AND 
 
 CLINICAL APHORISMS 
 
 SAMUEL JONES GEE II
 
 Ex Libris 
 C. K. OGDEN 
 
 ' 
 
 7
 
 OXFOED MEDICAL PUBLICATIONS 
 
 MEDICAL 
 LECTURES AND APHORISMS
 
 OXFORD MEDICAL PUBLICATIONS 
 
 MEDICAL LECTURES 
 AND APHORISMS 
 
 BY 
 
 SAMUEL GEE, M.D. 
 
 FELLOW OF THE KOYAL COLLEGE OP PHYSICIANS 
 
 HONORARY PHYSICIAN TO II.E.H. THE PKINCE OF WALES 
 
 AND CONSULTING PHYSICIAN TO ST. BARTHOLOMEW'S HOSPITAL 
 
 SECOND EDITION 
 
 LONDON 
 
 HENEY FROWDE HODDER & STOUGHTON 
 
 OXFORD UNIVERSITY PRESS WARWICK SQUARE, E.C. 
 
 1907
 
 OXFORD : HORACE HART 
 i'UINTKR TO THE UNIVERSITY
 
 CONTENTS 
 
 PAGE 
 
 I. THE HISTORY or A CASE OF CEREBRAL HAEMOR- 
 RHAGE 1 
 
 II. THE MEANING OF THE WORDS COMA AND APO- 
 PLEXY 11 
 
 III. LARGE HEADS IN CHILDREN .... 17 
 
 i. LONG HEADS 19 
 
 Hypertrophy of brain .... 22 
 
 Rickety heads 23 
 
 ii. ROUND HEADS AND HYDROCEPHALUS . 25 
 
 IV. APHASIA 27 
 
 V. THE MEANING OF THE WORD DELIRIUM . . 34 
 
 VI. NERVOUS ATROPHY (ATROPHIA VEL ANOREXIA 
 
 NERVOSA) 40 
 
 VII. SPINAL MYALGIA 49 
 
 VIII. THE CAUSES AND FORMS OF BRONCHITIS . . 60 
 
 CAUSES 62 
 
 CATARRH 70 
 
 PITUITOUS CATARRH .72 
 
 SUFFOCATING CATARRH AND BRONCHO-PNEU- 
 
 MOXIA ... 82 
 
 CHRONIC BRONCHITIS 85 
 
 IX. THE NATURE OF PULMONARY EMPHYSEMA . 94 
 
 i. ACUTE EMPHYSEMA .... 96 
 
 ii. CHRONIC EMPHYSEMA 108 
 
 1 117135
 
 vi CONTENTS 
 
 PAGE 
 
 X. THE NATURE OF ASTHMA . . . 129 
 
 i. SPASMODIC ASTHMA . . . .136 
 
 ii. PNEUMONIC ASTHMA .... 140 
 
 Asthmatic bronchitis . . . .141 
 
 Spasmodic croup 145 
 
 Paroxysmal coryza 151 
 
 Paroxysmal bronchorrhoea . . .155 
 
 Hay fever 157 
 
 XI. ENLARGED SPLEEN IN CHILDREN . . . 162 
 
 XII. TUBERCULAR PERITONITIS 164 
 
 XIII. THE SIGNS OF ACUTE PERITONEAL DISEASES . 175 
 
 ACUTE PERITONITIS 180 
 
 SUDDEN ONSET OF CHRONIC PERITONITIS . 198 
 
 PERITONEAL HAEMORRHAGE .... 198 
 
 PERITONEAL PERFORATION .... 200 
 
 XIV. SECTS IN MEDICINE 214 
 
 DOGMATIC 218 
 
 METHODIC 220 
 
 HOMOEOPATHIC 223 
 
 PNEUMATIC . 228 
 
 PHARMACOLOGICAL 230 
 
 EMPIRICAL 236 
 
 EXPECTANT 240 
 
 XV. CLINICAL APHORISMS 243 
 
 SOME PULMONARY PHYSICAL SIGNS . . 243 
 
 PHTHISIS PULMONAHS 245 
 
 HAEMOPTYSIS 247 
 
 BRONCHITIS AND EMPHYSEMA . . . 250 
 
 STINKING EXPECTORATION .... 251 
 
 PLEURISY AND EMPYEMA .... 252 
 
 PNEUMONIA 257 
 
 DISEASES OF HEART AND PERICARDIUM 258
 
 CONTENTS vii 
 
 PAGE 
 
 CLINICAL APHORISMS (continued): 
 
 DISEASES OF BLOOD AND BLOOD-VESSELS . . 263 
 
 NEPHRITIS, ALBUMINURIA, AND DROPSY . . 265 
 
 GASTRIC ULCER AND CARDIALGIA . . . 268 
 
 DIARRHOEA AND CONSTIPATION . . . 271 
 
 ABDOMINAL TUMOURS 271 
 
 DISEASES OF LIVER 273 
 
 JAUNDICE 274 
 
 CEREBRAL HAEMORRHAGE AND HEMIPLEGIA . 275 
 
 MENINGITIS 278 
 
 EPILEPSY 279 
 
 HYSTERIA 280 
 
 MYELITIS 281 
 
 NEURITIS 281 
 
 SOME OTHER NERVOUS DISEASES . . . 283 
 
 DELIRIUM 284 
 
 HEADACHE 285 
 
 APHASIA 286 
 
 DISORDERS OF SLEEP 287 
 
 SOME INFECTIOUS DISEASES .... 288 
 
 ENTERIC FEVER 289 
 
 SOME TUBERCULAR DISEASES .... 291 
 
 CHOREA AND RHEUMATISM .... 293 
 
 SYPHILIS 295 
 
 SOME SKIN DISEASES 296 
 
 DIABETES AND GLYCOSURIA .... 296 
 
 SOME SIGNS AND SYMPTOMS .... 298 
 
 FEVER 301 
 
 FOOD IN DISEASE 302 
 
 CHILDHOOD AND OLD AGE 303 
 
 MISCELLANIES 303 
 
 INDEX 305
 
 THE HISTORY OF A CASE OF CEREBRAL 
 HAEMORRHAGE 
 
 CONTRASTING hospital practice and private prac- 
 ; tice we may say that the main advantage of hospital 
 practice is the opportunity it affords for examining 
 i the bodies of patients after death. The main advan- 
 tage of private practice is that you know so much 
 more about your patients during their life than you 
 can by any means discover about persons who flit 
 through a hospital and vanish into the darkness 
 whence they came. Private patients say that you 
 come to know their constitution, and there is much 
 in this knowledge which is apt to be underrated by 
 \the inexperienced. The hospital offers ' a case in the 
 wards', a patient whom you attend for a few days 
 or weeks. Concerning his state of health, good or 
 bad, before you saw him you know nothing more
 
 2 THE HISTORY OF A CASE OF 
 
 than you can guess from what he tells you. What 
 becomes of him when he leaves the hospital is usually 
 quite unknown. Hospital experience is fragmentary, j 
 Private practice, on the other hand, sometimes affords 
 the opportunity of knowing a man from his birth till 
 his death. Very often you can trace throughout his 
 whole life a series of connected morbid changes 
 which end by bringing about his death ; and when 
 your patient is suddenly taken ill, in a manner most 
 unexpected by his friends though not by you, your 
 thorough knowledge of his constitution enables you 
 to foretell what has happened before you see him. 
 This is genuine prognosis, not guessing, but true fore- 
 sight. ' Sic praeivit Hippocrates meruitque caelum.' 
 A man just past middle life begins to consult you 
 about what he calls biliousness, nor can you do better 
 than call it by the same name. Up to this time he 
 has been a robust man, capable of great exertion of 
 both body and mind, and he has been free from 
 disease. But you know that, being prosperous and 
 rich, he fares sumptuously every day. With respect 
 to wine more particularly, you know that whereas 
 formerly he drank it freely because he liked it, and
 
 CEREBRAL HAEMORRHAGE 3 
 
 because it seemed to do him no harm, now he drinks 
 it partly from habit and partly from necessity, because 
 he cannot do without his wine ; he needs it to spur 
 his appetite for food and his capacity fox work to 
 their wonted activity. About this biliousness I will 
 say no more than that it indicates a poisoned state of 
 blood due to depraved digestion (cacochymy) ; but to 
 the next phase of his life I wish to draw your par- 
 ticular attention. 
 
 When he is between forty and fifty years of age, 
 all at once he passes blood with his urine. There are 
 no other symptoms of any kind, and especially there 
 is no pain ; he would not have thought there was 
 anything the matter with him had he not seen blood 
 in his urine. Somebody tells him that he has a fit of 
 gravel, but on examining the urine you find no gravel, 
 nothing but blood. Careful examination of the 
 abdomen detects nothing. You suspect that he may 
 be the subject of granular kidneys, and looking at 
 him from this point of view you observe that his 
 eyelids are certainly more puffy than they formerly 
 were : he was always pale, but now perhaps looks 
 paler; his arteries at the wrist are palpable, a little 
 
 E 2
 
 4 THE HISTORY OF A CASE OF 
 
 tortuous, and the pulse a little hard. Examination of 
 the heart makes out nothing. The blood in the 
 urine passes away in a week or so ; careful examina- 
 tion afterwards detects not even a haze of albumen. 
 
 He resumes his former habits of life until, two or 
 three years afterwards, he has another attack of 
 bloody urine, resembling the former illness in all 
 respects. It now seems to you still more probable 
 that he suffers from chronic nephritis leading to 
 granular kidneys. Nephritis is often quite latent. 
 It is said that one person out of every two or three 
 who die after the age of forty years is found to have 
 kidneys more or less granular. And ever since the 
 writings of Gull and Sutton upon what they called 
 Arterio-capillary Fibrosis, it has been agreed that 
 granular kidneys are almost always associated with 
 similar disease of the small arteries. This arterial 
 sclerosis is connected with other lesions, especially 
 hypertrophy of the left ventricle of the heart, or, on 
 the other hand, with degenerative changes in the 
 myocardium. 
 
 Believing that a patient's arteries and kidneys have 
 undergone these fibrous changes, you inquire upon
 
 CEREBRAL HAEMORRHAGE 5 
 
 what do they in turn depend. Upon two conditions 
 in chief. I. The age of the patient. For although 
 no age is exempt from the possibility of arterial 
 sclerosis and granular kidney (and I myself have 
 seen an extreme degree of both lesions in a girl only 
 ten years old), yet they are not common before middle 
 life. After middle life they become very common. 
 Our age is to be reckoned by the state of our arteries. 
 These are no new discoveries : the connexion between 
 progressive arterial changes and advancing age was 
 dimly known to Boerhaave, 1 and very likely to 
 physicians before his time. II. There is a diathesis 
 (or disposition to some special form of disease) which 
 is very common, but for which it is difficult to find an 
 appropriate name, because we do not understand its 
 nature or essence. Among the diseases related to or 
 dependent upon this diathesis are gout, gravel, obesity, 
 diabetes, eczema, emphysema of the lungs, chronic 
 nephritis, and, what concerns us most at present. 
 
 1 See his 55th aphorism, and Van Swieten's commentary. 
 ' From this gradual condensation of the smaller vessels, and con- 
 sequent rigidity of the larger ones, the progress of the human 
 body from infancy to old age is accounted for.' Armstrong, Art 
 of Preserving Health, book ii : 1744.
 
 6 THE HISTORY OF A CASE OF 
 
 arterio - capillary sclerosis. For want of a better 
 name these diseases are often called gouty, but gout 
 is only one form of this diathesis. 
 
 Everybody knows that this arthritic or gouty ten- 
 dency depends mainly upon two conditions : it is 
 highly hereditary, and it is much promoted by good 
 cheer in the way of eating and drinking. Applying 
 these doctrines to our patient, we find that there is 
 a gouty tendency in his family, and that his habit of 
 living well is a matter past doubt. With respect to 
 alcohol more particularly, he has probably never been 
 drunk in his life, and has seldom been very obviously 
 the worse for his wine ; indeed, he is one of those 
 unfortunate persons who can carry, as the saying is, 
 any quantity of liquor. 
 
 Now comes the important practical question : What 
 you are to advise him to do. You cannot make him 
 young again ; you cannot change his hereditary dis- 
 position ; the only condition with which you can deal 
 is his manner of life. But beware how you attempt 
 reformation here : ' A man like your patient, full of 
 coarse strength, butcher's meat, and sound sleep, will 
 suspect any philosophical insinuation, or any hint for
 
 CEREBRAL HAEMORRHAGE 7 
 
 the conduct of his life which reflects upon this animal 
 existence, as if you were fumbling at the umbilical 
 cord and might stop the supplies' (Emerson). Never- 
 theless you feel it to be your duty to make sugges- 
 tions as to an altered mode of life, and let us suppose 
 the effect to be, not that he follows your advice, but 
 that he looks askance upon you, shuns you, and con- 
 sults some other medical man who is more buxom 
 and pliant, who thinks the patient is a peg too low, 
 and recommends good old port. This you regret 
 because you know that arterial degeneration is pro- 
 gressive, and that even plain living cannot altogether 
 arrest it. But he will not live plainly, and so things 
 go on. 
 
 In the course of time you are asked to see him 
 in a hurry because he has had a fit of some kind. He 
 suddenly felt an unusual sensation in his head and 
 became confused for a short time. The first thing 
 you observe is that his speech is indistinct in con- 
 sequence of defective articulation. He complains of 
 a feeling of numbness in the right arm and leg, especi- 
 ally in the hand ; and, on further examination, you 
 discover that he is suffering from a slight hemiplegia
 
 8 THE HISTORY OF A CASE OF 
 
 on the right side, affecting arm, leg, and face. The 
 urine contains a cloud of albumen, but you find no 
 casts or corpuscles, specific gravity about 1017. The 
 palpable and visible, rigid, tortuous, and uneven arteries 
 testify more strongly than was formerly the case to 
 arterial degeneration. The hard pulse and somewhat 
 heaving heart-impulse indicate hypertrophy of the heart. 
 
 This hemiplectic seizure makes it necessary for you 
 to speak in a more decided tone. You tell him that 
 he is lucky that his attack has not been worse, you 
 say he is threatened with incurable paralysis, or with 
 rapidly fatal apoplexy, and you give him to under- 
 stand that his only chance of escaping these dangers 
 consists in living a most abstemious life as to food 
 in general, and in giving up alcohol altogether. He 
 listens more attentively than he did on the former 
 occasion, because he has found that your predictions 
 come true : he speaks as if he intended to reform, 
 perhaps for a few weeks he does reform ; he recovers 
 clearness of speech, he regains the power of his limbs 
 almost entirely, and you lose sight of him again for 
 a time. 
 
 Nothing is more dangerous for such a patient than
 
 CEREBRAL HAEMORRHAGE 9 
 
 excitement of any kind, what is called a high flow 
 of spirits. It is well known that an exhilarating 
 climate, the Riviera, for instance, is peculiarly unsuit- 
 able for a patient threatened with apoplexy. To such 
 a place our patient goes, without consulting you in 
 the matter, and the next thing you hear of him is that 
 he died rather suddenly. You are told that before he 
 went from home he had relapsed into all his former 
 habits of good living ; he had even drunk more freely 
 than before, being never apparently the worse for it, 
 and being actuated by that strange spirit which impels 
 patients to glory in defying the doctor and all his 
 craft. He went to an English seaside place in brilliant 
 weather, and he seemed for a day or two to renew his 
 youth ; he was full of life, ate largely, drank largely. 
 One morning, after a very good dinner the evening 
 before, he was awakened early by a bad pain in his 
 head : the pain increased ; he vomited several times. 
 He sent for a doctor and told him that it was a bilious 
 attack of the kind to which he was subject. Unluckily 
 the doctor believed him, and with the purpose of 
 relieving the pain in the head, which had now become 
 violent, he gave a dose of nitroglycerine a dangerous
 
 10 CEREBRAL HAEMORRHAGE 
 
 remedy under the circumstances. In less than an hour 
 after the doctor had left the house, he was hastily 
 called back, and found his patient deeply comatose, 
 dying indeed, for he lived only eight hours after the 
 beginning of the headache. No examination of the 
 dead body was made, but we know what would have 
 been found : the brain substance torn up by blood, the 
 cerebral ventricles full of blood, the heart hyper- 
 trophied, and the kidneys granular. He was nearly 
 sixty years of age.
 
 11 
 
 II 
 
 THE MEANING OF THE WORDS COMA 
 AND APOPLEXY 
 
 I. THE original meaning of the word Coma is heavy 
 sleep, a definition which no doubt affords a clear 
 notion of the appearance which a comatose person 
 presents to us. Yet coma and sleep are very different. 
 Sleep is ' privation of the act of sense, the power 
 remaining ', but coma signifies privation of both act 
 and power. A comatose person cannot be roused. 
 
 II. A comatose person is said to be Insensible, and 
 apparently this is true : it certainly seems that he 
 cannot see, hear, or feel. Every organ of sense con- 
 sists of three parts: an exterior organ which relates 
 to the object ; an interior organ or sensorium which 
 relates to knowledge ; and a bond between these two 
 terminal organs. The sense of sight provides an apt 
 illustration of these facts. Pathology indicates that 
 the visual sensorium, the ' mind's eye ', the ' inmost
 
 12 THE MEANING OF THE WORDS 
 
 seat of mental sight ', is to be found in the cerebral 
 convolution called cuneus. Lesion of any part of 
 an organ of sense produces anaesthesia, and a comatose 
 person may be locally anaesthetic ; for instance, he may 
 be blind ; but this constitutes no part of the coma. 
 
 We know much about the senses, and quite enough 
 to justify us in believing that, if the organs of sense 
 be implicated in coma, it is through their sensoria all 
 and sundry. The anatomy of the brain gives no sup- 
 port to the notion of a sensorium commune such as 
 Thomas Willis was disposed to find in the corpora 
 striata. But most people think that coma is more 
 than universal anaesthesia, and hence a third definition. 
 
 III. A comatose person is said to be Unconscious. 
 Con-scious means that which knows with another, 
 that which participates in knowledge, that which 
 is an accessory or accomplice in knowledge. Thus 
 the word consciousness or conception implies ' facultas 
 quae se sentire sentit ' (Lord Herbert) ; it implies 
 something beyond and above mere sense or perception. 1 
 
 1 The distinction between perception and conception is so ancient 
 and so universal as to indicate what Herbert would call a natural 
 instinct of mankind in favour of the doctrine of Plato and 
 Cudworth.
 
 COMA AND APOPLEXY 13 
 
 In short, consciousness implies mind regarded with 
 special reference to sensation. 'Mind hears, mind 
 sees,' the organs of sensation are deaf and blind. So 
 that definition of the word consciousness raises the old 
 metaphysical question concerning the nature of know- 
 ledge, a dispute which in English philosophy is asso- 
 ciated with the opponent names of Hobbes and 
 Cudworth. But with meta-physics we, as physicians, 
 need not concern ourselves. I will only transcribe 
 a sentence from Cudworth which sets forth both 
 opinions in few words. ' Knowledge is not a passion 
 from anything without the mind, but an active exer- 
 tion of the inward strength, vigour, and power of the 
 mind displaying itself from within; and the intel- 
 ligible forms by which things are understood or known 
 are not stamps or impressions passively printed upon 
 the soul from without, but ideas vitally protended or 
 actively excited from within itself.' 
 
 IV. A comatose person does not move and appar- 
 ently cannot move. A man can make his sensibility 
 (or consciousness) manifest to another only by means 
 of movements : and when these movements are of 
 a kind which we know by our own experience to
 
 14 
 
 be performed with a purpose whereof we are sensible 
 or conscious, -we call them voluntary movements. So 
 that the sign of coma is universal loss of the power 
 of voluntary motion. Movements which we call in- 
 voluntary occur in coma : either natural movements, 
 such as those of breathing ; or unnatural movements, 
 such as convulsions. What movements are to be 
 called voluntary, and what involuntary, is a question 
 of experience and custom. 
 
 We know much about the anatomy of voluntary 
 motion, and we know that its organs are analogous to 
 those of sensation, consisting of three parts : an ex- 
 terior organ, the muscle ; an interior organ, the 
 motorium in the cerebral cortex ; and the bond be- 
 tween the terminal organs. A lesion of any part 
 of these structures results in paralysis ; and a coma- 
 tose patient often manifests signs of local paralysis 
 over and above his coma. But most people think 
 that the universal immobility of coma implies more 
 than universal paralysis, and thus we approach again 
 the dim region of metaphysical dispute ; this time 
 concerning the existence and nature of will. 
 
 Apoplexy. Just as a comatose patient resembles
 
 COMA AND APOPLEXY 15 
 
 a person asleep, and is therefore called comatose, so an 
 apoplectic patient resembles a person stunned, and is 
 therefore called apoplectic. The word apopUttein 
 means to stun, and apoplexy means that the patient 
 is stunned, not by a blow from without, but by 
 a blow from within. 1 In other words, apoplexy signi- 
 fies deep coma coming on suddenly and lasting till 
 death. This is the original meaning of the word, and 
 if it be not used in this sense, it had better not be 
 used at all. For apoplexy is a word which has 
 undergone strange perversions of meaning, the most 
 extravagant being found in the phrase ' pulmonary 
 apoplexy '. 
 
 Defining apoplexy thus, it is an uncommon disease. 
 Unless a comatose patient have been seen to fall 
 suddenly, stunned, we cannot aver that the coma 
 is apoplectic. It happens that the few cases of genuine 
 apoplexy which I have met with have all been due to 
 haemorrhage into the pons Varolii. Although I do 
 not suppose that this lesion is the constant cause of 
 
 1 ' Whilst Apoplexy crammed intemperance knocks 
 Down to the ground at once, as butcher felleth ox.' 
 
 Casile of Indolence.
 
 16 COMA AND APOPLEXY 
 
 apoplexy, yet this I say, that, taking the word cerebral 
 to signify relative to the cerebrum (in its narrower 
 sense), apoplexy is very seldom a symptom of cerebral 
 haemorrhage. 
 
 It is universally known that the coma of cerebral 
 haemorrhage is delayed, deuteropathic, and supervenes 
 upon other symptoms which mark the onset of the 
 attack headache, faintness, vomiting, dizziness, for 
 example. The phrase ' ingravescent apoplexy ' has 
 been invented to designate this form of disease ; but, 
 taking the word apoplexy in the sense defined above 
 ingravescent apoplexy is a contradiction in terms.
 
 17 
 
 III 
 LARGE HEADS IN CHILDREN 
 
 ADULTS seldom or never consult us on account of 
 the size of their heads, but children are very often 
 brought for an opinion about their heads, which are 
 thought to be too big, and to indicate water on the 
 brain. 
 
 Much of what I have to say is taken from a paper 
 which I published in St. Bartholomew's Hospital 
 Reports for the year 1871. The length of time which 
 has since passed away gives me the advantage of 
 sitting in judgement upon my own article, of cor- 
 recting it, and of adding to it the results of larger 
 experience. 
 
 In the first place we must remember the rapid 
 growth of the brain in childhood. During the first 
 year the weight of the brain is more than doubled. 
 ' Sommerring concluded that the brain reached its full 
 size as early as the third year ; the Wenzels and
 
 18 LARGE HEADS IN CHILDREN 
 
 Sir W. Hamilton fixed the period about the seventh, 
 and Tiedemann between the seventh and eighth.' This 
 is not far from the truth. Hence the cranium or 
 brain-pan grows much more quickly than the face 
 and rest of the body ; and hence the skull is often 
 wrongly deemed to be unduly large, even in a per- 
 fectly healthy child. 
 
 When we are asked for an opinion about a big 
 head, the first thing to do is to study, not its size, 
 but its shape. Here we are helped by the eyrto- 
 meter, which will give us an exact outline of the 
 head in any plane. Of the three chief planes of the 
 skull to wit, the horizontal plane and the two 
 vertical planes (longitudinal and transverse) the 
 horizontal plane is certainly the least useful, and 
 the longitudinal vertical plane the most useful. This 
 plane passes through the tuber occipitale, sagittal 
 suture, and glabella. It is the plane which anthro- 
 pologists have chosen, as being the most important ; 
 so much so that Mr. Huxley deems it a disgrace in 
 any ethnological collection to have a single skull 
 which is not bisected thus. 
 
 Our cyrtometric tracing, then, passes from the
 
 LARGE HEADS IN CHILDREN 19 
 
 deepest part of the nape of the neck just below the 
 tuber occipitale, over the top of the head to the deep- 
 est part of the bridge of the nose, a little above the 
 canthus internus of the eyelids. The shape of a 
 natural head, upon this plane, is that of an irregular 
 pentagon with curved sides. Of the five sides of this 
 pentagon, four belong wholly to the cranium, four 
 increase in length as the cranium increases in size. 
 The fifth side belongs partly to the face, and does 
 not grow at the same rate as the other sides or as 
 the cranium. This fifth side may be called the base 
 line, inasmuch as it is a straight line joining the 
 deepest part of the nape of the neck with the deepest 
 part of the bridge of the nose, and corresponds roughly 
 with the base of the skull. This base line, because 
 it is somewhat of a constant, which does not change 
 altogether with cranial changes, is most useful as 
 a standard of comparison. 
 
 The greater number of big heads retain the penta- 
 gonal shape ; some do not. I call the former long 
 heads or dolichocephalae, and the latter round heads or 
 cyclocephalae, for reasons which will appear hereafter. 
 
 I. Long Heads. The cranium enlarges, but the 
 c 2
 
 20 LARGE HEADS IN CHILDREN 
 
 base of the skull does not grow in proportion. The 
 cranial sides of the pentagon lengthen, but very much 
 more than the base line. The result is that the pro- 
 portion between the greatest length of the cranium 
 from before backwards and the base line is changed. 
 I have measured a good many heads of healthy 
 children under three years of age, and I find that 
 the ratio between the greatest length of the cranium 
 and the base line is as six are to five ; in other words, 
 the cranium is about one-fifth longer than the base. 
 In these measurements, the greatest antero-posterior 
 diameter must be taken parallel to the base line, an 
 easy thing to do in the cyrtometric tracing. But 
 even in a well-shapen head the length of the cranium 
 may be greater than the average ; yet the ratio of 
 greatest length to base line is seldom or never more 
 than as five are to four that is to say, that the 
 cranium of a healthy head is never longer than the 
 base line by more than one-fourth of the latter. If 
 the cranium is longer than this, I call it dolicho- 
 cephalic. This is not the meaning which Retzius, 
 who invented the word, gave to it ; nevertheless, 
 I have ventured to change the meaning for medical
 
 LARGE HEADS IN CHILDREN 21 
 
 purposes, and for reasons given in my paper in the 
 Hospital Reports. The increased length of cranium 
 shows itself before or behind, or in both directions. It is 
 observed that the child's forehead is ' overbuilt with 
 most impending brows ', or that the occiput is very pro- 
 tuberant, or that the head projects both back and front. 
 
 Let us now inquire into the state of things within 
 a dolichocephalic skull. In my former paper I de- 
 clared my belief that c dolichocephalus is always the 
 result of increase in the solid contents of the skull, and 
 not in its liquid contents. In other words, dolicho- 
 cephalus indicates a big brain, and not water on the 
 brain.' I have now to say that this proposition is not 
 universally true ; on the contrary, dolichocephalus is 
 only sometimes indicative of a big brain. 
 
 1. The big brain, in most cases, is naturally big. 
 It does not afford any signs of disease, either during 
 life by lesion of function, or after death by lesion of 
 structure. The person has a head and brain too great 
 for his body ; that is all we have to say of him ; but 
 that is saying much, because it is saying that he is 
 not suffering from the incurable disease which is 
 always supposed in such cases.
 
 22 LAKGE HEADS IN CHILDREN 
 
 2. The big brain is sometimes unnaturally big ; it 
 is said to be hypertrophous. Its functions during 
 life are much impaired. Yet the naked eye cannot 
 detect any structural changes after death. Some 
 there are who affirm that hypertrophy of the brain 
 is due to ' diffuse interstitial hyperplasia of the 
 neuroglia ' ; it would seem to be more agreeable with 
 our present knowledge neither to affirm nor to deny. 
 For hypertrophy of the brain is an uncommon disease. 
 Few cases are on record, and for this reason I will 
 narrate the following instance. 
 
 A boy two years and three-quarters old when seen 
 for the first time. He was never able to walk ; he 
 did not cut his first tooth until he was ten months 
 of age. When two years and a half old he became 
 feverish, vomited, and screamed a great deal, and 
 had fits, sometimes two a day, sometimes two a week. 
 His mother's attention being drawn to his head, she 
 noticed for the first time that it was large. He was 
 highly rickety ; head, breast, and limbs all deformed. 
 His head was much enlarged ; but I have preserved 
 no tracing of it, because at that time I did not use 
 the cyrtometer. The fontanelle was widely open, not
 
 LARGE HEADS IN CHILDREN 23 
 
 raised. Slight internal squint of right eye ; no blind- 
 ness ; pupils equal. He seemed very dull, and cried 
 fretfully. Two days afterwards he was convulsed, 
 and died. Post-mortem appearances : Body not very 
 thin ; weight 17| Ib. Skull : fontanelle on a level 
 with bones, about 1^ in. square. Recent black thrombi 
 in posterior half of superior longitudinal sinus and 
 of lateral sinuses. No flattening of convolutions. 
 No excess of intracranial fluid anywhere. Brain 
 weighed 59 oz. (more than one-fifth of the whole 
 weight of the body). To the unaided eye its structure 
 seemed natural ; the grey matter was increased as 
 much as the white ; the corpora striata were very 
 large. The consistency of the brain was natural, it 
 was not toughened or hardened, and its specific 
 gravity did not seem to be increased. The other 
 organs were natural. 
 
 3. But in by far the greater number of dolicho- 
 cephalae which I have examined the brain has not 
 been larger than natural. Wherefore, in such cases, 
 the brain does not fill the skull, and the space between 
 them is occupied by water. The effusion is both 
 external and internal ; it seems to be passive, simply
 
 24 LARGE HEADS IN CHILDREN 
 
 filling up what would otherwise be a vacuum. Nor 
 are there any signs of pressure upon either the skull 
 or the brain. In these particulars this kind of hydro- 
 cephalus, or water on the brain, differs altogether 
 from the active hydrocephalus I shall have to speak 
 of hereafter, which is ventricular or internal, which 
 dilates the skull by equal pressure in all directions, 
 into a sphere ; and which also compresses the brain. 
 
 Now most, if not all, of these children are rickety ; 
 indeed, this kind of dolichocephalus and hydro- 
 cephalus is peculiar to rickets. The earliest writers 
 upon rickets knew this ; for details upon this point 
 I may refer to an article of mine upon rickets in 
 the Hospital Reports for 1868. No satisfactory 
 explanation has been given of this rickety head. 
 I think we must be content with the simple asser- 
 tion that the skull in rickets is often enlarged so 
 as to be greater than is necessary for the brain, and 
 the excess of space is occupied by water. 
 
 I will now speak of the manner in which the 
 head is enlarged by inherited syphilis. It does so 
 in two ways. First, the characteristic enlargement is 
 due to extensive growth of the osteophytes described
 
 LARGE HEADS IN CHILDREN 25 
 
 by Parrot. The cranial bones, especially the frontal 
 and occipital bones, become greatly thickened, it may 
 be as much as two or even three centimetres. The 
 big head, such as it is, is indicative, not of a cranial 
 cavity larger than natural, but only of a thickened 
 skull. Wherefore the enlargement of the head from 
 this cause is never great. Secondly, the head of 
 syphilitic children often possesses all the characters 
 which I have just assigned to the rickety head, and 
 I have always deemed these children to be both 
 syphilitic and rickety, and have even gone so far 
 as to believe that syphilis may be looked upon as 
 a cause of rickets, but without the slightest disposi- 
 tion to assent to Parrot's doctrine that syphilis is not 
 only a, but the, cause of rickets. 
 
 II. Round Heads. In this kind of big head the 
 shape of the skull is fundamentally changed ; it 
 ceases to be a pentagon, and becomes a segment of 
 a circle. Cyclocephalus is the shape proper to ventri- 
 cular hydrocephalus, a disease characterized by an 
 active distension of the ventricles of the brain by 
 water, and a much more serious disease than the 
 passive hydrocephalus I mentioned just now as being
 
 26 LARGE HEADS IN CHILDREN 
 
 present in some rickety dolichocephalae. Hydro- 
 cephalus does not produce a round head after the 
 fontanelles are closed and the sutures well united. 
 Acute ventricular effusion, occurring in tubercular 
 or purulent meningitis, does not produce a round 
 head, even when the fontanelle and sutures are not 
 closed ; the pressure, we may suppose, does not last 
 long enough. 
 
 Another well-known effect of active distension of 
 the skull from within by fluid is the peculiar change 
 in the position of the eyeballs with respect to the 
 eyelids ; a condition due to excessive obliquity and 
 drawing-upwards of the orbital roof, and never associ- 
 ated with dolichocephalus. 
 
 Optic neuritis, going on to atrophy of the disks, is 
 sometimes caused by hydrocephalus ; especially when 
 it sets in after the fontanelle has closed. When the 
 head admits of distension, and becomes cyclocephalic, 
 the optic neuritis is often absent. 
 
 Lastly, in extreme hydrocephalus, the head is some- 
 times seen to be translucent in a strong light, such 
 as that of the sun.
 
 27 
 
 IV 
 
 APHASIA 
 
 IF we read the writings of the ancient physician, 
 Sextus Empiricus, we find that aphasia was a word 
 much used by the new academic and sceptical philo- 
 sophers. But they denoted thereby rather unwilling- 
 ness than inability to speak. We, on the other hand, 
 mean by aphasia inability to say what we wish 
 to say. 
 
 What do we understand by the word ' saying "? 'Is 
 not thought the same as speech, with this distinction, 
 that thought is the unuttered conversation of the 
 mind with herself, and that the stream of thoughts 
 which flows through the lips and becomes audible is 
 called speech ? ' (Plato). Hobbes adopts Plato's teach- 
 ing thus : ' The general use of speech is to transfer 
 our mental discourse into verbal, or the train of our 
 thoughts into a train of words.'
 
 28 APHASIA 
 
 Another truth which seems to have been perceived 
 by the Greeks even before they began to philosophize 
 is this : that, in the case of speech, the thought is 
 a word. Logos means both thought and word, one 
 notion regarded under different aspects. 'The logos 
 which is a thought so long as it dwells within the 
 breast becomes a word so soon as it is uttered 
 (catered) or comes forth ' (Plato). Or, as Hobbes 
 puts it in his sarcastic way : ' The Greeks have but 
 one word, logos, for both speech and reason ; not that 
 they thought there was no speech without reason, 
 but no reasoning without speech.' 
 
 Aphasia implies a breach in the procession from 
 within to without ; the indwelling word cannot be 
 uttered ; the stream of thoughts is interrupted before 
 it pass the lips : the mental discourse cannot be 
 transferred into verbal : the train of thoughts cannot 
 become manifest as a train of words. 
 
 So much for what aphasia is ; now for what it is 
 not. I. It is not defect in the u mattered word, that 
 is to say : i. Aphasia is not loss of memory for 
 words ; this is amnesia, forgetfulness, a form of 
 dementia. Aphasia implies no mental defect, al-
 
 APHASIA 29 
 
 though, of course, aphasia and dementia may be 
 combined, ii. Congenital inability to speak from 
 idiocy or deafness (deaf-dumbness) is not aphasia : 
 the unuttered word is wanting. II. Aphasia is not 
 defect in the articulation of words : although of course 
 the two conditions may be combined. 
 
 The man has words in his mind, and he can arti- 
 culate words, yet he cannot speak or cannot speak 
 properly, he cannot utter words or utters wrong 
 words : this is aphasia. 1 
 
 What is the nature of aphasia : to what more 
 general term can we refer the species ? Aphasia is 
 a species of paralysis : paralysis of the special move- 
 ments of speech. In uncomplicated aphasia the 
 muscles employed in speech are not paralysed except- 
 ing for speech. Compare bulbar paralysis : in this 
 disease, the speech often becomes quite unintelligible ; 
 but the muscles are paralysed for all movements, 
 swallowing, blowing, whistling and the rest. 
 
 Aphasia is either acquired or congenital. I. Ac- 
 
 1 Cicero translates aphasia by the word infantia : ' Infantia 
 dicitur quum quis rcm aliquam novit et earn dicendo non potest 
 cxplicare.' Stephanus, Thesaurus Liny. Latinae.
 
 30 APHASIA 
 
 quired aphasia is connected with permanent disease 
 of the brain or not. 1. Concerning the permanent 
 changes in the structure of the brain which induce 
 aphasia, I will say no more than that it is quite 
 possible for the aphasia to pass slowly away although 
 there may be good reasons for believing that the 
 damage done to the brain is permanent. 2. But 
 aphasia sometimes lasts so short a time that we may 
 infer that the corresponding cerebral disorder has 
 been equally temporary. 
 
 i. Temporary aphasia is very prone to occur in 
 persons who are subject to migraine. A surgeon, 
 liable to migraine, went on business out of town, and 
 passed many hours without food. Returning by 
 railway and crossing the Thames, he was asked by 
 a fellow passenger for the name of some place they 
 saw from the bridge. My friend, to his great sur- 
 prise, found that he could not speak. When he 
 reached the terminus he called a cab, but could not 
 tell the driver whither to go. However, he managed 
 to direct the man with his umbrella, and came 
 straight to my house. He was much alarmed, but 
 by the time I saw him the aphasia, which lasted
 
 APHASIA 31 
 
 about half an hour, had passed away. He lived 
 some years after this attack, and never had another. 
 
 A surgeon, prone to migraine, had three attacks of 
 temporary aphasia, each lasting half an hour. Soon 
 after the beginning of one attack he tried to write 
 a letter: the result of his attempt he gave to me. 
 He told me that 'he was able to speak pretty well 
 at the time ; anyhow, to make himself easily under- 
 stood. The only other fact that he remembered 
 during the attack that struck him as curious was, 
 that he could spell out loud many words that be 
 could not say, and yet he could not repeat the 
 alphabet farther than D.' His letter ran thus : ' Dear 
 you can. Pleaearue you can give to if you can some 
 if you can come in come again some time aphasia 
 agaain.' Here he left off, for he knew that he was 
 writing nonsense. One or two other similar instances 
 make me think it probable that the aphasia of mi- 
 graine is mostly accompanied by agraphia. 
 
 ii. Emotion. A gentleman, sixty-five years old, 
 had two attacks of temporary aphasia, with a short 
 interval. I saw him during his second attack : he 
 had been for a long walk, and had come home very
 
 32 APHASIA 
 
 tired, when, for some reason or other, he flew into 
 a great rage with his butler. While he was yet 
 scolding the man he lost the power of speech : ' vox 
 faucibus haesit.' The aphasia passed slowly away in 
 the course of two or three days. 
 
 iii. It is well known that an epileptic fit is some- 
 times followed by aphasia, either alone or associated 
 with right -sided hemiplegia or monoplegia. iv. 
 Aphasia has been known to follow the use of certain 
 drugs ; for instance, santonine. v. Whether the dumb- 
 ness of hysterical persons be a case of ' cannot speak ' 
 or ' will not speak ' is a question which may be left 
 unanswered until the essential nature of hysteria has 
 been determined, vi. The aphasia which sometimes 
 follows typhoid fever, though temporary, lasts more 
 than a few days. 
 
 II. Congenital aphasia is a curious and rare dis- 
 order. It must be carefully distinguished from idiocy, 
 and this cannot always be done without repeated 
 examination of the patient, and some little delay. 
 In a doubtful case we should remember that the 
 affection is much more likely to be a somewhat 
 uncommon form of a common disease, dementia, than
 
 APHASIA 33 
 
 to be an instance of that very uncommon condition, 
 congenital aphasia. The pretty story which Herodotus 
 tells about the son of Croesus is well known. The lad 
 was dumb and suddenly acquired speech when under 
 the influence of strong emotion. The faculty thus 
 aroused was permanently retained. From time to 
 time similar cases have been recorded, and there 
 seems to be no reason for doubting the occurrence of 
 the fact. The same sudden recovery of speech under 
 emotion has been observed in cases of acquired 
 aphasia : and it is an interesting reflection that 
 powerful emotion sometimes promotes eloquence and 
 sometimes takes speech away ; sometimes causes 
 aphasia and sometimes cures it. 
 
 r.l.l.
 
 34 
 
 V 
 
 THE MEANING OP THE WORD DELIRIUM 
 
 WE may gain from etymology a clear insight into 
 the meaning of the Word delirium. ' Etymologies 
 are no definitions, and yet when they are true, they 
 give much light towards the finding out of a defini- 
 tion ' (Hobbes). The Latin word lira signifies a balk 
 or ridge of earth raised by the plough : the verb lira 
 signifies I plough; and ploughing is or ought to be 
 straight and right. De-liro signifies, I plough awry ; 
 and from deliro is derived the word delirium. 
 
 With respect to the actions of men, we set up 
 a standard, rule, or notion (founded upon common 
 sense or opinion) according to which a man may act 
 and be deemed in his right mind. To deviate from 
 this standard is to be delirious, to ivander in the 
 mind. 
 
 Delirium implies failure of the mental powers, but 
 not of all these powers. Just as in falling asleep, one
 
 THE WORD DELIRIUM 35 
 
 faculty slumbers after another, and not all at the 
 same time, so delirium indicates partial failure of 
 mind. Reason, which is 'the power of judging 
 aright, and of distinguishing truth from error', 
 slumbers ; and the other faculties, being uncontrolled, 
 run riot. (1) Imagination tends to be especially 
 active ; delirium of this kind has a close resemblance 
 to dreaming. The patient perceives phantoms or 
 alucinations, and cannot distinguish them from true 
 and trustworthy appearances. These alucinations 
 relate to any of the senses ; to touch perhaps most 
 seldom of them all : sights, sounds, smells, tastes, all 
 may be delusive, and especially sights. The mere 
 perception of phantoms does not constitute delirium : 
 if the patient know them to be phantoms, apparitions, 
 visions, and rate them at their proper value, he is not 
 delirious. But if reason (the ruling or hegemonic 
 power) be weakened, when phantoms appear, the 
 patient believes in them, and delirium follows. 1 
 
 1 ' All power of fancy over reason is a degree of insanity ; but 
 while this power is such as we control and repress, it is not visible to 
 others, nor considered as any deprivation of the mental faculties ; 
 it is not pronounced madness but when it becomes ungovernable, 
 and apparently influences speech or action." Easselas : chap. 44. 
 
 D 2
 
 36 THE MEANING OF 
 
 (2) The passions also are unusually manifest, being 
 unrestrained. The dictum of Hobbes, that ' madness 
 is nothing else but too much appearing passion', 
 would be more accurate if thus expressed: that too 
 much appearing passion is a sign of madness: 'ira 
 brevis furor.' 
 
 What coma is to sleep, delirium is to dreaming ; 
 for ' delirium is a dream arising from disease ' (John 
 Hunter). In both dreaming and delirium, reason 
 slumbers. A dreaming person can be roused to full 
 and lasting wakefulness ; a delirious person can be 
 roused but incompletely, and for a short time, or not 
 at all. Just as the dreamer is only half asleep, so 
 delirium is a state midway between consciousness 
 and coma, that is to say, the reason (primum dor- 
 miens), is already comatose. Thus delirium often 
 precedes, and sometimes follows coma. 
 
