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CHAMBERS' LECTURES. 
  Dr. Chambers having been induced to adopt a new title for
the Third Edition of The Renewal of Life (from which this is a
reprint), which he fully explains in his preface, the publishers of
the First American Edition have thought it advisable to retain,
in part, the title of the two former editions, that the work could
at once he recognized, its great  popularity and extensive sale
being under its original title. 
THE RENEWAL OF LIFE.
LECTURES
CHIEFLY  CLINICAL.
THOMAS KING CHAMBERS, M.D.,

   HONORARY PHYSICIAN TO H. B. H. THE PRINCE OF WALES J
     PHYHICIAN TO ST. MARY'S AND THE LOCK BO»P[TAL8.
gvttw, ifo* (Tlutftt gtuAon (t-&it\Bi&.
      PHILADELPHIA:
LINDSAY AND BLAKISTON
          1865. 
I
WB
 1865
HEMilY B. ASH51EAD, PRINTKB,
   1102 and 1104 Sansom Street. 
     PREFACE
           TO THE

THIRD  EDITION.
   In two former editions I named the selection of clinical
 observations which I laid before the public " The Renewal
 of Life," intending thereby to intimate what is more fully
 stated in the first and second introductory chapters, that
 the main point for the physician's consideration in disease
 is the deficiency of vital action, and that all successful
 medical  treatment  is a renewal  of that vital action.   To
 my regret the words have been found strangely "open to
 misrepresentation" by several of the literary men engaged
 in reviewing the  work.   Such  a risk seems to outweigh
 the advantage  of expressing in an epigrammatical form
 the principles  advocated, and  has  led  me to  take the
 unusual  course of leaving out  a great part of the title.
 But I am more than ever impressed with the importance
 of these  principles in practical therapeutics, and  have
enforced  them  anew by revising carefully the original
matter,  dovetailing into it  many remarks made  to ray 
 vi          PREFACE TO THE THIRD EDITION.

 class on  recent  passing  cases, and adding twenty-three
 new lectures, three given at the College of Physicians,
 and the rest  in  my post as a teacher of medicine at St.
 Mary's Hospital.
   The  original  first  lecture was published  as a field for
 the  discussion of conflicting theories by those  who did
 me  the  honor of  criticism.   That object  having  been
 attained,  and  answers given in a  concluding essay, the
 greater part  of it has been omitted,  and  the remains
 interpolated elsewhere.
   It may be  remarked that most  of the "Lectures," as
 here presented  to  the reader, combine  materials orally
 delivered  at  several, and often at distant, times.   These
 are  obviously  short  fragments  of lectures, made  still
 shorter by the  omission of the elementary instruction
 on diagnosis.   They are here united under subjects, and
 to avoid chronological confusion  the dates of their  viva
 voce production are set at the head of each.  I trust the
 disjointed aspect  thus given will be pardoned, as we par-
 don, in a portfolio of sketches made  on the spot, rough-
nesses inexcusable in the finished works of the studio.
                                          T. K.  C. 
CONTENTS.
                            LECTURE I.

                          DEATH AND LIFE.
                                                                 PAGE
Reasons for an introductory lecture—Decay of dead bodies—Decay of
    living  bodies—Life is renewal, and cannot be in  excess—Health,
    death,  and disease—Illustrations of partial death as exhibited in
    disease—in degenerations—in hypertrophies—in malignant tumors
    —in catarrh—in boil and abscess—in fever and zymotic diseases—
    in anosmia—in mixed anosmia—in tuberculosis—Classes of dis-
    eases in the hands of the nosologists—The restorative direction of
    modern improvements in medicine—Constructive  and  destructive
    life—Restorative pharmacopeia   .       .       .      .      .25
                           LECTURE II.

                        DISEASE  AND CURE.

What is cure ?— Classification of disease, for therapeutical purposes,
    into deficiencies of growth and deficiencies of moulting—Deficien-
    cies of growth from Cliossat's observations—Analogous natural
    states  in disease—Deficiencies of moulting—True and apparent—
    Mixed lesions—Natural  cure and artificial cure—Cure originated
    by the healthy parts of the body—Classification of means of cure—
    Constructives—Destructives—Arresters of construction—Arresters
    of destruction      .       .       *       .       .       .       .42 
Vlll
CONTENTS.
                           LECTURE III.

                  FORMATION  OF MUCUS AND PUS.
                                                                 PAGE
 Office of mucous membranes— The identity of mucous globules and nascent
    epithelium—Self-supported growth of mucous globules—Similar to
    organic growth of a parasite—Is this form of an,excess or a defi-
    ciency of normal life f     .      .      .       .       .      .66


                           LECTURE IV.

                  FORMATION  OF MUCUS AND PUS.

Mucous globules not cells, but nuclear matter—The representative of the
    cell is the medium in which they float—It is therefore not likely to
    retrograde  into  globules—Formation of pus from mucus—How
    does pus appear on the surface?—Observations of several observers
    —Passage  of globules  Hirough epithelium—Pus-globules  not  de-
    scendants of epithelial cells,  but parasitic formations inside them
    — Epithelium  semifluid—Breach of epithelium  in some  cases—
    Growth  of pus     .      .       .       .       .       .       .74


                           LECTURE V.

                  FORMATION  OF MUCUS  AND  PUS.

Mucus and pus compared—Grades of loss of vitality in mucous mem-
    branes—Exemplification of these grades in small-pox pustules—
    Practical deductions from the various points commented on in the
    three lectures      .       .      .      .      .      .       .84


                           LECTURE VI.

                            TYPH-FEVER.

Case—Cause of fever—Why it affects some and not all—The virus acts
    slowly, and enters probably by the alimentary canal—Case showing
    the progress of fever-poisons checked by emetics—Action of fever-
    poisons on living organism—Devitalizing power on blood—The first
    symptom of partial death is a rigor—Next symptom, pain—Loss
    of appetite which does not arise from defective  metamorphosis—
    diarrhoea, hcemorrhage, and increased heat, all are evidences that 
CONTENTS.
ix
disease is something less than life—The object of treatment is not
the mere typh poison, but the interstitial death of the tissues—The
touchstone of restorative medicine is its application—Use of emetics
—Tepid sponging—Cold, affusion removes but does not check the
formation of heat—Supply of food—Hydrochloric acid—Alcohol—
Local blood-letting—Principal difference between patients lies in the
stomach—Two instances—Deduction      .       .       .       .98
                          LECTURE VII.

                             TYPH-FEVER.

Therapeutical statistics  .......  118
                          LECTURE VIII.

                            TYPH-FEVER.

Cases with running commentary—Relapse  of rose-spots—Contagion
   from patients to a nurse—Leeches and mercury—Mulberry-rash—
    Intermittent pulse—Rose-spots or mulberry-spots, which the most
    dangerous ?— Wine in fevers—Retarded  emaciation—Subcuticular
    eruption— Contagion—Artificial cuticle in bed-sores—Sudamina—
    Low condition in convalescence, its symptoms     .      .      . 122
                           LECTURE IX.

                             TYPH-FEVER.

Part I.—Three fatal cases since October, 1861—One brought in mori-
     bund, one treated with hydrochloric acid, &c, one not—Four cases
     in hospital related, with comments—Danger of giving solid food
     too early in convalescence—Absence of enteric symptoms best guide
     to administration of solids—Dose of hydrochloric acid for children
     — Connection of  typh-fever and  pneumonia—Small-pox caught
     during convalescence from typh-fever      .       .       .       .128
Part II.—Additional case, illustrative of the connection bettceen the two 
X
COS TENTS.
    forms of typh-fever  eruptions—Precautions in case of threatened
    pneumonia—Caution against moving patients in fevers    .       .  134
Part III.—Four additional cases with comments.   Case 1.—Difficulty
    of distinguishing typhus and enteric fever—Relief of enteric pain
    —Dry, glazed, cracked tongue in enteric cases—Arrest ofdiarrhosa
    by hydrochloric acid,  by Dover's powder, &c.  Case 2.—Fever spots
    and  flea-bites—Fever cut short by an emetic—Emaciation during
    convalescence not prevented by the cutting short of the fever.   Case
    3.—Fever cut short by an emetic—When not arrestive, this  treat-
    ment is  palliative.  Case 4.—Fever contracted in the  hospital
    aggravated nearly to a fatal extent by inflammation of previously
    diseased  genital organs and bladder,  and by  a slough on  the
    sacrum—Treatment .......  138
Part IV.—Case of typh-fever contracted in the hospital by a patient
    admitted for acute  rheumatism—Emetic only partially successful—
    Administration of solid food and wine     ....  142
                           LECTURE X.

                             SMALL-POX.

Part I.—Case of small-pox  watched from first infection—Sequence of
    phenomena—Memoria technica by which to remember them— Use of
    observing them—Action of oxygen  on the general  health of the
    patient  and on the skin contrasted—Microscopical examination of
    the contents of the pocks, with practical  deductions  therefrom—
    Depth  of injury  to skin  in  small-pox—Reasons for cutting the
    hair .........  145
Part II.—Spread of small-pox in  the hospital from the above case—
    Example of the  use of vaccination in modifying the disease—Ac-
    tion of vaccinia not homoeopathic or counter-irritant, but preventive
    —Infectiousness  of small-pox compared with  other diseases—Dif-
    ferent degrees of infectiousness demand different precautions      .  150
                           LECTURE  XL

                         RHEUMATIC FEVER.

Relations of the practitioner and lecturer to rheumatic fever—Descrip-
    tion of treatment—(1) Bedding—{2) Fomentations—{3) Remedial 
CONTENTS.
xi
                                                             PAGE
agents—Bicarbonate of potash, Iodide of potassium—(4)  Opium—
(5) Leeches—(6) Poultices  in pericarditis—(7)  Diet—Commenta-
ries on the restorative agencies of the aforesaid treatment  .       .  155
                           LECTURE XII.

                         RHEUMATIC FEVER.

Exceptional cases  of rheumatic fever—Inflammation of heart arrested
    by  epistaxis—Delirium and  gangrene in rheumatic fever—Treat-
    ment— Case of rheumatic fever in a tubercular subject, toith conse-
    cutive purpura of the legs—Treatment by lemon juice     .      .  167


                          LECTURE  XIII.

                         RHEUMATIC  FEVER.

Therapeutical statistics  .......  174


                          LECTURE  XIV.

                     GONORRHCEAL  RHEUMATISM.

Case.—Name of disease not strictly correct—Its relation to pycemia—
    May occur at any period of the gonorrhoza-^-Not a metastasis—Ob-
    jection to  any treatment grounded on its being a  metastasis—Ure-
    thritis a worse  disease than gonorrhoea—-Possible pecidiarity of
    gonorrheal virus in these cases—Rarity of such severe cases as this
    shown  by the results of seventeen other  cases, which  represent the
    more usual aspects of the disease—Specimen of a more usual case
    of gonorrhceal rheumatism and its treatment—Recurrence ofjgonor-
    rhozal rheumatism  .......   179
                           LECTURE XV.

                            PERICARDITIS.

Case of pericarditis .coming on in the hospital—Rarity of this circum-
    stance—Explanation of its occurrence in this instance—Diagnosis
    of old and recent disease by the physical  signs—Practical value of 
Xll
CONTENTS.
 diagnosis—Treatment—Leeches—Blisters—Poultices—Prevention
 better than cure—Case illustrative of the use of mercury in similar
 circumstances,  and the reason  why it is no longer employed by the
 author—Fatal  case of pericarditis from exposure to the cold during
 convalescence from typh-fever—Two cases of pericarditis, one aris-
 ing from a linen shirt-front next  the skin during rheumatic fever,
 the other of doubtful origin—Action of opium on the pulse—Varia-
tions in the pulse—Remarks on the pain of pericarditis—Case
 illustrating its  absence, and the non-reduction of the pulse by opium
—Fatal pericarditis in a patient of choreic diathesis      .      .  191
                          LECTURE XVI.

                              PLEURISY.

First case, and its  treatment—Cases of pure pleurisy not common in
    hospital practice—It is a slight disease, but capable of being made
    much more severe by bad management—Remarks on blisters and on
    local  blood-letting—Their final  intention restorative—Poultices—
    Continuous warmth  as  a renewer of life—Second case—Chronic
    effect  of acute pleurisy—Treatment—Diuretics—Third  case—Py-
    osmic pleurisy, its fatality ...... 204
                          LECTURE  XVII.

                           HYDROTHORAX.

Term "idiopathic hydrothorax" justified—Form of pleuritic disease—
    Which form is here intended—two cases—Hydrothorax, a collection
    of fluid in the pleura—Difference between collection and effusion-
    Source of the fluid—Action of physical agents in the production of
    the  disease—Treatment founded  upon the pathology—Blisters—
    Poidtices — Mercury— Food—Digitalis — Squill—Niter—Scopari-
    um—Sequel  of the second case, seven months afterward—State of
    chest, and explanation  thereof—Another case  of displaced heart—
    Treatment by paracentesis—Large quantity drawn off without re-
    turn of heart—Comparison of these two cases as to treatment—
    Results inferred from them, and from an analogous case of empye-
    ma,  opening externally     . 
CONTENTS.
                         LECTURE XVIII.

                         ACUTE LARYNGITIS.

Case related—Important point  in the pathology of the disease is its
    locality—Tracheotomy must  not  be represented  as  a last  hope—
    Reasons for delaying it and reasons for not  delaying it—Care of
    digestive  organs— Wine—Solid food—Antimony—Mercury—La-
    ryngitis,  acute and chronic—Difference in pathology and in prin-
    ciples of treatment  .......
                          LECTURE  XIX.

                        CAPILLARY CATARRH.

Definition of the disease—The mildness and severity depend on the
    quantity of bronchial membrane involved—Slight cases essentially
    of the same nature as the severe cases here brought forward—(First
    case)  Uncomplicated bronchial catarrh—(Second case)  The same
    arrested on the brink of merging in broncho-pneumonia—Treatment
    by warmth and moisture—The same treatment (Mudge's) applicable
    to mild  cases—Blood-letting—(Third case) Bronchial catarrh fatal
    by supervening on lung previously imperfect—-Autopsy—Such form
    of fatal disease aptly described as paralysis of the lung—Equally
    fatal to  strong as to puny people—Arises from exposure to cold air
    during a catarrh—Danger much increased by imperfection of lung
                          LECTURE XX.

                             PNEUMONIA.

Three cases of pneumonia—1.  Frank uncomplicated double pneumonia
    in a temperate man, with excessive  dyspnoea—Cured with venesec-
    tion, jacket-poultice, continuous feeding and wine.  2.  Pneumonia
    of upper and lower lobes of one lung, very slight in the other lung,
    in a broken-down old man—Cured with  cupping, jacket-poultice,
    continuous feeding and wine.  3.  Congestive pneumonia of lower
    lobe in typh-fever—Cured with half jacket-poultice, cupping beneath 
                         CONTENTS.

scapida, continuous feeding, wine and bark—Commentary—Patho-
]°9y °f pneumonia—Importance with proportion  to  quantity of
tissue involved, not to stage of progress—Hence the value of a ready
and quick means of checking its progress—Blood-letting—Action
of it—General and local compared—III effects  of  loss of blood—
Mode of judging of the necessity for it—Compensation for it—Poul-
tices—Their action—Especially adapted for infants—How to make
them—Alcohol, when required—Effect of position in the pneumonia
of typh-fever—Blood-letting—Purgatives—Blisters—Antimony and
mercury     ........
                          LECTURE XXI.

                            PNEUMONIA.

Record of six cases during recess—(1st Case) Caution  about blood-
    letting—(2d Case) Pneumonia of upper lobe in third stage, viz., of
    abscess—Repeated attack of pneumonia during convalescence, fatal
    to  this patient—Post-mortem examination—Remarks on treatment
    — Cause of second attack—(3d Case) Pneumonia in  Bright's dis-
    ease  cured—Slate of lung  afterward—(Ath Case)  Pneumonia in
    measles—Catarrhal  pneumonia—(5th  Case)   Pneumonia treated
    with opium—When opium is desirable—Reduplicating pulse—(6th
    Case) Pneumonia in a pregnant woman  treated with opium—Re-
    marks on vomiting in pregnancy—Additional cases present in hos-
    pital—(1th Case)  Early occurrence of pneumonia in typh-fever—
    (8th  Case)  Double pneumonia  in  a fatal case of delirium tremens
    —(9th Case) Double pneumonia slowly progressing from one lung
    to  another—Pleurisy also  on one side—Food in convalescence—
    Mode of recovery of consolidated lung—(10th Case) Catarrhal pneu-
    monia—Severity of symptoms at first, and rapid relief—Treatment
    by poultices and local blood-letting—-(11^ Case) Double pneumonia
    in a man of drunken habits—Also catarrhal, and therefore distin-
    guished by the severity of the  symptoms  at first—Treatment with
    opium, poultices, and cautious cupping—Delirium—Wine—(\2th
    Case) Pneumonia morientum in death from  other causes—Reca-
    pitulation    . 
CONTENTS.
xv
                         LECTURE  XXII.

                       EMPHYSEMA OF  LUNGS.
                                                                 PAGE
Illustration of the morbid anatomy of emphysema—Fatty degeneration
    of  the pulmonary membrane—Degeneration sometimes fibroid—
    Cause of the proneness of children's  lungs to become emphysema-
    tous— Questions whether inspiration or expiration most tends to
    produce emphysema—Action of the  lungs in breathing illustrated
    by an example of a man without a sternum—Expiration more pow-
    erful than  inspiration—Application  of the morbid  anatomy of
    emphysema  to clinical questions— Case of emphysema in an albu-
    minuriac—Case of emphysema  depressing the heart—Treatment
    and its  objects—Iron—Tobacco—Lobelia—Stramonium—Mercury
    —Alcohol—Expectorants—Two cases  of emphysema in young wo-
    men exposed to adverse circumstances—Treatment by iron—Trial
    of expectorants     .......  283
                         LECTURE XXIII.

                     PULMONARY CONSUMPTION.

Pathological data—The disease localized by morbid anatomy and  aus-
    cultation—Pitfalls of this  knowledge—Not the presence,  but the
    increase, of tubercle, is the  chief point—Innocuousness of non-pro-
    gressive tubercle—Object of treatment should be the organs of nutri-
    tion, not those of respiration—Food—Cough  medicines—Appetite
    —Iron—Cod-liver oil—Alcohol—Remedies for diarrhoea—Cachec-
    tic phthisis—Chlorate of potash—Delirium in the last stage of
    phthisis, how caused, and how  to be treated—Specifics    .      .  297
                         LECTURE XXIV.

                        THORACIC ANEURISM.

First case of aneurism, probably of the innominata—Reasons for diag-
    nosis—Aortic valvular murmur accounted for—Probable abnormal
    position  of artery—Progyiosis  unfavorable—Second case—Aneu-
    rism of aorta and its treatment—Blood-letting and low diet—Patho-
    logy of aneurism—Object of treatment—Favorable prognosis—Two 
XVI
CONTENTS.
cases of favorable result of treatment—Fatal case of aortic aneurism
—Rupture of sac into the pleura in a healthy working man—Length
of time a patient may live with a ruptured aorta an encouragement
to treatment—Case of aneurism compressing the trachea, producing
congestion of the lungs, and so fatal—Actions of bleeding, leeching,
and digitalis—Action of digitalis on other involuntary fibers, as on
the uterus in menorrhagia, and on the bladder in incontinence of
urine       ........  319
                          LECTURE  XXV.

                         DISEASE  OF  HEART.

1st Part.—Comparison of injury to life from the  two sets of valves,
    severally—Deductions from autopsies—Case in point—Treatment
    calmative and  restorative.   Second case—Diseased mitral  and
    aortic valves with dilated parietes—Treatment similar to last case,
    with certain additions      ......  332
2d Part.—Degree  of importance to  be attached to  the different points
    ascertainable by auscultatory diagnosis—Consequences of valvular
    disease different in different classes of life—Cases in illustration
    of its  effects in the upper classes as distinguished from hospital
    patients—Causes of difference—Treatment of patients with disor-
    ganized valves—Avoidance of dangers—Iron— Chloride of sodium
    —Hydrochloric  acid—Abuse  of alcohol—Danger of rupture  of
    valves—Case—Angina pectoris—Pathology of dilatation—Expla-
    nations to patients—All diseases of heart to be viewed practically
    as one      ........  337
                          LECTURE  XXVI.

                               PURPURA.

Descriptive definition of purpura—Case 1.  Young man affected with
    fatal haemorrhage and purpura without previous disease—Case 2.
     Menorrhagia and purpura in a girl otherwise healthy—Case 3.
     Purpura in a fatal case of diseased heart and kidneys—Pathology
     of purpura—Its connection with lesions of the circulating system—
     Its treatment based on its pathology—Cautions respecting the admi-
     nistration  of digitalis—Case 4.—Purpura fatal  by haemorrhage
     into the brain       .       .       .       .       .       .       .351 
CONTENTS.
xvu
                         LECTURE XXVII.

                               ANEMIA.
                                                                  PAGE
Part I.—History of a case of anaemia—Objections to the nomenclature
    of the disease—Its pathology—It consists of a functional deficiency
    of life in the blood-making organs—Application to this case—The
    defective morbid anatomy does  not impede our treatment—Transi-
    tory curable states usually dependent on the' mucous membranes,
    which have little post-mortal anatomy—Sketch of the active life of
    mucous membranes—Their importance in disease—Effect on health
    of their diminished vitality—Application of this pathology to prac-
    tice—Intention of treatment to introduce nitrogenous food, iron, and
    chlorine—Mode of doing this, its effects, and reflections thereon    .  361
Part II.—Effect of anazmia on the mental faculties—Practical deduc-
    tions.       ........  371
Part III.—Anaemia, when the result of permanent organic lesion, amen-
    able to the same treatment as when functional      .      .       .  372
                        LECTURE  XXVIII.

                     PROMINENCE  OF EYEBALLS.

Cases tcith commentaries—The pathology of the disease associated icith
    that of anozmia, and the requisite treatment thence deduced        .  375
                         LECTURE XXIX.

                       ATROPHY OF MUSCLES.

Part I.— Cases—Pathology—Treatment—Questions respecting  hyper-
    trophy .     .       .       .       .      .       .       .       .382
Part II.—Case of dropped hand from the poison of lead—Pathology of
    this form of paralysis and its connection with colic—Reasons for
    not considering its localization as  dependent on the immediate ab-
    sorption  of lead—Treatment with  iodide of potassium, sulphur
    baths, splints,  electricity, quinine, oil, and  blisters—which  benefi-
    cial, which hurtfid  .......  390
        o 
xviii
CONTENTS.
                          LECTURE XXX.

                               CHOREA.
                                                                  PAGE
Part I.— Case treated without drugs—This case a recent one—Principle
    of treatment.       .       .       .       •      •       .       . 394
Part II.—Four long continued but curable cases treated with arsenic—
     Quoted as specimens of the disease as usually seen—Effect of forci-
    ble control over the movements      ..... 398
Part III.—Records of three fatal cases and two unaffected by treatment
    —Connection of chorea and rheumatism and disease of heart sta-
    tistically deduced from  the records of thirty-three cases under my
    care ......... 403
                         LECTURE XXXI.

                              EPILEPSY.
Cases illustrative of the use of iodide or  bromide of potassium—Sug-
    gested explanation of the benefit so derived—Accessory treatment  .  407
                         LECTURE XXXII.

                              HYSTERIA.

Part I.—Hysteria  not fatal,  but not therefore unimportant—Not a
    uterine  disorder—Its pathology  lies  between mind and body—Its
    forms to be divided according as it approaches one or  the other—
     Such a  division has a direct bearing on the treatment—Mental hys-
    teria—Treatment, restoration of voluntary mental force, of cutane-
    ous circulation, and of emotional control—Corporeal cause for
    hysteria—Treatment,  tonic to mucous  membranes—Effects of tea-
    drinking— Treatment, dietetic      .....  412
Part II.—Hysterical vomiting—Three cases in hospital compared with
    some private patients—It is not in strictness vomiting—Diagnosis
    and treatment—Their difficulties—Hysterical cough—Contagious-
    ness of hysteria     .......  427
Part III.—  Connection between hysteria and insanity illustrated—Medi-
    cal curiosity  about private history of patients—A physician not a
    confessor    ........  432 
CONTENTS.
xix
PAGE
Part IV.—Periods  of life prone to hysteria—Blighted affections, low-
    ering diseases, and climate, as causes—Two cases of hysterical loss
    of voice treated by valerian and shower-baths—Spasmodic cough
     and spitting of blood in  one patient—Advantages of auscultation
     i n the diagnosis of the latter       .                             *54
pYRTV.—Treatment by ice—Treatment by blood-Idling—General con-
     elusions    ...•••••
                        LECTURE XXXIII.

                         SPINAL PARALYSIS.

Case of paralysis caused by meningitis of the spinal  cord—Action of
    iodide of potassium   ..•••••
                        LECTURE XXXIV.

                           ■   SCIATICA.

Anatomical pathology of the disease—Case of rheumatic sciatica—Ro-
    kitansky's description  of  the  morbid anatomy of sciatica—The
    disease a  local one—Therefore requiring local remedies—Case of
    gouty sciatica—Relief from cupping—Peripheral pain sometimes
    more lasting than central disease—Sciatic paralysis of bladder-
    Case of anaemic sciatica—Local  treatment first requisite—Use of
    iodide of potassium—And of quinine—Other forms  of sciatica-
    Other remedies besides those named—Deductions and reflections  .  446
                        LECTURE XXXV.

                           ALBUMINURIA.

Indications afforded by the presence of albumen  in  urine, and progno-
    sis derived therefrom—Treatment, based not on anatomical division
    of forms of degeneration in the kidney, and not on the quantity of
    albumen,  but on  the circumstances accompanying its presence—
    Adjuvantia, viz., iron, digitalis, strychnia—Lozdentia, viz.,  mer-
    cury, calomel—When each  are justifiable—Treatment of dropsy by
    baths, jalap, cream of tartar, elaterium, and acupuncture—Sloughs
    of skin, how treated .       .       •      -       •       •      .  4oo 
XX
CONTENTS.
                       LECTURE  XXXVI.

                          ALBUMINURIA.
                                                                PAGE
Case of albuminuria with vomiting from ague cured—Case of albumi-
    nuria fatal from sudden pneumonia—Case of albuminuria fatal
   from epistaxis, and loss of blood and albumen— With comments on
    each.........464
                       LECTURE XXXVII.

                              ASCITES.

Part I.—Case  of ascites from hepatic  degeneration relapsing after
    tapping several times prevented from returning by the use of iron—
     Cause  of the disease irremovable, yet the disease capable of cure—
    Pathology of ascites,  and connection of the treatment  with that
    pathology   ........  472
Part II.— Case of ascites from renal degeneration treated with iron
    and cured, though the albuminuria remains as before— Contrast of
    this with two cases of albuminuria from  a remediable cause      .  477
                      LECTURE XXXVIII.

                             DIABETES.

Case of diabetes, with history of treatment adopted—Arrest of function
    of construction of diabetes—Saccharine diet wasteful and harmful
    —Test of treatment is gain of flesh—Patients to be made into car-
    nivorous animals—Sugar may be formed from flesh diet, or from
    hepatic tissue—But from dead not live tissue—How far a very strict
    dietary should be enforced—Opium—Cinchona—Iron—Iodide of
    potassium—Gratification of thirst  ..... 482
                       LECTURE XXXIX.

                          MORTIFICATION.

Complete death of a part contrasted with nekrobiosis—Case of mortified
    toes from cold and senile arteries—Treatment explained—Preserva- 
CONTENTS.
xxi
                                                             PAGE
tion of dead tissue from decomposition—Defense of weak vessels—
Food—Appdite—Action of oxygen on sore places—Carbonic acid
the normal atmosphere of internal parts—Superiority of nature's
surgery to man's    .      .      .      .      .      .      .489
                           LECTURE XL.

    IMPORTANCE  OF THE  DIGESTIVE ORGANS IN  THERAPEUTICS.

Disease of the digestive viscera affects the whole body—Instances, tuber-
    culosis, degeneration, mental  disease, gout  and rheumatism—Di-
    gestive viscera the chief recipients of remedies, and not only of con-
    structive,  but  of destructive  and  arrestive remedies—Effects in
    disease of healthy and unhealthy digestion—Importance of replacing
    destructive by the aid of constructive action—Digestive tract single  494
                          LECTURE XLI.

                     INDIGESTION  IN GENERAL.

Justification of the term as designating a class of diseases—Position of
    it in nosology—Its importance—Examples—Its action on chronic
    disease—on acute disease—Use and abuse of purgatives—Cause of
    death in acute fevers—Mode of introducing food  .      .      .  501
                          LECTURE  XLII.

                   SLOW DIGESTION AND  ACIDITY.

Healthy digestion is easy, quick, and  complete—Unhealthy digestion is
    painful,  slow,  and defective—Phenomena  exhibited in unhealthy
    digestion—Heart-burn—Acidity   .....  513
                         LECTURE XLIII.

                       PAIN IN THE STOMACH.
Local weight, tightness, distention, dependent  on excessive secretion of
    mucus—Gastric catarrh, acute and chronic       .       .       .  526 
XX11
CONTEXTS.
                         LECTURE  XLIV.

                    ERUCTATION AND VOMITING.
                                                                 PAGE
Anatomy and physiology of ervctation—Relaxation of oesophagus—
    Spasm—Analyses of gases by chemists—Deductions therefrom—
    Secretion of air  by mucous membrane (?)—Defective absorption—
    Decomposition of food—Fermentation prevented by acidity— Classi-
    fication of morbid states in which eructation occurs—Indications of
    treatment in the several classes—Antacids—Astringents—Valerian
    —Ammonia—Sulphurous  acid— Charcoal— Vomiting— Causes of
    —Indications afforded by the contents of the vomit—Remedies for—
    Hydrocyanic acid—Carbonate of magnesia—Opium—Chloroform
    —Leeches—Lime-water and milk—Brandy— Creosote— Valerianate
    of zinc—Ice—Possibility of starvation from vomiting of a purely
    functional character—Sea-sickness and its remedies       .       .  536
                         LECTURE XLV.

                             DIARRHCEA.

Pathology of diarrhoza—Difference of it from mere frequency of evacu-
    ation—Division  of diarrhozas—Bilious— Watery—Mucopurulent
    —Bloody—Putrid—Their causes and indications—Supplementary
    and reflex diarrhoza—Infantile—In fever—Ulceration of bowels—
    Mucous flux—Copious solid matter—Acid diarrhoza—Use of opium
    —Riding—Cautions about traveling—Flatus in  ilia—Charcoal,
    &c......      .      .      .       .548
                         LECTURE XLVI.

                 COSTIVENESS  AND CONSTIPATION.
The difference between costiveness and constipation—Costiveness depend-
    ent on retained excernible matter—What diseases it accompanies—
    Cause, defective vitality—Effect on the nervous system and mind of
    retained excernible matter—Indications of treatment—Inconveni-
    ences of purgatives—Sort of purgatives to be adopted—Dietary—
    Water—Watering-places—Cautions in using them—Hydropathy— 
CONTENTS.
xxiii
Constipation— Causes — Irritating  food— Unabsorbable  food—
Remedies—Flatulence  in colon—Distinguished from that  in  ilia
—Remedies—Slight cases difficult to relieve       .      .       .  562
                         LECTURE XLVII.

                              DIETETICS.
Thesis of Dietetics based on the principles of sparing the weakest part
    —/. Stomach—II.  Intestines—III.  Increase  of absorption—IV.
    Delay of absorption— V. Gradual return to normal diet   .      .  572
                        LECTURE XLVIII.

                             CORPULENCE.

Obesity to be distinguished from fatty degeneration—Origin of adipose
    tissue from food either containing fat  or elements capable of con-
    version into it in excess over the respiratory consumption—Presumed
    possibility of relief by dietetic treatment—Tendency to obesity con-
    genital  and hereditary—Deductions from  thirty-eight tabulated
    cases as to the peculiarities of obese persons, and the exciting causes
    of their  condition—Obesity a comparative hypertrophy arising out
    of a comparative vital deficiency—Principles of rational treatment
    thence deduced—Difficulties in enforcing their adoption—Specimen
    of detailed  scheme of dietary—Limits to attempts at reduction—
    Drugs, such as  liquor potassaz, vinegar,  iodine, and diuretics, dis-
    cussed—Belts and baths—Prognosis of obesity     .       .       . 581
                          LECTURE  XLIX.

                             ON PEPSINE.

History of the use  of gastric juice in medicine—Difficulties of its use
    obviated by preparation—Experience of its use  in  a few typical
    cases—Ltmits of advantages gained—Details of administration   .  589 
xxiv                        CONTENTS.


                           LECTURE  L.

                            ON  ALCOHOL.
                                                                 PAGE
Experiments showing the action of alcohol on the vital metamorphosis
    of the body, with a running commentary on each—Opposite opinions
    about the use of alcohol—Best guide to therapeutical use is physio-
    logical observation of its action on the healthy body— What is a
    stimulant f—The  effect of alcohol is arrest of nervous function-
    How it comes to be an indirect restorative—Rules for the adminis-
    tration of alcohol—Form of administration       .       .       .589
                           LECTURE LI.

                         ON  BLOOD-LETTING.

Part I.—The power of renewal in the animal body exemplified by the
    quick restoration of normal blood in an anaemic girl—Application
    of these facts to the artificial anozmia induced by blood-letting—
    The necessary conditions for the repair of anozmia—Starving and
    bleeding at the same time bad practice—Reasons for bleeding—
    Fallacies of the ancients   .       .      .      .      .       .612
Part II.—Cases in which loss of blood is beneficial—In some cases of
    apoplexy—In pneumonia—In the  congestions of typh-fever—In
    serous  inflammations, in pleurisy, pericarditis, and peritonitis—
    In renal congestion and hozmaturia—In paralysis of the circulating
    organs from  overdistention—In  chronic diseases of the skin—
    Conclusion .      .      .       .       .       .       .       .617
                          LECTURE  LII.

                     ANSWERS TO OBJECTIONS.
(Lectori benevolo.   Not delivered viva voce.)    ....  626

L'EXVOI........  634 
LECTURE  I.
                 DEATH  AND  LIFE.

Reasons for an introductory lecture—Decay of dead bodies—De-
     cay of living bodies—Life is renewal, and cannot be in ex-
     cess—Health,  death, and disease—Illustrations of 'partial
     death as exhibited in disease—in degenerations—in  hyper-
     trophies—in malignant  tumors—in catarrh—in boil and
     abscess—in fever and  zymotic  diseases—in  ansemia—in
     mixed ansemia—in  tuberculosis—Classes of diseases in  the
     hands of the nosologists—The restorative direction of modern
     improvements  in medicine—Constructive and  destructive
     life—Restorative pharmacopoeia.

(Introductory Clinicals,  St.  Mary's, October 4,  1861,  and  Oc-
                        tober 2, 1862.)

  Before I enter, as a  teacher of clinical  medicine, upon  my
duty of showing you how to read the lessons  which are  spread
out before your eyes in the hospital wards, it is my custom to
give you an introductory lecture.  I  think this saves time in the
end, for " claudus  in vid antevertit  cursor em extra viam,"  as
Bacon tells us, and my object is to show you the way.   Doubt-
less all your past professional studies have been in  a manner in-
troductory to this crowning study ; your anatomy, and chemistry,
and physiology, and the systematic principles of medicine learnt
under me and my colleagues, have led up to  this  end.  But I
wish shortly to recall to your memory what points in those studies
of life and death have the most special bearing on the matter in
       3 
26
DEATH AND LIFE.
hand, and to show how a consistent theory of therapeutics may
be built up from them.
  It is true that there are, and always have  been, practitioners
who declaim against theories altogether, who even boast that
they can do without them, and think them useless, not consider-
ing that to express  such scorn is as if we should be proud of not
knowing what we do when we  act, or what we say when we talk.
To  reason at all is  to theorize;  no one  without theorizing can
direct  a  method of  cure to a sick person except at  haphazard.
As  a matter of fact, none of these objectors ever do  prescribe
without theorizing about either the individual sufferer or the class
to which they refer his sickness, though not always  able to put
their theory into words.  In short, the want of a guiding princi-
ple  to connect the loose facts of daily experience has at all times
been felt.
  From this practical need have been bred the many systems of
therapeutics  stamping their mark  from time to time on the his-
tory of our art.   They have sprung from the brains of working
men at the bedside, not from philosophers in their closets.  Their
adopters have not necessarily any strong faith in their truth or
universal applicability; but the heart wearies for a chain to link
together the scattered fragments of knowledge—a string for its
pearls; it must have an idea on which to codify the  laws of ac-
tion.
  It would be a long task to quote the curious systems founded
on imperfect data, but numbering their hosts of followers in for-
mer ages, which have been given up as false and dangerous: I
do not wish twice to slay the slain.   I shall content myself with
putting before you  that which influences me in my  practice, to
which I now proceed.
  Man's body may be likened  to a stately mansion, made of
beauteous but very  perishable  materials, all of which are always
needing repairs to keep up the shapeliness and usefulness of the
building.   But not  all in equal degrees ; some of the walls may
stand unaided for  years, while  other  parts  may  want  almost
hourly looking after.   When the owner leaves the dwelling the
repairs cease, and then we see, not  all  at  once, but one  after 
DEATH AND LIFE.
27
another, the materials falling into ruin.  It will serve a purpose
in my argument to think over the several steps of this ruin for
a few minutes.
   Already while the soul is withdrawing we know that  changes
begin, very obvious to even the most superficial observer. These
changes are  mostly due to the  loss of water by evaporation.
The eyeball loses its brilliancy and gets dry and flat, the features
shrink,  the gloss leaves the hair and skin.   All this  goes  on
all the more  rapidly after decease, and then we  hide our  dead
out of our sight, and the future fate of the body  is less familiar
to us ;  we must search for exceptional cases or special observa-
tions if we want  to know what  happens.   These we may cull
from sundry independent sources.   Here is one  which old bar-
barous  manners  afford  us.   "Rizpah the daughter  of Aiah,
the concubine  of  Saul," watched  for six months,  from " the
beginning of barley-harvest" in  April, to the rainy season in
October, "till  water dropped upon them out of heaven," to
guard the corpses of her murdered kinsmen from the beasts of
prey.   So long under the sky of Palestine did they hold out a
quarry  for the  wild dogs and vultures.
   In a moister air decay is  quicker, but still not so quick as is
often  supposed.  Here  is another  observation redolent of the
refinements of modern science.  The notes made by M. Devergie*
on the bodies at the Morgue at Paris, show that for two months
and a half after decease  the muscular structures still keep their
natural  forms  and  hues.  Up to three months and a half, the
scalp, eyelids, and nose so far retain their ordinary features that
the age of the  person may be told.   It is  four  months and a
half before complete destruction of the face occurs, or the bones
become  brittle,  and the bulky muscles of the neck  and thighs are
converted into  adipocere.   So that we may call three months
and a half a short  time  to be  occupied by the decomposition of
a human body.  So long does flesh last as flesh,  and tissue as tis-
sue, and is not  melted into its mother earth.
   Let us come forth  quickly from these  ghastly scenes of the
charnel-house to the joyous bustle  of brimming life, and  ask
             *  Devergie, " Medecine Legale," t. ii, chap. v. 
28
DEATH  AND LIFE.
 how long it takes  not a dead but a living body to decay ?   "A
 living body decay V"   Yes, in truth ; but whereas in the former
 case it was a thing to make men shudder, the  fading of a long-
 loved image, the tearing up of  a fair garment,  the fall of a dar-
 ling home, the  violation of a worshiped shrine, the forcible di-
 vorce from our nearest and dearest—it is all this and more—in
 the latter it is associated with  the  fullest fruition of all that is
joyous in existence, the bounding pulse, the  free-drawn  breath,
 the swelling chest, the thrilling feel of health,  the  highest uses
 of mind and body.  Decay is more  truly a part of life than it is
 of death ; for it goes on unstayed through the whole of corporeal
 being; whereas, after  dissolution, it gradually  ceases, and ends
 its  work  with the reconversion of the organic particles  into
 eternally changeless elements.  The most living body is the most
 active in decay : the more bodily and mental vigor are displayed,
 the more quickly do the various tissues  melt down into substances
 which are without  delay removed by the excreting organs.   The
 more the blacksmith toils with his arms and the more the states-
 man with his brain, the heavier bulk of  carbon, nitrogen,  oxygen,
 and  hydrogen is thrown out  by lungs, liver, skin, and kidneys.
Do they  then wear out by this constant use, friction, and drain ?
 No, no—the more bricks are removed from the old wall, the
 more new bricks will a good  builder put in; and so—provided
 that the  supply is sufficient, and that the builder is a good one—
 the more rapid the drain—the newer and stronger and fitter for
 its uses will the body become.
   But  I  will leave generalities and try to represent  in  figures
 how long it takes  by living decay for  the  living body to drain
 away, and to have its  substance renewed.  In  the  grim details
 which I recalled to your memory at the beginning of this lecture,
 the nitrogenous or fleshy parts were most accounted of and espe-
 cially named as giving shape and the  general  look of a man to
 the melting corpse.   So of the nitrogenous  parts we will  now
 speak—How long are they in being removed by vital decompo-
 sition ?
   We may reckon with Drs. Bidder and  Schmidt* that the body
          * " Die Verdauungssafte und der Stoffwechsel," p. 400. 
DEATH AND LIFE.
29
of a mammal contains 35"45 grammes of nitrogen per kilogramme;
and, therefore, that an animal  of  130 lb.  (which is the mean
weight of a man) contains upwards of 4-6 lb. of nitrogen.
  Then  again, taking  our numbers from  an equally sound and
independent source,  we may reckon with B.aron Liebig* that the
liquid and solid  excreta of a man  by kidneys  and bowels for a
year  contain  16*41  lb. of nitrogen, or  for three months and a
half 4-7  lb. of nitrogen.
  That is to say, in  three months and a half a quantity of nitro-
gen is removed by excretion, or vital decay, equal to the quan-
tity of nitrogen in the whole mass of the chief nitrogenous tissue.
  What  attractions  has this  term three months and a half for
us ?—what memories does it rouse ? Why, this was the very time
we fixed  upon for the fleshy framework of the corpse to melt away
in.   Here is a pregnant fact, a light thrown on the mysteries of
nature from a most unpromising source !  Dead flesh and living
flesh  last as nearly as, possible the same time—the former,  if
anything, rather  the longer.   As far  as we  can judge, the albu-
men, fibrin, gelatin,  &c, which make up the live body,  differ in
nowise from the same matters dead; they are liable to the same
changes, affected by the  same reagents, and  naturally  are re-
solved into their elements in the same time; just as the marble
in the Apollo Belvidere is to a mineralogist the same  stone as it
was in the quarry, liable  to the same accidents and possessed of
the  same properties,  though temporarily endowed with a different
value, and made god-like by its adventitious form.
  What,  then, raises to the rank of living creatures, and clothes
with loveliness the masses of organic matter which are growing,
moving,  breathing, thinking, all around us ?  It is the power of
the  individual  Life to create its own  individual  Form.   A man
has no right of property over the particles of his body, except so
long as they remain  particles of his body and retain  his shape.
He  hardly calls his  the snappings of  his hair  or the  parings of
his nails, much less the carbonic acid  he exhales from his lungs
or skin ;  all that he  throws off is by common consent claimed as
a perquisite by the  public ; and the battle-fields which  he  has
   * Liebig's " Chemistry of Agriculture and Physiology," part i, chap. ix. 
30
DEATH AND LIFE.
fertilized with his blood enrich, not him, but the peaceful farmer.
Yet as long as these organic constituents  retain the form im-
pressed upon them by the individual life, they are more truly his
than any portion of his inheritance.
  A conjectural theory has been hazarded that Life mysteriously
endows living matter with a defensive virtue,  which enables it to
resist the chemical and other  powers acting  regularly on  inor-
ganic and dead matter.  The most notable instance cited is the
stomach, which digesting everything else is not itself digested.
This consumer of flesh is itself made of flesh, yet  is not con-
sumed. An answer seems given to the witty philosopher, who on
hearing an alchemist boast his discovery of an universal solvent,
inquired  "In what vessel do you keep it ?"  The stomach says
(it has been in the habit of  saying wise things from the time of
Menenius Agrippa), " In a vessel like me, which is destroyed in-
deed  continuously,  but  is  continuously rebuilt."   Recent re-
searches show that living matter, such as parts of living animals
swallowed for instance,  is dissolved by the gastric juice, and
moreover that its own epithelial coat is destroyed, but is immedi-
ately replaced by a new one.   By this activity of growth (the
idea of the impudent members  calling the belly lazy !), and by a
constantly flowing supply of alkaline blood to neutralize any of
the acid secretion which  might penetrate too deep, it retains the
same shape for threescore years and ten. But it has no privileged
immunity against the solvent it makes.
  It is, then, the Form which constitutes the  Self;  and it is not
the changing, decaying matter  which "was mine, is his, and may
be slave to thousands."   The organic materials are  the property
of the form only so long  as it retains them, and no longer—they
are a floating capital.   Over  the innate essential nature of the
material it has no control. Life cannot make the  brute materials
which it uses live longer than that which it leaves unused, but it
has the power of making them anew, and building them up into
a certain shape for  the time they are made  to last.   In short,
Life rests on the metamorphosis or Renewal of the body ; as this
renewal is more thorough, the individual is  more  perfect, and
fulfills better and more completely the duties of its position.   If 
DEATH AND LIFE.
31
it stops altogether, the body is no longer living.  If it partially
stops, the order of normal  phenomena is disarranged, and ease
is expelled—there is a state which we call " dis-or&ev" or udis-
ease."
  To speak, therefore, of "a  superabundance of life," or of an
" excess of vital action," is a  contradiction in terms. There can-
not be too active a metamorphosis of the tissues, for the  fresher
their organic constituents, the more serviceable they are,  and the
longer duration they have before them. There cannot be too close
an  adherence to that  typical form which it is the business of
metamorphosis to keep up, any more than there can be too exact
an obedience to law and order.
  The  most active metamorphosis  of the body possible, the
highest possible development of life in  every part, is Health.
  The complete cessation of metamorphosis is Death.
  The partial cessation, or arrest, is Disease.
  In death the flesh goes on  being decomposed as  during life;
but not being renewed, the form is lost entirely.  In disease, de-
composition goes  on, but  renewal  flags, and  the  decomposing
tissues are not sufficiently pushed out by new-formed substance.
They are retained as part of the imperfect body—a sort of  " death
in life"—and are rightly termed by the pathologist  " degene-
rate."  They are  generated, but not  re-generated;  they are
generated in an inferior mould of form.
  Take as  an example  what  happens sometimes  to voluntary
contractile fiber.  We all know that if an animal's limbs are duly
employed, the muscles keep up their  shape and their vigorous
power of contraction;  their tissue is of a rich  bright-red  color
when the  animal is fully grown,  and is  firm and elastic.   Ex-
amine it under a microscope,  and you  find it  made up of even
parallel fibers, each fiber seeming to be engraved over with deli-
cate equidistant cross-markings,  like a measuring-tape very mi-
nutely divided.  The more the muscle has been used in a well-
nourished frame,  the more closely it conforms to  the  typical
specimen of the physiologist:—
              " Use, use is life; and he most truly lives
               Who uses best." 
32
DEATH AND LIFE.
   But suppose this muscular fiber has been unworked—suppose
it is in the biceps of an Indian fakeer, who has fastened his arm
upright till it has become motionless, or in the gluteus of a sol-
dier's amputated leg, or the calf of a Chinese belle, or in a para-
lyzed limb—then the flesh is quite different in aspect; it is flabby
and inelastic,  of a pale-yellowish hue, and makes greasy streaks
on the knife that cuts it.  Sometimes even all traces of fibers have
disappeared, and it is converted  into an unhealthy fat.  Some-
times you may trace fibers  under the  microscope, but their out-
line is bulging and irregular, the cross-markings are wanted, and
you see instead dark, refracting  globules of oily matter in them.
In short, the muscle is degenerating into fat, retaining in a great
measure its shape, but losing  its substance.  Such is, by God's
law, the penalty of not using His gifts for four  or five months.
   Now go back to our first sepulchral illustrations. M. Devergie
found that in a period of between four and five months the flesh
of a corpse is converted into a substance technically termed
"adipocere:"  an oleaginous substance between  fat and wax—an
artificial fat the result of chemical decomposition.   What is this
but  precisely that which happens to the disused muscles in the
cases quoted ?  At the Morgue,  a continuous  stream of  water
washed away the fetid gases from the  subject of M. Devergie's
observations, and in the  living body destructive metamorphosis
and excretion  remove the  more directly noxious particles ; in
both there remains the same oleaginous residuum.
   The instance chosen of  diseased structure was purposely an
extreme one ; but even there, a very high degree of partial death
was seen not to be inconsistent  with life.   A less decree is not
inconsistent even with  active usefulness.  Look at  many a man
whom his  physician knows to have a weak  or slightly-dilated
heart; he goes on with his  profession, mixes in society, enjoys
his quiet pleasures, and  may even insure his life  by paying an
extra premium.  Yet if an accident at any time should cut him
off suddenly, the muscular tissue of the  heart will be found pale
and  soft, while under the microscope the fibers are seen deficient
in clear  outline and in  cross-markings, and exhibit here  and
there minute specks of that fatty degeneration which was so con- 
DEATH AND LIFE.
33
 spicuous to the naked eye in M. Devergie's subjects and in the com-
 pletely palsied limb.   The more dilated and the more weak the
 heart, the more widespread is this degeneration.   Yet enough of
 active structure is left  to carry on the  work of the heart, and
 perhaps to prolong life to its allotted threescore years and ten.
   A close copy of the pathological  process may be made by
 soaking a piece of muscle, say from a healthy sheep's heart, in
 a running stream, in weak spirits and water, or in nitric acid and
 water, for a few weeks, when  sections made from  time  to  time
 will exhibit  the several stages  of fatty degeneration, from the
 minute specks in the scarcely-altered  muscle up to complete con-
 version into  adipocere.*
   Remark in these cases of fatty degeneration or decay that the
 substance which replaces the highly-organized animal matter is
 not utterly inorganic.   It is less organized and less organizable,
 but still capable of being called  alive.   Of our living bodies fat
 is a part and a necessary part; but still  it is not  capable of per-
 forming the highly vital duties  of muscular tissue, of being as
 thoroughly alive.   Degenerated products, therefore, so long as
 they form part of the body, may still be  said to be alive, but less
 alive than the normal tissues  they  replace; and degenerate
 growth may  be justly described as " diminished life,"—or in the
 words I  lately used, "partial  death."   Degeneration, in short,
 is a more or  less relapse into a lower  and lower form of organic
 life, and exhibits itself therefore in a  variety  of  grades  and
 amounts. Occurring in various parts,  it occasions three-quarters
 of the chronic illness which give work to the  physician.
   Let it be well understood that these half-living tissues are by
 no means necessarily lessened in size.  A  battered and renovated
 vessel is oftener much bulkier than a strong new one ; and in the
 same way these under-nourished  parts are often enlarged, and so
 have  been wrongly supposed to be over-nourished.   They often
 attain a most cumbersome weight and bigness without really  con-
 taining tissue enough to do their work.   They become, in truth,
 a foreign substance.  Sometimes they-acquire what seems like a
  * Figured in " Medico-Chirurgical Transactions,"  vol. xxxiii, plate v, in illustra-
tion of a paper by Dr. Quain. 
34
DEATH AND LIFE.
parasitic life, and grow as if independent of the body which they
inhabit.   Then you justly look upon them with a peculiarly un-
favorable eye, and call them by the epithet "malignant."   Can-
cer is  the best-known example  to quote; and  you who  have
watched its deadly quickness  of  growth are perhaps wondering
that it should be put forth as an  instance of lessened vitality.
But watch further with the mind  and not with the eye only; you
will see that its  tissue never gains the  higher characteristics of
life ; it never puts on the form of  the part it is  planted in, nor
performs  its  duties.   Moreover,  its half-life, so  easily  acquired
and so easily multiplied, is also  easily lost.   Its very tendency
to die and to ulcerate is one of the chief dangers in which it puts
your patient.
   But we are now driven to seek our illustrations among these
dreadful sorrows of our kind, when  we can find them in less pain-
ful scenes.  Every one connects cancer and  degeneration with
death;  but perhaps it is  not quite  such a familiar  idea to see
partial death in  a cold in the head  or relaxed throat.  However
much you may smile at the notion,  it is a true one; and I should
advise your taking the next chance which a catarrh  gives you of
seeing the truth and its bearings.   It is almost worth while to
catch one on purpose, so valuable is the lesson.  And perchance
your smile may  become a grave  and thoughtful  one, when  you
reflect on the mysteries of life;  when you think that the  slight
inconvenience you are bearing is  of the  same  nature  as that
which divorces soul and  body, a distant and indistinct foretaste
of that dread cup which we must all one day drain.*
   Look at your  catarrhal throat  in a mirror—what  do you see ?
The surface  red, puffy, and with the component parts, such as
the uvula, enlarged.   There is also poured out a  quantity of
slimy material, which you well know by the name of mucus. At
first you may be disposed to cry,  "  Surely here is an active busi-
ness going on ; everything seems much  more lively than usual;

  * And perchance  also this may be an  useful meditation, not only for medical
men, but also (as is  remarked  in an article on " The Renewal  of Life"  in the
" Medico-Chirurgical Review" for -July, 1863) for amateur tamperers with life,
who in their zeal without knowledge are so found of remedying minor bodily ills. 
DEATH AND LIFE.                   35
life is increased, not  diminished."   Not  so'fast—examine in a
microscope a little of this mucus, and you will find it made up of
minute balls of  transparent jelly with a granular aspect, techni-
cally  called " exudation globules," " mucus globules," and "pus
globules," floating quite free, and rolling over and over without
any tendency to adhere together.  Are these bodies a new crea-
tion, something  which an inflamed membrane can produce, while
a healthy one lacks the power ? are they evidences of an addi-
tional life-force  ?   By no means ; for they have been  identified
with those elementary forms of nascent life by  which all organic
matters grow ; they are young cells, or rather nuclei.*  They are
the form assumed by  all  liquid living  material which under the
influence of life is  being transformed  into a solid; they are  an
infant tissue strangled in its birth. Instead of uniting into a con-
tinuous web to  clothe with  epithelium the surface of  the  mem-
brane, they float off helpless from deficient vitality.  The business
of mucous membranes is to be covered with  epithelium, not to
throw off mucus;  and when they are doing the latter, they are
so far forth in a state  of diminished life.
   But you may ask, what is that redness and that throbbing of
the inflamed part ? do not they show an  increased circulation of
the vital fluid, and therefore increased life ? Quite the contrary,
for the membrane is red because its blood-vessels are relaxed and
dilated from loss of vital elasticity;  the blood  sticks in them as
water in a bulged  pipe; and the arteries,  pressed upon from be-
hind by the heart,  throb because  the obstruction impedes their
action.
   " But the pain,—does not that show that the vital  power of
sensibility is increased?  I  cannot, in general, feel that  I have
got a throat;  and now I am reminded  most disagreeably of the
fact."   No ; pain does not indicate an increase of proper sensi-
bility ; in this case it is associated with a  very  marked decrease.
During your catarrh the lining  membrane of the fauces loses its

  * The identification of young epithelium and pus cells, was some years ago
amusingly made out by JI.  Lebert,  who, in plate iii, figs. 3 and 6, of the atlas to
his  " Physiologie Pathologique," places them in opposition, with the intent of
pointing out their differences, but with the result of showing iheir identity. 
36
DEATH AND LIFE.
delicate  appreciation  of flavors—everything  is  equally  nasty,
unless there is a pungency in it too powerful to be pleasant to the
healthy taste. And it is wanting also in common sensibility; for
it does not  distinguish the shape or size of morsels swallowed,
all of which feel equally large  and awkward.
  Or you may get a whitlow on your finger, or a boil, and study
how the nail is stayed in its growth, and the skin is killed  ; while
the materials  intended to  renew them are checked in  their  de-
velopment, and go to be deposited  as pus, a concentrated form
of half-vitalized fluid, very similar  in  every respect  to  mucus.*
And, like your catarrhal throat, your inflamed finger-tip is want-
ing in sensibility : try it, and you will find for any delicate work,
such as feeling the fine lines of a copper-plate, or the flaws in a
polished surface, it fails in  its duty.  Pain, in short, is the brothe r
of death ; a painful part is  never performing its whole vital func-
tions—it is partially defunct.
  The same  partial death, which has been hitherto described as
constituting the various diseased states of the  solid structures of
the body, may also attack the fluids; and in them, as in the solids,
it may show itself either  as a destructive  relapse  into  a  less
organic life, or as  an arrest of development.  The poison of fever,
for  example,  destroys  and renders useless as nutriment some
constituents of the blood; the insufficient blood is circulated to
all parts of the body, causing, not local pain, but general malaise
by  its deficient vitality.  The half-poisoned  tissues allow the
poisoned material to ooze  through them, causing  diarrhoeas, ex-
halations of blood from mucous surfaces, purple blotches  on the
skin, and a  general staining of the  whole body of a dusky hue.
If the quantity of blood poisoned is moderate, it  can  be  easily
spared ;  it is carried off gradually by excretions, and its place is
filled up in time by new blood.  But if the rare case happens of
so much being  poisoned at  once that too little  remains to earry
on the business of the body, then death occurs by sudden shock;
or if, through ignorance, carelessness, or false theory, there is an
  *  On the pus formation in connective tissue, see Virchow's  " Cellular Pathol
ogy," fig. 137, and text adjoining, and the  Lumleian  lectures which follow in
this present volume. 
DEATH AXD LIFE.
37
insufficient  supply of material to take the  place of the killed
blood, the vitality wanes away more slowly.  And as its loss oc-
curs more slowly,  some one part more than another is usually
affected; there  is congestion and  inflammation—that  is, local
death—of the digestive viscera, or  of the lungs, or of the brain,
and the patient's  disease is allotted by name to that last cause.
And thus in fever, the  blood  relapses  into a less organic form
through its  vitality being destroyed by a morbid poison.
   Let us next look for an instance  of imperfect life in the blood
occasioned by arrest of development.   You  are  all practically
familiar with  the  condition,  so common  among hospital  out-
patients, which you have already learnt to  call  ansemia.   The
word means literally  " bloodlessness," but in  reality relates
rather to deficient quality than deficient quantity. The  circulat-
ing fluid cannot but fill the hollow vessels which hold it, but it is
wanting in the  most highly organized, the most  truly living of
its constituents.   It is pale, from  the diminished  numbers  of
those floating red globules which give it florid hue.   This capital
of red globules is by far the most important portion of the blood;
so much so,  that it may be taken as a direct measure of corporeal
and mental  vigor; a man has  a larger proportion than a woman,
a strong man  than a weak man, an adult more than a  youth or
an elder, a patient after recovery more than during his sickness
of whatever kind, a horse in high condition  more than when
brought up from grass.   Yet  in spite of this  importance, we find
to  our surprise that this floating  capital may  be  largely  en-
croached upon without a bankruptcy.   For example, Dr. Andral
has analyzed the blood of a patient with ansemia, where the blood-
globules amounted to less than 39  parts in 1000, whereas their
natural proportion should be at least 120 parts in 1000.  More
than two-thirds of this constituent were missing !  And yet the
patient was living and moving, and very likely quite recovered
in the  end  if rational  treatment was  adopted.   Now, in pure
ansemia there is not found any degenerated devitalized substance;
the missino-  globules have not relapsed into a lower  life, so  that
their ruins or ddbris should constitute a foreign morbid matter;
they have been used up in the regular  way.  and have  supplied 
38
DEATH AND LIFE.
materials for the tissues, as they are moulted  off from  day to
day;  while at the same time there has been a want of renewal,
an  arrest of that  continuous  development of  blood, which is
necessary to complete life.
  Pure anaemia  has been spoken of; but,  as might have been
expected, this defective supply of the materials  of growth much
weakens the vitality of many of the manufacturing and excreting
viscera: for their  machinery needs continual repair, as much as
any part of the voluntary apparatus.  Hence, in  cases of anaemia
we  often find that the liver  is not so  lively  as it should be,  and
some of the color it ought to get rid  of stays in the  circulation,
or exudes and chronically stains the  skin of a bilious  hue.   Or
perhaps the kidneys do only half work, and the urea which they
ought to drain off is retained, causing very  serious derangements
of health. Thus there is a mixed pathology in these cases, a com-
bination of arrested life with a relapse into  a lower life ; the life
of the specially  affected organ is diminished, and it leaves behind
in  the  system  substances  of inferior vitality  which its  proper
business is to excrete or separate.
   Or again, ansemia  may  so  lower  the creative power of the
blood, that instead of  the body being built of elastic and highly
vitalized fibrin,  it has  to put up with a cheesy,  brittle  substance
called tubercle.  This is just the sort  of fraud a  rascally contrac-
tor commits, when he  lays your floors on half-seasoned timbers.
Your house is  destroyed by dry-rot;  and the lungs in which
tubercle has been substituted for healthy connective tissue gradu-
 ally  soften  and break up.  The most effectual remedy  in  both
 instances is to look after the builders, to  secure  the honesty of
 the one and the vitality of  the other as far as possible.
   When the various accidental circumstances of our daily habits
 dispose various parts  of the  body to even the few elementary
 forms of disease which I have mentioned here, a great variety of
 abnormal  phenomena may  be produced.   Our  body is a  harp of
 so many strings,  that all sorts of discords may arise out of  its
 combinations.*   These  discords  have received much attention
               * " Strange that a harp of thousand strings
                  Should keep in tune so long."—Watts. 
DEATH AND LIFE.
39
from  minds with a taste for  order;  they have been  classified
into groups ; and if, unfortunately, the orderly mind was afflicted
with a theory, sadly have facts sometimes suffered by the Pro-
crustean bed of a Nosology, into which they have been forced.
On the whole the  nosologists  (NoaoAoyoi—people who talk about
diseases) have been convenient, for their nomenclature often
helps us  to describe in  one word what otherwise would Avant a
parenthesis.   But they have  been a  convenient evil, and their
labors have had this bad result; they have attributed a positive
existence to that which in reality is a negation.  " A Disease"
under their manipulation, instead of  being a mode in which life
is deficient, becomes an actual motive  power; the  giving it a
generic and specific name links it in our minds with  the subjects
of  a naturalist's studies, and  we get to clothe it in individual
characteristics, and to assign to it individual actions.   The con-
sequences  in science have been most fatal to true progress.   It
has had upon the  art of medicine just the effect that would be
wrought upon Optics by regarding a shadow as a material object
instead of  an absence of light, upon physics  in general by ac-
counting cold instead of heat as the active agent. The main hope
for bringing Therapeutics up to the level of modern science lies
in  discarding at once and forever this traditional notion.
   I am glad to say less practical harm than  might have been
feared has been done by these false notions.   In the first place,
man's body is tougher than  usually thought, and will stand  a
great deal of wrong treatment;  and, secondly, experience  has
somewhat  checked  the  bold  hand of a  relentless  adhesion  to
theory. Still, it can hardly be doubted that the increased chance
of cure under professional  treatment has not been so much as
might have been expected from the advance of general knowledge.
    Of late  medical art, as far  as practice is concerned,  has been
turning  over a new leaf;  nosologists are of less repute, and at
last, under the influence of common sense, attention  seems  di-
rected to  the maintenance of life in the body more than to the
expulsion  of  death out of it.   Such  is the true preaching to the
sober mind of the new modes  of treatment which, without falling
in with the  dogmas of any particular upathy," have yet  been 
40
DEATH AND LIFE.
 silently adopted by the rational adherents of each within the last
 few years.  I may instance the care bestowed upon the selection
 of alimentary substances;  the use of water, of oxygen, of iron,
 of animal oils, of chlorine, of soda in doses more like a food than
 a drug, of lactic and other organic acids, of salts of  phosphorus
 and lime, of sulphur, ammonia, bile, pepsin, and  several other
 agents established by common consent without being suggested
 by  any previous  theory of therapeutics, or  traditional rules of
 the medical art. These are constituents of the animal frame, and
 are administered  and trusted to as filling up an obvious void.
  If  experience has taught us to reform our practice, should it
 not teach us to reform our theory too ? that so the  partial ad-
 vantages which have been  gained might become universal, and
 our words and acts might cease to be inharmonious.
  I began this lecture by likening the animal body to a building
 constructed of  perishable materials, which need  continuous re-
 newal to maintain the usefulness  of the structure.  To keep up
 the simile, the permanent architect is the indwelling life, and he
 best performs his duty, not  by fits and starts of  work, but  by
 ever-watchful industry.   He should be every moment removing
 decaying materials from the walls and working  machinery to be
 carted away at convenient  periods, and he should be every mo-
ment  supplying their place by fresh.  Thus there are two depart-
ments carried  on  simultaneously—the  "destructive" and "con-
structive;"  and upon their harmony and completeness depend
the perfection of life which we call health.  Both are  necessary ;
and the deficiency of either or both, or  the preponderance of one
over the other in various parts, or their deficiency in one part
while  other parts  remain  active, constitutes a deficiency of life—
a disease.
  This deficiency the physician is called upon to remedy ; and it
is of the utmost importance to his usefulness that he  should re-
cognize that it is a deficiency, and act upon the recognition. He
must  look  at  his  pharmacopoeia  with  this  thought  constantly
present before him, with  an  eye  to the ultimate benefit of the
patient, to a goal beyond  that of the  immediate effects.   He
should make his chief thought how each of the reagents employed 
DEATH AND LIFE.
41
will finally touch life;  whether they are calculated to add to or
diminish the vital functions, to add to or  diminish  the vitalized
substance of which his patient is made—whether by temporarily
diminishing the functions or substance he may not remove an
impediment to their balanced actions, so as to lead  to a final in-
crease—or whether this artificial diminution of functions or sub-
stance may not become permanent, and inflict permanent injury
on his patient.  This final goal of life renewal must be consciously
or unconsciously in the heart of the physician, or in the heart of
his guides; otherwise  I  am sure he  contributes more to the ill
health than to the good health of mankind.
4 
LECTURE  II.
                DISEASE  AND  CURE.

 What is cure?—Classification of disease, for therapeutical pur-
    poses, into deficiencies of growth  and deficiencies of moult-
    ing—Deficiencies of groivth from  Chossat's observations—
    Analogous natural states in disease—Deficiencies of moult-
    ing— True and apparent—Mixed lesions—Natural cure and
    artificial cure—Cure originated by the healthy parts of the
    body—Classification of means of  cure—Constructives—De-
    structives—Arresters of construction—Arresters of destruc-
    tion.

         (Introductory, St. Mary's, October 5, 1863.)

  You are entering the hospital wards  to study Disease—that
fitful twilight coming between the  glad  radiance of life we call
health, and death, the drear darkness of its departure.   You see
the gloom sometimes  irrevocably deepen, more often melt  back
again into the beams of returning day; and you would fain learn
how to aid this joyful event which we hail as cure.   To  minister
to it is to  be  the business of your lives ;  and therefore time can-
not be wasted in first thoughtfully  considering what it is.
  Healthy life consists in  a  continuous and equally  balanced
repetition of  the two necessary parts of the renewal of the body,
constructive and destructive assimilation, in other words, " grow-
ing and moulting."   The essential nature of disease, that which
makes it disease, is a deficiency of health, a deficiency of either
construction  or destruction in one or more points.   The cure of 
DISEASE AND CURE.
43
 disease, natural or artificial, consists in a new birth or renewal
 of the deficient life.
   The practitioner,  to whose mind the cure  should be the ever-
 present object, will therefore do well to classify as far as he can
 all morbid  phenomena on  this principle; for  on this  principle
 will be based his most successful practice.
   Do not suppose  that I am here condemning  or proposing to
 reform the  existing nosology of statisticians.  Every classification
 must be constructed  for a specific  purpose; it  can be complete,
 and its classes be prevented from  overlapping, only by that one
 specific purpose being adhered to.   The hospital  porter  divides
 diseases into those of males and those  of females, and subdivides
 these again into  medical and surgical.   An  officer of health di-
 vides them into  epidemic, endemic, enthetic,  sporadic,  &c.;  a
 philanthropist according to their causation  by various occupa-
 tions, as diseases of painters, clergymen, coppersmiths, chimney-
 sweeps, &c.   An anatomist arranges  them "a capite a calcem'
 (as Morgagni says he does), according to the part affected.   A
 pathologist aims high at a kind of  natural system, and  classes
 together those phenomena whose  essential nature, whose  morbid
 processes seem alike ; for him diseases  are primarily divided into
 zymotic, tubercular, cancerous, hemorrhagic, catarrhal, arthritic,
 &c.  The Registrar-General, who has to provide a single nomen-
 clature for a great  variety of temporary purposes, and  suited to
 a great variety of minds, wisely contents himself with  a very
 imperfect and illogical classification  as a gradual stepping-stone
 to a better.  For nomenclature the best working classification is
 the  one which contains the greatest  quantity  of well-known
 names, and for common purposes that  which  is  most common.
  But this classification is  most faulty when  applied to aid us in
therapeutics.   To make it our only  classification is to introduce
 an arbitrary method  into the treatment of disease which  cannot
but impede  all true progress, not only in the mind of  the indi-
 vidual  practitioner, but of  the  art itself.*   However,  our  pos-

  * The danger is clearly pointed out in the  " London  Medical Review" for
March, 1803.  "The dictionaries and encyclopaedias of medicine, useful as store-
houses of facts, have done much to perpetuate  this error  with the unthinking 
44
DISEASE AND CURE.
session of  it and  use of it for its intended purposes, does  not
preclude special classifications for special  objects;  and, indeed,
the more ways a  man  has of classifying a subject the  more he
will know about it, and the more ready he will be with his knowl-
edge.
  I shall, therefore,  not hesitate to recommend for therapeutical
purposes an attempt  to classify morbid phenomena after a fashion
which I confess would be inconvenient, if not impossible, to apply
to them for other objects.
  Life we  know  to  be a  state of unending change; and  this
change is double—constructive of the body from  foreign  ma-
terials, and destructive of it into inorganic elements.  The phy-
sician, then, in his ministry of the living body, has  to be always
dealing with construction or destruction, or both together ;  and
it must make a great deal of difference for him to be able to re-
cognize which part of life he is dealing with; because the instru-
ments he employs to modify these opposite parts of life must be
in some way of opposite natures.
   Therefore I  cannot  but think we should be  contributing very
much to our practical usefulness, if we tried habitually to divide
morbid phenomena into (1) Deficiencies of nutrition or construc-
tive form-building,  and (2) Deficiencies of moulting or  form-
destruction.
   We should thus have ready to hand a decisive spur to a definite
course of treatment  in all cases;  whatever  empirical or  tradi-
tional means we adopt would be under the control of a final prin-
ciple, and we  should feel quite sure that we were at all events
aiming at a rational  end.*

portion of our fraternity.  With many even at the present day a  sick person is
regarded as a sort of living conundrum to which  there is but one correct  solu-
tion—a Greek or Latin word indicating his disease.  When this is guessed, the
word is as it were ' looked out' in a sort of mental dictionary where  the practi-
tioner finds against it appropriate treatment  according to his lights.   The  arbi-
trary practice thus induced strongly resembles the child's idea  of coloring  a
printed sketch—this is a  tree, and therefore it must be green; sky, blue of course;
water, ditto;  glass, ditto; a road, burnt sienna."  There are some excellent re-
marks on classification in the preface to Dr. Reynolds' volume on Epilepsy.
  * In my systematic lectures on the practice of medicine I have been used for 
DISEASE AND CURE.
45
   But is it possible to make this division ?   Much more possible
than appears  at first  glance, if we will first consent to clear our
minds  of nosological prejudices  begotten  of old theories, and
come to  the task fresh  and  unfettered, ready to  accept all the
conclusions which independent observation  may supply.   I will
point out a few of the more obvious sources of knowledge  which
may help us to the required end.
                                (I.)

   First, for deficiencies of nutrition  or form-building.
   The morbid phenomena capable of being  classed under  this
head are doubtless to be found most  purely displayed by starva-
tion and loss of blood in otherwise healthy bodies.   The labors
of M.  Chossat  and  Dr.  Marshall Hall have almost exhausted
these  subjects, and are easily accessible to  all.
the last ten years to adopt a classification similar to this in the first  part of the
course, which includes general pathology, and consequently the principles of
therapeutics.
                                      f Of whole of blood—Haemorrhage,
                r r     .      .     .      transudation.
                |  Loss of normal constit-    „
                                     ■{  Of part  of blood—Serous   dis-
                      uents.......I    ,            r. .
                |                         charges, sero-fibnnous  ditto,
                                      I  anaemic, albuminuria, &c.
                j                      f Uraemia, asphyxia, jaundice, lithic
                  Abnormal retention of i     .,    ,   ,.    .-,...,
                                     J   acid and oxalic acid diathesis,
                    excretions......!
                                      L  &c.
Morbid Changes
  in Fluids . .  .
Foreign additions
{I
Arrests of development
  into normal tissue . .
                                        Common poisons.
                                     2. Morbid poisons.
                                    r (I.) Of blastemas—Mucus,  pus,
                                         tubercle.
                                     (2.) Of cartilage-cells—Cancerand
                                         some other tumors.
                                     (3.) Of white fibrous tissue—Cir-
                                         rhosis, false membranes, gra-
                                         nular   kidneys,  contracting
                                         scars,  &c.
                Retrograde  change into less vital tissue, or  degenerations,
                                         fibrinous, waxy, fatty, chalky,
                                         or mineral, &c.
              i  Foreign additions .... Parasites.
In the second part of the course these changes are arranged anatomically.
Morbid Changes
  in Solids .  . . 
46
DISEASE AND  CURE.
   We find fully established by M. Chossat's* rigorous experi-
 ments on  healthy animals certain  phenomena as  resulting from
 the  deprivation of food, and therefore as resulting from the ar-
 rest of continuous growth  by the want of its material.   They
 are as evidently phenomena of innutrition as the  ruin of an un-
 repaired building is a phenomenon of the want of bricks.
   Prominent among these phenomena we find—

   1.  Collections of fluid in  the serous  sacs (p. 73).
   2.  (Edema of the extremities (p. 82).
   3.  Softening and destruction of the mucous membranes (p. 85).
   4.  Thickening of the epithelium in other parts  (p. 86).
   5.  Blackening of the viscera, especially the liver;  and red-
 dening (? with  hsematine) of the secretions, at least of the  bile
 (p. 74).   Sometimes the substitution of brownish-red congestion
 for the black (p. 74).
   6. Bluish, livid, yellow, whitish  and reddish stains during life
 in the transparent parts of the skin (p. 73).
   7. Loss of weight, producing death when it amounts to t4q of
 the normal weight (p. 21).
   8. Hectic fever.   That is to say, very marked  oscillations of
 the diurnal variations of temperature (p. 123).
   9. A continuous decrease in the power  of the  body to  resist
 cold  (p. 132).
   10.  At  first a scanty excretion of  dry, bilious, grass-green
 fseces, and afterward diarrhoea of liquid saline matter  (p. 151).
   11.  Excitability  of involuntary muscular  fibers by  stimuli.
Even after death the auricles of the heart of starved animals re-
tained for an unwonted length of time their contractility on being
touched (p. 150).
   12.  Convulsions,  similar  to those in death by hsemorrhage
(p. 187).   The convulsions were often  opisthotonic.
   13. In  comparing the losses  of substance in  the  different
tissues of  starved animals, the  nervous system appeared to have
suffered least, and  indeed retained nearly its full weight after
* " Recherches experimentales sur l'inanition."  Paris, 1843. 
                      DISEASE AND CURE.                  47

 death.  This and the former observations seem to point it out as
 the true ultimum moriens in such circumstances (p. 91).

   Here are a collection of phenomena which we are daily wit-
 nessing in  our  patients, modified of course by the  fact that in
 them usually the defect in the supply  of materials of growth is
 but partial.  Shall we be wrong in attributing such phenomena
 to innutrition?   Still more, shall we be wrong in treating them
 as innutrition ?
   I  will allude to  a  few of the cases in which  you  see these
 phenomena as the result of the imperfect vitality we call disease,
 referring by a corresponding  numeral to  similar phenomena
 intentionally produced  by  starvation  in M.  Chossat's experi-
 ments.
   1. The conventional  term  "effusion"  applied to  dropsies of
 the  serous sacs  is misleading to students.  They are apt to fancy
 it an active process, in  which the inconvenience  arises from the
 membrane  " effusing" too much fluid, and their  minds are  im-
 mediately directed to the necessity of checking  this imaginary
 activity;  whereas in reality the membrane need not pour  out
 more than it does in health, nay, it may pour out much less than
 it does in health, and yet dropsy very rapidly take place by the
 arrest of absorption;  and it is from this arrest of absorption in
 consequence of  generally diminished vitality that collections (as
 they should be called rather than " effusions") of fluid take place
 in the pleural, peritoneal, and pericardial sacs.*  You find them
 in ansemia,  hydrsemia, ursemia, leucocythsemia, and other con-
 ditions yet  unnamed,f where the blood in the diminished propor-
 tion of its chief vital constituent of red globules typically repre-
 sents in common parlance the generally diminished vitality of the
 whole body.  From the  diminished consistence of the circulating
 fluid the  endosmose inward of liquids, that  is,  absorption,  is
 diminished according to  the  well-known law of transfusion.
  * See Lecture XVII of this  volume, on hydrothorax.
  f It must not be  supposed that nosologies contain a name for every possible
morbid state:  many, by no means uncommon, can be described only by a peri-
phrasis, simply because nobody has taken them up in special—carent quia vate
sacro. 
48
DISEASE AND CURE.
  Again, these collections of fluid arise wherever the circulation
is arrested by mechanical impediments, as in cardiac or hepatic
disease  for  example.   Here  comes  into  play another law  of
diosmose, namely, that  in the case of  a moving liquid it takes
place in a direct ratio to the quickness of the motion. The more
the circulation is slackened the more obstinate the dropsy is, and
increasing its living force and freedom cures the patient.
  If we cannot detect any  of  these explicable  organic modes of
dropsy's origin, it is still surely philosophical to conclude that a
similiar agency, a similar deficiency of life is acting throughout.
  2.  The remarks I have  made apply equally well to anasarca,
which is a collection of fluid  in the minute  sacs of the areolar
tissue, instead of the large serous sacs.
  3 and 4. It is  most  interesting to find  morbid  states of the
mucous membrane  characterized  by  softening and destruction,
and also by thickening,  produced as the  direct result of inanition.
How apt we have been to look  upon this changed form of vitality
and this accumulation of semi-vitalized substance as evidence of
activity! how apt we have been to reduce the vitality in our aims
at cure!  I need hardly allude to ulcerations and rugged condi-
tions of the stomach, of the throat, of the vagina, and  neck  of
the  womb, which have  been  treated to their great injury by
depressing medicines.
  5.  We are very much inclined from ancient prejudices to take
congestion for a proof of active life, and the red, black, or other
dark-colored  relics of  congestion, as  post-mortal evidences  of
activity in the organ so discolored.   It appears  to  indicate the
direct contrary.
  6.  So also with livid  and reddish discolorations  of the living
skin.  How often do you hear it remarked that a red, bloated-
faced man wants "bringing down,"  when, in fact, what  is re-
quired is a more vitalized  blood, and a more vigorous action of
the heart  and arteries.  How often  is a patient drenched with
mercurials and purgatives because he is " black under the eyes,"
when tonics and bitter diet are the true specifics.  Blueness and
blackness of  the sclerotic, again, is a safe  indication for tonics,
and the finger nails may also be used as a guide to the same
treatment. 
DISEASE AND CURE.
49
  7. The regularity with which death results  on the loss of a
certain amount of weight should lead us  to make more use than
we do of the balance, that easily applied aid to diagnosis, prog-
nosis, and  treatment.   It is a direct measure  of the success of
our medicines, or of the progress of disease.
  8.  Hectic fever is  an obscure subject.   But I  think  some
approach to an  elucidation  of it may be made from the direc-
tion of  those  singular  nycthemeral oscillations of temperature
which take  place in health.   In full vigor, the normal  produc-
tion of animal heat rises gradually up to its maximum at noon,
and falls to its minimum at  midnight.   In health this variation
is slight, but in the simple debility produced by deficient food it
is more than quadrupled.  In M. Chossat's experiments it rose
from 0*74°  to 3-28°.   The  extreme of heat was so  much more,
and the extreme of cold was so much more than in health; and
not only was this  change observed, but also that the  periods of
the accession  and diminution became  irregular, and were  not
governed by the diurnal time.  Do not  these observations dis-
tinctly associate periodic fevers, and through them perhaps  the
periodicities of disease, with direct debility?
  9. The liability to be injuriously affected by external agents,
especially by  cold, is  a sure proof of deficient  vitality.  This,
in our patients, is not always accompanied  by sensitiveness to
the  changed  temperature,  but is made evident by catarrhs,
bilious  attacks, local  inflammations, congestions,  &c, and is
often popularly  rated as characteristic of "an inflammatory
subject."
  10.  M. Chossat's observations  of the  alvine evacuations  are
very valuable.  Let us  never forget that not only constipation,
but also diarrhoea and an exceedingly foul condition of the  ex-
cretions, may, and in  fact generally do, arise  from mere inani-
tion.   This is an important lesson for routine adherents of blue
pill, gray powder, and black dose.
  The commonest instance  we have of fetid  evacuations from
inanition is that of unfortunate babies who  have been  starved
by  hand-feeding,  or the imperfect condition of their mother's
milk.  Doubtless mercury will make the  stools  less disagreeable, 
50
DISEASE AND CURE.
for it throws into the bowels a quantity of bile, which  prevents
their decomposition, but that is done at the expense of  the  poor
infant's body, and the patient is sacrificed to save our noses or
our theories.
   11. The weaker the life the quicker the heart beats, and the
readier  it  is excited.   This  phenomenon is particularly  well
marked in zymotic  fevers,  where the rapidity  of the pulse is
a good guide to the degree in  which the poison of the fever has
affected the system, and what force the system has to bear up
against  the poison.  In  pneumonia,  too, the rapidity of the
pulse is usually in a direct  ratio to the  danger, and to the ne-
cessity for opiates and stimulants.   In pulmonary consumption,
starving, depressants, expectorants, salines, and all that is  usu-
ally classed as antiphlogistic treatment, makes the pulse quicker
and quicker, and nothing reduces it so  steadily as oil and other
restoratives.
   12. The  knowledge that convulsion  arises when there  is a
deficient supply of blood to the brain, has been a long time in
forcing upon the profession the conviction that it is a disease of
inanition.   Perhaps the impediment has been the finding in post-
mortem examinations black blood, rendering abnormally conspic-
uous the smaller vessels and capillaries, when, in certain  diseases,
convulsions have preceded death.   The blood is too visible, and
so the fallacy has  been jumped to that it is too abundant.   The
real fact is, that it  is too stagnant, that  it is too arterial, too
little renewed.   Perhaps the great  show that convulsions make,
the natural awe which they excite  among the by-standers, and
the active help they seem to call for, impress us with an idea of
activity of life in the sufferer.   Chorea, epilepsy, teething fits,
convulsive apoplexy, delirium  tremens, hysteria,  and some forms
of mania  are  familiar instances.   But in all of these every ex-
perimental improvement made from year to year in the treatment
is  in the  direction of replacing lost nervous power, not  of re-
straining its excess.
   13. The difficulty which the nervous tissue exhibits in parting
with its substance by vital  decay,  explains  the difficulty of its
renewal.  There are no patients so slow in recovering health as 
DISEASE AND CURE.
51
 those whose nervous system is exhausted.  They are months or
 years in getting ill perhaps, and they are months or years in
 getting  well.  Let  our recollection  of the slow growth  of this
 tissue comfort us under such circumstances.   The time and com-
 pulsory  idleness  needful for its  restoration  make it the  most
 expensive of tissues to get worn out, and  rightly enough its
 higher manifestations are most highly paid for.
   Among diseases of deficient construction may also be included
 the  tissue diseases of degeneration, where instead of highly vital-
 ized elastic material a brittle, or a  soft, or a formless mass is
 deposited.   It is alive, but  imperfectly alive, easily dies, and is
 useless while it lives.   Tubercle is a substance of this sort.
   It appears strange at first glance that some organic matters
 which are referable  to  this  class  should carry out of the system
 with them a spark of  half independent vitality.  Cancer, for
 example, multiplies itself conspicuously, and  so  does pus  in  a
 more hidden manner, so long  as  they can get their  food  from
 the  body.   But  this multiplication is the lowest (one might say
 the  most diluted) form of life, and certainly indicates no redund-
 ancy in  the parent system.
   M. Chossat remarks, "Bichat and the physiologists who  have
 been occupied on the  same subject before and after him  have
 thrown the greatest light upon the causes of  death, by classify-
 ing  them according  to  the  functions which help  to bring them
 on.   In  dividing death into death by the brain, death by the
 lungs, and  death by the heart, they run through the series of
 vital functions, and suppose that they have thus  exhausted the
 subject.   However,  on coming to  facts,  it is certain that we
 thus explain but a small number of the cases of death, and that
 the great majority of those brought under our observation escape
this classification.  This is so even in the cases which seem easiest
 to lend themselves to this division.  In pulmonary consumption,
 for instance, who can say that usually death  supervenes  by as-
phyxia?  for the  lung on the day of decease is not, as a rule,
more disorganized than it was the day before;  and yet the  day
before it sufficed for the aeration of the  blood.   On  the other
hand, who has not witnessed autopsies in a  number  of febrile 
52
DISEASE AND CURE.
maladies, in which there  is no morbid change found, except le-
sions, often very insignificant, in the intestinal canal?  One can-
not, without doing violence to the judgment, consider these as
sufficient to  account for the death.   The fact is, the classification
of Bichat does not explain all, and to the three  modes of death
which he points out we must needs add at least a fourth—death
by the digestive apparatus, or inanition."*
  M. Chossat is quite right; indeed he rather underestimates
his  case:  very much more than half the  patients we lose die
from  imperfect nutrition, and very much more than half of those
who recover gain that end by chanced or designed restoration
of their digestive functions.
  Exactly the same  means  that prevent death,  prevent or cure
disease.  This  may seem a platitude, but it is a very important
one, and must not be allowed to "lie bed-ridden in the dormitory
of the soul" because it is so true.  We are all ready enough to
admit that when a patient is in danger, the first thing to be done
is to keep him alive.   Let us act in the same wTay when he is not
in danger;  cure him by keeping up the partially or locally fail-
ing life.  Postpone  partial death, as you would postpone total
death.

                            (II.)

  Disease of destruction, or deficient moulting,  arises when the
functions whose business  it is to remove effete products from the
tissues  are  inefficient.   I say " functions" designedly instead of
organs, in order to include the  whole process  from the  period
•when the tissue becomes  effete to  the expulsion of the products
of its decay from the body.  For in whatever part of the process
a check takes place, the  result on the whole health is identical,
and the principles, though not  perhaps all the details,  of the
treatment must be the same.  And in whatever part a check
takes place, the main  injury is  the stoppage of vital  metamor-
phosis at its origin.
  This is the case even in mere  mechanical obstruction.   Take
* Page 194. 
\
                    DISEASE AND CURE.                 53

for instance the  impaction of a gall-stone in the common  duct;
first, the intestines are in want of bile—that is a deficiency they
can easily bear ; then the gall-bladder and ducts get distended—
which does not interfere  very much with the patient's comfort;
but the real serious injury is the  non-removal from the blood and
tissues of what forms the biliary  secretion.  And the injury is of
exactly the same nature, whether the jaundice arises in the me-
chanical way alluded  to, or  whether it arises in the ultimate
tissues  themselves,  as  jaundice from mental impression for ex-
ample.
   It might seem at first sight as  if diseases of deficient moulting
were exceedingly easy to detect, and to reduce to  classification.
We are in a position to measure accurately the quantity and
quality of  the most important excretions, and can  approximate
to a knowledge of those not so readily reckoned.  We can know
by experiment the daily  excretion  of urea, phosphoric acid, sul-
phuric acid, and water by the kidneys; of carbonic  acid by the
lungs ;  of  fseces by the bowels;  of water and salts by the skin,
and we can find out with a fair approach to accuracy when these
are diminished.   But in the great majority of cases this diminu-
tion is in reality the consequence of deficient supply : vital decay
does not remove the tissues, because there is no new material to
take  their  place.  To call  these  cases  instances of deficient
moulting is a misappropriation  of  terms, and to treat them  as
such most pernicious.
   The  most familiar example  is  the amenorrhoea  of  weakly
females.  To what purpose  are emmenagogues?   Why should
we wish to force the ovaries or uterus to bleed, when the reason
why they do not bleed is that there is not enough blood formed ?
The custom of administering purgatives, whenever the bowels
are not open so  often as those of robust persons, is another too
familiar instance of  mistaking the true nature of the deficiency.
   The only diseases we  can  safely refer to the class  now con-
sidered are those where  the effete product is obviously retained
in excess in the  system,  and where the  impediment to its excre-
tion is usually the imperfect action of the secerning organ, such
as uraemia  or the excess  of urea in the blood from  degenerated 
54
DISEASE AND CURE.
kidneys, asphyxia or retention of carbonic acid from non-aeration,
jaundice from  mechanical impediment, or incomplete develop-
ment of hepatic cells, and perhaps certain cases of the lithic acid
diathesis.
  In most of the  patients we have to do with, both classes of
morbid  phenomena are united; there is a general deficiency of
life, and both nutrition and destruction are below par, often in
equal, more often  in unequal proportions.  The instance I have
just given of ursemia is in point;  one marked change in the blood
is the retention in it of urea, the product of destructive  meta-
morphosis, which acts as a poison; but another change, certainly
more worthy of consideration as being more under our eontrol,
is the absence of red blood-discs by reason of defective nutrition.
Hence we have mixed phenomena from the union of the two..
  I would say incidentally that there are few cases in which the
defective nutrition is not at the same time the most important in
a pathological sense as explaining natural phenomena, and at the
same time the most important in  a therapeutical sense, as being
the most easily compensated.
  Be it remarked  also that mixed phenomena,  requiring mixed
treatment, arise sometimes from the deficiency in one part of the
chain of vital acts overthrowing the balance of  functions found
in health.  An apparent excess of certain functions or constituents
arises from  the absence of those which normally are  in corre-
spondence with them.   Thus Dr. Prout, to whom the pathology
of urinary diseases owes so much,  speaks  of a "phosphatic
diathesis," and we not uncommonly hear medical men  speak of
" phosphatic urine," as if the ailment were an excess of the salts
of phosphorus; although in reality in such cases those constitu-
ents of  the excretion are usually less copious than in health, and
are deposited only from deficiency of the  acid which should hold
them in solution.

  The object of medical treatment  is  cure.   The  end of the
physician's labor and care is accomplished by the patient getting
well. What is this cure or getting well ?   It is a restoration of
the disordered  body to its natural state of ease or health. 
DISEASE AND CURE.
55
   This restoration we often see come to pass independent of any
interference  from without, by  what is allegorically called an
" effort of nature."   Wounds heal,  diseases cease, in men and
animals who  have none to help them.   The event comes about,
not in consequence of the driving out of any materies morbi, but
on the resumption  of  their normal functions by  the  diseased
organs :  the  full vital force regains its influence in  them, and
they recover.  The  social  disease of a " strike"  is  cured by the
hands going  on work again.
   Now diseased organs must necessarily have less power in them
than healthy ones;  and it is obvious therefore  that the curative
vitality must mainly be due to, and proceed from, those which
remain healthy. It is to their having some sound action to  spare
that the sick man owes  his recovery. The vital  force at the same
time removes the retained products from the tissues, and replaces
them by new material.   This is the true teaching of  nature's
cure.
   Cures by  art are effected in exactly the same way.  Every
artificial appliance which does not aid this one  only mode of re-
covery is  an impediment to it, or simply a nullity.   A drug in
itself effects  nothing by its mere chemical or neutralizing in-
fluence ;  it is the vital power which this drug calls forth, or  frees
from a burden, that  is the true healer.   Quinine, for instance,
will not neutralize malarious poison ; Peruvian marshes are not
less deadly for cinchona trees falling into them; but  the drug's
vital action on that which remains healthy of the body cuts  short
the fever which is the consequence of that malarious poison. The
action of a remedy by which a sick body becomes sound must be
looked upon  as a vital act of the body itself and not a simple act,
but a series of vital acts, which grow out of one another in regu-
lar succession as the branches grow  from a tree.  They are not
dependent  upon  the continuous  presence  of  the remedy, but
persist long  after it is removed from the system, just as a rail-
way train goes on "of itself"  (as we conventionally  say) when
disconnected  from the locomotive.   The true art of  healing con-
sists in the establishment of vital acts  tending toward the re-
newal of the  body, toward  a new birth of deceased tissue, and in 
56
DISEASE AND CURE.
 the  encouragement  and aiding of those vital acts after the re-
 moval of their original excitant.
   Since there are two parts in the chain of life, " construction"
 and  "destruction,"  and since external agencies  may act upon
 these in two ways by increasing them or diminishing them, a
 primary fourfold classification of curative agents naturally arises;
 and  this will be the most handy classification for a  practical man.
   We have—
   (1.) Constructives (^iaTOTp6<j>im) or aids to formative nutrition.
   (2.) Destructives ('iotoXvtcko) or augmenters  of destructive
 assimilation.
   (3.) Arresters of construction (piodeo-fievTata).
   (4.) Arresters of destruction (j3io<pvUktcko.).
   Among Constructives we have the following classes :—
   1st.  The  materials of which  the body is built  up: albumen,
fibrine, gelatine, fat, oil, water, iron, lime, phosphatic salts, soda,
 ammonia, sulphur, oxygen, S?c., which are generally taken in the
 form of food.
   2d. Medicines which  appear  to act  by replacing necessary
 constituents of the body.—This  is as yet a very dimly under-
 stood class; but  we may hope something  from the progress of
 physiological chemistry to  explain the action  of sundry medi-
 cines, which we cannot doubt will be proved restoratives, though
 we cannot at present see by what steps.  Quina and other vege-
 table alkaloids  may be taken as an example, whose cure of ague
 may be best explained  by supposing them to replace some con-
 stituents of  the body destroyed by malaria.
   3d. Digestive solvents.— Water, which  must be in  excess of
 that required in the structure of tissues, and without which the
 said materials cannot be absorbed.   Carbonic acid—required to
 be present in the water for the easier solution of bone, earth,
 carbonate of lime,  and albuminous food which contains them.
 Pepsine, to  replace deficient gastric juice. Lactic acid—required
 in the stomach to acidify the mass and enable the  albumen to be
 acted upon by the gastric juice.  This may be replaced by other
 acids, such as hydrochloric, or acetic, or malic, for example, in
 some cases.  Bile, in the form of inspissated ox-gall, or liquid 
DISEASE AND CURE.
57
 ox-gall in capsules, to supply the place of that which is arrested
 in  its passage  or  in its formation  by disease.  Pancreatine,
 similar to pepsine.
   4th.  Excitants of digestive solvents.—Mineral acids mixed
 with the food increase the flow of bile ; indeed all acid substances
 have the power of exciting alkaline  secretions.   Thus they are
 useful, not only in jaundice from suppression, but in many cases
 of  indigestion where this  solvent is  too  sparingly formed.  In
 many cases, too, of flatulence from fermentation of the ingesta,
 mineral acids are beneficial, by causing the pouring out into the
 intestinal canal of bile which  arrests putrefaction.  Alkalies, on
 the other hand, will also increase the flow of bile.  Perhaps it is
 that they supply one of its constituents; perhaps (as Dr. Harley
 explains it) they stimulate a secretion of gastric juice, according
 to a converse law to that quoted  in respect of mineral acids, and
 this gastric juice excites the bile-flow.  It is obvious that to ac-
 complish this object, alkalies must be taken on an empty stomach,
 otherwise they are wasted, or rather  do  harm, by neutralizing
 the acid already mixing with the  ingesta.   Sugar, peppers, mus-
 tard, spices, and other  condiments  act  in a moderate degree in
 the same way, as may be seen by the effects on the saliva ;  but
 their influence is limited.  Rase of mind, or cheerful conversa-
 tion, excite the gastric juice ;  or, I should rather say, they pre-
 vent  the opposite state of mind which  retards  the  secretion.
 Oxygen has a direct effect in exciting the flow of all the digestive
 solvents  from  the  saliva  downward.  Water  increases  their
 quantity in  the same way that it adds to the solid bulk as well
 as to the liquid bulk of all secretions.
  5th. Artificial replacement of  wanting vital functions.—The
normal  animal warmth is a great element in  promoting normal
reconstructive growth. We know how much more readily internal
wounds heal than external wounds;  how much more quickly,
when they have been carefully covered up and kept at an even
temperature, than when they have been laid open to the varying
influences of the variable air.   Disease lowers the power of pro-
ducing heat in the diseased tissue, or it  causes  heat to be pro-
duced in a fitful irregular way.  An even artificial heat is there
       5 
58
DISEASE AND CURE.
fore a strong means of renewing life. Where vitality is deficient   •
throughout the whole body, we can economize it by clothing im-
pervious to atmospheric changes, as woolen, silk, &c, and by
avoiding linen, as in albuminuria among chronic diseases, and in
acute rheumatism among acute. Where there is a local deficiency
of vitality, as in pneumonia,  pleurisy,  pericarditis, peritonitis,
ulcerated bowels, &c, none of our curative appliances are so im-
portant as a continuous poultice.   Warm baths  supply a large
quantity of assimilated heat, which lasts for a considerable time,
and hence, in certain  cases, they are felt  as a tonic.   But they
will only suit patients who are  benefited by, or at least are not
injured  by, the absorption of a great deal  of water.
  Electricity supplies the  contractile  muscular  fibers with a
stimulus to action which  is wanting  in cases of deficient  nerve-
force.   Hence it keeps up the habit of motion in paralytic limbs,
prevents their getting atrophied, and sustains them in possible
activity till such time as the injured nerve-force  recovers itself.
Artificial motion and rubbing act much in the same way.   Me-
chanical aids to sight, sound, hearing,  and movements, rightly
employed, may come under the same category.
  6th. A temporary revival of deficient functions.—For example,
the deepening of sluggish breathing by ammonia, valerian, ethers,
and essential oils.   This stimulation, though it may be only tem-
porary upon the organ directly acted upon, is therefore followed
by a reactionary collapse ; yet indirectly it contributes  to life by
the influence of the organ's functions upon other parts.   Thus
the deepening of the breathing, instanced just now, aerates the
blood and strengthens the circulation, and so makes to the capi-
tal of life an addition which lasts long after the passing stimulus
has lapsed into a corresponding degree  of deficiency.   Perhaps
the permanent benefit of warm bathing, often so  much greater
 han can be accounted for by the short increase of warmth, may
be explained in the same way.   Alcohol  often acts  beneficially
in full doses at long intervals, in  cases  where  its  continued in-
fluence in smaller doses would be hurtful,  probably on this same
principle.  But as a general rule, those stimulants are to be pre-
ferred for the purpose whose effect is more transient. 
                    DISEASE AND CURE.                  59

  7th. Increasers of absorption are purely constructive medi-
cines, provided that they are not increasers of destructive meta-
morphosis  at  the  same time.   Vegetable bitters brace up  and
harden the mucous membranes, as may be  easily tried by their
effect on the mouth.  Hence exosmosis is lessened, and endosmosis
increased.   Thus  digestion is  made  more  rapid  and effectual,
more nutriment is taken up and quicker.  Even in a healthy
person the remains of the last meal are sooner disposed of, and
the appetite for the next sharpened by a bitter. This is the pure
action of a vegetable bitter; but a good many of the plants we
use as such contain various matters which otherwise unfit them
for our purposes in certain cases.  Perhaps none exercise so few
of these noxious influences  and are more  generally applicable
than the products of the inimitable cinchona.  Astringents also
may reasonably have some of their beneficial influence on the
digestive canal explained by their restraining the formation of
mucus.   When mucus is  in excess, it doubtless  interferes much
with the taking up of nutriment by mucous membranes, and the
checking its growth is an indirectly constructive act.  Many of
the vegetable bitter drugs contain tannin or other astringent
constituents, and are thus peculiarly suited to the leucophleg-
matic (or mucogenous) diathesis.  These drugs are  suitable not
only for  the digestive canal, but to other internal tegumentary
membranes.   Thus the  renewal of life in the uterus and ovaria
is very much aided by checking leucorrhcea with astringent injec-
tions.  The absent  catamenia will  often  reappear while the
weakening  discharge is being thus arrested ; and stagnant ulcers
will form fresh healthy tissue, wounds will  close,  and abscesses
heal after,  nay, during the application to them of  astringents.
Sulphate of copper and  nitrate of silver are most active in this
way; but,  as  you know well from  your experience as dressers,
heed must  be  taken lest when  destroying the mucus and  pus-
formation you also destroy the life of the adjoining tissues whose
preservation is your  care. Sulphate of copper is a most powerful
internal medicine, as a reviver of health in ulcerated parts of the
intestinal canal, and it  also  seems to act as a tonic generally
to the digestive tract. Nitrate of silver would probably be equally 
60                  DISEASE AND CURE.
useful, but unhappily it is too soon converted into the inert chlo-
ride by the salt of the secretions.
   8th. Excitants of the  involuntary  muscles  which  subserve
absorption are  also constructives.  Thus strychnia and aloes
increase the appetite by hastening the passage  of the alimentary
mass, and this joined to their bitterness makes them tonics. But
they both are  better when aided  by other tonics.  Succussion
stimulates these muscles, and so very gentle exercise promotes
digestion, but violent muscular exertions arrest it, because they
engage the nervous energy elsewhere.
   There are certain drugs which, in a manner as  yet quite un-
explained by physiology, appear to alter toward health particular
tissues.  They are not constituents of the body, nor do they seem
suited to take the place of constituents of the body, nor do they
cause any evacuation of retained effeta, nor do they apparently
act on any of the healthy organs.   Iodine and bromine, for ex-
ample, have this effect on the white fibrous tissues, and as they
originate  renewal, I can hardly help classing them among con-
structives.

   With  Destructives our  forefathers  have  left  us  well  ac-
quainted.  Time out of mind  the world has  had long lists of
drugs, classified  according to the organs through wrhose  gates
they disgorge  the products of metamorphosis.  " Sudorifics,"
"purgatives," "diuretics," "expectorants,"  &c, are familiar to
both doctors and the  unlearned ; while  others, as  mercury for
example, are kno'wn as general  " liquefacients," promoting  de-
structive metamorphosis universally, and a consequent increase
of solid  evacuation  from all quarters.   And  other expedients
again, such as bleeding, are a direct mechanical abstraction of a
part of the living body.
   The uses of Destructives are the following :
   1st. To remove from the system effete matters which are toxi-
cally noxious to healthy life.—Nothing does this so universally as
water. The biliverdin which we see staining the skin in jaundice,
and  which  indicates also  the  presence  of the more injurious
biliary acids, may be removed by mercurials, by podophyllin, by 
DISEASE AND CURE.
61
soda, and, according to Dr.  Harley, by benzoic  acid, provided
always care be taken that the passage for their exit is free, that
the bile-ducts are not obstructed.   So also uric acid  may  be
eliminated from  the blood by niter and by some other neutral
salts, when the kidneys are healthy and neither degenerated nor
congested.   In  applying  these remedies  it is  necessary to see
clearly what is the effete matter we wish to get rid of, and to use
the appropriate  drug. No laborers in the present field of materia
medica deserve so well of  the world as those who inquire into the
real intimate working of  medicines.   Our  chemists' shops are
quite full enough, and it adds much more to true useful knowledge
to make  a single step toward explaining the action of one estab-
lished remedy, than to add a hundred even  active articles to the
pharmacopoeia.   One would be glad to know in the case of each
eliminating  drug which of the effete constituents  it most readily
acts upon.   Thus much milder drugs might often be employed,
which would go  straight  to  the point,  instead of .having some
violent but perhaps unnecessary action joined to them.  Do not
let us be satisfied with the nomenclature of  "purgatives," "diu-
retics," "sudorifics," if it is possible to discover what it is they
purge  out, what constituent is  specially removed through the
kidneys and what through the skin by the augmented secretion.
   2d.  To remove mechanical impediments to normal excretion.—
The proviso which I made just now in the case of the  liver and
kidneys, namely, that there should be nothing in their structural
state which can  impede the flow of bile or the  urinary constitu-
ents, reminds us of another use for destructives.   For example,
leeches on  the right  hypochondrium will often restore a flow of
bile, in diminishing a congestion of the hepatic tissue  by which
its formation  may be  stayed.   Cupping  the loins will act as a
diuretic by relieving congestion of the kidneys after scarlatina or
other cause.  Leeches to the anus, or artificial hsemorrhois, will
empty the  stagnant portal circulation, resuscitate  its  activity,
and by this means enable medicines to be absorbed  and food to
be digested.  General bleeding will  at a great  expense to  the
system, and not perhaps  more  readily,  effect all these objects at
once.  The advantage of venesection to our forefathers was that 
62
DISEASE AND CURE.
it did not require any accuracy of diagnosis of the  organ to be
attacked, but made a general assault on all together.
   3d.  The removal of impediment to absorption is another good
reason for the administration of  sundry  destructive medicines.
This is  often merely a  question of  mechanics, and  if we could
apply mechanical means to  the required locality,  they  often
would  do better.  Such for  example is the removal  from the
stomach and intestinal  canal of  mucus, whether peopled with
parasitic worms or not.   Mucus  is in itself peculiarly insoluble,
and  therefore indigestible, and it  also  firmly resists diosmose:
thus its presence stands in the way of  the  absorption of. nutri-
ment by the digestive membranes.   It is not easy to  rid the
patient  of these incumbrances without  abnormally augmenting
destructive excretion, but if it can be done we should be glad to
do it.
   4th.  The removal of systemic poisons which are the  cause of
disease by destructives seems shown to  be possible by the effect
of mercury on the syphilitic  virus.  The  body is  endowed with
power  to  gradually eliminate this virus, and  after a course of
diseased states of long, perhaps years-long duration, to return
again to health.  Indeed if it had not this power, remedies would
be useless; for drugs, though they can arouse sluggish capabilities,
can bestow none not originally inherent in  the nature. The natu-
ral elimination, tedious always and perhaps sometimes otherwise
impossible, is, according to Mr. Lee and  other experienced syphi-
lographers of late years,  much quickened by mercury.  Mercury
does not, like sarsaparilla, bark, iodide  of potassium, and other
constructives, benefit by  curing the diseases caused by the virus;
it aids the system to destroy the virus itself.   That it should do
so is not surprising when we see  its wonderful  destructive action
on animal tissues; how they become softened and  blanched and
dwindled in decay when the system is saturated with the drug.
  Were there any other  chronic  diseases so  indubitably kept up
by the obstinate adhesion in the  system of a morbid poison, it
might be worth while to destroy the poison in the same way.  It
might be worth while to  submit to having the healthy parts of
the body scotched, for the sake of  prematurely killing its baleful 
DISEASE  AND CURE.
63
guest; but I do not think we can  find another instance among
maladies common enough for us to be well acquainted with their
pathology.
  In acute fevers dependent on organic  poison the system casts
it forth so quickly that sometimes danger  is  borne  of its very
haste and effervescence.  We should be at no pains to hurry the
process, did we  possess  the capability of doing so.   Under the
same restrictions as morbid poisons comes the removal of inde-
pendent parasites, such as  lice, itch acari, the fungi of favus and
pityriasis versicolor, of dead or  incurable  parts of the body
which  react upon and become the causes  of diseases, and of
foreign matters  generally.   We must balance the  injury we may
be obliged to inflict  in removing them against  the good done by
such remoAral.
  A free review  of  the rational  reasons for  using  destructive
treatments in the cases I have given as  examples, will confirm
the universal  rule that they are never to be employed for their
own sake, but only  to either make room  for, or to give play to,
constructive growth.

  Arresters of constructive life, as such, can  scarcely come.
under  the denomination of medicines; physicians never wish to
stop growth in human patients.   As  poisons we do use them on
animals for certain  purposes of our own:  alcohol is  given to
puppies to keep them small dogs ;  and it is stated  that dwarf-
like jockeys have been  produced  by the  same treatment.   We
have thus a warning of what the effect of the agent is.
  The same article of diet,.however, appears in another light as
an arrester of destruction.   We not seldom wish to stay the pro-
cess of vital decay in our patients,  and are provided with a means
of doing so in alcohol.   In a lecture published some time ago* I
  *  Lecture XLVII of this volume. I would take this opportunity of saying that
the lectures are not placed in the order in which they were delivered. Clinical
instruction is. or should be, given as the cases occur; so that the student should
come fresh from the bedside observation of the patient to the deductions made
therefrom.  Introductories, however, at the beginning of each session, afford  a
legitimate opportunity for a systematic statement of principles, for going back to
the abstract truths which are the result of previous practice and experience, "^o 
64
DISEASE AND CURE.
explained the reasons for thus viewing alcohol, and went into
details of the circumstances which should guide and. govern its
administration ;  so I will  not repeat them now.  I there classed
it as an anaesthetic, whose primary action is on the nervous sys-
tem, and attributed to that action its effect in staying destructive
metamorphosis.
  Our other  more generally acknowledged ansesthetics have a
similar action ; they prevent the wearing out of the body by the
painful and destructive functioning of the nervous system during
disease.
  Why is the functioning of the nervous system during disease
painful and destructive ?   It seems to me that  M. Chossat's ex-
periments throw some light on this obscure  subject.  The nervous
system is the liultimum moriens"—the member of the body the
least affected by vital decay, that upon which  starvation, de-
ficiency of  life,  disease,  have least  decomposing influence.   It
remains  therefore energetic, sensitive, and motive, while  the
others become deadened and sluggish.  Thus the due balance of
the functions is overthrown.   By a restriction placed upon the
normal but inconvenient force of the  nervous system we  get a
state more like  to health, by  reason  of  its nearer approach to
balance, and guard the tissues against the disorganizing tendency
 of its abnormal disturbance.
   The same aim of  restoring the balance may be effected  by
 raising the depressed vitality of the non-nervous deficient func-
 tions.  And  where this can  be done, of  course it is the best
 treatment.   Where means of  accomplishing such a desirable ob-
ject are wanting, ansesthetics  are the next best resource.  Just
 as in machinery when a wheel has got worn and inefficient, it is
 best to put in a new one, if possible ; but where we cannot, we
 slacken the steam power—quod opibus deest, arte sarcimus.
    Is pain the expression of the want of balance I have spoken of,
  or is it only a co-ordinate phenomenon ?   Certain it is that pure

  the reader it is convenient that these should come together at the onset; and the
  sequence of time being thus disturbed, I have preferred to set the  rest in a sort
  of natural order, putting together those which seemed to have most bearing on
  que another, rather than to arrange them chronologically. 
DISEASE AND CURE.
65
pain,  such  as neuralgia, is relieved either on  raising the vital
functions with  food, tonics, &c, or on blunting the nerves with
ansesthetics.
  Remark now that destructives  and arresters are not in  any
case final  treatment; the end is in every instance reconstruction
or renewal—an aim which  must be kept in view in all the physi-
cian does  or counsels.
  These principles of therapeutics I make it the business of my
clinical lectures to enforce and illustrate by the examples  of
disease which you are at the  moment seeing  under your eyes.
But do not suppose these examples to be picked examples—cases
selected to prove my points :  no—each one of my patients in the
wards teaches  the same lessons to all, at least to all those  who
are willing to be taught by nature rather than by books.  Let
me entreat of you not to neglect the opportunity which is afforded
by our liberal public charities and the independence of your pupi-
lage to learn truth, and ^hen you will  not fail in after-years to
practice truth. 
LECTURE  III.
         THE FORMATION OF MUCUS  AND PUS.

Office of mucous membranes—The identity of mucous globules
     and nascent epithelium—Self-supported growth of mucous
     globules—Similar to organic growth of a parasite—Is this
    form of life an excess or a deficiency of normal life f

     (First Lumleian Lecture at the College of Physicians,
                        Lent, 1863.)

  The subject which I have chosen for these Lumleian Lectures
is one wliich must  be interesting to physicians above all other
observers of nature.  A physiological Fellow of our College was
in the habit of reckoning his patients as so  many "mucous mem-
branes." On his retirement from active practice he said, " I have
taken my  last fee from my last mucous membrane."   I do
not think his term  was an exaggeration, for in very few indeed
of the cases ministered to by us  has  not  either the cause of the
death acted on the  body through these integumentary coverings,
or manifested its action by  a perversion of their  functions.  A
great majority of our drugs  are intended to act on mucous mem-
brane, and  all are introduced into  the body through it. We can-
not therefore but be  grateful to those who have  endeavored to
add to our knowledge of its nature and habits.
  The term by which it  is conventionally designated is apt to
lead the most thoughtful  of us into a fallacy.   Active members
of society are named after the work which is their most important
occupation.   The industry of the lawyer is the administration of 
           THE FORMATION OF MUCUS AND PUS.         67

the "law;" the doctor is most efficient when he is most "learned;"
the duty of bishops and overseers is knaTKonhv "to oversee" each
their several  departments.  But the office of mucous membrane
is not to secrete mucus. It is most active when it is not doing so,
and its activity is decreased just in proportion to the copiousness
of the mucus.  Typical health certainly consists in its absence ;
many robust people  pass weeks without expectorating; many
find their handkerchiefs clean and unrumpled after being days
in their pockets, in spite of all the artificial and  accidental irri-
tants to which  the Schneiderian membrane is subject; and the
urinary and  intestinal  canals  contribute only  an infinitesimal
quantity, which may fairly be attributed to a temporary departure
from health of some fraction of their large area.
   The business of mucous membrane is to  offer a passage  for
oxygen, water, fat, albumen, and other nutrimentary substances,
and to defend the less easily renewed tissues beneath it from the
deleterious action of external agents.   These functions  it best
fulfills when it is bedewed with a  moderate watery exhalation,
and not with mucus.
   This exhalation is  transparent  and  watery,  and possesses
nothing of that stringy  adherent character  by which we ordi-
narily recognize the substance known as mucus.  It carries out
with it the epithelium scales shed or moulted from  the surface;
and these  scales are  consequently found in the  excretions;  but
it is itself absorbed again as quickly as it is exhaled, and  does
not contribute to the substance of any of the ejecta of the body.
The typical healthy  condition of a  mucous  membrane may be
considered to be a constant dampness without visible fluid, and
a moderate and gradual shedding of epithelium.
   Shed epithelia are found also in mucus, but not as a peculiar
characteristic, nor modifying  its physical properties.  Its most
obvious characteristic is the  presence of  transparent bodies, ap-
parently of a gelatinous  consistence, of a more or  less rounded
or  oval  form, and with one or  more nuclei, seemingly of a less
transparent  consistence,  in  their  interior.   But  its  physical
properties of consistence and adhesiveness, which so peculiarly
distinguish it from all other transparent fluids, seem to be de- 
68         THE FORMATION OF MUCUS AND PUS.

rived from the medium in which these globules are placed.  This
origin  may  be inferred because similar  globules, quite undis-
tinguishable in appearance and behavior, constitute also the bulk
of pus, a fluid of quite distinct attributes and properties.
  There are probably  no observations  more suggestive and
luciferous to rational medicine than those contained in the paper
of Henle published about  a quarter of a century ago in  Hufe-
land's  Journal.  It is  an excellent  example  of physiological
reasoning, and later  observation  seems  to  set  the  matters of
which  it deals beyond reasonable doubt.
  Professor Henle's  argument  aims,  successfully I think,  at
tracing the  globules which are  seen in mucus under the micro-
scope to that substance which in the normal state of typical per-
fection would form epithelium.  They appear to be young eithelium
arrested in  its growth, and prematurely moulted off from the
body.   The condition which produces them is an arrest of de-
velopment.
   To  feel the full force of the experiments and observations
which confirm this view, it is  necessary to see the connecting
links of resemblance which run through the course of the integu-
mentary membranes.   We must  pass over for the nonce the
differences which fit for their various uses the external skin, the
covering of the tongue  and mouth, the secreting lining of the
stomach, the  absorbing lining  of  the intestines, the defensive
coats  of the bladder, urethra, rectum, &c.   We must look upon
them  as one whole. Just as the skin clothes the muscular frame-
 work  of the body, moulded on  the form of the skeleton, so the
 mucous membrane lines the internal  canals, pits, and galleries,
 following their intricate windings throughout.   And for exactly
 the same purpose—namely, to be a  defensive  medium of com-
 munication between  the individual being and the  outer world,
 between the microcosm and the megalocosm, in all their chemical
 and mechanical relations to one another.
    For the fulfillment of this common duty they have  a common
 structure.  Strip off a piece of epidermis, and  you find that  its
 outermost layer consists of flat polygonal scales pressed close
 together and united both by the edges and surfaces so as to form 
            THE  FORMATION OF MUCUS AND PUS.         69

a continuous leathery tissue.   They are welded into one fabric
like the exposed part of an old macadamized road.  But just as,
when you pick up the surface of this road, you expose a deeper
layer of stones loose and separate, so beneath  the scarf skin you
find what Malpighi, with philosophical prescience, called the rete
mucosum. This consists, like the scarf skin, of separate corpuscles,
which, like  the stones of the macadamized  road, become  looser
in structure, less adherent, and less similar to the upper  layers
as you go deeper. The superior corpuscles are indeed flattened,
and exhibit a flattened nucleus inclosed in  a clear cell as an
epidermoid  scale.  But as you get nearer the cutis the nuclei are
rounder and rounder, and the transparent area of the cell is less
and less visible; until at last, on  the cutis, the  corpuscles  are
seen to consist of only granular masses.  These granular masses
are identical with those seen in mucus.
   Just in the same way the  mucous membranes are clothed with
epithelium,  loosely scaly in some parts,  welded together  like a
macadamized pavement  in another, columnar  in another.   And
when this is stripped off or injured, there are  brought into view
floating granular masses of various sizes, which constitute what
are familiarly known as "mucous globules."   They are exactly
identical with the inner strata of the epidermis, the rete mucosum
of Malpighi.
   What  are these globules ?   Are  they something special, be-
longing to special tissues, and appearing only under special cir-
cumstances ?   Or are they a form of organic  matter common to
other parts also ?  Are we to apply here the Baconian myth of
Proteus, and look for their  natura naturans  as exhibited else-
where in various  shapes?  I think it is philosophical to do so.
   The appearance they  have is that of all matter when it  first
puts on life.   The telescope  and the microscope equally reveal
to us  these nebulae as the earliest indication of vitality, drawing
the surrounding chaos toward a central  point, then exhibiting
that central point as a kernel  or nucleus.  And then this  kernel
becomes the parent of new centers,  individual  and separate, and
these  again  starting-places of new action.  The dawn of vitality
is exhibited  in  the coalescence of molecules of organic matter so 
70         THE FORMATION OF MUCUS AND PUS.
 as to form nuclei, which, under favorable circumstances, develop
 either separate cells or tissues.
   Up to this point each focus of life seems to be a separate in-
 dividual.   It takes  in  nourishment by its innate power from
 without;  it increases  in  size and  alters in  shape.  And  this
 alteration in shape seems principally to take  place from within.
 It is not merely an aggregation outside of new molecules, but a
 plastic change of internal appearance.   Nay more, it possesses
 the faculty of giving birth to an individual, and so to a succes-
 sion of individuals, like itself.  No  better evidence  of automatic
 existence  can probably be given.
   These phenomena can be seen without much  difficulty in the
 globules of  mucus.   That which answers  best is what we often
 expectorate in little semi-transparent gelatinous lumps from the
 bronchi in the morning after exposure to night  air.  This must
 not be mixed with water, or be allowed to cool,  but kept at the
 temperature of the body, and put immediately under a lens of as
 high a power as  you can command.   Dr. Beale  showed me  the
 phenomena  first under  a 24th, but  I have seen them very well
 under  an 8th inch in an old-fashioned Powel's  microscope. Keep
 your eye  fixed on one  nuclear mass, and you will often see a
 gradual change in its appearance.   First a clearer nucleus ap-
 pears in it; then, as you gaze, two, three, or more smaller nuclei.
 Then the fine granular specks in its sides coalesce into a nucleus.
 Then you see that it has a bulge in its  side, and that a nucleus
 forms a bud, and then has a constricted neck or stalk. And then,
 perhaps, if you are lucky enough  to get  the  mucus in  motion
 without losing sight of your object, the bud  may float off as a
                             separate globule.   Or the whole
 I^IlP   lkM§i     C^vls) globule may divide into two, each
                             with a separate nucleus, as I have
                             tried to represent in this drawing
                             from life of  five  globules  in this
                             state of transition—
  A temperature  below that of the body seems to check this de-
velopment, but you may often keep it on by  means of a spirit-
lamp.  The globules in  which I have seen it take place are those
 
THE FORMATION OF MUCUS AND PUS.         71
from  the  trachea, from  the  os  uteri,  and from  warm freshly-
passed urine in cases of inflamed bladder.
  When the fluid has got dried up by the heat thus constantly
applied, you may in some degree restore its activity by moisten-
ing it with a viscid animal fluid, such as saliva. The greater part,
indeed, is  broken up into molecules, and these show no disposition
to unite into globules, but among them will remain some globules
unbroken, and these will again form new nuclei, and bud as they
did at first.
  Is this organic growth ?  Or is it the aggregation into visible
masses of particles already existing, like that which Mr. Rainey
has described  as taking  place in mineral matters?  Is  it a mere
coalescence, or something more ?  I must  say that  to  my mind
the production  of  an individual  like  itself, capable  again of
reproducing another individual still resembling the grandmother
globule, is identical with organization.  And I think, too, that
the multiplication of the nuclei inside is quite unlike any sort of
coalescence, which would add matter  to  the  outside, like  an
urinary calculus or an avalanche.
   It seems to me that each of the globules contains a center of
life, into which the pabulum  passes from the  outside, nourishing
them  and giving them means to  increase in number.  This would
account for the enormously rapid collection of mucus filled with
globules on inflamed membranes, even on membranes which in
the healthy state shed  very little  epithelium, or have but  one
layer of it, as in the bronchi, and therefore  cannot be supposed
naturally  to form  much young epithelium.   The first parent
globules may  be aborted young epithelium cells, and these may
be  the ancestors of others which form the bulk of the mucus,
begetting them with the extreme rapidity characteristic of gen-
eration in low organic life.
  If  this  be true, mucus may be viewed as a parasite, receiving
from the body its nutriment  indeed, but not  in its form nor its
claim to vitality.
  Doubtless the growth of mucus is most rapid where there is
normally a thick layer of epithelium, and where a large growth
of young  epithelium is  constantly being  formed to replace the 
72         THE FORMATION OF MUCUS AND PUS.
rapid moulting.  But still it  is much quicker on localities with
a thin layer than could be accounted for by each globule  being
an  aborted scale; there could not be enough  aborted  scales to
furnish  so much mucus so full of globules.   I believe, therefore,
that it  grows on the  surface by their budding and  splitting  in
continuous succession.
  If you compare pus which has been  some time accumulating
on the surface of a mucous membrane with that which  is  being
freshly  formed, you  will remark a  decided difference in the
globules they contain.  Take some accessible mucous surface—
the eye, or the vagina, for example—thickly covered with opaque
secretion, and you will find  the globules  nearly all of a size,
even and spherical.  Then wash it clean with cold water, and
examine the first-formed secretion: the  globules are  of  all sizes
and of  irregular shapes, oval,  bulging, budding, with or without
nuclei.   This  seems to indicate a general  change of  form  by
time—a certain  completion of  creation in that which has  been
longest  formed.
  When we  see, as  I  have  described, the  globules of mucus
budding, dividing, and subdividing in active haste—new foci  of
independent vitality generated and multiplying even when  sepa-
rated from the body—it  might appear that a  local increase  of
life was being exhibited.  Certainly  a greater bulk of  living
substance is formed by  a membrane  secreting mucus or pus,
than is  the case  in the healthy state; for  the  secretion out-
weighs by a hundredfold the daily quantity of  epithelium which
its original material was  destined to  make.  But what sort  of
degree  of life  is exhibited  by  this  secretion ?  Is  rapidity  of
multiplication  to be looked upon as evidence for or against  force
of vitality?  Against, I think.   The lower we go in the  scale
of creation, the more quickly and the more copiously do the
living forms  representing the  various  classes  reproduce  their
kind.   The less functions and  force and  intensity of existence
they have, the more  prominent becomes  reproduction as the
main object of their being created.  This seems to be  the uni-
versal rule, to be  traced  all  through living  beings  till we get
down  to the  Amoeba  and the  mould,  in which  no trace  of  a 
           THE FORMATION OF MUCUS AND PUS.         73

function  can be  detected  beyond  the multiplication of their
simple substance.
  Here,  indeed, it becomes  difficult to draw the line  between
organic and inorganic.  Instead of being in contrast and in con-
flict with the physical force of inanimate nature, vitality seems
to obey laws which closely resemble them.   The main  point of
distinction seems  to  be the  growing from a  center outward of
organic,  and the  aggregation toward the center  of inorganic,
individuals.
   When organic  matter destined to  form part of an animal  has
attained the  end of so becoming a member of a consistent whole,
it ceases to multiply  itself.   Cells do not  normally go  on split-
ting up and  producing cells similar to themselves in situ.  The
highest development  of their vitality is ceasing to exist as grow-
ing matter.   A fully-formed epithelium scale does not produce
another  scale, nor the  nucleus of a muscular fiber  another  nu-
cleus.  The  retention of reproductive force is an  expression of
the lower and an exclusion from the higher functions of life.
   In the mucous globule, then, we find  organic  matter, whose
destination was the  formation  of  epithelium, arrested in its
development when it  has attained only  the  lowest degree of
life — that lowest degree of  life being the function of repro-
duction.
tj 
                   LECTURE  IV.

