MODERN MEDICINE. 
BT 
WILLIAM 0. JOHNSON, M.D.' 
Reprinted from the North i^rtfjr^J.873. 
BOSTON: 
JAMES R. OSGOOD AND COMPANY, 
Late Ticknor & Fields, and Fields, Osgood, & Co. 
1873. MODERN MEDICINE. 
BY 
WILLIAM 0. JOHNSON, M.D. 
Reprinted from the North American Review, July, 1873. 
BOSTON: 
JAMES R. OSGOOD AND COMPANY, 
Late Ticknor & Fields, and Fields, Osgood, & Co. 
1873. University Press : Welch, Bigelow, & Co., 
Cambridge. MODERN MEDICINE. 
1. Medicine in Modern Times, or Discourses delivered at a 
Meeting of the British Medical Association at Oxford. Lon- 
don : Macmillan & Co. 1869. 12mo. 
(1.) The General Delations of Medicine in Modern Times. 
By Henry W. Acland, M. D., F. R. S., LL. D., etc., 
Regius Professor of Medicine in the University of Ox- 
ford, President of the Association. 
(2.) Clinical Observations in Relation to Medicine in 
Modem Times. By Sir W. W. Gull, Bart., M. D., 
D. C. L. Oxon. 
(3.) Therapeutical Research in Relation to Medicine in 
Modern Times, as illustrated by Researches into the Action 
of Mercury on the Biliary Secretion. Report by Professor 
J. Hughes Bennett, M. D., F. R. S. E.j etc. 
2. The Physiology and Clinical Uses of the Sphygmograph. By 
F. A. Mahomed, Student of Guy’s Hospital. London Medi- 
cal Times and Gazette, 1872, Jan. 20, Feb. 3, Feb. 24, 
March 2, March 23, April 13, May 18, etc., etc. 
3. On the Use of the Ophthalmoscope in Diseases of the Ner- 
vous System and of the Kidneys ; also in certain other General 
Diseases. By Thomas Clifford Allbutt, M. A., M. D., 
Cantab., etc. London and New York: Macmillan <fc Co. 
1871. 8vo. 
4. On the Temperature in Disease, from the 2d German Edition 
[Das Verhalten der Eigenwdrme in Krankheiten. Leipzig. 
1870]. By C. A. Wunderlich. Translated by W. B. 
Woodman. New Sydenham Society’s Publications, Yol. 
XLIX. London. 1871. 8vo. 4 
5. De VElectrization Localise et de son Application d la 
Pathologic et d la Therapeutique par Courants induits et 
par Courants galvaniques interrompus et continus. Par lo 
Docteur Duchenne (de Boulogne). Troisieme Edition en- 
ticrement refondue, etc., etc. Paris. 1872. 8vo. 
6. On the Pathology and Treatment of Cholera. By George 
Johnson, P. R. C. P., Physician to King’s Hospital. 
Medico-Chirurgical Transactions. Yol. L. Art. X. London. 
1867. 
The long array of titles in medical literature we have thought 
proper to associate with this article need not excite in the reader 
any apprehension that he will be called upon to assist in the 
process of conventional criticism. But we have selected them 
for the reason that, each and all, they march upon the highest 
planes of medical thought, and are themselves the very stand- 
ard-bearers of its advance. Upon their authority we shall rely 
for the ideas we hope to develop, and it is with their assistance 
that we propose to sketch in consecutive narration such accepted 
general principles and such special but essential technicalities 
as shall constitute in reality an essay upon the thesis of Modern 
Medicine. 
Medical men are charged with a liability to fall into one or 
the other of two opposite errors. They are charged with either 
being too content to regard their profession exclusively as an 
art, and with rather exulting in the assumption of an attitude 
of pure empiricism, or, on the other hand, there is ascribed 
to them an ambition to associate medicine with the dazzling 
but often delusive propositions asserted from time to time with 
a confidence which rarely accompanies even the best demon- 
strated facts in science. The truth is, we cannot establish with 
exactness or logical precision many of the fundamental notions 
to which medicine, as a profession, owes its very existence. 
Often we have to depend upon personal conviction alone, 
reasoning to ourselves from , facts which we cannot explain, 
and acting in emergencies solely upon our rapid estimates of 
the probable. Pure Science admits no uncertain elements, but 
we cannot wait for her elimination of them; and when a phy- 
sician, upon a balance of probabilities aloue, acts, as he must, 5 
with a promptness flush with his decision, he is only like the 
navigator who trusts to his instincts in the tempest as readily 
as to his observations in the calm. 
The older physicians conducted their observations in the true 
spirit of science, and reasoned with a caution which grew out 
of their consciousness of the uncertainty of the ground to be 
explored, and of the intrinsic inadequacy of their methods. 
Within certain limits we can place far more reliance upon the 
results of our own observations ; but with more extended and 
precise methods comes the possibility of being found wanting 
in their characteristics of patience and care ; while the ingenious 
mechanical appliances upon which we depend may be as much 
the measure of weakness as the proof of strength ; and though 
by their aid the immediate judgment is rendered less difficult, 
the art of judging as a process of reasoning may eventually 
come to languish from disuse. 
Without any sympathy with purely empirical medicine, we 
are still less in accord with that disposition to remote theori- 
zation which assumes that the spirit of modern medicine 
requires us to subordinate its advance to the vast and exhaust- 
ive generalizations of the science of the day. We can fit to no 
place in practical medicine the new dicta of the speculative 
physicists which assert that “ an action of which we are imme- 
diately cognizant is but the result of the operation of the solar 
heat upon and through independent and correlative existences ; 
that all things in this system are capable only of interchange ; 
that there can be no destruction of that which exists, and no 
creation of new energy ”; “ that the human mind itself, 
emotion, will, and all their phenomena were once latent 
in a fiery cloud ”; “ that all our poetry and science and art, 
Plato, Shakespeare, Newton, are potential in the fires of the 
sun.” 
Now, instead of demanding upon what rests this projec- 
tion of human thought into the infinite unknown, some of 
our outposts concede the very key to our position by the sur- 
render of all notion of a vital principle or a Final Cause. 
This theorem of the conservation of energy controlling the laws 
of affinity and bringing all vital phenomena within the domain 
of physical necessity enters into every conception of organic 6 
change ; and as a corollary, if we cannot separate medicine from 
the indirect any more than from the direct influence of science, 
we must be governed by such remote physical speculations, and, 
abandoning all previous inductions, substitute for them a mere 
collection of undemonstrable postulates. 
We pretend to have learned the methods by which the 
earth’s crust became fitted to produce the chemical conditions 
which render the evolutions of organisms possible,- but we can- 
not describe the commonest chemical changes going on every 
moment of our lives in our own bodies. We assume to fix the 
periods of the earliest geological transformations, but we can- 
not define the simplest of the vital processes. In the words of 
the chemist Bertholet, “ We know nothing of any one of them 
thoroughly, since a perfect knowledge of any one involves the 
perfect knowledge of all the laws and all the forces which com- 
bine to produce it; in other words, a perfect knowledge of the 
universe.” 
The difficulties with which medicine has to deal are not due 
to the vastness of its included subjects, nor to any doubt as to 
their basis in science, but to the fact that it is itself a science 
which is complicated with an art and operating upon one of the 
obscurest of chemical processes. Nothing can be true in medi- 
cine that is not based upon unalterable law, and the law that 
underlies all therapeutic effort rests upon the maxim that living 
matter must act definitely in definite conditions. When failures 
are explained (says Mr. Mill, we believe), they become part of 
the law to which they were supposed to be an exception. 
Chances in disease are its variable causes, and there can be 
no assumption of erratic procedure, only to account for devia- 
tions for which no better reason can be given. 
While the advance in medicine is in a great measure, but not 
so absolutely as some of our authors imagine, correlative with 
the general advance in science, it is by no means so certain that 
those departments with which medicine is the most closely con- 
nected are marching with the rapidity and precision of others 
with which we can claim no immediate relations. In the dis- 
cussions of vital theories, which surely is where general science 
impinges most undeniably upon our pre-emptive domain, we 
find little else than opposed and controverted theories, with 7 
mere fancies more or less whimsical, and dogmas in every 
stage of assertion and rebuttal. Chemistry, on the contrary, 
till quite recently exclusively analytical, has just entered upon 
a new career of combinations ; and as there are really no limits 
to the possibilities of synthesis, we can follow it no further than 
the threshold, and must henceforth gaze upon its progress from 
afar, content with what our pharmacist shall distil from it, 
and grateful for what the chemical physiologist shall give us 
(and take back again) from year to year. But apart from all 
lofty connections and in its own career, medicine, while station- 
ary with all learning for many centuries, is now fairly abreast 
of its tributary sciences, while as a practical art it lays under 
contribution the highest developments of all other arts. 
