 deranged. 
 
 So long as health is undisturbed by any counteracting 
 agency beyond the natural wear and tear of time, life will be 
 prolonged to its full term of years, but in our path through 
 life we are liable to disturbing influences which destroy the
 
 SECOND LECTURE. IQ 
 
 equilibrium. These accidents draw on the vital powers 
 and reduce them below the level of the standard health, and 
 disease follows as an almost certain result. Let us suppose 
 a man to consume each day a given amount of food. Ac- 
 cident deprives him of a portion of this food, which I will 
 conclude equal to one-half of a day's ordinary consumption. 
 To this amount he fails in the supply of material in blood- 
 making, and his circulation is weakened in proportion. 
 That man has become more susceptible of disease, in a ratio 
 with his loss of blood, than he was prior to the occurrence. 
 Another man, under circumstances, whether of choice or 
 compulsion, sustains an unusually great and prolonged 
 physical effort, whether in walking, or riding, or in rowing, 
 of which we see abundant examples in the annual folly of 
 the university boat-race. Inasmuch as the serious conse- 
 quences of these physical efforts, on which the reputation for 
 learning of the great Universities of England appears to de- 
 pend, are remote, they are not detected. I have seen several 
 examples of disease developed in men who have undertaken 
 a walking tour in Switzerland, who have overtasked their 
 powers of endurance, have returned home exhausted by the 
 effort, and have been laid up ill for months. 
 
 Any cause which tends to reduce the quantity of blood 
 
 in the system, whether by direct abstraction or by deprivation 
 
 i of food as the source of blood, reduces the vital powers, and 
 
 \ disease or illness in some form is the consequence. The 
 
 same principle is involved in the defective supply of oxygen 
 
 to the lungs, and indeed is applicable to any, and all causes 
 
 that either reduce the blood in quantity, or impair its strength 
 
 for circulation. Any great and unusual physical effort re-
 
 2O SECOND LECTURE. 
 
 duces the powers of life in proportion to its degree, more 
 especially when coupled with loss of sleep. Exposure to 
 cold, when severe or prolonged, is a source of subsequent 
 derangement of health, and among other causes may be in 
 eluded either shock to or exhaustion of the mental powers, 
 such as great anxiety of mind or mental emotion, and labor- 
 ious and continued mental labor. 
 
 Of the above causes of disease, direct or indirect loss of 
 blood and deficient food are the most common ; and al- 
 though I have above referred to them, as also the remaining 
 causes, as sudden, they may be more or less chronic both 
 in their nature and in their consequences. I refer rather to 
 sudden and severe illness or disease as the result of some 
 sudden and palpable change in the routine of life of the in- 
 dividual, in which the evidence of cause and effect is imme- 
 diate and conclusive. I believe, then, that in the large ma- 
 jority of illnesses you may trace back the malady, be it what 
 it may, to one or other of the above incidents as its direct 
 and obvious cause : and as certainly as one or the other of 
 these causes has existed, you may with reason and proba- 
 bility look out for its result in some early attack of illness, 
 medical or surgical, local or constitutional. 
 
 Whatever function or structure is most liable to derange- 
 ment, the consequences fall upon it in the first place. It 
 may be diarrhosa, or pneumonia, or abscess, or erysipelas, or 
 rheumatism, or general debility. If you will adopt the habit 
 of tracing back the recent history of any or every patient 
 you prescribe for, laboring under positive disease, you will 
 learn something bearing upon it of the nature I have refer- 
 red to, some effort overtaxing the physical powers or reduc-
 
 SECOND LECTURE. 21 
 
 irig the circulation or nervous powers of the system ; and 
 if so, is it not a reasonable inference that all disease. begins 
 by iveakness ? The first link in this chain consists in a 
 reduction of vital power, from which reduction the effort 
 of the Physician or Surgeon consists in restoring the 
 lost power and bringing the patient back to the standard of 
 health. 
 
 In illustration of these principles I will relate a few cases. 
 A healthy lady, of about 34, consulted me on account of 
 an abscess in the breast. I concluded she was suckling a 
 child, but I was mistaken. Anxious to ascertain the cause 
 of so unusual an occurrence in an apparently healthy per- 
 son, I made every inquiry into her past recent history. 
 Have you had a blow on the breast? No. An attack of 
 illness ? diarrhoea ? any unusual or excessive loss of blood ? 
 any great muscular effort or loss of food ? All these ques- 
 tions she answered in the negative, and I was about to re- 
 linquish my inquiry when the lady said, " Perhaps I ought to 
 tell you that a few weeks ago I sat up seven successive nights 
 with a dying child." I thanked her for such important in- 
 formation, and the mystery was solved. Why should this 
 lady have abscess in the breast? She had not borne a chlid 
 for many years. There must be some cause for abscess, 
 local or general. It might have been produced by a blow, 
 but it was not. Investigation proved it to be the result of 
 sudden reduction of her vital powers by great physical and 
 mental effort. Why it assumed this particular form I know 
 not. I only know that a great cause of derangement 
 of her system had occurred, and the consequence fell 
 on that particular organ. The late Lord R. , aet.
 
 22 SECOND LECTURE. 
 
 54, whose recent and sudden death caused so painful a 
 sensation, became the subject of phlebitis consequent on 
 severe bodily exercise. His pulse was constitutionally low, 
 seldom ranging above 50, and frequently not exceeding 48. 
 There was a remarkable feature in his personal history, 
 which consisted in a singular tolerance of the effects of al- 
 coholic stimulants. No quantity that he ever consumed 
 was known to have produced any apparent effect either on 
 his spirits or on his pulse. The daily consumption of two o) 
 even three bottles of wine left his pulse as it found it, at 50 
 or 52. In the two months during which he was under my 
 care, I prescribed stimulants to the full extent of prudence ; 
 but he was as calm and as free from all indications of excess 
 in the evening as in the morning. His appetite for food was 
 large, and he indulged it. If I reduced his wine or his 
 brandy by the substitution of medicated stimulants ammo- 
 nia, aether, &c. he flagged. By the frequent resort to wine 
 in reduced quantities I raised his pulse to 56. Through- 
 out his attack he often assured me that he had never had 
 the sensation of better health in his life, and he only 
 desired my permission to get out and take exercise. 
 His left leg was first affected, which passed through all the 
 stages of obstructed venous circulation in about five weeks 
 consolidation, pain over the track of the larger veins, 
 osdema of the entire limb, and, finally, softening of the veins, 
 and absorption of the fluid. The right leg then became 
 the subject of the same disease, and, under the same treat- 
 ment, it progressed satisfactorily to its final stage. His con- 
 finement to his couch was limited to the additional term of 
 ten days, when I assured him he should take a drive. On
 
 SECOND LECTURE. 27 
 
 this information, and in the delight he felt at the termination 
 of his long and severe confinement, he struck his thigh a 
 smart blow with his open hand, to prove to me how free his 
 limb was from pain. This occurred late in the afternoon. 
 At half-past ten he had some difficulty of breathing, and he 
 broke out in a profuse perspiration. Stimulants availed him 
 not, and at half past eleven he was dead. 
 
 Here is physical exhaustion as the cause, acting on a sys- 
 tem characterized by an unusually low circulation phlebitis 
 the effect, and sudden death by embolism. 
 
 Inflammation of the uterus, or of the venous system below 
 it, follows haemorrhage in parturition. Accoucheurs with 
 large experience will confirm this fact. 
 
 Many years ago I was present at the attempt to reduce a 
 dislocation of the femur in a London Hospital. The man, 
 who was to all appearance in perfect health, was bled largely 
 from both arms and from the temporal artery. He also 
 took tartar emetic to the extent of some fifteen grains or 
 more. The quantity of blood abstracted from his circula- 
 tion must have rendered the functions of the heart a sinecure, 
 for it amounted to 120 ounces. He survived a week, and 
 died of phlebitis, as I had predicted. 
 
 I might multiply these examples, but it is unnecessary if 
 you comprehend the force of the few cases I have quoted. 
 
 The causes of disease I refer to above may be classed as 
 follows : 
 
 1. Loss of blood, whether accidental or effected at the 
 hands of science : catamenial, haemorrhoidal, &c. 
 
 2. Loss of food, or failure of the material of blood-making. 
 
 3. Excessive purgation, whether natural and spontaneous,
 
 24 SECOND LECTURE. 
 
 as in diarrhoea, or artificial at the hands of science, carrying 
 off nourishment. 
 
 4. Breathing impure air, by which the quality of the 
 blood is deteriorated. 
 
 5. Loss of sleep. 
 
 6. Excessive muscular effort, as in walking great distances, 
 boat-racing, &c., as in the annual University struggle, of 
 which it may be said the higher the rank of the antagonists 
 the greater the danger. 
 
 7. Extremes of temperature, especially of cold. 
 
 8. Great mental emotion or mental shock. 
 
 9. Protracted anxiety of mind. 
 
 Of the above sources of subsequent illness or disease, the 
 influence of the first four is received more directly by the 
 vascular system, the five latter either partially or entirely by 
 the nervous. 
 
 Before speaking of the general treatment of disease, to 
 which I shall shortly come, I wish to say a few more words 
 on the subject of some prevailing doctrines which are so 
 generally adopted by our profession, and the entire soundness 
 of which appears to me yet open to question, and inquiry. 
 Why do you order an aperient in nearly every case of disease 
 you are called to see? If the patient is strong and vigorous, 
 the dose is a full one if weakly, a milder form ; but always 
 an aperient; and generally it is combined with mercury, 
 which indeed forms the staple of the medicine all but univer- 
 sally prescribed. As we commonly go at once to the cause 
 in our treatment, and prescribe our best remedy, the natural 
 inference is that there is either liver, or intestinal derange- 
 ment as the cause of the disease. You say you desire to
 
 SECOND LECTURE. 25 
 
 unload the liver and to remove extraneous and irritating 
 
 t> 
 
 matters from the intestinal canal ; and very good treatment 
 too, if the liver is at fault and the alimentary canal demands 
 that kind of relief. But what evidence have you of it ? You 
 say the liver is congested. It is a term in the mouth of 
 nine-tenths of the profession practising medicine and surgery 
 in the dominions of her Majesty the Queen. The practi- 
 tioners on the Continent of Europe take a different view of 
 these matters, and not without some show of reason, for 
 English doctors, though I entertain the highest respect for 
 their attainments, do not monopolize all the knowledge of 
 the world. In discussing the subject, I am prepared to ac- 
 knowledge the occasional presence of constipation as the 
 result of torpid action of the bowels, in which condition the 
 liver may, or may not, be involved ; but I am myself un- 
 able to detect what appears so obvious to many others a 
 congested state of this organ, calling for large doses of chloride 
 of mercury, supposing that form of drug to be the best cor- 
 rective of the evil. 
 
 As I believe a person who is the subject of disease, itself 
 so commonly the product of exhaustion, should not undergo 
 further reduction of his strength without a good and suffic- 
 ient reason, and as I doubt the congested state of the liver 
 and find the torpid condition of the large intestine, if it exist 
 at all, an evil on a small scale, I prefer to look to the disease 
 itself (suppose it, if you please, erysipelas or any other 
 malady), and if the pulse is soft and compressible, indicating 
 distinct constitutional weakness, and not otherwise, I prescribe 
 at once a tonic remedy. I look upon this torpid condition 
 of the large intestine for, observe, nearly all constipation
 
 l6 SECOND LECTURE. 
 
 is limited to this part of the alimentary canal as merely a 
 symptom of the general debility, and is increased by loss of 
 appetite and the absence of food, and is not to be rudely and 
 violently assaulted by drastic purgatives; and one of the 
 first signs indicating the sound principle of a tonic treatment 
 will appear in the gradual, but certain, restoration of the func- 
 tions of the alimentary canal to a state of health. Consti- 
 pation is very commonly, though not invariably, the con- 
 comitant of weak health a.nd low vital power, and is 
 caused by defective power of the muscular fibres of the 
 large intestine, which are, when compared to the small intes- 
 tine, very limited in quantity in relation to the size of the 
 intestine. You treat constipation by means of purgatives 
 which act on the mucous membrane only, I prescribe iron 
 to give tone to the muscular coat. Your treatment affords a 
 temporary and transient benefit ; mine is a permanent one. 
 Which will you prefer ? 
 
 And this subject leads me to add a few words on the 
 treatment of disease adopted by my own respected teacher, 
 Mr. Abernethy, who upheld the doctrine that health de- 
 manded the daily action of the bowels, and that the liver 
 was an offending organ requiring the daily administration of 
 a stimulant or a supposed provocative to the secretion of an 
 increased quantity of bile. No doubt Mr. Abernethy's 
 treatment was to an extent successful, because, as the ten 
 dency of the large majority of diseases is towards recovery 
 at the hands of Nature, his cases prospered like those treated 
 on other principles. In these days one does not quite com- 
 prehend how a man of Mr. Abernethy's grasp of intellect 
 could delude himself with the idea either that disease could
 
 SECOND LECTURE. 2J 
 
 so generally depend on torpidity of the liver, or on imperfect 
 action of the muscular coat of the large intestine. If it be 
 necessary to obtain as the requisite condition of health a 
 daily action of the bowels, why did Nature give us large in- 
 testine sufficient to contain at least a week's consumption of 
 food! 
 
 In cases of extreme weakness good service is often ren- 
 dered by "locking up" the bowels, and reducing their action 
 to that of alternate days. 
 
 I consider the treatment of the great majority of diseases to 
 consist in increasing the quantity of healthy blood and giv- 
 ing force to the action of the heart. You can't cure disease 
 . with a feeble pulse. Mend the pulse, and Nature will do 
 the rest of the work. On this principle disease in general 
 may be treated, so far as my observation has gone, with pre- 
 eminent success. In order to appreciate fully its force, you 
 must start with the conviction that Nature cures and not 
 man man removes obstructions from her path, and nothing 
 more. This done, he awaits the onward move of the great 
 machine, like to a great ship of gigantic weight, which, 
 quietly held in her position at rest by a few timbers, im- 
 mediately obeys the great natural law of gravitation on 
 their removal, and glides into the water below. Did man 
 launch this vessel, or did Nature ? With as much title 
 may the Phvsician or the Surgeon declare that he cured 
 a disease. There are of course occasional exceptions to 
 this assertion in some cases of operative surgery. 
 
 The object of treatment is to restore the pulse to its nor- 
 mal standard of force and frequency. Give it due force, 
 and the heart will determine the number. As a rule, in
 
 28 SECOND LECTURE. 
 
 cases of debility, it is too frequent, and frequent, because 
 the quantity of blood in the system is below the standard of 
 health. Increase the quantity and the pulse falls. Assure 
 yourselves of this. Unthinking persons jump to the con- 
 clusion that brandy or other stimulants necessarily raise the 
 pulse, but this supposes that we start with a healthy pulse 
 at par. I am talking not of health, but of disease. In my 
 capacity of Examiner at the College of Surgeons, I often 
 put this question. If you take a pint of blood from a 
 healthy man of 40, with a standard pulse of 68, what effect 
 will be produced on the number of pulsations by the loss ? 
 What do you imagine is the frequent reply ? " It reduces 
 the number to 60 !" And this curious answer explains 
 something of the phenomena of venaesection so universally 
 practised some years ago, when in reporting on a case it is 
 said, " His pulse rose on bleeding, and so I bled him again." 
 As a rule, you will find that, whenever the frequency of the 
 pulse is above the standard of health, as an indication of de- 
 bility, a stimulant will reduce it. I tried this experiment, or 
 rather I obtained this test, for it was not an experiment. On 
 coming out of a Turkish bath of something more than the 
 usual intensity of heat, my pulse had risen to 90 ; I drank 
 about two ounces of wine, and my pulse fell to 75 within a 
 few minutes. 
 