 Madness is the English word for delirium ; but 
 madness has come to mean lunacy. The distinction 
 between lunacy and what is commonly called delirium 
 is founded upon practical considerations. When 
 delirium is habitual, so that the patient is always 
 mad, or is liable to frequent outbreaks of madness,
 
 THE WORD DELIRIUM 37 
 
 we call it lunacy and subject the person to special 
 laws and treatment. 
 
 Delirium when attended by fever constitutes 
 phrenitis or brain fever. The Greek word phren (or 
 rather its plural, phrenes) signifies mentis sedes, the 
 seat of mind. It seems to be a natural instinct of 
 mankind, in an early stage of knowledge, to deem the 
 praecordia, that is to say, the parts where the heart 
 can be felt to beat (and especially the pit of the 
 stomach or epigastrium) to be mentis sedes. Hence 
 the use of the word phrenic as relating to the 
 diaphragm ; and hence, in some of the Hippocratic 
 writings, phrenitis is classed among diseases of the 
 abdomen. The Hebrew phrase, 'an understanding 
 heart,' and the old English phrase, ' wood-heart ' 
 ( = woodness or madness), testify to the same ancient 
 physiology. The Hippocratic treatise De Morbo 
 Sacro marks the progress to later doctrine that the 
 brain is mentis sedes. 
 
 Some people possess an original tendency to 
 delirium, which is often the same thing as an in- 
 herited tendency to insanity. For an instance well 
 known to occur : a woman will surfer from mania at
 
 38 THE MEANING OF . 
 
 the birth of each child, several members of her family 
 having been insane. But what is less well known is 
 the fact that, in persons of this kind, not only serious 
 disease, but very slight ailments may be attended by 
 delirium lasting for a few days. I have known 
 prolonged toothache, strong emotion, the fatigue 
 of a railway journey, to be causes of temporary 
 mania. 
 
 A disposition of much the same sort is that which 
 consists in an extreme susceptibility to drugs which 
 act chiefly upon the brain. Alcohol may make such 
 persons not drunk, but raving mad. An injection of 
 morphia may produce not sleep, but excitement and 
 delirium. No drug acts more powerfully in this 
 respect than cannabis indica : e. g. an unmarried lady, 
 thirty years old, after taking ten minims of the tinc- 
 ture, almost immediately complained of a feeling of 
 fire in the head, and of other strange alarming sensa- 
 tions, she not knowing what drug it was she had 
 taken. Narcotic drugs act thus more frequently in 
 women than in men. It is best to give morphia 
 cautiously to a woman until it is known how she will 
 bear it, and not to give hemp at all.
 
 THE WORD DELIRIUM 39 
 
 ' When sleep puts an end to delirium, it is a good 
 sign.' 1 Most true; but it is not always easy at first 
 to say that what looks like sleep may not be super- 
 vening coma: and how great the prognostic difference; 
 the one signifying recovery, and the other death. 
 
 1 Hippocrates, Aphorisms, ii. 2,
 
 40 
 
 VI 
 
 NERVOUS ATROPHY 
 
 (Atrophia nervosa : Anorexia nervosa) 
 
 THERE is a disease, almost peculiar to young 
 women, which is characterized by great loss of flesh 
 and of appetite for food. Richard Morton described 
 this malady in his remarkable book on Phthisis. He 
 used the word Phthisis in its original and universal 
 sense, to signify wasting, consumption, atrophy of the 
 whole body : and he distinguished the particular 
 form of atrophy aforesaid by the special name of 
 Atrophia vel Phthisis nervosa. In the Clinical 
 Society's Transactions for 1874, Sir William Gull 
 published a few instances of this disorder under the 
 name of Anorexia nervosa, laying stress upon the loss 
 of appetite rather than upon the loss of flesh. The 
 name Atrophia nervosa seems preferable for reasons 
 which will appear at the end of the paper.
 
 41 
 
 When the disease has lasted for some time, the 
 patient becomes extremely emaciated, ' sceleti instar 
 cute vestiti/ nothing but skin and bones. The re- 
 pugnance to food is extreme, though we can hardly 
 help suspecting that it is not so much a case of 
 cannot eat as of will not eat, for there are no signs 
 of indigestion. Constipation more or less obstinate 
 is always present. The menses always stop. If the 
 breasts are not fully developed they remain unde- 
 veloped. The blood circulates feebly, the hands and 
 feet are cold and blue ; some patients show a faint 
 livid discoloration of the cheeks. In a few cases 
 slight inconstant albuminuria will be found. 
 
 The disease is allied to insanity and occasionally 
 ends in insanity. When we are allowed to explore 
 the recesses of the family history we sometimes dis- 
 cover that certain relatives of the patient have been 
 actually insane, or at least eccentric. Some of them 
 may have been supposed to possess or to be possessed 
 by a genius. 
 
 Nervous atrophy affects young women about the 
 age of puberty, or afterwards until they are about 
 five and twenty years old. Moreover, the patients
 
 42 NERVOUS ATROPHY 
 
 are unmarried. But these three propositions con- 
 cerning the sex, age, and unmarried state are not 
 universally true. I never saw a more marked in- 
 stance of nervous atrophy than in a boy eleven years 
 old, and the like symptoms occur in still younger 
 children, boys or girls. In a girl three years old, the 
 aversion to food was associated with that depraved 
 appetite which is called pica; she would eat coals, 
 plaster, or mud. 
 
 In young women the mental disorder takes on the 
 form of melancholy, which is no more than a high 
 degree of the melancholy which affects so many girls 
 about the age of puberty and for some years after- 
 wards. The melancholy seems to arise from a morbid 
 excess of that craving for sympathy which is common 
 to all mankind, as is especially strong in the female 
 sex. A young maiden, with small experience of the 
 world, expects more from life than life can give : the 
 sympathy desired is not forthcoming ; hence dissatis- 
 faction and discontent. In the extreme degree of 
 this melancholy, the patient suffers from perverse 
 conceits and strange notions. She thinks that people 
 take not sufficient notice of her, she thinks that she
 
 NERVOUS ATROPHY 43 
 
 is misunderstood, fancies that she is censured or 
 judged hardly. She becomes irritable and passionate, 
 envious and jealous, timorous and sad ; she feels a 
 sort of indescribable dread, yet dread of nothing in 
 particular; she is without hope of better fortunes, 
 thinks she has not long to live, almost wishes for 
 death. One of these girls, when she was alone in the 
 drawing-room, was overheard to tell her parrot that 
 she was not much longer for this world. 1 Lost in 
 her museful mopings, she takes delight in nothing 
 and loves to be alone, though solitude does her more 
 harm. In short, she becomes highly peculiar. 
 
 Her perverse notions sometimes relate directly to 
 food. The girl thinks that people can live without 
 food. One young woman thought that it was wrong 
 to slaughter animals for food, and tried to regulate 
 her diet accordingly ; a delusion which was not found 
 out until I suggested to her mother that she probably 
 had odd notions. Sometimes the girl will think that 
 exercise is very necessary and will take long walks 
 
 1 Look at the first woodcut in Sir William Gull's paper for the 
 portrait of a young woman, seventeen years old, the very picture of 
 pathetic resignation, worthy of a mediaeval saint.
 
 44 NERVOUS ATROPHY 
 
 far beyond her strength, or she will try the eccoprotic 
 powers of leaping and dancing in her bedroom before 
 daybreak, until the awakened household protest 
 against the continuance of such preposterous thera- 
 peutics. 
 
 In the last stage of nervous atrophy the patient 
 resembles a person dying from some form of tuber- 
 cular disease. Indeed tubercle is often suspected in 
 these cases, but inasmuch as any local signs thereof 
 are absent or very doubtful, the tubercle is supposed 
 to be latent. The patients are apt to become slightly 
 febrile. Anasarca sometimes occurs, especially in the 
 legs, hydrops tabidarum. Should the patient die, 
 a post-mortem examination will reveal no anatomical 
 explanation of the disease. But death is an un- 
 common termination : if the nature of the malady 
 be recognized and appropriate treatment be adopted, 
 most patients will slowly recover and at last regain 
 their former health. Recovery cannot be deemed 
 complete until the menses have regularly appeared. 
 
 There is yet an intermediate result, the patient 
 neither recovers nor dies. I once saw the daughter 
 of a small tradesman; she was forty years old, and
 
 NERVOUS ATROPHY 45 
 
 had lived all her life at home, with nothing to do. 
 For twenty years she had suffered from marasmus 
 and anorexia steadily increasing. Her menses had 
 Ceased for three years. She was bed-ridden and ex- 
 tremely emaciated : the loathing for food was extreme. 
 I was told that she took no more food in a week 
 than a healthy child four years old would take at 
 one meal. There were no signs of any local disease. 
 She was full of aches and pains, was very costive, 
 and very sleepless. But she had never been properly 
 treated. 
 
 Should such a case as this become the topic of 
 gossip in a neighbourhood of ignorant and silly 
 people, the patient may attain to the notoriety of 
 a fasting girl. To credulity on the part of the public 
 is now added imposture on the part of the patient, 
 and nothing more is necessary. Vain were it to 
 waste words upon these deplorable exhibitions of 
 folly : I prefer to entertain the reader by quoting 
 from a letter written by Thomas Hobbes ; a fine 
 sample of the powerful, keen, contemptuous, and sar- 
 castic humour of the man. 
 
 ' The young woman atO ver-Haddon hath been visited
 
 46 NERVOUS ATROPHY 
 
 by divers persons of this house. My Lord himself 
 hunting the hare one day, with other gentlemen and 
 some of his servants, went to see her on purpose : and 
 they all agree with the relation you say was made to 
 yourself. They further say on their own knowledge 
 that part of her belly touches her back-bone. She 
 began (as her mother says) to lose her appetite in 
 December last, and had lost it quite in March follow- 
 ing : insomuch as that for the last six months she 
 has not eaten or drunk anything at all, but only wets 
 her lips with a feather dipt in water. Some of the 
 neighbouring ministers visit her often: others that 
 see her for curiosity give her money, sixpence or 
 a shilling, which she refuseth, but her mother taketh. 
 But it does not appear they gain by it so much as 
 to breed a suspicion of a cheat. The woman is mani- 
 festly sick, and 'tis thought that she cannot last much 
 longer. Her talk (as the gentlewoman that went 
 from this house told me) is most heavenly. To know 
 the certainty there be many things necessary which 
 cannot honestly be pryed into by a man. Whether 
 any excrement pass, or none at all. For if it pass, 
 though in small quantity, yet it argues food proportion-
 
 NERVOUS ATROPHY 47 
 
 able, which may, being little, be given her secretly. 
 Whether no urine at all pass ; for liquors also nourish 
 as they go. I think it were somewhat inhumane to 
 examine these things too nearly, when it so little con- 
 cerneth the commonwealth : nor do I know of any 
 law that authoriseth a justice of peace, or other sub- 
 ject, to restrain the liberty of a sick person so far as 
 were needful for a discovery of this nature. I cannot 
 therefore deliver any judgment in the case. The 
 examining whether such a thing as this be a miracle 
 belongs I think to the Church.' ' From Chatsworth : 
 October 20, 1668.' 
 
 Nervous atrophy is not quite peculiar to maids; 
 it is occasionally seen in young married women who 
 are left much to themselves ; their husbands being 
 from home all day at business. 
 
 In the treatment of nervous atrophy the first thing 
 to be done is to secure the confidence of the patient's 
 friends, and to persuade them to allow her to be put 
 under the care of strangers, away from home. Indeed 
 the treatment is essentially the same as that which 
 bears the name of Dr. Weir Mitchell. When separated 
 from their relatives, these girls and boys can gradually
 
 48 NERVOUS ATROPHY 
 
 be persuaded to take food enough. They must be 
 fed at regular intervals : the frequency of feeding 
 depends upon the amount taken at a time : at first 
 the food must be put into the patients' mouths, if 
 they lack energy enough to take it themselves ; more- 
 over, any solid food should be so prepared as to need 
 no chewing. 
 
 But even when they take their food, it by no means 
 follows that they soon recover. It may happen that 
 the marasmus, constipation, amenorrhoea and melan- 
 choly continue : a manifest proof that the disease is 
 not the result of mere anorexia. In a case of this 
 kind, even a long holiday of travel through foreign 
 lands did not suffice to bring about a cure. Soon 
 after the patient's return her father was suddenly 
 attacked by a serious illness. She had been the old 
 man's darling, but now, all the solicitude of the family 
 being diverted from her to him, she made a rapid 
 recovery. 
 
 Relapses, so far as I kuow, do not occur.
 
 VII 
 SPINAL MYALGIA. 
 
 DISEASES which consist in pain, and in little or 
 nothing but pain, place us almost wholly at the mercy 
 of our patient; we can do little more than register 
 what he or she tells us ; we have few means of putting 
 the accuracy of these statements to the test. Yet 
 some sort of test is very necessary, because these pain- 
 ful affections occur for the most part in women ; and 
 women who suffer thus, usually suffer at the same 
 time from another disorder which is the main cause of 
 our difficulties, I mean an uncontrolled disposition to 
 exaggerate. Uncontrolled, and sometimes I suppose, 
 uncontrollable ; we do not believe that they all lie 
 wilfully ; but the result, so far as we are concerned, is 
 just the same as if they did. 
 
 It commonly comes to this. You visit your patient 
 with a candid mind, desirous to hear what she has to
 
 50 SPINAL MYALGIA 
 
 say, as in duty bound, so that you may afterwards do 
 all the good to her our art can do. But you soon find 
 that the more patient and attentive you are to the 
 story, the more does it lengthen ; there seems no end 
 thereof in view ; it flows, and as it flows, for ever will 
 flow on. In young women there is often the opposite 
 difficulty ; they are not too voluble ; indeed they will 
 vouchsafe no information at all ; they reply to your 
 questions in monosyllables ; they roll the bedclothes 
 round them, and resist all your well-meant endeavours 
 to discover the nature of the malady. And yet you 
 cannot help thinking that in this taciturn manner the 
 intention of the patient is the same as that of her 
 loquacious sister, namely, to exaggerate. 
 
 Your examination over, you prescribe the treatment. 
 At this stage you must expect one of two results. 
 Either your patient will never admit that you do her 
 the slightest good ; very likely she will give you 
 plainly to understand that you have made her worse. 
 Or you will find that as soon as you have dispersed 
 one set of disorders, new crops arise, and your task 
 seems endless. Moreover, you are told by those who 
 are more constantly than you in the company of the
 
 SPINAL MYALGIA 51 
 
 patient, that her conduct hardly tallies with her com- 
 plaints. The question even arises whether hers is not 
 altogether a case of imposture. But supposing that 
 you dismiss this suggestion, yet there is so much 
 about the patient which is not straightforward, that 
 you are wearied with your vain attempts to get at the 
 truth, and are glad to be rid of her. 
 
 In no disorder are these truths more apparent than 
 in the female complaint which has been called an 
 irritable spine. The word irritable used in this way 
 means painful. An irritable uterus is a painful uterus. 
 The term seems to have been introduced about the 
 year 1820. Older terms, used in what is essentially 
 the same sense, are rhachialgia and notalgia. As 
 these Greek words signify, the disease consists in pain 
 referred to the spine and back. There is pain and 
 nothing else ; nothing else discoverable during life, 
 and no doubt nothing would be discovered on an 
 examination after death. The pain constitutes the 
 whole of the disease. 
 
 Now this would seem to be a very simple notion. 
 Yet a conception of irritable spine which has widely 
 prevailed is anything but simple; is indeed most 
 
 E 2
 
 5.2 SPINAL MYALGIA 
 
 complicated, and for this reason. The earlier writers 
 upon the disorder (Player, Brown, Darwall, Teale, 
 and Griffin) considered this spinal pain to be due 
 to an irritable, or irritated, or ' subacute inflammatory 
 state ' of the posterior roots of the spinal nerves, or 
 even of the spinal marrow itself. Any other pains or 
 disordered functions, which concurred with the pain 
 in the back, and which could by any possibility be 
 supposed to be due to disease of the spinal nerves, 
 were attributed to the irritable spine. In other words, 
 the irritable spine was thought to be the cause of 
 a host of other aches and troubles. Symptoms such 
 as these were thought to be dependent upon the spinal 
 irritation, namely, a lump in the throat, palpitation, 
 dyspnoea, spasmodic cough, gastralgia, nausea and 
 vomiting, irritability of the bladder, or suppression of 
 urine. No doubt these disorders sometimes concur 
 with an irritable spine ; but they are not the effect of 
 it. Indeed some of the symptoms which have been 
 supposed to be effects of irritable spine, are much 
 more likely to be its cause ; for instance, menorrhagia. 
 We will confine our attention to the simple notion 
 of pain referred to the region of the spinal column.
 
 SPINAL MYALGIA 53 
 
 There is pain, and nothing but pain ; no reason to 
 suspect disease of the" vertebral column, of the spinal 
 marrow, or of its membranes. The pain extends over 
 the width or length of two or three vertebrae, seldom 
 more. The most common situation is along the nape 
 of the neck, or between the shoulder-blades ; some- 
 times, but not often, lower down in the loins. The 
 painful part is tender to pressure made upon or along- 
 side the spinous processes. The overlying skin is 
 often tender. Application of heat or galvanism has 
 the same effect produces pain. But, at this point 
 of your examination, you must distinguish two cases. 
 Sometimes, if you follow the course of the sensitive 
 nerves which emerge from the tender or painful spot, 
 you will find other spots where the patient complains 
 of pain, spontaneous or produced by pressure, in 
 a nerve remote from the spine. This is neuralgia. 
 And so you get an irritable spine in connexion with 
 neuralgia of the cervical plexus, or cervico-occipital 
 neuralgia ; neuralgia of the brachial plexus, or cervico- 
 brachial nerves ; neuralgia of the intercostal nerves ; 
 and much less commonly in lumbo-abdoniinal, anterior 
 crural neuralgia, and sciatica.
 
 54 SPINAL MYALGIA 
 
 Sometimes you cannot make out any pain or 
 tenderness in the course of the nerves which corre- 
 spond with the spot of pain in the spine. There may 
 be pain elsewhere, beyond that in the back, but there 
 is no anatomical connexion between the two seats 
 of pain. This kind of irritable spine was deemed by 
 Dr. Inman of Liverpool to be due to myalgia : and 
 I believe that he was right. By myalgia he meant 
 muscular pain, pain referred to the tendinous ex- 
 tremities of muscles. Myalgia is closely allied to 
 fatigue. Speaking generally, we may say that my- 
 algia is due to one or both of two things : either the 
 muscle is overworked, or the whole health of the 
 patient is lessened, so that exertion which could 
 be easily borne in a robust condition becomes over- 
 work in the weak condition, even though the exertion 
 be small. The muscles of the vertebral column are 
 especially prone to be overworked, because ' there 
 is scarcely a single motion of the body in which one 
 or more muscles attached to the spinous processes are 
 not brought into operation, and there is, therefore, 
 throughout the whole day (except during absolute 
 rest), a constant and unremitting strain upon the
 
 SPINAL MYALGIA 55 
 
 fibres by which the muscles are inserted ' into the 
 spinal column. (Inman, On Myalgia, p. 226 : a book 
 which has not received the notice it deserves.) This 
 spinal myalgia is increased by any movement which 
 brings the affected muscles into play, and is diminished 
 by any position which relaxes the muscles, for in- 
 stance, by lying down perfectly still, or by artificial 
 supports like stays. 
 
 Over and above the fact that women are not capa- 
 ble of so much muscular exertion as men, women are 
 especially prone to myalgia of all kinds, by reason of 
 menstruation, childbearing, and suckling. 
 
 I will now narrate an instance of irritable spine 
 due to myalgia. A woman, aged forty-two years, 
 married, has had eleven children, of whom four are 
 now living, two were stillborn, and she has had one 
 miscarriage. Patient is a cook at an hotel, she has 
 been very much overworked, kept up late at night, 
 and obliged to rise early in the morning. She corn- 
 plains of sharp darting pain in her back, between 
 the shoulder-blades, which leaves a dull aching and 
 tingling sensation, aggravated by movement, and 
 especially felt over and near the spines of the first and
 
 56 SPINAL MYALGIA 
 
 sixth dorsal vertebrae. She also feels a pain which 
 follows movement in the muscles which extend the 
 head. In the lumbar region there is a well-defined 
 naiTow band of pain (a feeling of tying tight), reach- 
 ing from the spine of the second lumbar vertebrae to 
 the crest of the ilium. A sharp, breaking pain is felt 
 in the middle of the arm on raising it just before 
 it reaches the level of the shoulder. On using her 
 arms a pain is felt between the shoulders, on the 
 opposite side to that of the arm used. The arm- 
 muscles ache after use. A catch is sometimes felt 
 in the epigastrium on taking a deep breath. She is 
 fairly healthy and well nourished, complains of weak- 
 ness, but chiefly of the pains in her neck and back. 
 She soon improved. 
 
 This woman had an irritable spine, due to myalgia 
 of the muscles attached to the vertebrae. I think that 
 she exaggerated her sufferings, but the account she 
 gave of her pains tallied too closely with our general 
 notion of myalgia and irritable spine to justify us 
 in supposing that she had no pain at all. If she were 
 an impostor, she was deeply versed in the signs and 
 symptoms of spinal myalgia.
 
 SPINAL MYALGIA 57 
 
 In treating these myalgic people, the first thing is 
 to see that they take food enough. Often they take 
 very little food ; especially if they suffer from con- 
 current nervous^ disorder of the stomach, atonic or 
 flatulent dyspepsia, or cardialgia. But take food 
 they must : if they cannot or will not take much 
 at a time, they must feed often. A moderate allow- 
 ance of alcohol, in form of stout, ale, or wine, may 
 be reckoned as so much food. The muscles must 
 have an opportunity of being well nourished, or your 
 other treatment will do little good. 
 
 Secondly, the muscles should be rested. The pain 
 is a kind of fatigue. The muscles of the neck and 
 back cannot be rested unless the spine be supported 
 in its whole length : the patient must lie on a couch, 
 or recline in a very easy chair with a long, high back, 
 and with elbows, so that the weight of the arms is 
 taken off the spine. Yet here is a difficulty. A 
 prudent man thinks long before he condemns a 
 woman to the sofa. There is danger lest she may 
 never rise from it, and so be a burden to herself and 
 her friends for the rest of her life. Beware of insist- 
 ing too much upon the repose of a couch ; it were
 
 58 SPINAL MYALGIA 
 
 far better that the patient should continue to com- 
 plain of her pains. The best advice I can give you 
 is that you should recommend a certain amount of 
 reclining, and carefully watch lest your patient 
 show signs of becoming a slave to the sloth of the 
 sofa. With the better sort of women there is little 
 fear of this : they prefer an aching spine to laziness. 
 
 Another means of resting the muscles which 
 perhaps occurs to you, is well-fitting stays. But on 
 second thoughts you will see that stays do not come 
 high enough to support the head and shoulders ; 
 and it is here that spinal myalgia most commonly 
 occurs. 
 
 Daily massage to the whole body, and especially 
 to the muscles of the back, is a third point of 
 treatment. 
 
 Pain is relieved by heat, and most effectually by 
 hot- water douches (as hot as can be borne) to the 
 painful part for a quarter of an hour daily. But 
 douches require special apparatus which cannot be 
 found in private houses, and not in many towns. 
 Makeshift substitutes such as hot- water bags and 
 tins, bran bags dipped in hot water, are less efficacious,
 
 SPINAL MYALGIA 59 
 
 though useful. Belladonna, aconite, and turpentine 
 liniments may be tried : also acupuncture of the most 
 tender spots : and in bad cases subcutaneous injection 
 of cocaine or even morphia ; a secret not to be 
 divulged to these painful persons. 
 
 Lastly, I think that patients who have once 
 developed an irritable spine, seldom altogether lose 
 it ; or at least they will seldom confess that they 
 are altogether free from pain in the back.
 
 60 
 
 VIII 
 
 ON THE CAUSES AND FORMS OP 
 BRONCHITIS l 
 
 SCATTERED through the Hippocratic treatises are 
 frequent references to a doctrine that the brain 
 resembles a gland and is the ' metropolis ' for separa- 
 tion or secretion (words which have almost the same 
 meaning) of cold and viscid humours. When these 
 humours have accumulated in excessive quantity the 
 brain purges itself by discharging them upon the 
 lower parts of the body ; a process called catarrh, 
 defluxion, or distillation of rheum, pituita, or phlegm. 
 In the name of the pituitary body we find a survival 
 of this doctrine. The diseases which result from 
 defluxion of rheum have, says Plato, ' many names, 
 because the places subject to flux are manifold.' By 
 
 1 Lecture given before the Royal College of Physicians on March 
 16, 1899.
 
 CAUSES AND FORMS OF BRONCHITIS 61 
 
 the Hippocratic writers seven kinds of catarrh are 
 enumerated ; by the time of Celsus the number had 
 been reduced to three. In the Salernitan verses 
 these same three defluxions are enumerated, but the 
 name catarrh is restricted to defluxion upon the 
 lungs, catarrhus ad pulmones, pulmonary catarrh. 
 
 The change from ancient to modern doctrine is 
 marked by a voluminous treatise in six volumes 
 quarto, published between 1660 and 1664, and 
 written by Schneider, whose name has been given 
 to the Schneiderian membrane. We must admire 
 the divine leisure of the times which could allow 
 any man to write such a book or any man to read 
 it. This change in the doctrine of catarrh was 
 brought about partly by the progress of anatomy 
 and partly by Harvey's discovery which sapped the 
 authority of the ancients. 
 
 Since Schneider's time catarrh has denoted exces- 
 sive secretion of more or less altered mucus from 
 a mucous membrane. Hence Pulmonary Catarrh 
 signifies a disordered function of the pulmonary 
 mucous membrane, the result being an excessive 
 secretion. The corresponding lesion of structure
 
 62 ON THE CAUSES AND FORMS OF 
 
 that is to say, inflammatory changes in the mucous 
 membrane is called Bronchitis, a word which was 
 invented in 1814 by Dr. Charles Badham, and which 
 has to a great extent superseded the old phrase of 
 pulmonary catarrh. It is amusing to contrast the 
 diminutive duodecimo of Badham with the gigantic 
 work of Schneider. The use of the word bronchitis 
 marks the predominant influence of morbid anatomy. 
 Bronchitis and pulmonary catarrh although for the 
 most part they denominate different aspects of the 
 same disease yet do not exactly tally; bronchitis is 
 not always catarrhal ; for instance, it may be attended 
 not by flux of mucus but by formation of false 
 membrane. 
 
 CAUSES 
 
 Bronchitis is a disease of much interest for the 
 English people, inasmuch as in our country a pul- 
 monary catarrh is the commonest of disorders at all 
 ages and in all ranks and conditions of life. In 
 speaking thus of the frequency of bronchitis it is 
 worthy of note that this opinion is derived from 
 clinical experience, and that bronchitis is not a con-
 
 BRONCHITIS 63 
 
 dition which attracts much attention on the post- 
 mortem table, where the severe forms only of the 
 disease are recognized, or, indeed, one might almost 
 say, can be recognized without much more minute 
 examination of the bronchial tubes than they usually 
 receive. When we ask why bronchitis should be so 
 common we are led to consider the causes of the 
 malady. Let us begin with the simplest case possible 
 and seemingly the most intelligible. 
 
 A number of men are working in a room when 
 a large carboy of fuming nitric acid is broken. 
 They all flee. After a time a healthy young man, 
 having tied a wet towel round his mouth, goes back 
 into the room and opens the windows. Symptoms 
 of bronchitis immediately appear, painful soreness 
 down the sternum and dyspnoea, his voice remaining 
 natural. Next day he has a harsh, dry cough and 
 abundant small mucous rales all over both lungs ; 
 his temperature rises to 101-4 F., his pulse to 100, 
 and his respirations to 56 in the minute. On the 
 third day the temperature varies between 99 and 
 101, the respirations fall to 44 ; the signs in the 
 chest are much the same. On the fourth day the
 
 64 ON THE CAUSES AND FORMS OF 
 
 temperature falls from 100 in the morning to 
 the normal in the afternoon ; the rales have almost 
 disappeared. On the sixth day he is quite well. 
 
 Bronchitis, being an inflammation, presumes irrita- 
 tion of the mucous membrane, and in this case there 
 was no reason for supposing that the irritation was 
 originally due to anything besides the nitrous fumes, 
 even if we admit the possibility that microbes might 
 afterwards come to play their part upon a soil thus 
 prepared for them. But the cause of bronchitis is 
 seldom so simple as this. 
 
 Breathing dust has long been recognized as a cause 
 of pulmonary catarrh : for instance, Ramazzini two 
 centuries ago devoted several chapters of his book, 
 De Morbis Artificum, to the diseases, chiefly pul- 
 monary, which attend dusty trades. At the outset 
 it seems to be necessary to distinguish between dust 
 which is alive, and inanimate dust. Taking inani- 
 mate dust first, as being the less complex topic, we 
 must again distinguish between dust which contains 
 soluble constituents and that which does not. 
 
 Insoluble dust is, in most cases, of mineral nature, 
 yet the air of a cotton mill is smoky with vegetable
 
 BRONCHITIS 65 
 
 dust. The bronchitis resulting from dusty trades is 
 very chronic, insidious in onset and slow in progress. 
 Insoluble dust is supposed to act as a merely 
 mechanical irritant to the bronchial membranes, but 
 can we say that any sort of dust is absolutely in- 
 soluble 1 ? And when we endeavour to look more 
 deeply into the matter other doubts arise, as usual. 
 We suspect that the tendency to bronchitis which 
 prevails among workmen in dusty trades is often 
 aggravated by intemperate habits in respect of 
 alcohol and tobacco. Probably in some workmen 
 there is an original disposition to suffer in this way, 
 such as we see in many asthmatics, who are very 
 sensitive to dust. Moreover, the dust of unclean and 
 ill- ventilated rooms will be very likely to contain 
 morbific microbes, and the irritation of the air- 
 passages set up by inanimated dust will favour the 
 operations of the many bacteria which are potent 
 to cause bronchitis. It obviously would be very 
 improbable that these microbes should swarm in 
 impure air and should not be found in the upper 
 air-passages of man. And thus, as a matter of fact, 
 our mouths, noses, and throats harbour many morbific
 
 66 ON THE CAUSES AND FORMS OF 
 
 microbes in a latent state; they are there awaiting 
 a favourable opportunity for becoming active and 
 virulent, when, to quote the Virgilian phrase of which 
 Sydenham was so fond, ' Qua data porta ruunt.' 
 
 Although it is probable that inanimate dust is 
 sometimes noxious by reason of its soluble con- 
 stituents, yet it is not easy to point to many instances 
 of this kind. The dust of ipecacuanha, which is 
 often referred to, produces asthma rather than 
 catarrh, but it may be that this is a distinction 
 without real difference, should asthma be in essence 
 no more than catarrh. 
 
 The topic of living animated dust follows in 
 natural order. The best instances of this kind of 
 dust is afforded by the pollen of grass, which seems 
 to have been proved capable of causing hay fever in 
 some susceptible persons, though that in which the 
 irritant power of pollen inheres is not known. And 
 the question is complicated by the fact that in a few 
 persons the mere odour of roses and some other 
 flowers seems enough to provoke catarrh, although, 
 since the famous experiment of Dr. J. Noland 
 Mackenzie, with an arti6cial rose, we have learned
 
 BRONCHITIS 67 
 
 how large a part in the production of such a catarrh 
 can be played by the power of imagination. More- 
 over, the particles which convey the smell of flowers 
 must be far too minute to be rightly called dust, and 
 therefore we will not pursue the subject here, but 
 only remark that hay fever affords the best evidence 
 of that idiosyncrasy which predisposes to catarrh. 
 
 The catarrh which is caused by the living dust 
 thrown off by certain moulds and fungi is sometimes 
 a much more serious affair. The best known of these 
 fungi is the dry rot of deal wood, merulius lacrimans. 
 The disease it sets up is sometimes fatal. Beside the 
 catarrhal symptoms indicated by the epithet 'lacri- 
 mans ' there are signs of poisoning of the whole 
 body. The fungus grows upon the mouth and fauces, 
 whence we may assume that the morbific agent con- 
 sists of living seeds which under favourable con- 
 ditions will strike root in the human body, will 
 increase and multiply, will become, in fact, true 
 parasites, and poison us with their secretions. 
 
 Grass pollen is morbific, dry rot is morbific and 
 parasitic, but they are only accidentally so ; it is not 
 the purpose of their life to cause disease in man. 
 
 F 2
 
 68 ON THE CAUSES AND FORMS OF 
 
 But there are certain living particles, called microbes, 
 which are essentially morbific and parasitic ; which to 
 the best of our knowledge are that and nothing else ; 
 which continue to exist by causing disease, and for 
 that sole purpose, as it seems to us ; which are mor- 
 bific or nothing at all, because, being merely parasitic 
 in animals, it follows that if these animals ceased 
 to exist the microbes also would become extinct. 
 Some of these microbes are found almost everywhere ; 
 they pursue the steps of men and are apt to attack us 
 at all times and places. But some microbes thrive 
 only under certain circumstances ; the best known of 
 these less universal causes of bronchitis are typhoid 
 fever and influenza. In some forms of bronchitis 
 the disease is local and expends itself upon the 
 mucous membrane ; the catarrh is protopathic. But 
 in typhoid fever and influenza the case is different, 
 the catarrh is deuteropathic and secondary to infec- 
 tion of the whole system. These two diseases are 
 members of the great class of specific fevers, and we 
 are compelled by analogical reasoning to believe that 
 other members of that class which are still more 
 powerful causes of bronchitis are also rnicrobic in
 
 BRONCHITIS 69 
 
 nature, for example, measles and whooping-cough. 
 How they cause bronchitis is a question not yet ripe 
 for answer, meanwhile we assume that some irritant 
 is conveyed to the mucous membrane by the blood. 
 
 We have now passed from the simplest to the 
 most complex causes of bronchitis so far as our 
 knowledge will allow, and yet by far the greater 
 number of actual cases of bronchial catarrh remain 
 unexplained. What is the explanation of a common 
 cold? We can hardly doubt that chill by exposure 
 of the body has often much to do with it, but how ? 
 Let us note that colds are seldom caught, as we say, 
 in pure air ; at sea, for instance ; no matter how great 
 the exposure. Let us note also that common colds 
 are often contagious with an incubation period of 
 about three days. You will remember the deeply 
 interesting experience of the St. Kilda cold, a fact 
 which seems to be well proven, notwithstanding the 
 incredulity of Dr. Samuel Johnson, and which seems 
 to show that persons who are not themselves suffering 
 from catarrh may yet convey the disease to others, 
 and that a cold past and gone confers temporary 
 immunity. We have heard of late that upon some of
 
 70 ON THE CAUSES AND FORMS OF 
 
 the small islands in Torres Strait the natives, until 
 they took to wear clothes, were exempt from coughs 
 and colds. But it is difficult to understand how the 
 mere fact of clothing pure and simple can have been 
 the cause of those disorders. It would seem to be 
 more probable that the inhabitants have been infected 
 by their clothes or other means, and that the catarrhs 
 have been really due to the intruding foreigner who 
 brought along with him his civilization and his 
 diseases. 
 
 THE CATARRH 
 
 Of the signs which make bronchitis manifest in 
 the living body the most important is the catarrh, 
 the excessive secretion of mucus. We might expect 
 that physicians would pay great attention to the 
 sputa, and such has been the fact from the earliest 
 times. A sharp distinction has been drawn, since 
 Hippocrates at least, between transparent sputa and 
 opaque sputa; chiefly for prognostic reasons based 
 upon the old doctrine of the concoction of humours, 
 opacity being the sign of maturity, and a stage 
 which the secretion passes through before the catarrh
 
 BRONCHITIS 71 
 
 ends in recovery. This distinction being of such 
 prime importance in the opinion of ancient physicians, 
 it is remarkable that they had no words in use to 
 correspond with their ideas. Phlegrna, blenna, pituita, 
 mucus, all these words were used haphazard to signify 
 matter constituting the sputa, whether transparent 
 or opaque. In truth, the distinction is not of great 
 value ; however true it may be of acute coryzal 
 secretions that the mucous discharge becomes muco- 
 purulent on the way to recovery, we do not always 
 mark these stages in bronchitis even when acute, 
 while in chronic bronchitis the distinction is of small 
 importance, either prognostic or diagnostic. How 
 common it is to see mucous and purulent sputa in 
 the same spitting-pot ; to see purulent sputa floating 
 or lying in thin, transparent, colourless mucus : 
 probably the different secretions come from different 
 parts of the bronchial tracts. How common it is to 
 observe that sputa expectorated at different times of 
 the day are different in character, the secretion being, 
 for example, nearly pure mucus throughout the day, 
 but much more purulent the first thing in the 
 morning after sleep.
 
 72 ON THE CAUSES AND FORMS OF 
 
 PITUITOUS CATARRH 
 
 To the general rule that the distinction between 
 crude and concocted sputa is unimportant there is 
 one exception worthy of special note. Laennec, in 
 his chapter upon pulmonary catarrh, has much to say 
 concerning a form of catarrh which he calls pituitous. 
 He uses the word pituita in a sense of his own ; he 
 makes it signify colourless, transparent, stringy 
 sputum, frothy at the top, and which when the froth 
 has been removed resembles water stirred up with 
 white of egg. We must all recognize the truthful- 
 ness of this description. Louis compared the sputum 
 to gum- water, Borsieri to soapsuds. It is to be 
 wished that the word pituita be used to denote this 
 kind of sputum only, because there is no doubt that 
 the catarrh which Laennec calls pituitous does present 
 peculiar characters. 
 
 He remarks that pituitous catarrh is symptomatic 
 of other pulmonary diseases besides mere bronchitis, 
 especially oedema of the lungs and miliary tubercu- 
 losis. With respect to oedema of the lungs let us 
 note that the albuminous or serous expectoration
 
 BRONCHITIS 73 
 
 which occasionally ensues upon paracentesis for 
 pleural effusion, and which depends upon acute 
 oedema of the lungs, and which always brings danger 
 and often death, has to the eye all the characters of 
 pituitous flux. Testing the sputa can alone distin- 
 guish the two: serous expectoration is highly albu- 
 minous ; pituita is not albuminous at all. With 
 respect to tubercle let us note that not only miliary 
 tuberculosis, but also massive grey tubercular infiltra- 
 tion, may be attended by pituitous expectoration. 
 
 Besides pulmonary oedema and tubercle there are two 
 other diseases of the lung which are often attended by 
 pituitous expectoration ; namely, the congestion which 
 is consequent upon a dilating heart and contracting 
 cancer. 
 
 Pituitous catarrh is sometimes idiopathic ; a word 
 which we need not fear to use provided we attach 
 a definite meaning to it. The original and etymo- 
 logical meaning of the word is its true meaning, and 
 pifcuitous catarrh is idiopathic when it constitutes the 
 whole of the disease. It is sometimes acute, some- 
 times chronic, and in either case is a very serious 
 condition. The acute catarrh occurs at all ao-es and
 
 74 ON THE CAUSES AND FORMS OF 
 
 often in persons perfectly healthy, who have shown no 
 previous tendency to pulmonary disease. The secre- 
 tion rapidly becomes so profuse that it puts life in 
 jeopardy, and will sometimes even kill by suffocation 
 in a day or two. Yet for the first few hours the 
 attack resembles a common cold with cough, and 
 there are no peculiar symptoms attending the earliest 
 stage which enable us to foresee that we have to 
 do with the beginning of so formidable a disease. It 
 does not always kill ; sometimes it runs the course 
 of ordinary severe bronchitis and ends in recovery. 
 
 Chronic pituitous catarrh is more common. It is 
 serious on account of its obstinacy. To Laennec's 
 admirable description of this disease there is nothing 
 to add unless it be to say that it does sometimes attack 
 persons in the prime of life. A Japanese, twenty-five 
 years old, came over as a ship's steward to England, 
 and immediately upon his arrival began to suffer from 
 shortness of breath and cough ; a new thing for him. 
 After these symptoms had lasted for fourteen weeks 
 he was admitted to the hospital. There were much 
 dyspnoea and most abundant expectoration of pituita. 
 Tubercle bacilli were not found. The physical signs
 
 BRONCHITIS 75 
 
 were those of severe bronchitis. For days together 
 he seemed about to die from suffocation, but under 
 very careful treatment he improved until, without any 
 obvious cause, the symptoms recurred in full severity. 
 Another improvement was followed by another re- 
 lapse, and more than four months had passed away 
 since his admission ere he could be discharged fairly 
 convalescent. This was on May 8 ; but on June 16 he 
 was readmitted with all his former symptoms ; he 
 went out on July 16. On December 5 he was ad- 
 mitted once more, and the time of the year was 
 probably the reason why we could not get rid of him 
 till February 25. He had now been a patient on and 
 off for more than a year, and as there seemed no end 
 to this sort of thing the sister of the ward got up 
 a small subscription and shipped him off to the 
 antipodes. 
 
 PECULIAR KIND OF BEONCHITIS 
 
 There is a form of disease which may justly claim 
 to be called catarrhal, if we use that word in its strict 
 etymological sense. Graves, speaking of the condition 
 referred to, says : ' When an old person reduced by
 
 76 ON THE CAUSES AND FORMS OF 
 
 some previous disease catches cold and gets in conse- 
 quence a sudden and remarkable hoarseness so that 
 he can only speak in whispers ; when in addition to 
 this he has cough, stridulous breathing, and copious 
 muco-purulent expectoration, you may be sure that 
 the case is a bad one and the patient in most imminent 
 danger.' He goes on to say that the disease is accom- 
 panied by considerable fever, and that he did not 
 recollect that he had ever seen an attack of this kind 
 that did not terminate fatally. He narrates the case 
 of an eminent country practitioner who ' had got an 
 attack of cold followed by hoarseness, which went on 
 for two or three days without being attended to, until 
 one evening he suddenly became alarmingly ill. He 
 was found to be labouring under hoarse breathing, 
 constant laryngeal cough, prostration of strength, and 
 enormous muco-purulent expectoration. His pulse 
 was very rapid, he complained much of oppression 
 of the chest, and he died on the following night, more 
 with symptoms of exhaustion than of asphyxia.' 
 Graves tells of another similar case in which the 
 ' breath became exceedingly foetid. The expectoration 
 also exhibited a very remarkable change ; it was
 
 BRONCHITIS 77 
 
 greenish, ichorous, and had a most intolerable foetor. 
 He now began to manifest symptoms of awful pros- 
 tration ; his distress of respiration became intense, 
 his eyes fixed, his extremities cold, and he expired 
 in about forty hours from the commencement of the 
 attack.' 
 