         THE  FORMATION OF MUCUS AND PUS.

Mucous globules not cells, but nuclear matter—The representative
     of the cell is the medium in which they float—It is therefore
     not likely to retrogade into globules—Formation of pus from
     mucus—How  does  pus appear on  the surface f—Observa-
     tions of several observers—Passage  of globules  through
     epithelium—Pus-globules not descendants of epithelial cells,
     but parasitic formations inside them—Epithelium semifluid
     —Breach of epithelium in some cases—Growth of pus.

   (Second Lumleian Lecture  at the College of Physicians,
                        Lent, 1863.)

  I  described in my last lecture  the mucous globule forming
nuclei  in its center, and these nuclei splitting up into two or
more, subdividing and separating the whole globule into several.
From this it has been inferred that it  is in this way that the
globules  grow—that they are,  in fact,  cells  which multiply by
subdivision.   But I described also the formation of buds  at the
side  of the  globules.   These buds commence  by the granules
of which the mass  of the  globule  consists becoming  gradually
more visible and distinct, and forming centers of growth distinct
and  separated by a conspicuous interval from the central nuclei.
They are not derivatives from  the central nuclei, but new start-
ing-points of growth.   This is important, because  it takes the
globules  out of the category of cells.   In a  fully-formed cell 
           THE FORMATION OF MUCUS AND PUS.         75

it is only the nucleus, and not the transparent area of formed
matter, which grows; whereas  here  the whole substance grows
and  originates  growth.  The globules are, in fact, nuclei.  Or
we  may more properly call them  "nuclear matter;" for  a nu-
cleus must be a nucleus of something, whereas these are nuclei
of nothing.  Nuclear  matter is that which  is fitted to be the
nucleus of something,  unless  arrested in  its development—in
other words,  organic living  matter in a  condition to grow and
multiply.   A confirmation of this occurs in a drawing by Dr.
Beale.  When tissues are steeped in a weak solution of carmine,
the only parts which receive a permanent stain are the nuclei, or
young growing matter in them.  Now, of  the mucous globules
the whole substance receives a permanent  stain, as is shown  in
the drawing here exhibited.   It appears,  therefore, to be wholly
formed of nuclear or growing matter.
  It  may  be remarked that the mucin,  or transparent  fluid
medium in which the globules float, does  not receive so marked
and  so permanent a stain from the  carmine; and this appears
a very fair argument for considering  it as the formed substance
of wThich the  globules  are  the  nuclei—a sort of common trans-
parent  area,  a common cell-wall  to  numerous nuclei;  just  as
coral is the common skeleton to millions of coral insects.   Each
perfect epithelial scale, each nucleus, has  its own formed sub-
stance constituting  its own cell-wall; in  the  lower grade of life
represented by mucus there is a less perfect common formed
substance, constituting a common cell-wall.
  Now, if the mucin, or transparent medium  in  which  the
globules and granules  float, stand in the place of fully-formed
organic substance or cell, it will not  retrograde into the condi-
tion of ^rowing substance.  Such a retrogression does not happen
in cells.  In an epithelial  scale,  for instance, the transparent
area does not become nuclear matter.  But it transmits the nu-
triment to the nucleus inward through  its  substance without
beinc destroyed.   On this  supposition, the formation of mucin
will be the highest development of the life  of the globule, for it
answers to the formation of tissue from nuclear matter.   And
in that case we should expect to find that the nearer its normal 
76         THE FORMATION OF MUCUS AND PUS.
condition the morbid secretion can be collected, the more of this
higher state of life it would exhibit, and that the further  from
its normal condition  it  is, the less there would be of the formed
matter.  Such is the fact.   The fluid which first forms on  an
inflamed surface contains  few globules and much stringy trans-
parent medium.  Its nuclear matter has so far departed  from
life that it  cannot form separate cells, but  only an imperfect
common area.  But  as  the  inflammation goes on, this power is
still more and more lost; the nuclear matter cannot form the
mucin, it can only multiply;  and hence the  stringiness of the
mucus disappears, and  it becomes what we know by the name of
"pus."  As far  as  the morbid matter itself is concerned, pus
indicates in it a further deficiency of vitality than mucus—a de-
ficiency of vitality shown  first in its internal self-multiplication,
and secondly in its non-production of mucin.
   The  question naturally  arises as to how  these products of
arrested vitality make  their way to the surface of the mucous
membrane where  we  find them.   The pabulum whence they are
developed lies on the  inner side of the epithelium, whereas we
find them quite uncovered.  The first explanation that occurs
would be that the epithelium is destroyed, and that they are in
the first place the debris of the dissolution, united to that which
would normally go to form it.  This would, in fact, be a modifi-
cation of the old idea, that pyogenesis was a kind of ulceration,
and involved a certain solution of continuity in a tissue.   In-
deed, it would amplify the idea, for it would extend its applica-
tion to mucus as  well.   To this idea Professor Virchow seems to
incline in the edition of his "Cellular Pathology" published in
1858 (p. 395), where he represents the formation indeed of  the
mucus  and  pus-globules to take place in the lower layers of  the
epithelium,  but to be mixed with and  to have  their bulk added
to by the outer layers  which they push off.
   Since then, however, several observers  have found that  the
most intense catarrhal condition of mucous membranes may exist
without any loss of the superficial epithelium.  Even in that most
 destructive  state commonly known as  diphtheritic inflammation,
 where  fibrin is thrown out with the pus, the  epithelium  may be 
            THE FORMATION OF  MUCUS AND PUS.         77

 perfect.  Dr. Sanderson has kindly lent me some notes he made
 of the  autopsy of a  child who died at St. Mary's Hospital of
 diphtheritic angina, in whose larynx this  fact was very clearly
 seen.   The whole interior of the organ was  lined with a firm,
 closely adherent  false membrane.   When that  was  detached,
 portions of flabby  concretion  still  remained,  which could be
 washed off with a stream of water.  " On examining the sur-
 face," says Dr. Sanderson, "after much washing, it was  found
 to be entire.  It exhibits to the naked eye, indeed, marked in-
 equalities of appearance, as if eroded; but these must be  de-
 pendent on the adhesion of minute particles of concretion; for,
 on making snips of the surface with sharp  scissors at those parts
 where the  eroded  appearance  was most  obvious, viz., on  the
 upper surface of the epiglottis, the  epithelium was  found to be
 entire.  The only exception was at the  upper margin  of  the
 ventricles,  where the epithelium  was  adherent only  here and
 there;  but  there was no trace of thickening or alteration of  the
 basis-membrane, which exhibited its normal appearance."*
   Fb'rsterf has also carefully examined, by both horizontal and
 perpendicular section, the epithelium of mucous membranes in
 a state of purulent catarrh, and  has found in it either no change
 or very unimportant change from  the normal  state.
   The globules, then, or the material of the globules, must some-
 how be passed  through the  epithelium.  Dr. Buhl, of Munich,
 has lately detected it in transitu,  and drawn figures of it on the
 road.   The case on which his observations were made was one
 particularly well suited for the purpose.  The patient had died
 of pyaemic inflammation of the portal vein and of the  bile-ducts
 of the liver.  Now, the epithelium of the  bile-ducts presents a
 very marked character; its cylindrical  bodies exhibit an unmis-
takable shape.   So obvious is this shape that  it can be detected
even when  considerably distorted; and  therefore he was able to
trace the epithelium scale, modified by what he rationally enough
concludes to be the presence in it of pus-globules.  This  is clearly
 * Private Notes of Dr. Sanderson.
 f Communication from the Wiirzburg Institute of Physiology and Anatomy,
 Wurzburger Med. Zeitschrift," bd. i, part 2. 
78         THE FORMATION OF MUCUS AND PUS.

exhibited in his sketches of the various forms or stages of altered
epithelium  as he saw it floating loose in the fluid pus or massed
into clots.   First, he shows the normal  epithelium  cylinder, as
a medium  of comparison, and of these there were great quan-
tities.   Then come a number of bodies which we can recognize,
when they  are here placed in a row, as  perversions of the  cyl-
inder, gradually increasing in rotundity and receding in likeness;
but which in their extreme of dissimilarity would not be seen to
have any connection with it,  except by a previous knowledge of
the fact.
(After Buhl.)
   The majority of the enlarged cells were filled with oil-granules.
 Others, in which "the fat was accumulated to a smaller amount,
 contained from two to ten rounded  bodies exactly like the free
 pus-globules surrounding them—so  like, that  hardly any doubt
 could  be  entertained  that they  were cells pregnant  with pus-
 globules.   As a rule, the groups  of pus-globules lay close to the
 thick end of the cylinder; but often between the thick end and
 the groups of pus-globules there  was to be seen a degree  of con-
 striction, making the cell bottle-shaped.  Sometimes the tail of
 the cell was  obliterated or torn off, when it was almost globular,
 but even then capable of recognition.
   In  calls where there were  only two or  three  globules the
 nucleus remained distinctly visible and  perfect.   In others the
granular globules seemed to be  dividing and  splitting up into
four or six, the  original nucleus  of  the cylinder still remaining 
            THE FORMATION OF MUCUS AND PUS.         79

visible.   So that pus-globules evidently do  not of necessity take
their rise in the degeneration of nuclei of existing tissue.
   In other examples, again, the cell-contents seem entirely to
have degenerated into fatty molecules, whether from the growth
of the globules just described or from other causes, and in them
the nucleus had degenerated along with the rest of the cell.
   I have  noticed  in the  epithelial  scales from  the  vagina, in
cases of purulent discharge, a somewhat similar repletion with
granular matter without alteration of the nucleus.   And mixed
with them there were also large round granular corpuscles, which
had the  appearance of containing pus-globules, and which might
have been degenerated epithelial scales.   But scaly epithelium
has not  such a definitely marked form as the cylindrical variety,
and it is difficult to identify it in a state of transmutation.
   Remak* has also found in the pus from inflamed bladder large
cells which he  thought he identified  as the  epithelium from the
fundus  vesicse.   These contained from six to fifteen globules,
entirely filling up the interior, and in every respect like  mucus-
corpuscles. But he does not trace a series of transitional forms.
   It will be seen by these  observations that the pus-corpuscles
are not so much descendants of the epithelial  cells as what may
be called parasitic  formations within them.   They are parasites
inside the epithelial cells, capable  of increase by propagation
within the tissue, just as on the surface the mucous globules were
shown as parasites  capable of increase  by propagation without
the tissue. And they grow quite independent of the true nucleus
of the cell,  and are not derived from  it.  Thus the nuclear
material may pass through the substance of the epithelial coat of
mucous  membrane  without  destroying it, and  not only be itself
unaltered, but may increase in quantity  during the progress.
This is  one way in which the pus-material may reach the sur-
face, and explains  those cases  in which the epithelium is quite
uninjured.
  We find these fluid or semifluid properties  exhibited b^ epithe-
lial cells in their daily duty of absorption.  Fat, from its highly
refractive  powrers, can easily  be traced, though a  fluid,  by the
                * Virchow's " Archiv," bd. xx, p. 198. 
80         THE FORMATION OF MUCUS AND PUS.
microscope; and fat in globules can be seen passing through the
substance of the epithelial  cells of the  intestines during their
active state.   This is well shown in some recent drawings, made
by Balogh,* of intestinal epithelium during the ingestion of fat;
the whole thickness,  not a central tube, but the whole thickness
of the cell, is seen permeated by it, and allowing it free passage.
The physiological passage  of fat-globules  inward may reconcile
us to the idea  of the pathological passage of pus outward.
  But Professor Henle well says : " If they are sometimes formed
in the  interior of a  cell  saturated with their  material, this fact
does not exclude the possibility that just in the same way they
may sometimes be developed from the same plasma beneath the
cells."   In such case they would be projected on  to the surface
between the separated epithelium cells.
  This other mode of growth  and attaining the surface is  strik-
ingly shown in a drawing by Dr. Edward Rindfleisch, of Breslau,f
which exhibits in section the nictitating  membrane of  a frog
affected with a partial catarrh of the eyes.  Fig. 3 is the normal
state, where the membrana propria (as Professor Henle calls it)
is seen  as  a  moderately transparent layer,  with its  delicate
(After Rindfleisch.)
areolar-tissue-corpuscles, and the epithelium as two parallel rows
of equal-sized cells.  In Fig. 4 the pathological  condition is re-
presented : the pavement of epithelium is thrown up and sepa-
rated by nucleated pus  or mucus-globules, which are seen  to
proceed from the membrane beneath. And the substance of this
membrane appears to be saturated and rendered opaque by what
.must be an earlier condition of the same bodies.
     * Moleschott's " Untersuchungen zur Naturlehre," bd.  vii, 6tes heft.
     f Virchow's " Archiv," bd. xxi, plate viii. 
THE FORMATION  OF MUCUS AND PUS.         81
  These observations seem to show that the pus or mucus globule
on mucous membranes  is the material of young or renovated
epithelial cells, arrested in its development at the earliest dawn
of life, before it has assumed the form of a cell, when it is almost
as unlike its destined final form as an egg is to a chicken.  They
seem to show that in this state it may be thrown directly off by
the epithelium being broken, or it may pass into the substance of
the epithelium.   In either case it does not part with the low de-
gree of life it  has acquired ; but neither does it acquire a higher
degree ; it goes on propagating, but nothing more.
  Both Buhl's and Rindfleisch's observations seem also to prove
that pus-globules are not produced, or at least not produced only,
by the degeneration of  existing cells ; they are not  tissue retro-
grading into a lower form of life like fatty, amyloid, and similar
morbid matter.   Buhl's drawings especially exhibit the nucleus
of the  epithelial cell intact along with the newly-formed pus-
globule.  They differ, however, in one  particular, that  whereas
according to Buhl the first pus-globule  produced free in the cell
increases itself by division, Rindfleisch assumes a splitting up of
the whole  contents  of  the cell according to the analogy of the
egg-yelk.  As Buhl's  observations are  made  upon epithelium
alone and Rindfleisch's upon areolar tissue also, and in  one case
the epithelium remained perfect and in the other was broken up,
I can see no inconsistency in allowing both to  be correct, and to
represent the different behavior of growing matter under  different
circumstances.
   A very ingenious  place has been selected  by Junge* for the
investigation of the growth of pus—viz.: the tunic of the aqueous
humor in the eye.   He caused  inflammation by the application
of a hot wire  to the  cornea of an animal, and was thus able to see
what went on in  the deeper parts of the eye without exposing the
affected tissue to the air or  any other  extraneous agency.  He
was thus  able to see the active growth of globules by division
and subdivision so far  as the formation of large masses.
   As the secretion on the surface of mucous membranes becomes
  * " Uber Eiterbildung," &c.: " Archiv fur Path. Anatomie und Pbysiologie,"
bd. xxii, heft 1, 2, p. 193. 
82         THE FORMATION OF MUCUS AND PUS.
 more opaque or "purulent," so the globules are more and more
 regular in size, rounder, and  more like  one another.  In trans-
 parent mucus most of them are oval, with nuclei indistinct and
 various  in number, while  there  are often lumps on their sides
 distorting the form.  In creamy pus they are nearly all of a size,
 and present two  or  three well-marked  nuclei.  This is easily
 accounted for, if Ave admit that they are multiplied on the surface
 of the membrane.  When first  formed, they appear under violent
 and varying circumstances, different in  degree  every moment,
 and therefore  are different in form; but when once separated,
 they may go on multiplying  under favor of  nutriment and heat
 for several generations.   Thus, like wild races of animals, they
 lose individual differences, and become more and more  similar
 and uniform  in characteristics.
   The formation of pus in deep-seated parts is, of course, not so
 easy to trace as on surfaces, and experimenters seem deterred by
 the difficulty of the subject.   In all tissues where pus is found,
 its optical characteristics are the same as the fully-formed  pus
 of mucous membranes:  it presents globules all nearly of the
 same size, and  with a pretty even amount of nuclei.   This is its
 complete condition; but what  it is like immediately on its sepa-
 ration  we do not  know.   We cannot  trace  it through a stage
 analogous to  mucus.
   Of its  previous condition, however, we may form a shrewd con-
jecture.   The same elementary substance which appears on, or
 rather  in, integumentary tissues as the common material of  the
 various kinds of epithelium, appears also as  granular nuclei in
 other tissues—in the  ganglia  of nerves, in the brain,  in  the
 parenchyma of the liver, in the spleen, thyroid and  thymus,  &c.
 The  same bodies occur also in the blood, where they have been
 termed " chyle-corpuscles"  and " white cells." They  are found in
large quantities in  the most recently formed, most quickly grow-
ing,  and  most actively renewed component parts  of the animal
frame.   In short, the  most rational interpretation of this form of
organic matter is that  which represents it as the common material
of all tissues in its  earliest state of elementary life.   And as that
which was to  have formed  epithelium is  cast off as  the basis of 
           THE FORMATION OF MUCUS AND PUS.         83

the mucus and pus-globule, so  that  which was to have formed
hepatic parenchyma, nerve, or areolar  tissue  becomes pus, per-
haps through some unsuspected  transitional stage.
  In this account of organic forms in pus  and mucus I have en-
deavored to harmonize the contributions of several observers.   I
have  done this  mainly by omitting  points of observation and
deductions in which  they differ from one  another, and  putting
together those  on which they agree.   Their  harmony also has
been much assisted by translating into a common language the
various terms in which they express the laws  of life which their
observations  appear to  exhibit.   It is  curious how often plain
English reconciles difficulties. 
LECTURE  V.
         THE FORMATION OF MUCUS AND PUS.

Mucus and pus compared—Grades of loss of vitality in mucous
    membranes—Exemplification of  these grades in  smallpox
    pustules—Practical deductions from the various points com-
    mented on in the three lectures.

(Third Lumleian Lecture atthe College of Physicians, Lent, 1863.)

  In the vitalized forms which they present, we may consider pus
and mucus as identical; the  pus-globule being merely the de-
scendant more or less  remote of the mucus-globule, and  both
retaining  only  that low degree  of life  which  they  originally
derived  from  the body.   The physical differences  between the
two depend seemingly upon the medium in which these vitalized
forms are suspended. Neither  in pus nor mucus are  the contents
of this medium constant  in their proportion  to one  another; no
two analyses of pus or mucus are ever the same.
  Indubitable pus and indubitable mucus may be clearly defined
as the two ends of a scale, between which there are innumerable
gradations. The most transparent, stringiest, and least globular
mucus consists principally of a peculiar animal matter, which is
not albumen,  though it closely resembles it.  It  is not coagulable
by heat, and it contains  more  oxygen on ultimate analysis than
albumen does. Sulphur  also appears not to be one of its constit-
uents.   Until it can be found reducible to be considered a com-
pound of some known  intermediate substances, it is temporarily
called "mucin."  This  word simply means mucus divested of 
THE FORMATION OF MUCUS AND PUS.         85
those contents which are capable of another nomenclature and
physical separation—as, for  instance, epithelium  scales, blood,
the ammonia of decomposition, &c. The analyses are well known,
being reprinted in every work of  physiological chemistry, but
shed little light, for the obvious reason  that the substance ana-
lyzed is hardly ever twice the same.
   Pus, on the other hand, contains a large quantity of albumen,
and a large quantity of fat.  A modification in the mode of the
loss of health is characterized by the presence of fibrin, and cer-
tain forms of defective vitality by casein being also found.  The
inorganic constituents of both  seem to  be the  same as those of
blood-serum with some of its water lost.   Our diagnosis, then,
of the morbid secretions of the  mucous membranes should be not
absolute—not that such and such a specimen is pus or is mucus—
but comparative, that it is more or less  purulent, according as it
exhibits a greater or smaller quantity of albumen ; a fact easily
ascertained by the degree of its coagulation by heat when diluted
with wrater.  And this is thoroughly practical and  important, for
it indicates the degree of loss of local vitality in the  secreting
membrane.  Equally practical also  and important is the observa-
tion of  the presence of fibrin and its  amount.   In large and
overwhelming  quantities we are familiar  with it as occurring in
the most serious deficiency of life consistent with life at all which
we find in mucous membranes; and there appears even in minor
cases a close connection between its amount and the  degree of
deficient vitality or inflammation.   During a severe cold in  the
head minute clots of spontaneously coagulating  fibrin may be
found in the secretion of the  Schneiderian membrane, which,
existing in  large quantities, form the false membranes  indicative
of the serious poisoning of the  system in diphtheria and croup.
   The phenomena we see on the mucous membranes are a question
of degree rather than  of essential difference.
   Loss of vitality, as  shown in mucous membranes, seems to be
exhibited in the following degrees:
   First there is an  arrest of function.   For example, from  the
impression  of  cold the Schneiderian membrane is  temporarily
deprived of its endosmotic force;  it ceases to  absorb  the water 
86          THE FORMATION OF MUCUS AND PUS.

which is condensed on its surface from the breath, and that water
drips from the nostrils.  Or the stomach or intestines, from men-
tal  or physical causes, are deprived of their power of absorbing
and digesting the fluid matters presented to them,  and partially
first excreted from  them;  and  these  fluids may pass away by
diarrhoea.  Or the skin is chilled, and shows its deficient vitality
chiefly in the deficiency of its most prominent function ; though
it feels painfully, it cannot feel so  delicately as it  ought.   In a
vigorous person full life is soon  regained: the nose recovers its
natural degree  of dryness ;  the intestines  absorb  again before
the fluids have  passed from  the body, and  the  temporary indi-
gestion does not arrive at diarrhoea; the skin recovers its feeling
after  a temporary painfulness.  But we know that our invalid
patients,  whose vitality  is  low, are  not so  easily reinstated.
Catarrh of various parts quickly and readily follows the action of
physical agents. It is  probable that in this least degree of injury
the capillaries  are  contracted in  area, and  consequently  the
rapidity of their stream increased,  by the action of the nerves.
This phenomenon is wanting if the  injury is greater;  in experi-
ments upon  animals the microscope  does not detect  it, if the
reagent applied is powerful.
  2.  A greater degree of injury is  accompanied  by  a loss of
elasticity in the capillaries.  Their dilatation, and  the consequent
retention and stagnation of the blood in  them, is familiar to us
all, in both the  living and dead subject, as  " inflammatory con-
gestion."
  3.  This stagnation  may be in  isolated spots  complete;  the
blood-discs adhere together in rolls, as when removed from the
body,* and  block up  the passage.   Thus the arterial wave is
obstructed in its course, and like an ocean swell shattered against
a shore of rocks, becomes more evident to the senses as the well-
known "throbbing."  It is  shortened and sharpened, but there
is no  evidence that it is strengthened ; indeed, the analogy I have
  * It is not  necessary here to go  into the question, so ably treated by Mr.
Lister, as to the first origin of this evidence of death; whether  the  blood-discs
adhere in consequence of their own idiopathic death, or in consequence of the
withdrawal of the  influence of the  tissues, which normally keep  them  from
adhering. 
           THE FORMATION OF MUCUS AND PUS.         87

cited, and the general fact of weakness being accompanied by
quickened pulse, would seem to  show that  it is diminished in
propelling force.
  In the mean time there is an accumulation of that constituent
of the blood which most resembles in appearance the element of
young growing tissue—the colorless blood-corpuscles. The blood
is dark, indeed, to the naked eye, but under the microscope is
seen to be made  dark by being filled with these pale  bodies,
possessing a high refractive power.
  The loss of elasticity in the coats of  the capillaries renders
them more easily permeable by the contained fluid.  Serum is
poured out into the neighboring parenchyma, and joins with the
swollen  capillaries in producing " swelling."  The loss of vitality
in the blood-discs may be so complete that their hsematin is dis
solved in the  serum, and we get the surrounding parts  stained
with it—as for a short time in typhus fever, and for a long time
in syphilitic eruptions. Or the blood-vessels may completely lose
their cohesion and be  ruptured, allowing of haemorrhage.   But
in all this there is no new process, nothing which is not a direct
deficiency of function.
  In solid structures this effusion is followed by an endosmotic
current of the watery part back again into the circulation,  leav-
ing behind it the more solid and coagulable constituents.  On free
surfaces, covered only by soft open  epithelium,  the water and
salts therein dissolved escape, forming the fluid of the  mucus.
The elements of new tissue,  being there very copious to supply
the constant  demand  for growth, ooze  out copiously with the
serum, and  constitute the mucous globules.  They are  wasted
elements of new growth, not  themselves a new creation,  or evi-
dences of superadded life.
  How  do these matters get through the coats of the capillaries ?
There cannot be holes for their escape, or  else the blood-discs,
which are the smaller of the  two, would escape also.  Doubtless
this is  one of the great riddles of physiology.   But the art of
drawing is in a certain degree responsible for some of the diffi-
culty which it presents to our minds.  When we have no means
of correcting by our other senses impressions made on the eye, 
88         THE FORMATION OF MUCUS AND PUS.

we are too apt to consider everything with  an outline as equally
solid.  The necessarily hard  outlines of the engraver express to
us forms which may, for all the paper shows, be spheres of  cast
iron, whereas in truth they are as delicate as aerial clouds. Why
may they not pass through tissues, mutually dissolving' and dis-
solved by the materials of those tissues ? Just as we see a stratum
of fleecy cloud among mountains, or in Turner's pictures,  disap-
pear when it comes to a stratum of warm air, and reappear in the
same form when it emerges on the other side.   To get just ideas
of nature, we must look upon solidity as a comparative,  not as
an absolute, quality.
  4. In a higher degree of deficient vitality the serum contains
albumen and fat also exuded with it; and  this mixed with the
multiplied globules constitute the fluid we call  " pus." The albu-
men and fat not only escape on free surfaces, but  saturate  also
the tissues they escape through, making them more retentive of
water than would otherwise be the case.  Inflamed cuticle takes
a much  longer period to dry than normal cuticle.  Langhans
found that a piece  of healthy  rabbit-skin was  crisp in three
hours, but a  piece of the same skin which had  been inflamed
during life took twenty hours to part with its moisture  to the
same extent.*  It appears to be saturated with  the nutriment
which it has lost the power of employing aright.
  5. Pus formed as I have  described is a  soft and  greasy lini-
ment, capable of shielding the parts with which it lies in contact
from foreign influences,  which in their  condition  of  lowered
vitality  would be noxious to  them.  It is more bland and  less
liable to decomposition than  any artificial application; for,  laid
on  the  healthy skin, it causes less irritation  than even  water.
But under  certain  circumstances  it  becomes what we term
ichorous ; and then it is corrosive, poisonous, and  destructive to
the neighboring tissues.   Now, this cannot arise simply by the
chemical decomposition of the pus itself in consequence of reten-
tion ; because in a good many cases (as in  cancrum oris, for ex-
ample) it has not been retained so long as usual, but is thrown off
ichorous and irritating as it is formed.  But  you  may observe
           * » Zeitschrift fur Rat. Med.," R. iii, bd. xii, heft 2. 
            THE FORMATION OF MUCUS AND PUS.         89

that in all these instances of ichorous pus there is necrosis, mor-
tification, ulceration, or some other form of actual loss of tissue.
Tissue may be  formed, as  in granulations; but  it is being  de-
stroyed at the same  time with abnormal rapidity.  I cannot  but
think therefore that the ichorous nature of such pus may be  due
to its saturation with the  organic acids which are the results of
the decomposition, not of the pus itself, but of the  melting tissues.
Wash away this irritating pus, clean the sore, and that which is
then formed often is quite bland and benignant.  As pus differs
from  mucus, so  ichor  differs from pus in the nature of its acci-
dental fluid constituents.
   The formation of  ichorous pus exhibits a further stage of loss
of vitality.   The  poisonous part of  it seems to be peculiarly
soluble,  and  capable  of uniting  with, and destroying  animal
tissues.  Absorbed  into the  blood,  it naturally destroys  the
vitality of the constituents of that fluid, causes it to coagulate in
localized spots,  and thus  to give rise to the congestions  and
abscesses of pyaemia.  When we reflect how easily ulcerations
may arise in mucous membranes, and what an active surface they
offer for absorption, we cannot be surprised at the frequency
with which pyaemic abscesses follow slight injuries, such as oper-
ations on the bladder, crushing  of calculi, typhous  inflammation
of the bowels—cases  vjhich seem of minor moment, but which
certainly involve  solutions of  continuity, with  consequent  de-
composition of tissue  and the formation of  ichor, in a  situation
very open to absorption.
   6. The formation of fibrinous coats on mucous membranes I
have already shown  not necessarily to  involve destruction of the
epithelium.   Is  the  loss of  vitality which causes it to exosmose
through  the capillaries in the fibrin itself or on the walls of those
vessels?   Whichever it may be, such an  exudation certainly is
evidence of a great deficiency  of life; and, moreover, by  the
mechanical impediment it  throws in the way of the functions,
usually leads to further deficiency.
   These facts, so familiar  to us all  in our daily work,  viewed
thus in connection with one another,  cannot  fail to  impress us
writh the feelin^ that the seeming activity of mucous membranes
       7 
90         THE FORMATION OF MUCUS AND PUS.

in diseases is in truth a descending scale of loss of vitality.  And
this feeling must, I think, have great weight in our therapeutical
dealings with those diseases ; indeed, I cannot imagine anything
of more practical importance to physicians and their patients.
  The influence of physical agents on mucous membranes which
are throwing off mucus or pus, or are disposed to do so, is very
different from what it is during their health.   A degree of cold,
which  is borne with ease  by them when in full vigor, causes a
further arrest in their functions, and heat is equally badly borne.
The action of oxygen, as contained in atmospheric  air, is to  the
healthy tegumentary tissues  invigorating   and beneficial;  but
when their  vitality  is lowered, exposure  to it kills them  still
further, and may even alone prove fatal to the patient, as we see
in the  instance  of extensive burns.
  I was lately much struck with the noxious influence of atmos-
pheric air on the pyogenic skin in a case of confluent smallpox.
At the period of the maturation of the pocks, when just preparing
to begin drying up, they presented three grades, distinguishable
by the following microscopic  differences in  their contents.  In
one sort the matter was of  the consistence of thin lard, white* and
opaque.   Examined under the microscope, it was seen to consist
of epidermic scales,  many  of normal aspect, but some filled with
granular  matter hiding  from  view the central  nucleus.  In
another sort the normal  scales  were few, the granular scales
equaling them in number; but more numerous than either were
pus-globules  of various sizes and of irregular  shapes, as if bud-
ding on several sides.   In a third sort, taken  from the very con-
fluent  parts  of  the  eruption, there was nothing to be  seen in
general but  regularly formed pus-globules  of even size, and a
number of highly refractive globules (of fat) among them.   The
fully formed pus was so copious that it overpowered the debris
of epidermis, which was barely visible.  These three classes of
microscopic phenomena represented three grades of  destruction
which the skin had  undergone  from the  effect of  the variolous
poison.   In  the first  the  epidermis was  merely destroyed,  and
the materials for renewal were available for a new  one.   In the
second to a slight degree, and in the third completely, these were 
THE FORMATION OF MUCUS AND PUS.         91
converted into  pus to  a great depth.  Consequently there was
great risk of permanent destruction of the skin, or a scar. Now
I found that the grade of destruction bore a direct ratio to the
exposure  of the various parts to the air.   The  most favored
situations were the thighs, abdomen, and tongue, where the pocks
of the first or less  injurious kind were  very numerous.  Next
came the legs and  back, and then the hands and forearms.  The
face was the most  purulently affected of  all.  The back (where
the eruption was confluent) maintained its comparative immunity
in spite of the cuticle being much chafed by the movements of
the sufferer. You will notice that the most affected situations are
those which are most exposed to oxygen  and evaporation, which
are life to the healthy skin, but death to  it when diseased.
   On  rational  grounds, then, I think the practice of painting
over the pocks in  prominent  and important situations with col-
lodion, caoutchouc, or gutta percha may  be  fairly defended.   In
this way we do all we  can  to  secure a local  atmosphere of car-
bonic acid—the normal atmosphere of internal tissues,—and to
prevent the loss of vitality  in the covered parts.
   More than this,  I think  we should  be  led to consider whether
we do not sometimes err in  applying too rigidly the theory of the
universal wholesomeness of fresh air.  Fatal cases teach us that
it is bad for inflamed  skins; is it good  for  wounds ? is it good
for  abscesses? is it good  for inflamed  lungs?   As physicians
we have most to do with the  latter case ; and I must say I find
that few things  contribute  to  the ease and  recovery of my
patients, so much  as limiting the supply  of oxygen in the atmos-
pheric air by saturating it with watery vapor.  I refer here not
only to pneumonia, but to all catarrhal affections of .the breathing
apparatus.
   The stomach, again, is much benefited by carbonic  acid.  It
naturally contains  that gas, and some cases of deficient digestion
appear to arise from its absence.  Atmospheric air swallowed
with the food,  or by a pernicious habit, produces dyspepsia; and
nothing benefits that dyspepsia so much as solutions of carbonic
acid in water.   Our soda water, potash  water, and lithia water
derive their main virtue from the fixed air they contain. 
92
THE FORMATION OF MUCUS AND PUS.
  I believe that the only way in which carbonic acid is employed
in surgery is under the form of yeast poultices, which certainly
stay the progress of death in the skin quicker than most applica-
tions. Were I a surgeon, I should like to try the use of the gas in a
purer form as a healing agent for wounds, operative or accidental.
  Such an  atmosphere of carbonic acid is to a certain extent
secured to sore places by a layer of pus or mucus, which is satu-
rated with  that gas, and  not very pervious  to oxygen.   It is a
great defense against noxious agencies, and I think we are wrong
to clear it away more than is necessary to comparative cleanli-
ness and  the  patient's  comfort.   We know how much lighter
gonorrhoea is  in the female than in the male, and one reason
appears to be that the secretion is not constantly washed off the
mucous membrane by the passage of the urine.  Dirty people
seem hardly to notice the existence of these discharges from the
mucous membrane—they come and go of their own accord  with-
out  causing any  illness; while,  on the other hand, cleanly
patients are martyrs to their minor virtue and to their sensitive-
ness, protracting and aggravating disease by constantly removing
the defense which pus  or mucus  presents against oxygen and
cold.  Of course an exception must be  made of cases where the
pus is ichorous and poisonous in  its quality, when the sooner it
is removed the better for the patient.
   On the principle of not too frequently cleansing away mucous
 secretions I should attribute greater advantages than we are in
 the  habit of attributing  to  opiates and other sedatives in pul-
 monary affections, where there is a copious bronchial discharge.
 Their obvious and immediate  effect is to  ease the cough; and
 some medical men are in the habit of speaking of that alleviation
 as if it were merely a  convenient mask to  conceal the morbid
 process  which wTent on  uninterruptedly.    This easing of  the
 cough,  doubtless,  takes place through  the pneumogastric  nerve
 being rendered less sensitive to  the  presence of the abnormal
 secretion, and so allowing it to collect  in larger quantity before
 it is expectorated.  1 cannot but  think this  collection in larger
 quantities before  expectoration is beneficial as a defense and as
 a curative measure. 
           THE FORMATION OF MUCUS AND PUS.         93

  The idea which I have  endeavored to inculcate, that an  in-
crease in the quantity of living tissues is by no means an evidence
of an increase of their life or of their powers of  life—nay, fur-
ther, that it  is rather an evidence of deficient life, cannot  but
have  an important  bearing  on both pathology and practical
physic.   It is not a question of words, but of deeds.  If inflam-
mation be an abnormal increase of the vital powers of the tissues
affected, then we  cannot do better  than employ the many agents
which  have a direct power  of  weakening life, a power which
Boerhaave and Van Swieten  believed was the only one the art of
medicine could give.*   If inflammation be an  increase  of vital
powers, we should value our bleeding, our blistering,  and  our
evacuants in accordance with the degree in which they reduce
the strength.   If, on the other hand, the phenomena of inflam-
mation  indicate direct  deficiency of  vitality,  not  only in  the
general system, but in the part  affected, then we must make the
chief end to be kept in view  in our treatment the retention  and
increase of vitality.  And when we employ the means I have
named,  we must look upon their debilitating action as  an ugly
fault  unfortunately joined to some other virtue which they pos-
sess, and must try to  counteract  the evil while we  retain  the
good.
  Take  for  example  the remedy blood-letting.   Experience
shows it to be beneficial in  certain  cases, so  let us use it  by
all  means.  But  all its benefits can be rationally traced to its
mechanical hydrostatic action—to the taking away of so much
fluid pressure which the weakened  part is unable to bear.   Let
us,  then, so apply the remedy that these mechanical phenomena
should have most play, by making it as local and as  sudden as
we  can, and by using it with a reference to what we  want it to
do.  And all its evils can be also rationally traced to its physio-
logical action—to its detraction of so  much material of tissue
from  the circulation.   Let  us, then, when  we  use  it  for  its
mechanical advantage, counteract its physiological disadvantages
by replacing  to the best of our ability these materials of tissue.
  *  " All that art  can do is to weaken life."—Van Swieten's " Commentary on
Boerhaave," vol. i, \ 106. 
94         THE FORMATION OF MUCUS AND PUS.
Instead of designedly starving our patients  when Ave bleed, let
us feed them.
   We may reckon in the same way with other remedies less
directly destructive than blooddetting.   We  should value them,
not in proportion to their special evacuant power, for which they
severally are classified as purgatives, expectorants, sudorifics, &c,
but in proportion to the renewed growth of healthy tissue which
accompanies their action.  For  example, Epsom  salts and aloes
are both purgatives;  but take a case of anaemic  intestinal cos-
tiveness, and we know well that the more Epsom salts the patient
is dosed with the worse she is, but that aloes will restore a healthy
condition to the mucous membrane of the bowels, and gradually
reinstate its powers.   It is not  in proportion to their  purgative
powers that purgatives are beneficial, and we can hardly there-
fore consider that it  is because  of these purgative powers that
they are beneficial.
   The action of cantharides  upon the skin as  a curative agent
has been  established  by the  common  consent  of many genera-
tions.  Is it the blistering and destruction and drain of organic
matter set up by the epispastic which does the good, or is some
other part of its action?  Now in eczema  and herpes, and in
smallpox above all, we have  an enormous  amount of blistering
and destruction of skin and drain of organic matter;  "but instead
of distant inflammation -being arrested by them, or distant gene-
ration of pus prevented, we often see it produced.  In smallpox,
the more  pustules there  are on the body, the more likely the
patient is to have bronchial catarrh and pneumonia.  Burns bear
a still closer resemblance to the morbid  process set on foot by
cantharides; but  the  greater the extent of burn  the more risk
there is of  internal inflammation.  Then remark the stage of
their action when blisters do good:  their benefits are experienced,
not when the destruction  of epidermis is at its  height, not Avhen
there is most serum and  mucus  and pus evacuated, but as the
healing begins.   Observe, for instance, a case of water in the
chest under treatment: the level of the  pleuritic fluid does not
decline most rapidly when the blister on the surface is filled with
serum, but Avhen it is drying up and  healing.  Is it not, then,
the growth of new cuticle  which  restores  our patient? 
           THE FORMATION OF MUCUS AND PUS.          95

  In reckoning the beneficial actions of blisters as evidence for
the counter-irritant theory of therapeutics, we are apt to forget
the cantharidin  which is  absorbed  by the  skin, and the direct
action of which  absorbed drug on the mucous membranes  is to
bring them to a  more healthy state.   It appears, when taken by
the mouth,—for instance in chronic bronchitis, and sometimes in
gonorrhoea,—to be a direct stimulant of-their vitality.  Blisters
may be beneficial  in this way quite independent of their  more
eye-striking effect.
   Perhaps the most powerful for good of  all the  agents added
to the Pharmacopoeia of late years is  oil.  During the internal
use of oil the pus-secreting membranes  and tissues dry up and
become healthy, and their heated, congested  state is diminished.
And the more readily  assimilated  is  the form of oil,  so  much
the more marked  is this improvement; that  is to say, the  more
we saturate the system with a basis of growth, with  a material
capable of being built up into new  tissues, the less likely it is to
throAV off those tissues in a half-formed state.  The easy digesti-
bility of cod-liver oil to my mind more than accounts for its won-
derful effects, and makes  superfluous the chemist's  aims to find
iodine or any other drug  as a constant  constituent in it.   The
good we do by  administering it is in direct proportion to  the
largeness of the supply of nutriment thus presented to the tis-
sues, and bears  no relation to any pathogenetic results.
   In investigating the action of drugs, we are sometimes  apt to
look too far, and in'our search  for the mysterious  to  pass over
the obvious.  We are  apt to bestow too  little thought on the
immediate  action  of  these agents on the  mucous membranes
Avith which they  come in contact.   Quinine, for example, inas-
much as it passes through the blood so far as to reappear  in the
urine, doubtless influences most tissues of  the body; but still
nine patients out of ten  receive the greater part of the benefit
accruing from the  use of quinine by means of the augmented
appetite and  digestion which results from  its presence on the
mucous membrane  of the stomach, not in the blood.   It  seems
probable  that the improvement in the vitality of pus-secreting
parts which accompanies  a course of quinine  is due to the greater 
96         THE FORMATION OF MUCUS AND PUS.
quantity of nutriment which this useful drug causes the mucous
tract of the intestines to absorb.
  The influence of heat upon mucus is a suggestive fact.   If
allowed to get cold, the globules  cease to develop the little life
they have; but  if kept at  the temperature of the body, they
continue to grow into pus in spite of the  unnatural  circum-
stances in which they are placed  under the microscope.  This
seems  to  explain hoAV hot  fomentations  and  poultices "favor
suppuration," as surgeons  say, in boils and abscesses.   It ex-
plains  also  why suppuration  is usually more  rapid  in  deeply-
seated, well-covered parts  than in exposed situations.  But  is
it wise  thus to  "favor suppuration?"   Yes,  truly;  for  while
we  are  aiding the vitality of the  pus-forming  material, we are
also aiding the vitality of the surrounding tissue—we are ena-
bling it to recover that perfect state in which it need  no longer
waste its nutriment by throwing it off in a semi-vitalized stage;
while  at the same time the  pus formed is the most natural, the
warmest, the softest,  and  the least injurious  substance we can
apply to a sore tissue.
  The recognized benefit of moist warmth may,  I think, sug-
gest to us something  more.  When  an  animal submits to the
periodical  latency  of  the  higher functions which  take  place
during  sleep,  it instinctively seeks the warmest  berth it can
find;  it is instinctively careless about the supply of oxygen  so
that it can get  heat.  Beasts hide  themselves in unventilated
dens and burrows;  man  surrounds  himself with blankets and
curtains in a close  bedroom, and not all the questionable  argu-
ments  of  busy  philanthropists can  persuade  him to open his
window at night.   I  suppose that instinct is  hereditary expe-
rience transmitted by generation from sire to son, and continu-
ously  increased  through countless ages.  It is not  surprising,
therefore, that its silent voice should beat out of the field the
voice of argument, however  loquacious.   But I doubt if we phy-
sicians listen for it carefully enough.   In that  state of deficient
vitality which  constitutes  disease, we are sadly apt to leave  to
accident the duty of  cherishing the weak  life by warmth.   In
every hospital  I enter, the Avards are a  great  deal toe cold. 
           THE FORMATION OF MUCUS AND PUS.         97

Because their forefathers tried to keep the sick warm by unwise
methods, the public in the present day zealously oppose the better
means of  healthy warmth which new  inventions provide.   Can
we be surprised  at rheumatic  patients falling into pericarditis,
at fever patients having pneumonia, when house-visitors, vigor-
ous and well  fed, walk in from the park, and finding the wards
smell of mutton-broth and  poultices, order the windows open
without compunction ?  Such things are; but they might be pre-
vented if  physicians would  first convince themselves, and then
the public, that  an  atmosphere and  a temperature which  is
agreeable  and wholesome to  the healthy  need not be  either
agreeable  or wholesome to the  sick.
  I have  endeavored in these three lectures to  point out the
practical bearings of what is a limited though an important part
of the phenomena of life.   It is not indeed even the whole  of
that pathological state which we  conveniently call inflammation.
But I think no harm is done by pressing, to  results deductions
from even the most limited observations, so long as we remember
that they are limited, and so long  as we  do not forcibly bend
other observations into coincidence with them. 
LECTURE  VI.
                       TYPH-FEVER.

Case—Cause of fever—Why it affects some and not all—The
    virus  acts slowly,  and  enters probably by the alimentary
    canal—Case showing the progress of fever-poison checked
    by emetics—Action of fever-poison on living organism—De-
    vitalizing  power on  blood—The first  symptom of partial
    death is  a rigor—Next  symptom, pain—Loss of appetite
    which does not arise from defective metamorphosis—diar-
    rhoea, hemorrhage, and increased  heat, all are evidences
    that disease is something  less than life—The object of  treat-
    ment is not the mere typh poison, but the interstitial death
    of the tissues—The touchstone of restorative medicine is-its
    application—Use of emetics—Tepid sponging—Cold affu-
    sion removes  but does not check the formation  of heat—
    Supply of food—Hydrochloric acid— Alcohol—Local blood-
    letting—Principal  difference between  patients lies  in the
    stomach— Two instances—Deduction.

           (Clinical,  St. Marys, October 18, 1861.)

  You saw a case  of  continued  low fever (or, as I  shall call it,
for  shortness, Typh-fever) admitted four days ago, which pre-
sents a good many points valuable for  instruction.
  Charles P., aged 15, a shop-messenger, who has grown rapidly
lately,  and has been worked perhaps rather beyond his strength,
stated  on admission that he had felt  ill, languid, and unfit for
exertion during the last six weeks.  The past fortnight he had 
TYPH-FEVER.
99
come home every evening without any appetite for his supper,
and  had sat  cowering and shivering over the  fire.  For three
days  he vomited all food taken, had diarrhoea, and pain in the
belly.   Cough  also  had come on with a stitch in the right side
during inspiration, and he had expectorated transparent mucus
with sooty specks in it.
   There were  to be seen on the  surface  of the abdomen  and
chest upwards  of a dozen dingy fever-spots in several  stages,
some entirely disappearing  on pressure, some  not.  You found
no pain or gurgling  on pressure of the belly, and the  diarrhoea
was stated to have ceased.   You saw the patient prostrate from
great muscular  languor and inability to stand, and a very weary,
dull  look in his eyes.   His tongue  was thickly coated with
yellow fur; his skin was hot and dry; his pulse 104, small and
sharp.   His urine Avas high-colored,  and deposited a  copious
yellow sediment, soluble by heat.   The  quantity passed during
the next twenty-four hours after admission was fifteen ounces, of
the specific gravity 1-020.   Then you  noticed  that  the  right
cheek was flushed.   The lower  part of the right lung you heard
was  dull on percussion,  and to the  listening ear  there were
moist cracklings  coarse and  fine in it, and dry whistling sounds
scattered about the rest of the lungs.
   The  boy's mother stated  that they lived  in a healthy attic,
dry  and free from foul odors,  and could in nowise  account for
the illness.
   Here is a sporadic case of  one of the  low  continued fevers
common in this  metropolis, and which  have  received a  great
variety of names, according to variations  impressed upon them
by the  epidemic temporary constitution  of the air or the  pecu-
liarities of the  individual.  The two best-marked and best-known
varieties are called  "typhus" and  "typhoid," distinguished by
peculiarities of eruption,  and we hardly ever  get a case in
London which  may not either be classed as one or the other, or
be represented as a  transition between the two.   In  registration
at St. Mary's we make the distinction, and often also in speak-
ing pathologically of the cases.  But in treating them I do not
do°so:  and therefore in lecturing about  treatment, which is the 
100
TYPH-FEVER.
business of a clinical teacher, I have adopted a name which would
include both, from  its likeness would be generally understood,
would  not  invoH;e  adhesion to any theory of identity or  differ-
ence, and have in addition the merit of shortness.  When I speak
of continued low zymotic fever I shall call it "typh-fever."
   The present case has been a  good one  for study, for  it has
presented all the most important  symptoms, without the patient
being  so ill as  to  be unable  to  tell his  story, or  to  make the
repetition of it and the examination by pupils dangerous to him.
I will call your attention to what you may learn from it.
   There is every reason to believe that  one of the chief exciting
causes of  these fevers is a poison  generated  by  decomposing
organic matter  and received into the  body from without.  To
judge by its effects, it seems to be  widely diffused through the air,
especially in the neighborhood of its origin, in the air of sewers,
putrid marshes, and  crowded human habitations.   If you are
readers of popular sanitary literature, you are probably crop-full
of the accumulated and decies repetita evidence of  this fact.
You are tempted to  ask how  it is, if  the poison  is  spread so
broadcast,  that  everybody  does  not get  poisoned?  You will
wonder why it should get into the body of this boy, while you,
really much more exposed to it, escape.   But  remember there
are two things necessary to poisoning; not only the poison, but  a
person apt to be poisoned.  And, in point of fact, the latter is
the most important element in the transaction.  It is only on  a
predisposed body that a morbid poison acts.  Most  likely we  are
all constantly taking in minute doses of the poison Avhich is  the
exciting cause-of these continued fevers, and can digest, oxidize
it, or otherwise render it harmless under ordinary circumstances.
But should some epidemic influence or exceptional deficiency of
vitality  rob us  of the poAver  of doing so, then we  suffer  the
effects,  and have  typhus or typhoid  fever,  as the  case may
happen to be.   There was reason enough  for  this boy being  the
victim, Avhile  others  escaped, shown in his recent  rapid  growth
and in his strength being overtasked by his work.   The exhaus-
tion of vitality allowed the poison to do its work.
    Besides this purely foreign mode of  generation of the  poison, 
TYPH-FEVER.
101
it would appear capable of being produced within the body itself
—out ofc  its own substance—idiopathically.  At least  such a
closely similar train  of phenomena folloAV,  Avhere an external
origin Avould seem a forced interpretation of nature, that we can
hardly help coming to the conclusion I  have stated in the last
sentence.   Thus  a typhous  state follows  severe  and disorgan-
izing Avounds, where all noxious foreign  influences  have been
cautiously shut  out;  and mere  climatic agencies, such  as the
unwonted heat of the  sun,  overwork,  chills, damps, and espe-
cially a combination  of these circumstances, will bring on the
well-known "febricula," perhaps of only a few days' duration,
perhaps  protracted into  or (as  some word it) "changing into"
a regular typhus.
   I speak of the exciting cause of fever as of a material ponder-
able substance for the sake  of convenience.   But I do not wish
to  exclude  the possibility of its being an immaterial power or
force, like light, heat, electricity, or sound, are held to  be.   If
it is so, it is like them  associated with  ponderable  matter, and
becomes  knoAvn  to us  only by means of such association.   We
speak of  a thunder-cloud causing certain phenomena, although
we know  it is the electricity of the cloud which does so; of the
sun burning us when Ave mean the heat of the sun;  of a  cannon
deafening us Avhen we refer to the vibrations of  the air acting
on our ears.  And so we may speak of the poisoning  power as
a part of that modification of matter to Avhich  it  is joined, in
spite of that modification of matter possibly existing in a similar
form (chemically speaking) Avithout being joined to it.
    Observe how sloAvly the power acts in some cases.  Our patient
 is upAvards of five Aveeks ailing before any of the distinctive feat-
 ures of his  fever show themselves,  and then they creep out one
 by one.   The time is not usually so long, especially during epi-
 demics, but you  may detect  it in the history'of almost every case.
 And you ought to notice it, because from  some  systematic works
 you might be led to thinking that  a continued fever was easily
 to be measured by days and hours  from the very moment of in-
 vasion.   This is impossible in practice, and would be of little use
 Avere it possible. 
102
TYPH-FEVER.
  I rather incline to think  that  the most usual path by which
the virus enters is the  digestive canal, in cases where it is  be-
gotten of decomposing organic matters foreign to the body.  It is
probably mixed with the saliva and carried down to the stomach,
where it possibly may increase and multiply in the gastric mucus.
During severe epidemics it has been  observed that  those who
smoke or chew, especially if they spit  out the saliva instead of
SAvallowing it, are less liable to be attacked.*  And at an  early
stage, even after the  virus has begun to act upon the system,  the
fever may be stayed by emptying the stomach, and thus prevent-
ing the whole  dose being taken up.  Those who  have watched
my practice will have witnessed several instances of the  success
of this treatment; they will  have seen the fever cut  short, and
convalescence entered upon immediately, with its characteristics
of painless weakness  and emaciation gradually passing away.
   One case last autumn gi\;es me the opportunity of  putting on
record that the influence of the  remedy is not merely apparent
or accidental, but that it really removes an essential part of  the
disease.   W. S., a robust lad aged 15, came into the  hospital
September 5,  1860,  with hot skin, rigors,  excessive muscular
languor, pain in the back, limbs, and head of four days' duration,
gurgling in the right iliac fossa, and rose spots.  For the first
twenty-four hours he had no medicine, and  the urine was kept
and analyzed.   The  result  exhibited the following quantities of
its various constituents daily  excreted:—
                                           Grammes.
	Date.	£& a	° hi « 2>	0}	!2	o .	3-d	p-'S
		a a.5	« to	P		•a'	2r* a	i<
		a S				O		Ph
Sept. 6,	1860. . . .	1000	1-027	50-63	•43	•23	3-48	3-24.
Then an emetic  was administered, and  coincident writh  a uni-
versal  remission  of  all the symptoms, the  urine exhibited  the
  * Mr Catlin, of American-Indian celebrity, attributes the comparative freedom
of his wild friends from malarious influences to their being taught as infants to
sleep  with their mouths shut, and to their being prevented by etiquette  in after-
life from ever opening them, except for eating or speaking. 
TYPH-FEVER.
103
following  remarkable  change in the amount passed  during the
next five periods of twenty-four hours:—
Grammes.
Date.
Sept. 7......
Sept. 8 and 9 ; mean of
 two days' urine mixed
Sept. 10.....
Sept. 11.....
a i = 3.5 fa at S
530 770 1200 1320
1-028  29-37

1-016  14-79
1-011  18-42
1-006  1671
	^		..
	o •		
		5-d	■5 "2 1
P	"Is		I" 3 s i
a trace	0-79	1-97 |	114
0-037	2-68	1-008	0-72 i
0-090	4-20	1-34	0-32 !
a trace	4-62	0-96	0-71 '
  Now, the contrast betAveen these specimens of urine is exactly
that Avhich is found between the urine during typh-fever and the
urine during convalescence.   In the first there is evidence of
destructive metamorphosis going on with extreme  rapidity; in
the latter the  destruction is overtopped  by renewal.   And  this
change into convalescence was most strikingly marked as  due to
the operation of the emetic.  When we see so often the  imme-
diate consequence of one dose of so simple a remedy, it is difficult
to avDid the conclusion that its benefit is purely mechanical, and
that it acts  by removing from the  mucous membrane  of the
stomach a poison only partially absorbed and still adherent to it.
Another reason for guessing  that the gastric mucous  membrane
is an early if  not  the earliest recipient,  is that  it^early exhibits
such  special phenomena  as usually accompany the ingestion of
an unwholesome material.   Spontaneous vomiting is Aery  gener-
ally found in the first stage of  the attack (as  you have observed
in the patient under consideration),  and seems to offer  a  pre-
sumption that the part which is then most feeling  the effects of
the  poison  is  that  organ Avhich most  resents it—the  gastric
mucous membrane.   Such is the evidence  by Avhich I  have been
led to believe that the exciting cause of typh-fever enters usually
by  the digestive canal—valeat  quantum.
   When the. poison  has once gained admission and is diffused by
means of the circulation through the  system, its effect is to
4 
104
TYPH-FEVER.
destroy the vitality of a considerable amount of the organic living
matter with Avhich it comes in contact. The destruction is inter-
stitial, not local—I mean, it does not  kill wholly a certain  spot
which  it touches, like sulphuric acid, but  it kills only certain
constituents of the tissues.   The destruction is also  partial, not
entire—the organic matter is by no means utterly disorganized,
but only brought down to a less vital, less organic condition.  It
may be traced easiest in the changes found in  the medium by
which  it is diffused.   The blood, the common thoroughfare for
distribution of good and evil to the  tissues, is seriously changed.
If you  examine it under the microscope you will find that the
normally-shaped red disks are diminished in numbers as compared
with Avhat pathologists call  " melanosed" corpuscles, that is  to
say, dying or  dead disks, shriveled and small, of a dark color,
with black specks in them, and with giraped edges. In bad cases
these are unable to  range themselves in  rolls, as healthy blood
does Avhen it coagulates ;  they seem  to have scarce  any attraction
for one another and lie in amorphous heaps. They  dissolve easily
in the  serum and form with  it a red fluid.   You may trace  this
dissolution in the dusky  stain which the  blood communicates  to
the skin in typh-fever.
   The poisoning apparently  goes  on very gradually in some
cases, and quicker in others.  You heard from this boy that he
was  five  weeks ailing before he  gave  up work.   There was an
imperfect renewal of the body, sIioavii by languor  after exertion
and  by loss of appetite  or deficient demand for  new material.
But  destructive assimilation was  not checked, there was no im-
pediment to the carrying off of the effete tissues by excretion.  It
may be that in a great many cases the disease, the partial death,
stops here, the destroyed tissues and their destroyer together are
disorganized,  and reduced to  their elements and pass away.
The idea is  incapable of proof, but it would account for a  vast
number of those mysterious languors, unclassified,  unnamed, and
often unpitied, which distress patients and puzzle  doctors.
   It is a characteristic of this sort of virus to poison mainly the
nervous system.  The fevers  it produces get their  name from
thence—ri^og = a smoke or  mist  overclouding the instrument  of 
TYPH-FEVER.
105
connection between body and mind. In no other diseases of equal
curability is it so much affected.   When therefore the  poisoning
has reached a certain pitch, and that not a very high pitch, early
in the disease, the nervous system takes notice thereof, and ex-
presses itself in its most common mode of taking notice of  partial
death, namely, by  a shivering fit.   Any severe  injury  to  the
body, a stretching  of fibrous tissues, an operation, the fear of
an opinion, the absorption of destructive drugs, such as antimony
for example, will cause more or less of a rigor in proportion to
the sensitiveness of the individual.   And thus  also in zymotic
fevers, when the intestinal death of the neutral  constituents of
the body arrives at a certain degree, there follows a rigor. This
rigor recurs from time to time at uncertain intervals, but  gen-
erally about once a day, and most commonly in the evening, as
the mother remarked in the case which forms  the text  of my
lecture.
   Then  commences  another  symptom of partial  death—pain.
This boy described his head, his limbs, and his back as aching all
at once.   That is to say, wherever there was most tissue  with
sensitive  nerves  in  it,  there was found pain,  indicating  the
diseased state of that tissue.   Now this aching is a symptom of
the earlier, rather  than  of the more  advanced  stages of typh-
feArer;  not because there is in the latter less death, but because
then the nervous system  becomes partially dead too, and  does
not feel so acutely; while  in the former it  retains most of its
normal sensibility.
   Observe that our patient tells us of nausea and loss of appetite,
which diminished the food  eaten—of vomiting,  which rejected
the greater part of that  diminished food—and of diarrhoea,
which carried off the remainder scarce digested at all.   Yet in
spite of all, the amount of solid matter passed from the kidneys
is fair ;  the specific gravity of the fifteen ounces of urine  passed
in the twenty-four  hours is L020, Avhich is a good deal for  a
person not in strong  health.  The metamorphosis, therefore, of
the worn-out tissues into urea and salts is active ; there is a  con-
tinuous  destruction  of them in spite of the defective supply.
This goes on so long  as the poison lasts in the body;  but when
       8 
106
TYPH-FEVER.
 it is got rid of, the destruction ceases; no more of the tissue is
 metamorphosed than is required to make  room for new material,
 and the specific gravity of the urine falls during convalescence.
 This may take place very suddenly, as in  the instance I gave you
 of a fever cut short by an emetic;  but in general the  alteration
 is more gradual.
   I have mentioned the large amount of urea, in  proportion to
 the  nutrition, contained in  the  urine  of typh-fever, which is
 rendered evident by its high specific gravity.   There is also an
 increase very evident to the naked eye  in another constituent of
 some importance, the colored organic  material, which gives the
 secretion its ordinary hue.  You saAV how dark this boy's water
 was, and how  deeply it  stained the vessel  from which I poured it
 on a piece of Avhite linen.  We have great reason  to think that
 there is a close alliance between this substance and whatever it
 is which gives the red tint to the blood-disks, and that its excess
 depends on excessive destruction of those important little living
 particles.
   The  sulphuric  and  phosphoric acids  combined  with bases,
 which form a necessary part of urine, do not  in fevers follow the
lead of the urea;  their amount is less than in health.  Whether
 this is due to the  destructive metamorphosis taking less effect on
 the chief tissues containing sulphur and phosphorus, than it does
 on the blood and  muscles, is doubtful.   Dr. Parkes suggests that
perhaps a third of  the normal  sulphates and phosphates of the
urine are derived directly from the food, and not from.the meta-
 morphosis of tissue ; and therefore that their diminution in typh-
fever may be  owing to the starvation, while the amount which
still remains represents a fair proportion of destruction.*
  The  chlorine, in the shape of chloride of sodium,  is  also  in
small quantity, but not so deficient as to lead us to suppose that
the metamorphosis of the chlorinated materials of the body does
not go on, or that there is  retention of  them in the fluids.  The
 great quantity of chloride of sodium taken as food, and directly
mixing with all the fluids, again brings in difficulty.  And another
is thrown in our way by the frequency of intercurrent pneumonia,
            * Parkes " On the Urine," B. ii, part iii, sect. 4. 
                        TYPH-FEVER.                    107

which itself causes a retention of the chlorides naturally excreted
from the kidneys.  This youth, for example, has a little pneumonia,
and we could not, therefore, say if absence of chlorides in his
case were due  to that inflammation or to typh-fever.   In other
cases our impediments to knowledge are diarrhoea or colliquative
sweating, which carry off chloride of sodium.
   The diarrhoea so frequent a companion of continued fever is a
further evidence of death in the blood. Let the fluid fever stools
be set aside in a tall glass, and you will see them shortly sepa-
rate into two parts ; the higher one a half-transparent serum, in
which float epithelial scales and crystals of ammonio-magnesian
phosphate ;  the lower stratum  a greenish-black flocculent pre-
cipitate. This last has no smell of bile, nor  is bile to be found in
it by chemical  tests ; but it contains broken-up blood-disks and a
great quantity of  dark, granular coloring matter—it is just like
blood  altered by the secretions of the bowels.  And very often
when you let the stools separate in  this Avay, and  look  at them
by transmitted light, you will see a visible  sanguineous  tinge in
them, and  blood mixed  with mucus is visibly passed  from  the
bowels.  Blood, too, is not  unfrequently spat up with the mucus
from the lungs, and drips from the nose;  and in bad cases the
dried-up mucous membrane  of the mouth cracks, and exudes the
sanguineous serum on the surface of the tongue, producing  the
" dry, brown tongue"  characteristic of severe  fever.  All these
prominent symptoms call your attention to the  interstitial death,
the lessened life of the body.
  The increased heat in  fever is to the careless observer rather
adverse to the  doctrine which I have  advanced, that all disease
is an evidence of diminished vitality.   And in truth it  requires
some thought to see why it is not a conclusive objection.  But
an answer to the  idea of an augmentation of heat  being neces-
sarily an augmentation of life is afforded by the  fact of many
recorded instances of the increase of corporeal Avarmth having
taken place in corpses actually after  full  death;  so  that, dis-
carding at once thenotion of its being a proof of vitality, we may
try  and trace what  causes, really rather to be associated with
death, may give rise to it in the cases under our eye. In  the first 
108                     TYPH-FEVER.
       •
place, in fever you have a diminution of the evaporation which
takes place from a healthy skin, and which acts as a powerful
refrigerator, as  any physiologist who has  perspired knows full
well.  The dormant dry skin does not do its cooling office. Then
in the second place, there is a much larger quantity of dead
matter to be evacuated, and the  destructive  metamorphosis of
this dead matter, the semi-vital chemical destruction, raises the
temperature,  as  all chemical solutions do.   Wherever  metamor-
phosis is rapid,  the  temperature is raised.  But this  metamor-
phosis alone,  this passage of living into inorganic matter, cannot
be called an increase of life, inasmuch as it indicates an advance
of death. It i3 necessary, may be, to the removal from the body
of poisoned ingredients, and is so far an advantage, but still it is
an indication of the quantity that is poisoned.
   Such are some of the most prominent consequences of the typh
poison in the human body.
   You may call to mind, very likely, warnings I have given you
against  the  old humoral  pathologist's doctrine  of a materies
morbi, which was looked upon as the disease, and which he thought
he has  done his duty  by endeavoring  to eliminate.   " Surely,"
you will say, " this which you have been  describing  is a most
typical materies morbi;  if I eAracuate  this, I cure the disease."
Not so fast—the  bullet which  enters the  soldier's ribs is a ma-
 teries morbi,—have  you cured  the   disease  when  you have
 extracted  it ?   Nay,  more—suppose  the bullet  passed right
through the chest  and went out on the  other side, would you
 consider the disease  gone ?   No, the typh poison is  not  the
 disease, any more than a bullet, or sulphuric  acid, or opium is a
 disease, though each  may be a material cause of disease.  The
 partial death Avhich these agents cause is the disease—is that
 which requires  to  be treated, and must be  the  chief point for the
 physician's consideration.
   Here let us  bring our  doctrines to their touchstone—bedside
 application.   The physician should ask himself, what vitality is
 wanting, and Avhere ?   And, how shall I easiest supply it ?
   In the first place,  if  he sees the case  early, almost the only
 thing he notices is the lowered vitality of the stomach—how badly 
           \            TYPH-FEVER.                    109

it digests its food, and how it loathes its usual work.  He con-
jectures  that  its function  is arrested by the  presence of some
poison, and he empties it with an emetic. In many cases brought
under treatment early in the disease, this cuts it short at once,
as I told you  in a former part of the lecture, and as you  have
occasional  opportunities of observing in  the wards.
   Secondly, supposing he is too late for his coup de main, he re-
marks that the skin is hot and dry, in a great measure from
deficient perspiration and evaporation on the surface of the body.
He undertakes to supply this want by an artificial moisture. He
sponges  the whole person over three or  four  times a day with
tepid water, to which the  nurses here  generally add some dis-
tilled vinegar to make it more agreeable.  The relief  given  is
most sensible  and immediate ; but of course it soon passes away,
as changes of temperature  are in their very nature temporary.
It must therefore be frequently repeated.
   Cold affusion is sometimes  spoken of, both by opponents and
advocates, as  " checking" or " arresting" the febrile heat. This is
apt to give you a wrong notion.  If it really arrested  the meta-
morphosis which is the cause of that heat, it would be obnoxious
to all that could be  said against it.  But in fact it no more " ar-
rests" or " checks" the heat than emptying the bladder " arrests"
the secretion  of urine.   A few moments' thought will show you
that what  it does is  to remove the heat from the external surface;
and if it affects the cause of heat at all, it would rather encourage
it by making  room for more.
   If the attendants have sufficient leisure to attend to an opera-
 tion which consumes a good deal of time, it adds very much to
the comfort derived from the sponging to anoint the body with
 some  softly scented olive  oil.  This supplies  the place of the
 arrested sebaceous follicles, and softens the skin for the absorp-
 tion and exhalation of water.  It is a mistake to suppose that oil
 and water are at all inconsistent or incapable of mixing in the
 substance  of living tissues.
   Where there is pneumonia in fever,  or where the patient has
 recently had  acute rheumatism, I confess I am somewhat cautious
 about the  employment of aqueous  affusion.  It sometimes chills 
no
TYPH-FEVER.
 the chest and causes an attack of pleurisy on the inflamed side,
 or pericarditis.  Besides  which, in the  case  of pneumonia, it
 interferes with  a plan I have of keeping a large poultice outside
 the affected part, and which I find so beneficial that I do not like
 to omit it.   For this reason sponging was not ordered for the
 present patient.
    Thirdly, the  physician sees that a large supply of nitrogenous
 material must be wanting.   The nitrogenous  tissues are devital-
 ized, are running away in a disproportionate excretion of urea
 and other organic compounds, and nothing is  taking their place.
 Shall he act antagonistically, and give some drug whose tendency
 is to stop the passage of urea by the kidneys ?  I do not knoAV
 exactly how he would set  about it; but I do  know  that if he
 succeeded, he would  do positive harm ; for the very Avorst cases
 of fever are those in which metamorphosis is active (as shown by
 the heat), while the excretion of urea is arrested (as  shown by
 the lightness of  the urine); they resemble cases of uraemic poison-
 ing from diseased kidneys.  The other principles of  treatment
 which I noticed in  my introductory lecture of this session* would
 not perhaps be  so directly  injurious, but common  sense would
 still allot the palm  to restoration here. Let it be your chief aim
 to supply that which you clearly see is passing away—nitrogenous
 tissue.
   But how Avill  you supply it ?  Solid food would  in  all proba-
 bility be vomited, from the unbearable loathing it excites. If not
 vomited, it would lie for some time a mere foreign matter outside
 the mucous membrane of the digestive canal, and then  pass away
 by diarrhoea, with much flatus and  fetor  and much disengage-
 ment of gas during  putrefaction.  Your beef-steak might as well
 have been originally thrown  down its final destination,  the water-
 closet ;  to which it passes putrid though undigested.   Neither is
 it  wise to fill the stomach Avith large quantities of victuals, for the
 same result  follows. .No «|meals" must, therefore, be allowed;
 and prudence suggests the giving in their place very small doses
 of nitrogenous aliment very frequently.   These pass  over the
irritated stomach unconsciously, aid are taken up gradually by
             * Referring to Lecture I of the former edition. 
TYPH-FEVER.
Ill
the intestines, requiring but very little to make them fit for  ab-
sorption.  The suitablest food is that which is naturally supplied
to the weakest stomach.  The feeble digestive organs of babies
can assimilate milk, and milk forms the most appropriate nourish-
ment for the debilitated viscera of the fever patient.  By giving
two or three ounces every hour you may get down a quart and a
half per diem.   But in ordinary instances, every two  hours is
often enough, and that period is adopted for the boy before  us.
If there is sufficient acid left  in the stomach to  coagulate  the
casein into clots, and cheesy lumps are rejected by vomiting, as
happens sometimes in milder cases, you may guard against  this
by adding liquor calcis  or soda-water to the milk, or  you may
supply its place by beef-tea. But it is the lumping of the cheese
into solid masses that it is desirable to avoid, not the acidifica-
tion, which is beneficial. If the patient takes thus a good supply
of milk and beef-tea, not only is the imminent danger of death
by starvation  aAroided, but the emaciation which follows  during
convalescence is much less extreme, and the dangers in its wake
less formidable.
  Eggs are a highly nutritious food ;  if  taken  raw, and diluted
with milk or water, they are quickly absorbed. But should they
be delayed and putrefy, the products of their decomposition  are
peculiarly injurious :  the sulphuretted hydrogen and  ammonia
evolved are poisons to the intestines.   I  should recommend  you
to avoid eggs till convalescence has restored  the gastric powers.
The  same .objection does not lie  against milk, the lactic acid
arising from whose decomposition assists in the solution of  the
casein.   Sour buttermilk is by no means to be despised as a
food.
  Fourthly, the physician should turn  his attention to the phar-
macopoeia,  and consider what he can cull from thence which will
be of service.
  You have  been taught in  the systematic course on medical
pathology, that ammonia, which is always being formed and given
off from the animal body, is found much more abundant in certain
conditions than in others, and that these conditions are those in
which nutritive metamorphosis or groAVth Avas deficient as com- 
112
TYPH-FEVER.
pared with destructive metamorphosis, or those in which there is
retention in the blood of the products of that destructive meta-
morphosis.  Thus, more ammonia is found in  the breath after
toil than after  rest; more than  usual in  those who hurt their
digestion by smoking tobacco; a great deal in uraemia, where the
urea cannot escape  by the kidneys;  but above  all in typh-fever
is  this exhalation of decay noticeable, as  you Avill  find in Dr.
Richardson's valuable  work  on the  coagulation  of  the blood,*
where the phrase "super-alkalinity of  the blood" is applied  to
this condition. Dr. Richardson goes so far  as to attribute to this
super-alkalinity the special  typhoid symptoms, and  to suggest
that the absorption  of ammonia in excess may intensify fever  in
those who contract it from exposure to decaying organic matter,
or human exhalations.   He supports his hypothesis on the ex-
periment  of inducing  the symptoms, or  something  resembling
them, by the injection of  ammonia into  the veins of an animal.
The word "super-alkalinity" is expressive, and quite unobjection-
able, so long as it is understood that the superabundance is not
absolute, but comparative. For it  is not shown that there is more
alkali in the body than  there ought to be, but more than there is
acid to neutralize. " Sub-acidity" would be a synonymous term,
and would be more  suggestive of  the means we have at our dis-
posal for remedying the defect.
   Very difficult indeed  would it be for the  eliminator to get this
alkali out, but it is  easy for the restoratist to get acid in.   The
acid I have always given is hydrochloric, and you consequently
see on  this lad's card—" Tfy. Acidi hydrochlorici diluti  fi^xx.
syrupi 3j«, aquse  Jj. alternd qudque hord sumat."
   Rich patients like a  little more sugar, but I  have not found
them approve of the syrup  of mulberries and barley water, in
which more elegant vehicle the  late  Dr.  Maton used to  give
muriatic acid in fever.   They say  this is mawkish, and prefer the
cheaper form, even on  the score  of  taste.   But it is still more
approved of for its beneficial effects. This  boy said to-day of his
own accord, he hoped I should continue the draughts, they made
  * Richardson on the "Cause of the coagulation  of the blood," Appendix I.
(Edit. 1858.) 
TYPH-FEVER.
113
him " feel so much stronger," meaning to express a sensation of
relief to the wearisome languor of fever. In mild cases the tongue
begins to clean immediately, the thirst and diarrhoea much abate,
and the repugnance to food is diminished.
  In a clinical lecture at this hospital in January, 1858,* I gave
the details of the first dozen  cases treated  on this plan, and as
you are a different audience from that which heard me at  that
time,  perhaps I may be allowed to repeat the sentences in which
I then tried to interpret the  beneficial consequences :—" What
blood, when analyzed, comes nearest in its altered proportions
to the blood in low fever ?  Is it not that of scurvy and purpura ?
There is the same excess of blackened (melanos'ed) blood-disks,
the same deficiency of neutral salts and organizable (coagulable)
lymph.  Everybody treats these  chronic affections with acids,
and Avhy not also an acute  affection which corresponds with them
in one point at any rate ?   As to the  particular acid employed,
muriatic  certainly deserves  to  be tried before  others—first,
because it is such a large  constituent of the body that it might
almost be  called a food instead of a medicine;  and secondly,
because it is such a powerful arrester  of the  decomposition of
animal  matters.   Pour it  into  a sewer, and you destroy  the
miasma.  May it  not in the body stop that miasma from poison-
ing the tissues?"
   The allusion in the last sentence is to chlorine as a disinfectant.
But I now doubt if there is sufficient  evidence of  the benefit
derived from the hydrochloric acid being due to this property.
About sixteen  years ago, I employed  chlorine water as a medi-
cine in fever at the  Chelsea Dispensary; yet I was  not en-
couraged to carry on the treatment by tracing any benefit to it.
Whether the chlorine which can be introduced in this way is not
sufficient  in amount (for  it must be very dilute, or else it  will
induce choking), or whether it is  really useless, I do not know;
but the inconvenience caused  me to leave off its employment.
   Dr. Pereira in his " Materia Medica" speaks slightingly of the
use of hydrochloric acid in putrid fevers, and implies that it rests
  * Printed in the -'Lancet," January 30 and  February 6, 1858, and partly re-
printed in the next lecture but one. 
114
TYPH-FEVER.
   solely on exploded theoretical propositions.   He  should have
   noticed that Boerhaave and Van Swieten recommend it, and that
   Sydenham  used sulphuric acid in these forms of disease as an
   antiseptic drug.  And these were men not easily led into erroneous
   practice by a prevalent theory.   To their experience I can add
   my testimony, for I have employed the plan aboAre  described in
   every case of typh-fever since the  summer of 1857, and have had
   yearly more and more reason to speak well of it.*
     Dr. Pereira, in afterward  speaking of its use in dyspepsia,
   gives as a reason for its employment therein,  that first, "it is a
   constituent of the healthy gastric juice; and, secondly, when
   mixed with mucus, it has  a solvent or digestive power in the case
   of various articles of diet."   Is not this as much  a  reason  for
   giving it in acute cases as in chronic ?
     Whether, then, as Sydenham seems to have thought, any other
   acid Avould do as well as the  hydrochloric, I cannot say, but it
   forms so large a constituent of the body combined with alkali in
   the blood  and tissues,  and free in the solvent juices, that it
   appears  peculiarly suited to  the  purpose on  restorative prin-
   ciples.
     As to the use of alcohol in fevers, I am guided almost entirely
   by the condition of the nervous system.   If there  is very com-
•  plete prostration and delirium of a low muttering character, it is
   required.  A tremulous state of the muscles, marked  especially
   by a  quivering of the hands  and  fingers, is  a good test  of the
   necessity for it;  and so is the  sharp, weak, unequal beat of the
   heart. All these indicate  that the  nervous system is feeling very
   sensitively the destructive metamorphosis going on, and has  its
   power lowered by its sensitiveness.  Then is the opportunity for
   the powerful  anaesthetic  alcohol, which in severe cases you see
   me order without scruple,  but which I do not rank as part of the
   necessary methodus medendi of fever, and have not yet ordered
   for the lad we have  been prescribing for.  Above  all, I Avould
   caution you against employing it  as a  substitute for the  treat-
   ment which I have been describing.  Wine may be  useful as  an
   adjunct, but never must it take the place of the true  restoratives.
    * This yearly growing experience is put iuto numbers in a subsequent lecture. 
TYPH-FEVER.
115
   There is, though, another of the exceptional methods of treat-
 ment, which has  been employed with utility in this case—the
 local abstraction of blood.   The boy had congestive pneumonia
 of the lower part of one.lung, and I did not hesitate to cup him
 beneath the scapula on that side.   And  not unfrequently when
 there is pain in the right iliac fossa, with diarrhoea and tenesmus,
 I put leeches on the belly at the seat of pain.   You watched the
 dullness of percussion rapidly pass  away from the  lower  lobe in
 our patient here ; and you will often see an  equal relief to the
 abdominal congestion by the same agency.
   But  you will cry out that I am sadly  inconsistent.   I am
 feeding up the patient with one  hand and taking his pabulum
 vitas Avith another.  The reproach is just in a certain sense, but
 that  a very limited  one;  and, in  fact, may.be leveled  against
 half the operations of daily life.   We are constantly suffering a
 small loss for the  sake of a greater gain.   And I think the loss
 of a little blood is practically of no moment  at all compared with
 the advantage of  securing a freer circulation  through the lungs
 or a diminution of congestion in the intestinal canal.   Do not be
 led away by the superficial  notion that blood is blood, and blood
 is life.  That is not true, for blood varies immensely in its  com-
 position, some being very  valuable,  and some  worthless.  To
 lose a portion  of  the half-dead circulating  fluid of fever  is but
 little loss, and that  little loss is amply repaid  by the additional
 nutriment which a small blood-letting will enable to be absorbed.
 The deficiency is soon made up again under a restorative  system
 of treatment.
   In the sequelae  of low fevers, more than in any other diseases,
 the great difference between one patient and another as respects
 their power of recovery, lies in their  stomach.   There is a girl
 of four years old now in Victoria Ward, who was  admitted on
 the 2d of September for rose-spotted fever, which had come out
 during the concluding week of August. She passed through the
fever pretty favorably, but for the last seven Aveeks has  had a
succession of most formidable abscesses in the back, the cervical
glands, the internal ears, and the parotid glands;  yet, in spite
of the exhausting  effect of the large discharge of pus from these 
116
TYPH-FEVER.
spots, she has continued advancing in convalescence, she has
gained flesh and muscular power, so that now she  can sit up.
For this happy result she has to thank a most wonderful appetite,
which never seems satisfied,  even with an amount of food which
is large for an adult, and which she delights to wash down with
wine and porter.   No tonics  seem of so much Use to her as an
extra snack at physic time.
  The most striking recovery from these pyaemic abscesses after
fever you witnessed last year in a girl of sixteen (E. A., admitted
September 28, 1860).  She had very putrid fever, accompanied
by  haemoptysis, epistaxis, and bloody discharge per vaginam.
She got well of her fever by the help of hydrochloric acid and
wine.  But as she became convalescent in the third week of Oc-
tober, she began to have large boils  in the head; these were
followed by abscesses running on into  sloughing sores on the
back.  During the first week in November inflammation and
swelling of the left leg began, This  quickly passed into purulent
infiltration of the whole of  the left  thigh, an opening in which
on  November 28  discharged  two pints of pus in  twenty-four
hours, and smaller quantities daily for several successive weeks.
On December 12, there  was  a large abscess in the axilla, which
was lanced and discharged several ounces.  Her state of debility
was such that she could  not in the least help to feed herself. Yet
all this time her stomach was in a state that a glutton would look
up to as a  seventh heaven.   She Avas literally always  hungry.
As she swallowed her last bit of beef-steak  she  would  feebly ask
when she was to have some  more,  and what would  be her next
meal; and the way her eager eyes  followed any  article of food
that passed her bed was quite affecting. We allowed her wolfish
appetite its full liberty, and fed the puny  maid like  a  gigantic
gladiator.   The end of  the tale is,  that she recovered from an
amount of purulent disease which it would  have  seemed impos-
sible for the human frame to bear—and recovered perfectly, for
I saw her in the April of the next  year, looking as  healthy and
walking as briskly as if she had never been ill.
   The moral of these cases is to do all  you can to increase  the
appetite, and strengthen the  digestive powers. Reckon the value 
                        TYPH-FEVER.                    117

of this drug and that drug, one tonic and another tonic, solely
by the effect they have on the desire for food.   If any remedy
lessen this desire, insist upon leaving it off, whatever  authorities
may have recommended it; and form your judgment,  not from
tradition or prescription,  but from its effect in the particular case
before you.
f 
LECTURE  VII.*
                     TYPH-FEVER.

                 Therapeutical Statistics.

          (Clinical, St. Marys,  October 17, 1863.)

   I have often  spoken with confidence of the advantage of the
treatment you see me pursue in fever, and I am going to-day to
lay before you the reasons Avhy this confidence has Been growing
yearly stronger  and stronger.
   Since the opening of the hospital in the summer of 1851, to the
time of my  leaving London  for the vacation last August, there
have been registered as under my care 230 examples of continued
fever.   Of these, 109 have been treated on what may be termed
"general principles;"  that  is  to  say, they took neutral salines
three or four times a day, with small doses  once or  twice a day
of hydrargyrum  cum creta at first, and later in the disease, bark,
ammonia,  ether,  and wine, when these remedies seemed required
by the symptoms.   Leeches and  cupping Avere  employed to the
exterior of inflamed viscera  as occasion called, and food was ad-
ministered at the ordinary four daily meal-times.  The other 121
have been treated on a,n uniform  plan of continuous nutrition;
animal food, in a liquid form,  has been given every two  hours,
day and night, while the patients Avere awake, and between every
dose of nutriment a dose of hydrochloric acid.  They have been
sponged tAvo or three times daily with  tepid water, when the skin
was hot and dry; and, in a few instances, leeches  or  cupping
have been used to the exterior of inflamed localities in the abdo-
men or chest.
  * The substance of this lecture  was brought before the Medico-Chirurgical
Society in April, but a few additional cases have altered the figures a little. 
                         'TYPH-FEVER.                     119

   Those two classes of patients offer a fair basis for a statistical
comparison of the therapeutical agencies brought into play : it is
fair for the following reasons:
   1.  In the first place, each series is very nearly continuous ; all
the first-named  109 (with five purely accidental exceptions*),
occurred in the six years  before  September, 1857,  and all the
latter 121  in the  six years since.   No  fallacy can, therefore,
arise  from a selection for  special treatment having been made
intentionally or unintentionally.
   2.  They are spread  over a  considerable number  of years;
thus both sets  include sporadic cases, as well as the produce of
epidemics.
   3.  They were all treated by the same  physician in  the same
wards of a general hospital (where  the  cases  are usually more
severe than in  special fever hospitals), and they nearly all come
from  the same group of districts of which  our hospital is the
center.
   4.  The  diagnoses have  been made and the  records kept by
registrars  who have nothing to do with  the  treatment, and are
independent of the physician in attendance.
   The only opening for error that I can  discern is the bare pos-
sibility of a change of type in fevers having taken place at the
very  time when I changed the treatment,  and of its having lasted
for six years—possibilities which the records of other metropoli-
tan hospitals during the same period reduce to nothing.
   That the severity of the disease in the  two classes differed but
little, may  be sIioavii by  the near equality of the periods of  con-
valescence.  The mean  time of stay in the  hospital of the sick
who recovered was, in the first  series, 29-2 days ; in the second,
26-7  days; being a difference of but 2J  days.   The  ages,  also,
of the two series differed but little, the mean age of each being
between 22 and 23 years.
  * Three of these exceptions were treated on general principles by a colleague
taking my duty during my absence, and unaware of the experiment I was trying ;
in  one case I made  a  wrong diagnosis, having mistaken  typh-fever for  acute
hydrocephalus, and treated it with iodide of potassium till too late; of the fifth
I have no record, the patient having died within two days, and the clerk's notes
being imperfect, except as to the fact of its being a case of fever. 
I
120                     TYPH-FEVER."

  These averages are cited merely to show the general similarity
of the two series, and not to  demonstrate any pathological fact.
  Of the first series (viz., those treated on  general principles),
        9 are entered as Typhus, and of these there died   4
       44       "        Typhoid       "       "       16
       56       "        Of doubtful or unrecorded type  3

Total 109                                       Total  23
  Of the second series :
       25 are entered as Typhus, and of these there died   0
       52       "        Typhoid      "       "         2
       44       "        Of doubtful or unrecorded type   2

Total 121                                              4
  For purposes of comparison in a therapeutical inquiry, it will
probably be considered  right to exclude from  the first table two
deaths, and from the second table one death,  which occurred
within two days of admission ; for the exhaustion caused by the
journey to the hospital in severe fevers allows but little scope for
judging of the  action of treatment during that  period.  This
leaATes the average mortality under general treatment 21 in 107
=19J per cent., or nearly 1 in 5 ;* under the second method of
treatment, by continuous nutriment and hydrochloric acid, 3 in
121 = 2| per cent., or only 1 in 40.
  I  cannot, therefore, avoid the conclusion that the  means em-
ployed in the cases on the second  list are very efficient  in pre-
serving life ; and that out of every 100 persons attacked by con-
tinued fever, from 16 to 17  more  may be saved thus than by
treating them on general principles.
  The continuous liquid nutriment given every two  hours con-
sisted of strong beef-tea and milk,  of  which  together about  six
pints were administered in the twenty-four  hours.  The  hydro-
chloric acid was given every two hours in doses of twenty minims
of the Pharmacopoeal dilute acid in water or eau  sucre^.  Both
food and drugs were seen by the nurses to be swallowed,  and not

  * This mortality is higher than is usual  at special fever hospitals, being about
the same as at the other general hospitals in London. 
TYPH-FEVER.
121
left to the discretion of patients, who, from nausea and occasional
delirium, cannot be trusted to help themselves.
   The most immediate result  of  the  hydrochloric acid is the
more natural condition of the  digestive  mucous membrane, as
shown at its two extremities, by the cleaning of the  tongue at
the one end and the cessation of diarrhoea at the other.   The
more natural condition  of the mucous membrane enables the
greatest possible quantity of nutriment to be  absorbed to  take
the place of the tissues poisoned and interstitially destroyed by
the virus which  is  the cause of the fever.  That the acid in any
chemical way neutralizes, counteracts, or evacuates the virus is,
I think, unlikely.  For the mean period of convalescence in these
cases was  shortened by only 2^  days; and certainly it would
have been  shortened more than that were the  virus removed or
rendered inert.   That the convalescence is not more shortened,
cannot of course be judged of in individual cases, and I state the
fact from the statistics of the average stay of the  patients in
hospital, which  I before quoted.
   Whether the  hydrochloric acid would be equally useful in all
climates, I  cannot say; but in Shanghai, a climate as different
is possible from England, Dr. Henderson* states that its employ-
ment diminished the mortality of continued fever from 28 per
cent, to 7 per cent., a very marked decrease.
   The action of wine and of emetics in continued fevers is not
attempted to be tested in  this inquiry.   In both classes of cases
they  Avere  given;  the wine,  as usual, in accordance  with the
patient's age and the condition of the nervous system, and emetics
whenever the history we could  elicit made us conjecture that the
fever was in its  first week. My impression is that a vomit, when
given within the first four days, materially lessened the severity
of  the fever;  and  in some  instances  seemed  to cut  it short.
But I do not know how to obtain numerical evidence on the sub-
ject.   I have never found an emetic do harm, unless  there were
antimony in it, when it sometimes caused or increased diarrhoea,
and failed of the intended purpose. For this reason I prefer plain
ipecacuanha.
                 * "Medical Times," March 21, 1863.
       9 
LECTURE  VIII.
                      TYPH-FEVER.

Cases with running commentary—Relapse  of rose-spots—Con-
     tagion from patients to a  nurse—Leeches  and mercury—
     Mulberry-rash—Intermittent pulse—Rose-spots or mulberry-
     spots, which most dangerous ?— Wine in fevers—Retarded
     emaciation—Subcuticular  eruption— Contagion—Artificial
     cuticle in bed-sores—Sudamina—Low  condition in conva-
     lescence, its symptoms.

  [It may be remarked that the date attached to the ensuing matter is earlier by
more than five years than  that which precedes it here.  The cases  are taken
from the latter half of a clinical lecture published in the " Lancet" of February
6, 1858, where, after nine others in which general  treatment was employed, are
detailed the particulars of the first twelve instances of the use of the method
described a few pages back.  It was not  therefore  necessary again to allude to
these patients, nor  to the  fact of their having passed favoraBly through the
attack.   But some of them illustrating points of pathological interest, and some
of them, besides the  common treatment of the disease, having required that which
was specially suited to each case, they are here reproduced.]

           (Clinical, St.  Marys,  January 20, 1858.)

   Case  10.—William W.   (Case Book  103, p. 52.)  This was
the deputy coachman from  the  infected house  I  spoke of  in
Case 8.   He had equal muscular prostration but not nearly so
much  mental affection as the housemaid.   On the skin there were
rosy spots,  coming  out slowly  and in consecutive  crops.  One
peculiarity in this case is, that during convalescence, when walk-
ing about and eating meat, he had  a  relapse, and the rosy  spots 
TYPH-FEVER.
123
came out again, with delirium, prostration, &c, nearly as bad as
at first.  It is very rare to have a relapse of- rosy petechias, but
you see it is not impossible.
   Case 11.—Mary Ann B.  (C. B. 103, p. 64.) A nurse in the
hospital, had mild delirious fever without any eruption.  I am
afraid we must allow that she caught it  from  the  patients, for
certainly there is no bad  drainage here  to generate it.  There
occurs one case now and  then, to show  you that  low  fever is
contagious, and but one to show you that  it is very slightly so.
   Case 12.—Fanny A.  (C. B. 103, p. 66.)  This girl complained
a good  deal of pain in the right iliac fossa several times recur-
ring, which at last was treated with  leeches and  mercury with
immediate relief.   You may often hesitate about these remedies,
for fear of lowering the patient's  strength by depletion; but if
the pain is made a subject of  complaint, you may  feel safe;  for
the very fact of the sensitiveness of the body shows  that it is not
too low to bear them.  Those who are so  much prostrated  as to
make a few leeches dangerous, are insensible to slight pain, and
do not complain unless pressed.
   Case 13.—Emma B.   (C. B. 103, p. 82.)   I never saw a skin
more  thickly  covered  with a  mulberry-rash than in  this fine
stout brunette of eighteen; yet few have recovered so quickly.
She came in on October  5, having been  ill eight  days, with a
pulse of 120 and great prostration;  on  the 6th, her pulse was
"80,  and intermittent;"  on the 7th, "70,  and intermittent;"
on the 8th, "natural;" after which medicines Avere left off, as she
was convalescent.   I am inclined  to think that the  natural  tend-
ency to deArelop coloring  matter exhibited  in  the  skin  of dark
persons causes them also to develop more freely than others  the
colored eruptions.
   You will read in many old books (and sound books too)  state-
ments to the effect that dark livid  spots in fevers are an eA'idence
of more danger than rosy spots, and  that the danger is greatest
when this dark rash is  most  abundant.  You will haAre ample
opportunities during your student life of seeing that neither of
these rules is applicable to facts as they come before you.  There
are most deaths among the rose-spotted,  and you  will see  many 
124                     TYPH-FEVER.
cases of  unusually  rapid recovery  among those with  a very
copious eruption.  ,Yet for all that I believe the ancients reported
right.   I believe that the difference is made by our more rational
mode of treating our patients—successful in both sorts of cases,
but most especially in  those where the livid rash shows the chief
force of the poison to  have fallen on  the blood.   Without wine,
the most fatal  cases  would be  among the livid-spotted-; with
wine, the most are among the rosy.*
  Emaciation did not commence in  this patient till she was so
far convalescent  as  to be  up and dressed, and then with great
rapidity she  lost flesh.  From the way in which she  withstood
and passed through the disease at  its height, you would  not
have  supposed her  to have  been so  severely ill as she really
was.   But the  quick destruction  of all  the tissues,  and their
necessary renewal before  the full  functions of life can  be  per-
formed, show how profoundly the  typhous poison affects them.
Emaciation may be rather  called part of the cure  than  part
of the disease; it is nature's  mode of getting rid of injured tissue.
   Case 14.—William W.  (C.   B. 103, p. 112.)  Pink spots;
abdominal pain relieved  by leeches;  quite en regie.
   Case 15.—Edward  P.  (C. B. 103, p. 114.)   This robust man
was again one of a set where the fever was traceable to a poison-
ous locality.  You  may remember that he made so much noise
by yelling "Dust-ho!" that he was obliged to be removed to the
noisy ward.   He turned out to be  a  workman  at a neighboring
dust-contractor's, and the foreman of the yard  was brought in  a
few days afterward, in  Dr.  Alderson's week; and  a third dust-
man came from close  by, and will appear as Case 19.   All these
were very muscular men and very noisy.   The first and second
had rosy raised  spots, which were peculiarly distinct and charac-
teristic in Dr. Alderson's patient;  but the third had a livid rash;

   * Let me not be supposed to say that  the use of wine in fever is a modern
 discovery.  All good authorities of all ages allow it in exceptional cases ; but
till the present generation modes of diagnosis have not been accurate enough
to separate entirely idiopathic fever and acute inflammations ; and therefore an
 adherence to Galen's condemnation of wine was really prudent in them as a
rule. 
TYPH-FEVER.
125
and in the first, who is at present under review, there were livid
mixed with rose spots.
  Remark  $e nature  of'  this man's occupation.    Typhous
miasmata are perhaps  generated  more rapidly when  the  sub-
stances whence they arise  are wet, because moisture aids  de-
composition.   But when once  they are produced, there is much
greater danger of their diffusion in poisonous  amount  from  dry
matters.  Workers in sewers sometimes get poisoned by sulphu-
retted hydrogen,  but they do not  catch fever: nor do the men
who cart night-soil into the  country for manure.   Rut when  this
is spread out on the fields,  and exposed to the  sun and air, it
often  causes a limited epidemic.  So too, when drains  are dried
up by the summer heat, the disease is more rife than in seasons
when  they are full.   A  dried marsh, and the banks of tidal rivers
exposed at  low water,  are made  more pestiferous.   So you see
sanitary improvements require judgment as well as zeal.  I be-
lieve  the safest mode of treating dust would be to wet it.
  You  will  observe that hearty people, when they do get  low
fever, generally have it very badly, as was the case here.  I
suppose their system is  able to resist small doses of the poison,
and when it absorbs large  doses they are the more completely
prostrated.   Be careful not  to give a favorable prognosis because
your patient is a strong man:  the muscular and the corpulent are
of all the population those Avho run most risk.
   Case 16.—Caroline  H.   (C. B. 103, p. 214.)  This woman
had great pain on pressing  the abdomen, and fever stools.  So
she ought, by rule, to have exhibited  a rosy rash; but, instead
of that, there wTas a dusky  subcuticular eruption, which is gen-
erally held to be of the mulberry sort.  Van Swieten describes  it
as "lying very deep  under  the skin, as if nature, overpowered
by the  violence of  the  disease, could  not  complete  the critical
translation which  she had begun."*   He considers it a danger-
ous sign, and I think he is right, as a  general rule;  for, though
this Avoman  recovered, she was very ill.
   Case 17.—Charles N.  (C. B. 103,  p. 228.)   This boy, again,
* "Commentaries on Boerhaave," vol. vi, sect. 723. 
126
TYPH-FEVER.
had liA'id  spots  accompanying abdominal complications, which
were relieved by leeches.
  Case 18.—Mary D.  (C. B. 103, p. 228.)  A washerwoman,
who became affected immediately after receiving the dirty linen
from a house Avhere there had been fever patients.  It seems to
me  difficult  to avoid  a  conclusion, that low fever may become
contagious when the poison is concentrated.  It is certainly wise
to act upon this opinion.
  Here again I made you remark the intermittence of the pulse
from debility during fever;  and I also called  your attention to
the natural appearance of the stools during  the height of the
disease, and to their  becoming liquid and fetid as  the  febrile
symptoms declined  and  she began  to emaciate.  A diarrhoea of
such a sort at such  a  time is a very favorable  occurrence ;  it is
a critical discharge of the peccant humors.
  Case 19.—John  G.  (C. B. 103, p. 232.)   This was the third
dustman.   His pulse was also intermittent, as in the three former
cases, but not till he was getting better.   At first it was  not
above 80, though he was very noisily delirious, and had a brown
tongue.  You may observe this abnormal slowness of fever pulses
to be particularly prevalent in certain seasons.    They have been
slower than is quite consistent with the severity  of other symp-
toms this winter.
  Case 20.—Stephen Ft  (C. B. 103, p. 246.)   I hear from Mr.
Sanders, of Chigwell, who attends this boy's  family, that  they
had  fever with  "mulberry-rash" in  the house, and   that  a
brother had died of it.  Stephen was sent to  London to be out
of the way, but sickened on  the day of his arrival, and had rose
spots in several crops.  It is difficult  to imagine the probability
of two brothers contracting  different  miasmatic  diseases in the
same house, at the same time, and from the same cause; and the
rational conclusion  would seem to be, that both were of the same
nature.  It could only be the most overwhelming evidence which
should lead us to think otherwise.
  Stephen was  near  following his  brother  to the grave.  The
more  propitious  hygienic  circumstances  under which he  was
placed,  in  an airy hospital,  instead of an  ill-drained cottage, 
TYPH-FEVER.                    127
weighted the scale in his favor.   I do not see anything fresh to
remark in the pathology of this case, except that the patient got
a superficial sore on the back by obstinately saturating his sheets
with  urine  and faeces, and continuously rubbing the  sacrum
against them.   You must distinguish these superficial sores from
sloughs, because the  same  treatment  will not  prevent them.
They will be produced by friction in spite of a water pillow and
all  possible cleanliness, as in this lad's case.  The best way of
managing them is to paint the parts directly they get  red with
gutta percha softened in chloroform, of the consistence  of paint,
so as to dry immediately on application.  You thus obtain an
artificial new  cuticle, and can renew it as many times  a day as
you like.
  Case 21.—Henry  G.  (C. B. 103, p.  292.)  Instead of colored
petechiae, the  eruption in this very low  case consisted of miliary
vesicles scattered like fine seeds all  over the chest and abdomen.
They are called in  the case-book  "sudamina."   The  word is
derived from their often accompanying excessive perspiration ;*
but remark  that the association is not a necessary one; this man's
skin was quite dry till he became convalescent.
  Case 22. f—John B.  (C. B. 103, p.  106.)   I have taken him
out of chronological  order, because  he  was not treated by mu-
riatic acid.  In fact,  the fever had  passed  away, and  he might
be called convalescent; yet you saw him very ill, unable to raise
himself*in bed, and  with a brown crust in  the center of his
tongue.   On inquiry I found that this  low  condition, remaining
after the special symptoms of the fever had passed away, arose
from  inanition.  Beef-tea, wine,  and bark set him up  directly.
You will see  a good many  such cases in dispensary practice ;
they die, though convalescent, from sheer  starvation.   It is of
some importance to  recognize this fact, and  you will  find  the
most pathognomonic sign is the coincidence of the brown tongue
with  a  perfectly clear mind and cool skin.   These latter show
that the typh poison  has passed away, and that the condition of
the mouth is the result of want of nutriment.
  *  Or perhaps from their likeness to beads of sweat scattered over the skin.
  | The numbers refer to the cases as they stood in the lecture originally pub-
 \shed in the " Lancet" newspaper. 
LECTURE  IX.
                     TYPH-FEVER.

Part I.—Three fatal cases since October, 1861—One brought in
     moribund, one treated with hydrochloric acid, Sec, one not
     —Four  cases in hospital  related, with  comments—Danger
     of giving solid food too early in convalescence—Absence of
     enteric symptoms  best guide to administration of solids—
     Dose of hydrochloric acid for children— Connection of typh-
    fever and pneumonia—Smallpox caught during convalescence
    from typh-fever.
Part II.—Additional case, illustrative of the connection bettveen
     the two forms of typh-fever eruptions—Precautions in case
     of threatened pneumonia—Caution against moving patients
     in fevers.
Part III.—Four additional cases with comments.   Case.  1.—
     Difficulty of distinguishing typhus and enteric fever—Relief
     of enteric pain—Dry, glazed, cracked tongue in enteric eases
     —Arrest  of  diarrhoea by hydrochloric acid,  by  Dover s
     powder,  8?c.   Case 2.—Fever  spots and flea-bites—Fever
     cut short  by an emetic—Emaciation during convalescence
     not prevented by the cutting short of the fever.   Case 3.—
     Fever cut short by an  emetic—When not arrestive, this
     treatment is  palliative.   Case.  4.—Fever contracted in the
     hospital aggravated nearly to a fatal extent by inflammation
     of previously diseased genital organs and bladder, and by a
     slough on the sacrum—Treatment.
Part IV.—Case of typh-fever contracted in the hospital  by  a
     patient admitted for acute rheumatism—Emetic only par-
     tially successful—Administration of solid food and wine.

           (Clinical, St.  Mary's, January 10, 1863.)
   Since October, 1861, when  I  last discoursed to you on  con-
tinued fever, it has been more than usually prevalent  in  both 
                        TYPH-FEVER.                    129

its enteric and typhus forms, especially in the latter form during
the present session.  I have persisted in the employment of the
same treatment I then commended to your notice, and with the
same encouragement to proceed.
  There have been  two  deaths among those so treated.  One
was in  the case of a little boy, age unknown, who was carried
into the ward  December  17, 1861,  quite  unconscious,  cold,
pulseless, with livid lips  and  colliquative diarrhoea.   I scarcely
can tell how much  of the nourishment given him was  swal-
lowed,  and he did not survive the morrow of his entering the
hospital.
  I should have  liked  to know in what state  this  child was
before  he was brought away from home.   It is not at all im-
possible that  he might then have been in a condition admitting
of jecovery;  for children very rarely die of typh-fever, however
severely they may have it.  At all events, it is certain that the
exhaustion of the journey hither was the immediate cause of the
fatal result.   The  patient Avas, to all practical purposes  of
restoration, dead before'he came inside the doors.
  If your future pursuits should place under your charge poor
people  at their own houses, I  do hope that events such as  these
(and they are sadly common) will make an impression upon you.
Pray do not send bad cases of typh-fever out of their beds to  be
dragged in an exhausted state to a hospital.  None of the ad-
vantages to be obtained  there can compensate for the chances
of life so thrown away.
  Another death occurred in  a girl of eighteen.  I was  away
for my holiday at the time of her decease, and no post-mortem
examination of  the body  was  permitted by her friends; nor are
the clerk's  notes very explicit—they seldom are  in vacation
time—but as far as I can judge from the history given me by
the ward-sister, she seems to have yielded to  a  very rapidly
congestive  pneumonia.   I am very sorry to have  no further
information  about  her,  as  nothing is  so  instructive  as the
investigation of the causes of failure of treatment usually suc-
cessful.
  Another case of death  from  the inflamed and ulcerated bowels 
130                    TYPH-FEVER.

which  so  often  accompany typh-fever, occurred in November
last.  But she was  unfortunately not treated  in my usual way,
for a reason which I will take the opportunity of telling you as
a warning, as I  trust the same reason is likely to be rare.  The
patient, Elizabeth T—, was a girl of eleven years old, who was
brought  here October  24, with  intense  headache, deafness,
delirium, vomiting,  picking at  the nose, and other symptoms,
which the mother attributed to a blow on the back of the head.
This led to a wrong diagnosis, and the child was, by my orders?
treated with iodide of potassium, and blisters on the vertex, as
for inflammation of the brain (hydrocephalus acutus).   I was
absent from London at  the time of her death also, but a post-
mortem examination was made.   The brain was congested and
wet, as it  usually is in those that  succumb to acute fevers, and
have blood more fluid than natural.   There was hovrever nothing
like  the appearances  caused by acute hydrocephalus, nor  any
trace of injury.   On opening  the  abdomen, the cause of death
was at once referred to the ilia, which were extensively inflamed
and ulcerated in the manner usual  in typh-fever.
   I wish people would more frequently put on record mistakes
made in diagnosis; they are full of interest  and instruction for
themselves and others.
   The rest of the fever patients which have passed through the
wards have done well, and I have no record of  anything note-
worthy in  their cases, beyond  circumstances  to which  I have
called  your  attention in  former  lectures  apropos of  former
instances.  I do not lecture  to you  about by-gone patients,
except they have presented  phenomena unlikely to occur again,
preferring to wait patiently till I can illustrate my words from
the life.
   I will confine  my remarks, then, to the four cases now remain-
ing under your  eyes, two in the male, and two in the  female
wards.
   Elizabeth T—, aged twenty-two, Avas made my patient Decem-
ber 9,  1862, with rose-spotted  fever  of five days' duration since
the introductory rigor, with very thickly coated tongue, diarrhoea,
and severe pain  on pressure of the abdomen.  Everything went 
TYPH-FEVER.                    131
on well, no fresh spots came out  after the  13th.   On the 18th
the appetite returned,  and  she  was allowed fish  diet at her
urgent request, although some tenderness remained in the  abdo-
men, and on the 20th meat and beer.   On the 25th it seems her
appetite had failed again, and she had a rigor and some vomit-
ing.   When I saw her on  the 26th she was unable to stand;
her whole aspect denoted  a relapse, and I sent her to bed with
a return to my usual treatment of fever, dietetic and medicinal.
It was a  short attack,  and no spots were seen on the skin.  So
that on January the 7th, she was convalescent, and is now eating
solid meat.
   The remark I have  to  make  on this  case is  to warn you
against too  early yielding  to  the request  of patients for solid
food.   They have a fallacious notion that  it is  more nutritious
than the continuous liquid diet which is given them, and in order
to get it will pretend to feel more appetite than  they really do
feel.  They will  also often conceal that tenderness of the  abdo-
men Avhich  is the sign of the yet unhealed  congestion of the
mucous membrane of the ilia.   I  should tell you, too, that when
the patients take hydrochloric acid, you  are more frequently
tempted to  the error in judgment against  which  I am warning
you than when  they have other medicines.  The acid causes a
more rapid  renewal of the lingual, and I  suppose, at the same
time, of the  intestinal, epithelium: the  dead, dirty coat is cleared
away, and you have a clean tongue earlier  than would otherwise
happen.  I  was talked over by the patient too easily in this case,
and ought to have been deterred, by the abdominal  tenderness,
from giving  her meat so soon.  The consequence was, the  slight
relapse which you have Avitnessed.
   William  W—, a dirty,  dissipated-looking  person, thirty-six
years of age, Avas sent to bed on the 28th ult., in a state of weak-
ness and constant delirium, which entirely prevented his giving
any account of himself; and now  that he is getting well, his
memory of recent events seems  very dim.   He was said however
to have been ill a week, his body was covered with livid spots,
his tongue Avas brown  and  dry, and his tremulous hands kept
picking at fancied objects before his eyes and on  the bedclothes.
There was no diarrhoea or pain in the abdomen. 
132
TYPH-FEVER.
  He was treated in the usual way, and had ten ounces of port
wine daily, with the usual result.
  It is noted in the diary that he had some evacuation of liquid
motions soon after admission, but that the stool was "natural"
in appearance.   What is meant is that  it was  such  as  is
naturally caused by a purgative drug, not the dark fetid excre-
tion  of fever, and in fact was traceable to an emetic draught
which was  administered on admission, and which  did not cause
vomiting and therefore went off by the  bowels.   Be careful  to
distinguish phenomena  arising in the course  of  disease which
are caused by art from those which  are morbid and part of its
essence.
  This man had no real diarrhoea and no pain on pressure  of
the abdomen, and therefore I did hot hesitate  on January 7
to order him meat diet on his expressing himself desirous of it,
although he was not sufficiently recovered of his fever to be able
to raise himself in bed ; and I feel confident  he will continue,  as
heretofore, to do justice to  his treatment.
  Edward  C—, a boy seven years of age, was seized on De-
cember 28 with rigors,  nausea,  loss  of  appetite,  nocturnal
delirium, and febrile depression, so that he could  not lift up his
head.   He was brought  under my care on  December  31, by
which time there were numerous dusky fever spots on the belly.
He was put upon the usual treatment, and is now convalescent.
I have to remark about the orders on the medicine card, that he
took the same quantity of  hydrochloric acid which  is adminis-
tered to adults, namely, twenty minims every tAvo hours, without
any inconvenience following.   I have not generally given  such
large doses to children, but shall know now that it may be done
with propriety.
  It is remarkable that a few days before this  boy was attacked
by typh-fever, Avithout any local complication whatever, his father
fell ill, and jvas brought  into the hospital on December 29,
with pneumonia affecting between one-third  and half of the left
lung.  The father has had no  delirium,  nor more  nervous de-
pression than is accounted for by the condensation of the lung,
no eruption on the skin, no diarrhoea, nor anything which  would 
                        TYPH-FEVER.                    133

lead one to set doAvn his  complaint as due to the  same cause  as
his  son's.  Yet the coincidence, joined to the fact of their resi-
dence being in an  ill-drained, ill-ventilated  house, where almost
every one  has been  ill,  is too striking  to be passed over  in
silence.  Did the exposure to cold and  wet  during  his 'daily
labor predispose  the  hard-worked father's  lung  to  be affected
by the same cause, the typh-poison, as absorbed  into the boy's
blood acted principally on the nervous system ?  Was  his more
robust frame,  and the dura messorum ilia  able to  pass unscathed
a dose of the typh sufficient to poison the more delicate tissues
of the  younger subject,  while at the same  time his  lung,  devi-
talized by wearing toil  and exposure, yielded to its influence ?
Is, in short, the pneumonia the expression  of a quantity of poison
enough to injure  a failing part  but  not enough to  affect his
whole  body ?  I  do not like to  answer these questions  ex
cathedrd, but I cannot  help  seeing some connection between
typh-fever and inflammation of the lung.
  The  different  way in  which the same morbid agent affects
different individuals should guard you against considering it as
the  disease, against looking upon illness as something to  be
evacuated or neutralized.  The disease, that against which you
have to struggle, is the partial deficiency of life caused by this
morbid  agent, and  your struggles must take different forms
according to the different forms of the deficiency.
  The fourth case of typh-fever still  in  the hospital  is that  of
Sarah H—.  She is a  married woman,  aged twenty-eight,  of
slim figure, and not muscularly strong.  She  was admitted De-
cember 5, having rose-spotted fever  of  three  days'  duration
since the  rigor,* and accompanied by delirium.  As is usually
the case with delicately-framed susceptible  females,  the nervous
system was especially affected: we were forced, in  addition  to
the usual fever treatment, to give her a great deal of port Avine ;
the  belly became tympanitic, and I was  at one time  seriously
alarmed about her.  However, on  December 18, she was in her
rio-ht mind and convalescent, though unable to raise herself from
the lying posture  for her natural evacuations.
   I mention the  fact of her  being  quite  confined to  bed for a 
134
TYPH-FEVER.
speeial reason.   On the last-named date there was in  the ward
for a  few hours, a patient who was discovered to have variola,
and was  sent off to the Smallpox Hospital.   Now, Sarah  II—
was the only unvaccinated person  in the ward, and the conse-
quence was that she  received the infection, and has since  gone
through a severe attack of the confluent form of smallpox.   In
spite, however,  of having  thus imbibed a new poison, she  con-
tinued to increase in health and strength till the 30th.  On the
morning of the 31st she had a decided rigor, she became feA'erish,
lost  her  appetite, and had  nausea.   The  pulse  rose to  110.
Thinking she Avas about to have a relapse, like the first patient
to whom I drew your attention, I put her  back on the usual
fever treatment, which she  has continued to have ever since.
  One piece of information you may gain from the accident of
this  unfortunate patient having the tAvo diseases  so close upon
one another, is the fact that typh-fever does not prevent a person
receiving the infection of smallpox.  A second is,  that the pres-
ence, in  a latent state, of the morbid poison  which gives rise to
the latter disease, does not retard the progress of  convalescence
from  the former; and is in reality dormant as well as latent.  A
third is, that  on the* whole,  the sufferings  from  smallpox are
more severe than those from  typh-feArer.   Our patient declared,
at first, that the fever was the worst of the two, but by the time
the pustules had completely maturated, and she Avas sore all over,
she frankly confessed to me her error.

          (Clinical,  St. Marys, February 13*, 1863.)