 I have something more to say on common matters 
 relating to the routine of every day's practice. There is 
 great repugnance prevailing in the medical mind to the 
 employment of stimulants. It is, perhaps, mainly founded 
 on the moral evils of excess. Inebriety is a low, vulgar 
 vice, and therefore the agents producing it are morally
 
 SECOND LECTURE. 29 
 
 objectionable and medically injurious ; but you must draw 
 a distinct line between health and disease. In health I am 
 the advocate, both in precept and example, of moderation, 
 in disease not. I think one reason why stimulants are so 
 little resorted to in cases of debility is because, being 
 administered in hesitating quantities of doubtful utility, their 
 value is not appreciated. You must not gauge the capacity 
 for alcoholic stimulants in disease by the capacity of the 
 same person in health. Those only who adopt this 
 treatment as a principle are cognizant of the remarkable 
 tolerance of stimulants under great prostration of the vital 
 powers, and when required as the antidote to prostration I 
 maintain they are perfectly harmless. It is the remarkable 
 tolerance of alcoholic stimulants in these persons to which 
 I wish to direct your earnest attention. You can't 
 intoxicate these people ; you cannot even unduly excite 
 them. It is a common remark among observant persons 
 under treatment, "I drank three glasses of wine, but it had 
 no more effect on me than so much water ; " whereas less 
 than the same quantity during health would have produced 
 partial intoxication, or at all events excitement. These are 
 the persons who demand the free and fearless resort to 
 stimulants, and to whom alcohol is life. 
 
 Do not, I again urge upon you, measure the quantity to 
 be administered by the glass. Gauge it by its effects, and so 
 so long as weakness prevails, indicated by the pulse, persist 
 in its use ; and as you proceed in your treatment, and the 
 services of the wine become more and more palpable, you 
 will not fail to see that its consumption becomes less and 
 less essential to onward progress, and in the course, it may
 
 JO SECOND LECTURE. 
 
 be of months, of weeks, or even of days, you will reduce 
 the quantity to the standard of health, for the capacity for 
 wine has passed away with the disease that claimed it. 
 You need never listen to the objection, often urged, that 
 the resort to stimulants will become habitual ; be assured it 
 is entirely groundless. 
 
 Now listen to the following examples of this principle of 
 treatment. A young lady whose daily consumption of 
 wine has never exceeded two glasses, oppressed by the 
 heat of a crowded room, faints. The heart and the brain 
 have failed in their functions by reason of the imperfect 
 oxygenation of the blood. Recovering from the first stage 
 of sudden depression of her vital powers, her symptoms 
 pass into those of hysteria. We have all witnessed cases 
 of the kind. Ordinary and mild stimulants are unavailing, 
 and make no impression. An hour, two hours, have 
 elapsed, and she is yet prostrate. Before her recovery this 
 sirl has consumed three wine-glasses full, or upwards of 
 half a pint, of brandy and other cordials, and often more. 
 What is the explanation ? What is the physiology of this ? 
 Had you administered this quantity to your patient during 
 health you would have done her a serious injury. She 
 now takes it with benefit and with absolute impunity. The 
 shock to her system was for the time dangerous ; the 
 stimulant, given at another time, would have proved 
 dangerous also ; the two united are harmless. The one 
 has balanced or antagonised the influence of the other. 
 There remains neither headache, nor nausea, nor any 
 evidence of excess, because all the stimulating power of 
 the brandy was required and consumed in re-establishing the 
 circulation.
 
 SECOND LECTURE. JI 
 
 Again : A gentleman of abstemious habits, ill clothed 
 for the occasion, ventured, in a cold season of the year, to 
 mount to the summit of a mountain in Wales. He was 
 seized with intense and sudden prostration from the effects 
 of the temperature. His suffering was severe. At this 
 opportune moment, a friend supplied him with a half-pint 
 bottle of raw brandy, every drop of which he drank at a 
 draught, as he would have drunk a glass of table beer. 
 The only effect produced on his system was warmth. He 
 drank more brandy at that moment than he had ever before 
 consumed in a week. No evil resulted. The cold and 
 the brandy being in antagonism, each entirely neutralised 
 the injurious effects of the other. I need not say that a 
 similar draught, unprotected by the depressing influenceof 
 the intense cold, would have proved almost dangerous to 
 life itself certainly most injurious to health. 
 
 I attended in his last illness the late Duke of , a 
 
 man of remarkably abstemious habits. His malady was a 
 mortal one. Some months prior to his death he became 
 the subject of frequent attacks of rigors, which continued 
 with great severity for two or three hours, and left him in 
 a condition of extreme prostration. I called one day 
 opportunely, and found him laboring under one of these 
 attacks. I gave him two-thirds of a wine-glass of raw 
 brandy without effect. In five minutes I repeated it, and 
 he took a wine-glassful of brandy every seven or eight 
 minutes till the attack passed off. He had then consumed 
 three-quarters of a bottle of pure brandy within an hour. I 
 saw him in four hours afterwards, apparently well. In 
 reply to my question, " How do you feel ?" he answered,
 
 J2 SECOND LECTURE. 
 
 " Well, I think you gave me pretty large doses of brandy, 
 but I cannot say I feel in any respect the worse for it." 
 Nor was he. Throughout his subsequent illness he had 
 no attack of rigors. The prostration of the vital powers 
 in this case must have been immense. 
 
 One of the last cases attended by a late eminent Physi- 
 cian now, unhappily for the cause of Medical Science, 
 lost to the profession was a gentleman of about 30, who 
 was the subject of hydrothorax. His case was urgent, and 
 I was requested to see him. Concurring in opinion with 
 the Physician in attendance on the necessity of giving 
 immediate relief by operation, I punctured the chest and 
 got away six pints of serous fluid. The cavity thus made 
 was entirely occupied by atmospheric air, to the admission 
 of which I have never yet ascertained the grounds of 
 objection, or seen any injurious result therefrom. I have 
 done this operation often, and have never considered it 
 desirable to exclude the air from the cavity within. Though 
 irrelevant to my subject, I cannot forbear asking the simple 
 question, What is supposed to occupy the space from 
 which the fluid has been removed ? Certainly the lung 
 will not immediately expand, and the walls will not collapse 
 for a period of weeks or months. At the conclusion of 
 the operation the patient was much exhausted, with a 
 pulse of 130. It was a great object in the treatment to 
 reduce it. What means would you have adopted : What 
 does professional usage demand ? Salines, think you, or 
 purgatives ? No, on the contrary. He took the only 
 remedy that could have probably saved his life. He was 
 ordered one oz. of brandy diluted with an equal quantity of
 
 SECOND LECTURE. JJ 
 
 water every three hours, and on the day following his pulse 
 had fallen to 90, and he recovered. If this treatment was 
 not sound, it ought to have proved fatal. 
 
 I have abundant examples at hand of the efficacy of this 
 principle, but I have quoted sufficient for my present 
 purpose. They go to exemplify this therapeutical principle 
 viz., i. That stimulants alone can restore the vital 
 powers under great and sudden prostration; and 2. That 
 under great and sudden prostration the capacity of the 
 system for stimulants is enormous, and that they may be 
 administered to almost any amount with safety. 
 
 Now, gentlemen, in the prosecution of your profession, 
 while engaged in the study of by far the most critical 
 department of medical education the nature of disease, or 
 diagnosis have you ever thought of the important 
 distinction which exists between the diseases of Animal and 
 Organic life ? And yet they are worth considering. A 
 few years ago I made some calculations on the subject of 
 the relative quantity of blood supplied to each. I have not 
 these calculations at hand, but the quantity of blood so , j 
 distributed is nearly equal, though rather the largef 
 proportion supplies the structures of Animal life. 
 
 The nerves, as you know, are essentially different. 
 Animal life being spinal, Organic life, ganglionic. If we 
 take the whole material of the body into the calculation, 
 the structures of Organic life do not exceed one-tenth of 
 the actual weight, yet they receive nearly one half of the 
 whole quantity of arterial blood. 
 
 The " two lives," as they were termed by the great 
 French physiologist, Bichat, are more or less independent 
 3
 
 34 SECOND LECTURE. 
 
 of each other, both in health and in disease. The diseases 
 of Organic life are more serious, because they involve 
 structures more directly essential to life itself, and the 
 derangement of any one of them involves the whole 
 system more thoroughly, than does a similar amount of 
 disease in the structures of Animal life. 
 
 You will hear a man say " he can't have much wrong 
 with him," because he is capable of great exercise, and can 
 walk any reasonable distance. This is a bad test. So 
 long as the muscular system is not directly involved, and 
 sufficient blood is made to supply both it, and the spinal 
 cord, from which it derives its nerves, a man may labor un- 
 der considerable amount of disease of the structures of organic 
 life without his muscular system being involved. When we 
 speak of a man's " health " in general terms, we refer in- 
 stinctively to the functions of the interior of the body, or of 
 the organs, not of the muscular system ; we refer to the 
 functions of the brain, to respiration, to circulation, to di- 
 gestion, and the assimilation of food, &c. The muscular 
 is but subservient to these other organs which really consti- 
 tute life itself. 
 
 You will find this subject, which makes palpable the 
 broad distinction between the two classes of diseases, one 
 of the most interesting connected with the study of your 
 profession. It marks the subsidiary character of the mus- 
 cular system, and of the structures subservient to it, as 
 holding secondary rank in the general economy of the body, 
 while its deviation from health influences the economy in a 
 secondary degree only. You can form no true gauge of a 
 man's capacity for muscular effort, however perfect may
 
 SECOND LECTURE. 
 
 35 
 
 be all his attributes of health, any more than you can rightly 
 infer the soundness of his organic system because his capa- 
 bilities of prolonged physical effort are great. Take the 
 
 case I have above quoted of Lord R , a man capable of 
 
 unusually great muscular exertion, and who could walk for 
 hours without fatigue, while his heart and arterial system 
 betrayed a condition of weakness which suddenly termin- 
 ated his life. 
 
 A yet more remarkable example is found in the case of a 
 young gentleman who died some years since, whose mus- 
 cular system was the subject of a form of paralysis, first de- 
 scribed by Dr. Meryon in a paper in the Medical and 
 Chirurgical Transactions, and subsequently by Cruveilhir, 
 in which the muscular filaments of animal life failed in their 
 development throughout the body, while all the organs 
 within the body, and the organic muscular fibres subser 
 vient to them, gave evidence of perfect health. I have a 
 young gentleman under my care at the present time whose 
 physical frame is characterized by remarkable muscular 
 power. His strength is prodigious. But he has a feeble 
 pulse, is very susceptible of cold, and is subject to fainting 
 fits that are all but alarming. 
 
 But it is scarcely necessary to refer to individual exam- 
 ples which proclaim the subservient nature of the muscular, 
 to the organic system of our frame. It may be seen at every 
 step of our professional lives.
 
 N/ 
 
 THIRD LECTURE. 
 
 ON HYSTERIA OR GENERAL AND LOCAL NERVOUS IRRI- 
 TATION. 
 
 Imitations of real disease The study of, much neglected by the profession 
 Indicated by local pain and muscular spasm Distinct from inflammatory 
 diseases The term " Hysteria" objectionable Nature and source of Hys- 
 teria Errors in diagnosis Critical examination of cases Hysteric affection 
 of joints Hysteric affections of the spine Hysteric contraction of 
 fingers. 
 
 IN the whole range of practical surgery there is, perhaps, 
 no one subject that claims your earnest study more impor- 
 tant than that which I have selected for this and the following 
 lectures. It is not a question of diagnosis between two 
 diseases more or less resembling each other. It is a question 
 of disease or no disease, of reality or imitation, of true or 
 false of whether your purgatives, your bleedings, sweat- 
 ings, irritants and counter-irritants, and your whole battery 
 of antiphlogistics, shall be launched against a true disease in 
 the flesh, or its ghost whether you are to contend with a 
 reality or a shadow. This absence of discrimination be- 
 tween two conditions of disease and no disease are painfully 
 frequent among medical men, especially among those to 
 whose charge is assigned the care of local and surgical dis- 
 eases. " In one shape or another," observes the greatest of 
 modern surgeons, " you will meet with them at every turn 
 of your future practice."
 
 THIRD LECTURE. 
 
 37 
 
 It may be asserted with truth, that every part of the human 
 body supplied with nerves, be they cerebral, spinal, or gang- 
 lionic, may become under provocation the seat of local 
 symptoms so closely resembling those of the real disease to 
 which that part of the body is liable, as to appear identical 
 with it, and the resemblance to which is so perfect as to 
 deceive the best of us. They are not cases of occasional 
 or rare occurrence. They come before us in the daily and 
 hourly walks of professional life. They monopolize a share, 
 and not a small one, of all cases under treatment, whether 
 medical or surgical, but the latter predominate. The closer 
 you scrutinize them, the more penetrating your inquiry 
 looking into, and not at them the more perfect will 
 be your diagnosis, and the more will you be astonished 
 that a form of disease so remarkable and so com- 
 mon should have hitherto occupied so little of your 
 thoughts. 
 
 It is well to call your attention to this description of 
 malady at the early stage of your professional career. Many 
 men pass through life, engaged in active warfare against dis- 
 ease, on whose convictions this variety has scarcely dawned. 
 And this is a truly remarkable fact, which owes its existence 
 to the predominating influence which the heart and the 
 arterial system exercise over the judgment of the profes- 
 sion at the expense of a system yet higher in the scale of 
 organization, more sensitive, and far more liable to morbid 
 impressions viz., the cerebro-spinal nervous system. 
 
 Whenever a new case of disease presents itself to us, we 
 jump to the old doctrines of inflammation, we talk of conge's- 
 tion, and of capillary action, and of deposit of lymph, and we
 
 ^8 THIRD LECTURE. 
 
 refer the attendant pain and heat to an inflammatory condi- 
 tion, of which the local nervous derangement is an ordinary 
 symptom. We should endeavor to assign to each system 
 its proper place in the pathological scale, and to discrimin- 
 ate more accurately than is generally done, the indications 
 which belong to the morbid conditions of each, whether ex- 
 isting in combination or separately. For be assured they 
 do exist, both separately and in combination with each other. 
 You may have varieties of inflammation in which the local 
 pain is trivial when compared with its severity in other cases ; 
 while, on the other hand, examples daily occur in which 
 local as well as general derangement of the nerves, whether 
 of the part or of the whole body, exists as a morbid condi- 
 tion entirely independent of the vascular system. Nor is 
 this derangement confined to the sensory nerves. If we 
 have local pain as the indication of excessive activity of the 
 nerves of sensation, we have spasms and convulsions indi- 
 cating derangement of the nerves of motion, each of which, 
 or both, may prevail without heat, or redness, or swelling. 
 We daily see severe forms of nervous exacerbation without 
 the slightest corresponding increase of action of the vascular 
 system. There is this important difference between the 
 morbid states of the vascular and nervous systems, that 
 while local inflammations are dependent on local causes, ag- 
 gravated only by the impaired condition of the general health, 
 local nervous diseases for the most part originate in the cen- 
 tres of nervous power, the effects of which are exhibited in 
 remote parts of the body it may be in a pain localized in a 
 given spot, whether on the surface or in deeply seated parts 
 which to our senses holds no especial relation to its nervous
 
 THIRD LECTURE. 
 
 39 
 
 centre ; it may be in a temporary, or- spasmodic, or perma- 
 nent contraction of the voluntary muscles bending the joints 
 of the extremities in permanent flexion, or obliquely draw- 
 ing the head upon the trunk, or involving the whole motor 
 system, as in tetanus. No known nerve that conveys sen- 
 sibility from its centre to its periphery no motor nerve 
 that carries volition from the brain or spinal cord to a volun- 
 tary muscle is exempt from this morbid tendency. 
 
 The vascular system, consisting of arteries, capillaries, 
 and veins, has its own special diseases peculiar to the struc- 
 tures engaged in the circulation of the blood. The attend- 
 ant symptoms are heat, redness, pain, and swelling, the lat- 
 ter symptom being due to a separation from the capillary 
 system of some constituents of the blood, whether in a fluid 
 or solid form, while the morbid conditions of the nerves and 
 the structures in which they originate are characterized by 
 simple aggravation or excess of the functions of the nerves 
 affected, the natural sensibility of the sensory nerves running 
 into pain, and the moving power of motor nerves into con- 
 vulsions, or spasm, or permanent contraction. In diseases 
 of the vascular system we have changes of structure ; in the 
 latter not. It is necessary to make very clear the line 
 which separates the two classes of disease, lest we fall into 
 the common error of applying to both the remedial agents 
 which are applicable to one only. 
 
 The diseases originating in or involving the vascular 
 system we treat locally by various agents leeches, blisters, 
 &c. ; in diseases confined to the nervous system these 
 local remedies are useless and even injurious, and we treat 
 them through the constitution. In cases of Tic do we
 
 40 THIRD LECTURE. 
 
 derive benefit from leeches, or blisters, or from other form 
 of depletive agents ? Assuredly not. 
 