As the physician can never more hope to comprehend more 
than an insignificant portion of any one of the allied sciences, 
it is consolatory to feel that in limiting the conception of pro- 
fessional duty and requirements to the single department of 
clinical medicine, the pure medical scientist of the future will 
be a far superior intellectual resultant to the quasi-universal 
sciolist of the past. For, as Sir William Gull says, “if it were 
possible to conjoin in one human intelligence all that is now 
known of all other sciences, such knowledge would be compati- 
ble with entire ignorance of clinical medicine.” And bringing 
the subject into these narrow limits which we intend to claim 
as the only proper sphere of the medicine of the day, as the 
phenomena of living tissues are not explained by their chemi- 
cal composition, so the phenomena of disease are not explained 
by the knowledge of healthy tissues or by the action of healthy 
organs. There are problems to which we are not bound to 
give a scientific solution, but which involve an action within the 
resources of art. We find ourselves surrounded by ailments and 
suffering, and in the main we know how to relieve them. The 
outcome of our knowledge is not philosophical contemplation, 
but it is adaptation and action: we cannot wait for absolute 
methods, nor shun the contingency of failure. And then we 
apply our art, “ leaving physiological questions to the physi- 
ologist, and chemical questions to the chemist.” 
Having thus reduced our conception of medicine to its clin- 
ical phases alone, in dissent from the more ambitious flights of 8 
Professor Acland, and having shown, we trust, that while elu- 
cidated by, it is not comprehended in the kindred branches of 
learning, we propose, before commencing the special subjects 
included in our general purpose, to point out a few changes 
in the broader ways of medical thinking. 
In uniform conditions of human life, individuals are mainly 
alike, and are equally susceptible to physical ailments of what- 
ever origin. Their occupations are the same, their food at 
given seasons is the same. Among savage nations, therefore, as 
the type of an identity of condition, we are not surprised to find 
whole tribes or communities carried off by a general epidemic, 
or by a single disease, like leprosy, plague, or small-pox. From 
the diversity of conditions in civilized life, on the contrary, there 
arises an immense variety of ailments to be studied. The 
diagnosis of these ailments, or the art of distinguishing a given 
one from all others, rests upon the basis of knowing the sum 
of the possible in morbid processes. But what is exhaustive in 
the pathology of to-day may be very far behindhand to-morrow. 
For while the whole subject of morbid anatomy is said to have 
been studied out to its ultimate, to be in fact an exhausted 
mine, such a conception of it must only turn, we fancy, upon 
whether its phenomena are now to be ranged as causes or as 
resultants. And next to the possible in disease come the 
second elements in the probable, as learned from the largest 
and most varied experience. 
Our danger will always lie in deviating from our own narrow 
but trustworthy path, and wandering away into the tempting 
fields of physical or chemical analogy. Yielding to external 
importunity, we are induced at one time to look upon the human 
body as a sort of undeveloped galvanic battery, and at another 
we fancy it to be simply an animated oxidizer, and that all our 
ailments arise from defects in its machinery or obstructions in its 
chemical processes. Not very long ago the microscope seemed 
likely to disintegrate all large conception of clinical phenom- 
ena, and to tie us down to what Nelaton called the beetle-eyed 
habit of observation. Nor should we leave out of the reckon- 
ing a method of studying disease by columns and averages, 
calling itself in its short-lived day the “ Numerical System,” 
and which never, as it pretended to do, at any time replaced 9 
opinions by facts, but which really retarded the scientific 
induction and philosophical study which are the characteristics 
and the pride of the present day. Its labors were wasted in 
mere counting-house puerilities with disjointed and irrelevant 
details, and for years some of the foremost men in France and 
America, but never, we believe, in Germany or England, found 
no better occupation for their faculties than the inconsequent 
tabulations and the fatuous arithmetic of this happily effete 
substitute for medical observation. 
Modern medicine inclines to regard diseases no longer as 
distinct entities, but rather as perverted life-processes with 
their proper access, culmination, and decline, requiring only 
time and rest for their completion ; and it is not by setting up 
distinct'conceptions in opposition to the standards of health 
that these processes are best to be studied. Perverted func- 
tions must be attributed to failure of action, not to excess of it, 
and we are to watch the very first deviations and shortcomings 
from the condition of health itself. Organic strength is now 
known to exist in full nutrition and in healthy function only, 
never in their perversions. But we are still hampered by the 
old nomenclature, and with the clearest conceptions we cannot 
always avoid confusion and apparent contradictions. The terms 
“ sthenic ” and “ asthenic ” are relics of the old “ phlogiston ” 
which itself still survives in the expression “ anti-phlogistic.” 
Strength and weakness are descriptions of no value in semei- 
ology; they are deduced from subjective and only superficial 
phenomena. The quickened pulse, the acute delirium, the 
burning fever, all once supposed to indicate a preternatural 
strength, are but the tokens of a deficient balance-power, and 
heat itself has come to be the surest measure of organic waste. 
The terms “ zymosis ” and “ zymotic disease ” have for a 
long time held a position in medicine for which no valid reason 
can be given. There is really no clinical condition which we 
can intelligibly or with any propriety define as fermentation. 
The specific tokens of a fever are to be found in its attendant 
tissue-changes, not in the multiplication of hypothetical organ- 
isms. “ Zymosis ” in classification is the superfluous survivor 
of the old scholasticism which generally explained the obscure 
by something that was still more obscure. 10 
In every part of the body are developed proclivities to some 
special morbid action, with its appropriate mode of repair, whose 
course of life is as natural as that of the tissues from which it 
springs. We may take as the type the plastic lymph which 
helps on the resolution of the inflammations of the lungs, of the 
heart, and of their investing membranes. Knowing these 
intrinsic tendencies, we trace back the morbid action to its 
sources, and are prepared for its coming results. The brain 
also, without apparent cause, is liable in the adult to the forma- 
tion of tumors, and in the young to insidious softening ; from 
certain external phenomena we are led to suspect these condi- 
tions, finding a meaning in elements once entirely overlooked ; 
and mere symptoms have come to be of little value in any dis- 
eases of the brain. Studying them only from books, we read 
of the most diverse affections presenting identical symptoms, 
and the most extensive lesions developing no symptoms at 
all; while in their pathological study the whole catalogue of 
symptoms may have one after the other appeared, and not the 
trace of disease have been left. 
Certain textures are prone to morbid action, while others are 
almost sure to be free from it. Portions of a single continuous 
tissue have the same liability or exemption, and why, we cannot 
say; but knowing the fact, we may distinguish with certainty 
the structures of the parts affected. We recognize analogies 
between the infantile and the senile affections, as different and 
as like as “ the tints of the rising and of the setting sun.” 
Special forms of convulsions, of abdominal pains, of skin dis- 
eases, of uric-acid deposits, are common to both periods, and 
reveal alike the failing power of degenerating tissues in age, 
and inadequacy of power in the growing tissues of infancy. 
A number of very common acute disorders are now believed 
to be secondary to latent chronic lesions, or dependent upon 
distinct degenerations, the potential lesion of causation being 
unnoticed in the storm of symptoms it has excited. Some of the 
acute inflammations within the abdomen and the encephalon are 
only the ultimates of a morbid process of many years’ duration, 
and a disease, long regarded as local, turns out to be not the 
sole or immediate cause of death, or even the most important 
change. And we now comprehend, as never before, the old 11 
Hippocratic axiom, “ Diseases do not fall upon men instantane- 
ously, but being collected by slow degrees explode with accumu- 
lated force.” These unquestioned facts of the changed relations 
of acute and chronic disease, like all reversals of long-estab- 
lished opinions, are in danger of leading to the opposite ex- 
treme, and Sir William Gull especially seems to entertain the 
conviction that acute disease is, upon the whole, more likely to 
be the result and not the cause of accompanying chronic lesion. 
Where extreme views of this sort are once fixed, the pathology 
can always be made to conform to the theory ; and as it is very 
difficult in post-mortem inspections to determine with exactness 
the cause of death, we should be wary lest the scalpel and the 
microscope give us back only our own a priori conceptions. 
The general belief that chronic conditions are mainly the result 
of irremediable acute ones is too firmly fixed to be reversed but 
with the greatest caution.* 
* After these passages were prepared for the press, we received from England a 
copy of the “ Medical Press,” published in Dublin, of the issue of January 15. 
Among its contents are the reports of the medical attendants of the late Emperor 
Napoleon III. upon the causes of his death. It will be remembered, perhaps, that, 
from its suddenness, this was at first attributed to embolus and afterwards to 
chloroform. We shall transcribe the lesions actually found after death. They furnish 
a striking comment upon the determination with which even a philosophical mind 
will carry out a preconceived theory, and, as we intimated in the text, make the patho- 
logical appearances conform to it. They furnish, in fact, a swift and complete 
confirmation of the objections we ventured to raise in our criticism of Sir William 
Gull’s opinion as to the relations between acute and chronic disease. That very 
eminent man could not have desired a better opportunity to illustrate his theory, 
and it was inevitable that he should avail himself of it. We feel bound, therefore, 
to reproduce the facts in the case at length ; as we had already asserted that any 
fixed general notion of this kind would be likely to lead to error under circum- 
stances where the fact of priority of condition must be a matter of conjecture 
mainly. 
The autopsy of the Emperor was made by Dr. J. Burdon-Sandcrson, in the pres- 
ence of those whose names are appended to his report. Sir William Gull does not 
appear to have been present, but he has placed upon record his dissent from the 
opinions of those who were, upon a single point only, and that point involves the 
very matter upon which we had taken issue with his theory. 