  On Ellen D—, a servant-girl  aged sixteen, who came under
your  observation three days ago with typh-fever of a week's
duration, you haAre seen an instance of two of the  most common
forms of eruption in  this disease.  The bosom and abdomen were
thickly  covered  with dark livid spots, many of  them as  deep
purple as those of purpura haemorrhagica.   She was  in a very
low state, the blood  being very venous.  Yesterday, in addition
to the  purple spots, I observed  on  the abdomen several  spots
slightly raised above the surface of the skin, and of a much more 
TYPH-FEVER.
135
pinkish hue.  Her hair,  and probably therefore her skin, are
naturally dark, so the maculae are not so pink as they would be
in a blonde  complexion; but still, no one would hesitate to call
them " typhoid" spots.  This shows you the great difficulty that
lies in the  question of whether there are two distinct animal
poisons causing "typhoid" and  "typhus" fever.   Doubtless, it
is not impossible  that both may exist  in the body at the same
time, and give rise to two distinct fevers at the same time; just
as a person  might be poisoned by a  mixture of strychnine and
antimony, and exhibit the effects of both drugs together.  But
in the  case of morbid poisons which  increase in  the body, such a
joint progress shows at least a very close relation between  the
two.   There are  also other instances where the eruption  seems
to exhibit a transitional character, or where there is not  a suf-
ficiently distinctive eruption.  In our  register these cases  are
not distinguished, but are entered simply as  " fever."   If then
there are two poisons which cause typh-fever, a point I consider
not proved,  they  must be  much nearer allied to one another than
those which originate the usual eruptiAre fevers, such as scarlatina,
smallpox, &c.
   You may have observed that I am loose in my nomenclature
of this class of diseases, speaking sometimes of " common con-
tinued fever," sometimes of "continued fever," sometimes of
" Ioav  fever," sometimes of "typh-fever," sometimes  of  "fever"
simply, when I mean the  same thing.  This is not from careless-
ness, but to show you my opinion that for therapeutics, to which
the greater part  of my clinical lectures refer, the name is unim-
portant; and also because the terms "typhoid" and "typhus,"
having  acquired a special limited  meaning, and  when  used by
me, being used in that special limited meaning, are  unsuited to
my general purpose.  Their employment would seem  to prejudge
a question upon which I am  not engaged in this chair.
   I should  advise you also not dogmatically to prejudge the
question.   Use,  if you like, the popular nomenclature, but do
not be  skeptical of the possibility of the  eruptions being phe-
 nomena of one morbid poison, varied by varying circumstances,
 any more than you are skeptical about their being indications of
 two poisons. 
136
TYPH-FEVER.
  There is no necessity for being in a hurry to decide, for it  is
not a matter  of  any importance to yourself or your patient.
Both forms of disease are infectious to a certain extent, as occa-
sional instances in the Avards show you.  Typhus is said to be
most so, perhaps from its following a larger  dose of the poison;
but neither are very infectious, and do not  require the extraor-
dinary precautions proper  for smallpox, measles, or scarlatina.
And both  call for the  same treatment, and are accompanied,
though in  varying proportions, by the same  local inflammations.
  While on the subject of typh eruptions, I may take the oppor-
tunity of warning you not to limit your  observations solely to
the surface of the chest or abdomen, as is very commonly done.
The flanks and buttocks are often the seat of them, and I have
sometimes  found  spots  very marked and indubitable in these
situations,  when  their  presence  elsewhere was  doubtful.   In
females especially it is convenient to find them here, as it obvi-
ates the necessity  for baring the front of the person, a proceeding
naturally repugnant to a delicate  mind.
  In this  girl there was great general congestion of the lungs;
the respirations were  much hurried, amounting to thirty in  the
minute; there were sibilant rales all over the chest, most intense
at the back part; but there was no localized dullness on percus-
sion.   In  consequence, I believe, of  this congestion, the pulse
was quicker than  usual, 140 in the  minute; for you will rarely
find it  above 120 when the pulmonary tissue is in  a healthy
state.
  When there is  such an  amount of congestion as to  produce
marked dyspnoea, it is better to omit the usual sponging of the
surface of the body,  or  you run the risk of pneumonia.  This
had been done in  the  present instance, and  the chest has been
enveloped in a "jacket poultice."  She now breathes easier, has
less cough, and the pulse has sunk to 110, getting  stronger at
the same  time.   The  continuous and  even temperature of  a
poultice is by far the best means of restoring the deficient vitality
of the  lungs, where that  deficient vitality is general, instead of
being localized in one spot, as it is in circumscribed pneumonia.
  You may observe that almost  all non-delirious patients with 
TYPH-FEVER.
137
typh-fever say, on the first visit, that they are worse than before
they left  home to come into the hospital.  Sometimes even
deaths occur within the first thirty-six hours, of which I related
you an instance in a former lecture,*  the patients being, in fact,
death-struck from the moment of admission.  This arises from
the exhaustion induced by the journey hither, of which you may
always see traces, hoAvever short it may be.   Removal even from
the next street does harm, and  the harm increases in a  mathe-
matical ratio  to  the  time  and distance required.  Bringing
patients in from a great way is most  murderous; no  excellence
of nursing or superior comforts can atone for the risk run.  As
far as we possibly can, we limit our reception of typh-fever to the
neighboring parishes, and prevent persons from a distance being
admitted, if we hear  beforehand of their  coming.   And once
within the walls, they are spared every unnecessary movement;
they are sent up stairs to  bed in the lift, not allowed to  raise
their  heads from the pillow  to  drink, and  are supplied with a
bed-pan for the other calls of nature.
   In  typh-fever everything depends on sparing most avariciously
the little vital force that remains.   You  will  have reason to
regret every muscular exertion that you allow patients to make.
I was called lately to Hertford to see what seemed to have been,
and to be, a very moderate case of fever with intestinal affection.
None of the distinctive bad symptoms peculiar to the disease had
showed themselves.  But unfortunately the  patient had  been at
Brighton  when taken  ill; she pined for home, was  allowed to
move thither, and never rose from the prostration caused by the
journey.  I  have heard of cases where the permission to sit up in
a chair, instead of lying in bed, has resulted in fatal prostration.
   You will find  of course more obstinacy  on this point among
the upper classes than  the lower, and you will  sometimes have
great difficulty in overcoming it.  But it is  your duty to try and
do so;  and should patients persist in disobeying orders to keep
quiet, I advise you rather to cease your attendance than to give
way.  You must not allow people to sacrifice your good  fame as
well as their OAvn lives.
                  * January 10th.  See page 129.
        10 
138                    TYPH-FEVER.
            (Clinical, St. Mary's, March 6, 1863.)

  Eliza C—, a stout, muscular  girl of eighteen, was  received
February  27,  with  the usual symptoms  of continued fever.
The eruption was at first of a doubtful character; nobody could
have decided accurately whether the spots were a pale example
of those usually  called typhus, or  whether they were  fading
typhoid spots.  This difficulty is one of the many which beset
the investigation of the question of their identity or non-identity.
Inasmuch  however as from the same house her sister was at  the
time under my care,  and an aunt had just died with indubitable
typhus, I thought it very likely her  eruption would exhibit  the
same  variety  of  appearance.  But  no—it  proved  not so,  for
since then  many rosy spots,  slightly elevated above the surface
of the skin, have come out in successive crops.  I mention this,
because these rosy spots are  a warning to the physician that he
may expect inflammation of the intestines.  And the warning
has been justified in this case; for the patient's principal complaint
during the last few days has been pain  in  the abdomen, aggra-
vated by pressure of the right iliac fossa, and much lightened
by a linseed-meal poultice.  There is nothing does patients with
enteric  symptoms so much  harm  as moving about  and  the
impression of dry cold, and nothing does them  so much good as
lying quite still on the back  and applying moist warmth.   A
poultice  accomplishes  both  objects, it  keeps  the  patient  im-
movable,  and acts as  a  sort of perpetual Avarm-bath  to  the
abdomen.   It entails of course abstinence from the  sponging
treatment.
  Another warning of enteric  inflammation  Avas seen in her  dry
tongue, without much coating of epithelium,  and with transverse
cracks from side to side. It is  seldom that you see a tongue like
this without the intestines being inflamed.
   This girl has had  scarcely any diarrhoea.  The fact is, that
the hydrochloric acid treatment always prevents the diarrhoea of
fever from  attaining  any prominence as a symptom.  There is
usually just about enough to show what it would be if not stayed. 
TYPH-FEVER.
139
Should the hydrochloric acid alone be not sufficient, the diarrhoea
is  best  treated by Dover's powder,  both the opium  and the
ipecacuanha in that preparation  being good for dysenteric in-
flammation.  Kino powder is also applicable to such cases; but
chalk is of course out of the question while you are administering
hydrochloric acid.

   Thomas W—,  a robust boy  of sixteen,  was  brought here
February 28,  with symptoms  of low continued fever  of three
days' duration.   There was very great depression when the resi-
dent medical  officer, Dr.  Rhodes, saw him  then, and  he fully
expected it was going to  be a very bad case.  He ordered an
emetic immediately, and the consequence was the vomiting of a
quantity of blackish matter like semi-digested blood.  When I
saw the lad the next day, he was so brisk-looking  in  the face,
and exhibited  so  little  febrile depression, that at first sight I was
disposed to question  Dr.  Rhodes' diagnosis.   But then I was
shown the abdomen and chest covered with  small purple  spots.
Even then I was  not convinced,  and put the spots to the test of
examination by the microscope.  I thought they might be flea-
bites.
   Now, fleas cannot leave their marks  without a  puncture, and
in  all flea-bites you may, with a  lens of very moderate  power, if
not with the naked eye,  detect  this  puncture as a very minute
dark-crimson point.   The spots  stood  this test,  there was no
puncture, and they were certainly purpuric typhus  spots, which
have since faded  away. But how is it that he had, and,  indeed
has had since, so little  febrile depression ?  The  fact is,  this is
one of those fortunate cases of  a fever cut short  by an emetic.
He is  now emaciating, and  emaciating extensively,  and con-
valescent.
   In the last sentence  I laid some stress on the word "emaciat-
ing."  The emaciation is a  phenomenon of great interest; it
shows how large an amount of tissue is interstitially poisoned m
typh-fever; how  large  an amount requires to be  carried off by
destructive metamorphosis during the renewal of life.   In such
cases as this, when the fever is cut short, it by no means follows 
j 40                    TYPH-FEVER.

that the emaciation should be cut short, and in point of fact it is
not so.  The removal of the destroyed tissue is a necessary part
of the case.
   Strokes of good fortune are sometimes equally gregarious with
the proverbially " seldom single" misfortunes.   Next bed to the
boy lies a man whose fever has been in the same way cut short
by an  emetic.  Thomas B—, aged nineteen,  exhibited on  the
3d of March the usual symptoms of continued fever of three days'
duration.   There have been all along but few spots, and  those
of obscure indeterminate character on the abdomen. But he had
the aspect of being very ill, and  his tongue was  thickly coated
with yellow fur, and showed a tendency  to get  dry.   He was
treated in the same way as the last  patient, with  an emetic and
hydrochloric acid, and has entered forthwith upon convalescence.
It is now nearly  two years since I have had a case of fever so
 decidedly cut short by an emetic; so do not expect it often; but
nearly all  have the violence  of the  disease alleviated by that
remedy; so that  it is never out of place during the first week of
 the fever.
   Emily H—, aged twenty-six, married,  was  entered to the
 ward assigned to uterine diseases, for irritability of the bladder
 arising from antiversion of the womb, in middle  of last month.
 On the 2d instant she was  taken with feverishness,  loss of appe-
 tite, and pains in  the  head and back.   She had  a  rigor that
 night;  she was  transferred to me yesterday;  and then there
 were obscure livid  spots on the abdomen, and pain on pressure.
 She has been put on the usual treatment, and it appears likely
 to prove a mild case of typhus fever.   I only mention it here as
 having been apparently contracted in the hospital, which I am
 glad to say is not a common occurrence.

            (Clinical, St. Mary's, March 20,  1863.)

    Emily H—, about wThom I said a few words on  the day after
 her coming under  my care, has given us more anxiety than I had
 looked for.  Her antiversion of the uterus had been treated by
 a pessary, and her delirious,  semi-conscious state,  caused by the 
                        TYPH-FEVER.                    141

 fever, prevented  her making this known to the nurse.  The in-
 strument was removed  immediately that it was  discovered,  and
 was followed by an excessively fetid discharge from  the vagina,
 which lasted some days. A vaginitis had, in fact, been produced
 by the pressure,  easily enough  borne  by a healthy  vagina, but
 acting destructively on that part when its vitality was  lowered
 by general disease.  I was fearful that the patient was going to
 have internal sloughing, but she has  escaped by good  fortune
 and the use of an injection of decoction of cinchona and chlori-
 nated soda. She  has escaped so far as  her generative organs are
 concerned, but not altogether:  the vaginitis  and fever united
 entirely  paralyzed the sphincters  of  the bladder and  of  the
 rectum, and it was impossible to prevent the pillow on which her
 sacrum lay from  being soaked with the excretions.   Her con-
 stant delirium also, at first, made her very unmanageable.   We
 could not prevent the pressure on the  sacrum as we  did in the
 other part, and the consequence is  that she has rather a deep
 slough formed there.
   This woman afforded an example of  how the mental qualities,
 as well as the corporeal, suffer  degradation  in illness.  During
 her raving she was constantly attempting  to practice masturba-
 tion, and was uncurbed by shame, so that  the nurse was obliged
 to be constantly on the watch to withhold her. I have no reason
 to suppose  her a generally vicious person,  and in recovering her
 reason she  has recovered her modesty and self-restraint.   When
 the human mind loses some of the divine powers bestowed by its
 Creator, it becomes  as  the  mind of a brute.   Madness is  not
 something added  to it, but something taken away; those powers
 are taken away by virtue of which it is said to be made " in  the
image of God," and by virtue of which it  resists  degrading in-
fluences.  The degrees  or forms of madness are  degrees of  loss
of free-will and self-control.
   I am happy to  say she has now become rational, and also re-
gained control over her sphincters,  so  that she is on the road
toward convalescence.   But if any more accidents happen, I  will
bring the case before you again.
   You saw that till the  inflamed, or dying, portion of skin gave 
142
TYPH-FEVER.
way and broke, I kept it carefully painted over with gutta percha
dissolved in chloroform;  she has also had a water-pillow. The treat-
ment  Avas  unsuccessful indeed in this instance, but still it is the
best.   After the skin was broken,  a  cinchona cataplasm was ap-
plied,  which, by-the by, I may tell  you how to  prepare  most
economically.  Do not make it entirely of bark, but sprinkle the
powder thickly over  a common bread or  linseed poultice ; you
thus save an expensive drug, and also keep it moister. Now that
the sloughy cellular tissue has separated and been cast off, I shall
treat the sore by touching it alternately with nitrate of silver and
applying tincture of  benzoin, whenever  the edges look livid and
unhealthy.
  These low inflammations in continued fever are almost always
a reason for giving alcohol to sustain the nervous system. Emily
H— had at  first six ounces of  port wine daily, but I was soon
obliged to increase her allowance to half a bottle, and  she will
probably continue that during a great part of her convalescence.
There is danger in suddenly leaving off stimulants which  have
been begun in fever.

          (Clinical,  St. Mary's, January 24, 1863.)

  Elizabeth J—, aged nineteen, came  in on  January 16, with
rheumatic fever, affecting  principally the feet, knees, and hands.
There was one day considerable pain  on pressure of the cardiac
region, such as is caused  by rheumatism of  the intercostal
muscles; but that was  immediately  relieved by  the application
of half a dozen leeches,  and there were  no symptoms or signs of
the disease spreading to the heart or pericardium.  The pains
were quite gone on the 21st, and on Sunday, January 25, she
was up and  dressed,  though still on  the  low diet, which seems
best to suit convalescents from acute rheumatism.   On that day
she was taken with rigors, sudden loss of  appetite, severe pains
in the head, in the back and limbs, and  complete prostration of
strength.   When the house surgeon saw her in the  evening, the
tongue Avas exceedingly  clammy, and covered with a whity-broAvn
coat,  as if getting dry ; she was delirious;  the pulse was 120 ; 
                        TYPH-FEVER.                    143

and  the skin  hot, and of a  dusky mottled  color.   Now, these
symptoms a* ere certainly not caused by the alkaline treatment
of the rheumatic fever, for she took the bicarbonate of potash
only five days, was not  prostrated by it, and had left it off for
four days; but as  there had  been a constant succession of  bad
cases of typhus fever in the ward, and the patient had all the
symptoms of that complaint, Dr. Rhodes wisely decided that she
must have caught it; and he, wisely also, acted in a decided
manner.  He  immediately gave her an emetic, and  put her on
continuous liquid  animal diet and hydrochloric acid every two
hours, with tepid sponging three times a day.
  I have told you that emetics will sometimes extinguish a typh-
fever by a kind of coup-de-main.   But really the cases in which
this fortunate result  follows are so rare, that you might hesitate
whether it was worth aiming at, if no other good  was to be
gained by such bold treatment.  It did not follow to the patient
now under consideration ; she remained delirious, quietly talking
nonsense about various things ; during the next day (Monday)
and part of Tuesday, her tongue  got  dry, although cleared by
the treatment, and the pulse kept  quick.  The prostration  and
tremor of hands were very great.  It was impossible not to con-
clude that she was  under  the influence of a powerful  poison.
The cause of  the disease was  not removed, nor  the  disease
extinguished.
  Yet, though  not extinguished, it was  certainly shortened, for
on Wednesday you saw her with her tongue clean and moist, the
skin much cooler, and the pulse, though still 120, much firmer.
Noav, the normal duration of such a severe typh-fever, as she
gave  every promise  of haAdng to  go through, is at least three
weeks;  and she would have had,  in the course of nature, to be
much worse before she was better.  But here you see her in three
days enter upon a  convalescence Avhich  I do not doubt will be
permanent; and I cannot help attributing this abbreviation of
the malady to  the emetic.
  She was so much  better on Wednesday, that I  was asked if
she should leave off the acid and be put upon the bark treatment
of convalescence, and also whether she should haA'e wine.   I 
144                     TYPH-FEVER.
have never made the alteration of medicine so early in the disease
as this; but I have occasionally been induced by the cleanness
of the tongue to do so only a few days later.   And I must say,
I have usually seen reason to regret it.   The too early adminis-
tration of cinchona, as well as the too early administration of solid
food, have appeared to me to have been the causes of relapse in
several cases.  It is better not to give  cinchona at  all, and  to
postpone solid food till the patient is quite strong again, than
to give them imprudently soon, and so  to  run the  risk  of re-
lapse.
   As to wine, seeing  that she is a young girl not habituated to
alcohol, and  has  got  over her delirium without it, I think it a
superfluous expense. 
LECTURE  X.
                      SMALLPOX.

Part I.— Case of smallpox  watched from first  infection—Se-
     quence of phenomena—Memoria technica by which to re-
     member them— Use of observing them—Action of oxygen on
     the general health of the patient and on the skin contrasted—
     Microscopical examination of the contents of the pocks, with
     practical deductions therefrom—Depth of injury to skin in
     smallpox—Reasons for cutting the hair.
Part II.—Spread  of smallpox  in  the hospital from the above
     case—Example of the use of vaccination in modifying the
     disease—Action  of vaccinia not  homoeopathic  or counter-
     irritant,  but preventive—Infectiousness of smallpox  com-
     pared with  other diseases—Different degrees of infectious-
     ness demand different precautions.

           (Clinical, St. Marys, January 16, 1863.)

  You have had an  opportunity, such as rarely falls to the lot
of medical students, of watching the whole progress of smallpox,
from the  first introduction of the poison into the body, in the
case of a young woman about whom I lectured last week apropos
of her previous attack of typh-fever.*  On December 18, Sarah
H__was  confined to her bed in Victoria Ward, when a person
with a variolous eruption fully developed was  brought in, the law
excluding such cases having been violated by an oversight con-
sequent on the occupation of the officials by a hospital election.
                        * See page 133. 
146
SMALLPOX.
This person remained about two hours  in  the ward, and was
never nearer to Sarah H— than thirty-six feet.   But an  extra
nurse,  who was then engaged,  may  very likely have been  in
attendance on  both, and have carried the infection in her clothes,
not having been reserved, as she ought  to  have been, to the
dangerous patient. That such a mode of transfer may have taken
place is rendered probable by this nurse having  communicated
smallpox to her own child, with whom she slept, without taking
it herself. The nurse, however, and all in the ward except Sarah
H—, had been  fully vaccinated; and  it shows the  powerful
protection thus afforded, that all escaped personal harm  except
Sarah H—.  On her, indeed, the operation had been attempted,
but it had failed.
  Here you have been enabled to fix  the  exact time  Avhen the
poison was received, and to trace the history of the resulting disease,
unmodified by  any protective or disturbing causes.  The  pathology
of smallpox, as Ave are taught in the books of systematic  medi-
cine, is  derived from such  examples  as these, occurring  in the
olden time before it was  neutralized  by Jenner's immortal dis-
covery.   And  it should give us confidence  in our  forefathers'
powers  of observation  that cases of unmodified smallpox, then
the rule, now happily the rare exception, are rightly described.
You have seen a sequence of phenomena punctual to the due
times laid down by them, and which I teach you in my systematic
lectures on their authority.  Twelve days did the seed lie dormant;
then its presence was declared by a three days, a  more properly
two days and a half, fever  (counting  from the first rigor); then
for two days  it bore a crop of papules; after that, a  vesicle
growing gradually opaque for three days more, and then for two
days encircled by a halo of rosy inflammation; the next night
brought the evidence of the complete filling of most of the pus-
tules, by the rupture of the little band of epidermis which had
hitherto fastened their centers to the cutis.   When  the vesicles
were two  days old, the face swelled and  there was considerable
salivary secretion; and the distention of the  pustule was  ac-
companied by  swelled extremities.   Since then the eruption has
been gradually drying up. 
SMALLPOX.
147
  To assist my memory as a pupil, I put  these  facts into  some
doggerel Latin verses:
           Bis sex celatur virus, tres febre notatur,
           Fertque duos soles papulam, tres postea opaquam
           Vesicam, roseumque duos perfectior orbem;
           Vincla cutis medii dissolvit postera luna.
           Bidua vultum inflat vesica,  movetque salivam.
           Pustula fert distenta manumque pedumque tumorem.
  Rough  and bad as they are, they served my purpose.   You
may easily fix them in your minds by taking the trouble to  make
improvements in the versification, for which there is ample room.
There is a real clinical  use in such an exertion of school-boy
knack.
  This normal  order of the phenomena of variola is important to
remember, not merely because it is a matter of scientific interest,
but that you  may be able to satisfy yourselves and your patients
that all is going  on  right, and  that the very disagreeable and
painful appearances which they  present are not  signs of over-
hanging  danger.  I refer especially to the swelling of the face
and hands occurring in  proper succession, and which would be
alarming if unexpected; whereas if you are enabled to foresee
them, they are rather good omens than the contrary, and are a
source of justifiable consolation.
  The unvarying sequence of the symptoms in smallpox may also
serve in doubtful cases as a  means  of  diagnosis, not only from
other eruptive fevers, but  even from  chronic  diseases.  I have
known, for instance,  a case of eruption in a baby at the breast,
where it was  impossible to decide, by the appearance, whether it
was variolous or syphilitic, and where the counting of the days
alone enabled  a conclusion,  afterward  proved correct,  to be
come to. I see you smile at the idea of two such different diseases
as syphilis and smallpox being confounded.  But your smile is
one of imperfect knowledge.  Syphilis, child  of sin, shows its
kinship to the father of lies by  imposing upon us imitations of
almost every innocent morbid state;  and  among the rest it
will often, in the infant, assume  the exact aspect of smallpox,
with central depression, red halo,  and other usual diagnostic
marks.  The reckoning of the days of latency and of the progress 
148
SMALLPOX.
of the eruption will alone save you from  falling into  our  fore-
fathers'  original error of confounding the  " small"  and the
"great" pocks in babies.
  You may have observed that this woman was placed in a large
room by herself, with a blazing fire and two windows open night
and day.   To this access of fresh air to the lungs a great part of
her freedom from the unfavorable symptoms so often accompany-
ing confluent smallpox  is doubtless to be attributed.  She has
enjoyed her liquid food all along, and has several times prompted
the addition of eggs, pudding, ale, &c, to her diet  card, and I
have no doubt will ask for solid meat as soon as the sore pustules
in her throat will allow her to swallow it.
  But though the copious access  of oxygen  to  the  lungs  is so
highly desirable, I question  very much whether it is equally
desirable to the skin.  I am led to this doubt by the following
observation.  When the pocks were  filled out, I opened  a  good
many with a lancet, and examined under a microscope the con-
tained matter.   This was divisible  into three classes:
  1. That taken from pocks of small size and with slight inflam-
matory halo.   It was of the consistency of thin lard, white and
opaque.   Microscopically examined, it was seen to consist en-
tirely  of epidermic  scales, the majority of normal  aspect, but
some  filled with granular matter hiding from  view the usual
nucleus.
  2. That taken from distinct and non-confluent pocks, with a
broad  halo, but  not the largest or most  humid of their kind.
Here the normal scales  were few, the granular scales equalizing
them  in number,  but more  numerous  than  either  were  pus-
globules of various sizes and of irregular  shapes, as if budding
on several sides.
  3. That taken from  the worst of the distinct  pocks and  from
the confluent parts. This consisted in several specimens entirely
of equal sized pus-globules, with many dark  specks and  highly
refractive fat-globules among them.   There were  hardly any
epidermic scales  visible.
  Three grades  of death in the skin are represented by these
three classes.   In the  first, the  growing epidermis  is merely 
SMALLPOX.
149
loosened and thrown off in a pasty state ; in the second, the cells
are destroyed  at  an earlier stage of their existence,  and only
partially acquire a right to be called  scales at all; in the  third,
they are killed still earlier, and their constituents form new pus.
  By the last condition certainly, and by the  second  possibly,
the cutis runs great danger of being permanently scarred.  Any
accidental rubbing  or  disturbance must risk the causing it to
ulcerate, and  thus to form  a pitted cicatrix.  It is therefore of
great consequence to the future  appearance of the  patients, if
not to  their freedom  from consecutive  fever, that the  pocks
should be kept from assuming such a condition.  Noav, on look-
ing over the person of this woman, I found it to be  a  rule that
the grade of destruction bore a direct ratio to the exposure of
the various  parts  to the air.  The most favored situations were
the thighs, tongue, and abdomen, next the  legs and back,  and
then the hands and forearm.  The face was the most purulently
affected of all.   With regard to the back, I should observe that
it maintained its  comparative immunity from advanced  inflam-
mation in spite  of the  cuticle being much chafed  and rubbed off
in large patches by the movements of the patient.   So it would
seem that oxygen and  evaporation, so beneficial to the healthy
skin, are  death to it when diseased,  and that  the best hope of
preventing its destruction in smallpox is  to defend it from these
agents.
  To assist, then, the restoration of the skin, in parts important
to the appearance, I believe it to be  a most reasonable practice
to cover it over  with a  coating, as impermeable  as can be, of col-
lodion or  solution  of gutta percha.*   This can be easily done on
the nose, cheeks,  forehead, and  ears, without interference with
motion, and the coating itself and the rest of the face may be
thickly  oiled.   It  is only the most  staunch adherents of thera-
peusis by evacuation that could object to this practice. Another
rather more antiquated plan is  to puncture  the vesicles directly
they  are  fully formed.  The same  object is aimed  at, namely,
the prevention of ulceration in the skin, and it is usually attained.
  * Dr. Smart has found that a solution of caoutchouc applied in the same way
is better; it is elastic,  and does not crack and peel off like gutta percha. 
150
SMALLPOX.
 But this latter expedient is rather troublesome, as it runs a chance
 of being roughly and coarsely executed if left to  a nurse.
   The depth to which the cutis is injured by the more severely
 inflamed of the pocks is curiously exemplified in the case of a
 young woman readmitted to-day with  valvular  disease  of the
 heart (Eliza M—.  Folio 169, p.  20).   Her face  is seamed and
 graven over with white cicatrices, the relics of a variola by which
 she was affected years ago.  The  cicatrices are made more  than
 commonly conspicuous by the extreme venous  congestion of the
 rest of the skin of the face dependent upon her  cardiac lesion.
 This  venous congestion was so livid (almost black), that I should
 have been very much alarmed about it, as significative of a  dan-
 gerous disturbance of the circulation, had I not remembered her
 as an old patient, and been familiar with her scarred face.   By
 experience I knew that a moderate  amount  of  dyspnoea  was
 accompanied  in her case with extreme congestion of  the capil-
 laries of the dilapidated skin.  This may serve as a lesson to you
 not to be too  soon frightened at the venous blueness of the coun-
 tenance in pock-marked patients.
   You may have observed that the smallpoxed patient's hair has
 been  cut short with scissors, leaving it about half an  inch long
 all over.  The object of this is partly cleanliness, for it is impos-
 sible  to keep  long hair from being saturated with the  discharge
 from  the pocks, and then it becomes most fetid.  The scalp is
 so sore, from  being covered Avith the eruption, that brushing, or
 combing,  or washing is barely possible.  Besides Avhich the hairs
 are so much loosened by the purulent condition  of the skin, that
 they  are  easily dragged out in handfuls,  almost  by their own
 weight, if long. This forcible dragging out injures the hair-bulbs,
 so that they will not sprout again.   And it also still further in-
 flames the scalp.   So that the best chance for saving the hair is
 to cut it short, since shaving the head is out of the  question from
 the pain it Avould  give.

           {Clinical, St.  Mary's, February 5, 1863.)

  An order from  the weekly board to empty  the beds and clear
the wards, on  account of the late spread of smallpox among  our 
SMALLPOX.
151
inmates, leaves me no patients to lecture upon, so I will make a
virtue of necessity and give you a few more remarks on the cause
of this misfortune.
   Since I took variola as my text three weeks ago, seven more
persons have contracted it within our walls.   They have had it
in various  degrees, and two have died.  But as none of them
have been under my charge, I have not their symptoms to com-
ment upon.  Among the seven was one of yourselves, a house
surgeon, who had prudently revaccinated himself when he found
the disease was spreading.   While the vaccine pustule was form-
ing, he found his body  overspread with an erythematous blush,
Avhich  he thought at first  to be  scarlatina, but  it soon showed
itself to be only the forerunner  of a variolous eruption.   This
precautionary  vaccination  was not then completely successful.
But his attack of smallpox has been very slight, it has not con-
fined him to bed, and the  few scattered pustules are  dying off
without causing any inflammation of the skin.  The protection,
though not complete, was probably still useful.
   To be of use, the poisoning by vaccinia must  precede that by
variola.  The  eruption of the  first  must be formed before the
fever of the second comes on.    This is not my own statement,
but derived from the experience of Dr. Munk, the accomplished
physician to the Smallpox Hospital, and it is what one would
a priori have expected.
   You must be careful not to  look  upon vaccination as in any
way antidotal  or remedial to smallpox.  It is  not  a  case of a
smaller and slighter disease curing a severer one already exist-
ing; otherwise it might perhaps be taken as evidence in favor of
either the homoeopathic or counter-irritant theories.  It does not
cure it, or even modify it when already existing.  The rational
view of the relation of the tAvo is this: there exists in  the living
body a certain unknown constituent, which, coming  into contact
Avith the virus of vaccinia  or variola  respectively, is capable of
being converted gradually into  that virus, just as  surely  as a
thousand hogsheads of malt sugar may be converted into alcohol
by an ounce of yeast.   But Avhen it has once been thus converted
and passed away, there remains nothing for the virus to act upon, 
152
SMALLPOX.
and it is consequently harmless.  Vaccinating a child  is an act
done  on the same principle as cutting off the dew-claw from a
puppy, lest it  should lead to inconvenience  in  after-life.   We
exhaust or  obliterate a  useless substance  which might lead to
evil.   To call it a remedy in  the sense in which  medicines must
be  remedies for disease is like calling the removal of  the dew-
claw a  cure for a torn leg, Or to talk of putting out a conflagration
by  previously removing  the inflammable furniture.   Prevention
is not cure,  however  much better it may be.           s
  It is  obvious that the modification of diseases on the same prin-
ciple as vaccination is  applicable only to those which occur  but
once in life.   But  there is no reason for the  world to despair of
seeing  scarlet-fever  and measles rendered as rare, at  least, as
smallpox, by some analogous  means.   Any plan which offers a
reasonable  chance of success will not now find skeptics to oppose
it before trial in the  ranks of our profession.
  The  way in which the  smallpox  has spread,  in  spite of  our
efforts  at quarantine, shows you  how very infectious  its nature
is—how much more  infectious than  scarlet-fever, measles,  ery-
sipelas, or  typh-fever.*    I have  placed them  in  the  order in

  * I had a striking  instance a few months ago of the  almost  incredible  con-
tagiousness of smallpox.  A lady about to be confined summoned her monthly
nurse on October 29;  on  November  I her child was born; on November 12 an
eruption  of smallpox appeared on it, and  went mildly and regularly through its
regular stages, affecting the child's health very slightly.  The interest of the case
lay in tracing the history  of infection; for it is obvious that, allowing two days'
fever and twelve days' latency, which are invariable  in an unprotected person,
the virus must have been  communicated two days before birth.  Every one who
had been in the house positively denied having seen anybody affected with the
disease, and the mother had not been in a street cab for weeks previously.  At
last it was discovered that after the  monthly nurse had  left her last place, the
child she had been bringing up sickened with smallpox  and died, and the infec-
tion was traced to the household of the family washerwoman, whose daughter
had been laid up with an attack so mild as to be capable of concealment.  The
travels of the  virus were, then,  as follows: A (the washerwoman's daughter)
develops it; it is carried in the clean clothes B to the household C, from whence,
before it  has been redeveloped or multiplied by the child who died, it is carried
by the nurse D to the pregnant lady E; E, being protected by A'accination, does
not exhibit it, but passes  it on to the child in her womb F within twenty-four
hours after she first saw the nurse and two days before it came into the world. 
SMALLPOX.
153
which, in my judgment, there is risk of communication from one
person to another, viz.:  scarlet fever, measles, erysipelas, typh-
fever.   Of scarlet-fever and measles, most cases are  treated at
home; we have not a dozen cases of each in the wards annually.
Although I must allow that a good many instances have occurred
of scarlatina spreading, yet, as a rule, we are able to retain the
patients in the general wards without its doing so, by  the simple
precaution of allowing an interval of eight or ten feet between
the scarlatinous bed  and the next.  So that, without  expressing
an  opinion as to the propriety of admitting scarlatina into a
general hospital, I do not think the matter of sufficient import-
ance to exclude them by law.  Of the communication of  erysipelas,
again, most of you during your pupilage see just an instance or
so which serve to illustrate the fact. We have not enough cases
in the wards to supply  many  examples.  But of typh-fever we
are seldom free, seldom indeed are we long without having many
more than we like at once.  Had it the virulence of smallpox,
which of the  patients, which of the physicians or students, un-
protected as we are,  could possibly  escape?  Only an occasional
rare exception, just enough to prove the facts by tradition among
you,  occurs of its being contracted in the hospital.  I can recol-
lect only three instances in my practice of such having been the
case.
   But smallpox, in spite of the protection of vaccination, hardly
ever  comes among us without  leaving a virus which is most diffi-
cult to eradicate.  Each time that  a patient has slept a night in
the house several others have taken it, each time has a  house
surgeon been  infected, and we have got  rid of  the plague only
by dint of clearing the wards, whitewashing, and painting, as we
are now doing.
   Being infectious, then, is not an absolute quality of a disease,
requiring some one and absolute means of prevention. It is com-
parative°and has a very different meaning whether it is applied
to  smallpox, or to yellow-fever, or to scarlatina, measles, typh-
 What a notion this gives of  the infinitesimal subdivision of matter, and also of
 the powerful protection afforded by vaccination, which guarded the mother's
 body, through whom the virus passed without the slightest injury.
        11 
154
SMALLPOX.
 fever, glanders, syphilis, itch, &c.  The means need to be applied
 in very different  degrees according  as one or the other of these
 complaints are to be provided against.
   The principle indeed involved in  the most important of these
 measures is the same;  it is dilution of the virus which  is the cause
 of disease, by air and water, before it can come in contact with
 any focus of increase, that is to say, with any  human  body.
 Chemical "disinfectants" (so called) are useless, unless applied
 in such quantities as really to be diluents; and being  useless, are
 dangerous, lest they should be trusted to and exclude  the employ-
 ment of the really efficient agents.  If you advise the  use of them
 at all, select  the most disagreeable in odor, that thus the servants
 may be driven to dilute  the  poison by diluting the disinfectant.
. It has been coarsely but truly said that chloride  of lime is good,
 for "it makes such a stink, that you are obliged to open the win-
 dows." 
LECTURE   XI.
                RHEUMATIC  FEVER.

Relations of the practitioner  and lecturer to  rheumatic fever—
     Description of treatment—(1) Bedding—(2) Fomentations—
     (3) Remedial agents—Bicarbonate of potash, Iodide of potas-
     sium—(4) Opium—(5) Leeches—(6) Poultices  in pericar-
     ditis—(7) Diet—Commentaries on the restorative agencies
     of the aforesaid treatment.

             (Clinical, St. Mary's, May 24, 1862.)

  Rheumatic fever is a pleasant disease—I mean for the doctor
to treat, though not for the patient to bear.  It is  pleasant for
him to treat it, because he then feels himself strong and useful.
In  the  first place he can, by the judicious exercise of his art,
insure the sufferers against several perils to which the nature of
their complaint  exposes them.  Again, he can save them much
pain.  Thirdly,  he can shorten the otherwise  long duration both
of the illness and  of  the convalescence.   Truly in most diseases
he can effect one or other of these objects, but  in none I think
so many of them, so surely and so simply,  as in  rheumatic fever.
  Rheumatic fever is also a pleasant disease to lecture about.  It
presents an unusually uniform type, so that the short descriptions
you have had in the systematic course of lectures on the practice
of medicine  are found really  applicable at the  bedside/without
the necessity for guarding them with all sorts of exceptions and
variations, which clinical  teachers  are so often  obliged to resort
to in other cases.   The classification I adopt points to  a differ-
ence rather of degree than of essence, viz.: "acute rheumatism," 
156
RHEUMATIC FEVER.
or rheumatic fever,  where there is  febrile  reaction,  shown by
furred tongue, &c, and "subacute rheumatism" where there is
none.  And a  very  simple  uniform treatment may  be recom-
mended,  which hardly ever requires modification.   So that if
your authority with your patient is sufficient to enforce due obedi-
ence to orders,  and you are certain of your diagnosis, you need
have but little anxiety about the result.
  There  are hardly ever absent from the wards specimens of the
mode of  treatment I adopt.   My present business is to tell you
my reasons for  the plan pursued.
  But first let me speak of the plan  itself.
  1.  The patient's bed is made  in a peculiar fashion.   It is a
standing order that no linen is to touch the skin. A slight calico
shirt or shift may be allowed;  but if the patients possess under-
clothing only of the prohibited sort, they are better naked. Even
a linen front to the shirt is dangerous.  Sheets are removed, and
the body is carefully wrapped up in blankets, which are so arranged
as shut off all accidental draughts from the head.   The newest
and fluffiest blankets that can be got are used.
  The bedclothes being put so,  are  kept so, and the attendants
and students are warned that  when  the sounds of the heart are
listened to, they must not throw off  the wrappings, but insert a
stethoscope (first warmed) between the folds.
  2.  Those joints or limbs which are swollen, red, or painful, are
wrapped  up in flannels soaked with a hot fomentation consisting
sometimes of plain water, sometimes of decoction of poppy-heads
with half an ounce of carbonate of soda to each pint.
  3.  The following drugs are prescribed with a curative intention.
  (a) If the skin is red, swollen, and painful about the joints—
if the cellular tissue around the  muscles is infiltrated  and sensi-
tive,  so that motion is impossible or exquisitely painful—more
especially if these phenomena are metastatic, leaving one part
free and attacking another;—patients have then the "alkaline
treatment" pure and simple: they have a scruple of bicarbonate
of  potash in camphor water every  other hour, night and day,
when awake.
  (b) If the above symptoms are insignificant, and the pain is
i 
RHEUMATIC FEVER.
157
felt  more in the bones—if it is intensified rather by pressure
than by motion—if it is fixed  in  one spot and not metastatic;
—then I add  two  grains of iodide of potassium to each dose;
and directly the symptoms have taken a  turn toward allevia-
tion, I leave off the alkali altogether, and  give only the iodide
of potassium.
   4. Opium is given  in exact  proportion to the degree of sub-
jective sensation of pain.-  If one grain be not enough to entice
sleep, a grain and a half is administered; if  that do  not avail,
two grains.  Directly the pain is  relieved, the quantity of the
drug is diminished.  Nothing effects  the  desired object  so well
as pure opium  in pill or  in tincture.
   5. If the pain remains fixed in one joint, instead of leaving it
as it leaves  other places, leeches are applied there, and the part
is kept  poulticed.   Sometimes bruised laurel leaves are mixed
with the poultice.
   6. Leeches and poultices are also applied to the cardiac region,
if the heart has become  inflamed either inside or  out.  The pain
felt is taken as an indication of the extent to which the leeching
is to be pushed, so soon  as it is  proved by auscultation that such
pain arises  from inflammation of the heart, and not from rheu-
matism of  the  pectoral  muscles.   The  constant application of
the poultice is  made imperative after the leeches.
   7. The diet  is varied  in some degree according to the social
and personal  state of the patients.  If they have been hearty,
well-to-do persons before the  attack, they will  bear a good deal
of starvation, and are accordingly put on our "simple diet;" to
wit, bread  and butter, gruel,  and tea.   If previously  they  have
been ill nourished,  by reason of either ill health or poverty, or
if they have been ill for some time, a pint of  broth or beef-tea
is added.
   I will now proceed to  comment on the several items of treat-
ment in the order in which I have placed them.
   1. Bedding.—It is impossible to make too  much of the value
of absolute  rest and an  evenly high temperature to the  skin in
rheumatic fever.  They  are worth  all the other means  of relief
put together.   Since I have  succeeded in getting our nurses to 
158
RHEUMATIC FEVER.
adopt them as a universal rule in every case of rheumatic fever,
without exception, I have had  hardly any patients to treat  for
inflammation of the heart.*
   The rationale of the action of warmth is very simple.   Rheu-
matic inflammation is an injury to  nutrition Avhich  is entirely
compensated for by the restored  function on  return to health.
Rheumatic inflammation passes away and leaves  no after-sign,
no wound no scar.   This  only  happens, hoAvever, if the parts
affected are kept perfectly still.  Should duties be asked of them
which they are unable to perform in their imperfect condition—
should necessity or ignorance lead the patient to keep moving a
swollen joint, for example,  then common inflammation is  super-
added.  Then the pain and swelling become fixed, and no me-
tastasis can take place.  You see this frequently in poor working
people,  who, through need or ignorance of what is likely to
follow, strive to go on with their business up to the last minute.
Laborers come into the  hospital with the disorder fixed in their
knees, carpenters in  their elbows, laundresses in their wrists; so
that you may make a shreAvd guess at their trade from the part
where the disorganizing inflammation is situated.   Pain may be
called the proof of beneficent design in God's  laws as shown in
disease; it is a warning to withhold  one's self from that Avhich
excites it.   The pain of rheumatism is a call to voluntary abso-
lute rest.  Now, in the  joints this is easily obtained, and, under
any treatment, you hardly ever see disorganizing inflammation
begin in a joint after a  patient has once taken to his bed.  But
there is one  organ whose business admits of no rest;—the heart
must needs  keep beating at whatever cost;—and the  heart ac-
cordingly  is  well known to be fatally apt  to be struck with
common fibrinous inflammation  at all stages of rheumatic fever.
Taking a lesson from what  I have noticed in the joints, I try
and assist the heart to gain, not of course the Utopia of absolute
rest, but the nearest  approach that is possible.
   Perhaps you may think that object would be gained by simple
confinement to bed in the horizontal posture.  It is not so.  Next
to jumping  and running, there is nothing gives the heart so
       * On this point see the statistics in the next Lecture but one. 
RHEUMATIC FEVER.
159
much work  to  do as alternations of heat and cold.  Let  the
physiologist observe the healthy organ, let  the physician  ex-
amine it in  a state of disease, and they will  find that a change
of temperature on the surface of the body is followed by a longer
and stronger stroke as felt by the finger, by a longer and stronger
sound as heard by the ear  in the cardiac region.  The interval
between the strokes  is shortened; and thus is  encroached upon
the only wink of  sleep the hard-working muscle ever indulges
in.  What  does  the accoucheur do  who wishes to  apply the
strongest vivifier  to the dormant nerves of a still-born  baby?
He dashes  cold water and  cold air on the  skin,—he rubs the
chest dry and  applies hot cloths apace,—again he dashes it with
cold,—making as many changes as he can.   What  the  accou-
cheur is so anxious to accomplish there, Ave are most anxious to
avoid here; and  I feel sure that it is by virtue of screening pa-
tients with rheumatic fever from the influence which variations
of heat and cold  have over the  dependencies of the pneumogas-
tric  nerve that the  treatment  now advised  is  so successful.  I
never have pericarditis come on when it is once fairly begun and
persisted in.
   I  scarcely need to  say that  the most  important  part  of the
person, as respects the attainment of the accoucheur's  object,
and  our  opposite object,  is the chest.   There  he  applies  his
"stimulus," and   there we  must as carefully  watch  against it.
A patient of mine at this hospital (year 1859, No. in Reg. 711)
got  pericarditis by  being  doAvsed with  cold water on the  face
and  neck for an hysteric  fit accidentally occurring during  con-
valescence  from  rheumatic fever.  And as a student I  used  to
see many and many a  case of pericarditis  brought on  by the
careless way in Avhich the  thorax was bared  in the daily  stetho-
scopic examination.   It is doubtless necessary to listen to the
heart thus  often, in order to convince  ourselves of the absence
of morbid sounds: but by Avarming the stethoscope in our pocket
or under the axilla, and  making the blanket into a tube by which
to insert it, we  cause the least possible  degree of danger, and
aAToid the merited accusation of meddling to the patient's  hurt.
   You saw a  fortnight ago an instance of  the danger of the 
160
RHEUMATIC FEVER.
 exposure I have been deprecating.'   Margaret K., aged 23, was
 admitted  March 28 for rheumatic  fever, with swellings in the
 arms and legs; from this  she  recovered  perfectly without  any
 affection of  the heart, and was transferred  to the  convalescent
 ward.   On April 17 she had a relapse, principally affecting the
 legs, and on the 19th I found her in bed again.  By an oversight
 she had not been blanketed, and, when I felt the cold sheets damp
 Avith the patient's perspiration, I was not surprised that she com-
 plained of constriction across the chest.  You heard me rebuke
 the nurse in no measured terms, and prognosticate evil.   With
 justice; for  before two days Avere over there was a melancholy
 systolic murmur distinctly audible.    I trust this case has been a
 warning to you.
   2. Fomentations.—By comparing in occasional  cases one limb
 wrapped in fomentations of simple hot water, with  another where
 decoction of poppy-heads was used, I have come  to the  conclu-
 sion  that either the viscid vegetable  matter, or the small quan-
 tity of opium in the poppy-heads, contributed toward alleviating
 the pain a little.  And a similar experiment has  led me to the
 same opinion as respects an alkaline carbonate.   But the heat
 is the most  important element in  this  part  of the treatment.
 Look well after your nurses, and see that they keep the foment-
 ation warm.
   3.  Curative Drugs (a).—With unimportant exceptions, I have
 treated every patient for the  last  seven years with bicarbonate
 of potash, being convinced of its power to  shorten and alleviate
 the disease by daily experience as well  as  by the  statistical de-
 ductions of Dr. Garrod.   In a great  majority of  the cases very
 rapid relief commences with the commencement of the treatment,
 and continues permanent.   But in' a certain number no  effect
 appears to be produced, sometimes even after the' urine has been
 made alkaline.   In a few of these there has  been committed a
 pardonable error of diagnosis,—the patient is gouty.  In a few,
 also, we are deceived by gonorrhceal rheumatism, a disease  allied
to  pyaemia, and requiring  quite different management.   Still
there are a certain  number of instances where true rheumatic
inflammation  is very obstinate and does not yield to the alkaline 
RHEUMATIC FEVER.
161
method.  And in these you will find the periosteum  and peri-
condrium affected.  When the patient, then,  after five  or  six
days of the alkaline treatment, is no better, or but little better,
I add, as I told you, iodide of potassium to the potash, and in a
few days more continue the iodide alone during the convales-
cence.   Of course, if  I am  enabled to make  this condition of
the periosteum out at the first visit, I begin such treatment forth-
with.
   I mentioned just  now that I had, in a few instances, for  ex-
ceptional reasons, not given the alkaline treatment for rheumatic
fever.   Among those are included a middle-aged  laborer and his
wife, both attacked together and just recovered, in which  cases
you saAV no drugs given during the acute stage.   The object of
this omission was partly to test a suspicion that the alkalies might
cause or augment the  anaemia and weakness so  general in  the
convalescence of rheumatic fever, or perhaps might give rise to
relapses by checking the course of the disease.  These two cases
did much to  disabuse me of that fear.  We saw  that the loss of
flesh and strength was  in both husband and  wife as great as
usual,  if  not greater  than in the majority of examples which
come before  us in the wards—satisfying us that it is the disease,
not the remedy,  which is to blame for the usual  emaciation and
weakness.  We saw, also, that one of the patients (the man) had
a relapse, showing that to nature and not to art is to be attrib-
uted this unfortunate occurrence, so frequent in rheumatic cases.
  Partly also, in  these two cases,  I omitted drugs, to use them
as a pretext  for reminding you that you do not carry in your
medicine chests any absolute  or  indispensable  powers—to show
you that  rheumatic fever  is a state in which the  forces of life
move in a circle, in  a road which  leads of itself back toward
health, and is hot a chronic disorganizing process, whose path
may be drawn as a straight line, approaching nearer and nearer
to death the farther it goes.   It ends of its own accord, or at  all
events  without  the aid of  drugs, often  in a few  days, often  (as
you saw here) in a time quite as short as could  have been ex-
pected had medicines been administered.  This consideration is
needful to enable you to rate duly the value of numerical argu- 
162
RHEUMATIC FEVER.
ments, and  to understand that a very large collection of cases,
much larger than any experience in private  practice ever can
supply to you, is needed to prove the ability of a drug to shorten
rheumatic fever.   If you forget this, you risk  being misled by a
fallacy, with an instance of which applied to experience of this
very disease I was amused a few years ago.   I had an interview
with an irregular practitioner (very irregular indeed), who  told
me that he gave no medicines, but followed "the method of St.
James"—he "anointed with oil them  that were  sick, and the
Lord raised them up."  As proof of the success of his plan, he
gave me the history of two attacks he  had undergone of rheu-
matic fever.   In  the first he was treated professionally, and was
laid up for more than three weeks; in the second he obeyed the
perversion of  Scripture above quoted, and was out of  bed in five
days.  Of course he was perfectly impervious  to argument.
   Do not misunderstand  my words, or  interpret  them  as  if I
intended to ridicule the proof brought by Dr. Garrod  of the
success  of  the alkaline treatment in  shortening  the average
length of  our patients' pains.   I think his calculations fairly
prove that point, though they do not show that the whole dura-
tion of the disease is less.  But my principal reason for adopting
them is that the use of  such drugs is  quite in  harmony with the
principles of restorative medicine.  The deficiency of alkali |in
the body is shown in all quarters by the appearance of free acids.
In indubitable cases of rheumatic fever left without treatment the
sweat is acid, the saliva is acid, the urine, instead of being mod-
erately acid, is intensely acid; the breath even smells acid.  The
blood, indeed, remains  alkaline, fortunately for the life  of the
patient; but that  only is done  at the expense of becoming ex-
ceedingly watery, and producing the anaemia which is so charac-
teristic of the  convalescence of rheumatic fever.   If the blood is
aqueous, and contains less solids than normal, at the same  time
that the salts bear their usual proportion to the rest of the solids,
it  is obvious that  there must be a great deficiency of  those  salts
in the body.   Though the blood be not  acid, it is easy to under-
stand that it carries less alkali  than it ought to do.
   A real deficiency is attempted to be  replaced by the  carbon- 
RHEUMATIC FEVER.
163
 ated alkali.  And when we think how great is the mass of living
 matter over the whole of which this great deficiency exists, then
 is explained the need for large and repeated doses, which  all
 good observers insist upon.   To give a few grains three times a
 day is mere playing at healing, and cannot be reckoned as treat-
 ment at all.   I do not think anything less than half  an ounc^
 of the bicarbonate of potash in the twenty-four hours  is of real
 use.   Again,  if this runs off straight by  the  kidneys, making
 the  urine  alkaline too quickly,  it is of little  avail;  but  if  it
 mixes with the  mass of the corporeal fluids, and is some time
 before it is found by its alkaline reaction in the renal secretion,
 the  good  effect is sensibly felt by both  the  patient and his
 attendants.
   Again, I do not think  it a fair trial of the treatment to give
 the potash neutralized by an acid, as tartaric or citrate.  These
 salts may  be  good for rheumatism, but they  do not  test Dr.
 Garrod's statistics. And similarly, larger doses at longer intervals
 do not fulfill the indications.
   A collateral advantage of frequent doses is the more attentive
 nursing which it insures.  In these oft-repeated visits the attend-
 ant  looks well after the arrangement of  the  bedding,  sees that
 no part is left exposed to the air, and as our naval  friends say
 " makes all taught."
   (b) The employment of iodide of potassium is more empirical.
 By none can the  fact  be explained that this  remarkable sub-
 stance restores their normal  functions to several tissues—most
 notably to those sparingly supplied  with blood-vessels, such  as
 cartilaginous and white, hard, fibrous parts, the periosteum, the
 sheaths of tendons and of nerves—and even influences the hair,
 the nails, and the outer layers of skin.   Iodide of potassium is
 of signal  service when rheumatism  or gout attack the tendons
 or the thecae inclosing the muscles  and tendons.  I think we
 cannot doubt the words of the sufferers when they say that they
 feel the better for  it, however inexplicable the fact may be.
   The earlier  in the disease that iodide of potassium  be given
the quicker it  acts.  You may see this to be the case in syphi-
litic  periostitis, which when recent, yields rapidly, and when of 
164
RHEUMATIC FEVER.
 long standing, yields  but  slowly, to  the  influence of the  drug.
 So  is it  in  rheumatism;  the old chronic cases  are aided by
 iodide of potassium, indeed, but prove as a rule very obstinate;
 Avhile  this affection of the white fibrous tissues  which follows
 rheumatic fever, and which we are now concerned Avith, is usually
 removed  in a few days, because it is taken in hand  at an early
 period.
   4. Opium.—This is given purely as an anaesthetic.  There is
 no reason to think  it either shortens  or lengthens  the  time  the
 disease lasts.  Curiously enough, it  does not usually  stop  the
 action of the bowels  so long  as  the  painful  condition remains
 which it  is given to  lighten.  Should constipation  follow,  the
 inconvenience is  easily obviated by adding two or three grains
 of good extract of colocynth to the opium pill.
   5. Blood-letting.—The treatment by leeches  and poultices of
 the  common inflammaticin which  may sometimes  override  the
 rheumatic in joints moved about during their  weak state,  has
 nothing special about  it.   It  may generally be  depended  upon
 to prevent disorganization, because in point of  fact  the inflam-
 mation is very slight and diffused.
   6. Carditis.—I have told you inflammation of the heart does
 not come on in patients who have once been placed and kept under
 the treatment detailed  to you.  But  in a good  many instances
 the exposure the  poor people have been subjected  to previously,
 and  sometimes the necessary time spent in our waiting-room,
 gives you an unlucky opportunity of seeing me treat this com-
 plication.  If it is found out within twenty-four  hours of coming
 to the hospital, it is of course registered as due to the circum-
 stances I have named, and our nursing is not to be blamed  for
 it.   I feel satisfied  that it need make no difference in the appli-
 cability of the  alkaline method;  indeed it  rather strengthens
 my resolution  to insist on  this  being  fully carried out.  It
 determines me also  to be more than usually watchful about  the
 maintenance  of temperature by blankets, and to  take care of  the
 chest in special by continuous poultices.   When cardiac symp-
toms are  detected, Avhen there is  friction or a murmur  detected
by the ear, or even Avhen pain is  felt on pressure of that vital 
RHEUMATIC FEVER.
165
part, from six to twelve leeches  are  forthwith applied; these
usually relieve the pain somewhat; but if it returns again next
day, they are to  be  repeated, and this may be done again  and
again,  as  long as pain lasts.   The pain  is the best measure of
the acuteness of inflammation  in serous membranes ; and so long
as acute inflammation  remains, leeches and  poultices are the
best remedies for it.*  To mercury I have never been  able to
trace any advantage at this stage; indeed, I am not sure that it
does not dispose  to pericarditis  by increasing the proportion of
fibrin to the  other constituents of the  blood.   Perhaps after
effusion has  taken place it may be useful, but I am not quite
satisfied that it is desirable in all cases even then.
   Opium may be given in full doses; and far from being contra-
indicated on  the score of cardiac inflammation, it is all the more
urgently called for.    For it  certainly does control and lower
the hurry of circulation which is so dangerous.  Under its  use
the pulse is diminished in  frequenc}r, sometimes even below the
normal  standard; and this must surely be an important object
in a diseased state brought about by the continuous motion of
the heart.
   The treatment of pericarditis  brooks no delay.  Lost minutes
are more  hurtful here than in any disease I know of.  Send
for leeches and have  them applied immediately that your  sus-
picions  are aroused  by an abnormal murmur, and if they are
not at hand,  cup  the cardiac region.   It is better even to antici-
pate evil than to be  too late.  On this principle you  saw me a
fortnight ago leech and poultice the heart of the young woman
before mentioned (case of Margaret K.), where you could hear
no friction in the pericardium, and you wondered at my "sharp
practice."  But the fact is, it  was a case of relapse ; and as the
patient  slept in  the  convalescent ward,  the  nurse  carelessly
neglected  to wrap her in blankets:  the cold damp linen  was
beginning  to  do  its  work, and the lengthened heavy  stroke of
the left ventricle, accompanied by a sense of tightness  and pain
on  pressure,  warned  me  to  try  and prevent  the  threatened
inflammation.  I was  only partially  successful;  the  foreseen
          * This subject is fuller treated in a subsequent Lecture. 
166                 RHEUMATIC FEVER.
evil  did  come ; in two days'  time an exo-cardial  murmur was
distinctly heard.  But I am sure the pericarditis was in a much
milder form  than it  would have been had leeches  not  been
applied.
  7. Diet.—In rheumatic fever there is a painful  necessity for
restricting  the supply of an important  class of nutriment.  If
meat be given, it seems to turn into lactic acid,  at  all  events it
adds to the quantity of organic  acids in the body.  The power
of fully converting it into living flesh is  wanting, and  until this
power  is restored, a semi-conversion into the substance named
takes place.
  Even when the pains  are gone  and there is  such an urgent
call for replacing lost flesh, the most suitable diet for supplying
it will  sometimes  bring on a relapse.  Hence I find it  needful
to give patients  less  food than their  feelings prompt them to
take.  The redder and more muscular it is, the more it seems to
disagree, and you must very  cautiously get  back to " ordinary
diet,"  else you run  a risk of losing more by a second  attack of
the  disease  than is to be gained by haste.   Vegetable matter
does not expose patients to the same danger, and  thus  by dint
of rice pudding, porridge, gruel,  bread, mashed potatoes, and
the  like, you may try to satisfy the mouths which often loudly
complain of  starvation.   If, however, you  cannot, by such  per-
suasion, succeed  in staying the appetite, it is  your duty  to be
cruel, for observation will soon convince you of the hurtful effects
of animal food in causing relapses. 
LECTURE  XII.  ■
                RHEUMATIC  FEVER.

Exceptional  cases of rheumatic fever—Inflammation of heart
     arrested by epistaxis—Delirium and gangrene in rheumatic
    fever—Treatment—Case of rheumatic fever in a tubercular
     subject, with consecutive purpura of the legs—Treatment by
     lemon juice.

            (Clinical, St. Mary's, June 27, 1863.)

   A young woman with rheumatic fever in the corner of Victoria
Ward was found the other day by the house surgeon, Mr. Mahon,
to be suffering from pain in the cardiac region increased by firm
pressure.   Although he  could detect  no abnormal  sound  on
auscultation, yet he thought  it advisable to order half a dozen
leeches to be applied  to the part.   He was wise, I think, in so
doing;  for the  course followed  by inflammation of the heart in
rheumatic fever is this;—first the rheumatism, such as you see
it and feel it in the limbs and joints, settles in the heart, just as
it might settle in any other part,  and as in any other part with-
out common or disorganizing  inflammation;—but,  as in any
other part, motion will change the rheumatic into disorganizing
inflammation; and therefore as  you cannot stop  the heart's
motion, you must try and get  rid  of the rheumatism quickly,
and  for the  time only  perhaps, but at any  rate for the time,
from this dangerous locality.  And you must not mind making
some sacrifice to accomplish such an important object.   Now,
local blood-letting does do this even in the joints, only that it is
not in  general worth while to get rid of the rheumatism, out of
• 
168
RHEUMATIC  FEVER.
 the knee for example, when in half an hour it may come on just
 as bad in the hand.  But in the case of the heart it is  worth
 while, well worth while, to do much more (if wanted) than putting
 on a few leeches.
  But do the leeches really prevent it in  a natural and physio-
 logical way ?  This case has shown you  that the treatment is
 entirely in accordance with  nature (if that is any recommenda-
 tion) and  reasonable physiology.  Though ordered, the leeches
 were  not put on—and why ?   Because in the mean time  the
 woman's  nose  burst  out  bleeding,  and  that  event entirely
 relieved the pain in the heart, and most completely justified the
 prescription which had been written.
  I do not  want you to accept  the epistaxis as an  " effort of
 nature," designed to relieve threatened carditis ; for, as a matter
 of fact, any idiopathic  haemorrhage  is very uncommon  under
 such circumstances—but as a fortunate accident.   If it had any
 design at all, it was designed to teach you medicine; to  teach
 you  that  a very moderate loss of blood may avert a  great
 danger.
  But I have spoken of loss of. blood even in moderation as a
 sacrifice.  And  it is  so peculiarly in rheumatic  fever.   The
 disease is one which, cseteris paribus, attacks the weakest persons
 at their weakest times; women, children, the aged, the debili-
 tated  by sickness are the most  liable, if exposed to the  usual
 causes. And not only the weakest persons, but the weakest parts
 of those persons.   I  admitted  a  man  named  Amos F.  into
 Albert Ward on June 12,  with rheumatic fever.  Two  years
 ago he was in this hospital  for paralysis of the right arm and
 leg, in consequence of some  cerebral lesion probably, and he  has
 never recovered  full power in the upper extremity.   Since then
 he has had rheumatic fever twice, this  being the second occasion,
 and both  times  the right elbow  and hand  have been the  place
 first affected, and the place longest and worst affected both with
 pain, and swelling, and redness.   If then rheumatic fever affects
by preference the weakest  flesh, it is right to view everything
that weakens the flesh a  sacrifice.  In that light we must con-
sider loss of blood, prudent and wise though the sacrifice may be. 
RHEUMATIC FEVER.
169
           (Clinical, St. Mary's, October SI, 1863.)

  Exceptional cases occur  seldomer in rheumatic fever than  in
any other disease I can at this moment call  to mind.   Yet they
do occur; and there is now in the wards one noteworthy instance
of rare symptoms  and rare treatment, both markedly different
from what I have described as those of at least ninety-nine out
of a hundred of the patients you will have.   For this hundredth
case you ought to be prepared.
  The  fever  of acute  rheumatism  bears the  type which our
grandfathers  called "synocha," and our  fathers  "inflamma-
tory ;" that is to say, the relations  of the senses and  the mind
are not impaired in the  direction of either obtuseness, coma, or
delirium ;  there  is no tendency to the local death of tissues  or
gangrene; and the  congestions which may intervene  result in
active and fibrinous inflammation.   But occasionally it exhibits,
from the very beginning, the character of typhus;  the nervous
system is  deeply affected in its  most  important functions, there
is an  excessive depression  which may end  fatally, and a great
danger  also  from  sloughing of the parts  compressed in  the
recumbent posture.
  Such are the peculiarities in the instance of George R., re-
ceived as an  urgent case  in the middle of last  week, October
21.   He is a wiry little letter-carrier, only twenty-four years
old, who has never before suffered from any serious illness.  He
has a  happy  home, and a merry,  affectionate wife;  is active,
prosperous, and intelligent, employing his leisure hours in playing
the organ at a neighboring church.   I recount these particulars
to show that his antecedents are not of a noxious kind.   On the
7th of October he  cleared  out a  dirty cistern and got very wet
and cold.   On the 9th he felt out of sorts, and took a hot bath.
This exhausted him, and he  also got chilled in  coming home.
Pains in the limbs  came  on, and on the 11th he was laid  up  in
bed with increased pain accompanied  by swelling and redness in
the  joints.  He then had another hot bath, after which he was
still  worse.   His  wife  perceived then that his mind  began  to
       12 
170
RHEUMATIC FEVER.
wander from time to time, and before his admission, on the 21st,
the delirium  was  constant  and of a  violent character.   The
wrists, hands, one ankle, and the other  knee were red and much
swollen, and in the knee-joint  the  fluctuation of fluid could be
felt.  But during his ravings he moved these limbs about, seem-
ingly regardless of the pain which is usually so acutely felt in
rheumatic fever.   His  tongue was of  a  yellowish brown  and
nearly dry, the lips and teeth were  parched and brown with
sordes.  The skin was  sometimes dry, sometimes bathed in a
profuse sweat  of a rancid, sour odor.   His chest  was covered
with a copious eruption of sudamina.   His pulse was variable,
seldom above 100, however.  His bowels were constipated; but
after  a dose of  castor oil they were normal in action.   A stetho-
scopic examination of the chest proved the heart and lungs to be
free of any inflammatory lesion, their sounds being quite healthy.
He became so noisy and violent at night that he was obliged to
be moved into a room by himself, and then his delirium assumed
a more rambling form, and he made no more spasmodic attempts
to get out of his blankets.
   I saw him the next day, the 22d, and ordered—Jfy Opii, gr. j.
omni  node.  1^ Potassi iodini, gr. xv  ; Ammonise sesquicarb.,
gr. iv ; Decocti cinchonse, Sj.   4dis horis.  Six ounces of port
wine daily, and a cup of beef-tea every  two hours.
   His delirium and  low typhus symptoms continued till the
25th,  but on the 24th he was sufficiently quiet to be  moved up
into the ordinary ward.   On the 24th the spine of  his back was
noticed to be red, and on the 28th it  is noticed in the case-book
that a small slough had  formed on the sacrum.  His  tongue
however had got quite clean, and he had not been delirious since
the 25th.   The pain, swelling,  and redness had all disappeared
at that date.
   Such is the history of a more than ordinarily satisfactory ter-
mination of typhus rheumatic fever.   I have  seen several end
fatally, and was at first very anxious about this young man, and
was all the more anxious from some answers he gave  to our first
questions  having induced a notion that he had been suffering
recently from gonorrhoea; and I thought it just possible that we 
RHEUMATIC FEVER.
171
might have to amend our diagnosis, and that it would turn out a
case of  urethral pyaemia  affecting  the joints.   This  unworthy
suspicion  was however taken away by the indubitably correct
account his wife was able to give  of his freedom from that dis-
grace, and his own assurance when he recovered his senses.
   You may have remarked  that in relating his history I impli-
citly attributed some part at least of the severity of the disease
to  the  hot-water baths taken.    Possibly you may think this
accusation  of mine  somewhat  inconsistent with my  keeping
rheumatic fever patients  in a sort of perpetual warm bath, by
wrapping them up in fomentations  and blankets; so I take this
opportunity of teaching you that the two operations are not only
essentially different, but essentially contrasted with one another.
A hot-water bath involves too great changes of temperature, a
rapid one from the original heat to a degree above the original,
and a slower cooling afterward.  Packing in blankets with con-
tinuous  fomentations  not only keeps  the production of animal
heat even,  but it also defends the  patient against external varia-
tions.  So that where one does good, we may reasonably con-
 clude that the other does harm.
   About the treatment I do not wish to say much, except that
 it was in the highest degree stimulant and nutritious, in marked
 contrast to that  which I find adapted to ordinary cases of rheu-
 matic  fever.  I  have never administered iodide  of potassium
 before  under the same circumstances, but I think I shall again.
 Bark and ammonia alone I  have given on former occasions, but
 not with equally good results.
    You will have observed that my first act on hearing the history
 was to apply my stethoscope to the heart, and then to the lungs,
 although  there was no account of any symptoms referrible to
 those viscera.  The fact  is that delirium, which is the secondary
 result  of  pneumonia  or  pericarditis in rheumatic fever,  usually
 masks its  cause, and violent  inflammation may go  on  without
 showing  any external evidence of its presence.   It  is right
 therefore to look for  these local inflammations, for in  point of
 fact delirium of such  an  origin is more  common than that which
 we see here with lungs and heart healthy. 
172
RHEUMATIC FEVER.
    The delirium in both cases I believe to be of the same nature,
  to be in  itself  indicative of the  same pathological condition of
  the nervous  system, and to be  suggestive of  the same  line of
  treatment, whether it exists along with thoracic inflammation or
  without thoracic inflammation.   I believe it indicates a threat-
  ening of death  by the nervous system, which must be warded off
  as you have seen it warded off here.  It is only when rheumatic
  pneumonia and pericarditis have gone  too far to  admit of de-
  pletory or debilitant measures, or occur in a frame already dis-
  posed to typhous depression, that they impair the cerebral func-
  tions.  When therefore delirium  supervenes, I would  advise you
  to treat any inflammation of the  heart or lungs  which you may
 find with it, in  such  a way as not to interfere with  your bark
 and your wine and your opium.
   There are two ways in  which the pathology of these low forms
 of rheumatic fever may be explained.
   First, it is not impossible that a zymotic poison may enter at
 the same time with, and combine  to form a new  compound influ-
 ence with the influences which originate the rheumatism.   And
 such an explanation would chime in very well with the history of
 the case  under our eyes;  for the  man says  his ailment  was
 caused by cleaning out a  foul cistern, where decaying  organic
 matter would be the suitable birthplace of febrile malaria.  But
 I have  not been able to  trace this kind  of evidence in  other
 instances.
   Secondly, we  may view it as an imitation rather  than as the
 child of typh-poisoning.   The symptoms by which we recognize
 the action of that virus are especially exhibited in the nervous
 functions—the rigors,  the languor, the delirium, are witnesses
 of death in the nerves; and  when such death in the nerves is
 due to other causes, the same symptoms arise.   Hence you have
 the low,  or typhous, state  arising after severe injuries  of al
kinds, when the destructive consequences of those injuries arrive
at the nervous system.   This may, under  special circumstances
of which we are  ignorant,  be  the exceptional case in rheumatic
fever.
  Neither view modifies the treatment. 
RHEUMATIC FEVER.
173
          (Clinical, St. Mary's, December 12, 1863.)

  In Cambridge Ward is an example of rheumatic fever, which
has lain in  the hospital longer than the usual time, and is not
yet fit to be discharged.   The patient is a carman;  John H.,
aged  26, admitted November 7.   The peculiarity that  distin-
guishes it from the ordinary run of cases is, that he has consoli-
dation, detectible by bronchial breathing, and presumably tuber-
cular, of the upper lobes of both lungs, and copious muco-purulent
secretion from  the bronchial membrane (chronic bronchitis)  in
consequence of it.  Whenever he is put upon low vegetable diet
and sweated in blankets,  his rheumatic pains and  swellings  of
the joints subside  as readily as do those of other patients ; but
then he grows terribly weak, and the expectoration increases in
quantity and purulence, so that  we have to give him full allow-
ance of animal food and  quinine.   This brings  back the semi-
acute  swellings  and pains,  with sour rheumatic  odor  in the
sweat, and even some degree of fever.  Iodide of potassium has
not prevented these relapses,  which have occurred  three times.
  In  examining  his legs  on  the  occasion of the last relapse, I
found  around the ankles  a copious crop of pin-head specks of
purpura.   On  this  indication, I ordered  him  three ounces  of
lemon juice daily, and the treatment seems to succeed very well,
for he is gaining  strength now without relapsing, although eat-
ing meat daily.
  Had this  man been treated by alkalies, it is most likely  some
of us  would have  attributed his purpura to that cause.  But the
rheumatism, in its acute stage, was  alleviated only  by the usual
blanketing and low diet.   And moreover, I take this opportunity
of saying that, whatever may be the defects of the alkaline treat-
ment (which I am not going  to discuss now), the production of
purpura is not one of them.   I have not seen such scorbutic con-
dition more frequently among rheumatic fever patients so treated,
than among others.
  This seems to  me just  one of those specially circumstanced
cases of rheumatic fever  where  lemon juice is  suitable, and I 
174
RHEUMATIC FEVER.
think that it was from the obvious advantage derived from  it in
similar instances that its credit as a remedy has been gained.
  The difficulty of trimming the dietary where one complaint is
to be benefited by starvation and another by high feeding is  very
great, and it is  a most  fortunate circumstance  that  this com-
bination  is rare in the  case  of rheumatic  fever, which seldom
occurs in comsumptive persons. 
LECTURE  XIII.
                 RHEUMATIC  FEVER.

                  Therapeutical Statistics.

            (Clinical, St. Mary's, January 9, 1864.)

  Statistics, like many other excellent things and people,  are
apt to prolong themselves into bores, and in so  doing lose much
of their legitimate force.   It will  be my aim therefore  to make
this lecture as short as I can.
  Between June 1851 and Christmas  1863 there have been in
the wards under my care at  St. Mary's 257 cases of rheumatic
fever.  Of these (cases under treatment on  Christmas day  not
being included)—
    26 were treated with 5j of niter three times a day;—
  174 were treated with bicarbonate of potash—viz.,
          141 with 3j, or more, every two  hours;—
           33 with a  less quantity ;—
    32 were  treated,  during  the first year, in  various  other
       ways ;—
    25 (that is to say, all since May last) have had none of these
       supposed curative drugs ;* only a little  opium when  the
  • I suppose it is natural, as one advances in years, to adopt milder and milder
methods of treating rheumatic fever.  Sydenham did so.  In 1675, the date of
the  third  edition of the " Observationes  Medicae," he was trying the " curatio
repetitis venae-sectionibus:" in 1680 he writes to the Warden  of Caius College,
Cambridge,  " verosimile  esse  judicabam  morbum  diasta simplici, admodum
refrigerante, et mediocriter nutriente, agro imperata, aeque feliciter  ac repetitis
venae-sectionibus profligari posse;  etiam evitatis, qua?  alteri methodo adjunge-
bantur, incommodis: neque me fefellit diaeta  e sero lactis  phlebotomise loco
substituta."  This  is repeated in  the revised  edition of the " Epistolae Re-
aponsorire," date 1685. 
176                 RHEUMATIC FEVER.

      pain was very severe, and a purgative when the bowels
      were abnormally costive.
  No selection  of cases was made, but each method was adopted
in every case for a time.


        1. Results of drugs on the duration of illness.

  Of the  26 treated with  niter,  the  mean  stay in hospital was
40-0 days.
  Of the 141 treated with  the 9j bihoral doses of bicarbonate
of potash, the mean  stay in hospital was 34*3 days.
  Of the 33 treated  with less quantities of the potash, the mean
stay in hospital was 40-0 days.
  Of the  25 treated without  curative drugs, the  mean  stay in
hospital was 27-7 days.
  If  we exclude the last  class,  which  is as yet  imperfect  for
statistical purposes,  as it does not include  examples of all the
four seasons, it would seem  that,  though smaller doses exert no
effect, yet that  full doses of the bicarbonate of potash have some
influence in shortening the duration of the illness  from  the time
of commencing the  treatment to  that  of  the patients being
sufficiently convalescent to return to their usual occupations with
safety.
  I may remark here, that any other  measure of the duration of
the disease is quite untrustworthy for statistical purposes.   The
different degrees of  susceptibility to pain exhibited by  different
patients, the desire of some to extenuate, of others to exaggerate
their sufferings, makes it impossible  to  register truly even  the
exact day when the pain  ceases.    Whereas, in  such  a  short
period as it lasts after the commencement of treatment  (namely,
two or three days usually), the exact hour  would require to be
noted.   It is  equally impossible to  measure when,  or even
whether, the swelling or redness is all  gone.  Those who have
set clinical clerks to observe these facts know how  little  the case-
books are to be relied on. 
RHEUMATIC FEVER.
177
     2. Results of drugs on the consequences of the illness.

  In  respect of their several  preservative powers  against the
consequences of rheumatic fever—
  Of the 26 treated  with niter, there were attacked with  acute
inflammation of the  heart while  under treatment (carefully ex-
cluding all those admitted with it already existing as a result of
the current attack) 5, or 19-2 per cent. (4 cases of  pericarditis,
1 endocarditis  only); 4 have  died—2 of  inflammation of the
heart,  and two  of sloughing back.
  Of the  174 treated with bicarbonate of potash, there were at-
tacked with inflammation of the heart 9, or only 5-3 per cent.;
none have died.
  It would seem from  this,  at first sight, as  if bicarbonate of
potash had some preservative force.  But the fact is, that nearly
all of those treated  by  the alkaline method have been subjected
also to what both rational physiology and the statistics following
seem to show has a much more  powerful influence than any other
drug  in keeping the heart free from inflammation.  I  refer to
blanketing the  patients.

                   3. Effects of blanketing.

  Up to May,  1855, no difference was  made  in the bedding of
my patients  with  rheumatic fever from that  of  others in the
ward; but after that date they were ordered to be  rolled  up in
blankets,  and no linen was let touch the skin.   In nearly every
case the orders were strictly obeyed.
   Of 63,  either bedded in sheets, or who had willfully thrown  off
their blankets,  6 contracted newly  pericarditis at  least, if not
endocarditis as well; 3 had relapses of pericarditis on old cardiac
lesions; 1 had endocarditis  alone;  on the whole 10, or nearly
16 per cent., had inflammation of the heart, and 4 died.
   Of 184 in blankets, none have contracted newly pericarditis;
none have died ;  1 had a relapse of pericarditis on old cardiac
lesions; 5 had endocarditis  alone;  1  a relapse of  endocarditis
on old cardiac  lesion. 
178
RHEUMATIC FEVER.
  One of these included  cases of pericarditis was brought on
during convalescence by  the  patient  being dowsed  with cold
water for an accidental hysteric fit.
  Not 4 per cent,  have had any acute affection of the heart;
when it came it was of a milder character, and was generally to
be accounted for by some  imprudent exposure.
  That is to say, that bedding in blankets reduces from 16 to 4,
or by a good three-quarters, the risk of inflammation of the heart
run  by patients in  rheumatic  fever, diminishes the intensity of
the inflammation when it does occur,  and diminishes still further
the danger of death by that or  any other lesion ; and at the same
time it does not protract the convalescence. 
LECTURE  XIV.
         GONORRHEAL  RHEUMATISM.

Case.—Name  of disease not  strictly correct—Its relation  to
    pysemia—May occur at any period of the gonorrhoea—Not a
    metastasis—Objection to any treatment grounded on its being
    a metastasis— Urethritis a worse disease than gonorrhoea—
    Possible  peculiarity of gonorrhoea! virus in  these  cases—
    Rarity of such severe cases as this shown by the results of
    seventeen other cases, which represent the more usual aspects
    of the disease—Specimen of a more usual case of gonorrhceal
    rheumatism, and its treatment—Recurrence of gonorrhceal
    rheumatism.

            (Clinical, St. Mary's, May 30, 1863.)

  Mrs.  W—, aged  twenty-six, exhibited, on  February 12,
symptoms resembling to my eyes those of a first attack  of acute
synovial  rheumatism.  She had been seized three days before
with pains in the joints, and the right knee and left elbow were
much  swollen, and  showed a slight erythematous blush of red-
ness.   There was headache and thirst;  the pulse was 112, and
the tongue white and furry.   The case so strongly resembled
one of rheumatic fever, and so little one of  gonorrhceal  rheuma-
tism, and moreover  the latter is so rare in the female sex, that I
felt no  hesitation  about the  diagnosis,  and put her  on the
alkaline  treatment  for the  disease I thought it was, with the
addition  of a  few leeches to the affected joints.   This  went on
till the third week in  March, when the extreme obstinacy of the
painful swelling, and its  fixture in particular joints, induced me
to make  a more particular examination of the case with a view 
180
GONORRHEAL RHEUMATISM.
to a revision of my diagnosis.   She then confessed the follow-
ing sad tale:—Three years  previously she had been infected by
her  husband with syphilis,  and bore  a diseased  dead child.
Again she became pregnant, having in the mean time had second-
ary sore-throat and a cutaneous eruption.   The second child was
born at seven months, and lived but a  few hours.   It  also had
an eruption on its body.   She said she was  again pregnant with
a third, and was anxiously fearing for its  life  too, as  she  had
then a purulent discharge contracted from her worthless husband.
Curiously enough,  he was stated by her to be also suffering from
what she called "rheumatic gout," that is to say, a disorganizing
inflammation of the joints, which had  followed his gonorrhoea.*
It was satisfactory to hear  of the  punishment of the guilty as
well as of the innocent.
  I then  changed the treatment, leeched  freely,  and  blistered
the principal joints,  applied constant poultices, and gave her
iodide of  potassium to the amount  of thirty grains  a day.   In
the chronic state which the complaint had  assumed, the blisters
(according to  the  patient's  statement) gave more relief to the
pain than  leeches, and the result of this treatment  was to reduce
the size of the joints by the  absorption of synovia,  and to relieve
the patient much.  But I am sorry to say the right knee and left
elbow appear to me too much disorganized  for any likelihood of
her ever entirely recovering the free use of them.
  On May 26, she was  confined of a  healthy child at the full
term, so that it must have been begot at the  end  of September
last  year.   At that time she is sure that  her husband had no
complaint of any kind, and that he  did not  have the gonorrhceal
discharge  I have spoken  of till  the middle of December.  This
accounts for the germ of the infant being healthy;  and it is an
encouraging circumstance to find  «the filtration  (if I  may  so
speak) of  the  mother's blood through the placenta purified it of
the poison which began to work in her system afterward, when
her baby's ante-natal life was advanced to about four and a half
  * I afterward found this man in Middlesex Hospital,  under the care of Dr.
Stewart.  This case was entered in the case-book as  one of gonorrhoeal rheu-
matism, and it seems he had had several previous attacks  of the same nature. 
GONORRHCEAL RHEUMATISM.
181
months.   It  is valuable  also to know that  the  thirty grains of
iodide of potassium, which she took daily for ten weeks, and left
off  only  when  in  labor, has no  bad  effect on  utero-gestation,
and may be safely given to breeding women.
  You have seen her  to-day fulfilling the maternal duty of suck-
ling her healthy infant.
  During the last  fortnight of pregnancy there was  a singular
firm elastic tumefaction in the vastus externus of the right thigh.
It felt like very soft India-rubber, was painless, distinct, and as
big as a large orange.  What it was I do not know, and  it has
now disappeared almost entirely.  I  do  not think it had  any
connection with those remarkable swellings in the muscles which
Ave  find in syphilitic  patients, because these  do not vanish so
quickly, being much more permanent.
  Before I proceed to comment upon the disease which has been
the special object of treatment in this case, I would  remark upon
the healthiness of her present  child.   Such cases are a  strong
negative reply to a doctrine  which is very popular, as  to the
irremovability of the syphilitic virus.   I mean the doctrine which
maintains that when it has  once  gained a firm  hold of the con-
stitution, it is always transmitted to all future  progeny.  Here
you have  convincing evidence of  the constitutional affection in
the deaths of the  two first fruits  of the womb, and evidence of
its  eradication in the  health of the third.
  Gonorrhceal  rheumatism is a  convenient conventional term
which we  continue to employ, really for  want  of a better.  It
means a specific acute or subacute inflammation of joints  and
the neighboring white tissues, bearing in its external aspect a
resemblance  to  sometimes one and sometimes another of the
forms of  the disease it is  named after.   But it  has not the
slightest other relation, either pathological or  therapeutical, be-
sides external similarity, to rheumatism.
  It is really due to  a poison  absorbed into the blood  from a
mucous membrane  affected with  purulent gonorrhoea, and thus
has more claim to be classed  by the side of pyaemia than in the
position Avhere it  is now placed.   Like  pyaemia, too, it has a
strong tendency to disorganization of the affected part; pus and 
182
GONORRHCEAL RHEUMATISM.
fibrin are formed, and the tissues are destroyed  in bad cases.
Like  pyaemia, too, it does not exhaust itself by the inflamma-
tions which arise; it is not an acute disease, in the sense of tend-
ing to recovery, but a chronic disease, getting worse and worse
if not arrested.  It is an accident of gonorrhoea, not an essential
part of it, just as pyaemia is an accident of surgical operations
on wounds.
   Its extreme rarity in the female sex is an additional evidence
in favor of the poison being absorbed from the locally diseased
part.  In woman the mucous membrane principally affected by
gonorrhoea is the vaginal,  a tough, strong surface which bears a
great deal of ill treatment without serious  injury.  Its diseases
have but little influence on the general health.   But the male
urethra  is a much more  delicate part, and we can easily com-
prehend that it should oftener take up the gonorrhceal virus  and
communicate it to the rest of the body.
   Being an  accident, it may occur at any period of the gonor-
rhoea, sometimes happening  only a few days after the first com-
mencement of the running; but by the simple doctrine of chances
 of course more likely in  the longer period before the patient  is
 free.  Hence it often appears just  as the urethra or vagina  is
 getting well, and so has been reckoned an  instance of metastasis.
 Metastasis  however it is not, for often and often the discharge
 continues as bad as ever, or even grows worse, while the joints
 are swollen.  And  when the joints get better, there is no return
 or aggravation  of the original ailment.
   This  is not merely a pathological question;  for on the notion
 of metastasis  it has been proposed to  try and bring back the
 gonorrhoea to the genital organs by irritating injections.   I have
 seen this actually done, but without any of the desired effect  on
 the  arthritic affection.   Even if it Avere  a curative operation I
  should  be  averse  from practicing  it, for the disease which you
  thus  give the  patient is not true gonorrhoea, but urethritis  or
  vaginitis, and that  of a chronic character—a much worse thing.
  I say it is  a  much worse thing, because it is so  dangerous, so
  very difficult of cure, not rarely indeed proving  quite incurable. 
GONORRHCEAL RHEUMATISM.
183
I published in the "Lancet," two years ago,* the case of a young
man who died of inflammation of the bladder, caused by the ma-
nipulations of a spermatorrhceist on his urethra, and I contrasted
there the violence  of the  disease artificially produced with the
mildness of a real specific gonorrhoea virulenta left to nature.  A
clergyman sometimes consults me about his general health, who
has had purulent urethritis for the last three years, for which he
has  been to  several of  the principal surgeons in London, and
tried all  sorts of* local remedies without relief; so that he has
now made up his mind to bear it with patience  and try no more.
It was first caused  by a  too zealous  practitioner having  passed a
catheter to ascertain whether certain nervous urethric symptoms
were due to stricture.   It was at one time suggested  that the
catheter might have been an infected one, but the absence of any
specific virus was proved by his wife not contracting gonorrhoea,
though  he had not foregone matrimonial  intercourse.  It is a
simple urethritis, just such as we should cause by local irritants;
and I think, with such cases before  my eyes, I am quite justified
in deeming urethritis a worse thing than gonorrhoea, and in de-
clining  to use it as a means of cure.
   To return  to the patient now under our observation.   She will
tell you that there has  been nothing like  a metastasis  to  other
parts of her body; the  purulent  discharge continued quite un-
affected by the swelling  of the joints, and  she  says the same is
true of her husband also.
   It is  a very singular thing that  the gonorrhoea  in both hus-
band and wife should have been followed  by the  articular affec-
tion ; it looks  as if there was something special in  the form of
the  original disease.   But  such  an occurrence is quite excep-
tional,  and may be a mere coincidence.  Indeed, my only reason
for mentioning it, is to warn you  of its rarity, in order that you
may not put it down in  your pathological  sketch of gonorrhceal
rheumatism.
   I must also warn you of the rarity of such severe consequences
  * Viz., June 15, 1861, in a clinical lecture given at St. Mary's, but not repub-
lished in this volume,  as it has no special bearing  on therapeutics or on the
Renewal  of Life. 
184
GONORRHCEAL RHEUMATISM.
of gonorrhceal rheumatism as  these which  you see before  you
now.  In the great majority of instances, especially if they are
treated  early and  actively, complete recovery results.   I have
not had  an opportunity of bringing such a case before my present
class, because there has not been  one under  my care lately;  so I
will extract a few examples from my old case-books.
  William M. (No. in Hospital  Register, 2801), aged twenty-
two,  admitted  November 26, 1853, had pain  in  one hip, with
swelling and redness of the feet  and ankles.  •He got no better
for treatment with niter and warm-baths; and then it was found
that  he had a gonorrhceal discharge, and confessed that he had
had a similar sort of rheumatism  with  gonorrhoea three years
previously.  He was cupped several times on the affected joints,
and got well.
  Thomas J. (No.  in  Reg. 4119), aged forty, admitted October
27, 1854,  had contracted gonorrhoea, and got cold in  a hay-field
in August, and had  had  pains and swellings of the joints ever
since.  He had, on admission, swellings of the right wrist, and was
helpless from pain in the knees,  though those latter joints were
not  apparently  enlarged.   He  got  better in six days, with
warmth, niter, and colchicum,  and was dismissed.
  James C. (No. in  Reg. 4202),  aged twenty-six, was admitted
November 17, 1854.   Five years previously this man had con-
tracted  what he  called "venereal disease," accompanied  by an
urethral discharge.  Immediately  afterward his knees  became
swollen  and  painful, and had remained  so ever since, in spite of
blistering.   On  admission, the right knee  measured in circum-
ference  17 inches, the left  13J  inches.  The right  elbow was
also  enlarged and stiff.   The  jaw-joint  had  been similarly
affected, and he could open his mouth but a very  little way.
The orifice of the urethra was red, and itched a good deal, but
there was  no gleet.   Colchicum  internally, and iodide of mer-
cury  ointment to  the joints did him  no  good.  He was then
treated  with leeches, iodide  of  potassium, and copaiba.   The
pains were relieved,  and  the circumference of the largest joint
was  reduced to 15J inches by the  second week in March.   He 
GONORRHCEAL RHEUMATISM.
185
had then been in the hospital more  than four months, and, as
he considered himself able to work, I dismissed him.
  David 0. (No. in Reg. 5117), aged thirty-eight, was admitted
July 10, 1855.   After infection by gonorrhoea three weeks pre-
viously, pain and swelling of the left knee, and pain at the side
of the head, had come on.   There was a good deal of fluid in
the synovial sac, and he thought it was increasing.  The urethral
discharge was irregular, sometimes absent, sometimes present.
He was  ordered, for about ten days, three grains of calomel
every night, and a senna and a jalap draught in the morning,
and leeches were applied to the knee every other night for four
times, and a weak chloride of zinc injection.  The discharge and
rheumatism ceased together, and  he went out well in forty-five
days.
  James K. (No. in Reg. 7717), aged twenty-four, was admitted
April 17, 1857, with pain and swelling of several joints, accom-
panied  by  redness of one wrist.  He was  treated at  first with
alkalies as  for acute  rheumatism.   Then sclerotitis was observed
in one eye, and, on examination, he was found to have a purulent
discharge from the  urethra, which he had hitherto concealed.
He was leeched round the eye and joints, and both got well at
the same time that the urethra ceased to secrete pus.   He was
in the hospital thirty-three days.
   William  B. (No.  in Reg. 8290), aged twenty-one, admitted
August 21, 1857, at Whitsuntide  had become infected with gon-
orrhoea,  which had continued ever since.   At the beginning of
July his ankles  and one Avrist got  painful and swollen.   They
were not red on admission, though he stated that they had been
so previously.  For the first day he Avas treated with bicarbonate
of potash,  but, on the history being  made out,  it was  left  off.
The treatment Avas changed; he was bled once and leeched twice,
and took copaiba, with some relief.   Then he was packed for an
hour a day in a wet  sheet, but experienced no advantage  at all
from it.  Then  he  took forty-five grains of iodide of potassium
in decoction of bark daily,  and went out  cured  on the  30th of
October.
   Frederick M. (No. in  Reg. 497), aged twenty-six, a butcher,
       13 
186
GONORRHCEAL RHEUMATISM.
caught  gonorrhoea in the beginning  of July, 1858, and was an
out-patient of this hospital for it, not having any bad symptom
to require his admission.  The discharge ceased, apparently in
consequence of treatment, and, about the same  time, he  began
to suffer from pain in the knees and ankles.   They soon swelled,
and, on his admission, on August 19, were slightly red.   His
feet and ankles were freely leeched, and he had  senna  every
morning.   As the pains relaxed, iodide of potassium Avas  also
given.   He was discharged as cured in tAventy-four days, but he
was admitted  again under Dr. Alderson  in November, and re-
ceived benefit from colchicum.
   Cornelius W. (No. in Reg. 581), aged twenty-five, was admitted
September  24, 1858, with pains in the hands and feet, moving
about in those affected parts, but not attacking the larger joints.
The patient presented at first the appearance of slight subacute
rheumatism, but, as it came out that he had gonorrhoea, he was
treated  with iodide of potassium, purgatives  every morning  and
hot baths.  He began to get better immediately,  and left the
hospital in  ten days.
   William  M. (No.  in Reg.  359), aged twenty-eight, admitted
Midsummer-day, 1859, stated that three years previously he had
suffered from gonorrhoea, which had been accompanied by severe
pain and swelling of the knees.  At the beginning of the current
month  he  had again  contracted the  same complaint, and the
knees and feet swelled and became painful.  On admission there
was still a running from the urethra, and the swollen ankles had
a slight blush of redness.   He was treated with leeches, purga-
tives, and iodide of potassium.  He left the hospital nearly well
in a fortnight.
   Mary Ann M. (No. in Reg. 84), aged twenty-nine, was admitted
February 10, 1860, and treated as a case of subacute rheumatism.
She went out disappointed  of  relief on  the  16th of the next
month.  It appeared she had, a few weeks previous to admission,
contracted  gonorrhoea, and that very possibly was the cause of
the obstinacy of her symptoms, especially as she was not treated
accordingly.  I extract the case mainly as a possible example of
gonorrhceal rheumatism in the female, not leading to disorgani- 
               GONORRHCEAL RHEUMATISM.            137

zation of the joints, as has happened to the patient whose history
began this lecture.
  Henry P. (No.  in  Reg. 91), aged twenty-three, was admitted
February 10, 1860.  Eighteen  months previously a purulent
urethral discharge (which had continued for  nearly two years)
ceased, and about the same time he began to be affected with
pains in the knees and feet, which got so  tender he could not
stand upon them.  The  feet were thoroughly  Avell leeched three
times, he was purged and took iodide of potassium, and in three
weeks was well enough to return to his work as a painter.
  James B. (No.  in  Reg. 758), a smith, aged  tAventy-eight, had
contracted gonorrhoea virulenta  two  years previously, but the
purulent discharge frequently returned, and had never  quite
ceased.   He had, on admission, pain and a collection of synovia
in the knee-joints, for which he had  been from time to time
under treatment  during  the last  year and a  half at his native
place, Hastings, but without benefit.  He was admitted into St.
Mary's, Nov. 9, 1860, was  leeched three times, and  had iodide
of potassium so as completely to restore his health, at all events
for the time, and left well Dec. 3.
   Henry L.  (No. in Reg. 34), a gardener, aged thirty-nine, was
under my care for four  months at the end of 1859, for what I
considered and treated as chronic gout.  On his readmission  in
January, 1861, he confessed to his former and present attack being
consequent upon  " a gleet."  What he complained of principally
was excessive heat and  tenderness of the  heels, soles,  and toe-
balls of both feet.   They got red and swollen when he walked
upon them,  and  quite prevented his  following  his occupation.
He  took iodide of potassium, was  bled once, and was leeched
twice on the feet.  In about  a fortnight he was freed from  the
ailment  for  which he came  to the hospital, but unfortunately
some of the leech-bites  suppurated and sloughed, and he had to
take bark and remain in till the 15th of March.  That,  however,
was not so long as he had been under treatment inappropriate to
his disease on a previous occasion.
   William B. (No. in Reg. 362),  aged twenty-five, was  admitted
May 18, 1861, with buboes in the groin, accompanied by a puru- 
188
GONORRHCEAL RHEUMATISM.
 lent urethral discharge of five weeks' duration.   His knees and
 ankles had become swelled and painful, for which he came under
 my care.  He was at  first treated with alkalies for subacute
 rheumatism, and  was reported  better; but on getting  up his
 pains immediately returned again,  and he was put upon  iodide
 of potassium, Avhich quickly cured him.  He left  the hospital
 June 14.
   Henry P. (No. in Reg. 847), aged twenty-three, was admitted
 August 9, 1861.   Five years previously he had had gonorrhoea,
 which got well without any bad symptoms.  A month  before
 admission he was attacked with pains in the ankles, knees, hips,
 and right elbow.  He then found  he  had a purulent inflammation
 of the urethra, with a scalding on making water. On examination
 the feet  and  knees were found swollen, and there were some
 superficial excoriations on the glans penis, attributed by  the
 patient to the collection of discharge, which the stiffness  of his
joints prevented him from cleaning away.   (This seems to show
 the peculiar acrimony of the virus in these cases, for  ordinary
 gonorrhceal pus does not excoriate the skin.)  This patient had
 also gonorrhceal ophthalmia.  He was  leeched and took  iodide
 of potassium, and went  out well  September 6.   It may  be  re-
marked,  in passing, that his leech-bites also inflamed, like  Henry
L.'s,  but whether that  is  the  fault  of the leeches or  of  the
patients, I cannot say.
   John B. (No. in Reg. 66), admitted January  24, 1862, had
had a chronic purulent discharge from the urethra for a year, but
had experienced no further inconvenience from it till  January
20, when he was taken with  rigors and  aching in all his  limbs.
Then his joints swelled.  He was cupped, leeched, and purged,
and had blisters applied to his knees, and took internally copaiba
and cubebs.  He went out well on the 21st of March.

          (Clinical, St.  Mary's, November 14, 1863.)

   James M., aged forty-six, a butler, caught gonorrhoea  three
months ago; and six weeks ago, as the urethral discharge was
ceasing,  pains  commenced  in the  elbows,  ankles,  and knees.
These pains were fixed, not metastatic, and grew worse and worse 
GONORRHCEAL RHEUMATISM.
189
 in spite of treatment. The left knee swelled more and more, and
 at his admission on November 7, there was a considerable accu-
 mulation  of synovia  in the joint.  His general health was good,
 his appetite large ; the bowels, pulse, and skin were  normal.  I
 kept him in bed, starved him, leeched twice, and steadily fomented
 the  enlarged knee, gave  him  a scruple of iodide of potassium
 daily.  Under this treatment  for a week, the swelling has quite,
 and the pain nearly,  disappeared from the knee ;  the other joints
 feel quite well.   He cannot,  however,  straighten the leg, the
 tendons of the ham being impeded in their action by having con-
 tracted partial adhesions to the surrounding parts.   I expect the
 slight pain that remains will be somewhat obstinate, and that we
 shall have to leech the knee a good many times  before it disap-
 pears.*  If the contraction remains after that, mechanical means
 to free the tendons may be employed.
   I detail this case to you as a specimen of  the more usual, or
 mild form of gonorrhceal rheumatism.   If left alone and allowed
 to be ingrained into the constitution it becomes very obstinate of
 cure, and doubtless would have done so in this instance, unless
 the patient had been submitted to active treatment at this early
 stage. Now you  see it is more manageable, but still by no means
 so easy of cure as ordinary rheumatism or gout.
   As  to  the  rationale of the treatment.   The reason  for  its
 adoption is experience of  its good effects, the little effect which
 other treatment has,  and the certainty that the tendency of the
 disease is to get worse and worse if left  alone.   My  conjectural
 explanation of its action is as follows : I suspect the cause of the
 disease to be a virus  especially fatal to the vital functions of the
 white  non-vascular tissues, which  is  carried  to  them from the
 urethra by the blood. The partial loss of vitality in these white
 tissues causes congestion  and  inflammation in the neighboring
 capillaries,f  with  pains  and   extra-vascular accumulations  of

  * He was leeched  eleven times before he left the hospital for Christmas day,
having found that nothing did so much good as that treatment.   His leg was
not quite straight even then, and I cannot  say that the last four leechings were
of any use.
  f See " Lister on the early stages of inflammation."  Philosophical Transac-
tions of Royal Society, Part II for 1858. 
190
GONORRHCEAL RHEUMATISM.
serum.  The leeching and fomentations act upon the inflamma-
tion, and the iodide of potassium directly as a restorative to the
white tissues; as to the  starving, I do not know what to say—
perhaps it does good by promoting absorption—perhaps it is not
so requisite as we suppose.

           (Clinical, St. Mary's, February 6, 1864.)

   The sequence of rheumatism after gonorrhoea seems to depend
more upon the diathesis of the individual attacked than upon any
peculiarity  of the  infecting virus; for,  while  some  have  the
urethral part of the affection over and over again and suffer no
further, there are others who never contract the slightest puru-
lent  discharge  without  the  limbs  being  afterward  crippled.
This is illustrated by a man who was admitted on the 2d  instant,
Henry P., aged twenty-seven.  He was under my care  here in 1860
for gonorrhceal rheumatism, and went out in three weeks quite cured
by leeches, poultices, rest, and iodide of potassium.*  He seems
to think himself exceptionally virtuous  and lucky in having  not
again caught gonorrhoea till last August, and unlucky in its being
followed in five  weeks by painful swellings in his two ankles and
one knee, which have  continued to get worse.  You heard  me,
in rebuking  him for his nauseous vice of  fornication, threaten
 him that each time he contracted gonorrhoea it would certainly
be followed by this  painful consequence; and I believe that  I
was not at all exaggerating, when I stated that possibly  it might
 in the end cripple  him for  life, for I have  seen instances of its
 really doing so.  I shall this time put him under the same treat-
 ment as before, with probably the same result; but I  feel strongly
 disposed to  reject him as a patient, for having a second attack
 after he had once received such a warning of the consequences
 of vice.  I think  the threat  of rejecting him will  have an in-
 fluence, for  though he has been under medical treatment  four
 months, he has got no better and feels the  need of  the leeching,
 poulticing,  starving, and vigorous nursing which  he will  now
 receive.
            * The case is catalogued in page 187 (No. in Reg. 91). 
LECTURE  XV.
                   PERICARDITIS.

Case of pericarditis coming on in the hospital—Rarity of this cir-
    cumstance—Explanation of its occurrence in this instance—
    Diagnosis of old and recent disease by the  physical signs—
    Practical value of diagnosis—Treatment—Leeches—Blisters
    —Poultices—Prevention better than cure—Case illustrative
    of the use  of  mercury  in  similar circumstances,  and the
    reason why it is  no longer employed by the  author—Fatal
    case of pericarditis from exposure to the cold during conva-
    lescence  from  typh-fever— Two  cases  of  pericarditis, one
    arising from a linen shirt-front next the skin during  rheu-
    matic fever, the other of doubtful origin—Action of opium
    on the pulse— Variations in the pulse—Remarks on the pain
    of pericarditis—Case illustrating its absence, and  the non-
    reduction  of  the pulse  by opium—Fatal  pericarditis in a
    patient of choreic diathesis.

            (Clinical, St.  Mary's, June 21,  1862.)

  You may see an  example of pericarditis which  has come on in
the hospital in a little  girl named Fanny R—,  admitted May
31.  She has always  been delicate, she says, and looks younger
than seventeen, which is entered as her age.  She has never spat
blood,  but often has had cough, and for  the last three months
of 1860 was in  the  Consumption Hospital. Also eight years ago
she Avent through rheumatic fever.  On admission she  said she
had been then ill four days, and that she had been attacked with
rigors  and Avith  pains and swellings in the knees and  wrists at
first.   HoAvever, nothing of the sort was to be found  on examina- 
192
PERICARDITIS.
 tion; but dullness on percussion, with aegophony and  absence of
 breath  sounds,  showed the  presence  of  pleuritic fluid, though
 there was but the slightest possible evidence of any acute inflam-
 mation of the serous membrane  in the  presence  of stitch on
 inspiration.  In spite of her being an  intelligent girl, she seems
 peculiarly insensitive to pain.   She was treated with a poultice
 first, and then a blister on the side, and " teacup" diet of beef-
 tea and milk.  It was on the night of the 4th that  the blister
 was  put on.  She was going on very well, improving in strength
 and in power of inspiration, till the morning of the 7th instant,
 when she complained of pains in the hands and wrists, which on
 inquiry were found swollen, as if from  rheumatic inflammation.
   She strongly denied having any pain in the cardiac  region,
 even on firm pressure; so that, had I not been aware of her degree
 of insensibility to pain,  I  should have concluded at once that
 the heart was free from lesion.  Fortunately I  was cautious, and
 on listening with the stethoscope, a loud murmur was heard with
 the first sound of the heart, loudest indeed at  the center of the
 organ, but propagated over the  upper  part of the chest.  Take
 warning from this, and  do not omit to consider whether your
 patients feel like other people or not before  you  let  your diag-
 nosis be guided by their feelings.
  WTith regard to this murmur, there  arose a question of diag-
 nosis, very important as  regards treatment.   Did it denote an
 old incurable injury derived  from the former attack of rheuma-
 tism, or Avas it an acute state admitting of restoration ?  In the
 first place, there was in favor of its being an old valvular mrumur
 the fact of the previous  rheumatism, and the  peculiar liability
 of children, even more than adults, to  have the heart affected :
 then there was its  single character (pericardial murmurs being
usually  double)  and  the  entire  absence of pain.   To  weigh
 against the latter argument  might be urged  the already-named
 stoical character of the patient; and in favor of the recent nature
 of the injury there was stated the fact  that nobody had heard it
before, though the chest  had been examined  in reference to the
lungs.   But  on  the other hand, it should be remembered how
very apt the ear is  to let pass unheard even  a  loud sound when 
PERICARDITIS.                   193
 the attention is directed elsewhere.  So  you see there was an
 awkwardly even balance of arguments.
   In this dilemma I found the advantage of what I can recom-
 mend to you as  by far the best  extant means of distinguishing
 single pericardial and valvular  murmurs—sounds precisely the
 same in their effect on the ear, and occurring often at the same
 period of  the cardiac movements,  and  therefore undistinguish-
 able  unless particular manipulation be used.   The plan is—first
 fit  the stethoscope firmly  and steadily on the place where the
 murmur  is loudest, and get impressed on the auditory nerve
 clearly the special character of the murmur ;  then, keeping the
 instrument still closely applied to the chest in  the same position,
 remove your head very gradually, and  try to gain a point at
 which you can hear the normal  heart sounds without the mur-
 mur.   If you can do this, the murmur  is pericardial.  If you
 cannot, but the murmur is  heard  as far off as the heart sounds,
 it is endocardial.  In  all cases where the disease is endocardial
 only, or  pericardial only, the knowledge thus obtained may be
 safely acted  upon.
  I  acted  upon it in this  instance, in  spite of  a  prepossession
 derived from the history and from the absence  of pain,  that it
 was an old valvular injury  which  gave rise to the symptom.  In
 three days' time the conclusion Avas proved correct by the mur-
 mur becoming a  double rubbing  with the familiar characters of
 pericarditis.
  I had enough faith in the test to  order directly four leeches
 over the  cardiac region, followed by a half-jacket poultice, and
 to attend  to  the more important  serous membrane now inflamed
 instead of  attending to the  pleura.  The patient was also put
 upon  the  usual treatment  for rheumatic fever which I  have
 detailed in previous lectures.  After four days  the double rub-
 bing  £ot shorter in duration and more  limited in  the  extent
 over Avhich it Avas heard, and then I ordered a small blister over
 the  base of  the heart.  The rheumatic  swelling had left the
hands, so the alkaline treatment was  then left off, but the  poul-
tice was continued.
  I have related these details to impress  upon you  the plan to 
194
PERICARDITIS.
be pursued in rheumatic pericarditis from whatever cause it has
been unhappily induced.   Had the painful swelling of the hands
in this poor broken-down  child preceded by a sufficient interval
the inflammation of the  heart,  we  should have had  a timely
warning, and possibly the useful careful treatment pursued by
our nurses would have  prevented  the  misfortune.   But  the
occurrence of both at once, and the unlucky neighborhood of
the already diseased lung, combined to inflict  upon us the sad
sight  of an irremedial mischief in process of formation.  I say
an irremedial mischief, because it cannot be doubted that  this
adherent  pericardium will cause  her to suffer from the evils of
diseased heart in future years.
   One part of the treatment which particularly wants remark
is the application of blisters.  At the beginning of acute serous
inflammation they unquestionably do much harm.   They increase
its heat  and violence, and all the  more the nearer they are to
the part affected.   The action of the cantharides is  to cause  a
fibrinous serum instead of a plain serum to be thrown out, which
is a result decidedly to be deprecated at the beginning.   But at
a later stage, when  pus is our chief dread and not fibrin,  then
the virtues of cantharides come to our aid.  At this conjuncture
apply your blister, and  apply  it  as close as  you can  to  the
affected part; the healing process which follows its action on the
healthy tissue  spreads by continuity to the diseased tissue, and
you feel yourself powerfully aiding the forces of life.
   You should  keep a poultice on the cardiac  region during the
whole time that pericarditis lasts.   Nothing is of more import-
 ance in the treatment.  Neither leeches nor blisters need stand
in the way of its application ; it  is  of at least equal  importance
 to either of  them in  restorative action, and  is suitable for all
 stages of the disease.

              (Clinical, St.  Mary's, July 5, 1862.)

   Fanny R., whose case  I lectured about  a fortnight  ago, has
 got into a state to justify her discharge from the hospital in  a
 few  days.   The pulmonary  regions have become resonant on 
PERICARDITIS.
195
percussion, though  some crackling (rdle de retour) accompanies
the air returning  to the scarce restored tissues of the left lower
lobe.   The opposite sides of the pericardium may be adherent at
some  points, and the adhesions impede the contraction of the
heart, I much fear; for there is a soft initial murmur with the
systole heard as far off as the first sound can be heard, caused
probably by the val,ve not clinching completely and  so allowing
of regurgitation.
   The pericardium  can hardly help becoming adherent  after its
inflammation, and the moral I Avould draw from  this case is to
think the prevention of the injury, when threatened,  a thousand-
fold more important  than its  treatment, when  established.   I
told you, six weeks ago, in a lecture on rheumatic fever, how
this prevention is  to be aimed at, and how it may generally be
accomplished.*
   I do not order mercury in acute pericarditis, and I  will frankly
tell you why, since it is right  that I should make  my practice
useful to  you as  a  warning as well as an encouragement.   Ten
years since a robust and excitable girl of  sixteen had rheumatic
fever ; from her  constitution I feared she  was likely to have her
heart affected,  for young persons of a nervous temperament are
much the most liable.  I had then an impression that mercury
Avould prevent the occurrence of inflammation in  serous sacs.
I put her under the influence of mercury—the pericarditis came
on, and in it3  most virulent form—and the patient died  in the
height of it.   This result  made a deep impression on my mem-
ory ; her fair young  face always  rises before me  when the idea
is mooted of preventing pericarditis with mercury, and I shrink
from using  it.   Of course, to the reason a single case does not
prove so much as  statistics of many, and I do not cite this  as
sufficient evidence to your minds against  the use  of mercury.
 But it gained a  powerful  hold on my imagination,  and if prac-
 titioners Avould be  honest to themselves, they would often confess
 that some such feminine evidence as  that above quoted governs
 a good deal of their practice.  If I am illogical in my reason, at
 all events I will  be manly enough to confess it.
                         * See page 157. 
196
PERICARDITIS.
          (Clinical, St. diary's, February 20, 1863.)

  I have an unfortunate occurrence to relate to-day.  The poor
girl, Elizabeth  J., about whom  I  lectured  to you three weeks
ago,*, and whom  I  described as then recovering  from  a short
attack of typh-fever caught in the hospital during convalescence
from acute rheumatism, has since died.  She went on  very  well,
and had began to eat meat and to be up and dressed on  the out-
side of her bed, when  she was exposed to severe cold from the
ward windows being all opened  during  the  frosty days we had
last week.   This  brought  on an attack of  pericarditis on  the
14th,  of which she died on the 16th.   I show you here the peri-
cardium honeycombed  over with fresh lymph.  But I doubt if
it was her first attack of pericarditis.  On admission  she stated
that she had been previously  subject to rheumatism, and during
the attack for which she was admitted  there was  one day pain
on pressure on the  cardiac region, sufficient to make me order
leeches to be applied, although  there was no murmur.   I  think
it  is  to some former  attack probably  that the  firmer of the
adhesions  are due.
  I mention this case  mainly to warn you against exposing to
the assaults  of cold persons of rheumatic diathesis.   All this
injudicious ventilation  which caused our patient's  death was
practiced  for the  safety of others.   Because she had typh-fever
she was placed between tAvo open  windows, and  continued to
occupy the bed after all risk  of infection had passed away.  It
was a sad  misadventure, but  you must not attribute her death to
fever, or your statistical calculations will be erroneous.

            (Clinical, St. Mary's, January 9, 1864.)

  You have visited with me  to-day two examples of pericarditis,
which are worth notice.
  George D. is a pale spare man of unhealthy aspect, a car-
penter, aged nineteen,  who was admitted December 22 for rheu-
* See page 142. 
PERICARDITIS.
197
matic fever of nine days' duration, principally affecting the feet
and knees.   There was no bed for him except one close under a
window, Avhich, unfortunately, cannot  be always  kept  shut.
However, he was wrapped up close in blankets, and  I dare say
Avould have done very  well, but for an important neglect of part
of the usual treatment.   You know I  give strict  orders that
rheumatic fever patients are not to have any linen  touch  their
skin.   Well, on my visit to this man on the morrow of Christmas
day, I found him with a pericarditis, of which I  had made out
the absence  on  his admission  and on Christmas  eve.  And on
putting aside the clothes for the purpose  of auscultation, I found
that the only covering to his bosom was  cold, hard,  damp linen.
My rebuke  to  the ward-sister was met  by the statement that
she thought  it  was only a linen shirt that I objected to, and
that the patient really had on one of calico.   This I  found  to be
true enough, but  yet  there was  a linen front to it (for  orna-
mental purposes),  and  the  front unfortunately  covers just the
most important part of the body, the cardiac region.   I am sure
Ave  may safely attribute the occurrence of pericarditis  to this
chilly  decoration.
  To  avoid in future such an evasion of  the standing orders for
the treatment of  rheumatism, I  shall have a flannel waistcoat
put next the  skin  of each person  so affected.
  George D. has  had  his chest leeched  and poulticed, and has
taken opium  freely, according to my usual practice, and the peri-
carditis has  run through the course  it  usually takes Avhen not
verv severe.  First there was pain and a murmur only occasion-
ally double,  whose frictional  character was made evident only
by collateral  evidence;  then the murmur  became faint and  there
was slightly increased dullness on percussion of the cardiac region,
with pain still remaining, indicating an accumulation of fluid in
the sac; then a freedom from pain, accompanied by a double
friction sound,  indicating the absorption of the fluid.  To-day,
the fifteenth after the first assault of the pericarditis, the murmur
is single and  scarcely to be heard, the sounds being very soft and
feeble.
  George D.'s strength had been much reduced by the rheumatic 
198
PERICARDITIS.
fever, prolonged as it was by the  pericarditis,  so  that at the
beginning of this week I  found  a slight sore from a superficial
slough of the skin on the sacrum.  Accordingly, I put him upon
bark and ammonia, and augmented his diet to an extent unusual
in rheumatic fever.   To-day the sore is nearly healed, but the
patient is so weak that he can scarcely turn in bed.
  The other case is  that of Ann  B.,  a  fresh-colored, cherry-
lipped girl, aged nineteen.   When I'came  to  admit patients
yesterday,  I found her in the  waiting-room, throwing herself
back in the chair, breathless and gasping, and plucking with her
hands at  the fore part of her dress  as if she would  tear it open.
She  said she was choked by violent pain in the front of her
chest,  cried  out  and  whimpered,  and  was  so   exaggerated
altogether  in her manner that  I  felt  doubtful  if it would not
turn out to be a case of hysteria.   Yet her aspect was not that of
an hysterical person,  so I  sent her to bed; and being then able
to examine the thorax, I  found  localized in  the cardiac region
excessive pain on pressure, and a distinct double friction sound.
The breathing was very hurried, and the pulse  120,  small and
weak.
  When  more composed, the history she gave was this: she has
never had  rheumatic  fever or any  other serious illness; but  for
several winters past has had pain, of no great consequence, across
the front of her chest.  For the last three weeks  she has felt
unwell, but has  not been  laid up from  work till the 6th instant.
Then this pain commenced, got rapidly worse  on the 7th, and
on the 8th (yesterday), as I have said, she came here.  She can
assign no cause for her illness, nor can anything be elicited  by
cross-examination to account for it.
  I ordered her a dozen leeches to the cardiac  region, to be im-
mediately followed up by  a continuous linseed  poultice, a grain
and a half of opium every four hours, and "simple" diet.
  At our visit to-day  you  saw a great change in the twenty-four
hours. The patient had not been made  sleepy by the opium, but
had been calmed in a remarkable degree.  A numerical reckon-
ing of the  amount of calm was afforded by the  pulse, which had
sunk from 120 to 56, was firmer and stronger.  This effect of 
PERICARDITIS.                    199
opium is very important in pericarditis, when quiet for the busy
heart is so  desirable and so difficult to procure.  It is  singular
what a large quantity may be taken without hypnotism, or even
constipation, in all serous inflammations.   So that when time is
of value, as in this case, you should begin with what cannot be
called, under ordinary circumstances, imprudently large  doses,
or you will  not have mounted up to the efficient quantity early
enough to be of use.  I have increased  the  quantity now to a
grain and a half every three hours.
   Pressure  on the cardiac region gives  less pain to-day,  and,
the heart being quieter, the stethoscopic evidence of the disease
is easier to  make out.   The  to-and-fro  friction  sound is well
marked.
   The patient says that at present her chiefest pain is caused by
breathing deep and by swallowing.  The  first  she can of  course
shun,  and  I dare say will do so.  The  second  is to a certain
extent  unavoidable,  but we will do our  best to  relieve her by
giving only liquid food, and in very small quantities at a  time.

           (Clinical, St. Mary's, January 23, 1864.)

   Ann B., about whose pericarditis I lectured to you lately, has
interested us by the variations in her pulse.   It continued slow
till the 12th, when a visitor in the middle of  the day appears to
have engaged her in a conversation too long, and it rose,  so that
by night it  was 120.  She continued to  take  the opium  (gr. iss
every third hour), and on the 18th it dropped to  96, on the 14th
to 86, on the 15th to 80, on the 16th to 76, on  the 20th to 72,
and on the  23d (to-day) it has risen again up to 88.  This rise
may be partly due to the patient's menstrual  period, which has
just commenced,  making her sensitive   and excitable,  partly
perhaps to  a slight  relapse of inflammatory action  in  the peri-
cardium.
   The pericardium has, on the whole, progressed favorably; the
friction sound continued double till the 13th, Avhen it was found
to be single only.  It got less loud, and on the  20th one  could
hardly say there was a friction at all, though with the first sound 
200
PERICARDITIS.
of the heart there was a peculiar harsh tone.  However, to-day
I can distinctly detect a friction sound.
  The opium has agreed with her well.  On the 16th it was
increased to two  grains every three  hours, and it produced no
abnormal sleepiness  or constipation; nor has it prevented the
return of her appetite, for on the 20th she was ordered a mutton-
chop, on her own statement of feeling very hungry.   To-day, the
23d, I have increased the dose of opium  to  gr. iij every  three
hours during the catamenia.
  Of course we have been watching  for any symptoms of  rheu-
matic fever;  and on  the 16th I thought that a pain she felt in
one foot was an announcement of  its approach; but that passed
away quickly, and was accompanied by no redness  or swelling.
  I am anxious  to draw  your attention to the  more than ordi-
nary pain which  this young  woman has experienced from her
pericarditis.  At first it was excruciating; and even on the  20th,
Avhen the friction murmur had ceased, firm pressure of the car-
diac region made her wince.  I especially wish you to notice it,
because there is a case of pericarditis which was admitted nearly
at the same  time, where there is  a remarkable  absence of this
symptom.
  John C, a journeyman butcher,  aged twenty-four, was taken
ill Avith rheumatic fever on the 10th instant.   I saw him first on
the 13th, when he complained energetically of the painfulness of
the swollen joints, but disclaimed  having  any inconvenience in
the chest; nor till I pressed my stethoscope on the cardiac region
really hard, would he allow that it hurt him.  Notwithstanding
which, when  I applied the ear I  found a loud double friction
sound.  The sounds  grew coarser,  but shorter, up to yesterday,
the 22d, when I could no  longer hear them, and conjectured that
adhesion had taken place.
  I cannot explain why there is pain in one  case more than in
another;  it certainly does not denote severer disease, because in
all  other respects the man was the  worst of the two patients.
Perhaps  it  may have something to do  with' the  absence of
rheumatism, the pain of  which withdraws the attention of the
sensation to the joints, or wherever the swellings and redness
may be. 
PERICARDITIS.
201
  Attacks of non-rheumatic pericarditis  are  more common in
private practice than in hospitals.  They usually arise from sim-
ilar causes to those which cause pleurisy, namely, exposure of
the part to sudden chills while its vitality is lowered by previous
exertion.   I  had  a case this week arising from walking out into
the night air after exertion at a dinner party; and in  boys foot-
ball and boating are often to blame.
  The treatment of John C. was the same as that of Ann B.  He
was twice leeched, and is still enveloped in a linseed poultice.
On the 13th, he was ordered gr. iss of opium  every four hours;
and on the 17th, as he was somewhat  delirious, and the pulse
was 120,  gr. ij every  three hours.   The  delirium then ceased,
but the pulse kept up.  On the 20th, gr.  iij  every  three hours.
On the 22d, he said he was certainly more drowsy than usual, but
the bowels were not made costive by the opium.  The pulse kept
up  to  120.  As  he was entirely free  from rheumatic pains, I
ordered the quantity of the drug to be diminished to gr. ij every
three hours, which he is continuing to take.
  The extreme quickness and  weakness  of  this  man's pulse
throughout has made  me very  anxious about him.  The opium
has seemed not to diminish it, as it did in Ann B., and that is
the reason why I  have pronounced him the worst of the tAvo.