 Now the disease which forms the subject we have to 
 consider belongs to the nervous and not to the vascular 
 class ; and I select from this variety that occasionally 
 known under the term " Hysteria," than which no name 
 can be more inappropriate or objectionable. It may well 
 be doubted whether, except under very occasional 
 circumstances, such a relation holds between the uterus 
 and this remarkable train of symptoms as to justify the 
 employment of the term Hysteria. In the large majority 
 of cases there is no connection between them beyond that 
 which the disease holds with the other organs of the body. 
 In the name of a disease we are supposed to recognize its 
 form and nature, whereas the term I have quoted conveys 
 to the mind no distinct idea of either one or the other. 
 And there is a positive objection to the resort to it, in the 
 fact that the word carries with it the association of a 
 malady of small and insignificant dimensions, while the 
 malady itself is of great magnitude. We associate with it 
 the idea of " hysterics " and " vapors," as they were 
 formerly called. I wish to raise your attention to the 
 level of a great malady, and not of a trivial derangement 
 of the hour. I remember a law case in which the counsel 
 challenged a medical witness as to the name of the 
 disease, and he replied, Hysteria. " Hysteria !" said the 
 learned counsel, addressing the jury ; " We all know 
 what Hysteria means. My client has come into court 
 to obtain compensation from a jury of his country for a 
 permanent injury, by which all his prospects are blighted.
 
 THIRD LECTURE. 4! 
 
 &c., &c., and the gentleman in the witness-box, with 
 no sympathy for his misfortune, proclaims the disease 
 to be that of trumpery hysterics ;" and the jury, with rod 
 in hand, let it fall heavily on the defendant's back. 
 
 But there is a more solid objection than these, viz., that 
 it is founded on a false pathology, by the employment 
 of a term that conveys an impression of its source and 
 nature, founded in error. The disease consists in the 
 local evidence of some irritation or derangement of one or 
 the other of the nervous centres of the body, viz., the 
 brain or the spinal cord at least, such is the received 
 pathology. But the subject is a very obscure one. We 
 have no very definite idea of what we mean by 
 " irritation." We all employ it, and so general is its use 
 that I don't know how we can get on without it. 
 " Irritation of the nervous centres " is a useful and not an 
 ill-sounding phrase, though somewhat mysterious, but it 
 is no reflection on medical science that we cannot explain 
 all the phenomena of life ; and as the term is somewhat 
 wide in its application, and does not commit its employer 
 to any very defined opinion on obscure matters, on which 
 it is very difficult to form any opinion at all, I presume we 
 shall retain it. 
 
 One good reason that may be assigned for the persistent 
 employment of the term Hysteria a term we all know to 
 be objectionable is the difficulty of finding a substitute for 
 it. We call the disease " local nervous irritation." It is- 
 11 exalted nervous sensibility ;" but in naming a disease so- 
 definite as this we require a term equally pointed and definite 
 with the thing itself. That we have not got. Sir B.
 
 42 THIRD LECTURE. 
 
 Brodie says, " I employ the term Hysteria because it is in 
 common use, but the etymology is calculated to lead to 
 great misapprehension." 
 
 Failing the name, let us look to the thing, and if it be so 
 critical as I have assured you, let us attach to it the grave 
 importance its frequency and its magnitude demand. 
 
 It may be asserted with truth, that every part of the body 
 may become, under provocation, the seat of an apparent disease 
 that in reality does not exist that it may and often does as- 
 sume all the attributes of reality with an exactness of imita- 
 tion which nothing short of careful and accurate diagnosis 
 can distinguish from the real disease. You think this im- 
 possible. Surely you know a diseased knee-joint, you reply,' 
 when you see it. You find severe pain, aggravated by the 
 slightest movement. The temperature of the joint may be 
 raised, and it is slightly swelled. You leech, you blister, 
 you employ an iodine liniment (few cases escape it), you 
 may even resort to issues, but the evil remains in spite of all 
 your remedies, which have been applied to the wrong "sys- 
 tem." It is the nervous, not the vascular, that is involved, 
 but the nervous has imitated the vascular and deluded you, 
 and led to the employment of false remedies, which have 
 failed to reduce the pain or give mobility to the joint, and 
 the general influence of which on the health of the patient 
 cannot be said to have proved eminently serviceable. 
 
 The case on more perfect investigation, proves to be one 
 of local nervous irritation, or Hysteria. You think you will 
 not be again deceived, but you are mistaken. A sin- 
 gle error, corrected by the experience of another, will not 
 teach you Hysteria. You are consulted by a lady in ref-
 
 THIRD LECTURE. 
 
 43 
 
 erence to a daughter eighteen or twenty years of age, who 
 has exhibited failing health for some time, and now com- 
 plains of her inability to walk in consequence of a pain in 
 her back. You examine her, and discover that she suffers 
 extremely on pressure over two or three of the lower dorsal 
 vertebrae, or on any other of the twenty-four. You repeat 
 the examination with the same result, and you make a re- 
 port to the mother that her daughter has "spinal disease" 
 The result of your opinion is two or more years' confine- 
 ment to her couch, coupled with the usual concomitants of re- 
 stricted diet, alterative and other depletive medicines, leeches, 
 blisters and issues. Suppose those structures which you 
 have declared to be the seat of organic disease to be exam- 
 ined under a microscope, what would you discover? Noth- 
 ing. There is no disease whatever. As the nature of this 
 malady dawns upon you, now awakening to a conviction of 
 its frequency, you resolve to be more wary in your future 
 diagnosis. 
 
 You are now consulted by another young female patient 
 on account of a tendency in one or more fingers to close in 
 flexion. In the attempt to straighten them you cause in- 
 tense pain, and if persisted in the consequences may be 
 serious. Your patient appears in fair average health, and 
 all her functions are regular and healthy ; while the hand, 
 for all ordinary purposes, is useless. Under the idea that 
 she may have some chronic inflammation of the theca or 
 of the palmar fascia, you treat it with the usual remedies. 
 But your remedies produce no impression on the finger, 
 which continues obstinately flexed as before ; you adopt 
 another principle of treatment founded upon a more correct
 
 44 THIRD LECTURE. 
 
 diagnosis, and your patient recovers. These cases sound 
 strange to your limited experience. You think they are 
 rare, and brought forward from a distance, and with an 
 effort. By no means. They are cases of daily occurrence. 
 If you could suddenly throw off that nebulous vision of 
 vascular disease which years of bad pathology have im- 
 pressed upon your judgment, you would see them in their 
 true light. You may deem them to be exceptional. I assure 
 you they constitute the rule of disease, and not the excep- 
 tion. Real disease is the exception. Speaking of one variety, 
 and they have all characters in common, Sir B. Brodie, a 
 man who rarely committed an error in diagnosis, says : " I 
 do not hesitate to declare that, among the higher classes of 
 society, at least four-fifths of the female patients who are 
 commonly supposed to labor under diseases of the joints, 
 labor under Hysteria and nothing else." I would venture 
 to enlarge this statement as regards the " upper classes," 
 by including a large proportion of the lower; for much of 
 my own experience of Hysteria has been obtained from the 
 wards of St. Bartholomew's Hospital, and in reference to 
 spinal affections in young persons, I unhesitatingly assert 
 that real disease is not found in a greater proportion than 
 one case in twenty, and even this is a liberal allotment. 
 
 Have you never experienced the difficulty of discovering 
 an object floating on the air, such as a bird singing overhead, 
 or an early star in the evening ? When once the object 
 becomes visible, the eye is readily adjusted to it, and when 
 you look again in the right direction, it is the first object 
 that strikes the eye.
 
 THIRD LECTURE. 
 
 45 
 
 And so with this class of diseases. They are not seen, 
 because they are not looked for. If you will so focus your 
 mental vision and endeavor to distinguish the minute texture 
 of your cases, and, as I have said, look into and not at 
 them, you will acknowledge the truth of the description, 
 and you will adopt a sound principle of treatment that meets 
 disease face to face with a direct instead of an oblique force, 
 which far too generally claims the credit of a success for 
 which nature alone is responsible. 
 
 I have selected above three varieties of this local hysteric 
 affection. Let us consider them a little more in detail, 
 with a view to detect the fallacy which classes them under 
 diseases of the first or vascular division, by which I mean an 
 abnormal condition of the blood-vessels, leading to changes 
 of structure, or altered relations of the parts, whether by 
 suppuration, or ulceration, or fibrinous deposit, or local 
 death of the tissues involved. In the first case the knee is 
 the seat of pain. The subject is a young female. What 
 evidence do we commonly look for when the joint is really 
 diseased ? We look first for a cause. Diseased joints do 
 not occur without a palpable one, and particularly in young 
 persons. There has been no violence, no fall or blow, to 
 which to attribute it. Had there been, the nature of 
 the disease is obvious enough. There is no consid- 
 erable increase of heat, and if inflammation is present 
 perceptible increase of heat is constant. There is no effu- 
 sion into the joint; the form of the articulation is un- 
 changed. The pain and the immobility or stiffness of the 
 joint remain, notwithstanding your remedies. Local deple- 
 tion relieves the pain of inflammation, but not of Hysteria.
 
 46 THIRD LECTURE. 
 
 But you persist in your principle, and the depletive treat- 
 ment is continued, and thus months elapse yes, even years, 
 I was onee told by a young lady that she had applied twenty- 
 seven blisters to her knee-joint, from which she could not 
 say she had derived any benefit. Now, it ought to be ob- 
 vious that, if a painful joint occurring in a young female 
 without local cause is unaltered in form or size, and is free 
 from heat or redness, and that the chief and almost the only 
 symptom, that of pain, varies in degree at different times, 
 and is fluctuating in character, the disease is not of the in- 
 flammatory class ; and if not it must be nervous, and you 
 can't cure pain with leeches. You know that pain alone, 
 which consists in an exalted nervous sensibility, does not 
 constitute what we strictly understand by the term disease^ 
 although we apply it generally to any deviation from health, 
 whether local or constitutional. At length the truth is 
 brought home to you. You change your treatment by the 
 substitution of local sedatives and general tonics, and your 
 patient at once moves forward in the direction of recovery. 
 Take the second case. You have declared your opinion 
 that this girl is the subject of disease of the spine upon the 
 single evidence of local pain produced by pressure of the 
 fingers on the spinous processes of the vertebrae. It has 
 eecaped your observation that this pain is equally severe 
 whether pressure is slight or not. In fact, the degree of 
 pain indicated either by writhing or exclamation holds no re- 
 lation to the force of the pressure made. The slightest 
 touch creates as much suffering as the greatest pressure of 
 the hand, and often more. It is on this evidence alone you 
 have founded your opinion of disease of the bony structure
 
 THIRD LECTURE. 47 
 
 of the spinal column. It is on this evidence you have con- 
 signed this young lady to two years' confinement to her 
 couch, to the loss of education, to restricted social and do- 
 mestic intercourse with her family and friends, and to much 
 moral and physical suffering. Now when you talk of dis- 
 ease of the spine, what do you mean ? What structure is 
 diseased, and what form of disease is present ? Is it seated 
 in the body, or in the processes of the vertebrae, or in the en- 
 tire bone ? and what description of disease has invaded the 
 particular vertebra of the twenty-four ? Is it inflamma- 
 tion, or caries, or necrosis ? Caries you will say ; and you 
 select this form because, and only because, you know the 
 spinal column is the subject of carious disease under condi- 
 tions favoring it. But there is this remarkable feature in 
 carious disease of bone well worthy of notice viz., that it 
 is almost destitute of pain, that there exists no relation be- 
 tween the extent of the disease, which may be great, and 
 the pain attendant on it. It is not like inflammation of bone 
 whether simple or severe ; nor does it resemble necrosis or 
 simple death of bone. Presuming this statement true, can 
 you in reason feel satisfied with the evidence of disease ob- 
 tained by manual pressure ? Then, again, where is the 
 disease situated ? what is its precise locality ? If in the body 
 of the vertebra, is it not almost absurd to suppose you can 
 detect it by the slight pressure of the finger on the summit of 
 the spinous processes, which are themselves rarely involved ? 
 
 Fifty or sixty years ago a provincial urgeon of some note 
 recommended the application of a hot sponge to the spine, 
 with a view to detect disease of the bodies of the vertebrae. 
 There was some excuse for ignorance on this subject at
 
 48 THIRD LECTURE. 
 
 that time ; there is none now. Of all the fallacies that cling 
 to professional practice, of all the false doctrines which the 
 pardonable ignorance of a former generation has entailed on 
 modern surgery, none can surpass that which affects to de- 
 tect carious disease of the body of a vertebra by drawing the 
 fingers down the spine. It is only not ludicrous because 
 the consequences are so serious to the victim. It 
 would be a bold assertion that such morbid changes in the 
 spinal column cannot occur ; but I do think humanity 
 would be a gainer if all teachers concurred in asserting that 
 they could not, so rare is the real disease, and so palpable to 
 the eye when present. Suppose a young person in moder- 
 ate good health, and occupied in daily exercise, complained 
 of a pain it the condyle of the femur, without any other in- 
 dication, should you be warranted in declaring she had 
 serious disease of the bone ? Look to the functions of this 
 important vertebral column ; how is it possible it can sup- 
 port the body in an upright posture if one or more of the 
 component bones of the pillar are destroyed ? And yet I 
 have known many examples in which the subject of this 
 imaginary disease has joined a party and danced for the whole 
 evening. One wonders that such a person did not drop 
 into pieces ! For myself I candidly declare that I have 
 scrcely ever seen a case of true disease of this form. I can 
 bear testimony to spinal affections and destruction of bone to 
 any amount in psoas or lumbar abscess, or in angular curva- 
 ture, or to damage done to the column by local injury ; but 
 to these suppositions cases which exist only in the brain of 
 the surgeon, I am a stranger, and if they exist otherwise 
 than as rare examples of spinal disease I have much to learn.
 
 THIRD LECTURE. 
 
 49 
 
 Have you ever seen a person recover from actual disease 
 of the spine ? I do not mean to infer that death inevitably 
 follows, though that result is by no means uncommon ; but 
 I allude to recovery without some distortion or some per- 
 manent evidence of past disease. And yet you may be sur- 
 prised when I assure you that all these young people recov- 
 er sooner or later sooner if the surgeon in attendance is fa- 
 miliar with hysteric affections, later if he is not. Thirty or 
 forty years since these cases were, happily for our time, far 
 more common than at present. At that date, and for how 
 many years anterior I know not, all the sea-side towns were 
 crowded with young ladies between seventeen and twenty- 
 five years of age and beyond it, who were confined to the 
 horizontal posture, and were wheeled about on the shore in 
 Bath chairs, on the supposition that they were the subjects 
 of spinal disease. They were placed under much medical 
 and dietetic discipline, not of the most invigorating charac- 
 ter, and the large majority carried a pair of handsome issues 
 in the back. Brighton, Worthing, Hastings, and other places 
 on the South Coast were largely tenanted by these unfor- 
 tunate females, to which a moderate sprinkling of young 
 gentlemen was added. What has become of all these cases ? 
 They appear to have vanished just in proportion as the eyes 
 of the surgeon have opened to the absurdity of inferring 
 that pain alone which locates itself with remarkable decis- 
 ion is Hysteria on a given vertebra, can indicate the presence 
 of organic disease of the body of the bone without collateral 
 evidence in its favor. When the spinal column is really dis- 
 eased the case is obvious at a glance ; the health is degen- 
 'erated, and the whole system proclaims to the eye of the 
 4
 
 O THIRD LECTURE. 
 
 surgeon the presence of a great evil. These examples are 
 but a miserable mockery of the reality, and a fraud on the 
 judgment of the ignorant. 
 
 With regard to the third example, that of permanent 
 flexion of the fingers, it is apparently so truly local an 
 affection that there is some excuse for error, but only 
 because hysteric affections are not half studied. When 
 one or more of the fingers is permanently flexed from 
 local causes, the seat of disease will be found in the 
 fascial structures of the hand or in the finger itself, or a 
 joint may have been diseased or dislocated j but here there 
 is no thickening, nor hardness, or other morbid change of 
 structure. The finger is simply bent, and the attempt to 
 straighten it is painful. The cause of this morbid 
 condition of the flexor muscle is referred to its nervous 
 centre placed in the cervical portion of the spinal cord. 
 