It would seem that an impression prevailed in England that the true nature of 
the Emperor’s complaint had never been detected by his French advisers ; and the 
facts which were developed in the communications this belief elicited prove the long 
existence of the more potential cause of death, and disprove entirely the assumption 
upon which Sir William founds his non-concurrence; while they also show, which 
is not so much to our purpose, however, that the French faculty were perfectly 
acquainted with the nature of the case. 12 
There are drawbacks in the medicine of the period. It is 
inclined to neglect the broader study of general diseases for the 
closer methods in diagnosis alone, and to assure it by ingenious 
aids. Its exclusive study of small portions of the body limits 
the mind to a localized pathology. It is even to the disadvan- 
tage of skilled auscultation that it diverts attention from the 
more general cause which has induced the local affection ; and, 
finally, it is only the local or special diseases that are now con- 
sidered fit subjects for monographs. 
On the whole, the more careful study of morbid processes has 
resulted in the isolation, not only of the individual, but of the 
separate life of his special organs and tissues ; of which the nat- 
ural and fortunate consequence is a method of treatment ap- 
“ The most important result of the examination was, that the kidneys were found 
to be involved in the inflammatory effects produced by the irritation of the vesical 
calculus (which must have been in the bladder several years) to a degree which was 
not suspected ; and, if it had been supposed, could not have been ascertained. Death 
took place by failure of the circulation, and was attributed to the general constitu- 
tional state of the patient. The disease of the kidneys was of such a natnre and so 
far advanced, that it would in any case have shortly determined a fatal result. 
“ Signed by all present:— “ J. Burdon-Sanderson, M. D. 
Dr. Conneau. 
“ Le Baron Corvisart. 
Henry Thompson. 
J. T. Clover. 
John Foster. 
“ Camden Place, Chislehukst, January 10,1873,'6.30 p. m.” 
Sir William Gull records a separate opinion on one point only, namely, the origin 
of the calculus, in the following terms : — 
“ I desire to express the opinion that the phosphate of lime calculus which formed 
the nucleus of the mass was the result of the prior cystitis, not the cause of it. This 
nucleus was of uncertain duration, and may even have been more recent than sup- 
posed in the appended report.” “ It seems, to my judgment, more in accordance with 
clinical experience to regard the cystitis [inflammation of the bladder] as the prior 
lesion, and that this by extension, as is common in such cases, affected subsequently 
the ureters and pelvis of the kidneys. No doubt in the later stages of the malady 
the calculus by its formation and increase was an augmenting cause of the lesions.” 
(The italics are ours.) 
Now, as we learn from the Union M&dicale, “On July 1, 1870, the Emperor 
Napoleon feeling very ill, a consultation took place between Doctors Nelaton, 
Ricord, Fauvel, Corvisart, and See. Their diagnosis was that of stone, and an 
immediate operation was recommended.” But from political considerations “ the 
disease was allowed to go on augmenting for two years and a half.” As the “ Press ” 
remarks, “ the report is in strict accordance with clinical experience, and, what is 
more to the point, with the clinical history of the case itself.” 13 
plied to the individual, and not to the name we may have to 
give to his complaint. His own life constitutes the individual, 
and all the alterations of that life, therefore, are individual and 
not general. One person dies in an epidemic, and another 
recovers, from causes peculiar to these individuals. Only to 
the charlatan is disease a congeries of symptoms, for every 
one of which its special drug has been catalogued. 
Certain abnormal conditions have now ceased to be regarded 
as diseases. Mere “ ailing ” is as natural a process in advan- 
cing age as health. “ The Diseases of Advanced Life,” so ably 
treated by Dr. Machlachlan, who studied them among the Green- 
wich pensioners in his charge, might more properly, we fancy, 
be entitled “ The Natural History of Old Age.” The natural 
changes of age only simulate the diseases of a younger period, 
and even well-marked special diseases once fastened irremedi- 
ably upon the system lose their distinctive characteristics and 
become merged in general decay ; and this view has been 
recently corroborated most strikingly by the facts developed in 
relation to a recent discovery at Vienna. 
The now well-known tendency of renal disease and its con- 
sequent ill-nutrition to induce chronic or sub-acute inflamma- 
tions in the encephalon, we can allude to more conveniently in 
another section of this article. 
A great variety of related phenomena from a single cause, 
varied by individual tendencies, were formerly classed as half 
a dozen different diseases. The term epilepsy once denoted a 
special morbid state with convulsions and unconsciousness. 
We see in it now a condition of disturbed molecular nerve 
force, such as is likely to occur in any other aggregate of mole- 
cules, in which may occur not only the common phenomena of 
epilepsy, but coma without convulsions, paralysis following con- 
vulsions, sudden and transient mania, and peculiar forms of 
neuralgia; we must therefore cease to give reality to such an 
affection apart from its phenomena. 
Among the new connections in which old symptoms appear, 
there are two which deserve special mention as trophies of 
more minute exactness in study, namely, embolus and loco- 
motor ataxia. To Virchow of Berlin we are indebted for a 
pathological discovery which has cleared up many obscurities. 14 
Minute doses of fibrine, or coagula of blood, called thrombi, 
become detached from the chambers or valves of the heart, 
travelling either in small particles or in masses to the smaller 
arteries, or they may course along the veins back to the heart. 
To the coagulation of blood in the living vessels, starting from 
the fact that arrested blood coagulates at the temperature of the 
body, 98° F., Virchow has developed his theory of the “ inflam- 
mations of veins ” as it was before regarded, and explains many 
results formerly attributed to “ palsy of the heart,” “ retroces- 
sion of gout,” “ metastasis,” “ sudden death,” etc. To the 
formation of clot Virchow gave the name of thrombosis. The 
projection onwards of the clot or thrombus along the vascu- 
lar system is called embolism, and the whole series of actions 
is now known specifically as embolus. From this discovery, as 
it may almost be called, many things before involved in mystery 
are brought to light and arrange themselves in definite order, 
enabling us to anticipate the occurrence of other results, and 
to prevent them. 
The ataxie locomotrice, first described by Dr. Duchenne of Bou- 
logne, is the result of a degeneration of the posterior columns 
of the cord which, after all the discussion, is the main and dis- 
tinctive seat. Dr. Baillie, however, had proximated the matter 
in his description of a sort of “ paraplegia, from excessive morbid 
secretion of the cerebro-spinal fluid, which in the erect posture 
gravitates to the lower part of the sheath ” and pressing upon 
the cord embarrasses the co-ordination of movements. The 
isolation of the motor columns in this affection harmonizes 
with an old physiological notion, that these parts had their own 
vitality and a separate function, being mere commissures or con- 
necting bands: textures limited to such a function may have a 
lower vitality than others whose functions are more essential, 
and at the same time a greater tendency to disease than those 
of higher vitality. 
Having stated much that has been learned of late, let us 
confess to a little ignorance and to a few wants. We do not 
know why it is that in the two poisons, cholera and diphtheria, 
both developed on mucous surfaces from the blood, all the 
salines and water are poured out in the one, and a fatal effu- 
sion of fibrine takes place in the other. The cattle plague and 15 
the horse disease are as far removed as possible beyond the 
reach of cognition or prevention. Do what we will, epi- 
demics must always he anticipated in some form or other, and 
hygiene can never replace therapeutics. Finally, we are 
sadly in want of simple and ready means to recognize chem- 
ically the urinary morbid products as easily as we now detect 
sugar and albumen. They are largely connected with changes 
in health and disease, and chemistry still owes such methods 
to medicine. 
The Sphygmograph. — Our purpose requires no comment upon 
the pulse. Well studied by the ancients, during the Middle 
Ages any reliance upon it was generally regarded as a super- 
stition in the category of astrology; “it was doubted if its 
varieties, as described by Galen, could really be observed or 
understood.” The pulse, however, will always be recognized 
as the unerring index of a function whose continuance is essen- 
tial to life. Not only must the heart not cease its action for a 
single moment, but we are suspicious of the slightest token 
that it wearies or faints at its work, for the issues of its halting 
are the issues of life and death. Apart from its immediate 
connection with the special disorders of this great centre, the 
pulse has not lost its position as chief among the methods of 
finding out the working of every portion of our physical 
machinery. The sense of touch, however, is not only decep- 
tive, but it cannot be taught; no teacher can ever impart to his 
pupil the experience or knowledge that his own well-educated 
finger derives from the pulse. The sense of sight, therefore, is 
not only a much more reliable guide in itself, but it is a far 
better medium for description and instruction. 
Galileo was the first to conceive the idea of recording accu- 
rately and visibly the characters of the pulse, and he con- 
structed for the purpose what he called a pulsilogia, which 
made no impression in its day and left no trace but its name. 
Yierordt invented a sphygmograph, but it was full of fallacies 
and of no clinical value. The name of Marey is now ex- 
clusively associated with the modern instrument which is made 
to register the pulse-shock and the wave of the blood column 
along the arteries. 