 But this form of bronchitis sometimes occurs in old 
 people whose health has certainly not been ' reduced 
 by some previous disease '. I saw a lawyer, seventy- 
 four years old. He was in good health when one 
 April, while waiting for a train at Wimbledon, he was 
 exposed to a chilling east wind. Next day, April 8, 
 he lost his voice. On the 9th his breathing became 
 a little affected and swallowing was very painful. 
 His voice was not much more than a whisper. Seen 
 by the laryngoscope, the epiglottis was very red but 
 not much swollen ; the ary-epiglottic folds were not 
 swollen ; the glottis was widely open and through 
 it there welled up much muco-pus. On the 10th he 
 seemed better in all respects. He expectorated much 
 brownish muco-pus, which, both in colour and smell, 
 reminded one of the sputum of gangrene ; this phlegm 
 came up with the least possible effort, hardly amount-
 
 78 ON THE CAUSES AND FORMS OF 
 
 ing to cough. The laryngoscope showed that the 
 redness of the epiglottis was less and that there was 
 no swelling whatever. The voice was much louder. 
 But during the night he became worse ; fever appeared 
 for the first time, and he complained of pain in the left 
 side. The laryngeal symptoms were gone and his 
 voice was natural, but his breathing became very 
 frequent, and he died at evening on the llth. The 
 foetid expectoration calls for remark. Graves assumes 
 that in his case the lung had mortified, but he gives no 
 proof of this, and in my case the foetor occurred within 
 forty-eight hours from the beginning of the illness, 
 in a man previously healthy. Gangrene would hardly 
 set in so rapidly as this. To suppose, in the absence 
 of post-mortem examinations, that the smell is due to 
 decomposition of the secretions (to a foetid bronchitis, 
 in short) would seem more probable. 
 
 Disease of this kind is not peculiar to the old. 
 Some years ago I saw a boy, aged seven years. The 
 patient had been seized a day or two before with 
 laryngeal symptoms which, when I saw him. deserved 
 the name of croup, and the dyspnoea became so urgent 
 that tracheotomy was demanded and performed. We
 
 BRONCHITIS 79 
 
 could see that the epiglottis was not swollen, but we 
 could make out nothing more, for examination by the 
 laryngoscope brought on vomiting. The dyspnoea 
 was somewhat relieved, but the boy died a few hours 
 after the operation, with all the signs of pulmonary 
 dyspnoea. The only part which we were permitted 
 to examine post mortem was the larynx ; its mucous 
 membrane was exceedingly red, but there were no false 
 membranes and no oedema, nor were false membranes 
 expectorated or seen during life. The laryngitis was 
 a part (but at first the most obtrusive part) of more 
 widely diffused inflammation. When tracheotomy set 
 the laryngeal symptoms aside the bronchitis became 
 manifest. Moreover, in this case there was no reason 
 for suspecting measles. The analogy of the early 
 laryngitis stridula of that disease will occur to your 
 minds at once. 
 
 It is likely that the disease in question is essentially 
 of the same nature as oedema glottidis ; that is to say, 
 a specific inflammation spreading rapidly, like ery- 
 sipelas. Hippocrates uses this very word, and in 
 several places speaks of erysipelas in the lung, but to 
 identify the disease thus designated by him is not easy.
 
 80 ON THE CAUSES AND FORMS OF 
 
 DYSPNOEA 
 
 To breathing with conscious effort we give the 
 name dyspnoea. It arises from a peculiar sensation 
 which is not always of the same kind. Two sensa- 
 tions at least can be distinguished. One is sensation 
 of want of breath and impels to inspiration ; another 
 sensation impels to expiration. The feeling of want 
 of breath arises within the chest and seems to involve 
 all the thoracic organs. The feeling which impels to 
 expiration seems to arise from the windpipe ; that 
 is to say, a patient suffering from expiratory dyspnoea 
 will refer this feeling to the manubrium sterni and 
 region of the trachea. This tracheal sensation closely 
 resembles the feeling which impels to cough, and it 
 is the cause of that expiratory groaning which is so 
 common during the uneasy sleep of patients suffering 
 from bronchitis, emphysema, or heart disease. I do 
 not refer to snoring or stertor, which are inspiratory 
 noises. Thus medical physiology requires two re- 
 spiratory centres, one for inspiration and one for 
 expiration. 
 
 It has been said that, in bronchitis attended with
 
 BRONCHITIS 81 
 
 laborious breathing, the chief difficulty is in inspira- 
 tion ; that the expiratory act, on the contrary, is 
 always accomplished with comparative ease ; and 
 that these phenomena of laborious breathing, par- 
 ticularly the long-drawn, exhausting, inadequate in- 
 spiration, are probably quite peculiar to obstructive 
 bronchitis. But surely these propositions are far from 
 being universally true. Even in slight bronchitis 
 occurring in a man, who never had bronchitis before, 
 the expiration may be much more forced than the 
 inspiration, in consequence of the provoking tracheal 
 sensation spoken of before. In chronic bronchitis, 
 when the patient raises phlegm with difficulty, the 
 most obvious thing about the respiratory movements 
 in many cases is the forced expiration. If we would 
 see inspiratory dyspnoea in its highest degree and 
 purity, it is not to bronchitis, but to laryngitis, that 
 we must look ; to angina laryngea, not angina bron- 
 chialis. In mere bronchitis we seldom see anything 
 like the inspiratory dyspnoea of croup.
 
 82 ON THE CAUSES AND FORMS OF 
 
 LIVIDITY 
 
 Lividity is not a marked symptom of bronchitis 
 except in the worst cases. When we see a patient 
 whose dyspnoea amounts to orthopnoea, and whose 
 lips are purple or almost black, we suspect at first 
 sight disease of the heart rather than disease of the 
 lungs. Again, if we see great lividity in a case of 
 bronchitis we suspect some complication, for instance, 
 pulmonary emphysema, extensive collapse, broncho- 
 pneumonia, scattered tubercle, or distended heart. 
 
 The phrase, Suffocating Catarrh, has been used in 
 senses so varied that some persons have suggested 
 that it should be wholly discarded. Even apoplexy and 
 croup have borne that name. We can continue to use 
 it only on condition that suffocating catarrh shall signify 
 bronchitis in which the patient is in danger of being 
 stifled by bronchial secretion thrown out more rapidly 
 than it can be expectorated. The metaphorical phrase, 
 paralysis of the lungs, has been applied to these cases 
 of catarrhal infarctus. We meet with suffocating 
 bronchitis under three conditions. First, in infants ; 
 and a main cause of their liability to suffocating
 
 BKONCHITIS 83 
 
 catarrh is to be found in the shape of their thorax 
 which, being almost circular on horizontal section, is 
 incapable of more than small lateral expansion. The 
 only extraordinary enlargement which their chest can 
 undergo is by vertical elongation, upwards by means 
 of the accessory inspiratory muscles and downwards 
 by excessive diaphragmatic contraction. Moreover, 
 their ribs are often soft and rickety. Next, we meet 
 with suffocating bronchitis in adults when they are 
 attacked by pituitous catarrh in a severe degree. 
 And, thirdly, suffocating bronchitis is common as an 
 exacerbation of chronic bronchitis in persons who are 
 for the most part advanced in life. 
 
 In these cases, post mortem, we often find that 
 form of Pneumonia which bears no name adopted 
 universally. Our own ' Nomenclature ' gives us the 
 choice of three names. We may use the name lobular 
 pneumonia, in contradistinction from lobar pneumonia ; 
 or broncho-pneumonia in contradistinction from pleuro- 
 pneumonia ; or catarrhal pneumonia in contradis- 
 tinction from what has been called croupous pneu- 
 monia. The name of broncho-pneumonia is to be 
 preferred. Croupous pneumonia is what Polonius 
 
 G 2
 
 84 ON THE CAUSES AND FORMS OF 
 
 would have called a very vile phrase. It is amusing 
 to note how the Lowland Scotch word croup (the 
 cognate English word is roup) which signifies a certain 
 kind of noise, has come to be applied to a morbid 
 exudation ; a perversion due to foreign pathologists 
 who could not have known the meaning of the word 
 which they were using or abusing. And thus croup, 
 having undergone this strange metamorphosis in the 
 course of his travels abroad, comes back disguised to 
 his native land, and we receive him with open arms. 
 Such are English ways. 
 
 Broncho-pneumonia is the last stage of inflamma- 
 tion extending downwards along the air-passages into 
 the pulmonary lobules. Catarrh implies a mucous 
 membrane ; but the bronchiola, which feed the 
 pulmonary lobules with air, possess no mucous 
 membrane ; in these parts, therefore, lobular hepatisa- 
 tion takes the place of bronchial catarrh. The differ- 
 ence in the products of exudation depends more upon 
 the situation of the disease than upon any difference 
 in its cause. One very practical truth has been well 
 established, namely, that in measles the frequency 
 with which broncho-pneumonia occurs is dependent
 
 BRONCHITIS 85 
 
 upon the degree of impurity in the air breathed. The 
 main cause of death in measles is broncho-pneumonia, 
 and the mortality in some epidemics has been as high 
 as fifty per cent. Thus any mysterious change of 
 type or epidemic constitution seems to be resolved, so 
 far as concerns measles, into the condition of the air 
 breathed by the patients. Hence the necessity for 
 isolation, for ventilation, and for cleanliness. 
 
 The pneumonic part of broncho-pneumonia is a post- 
 mortem disease or, in other words, it can seldom be 
 detected with certainty during life. In severe pro- 
 gressive capillary or suffocating bronchitis which 
 threatens the patient with death we may assume 
 that lobular pneumonia is present, inasmuch as it is 
 the last stage of the disease. Neither symptoms nor 
 physical signs help us much ; the patient is too ill 
 to bear prolonged examination ; nor does it matter in 
 the least whether we detect the pneumonia or not, for 
 our treatment is the same in both cases. 
 
 CHRONIC BRONCHITIS 
 
 Chronic bronchitis associated with emphysema, and 
 in all respects like the disease common in old people,
 
 86 ON THE CAUSES AND FORMS OF 
 
 is by no means very uncommon in the young, that 
 is to say, in patients under twenty years of age. But 
 this is the case especially among the lower classes of 
 the people ; among the well-to-do, chronic bronchitis 
 is uncommon in the young. When we bear in mind 
 that with asthma it is quite the reverse ; that juvenile 
 asthma is common among the well-to-do and un- 
 common among the lower classes ; the suspicion arises 
 that we have to do with what is essentially the same 
 disease assuming different forms under different con- 
 ditions of life. The poor are very careless with regard 
 to their health, and it is probable that, through 
 neglect, what would otherwise be asthma becomes 
 a chronic pulmonary catarrh. 
 
 The heart is dilated more easily in children than 
 in adults, and thus cases of juvenile chronic bronchitis 
 gradually pass into a state wherein the symptoms of 
 dilated heart predominate over those of the original 
 disease. Some years ago I examined the body of a 
 boy, thirteen years old, who had suffered from chronic 
 bronchitis since eighteen months of age, when he 
 had measles and whooping-cough. He was so deeply 
 cyauotic that the question of malformed heart arose ;
 
 BRONCHITIS 87 
 
 his fingers were much clubbed and there was universal 
 dropsy. The post-mortem examination showed em- 
 physema of the lungs, especially of their anterior 
 parts. The right side of the heart was much dilated 
 and hypertrophied, but there was no valvular disease 
 nor was there any malformation. The liver was 
 nutmeg. 
 
 That predisposition which tends to make bronchitis 
 chronic is often hereditary and is often acquired. In 
 many persons a powerful assistant cause of the chronic 
 bronchitis is alcohol. Sydenham alludes to this fact 
 when speaking of ' peri-pneumonia notha ', which no 
 doubt for the most part consisted of febrile exacerba- 
 tions of chronic bronchitis. He says that the disease 
 ' affects those who are of virile age, or, what oftener 
 happens, those who are older and who have been too 
 much given to spirituous liquors, especially to brandy '. 
 The evil effect of alcohol is sometimes seen in persons 
 who cannot be justly called intemperate, and a 
 marked diminution of the tendency to bronchitis 
 will sometimes occur in patients who become total 
 abstainers after having been in the habit of drinking 
 not more than a usual quantity of wine. The swollen,
 
 88 ON THE CAUSES AND FORMS OF 
 
 deeply red, and irritated soft palate of many hard 
 drinkers probably affords a clue to the nature of 
 alcoholic bronchitis. 
 
 Post-mortem examination of the bodies of persons 
 past middle life reveals the fact that their chronic 
 bronchitis is seldom unassociated with chronic ne- 
 phritis, arterio-capillary sclerosis, chronic endocarditis 
 or pericarditis or myocarditis, and atheroma of the 
 aorta, not to speak of pulmonary emphysema ; lesions 
 which constitute an important part of the condition 
 which we designate old age. 
 
 That a tendency to chronic bronchitis and a ten- 
 dency to gout concur in many patients is a frequent 
 experience, and there can be no objection to our 
 expressing this fact by calling the bronchitis gouty, 
 provided the evidence of gout be sufficient. But 
 I fear that gouty bronchitis is often talked about 
 when the evidence of gout is small. Before the term 
 ' gouty ' is predicated of any disease the reasons for the 
 affirmation ought to be carefully examined. To define 
 the word ' gout ' is not possible ; the essential nature 
 of gout we do not know. Doubtless there are satis- 
 factory criteria or notes of gout, such as regular
 
 BRONCHITIS 89 
 
 attacks in the hand or foot, tophi, and the discovery 
 of uric acid in the blood. But medical men are often 
 content with much lower probability than this, when 
 they pronounce a patient to be gouty ; and I ani far 
 from saying that they are always wrong. Howbeit 
 the name of gout has been extended in meaning so as 
 to include a vast number of diseases, but whether 
 these speculations are as sound as they are ingenious, 
 whether they are solid structures grounded on truth 
 or no more than the phantoms of a lively imagination, 
 I will not take upon myself to determine. Time will 
 show. ' Medicina non ingenii humani partus est sed 
 temporis filia.' 
 
 PHTHINOID BRONCHITIS 
 
 There is a form of chronic bronchitis which bears 
 a close resemblance to tubercular pulmonary con- 
 sumption ; the disease is nothing but bronchitis, yet 
 the symptoms are those of phthisis pulmonalis. The 
 interest of this topic is mainly antiquarian for us, 
 because it throws an important light upon the pro- 
 gress of pathology. Before the invention of ausculta- 
 tion, the patients alluded to were necessarily believed
 
 90 ON THE CAUSES AND FORMS OF 
 
 to be suffering from pulmonary consumption, and, 
 indeed, they were so suffering in the original sense 
 of the phrase. For the epithet, consumption or 
 phthisis, related to the condition of the whole body, 
 to the progressive emaciation in fact, while the word 
 pulmonary indicated that the disease, whatever it 
 was, which caused the emaciation was seated in the 
 lungs. In the phthinoid or consumptive form of 
 bronchitis there is an abundant expectoration of 
 purulent sputa. The early physicians knew of no 
 source of pus but an ulcer, and hence they inferred 
 that the lungs were ulcerated. The first man to 
 discover that this was not the case was that singularly 
 accurate observer, Antony de Haen ; but even after 
 he had shown that the lungs, examined post mortem, 
 were to all appearance sound, free from all ulcera- 
 tion, and yielding not a drop of pus on section, yet 
 matters were not much advanced for practical medi- 
 cine, because the diagnosis could not be made during 
 life. And here the subject stood until the time of 
 Laennec. Sir Thomas Watson confesses in his 
 lectures that he once made this mistake, and pro- 
 nounced a young woman to be in the last stage of
 
 BRONCHITIS 91 
 
 consumption who soon afterwards made a rapid and 
 complete recovery, he having omitted to auscultate 
 her chest. Even auscultation does not always enable 
 us to distinguish these cases with perfect certainty, 
 but since Koch's discovery of the tubercle bacillus we 
 have a potent auxiliary to diagnosis in the microscopic 
 examination of the sputa. 
 
 CONCLUSION 
 
 In conclusion, we will revert to the results of our 
 search into the causes of bronchitis. We found it to 
 be highly probable that most catarrhs are due to 
 a specific infection, and that they often depend upon 
 contagion spreading from man to man. This doctrine 
 has very important bearings upon medical practice. 
 It leads us to believe that the means by which we 
 may prevent catarrh are to be found in ventilation 
 and cleanliness, if, indeed, ventilation be not a kind 
 of cleanliness. Experience confirms this belief. When 
 epidemic catarrh prevails where do we find most of 
 our patients'? In those houses which are obviously 
 the worst ventilated, even though they be the spacious 
 houses of the rich. And where do our patients catch
 
 92 ON THE CAUSES AND FORMS OF 
 
 their catarrh 1 Either in houses of the kind which 
 I have mentioned or in buildings where men most do 
 congregate, especially in offices, shops, and churches. 
 Large shops and stores, public museums and libraries, 
 are ventilated as little as possible for fear of their 
 contents being spoilt by smoke and dust. Many 
 churches both in town and country are never properly 
 aired for another reason, namely, because their archi- 
 tecture does not admit of it. Those 'rich windows 
 which exclude the light' do worse than this, they 
 exclude fresh air. The revival of Gothic architecture 
 has been, like the mediaeval revival in general, 
 a relapse into barbarism. Our despised forefathers 
 of the eighteenth century erected plain and simple 
 buildings which could at least be well-aired, well- 
 lighted, and kept warm and comfortable; nay, even 
 the much-ridiculed churchwarden, with his brush 
 and pail of whitewash, was a praiseworthy minister of 
 health. Modern dwellings are no better than the 
 churches. In the matter of domestic sanitation people 
 have fixed their attention too exclusively upon the 
 drainage and the water-supply ; light and air are not 
 reckoned. Many of the large red-brick houses, which
 
 BRONCHITIS 93 
 
 have been built in great numbers at the West End of 
 London and else where, during the last five-and-twenty 
 years, cannot be properly ventilated. The well of the 
 staircase ought in every house to be a reservoir of 
 pure air and to have an independent supply from 
 without. But in many houses the staircase cannot 
 be ventilated except through the rooms, and, in fact, 
 it never is ventilated. Nor are the rooms themselves 
 much better off: their heavily mullioned windows are 
 designed with small regard to the transmission of light 
 and air. The subsidiary and merely ornamental arts, 
 which do no more than please the eye, are studied to 
 the neglect of that far greater art which promotes the 
 happiness and welfare of the whole man, the Art of 
 Preserving Health.
 
 94 
 
 IX 
 
 ON THE NATURE OP PULMONARY 
 EMPHYSEMA ' 
 
 IN 1764 Dr. William Watson read before the Royal 
 Society ' An account of what appeared on opening the 
 body of an asthmatic person '. He described what he 
 called an ' emphysematous state of the lungs ', a con- 
 dition which he deemed to be due to an ' extravasation ' 
 of air into the lungs from the ' bronchia and vesicular 
 substance ', and what was no doubt vesicular emphy- 
 sema of the lungs in the sense which we give to that 
 phrase. Pulmonary emphysema has been known in 
 one of its results, namely, the barrel-shaped chest, 
 from the time of the ancient Greeks. The lesion of 
 the lungs themselves was first noted by Valsalva and 
 Ruysch in the earlier part of the eighteenth century. 
 
 1 Lecture given before the Royal College of Physicians on 
 March 21, 1899.
 
 NATURE OF PULMONARY EMPHYSEMA 95 
 
 However, Laennec was not far from the truth when, 
 in the first edition of his great work published in 
 1819, he said that 'emphysema of the lungs, such as 
 he had described it, seemed to him to be a disease 
 hitherto unknown '. 
 
 It is universally agreed that the note of pulmonary 
 emphysema is to be found in enlarged capacity of the 
 acini and lobules of the lungs, beyond what can be 
 produced in health by the deepest inspiration. This 
 change in the structure of the lung, the anatomical 
 characteristic of emphysema, is pretty thoroughly 
 known ; but when we come to inquire into the pro- 
 cess which leads to emphysema the case is very 
 different. For we cannot know the process in the 
 same way as we know the result ; we cannot watch 
 the lungs becoming emphysematous ; we can only 
 argue about the process. Deprived of the intuition 
 of sense, the light of nature, we must follow the light 
 of reason and beware lest it prove to be ignis fatuus. 
 And unfortunately we can get no help from experi- 
 mental pathology ; we cannot set up progressive 
 emphysema in the lower animals and mark its stages 
 in the same manner as we can set up inflammation.
 
 96 ON THE NATURE OF 
 
 Hence the many theories of emphysema and long 
 discussions which, however, do not dishearten me from 
 attempting the difficult topic once more ; my only fear 
 is lest I should weary you. 
 
 ACUTE EMPHYSEMA 
 
 The emphysematous process, like all nature's pro- 
 cesses, may be assumed to be complex, and we shall 
 do well to begin by endeavouring to resolve it into its 
 simplest elements. Nature itself helps us much by 
 offering to our consideration a form of emphysema 
 which certainly is simpler than ordinary emphysema, 
 and which seems to consist in a mere over- distension 
 of lung. I allude to the acute emphysema first 
 adequately described by Fauvel in his essay upon 
 capillary bronchitis. You know the condition : both 
 lungs distended with air, as if insufflated by the fullest 
 possible inspiration, but some parts of the lung dis- 
 tended more than this, emphysematous in short, and 
 especially so in the upper lobes and their anterior 
 portions. This acute emphysema is especially met 
 with in young children who have died from suffocating 
 capillary bronchitis or from diphtheritic croup. Many
 
 PULMONARY EMPHYSEMA 97 
 
 of these children have enjoyed perfect health until 
 they were attacked by the bronchitis or croup, so that 
 there is no question in them of any preceding disease 
 of the lungs. Suffocating bronchitis will often prove 
 fatal within a week from its beginning ; croup will 
 kill in a still shorter time ; and there is a disease, very 
 much less common, namely, haemorrhage into the air- 
 passages, which may suffocate in a few minutes, acute 
 emphysema being found post mortem in all cases. 
 
 Croup. Let us turn our attention to croup in the 
 first place, inasmuch as it is often entirely free from 
 one condition which might complicate the question, 
 namely, collapse of the lung. For although fatal 
 croup is usually associated with abundant puriform 
 secretion into the small air-tubes of the lungs, yet in 
 spite of this form of bronchitis there is sometimes no 
 collapse at all, even when the lungs have become 
 highly emphysematous, so that collapse, when present, 
 can be no more than somewhat contributory to the 
 emphysema. In other words, the emphysema is but 
 slightly, if at all, compensatory to any collapse. 
 John Cheyne, in his book on the ' Pathology of the 
 laryngeal and bronchial mucous membrane' published
 
 98 ON THE NATURE OF 
 
 in 1809, frequently alludes to the emphysema and 
 puriform catarrh of croup. For example, he says : 
 ' The lungs were so filled that they did not recede in 
 the least when the thorax was opened ; every surface 
 which was cut poured out this puriform fluid from 
 several points/ 
 
 Setting collapse aside, the conceivable causes of 
 acute emphysema are two, namely, dyspnoea and 
 cough ; that is to say, the movements of dyspnoea 
 and of cough, not overlooking the fact that they 
 usually concur. Here also the question is simpler 
 in the case of croup. In capillary bronchitis both 
 dyspnoea and the cough are great, and therefore the 
 question of the associated emphysema is complicated. 
 But in croup the dyspnoea is extreme, while the cough 
 is insignificant or even absent, so that it may be left 
 out of consideration, and all this in cases affording 
 a high degree of insufflation and emphysema of the 
 lungs. 
 
 Our analysis thus leads us to infer that dyspnoea is 
 the cause of acute emphysema. Now, the movements 
 of dyspnoea are forced movements, inspiratory or 
 expiratory, or both. But before proceeding further
 
 PULMONARY EMPHYSEMA 99 
 
 with this part of our subject let us cast a short glance 
 upon the movements of breathing in general. 
 
 Respiratory Movements. From the earliest times 
 the diaphragm has been regarded as the main agent 
 of respiration. We may say of respiration, and not of 
 inspiration only, because expiration is little more 
 than a result of inspiration. Galen was the first to 
 show that most of the intercostal muscles were ordinary 
 muscles of inspiration. Guided by the researches of 
 Duchenne, we may disregard the exceptions which 
 Galen made, and we may say that all the intercostals 
 act simultaneously and are employed in ordinary quiet 
 inspiration. They not only raise the ribs, but keep 
 the intercostal spaces tight, during the descent of the 
 diaphragm. When the intercostal muscles are para- 
 lysed, but the diaphragm is not, the upper two-thirds 
 of the chest are motionless. 
 
 The chest may be roughly compared to a bow, 
 inspiration to a bow when pulled upon by an archer, 
 and expiration is little more than the elastic recoil of 
 the bow when the archer lets go the string. But the 
 inspiratory muscles do not altogether let go when 
 expiration begins, they continue to act as moderators 
 
 H 2
 
 100 ON THE NATURE OF 
 
 of the expiratory movements, and hence expiration is 
 more gradual than it would be were it a mere elastic 
 recoil. In short, the muscular contractions of expira- 
 tion are persisting contractions of inspiratory muscles, 
 unless the expiration be forced, and then extraordinary 
 muscles of expiration come into play. 
 
 Physiologists seem to be agreed that although the 
 outward pressure of the air at the mouth during 
 expiration is greater than the pressure inwards during 
 inspiration, yet the forces concerned in inspiration are 
 decidedly much greater than those of expiration. These 
 propositions at first sight seem to be discordant, but 
 we are not called upon here to explain the apparent 
 discrepancy, we will only remark that they indicate 
 a provision in the human economy for repressing the 
 greater powers of inspiration. Let us especially note 
 that the elastic retraction of healthy lung is not satis- 
 fied by the deepest expiration, and that the lungs are 
 provided with a considerable reserve of elasticity ; so 
 necessary is it to maintain sufficient deflation of the 
 lungs, or in other words to keep them sufficiently 
 empty of air. For if there be insufficient efflation 
 there must be insufficient inflation.
 
 PULMONARY EMPHYSEMA 101 
 
 Forced Breathing. In the forced breathing of healthy 
 persons there is the same disproportion between the 
 powers of the antagonist movements. Physiological 
 experiments relate to a few forced respirations studied 
 in a healthy subject : but the forced breathing of 
 disease introduces a new set of conditions, and requires 
 that we proceed to an analysis. The extraordinary 
 muscles of Inspiration are chiefly three : the sterno- 
 mastoids, the scaleni, and the upper third of the 
 trapezii. These muscles can be seen contracting during 
 inspiratory dyspnoea. Other muscles there are which 
 assist to some degree, but to enumerate them is not 
 necessary. These extraordinary muscles act by raising 
 the upper part of the chest and fixing it, so as to 
 enable the ordinary muscles of inspiration to act with 
 extraordinary power. The fixity of the clavicles and 
 first ribs enables the intercostals to contract with their 
 greatest power, and to elongate the chest in a direction 
 upwards at the same time that the diaphragm elongates 
 it downwards. Observation of the living patient 
 shows us that forced inspiration tells chiefly upon 
 the front part of the thorax above Harrison's furrow. 
 
 The extraordinary muscles of Expiration affect
 
 102 ON THE NATURE OF 
 
 another part of the chest. In a patient coughing 
 violently we see the muscles of the abdominal walls, 
 especially the recti, contracting so as to straighten and 
 depress the front part of the chest below Harrison's 
 furrow. The diaphragm, being relaxed, is necessarily 
 driven upwards. If the largest air-tubes be obstructed 
 by mucus or by partial closure of the glottis (as in 
 the case supposed of coughing) it is very instructive 
 to see how forced expiration dilates exactly the same 
 part of the chest as that which is dilated by forced 
 inspiration. Hence in diseases attended by cough or 
 dyspnoea, the unfortunate upper and front part of the 
 thorax has no chance ; forced inspiration and forced 
 expiration combine to keep it distended. Nature 
 provides that the result of ordinary inspiration shall 
 be fully countervailed by expiration ; nature provides 
 extraordinary muscles to reduce the distension of the 
 lower part of the chest caused by forced contraction 
 of the diaphragm, but nature provides no extraordinary 
 means by which the injurious effects of forced inspira- 
 tion upon the upper part of the chest can be repaired 
 by forced expiration. On the contrary, both move- 
 ments concur to the same end ; or, in other words, no
 
 PULMONARY EMPHYSEMA 103 
 
 muscular contractions can reduce over-distension of 
 the upper chest, and if the inherent elasticity of the 
 lungs and ribs cannot reduce it, nothing can. 
 
 Before leaving this topic let us repeat that we must 
 be careful to distinguish between the voluntary forced 
 breathing of a healthy person and the involuntary, 
 instinctive, automatic forced breathing which attends 
 dyspnoea. Voluntary excessive movements soon 
 fatigue, but automatic breathing is not attended by 
 a feeling of fatigue, and thus the extraordinary move- 
 ments of dyspnoea can be continuously kept up for 
 hours, days, or weeks ; may we not say, indeed, for 
 months or years? Moreover, let us note that this 
 remark applies to the movements of breathing only, 
 but by no means to those of cough ; cough must be 
 intermitting. 
 
 Acute Emphysema. We will now return to the 
 consideration of the acute emphysema of croup. In 
 the living patient a very few hours of dyspnoea suffice 
 to produce a marked bulging of the front of the chest 
 above Harrison's sulcus. After the patient's death 
 we find that the corresponding part of lung is the seat 
 of a high degree of emphysema. The whole lungs are
 
 104 ON THE NATURE OF 
 
 insufflated or distended with air, but nowhere is the 
 emphysema so marked as in the situation just indi- 
 cated. This is the very part of the chest which is 
 most expanded by forced inspiration, and which is 
 expanded by forced expiration also in the case of 
 cough, but expanded, let us note, by a different 
 mechanism in the two cases. In deep inspiration this 
 part of the chest- wall is expanded in the first instance, 
 and the expansion of lung follows ; whereas in forced 
 expiration and in cough, this part of lung is ex- 
 panded in the first instance and it drives the chest-wall 
 outwards. The mechanism by which cough produces 
 emphysema here has been explained by Sir William 
 Jenner. The glottis is closed in preparation for a 
 cough or for any great effort : forcible expiration 
 follows ; certain parts of lung are compressed, from 
 which the air escapes, but not being able to pass the 
 glottis it is driven into those parts of lung which are 
 not compressed, especially the upper anterior parts so 
 often mentioned. No doubt expiration under these 
 conditions can produce emphysema in certain places, 
 but in the case of croup, inspiration is by far the more 
 potent agent, being incessant in its operation, whereas
 
 105 
 
 cough is only occasional and sometimes there is no 
 cough at all. Moreover, forced expiration cannot 
 explain the highly insufflated state of the whole of 
 both lungs, for the distension caused by expiration 
 must be partial. 
 
 Defective Expiratory Power. We are yet far from 
 having reached a full understanding of the mechanics 
 of acute emphysema. We have arrived at an extra- 
 ordinary expansion of part of the lungs, but the 
 essential cause of the expansion lies deeper than this. 
 You will understand what I mean when I ask this 
 question, Why does the expansion remain permanent ? 
 And I think that from what has gone before, the 
 answer will readily come, Because nature has omitted 
 to provide the thorax with muscles by means of which 
 this acute emphysema can be prevented or overcome. 
 The only means which nature has provided towards 
 this end is the elasticity of the lungs and ribs, espe- 
 cially of the lungs, and this means, unfortunately, is 
 inadequate. It is vain to object that physiological 
 experiments prove forced expiration to be more 
 powerful than forced inspiration, because these ex- 
 periments deal only with the lungs as a whole and
 
 106 ON THE NATURE OF 
 
 cannot tell us anything about the respiratory powers 
 of different parts of the lungs which is the very thing 
 we want to know. Can it be thought for a moment 
 that the expiratory power of the upper part of the 
 chest is greater than the inspiratory 1 Certainly not. 
 
 The elasticity of the lungs, then, falls sadly short of 
 what is required of it during an emergency of dyspnoea. 
 How is this ? Either the elasticity is defective abso- 
 lutely, or it is defective only in respect of the increased 
 demand made upon it, and probably both conditions 
 concur ; that is to say, the elasticity is called upon to 
 do more than usual at the very time when itself is 
 weakened and able to do less. In the first place, this 
 unusual demand upon the pulmonary elastic recoil is 
 due to the abnormal secretions in the air- passages, and 
 the expired air has to overcome the resistance of these 
 secretions, in addition to what is the only obstacle to 
 expiration met with in health, namely, the atmospheric 
 pressure. The elasticity has too small a reserve ; it is 
 equal to overcome the atmospheric pressure, but not 
 much more. Inspiration, being the more important 
 motor of the upper lung, can draw air past the 
 obstructing secretions ; of which air, expiration can
 
 PULMONARY EMPHYSEMA 107 
 
 expel only a portion, and thus much air comes to be 
 imprisoned in the parts which are, or which become, 
 emphysematous. In the second place, the elasticity 
 of the lung is probably damaged. We have already 
 compared normal inspiration to drawing a bow, and it 
 does not seem a very far-fetched similitude to compare 
 the result of an enormous number of forced inspirations 
 to a bow which has been overdrawn, bent, and crippled. 
 The elastic recoil of the lungs is weakened. So far as 
 I know no careful microscopic examination of the 
 pulmonary tissues in acute emphysema has ever been 
 made. 
 
 Summary. And now to sum up the conclusions at 
 which we have arrived. The feeble expiratory power 
 of certain portions of the chest is a condition which 
 predisposes the underlying portions of lung to suffer 
 from acute emphysema in cases of Croup. Given this 
 predisposition, the aforesaid portions of lung become 
 over-distended in consequence of forced inspiration, or 
 of forced expiration, or of both. 
 
 The acute emphysema of Suffocating Bronchitis will 
 now be easily understood. This affection is referred 
 to by Aurelian in his chapter upon peri-pneumonia
 
 108 ON THE NATURE OF 
 
 where he says that as the disease gets worse the chest 
 becomes more protuberant. The causes of the emphy- 
 sema are the same as in croup, but with this addition, 
 that in peri-pneumonic catarrh, more or less collapse 
 of the lung is common and tends to aggravate the 
 distension of the rest of the lung, according to the 
 mechanism explained by Sir W. T. Gairdner. 
 
 CHRONIC EMPHYSEMA 
 
 Acute emphysema is a condition which often ends 
 in recovery. Chronic emphysema, on the contrary, is 
 a progressive disease. Although it was first adequately 
 described by Laennec it had engaged the attention of 
 physicians long before his day, not, however, as a 
 lesion found upon the post-mortem table, but as a 
 disease of the living subject. Being looked at merely 
 from the clinical point of view, emphysema was usually 
 called asthma; for example, Heberden, speaking of 
 what must have been chronic bronchitis and emphy- 
 sema, says : ' When a constant cough has afflicted 
 people in youth and adult life, in their old age they 
 become asthmatic.' 
 
 Laennec tells us that there was a time when he
 
 PULMONARY EMPHYSEMA 109 
 
 thought emphysema to be a very rare disease, but 
 that afterwards he became convinced that it is common 
 enough. Virchow supplies figures intended to show 
 that emphysema is not common. In ten years only 
 0'3 per cent, of all patients admitted into the Charite' 
 Hospital of Berlin were admitted on account of em- 
 physema ; in only 0-6 to 0-7 per cent, of the bodies 
 examined post mortem was emphysema the chief 
 lesion found, and in only 5-5 per cent, was there any 
 emphysema at all. The statistics of St. Bartholomew's 
 Hospital yield these figures : in four years (1 894-1897) 
 9,928 patients were admitted into the medical wards ; 
 165 or L66 per cent, were believed to be emphysema- 
 tous ; 1,363 post-mortem examinations were made and 
 emphysema was found in 154 bodies, or in 11-3 per 
 cent. Our figures justify Laennec's opinion ; a lesion 
 found in 11 per cent, of persons dying in the medical 
 wards of a hospital cannot be called uncommon. 
 
 Anatomy. The anatomical sign of chronic emphy- 
 sema consists in actual loss or atrophy of the lung 
 tissues ; yet many pathologists of the first rank have 
 expressed a different opinion, namely, that there is 
 a hypertrophy of lung tissue, either a hypertrophy
 
 110 ON THE NATURE OF 
 
 preceding the atrophy, or a local hypertrophy simul- 
 taneous with local atrophy. Laennec himself thought 
 it highly probable that emphysema is usually accom- 
 panied by a certain degree of hypertrophy, finding 
 that the lung feels firmer and less flexible when 
 pinched between the fingers. Yet he recognized the 
 associated destruction of tissue, as indeed such a man 
 could not help doing when he examined emphysema- 
 tous lungs in the manner which he recommends, 
 namely, by inflating and drying them. Laennec's 
 contemporary, Louis, was less sagacious : he admits 
 no exception to his universal affirmation that emphy- 
 sema implies increase or hypertrophy of lung tissue. 
 When we ask how Louis detected the pulmonary 
 hypertrophy we get no clear information : he seems 
 to have done no more than adopt Laennec's methods, 
 and to have examined the lung by pinching it and by 
 drying it. These doctrines are not altogether incorrect, 
 only we must express them a little more precisely. 
 In the first place, emphysema in its earlier stages does 
 not affect the whole lung, or does not affect it equally. 
 And next, the great and extensive atrophy of tissue 
 cannot be gainsaid in the case of emphysema in its
 
 PULMONARY EMPHYSEMA 111 
 
 later stages, the lungs being examined according to 
 Laennec's method; they feel, as he says, no longer 
 firm and inflexible, but soft and downy and the loss of 
 tissue is most obvious to the eye. Induration is a 
 better name than hypertrophy to give to the abnormal 
 firmness and rigidity of the alveolar walls, and this 
 induration is always very partial and found only in 
 the earlier stage of the disease. 
 
 The microscope has not yet disclosed any primitive 
 tissue changes apart from mere atrophy, if such changes 
 there be ; and I need not refer to hypotheses, such as 
 that of Rainey, who deemed the primary lesion of 
 emphysema to consist in fatty degeneration of the 
 alveolar walls; or that of Villemin, who described 
 a sort of granulation of the connective tissue which 
 supports the capillary network of the lungs ; for in 
 all probability what both these -anatomists saw were 
 degenerative changes in the epithelium ; changes 
 secondary to a preceding failure of nutrition, what- 
 ever the nature or cause of that failure may be. 
 Other pathologists have supposed a primary affection 
 of the capillary blood-vessels, or of the unstriped 
 muscular fibres, or of the epithelium, but the truth
 
 112 ON THE NATURE OF 
 
 is that the earliest changes are very imperfectly 
 known. 
 
 Causes of Chronic Emphysema. We are thus led 
 on to survey the great field of strife in the topic of 
 chronic emphysema. There is rarefaction of the lung 
 and there is destruction of lung. Does one cause the 
 other "? and if so how ? And this is not all ; we desire 
 to look deeper still, and we ask how the primary defect 
 (whether it be rarefaction or destruction) is brought 
 about ; to what is it due "? In other words, What is 
 the essence of emphysema? We wish if possible to 
 witness emphysema in the making, and inasmuch as 
 morbid anatomy can show us no more than the final 
 result, we must discuss the subject from the clinical 
 point of view. 
 
 Symptoms. First, we will inquire what means we 
 have for discovering the existence of emphysema in 
 the living subject, and we are met at the outset by the 
 fact that most of these patients suffer from manifest 
 bronchitis also. These complex cases are not suitable 
 for our present purpose ; we cannot disentangle the 
 symptoms of the two diseases so as to be able to say, 
 This is due to emphysema and this to bronchitis :
 
 PULMONARY EMPHYSEMA 113 
 
 whilst as to the physical signs of emphysema, there 
 are none, excepting in advanced cases, which are 
 always complicated with bronchitis. If we require 
 instances of emphysema quite unattended by catarrh, 
 such instances are not to be found. However, let us 
 consider a case of marked progressive emphysema, in 
 which the indications of bronchitis and catarrh are the 
 least possible. 
 
 Progressive Dyspnoea. A man, about middle life, 
 begins to suffer from slight shortness of breath on 
 exertion ; he is short of breath, that is to say, the 
 patient feels that he cannot inspire so much breath as 
 he seems to need, in a sense like that in which we say 
 that a man is short of money. His breathlessness 
 increases slowly and insidiously, until his breath is 
 always short ; but no signs of dyspnoea, no laborious 
 or extraordinary movements of respiration, are appar- 
 ent so long as he is at rest, not until he makes some 
 effort, such as that of talking or moving the body. In 
 cases still worse, dyspnoea persists even when the 
 patient is at rest. The dyspnoea of emphysema, like 
 most other kinds of permanent dyspnoea, is liable to 
 paroxysms in which the shortness of breath becomes
 
 114 ON THE NATURE OF 
 
 very distressing. These paroxysms are induced by 
 any effort, such as hurrying, or even no more than 
 straining at stool, raising the foot to enter a carriage, 
 or lifting the arm to shave. A paroxysm will some- 
 times occur during sleep and will suddenly awaken 
 the patient, or will sometimes occur just as he is 
 falling off to sleep. The mere taking of food may be 
 enough to provoke an attack ; so will any sudden 
 change in the temperature of the air breathed, such as 
 occurs on leaving a hot room. The paroxysm is 
 sometimes very sudden and severe, and the patient's 
 description of it sounds very much like that of an 
 attack of angina pectoris ; indeed, the heart probably 
 does participate, for I have known a pulse which was 
 habitually about 80 fall to 60 or 70 during the 
 paroxysm. 
 
 Now suppose a patient suffering from progressive 
 dyspnoea of this kind and from no other symptoms, 
 no cough, no expectoration ; and suppose we find by 
 examining his chest that his lungs are enlarged or, in 
 other words, that he presents the physical signs of 
 emphysema, we might well ask whether he were not 
 the subject of protopathic emphysema. And some
 
 PULMONARY EMPHYSEMA 115 
 
 physicians say that they have met with such patients, 
 and that therefore they believe in the occurrence of 
 emphysema, pure and simple and uncomplicated. I 
 cannot say that this has been my experience. I have 
 never known this progressive dyspnoea and emphy- 
 sema to be unattended by cough and expectoration. 
 
 Cough. The cough is a tickling cough (tussis 
 titillatoria) brought on by a troublesome sensation 
 referred to the larynx. A person, affected in this 
 manner and who, in the spirit of the age, diagnosti- 
 cates the nature of his own disease, goes to a specialist 
 who snips off the tip of his uvula or discovers an 
 irritable spot in the larynx, but fails to afford relief. 
 The cough, like the dyspnoea, steals insidiously upon 
 the patient, until in the course of years he becomes 
 liable to fits of coughing which are very severe, 
 during which he becomes purple in the face, and 
 sometimes even suffers from giddiness ; giddiness 
 which is in any degree of intensity, from an attack 
 so slight that the man declares that he has retained 
 his sensibility throughout, to an attack which amounts 
 to total loss of consciousness ; in which latter case 
 the patient sinks to the ground and sometimes hurts 
 
 I 2
 
 116 ON THE NATURE OF 
 
 himself in his fall ; but even at its worst the coma 
 does not last more than two or three minutes. The 
 expectoration which attends the cough is very scanty 
 and consists of pure mucus. Or it may be that 
 there is no expectoration at all, or, at any rate, no 
 exspuition. 
 
 Aretaeus describes a class of persons whom he 
 designates ' pneumodes ', a word which Stephanus 
 interprets to mean pulmonis vitio laborantes or 
 pulmonarii, and which seems to have the same mean- 
 ing as the French word poitrinaires. Now, if it were 
 not for one particular in Aretaeus's picture of the 
 disease, we could not doubt that his ' pneumodes ' 
 were cases of progressive emphysema. The disease, 
 he says, is a kind of asthma, and there is little differ- 
 ence in the symptoms of the two diseases : all patients 
 labour under shortness of breath as in asthma, but 
 they have this as peculiar, that they cough as if about 
 to expectorate, but their effort is vain for they bring 
 up nothing ; or, if anything is forcibly raised from 
 the lungs, it is a small, white, round substance re- 
 sembling a hailstone. The thorax is broader than 
 natural but not altered in shape ; the lungs, though
 
 PULMONARY EMPHYSEMA 117 
 
 free from suppuration, are filled with humours ; in 
 some cases the affection terminates in dropsy about 
 the lungs or in anasarca. But the pneumodic disease 
 proves fatal within a year from its onset, and this is 
 so grave an objection to our supposing that Aretaeus 
 was referring to cases of pulmonary emphysema that 
 I should not have alluded to his description, were it 
 not for the peculiar sputum which he depicts and 
 which possesses the same characters as those of the 
 sputum expectorated in the affection which Laennec 
 denominated ' catarrhe sec '. 
 