 There are some curious phenomena connected with 
 this form of Hysteria to which I shall call your attention in 
 the next Lecture.
 
 FOURTH LECTURE. 
 
 Symptoms of common paroxysmal Hysteria Constitutional liability Nerve 
 and nervous system Effect of railway accidents Influence of the mind 
 Effects of an unstrung nervous system on the actions of daily life Imita- 
 tive or contagious Hysteria Surgical cases of Distinct from Neuralgia 
 Relation between Hysteria and the brain or spinal cord Hysteria com- 
 bined with real disease. 
 
 ON HYSTERIA, OR GENERAL AND LOCAL NERVOUS 
 IRRITATION. 
 
 IN the last Lecture I referred especially to Hysteria in 
 its local forms. You need scarcely be told that it isjt 
 disease involving the entire constitution. It is not my 
 intention to enter at length into the detail of this more 
 common form even were I capable, but I have something 
 to say on this head that may be useful to you. You will 
 not believe that either the mild or the severe and 
 paroxysmal attacks of hysteria occur without a cause. 
 That cause may be traced to constitutional weakness or 
 previous exhaustion in some form or other, fatigue of body 
 or mind, or great mental emotion, causing a shock. Then 
 follows at different intervals of time the attack, attended 
 by headache, nausea, pain in the back globus hystericus, 
 as it is termed uncontrolled muscular contraction, con- 
 vulsion of the diaphragm, indicating by fits of crying, 
 sobbing, laughing, its close relation to mind, violent
 
 52 FOURTH LECTURE. 
 
 palpitation of the heart, fixed pain under the short ribs, 
 increased secretion of urine not uncommon in all nervous 
 affections, especially of women. Such are the predomi- 
 nant signs of general hysteria. It is a medical disease, not 
 a surgical one, and I dare say you are as familiar with the 
 general symptoms as I am. The great Dr. Sydenham has 
 testified to the general prevalence of this disease in all 
 classes of society. He says, " The frequency of hysteria 
 is no less remarkable than the multiformity of the shapes 
 it puts on. Few maladies are not imitated by it ; what- 
 ever part of the body it attacks, it assumes the appearance 
 of the disease to which that part is liable." I don't see 
 how this striking truth can be told in stronger language ; 
 and again I tell you the mock is far more common than 
 the real disease, and I warn you against that error in 
 diagnosis which confounds the one with the other. 
 
 It is not an easy task to select the class of constitutions 
 most liable to hysteric disease. Probably under certain 
 conditions of impaired health the large proportion of the 
 community would give evidence of its presence. Certainly 
 it is uncommon in the lower class of males, and among 
 those who occupy the beds in our public hospitals. We 
 know, on the other hand, that it is most prevalent in the 
 young female members of the higher and middle classes, 
 of such as live a life of ease and luxury, those who have 
 limited responsibilities in life, of no compelled occupation, 
 and who have both time and inclination to indulge in the 
 world's pleasures persons easily excited to mental 
 emotion, of sensitive feeling, often delicate and refined. 
 Such are among the mental attributes of hysteria. But 
 hysteric diseases are not confined to the young. I have
 
 FOURTH LECTURE. 
 
 53 
 
 seen many examples in females of 40 and 50. Do not 
 imagine hysteria to be a disease peculiar to persons of weak 
 minds. It will often select for its victim a female member 
 of a family exhibiting more than usual force and decision of 
 character, of strong resolution, fearless of danger, bold 
 riders, having plenty of what is termed nerve. If you tell 
 such young people they are nervous, they take offence, 
 because they misinterpret the meaning of the word, and so 
 may you. And they may well misinterpret it, for, like the 
 word " irritation," its popular meaning is both various and 
 indefinite. It is essential that we attach a definite idea to 
 this term in its different applications, and I must digress for 
 a moment to endeavor to explain them. 
 
 I have already used it in one sense. 
 
 1st. The word nerve is employed to express the mental 
 condition of vigor, boldness, and resolution as when 
 a man's nerves are strung up to meet danger ; so ladies 
 are said to ride with more or less "nerve." 
 
 id. We employ it in its physical sense as a part of the 
 general system of the nerves of the body. 
 
 3d. We have the terms " nervous system," which may 
 be not inappropriately defined as holding the same relation 
 to the " system of nerves " in its physical sense that the 
 physiology of a part holds to its anatomy. Yet this 
 definition is imperfect, because the properties of the 
 nerves of the cerebro-spinal system, with the small 
 exception of those of specific sensibility, such as sight, 
 smell, taste, etc., begin and end in the functions of motion 
 and sensation. By the term " nervous system " we 
 understand the general influence which the nerves in a 
 physical sense exert on the constitution, the healthy or
 
 54 FOURTH LECTURE. 
 
 tonic condition of which is in a ratio with the combined 
 force of the two systems viz., the arterial, or circulation 
 of blood, and the nervous. Health depends on the coinci- 
 dence of these systems in perfect action. If the circulation 
 fails in power, the consequence of this weakness falls on 
 the nervous system, which is dependent on the circulation 
 for its health and vigor. Failing an adequate supply of 
 blood, this system is unstrung, and morbid sensations, 
 endless in variety, take the place of real ; and of all 
 consequences, hysteria is the most common. In the 
 deficient supply of blood to the brain the faculties of the 
 mind are involved. Confidence of strength gives place 
 to fear, mental vigor to weakness and irresolution. Such 
 indications are as untrue to the real character of the 
 individual, as the physical sensations are false and 
 deceptive. 
 
 Such is the nature of the large proportion of cases of 
 persons who come into courts of law for compensation for 
 injuries erroneously deemed to be permanent, bringing 
 with them headaches, spinal pains, tingling of the 
 extremities, impaired vision, loss of memory, and many 
 other symptoms of an unstrung nervous system a series of 
 grievances of the incurable nature of which an acute 
 lawyer takes care to provide himself with ample testimony, 
 and which will always be obtained so long as the diseases 
 of the vascular system and their consequences monopolize 
 a too prominent share of the attention of our profession. I 
 have traced several of these persons in their after-career, 
 the large majority of whom entirely recover. I believe 
 it is to the prevalence of error in the early management of 
 these persons, who are almost invariably subjected to
 
 FOURTH LECTURE. 55 
 
 depletive treatment, and to the imperfect knowledge of 
 nervous diseases which prevails in the profession, that large 
 sums are awarded for injuries erroneously supposed to be 
 permanent and incurable. Can it be reasonably expected 
 that the truth will be brought home to the mind of a 
 lawyer so long as our own opinions are yet uninstructed 
 upon it ? Sooner or later their true nature will become 
 established facts in the minds of our profession, and 
 we shall no longer hear the painful discrepancies of opinion 
 among medical .men that now prevail. The light of 
 improved knowledge will dissolve the mysteries which 
 daily surround these cases in the form of supposed 
 spinal concussions, partial paralysis, effusions into the 
 theca vertebralis, thickening of the membranes of the 
 brain, spinal cord, and lesions of this organ or that. These, 
 as Dr. Sydenham declares, are but imitations and 
 resemblances, and not realities ; and that they deceive 
 the multitude is undoubted. When real disease prevails, 
 there is no difference of opinion among medical men as to 
 its existence. 
 
 It is a very interesting question to investigate how far the 
 functions of the mind are involved in hysteric disease, and 
 how closely it is connected with it, whether the relation be- 
 tween them is direct and immediate, or remote. In cases 
 of local pain, and also in the local contraction of muscles, 
 arising either from an excessive action of one muscle, or 
 from the loss of harmony of action with its antagonist, as 
 in a permanently flexed forearm or finger, it seems difficult 
 to identify the evil with that part of the brain which we be- 
 lieve to be the seat of mind. And yet an inquiry into the
 
 ^6 FOURTH LECTURE. 
 
 past history of such persons will often reveal the fact that 
 they have been at one time or other the subjects of genera! 
 or paroxysmal Hysteria, or, in other words that they have 
 had hysteric fits ; and as mental emotion is more or less as- 
 sociated with this form of Hysteria, it would appear not un- 
 reasonable to infer some remote relation between the mind 
 and this variety of a disease apparently simply local in its 
 nature. There is something in the mental development of 
 these young persons very characteristic. They are quick 
 and excitable, liable to sudden emotion without adequate 
 cause. In very young persons the local disease may be 
 developed before the mental character is fully matured, but 
 advancing years will exhibit its peculiar features. 
 
 It is curious to observe the influence which the nervous, 
 system exerts on the daily condition of us all. When un- 
 strung it preys upon ourselves. It is not in the varying 
 force of our pulse, for that gauge is not sufficiently fine to 
 detect the variations of health, that we can refer a con- 
 sciousness of strength and vigor on one day that fails us on 
 another. It is that our nervous system is more or less relax- 
 ed. There is a real illness and a factitious illness, and in 
 this we observe the remarkable influence of mind in exer- 
 cising a controlling power over the body. People without 
 compulsory occupation,who lead a life of both bodily and men- 
 tal inactivity people whose means are sufficiently ample to 
 indulge in, and who can purchase the luxury of illness, the 
 daily visit of the Physician and, not the least, the sympathy 
 of friends these real comforts come home to the hearts of 
 those ornamental members of society who are living exam- 
 ples of an intense sensibility, whether morbid or genuine,
 
 FOURTH LECTURE. 57 
 
 who can afford to be ill, and will not make the effort to be 
 well. They are, in truth, well or ill, as you choose to take 
 it, and they are only ill because they fail in mental effort 
 that mental resolution which is sufficiently powerful to rouse 
 the dormant energies of the body and throw off the sensa- 
 tions of lassitude of unreal fatigue and weariness of body 
 and mind. A poor man cannot afford this indulgence, and 
 so he throws the sensations aside by mental resolution. 
 How often does a sense of weariness and fatigue succumb to 
 active and vigorous muscular exertion ? 
 
 There is a real fatigue, and a nervous or unreal fatigue. 
 A lady will tell you she was so tired that she could not 
 walk another step. She thinks so, and without an adequate 
 motive she cannot make the required effort. Give her the 
 motive, such as the sudden illness of a relative or friend at 
 a distance, and she will extend her walk to miles without 
 effort or subsequent fatigue. How is this ? It is that by a 
 great motive acting through her mind she has called upon 
 those dormant powers of her system which are possessed by 
 all of us to be employed on critical occasions. Rarely, if 
 ever, is the body subject to a degree of fatigue so great that 
 an adequate motive will not obtain renewed exertion. When 
 a lady tells you she can only venture on a walk of half a 
 mile, you will understand that this effort is determined by 
 the ordinary, not the extraordinary motive. It is your duty 
 as her medical attendant to place before her such induce- 
 ments to a greater effort as shall call on the exercise of her 
 dormant power, the reserved fund of physical strength, and 
 she will walk four times the distance without fatigue. A 
 poor man runs a race against time, and reaching the goal he
 
 ^8 FOURTH LECTURE. 
 
 drops from fatigue. Offer him at the moment ,100 if he 
 will run one hundred yards farther. He will accept the 
 offer, run the required distance and then drop. This 
 resolution acting on his muscular powers through his nervous 
 system, screwed up by an extraordinary mental effort. 
 
 And this law of Nature is applicable to us all in our daily 
 intercourse with the world. A man resolves to accomplish 
 a certain amount of work on a given day, and he completes 
 the task he has assigned himself by virtue of his resolution. 
 Such resolution is eminently protective against fatigue. 
 
 A question arises to one's mind is Hysteria what is 
 termed a specific disease, or is it the invariable result of a 
 condition of health into which all persons pass in reduced 
 states of bodily vigor, but only modified in degree ? I pre- 
 sume it is associated with a peculiar organism common to 
 man but not involving all, as some persons amenable to the 
 influence of mesmerism pass readily into profound sleep, 
 while others are entirely unaffected by it. It notoriously is 
 far more common in women than in men, and in young per- 
 sons from the age of seventeen to thirty, in the unmarried 
 than in the married. We do not associate hysteric affec- 
 tions with persons of either sex who are characterized by 
 vigor of mind, of strong will, of strength and firmness of 
 character. Such persons may be reduced by protracted ill- 
 ness to a condition of weakness both bodily and mental, but 
 they do not in their reduced strength, so far as I know, ex- 
 hibit any of the peculiar features of hysteric affections. 
 
 There is a remarkable form of Hysteria which affords 
 evidence on this subject. It is notorious that the sight of 
 a person under a hysteric attack has a tendency to involve
 
 FOURTH LECTURE. 
 
 59 
 
 other hysteric persons around her. It has happend to me 
 several times in my Hospital career to witness the contagious, 
 or rather the imitative, form of active or paroxysmal hysteria 
 on a large scale. On one of these occasions, in a ward of 
 twelve females, no less than nine young women were affect- 
 ed at the same time. Several were so violent as to call for 
 the assistance of sisters, nurses, and other servants of the 
 establishment to restrain them; and inasmuch as a person 
 under the influence of Hysteria brings into action all the 
 latent strength of her muscular frame, which is greatly in 
 excess of her apparent strength, the services of these attend- 
 ants were scarcely sufficient for the purpose several requir- 
 ing three or four strong men to prevent injury to their per- 
 sons. The attack commences in the person of one girl 
 who may have been the subject of some trivial operation, 
 or been brought under the immediate influence of the disease 
 by mental emotion. No sooner is the condition of this per- 
 son observed by her fellow-patients than her influence is 
 felt throughout the ward, and the second subject may be- 
 come involved, occupying a bed at the remote end of the 
 room, and thus it passes irregulary from bed to bed, each 
 patient appearing to take the disease in the order of their 
 constitutional liability. In the course of an hour, more of 
 ess, it subsides, and tranquillity is restored, but the evil only 
 slumbers, and on the following day the same scene may 
 recur less violent, perhaps, but acted by the same persons 
 as at first. Some of these patients, who were not affected 
 to violence, were affected to tears and wept in silence, while 
 some few were not implicated at all, nor did they show any 
 tendency to sympathise with the disease. These curious
 
 6O FOURTH LECTURE. 
 
 attacks, though they appear to the subjects of them irresisti- 
 ble, are yet but the result of what has been termed a "sur- 
 render," and might be prevented by an adequate motive. 
 The mode adopted to arrest this curious malady consists in 
 bringing these persons under the influence of some power- 
 ful mental emotion, and in making some strong and sudden 
 impression on the mind through the medium of, probably, 
 the most potent of all impressions, fear. They are not lost 
 to consciousness, and for the moment, except in the inten- 
 sity of their paroxysm, they will listen to the voice of 
 authority. Sympathy and kindness, or tenderness of voice 
 and manner, are worse than useless. They rather aggravate 
 than mitigate the evil. Ridicule to a woman of sensitive 
 mind, is a powerful weapon, and will achieve something ; 
 but there is no emotion equal to fear, and a threat of per- 
 sonal chastisement will not necessarily be required to be 
 carried into execution. On two of the occasions I have 
 referred to, a few quarts of cold water suddenly thrown on 
 the person of a chief delinquent instantly brought the ward 
 to a state of reason and subordination. The disease suc- 
 cumbed to the indignity of the treatment. There can be 
 no doubt, then, that a malady spreading by sympathy and 
 cured by fear, has its origin in the mind. I think you will 
 find on close inquiry that nearly all cases of paroxysmal 
 Hysteria originate in some form of mental excitement, and 
 that of a depressing character, such as sorrow or disappoint- 
 ment. It is not the result of mere emotion. Joy, gladness 
 of heart, or a sense of pleasure rarely produce it ; yet it is 
 difficult to explain either its immediate or proximate origin 
 in attacks occurring during sleep. Sometimes these patients
 
 FOURTH LECTURE. 6l 
 
 suddenly awake from sleep with severe palpitations of the 
 heart leading on to a direct attack. What can be their im- 
 mediate cause ? There is no disease of the agents of cir- 
 culation, or any suspected variation in the quantity of blood 
 thrown upon the heart by which to explain it. Whence, 
 then, the eccentric action of this organ ? Possibly some 
 mental emotion in the form of a forgotten dream or some 
 other occult mental operation which escapes cognizance, 
 such as occurs in cases of somnambulism. 
 