The sphygmograph is essentially an arrangement of levers 16 
by which the wave as transmitted is increased in apparent size, 
or rather exaggerated in action, by movements similar to those 
of a small upon a larger wheel. An ivory pad rests upon the 
artery, usually that at the wrist, the rush of blood along the 
vessel lifting the pad perceptibly even to the eye. But how- 
ever slight the movement, it is sufficiently exaggerated by the 
levers to procure a distinct tracing of its normal outline and of 
its every variation. The impulse received by the ivory is 
transmitted by a long slip of light and flexible wrood, at the 
opposite or free extremity of which is affixed a fine steel point, 
which we will call the stylus. By a secondary arrangement, a 
slide, placed at a right angle with the lever and in contact with 
the stylus, is made to move by mechanical appliances from 
right to left across its point, so as to give when in motion, to the 
liftings of the pad and to the movements of the lever and of 
the stylus, the effect of tracings in free running hand from left 
to right. The rate at which the slide moves is made to corre- 
spond with the time required by each pulse-wave to effect dis- 
tinctly the whole of its individual tracing, that is, the rate of 
about four inches in ten seconds. At this rate of speed, each 
impulse occupies about four tenths of an inch in space upon the 
slide, and we here premise that the spaces and lengths to be 
spoken of assume a healthy pulse, without pressure and with 
the motion of the slide graduated to this rate. We may also 
state that the instrument as it was left by Marey, like most 
mechanical appliances requiring practice and skill in manipu- 
lation as well as judgment in induction, has usually sunk out 
of sight as fast as introduced. It had faults and imperfec- 
tions which speedily destroyed its reputation for reliability, and 
at last it came to be scarcely mentioned even in medical text- 
books. In fact, it had dropped into what seemed to be its 
natural place as simply a physiological curiosity. The mon- 
ographs upon its uses, especially that by Dr. Burdon-Sander- 
son, are more in the nature of scientific treatises than adequate 
guides to its clinical use. 
These considerations were probably what induced Mr. Ma- 
homed, a student of Guy’s Hospital, to commence an extended 
and exclusive study of the subject, and by his improvements in 
the instrument, accommodating its movements to the feeblest 17 
pulse, and with the advantages of a nearly perfect mechanism, 
he has been enabled to present, not only a new method, but a 
new literature of the sphygmograph. 
Although a pen actually dipped in ink may be made to do 
spliygmographic writing upon white paper, the best register is 
a tracing by the steel point upon smoked paper made portable 
and permanent by varnish. And if the reader will now at- 
tempt to form a mental picture as he goes along with us, we 
will endeavor to clear up the mystery of the sphygmograph as 
intelligibly as it can be done without diagrams, at least to give 
some conception of the simple process by which the heart is 
made to write out a description of its own ailments at the end 
of a telegraphic wire a thousand miles away. 
The first impulse imparted to the pad by the artery sends 
the stylus suddenly upwards on the smoked paper, scratching a 
straight line of about half an inch or less in vertical height. 
This first up-stroke is called the percussion stroke, and pro- 
ceeds from the shock received by the blood-column as a solid 
body, on the bursting open of the aortic valves as the blood 
leaves the heart for the general circulation, — a shock communi- 
cated almost instantaneously to the whole arterial system. In 
the normal condition this stroke is distinct from the true pulse- 
wave ; if confused or identical with it, it becomes a sign of dis- 
ease. It is the index of a healthy suddenness and force of the 
heart’s contraction, and measures its muscular strength or 
weakness in acute disease, but it is not a guide as to the rela- 
tive amount of blood forced into the aorta for-distribution. 
After marking the percussion stroke, the stylus next drops 
about a tenth of an inch, at a slight distance away from the 
vertical line and making a very acute angle with it, and its 
descent is cut short at this point, and sometimes pushed slightly 
up again, by the distension of the artery by the true tidal wave. 
Its next fall forms a curve with the concavity downwards. Up 
to this point the whole tracing is called the percussion wave, 
from the starting-point of the percussion stroke to the end 
of the first curve; and the space between the vertical line 
and the next regular ascent of the stylus measures the time 
elapsing between the opening of the aortic valves and the 
arrival at the wrist (of the tidal impulse). Next follows the 18 
second up-stroke and fall of about half the height of the verti- 
cal line, whose force and comparative height measure the 
amount of blood forced into the arteries; and the degree of 
pressure, usually about twenty pounds, required to extinguish 
it, shows the actual propulsive force of the heart’s contraction, 
a much slighter pressure being sufficient to efface the percus- 
sion wave. We are now about half-way over the inter-vertical 
space, as we may call it. The next motion traces a curve with 
its concavity upward, and the notch from which it starts is 
called the aortic notch, and the impulse ends with the closure 
of the aortic valves. The second elevation is due to arterial 
expansion, and the whole stroke ends with a gradual fall of the 
stylus to the base line corresponding with the collapse of the 
artery. This base line*, drawn through the bottoms of all the 
vertical lines, Marey’s ligne d? ensemble, is curved, with its con- 
vexity upward on forced expiration, and conversely, on forced 
inspiration, it forms a downward curve, and might be called the 
respiratory line. The whole pulse, then, is divided into two 
parts, corresponding with the contraction and the dilatation of 
the chambers of the heart; and we are now prepared to see 
what the deviations from these normal characteristics indicate, 
as derived from a few simple inductions. 
First, the graduated amount of pressure required to efface 
the tidal wave shows a hard or a soft pulse. Secondly, the 
verticality of the percussion stroke and its proportion to the 
tidal wave show a slow and feeble or a sharp and strong heart 
action. Thirdly, the height of the tidal stroke shows the 
amount of blood expelled from the ventricles. Fourthly, the 
degree of convexity of the succeeding curve indicates the 
amount of obstruction to the arterial collapse from any cause. 
Fifthly, the dicrotic ascent or rebound indicates disturbed 
relations between the heart’s contraction and the arterial 
tension. Sixthly, the spaces indicate the relative duration 
between contraction and dilatation ; and seventhly, the con- 
vexities of the lignes <Tensemble show the effect of the act of 
respiration upon the pulse. 
The pulse of every individual is as characteristic of him as 
his intonations or carriage, and we do not doubt but that the 
sphygmograph might sometimes settle questions of personal 19 
identity; but in disease the pulse loses this individuality, and 
varies with the general circulation. The spliygmograph has 
differentiated between diseased conditions of the brain, which 
even the ophthalmoscope had left in doubt. But it should not 
be forgotten that its action is circumscribed and its value limited. 
It is the index of the vital and dynamical condition of the cir- 
culation alone. We have only to add that tracings can be taken 
from the apex-beat of the heart, when they are called cardio- 
graphs ; they are wanting in the finer details we have above 
specified. 
The Ophthalmoscope. — What we have to say of the ophthal- 
moscope will be limited to its uses in general diseases; with its 
employment by the specialists in the examination of local affec- 
tions we have nothing to do. Nor is it necessary to describe 
the well-known little mirror which is a part of the programme 
in the visit to the “ ophthalmic surgeon.” Invented by Helm- 
holtz, but brought into its present use and nearly perfected 
by Liebreich, it certainly has worked a revolution in ophthalmic 
science. It may not be superfluous, however, to remark, that 
the instrument in question is primarily a concave reflecting 
mirror with a perforation in its centre, which catches the 
rays from a light placed by the side of the patient’s head, and 
throws them back to the bottom or fundus of the eye, which 
is itself a part of the magnifying power. Any transparent 
reflecting body is an ophthalmoscope, and with an ordinary 
lamp sufficient light is returned from the concavity of an 
ordinary watch-glass to exhibit all the details at the back of 
the eye ; and it is said that it possesses the advantages of not 
requiring dilatation of the pupil by atropia. We do not be- 
lieve, however, in simplifying or extemporizing processes in so 
important a matter as diagnosis of optic changes. The most 
perfect instruments and skilled manipulation, with every ac- 
cessory to facilitate the examination, should be made use of, 
nor should our own judgment be trusted till after long practice 
and many comparisons. 
The specialists Graefe and Liebreich were the first to observe 
the effect of constitutional lesions in the structure of the eye ; 
and although great progress has been made in their study by 
both French and English physicians, the first English classic on 20 
the subject is but hot from the press, — the beautiful volume 
by Dr. Allbutt. Ophthalmoscopy has been for years gaining 
ground in medicine entirely distinct from its specialistic utility. 
But a short time ago an eminent London physician said to 
the author, “ It is nonsense to pretend to localize diseases 
within the encephalon; ingenious guesses you may make, 
but such guesses seldom prove to be worth much in the dead- 
house.” 
Clinical observation in this direction has been stimulated by 
the great advance in our knowledge of the morbid and the 
minute anatomy of the central nervous system. The brain is 
so complex and inaccessible an organ that it has kept out of 
the reach of the rigorous analysis which has of late changed the 
whole aspect of medicine. The inspection of its actual morbid 
processes will go far to disperse those transcendental habits of 
thought which, driven from every other position, still have 
their foothold in the brain, and to establish the fact that as its 
functions are only the movements and relations of its tissues, 
so the diseases of the encephalon can only be the abnormal ac- 
tion of its component parts. 
Disturbed vision or absolute loss of it has always been known 
as an attendant upon diseases of the brain. Soon after Bright’s 
discovery of the connection between albuminuria and renal dis- 
ease, amaurosis was noticed as an occasional symptom of the 
new disease. The ophthalmoscope discloses not only the mode 
by which sight is thus affected, but that very process itself 
makes important revelations as to the remote cause residing in 
the kidneys. It not only tells what we could not otherwise 
know, but it is sometimes the only solution of a difficult prob- 
lem, and in distinguishing and foretelling results its value is 
immediate and irreplaceable. 
But it must not be forgotten that the use of the ophthalmo- 
scope in general medicine is limited to that state of the intra- 
cranial circulation shown in the vascular system of the optic 
nerve and retina; nor is it infallible here. As we have intimated, 
the interpretation of phenomena by it is not easy, and the 
absence of change in the retina may coexist with abnormal 
cerebral circulation. 