  In  John C.  you have seen pericarditis in  its most familiar
aspect, that is  to say, arising in the course of rheumatic  fever,
as a consequence of the  exposure of the chest to  cold, or  the
attempt at bodily exertion.  In Ann B. there is no evidence of
its  connection  at all with rheumatic fever.  In the case I  am
going next to relate to you, there was no rheumatic fever present
indeed when the pericardial inflammation came on, but there  was
a diathesis somewhat  connected with the  rheumatic,  though in
what Avay it is difficult to define.*
         *****
  Alfred  M., a delicate and thin boy of ten,  was admitted  De-
cember 18th  ult. for chorea.  He had  had the same  two years
preATiously, and also at some periods, which he could not remem-
         * See the concluding part of Lecture XXIX, on Chorea.
       14 
202
PERICARDITIS.
ber accurately, redness and swelling of the joints.   On admis-
sion, he said his feet were painful, but  I could see nothing like
rheumatic swelling.   There was  a loud rumbling,  continuous
murmur with  the  heart's action, which was violent and tum-
bling.   This I attributed, I cannot say how correctly, to lesions
produced by  old disease.   The cardiac symptoms were better
after the lad had been quiet in bed a few days and had had a few
leeches  on.   He was  then  treated with arsenic for the chorea,
and got better, so  as to  be playing  about the ward with  some
other boys up to the morning of the 20th of January.  On that
morning he told  the nurse  he had a  severe pain in the front of
his chest; so  she bade him lie in  bed, and  sent immediately for
the house surgeon,  Mr. Coombs. He found a loud double friction
sound in the cardiac region, and  immediately leeched and poul-
ticed it; but  the lad got  rapidly worse, and died in the evening
of the same day.
   You see here the heart and pericardium.  The visceral portion
of the serous  membrane  is partially covered with grains of soft
lymph, in some places forming a reticulated coating: the parietal
portion has a smaller quantity of the  same lymph  attached to it.
Exposed parts of the  serous membrane are  (and were still more
when first taken out) deeply stained with a purplish red conges-
tion.   The sac was filled with five or six ounces of transparent
serum.  And in the adjoining pleura  of the left side there was a
larger  quantity of  similar fluid;  but  as they flowed together in
opening the chest,  I could not apportion the property of the re-
spective cavities.   The opposite  surfaces  of the pleura were
joined  by some delicate threads of very soft lymph.   The other
viscera were normal in aspect.
   The heart  is large, weighing with the pericardium 10 J ounces.
It has  not been opened in the usual way, because  I was anxious
to show you the phenomena of pericarditis in its early period,
the reddening of the  membrane in the first stage of death, and
the soft, almost creamy, coagula of lymph which produce friction
sounds.  But I can hardly doubt that there  is old valvular lesion;
and to the  old lesions I  attribute the  remarkable rapidity with
which  the patient  sank under what I suppose may be called  an 
PERICARDITIS.
203
acute pericarditis, occurring without rheumatism to a rheumatic
individual,  and  in a predisposed heart.   The  external motive
cause  I  can only conjecture to be some secret  escapade of the
poor child's, which exposed him to cold and unauthorized exer-
tion, and which he concealed from fear of a scolding.

  [A few days afterward John C. wa3 able to get up, eat meat, and leave off
opium.  He was discharged  cured on February 6.  Ann B. had the quantity of
opium gradually diminished to gr. j night and morning, which to-day (February
10) she says makes her sleepy, so it is omitted altogether. There is no murmur
audible in the cardiac region, but the first sound is very long.  She is up and
dressed.] 
LECTURE  XVI.
                        PLEURISY.

First case, and its treatment—Cases of pure pleurisy not common
     in hospital practice—It  is a slight  disease, but capable of
     being made much more severe by bad management—Remarks
     on blisters and on local blood-letting—Their final intention
     restorative—Poultices—Continuous warmth as a renewer of
     life—Second case—Chronic effect of acute pleurisy—Treat-
     ment—Diuretics—Blisters— Third case—Pysemic pleurisy,
     its fatality.

             (Clinical, St. Mary's, July 5, 1862.)

 ' I am glad to'have an opportunity of bringing  before you to-
day an example  of a disease  so common in practice as to be one
of serious import for you to  study, but of which  specimens do
not very often occur in our hospital wards,—pleurisy uncompli-
cated with further inflammation of the lung.
  Thomas G., a  day laborer,  aged twenty-nine, was warded June
19, with anasarca of legs  and belly  of  a fortnight's duration,
which he attributed to exposure  to the Aveather.   His  urine was
found to be albuminous.   The house surgeon gave him a hot-air
bath, a jalap purge,  and some draughts of nitric ether and digi-
talis.  When  I visited him next day (June 20), he complained of
sharp pain on both  sides of  the waist, which  he  said  had been
coming on for two days, and  was getting worse.  On auscultation
I heard pleuritic friction beneath both scapulte and in the lateral
regions; the normal respiratory murmur  was still to be made out
in spite of it;  but there was a leathery creak, lasting through the 
PLEURISY.                     205
whole of respiration and the latter part of expiration.   The
tongue was furred, and there was thirst.
  He was ordered to be cupped, but as the instruments had un-
luckily gone  to he mended  and would not be returned for an
hour or two,  a dozen leeches were applied along the lower edges
of the ribs, in the infra-scapular region. Immediately they came
off a large poultice was placed all over the back of the chest.
  The next day (June 21) the  pain and fever were  quite gone,
the friction sound was heard over a limited  space,  and on the
22d had departed  altogether.  The poultice was continued one
more day,  as the patient remained in  the hospital to be treated
for  albuminuria.
  Patients with  pure  fibrinous inflammation  of  the  pleura,
usually called pleurisy,  without  any affection of  the  pulmonary
tissue,  you  have  as  yet probably not often had a chance  of
seeing.   But you know from your post-mortal experience in our
mortuary how common it must be.  There are few even of the
most healthy chests in which you do not see old adhesions  of
the pleuritic  surfaces, the  relics of pleurisy, sometimes in one
part, sometimes in another, sometimes partial,  sometimes uni-
versal ; they are so common, that they were  supposed to be the
normal condition of the parts when anatomy began first to  be
studied after the restoration of learning.  What is  the reason,
then, that you  have but few  opportunities of learning how to
treat this very common disease while you are pupils ?  Simply
because it  is scarcely ever so severe as to bring the patient into
our hospital wards,  and is fatal  only by very rare exception;
so that your only chance of observing it is when it is joined to
some more alarming disorder.   The man  who is the occasion of
these remarks would never have been admitted to  St. Mary's
had he not been taken  dropsical at the same, time as he caught
his pleurisy.
  Nine times out of  ten pure pleurisy begins and  ends with a
catching  pain in  the side  on  inspiration, and a slight inflam-
matory fever, making the patient coddle at home and take  slops,
but not employ  a  doctor.  It would be, perhaps, better for him
if he did, for possibly his may be the  hundredth or  exceptional 
206
PLEURISY.
 case, and his illness may turn out a more serious affair.   More-
 over, in every case, the  pain in the side  and the fever  may be
 shortened by good management and lengthened by bad.
   For  example—blisters at the  outset of pleurisy invariably
 protract the duration of the inflammation and make it more
 severe.  The property of cantharides is to cause and augment
 that very fibrinous crasis from  which the membrane is already
 suffering.  Exposure to  cold and to changes  of  temperature,
 baths and the like, make it worse, as  do strained postures of the
 body and exercise.  Opiates cover  up the  evil with  an anaes-
 thetic mask, and prevent the patient knowing how he really is.
 Mercury is an unnecessary call  upon the whole system to make
 destructive sacrifices for the sake of a very small and not  highly
 important member.   Purgatives do  no  good,  and expose the
 patient to catch  cold at the water-closet.
   On  the  other  hand,  the treatment you saw applied gives
 decided  and immediate relief, and prevents the danger  of the
 disease continuing.
   It is necessary to remark that the whole of it was not  meant
 for the benefit of the pleura; the hot-air baths, the diaphoretic
 draughts, and  the jalap were  intended to rid the  skin of ana-
 sarca,  and were  successful in so doing; while the treatment to
 which I  design to call your  attention as that  specially appro-
 priate  to pleurisy is the application of  the  poultice and the
 leeches—the poultice always, and the leeches whenever the pain
 is decidedly "catching" or "stabbing" on inspiration.
   I will  speak of the last first, as it is most open to exception.
   The object of  leeching and all local blood-letting is to relieve
 inflammatory congestion, not only an evidence  of  loss of vital
 power  in the local blood-vessels, but  also the  cause of further
 loss of vital power by leading to the other stages of the inflam-
matory state.   The  blood-vessels, from  loss of elasticity,  are
unable to empty themselves  naturally, so you  roughly take the
place of vital power and empty them artificially.  You may
perchance say, that it is all very well in external inflammation,
when you can draw off the blood which is causing the "rubor"
and " tumor" visible to the naked eye; but you may doubt how 
PLEURISY.
207
the pleura, especially the pulmonary pleura, is to be affected by
depleting the  capillaries of the skin.  Your  recent experience
in the dissecting-room reminds you that it is a  very long way
round before you  can  find any vascular connection between  the
parts; you  may think local blood-letting only beneficial by de-
tracting  so much blood,  and that  a  small venesection would be
more convenient  and  equally effectual.  Now it  is not at all
essential  that there should be a  vascular connection  between
separate parts for altered states and conditions of life to spread
from one to another.   I have seen in the dead body a round
circumscribed spot of costal pleura affected with fibrinous in-
flammation, and this had spread, not laterally to the neighboring
surface of serous membrane, not to that tissue intimately  one
with it in vascular connection, but to the opposite surface on the
lung, betAveen which and its substance  lay the great gulf of  the
pleural cavity—the great gulf, anatomically speaking,  but  not
physiologically,  as proved by this instance.   If this gulf can be
spanned  by disease, the  negation, the deficiency of  life, shall it
not be yet easier stepped across by the remedy, the renewer of
life ?  I  do not myself  feel any hesitation  in believing firmly
what experience seems to teach, that in inflammations of serous
sacs, depletion applied to the external surface has a power pro-
portionate, not alone to  the quantity of blood taken, but in an
equal degree to the locality from which it is taken.
   I  have called the local drawing of blood a  "renewer of life,"
and  I think it is but fair to explain in  what sense I so speak of
it.   The taking away  the vital fluid is  taking aAvay part of  the
body, and so is directly a destructive agent.  But then blood
thus lost from an inflamed part is not all loss; a  great deal of it
is black, "melanosed," partially dead  and unfitted  for the pur-
poses of life, and only a minority of its  constituents can really
be called living.   Then  again, granting that  loss of blood is  a
direct loss to a living body, still the indirect gain is a  full com-
pensation in cases where it is rightly applied.  The blood-vessels
resume their elasticity, their current renews its force, and a  loss
of substance is a regaining of function.   So that a  destructive
becomes  in the end a constructive remedy. 
208                      PLEURISY.
  In the action of poultices there is no even seeming paradox to
stumble at.   Continuous steady warmth is the most direct agent
in our hands of vital development.  It not merely fosters  vital
growth, but makes that growth take a higher form of life.   Mr.
Higginbottom found that different detachments of tadpoles  kept
in the dark and treated with  different degrees of temperature,
threw off their tails and branchiae, and  developed their lungs
and became frogs, with  a quickness exactly proportioned to the
warmth they were subjected to.*   Do not let any experiments
on life escape you: turn to a practical use even that which seems
at first glance most remote from practical  use.   Warmth, espe-
cially when kept steady and even by moisture joined with it, has
the same effect on the failing functions of tissues in the higher
animals as in the lower;  it raises and  restores  the life to  its
normal  force of  development.  If the milk  is  scanty in the
breast of  a suckling mother,  a hot poultice  or  gentle  friction
with oil will revive its flow: if the liver ceases to make bile, hot
fomentations will  act as  a cholagogue.  As heat renews the
vitality  of  the sluggish glands, so  also it renews the  injured
membrane, which had  been lowered  to that condition we call
congestion or inflammation, into the higher life of warm-blooded
circulation.  As  it  developed the tadpole  into  the frog,  so it
develops the half-killed diseased part into full life.
  You must take care not  to  follow up the  application of quick-
ening warmth by the depressing influence of cold, or it becomes
doubly depressing by contrast.  Your poultice, must be kept on
hot and hot till all  pain  is gone  and the  breath can be drawn
quite freely and easily.  And it will do no harm to beguile  your
patient  into retaining it even  a little longer, as was done in the
case which is now my text.
  Such  means  will not fail to  cut  short an   attack  of  pure
pleurisy.

  *■ 20 tadpoles placed in a dark cellar at—
              56° produced in 89 days 10 frogs,
              53°    "     103 "  10  "
              51°    "     131  "   9  "
  —Proceedings of the Royal Society (1863).  Vol. xi, No. 48, p. 532. 
                         PLEURISY.                      209

  But you will say there are cases of pleurisy which are not cut
short, and notably just now there is one a few beds off from the
last patient, whose case I will extract from the case-book.
  John C, a  railway navvy, aged  thirty-four,  always  enjoyed
good  health  till six months  ago, when, on  the  third day after
lying in a damp bed, he was  seized with a violent sudden  pain
on the right side which obliged him to take to his bed.  He was
there a fortnight, and was treated with mustard plasters.  He
coughed up a good deal of frothy sputa, and was a little  delirious
several nights.   The pain then shifted  from the right side and
settled in the left, but did  not prevent his getting to work again,
a month after the first attack.  His work has not been  hard, as
he.reckons hardness, and he has kept at it, with a  chance day's
exception, till his arrival here on June 25.  The principal trouble
he has had and the cause  of his being  off work  sometimes, has
been  dyspnoea.  He feels  pain  on bending forward  and on
drawing a deep breath.
   On auscultation  in a  sitting posture,  there  is very absolute
dullness of the lower half of the lateral and scapular, and of the
whole infra-scapular  region on the  left side.   The rest  of the
thorax  is  resonant.   When he lies on his belly and  puts the
shoulders below the level  of the chest, hanging his arms and
head  down,  this infra-scapular region  becomes more, but not
quite, resonant, showing that the cause of the dullness is in part
at least due to  fluid which shifts about  by the  force of gravity.
Still some dullness remains,  and  there  is a Avhiffling sound with
inspiration and expiration.   And in the lateral region  the  dull-
ness is unchanged by any posture.
   The secret  history appears to me to be this—that  the man
Avas seized with double pleurisy, worse on the right side than the
left—that the treatment relieved it—but that the left side being
the least cared for, the inflammation spread  to the  pulmonary
tissue, and caused its insidious condensation.  The cause of the
dullness on percussion is partly fluid which is affected by gravi-
tation,  partly  solidified lung which is  not so altered in its
position.   The fluid in the pleura and the condensed pulmonary
tissue have mutually kept  one another from being restored  to
perfect life. 
210
PLEURISY.
   Such is the most ordinary cause of those exceptional cases of
pleurisy which become chronic.
   The longer they have lasted, the more obstinate  usually are
they in yielding.  As respects treatment, you will  find on the
card the following,  which may be  considered the  "processus
integer" (as Sydenham  calls it) of such cases:—
       June  25.   Empl.  Cantharidis (62 pollices) lateri.
             I$s   Misturse potassse nitratis oj,
                  Tincturse ferri sesquiehloridi TTJxv.
                                               ter die.
             ty,   Pilulse hydrargyri,
                  Scillse,
                  Pulveris digitalis, aa, gr. jss.
                               omni node et mane.

   You will  observe that the medicinal treatment is  a  union of
destruction and  construction;  it is designed to alter,  as far as
possible, the  whole habit of the system—to cause by  destruction
a demand for new  material, the supply of which is  guaranteed
by the iron.   The mercury causes a general  increase of meta-
morphosis, the waste products  of which are directed  to  the kid-
neys  by the squill  and niter.  The digitalis  tends to  relieve
congestion by increasing  the  activity and  tone of the  blood-
stream.  So that by a union of virtues the combination prescribed
in the pills will  rarely fail to prove a powerful diuretic.
   The blister which has been put on the  side Avill probably have
to  be repeated once,  and perhaps again.   You will observe
however that I shall leave  a considerable interval of time between
each blister.  I shall not apply first one on  the side, then one
on the scapula, then one  beneath the collar-bone, stroke upbn
stroke, one on as  fast as the other comes off.  This is  not an
uncommon practice; and the  object of  it is  to  save  time, by
getting the two or three needful blisterings over as soon as pos-
sible.   I do  not myself adopt it: ami I will tell you  why; as the
reasons give a very good example of the restorative system of
medicine which  it  is my object to  teach.
   The action of vesicants is first to destroy the epidermis and 
PLEURISY.                      211
to cause  the  exudation of a fibrinous scum beneath it.   Very
probably a similar  but more remote effect is produced  on  the
neighboring tissue of the  pleural sac.  Nevertheless it is not at
this stage of the process that the chief benefit accrues.   If you
watch carefully  the line of dullness marking the upper margin of
the collection of fluid in the chest, you will find that it falls—
not when the blistered skin is full of liquid  and is  discharging
serum—not when the counter-irritation may be fairly concluded
to be at its height—but after  it is all over.   As the sore heals,
then the level goes down with the greatest quickness.   That is
to say, that the  true use of blisters in such causes is to  start  a
healing process, or a renewed life  on the outside  skin, in order
that it may spread to the neighboring viscus inside.   As  long as
this influence continues to be exerted, you will gain  no time by
a recommencement of the process, and your too hurried repetition
of blisters would add to the patient's distress, without conducing
to his cure.  Wait till the effect  of one blister has  quite gone off,
before you order another.
   Another case of pleurisy which has occurred this week, I do
not cite as primarily instructive in a therapeutical point of view,
for it was rather an instance of  the weakness of our art—but as
having a pathological interest.
   Charles D., aged eight, was admitted on June 24, with pyaemia
after scarlet fever, affecting  the principal  joints, and with an
incipient slough  on the sacrum.   On July 1 he died.   At  the
request of the parents the curator cut into one only of the. joints,
and that was tense with creamy pus;  so that the same condition
may be assumed to have  existed in all.   On opening the chest,
serum filled Avith flakes of fibrin  gushed out from the right pleura.
Bands of soft, elastic, straw-colored fibrin of  an  inch in length
united the  opposite  sides of  the whole  pleura, and coated  the
surfaces with a honey-combed  layer.  The lung, pressed back
against the spine, was non-crepitant, inelastic, and tough.  Now
the front of this boy's chest had  been examined  on the day of
his admission by myself,  the  house surgeon, and  clinical clerk,
and I cannot but feel sure that had pleurisy existed at that period
we should  have found it out.  Afterward,  the wailings of the 
212                      PLEURISY.

poor child at the idea of being touched became so  piteous, and
the torture of moving the arms would probably have  been  so
great, that an examination to discover the cause of the pain he
complained of in the side was  out  of the  question.  The day,
then, when the pleurisy came on is unknown, but it must have
been  less than a week before decease.
   What an amount of disorganization to have happened in such
a short time ! What a quantity of serum and fibrin to be formed!
What a laying waste of the pulmonary tissue!  Pyaemia is cer-
tainly the most destructive result of an idiopathic poisoning that
we know; but yet, before  seeing  such  a case as that of this
child, we should scarcely believe the swiftness of its action to be
so great.
   The moral is, if the march of death be thus hasty, let there be
 no delay in your remedies.  Apply  your cupping, or leeching (or
faute de mieux venesection), your bedding and your poultices,
 your slops and your diuretics, without losing  a minute.   Do not
 leave alone patients to nature in any disease ; least of all in acute
 pleurisy, when  really acute and dangerous.   But I must warn
 you  against looking upon  this as a typical case.  There  was
 present in the body that  frightful poison which  produces  the
  destruction  of life we call pyaemia, and which would  infallibly
  have proved fatal some other way  had it not been so by pleurisy.
  The really, typical cases are those  which I described at the begin-
  ning of lecture as getting well by employment  of the simplest
  restorative means, or even in spite of their neglect. 
LECTURE XVII.
                   HYDROTHORAX.

Term  "idiopathic  hydrothor ax" justified—Forms of pleuritic
     disease— Which form is here intended—Two cases—Hydro-
     thorax, a collection of fluid in the pleura—Difference between
     collection and effusion—Source  of the  fluid—Action of
    physical agents in the production of the disease—Treatment
    founded uponfhe pathology—Blisters—Poultices—Mercury
     —Food—Digitalis—Squill—Niter—Scoparium—Sequel of
     the second  case, seven months afterward—State of chest,
     and explanation  thereof—Another case of displaced heart—
     Treatment by paracentesis—Large quantity drawn  off with-
     out return of heart—Comparison of these  two cases as to
     treatment—Results inferred from them, and from  an anal-
     ogous case of empyema, opening externally.

          (Clinical, St. Mary's, November 22, 1861.)

  Two cases of idiopathic hydrothorax in the wards shall supply
us with instruction to-day.
  Idiopathic "hydrothorax,"  or "hydropleurisy," is an expres-
sion which I find requires  a defense.   In the " Cyclopaedia of
Practical Medicine," and  in  the  "Library of Practical  Medi-
cine" (Avhose good indices render them the most frequent books
of reference for busy men), the existence  of  such an idiopathic
state is denied altogether.  Effusions of fluid into the pleural sac
are stated  always to depend* either on some visceral  cause of
dropsy, such as organic changes in the heart, liver, and  kidneys,
or to consist of pus, when the case acquires a title  to be classed 
214
HYDROTHORAX.
as empyema.  An acute  collection of serum in the pleural sac
from causes depending on the  pleura  itself, is either ignored
altogether, or merged in  the common description of "pleurisy."
This I hold to be bad pathology, likely  to lead to bad practice.
That a quantity of fluid  sufficient to fill one side of the chest to
complete dullness, that  is to say between four and  five  pints,
should disappear in ten days or a fortnight, is surely conclusive
against that fluid being pus. Pus is absorbed, if absorbed at all,
with extreme slowness.
   Then as to the undifferentiated classification of these cases as
"pleurisy,"—is that practically correct ?  Let us examine.  Half
of our pleuritic patients have no fluid collected at  all; there is
pain in the side,  and rubbing sounds on auscultation of the
roughened  surfaces, but no  dullness on  percussion.  This  is
"pleurisy pure,"  and gets well fast enough  when  treated as
such.  Then, again, there are very severe inflammations  where
the dullness is unfortunately due to pus.  This is "pleurisy with
empyema," and  requires the empyema to be treated as well as
the pleurisy, if it is to be  cured.  Then there is  a third  class
where all the general symptoms, such  as pain on  inspiration,
fever,  and so on, are accompanied by stethoscopic  signs of a
moderate collection of fluid, but whose rapid absorption shows it
to be serum.  This is "pleurisy with serous effusion."  But the
serum is not a matter of importance; it  causes  no increase of
dyspnoea beyond what is due to the  pleurisy, and  it  disappears
without any special treatment when the pleurisy is  cured.  The
medical attendant is wise to think much about the  pleurisy and
little about the serum.
   There is a fourth  class, to two examples of which I call your
attention  to-day,  where this condition is reversed,  where the
pleurisy is absent, or of small moment, and the amount of serum
is great;  and where the nomenclature, if it is to be of use, must
indicate this.   Here the practical physician feels that what he
has to attend to is primarily  the serum, and secondarily only (if
at all) the pleurisy, and  he requires  a word to express this state
of things. With Laennec, I would advise adherence to the name
"idiopathic hydrothorax," meaning a collection of  serum in  the 
HYDROTHORAX.
215
 pleural sac injurious to  health from its quantity, and arising
 from an abnormal state of the pleura itself.
   Case 1.—Maria  G., a housemaid  aged twenty, has always
 enjoyed sufficiently  good  health to  continue in domestic service,
 though subject sometimes to " bilious headaches," to pain in the
 hepatic region, sties in the eye, and irregularities of the cata-
 menia. She easily catches cold, and has habitually a dry cough,
 but never expectorated blood or indeed any sputa at all.   Her
 father died at forty, of some chest  complaint, but her mother is
 alive and well, and  she has not  lost any collateral relations in
 adult age.  In short, though she is well grown and hearty look-
 ing, her constitution, perhaps inherited from the paternal side, is
 endowed with little power of resistance to external influences.
 She is  just the sort of person who might through force of un-
 toward circumstances develop tubercle; though I feel sure she
 has not done  so as yet. I say she has not done so as yet, because
 such a constitution as hers gives  way very rapidly  when  once
 disease  has begun; and  she is  also very sensitive, so that she
 would be sure by this time  to  have shown it, did any internal
 organic lesion exist.
   She  was in her usual health up  to  October 27 last, and  had
 menstruated naturally the week before.  On that day and on the
 28th, without any  assignable  cause,  she felt  " giddy, nervous,
 and ill;" and in the evening of the 28th  she felt a difficulty in
-breathing, with a stabbing pain in the right side.  The sharpness
 of the pain lasted three hours, Avhen it went off, and was followed
 by what she describes as an "aching."   On  the 29th, she  went
 to a neighboring surgeon, who sounded her chest, gave her some
 pills and medicine, and bade her call again in a week.  From that
 time up to her entry into the hospital she was unable to work ;
 the dyspnoea kept on increasing, as did also a sensation of tight-
 ness round her waist; she lost  her appetite, and was  thirsty;
 she had also frequent shiverings during the week, but  cannot fix
 the date of the first.
   I saw her first on November-6.   She had to be propped up in
 bed from the  orthopncea and dyspnoea  under which she labored.
 There was complete dullness of the whole of the right side of the 
216
HYDROTHORAX.
chest,  except a  small  piece  beneath the clavicle, which was
resonant as compared with the lower  part, but still dull as com-
pared with the other side.   In this part alone were there  breath   •
sounds to be heard; and these were  of a bronchial character,
like the noise produced by bloAving in and out through  a  stetho-
scope.   The pulse was small, 120.  The tongue was quite clean.
She was ordered 1^ Pilulse hydrargyri, Scillse,  aa gr. jss, Pul-
veris digitalis, gr. ij, in piluld ter die cum haustu sequenti—fy,
Potassse nitratis, gr. xx,  Spiritus setheris  nitrici, Ttjxx, Mist.
camphorse, Sj; and a poultice was continuously applied to the
right side of the chest.   Diet:  two pints of beef-tea, one pint of
milk, bread ad libitum.
   Nov. 8.—The  breathing is  more  labored;  the  dullness on
percussion reaches higher;  the pain  has  returned to the right
side of  the waist.  Applic. cue. cruentse ad Sviij, lateri dextro ;
perstet in usu pilulse et haustus ter die.
   Nov. 9.—The  sense  of  tightness and  pain  around waist  are
much relieved since the cupping.   Othenvise there is no change
in symptoms.  Add to diet another pint of milk.
   Nov. 10.—The same report.  Emplastrum cantharidis lateri.
   Nov. 15.—The gums feel, but do not look, sore.   The breath-
ing is decidedly easier,  but I can remark no diminution in the
extent of dullness on percussion.  Omitte pilulam in unam diem.
Add to diet an egg and rice pudding.
   Nov. 16.—There is a decided improvement in the breathing.
She can lie down with the  addition of only an ordinary pillow to
the bolster. There is breathing of a mixed bronchial and vesicular
character over the whole infra-clavicular and  over  part  of the
mammary region, and more resonance on  percussion.  No rales.
Resumat pilulam bis die.   1^  Decocti scoparii 5jss  ter die, vice
haustus nitri prior is ; repetatur empl. cantharidis.
   Nov. 18.—Chest quite resonant in  front.  Beneath the scapula
behind  there is  dullness on  percussion,  and  aegophony.  The
gums  not  sore, but  there is  a mercurial taste in the  mouth.
Perstet in usu pilulse et haustus. Diet  "simple,"—mutton-chop,
two pints of milk.
   Case 2.—Annie M., wife of a builder's  clerk, aged twenty- 
HYDROTHORAX.
217
seven, of a healthy long-lived family, has never been ill since the
age of fifteen, when she had influenza for a fortnight.   She  has
once borne twins, who died, but she has two living children,  the
last of whom was born  May 23, and she suckled him up to  Oc-
tober 14, when she was forced to desist by her  present illness.
This illness  she accounts for by the following history:
   During the first week of October her baby had an  arm very
sore after vaccination; and  she fed  him from  the  left breast
exclusively to avoid  rubbing the tender place.   To soothe  the
natural crossness of  the infant she used to do this  even  out of
doors, and once when  so engaged  under  a  tree in Kensington
Gardens she felt much  chilled.
   During the second and third weeks of October dyspnoea grad-
ually came  on,  accompanied by an  uncomfortable feeling, by
degrees amounting to pain, in the cardiac region, so that she  told
her husband she felt  sure  something was the  matter with  the
heart.  She positively  denies having felt any stitch in breathing,
or other pain in the  side; she did not lose appetite, and did not
experience  any thirst, or other signs of fever.  Her complaint
was of dyspnoea, pain in  the heart  on exertion, and a dread  that
she was going into a consumption.   This dread was increased by
the coming  on of a cough, accompanied by much expectoration
of glairy matter.
   She was  admitted into St. Mary's Hospital  on November 1.
On examination,  the whole left side of the thorax was absolutely
dull; it was nearly two inches by  measurement larger than the
right round the  lower part of the waist, and  there was  entire
absence  of  breath-sounds.   The heart was  dislocated from its
usual place; the  apex could not be distinctly found to impinge
anyAvhere, but the general pulsation was felt partly in the  epi-
gastrium, partly  behind the cartilages of  the right ribs—not at
all in  the cardiac region.   She could not breathe when lying
down, and the inspirations Avere irregular, shallow, and frequent.
On the right side there was excessive motion  of the ribs  and
puerile  breathing.   The sputa consisted of transparent  mucus
with but little froth.  The pulse was  upwards of 120, sometimes
       15 
218
HYDROTHORAX.
irregular and intermittent.  The appetite was natural; there was
no thirst,  and the tongue was clean.
  The patient was ordered "half ordinary diet," a pint of beef-
tea, and a pint of milk daily.  A blister six  inches  square was
put  on the  left side,  and  the  following drugs prescribed:
Jfy Pulv. digitalis, scillse, pit.  hydrargyri, aa gr. jss; omni node
et manS.  1^ Potassse nitratis, gr. xx; Spiritus  setheris nitrici,
TTjxx, Mist, camphorse, §j ter die.
  November 4.—Her breathing is equally laborious.  The sputa
are more copious, and the cough increased, probably by a draught
from the window upon her bed.  Pulse 100, weak.   No change
in medicine.   Blister repeated.   Add an egg to diet.
  Nov. 9.—The  breathing is easier  since  last report, and the
measurement of the thorax three-quarters of an inch less.  Add
a bottle of stout to diet.
  Nov. 11.—She says  she coughs only  in the  daytime,  when
there are windows and doors unavoidably open in the ward.  She
lies on the  affected  side Avithout pain  or inconvenience  to the
heart,  though it still remains dislocated.   Diet  "simple," with
one chop,  one egg, one bottle of stout.
  Nov. 14.—Soft and distant breath-sounds Avith  inspiration and
expiration under left clavicle.
  Nov. 15 to 18.—The medicine was omitted, and effervescing
draughts with prussic acid were given on  account of nausea and
vomiting,  which did  not  come on  after eating, but occurred the
first thing in the morning, when the stomach is empty.
  Nov. 18.—She resumed the medicine before prescribed.
  Nov. 20.—There is very little, if any,  diminution of dullness
on percussion since admission, although air noAV enters the upper
lobe.   The fluid does not seem to have  been continued to be ab-
sorbed since the 14th.  Perhaps this non-diminution of dullness
arises from the partial return of the  heart  to its place; for the
organ  can now be felt pulsating behind the  cartilages of the left
ribs as well as on the wrong side of the  chest.   Pulse 100, of
good power.   The stout  caused her face to flush after dinner,  so
it is left off.  Other  diet as before.   1^ Pit. hydrargyri, gr. iij;
Scillse, Pulv. digitalis, aa j£, ter die; Potassse nitratis,  gr. xx; 
HYDROTHORAX.
219
 Spirit us  setheris nitrici, TTLxx; Misturse camphor se, 5j ter die;
 repetatur emplastrum cantharidis.
   In the first of the cases  I have narrated (that of Maria G.)
 there  is every reason to believe that the abnormal state of the
 pleura  was of an inflammatory character.   The pain in the side,
 the stitch on inspiration, the rigor, the loss of appetite and fever-
 ishness, all support  the opinion that there was  inflammation of
 the serous membrane.  And probably there was fibrinous exuda-
 tion too, as there usually is in even  slight pleurisy.  But  this
 attack  seemed to have been  of  a  very unimportant character in
 itself;  she was not confined to bed, and the  excellent practitioner
 whom she consulted in the first instance "gave her some physic
 and pills,  and told her to call again in a week," so little did he
 think of it after examination of the chest.   It was of an unim-
 portant character in  itself, but it led to results which might have
 been very serious, perhaps fatal.
   In the second case there is nothing that you can set down as
 evidence of pleuritis.  The patient is of a nervously sensitive tem-
 perament, very susceptible of physical or moral pain and pleasure,,
 so that had there been anything disagreeable to feel she is  not
 likely to have forgotten it;  yet she most  positively avers that
 there never has been since she was taken ill  any stitch in the side
 or catching of the breath in inspiration; the only pain in  the
 chest at all being that arising from the forcible dislocation of the
 heart, and closely connected with its  struggling palpitations.
 There was no rigor, no thirst, furred tongue, or loss of appetite,
 such as accompanies pyrexia.  Yet the hydrothorax is greater
 in extent, and is rather more obstinate against remedies than in
 the former instance.
   We have, then, got so far  on  with the pathology of idiopathic
 hydrothorax as to be able to say that—1st.  It does not follow
 severe pleurisy,—for that produces pus  and fibrin in  quantity
 proportioned to its intensity, and  not serum.
  2d. It sometimes follows slight pleurisy,  as  probably here.
  3d.  The  pleurisy is sometimes  so  slight,  that it may come
under the rule de non apparentibus.
  Yet that the cause of  the  hydrothorax is the pleura itself, we 
220
HYDROTHORAX.
can hardly doubt, when we find  all the other viscera painless,
apparently normal, and doing their duties in the usual manner.
Moreover,  it is  absorption, a function  of the  pleura, the want
of which truly constitutes the disease.  You must not  let the
commonly used but deceptive word "effusion," mislead you into
viewing dropsical fluids as products of extra  exertion on the part
of the sacs which contain them.   Like all  morbid phenomena,
dropsical fluids are proofs of sluggishness,  of deficient vitality.
In full vigor of health, the pleura, pericardium, and other similar
membranes probably pour out a  much greater quantity of fluid
than they do in disease:  this fluid,  in the normal state, is taken
up again by absorption as soon  as  exhaled, so that on opening
the serous  sacs  we find  them damp, indeed, and dripping, but
empty.   By disease absorption is stopped or at  least slackened,
and the natural transudation still continuing,  a collection of its
products remains ensacked.  Think  of dropsy as a  collection,
not as an effusion, and your pathology will be right.
  Do you ever, while  looking in  a dead  body at these thin, ap-
parently unimportant,  membranes—seemingly only the sacs, as
they are called—do you ever reflect on the business they transact
when they are alive ?  The experimental observations of phys-
iologists tend to assign  to them an  activity almost  incredible,
and pathologists will do well not to neglect the hint.   Professor
Lehmann* opened the pericardium of  a  healthy criminal, and
collected the fluid which ran from it in three minutes and a half.
It amounted to 33*8 grammes (9| fluidrachms).  If always ex-
haled at that pace, the quantity in twenty-four hours would be  a
gallon and a half from the pericardium alone!—equal to  about
one-sixth of the whole weight of an average man.  This in  a state
of nature would  be immediately reabsorbed;  and lest we might
hesitate to credit the serous membranes with such an enormous
power of endosmosis as well as  exosmosis, we  can refer  to Dr.
Richardson'sf experiments, which exhibit this power  in action.
This physiologist injected into the peritoneum of a dog weighing
23 lbs.  water  to  the extent of 4 lbs., or more than one-sixth of
  * Lehmann's " Physiol. Chemie," ii, 309.
  f Dr. Richardson on the "Coagulation of the Blood," Exps. 36, 37, 38, 39. 
                       HYDROTHORAX.                   221

its weight.   Twelve hours afterward the animal gradually sank,
and  was examined an  hour after death.  Not a trace of fluid
was  found in the peritoneum.   It had all got into the veins, and
caused death by dilution of the blood.  Three  repetitions of the
same experiment produced results essentially the same, the injec-
tion of a quantity of water equal, or nearly equal, to one-fifth of
the weight proving fatal  by artificial anaemia—not by retention
of the fluid in the serous sac, but by its being taken into the cir-
culation.  When a less quantity  is  injected,  the animal recovers
in about three days; but even in the fatal cases, the serous mem-
brane does its duty,  in taking up with an almost  incredible  ac-
tivity the water presented to it.
  When you reflect upon the  activity of the serous membranes
in a normal state, you  will have no  difficulty  in understanding
where the great mass of fluid comes from in dropsies of the serous
sacs. Nor will you fail to see whither it ought  to go.   And then
you  will clearly see that the disease to be treated is no  excess of
life,  no exaggerated transudation, but a defect of life, an arrested
absorption.
  How do the physical agents to which illness  is traceable beget
the varieties  of pleural disease Avhich  I  have  noticed?  When
by the impression of  cold, or by direct  mechanical  injury, an
inflammation of the pleura is  produced, with great congestion of
the  veins at first,  and afterward with a copious formation  of
fibrin, the absorption indeed is interfered with most forcibly; but
yet it is not these severe pleurisies in which you have the largest
collection of  fluid.  The reason of which is that the normal  ex-
halation is then slackened at  the same time.   But it is arrested
by a less  severe impression than the absorption is; and either
only a local obstruction of the absorbents may take place by a
local formation of fibrin or by congestion, or a partial  arrest of
it throughout the whole area by a force unequal to the production
of actual  inflammation.   In each case, the exudation remaining
nearly normal quickly causes  a copious collection of fluid.  The
reason why hydrothorax is not more common, is that usually the
arrest of the exudation is contemporaneous with, and in propor-
tion  to, that of the absorption. 
222
HYDROTHORAX.
   On  this pathology is  founded the treatment.  The aim is to
restore the function of absorption, and to that end our remedies
are directed.  I will remark upon them severally.
   Blisters.—I will not insult pupils who have gone through a
course of physiology by supposing that they would do  anything
but smile at the'vulgar idea that blisters do good by "drawing"
to the outside the fluid from the inside; for it must be obvious
to the most superficial medical  student, that  the quantity thus
elicited is too small to be of any service.  But still perhaps you
may not have clear notions as to their real action; and therefore
there is danger of your sometimes applying them wrongly.  The
true profit to be  got out of  cantharides is, in the first  instance,
the encouragement of absorption, a power which is exerted over
fluids and solids  equally, and therefore is quite  independent of
the evacuation of serum by the cutis.  The explanation of  the
steps in this process most  reconcilable  to  physiology, is  the
attraction of blood toward  the capillaries of the skin in the first
place; secondly, its dispersion, and  the consequent quickening
of the capillary circulation in the neighboring parts.   With the
quickened capillary circulation follows increased endosmosis, ac-
cording  to the well-known law, that  the attraction  of fluids
through membranes is in the direction of the fluid set in motion,
and  proportioned to the rapidity of the motion.  A further  ad-
vantage is derived from the renewal of growth which is entailed
on the tissues by the self-renewing skin.  The process  seems to
be propagated to surrounding parts, notwithstanding dissimilar-
ity of tissue.
   The practical knowledge to be derived from this physiological
view of the action of a blister should teach you patience in wait-
ing for  the advantages  to  be derived from it; for they are  ob-
viously by no means limited to the period of its application, but
rather begin after it is removed, and continue even after the sore
place is  healed.   You may also learn  by this view of  its action
not to torture your patients needlessly by keeping the blister on
too long, under the mistaken idea that you cannot have too much
of a good thing.
  In some cases I do not even allow the blister time to raise the 
HYDROTHORAX.
223
 scarf-skin, so that I may have the opportunity of repeating it in
 the same place.   But, as a general rule, I think the detachment
 of the epidermis desirable, for it appears to me that absorption
 is particularly active during the groAvth  of  the new skin.  Per-
 haps  the  capillary circulation  is quickened by the  demand  for
 new material entailed by new growth, and perhaps the industry
 of increased life may spread to the neighboring absorbents and
 solid tissues.  Whatever the explanation may be, the fact is that
 during the healing of a blistered surface its chief benefits are to
 be found.
   Next in power to blisters come poultices.  Their action in a
 great measure  depends on the  continued moist warmth acting
 on di-osmotic processes according to the law of their augmenta-
 tion by heat.   But it is also partly in  a more special manner
 vital; for the skin is reddened, swelled, and made more delicately
 sensitive by their application.  They are useful in pleurisies and
 moderate  collections  of fluid, when their size needs to be mod-
 erate only; but it is inconvenient to keep the whole side covered
 up with a poultice, and if they are not  constantly put on hot
 and hot, the surface is apt to get chilled.
   Mercury distances  all the contents of our  pharmacopoeia in
 the  power of hastening destructive metamorphosis.   Under  its
 influence all the  excretions are increased  at the expense of the
 tissues. It is quite  true that by such a process nothing is directly
 gained in cases like those before us;  there is no poison  to
 evacuate, and the debility which follows is so much  ground lost.
 Harm certainly is done by it, but with the harm is joined a good
 which I think is worth the  loss.  No drug  so  consistently and
 steadily aids absorption as mercury, and nowhere can you trace
 its effects so easily as in hydrothorax.  In  the history of  both
 these  cases you may observe  that no immediate improvement
 follows the ingestion of the remedy; but that immediately on its
 pathogenetic effects being produced,  immediately on the gums
 becoming tender, the dispersion of the fluid can be tested  by
 relief to the breathing and commencing resonance on percussion.
 And from  this point a steadily advancing progress  is made  to
■recovery. 
224
HYDROTHORAX.
  I would wish you to remark that the relief to the dyspnoea has
preceded by a short time the return of  resonance, especially in
the woman whose hydrothorax is on the  left side.   The  reason
is that when a certain quantity of fluid is removed, the emptied
space is filled up in both instances by the re-expanding lung, and
in the left side by the return also of  the dislocated heart.   It is
necessary to note this in order to trace correctly the period when
the remedy begins to work.
  When absorption is once set agoing, it is not necessary to con-
tinue the full doses of mercury; if any evil accrues from it, you
may leave it off  altogether; for its beneficial effects, like those
of blisters, may be calculated upon as likely to continue after its
intermission.
  And you may also avoid the injury liable to accrue from the
destructive drug by amply supplying the materials  to take the
place of the loss.  Be very careful that your patient has food in
the most frequent doses possible, in the  largest  doses that will
not give nausea, and in the forms most easily digested.  You have
seen this aimed at in the dietaries of the cases under your notice,
on principles which I need not again recount.
  Digitalis, squill, and niter  were  ordered  for  their  diuretic
qualities only.   That they all, both separately  and combined,
increase the quantity of the urine, is  established by observation ;
and  that  such action  is beneficial in dropsies, is  a traditional
belief. For my part I have no reason to doubt it, for I remember
as a student to have seen patients recover in whose treatment the
diuresis was the only therapeutic  agent that I could at all recon-
cile with rational physiology.   Diuretics do not promote absorp-
tion in the same manner as mercury, by the hastening of destruc-
tive metamorphosis.   The experiments collected by Dr. Parkes*
show that though the water of the urine is  augmented, yet that
the daily excretion of  urea is  either diminished  or unaffected,
thus proving  that at least one great  class of the constituents of
the  body, namely, the  nitrogenous, is exempted.  This con-
sideration has an important bearing on practical medicine, for it
allows us freely to  administer these reagents  combined  with
               * " Parkes on Urine," pp.  158, 170, 173. 
HYDROTHORAX.
225
mercury, without fearing that we shall thereby add to the un-
avoidable evils of that mineral.
  Scoparium.—The most memorable example to my own  mind
of the good effects of broom-tops, is that of a case  in which I
differed in  opinion with a patient, and in which he was  right
while I was wrong. A poor fellow with a slowly growing malig-
nant disease of liver and peritoneum was taking under my orders
this remedy for the ascites  caused by the abdominal tumors.  It
still  increased,  and pressed upward the diaphragm so much that
I wished the peritoneum to  be tapped.   He flatly refused, and so
of course ceased to be  a patient of mine.   About  six months
afterward he came to  me again with an  extension of cancer to
the costal periosteum, of which he shortly afterward died.  To
my surprise I saw his ascites  was all gone, and inquired who had
cured it.   He stated that he had continued the use of broom-tea
for two months after his dismissal from my care, and that during
that  time his abdomen was  reduced  to its natural size, and had
not again swelled. Surely a course of treatment under  Avhich
dropsy due to  increasing malignant tumors  has got well, must
have no ordinary power.
  Besides acting as a diuretic, broom has the additional advantage
of giving an appetite by the bitter which it contains.

            {Clinical, St. Mary's, June 21,  1862.)

  During my visit a few days back a young married woman was
in the ward,—Annie M., about  whom I gave a clinical lecture on
hydrothorax at  the end  of last November.  You may remember
that  then her chest was filled with  fluid  and the heart  pushed
over  to the right side. She  did not come for advice, but to thank
me and shoAV her  chest,  which I  was curious to know the state of.
We found that the heart had  returned wholly to its natural site,
and that there was to be heard vesicular breathing, mixed with
a few occasional crackles, throughout the pulmonary tissue. The
lung has expanded, lets in air, and does its work.   It has ex-
panded, but it has not  expanded to its full size, nor does it let
in all the air it ought.   For  on percussion the part below the 
226
HYDROTHORAX.
 clavicle is still dull, and is flatter than the opposite side, and the
 left ribs do  not open out with inspiration so well  as the others.
 I have no doubt that from long compression the lung tissue  has
 partially degenerated, and that it will be months, perhaps years,
 before it recovers its full life.  Her occupation of nursing a sick
 husband is not the most favorable one for regaining vitality, but
 still you see her in as fair a way to  do  so as can be  expected
 under the circumstances.
   Over and above the possible degeneration of the tissue, there
 may be another cause for the dullness on percussion.   I pointed
 out to your  notice in the wards a week  or two ago  a vessel of
 serous fluid, which had been drawn off by paracentesis from  the
 thorax of a  patient of Dr. Sibson's.   It  was transparent, straw-
 colored,  and not perceptibly  reddened by blood.   In the center
 of the porringer floated a delicate fibrinous clot, just such  as
 forms in blood, but wanting the red globules. It was coagulable
 fibrin that had  coagulated after being  drawn off.  Now if this
 fibrin should collect  and be coagulated inside the pleural sac, it
 clothes the lung with a strong coat which impedes its expansion;
 and if it form also a layer over the  costal pleura, each fibrinous
 mass  would separately produce partial  dullness  on percussion,
 without the  pulmonary tissue being seriously the worse for it.
  I am glad Annie  M. came to show herself just now, as you
 have under your eyes a case very similar to hers, where  a some-
 what different treatment has been pursued.
  James S., a tall and muscular day-laborer, aged tAventy-six,
 was admitted May 30, 1862.   For nearly a year he had found
 his  breath short, but was not  so seriously hampered by it as to be
 obliged to give  up work, till last Christmas. Shortly before that
 date he says he remembers observing that his heart beat on the
 right side of the chest instead of the  left.   That symptom was
 certainly very conspicuous on his admission; you could not hear
 or feel a trace of heart-strokes except  on  the right of the  median
line, and there they  were very strong and loud.   So  one can
 easily conceive  its  having been  remarked even by an unprofes-
sional person.   There was an entire absence of breath-sounds on
the left  side,  which also  was  absolutely  dull on percussion. 
HYDROTHORAX.
227
Several  careful examinations  on successive  days by  different
parties made sure of the fact that the left side was not in the
least dilated, eighteen inches from median line to spinous process
being the exact measure of the semicircumference of the thorax
on the left and right.
   He is  a hearty strong man with the exception of dyspnoea, and
appears to have no other disease about him beyond that of the
pleura.
   He was at first treated with the diuretic pill (Pil. hydrargyri,
pulv. digitalis, scillse,  aa gr. jss) every night and morning, a
draught  containing niter and iodide of potassium three times a
day, and  a large blister to the  side.  But after a week of this
treatment no ground seemed gained, no respiration was to be
heard in any part of the left lung, and the heart seemed if any-
thing rather  more over  to the right side  than  before.   He him-
self thought that the dyspnoea was increased.  I therefore tapped
the chest with a small trochar between the fifth and sixth ribs in
the lateral region, and drew off sixteen fluidounces of fluid, and
then continued the same treatment as before, to try and encourage
absorption.
  The fluid drawn was a yellow serum slightly opalescent.  After
standing, it  deposited  some of the gray opaque matter which
caused its opalescence.   The opaque matter examined under the
microscope was seen to  consist of fine granules,  irregularly con-
glomerated into globules of various sizes.  The  application to it
of acetic acid did not exhibit the  presence in those globules of
any nucleus,  but rather dissolved them, and rendered them still
less like  pus  than they  were previous to its application.
  My  OAvn impression  is, that the  granular matter is  fibrin
altered by long soaking in serum—the same fibrin in fact which
I showed you, showing  signs of recent life by  coagulating into a
clot, in the fluid drawn from Dr. Sibson's recent  case ; but which
has become by time dead and unable any longer to coagulate.
It is the  fibrin which is exhibited in ordinary  blood-serum, and,
after exuding through  the coats of the vessels, is  still found in
the more watery serum  of serous sacs.
  On the day of the operation there was some bronchial breath- 
228
HYDROTHORAX.
ing to be heard beneath the left scapula, but the dullness of the
left chest on percussion, and the dislocation of  the heart,  were
unaffected.
   Two days  after that I  could  not hear  even the bronchial
breathing,  and the patient seemed in no  better case than on
admission.
   Four days after the first tapping he was  tapped again to the
extent of eighty-eight fluidounces.  After this, breath-sounds
were to be heard  very distinctly in the lower lobe, but not in the
upper.
   On the 18th of June the diuretics were  left off, and the fol-
lowing prescription was ordered:
   Jfy  Quinse etferri citratis gr. v, cum olei morrhuse 5y\ t^r die.
   Though the diuretics seemed to be doing no  positive harm, yet
I thought it possible that tonics would do him  positive good, and
ordered them as above described.
   He was allowed to have full meat diet, and also to get up and
walk  about;  for I have noticed that absorption  will often  take
place quicker when the patients are in the erect posture  than
when they are confined to bed.

    (Case continued in a subsequent lecture, July 19,  1862.)

   One would have thought that enough liquid had been draAvn
from  James S. to allow the heart to  return to  its place.  But  it
was not so.   On  the 6th of July, five weeks after admission, he
was punctured again and fluid let out to the amount of forty-four
fluidounces.  He  has  also had the chest painted with iodine to
encourage absorption.   But the heart has not  come back.
   This advantage only is  gained, that the  pulmonary tissue has
been  gradually returning  to its  allegiance; there  is very fair
breathing beneath the scapula and some in the lateral and in the
supra-mammary regions.
   You  may have remarked that the lung  remained dull  after
each  tapping, although the breath-sounds increased.  This I con-
ceive to be due to a layer on  the  pleura  of that fibrin Avhich I
have  pointed out  to you as a natural constituent of the serum  in 
HYDROTHORAX.
229
both the recent and more chronic forms of hydrothorax.   I be-
lieve the abnormal coating binds  down the lung, preventing its
expansion, and counteracting the  remedial action of the opera-
tion.  So that much less than you  might have expected has been
gained by it, and  the  patient remains on hand  as  long  as  the
young woman, Annie M., whom I showed  you in the ward and
lectured about a month ago, and  who was not tapped. In fact, the
chest refuses to be hurried by violence and must take its own time.
   I say this not to discourage you from practicing the operation
of paracentesis;  for it is an  easy, safe operation, and in  recent
cases very effective ; but simply to prevent your  disappointment
in case you should anticipate too immediate benefit therefrom in
chronic collections of fluids.
   As an experiment upon the heart, I have had James S.'s chest
bound up with a stout tight bandage, as if the ribs  were fractured.
The design is to  make the bony parietes  of  the  thorax a fixed
point, so that the healthy right  lung  may compress the heart by
its expansion ;  and as it moves more than the left imperfect lung
by reason of its healthiness,  it may possibly assist in reinstating
the displaced organ.   All I  can report upon the experiment as
yet is that it seems to do no  harm, but I cannot say it does any
good.
   The patient also continues his  tonic  treatment, and I think
that each time I listen the breathing  in the lower lobe is more
distinct.  The  upper lobe expands much more  slowly.   I sup-
pose the diaphragm has not the  same  power over it to draw the
air in, and so Ave find only an indistinct distant breathing  in that
part.
   You will probably ask what is  likely to be the result  of  this
case.   In answer  I refer to  that  of Annie M., which Avas  one
exactly similar.*    And I may refer  also to another, not  indeed
of hydrothorax, but of a disease whose  mechanical  relations to
the chest  are closely analogous,  empyema thoracis.
  * Shortly afterward this man, James S., returned to work  at his own request.
I did not dissuade him, as he was able to run up stairs without dyspnoea, and felt
sure he would be able to earn a fair day's wages.  The heart however remained
beating on the right side.   I have not heard of him since then.  October, 1863. 
230
HYDROTHORAX.
  An old patient of mine, formerly a horse-jockey,  aged now
fifty-four, is occasionally to be seen about the streets near here,
whose chest presents a striking instance of the form which con-
tracted ribs assume.   It is a case not indeed of hydrothorax, but
of empyema after pleurisy, which occurred in this hospital  in
1857, and is reported by the  then house surgeon, Mr.  Ash,  in
the "Lancet" for May 31, 1862.   The empyema was cured  in
the only  mode in which it can be cured, namely, by the external
discharge of the pus.   Thus the chest was put into  the same
relative mechanical condition as is that of the patient now in the
wards upon whom I  am lecturing.  The  heart, which had been
displaced to the  right side for two months, returned to its place
in about  a month.  After that the ribs fell  in, and  became flat-
tened very gradually, so  that they  did not  attain  their  utmost
flattening till the autumn of 1859, two years after the empyema.
And then  how  were they  flattened ?—not  in the part where
the empyema had been, and whence it had been discharged—
not in the lower part of the thorax—but beneath  the clavicle,
which is  so depressed that  the man looks quite lop-sided as he
walks.
  I fully expect the  ribs of our present patient will fall  in after
the same  fashion, and that his heart will in due course of time get
back to the right place, but that as  the displacement has lasted
longer, so that the restoration will be longer about.
  It may be remarked further, that in  the  lop-sided old jockey
the ribs,  though  flattened, move freely and equally on both sides
with the  breathing, and that the air enters  the two  lobes of the
lung on  the formerly affected  side  fully  and equally.   This  is
a cheering  observation; it eneourages  us  to  prophesy  that
our present patient  also will with  time recover  the full use  of
his lungs. 
LECTURE  XVIII.
                ACUTE LARYNGITIS.

 Case related—Important point in the pathology of the disease is
     its locality— Tracheotomy must not be represented as  a last
     hope—Reasons for delaying it and reasons for not delaying
     it—Care of digestive organs— Wine—Solid food—Antimony
     —Mercury—Laryngitis, acute and chronic—Difference in
     pathology and in principles of treatment.

           (Clinical,  St. Mary's,  October 25, 1861.)

  Maria F., aged  twenty-two, a  domestic  servant, was placed
under my care a fortnight ago.  It appeared that she came first
as an out-patient, with a catarrhal cold of head and chest of a
feAv days' duration.   But she found so much difficulty in breath-
ing that on the second day of her attendance she could not leave
the hospital,  and was sent up to bed.   She was, when first seen
(on October 12), cold and shivering, her face was livid, her pulse
weak, her breathing labored, noisy, and spasmodically irregular.
There  was also slight fullness of the throat and  tenderness
on  pressing  the upper part  of the larynx.  She was ordered
inhalations of hot steam, and frequent teaspoonfuls of hot beef-
tea and wine; four leeches were  applied  to the trachea, and  a
draught of an ounce of decoction  of cinchona, and a drachm of
compound tincture of cinchona, ordered to be taken every alter-
nate hour.
  Next day,  October  13, it is reported in the clinical case-book
of Mr.  Young, the house surgeon  :
  " She  passed a very bad night.   The dyspnoea is increasing ;
but she was  able to swallow till  11 a.m., with difficulty.   The 
232
ACUTE LARYNGITIS.
throat is more tender.  She is obliged to be propped up in bed,
as she could not  breathe in any other position.   There is slight
cough, the face is  flushed, the lips livid, the eyes swollen, and
countenance anxious.  These symptoms gradually increased till
7.30 p.m., when she was found gasping for breath, and asphyxia
was  fast coming on, when a little chloroform was administered,
and  Mr. Young performed  tracheotomy.  After the operation,
the pulse was 100;  she was able to swallow,  and expressed  her-
self greatly relieved.
   "Oct. 14.—She  could not sleep  very well.   She took a little
nourishment.  The breathing was tranquil.   She was ordered to
have  an enema of mutton-broth, with ten  minims of laudanum
every three hours;  and also as much nourishment as she could
take by the mouth.
   " Oct. 15.—She slept pretty well.  Pulse 100.  Tongue furred.
Slight cough.  She breathes a little through  the nostrils.
   " Oct. 16.—The trachea and larynx are not so tender.  Pulse
98.
   " Oct. 17.—The  tube was withdrawn, and  she breathes tran-
quilly.  The bowels  have not  acted since  the  operation.  A
simple enema was ordered at bedtime.   Her appetite  is very
fair;  she is able to  take three eggs, beef-tea, &c, in addition to
enemata of mutton-broth.
   " Oct. 18.—The  bowels acted  freely.  The wound is granu-
lating a little.  Air still passes through the opening, which is
covered by a piece of muslin gauze.
   " Oct. 19.—She is cheerful.   Tongue cleaning at edges, but
still very much furred in center.  Pulse 95.
   " Oct. 21.—Pulse natural.   She sleeps  tolerably well.   She
has slight cough,  and expectorates a little.
   " Oct. 23.—The appetite improves.   She was ordered to have
half a dozen  oysters daily in addition."*
       *        *        *         *        *        *     .
   Inflammatory laryngitis (or  rather glottitis)  is a  disease in
which  the  power we  wield of saving existence by restoring a
  * The wound healed on  October 28, and on November 4 she was employed in
assisting the nurses in their care of the sick. 
                     ACUTE LARYNGITIS.                 233

 deficient function is most strikingly exhibited.  What a paltry
 Bcrap of flesh is damaged !  Yet how frightful the results are to
 witness!  The question of life or death is a question of an eighth
 of an inch more or less diameter in a tube.  If the same amount
 of inflammation were in your finger or at the end of  your nose,
 anybody would laugh at you for going to a doctor about it; if
 it were in your  digestive  canal, you would perhaps  stay away
 from lecture, and take some slops, but  you would not care to
 make an  accurate  diagnosis  of its whereabouts.   Catarrhal
 inflammation may even attack  the  lower  part  of  the  larynx
 itself pretty severely, and  yet what one may call "old nursey"
 practice be all that is required.  A girl in an adjoining bed, who
 came in at the same time as this one, had lost her voice from
 the tumefaction of the vocal cords, yet I did not think it worth
 while to treat her further than by keeping  her in bed with  hot
 water inhalations and ammoniated salines.   But once  let  inflam-
 mation  sink  through the mucous membrane of the glottis to its
 submucous tissue, let that become anasarcous, and you see what
 a piteous call for active interference arises !   I say like  QEschylus,
 "you see" the call, because, though the  patient has all  the
 appearance of screaming loudly, and  mayhap is trying to do so,
 no cry reaches your ears.   It matters not  if the inflammation
 be violent or weak, be rapid or slow—directly it has caused  the
 edges of the glottis to swell to  the point of not admitting as
 much air as the lungs want—instantly that it has reached this
 point, life is in immediate danger.  It matters not what was  the
 former state of the patient—the present moment is  a present
 and  pressing peril—a Samson or a Lazarus  equally hovers on
 the edge of the grave.
   In  point of fact, the  importance of acute laryngitis depends
 not on the  degree of injury to life, but on the localization of the
 disease.   And hence the value of remedies is closely proportioned
to the special definiteness  of  their action on the part affected.
 There may be perhaps in the druggist's shop excellent remedies
for inflammation, which would  act most powerfully all over  the
body of your patient—all over the body of an animal of three
times the size; but  you do not want just now to act all over
      16 
234
ACUTE  LARYNGITIS.
her body, only on that  little spot which stands between her and
life.  Do not run the chance of acting deleteriously on the whole
person for the sake of a possible benefit to such  a minute  por-
tion of it.   Do not mistranslate from  Hippocrates, " extremis
morbis extrema remedia,"* and ransack your brains  for  that
which  is the extremest remedy for this extremely dangerous in-
flammation ; but seek for that which will get nearest to the seat
of peril.  When this woman came into the ward, she was (as
described in the report) blue in the face, speechless, incapable
of swallowing, and breathing without labor and  noise.  It was
very obvious that something must be done  to relieve  her with-
out delay.  But her skin  was cold, her pulse  was weak and
quick, and  she was worn  out by want of food  and weariness.
Wherefore, though I expected tracheotomy would have to be
practiced, I thought  it well to try other measures first, especi-
ally as there  are other measures equally local and equally im-
portant without being  so  alarming.  I  got  her  warm in  bed,
gave  her teaspoonfuls of hot  beef-tea and  wine, made the air
damp  and soft round the  mouth with hot steam, and  put four
leeches on the outside of the trachea.   There was some degree
of relief from this, and the purple  hue of the face wore  away
during  the afternoon.   But the  next evening  it  came back
again; and Mr. Young carried out the provisional  order for
tracheotomy.   Then  the relief was immediate;  the  lividity of
countenance vanished ; she shortly fell asleep, and went  on  after-
ward respiring through the  tube till such time as the. swelling
of the glottis  subsided enough for her to breathe in the natural
way;  on which the instrument was taken out.
   Tracheotomy is an alarming  operation to hear of or to look
at, but in reality it is not a dangerous one.   Ignorant suicides
often open the windpipe by cutting their throats right  in  front;
yet they fail  to kill themselves, if they miss the great vessels.
  * Few wrong renderings have done so much harm as this, which has led people
to intrench themselves under the authority of the shrewd  Greek,  when they
increase the violence of their remedies in proportion to the violence of disease.
I have heard M. Chomel do so when bleeding the most severely the worst cases
of pneumonia; and "the more syphilis the more mercury" was the rule acted
upon at the Lock Hospital not many years ago. 
                    ACUTE LARYNGITIS.                 235

And if a wound  under such circumstances of violence does not
kill, how is it  likely to do so when made  with the deliberate
caution of a surgeon ?   In point of  fact I cannot find on record
an instance of its being fatal.  Patients often die after it, because
laryngitis is so  often  complicated  with extensive  pneumonia,
croup, diphtheritis; but  I  cannot find  anything to show that
tracheotomy^Jias  ever hastened the death; nay, in most even of
these it  seems to have postponed the unfortunate termination.
Do not,  therefore, alarm  the patient's friends by speaking of it
as "a last hope," "a final resource," or by  any similar weak
expression.  Doubtless there is danger in the operation—the
danger of haemorrhage into the trachea; but there is  not half the
danger your patient's  friends are  sure to  anticipate,  and are
ready to exaggerate, if encouraged by your  giving way to weak
fears.   The consequence of this conduct on  your part  is  that
they beg you to  postpone it a little and a little longer, till the
time has passed for a chance of success.   Each minute the throat
is becoming more swollen and filled with black blood, and there
is more likelihood of the surgeon's hand being  stayed by trouble-
some haemorrhage; and haemorrhage is the  only thing at all to
be feared  in the performance of the operation.  Each  minute
congestive pneumonia is becoming  more and  more probable;
more and more incurable, if already existing.
  The only reason for delay is  that of which  you saw an in-
stance in the present patient; namely, a  possibility that the
excessive urgency of the symptoms may be due to some easily
obviated external cause, such  as cold, weariness, nervous excite-
ment, hysteria, or the like cause.  It was not improbable that
a patient, chilled  with coming to the hospital and sitting in the
waiting-room, might appear wOrse than she really was, and that
warmth,  food, and  rest might  alleviate the  pressing  danger.
They did so to  a  certain extent;  but not so far as to prevent  a
relapse.
  It is not my  place to say much about the  surgical part of the
business.   I will  merely tell you what the physician requires of
the operator.  His requirements  are:—1. That blood shall not
be alloAved to get into the trachea (to secure which the use of a 
236                 ACUTE LARYNGITIS.
simple scalpel, and the waiting for all serious bleeding to have
ceased before the  cartilages are cut, are  the  best means).   2.
That the opening shall be large enough to admit of a  sufficient
body of air; that is to say, it must be capable of being stretched
to nearly the diameter of  the trachea.  3.  That the instrument
inserted should  be capable of being kept  clean by a nurse, and
not easily jerked out by spasmodic  movements  on  the part  of
the patient.  The ordinary  curved double cannula seems to me
the best.
   So  far for restoring the deficiencies of the  respiratory func-
tions.
   But other functions call for care also.  You will have seen in
the case-book that half a  pint of warm beef-tea was ordered to
be thrown up into the colon by enema every  three hours from
the first hour of admission.  These patients are usually suffering
as much from want of food as from want of air.  The deficiency
does not kill them so rapidly as the impediment to respiration;
nor does it make itself so conspicuous; and for that very reason
is  apt to be forgotten.  But  observe the convulsive motions of a
patient with laryngitis on  trying to swallow, and you will not be
surprised that they resist all attempts at feeding by the mouth,
and that nurses  have no heart to  force them.    The attempt is
another name for  strangulation.   Yet if  they get  no nourish-
ment, they are hourly becoming less able to bear up against the
depressing influence of the devitalized blood, less able  to renew
the injured larynx. This is  a matter of great moment, not only
as regards the present retention of life, but as regards  the latter
prospects  of the patient.   For the last hundred years  people
have been writing  a great  deal, more or less wisely, about laryn-
gitis;  but I do  not think any one has noticed this important
part of the treatment since Van Swieten a  hundred years ago.
("Commentary on Boerhaave," vol. viii, sect.  713, ad fin.)   It
seems not improbable, from the details given in published cases,
that many of those whose immediate danger has been  happily
postponed by the operation,  have died of starvation  through the
neglect of this simple measure.
   Whenever you want to  administer nutriment in  enema, it is 
ACUTE LARYNGITIS.
237
 well to prevent it from running off before being absorbed by add-
 ing  a few drops of an opiate.   This  was done at first in  our
 patient's case; but it was  not necessary to continue it, as no
 faeces were passed per anum for three days.
   When the powers of life have been so reduced by the deficiency
 of the respiration that the mucous membrane of the intestinal
 canal rejects the food  undigested, you may mix pepsine with it;
 and you may appropriately  administer tincture of bark and port
 wine.  Both were ordered on  this girl's card; but little of either
 was given, since  within forty-eight hours after the operation her
 pulse had got full and natural.   Always remember what I  told
 you when lecturing on low fever—wine is an adjunct or help to
 restorative treatment, but if made to take its place, is hurtful.
   When the patients  begin to take food  again by the mouth,
 you will often find  that solids of certain kinds are easier swal-
 lowed than pure liquids.  This is noticeable in all kinds of dys-
 phagia;  in fact,  the embracing of a gulp of fluid by the semi-
 voluntary pharyngeal  muscles  is a greater effort,  and more apt
 to cause spasm, than happens with a more resisting mass.   You
 can  try this any day in your own throats.  You must therefore
 choose as the solid you administer to the patient some one which
 slips down easily, such as the oysters which have  been  ordered
 for this girl.
  I  feel you  expect  me to say something about two drugs  which
 have been recommended in acute laryngitis—antimony and mer-
 cury.  I must  confess I have  never been able to  trace any ad-
 vantage from their  use, either in cases of recovery or of death.
 I no longer use them, and do not recommend them to you. The
 action of the  salts of these metals is to increase destructive meta-
 morphosis, and to lower the force of the heart.   By such means
 they certainly do appear to  me to have a controlling power over
inflammation.  But  it  is a  power exercised slowly, and at  the
 expense of depressing  the general vitality rapidly;  so that they
are peculiarly unsuitable for cases where an effect is desired to
be quickly produced ;* for, if enough of them is given to stop in-
flammatory action in the short time allowed-us, a serious lower-
ing of the vitality follows, extremely dangerous in its more remote 
238
ACUTE LARYNGITIS.
consequences to patients who have already had to bear the shock
of being half stifled.
  What I would have you  mainly keep in mind in  your treat-
ment of laryngitis is as follows:
  1. If the external and obvious conditions  of the patient  be
such that some part of the  symptoms may be due to those con-
ditions, remove them.  Warm the surface  of the body; saturate
with hot steam the air inspired; put on leeches, and hot foment-
ation to the throat.  In special favorable cases, bleed.
  2. If benefit do  not quickly follow, perform tracheotomy, or
get it performed.
  3. If a relapse occur  after  temporary  benefit,  every minute
that the operation is delayed is an opportunity lost.
  4. Food must  be sedulously administered,  if not by mouth,
then by rectum.   This is especially needful if leeches are put
on, more especially if you decide to bleed, and still more especi-
ally than  ever if  mercury or antimony have been  thrown  in  by
yourself or others.
  5. Let  the  restored air for respiration be  moist  and warm;
and take care that there is enough of it, by inserting a full-sized
double cannula in the trachea, and heedfully watching the orifice
day and night, lest it get blocked up by mucus.
  As a contrast to the disease in the larynx inducing such serious
danger by its  locality, but rapidly recovered from by reason of
the slight morbid  alteration which  has taken  place,  I show you
here a larynx taken this week from the body of a man avIio died
of pulmonary consumption.  See how extensively it is disorgan-
ized.   The  mucous  membrane covering all the upper part is
white, thick, and rough; just below the vocal  cords on the right
side there is a ragged deep ulcer, which has bared the arytenoid
cartilages, and caused them to become necrosed by killing the
pericondrium; a piece of the dead cartilage projects into the bot-
tom of the cavity.   There is  another superficial ulcer in a cor-
responding place  on the opposite side.   Yet here the symptoms.
referable  to the larynx were of very little weight.  The man's
voice was  indeed hoarse and weak, but not  more so than you find
in most sufferers dying with a very large vomica  in one lung and 
                    ACUTE LARYNGITIS.                239

the other filled with crude tubercles, as we found in this autopsy.
There Avas  a considerable secretion of pus also, and pain in the
larynx when pressed, but  there was no difficulty of breathing, in
whatever position the patient lay.   Consequently no local appli-
cations were made to the  organ. There was no demand for local
interference, and certainly it would  have been useless for  the
lengthening of life.   The need calling for restorative treatment
was the weighty one of chronically deficient  nutriment to  the
whole system.   The larynx was ulcerated and degenerated for
the same reason that the  kidneys  were  shrunken  and granular,
and that the whole  person was worn  down to a skeleton—suffi-
cient aliment was not absorbed to  compensate waste. A despair-
ing effort indeed we made to supply this by  trying  to restore
digestive and absorbent powers to  the alimentary canal  with
quinine and iron, and to feed muscle and fat with meat and cod-
oil.  But in vain. Sentence of death had long before gone forth;
and it w*as hard to say that the decree was in any measure stayed
by treatment, however suitable it may have been.   My object in
quoting this case now is not by it  to praise the remedial agents
brought into play, but to draw your attention to the rule, that—
the immediate danger of  diseases is  mainly traceable  to their
locality, the final danger to the extent and intensity of the patho-
logical changes.
   I would lay it down as a law  to  be obsen-ed, that in cases
where the danger is imminent, the attention of the medical at-
tendant should be directed to locally  active remedies; where the
risk is more remote,  his mind  should  be turned to  those of  gen-
eral agency.  Thus in acute laryngitis  you are to think of the
larynx alone, to the temporary neglect of other parts; in chronic
laryngitis, you are to consider the general nutrition in preference
to the local injury.                  i 
LECTURE  XIX.
       CAPILLARY (or SUFFOCATIVE)  CATARRH.
                v
Definitions of the disease—The mildness and severity depend on
    the quantity of bronchial membrane involved—Slighter cases
    essentially of the same nature as the severe cases here brought
    forward—(First case)  Uncomplicated  bronchial catarrh—
    (Second case)  The same arrested on the brink of merging in
    broncho-pneumonia—Treatment by warmth and moisture—
    The same treatment (Mudge's) applicable  to mild cases—
    Blood-letting—(Thirdcase) Bronchial catarrh fatal by super-
    vening on lung previously imperfect—Autopsy—Such  form
    of fatal disease aptly described as paralysis of the lung—
    Equally fatal to  strong as to puny  people—Arises  from
    exposure to cold air during a catarrh—Danger  much  in-
    creased by imperfection  of lung.

          (Clinical, St. Mary's, January 23, 1864.)

  The late  frosty weather has borne its  usual crop of many
severe acute bronchial catarrhs.  Three of these came  under my
care last week, and I shall take the opportunity of making  a few
remarks upon  the  nature of the disease and the  treatment  re-
quired by the patient.
  What you see  before you is a disease consisting of  a rapidly
occurring congestion of the mucuous  membrane of large and
small  air-passages, resulting in the pouring out  of mucus and
pus, and tending to destroy life by dyspnoea.
  In its  slighter forms, and when affecting the trachea princi-
pally,  it  constitutes the well-known #" cold  on  the  chest" or 
CAPILLARY CATARRH.
241
" bronchitis"* of the public in general.  And when it is prev-
alent on an epidemic scale,  it is  called " influenza."   In these
cases it appears to affect almost entirely the trachea and larger
air-passages, and  the oxidization of the blood is hardly at all
interfered with.   When the  smaller or capillary bronchi suffer,
then  a serious interference with the  aeration takes place, and
the catarrh becomes, what is well called in old writers, " suffo-
cative," or in more anatomical phraseology,  "capillary catarrh."
   These cases differ from other bronchial catarrhs in the extreme
sense of suffocation or  dyspnoea, quite out of proportion to the
physical  signs elicited  by auscultation,  or to the  cough and
amount of expectoration.
   Important as the slighter  cases are on the score of frequency,
I cannot find suitable  examples  for clinical lecturing, for  they
usually are so much better after the seventh day, if  there  is no
other disease in the chest, that they seldom  appear in the wards.
I  can, however, exemplify by the more  severe cases the treat-
ment ; the principles  of which, and most  of the details of which,
are applicable equally to all.
   The first patient to which I ask your attention is  Ellen  C,  a
married woman, aged  twenty-two, eight months pregnant  with
her second child, who  was admitted  on  the 8th  instant, during
the frost.  She is robust and sturdy, and has not suffered any
inconvenience from her pregnancy.  She had a cough for a fort-
night, but it gave her so little inconvenience  that she had not
laid up  till New-year's day, when it got much worse, and was
accompanied by such shortness of breath that she  was obliged to
keep  her bed, and was conveyed from thence to the  hospital.
You saw that the dyspnoea and orthopncea were excessive, her
face was congested and  the lips livid, and  she brought up by
frequent coughing a small  quantity of tenacious sputa, partly
frothy with large bubbles, and partly consisting of small, round
  * This word  is vaguely applied, both by  the vulgar  and by the profession
when talking to the vulgar, to any cough with expectoration.  I believe patients
like much better to hear that they have " bronchitis," than to hear that they are
coughing and spitting; but I think among ourselves we ought to give up the term
as the name of a definite ailment; for it has been so much  misused that it ia too
late to make it scientifically distinctive. 
242                CAPILLARY CATARRH.

lumps  of  tough mucus.   The  pulse was  120.   Auscultation  of
the chest  showed the lungs resonant, but filled with whistling,
cooing, and all kinds of dry r&les throughout, so loud, that the
few moist  sounds were seldom  audible.  She appeared  in immi-
nent danger.
  The whole  chest was immediately enveloped in a jacket poul-
tice of linseed  meal, and  she  was directed  to  breathe entirely
through a Mudge's inhaler, kept supplied with hot water.
  On  the  next day, the 9th,  the dyspnoea was much  relieved,
and the pulse had sunk  to  100.   The same treatment was  per-
sisted in.
  On the  13th the pulse was 88, and she left off the inhalation;
on the 16th  it was 72; the sputa were  more opaque, and she
breathed  easily.   The  poultice was  then  discontinued,  and a
blister was applied to the chest.   An ounce of decoction of bark
was also ordered to be taken three times a day.
  This is  a case of generally diffused acute bronchial catarrh
without tendency to pneumonic condensation.

  The second case  is that of  Edward C.,  aged twenty-four, a
bricklayer, now in Albert Ward. He said he had been first seized
by a cough and pain across the front of the  chest on Christmas
eve.    This took him off work immediately, but his breath did
not get -short, as it was when  we first saw him, till a fortnight
had elapsed,  and the frost  had commenced.  Before admission
he had been  attending a few times as  an  out-patient, and it was
on the last occasion of his so attending, viz., on  the 13th instant,
that Dr.  Markham sent him  up stairs to bed, as too ill to  be
allowed to leave  our doors.   The dyspnoea and lividity of the
face were not so great as in the last patient, but there was the
same general diffusion of sibilant rales without  dullness on per-
cussion marked in  any region.   I say the dullness was not
marked in any part; but after  examination by the stethoscope
had shown some fine crepitation beneath the right clavicle I per-
cussed again, and then  some of the by-standers thought that the
upper lobe was not quite so resonant as the  other.   The tongue
was white and furred, the sputa copious and frothy, and reported
to have sometimes a yellow stain. 
                   CAPILLARY CATARRH.               243

  He wanted to go home to fetch "his things," but his request
was not complied with.  He was ordered to be put to bed imme-
diately, and to be  cupped to the extent of six ounces beneath
the right clavicle, the chest to be enveloped in a jacket poultice,
and the vapor of hot water to be inhaled.
  On the 16th there was no fine crepitation or dullness on per-
cussion.   On the 20th the sputa had become purulent, and the
cough alleviated during the day, though troublesome at night.
He Avas then ordered two grains of  quinine thrice a day, and to
leave off the poultice, and has continued to convalesce.
  This is a case of acute bronchial catarrh arrested just on the
verge of resulting in bronchial or catarrhal pneumonia.

  You may observe that the treatment of both these cases has
been essentially the same as  regards the most seriously injured
part,  the bronchial mucous membrane.  Moist warmth has been
kept continuously  applied to both the inside and  the  outside of
the chest.  Moist  warmth is the  most powerful restorer of
arrested circulation and vital  action that we  possess,  the  safest
therapeutical engine we know of, because the most  direct renewer
of life.
  Perhaps you may exclaim that this mode of inhalation limits
the supply of oxygen, which is so much needed for the aeration
of the blood.   I frankly grant that there is less free oxygen in
warm steam than  in  cold  air, and  that therefore certainly less
oxygen goes into the trachea; but I  am not sure that less oxygen
is absorbed by the pulmonary membrane.  For  this dilution
with warm steam softens the tissue, and  makes it more apt for
endosmose;  and even in its immediate action  it may cause more
oxygen  to be digested (if I  may say  so) from the weak, than from
the  strong supply.
  But oxygen  (as  I have  often pointed out to you)  is exceed-
ingly  injurious  to tissues in the state of partial death which we
call inflammation, and therefore the limiting, to such extent as
is consistent with safety, its supply is not a thing to be avoided.
  You may ask whether this mode of treatment be applicable to
the  milder cases, such as you will have more to do with in private 
244
CAPILLARY CATARRH.
 practice  than in  a hospital.  Yes—there is  nothing like the
 inhaler for a cold on the chest, for which, indeed, it  was first
 introduced by Mudge.*  But you will not persuade patients with
 a will of  their own to  submit to a jacket poultice, unless  they
 are nearly as ill as our present patients.
   If there is much thirst, effervescing draughts of citrate of am-
 monia seem  to be liked;  but when the illness is a serious one
 there  is some danger in advising  treatment by drugs, because
 sick persons are so prejudiced by habit in its favor, and it is  so
 convenient to them, that there is a risk of their neglecting the
 other and more important parts of  the  advice.
   As soon as the mucus became opaque, you will observe that I
 ordered quinine.   Begin your tonics  always as soon as you can,
 for they enable more food to be digested, and thus they shorten
 the convalescence.
   In the  second case, blood-letting by cupping-glasses was or-
 dered beneath the right clavicle.  This  was done, because pneu-
 monia seemed to  be just commencing  in the upper lobe of the
 lung—a very dangerous  situation for it to commence in, much
 more dangerous than in the lower lobe, and demanding prompt
 measures  as  much as the more generally diffused bronchial af-
 fection.

   The third case  I shall commence by the post-mortem dissec-
 tion.   On Wednesday, some of you saw the examination of the
 body of a  woman aged about forty, externally in good condition,
 and not emaciated or presenting any aspect of chronic  ailment.
 The removal of the ribs disclosed the right lung contracted very
 much,  and clothed as to its  lower part  with a smooth white
leathery coat, not  adherent to the  walls  of the chest, and but
 slightly to the lung,  though it had bound the lobe together in its
 contraction, and had caused atrophic degeneration of its tissue.
 It was probably the  remains of old hydrothorax, for which she
was in St. Mary's about three years ago.  The upper lobe of the
same lung was not much better fitted  for receiving air, for  it
  * " Radical cure for a recent catarrhous cough,  with a chapter on the vis vita?,
&c."  Second edition.  1779. 
CAPILLARY CATARRH.
245
contained old and contracting chalky tubercle, and a vomica of
ancient date as big as a chestnut.  In the left lung there was no
tubercle  or  consolidation  or signs of pleuritic disease; but the
whole  substance was doughy, retaining the marks of the five
fingers when the hand was pressed upon it.   The tissue was not
nearly so crepitant as it should be, and it was black with venous
blood.    Some  parts seemed  more  decidedly  emphysematous.
The trachea and bronchi were deeply reddened and dry, no pus
exuding, as  it so often does, from their orifices when cut across.
Heart  and abdominal viscera were of quite normal appearance.
   This woman was in the  hospital but four days, and was too ill
for us  to learn much  from  her during life.   She was a  quiet
gentleman's cook, and, though habitually subject  to cough and
short-winded, had been able to do her moderate work somehow
till the arrival of our late  severe weather. That laid her up, and
in a Aveek reduced her to  the condition in which she was on ad-
mission, namely, hardly able to breathe even when propped up in
bed, with the face livid, and the purple blood-shot eyes starting
out of their  sockets.   I do not think she had any expectoration.
Dry cupping and poultices did no good, and she was unable to
foment the bronchi with Mudge's inhaler.   As, from the reso-
nance  on percussion over the cardiac region, I had suspected
there was a good deal of emphysema, I gave  her some lobelia
and ether, but I could not perceive that it brought any relief.
   There  is more instruction  to  be gained from the appearances
after death.   I dare say some of you can call to mind that ter-
rible February during the  Crimean war, Avhen the stern sovereign
of our stern  enemies was  suddenly death-struck, while actively
engaged  in  his patriotic  duties.   Few can forget  the ghastly
satire,  too bitter for  us  even  at  that bitter time, with which
"Punch's" artist hailed the event;  and medical men remember
how the public was puzzled by the bulletin of the German phy-
sicians, who announced the death as due to " paralysis of  the
lungs."  By this  unusual but not inapt term they intended to
designate that complete obliteration of function which we see in
such lungs as these; and the Emperor's illness was of the same
nature as I am quoting three examples of to-day, namely, inflain- 
246
CAPILLARY CATARRH.
mation—a  partial death—of the bronchial mucous membrane,
resulting in obliteration of  function.  It arose, too, under  the
same  circumstances  of  exposure to severe dry frost during a
catarrh.
  People were  surprised at the rapid sinking of a man so  re-
markably  muscular  and strong  as  our gallant enemy.   But I
happened at that very time to be called to see a country clergy-
man of large frame- and great height, who sank  in the same way
from fatal  bronchial catarrh, brought on by exposure during a
cold on the chest.  So that I felt less surprise than others. And
I am rather disposed  to think that big burly people, once severely
smitten, yield to the  disease  even sooner than others.
  I have noticed, in  the second  case, how anxious I was to pre-
vent the man from going out in  the cold  after we had once  got
him up into the ward.   My re%son was, a feeling of the  extreme
danger not only of the extension of  the catarrhal state which is
brought about  by cold  air,  but also of the penetration of  the
inflammation to  the tissue  of  the  lung  (lobular or catarrhal
broncho-pneumonia).  Of the two ways by which inflammation
penetrates  to the lungs, from the inside or the outside, the former
is much the worst.   I have no doubt but what it was the unfor-
tunate independence  of control, which is a necessary part of sove-
reignty, that destroyed  the Emperor.  He was determined to go
on with his duties, come what might,  and nobody's will was strong
enough to say,  "We will not let you."
  Any disease which has previously limited the  area of available
lung increases very  much the danger of capillary catarrh.  In
the patient who is my  present  text the  atrophied state of  the
lower right lobe, the ancient tuberculosis of the upper,  and  the
possibly prevenient emphysema  of parts of the left lung, took
away her chances of renewed life.   Had I been aware of them
all, I should have given a still more unfavorable prognosis than
even the symptoms made me give.
  In  the last sentence I applied the  epithet  "possibly preve-
nient" to the emphysematous state  of  the pulmonary tissue.  I
did this because the patient had given us during life some broken
history of shortness  of breath affecting her for a considerable 
                   CAPILLARY CATARRH.               247

period,  and it  would be difficult to  say that this degenerated
condition of the lung membrane had not existed  as  its cause.
But I said  "possibly," because in fatal cases of capillary catarrh
emphysema is so often found, even in patients previously healthy,
that it certainly must be a consequence, and not the origin of the
complaint.   This is  especially the case in infants,  whose lungs,  *
when they die of bronchial catarrh or of broncho-pneumonia,
are almost invariably highly emphysematous; a state of things
which their age and  previous good health show to be capable of
very rapid development. 
LECTURE  XX.
                     PNEUMONIA.

Three  cases  of  pneumonia—1.  Frank, uncomplicated  double
    pneumonia  in  a temperate man, with excessive dyspnoea—
     Cured with venesection, jacket poultice, continuous feeding,
     and wine.   2.  Pneumonia of upper and lower lobes  of one
     lung, very slight in the other lung, in a broken-down old
    man—Cured with cupping, jacket poultice, continuous feed-
    ing, and wine.  3. Congestive pneumonia of  lower lobe in
     typh-fever—Cured with half-jacket poultice, cupping beneath
    scapula, continuous feeding, wine, and bark—Commentary—
    Pathology of pneumonia—Importance in proportion to quan-
    tity of tissue involved, not  to stage  of progress—Hence the
    value of a ready and quick means of checking its progress—
    Blood-letting—Action of it—General and local compared—
    III effects of loss of blood—Mode of judging of the necessity
    for it—Compensation for it—Poultices—Their action—Es-
    pecially  adapted for infants—How to make them—Alcohol,
    when required—Effect of position in the pneumonia of typh-
    fever— Blood-letting — Purgatives —Blisters — Antimony
     and mercury.

             (Clinical, St. Mary's, May 10, 1862.)

  There have been three  patients under my care  in the  Albert
Ward for males this week, to whom I have drawn your attention,
as illustrative of the most common phases under which we have
to treat pneumonia  in the  adult.
  No. 1 is a case of frank, uncomplicated  inflammation  of the
pulmonary tissue. 
                          PNEUMONIA.                    249

   R. G., aged  twenty-one, a very steady and temperate  police-
 man, well  made, robust, and never previously ill, was on April
 12 taken with severe rigors, followed by a dull  pain in the side,
 and  cough.  He got worse under treatment from day to day. and
 on the 18th was so alarmingly ill that his friends carried him to
 the  hospital.   I  saw him shortly after he was  put to bed, and
 certainly felt that they Avere justified in their alarm.   The respi-
 rations were  abdominal  and were thirty-six in  the minute;  he
 struggled and gasped for breath; his lips and tongue were livid;
 the pulse was very quick and small, but the heart beat strongly
 in spite of its great rapidity.  The expectoration was copious and
 glairy, of a deep tawny color, and with a few small striae of blood
 in it.
   The whole of the ribs on the  right side were motionless during
 inspiration, while  the  movement of those on the left front was
 very visible.   In the upper half  of  the upper right lobe, and in
 the lower right front, there was fine crepitation and comparative
 dullness on  percussion.   Beneath  the  right shoulder-blade the
 dullness was more absolute and there were coarse rales. Beneath
 the  left there was fine crepitation.   It was obvious that active
 inflammation raged  throughout nearly the whole  (if not quite
 the whole) of the  right lung, and in the  lower lobe of the left,
 and that it was most advanced in the back part of the right side.
 At most a third of the pulmonary  tissue  Avas in working condi-
 tion,  so no wonder that exaggerated puerile  breathing was heard
 in that  third, and the ribs  were  heaved in an extraordinary
 manner, where heaved at all.
   The patient was bled to three-quarters of a pint from the arm,
 took  eight ounces of port wine during the twenty-four hours, and
 beef-tea every two hours, and had his chest completely enveloped
 in a thick hot linseed-meal poultice.   He was ordered also three
 effervescing draughts of citrate  of ammonia* daily.
   I am told that relief began immediately after the venesection.

  * Ammonia sesquicarb , "^iss, Acidi citrici, "^iss.  This is so refreshing to the
feelings when one is tired or ill, that I think it must be a directly constructive
drug.  Both the carbonic  acid  and the ammonia take part in forming the sub-
stance  of the body.
       17 
250
PNEUMONIA.
At all events, next morning there Avas a great  improvement, the
breathing being  much  easier, the patient expressing himself as
"stronger," and the sputum being but slightly tinged with brown.
On the succeeding day there was a further step gained, and the
pneumonic hue had disappeared altogether from the mucus ex-
pectorated.  However, in the  parts of the right  chest in front
whence  I raised the poultice temporarily for examination, Ariz.,
an inch beneath  the collar-bone and an inch beneath the nipple,
the dullness on percussion seemed very decided.   But I will not
allow myself the enticing  task  of describing  a patient's daily
progress  toward  health: suffice it to say, that on the 26th, eight
days after admission, the effervescing draughts were exchanged
for decoction of  bark, and that to-day, May 10, he goes out well.
The respiration is quite natural, percussion and expansion normal
in the upper lobe and  back part of the lower lobe recently in-
flamed;  but there still remained yesterday some little crepitation
mixed with the healthy breathing, and slight  comparative dull-
ness below the mamma.  I dare  say it is gone now.
  No. 2.—Hugh J., aged sixty-three, porter at a charitable in-
stitution, a respectable man, but not quite free from  a  suspicion
of petty tippling, had an attack  of pneumonia of the lower half
of the left lung under my care about this  time last year, from
which he entirely recovered so far as the local symptoms were
concerned, but he has  looked older since.   At  the beginning of
last week, April 28, he was again taken ill.   I saw him  at his
home on the 2d  of May, and sent  him up to this hospital.  On
the right side the whole lower lobes and the greater part of the
upper lobe  were consolidated.  In the upper lobe, fine  crepi-
tations were heard throughout.  There was also some fine crepi-
tation in the back part of the left lung.  His tongue was thickly
furred and clammy, his hands tremulous, and his manner excited.
There was also occasional delirium.  The pulse was large, short,
and empty—such  as is usually found with the inelastic arteries
of old age.  He was cupped that day to six ounces on the cardiac
region, and on the morrow  to the same amount beneath the right
clavicle.  The chest was completely enveloped  in a jacket of lin-
seed poultice.   He was ordered  eight ounces of port wine, food 
PNEUMONIA.
251
 every two hours, and three  effervescing draughts daily of car-
 bonate of ammonia and tartaric acid.
   May 5.—Pulse 128.  On the 4th there was considerable diar-
 rhoea, which ceased on the following  daybreak,  after a small
 dose of DoArer's powder.
   May 6.—Less crepitation in left upper lobe, but dullness on
 percussion, and coarse mixed with fine crepitation in right upper
 lobe.   Sputa have been for  the last three days very abundant,
 and of a deep rusty color.
   No change in the symptoms, except the  gradual diminution in
 quickness of the pulse, is noticed till to-day (the 10th), when the
 sputa are darker and more like prune-juice, but showing signs of
 improvement by having some specks of  opaque purulent matter
 in them.   The tongue is also a little moist, and only gets quite
 dry after  sleep. He may be considered to have turned the corner
 in his progress toward recovery,  and I have no  hesitation now
 in pronouncing a favorable prognosis.  No change  has been made
 in the treatment.
   [On May 16 he began to take bark and  ammonia.  On  the
 morrow the expectoration is noticed to consist of clear mucus for
 the first time  since his admission,  and he left the hospital to re-
 turn to his place on May 30.  Case-book 161, p.  187.]
   No. 3.—John L., aged  seventeen, was  brought here from a
 house where  his mother  and sister have just died of "'typhus-
 fever," according to the account of an aunt who came to see him.
 He was taken ill  on April 20, and when admitted on April 23,
 Avas  as unfavorable  a  subject to look at  as  I ever  saw at that
 early period of low continued fever.  There  was complete pros-
 tration and constant delirium, the tongue was clammy and tremu-
 lously protruded with great difficulty from  the dry lips, the pulse
 120 and small, the skin hot and dry.  The eyes were bloodshot,
 and on the front of the body Avere from thirty  to forty fever spots
 of various hues, some slightly raised and inclining to rose color,
some  livid, some completely purpuric and  not changed by pres-
sure.   I mention  these details because it is such  cases of typh-
fever, Avhere  the  haematine of the  blood is apparently so much
poisoned,  that are aptest to be accompanied by inflammation of 
252
PNEUMONIA.
the lungs.   He was treated in my usual way with hydrochloric
acid and tepid sponging, and  was going on as usual very Avell
till May 3, when some fine crepitation and dullness on percussion
were found in the lower lobe of the right lung, accompanied by
slight  cough,  but without expectoration.   On the  4th he was
cupped beneath the right  scapula to four ounces, a poultice was
applied over that  part, and he was directed to be kept turned
over on the left side.  On the 7 th the breath-sounds were healthy
except a little  coarse crackling mixed with vesicular breathing,
such as is generally found in  typhous patients;  the percussion
was normal.   The tongue and other  muscles were scarcely, if at
all, tremulous.   He is now going through a rapid convalescence
undef bark and wine,  and in a few days will doubtless be able to
stand on his legs.
   While speaking of this case, and before I enter upon the treat-
ment of pneumonia, I will make  one observation to you on the
importance of the diagnosis of the cause of dullness on percus-
sion in acute fevers.   In this  instance there was no doubt about
the prognosis of the rapid termination of the congestive inflam-
mation.   But  you must not  say the same  on every occasion of
finding the pulmonary  tissue  condensed in fever.   A man will
leave the hospital for a  distant home in  a few days, Avho has re-
covered very  slowly from an attack of spotted-fever rendered
severe by dysenteric diarrhoea.  He  has had at the  same time
primary syphilitic sores and  a bubo, and  had been taking mer-
cury ;* so that his tedious convalescence  was quite accounted for
by his previous  history.  Besides this, during the  time he was
laid on his back, I had  found  a considerable amount of consolid-
ation  about the middle  of the right  lung, and at the apex crepi-
tations.  As at that time he was not well able to  give an account
of himself, I was inclined at first to set this down to pneumonia,

   * I would remark in passing that this man's dysenteric diarrhoea (i. e. pain in
 the bowels with fever and blood-stained stools) came on very early in the ill-
 ness, namely, on the third day, although the usual tendency of continued fever
 this year is by no means dysenteric.  He was under the influence of mercury at
 the time.  The action therefore of that drug is at least not preventive of bowel
 affection.  Is it curative? 
f
                         PNEUMONIA. .                    253

to treat it as such, and anticipate its disappearance.   You saw,
however, that this morbid state remained unaltered when I ex-
amined him for his discharge, and it seemed to me by his tale of
former winter cough and haemoptysis to be due to chronic tuber-
cle.   He  will probably become  consumptive some day.   Learn
from this  case  to take good heed before you hail a consolidation
of the lung in  fever as merely congestive.
   Now to return to the text of to-day's lecture.
   In pneumonia a most truly vital organ  is smitten;  and so far
as the disease extends, the destruction is total.  A consolidated
or even congested piece of pulmonary tissue is absolutely power-
less  to fulfill its duties, and yet  that  those duties should be ful-
filled is essential to animal life.   It is easy therefore to under-
stand that the gravity of  the  pneumonia  is in direct proportion
to the quantity of lung  involved.  The degree or form of the
inflammation or condensation is of much  less weight, so far as
immediate danger is  concerned, than  the  extent of tissue over
Avhich it is spread.
   Hence comes the importance of having some ready and effectual
means at hand to check the march of the inflammation  into fresh
parts.  If we can do this, we contribute more  certainly to renew
the  patient's life  than if we  regulated, however favorably, the
progress of it in already affected places.  No means is so readily
applied, so immediate in its operation, as blood-letting.   Its action
has not to be waited for, like  that of  drugs in medicinal doses,
but begins at the moment of application.   That is a great point
where time  is  so valuable.  I believe also that it is  the most
active of the agents  at our disposal, and that rightly used it is
the saving of many a life in pneumonia.   But at the same time
I would have you clearly understand that "this is  not  a bow for
every man's drawing"  at eA'ery time, that though it is most rapid
and  active for good,  it may be  also  most rapid and  active for
evil, and  that  foolishly and thoughtlessly used it has caused
many a death.
  The good done by  blood-letting in pneumonia is mechanical.
The  pathological state which  asks its  aid  may be drawn  as fol-
lows: by  the  temporary  death  of  a  portion  of the  lungs the 
254
PNEUMONIA.
blood  cannot be quickly enough passed onwards through their
tissue; it can run freely as far as the right side of the heart, but
there  it is stopped;  the  throng pressing onward from behind
makes matters worse, and thus the  balance between the venous
and arterial  heart is destroyed.   You  can feel the apex of the
organ beating  strongly against  the ribs, the muscular action
being  excited by the  presence of an unwonted amount of venous
blood;  yet the  artery at the wrist is at the same time striking
your finger  with a weakened  force.  Take  away some of the
blood from the veins, and the balance is restored;  the pulse be-
comes in technical phrase  "freer;" that is to say, the heart being
relieved of the  undue crowd in the right  side, is not checked in
its contraction,  but is able to clinch upon  its contents, and sup-
ply them steadily to the arteries.
   Judge then of the fitness of this treatment by the balance
between the heart and the arteries.   If the apex of the former
organ  strikes strong,  while the pulse at the wrist is oppressed,
act freely, and confidently.   If, on  the contrary, the ventricles
are weak, while the  pulse is large and rapping,  be cautious in
what you do, and if you draw blood at all, let it be by cupping
the chest.
   The advantages of general and local blood-letting are of essen-
tially  the same nature, though  the operations differ somewhat in
degree, and are diversely applicable. Where the patient, previ-
ous to his current illness, was in vigorous  health, actively digest-
ing his food  and actively renewing  his  tissues, he will bear and
easily repair  the abstraction of a good large quantity of blood.
And a good large quantity of blood is most conveniently drawn
from the arm.  To  get the  full  advantage of the remedy, you
would practice venesection.   But if the pneumonia has come on
a  person previously an invalid, or in weak health, you fear for
the possible  bad consequence of your treatment, and you  cast
about for some means of getting the greatest  advantage out of
the least loss of blood.  This is  obtained by  eupping  on the
region of the heart.  Your four or five ounces taken from thence
in a delicate invalid seem to produce as much corresponding effect
as the loss of twelve or fourteen  let from  a vigorous man's arm. 
PNEUMONIA.                    255
   Or, if it be more convenient, you may put on leeches.   As a
rule, however,  I prefer cupping, for you can easily graduate the
depth of the cuts, so as to be able to stop them with ease; whereas
leech-bites will sometimes go on oozing for a long time, unper-
ceived,  into the poultice, which (as I will instruct you presently)
is to be put round the chest.
   Another advantage of local blood-letting is the relief it gives
to pleurisy.  There  are few cases of pneumonia where there is  ,
not^some amount of inflammation of the serous coat of the  lungs
or ribs;  and though the feeling of oppression in the chest over-
tops and deadens the stitch in  the  side, which would otherwise
be felt,  yet there is no  doubt but that the pleurisy adds to the
distress, and the  relief of it. is no mean matter.   Local blood-
letting  is for this purpose more effectual, in proportion  to its
quantity, than  general.
   You will find some authors try to ground rules about  blood-
letting in pneumonia  on the supposed degree of consolidation of
the pulmonary tissue.   These rules are practically inapplicable.
They say you should  bleed so long as you know that the lung is
in its first  stage of condensation (i. e. congestion), as proved by
fine  crepitation and incomplete dullness;  and that you should
not bleed after it has once  become  completely consolidated  so
as to admit no  air into the finer bronchi, a state declared  by the
sound of coarse crepitation and complete dullness.  Such a rule
is quite useless at the bedside,  and will often prevent your em-
ploying active practice  in  cases where it is urgently called for.
In the first place, in a majority of cases fine crepitation is masked
by the mixture of coarse crepitation, produced by the  presence
of catarrhal mucus in the larger bronchi, especially in the catar-
rhal pneumonia of the young. If you wait  till you can distinctly
hear fine crackles, you will wait too  long.  Moreover, the dull-
ness of congestion  is not  necessarily incomplete; as  you may
satisfy yourselves by  examining recent congestion in continued
fever, which  is often  very absolute, though so  transitory that a
mere  change of position  may remove  it in twenty-four  hours.
Then again, a slight collection of serum in the pleura may make
the lower lobe  dull  at the very outset, and prevent your  bleed- 
256
PNEUMONIA.
ing at a very early stage, if you were to follow the rule I quoted.
But the most serious objection to the rule is, that you may have
all stages of partial tissue-death going on at the same time; one
lobe, or one part of a lobe  may have advanced even to yellow
hepatization, while another  part is just  beginning to enter into
red hepatization, that is  to say, into a condition which by gen-
eral consent is  most capable of benefit from blood-letting.
   Your best guide to the  necessity will be the dyspnoea.  If your
patient is  inhaling  laboriously from  twenty  to  thirty timgs a
minute,  straining convulsively the muscles of inspiration,  you
may know  that the congestion is recent and is spreading to new
spots;  and you "will act wisely by endeavoring to stop it.  And
your best check against excess will be the balance  of the heart
and arteries.
   Remember that in letting blood you are wielding a dangerous
weapon.  While  from a mechanical point of view nothing can
equal the aid it gives, at the same time its more remote or phys-
iological action is baneful.  If you gain the inestimable boon of
a restoration of  balance  in the circulation,  and a consequent
relief of dyspnoea and renewal  of life in the lungs, you  must not
complain if some evils attend the process.   The mere loss of so
much  "liquid flesh" is in itself an evil, but a  minor one; of
greater import is the increased proportion of the effete fibrin
and water which  it  induces, the  diminution of solid haematine,
and the  consequently diminished power to bear up against the
destruction,  however temporary,  of so  much pulmonary sub-
stance.
   Remember also  now what  I told  you about  bleeding  in a
former* lecture  on anaemia  and blood-letting—be  careful to
supply material in the place of that which you are taking away.
Let the  patient be fed with beef-tea or  milk every  two hours,
just as if he had typh-fever.   This  is to be done  in all severe
cases irrespective of other treatment;  but I mention it next to
the bleeding, to remind you of the close connection which there is
between the two,  between  exhaustion and supply.  It contributes

  * " Former" in respect of time of delivery.  It comes later in this volume. 
PNEUMONIA.
257
as much to your success, whether you elect to bleed, or whether
you do not.
   I come  next to another direct  restorative about the use of
which also anywhen and anywhere  you need have no manner of
hesitation.  You can always, without any exception of age, sex,
condition, cause, or complication, follow a  treatment to which I
attribute more power of saving the lives of pneumonic patients
than to any other, and which you see me  apply in all cases; I
mean the wrapping up the  chest in a large bath-like poultice.
The action of warmth and moisture  on  animal tissues tends
directly to increase their vitality.   You may see with the naked
eye a healthy surface of skin under their application renew its
life; it empties itself quicker of its  pale, livid, venous blood, and
glows with a fresh access of the bright arterial stream; it swells
up elastically  with fresh juices; it is  more  delicately sensitive
Avhen used for the purposes of touch; at the same time it feels
no  pain, but  on the contrary an exquisitely pleasurable calm.
You cannot see with your  eyes this renewal of  life in internal
organs,  but  you may infer that what takes place in one tissue
takes place also in  another, with  modifications of course de-
pendent on distance  and other  difficulties of application.  And
you may infer  it also in  pneumonia from the results;  for yoU
find the dyspnoea diminished, the breath being  easily  drawn in
spite of the weight of the poultice ;  the hot fevered skin becomes
moist and active, and soon the ribs  begin to move again,  and air
is  readmitted into the hitherto paralyzed lung tissue.   These
effects are  the most strikingly  shown in  the case of infants,
whose thin chest-walls are  rapidly and efficiently penetrated by
the influences of the poultice, and in whom  also this remedy is
the only one really safe  and  invariably  necessary;  for  they
cannot afford much loss of blood.   I  cannot  speak too strongly
of the importance of your adopting  it, and letting  all other
treatment be passed  over rather than this.
  The poultice is best made of linseed meal, because that keeps
moist the longest.   It should be  spread half  an inch thick  on a
cloth or flannel as broad as the circumference of the thorax.  If
any portion  of the upper lobes be  inflamed  it is essential, and 
258
PNEUMONIA.
even if only the lower lobes are inflamed it is prudent, that the
poultice  should be deep enough to cover the whole chest from
the collar-bones to the hypochondria.   Lay the  patient in it on
his back, and fold it-across the front till it meets.   In adults  it
will usually keep  in place of its own accord; but in children you
should have a tape stitched on in front, and a tape behind which
you  can tie over  each  shoulder in the  manner of a shoulder-
strap ; otherwise  the little  prisoners wriggle out  of their soft
breastplates.  When once you have got this jacket poultice in
situ, keep it there, and  desire the nurse, on pain  of  dismissal,
never to take it off until another hot one is ready to go on.
   In low fever  the continuous poultice somewhat stands in the
way of  the cool sponging.  But in practice this last part of the
treatment  of fever becomes less necessary at  the period  when
congestion and pneumonia  occur; the  skin has  then become
cooler and more  active.  Besides, the  poultice often  takes the
place of sponging by softening and suffusing with  a gentle per-
spiration the whole body.   I have often heard pneumonic pa-
tients grumble at the  way in which  the  moist warmth  makes
them sweat.  Of course  they were  comforted when they were
told it did them good.
 * Alcohol, especially in the form  of port wine, is very useful  in
treating pneumonia.  Even  in hearty, temperate persons, when
you  are going  to bleed, it  is desirable to give a  little, as was
done in  Case  1.   A glass  of hot negus before the operation,
makes it safer.   And whenever you observe  the nervous system
prostrated by the extent of the disease, so as to produce tremor
of the  hands,  quivering of the  tongue,  delirium, dry  brown
tongue or  a tendency thereto, throAV in a little wine from time
to time.   Old persons,  especially in the upper classes, who have
been used to good living, and persons of all ages ay ho have in-
dulged too freely in alcoholic liquids (as Case 2), may begin wine
immediately;  you need not wait for  any symptoms as  above
described.  In children, on the other hand, it is rarely required,
and they get well quicker without it.
   In the  administration of  alcohol in any form, a rule directly
opposite to that which governs the giving nutritious food  should 
PNEUMONIA.
259
•  be obserA^ed.  The quantity considered necessary,  in proportion
  to the previous habits of the patient, should be given in one, or
  at most two doses during the tAventy-four hours.   The frequent
  repetition of small doses has appeared to me injurious, or at  all
  events less beneficial than  the  same quantity in  a few larger
  doses.*
     In the pneumonia of low fever position is of great importance.
  As long as the walls of  blood-vessels  retain their natural  elas-
  ticity they are  able  to  bear up  against the  gravitating force
  acting of course on the blood as on all matter;  but when  their
  life is lowered in disease, the elasticity is the first vital property
  that suffers, and the blood is then drawn toward  the lowest part
  of the viscus.  This is especially the case in low fever.  Lay
  the patient, therefore, on  the  opposite side  to that affected (as
  was done in Case 3), or even on his face for a  time, if both sides
  are affected; and  thus  the very force of gravitation which you
  feared as an enemy, becomes a friend, by withdrawing the con-
  gestion from the Aveaker point.
    This boy was cupped on the side.  You need not shrink from
  taking a  little  blood  in low fever, where  an important viscus
  requires it.   A  large portion of the vital fluid you take away is
  poisoned and dead already, and unfit for the purposes of life, so
  that you are not  robbing the patient to  the full extent of the
  quantity drawn.   You saw the  lad was  much more lively after
  his cupping than before.  It is better  to bleed locally  than gen-
  erally, because local benefit is expected from it, and not general,
  and the dyspnoea is seldom very urgent.
    I  always shrink from giving  purgatives in pneumonia.  My
  reason is  because I  have  observed  that  patients who have
  diarrhoea at  the same time generally do very badly.   And if
  natural diarrhoea does harm, I infer that artificial diarrhoea does
  harm also.  I prefer to produce constipation by opiates, where it
  does not already  exist.   If the rectum  gets  blocked up  with
  faeces, it is easy to Avash it out with warm gruel.
    Blisters have seemed to me to do harm in a few cases where I
  have known  them  to have been  employed before the patients
         * For reasons see Lecture XLIX. <; On the use  of alcohol." 
260                     PNEUMONIA.

came  under my care.  It is usually  non-medical  persons  who
put them on, under the general  idea  that they are good for a
cough with pain in the chest.
  I am afraid I  must  equally condemn antimony and mercury,
drugs formerly often administered in pneumonia.  When I used
them I was often and often driven to  leave them off on account
of bad symptoms due to their agency,  and in prosperous cases I
always felt doubtful if the success could be fairly traced to them.
Looking now at  disease by the light of the theory of  cure which
I always set before you, this  failure is rationally explained.   The
drugs named are pure destructives; the  disease is also one of
pure destruction;  there are in  it fewer of the phenomena of
retention  tlian   in  any other, and  none of the insertion of a
morbid poison in the system.  The  gain then which,  destructive
drugs can bring is infinitesimal, and the risk infinite.   They do
more harm than bleeding by their physiological  action, Avithout
any of the mechanical recommendations of that remedy.  They
merely aid the disease in its worst effect. 
                  LECTURE  XXI.

                     PNEUMONIA.

Record of six cases  during recess—(1st Case) Caution  about
     blood-letting—(2d Case) Pneumonia of  upper lobe in third
     stage, viz., of abscess—Repeated attack of pneumonia during
     convalescence, fatal to this patient—Post-mortem examina-
     tion—Remarks on treatment—Cause of second attack—(3d
     Case) Pneumonia in Bright's disease cured—State of lung
     afterward—(4th  Case) Pneumonia  in  measles—Catarrhal
     pneumonia—(5th Case) Pneumonia treated  with  opium—
     When opium  is desirable—Reduplicating pulse—(6th Case)
     Pneumonia in a  pregnant woman treated with opium—Re-
     marks on vomiting in pregnancy—Additional cases present
     in hospital—(1th Case) Early occurrence of pneumonia in
     typh-fever—(8th  Case) Double pneumonia in a fatal case of
     delirium tremens—(9th Case) Double pneumonia slowly pro-
     gressing from one lung to another—Pleurisy also on one side
     —Food in convalescence—Mode of recovery of consolidated
     lung—(\0th Case) Catarrhal pneumonia—Severity of symp-
     toms at first, and rapid relief—Treatment by poultices and
     local blood-letting—(11th Case) Double pneumonia in a man
     of drunken  habits—Also  catarrhal, and therefore distin-
     guished by the severity of the symptoms  at first—Treatment
     with opium, poultices, and cautious cupping—Delirium-—
     Wine—(12th Case)  Pneumonia morientum in death from
     other causes—Recapitulation.

             (Clinical, St. Mary's, May 2,  1863.)

  I  believe  complaints  are  sometimes made against  clinical
lecturers, that  they do not  sufficiently interest their pupils by 
262
PNEUMONIA.
 presenting for consideration strange and rare cases.   I shall be
 deeply grieved if my exertions cease to arouse your attention;
 but I must at once say that it is a matter of conscience with me
 to set before you a subject for instruction in the lecture theater,
 and  for the less formal bedside teaching, primarily and mainly
 those forms  of disease which you will most commonly have to
 treat in aftef-life.  The time I shall endeavor to allot to each will
 be proportioned  as closely as  possible to the frequency of  its
 occurrence.  I believe that to be the most  accurate  measure of
 its importance to the public, and therefore to medical men.
   Since I last addressed you before the Easter vacation  there
 have been six cases of pneumonia under my care in the hospital,
 which are sufficiently ordinary examples of the disease to present
 several points of practical instruction.
   I. Caroline D., though a sexagenarian, has never been seriously
 ill before, and Avas quite well till the 3d of April,  Avhen she sud-
 denly lost her appetite and felt ill all over. She had a bad cough,
 but no local sensation of pain in the chest or elsewhere. She was
 admitted April 10.  Her pulse was 104, empty, sharp, and weak.
 The inspirations were thirty-six in a minute. There was dullness
 on percussion and fine crepitation of the lower right lobe, and
 some fine crepitation mixed with healthy breathing in the lower
 left lobe.   She was  ordered—1^  Ammonia sesquicarbonatis gr.
 iv.   JEtheris  TT|xv.   Misturse  Camphorse  5j; alternd qudque
 hord.  Hirudines xii  infra  scapulam dextram,  et postea cata-
plasmata assidue applicentur.
   The signs of inflammation did not further  spread, but the right
 lower lobe became consolidated, so that on the 18th bronchial
 breathing and dullness on percussion is noted in  that situation.
 On the 22d  the pulmonary tissue  began  to  become  pervious
 again, and there was the well-known "crepitation of return" in
 the place before consolidated.  The medicine was changed for a
 mixture of squill  and  senega,  but she complained  that  this
 nauseated her, and it was left off, and no drugs given at all.

  You may perhaps  be surprised that in treating a patient so old
 as threescore, and where the  pulse was empty, sharp, and weak, 
PNEUMONIA.
263
I should have ventured upon taking blood.  But I had calculated
here upon receiving valuable aid from the digestive organs. Like
most persons Avho have lost appetite from severe febrile disorder,
she had eaten scarcely anything for several days.   I calculated
therefore that a continuous animalized diet, such as beef-tea  and
milk  every two hours, would more than replace a  moderate  loss
of blood, and I should have been  sorry to miss the  advantage
which its  local application  confers  by staying the  progress of
congestion towrard condensation in the  pulmonary tissue.
   In old age it is quite true that the detraction of blood does
more harm than in youth or middle age, because there is  less
strength to spare; but at the same time it does more good than
in  youth  or middle age, because  of the  tendency in  later  life
which congestions have to increase,  and to  increase so very
insidiously, and to recur when  checked.  So you must not forget
what a powerful weapon you are wielding, and how double must
be your caution in old age.
   The  second  case  of also an aged  woman, is in point here,
although a fatal one.
   II.  Mary McK., admitted February 27.   She  did  not know
the date of her birth, but looked upward of sixty.  She had been
quite well  of late  years till three weeks previously, when  she had
slept in a damp  bed after being  exposed to much heat  as a
washerwoman.   This  was immediately followed by  rigors, feeling
of complete prostration, and loss of appetite.  I fear she  had but
little care  taken of her during the  height of the  inflammation,
for she seemed on admission to be almost moribund,  and abso-
lutely refused food.   On examination of the chest  the upper  lobe  '
of the right lung was found  completely condensed,  absolutely dull
on percussion,  Avith tubular breathing  and coarse  mucous rales,
 and in some places coarse bubbling. There was but little cough,
 but copious green expectoration.

   From the localization of the part affected in the stethoscopic
 examination, it ay as very doubtful whether this were not a  case
 of senile  tuberculosis.   But the suddenness  and  recency of the
 invasion were  against  that diagnosis, and I inclined  to think it
 the third stage of inflammation of the upper lobe. 
264                     PNEUMONIA.
   The diagnosis made but little difference in the treatment; for
 I gave her quinine and cod-liver oil, much as I should have done,
 had it been determined to be tubercular phthisis.
   We had great difficulty about the patient's food; she said, on
 admission, she could eat  nothing, and  at first  she  persisted in
 eating nothing voluntarily, the nurse having to use actual force
 in giving her the  beef-tea and milk which I had insisted upon
 her swallowing. She improved considerably under this treatment
 by three weeks after admission.  On the 18th  of March I found
 there was not the same extent of dullness below the right collar-
 bone, but  there Avas still very considerable dullness  and very
 coarse low-toned bubbling rales.   She was recovering also  her
 flesh and  strength, and was  capable of being  intrusted so  far
 with her diet that she was allowed to be dressed and have ordi-
 nary diet and porter with the other patients.  She seems to have
 freely used her  permission to get up, and to have fatigued herself
 very much on the 19th and 20th.   On the morning of the 21st
 she had a shivering fit, she lost her appetite and-became feverish,
 and had severe  pain in the head.   There was  then  a good deal
 of typh-fever in the wards, and it seemed very much as if she had
 caught that disease.  So  she Avas given a couple of emetics, con-
 tinuous food, wine, and hydrochloric acid.  But on the 26th  my
 attention was drawn to her lungs by the expectoration of orange-
 colored sputa in considerable quantity.  Her tongue had become
 dry and brown in  spite of the wine, and yet there was none of
 the nervous symptoms (such as obtuseness of the sense, delirium,
 or tremor of  the muscles) which one looks for  in cases of typh-
 fever.  An examination of the chest detected the serious fact that
 the diagnosis had been too hasty, and that the symptoms really
 were due to pneumonia.   The whole of the right lower lobe was
 already impervious to air from recent  consolidation, and there
 was fine crepitation also in the left lower lobe.  Half a  dozen
 leeches were  put on the  latter side, and a jacket  poultice over
 the whole  chest:  bark  and wine Avere  freely given: but little
hope could be entertained of preserving life.   She survived just
long enough for the expectoration to become purulent, but died
on the  6th of April. 
PNEUMONIA.
265
   At the post-mortem examination we found the right upper lobe
of the lungs Avas in many parts consolidated and of a gray color,
and of a fine granular appearance, shading off in the natural red
color in the parts pervious*to air.  There were in that lobe several
small abscesses, and  one as large  as  two  walnuts.  The right  '
lower lobe, and to a less  extent the left lower lobe, were consoli-
dated and of a red color, leaving on the whole  about six  inches
square of the whole  pulmonary tissue permeable  to air.  The
ventricular parietes of the heart were  pale in  patches, and the
mitral valves white and  thickened.  The kidneys exhibited an
atrophied appearance, the cortical structure being diminished in
quantity and  containing many small  cysts.   The liver  had a
thickened opaque capsule  and a granular (nutmeg) appearance
when cut into.