 In these current remarks on general Hysteria, we must 
 not lose sight of the subject taken in a surgical point of 
 view. I have stated, both in this and in the last lecture, 
 that under the condition of impaired health the nerves of a 
 part of the body may become the subject of a deranged 
 action, by which, as Dr. Sydenham has declared, and we in 
 our generation almost daily observe, so many symptoms of 
 actual disease of that part may appear, as to give the exact 
 aspect or verisimilitude of local organic change of struc- 
 ture when such disease is entirelv absent. There may be 
 nothing apparent on a first inquiry to associate the case 
 with Hysteria, whether local or general. It is not neces- 
 sarily nor commonly preceded by hysteric paroxysms. 
 There may be no appearance of illness, no heat or undue 
 excitement of the system, nothing, in fact, to connect it 
 with hysteric disease ; yet it is nothing but local nervous 
 exacerbation, and from the want of a better name we call 
 it Hysteria. You must not confound it with simple neu- 
 ralgia ; and with still less reason, with Epilepsy. It is not, 
 however, always easy to draw a distinct line between neu- 
 ralgia and Hysteria, for both may have a constitutional
 
 62 FOURTH LECTURE. 
 
 origin, and be amenable to nearly the same treatment. In neu- 
 ralgia, we have a more generally local and more persistent 
 affection of a nerve. The disease appears to be limited to 
 the nerve itself, the course of which may be traced by the 
 pain, which is often excessive ; whereas in those cases of 
 Hysteria marked by local pain, the pain is general, involv- 
 ing the structures around, in common with real disease of 
 the part affected. In neuralgia the disease is placed on a 
 recognised nerve, and a person is said to have neuralgia of 
 a given nerve, such as the frontal, mental, or digital. In 
 Hysteria any locality may be affected without reference to 
 the distribution of nerves ; while epilepsy is characterized 
 by well-marked symptoms clearly of a cerebral origin. If 
 you amputate a limb for hysteric pain, you throw the disease 
 back on its nervous centre, and you kill your patient. In 
 the early part of my hospital career I have seen this fact 
 more than once exemplified. In such cases operative sur- 
 gery is entirely out of place. 
 
 Now, before I proceed to illustrate these statements by 
 reference to cases, of which I have a sufficient supply, 
 I wish to make a few remarks on the relation between 
 local Hysteria and the nervous centres viz., the brain 
 and spinal cord. Any facts that tend to throw even a 
 gleam of light on the connection between them must be 
 interesting. 
 
 I refer to the influence of anaesthetic agents, especially 
 of opium and chloroform. In cases of Hysteria marked 
 by local pain, relief is given by the application of opium 
 to the affected part a fact which does not confirm the 
 generally entertained opinion that the local affection is
 
 FOURTH LECTURE. j 
 
 dependent on irritation of the nervous centre. Select a 
 case of hysteric contraction of the muscles of a joint 
 the elbow or fingers. If you administer chloroform,, 
 the contraction of the muscles which may have existed 
 for months, and which has resisted repeated attempts to 
 extend them, will now yield to a gentle effort of extension,, 
 and the limb is immediately restored to apparent repose. 
 Supposing this morbid contraction of one or more 
 muscles to be caused, as we believe, by irritation of the 
 nervous centre, how does opium or chloroform affect it? 
 The effects of chloroform on the circulation are assuredly 
 not in the direction of health, for it converts arterial into 
 venous blood, or, at least, it gives to arterial blood the 
 dark color of venous, and we can hardly believe impaired 
 circulation of a part of the body compatible with its 
 improved function ; and yet the disease subsides. This 
 "irritation of the nervous centre," as I told you, does not 
 convey a very clear idea of the nature of the relation 
 between the respective parts viz., the seat of the disease, 
 and its source or centre. Perhaps the nearest approach 
 we can make to a solution of the difficulty is by saying that 
 these two agents opium and chloroform suspend for the 
 time the influence of both sensory and motor nerves, 
 under which suspension the local pain, or the erring muscle, 
 partakes of the general influence of the anaesthetic. To 
 bring this morbid state of the muscle within the influence 
 of the mind as its cause, is almost of necessity to infer .the 
 local evil to be wilful ; but if it were so, the state of 
 unconsciousness during sleep would remove it, which it 
 does not, for the contraction is constant by night
 
 ^4 FOURTH LECTURE. 
 
 and day, while the specific influence of the chloroform 
 suspends the disease, if it does not cure it, and the renewed, 
 though partial, contraction of the muscle is now prevented 
 ty mechanical agency. The remarkable circumstance 
 consists in this, that a disease of long standing which 
 incapacitates for exercise and occupation is removed in a 
 few minutes by the agency of chloroform, and the patient 
 placed at once on the high road to recovery. Is this 
 curious fact confirmatory or otherwise of the origin of the 
 disease in the nervous centre ? 
 
 Unfortunately hysteric persons have no exemption from 
 real disease, and when the two are found in combination, a 
 difficulty in diagnosis will frequently occur to test the path- 
 ological knowledge of the surgeon. The local disease is 
 accompanied by symptoms of an eccentric character that 
 do not legitimately belong to it. Local pains are aggravated 
 in the active stages, and do not subside in a degree propor- 
 tionate to the local improvement. A small malady, such 
 as a sprained wrist or ancle, is magnified into a large one. 
 The constitutional symptoms take the direction of Hys- 
 teria instead of fever. The vascular system indicated by 
 the state of the pulse, the skin, etc., is less involved than 
 the nervous, and months will often expire before recovery 
 is complete. To a surgeon not familiar with hysteric 
 disease, who practises his profession with reference to one 
 only of the two systems of which the body is composed, 
 these cases will always be obscure and difficult of manage- 
 ment. When an injury occurs to the person of a young 
 female, and to many others neither young nor female, hys- 
 teric symptoms are almost certain to develop themselves in 
 some form or degree before recovery is complete.
 
 FIFTH LECTURE. 
 
 HYSTERIA CASES. 
 
 Distinctions between nervous and vascular diseases recapitulated General Lo- 
 calities of Hysteria Case of Hysteria of the muscles of the larynx Hys- 
 teric affection of the mammary gland Value of excercise Relative value 
 of foot and horse excercise General and local treatment Hysteria of 
 hypochondriac regions Spinal affections Cases Efficacy or inefficacy of 
 issues Cases Railway actions and extortions Cases Hysteric joints 
 treatment of Cases. 
 
 BEFORE I quote cases in illustration of the principles in- 
 culcated in the last two lectures, so all-important is the sub- 
 ject in the practice of our profession, so grave the conse- 
 quences of false diagnosis, that I briefly restate the ques- 
 tion under our consideration. It is a notorious and undis- 
 puted fact that any part of the body can be the seat of such 
 local derangement, either of the nerves of sensation or of 
 motion, as shall accurately represent real disease of that 
 part, when no disease, properly so called, really exists, and 
 that the detection of the truth is only made on a closer ob- 
 servation by the surgeon than is generally awarded to it. 
 The examples of derangement, whether of the nerves of 
 motion or of sensation, are local and general, and are treated 
 both by the physician and the surgeon, but more commonly 
 by the latter, when the evidence of local change of struc- 
 ture (or disorganization) is absent. 
 
 5
 
 66 FIFTH LECTURE. 
 
 As a rule the malady, with the exception of true Neuralgia, 
 comes under the variety of hysteric disease ; and the occur- 
 rence of such maladies in the persons of the young, and es- 
 pecially of females whose nervous system is more lightly 
 strung and more readily deranged, clears the path to 
 an early diagnosis. Draw the line, as clearly as you are 
 able, between the diseases of the vascular and the nervous 
 systems. Recall to your minds the local consequences of 
 increased action of the blood-vessels, both immediate and 
 remote local heat, local swelling, local redness, if the 
 structures involved are visible; and, lastly, local pain. This 
 is inflammation, which may either pass off, leaving the tissues 
 unaltered in structure, or may leave behind it evident marks 
 of its activity in the form of deposits, of thickening, of abscess, 
 or of death. Local nervous affections have little in common 
 with such maladies, and are distinguished from them by the 
 absence of those features which characterize diseases of the 
 vascular system. They have neither heat, nor redness, nor 
 swelling, in a measure compared with them ; and yet the two 
 maladies are daily confounded. Excessive or undue action 
 of the vascular system more readily involves the nervous 
 than the nervous implicates the vascular. 
 
 Cases of real Hysteria may be reckoned in multitude in the prac- 
 tice of any one surgeon. The more common seats are the fe- 
 male breast ; the side of the trunk under the ribs ; the whole 
 spinal region from the atlas to the sacrum ; any joint, but 
 especially the knee ; the stomach, the bladder, and the 
 ovaries ; the muscular system of the extremities, indicated 
 by spasm or permanent contraction ; and the muscles of 
 the larynx. But no part of the frame has exemption from 
 liability, so far as I am aware.
 
 FIFTH LECTURE. 6j 
 
 I will first quote a very simple case of Hysteria, the evi- 
 dence of which is immediate, and the attack transient. In 
 some slight forms the patient loses all command over the 
 voice, which suddenly sinks to an almost inaudible whisper, 
 without any other accompanying symptom. I have seen 
 many examples, but that I give occurred under my own ob- 
 servation, as it has probably in some form occurred under 
 that of others, for it is as old as history. The subject was 
 a young lady of about twenty, as Sir B. Brodie observes, of 
 pale complexion, and having cold hands and feet. While 
 I was engaged in conversation relative to her health, I some- 
 what imprudently remarked that a mouse was running about 
 under the table at the end of the room. She uttered an ex- 
 clamation of alarm, and in an instant so entirely lost the 
 power of audible speech that I was obliged to approach her 
 and to put my ear close, to hear her. The ferocious cause 
 of the mischief having paid the penalty of its intrusion by 
 the loss of all it possessed on earth, the lady in the course of 
 an hour recovered her voice. Had this person been in sound 
 and vigorous health, she would probably have sustained the 
 shock to her nervous system with less derangement of it. 
 The case is interesting, as showing the sudden influence of 
 the mind on a particular nerve in the general system. Am- 
 monia, chloric ether, henbane, etc., quickly administered, 
 would probably shorten the attack, and for which agents 
 brandy is a good substitute. 
 
 Cases of hysteric affections of the breast occur in young 
 persons from 16 to 20. They are associated with a 
 disturbed condition of the general system, but not 
 especially with the functions of the uterus itself. Although
 
 68 FIFTH LECTURE. 
 
 the catamenia is often deranged and defective, it is not 
 necessarily so. The general system is at fault, indicated 
 by a low circulation frequently a chlorotic aspect, failing 
 appetite, languor, and indisposition to any form of active 
 bodily or mental effort. In the cases I have seen, the 
 breast has been small and soft. The disease consists of 
 simple pain in the organ, one or both, but more severe in 
 one than the other. It is most active at the catamenial 
 periods. The breast is unaltered in form and substance. 
 The evidence of local inflammation is entirely absent. 
 Leeches, or other form of local depletion, give no relief. 
 Blisters and irritating plasters and ointments, answer no 
 useful purpose. The degree of pain varies with the 
 condition of the health. For a period it may almost cease 
 a period co-existent with a change of air and occupation, 
 or a residence of a month or two at the seaside, but the 
 pain relapses on the return of the subject to the ordinary 
 habits of life. The pain is dull and aching, and very 
 unlike the smarting and shooting pain which accompanies 
 abcess or the more formidable diseases. 
 
 With this history who will doubt the constitutional 
 nature of the malady or the efficacy of such remedies as 
 tend to change weakness for strength, to promote appetite, 
 to keep the circulation in action by frequent exercise, taken 
 at least twice daily ? 
 
 Such exercise should be active neither strolling nor 
 sauntering out of doors, " to take the air," as ladies term 
 it, nor gardening, nor lounging about but adopting a good 
 brisk walk, at a pace of at least three miles an hour, ever 
 stopping short of fatigue. People will often tell you they
 
 FIFTH LECTURE. 69 
 
 " take plenty of exercise about the house, and they are on 
 their legs during many hours of the day." This is fatigue 
 without exercise. What we want for health is exercise 
 without fatigue, for fatigue is exhaustion, and health is to 
 be obtained only on the terms I have mentioned. I do 
 believe there are many maladies, or at least many forms of 
 indisposition, which, with a strong will, may be walked 
 away, provided the exercise be taken systematically and 
 rendered a prominent feature in the daily treatment. The 
 distance walked should be increased daily, and a claim 
 made on increasing strength for increasing exertion. I 
 doubt whether horse exercise, however agreeable or 
 however stimulating both to mind and body, is equal in 
 sanitary value to exercise on foot. In the case of horse 
 exercise the muscular exertion to an experienced rider, 
 male or female, is very slight, and though the distance 
 compassed may be great, the muscular exercise, so far as 
 it is an important element of treatment, falls short of the 
 requirements of health. That the effort is comparatively 
 not great is proved by the long distances ridden and the 
 number of hours during which a delicate girl is seated on 
 her saddle. The general concussion or shaking of the 
 muscular frame incidental to this exercise in an unpracticed 
 rider subsides on its frequent repetition, and when the 
 rider becomes familiar with the action of the horse, so 
 slight an effort is requisite to maintain the equipoise of the 
 person in motion, and so entirely do the movements of the 
 rider respond to those of the animal ridden, that the 
 muscular effort amounts to almost nothing. Horse 
 exercise, therefore, cannot strengthen the muscles, because
 
 JO FIFTH LECTURE. 
 
 it does not sufficiently exercise them. It is an agreeable 
 and a useful recreation, but I suspect its influence as a 
 source of health acts more beneficially on the mind than 
 on the body. I do not wish to undervalue exercise on 
 horseback ; I only desire to meet the too general belief 
 that horse exercise can supersede exercise on foot as a 
 means to restore health. 
 
 Although you cannot cure these maladies by local treat- 
 ment, you can generally mitigate the severity of the pain by 
 the application of opium and other sedatives, but I have the 
 greatest reliance on opium as the most efficient. Do not 
 fall into the error of supposing that a "cooling lotion," 
 which shall contain tincture of opium as a component part, 
 can exercise any sedative property on the pain, but resort at 
 once to the extract known under the name of extractum opii 
 fluidum. Spread the pure extract on lint, or dilute it slightly 
 with water, and apply it to the breast ; give tonic medicines, 
 especially in the form of bark and iron such as eight or ten 
 grains of the ferro-citrate of quinine, or two drachms of 
 tincture of bark, with a pill of two or three grains of sul- 
 phate of iron, twice daily. Tonics are out of place in the 
 after part of the day, and especially after dinner. If the 
 pulse indicates weakness and it is highly probable it will 
 give wine frequently, and in sufficient quantity to produce 
 an impression. It is not the consumption of a single glass 
 or more that will effect the end you have in view. You 
 must meet the very marked tolerance of wine by an equally 
 positive increase in the quantity, and administer it not once, 
 but twice or thrice in the day, so long as weakness of the pulse 
 and the patient are indicated.
 
 FIFTH LECTURE. Jl 
 
 Of examples of hysteric pain situated under the ribs, 
 more commonly on the left side, it is needless to quote indi- 
 vidual cases they are so common. From some cause not 
 very apparent, they are, however, seen less frequently at the 
 present day than formerly. I attended some years ago, a 
 young married lady, the mother of three or four children, 
 the daughter of a medical man of large experience, by whose 
 direction she had been cupped about fifteen times over the 
 seat of pain. The malady prevailed in her system in its 
 active form during many years, and she was not free from 
 it when I saw her at the age of 30. This treatment, which 
 included the local application of leeches by the hundred, 
 and blisters, the sum of which might be calculated by the 
 square yard, while it gave no permanent relief, has left its 
 mark in more senses than one on the person and constitu- 
 tion of this lady for life. At all events, her excellent 
 parent has the merit of perseverance, if not of discrimina- 
 tion. 
 