The indication of cerebral disease through the optic nerve is 21 
due to its great vascularity, its large share of connective tissue, 
and its contiguity with the parts at the base of the brain. The 
nerve and the retina are independent of each other in their vas- 
cular supply ; the central artery and vein of the retina lie among 
the fibres of the nerve, but distribute no branches to it. But 
in the optic disk, which is the great centre of observation, a 
network of vessels connects together the nerve and retinal ar- 
teries, etc. The disk therefore is closely connected with the 
cerebral vascular system, and is the best index of its condition 
and disturbances. An inflamed or congested optic nerve may 
be watched from hour to hour, and false conclusions be avoid- 
ed, even if the cause cannot always be known and located, 
and its nature, often more important than its seat, be ascer- 
tained. Before the connection between changes at the back 
of the eye and the effect of intra-cranial blood pressure upon 
vision were known, the utmost confusion prevailed as to the 
cause of the disturbance. At one time a tumor would bo 
found pressing upon the optic nerve or ganglia; at another 
identical phenomena would occur without tumor, and the sym- 
pathetic system, the original sin of baffled nerve science, would 
be suggested as the offender. The most careful clinical ob- 
servers are still in doubt as to the actual value of optic changes 
in the diagnosis of tumor, though Dr. Allbutt avers that noth- 
ing is more certain than that “ intra-cranial tumors commonly 
give rise to changes in the optic disk.” Without entering into 
any discussion of disputed points, we propose, in accordance 
with our plan, to state a few illustrations of the clinical uses 
of the ophthalmoscope. 
The “ choked disk,” ischcemia, is due chiefly to such causes 
as distention of the ophthalmic veins, inflammation of the brain 
membranes, hydrocephalus (the affections of youth), and tu- 
mors ; conversely, acute and chronic softening, hemorrhage, 
hardening and arterial degeneration (the affections of age), do 
not cause it. The appearance called neuro-retinitis is an ex- 
tension of inflammation from the brain, especially if its seat be 
near the optic tracts. What seems remarkable is, that no in- 
ferences can be made as to the state of the optic disk from 
degrees of vision. Choked disk, nerve inflammation, and ad- 
vanced atrophy may all exist without any affection of sight, 
without pain, and without sensitiveness to light. 22 
The study of some particular affection will give a better 
insight into the value of the instrument in general diseases 
than any other course, and we will take for this purpose epi- 
lepsy. Between the paroxysms of epilepsy, the optic disk is ob- 
served to be of a deeper red, the vessels are larger than normal; 
during the convulsions the disk is of a pinkish color, the arteries 
are small, the veins large; after the fit the disk is pale, the 
arteries small, and the veins are unchanged. As consciousness 
returns, the disk becomes of a deeper red, the arteries are larger, 
and the usual retinal appearances return. The stage of stupor 
indicates a general condition of anaemia. These appearances 
confirm the present theory that epilepsy is due to anaemia, and 
not to congestion of the cerebral vessels. If maniacal excitement 
follows the fit, there is even more congestion. The degree of 
congestion is in direct ratio to the number of fits and their 
severity. Now when the fits are reduced in number by bro- 
mide, the congestion is lessened ; but if the fits recur with their 
former frequency, the congestion returns. It is inferred there- 
fore that the reduction of congestion is not due to the imme- 
diate and direct action of the bromide on the blood-vessels, but 
is due to the absolute reduction in the number of the fits, pos- 
sibly through some other action of the bromide, which loses its 
power to control the morbid tendency after the constant vas- 
cular disturbance caused by the fits has led to marked passive 
congestion, but frequently controls it when congestion is not so 
far advanced. We thus arrive at a modification of the general 
belief as to the action of bromide absolutely, and at some 
knowledge whether it is likely to be of benefit in a given 
case. 
In renal disease the most conspicuous change is retinitis, 
with subsequent degenerations of and about the disk, so charac- 
teristic as to be at once recognized as due to albuminuria; not 
confined to any one form of renal disease, but most common 
with contracted granular kidney. It is believed that these 
initiative changes in the retina are set up originally by uraemic 
poisoning. The mirror reveals two classes of eye-affection, 
those due to uraemia, which are sudden and temporary, and 
more gradual impairments arising from visual degenera- 
tion. 23 
Spinal disease, if chronic or if slow in access, is detected by 
optic changes. If it arise from injury, the higher its seat the 
sooner the after-changes appear. These changes are, first, 
simple primary atrophy, which is never the result of injury, but 
is common in chronic degeneration of the cord and in locomo- 
tor ataxia. Secondly, indistinguishable retinal arteries with 
swollen, dark, and tortuous veins; the disk red, its borders 
lost; these are seen only in injury, never in degeneration or 
ataxia. 
As new instruments of precision open new avenues to knowl- 
edge, so an improved method stimulates research, and the mind 
itself is invigorated by the new opportunities, and from habits 
of accurate and industrious observation comes that intimate 
knowledge which is founded upon facts, however they may 
oppose tradition. 
The Thermometer in Disease. — In 1754, Antonius de Haiin, 
the first known teacher of clinical medicine in the Hospital of 
Vienna, taught his pupils to ascertain the temperature of the 
body in fevers according to the measurements of the ther- 
mometer, and not through the impressions received by the 
hand. It had not escaped notice, even at that period, that in 
the cold stage of ague, with chattering teeth and shivering 
skin, pallid and cold from contraction of its blood-vessels, the 
temperature of the body beneath was rapidly rising, and even 
with the rude instruments of the period the increase of heat 
could be accurately measured. The hand of the physician and 
the feelings of the patient are alike fallacious and unsatis- 
factory. 
The instrument of precision now exclusively used in obser- 
vations of animal temperature is a sensitive mercurial ther- 
mometer, graded between 85° and 115° Fahrenheit, self-regis- 
tering, and measuring with fifths or even tenths of a degree. 
As a rule, the temperature is taken at the armpit, the skin 
being folded over so as entirely to cover the bulb, at different 
periods both of the day and night, and the daily changes are 
accurately noted on the proper thermometer charts. We must 
start from the normal standard of fluctuations within the limits 
of health, and with the correlations of animal heat with the 
pulse and respiration. 24 
The normal heat of sheltered portions of the human body is 
98°; and a rising above 993.5, and a depression below 97°.3, 
if persistent, are certain signs that disease of some definite 
type is present, or, as we should express it, some special devi- 
ation from health. But there have long been on record obser- 
vations on normal temperature under variable circumstances 
within the limits of health: those communicated by Sir John 
Davy to the Royal Society disclose the following facts: — 
In temperate climates the maximum temperature is in the 
early morning; after waking it fluctuates till nightfall, and is 
lowest about midnight, but the average difference is less than 
one degree (0\82). In tropical regions the minimum is in 
the early morning; after waking it fluctuates, and is highest 
during the day. Davy also observed that “ an undue degree 
of elevation was some criterion of the intensity of diseased 
action.” 
Animal heat is affected by a great variety of collateral cir- 
cumstances, but the great distinction between the variations 
of health and those of disease is, that the first are temporary 
and within narrow limits, amounting to mere fractions of a de- 
gree ; those of disease are of much greater extent, and persist 
during the continuance of such disease. Besides changes due 
to physical exertion, atmospheric changes, etc., it is ascertained 
that sustained mental exertion depresses heat half a degree; 
that after a full meal or the use of alcohol, heat is at first 
reduced, as digestion advances the temperature rises ; that 
the average temperature in the tropics is one degree higher 
than in temperate zones; that the temperature is more sensi- 
tive and more readily and rapidly affected than either the pulse 
or the respiration, especially in disease. The degree of abnor- 
mal increase of heat is usually in proportion to an increased 
frequency of the pulse (about one degree to ten pulsations), 
and is in direct ratio to the severity of other general signs of 
disease ; and where disproportion or incongruity exists between 
the heat and the pulse, or other febrile phenomena, as some- 
times happens, the accurate measurement of the temperature 
is the most to be relied upon. The maintenance of the tem- 
perature within its known normal limits is a complete assur- 
ance that any disturbance shown by other clinical indications 25 
must be local and unimportant; and in military practice it dis- 
closes whether disease is feigned or real. 
The conditions in which the thermometer serves a purpose 
which no other means can attain, are fever and tissue-waste. 
The essential element in fever is preternatural heat. Our 
knowledge of the natural history of febrile diseases has reached 
great exactitude and certainty during the past few years, hut 
heat, after all, is the important feature. Whatever other 
theories have prevailed during twenty centuries, heat bears 
the same relation to fever as in the time of Galen. It is never 
absent; without it fever cannot exist. Eigors and chills are 
mere external phenomena; the sensations of heat and cold are 
subjective impressions due to the special condition of the 
peripheral nerves, not to any absolute condition of the tem- 
perature ; and conversely, while the skin may be ice-cold 
to a bystander, the patient may feel that he is burning up 
within. 