   Here are two examples of pneumonia in one patient.  The first
attack in the upper lobe  she had rendered much more serious in
its consequences than it  otherwise would  have  been by starving
herself.  It had absolutely condensed the pulmonary tissue, and
Avas running  on  to abscess on  her admission.   And she was re-
duced to an extreme state of emaciation and weakness.   So that
a condition was present closely resembling tubercular consumption,
and distinguishable from  it only by the history.  Yet the doubt-
ful diagnosis  gave me no anxiety, for it  made  not the slightest
difference in the treatment of the  patient, whose prescription-
card made many  of  you set  it  down as an  ordinary case of
phthisis.
   I cannot forbear here leaA'ing for a few minutes the considera-
tion of the cases  immediately  before us,  in order  to make a few
remarks which possibly  at some  future time  may cheer  your
hearts under chilling  anxiety.   I know of nothing more  fearful
than the feeling  that upon  your knowledge  or ignorance depends
the life of a fellow-man.   This feeling runs through, and ought
to run through, your whole  professional career; for the good of
your patients your consciences cannot be too tender.   But it is
necessarily experienced  in very different  degrees in  different
cases, and in the  present age you will  find  your anxiety gener-
       18 
266
PNEUMONIA.
ally turns upon diagnosis.  The patients who make you dream
and roll about in your bed of nights, and who spoil your appetite,
are oftener those with whom  you cannot find  out what is  the
matter, than those  with whom  you do not  know what to  do.
Now,  it is often a great comfort to reflect, and  I am  sure it is
true, that where  pathological conditions  closely resemble one
another in  the symptoms they produce, the  treatment they
require is probably exactly the same.  I should be sorry to "lay
a flattering  unction to  your souls," but this is simply justice to
yourselves.   How often  is it impossible  to  ascertain, without
questions which it is impossible to press, whether certain diseases
are due to previous syphilitic infection or not!  Fortunately the
same  drugs  are curative in both  circumstances.  How often do
we reasonably fear to  alarm a  timid  mind by inquiries into
hereditary tendencies to lunacy or consumption!  The cases are
exceptional where these inquiries are absolutely necessary. And
in this instance it made no difference  in the performance of my
chief duty, that  of prescribing  for the  patient, whether those
were  right who thought the consolidation was  tubercular, or those
who thought it pneumonic.  '
   The second attack of pneumonia happening under our eyes in
the hospital, though hid from  notice at first  by its  insidious
manner of invasion, I cannot  but attribute to the patient having
got up and  overworked her weak muscular powers.  You may all
be aware, from experience, how even in healthy persons unwonted
 exertion will cause temporary congestion of the respiratory tract.
 The  stitch in the side and shortness of breath  after running are
 well  known. If we take violent exercise  during catarrh, the
 mucus is often stained yellow some hours afterward.  I have had
 haemoptysis on the morrow of a hard day's  skating  at Oxford.
 In an injured lung this tendency  is still more marked and hurt-
 ful.   Consumptive persons often spit blood the day after unusual
 exercise,  although their hearts are  quite  sound.  There  was,
 then, nothing more likely than that this aged woman should get
 congestion from  the same cause,  and nothing  more  likely  than
 that it should run on rapidly to consolidation in her  weak state,
 and  with  her antecedent tendency  to degeneration.  It  is a 
PNEUMONIA.
267
warning to us to be more careful in watching over  patients, and
in avoiding everything which tends to exhaust the failing life.
   The degenerative tendencies made evident by the state of  the
kidneys, liver, and heart  rendered the  renewal of life very  un-
likely in this case.  But that is nothing against doing our best.
Patients as much  degenerated  as  that often go about for years,
and with extreme  care  may sometimes  be  brought round from
apparently fatal illnesses.
   III. William W., aged thirty-seven, a post-boy,  was admitted
April 15,  with extensive anasarca  and some fluid in the pleura,
arising from  Bright's degeneration of the kidneys.   He  was
treated with  sesquichloride  of iron and  hot-air  baths.*  The
dropsy diminished a  little.   On  the 23d he got  chilled by an
open window, and on the 24th the dyspnoea increased very much,
his previously sero-mucous expectoration acquired a rusty-brown
color, and there was extensive fine crepitation in the lower lobes
of both lungs.  He was cupped between  the shoulders, and a
small  quantity (six ounces)  of blood  taken.  A jacket poultice
was kept  round his chest, and  he took  5ss of ether, and Tr|x of
chloric ether every three hours, and four ounces  of gin daily.
The dyspnoea was somewhat alleviated by these means, and on
the 27th the sputa became gradually purulent, instead of rusty.
On the 29th it was still more purulent and copious.   With  the
increased dyspnoea, induced by the attack of pneumonia,  the
anasarca  of the arms, chest, and upper part of the body generally
had very much increased.
    In  this man's  case  the  imminent danger arising from  the
pneumonia has indeed almost passed  aAvay, and  the increased
dropsy of the upper  extremities, arising from the extra impedi-
ment  to the passage of blood through  the lungs, is alleviated;
but I fear that  his  broken state  of health forbids our hoping
for his final  recovery.  You may remark, however, that alcoholic
stimulants, which certainly do not benefit albuminariacs in gen-
 eral, are  here  well  borne  and  decidedly beneficial  while  the
pneumonia is acute, and that they  have  sustained the patient
 while ready to perish.  They have also not  produced any tend-
 ency to coma (which is so much to be dreaded in  these circum-
 stances),  but have aided'restorative action. 
 268    .                PNEUMONIA.

   This person had hardly a spark of life to spare, so as to allow
 of blood-letting to  any extent,  and it  was  only the imminent
 danger of death by congestion that induced  me  to employ the
 cupping.
   [The man died toward the end of May of gradually increas-
 ing dropsy in all the serous sacs, and anasarca.  The pulmonary
 tissue  at  the back  part of both lungs was  scarcely crepitant.
 But it was  not dark  and  congested,  as is usual in cases  of
 dropsy.   It was mottled with yellow, as if it had been solidified
 by the pneumonia  and were recovering.   The kidneys  were
 mottled and granular, not  shrunken.   His case is again alluded
 to a few pages on.]
   IV.  George  P., aged  twenty-seven, a coachman, was warded
 on April 14.  He had had a cough for four days.  On the  13th
 had felt very ill, and  in  the evening of the  same day an erup-
 tion of measles came out.  His  nose had been bleeding a little.
 His tongue was pretty natural;  the pulse 88 ;  the  respiration
 32 in a minute.   There was fine crepitation without dullness, on
 percussion beneath the right scapula. He was ordered ten leeches
 beneath the right scapula that day, and  ten the next,  and a  half-
jacket poultice.  He drew his breath  much more easily after
 each application of  the leeches.   Dullness on percussion in the
 affected part, which was noted on the 16th, had disappeared on
 the 18th, and he took quinine till he left us on the 30th, the  dull-
 ness gradually merging into moist crepitation of return. His cer-
 vical  glands swelled as the eruption went off, and he had half a
 dozen leeches and hot fomentations to that part.

  Here, contrary to what I remarked  in the last case, there
 was  plenty  of life  and vigor.   Very probably the man would
 have got over his pneumonia well  under any  circumstances, but
 the leeching certainly relieved  his deep pain in the side (the
 stitch of congestion) and  I think  it made things more  safe.  For
 in measles the  pneumonia is the variety conventionally named
 "catarrhal pneumonia," that is to say beginning with and arising
from bronchial  catarrh,  and is  very apt to go  on  spreading.
 It does not  come on as it were with  a  gush,  and  involve  at 
PNEUMONIA.
269
once the pulmonary tissue it  is going  to  involve, but creeps
onward from lobule  to lobule  in a  troublesome manner, unless
checked.
  This  is familiar enough to those who have much to do with
measles, but  I do not think  I  had  an opportunity of remarking
it to you before, because we so seldom have an example of that
disease in the hospital wards.  Occurring mostly in children, and
being in them a malady of small moment unless complicated with
pneumonia, it is rarely admitted into a general hospital.
  The swelling of the cervical glands is common in all zymotic
diseases, and had nothing to do with the pneumonia.
  V. Samuel F., aged  twenty-eight, a laborer, was  seized on
April 11 with a stitch in the right  side and dyspnoea.  I saw
him  on the  14th.   There was  fine crepitation, and comparative
but  far from absolute dullness on  percussion in the lower half
of the right lung.  The expectoration contained some streaks of
blood, and was a little yellowish.   He had previously six leeches
on his  side.   I ordered him sixteen more and a jacket poultice.
On  the 16th  the expectoration was rusty, and his nose had been
bleeding.   His bowels were open  for the  first  time  since  his
illness.   His pulse was 104, and soft.   He had had delirium on
the previous  night.   His tongue and hands were tremulous, and
the tongue  had a yellowish tinge like that produced by chewing
tobacco, which hoAvever he had not been  doing.  He was ordered
TrLx of laudanum every four hours and  six ounces of port wine
daily.
  By the 22d the crepitation  of return was heard, though the
expectoration continued to exhibit a yellowish tinge mixed with
the pus of which its  bulk consisted.  He was ordered quinine,
mutton-chop, and porter  in  place of  the laudanum and teacup
diet.
  On the 29th, cough and expectoration had ceased.

  Here the  opiate  treatment of pneumonia was  adopted.   I
think it especially suited to cases where there is evidence of
deficient power  in  the  nervous system, where  there is great
prostration or tremor of the hands and tongue.   Where also the 
270                     PNEUMONIA.
tongue has a smooth whitey-brown-paper colored coat.  I give
it also where there is diarrhoea, or even any tendency to diarrhoea,
such as two  fluid motions daily, in pneumonia; for of all un-
fortunate  complications  there  is none so bad' as  looseness of
bowels : those patients always do best who are constipated either
naturally or artificially.
   When in consultation  you are'obliged to defer to the opinion
of others, and give either mercury or  antimony, especially the
latter, in  pneumonia, always make a proviso that a good dose of
opium shall be joined;  it prevents a  great deal  of  the  harm
which normally results from the use of those drugs.
   It is remarked several times  in the note book that no drowsi-
ness was produced, although  the opium was given to the extent
of three grains daily.   This is characteristic  of the action of
opium in acute inflammations, when it proves beneficial.  If the
normal  effect of the drug is fully manifested, I have not found
that it has agreed so well.
   You will find  it remarked on the  18th that the  pulse was
" reduplicating."   This is rather an awkward  attempt to trans-
late Galen's term &V°™f, a character of arterial beat graphically
compared by him to the stroke of a hammer brought down loosely
on an anvil, which rebounds and so gives a second little stroke
afterward.  It seems he often found  it in the malarious fevers
of southern Europe, and observed that it indicated  an approach-
ing crisis.   I should  think that very  probable, for it seems to
me to arise from the renewal of the natural  course  and force
of the  circulation, when  that  return to health  is  associated
with Aveakness of the cerebro-spinal system—when the restored
strength of the muscular tissue is not supported by a correspond-
 ing renovation of nervous function.   It is an  indication for the
 use of alcohol and  opium, I think,  although I have not observed
it long enough to be sure.
   VI.  Jane W., a young wife, the mother of one child, and six
months pregnant with her second, was admitted April 12.  She
had been quite well in the morning of the previous day, till she
was taken with  sickness and cold  shivers at  9 a.m.   Between
12 and 1 pain came on in the left side accompanied by dyspnoea. 
PNEUMONIA.
271
She was treated with sixteen leeches, in two detachments, to the
left side, jacket poultice and hydrochloric acid.  On the 14th
the case was  identified as one of pneumonia by fine crepitation
in the whole lower half of the left lung with very slight com-
parative dullness on percussion, and she was put upon a grain of
opium every three hours.  The next day no sleepiness having
been  produced by the opium, and the tongue being yellowish,
Avhite and  pasty, she  was put upon wine, but it seemed to pro-
duce vomiting, and was left off  next day.  The crepitation was
succeeded  by absence of breath-sounds  and increased dullness.
On the 21st crepitation (of return) was  heard, the  appetite re-
turned, and  she was put on quinine  instead of the opium.  She
was discharged cured on the  22d.   The  vomiting, due partly as
it seemed to her pregnancy, did not recur.

   There is nothing  particular  to be remarked in this case re-
specting the pneumonia  and its opiate  treatment, beyond the
fact of the advanced  pregnancy, which seems to have offered no
impediment  to its success.  You may observe that  wine in a
young person unused  to  stimulants produced vomiting, Avhich
ceased on its omission after the trial of a few glasses.   Vomiting
in pregnancy is very often the consequence of persistence in
 taking alchoholic drinks.  Alcohol is familiarly known to be an
 emetic when SAvallowcd in excess, and in the sensitive  state of
 the abdominal and thoracic nervous system which accompanies
 pregnancy,  a very small quantity is in fact an excess, so far as
 this effect is concerned.  Foolish women, feeling what they term
 " weak " from the extra weight of body they have  to carry during
 pregnancy,  and  perhaps also glad of  an excuse  for indulgence,
 sometimes  take an additional  quantity of wine and beer at this
 time, and  are punished by troublesome vomiting.  This can often
 be checked  at once by making them leave off the stimulant, and
 take only light digestible food in  small  frequent quantities.
    You may remark that she was put upon hydrochloric  acid for
 a  couple of days.  This Avas  on  her  first admission, when  the
 prostration, more than usual  in  single pneumonia, and caused
 probably by her journey to the hospital, made us suspect typh- 
272
PNEUMONIA.
 fever.   However,  absence of delirium, of cutaneous eruption,
 and of any other signs of that fever, set the question at rest very
 soon, and fine crepitation  in  the pulmonary tissue pointed out
 the true disease.

             (Clinical, St.  Mary's, May 30, 1863.)

   I shall resume the subject of pneumonia with a few additional
 cases.
   VII. Elizabeth M., a girl of sixteen, was taken ill on  May
 23,  with  drowsiness, nausea, vomiting,  pain  in  her back  and
 limbs, and in short the usual  symptoms of typh-fever.  On her
 admission, two days  afterward, these were more decided,  and
 the  tongue was dry  and brown in  the center.   But there were
 no fever spots, nor  have any appeared since.  She  had some
 diarrhoea on  admission, and there was pain on pressure of the
 left  iliac  fossa.   On examination  of the chest  we found  fine
 crepitation and  slight comparative  dullness in the  left  lower
 lobe, and this has since extended in a minor degree to the right
 lower  lobe.   On further examination we  found  also  a valvular
 murmur with the first sound of the heart on the left side of the
 apex, very local  and  scarcely heard at the center of  the heart,
 probably due  to valvular disease  from an attack of acute rheu-
 matism two years ago.
   The only additions made to the usual treatment  of typh-fever
 were six leeches  beneath the  shoulder-blade, a jacket poultice,
 and ten grains of compound kino powder three times during the
 first day.

   This case  is distinguished  by the very early  occurrence of
pneumonia in typh fever.   It is not a mere congestion from the
long gravitation of poisoned blood in the sluggish tissue, accord-
ing to  the commoner history of such accidents ; but it  began the
first day or the second day of the disorder.  The probable ex-
planation of this is the imperfection of the girl's heart, by which
the circulation was  more  than ordinarily retarded.   Observe
how latent  the pneumonic  symptoms are: they came on  quite 
PNEUMONIA.
273
unawares to the patient or her friends, and the lesion was made
evident only by auscultation.  It is  usually so in typh-fever;
for the normal  sensitiveness of the system  is blunted  by the
poison, which by its effects might almost  be  called a narcotic
poison, only that it does not produce true sleep.  This is a warn-
ing to  be very industrious in not neglecting the use of your ears
in all cases of typh-fever.
   The compound  kino powder was ordered for the purpose of
putting an immediate  stop to the diarrhoea.   The hydrochloric
acid would have done that gradually in twelve or twenty-four
hours,  but a  purged  state of bowels is such a pernicious circum-
stance in pneumonia, that I was in a greater hurry than usual to
arrest  it.                                                     »
   VIII.  Timothy MacC, a burly,  hard-drinking brickmaker,
about twenty-seven,  we found in bed May 27.   He was too ill to
tell a consistent tale, but he  stated that he had been quite well
till the 22d, when, on getting up in the morning, he was  seized
with a trembling so  severe that he could hardly dress  himself,
and was  nearly two hours  trying to do so.  These "trembles"
continued on admission; he could not hold  his hand out straight,
and said that when alone he saw flocks of sheep scampering past,
and shadows of persons not really present.  He had a hard bad
cough, and his sputum was rusty and copious, with pus in it. On
the right side of the chest, both in front and  behind, there was
a diminution of vocal resonance, dullness on percussion, aegoph-
ony, and coarse bronchial breathing.   On the left side there was
dullness on percussion^n the lower lobe behind, bronchophony and
coarse rales.  In  the front of  the same side  there was puerile
respiration.  There was also stitch in the side and pleuritic fric-
tion on both sides. The respirations were twenty-four, the pulse
111 in a minute.
   He  was  ordered ten drops of laudanum in effervescing am-
monia draughts three  times a day, jacket  poultice, teacup diet,
and eight ounces of port wine daily.
   On  the  28th the pulse was  120, the respirations forty-two.
He Avas very delirious.  A pint of bottled stout was  ordered in
addition to the wine. 
274
PNEUMONIA.
  He died early on the 29th, tAvo days after admission.  No post-
mortem examination was allowed by the friends, who carried off
the corpse directly.

  This  is a case  of that severe form of pneumonia which not
uncommonly comes  on as a consequence of delirium tremens  in
hard drinkers  much exposed to the weather.  The nervous symp-
toms  are, in proportion to their prominence, an  unmistakable
warning to avoid depressants and to  keep up  the  patient's
strength by all the means in your power.  Bleeding such a man
would probably kill him in raving mania, and I would not venture
even to cup or leech him, useful as it would probably be to such
a state  of lung in a temperate strong person.  Alcohol must  be
given without  stint;  but yet I fear  that, however active and un-
sparing your hand may be, you will still lose the greater number
of your patients who have pneumonia come  on  in the course of
delirium tremens.
   IX.  George F., aged twenty-three, was attacked on the 3d of
May  with rigors, and  about four hours afterward  felt a severe
lancinating pain in the right side, much increased by inspiration.
He was sent up to bed  as  an  urgent case in the  evening, with
great dyspnoea, a short sharp pulse, and dullness  on  percussion
in the lower part of the right thorax.   It seemed to be a case of
pleurisy, and  the house surgeon put him  on mercurials and  sa-
lines, and applied leeches to the painful part.   On the 6th, the
sputa became  tawny and speckled  with blood.  At that date,  al-
though the dullness  on percussion was  less marked  than  on
admission, it  was still present, but all over the  infra-scapular
region on the  right side, and partially on the left, there was fine
crepitation.   He was  then enveloped in  a jacket poultice, and
given seven minims of laudanum every three  hours. On the 9th,
the pneumonic sputa were still more strongly marked, and he was
ordered, in  addition to the opium, tincture of bark and ammonia
and port Avine.   Two or three days after  we found the respira-
tion  quite  absent in the  lower lobes,  though  there was  large
bronchial  breathing.   But on the 16th  crepitation began to
return  on the right side,  and  on the 18th some  on  the left side, 
PNEUMONIA.
275
too—a joyful sound !  By the 20th it was well marked and clear
on both  sides,  and I thought myself justified in ordering him
ordinary diet  and porter,  though the  sputa  were  still mixed,
tawny, and purulent.
   Since  then he has been  steadily convalescing, with the assist-
ance of a blister to the right side, where he felt some pain, and
yesterday got up and partially dressed himself.
   There are two  directions from which pneumonia  attacks  the
lungs: it begins  either from  the .inside,  that is, the bronchial
mucous membrane, in which event it constitutes catarrhal pneu-
monia, or the  "suffocative  catarrh" of our forefathers; or from
the outside, when it may be fairly named pleuro-pneumonia.  The
latter is  exemplified by the present case.   I should say that, as a
rule, the chief danger of catarrhal pneumonia was  at the first
onset of  the illness, when it sometimes ends very rapidly; while
pleuro-pneumonia causes about an equal degree of danger through-
out, till convalescence  begins.  And convalescence is generally
in such  cases very slow, the destroyed  pleura not allowing the
restored lung to expand freely so as to dilate the air-cells.  The
tissue, therefore, is apt to remain condensed.
   I dare say you wondered to see me order to a  man, whose
lungs were in such a  state as to cause dullness on percussion
and crepitation, beef and porter like  a laborer at work.  But
I  reckoned  that where there was vitality enough in the  system
to cause so quickly the returning sound of expansion, there Avas
vitality enough to  digest normal victuals.   I do not say you can
always  succeed in getting  solid meat digested thus early, but
where you can, it shortens the  convalescence very much.
   The mention of returning crepitation after pneumonia induces
me to recall  to  your recollection  a post-mortem  examination
which took place a fortnight ago on a patient  about whom I lec-
tured on May 2, William W., who died of anasarca from diseased
heart and kidneys, in the  course of recovery from  pneumonia.
I say "in the course of recovery, ' because the pulmonary tissue
had  again become partially crepitant, and the sanguineous ex-
pectoration had ceased.  After death Ave were able to see what
pathological  condition these signs  indicated  during life.  The 
276
PNEUMONIA.
tissue of the back part of each lung was barely crepitant, but it
floated in water and admitted some  air.   It was mottled,  as if
measle-spotted, with yellow and red: on pressing it hard a small
quantity of thick fibro-purulent stuff could be squeezed out  from
the yellower portions, but the others seemed quite empty.
  I have no doubt in my own  mind, that the way in which con-
solidated lung recovers, is by the exudated fibrin breaking down
into pus  and  being  expectorated,  Avhile  the  obstructed  air-
vesicles regain their elasticity and capacity for performing  their
functions.  This is a strong argument for  an ample supply of
nutriment during the regenerative process.
  You  may  have remarked,  both from  the  progress of  this
patient,  who  is slowly recovering,  and from  the  post-mortal
appearance of the lungs in the one who died from  other causes
during convalescence, that pneumonia is  not a sudden  attack,
which strikes at once all the pulmonary tissue that is going to be
affected.  Its  onward march is gradual; it creeps on from spot
to spot, and  from lung to lung.  And its  backward march is
gradual too; the parts first paralyzed in their functions recover
first, and those last wounded recover last.    This too they do, in
spite of the latter being perhaps the least affected.
  It is from observations  like these that the great advantage of
our post-mortem examinations is  derived.   The chief cause of
death  is often the least noteworthy fact about them.   In nine
cases out of ten it  is some  utterly irremediable organic lesion,
the sight of which merely flatters your vanity by verifying your
diagnosis.  But the lesions which  do not kill, and which are
curable,  are those you  are  concerned with, and to understand
which makes you good practitioners.

            (Clinical, St. Mary's, July 11, 1863.)

  George F.,  about whom I lectured to you six weeks  ago, has
justified by the slowness  of his convalescence  the distinction I
pointed out to you, between pneumonia commencing from the
interior of the lung and from the outside.   The lower right lobe
still remains dull  on percussion, and air is  very sparingly ad- 
PNEUMONIA.
277
mitted into it. *  Some parts  of the pulmonary tissue have also
broken down into a small  abscess in the front part of the lower
lobe.   He has fortunately no hectic, and is getting strong and
stout slowly upon iodide of iron and cod-liver oil.  The ribs will
probably fall in on that side just as they do after empyema, but
we shall not be able to keep him in the hospital long enough for
you to see this result.
  Two other cases of pneumonia were taken in yesterday Aveek.
  X. Mary P.,  a child just at the  age of puberty, was admitted
July 2.  She had  had  cough and cold for a short time, but did
not give up her work as a domestic servant till the  morning of
her admission, when  she was taken very ill, with shortness of
breath.  On admission  the breathing was very labored, and she
raised the alae nasi in inspiration.   The respirations were 44 in
the minute ;  the pulse 114.   There was bronchial breathing and
whistling rales all over the chest.   The whole of the right lobe
was  dull  on  percussion.   No stitch in the side, or pain  on
pressure.   She was cupped to 5iv between the shoulders, eight
leeches were applied beneath the shoulder-blades, and the chest
Avas  enveloped in a jacket poultice.   I also ordered her  TTLx of
laudanum every three hours  and teacup diet.
   On the 4th, when I came round, she wTas asleep, and the respi-
ration Avas evidently so much relieved that I did not care to rouse
her.   She had expectorated some blood-stained mucus.
   On the 5th the pulse was 130;  the respirations 36.
   On the 8th the pulse was 120; the respirations 26.  The dull-
ness on percussion extended half way up  the  right lung, ,and
coarse  crepitation had succeeded to the whistling rales.  The
tongue was brown; but that  did not seem caused by  any aggra-
vation  of the  symptoms.  On inquiry, I found  she had been
sleeping that night and morning much more than usual, and sus-
pected  that  the brown coat  of epithelium was caused  by the
opium.  I left off all drugs, and trusted to the poultice only.
   On the 9th her tongue was clean.
   To-day (the 11th)  the respirations are natural, and  the  air
enters  freely to the base  of the lung, which is resonant on per-
cussion.  Only on a full inspiration can you hear a little crack- 
278
PNEUMONIA.
ling in the pulmonary tissue.   The sputa are purulent, with a
slight orange  tinge in some specimens.  She says her bowels
have not been open the last six days.   She makes so much  of
this observation, that I have  given  her a dose of castor oil,  to
quiet her mind.

  Remark in  this girl  how severe the  symptoms Avere at first,
how dangerous indeed to life, yet how soon the alarming part of
them passed away.   This Av/ould  not have been  the case if she
had had pleuritic pneumonia,  instead of catarrhal or bronchitic •
pneumonia.
  The opium  agreed with  her very  well; but ten drops  every
three hours is a large  dose for a child, and  therefore, when it
did not  seem to be demanded by the symptoms, I was glad  to
leave it off.   You will usually find that the time for doing so is
marked  by  tolerance of the drug  ceasing,  and increased  droAv-
siness coming on.
  Remark the constipation, and how well it agrees with  pneu-
monic patients.
  XL  George L.,  a muscular laborer, aged thirty-two, came
under my care July 3.  He confessed  to being  a hard drinker,
and to having had  several attacks of  delirium tremens.   After
ailing for a  few days to such an extent only as allowed him to  go ,
on with his work,  he was taken  on June  30 with rigors and
dyspnoea, so as to completely prostrate him.   When I saw him
the respirations Avere 60;  the pulse  small, 140;  his  tongue
thickly coated.  The skin was hot  and dry, and there was  an
eruption of herpes  on the lips.  There was dullness on percus-
sion, with bronchial breathing, in the whole of  the right lower
lobe,  and dullness  less decided in the lower part of the  left
lower lobe,  Avith fine crepitation at the upper level of the dull-
ness.  He was cupped to §viij beneath the shoulder-blades, put
in a jacket poultice, and ordered twenty  minims of laudanum
every four hours, and teacup diet every two hours.
   On the 4th the pulse was 130, larger and fuller; the respira-
tions 44.
   On the 5th the  pulse was 120; the respirations 40.  I found
him raised  in bed and reading a neAvspaper. 
                        PNEUMONIA.                    279

  On the 6th the pulse was 132; the respirations 36.   He had
been noisy  and delirious the night before.   Four ounces of port
were ordered to be added to the treatment, to be taken at night.
  On the 7th tawny expectoration commenced.
  On the 8th pulse 108; respirations 36.
  To-day (the  11th) his  pulse is 100; the respirations 26; the
air  enters  freely  into the right lower lobe, with only a certain
coarseness  on  full inspiration.  That part is also resonant  on
percussion.  In the left lower lobe a slight comparative dullness
remains, and there are the  crackles of returning breath-sounds.
  The lung tissue you see has  returned to its allegiance in the
order in Avhich it ceased to work.   First  the right  loAver  lobe,
which was  the most condensed on  admission, and was the first
affected; then  the left  lower lobe,  which  was the last to suffer,
and is, therefore, the last to get well.   Pneumonia does not
strike like  a thunder-bolt the whole that  is going to be injured,
but creeps on from one spot  to another, and creeps  away in the
same order.

   The  remark Avhich I  made  in the last case as to the form of
pneumonia, and  the alarming  earliness of its severe symptoms,
applies equally to this man.  Though his  breathing was so short,
and his  pulse so quick on the 4th, yet on the 5th he had strength
 enough  to  be reading his Sunday  newspaper.  But  the exertion
 was as  bad for  his body as  the politics  doubtless  were for his
 mind, and  in the evening he got delirious,  and was inconveniently
 violent during flhe night.   I  had hoped to spare our wine but was
 forced by  this delirium to order him a couple of glasses of port
 to  be taken every evening.
    You  may learn  by this  instance how  important quiet is in
 pneumonia both  for mind  and body.  Nearly all our  dangerous
 and fatal  cases are made dangerous and fatal by neglect of this;
 and though this  patient is not seriously injured by his  imprudent
 obstinacy, yet I have  no doubt his coiiA'alescence Avill be  the
 longer  for it, and we  have had  to  give him stimulants  which
 might  possibly have been spared.   If the stimulants had  not
 been given, he would very  likely have had  delirium  tremens;
% 
280                    PNEUMONIA.

the lungs would  have become more congested,  and he  might
have died like a man I lectured  about on a late occasion.   (See
Case VIII.)
   When I say this, however,  I ought to guard my words.  For
in reality he would not have been  in anything like the danger
of that poor fellow.   Truly enough the two diseases are a most
perilous  combination ;  but it  makes  a  great deal of difference
whether the  pneumonia  is a consequence  of an  antecedent
delirium tremens, or whether the  delirium tremens is a con-
sequence of the  pneumonia coming  on a predisposed  subject.
In the former case a fatal result almost invariably happens, but
not so in the latter.   So that though  he might have died, yet he
would  not have been so certain to die as our former patient.
   XII. A  little boy, four years old,  was conveyed here on the
3d instant, just at his last gasp,  and  died  about a  quarter of  an
hour after I had seen him, while the sister was  putting him into
a poultice, and giving him some  wine and beef-tea.
   It was entered in the "urgent admission book" as a case of
pneumonia ; and so there was pneumonia, but it had nothing  to
do with  his death, which  in reality  arose from  the impaction
of a calculus in the right ureter  and inflammation  of the kidney
following thereon.   The pneumonia was  a  consequence, not
a cause, being of the sort fairly designated " pneumonia  niori-
entum."   It was  the consolidation of scarce a  half of the right
lower  lobe by this  congestion of gravitation which  caused the
patient to be entered as I have said,  and  placed  in the medical
wards.   Had  that been the only anatomical crtange, this child
might  easily have  recovered;  and I  mention  the case  only to
guard you against crediting  the death purely to pneumonia.

  The dozen cases of pneumonia which  I have made the subject
of a considerable portion of three clinical lectures since Easter,*
may be  held  to be  a fair  representation of an  average four
months'  hospital experience of  the disease.   There  have been
specimens of its  most ordinary forms  very much in the pro-
  * Viz., on May 2, May 30, and July 11.  They*are here massed together into
one lecture. 
PNEUMONIA.
281
portions in which they will occur to you in practice.   They have
included
  2 cases of pleuro-pneumonia, one fatal, one not (VIII, IX).
  1 case of pneumonia in measles (IV).
  1 case of pneumonia in typh-fever (VII).
  1 case of pneumonia in Bright's disease (III).
  1 fatal  case of pneumonia relapsing on a previously consoli-
       dated and broken-down lung (II).
  5 cases  occurring in  previously healthy  persons  (I, V, VI,
       X, XI).
  1 case occurring  as  a  complication of the  death  agony from
       another disease  (XII).
  In  the fatal cases the  death was caused in one by the pneu-
monia coming  on a previously consolidated  lung (II),  in  the
other  on  a  severe attack of delirium tremens (VIII).  In  the
third  the pneumonia was caused by the death (XII).
  And as  to treatment  I have taken current opportunities of
impressing upon you the following rules :
    I. Take blood locally, cautiously, in the early stage only,
         and  with  a distinct reference  to  the  power of each
         patient.
   II. Keep the chest from first to last enveloped in a jacket
         poultice, and allow of as little movement as possible.
  III. Administer  food  frequently,  largely, and  in a liquid
         form.
  IV. Where the nervous system is deeply smitten, as indicated
         by tremulous muscles, mental excitement, delirium,
         tawny tongue at an early stage, great depression, &c,
         give opium ; and in some cases give alcohol,  but not in
         small repeated  doses.
   V. Where there is diarrhoea, stop it  immediately with opium
         or kino.
  VI. Consider antimony, mercury, and purgatives  as poisons
         in pneumonia.
  I have heard the plans of treatment which I recommend you
to adopt  described  as  "trusting to  nature;" and  sometimes a
deprecatory "merely" is added—"merely trusting to nature."
       19 
282                     PNEUMONIA.
In one sense this is true, for all  methods of cure, at least  all
successful methods of cure, must  depend on the regaining of
natural vital forces ; and the agencies brought into action by our
interference must  be the natural vital forces of the body acted
upon.  The heat and moisture, for example, which we employ in
pneumonia, are  an imitation  of and compensation for the de-
ficient steadiness of the vital warmth ; the current of blood which
we  cause  to flow with our cupping-glasses  is a replacement of
the natural current; we give opium to bring the condition of the
nervous system into harmony with the functions arrested by the
disease.   There is no successful method of cure but what is suc-
cessful by virtue of thus restoring vitality.   But in the sense
intended  by those who  slightingly use  them,  the words are
synonymous with doing  nothing, or leaving the patient to him-
self, with  la medecine expectante, with the contemplatio mortis of
the satirist, Avith a hardened skepticism.   It is a saying like those
clever sneers of Job's adversary, which, under the guise of a
truism, hide a lie.
  Doing nothing or leaving the patient to himself, would indeed
be dishonest; but do we  do so ?   Is it doing nothing to keep up
constant  relays of poultices  night and  day for a week or ten
days ?  Is the  enforcement of continuous nutrition  no  labor ?
Is there no anxiety and thought expended in hourly watching
the need of variation in our doses of opium  and wine for serious
cases ?  Is the  moistening and warming the air to an even tem-
perature not enough to occupy our time ?   Is it so much easier
to support the waning life than to weaken it, that the former
should be condemned  as  idleness, the latter praised as activity ?
If the pneumonic patient were left to himself, would  he—could
he—adopt any of the means  suitable for  his recovery ?  Would
he  not  very likely be taking colocynth, senna, calomel, anti-
mony, ipecacuanha, salines,  senega,  squill, hydrocyanic  acid,
colchicum, be rubbing in  mercury, applying  mustard poultices
and blisters, be bled  coup sur coup, or have  brandy every half
hour ?.  Is it nothing to stand sentry against the fatal seductions
of poly-pharmacy ? 
LECTURE  XXII.
           EMPHYSEMA  OF THE  LUNGS.

 Illustration of the morbid anatomy of emphysema—Fatty degene-
     ration of the pulmonary membrane—Degeneration sometimes
     fibroid—Cause of the proneness of children's lungs to become
     emphysematous—Question whether inspiration or expiration
     most tends to produce emphysema—Action of the lungs in
     breathing  illustrated by ^an  example of a man without a
     sternum—Expiration more powerful than inspiration—Ap-
     plication of the morbid anatomy of emphysema  to  clinical
     questions—Case of emphysema in an albuminuriac—Case
     of emphysema depressing the heart—Treatment and its ob-
     jects—Iron—Tobacco—Lobelia—Stramonium—Mercury—
     Alcohol—Expectorants—Two eases of emphysema in young
     women exposed  to adverse  circumstances—Treatment  by
     iron—Trial of expectorants.

           (Clinical, St. Mary's,  March 13, 1863.)

   The  following  case, of which you now see the post-mortem
 examination, is a fair illustration of the morbid anatomy of pul-
 monary emphysema.
   Of the diseases which the  deceased  had  suffered from de-
 pendent on this condition the  history was given by him as fol-
 lows :
   George W., aged forty-two, a temperate laborer, much exposed
by his  work to cold and wet, had always  "a good wind" till
three years ago.   Since that time he has been what he terms
"asthmatic," that is  to say, he has been habitually short  of
breath and liable to contract catarrh accompanied by dyspnoea 
284
EMPHYSEMA OF THE LUNGS.
on moderate exposure. He was still always able to do an average
day's work till last Christmas, since which time he has been too
short of breath. He cannot assign any cause for his illness except
exposure to cold.
  When you  first examined  him, March 2, he was breathing
spasmodically and with extreme difficulty; his lips and face were
dark purple, but without any of the bloated appearance you so
commonly see in cases  of dyspnoea  from enlarged  heart.  On
examining the chest we  found  the  cardiac region, as well as the
whole  lower part of the thorax,  preternaturally resonant, and
the ribs were  bowed and  raised, so as to  make the  bony frame-
work of the upper half of the  trunk  more globular than natural,
and to throw backward the  lower angle of the  scapula.   The
intercostal spaces were not protuberant.  The number of respira-
tions was thirty-four in a minute, the pulse 104.  In the cardiac
region, and in several  other of the  lower parts of the chest, I
drew your  attention to a peculiar crumpling sound in inspiration,
not unlike  that  produced by squeezing up fine paper  in the
hand.
   He experienced a certain degree of relief from the rest in bed,
 and a draught three times a day containing lobelia  and chloric
 ether; so  that  on the 4th  his  respirations were  reduced to
 twenty-eight in a minute.
   But he soon fell back again, and  sank  exhausted  and breath-
 less on  the 11th, and  we have now to make the  post-mortem
 examination.
   On opening the chest the heart is seen completely overlapped
 and hidden by a layer of lung about two inches thick, consisting
 of lobular masses of pulmonary tissue, pale  in tint, dilated into
 vesicles, and looking more like flesh-colored  soapsuds than any-
 thing else.   These masses of vesicles are firm and  elastic from
 retained air; but when that  is let  off by a puncture, they sink
 doAvn into a flabby non-crepitant  substance.  The same appear-
 ance is seen in the greater part of the lower left lobe, and at the
 apex of the upper lobe;  and the  lower right  lobe is partly in  a
 similar condition. The  flesh of the heart is pale, and its cavities
 are large.  The wall of the left ventricle is thinner perhaps than 
EMPHYSEMA OF THE LUNGS.            285
natural, but the whole organ is not so much dilated as to render
the valves inefficient; and they are healthy in appearance.  The
kidneys and other viscera are quite normal.
   On the whole you are perhaps rather surprised at  the small
extent of obvious organic change,  considering the violence  and
fatality of the symptoms.   But now examine again the portions
of lung not affected with these bullae of emphysema.  They are
doughy, flabby, and non-elastic.  They keep the mark of a finger
pressed  upon them.   They are very slightly  crepitant when
squeezed.  You may reasonably feel doubtful whether such pul-
monary tissue can perform the functions which require elasticity
and firmness.
   Now let us make a section, and  cut out with a pair of curved
scissors a few snips as fine as we can, tease them out with  a
needle, and place them under the microscope with a lens of  one-
quarter inch focus.   You thus get a sight  of  the pulmonary
membrane.   You  know it ought  to  be a continuous skin-like
membrane, transparent, and distinguished  principally by bundles
of fibers gently curled  and interlaced.  In a healthy lung it does
not exhibit any cells or corpuscles.   But here you see scattered
about it numerous fine dark specks, and somewheres there are
round bright globules with a dark outline, and somewheres the
globules and specks are collected  together into masses,  denser

toward the center—so *'°  * JS&' —just like the  masses of
fatty degeneration which  you have in the muscular structure of
atrophied hearts.  This is an example in fact of the same morbid
state in another tissue, the fatty degeneration  of pulmonary
instead of cardiac tissue.
   You will  easily understand how emphysematous  bullae arise.
Melt one side of an India-rubber ball in a  candle and squeeze it;
you see it bulge out into a bubble just in the same way, and just
from the same cause, loss of elasticity.   What the melting is to
the India-rubber  ball that to the pulmonary branch of vesicles  is
the wasting of its elastic web into  fat.  When any dilated force
is exerted upon  the walls  of the vesicles  they give way and do
not contract again. 
286
EMPHYSEMA OF THE LUNGS.
    It is not always fatty degeneration which is found in emphy-
  sematous lungs; sometimes it is fibroid degeneration, and Dr.
  Jenner has in his experience found this latter the most common.*
  Either sort of partial interstitial death involves a loss of the  func-
  tions of elasticity and contractility in the tissue—fatty degenera-
  tion probably the most loss, and therefore it is that you find it in the
  most rapidly fatal and most marked cases, such as the one under
  our eyes. The same softness and proneness to give way may also
  be supposed to exist in the lungs of children; for the younger
  the tissue the softer it  is;  and thus children's  lungs are  very
  prone to become emphysematous without there being any inter-
  stitial change to be detected in the pulmonary tissue.
   The anatomical or predisposing cause of the  disease we are
 considering may then be held  to be a too great  softness of tissue,
 from the lung either not  having yet acquired its full power of
 resistance, or from having lost it by morbid change.
   And now let us look  for the external or determining  cause,
 quite  as important an element in  the production of disease.   It
 is the act of breathing of course, and the act of breathing forcibly,
 that breaks  down the over-soft tissue.   But is it inspiration or
 expiration that is most to blame, or both equally ? The question
 rests on the point of which causes most pressure of air on the
 pulmonary membrane of the air-cells.   And because inspiration
 fills these air-cells, it has appeared to some to cause most pressure
 on their walls. Doubtless in inflating a bladder you increase the
 atmospheric pressure on the inside, and  I suppose it must be this
 analogy which has led physiologists  astray.  But the  cases are
 quite  different;  the  lungs are not inflated by blowing air  into
 them,  but by the expansion of their walls drawing air into them,
 in fact by the atmospheric pressure on the interior being forcibly
 lessened through the action of the diaphragm and other respira-
 tory muscles.  A fairer  analogy would be a pair of bellows, the
 leathern sides of Avhich are certainly not bulged outward by  the
 filling of the instrument.  And if that leather was softened it
 would swell and stretch during  the blowing of the fire, not during
the drawing in of the air.
          * " Medico-Chirurgical Transactions,", vol. xl, p. 26. 
                EMPHYSEMA OF THE LUNGS.            £87

   Not  inspiration, but  expiration, must be  the  most efficient
 determining cause of the dilatation of the air-vesicles in emphy-
 sema.  The difficulty which people feel in  understanding this
 arises from their thinking of the thoracic walls as a contracting
 ball or box, of equal contracting, force throughout, and which
 therefore  in  its contraction  during expiration would  equally
 diminish the area of all the pulmonary vesicles at  once.  And
 diminishing  the  area, say they, is certainly inconsistent with
 dilatation.  But this idea of the chest is an erroneous one. The
 thoracic walls, from their irregular shape and from their varying
 solidity in various  parts, press with a very  unequal degree  of
 force on different parts of the lungs.   The apices of the upper
 lobes for example, from the  deficiency of the  bony framework
 above them, and the  edges of the lower lobes  from being in an
 angle, escape the compression of the ribs and diaphragm to a
 great extent.  When then the air by the action of the respiratory
 muscles is  squeezed out of the more readily compressed parts, it
 is driven into or at least is driven toward these less compressed
 parts.
   Two  or three years  ago  some  of you were shown in this
 theater the action of expiration upon the less compressed  parts
 of the lungs by a M.  Groux, a poor  gentleman Avith a congenital
 deficiency of the sternum and a consequent fissure in the thoracic
 walls, which fissure was covered only by skin and cellular tissue.
 Of course the portions of lung behind this fissure were less com-
 pressed than any part of the pulmonary substance;  and during
 expiration you saw them bulge out, just like the leathern sides of
 a bellows during a corresponding movement.  Those who witnessed
 the curious sight admired the toughness of pulmonary tissue which
 could resist injury from such an abnormal state of things.  And
 they could not fail to understand  that if M.  Groux's lungs had
 been wanting in elasticity, they would never have been able to
resist the dilating poAver exerted by expiration on this undefended
part of  the tissue.  The same  condition which M. Groux's de-
ficiency of sternum exhibited in an exaggerated way, the normal
partial deficiency of bony framework  presents in a  less degree
to the apices of the lungs, and their peculiar angular position to 
288
EMPHYSEMA OF THE LUNGS.
the bases.   It is in these parts that expiration causes the atmos-
pheric pressure to be  greatest, and  it is in these parts that
emphysema most commonly appears, as exemplified in the instance
before us.   It is at the apices and  anterior edges of the lungs
indubitably that we most often find this morbid state when the
degeneration is generally diffused.
  When emphysema  appears elsewhere in the lungs, the apices
and edges being free  from it, it is due to the degeneration being
local, and  to those peculiarly liable parts at apices and bases
being shielded from injury by their healthy elasticity.
  Another reason for thinking  that expiration rather than  in-
spiration is the main  cause of the final injury to  the vesicles in
emphysema, is  that  it  is much  the most powerful of  the two
muscular efforts.   If a man can draw in the air through his nos-
trils* with sufficient force to raise a column of mercury (say) two
inches, he can by expelling it steadily raise the level 2| inches:
if he is strong enough to lift the fluid by inspiration 2| inches,
his expiratory power  will mark 3^.  Thus,  even though it is pos-
sible that both  inspiration and expiration  may tend to rupture
or dilate the pulmonary membrane, inasmuch as all motion must
endanger an abnormally friable tissue, yet  expiration tends to do
so much the most.  That is the real practical point, as I will
show you presently, wdien I come to apply our knowledge to its
true end, the relief of distress.
  This fatal case  then  has shown you the true  nature of the
anatomical  injury you have to deal with  in emphysema of the
lung.   It is an interstitial partial death, or degeneration of the
pulmonary membrane.   This membrane, which forms the frame-
work  of  the vesicles,  thus loses its elasticity and is determined
to dilatation by the action of forced expiration.
  It may be asked whether the degeneration  is not rather the
result instead of the cause  of the dilatation. It may be suggested
that bronchitis and violent cough originate the  rupture of the

  * The nostrils must be used  in the  experiment, because  the action of the
tongue and cheeks in suction and puffing introduce a fallacy, bringing into use
muscles which are not muscles of respiration.  See  Dr. Hutchinson's paper in
" Medico-Chirurgical Transactions," vol. xxix, p. 199. 
EMPHYSEMA OF THE  LUNGS.
289
vesicles, and that the ruptured vesicles, being unused, fall, like
all  unused tissues, into fatty decay.  I will not deny the pos-
sibility of such a sequence of events in some instances, because
in point of fact we do find emphysema of unaltered pulmonary
tissue in children.  But it was not so in  the case before us, be-
cause the  patient had not been subject to bronchial  catarrh, had
no mucous secretion  before he got  short of breath, and indeed
had very little even up  to  the fatal termination.  And  the case
before us is a well-marked type of uncomplicated emphysema in
the adult.
  Do not  rest satisfied with having learnt the pathology of a
disease Avithout applying the  pathology to  its treatment.   If  it
were not capable of such  an application I should not  make it  a
subject  for clinical  lecturing.  The  pathology of emphysema
shows us a gradually increasing loss of vitality in the pulmonary
membrane.  We must  so treat the patient as  to  increase the
vitality.   A constant supply of nutritious food and long courses
of iron give  the  best  chances of doing this.   I  should have
adopted it for our poor  patient had he lived long enough.
  The  pathology may  teach something more.  Expiration  is
the dangerous and injurious part  of breathing, and especially
forced  and arrested expiration.   Let your  patient carefully
avoid all such employments as strain the respiratory muscles—
all  such labors as make a man hold in his  breath and then  puff
it out with a jerk—such  as lifting and carrying heavy weights,
digging, pitching, rowing, &c.   I  do not think you need trouble
yourselves about Avind instruments or singing; persons with em-
physematous lungs are  not likely to be addicted to  them, and as
a matter  of fact those who use the chest freely, such as  public
singers, do not get emphysema from the exercise  of their pro-
fession.   Of this latter fact I am  certain—it is not the due use,
not the " straining" of the pulmonary membrane which causes it
to degenerate, but rather  the want of use.  In this respect  it
resembles all other living animal tissues. 
290
EMPHYSEMA OF THE LUNGS.
            (Clinical, St. Mary's, March 27, 1863.)

   I will  take the opportunity of having admitted,  a week ago,
two cases of pulmonary emphysema, to recur to our  subject of
a recent  lecture.
   " John D. is a poor street-sweeper now, and  nearly seventy
years old, but has been a gentleman's servant, and has had 'his
beer regular,' and taken it freely.   This confession is corrobo-
rated by the shaking of his hands when he puts  them up.  He
says  he  has been  'queer and wheezy' and subject to frequent
coughs for six years, and five years  ago was under my care for
asthenic  gout.  The cough is of a violent spasmodic  character,
and does not bring up  much mucus.  His chest is resonant and
rounded,  and moves very little on inspiration.   The cardiac
dullness  commences at a low level at the base of the heart, and
the pulsations of the organ  are felt in the epigastrium.  His
corpulence prevents us from getting the auscultatory signs of
emphysema so clearly marked as one Avould wish.  There is  not
now, nor does there ever appear to have been, any anasarca.
   " The  urine is albuminous, of the specific gravity 1-012."
   In  this case I think  there is a generally distributed  deficiency
of elasticity in the pulmonary tissue, which has arisen from the
same  diathesis as the morbid state of his kidneys (shown by the
albumen  in the urine) and perhaps of other organs as well.  But
his general weak health,  graphically described  by him  as
" queer," has prevented his working hard, though I dare  say he has
lived hard and drank hard: and in consequence the determining
cause which I explained to you  fully, in my lecture a fortnight
ago, of forced and impeded expiration, has not been present.  Thus
local spots of very marked emphysema are not found.   The  de-
fective vitality of the renal tissue, which makes him an albumin-
uriac, is doubtless of the same nature as that in the lungs: and
it causes  a tendency  in the blood to throw out its serum and thus
to saturate the lungs with fluid, which assists also in concealing
from our ears the signs of the emphysema present.
  The prognosis is certainly favorable as far as his  chest is con-
cerned, but I fear we cannot make a young man of him. 
EMPHYSEMA OF THE LUNGS.            291
    The other case is the following:
    " George H., aged  fifty-three, a plasterer, first became asth-
 matic two  years and  a half ago.  After suffering a few weeks
 and expectorating  a  little  mucus streaked with blood, he was
 admitted into the hospital  under Dr. Sibson, and remained six
 weeks, having  during that period  had a carbuncle  on his neck
 and an  abscess in  the left axilla.   He went out relieved, and
 has been able to work ever since,  in  spite of his asthma, till a
 month before Christmas last, when he again was obliged to give
 up.  On his coming under my chaise, March 20, he  presented
 the usual  marked signs of extensive emphysema of the lungs.
 His chest is rounded,  and the lower angles of the  scapula are
 thrown  upward and  outward.  The left side of the  thorax  is
 larger and  more rounded than  the right.  There  is very marked
 resonance all over it, including the cardiac region, and the heart
 is pressed  downward, pulsating  regularly  in  the epigastrium;
 the valve sounds are healthy.  The breathing is  abdominal; the
 respirations are twenty-eight  in a minute.   The face is  livid,
 and the lips blue, but  without any of that bloated appearance so
 common in  asthma from diseased heart.  There  is a good deal
 of frothy expectoration, but no blood streaks in  it.   The urine
 is healthy."
   While  examining  this and some other emphysematous chests,
 I have been asked by  pupils how it is that there is no bulging of
 the intercostal spaces,  and I have been given to understand that
 bulging of the intercostal spaces  is taught as a sign of emphy-
 sema at some schools.   This is an error—the intercostal spaces
 do  not "bulge," like as when the pleurae are full of fluid,  a fact
 which  you  may  ascertain  for  yourselves now.   But of course
 from the  chest being always in a state of fullness, the ribs are
 widely separated from one  another.  This, however, is a  very
 different thing from  intercostal bulging, as you may see in  both
 the dead and living body.
  I have ascertained, by a reference to Dr.  Sibson's case-book,
that the  signs and  symptoms exhibited  by  this patient were
much the  same on his  former admission as  they  are now.   He
is not essentially worse, and indeed his trade is not  one which, 
292
EMPHYSEMA OF THE LUNGS.
with ordinary care and prudence, would be  an injurious one.
The prognosis therefore may be favorable.
  I will view as one  the treatment of these  two persons, inas-
much as I have ordered them both the same medicine, viz.:

             1^ Tind. ferri sesquichloridi 11^ xx,
                 Tinct. lobelise setherese HLxv,
                Mist, camphorse Sj,
                                ter die.

  The object of the iron is to try and restore its  full vital powers
to the creative arterial blood, so that it may reneAV the pulmonary
membrane, that it may form healthy elastic tissue, instead of the
imperfectly elastic  degenerated tissue.   That places where the
walls  of the air-vesicles are broken away,  and where bullae exist
instead of vesicles, should be filled  up  again with a new growth
is, I fear, out of the question; but that where the form of the
lung substance  remains  perfect, where to the  naked eye it  is
intact, and only under the microscope  exhibits its incipient
death, there I believe we need  not despair of our restorative
agent  having  a fair  chance of success.   The  best restorative
medicine is the healthy blood of the patient's own body, and  to
make that blood healthy is the most rational aim we can have.
  To the iron I shall  at a future day add, in the case of George
H., cod-liver oil, as a means of affording a molecular base to the
growth of new tissue.  He  is thin, as you see, and it will be
readily absorbed by the intestines, and probably agree well with
him.   I feel more doubtful about oil in the case of John D.,  as
he is so flabbily corpulent;  but I shall  try cautiously  how he
bears it.
  You may have remarked that I refused  the  very urgent  re-
quest  of John D. for beer, which he said habit had made a
necessary for him.   I  hope,  if possible, to  break him of the
habit, for nothing is so  injurious to degenerative tendencies  as
alcohol, and no form of alcoholic liquid so bad as beer.
  No—I must make one  exception to the bad pre-eminence  of
alcohol, that is, mercury.  Avoid mercury in these cases as you
would a poison.   Avoid also purgatives. 
EMPHYSEMA OF THE LUNGS.
293
  The lobelia is ordered as a substitute for a more powerful
medicinal agent, tobacco.   Nothing calms the distressing asthma
so Avell as a few whiffs of strong Virginia.  But to allow smoking
in the hospital would lead to breaches of discipline; so I order
that which  is apparently  the  next best thing.  Like tobacco,
lobelia is a very variable  article; there  seems to be as much
difference between  one  specimen and  another, as  between the
mildest cigarette and the  strongest  shag.   This accounts for
Avhat we read of enormous doses being sometimes perfectly inert,
and of much less quantities having acted as a poison. A further
safety to  those who have taken large doses lies in the fact of its
being, like tobacco, an emetic, and so freeing the stomach of its
presence in excess.   I  should  advise you to use  the  strongest
sort, paying the best price at the best  shop, so that you may
give  it in  moderate and graduated doses.   Lobelia does not
disagree with the digestion like opium, and you need not on that
score abstain from its use.
   Another  agent of  the same character as tobacco is stramo-
nium.   It also  is best  administered in  a pipe, but here again
the hospital discipline  interferes, and I am obliged to give it
him in pills made with the extract, which you may see are not
so efficient in this instance as the lobelia, though in the form of
smoke it is  often more useful.
   Perhaps  some of you may doubt whether it is  quite wise to
diminish  by calmatives the action of the respiratory function,
and may think  the asthma an effort of  nature, ordained  to  ac-
company  emphysema for a beneficial purpose.   This is a case in
point very subversive of the theory of disease being an "effort
of nature." The forced breathing, nay, even the natural breath-
ing, tends to dilate the vesicles, and if it were designed to benefit
the patient, we should have to conclude that the design was erro-
neous—a conclusion repugnant to instinctive reverence.
   When  there is an unhealthy condition of the  mucous  mem-
brane of  the trachea and large bronchi, evinced by copious  ex-
pectoration, you will find benefit from cantharides or turpentine,
either administered by the mouth, or applied  to  the  surface of
the chest in the form of blisters  and rubefacient embrocations. 
294            EMPHYSEMA OF THE LUNGS.
 These drugs often act very powerfully as restoratives of healthy
 action to diseased mucous membranes.  They indirectly in this
 way benefit  the  emphysematous lung, by preventing the  neces-
 sity for  so much  coughing;  but they are not  directly useful to
 the tissue mainly at fault.
   I do not approve of the use of squill or ipecacuanha, and still
 less of antimony.  Even if  they appear to relieve  for the mo-
 ment, which is by no means generally the  case, yet they lower
 the appetite and the powers of  digestion, and thus stand  in the
 way of active restorative treatment in emphysema.

           (Clinical, St. Mary's, October 31, 1863.)

   There have been under your eyes during the month two cases
 very graphically illustrative  of the pathology of emphysema.
   On October 7, there was received from the  Servant's Home
 (where  she had been living,  while attending as an out-patient)
 Annie C, aged seventeen, a fat but  stunted maid of all work.
 She was in  the hospital during  the summer of last year, and  I
 find that her illness  then was a typh-fever, slight in itself, but
 which  had come on during  a wet  and  cold foot-journey from
 Norfolk, and which had, under the  adverse circumstances  of its
 supervention, caused pneumonia of the lower lobes.  She re-
 covered  perfectly to all appearance both the use of her  lungs
 and her  flesh at that time.  But yet she says she has  never
 quite ceased to suffer  from shortness of breath.  This shortness
 of breath has been gradually growing upon her,  and prevents
 her keeping any place as a domestic servant.   On admission she
 was very blue in the  lips and face, and was  suffering great dys-
 pnoea; the respirations being forty in the minute.  She said she
 had  not  been able to lie down in bed for two months.   There
 were loud snoring and cooing rales  throughout the lungs, inter-
 spersed with  occasional  cracklings in various parts, a roundness
 of the  thoracic walls, abdominal and heaving  respiration,  and
resonance on  percussion more extensive  in every direction than
it ought to be.  The heart, however, is not  entirely overlapped
by the lung, so that this evidence of local emphysema in the  left
lung is not complete.  Its sounds are healthy. 
EMPHYSEMA OF THE LUNGS.
295
   Emphysema is not usual in girls of seventeen, and we are able
 therefore the more distinctly to refer this case to the peculiar
 adverse circumstances in which  she  had been  placed.   Con-
 gestive inflammation of the  pulmonary substance had been  in-
 duced by exposure in a person previously disposed to  it by the
 typhous state.  The congestion had  been relieved by treatment,
 but there was left behind the weakened life of the tissue unable
 completely to recover itself.   This has resulted in gradual local
 degeneration;  in spite of the patient's generally well-nourished
 condition, her lungs are starved.
   This is  the reason why I have  treated her  with  iron and
 quinine, in  addition to the aethereal tincture  of  lobelia,  which
 latter was  ordered  to  alleviate the special symptoms at  first.
 She is  now able to breathe easier  and to lie down in bed, but I
 am  afraid  she must be turned adrift on  the  cold  world next
 week, for one can  hardly expect to fit her for  domestic service,
 and more pressing cases demand our beds.
   Bridget G., an unmarried  servant, aged twenty-five, was ad-
 mitted on the 19th.   She has the same sturdy build and bloated
 look as the  last patient, and I cannot help thinking that most
 probably the pathological history of  her case is the same.   It is
 true that we cannot draw from her any account of pneumonia;
 but she is impenetrably stupid and ignorant, and hardly under-
 stands the English language, so that  I do not reckon her answers
 to cross-questions as of much worth.  She might easily  have had
 slight  pneumonia  without  recording in  her  memory  anything
 which could lead us to a knowledge of it.   Even  in the former
 case, I doubt if the clinical clerk would have made out the oc-
 currence of pneumonia and typh-fever from the girl's tale without
 the aid of our former notes.
   Bridget's  symptoms have been coming on three  years, and  in
 consequence  the lungs  occupy a larger space  than Annie C.'s,
 overlapping the heart and rendering the cardiac region resonant.
 Her degree of dyspnoea, however,  is not  so great,  nor is the or-
 thopnoea so marked.   I have often remarked that  the asthmatic
 symptoms of emphysema are  by no means proportioned to the
large extent of the parts affected;  their severity rather depends 
296             EMPHYSEMA OF THE LUNGS.
on the rapidity with which the degeneration has advanced or is
advancing.
  I have put her on a course of iron, for which I have already
to-day told you my  reasons.
  I have also had her cupped between the shoulders, as an expe-
dient of immediate, though temporary, relief;  and an expedient
which the prominence of the venous crasis amply justifies in her
case;—she will soon recover the blood lost.
  She had been taking,  by somebody's orders, some pills of
squill and ipecacuanha every night.  I continued them, in order
to observe their influence.   On leaving them off she slept quite
as easy as (she  said easier than) when taking them, and I could
detect no change in  the quantity or quality of the  sputa.  So
that expectorants are  evidently of no use, an observation I have
often had occasion to make in cases of emphysema.
  You have fairly exhibited in the history of these two girls the
slow and gradual march of  a degenerative lesion as a local affec-
tion in a sanguine  and otherwise healthy  person.   You see it
caused by privations  and  injuries, rather  than by any violent
special exertion of the part.  And you see  how these causes act
even in persons not constitutionally liable to such degeneration,
namely, with great  slowness and without threatening any immi-
nent danger.   It is  different with leuco-phlegmatic persons.  In
their case the advance of  degeneration is rapid and acute, and,
if not checked by  active  tonic treatment, proceeds  soon  to its
fatal termination.
  You will say this  is a great advantage for persons of sanguine
temperament.   So it is.  But it has its counterbalance.  Degen-
eration in them is much less amenable to treatment, especially
to treatment  by iron, which  is the most valuable, than it  is in
the leuco-phlegmatic.   Though rarer and  slower, its march in
them is unfortunately surer, when it has Once begun. 
LECTURE  XXIII.
         PULMONARY  CONSUMPTION.

Pathological data—The disease localized by morbid anatomy and
     auscultation—Pitfalls of this knowledge—Not the presence,
     but the increase, of tubercle, is the chief point—Innocuous-
     ness of non-progressive tubercle—Object of treatment should
     be the organs  of nutrition, not those of respiration—Food—
     Cough medicines-—Appetite—Iron—Cod-liver  oil—Alco-
     hol—Remedies for diarrhoea—Cachectic phthisis—Chlorate
     of potash—Delirium in the last stage of phthisis, how caused,
     and how to be treated—Specifies.

           (Clinical, St. Mary's, December 13, 1861.)

  I shall not  to-day detail  any particular instances of  pulmo-
nary consumption.  There are now, and always are, several in
the wards, to which I have  called your  attention on points of
diagnosis;  but  it would be wasting the valuable time of a clinical
lecture to recite their familiar phenomena, which, so far as they
affect the treatment, are very uniform,  and perfectly familiar to
you I should presume.
  I take it for  granted also that in the systematic course of  lec-
tures on medicine you have heard the following propositions,
which seem to  me to comprise  the chief points contributed by
pathology  toward  the treatment of the disease, and in  proving
which a great deal of time and  thought have been worthily, be-
cause usefully,  spent.  I shall assume—
  1. That the cause of the symptoms, of the disease, of its fatality
in fatal cases, is the occupation  by tubercle of vital organs, espe-
cially the lungs;—
       20 
298             PULMONARY CONSUMPTION.
  2. That the tendency to the formation of tubercle resides  in
the constitution of the individual;—
  3. That this tendency may be either  hereditary or acquired,
or both hereditary and acquired at  once;—
  4. That the circumstances  which quickest develop this tend-
ency are  the same as contribute  to  ansemia,  want of supplies
for  the formation of  tissue—namely, starvation, bad air, depri-
vation  of light,  exposure to  cold  without power of resistance,
fatigue, previous  illness; in short, all depressants of the powers
of life.
  Anatomy and  auscultation have rendered us  the  enormous
service of tracing out truly in death  and life the organs chiefly
injured in pulmonary consumption, and the nature of the injury
done.   What an incalculable advantage we have over our grand-
fathers in this respect!   What a contrast between the dangerous
confusion of various  diseases under  one head, the  distinctions
without differences spoken of in  the writings of the by-gone age,
and the almost finical precision of our  diagnosis!  But do not
stop here ; pathology must carry you  on  further, or you will have
gained so little from science, that I doubt if your practice will be
any better than your grandfathers',  in  spite of  the treasure  of
additional knowledge you possess.   Often,  during  our talk up
stairs,  I perceive  signs of your considering the tubercle as "the
disease" against  which you have to direct the energies of your
minds, and from which the patient has to be rescued.   You want
to do something  to "stop" it, to "absorb"  it, to "counter-irri-
tate"  or  "evacuate" it; you seem to imagine  that  if you could
take away that mass of cheesy matter  which  auscultation puts
almost as clearly  before your mind as if the ribs were  transparent,
your treatment would be perfect.
   And I fear that in this you might be upheld very  often by the
tone of medical literature, even of modern date.  For example,
I read in the "Cyclopaedia of Practical Medicine"  that emetics
are useful in the early stages of phthisis,  by displacing and evacu-
ating the tubercles from the  lungs.   Can the writer ever have
really tried with a scalpel to pick out a tubercle from the pulmo-
nary tissue, when he thus  suggests the  possibility of the gentle 
                PULMONARY CONSUMPTION.            299

pressure of vomiting effecting such a feat?   And I find the effects
of cod-liver oil sometimes  attributed, not with obvious  common
sense to its  being an easily digestible oil,  but  to  the minute
traces of iodine which it contains.   Yea, iodine itself has been
given in long courses Avith the idea of bringing about  the removal
of the tubercles.
   I Avish to put these notions out of your heads.   What the pa-
tient has to fear, is not the remaining of the tubercle  in the body,
but its  increase.   That which is once there has done  its  mischief,
its patb/of ruin is  past, the portion  of lung which it has occupied
is  gone forever, and  cannot grow again any more than an am-
 putated leg.   The dissections  of  consumptives almost  always
 show the cause of death to be a fresh formation of tubercle at no
 distant period, which has  abridged the remaining organ to a de-
 gree inconsistent with life.   A single deposit of tubercle to a
 moderate  extent  can almost always be recovered  from.  It  is
 the continuous repetition of the  morbid process which is so fatal.
    I  cannot, therefore, too strongly impress upon you, that not
 so much the  tubercle as the 'tendency to form tubercle, not  the
 morbid matter but the  diathesis,  is that which  should occupy
 your thoughts.
    When tubercle  first takes its place in the pulmonary tissue,
 the lung feels a good deal inconvenienced by its presence; there
 is cough,  inflammation round the foreign body, and condensation
  of the neighboring substance; and this is accompanied by general
  ill health, arising from the  sudden loss of part of the respiratory
  function,  to which loss  the  system has not had time  to become
  accustomed.  These consequences are directly proportioned to
  the quantity  of lung spoilt.  They may be so severe as to cause
  death by what is called."tuberculous pneumonia," or by "gal-
  loping consumption," when a large extent of lung is very quickly
  rendered unserviceable.   Or, when the injury is  more gradual
  a»d slighter, they may be so insignificant as not to have attracted
  notice at all. The other day in  a patient  of mine who died of
  chorea dependent on a  tubercle in the spinal cord,  you saw at the
  post-mortem examination scattered tubercles in both lungs which
  had caused no symptoms at all during life, though they probably 
300              PULMONARY CONSUMPTION.

had been  there much  longer than the tubercle in the less usual
situation which proved fatal.   And very often in persons killed
by accident, apparently in the prime of activity and with no his-
tory of any serious illness, you  find  crude tubercles, scars  of
former tubercles, and the chalk-like debris of tubercular matter.*
  Passing on to more  agreeable evidence—we find people with a
very large quantity of tubercle in the  lungs, so large as to have
almost proved fatal, who yet  recover to a great extent from the
mischief which it has caused.   When once the lung has got over
the shock produced by the presence  of the first loadV>f dead
matter, the health recovers, and the patient (though imperfect in
body of course) has only to fear a fresh crop.  It is astonishing
what enormous ravages may be made  in the lung, and yet with
the help of what remains how people will recover the health that
has been lost.  I dare say you may remember last summer a poor
old woman sent to the hospital to die.  There was in the left
upper lobe a vomica, so large  that there was "metallic tinkling"
in it;  and for some Aveeks I took the opportunity of teaching
you this sound.   You  know from my lectures on diagnosis that it
hardly ever occurs except in pneumothorax with perforation, and
not always there; that it is very rare in vomicae, and when present
indicates a cavity bigger than your fist at least.   So weakened
was the patient by the loss of so much lung, that she was first
unable even to feed herself, and quite soaked the bed with colli-
quative perspirations.   Yet, contrary to all our expectations, she
lost her night SAveats, gained flesh, walked about the ward, and
finally walked home during my absence from  London, so that I
cannot  say Avhat was  the exact  state of  her chest on leaving.
But I will take for granted that  the cavity remained unclosed,
and probably will remain unclosed for the rest of her life.
  I say I take for granted  that the  cavity will remain unclosed
for the rest of her life, from  my experience of post-mortem ex-
  * In 556 autopsies of tubercular persons, which I  found recorded in the post-
mortem books of St. George's Hospital, during ten years, there was seen the so-
called "cretaceous"  matter in the pulmonary  tissue in 65.  See "Decennium
Pathologicurn," chap, v, sect.  7, where statistical arguments are assigned  for
considering  this solid substance to be really of tubercular character. 
PULMONARY CONSUMPTION.
301
animations, Avhich lead to the conclusion, that in cases of cured
phthisis pulmonalis vomicae rarely heal up, but that they become
dormant and comparatively innocent, lined with  a  thick,  pus-se-
creting membrane, and thus separated from  the  healthy lung
around them.*
   I can give also other and living evidence.—For example, R.
S., a  wine merchant  aged forty-two, was,  in  1846, under the
care of several of the most  experienced in chest  complaints of
the London physicians.  He had a large vomica  in the left apex,
was excessively debilitated by  it, and was  sent home with the
information that he could not  live a  month.  Well, he  picked
up strength and flesh, was enabled to  return to  his  business,
and, when I saw  him in 1858, twelve years afterward,  he was
in fair health, and  as  able to do a moderate day's  work as any-
body I know ;  but auscultation left no doubt that the vomica was
still open in the lung, and that the small  quantity of  pus he
expectorated came from it.
   In  1855, I  advised  a young  man, with softening tubercles  in
the left lung, to accept a chance which he had of settling in the
West Indies.   Six and a  half  years afterward,  he returned  to
England for a temporary  purpose, and  came to  me about some
symptoms not connected with his chest.  I found that his vomica
was still there, and secreting pus ;  but that he had never per-
manently lost again the flesh which a course of iron and  cod-oil
had put upon him.  He had even had an attack  of haemoptysis,
and gone  through yellow fever,  without serious injury.
   As a contrast to such cases—and  the way in which Ave lose
sight of our patients prevents our multiplying  them—as  a con-
trast to these where vomicae have  become innocuous,  compare
those in which chronic consumption proves fatal.    In the latter,
a dissection always (accidental cases excepted) reveals, either in
the lungs  themselves  or in  other Aatal  organs,  a  formation  of
fresh hard tubercle as  the cause of death, besides  the established
vomica or the old masses of morbid matter.
  * Reasons are given in the chapter cited in the last note from  my '•' Decennium
Pathologicum." in the Medico-Chirurgical library, for believing that  "chalky
masses" in the pulmonary tissue are not the remains of vomica? but of hard
tubercle, which has dried up without softening. 
302
PULMONARY CONSUMPTION.
  It is clear, therefore, that it is the tendency to tubercle, and
not the existing tubercle, which we  have to fear and to guard
against; and  that for the successful treatment of consumption
we must withdraw our minds  from the morbid  anatomy of the
locality to the fatal propensity of the constitution.
  To my mind, it is  a great  relief  and rest to be able to map
out by auscultation  the exact extent of the mischief done, and
to know that  there is enough of the morbid change discovered
to account for the severity of the symptoms.  I feel  then like
a general who is acquainted with the exact position and whole
force of  his enemies, and is sure that the country will suffer no
further loss if they can only be kept from advancing.
   In the case of chronic consumption,  hope should never be
entirely lost.  If the remaining  portion  of lung  has retained
life so.long, it can retain life longer, and the whole attention can
be applied to its conservation.  There is  no question about the
future conduct of the war, if only reinforcements for the enemy
can be stopped in their march.
   To what  quarter  must we  look for aid in this conservation ?
 I know you are  disposed  to  turn first to the lungs.   But if we
 inquire  into  the histories of those who  have  lived  long with
 vomicae  or tubercles, they  are by no means found to have taken
 special care of their chests—they have not coddled or lived in-
 doors in even  temperatures, hanging their lives on  to their
 thermometers for fear of coughs : they have gone on with their
 professions or business or  work: they have not " laid a knife to
 their throat," but have eaten and  drunk like other people, and
 have enjoyed the gratification of their appetites.  A patient of
 mine, over fifty, with copious pyoptysis and condensed lungs (of
 probably a tubercular nature) from his youth, has kept hounds,
 broken  his bones like other Nimrods, contested county elections,
 sat in parliament, enjoyed his champagne and other good things,
 but never allows any doctoring of his chest.  An  examination of
 it is a favor, as  a contribution to science.
    Nor  is it  only when tubercle  is established  that  it  may be
  arrested by exposure of  the body to active change; even the
  tendency may be  averted.    I examined  for  insurance a few 
                PULMONARY CONSUMPTION.             303

weeks back, a gentleman aged fifty-five, the second of a family
of eleven in  whom phthisis  was hereditary.   Circumstances
have caused the three eldest to rough it in the world; they have
traveled  and worked, and now'when wealthy, they are healthy,
active sportsmen.   The seven youngest were coddled and petted,
and all died of consumption under twenty-five.
   The necrological statistics of  the  phthisical in the tAvo sexes
corroborate  this deduction.  Although males are more liable to
tuberculosis than females,  yet they are less liable  to have that
tuberculosis exhibited in the lungs.   (See " Decennium  Patho-
logicum," chap, iv.)  Now in all classes of social life,  women
are the least disposed to exert and expose their lungs; they are
more  ready to  invalid  themselves; and in the lower classes,
whence these statistics are taken, they do not wear low dresses
or tight  stays (to which  habits some have  attributed consump-
tion).  Yet  we find that tubercle with them takes the direction
of the spared organ.
   You may perhaps say, " This spared organ is a most important
one: I will  sacrifice the others  to the possible chance of saving
it."   But consider—what  is this tubercular matter ?   It is not
anything peculiar to the lungs, but may arise from degenerated
nutrition—the inferior development of life—of any part,  and
may occur  in any  part.   Now,  excepting  my glands, many of
which I could easily spare, I should prefer having it in my lungs
to any other part of my body; for I know that  I can live with
a  good deal less pulmonary tissue than nature has  given  me.
But  I cannot live with it in my brain, or my heart, or my ali-
mentary canal, of which  I have only. one.   So that if tubercle
is to exist at all, I really do not know that we should look upon
it as a misfortune when it occurs in the chest, as  it is safer there
than in most parts of the body.
   If then care bestOAved upon the lungs and special coddling of
them increases the danger of tubercular tendencies, as the above
arguments clearly show; and if, supposing that special medication
could keep tubercle out of the lungs in particular, no  advantage
is thus gained—to A\hat would I have you turn ?
   Leave the respiratory organs  alone,  and direct your thoughts 
304
PULMONARY CONSUMPTION.
to the organs of nutrition, the stomach and bowels, which will
receive with thankfulness and return with interest any care you
bestow upon them.
   It is truly by aid of the digestive viscera alone that consump-
tion can  be curable.    Medicines addressed to other parts may
be indirectly useful sometimes, but they more commonly impede
the recovery; whereas aid judiciously given in this quarter is
always beneficial and usually successful.
   The chest  is  the battle-field of  past conflict, the stomach the
ripening ground for new levies of life.
   Your aim  should  be to get the greatest  possible amount of
albuminous  food fully digested  and applied to the purpose of
the renewal of the body, at  the same  time  that  the renewing
agencies  are brought  to  their highest  state of efficiency.   In
this way a healthy cell-renewal takes the place of that  morbid
imperfect cell-renewal  which  appears in the shape of tubercular
matter.
   With this view I shun, as far as I can, all those "potent herbs
and baneful drugs" which may be classed together as "cough
medicines," meaning antimony, ipecacuanha, and squill especially.
I avoid also mercury, purgatives, and  neutral salts, which are
debilitants.  Where the heart is thin and weak, digitalis is some-
times useful, by regulating and calming its action; but as a rule
it is injurious, by reason of the nausea and loss of appetite which
it causes.
   The appetite should be the  great object of your  care.  You
will often find it sadly wanting;  and where that happens, the
mucous membrane of the stomach and  bowels should be braced
up  by quinine and  strychnine.  The  latter acts quickly,  and
may be added to the other medicines from time to time;  but the
former is most permanent in  its effects,  and should be begun at
once,  and continued  through  the whole process  of  medication,
till the appetite equals or exceeds that of a healthy person.
   Iron, again, you will find a most powerful ally.  The  increase
in the haematine of the blood which  follows its  use is all-im-
portant ; for thus you  supply to the tissues the true life-giving
medicine—red blood.  Begin iron in small doses, and gradually 
PULMONARY CONSUMPTION.             305
increase it till you have found the full quantity the patient can
take,  and then continue to administer rather less than  that, so
as to leave  room for an occasional  augmentation  according to
circumstances.  Where you give digitalis, make it a rule to  add
iron and sometimes strychnine to the dose, as you thus get  the
full advantage of the digitalis, and  shirk  some of its  possible
evils.   Iron  prevents  nausea,  and  strychnine co-operates  in
strengthening and regulating the action of the weakened heart
  When the repugnance to eating is extreme, adopt the plan  you
so often see used in these wards  with success, of giving milk in
small and very frequently repeated doses.  Nutrition has a habit
like that of arguing in a circle ; food creates the desire for food—
of course, by strengthening the digestive organs ; and thus, after
a few days of milk  diet, the  patients  will voluntarily ask for
meat, and  enjoy  as a  luxury that which a  short  time before
excited the greatest disgust.   If you  find the milk lie long in the
stomach and  produce heartburn or  acid eructations, add lime-
water or soda-water to it.  The first  is  the cheapest, the latter
the pleasantest.
   Cod-liver oil will also often, like milk, create an appetite.   But
as a rule, especially in private practice, it is well not to commence
it too soon; for the nastiness of the taste and feel is hard to get
over at first, and it is much easier to take it when the appetite
has begun to be renewed.   Then it is not felt as a hardship even
to begin, and  in a short time  patients will get really to like it.
And they will like it, not merely as reasonable men  like that
which does them good, but irrespectively of such knowledge they
Avill find it nice to the palate.  Thus children, who always  hate
being done  good  to, will still often take to their oil with gusto.
And as a proof that exalted reason has nothing to do with the
preference,  the  same thing has been  observed in brutes.   A
clerical friend of mine had a consumptive Skye terrier, which he
treated seeundem artem Avith cod-liver  oil.   At  first the poor
beastie abhorred it, and looked sad before and. after each dose ;
but in a short time he began to lick his lips after it, and if he  was
forgotten, would go and beg more canino at the door of the cup-
board where it was kept. 
306
PULMONARY CONSUMPTION.
  The best sort of cod-oil is the most agreeable, the clearest, the
sweetest, and  the  most  scentless—that, in fact, which is  thor-
oughly free from  extraneous  dirt.   The oil from the same fish,
formerly used by curriers, was sold for their use cheap and foul,
and  no doubt was quite good enough for manufacturing pur-
poses ; but it  must excite a very natural disgust in any one but
an Esquimaux or a Avhaler, I should think,  for it stinks like old
train-oil.  Its low price wholesale allows of certain firms spending
large sums in  widely advertising it  as a superior  form  of  drug;
but  I  strongly advise you never to practice  the "brown-oil"
(as the name runs); it is never beneficial where the pure oil fails,
and  it often and often makes the patient protest he will  on  no
consideration  take  it again.   The  mode of manufacture which
causes the difference of the " brown" and " pale" oil is described
in an article of the " Medico-Chirurgical Review" for January,
1856, and is quite enough to prevent any reader of delicate per-
ceptions ever  ordering or taking it again.
  The best plan is to give at  first  a teaspoonful, and afterward
two  teaspoonfuls thrice  a  day, floating on the quinine or iron
mixture  to which the patient has already become habituated.   I
think an ounce a day is  enough to administer  as the  full dose,
and  need not  be exceeded.  If the patient absorbs all that, you
may be quite  satisfied; and more will be apt to turn rancid, and
cause  indigestion—the worst foe of the  phthisical.  The best
time to take it is a tthe greatest  distance from meals, as  thus  a
sort of  additional meal is gained, and food and physic are not
confused ;  but if  your patient likes any  other time  better, on
account of taste or business, do not stand in the way of his fancy.
   The effects of cod-liver oil  become less and less a marvel, the
more  we know of physiology.  The  instinctive desire shoAvn by
all nations for an  oleaginous  diet,  and their association of sub-
stances of this nature with, proverbial ideas of happiness in all
ages, show  the value of a certain amount  of it to man's comfort.
The "butter and  honey" of the  prophet, used as a phrase for
royal food, and the constant reference in the Bible to oil as  a
luxury (though it could have been no rarity in '■ a land of oil-
olive")—these are sufficient  to prove its  estimation among the 
PULMONARY CONSUMPTION.
307
Hebrews.  The Hindo  laborer, when  he devours his gallon of
rice for a meal, will spend all the pice he can get on the clarified
butter of the country ; and " as good as ghee !"  is his expression
of unqualified admiration.   It was a mistake in Baron Liebig to
state that oily foods are disgustful to natives of hot climates.  All
races of men require them and seek after them ;  and the taste of
the Esquimaux, so often quoted, depends mainly on the abundant
supply of the article which the sea places at his  disposal, coupled
with a scantiness of other provisions.  Throughout mankind there
is  an  instinctive appreciation of the importance  of  this aliment,
independent of accidental differences of  nation or locality.   It
seems felt to be, as  science shows that it really is, a necessary
material for the renewal  of the tissues, and the  desire  for it
becomes synonymous with a desire for augmentedMife.
   An easily assimilated oil  comes, in fact,  into the short list of
directly life-giving articles in the pharmacopoeia;  for it is itself
the material by Avhich life is manifested.   Hence, under its use,
beneficial influences are exerted throughout the  whole body ;  old
wounds and sores heal up ;  the harsh, wrinkled skin regains the
beauty of youth ;  debilitating discharges cease,  at the same time
that the normal secretions are  more  copious;  the mucous mem-
branes  become  clear and moist, and are no longer loaded with
sickly epithelium;  the pulse, too, becomes  firmer and  slower—
that  is to  say, more powerful, for abnormal quickness here is
always a proof  of deficient vitality.   Such are  the effects, per-
fectly consistent with physiology, of supplying a  sufficiency of
molecular base for interstitial growth.
   The addition of a small  quantity of alcohol  will often enable
the oil to  be  absorbed  more  readily.  This is a principle well
understood by  growers  of live stock for prizes at agricultural
shows, who, by the addition of fermenting grains or spirits to the
animal's food, often fatten it more quickly.   The addition there-
fore of Avine, Avhisky, tincture  of orange-peel,  or  of any other
harmless bitter to the medicine, is rational, and may be  freely
conceded, if the patient finds it agreeable.
   The liberal use of  it  as a remedy or preventive is a different
question. 
308
PULMONARY CONSUMPTION.
   In my opinion alcohol is not only useless but injurious to the
consumptive, excepting for its beneficial action upon the mucous
membranes.  It arrests and obstructs the vigor  of  vital action;
by it growth is  checked, as  we see practiced  in animals  kept
small for artificial  purposes, and in men who  have from youth
habitually indulged in ardent spirits.  Under its  use renewal
goes on slower, as we know by the diminished excretion of urea,
water, bile, &c. (see Dr. Booker's  " Experiments,"  and the con-
cluding lecture  in  this volume),  and we can hardly therefore
reckon it advantageous where the  chronic  renewal of  vital
powers is our primary object.
   But you  may ask how are  to be explained cases like the fol-
lowing, in which to all appearance alcohol seems the preservative
of life.      •
   J. P.,  a  butcher, remarkably strong  and stout,  Avas first  at-
tended by me for delirium  tremens, which  he had suffered from.
several times before, and  was ahvays well in  the  interval;  an
attempt to becomea teetotaller was immediately followed by gal-
loping consumption.
   J. A.,  a  brewer, came to me last year  about indigestion and
pimples (acne rosacea) on his nose and face; I urged him to give
up brandy-drinking before breakfast  and between meals; and I
find now a  developed vomica in his lungs, of which previously
there  was no evidence.
   You may cite instances such  as these, and  attribute  the
vomicae to  the  omission of alcohol,  which therefore you may
represent as a  direct preservative.   I  think you would  be
 wrong.
   I confess I do not take  such cases as mere  coincidences,  but
 I explain them in a way by no means corroborative of the idea
 that spirit-drinking keeps  off consumption.  I think that alcohol
 acts as an anaesthetic, and prevents the system from resenting
 the presence of the tubercles; then, when it is left off, they act
 with doubly deleterious effect on  the body, unprepared by their
 gradual increase to bear them as it were  by habit.  The  quon-
 dam tipler is then  in the same relative  position as  one in whom
 there is a large sudden  development of the morbid  matter; 
PULMONARY CONSUMPTION.
309
for  the existence  of the morbid matter unexpectedly becomes
known to the system, and its ravages suddenly taken notice of.
Thus instead of really  checking tubercular disease,  the alcohol
has acted merely as a mask, behind which  the evil has gone on
unawares.
  What  should you do in such cases as those above related?
Should you advise a return to drinking habits ?  I think  not;
for though the symptoms are somewhat lightened thereby, this is
merely a misty  cloud of  anaesthesia which stands between the
patient and his pain, and  I doubt  if life is prolonged.  More-
over, it is possible to adopt measures as immediately effectual,.
while certainly offering more  prospective  advantages.   In the
last case which I  quoted, after a certain  struggle  with bron-
chitis, night-sweats, and  emaciation, weight  and strength are
being gained under cod-liver  oil  and quinine,  although the
allowance of alcohol is reduced to that of a temperate man.  So
to such remedies I advise you to trust in all like cases.   Here,
as ever,  the appetite must be your index;  the stomach must be
the viscus whose health is to be your care.
   In advising foreign travel, again, take the stomach for a guide.
At the dreary time of the English year, when  your patients can-
not get enough light and  exercise to give  them an appetite, let
them seek those sunny climes where the winters are the holidays,
the joyous seasons for out-of-door  employment.   Madeira is the
best.  The next  is that  lovely Mediterranean  shore recently
annexed to  France, from  Cannes  to Mentone;  and after that
comes a  long list of localities highly praised by their inhabitants,
but with a more uncertain climate.
   Instead of naming one  place after another, and thus  risking
offense to a large number accidentally  omitted, I prefer  to give
you a simple common sense rule  by which you may help your
patients to make the best use  of the Avinter season.
   In choosing a home  for  your consumptive, do  not mind the
average  height of the  thermometer, or its variations;  do not
trouble yourself about the mean rainfall; do not be  scientific at
 all, but  find out from  somebody's journal  how many days were
fine enough  to go out forenoon  and afternoon,—that is the test
you require, and by that you may be confidently guided. 
310             PULMONARY CONSUMPTION.

  Do not suppose all is done when you have  chosen a climate.
Your responsibility is by no means ended; you must be careful
in enforcing a right use of the climate.   If your patients, from
distaste of foreign habits, from pining after home, or other causes,
take to moping in-doors, or find themselves overwearied on going
out, the sooner they return to  England the  better.  They are
getting no good, and they are running the risk of diarrhoea,  low
spirits, hysteria—or still worse, of failing so much, that they
cannot return home, and  must remain to die, " by strangers
honored, and by strangers mourned."
  But if they write you word  that they are boating, riding,
swimming, sketching, catching lions in Algeria, or butterflies in
Madeira, you may congratulate yourself on having added perhaps
months, perhaps years, perhaps lustra, to their lives.
  Next to the stomach, the boAvels claim  your main care.  Of
course, during this course of lectures, in which I  am impressing
upon you the principles of restorative medicine, it is needless to
say that  in  pulmonary consumption you  are to  shun artificial
purgatives.  But I had better remind you of the importance of
being on your guard against natural diarrhoea.  Do not allow it
to go on an hour longer than  you can help.  The best remedies
are sulphate of copper, haematoxylum, and opium.   Chalk mix-
ture will sometimes act well; but, if it fail, you have lost valuable
time; so, if you follow custom  in  beginning with it, do not be
obstinate in the  continuance of your remedy.   The  sulphate of
copper may be begun in doses of one-fourth of a grain, and in-
creased up  to two grains, if required to  be persisted in.   The
haematoxylum may be given as an extract from four  grains up to
any amount required, but should not be  mixed with the copper,
or you produce an ink. If you give both, let there be three hours'
interval between them.
  You see almost daily cases of consumptive diarrhoea checked
sometimes for a season, sometimes even permanently in patients
whose disease is  too extensive for recovery.  This is doubtless a
great point gained, and some time added to life.  But more than
this, I believe that the tendency to deposit tubercle also is  some-
times arrested by  arresting the  bowel-complaint.   Just  after 
PULMONARY CONSUMPTION.
311
Lady-day 1861, Miss Harriet B., aged thirty, whose " father and
mother had both died of decline,"  Avas placed under my care by
Dr. Buckell,  of Chichester.  She  had evidence of a small focus
of tubercle in the apex of the left lung, producing pain, dullness,
and crepitation (from the partial condensation of the lung round
it) but no marked pulmonary ailment. I thought that the quantity
of tubercle was slowly increasing from Aveek to week.  What she
complained of, however,  was  emacfetion and diarrhoea,  ac-
companied by the passage of pus and sometimes streaks of blood
in the mucous  faeces.   She was soon relieved of this  by appro-
priate remedies ;  and with a store of haematoxylum and  copper,
was able to go on a long summer visit to some friends.   I heard
of her as going on well, and did not expect to see  her again, or
to make  her case available for science.   But  as  she returned
through London in September,  proclaiming herself quite well and
stout, I had an opportunity of examining her chest again; and
much to  my delight was  it that  I  did  so.   To my surprise, I
could detect no disease at all in the lung;  so that, instead of
increasing, as  I had feared, the pulmonary tubercle had become
dormant, solely by the  cure of the bowel-complaint.  Not  all
cases do  as  well as this, but still what  has since  befallen may
befall again, and it is the surest road to success to hope for it.

             (Clinical, St. Mary's,  June 7, 1862.)

   In some cases of consumption there is a considerable amount
of cachexia, the gums become spongy, or AvhitloAvs form  on the
fingers, or there are various kinds of skin diseases.   This hap-
pens usually in consequence of low  living, damp, and depression
of mind.
   There  is  now in Victoria Ward a girl  of  sixteen, Avho was
transferred from a surgical ward.   She  was at  first in a deplor-
 able  condition; she had been admitted for impetigo,* with which
her cheeks and nose were covered,  while the pads  of  her finger-
   * Impetigo = " a superficial formation, consisting mainly of pus from the de-
 nuded connective tissue of the corium, without external exciting causes."
   Eczema = " the same of serum." 
312
PULMONARY CONSUMPTION.
tips and nails were sore  and purulent from the same eruption.
Yet the impetigo did not account for  colliquative night-sweats,
extreme emaciation, and weakness  so  great that she could not
raise  herself in bed :  these symptoms Avere explained by dullness
at the apices of the lungs and localized rales, indicative of tuber-
cular condensation.   Some  thought there was a vomica at one
apex, on account of the  cracked-pot sound on percussion, but it
wras a doubtful point—th^cracked-pot sound  is a very fallacious
sign.   She did not behave as if there were a vomica, for she has
been gaining strength and flesh daily up to this time.  My reason
for recalling this case to you is to notice that, in spite of  tonics
and high feeding, before she came under  my care she had been
getting weaker and weaker. The  only change I made was to give
Avith her tonic mixture half a drachm of chlorate of potash daily
in  some cod-liver oil—I confess with but little  hope that she
should revive.   I was never so  struck before by  the  directly
vitalizing force of this salt upon connective tissue. In a fortnight
her " flesh came again like unto the flesh of a little child,"  as the
Hebrew  historian beautifully expresses it; the  clear  doll-like
complexion  of face and  the pink babyish finger-tips are very
pretty.   And I  have no  doubt that  a  like quickening has gone
on in the skins of the inside—the mucous membranes—so much
strength and appetite has she gained.
  This case  shows  you when to give chlorate of potash in con-
sumption with hope of profit.   And I  am glad you have the op-
portunity of seeing  this, because a  short time ago chlorate of
potash blazed forth as a  cure for  phthisis  in general;  and  if you
have tried and* found  it wanting in some ordinary instance, you
might be tempted to treat with undeserved contempt a medicine
of really great service in proper cases.

          (Clinical, St.  Mary's,  February 6,  1864.)

  On my last admission  day, January 29, there were received
under my care two very distressing cases  of consumption.  Both
were in the extremest state  of emaciation  and exhaustion  from
suppurating vomicae in the lungs, and so far presented a spectacle 
PULMONARY CONSUMPTION.
313
which is sadly familiar to the medical man.   In addition, the
Avoman  was purple in the  lips  and face from intercurrent pneu-
monia, the man was in a cold sweat and had diarrhoea.   But the
symptom  exhibited  by both  in common, whicht leads me to
mention the cases to-day,  is one not quite so usual as these, yet
sufficiently usual  to  make it of practical importance.  I allude
to delirium.   The  man got temporarily somewhat better  of  it
after a  few days' residence in  the hospital, so  that  his  mind
Avaiidered only at night, but the woman has been disturbing the
ward Avith her continuous ravings, has been very violent, exert-
ing her small remains of  strength to throw the beef-tea at the
nurse.   She uses such abominable  language that it has  become
necessary to place her in  a room by herself.
   Delirium at the latter end of  exhaustive diseases  is a sign of
the participation  of  the nervous tissue in the destruction which
is going on among all the  tissues of the body.   It answers to the
convulsions and obtuseness of  sense, which M.  Chossat observed
in animals starved  to death.*  The  nervous system, being the
ultimum morie.ns  of  the body,  suffers  last, but does suffer in the
end.
   This  delirium  is  commonly accompanied by deafness, and  is
so accompanied in the two cases before us.  I cannot say I have
been able  to trace  a corresponding deficiency in the organs of
sight, but certainly the taste and general sensation are deficient.
The pain in the chest and suffocation, which  the poor woman
complained of on admission, are denied  now that the  raving  is
worse,  and she does  not appear to know food from medicine.
  The  immediate cause,  to  which  I have most usually seen
occasion to attribute it, has been unwonted and excessive bodily
exertion, at a time when  extreme  rest constitutes the only pos-
sible means of economizing the vital power.   I  have  no doubt
but what it Avas  the being brought out of their beds to the hos-
pital, Avhich made these patients  so much worse  directly on  their
arrival,  and which threatens to shorten their lives.
  In those who die, no morbid change in  the nerve substance is
visible  after death, though the symptoms during life generally
              * See before, pages 45-49 of this volume.
       21 
314
PULMONARY CONSUMPTION.
cause it to be carefully looked for.  This fact is familiar enough
to those who have the inestimable  pathological privileges of  a
public institution: but  I think it is often unknown to others;
and consequently the natural connection in their minds between
the increase of symptoms and the spread of tubercle in consump-
tive cases is  apt to lead to their assigning the delirium we are
considering  to a development  of tubercle in the brain.   Two
months ago an old gentleman in the last stage of senile phthisis
was brought up from the country by his family, contrary to the
excellent advice of their  own medical man, to obtain " a London
opinion."  I believe they had already taken him to one physician
previously, when he  arrived, .excited in mind and worn out in
body, in my study. I felt much relieved when a glass of Madeira
enabled him  to  be got  back to  the carriage, for  I should not
have been much  surprised  at  his dying in my house;  and  you
may easily imagine that I rebuked the folly of his friends in
strong language.  However, he did get home.   But very soon
he became delirious  and raving,  as I learned by letter; and  I
found that this delirium was  attributed by those who  attended
him in the country to tuberculosis of the  brain.   The idea is  a
natural one, but  it might have injured  the patient had  it influ-
enced the treatment.   His death in delirium was indubitably due
to the almost superstitious folly of his friends in bringing him up
to London.
   As to treatment, opium, wine, and continuous nutriment seem
indicated, and to be  of some use; but such cases of extreme dis-
ease are not  usefully illustrative  of medical regimen.   The man
has been  better since  he  began cod-liver oil and  quinine, and
perhaps the  nourishingf thus the nervous tissue, if the food can
be assimilated, is the best application of restorative principles.


           (Clinical, St. Mary's, May 10, 1862, £c.)
          ******
   A  few words as to specifics for consumption.  Some years ago,
Dr. John Hastings proclaimed "naphtha" as an unerring cure.
Some people tried it, and  soon learned that it Avas applicable  at 
                 PULMONARY CONSUMPTION.             315

all only in cases where alcohol was beneficial, and even to such
patients  they found that  the purer and wholesomer  forms  of
alcohol in daily use were both more useful and more acceptable.
All the advantages of the  remedy had been  in the hands of the
public in a pleasanter form centuries  ago.   Determined at last
to try a virgin substance—
                    —" integros accedere fontes
                  Atque haurire "—
the same gentleman has  lately announced  that  serpents' dung
now succeeds to the throne where naphtha lately reigned.  Our
rude  forefathers  in  art administered  many curious  things; the
ashes of toads, the urine of boars, live  spiders, human liver,
human ordure, the skull of a murdered man, the blood  of the
patient's father,  and other gatherings from witches' caldrons,
are  in their lengthy  pharmacopoeias,  and are  many of them
stored in that interesting collection of ancient articles of materia
medica at the College of Physicians.  Their  intention was  to
drive  out the devil by disgusting him.   But I do not think that
they ever  hit upon the bright thought of using the very dung
of the accursed type of evil, that as he indignantly  "goes out,"
he may say:
               " That eagle's fate and mine are one,
                  Who in the shaft that made him die
                 Beheld a feather of his own
                  Wherewith he wont to soar so high."
I really  believe this expansion of the idea to be quite original.
   Good coprologists tell  us  that  the united excreta of snakes
consist mainly of lithate of ammonia—an unattractive substance,
which persons familiar with physiology believe to be harmless.
I rested satisfied with that belief till I heard Dr.  Hastings,
when arraigned before a  public court  of justice  for avaricious
 malpraxis in knowingly  administering inert remedies, depose
 positively on oath that he  held what he administered to be a
 powerful physiological agent.   His powerful physiological agent
 was  made by dissolving (i.e. destroying) sixteen  grains of boa
 constrictor's ejecta  in a gallon of Avater by the  addition of bro-
 mine.  Such a solemn affirmation was not to be lightly treated, 
316
PULMONARY CONSUMPTION.
and after that I could  not feel justified in believing faeces to be
useless till  I had  tried them.   I  procured forthwith a  sample
from the secretary of  the Zoological Society, and caused to be
made a quantity of the so-called "solution" under the name of
" mistura pythonis," and you have seen me order it pretty often
since in cases where, no drugs being required for a time, I felt
myself justified  in so  doing.    But instead  of half an ounce,
which was said by the  witness  to be so active, I have given two
ounces three times a day.  You have seen that its effects are
exactly the same as those of so much ditch-water.
  Such  is the fate of specifics for  phthisis—ex uno disce omnes
—and  lucky is  the public  if all  specifics are  as innocent as
snakes' dung.
  But do not let  us part without a  moral, or be satisfied with
merely laughing at a delusion.  Remember, you are acting no
better than the vaunters of vain specifics Avhen you vaguely pre-
scribe one  thing or another, even of known or acknowledged
power, because you have heard of  its being " good for consump-
tion."  The  time  which is lost  in trying  this  and trying that
remedy is lost  forever.   You have no  warrant  for supposing
that  there  can be any specific  for that complex morbid state
which causes phthisis ;  you  have no warrant for substituting a
vague search after such specifics for rational treatment; nor can
you  justify yourselves  for standing in the way  of  the  patient
getting his  chance of  a  renewal of his  waning life by the un-
sparing use  of restorative  agents.
  The  proper persons upon whom to  try the  effects  of  new
remedies in  the first place  are not the sick,  but the healthy or
nearly healthy.   If no  obAdous results follow the use  of  full
doses by  yourself or another free from present illness, you may
be pretty certain the same will  be the case with  your patients.
There are always  to be found  in  hospitals specimens of malin-
gerers  and "old soldiers," and  convalescents, upon whom it is
quite safe to try these  experiments under proper supervision, so
as to satisfy any doubts  you may have.  Or if you have no doubts
to begin with, you will thus gain a  right  to make the shortest
and most telling answer to inquiries,  " How does such and such
a cure succeed ?"   " I've tried it and it is useless." 
                PULMONARY CONSUMPTION.            317

  You should make it a rule absolute, that objective phenomena
rather  than subjective are to be taken as tests, and that all things
are to  be " delivered in number and weight," according to the
sage advice of the Son of Sirach.   For instance, if you  were
examining  the action  of  quinine, the  changes of temperature
must be estimated by the  thermometer, the changes of urine in
the laboratory, the action on the skin from the amount of per-
spiration.   And you  must  not waste time  by performing as
tests experiments which do not admit of physical or arithmetical
proof. 
LECTURE  XXIV.
              THORACIC  ANEURISM.

First case of aneurism, probably of the innominata—Reasons for
     diagnosis—Aortic -valvular murmur accounted for—Prob-
     able abnormal position  of  artery—Prognosis unfavorable
     —Second case—Aneurism of aorta and  its  treatment—
     Blood-letting and low diet—Pathology of aneurism—Object
     of treatment—Favorable prognosis— Two cases of favorable
     result of  treatment—Fatal case of aortic  aneurism—Rup-
     ture of sac into the pleura in a  healthy working  man—
     Length of time  a patient may live with a ruptured aorta an
     encouragement to treatment—Case of aneurism compressing
     the trachea, producing congestion of the lungs, and so fatal
     —Actions of bleeding, leeching, and digitalis—Action of
     digitalis  on other  involuntary fibers  as  on the uterus in
     menorrhagia, and on the bladder in incontinence of urine.

           (Clinical, St. Mary's, January 5,  1861.)

  I take the  opportunity of having two patients in  the wards
affected with aneurism of that sort which  alone comes  under a
physician's case, viz., thoracic  aneurism, to call your attention
to the medical aspects of the lesion.
  The board admitted, yesterday, into Victoria Ward a young
woman of twenty-two, who  has been a patient of mine in the
Lock Hospital.   She has had syphilis on and off ever since the
age of fourteen; and though the eruptions and sores  are now
healed,  her  health   is  much broken,  and she is  stunted  and
weakly.   She applies at St. Mary's not  for her old complaint,
but on account of palpitations, and pain across the front of the 
                   THORACIC  ANEURISM.                319

chest, which she states  that  she  has felt for three years, but
which lately had  got much worse.  She also frequently suffers
from giddiness and fainting; and last Sunday was carried out of
chapel in a  dead swoon.  A message has just come to say that
on account  of one of these attacks she is unable to come down to
the theater, as I bade her.
  She has often a  difficulty in swallowing food,  especially solid
food.
  She states that she has very partial use of the left arm ; and,
on examination, it is smaller  in girth to  a marked degree, and
the muscles are flabbier than  on the right side.   No pulse can
be felt at the left wrist, nor at the bend of the elbow, nor on the
inner side of the biceps.   The axillary artery can be felt beating
very feebly  above the collar-bone.
  In a marked contrast to this stands the right side. The pulse
at the wrist is  natural, and above the collar-bone may be per-
ceived a strong pulsation, and at  the origin of and for an inch
or more along the carotid artery a very distinct  thrill.  In the
holloAV above the sternum the same pulsation is even stronger,
and throws  forward the  trachea, when you  press upon it with
your finger.
  With a stethoscope a purring whiz is heard in the same situ-
ation  as the pulsation is felt.   A  murmur is  heard also  at the
upper part of the  sternum, and is  particularly loud  on the level
of the fourth costal cartilage, where it sometimes- has a musical
tone.   There is no dullness on percussion beneath the clavicle.
  My diagnosis of this case is, that she has an aneurism  of the
ascending aorta at the part Avhere the innominata  is given off,
and that this lesion involves  the innominata  and the origin  of
the carotid  artery.   I  do not think it an enlargement  of the
innominata alone,  because of its being situated  so much at the
back of the trachea as to throw the tube fonvard by its pulsations
and also  to press upon the oesophagus, and interfere with deglu-
tition.   Besides, in the only case I have seen during life of pure
aneurism of the  innominata,  proved  to be so after death, the
tumor Avas smaller  and rounder, and  pointed  more distinctly  in
the supra-clavicular holloAV. 
320
THORACIC ANEURISM.
   You have here nearly all the signs of aneurism of  the  aorta
—(1) pulsation; (2) whiz; (3) impaired  deglutition; and  (4)
impeded circulation.
   But you may say there is the same whiz  at the aortic valves.
What is  the cause of that ?  It is not, I think, produced directly
by aortic aneurism, but  it is produced by the  same original
cause.   Aneurism  forms  because there  is  a friability or loss  of
elasticity in the coats  of the  vessel, due generally to  a  deposit
of white  opaque matter and  to a partial degeneration of them.
What is  more likely than the  existence of the  same disease  in
the aortic valves?
   Now I come to  the  puzzling part of  the  case.  You will ob-
serve that the right axillary artery  is quite free ;  there is  quite
an  open passage  through it  to supply the radial at  the  right
wrist.  Yet it is in this supra-clavicular space that Ave have the
pulsation and  whiz; whereas  the  left  axillary, though it has
normally nothing  to do  with the  innominata,  is  not supplied
with blood, and the left arm is atrophied.
   I can account for this in one way, which I might as well detail,
though it is more a matter of  curiosity than of business.   (I  do
not bind you.  to accept  the interpretation ; and if any of you
fresh from the anatomy  school can suggest  a better,  I  shall
receive it with pleasure.)  In  many beasts, in the ruminants and
solidungula, and  in some pachydermata—as for instance the
hog—the aorta divides into  two branches, the ascending giving
off the two subclavians and  the two carotids, while  the other
turns backward and becomes the descending aorta.  On this has
been founded, by the earlier anatomists, the popular division of the
aorta into "ascending" and "descending," a division  awkward
in the human species, but exceedingly applicable to the domestic
animals whence the ancient men of science learnt their  anatomy.
It is by no means impossible that the patient before us may have
a malformation, Avhich is an approach to this loAA'er  condition of
animal life—a malformation,  of which specimens may be  seen in
many museums ; namely, where the left subclavian, as well  as
the right, is given  off by  the  innominata, and has to cross over
the arch  of the aorta to get to its work; and in  this crossing  it 
THORACIC ANEURISxM.                321
 would be interfered with by the tumor of the top of the arch.  I
 cannot othenvise unravel the enigma, as the tumor is  not  large
 enough to obstruct  a normal left subclavian.   As an  argument
 in support of the explanation, I may mention that  the patient
 has a congenital deficiency of the reproductive organs,  curious in
 a social point of view to find in a person of her degrading habits,
 for she is a common prostitute.   She has no uterus, the vagina
 ending in a short cul-de-sac.  A  malformation in one part is a
 probable argument for it in  another.
   This aneurism presents several  points which lead me to pro-
 nounce an unfavorable prognosis.   First.  It is in the ascending
 part of the aorta.   Now, you will find that almost all aneurisms
 of the  ascending  aorta  are rather dilatations  than aneurismal
 sacs.   They have  no sharp edge opening  out  suddenly into a
 distinct bag.  And  these dilatations  are more difficult of cure
 than  the  sharp-edged  sacs, because there is  a clear stream
 through, and  no back current, so  that you cannot  get clots to
 form in them.   Secondly. The absence of clots is confirmed by
 the strength of  the thrill.   Thirdly.  The supply of blood to the
 brain is seriously diminished, as is shoAvn  by her fainting fits.
 Fourthly.  The impeded  deglutition and the suspected malforma-
 tion are discouraging.   Fifthly.  She  is a poor anaemic woman,
 reduced by poverty, syphilis, and mercury to a  very low state.
 She will not bear lowering treatment,  I am sure.   Sixthly. She
 is said to have,  like  most of her unhappy class, a violent temper;
 so it will be difficult to detain her  in the hospital, or  to keep her
 circulation quiet while there.*  It is  doubtful how far  we  shall
 be able to apply the treatment suitable for the disease,  and how
 far  it will prosper, if applied.  What  that treatment is, I  shall
 best tell you after the next case.
  Henry E., a negro, aged twenty-one, came under my care two
 months ago—viz., on November 9.   He is now a  commercial
 traveler, but during the  Crimean war Avas a sailor in a transport,

  * Very soon afterward it was necessary to turn her out of the hospital for
gross misconduct, and T have not been able to find what became of her. As she
is corporeally rather a remarkable person, perhaps this notice may bring the
desired information. 
322
THORACIC ANEURISM.
during which time he got a severe blow on the back of the neck
from a " derrick."   He says he never had cough or shortness of
breath, and was always " strong in  the chest," till  he began to
feel a pain  there in August, especially between the left nipple
and the  collar-bone.   This  pain  increased gradually,  though
intermittingly.  Three days before  we saw him, while he was at
his tea at Windsor,  it suddenly increased very much,  and he
says he felt "as if something was going up and doAvn from his
heart to his arm."   He fell down,  was struck dumb, and found
that he had lost the use of the left arm.  On his  admission, it
was found that the pulse in that  wrist w-as much weaker  than in
the right,  and there was  loss of  power, though  not absolute
paralysis  throughout  the  limb.    The  throat  was  externally
swelled on the left  side, and  the  carotid could scarcely be felt.
There  was  considerable swelling of  the whole mammary  and
infra-clavicular regions, in  which latter also there could  be dis-
tinctly  made out  comparative  dullness  on  percussion.   This
dullness was more  distinct on the  third rib  than  immediately
beneath the  collar-bone.   On applying  the  stethoscope to the
third rib, a  distant whizzing murmur could be heard, which  in-
creased in intensity in nearing the shoulder, and was less loud
toward the  sternum.  There was no  pulsating tumor, and the
lung-sounds were natural, except perhaps rather more bronchial
on the left side than on the right.  There was a breathing pul-
sation in the left  jugular vein.
   The signs of aneurism were not so distinct as in  the last case,
because it did not come so near  the surface.   I  am inclined to
think it is toward the back of the descending part  of the arch;
but wherever its  exact locality may be, it evidently interfered
with both arteries, veins, and nerves, which supply the arm, in-
tercepting the pulse-wave and the  nervous current, and  causing
anasarcous tumefaction from it's obstruction to the return of blood
by the veins.
   Local treatment was desirable, and leeches were applied several
times beneath the clavicle.  He wrould have been bled also; but
five days after admission he fortunately caught scarlet-fever from
a neighboring patient, and it struck me that  this might  prove  a 
                    THORACIC ANEURISM.                323

substitute for venesection;  for it gave us a plea for keeping him a
close prisoner in bed, and putting him on very low diet.  This
plan Avas the easier carried out from his being, like most civilized
Africans, of a mild tractable disposition, and it has been pursued
steadily up to the present time.   On  December  1, it is noted by
the clinical clerk that he had recovered power over the arm, and
that the pulses appeared nearly equal.  He has continued the
complete rest, and has taken prussic  acid  and digitalis.   There
is now no difference to  be  detected between  the radials, and he
has regained complete use of the  arm;  he describes himself  as
quite well enough to be an out-patient, and finds a bandage Avhich
he wears across the chest sufficient to relieve the occasional pains.
There is a murmur still in the infra-clavicular region; but all im-
pediment to circulation occasioned by the aneurism has ceased.
  The treatment which has been  adopted'here  is an exemplifi-
cation of the  principles which  I have taught in the systematic
lectures on the principles of medicine, and I  must refer  you to
those lectures for an historical account of the  adoption of this
practice in the seventeenth century by Valsalva.  It is a strict
following up of that which nature  adopts in  all aneurisms that
heal spontaneously.   In them  you find  a fibrinous clot formed,
and the sac shrunken up from lack of stream passing through  it.
Here  we have tried to make the  blood likeAvise form fibrinous
clots, by bringing it into that fibrinous state which loss of blood,
anaemia, and low  diet induce; and we  have tried to keep the
blood-stream as calm as possible by rest in the horizontal posture.
  The pathology of aneurism shows it to us as a local deficiency
of life in a hollow organ,  a deficiency of vital  elasticity, which
has let this hollow organ yield  to the continuous pressure of the
blood-stream.   Doubtless if we could at first have renewed this
vital elasticity, suclj would have been the legitimate aim of treat-
ment, and such would be the course pursued by a rational phy-
sician.  But here the mischief is  already done, the vessel has
dilated into an uncontractile sac and is beyond the reach of any
of the powers of life.  The object now must be to restore as much
as possible the original area of the vessel, and  to reinforce the
Aveakened walls by an  artificial clot;  so that though we cannot 
324
THORACIC ANEURISM.
 have a complete artery, we may have as good a substitute for it
 as circumstances will allow.
    There was much in favor of this patient from the outset: the
 aneurism was in the descending aorta; there was no  thrill; his
 general health was good;  and he is an  obedient quiet creature,
 very different from the ill-conditioned little woman last discussed.'
 At all events he has done very well; and I should urge upon you
 to make the carrying out of this principle of treatment the goal
 of your wishes in thoracic aneurism.  You will find patients very
 often rebel, but do your best; and if you attain not success, you
 will at any rate deserve it.
    I like in general to bleed the patients affected with  aneurisms
 from time to time, and should have employed that mode of treat-
 ment if this man had not had the scarlet-fever. A former patient
 of Dr. Sibson's,  noAv an out-patient, testifies from  his own ob-
 servation to the superiority of venesection over leeches in its
 calmative influence over an aortic  aneurism Avhich he  has  long
 had, and on which he is very observant to the effect of remedies.
 But I haAre heard an opposite  opinion given by patients.
   I said you will deserve success, and sometimes you will get it.
 I  kept a stone-mason in this  hospital under the bleeding and
 starving treatment for five weeks.  He had come in with a pulsat-
 ing tumor and aneurismal whiz under the left scapula, with severe
 pain in the floating ribs, which  some thought were being absorbed.
 At the end of the five weeks he rebelled,  and our relation as phy-
 sician  and patient was at an end;  but the  pulsation had disap-
 peared, and the whiz was scarcely to be heard; and I had reason,
 therefore, to think the aneurism in a fair way to be cured.
   Even  in  cases  where the treatment cannot be carried out a
 Voutrance, good may be done  by an approach to it.  In 1851, a
 lady was sent to  me by a surgeon in the country, to consult me
 about increasing corpulence and dyspnoea.  In investigating the
 cause of dyspnoea, I found a pulsation and an obscure whiz under
 the left  clavicle,  accompanied by deficiency of pulse in the left
 wrist.  I was satisfied that there Avas aneurism either of the  sub-
 clavian or of the  aorta at the origin of that branch.  But bleed-
ing was  undesirable, because she was so fat.  I have often told 
                    THORACIC  ANEURISM.                325

 you how badly obese people bear bleeding.  Moreover, she was
 sixty years of age.  But, as she Avas a sensible woman, I managed
 to gain her confidence, and starved her for several weeks, giving
 her at the same time drachm doses of liquor potassae three times
 a day.   The effect was a reduction of her corpulence, a diminu-
 tion of the pulsation in the tumor, and greater freedom of breath-
 ing.  I did not see her from 1851 till 1856, when, being in Lon-
 don, she called to show herself, saying how well she was. The pulse
 in the radial artery had not returned; but there was no beating
 in the tumor, and only a sort of roughness in. the sound  of the
 artery.  She felt confident  herself of the good effect of the starv-
 ing treatment.
   I have taken the  opportunity of  your having two patients
 together under your eye to bring the subject  of  aneurism  before
 you, because of late the objections urged  against venesection in
 excess and in improper cases have produced a fashion of decry-
 ing its use altogether, and especially in thoracic aneurism.  Bleed-
 ing and starving, it is urged, induce  debility and anaemia; that
 is to say, in physiological language, they  lower  the force of the
 heart, and they cause a comparative excess of fibrin over  blood-
 disks in the blood.  These are both steps toward the mode adopted
 in nature to effect a  cure of aneurism, and, perhaps, of some
 other diseases also.  So that, I contend, not merely is it the best
 mode, but the  only honest mode of treating aneurism  of the
 trunk-vessels; because it is the only one we at present know con-
 sonant to reason and  experience.

          (Clinical, St. Mary's, February 20, 1863.)

   Thomas W., aged thirty-nine, a decorative painter, had always
 enjoyed robust health till  the 4th of this month, when he was
 standing on a ladder graining a  shop-front.  Without any  warn-
 ing or previous feeling of illness he suddenly  lost his senses and
 fell down.  On coming to himself after a few minutes he  found
he was  not paralyzed in any part, but had severe  pain  in  the
side.  This he  attributed to  the fall, and thought that  he had
broken a rib. No fracture  of the bones however  could be found, 
326                THORACIC ANEURISM.

and the pain  in  the  side appears to have been treated as  for
pleurisy caused by the injury, the most natural diagnosis under
the circumstances.  On his admission to the hospital on the 11th,
a week after the  accident, the whole of the left side  of the chest
was dull on percussion before  and behind, and there was entire
absence of breathing except in the  two upper inches next  the
collar-bone, where  it was bronchial, the sough of expiration
being very prolonged.  There  was no pulsation or heart sounds
perceptible  in the  cardiac region, the organ being  pushed over
to the right side  beyond the median  line.   A blister was applied
to the left side, and on the 14th the heart  was much nearer to
its natural place  than before, and the breathing in the upper lobe
of the left  lung  more normal.   He  said he had less difficulty in
respiration, and  no pain in the  side.   I  still continued to hold
the original diagnosis, and supposed the  pleuritic fluid to be in
course of absorption.
   He continued  going on well till the  night of the 15th, when
he suddenly jumped up, exclaiming that he was dying, put his
hand  to  his  side,  fell back  deadly pale, and  soon  ceased to
breathe.
   The post-mortem examination  has explained the mystery. You
 see here  in the  descending portion of the  thoracic aorta, just
 above the  diaphragm, the sac of an aneurism large  enough to
 hold  a man's  fist, out of the left side of which a smaller sac, about
 as big as a chestnut, protrudes toward  the left pleura.  And in
 this smaller sac  there is a rent a quarter of an inch long, which
 alloAved the blood to  flow freely out  into the cavity of the pleura,
 and to fill it up  with between five and  six pints of  blood.   The
 blood had so far  separated into serum and coagulum  that the fluid
 which first issued on opening the chest was about as clear as that
 which you  find in a bleeding-cup carefully put by;  it was hardly
 at all stained red.   The heart was not at all injured by its dislo-
 cation, though lying entirely  to the right of the cardiac region.
 The  left lung was very little  pervious  to air, being sodden and
 inelastic in tissue.   The pleura was quite  natural, showing no
 signs of  inflammatory action.
    I need hardly say that no suspicion of the true state of things 
THORACIC ANEURISM.               327
crossed anybody's mind during the patient's  life.  The mode of
death  is so rare, that if  an exactly similar case appeared to-
morrow, while this one was fresh in my mind, I think I should
make the diagnosis  I did here, of  a collection of pleuritic fluid
from injury to the pleura or lung.  Even during the autopsy a
gentleman present, with a juvenile objection to being wrong in
a diagnosis, upheld the idea of its having been originally a case
of serous effusion, into which the aneurismal sac had  burst at
the time of death.  Tempting as it is to prove one's self right after
all, I was compelled  to differ;  for had such been really the case,
the blood  suddenly mixed with the previously collected fluid
would  have stained  it all deeply, and not have been  seen sepa-
rated into serum and  crassamentum, as it was,  on opening the
pleura.
   I feel sure  that the aneurism first burst  at the time of the
man's  accident.  Then that the prone posture and the fainting
allowed a fibrinous plug to stay further mischief for a time; and
that the giving way of the  plug  was the immediate.cause of
death.
   This case shows how imperceptible and with how little injury
to  health may be the growth of  a  large aortic  aneurism—even
one extensive  enough to have eroded the vertebral  column, as
this has done.   The patient  did not know what illness was till
the rupture took  place.   And perhaps that was a consequence
of the fall in a fainting fit.  Do not let this discourage or terrify
us  with the fear of carrying, Avithout being aware of it, such a
dreadful inmate in  our chest.  Let us rather comfort ourselves
with  the  assurance, that  if it has wrought so little harm when
not knoAvn of, it may be prevented from doing harm  when it  is
known of, if prudence is  used to avoid accidents.  A clot inside
this sac Avould have  completely restored  the form and functions
of  the aorta.
   Even with a rent a quarter of an inch long  in it, you see it
was not necessarily  fatal.   The patient lived nearly a fortnight,
the blood first poured out was beginning to be absorbed, the
heart was returning to its place, and the lung  to its breathing.
If  we could have seen what was  going on  inside, there would 
328
THORACIC ANEURISM.
have  been nothing extravagant in the hope  that  a permanent
stoppage of the hole might have taken place; though, of course,
the risk of the fatal accident which has really happened would
have been equally clear to us.