 Among the cases of the sympathetic or imitative forms 
 of Hysteria which I have already quoted, two of these 
 females exhibited the scars of similar local treatment for 
 supposed organic disease under the ribs, and I have seen 
 many others. I need hardly tell you that this is a constitu- 
 tional and not a local infirmity, and must be treated accord- 
 ingly, or not treated at all. What structure or organ occu- 
 pying this region on the left side, under the lower ribs, can 
 be supposed the seat of this pain ? It is deep-seated, and 
 therefore the abdominal muscles are beyond suspicion. Is 
 it the colon, or the spleen, or the base of the left lung, or 
 the_diaphragm ? Whichever structure is involved, if any,
 
 72 FIFTH LECTURE. 
 
 rely on it the essence of the malady is seated in the nerves, 
 and in the nerves only. If it were organic disease, its 
 nature would become in time palpable. There is this im- 
 portant distinction between the two affections that organic 
 disease has a crisis, and nervous affections for the most part 
 have none. 
 
 Spinal hysteric affections are, perhaps, of all hysteric 
 maladies of the most common occurrence happily they 
 are becoming somewhat notorious. It is in the records of 
 pathology, no doubt, that a young female may be the 
 subject of real spinal disease ; but where are the cases to be 
 found? You may pass through life and not see two. 
 And while I state this opinion your minds may possibly 
 revert to some case you have already attended which you 
 think exceptional. Look more closely into it, and you 
 will detect your error. In forming an opinion on any 
 given case on which you may be consulted hereafter, you 
 had better make a starting-point from the knowledge of 
 this*fact, that nothing in pathology is more improbable 
 than that a young lady should be the subject of organic 
 disease of the spinal column. 
 
 Well ! a case presents itself for your opinion. A young 
 female, in any class of life, in apparent health, pale or florid 
 in complexion, bearing in her appearance no indication of 
 disease, complains of pain in her back. This pain may be 
 announced without surgical inquiry, or may be detected 
 only on examination. The spine is exposed while the 
 person is placed in bed. Pressure is made by one or more 
 fingers on the spinous processes of the vertebras, beginning 
 with the atlas. On reaching perhaps the last dorsal or
 
 FIFTH LECTURE. 73 
 
 first or second lumbar vertebra, the girl utters an 
 exclamation of pain, and she instantly shrinks from the 
 pressure. The examination is renewed again and again 
 with the same result. Twenty-three vertebrae admit of 
 pressure through their spinous processes without causing 
 suffering. Pressure on the particular one, or perhaps two, 
 causes instant and often severe pain. By-the-bye, who 
 ever heard of real disease attacking one or even two 
 vertebrae only? 
 
 I have already told you the probable result of this 
 inquiry, but you, I trust, will not be deluded. Be assured 
 to the extent almost of certainty, that there is no organic 
 disease, either of bone or of any other texture. 
 
 I attended a girl in St. Bartholomew's Hospital of about 
 twenty years of age. She had the appearance of a strong 
 and healthy person, and there was nothing in her aspect to 
 indicate that she was the subject of disease. Before I 
 reached her bedside the House-Surgeon informed me she 
 was the subject of "spinal disease," and I smiled at his 
 credulity. To the students around I said : " If on 
 examining this girl she makes an exclamation of pain and 
 shrinks from the pressure of my hand, rely on it she has no 
 disease whatever, and that her case is one of simple 
 hysteria." On reaching the first and second lumbar 
 vertebrae she uttered an expression of severe pain, and 
 nearly threw herself out of bed. The diagnosis was 
 confirmed, and she was treated for a nervous, not a real 
 disease. Extract of opium dissolved in soap liniment was 
 rubbed on the spine for a few days, and then the opium 
 was omitted, and the back generally rubbed by the hand
 
 74 FIFTH LECTURE. 
 
 twice daily with some force of pressure. She was ordered 
 valerian, bark, iron, and a full diet, with wine. Her 
 recovery occupied one month. 
 
 I was consulted in the year 1862 on the case of a young 
 lady of about 24 years of age. She had had " spinal dis- 
 ease " for several years, and many surgeons of more or less 
 eminence had been consulted on her " very remarkable 
 case." Her aspect was that of a healthy person. She 
 was inclined to be stout, and exhibited no indication of se- 
 rious disease, or indeed of disease of any kind. During 
 five years her back had been liberally cupped, leeched, blis- 
 tered, and embrocated without benefit. I was informed 
 that the pain had occasionally intermitted, that her condition 
 had improved for a time and then relapsed, and that although 
 nearly the entire five years had been passed in her chamber 
 and in the horizontal posture, yet that occasionally she 
 would join her family and seek relief from the monotony of 
 her life in the gaiety of the ball-room, where she forgot her 
 diseased spine and all its attendant miseries, and danced for 
 hours with life and animation. I examined her back with 
 more than usual care. The pain, always true to its own 
 locality, occupied the second lumbar vertebra, and always 
 returned on the pressure of my finger on that particular 
 spot. Occupying her attention by conversation, I grad- 
 ually subjected the whole back first to gentle, and then to 
 severe, pressure. With both hands I grasped the trunk, and 
 moved it forcibly in all directions without creating any sensation 
 of pain. I then passed the flat of my hand rapidly down 
 the spine, employing not pointed, but obtuse pressure over 
 the whole surface, and thus satisfied myself that there was
 
 FIFTH LECTURE. J$ 
 
 no disease. After the interval of a few minutes, pointed 
 pressure on the second lumbar vertebra produced the same 
 symptoms as at first. On examining the surface I observed 
 the mark of a cicatrix of about three inches in length run- 
 ning along the side of the affected vertebra, and on inquiry 
 I learnt that one surgeon whom the family had consulted 
 had deemed it necessary to look within and below the sur- 
 face, under the supposition that there might possibly be a 
 tumour or some morbid growth, the removal of which 
 would be conducive to her recovery ! Nothing, however, 
 was found, and the excision of a small portion, I presume 
 of the erector spinas muscle, afforded no permanent relief 
 at least no benefit had arisen from the operation at the ex- 
 piration of many months, when I was requested to see her. 
 It struck me that this was carrying the experiment of ope- 
 rative surgery rather far, but I did not make any remark to 
 that effect at the time. I certainly made an inquiry as to 
 the product of the operation, and the father of the young 
 lady told me that he was shown something, but he was not 
 competent to state exactly the nature of the substance re- 
 moved. On discussing the pathology of the case with the 
 family and the attending surgeon, I expressed my conviction 
 of the hysteric nature of the disease, and that the lady was 
 capable of exertion could she be induced to attempt it. I 
 saw at once that I had failed to convey my own convictions 
 to the family, that my opinion was not satisfactory, and 
 that in the judgment of the lady's father, a very sensible 
 person, the opinion of one man could not outweigh that of 
 the many, and that the testimony of the many was the safer 
 guide. The patient returned to her couch, on which she
 
 76 FIFTH LECTURE. 
 
 may be now reposing for aught I know to the contrary, for 
 I saw her but once. I had, however, the satisfaction to 
 hear the medical man say as I left the house, " I believe 
 your view of the case is the only true one." 
 
 As treatment by means of issues was formerly in great 
 resort, and is yet far from being abandoned as a means of 
 checking the progress of carious disease in the vertebrae, it 
 is worth considering for a moment the principle of their ac- 
 tion. To control one disease you make another, which is 
 supposed to act as a drain in carrying off the morbid actions 
 of the original disease by derivation, or counter-irritation as 
 it is termed. An issue is an ulcer, secreting matter, and 
 drawing more or less on the powers of the constitution. An 
 ulcer is a disease. All disease excercises a depressing, not 
 an invigorating influence on the system. The sum total, 
 then, is increase not diminution, of the evil. The morbid 
 condition of true spinal affections is that of caries or crum- 
 bling of bone, not inflamation. Is it probable that a pair 
 of secreting ulcers can tend to restore bone that is lost ? 
 \Vill the capillaries be more likely to secrete material to be 
 converted into healthy bone within the body, because you 
 have made an ulcer outside ? The actions going on within 
 are those of deficiency, not of excess. Here comes in again 
 the old doctrine of inflammation. The operation of an issue 
 is equivalent to that of the lancet, and in these days that in- 
 strument has become obsolete in the hands of all sensible and 
 thinking men. I acknowledge with all regret, in looking 
 back at the early part of my own professional career, to have 
 frequently committed this error in treatment, and I willingly 
 make retribution to another generation by declaring my con-
 
 FIFTH LECTURE. 77 
 
 viction of the entire futility of an issue in this description of 
 disease to answer any useful purpose. 
 
 While on a visit to the house of a friend in the country, I 
 was requested to see one of his daughters who had been 
 confined to her room for fifteen months, in consequence, as 
 I was told, of diseased spine. She was twenty-one years 
 of age. Her countenance was pale, but not unhealthy. 
 She had been condemned by a court of surgeons to a long 
 confinement to the horizontal position, and she bore 
 the judgment against her with resignation and humility. 
 From the appliances around her, and the general arrange- 
 ments of the room, it was obvious that the siege was to be 
 long and vigorously maintained. My visit was not a pro- 
 fessional one, and I did not propose to myself at the time 
 to discuss the subject of her illness. Accident brought me 
 in contact with her medical attendant, and in the course of 
 conversation with him some features of her case were men- 
 tioned, which appeared not very consistent with real disease 
 of the vertebrae. We examined her carefully, and the con- 
 sultation which ensued terminated in the proposal that his 
 patient should change the horizontal posture for that of a 
 semi-inclined plane. In a week she sat upright in an easy 
 chair, and within a month she joined the family circle, en- 
 tered into all their pursuits, and could ride any reasonable 
 distance on horseback without fatigue. 
 
 I see no advantage in multiplying these painful examples 
 of hysteric disease. They have all general characters in 
 common, and are amenable to the same principles of treat- 
 ment. And so with cases of supposed injury from railway 
 accidents. Again and again have I heard medical men,
 
 78 FIFTH LECTURE. 
 
 physicians, surgeons, and general practitioners, come into 
 courts of law and state their opinion that the plaintiff had 
 sustained grievous, and probably permanent bodily detri- 
 ment to the spinal column, on the evidence of pain pro- 
 duced by pressure of the ringer on one or more of the 
 spinous processes evidence far more than counterbalanced 
 by the fact that these deluded persons have walked unaided 
 into court, and have stood or sat in the witness-box for 
 three-quarters of an hour while under examination. 
 
 No evidence of the reputed symptoms of these persons 
 is obtainable either through the eye or the touch of the 
 surgeon. There is nothing palpable, nothing organic. 
 You take the assertions of your patient on trust, you iden- 
 tify yourself with his case ; you place an object before 
 him, and he declares he cannot see it ; you refer to an 
 occurrence that happened last week, he declares he does 
 not remember it. He suffers incessant pain in his back ; he 
 staggers in his walk, occasionally coming to a harmless fall ; 
 he has convulsive twitchings in his legs, occurring chiefly in 
 bed, which he says he cannot control. He passes blood in 
 his urine, which always escapes the notice of others, for it 
 is invariably passed at the water-closet and at no other time, 
 but on inquiry you will find that this afflicted person can 
 walk four or five miles ; that as regards his vision his iris 
 acts well, and the ophthalmoscope detects nothing ; his 
 appetite for food is sufficient for perfect nutrition. And let 
 me ask you finally, whether on these conditions it is more 
 than remotely possible such a person can be the subject of 
 any serious organic disease ? But presuming on the possi- 
 bility of such contradictory evidence occurring in a single
 
 FIFTH LECTURE. 
 
 79 
 
 and exceptional case of real disease, will your credulity 
 reach so far as to admit of their frequent occurrence ? To 
 you such cases will be presented singly and individually, 
 but they are brought into courts of law in multitudes, and 
 with their sympathies enlisted on behalf of a plaintiff, no 
 great skill is required to impress the jury in his favor. 
 
 One of such cases I will give you as an example : A 
 man without property or profession brought an action 
 against a railway company for injury to his spine. This 
 statement, on the face of it, is an absurdity. How can a 
 man without property bring an action at law ? Well, he 
 applies to a lawyer, who undertakes the case on his behalf, 
 with a certain compact and understanding as to the question 
 of future payment ! Thus the lawyer becomes the plain- 
 tiff, and the plaintiff the witness in his own case. The man's 
 injury was made out to the entire satisfaction of the jury, 
 and very heavy damages were awarded by them, coupled 
 with severe comments on the negligence of the railway 
 directors. 
 
 It was positively known, at the time, by several persons 
 engaged in the action, among whom was a detective officer, 
 that within a few days of the trial the plaintiff, or the wit- 
 ness, whichever you please to term him, had walked a race 
 against another man ! Yet this man was declared on 
 authority to have sustained a permanent injury of his spinal 
 column ! 
 
 With respect to hysteric affections of joints, knee cases, 
 &c., they are in truth as common as Sir B. Brodie has de- 
 clared them to be, and I thoroughly corroborate all he has 
 said on the subject of this most important and interesting
 
 8o FIFTH LECTURE. 
 
 disease. Three-fourths of all knee cases in the upper 
 classes of society, says this great authority, are not cases of 
 inflammation, though they appear so. There is no organic 
 disease whatever in the joint. They are cases of local 
 pain, originating in impaired health. They are not amenable 
 to treatment for inflammation and its consequences. Your 
 liability to an error in diagnosis is just in proportion to the 
 supposed infrequency of local nervous, as compared with 
 vascular, derangement. The knee is by far the most 
 frequent seat of these affections, and the cases are 'found 
 among young women not in the lower class of life but 
 even this class is not exempt. You will find, on the occa- 
 sion of your first visit, the patient walking lame. This 
 lameness has existed for several days, probably weeks, before 
 attention has been attracted to it, and has come on very 
 gradually. The joint is stiff not that it won't bend, but 
 the movement is painful. There may be some increased 
 heat in the joint when compared with that of the opposite 
 limb, but not much in degree. The knee is slightly swol- 
 len. If you seethe case after treatment has commenced 
 ;'. *., after the repeated application of leeches, blisters, and 
 tincture of iodine (the almost universal agent in difficulty) 
 the swelling will be palpable, and the outline of the joint has 
 undergone a change. As the case progresses, the lameness 
 increases, but the aspect of the joint remains as in the first 
 stage neither the swelling nor the heat increasing in the 
 same proportion. In this condition the limb may remain 
 for months, or even for years, subject to the same treat- 
 ment, without improvement. One feature in this case 
 ought to have struck you as worthy of notice viz., that
 
 FIFTH LECTURE. 8l 
 
 so many months have passed without organic change ; the 
 joint is neither stiffer, larger, nor hotter than it was in the 
 early stage of the treatment. I say it ought to have struck 
 you. Perhaps it has not ! The aspect of this lady is that 
 of un-health. She has become pale, partly from depletion, 
 partly from loss of exercise. Her pulse is weak, her ap- 
 petite bad, and the the catamenia, as a rule, defective. You 
 fear to give tonics and alcohol, lest you aggravate the sup- 
 posed local inflammation. 
 
 Having exhausted the negatives in treament, you now 
 venture on an onward step, and you give bitter infusions, 
 gentian, cascarilla, with ammonia and ether. But you are 
 still behind the necessities of the case ; you have adopted 
 from the beginning a false diagnosis, and the difficulty is 
 how to get back to the right groove. There is only one 
 course ; begin afresh, and treat your case on a different 
 principle ; convince yourself that nerves may go wrong as 
 well as arteries and capillaries, and as you treat excessive 
 action in the blood-vessels, rightly or wrongly, by local de- 
 pletion, so apply such remedies as check excessive action of 
 nerves, in the form of opium, belladonna, chloroform, &c. 
 Build up the health by increasing the force of the circula- 
 tion. The agents are a thoroughly nutritious diet, wine 
 frequently in small quantities, tincture of bark, iron, fresh 
 sea air, change of locality and associations, agreeable 
 mental occupation. Assure your patient she has no real 
 disease, but the semblance only. Leave the functions of 
 the alimentary canal to take care of themselves. The con- 
 stipation incidental to a low innutritious diet and an inac- 
 tive life will subside under the influence of a nutritious one, 
 
 6
 
 82 FIFTH LECTURE. 
 
 improved health will restore its function. There is no real 
 harm in a day's constipation ; it is sometimes a good. At 
 all events leave the bowels alone. With regard to the joint,, 
 rub in some blue ointment and extract of opium, in the pro- 
 portion of one-third of the latter, and roll it firmly with 
 a flannel bandage. Encourage moderate daily exercise on 
 a level ground, on a carpet or on a lawn. If the case is. 
 chronic,don't be disappointed if the progress be yet protracted 
 to weeks. The pain and the stiffness may subside very 
 slowly by virtue of their long possession by the joint ; but 
 you are in the right path, and rely upon it your patient's re- 
 covery will justify the sound principles of your treatment. 
 