 Dry Catarrh. All physicians admit a close con- 
 nexion of some kind between bronchitis and emphy- 
 sema ; a connexion in many cases so obvious as to 
 be past all doubt, but in other cases not so. Laennec 
 went so far as to say that emphysema is almost always 
 the result of intense and extensive catarrhe sec. All 
 writers on emphysema mention this opinion of 
 Laennec's ; few, if any, adopt it or even discuss it, 
 but no opinion of that remarkable man can be passed 
 over lightly. What does he mean by dry catarrh? 
 He himself admits that the phrase is a contradiction 
 in terms ; to find appropriate names for diseases was
 
 118 ON THE NATURE OF 
 
 not a strong point of his ; witness his perversion of 
 the meaning of the word ' apoplexy ' in his phrase, 
 ' pulmonary apoplexy.' But medical writings are full 
 of this fault, and Laennec is no worse than many 
 other physicians. A better name than dry catarrh 
 would be dry bronchitis (bronchitis sicca), for the 
 word ' siccus ', as applied to pulmonary diseases, de- 
 notes scantiness or absence of expectoration. Stoll 
 speaks of pleuritis sicca and pleuritis humida ; Hippo- 
 crates of dry orthopnoea ; and the phrases dry cough 
 and dry asthma are colloquial. 
 
 In the lungs of persons who died in an early stage 
 of dry catarrh Laennec used to find the mucous mem- 
 brane of the bronchia swollen and dull-red or violet 
 in colour ; conditions most notable in the smaller 
 bronchia, which might be almost completely obstructed 
 by the swelling. The extent of the swelling was not 
 more than a few lines, the mucous membrane in the 
 same tube above and below being natural. This local 
 bronchitis was extensive in proportion to the duration 
 of the disease. When the dry catarrh was universal, 
 or even very extensive, it always ended by deter- 
 mining emphysema. He often found the partially
 
 PULMONARY EMPHYSEMA 119 
 
 obstructed tubes to be plugged by pellets of viscid 
 mucus of the size of hemp or millet seeds, and it is 
 these mucous pellets which make up the pearly sputa 
 which such patients, even when they think there is 
 little or nothing the matter with them, expectorate in 
 small quantity every morning. 
 
 During life the dry catarrh often continues to a 
 slight degree for many years, Laennec goes on to say, 
 or it may be altogether latent, the patient noticing no 
 more than that his breath is shorter than that of 
 other men, especially upon exertion. This dyspnoea 
 increases gradually, and the patient becomes subject 
 to attacks bad enough to deserve the name of asthma. 
 The tendency to dyspnoea is accompanied by cough, 
 which at the beginning of the disease is, like the 
 dyspnoea, slight. The cough is attended by expector- 
 ation of what Laennec calls pearly sputa, which closely 
 resemble the hailstone sputa (chalazia) described by 
 Aretaeus and Galen. Such is a brief summary of 
 Laennec's characterization of his catarrhe sec. 
 
 Now, if we admit that a man in a state of perfect 
 health ought not to cough or expectorate, and also 
 that expectoration implies catarrh, it follows that at
 
 120 ON THE NATURE OF 
 
 no period of the progress of emphysema is that con- 
 dition unassociated with catarrh. Again, inasmuch 
 as emphysematous patients always become, in the 
 advanced stage of their disease, manifestly bronchitic 
 or catarrhal, it is reasonable to believe that in the 
 early stage also their cough and expectoration indicate 
 slight bronchitis or catarrh. Lastly, the symptoms 
 of progressive emphysema (as I have already attempted 
 to depict them) and those of Laennec's dry catarrh 
 seem to relate to the same disease looked at from two 
 different points of view. 
 
 Conclusions. We have now reached a position 
 which enables us to resume our discussion of the 
 nature of emphysema. Starting from the note of 
 progressive emphysema ; namely, the Atrophy of lung 
 tissue, the problem may be resolved into a choice 
 between these alternatives. Is there a primary de- 
 generation of lung tissue, rendering it apt to be 
 permanently distended, and also to be destroyed 
 particle by particle ? Or is the atrophy due to dis- 
 tension of the lung; and if so, what causes the 
 distension ? In briefer language, is the atrophy 
 primary or secondary ? The easiest answer is that
 
 PULMONARY EMPHYSEMA 121 
 
 which assumes the atrophy to be secondary to dis- 
 tension. Laennec asserts that ' pulmonary emphysema 
 is almost always developed in consequence of intense 
 and extensive dry catarrh ', and we have seen that 
 clinical observation supports this opinion. But in 
 speaking of the priority of catarrh, we must under- 
 stand it only as a priority of order and conception, 
 and not as a priority of time. Another argument in 
 favour of Laennec's opinion is this, that inasmuch as 
 acute emphysema is undoubtedly dependent upon 
 bronchial affections, it is probable by analogical reason- 
 ing that chronic emphysema likewise is so, I will 
 not repeat Laennec's explanation, which you all 
 know, concerning the manner in which he supposes 
 dry catarrh to lead to emphysema, and I will only 
 remark that his hypothesis is not so easily set aside 
 as some people think, by pointing out that the air- 
 current at the mouth of a healthy man is more power- 
 ful during expiration than during inspiration, for the 
 conditions in pulmonary catarrh are obviously not 
 the same. 
 
 Let us fix our attention upon the fact of the Barrel- 
 shaped cJiesl in cases of emphysema. It is a chest
 
 122 ON THE NATURE OF 
 
 more capacious than a healthy chest could be rendered 
 by the deepest and most powerful inspiration. The 
 distended chest is a sign of distended lungs, and this 
 fact puts before us a disjunctive hypothesis : either 
 the distended chest distends the lungs, or the distended 
 lungs distend the chest. Now the latter hypothesis 
 affords no explanation at all, because it leaves the 
 distension of the lungs unexplained ; and the cause 
 of this pulmonary distension or emphysema is the 
 very thing we are searching for. Wherefore let us 
 consider the former hypothesis, namely, that the dis- 
 tension of the lungs is consequent upon increased 
 capacity of the thorax. In normal inspiration which 
 fact precedes the other ; dilatation of the lungs or 
 dilatation of the chest ? And by what powers can the 
 chest be over-distended? Obviously by the inspira- 
 tory muscles, ordinary and extraordinary, and by no 
 others. And if the chest be over-distended, what 
 must ensue ? Over-distension of the lungs, because 
 the potential vacuum caused by extraordinarily deep 
 inspiration is certainly not filled up in any other way. 
 In health the inspiratory distension of the lungs is 
 exactly countervailed by the expiratory contraction.
 
 PULMONARY EMPHYSEMA 123 
 
 Why, then, in the barrel-shaped chest is this no longer 
 the case? Obviously because the expiratory powers 
 have been unequal to the task of restoring the chest 
 to its natural shape and size. That is to say, the 
 expiratory powers are no longer equal to the inspira- 
 tory. And is not this a sufficient reply to those who, 
 relying upon spirometrical observations made upon 
 healthy people, reject Laennec's explanation of the 
 mechanism of emphysema 1 
 
 In emphysema, then, there is Failure of expiratory 
 poicer ; nay, more, this is the essence of emphysema. 
 Expiration being no longer able to rid the lungs of 
 their exhausted air, ordinary inspiration cannot supply 
 the necessary quantity of fresh air. And there is 
 only one means by which the expiratory failure can 
 be met, and that is by inspiratory movements extra- 
 ordinary in power and amplitude. These extra- 
 ordinary inspirations being repeated for weeks, months, 
 and years, the chest becomes permanently over-dis- 
 tended, and hence the lungs become permanently over- 
 distended, and this is emphysema. 
 
 We have no clear and certain knowledge respecting 
 the nature of the expiratory failure. We may con-
 
 124 ON THE NATURE OF 
 
 ceive it to be absolute or relative. Absolute, that is 
 to say, the elastic and muscular movements of expira- 
 tion are weakened ; relative, that is to say, the 
 resistance which expiration has to overcome is in- 
 creased. 1. The notion of an absolute debility of ex- 
 piratory movement must relate to the elasticity of the 
 lungs only, because there is no reason for supposing 
 the elastic or muscular movements of the chest to be 
 primarily weakened. And thus we are led back to 
 the question of degeneration of lung tissue, either 
 primary or secondary to other disease ; an obscure 
 topic which we will again defer for a while. 2. But 
 the notion of a relative debility of expiration is that 
 which lies at the bottom of Laennec's doctrine, the 
 resistance to expiration being increased by the presence 
 of mucous plugs in the air-tubes, and by swelling of 
 the mucous membrane. True, reply his critics, but 
 these obstructions are equally great for inspiration 
 as for expiration, and thus we are again met by the 
 question concerning the relative powers of inspiration 
 and expiration, a question which is answered by 
 reiteration of the fact that nature has provided us 
 with very feeble means of reducing by forced expira-
 
 PULMONARY EMPHYSEMA 125 
 
 tion the distension of the chest and lungs produced 
 by forced inspiration. The extraordinary muscles of 
 expiration are inadequate, whilst as to the elastic 
 tissues of the lung we may hazard the conjecture, that 
 if overstrained they do not easily recover, and it is only 
 inspiration that can overstrain them. 
 
 Now, just to consider for a moment the question 
 whether the over-distended chest can possibly be due 
 to over-distended lungs. In other words, can we 
 assume a primary over-distension of the lungs power- 
 ful enough to distend the whole thorax, and to make 
 it barrel-shaped ? If so, what distends the lungs ? 
 Forced expiration is sufficient to distend certain 
 portions of lung which are unsupported by bone or 
 muscle, such as are the apices. But more than this 
 is inconceivable ; it is inconceivable that expiration, 
 how forcible soever, can produce a shape of chest 
 which is identical with that produced by forcible in- 
 spiration. Again, a favourite seat of emphysema is 
 the undermost surface of the lung where it lies upon 
 the diaphragm : how can coughing an act during 
 which the diaphragm is driven powerfully upwards 
 over-distend this portion of the lung? Surely it is
 
 126 ON THE NATURE OF 
 
 the powerful inspiratory descent of the diaphragm 
 which produces this effect ; and let us remember that 
 the forced expiration of persons coughing, of musicians, 
 or of horses tugging up a hill is rendered possible 
 only by a preceding forced inspiration. In short, we 
 cannot understand the occurrence of a primary over- 
 distension of the lungs sufficient to distend the thorax. 
 Now to discuss and finally to dismiss the question 
 of the Degenerative lung changes. In the first place ; 
 it is probable that the elasticity of the lungs is injured 
 if the tissues be much or often overstretched, and any 
 such loss of elasticity must tend to increase emphysema 
 by weakening expiration. In the second place ; it is 
 very reasonable to believe that the anaemia, which is 
 the visible and undoubted result of over-distension of 
 any portion of the lung, will cause degeneration and 
 atrophy of the tissues thus imperfectly supplied with 
 blood. In the third place ; it is possible that there is 
 such a lesion as primary atrophy of lung, analogous 
 to the atrophy and perforations which we often observe 
 in the omentum, falx cerebri, and valves of the heart. 
 In the fourth place ; it is not unlikely that the form 
 of pulmonary emphysema in which the total size of
 
 PULMONARY EMPHYSEMA 127 
 
 the lung is not increased, atrophous emphysema, is an 
 atrophy of the second or third kind. And lastly : 
 there are good grounds for believing that even ordinary 
 progressive emphysema with enlarged lungs is, from 
 its very beginning, an atrophic process, even although 
 to the mind's eye the destruction be secondary to the 
 distension. 
 
 Summary. To end our inquiry by recapitulating 
 the results at which we have arrived, I submit these 
 propositions : (i) That pulmonary emphysema is 
 chiefly due to forced inspirations, although forced 
 expiration may to some extent play its part, (ii) That 
 the distension of the lung, in so far as it is due to 
 inspiration, is secondary to distension of the chest, 
 (iii) That the forced inspiration is rendered necessary by 
 a feeling of dyspnoea, (iv) That the dyspnoea, which 
 occurs at the beginning of pulmonary emphysema and 
 which determines it, is consequent upon obstruction 
 of the air-passages, (v) That in chronic progressive 
 emphysema, this obstruction depends upon bronchitis, 
 either humid and attended with free secretion, or dry 
 with scanty secretion, (vi) That when once emphysema 
 is set up, the dyspnoea and the necessity for forced
 
 128 NATURE OF PULMONARY EMPHYSEMA 
 
 inspiration are increased by the natural defect of ex- 
 piratory power in the lungs and in certain parts of 
 the chest, nature having provided means insufficient 
 for reducing excessive inspiratory distension to the 
 normal, and for thus emptying the lungs of residual 
 air. (vii) That the degeneration and atrophy of lung 
 tissue are usually dependent upon preceding over- 
 distension, although it is possible that pulmonary 
 atrophy may to some extent be primary.
 
 129 
 
 X 
 
 ON THE NATURE OF ASTHMA 1 
 
 BEFORE proceeding to discuss the nature of asthma 
 it is desirable that we should come to an agreement as 
 to the meaning of the word. It was used in a simple 
 etymological sense until the time of Thomas Willis. 
 Asthma originally denoted any kind of panting, 
 gasping, pursy breathing, such as follows upon running 
 or exertion. Hence asthma and dyspnoea were syn- 
 onymous for most of the older physicians. A few, 
 such as Celsus, signified by asthma the highest degree 
 of dyspnoea, but this was all ; asthma was never 
 regarded as a special sort of dyspnoea. In reading 
 the writings of the ancients we must always bear this 
 in mind, and beware of importing into their generic 
 use of the word the special meaning which it bears in 
 
 1 Lecture given before the Royal College of Physicians on 
 March 23, 1899.
 
 130 ON THE NATURE OF ASTHMA 
 
 modern times. It is interesting to note that those 
 most conservative of people, the illiterate, continue to 
 use the word in the sense of Hippocrates and Galen. 
 
 Thomas Willis was the innovator upon the doctrine 
 of the ancients. His opinions, in their mature form, 
 are found in the second part of his Rational Phar- 
 maceutic, published in 1675, after his death in the 
 same year. He says, truly enough, that the ancient 
 physicians, and also most moderns up to his time, had 
 admitted only one kind of asthma, that which he calls 
 pneumonic asthma, and which had always been deemed 
 to be consequent upon the air-passages of the lungs 
 being obstructed or not open enough. It would be 
 a more accurate expression to say that the ancients 
 regarded all cases of asthma as pneumonic, and 
 dependent upon bronchial obstruction. From this 
 pneumonic asthma, Willis distinguishes a second 
 kind, which he calls convulsive asthma, the primary 
 fault being in the motive organs of the lungs, to wit, 
 in the moving fibres or muscular coats of the air- 
 vessels, or in the diaphragm and muscles of the chest, 
 or in the nerves of the lungs and chest, or in the origin 
 of those nerves in the brain. There is also, he says, a
 
 ON THE NATURE OF ASTHMA 131 
 
 mixed asthma, both pneumonic and convulsive, and 
 inveterate asthma is usually of this kind. 
 
 Willis's doctrine is very comprehensive, and he 
 dimly anticipates all the theories of asthma which 
 have been propounded since his day. His new notion 
 of convulsive asthma was soon laid hold of; the 
 term asthma came to be reserved for the exclusive 
 denomination of that form of the disease which was 
 believed to be convulsive (or spasmodic), and this is 
 the sense in which the word is still used by most 
 persons even in our own day. Willis's influence upon 
 this question of pathology has been so great that the 
 present essay is to a large extent an endeavour to 
 determine whether he were the discoverer of an im- 
 portant truth or the parent of a delusion. A satis- 
 factory definition of the word asthma will be the end 
 of our discussion, if we succeed in attaining a clear 
 and distinct notion of the nature of the disease, for, as 
 Milton, writing in the spirit of both Plato and Aristotle, 
 says : ' Definition is decreed by logicians to consist 
 only of causes constituting the essence of a thing.' 
 But meanwhile we may perhaps be able to agree upon 
 a sort of provisional definition, logically less exact. 
 
 K 2
 
 132 ON THE NATURE OF ASTHMA 
 
 Thus, some diseases are defined, accurately enough, by 
 means of their anatomical characters, or the attendent 
 lesions of structure ; and some diseases are defined less 
 accurately by their symptoms or the attendent lesions 
 of function. Let us examine asthma from these two 
 points of view. 
 
 First, what is the Morbid Anatomy of asthma? 
 Here I discover a curious and remarkable fact. We 
 may look through a big book upon asthma, an elaborate 
 treatise deserving the repute it has gained, and we find 
 no chapter dealing with morbid anatomy. Yet surely 
 some asthmatic patients die uncured. and some of their 
 bodies are examined, and in all the bodies examined 
 material lesions are found ; what are they ? Now 
 many of these lesions are found in some bodies only, 
 and therefore cannot have anything to do with the 
 immediate cause of asthma. Some of these inconstant 
 lesions are those which are apt to occur in the decline 
 of life, and it is noteworthy that Rostan (who practised 
 at the SalpeViere in Paris, the great hospital for old, 
 infirm women) after asking the question, Whether the 
 asthma of old people be a nervous affection ? replies, 
 as the invariable resultof his post-mortem examinations,
 
 ON THE NATURE OF ASTHMA 133 
 
 That the asthma of old people is a symptom of an 
 organic lesion, and especially of atherorna of the aorta 
 and of hypertrophy of the heart. Most physicians of 
 our day would probably agree that Rostan's opinion 
 is correct so far as its general principle is concerned, 
 namely, that organic lesions in the chest are found, 
 but he errs in his particulars by being far too exclusive ; 
 other morbid changes are much more frequently met 
 with than those which he mentions. Again, such 
 lesions as tubercular affections of the lungs, phthisis 
 (active or retrograde), and acute miliary tuberculosis, 
 though often found in asthmatics who are not old, 
 cannot be deemed essential to asthma. But signs of 
 bronchitis and pulmonary emphysema are always 
 found ; and though we are not prepared to call them 
 the anatomical characteristics of asthma, yet the fact 
 that they are constant demands that they should not 
 be passed over, or dismissed with the remark that 
 they are mere complications, an obvious begging of 
 the question. That the bronchitis of asthma should 
 be regarded as an accidental complication, and by no 
 means as an essential element of the disease, is due to 
 the fact that since Willis's time there has always been
 
 134 ON THE NATURE OF ASTHMA 
 
 a strong tendency to look upon asthma as something 
 mysterious and its cause as supersensual. However, 
 you will probably assent to the proposition that either 
 bronchitis and emphysema constitute the morbid 
 anatomy of asthma, or it has no morbid anatomy. In 
 either case we must reluctantly conclude that structural 
 lesions cannot help us to a definition. 
 
 Secondly, definitions based upon Symptoms, or dis- 
 ordered functions observed in patients during life, are 
 seldom satisfactory. In the case of asthma, any defini- 
 tion of this kind would involve so many explanations, 
 reservations, and distinctions that it would be nothing 
 less than a description of the disease. I will not 
 attempt to succeed where all nosologists have failed, 
 and I fear that we must confess that symptomatology 
 cannot help us to a definition. 
 
 So we will proceed to our investigation in the belief 
 that, in the case of a given patient, most physicians 
 would be able to agree whether he were suffering from 
 asthma or not, and that we have a pretty unanimous 
 though an indefinable notion of the disease. Yet we 
 must admit that the notion has been inconstant ; that 
 the extent of meaning of the word has been growing
 
 
 135 
 
 narrower and narrower. Much of what Willis called 
 pneumonic asthma has long since ceased to be called 
 asthma at all ; much of what, by way of exclusion, 
 was formerly deemed to be convulsive asthma, is now 
 known to be dyspnoea due to disease of the heart, 
 blood-vessels, kidneys, to poisoned blood, and other 
 conditions which need not be enumerated. Thus there 
 is a risk lest asthma should become a mere caput mor- 
 tuum, a kind of dyspnoea left when all known causes 
 of dyspnoea have been separated, the definition of the 
 word being purely negative, indicative of what asthma 
 is not. But asthma is not a mere caput mortuum. 
 
 Ina.smuch, then, as our most trustworthy guides in 
 all the physical sciences, our senses, seem insufficient 
 to enable us to explore the essence of asthma, either in 
 the living body, or the dead, we must try to grope our 
 way by the help of reason. And we will recur to the 
 rival hypotheses already mentioned and will debate 
 the question (which remains much as Willis left it) 
 whether asthma is a pure affection of the nervous 
 system ; or whether it is all pneumonic, due, that is to 
 say, to gross material changes in the lungs ; or whether 
 it is a combination of the two.
 
 136 ON THE NATURE OF ASTHMA 
 
 I. Spasmodic Hypothesis. In the first place let us 
 discuss the nervous, convulsive, or spasmodic hypo- 
 thesis. 
 
 1. That the Air-tubes possess muscular coats, or 
 moving fibres, was well known to Willis. That these 
 fibres contract under appropriate stimulus, so as to 
 diminish the capacity of the bronchia, has been 
 demonstrated many times by experiment, the vagus 
 being the motor nerve. But farther than this our 
 knowledge does not extend. From the best and latest 
 works upon human physiology we cannot learn what 
 the use of these fibres is, nor under what conditions 
 they contract, nor whether they contract quickly or 
 slowly, nor whether their contraction is momentary or 
 enduring, yet surely we ought to be able to answer 
 these questions before we can deduce a pathology of 
 asthma from perverted function of these fibres. The 
 prevailing opinion is that they help the bronchial 
 walls to resist distension of the air-tubes. But even 
 supposing this opinion to be true, we are no nearer to 
 understanding the part which these fibres have been 
 assumed to play in the production of asthma. We 
 will admit that it is conceivable that their contraction
 
 ON THE NATURE OF ASTHMA 137 
 
 may cause dyspnoea, but we must make the reservation 
 that there is no proof of this assumption. And one 
 thing seems to be certain, namely, that if there be such 
 a disease as bronchial spasm, pure and simple, it must 
 be a very rare condition, because it is inadequate to 
 explain the catarrh which manifestly attends most, if 
 not all, asthmatic seizures. Willis himself was far too 
 sagacious a man not to have seen the meaning of this 
 fact. He writes thus : ' Although an asthma is some- 
 times simple from the beginning viz. either merely 
 pneumonical or convulsive, notwithstanding, after 
 either disease hath for some time increased, for the 
 most part it gains the other to itself, hence it may be 
 concluded every inveterate asthma to be a mixed 
 affection.' But we have already seen good reason for 
 doubting whether this doctrine of Willis's goes far 
 enough. The whole subject of bronchial spasm is 
 involved in so much obscurity that we cannot admit 
 more than that it perhaps takes a share in the pro- 
 duction of asthma, but is seldom, if ever, the chief or 
 only cause. And we may dismiss this topic by adopt- 
 ing the words of Robert Whytt, ' that a true nervous 
 or spasmodic asthma, without any other fault in the
 
 138 
 
 lungs than uncommon delicacy or irritability of their 
 nerves, is a disease which we seldom meet with.' 
 
 2. Let us come to the Muscles of Respiration. When 
 I began to lecture on medicine at St. Bartholomew's 
 Hospital it seemed necessary that I should expound 
 some theory of asthma. I had been much struck by 
 observing, in bad attacks of asthma, the fixed immo- 
 bility of the chest in a state of the fullest possible 
 inspiration. About the same time I came across a 
 paper by an experimental physiologist who had found 
 that centripetal excitement of the vagus, divided below 
 the junction of the superior laryngeal nerve, produced 
 tetanic contraction of the diaphragm, intercostals, and 
 other inspiratory muscles ; a state of things which is 
 necessarily accompanied by dyspnoea, and which, in 
 this respect, resembles the asthmatic paroxysm. And 
 so for a year or two, I taught that the fit of asthma, at 
 its beginning at least, was due to centripetal irritation 
 of the vagus. But maturer experience soon showed 
 me that this fixed inspiratory distension of the chest 
 is by no means a constant attendent upon asthmatic 
 dyspnoea, that the inspiratory movements are some- 
 times free and ample enough, and thus I lost all faith
 
 ON THE NATURE OF ASTHMA 139 
 
 in the doctrine of protopathic inspiratory spasm. 
 Moreover, what is the evidence of inspiratory spasm 
 during the attack of asthma 1 ? No doubt the chest is 
 in a state of inspiratory distension, dilated to its utmost 
 capacity and fixed in this position. But it is more 
 likely that this state of things is due, not to inspiratory 
 spasm but to expiratory debility. Air is imprisoned 
 in the lungs, and no amount of forced expiration can 
 empty them. In the last lecture I showed what a very 
 partial process forced expiration is; over many portions 
 of the lung it has no power. If the sufferer could empty 
 his lungs he could fill them again ; it is the deflation 
 which is at fault, and the extreme inflation is due to 
 incessant forced inspiratory efforts to make the most 
 of what little room for fresh air can be provided by 
 forced expiration. This fact is very well expressed in 
 a tale told by Dean Swift of a farmer who, when dying 
 of asthma, said : ' Well, if I can get this breath once 
 out I'll take care it shall never get in again.' And 
 thus to conclude this topic I submit that inspiratory 
 spasm is not the cause of the asthmatic paroxysm. 
 
 3. Again, Willis thought that convulsive asthma 
 might sometimes proceed from irritation of the pul-
 
 140 ON THE NATURE OF ASTHMA 
 
 monary or thoracic Nerves, or of the origin of these 
 nerves in the brain. This is one of those recondite 
 propositions which can be neither maintained nor 
 refuted. Contraction of the bronchial muscular fibres 
 or of the respiratory muscles, if it play any part in the 
 asthmatic paroxysm, may doubtless be due to irritation 
 of appropriate nerves, but the muscular contraction 
 itself has not been proved to occur, and this must be 
 done before we need discuss its causes. The influence 
 exerted by the nervous system upon secretion, nutri- 
 tion, and the blood-supply is well known as a general 
 fact, but any particular application of this fact to 
 explain the pathology of asthma is at present beyond 
 our power. Thus we have no evidence to show that 
 asthma takes its origin from the nerves or brain. 
 
 II. Pneumonic Hypothesis. But if asthma be not 
 convulsive, we are thrown back upon the hypothesis 
 of pneumonic asthma, for we have no third explanation 
 before us. Let us review the argument in favour of 
 pneumonic asthma. This argument is wholly ana- 
 logical. There are several diseases which resemble 
 asthma in certain respects, more or less. Perchance 
 we understand the pathology of these diseases some-
 
 ON THE NATURE OF ASTHMA 141 
 
 what better than that of asthma. If so, we may 
 inquire whether the nature of asthma can be assimilated 
 to that of the diseases which it resembles. Obviously 
 such an argument as this is far enough from deserving 
 the name of induction, but we may be comforted by 
 the reflection that to us probability is the very guide 
 of life. Let us enumerate and illustrate the diseases 
 referred to. 
 
 1. A peculiar form of Acute Bronchitis. ' Last 
 summer I went out of town to see a little boy, seven 
 or eight years of age, whose life was very precious to 
 his family. He was thought to be dying of inflam- 
 mation of the lungs. I found him raised up in bed, 
 supported by his nurse, and breathing with all his 
 might. His skin was hot, his faced flushed, and his 
 chest heaved, and his nostrils quivered frightfully. 
 There was no croupy sound. Whatever the disease 
 was it was all within the chest. I percussed the 
 chest : it sounded well in every part. I listened : the 
 air entered freely and reached every cell and vesicle 
 of the lungs ; but there was not the least perception 
 of the natural respiratory murmur; a shrill sibilus 
 had taken place of it altogether. Wherever you
 
 142 ON THE NATURE OF ASTHMA 
 
 applied your ear to the chest you might fancy you 
 heard the piping and screaming of a nestful of un- 
 fledged birds.' Probably many hearers will recognize 
 the hand of Dr. Peter Mere Latham in the somewhat 
 rhetorical character of the description I have just 
 quoted. I have set before you his description of the 
 disease because it serves as an emphatic text, and not 
 because the affection is very uncommon ; it is alluded 
 to by many of the best authors and I myself have 
 seen a considerable number of cases. Latham goes 
 on to say : ' I am speaking of a disease which must 
 be distinguished from asthma according to the usual 
 acceptation a disease not habitual to the individual 
 and of which, perhaps, he has never suffered a previous 
 attack.' But of course an asthmatic must have his 
 first attack, to which Latham's criterion of habit 
 cannot be applied, and unless he had told us that his 
 patient had never before suffered from a similar 
 attack, and never had one afterwards, his argument 
 that the disease was not asthma falls to the ground. 
 
 Latham's patient certainly suffered from acute dry 
 pulmonary catarrh, to use the phrase of Laennec ; but 
 in this form of disease the catarrh is not always dry ;
 
 ON THE NATURE OF ASTHMA 143 
 
 on the contrary, small raucous rales are sometimes 
 heard all over the chest. I saw a girl, four years old, 
 who one morning had a little cough, but was quite 
 well in all other respects. In the afternoon she 
 suddenly became much worse and her state alarmed 
 everybody. In the evening her distress, dyspnoea, 
 and lividity were great ; the upper part of the chest 
 expanded considerably on inspiration, but there was 
 at the same time much depression of the root of the 
 neck, of the epigastrium, and of the base of the chest. 
 All over the lungs small mucous rales were heard. 
 Her voice and cry were natural, so that there was no 
 reason for suspecting laryngeal disease. Her tempera- 
 ture was below the normal. I was told that she had 
 suffered from several sharp attacks of what had been 
 called ' bronchitis ' and ' congestion of the lungs ' ; 
 that she had been subject to eczema all over the body ; 
 and that her father's father and brother had been 
 ' asthmatics ' until they reached maturity. The very 
 same night she improved much, and next day she was 
 comparatively well ; recovery was rapid. 
 
 The chief characteristics of this form of bronchitis 
 may be thus enumerated : the rapidity with which
 
 144 ON THE NATURE OF ASTHMA 
 
 the dyspnoea becomes extreme ; the attendent fever, 
 little or none ; the whole attack seldom lasting more 
 than two or three days ; and the great tendency to 
 recur. In the intervals, most of the patients are free 
 from pectoral symptoms, but in some cases emphysema 
 occurs, and I have seen it well marked in a patient 
 only three years old, subject to this disease. Most of 
 the children have suffered from eczema, and most of 
 them come from families prone to asthma, bronchitis, 
 and gout. 
 
 When we inquire into the previous history of 
 patients who during youth have been liable to un- 
 doubted asthma, we find that in a certain number of 
 them their disease dates from one or more attacks of 
 this kind. And surely these attacks u'cre asthma 
 from the very first, although they were not deemed 
 to be so at the time, but were called in Latham's 
 language ' acute bronchial inflammation putting on 
 a peculiar form and affecting a peculiar course '. The 
 bronchitis does not cause the subsequent asthma, but 
 it is asthma ; the two diseases are identical in nature 
 and the asthma is bronchitis, although a peculiar form 
 of bronchitis,
 
 ON THE NATURE OF ASTHMA 145 
 
 2. Spasmodic Group. This is an old phrase now 
 seldom used, yet I do not know that we have a better. 
 It is not a good phrase, because it implies a hypothesis 
 which is probably untrue. The disease is characterized 
 chiefly by acute dyspnoea ; indeed, most of the cases 
 described by Millar under the name of ' acute asthma ' 
 were cases of spasmodic croup. Spasmodic croup is 
 not laryngismus stridulus, for the dyspnoea of laryn- 
 gisinus is momentary, whereas that of spasmodic croup 
 lasts for several hours, and on and off for days. 
 Spasmodic croup is not quite the same thing as 
 laryngitis stridula, a disease which is characterized 
 more by dysphonia than dyspnoea. Dr. Benjamin 
 Rush of Philadelphia was the first to apply the epithet 
 ' spasmodic ' to the disease, an indication probably 
 that he as well as Millar recognized a resemblance to 
 spasmodic asthma. I enter into these details because 
 there still exists, as there always has existed, much 
 confusion in the use of these names. Millar's descrip- 
 tion of the disease, published in 1769, is vitiated by 
 the fact that he does not distinguish the different 
 kinds of acute laryngeal disease which cause dyspnoea 
 in children. Rush's description, published in 1789, ia
 
 146 ON THE NATURE OF ASTHMA 
 
 much more precise, perhaps because more concise. 
 He says that ' the cynanche trachealis spasmodica is 
 known (1) by coming on suddenly and that generally 
 in the night ; (2) by frequent and perfect intermissions 
 of the symptoms for hours, and in some instances 
 for days, without the least sensible discharge from 
 the trachea ; and (3) by yielding to anti- spasmodic 
 remedies, particularly to the warm bath '. Rush had 
 examined the body of a fatal case and had found no 
 marks of a membrane or even of mucus in the trachea; 
 the lungs and trachea appeared to be in a sound state. 
 Many persons have believed in a close analogy 
 between spasmodic croup and spasmodic asthma. 
 Some have even gone so far as to say that ' children, 
 who have been the subjects of croup or stridulous 
 laryngitis in their earlier years, are prone to suffer 
 from true asthma in later life ', but judging from the 
 facts of my own experience I am disposed to think 
 that this sequence is not common. Unfortunately, 
 the pathology of spasmodic croup is not well under- 
 stood. I do not know that the glottis has ever been 
 seen by means of a laryngoscope during the attack of 
 dyspnoea. Could this be done it would go a long
 
 ON THE NATURE OF ASTHMA 147 
 
 way towards clearing up the darkness which hangs 
 over the subject. Moreover, patients when attacked 
 by spasmodic croup seldom die, and thus we are 
 deprived of the information which minute post-mortem 
 examination might afford. Nobody doubts that the 
 disease implies an element of acute laryngitis, or of 
 croup, for these two terms are almost synonymous, 
 croup being the acute laryngitis of children. The 
 evidence of laryngitis depends mainly upon these two 
 facts: first, that the attack of dyspnoea is preceded 
 for a few hours by hoarseness and croupy cough and 
 perhaps by other signs of catarrh of the respiratory 
 mucous membrane j secondly, that the interval be- 
 tween the attacks is not free from the same symptoms. 
 Admitting, then, that there is a fundamental ground 
 of laryngitis, we must inquire in the next place into 
 the cause of the dyspnoea, so sudden, and so temporary, 
 and here lies the difficulty. The epithet ' spasmodic ' 
 begs the question by assuming that spasm of the 
 glottic muscles is superadded to the laryngitis. But 
 when we compare spasmodic croup with what is 
 universally admitted to be a glottic spasm that is to 
 say with laryngismus stridulus the difference between 
 
 L 2
 
 148 OX THE NATURE OF ASTHMA 
 
 the two diseases appeal's to be so great as to make us 
 doubt whether the dyspnoea of croup can be spasmodic. 
 In laryngismus the dyspnoea sets in very suddenly, 
 and lasts only a few seconds, for if it last longer the 
 child will die. At any rate if the croup be spasmodic, 
 we must assume that the spasm is very incomplete 
 and that it lasts several hours, assumptions which 
 seem improbable. It is improbable that the spasm 
 should be always incomplete, and should never become 
 a thorough laryngisrnus, and thus kill the patient; 
 whereas deaths from spasmodic croup are so uncommon 
 that we may almost say that they do not occur. 
 Moreover the catarrhal swelling of the laryngeal 
 mucous membrane would render any spasm much 
 more likely to prove fatal ; and we must never forget 
 the small size of the glottis in children when we speak 
 of their laryngeal diseases. 
 
 But, if we give up the notion of spasm, are there 
 any other explanations which we can fall back upon? 
 Two have been offered. One was put forward first, 
 so far as I know, by Felix Niemeyer. He supposes 
 that viscid mucus accumulates in the glottis while the 
 child is asleep ; that this mucus becomes dry and so
 
 ON THE NATURE OF ASTHMA 149 
 
 glues up the rima glottidis ; an ingenious explanation, 
 not wanting in plausibility, but which can be neither 
 proved nor disproved. The chief argument against 
 this hypothesis is found in the great resemblance 
 between spasmodic croup and the peculiar form of 
 acute bronchitis which we discussed just now. In 
 both diseases, the same slight premonitory catarrh, 
 the same sudden onset of alarming dyspnoea in the 
 afternoon, the same speedy abatement of the dyspnoea, 
 the same freedom from fatal results, and the same 
 tendency to recur. Now, there is no reason for 
 thinking that the bronchitic dyspnoea is due to ac- 
 cumulated mucus, still less to dried mucus ; and hence 
 we may well doubt whether spasmodic croup is due 
 to these conditions. But yet, until we can bring our 
 senses to bear directly upon the glottis, until we can 
 see what actually takes place, we may admit that 
 there is possibly some truth in Niemeyer's hypothesis. 
 How often are we tempted to exclaim with the surgeon 
 in the old novel, ' A fig for reason, I laugh at reason ; 
 give me ocular demonstration.' 
 
 The other explanation seems more probable. It 
 supposes a sudden and temporary swelling of the
 
 150 ON THE NATURE OF ASTHMA 
 
 mucous membrane of the larynx, such as sometimes 
 occurs in the pituitary membrane during acute coryza, 
 when one nostril becomes suddenly blocked ; and not 
 by mucus, so far as can be made out, or at least no 
 mucus can be expelled from the affected nostril. In 
 the case of the nose, this sudden swelling can be easily 
 understood, for anatomists tell us that the veins of 
 the mucous membrane over the turbinate bones con- 
 stitute a cavernous structure, and that the membrane 
 in this situation is erectile. No structure of this kind 
 has been detected in the mucous membrane of the 
 larynx, and hence the argument from analogy is 
 weakened to a corresponding degree. In short, the 
 opinion that spasmodic croup is due to sudden swelling 
 of the mucous membrane depends mainly upon -reason- 
 ing by way of exclusion, there being fewer objections 
 to this pathology than to the hypotheses of spasm or 
 of mucous obstruction. 
 
 Leaving these dry catarrhs of the respiratory tract 
 let us turn our attention to certain catarrhs of a 
 character exactly opposite, being attended by abundant 
 secretion of mucus ; for these catarrhs also have 
 a close affinity with asthma.
 
 ON THE NATURE OF ASTHMA 151 
 
 3. Paroxysmal Coryza. In the first place we will 
 consider paroxysmal coryza or ' paroxysmal sneezing ' 
 as it is sometimes called. And let me set before you 
 a vivid picture of the disease, drawn by a sufferer, 
 a married lady, aged twenty-nine years. I copy the 
 exact words of a letter she wrote : ' Severe cold in the 
 head every morning for two or three hours after 
 waking; continual running of the nose, sneezing, 
 watering of the eyes ; pocket-handkerchiefs are of no 
 use, I have to use towels. Frequent fits of violent 
 sneezing, perhaps repeated a dozen or twenty times. 
 Continual rising of phlegm into the mouth in the 
 morning on waking; often an accumulated mass of 
 phlegm has to be got rid of. Loss of taste and smell, 
 and impaired voice in singing. The above symptoms 
 have been present for five years, though they have 
 increased of late. In addition the following have 
 occasioned trouble during the past nine months : 
 a wheezing in the chest, difficulty in breathing, or in 
 taking a deep breath. At times this prevents me 
 from lying down at night ; at least I go to sleep in 
 the usual way, but am disturbed three or four hours 
 after by a feeling of suffocation and am obliged to
 
 15.2 ON THE NATURE OF ASTHMA 
 
 spend rest of night sitting in a chair. This feeling 
 sometimes comes on without any warning. Last 
 week, when returning from a dinner party, I suddenly 
 became oppressed in breathing, and had quite to 
 struggle for breath for ten minutes or so. Violent 
 exercise, such as running and, I think, swimming, 
 also hearty laughing, produces much the same effect 
 viz. a wheezing and difficulty in breathing freely. 
 Voice in singing much fallen off. Damp weather and 
 cold winds seem to increase the tendency.' Thus far 
 the patient's own report, to which the following facts 
 may be added : there was a tendency in her family to 
 asthma, eczema, and gout ; she herself never had 
 eczema, but it had appeared in several of her relatives, 
 and also in her only child, fifteen months old. 
 
 The connexion between paroxysmal coryza, asthma, 
 and eczema is remarkable. A girl, eleven years old, 
 had suffered from frequent attacks of asthma since 
 the age of two years. Moreover, she had always been 
 liable to fits of bad sneezing with running from the 
 eyes. This sneezing was sometimes followed by 
 asthma, sometimes not. When a baby she had eczema. 
 In her father's family there was a tendency to eczema
 
 ON THE NATURE OF ASTHMA 153 
 
 and gout, but not to asthma ; in her mother's family 
 there was probably a tendency to asthma. She had 
 a younger brother who was asthmatic, and who 
 suffered from eczema in infancy. The girl, the brother, 
 and the mother were all of a dark complexion. A 
 second girl, sister of the patient, was of a fair com- 
 plexion, and had shown no tendency to asthma. 
 
 A boy, two years and a half old, became eczematous 
 at six months of age. The eczema cleared off at 
 twelve months and then he began to suffer from 
 asthma. And mark that his attacks of asthma began 
 with sneezing and running from the nose, and that an 
 evidence of the chronic nature of the coryza was 
 afforded by the ill-developed condition of the bridge 
 of his nose. But there was no obstruction to breathing 
 in the nose itself. 
 
 I will give a brief outline of another case which 
 shows the connexion between this recurrent coryza 
 and spasmodic croup as well as asthma. A lady, 
 thirty years old, was subject to spasmodic croup when 
 a child, and had been liable to bronchitis all her life. 
 Since the birth of her first child, three years ago, she 
 had become asthmatic, that is to say, she was con-
 
 154 ON THE NATURE OF ASTHMA 
 
 tinually rather short of breath, but, more especially 
 soon after arising in the morning or upon any sudden 
 effort ; her breathing would sometimes become very 
 bad, she would turn blue, and the whole attack would 
 last two or three hours ; it had occasionally recurred 
 three or four times in the day. Moreover, for two 
 years she had been subject to attacks of sneezing 
 almost daily, with copious distillation from both 
 nostrils, as bad in winter as in summer. There were 
 no objective signs of disease in the chest, nasal fossae, 
 or pharynx. 
 
 It is no part of my plan to discuss the relation 
 which exists in some cases between these paroxysmal 
 disorders and permanent disease of the nasal and 
 post-nasal regions. But with regard to the actual 
 attack of coryza I will observe that it is more than 
 a mere defluxion of mucus. The mucous membrane 
 of the nasal fossae is swollen, especially the cavernous 
 tissues over the turbinate bones, which swelling may 
 be enough to make the opposite surfaces of the mucous 
 membranes touch, and to the tickling sensation which 
 ensues upon this contact much of the sneezing and 
 much, in all probability, of the distillation are due.
 
 ON THE NATURE OF ASTHMA 155 
 
 The fact that in some cases asthma very quickly 
 follows coryza suggests the notion of a rapid spread- 
 ing of the catarrhal affection downwards along the 
 respiratory tract ; what in the upper part is a 
 paroxysmal coryza becomes, in the lungs, paroxysmal 
 dyspnoea or, in other words, asthma. 
 