Some of the most exact and useful observations were made 
long ago in our own country by Dr. Joseph Jones, late Sur- 
geon-General of the Confederate forces ; but beyond everything 
in the way of recorded observations are those of Wunderlich, 
the Leipzig professor, whose book, translated by the New Syden- 
ham Society, contains the record of half a million of exact 
thermometric observations, following the continuous process of 
nearly every human form of disease, and comparing the results 
from more than five thousand patients. Among them are in- 
stances where disease was demonstrated by the thermometer 
before it was possible to detect it through any other means, and 
sometimes a definite diagnosis was based upon a single obser- 
vation. Sir John Davy gives a singular instauce of rise in 
temperature where it was impossible to recognize disease by 
any of the ordinary methods. A lunatic soldier had for many 
weeks a temperature of 104°. The insane do not suffer from 
cold and heat like others, and certain organic lesions are apt 
to occur in them without the usual symptoms. This man made 
no complaint; his appetite and digestion were good. He died 
at the end of a month of acute tuberculosis, without any other 
symptom from first to last than this great and persistent eleva- 
tion of temperature. There were ulcers in the larynx which 26 
had not affected his voice ; there were large cavities in the 
lungs which had not caused cough; there was ulceration in 
the intestines without diarrhoea; and various other lesions, all 
masked and latent. 
There is no form of illness characterized by fever which the 
thermometer cannot accurately distinguish, and recognize the 
type of; and if it be of an anomalous type, its departure from 
known types may be defined and described. But its most im- 
portant use is to mark the daily changes in the condition of the 
individual affected : the development and progress of his febrile 
state, its abatement, subsidence, and defervescence, and the 
approach of local lesions. The term “ defervescence ” indicates 
the period during which the temperature of the fevered body is 
declining from the intense degree of heat which marks the 
state of accession towards the normal standard ; if sudden, the 
defervescence is called crisis; if gradual,lysis. 
Some of the best established clinical inductions in medical 
thermometry are as follows: The highest temperatures just 
before death have been observed in scarlet fever and in lock- 
jaw. When the temperature goes above 99°.5 we know that 
the patient is ill from some definite cause ; if it rises to from 
101° to 105°, febrile phenomena are present with great severity ; 
if it goes above 105D, the patient is in imminent danger ; in a 
range from 106° to 109°, a fatal result is all but certain and is 
immediately at hand. In any disease, a temperature of 104° 
or 105° shows that its progress is not checked, and that com- 
plications are still possible. The thermometer, therefore, is 
the best and earliest warning of an additional development of 
disease, or that some visceral complication has occurred ; and 
if in any accurately distinguished case of disease the temper- 
ature departs from its normal and typical range for that disease, 
we are to anticipate trouble. As convalescence only com- 
mences when the disease process ends, we know that it cannot 
occur till the normal temperature returns and maintains itself 
through all periods of the day and night, and during conva- 
lescence any considerable fall of the thermometer foreshadows 
collapse. 
The morbid development of heat is sometimes associated 
with more, sometimes with less, abundant bodily excreta than 27 
in health. The temperature and the amount of the excretions 
bear certain as yet undetermined relations to each other. The 
loss of weight in a patient is due to an increased and rapid 
elimination of material with increased tissue changes, and is 
associated with increase of temperature, — more certainly as 
regards urea than with the other excretions ; whence it is con- 
cluded that heat is attended with increased elimination of 
urea, and therefore with greater tissue change. While the 
product of metamorphosis, as determined by the excreta, may 
be diminished in fever, there may still be increased metamor- 
phosis with less elimination. Finally the pulse, the respira- 
tion, and the temperature, each and all, represent forces at 
work within the living body which can be measured with great 
exactness, and such measurements show how closely the ex- 
penditure of forces is related to the excreta which represent 
the waste of tissue in health and in disease; show, also, the 
decline in that nervous control that regulates the functions in 
health : that is, in the force that limits the working of all 
other forces. 
Localized electricity, or electrization, as it is commonly 
called, is now conceded to be a most powerful agent in the 
treatment of disease ; but, to borrow the language of Dr. Rus- 
sell Reynolds, “ it is useful, useless, or mischievous, according 
to the manner in which it is applied ” ; and although the 
greater part of what we have to say about it will be as a mode 
of treatment, it is introduced here by virtue of the rank it has 
just begun to take as a most profound and scientific method of 
diagnosis. 
The term “electrization” is generic, and should never be 
otherwise employed. It is common in medicine to restrict 
electric effects to the three varieties, of friction, of contact, 
and of induction. Frictional electricity, which Faraday himself 
called the Franklinic, is also known as “ static ” ; while the 
two other forms are confounded under the common name of 
“ dynamic.” A primitive form of the static was the now obso- 
lete electric bath, or the immersion of the feet in buckets filled 
with electric eels ; the only forms of its present application are 
through sparks, or by means of shocks from the Leyden jar, or 
by insulation upon the glass stool, when the patient is charged 28 
like a prime conductor. Static electrization, however, may be 
regarded as practically in disuse, the milder forms having no 
appreciable tonic effect, and the great “ tension ” required from 
the Leyden jar to reach well-covered muscles or deep-seated 
parts cause such disturbances as render its application difficult, 
if not impracticable. Curative results, however, have been 
produced when other modes have failed, by its application to 
the larynx in obstinate nervous aphonia, than which, as some 
writer has said, “ nothing short of being hanged could be 
more unpleasant.” 
Dynamic electricity is employed nearly equally under the 
two forms of galvanism and Faradisation, and is that variety 
which is developed by chemical decomposition. Galvanism, or 
the “ interrupted continuous current,” is of low intensity in its 
action on the nerves and muscles; but it produces chemical or 
“electrolytic” results, as in the coagulation of blood, the 
mortification of tissues, and a calorific action, which are not to 
be obtained from the Franklinic or even from the Faradic pro- 
cesses. 
Faradism, or the “ induced,” “ magneto-electric,” “ voltao- 
magnetic,” or “ voltao-dynamic ” electricity, as it is variously 
called, is of very high tension, and more like the Franklinic 
than the galvanic. Its chemical and calorific action are insig- 
nificant ; it has not the burning and heat of galvanism, but 
produces marked contraction of the muscles and powerful 
action on the nerves, both of sensation and of motion. It is 
induced, but only of momentary duration; and these mo- 
mentary currents, made by breaking and resuming the galvanic 
current, are effected so rapidly that a great many of only mo- 
mentary duration, but of very high tension, pass in both direc- 
tions in a single second of time. 
The question which Dr. Duchenne has undertaken to solve 
is: Are the physical and therapeutical qualities of the different 
forms of electrization identical, and can they be indifferently 
applied ? From the time of Reinak, whose name is identified 
with electrization in Germany, very acrimonious discussion 
has been going on upon this point, and it has never been 
more bitter than since the late Franco-German war, cropping 
out in quite a number of French and German prefaces we have 29 
had occasion to look at. The dictum of the Regent of the 
University of Berlin, “ that Germany was a contented nation, 
and coveted nothing beyond its own boundaries,” rankles deeply 
within the bosom of the Gaul. But Avliile in Germany the 
school of Remak still adheres to galvanism, *it is still in 
France that, in Becquerel and others, Dr. Duchenne finds 
his most persistent opponents. In England and America both 
currents are employed: in general practice the Faradic, with 
specialists the galvanic, more or less exclusively. Dr. Duchenne 
maintains that the two currents, whose physical action is so 
dissimilar, ought to produce different therapeutic actions, and 
each should correspond to special indications. 
Electropathy is an art so difficult that slight shades of differ- 
ence should not be allowed to complicate treatment, and the 
question mainly is whether any such difference is one of kind 
or of degree. Practically, it is of degree only ; the object is 
to get electricity in the form most suitable for the emergency. 
In electro-surgery both currents will avail to disperse tumors, 
heal ulcers, or hasten absorption. The galvanic is said to be 
superior to the Faradic in power of overcoming resistance, and 
it might therefore be expected to act more effectually on the 
brain, the spinal cord, and the sympathetic nerve,—the anatom- 
ical position of these parts requiring considerable resistance to 
be overcome. It also produces muscular contractions where 
the Faradic fails; and after a certain amount of treatment by 
the galvanic current, paralyzed muscles frequently resume 
their susceptibility to the Faradic. Thirdly, it has a different 
and more chemical effect for the purposes of cautery, using 
elements that generate large quantities of electricity, and com- 
bining them in a particular way. An ordinary single ele- 
ment, or a large number arranged for intensity, are but feebly 
electrolytic, and the alleged superiority of galvanism in 
•neuralgia, atrophy, or rheumatism is probably due to the 
molecular or other tissue changes produced by this chemical 
action. 
Oil the other hand, Faradism, through its frequent inter- 
ruptions, produces muscular contractions if applied anywhere 
over the muscle. While in galvanism one of the electrodes 
must be placed upon the motor nerve of the muscle, and the 30 
galvanic current requires to be broken to produce effects, tho 
Faradic is already in the condition of constant interruption. 
But the advantages of Faradization are most marked in general 
electrization, its powerful tonic effects being largely due to the 
passive exercise and consequent important tissue changes re- 
sulting from the myriads of muscular contractions, while it is 
less likely to produce unpleasant or injurious effects. Under 
particular circumstances it is the only one that can be used 
with benefit or safety. 