 In the course of last year I was consulted by the family of 
 a young lady of eighteen years of age living at a distance 
 from London relative to an affection of the knee, from 
 which she had been suffering for a period of ten months. 
 The joint was stiff and painful ; she moved about on crutches ; 
 there was no considerable amount of heat, and what altera- 
 tion existed in the form and outline of the knee was due to 
 the activity of the past treatment ; the tissues had lost their 
 natural softness and flexibility ; the joint had been repeated- 
 ly leeched and blistered, and subjected to the application of 
 liniments in variety of color and composition ; an issue had 
 been made on the inner side of the patella, which, judging 
 from the cicatrix it left behind, had not been a small one > 
 and the curative influence of which had not been discovered 
 during four months, at the expiration of which Nature was 
 allowed to heal it. 
 
 I consider this a case of Hysteria on the following evi- 
 dence. The subject was a young lady of a hysteric age.
 
 FIFTH LECTURE. 83 
 
 She had sustained no sudden injury to the joint, neither blow, 
 nor fall, nor sprain. The malady was gradual and sponta- 
 neous. Had the disease been of the inflammatory class, 
 the remedies would have probably long since cured it. 
 There was no appearance of disorganization otherwise than 
 integumental. The pain was generally aggravated at the 
 catamenial periods. Bending the joint afforded no evidence 
 of disease within it, no grating or roughness of the cartila- 
 ginous surfaces. The pain varied greatly in intensity at 
 different periods. 
 
 This evidence was sufficient, and, to my judgment, con- 
 clusive. I strapped up her joint in an opium plaster. She 
 took bark and iron and wine, and in a fortnight began to 
 walk about without her crutches ; but two months had 
 elapsed before her recovery. 
 
 Many years ago, when I was less familiar with hysteric 
 affections, I attended the case of a young lady of 19 in 
 conjunction with Mr. Stanley. We both deemed the dis- 
 ease to belong to the class of inflammation, and conjointly 
 adopted the usual remedies so indiscriminately resorted to in 
 all painful affections of joints. Many weeks elapsed with- 
 out improvement, and I remember that we discussed with 
 some anxiety the probable issue in abscess, destruction of 
 ligaments, absorption of cartilage, and ultimate amputation 
 of the limb ! 
 
 One day my patient informed me that her sister was 
 going to be married, and that, cost what it might, she had 
 made up her mind to attend the wedding. At this proposal 
 I shuddered. Having expatiated, to no purpose, on the 
 probable consequences of so rash an act, with all the force
 
 84 FIFTH LECTURE. 
 
 of language I could command, I determined to give stabil- 
 ity to the joint for the occasion, and I strapped it up firmly 
 with adhesive plaster. On the following day I visited her. 
 She told me she had stood throughout the whole ceremony, 
 had joined the party at the breakfast, and had returned 
 home without pain or discomfort in the joint. Within a 
 week her recovery may be said to have been complete. 
 
 This case first brought home to my mind the nature and 
 the frequency of hysteric disease.
 
 SIXTH LECTURE. 
 CASES OF HYSTERIA Continued. 
 
 Hysteric affection of the oesophagus Hysteric affection of the stomach ; 
 gastrodynia Of the ovary Hysteric contraction of muscles Wry neck 
 Contraction of fingers Contraction of elbow-joint Hysteric contraction 
 of the muscles of the leg and foot Hysteric paraplegia Hemiplegia. 
 
 THE cases of hysteric affections of the knee-joint I have 
 selected for comment in the last lecture may be taken as a 
 type of them all, each case exhibiting some peculiar feature 
 more or less striking on which to fix the attention to the 
 surgeon. It may well be supposed that a large hospital, 
 such as St. Bartholomew's, would furnish examples of 
 them in the course of years in multitudes, and with regard 
 to which I can only refer you to the general description I 
 have previously given of hysteric affections. They may 
 be summed up under the definition of chronic painful 
 affections of joints, attended by stiffness and immo- 
 bility, without disorganization, and they will only be 
 successfully treated through the agency of the constitution. 
 
 I will now give you a few examples of hysteric disease 
 attacking regions less common than those I have yet 
 referred to, but not less distinct in their character : 
 
 A young woman, aged 24, was admitted into one of
 
 86 SIXTH LECTURE. 
 
 my wards at the Hospital who was the subject of difficult 
 deglutition. She was a very respectable person in character 
 and position, and had been for several years a much 
 esteemed servant in a good family, and was a young woman 
 of some education. For two months previous to her 
 admission she had complained of difficulty of swallowing 
 her food. As the evil appeared to increase, the family 
 medical attendant was consulted, by whom she was treated 
 for a stricture of the oesophagus. One or more consulta- 
 tions were held on her case, and the oesophagus examined 
 carefully by means of probangs and bougies. These 
 instruments, however, failed to pass a given spot corres- 
 ponding with the base of the neck, or about one third from 
 the commencement of the tube. She had no local pain 
 whatever. As the obstruction infcfeased, nothing but semi- 
 liquid food passed into her stomach, and this was only 
 effected with a difficult and painful effort. She became 
 emaciated by reason of defective nutrition, and at the time 
 of her admission into the Hospital was weak and somewhat 
 attenuated in form. For many weeks she had taken no 
 description of solid food, and even liquids passed the 
 obstruction with difficulty. The malady now assumed a 
 serious form, and with a view to additional advice she was 
 sent to the Hospital. The case was reported to me on her 
 arrival as that of " stricture of the oesophagus," and I will 
 tell you the preliminary train of thought that passed 
 rapidly through my mind before I opened my lips to the 
 students on the subject. (i.) Real stricture of the 
 oesophagus is at all times a rare disease. When present it 
 is almost invariably a cancerous affection. Cancer is a
 
 SIXTH LECTURE. 87 
 
 very rare disease at this young woman's age. For so 
 serious a malady as cancer she does not look ill enough ; 
 for though the presence of cancer of the breast occurring at 
 a later period of life by twenty years may be for a time 
 compatible with fair average health, cancer of the 
 oesophagus stamps the constitution early. (2.) She is of an 
 hysteric age, and though thin, she does not look absolutely 
 ill. There is nothing of disease in her aspect, nothing that 
 may not be referred simply to defective nutrition. The 
 history of her case was given me by her medical attendant, 
 who was present on the occasion, and I had no hesitation 
 in recording her disease as that of " Hysteria." I declined 
 the use of a probang or bougie which lay on the table 
 before me, and I simply said, "We will endeavor to 
 remove the obstruction without the aid of instruments of 
 any kind." Her catamenial discharge had been regular 
 throughout. I ordered her bark, iron, valerian, wine, 
 milk with brandy each to be given in the largest quantities 
 at the shortest intervals consistent with reason and moderation ; 
 three times in twenty-four hours, enemata of thick soup 
 with an ounce of brandy. These various agents were 
 absorbed into her system with the greatest advantage to her 
 health. Within a week she could swallow finely minced 
 animal food, and in three weeks she ate a portion of rump- 
 steak without difficulty, and was, in fact, convalescent. 
 She was in high spirits at her recovery, and the only 
 vexation she suffered arose from my refusal to pass a 
 probang down her throat before she left the hospital. 
 This I peremptorily declined to do, assuring her that a 
 probang of rumpsteak was a far more efficient test of her
 
 88 SIXTH LECTURE. 
 
 recovery than any instrument in surgery bearing that 
 name. 
 
 A young lady ofi8, and of slight form, was brought to me 
 from the country with gastrodynia. For upwards of a year 
 she had suffered intolerable pain in the stomach on taking 
 food of any description. She was much emaciated, and 
 her pulse extremely feeble. Neither trouble nor expense 
 had been spared in her treatment. Her family had consulted 
 medical men of eminence in more than one metropolis, but 
 the severity of the pain continued in spite of treatment. On 
 entering the drawing-room, I heard the sound of suffering 
 from an adjoining room, and I was told that my future 
 patient was paying the penalty of a slight meal of arrow- 
 root, of which she had swallowed a few table-spoonsful only. 
 Having intruded myself into the room somewhat unexpect- 
 edly by its occupants, I saw this young lady in a condition 
 of great suffering, in the upright position, leaning her head 
 on her mother's shoulder, and sobbing painfully. In the 
 course of a quarter of an hour I had obtained some insight 
 into her case, but I could not fail to observe that the mother 
 habitually interposed replies to questions addressed to the 
 daughter, and I explained to her the necessity of my ob- 
 taining the answers to my inquiries direct from her daughter. 
 At my request she left the room. Up to that time I had 
 but an imperfect knowledge of the case, but I then led the 
 conversation to subjects which carried the girl away from 
 her malady and all its associations. I spoke of her home 
 and the scenery around it, of which I described the general 
 characters, and enlarged on the beauty of the neighborhood, 
 the lovely rides and excursions, etc., and in all of which I
 
 SIXTH LECTURE. 89 
 
 was tolerably successful, considering that at that time I had 
 never seen it. However, the description was sufficiently 
 accurate for my purpose, for it succeeded in distracting the 
 young lady's attention from her suffering, and during the 
 few minutes which this conversation occupied she was to all 
 appearance entirely free from pain. She talked freely and 
 cheerfully, and not the slightest reference was made by 
 either of us to her former suffering. I then changed the 
 subject by saying, "I think your pain has flown away," 
 when she immediately resumed her crying fit, and sobbed 
 as before. She assured me she was in great pain, and that 
 the sensation had been but suppressed. That this was a case 
 of severe Hysteria was highly probable even had I gone no 
 further with the evidence, relative to which the following 
 thoughts occurred to my mind. What could be the nature 
 of this pain if not hysteric ? I was told by her family that 
 pain followed the act of deglutition, not remotely or at 
 an interval of one or more hours, but almost as immediately 
 as the food could reach the stomach. This could not be 
 dyspeptic or common gastrodynia, which waits on the pro- 
 cess of digestion, and rarely occurs within a period of two 
 hours of taking food. There is one disease only of the 
 stomach in which pain follows the admission of food into 
 it, and that occasionally only viz., cancer. Was it pro- 
 bable, or scarcely more than possible, that this girl of 1 8 
 could have been for so many months the subject of unde- 
 tected cancer of the stomach r If cancer, could the attend- 
 ant pain, so severe as it appeared at the commencement of 
 my visit, be suspended by conversation ? It was neither 
 gastrodynia, the result of indigestion, nor cancer; and if
 
 SIXTH LECTURE. 
 
 not, what remains behind to elucidate the case? It 
 could be nothing but Hysteria, and Hysteria alone could 
 solve the mystery. But she had been treated for gas- 
 trodynia and treated for cancer, but she had not been under 
 treatment for Hysteria, simply because these varieties of 
 local Hysteria have never yet fixed themselves on the at- 
 tention of the profession. To tell a practitioner of the old 
 school that a young lady was the subject of Hysteria of the 
 stomach would be to raise a smile at your expense. 
 
 It would be an unprofitable employment of our time were 
 I to enlarge on the subject of the previous treatment. The 
 remedies included, in different proportions and in varying 
 doses, ammonia and other alkalies, under the mistaken sup- 
 position of acid secretions ; opium in various forms, creosote, 
 bismuth in small and large quantities, mineral acids, etc., 
 etc. 
 
 How difficult it is to ascertain beyond all question the 
 real value of many drugs in daily use amongst us ! Although, 
 in common with others, I have frequently employed the 
 trisnitrate of bismuth, I have to this hour no conviction of 
 its utility. 
 
 This case did not terminate so satisfactorily as I hoped. 
 That it was a case of Hysteria admits of no doubt, but I 
 had difficulties to contend with in the domestic management 
 of the young lady. Although her symptoms remitted 
 greatly under the use of remedies, she did not entirely re- 
 cover in the brief period of three or four weeks during 
 which she remained under my care. I gave her small 
 doses of ferrocitrate of quinine, two or three times a day a 
 wineglass of port wine boiled with spice, and I ordered a
 
 SIXTH LECTURE. 9! 
 
 plaster of the fluid extract of opium to be applied on the 
 epigastrium. If, coupled with these remedies, I could have 
 separated the girl from her family, whose sympathies with 
 her were far too redundant for her benefit, I think she 
 might have been cured in one month. In a case of this 
 kind good domestic moral treatment is indispensable to suc- 
 cess. 
 
 Hysteric affections of the ovaries are extremely common. 
 Several of such examples I attended with my late friend, 
 Dr. Rigby. The cases I have seen have occurred in young 
 females of between 20 and 25 years of age. They are 
 characterized by deep-seated aching pain in the region of 
 the ovary, about two inches above the crural arch. My 
 own observation would lead me to say that the right organ 
 is more frequently affected than the left, but this is prob- 
 ably accidental. Like other hysteric affections, its severity 
 varies with the constitutional health, mental and bodily. It 
 yields but slowly to remedies, and though mitigated, it often 
 returns at longer or shorter intervals. I have applied opium 
 locally with advantage, but an entire change of air, scene, 
 and occupation, combined with tonic treatment, are indis- 
 pensable to recovery. 
 
 There is no class of hysteric affections more interesting 
 to the surgeon or more critical than cases involving morbid 
 
 o o 
 
 contractions of a part of the muscular system. These 
 affections of the spinal nerves are to be found in abundance 
 in all our public hospitals, where in times not long past, if 
 entirely past vet, the knife has been too often called into 
 requisition to settle the question of an obscure diagnosis, to 
 the damage of the patient and the discredit of the surgeon.
 
 p2 SIXTH LECTURE. 
 
 Muscles were cut asunder and limbs were amputated, and 
 the disease yet remained behind, to develop itself in some 
 shape yet more formidable, and now beyond the range of 
 cure. On such cases, several of which are in my memory, 
 I shall not enlarge. I prefer to look forward, and to dis- 
 charge the duty I have undertaken by teaching you the best 
 means of avoiding their recurrence. 
 
 A young woman, aged about 27, the daughter of a small 
 tradesman, was the subject of contraction of the sterno- 
 mastoid muscle on the left side of the neck, by which her 
 head was much drawn to the side, and her personal appear- 
 ance disfigured. The surgeon in attendance upon her pro- 
 posed to divide the muscle at its tendinous origin from the 
 sternum ; but before the operation I was requested to see 
 her. She was of a nervous temperament, and was out of 
 health at the time. I considered the disease to be Hys- 
 teria, and nothing beyond it. The fixed contraction of the 
 muscle had occurred without local injury of any kind, and 
 it had increased gradually to its then condition. I recom- 
 mended such general medical treatment as we find useful 
 jn similar cases of Hysteria. Failing to influence the opin- 
 ion of the attendant surgeon, I suggested a second consult- 
 ation, mentioning the names of one or two surgeons of 
 experience in such cases, who, having visited the patient, 
 expressed a similar opinion to my own. 
 
 The operation was performed, and though I was not 
 present I will guarrantee the entire division of the muscle 
 as proposed ; but it was not attended with benefit, and a 
 second attempt to remove the deformity was undertaken 
 with a similar result. You will not unreasonably infer that
 
 SIXTH LECTURE. 93 
 
 the operator in this case a man of great knowledge and 
 large experience was not familiar with this class of disease ; 
 and he had the candor to acknowledge it. Need you have 
 more conclusive evidence that we have not yet acquired 
 all the requisite knowledge on the subject of local Hys- 
 teria ? 
 
 A young lady, of 17, high born, surrounded with all the 
 comforts which wealth and parental care could furnish her, 
 became the subject of contraction of the fingers of the 
 right hand which was entirely closed in flexion. Any 
 attempt to open the hand was attended by severe pain. She 
 was of a nervous temperament, but failed in no respect in 
 mental power or moral force of character. Having been 
 for some months under treatment in England, she was sent 
 to Paris with a view both to education and to surgical treat- 
 ment. At the expiration of six months her hand had 
 undergone no improvement, and she returned to London, 
 when I saw her. I should have supposed there could 
 hardly be two varying ^pinions as to the nature of this 
 morbid action of the flexor muscles, and that nothing but 
 Hysteria could explain a condition of the muscular system 
 which existed in a young girl of 17, who had sustained no 
 local injury to account for it. In this, as in many other 
 similar cases, there was no catamenial derangement. I 
 ordered her a full nutritious diet, excercise, and tonic reme- 
 dies in the form of bark, iron, and valerian, and she re- 
 turned to her home and family in the country. Some weeks 
 afterwards, finding the condition of the hand not improved, 
 she returned to London, and I put her under the influence 
 of chloroform, and the flexor muscles immediately relaxed.
 