          (Clinical, St. Mary's, December 12, 1863.)

   Albert D., a carpenter, aged thirty-three, enjoyed general good
health till three months ago, when he became an out-patient for a
constant distressing cough and shortness of breath.  This state
of things became worse and worse, and he was sent  to bed, under
my care, November 11.  It was then found that the pulse in the
right wrist was very much smaller than in the  left, an abnormal
degree of pulsation was felt in the hollow above the collar-bone,
and a characteristic whiz, as  of an  aneurism, could be heard
where  the pulsation was strongest.   I believe all who examined
him came to  the same  conclusion, that there was an aneurism  of
the arteria innominata, or at all events involving the arteria in-
nominata, and pressing upon the trachea.  The  diagnosis was too
clear to be of much interest.   The  lungs Avere very much con-
gested, coarse and fine crepitations being heard in  various parts,
and the finer crepitation's especially in the lower lobes, of which
the right, on  percussion beneath the scapula, was duller than the
left.   The  patient  was harassed by constant dyspnoea and fre-
quent cough,  especially at night, and had severe pain, sometimes
spasmodically aggravated, in the  neck behind the right collar-
bone.   There was copious muco-purulent expectoration.
   To  relieve  the  afore-mentioned pain, general bleeding  from
the left arm was once resorted to, and several times leeches were
applied above  the  clavicle.   The patient said that the leeches
gave the most relief;  an assertion different from  what  I  have
heard made in other cases of aneurism of the  trunk vessels, and
I am sorry to say I cannot explain the discrepancies.
   Digitalis and lobelia Avere  also administered internally, and
blisters and  mustard poultices were  applied externally;  but  I
cannot say that either  gave any relief to the cough or dyspnoea;
and indeed a Aveek before his death they were left off as ap- 
THORACIC ANEURISM.
329
parently inefficient remedies.   Morphia alone and the afore-
mentioned leeches seemed of any advantage.
  A week ago he had  an attack of haemoptysis;  but that was
arrested by leeches, and he went on without much change, vary-
ing in his fortune from  time to time, now better, now worse, till
yesterday.   In the morning he told the sister of the ward he
thought he was really improved in health, and that he could lie
down easier in bed. ■  But after dinner he experienced great dif-
ficulty in breathing, said he felt he was dying, sent for his wife
and mother, and became livid  and insensible almost before they
arrived.  To-day you  are going to see the post-mortem examina-
tion.
  \Extrad from  record  of post-mortem  examination  by Mr.
Nayler, curator to St.  Mary's Hospital Museum:  "The aorta
in its ascending and transverse portions was greatly dilated, and
involved the origin of the innominata artery.  Its coats felt also
somewhat hard and brittle.  In consequence of its increased size,
the aorta rose much higher than natural in the chest, and  ob-
scured the root of the innominata.  On laying open the trachea,
its  upper part was found to be healthy, but in its lower half the
mucous membrane was much congested, and its rings flattened,
and at this point they appeared to have undergone partial  ab-
sorption.  The heart was soft and thin.   The lungs were very
full of blood,  and at  the back part were not universally crep-
itant."]
   The  cause  of death  doubtless was a sudden increase of  the
congestion of  the  lungs from the interference of the dilated ar-
tery with the  pneumogastric nerve, perhaps especially  Avith the
recurrent branch.  Probably the only chance of relief for him
would have been a recurrence of the haemoptysis which was of use
a week ago.  I should have practiced bleeding and leeching more
assiduously, had  not  the weakly pulsation of the heart given a
warning against  it, and made one doubt if life would be pro-
longed by that expedient, while complete  renewal or cure  was
out of the question.
   Do not set  d*own loss of blood as a mere destructive agency,
pure and simple.   The more  perfect and  accurately graduated
       DO 
330
THORACIC ANEURISM.
form of it  exhibited in haemoptysis,  and our rough  imitations
with lancets and leeches, by relieving the congested lungs of  a
burden that impedes their functions, cause more new blood to be
made than  heretofore, and so are an indirect renewal  of life.
  You may observe that this man has had a considerable amount
of digitalis, and that no beneficial result has been apparently
produced by it.  I must therefore say something justificatory of
myself for  administering it.  My reason is,- that digitalis  seems
to me to exert a special influence over involuntary muscular fiber,
causing its contraction to be more firm  and powerful; and that
it exerts this influence  most especially when the  muscular fiber
is abnormally lax, or when  it is degenerated.  Cats killed during
the action of digitalis were found by Dr. Handfield Jones, in ex-
periments he made some years ago, to have the heart strongly
contracted.   In the human subject I have, ever since I  have
been physician  to  St. Mary's, hardly ever omitted to give digi-
talis to cases of thin dilated heart, with irregular failing pulse;
and the general result you have often seen to be, that the pulse
grows firm  and regular. Digitalis acts also upon the involuntary
fibers of the  uterus, renewing their tone, bracing them  up, and
stopping the menorrhagia of relaxation.   You have several times
had an opportunity of  seeing  menorrhagia  stayed  in this way,
and notably one case admitted under my care rather  more than
a fortnight ago, which I especially mention now, because  other
involuntary fibers than those of the uterus were influenced.
  Emily T., a quadroon nursery-maid, out of place from illness,
aged seventeen, was admitted November 27, suffering from men-
orrhagia, which had been almost constant for about three months.
The quantity of blood lost was  not large  at any one time, but
there was a continuous drain which had  weakened her very much
and rendered her very anaemic.   Her mother, a tall and  stout
mulatto, stated that the disease was hereditary, she having her-
self been laid up in the same way when a young woman.   The
girl's uterus  comes down very low in the vagina, almost to the
hymen, and the os uteri is soft, tumid, and painful.  There  is
also pain on pressing the  region of the ovaries.   She stated in
addition, and the  statement was confirmed  by her  mother, that 
THORACIC ANEURISM.
331
from childhood she had been afflicted with incontinence of urine,
and never remembered to have  passed a night without wetting
her bed.   Infusion  of digitalis  was prescribed,  and the dose
gradually increased up to two ounces every three hours.   At this
point it was left off, for nausea and faintness with loss of appetite
were induced,  and the menorrhagic  discharge ceased.   It has
since returned once for a few hours, but was immediately checked
by a resumption of the digitalis.   So far the course of events
was the usual and expected course; but the  next observed phe-
nomenon is to me at  least new; the patient states that the incon-
tinence of urine has  quite disappeared since the night before the
arrest  of the menorrhagia, that for the first time within her
memory  she has been  able to  hold her water during sleep, and
now  has  not wetted her bed for ten nights.
   The beneficial  action  of digitalis  over  the sphincter  of the
bladder is of a piece with its action over the uterus,  and is truly
not surprising.  I was not aware of it before,  but shall certainly
test it  again, both in  this girl in case of a return, and in other
instances of  that most unmanageable disease, incontinence  of
urine in  the female.
   This digression is for  the purpose of excusing  my hope  that
digitalis  might prove of use to the dilated  and relaxed muscular
fibers  of arteries.   The hope may be grounded on  imperfect
knowledge, and was  disappointed in this instance; but it is not
an utterly  irrational one, not  a  mere excursion into the  realms
of empiricism. 
LECTURE  XXV.
                DISEASE  OF  HEART.

1st Part.  Comparison of injury to life from the two  sets of
     valves, severally—Deductions from autopsies—Case in point
     — Treatment calmative and restorative.   Second case—Dis-
     eased mitral and aortic valves with dilated parietes—Treat-
     ment similar to last case, with certain additions.
2d Part.  Degree of importance to  be attached to the different
     points ascertainable by ascultatory diagnosis—Consequences
     of valvular disease different  in different classes  of life—
     Cases in illustration of its effects in the upper classes as dis-
     tinguished from hospital patients—Causes of difference—
     Treatment of patients with disorganized valves—Avoidance
     of dangers—Iron—Chloride of sodium—Hydrochloric acid
     —Abuse of alcohol—Danger  of rupture of valves—Case—
     Angina pectoris—Pathology of  dilatation—Explanations to
     patients—All diseases of heart to be viewed practically as one.

          (Clinical, St. Mary's, December 20,  1861.)

  In speaking of diseases  of the cardiac  valves I practically in-
tend what is said  to apply only to those of the left side of the
heart;  for the tricuspid  and pulmonary are seldom affected alone
with such severity  as to  produce either symptoms during  life, or
lesions  recognizable after death;  so that physicians know  very
little about them.   It is the mitral  and  aortic valves  whose al-
terations  we are best able to recognize by physical signs, and
whose  defects cause injury to the muscular walls of the heart.
They are a source of anxiety to us in our daily  duty, whereas
the others are rather a matter of curiosity. 
DISEASE OF HEART.
333
  Comparing the different valvular lesions of the left heart, with
regard to the injury they inflict,  and the consequent propor-
tionate goodness or badness of the prognosis to be formed, I find
that the worst cases, that is, the most liable to have serious  con-
sequences, are those in which both the aortic and mitral valves
are simultaneously imperfect;  the next worse are those in which
the aortic have suffered; and the most favorable are those where
the mitral alone are inefficient.
  Thus I find that in 115 cases  recorded in  the "post-mortem
book " at St. George's Hospital from 1840 to 1850, where disease
of one set of valves was accompanied by alteration in the cardiac
walls, the aortic valves alone were diseased in 64,  the mitral
valves alone in 51.   And in  the former case also the alteration
had assumed a more  marked  oharacter;  for in cases where the
aortic valves alone were  diseased, the size of the cavities  was
disproportionally large in comparison with the enlarged walls  in
36;  whereas, when the mitral valves  alone were diseased, the
disproportionate enlargement occurred in  only  18.  And  this
difference, it is to be  observed, is  not dependent on the  greater
frequency of lesions of the aortic  valves alone,  for  in point  of
fact  they are not more frequent.   Thus in hearts whose walls
were  still normal, there was  more or less  lesion of  the mitral
valve in 34, of the aortic an 30.
  The powerful influence  of the double lesion (i.e. of both valves
at once) is shown by its being found with healthy heart-walls  in
only 6.
  Now this  diseased state of  the  heart's walls is so  very much
the most important, and so very much the most frequent of the
evil consequences of disorganized valves,  that practically speak-
ing it may be taken to represent the whole of those consequences.
All our calculations of prognosis in cases of valvular injury need
have reference to it alone.
  I have been hitherto quoting from my systematic lectures  on
the practice of medicine,  apropos  of a prognosis  I have given of
a case now under your eyes,  and which I have  selected as one
promising enough to use as an illustration of treatment.
  A. J., aged thirteen, had rheumatic fever three years  ago at 
334
DISEASE OF HEART.
Brighton, of which illness she has not much recollection, but she
shows marks on the cardiac region of leeches, probably applied
at that time for inflammation of the heart.  She has since then
always suffered from palpitation on the slightest exertion, or on
any emotion; and she has dyspnoea on attempting to go up stairs
or up hill, or to walk above her usual pace.   She had an attack
of spitting of blood eighteen months ago, but otherwise her health
has been good.   Her complexion and appearance fully bear out
this statement; she is  fresh-colored, muscular, bright-eyed, and
plump;  her mind is active and intelligent, and though the mam-
mae are  infantile  and the catamenia have not appeared, she has
the air and  appearance of a girl two years older than her real
age.  I may remark in passing that  such a backAvard develop-
ment of the reproductive organs.as you here see  is a very com-
mon effect of cardiac disease in both sexes.  The growth of the
other  organs or functions, mental or bodily, does not seem to be
retarded.
   The palpitations  have been  lately rather more  troublesome
than usual,  and on examination of the chest they are explained
by a vibrating  tremor  sensible  to  the finger at the apex of the
heart, and at the  same point a very loud systolic murmur.   The
second sound is loud and  sharp.    The interval is clear.   The
systolic  murmur is heard only very indistinctly at the base of the
heart.   On  admission the  pulse and heart-stroke were uneven in
strength, but have by rest in bed become nearly natural.
   On percussion  the dullness of  the cardiac region does  not
appear to extend  beyond the breadth and height which is usual
in the normal state.
   This  girl appears to labor under lesion of the mitral with
healthy  aortic valve, one of the varieties  of cardiac injury the
least likely to cause enlargement, and therefore the least injuri-
ous of any;  and since I cannot find that the heart is as yet en-
larged, let us give her the benefit of the doubt, and hope that it
may not become so.
   In the treatment, the first object is to restore regularity and
calmness to  the affected organ.  With that view she has  been
kept lying down for a week; she has had once two leeches and 
DISEASE OF  HEART.
335
once one leech  applied  beneath the left breast, and has taken
five minims of tincture of digitalis three times a day.  This has
been  so  far effectual, and will be continued only a short time
longer.
  The next object is to keep the blood  in as rich and nutritious
a state as possible.   The child has a critical period of her life to
go through sooner or later, the time of puberty, when there is a
call upon all  the powers of growth.   If she  gets anaemic  then,
the heart will but too surely enlarge by dilatation.  I have begun
therefore giving her iron from the first, and shall urge  its con-
tinuance as long as I can keep sight of her.
  The richness of the blood, instead of increasing the chance of
haemoptysis, as you might have imagined, diminishes it.  Thin
watery blood easier oozes out; and  besides,  the more nutritive
the circulating  fluids, the more active is the  heart, the better  it
empties itself, and the less is the blood  kept  back in the  lungs.
  Another case in  the  same ward  is not quite such a  hopeful
one.   Mary  K., aged  twenty-two, single, has been here since
November 25.   She says that  she has had rheumatic fever once
this time seven years.  She  had no pain in  the chest then, and
perfectly recovered, remaining well  till  an  attack  of what she
calls " bronchitis," three  years ago.   After this again  she was
quite well till two  years since, when she began to suffer from
severe pain in the cardiac region, and had frequent colds.   She
also frequently had bleeding  at the nose, and spitting of blood,
even when keeping quiet, and when she moved about experienced
much dyspnoea and palpitation of the heart.   She however con-
tinued in.service, and did her work.  Six weeks before admission
she observed  that she got blue in  the  face, and suffered more
than usual from  dyspnoea, so that three weeks before  she was
obliged to give up Avork.
  When  you first  saw her she was very blue  in  the  face, and
could hardly get  her breath;  she was spitting blood, and there
Avere loud sibilant and crepitant rales all 0Arer the lungs  without
any localized dullness on percussion in the  pulmonary  regions..
The  pulse  Avas very irregular and intermittent.   The  cardiac
region was dull on percussion up to the interval above the third 
336                 DISEASE OF HEART.
   rib, and  as far as the  sternum toward the right side.   The
   second sound of the heart Avas scarcely to be heard at all, but
   was replaced by no murmur.   There was a loud systolic murmur
   loudest at the apex, and  followed by a peculiar chirping sound,
   rather anterior  to the time of  the second sound.   The intervals
   were imperfectly marked.
     In  Mary K. there  is  probably  regurgitation  through  both
   aortic and mitral  valves.  What she  has suffered from is ob-
   struction to the passage of blood through the lungs, and conse-
   quent non-aeration and  venosity.  She had  some haemoptysis
t*  which gave relief, so  I took the hint and cupped her, and put on
   some leeches several  times, which have also  given relief.   The
   irregularity and excitability of the pulse have been successfully
   •treated by digitalis.
     The venosity  of the blood is  in great danger of being succeeded
   by anaemia, especially as her appetite  it very deficient.   The
   heart is already enlarged, and I  fear it  is improbable that she
   will ever be able to get her own  living again ;  still I  think  it
   right to give her iron, and purpose to continue it as long as pos-
   sible, that at all events she may obtain all the advantage she  is
   capable of receiving.   The most unhappy event for her would be
   degeneration of the muscular walls of the affected viscus, so that
   they should fail from debility duly to circulate its contents; and
   I believe the best  chance of avoiding this degeneration lies in
   keeping up the  supply of a really nutritious blood.
     You may observe that  the digitalis was left off several times.
   This was  not on account of its failing in  its objeet of calming
   and reducing to regularity the irregular heart, for thai it effects
   well;  but because, when  given in larger doses than five minims
   of the tincture,  it produced nausea and prevented her taking her
   meals.   Now the  physic  we order on  the diet card is  at  least
   equally important  with that on the medicine card,  and you  must
   be careful where  you want to renew life not to diminish the
   means of  that renewal.   The  production of  nausea and loss of
 k  appetite would do more harm than any action of the drug could
   do good. 
DISEASE OF HEART.
337
(Clinical, St. Mary's, December 6, 1861, with additions in 1862.)

  There are  always in our wards  a few chronically diseased
hearts, and  I very seldom walk round without calling  your at-
tention to one or two as studies of diagnosis.
  I notice that when you  begin the physical examination of the
patient whom you know to have a cardiac complaint, you search
first and foremost for endocardial murmurs, and  then  you  often
rest from your labor  and  say what you have found.  You  seem
to consider that sign as the most essential part of the diagnosis.
You are  partly right and partly wrong.
  This knowledge doubles the value of other future observations
about the heart, but standing alone it is of less importance than
any of them.   While then I willingly receive  this report first, I
always beg you to go on without delay to further observations.
  The importance of the existence or non-existence of valvular
disease lies not in the injury it inflicts itself, as in the likelihood
of the induction of the other lesions of the heart.  If the mus-
cular structure  remains healthy, injured valves  do not appear
capable  of causing death.   But very surely are they fatal when
they are followed  by dilatation or thickening or degeneration of
the cardiac  walls, with their sad train of dropsies, apoplexy,.
pulmonary haemorrhage, &c.
  In  the 2161 post-mortem  examinations  at  St. George's Hos-
pital in ten  years, the cardiac valves were  diseased without the
walls of  the heart being affected  113 times; but in every case
there were other  lesions amply sufficient  to account for death
quite independent of the valves, such as accidents, surgical com-
plaints,  cancer, low  fever, &c.  In  one alone, where  anasarca
from  granular kidneys was the immediate cause of death, could
any symptom  be debited to diseased valves with  healthy hearty
and that symptom was pulmonary haemorrhage.*
  In the classes of people  represented by  hospital patients,, the
probability that valvular disease will be followed by its unhappy
consequences is very great.   When a patient thus affected leaves
* " Decennium Pathologicum," chap, x, sect. i. 
338
DISEASE OF HEART.
the wards, you may expect to see him again shortly, and on each
fresh admission with a more severe complaint.   Hence the more
attentive students you are the worst prognosis do you justifiably
form.  But you must not  apply the  same rule  to the different
grade of society among whom you hope your private practice
will lie.   With  persons in  easy circumstances valvular lesions
exist for years and years, perhaps through the greater part of a
long life, and not  only not  prove  fatal, but  may  fail even to
cause symptoms bad enough to make  them consult a medical
practitioner.
   To prove to you this  fact, I will quote from my private notes
some cases of persons in easy circumstances in whom the stetho-
scope or the  history, or both, gave every indication of injury to
the valves of long standing, but in whom no inconvenience suffi-
cient to be called illness by themselves has followed.
   Defective valves of 57 years' standing.—Col.  R.  S.  at eight
years old  had a bad  attack of rheumatic fever, which laid him
up for eleven months, and from which his heart has never wholly
recovered.  At sixty-five years of age he had a very loud murmur
with the first sound.  The year before he had had an attack of
inflammation (congestion?)  of the lungs, which had  left a con-
siderable portion of the pulmonary tissue impervious, for his vital
capacity tested by the spirometer was only 150 cubic inches, his
height being  5 feet 10J  inches.
   Defective valves of 50 years' standing.—Archdeacon B. at six
years of  age had  an attack  of inflammation of the heart, and
since that time has been subject to irregular action of the organ,
often followed by fainting fits.  He  has for  some years lived
more generously than he used to do, and suffers much less in-
convenience.   The action of the heart is irregular and uneven,
and there is a murmur with the first sound.  He is now fifty-six,
well, and moderately active.   (Dec. 1861.)
   Defective valves of 44 years' standing.—C. B. at twenty-eight
had rheumatic fever from sleeping in  a damp bed.   At sixty-
three years old (in  1852) he  had a marked systolic murmur at
the apex of the  heart, but considered himself  quite well, and is
alive now (1861) when he must have long passed his threescore
years and ten. 
DISEASE OF HEART.
339
  Defective valves of 27 years' standing.—T. H. G. at six years
old had rheumatic fever.   Since then he has  had no illness of
any kind.  In June, 1860, when he was thirty-two, I detected a
loud whizzing murmur with the first sound; in July, 1861, the
same  murmur remained.   He is  alive and I believe well now.
(Dec.  1861.)
  Defective  valves of  about  21 years' standing.—C.  S., aged
thirty-six, in 1855 had a  low blowing mitral  murmur.   He  used
to have, severe palpitations  when  an under-graduate  at Cam-
bridge; he has enjoyed average health since, with the exception
of what he calls "colds," that is, a feeling of general malaise,
for which he  takes tonics, and is always better for the practice.
He is alive and well  now in 1862.
  Defective valves of 15 years' standing.—E. G. in  1846 had in-
flammation of the chest accompanied by severe pain in the heart.
I saAV him first in June, 1848, when there was  a  loud musical
murmur with the first sound.   In December, 1848, and in Janu-
ary, 1850, the same  murmur  remained.   He is still alive, aged
seventy-two.
  Defective  valves of at  least 11  years' standing.—R. H., who
in 1861 was still  alive and forty-two years of age, had in 1850
a blowing systolic mitral  murmur.
  Defective valves of at least 7 years' standing.—R. A. A., who
in 1862  is still  alive, aged fifty-three, had a blowing systolic
murmur when I saw him in 1854.  He is a robust, muscular man,
in the habit when young of  pulling in boat races, to which he
attributes the palpitations he now occasionally suffers from.
  Defective  valves of 7 years'  standing.—T.  J., aged twenty-
three  in 1854, had undergone scarlatina at sixteen years old  and
never any other illness.  I could hear a blowing systolic murmur
at the apex of the heart, and he had pain in the cardiac region
after exertion, but was not otherwise ill. His subsequent history
is unknoAvn to me.
  Defective  valves of 7 years' standing.—D. F., aged  twenty-
nine in 1852, also  had scarlatina at twenty-two years of age,
accompanied by pain in  the heart and followed by palpitations
of six weeks' duration.   There was with some beats  a systolic 
340
DISEASE OF  HEART.
murmur loudest at the apex at that  period, Avhich  was seven
years after the reported cardiac affection.   His subsequent his-
tory is unknown to me.
   \Defective valve of 7 years' standing.—Miss S. had rheumatic
fever from sleeping in a damp bed, accompanied by pain in the
cardiac region, in 1856, when she was twenty-three years old.
There is a distinct very localized systolic murmur at the level of
the aortic valves.   She has attacks of angina pectoris  from ex-
posure to cold, but  with care is able to live  like  other, people.
Between April, 1862,  and July, 1863, she had  lost no ground,
and had only two slight attacks of angina pectoris.]
   Defective valves  of  at least 5 years' standing.—F.  J.,  aged
thirty in 1856, had then an  irregular pulse and a  systolic mur-
mur, without any dyspnoea or general symptoms  arising from the
imperfection of the heart.   He  is alive now.   (Dec. 1862.)
   Defective valves of 18 months' standing.—A. D., aged forty-
three in 1850, had had rheumatic fever eighteen months previ-
ously.  The heart's action was irregular and there was a systolic
murmur, but no general symptoms  at all referrible to cardiac dis-
ease, nor any suspicion that cardiac disease existed.   His subse-
quent history is unknown  to me.
   Defective valves of a year's standing.—W. H.  C, aged thirty-
one in 1850, had had rheumatic  fever a year before, with inflam-
mation of the heart, but considered that he had quite recovered,
and he really seemed to have done so; for his vital  capacity was
220 cubic inches, his height being 5 feet 9 inches,  so that there
was no  pulmonary  obstruction.   There was a systolic murmur,
loudest  at the level of  the aortic valves.  His subsequent history
is  unknown  to me..
   Defective valves  of unknown duration,  but  at the date of
examination without any deleterious effect on the general health.—
J. P., aged thirty  in  1854, had  an  intermittent pulse with  a
systolic murmur loudest at the base and middle of  the heart.
Unusual exposure  affected his chest so as  to lay  him  up with
cough, but  his general health was good.   Subsequent history
unknown to me.
   G.  P., aged twenty-six in 1856, had a very irregular, unequal, 
I
                     DISEASE OF HEART.                  341
                                                             <<
 and intermittent pulse, accompanied by a systolic murmur.   He
 never suffered from palpitation, cough, or any illness at all.  Sub-
 sequent history unknown to me.
   F. D., aged forty-nine in 1857, had a sawing systolic murmur,
 but never had any illness or inconvenience referrible to the heart.
 Subsequent history unknown to me.
   J. B., aged  forty-eight in  1856, had  an intermittent pulse and
 a blowing murmur with  first sound most distinct at the base of
 heart.  He never suffered from palpitations.  Subsequent history
 unknown to me.
   Irregular pulse of long standing without date.—Lord-------,
 aged seventy-four in 1862, and  alive now, with a soft systolic
 murmur to be  heard at the apex of the heart, has a distinct recol-
 lection of having an irregular pulse as  long as he can remember
 anything.   And other old people have  told  me the same, though
 I have not kept a note of their cases.
   Injury to heart from rheumatic fever of 10 years' standing.—
 T. A. 0., aged fifty-one in 1855, had  had  rheumatic fever  ten
 years  previously,  and since  then frequent  "faintingfits"  and
 palpitations.    The action of  the heart is jarring, and there is
 extended dullness on percussion, but no evidence of valvular dis-
 ease.   He does not get worse.
   You know very well that eases like  these are not to be met
 with in hospital practice or among  the  paupers in  a workhouse.
 Wherein lies the difference ?   It is discoverable  generally from
 the histories Avhich these poor people tell of  the final breakdown.
 The tale usually runs, "I was pretty well, or only a little short-
 winded, till I was thrown out of work and had to live low: then
 my heart got to beat worse, and my feet swelled."  Or, "I could
 always earn  my living till I was overworked last summer," or,
 "till I caught a bad cold last Avinter," or, "till I had sit up with
 my mother who died,"  and  so on.  And from this" breakdown
 they never get quite up again, they  never  regain  lost ground.
 In short, you will see that injured valves  are slow  to lead to
further cardiac lesion in the well-nourished, and quick to lead
to further lesion in the ill-nourished;  and that the motive cause
of their evil effects is anaemia, exhaustion, debility! 
I
£42                DISEASE OF HEART.

   Do not look upon this disadvantage of the poor in respect of ■
cardiac disease as merely an universal rule in all diseases.   In
a good many cases the poor recover easier than the wealthy, and
the good prognosis which you have habitually attached to certain
morbid states in hospital practice will not be justified in private.
Continued fever, to wit, is less fatal in the lower classes, although
more common;  consumption is less frequently  "galloping;" it
is more chronic, and more rapidly benefited in their case; again,
anaemia is more often found dependent on removable  causes, and
therefore quicker cured in cottages than in palaces.
   The peculiarly fatal nature of valvular disease of the heart
among those who live by bodily labor arises from the fact just
mentioned of lost ground being never recovered from.  The heart
is (physiologically speaking)  a single organ with the  single me-
chanical function of forwarding the blood, and consisting of a
number of unique parts mutually dependent on  one another.  If
the left ventricular valves are injured, the right cannot take their
office, nor the aortic replace  the pulmonary.  It is a  chain, pro-
verbially never  stronger than its weakest  link.  Therefore  no
relief can be given to a failing part by another  part taking  its
duty; no rest for the purposes of recovery can  be taken.  The
designer of our frames has been here peculiarly sparing of reserve
function.   Such is not the case in other  organs; if one kidney is
destroyed, the other supplies its place and as much  urea is ex-
creted as before: large portions of lung may be impervious  from
tubercle,  yet  the blood be aerated  normally by the  remainder,
and the patient recover of consumption.  But in the heart each
successive little injury can never be compensated for, and is added
in turn to the previous list.   The wealthier classes can avoid  all
the many circumstances which produce these successive little  in-
juries—cold, want of food, oArerexertion, mental worry;  and so
under good advice can keep  their imperfect valves from getting
worse; but those who depend upon daily toil for daily bread run
the risk  and suffer the unhappy results.
   I said early in the lecture that  I did not blame you for begin-
ning your examination with  listening for cardiac murmurs, but I
do blame you very much if you stop there.  The evil import of 
•
                    DISEASE OF HEART.                 343

valvular injury lies in its probable consequence, namely, enlarge-
ment of the muscular walls; and it  makes all  the  difference  in
the world  to you and to the patient to ascertain if this  already
exists.   Percussion and  palpitation  are a much more necessary
part of the examination  than mere listening with a stethoscope.
If the heart is dilated or thickened, or dilated  and  thickened,
your ascertaining the fact makes all the difference in the world
to your prognosis, and to the hopes which  you have  that your
treatment may be successful.
   It is obvious that in the treatment of the disorganized valves
themselves, restorative medicine  in the strictest sense must be
quite at fault.   The renewal of the destroyed tissues is impossi-
ble, and equally so is any compensation for the arrested function.
But indirectly it is almost as effective in prolonging life, as if it
could put  in a new valve, or make another  muscle do duty for
the resting ventricle.  It may repair those reparable conditions
which  are  so  injurious,  and which by bringing on enlargement
constitute the  real danger in cardiac cases.  In this, as in all dis-
eases, try and cure what is curable and trouble yourselves as little
as possible about by-gone injuries.
   Learn from  the  histories  you hear in the wards what  are  the
external causes which have  brought on the first affection of the
health, and you will thus learn the perils which your patient with
valvular injury has  to fear.   These are, placed roughly in  the
order of prominence—
   fresh attacks of rheumatism;
   insufficient food;
producing anaemia.
  mental anxiety;
  drinking;
  overwork;
  temporary violent exertions.
  The first danger  is to be avoided by warm  clothing, dry air,
especially in the sleeping room, and a residence in such a climate
as does not naturally induce rheumatism.  As a rule, high ground
is to be preferred to low, and an inland to a seaside or island
abode.  A town life, as being  more healthily sedentary and
avoiding changes of temperature, is  rather to be chosen  than
rural occupations. 
344                DISEASE OF HEART.

   During the attacks,  if unfortunately they come on, you cannot
do better than adopt the full treatment of rheumatic fever, namely,
the greatest possible quantity of potash and sufficient doses of
opium, as more largely  set forth in my lecture on  rheumatic
fever.   And you must leech or  cup  the cardiac region, if there
is any pain  there indicating the probable presence of fresh en-
docarditis or pericarditis.
   But do not let the  license you give yourself of local blood-
letting to a  moderate extent for  the relief of an acute condition,
which you  fear  may aggravate  existing eAdls,—let not, I say,
this license  lead to  your adopting the old "heroic" practice of
thinking to  cure  established valvular injuries  by continuous
bleeding, like our  forefathers  Albertini  and Valsalva.  They
fell into  the'mistake thus: they first supposed every enlarged
part was overnourished, or hypertrophied;  then they thought'
that the best thing to prevent its overnourishment was to under-
nourish it;  and then finding that bleeding in moderation  some-
times lightened a few symptoms, they determined that it did so
by undernourishing  the heart, and that of course the  more the
patient got of it the better.  Under the idea of producing its full
influence, they bled frequently in small quantities—the  most
effectual  way of accomplishing  the end they had in  view, the
impoverishment of the  blood.  With  bleeding for such  an end it
was strictly  reasonable to join starvation, as certainly the  most
direct way of diminishing nutrition.  What  the results would be
of thus deliberately inducing anaemia  we can easily  guess, for
daily experience shows that in none do the hearts so rapidly be-
come  enlarged, and on none does that enlargement have more
baneful effects than  on those people  who are subjected to all or
any of the  causes of anaemia  which I have named.   Had the
Sangrado treatment really been in  vogue  now in England,  I
should have  certainly  ranked it in the first class of the origins
of disease in patients with lesed  valves.
  I have spoken of the poor as without doubt the most exposed
to the effects of those agencies which produce or aggravate val-
vular  lesion; but the rich are by no means exempt,  and often
require the  protection  of sound  medical advice.  Even "insuffi- 
DISEASE OF HEART.                345
cient food" is not an unknown cause of illness among them; the
power to buy it does not always imply the power to eat it.   They
not uncommonly become anaemic from loss of vigor in the digest-
ive organs.  To  counteract  the  risk of this anaemia I usually
recommend that persons with affected valves should, three or four
times a year, take a fortnight's course of iron under the  eye of
their ordinary  medical man, whose  watchfulness is needed  to
prevent excess.  The insoluble forms of the metal, such  as the
sesquioxide, or the finely pulverized metallic iron made by French
chemists, or the mistura ferri  composita, are the fittest for the
purpose.   Chlorine  also in the form of hydrochloric acid  baths
is a tonic not contraindicated by  any circumstances in this case,
and  is a good  accompaniment to  the iron.   The habitual  use  of
a large quantity of chloride of sodium with food is another way
of guarding against anaeriiia, which can readily be adopted by the
patient.
   When there is reason to fear that dilatation has already begun,
I often join with the iron small  doses  (from 3Vth to yTth  of a
grain) of strychnine.  If the pulse intermits, this remedy some-
times exerts its tonic power  over muscular fiber by restoring
regularity  of beat, and thus gives you the satisfaction of feeling
the good you do with it.  When there is much palpitation on
occasion of slight nervous excitement, especially if that is joined
with unevenness and intermittence of pulse, a few small doses of
digitalis are useful.   Strange it is that this drug, which makes a
healthy heart first intermit and then stop altogether, should bring
back to order the organ when it is weak and beating irregularly!
We can only account for the  seeming anomaly by supposing it
to act as an anaesthetic upon the cardiac  nerves, withdrawing
them from  normal and needful stimulation in the first case, and
from abnormal and hurtful stimulation in the second.   The worst
aspect of digitalis is, that its benumbing influence extends not to
the heart alone, where it is Avanted, but to  the whole tract of the
pneumogastric  nerve;  it reduces  the  appetite and produces
nausea; so I  pray you  to be cautious and not to continue it
longer than necessary.
  While you bid your patients live generously, you must take
       23 
346
DISEASE OF  HEART.
 care to disabuse them of the notion that the advice  includes ex-
 cess in alcohol.   Alcohol is really the most ungenerous diet that
 there is.  It impoverishes the  blood, and there is no surer road
 to that degeneration of the muscular fiber which is so much to be
 feared.  And in heart  disease it  is more  especially hurtful, by
 quickening  the beat,  causing capillary congestion and irregular
 circulation,  and  thus mechanically inducing  dilatation  of  the
 cavities.  Let the  alcoholic  drink be limited  to that  quantity
 which increases  the appetite, and  fills but does not hasten  the
 pulse.  In  a great many instances this quantity may be very
 shortly written down  —0.
   To mental anxieties perhaps their social relations expose  the
 rich quite as much as the poor, -and their education  makes them
 more sensitive.   Both joys and sorrows affect them more deeply,
 and inst; ad  of balancing one another do equal harm.   Happiness
 is as hurtful as misery.  For example, I have a patient whose
 first attack  of dilatation arose from grief at his  first wife's death,
 and his  second  during  the  honeymoon of her successor.  But
 alas! ungrateful  discontented man seldom  lets the blessings he
 is daily receiving affect his emotions so deeply as his occasional
 misfortunes.
  Ky overwork as a cause of anaemia, I mean too long-continued
 wearying toil either intellectual or bodily.  I would have you
 distinguish  from it short extraordinary exertions, to which we
 can  sometimes, though .not very commonly, trace injury of  the
 valves.
  Now and  then  a case  occurs showing the possibility of a valve
 being  ruptured  by its  own forced  action.  Thus  I remember
seeing one of Tattersall's stablemen under  Dr.  Nairne's  care at
 St.  George's Hospital,  who  distinctly traced  his  first  cardiac
symptoms to a sudden pang which  he  felt, when running a fast
horse down  the yard a year before.  After death two  of  the
pouches of the  aortic valve were  found torn, and from  the  re-
gurgitation thus arising the ventricles had become  enormously
dilated during the year that he had lived. But  the torn portions
were not of normal structure; the tissue was  thickened and
opaque, and therefore wanting in elasticity of power of resistance. 
DISEASE OF HEART.
347
And I  believe this always is found  to  be the case in valves
ruptured by violent strains;  I am not aware of any instance of
healthy valves having been found broken.
   Where the tissue has become bony and brittle, rupture is more
common ; but then of course it will have been preceded by a long
course of ill health, for such an  advanced lesion  as ossification
could not exist  without seriously incommoding the individual.
You will not be  long  without  seeing in the dead body the cords
of a mitral valve thus broken,  rather from the quantity of lesion
than from any external strain or violence.
   More common still  are cases that you see during life of sudden
pangs from exertion—such as  race-rowing, jumping, fighting,—
sudden pangs followed by increased  palpitation, and other signs
of aggravated enlargement of the heart.  Yet the aggravation
is not such as must surely accompany  a broken valve, nor is the
path to death so straight  as it was in  the case which I have re-
lated to you.  Moreover, in some  instances where an  autopsy
reveals  that  the valves are whole, you had previously  heard a
history of such  pangs, and sometimes  had seen them  in the
wards.  What is  going on in the heart  during these fits of angina
pectoris no one precisely knows, but it seems to me very probable
that its state is one of temporary dilatation.  The pain has the
same tearing and paroxysmal character that you find accompany-
ing the distention of hollow fibrous  organs usually insensitive,
such as the  stomach, the colon, the bladder.*   And the con-
sequences too are similar as well as the pain; that is to say, like
the bladder or the stomach, the heart may completely recover
in one case;  or in a second, it  may be completely  paralyzed and
cause death; in a third, it may remain partially powerless and
dilated.  As in  the bladder, so in the heart, any one of these
results may follow.
   Having said so  much about the  nature of injury by sudden
strain, it is needless to remark that it  is to be avoided by all the

  * The pain is of the same nature as  that felt in overstrained tendons, or mus-
cles wearied out by sustained efforts ; it appears associated with the stretching
of usually insensitive fibers, and is sometimes the most dreadful agony the body
can bear, as the inventors of racks and other instruments of torture well know. 
348
DISEASE OF HEART.
expedients that lie in the patient's power;  and perhaps the best
way of strongly impressing upon  him (if he is  a sensible man)
the importance of your advice, is to explain, that is put into plain
words, the pathology of the case.   I cannot  agree with those
who would make a mystery of our science.  I am sure that we are
never called upon to  pervert the truth,  seldom  even to be pas-
sively reticent, and that the most thorough  openness is  always
the best policy.  To this end a complete explanation is generally
necessary.  The  patient must be  told  how erroneous  are  the
vulgar notions derived from popular fiction  about the extreme
deadliness of organic  disease ; the true facts of the case must be
stripped of their picturesque  hangings,  and  he must be led to
look upon his condition with the same business-like reckoning of
results as a physician.   Unless this is done, your half truth will.
act as a lie.
   I should strongly  advise you to  get  a habit of giving these
clinical lecturettes in clear untechnical words.  Let your pa-
thology shape itself within your own minds in  such language as
all educated  persons  can enter into; and  not  only will you be
able to explain matters more easily to your patient, but you will
understand them better yourself.  For this last statement " ex-
perto crede."
   In practical lectures it is always wisest to take chronic diseases
of the heart  as  one  individual subject, for  this is  the way in
which you have to think of them at the bedside.   You should
not treat  patients with spoilt valves on one principle, those with
dilated ventricles on  another, those  with thickened ventricles on
a third; but, as I have tried to make you think, each and all with
a reference to the same function impeded  in  the same  manner.
Division  leads to unnecessary repetition,  and you may observe
that I am careful to  avoid it both in the way in which I class the
patients in the wards for instruction, and in the extracts I make
from case-books  for the lecture-room. I do this with a design of
impressing upon  you what I consider  the main  points in the
management of diseased hearts, viz.:
    1. The importance of valvular lesions consists in their liability
to cause  enlargement of the heart. 
DISEASE OF  HEART.                 349
  2. In auscultation we should strive more to find out the state
of the heart-walls than of the valves.
  3. The danger of enlargement is greatest where the muscular
fiber is weakest.
  4. The  muscular fiber is weakest  where the blood  is most
anaemic.
  5. The  principal  object  therefore of treatment is  to avoid
anaemia.


          (Clinical, St. Mary's, January 30, 1863.)

  Eliza M., an unmarried woman,  aged twenty-six, has been in
the hospital four times during the  last three  years with  attacks
of haemoptysis and dyspnoea, arising from valvular disease of the
heart.   She  was last  admitted January 16, with dyspnoea ac-
companied by excessive lividness of the face.   She was soon
relieved  by the recumbent  posture and half a dozen leeches to
the cardiac region.   My reason for mentioning  the case  to-day
is to draw your attention to the dyspeptic symptoms which seem
dependent upon the disease of the heart.  On admission she said
that she vomited up all her food, and although she only did that
once after coming into the  hospital, still she suffered from con-
stant  nausea  after eating, and tympanitic  distention of the
intestines.  I have often found this form of indigestion  in cases
of heart affection.  There is nausea, vomiting, sometimes a great
collection of mucus in the stomach, and intestinal flatulence.  I
 attribute  the nausea  and  vomiting partly to the constant jar
 communicated to the walls of the stomach by the palpitating
 heart, and which acts  somewhat as the rocking of a ship  produces
 sea-sickness.   Partly  also  I think  it may be due to the general
 venous congestion which I have no doubt  exists  equally in the
 mucous membrane and in the  external skin.   The flatus in the
 digestive canal I think arises  from the deficiency of absorption
 produced by congestion of the portal system.
   You must not look upon Avind as a purely abnormal denizen of
 the alimentary canal.  It would be  a very abnormal  state  of
 things indeed if there were none found there.   The greater part 
350                 DISEASE OF HEART.
of it is carbonic acid and atmospheric air derived from the food.
But in health its quantity is limited and kept from inconvenient
excess by its continuous passage  by endosmosis into the portal
and venous blood.   Now it is  a familiar law of osmosis that the
ratio of the  rapidity of its current bears a direct relation to the
motion  of the  fluid  toward  which it sets.   Obviously,  then,
obstructions to  the  circulation, by diminishing  the quickness  of
the moving blood must impede absorption, and so allow the flatus
to accumulate.  It must  be  viewed as a collection not as an
effusion.
  As regards remedies, I have found  hydrocyanic  acid have a
beneficial effect.  And in this  case  especially to give it is to ac-
complish two indicata with the same agent; for by its  general
action upon  the pneumogastric nerve it alleviates the  dyspnoea,
at the same time that it deadens the oversensibility of the gastric
plexus in special. 
LECTURE  XXVI.
                       PURPURA.

Descriptive definition of purpura—Case 1.  Young man affected
     with fatal hemorrhage and purpura without previous disease
     —Case  2.  Menorrhagia and purpura in a  girl otherwise
     healthy—Case 3.  Purpura in a fatal case of diseased heart
     and kidneys—Pathology of purpura—Its connection with
     lesions of the circulating system—Its  treatment based on its
     pathology—Cautions respecting the administration of digi-
     talis—Case 4. Purpura fatal by  hsemorrhage into  the
     brain.

           (Clinical, St. Mary's, February 6,  1864.)

  I wish to call your attention to-day.to three examples of pur-
pura under my care this week, which illustrate the phenomenon
under several different aspects.
  Purpura, or "the purples," consists of a diseased state of the
capillaries, which causes  them  to rupture  idiopathically or of
their own accord, just  as they would  do in consequence of local
violence.   On soft, or  loosely constructed surfaces, such  as
mucous membranes,  the escaped  blood flows  away  in  a fluid
state; where a tougher structure prevents  this escape, as in the
external skin for example,  it  forms purplish black spots of
rounded shape and various sizes; in parenchymatous or semi-
parenchymatous tissues,  such as the brain or  lungs,  it may  col-
lect  into masses which lacerate their substance  and obstruct
their functions.
  Case 1.  John K.,  a  laborer, aged  thirty-five, previously quite
well, was taken  ill  at tea-time on  January 29, with bleeding 
 352                      PURPURA.       .           ,

 from the mouth.  This  haemorrhage rapidly increased and be-
 came very profuse ; so that by the evening of the 1st instant,
 when he came up by railway to St. Mary's, he reckons that he
 lost a gallon.   And  indeed it was very copious, for on each of
 the first two days of his being here there was very nearly  a pint
 of fluid, exactly like  pure blood, with a vermilion  froth on the
 top, in the porringers by his bedside.  But a good deal of saliva
 was mixed with it, so much so at least as to prevent its coagula-
 tion, except in very small broken clots.  On admission his  mouth
 was full of clotted  blood, which adhered to the  gums; on the
 tongue were half a dozen black vesicles  of the size and shape of
 split peas,  and blood was oozing from their  edges.  On the lips
 and face, on  the hands, arms, and  various other parts of the
 front of the body, were numerous black spots of about the same
 diameter as those on the tongue, but not raised  above the sur-
 face.  His urine contained blood, and, of course, albumen;  but
 I could not find that blood had been passed  from the bowels.
 He said  he felt weak and tremulous;  but he had walked  to the
 hospital, and he sat upright, waiting  for a bed to be  prepared
 for him, for some time without faintness.  There was color also
 in his cheeks and lips, and altogether much less exhaustion than
 one would have looked for after such  severe haemorrhage.   His
 appetite was not affected, and the bowels were  open naturally
 without medicine.
   He was ordered ice, sulphuric acid and turpentine  draughts,
 and " teacup diet" of milk and beef-tea,  with a wash of logwood,
 catechu, and sulphuric acid, for the mouth.
  On the  3d there was little  if any improvement in the  local
 symptom, but  his color and pulse had not failed.  He was bid-
 den, in addition to the previous treatment, to keep in his mouth
 a lump of ice smeared with powdered tannin.
  On the 4th the haemorrhage from the mouth was not lessened
 much; there was about three-quarters of a pint of froth-covered
blood.   It was stained brown by the local applications—in fact
tanned.   The  pulse was quicker and weaker, about 108 in the
minute and uneven.  An ounce and a half of infusion of digitalis
was ordered to be taken every third hour, and the sulphuric acid
and turpentine were left off. 
PURPURA.
353
  On  the  5th (yesterday) the pulse was  120  in  the morning,
110  in the afternoon, regular, even, and narrower than on  the
previous afternoon.   The haemorrhage was not diminished.   Sore-
throat, faintness, and  nausea were complained of.   After  he
had taken  six doses the digitalis draughts were given every four
hours  only.
  Late last night the breathing became short and difficult, and
he died early this morning.   Our secretary telegraphed to the
poor man's wife  at the village where they lived.  The telegraph
clerk was  unable at first  to deliver  the  message, there  being
several people of the same name in the place ;  but hearing that
a few days before  a man bleeding much  from the  mouth had
gone by train to London, he  tracked him backward from  the
station to  his cottage  by the blood which  had  been spat upon
walls and stones by the wayside.   This shows that  the account of
the excessive haemorrhage before admission was not exaggerated.
  [A post-mortem examination was made on the 8th, two days and a half after
death.  The whole front of the body was covered with spots of purpura, of which
those on the  chest had pale-yellow centers.  The rest of the skin was very pale,
and there were very few  spots on the back.  There were numerous spots of pur-
pura on the pleura, pericardium, small intestines, bladder, bronchi, trachea, and
larynx.  In the upper part of the latter organ they became more numerous, and
in the fauces and tongue formed a continuous discoloration.  On the tongue
they were black and swollen as before death, and from the pillars of the fauces
blood oozed on their being handled. There was no purpura on the oesophagus.
The left auricle contained  a firm  non-adherent clot of  fibrin, and there  was
another similar clot loose in the aorta.   The heart was hard and firmly con-
tracted.  The ventricles are preserved unopened.  The other viscera were quite
normal in appearance.]
   Case 2.  Jane N., aged nineteen, spinster, came in  on January
29.   She has a  transparent ivory complexion, firm large limbs
and muscles, and an aspect of strength.  She has ahvays enjoyed
good  health, but during the last three months  the catamenia
have  been very profuse, and have gone on  lasting  longer  and
longer each period, till now she has hardly a week's interval.
During the week before admission she several times found blood
in her mouth, and on the 26th purple spots came out on the face,
arms, bosom, and legs,  and continued  to  increase in numbers
daily.   They were  of  sundry sizes, from that of a mustard seed 
354
PURPURA.
up to that of a pea, the smaller  being far the most  numerous.
They were of an intense purple color,  and presented  a  singular
appearance  from their striking  contrast with her clear waxy
complexion, the hue being perfectly complimentary.   Their sur-
face was not raised above the neighboring skin.  I saw none on
the mucous membranes of the mouth, but her gums looked a little
red at the edges.
  Her bowels were regular.   The urine could  not be examined
on account of the presence of the catamenia.   She had lost her
appetite, but I think  that was accounted for  by her sorrow at
parting with  her mother and coming into  a hospital,  as she has
eaten fairly since she has found it to be not such a terrible place
as she fancied.
  She was ordered the following :
           I^s Dilute sulphuric acid, min. xxx,
              Tincture of digitalis, min.  xv,
              Camphor water, fl. oz. j,
                             every 4  hours.
              A teacup of milk or beef-tea every 2 hours.

  On the morrow I  found  her appetite was not so entirely lost
as she said ;  so I ordered her  broth and meat, potatoes and  a
lemon, and on February  3 ordinary meat diet.
  Twenty-four hours after commencing the  medicine  I pointed
out to you that the center of each spot was lighter than the cir-
cumference.  It became  distinctly yellow  to the naked eye, and
the dark color gradually faded away altogether by February 4.
The  sanguineous discharge ceased  at  the same  time.   She is
quite convalescent, but I observed that after an  interview with
her mother yesterday she was paler in  the lips  and depressed in
spirits; so  I shall keep her in a little bit  to watch against a re-
lapse and give her a  good rest.
  Case 3.  William  H., a  butler, aged forty-five, was admitted
on January 29 sinking with emaciation,  anaemia, and  pain in
the cardiac region.   The anatomical lesions found at the post-
mortem examination  on February 3, were a  dilated heart, with
its mitral valve degenerated into wart-like growths, and kidneys 
PURPURA.
355
 atrophied through  the  occupation of their substance by many
 curiously large cysts.
   The imperfection of the mitral valve  had been  known before
 death, but  that did not explain the disease;  and the circum-
 stances prevented any further diagnosis, or much  association of
 the symptoms during life with the appearances on  dissection.
   The chief causes of death  do not  therefore offer a profitable
 opportunity of clinical instruction, and  I cite the case to-day to
 notice a  secondary phenomenon.  Two  days before death there
 appeared a large blotch of purpura  on  the nose, occupying the
 greater part of the feature, and another spot on the  left hand,
 which was  slightly  cedematous.  The discoloration remained in
 the dead body.  The blood was fluid.

   These three cases present to you three aspects of purpura.
   In the  first two the disease was due to a marked loss of func-
 tion in the capillary vessels, so that their  coats w7ere ruptured,
 and the contained fluid oozed out. In the first danger arose from
 the accidental location of this oozing in  a loose surface, so that
 the  haemorrhage was excessive.   In the  second there was no
 danger at all.   In the third the deficiency of the capillaries was
 at a minimum, and  would  not alone  have given rise  to extrav-
 asation ; but it was supplemented by the impediment to the  cir-
 culation in  the heart, and probably by the retention of urea in
 the blood.  It  was in itself unimportant.
   Like all diseases of the peripheral circulating system, purpura
 is most common in the parts most distant from the center.  Such
 is the rule, though its want of universality is exemplified by  the
 instances  before us.   But it is not most common in the most de-
 pendent parts, and in the legs it appears as often on the front as
 the back,  on the body almost  always on the front.   This seems
 to remove its etiology from the category of being primarily trace-
 able to lesion of the central organ of circulation or of the mass
 of the  circulated fluid.  Were such its origin, it would  appear in
cases where the first is most affected, and in places where the
latter is most abundant and most unhealthy.
  You must not fall into the old-fashioned error,  inculcated when 
356
PURPURA.
I was a pupil, of lazily attributing all illnesses where the blood
is abnormal in composition to "diseases of the blood," and there
ending it.  The blood is like  a pond or reservoir attached to some
great manufactories: the refuse of the manufacture flows into it,
and the engine boilers are fed from it; waste products and latent
power are mingled in its streams.  If there is anything unusually
foul in the water, the master does not lay the blame of that foul-
ness on the innocent element, but traces it to defects in  the pro-
cesses drained  and fed.  So in purpura, the circulating fluid is
probably always abnormal;  but it is surely unwise  to  stop our
explanation at this point,  and to search no further.   For the
haemorrhage, whether free or into  the cutis, makes it abnormal,
and the degeneration of  the red disks, discernible by the micro-
scope, is just  what is found in cases where there is no purpura.
 It is  surely going  backward, when the function we see to be  de-
ficient (namely, the retention of the blood) is  a function of  the
 capillary vessels, to say that their diseased contents  are a cause
 of that deficiency.
   On this pathology is  based  the treatment.  The less severe
 cases will recover  under the use of cool, unirritating, but nutri-
 tious diet with vegetable and  mineral acids,  which astringe  the
 capillaries.  I think very possibly  the  young woman, Jane N.
 (Case 2) would have done so;  though not so quickly as she  has
 now  done, because mineral  acids  alone  are slow to  stop menor-
 rhagia, with which, as well as  with purpura, you will remember
 her  to have been affected.   But you saw that this treatment had
 no influence over the dangerous purpura of  the first patient,
 although supplemented by other very povverful astringents.  The
 most powerful remedy taken in both instances  has been digitalis,
 whose agency in diminishing  the  area of the circulating system
 (probably through the functions of the involuntary nerves) I have
 often pointed  out to you.  Under  its use the artery  becomes
 smaller,  the  pulse-wave is narrowed and haemorrhage ceases.
 This happens not only when the haemorrhage is on the loose  sur-
 face of  a mucous membrane, but when it is subcutaneous.
   You saw the purple  blotches on  the young woman fade aAvay
 at a marvelously  quick rate;  and you saw them  fade aAvay from 
PURPURA.
357
the center, not from the circumference, exhibiting yellow spots
in  the middle while the rim was still dark, thus proving that the
action is not merely peripheral, but internal.   At the same time
you heard that the vaginal haemorrhage was equally ceasing, as
it  usually does in  simple menorrhagia under the action of digi-
talis.   In the first related case there is no evidence of curative
action,  except the yellow centers to some of the blotches seen in
the dead body.  In the third case the purpura was such an un-
important part of  the  patient's illness, that it had no treatment
at all.
   The chief caution which  I think it necessary  to give you about
the administration of  this remedy is, that you should provide
against the danger accruing  from the  sudden uprising of the
patient.  From the diminution of the area of the vessels so much
less blood is sent up into the brain, that fatal fainting may ensue
if the usual hasty demand  entailed by this change of posture  is
made.   The symptoms of deleterious action, and which warn us
to suspend the employment of digitalis, are giddiness and nausea,
accompanied sometimes by irregularity of pulse.  Dilatation  of
the pupils, cold  sweats, and complete syncope, alluded to in your
books of materia medica, are late phenomena, which I have not
had an opportunity of witnessing, and before  the supervention
of which you ought to have left off your drug.
   Digitalis seldom, if  ever, begins to do harm till it has  ceased
to do good, and till therefore the necessity for it  has  passed.
When the condition for which  it  may be wisely prescribed has
passed  away, then, and rarely before then, its poisonous power
is exerted.   And  the more and more the original morbid con-
dition is  departed from, so  is the  novel morbid  condition, the
poison by the drug, developed.   Hence its action appears to in-
crease.   Metaphorically it maybe called "cumulative;" but the
use of that word must  not lead you to suppose  that soluble alka-
loids, such as those in foxglove, are likely to accumulate in sub-
stance  in the blood.   The stricter explanation would be that  its
action is permanent, and therefore that each new dose adds to  it.
   This account  of the  action of digitalis affords a reason for the
plan which you see me adopt, of  diminishing forthwith the dose
directly that a beneficial effect has began to be produced. 
358
PURPURA.
          (Clinical, St. Marys, February 25, 1864.)

   Having very lately lectured on the subject of purpura, I shall
bring before you, as an addition  to that  lecture, another  case;
though, as a fatal one and not  seen by you or me during life, it
is but little instructive taken singly.
   Tavo days ago a man, apparently of about thirty, was brought
in evidently moribund, who was stated to have had "typhus-fever."
He died an hour and a half afterward, without  having manifested
any diagnostic symptoms.   At the post-mortem examination yes-
terday, we observed on the dorsum of one foot a small spot of
purpura, another at the side of the leg, and a good many  more
on the back.  The largest were about one-eighth of an  inch in
diameter.   The skin in many parts of the person was mottled,
like that of a. corpse when  decomposition is commencing, the face
was purple, and the scrotum Avas reddish purple as if bruised.
The body was well proportioned, and there was a healthy quan-
tity of firm adipose tissue in the walls of  the  belly.   The heart
was hard and large, weighing with the pericardium one pound
ten ounces.  The pericardium was universally adherent,  as if
from long-past inflammation, no connecting fibrin  being visible.
The valves were healthy,  and in the cavities were contained the
usual fibrinous coagula; there were none in the arteries or veins.
No trace  of chronic organic lesion was detected  in  any other
organ.
   I show you here specimens removed from several of the viscera,
which present a singular and uniform appearance, the differences
being assignable generally to their different anatomical structure.
Here are pieces of the brain, of the  liver, and of the small in-
testines,  the kidneys, and the  heart.  You see scattered  over
them, iriside and out, dark spots of  purpura, such as I have de-
scribed on the skin.  This gives a very  strange aspect  to the
kidneys, which look like the speckled belly of  a trout. In a few
of the spots the fibrin seems to have  separated itself,  forming a
yellow center to the effused blood.   There is no halo  of inflam-
mation around any of them.  Many of the spots in the liver are
more yellow than red. 
PURPURA.
359
   In the brain the spots are large, and branch  out  along  the
 course  of the vessels on the surface.   In the right anterior lobe
 the nervous substance  is broken up by a large black  gelatinous
 clot of blood.   It is evidently, as you may feel, of considerable
 size, at least twice as big as a chestnut, but I wish to harden it
 in spirit before  I  make  a section.  There are two  more clots
 about the size of small  peas at the back part of the hemispheres.
   No other abnormal  appearances were  observed, and this clot
 in the brain is enough to  account for death.
   The  history of the case, which  I  have since obtained, is as
 follows: The patient had previously suffered twice from  acute
 rheumatism, and since November last had been badly off, living
 principally  upon potatoes and bacon, but was in his usual health
 and spirits on the 18th  instant.   In the evening of that day he
 was attacked with sickness, pains in the joints,  pain in the side,
 thirst and feverishness, which symptoms  went  on from bad to
 worse.   On  the  21st he was  seen  by Dr. Asprey, the medical
 officer of the Western  General  Dispensary, and found to have
 excessive pain in the joints and a brown tongue.  In the evening
 he became delirious.  On the 22d  Dr.  Asprey found  him in a
 state of partial coma, but capable of being roused  by effort, and
 certainly not anywhere paralytic.  The  tongue  was  dry and
 brown,  and  the pupils  dilated.   On  the  same  evening he was
 brought to the hospital,  as I have related, just before he breathed
 his last.
   This  case shows  how serious may be the  consequences of
 purpura, a  condition which,  judging  from the more ordinary
 examples seen by us, we are in the habit of rating low down in
 the scale of  causes of mortality.
   In such a case of  cerebral haemorrhage as this  paralysis  and
 apoplexy Avere not to be expected, because the central  parts of
 the brain*were not pressed upon,  the sanguineous effusions tfking
 their origin from and being confined to the surface. I remember
 the case of a young  woman, who, after a mental affliction, died
Avith  tvph-like symptoms  not very dissimilar  to this  man's.
There Avas found in the  brain a clot of blood so large  as to con-
ceal the greater part of  one  hemisphere, but it was thin and lay 
360                      PURPURA.

quite on the surface;  so that I suppose it did not  compress the
inner portions of the cerebral substance; for there had been no
paralysis.   It is  not  so much  the size as  the shape, and  still
more the situation of clots which make  them apoplectic  or  not.
A clot,  one-tenth of the size of this, in the fornix or hippocampi  •
would certainly have been apoplectic.
» 
LECTURE   XXVII.
                        ANAEMIA.

 Part I.—History of a case of ansemia—Objections to the no-
     menclature of the disease—Its pathology—It consists of a
     functional deficiency of life in the blood-making  organs—
     Application  to  this case—The .defective  morbid anatomy
     does not impede our  treatment—Transitory curable states
     usually dependent on  the mucous  membranes, which have
     little post-mortal anatomy—Sketch  of the active life of mu-
     cous membranes—Their importance in disease—Effect  on
     health of their diminished vitality—Application  of this pa-
     thology to practice—Intention of treatment to introduce ni-
     trogenous food,  iron,  and  chlorine—Mode of doing  this,
     its effects, and reflections thereon.
 Part II.—Effect of  ansemia on the mental faculties—Practical
     deductions.
 Part III.—Ansemia, when the  result of permanent  organic  le-
     sion, amenable to  the same  treatment as when functional.

      (Part I.—Clinical, St. Mary's, November 15, 1861.)

   I am going to make the common and  typical case of anaemia
a text on  which to  hang a few practical observations on  that
disease.
   You will all remember the corpse-like  paleness, made all the
more striking by red  hair, of a girl we first visited this day fort-
night,  named Margaret C.  She  smiled courteously,  though
quite  unable to raise herself from the bed, and in  answer  to
cross-examination, gave her  history as follows:
   Her age is twenty,  and she seems to have had generally very
       24 
362
ANAEMIA.
good»health, as is shown by her remembering that she had such
an unimportant discomfort as a pain in the right side when she
was a school-girl of seven.  She Avas carefully brought up by a step-
father in a higher class of life ; but three years ago she lost him,
and had to go into service  as a housemaid at the age of seventeen.
For that work she  was scarcely strong  enough, and  had been too
tenderly nurtured; so after eighteen months' trial she gave it up,
and was  apprenticed to a  Berlin-wool  shop.  There her  mental
superiority was recognized, for she quickly became forewoman
with three girls under her in a shop at  Maidstone.   She felt the
responsibility a good deal, and also thought the closeness of the
shop did not suit her, although it did  not seem to  make others
ill.  However, she  retained in her face a high color, for which
she seems to have been somewhat admired,  till nine months ago,
when she began to lose it,  and in a few  weeks became as Avax-like
in hue as she is now.   In the first stage of her ailing the appe-
tite was large, so that she always felt in want of food; but after
three months it failed, then ceased entirely, and she  took a dis-
gust to all nutritious articles of  diet.   She had a good  deal of
pain in the epigastrium and to the left side of it, and also suffered
from palpitations and pain of the heart.   A quarter of a year
ago she spat up some blood, and had a  little cough,  which fright-
ened her much.   Thrice during the  nine months  she  has had
attacks of low spirits with crying, but  there is nothing abnormal
in a girl being sad when she is  out of health, or  in  her crying
when she is sad, and Margaret C. does not appear  at  all hys-
terical now.   The catamenia had always been quite regular and
sufficient till the commencement of the anaemia nine months ago,
when they began to get scantier  and scantier, and at last ceased
entirely.  The urine is  pale and watery,  the  stools are scanty
and steadily rare;  but there is never  any sudden gush of bulky
stools, no diarrhoea alternating with constipation, or  other indi-
cations of accumulation of faeces  in the intestines.
   The patient expands her chest  perfectly,  and  there are no
signs to give rise to a suspicion of pulmonary tubercle, or  at all
events  of  tubercle  in  such a quantity as to account  for  the
anaemia.   There was at first a soft systolic murmur in the heart 
AN.EMIA.
363
when she was agitated; but it went away after she had rested in
bed five days.
  First, for the  name by which I have already designated  this
girl's disease.   Anaemia, or "bloodlessness," means in scientific
language a deficiency in the red disks in the blood.  The word
has  been  objected to because  it has  been supposed to imply
etymologically that there is a deficiency in the actual quantity
of circulating fluid, of which deficiency in quantity there is truly
no proof.   And "spanaemia," or "thinness of blood," has been
proposed in its  stead.  Such  accuracy would be highly praise-
Avorthy, if it Avere only accurate;  but really the mere  fact of
thinness does not hit  the essential feature of the disease; for the
specific gravity of the blood might be raised as high as you like,
but  if you did  not  restore red  blood-disks nothing would be
gained; the morbid state Avould still exist.   In truth there is no
occasion for fault-finding.  " Anaemia," by the analogy of Greek
etymology, does not  mean  deficient  quantity of blood, but  de-
ficient quality,  just  as it is  in Aristophanes, anpoauTzoc does
not  mean a man  "without a face," but "with an ugly face,"
tlvapidfioc means  " difficult  to  count," and  so  on in numerous
instances of the use of the  a privative.  I  shall therefore  con-
tentedly use the term anaemia to include all cases in which  the
amount of blood-disks is below the normal proportion.
  Anaemia has  existed during life in the  patients  from whose
bodies has  been taken a great number of the organically changed
tissues which you see preserved in museums and  shown in  lec-
tures on morbid anatomy, and which may also be  found out by
diagnosis.   In  other cases of  equal import  and  prominence
anaemia is  Avanting.  Again,  very  frequently  you find  it in a
high degree in  cases  where there can be discovered no  organic
changes of the solids at all, and where from the transitory nature
of the bloodlessness there is reason to conclude that such organic
changes  do  not  exist.   Under  this  last  category comes  the
patient who is the occasion of to-day's lecture.
  To understand how it is that so many causes  are followed by
the same effect  and by an  effect not  at all  proportioned  to  the
general importance or want  of  importance of the. cause,  you 
364
AN.EMIA.
must reflect upon the true relation which the blood bears to the
rest of the organism.  It may be compared to a chief thorough-
fare in a great city.  Very few trades, still fewer manufactures,
are carried on  out of doors, or in the street itself, yet from the
nature, the  number, the pace, and other characteristics of the
passing vehicles and people, a pretty shrewd notion of the com-
mercial activity of the population may be formed.  An observant
foreigner standing in Cornhill and viewing the quick steady pace
and careful yet healthy faces of the many-classed Avayfarers, the
well-packed loads of the vehicles, and  their varied  contents,
could not fail to know that he  was in.the center of a prosperous
trading nation.  But it  would not be, or ought not  to be, the
mere numbers  of the people collected together that suggests to
him the observation.   On last  Saturday he would have  seen a
greater  crush  than usual at the same place, but on inquiry he
would have found that it was only in consequence of all business
being suspended for Lord-Mayor's day.  And at Naples, till
lately, the lazzaroni and  pickpockets who blocked up the pave-
ments in the main thoroughfare were evidences of trade being
not only  stopped there, but made  impossible by a  horde of vil-
lains.  So that it  is  not  the fact  of crowding which should
connect the idea of wealth with what is seen.
  In the blood the physician traces proof of constructive meta-
morphosis (the  city's manufacturing industry), destructive meta-
morphosis (its  consumption), and effective  life (its social hap-
piness) being  carried on.  But as our intelligent  traveler,  in
estimating the wealth of  a  community, must not be deceived by
an  idle  crowd  at one spot, so  the medical philosopher must not
set down mere local congestion as proof of wealthy blood.  In both
experience finds strong presumptive evidence of something amiss.
  Neither must a mere  bustling throng  be reckoned as indus-
trious citizens.   There are cases where a large amount of solid
matter, even where a large amount of  red disks in active motion,
adds no more to the usefulness of the circulating fluid than the
lazzaroni to Naples, and  which therefore, as far as treatment is
concerned, are  really in  the same  category as obvious anaemia.
Of  these I shall take a future  opportunity of speaking. 
ANAEMIA.
365
  But though crowds are no evidence of sound political  health,
yet it is certain that deserted streets prove political disease.   So
anaemia, or deficient redness in  the blood, shows a deficiency of
life in the ministers  to that redness; either the supply of food
is too small, or its assimilation is defective; in either case the
supply of red disks, either absolutely or relatively, is not  com-
mensurate with the existing demand.
  In  many  instances of  anaemia  it is  easy enough tp lay the
finger upon the instrument of life which is to blame. We detect
without difficulty causes at work to produce it—starvation, which
anybody can  understand, leads to an absence of the organic mat-
ters made out of food; degenerated stomach, in which the ali-
ments are not prepared for  assimilation;  degenerated liver and
duodenum, producing the same  result; lesions of  intestines or
their  glands,  checking the imbibition of adipose matter,  and so
preventing cell growth; changes in the  spleen or lungs—organs
which our physiological experiments, independent even of our
observations of morbid phenomena, show to be answerable for the
formation of new blood-disks in a way yet unknown; mental de-
rangement, care, disappointment—which  so readily arrests the
activity of the  assimilating viscera; these agencies, and many
more, are readily comprehended as causes of anaemia.  But there
are many cases where nothing obvious of  this sort  is to be made
out, yet where the paleness of the blood seen in the face, lips,
tongue, or in a drop  taken from  a pricked finger, and where evi-
dences of it in fainting, weakness, palpitation, anasarca, amen-
orrhoea, &c,  are  even more marked than where  demonstrable
lesion is  to be  found.   So  it is  in the present instance.  The
young Avoman's history gives no reason to suspect any organic
disease of the lungs or other organs, and the  functions of life
were fairly performed till she began to get pale and languid nine
months ago.  The want of red blood, which we look upon as the
important feature  in her case, also attracted her own attention
particularly,  as  she had  previously had an ornamental fresh
color.  Then, after an interval amply sufficient  to enable  us to
separate  cause  and  effect, come the  symptoms which I wish to
notice as the consequences of anaemia.   Causes, no doubt,  they 
366
AN.EMIA.
are in some instances, but  here  consequences.   I mean the loss
of appetite, impeded circulation, amenorrhoea, haemorrhage from
the respiratory organs, and hysteria in a person previously unaf-
fected in that way, which are noticed in the case-book.
   The only explanation she can give of her loss of  health is her
having been employed in  a shop less  perfectly ventilated than
she had been used to, and having the main responsibility of the
concern thrown upon her.   Alone neither  would have been suffi-
cient, as  the shopwomen under her do not appear to have suffered
from the air; while, on the other hand, women engaged in retail
business  are not as a rule anaemic.   But still I think that both
together  may perhaps be fairly charged with the* blame, for while
the increased  mental labor was increasing metamorphosis, the
the greater demand was not responded to by greater supply, but
on  the contrary assimilation was  checked  by  the  comparative
unwholesomeness of  the respired air.
   The not being able to trace deeper the anatomical cause arises
from the  imperfection of  our  knowledge,  but it  does  not arise
from neglecting to apply such knowledge as we  possess to prac-
tical medicine.   If  we were to make an autopsy of this patient
instead of curing her, we should in all likelihood see no more
solid lesions capable of accounting for her disease  than  we al-
ready know of, we should probably find nothing abnormal in any
part.  So that you need not lament the opacity of your patients'
bodies, or suppose yoursehres likely to learn how to treat them
better if you could see their insides.
   Anaemia without  obvious  organic lesion, when properly man-
aged, is a very curable condition; and this should  still further
reassure you that you miss  nothing by not being able to study
its post-mortal pathology.   For passing and curable states leave
but faint  foot-prints  behind them for anatomists.   In a great
majority  of cases they depend upon morbid changes of the  mu-
cous membrane, of  all the tissues in  the  body the one most
speedily affected by decomposition after death, and then present-
ing the worst possible picture of its condition during life.
   The intestines, as the anatomist sees them, are about as much
like the intestines in health as the crumpled folds of dank parch- 
ANAEMIA.                      367
ment which surround the mouth of a corpse resemble the same
lips swelling with joy and expression.
  Let  the picture which is painted on our minds be taken, not
from the  dead-house,  but  from the familiar  view  of  our own
mouths in a looking-glass; for one sketch drawn from the life
is worth ten from the museum.   Turn down  the lower lip, and
observe the infinite life going on.   There  is evidently as much
blood as vessel;  and seeing that blood, from the quantity of solid
matter  visible in it, has a right to be called a semi-solid, this
membrane has  an equal right to be thought of  as  a semi-fluid.
And when we think of it as semi-fluid, let not the idea  of a stag-
nant marsh be presented to us, but of a headlong rapid.  It is a
useful way of keeping lively our feelings about the circulation, to
examine through the microscope occasionally the toe-web of the
slow-blooded frog.  The action and ceaseless whirl  of  the living
stream  we see there quite driA7es us  dizzy.  What  then must it
be in our OAvn warm selves !  If in  a membrane so little animated
as the  frog's toe, or the bat's wing, which by the naked eye we
should judge to be entirely devoid of  blood, we still are enabled
by our microscopes to see such a network of tubes conveying it—
if in a creature, the greater part  of whose blood is driven  from
the extremities to the center by the temporary fright we cau.se
in putting him under a microscope, we find such a busy scene of,
circulation, what must be going on in a tissue glowing with red
life and health!
  To the fault of the -mucous membranes I am disposed to lay
the condition in which we find our  present patient.  The two cir-
cumstances to which I have traced  the illness both act directly or
indirectly on this  tissue.   The mental exertion  involved in an
unAvonted  responsibility thrown on a conscientious person would
lessen the life of  the involuntary muscles which carry  along the
mass of food through the alimentary canal.  You know well how
long your food is in leaving the stomach if you  are called to an
important midAvifery case just after a  hearty meal; and several
commercial  and literary men  have complained to me of attacks
of vomiting (that is, temporary paralysis of the stomach) when
they took  dinner  alone, and so were apt to let  the mind dwell 
368
ANAEMIA.
deeply on some  interesting subject; and they have told me  in
wonder that they could  dine out and eat  and drink all sorts of
rich things  with impunity.  They  did not  seem aware of the
preservative value of frivolous conversation.
  At the same time that the moral causes thus impeded diges-
tion, the unwholesomeness of the air in the close shop where our
patient was employed poisoned the mucous membranes, diminish-
ing the vitality of their epithelium,  and causing them to be ab-
normally covered with a thick layer  of mucus.  By this tenacious
coating the entrance of alimentary substances into the veins and
absorbents was impeded, and the owner  pined in  the  midst of
plenty.   So all  the  usual  signs of  starvation followed.  First
hunger,—by no means a constant companion of chronic depriva-
tion of food, yet  sometimes present as here;  then loss  of appe-
tite, a much more frequent phenomenon; then paleness, languor,
weariness, and pain in  the stomach; then anasarcous  oedema,
and, in short, the other more marked symptoms of anaemia.
  You may observe that the loss in those constituents of  the body
which are of a nitrogenous chemical composition, is more marked
than that in the  hydro-carbonaceous fat.   The reason is partly
that the destruction of adipose vesicles is  somewhat shrouded by
the saturation of the tissue with  serum,  which gives  it a false
plumpness—partly that  fat, being absorbable  without  much (if
any) alteration, is easier taken up into the system than fibrin or
albumen, which require  a  chemical  solution  before they can be
absorbed.  So that, though starved, Margaret looks  but little
emaciated.
  All that I have now  said must have of course for its moral
some hints on the treatment.  My aim in anaemia is to introduce
as quickly as I can the largest  possible amount of (1) nitrogen-
ous food, (2) iron, (3) chlorine.  When I  say "introduce," I do
not mean "throw in," or get swallowed, but  cause to be assimi-
lated in the system.
  As regards the first, it is obvious that if  I had written down
ever so  many  "ordinary diets," one to whom the very sight  of
food was an abomination would have gained nothing by it; she
would  simply have gone without.-  I directed no meals at all  to 
ANAEMIA.
369
 be taken, and no solid food;  but a cup of milk with a third part
 of lime-water in it to be given as medicine every two hours, and
 a pint of beef-tea in divided doses during  the day.   After two
 days she managed to eat an egg also daily, and after twelve days
 of gradual  additions of this sort, you will find her on full allow-
 ance of mutton-chops, porter, beef-tea and milk.
   Iron is required to supply the anticipated new growth of red
 disks with their metallic constituent.   You cannot force into the
 system in any way sp certainly as by the  " mistura ferri com-
 posita "  of the pharmacopoeia.   Large doses of the more soluble
 salts of iron have an action on the  mucous membranes which not
 only prevents their being taken up, but also checks the digestion
 of other food.   Evidence of the last-named  effect is found in loss
 of appetite  and feverishness,  and in the rejection of iron and un-
 digested food among the blackened stools much sooner than when
 the  drug is  given in the  form named.   In spite of the elegance
 of preparations constantly put before  us, and recommended for
 their solubility, such as the chloride, acetate, citrate, phosphate,
 and other salts of iron, I often prefer the unchemical mixture.
 It seems as if  the carbonate which  is  preserved  from decomposi •
 tiorl by the  sugar, and the  finely divided  oxides diffused through
 the  thick liquid, were peculiarly easy of solution in  the water
 saturated with salts and carbonic acid, the solvent with which we
 have to do, not  only in  the stomach,  but throughout  the whole
 body.*
   I have found that some cases which  did not get on so fast as I
 could wish  under the above  treatment, made a sudden start of
 improvement  when to it there was added the administration of
 chlorine in the form of warm hydrochloric  acid baths.  More iron
 is taken up, the blackening of the faeces ceases,  and it may be
 that the  presence of more acid in the system retains more of the
 metal.  In a feAv cases I tried for experiment's  sake the hydro-

  * In reckoning the solubility of medicines, physiological pharmaceutists are
 apt to count the fluids of the body as distilled water, and because a Bubstance is
 not soluble in "that  medium, to call it insoluble altogether; whereas, if it be
soluble in water saturated with carbonic acid and salts, it is sufficiently soluble
for the purposes of life. 
370
ANEMIA.
chloric acid baths alone ; and even then it was beneficial, seem-
ing to confer  muscular strength in the same  way as the drugs
which are  commonly called tonic.   On these  grounds I cannot
but think that hydrochloric acid supplies  a distinct want in the
system, that it is a directly restorative medicine in anaemia.
   It is not difficult  to  make this empirical  observation accord
with rational  pathology.   In anaemia the  blood is more watery
than natural; the proportion not only of  organic matters but of
salts  is deficient.   Chloride of sodium is the most important of
these salts, and the supply of one of the constituents of this ma-
terial may be without fancifulness  conjectured to be an aid  to
that renewal of life, which is the end of all medication.
   Besides  the above-named medicines, you see that I have pre-
scribed Pil. aloes cum myrrhd, gr.  iv, omni node sumenda.   Do
not suppose that this is ordered  merely as a purgative, or that
any other  purgative would do as well.  On  the contrary, most
purgatives are injurious in anaemia.   Gamboge, sulphate of mag-
nesia, colocynth, mercury, and several others which  produce
elimination of serum and increase  secretion  generally,  do harm
just in proportion to their activity.   It seems established, by the
experiment of making them act as purgatives when injected into
the circulation, that  their soluble principles have a  destructive
agency upon  the blood;  whereas the  soluble  alkaloid  in aloes
(aloine) is, in  fact, a bitter tonic, and the purgative power of the
drug  resides in its insoluble resin.*   Its  action is  very moder-
ately eliminative—in small doses it slightly adds to the  solid ex-
creta of  the colonic glands, and elicits faeces  feculent  in smell
and of consistent form—while at the same time it retains by its
bracing bitter the formation of mucus.  See its action  on moist
piles, how  it dries them up and makes them smart!   And judge
from  this what  its  action on the  gastro-intestinal mucous mem-
brane is  likely to be.   At the  same time, by the more  vigorous
peristaltic  action and by the solid mass passed  along the gut, the
already  existing mucus  is cleared away.  Aloes is employed
strictly as  a clearer of the intestinal,  especially of'the colonic,
  * Headland on the " Action of Medicines," p. 331; and  Robiquet, in  the
"Journal de Pharmacie" for April, 1856, quoted by Dr. Headland. 
AN.EMIA.
371
membrane, and it is joined with myrrh, partly to divide  it mi-
nutely and make  a small  dose go further, and partly to get the
advantage of the  extra resin.

     (Part II.—Clinical,  St. Mary's, January 23, 1863.)

   In a young unmarried woman, who leaves the hospital to-day,
you may see an  example of an occasional  effect of anaemia to
which I have not  hitherto called your attention; I mean its effect
on the mental faculties.
   Margaret II., aged nineteen, a stout and well-made, but  small-
boned, girl from  the City of Cork, was admitted at Christmas
with pallor, palpitation of heart, oedema of ankles, loss of appe-
tite, amenorrhoea, and some other of the usual symptoms of anae-
mia without organic disease.  She was not at all hysterical. She
stated that she had been eight months in London engaged as a
maid-of-all-work,  and  attributed her present illness to the hard
labor entailed by that situation.   She was  ordered food  every
two hours and Griffiths' steel mixture thrice daily, and has been
taking the latter  up to the present time with the usual improve-
ment to her health.  So  far she exactly resembles a class of
cases, of which we admit two or three every week.
   The only peculiarity was her excessive sluggishness of body
and mind.   She would lie or sit for hours without moving  in the
posture she was placed in ; and if  desired to walk dragged her-
self along like a  sloth.   If questioned she sometimes did  not
answer, or confined her reply to rigid monosyllables.   This slow-
ness of  nervous and intellectual power remained even after she
had begun to regain color in her lips  and cheeks;  so that  the
sister and  nurses set her down  as naturally  half-witted, and
doubted the possibility of her gaining her livelihood as a servant
even  in the  humblest capacity.   As  she possesses more than
ordinary personal attractions, I dreaded sending out such  a sim-
ple-minded creature defenseless into the wicked world of London.
But during the last week some accident has set her to work at
crochet, and  I found her fingers nimbly twinkling at this  occu-
pation, which it seems she  had been accustomed to in Ireland. 
372
ANEMIA.
She was  encouraged to proceed, and to our  surprise the manual
operation, monotonous and mechanical as it seems to us, acted
like magic;  in a few days she became cheerful, laughs and talks
to the patients, and  has  turned out a brisk  girl of more than
average intelligence.  In consequence one of our hospital visitors
has proposed to get her a place as lady's maid.
  Doubtless the way was  prepared, by the  action of the iron in
curing the anaemia, for  a very slight extra  restorative agent to
enable her to regain her mental powers.   Still I cannot but at-
tribute very considerable  influence to the  habitual  occupation,
associated  as it is with memories of her former happier life,
taking her thoughts away from the dark noisy back kitchen of a
small London shop to the old merry days in County Cork.
  There were here two deficiencies to be restored:  first, that of
red globules in  the blood, which  was effected by food and iron in
the manner I have so often  explained to you;  and  secondly,
that of the mental faculties;  some new and brighter  associations
were required to excite her voluntary nervous system to  action
and to break the dull chain of her daily routine.  Accident sup-
plied this in the present patient's case, and with such good effect,
and  so strikingly, that I trust  you may be led to  make your
reason in other cases take example, and do intentionally what
was  here done by a  lucky chance.   Occupation, and that not
merely of an amusing character,  but of sufficient  interest  and
importance to require constant attention, is often a most valuable
aid to treatment.   I have known the little household duties which
are a woman's  function, even needle-work which must be done
by a  certain time, such as making  a pair  of slippers for their
doctor, have a most beneficial effect  upon the weakened mind.

      (Part III.-— Clinical, St. Mary's, February 6, 1864.)

   The cases entered  as anaemia in the register are usually such
as do not display signs of any organic lesion to account for the
deficient supply of red blood to the tissues.  And the knowledge
that these patients are  readily cured by iron is so familiar  to
you that  it seems almost like a  truism.  I am not sure  if you 
ANAEMIA.
373
equally entertain the fact that the same treatment is not less
applicable to those whose defect is explained, either mechanically
or physiologically,  by some  discovered structural change of a
permanent nature.  You are too apt to look upon this structural
change as the main point to be considered, and in consequence,
where  it happens to  be irremovable, you  do  not pay sufficient
attention to such results of it  as are really quite susceptible of
cure.
  To illustrate my words I will call to your recollection a young
Avoman who has just left the hospital.  On January 8  Louisa
0., an unmarried servant, aged twenty-five, was obliged to  be
sent up to bed with anaemia of a very marked  character.   There
was not a trace of red in her cheeks or lips even under the influ-
ence of excitement.   She was hardly  able to stand upright, and
the attempt to  do so  brought on  great faintness and giddiness.
The catamenia which last flowed, though  at  the regular time,
were of a greenish color.  She had palpitation of the heart, and
had been getting paler for several weeks, but the  inability to
stand was only of a fortnight's duration.  There was pain com-
plained of in the cardiac region, and a loud blowing murmur was
to  be  heard  with the first  sound.   This blowing murmur  was
very audible all over  the cardiac region and up the large vessels
into the neck, but loudest and of  a harsher character than else-
where  just at the level  of the aortic valves.  She could give  no
history of rheumatism, but had scarlatina some years ago.  She
was treated with iron mixture every three hours, and beef-tea
and milk  every two hours.  On the 13th she was able to eat a
mutton-chop.   On the 16th the lips were getting rosy, and she
Avas able  to color up Avhen  spoken to.  By  the 27th she had
gained a  very fair color, even Avhen not blushing, and she was
discharged on the 29th.  But the cardiac  murmur remained as
loud, if not louder, and was equally ringing in  its  tone at the
level of the aortic valves.  She went home registered  as"  cured"
(for it  had been indexed as a case of  " anaemia"), was supplied
with a large bottle of her mixture, and was advised every two or
three months to  take a ten days' course of iron in some form.
She was  warned also that  mercury,  purgatives, antimony, and
all debilitating medicines were very bad for her constitution. 
374
AN.EMIA.
  I have no doubt in my own  mind that this  patient's  central
organ of circulation is in an imperfect condition ; and the special
auscultatory signs induce me to  think  that the imperfect con-
dition consists of a narrowness of the aortic orifice.  It is true
that s"he has never had  any of  the illnesses which usually cause
cardiac  lesion, and therefore I do not suppose the lesion to be of
a degenerative kind.  I should conjecture it to have more of  the
nature of an arrest of development.  She is a puny, incompletely
grown  person, of slim figure, with narroAv hips and hardly any
bust, with fine  soft hair and a delicate skin.   Though turned
twenty-five, she has rather the aspect of seventeen.   I think it
very likely that the aorta and its valves have not grown with  her
growth, but  still retain  the caliber suitable for a girl.  She is
consequently unable to do woman's Avork;  and even  the usual
monthly discharge from the uterus, which is a relief to the fully-
formed  female  body, is too much for her.   For  the  supply of
blood to support such work is  limited by the limitation of area
through which it has to  pass.
  Whether the aorta will ever  make  up for  lost time, and,
though  late, accommodate itself to the body, I cannot tell.  But
I can tell by the results of this and similar cases that the watery
blood is capable of renewal, though it be watery in consequence
of a still existing cause.  And if any agent ever removes that
still existing cause, by renewing its imperfect life, I am sure that
agent will be healthy human blood, the best medicine ever devised.
  The warning I gave her was directed against an unfortunate
tendency, common to both the public and our profession, toward
commencing  treatment habitually Avith  destructive  remedies.
They call this " clearing the decks for action;" in a majority of
instances they throw overboard much of the best tackling in  the
ship and  loosen her armor-plates.  A  so-called " sluggishness
of the liver" is a frequent pretext.  In a half-nourished person
with pale blood, of course the faeces are light colored  and
ought to be scanty.  Blue pill gives them immediately a darker
color  and increases their  quantity, but  sadly at the cost of  the
patient's strength;  while the temporary change soon passes  off.
Meat and iron produce  the same  result, by giving them more to
be made out of,  and the improvement is a real and permanent one. 
LECTURE   XXVIII.
          PROMINENCE  OF  EYEBALLS.

Cases with commentaries—The pathology of the disease associated
     with  that  of  ansemia,  and the requisite treatment thence
     deduced.

             (Clinical, St. Mary's, May 2, 1863.)

  A young woman who left the hospital  yesterday exhibits one
of the occasional accompaniments of anaemia in a marked degree.
She is a subject of that state of the eyes called (somewhat  bar-
barously) Exophthalmia or Exophthalmos.
  Emily M., aged twenty-three, spinster, had been in since April
the 10th.  She is a leucophlegmatic flaxen-haired girl, but tall
and  well grown, "with great  marble  limbs."   Her  complaint
was menorrhagia, which had began a month before by a slight
attack of haemoptysis.   Of this she was soon  relieved by an
ounce of infusion of digitalis three times a day, a grain of opium
every night, and complete rest in  bed;  and I am  not going  to
lecture on that subject now.  She  has had  two attacks of rheu-
matic fever, the first when a child, the last tAvo years ago.  Four
years ago she  had measles rather  severely, and since that  date
her eyes have gradually got very  prominent.   The prominence
varies someAvhat with her state of  health, and on her admission
AA-as worse than usual.   Her left eye squinted disagreeably out-
ward, as  is usually the case Avhen  she is in her worst state  of
health.   On gently applying firm  pressure with the  fingers  to
the eyeballs, they may be got back to their natural place in the
sockets, and  at the  same time the cellular tissue beneath the
lower eyelid  swells out. 
376
PROMINENCE OF EYEBALLS.
   There is a slight dullness on percussion, accompanied by bron-
chial breathing, below the right clavicle.  There is a loud systolic
murmur in the heart, much most marked at the level  of the
aortic valves, and not affected by change of posture.
   This  prominence of the eyeballs is a pathological problem not
yet at all satisfactorily solved.   There are four ways in which it
has been accounted for :  first, by describing it as an enlargement
of the eyeball itself, a view advocated by Drs. Begbie and Stokes;
second,  by its protrusion in  consequence  of  hypertrophy of
the tissues at the back of the orbit, as is maintained by Basedow;
third, by a congestion and dropsical swelling of  the  same tis-
sues, accompanied by want  of  tone  in the ocular muscles, to
which Mr. Cooper ascribes it; fourth, by an increase of the fat
which forms the padding of the globe, which Dr. Heusinger has
found in two post-mortem  examinations.  These different views
are  described and enlarged  upon in the "Edinburgh Medical
and  Surgical Journal" for 1854, page 426, where you will  find
full references to the literature of the subject.
   The first explanation certainly can apply only to exceptional
cases.   In those  at present under my  care  no  enlargement of
the prominent organ can be detected; nor in two patients I saw
cursorily several  years ago, do I remember to have observed it.
Indeed, in the girl Avhose history I have just related, the globes
are  both rather small for one of her height and size.   I can
hardly imagine a tough,  leathery sac, like  the eyeball, swelling
without a local disease of its  coats, such as cancerous degenera-
tion  for example; and  that  would produce  a disease of quite
another class, and not to be confounded with the subject of  this
lecture.   " Hypertrophy "  of the tissues at  the base of the orbit,
suggested by Basedow, would  imply a persistent and irremediable
condition;  whereas I  am sure that the eyes are at some times
more .prominent than at  others, and that considerable improve-
ment may take place.
  My own  impression is that the slighter and incipient cases may
be quite accounted for by  relaxation of the muscles,  and that
would soon be increased  by a consequent filling up of the tissue
by fluid  and congested vessels.  I incline therefore to the opinion 
PROMINENCE  OF EYEBALLS.
377
giA'en by Messrs. Cooper and Dalrymple, who attribute the dis-
ease to this cause.
  At the same time it must be observed that Dr. Heusinger sup-
ports his opinion as to its dependence on an increase of fat in the
post-ocular space by two post-mortem examinations, in which he
found that condition  of things.   And I do not see any incon-
sistency in supposing  that while the lighter cases are explicable
in the way I have first advocated, the fatal and more protracted
should exhibit  a more permanent morbid change.   The deposit
of fat in the tissue is quite analogous to what takes place in parts
which have been stretched or temporarily enlarged, such as in
the mammae or abdominal  parietes after frequent pregnancies, in
old hernial sacs, in the  scrotum  after long-continued varicosity
of the veins, in the ear and lips after they have been unnaturally
stretched in accordance with savage ideas of ornament.

  I mentioned having two other cases now under my care.  As
it is rather a rare disease,  I shall take the liberty of breaking my
usual law for  clinical lectures and of relating their  histories,
though I cannot enable you to verify them for yourselves.  Mary
B., a surgeon's daughter  now aged thirty, first came to me in
June last year.   She  had  been for several years the unremitting
nurse of an invalid mother, and  restricted from the enjoyments
almost essential to the  health of her age and  sex.   For three
years the  catamenia had  been irregular,  and sometimes absent
for several months at a time.  Her face and lips were pale, and
her skin fair and delicate, easily flushing with  excitement.   Six
months previously she had a severe pain  in the region of the
heart, and her doctor  told  her it was "rheumatism of the heart,"
and  she had  also  suffered from  palpitations.   About that time
she began to perceive a prominence of the eyeballs, and this had
gradually  become  so marked as  to  make  her uncomfortable  by
the observations it excited among her acquaintance.
  Examination of the chest showed  the lungs to be quite healthy.
The action of the heart Avas sharp,  and there was a short harsh
scrape audible toward the  end of the first sound  at the level of
the aortic  valves. *
25 
378             PROMINENCE OF EYEBALLS.

  I ordered her to take an ounce of the following mixture twice
a day:
     ly;  Tincturse ferri sesquichloridi, Tfij,
        Strychnise Jiydrochloratis, gr. \,
        Tincturse digitalis, 5j,
        Misturse camphorse, 5x.
     Fiat mistura, cujus sumantur cochlearia ij maxima bis die.

  I kept her in London a few Aveeks as a rest, and since  then
she has  taken  every two  months a  three  weeks' course of the
medicine.  She sends me  word that  now Avith the  improvement
of her general health the eyes have become much less prominent,
and that she is by  no means remarkable in  her appearance.
  The other case  is that  of a puny  woman of about fifty, who
says she has been  always  ailing all her life, but never quite ill.
She is the subject of a goitre of the central  part and right lateral
lobe  of the thyroid gland.   There is  also a good deal of palpita-
tion of the heart, but I cannot satisfy myself of the existence of
any decided murmur.   She is a very timid nervous person, and
has some sort of fits, probably of an hysterical nature.   I gave
her iodide of potassium, and applied iodine externally to the tumor
of the throat.  But after  three weeks it Avas  but little, if at all,
reduced, and she felt sure  that her general  health was the worse
for the  treatment.  So  then I gaAre  her iron in full doses, and
she seemed stronger again.  She was at this conjuncture much
thrown  back by the alarm occasioned by a fire in her house. Her
eyes are no better, but she is an unsatisfactory patient, and I
question Avhether she perseveres in her medicine.
  Another case came under my care in the hospital during the
first  week of 1859:*
  Charlotte B., aged thirty-nine, a dressmaker, hadbeen in poor
health for more than three years, and had always been a weakly
creature, of pale leucophlegmatic aspect.   At the period named
a swelling about as big as  an egg came in the front of the throat.
It was hard and had increased in size gradually to that of nearly
three eggs at the  time  of admission.  Latterly there had  been
                    * See Case Book XIX, p. 95.  - 
PROMINENCE OF EYEBALLS.
379
strong pulsation in it, and it had caused occasional dyspnoea, for
Avhich leeches had been applied a week previously, with tempo-
rary relief.   She was hysterical and had a nervous cough of a
spasmodic, noisy character.  Both eyes wene  excessively promi-
nent, and this prominence she said had first been observed a year
before, and had increased up to admission.
   I cannot tell you much more about this case, as I was just then
obliged to go abroad, but she is shown by the register to  have
left the hospital at Lady-day, and has not been again admitted.
She  has attended from time to time, however, as an out-patient,
and finds  the occasional course of steel she gets beneficial, or she
would not come for more.   I  have seen her about in the neigh-
borhood, and her eyes seem no worse.
   All these cases, and indeed all the cases recorded by Ararious
authors, so ably collected by Dr. Begbie,* however much  they
may differ in minor details, agree in connecting the disease Avith
anaemia, and especially Avith those  tendencies in anaemia to dis-
order the  heart and the growth of the thyroid gland. Experience
seems to refer the goitre, the weakened heart, and the protrusion
of the eyeballs to the same motive causes.   They may not be
connected with  one another,  but they are all connected  with
anaemia.
   Although, therefore, the direct  mechanism by which  the eye-
ball is pushed outward may be  obscure, it seems to me that we
know enough  about the  ailment to  be quite satisfied as to the
right treatment, the most important point for both the  patient
and ourselves.  Courses of steel and restorative diet, rest of body
and ease of  mind are the  most effectual means of recovery, and
seem  to have been adopted by  all those who have mentioned their
treatment in  the histories they put on record.
  In  addition to this I should  direct the  patient to  gently press
back the eyeballs,  and to wear a bandage  over them at night.
  We know  enough about the  ailment also not to be alarmed at
it, and to  assure our patients that it is not of a nature  in itself
fatal to either life or sight.
* "Contributions to Practical Medicine," 1862. 
380
PROMINENCE OF EYEBALLS.
            (Clinical, St. Mary's, May 30, 1863.)

  Elizabeth M., aged sixteen, about whom I have been lecturing'
as having pneumonia and typh-fever, is worth  observation also
on account of the singular expression given to her face by eye-
prominence.   It seems she has  always been a delicate child, and
she has had several  acute illnesses of which the  last Avas rheu-
matic fever, accompanied by pain in  the heart, two years ago.
There  are clear signs of regurgitation through the mitral valve
now heard by  auscultation, but  no other evidence of cardiac dis-
ease.   She is  now flushed with  the fever and pneumonia, but is
generally pale, and is thin and  weak looking.   Though she is of
full age, yet her mother says she has  not yet been monthly, and
her bust is quite child-like.
  This unnaturally protracted childhood is a frequent accompani-
ment of valvular disease of the  heart; so common is the associa-
tion, that it has not rarely been the very phenomenon which has
drawn  my  attention to the heart; and led  to  my  finding out
cardiac lesions before unguessed at.  It  continues often till after
twenty years of age.   I take the explanation of the facts to be,
that from obstruction or regurgitation  in the central organ blood
enough is not spread over the  body to  carry out the functional
development fitted to the time of life.   Here you see a striking
instance of it.
  In marked contrast to the undeveloped  mammae is the throat
of  this girl.  It has the full  round  form,  swelling out in the
middle and sides, characteristic of plump and perfect womanhood.
On examination by the hand this is found due  to a soft enlarge-
ment of the thyroid gland—an enlargement which I told you in
my last lecture on this point is very commonly associated with
the eye-prominence  of which our patient is the subject.
   Like the last instance we had of this  disfigurement it is stated
to be worst when the patient is ill, and indeed it has become more
remarkable since she has  been in the hospital;  as has also  the
goitrous swelling,  which at first was  scarcely perceptible.   I
mentioned to you before the same thing as occurring in the case 
                PROMINENCE OF EYEBALLS.             381

of a surgeon's daughter, whose eye-prominence is aggravated by
severe  dancing, long walks, and the like.  Couple with this the
fact that it entirely disappears after death, the eyes receding
completely  into  their sockets, and  I  think you have evidence
enough that  however long and obstinate it is still a temporary
curable disease; and moreover, what is of more consequence,
evidence enough to lead you to the means of cure, namely, those
remedies which cure anaemia.   This swelling of the thyroid is of
a sort which will be more benefited by iron than by iodine. 
LECTURE  XXIX.
             ATROPHY  OF MUSCLES.

Part I.—Cases—Pathology—Treatment—Questions respecting
     hypertrophy.
Part II.—Case of dropped  hand from  the  poison of lead—
     Pathology of this form of paralysis and its connection with
     colic—Reasons for not  considering its localization as  de-
     pendent on the  immediate  absorption of lead—Treatment
     with  iodide of potassium, sulphur baths, splints, electricity,
     quinine, oil,  and blisters— Which beneficial, which hurtful.

       Part I.—(Clinical, -St. Mary's, June  13, 1863.)

  Nathaniel B.  is a thin ascetic-looking man, of a faded-leaf
complexion, aged  forty-five.  His expression  recalls some stern
" Bind-their-kings-in-chains" of the Great Rebellion,  or those
faces one  sees in old Spanish monasteries, not in  the  flesh, but
looking out of the grim  canvas  of  a Zurbaran or a  Ribrera.
Nathaniel B. is a top-sawyer  by trade, and was  always a hearty
fellow, able to do a good day's work, till ten months ago; when,
after violent exertion in turning over a mass  of timber, he got
what he calls "a wrench" in the pit of the stomach, and " has
never been the same man since."  The  appetite failed and there-
with the strength; the muscles wasted, and the whole body grew
emaciated.  The  loss  of appetite then became entire,  and  then
increased  to an utter loathing of food.  He went into Guy's Hos-
pital three months ago, but left apparently dissatisfied and un-
grateful.  On gaining admission to St. Mary's, May  22, he seemed
much cast down, expecting never to get any better.   He  was
able to walk about, and the  chief loss of power seemed in the 
ATROPHY OF  MUSCLES.
383
shoulder muscles, the deltoid and  biceps; and when he  tries to
" put up"  the  latter, that is to throw  into it the contractile
nervous force, it feels quite  soft, without any of the corky elas-
ticity which distinguishes a  sawyer's arm.   He is  the father of
thirteen  children, but since  the commencement of his  present
illness, he has entirely lost virile power.   He states  himself to be
a perfectly sober  moderate man, and has a good character on that
score from his employer.
   It is scarcely necessary to say that the epigastrium and hepatic
region were carefully examined for evidences  of cancerous de-
generation, and none was found.   The lungs also were well aus-
cultated, and nothing abnormal was detected, beyond a suspicion
of slight comparative dullness in the right  apex.   He had not
suffered from habitual cough or had any  diarrhoea.
   He was at first kept in bed and  given  milk and beef-tea every
two hours, with ten grains of  Boudault's pepsine  powders  three
times daily.  In  a few days his excessive nausea and lowness of
spirits had abated, and he was ordered six grains of quinine and
three drachms of cod-liver oil daily in addition.  In a few days
more he was tried with half a mutton-chop,  digested it well, and
on the sixth of June was able to take our whole ordinary diet, a
pint of milk, and  a pint of beef-tea, and a pint of porter. On the
12th (yesterday)  he was  so  much  better, that I thought it was
scarcely justifiable to let him occupy a place in the hospital any
longer,  and I trust he will be able  to get on as an out-patient.
   As he was confined to his bed at first,  it was not convenient to
put him in the scales, but  on May 24, Ave  found  his weight 8
stone 5J pounds; on the 30th,- 8 stone 7£ pounds;  on June 6, 8
stone 10 pounds ; on June 12, 8 stone 10J pounds; his height
being 5 feet 6 inches.
   The only day on which he did not take the pepsine was May
29, when the stock  was accidentally exhausted.  He then com-
plained of pain at  the  epigastrium and attributed that to the
omission of the pepsine.
   This is a specimen of  disease not quite so common as those  I
usually make the subject of my  clinical lectures, and  on that
score not quite  so interesting or important.   Nevertheless it has 
384
ATROPHY OF MUSCLES.
this importance, that if you do not understand its  true nature,
you will be very apt to treat badly the patients afflicted, and to
make them worse.
  I have often told you that neglect of the powers our  Creator
has dowered us with is punished by their withdrawal:  the intel-
lectual sluggard becomes year by year more and  more wanting
in memory  and judgment; the arm of the Hindoo fakeer, tied
upward for a few months,  withers aAvay ;  and  the calf of the
Chinese  belle or of  the  stiff-booted  clodhopper is flabby and
wasted.  It is very important that  you should know that the
same penalty which is thus  inflicted on willful underwork, is also
exacted from  overAvork, voluntary or  involuntary.  If a muscle
is used so as to be worn  out to a degree beyond that  which the
supply of nutriment is able to repair,  or if it is so continuously
used that there is no time for repair, it becomes degenerated, just
in the same way as if it had not been used  at all.*
  You saw in the Cambridge Ward two months ago a blacksmith's
apprentice, of slight frame and with an  imperfect aortic valve,
whose arms, especially the right, had become  atrophied  from
wielding too  heavy a hammer.   A few years ago I had in the
same ward a patient whose chief employment was  turning over
large rolls of lead; and the extensors of his right forearm had
become paralyzed.  About the same time  a hard-drinking and
hard-smoking, but  hard-working,  cobbler  was under  my care,
who was unable to raise the arms from  atrophy of the triceps and
deltoids, muscles absolutely needed in giving the artistic jerk to
the thread which these workmen affect.  But his legs, which he
had rested, were strong enough.
  The following cases, exhibiting the same agencies in action
under different circumstances, are from my private note-book.
  *  And I am not sure, though for obvious reasons I should shrink from saying
it to a mixed  class of medical students, but what incautious intellectual work
produces analogous results. How many men do we meet  burdened, like little
David would  have been in Saul's armor,  with  more knowledge than they can
wield!  Their minds seem  day by day weakened by the stores they cannot use,
30 that they become less and less able to apply them. To how many of our pro-
fession does the increase of practice bring the  diminished, rather  than the in-
creased results of experience, if they do not sternly and conscientiously reserve
to themselves time for " the sessions of sweet silent thought I" 
ATROPHY OF  MUSCLES.
385
  E. C, aged fifty, had always  been used to the regular habitS
proper for a London lawyer's Avife, and  not being fond of needle-
work, had generally amused her leisure with reading.   At that
time her eyes somewhat failed, and  she was  advised not to read
so much, especially in the evening.   As an employment she set
herself the task of knitting, first some strong nets, and then a set
of drawing-room  curtains.  She worked several  hours a day,
fastening the work to her foot secundum artem, and drawing the
thread upward.   After a  time she felt a weakness in the  right
shoulder, then a  pain  and stiffness; being  a very determined
kind of person, she tried to work it  off, rubbed and dowsed and
shampooed her arm ; but the more  she did  so, the worse it got,
and she was alarmed at last  by the  joint becoming  exquisitely
painful to the touch.  Then her  arm was put in a sling and tied
up,  she took steel and wine  and nutritious  diet  and quite re-
covered.
  M., aged fifty-four, has  lived an  active literary life, writing
much and well. Her vigor of constitution is shown by the menses
only lately beginning to grow scanty and irregular.  But she has
a theory of corporeal  discipline not reconcilable with  rational
physiology; she has thought to compensate for the exhaustion of
mental labor by violent bodily exertion, and has been in the habit
of occupying her leisure by furiously digging  her garden with a
masculine spade, and mowing her lawns, not with one of the ele-
gant  new machines, but an  old-fashioned  scythe.   The  conse-
quence is that her good right hand has lost its cunning,  and a
letter she  sent to  seek my advice was scrawled Avith the left.
The principal  atrophy is in the deltoid  and biceps muscles  (those
used in mowing),  Avhich are painful when moved, but not when
pressed.  She cannot raise her arm  by  independent efforts  above
the level of her waist,  and it  " feels out of joint if she  tries to
force it."   Friction, brandy and salt, mustard, &c, have only
made her Avorse.  Her arm is now by my advice tied up, and she
is taking quinine  and steel and cod-liver oil  in small doses.
 • You may easily recognize  in  all these cases the same evil in
action under  corresponding  circumstances — atrophy produced
by local overwork of voluntary  muscle.  And if you think, and 
386
ATROPHY OF MUSCLES.
famine closely the relations of the muscle to the rest of the or-
ganism, you will see that  this overworked tissue is in a position
not very different from the underworked tissue, whose degenera-
tion is so generally made  the subject of remark by physiologists.
The defect is in both instances a want of renewal. In underwork
no demand is made  for renewal, and in overwork the demand is
made, but is not efficiently supplied. In the one the nerve-force,
which  should guide and govern  the  metamorphosis,  is let lie
asleep, and in the other has  been so used up by unwonted toil,
that it is exhausted, and for a time does not exist.  So that the
last effect on the muscular fiber is the same.   No  new store of
muscular  substance is laid  in,  and the old  degenerates  into
inelastic fiber, and  finally into a pale  fatty tissue of  still lower
vitality.
  What is called "overtraining" in the prize  ring has a similar
pathology.  The power of nerve over muscular fiber  is capable
of increase by education, so that it continues to brace it up  more
and more and to make the muscles harder and harder daily, till
the "gladiatoria totius corporis firmitas" is attained, probably in
as great perfection in our days as in Cicero's.   But the muscular
fibers themselves are not capable of proportionate augmentation,
and when the nerves have learned to exercise them up to their
full force, are incapable of further improvement.  If then the
training is continued,  the nerve-force expends itself in exciting
the continuous  functioning of the muscles, destructive assimila-
tion exceeds the constructive; the body "eats into itself for lack
of something else to hew and hack," and loses weight beyond the
mere  loss of fat.*   Nerve-force is capable, as far  as we know,
of indefinite improvement; but the instrument it plays upon can-
not be made stronger than  it was originally intended to be, and
when it is overstrained it  degenerates.  Hence premature decay
is not rare among pugilists,  boat-racers,  runners, &c,  whose
ambition  is greater than their powers, and those  who  live by

  * A moderate allowance of alcohol during training, by acting as an anaesthetic
to the nervous system, tends to prevent this result.  Modern trainers are apt to
enforce too great abstinence, with immediate selfish advantage probably, but to
the final injury of their pupils. 
ATROPHY OF MUSCLES.                387
extraordinary exertions  of physical strength have  a short  av-
erage of life.
   The pathology is the same of that impotence of the generative
and muscular functions which sometimes follows an active lfe in
a tropical climate, and which cuts short the useful career of many
of our countrymen in the  East, and which is often  unjustly at-
tributed to lechery and drunkenness.
   But the most common examples of the disease  are where it
occurs in one set  of  muscles  from special and partial overuse,
such as we see in turners, carvers of ivory and hard woods, and
similar handicraftsmen.
   Muscles affected with  atrophy are in an unnaturally soft and
friable condition;  they are pale colored, and  look as if they had
been macerated  in warm water.   They become like the muscles
of a very aged person, and in fact the change is not  much dif-
ferent from a premature  local  old age.
   The change is usually first discovered by the patient in a much
more  sudden manner than you would have expected from  its
pathology.  The "wrench" which our sawyer felt in his waist
was not the  real  beginning of his ailment, but the last straw
which broke the horse's back.  And often  painters will tell you
that they went on earning full wages till a certain day, when they
became  utterly unable to raise their hand.
   Pain  is a variable  symptom.   Where one or a  few muscles
only are affected, it is a  pretty constant accompaniment, and is
usually  set down as  rheumatism, or  as stiffness, the result of
cold.   In our present patient, Avhere  many muscles were more
or less acted upon, it was absent,  or so generally diffused as to
produce rather a feeling  of mental depression and malaise than
of local distress.
   Muscular atrophy  and local paralysis  will sometimes follow
chronic  poisoning by  malaria.  I have a strong impression that
those are right who locate in the nerves the chief injury inflicted
by such agencies as cause ague and its allied disorders of inter-
mittent  type.  I am  not therefore surprised  at finding  loss of
nervous function, either  in the form of neuralgia  or paralysis,
which can be attributed only to the poison above named.   The 
388
ATROPHY OF MUSCLES.
Only thing which distinguishes the paralysis from the other forms
of aguish disorder, and consequently obscures the diagnosis, is
that it is not intermittent.
   The treatment follows as a matter of course from  the pathol-
ogy.   It consists, in the first place, in enforcing complete rest
of the diseased parts, in no tallowing them to have even the labor
of supporting the members they belong to.  The dropped hand
we fasten on a splint;  the paralyzed humerus  we put in a sling,
taking care that the elbow is well supported and does  not drag
upon the shoulder;  this  patient, who is the text  of my lecture,
we put to bed and kept him there a few days.   Then we admin-
istered animal food in a form by which the patient takes as much
as the stomach can possibly digest.   In this instance there was
utter anorexia; so beef-tea and milk were swallowed in medicinal
form every two hours.  To aid in digesting it pepsine was ordered
three times a day. To supply a basis for molecular growth, cod-
liver oil was given, as soon as the nausea was beginning to abate.
And quinine was added to brace the mucous membrane up to its
duty of absorption.   I have not prescribed iron, but  it would be
quite rational to do so now that the intestines  have begun to re-
cover tone.
   Where the pains are severe, cold douche baths and cold water
compresses give more relief than anything else.   Warmth and
stimulating embrocations seem  to do harm.
   Where malaria has been  to blame, you must be careful in
desiring your patients to avoid the  dew-times—"when the mists
arise that  have  strength to kill."   A Roman  proverb warns the
native against the  hour before and the  hour after both  sunset
and  sunrise, and many a stranger  has suffered  in that  climate
from a neglect of popular experienc.e.  In England  the healthy
population  is not debarred  from  the sweet  influences of these
romantic hours, but those who have once  suffered from malaria
must remember that  they are  more than  ordinarily liable to a
 fresh reception of the poison.
   You may be tempted to inquire, if overuse of voluntary muscle
 causes atrophy, and  underuse also, while moderate use leaves
 our frames well proportioned, what sort of use is it which induces 
ATROPHY OF  MUSCLES.
389
hypertrophy.  I confess that, in spite of the decies repetita state-
ments of physiologists, who have been copying one another from
the time of Galen, I  do  not know that any kind of use at all
does so,  in the  sense of making  the  substance  of the  muscle
larger when measured in  a state of rest.   Doubtless an actively
employed biceps or gastrocnemius will more readily be acted
upon by the voluntary nerves, will contract more  strongly, and
be harder  and more prominent when contracted;  but I  cannot
find that it grows at all bigger.  I do not absolutely deny the
existence of the physiological hypertrophy of muscle; I only say
that at  all events it is very rare, for I cannot find any instance
of it.
   The most notable example of muscular hypertrophy ought to
be an active, well-made, one-legged or lame man ; seeing  he uses
one leg instead of two, it ought surely to  be enlarged.   Yet in
measuring in  several instances the remaining leg  in a state of
rest, I cannot find that the proportion which it bears to the arm
is at all different from the proportion in ordinary persons of the
same build.  And I cannot find that as a rule blacksmiths' arms
are  out  of proportion to their legs.  Both are muscular; for
none but a muscular  man can work at such a trade, and when
excited,  the brachial muscles contract firmer than those of the
lower extremity, and are more marked; but they are not dispro-
portionately large when relaxed.
   Of course you will find employed in occupations where excel-
lence may be  attained by the special exercise of one set  of mus-
cles, men who have those parts Avell developed;  but they are so
developed  originally, and  not by the trade.   Big-armed men
become  pugilists, big-legged  men acrobats; but they  do not
become big-armed or  big-legged because they are pugilists  and
acrobats.
   Sometimes  the development is strangely out of accord with the
occupation ; the Avrong man gets into  the Avrong place.   I give
you the  measurements of the upper extremities of Cordonnier,
an horticulturist at Lisle, avIio has a most extraordinary develop-
ment of the muscular and bony structure.   He is not  fat, but
hard and firm, weighing  in his clothes but  sixteen stone, yet the
circumference 
390
ATROPHY OF MUSCLES.
             of the neck     .     .   is 18 inches.
                "   breast   .     .   " 44J  "
                "   forearm .     .   " 13   "
                "   Avrist    .     .   "  8|  "
                "   palm of hand  .   " 11£  "

   How were these Herculean thews bred ?  In strangling drag-
 ons, stunning wild bulls, cleansing Augean  stables ?   Did their
 OAvner—
                " Tear the lion as the lion tears the kid,
                 Run on embattled armies clad in iron,
                 And weaponless himself
                 Make arms ridiculous ?"

   No—they are employed  in tying up ladies' bouquets, for  his
 skill in Avhich  accomplishment  Cordonnier is  famed.   I have
 never heard  of  an hypertrophy like that  being due  to  overuse.
 Where the hypertrophy exists in voluntary muscles,  I suspect it
 is due to a congenital peculiarity, and not to occupation.


      (Part 11.—Clinical, St. Mary's, October 31, 1863.)