Dr. Duchenne claims that Faradization is the only therapeu- 
tic agent which, limited to the skin, can produce most acute 
sensations, which cease at once with the operation, and can bo 
graduated from the slightest tickling to the most intense pain, 
passing through intermediate degrees or going suddenly from 
one extreme to the other without ever disorganizing the skin 
or leaving any trace upon its surface beyond a slight erythema 
or elevation. Such an agent must respond to innumerable in- 
dications, from restoring simply lost sensibility to the skin 
itself to the most powerful revulsion in deep-seated neuralgias. 
It can be tempered, moreover, to the degree of excitability of 
any individual, and even of each region of the body ; and in 
the intense current required for certain muscular affections, 
induction is the only appreciable form. Claiming this, Dr. 
Duchenne admits that its electrolytic action is too feeble to 
coagulate the blood in aneurism or to affect the atrophization 
of morbid growths. 
We have considered electrization, so far, in its relations to 
treatment, and have but little space left to devote to any 
account of its uses in diagnosis.. Its conclusions in this field 
of study, however, are not universally accepted; in fact, are not 
very widely known. Professor Acland says, “ The exploration of 
the nervous system by electrical agencies in .evidence of chem- 
ical alterations and in proof of corresponding changes in the' 
organism (by Dr. Duchenne of Boulogne) shows the certain 
advance of physical inquiry as applied to disease.” It is due 
to the great reputation, moreover, of Dr. Duchenne to state 
that he was the first to describe the character and pathology of 
the progressive paralyses known respectively as, (1.) Pro- 
gressive muscular atrophy; (2.) Progressive locomotor ataxia; 31 
(3.) Glosso-labio-laryngeal paralysis: all of whicli types are 
now well recognized in practice. And in this his third edi- 
tion, which we have just examined fresh from the press, he 
adds another morbid condition not hitherto described, hut 
not less fatal in its march and termination, namely, pseudo- 
hyper-trophic paralysis or myo-sclerosis ; also a form of in- 
fantile or “obstetrical” paralysis, and an acute and a sub-acute 
anterior spinal paralysis of the adult. These therapeutical re- 
searches are the result and aggregate of Dr. Duchenne’s 
indefatigable clinical and pathological studies, most of them 
having been communicated during the past few years to the 
different scientific societies of France. 
The report on the action of mercury by Dr. Hughes Bennett 
and the committee appointed by the British Medical Association 
must have greatly astonished the average British practitioner. 
Although a few medical men now profess to have long been 
sceptical as to the action of mercury, nothing was ever more 
generally believed than that it stimulated the biliary secretion. 
Abernethy’s eternal blue-pill is a matter of history, and it was 
almost the only medicine that Sir Astley Cooper knew any- 
thing about. Sir Benjamin Brodie was asked why he always 
gave blue-pill in certain cases, and could afford to answer, 
“ because he always had given it, and it had always been 
right.” 
The point for the committee to determine was whether mer- 
cury was a chologogue, that is, a bile-stimulant, and these were 
not the first experiments that had been undertaken to deter- 
mine the specific action of mercury. Professor Nasse, in 1852, 
seemed to have ascertained by direct experiment that calomel 
did increase the absolute quantity of bile, but that it diminished 
the amount of the solid contents. Holliker and Muller demon- 
strated that the first dose of mercury increased the quantity of 
bile, and that subsequent doses diminished it in quantity but 
increased its consistency. Dr. Mosler investigated in order to 
determine “ what substances introduced into the blood were 
found afterwards in the bile,” and his conclusions were that 
calomel, in large or in small doses, “ does not pass so readily 
into the bile nor produce the marked increase of the biliary 
secretion that medical men imagine.” Dr. Scott found “ a dim- 32 
inution in the amount of bile and bile solids secreted after the 
administration of large doses of calomel.” This was the state 
of the question in literature. 
Dr. Bennett tells us that bis committee comprised “ the skill 
of the anatomist, the analytical power of the chemist, and the 
varied knowledge, theoretical and practical, of the histologist, 
physiologist, physicist, pathologist, and therapeutist, as well as 
the physician whose knowledge of diagnosis is unimpeachable.” 
Every instrument, appliance, and chemical, together with a 
public hospital and the sum of one hundred and twenty-five 
dollars (!), were placed at the disposal of the committee. At 
their first meeting, November 10, 1866, the first and, as we 
think, fundamentally vicious conclusion was arrived at, that no 
kind of examination of the dejecta could yield trustworthy re- 
sults ; supposing that the characteristic constituents of the bile 
found their way into the alvine evacuations unchanged, “ the 
imperfections in the analytical method (!) render their quan- 
titative analysis impossible,” either by lloppeseyler’s method or 
by the simpler process with alcoholic extracts. (Iloppeseyler, 
professor at Tubingen, estimated the amount of bile acids from 
the effect which their solution exhibited upon the ray of polar- 
ized light, which Professsor Tyndall’s experiments have made 
comprehensible.) We are to infer, therefore, that neither the 
bile acids nor the coloring matter were determined or estimated. 
For an examination of the excreta, they substituted the forma- 
tion of biliary fistulas in living animals, and the collection of the 
amount directly through such fistulae from the gall-bladder. 
The committee admit that, under the action of purgatives, 
unchanged bile is occasionally discharged from the system; 
and it is also evident to us, from an inspection of their numer- 
ous tables, that the biliary secretion wras increased after the first 
dose of mercury. We observe also that the animal began to 
fail soon after the process of drawing off its bile commenced ; 
that in fact the very organs and tissues experimented upon 
were on the road to death ; that it was not only an animal which 
was not man, but a wounded and a diseased animal. 
From the experiments, however, such as they were, and Dr. 
Bennett states that they were carefully repeated under every 
varying circumstance that could be thought of, the following 33 
conclusions were reached: first, that in whatever form or dose, 
whether continuous moderate doses of blue-pill, minute and 
frequent doses of calomel, or large doses of it, mercury utterly 
fails to stimulate the liver. The constitutional action of mer- 
cury excited both slowly and rapidly by corrosive sublimate 
produced the same results. In poisonous doses the bichloride 
produced a marked diminution in the flow of bile. Mercurial 
inunction was followed by negative results; and it was re- 
garded as proved that, so far from increasing, mercury, by its 
general depressing action on the system, actually diminished 
the amount of bile. 
Now we submit that, as depression does lessen the vigor of 
the secretive process, a much more potential cause for depres- 
sion is to be found in the condition of the animal from his 
wounds and the presence of the canula, and from the actual 
wasting disease engendered by the deprivation of bile, than 
lies in the giving of a few doses of calomel, which at first, as 
we have seen, before the constitutional symptoms began, actu- 
ally increased the flow; and the next conclusions of the report 
corroborate this idea, for it was found, secondly, that abstinence 
from or considerable diminution of food checked the secretion 
of bile; and, thirdly, in deprivation of bile, emaciation comes 
on, the appetite fails, the excretions assume a peculiarly foetid 
odor, and death occurs from inanition. Starvation diminishes 
the secretion, and nothing beyond giving food or supporting 
health increases it. 
Whenever we hear of a new anaesthetic, we think of the time 
when the taking away of pain was to “ harden society and rob 
God of the deep, earnest cries which arise in time of trouble for 
help,” as the Scotch parsons told Sir James Simpson ; and when 
even surgeons argued that “ pain was a premonitory condition, 
no doubt fitting parts the subject of lesion to reparatory action,” 
and that they would therefore “ feel averse to its prevention ” ; 
when a famous living physician concluded a paper read 
before a London medical society, “ Upon the Injurious Effects 
of Ether Inhalation,” with queries as to “ the desirability of 
removing pain ”; when a great American surgeon declared, 
after some untoward details in giving ether, “ that he would 
never again remain in a room where it was to be given.” 34 
After much experimentation for ether substitutes, a sub- 
stance has been found which will actually manufacture chloro- 
form in the blood, and, what is better, its invention is the re- 
sult of purely a priori considerations. On the second day of 
June, 1869, Dr. Otto Liebreich, of the Pathological Institute of 
Berlin, introduced to the Medical Society of that capital what 
he defined as “ a new hypnotic and anaesthetic agent.” ; this 
was the hydrate of chloral. Chloral itself was discovered some 
thirty years ago by Liebig as the product of anhydrous alcohol 
acted upon by dry chlorine gas, ultimating in a dense oily 
liquid, colorless, boiling at 210° with a sharp, pungent odor. 
Mixed with water this becomes the hydrate of chloral, and is 
converted into a white solid substance. The new agent be- 
came at once widely known, and in London Dr. B. W. Richard- 
son, who is constantly experimenting with anaesthetics, was 
appointed to investigate it and report upon it. 
The theory of its action, according to Liebreich, is that the 
hydrate of chloral, treated with an alkali, is resolved into 
chloroform, and into a formate which soon disappears; the 
blood is an alkaline fluid, therefore the hydrate, when it is ab- 
sorbed, enters the blood, where its particles consume the sur- 
rounding alkali, and decomposition is effected after the required 
amount of alkali has been furnished by the blood. A minimum 
quantity of chloroform is then instantaneously formed, is set 
free in the tissues and passes to its first stage of action, the 
ganglia cells of the brain; as the chloroform increases in amount, 
its action extends to the spinal ganglia cells, and lastly to those 
of the heart corresponding with the slowest possible adminis- 
tration of chloroform, and passes out of the system as chloro- 
form. From Liebreich’s array of facts also was derived the 
necessary deduction that the agency at work was chloroform, 
chemically formed in the blood. There are few now who have 
not experienced or observed the profound and tranquil sleep 
produced by chloral; but it is the rival of opium rather than of 
ether, although it can be administered by inhalation. Besides 
producing sleep, it removes sensibility, reduces the animal tem- 
perature, causes extreme muscular relaxation, practically con- 
firming the theory of its action as chloroform. Its physical 
action being clearly understood, its applications must be ex- 35 
tremely varied, and in fact it is now employed to relieve almost 
every known abnormal symptom or condition of body or mind. 