 4. Paroxysmal Bronchial Flux. Closely allied as 
 paroxysmal coryza and asthma undoubtedly are, 
 there is an obvious unlikeness between them in one 
 respect, namely, in the amount of mucous secretion. 
 But there is a peculiar form of what Laennec calls 
 acute pituitous catarrh of the bronchial tubes, which 
 more closely resembles recurrent coryza, in the abun- 
 dance of the flux, its short duration, and its tendency 
 to recur. 
 
 ' A woman, aged thirty-two years, corpulent and of 
 fair complexion, had suffered for some months from 
 an obstinate cough, when one evening she was attacked 
 by a complaint which very much resembled the 
 paroxysm of spasmodic asthma except that it was 
 much more violent than first attacks of that disease 
 usually are, and that its remission was attended with 
 a very copious discharge of frothy serum from the
 
 156 ON THE NATURE OF ASTHMA 
 
 bronchial tubes, which was thrown up by a slight 
 though almost continual cough/ On the next morning 
 she was much better and she soon recovered. Some 
 months afterwards she had another attack of the same 
 kind and about eighteen months after the first attack 
 she had a third, much more violent. ' She was sud- 
 denly seized with dyspnoea attended with a convulsive 
 kind of cough, which in less than five minutes from 
 the time of attack increased so as to produce the 
 appearance of suffocation. Her senses forsook her, 
 her face became livid, her extremities were cold, and 
 the action of the heart was so much diminished that 
 no pulsation could be felt in the wrist, and but very 
 little in the left side. She remained in this state 
 nearly two hours, during which time a very large 
 quantity of frothy serum tinged a little with blood 
 was discharged without any visible effort by the 
 mouth and nostrils. About the end of that time, 
 some very faint and involuntary efforts to cough 
 came on which gradually increased, and with every 
 effort large quantities of the frothy serum were thrown 
 off; perhaps the whole quantity might amount to 
 three or four pints. About three hours after the
 
 ON THE NATURE OF ASTHMA 157 
 
 beginning of the attack, the difficulty of breathing 
 became very sensibly diminished and her senses were 
 observed to return.' In a few hours she had recovered 
 so as to be much the same as she was before the seizure. 
 After a. somewhat longer time she had attained the 
 condition of a person in the best state of health. This 
 woman was a patient of Mr. Thomas Baynton of 
 Bristol and her case is narrated in a book published 
 by the well-known Dr. Thomas Beddoes of the same 
 city. You will have observed that the profuse expec- 
 toration is said to have been ' serous', but this word is 
 no doubt used in a loose sense, for Beddoes who was 
 a good chemist expressly says that the fluid was 
 ascertained by careful inquiry to be mucus, and not 
 saliva, as he at first suspected. In the lecture on 
 bronchitis I spoke of acute pituitous catarrh (page 73), 
 always a serious disease ; and Baynton's case was an 
 instance of this affection, but peculiar from its tendency 
 to recur, and in this respect closely resembling 
 paroxysmal coryza and asthma. 
 
 5. Hay Fever. In this place I might refer to the 
 fact that hay fever, which usually assumes the form 
 of coiyza and lacrimation, sometimes becomes asthma.
 
 158 ON THE NATURE OF ASTHMA 
 
 The paroxysms of hay asthma and of what we call 
 ordinary spasmodic asthma differ in no particular. 
 This topic has been so fully discussed by Sir Andrew 
 Clark that I need not allude to it here. I will only 
 repeat that the cause, whatever it be, of hay fever 
 will produce ophthalmia, coryza, or asthma according 
 to the portion of the mucous membrane which is 
 affected. 
 
 Summary. To sum up the argument in favour of 
 the opinion that asthma is (in Willis's phrase) pneu- 
 monical, as distinguished from the convulsive (or 
 spasmodic) form of the disease : the assumed bronchial 
 obstruction being due, not to any sort of spasm, but 
 to what he calls an afflux of humours upon the air- 
 passages. We have seen that there are five or six 
 affections of the respiratory tract which are akin to 
 asthma, and which may be said to constitute, together 
 with asthma, a special class of diseases, characterized 
 by fits of dyspnoea, or of mucous flux. The attacks 
 set in suddenly, they speedily reach their highest 
 point of severity, their duration is short, they are apt 
 to recur, and in the intervals the patient is more or 
 less free from signs of disease, until the catarrh be-
 
 ON THE NATURE OF ASTHMA 159 
 
 comes chronic. The tendency to the disorders is 
 hereditary and runs in families ; many patients mani- 
 fest a tendency to two or more of these complaints. 
 If the force of these analogies be admitted, we may 
 carry the argument farther and observe that all these 
 diseases are catarrhal. Now catarrh implies two 
 conditions, namely, increased secretion and swelling 
 of the membrane, but as matter of fact neither of these 
 conditions is constant. The defluxion or increased 
 secretion may be absent or at most may be very small, 
 and this constitutes Laennec's dry catarrh. The 
 swelling is more constant, at least in acute catarrh ; 
 in paroxysmal coryza, which has so close an affinity 
 with asthma, the swelling can be seen ; moreover, 
 both defluxion and swelling occur with great rapidity. 
 These two concomitants of catarrh will explain the 
 most important symptoms of all the disorders in 
 question, including asthma. 
 
 If we consider the catarrhal tendency to be due to 
 an inherent delicacy or irritability of the mucous 
 membrane, a tendency usually inherited, we seem to 
 be able to understand the reason of the fact that 
 asthmatic persons during childhood are so often liable
 
 to eczema, which may be deemed to be indicative of 
 a similar condition of the skin. 
 
 In the earlier part of this essay we arrived at the 
 conclusion that the doctrine of spasmodic asthma is 
 very imperfectly supported by facts, and now the 
 argument has led us to believe that all asthma is 
 merely a peculiar form of bronchitis, and that there 
 is no need for any hypothesis of spasm in order to 
 explain the phenomena of the disease. Should it be 
 objected that bronchial spasm may possibly aggravate 
 the effects of catarrh, we may appeal to the philosophic 
 law of parcimony, ' Entia non sunt multiplicanda 
 praeter necessitatem.' This is not a new doctrine. 
 Many years ago it was maintained very ably by Beau. 
 Sir Andrew Clark arrived at the same conclusion 
 by a different path, by noting how one and the same 
 cause, hay fever, produces sometimes coryza, sometimes 
 asthma, and sometimes both together. Which element 
 of the catarrh, defluxion, or swelling, obstructs the 
 tubes is a question which naturally arises. The inter- 
 esting observations of Lefevre, published more than 
 sixty years ago, upon the expectoration of peculiar 
 mucous cylinders, which he compared to cooked
 
 ON THE NATURE OF ASTHMA 161 
 
 vermicelli, towards the end of an asthmatic attack, 
 render it very probable that both secretion and swell- 
 ing concur, to obstruct the bronchia. But there re- 
 mains another and much deeper question which 
 concerns the asthmatic tendency, In what does it 
 consist? Why are some persons prone to asthmatic 
 catarrh and others not? Why does the disposition 
 run in families ? What is the bond which in so many 
 cases connects the several diatheses of asthma, eczema, 
 and gout?
 
 162 
 
 XI 
 
 ENLARGEMENT OP THE SPLEEN IN HERE- 
 DITARY SYPHILIS AND IN SOME OTHER 
 DISEASES OP CHILDREN 1 
 
 I. IN about one-fourth of the cases of Hereditary 
 Syphilis the spleen is much enlarged. Sometimes 
 enlargement of the liver and lymphatic glands is 
 superadded. The degree of splenic enlargement may 
 be taken as a sort of index of the severity of the 
 cachexia : the majority of cases with great enlarge- 
 ment die, but sometimes such children survive, the 
 spleen gradually diminishing in size as the health 
 improves ; not diminishing however at the same rate 
 as the health improves, but remaining for a long time 
 a monument of past cachexia. Thus the spleen can 
 often be felt enlarged in children of three years old 
 and upwards who bear the marks of past syphilis 
 
 1 Summary of a paper read before the Royal Medical and 
 Chirurgical Society on March 26, 1867.
 
 ENLARGEMENT OF THE SPLEEN 163 
 
 upon them. Sometimes an enlarged spleen is the 
 only sign of an active syphilitic cachexia. 
 
 II. In Ague also it is sometimes the discovery of 
 an enlarged spleen which first puts us upon the right 
 scent, and enables us to detect the existence of ague 
 which would otherwise be latent. 
 
 III. Children, in whom we can all but positively 
 deny the existence of syphilis or ague, occasionally 
 acquire a greatly enlarged spleen, attended with 
 a cachexia which issom times very profound. We 
 can exclude leukaemia, lymphatic anaemia [lymph- 
 denoma], rickets, purpura and primary disease of the 
 liver, in the cases referred to ; whence it is inferred, 
 that children are subject to one or more cachexiae not 
 yet defined, or else that the known cachexiae may 
 present themselves shorn of all the usual signs by 
 which they may be recognized. For the cases in 
 question, the name of Simple Splenic Cachexia is 
 proposed : a condition which seems to be analogous 
 to lymphatic anaemia. 
 
 M 2
 
 164 
 
 XII 
 TUBERCULAK PERITONITIS IN CHILDREN 
 
 THERE are three kinds of tubercular abdominal 
 disease occurring in children : chronic peritonitis, 
 decay of the mesenteric glands, and ulceration of the 
 intestines. These diseases are sometimes associated 
 in different ways, sometimes they happen each alone 
 by itself. They constitute a condition which the 
 common people call * consumption of the bowels '. 
 although this term also includes the chronic enteritis 
 which is not tubercular. 
 
 My present topic is tubercular peritonitis, or, what 
 in the case of children is almost the same thing, 
 chronic peritonitis. 
 
 I. PATHOGNOMONIC SIGNS 
 
 They are discovered by physical examination of the 
 abdomen, and are of two kinds : indurations and 
 suppurations. 
 
 1. Indurations are detected by palpation. They
 
 TUBERCULAR PERITONITIS 165 
 
 have the form of bands and patches, or of lumps and 
 knots. They certainly are present in most cases at 
 some period or other of the disease. They begin to 
 appear within a few weeks of the onset of the illness 
 or even as early as the second week. They are more 
 or less obscured by co-existing tympanites ; and for 
 this, or some other reason, they are not felt equally 
 well at all times in the same patient. The bands are 
 commonly transverse, stretching right across the belly, 
 or confined to one side of it. They are felt above the 
 navel, on a level with the navel, or below it ; for 
 instance, parallel to Poupart's ligament. They are 
 sometimes remarkably hard. They are mostly about 
 the breadth of the finger, or rather more. The patches 
 of induration, like the bands, may be met with any- 
 where. The lumps and knots are sometimes very 
 numerous, sometimes there are only one or two. 
 Their size is very different, they often feel like nuts or 
 pips. They differ very much in situation ; there is no 
 rule in these matters. The distinction (not always 
 possible) between peritoneal and glandular lumps is to 
 be found in the fact that the former are as a rule 
 more superficial, less deeply seated than the latter.
 
 166 TUBERCULAR PERITONITIS 
 
 2. Suppuration. Discharge of pus from the navel, 
 due to a local peritoneal abscess, is likewise character- 
 istic. Sometimes there is nothing more than an 
 appearance of pointing, which afterwards subsides, 
 and never goes on to discharge. The navel looks red 
 and swollen, not merely protruded, but its tissues 
 swollen : a sign which is no less characteristic. The 
 pus is sometimes mixed with faeces : a condition which 
 indicates ulceration of the intestine, and a very much 
 more dangerous affair than the discharge of pus alone. 
 
 Examination of the abdomen will often discover 
 two other morbid states, by no means pathognomonic, 
 namely, tympanites and ascites. 
 
 3. Tym^Mnites : the abdomen distended, elastic, 
 and everywhere resonant to percussion. The diagnosis 
 is not possible unless there be concurrent signs of 
 induration, suppuration, or of tubercular disease else- 
 where. 
 
 4. Asiites is less common. It sometimes supervenes 
 upon tympanites ; and this sequence of symptoms, 
 tympanites asciticus, always makes the existence of 
 tubercular peritonitis probable. Still more probable 
 or even certain is the diagnosis if the ascites be
 
 IN CHILDREN 167 
 
 associated with palpable indurations or with manifest 
 tubercular disease elsewhere. 
 
 II. ONSET OF THE DISEASE 
 
 Tubercular peritonitis is usually idiopathic, that is 
 to say, it constitutes the whole of the disease. This is 
 the only case which I consider on the present occasion. 
 I pass by the chronic peritonitis which is associated 
 with manifest tubercular disease of the lungs, intestines, 
 or other parts. 
 
 1 . The onset of protopathic tubercular peritonitis is 
 mostly gradual. The belly becomes tender, painful, 
 and big ; at the same time the health of the child fails ; 
 there are emaciation, loss of appetite, and in many cases 
 slight fever. At the beginning, examination of the ab- 
 domen discovers nothing but more or less tympanites, 
 sometimes associated with a little ascites. The tympa- 
 nites usually remains moderate, but in some children it 
 becomes excessive, so much so as to cause permanent 
 dyspnoea. The ascites of the onset is small in quantity, 
 and mostly goes away in a few weeks. Afterwards the 
 indurations which I spoke of begin to appear. 
 
 2. The onset is sometimes sudden and attended by
 
 168 TUBERCULAR PERITONITIS 
 
 severe symptoms relative to the alimentary canal : 
 for instance : 
 
 i. Vomiting and tympanites. 
 
 ii. Ileus: obstruction of the bowels. A boy, six 
 years old, was attacked by sudden pain in the belly, 
 vomiting after everything he took, complete constipa- 
 tion and pyrexia. The intestinal obstruction (doubtless 
 due to paralysis of the muscular coat) yielded in five 
 days, and was followed by great tympanites, and later 
 on by other signs of tubercular peritonitis. 
 
 iii. Acute gastro-enteritis. A girl, twelve months 
 old, came of a family in which there is a tendency to 
 tubercular disease. She was in good health until 
 March 13, when she suddenly vomited and her belly 
 swelled. Next day, the vomiting continued and 
 diarrhoea was combined with it. On the third day 
 I saw her : the vomiting and diarrhoea had ceased, 
 but they had lasted long enough to produce con- 
 siderable emaciation : her temperature was 102 : the 
 tympanites was great, nothing was palpable in the 
 abdomen, and there was a universal clear percussion 
 tone, even over the region of the liver. The stomach 
 seemed to be much distended : there was a globular
 
 IN CHILDREN 169 
 
 resonant swelling in the left hypochondrimn, reaching 
 nearly to the level of the navel. My opinion was 
 this : that the tympanites was due to the gastro- 
 enteritis, that there was no reason to suspect intro- 
 susception of the bowel, and that although peritonitis 
 was possible there was no proof of it. Afterwards 
 she improved a little until April 16, when the severe 
 vomiting recurred, this time attended, not by diarrhoea 
 but by obstinate constipation : indeed it seemed that 
 the tympanites was about to end in ileus. The 
 vomiting and constipation continued, and now the 
 signs of tubercular peritonitis became obvious : the 
 distension of the abdomen was very great : on the 
 right side, on a level with the navel, was a hard band, 
 two inches long : on the left side, something of the 
 same sort. The obstruction of the bowels gave way 
 in a day or two, and the child lingered two weeks 
 longer before she died, about two months from the 
 beginning of her illness. 
 
 III. COURSE OF THE DISEASE 
 
 Suppose the chronic peritonitis established, we shall 
 most likely be able to detect one or other of the
 
 170 TUBERCULAR PERITONITIS 
 
 pathognomonic signs which I spoke of at the beginning. 
 I will now speak of the symptoms which are attendent 
 upon the confirmed disease. Emaciation from the 
 first ; appetite bad ; vomiting now and then. Action 
 of the bowels uncertain. Diarrhoea, occasional or 
 even more continual, is no proof by itself of the co- 
 existence of intestinal ulceration. Constipation is 
 common, and it goes on in a few uncommon cases to 
 absolute obstruction of the bowels. This obstruction 
 is either temporary, giving way at length to the 
 remedies employed, or it is permanent, and causes the 
 death of the patient. Obstruction of the bowels, 
 although it may have been relieved, is apt to recur. 
 Pain in the belly is sometimes severe, and is sometimes 
 felt on heavy pressure only. The movements of the 
 bowels are sometimes visible, whether there be much 
 tympanites or not. Fever is present at first, but is 
 seldom high ; sometimes it is quotidian intermittent 
 apart from any suppuration ; sometimes a low degree 
 of fever is constant throughout the whole course of 
 the disease ; sometimes fever is absent for weeks 
 together, or even throughout the whole disease. So 
 that at the time we see our patient it may happen
 
 IN CHILDREN 171 
 
 that there are no fever or other symptoms of disease, 
 except the emaciation and the abdominal signs already 
 spoken of. 
 
 In rare cases emaciation is absent until quite the 
 end of the disease : the patient may be plump and fat, 
 and especially so over the abdomen. 
 
 The Diagnosis sometimes is impossible. A lad, 
 seventeen years old, suffered for a year from attacks of 
 vomiting frequently recurring. He was very thin : 
 his tongue was always very red : nothing could be 
 detected in the abdomen, and there were no other 
 signs of disease. He died suddenly. Examination 
 of the body discovered tubercular peritonitis, universal 
 adhesions : the rnesenteric glands not enlarged, and 
 the lungs absolutely free from any form of tubercle. 
 Examination of the bodies of persons dead from 
 pulmonary consumption not seldom discloses tuber- 
 cular peritonitis unsuspected during life. 
 
 The disease sometimes simulates typhoid fever. 
 A lad, fifteen years old, fainted at his work on April 
 18, felt pains and aching in his limbs, and took to bed. 
 On April 27, when first seen, he was febrile, the belly 
 somewhat swollen, soft and nothing palpable in it :
 
 172 TUBERCULAR PERITONITIS 
 
 he was delirious at night. The spleen became per- 
 ceptible, two rosy spots appeared, but two only ; the 
 stools were sometimes solid, sometimes like pea-soup ; 
 the fever varied between 99 and 103, with quotidian 
 remissions. On May 11, he vomited, his belly was 
 painful and tender. On May 12, the vomiting was 
 very frequent, his pulse was very small and feeble ; 
 the question of intestinal perforation arose ; but the 
 belly was not much distended. Next morning he 
 died. It was a case of tubercular peritonitis ; peri- 
 toneal adhesion universal ; a few tubercular ulcers in 
 the ileum ; not much tubercle elsewhere. 
 
 IV. TERMINATION OF THE DISEASE 
 
 1. Recovery from tubercular peritonitis is common. 
 In the course of months, or a year or two, the tym- 
 panites disappears, and the indurations cease to be 
 palpable. The patient is left pale and weak, and may 
 continue so for the rest of life. On the other hand, he 
 may regain his original state of health. 
 
 2. Deatli from tubercular peritonitis occurs in 
 several ways. A slow exhaustion is common, especi-
 
 IN CHILDREN 173 
 
 ally when other forms of tubercular disease come to 
 complicate the case. Increasing and great ascites may 
 be the cause of death. In these cases, tubercular 
 peritonitis is sometimes associated with highly marked 
 cirrhosis of the liver. Or fatal obstruction of the 
 bowels may occur. 
 
 When suppuration has occurred there is an addi- 
 tional danger. Mere pointing sometimes goes away 
 without any manifest discharge of pus from the navel 
 or any other part. When actual discharge of pus from 
 the navel has occurred recovery is still possible. But 
 when there are signs of a fistulous opening into the 
 bowel the case is hopeless. * 
 
 V. THERAPEUTICS 
 
 The first thing to mind, in the treatment of tuber- 
 cular peritonitis, is to keep the abdomen at rest. 
 This can be done only by keeping the patient in bed. 
 A boy, who was slowly recovering whilst he was in 
 bed, underwent a fatal relapse of his disease by being 
 taken up and dressed against orders. 
 
 Another part of the treatment consists in putting 
 a flannel bandage round the belly, so as to reach from
 
 174 
 
 the hips to the ribs. Much pain in the abdomen is 
 alleviated by hot and moist fomentations, as hot as 
 the patient can bear ; linseed meal poultices, flannel 
 fomentations, or, what is usually best, a flannel bag 
 full of bran or camomile flowers, which can be heated 
 in hot water or an oven as often as needful. You may 
 sprinkle the fomentation with landanum ; or you may 
 smear the abdomen with a liniment composed of equal 
 parts of extract of belladonna and glycerine. 
 
 It is needless to say much about the necessity of 
 allowing none but the most easily digestible kinds of 
 food ; in short, to feed the patient very much as you 
 would feed a baby. Cod-liver oil, if it can be taken, 
 is sure to do good. 
 
 The effusion of ascites, when recent and small in 
 quantity, often disappears by being let alone. But 
 when the effusion is abundant, and shows no signs of 
 diminishing, an incision should be made, so as to let 
 all the liquid out ; the wound being carefully stitched 
 up afterwards. The fluid is sometimes bloodstained. 
 
 An abscess should be opened and drained.
 
 175 
 
 XIII 
 
 THE SIGNS OF ACUTE PERITONEAL 
 DISEASES 1 
 
 PERITONITIS is a word strictly anatomical, and 
 relates to an affection of structure only. The structure 
 affected is known by its ancient Greek name, peri- 
 toneum : the corresponding English term, the rim, or 
 rim of the belly, has gone out of use, or is remembered 
 by being found in old books, such, for instance, as the 
 writings of those learned anatomists Robert Burton 
 and Phineas Fletcher, contemporaries of Harvey. 
 
 The peritoneal structure has functions no doubt, 
 but they are so unimportant or so obscure, that, 
 however much they be disordered or suspended, no 
 signs peculiar to the consequent disease can be dis- 
 cerned. This is the reason why the ancients, whose 
 nosology was founded almost wholly upon symptoms 
 
 1 Lecture given before the College of Physicians in 1892.
 
 176 THE SIGNS OF 
 
 or disordered functions, knew nothing about peritonitis 
 as a disease of the peritoneum. In other words, 
 peritonitis was not recognized before morbid anatomy 
 began to be studied ; nay, not until morbid anatomy 
 had been studied for many years. In Morgagni, and 
 even in Matthew Baillie, there is little or nothing 
 about peritonitis ; indeed nothing about it under that 
 name. Nor could anything be more natural than this 
 state of opinion. When the abdomen was laid open, 
 in a fatal case of peritonitis, it was not the peritoneum, 
 but the intestine, the stomach, the omentum, all highly 
 inflamed, that caught the mind's eye of these early 
 anatomists : nor did they inquire which portion of 
 those viscera was inflamed first and foremost. Hence 
 the nosologist, Sauvages, invented the terms, gastritis, 
 enteritis, mesenteritis, metritis, cystitis, to signify 
 inflammation of the respective organs as manifested 
 by changes in their outer peritoneal tunic : and from 
 1750 for many years onward, these words were much 
 used, and always in the sense indicated. Sauvages 
 invented the term peritonitis also, but he meant 
 thereby inflammation of that part alone of the peri- 
 toneum which lines the abdominal walls and covers
 
 ACUTE PERITONEAL DISEASES 177 
 
 no viscus. No wonder that the word, while this was 
 its meaning, was very seldom employed : no wonder 
 that Cullen, who, in his Nosology, gives a place to 
 peritonitis, excludes it from his First Lines, saying 
 that the disease, when existing alone, is hardly 
 to be recognized and does not require any special 
 treatment. 
 
 This state of morbid anatomy, this failure to re- 
 cognize the unity of peritonitis, faithfully reflected 
 the state of anatomy in general. The peritoneum was 
 known as being the outer tunic of the stomach, 
 intestines, and other abdominal viscera, but of peri- 
 toneum as a uniform continuous structure, as a single 
 organ, so to speak, anatomists, before the time of 
 Bichat, had little or no notion. 
 
 The study of puerperal fever led the way to more 
 modern opinions. That disease had been known for 
 many centuries, but by its symptoms only: one of the 
 best descriptions of it, written from this point of view, 
 is to be found in the works of Thomas Willis. He, in 
 all likelihood, never examined a case after death, and 
 he therefore deemed the fever to consist wholly in an 
 infection of the blood, not secondary to any local
 
 178 THE SIGNS OF 
 
 inflammation. It was not until the middle of the 
 eighteenth century that it came to be known by many 
 that the abdominal viscera, or rather their peritoneal 
 surfaces, are inflamed in most cases of puerperal fever ; 
 and from this time onward one form at least of 
 universal peritonitis was well known. But not 
 known by the name of peritonitis : that term had 
 been invented but was never employed, a fact which 
 is proved by a story which John Hunter used to tell 
 in his lectures. He said : 'A man whom I tapped at 
 the hospital died the third day, I said he died of the 
 puerperal fever. This was smiled at in the hospital, 
 and some were pleasant in remarking on the curiosity 
 of a man being delivered ; but a few months afterwards 
 another having the same fate, I convinced them, by 
 dissection, that he had died of suppuration of the 
 peritoneum, which we must admit to happen in puer- 
 peral fever.' 
 
 A great change of opinion, and a conversion to the 
 modern conception of the peritoneum, is marked by 
 the publication of Bichat's Treatise on Membranes, in 
 1800. Henceforth the peritoneum is deemed by all 
 to be not many several portions but a single whole.
 
 ACUTE PERITONEAL DISEASES 179 
 
 Discoveries are seldom made at a bound, the sunrise 
 is foretold by the daybreak ; and there were those 
 who, before Bichat, had perceived the unity of the 
 peritoneum ; I refer especially to James Douglas and 
 Johann Gottlieb Walter. Bichat was more than an 
 anatomist, he was a great morbid anatomist : he had 
 attained to modern doctrine with respect to peri- 
 tonitis also. But what his early death, a death 
 too early, suffered Bichat not to write, was written by 
 his disciple Laennec, whose Histoires d' Inflamma- 
 tions du Peritoine, published in 1803, was the first 
 essay on peritonitis conceived in the modern spirit. 
 And here I will bring my preHminary history of 
 opinion to an end. 
 
 It is not my intention to speak of the morbid 
 anatomy of peritonitis. Nor of its causes, a topic 
 which has become altogether one of microbes and 
 morbid poisons. The changes which peritonitis be- 
 gets in the living body is my theme : I do not 
 suppose that I can say much that will be new to my 
 hearers ; all that I can pretend to do is to recall to 
 their memories the facts of their own experience, and 
 
 N 2
 
 180 THE SIGNS OF 
 
 to arrange, criticize, and endeavour to explain those 
 facts. 'Ament meminisse periti.' 
 
 I. Local Signs. The chief local signs of acute 
 peritonitis are three pain, meteorism, and ileus and 
 to these I will, in the first place, direct your attention. 
 But before I proceed I may remark that, with regard 
 to the symptoms, both local and universal, of acute 
 peritonitis, it would be possible to take the term 
 ' peritonitis ' in the sense of any affection of the peri- 
 toneum. Which is all that the word signifies, strictly 
 speaking. The termination -itis is a feminine adjectival 
 suffix which has nothing to do with implying inflam- 
 mation : peritonitis means no more than peritoneal, 
 disease (nosos) being understood. The symptoms of 
 sudden inflammation of the peritoneum, of sudden 
 haemorrhage into the peritoneum, and of sudden 
 perforation of the peritoneum are essentially the same. 
 However, I have not the slightest intention of using 
 the word in any but its customary sense, and periton- 
 itis shall mean, as it always has meant, inflammation 
 of the peritoneum. 
 
 i. Pain. Broussais speaks of pain as being the 
 only pathognomonic sign of peritonitis : I think it
 
 ACUTE PERITONEAL DISEASES 181 
 
 would be nearer the truth to say that there is no 
 pathognomonic sign at all. Yet, however vague and 
 uncertain a sign of disease pain may be, it often is, 
 at the onset of peritonitis, our only guide to the 
 locality of the affection, although an untrustworthy 
 guide. The earlier physicians called the pain of 
 peritonitis ' colic ' : nor is it always easy, even in the 
 present day, to distinguish colic from peritonitis. 
 The symptoms associated with the pain do not always 
 help. In some cases of mere colic (or intestinal pain), 
 say lead colic, the abdomen is very tender to the touch, 
 and the pain is not relieved, but is even increased, by 
 firm pressure. Moreover, colic is sometimes a febrile 
 disease ; and for proof of this assertion I may again 
 refer to lead colic ; the temperature of some persons 
 suffering from that disease will rise considerably and 
 remain for days above the rule of health. The colic 
 of indigestion is sometimes indistinguishable from an 
 attack of peritonitis, until the threatening symptoms 
 pass away with a free action of the bowels. 
 
 But the most puzzling disorder of this kind which 
 I have met with is the abdominal pain which some- 
 times accompanies the menses in young women.
 
 182 THE SIGNS OF 
 
 Pain, having all the characters of colic, is common 
 enough about the menstrual period and causes no 
 difficulty. Menstruation is not seldom a febrile 
 process, and -when this is all. we know with what we 
 have to do. But when abdominal pain and fever are 
 associated, when they precede the appearance of the 
 menses by two or three days, when the patient 
 shivers once or twice, vomits, lies with her knees 
 drawn up, and when her belly becomes swollen, how 
 can we at first have any doubt that she is suffering 
 from peritonitis ? Yet no sooner do the menses occur 
 than all these symptoms disappear, and then how can 
 we any longer believe that her complaint has been 
 peritonitis ? Not only does colic simulate peritonitis, 
 but the reverse is also sometimes true, that peritonitis, 
 at the onset, cannot always be distinguished from 
 colic. This diagnostic difficulty may be met with, for 
 instance, in peritonitis due to sudden perforation of 
 a hollow viscus, especially the stomach or duodenum. 
 In such cases it often happens that the temperature of 
 the body does not rise ; and for some hours at least 
 the pain has all the characters of colic pain, and there 
 are no other signs distinctive.
 
 ACUTE PERITONEAL DISEASES 183 
 
 But it may be that in contrasting thus the pain of 
 peritonitis with the pain of colic, we are seeking for 
 a distinction where there is no real difference. Indeed 
 it is highly probable that the earlier physicians were 
 often right, and that much of the spontaneous and 
 paroxysmal pain of peritonitis is due to colic, that is 
 to say, to vermicular contractions of the intestines 
 much more powerful than usual. Surgeons tell us 
 that when they open the abdomen in order to remove 
 an ovary, the intestines are seen to be at first in very 
 active movement ; and that these movements may be 
 painful is proved by what we sometimes observe in 
 intestinal tympanites, when the peristaltic contrac- 
 tions of the bowels can be seen through the abdominal 
 walls, each contraction being attended by an unnatural 
 sensation or by actual pain. Moreover, surgeons say 
 that they can handle, cut, and scratch the stomach or 
 intestines of a man who is quite sensible, and not 
 cause in him any sensation of pain : but we cannot 
 go so far as to affirm that an inflamed peritoneum may 
 not be extremely sensitive to painful impressions. 
 
 As to tenderness upon pressure of the abdomen, is 
 it not a mistake to suppose that it is pressure upon
 
 184 THE SIGNS OF 
 
 the peritoneum alone which brings forth the pain? 
 The skin also is tender, and is sometimes tender to 
 the gentlest touch. In bygone days I have attempted 
 to shave the head of a patient suffering from acute 
 meningitis and have been compelled to desist on 
 account of exquisite tenderness of the scalp. No 
 question of pressure upon the membranes of the brain 
 can arise under such conditions. Indeed, tenderness 
 of the skin is apt to follow great pain of any under- 
 lying part. I have already remarked that simple 
 colic may be accompanied by great tenderness on 
 pressure. And I commend the consideration of these 
 facts to those who find a difficulty in believing that 
 leeches or blisters applied to the skin can possibly 
 affect a deeply seated part with which the skin has 
 no obvious connexion. 
 
 ii. Meteorisni. Leaving the topic of pain, I now 
 pass on to the other local signs of peritonitis, namely 
 meteorism and ileus. The pain is in great part 
 intestinal, meteorism and ileus are wholly such. The 
 pain is in great part due to intestinal spasm, meteorism 
 and ileus are due to intestinal paralysis. The hollow 
 viscera with muscular coats are the only viscera
 
 which are directly affected by the peritoneal inflam- 
 mation, and this affection takes the form of spasm or 
 paralysis. Patients with peritonitis are often unable 
 to pass their water ; whether from paralysis of the 
 bladder, or from inability to start the reflex act, may 
 be open to question ; the latter is probably the more 
 usual cause. But about the intestinal paralysis there 
 can be no doubt. It manifests itself in its earlier and 
 slighter degree by meteorism or acute flatulent disten- 
 sion of the bowels. I do not speak of that peritoneal 
 meteorism which is due to the escape of air into the 
 peritoneal cavity in consequence of rupture of some 
 part of the alimentary canal, but of that intestinal 
 meteorism only which is secondary to peritonitis. In- 
 testinal paralysis is no longer a matter of inference : 
 abdominal section nowadays often gives surgeons the 
 opportunity of seeing how intestines which, when first 
 exposed, were in active movement, afterwards become 
 exhausted, and lie limp and motionless. This intestinal 
 paralysis is not continual or not universal, for in 
 patients whose abdominal walls are thin, vermicular 
 movements of the intestines, either spontaneous or pro- 
 duced by handling the belly, can be seen sometimes in
 
 186 THE SIGNS OF 
 
 spite of very great ineteorism. But this is an exception 
 to the rule : usually no intestinal movements can be 
 seen, and probably none occur, or else they are too 
 weak to show themselves. So we may suppose that 
 the flatulent distension is due partly to relaxation of 
 the intestinal walls and partly to weak peristaltic 
 movement insufficient to pass the wind onwards, 
 a condition closely resembling constipation. This 
 torpid meteorism, I just remark in passing, may be 
 attended by great and constant pain ; a fact which 
 seems to show that the pain of peritonitis is due not 
 altogether to colic, or painful intestinal contractions, 
 but partly to the inflamed peritoneum itself. Another 
 proof that the intestines are not so utterly paralysed 
 as might at first seem likely, or that the large intestine 
 at any rate escapes, is afforded by the fact that 
 natural defaecation, or even diarrhoea, will accompany 
 acute peritonitis. This was so in the epidemic 
 disease which caused the death of Dr. Francis Anstie. 
 Fifty-two girls in the Royal Patriotic School at 
 Wandsworth were attacked, within one week, by 
 a disease characterized by two main symptoms, 
 namely, by lipothymia with coldness and lividity of
 
 ACUTE PERITONEAL DISEASES 187 
 
 the face and limbs, and by great pain in the belly, 
 which was tender also to the lightest touch. Four 
 children died, and dissection of the bodies revealed 
 peritonitis. One fatal case suffered from diarrhoea 
 with rice-water stools, and was examined by Dr. 
 Anstie. He pricked his finger, and died six days 
 afterwards. A remarkably similar epidemic which 
 occurred in a charity school for girls at Edinburgh, 
 called the Merchants' Hospital, is described by Aber- 
 crombie. Peritonitis, by itself, would probably always 
 be attended by the constipation of paralysed intestine : 
 and surgeons note great constipation in cases of 
 peritonitis following abdominal section. When diar- 
 rhoea concurs, modern doctrine would lead us to infer 
 the coexistence of an infection of the intestinal 
 mucous membrane, especially that of the colon. 
 
 iii. Ileus. A higher degree of intestinal paralysis 
 is marked by the state called ileus : a word which has 
 been sufficiently constant in its meaning from the 
 earliest times. It denotes disorder of an intestinal 
 function, namely of the peristaltic function, and 
 implies inability on the part of the intestine to 
 propel its contents. The kind of ileus which concerns
 
 188 THE SIGNS OF 
 
 us here is that which is due to inflammation of the 
 intestines, or enteritis. I have already remarked that 
 the term enteritis originally meant an inflammation 
 of the peritoneal coat of the bowels. It was Broussais 
 who most unwarrantably perverted the meaning of 
 the word, and who used it to signify an inflammation 
 of the mucous membrane of the intestines : one out 
 of many instances showing the degree to which cor- 
 ruption of our technical terms has been carried. They 
 who continue to use the word enteritis in its original 
 sense do no worse than follow the example of Pember- 
 ton, Abercrombie, Graves, and Watson. For those 
 who desire a name to express inflammation of the 
 intestinal mucous membrane, the terms eso-enteritis, 
 muco-enteritis, enteritis mucosa have been invented. 
 
 The sign of ileus is vomiting becoming faecal. The 
 Father of physic has well described the course of 
 events ; the matters vomited being first mucous, after- 
 wards bilious, and lastly faecal. Until the vomit 
 become faecal, or at least porraceous (meaning thereby 
 an appearance like chopped grass or spinach), it is 
 impossible to affirm the existence of ileus. The con- 
 currence of constipation is no help : and indeed, on
 
 189 
 
 the other hand, faecal vomiting may be attended by the 
 evacuation of small loose stools, resembling in colour 
 and other respects the pale, uniform, pasty intestinal 
 contents found in cases of mechanical obstruction. 
 
 iv. Incision. So that pain and the signs of intes- 
 tinal paralysis are the only evidences of acute peri- 
 tonitis. It were much to be wished that the disease 
 afforded physical signs such as are usually present 
 in chronic peritonitis. There is, however, a surgical 
 sign of the disease, a sign truly pathognomonic, which 
 we need not hesitate to elicit when a patient's life is 
 in jeopardy, and when accurate diagnosis is essential 
 to rational treatment : I refer to direct observation 
 of the state of the peritoneum as rendered possible by 
 incision through the abdominal walls. 
 
 II. Universal Symptoms. Let us now pass on to 
 consider the remote or universal effects of peritonitis, 
 i. And first of Fever. No symptom more uncertain 
 than this : the temperature being sometimes high and 
 reaching 105 or more ; usually but moderately raised ; 
 whilst in other cases there may be no fever at all, 
 so far at least as can be judged by a thermometer 
 in the mouth or axilla. This apyrexia is a remark-
 
 190 THE SIGNS OF 
 
 able symptom when present, as it sometimes is, from 
 first to last in peritonitis the most intense and fatal. 
 We are tempted to speculate upon the cause of so 
 strange a phenomenon ; whether an ordinary febrific 
 poison be not produced by the inflammation, or 
 whether an extraordinary febrifuge poison be pro- 
 duced : at present we cannot do more than note the 
 fact. Apyrexia sometimes becomes algidity ; an im- 
 portant sign of the lipothymial state, to which I shall 
 soon refer. 
 
 ii. Putridity. More certainly due to an infection 
 of the blood are the putrid or septic symptoms 
 which sometimes happen. When we bear in mind 
 what Bichat pointed out, that the peritoneal cavity 
 is a lymphatic sac with a most extensive absorbing 
 surface and an extraordinary power of absorption, 
 the wonder is that these symptoms do not occur 
 oftener. I will illustrate this form of disease by the 
 case of a young man who was running along the 
 street and got a heavy fall, which was the only dis- 
 coverable cause for the acute peritonitis that occurred 
 within forty-eight hours. Delirium and diarrhoea 
 were associated with the abdominal pain and vomiting
 
 ACUTE PERITONEAL DISEASES 191 
 
 of the first few clays. On the sixth day he complained 
 chiefly of pain in his joints : his feet and one shoulder 
 were swollen and excessively tender. The skin over 
 the feet, wrists, and ankles was red in patches. His 
 urine was highly albuminous, but no blood corpuscles 
 or casts were found in the sediment. The diarrhoea 
 continued : he lay in a state of typho-mania, that is, 
 of delirium with consciousness much impaired : he 
 had a greater tendency to chills and occasional shiver- 
 ing than is usually met with in cases of peritonitis ; 
 the temperature varied between 102 and 105 until 
 a few hours before death, which occurred on the 
 eighth day. At the post-mortem examination nothing 
 was found but peritonitis and its results ; its cause 
 was not found. 
 
 iii. Lipothymia. I will next speak of that marked 
 failure of the vital functions (that is to say, of the 
 circulation, respiration, and body-heat) which very 
 often accompanies peritonitis. It is a matter for 
 surprise and regret that we have no term in common 
 use to express this set of symptoms. No English 
 word being precise enough, I suggest that we resusci- 
 tate the Greek word, c lipothymia,' to denote defectio
 
 192 THE SIGNS OF 
 
 animae, this failure of the vital constitution ; whether 
 it be attended or not by lipopsychia, defectio animi, 
 or failure of the animal functions, marked by coma, 
 delirium, or both. Sudden lipothymia is syncope or 
 swooning ; syncope due to injury is shock. Lipo- 
 thymia is manifested by a small, weak, and sometimes 
 irregular pulse, by weakness of the heart-sounds, by 
 shallow breathing, by lividity with pallor (deathly 
 paleness), and by algidity or failure of the body- 
 heat, at least so far as the skin is concerned ; the 
 inner heat, as measured in the rectum, may or may 
 not fail to a proportionate degree. In peritonitis 
 (apart from perforation) lipothymia sometimes marks 
 the whole course of the disease (witness the Wands- 
 worth epidemic to which I referred a short time 
 since) : and when to lividity, coldness of skin, and 
 a weak small pulse, are added diarrhoea with watery 
 stools and suppression of urine, the resemblance to 
 cholera is great indeed. But more frequently lipo- 
 thymia occurs only towards the end of life ; and then 
 it may assume, as far as the body-heat is concerned, 
 the form of lipyria (another ancient word which might 
 be revived with advantage), that is to say, while the
 
 ACUTE PERITONEAL DISEASES 193 
 
 skin, especially of the limbs, is quite cold, the tempera- 
 ture of the inward parts, as measured by a thermo- 
 meter in the rectum, is much above the normal, it 
 may be 105. a very bad prognostic sign in all acute 
 diseases, and a plain proof of extreme weakness of the 
 circulation. 
 
 Another sign which sometimes attends this final 
 lipothymia, this mortal agony or struggle with death, 
 a sign which has attracted the notice of physicians 
 from the earliest times, is the disappearance of pain 
 and suffering whilst the patient remains perfectly 
 conscious : yet all the symptoms of vital failure 
 persist; and he only, whose attention is fixed upon 
 the local signs to the neglect of the prognostic con- 
 dition of the whole patient, can be surprised by what 
 will seem to him to be a sudden and unexpected 
 death. It were curious to inquire into the causes of 
 this cessation of pain, whether it be due to cessation 
 of cramp, whether an anodyne poison be produced in 
 the course of the disease, whether the lipothymia 
 arrest the nutrition of the nerve-endings, or whether 
 the sensorium for pain be similarly affected. 
 
 Still more remarkable, although much less common,
 
 194 THE SIGNS OF 
 
 is the case of peritonitis attacking a healthy person, 
 lipothymia supervening in the course of a few hours 
 from the beginning, and any local signs of abdominal 
 disease disappearing at the same time. The patient, 
 when first seen, makes little or no complaint of the 
 abdomen, it is not swollen and can be pressed deeply 
 without causing pain. But the skin is cold, the 
 heart beats very frequently, no pulse can be felt at 
 the wrist, the respirations are very frequent, the 
 secretion of urine is suppressed. The mind is affected 
 little or much. The patient dies on the first or 
 second day of illness : at the post-mortem examina- 
 tion, acute peritonitis is found, but not necessarily 
 perforation of the peritoneum, or disease of any other 
 abdominal structure. 
 