   In Benjamin  Franklin you have an  example of a  disease you
will very often  have to treat, if your  practice  lies among arti-
 sans,  the  " dropped hand" of  painters and glaziers.   He has
 been employed in the carriage building department of the Great
 Western Railway, and  is  an old-looking man, though only forty-
five.    He  has  been a spirit-drinker,  but never gets  actually
 drunk.  He has had gout off and on for the last ten winters, and
used to take a great  deal of colchicum.   He  found  however
 that  drug  to produce  symptoms resembling those  of delirium
tremens, and has given up the  use of it in favor  of iodide of
potassium,  Avhich agrees with him well.*   On September  28 he
gave us the folloAving history.  He had been first  taken  ill three
weeks previously Avith crampy pains in the belly, which got worse
  * His plan is this—when the gout comes on  he buys four pennyworth, or a
drachm, of iodide of potassium, dissolves it in a pint of water, and takes it in
the twenty-four hours. 
                   ATROPHY OF  MUSCLES.               391

in spite of castor oil, till  the 28th.   About the same time his
hands began to  droop, and when  we took him in hand, at that
date, he could not  raise them on  the wrist at  all.   There were
also severe  pains in  the calves and thighs.   The gums had  a
livid line, characteristic of saturnine poisoning, to the breadth of
an  eighth of an inch round the  teeth, and the description he
gives of his employment shows that he is much exposed to the
influence of Avhite lead.   Besides  using white-lead to form what
is technically called the  " body" of the color laid on, he has also
employed mercurial colors in the  fine Avork required.   And this
addition of  mercurial to  saturnine poisoning, or perhaps his bad
habit of spirit drinking, caused a little peculiarity in  the case,
which Avas observed on his first admission : his arms were noticed
to tremble when he held them  out, as if afflicted with paralysis
agitans.  This   peculiarity  soon  passed  away,  and  there  is
nothing else to take the  case out of  the category of typical and
ordinary instances  of disease, such  as I endeavor  to select for
my clinical  illustrations.
   I am disposed to  explain a  great part of  the  pathology of
painter's dropped hand on the same principle which I stated to
you on  a  former occasion  apropos of simple muscular atrophy.
The white-lead  is  slowly  absorbed  by its gradual and sparing
solution in the fluids  of the body,  which are rendered capable of
dissolving it by their  saturation with carbonic acid.   In the
blood it destroys the red  globules,  and carried to  the muscles
removes their red  color also, and  renders them  incapable of
•contracting except  under extraordinary nervous influence.  This
paralyzing  effect is  most commonly  shown in the involuntary
fibers of the intestines, producing  the well-knoAvn painter's colic.
There are two  reasons  why it  should be exhibited soonest  on
these intestinal  fibers:  first, they are the  nearest to the  usual
portal by Avhich the  poison enters, the path of the food ; sec-
ondly,  they are weak muscles, and yet have constant, almost
unintermitting work to do, so that they can have but little repose
during  which  recovery  from  exhaustion  might   be  possible.
Hence colic and constipation from arrested vitality in the intes-
tines are  the commonest results of lead poisoning. 
392
ATROPHY OF MUSCLES.
  To the muscles  of voluntary motion  in  the trunk  and limbs
the same principles apply, and most especially the fcrtter.  Those
muscles become most paralytic which are most  exhausted by
the peculiar employment of the individual.   I had a  patient a
few years ago  whose work lay in a sheet-lead  warehouse,  and
consisted of moving very heavy masses  of  that weighty metal.
He became gradually paralytic in the right forearm,  and weak
in  the  loins,  parts  extraordinarily exhausted  by his  labor.
Painters, especially fine painters, such as those  employed upon
carriages, do not use the biceps,  or the  shoulder, or the  dorsal
muscles more than other people; but they do use excessively the
extensors of the hand.  Try for yourselves  the  draAving of fine
lines  on a Avail with the arm free, and you will find  how pain-
fully tired the outside of the forearm soon gets.  Artists usually
rest the wrist  on  a mahlstick, with the result  of saving these
muscles, and  seldom get paralysis.  But  for some reason or
another artisans generally  adopt another  plan of gaining the
requisite fulcrum for steadying  the line; they fix the hand by
means of the fourth and little finger on the  plain surface, calling
the support thus obtained their " compass," and then  wield the
brush Avith  the thumb and forefinger.  This throws  a terrible
strain on the extensors of the wrist, and they suffer accordingly.
The overexhausted fibers become atrophied, pale, and paralytic;
Avhile  other muscles  escape,  although  equally exposed  to the
baneful influence of the lead, but not so much used.
   I am not certain whether the  neighborhood to  the  paint has
much to do with the hand becoming paralytic.   At first sight
one would be disposed to think it  had.   But  then on reflection
you will observe that other muscles which are equally near,  such
as the flexors, do not become  affected ; and  others which are still
nearer also  escape.   A  dropped  hand  can often twiddle its
fingers with their interossei and lumbricales, bend in  its thumb
Avith  its adductor pollicis, and even exhibit  the delicate action of
the palmaris brevis.  Now, the fibers of these muscles have but
a layer of skin and dirt between them and the paint during the
whole of working hours, Avhereas the forearm  is scarcely  even
directly exposed to it; for it is Arery unusual to  see fine painters
tuck  up their  shirt sleeves,  and the majority even work in their 
ATROPHY OF MUSCLES.
393
fustian jackets; yet it is the forearm that becomes affected, and
not the more directly exposed muscles.
  This man was treated with iodide'of potassium, to  bring  the
lead remaining in him into a soluble form capable of being re-
moved by the fluid excretions.  He had also sulphur baths thrice
a week to test the progress of this removal of the poison.  For
ten days the secretion of his skin in the delicate places (such as
the axillae)  was stained blackish with each bath from the  sul-
phuret of lead formed.   But after ten  days the stain was  no
longer visible;  and at  the same time the livid  line  round  the
gums  began to vanish.   He was losing his lead—the cause of the
disease was being removed.
  Yet though the cause  was being removed, the disease remained,
and indeed still remains to a considerable extent.  The treatment
applied  to it has been  first—rest.  The  hands  are  placed  on
splints for the greater  part of the day and night, so  that their
weight may not drag upon the muscles.   Secondly—intermitted
motion.  Electric  shocks are passed through the muscles for a
short  time  daily.   Thus the atrophy of overexertion and the
atrophy  of  disease are  both guarded against by imitating the
most  healthy natural circumstances of rest and motion.
   He is  also taking quinine and  cod-liver oil, to  furnish a basis
of molecular growth for renewed muscular fiber, and with this
treatment he has decidedly improved in  general health, and is
able to raise the wrists much better.
  But while I tell you what has benefited him, I should also tell
you of one thing which in both his and my own opinion has done
harm.  As an experiment I treated the forearms for three  days
with small flying blisters, never allowing  them actually to  pro-
duce vesication, but to be moved onward when the skin became
reddened.   The paralysis was certainly worse during  this appli-
cation, and for several  days  afterward, so of course I shall not
repeat it.  What I have previously mentioned to you constitutes
the ordinary  and  typical  treatment  of  dropped hand,  and,
though I mention it as a part of the established treatment in my
systematic lectures, I have ahvays felt doubtful  in what  sort of
cases  blistering is beneficial, if any. 
LECTURE  XXX.
                        CHOREA.

Part I.—Case treated without drugs—This case a recent one—
     Principle of treatment.
Part II.—Four long-continued but curable cases treated with
     arsenic—Quoted as specimens of the disease as usually seen
     —Effect of forcible control over the movements.
Part III.—Records of three fatal cases  and two unaffected by
     treatment—Connection of chorea and rheumatism and disease
     of heart statistically deduced from  the records of thirty-three
     cases under my care.

     Part I.—(Clinical, St. Mary's, February 20, 1863.)

  A lad  of nine, Henry G., was  taken  in on the 19th of last
month for chorea.   His parents  stated that the attack had come
on suddenly a week previously without any assignable cause and
while he was  sitting at  dinner.  It  began by convulsive  move-
ments of the arms and facial muscles, and very soon  the whole
body became affected.  As  he lay in bed I think I never saw
more violent and uncontrollable  motions of the limbs and body.
He was never still, but speaking to him or touching the bed ex-
cited convulsions in the same electric manner as in hydrophobia,
and judging by his wailing they  seemed to be very painful.  He
was unable to retain his faeces or  his  urine.   He was stated to
have been subject  to worms, as is the case with half the children
of our laboring classes;  so  I gave  him once and  again a stout
jalap,  aloe's, and calomel purge to  ascertain .the  fact; but no
worms or  mucus appeared, nor had there  been any collection of
old faeces  in the colon.   Beyond that  he  has  had no medicine, 
CHOREA.                       395
 except on  one occasion  a little  catechu  to  solidify the  stools,
 which were passed involuntarily,  and prevent them dirtying the
 sheets so much.  Yet you have seen the chorea pass away en-
 tirely, so that on the 14th instant the case-book records that he
 carried the inkstand steadily round the ward for us, handing it
 with one hand, and he has been  making  himself  useful to the
 sister by serving out patients' dinners.   I have kept him  in the
 hospital till to-day, solely to see if any relapse  would occur.
   I said he had no medicine for the chorea, but I did not say he
 had no medical treatment.  He was surrounded as he lay in bed
 Avith toys, and he was induced to make every effort to retain them
 in his hands.  In two days he? began to get quieter, but not much
 more advance was made, till his regaining some power over the
 sphincters enabled us to have him dressed and to set him to walk
 in measured  step about  the  ward.  Then  we imperiled  our
 crockery in a good cause by letting him  carry it about and clean
 it, till he rapidly acquired the  steadiness you saw him exhibit a
 week ago.
   The object  aimed at was to  draw off his attention from  his
 miserable state, to  concentrate the psychical forces in  the  en-
 deavor to acquire  power over voluntary  muscles,  and  thus  to
 renew their lost control.
   Chorea is obviously not a disease which must necessarily go
 on from bad to worse if unarrested by drugs.  The long list of
 varied remedial agents  employed, many of  them repugnant  to
 one another, is enough to make us suspect  this.   Dr. Reeves,  in
 his statistics of  eighty-four cases occurring in the Norwich hos-
 pital, states that  the shortest duration of the disease under
 pharmaceutical  treatment  was  two  weeks;  the longest  eight
 months;  and  the  common  average, seven weeks.*  I  suspect,
 though I have no statistics to show it, that the common average
 of duration of recent cases, Avhere no drugs are taken, would be
 very similar.
   The pathology, or explanation of the immediate internal cause
of chorea, is quite unknown. Sydenham ascribes it to a " humor
thrown upon the nerves."   In three fatal cases I have seen, the
       * " Edinburgh Med. and Surgical Journal," vol. viii, p. 314. 
396
CHOREA.
nervous system  seemed  perfectly healthy; in one there were
tubercles in the spinal cord. Dr. Cullen thought that the malady
depended on " a state of mobility" of the system ; that is to say,
that the limbs move about too much because they are too movable.
Dr. Marshall Hall attributed it to "reflex action;" but  talking
of " reflex action" is merely to class the phenomena of convulsions
under  a common  name, for nobody has yet  dissected  out the
"reflex" nerves.
   You may observe that in chorea the principal muscle in any
intended motion is pretty fairly  obedient to  the will;  the lad,
when he was bidden to  put  out his arm, put  it out; but those
muscles whose motions are normal^ associated with the princi-
pal one, did not act;  he did not put it out straight, and twisted
it in every direction but the correct one.  Hence Darwin classes
it among "diseases (defects) of association," that is to say, cases
where the necessary connection between certain  vital  acts  is
overthrown.
   The existing or  external causes are sometimes  easier  to dis-
cover.  You have  cases where the patient is anaemic, is teething,
has mucous intestines and disordered alvine secretions impeding
digestion,  skin  eruptions,  retarded  catamenia, pregnancy, dis-
eased bladder or uterus, perineal fistulae, tubercles in spinal cord.
(In these three latter cases I am recalling to my mind examples
of fatal termination.)   Many others again  attribute the disease
to fright.  In such instances you find that the  chorea obstinately
remains as long as the existing cause does,  and on its departure
begins gradually to decline.  Urider such circumstances the plan
of treatment is obvious enough; you must turn  your efforts to
the removal of the  exciting cause, if it is  removable, and then
expect with confidence that the chorea will  disappear in  about a
fortnight.   If  the exciting cause is irremovable, or if (as in the
case of pregnancy) it is  too valuable  to  be got rid of, I cannot
find that specific drugs do any good to the chorea.
   But in  a very large  number  of cases you can discover  no
 exciting cause.   Perhaps it has passed  away; perhaps  even if
 you had watched  the patient  all along,  you Avould not have dis-
covered it on account of its secret nature.  In such cases I have 
CHOREA.                       397
usually been in the habit of administering  arsenic; but really I
cannot say  that  any patients  under arsenic  have  ever passed
from a severe  state of chorea to one of complete voluntary con-
trol more quickly than this boy without arsenic.
  You may say truly that chorea exhibits sometimes a tendency
to become chronic  in cases where  the  general  health  only has
been attended to.   But I  do  not think that proves anything
against my idea of  its nature being to get well of its own accord.
I believe  that in these protracted  cases there is a  continual re-
newal  of  the cause of the disease;  that it  is in fact kept up by
injudicious  management.   One of the most  common  forms  of
injudicious management is the fixing of the patients' attention
upon the deficiency of voluntary control.   They are told, and
wondering by-standers are told, often with exaggeration, how bad
they are; the malady is painted in heightened colors; pitying
friends offer unnecessary help; cruel  companions  ridicule their
infirmities;  till, like the subjects of electro biology or  mes-
merism, they lose control more and more from being  told that it
is lost.  You may see'this mental cause of the  aggravation of the
disease most clearly shown if two or three choreic patients chance
to be put together  in the same ward.   It  is impossible to avoid
it sometimes,  but you will observe  that they always make one
another worse.  If one is getting better, she will be immediately
thrown back again by the introduction of a new companion simi-
larly affected; and not rarely a patient previously free will catch
it by the  contagion of the eyes.
   The  influence for you to exercise is the very reverse of this;
you must encourage the patients to make every exertion to direct
the movements of  the limbs, and let them perceive  as little as
possible their deficiencies in this respect.   Above  all, let them
avoid  looking-glasses or the depressing sight of other unfortu-
nates  in  the same  condition.   Poor persons are best treated as
in-patients of a hospital, as the advantage  of  getting them away
from their  injudicious friends outweighs   the  risk of possibly
coming in contact with other choreics.   If the patients are not
in a position of life to make this resource available, at all events
get them away from home as  soon as possible.   Sent under the 
398                       CHOREA.
care of a judicious governess to the seaside, or anywhere else for
an  excuse, many children recover rapidly, who at home would
have gone on relapsing and relapsing again every week.
  Slow walking in timed step is excellent practice for regaining
directing power, and I dare  say slow music  and solemn minuets
would be equally efficacious;  you may remember that  the Taran-
tella was so called from being used to relieve a nervous affection
falsely attributed to a poisonous spider.*  Carrying  trays and
crockery, and other things that demand care, assists the cure.
In short, using the will contributes  more. than anything else to
its renewal, and is the only real  "specific" for chorea, when once
the original exciting cause has been removed.


       Part II.— (Clinical,  St. Mary's, May 30, 1863.)

  Maria S., aged thirteen, was received May 1 with very severe
chorea of six weeks' duration.   No cause could  be  assigned by
her mother, nor could any worms be found in the faeces, but, from
her dirty and neglected appearance and the unnatural smell and
color of the alvine excretion, I have no doubt she  has been fed
on diet very unsuitable to a growing  girl.   The  muscular move-
ments were so excessive as entirely to prevent her speaking in-
telligibly, but she was  quite quiet when  asleep.  She is  a thin
but healthy looking child, and the only abnormal phenomenon is
the fetidity of the stools.  She was kept for six days without
medicine to  observe the case,  and  no improvement  was found
from the better food  and discipline  of the hospital.   She was
then put upon  four  minims thrice  a  day of liquor potassae ar-
senitis, and immediately  began to get  better.  On the 9th  she
could walk up and down the ward and feed herself, and is now
able to assist in washing up the crockery, and will leave the hos-
pital shortly.

  * In Kircher's specimens of Tarantella tunes the first are merry jigs, but the
last is like a funeral march, and must have been composed, as one would guess,
for some church dignitary affected with the  curious contagious chorea of the
fifteenth century.   See Hecker's " Epidemics of  the  Middle Ages."—Dancing
Miinia, p. 172. 
CHOREA.
399
   Along with the last  patient I also took in Richard B., aged
nineteen, a chairmaker.   Three months  previously he had been
obliged to walk  home  four miles in  the  dark, of which he had
from  childhood  been much  afraid.  He  was overwhelmed with
fright, but concealed his fears out of shame.  After this he be-
came very nervous, and chorea gradually came on.  The chorea
increased so much, that for six weeks he had been unable to work
at his trade.   He is very thin and pale,  with blue cornea to his
eyes.  He was put  upon misturse ferri Sj ter die, to  which  has
been  added since 5j of cod oil.  And he has also now a shower-
bath every morning.   On the 9th he was  steadier than  on  ad-
mission,  but then the improvement became stationary, so that I
resolved to treat him also with arsenic.  The quantity has been
gradually increased up to 1T|xvi of the liquor potassae arsenitis
three times a day, and  he has been slowly but steadily improving.
   A third patient, Emma B., aged  fifteen, has been  under  my
care only eight days.  The catamenia had occurred for the first
time  two months previously, and about the period when they
ought to have been again present she was observed to get rest-
less and  fidgety.   In a fortnight's time this restlessness became
complete chorea, which was the prominent disease on admission.
The movements were then almost entirely confined to the right
side of the body.  Two nights before admission she had an hys-
terical fit, but this had not before or  since been observed. After
she had  been in hospital a few days we  found  that the  chorea
came on in paroxysms of about two hours' duration, during which
it was very violent over the whole  person.   In the intervals she
was  comparatively quiet, and  could speak easily, though not
extend the right arm straight.
  I ordered  at first  valerian, which  seemed to do no  good, and
now she is taking arsenic like the others.   She has also in addi-
tion a warm hip-bath nightly.
  These  are interesting cases for you to Avatch, for they present
examples  of the disease  when it has  already assumed  a chronic
form, and Avhen the mere  fact of its existence makes it  reproduce
itself, if  I may so express myself.  I mean that  the constant
movement and annoyance arising from the  chorea  still further 
400
CHOREA.
weaken the already weakened and predisposed body, and so in-
stead of tending to recovery naturally tend to a prolongation of
the malady.   In  this stage it will not get well without some'
strong  measures in the way of drugs.  You saw that the child
Maria  S. got no better during the week that she was treated by
diet and discipline alone.   We must have recourse to the phar-
macopoeia.
  One  very powerful aid is iron, and a great many cases may be
cured with  that remedy, either in the form of the red rust or of
Griffith's mixture.  But you saw that iron was beneficial only
during  the  first two or three days  to the boy Richard B.  And
the disease  may come  on  even while  a patient  is taking iron.
It did  so a few years  ago in a boy in  this hospital, for whom  I
had prescribed that mineral for tubercular consumption (No. in
Register 8627, November  13, 1857).  Nevertheless he got well
of it without  any change  in the treatment.  Perhaps he caught
it by imitation of some  other patient in the ward, but the clerk
has made no note of the  fact.  If so, both the supervention of
the malady and its cure are easiest explained.
  Valerian is  sometimes useful  in chorea which arises  in girls
about  and  soon after  the time of puberty, when  it is  apt  to
assume a paroxysmal form.  This paroxysmal form we observed
in Emma B., but  still the  valerian  did not cure her.
  In all forms, however, you have  seen a very decided improve-
ment under the use of arsenic.
  I should not have called upon you to notice this, had they been
recent  cases, or if they had been  cases in which a turn toward
recovery had already been taken. Under such circumstances you
may easily  deceive yourselves as to the action of medicines, which
do not cause,  but are merely given along with the cure.   About
arsenic, however, I do not think you can have any doubt, ob-
serving these and  similar patients, that it really acts as a special
tonic to the nervous system,—curing the chorea irrespectively
of  the cause  whence  it  has  originated.  As arsenic is not  a
normal constituent of  any part of the body,  and cannot be
imagined to replace any normal constituent;  while at the same
time patients  increase in  strength and weight during the course 
CHOREA.
401
of taking it, I suppose it must be an indirect constructive, acting
powerfully on the nervous system.

            (Clinical, St. Mary's, June 13, 1863.)

  Of the  three patients about whom I lectured a fortnight ago,
Maria S. has gone  home well, Emma B. is  at work washing up
cups  and  saucers, and Richard B. has improved as to his arms
and  legs,  being able to walk straight and hold  out an inkstand
for  me to write prescriptions from.   But his organs of speech
have not improved at all.  He stammers, and chews, and gnashes
his teeth most painfully, whenever he struggles to talk.
  Impediments to articulation are usually the most difficult part
of chorea to cure.   Many who have had chorea only in  child-
hood will  stammer all their lives.   So delicate  are the muscular
motions required  for the rapid modifications  of  form which make
the sounds  of the  different letters in speaking, and  so decided
and  firm  must they be  for intelligible enunciation, that  the
slightest deficiency becomes immediately apparent.  A muscular
contraction which might be well  enough directed to  guide the
fingers in  writing, may be very incompetent  to shape tongue and
lips in pronouncing.  A tremor not noticed  in the former  is dis-
agreeably prominent in the latter.
  The annoyance to the patient  caused  by this difficulty still
further  increases  it, so that it  reproduces  itself and  becomes
chronic.   More than that, the glottis is irregularly acted upon
and closed when it ought to be opened, so that speech, and some-
times the breath  is absolutely arrested.  Nobody stammers in
singing, when the glottis is kept  open to form the musical tone.
  Stuttering and stammering are in fact a local chorea.   There
is a deficiency of  voluntary control over the  muscles of speech.
  In a recent case, such  as this, very likely the  arsenic will  be
of use, but I do  not know whether it would be available where
the defect has become habitual.   The best  way under that cir-
cumstance is for the person to humble himself to the infant state,
and  be taught to  speak all over again.  He can get  instruction
from those ingenious tutors who teach the deaf and  dumb, and 
402
CHOREA.
systematically learn to shape slowly and  deliberately his mouth
into the form  requisite for enunciating each letter separately.
By practicing  this  at his  leisure and before a looking-glass he*
may gain great control over the articulating muscles.
   I shall in this case continue the arsenic, and  not recede from
the large dose  (IrLxvi of the liquor potassse arsenitis) unless there
is  perceived  some  poisonous action, such as  sore throat, inflam-
mation of the  eyes, severe griping.   I have also directed him to
practice the reciting before a mirror sundry choice scraps of lit-
erature relating to Peter Piper and  his practices, which  are pop-
ular practice in p's.
  [This boy improved slowly, the arsenic having been increased up  to TT^xviii
of  the Fowler's solution three times a day.  He went out cured and able to go
to work on July 3.]
   I have begun arsenic with another patient taken in yesterday,
June 12, Ann W.,  whose  case  presents some analogy to the
present  condition  of this  boy, in  that the chorea is  confined
almost entirely to one part.
   The said Ann W., a fine tall girl  of thirteen only, though she
looks older, has been subject to occasional chorea since  she was
five years of age.  Latterly she has had an attack annually, and
last year two attacks.  The chorea  is almost always confined, as
now, to one arm; with one exception to the left arm.  But once
she had it in the right arm only, and last year in the left leg and
left arm  only.  The catamenia have not yet been established.
There is no abnormal murmur in the heart, and she  has never
been  subject to rheumatism in any form.  I have  ordered her
arsenic and shower-baths.
   It will be interesting to watch this case, and see whether the
very  local chorea  is benefited by  arsenic as decidedly as the
more general chorea.
  [The dose of liquor potassae arsenitis was gradually increased to Tt^xiv. The
patient was able to wash up crockery after she had been in hospital ten days,
and was discharged on July 3.
 For three days I tried the experiment of controlling the spasmodic movements
by  fastening the affected arm against the side.  The effect was to  make it de-
cidedly much worse.  This observation is quite in accordance with the theory I
hazarded in an earlier part of this lecture,  that the voluntary nervous force is 
CHOREA.
403
in chorea deficient from want of use, and that the exercise of the directing will
is an important element in the cure.  For that which is cured by the exercise of
voluntary effort you would expect to be made worse by forcible involuntary con-
trol, and vice versaJ\

          Part III.—(Continuation of same lecture.)

  I must not let you suppose, from the usually fortunate result
of chorea under treatment, of  which you are sure to see repeated
examples, that a favorable prognosis can be  always given as a
matter of course.   It  is  true that during the time in which you,
my present  class, have been pupils, there have  been no  deaths
among my patients so affected, nor indeed any discharged as
incurable.   But in my case-books there are several of both sad
sorts, and I will briefly extract them, to damp any too cheerful
ideas  you might have acquired about the disease.
  John D. (No. in Reg. 442), aged sixteen, was transferred to me
from  Mr. Coulson February 13, 1852.   He had been  operated
upon  for stricture by the perineal section, and had accidentally
been  placed in  a bed opposite to  one occupied by  a boy with
chorea.  He soon began  to imitate the choreic movements of his
neighbor, and  though removed to another ward he got worse and
worse, and lost all control over his  limbs.  When transferred he
was found to have  pericarditis, but the time of  its  supervention
had not  been noticed-  He continued  to get worse  and worse,
abrasions and  sloughs  and abscesses formed in  various external
parts, and he died delirious February 28. It is possible that the
pericarditis  and abscesses may have been due to pyaemia.
  Sophia G. (No.  in  Reg. 5003), aged eighteen, came to St.
Mary's on June 15, 1855, with debility and  pericarditis.   The
only illness  she was aware of having had was chorea at four years
old, which had not since recurred.  Her  pericarditis relapsed and
got worse, and the chorea, so  long absent, returned again.  She
died worn out with  chorea and dyspnoea on  July 21.
  Hannah M. (No. in Reg. 746),  a needlewoman, aged twenty-
three, was admitted November 1, 1861.   Her sister told me she
had been deserted by  a lover  the previous year, and had grad-
ually faded away ever since.  Her skin had got brown and harsh, 
404
CHOREA.
her body emaciated, and  her mind sluggish.  Then she became
feverish, and a fortnight before admission  exhibited the usual
symptoms of chorea.   These were then so bad that she could
hardly be kept on the bed.   No remedies were of any avail, she
grew delirious, and then raving, and then comatose, and died on
the 9th.   At the autopsy we found (first), some old dry tubercles
in the lungs and mesentery, dating probably from her first pining;
(secondly), degenerated supra-renal capsules, connected,  it may
be presumed, with the bronze-tinted skin; (thirdly), a scrofulous
tumor as big as a filbert in the lumbar enlargement of the spinal
cord, which probably was  recent, and was the cause of the  recent
chorea.
   Two other cases were not fatal, but Avere not at all benefited
by anything they received from the hospital.
   Sarah C. (No. in Reg. 24), aged twenty-three,  married  and
full six  months pregnant  for the first  time, was attacked on June
20, 1851, with acute  rheumatism of  left elbow and right foot,
and at the same time her right arm became  affected with chorea.
She was free from pericarditis on her  admission, June 27, but got
it on the morrow.  Her rheumatic and cardiac symptoms  sub-
sided, but the chorea was as bad  as ever when she went  out on
July 21.  It continued till her child was born, two months after-
ward, and then was cured.   Had  this young woman been  in any
danger, it would have been worth while to have induced  prema-
ture labor, but I do not suppose anything else would have stopped
the chorea.
   Robert F. (No. in Reg. 804), aged eighteen, son of a medical
man, was transferred here from a madhouse, Nov.  30, 1860.  He
had practiced masturbation from the  age of seven, but does not
appear to have suffered in his health till he was sixteen, when he
became  affected with  chorea  for six weeks.   He then remained
well till the end of 1859, when  the  disease was brought back
again by the same filthy  practice  I have spoken of.  It was  of a
peculiar description, coming on in paroxysms, principally affect-
ing the muscles of the neck, and twisting his head so far round
sometimes as to cause him to tumble  down,  screaming and bark-
ing.  He had been in a lunatic asylum, for which of course he 
CHOREA.
405
was not a  fit  patient, and had  had subcutaneous injections of
morphia at St. George's Hospital without benefit.  Morphia  was
also tried here without permanent benefit, and also cauterization
of the urethra.   He was  discharged  incurable after  a month's
trial of various expedients.
   So  you see chorea is not always a disease of so little moment
as appears  from the bulk of cases, and perhaps from all the cases
you may happen to witness during your novitiate.

   I will also use the hospital records to point out to you a curious
fact in the  history of chorea, which happens to be illustrated by
none of the four patients at present under your eyes, nor in truth
by any admitted  under my care  this  session.  I mean the con-
nection betAveen it  and acute  rheumatism.  Out of thirty-three
cases Avhich I  have looked over in my old case-books, in the fol-
lowing six  the nervous affection either began during rheumatic
feyer, or followed immediately after it before convalescence was
complete, or else rheumatic fever succeeded to the chorea.
   Sarah C. (No.  in Reg. 24), aged  eighteen, mentioned just now
as an instance of the chorea being unaffected by remedies, had
both ailments  at the same time,  but without cardiac lesion.
   John J. (No. in Reg. 291), aged sixteen, had  chorea imme-
diately after rheumatic fever, but was also infested with intes-
tinal  Avorms.  There was  no cardiac lesion.
   Sophia  G.  (No.  in Reg. 5003),  aged eighteen, died of peri-
carditis, very  probably rheumatic, and chorea.  I have mentioned
this case before among the fatal ones.
   Sophia  M.  (No.  in Reg. 6425), aged seventeen, had chorea
come on in the hospital during  an  attack  of  acute rheumatism,
free from any cardiac complication.
   Eliza B. (No. in Reg. 6437), aged seventeen, had chorea come
on in the hospital during an attack of rheumatic fever, but  she
had no recent affection of the heart detected then.  When again
admitted  for  chorea in the succeeding year, there Avas a soft
murmur, systolic and probably anaemic.
   Martha  C. (No. in  Reg. for 1861, 346), aged twelve,  was
admitted with chorea.  She denied having had rheumatic fever,
though she said  she had  had  rheumatic pains.   The heart Avas 
406
CHOREA.
healthy.  Next year she was under Dr. Sibson's care for rheu-
matic fever, and then again the heart was  examined  and found
healthy.
  You will observe, that though the association with rheumatism
is evident, there is  none made  out with  previous lesion of the
heart; for,  though  Sophia  G. had  pericarditis, yet  the others
had no  cardiac affection. Considering how very common inflam-
mation  of the central organ of circulation is in rheumatic chil-
dren,* and that it is at  this age that  chorea usually occurs, on
the mere doctrine of chances they would often coincide ; but the
cases I  have last referred to show that the constitutional con-
nection is really with  rheumatism, and not with the valvular or
pericardial injury.
  Indeed, when you come to consider  that  the red contractile
tissue in the  majority of cases of acute rheumatism is seriously
affected in its functions,  and in some cases (muscular rheumatism)
is the only tissue affected,  and that chorea is  manifested by a
want of control  of the muscular  nerves over  the* muscles, a con-
siderable light is thrown upon the relation of two diseases at first
sight so dissimilar. They are defects of vital function in the same
part.  In one case the sensitive, in the other the motor function
is injured.
  I am sorry to say no practical assistance in their cure has been
afforded by the  observation  of the  connection between the two
diseases. I have, in a few cases, applied to chorea the same treat-
ment I  should have applied  to rheumatism, namely, warmth and
alkalies, and it  seemed  to me rather  injurious than  beneficial.
But the inverse inference I have not acted upon, and I do not
know but what arsenic might be of use in rheumatism, and should
be glad to hear  of the experiment being tried.I
  * It is dependent partly on the natural activity and excitability of muscular
fiber in young persons, partly on their intolerance of pain  and warmth, and the
difficulty of keeping them from throwing off the bedclothes, and exposing their
chest to cold air.
  f One  such experiment, a decided failure, is recorded at the end of Lecture
XVI, page 201, where a boy taking arsenic for chorea connected with old valvu-
lar lesion, and of rheumatic  diathesis, was attacked by fatal pericarditis, pre-
sumed to be of rheumatic type.  January, 1864. 
LECTURE  XXXI.
                       EPILEPSY.

Cases illustrative of the use of iodide or bromide of potassium—
     Suggested explanation of the benefit so derived—Accessory
     treatment.

            {Clinical,  St. Mary's, June 20, 1863.)

   The following' are the cases of epilepsy which have been in the
hospital under my care since January 1.
   Richard L., aged forty-four, a married groom, had neATer any
serious  illness  before  February 20.  On that day,  soon  after
going to his work at seven in the morning,  he felt giddy, and in
two or three minutes afterward he became insensible and fell on
the stable floor in a fit, during which, his  companions told him,
he was convulsed.   A  similar fit occurred the  night after, and a
third the next day.   This was followed by a succession of fits for
twehre hours, with intervals of from four minutes to a quarter of
an hour.  After that he had about three fits  during  each day.
But during the nights they were  more frequent, coming on when-
ever he tried to go to sleep.  On the 27th of February he applied
for admission, and had an epileptic attack in our board-room.
This one was seen to last about five minutes, being accompanied
by casting up and twitching of  the eyes and slight convulsions.
His urine was  natural, the genital organs  normal in function,
and no blow on the head or any  other possible cause for the fits
detected.   He had the air of a sober respectable man.
  He was' immediately put upon the following treatment: 
408
EPILEPSY.
               1^ Potassii iodidi, gr. iv,
                 Tincturse cantharidum, Trjxv,
                 Mist, camphorse, 5j,
                                     ter die.
   A small blister of an inch circumference behind each ear.
  The fits never recurred, and  he  entirely lost the feeling  of
giddiness and general malaise which had been experienced dur-
ing their continuance. As his home was in the neighborhood, he
was discharged as cured  on March 6,  with  a determination  to
come back  if he felt any likelihood of a  relapse, to guard against
which he was provided with medicine for a fortnight.   [He has
not since made his appearance.  February, 1864.]
  A." M., a boy of twelve, had a cut on the head by a fall  in
fighting at  ten years  old.   After it had healed he was quite well
till last November. At that date he began to have epileptic fits.
At first they  resembled fainting fits, and  occurred with various
frequency, sometimes as often as seven  or  eight times a  day.
Since then they have become of a convulsive character and have
occurred mostly at night.  When they are coming on it seems  to
him as  if  the  room  were on fire; this is succeeded by sudden
darkness, and he knows  no more.  His  mother states that he
almost always goes to sleep immediately after the fits.  His ap-
pearance is healthy,  and  there are no worms to be found in his
stools, though his mother had  given him  strong  purgatives and
carefully examined the results.   There was  ordered for him on
March 20 the following prescription:
                ]^ Potassii iodidi, gr.  iv,
                   Tincturse cantharidum, TT[y,
                  Mist, camphorse, 5j,
                                        ter die.
  Up to March 25 he had a fit each day.  His eyes were fixed,
and the pupils much contracted during them, and he fell down,
but did not bite his tongue.
  On April 1 he had at dinner time a  short  fit, and after  that
no more.   He was discharged cured on the 11th, having taken
no remedies beyond that  named and two doses of castor oil. 
EPILEPSY.
409
  Eliza D.,  an unmarried nurse-maid, twenty-four years of age,
was  admitted  by governor's order, May 1, for  epilepsy.   She
had  her first fit  sixteen months previously, when she was at the
Cape with  her  mistress.   At first she was not completely in-
sensible during the fits,  and had no convulsions, but soon they
took on a more decided epileptic character, and  latterly they
have come on more frequently, sometimes as often as two or
three times a day.  The catamenia have never been quite regular
to time, but otherwise she has been a healthy woman, except for
the epilepsy.  She is spare, brown, and intelligent, Avithout any
signs of hysteria.   She was put upon the treatment by

                 Tfy Potassii bromidi, gr. xv,
                     Mist, camphorse, 5j,
                                         ter die.

  During  the  night of the 5th she had two epileptic fits in
which  she bit  her tongue.   The bromide of potassium was in-
creased to gr.  xx, and she had no more fits.
  Thomas K., a G.  W. R. porter, was  admitted  on April 11
during an epileptic fit, which he  had in going to his work at four
in the morning.   He was treated with a turpentine enema and
a blister at the back of  neck, but as he did not wish to be kept
from his work  I  lost sight of him.

  I bring  to your notice these four last cases of  epilepsy which
have been under my care  in the hospital, because in most of
them a similar remedy has  been  used with apparently great suc-
cess.   Two have taken  the iodide and one the bromide of po-
tassium, and it certainly seems to have controlled the disease in
an extraordinary way.
  Remark  that  all  these  three epilepsies are comparatively
recent.  I have,  as a rule, refused to admit long-standing cases,
as causing a great  deal of trouble and  expending in vain the
funds of the hospital.   And I think that trials of  all remedies
should be made on recent  cases, for  confirmed epilepsy has be-
come such a habit in the syetem that it may be  looked  upon as
incurable.   Even there iodide  and  bromide of  potassium will
       27 
410
EPILEPSY.
alleviate the evil.  In one case due to an  old saber cut on  the
skull so long ago as the Greek war of independence, and accom-
panied by partial paralysis, I  gave,  in  consultation with Dr.
Watson, iodide of  potassium, and the  fits became  not only less
frequent but milder.   Another case of fourteen years' duration
and used  to recur every three weeks,  has now been nearly six
months without a fit  under the use of  fifteen grains of bromide
of potassium three times a day.
   This latter case had tried  to take the iodide,  but even in small
doses it so soon  produced its poisonous effects, sore-throat, irri-
tative fever, &c, that it was never fairly tested.
   Sometimes we fail.   I gave the iodide  last winter to a young
clergyman for epilepsy  of not above a  year's duration.   During
three weeks' stay in  London he was indeed free from fits,  but on
returning   home they  recurred  as  bad  as ever..  Singularly
enough I had a  few  years before given this inan large doses  of
iodide of potassium for non-syphilitic periosteal rheumatism, and
it  had acted like a charm.   Is it possible that the drug can have
lost its  effect  over one disease  by having been previously used
for another in the same patient ?  At all events  he left  it  off,
and when  I last heard, he was  taking, under  advice, mercurial
alteratives to act  on the liver  and  so on, not apparently with
any advantage.
   This class of neutral  salts seem to have a peculiar restorative
action over the  white fibrous  tissues.  They were  first brought
under  the notice  of the  profession by the effect of iodine  in
scrofulous  diseases of  the  glands, and  then by  their cure  of
syphilitic  periostitis. A notion  got into the profession that they
had some  antagonistic,  or controlling,  or  evacuating power over
syphilitic  virus; but the  more  recent surgical writers, such  as
Mr. Lee, think there is  evidence against that idea, and that they
benefit by  curing the diseases arising out of the presence of the
virus and  not  by removing the virus itself.  They cure the  pa-
tient's tissues, without  specially  affecting  the  materies morbi, if
we may apply  that misused  term to the  poison  which  is  the
foreign cause of disease.  You may  see proof of this opinion in
the fact of the equal benefit which they confer in rheumatic and 
EPILEPSY.
411
other non-venereal cases of periosteal  disease.  When  recently
affected, these patients are restored to health as readily as the
subjects of  secondary syphilis; and the apparent resistance in
some cases to the remedy is due to the protracted nature of the
ailments;  just  as  syphilitic periostitis,  when it  has lasted  a
long time without medical  aid, is very obstinate also.  On the
ground that iodide of  potassium has a special restorative power
over the white fibrous tissues, I should expect most direct benefit
from it in epilepsy to those cases where epilepsy is due to  some
lesion of the membranes of the cerebral or other masses of nerve
substance, whether that lesion  be temporary or permanent.
  But at the same time I have no data by which to doubt of its
curative influence, where the disease arises from lesed nutrition
or visible tumors of nervous  matter.  It may not  improbably
restore also that tissue to healthy vitality.-
  Neither should I be disposed to be skeptical of its virtue where
a peripheral cause exists for the convulsions.  That  peripheral
cause may be an altered state of  some fibrous tissue,  and it can
hardly act otherwise than  through an altered nutrition of the
nerve or its  envelopes.
  It is also  something  to say that no permanent injury to health,
and  scarcely any even temporary inconvenience is ever wrought
by iodide  of potassium.  Some persons, misled by an accidental
instance or two of lunatics  having previous to their lunacy taken
this  drug, have disseminated  the notion that  it weakens the
mental powers. At the Lock Hospital for syphilis we  administer
annually some hundredweights of it, but have never found  such
a result  follow.  So that  there are no  patients affected with
epilepsy on whom we are justified in not fairly trying the experi-
ment of its use.
  I need hardly tell you how important hygiene is in the treat-
ment of epilepsy.   The measures most to be insisted upon are
those specially connected with the etiology of the  disease in the
particular case.  Should mental causes, such  as fright, anxiety,
disappointment, lie at  the bottom of the evil, a complete change
of habits must be enforced; and  that is easiest carried out by a
complete change  of residence  and of companions.   The same 
412                       EPILEPSY.

expedient will also powerfully  aid  dietetic  improvements in
instances where the digestive tract is at fault.   In such cases a
mild soluble animal dietary which feeds the tissues by frequent
nourishment, without overloading the stomach by copious meals,
such as the diets of our  hospitals, is of the greatest value—of
such value indeed,  that some  even hesitate to  accept  hospital
experience of drugs in this  disease as conclusive of their  real
action.  All ambitious intellectual exertion, especially rapid and
discursive reading and writing against time, should be absolutely
prohibited.   But moderate-employment  of the  thoughts, espe-
cially on familiar and interesting hobbies, is useful in preventing
that stagnation or  concentration of the mind  upon itself which
is so hurtful in all chronic complaints. 
LECTURE  XXXII.
                       HYSTERIA.

Part I.—Hysteria not fatal, but not therefore unimportant—Not
     a uterine  disorder—Its pathology lies between mind  and
     body—Its forms to be divided according as it approaches one
     or the other—Such a division  has a direct bearing on the
     treatment—Mental hysteria—Treatment,  restoration of vol-
     untary  mental force,  of cutaneous circulation, and of
     emotional  control—Corporeal  cause  for hysteria—Treat-
     ment, tonic to mucous membranes—Effects of tea-drinking—
     Treatment dietetic.
Part II.—Hysterical vomiting—Three cases in hospital compared
     with some private patients—It is not in strictness vomiting—
     Diagnosis  and treatment—Their difficulties — Hysterical
     cough—Contagiousness of hysteria.
Part III.— Connection between hysteria and insanity illustrated
     —Medical curiosity about private history  of patients—A
     physician  not  a confessor.
Part IV.—Periods of life prone to hysteria—Blighted affections,
     lowering diseases, and climate,  as causes—Two cases of
     hysterical loss of voice treated by valerian and shower-baths
     —Spasmodic cough and spitting of blood in  one  patient—
     Advantages of auscultation in the diagnosis of the latter.
Part V.— Treatment  by ice—Treatment by blood-letting—Gen-
     eral conclusions.

      Part I.—(Clinical, St. Mary's, November 8, 1861.)

  Those who rate the  importance of diseases solely by the space
they  fill  up  in the Registrar-General's report of deaths, will 
414
HYSTERIA.
care very little about the subject of the present lecture.  Hysteria
does not show its face at all,in that  book.   The reason  is,  that
whenever it leads to a fatal result, it  qualifies itself to be classed
either as insanity, epilepsy, or some organic lesion ; and thus our
pathological friends who pay attention  only to what  people die
of, are apt to  ignore it altogether.  But this  is  not  a practical
way of  viewing the human  misery you are learning to lighten.
The sum total of suffering  from hysteria  to  patients and their
friends  is very great, and probably equal to that included under
most  of the names followed by  high  numbers in  the  lists  of
mortality.
  The chief thing that should make disease interesting to you is
the amount of misery which it inflicts, and the  likelihood there
is of your exertions alleviating this misery; not  the gratification
of your vanity by observing how the  phenomena during  life are
explained by the  post-mortem appearances.  I hope you will not
be  led  by the excellent opportunities  for the study of morbid
anatomy which student  life affords to rate  that science as the
only glass through wThich you should look  at disease.   It is very
rarely anything which can be put up in a bottle or made into an
interesting preparation or picture, that  patients feel,  and that it
is the business of your life to help them to feel  less.   The  true
use of morbid anatomy is  to teach the  consequences of  disease,
not the art of healing it, and it is the art of healing which must
be the prime  object of your work in  the hospital wards,  and the
business of your  lives.   You must not get a habit of classifying
ailments  according to parts affected  only, or a great many will
escape  altogether from your nosology, and some you will not be-
lieve in at all perhaps.   Of others, again, the  names will  give
you altogether  wrong  notions; and  of these hysteria is an
instance.
   It is seldom I  ask  you to erase anything from your memory,
but—will you please to try and forget for the nonce that hysteria
is derived from the Greek word 'varepa ?* That is the readiest way
  * Hysteria with the second syllable long, as usually pronounced, means " a
festival at which swine were immolated" (Donnegan), but I suspect the original
designers intended the e to be short. 
HYSTERIA.
415
of avoiding the trap which the name sets open for the  educated
student.  In reality it has no more to do with the organ of repro-
duction than it has with any other part of the female body;  and
it is no truer to say that women are hysterical because they have
wombs, than that men are gouty because they have beards. You
may see daily in the ward appropriated to uterine  cases all sorts
of pathological changes of the part in question, without  any
greater tendency to hysteria than in other women;  and on the
other hand, hysterical women are all around you, among both in
and out  patients, whose uterine functions are perfectly healthy.
Of two  women I have examined who were born without  any
uterus at all, one was hysterical.
   Our  forefathers, who invented  the  term still used,  seem to *
have fallen in with a popular notion that the Avomb really danced
about into all the strange  places where discomfort  is felt.  They
allowed their patients to think of  that mysterious organ as now
starting up under the left ribs and causing lumps and pain in
the side, and  properly  enough  therefore called "spleen" by
classical writers of the Addisonian period, now jumping right up
into the throat as a "globus,"  and  now intruding itself into
the brain, appearing like  a nail driven in—a " clavus"—over the
brow and disturbing the senses and passions.   You may easily
conceive that the believers in such superstitions were not trust-
worthy practitioners ;  but you Avill be equally bad if you fall
into the error of treating hysteria as a disease originating in the
womb.
   Observe impartially the phenomena in those cases which come
before you, and you will not fail to be convinced that the deficient
vitality of Avhich hysteria is a manifestation is  in that puzzling
part of  the eircle of life  which lies between spirit and matter.
We know so little about the chain which connects the  two, that
its links are reckoned by us as few and  short,  and  Ave have no
names for any of them.  Yet when we see the varied phenomena
produced by breaches or  impediments to the connection, we are
led to feel the depth of our ignorance  on the subject, and to con-
jecture that these abysses of  incertitude veil a  long list of vital
functions. 
416
HYSTERIA.
    In default of names for even the healthy functions of this part
  of life, we must not  expect an accurate nomenclature for  their
  aberrations from health;  and' the most we can do in trying to
  classify forms of hysteria,  is to trace how near their origin lies
  to one or the other extremity of the series of vital actions which
  are interfered with; what  relation their phenomena bear on the
  one  hand  to mind, and what  on  the other to  body.  We  shall
  thus have set in a natural series the  varieties of the disease, with
  pure insanity at the one end,  and epilepsy  traceable to  organic
  lesion at the other.  Such  a nosology has a directly useful  bear-
  ing on our treatment of the patient, which I cannot affirm of any
  other attempt at classification of hysteria that I  have yet  seen.
•  I say it has a direct bearing  on our  treatment  of the patient to
  observe in each individual case whether the disease is most re-
  lated to deviation from mental or bodily health ;  for I feel  con-
  vinced that it is only by this observation that we can avoid such
  disappointment as  leads many in our  profession to look  upon
  hysteria as an opprobrium  medicinse, which makes them  feel the
  same sort of anger against it  that is roused by moral guiltiness,
  and  disposes them rather to punish than to cure the patient who
  has thwarted them.
    After this unusually long introduction I  proceed to the  busi-
  ness of the day, by calling  your attention to three cases we have
  visited during the last week in the larger female  ward.
    The first couch we  come to is  tenanted  by E. J., a nursery-
  maid aged seventeen, who was brought here from her bed in her
  night-dress and wrapped up in blankets, as an " urgency" during
  the week.   She complained of dreadful pain and  absolute loss of
  power in the legs, so as to  be  quite incapable of standing.   She
  said that five days previously  her legs had been red and SAVollen,
  and  that they had been rolled up in  " bandages twenty yards in
  length;" though in the same breath  she declared that theyAvere
  so painful that  she could not bear them to be handled, and that
  it made her faint to have  them touched.   This  illness  she at-
  tributed to having caught cold, accompanied by diarrhoea, when
  with her mistress at  the seaside, whence she has just come back.
  She  complained also of stiffness and severe pain  in  the  muscles 
HYSTERIA.
417
of the neck and of pain in the heart, and of excessive perspira-
tions.  In short, she gave a fair description of the symptoms of
an attack of rheumatic fever, and in truth  she was sent to bed
as a case of rheumatic fever, and so  entered in the " Urgency
admission book."  But my eyesight did not let me concur in this
diagnosis. The legs and feet  were evenly smooth and white, and
she did not cry out when any part was handled except the calves,
to which she said the pain had retreated. Now the pain of rheu-
matic fever  retreats to the joints, and not to the calves.  More-
over, there Avas no swelling  of the neck which she said was so
painful;  and, on diverting her attention, the cardiac region bore
pressure  without her flinching.  And the  flushing of her  face
seemed not due to  fever, but  rather to mental excitement.  Then
Ave noticed  that the inside of her lips and her tongue were  pale,
and  that the latter was indented by the teeth; while there was
a soft, soughing murmur, such as you find in  anaemic  persons,
synchronous with the  first sound of the heart.  But what mainly
led me to the diagnosis which I formed of  hysteria was the ex-
pression  of  her countenance.  She  has an easily flushed  skin,
delicate  features,  quickly answering to the movements of the
mind, and  in  the  eyes a peculiar appearance which requires a
separate  sentence to itself.  The balls are large, and the  sclerotic
of a transparent sky-blue ;  the pupil is much dilated, giving a
general dark hue to a naturally light eye, and the conjunctiva is
smooth and  bright from  being overspread Avith tears  on every
emotion.   The eyelids are large, full toward the  outer canthus,
giving a  drooping, appealing expression to  the face.   I believe
this  is what ladies technically call " a  sweet expression."   Of
these several hysterical marks, the puffiness of the eyelid and the
dilatation of the pupil are the most constant—indeed are seldom
absent—and seldom deceive you.
   Her history has oozed out  in driblets  during the four days she
has been here, and has been made up partly by a motherly old
Avoman in the next bed; for  it excites her too much to attempt
much cross-questioning.   I  would  commend  to your  imitation
this  mode of piecing up a history by Avhat can be extracted from
the patient  by those who can listen  at  leisure.   Excitable per- 
418
HYSTERIA.
sons are prone to exaggerate, to invent, to forget, and to appear
to you impostors when cross-questioned by a stranger.
  It seems  that E. J. has been in service since she was twelve
years old, and  enjoyed capital  health till  sixteen  months ago,
when she had a sad shock.   She went home for  a holiday, having
heard of no illness in her family, and found  her father in his
coffin.   This completely upset her.   She has shifted about from
service to service, and has always been obliged  to leave from in-
ability to get through her duties. The first bodily symptoms she
perceived were  languor and a palpitation of the heart  on  exer-
tion; then she became subject to "fits," as she calls them; if any-
body made her  laugh, she could not stop, soon  began to cry and
to scream, and  fell into very low spirits afterward.   During this
period the catamenia flowed for the first time last December, and
appeared again in January: she says that she was neither better
nor worse for the  change of constitution.   Since January they
have been absent.
   This is a case  of  hysteria arising  from a  distinctly mental
cause, and showing itself in mental symptoms.   The organs first
affected are those which are especially obedient to the emotions
of both pain and pleasure.  First the heart, then the risory, lach-
rymatory, and expiratory muscles. In health, we know how these
are  affected by changes in the mind, but are still under its con-
trol.  When then we find in a patient that control deficient, and
when we can trace the deficiency to a cause purely mental, it is
rational to  conclude that  the broken link is nearer to mind than
to  matter,  and it is rational to let this conclusion  govern us  in
our treatment.
   I would here again warn you, as I did at the beginning of the
lecture, against associating hysteria with the reproductive organs
or functions.   To read some male authors on this subject one
would suppose that it was only  a euphemism-for lust.   A  signal
injustice is thus done to  the weaker sex, and they might well
 ask, as iEsop's lion did of the natural historian, if women wrote
books on  the  diseases of men  how would  the creatures be de-
 scribed ?   If you study in an  unprejudiced spirit the histories
 of the numerous cases of hysteria which fall  under your notice 
HYSTERIA.
419
you Avill learn that the sexual instincts are not oftener the moral
cause of the disease  than any  other  social circumstances, and
that physically the differential organs are less frequently at fault
than any of the important viscera.  Neither are lustful desires
the consequence of hysteria any more than they are  the  conse-
quence of all that weakens the mental  powers, of all that  lowers
our species in the scale of creation and brings us nearer to other
animals.  Emotional hysteria is a primary disease of the mind as
much as lunacy is.
   As in lunacy, so also in hysteria, there follow  morbid  phenom-
ena  connected with the manufacturing viscera.  The  stomach
loses its power of digesting food enough to supply the waste, and
the  person  becomes  anaemic.   Then  the  destructive metamor-
phosis is checked too,  the urea is excreted in diminishing quan-
tities, and the unrenewed blood supplies no coloring matter, so
that the urine is pale and watery.  In  short, the patient becomes
anaemic; and with anaemia, of course, there is a  deficiency in the
sanguineous excretions especially.  Thus in this  girl, as you have
heard, puberty truly began in spite of the illness; but power was
wanting to carry on its periodical evacuation of effete blood.  The
catamenia  flowed twice, and then  ceased.   Next to th*s stomach
probably ranks  the uterus in its  liability to be affected  by the
mind—a fright may suspend the catamenia or cause miscarriage
in a perfectly healthy woman; and in female lunatics the courses
are scarcely ever regular—so that it is quite in accord with anal-
ogy that the same defect  should occur in  the half-mental affec-
tions which we reckon as hysterical.
   Next notice  the treatment.
   First.  She was taken into the hospital as an in-patient.   You
will find in practice that hoA\*ever good your theory of the treat-
ment of hysteria may be, it is much more difficult  to carry out
and much  less effective  when the patients  are at  home than
Avhen you can remove them for a time from their ordinary habits
and associations. It is not merely that unprofessional nurses fail
to obey implicitly your orders, from misplaced tenderness or ig-
norance; but that the patient's mind, by running in its  habitual
groove, and being perpetually subjected perhaps to the influences 
420
HYSTERIA.
which engendered the  disease, less  readily takes  a  turn  toward
health.   If you expect in private practice to be as  successful as
hospital  physicians, you must try to imitate the circumstances
they have in their favor.   This is most easy in the  poorest  and
in the richest classes.   The  first can be sent into a  hospital;
and with the latter a thorough change of scene, under the charge
of some judicious friend, is not difficult to arrange.   But this is
often next to impossible for the families of farmers, retail shop-
keepers,  curates,  village doctors, and the like, from  the union of
a light purse with a weighty feeling of independence.  One good
plan that can sometimes  be adopted, to the saving of pride  and
pocket together,  is to negotiate an exchange of patients, where
two families of about the same social standing are simultaneously
afflicted with  an hysterical  member.  The relatives of A can take
charge of B,  and the friends of B repay the debt by their care
of A.   Mere kindness even may induce people to receive on a
visit such inmates, if  it is pointed out  how very  valuable  the
kindness really is, what a high office of Christian charity is thus
fulfilled, when  a sick  person, incurable at  home,  is  rendered
curable by removal.
   In the .wealthier classes the complete renewal of  mental asso-
ciations  involved in  foreign travel  is a mighty engine of cure.
But yet if an  hysterical patient be sent abroad during  conva-
lescence, you must not be  quite careless where you  send  her to.
Some places  enjoy a bad pre-eminence for producing  relapses.
These  are generally low-lying places of even temperature;  and
I suspect there is some  connection between malaria and the in-
duction of the disorder.  Rome is an instance  in point.   I  was
much struck, when  residing there  a few years ago, by the  fre-
quency Avith which  all disease was modified by hysterical  phe-
nomena  And one  case  I  saw of well-marked catalepsy, which
strongly impressed me.  It  occurred in  an' English lady who
never had hysteria before in  any form,  and who was excessively
frightened  by the  unfamiliar symptoms.   It came on  within
twelve hours  of her arrival on a  muggy spring  evening, when
she was  fatigued by her journey, and open to all  the injurious
aerial  influences  of the  Campagna Romana.  During her stay 
HYSTERIA.
421
she was from  time to time threatened  with a recurrence, and
feared  she was a destined victim of nervous invalidism; but on
leaving Rome the  symptoms vanished, have never recurred, and
were thus proved to be wholly due to the peculiar climate.   Be
careful that your hysterical patients keep clear of the Eternal
City.*   Much harm is often done by sending them to travel in
Italy without a warning on  this point.
   Whatever be  the scheme adopted for securing a  change in
habitual trains of thought, the  principle  of treatment will be the
same.  You must aim  at bringing back the control of the  mind
over the body. A link has been dropped, is becoming paralyzed
for want of use, and  must  be  renewed.  Let the patients be
exercised in voluntarily obeying specific  orders for the direction
of the will; moving the limbs to time, at first slowly,  and after-
ward with more  liveliness, till  at  last the culminating point of
dancing can be arrived at.   This is the  crisis of the cure ; and
Avhen a girl can be induced to join a quadrille in the evening, you
need  not fear a relapse into  hysterical paralysis. In the hospital
we are  obliged to substitute  "dull mechanic pacings to and  fro,"
assisting in the work of the  ward, &c.; but these are  much bet-
ter than  nothing.   The same  strong effort  requisite for  these
exertions is to be used to restrain the tendency to hysterical fits.
The  truth is to be forced upon the patient that she can learn to
repress these manifestations of weakness; and Avith the learning
will   come  the  power, and with  the   power  the absence of
occasions for exercising it.
   What you have to aim at  is  exactly the converse of the arts of
the electro-biologist, mesmerist, and medium-showman.  These
persons, with devil-like ingenuity, find means to induce a form of
artificial hysteria in subjects with a tendency to mental disease  ;
that is to say, they partially destroy the  control Avhich the  mind
has over the body, and subject it to the suggestions of their own
  * A reviewer of the second edition of this volume* throws a doubt on this
accusation against Rome.  I was not  aware that  it was new; but if so, I am
glad to find it confirmed by Dr. Scoresby Jackson in his recent excellent work
" On Climatology."   He describes the climate as productive of " a morbid nerv-
ous sensibility;" and afterward advises that all cases "of perverted nervous
sensibility" "should avoid Rome." 
422                     HYSTERIA.

will.   Let it be your happier task to restore this control by in-
ducing the patients to exercise  it for themselves.   Above  all
things, never be  led  by curiosity or idleness to repeat the ex-
periments  alluded to.  Each time that poor  creatures are so
practiced upon,  they become  more and more enslaved to the
morbid impressions, till they lapse  into permanent hysteria or
even insanity.  You might just as well give a  man pneumonia,
or break his leg,  for the purpose  of studying the consequences.
   Secondly.  Shower-baths were ordered to be given every morning.
The making up the mind to the shock of a  cold shower-bath, is a
capital exercise of the will.   In summer it  is most suitable; and
I  dare say you  remember in  July, 1860, a farmer's daughter
whom  our late  house  surgeon, Mr. Ash, sent up from Cornwall
with absolute paraplegia of both legs.   This case excited much
amusement at the time, because  it was attributed by the girl's
neighbors to witchcraft.   It was  due to hysteria; and she was
ordered a shower-bath twice a day, with the effect of enabling her
to walk one day to the Pantheon, and another round the Serpen-
tine, before she went  home cured.
   I say "cured," partly because I  have lately heard from Mr.
Ash of her really being so, and partly also because I should
anticipate the best results from the slow progress of her improve-
ment.   It is  sometimes possible by a strong mental emotion to
overcome suddenly nervous paralysis.   You have all, I dare say,
read at school  Herodotus' story of the dumb child of  Croesus,
who in a battle recovered his  speech, and  stayed the. soldier's
up-lifted sword by crying out  "Spare my father."  I know a
case of permanent hysterical paralysis which was several times
suddenly  cured,  once by the house catching fire, once by the
patient's maid being struck down by cholera, once by an obsti-
nate physician desiring her to rise up and walk.  After  each
trial she was able to move about for a few days, but she relapsed
again as bad as ever,  and remained paralytic till her death from
other   causes.   Gradual cures  are  indubitably the most trust-
worthy.
   In winter a shower-bath twice a day would be rather a,strong
measure;  and it is better to  prepare the patients for it by the 
HYSTERIA.                      403
use of a tonic warm bath, such as the following, which you often
see me order :
   !fy  Acidi hjdrochlorici diluti giss, aquse  calefadse ad  95°
Fahr. congios xxx.  31.  Fiat balneum.
   Shower-baths have also a good influence by arterializing the
cutaneous circulation.   Their immediate effect is to drive the
venous blood home to the heart and lungs ; and that which takes
its place is arterial, as every one knows who has reflected on the
pink cheerful glow of his person while drying himself after this
morning luxury.
   Thirdly.  Valerian was ordered to be taken three times  a day.
There are several substances dowered with  a special action on
those nervous functions which minister to the emotions.  They
come from  different kingdoms of nature, and agree in no one
point except in having all a very strong smell.   The  essential
oils of sundry plants which are the  pride and profit of the per-
fumer, the rose, bergamotte, tuberose, violet, hyacinth, fresh hay,
and some others of the few sweet scents that exist in the  world,
are poisons  to all with a tendency to hysteria, and are proscribed
by universal consent of fashion in all places where the disease is
endemic.   In Rome, you would as  soon think of going to an
evening party with a drawn sword as with a strong-scented nose-
gay, in any hope of its  acceptance.   Tea is equally baneful, and
the bad effect seems to dwell  rather in the essential oil than in
the alkaloid which it holds; for coffee, which is as rich in theine,
is by  no means so  hurtful.  On the  other hand,  the  bracers-up
of the nerves would seem to have this good  gift in  recompense
for their peculiar  offensiveness in their raw state to  the healthy
nose—valerian, assafoetida,  garlic, castor, musk, and I believe
some  others Avhose disagreeable virtues  are not familiar to  me.
The first two are the best; as, though musk is very beneficial,
its high price and  the unbearable permanence of its odor render
its use> inexpedient.  In hospital, you will generally see me ring
the changes upon  the following prescriptions:
   1^  Tincturse Valerianae compositse 5j, Infusi valerianse ad §j.
M.  Fiat haustus ter vel quater die sumendus.
   1^  Assafoetidse  gr. x in pilulis ter die sumenda. 
424
HYSTERIA.
   1^  Spiritus ammonise foetidse 5j ex aqud ter die sumendam.
   But in private practice more elegant substitutions can be made
to suit the patient's fancy, such as—
   ly  Tincturse  castorei ammoniatse (Pharm.  Dub.) 5ij,  aquse
fosniculi ad oj 5
or—
   I^j  Pilulse galbani compositse gr. x ;
or—
   Tfy  Zinci valerianatis gr. iij ;
   One or other to be taken three times a day.
   You will  remember,  I hope, that drugs, whatsoever may be
their  powers, can never take the place of other treatment.  They
are merely an aid and a means by which the  essential principles
of restoration may be  carried  out; but  if  they be trusted to
empirically, if the disease be prescribed for and not  the patient,
failure will attend your best efforts, and a disappointed skepticism
haunt you in or drive you out of our godlike occupation.
   The next case before us is an instance  of  hysteria exhibiting
a more material ailment from a more material cause.
   Maria E., a muscular matron of forty-two,  was confined of her
eleventh child nine months ago, and had gone on letting it suck till
the other day.  Very little milk there was  for it indeed; and
the only use  of  the nipple must have been as  a sort of opiate.
Notwithstanding its difficulties, by dint of other food the baby
has grown fit to be described as a "beautiful fat" one; but the
mother has been severely punished for kicking against the pricks
of instinct.   Four months ago she was taken with a succession
of fits, which dreAV her arms and legs up in convulsions, and took
away her voice.   She was sometimes quite paralytic, and  some-
times lost her senses, but never bit her tongue.  Then she became
afflicted with dyspnoea, which, even  now as she lies in bed, cuts
short her speech, and is constant when she is up.  Her appetite
is  quite gone, so that she loathes the sight of food. She has also
excessive pain in the left hypochondrium, which often, in her
own words, "quite doubles her up," but yet does not arise from
flatulence. The catamenia have returned at their proper periods,
in  spite of the illness brought on by  her too persevering attempt
to  suckle the child. 
HYSTERIA.
425
  You may see here again the hysterical eye, with  large pupil,
clear sclerotic, full upper eyelid, and look of appeal for sympathy.
This time it occurs in a brunette, and in a Avoman whose  face
might have led you to guess her to be of a stern, strong-minded,
or ascetic character.
  Now the treatment here is different from the last.  She was
ordered for medicine—
  1^  Tinct.  cinchonse  co.  5j,  decocti  cinchonse ad  5j.   Fiat
haustus ter die sumendus.
  She was kept quiet in bed, and bidden to take a cup of limed
milk every two hours.  I looked upon the  chain of causation in
this case as arising  thus—(1) exhaustion ;  (2) imperfect  gastric
digestion; (3)  anaemia; (4) innutrition of nervous system, and
the consequent exhibition of its weakness in hysterical phenom-
ena.  And I  considered that the easiest  channel  by which to
commence the renewal of life was the stomach.   It would  have
been useless  to load  the poor  organ with a quantity of heaA'y
victuals, of which it could only  have relieved itself by rejecting.
But frequent small  amounts are not  beyond its powers; and if
you give these  as medicine, the patients will not think themselves
at liberty to choose or refuse, as they do food.  Medicine indeed
it is ; for it is intended to cure the stomach of its anaemic,  inert
condition, and thus to give an appetite.  The cinchona is designed
to have the same effect, by astringing the surface of the mucous
membrane, checking its secretion of sticky mucus,  and thus en-
abling the gastric juice to reach the food.  And you see that
between them the effect is brought about; for, as we went round
to-day, the patient said her  desire for food was coming back, and
of her own accord asked for meat. The pain in the splenic region
was much better, and the dyspnoea gone.
   Wondrous is the power of the stomach!  When in its  right
senses, what a restorative  physician it is!  By the aid of our
patients'  stomachs alone we can cure nine-tenths of the curable
cases of disease.  Persius dubs it a " Master of Arts ;" I would
give it the degree of " Doctor of Medicine."
   Another case of  hysteria Avith a traceable bodily cause  came
to us on the same day.
       28 
426
HYSTBRIA.
  Maria D., a spinster of thirty-two, has been a general servant
in a light place for seven years.   She has been happy, and has
enjoyed pretty good health, interrupted only by occasional head-
aches ;  but for some time lately things  have seemed  to annoy
her more than they ought to do.  Three months  ago she had a
bad  "bilious" headache,  which  was  folloAved by some fits of
laughing and crying.  Five weeks ago she had an attack of di-
arrhoea, from which she got better, and went to work again in
spite of weakness, for she was loath to let her mistress want her.
But her exertion was in vain, for she no sooner tried to clean a
grate than she  fell down  speechless,  and  had a  succession of
hysterical fits, losing her senses, but not biting her tongue. Then
she began  vomiting everything she took, and this had been going
on for three weeks, and seemed to amount to a complete rejection
of all her  food immediately it was swallowed.  When you  saw
her, there  was excessive flatulence, the air bursting up from the
stomach in roaring eructations while one was  talking to her.
   In this woman, the effect of the wide pupil  and sympathetic
hemiptosis  is  not hidden  even  by  the  disfigurement of  blear
edges to the eyelids; and it quite accords with the droll earnest-
ness of her manner, which increases gradually as you let her go
on  talking about herself,  leaving no doubt  of her strong hys-
terical diathesis.
   As to cause, that is still  more directly traceable to the stomach
than even  in the last  case.  It would seem  that for some years
she has been  becoming more  and more given to  tea-drinking.
She confesses to  caring for little else, so long as  she could get
her favorite food or physic—or  poison—I  do not know exactly
hoAV to call it. Her mistress Avas quite angry with her for eating
so little meat; and, with a far-sighted economy not  common in
her class  of life, took much trouble to keep  up the  health of a
faithful servant.   But her Aveakened stomach refused meat, and
she was literally  starving in the midst of abundance.*

  * This patient has  just returned to the hospital.  She has been well from the
date of her discharge till a fortnight ago, when she sat up several  nights, and
was very anxious about her sick mistress. This has caused a return of hysterical
vomiting.  Feb. 1864. 
HYSTERIA.
427
   In this case diet will be the  cure.  When we can make our
 patient a carnivorous animal again, she will be well.  But what
 is the use of diet or medicine when it is all thrown up ?   None.
 With this feeling, at the same time (November 1) that I ordered
 her  limed  milk  every  two hours, I added  also an  enema of
 half a pint of mutton-broth four times a day.  On the 5th, about
 half the liquid swallowed was retained, and she complained that
 the anus was made sore  by the clyster-tube.  The enema was
 therefore omitted, and  the power  of  resisting nausea was aided
 by four  minims of prussic acid  every four hours.   On  the 7th
 she vomited  scarcely at all, and said she would try and keep
 down a piece of meat.   This she has continued  to do, and may
 be now counted convalescent.

       Part II.—(Clinical, St.  Mary's, May 16, 1863.)

   I Avill call your attention to-day to a case of hysterical vomit-
 ing,  namely, that of Hannah  P., aged eighteen, who has been in
 the hospital a fortnight.  She is a respectable farmer's daughter,
 and seems to have been much petted at home.  She has large
 black pupils  to the eyes, and puffy eyelids, and  allows that be-
 fore  her present illness  she used to have hysterical fits, but not
 since she has suffered  from Avhat she  came here for, namely,
 chronic vomiting.  I should rather call it  a rejection of food, for
 it occurs immediately after food has  been taken, almost  before
 it is  swallowed.   This happens at  every meal, and has lasted a
 year and a half, and during that time she has been for a short
 time in  her  county hospital with relief but not cure.   She has
 also pains in the back and in the splenic region.  She declared
 she was unable to walk  or even to  stand Avithout assistance, and
 when placed  upright in  the middle  of the room she fell down at
first.  Nevertheless, after  a scolding and decided  command  to
exert her will vigorously, she at last began to put one leg before
the other, and progressed a few steps even on the first day.  The
catamenia had been absent three months, and indeed had never
been established at regular periods.
   There is a peculiarity about hysterical  paralysis which  in a 
428
HYSTERIA.
great many cases guides you to its nature—and guiding  you to
its nature is here more than anywhere a  most important step in
the cure.   When you  set the patient up on  the floor, assisting
her with one or two hands or with your hands under the  axillae,
according to the degree of paralysis  and the  amount  of aid
wanted, the body is immediately thrown forward, and all  your
strength is called for to prevent her falling on the face.  Other
paralytics fall  to one  side or  the  other, or  backward, and  do
not stumble forward in this way. The peculiarity is well marked
in the present instance, and has aided the diagnosis.*
  This  is  an example of that extremely troublesome  disease
"hysterical vomiting;" by which  I mean a  vomiting of food
independent  of any organic or anatomical alteration of tissue,
and due to mental or functional deficiency of the nervous power
of control.   The pathology of the  disease  seems to be this:
when the food  enters the oesophagus, the lower muscular fibers,
being deprived of proper cerebral control, act too soon, and the
upper muscular fibers are too soon  relaxed,  so that  the  morsel
instead of being pressed downward into the stomach is returned
back again to the mouth.   Unlike  other persons, the hysterical
are unable to check by a strong voluntary effort  the conversion
of nausea into  vomiting; and often, if they are able, they are
unwilling to do so by reason of  the peculiar  perversion of  their
minds.
  The difficulty of the diagnosis lies in  the  proverbial difficulty
of proving a negative.  It is not wise or  honest to make an off-
hand statement that no  organic change of tissue exists to ac-
count for the phenomenon. And moreover, I believe that long,
continued hysterical vomiting may lead to organic change by the
unnaturally empty state of stomach which  it perpetuates.  It
may lead to  congestion of  the  mucous membrane, and thus to
ulceration.   You must watch your patient carefully and note all
indications of  the  organic disease  or  the contrary before you
  * This girl, after retaining mutton-chops and porter for a fortnight, and ex-
hibiting her muscular powers by a walk to Oxford Street and back, went home
well July 13. T hear from one of my pupils that she has this winter  not only
relapsed into her former condition, but has communicated it to a neighbor of
her own age.  Dec. 1863. 
                         HYSTERIA.                     429

decide;  for  though with the hysterical temperament it is the
most  common case for no actual lesion  to be  found,  yet the
chance of it is not entirely excluded.
  But the first thing to do is to observe whether  the hysterical
temperament exists.   For this knowledge no guide is so sure as
that peculiarity of eye and manner which I have often described
to you, and which is so strongly marked in this instance that
there was but little  question as to the nature of the ailment
being at all events much affected by it.
  In the treatment I adopted a plan which has been justified by
success, and which is also justifiable on rational and physiological
grounds.   I ordered that food should be taken only  in small
quantities, but frequently, and always in the standing  posture.
She was made to stand up and eat every hour.  The  object of
making  the patient  swallow only while erect,  is to  give the
oesophagus the aid of the force of gravity and  also to relieve it
of that muscular  effort necessary for its action when horizontal.
The method is of essential importance in the treatment of func-
tional regurgitation, and is also not without its  use in cases due
to organic change, ulcerative or malignant.  I am surprised not
to find it alluded to in practical works on the subject.
   The view proposed  by cold shower-baths is  the strengthening
of voluntary power.  The warm season we are having has allowed
of  their being taken twice a day, but in  colder weather that is
often too much,  and may bring on catarrh or catarrhal rheu-
matism, or  catarrhal  sore-throat.  Indeed one bath a day will
sometimes do that in this chilly climate.  A good precautionary
measure in females is to guard the head from the water; for  the
soaking of their long hair keeps it wet for an hour or more, and
is more apt to give catarrh than the shower-bath itself.
   Hysterical vomiting is more difficult  of cure by mere drugs
than any other  manifestation  of the  diathesis;  for  the usual
entrance for your means of  cure is barred against you.   I  say
designedly "barred," because  really the articles swallowed do
not get into the  stomach; they are not,  strictly speaking, vom-
ited, and the phenomena are in  fact more analogous to those of
oesophageal stricture.   For this reason the emaciation   is  not so
\ 
 430                     HYSTERIA.

 great as in chronic cases where the stomach is emptied by true
 vomiting;  for, though thrown up immediately, and to all appear-
 ance .wholly,  yet in reality some of the mass  swallowed slips
 through the spasmodic grasp of the oesophagus, descends into
 the stomach and keeps up the nourishment of  the body.
   You need not, therefore, be  in so much alarm about hysterical
 vomiting as the  symptom would at first appear to justify.  The
 patient will not be starved so soon as the friends  expect, and
 there is plenty of time for judicious treatment to be adopted and
 to act.
   In this form of hysteria, as in those with more obviously mental
 manifestations, a change of scene and habits has a marked effect,
 even although the present circumstances are not deleterious.   I
 do not think you would have seen so quick a cure of this woman
 at her own h'ome.
   I had  a whimsical instance of this last-named fact in a maiden
 lady aged  nineteen,  who  was  sent up to me  by Mr. Ayres, of
 Ramsgate.  After a preface of hysteria, she had had daily rejec-
 tion of food for  six months, sometimes of everything taken, but
 always unchanged in appearance, showing the  Aromiting to be
 oesophageal and  not gastric.  Soon after she came to  London
 she got  well.   She went  home to Ramsgate, and, being soon
 afterward frightened  by a chimney on fire, was taken with her
 old vomiting again. She returned to London, and the same day,
 without  any remedy,  the  vomiting ceased, and she swallowed
 everything easily.  It was the most  "veni, vidi, vici"  cure I
 ever saw.
  Not but that care and decision will enable you to be victorious
 sometimes even in cases Avhere  removal of dwelling is impossible.
 Dr. Woodhouse,  of Hertford, called me in to see a case of vomit-
ing in an hysterical young married lady, where, either from mis-
placed catamenia or congestion from retching, blood was thrown
up in considerable quantities. We succeeded in entirely removing
all food, and in feeding her with beef-tea enemata for a fortnight,
after which she  gradually  got back by the steps of spoonfuls of
milk to  ordinary diet,  and was  cured completely.   But Dr.
 Woodhouse quite tired himself out by the watchfulness  and de- 
HYSTERIA.
431
cision  he had  to  exert to get this plan  carried out.   Several
times Ave were  almost  driven to despair of success.  You must
be  ready for  a course of decisive  and  sometimes unrequited
labor in managing such cases.

  I extract from my note-book of a few weeks ago a case analo-
gous to the last, in so  far that  the deficiency of  healthy control
was exhibited  in the  same  set of nerves, namely, the pneumo-
gastric, but exhibited in a rarer form.
  Fanny T., aged twenty-one, was last year thwarted in hopes of
gratifying at once her affections and ambition by a very advan-
tageous marriage.   She is a reserved  proud girl, and very de-
termined to  make  no  sign of  weakness by showing herself as
low-spirited or hysterical.  She  had made  up her mind  to  be
independent of marriage altogether, and with a view-of securing
fame and fortune in the world of letters had been working very
hard at French, German,  and Latin literature.   In consequence
her general health was failing, the bowels became costive, and
the catamenia had  been irregular the last six months, occurring
sometimes  every fortnight, and sometimes  having intervals  of
five or six weeks.   She had also got thin  and strangely lost her
muscular strength, so that she was tired with the least walk, and
dropped from  sheer debility articles  of furniture and the like
which previously she was  used  to carry with ease.   For the last
three months she  had been troubled with a cough of a peculiar
loud barking character, very spasmodic and uncontrollable, un-
accompanied by any pain, and not followed by any expectoration.
At  first it used to come  on only when she  was  exhausted with
actual exercise, but latterly it had got much worse, and was ex-
cited  by even the effort of speaking to any  one  or by seeing  a
stranger, or even by allowing her thoughts to dwell long on any
exciting subject.  She had taken large quantities of expectorants
and felt confident that they made her worse: the breast was red
and raw from the application of mustard poultices, without even
temporary benefit being derived therefrom.  In fact, no medicine
had done any good.
  A stethoscopic examination of the chest  showed the lungs and 
432
HYSTERIA.
heart to be quite  healthy and remarkably well developed.   But
what  surprised me more was the  absence of hysterical manner
and aspect, and the extremely reasonable way in which she spoke
about her ailments.   It was  more from the history and  her own
statements, than from my  own eyes, that I was able  to guess at
the hysterical  diathesis.
  I look upon  this as an instance of a strong external disposing
cause overcome in a great  measure by a still stronger will.  In
a weaker-minded woman it would  probably have resulted in the
extremest hysterical phenomena;  in her it acted only locally on
one set of nerves.  I dare  say at a future time  I shall be able to
show you examples of the same thing in patients under your own
observation.

  It is worth while to notice in passing an illustration we have
also had of the contagiousness of  hysteria.
  Elizabeth W., aged eighteen, has been in hospital many weeks
with several relapses of rheumatic fever coming upon a  long dis-
eased heart.   She has been  all along somewhat disposed to hys-
teria, but  never so much as to require special remedies.   Our
patient with hysterical vomiting, Hannah P., being up and about,
was appointed by the nurse to give her her food, and was brought
into familiar relations with  her.  In  a few days Elizabeth W.
began to vomit her food also, and this  led me to order her vale-
rian.  The drug, a good scolding, and the removal of the conta-
gious intercourse with Hannah P., soon put a  stop to the  addi-
tional ailment, and I have bidden her continue the valerian as a
preventive and tonic.

     Part  III.—(Clinical, St. Mary's, February 5,  1863.)

   In the case of Elizabeth P., who has just left us, you have seen
an example of the connecting link between hysteria and  insanity.
She is a servant out of place, aged  twenty-two, muscular  and
well-made, but thin, and  of leucophlegmatic color  and aspect.
She was sent in as a case  of inflammation of the bowels, and I
found her in bed loudly complaining of violent pain in the abdo- 
HYSTERIA.
433
men, equal in external manifestations to that caused  by perito-
nitis.   But then she lay twisting herself about, and when I put
my hand on the part she immediately contracted strongly all the
muscles.   People attacked with peritonitis do not do that.  She
gave moreover no history  of shiverings, or of any probable cause
of peritonitis; whereas that inflammation is always preceded and
accompanied  by rigors, and can generally be traced to some defi-
nite occasion.  Then she buried her face  in the pillow, avoided
my gaze, and, when pressed to look at me, did so with a quick,
startled  glance, and quickly turned away her eyes.  The pupil
was widely dilated, the sclerotic sky-blue, giving the  organ a  "
much brighter and blacker appearance than  is consistent with
her blonde complexion.   There was the  hysterical droop and
fullness in the upper eyelid.   The catamenia  were regular, and
she had  no leucorrhcea.   The urine was very  pale, copious, and
of a specific gravity only from 6 to 7 parts in  1000  above that
of distilled water.   This again was  fatal to the diagnosis of peri-
tonitis.  There was a great abhorrence of  food, but no vomiting,
and it did not seem to cause  any inconvenience when  swallowed.
On all these  grounds  taken together I set it down as a case of
hysteria, psychical rather than bodily in its manifestations, and
depending rather on moral than on material causes.
   Subsequent  information  has seemed  to  confirm  this  view.
There is some sad point in  her private  story which seems  to
have been the starting-point of her illness.  What it is I do not
know, and more than that I do not  care to inquire; for I believe
inquiry  would do  more harm than good;  the fact  is enough.
You will often be tempted by natural interest and a pardonable
curiosity to elicit romances of real life from your patients.  And
there is  an agreeable sense  of responsibility in being the honor-
able guardian of a secret.   Women  more especially,  from an
innate love of confession, will favor this,  and  are only too ready
to  make you  a  confidant of their  own  and others' histories.
 Check  yourselves   and  check them,  directly you  have  heard
enough  to direct your treatment of the case.  Overmuch sym-
 pathy with mental distresses  and passions makes you a less  effi-
 cient medical man; even the appearance  of  sympathy weakens 
434
HYSTERIA.
your influence in many hysterical cases.  It is your business to
discourage a morbid dwelling on the past, and to strengthen that
English reticence which leads us to bury our sins and sorrows in
some  out-of-the-way corner of the memory,  and to resent the
prying curiosity of medical or spiritual attendant.
  The diagnosis of  hysteria was confirmed even before we  left
the ward by the patient going  off into a violent attack of noisy
sobbing; and the nurse told me that a few days afterward some-
thing made her laugh, and she was quite unable to restrain the
most violent and painful cacchinations for a quarter of an hour.
But it also appeared that before her  admission she had had tem-
porary delusions on various subjects, and often her manner in
the hospital was that of a melancholic.   By dint of  valerian and
daily shower-baths she got much better, and was able often vol-
untarily to keep off hysterical  paroxysms, when she heard that
having them would entail a shower-bath in the afternoon and at
night as well as in the morning.
  But her frightened  insane manner she did not lose till we were
able to set her to work helping the nurses to wash the crockery,
run messages, and wait on  the patients.   This was  much better
than the  dull walks  up  and down the  garden, which for some
time was  all the voluntary exertion  she could be got to make,
and it quickly wrought a cure.

    Part IV.—(Clinical,-St.  Mary's, November 14, 1863.)

  In the  case of Ellen----who  left the female wards two or
three  days  ago, cured of  hysterical vomiting  by valerian  and
shoAver-baths, there are a feAv circumstances worthy of practical
note.
  She states that for  the last three years she has scarcely ever
passed a month without an attack of vomiting accompanied by
great depression of spirits.  These attacks however seldom last
above  four or five days, and  are  usually cured by stimulants.
Last  August she went to Eastbourne  along  Avith the  family
where she lives as cook.  It was against her will that she went,
for  she says the seaside never agrees with her.   While there she 
HYSTERIA.                     435
 had an erysipelatous inflammation of the foot, which laid her up
 for a short time, and her  spirits got  depressed.  Then a very
 bad attack of her old complaint came  on;  she vomited after all
 her food, and continued to do so till her admission to the hospi-
 tal, October  22, after she  had gone  on suffering in  the same
 manner for two months.
    She is a tall dark unmarried woman of thirty three; she has
 an imposing aspect, with a fine-looking mouth and jaw; but yet
 she has  the hysterical eye.   Or at least she had it on admission,
 for her expression is a good deal altered since she came.   She
 has never experienced paroxysms of laughing  or crying, and is
 used to conquer her  depression of spirits by an effort of throw-
 ing it off.   She  seems a person of  strong  hysterical  diathesis,
 checked by  sound good  sense  and  powerful will, in whom the
 diathesis would not have developed into external manifestations
 Avithout  considerable motive causes.  These motive causes may
 be traced in her history.
   You observe, first, her age.  A single woman  between thirty
 and forty is  in circumstances which have  a great influence  on
 the mind.   She feels that her chances of  a settled and natural
 home are  daily becoming  less and  less, and that the affections
 she might expend on a house, a family, and a husband,  are being
 wasted and withered.  Hence  their  tendency to all mental and
 semi-mental ailments.
   Secondly, early in life  her affections were  cruelly deceived
 and blasted.   Long ago  she was an unmarried mother, and has
 ever since  suspiciously shunned the  change  of a similar disap-
 pointment.
   Thirdly,  her bodily vitality was  lowered by the depressing
 illness of erysipelas.
   Fourthly, she was in a climate which tended to aggravate the
 predisponents  already named.  Many hysterical  persons  are
 made worse at  the  seaside; and  moreover close to Eastbourne
 there are  some  recently drained  marsh lands, whose  crop  of
 malaria is in certain states of the wind blown toward the town.
 The eastern  side  is especially exposed  to  this.   Now malaria
is  very  poisonous to all nervous  patients;  it  does away with 
436
HYSTERIA.
all the advantage of the fresh  sea breeze  and the change  of
scene.
  It is in such cases as this, where there is under ordinary cir-
cumstances a balance between  the disease and motive causes on
the one side,  and the natural  cure of strong will on the other,
that you find the more irregular forms  of  hysteria developed.
And I must frankly say they are  not easy to recognize, and
often difficult of cure.
  I kept this woman at first in bed for a few  days, in order to
give her perfect rest, and to enable her to do without more than
a very small allowance of nutriment, namely, milk and beef-tea
given in doses of about two ounces at a time.   This broke to a
great extent the habit of vomiting.   Then she had a teaspoonful
of tincture of valerian every four hours, and strange  to say its
nauseous taste produced no nausea.   The  cure was completed by
a week's course of daily shower-baths.  The woman herself was
much struck with the effect, and in spite of this dreary weather
said she was determined  to go on with  them at home.   Her
mistress will doubtless accede  to this plan of keeping an active
servant in vigor, and armed with a prescription for valerian  drops
I think our patient is qualified to be her own physician.
  Compare this now with the  next case.  Jemima T., a house-
maid,  aged twenty, has at present hysterical aphonia.   She
was  originally  admitted September  28  for severe cedematous
angina.  She had been salivated before admission, and was fur-
ther reduced through the loss of blood by leeches, uncompensated
by  diet; for swallowing was  so difficult  to her, that she was
nearly starved.   At first I attributed the loss of voice,  remain-
ing after  the angina was well, to  paralysis of the vocal  cords
from the long-continued oedema in  the neighborhood, especially
as the edges of the glottis could be seen by  the laryngoscope to
be somewhat red.   But when we made the attempt to apply gal-
vanism internally to the cords, the true nature of the  aphonia
was  made known to  us by her having an  hysterical fit of  a vio-
lent convulsive character, in which she screamed out lustily in a
high musical note.  I  immediately  ordered  her  cold  shower-
baths daily and valerian.   She has  had no more hysterical par- 
HYSTERIA.
437
oxysms, but shows  in  the shower-bath her talent for holloaing,
and the voice is acquiring a tone.
  I have brought  forward  this case in  order  to remark  that
where  any special  lesion has  existed,  hysteria  will very often
choose the lesed locality for its manifestation.   This is puzzling
to you in practice,  because you do not know when to cease treat-
ing the lesion and  to  begin treating the hysteria.  I think the
general tendency is to be  too  dilatory in  changing the treat-
ment.
   I have also to remark an instructiA'e  clause in this girl's his-
tory.  She is a native of Edinburgh, or at least was long resident
there,  and always  enjoyed very robust  health and high spirits,
and  never  felt tired.   But on  her coming to London, eight
months ago, this high health almost immediately began to fade,
her nervous powers declined, so that she never felt up to a good
day's work, and she fell into a state of  perverted nervous sensi-
bility of  which you see the phenomena.  I cannot help attribu-
ting her illness to the  depressing influences of the climate of
London on a person used to the stern bracing air of the East of
 Scotland.
  [This girl regained her voice and general health, and left the hospital Novem-
ber 27 to take an opportunity which offered itself of returning to Edinburgh.]
   Another case of hysterical aphonia came in last week.   Sarah
 L., aged twenty-eight, lost her husband two years ago after a
 pulmonary consumption, which had laid him up for five years,
 and during which  she had nursed him  assiduously.   She  says
 her health has never  been strong since, though she cannot give
 a name to her illnesses : she has been frequently prostrated by a
 feeling of excessive weakness, but has had no definite classifiable
 ailment.   So she  continued till a fortnight ago, when she quite
 lost her voice, and then was taken with a severe cough, which
 "quite  tore her chest to  pieces."  A few days before we saw
 her here she began to spit up blood, but I could not make out
 from her account that the blood came up with the cough. When
 I first examined her  she  complained of exaggerated pains all
 over,  and her whispering attempts at conversation brought on a
 paroxysm of a violent spasmodic character, like hooping-cough 
438
HYSTERIA.
 without the hoop, but it resulted  in  no expectoration.   She
 said she was sure she was  going into a  consumption, but  per-
 cussion and auscultation of  the  thorax gave no evidence of any
 pulmonary  or  cardiac  lesion.   The next day  she  showed  me
 a quantity of slimy blood in a porringer, which  she had spat
 during  the  night and  day.   Blood it was truly, but yet it pre-
 sented  to the  eye not exactly the aspect of that which might
 come from  the lungs.   It  was neither scarlet  nor  frothy, like
 that so  common in early tuberculosis, nor did it consist'of streaks
 in the  mucus, like  that of  a more  advanced stage, but it was
 incorporated with and  soaked into  the  mucus, more like what
 you have in congestive pneumonia.  Now she  certainly had not
 congestive pneumonia, and therefore I believe it does not come
 from  the pulmonary tissue  at all.  This view is  confirmed  by
 the nurse, who  says the patient does not cough it up, but hawrks
 it up very gently.  My own impression is that it is drawn down
 into the fauces  from  the back of  the nose or comes at lowest
 from the trachea.
   What renders the case more complicated and puzzling is, that
 her breath is fetid and her tongue coated with a white fur, from
 some  mercurial medicines which  she  had been taking  before
 admission.   It  is very like  the tongue of inflammatory fever.
 But then to  balance this element of  difficulty  in the diagnosis,
 she has hysterical paralysis of the lower extremities, being
 really unable to stand, and stumbling forward  on the floor when
 I left her alone without support in the middle of the room.  The
 form of paralysis is  sufficiently special to mark its hysterical
 character,*  and  compensate  for  the  other  difficult points of
 diagnosis.
   It seemed perhaps rash and cruel, when to a patient who thus
 exhibited  the  symptoms of  haemoptysis, cough,  loss of voice,
 pain in the chest, quick pulse, and furred tongue, I straightway
 ordered valerian draughts and a cold shower-bath every morn-
ing.   But I felt safe in my diagnosis from  the characteristic
 appearance of the eyelids and the dilated pupils.  She said  she
was sure that the shower-baths would kill her; but she survived
                     * See before, page 428. 
HYSTERIA.
439
the first, and after the second confessed  that it did her a great
deal of good.   She is improving rapidly, and seems now really
desirous  of being well,  submitting  without a  murmur to the
moral influence which I have desired the nurses to exercise, in
giving her  employment, and not  allowing her  to  lie down and
think, as she is prone to do.
   This case is an instance of the enormous  advantage over our
forefathers which auscultatfon gives us.  Without the stethoscope
it  Avould have been a most anxious thing, nay almost impossible
for even  the most  shrewd to  have pronounced  the negative
opinion  that  this blood did not  come from the lungs, and that
the cough  was not produced  by  rapid  tuberculosis.  It is an
instance also of the reward Avhich follows bold and decided action
in these cases.

     Part  V.—{Clinical,  St. Mary's, November 28, 1863.)

   Sarah L.  went on very well,  having lost  her  cough  and
haemoptysis, and  recovering the  use of  her legs under the ad-
ministration of a  cold shower-bath tAvice a day, and valerian, till
November  23.   Then her monthly  period  began  in the usual
Avay,  and  according  to  established practice  the  ward-sister
ordered the shower-bath to  be  discontinued.  Sarah L. took to
her  bed next day, and  began  again  coughing violently,  and
expectorating,  really  expectorating this time, a quantity of
frothy bright blood with each cough.  There Avas  as much as
half a pint spat  up  in twenty-four  hours.  Yet the catamenia
continued to  flow, though  scantily.  I found her on the 25th in
bed, tortured with violent paroxysms of coughing,  and throwing
up blood each time.   I took a slab of ice, and placing it on the
sternum, directed  her to  hold  it  there with a piece of flannel.
The paroxysmal  cough and the  haemoptysis ceased  forthwith,
and Avhen I saw her next day, she said she had kept constantly
applying the ice, and that  it ahvays stayed the cough immedi-
ately.   The catamenia continued.  I bade that on their ceasing
she should resume the shower-baths.  But this morning, when
the nurse,  finding the prescribed time for their resumption had 
440
HYSTERIA.
arrived, ordered her to have one, she refused, and when remon-
strated with, still persisted in  her refusal, though acknowledging
all the good they had done  her.  Our necessarily strict rules of
discipline render her, therefore, no longer a patient at the hos-
pital, I am sorry to say, for I was very anxious to see  the result
of this curious and  instructive case.
  Several  examinations which I and  others made of her chest
convince me that there was no lesron of the pulmonary  tissue,
such as usually gives birth  to  haemoptysis.  I own  at first, and
even at the time of my last  lecture to you, I was suspicious that
the blood was  produced  by a voluntary effort, such as may be
exerted on the back of the  fauces, or  nasal fossae; but observa-
tion of this last attack completely exculpates the patient in that
respect.   No voluntary effort could cause the blood to be exuded
in such quantities into the trachea, for auscultation showed it to
be in  the trachea, not the bronchi.   Then  its occurrence  at the
menstrual period  induces me  to range it  in  that curious,  and,
fortunately, rare  class of cases, where the monthly haemorrhagic
nisus  of the female sex, instead of confining itself according to
the convenient  arrangement of  nature  to  the womb, an out-of-
the-way and secret part, is exhibited in other more  conspicuous
and troublesome places.
  Some of my third-year  hearers  may, perhaps, remember a
remarkable instance of this misplaced discharge in a young wo-
man  who  was in the hospital  two years and  a  half ago.   She
menstruated  by the usual path, but at the  same time had an
exudation  of  blood in minute puncta, from the skin  of the arms
or forehead, or legs or chest.*   I called it then a case of "bloody
sweat," for in looking at her  pale  face and gore-dabbled brow,
a memory of Gethsemane could not fail to offer itself,  and I
hope  such 'memories are not irreverent.  She  also, like our
present patient,  was hysterical, was suspected  of imposition,
and carefully watched, but no  deception could be detected.
  When that case of catamenial bloody sweat was  admitted, I
did not know at all  how to  treat it,  but I found experimentally
  * Full details of this case and the literature of the subject are published in
the " Lancet" of March 2, 1861. 
HYSTERIA.
441
that free leeching the spots where  tenderness gave  notice of
threatened  haemorrhage, not only prevented  the  immediately
imminent haemorrhage, but gradually lessened the tendency to it.
She had seventy leeches applied in this way, and lost  beside by
venesection twenty-four ounces of blood; yet she gained strength,
and became less hysterical, and went out nearly well  after four
months.  She had a recurrence last year, when I saw  her  once,
and ordered her some leeches  as an out-patient.   And again a
few weeks ago you saw her in the ward, having come to apply to
me for some leeches to relieve a  slight recurrence, in the cheek,
of her old complaint.   She stated that she had been previously
free of it for  many months.
   This last-named case shows that in misplaced catamenia with
hysteria leeches Avill  cure  the haemorrhage, without  damaging
the mental state ; and it was my intention to  have tried an analo-
gous method  of treatment  in  Sarah L.'s case, but her abrupt
departure has defeated my design.

   In all my lectures on hysteria, the conclusions to AvhichI have
endeavored to lead you by aid of the patients under  your eyes
are—
   1st.—That  it is  a disease  (a  word which I always use as
synonymous with deficiency  of life) of the* mind and of the body
also.
   2dly.—That in some cases the mental, in others the  corporeal
phenomena predominate.
   3dly.—That the predominance of one or other must be our
guide, whether moral or physical  agents are most required in the
treatment.
   4thly.—That the aim of  our treatment of the mind must be
the teaching our patients to  exert their will.
   5thly.—That the organ which aids us most in our treatment
of the body is the stomach, and on the proper regulation of this
viscus the success of that part of our practice will depend.
29 
LECTURE  XXXIII.
                SPINAL  PARALYSIS.

Case of paralysis caused by meningitis of the spinal cord—Action
                   of iodide of potassium.

            (Clinical, St. Mary's, June 27, 1863.)

  Meningitis of the spinal canal, about which I am going to
lecture to-day, does not present  the  interest of frequency.  It
may perhaps be many years before you have a case of it to treat,
perhaps you may never see another.  But the fact is, I have not
to-day any more  instructive  cases to lecture about, and I will try
and extract for you from  it what wisdom I can.
  William T., a  pale;faced, "sandy-haired, and delicate-looking
shop-boy of  seventeen, has been  under your  observation  since
April 10.   He stated that his father  and mother were alive and
healthy, and that he himself had always been well till Wednesday
in Passion Week (April 1), Avhen he  had to carry a heavy load
on his shoulders;  while thus employed, his foot slipped and he
fell down  against a wall, but did not knock his  back or bruise
himself.   At about two  o'clock the  following afternoon pain
came on suddenly in the lower part of the loins.   He  however
went on with his work that day ; he had a holiday the  next,
being Good  Friday, and  worked again on Easter Eve.   But on
Easter Sunday the pain was so bad that he took to his  bed, and
lay there  till  the  Thursday after, when  he got up and sought
medical advice, as the pains in the back were so bad that he could
not sleep  at all.   On the Saturday, April 11, he walked to the
hospital, and was sent  to bed.  But  though he walked, he said 
SPINAL PARALYSIS.
443
his left leg was very painful and numb.  He complained of great
thirst,  the skin was  hot, the pulse  quick and sharp, and  the
tongue thickly coated with a yellow fur.
   At first he was  treated with chloroform fomentations  to  the
loins, as for rheumatic lumbago; but two days after admission a
more accurate examination detected the seat of the pain to be in
the situation of the last lumbar vertebra at its junction with the
sacrum.   The pain was much increased by pressure and by per-
cussion.   Both legs then  appeared to be growing  numb, and
there was some difficulty in moving  them.  But the sphincters
were as  yet unaffected, and he retained his urine and faeces
naturally.
   These symptoms led to the diagnosis of meningitis of the spinal
cord. He was cupped to eight ounces at the painful spot  on that
and  the following day, and a continuous chloroform poultice Avas
kept on the sacrum.
   The paralysis of the legs increased, and sensation became very
deficient,  so that he scarcely felt the hot water bottle at his feet.
He was then (on the 15th) ordered ten grains of iodide of potas-
sium every three hours.   On the 18th  there was less inflamma-
tory fever, and the  tongue was  cleaner.  But the sphincter of
the  bladder had become paralyzed, and the urine trickled away
involuntarily. A catheter was then passed and the bladder found
to be  full,  being  incapable of  spontaneously emptying itself.
The urine drawn off was alkaline, and contained a small quantity
of floating pus globules.   Then  he entirely lost command over
the  sphincter ani, as well  as over the  bladder, and lost also  all
sensation of the passage of either fluid or  solid excrement.  The
urine was drawn off three times a day, and constantly contained
a large quantity of ropy  pus, sometimes quite obstructing the
catheter.   The iodide of  potassium was continued  in the same
doses,  Avith  no addition except that for tAvo days he had with it a
few  drops of tincture of cantharides, which was left off on the
bladder  being inflamed,  and occasionally  a little  tincture of
opium, to make the faeces more solid  and less troublesome to
those who cleaned his bed.
   The paralysis was at its worst about the 30th of April, after 
444
SPINAL PARALYSIS.
which it began to mend, first in the legs, and  afterward  in  the
sphincter ani, and then in the sphincter vesicae.  The amendment
in the two latter seemed to be considerably aided by the appli-
cation  of blisters  on  the  sacrum  and above  the  pubes.   The
patient can now move his legs about freely in every direction as
he lies or sits on the bed,  and can voluntarily retain  his faeces
and urine.   He can  prevent himself from making  water for an
hour together.   He is, however, excessively emaciated  and weak
and cannot of course walk about much.  The  introduction of a
catheter into the  bladder  shoAvs that it  spontaneously empties
itself, so that the muscular action has completely returned ;  but
still there is a certain  amount  of  floating pus in  it,  and it is
seldom decidedly acid.   He is taking decoction of  uva ursi and
cod-liver oil, and improving daily in every respect.
  [He left the hospital fat and well at the beginning of August, without any
purulent secretion from the bladder remaining.]
   I take this case  to have  been one of meningitis  of the spinal
cord ; that is to say,  inflammation of the white fibrous coverings,
and not of the nenrous tissue itself.    Instances of disease  of this
part are rare, and therefore one cannot of course be very pedanti-
cally positive in reasons for a diagnosis.  My principal reason
was the presence of local pain ;  for in disease of the spinal cord
itself there is no pain, as some of you  may recollect to have seen
in the case of a young woman Avho died with a scrofulous tumor
in its lower part, last winter session. The cause of her  death Avas
chorea, but there was no paralysis  or local pain.   Local pain is
also absent in cases where  haemorrhagic clots, tumors,  or inflam-
matory softening occupy the central parts of the cerebral mass;
while it is  on the  other hand almost always present when  the
dura or pia mater  are affected.
   My  clinical clerk, Mr. Philps, has shrewdly suggested another
reason for  the diagnosis, namely, that the pain was  situated very
low down,  to wit in the lowest lumbar vertebra.  He  says  that
as the  cord has given off all its  nerves and ended at the level of
the first lumbar vertebra, any pain  referred to a situation below
that must be in the envelopes which  continue  to  surround  the
bundles of nerves, rather than in the cord itself.   And I think
his reasoning very good. 
SPIXAL PARALYSIS.
445
  As to the origin of the disease in this case there is not much
to help conjecture.  Possibly a rupture of some fibers of the psoas
muscle by the strain in  stumbling under a heavy burden mav
have started an inflammation in the interior of the pelvis, which
affected secondarily the coverings of the sacro-spinal plexus, and
so spread upward.  Possibly there may be some scattered tubercles
in the meninges of the cord or its theca, just in sufficient numbers
to excite a curable inflammation, but not an incurable  one.  We
have not enough  data on which  to found  an anatomical diag-
nosis.
  But we have plenty of data for the foundation of a therapeu-
tical diagnosis.  There was paralysis of the lower nerves of the
spinal cord,  probably from inflammation of  its meningeal cover-
ings.   And  on this was based the treatment by iodide of potas-
sium.  You may  know from observations of its  use in tendinous
and  thecal  rheumatism,  in aponeurotic headaches, in  chronic
syphilis, in  periostitis, in inflammation of  the  eye, in hard en-
largements of the glands by disease of their connective tissue, in
some of the consequences of gonorrhoea, &c, how this drug causes
a renewal of  healthy life  in Avhite fibrous tissue, Avithout any
evacuation or destructive  action, as is shown  by the patient's
increase in weight during its appropriate employment.   By its
action on that tissue I explain its use  in such cases  as these.   I
employed it once as the only drug in a case of meningitis of the
brain in a young  man with the best results, and shall be disposed
to trust to it with equal confidence in  future. 
LECTURE  XXXIV.
                       SCIATICA.

Anatomical pathology of the disease—Case of rheumatic sciatica
    —Rokitansky's description of the morbid anatomy of sciatica
    — The disease a local one—Therefore requiring local reme-
    dies—Case of gouty sciatica—Relief from cupping—Per-
    ipheral pain sometimes more lasting than central disease—
    Sciatic  paralysis of bladder—Case  of anaemic  sciatica—
    Local treatment first requisite— Use of iodide of potassium
    —And of quinine— Other forms of sciatica— Other remedies
    besides  those named—Deductions and reflections.

          (Clinical, St. Mary's,  January 26, 1861.)

   Three of my patients now under  view in the wards are in-
dexed as cases of "sciatica."   The term,  though Latin, is not a
technically pathological  one ;  for it no more defines  a morbid
process than the vulgar  English "headache" or "stomachache."
Like those  words, it  points out  the  anatomical locality of  the
symptom, and  is applied to  pains  in the great sciatic nerve,
whatever their nature or cause  may be.
   It will better impress upon your  minds several  important
points in its pathology and treatment, if I recall to  you a few of
the anatomical relations of the  part affected.   The  sciatic is  the
largest nerve  in the body ; and on that score even slight inter-
ference with it may be expected to be severely felt. It is formed
by a union of  the sacral nerves ; which, inside the  pelvis (form-
ing the sacral  plexus), are covered on the left side by the rectum,
and on the right side are in close  proximity to the  caecum;—
hence  it is  very liable  to be  influenced by  the  condition of 
SCIATICA.
447
either of these portions of the intestinal canal separately.   It is
covered by a strong fibrous sheath, and may of course  be ex-
pected to experience morbid states which attack  such membranes.
It supplies motion as well as  sensation to the  lower limb, and
therefore loss of muscular power often follows its loss of vitality.
Inside the pelvis, branches are sent from the sacral plexus to the
bladder and other pelvic viscera; so  you will  not be  surprised
to find in sciatica occasional  paralysis of the bladder.   After it
passes beyond the border of the pyriformis muscle, it lies nearer
the surface than any great nerve, and it goes straight from one
of the warmest berths in the  body to  one of the coldest;  and
that it is soon affected by changes of temperature is readily to be
understood.
   The first case which I shall mention is a good instance of the
last-named fact. The affection is strictly local and pretty recent,
and is clearly traceable to a local change of temperature acting
on this part of the body alone.
   Case  1.—Henry T.,  aged  twenty-eight, a horse-patrol, of
temperate and  regular habits, had been  quite well  up to the
second week in December, when he got  wet in the saddle several
nights running, and his buttocks and thighs  were much chilled.
This was followed by  cold and shivering, but  by no particular
pains in  the limbs.  Suddenly, while grooming*his horse, he was
seized with a twinge in the hip, which made  him walk lame and
prevented his sitting on horseback, but  did not  quite lay him up.
He continued with the aid of a  stick to go through his beat a-foot
instead of riding.  One day, and one day only, before Christmas,
the pain quite went away; but, with that  exception, it  became
worse and worse.   Since December 29 he had  been laid up un-
able to stand, so bad  was the pain ; and he  had had  croton oil
rubbed in  externally, mustard poultices*  and   blisters, without
the  least relief.   The tongue, pulse, and action of the bowels
were  reported  natural, the urine  clear.   The situation  of the
pain, as  pointed out by one  finger, was the exit of the  sciatic
nerve, and pressure on that spot much  increased it.  He told us,
also, of a pain deep down in the pelvis, as if it lay at the  back
of the groin. 
448                      SCIATICA.
  There is here a purely local disease, asking for local remedies.
The morbid anatomy of it I cannot describe from any observa-
tion of my own ; none of us possibly ever have seen, or ever will
see, the necropsy of a person who dies during sciatica;  it is not
itself deadly, nor does it accompany deadly diseases.   But Pro-
fessor Rokitansky describes the sheath of the nenre as filled with
a yellow gelatinous fluid, and as having its blood-vessels injected
in sciatica.  This is just what you find  in the rheumatic inflam-
mations of other fibrous parts, and what a general knowledge of
pathology would teach us to  expect; and, therefore, I fully be-
lieve it is the unseen state in this and similar cases. It is a local
disease asking for local remedies.   You will say, it has been so
treated  in  this case, and  it has  not got well.   True;  but the
remedies were,  for  all that, of the right sort; perhaps not quite
powerful enough, and, moreover, not quite local  enough.   What
does that deep-seated pain in the  pelvis  mean ? It shows that the
sacral plexus is affected, as well as the trunk of the nerve ; that
the  remedies must  be applied  to that  part to  have their  full
effect.   Such, I take it, is its meaning.  Noav, applications to
the  skin of the hip  and thigh are a  long  way off  the  sacral
plexus, and you would not  get much nearer by placing them on
the  groin.   But you can get close to, indeed quite on, the seat
of action,  by calling to mind how the plexus is  overlaid by the
rectum.  His former treatment, mustard poultices, blisters, and
croton oil,  Avould be rather difficult to  apply to that part cer-
tainly ;  but you can use an allied remedy, turpentine ; and you
can introduce it to the pelvis either by  enema or by the mouth.
The former method is the most  direct; but I have  chosen the
latter in this case,  for the  mutual  convenience  of  nurse  and
patient.  His card records the following :
  Jan.  14.  Jfy  Olei terebinthinse, olei  ricini, mist,  acacise,  aa
§ss; mist,  camphorse, 5j-   M.  Fiat haustus manS sumendus.
  Jan. 16. Repetatur. 19th. Rep.  21st. Rep.   24th. Rep.   So
that five doses  of turpentine in all have been taken.  On the
16th the pain in the hip wTas much relieved, but he  had a little
strangury during the action of the turpentine.   On the 19th he
said he felt better after each dose, though the  pain came back 
SCIATICA.
449
 again.   The strangury was much less than at the first dose.  On
 the 23d, the pain was not felt during the day " a third as bad as
 it was." He could cross one leg over the other in sitting, and could
 walk without pain. But you will have  seen that he still walked
 lame, and spoke of a kind of numbness running down the thigh.
 This is a slight paralysis, very usual in sciatica, arising  from the
 pressure of the swollen sheath upon the nerve. lie said the deep-
 seated pain in  the pelvis was gone.  You will find the treatment
 here ordered the most powerful to cure the local condition of the
 part affected in sciatica.
   To-day (the  26th) he Avalks quite easily.   But, unfortunately,
 the turpentine, not having sufficient employment in doing good,
 has taken to doing mischief, and has brought on strangury again.
 He has had two grains of opium  as a suppository, Avhich has re-
 lieved it  to a  certain extent;  and, instead  of  continuing the
 turpentine, I have ordered him to be  cupped to four ounces on
 the hip.
   Case 2.—Another patient in the same ward, Francis  B., aged
 fifty-three, has no occupation noAV, but he tells us that formerly
 he did  a  business of X1000 a year, and enjoyed a famous  con-
 stitution.   Wealth and health were lost through  self-indulgence
 in eating  and drinking.  He  had gout thrice in one foot, and
 once in both feet, twenty years ago. Poverty made him temper-
 ate, but  two years ago he had some money left him, and "drank
 it out," being only stopped by a severe attack of  bleeding at the
 nose.  Since then he has not exceeded, but still had a twinge of
 gout six months ago.  After this he Avas quite well till six wreeks
 ago; at which  period, after  having  felt for three  days pains
 flying about him, he was attacked, Avhile sitting before  the  fire,
 Avith a stabbing agony in the back and left  hip, so bad that he
was obliged to go to  bed.  It has lasted ever, since, and he has
generally  kept  his bed; as, though he can hobble along without
actual suffering, he is in  constant fear  of a twinge.  All through
this last illness  there has been a difficulty in  voiding urine, and
the bowels have  been costive.    He  has been under  medical
treatment all the time, and has taken bark and quinine in large
quantities, and  has had blisters on, without being  at all relieved. 
450
SCIATICA.
  On admission, the tongue and pulse were natural. By manual
examination the chief seat of pain was found to be a spot midway
between the great trochanter and the tuberosity of the ischium ;
and in this part there was much tenderness on pressure, and the
patient had great dread of its being touched.  There was pain
also skirting along the outside of the fibula, but not in any inter-
mediate place.
  In  this case you  have seen a different cause  for sciatica—
namely, gout.  But whatever the  cause, the local condition of
the nerve is  probably much the same, and  is better for local
treatment in all cases—indeed it is rarely cured  without local
treatment.  The remedies given here have been  pretty active;
the patient came here on  the 11th, and  between that date and
the 26th he has had five half-ounce doses  of turpentine, and has
been  cupped tAvice to six ounces.  For four days he was allowed,
as an experiment, to have every night fifteen grains of Dover's
powder, Avhich I expected  the turpentine to carry off safely by
purgation next morning.   It did not make him sleep, or  appre-
ciably relieve the pain, so it was left off;  for, as a rule, I do not
like opiates in sciatica.   He  had  less discomfort on  the night
after it was left off.
   On the 18th he said he had experienced great relief after the
second cupping.  Take a hint from this—your second cupping
will often confer much more marked benefit than the first.
   " He felt pain in the lower part  of the  leg, but  not in the hip
unless it were  touched," says  the  case-book.  You  will observe
that where there is pain in the periphery of the  nerve,  arising
from disease in its trunk, this peripheral  pain  will  often last
longer than that which is  at the real  seat of injury.   Take
 care  to retain  this fact  in  your memory,  as it will often prevent
 you  throwing away uselessly on  the branches  those  remedies
 which should be applied to the trunk.
   On admission, the patient accused  the bladder of some want
 of power.   I have  seen this before in sciatica; and I believe  it
 arises from the Aresical branch of the sacral plexus being affected,
 and therefore shows that  the morbid condition has penetrated
 into  the interior  of the  pelvis.   If it really arise from that 
SCIATICA.
451
cause, and not from any old stricture, you need not be afraid of
causing strangury by turpentine.   You will have seen  in this
case the drug  doing no harm,  on the contrary, relieving  the
symptom which arose from a torpid condition of the bladder.
  On the 23d, he bore pressure on the sciatic nerve and walked
and moved the limb without fear, though with a certain  loss of
power.   He had remarked several times, that though the pain
was relieved after each cupping and  dose  of turpentine, yet it
returned before the next.   The cause of the  disease, the gouty
crasis, remains, and  must  be  treated, or else  he will have  the
sciatica back again.   I have therefore prescribed—
  ty  Vini colchici, TTjxx, potassi iodidi, gr. iv,  mist, camphorse,
5j.   M. Fiat haustus  ter die sumendus.
  Case 3.—Sarah B., aged nineteen, maid-of-all-work, pale  and
greasy-faced, Avith cheeks  and shoulders  covered with black-
heads (acne), was admitted January 11.  She has had occasional
pain in her hip three years.  It came on first when she was out
of place, and had  frequently got wet in her feet.   She has often
felt  pains  flying  about her limbs, but has never been laid  up
with any distinct attack of rheumatism  in her hands  or feet.
She often coughs, has  been always pale, subject to leucorrhcea,
and to pain in  the epigastrium  at night  and after  food.   Her
boAvels  are costive,  and her appetite bad.  She became lame
from sciatica a few days  before Christmas, and took to her bed
during the last few days of the year, because the pain got so
much worse.  Although an out-patient at the hospital, she does
not appear to have attended regularly ; so that Dr. Sieveking,
under whose care  she Avas, sent for her to come in.   On admis-
sion, her tongue was  clean ;  the  pulse Avas  92,  and weak;  the
urine pale.   The  catamenia were  stated to be  always  regular,
except  for three months,  when she was first ill, three years  ago.
The seat of the pain was clearly pointed out by the finger to be
the sciatic nerve,  and  not  the hip joint.  The  heart and lungs
seemed quite sound.
   Here is a cause  for sciatica the very converse of the last;
that was from eating and drinking too much, this is from eating
and drinking too little.   Indeed in a further page of the report 
452
SCIATICA.
you read a statement of the girl's own, that "the pain sometimes
entirely goes aw^y, especially after a good dinner;  but always
comes back again, especially at night."   But though scanty diet
has been the cause of her illness, yet full diet alone would not
restore health.   In point of fact, however much she may swal-
low, she cannot  really  eat,  that is  digest,  enough.   This  is
shoAvn by the want of appetite and the peculiar dyspepsia ; which
is  described as causing Aveight  at the epigastrium, and inability
to  lie on the left side.
  The local disease required treatment first;  so she was cupped
once to  four ounces and Avas purged Avith turpentine ;  and she
took four grains of iodide of potassium three times a day.
   Five days afterward it is registered  that " the pain in the
thigh is less than it Avas, and she is improved in every way."
   On the  23d,  she expressed  herself as  still better, and Avas
walking about the Avard.  She was put on quinine and iodide of
potassium.
   The last-named drug I intend to act locally when  I give it in
sciatica.   I want it to  promote  absorption of the yellow gelatin-
ous fluid which is effused in the sheath of the nerve,  and which
keeps up lameness by pressing upon it, just as you may  benumb
your finger by pressing the ulnar nerve.   Iodide of potassium
has a very peculiar restorative action  on the  vitality of the
white fibrous tissues,  whether  they form tendons,  sheaths  of
nerves, or periosteum; as you may see daily in those  parts when
they have been injured by the poison of syphilis.
   I do  not  suppose there is  any syphilitic taint  in this case to
be benefited by the iodide.  Nor, though I give her quinine,  do
I think  that the disease is of malarious origin.
   Yet syphilis and malaria do sometimes produce sciatica.  The
syphilitic form is of the same nature as periosteal nodes, but it
is  identical in  local  effects with rheumatic, gouty, or  anaemic
sciatica.   The malarious form is purely  neuralgic, and I do not
think it can ever  be accompanied by effusion.  It  may be dis-
tinguished  by its complete intermittence, and,  as  far as my
experience goes,  is comparatively rare.  The patients usually
have some  other consequence of the ague-poison, which will help
you to a diagnosis. 
SCIATICA.
453
  Sometimes  there  is a dull  kind of pain running down the
course of the  sciatic nerve in  persons  with sluggish,  costive
bowels, which, unlike the  forms I have been describing, is not
wrorse at night, but neither in the day is it attended by paroxysms
of agony, and it is not made worse by local pressure.  This kind
of sciatica depends, not on the state of the nerve or its  sheath,
but  on an unhealthy sluggish  condition  of the  lower  bowels.
When  on the  right side, it is due probably to accumulation of
faeces in the caecum;  when on the left (which  is the most usual
case), to  piles in  the rectum, and the consequently congested
state of the blood-vessels.  It is also not made worse by exer-
cise ; indeed,  I think it gets well sooner when the patient is
obliged to move about.   And for this  reason  you  do  not see
examples of it in the wards, for it is better treated  in the out-
patient department;  whereas in  the cases with  which  I have
been illustrating the subject absolute rest is essential.
  I do not like in clinical lectures to speak of  the treatment of
forms of disease not  at  the time under your notice, and, there-
fore, I Avill not say more about malarious, syphilitic, and costive
sciatica.  But I think it will be useful, in reference to the three
cases you have  been watching, to notice a few remedies Avhich
might have been given without glaring malpraxis,  but yet which
I do not think the best under the circumstances.  In the first
place, sedatives might have been considered desirable ; and you
will find in books a long list,  commencing with  opium, of those
which haA'e been  administered in sciatica.  The very length of
the list shows  how people have been disappointed with the action
of one after another; and my own experience is, that the benefit
from them is temporary, fallacious, and obstructive  to the final
cure.  The only one thoroughly unobjectionable is the external
application of chloroform.  Blisters and  acupuncture are reme-
dies of similar intention  to  those which  I have prescribed; not
quite so powerful, but equally rational and proper.  Plasters are
of no use  during the acute stage, but when the patient is  getting
about again, they are a  defense against the cold.   Let them be
spread upon stout  soft leather; for  it is the  leather, not the
" emplastrum," that  does  good, and  the kind that will stick 
454                      SCIATICA.
tightest ansAvers best.  Of electricity and baths I have no favor-
able experience to tell.  I have never seen  them of use to the
local disease  after the failure of those remedies which I men-
tion ;  though I dare say mild cases may be relieved by them, as
also by numerous other expedients, which I need not detain you
by naming.
  I will tell  you why I do  not  name them.  When  you have
once established in your OAvn minds that one particular methodus
medendi is the most effectual for a particular class of cases, you
should not continue to retain in your armory, to be used for that
same  purpose, the weapons which  it  has  superseded.   It will
merely burden your memory and confuse your judgment; and it
throws in your own  path  a temptation  to  wavering.   Let new
weapons be  tried by all  means, if  to  the  eye  of reason they
promise well; but let all  which have once  fairly proved them-
selves failures be rejected.
  At the same time be not too ready to  adopt as fixtures any
pet plans of treatment.  Let them rule  for the time, but let
them be prepared to make  way for better when  they fail to do
all  that is justly asked  of them.  Then   let their  conquerors
occupy the  same post under the same conditions.   When you
have  a new remedy you want to try, select some  cases in which
your  already established  treatment has failed, and  when you
have  found it succeed there several times, you may fairly depose
the old monarch in favor of  the new.  Thus will our art advance.
   The most important moral which I would draw from our ex-
perience of sciatica is this :  to apply to local diseases the needful
destructive  remedies as locally as possible.  Do not call upon
the whole body to  make  sacrifices for a single member, if you
can by any means avoid such sacrifices.
   This  rule  applied to  the  administration  of  destructives  is
directly antithetical to that which should guide us in the use  of
 constructive  agents, where  we  should  prefer in  every instance
 constitutional to  local action.   Remember that in the first case
 we are doing harm for the sake of future good ; in the other  we
 are doing general good for  the sake of particular good. 
LECTURE  XXXV.
                    ALBUMINURIA.

Indications afforded by the presence of albumen  in urine, and
    prognosis derived therefrom—Treatment based, not on ana-
    tomical division of forms of degeneration in the kidney, and
    not  on  the quantity of albumen,  but on the circumstances
    accompanying its presence—Adjuvaniia, viz., iron, digitalis^
    strychnia—Laedentia,  viz., mercury, alcohol—When each
    are justifiable—Treatment  of dropsy by baths, jalap, cream
    of tartar,  elaterium, and acupuncture—Sloughs of skin,
    how treated.