 94 SIXTH LECTURE. 
 
 I opened the hand without the smallest effort, and applied a 
 well-padded splint to the front of the forearm, extending 
 to the extremity of the fingers. The splint was retained 
 for some weeks, and occasionally removed for a time and 
 replaced. The muscles recovered their healthy tone, and 
 the hand its functions, with the exception of the little fin- 
 ger, the movement of which still continues, after an interval 
 of three years, in some measure restricted. 
 
 A young lady, aged 18, of nervous and susceptible tem- 
 perament, was brought to me by her mother with an affec- 
 tion of the left elbow-joint. The joint was fixed in half- 
 flexion and was supported by a well-made leather splint, 
 and had been carefully bound with straps and rollers. I 
 learnt that she had sustained no local injury to the arm, but 
 that it had been treated for some weeks for inflammation of 
 the elbow-joint ; but as the disease did not yield to the 
 treatment, I was consulted. Further inquiry into the his- 
 tory of the case led me to the belief that the affection was 
 of a hysteric nature. I removed the splint, not without 
 some expression of alarm on the part of the mother as to 
 the consequences. The joint itself was neither swollen, hot, 
 nor painful, but any attempt to straighten or move it caused 
 great pain. I explained my views of the disease to the 
 young lady's mother, and recommended a certain course of 
 treatment, which the lady, somewhat, as I thought, against 
 her own judgment and inclination, promised to follow ; and 
 I was brought into communication with the medical atten- 
 dant of the family in the country, to whom I explained 
 my views, and to whose judicious charge I consigned her. 
 Up to this time, and beyond it, I believe my opinions were
 
 SIXTH LECTURE. 95 
 
 not shared by either the family surgeon, by the mother, or 
 by the daughter, and I stood alone opposed in opinion to 
 more than one eminent authority in our profession. On 
 the occasion of her first visit, on removing the splint, I 
 placed the arm in a light sling. I advised the free applica- 
 tion of opium, with some blue ointment, to the arm, about 
 and around the elbow-joint, which I directed to be firmly 
 rolled ; and I prescribed iron, bark, and wine, and I advised 
 the lady to be taken into the country. Some weeks elapsed 
 without material improvement, when the young lady was. 
 again brought to London for the purpose of consultation. 
 To this end, four surgeons of well-known eminence were 
 assembled. Now observe, the largely prevailing opinion at 
 that consultation was, that the elbow-joint was the seat of 
 disease that is, of inflammation and that the inability to 
 move it, was due to disease of the joint, and nothing else. 
 I pointed out the absence of local pain, the normal appear- 
 ance of the joint, the hysteric character of the patient, and 
 I ascertained beyond doubt the fact that she had not long 
 prior been the subject of a true hysteric paroxysm. Before 
 I left the house my views were adopted by the majority, 
 and on the following day, while under the influence of chlo- 
 roform, I straightened her arm without effort or difficulty, and 
 fixed it in this position by means of a splint. Several 
 weeks elapsed before she regained the entire command 
 over the muscles of her arm, but her recovery was com- 
 plete. 
 
 When this morbid contraction of muscles has been once 
 struck down, the muscles fully lengthened out, and the posi- 
 tion retained by a mechanical impediment to further con-
 
 96 SIXTH LECTURE. 
 
 traction, of force sufficient to control the evil, the morbid 
 tendency yields, and the employment of the splint for a week 
 or two may suffice ; but the disease may stealthily return, 
 and the limb should still be kept under some form of re- 
 straint for several weeks. 
 
 In the year 1864 a young lady, of 16 years of age, was 
 placed under my care under the following circumstances : 
 For eight months prior to her visit to me she had been suf- 
 fering from inversion of the left foot, which was so twisted 
 as to bring the point of the foot to the opposite ancle in 
 fact, at _ nearly a right angle with the foot of the opposite 
 side. Her family consulted a surgeon of much experience 
 in the treatment of distortions, and of orthopaedic noto- 
 riety. The case was considered as an example of an ordi- 
 nary distortion, and the foot was placed in a very elabor- 
 ately made foot-splint, by the force of which it was made 
 to approach a parallel relation to the opposite foot ; but it 
 was an approach only, for no mechanism could retain it in 
 a perfect position, the toes yet in some degree pointing 
 inwards. Months elapsed, and the disease continued un- 
 changed. A second orthoposdic authority was then con- 
 sulted in conjunction with the first, and, as no new light 
 was thrown on the disease by the combined opinions of the 
 two, the same principle of treatment was recommended to 
 be continued, and the mechanism was yet somewhat more 
 elaborated. And thus the eight months of the young lady's 
 life passed away, during which no constitutional treatment 
 of any kind was resorted to, and loss of excercise for she 
 walked, it is almost unnecessary to say, with great difficulty 
 with other attendant evils, exercised a prejudicial influ- 
 ence on her health.
 
 SIXTH LECTURE. 
 
 97 
 
 When the apparatus, which she had so long worn, was 
 removed on the occasion of her first visit to me, the foot 
 immediately resumed its twisted form. The appearance of 
 the limb was singular. Its attitude was that of complete 
 inversion. I have studied the action of muscles a good 
 deal, but I should have found it difficult to explain by what 
 muscular agency of the foot this position was obtained, so 
 great was the inversion. One fact was quite obvious, that 
 it could not be due to the muscles of the foot only, but 
 that those of the whole limb tending to inversion must be 
 more or less involved. The very attitude of the limb was 
 an abnormal one. The disease had appeared almost 
 suddenly in a person hitherto healthy up to fifteen years of 
 age. It could not be due to congenital deformity, and the 
 limb gave no indication of disease or disorganization. 
 There was neither heat, nor pain, nor swelling. In this 
 case, also, there was no catamenial derangement. 
 
 I removed the apparatus from the foot, bandaged the 
 limb with a calico roller, ordered a full nutritious diet, with 
 bark and iron, and, having explained the nature of the 
 disease to the friend, sent the young lady home into the 
 country, recommending her to rely on the kindly offices of 
 Nature the greatest of all doctors, orthopaedists not 
 excepted. At the end of a month some progress had been 
 made, but not a great deal. She still walked with much 
 difficulty, but it was obvious that she was improving in 
 health and vigor of system. At the expiration of six 
 weeks she accompanied her family to a ball, her foot, as 
 she entered the ball-room, being not yet restored to its 
 normal position. She was invited to dance, and under this 
 
 7
 
 98 SIXTH LECTURE. 
 
 novel excitement she stood up, and, to the astonishment of 
 her family, she danced the whole evening, having almost 
 suddenly recovered the healthy muscular actions of the 
 limb! She came to see me two days afterwards. She 
 walked perfectly well into my room, and paced the room 
 backwards and forwards with great delight. The actions 
 of the limb were thoroughly restored, and all trace of the 
 previous malady had disappeared. 
 
 These cases, which you will meet with hereafter, show 
 that under a morbid condition of the nerves or nervous 
 system of a given part of the body the muscles supplied by 
 them may become the subject of hysteric contraction or 
 spasm, which can only be treated effectually through the 
 constitution, whether the disease has sprung from the ner- 
 vous centre or had originated in the nerve itself, either in its 
 course or in its distribution in the muscle. Where a single 
 muscle is involved, or, still more, a portion of a muscle, as 
 in the case of permanent contraction of one finger, one can 
 scarcely explain the fact on the supposition that the disease 
 extends so far back as the spinal cord, and which can impli- 
 cate one filament of the nerve only and leave the rest unaf- 
 fected. Still the probability of its seat in the cord is 
 strengthened by the evidence of cases in which the nervous 
 system of a considerable part of the body is involved, as in 
 cases of hemiplegia or general paralysis, and of such I have 
 seen several examples. Their true diagnosis will only be 
 obtained on the most careful investigation. Hysteric 
 paraplegia may sound strange in your ears, but if you will 
 study hysteric diseases you will find no difficulty in the con- 
 clusion that Hysteria, as Dr. Sydenham says, may attack
 
 SIXTH LECTURE. 99 
 
 any part of the body, and accurately represent the diseases 
 of that part. 
 
 A young woman, aged 20, was admitted into St. Bar- 
 tholomew's Hospital with the total loss of motor power of 
 the right arm and leg, and partial loss of sensibility. She 
 had been the occupant for two years of a country work- 
 house, where she was placed on the list of incurables. She 
 had been treated actively for hemiplegia, with cupping and 
 blistering and purgation, and no doubt with a rigid " atten- 
 tion to diet !" Notwithstanding these antecedents, the girl 
 was florid, and presented the aspect of a moderately well- 
 nourished person. This feature in her case struck me as 
 remarkable viz., that a girl of 20, who had been confined 
 to her bed in a country union for two years, with so serious 
 a disease as hemiplegia, should present so healthy an appear- 
 ance, and so unlike what might reasonably be anticipated 
 from the presence of a protracted disease. Then, again, 
 we do not find examples of this form of general paralysis in 
 young persons. Such cases must be very exceptional, and 
 I could not remember ever to have seen one, and least of 
 all should I expect to find such a disease in a hardworking 
 country girl. I observed that the motor power of both 
 hand and foot was totally lost. Volition did not reach the 
 extremities in any observable degree, and in the cases of 
 paralysis I had seen, some power of motion, however slight, 
 remained in the toes, but here there was none. The leg 
 lay perfectly dead to all motive power. 
 
 With this evidence the case was recorded as " hysteric 
 hemiplegia," and as such I treated it. The girl was ordered 
 animal food twice daily, bark and iron, and wine in small
 
 IOO SIXTH LECTURE. 
 
 doses, gradually advancing to large. The affected limbs 
 were rubbed for a quarter of an hour twice daily. Within 
 a week slight motion and increased sensibility had returned 
 in the fingers, and shortly afterwards in the foot; within 
 three weeks she sat up in bed. In the ensuing fortnight 
 she walked about the ward by the aid of crutches. At the 
 expiration of six weeks she returned convalescent into the 
 country, and for many months enjoyed fair average health ; 
 but I believe her entire convalescence was temporary only. 
 There is something more than mere shades of differ- 
 ence between a large metropolitan hospital and a country 
 workhouse ; between a school for medical instruction and an 
 asylum for paupers ; between an institution which com- 
 mands the large experience of the many, and one which 
 depends on the limited authority of an individual sur- 
 geon, and consequently the recovery of this girl was in- 
 complete ; but the character of her disease was, in my 
 opinion, thoroughly established in St. Bartholomew's 
 
 Hospital. 
 
 A young lady, aged 22, sustained a shock in a railroad 
 
 accident in the year 1863. There was no evidence that 
 she had been actually struck, aud although she was thrown 
 down with some force she was not incapacitated, because 
 she not only got out of the carriage unaided, but she was 
 able to give some assistance to others who were really 
 hurt. At the expiration of a week she was under the 
 charge of the family medical attendant with the loss of 
 motor power of the lower extremities. The power of 
 sensation was somewhat impaired, but not considerably. 
 Some months elapsed without improvement. She was treated
 
 SIXTH LECTURE. IOI 
 
 in the meantime for concussion of the spine, followed by- 
 supposed effusion into the theca, and chronic inflammation 
 of the membranes of the cord ! 
 
 I wish I could entertain the faintest hope that my 
 diagnostic powers could ever attain this amount of 
 precision, but it is not a very unusual opinion in cases of 
 this character expressed by medical men. 
 
 These consequences of the injury were considered 
 permanent, and an action was brought against the Company 
 for large damages. At this period I saw the case, and 
 expressed an opinion as to the probable hysteric nature of 
 the affection, and I advised a compromise with the 
 Company, who awarded the lady a considerable sum in 
 compensation for the real injury she had sustained. 
 Change of air and scene, mental occupation, tonic treat- 
 ment, adopted in despite of effusion and thickening of the 
 membranes of the cord, but which of the three membranes 
 was never positively stated, was followed by slow, but 
 steady improvement, and in the course of three months 
 the young lady was able to walk about without support, 
 and I subsequently heard that her recovery was com- 
 plete. 
 
 A young woman sustained a railway shock, but, as in 
 the last case, not immediately on the occurrence of the 
 injury. She had total loss of both sensation and motion 
 of the whole of the left side of the body, and partial loss 
 of both on the right. Some months elapsed before I saw 
 her. She had had extreme tenderness throughout over the 
 upper lumbar vertebrae. The loss of sensibility was so
 
 IO2 SIXTH LECTURE. 
 
 complete that she was quite unconscious of the puncture of 
 a needle. The paralysis was referred to local lesion or 
 disorganization of the cord and its membranes. It was 
 difficult to explain the severe lumbar pain at the expiration 
 of months on the supposition of real injury, the very 
 severity of which pointed to hysteria, and there were 
 no circumstances in the case, in my opinion, inconsist- 
 ent with that diagnosis, and for which malady she was 
 treated. 
 
 Her recovery, which occupied many months, was, 
 however, complete. 
 
 I have records of other cases of the same character, 
 which I have no time now to detail. 
 
 I pray you to recollect, and to keep always before your 
 minds in your future practice, that the human body may be 
 the subject of a class of diseases involving the nerves or 
 nervous system, whether of a small or a large portion of 
 the frame, which are essentially and pathologically distinct 
 from diseases of the vascular system ; that they carry with 
 them so much of resemblance to real disease or disorgani- 
 zation of structure as to deceive the most experienced, but 
 that they are destitute of some of the most prominent 
 features which characterize real disease ; that the varieties 
 of this affection, whether in situation, in form, or in 
 intensity, are great ; that the source of the affection is not 
 a local one ; that, as real disease very commonly holds a 
 relation with the functions of the heart and arterial system, 
 that of local or general hysteria is the product of a disturbed, 
 not a diseased, condition of the brain or spinal cord ; and
 
 SIXTH LECTURE. 
 
 that, finally, in considering the entire phenomena of 
 hysteric affections, it is difficult to deny their relation to the 
 mind, which appears to exercise some mysterious or occult 
 influence over them. 
 
 THE END.
 
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 I. Congestion not Inflammation Treatment of Congestion Cases of 
 Congestion Tonic Treatment exemplified in abscess Evils of deple- 
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 mined by the pulse Employment of wine in the London Hospitals 
 
 II. Remote causes of Disease Causes definite and traceable General 
 causes of disease The aperient system Treatment by increasing the 
 quantity of healthy blood Stimulants in debility reduce the frequency of 
 the pulse Alcoholic stimulants essential Cases Diseases of animal 
 and organic life Cases in illustration or the two varieties of disease. 
 
 III. Imitations of real disease The study of, much neglected by the pro- 
 fession Indicated by local pain and muscular spasm Distinct from in- 
 flammatory diseases The term " Hysteria" objectionable Nature and 
 source of Hysteria Errors in diagnosis Critical examination of 
 cases Hysteric affection of joints Hysteric contraction of fingers. 
 
 IV. Symptoms of common paroxysmal Hysteria Constitutional liability 
 Nerve and nervous system Effect of railway accidents Influence of 
 the mind Effects of an unstrung nervous system on the actions of 
 daily life Imitative or contagious Hysteria Surgical cases of Dis- 
 tinct from Neuralgia Relation between Hysteria and the brain or 
 spinal cord Hysteria combined with real disease 
 
 V. Distinctions between nervous and vascular diseases recapitulated Gen- 
 eral localities of Hysteria Case of Hysteria of the muscles of the larynx 
 Hysteric affection of the mammary gland Value of exercise Rela- 
 tive value of foot and horse exercise General and local treatment 
 Hysteria of hypochondriac regions Spinal affections Cases Effi- 
 cacy or inefficacy of issues Cases Railway actions and extortions 
 Cases Hysteric joints, treatment of Cases 
 
 VI. -Hysteric affection of the (Esophagus Hysteric affection of the stom- 
 ach; gastrodynia of the Ovary Hysteric contraction of muscles 
 Wry Neck Contraction of fingers Contraction of elbow-joint Hys- 
 teric contraction of the muscles of the leg and foot Hysteric paraplegia 
 - Hemiplegia
 
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