 Fades. The last sign of acute peritonitis which 
 I shall notice is that afforded by the look and expres- 
 sion of the face. These signs and such as these, 
 which constitute the prognostics so much trusted by 
 the earlier physicians, can be learnt in no other way 
 than by a long familiarity with disease. If I allude 
 to the countenance which still goes by the name of 
 t'acies Hippocratica, it is only to remark that Laennec
 
 ACUTE PERITONEAL DISEASES 195 
 
 has endeavoured to walk in the footsteps of his great 
 predecessor, and to depict an expression of face often 
 seen in peritonitis and other severe abdominal diseases. 
 This peculiar look, which he calls 'face grippeV, is 
 due chiefly, if not wholly, to the features being drawn 
 upwards, so that the forehead is more or less wrinkled, 
 and the naso-labial furrows are drawn inwards and 
 upwards towards the root of the nose and inner 
 canthi of the eyes. I have compared Laennec's verbal 
 picture with the living patient, and have found it to 
 be true to nature : but not universally true, not 
 present in every case of acute peritonitis. Indeed 
 I think that the face grippee denotes abdominal pain, 
 and that it usually disappears with the pain, although 
 the disease continue. But we must admit that the 
 local suffering and local signs of disease may be very 
 small, and yet the onset of peritonitis be denoted by 
 a profound change in the expression of the patient's 
 features. Surgeons remark this change when an 
 operation is followed by peritonitis : physicians also 
 when a perforation occurs in the course of typhoid 
 fever. 
 
 Latent Peritonitis. Now a few words concerning 
 O 2
 
 196 THE SIGNS OF 
 
 latent peritonitis. I have already spoken of peri- 
 tonitis which is latent in respect of its local signs 
 only ; peritonitis in which universal signs of disease, 
 those namely, of alarming lipothymia, predominate to 
 the exclusion of abdominal symptoms : the patient 
 being killed in a day or two as if by the operation of 
 a powerful venom. But peritonitis may be altogether 
 latent, and manifested neither by local nor by universal 
 symptoms: a form which is deuteropathic, intercurrent 
 in the course of other serious disease such as ascites, 
 renal dropsy, empyema. pyaemia, or typhoid fever; 
 the peritoneal inflammation being revealed by the post- 
 mortem examination only. What surprise we may 
 feel at this latency diminishes when we reflect that 
 the signs of peritonitis have little or no relation to the 
 peritoneum, but depend upon disorder of other viscera, 
 adjacent or remote. Suppose the onset to be marked 
 by vomiting : what is there distinctive in this : in 
 what disease does vomiting not occur : is not the 
 stomach the great sympathizer with distress in any 
 part of the body ? Add some pain in the belly and 
 how does this help us ? Possessing no direct physical 
 signs of peritonitis, and being compelled to rely upon
 
 ACUTE PERITONEAL DISEASES 197 
 
 indirect disturbance of the functions of other viscera 
 (for the peritoneum itself has no manifest functions), 
 we cannot expect to discover the presence of peritonitis 
 in cases such as these. 
 
 Types. After analysing the symptoms of peritonitis 
 I might endeavour to arrange them so as to form 
 concrete pictures of patients suffering from that 
 disease : but I will say no more than this, that 
 according as one or other symptom prevails so does 
 the appearance of cases of peritonitis differ ; and the 
 differences are so great that we have to admit divers 
 forms or types of the disease. We cannot manage 
 with fewer types than three, namely, peritonitis 
 characterized by pain, or by ileus, or by lipothymia : 
 for peritonitis discovered only after death cannot be 
 admitted to be a form of disease as looked at from my 
 present point of view. A given case of peritonitis is 
 by no means necessarily constant to one type through- 
 out : for instance, painful peritonitis may pass into 
 ileus : and moreover the local and universal symptoms 
 may be variously mixed. But the only reason I have 
 for referring to facts so obvious is to be assisted by 
 these types in comparing the signs of acute peri-
 
 198 THE SIGNS OF 
 
 tonitis with the signs of other peritoneal affections : 
 which I will now proceed to do. 
 
 i. Chronic Peritonitis. Peritonitis which is essenti- 
 ally chronic in its course, sometimes sets in suddenly, 
 and thus resembles at first the acute disease. This is 
 often observed in the commonest kind of chronic 
 peritonitis, the tubercular : when, as I suppose, a 
 sudden infection of the peritoneum takes place. The 
 forms assumed by this acute onset of tubercular peri- 
 tonitis are the same as those I have just discussed. 
 That most often met with begins with pain, vomiting, 
 and sometimes diarrhoea, and is followed in a few 
 days by meteorism which may become very great. 
 Lipothymia in a high degree may attend the choleric 
 symptoms. The least common type, which assumes 
 the form of ileus, deserves especial notice on account 
 of its close resemblance to mechanical obstruction of 
 the bowels : a resemblance so close that abdominal 
 section has been performed in such a case under the 
 notion that the patient was suffering from a strangu- 
 lated hernia (see p. 168). 
 
 ii. Haemorrhage into the peritoneal sac is another 
 form of peritoneal disease in which we meet with the
 
 ACUTE PERITONEAL DISEASES 199 
 
 same types. The painful form is well illustrated by 
 the_case of ' a woman, twenty-nine years old, who was 
 brought to the hospital in a most alarming condition, 
 although her illness had not lasted longer than a few 
 hours. She had been suddenly attacked by great 
 pain in the lower belly, and the pain had steadily 
 increased. She had the face grippee and was deadly 
 wan : her breathing short and frequent, interrupted by 
 hiccup, her pulse hurried and very weak, her belly 
 distended and tender. She died within forty-eight 
 hours from the beginning : at the post-mortem exami- 
 nation, there were found in the peritoneal cavity 
 nearly three pints of liquid blood which had come 
 from one of the Fallopian tubes : no peritonitis.' 
 How peritoneal haemorrhage may be attended by 
 ileus is shown by the case of a man, twenty-two years 
 old, who was admitted into St. Bartholomew's Hos- 
 pital in an extreme state of shock, following a fall off 
 the tail-board of a van in motion. He complained of 
 great pain at the pit of the stomach, and soon after 
 the injury he began to vomit incessantly. On the 
 second day the vomiting continued to be very frequent: 
 he had a great desire to defaecate, but passed nothing:
 
 200 THE SIGNS OF 
 
 his belly was very hard and tender : the urine was 
 suppressed : his temperature was 99-6. On the third 
 day he was worse : abdominal section was performed : 
 the peritoneum was found to be full of dark liquid 
 blood, and nothing more was discovered. On the 
 fourth day he died : the blood came from a rent liver, 
 iii. Perforation of the Peritoneum,, A much more 
 common acute affection of the peritoneum is that 
 which I mention in the last place, namely, perforation 
 or rupture of the wall of a canal or cavity or hollow 
 viscus, and escape of its irritant contents into the 
 peritoneal sac. When we seek to classify cases of 
 this kind, we come upon the three or four types of 
 which I have already so often spoken : the type 
 characterized by pain, or by ileus, or by shock, and 
 the latent type. But before depicting them, let us 
 ask whether peritoneal perforation yield any peculiar 
 signs ? None ; unless peritoneal tympanites ensue : 
 and this depends, of course, upon the perforated 
 cavity, whether it contain air or not. In the case of 
 peritoneal tympanites, physical examination usually 
 affords more or less probability of the presence of air 
 in the peritoneal sac, but seldom an absolute certainty.
 
 ACUTE PERITONEAL DISEASES 201 
 
 The distension of the belly is often very great, and 
 greater in perforation of the intestine than of the 
 stomach : when the distension is very great, the skin 
 is tense and shining to a degree seldom seen in in- 
 testinal tympanites. Visible coils of intestine or 
 vermicular movements are decisive evidence of in- 
 testinal tympanites. Absence of the liver dullness 
 to percussion is a useful, but not altogether a trust- 
 worthy, sign of peritoneal tympanites : for, when the 
 intestines are extremely distended with air, they may 
 come to lie between the liver and abdominal wall in 
 front, and I have known this to happen even when 
 the liver was enlarged to twice its natural size. On 
 the other hand, adhesion of the liver's convex surface 
 will obviously prevent the disappearance of its per- 
 cussion dullness, even though the peritoneal cavity be 
 full of air. The signs afforded by auscultation are less 
 important, because they are common to all great 
 accumulations of air within the abdomen, whether 
 contained in stomach or intestines, or free in the 
 peritoneal cavity. The chief sign is the bell-sound 
 discovered by Laennec. In his Auscultation Mediate 
 he says that by percussing lightly and at the same
 
 20.2 THE SIGNS OF 
 
 time applying the stethoscope near by, we shall hear 
 a silvery resonance: clearer, he thinks, in peritoneal 
 than in intestinal tympanites. I cannot do more than 
 just mention the other auscultatory signs of a large 
 air-containing cavity, and which are sometimes 
 present in peritoneal tympanites, namely, an amphoric 
 quality in the respiratory sounds heard over the 
 abdomen, metallic tinkle, and succession splash. A 
 valuable sign is yielded sometimes by an escape of 
 air into the cellular membrane of the abdominal walls: 
 this fact also is alluded to by Laennec (' a sort of dry 
 crackling is felt upon pressure ' he says), and is, taken 
 together with the signs aforesaid, peculiar to peritoneal 
 tympanites as contrasted with the intestinal. Or the 
 subcutaneous emphysema may be still more extensive. 
 To conclude this topic of physical signs I will remark 
 that, although their presence is a great help to 
 diagnosis, their absence proves nothing. Perforation 
 of a part of the alimentary canal (for instance the 
 appendix vermiform is) may occur, may be followed by 
 acutest peritonitis, and yet may be unaccompanied 
 by peritoneal tympanites : nothing escapes from the 
 rupture but offensive and poisonous pus.
 
 ACUTE PERITONEAL DISEASES 203 
 
 With respect to the symptoms of peritoneal per- 
 foration, all cases may be referred to the four types so 
 often spoken of, those characterized by pain, or by 
 ileus, or by shock, and those not characterized at all, 
 the disease being latent ; latent, that is to say, so far 
 as concerns the diagnosis. 
 
 a. First, of perforation characterized chiefly by 
 Pain. A lady had ailed for some time from pain in 
 the stomach and the side, but she seemed to be other- 
 wise in good health. One day after dinner, she 
 complained several times of pain : she drank some 
 succory water as a stomachic, and putting the cup 
 down with one hand, with the other pressed her side, 
 and said in a voice which betokened much suffering : 
 ' Ha ! what a stitch in the side ; what pain ; I cannot 
 bear it.' Speaking these words she flushed, and, 
 a moment afterwards, turned pale with a wan lividity 
 which alarmed everybody. She kept crying out, and 
 begged to be carried away, for she could no longer 
 hold up. Supported by the arms of others, she 
 managed to walk, but with difficulty and bent double. 
 Put to bed, she cried out more than ever that the pain 
 in the pit of her stomach was past belief : she tossed
 
 204 THE SIGNS OF 
 
 from side to side. A physician was fetched who pro- 
 nounced her complaint to be colic, and who prescribed 
 suitable remedies. But the pain continued ; she said 
 that her suffering was greater than could be conceived, 
 and that she would die. All this occurred in less 
 than half an hour. Whatever she swallowed made 
 her retch : she brought up only a little mucus mixed 
 with food. The efforts to vomit and the excessive 
 pain threw her into a state of exhaustion which 
 resembled repose : but she told the bystanders not to 
 deceive themselves, that the pain was as great as ever, 
 and that she had no strength left to cry out. She heard 
 some one remark that she was easier, and she said : 
 ' That is so far from being true that were I not 
 a Christian I would kill myself, so great are my 
 sufferings : it is wrong to wish evil to any,' she added, 
 ' yet I would that somebody could feel for a moment 
 what I feel, so as to know what my pain is like.' 
 Her pulse became imperceptible, her limbs cold : her 
 friends anxiously asked if nothing more could be 
 done ; they suggested a score of remedies, and at last, 
 her physicians, in sheer desperation, made an attempt 
 to bleed her, but the blood would not flow. They
 
 ACUTE PERITONEAL DISEASES 205 
 
 gave her some broth, for she had taken no food since 
 dinner : she no sooner swallowed it than her sufferings 
 (if not her pain) increased : she complained that her 
 stomach was filling up : death was depicted on her 
 face : the last struggle was short, and after two or 
 three convulsive movements about her mouth, she 
 died nine hours from the beginning of her illness. 
 
 Would you not suppose that I have set before you 
 a living picture in words, taken from the pages of 
 a modern Aretaeus or of Sir Thomas Watson ; or 
 have you already recognized that I have been reading 
 an account of the last hours of King Charles the 
 First's daughter, Henrietta, Duchess of Orleans 1 An 
 account written by one of her ladies in waiting, 
 Madame de la Fayette, a hundred and fifty years 
 before ulcer of the stomach was discovered, so we 
 may say, by Cruveilhier. That the patient died from 
 perforation of such an ulcer was proved by examina- 
 tion post mortem, although her physicians did not 
 understand what they saw, and it was left for Littrd 
 to explain the real nature of her illness. I have 
 always thought that reports of the kind just read, 
 drawn up at the bedside by persons of keen intelli-
 
 206 THE SIGNS OF 
 
 gence but with no medical knowledge, are of great 
 value. Such reports are true to nature, for the 
 reporters have no preconceived notions which dis- 
 colour and distort the appearances of things. More- 
 over these observers see the sufferer and nothing else : 
 but we physicians, on the other hand, in our eagerness 
 to discover abstract signs of disease, and to arrange 
 them into that wholly artificial notion which we 
 call the diagnosis, are apt to overlook the patient. 
 
 The physicians of Madame said that she was suffer- 
 ing from colic, and that a wretched pulse and cold 
 limbs, such as hers, were common in that disease. 
 I likewise have stood by a patient writhing under 
 the throes consequent upon perforation of stomach or 
 duodenum, and have asked myself whether there was 
 anything either in the pain or its concomitants which 
 might not occur in intestinal colic, and have been 
 compelled to admit that there was nothing. This 
 difficulty in diagnosis is not to be wondered at if the 
 pain be, as is very likely, in great part due to cramp 
 or painful spasm of the intestines and stomach, and 
 perhaps of the abdominal walls also. 
 
 Yet our diagnosis may reach a high degree of
 
 ACUTE PERITONEAL DISEASES 207 
 
 probability under such conditions as these : the 
 ruptured organ being more often either stomach or 
 duodenum than any other, there may have been some 
 forewarning symptoms of ulcer of one of those parts : 
 the perforation occurring suddenly, so does the pain, 
 and especially after a full meal or an effort or both. 
 The very acid contents of the stomach or upper half 
 of the duodenum poured into the peritoneal cavity are 
 excessively irritant, and the pain is violent in propor- 
 tion, being far beyond the pain whereof the sufferer 
 has had any experience or conception. The abdominal 
 walls are contracted, tight, and hard, and often very 
 tender. The pain will continue without remission to 
 the end, or will cease altogether, or will only diminish ; 
 as I said when speaking of acute peritonitis. 
 
 The associated symptoms may or may not assist 
 the diagnosis. Vomiting, often present, is sometimes 
 absent : some have thought that it is absent in 
 perforation of the stomach especially, but the excep- 
 tions to this rule, if it be a rule, are many and of both 
 kinds, namely, rupture of stomach attended by 
 vomiting, and rupture of a part not stomach yet 
 unattended by vomiting. Peritoneal tympanites will
 
 208 THE SIGNS OF 
 
 ensue if gas escape into the abdominal cavity ; but 
 gas does not always escape even when some part of 
 the alimentary canal is ruptured. Shock attends the 
 rupture, and usually the lipothymia persists to the 
 end. When perforation occurs in the course of a 
 febrile disease, defervescence is often a marked sign 
 of shock. Suppression of the secretion of urine is 
 common and seems to be sufficiently explained by the 
 vomiting and the lipothymia, and their necessary 
 consequences, defective absorption and secretion. 
 
 ft. The second kind of perforation, that characterized 
 by Ileus, is less common, and occurs especially in 
 disease of the appendix vermiformis. The discharge 
 of virulent offensive matter into the peritoneal sac 
 seems to stun the intestines, they neither feel nor 
 move. A woman, aged twenty-two years, was ad- 
 mitted into St. Bartholomew's Hospital on March 8. 
 She had taken, on the 5th, jalap and castor oil to 
 relieve her habitual constipation : the bowels acted 
 soon afterwards three times. Otherwise she was, so 
 she and her friends averred, in perfect health, and 
 quite free from pain or indications of disease in the 
 abdomen or elsewhere. Her menses, due on the 5th.
 
 ACUTE PERITONEAL DISEASES 209 
 
 did not appear. On the 6th vomiting began, and it 
 continued at intervals up to the time of admission. 
 The bowels had not acted. She was admitted on the 
 evening of the 8th, and one of my surgical colleagues, 
 who happened to be at the hospital at the time, came 
 straight to my house and told me that a woman with 
 obstruction of the bowels had just been sent in to be 
 under my care, and he thought that the question of 
 operation arose. We went to see her, and we found 
 a woman with no look of suffering, with a warm skin, 
 a temperature of 99-2 in the armpit, and with no 
 symptoms of failure of the vital functions, unless 
 indicated by a pulse of 144, which was however by 
 no means weak or small. The abdomen was fat and 
 moderately distended, the muscles were tight, but 
 there was no tenderness excepting about the right 
 loin : the right iliac fossa was carefully examined, 
 but nothing could be felt. Examinations per vaginam, 
 per anum, and for hernia detected nothing wrong. 
 An enema had brought away faeces. She vomited 
 dark green liquid without smell. The urine was 
 scanty, it contained a trace of albumen, was turbid 
 with scaly epithelium and highly granular cylinders
 
 210 THE SIGNS OF 
 
 like renal tube casts, but there were no exudation 
 corpuscles. The abdomen was opened : thin purulent 
 liquid escaped, the small intestines were distended 
 and purplish brown in colour. Examining the 
 appendix vermiformis, we found a sloughy hole at its 
 insertion into the caecum : the rest of the appendix 
 much dilated, its lining membrane ulcerated and 
 granular throughout, the outer surface covered with 
 lymph. She died two or three hours after the 
 operation. Nowhere any anatomical obstruction of 
 the bowels. 
 
 Between this form of disease and painful febrile 
 peritonitis there are all possible varieties in respect of 
 association of symptoms : the ileus being attended by 
 more or less pain, tenderness and fever. Peritoneal 
 tympanites is often absent : any distension of the 
 abdomen being due to acutest peritonitis, to intestinal 
 tympanites and inflammatory liquid effusion. 
 
 y. The third kind of perforation is characterized by 
 Shock. In some cases, particularly in rupture of the 
 stomach or duodenum, the shock kills within a few 
 hours ; and may be justly compared to the effect of 
 a blow upon the pit of the stomach : though why the
 
 ACUTE PERITONEAL DISEASES 211 
 
 shock of abdominal injury should be so especially 
 profound, I will not undertake to explain. In other 
 cases the patient lives a day or two, yet never rallies. 
 A man, forty years of age, who was under treatment 
 for a chronic ulcer of the stomach, became suddenly, 
 at eight o'clock one morning, pale, pulseless and 
 delirious (see page 192) ; he had evidently undergone 
 a great shock. Throughout the day he continued to 
 be delirious, consciousness never fully returned. Con- 
 siderable reaction took place, his skin became hot, 
 his pulse full and frequent ; he retched a little but 
 did not vomit. The same night he became comatose, 
 and so died at eight o'clock next morning. I regret 
 being unable to say whether the urine was suppressed 
 or not. On examining the body, the ulcer was found 
 to involve the pylorus, and to have perforated on the 
 duodenal side thereof. The contents of the stomach 
 were in the peritoneal cavity : but there were no 
 signs of peritonitis, neither excessive vascular! ty nor 
 exudation of lymph. 
 
 8. Lastly, the perforation may be Latent : that is 
 to say, unattended by any symptoms adequate to the 
 diagnosis. Not that symptoms are utterly wanting ; 
 
 p 2
 
 212 THE SIGNS OF 
 
 this is seldom the case ; there are more or fewer of 
 those so often mentioned, pain, vomiting, lipothymia, 
 and the rest, but they are rendered obscure by occur- 
 ring in the course of a disease marked by no less 
 serious disorders. The contrast between a person 
 when in good health and when suffering from per- 
 foration of the peritoneum is great indeed : but when 
 a patient has been exhausted by four or five weeks 
 of severe typhoid fever, the occurrence of perforation 
 may be a comparative trifle, so far as symptoms are 
 concerned : a little pain in the belly, a little vomiting 
 attracts no attention. Or there may be no pain, no 
 tenderness, no vomiting, nothing but a sudden defer- 
 vescence. Or again, a change in the patient's look is 
 
 i 
 
 sometimes the chief sign. During a state of typho- 
 mania, in particular, the gravest intercurrent lesions 
 often happen unsuspected. 
 
 But perforation, latent so far as symptoms are con- 
 cerned, will sometimes yield one or more of the 
 physical signs of peritoneal tympanites. For instance, 
 in the later stage of typhoid fever, a rapid and great 
 distension of the belly, such as to stretch the skin and 
 make it shine, and attended by disappearance of the
 
 ACUTE PERITONEAL DISEASES 213 
 
 liver dullness to percussion, is a tolerably trustworthy 
 token of intestinal perforation, and is sometimes the 
 only token. The liver dullness may disappear before 
 the abdomen becomes distended. 
 
 Incision for the purpose of diagnosis. To conclude 
 by referring once more to puncture of the peritoneum 
 as a means for ascertaining the presence of inflam- 
 matory effusion, of gas, or of chyme. An incision is 
 justified whenever the patient affords more or less 
 trustworthy indications of acute peritonitis, and when- 
 ever there are reasons for believing that perforation 
 of the peritoneum has occurred. In either case, 
 unless we can bring relief, the patient will probably 
 die. An incision will not make him worse ; the only 
 objection lies in the natural dislike to an operation, 
 however small. I wish I could believe that chloro- 
 form-sleep did no harm, but I fear that this drug has 
 a depressing effect upon persons suffering from acute 
 peritonitis. However, suppose a small incision made, 
 and we find that the peritoneum contains pus, 
 or air, or chyme, or blood, further operation now 
 becomes a means of treatment which affords the 
 patient the only chance of life.
 
 214 
 
 XIV 
 
 SECTS IN MEDICINE 
 
 THE subject of my address is ' Sects in Medicine '. 
 I shall endeavour to make the following propositions 
 clear unto you : That inasmuch as medicine is a part 
 of philosophy, the sects in both are essentially the 
 same. That these sects depend upon the original 
 constitution of the human understanding, upon its 
 native powers and weaknesses. And that inasmuch 
 as the powers of the human understanding seem to be 
 precisely the same now as they were when philosophy 
 began, we may expect and we shall find that the sects 
 are essentially the same in our time as they were 
 in the early days of medicine. 
 
 The existence of sects implies differences of opinion, 
 and differences of opinion imply imperfection of know- 
 ledge. There are no differences of opinion concerning
 
 SECTS IN PHILOSOPHY 215 
 
 Euclid's propositions, the truth of his definitions and 
 axioms being granted. Where knowledge is most 
 imperfect, there are sects most numerous. 
 
 I said just now that medicine is a part of philo- 
 sophy, and philosophy is full of sects, which are not 
 even agreed upon the meaning of the word philosophy. 
 The Stoics meant thereby the whole of knowledge ; 
 they divided it into six partitions : physics and 
 theology, logic and rhetoric, ethics and politics. This 
 is the sense in which Francis Bacon uses the word. 
 But the great English school which is represented by 
 Lord Herbert, Hobbes, Locke, Berkeley, and Hume, 
 defines philosophy to be the theory of knowledge ; in 
 other words, philosophy explains wherein knowledge 
 consists, explores the conditions of knowledge, and 
 thus refers chiefly to man himself. A third school, 
 which is represented by the Eleatics among the 
 ancients, and by Spinoza among the moderns, deems 
 philosophy to be ' the search for reality and unity, the 
 effort of thought to gain a point of view from which 
 the contrasts expressed by the terms One and Manj^, 
 Universal and Particular, Infinite and Finite, God 
 and Nature, shall be reconciled and harmonized ' ;
 
 216 SECTS IN MEDICINE 
 
 that is to say, philosophy is the theory of the cosmos, 
 the universe. 
 
 Man is a part of nature, therefore the knowledge 
 of man is a part of the knowledge which the Greeks 
 called physical (or natural) philosophy. I stop for 
 a moment to point out that this is the reason why we 
 are called physicians, for the knowledge of the human 
 body is the most useful part of physics. Again, man 
 is the most complex, most abstruse, and least under- 
 stood part of nature. No wonder then that the science 
 of man is overrun by opinions, by sects, by heresies, 
 far more than infest any other part of natural philo- 
 sophy. The same remark holds true of medicine, 
 as being part of the science of man. 
 
 To speak now of medicine in particular, I say that 
 it necessarily partakes of the diverse opinions which 
 inhere in philosophy. Now, the primary and funda- 
 mental philosophic sects are two, the Dogmatic and 
 the Sceptic. Dogmatists affirm that we can and do 
 know ; sceptics neither affirm nor deny. Observe, 
 sceptics do not deny, else they would be dogmatists ; 
 a strict sceptic cannot even affirm that he neither 
 affirms nor denies ; he cannot go beyond the question,
 
 PRIMARY SECTS 217 
 
 ' What know I ? ' But practically sceptics are deniers, 
 and systematic scepticism (such as that of Sextus 
 Empiricus) is full of dogmatism. In short, there are 
 no absolute dogmatists or sceptics, and the truest way 
 of putting the matter is to say that dogmatists tend 
 towards affirmation, and sceptics towards doubt. 
 
 These two sects exist and always have existed in 
 medicine. Every man is born with a natural bend 
 towards one or the other. A very little thinking will 
 convince you that dogmatism may assume an infinite 
 number of forms, whereas strict scepticism can assume 
 only one form, so that all that I have to say will 
 relate to different kinds and degrees of dogmatism. 
 
 Moreover, I have already hinted that I shall base 
 my remarks upon the medical sects which existed in 
 the ancient world. For the powers and limits of 
 human thought remain exactly what they were in 
 the time of Thales, and nature mocks, nay she 
 punishes, any effort to transcend them. The ancient 
 sects exhaust all possible fundamental differences of 
 opinion, and inasmuch as the story of the ancient 
 world is completed and we can survey it from afar, 
 we can comprehend it better than the world in which
 
 218 SECTS IN MEDICINE 
 
 we live. These ancient sects are reproduced in modern 
 times. My object is to illustrate the sects of our own 
 day, and I shall refer to ancient sects for this purpose 
 only. 
 
 I say that all sects are dogmatical, generally speak- 
 ing, but one sect was called especially Dogmatic ; the 
 other sects had other names. I will speak of the 
 species Dogmatism in the first place. The Dogmatist 
 seeks to understand what disease is ; he compiles 
 systems of medicine, in which he sets forth the aetio- 
 logy, anatomy, and physiology of diseases, in order 
 that from these pathological data he may deduce indi- 
 cations for treatment. In other words, his practice of 
 medicine is reasoned from his theory of disease ; he 
 aims at a rational therapeutics. To translate the 
 words of Celsus, ' They who profess rational medicine 
 hold it to be necessary that we should know, first, the 
 hidden yet essential causes of disease ; next, the causes 
 which are manifest ; after these the natural actions 
 (of the body, to wit, human physiology) ; and lastly, 
 the internal parts (or anatomy).' Did you ask me to 
 give an instance of this form of dogmatism, I could 
 call to mind no more recent name than that of Boer-
 
 DOGMATISM 219 
 
 haave, one of the most successful teachers that ever 
 lived. From him proceeded not only Gaubius and 
 the succeeding lights of the Leyden school, but also 
 van Swieten, De Haen and the great Vienna school, 
 and above all, Haller. No doubt his personal appear- 
 ance, his jovial temper, and his eloquence did much, 
 but the main element of his success lay in the fact 
 that he had a system. Students were not repelled by 
 a sceptic standing at the very door, but all things 
 seemed clear and easy. His pupils' interest and 
 attention were roused, and what more was needed "? 
 Even if the system were wrong, what matter? It 
 served as an excellent cement of facts for the common 
 class of men, whilst the Hallers were able, if they 
 cared, to invent systems of their own. So far as 
 I know, nobody has propounded a comprehensive 
 dogmatic system for many years past. The reason 
 seems to be that such a system requires the science 
 systematized to be at a standstill, not to say dead. 
 Knowledge in a ferment, expanding on all sides so 
 much and so rapidly as during the past hundred years, 
 must speedily burst the old bottle of any dogmatic 
 system.
 
 220 SECTS IN MEDICINE 
 
 But another species of dogmatism, a form which 
 is called Methodism, is far from being extinct. This 
 sect is a revolt against the infinite multiplicity of the 
 dogmatism which I have already discussed, and seeks 
 for some simple principle which underlies all these 
 innumerable particulars, and from which they may 
 be deduced. Methodists are those dogmatists who 
 strive to make the data of pathology and therapeutics 
 as few as possible in number, and as universal as 
 possible in extent. The dogmatist builds his sj^stem 
 upon the greatest possible number of particulars ; the 
 methodist erects his inverted pyramid upon a single 
 proposition. The reason of methodism lies in the 
 weakness of the human mind, impatient of slow pro- 
 gress towards a goal which recedes as we go on, and 
 wishing to find a royal road by which the end may 
 be attained without passing through the necessary 
 intermediate stages. 
 
 There have been methodists in medicine from the 
 earliest times. One of the most ancient medical books 
 which we possess is directed against a methodical 
 sect. I refer to the Hippocratic treatise On Ancient 
 Medicine, written about 400 years before Christ.
 
 METHODISM 221 
 
 ' They who, having undertaken to speak or write 
 upon medicine, have first laid down a hypothesis 
 for themselves, are clearly mistaken in much that 
 they say ' : so opens this venerable document. The 
 author then goes on to affirm that in medicine there is 
 no need for any hypothesis, inasmuch as medical 
 knowledge is gained by observation of particular 
 matters of fact. He proceeds to illustrate this doc- 
 trine, and then attacks the hypothesis from which some 
 methodists of his day sought to deduce the science of 
 medicine. This hypothesis is no other than the ancient 
 dogma 
 
 That hot, cold, moist and dry, four Champions fierce, 
 Strive here for Maistrie, and to Battel bring 
 Thir embryon Atoms. 
 
 ' For hot or cold, or moist or dry is that which 
 becomes injurious to man, and he who would treat 
 a sick person properly must apply cold to the hot, hot 
 to the cold, moist to the dry, and dry to the moist.' 
 Well may the Hippocratic writer say that ' he cannot 
 think in what manner those who advance this doc- 
 trine, and transfer the art from experience to hypothesis, 
 will cure men according to the principle which they
 
 222 SECTS IN MEDICINE 
 
 have laid down '. But alas ! my friends, this severe 
 critic of hypotheses has a hypothesis of his own, else 
 he would be hardly human. He rejects the dogma of 
 the four primary qualities, and sets up in its place the 
 dogma of humours. The famous humoral pathology 
 appears here in its earliest form. ' All the complaints 
 to which man is subject arise from the powers,' which 
 he explains to be ' intense and strong juices '. He does 
 not enumerate these juices, but his hypothesis soon 
 assumed the form under which the humoral pathology 
 governed the world for so many years, and indeed we 
 may say still governs it. When a man is called san- 
 guine, melancholy, or phlegmatic ; when a patient 
 complains of a bilious headache ; when we speak of 
 being in a good humour or a bad humour, we use 
 terms which are a survival of the undying humoral 
 pathology. 
 
 Celsus tells us that the name of Methodist was 
 first given to a sect which was founded by Themison 
 about a hundred years before Christ. But I have DO 
 intention of recalling the doctrines of that sect, nor 
 those of the many methodic sects which have arisen 
 in more modern times, have shone brightly for a time,
 
 HOMOEOPATHY 223 
 
 and have set for ever. I will illustrate methodism 
 bv the greatest living instance thereof, Homoeopathy. 
 But I think that it has not yet lived long enough 
 to enable us to discuss its doctrines in a spirit of 
 impartial historical criticism. Time is the final critic 
 in such matters. 
 
 The violent opposition which homoeopathy aroused 
 when first promulgated can be easily understood. In 
 the first place it broke utterly with medical tradition, 
 and attempted a revolution in our department of 
 knowledge like that which the French had just 
 attempted in politics. Homoeopathy thus became 
 what is worse than a sect, a schism ; we may differ 
 from our fellow men, we need not quarrel with them. 
 Again, homoeopathy was burdened with an article of 
 faith which seemed to be contradicted by the common 
 sense, or common prejudice, of mankind. I allude 
 to the doctrine of infinitesimal doses. To believe 
 that a millionth part of a grain of charcoal or flint 
 could possibly have any effect for good or for evil 
 upon the human body, would seem to require a con- 
 stitution of mind like his who exclaimed ' I know a 
 thing to be sure and certain because it is impossible '.
 
 224 SECTS IN MEDICINE 
 
 Yet the human mind is naturally pleased by the won- 
 derful, and especially by the wonderful in medicine. 
 I often meet with these expressions in books which 
 appear to be written seriously, that a certain drug 
 acts like a charm, or like magic. I suppose we must 
 give to persons who write thus the credit of not 
 meaning what they say. 
 
 But that which makes homoeopathy to be a 
 methodism is the dogma or war-cry contained in the 
 proposition that like things are cured by like things. 
 Proceeding to discuss this assertion, let me point out 
 in the first place that the method peculiar to homoeo- 
 pathy relates to pharmaceutics only. Homoeopathy 
 has nothing to say to pathology, accepts it as it 
 stands or ignores it; nor can I remember any addition 
 made to pathological science by a homoeopathist : 
 a fact remarkable when we bear in mind the great 
 progress which pathology has made during the past 
 century. Moreover, homoeopathy does not touch the 
 most important parts of therapeutics. And here 
 allow me to make a digression which will, I hope, 
 be of use in clearing the ideas of some of my hearers. 
 Our art relates to persons in health, to persons in
 
 THERAPEUTICS 225 
 
 disease, and to persons who are in a neutral position, 
 as it were, between health and disease, that is to say, 
 to healthy persons exposed to disease. With regard 
 to healthy people, our art teaches how to preserve 
 them so, and this is Hygienics. With regard to sick 
 people, our art teaches how they may recover their 
 health, and this is Therapeutics. Lastly, our art 
 teaches healthy people, who are exposed to disease, 
 how they may escape it, and this is Prophylactics. 
 Now, with reference to therapeutics in particular, 
 I hope that nobody here thinks that it means the 
 administration of drugs only. Therapeutics is a 
 Greek word which answers to the Latin medicina 
 or cu ratio, the treatment or cure of disease. And 
 therapeutics consists of three parts; first, Dietetics 
 or the management of the ordinary conditions of life 
 for the patient, his food and drink, his clothing, 
 his exercise and rest, his sleeping and waking, the 
 air be breathes, his evacuations, and so forth. Next, 
 Pharmaceutics or the use of drugs. And lastly, 
 Surgery, Chirurgery, which includes whatever you 
 do for the patient with your hands. Beginners 
 sometimes ask wherein consists the distinction
 
 226 SECTS IN MEDICINE 
 
 between medicine and surgery ; they might as well 
 ask wherein consists the distinction between Wales 
 and Great Britain : surgery is a part of medicine. 
 
 To return to homoeopathy : I say that its method 
 does not touch the most important parts of thera- 
 peutics, namely, dietetics and surgery ; and that 
 homoeopathy is a doctrine of pharmaceutics only. 
 Its formula, that like things are to be cured by like 
 things, requires expansion before it can be discussed. 
 What are the things compared and said to resemble 
 each other ? Doubtless the disturbance produced by 
 a disease, and the disturbance produced by a drug 
 administered to a healthy man. And the universal 
 homoeopathic method of pharmaceutics is to give to 
 a patient suffering from a certain disease that drug 
 whose operation upon the healthy body most closely 
 resembles the disease. This dogma is intelligible 
 enough ; the only question is whether it be true. No 
 reasoning for or against the proposition is of any 
 avail ; no dialectics after the Socratic fashion as to 
 the meaning of the words disease and similarity will 
 help us ; experience alone must decide. Appealing 
 to experience, we must admit that some drugs do
 
 HOMOEOPATHY 227 
 
 good homoeopathically. I find, for instance, that 
 small doses of arsenic will often check vomiting, and 
 that small doses of castor- oil are a good remedy for 
 diarrhoea. Homoeopathy does not profess to explain 
 how these results are brought about ; it applies its 
 criterion, an inexplicable criterion if you please, and 
 such experiences as I have mentioned tally with the 
 rule. But now I have to go further, and to point 
 out that, from a few particular instances in which 
 drugs may be fairly said to act according to the 
 homoeopathic canon, the universal proposition is 
 deduced that homoeopathy is the only rule of pharma- 
 ceutic practice. Let us see what experience has to 
 say to this exclusive and intolerant dogma. And 
 I will begin by the remark that in all matters of 
 natural philosophy I distrust universal propositions. 
 I agree with Baglivi that nature is more subtle than 
 the most subtle philosophy. I approve of the saying 
 of Celsus, that the medical art knows of hardly any 
 precepts capable of universal application. And 
 coming to particular instances, my experience tells 
 me that very few indeed of the most useful drugs 
 act homoeopathically. I believe that our patients 
 
 Q 2
 
 228 SECTS IN MEDICINE 
 
 derive much good from salicylate of soda and iodide 
 of potassium and iron and quinine and bromide of 
 potassium and mercury and digitalis, and aperients 
 and astringents and alkalies and anodynes, and very 
 many drugs which do not act homoeopathically. 
 Indeed, for my own part I would repeat my convic- 
 tion that very few of the most useful drugs can be 
 deemed homoeopathic in any sense of the word. 
 
 The English mind is averse from methodism, both 
 in philosophy and in medicine. None of the famous 
 methodic systems have sprung up in England. Van 
 Helmont and Stahl, Brown and Broussais, were not 
 English. It probably was not an accident that 
 homoeopathy arose in Germany in the high and 
 palmy days of the transcendental philosophy, spin- 
 ning the web of its sophistry from some such 
 universal terms as substance or being ; mere words : 
 for 'words are the only universals, and there is 
 nothing universal but words '. 
 
 I now pass on to consider another, yet similar, 
 form of dogmatism which is characterized by the 
 tendency to overrate the extent and import of 
 a favourite dogma. The cause of this form of dogma-
 
 PNEUMATISM 229 
 
 tisin lies in the small capacity of the human mind, 
 unable to accommodate more than one thought at 
 a time, and apt to see all things through the medium 
 of this thought. Which thought becomes a dogma, 
 very likely to be true so far as it goes : the fault lies 
 in making it exclusive ; for other dogmas, indeed an 
 infinitude of other dogmas, are no less true. This 
 fault is the source of innumerable sects and heresies. 
 In ancient times the Pneumatic sect stands forth as 
 an instance of the form of dogmatism now under 
 notice. The pneumatists were so called because of 
 the great (unduly great) stress which they laid upon 
 the doctrine of the pneuma or animal spirits. Let 
 me remind you that when any one speaks of being 
 in good or bad spirits, in high or low spirits, he 
 uses terms which imply the dogma of the pneu- 
 matists. 
 
 It would be easy, and wearisome, to accumulate 
 instances of this logical fault of overrating a favourite 
 notion : idols of the cave, to use Bacon's figurative 
 language. Such an idol has syphilis been to many 
 pathologists, who have seen all diseases through 
 a syphilitic fog. A few years ago an able French
 
 230 SECTS IN MEDICINE 
 
 physician propounded the doctrine that rickets was 
 a form of inherited syphilis ; but observe, a foundling 
 hospital in Paris was the field of his labours. His 
 generalization was probably correct so far as his 
 data went; but his experience related to a very 
 narrow field ; had he looked farther abroad, had he 
 examined puppies as well as babies, he would have 
 found that his opinion was exclusive, intolerant, and 
 therefore wrong a heresy, in short. Gout is another 
 idol with strange power to make the mental vision 
 dim. 
 
 Leaving pathology, I will draw an instance of this 
 fallacy from therapeutics, and will speak of the sect 
 of physiological pharmaceutists, or, as we will call 
 them for shortness, Phawiacologists. This sect is 
 at least as old as the days of Thomas Willis, who 
 wrote in the reign of Charles II a remarkable 
 treatise entitled ' Pharmaceutice Rationalis, or an 
 Exercitation of the operations of medicaments upon 
 human bodies'. The doctrine of the pharmacological 
 sect is as follows : 
 
 Pathology is a part of physiology ; the laws of the 
 internal actions, or functions, of the human body are
 
 PHARMACOLOGY 231 
 
 the same both in health and in disease, although the 
 conditions under which these actions proceed are 
 different in the two cases. Ascertain the manner in 
 which the healthy body is affected by a drug, or, in 
 other words, discover its physiological action, and you 
 have a principle to guide you to the use of the drug 
 in disease. Given a disorder of a certain function 
 of the body, called a disease ; this disorder can be 
 combated by the appropriate drug. Up to this point 
 the pharmacologists walk hand in hand with homoeo- 
 pathists ; but at the next step they part company. 
 They disagree upon two topics. In the first place, 
 the homoeopathists content themselves with giving 
 a drug to a healthy man and watching the result ; 
 they pay great attention to the effects of a drug given 
 in poisonous doses. The pharmacologists aim at pro- 
 founder knowledge than this, and rely chiefly upon 
 vivisection as a means of attaining this knowledge. 
 But supposing that a knowledge of the physiological 
 working of a drug is attained one way or the other, 
 the pharmacologists and homoeopathists differ utterly 
 upon the principle which should guide us in the use 
 of that drug in disease. The pharmacologists are
 
 232 SECTS IN MEDICINE 
 
 antipathists ; they argue in this manner : given, for 
 instance, a disease in which the contractions of the 
 heart are too frequent, and given a drug which can 
 lessen the frequency of these contractions, administer 
 the given drug in a case of the given disease, and the 
 contractions of the heart will be reduced to or towards 
 the normal. I need hardly say that the homoeo- 
 pathists argue in quite another manner ; they apply 
 their maxim of like curing like, concerning which 
 I have already spoken. Nor have I time to discuss 
 the doctrine by means of which some have sought 
 to compose the strife between these contradictory 
 sects : I refer to the theorem that the action of a drug 
 given in small doses is the exact opposite of its action 
 when given in large doses. If a homoeopathist employ 
 small doses upon this principle he is obviously an 
 antipathist in disguise. 
 
 To return to the pharmacologists : I say, in the first 
 place, that physiology owes much more to medicine 
 than medicine does to physiology. Nature and 
 surgeons perform vivisections for us. The greater 
 and better part of what we know concerning the 
 functions of many organs of the body, is derived from
 
 PHARMACOLOGY 233 
 
 pathological observation and not from physiological 
 experiment. Large tracts of physiology are regions 
 unexplored. What more important operation can 
 there be than the conversion of food into blood? 
 And yet how little can physiology say for certain 
 about the process! Some years ago a gentleman 
 brought his daughter to see me on account of en- 
 larged glands in the neck. Whilst I was prescribing 
 the treatment, he suddenly asked me what was the 
 use of the said glands. I at once called to mind the 
 story they tell of Razes, who became blind in his old 
 age. At first he thought of having his eyes operated 
 upon, and he consulted a surgeon for that purpose. 
 But when he found that the surgeon could not tell 
 him how many tunicles the eye possesses, Razes re- 
 considered his intention and threw it up. Yet I 
 believe that I gave my patient good and useful advice 
 concerning the treatment of her disease, although 
 I must confess that I felt painfully ignorant of the 
 functions of lymphatic glands. When the greatest 
 of discoveries in physiology had been made, namely, 
 the circulation of the blood, thoughtful men were 
 surprised to find that no corresponding improvement
 
 234 SECTS IN MEDICINE 
 
 in medical treatment followed. 1 So little do thera- 
 peutics depend upon physiology. 
 