Dr. Richardson’s report concludes with a warm tribute to the 
“ genius and industry of the distinguished Professor of Berlin 
who has placed in our hands so admirable and scientific a 
remedy.” 
With regard to Cholera, the novelty is in the treatment 
alone; its nature is universally understood. A poison is ab- 
sorbed into and infects the blood, spoiling certain of its constit- 
uents, which are ejected through the mucous membrane of the 
alimentary canal. A primary blood disease is thus produced, 
undergoing enormous multiplication in the body ; and the direct 
results of the alteration are changes in the function of respira- 
tion, while the copious discharges are the efforts of nature to 
throw off the noxious material, as a necessary process to recov- 
ery. From no other cause than a virulent blood poison does a 
person in full health become in a few minutes, and utterly with- 
out warning, shrivelled up, his whole body icy-cold, his face and 
hands turned purple, while death comes on in a few hours. 
We cannot refrain from reproducing the quotation very happily 
brought in by Dr. Aitkin : — 
“ Its effect 
Holds such an enmity with blood of man 
That, swift as quicksilver, it courses through 
The natural gates and alleys of the body; 
And, with a sudden vigor, it doth posset 
And curd, like eager droppings into milk, 
The thin and wholesome blood.” 
The well-known and especial danger in cholera is also its 
proper and distinctive symptom, characterized by the French 
pathologists by the term “ algide,” the sensation and fact of 
cold being one of the most remarkable and constant phenom- 
ena ; the thermometer in the axilla falling to 92°, more than 
six degrees below the natural standard in health, while under 
the tongue it is known to have fallen to 79°. Vomiting, purg- 
ing, and cramps have long ceased to be regarded as essential 
phenomena. Hale and hearty men have been suddenly seized, 
and have collapsed, and died within five minutes, without any 
evacuation; and death has repeatedly occurred within two or 36 
three hours after access, without any other cause than stagna- 
tion of the blood. 
Dr. George Johnson, long known to the profession in connec- 
tion with the correct pathology of kidney diseases, communica- 
ted to the Medico-Chirurgical Society of London, in 1868, the 
doctrine that the poison of cholera was received into the system 
from without, by inhalation or in food and water, and absorbed 
into the circulation ; that if the vascular excretion was checked, 
the risk of fatal collapse was greatly increased; and that 
the object in treatment should be, not to excite discharges from 
the mucous surface, but to facilitate the removal of matters 
lodged there, and that elimination of the poison from the sys- 
tem was the condition of recovery. 
Half a century ago the English physicians in India “ aimed to 
get rid of the offensive morbid secretions ” in cholera, but it 
was quite natural to attribute collapse to the drain of fluid mat- 
ters from the blood by the profuse and repeated fluxes from the 
bowels and stomach; and the treatment this view suggested 
was the “ locking-up ” plan by opium and astringents and by 
stimulants. Dr. Johnson’s opinions were not well received, 
and violent controversy grew out of them. It was soon settled 
that the collapse was not due to the evacuations, but that these 
were, in fact, eliminative of the poison. To establish relations 
of cause and effect between them, it should happen that the 
more profuse the discharge the more decided and certain 
should be the collapse; while in fact the most hopeless cases 
were those of scanty evacuations or of none at all. Also the 
continuance of the discharge should cause a more prolonged, 
deeper, and more dangerous collapse. But, on the contrary, 
patients not only emerge from the collapse while the evacuations 
are going on, but a cessation of them is always a fatal sign. If 
a vein is opened in cholera, after a moment or so, the dark 
treacly blood grows brighter, and the patient has been known 
to cry out that “ it had made a new man of him ” ; therefore 
collapse has nothing in common with ordinary syncope, which 
is relieved by stimulants, but would be disastrously affected by 
blood-letting. Dr. Johnson’s own paper in the “ Transac- 
tions ” is immediately followed by another, containing details 
of treatment upon his plan, on a large scale, in which the re- 37 
suits corroborated the'theory, and which demonstrated the re- 
markable fact that recovery never occurred without a continu- 
ance of the discharges or their restoration, if previously arrested. 
So great a change in medical opinion was effected by the 
new views, that Sir Thomas Watson, the president of the soci- 
ety, upon a careful revision, has fully recanted his own pub- 
lished opinions and adopted those of Dr. Johnson in the last 
edition of his well-known work on the Principles and Prac- 
tice of Physic, and he pays their author a noble tribute by de- 
claring that “ he has by his methodical display of facts, by his 
close and conclusive reasoning, now triumphantly established 
his own views of the pathology and treatment of cholera.” 
Lorstofer's Corpuscles. — During the past few years much at- 
tention has been given to the connection between what are 
called microscopic growths and contagious and infectious dis- 
eases. In Professor Strieker’s laboratory in Vienna, especially, 
attempts have been making to explain different diseases, particu- 
larly the infectious ones, by the presence of fungous growths in 
the blood, and in the secretions and excretions, as well as in 
the tissues of the body, but with hitherto only negative results. 
In the blood of syphilitic patients especially it was hoped to 
find traces of a low grade of organism. Could such once be de- 
tected, the discovery would not only have a vast specialistic 
importance, but would give a positive basis to an assumed theory. 
Dr. Lorstofer conceived that the negative results were due to 
low magnifying powers, and to the fact that the experiments had 
all been made with fresh blood in which such bodies may have 
existed in a state too minute for detection, and that they might 
grow to be visible (this very idea of growth, we may remark in 
passing, being corollary to the very idea underlying the re- 
search), if the specimens could be preserved for examination 
without destroying the organisms. Lorstofer commenced his 
experiments in August, 1871; and in January, 1872, at a meet- 
ing of the Vienna Medical Society, he announced the discovery 
of a form of corpuscle peculiar to the blood of syphilitic patients, 
and through which the diagnosis of syphilis might be made by 
a microscopic examination of the blood. 
In specimens properly prepared, in from one to three days, 
he averred that certain minute bright corpuscles became visi- 38 
ble, some immovable, others undulating; in a few days more 
they grew to the size of true blood corpuscles, of irregular shape, 
with one or more projections. In a few days longer a vacuola 
was found in the larger corpuscles, which soon extended over 
the whole body, and terminated the development of the growth, 
nor could their shrivelling and further retrograde development 
be arrested ; their relations of causation were not asserted. 
While Professors Hebra, Skoda, and Strieker indorsed Liir- 
stofer’s statement, and affirmed that they had tested it with 
almost uniform success, others who had long worked without 
success in the same direction were not satisfied. Wcdl pro- 
nounced the bodies described to be nothing but fat cells, and 
declared that they could be seen a few hours after the prepara- 
tion was made if water were added to the blood ; but as Lnr- 
stofer’s corpuscles do not acquire a visible size till the fourth day, 
and disappear at once if water is added, it was argued that Wedl 
could not have seen them at all, as he had violated Liirstofer’s 
conditions. Professor Strieker here took up the controversy, 
and Lorstofer himself seems to have been left out of it. Letters 
from Vienna to the English and American journals stated that 
the war speedily became outrageously personal and offensive. 
Strieker himself forms no opinion as to their true nature, but 
pronounces them to be formations hitherto unknown in the 
blood. Meantime a syphilitic patient in whose blood they had 
been uncommonly numerous began to show signs of phthisis, 
which drew attention to another point, namely, the possi- 
bility of a general ill-nutrition being concerned in their produc- 
tion, and in fact they were at once found in cases of cancer, of 
tuberculosis, of Bright’s disease, and of anaemia after small- 
pox. The investigation therefore seems to be sufficiently ad- 
vanced to pronounce the new organisms not exclusively 
pathognomonic of syphilis, but as existing in the blood in cer- 
tain cases of defective nutrition from long-lasting chronic dis- 
eases, and more particularly from syphilis. As yet there is no 
warrant for denying their possible existence in the blood of 
persons suffering from acute diseases, or even in the blood of 
comparatively healthy subjects. 
Wo have now completed our task upon a plan kept always in 39 
view; commencing with the general and larger relations of 
medicine, and showing where it would he better to reduce it in 
study to its clinical phases alone. We have selected the special 
subjects which best illustrate the latest or the highest methods 
in diagnosis, in therapeutics, and in pathology, and which were 
most likely to lend a uniform coloring to the picture. The 
medicine of to-day aspires to nothing more, and is content 
with nothing less, than to be the sum and the harmonization of 
all that can be gathered from observation and all that can 
bo added by induction. It has sometimes been difficult in 
the sketch to avoid the appearance of marshalling before the 
reader a parade of imposing generalities; it was not always 
easy to escape from tiring him with burdensome details. And 
the success may lag behind the aspiration. Be that as it may, 
enough if only he, to whom nothing that is human is foreign, 
shall any more clearly discern the spirit that ‘controls the 
science of modern medicine, or any more wisely distinguish 
the forces that direct its art.