 Again, physiological pharmaceutics deal with 
 nothing but the manifestations of disease, its signs 
 and symptoms ; which yield important indications for 
 treatment no doubt, but which constitute by no means 
 the only or the most important guides to therapeutics. 
 Many of our most valuable drugs are specific, that 
 is to say, they seem to act directly upon the more 
 original and occult effects of the disease, which escape 
 our anatomy and physiology ; unless it be that these 
 specific remedies act directly upon the specific cause 
 of the disease, which seems not always to be the case, 
 at least in the sense of destroying or nullifying the 
 cause : they modify or alter its action in some way 
 unknown, and therefore are sometimes called altera- 
 tives. 
 
 Again it is not possible to predict from the opera- 
 tion of a drug upon a healthy body what the effect 
 
 1 ' Doctor Harvey gave the first credit, if not rise, to the opinion 
 about the circulation of the blood, which was expected to bring in 
 great and general innovations into the whole practice of physic, 
 but it has had no such effect.' Sir William Temple : Of Health and 
 Long Life ; written about 1680.
 
 PHARMACOLOGY 235 
 
 will be upon a diseased body, simply because the 
 conditions are not the same in both cases. Obviously 
 no experiments upon the healthy could discover that 
 iodide of potassium is a remed^ for some forms of 
 syphilis. 
 
 Lastly, physiological experiment has hitherto con- 
 tributed little to practical therapeutics. Indeed, its 
 indications have been more often erroneous than not. 
 The conditions of disease are very complex, and 
 require much more than such physiology as ours to 
 make them understood. 
 
 Bordeu tells an amusing tale which will serve to 
 wind up what I have said about the dogmatists who 
 aim at a rational system of medicine. Chirac saw 
 a patient with three of his medical brethren, whose 
 master he deemed himself to be; for Chirac, like 
 Thessalus, the Roman physician, loved to be called 
 the conqueror of physicians. The patient, for eight- 
 and-twenty days and more had subsisted upon chicken 
 tea and barley water only. He was hungry, but 
 waited a long time before he durst say so ; at last, 
 compelled by necessity, he imparted the fact to one 
 of his physicians who seemed the least to agree with
 
 236 SECTS IN MEDICINE 
 
 the severe and terrible method of Chime. Chirac, 
 hearing of his patient's wishes, and seeing that the 
 other physicians were disposed to relax the treat- 
 ment so far that one of them would allow a little 
 mashed sweetbread, another, two spoonfuls of soup, 
 and the third, the yolk of an egg, Chirac, after 
 mature deliberation, declared that the patient might 
 take some broth, seasoned with two pinches of parsley. 
 To such lengths will dogmatism and rationalism and 
 credulity go. 
 
 I come now to the Empiric sect, much less dog- 
 matic than any of the sects I have mentioned hitherto. 
 This is the sect towards which I myself have the 
 most kindly feeling, being led thereto, no doubt, by 
 the hand of nature. In Celsus you will find a critical 
 account of ancient empiric doctrines ; indeed the 
 treatise of Celsus himself is an admirable instance of 
 empiric medicine. If you ask me for a modern author 
 thoroughly empirical, I give you the honoured name 
 of Heberden. But what characterizes empiricism ? 
 It relates to therapeutics only ; and an empirical 
 physician argues thus : My patient is suffering from 
 such and such a disease ; I treat him in such and such
 
 EMPIRICISM 237 
 
 a manner, because my past experience of patients 
 affected with this disease has convinced me that the 
 mode of treatment which I adopt is the best I know 
 of. I have no other reason for treating him in this 
 way. What better reason than experience would you 
 have? No one feels more deeply than I the truth 
 of the aphorism of the Father of Medicine that ex- 
 perience is fallacious and judgement difficult; but 
 this is a part of human frailty, and we have no better 
 guide. In particular you must not ask me much 
 concerning the manner in which drugs act ; I do not 
 know how iodide of potassium does good in syphilis, 
 and if you were to undertake to tell me, I could not 
 believe you in the present state of our knowledge. 
 Is this to despise knowledge 1 On the contrary my 
 only wish is that, in so serious an affair as medicine, 
 my knowledge should be true. It is my bounden 
 duty, and I desire nothing more than to increase my 
 knowledge on all hands, and thereby to attain the 
 ancient aspiration of our hospital, ' to bring health or 
 ease to my poor patients.' I like the tale which 
 Plutarch tells of ' one that cavilled upon a time with 
 Captaine Iphicrates, and by way of reproach and
 
 238 SECTS IN MEDICINE 
 
 minding to prove that he was of no reckoning, de- 
 manded what he was ? For (quoth he) you are not 
 a man at arnies, nor archer, nor targetter. I am not 
 indeed, I confesse (quoth Iphicrates), but I am he 
 who command all these, and employ them as occasion 
 serveth.' In like manner the empirical physician 
 says, I am ready to accept help from any source, 
 from physiology and pharmacology, but also from 
 mechanics, optics and similar sciences, from electricity 
 and chemistry, nay very gratefully from cookery, up- 
 holstery, ironmongery, and indeed from any source. 
 
 The method of empiricism begins by compiling 
 a history of diseases, the result of the most assiduous, 
 minute, and complete observation and examination 
 possible of sick people. These particular facts are 
 classified so as to constitute more universal types of 
 disease, which serve as a standard of reference. Bear- 
 ing these types in mind, the empiric proceeds to 
 examine a patient, no less minutely and completely ; 
 this is the autopsy. And this done, the patient's 
 disorder is referred to that generic type of disease 
 which it more or less closely resembles ; this is the 
 analogy or diagnosis : a most important affair for the
 
 EMPIRICISM 239 
 
 empiric, inasmuch as his line of treatment depends 
 thereon. So that the empiric would almost agree 
 with him who exclaimed that the first part of treat- 
 ment is diagnosis, and the second diagnosis, and the 
 third diagnosis. After the diagnosis comes the fourth 
 and therapeutic stage of the method, in which lies the 
 essence of empiricism, namely this argument : Because 
 my patient's disorder corresponds with such a type, 
 therefore the treatment is such as experience has 
 shown to be suitable in that disease. ' This was the 
 method of Heraclides Tarentinus, the most famous of 
 empirical physicians, who, according to Galen, never 
 said anything that was not true, not even on behalf 
 of his sect, and who recommended nothing which he 
 himself had not tried.' 
 
 You will have discerned the faults of empiricism. 
 In the first place, it is ' arena sine calce,' or, as we 
 may say, bricks without mortar. It consists of in- 
 dividual truths with nothing to make them adhere, 
 no hypothesis to hold them together. The empiric is 
 essentially asystematic, he writes aphoristically, he 
 is the ant which gathers facts but does not transmute 
 them. Another great fault of the empiric is this, that
 
 240 SECTS IN MEDICINE 
 
 in his eager search for knowledge which he sees to be 
 immediately useful, he overlooks much, the usefulness 
 of which does not at once appear. Not loving know- 
 ledge for its own sake, preferring fruit to light, he 
 meets with an appropriate punishment, his harvests 
 are scanty. Well for him that all physicians are not 
 empirics. 
 
 You will rejoice when I tell you, my friends, that 
 I have now come to the last sect which I shall mention, 
 the sect which most closely approaches scepticism ; 
 I refer to the Expectants. The fundamental principle 
 of this sect is a truth which is full of consolation for 
 both patients and physicians, to wit, that many of our 
 disorders spontaneously tend to recovery. Our body, 
 which turns external things, food, drink, and air, into 
 means of its own preservation, can likewise overcome 
 the noxious influence of disease. The maxim of the 
 expectants is that more diseases are cured by patience 
 than by drugs, and that it is better to stand still than 
 to go on groping in the dark. Contrast with this the 
 dogmatic maxim that a doubtful remedy is better than 
 none at all. The method of Hippocrates, which was 
 largely expectant, was deemed by Asclepiades, a stout
 
 EXPECTANCY 241 
 
 methodist, to be little better than meditation upon 
 death. But an expectant physician will reply, in the 
 words of Bordeu : ' Methinks I hear nature cry aloud, 
 Be not too officious with your help ; leave the business 
 to me : 'tis I and not your drugs that work the cure. 
 When to you I seem to be most stormy, I myself can 
 best save myself, if you have not robbed me of my 
 powers. Far better to cast all your care upon me 
 than to try doubtful remedies. Behold the true 
 catholicum, the panacea sought for by all the sects.' 
 Bordeu tells us that Stahl, in his old age, was so 
 deeply convinced of nature's power to control disease 
 and of the uselessness of drugs, that he came to order 
 nothing, for all sorts of disorders and diseases, more 
 than a few grains of sea salt. And now that we have 
 reached what would seein to be the extreme limits of 
 scepticism, let me point out to you that the greatest 
 sceptics do much for their patients, and that all these 
 doubts and all these sects relate to drugs and to hardly 
 anything but drugs. They are the cause of our disputes 
 and our differences. We agree, for the most part, upon 
 the principles of hygienics and prophylactics and 
 speaking of therapeutics proper, there are no sceptics
 
 242 SECTS IN MEDICINE 
 
 in dietetics and surgery. It is pharmaceutics which 
 is the weak point of medicine, and which will pro- 
 bably always be its weak point. And yet it is that, 
 unfortunately, upon which the mind of the laity is 
 most strongly set. 
 
 The fault of the expectants is the old fault of 
 mankind : they carry things too far ; their principle 
 is true, but not the whole truth. Drugs are often of 
 little use ; drugs may be given so as to be baneful ; 
 this we may confess, and yet refuse to go to the 
 length of affirming that drugs are never of any use. 
 Small as our knowledge of pharmaceutics is compared 
 to what we would wish it to be, yet men have taken 
 more than two thousand years to accumulate that 
 knowledge, and whoever would cast it away as 
 worthless, because it is so imperfect, could not be 
 deemed wise. Drugs are of use, sometimes they are 
 of great use ; and all honour to those who seek for 
 more knowledge in this part also of medicine, its most 
 difficult, most backward, and most disputed part.
 
 243 
 
 XV 
 
 CLINICAL APHORISMS 
 
 COLLECTED BY DR. THOMAS J. HORDER 
 
 ' II faut voir, toujours voir, des malades. Ces mate"riaux confus, 
 que 1'on amasse sans ordre et sans rne"thode, sont pourtant 
 d'excellents materiaux ; inutiles aujourd'hui, vous les retrouverez 
 plus tard enfouis dans les tresors de vofcre memoire.' TROUSSEAU. 
 
 I. OP SOME PULMONARY PHYSICAL SIGNS 
 
 1. No other terms convey any information about 
 the breathing sounds than those in the following 
 
 table : 
 
 Ii. Ordinary, 
 ii. Weak, 
 iii. Loud(= Puerile), 
 may be f. i- Ordinary, 
 
 ii. Bronchial. -. ii. Cavernous, 
 (iii. Amphoric. 
 Distinctions, which correspond with no definite 
 physical condition of lung, make a show of profound 
 
 R 2
 
 244 CLINICAL APHORISMS 
 
 and accurate knowledge, but really obscure it. They 
 are idola theatri. 
 
 2. Intense bronchial breathing is rightly called 
 cavernous because in most instances it indicates 
 cavity. Hence the condition is present in (i) tuber- 
 culous disease, (ii) dilatation of the air-tubes in 
 emphysema, or (iii) cirrhosis of the lung, with dilated 
 air-tubes. The co-existence of dullness would exclude 
 (ii), much sputum would suggest (i), and discovery of 
 tubercle bacilli would confirm it. 
 
 3. The screaming of young children rather helps 
 than hinders auscultation of their lungs, for we thus 
 obtain the signs afforded by deep inspiration and 
 vocal resonance, and especially bronchophony which 
 is often the most important sign of pneumonia. 
 
 4. In pleural effusion there is sometimes hardly 
 any breathing sound to be heard, and sometimes 
 there is loud bronchial breathing. If we accept the 
 view that the breath-sounds are all produced at the 
 glottis, then, bearing in mind that both solid lung 
 and fluid are good conductors of sound, we shall 
 rather wonder that the sign of bronchial breathing 
 is not always met with in these cases.
 
 CLINICAL APHORISMS 245 
 
 5. ' Consonating rale,' termed c cavernous rale ' by 
 Laermec a bad name, because it implied that the 
 sound was always produced in a cavity indicates 
 that the rale is produced either near consolidated 
 lung-tissue or in a cavity. 
 
 6. Children are sometimes thought to be the 
 subjects of pulmonary phthisis when post-mortem 
 examination shows no tubercles, but only cirrhosed 
 lung and dilated air-tubes. 
 
 7. There is no disease of the chest in which the 
 signs are more distinctive than in pneumo-thorax, 
 and yet there is no disease which is more often 
 overlooked. The observer, finding the percussion- 
 tone natural, assumes that the respiratory organs 
 are natural. 
 
 II. OF PHTHISIS 
 
 8. Phthisis at the bases of the lungs is not un- 
 common, but its existence is sometimes overlooked 
 because the apices alone have been examined. 
 
 9. In any case of phthisis the disease is more 
 extensive than the physical signs would seem to 
 indicate.
 
 246 CLINICAL APHORISMS 
 
 10. Most cases of confirmed phthisis progress more 
 rapidly, and terminate sooner, than is expected. If 
 physical signs are present, the probabilities are 
 against complete recovery ; but if the disease is 
 detected before this, there is hope that it may be 
 cured. 
 
 11. Before the appearance of physical signs it is 
 the presence of some or all of the following facts 
 which leads to a diagnosis haemoptysis, cough, loss 
 of flesh and colour, slight rise of temperature, and 
 hereditary liability to the disease ; but above all 
 detection of tubercle bacilli in the sputa. 
 
 12. Therapeutics must begin before physical signs 
 have developed ; for if you wait for physical signs, 
 you wait too long. 
 
 13. Always say three things to a patient whom 
 you suspect to be phthisical 
 
 (i) Get yourself weighed by the same machine 
 each time to see if you are losing weight. 
 
 (ii) Use a thermometer two or three times each 
 evening to see if there is any fever. 
 
 (iii) Save your sputa to be tested (for bacilli). 
 If, besides auscultation and percussion, these three
 
 CLINICAL APHORISMS 247 
 
 points give negative results, you may infer there 
 is no phthisis. 
 
 14. Never give a definite opinion as fcu how long 
 a patient suffering from phthisis will live; for the 
 only certainty is, that if you do, you will be wrong. 
 
 15. Almost every chronic affection of the apex of 
 the lung is tubercular in origin. 
 
 16. Phthisis may begin as bronchitis, as pneumonia, 
 as pleurisy with or without effusion, as pneumo- 
 thorax ; and in either case the beginning may be 
 sudden. 
 
 17. Tubercular phthisis, going on to the formation 
 of cavities, is not extremely uncommon even in 
 infants under a year old. 
 
 18. The diagnosis of phthisis is peculiarly difficult 
 in young children, because their expectoration can 
 seldom be obtained. 
 
 19. The absence of physical signs of disease, in some 
 cases of slowly progressive pulmonary consumption, 
 ending in death, is most remarkable. 
 
 III. OF HAEMOPTYSIS 
 
 20. The commonest cause of haemoptysis is phthisis ;
 
 248 CLINICAL APHORISMS 
 
 the next commonest cause is disease of the heart, 
 which leads to congestion or to embolic infarction of 
 the lungs. 
 
 21. When blood is brought up, if the sputa are 
 themselves bloody, the blood has come from the lungs. 
 
 22. Fatal haemorrhage from the lungs is fluor 
 sanguinis : a large quantity of unmixed blood gushes 
 up, and the patient dies from loss of blood or from 
 suffocation, before any remedies can be used. In the 
 usual case of sputum sanguinis, in which blood 
 mixed with mucus is coughed up sputum by sputum, 
 the patient seldom dies, however abundant the 
 bleeding. 
 
 23. Haemoptysis sometimes occurs, on and off, for 
 many years all through life, it might almost be said. 
 In these cases, it probably is due to the presence of 
 a small cavity, often not larger than a cherry, and 
 giving no physical signs on examination of the chest. 
 
 24. Haemoptysis during an attack of asthma with 
 bronchitis may be very great, and yet not dangerous. 
 
 25. Haemoptysis is not uncommon at the beginning 
 of an attack of pleurisy with effusion ; it is then 
 probably due to collapse and congestion of the lung.
 
 CLINICAL APHORISMS 249 
 
 26. In a young man an attack of haemoptysis is 
 quite sufficient indication for treating him for phthisis. 
 It is not so in the case of a young woman. Women 
 bleed much more easily than men, so that considerable 
 importance should be attached to the question of sex. 
 Again, in the case of a young man, it is not necessary 
 that the sputa should be wholly coloured by blood ; 
 a few streaks of blood, like threads of scarlet silk, are 
 sufficiently characteristic. 
 
 27. The treatment of haemoptysis by drugs is not 
 very satisfactory. The best drug is ipecacuanha 
 in emetic doses ; but it should be reserved for the 
 more serious cases. Gallic acid, though given in 
 sufficiently large doses to produce a green colouration 
 of the sputa, thus proving it to have reached the 
 affected region, does not stay the haemoptysis. Ergotin 
 seems sometimes to be of use, but at other times con- 
 spicuously fails. Opium is of value here as it is in all 
 cases of haemorrhage. But the patient who was wont 
 to treat his own attacks of haemoptysis by ' going to 
 bed. sucking ice, and feeding on milk', summed up 
 the main points of treatment.
 
 250 CLINICAL APHORISMS 
 
 IV. OP BBONCHITIS AND EMPHYSEMA 
 
 28. An ordinary case of bronchitis is not febrile for 
 more than a week or so. Later than this the tem- 
 perature becomes a valuable sign in diagnosing the 
 disease from phthisis or scattered tubercle. 
 
 29. Collapse of a large part of lung occurs in 
 children from very slight causes; especially pul- 
 monary catarrh. Hence when signs of consolidation 
 are found in a young child we must always remember 
 that they are possibly due to collapse. 
 
 30. I have satisfied myself that bronchi tic signs 
 may be wholly restricted to one lung, and the con- 
 dition still be mere bronchitis. But when this is 
 the case, there is always the suspicion that something 
 worse is at the bottom of the condition i. e. tubercle. 
 
 31. There are no more potent causes of chronic 
 bronchitis than alcohol and tobacco. 
 
 32. Diarrhoea setting in spontaneously in a case of 
 bronchitis relieves the pulmonary complaint ; but do 
 not attempt to imitate nature by inducing diarrhoea in 
 treating a case of bronchitis, for purgation does no good. 
 
 33. Chronic bronchitis and emphysema may simi- 
 late asthma in the character of the dyspnoea, the
 
 CLINICAL APHORISMS 251 
 
 attitude of the patient, &c. When this is so, it may 
 be of use to try anti-asthmatic remedies. 
 
 34. Progressive bronchitis, or emphysema, or 
 asthma, whichsoever opens the scene, the final 
 result is much the same. 
 
 35. Contrary to what might be expected, operations 
 upon small gangrenous cavities of the lung are some- 
 times attended by good results. 
 
 V. OF STINKING EXPECTORATION 
 
 36. The causes of stinking expectoration are five 
 (i) empyema ; (ii) gangrene of the lung ; (iii) phthisis ; 
 (iv) diseased bronchial tubes ; (v) abscess of the 
 bronchial glands, opening into the air-tubes. 
 
 (i) The physical signs in a case of expectoration 
 of an empyema are often very slight, because (a) the 
 cavity is small and deep-seated, or (6) the cavity 
 contains air. 
 
 (ii) Usually only a small piece of lung is affected. 
 It is not necessarily fatal. One may often get good 
 specimens of lung tissue from the sputa in these cases. 
 
 (iii) In those cases where the cavity contains 
 a small slough, or where the wall of the cavity itself
 
 252 CLINICAL APHORISMS 
 
 sloughs, both the cavity and the slough may be very 
 small. 
 
 (iv) Here we have two varieties : (a) Where 
 the tubes are dilated, and the secretions putrefy in 
 them : a condition which may be present in cirrhosis 
 of the lung. (6) Where the secretions of bronchitis 
 putrefy in undilated tubes. 
 
 (v) A rare condition, and difficult of diagnosis. 
 
 VI. OF PLEURISY AND EMPYEMA 
 
 37. It is safe to say that pleurisy is always due 
 to infection by microbes. Nevertheless, it would be 
 wrong to deny the influence of injury, exposure, or 
 local cold as determining causes of an attack. 
 
 38. Tubercle is the commonest cause of a clear 
 serous effusion. Cases occur where, on drawing off 
 the fluid, advanced phthisis is discovered, with the 
 existence of cavities in the lung, the detection of 
 which was quite impossible before the tapping. More- 
 over, many cases of serous pleural effusion end fatally 
 within ten years from tuberculosis. Again, tuber- 
 culous peritonitis is so often recovered from, that 
 probably tuberculous pleuritis is also recovered from,
 
 CLINICAL APHORISMS 253 
 
 cases never proved to be tuberculous having really 
 been so. 
 
 39. Vomiting is an almost invariable symptom at 
 the onset of pleurisy in children. Haemoptysis is 
 not uncommon in both children and adults. 
 
 40. Temperature is no guide to the nature of a 
 pleural effusion, whether serous or purulent. Neither 
 is the duration of the effusion. But rigor and a 
 discharge from the ear, if associated, probably point 
 to an effusion being purulent. 
 
 41. A large heart may so press upon the root of 
 the left lung as to produce collapse of its lower lobe. 
 Such a condition can be distinguished from pleural 
 effusion only by the needle. The symptoms which 
 attend an effusion occurring in such circumstances 
 are more often than not left unrelieved by tapping. 
 
 42. Solid tumours of the chest and pleurisy with 
 effusion give much the same physical signs ; but 
 the former do not displace viscera (e. g. the heart), 
 whereas the latter does. 
 
 43. In the presence of a pleural effusion the co- 
 existence of a pericardial effusion cannot be made 
 out by physical examination of the chest. Post-
 
 254 CLINICAL APHORISMS 
 
 mortem, many unsuspected pericardial effusions are 
 continually being discovered. 
 
 44. Blood-stained pleural effusion, though at one 
 time supposed to be diagnostic of malignant disease 
 of the lung, is not really so ; for it occurs in some 
 cases which rapidly recover, and, on the other hand, 
 it is absent in some well-marked cases of cancer, the 
 effusion being quite free from blood. 
 
 45. Serous pleural effusion so often clears up, that 
 it is not good practice to drain one off as soon as 
 it occurs. Hippocrates lays down fourteen days as 
 a good time after which interference is to be recom- 
 mended, and the rule is not a bad one. 
 
 46. Evacuate an abundant pleural effusion as soon 
 as you find it out, for it sometimes leads to sudden 
 heart failure (lipothymia) and death within an hour 
 or two. 
 
 47. Serous effusions do not tend to become puru- 
 lent. In the great majority of instances purulent 
 effusions are purulent from the beginning, and serous 
 effusions remain serous throughout. In rare cases, 
 an effusion which is purulent at first may be found 
 to be serous at a later paracentesis.
 
 CLINICAL APHORISMS 255 
 
 48. Those cases of pleurisy where one suspects 
 tubercle as the cause clear up quite as quickly as 
 others, if not more so. 
 
 49. You never know what may be at the bottom 
 of a pleural effusion, especially when chronic. Often 
 the treatment adopted is based upon the assumption 
 that the condition is one of simple pleurisy, whereas 
 one of several complications may be present (e. g. an 
 aneurysrn of the aorta), which render evacuation of 
 the fluid dangerous. 
 
 50. In passive pleural effusions, such as the hydro- 
 thorax of Bright's disease or heart disease, evacuation 
 of the fluid does not give much relief. If the distress 
 is great, however, it should be done for what little 
 relief does follow. (See Aph. 41.) 
 
 5 1 . The chronicity of a pleural effusion affects the 
 prognosis in a similar way, because the tendency is 
 great for the chest to refill almost as soon as it is 
 emptied in cases of long-standing effusion. 
 
 52. Paracentesis of the chest has been known to 
 cause fatal haemoptysis on the spot, as in a case 
 where it was due to the rupture of a minute aneurysra 
 situated in a small phthisical cavity of the lung.
 
 256 CLINICAL APHORISMS 
 
 53. There are three signs for desisting from the 
 aspiration of a pleural effusion : cough, pain in the 
 chest, and staining of the fluid by blood. The cough- 
 ing which is induced during a paracentesis is probably 
 due to oedema of the lung, set up by the returning 
 blood-stream ; this produces exudation, and, when 
 the coughing is considerable, serous sputa containing 
 much albumen are the result, involving a risk of 
 death from suffocation. 
 
 54. I was wont to think that empyema confined to 
 an apex of the lung did not occur, and that I could 
 therefore exclude empyema as a cause of dullness in 
 this region ; but I have since seen a case. 
 
 55. The microbe in the empyema of children is 
 usually the pneumococcus ; in that of adults it is 
 usually streptococcus. Hence, perhaps, the better 
 prognosis in the former class of patients. 
 
 56. Empyema rarely ruptures spontaneously now- 
 adays ; but if this does occur, the commonest situa- 
 tion on the left side is at the point where the normal 
 apex-beat of the heart is felt. 
 
 57. A small amount of most offensive-smelling pus 
 may be drawn off by aspiration from the pleura, and
 
 CLINICAL APHORISMS 257 
 
 no further operation be required for the condition to 
 clear up. If the amount present, however, is con- 
 siderable, the chance of recovery without drainage is 
 small. The foetor may be accounted for by the 
 proximity of the oesophagus. 
 
 58. There is risk in puncturing a hydatid of the 
 lung, even with a fine needle, and for the purpose of 
 diagnosis only. Aspiration is full of risk. 
 
 VII. OF PNEUMONIA 
 
 59. Pneumonia is not a local, but a universal 
 disease ; and the brunt of it may fall upon any 
 part lungs, endocardium, membranes of the brain, 
 intestines, kidneys. 
 
 60. Acute pneumonia in children often runs a short 
 course, the crisis appearing sometimes on the fourth 
 or fifth day, or even earlier. 
 
 61. Pneumonia may be a cause of otorrhoea ; in 
 many cases the pneumococcus is abundantly found 
 in the pus from the ear, 
 
 62. The way in which pneumonia clears up depends 
 much upon the state of health the patient was in 
 when attacked. In men who drink hard, the period 
 
 QEK S
 
 258 CLINICAL APHORISMS 
 
 of resolution may be long. If evidence of consolida- 
 tion of the lung be found after six weeks, the char- 
 acter of the consolidation is the same as it would be 
 at the end of one week i.e. hepatisation. At the 
 end of several months, however, it would be of the 
 nature of fibrous induration. 
 
 63. The mortality from pneumonia in patients who 
 drink hard is high, and one reason is to be found in 
 the fact that alcoholism predisposes to delirium. 
 
 64. So many and so great are the uncertainties in 
 the course of a case of pneumonia that a prudent man 
 will not attempt to predict the end, as to recovery or 
 death. Many patients, who for days show no un- 
 favourable symptoms, die: some patients, who look 
 as if they could not survive, recover. 
 
 65. Pneumonia is sometimes a cause of sudden and 
 unexpected death in people going about their busi- 
 ness, as if there were nothing the matter with them. 
 
 VIII. OF DISEASES OF THE HEART AND PERICARDIUM 
 
 66. In hospital practice, disease of the valves of the 
 heart : in private practice, disease of its nerves and 
 muscular tissues. In the end. both forms of disease
 
 CLINICAL APHORISMS 259 
 
 approximate each other : valvular disease leads to 
 affections of the muscular walls, nervo-muscular 
 disease leads to dilatation of the cavities and val- 
 vular orifices. In the senile heart, both conditions 
 are often associated from the first, although the 
 valvular degeneration may afford no physical signs 
 even throughout the whole course of the disease. 
 
 67. Affections of the muscular tissue of the heart 
 are usually more serious than those of its fibrous 
 tissue (e.g. the valves), but afford much less definite 
 physical signs, and therefore are less easily discovered. 
 A beginner can hear murmurs and detect , valvular 
 diseases ; but it requires long experience to appreciate 
 nervous and muscular affections of the heart. 
 
 68. If more than one valvular lesion be present 
 in a heart, it often happens that not more than 
 one is diagnosed. One of the commonest combina- 
 tions is that of mitral stenosis with aortic insuffi- 
 ciency, and then the development of the typical aortic 
 diastolic murmur may be considerably interfered 
 with. 
 
 69. Those valvular diseases of the heart which 
 yield the most peculiar and characteristic symptoms 
 
 S 2
 
 260 CLINICAL APHORISMS 
 
 are, aortic regurgitation, mitral constriction, and 
 tricuspid regurgitation. The other forms of valvular 
 disease are less significant or less common. 
 
 70. Dilatation of the left ventricle may occur in 
 a heart having mitral obstruction. This seems con- 
 trary to theory, but cardiac dilatation cannot be 
 wholly explained by a consideration of pressure- 
 effects. The amount of dilatation in the case above- 
 mentioned is sometimes astonishing. 
 
 71. There is no kind of valvular disease of the 
 heart which may not produce a thrill. 
 
 72. Mitral disease causes lividity by interfering 
 with the circulation of the blood, bronchitis by inter- 
 fering with its aeration, and emphysema in both ways. 
 
 73. Jerking pulse, capillary pulsation, visible pul- 
 sation and twisting of the arteries, though all useful 
 signs of aortic regurgitation. are none of them patho- 
 gnomonic. Each may occur without the presence 
 of any valvular lesion, and in old people they are 
 often due to arterial degeneration. Jerking pulse 
 is common in atheroma of the aortic arch. 
 
 74. Venous pulse in the superficial veins of the 
 arms or hands, however, must be regarded as a more
 
 CLINICAL APHORISMS 261 
 
 conclusive sign of aortic regurgitation, for it only 
 occurs in the course of that disease, and perhaps 
 in a few cases of extreme debility. 
 
 75. A rarer sign but one which is pathognomonic 
 of aortic regurgitation, is conduction of the diastolic 
 murmur into the large arteries, such as the femorals, 
 over which vessels it is heard on auscultation, without 
 using pressure by the stethoscope. In these cases the 
 murmur is shrill. 
 
 76. Ulcerative endocarditis may produce quotidian 
 fever some weeks before the appearance of physical 
 signs on auscultation of the heart. 
 
 77. Very great dilatation of the heart is commoner 
 in children than in adults, and may be produced 
 more rapidly ; in a few weeks even. 
 
 78. Signs afforded by the jugular veins are as 
 useful indications in disease of the right heart as are 
 signs afforded by the arteries in diseases of the left. 
 
 79. In the discovery of adherent pericardium we 
 seldom get farther than a guess. 
 
 80. Pericardial effusion, even when not abundant, 
 is sometimes a cause of sudden unexpected death. 
 
 8 1 . Pericarditis is not so common now as formerly ;
 
 262 CLINICAL APHORISMS 
 
 a fact which must be attributed to the use of sodium 
 salicylate in the treatment of rheumatic fever. Endo- 
 carditis, however, seems as common as ever: for it 
 occurs before the patients come under treatment. 
 
 82. In cases of erythema you should always 
 examine the heart, for pericarditis is sometimes 
 found without any other rheumatic symptoms. 
 
 83. Pericarditis is common in Bright's disease, but 
 is not often detected ante-mortem. 
 
 84. In pericarditis the friction sound may remain, 
 in spite of a considerable liquid effusion. 
 
 85. Dropsy, lividity, scanty urine, and weak ir- 
 regular pulse these are the four symptoms which, 
 taken together, indicate the use of digitalis, without 
 regard to the nature of the heart-lesion producing 
 them. On the other hand, the use of digitalis is 
 not indicated by finding on examination that the 
 heart is dilated, the above symptoms being absent. 
 
 86. Orthopnoea is usually a sign of heart disease ; 
 even if the lungs be affected in the first place. 
 
 87. Leaning forward in bed : a sign of disease 
 of the pericardium, aorta, or mediastinum, or of a 
 very large heart
 
 CLINICAL APHORISMS 263 
 
 88. In cases of heart disease we should investigate 
 first the symptoms afforded by the attitude of the 
 patient in bed, by the colour of the lips and cheeks, 
 by the pulse, by the jugular veins, or by dropsy, 
 before proceeding to physical examination. For this 
 reason books written before the discovery of auscul- 
 tation (such as the treatise of Corvisart) are worth 
 reading, if only to show how much the physicians 
 of that day could find out apart from the help of 
 physical signs. Symptoms and not physical signs 
 guide our prognosis and treatment. 
 
 IX. OF DISEASES OF THE BLOOD AND 
 BLOOD-VESSELS 
 
 89. It does not seem proven that what is called 
 ; pernicious anaemia ' is a definite disease. Cases so 
 diagnosed often turn out on post-mortem examination 
 to be cancer undiscoverable during life. 
 
 90. True leucaemia is rare in children. I have seen 
 two cases, and hardly expect to see another. The 
 term 'leucaemia' is ill defined; its use should be 
 restricted to those cases in which the number of 
 white blood-cells almost equals the number of red
 
 264 CLINICAL APHORISMS 
 
 and used in this way it may be said that cases 
 of leucaemia never recover, though they may rally 
 for a time. 
 
 91. In contradistinction from true leucaemia is 
 that disease of young children in whom the spleen 
 is enlarged sometimes reaching the right iliac fossa 
 and in whom there are anaemia, bleeding from the 
 gums, and a liability to bruising. Here, however, 
 the prognosis is not necessarily bad, for the cases 
 often recover. (See page 162.) 
 
 92. You should never see anaemia in a young 
 woman without thinking of phthisis as a possible 
 cause. 
 
 93. It is often a question, when called to treat a 
 young woman suffering from dyspepsia and anaemia, 
 whether the dyspepsia be due to the anaemia, or vice 
 versa. To cure the indigestion will sometimes cure 
 the anaemia : to cure chlorosis will cure attendent 
 gastralgia. 
 
 94. There are cases of permanent anaemia in which 
 the blood-forming faculty, wherever that resides, is 
 feeble, and we cannot stimulate it. A single haemor- 
 rhage may result in anaemia which lasts throughout
 
 CLINICAL APHORISMS 265 
 
 the rest of life, as in the case of Paulina, the wife 
 of Seneca, recorded by Tacitus. 
 
 95. Iron is not of much use in the anaemia of 
 nephritis, or indeed in any form of anaemia but 
 chlorosis, for which it is specific. 
 
 96. It is not uncommon for a patient to live after 
 rupture externally of a thoracic aneurysm. Fainting 
 after the first gush of blood tends to stay the flow, 
 and the deposit of laminated fibrin protects from 
 severe loss of blood afterwards. The presence of this 
 fibrinous layer and its thickness or thinness are 
 important points in determining the length of life 
 in these cases. More common than actual rupture, 
 however, is a process of gradual ulceration and leakage 
 or oozing from the vessel. 
 
 97. Very copious epistaxis may be followed by 
 dementia lasting for many months. 
 
 X. OF NEPHKITIS, ALBUMINURIA, AND DROPSY 
 
 98. You will seldom be wrong if you consider 
 all cases of nephritis not associated with some obvious 
 specific disease, such as scarlet fever, diphtheria, 
 pneumonia, &c., to be chronic.
 
 266 CLINICAL APHORISMS 
 
 99. Quite apart from either diphtheria or scarlet 
 fever, patients suffering from attacks of sore throat 
 are liable to nephritis, which is of temporary duration, 
 lasting as long as the quinsy. The urine is usually 
 bloody in such cases. 
 
 100. It is not easy to distinguish with certainty 
 between the varieties of nephritis during life; much 
 albumen and little urine may be found in a case 
 of chronic interstitial nephritis. 
 
 101. Nothing cuts off the flow of urine so much 
 as persistent vomiting. This failure of urinary 
 secretion may be so marked, that unless the cause 
 be remembered, you may suspect suppression of urine. 
 
 102. Having excluded calculus and uric acid 
 gravel, haematuria in people who are past middle 
 life is most commonly due to granular kidneys. 
 
 103. Haematuria repeated at long intervals may 
 be the only evidence of the existence of granular 
 kidneys. (See page 3.) 
 
 104. Granular kidney may exist to a high degree 
 without constant albuminuria. Moreover, in some 
 cases no signs of cardiac hypertrophy can be made 
 out. These cases usually terminate either by the
 
 CLINICAL APHORISMS 267 
 
 development of the ordinary symptoms of Blight's 
 disease, or by uraemia, or by the occurrence of cerebral 
 haemorrhage. 
 
 105. Black hellebore and cantlarides are the two 
 most efficient drugs for arresting haematuria due to 
 granular kidney. The latter drug, however, is a 
 dangerous remedy, sometimes producing suppuration 
 in the kidney, if carelessly used. 
 
 106. It is a mistake to suppose that early morning 
 urine is best for testing for albumen; often it con- 
 tains none, when that passed later in day contains 
 a good deal. The same statement is true of sac- 
 charine urine. 
 
 107. With valvular disease of the heart you can 
 never tell at first the significance of albuminuria; 
 it may be transient and due to mere congestion of the 
 kidneys. But if casts are found in the uiine as well 
 as albumen, this is an observation of more value, 
 for it indicates the existence of disease of the kidneys. 
 
 108. An epileptic attack, like an apoplectic fit, 
 may cause temporary albuminuria. 
 
 109. Travelling, and especially railway-travelling, 
 produces temporary albuminuria in some people.
 
 268 CLINICAL APHORISMS 
 
 110. Bad cases of chronic nephritis sometimes 
 preserve a ruddy complexion to the very end. 
 
 111. Sudden anasarca sometimes occurs in persons 
 who have been the subjects of alburninuria without 
 dropsy for a long time before. 
 
 112. Do not reduce the allowance of fluid food 
 in dropsy ; it is bad practice, for anything is bad 
 practice which reduces the amount of urine. For 
 this reason, one of the best remedies for nephritis 
 with scanty urine or with a tendency to uraemia, 
 is whey. 
 
 113. Purgatives in dropsy are not of much use; 
 the practice is a survival. If we cannot act upon 
 the kidneys, we should do nothing to add to the 
 patient's discomfort. 
 
 XI. OF GASTRIC ULCER AND CARDIALGIA 
 
 114. In chronic ulceration of the stomach, when 
 the patient is young, it is generally a succession 
 of ulcers you have to deal with; when the patient 
 is old, it is generally one ulcer, which will not heal : 
 a Chironian ulcer. 
 
 115. In young women a gastric ulcer which has
 
 CLINICAL APHORISMS 269 
 
 been diagnosed seldom perforates. Perforation when 
 it takes place, is often the first definite symptom. 
 Under treatment the risk of perforation is small. 
 
 116. Chronic gastric and duodenal ulcers are seldom 
 to be distinguished clinically. Duodenal ulcers only 
 occur in the 'gastric' part of the duodenum, i.e. 
 above the opening of the bile and pancreatic ducts, 
 where the contents of the gut are still acid. 
 
 117. In chronic gastritis and gastric ulcer the 
 pain is commensurate with the acidity of the stomach 
 contents. It is owing to this fact that relief follows 
 the act of vomiting. It is owing to the same fact 
 that the pain usually comes on half an hour or so 
 after food is taken. 
 
 118. The 'Carlsbad treatment' in cases of chronic 
 gastritis is useful, though it has become of less im- 
 portance since the introduction of the stomach-tube. 
 It consists in the free use of alkalies and aperients. 
 Carbonate of magnesium is a particularly useful drug, 
 for it is a powerful antacid, and the soluble salts 
 of magnesium are aperient, ensuring emptying of the 
 stomach. No fermentible foods should be given in 
 these cases ; but milk is an exception to this rule,
 
 270 CLINICAL APHORISMS 
 
 for though it is fermentible, experience shows it to 
 be devoid of ill effects. 
 
 119. Washing out the stomach in cases of ulcer is 
 not free from risk : I have known it cause fatal 
 haematemesis. 
 
 120. Sub-diaphragmatic abscess occurring as a 
 metastatic abscess (i.e. the result of pyaemia) must 
 be very rare. Hence pyaemia (with a sub-diaphragm- 
 atic abscess) is to be regarded as secondary to the 
 abscess. 
 
 121. Cardialgia has been divided into two kinds, 
 as it occurs in a full or in an empty stomach. The 
 former depends upon excessive acidity (acrimony) of 
 the contents of the stomach : the latter is neuralgia. 
 The former kind requires careful feeding, so as to 
 exclude articles of food prone to undergo acid fermen- 
 tation : in the latter kind no special dieting is neces- 
 sary. In the acid form alkalies (especially magnesia) 
 are of great use : in the neuralgic form arsenic, can- 
 nabis indica and nitre-glycerine. 
 
 122. Change of air and scene sometimes brings 
 immediate relief in nervous cardialgia, when diet and 
 drugs have failed.
 
 CLINICAL APHORISMS 271 
 
 123. Neuralgia and atonic dyspepsia (which is 
 part of general weakness) are the only two common 
 affections of the stomach in a young man who is 
 temperate in food and drink. 
 
 XII. OF DIARRHOEA AND CONSTIPATION 
 
 124. In infantile cholera the temperature of the 
 surface of the body may be as low as 97, when that 
 of the rectum is as high as 102. 
 
 125. Many of those who are continually complain- 
 ing of constipation, are suffering more from fear and 
 hypochondria than from anything else. It is no law 
 of nature that the bowels should be relieved punc- 
 tually once in twenty-four hours. Some persons feel 
 in better health when the bowels act only once in 
 two or three days : free evacuations are followed by 
 a sense of weakness. Patience and contentment 
 with nature's operations are not the worst remedies 
 for constipation. 
 
 XIII. OF ABDOMINAL TUMOURS 
 
 126. In physical examination by palpation, organs 
 and tumours feel more superficial than they really are,
 
 272 CLINICAL APHORISMS 
 
 127. A renal 'tumour on the left side very often 
 pushes the colon in front of it; but this condition 
 is not found on the right side. 
 
 128. On palpation of the abdomen, in thin patients, 
 the normal urachus can often be felt as a cord, 
 stretching up from the bladder to the navel. In 
 cases of malignant disease of the abdomen, the urachus 
 often becomes infiltrated by the growth, and this 
 band may then be felt thickened, and measuring 
 as much as half an inch across. 
 
 129. In cases of malignant disease within the 
 abdomen, it is not uncommon to find post-mortem 
 a chain of enlarged lymphatic glands, stretching up 
 the thorax on one or both sides, and appearing behind 
 the clavicles. We may even be led to a correct 
 diagnosis of malignant disease of the abdominal 
 viscera by finding these glands. Thus, deep jaundice, 
 obscure abdominal pain, but nothing abnormal felt 
 in the abdomen itself, with hard glands behind the 
 clavicle, would point to malignant disease of the 
 head of the pancreas. Be this as it may, the dis- 
 covery of these hard and enlarged glands is always 
 most important,
 
 CLINICAL APHORISMS 273 
 
 130. The commonest seat of large faecal tumours 
 is the caecum. Smaller tumours are common in the 
 sigmoid flexure. Elsewhere faecal tumours are un- 
 common. 
 
 XIV. OF DISEASES OF THE LIVER 
 
 131. Enlarged spleen may be the only evidence of 
 cirrhosis of the liver. 
 
 132. Haematemesis in cirrhosis of the liver may be 
 severe enough to cause very marked and prolonged 
 anaemia, and may even be fatal. 
 
 133. There is a condition known as 'tympanitic 
 ascites ', where the abdomen contains liquid but is 
 everywhere resonant to percussion. Intestines will 
 give resonance through a layer of liquid an inch 
 thick. 
 
 134. Malignant disease of the liver may occur, and 
 the patient gain weight for a time, under the benig- 
 nant influence of hope : ' the only cheap and universal 
 cure.' Indeed, a patient's gaining weight whilst 
 under treatment does not exclude malignant disease 
 of any organ.
 
 274 CLINICAL APHORISMS 
 
 XV. OF JAUNDICE 
 
 135. Fatal (or malignant) jaundice (icterus gravis) 
 is indistinguishable at first from ordinary simple 
 jaundice. Let your prognosis be guarded in every 
 case of recent jaundice until you have some little 
 experience of the course that the disease is taking. 
 
 136. In jaundice the urine contains bilirubin before 
 the skin or conjunctivae become tinged by it. More- 
 over, urinary jaundice may be of very brief duration, 
 and jaundice of the tissues never appear at all. Iodine 
 is a better test for the presence of bilirubin in the 
 urine than is nitric acid. 
 
 137. A jaundiced skin may never wholly recover 
 its natural colour in chronic cases, even when the 
 cause of the jaundice is removed. 
 
 138. It is sometimes a good thing to let patients 
 suffering from chronic jaundice due to a gall-stone 
 take exercise. In this way the stone may be dis- 
 lodg-ed, a bad attack of colic ensue, and a spon- 
 taneous cure be effected. 
 
 139. In women past middle age, gall-stones are so 
 common, that one is not wrong to be always suspect- 
 ing them.
 
 CLINICAL APHORISMS 275 
 
 140. A distended gall-bladder is more often de- 
 pendent upon cancer than upon stones. 
 
 141. Recurrent jaundice is probably due to gall- 
 stones. 
 
 XVI. OF CEREBRAL HAEMORRHAGE 
 AND HEMIPLEGIA 
 
 142. Contrary to current opinions of apoplexy, 
 cases in which the patient is, as it were, struck down 
 by a pole-axe ' stunned,' as the word really means 
 are not common ; and when they occur, they are 
 usually due to haemorrhage into the pons, though the 
 haemorrhage may be quite small. The coma of fatal 
 cerebral haemorrhage is usually ' ingravescent '. (See 
 p. 15.) 
 
 143. In cases of hemiplexy (sudden hemiplegia) 
 with coma, rigidity generally indicates haemorrhage 
 into the ventricles, convulsions generally indicate 
 haemorrhage into the pia mater. 
 
 144. Right hemiplexy, accompanied by aphasia, may 
 bo safely said to be due to softening from arterial 
 obstruction, and not to haemorrhage. 
 
 145. Conversely embolism is not likely to be 
 
 T 2
 
 276 CLINICAL APHORISMS 
 
 the cause of right hemiplegia if there is no associated 
 aphasia. 
 
 146. In any case of hemiplexy, loss of conscious- 
 ness, especially if complete, is in favour of haemor- 
 rhage as its cause, rather than softening. 
 
 147. A hemiplegia, therefore, which comes on 
 suddenly (hemiplexy) and is unaccompanied by loss 
 of consciousness, is probably due to softening from 
 arterial obstruction. Hysterical hemiplegia also some- 
 times comes on suddenly, but is much less common. 
 It is generally believed that the face is never para- 
 lysed in the latter case, though this is incorrect. 
 
 148. Hysterical hemiplegia does not come on during 
 an emotion. Unless there be some positive evidence 
 for hemiplegia being hysterical, it should not be 
 confidently diagnosed as such. Hemiplegia appearing 
 during an emotion is more likely to be due to a 
 small haemorrhage. 
 
 149. Uraemic hemiplegia is well known, but rare. 
 Still, the possibility should always be borne in mind 
 when there are evidences of granular kidney in 
 a hemiplegic patient. 
 
 150. When hemiplegia has come on suddenly, its
 
 CLINICAL APHORISMS 277 
 
 continuance for more than three or four days excludes 
 both epilepsy and uraemia as possible causes. One 
 has then to discuss actual lesions : (i) haemorrhage, 
 and (ii) softening from arterial obstruction, as likely 
 causes. In favour of (i) is any evidence of granular 
 kidneys and a hypertrophied left ventricle ; conditions 
 so often associated with cerebral haemorrhage. In 
 favour of (ii) is the coexistence of aphasia with the 
 hemiplegia. 
 
 151. A haemorrhage into the internal capsule 
 produces rigidity sooner or later. It may appear as 
 early as the fourth day or as late as the sixth week. 
 Sometimes both legs become rigid even in hemiplegia ; 
 a fact explained by the incomplete decussation of the 
 pyramidal fibres. 
 
 152. In cases of hemiplegia it is difficult to say if 
 there is, or is not, any paralysis of the face when the 
 patient is lying upon the side. The examination 
 should therefore be made with the patient lying upon 
 his back or sitting up. 
 
 153. Congenital hemiplegia or ' birth-palsy ' ex- 
 cepted, the cerebral hemiplegia of children differs in 
 no respect from that of adults.
 
 278 CLINICAL APHORISMS 
 
 154. The pain in the limbs which sometimes follows 
 hemiplegia is often of the nature of arthritis, the 
 shoulder-joint being most commonly affected. At 
 other times tender points appear along the course of 
 the nerve-trunks. 
 
 155. The after-condition of old hemiplegics is often 
 very sad, when they suffer from aphasia and verbal 
 deafness also. They are little different, to all outward 
 appearance, from idiots ; but what the state of their 
 mental powers may be we can no more tell, than we 
 can tell what passes through the mind of a dog. 
 
 156. The only form of spinal hemiplegia you are 
 likely to meet with is that due to anterior polio- 
 mj^elitis. 
 
 XVII. OF MENINGITIS 
 
 157. We rarely see a case of meningitis without 
 being told of a blow upon the head some time before ; 
 but the blow seldom or never has had anything to do 
 with the disease. 
 
 158. No disease is more frequently followed by 
 tubercular meningitis than is hooping-cough. 
 
 159. A direct diagnosis of tubercular meningitis is
 
 CLINICAL APHORISMS 279 
 
 rarely possible, for the only direct evidence is the 
 discovery of tubercles in the choroid too often only 
 possible when the patient is moribund. But generally 
 a diagnosis may be based upon the fact that the 
 disease is as shown by the symptoms cerebral, is 
 in a child, and had a sudden onset. 
 
 160. Aphasia is occasionally the first symptom in 
 tubercular meningitis, and may be the only one 
 present for some days. 
 
 161. By far the commonest manifestation of general 
 acute tuberculosis in children is tubercular menin- 
 gitis. 
 
 162. Uraemia in children may closely simulate 
 tubercular meningitis, but albuminuria does not occur 
 in the latter disease. 
 
 163. Recovery from non-tubercular meningitis 
 sometimes occurs but is never to be desired. For 
 the recovery is apt to be incomplete, and the patient 
 is left paralysed, blind, deaf, or an idiot. 
 
 XVIII. OF EPILEPSY 
 
 164. Epilepsy does not admit of definition, because 
 we do not know what the essence of epilepsy is ; nor
 
 280 CLINICAL APHORISMS 
 
 has it any criterion ; certainly loss of consciousness is 
 no criterion. 
 
 165. Fracture of the base of the skull may be 
 produced by a violent fall during an epileptic attack ; 
 and the special signs of fracture may be absent. The 
 coma of the epileptic seizure becomes prolonged into 
 the coma due to haemorrhage caused by the fracture. 
 
 166. Epileptic attacks are common in the course of 
 any chronic disease of the brain or its membranes 
 sclerosis, general paralysis, chronic meningitis, old 
 hemiplegia, &c. 
 
 XIX. OP HYSTERIA 
 
 167. Hysteria is a distinct malady. It is a mistake 
 to employ the term to cover all the cases of obscure 
 nervous derangement in women which we do not 
 understand. 
 
 168. Hysteria is generally diagnosed by the method 
 of exclusion, and mistakes are sometimes made in 
 consequence. Yet very often no other method of 
 diagnosis is possible. The most characteristic symp- 
 toms are defects in sensation (especially anaesthesia), 
 and attacks of suffocation (passio hysterica).
 
 CLINICAL APHORISMS 281 
 
 169. Pain, muscular atrophy, loss of faradic excita- 
 bility by the muscles, and loss of knee-jerk either 
 of these tells against hysteria being the cause of a 
 paralysis. 
 
 170. Anaesthesia, and especially hemi-anaesthesia, 
 is more often due to hysteria than to any other disease. 
 
 XX. OF MYELITIS 
 
 171. In medicine you can seldom say that anything 
 is always the case ; but one of the instances most 
 nearly justifying such an affirmation is the production 
 of bladder symptoms in myelitis. 
 
 172. You will not be far wrong if you say that 
 only one disease of the spinal cord begins by affecting 
 the bladder, and that is myelitis. 
 
 173. The two most useful drugs in the treatment 
 of myelitis are belladonna and strychnine ; and there 
 seems a good deal of reason for adhering to the rule 
 in vogue since Brown-Se'quard's time : to give the 
 former in acute, and the latter in chronic cases. 
 
 XXI. OF NEURITIS 
 
 174. Sciatica is most commonly a neuritis, and 
 traumatic, i.e. due to much driving on a hard seat
 
 282 CLINICAL APHORISMS 
 
 In this connexion note the frequent occurrence of 
 some degree of wasting of the muscles, loss of sensa- 
 tion, &c., after the attack. 
 
 175. Loss of knee-jerks may be the sole sign of 
 post-diphtheritic neuritis. In one case the reflex was 
 lost by a patient in whom it was known to have been 
 previously well marked ; there had been abundant 
 discharge of membrane from the trachea, the fauces 
 and larynx being unaffected ; and there was no 
 paralysis. 
 
 176. The patellar reflex is the last function to be 
 regained in recovery from neuritis. 
 
 177. In cases of paralysis, pain must, as a rule, 
 be regarded as contra-indicating the use of massage. 
 
 178. In cases of muscular wasting of parts, where 
 the muscles are nicely antagonized, as they are at the 
 ankle-joint, galvanism must be used with great caution, 
 if at all. For by it you may do more harm than 
 good, improving the nutrition of the antagonistic 
 (unaffected) muscles out of proportion to any improve- 
 ment resulting to those that are wasted. In this 
 way deformity may be produced, or increased. So 
 far as I know, massage does not entail a similar risk.
 
 CLINICAL APHORISMS 283 
 
 XXII. OF SOME OTHEK NERVOUS DISEASES 
 
 179. Double internal strabismus is often the earliest 
 sign of tumour of the pons, because the sixth cranial 
 nerves are so easily compressed. Disease of the pons 
 is not uncommon in children, and is either tubercular 
 or a diffuse glioma. 
 
 180. It is erroneous to regard pin-point pupils and 
 a high temperature as diagnostic of a lesion of the 
 pons ; any cerebral lesion may cause the latter symp- 
 tom and the former is present in the case of haemor- 
 rhage into the ventricles. 
 
 181. Cervical opisthotonus of children l is not a 
 tuberculous affection ; it is due to chronic meningitis 
 around the medulla oblongata. It may, however, 
 occur as a temporary symptom in tubercular menin- 
 gitis. 
 
 182. There seems no reason for thinking that any 
 other difference than one of degree exists between 
 paralysis agitans and so-called senile tremor. 
 
 183. It is improbable that haemorrhage into the 
 spinal cord ever takes place apart from softening. 
 
 1 See St. Bartholomew's Hospital Reports, vol. xiv. p. 23.
 
 284 CLINICAL APHORISMS 
 
 The fact that myelitis often sets in suddenly leads to 
 the mistaken supposition of haemorrhage. 
 
 XXIII. OF DELIRIUM 
 
 184. Delirium, apart from insanity (which may be 
 regarded as a chronic or oft- repeated delirium), is 
 mostly due to alterations in the blood, i. e. to blood- 
 poisoning. This is an old notion ; thus Shakespeare, 
 speaking of a delirious man, has ' All his blood is 
 touched corruptibly.' 
 
 185. No conditions are more difficult of diagnosis 
 than those which are chiefly characterized by delirium 
 or coma. 
 
 186. If called to a case of delirium with fever 
 (phrenitis) it is useful to consider three conditions of 
 which it may be a symptom : 
 
 (i) Brain disease such as purulent meningitis ; 
 these cases the old physicians called 'idiopathic 
 phrenitis '. 
 
 (ii) Blood-poisoning including poisoning from 
 drugs (alcohol, belladonna, &c.) ; from specific diseases 
 (enteric fever, pneumonia, hydrophobia, &c.) ; and 
 from local diseases (pericarditis, &c.).
 
 CLINICAL APHORISMS 285 
 
 (iii) Insanity remembering that insanity is really 
 a chronic delirium ; that you may be dealing with 
 the first attack ; and that fever is not an uncommon 
 accompaniment of an acute attack of insanity, or 
 mania. 
 
 187. Delirium does not occur until the intellectual 
 faculties are more developed than they are in very 
 young children. 
 
 XXIV. OF HEADACHE 
 
 188. Some people seem to be incapable of headache, 
 even when they suffer from disease which is usually 
 accompanied by this symptom, i. e. typhoid fever. 
 
 189. Indian hemp is a drug of great value in the 
 treatment of chronic dull headache. Especially is it 
 of value in overworked men and in Bright's disease. 
 Its use should be cautiously commenced, especially in 
 women. Persons accustomed to take much alcohol 
 are usually very tolerant of the drug. 
 
 190. Iodide of potassium is very useful in head- 
 aches of a different character acute and violent 
 headaches, often accompanied by a raised tempera- 
 ture, the cause of which is obscure. Such cases are
 
 286 CLINICAL APHORISMS 
 
 not very uncommon headache and fever are the two 
 cardinal symptoms. Full doses of the drug should 
 be given, and are often followed by speedy cure, 
 though at first the pain may be aggravated by the 
 iodide. In these cases, though a tempting hypothesis, 
 syphilis can often be wholly excluded. 
 
 XXV. OF APHASIA 
 
 191. Aphasia is not a defect in the unuttered word, 
 nor in the uttered word ; it is a form of paralysis of 
 the special movements of speech (see p. 27). 
 
 192. In many cases of aphasia attempts to protrude 
 the tongue only succeed in getting it as far as the 
 teeth ; this illustrates the paralytic nature of this 
 condition. 
 
 193. The cases of aphasia suddenly appearing 
 during an emotion are not hysterical. The disorder 
 may occur in adult men, and is better described under 
 the term ' emotional aphasia '. The condition may 
 last for several days (see p. 31). 
 
 194. There is no aphasia in disease of the pons.
 
 CLINICAL APHORISMS 287 
 
 XXVI. OF DISOKDERS OF SLEEP 
 
 195. An apparition is sometimes nothing but a 
 dream seen with open eyes by a person who is half 
 asleep and half awake. When the awakening becomes 
 complete, the apparition vanishes. The prophet 
 Balaam ' saw the vision, falling into a trance, but 
 having his eyes open '. 
 
 196. People are born good sleepers or bad. A 
 tendency to sleep badly runs in families, and is some- 
 times observed in the youngest infants. To make 
 one who is naturally a bad sleeper into a good sleeper 
 is an impossible task: all that can be done is to 
 remove or remedy any accidental and temporary 
 conditions which hinder sleep. The risk run by bad 
 sleepers arises not so much from mere want of sleep 
 as from the temptation to fly to narcotic drugs: 
 hypnotic is nothing but a euphemism for narcotic : 
 the mischief lies in remedies much worse than the 
 disease. 
 
 197. Bad sleeping is largely aggravated by the 
 fretfulness which it causes in those who suffer from it ; 
 for they are often of a peevish disposition, given to
 
 288 CLINICAL APHORISMS 
 
 worry, and they will not or cannot let nature take 
 her course. Anxious desire for sleep hinders sleeping 
 according to the universal law that voluntary parti- 
 cipation in an involuntary act inhibits accomplishment 
 thereof. 
 
 XXVII. OF SOME INFECTIOUS DISEASES 
 
 198. The hoop is not an absolute criterion of hoop- 
 ing-cough. A child may hoop for weeks with a cough 
 which is not hooping-cough, and yet cannot be dis- 
 tinguished from it, except by the fact that the said 
 child does not convey the disease to other children 
 who are susceptible. 
 
 199. In measles, although the fourth day is the 
 commonest for the appearance of the rash, the eruption 
 may be the first sign of the disease, or, again, may be 
 delayed until the seventh or eighth day, the patient 
 meanwhile being very ill. Indeed, there is no disease 
 in which the duration of the invasion period is so 
 variable. 
 
 200. Mumps may produce many curious nervous 
 symptoms at times, e.g. intense giddiness.
 
 CLINICAL APHORISMS 289 
 
 XXVIII. OF ENTERIC FEVER 
 
 201. The febrile onset of secondary syphilis may 
 be mistaken for typhoid fever : and an incipient 
 syphilide may be indistinguishable for a few days 
 from typhoid spots. 
 
 202. Enteric fever seldom begins with a rigor ; 
 pneumonia often. The reason probably lies in the 
 fact that in the former disease the temperature rises 
 slowly, in the latter it rises rapidly. 
 
 203. Scarlatiniform symptoms a rash, sore throat, 
 &c. coming on early in enteric fever, are not un- 
 common. In such cases diagnosis at first is often 
 impossible. 
 
 204. Vomiting early in enteric fever, especially if 
 frequent, indicates a severe case ; it is accompanied by 
 bad headache. 
 
 205. Muscular rigidity in enteric fever always 
 marks a severe, and often a fatal case. 
 
 206. Deafness is common in enteric fever. Stoll 
 thought it indicated approaching convalescence, the 
 other symptoms being favourable : but a statement so 
 barely empirical ought to be well established before 
 much importance is attached to it.
 
 290 CLINICAL APHORISMS 
 
 207. Otitis interna is not uncommon in the course 
 of typhoid fever ; both ears are usually affected. By 
 means of this otitis, typhoid fever may be complicated 
 with meningitis, at least if optic neuritis followed 
 by atrophy can be accepted as evidence of meningitis. 
 
 08. That form of typhoid fever which is marked 
 by incessant raving delirium is hard to be distinguished 
 from meningitis or from phrenitis due to some other 
 morbid poison. This is especially the case when the 
 typhoid delirium sets in unusually early, during the 
 first week of the disease, and before the eruption 
 appears. Moreover, in some of these cases the 
 eruption never appears. And suppose that this raving 
 and roaring delirium (febris ululans) be attended by 
 constipation, a retracted belly, temporary rigidity of 
 the neck, and watery discharge from the ear ; suppose 
 that spots be absent throughout the whole course 
 of the disease, and that examination of the eyes be 
 difficult through the restlessness of the patient, and 
 the eyelids being kept tightly closed. Yet all this 
 happened to a patient of mine who died in the fourth 
 week of illness, and whose intestines showed typhoid 
 lesions of that period, the brain being healthy. Test-
 
 CLINICAL APHORISMS 291 
 
 ing the blood by cultivations of typhoid bacilli (Widal's 
 test) must be employed as an additional means of 
 diagnosis, but a negative result may be expected early 
 in the disease. 
 
 209. Haemorrhage from the bowels in enteric fever, 
 if it occur not later than the second week, may be 
 disregarded. After that time it is a serious symptom. 
 The opinion of Graves and Trousseau that haemorrhage 
 in enteric fever is not of much importance, is probably 
 explained by assuming, with Collingridge, that they 
 were referring to the class of early haemorrhages. 
 Late and copious haemorrhage is a frequent precursor 
 of perforation. 
 
 210. Nothing can be done to relieve the tympanites 
 of enteric fever. Passing a rectal tube, puncturing 
 the intestines with a trocar, administering small doses 
 of turpentine or charcoal all these have objections 
 or produce no benefit. In patients fed on whey alone 
 there is but little tympanites. 
 
 XXIX. OF SOME TUBERCULAR DISEASES 
 
 211. A period of improvement in general condition, 
 even an increase in weight, does not exclude the 
 
 U 2
 
 292 CLINICAL APHORISMS 
 
 possibility of a child's disease being tuberculous in 
 nature, and fatal. 
 
 212. The existence of tubercles beneath the skin 
 a ' phlegmonous scrofulide ', but not lupus is a very 
 serious condition ; the patients die. The tubercles are 
 apt to soften, disappear, and signs of general tuber- 
 culosis follow speedily. 
 
 213. Tubercular peritonitis may come on quite 
 suddenly ; but when it does so, the acute symptoms 
 last for a short time only, and the disease then lapses 
 into the usual chronic state. During the acute stage, 
 however, the diagnosis from some form of intestinal 
 obstruction may be difficult (see p. 168). 
 
 214. In chronic tubercular peritonitis indurations 
 within the abdomen become manifest sooner or later 
 in most cases. 
 
 215. Tubercle of the brain substance occurs as 
 circumscribed tumours. There is, however, a very 
 rare condition of miliary tubercular encephalitis, 
 where the tubercles follow the ramifications of the 
 blood-vessels, but this is only found in conjunction 
 with tubercular meningitis. 1 
 
 1 See Reynolds' System of Medicine, 1st ed., vol. ii. p. 395.
 
 CLINICAL APHORISMS 293 
 
 XXX. OF CHOKEA AND RHEUMATISM 
 
 216. Choreic patients are nearly always weak- 
 minded, so long, at least, as the chorea lasts. 
 Insanity is an occasional accompaniment of the 
 chorea of girls. 1 
 
 217. I have never seen a fatal case of chorea in 
 which endocarditis was not found on post-mortem 
 examination. 
 
 218. Salicylate of soda, guaiacum, and aconite 
 the three drugs having a reputation for curing sore 
 throat have all more or less specific action in 
 rheumatism. Hence, if with a sore throat there is no 
 other indication, you are justified in treating it as 
 rheumatic. 
 
 219. The use of sodium salicylate was formerly 
 often attended by attacks of vomiting, salivation, and 
 delirium, which are now seldom seen. These effects 
 were probably due to impurities in the drug, such as 
 carbolic acid. 
 
 220. Salicin is a feeble remedy in cases of acute 
 rheumatism ; you may give a patient twenty-grain 
 
 1 See St. Bartholomew's Hospital Reports, vol. xxii. p. 89.
 
 294 CLINICAL APHORISMS 
 
 doses every two or three hours without any effect, 
 and then obtain almost immediate good from the use 
 of sodium salicylate. As a fillip, used like quinine, 
 and in mild cases, salicin is useful. 
 
 221. In rheumatic fever, delirium occurs under 
 several distinct conditions : 
 
 I. Temporary slight delirium is not uncommon, 
 even in persons who have not drunk hard; and 
 especially at night-time (' noctibus aliena loqui '). It 
 may be that large doses of salicylic acid have some- 
 thing to do with it. 
 
 II. But delirium is sometimes the main symptom 
 of the disease delirium which is raving and apt to 
 end in coma. The temperature in these cases may be 
 high, but is not necessarily so : that is to say, the 
 delirium cannot be attributed to the raised tempera- 
 ture. (1) This delirium is sometimes of the same 
 kind as that which occurs in typhoid fever, i. e. not 
 connected with any local disease ; indeed, the arthritic 
 symptoms are sometimes very slight. Cerebral rheu- 
 matism this form of delirium has been called. 
 Drunkards are prone to it. (2) Delirium is some- 
 times associated with, and dependent upon, local
 
 CLINICAL APHORISMS 295 
 
 inflammation, namely, pericarditis, pneumonia, or 
 meningitis. 
 
 III. Delirium occurring after the cessation of rheu- 
 matic fever ; a chronic lunacy, lasting for months, 
 and of the same kind as sometimes follows typhoid and 
 malarial fevers. 
 
 222. Rheumatoid arthritis, having an acute onset, 
 cannot at first be diagnosed from rheumatic fever. 
 
 XXXI. OF SYPHILIS 
 
 223. I have never been able to satisfy myself that 
 there is any such thing as syphilitic disease of the 
 lung. Syphilitic disease of the mediastinum undoubt- 
 edly occurs, but is very uncommon ; it is certainly 
 much rarer than aneurysm in this situation, which it 
 may closely resemble in its symptoms. 
 
 224. There is too great a tendency to call all 
 babies that are wasted and have sores on the bcdy, 
 syphilitic. These sores are often due to neglect, dirt, 
 want of food. 
 
 225. Syphilis is almost the only cause of sudden 
 blepharoptosis ; it is also the great cause of paralysis 
 of the iris : indeed of all forms of ophthalmoplegia.
 
 296 CLINICAL APHORISMS 
 
 226. Haemorrhage into the substance of the brain 
 may occur as a sequel to gumma of this organ, 
 especially when the patient is an infant. 
 
 XXXII. OF SOME SKIN DISEASES 
 
 227. Rheumatoid symptoms are very apt to occur 
 in conjunction with three skin diseases, in this order 
 of frequency : Erythema (especially E. papulatum), 
 purpura, and urticaria; and these eruptions some- 
 times interchange. 
 
 228. A person suffering from active psoriasis is 
 likely to get it upon any irritated piece of skin, e. g. 
 a scratch. 
 
 229. Ordinary facial psoriasis may simulate a syphi- 
 lide if washed much with soap and water, the spots 
 being no longer scaly, but becoming shiny, and of the 
 colour that is common in syphilides. 
 
 XXXIII. OP DIABETES AND GLYCOSURIA 
 
 230. Diabetes is a disease often overlooked, some- 
 times because the urine is not tested for sugar on 
 account of its having a fairly low specific gravity 
 (say 1015) ; which really is compatible with the
 
 CLINICAL APHORISMS 297 
 
 presence of a considerable amount of sugar: some- 
 times because the patient is a child : and sometimes 
 because there is no thirst or emaciation. 
 
 231. Diabetes sometimes becomes evident in two 
 or three members of a family at the same time, so as 
 to give an appearance of contagiousness. This notion 
 is by no means new, but there is no proof that it is 
 true. 
 
 232. Temporary and recurrent glycosuria, if not 
 due to the ingestion of large quantities of carbo- 
 hydrates, indicates a tendency to diabetes. 
 
 233. The great quantities of food which diabetics 
 sometimes consume, to satisfy the excessive appetite 
 which often occurs as a symptom of the disease, never 
 seem to cause dyspepsia. 
 
 234. Diarrhoea is not uncommon in diabetes ; it 
 may even be dysenteric. 
 
 235. Diabetes resembles motor ataxia in three 
 points loss of knee-jerk, perforating ulcer of the 
 foot, and darting pains in the limbs. 
 
 236. Why is the diabetes of hospital patients so 
 much more intractable than that of the well-to-do ? 
 
 237. It is dangerous to put diabetics upon a very
 
 298 CLINICAL APHORISMS 
 
 strict diet suddenly ; coma has come on when this 
 has been done. 
 
 238. The beneficial effect of opium in the treatment 
 of diabetes is probably due to the power the drug has 
 of allaying the feeling of weariness and discomfort, 
 and of acting as a euphoric. 
 
 XXXIV. OF SOME SIGNS AND SYMPTOMS 
 
 239. Intermittent pulse in children after serious 
 illness or indeed after illness which was not serious 
 is so common as to be of little importance. The 
 pulse of many old people intermits. 
 
 240. Difference in size of the pupils is often 
 temporary, and is by itself no sign of disease. 
 
 241. Tache cerebrate is a sign of little or no value. 
 
 242. The most infallible early sign of death is loss 
 by the muscles of faradic excitability. 
 
 243. During almost any acute illness the mind may 
 become so clouded that afterwards the patient re- 
 members scarcely anything that happened in the 
 course of his disease. 
 
 244. In all nervous diseases sensory symptoms are 
 apt to be fugitive.
 
 CLINICAL APHORISMS 299 
 
 245. Convulsions are often the sole symptom of 
 any kind of brain disease in infants. 
 
 246. So little is known about the anatomy of 
 anaesthesia, that, unless it be a hemi-anaesthesia, a 
 facial anaesthesia, or associated with some form of 
 paralysis, perhaps the less said about it for purposes 
 of diagnosis the better. 
 
 247. All sorts of anaesthesia are met with in disease 
 of the pons ; difficult to explain because we know so 
 little of the course of sensory fibres in this situation. 
 
 248. Examination of sputum for pus microscopically 
 is of no use, for the naked eye appreciates the only 
 important fact, that is to say, the amount of pus, 
 whether great or small, and not its mere presence, 
 which may always be presumed. 
 
 249. ' His cheek displays a second spring of roses 
 taught by wine to bloom.' Beer also is a cause of 
 this permanent dilatation of the capillary blood- 
 vessels, associated sometimes with gutta rosea : but 
 spirit-drinking, even for many years, often fails to 
 produce any change in the face, except pallor. 
 
 250. The blue line of lead -poisoning may become 
 apparent very early in the disease. When acetate of
 
 300 CLINICAL APHORISMS 
 
 lead was wont to be given freely for haemoptysis, a 
 blue line sometimes developed in three weeks from the 
 commencement of taking the drug. 
 
 251. There is no disease in which more or less 
 permanent crippling may not result from the patient 
 lying curled up in bed. In enteric fever and rheu- 
 matism it is not uncommon, and bad contractures are 
 occasionally seen in cases of neuritis. These deformi- 
 ties should be studiously prevented, or, if this has not 
 been done, they should be corrected early. There is 
 a tendenc}^ for dislocation of the tibia backwards 
 upon the femur to take place. 
 
 252. A muscle may be quite paralysed to faradism, 
 and yet not be paralysed to volition. The opposite 
 condition is, of course, much commoner, occurring as 
 it does in all cases of upper-segment paralysis. 
 
 253. In acute diseases, more valuable prognostic 
 signs are afforded by the breathing and aeration of 
 the blood than by the pulse. 
 
 254. Delirium or frequent vomiting occurring sud- 
 denly in a chronic disease is often prognostic of death 
 within a day or two. 
 
 255. When severe abdominal pain is dependent
 
 CLINICAL APHORISMS 301 
 
 upon caries of the vertebrae, aneurysm of the aorta, 
 aortic regurgitation, pneumonia, or pleurisy, the real 
 disease is sometimes overlooked. 
 
 XXXV. OF FEVEK 
 
 256. Sudden pyrexia, the temperature rapidly 
 reaching a high degree, without any other signs of 
 disease, seldom lasts. 
 
 257. Convulsions in children are often sufficient to 
 cause high temperature a rise of 9-10 even and 
 this hyperpyrexia will prove fatal unless counteracted 
 by cold bathing. In such a condition it is obvious 
 that no treatment can be much worse than the 
 customary hot bath. 
 
 258. Haemorrhage may be attended by a rise of 
 temperature quite apart from the disease causing the 
 loss of blood. This is well seen in some cases of 
 haemoptysis. With Cullen, fever formed part of his 
 definition of haemorrhage, ' Pyrexia cum profusione 
 sanguinis absque vi externa.' 
 
 259. Frequently a convalescent patient, whose 
 temperature will not settle down, acquires a steady 
 normal temperature on being allowed to get up. In
 
 302 CLINICAL APHORISMS 
 
 patients convalescent from rheumatic fever this is 
 especially noticed. 
 
 XXXVI. OF POOD IN DISEASE 
 
 260. Pre-digestion of food given by the mouth is 
 of very little value in any disease. 
 
 261. You must not think that fever in itself contra- 
 indicates the administration of solid food. 
 
 262. An apparently good condition of a patient fed 
 only upon nutrient enemata is often deceptive, for 
 dangerous symptoms of inanition may appear suddenly 
 and without warning. A very little food in the 
 stomach is much better than a large amount in the 
 rectum, and on this account the former method of 
 feeding should never be wholly abandoned without 
 real necessity. 
 
 263. A strict milk diet is not to be recommended in 
 cases of chronic nephritis. Some patients fare better 
 upon a meat regimen, and few fare worse. Whey is 
 always suitable. 
 
 264. In typhlitis avoid those kinds of food which 
 leave much residue after digestion. For this reason 
 whey is better than milk.
 
 CLINICAL APHORISMS 303 
 
 265. The best remedy for uric acid gravel is whey. 
 
 XXXVII. OF CHILDHOOD AND OLD AGE 
 
 266. Boys are sometimes very backward in learning 
 to talk ; but if a boy cannot talk at four years of age, 
 he is with a single very rare exception either deaf 
 and dumb or an idiot. The former alternative can 
 easily be excluded. The exception mentioned is the 
 condition of congenital aphasia (see p. 32). 
 
 267. There is often a remarkable latency about the 
 diseases of old people. Phthisis particularly is often 
 overlooked because of its supposed improbability. 
 
 268. People who are said to die of ' old age ' die 
 nevertheless from failure of a particular organ, and 
 not from universal senile decay. Still, it is sometimes 
 difficult to say from what an old person is dying. 
 
 XXXVIII. MISCELLANIES 
 
 269. Prolonging life at the end of hopeless diseases: 
 say rather, prolonging the act of dying. ' Mors minus 
 poenae quam mora mortis habet.' 
 
 270. Gout and diabetes, two most mysterious 
 diseases, both so easily known in their glaring mani-
 
 304 CLINICAL APHORISMS . 
 
 fesfcations, and both so utterly unknown in their 
 essential nature. 
 
 271. A letter containing four pages or more, closely 
 written and narrating the writer's own disorders, is 
 a sure and certain sign of hypochondria. 
 
 272. When we have prescribed that continual 
 temperance in all things which is necessary to the 
 cure of most disorders, how often do we find that our 
 patient reckons the loss of pain to be purchased too 
 dear by the loss of pleasure.
 
 INDEX 
 
 Abdomen : pain, 300 
 
 Ague : enlarged spleen, 163 
 
 Albuminuria : aphorisms, 265 
 
 Anaemia : aphorisms, 264 : 
 pernicious, 263 : in phthisis, 
 264 
 
 Anaesthesia : aphorisms, 299 : 
 hysterical, 281 
 
 Aneurysm : haemorrhage from, 
 265 
 
 Aphasia : aphorisms, 286 : con- 
 genital, 32 : definition, 27 : 
 emotional, 31 : in migraine, 
 30 : its nature, 29 : in tuber- 
 cular meningitis, 279 
 
 Apoplexy : aphorisms, 275 : de- 
 finition, 15 
 
 Apparitions : 287 
 
 Arterio- capillary Fibrosis : con- 
 ditions, 5 : in nephritis, 4 
 
 Asthma : allied diseases, 141 : 
 haemoptysis, 248 : its nature, 
 129, 158 : pneumonic, 140 : 
 spasmodic, 136 
 
 Backwardness in Talking : 303 
 Barrel-shaped Chest : its causes, 
 
 121 
 
 Biliousness : 3 
 Blue line in Gums : 299 
 Brain : hypertrophy, 22 : tuber- 
 cular diseases, 292 
 Bronchitis : aphorisms, 250 : 
 asthmatic, 141 : causes, 62, 
 91 : chronic, 85 : dyspnoea, 
 80 : paroxysmal bronchial 
 
 flux, 155 : peculiar kind, 75 : 
 pituitous, 72 : pulmonary em- 
 physema in, 107 : resembling 
 pulmonary phthisis, 89 : sputa, 
 70 : suffocating, 82 
 
 Cancer : abdominal, 272 : he- 
 patic, 273 
 
 Cardialgia : aphorisms, 269, 270 
 
 Catarrh : definition, 60 : dry, 
 117: pearly sputa, 119: sputa, 
 70 
 
 Cavernous Breathing : 244 
 
 Cerebral Haemorrhage : aphor- 
 isms, 275 : history of a case, 1 
 
 Cheeks, Ruddy : 268, 299 
 
 Cholera Infantum : its tempera- 
 ture, 271 
 
 Chorea : aphorisms, 293 
 
 Colic : resembles peritonitis, 181, 
 206 
 
 Coma : definition, 11 
 
 Consonating Eale : 245 
 
 Constipation : 271 
 
 Convulsions in Children : 299, 
 301 
 
 Coryza, Paroxysmal : 151 
 
 Crippled Joints : in muscular 
 atrophy, 282 : from long re- 
 cumbency, 300 
 
 Croup : acute pulmonary em- 
 physema, 97 : meaning of 
 word, 84 : spasmodic, 145 
 
 Death : prognostics, 300 : sign 
 of, 298
 
 306 
 
 INDEX 
 
 Delirium : aphorisms, 284 : de- 
 finition, 34 : in rheumatic 
 fever, 294 : tendency to, 37 : 
 in typhoid fever, 290 
 Diabetes : aphorisms, 296 
 Diphtheria : neuritis, 282 
 Dolichocephalus : 21 
 Dropsy : aphorisms, 268 
 Dusty Trades: 64 
 
 Eczema : in asthma, 143, 160 
 
 Emphysema of Lungs : acute, 
 96: causes, 98, 103: chronic, 
 108 : its nature, 94, 120 : symp- 
 toms, 112 
 
 Empyema : see Pleurisy 
 
 Enteritis : meaning of word, 
 176, 188 
 
 Epilepsy : aphorisms, 279 
 
 Epistaxis : 265 
 
 Erythema : 296 
 
 Faecal Tumours : 273 
 Fever : aphorisms, 301, 302 
 Food : aphorisms, 302 
 
 Gall-stones: 274, 275 
 
 Gout : in asthma, 152, 161 : use 
 
 of word, 88 
 Gravel : 303 
 
 Haematemesis : in cirrhosis of 
 
 liver, 273 
 
 Haematuria : in granular kid- 
 neys, 3, 266 : in quinsy, 266 
 Haemoptysis : aphorisms, 247, 
 301 : in paracentesis thoracis, 
 255 
 
 Haemorrhage : febrile, 301 
 Hay Fever : asthmatic, 157 : 
 
 cause, 66 
 
 Headache : aphorisms, 285 
 Heads, Large, in Children : 17 
 Heart, Diseases of: aphorisms, 
 258 
 
 Hemiplegia : aphorisms, 275 
 Hooping Cough : 288 
 HydatidofLung: 257 
 Hydrocephalus : shape of head. 
 
 25 
 Hysteria : aphorisms, 280 : he- 
 
 miplegia, 276 
 
 Ileus : in acute peritonitis, 187, 
 208 : in tubercular peritonitis, 
 168 
 
 Jaundice : aphorisms, 274 
 
 Kidneys : granular, 4, 266 : 
 tumours. 272 
 
 Leucaemia : 263 
 
 Lipothymia : meaning of word, 
 
 191 : in acute peritonitis, 191, 
 
 210 
 Liver : cirrhosis, 273 : cancer, 
 
 273 
 Lungs : atrophic changes. 126 
 
 Measles: 288 
 
 Meningitis : aphorisms, 278 
 
 Menstruation : 181 
 
 Mumps : 288 
 
 Myelitis : aphorisms, 281 
 
 Nephritis : aphorisms, 265 : food 
 
 in, 302 
 Nervous Atrophy : description, 
 
 41 : treatment, 47 
 Neuritis : aphorisms, 281 
 
 Old Age : 303 
 
 Paralysis Agitans : 283 
 Pericarditis : aphorisms, 261 
 Peritoneum : haemorrhage into, 
 
 198 : perforation of, 200 
 Peritonitis : signs of acute dis- 
 ease, 175 : progress of opinion,
 
 INDEX 
 
 307 
 
 175 : local signs, 180 : pain, 
 180, 193: meteorism, 184: 
 choleric symptoms, 186 : ileus, 
 187 : fever, 189 : septic symp- 
 toms, 190 : lipothymial symp- 
 toms, 191 : face grippee, 195 : 
 latent, 195 : chronic, 198 : 
 due to perforation, 200 : in- 
 cision, 213. See Tubercular 
 Peritonitis 
 
 Pharmacology : 230 
 
 Phrenitis : definition, 37 
 
 PhthisisPulmonalis : aphorisms, 
 245 ; haemoptysis, 248, 249 : 
 simulated by bronchitis, 89 : 
 by pulmonary cirrhosis, 245 
 
 Pleural Effusion : its breathing 
 sounds, 244 : haemoptysis, 
 248 : aphorisms, 252 
 
 Pleurisy : aphorisms, 253. See 
 Pleural Effusion 
 
 Pneumodes : meaning of word, 
 116 
 
 Pneumonia : aphorisms, 257 
 
 Pneumothorax : apt to be over- 
 looked, 245 
 
 Pons Varolii, Diseases : stra- 
 bismus in, 283 : miosis pu- 
 pillae, 283 
 
 Psoriasis : 296 
 
 Puerperal Fever : its peritonitis, 
 177 
 
 Pulse, Intermittent : 298 
 
 Pupils Unequal : 298 
 
 Respiration : its movements, 99, 
 138 : prognostics, 300 : sounds, 
 243 
 
 Rheumatism : aphorisms, 293 
 
 Rheumatoid Arthritis : 295 
 
 Rickets : big heads, 24 
 
 Sciatica : 281 
 
 Sects in Medicine : 214 : dog- 
 matic, 218 : methodist, 220 : 
 homoeopathic, 223, 226, 232 : 
 pharmacological, 230 : em- 
 pirical, 236 : expectant, 240 
 
 Sleeplessness: 287 
 
 Spinal Myalgia : definition, 51 : 
 treatment, 57 
 
 Spleen Enlarged: in children, 
 162, 264: in hepatic cirrhosis, 
 272 
 
 Sputa: in bronchitis, 70: pitui- 
 tous, 72 : pearly, 119 : stink- 
 ing, 251 
 
 Stomach, Ulcer of: aphorisms, 
 268 : perforation, 203 
 
 Syphilis: aphorisms, 295: en- 
 larged head, 24 : enlarged 
 spleen, 162 : an idol of the 
 cave, 226 : simulates typhoid 
 fever, 289 
 
 Tache c(5rebrale : 298 
 
 Therapeutics: meaning of word, 
 225 
 
 Tubercular Diseases: aphorisms, 
 291 : of brain, 292 
 
 Tubercular Peritonitis in Chil- 
 dren : 164 : pathognomonic 
 signs, 164 : tympanites, 166 : 
 onset, 167, 198, 292: ileus, 
 168 : gastro-enteritis, 168 : 
 course, 169 : diagnosis, 171 : 
 end, 172: treatment, 173 
 
 Typhlitis : food in, 302 
 
 Typhoid Fever : aphorisms, 289 : 
 perforation, 212 
 
 Uraemia : hemiplegia, 276 : in 
 children, 279 
 
 Whey : 302, 303
 
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 A Manual of Venereal Disease. 
 
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 Introduction by The Director-General of the Army, 
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 THE OXFORD MEDICAL PUBLICATIONS. 11 
 
 Cancer of the Womb : its Symptoms, 'Diagnosis, 
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 12 THE OXFORD MEDICAL PUBLICATIONS. 
 
 Jl Laboratory Handbook f Bacteriology. 
 
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 earliest disorders of the infant, also to the causes and
 
 THE OXFORD MEDICAL PUBLICATIONS. 13 
 
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 A SYSTEM OF SYPHILIS, by various authors. 
 
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 THE OXFORD MEDICAL PUBLICATIONS. 15 
 
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