   The presence of albumen  in the urine (or albuminuria) is a
notice whereby we  learn the partial death  of one of the most
valuable structures  in the body.  It shows  the inefficient state
of those organs through Avhich the  urea is  separated from the
blood—the urea, which is a measure of the amount of destructive
metamorphosis, a measure  of the amount of one of the most
essential parts of vital renewal.  The  knowledge of this partial
death is justly regarded as a most important  piece of information
for us to gain.   And you see it is easily and quickly gained by
the well-known test of boiling and nitric acid.
   Remark first—it is as a notice  that the presence of albumen in
the urine is important.   The  quantity of albumen  lost makes
little  difference.  The patient  would be in  a sad way indeed if
such a small loss were of great consequence to  him.   It is the
mere  fact of its presence  at  all that affects our prognosis so
much.  Hence not  the  proportion of albumen  made visible by
our tests, but the circumstances accompanying the  discovery,
make that prognosis favorable  or the contrary. 
45G
ALBUMINURIA.
  One very important  circumstance  is the permanence of the
symptom.  A single experiment should never make you a gloomy
prophet; for albuminuria is sometimes only of a transitory char-
acter; and though that single occurrence may lead you to be sus-
picious and anxious about the future history of the patient's
kidneys, yet it may be years and years before any harm happens.
  Another thing that you should search for is blood.  If there
is a stain of it in the renal excretion, or if blood-disks are to be
found by the microscope in the sediment after the specimen has
stood quiet for half an hour, you will knoAv that the disease has
not yet  lasted  very long, and therefore  is more  likely to be
transitory  than if it were of old date.   This observation  is of
great prognostic value after scarlatina.  In patients  recovering
from that complaint the absence of blood from albuminous urine
is a  bad sign, as shoAving that the kidneys were probably un-
healthy before the accident of the eruptive fever; while the pres-
ence of blood, as shoAvn by a red or dusky or smoky tinge, is an
encouraging one. If the urine must be albuminous,  it had better
be bloody,  as far as prognosis is concerned.
  The secretion  of  a great quantity of water  in albuminuria is
some  evidence of the chronic character of the  ailment,  and is
thus  far unfavorable; but  this phenomenon is so much varied by
the daily habits of the patient, the state of the  skin, bowels, &c,
that it is difficult to give any strict rules of prognosis dependent
thereon.
  The leading fact for you to note in albuminous  urine is the
quantity of solid matter which is daily passed.   The quantity of
solid matter (three-fifths of which is urea) is practically a direct
measure of the vitality of the secreting portion of the gland from
whence it comes; and you know that  if there  is a fair average
amount of  that substance  made in the twenty-four  hours, there
is a  sufficiency of healthy kidney  remaining, however abnormal
the remainder may be.
  Hence you derive the following rules:
  1.  The prognosis is best, if the specific gravity is as high as
that of healthy urine, and the quantity natural.
  2.  It is next best, if the quantity is diminished without dimi-
nution of the specific gravity. 
ALBUMINURIA.
457
  3. Next, if the  specific gravity is diminished without diminu-
tion of the quantity.
  4. Worst, if both specific gravity and quantity are diminished
together.
  In the  course of lectures on systematic medicine, I describe
as in duty bound  the  many shapes which  degenerated kidneys
assume, the "large yellow," the large and small "mottled," the
"granular,"  the  "cysted"  large  and small,  the  "hard," the
"atrophied,"  and whatever  other I can  find represented by
specimens in the museum, or sketched in my portfolio. I seldom
conclude the subject without being  asked whether  these diverse
forms are witnesses of diverse noxious agencies—whether some
arise from one cause and some from another—whether some im-
pede one function and some another—above all, whether special
remedies are needed for each.  I am forced in honesty to answer,
to the best of my belief, No; and to say further that it is lucky
it is so, for at present our means of diagnosis do not enable us
to find out which form lies hid in the body of a sick man.   The
light has failed which it was hoped microscopic research of the
renal casts  might  throw upon  the  matter, and it  is only by a
statistical observation  as  to which is most usual  at particular
periods of life that a rough guess can be made.   We must not
base our  treatment on post-mortal  anatomy, or we shall fail in
our duty to our patient.
  Upon observations of the same phenomena, which form the
groundwork of our  prognosis,  should be grounded  our  thera-
peutics also.  We need not, as a general rule, attend to the pro-
portion of albumen contained in the specimen of urine examined;
we  must not augment our vigor because the coagulum forms a
more than usually solid  clot; nor must we consider  it less neces-
sary in  a case where we can only obtain indications of the ab-
normal contents by a slight opalescence insoluble in nitric acid.
And knowing that the greater or less amount of albumen present
is rarely of practical importance, let us not waste  our time and
drugs by direct attempts to curb its evacuation.  We may, for
instance, Avisely look upon the administration of astringents, such
as gallic acid given with a view to step the  emission of albumen,
      30 
458
ALBUMINURIA.
as childish.  We know that not the loss of albumen, but the state
of constitution of which that loss of albumen gives notice, is the
real object to be attended to, and  to be made  the end of medi-
cation.   One  runs a great risk of being led off the true track by
following by-ends.
   What, then, is the essential nature of the state of constitution
which leads to  the  presence of albumen?  It is an imperfect
growth,  a lower vitalized state of that epithelial cell-tissue which
separates the  effete  matters from  the blood in the form of urea.
A portion of  these cells remain dead and sticking in the tubuli
uriniferi, degenerate into fat mixed up  with  the fibrin derived
from the blood,  and thus replace a pervious gland by a solid and
obstructive  mass.  Others, more luckily for the patient, are shed
in the form of microscopic casts of the tubes.   It is obvious that
the intention of all successful treatment must be to replace them,
not to prevent their being shed.   The patient loses no more by
getting rid  of this useless tissue than is lost by the separation of
the sequestrum of a dead bone, and it is as bad policy to  try and
avoid one as the other.   Indeed,  the shedding, in contradistinc-
tion to the  degeneration without shedding, is  to be looked upon
 as a thing to  be wished, and need raise no alarm, if other  circum-
 stances  are in the patient's favor.  In those cases which recover,
 the casts are often  to be found in the urine  after  the urea has
 regained its normal proportion, and albumen can no longer be
 discovered in it.
    The main  object  of  our treatment should  be to restore the
 blood to that sound vital condition  which will supply a  healthy
 growth  of new  epithelium equal to carry on the renal functions.
 This is best done by iron.  Though I from habit order the tincture
 of the sesquichloride, I am nowise bigoted to that preparation,
 and if any reason can be given for another form of the metal,  I
 do not object.  The quantity of hydrochloric acid  in the salt is
 not sufficient to allow one  to attribute any calculable efficiency
 to it; the  iron is  the essential matter,  and  the more of it the
 patient  can take the better.
    Joined to iron, digitalis seems serviceable.  I suppose  it must
 act by  restoring  the balance of  the  circulation, and so making 
ALBUMINURIA.
459
the supply of the vital fluid more regular  and full.  With de-
generated kidneys there is often  joined a  like degeneration of
the heart-muscle, so incipient as not to exhibit alone any symp-
tom, yet possibly advanced enough  to  aggravate  other existing
evils.  It is in these cases of weak heart, especially with irregular
pulse,  that digitalis  is so useful.  From 25 to 50 minims of the
pharmacopceial tincture daily is enough.
   Strychnine is  also a valuable tonic.   It  may possibly act by
strengthening the  muscular action of the  heart.   The  doses
should be small;  one-tAventieth  of a grain three times a day is
enough to begin upon; but with many patients, to whom the
drug is especially serviceable, you may often increase it gradu-
ally to double that dose.*
   There is no physical agent capable of doing so much harm in
albuminuria  as mercury.  Its  action  as a destructive is much
more rapid in this state of the  system than in any other.  You
can almost see the increase of the anaemia under your very eyes.
In  advanced  cases of renal degeneration, after one or two doses
sometimes the gums will show how the  tissues are melting away,
though there is hardly vitality enough  to exhibit an increase of
normal metamorphosis.
   Yet this poisonous reptile carries, like the fabled toad, a jewel
in its head.   Where the specific gravity of the urine, and a quan-
tity at all approaching the  normal, indicate a trustworthy amount
of  metamorphosis, you can use this metamorphosis with most
powerful  effect to remove  the dropsies  Avhich are so common in
albuminurias.  You may  save  the patient's life  by an  agent
whose full effect  is poison  to him.
   But remember you are Avielding a sledge-hammer. Visit your
patient between  each blow, and watch its action with extreme
suspicion.  Do not let the  blows be  too  frequent—one in the
twenty-four  hours is quite enough.  And do not wield it against
such butterflies as  swelled ankles and puffy eyelids, nor on any
but urgent cases unless you  have  tried other means first.
  * It may be  remarked that the safest form of strychnine is the hydrochlorate
dissolved in a solution.   The dose is  the same as that of the alkaloid.  It is
safer made up in a draught than in a pill. 
460
ALBUMINURIA.
   I have not myself employed any forms of mercury besides the
bichloride and  the blue pill, but I have nothing to say against
other preparations.  I usually give them combined Avith digitalis,
and sometimes with squill;  that latter drug seems to increase the
quantity of water and salts in the urine, which are serviceable
as a vehicle for the urea of metamorphosis.
   Next to mercury, I think alcohol has the  most harmful power
in albuminuria.   Theoretically, we may suspect the injury to lie
in further checking  the already wanting metamorphosis of tis-
sues.   As a matter of fact, you will find under its use the skin
become anasarcous, fluid accumulate in the serous  sacs, soaking
of the lungs, producing dyspnoea and cough, poisoning of the
brain with  ureous blood, indicated  by stupidity, giddiness, and
coma, and, in short, all the evils you most  dread in these cases.
And alcohol has not, like  mercury, a virtue which makes you
overlook its felony.  It seems  to do nothing but harm in that
deficiency of life which is the essence of the disease.
   The only reason which can justify you in employing alcohol is,
that  the mind and nervous  system of the patient happen to have
been so long accustomed to its  abuse, that when you have fairly
tried to leave it off they sink from want of  it.
   In the last sentence I designedly used the word "abuse" in-
stead of "use."  You may readily distinguish those  who have
exceeded Avhat  is good for  them in  their employment  of alcohol
by this very weakness; they cannot bear to leave it off when on
a bed of sickness—the bond-chains are so welded on to the nerv-
ous tissue, that in tearing them off you tear away life with them.
Whereas a temperate user,  who regulates the quantity of alcohol
by its  benefit to  his digestion, and habitually lets the effect of
each dose go quite off before he takes another, can bear without
inconvenience  to his nerves  the removal of his accustomed in-
dulgente.   Be  careful to  ask  your patients if they  ever  take
alcoholics in the  forenoon  or between meals, as, if they do not,
you need not in general be  at all afraid of ordering them entirely
to abstain.
   A  very important item in the treatment of albuminuria is warm
clothing, especially woolen, next the body.   It is not merely the 
ALBUMINURIA.                    401
warmth, but the electric action  of the animal  fabric which  is
beneficial so the skin.  This is much  more necessary to be in-
sisted on than a high temperature in the house, for in fact it  is
not a high but an even temperature that is required, and that  is
best secured through the normal retention of the heat by such
sort of clothing;.
   Dropsy of an  extent to require special treatment will scarcely
ever come on when patients conform to  the above treatment.  But
you may find it already existing, as happens with the  majority
of albuminuriaes admitted  to hospitals, so that practically you
have as often to treat it  as to prevent  it.
   The quantity  of water excreted per urinam  is defective, and
hence much  good is often  done by simple confinement to the
horizontal  position  in bed,  and the  administration  of watery
drinks in greater amount than the thirst demands.   Frequent
doses of Aveak broth attain that end very well.   For water is a
true restorative diuretic; it increases the  amount of  fluid se-
creted to a proportion  greater  than its own  bulk, and it also
increases the amount of  urea and salts, thus directly increasing
vitality.   That  niter has the same  power is rendered extremely
probable by the experiments of Parkes and Dr. Shirks (quoted
by the former*), and I therefore freely administer this neutral
salt  Avith Avater in all cases  of dropsy.  Under the use of  these
means the appetite  improves, the lips become redder, and the
pulse stronger, at the same time  that the anasarcous SAvellings,
and  sometimes even  ascites, diminish.
  Warm baths, soured with hydrochloric  acid,  seem also useful.
In tAvo chronic cases  (mild ones though) the excretion of albumen
in the urine has disappeared, as well as the dropsy, under their
employment. But I  have never ordered them alone, the patients
always having  iron  at the  same time; so that  I cannot  speak
very positively on the subject, except so far as to say that they
certainly do no harm, and probably do good.
  While on the subject of baths, I would remark that you must
be careful  not  to let them  be too  hot.  " The warmth of the
body" is doubtless a wise rule, but then the warmth of the body
    * Parkes on the urine. "On the Urine in Health," chap, ii, sect, iv, 8. 
462
ALBUMINURIA.
in albuminuriacs is much below that of yours in health, and 98°
Fahrenheit often produces in them  gasping, faintness, and ex-
haustion.   They  bear sudden  changes  of  temperature in the
direction of heat quite as ill as in the direction of cold, and 92°
is usually quite high enough for them.
  Hot-air or vapor baths you sometimes see me order.   Their
advantage is that they can  be used Avhere the patient is so much
swollen as to make  getting  up painful; but the effect is very
stifling, even though the head is kept out, and is not more pow-
erful in promoting the action of the skin than water baths.
  It is only when these means have failed that  I betake  myself
to mercury, with the fear and trembling above described.
  An occasional active purge of jalap and cream of tartar will
often be of service by setting up absorption of the extravasated
fluid back into the veins. -  It is then thrown off by the kidneys.
But you cannot trust to purgatives alone even to remove the
dropsy, and on the albuminuria their influence is to be suspected.
It is probably harmful, by increasing anaemia.
   Of all purgatives the most weakening is elaterium.   Its action
is a peculiar one:—it causes  an enormous flow of watery serum
from the first mucous membrane that absorbs  it:—if  its vapor
be drawn  up into the  nostrils for a short time, it is  a  powerful
errhine, and is folloAved by  a secretion of a pint or more of Avater
from the Schneiderian  membrane: — if it  is dissolved  in the
oesophagus it causes such a deluge  of the gastric fluids, that the
stomach cannot retain them, and they are rejected by vomiting:
—if it  succeeds in passing the pylorus, a choleraic diarrhoea
gushes forth, stripping the  membrane of its epithelium just like
its morbid prototype.  It is therefore very uncertain in its ope-
ration, and I am  sure I have seen patients not only frightened
but really hurt  by  it.   Moreover, I have never found  benefit
from its use in renal dropsy where jalap and bitartrate of potash
had failed.   If you are steadily purposed to give elaterium, use
the form of enema, for you thus avoid the vomiting which  is so
apt to  arise.
   To puncture the anasarcous  skin  for the sake of  relieving
temporarily the distention  is justifiable  Avhere that distention is 
                       ALBUMINURIA.                   463

causing more harm than a mere inconvenience, as for instance
in the penis where it impedes the passage of urine, or in the
scrotum and legs when it threatens to crack or to be frayed into
sores.   It is better to puncture it with a lancet to the depth of
about a quarter of an inch than with a  needle: the slits thus
made discharge more freely and continuously,  and are less likely
to cause erysipelas than the smaller but more numerous needle
pricks.   I have scarcely ever found any evil result to  follow this
practice, and where the skin and areolar tissue have  been very
tense, I think they have by its means been often preserved from
sloughing.
   When in  dropsy from either albuminuria or diseased heart you
are unfortunate enough to have a patient's skin slough, I should
recommend  you  to employ a  lotion  found highly efficacious in
our wards, made of equal  parts of  glycerin  and of  water sat-
urated with  chlorate of potash, and to keep the surface carefully
covered from the air.   The rapid restoration of vital action to
the edges of the mortified tissue under the use of these means
is very remarkable. 
LECTURE   XXXVI.
                   ALBUMINURIA.

Case of albuminuria  with vomiting from ague cured—Case of
    albuminuria fatal from sudden pneumonia—Case of albu-
    minuria fatal from  epistaxis, and loss  of blood and albu-
    men— With comments on each.

           (Clinical,  St. Mary's, October 31, 1863.)

  Robert  H., aged thirteen, was brought by  his father  to the
hospital the first week in September.   They  had both landed
three days before at Deal, out of a small schooner from Algeria.
They had been four weeks and a half on the  voyage, and during
the whole of it had nothing  to  eat but potatoes; for  the beef
taken in store had got putrid.  They slept in  the life-boat and
frequently got very wet.  The father was  taken  with quotidian
ague when about half way over, and this lad had one paroxysm
on the sea, and  one after landing. For this ague  he was brought
in here, was treated with quinine, and had no  return of it.  It
was observed, however, that his spleen was  large, and he had
some anasarca during  this first residence in the wards.   On the
25th of September  he  was discharged, and a  week afterward the
anasarca returned  in  his legs, and  the abdomen swelled.  He
was readmitted  on  October 9, with anasarca of the whole loAver
part of the body.   There Avas fluctuation in  the peritoneum on
percussion, and dullness of its lower portion  on both sides.  No
enlargement of the spleen could be detected.   The heart sounds
were normal.  The urine Avas of a dusky-brown  color and very
albuminous. 
ALBUMINURIA.
465
   On the 10th he was ordered this draught—
         R Tincturse ferri sesquichloridi, 1T|xv,
            Potassre nitratis, gr. xv,
            Misturse camphorae, 5j,
                                  ter die,
            and a hot-air bath every night.

Then occurred a symptom which is not uncommon in albuminuria,
namely, vomiting.   He felt constant nausea, and threw up the
contents of the stomach several times daily.  But in  spite of this
the anasarca disappeared, and the  greater part of the fluid was
absorbed from the peritoneal sac.    But yet it struck me  that
the medicine might have had something to do with the sickness.
So I left it off once and again, and both times the inconvenience
ceased.
   But I did not like foregoing the use of iron altogether, so I
have since the 24th kept him on an ounce of mistura ferri three
times a day.   That he bears  well and profits by.  There are no
signs of anasarca or ascites;  and what is of  more happy augury
still, the albumen no longer is to be found in the urine, Avhich is
of normal color  and acidity, and 1015 in specific gravity.   He
remains in the hospital only  because his father  cannot for a few
days return  from the country to fetch him home.
   The only peculiarity in this case is the vomiting,  which, how-
ever, as here, you may often  by experiment trace to some un-
suitable article in the medicine or  food.   Where  you cannot
find  any such cause, and it  continues  obstinate, I have found
alkaline effervescing draughts the most effectual remedy in albu-
minuriacs.

               (St. Mary's,  October 26, 1863.)

   I show you  here the  kidneys just taken from the  body of a
man Avho Avas yesterday brought into the hospital dead.  He had
been long a delicate  man, but able  to do a fair stroke of work.
Two days before he had come as a casualty patient to the house
surgeon, Avho found him suffering from a certain amount of pneu- 
466
ALBUMINURIA.
monia and catarrh, but was unable to admit him as an in-patient
on account of the fullness of the wards.   The next day he was
Avorse, but still got up.  On the morning he  died, a man came
and said he  was very ill indeed, and obtained a promise of a bed
for him.  Before he got to it he had expired.
   On examination, it was found that at most a quarter, I should
have said not so much, of the right lung was imperfectly con-
densed with recent  inflammation.  The  rest of the pulmonary
tissue on that side and the  whole left lung was free from con-
gestion, though wet.   We began  to wonder at the man's death
from so insignificant a  cause;  for we are  not used to have pneu-
monic patients die, without  the pneumonia being either double,
or at least occupying the whole of one lung.   The heart too was
quite  uninjured.   But the  mystery was cleared  up  when we
opened the abdomen  and found the kidneys I show you.
   On tearing off the  capsule you see that it adheres much closer
than it should do, and that when  it is  gone, the surface of the
organs is coarsely granular, instead of being smooth and shining.
And a section exhibits  the tubular and cortical structures much
less distinct and different  than  natural.   It  looks  as if some
dull flesh-colored or  taAvny stuff had been  mixed up  in both  of
them.   Truly there is nothing here very conspicuous to students
on the remoter benches of-the theater; but still, if you examine
the parts in your osvn hands, you will see  a good deal abnormal;
and if you apply your  minds you will see more still.   You will
see that there is much here which should  not be, and yet that
the kidneys  are anything but increased  in  size.   There must,
therefore, be a serious loss or destruction of the  important secret-
ing structure of the organ.   It is  in point of fact not absolutely
destroyed and removed, but it is  partially devitalized into a less
organized substance, which  is utterly  incapable of performing
the duties of separating the  urea  from the blood, and of retain-
ing the albumen in the blood-vessels.  Hence the importance  of
lesions of the kidneys.  And hence their, importance is in direct
proportion to the amount of secreting substance partially killed;
not at all in  proportion  to their conspicuousness, and to the show
they may make in the hands of an artist of morbid anatomy. An 
ALBUMINURIA.
467
abscess, or a stone, or an hydatid, may be more capable of artistic
development, but they are by no means so important in their in-
fluence on health as a Bright's kidney so little apparent as to be
easily passed over by a careless dissector.
  I say the patient's rapid death was  explained by the degen-
eration of his kidneys.  But I  do not by any means  intend to
imply that he  died of  the renal disease.   On  the contrary, I
bring this case forward especially to show you that  it is not
necessarily a fatal lesion.   This man had lived Avith it probably
for years, and  gained his livelihood, and might have continued
to live and gain his livelihood for an indefinite  period.  It was
no recent  or sudden increase of the long-standing visceral lesion
which caused death, but the addition to it of a slight pneumonia,
due to external causes, and very far from  sufficient in  itself to
kill.
  Both of these facts are highly important and  suggestive: the
first shoAving that a  patient with degenerated  kidneys and albu-
minuria may live, to a certain extent enjoy life, and be an useful
member of society;  and the second, that if insignificant inflam-
mations are added, they may very possibly prove  rapidly  fatal.
Both facts should encourage us  to  spare no pains in preserving
the health of our albuminuriacs, in the  well-grounded hope that
such pains will not be thrown away.

          (Clinical,  St. Mary's, December 12, 1863.)

  You have often heard me say that the amount of albumen con-
tained in  the urine  of those affected by Bright's  disease, is a
matter of  no practical moment;  and I have corrected you  when
you have anticipated evil results to a patient,  because the quan-
tity exhibited by boiling and nitric acid chanced to be unusually
large, or when  you have slurred  over the serious import of find-
ing some slight traces of its presence in other instances.  The
fact is, that  the loss of albumen is easily replaced by food.  Con-
sider that  100 parts of meat contain from 15 to  20 parts of pro-
teine, which  are  converted by digestion into  a soluble form of
albumen and pass directly into the blood;  and,  consequently, a 
468
ALBUMINURIA.
daily loss of 10 grammes of albumen may, if the digestion is
fair, be replaced by three ounces of meat taken as food.*  And,
as a matter of fact, it usually is so replaced in our hospital pa-
tients, Avhose anaemia hardly ever increases while in the Avards.
   Yet exceptional cases do occur, to one of which I have to call
your attention to-day. Michael B., aged twenty-two, of a marked
leucophlegmatic temperament, Avith  pale blue eyes and yelloAV
hair, a new patient on  November 27, stated  that he had con-
tinued Avell and able to  work as an ostler till  four Aveeks before
that date, when he Avas  taken with vomiting, rigors, prostration,
sore-throat, and feverishness, and was  forced to lay up in his
miserable lodging-house.  He could not remember  that he or
anybody else had observed any eruption of the skin;  yet I can-
not but think that this feverish  attack was  scarlatina  ; for after
four days' illness his face and legs began to SAvell,  and anasarca
continued up to the time of his coming  under treatment, when
the ankles, thighs, and abdominal parietes all pitted on pressure.
At the same time  that he became dropsical he began to  suffer
from pain in the loins, and he observed his urine to be frequently
bloody—indeed more often bloody than  not.  He had  suffered
also from bleeding at the nose, and from vomiting.  His respira-
tion during the previous  week had  become short and difficult when
he lay doAvn in bed,  so that he had  to sit  up, and snorted  and
snored a great  deal in breathing, often  also gasping  for breath
and sighing.
   He was sent to  bed and  cupped to eight ounces on the loins.
Sesquichloride of iron and tincture of digitalis were at the same
time prescribed for him.   This  treatment was commenced  im-
mediately, and perhaps  it was in consequence of it  that we never
saw the urine bloody, and that he  had no more pain in the back.
At all events such Avas the fact.  But though there was no blood
in it the urine contained an unusually enormous quantity of
albumen, some specimens  coagulating  by heat nearly  into a
gelatinous mass.  It  was copious,  light colored, and of a specific
gravity always below 1015.  A  drop of  blood drawn from a
needle prick of the finger was very pale, and  placed  under the
             * Vogel on "Quantitative tests of albumen." 
ALBUMINURIA.
469
microscope exhibited a deficient number of red disks in propor-
tion to the white globules, which latter were in  comparative ex-
cess ;  and  there was  a considerable abnormal  quantity of the
fine granules in the serum. Many of the red disks had also fine
granular specks in them as if degenerating, and quickly became
crcnated at the  edges; they however formed  into rolls in the
natural fashion.
  On the 28th he had some epistaxis, and several times threw up
his food.   In it there were s*ome masses  of  mucus stained with
blood, but whether these came from the  stomach itself or from
the nose could not be rightly determined.
  By the 2d of  December the anasarca had quite disappeared.
But the  patient  still  breathed noisily, irregularly, and quickly,
and gasped often like a person exhausted by loss of blood.  The
uvula was much relaxed, hanging down on the  top of the glottis,
and he coughed frequently and spoke in a whisper.
  On the 1th he got up and  moved about the ward a little, but
was terribly exhausted by the exertion.
  On the 5th the epistaxis had become more frequent, but was
very small in quantity at a time.  It little more  than just stained
the handkerchief, so pale  was his blood.  The enormous quantity
of albumen lost by the kidneys was unabated, but he kept down
more food.   On account  of  the epistaxis I ordered him 3j  of
gallic  acid three times a day.
  On  the 6th I found him sinking.   The  countenance was ex-
cessiA^ely anxious, he was throwing his arms  about in  an agitated
manner, gasping and sighing and complaining of  pain all over,
especially  at the  epigastrium.  His tongue got dry and yellow,
sordes collected on the teeth.  But his mind was perfectly clear,
and seems to have remained  so till his  death next day.
   The case will of  course be entered  in the register as  one of
" dropsy," for with that disease he was received  into the hos-
pital ; but yet he did not  die of dropsy, either in the form of
anasarca, hydrothorax, oedema pulmonum, effusion on the brain,
or of any of the kinds of local congestion which conclude nearly
every renal  degeneration.  Altogether, his  end resembled that
of one killed by long haemorrhage.  And in truth that may be 
470
ALBUMINURIA.
said to have been the manner of it.   For though  latterly there
was  scarce  any appearance of red blood  in  what he lost, yet
what he lost Avas a  part of the  blood  next in  importance to the
red constituents ; while at the same time the state of his stomach
prevented  the drain of albumen  passing  away from being re-
placed.
  The case is very different from  one of uraemic  poisoning; it
is the albuminuria,  the loss of constructive material, and not the
uraemia or retention of injurious material, which  has killed the
patient.  There was none of the coma, or merciful overclouding
of mental perception, which is the  usual end in Bright's disease;
but on the contrary extreme sensiti\reness and agitation.  I rejoice
to think that such a termination is  rare, for it is most painful to
witness.
  But for all  that  there is no  doubt  of the kidneys being ex-
tensively  disorganized  by  some form of Bright's disease,  and
considering his age and  the rapidity of the fatal result I should
rather expect to find at  the post-mortem  examination you are
going to  see, a specimen of  the large yellow smooth kidney.*
How long he has had it  none can tell;  but it  cannot have  been
long, for he  was not  injured by it till the scarlet  fever (as  I
suppose) added its  renal congestive influence  to  a pre-existent
lesion.
  I drew your attention to his  leucophlegmatic crasis.  Now, I
am far  from wishing you to put faith  in all  the  vagaries  built
upon the  doctrine of temperaments, as you know well from my
systematic course on the practice of medicine.  But yet I cannot
shut my eyes to the fact, that there are certain forms of internal
constitution, which, Avhen they  exist in a marked  degree, do de-
clare themselves by the external appearance  and features, and
that it is not entirely devoid of practical utility to take heed to
these external features in regulating  our treatment.  Of these

  * It was rash to have dared so publicly to  predict the form of degeneration,
as the account of the dissection extracted from the " Post-mortem Record"
shows.  But I certainly did expect it, and it would be  scarce honest to omit
this sentence.  It will at all events serve as a  warning to clinical lecturers not
to be over-precise in their predictions. 
ALBUMINURIA.
471
classes of constitutions one of the most important in respect of
our practice is  the leucophlegmatic.   This is not the  place or
time to paint its peculiarities, which has been done so often by
more graphic artists than I can hope to be.  But all agree in con-
trasting it with the sanguine, and making, in short, these two
temperaments antithetical to one  another as to all their habitual
phenomena.   Noav, it has  always struck me  that the most  im-
portant  antithesis between them is one not usually brought for-
ward, or at least only indirectly alluded to. I mean the relation
wdiich they bear to degenerative disease.   In the sanguine tem-
perament febrile disease is short, violent, and soon ended—cito
mors venit, aut victoria laeta—while degenerative disease is slow
in progress,  slightly marked in its phenomena, and little affected
for better or for  worse by remedies.  In  the leucophlegmatic
temperament febrile disease  is  sluggish  in  progress,  and  im-
perfectly marked  in its characters; while  degenerative disease
is extremely rapid, strongly marked, and either  quickly fatal or
freely amenable to remedies.  It has been, as you have witnessed,
rapidly  fatal in the  patient who is the text of this lecture ; but I
have often  pointed it out to you  checked with equal  rapidity in
more fortunate  leucophlegmatic subjects. The observation, there-
fore, of the temperament affects  both our  prognosis and our
treatment.
   [Extract from Record of post-mortem examination by Mr. Nayler, Curator to St
Mary's Hospital Museum.
   Examination five days after death.—The kidneys were of small size, weighing
respectively only one and a half and two ounces ; they were studded with small
cysts  varying  from a millet-seed to a pea in diameter.  They were pale and
mottled externally and the capsule was readily detached.  The lungs were very
pale, but otherwise healthy and expansible.  There was a good deal of blood-
stained fluid in both pleura.  (The blood-stain of the  effused fluid, and  some
other phenomena  not necessary to  notice here, were  probably caused by the
length of time which  was unavoidably allowed to elapse between the death and
the autopsy.—T. K. C.)] 
LECTURE  XXXVII.
                        ASCITES.

Part I.—Case of ascites from hepatic degeneration relapsing
     after tapping several times prevented from returning by the
     use of iron—Cause  of the disease irremovable, yet the dis-
     ease capable of cure—Pathology of ascites,  and connection
     of  the treatment with that pathology.
Part II.—Case of  ascites from renal degeneration treated  with
     iron and cured, though the albuminuria remains as before—
     Contrast  of this  with two  cases of  albuminuria from a
     remediable cause.

     Part I.—(Clinical, St. Mary's, January 16, 1863.)

  William S., aged thirty-four, though he himself denies having
lived an intemperate life, receives a different character from his
brother, who says he  has, at various periods, drank  hard, and
that even  when not indulging  in drunkenness, he has been in
the habit of taking drams and  beer between meals, and has kept
himself in consequence in a low position in the social scale.  The
patient says that the only illness different from  the present he
has ever suffered from is rheumatism Avithout swelling (chronic
rheumatism  or rheumatic  gout), with which he was laid up
twelve years ago.   Two years  ago his friends noticed that  his
complexion became jaundiced, and  a  year  ago his  abdomen
swelled, for which he was in St. George's Hospital for five weeks,
and went out somewhat relieved.  He then drank green broom
tea, and got much smaller in consequence.   In August, however,
he swelled again much larger than before,  and at the end of Oc-
tober was  so large that his surgeon tapped him,  and drew off a 
ASCITES.
473
large quantity of fluid.   Immediately however he  swelled again
bigger than ever, and on admission at St. Mary's,  November 18,
1862, he was so ascitic  that he could not stand;  the breathing
was much interfered with,  and there was  some  anasarca of the
legs.  Tapping was  accordingly  again  resorted to, and the
quantity drawn away amounted to a few ounces over four gallons
of  clear fluid.  At the  same time, as the urine did  not exceed
about half a pint in the twenty-four hours, he was ordered the
following diuretics:

                Ify Pil. hydrargyri,
                   Scillse  pulveris,
                   Digitalis pulveris, aa  gr. ij,
                         omni node  et mane.
                   Infusi scoparii, Siij,
                   Sps. setheris nitrici, 1T]xx,
                   JEtheris  chlorici, TT[x,
                          quartd qudque hord.

  But in six days he was  quite as full of water again  as  ever,
the abdomen was distended and painful, there was pain in taking
food into the stomach, and it was often vomited  up again.  The
urine too  remained excessively  scanty,  depositing  a  copious
orange-colored precipitate.   Elaterium was then  given in ad-
dition, but with no beneficial effect, either when  administered in
enema or by the mouth.  He took it for ten days,  and then was
seen to  be  growing gradually larger  and  more incapable of
motion.  On December  10 you  may see that  all  his former
remedies were left  off,  and he was treated with  the following
draught  three times a day:

            Tincturse ferri sesquichloridi, HLxx,
            Potassse nitratis, gr. xv,
            Misturse camphorse, §j.

  He very soon began to improve.  His appetite  returned, and
on the 25th he was  able to get up, dress  himself,  and be  about
in the Avard.  His abdomen  ceased to increase, indeed Avas an
      31 
474
ASCITES.
inch or so less in girth than before the change of medicine.  But
here it was  stationary,  so on the 31st ^1 persuaded  him to be
tapped again; nineteen pints of fluid were  drawn off, when it
ceased to flow, and some was apparently left in the peritoneum.
Since then he has not again swelled, the bowels are regular and
the appetite good.  A  fortnight after the  tapping  I find  the
clinical clerk has noted  that he has got smaller  in  girth,  and
that he makes a pint of urine every night and a good deal during
the day.  This increase in the  action of the kidneys has been
gradual and did not immediately follow the  last tapping.   The
patient is so impressed  with the source of his disorder being
traceable to alcoholic drinks, that he asked to have an egg daily
in place of some ale which had been  allowed  him.
   This case is a typical instance of the very common  history of
continual  indulgence in  depraved tastes.  The constant presence
of alcohol in the blood obstructs the  necessary renewal  of  the
fibrous capsule of the liver ;  contraction of the degenerated tissue
ensues; the portal blood  cannot pass through the viscus,  to  get
rid of its effete particles or to bear the nutriment to  the general
circulation ; the natural halitus  of the peritoneal  sac  cannot be
reabsorbed,  and therefore accumulates to form an ascitic  (or, as
the Greek  word means,  an  " ensacked") collection   of serum.
With this fluid is mixed also the albuminous serum and fibrous
serum which exudes from the obstructed capillaries,  and often
these capillaries rupture and blood-corpuscles are found  in  the
dropsical  fluid.
   Observe that in such cases as these,  of which William S.  is a
strongly-marked example, Ave have permanently fixed in the body
a constant source of disease, a deformity of  an important organ
which is absolutely incapable of being replaced.  The patient's
liver  is indubitably the cause of disease; if we could see it we
should probably find it puckered up and scarred with hard  con-
tracting fibrous  tissue, compressing and causing atrophy of  the
secreting structure.   The majority of the hepatic  cells are prob-
ably  dead and converted  into or filled with fat; and there is not
room for new cells to grow.  You can no more cure  this, than
you can cure the hard useless scar of a burn.  It  is  not the  dis- 
ASCITES.                      475
ease.  The disease is its consequences, the ascites, the anasarca,
the diminished urinary secretion, the jaundice, the anaemia, the
general discomfort under which the man labors.  These are ca-
pable  of very decided alleviation and often of cure.  You may
look at the matter in this light—you have a patient whose body
is deformed by a deficiency of liver ;  and as you are unable to
give him back a liver,  your aim must be to giAre him back those
functions and those constituents of  the body which the wanting
organ  has ceased to supply.
   Remark what happened when the ascites was treated merely
as a foreign body, as a thorn in the flesh to be  plucked out. The
quantity and weight of the  fluid was a very painful burden to
him; it entirely prevented his getting up, pressed on the stomach,
produced vomiting, and seemed  to  the patient to leave no room
for his meals. So there was a reason  for its removal by tapping.
But he immediately swelled  again as large as ever, if not larger,
on the  two first applications of this process.   And during this
period the most powerful diuretics Avere vainly directed  to in-
crease the action of the kidneys.  He himself felt  strongly the
failure, and  declared that it  should never be done again.
   See, however, the effect of a three weeks' course of iron.  He
recovered strength so far as  to remain sitting up in the ward  a
great part of the day; although the abdomen was as large as at
first and much impeded motion, his muscular power enabled him
to walk about;  he  gained flesh and some color in his cheeks.
Then was the time for tapping  to  be effectual, and with some
trouble we persuaded  him to retract his resolve and to submit
again to what he justly enough urged had failed before.  A con-
siderable portion of the  fluid Avas  drawn off, and  that amount
which  Avas removed has not again  accumulated.   He continues
to get  smaller in girth daily, and I hope in two or three  weeks
will be fit  to leave the hospital.
   The rationale of his improved condition  is  that  the iron  has
restored the blood to its natural state, and  thus supplied to  the
tissues that which is the final end of nearly all  our manipulations
with pharmacopoeias  and with nursing—namely, healthy  nutri-
ment.   Without this, treatment  would be utterly useless; with 
476
ASCITES.
it, you see a rough treatment, namely, tapping, which had been
unsuccessful once and  again under previous circumstances, has
now led to a happy result.  Can Ave refuse to  recognize this  as
true restoration, as real cure ?
  I am sorry to say it has been impossible entirely to keep  his
old habitual  poison from  him.   His spirits and nervous system
generally got so low that  it Avas necessary  to allow him some gin
daily.  I am gradually  diminishing his allowance, but I fear that
when  he gets out  of our sight he will not be able  to refrain.
This of course must keep up, even if it does  not increase, the
degeneration of the hepatic tissues, and very slight accidents will
readily bring back his dropsy.  But so far as he is restorable, I
think you have learnt the way to restore him.
  The pathology of ascites I presume to be this—from obstruc-
tion of the  liver, either temporary, of which you have one ex-
ample in diseases of the heart, or  permanent, as in degeneration
of the hepatic tissue itself, or in compression of it by malignant
tumors and the like, the passage of blood through it is hindered.
This imperfectly vitalized blood insufficiently nourishes the ves-
sels of the peritoneum,  which consequently become  inelastic and
more  ready even than they should be  to part  with their watery
contents by exosmosis.    At  the same  time the sluggish move-
ment of the circulating  fluid retards absorption, according to the
well-known law of osmosis that, in the case of a fluid set in mo-
tion,  it is rapid in a direct ratio to that motion.  Thus you have
a double  reason  for the collection of the fluid, increased exos-
mosis from  the blood and diminished endosmosis into it.
   Rational treatment makes its chief aim the  remedying, as far
as remediable,  such a state of things.   It aims at  restoring the
strength and elasticity of the abdominal capillaries, at quickening
and vitalizing the circulating blood, and thus  renewing absorp-
tion to its normal activity.   Normal activity !  No slight thing
is this we  are speaking of: remember  Dr. Richardson's experi-
ment, by which he showed that fluid equal to  at least one-sixth
of an animal's whole weight may be absorbed by the peritoneum
in twelve hours;* and  then consider that if a man's  peritoneum
           * See the previous Lecture on Hydrothorax, page 220. 
ASCITES.
477
can Avork at an  equal rate (as I dare say it can) he will be able
to dispose of at least a couple of gallons in the same time. So that
if you can secure anything like a normal activity, you will  soon
do away Avith the ascites. Look upon it as a collection dependent
on deficient vitality, not as an effusion dependent  on some imag-
inary increased activity, and your treatment has a better chance
of being  rational and successful.
  You Avill perhaps say  that I Avas inconsistent in not trusting
wholly to the iron, and  that tapping ought to have been need-
less.  But  the fact is that, after long soaking with the ascitic
fluid, the tissues  are  so saturated with it that they can return
to their  allegiance  very slowly; and that the process is much
hastened by removing the  already collected serum.   After the
operation indeed you may  give the iron with safe  confidence,
and your confidence will often  be justified by a similar success
to that wrhich has attended this case.

       Part II.—(Clinical, St. Mary's, July 25, 1863.)

  Dennis S. has been under  your observation since June 12.
His age is sixty, and his employment that of a costermonger.  I
have no reason to doubt his statement that he has been always a
sober and temperate man, but of course in his trade he has been
a good deal exposed to  inclement weather.  Tavo years ago he
was  knocked down  by a cart, which  passed over his  loins;  and
during the illness which followed there was blood in his urine,
and  he Avas told by the physician who  attended him that his
kidneys were injured.  After that he recovered health, and was
Avell till last March, when he felt ill, and had cold skin and fre-
quent shiverings.   Soon his legs began to swell, and he  had
looseness of  boAvels,  amounting  sometimes to diarrhoea,  after
eating.   He had also much  cough, accompanied by thin mucous
expectoration.  In May the belly began to swell, and he lost his
complexion, becoming of a pale faded-leaf color.
  When  first I saw him in bed there was very considerable ana-
sarca of  the legs and ascites of the  abdomen.  But a couple of
days' confinement to bed took away all the swelling of the lower 
478
ASCITES.
extremities, leaving the ascites as the marked feature of the case.
He measured forty inches round at  the level of  the  navel, and
the dullness on percussion caused by the fluid rose to Avithin four
inches of the  mesian line.  His urine Avas light colored, copious,
of specific  gravity  from 1*010  to 1*015, and very albuminous.
There could be found in it sometimes granular, sometimes smooth
casts  of the tubes.
   He was ordered tr|xx  of the tincture of the sesquichloride of
iron four times a day, and had hot-air baths* at night.
   On June 24 he measured thirty-eight inches round, and on the
26th thirty-seven inches.
   I must remark that this measurement did not fairly represent
the total diminution of fluid.   For the abdomen was very reso-
nant  in places where it had previously been dull.  In fact  the
vacant space  left by the serum  absorbed from the cavity of the
peritoneum had been occupied  by ilia and  colon blown up with
wind.  Do not  forget this in your  estimate of the decrease of
ascites—the intestinal  walls, from being so  long  soaked in half-
dead  serum,  lose their contractility  and become  distended with
flatus; and thus the mere circumference does not  show how much
fluid is in the sac.   You must correct your reckoning by the ex-
tent of dullness.
   To replace the lost  contractility I added ^o °f a grain of hy-
drochlorate of strychnia to each dose of iron.  I find no drug so
powerful as this to restore that deficient muscular force which is
shown in flatus of the ilia.  And while I  am on the subject  I
would give you  a hint  that you have no need to be alarmed at  a
few twitches  or  cramps or at a slight stiffness of  the jaw  arising
in patients who are taking it; the healthy muscles, the  muscles
you do not care to affect, are affected first in many cases; should
this happen,  all you have to do  is to leave off the medicine for  a
day, and then begin it  again in somewhat smaller doses.   Do not
leave it off altogether.   I have never seen the slightest real harm
done by strychnine, though it is a favorite remedy of mine.  The
notion of its "accumulating" in the body  seems to be a fallacy
   * I have omitted to note when the baths were  left off, but  I think he had only
five or six; as they were ordered in consequence of the anasarca. 
ASCITES.
479
derived from its  occasionally acting more visibly as the patient
nears health.
  On June 26  his girth was thirty-seven inches, and continued
steadily to decrease;  so that on July 15 (if not before) his belly
was soft and lax, and of its natural size, as tested  by the waist-
band  of  his former trousers,  namely  thirty-two inches.   This
represents the absorption of from three pints to half a gallon of
serum.
  He left the  hospital yesterday in sufficiently good case to re-
sume his  trade, at least  for the  summer.  For along with the
anasarca  and  ascites the  cough,  arising from  a dropsical  state
of the pulmonary tissue,  has  got well.  But the  urine is still
albuminous.

  The last example of  ascites upon which I gave a clinical lec-
ture,* was one arising from degenerated liver.  On William S.'s
return from AYalton, six weeks after he left St. Mary's, he pro-
fessed to  be quite well,  and to  be  convinced of the importance of
temperance and iron to keep him so.   I hope he is sincere.
   The present example arises principally from degenerated kid-
neys, of which the diseased urine (albuminuria) affords evidence.
Degeneration  of  these organs is usually due to  exposure to
Aveather,  and is no proof at all of indulgence in alcohol.   I am
disposed  fully to credit this  man's statement  that he has lived
temperately.
   Whether he has not  also  some  slight degeneration of the
hepatic  substance,  I  cannot  say.  Very possibly  he has, to
judge by the  ascites being  such a marked feature  in his case.
For where the kidneys alone are at  fault, anasarca is usually
the prominent disease.  But  where some other organ fails also
in a minor degree, such  as  the  lungs, or the brain, or the liver
for instance, then the  joint influence of the two deficiences ap-
pears in  that  quarter, in  the shape of hydrothorax, or apoplexy,
or  (as here) of ascites.
   Whatever the anatomical cause of the  disease may be, it has
 been cured by iron, rest, good food, and strychnine.   We may
        * Viz., that of January 16, 1863, which begins this Lecture. 
480
ASCITES.
take for granted that his kidneys  are  as  degenerated as ever;
but he may be freed from disease,  and may keep  free from dis-
ease if he can get the wherewithal, and possibly attain his three-
score  years and ten.
  I want you to understand that Avhat you have to  treat  is  the
ascites or the anasarca, as the case may be, and not the liver or
the kidneys.   Without the help of, or with the very imperfect
help of the liver and the  kidneys, you have got to restore to  the
blood-vessels  that defective elasticity, and to the blood that de-
fective composition, for want of which the balance of endosmosis
and exosmosis is reversed.  I have  already told you how iron
does this.
  In medicine you have  often thus to cure the wound with  the
bullet still in, to relieve the burn with the fire  still scorching it;
for the bullet and the fire are parts of the body itself and cannot
be extracted.
  But it is not  always so in cases of dropsy from albuminuria.
You have two proofs  to the  contrary, which have been close
neighbors to  the ascitic  patient in  the  same ward—two little
boys,  each six years  old, who were  admitted with dropsy and
albuminuria,  the one (Michael K.)  on July  3,  and  the other
(Walter P.) on July 7. In both of  them not only has the dropsy
got well,  but the urine has  ceased  to be albuminous.   Why?
because it arose from  a temporary  not  a permanent cause, from
a congestion of the  kidneys which  can pass away.   In one lad's
case there was a clear account of scarlatina,  for some of  our
house surgeons had  seen it; and, though the mother of the other
denied that it had had any cutaneous eruption, yet she admitted
that she was  always out  charing all  day; and she  brought  her
child here in  such a filthy, lousy plight, that I do not think she
could  have looked much at its skin.   There was an abscess also
in one of the tonsils, and that combined  with the  dusky color
of the urine  assured me that it was  an instance of scarlatinous
dropsy as well as the  other, and encouraged  me to give  a favor-
able prognosis.
  I said the "dusky  color of the urine" encouraged me.   In
fact, that showed me that at least a part of  the obstruction of 
ASCITES.
481
the renal tissue was due to blood, which may be expected to
move on; and not,  as in the old man's  case, to a degenerate
solid, Avhich is  an  immovable impediment.  You may remember
the porter showing some of us a few weeks ago a  kidney which
he had  taken from  a  patient, whose death he said arose from
scarlatina.   At all  events,  what he showed us presented in a
marked degree the  character of a  scarlatinous  kidney.  The
medullary cones were clear and pale toward their apices,  indeed,
paler than usual;  but  their bases had a  dark blood-red halo of
intense  congestion,  rendered  more  conspicuous by the  natural
color of the  rest of the  cortical substance.   They looked like
flesh-colored fans, whose broad ends had been soaked in red wine
lees.  Such a state  of congestion as this is perfectly curable;
and, without  there should be any evidence to the  contrary, any
previous illness or the like, this is the  state you should assume
to exist in  albuminuria after or  during  scarlatina.  This is the
state  Avhich  you see me  endeavor to prevent in scarlatina,  by
keeping the  patients from  cold chills (after the  skin has been
cooled by sponging), and by giving them a dose of castor oil
every morning.  A treatment Avhich Avill,  indeed, as a rule, pre-
vent scarlatinous dropsy, but of course will not cure it  when once
began.
   Both  of these children had the same treatment as the old man,
hot-air baths  and iron.   Walter P., in whom the  scarlatina Avas
the most certain and most recent, and Avho seemed to experience
some uncomfortable feeling  in his back which he Avas too young
to describe, had also four leeches and a poultice applied to the
loins; the reason for which I have sufficiently pointed at by my
sketch of the morbid anatomy of the disease.   The happy result
which has folloAved is that which usually  reAvards  our efforts in
cases  of scarlatinous dropsy, if no previous degeneration  has
existed. 
LECTURE  XXXVIII.
                       DIABETES.

Case of diabetes, with history of the  treatment adopted—Arrest
    of function of  construction in diabetes—Saccharine diet
    ivasteful and harmfid—Test of treatment is gain of flesh—
    Patients to be made into  carnivorous animals—Sugar may
    be formed from flesh diet,  or from  hepatic tissue—But from
    dead, not live tissue—How far a very strict dietary should
    be  enforced—Opium—Cinchona—Iron—Iodide of potas-
    sium— Gratification of thirst.

            (Clinical,  St. Mary's, July 19, 1862.)

  We know so  little  of the  pathology of diabetes, that it is easy
to fill a volume with the discussion of  the subject;  for  you will
observe that talk is  always in an inverse  quantity to practical
knowledge.  I shall cite only that which bears on a case before us.
  William  S., aged  twenty-two, a thin, whiskerless and young-
looking farm laborer, has suffered for at least two years  ailments
of various  kinds, Avhich are usually held by pathologists to be
symptomatic of diabetes.   He  has been  weak  and unequal to
labor, felt  always thirsty and  usually hungry, and  daily voided
large quantities of urine.   For the last year he  has been unable
to work at  all from general debility, and on that account came
into St. Mary's May 31, at which time the above-named symp-   •
toms were  noted.  The chest  Avas examined and found  healthy,
the pulse was  slow  and regular, the bowels acted daily.  The
skin was naturally moist, and he  stated that at night he often
perspired;  but the sleep was sound, except when he was awakened
by  the bladder getting full of  urine.   His weight was 6 st. 11J 
DIABETES.                      483
lbs.   He  remained in hospital five weeks, during which period
the folloAving variations  in the  urinary symptoms, Avith the
changes in weight during the corresponding time, and the alter-
ations in treatment to which I trace these changes, are noted in
a table condensed from  the  case-book.

During the first week  the total  quantity of urine
    passed was    .......    fl.5 680
Of the specific gravity before fermentation      .        1*042
   "         "        after fermentation     .     .     1*012
His weight had increased to 6 st. 12 lbs.
During the second week the total quantity of urine
    passed was    .......    flo 449
Of the specific gravity before fermentation from  1*039 to 1*040
His weight had decreased to 6 st. 11J lbs.
During the third week the total  quantity of urine
    passed Avas    .......    fio 472
Specific gravity......1*039 to 1*041
His weight had increased to 6 st. 13 lbs.
During the fourth week the total quantity of urine
    passed was    ..*....    AS 452
Specific gravity  ......     1*040 to 1*042
His weight had increased to 6 st. 13-J lbs.
   During the fifth week he  lost half a pound in weight, and then
left the hospital  by his own  desire.
  During the first week he was treated with a grain of opium
every night, a  mutton-chop  for breakfast,  in  addition  to the
ordinary full diet, with three captain's biscuits in place of bread,
daily.
  During the second week  the opium was left off, and the treat-
ment altered to eight grains of iodide of potassium three times a
day, Avith a drachm of  cod  oil; he was allowed but one captain's
biscuit daily instead of bread, but as much meat as he could eat
and as much milk  as he could  drink. 
484                      DIABETES.
  During the third iveek the captain's biscuit was changed to bran
biscuit; but in point of fact he did not eat that substance, pre-
ferring to go without bread-stuffs altogether.   No  other change
was made.
  During the fourth week no change wTas made.
  In the fifth week we tried to persuade him to eat Bouchardat's
gluten bread toasted and buttered, but in vain.
  The first practical point to be observed in the pathology of
diabetes mellitus is the arrest in the function of construction.
  That generally used material of nutrition, sugar, which ought
to be assimilated as food and made available to the growth of the
body, passes into the thoroughfare of the circulation and out
again unaltered, and is ejected in the urine.   And here I refer
not only to the sugar which is taken as such into the mouth, but
also to that which is formed out of starch by the action of the
saliva.  So that in one thoroughly diabetic the whole of the sac-
charine and amylaceous matters in the dietary are utterly wasted.
Trying to feed him upon them would be just the same as feeding
him upon  nothing at all.
  More than  this,  I  think you  are doing him harm.   These
useless articles of food, though they contribute nothing  to his
support, destroy his appetite, and so he does not eat the needful
quantity of really nourishing things. And moreover, the analogy
of other diseases would lead to the conclusion that burdening a
disabled function with work to which it is unequal will disable it
more and  more.  If the stomach rejects undigested an ounce of
beef, it is  made worse by the administration of  a steak.   If the
eyesight fails, or the brain reels on slight  exertion, common ex-
perience forbids us to demand violent efforts.
  Therefore you need not Avonder  to find that cutting off a dia-
betic's sugar, bread, and potatoes, by no means  loAvers him.  On
the contrary, he often gets heavier under  the restriction.   And
one can easily believe the instances recorded by Dr. Pavy where
treacle, honey, and sugar, intentionally administered  as an ex- 
DIABETES.
485
periment to  diabetics,  made  the patients  feel worse  and lose
weight.
  I do not mention  in  evidence or rate  of any importance the
increase  or diminution  of sugar in the excretions, under the in-
fluence of  saccharine .or non-saccharine diet.   It is less when
little starch and sugar are taken, it is more when much is taken.
But  the  real point is the acquirement of flesh, and the test the
addition of Aveight.  You will find, Avhen the ordinary mixed food
of healthy men is used by diabetics, that much flesh is lost, and
that it is regained when a carnivorous dietary is rigidly enforced
on  them.   With the flesh also comes strength,  showing that
muscle is gained, and not mere fat.
  The great point then, in the treatment of diabetes, is to accus-
tom the  patient gradually to live entirely on meat, or at  least
entirely on albuminous  and gelatinous food. This need not  seem
a mighty hardship; the iron framed  Esquimaux do it, and the
Aviry, tough, half-breeds of the Pampas, with a bill of fare cer-
tainly less  varied  in flesh-meat than  our European meadoAvs
afford.   You may then  fairly direct your energies to attain this
goal with a good chance of success.   What nations live and in-
crease upon  may be trusted to nourish a single  individual.
  Laying this  doAvn  as  the  main  point in the treatment, let us
see what is likely to be  gained by it.
  You Avill learn from  the history of our present patient that
turning him into a carnivorous animal does not entirely remove
a diabetic's  peculiar ailment.  Twenty days  after all vegetable
matters  had been  cut  off' from his diet-card, and  he has  been
carefully Avatched by others set to detect any breach of the rules,
still the  urine  is full of sugar.   So that it must be derived from
some other quarter than the starchy and saccharine constituents
of the food.
  We shall feel less surprise  at  this formation of sugar  from
animal matter  alone when Ave call to mind that there is a normal
secretion in which  sugar may be found under even  normal cir-
cumstances.  The milk of carnivora contains it.*
  * Bensch has put on record the presence of sugar in the milk of bitches fed
entirely on meat.  " Anualen der Ch. und Pharm.," Bd. lxi, 221, quoted  in Dr
Lehmann's " Phys. Chemistry." 
486
DIABETES.
   Moreover, sugar may be formed in the laboratory by a process
of decomposition without the presence of life.   Nay, rather only
when life is extinct.  The simple application of oxygen will cause
some animal substances to be converted into  sugar.   This has
been noticed by Dr. Claude  Bernard to be especially  the case
with the tissues which  form  the liver, Avhich,  carefully Avashed
from blood and exposed to the air, quickly become copiously sac-
charine. So that your patient has a fertile source of sugar in his
own body, even if none is supplied by the aliment  consumed.
He carries in his abdomen about three pounds of viscus capable
of easy conversion into  sugar.
   But remark it is dead  liver, not live liver, which in health  is
decomposed as above stated.   Normal vital action seems to have
another. Avay of  removing  the hepatic substance, for during life
no sugar can be  detected as formed from the organ.  Diabetes,
then, like all diseases of which we know more than the superficial
symptoms, turns out to be a death in life, an  antepabt of the
post-mortal properties  of  the bodily constituents.   This is an
additional reason for casting  about how  best to apply restorative
medicine in  its  treatment, and  for urging  an  ample supply of
the right material for revivifying the  frame. If the dying liver
is passing off quickly by the  kidneys, we must give the patient
quickly the Avherewithal to make new liver.  Now you gain an
additional reason for enforcing animal diet  in diabetes.
   To accustom  this  patient  to  leave off by degrees vegetable
aliments,  I gave  him  first  captain's biscuits  for  a  fortnight.
During that time  scarce any weight was gained, and the urine
was but little altered.  He liked those biscuits very  well.  Then
I ordered him bran biscuits, but  he said they were  so nasty he
could not eat them, and he wasted some of his milk in trying
to make them palatable.   Nevertheless he  increased in weight
by two  pounds  during two weeks, and made  eleven  pints less
urine weekly than on  his  first admission.   And this  although
he drank as much as he felt disposed to  take.
  After this Mr. Van Abbott was good enough to give him  a
supply of the gluten bread, which is  manufactured by  his firm
according to the prescription of  Dr. Bouchardat.   For a week 
DIABETES.
487
he tried hard to  eat  it in addition to  his  former allowance  of
meat;  but I am sorry to  say he  failed  in  acquiring a taste  for
it.  His appetite  fell off during the experiment, he lost half a
pound  of the weight he had gained, and was so annoyed at being
pressed to eat the gluten bread that he insisted  on  returning
home on July 12.
   My  own feeling is that we  do not act wisely in enforcing a
dietary which is really unbearable by the patient in any chronic
disease.   The great object to be gained is to conciliate the stom-
ach, appetite, and fancy into taking the greatest possible amount
of animal  food, and if practically you find that the patient eats
more by having a biscuit, or a crust, or even vegetables  with his
meals, it is better to  give him  his way than to act the tyrant.
   As  to drugs:
   Opium was given to this  patient for a week.   It did not in
 this particular instance seem  to •"exercise any influence at all.
 However,  in some cases it certainly does  seem to diminish the
 excretion  of water.   But is that any advantage? or is it an ad-
 herence to the prejudices instilled by antiquated theories that
 we reckon on help from such  an interference?  I own  it seems
 to me that if the blood gets loaded with sugar, as analysis proves
 to be  the case, it  is better that the sugar should be washed out
 by an amj.le diuresis, than that  it should  remain  at the risk of
 poisoning the tissues.  I have never distinctly traced any harm
 to opium, truly; but I have traced  harm to a drug whose action
 is  similar.  Cinchona also  like  opium diminishes the flow of
 urine, and I once gave that to a diabetic patient.   After a short
 time  he  became  comatose, and  after death I found a collection
 of fluid in the ventricles in the brain.  The  effused  serum was
 loaded with sugar, which it  was the business of  diuresis to have
 diluted and  washed away.
   For this reason I  shun cinchona in diabetes, even when I wish
 to give tonics for the sake of increasing appetite.  I prefer iron
 and strychnine.   An elderly  patient of mine with moderate di-
 abetes is now taking these drugs, with  advantage to his strength
 and digestion, and without  any hurtful action exhibited in  the
 urine. 
488
DIABETES.
  The iodide of potassium, which you see prescribed on the med-
icine card, was given on purely empirical grounds.  There are no
drugs known to do good to the essential phenomena of diabetes;
there were  no secondary symptoms demanding special medica-
tion ;  so I thought it a fair case for an experiment.  The result
was that at all events no harm was done;  the patient continued
to gain weight and strength,  and did not exhibit any of the usual
symptoms of intoxication by iodine.
  This is not like substituting an  experiment in search of a pos-
sible specific in place of rational treatment; such conduct is in-
deed most blameworthy;  but here there is  no medicine omitted,
for there is none to  be given that  offers any hope of its possess-
ing an alterative agency, and it  is a question of either some-
thing new or a  mere placebo.  I  shall  try the iodide  again on
the next similarly pure and  uncomplicated  case.
  People sometimes feel a  deubt how far they ought to gratify
the patient's unnatural thirst.   On this  point the same  con-
siderations  weigh with me which  influence  my objection  to cin-
chona.  I  think  there ought to be kept up  a  flow  of water
through the system  in proportion to the  abnormal quantity of
sugar in the blood, in order that no retention or discharge in un-
usual places of this material may take place.  I  therefore let
patients drink as  much as they feel disposed for.
  You will  find that  the  demand for fluid food is closely pro-
portioned  to the  quantity of sugar required to be got rid of.
Thus when  the dietary is changed from starchy to meat food,
much less is drunk, and much less is evacuated by the kidneys,
though no restriction is placed upon the thirst.  Such was  the
case with the lad noAV lectured on; during the second week he
made tAvelve pints  less urine, though  he was recommended at
the same time to drink as  much water as he liked.   The specific
gravity also of  the secretion was  not raised,  which it  certainly
would have  been had  the diminution  in quantity depended on
any other cause than  a diminution of  the instinctive call  for
diluents.   I believe  the thirst  depends on the saccharine con-
tents of the blood ;  it is therefore wise to gratify it, and to pro-
vide the normal outlet for the abnormal constituent. 
LECTURE  XXXIX.
                  MORTIFICATION.

 Complete  death  of a part, contrasted with nekrobiosis—Case of
     mortified toes from cold and senile arteries—Treatment ex-
     plained—Preservation of dead tissue from decomposition—
     Defense of weak vessels—Food—Appetite—Action of oxygen
     on sore places—Carbonic acid  the normal  atmosphere of in-
     ternal parts—Superiority of nature's surgery to man's.

             (Clinical, St.  Mary's, June 27, 1862.)

   The  greater  part  of  my lectures  have been  taken  up with
 those forms of partial interstitial death, those  mixtures of half-
 life  and  half-death  in  the same  substance,  which constitute
 morbid  actions.   Schulz calls them " nekrobiotic processes."  I
 wish now to call  your attention to complete death, or "nekrosis."
 I  do not mean  complete death of the whole body,—I  said  the
 few Avords I  had to say on that head in my introduction,—but
 complete death of a part, the general health remaining untouched.
   You had an excellent example on which to study this phenom-
 enon in an old man who has been in  the wards for  the first fiA7e
 months  of this year Avith mortification of the foot.
   His history is as follows :
   G. B., aged sixty-six, is a cowman of steady religious habits
 (as I learn from a cousin of his whom I know speaks truth, for
she taught me to do so—in fact my nurse), living very temper-
ately on small Avages, seldom eating meat, and  still  more seldom
taking beer or any alcoholic drink.   In appearance he is quite
a model for Burns's cotter.   His health has been as good as he
deserves, though he has felt for the last twelve months or there-
       32 
490                   MORTIFICATION.

abouts not quite so young as he Avas, and you may observe a sure
sign of age in the eye, an arcus senilis around the iris.  In the
second week of last  December he got a severe chill  by sitting
for several hours in wet clothes.   He had then much pain in the
left foot, and he observed that it was swollen and that its  nails
were livid.  This blueness and swelling passed off when he had
lain up for a few days, and then he Avent to his work again.  But
at Christmas-tide again he got wet through, and back came the
pain in the foot  and ankle.   On  looking at it he found all the
toes above and  below and their balls quite black, the blackness
reaching about half an  inch  beyond  the  balls in toward the
hollow of the sole.  Sensation here was  quite lost,  the whole
foot and  ankle were swollen, red,  and very painful, the pain ex-
tending up the inside of the leg.  In this state he came into the
hospital on January 3.   His appetite then  was quite  gone, the
tongue was smooth and clammy, with  a  brownish center, the
pulse large and empty, with the sharp stroke usual in old  age.
Nothing  abnormal could be detected  by auscultation in heart or
lungs.
   He was laid in bed with the foot raised above the level of the
body.  The leg was Avrapped in cotton avooI,  and kept warm  with
a hot bottle.  The swelling went down, and  circulation returned
to the ankle in  a week.  An offensive smell being perceived to
ooze out from some weeping  cracks between several toes, the
foot was  kept in charcoal powder.   When after tAvo months the
gangrene began to separate at the edges,  a  fermenting yeast
poultice was  applied night and day.   For  three weeks he had
" teacup diet," i.e. a teacup of beef-tea or milk every two hours,
from four to  six ounces of port wine, and  bark.  He then re-
covered appetite, and ate meat largely, going on with  his wine.
At the end of May he went out, having lost the last phalangeal
bones and the cellular tissue from each toe, some from the  sole
of the foot, and his old nails.  However,  new though deformed
nails are growing.
   The object of this  treatment, as you may readily guess, was
not to restore life to the  completely mortified parts, but to the
mortifying tissue in their neighborhood.  Our province is not to
raise the dead, but to heal the sick. 
                      MORTIFICATION.                   491

  The only attention  which I paid to the destroyed  portions
was to keep  them from  putrefying and to keep them  attached
as long  as may be to their parent foot.   You will perhaps  say,
" Why, Mezentius-like, bind the living to the  dead  in hateful
union ?   Why not rid  the poor man of what  he can never use
again?"    There are  several  objections  to such  a trenchant
course of procedure.  In the  first place, probably your rough
hand would root up  the wheat with  the tares, and could hardly
help cutting away much tissue  capable  of regaining vitality.
Secondly, the wound Avould still further  render inefficient the
degenerated  blood-vessels which were  the cause of the disease ;
they would be unequal to the  task of  healing up the sore, and
further  mortification would  be likely to ensue.   Thirdly, there
is no better guard for the dying tissue against external injurj»
than the dead tissue  which exactly fits on  to the  place, and shuts
out the  air more  thoroughly than  any plaster ever invented.
There must, howeA'er, be this proviso, that it does not get putrid,
so as to be a nuisance  to its neighbors.
  With the view of  securing  this preservation  from decay, we
adopted  precisely the  principle on which  meat  is preserved for
food—we kept the tissue from air, we kept it from moisture, and
we salted it.  The foot was  carefully wrapped up, first in cotton
wool, and then  in charcoal poAvder.  But moisture at last began
to soak out from the  inside, and the parts got podgy; then I
used salt and muriatic acid, which acid, uniting  with the soda of
the serous exudation, also formed brine, and assisted in harden-
ing the  tissue.
  So much for  forming Avhat I conceived to be the best mechan-
ical protection to the weak,  half-dying blood-vessels and nerves
in the neighborhood of  the dead.   Half-dying as they were,
we were asking of  them extra work, even the growth of new
connective tissue, neAv skin, and a scar,—in  fact, all we  could
get  out of them.  Urgently needed therefore was this protec-
tion.
  Let us do all we can to save them their ordinary work.   With
this view the foot Avas kept absolutely quiet,  and raised above
the  level of the  chest: so that at all events it  might be spared 
492                   MORTIFICATION.

the exertion of the usual elastic force in the vessels to resist the
gravitating  blood;  at the same time the defective animal  heat
was reinforced by a vessel of warm water always kept  in close
neighborhood.
   And  let us lay in good store of  the  materials for new tissue.
Food was administered every two hours in small quantities  and
in a liquid form, for his stomach turned at the notion of eating.
Bark was prescribed, and a daily dose of wine.   The desire Avas
begotten  by the  gratification of it, and gradually the  appetite
rose ; so that not only did he relish " ordinary diet," but before
a month was over asked for an extra  allowance, in spite  of being
unused  to meat, and in spite of having  no exercise or any of the
usual calls for nutrition in muscular exertion.  Remark here that
you must not wait  till a  siek body of  its own  accord  asks for
nourishment by instinctive hunger.  In health the stomach  is
"clock to itself," but in  sickness the instinct, or corporeal rea-
son, is  overclouded, and the spiritual reason must be its clock.
As life returns, so  returns the vital desire, and  thankfully con-
fesses the justice of the martial laAV established by its conqueror.
   As the new tissue grew it refused to be allied with  the  now
foreign substance  overlying it;  the  former kinship  was  dis-
 owned ; it was no longer bone of its  bone, and flesh of its flesh;
 and so there was a  separation  at  the edges of the black mass,
 and  some of the new birth was laid bare.   An abnormal and
 hurtful state of things is thus  introduced; it is most unnatural
 and painful' for tissue to have  to  grow while open  to the sharp
 influences of oxygen—the "biting bitter air,"  as poets call it.
 Where oxygen is intended to touch a living surface, that surface
 is closely clothed in skin or mucous  membrane.  A fluid loaded
 with carbonic acid is  the healthy  atmosphere of an inside  part,
 and  thick darkness its light.  So we restored as far as  we  could
 the conditions of growth and healing; we covered up  the  part
 with a fermenting  poultice of yeast,  which was  continuously
 giving out warmth, moisture, and  carbonic acid.  Under its in-
 fluence the restoration went  on prosperously.
   I  believe an atmosphere like this of carbonic acid would be
 exceedingly useful in all cases  of wounds, and  that it is from its 
                      MORTIFICATION.                   493

production that internal  lesions, as a rule, heal so much quicker
than external.   The instinctive surgery of the dog leads him to
cover his wounds  with saliva  and warm breath, and  I do not
think man can  do wrong in learning of his dog's  instructress,
experience.  In the brute the  experience  is hereditary, in the
man it is almost entirely individual.   In the  brute it  is purely
selfish, in the  man it  is philanthropic.  But  as a  physician, I
have no opportunity of putting the principle into practice.
   In the fourth month the soft parts, the connective tissue and
muscles gradually rotted off, like the flesh of the corpses watched
by the concubine of Saul and by M.  Devergie.*  And then you
were  able to appreciate the  full advantage gained by the  con-
servative practice.  Had a knife been used, nobody would  have
removed less than the  terminal phalanges of the toes at the very
least; for they all looked black and dead.   But what do you see
here ?  The pads of the toes have rotted off, the bones have dried
up into brittle, brown sticks,  Avhich are being  gradually  sepa-
rated.   But  on three of them the nails are  growing !—distorted
indeed, and not ornamental, but still true  nails. A rough and
ready operator would  never  have thought of leaving  the  little
bits of nail-matrix, which have themselves grown, and also given
birth to  those defenses so essential to comfort.
   I have occupied the greater part of a clinical  lecture with this
man's semi-surgical case perhaps to the surprise of some, who
will cry  " ne sutor ultra crepidam."   I am desirous, however, of
thus pointing out  to you that I place no limit to the application
of restorative  principles.  In surgery as much as in medicine
the thing mainly to be considered and  treated is the living part,
not the dead part—the normal functions, not the abnormal—the
health, not the disease.  Mark what is wanting, and what is left
whole ; supply the former, and use the latter.   Make your chief
end of ends, " the reneAval of life."f
   It will require some courage in you consistently to follow this
advice.  •  You may be  accused of dishonesty for  not doing more;
   * See illustration at the  beginning of Lecture I.
   f This was the half-title of the first and second editions of  my clinical lec-
tures. My reason for altering it is given in the  preface to this volume. 
494
MORTIFICATION.
and I have even heard it denounced as quackery to call that end
which is consequent on our fostering  care of the powers of life
"a cure."  Were this true  modesty, the  "non  haec  humanis
opibus" of an laspis or the " 0 altitudo" of a David, one would
shrink from blaming it; but it is not so; a sort of contrast is at-
tempted by  assigning the word " recovery"  to such a result, and
" cure" to that which may  follow antipathic  treatment; and it is
implied that no credit is due to the medical attendant for the
former, whereas by the latter he has fairly earned  his reward.
In point of fact there is no contrast at all; every restoration to
health must depend on a renewal of  the deficient life ; in every
case this renewal must be wrought out through the agency of the
vitality remaining yet uninjured ;* and all counsel given by us
which  contributes to bring  about this result is  strictly curative.
Fear not the charge of having done  too  little ;  refer to success
as an  evidence of real activity.
* See Lecture II. 
LECTURE   XL.
 IMPORTANCE   OF  THE   DIGESTIVE  ORGANS
                  IN  THERAPEUTICS.

 Disease of the digestive viscera affects the whole body—Instances,
     tuberculosis,  degeneration, mental disease, gout and rheu-
     matism—Digestive  viscera the chief recipients of remedies,
     and not only of constructive, but of destructive and arrestive
     remedies—Effects in disease of healthy and unhealthy di-
     gestion—Importance  of replacing destructive by the aid of
     constructive action—Digestive tract single.

                 {St.  Mary's, April, 1862.)

   I am anxious that you should be duly impressed with the  im-
 portance of  the  digestive viscera to the  cure of disease.  In
 every case,  surgical or medical,  the modification of the result
 produced by our efforts depends almost entirely on how far, how
 wisely or how foolishly,  these organs are watched over; Avhether
 they are well or ill-treated,  either by the scientific guidance  of
 the skilled physiologist,  or by the empirical rules of the routine
 practitioner, or  according to the  tradition of the nurse, or  the
 instinct of the patient.   Each and  all of these may be useful
 guides; but Avhere  there  is a difference  of opinion,  I prefer
 trusting to the first-named principle of action, and  so does  the
 public, except Avhen in a fit of obstinacy or prejudice, and so, I
 hope, Avill you.
   It will be my endeavor,  then, to give to the attention which I
 trust will  be bestowed upon the  functions of these  organs, the
rock-laid foundation of prescient science, and not the sandy sup-
port of mere empiricism. 
496         IMPORTANCE OF DIGESTIVE ORGANS.
  To an unhealthy state of the digestive  viscera  physiology
enables us to trace, by steps more or less distinct, several morbid
conditions not manifested in the  organs themselves, but affecting
the whole body.   Take for example the very common condition,
tuberculosis.  One cannot fail to connect both empirically and
rationally this state with deficient supply.  Among  whom is it
most frequent ?   Among those Avho have either not enough to
eat, or those who from imperfect assimilation are unable to con-
vert into blood what they swTallow.  The starved fluid does  not
sufficiently stimulate the vitality  of the body, connective tissue is
removed by metamorphosis, and  its place  is supplied,  not by new
healthy connective tissue, but by a cheesy semi-vitalized sub-
stance, which Ave call " tubercle."
   The next most frequent material cause of  disease  in the ana-
tomical structure of the  body is degeneration.  By birth it is
closely related to  tuberculosis.   Unrenewed  effete particles "re-
main as fat in the tissues; and so you get softened and dilated
hearts,  fatty liver, Bright's kidney,  atrophic softening  of the
brain, apoplexy, &c.
   To the same  cause may be  traced  an  obscure  inefficiency of
mind,  very  common among our chronic  invalids  and habitual
patients.  They complain that  they aAvake  in the morning, not
only unrefreshed by'sleep, but seemingly more  tired than when
they went to bed.  There is an  unaccountable despondency and
carelessness about the future, accompanied by a conviction that
something  or  another unfortunate  is going  to happen.   They
have no power to prevent this ; and they  are not sure they would
exert the power if they had it.  Their unwilling limbs are dragged
languidly to the daily task, but  they are  quite unable to do any-
thing as they ought.  The figures get confused as  the merchant
adds up his ledger; the clerk knows he has some important duty
to perform, but  cannot call to mind Avhat it is; to  the matron
even the light labors of daily housekeeping are a heavy burden.
A morbid dislike to the idea of  food  causes the family meal to
be simply repulsive. Sleep is sought, and perhaps obtained, but
is broken by painful dreams, or  fidgets, or wakefulness. If there
is an inborn or hereditary tendency to insanity, now  is the time 
IMPORTANCE OF DIGESTIVE ORGANS.        497
when it  bears  fruit: spectral  illusions, derisive, tempting, or
foolish voices half deceive, half irritate the victim ; and he is for-
tunate if he is saved from crime or a mad-house  by the curable
source of his unhappy state being correctly traced.  But if there
is no previous tendency, the mental miseries may go on for years,
and  yet  not produce  any positive  unsoundness of mind.   In
these cases, without further  symptoms than those named,  you
may be safe in  referring the origo mali to the digestive canal;
and  the  success  of your treatment will usually confirm your
diagnosis.
  There is also a suspicion that some acute diseases of the fibrous
tissues, such as gout and rheumatism,  may be  due  to  imperfec-
tions of  the digestive organs.   During these  ailments organic
acids, uric or lactic, and perhaps others, yet unnamed,  are found
in excess over the alkalies ; or rather more  correctly  speaking,
the alkalies are in a state of deficiency in respect of the quantity
of acid ; and, as acids are certainly formed by the decomposition
of the food, and one of them (the lactic) especially in great abun-
dance, while the alkalies also come from the  food, it is  presumed
that the cause of the malady resides in  the viscera which contains
the food during digestion.  This idea  that the digestive organs
are to blame for gout and rheumatism  is of ve"   old  date; yet it
must be confessed that the evidence for it does     increase; and
it remains, as of yore, a strong  presumption, Avaiung to  be  con-
firmed by a physiological  tracing of its steps.
  Whatever value Ave may attach to the evidence of the depend-
ence of diseases on the digestive organs, it is very clear  that we
look to them for relief from  those diseases.  Out of the  six or
seven hundred  forms of drugs in habitual use, very few indeed
are not occasionally offered  to the stomach  for acceptance, and
an overwhelming majority of them  are adapted  for use only in
this  way.   If we are still to employ this time-honored  agency in
our attempts to cure bodily ailments (and I see  no  threatening
of a change at present), it is surely a matter of great interest to
secure the active working condition  of the stomach.   It is waste
toil to try  and  enter locked doors.
  A great advantage of paying special attention to the digestive 
498         IMPORTANCE OF DIGESTIVE ORGAXS.
 organs is that, as a rule, they are more directly curable, and that
 by their means distant parts, otherwise out  of our control, may
 be favorably influenced. The evil of neglecting them  is obstinate
 disobedience of the disease, or rather of the  body of the patient,
 to any drug  administered ; recovery rather in spite than by rea-
 son of it; and in a candid  mind the development of  skepticism,
 the great enemy of right reasoning in medical matters.
   Let it be observed that it is not constructive medicines only,
 not alone aids to the normal work of the alimentary canal, that
 we try to put in through its walls.   We look to it also to take
 up those whose agency is,  physiologically speaking, the  direct
 converse, whose effect is that of augmenting destructive  meta-
 morphosis.   We call upon the bowels  to absorb calomel as well
 as bark  and wine  and oil.   We  shall  find it then of equal im-
 portance to have  them in a normal state when our aim  is de-
 struction, as when it is construction or arrest.
   When a sudden poison or paralysis  has fallen on these  gates
 of entrance, our hands are paralyzed too; the staffs  we  lean on
 fail us.  What buckets of physic used to be  poured through the
 half-dead boAvels in  our first  epidemics of  cholera!  It  might
just as well have been thrown at once into the night pan—its
 ultimate destination if the patients lived long enough.*
   So that  calomel pills, and calomel  powders, and  opium, and
 Cayenne pepper were a frequent constituent of  cholera stools;
 in short, I believe that nine-tenths of the drugs swalloAved  in the
 stage of  collapse followed  the same fate, or  the patients  could
 not have survived the poisonous doses which are recorded  to
 have been given.
   But it is when reconstruction is  the immediate object  of the
 remedies sought to be administered, that the importance  of the
 digestive organs is most obvious.   Mark the difference between
 two consumptive patients taking cod-liver oil.   One, whose di-
 gestion has been carefully brought into a healthy state, swallows
 it in large quantities, at any time of day you please, complains
  * I once found a drachm of ipecacuanha, which had been administered with
 other emetics three hours before death, safe in the cardia of a patient, in whom
 it had produced no vomiting, and had not been moved  toward the pylorus. 
            IMPORTANCE OF DIGESTIVE ORGANS.        409

of no inconvenience, enjoys life, does credit to the doctor, laughs
and grows fat.   Another, in consequence very likely of some
easily removable cause, nauseates the smallest dose; if in spite
of instinctive repugnance it be forced down, it gets rancid ; fetid
eructations follow;  and the patient not  only gets no advantage
from the  drug, but is  prevented by it from deriving the usual
benefit from the daily meals; appetite is lost, and rapid emaci-
ation shows  how little  construction is carried  on in the tissues.
   Watch a case of typh-fever, and see what immediate  improve-
ment follows the shedding of the dead epithelium with Avhich the
mucous membranes  have  been coated—a change  which is  an-
nounced by what is called the "cleaning  of the tongue,"  but
which foreshadows much more, in fact the cleaning of the whole
intestinal tract. See how immediately on this the poisoned nerv-
ous  system  begins  again to  renew its life, and delirium  ceases,
as  new nervous  matter fit for duty is generated.   Or watch
another less fortunate  case  of the same malady,  how  as  the
tongue gets  dirtier and dirtier and  drier and browner  each day,
the weakness of the nervous and muscular system increases, and
hope is more and more clouded over.
   In both instances, the difference between one case and another,
between the patient who is a  credit and  a joy to us  and the  pa-
tient who  continues to wring  our heart with  anxiety, lies in  the
more or less vitality of the digestive mucous tract.
   Then again, however  skeptical we may own ourselves as to the
dependence of gout and rheumatism upon the  digestive viscera,
it  is  through those organs  that we  mostly try to reach  the
malady.   'Tis through those  organs that we endeavor to get our
large doses of potash and our iodide of potassium into the blood.
There are practitioners Avho, in their treatment of these affec-
tions, rest more exclusively on the  drugs named than you have
seen me do;  and to them  even still more than to us must  the
integrity of the digestion be a care.
  We must  remember also that it is of no use to employ  the
best possible means of staying the morbid symptoms, unless  the
digestive organs  assimilate sufficient material  to  replace that
which is diseased, and  to  remove which Ave are bestowing our 
500         IMPORTANCE OF DIGESTIVE ORGANS.
pains.   Labor is wasted in clearing away abnormal structure, if
neAV  structure does not take its  place.  To that end the only
path is to insure  the assimilation of food.   And to  insure the
assimilation of food, the stomach  must be in working  order.  So
that  in point of fact the only fair  trials of depletory measures
must be connected with feeding, and  they Avho would uphold
their good fame must be careful of their patient's digestion.
   The  digestive tract has not the advantage  enjoyed by the
respiratory and by the upper part of the urinary apparatus, and
other parts,  of  being  double.  An animal has two  lungs, two
kidneys, two hemispheres to his  brain, two testicles  or ovaries,
but only one stomach, and one intestinal canal.   This is  a fur-
ther reason for great caution in preserving each in its integrity:
we have less  to spare  for disease to  affect.  A deposit  of tubercle
(for instance) the size  of a nut in the pulmonary tissue may be
neither here  nor there, may be never known by its effects; but
put it in the  heart, in the peritoneum, or in Peyer's glands, and
Avhat a disturbance is produced !
   This singleness also helps to  explain the powerful influence
which  derangement of any one of its parts has not only over the
whole  tract,  but over  the whole  body and  mind.  No chain is
stronger than its weakest link, and.an  interruption of the func-
tion at one point is an interruption of the whole.
   [I do not therefore think it will be  out of place in a volume
of lectures selected  and  edited as  illustrations of  restorative
medicine  or the artificial renewal of life, to insert several given
a  few years ago, which were  specially devoted to a consideration
of disorders  of the stomach and  bowels.   I  look  upon these
viscera as a  means of cure,  as an  agency for me to  employ for
the  renewal  of life, in fact as  part of my Materia  Medica.
The lectures which follow  may then be considered as  being
upon the subject  of therapeutical  agents  rather than as on the
subject of disease, and are set together as having that natural
bond of union.
   Questions  of morbid  anatomy  and diagnosis are  here,  as
throughout the volume, noticed  as  shortly as  possible, and pa-
thology introduced only  so  far  as may  be needed  to afford a
reason for treatment.] 
LECTURE  XLI.
           INDIGESTION IN  GENERAL.

Justification of the term  as  designating a  class of diseases—
    Position of it in nosology—Its importance—Examples—Its
    action on chronic disease, on acute diseases—Use and abuse
    of purgatives—Cause of death  in acute fevers—Mode  of
    introducing food.

      (Extra Course, St. Mary's, Summer Session, 1857.)

  The term "indigestion" or "deranged digestion" speaks  to
the mind of the physician of a very  large class of morbid phe-
nomena,  various in their  nature and appearing under  a great
variety of circumstances.  There  are those who would banish
the words  from  our nomenclature;  some because the outward
manifestations are so diverse that  it is impossible to bind them
together  in any symptomatic nosology; some because the parts
of the body whose morbid states induce indigestion are so many
that it cannot be brought under any anatomical arrangement.  It
is quite true that a  definition of it  cannot be given according to
the symptoms, and equally true that it cannot be called a disease
of one part or of any set of parts or tissues.  When symptomatic
phenomena are  made  the principle  of classification, those at-
tendant on this morbid state  are so numerous and so discordant
that they appear in every class; and if the organs that originate
diseases  are employed to  give them  names  also, there are very
few organs in the body which do not  sometimes produce the dis-
order in question.   Still to the practitioner and to the common
sense  of the non-medical public the  name has a distinct meaning,
and is a  definite guide to action.   No nosological, anatomical, 
502
INDIGESTION IN GENERAL.
or even chemical  considerations  have prevailed over it, simply
because it indicates a true thing, because it applies to a class of
disease having a connecting link in nature, though not in some
of our artificial systems.
   The common link which ranges into one class the diseases of
deranged digestion is  a partial defect in the necessary supply of
thiit of Avhich the body is built up, before it arrives at the medium
of distribution ; these diseases are anterior to assimilation  and to
the blood; they intervene between life and the new matter which
it  seeks to renew itself withal.
   This explains the fact mentioned before and familiar to us all,
of deranged digestion  affecting more or less all  the functions of
the body, and producing such a variety of morbid phenomena as
immediate or remote consequences.  It perverts incipient life at
its very source, and therefore perverts all its future  manifesta-
tions.
   I am very anxious  that you should have brightly pictured on
your minds this idea of the position in pathology of diseases of
digestion.  It is of the utmost importance in your treatment of
patients.  It is  of no use for you to pour in remedies, however
suitable for the removal of some morbid constituents of the body,
if  the new material which is to replace it is itself insufficient in
quantity or morbid in quality.   While  if  you set  to work in
another way, and  endeavor to  provide healthy  material,  this of
itself will act as a remedy,  even  though  other treatment  should
have been  neglected.   Make it  a universal rule, then, that the
special medication  is  never  to interfere with or take the place of
the supply of the materials  of life.
   In the management of a deranged digestion, whether existing
alone, or as a  complication of other complaints, it is certainly
important to know what organs are in any of the degenerated
conditions  which  form the province of the morbid  anatomist.
Your prognosis is  modified, and  to some extent your treatment
is  affected by such knoAvledge.  I do not deny the importance of
this, but I assert that  it is  infinitely more important to observe
the functional disturbances which are the immediate impediments
to the healthy renewal of the body, and to learn how to modify 
INDIGESTION IN GENERAL.
503
them for the advantage of the patient.  You may remember my
pointing out in the hospital the other day, with respect to a con-
sumptive man, how little it helped us to know that half of the
upper lobe of  each lung was  filled with crude tubercles: pulmo-
nary remedies  had been of no benefit to him; but the reflection
that the stomach was secreting an excess of mucus at the same
time with the lungs,  led to  effectual  means for the relief of the
poor man's progressive emaciation,  cough, and other distresses.
I also, a feAV weeks ago, called your attention to a girl, the mitral
orifice  of whose heart was narroAved  by rheumatic inflammation
in childhood.   On her being  carried into the hospital, her face
was like that of a corpse, and she could not stand without faint-
ing from palpitation.  I presume no sane student would expect
to see remedies applied for the dilatation of  that mitral orifice
Avhose  contraction is the source of evil:  despair  was not  an
illogical conclusion from the diagnosis, and I was but little sur-
prised to hear the  remark,  "This  is not much of a case  for
treatment."   Yet observation of the functional state of the ali-
mentary canal, indicated by the cedematous tongue and  fauces,
made me express an  expectation that she would Avalk home Avith
color in her cheeks.  This  she  has been able  to do, and the
better-nourished heart now beats steadily and  evenly;  though
its mitral  orifice is as small as ever, if the ear and  stethoscope
are to be trusted.
   On  stating  in consultation an opinion  that some viscus is
chronically degenerated, one  is often met by the remark, " Well,
what is to be  done? we cannot cure that."  Very likely not;
then try and find something  else which you can cure.   In the
great majority of your patients you  may find this curable some-
thing  in functional  impediments to  the entrance  of nutriment
into the medium of assimilation;  and when you once can get nu-
triment in, it w ill act as the  best medicine.   Do not, therefore,
give way to despair, even after  it has become certain that  the
principal viscus which gives a name  and origin to the disease is
incurable; and repress any  conscientious  fancies  that you  are
not  fairly earning  your fees  in giving  careful attention  and
advice, though you prescribe  little for the organ mainly affected. 
504
INDIGESTION IN GENERAL.
It is neArer too late to try and administer to the failing organ the
most  potent of all  medicines, the healthy human blood of the
patient himself.
   The more I see of disease the more convinced I become  that
the most  important function for us to pay  attention to  in all
cases is the digestion; in chronic cases it outweighs all the other
functions put together. I am led to this conclusion not so much
by physiological reasonings, or by the important position of this
function in the great circle of life, as by observation of the effects
of remedies, prescribed perhaps with quite different views, and
often without any thought of the digestion at all.  The effect of
climate, for instance, in pulmonary  consumption is proportioned
with extreme accuracy to  the degree in which the absorption of
food is improved or injured  by it.  I had a striking instance of
this a few months ago, in the comparison of letters which I re-
ceived at the same time, about a couple of young ladies whom I
had  sent  to pass the Avinter in  a warmer climate.   The elder
(S. S.) Avas last year much the more advanced in disease;  half
of the right lung was rendered impervious to air and immovable
by tubercle, local inflammations, haemorrhages, and  pleural ad-
hesions.   She had also frequent dysmenorrhoea, and occasional
menorrhagia.  The younger (E.  W.) had a small deposit of tu-
bercle at  the  apex  of the right lung, which excited cough, but
no haemoptysis or  pleurisy.   She was the stronger  and more
muscular of the two, and  had least right to  hereditary disposi-
tion, for all her family are alive, while S. S. has lost her mother
by phthisis.  Both had been under  long courses of medicine by
my direction, so I set them to begin the winter at any rate, and
to go on as long as circumstances admitted, without any.  What
now  is the result which I said struck me so forcibly?   S. S., the
most  diseased anatomically speaking,  who  had certainly  the
greatest amount of morbid  tissue in  her body, found  the  warm
air assist  her sluggish circulation, enable her to take  exercise,
improve the appetite, and  add unwonted energy and spirits.  No
food  Avas passed undigested, and the evacuation from the bowels
was  normal in time and quantity.   The consequence  of which
condition of the assimilating organs, bowels, and blood, has been 
INDIGESTION IN GENERAL.
505
a most decided amelioration of the pulmonary local symptoms,
in spite of an intervening attack of haemoptysis.  There is scarce
any pain, cough, or dyspnoea; she has increased  in strength and
weight, and boasts in her letter that she had one day ridden her
pony five-and-twenty miles.  E. W. had a tendency to a relaxed
condition of bowels—not absolute diarrhoea, but the passage once
or tAvice  a day of unformed pultaceous  stools, containing a large
quantity of undigested  food.  It was easy enough by medicines
to prevent the motions being too frequent, but difficult to amend
the assimilation of aliment.  This diathesis seemed aggravated
rather than improved in the mild climate; there was greater and
greater inability to take exercise; then a return of pain and ten-
derness in  the upper ribs, and at Christmas  timevthe surgeon in
attendance found  a deposit of tubercle taking place at the apex
of the left lung, in addition to what already existed in the right.
Emaciation then commenced, and continuously progressed, quite
unchecked by cod-liver oil and other expedients, which I thought
it right  should be tried,  though  without much expectation of
success.   In  this  patient my only hope is in  the  restoration of
the digestive organs to  a healthy state.
   The remedy, the effect of  which I thought was  strikingly ex-
emplified in  this  pair  of cases  accidentally reported together,
is soft and warm  air in incipient, consumption.   The agreeable
effects on  the  respiration, the relief of dyspnoea, the poAver of
getting out into the open air were equal in  both,—but how dif-
ferent has  the result been !
   A very moderate experience of the cases we have seen together
in the hospital will soon enable you to class a dozen or more as
resembling in their type one or other of the two  above quoted.
The atmosphere  of our well-ventilated wards,  and  their even
temperature, in comparison with the depressing coldness  and
chilly  damps of  the streets whence our patients  come,  repre-
sents on a  small scale what Torquay, Madeira, and Mentone are
to the wealthy. And you may thus as students see, what private
practice will  still  more strongly impress upon you,  that the effect
of climate on digestion is the most important part of its action.
The atmospheric change alone without medicine will benefit those
       33 
506
INDIGESTION IN GENERAL.
who resemble the class  represented  by S. S., more or less, in
proportion to the extent of their disease, while those portrayed
by E. W. will usually grow worse in spite of drugs.
  In all forms  of dropsy, again, the effect which you  desire to
produce by remedies is strikingly dependent on the  condition of
the alimentary canal.  Where the portal system  is congested, I
have given that strongest of drugs,  elaterium, in doses gradually
augmented up  to three grains, without any of the vigorous  hy-
dragogue action naturally following; and then, by  applying a
few leeches to  the  anus, so as to disgorge the abdominal veins,
half a grain has produced excessive purgation, Avith reduction of
the dropsy.
  Another striking example of the dependence  of remedies on
their influence over the digestion  is found in anaemia.  If, as
generally happens, iron improves the condition of the alimentary
canal, so  that  the stools,  from being  scanty,  scybalous,  and
mucous,  consisting  mainly of wind and half-digested  food, be-
come natural  and  regular, then the body  is renewed  by fresh
nutriment, and  the strength is rapidly reinstated; but if it irri-
tates the mucous membrane, so as to make the evacuation irregu-
lar,  black, and slimy, your  patient remains as anaemic as ever.
Hence the importance of suiting to  the case the different form
in which the metal is  presented.   If ready solubility and pres-
entation to the absorbing surface, in such  a  shape as to get an
entrance of a large quantity quickly into  the system,  were  the
only thing to be considered, the question as to which is the best
preparation might be left to the druggist.  But it is not so; very
often the easily soluble salts so disturb the  gastric mucous mem-
brane that it refuses to pour out that secretion which is the chief
solvent of albumen ; the  food passes unaltered into the intestines,
and putrefying there, increases the disease. Whereas a sparingly
soluble form  of the  medicament passes unaltered  through  the
stomach, and  exerts its main  energy on the intestines.  Again,
some preparations, both soluble and insoluble, are  more or  less
astringent, and have various qualities acting on  various parts of
the alimentary canal, which render  them  appropriate or not to
individual cases.   So that  not  the most elegant, not  the most 
                 INDIGESTION IN GENERAL.              507

praised as ingenious by the druggist or scientific chemist, is the
oftenest selected by the judicious physician, to whom the cure of
the patient, not the harmony of the prescription, is the object in
view.
   It ought to be  better understood that the fitness of any sub-
stance ingested, Avhether food or medicine, for its final  destina-
tion, is not the only thing to  be considered.   Its capacity for
entering into the circulation must be taken into account, and,
above  all, its dynamic  influence over the organs of absorption
and digestion.  As  a general  rule, iron  is the chief agent we
think of in anaemia.  We think of it for its direct power of in-
creasing the haematin of the blood.  Yet it is by no means always
the first, or even  the best remedy when the blood-disks are de-
ficient from faulty assimilation.  I remember when I was a student
noting down  as a paradox  that salts and senna  acted as a tonic
in three cases running, where iron and bark and bitters had done
no good; yet that I could not  find  in  any Avork  a tonic  action
assigned to purgatives.   I then saw that the action of medicines
was not entirely according to their rating on our books.
   The fact is, that until you have removed the sluggish state of
the regions  presided  over  by the portal  circulation, which are
doing  nothing but  forming mucus and obstructing absorption,
you cannot get the  protein compounds taken up, and they form
a much more important constituent of blood-globules than even
iron.
   And  it is  not  only the  general health  that  is benefited by
attending to the functions of the stomach, but even organs as
far as possible removed from it in a physiological point of  view.
A patient consults me from time to time who  has an enlarged
prostate.  When  digesting well, his  urine  is quite transparent,
and free from mucus, even when microscopically examined; but
if the stomach is disturbed by any imprudence or accidental ill-
ness, there is a copious formation of pus in the bladder.
   I shall return to  this subject when I come to speak of medi-
cines  separately; now  I  mention  it merely as  an  accessible
instance to show you how all-important in  treating chronic dis-
ease is the condition of the alimentary canal. 
508
INDIGESTION IN  GENERAL.
  In acute disease you will be almost equally disappointed with
the effect of your remedies, if you do not, either by their means,
or by other means in addition to their administration, bring the
alimentary canal into a proper state for their reception.  In no
cases is this more marked than in erysipelas and delirium tremens,
and you may have observed  that I scarcely ever pass a bed in
the wards containing a patient affected with one of these diseases
without calling  your  attention to the fact.  I point out to  you
that  cinchona and wine are the proper remedies for the weak
rapid pulse, the yellow pasty tongue, and the low inflammation
of the skin in erysipelas ; but that if you give these remedies
without clearing away the  saburral epithelium  from the stomach
and bowels, they are quite thrown  away ; the circulation con-
tinues as weak as ever, and the patient goes on  advancing toward
death.   But if  you have got a purgative to act, and are then in
time with your  alcohol and bark, the corner is turned, and every
change which takes place  is a change toward health.  I have
often shown you, in the little room where we put raving cases of
delirium tremens, a man who has been taking large  amounts of
laudanum, morphia, and solid opium, yet is as  rabid and demon-
haunted as ever, his eyes  never closing  to the horrible visions
that surround him.  But on giving him an efficient dose of salts
and  senna by  mouth or  rectum,  powerful opiates  become no
longer requisite; he goes  off into a quiet sleep, sometimes with-
out any more, sometimes Avith an ordinary quantity of laudanum,
and the next day he is usually calm enough to be removed to the
common wards.
   Do not misunderstand, or suppose me to have turned "evacua-
tor," recommending an artificial diarrhoea as a panacea;  on the
contrary, I am anxious  to warn you that there are cases where
a purged state of the alimentary canal, natural  or  artificial, is
most injurious.   I would instance especially pneumonia and low
fever.  In the first, the  treatment pursued is beneficial just in
proportion  as  the bowels are  not  purged; and  if you  give  a
cathartic, you  very often destroy all the good  effect of your
remedies.   In  adynamic  fevers, the prognosis may be  almost
entirely governed by the  average proportion  of solid  matter to 
INDIGESTION IN GENERAL.
509
the liquid in the stools, and by the  degree in which  the food is
digested.   Any expedients which increase the  amount of solid
and diminish the liquid intestinal evacuations, any which promote
the taking up of nutriment by the mucous membrane, are doing
good ;  any that act in a contrary way, do harm.
   In pneumonia and low fevers, three-quarters  of those who die,
die of starvation.  I mean that the real immediate cause of their
death is the  non-renewal of the blood by  the supply of fresh
matter.   Both veins and arteries are filled with  a dark half-dead
fluid, a great portion  of which is incapable of fulfilling the func-
tions of life at all.  Expose this black  blood to the air, and it
remains nearly as black as ever.  No oxygen will redden it, for
it is too dead to imbibe oxygen, and it is only fit to be evacuated.
But then, when it is evacuated, something must  supply its place;
new blood-disks capable of living and absorbing oxygen must be
made, or the patient  dies.   If you think  only  of getting rid of
this dead matter by blood-letting and other evacuants, or if you
think only of arresting the rapid  destruction of the still living
matter by alcohol, you are taking an imperfect view of your
business, and not doing all that may be done to renew the patient's
life.  At the same time that you fulfill the other indications, it
is your  duty to adopt expedients  for promoting the supply of
nutriment to the absorbents.
   That is not to be accomplished by throwing in at once a large
quantity of food, which decomposes and stops digestion entirely.
The alimentary canal either rejects the load or suffers from such
treatment,  and is all  the  more starved  by the  very abundance,
like the Roman girl in Livy's legend, who was  crushed to death
by the stipulated rewards of her treachery.
   The way to attain your object is to give very small quantities
of food at a time aud  very frequently, so that a continuous flow
may be kept up through the  alimentary canal without  over-
burdening it.  The  system of a patient laid up with acute disease
is like that of a new-born infant, in the weak hold it  has of life,
and in the constant support it requires ; and the stomachs of the
two resemble one  another in the insufficiency of the meal they
can take at once to satisfy their wants for any length of time. 
510
INDIGESTION IN GENERAL.
 Treat them, therefore, in the same way; and as in proportion to
 its youth you order an infant to be fed frequently, so in propor-
 tion to their illness feed frequently your sick patients. A person
 prostrated  by a fever or by inflammation of an important vital
 organ, such as the lungs for example, ought not to be more than
 two  hours without food while awake, and I have not unfrequently
 administered it in doses of a few spoonfuls every hour, night and
 day, with decided advantage.
   You may take  a lesson,  too, from the nursing of infants as
 respects the nature of the food ; milk is the most perfect you can
 give.   The only disadvantage  is, that the caseine may be sud-
 denly coagulated  all  at  once in the stomach, and  then, instead
 of passing  on gradually, it has to remain there till  enough gas-
 tric  juice is secreted  to  dissolve it, and enough energy exist in
 the peristaltic muscles to move the mass onward; till which time
 it stops the way.   The better plan is to mix sufficient lime-water
 with the milk, to prevent any large quantity of lactic acid from
 being free ; much  of the  milk will then pass the pylorus uncoagu-
 lated, or at any rate  in  very small coagula,  and be digested by
 the intestinal juice, with no labor to the stomach.*
   You saw a month  ago, in the Victoria Ward, a  striking  in-
 stance of the effect of mere nutriment so  administered as to be
 capable of being absorbed in acute  disease.  A  young woman,
 the  subject of pulmonary tubercle, became  affected with  pneu-
 monia of the whole of one lung.  Her lips were livid ; the pulse
 not to be counted  ; the respirations irregular, and between forty
 and  sixty in the minute ; there were rales from the collecting of
 mucus even in the bronchial tubes of  the  unaffected lung; the
 tongue had a smooth yellow coat; and the repugnance to food
 was very great.   She had  up  to  this period  had nourishment
 given, or rather offered,  only at the usual  times of meals.  She
 had had some stimulants, but they had been thrown up.   I then
 ordered her a pint and  a half of  beef-tea and two pints and a
 half  of milk, guarded with  a pint of lime-water, to be  taken, a
  * On the action of the intestinal juice  see Bidder und Schmidt; "Die Ver-
dauungssafte (von Darmsaft) ;" and "Digestion and its Derangements," by the
author: Book I, chap,  v, sect. 4 and 5. 
INDIGESTION IN GENERAL.
511
small portion at a time every hour,  so as to finish  the whole in
twenty-four hours.   The next  day a sudden reviA-al had taken
place; the  tongue had  cleaned; the  respirations  were about
twenty-five or thirty; and  so  she continued to hold on to life
for five days, when a relapse occurred,  and  she died.  She died
truly, but it seemed pretty clear that death would have occurred
from the first condition  in which  the  patient was seen  by you,
except from the continuous supply of nutriment.  I cite this case
rather than any of those where final  recovery takes place,  be-
cause in  them  you might doubt whether the disease really is of
a necessarily fatal  nature ;  whereas here you have proof of  the
fact in its killing the patient soon afterward.  It was of a fatal
nature, yet death was arrested for a time,  and the sharpness of
the symptoms made the changes more striking than  in  patients
where your memory has to cast back for days or even weeks, in
order to trace the effect of treatment.
   Another  patient, now convalescent,  illustrates  a still more
purely dietetic  treatment  of acute disease.   I  mean  a young
man who was  brought in  three weeks  ago with low fever, his
tongue dry and brown, rose spots on  the  skin, weak fluttering
pulse, and the stools smelling  like rotten flesh.  The only drug
I  ordered him was a small quantity of chalk-and-mercury powder
at night, and  some  effervescing  saline  draughts.*  You have
often seen under such treatment the fetor of the stools continue,
and great weakness follow, even in those fever cases that  ulti-
mately get well.  But I ordered at the same time a diet of milk
and  beef-tea, to be taken in small  quantities every hour, and a
few ounces of port wine.   To  assist the absorption of this nutri-
ment I gave him  also a scruple daily,  divided into three doses,
 of a powder containing pepsine; and I was curious to know what
 the effect would be on the  digestion,  for it was  the first time I
 had given it in low fever.   The result was most encouraging—
 for the stools immediately  lost their putrid fetor, and  the food,
 instead of being passed in  a putrid undigested state, seemed to
 be entirely consumed in the  bowels.   In spite of  several  dis-
   * I had not at that date commenced  the acid treatment of continued  fever
 detailed in a previous lecture. 
512
INDIGESTION IN GENERAL.
couraging symptoms, I have never seen a case of bad fever where
the stools were less fetid, or where there has been less emacia-
tion and debility during convalescence.
  My object in this lecture has been to lead you, in your clinical
studies  in the  wards, and  also in after-life, to rate  aright the
importance of the management of  the  digestive  organs in  dis-
ease. I mean in disease generally, and not in that which specifi-
cally affects those  organs  alone.  And in future lectures on the
same subject, I intend the descriptions I  give of morbid phenom-
ena, and the simple classes into which it is convenient to  divide
the impediments to digestion, to apply equally, whether they are
alone and give a name to the illness, or  whether they  are united
to anatomical changes which afford ground for a more convenient
generic designation.
  Do not be deceived by the expression, " merely  symptomatic,"
sometimes applied  to the derangements  of digestion in phthisis,
anaemia, amenorrhoea, dropsy, hysteria, &c, such as I  have cited
for  illustration.  All parts and functions of the body are so knit
together to form the great circle  of life, that their comparative
value to individual existence is more a question of time than of
power.   The failure of any one shortens the days more or less,
and a "mere symptom" is as often the immediate  cause of death
as an organic change or a pathological process is.
  I shall, in the five following lectures, give as concise a sketch
as I can of the principal modes in which  the function of digestion
is deranged, either alone or in connection  with other diseases,
pointing out on  the way what rational indications of  treatment
they afford.   I  shall  afterward comment on some of the most
important means used to effect our purpose, and point out their
bearing upon rational medicine. 
LECTURE  XLII.
       SLOW  DIGESTION  AND  ACIDITY.

Healthy digestion is easy, quick, and complete—Unhealthy diges-
    tion is painful, slow, and defective—Phenomena  exhibited
    in unhealthy digestion—Heartburn—Acidity.

      (Extra course, St. Mary's, Summer Session, 1857.)

  Healthy digestion is  easy, quick, and  complete.  There can
be no excess of it, for food  cannot  be too  easily, quickly, and
completely converted into chyme and taken into the system, and
there is no such thing  as too much health.
  In  ill health digestion is  impaired  in  one  or  more of  these
qualities—it becomes painful, slow, defective.
  You may use Greek words, and call the  above-named erring
qualities of the digestion  dyspepsia, bradypepsia, and apepsia ;
only remember, that making the old  adjectives into  new sub-
stantives  adds no  whit  to  our knowledge, and  unless  care  is
taken, runs some risk of being a stumbling-block to its progress.
  For when we have in  this way given  a proper name with  a
capital letter, we are apt to think  we have defined an individual
and active motive power, instead of what is really the deficiency
of a function,  and thus we fall into the errors of our forefathers,
whose dangerous  aims at destroying their  abstract foe the " Dis-
ease,"  instead of restoring the existing patient, led to so  much
bad practice in  the generation now passing away.   I shall use
the English adjectives, but first I will say shortly what  I  mean
by them in this connection.
  Painful digestion may be, and often  is, both  defective and 
514
SLOW DIGESTION AND ACIDITY.
slow; but, on the other hand, it not unfrequently also is  com-
plete and  performed with  sufficient quickness.   All that is in-
tended by the word is to express that it is accompanied, at some
stage of its progress, by feelings varying from slight discomfort
to absolute torture.
  By slow digestion, I mean that the act in  some part of the
alimentary canal is  not completed by the  time when the conve-
nience of  the individual and of society require that it should be
completed.   The  stomach, for instance, may retain so  much of
a former meal that it is not in a fit state to receive the  neAv one
which  is absolutely  required for the sustenance of the  body.
This is generally indicated by  a want of the natural  appetite
which arises  when the upper portion of the digestive  apparatus
is ready to do its work, and, in chronic cases, by imperfect nutri-
tion, anaemia, debility, &c.  Or, if we attempt to force  food too
quickly on the unwilling stomach, we have  chemical decomposi-
tion and defective digestion as consequences.
  By defective digestion, I mean that food  capable of nourishing
the body cannot  do so, from lack of certain  changes which it
should naturally undergo  in the alimentary canal.  It is passed
from thence  either unaltered or  chemically decomposed.  There
are seen in the faeces, either by the naked  eye or the microscope,
lumps of muscular fiber, fat, starch, &c.; or else the products of
their decay, consisting of  various obnoxious gases and acids, are
developed in  quantity subversive of comfort.
  The morbid phenomena accompanying these errors of the di-
gestive function may be divided according as they occur during
the first stage, that is, before the alimentary mass has passed the
pylorus;  in the second stage, that is, during its  passage along
the small  intestines; or,  in the third stage, after the  passage
of the ilio-caecal nerve.  Now remark, I do not call, and I wish
you not to call, these phenomena diseases of the  stomach,  or of
the intestines, or  of the colon.   They are  not so, and must not
be treated as such.   The discomforts felt  in the  first stage, for
example, may be due to organs far aAvay from the stomach,—to the
uterus, to  the kidneys, to  the teeth,—yet they may be called by
the same names and treated by the same remedies as when they 
SLOW  DIGESTION  AND ACIDITY.           515
 are owing to anatomical changes in that part.   So those of the
 second and third stage often are  traceable not to anything wrong
 in the ilia or colon, but to excess of mucus or deficiency of pep-
 sine in the stomach.   This is a  consideration of much practical
 importance, for it much influences the treatment.
   In the first stage of digestion  we may notice, as common phe-
 nomena, those generally known by the following names:
   Heartburn;  Acidity;   Weight;  Tightness  (or  distention);
 Oppression;  Wearing  (or boring) pain; Cramp (or spasm);
 Eructation ; Vomiting.
   I would  commend  to  you these Avords rather than any new
 Greek  or  Latin  compounds which  profess to  include  them.
 Nine times  out  of ten the artificially  manufactured  terms are
 not nearly so accurate as those Avhich  have become defined  by
 daily use.

                          HEARTBURN

 is a sense of heat or cold (they  are much the same) at the car-
 diac orifice of the stomach, running at intervals  up  the course
 of  the gullet.
   From the effects which alkalies have in allaying temporarily
 this pain, there  seems no doubt that it  arises from  the action
 of  the  acid contents of the stomach on the cardiac and oesopha-
 geal nerves.  The gastric mucous membrane itself does not suffer
 from acids; it secretes them,* and bears them  in contact for the
 remainder of the  day without inconvenience.   The gullet, too,
 will bear them for a short time; swallowing a mouthful of sour
 victuals  or drink  gives a healthy man  no  immediate inconve-

  * There appears no doubt about the gastric juice being secreted acid, and be-
 coming neutral only from admixture with saliva.  See the recent experiments of
 Drs. Bidder,  Schmidt, Grunewaldt, and  Schroder, compared in my " Digestion
 and its Derangements," chap, iv, and " Experiments on  Digestion,"  by Dr. F. G.
 Smith, Philadelphia, 1856.  This last-named very valuable renewal of observa-
tions on  the patient with gastric fistula, formerly a servant of Dr. Beaumont's,
seems to show pretty conclusively that in the human subject  the acid  secreted
is not hydrochloric, but probably lactic.  The origin of the finding hydrochloric
acid in gastric juice is that the lactic acid fermentation decomposes the chloride
of sodium contained in all animal secretions. 
516
SLOW DIGESTION AND  ACIDITY.
nience; but a continued exposure becomes painful in close pro-
portion to its  length, as may be easily tried by  pouring down
such articles sloAvly for a short time, whereby pain will  be pro-
duced even in the most healthy.
   Heartburn, or pain from the action of acids on the cardiac
end of the oesophageal plexus, faaay arise in three  ways:
   1st. By oversensitiveness of  the nerves.
   2d.  By too long exposure to  the acids of digestion.
   3d.  By too much acid being formed.
   (1st.)  By oversensitiveness of these nerves (Overfeeling, hyper-
aesthesis*).   This is sometimes, but not always, accompanied by
oversensitiveness in other parts of the body, and  is the form of
heartburn  which weak, nervous, hysterical  persons suffer from.
It comes on almost immediately after eating, directly the con-
tents of the stomach have begun to assume that degree of acidity
which is natural and necessary to them.   If vomiting does not
occur, it continues  till  they have become  neutralized either by
the saliva which usually flows  abundantly down the  oesophagus,
or by taking some alkali, or by  the moving on of the mass toward
the pylorus.
   The worst of this neutralization,  natural or  artificial, is that
a good deal of the  albuminoid  food remains undigested.   It is
absolutely requisite for its  solution by the gastric juice that it
should be acid while in  the stomach; and if this  natural acidity
is prevented, because it happens to be painful  to the oversensi-
tive nerves,  the peptic solvent  cannot act.  Thus the digestion,
from being painful, is made defective also.
   A peculiarity of heartburn from oversensitiveness, which often
is a great  assistance to the diagnosis, is that  one kind of food
brings  it on as much as  another;  just in the  same way as  the
peculiar grinding pain of gastric ulcer (which will  be spoken of in
a future lecture) is frequently to be  distinguished by there  being
so little difference  felt in the effect  of different articles of diet.
   * Here  is a  flagrant  example of the confusion attendant  on coining  words.
Hyperasthesis  is used now  in writing and speaking, with  seeming propriety,
for morbid excesses of sensation; but so lately as 1831 it is defined in Hooper's
Dictionary, "error of appetite." 
SLOW DIGESTION AND ACIDITY.
517
It is to be  observed, also, that it is very often worse after the
early than after the later meals, even though the dietary should
be more sparing and  more digestible.   Indeed, in private prac-
tice, where  one  sees lighter  diseases than  those  in  hospital
Avards, I have notes of several  patients who have eaten dinners
and suppers without  distress, but who invariably suffered after
breakfast.
   This form of heartburn usually occurs in nervous,  sensitive
persons, whether their state  of  system is congenital, or induced
by outward  circumstances.  Any untoward condition of  the parts
supplied by the abdominal plexuses of sympathetic nerves often
brings it on.  Tumors of the uterus or pregnancy are a  very
 common cause, and  excessive or painful  menstruation  often in-
 duces it in the female;  and in the male I have known it brought
 on by piles and by mere constipation.  It is often accompanied
 by vomiting in persons  who have a tendency thereto.  In  these
 cases you have an opportunity of examining the contents of the
 stomach, and  confirming what I stated  about  their being in a
  normal condition, by no means overacid  or otherwise unnatural.
    Overanxiety, Avatching, harassing mental emotions, and,  in
  short, all external circumstances which  cause oversensitiveness,
  induce this state of digestion.  Local pressure on the epigastrium
  will also fix the disorder in that part.   It is curious  that while
  the ordinary nerves of feeling appear blunted by pressure and
  the frequent repetition of excitement, the sympathetic should be
  made more sensitive.   Such, however, seems to be the case with
  the epigastric plexus, to judge by the frequency with  which this
  form of heartburn occurs in  shoemakers, needle-women, clerks,
  and others whose ordinary occupations  involve pressure on the
  pit of the stomach.
     As anaemia, debility, and occupations which occasion  them,
  induce this heartburn,  so it too will  react, and increase them, or
  even bring them on.  An impoverished  stomach, thus unable to
  bear the labor of digestion, becomes poorer still from defective
  supply.  That happens in the human body which Martial com-
  plains of  as one of the vices of civilization—those most in want
  gather  least wealth—" Dantur  opes nulli  nunc nisi  divitibus." 
518           SLOW  DIGESTION AND ACIDITY.

But  at  the  same time a slight change of habits, or slight relief
from medicine, will equally react beneficially, and commence  a
march toward health with unhoped quickness.
  It will also, too, sometimes be associated with, and very much
aggravate, the intermittent  headache of marsh miasma, causing
"brow-ague" to begin after the mid-day meal, instead of at other
times.
  The  suddenness with Avhich heartburn will come on, and the
rapidity with which it often goes away, is a great help to the
diagnosis of the nervous origin of this affection, and it is also a
great encouragement  to the physician  to  promise relief to the
sufferer.
  The  sketch I have given of the physiology of this disorder
points out the treatment most likely to be successful in the end.
The  aim must be, not to  neutralize  the acid, but to blunt the
oversensitiveness of the nerves.   This can be done, first, directly,
but temporarily, by medicines known  experimentally to  have
that effect on sensitive nerves; secondly, indirectly,  by strength-
ening the  whole  system, so that  those  nerves along with it may
become  hardier to bear the brunt of their  necessary duties.
  You have seen me often in  the wards  of this hospital begin
the treatment with hydrocyanic  acid and  bismuth, and in a few
days commence  the  use of  steel, or  valerian, or quinine.  The
benefit found from the first-named drugs is decided, indeed, but
it is temporary,  and few cases Avill get  permanently well unless
they are followed up by the tonics.   At the  same time there is
a great  advantage, still greater in private  than in hospital prac-
tice, in commencing Avith  a  medicine whose  influence is imme-
diate, and Avhich will gain the confidence of your patient for any
future plan you may adopt.
  Where brow-ague or any other form of neuralgia is concomit-
ant or  consequent, you  will best treat  it  by four or five grains
of quinine, taken an hour  and a half before the meal after which
it comes on—that is to say,  in most instances, the mid-day meal.
I have  found this treatment of the neuralgia more effective  than
that  by iron, the quinine curing not  only more certainly, but
more rapidly. 
              SLOW DIGESTION AND ACIDITY.           519

  Sponging the body with cold sea-Avater, and the shoAver-bath,
are often most  useful  remedies,  acting  doubtless in  a great
measure  through the general  system.   But  cold  sponging or
douching the epigastrium, which may be easily managed sitting
in a hip-bath, appears  to have  a  special local  action, and cer-
tainly does still more good.
  The tonics which must follow up this  special treatment may
be varied according  to  the  case and the patient's convenience;
but, as a general rule, I find none do better than iron.
  (2d.) By too long  exposure to the acids of digestion.   Many
influences, which in moderation  are rather pleasant than other-
wise to the sensory  nerves, become  exquisitely painful Avhen
long continued.  For example, the immersion  of a limb in Avater
a few degrees below the temperature of the air  is not disagree-
able, and may be kept  on  with intermissions for any length of
time;  but it becomes absolute torture if persisted in  without an
interval  of rest.   So,  in many cases,  a sluggish  stomach,  in
Avhich  the progress of  digestion is too  slow,  causes the cardiac
orifice to be so long steeped with  acid that it becomes painful,
though a proper exposure for the natural length of time could
be  borne  with ease.  Just in the same Avay a continued dribbling
of faeces will make the  anus sore—a continual running from the
nose excoriate the nares, &c.
   This form of  heartburn never like the first comes  on immedi-
ately after eating.   It often does not occur till four or more
hours  are passed; in fact,  till the period at  which the stomach
ought to be nearly empty, and preparing for another meal. But
the most usual time is  an hour after eating.   Its  long continu-
ance will, however, be  apt  to induce that tenderness of nerves
which constitutes the first form, so that  it will  approach nearer
and nearer to the time  of meals, till at last it commences imme-
diately.   It  differs, though not  invariably, in one important
diagnostic peculiarity:  that it  is more  common after the  later
than the earlier meals.  It will  also, like the first  form, bring
on nervous headache,  and occasionally a  decided intermittent
neuralgia, aggravated by the same causes, and removable by the
same remedies as that  arising from marsh miasma.    Even if the 
520
SLOW DIGESTION  AND ACIDITY.
meal should be omitted, this headache Avill still come on; but if
the time of  the meal be changed, the time of the headache will
change with it.
  Though the oesophagus is relaxed so as to admit of some re-
gurgitation, yet what comes up is seldom more than air, usually
of a neutral inoffensive character, and not in the great quantities
and with the explosive force which marks the formation of car-
bonic acid by fermentation in the stomach.
  The persons in whom it occurs  are active men of  business,
literary laborers, clerks, overthoughtful and overcareful.  But
when once acquired, it is very apt to persist in spite of a change
in the mode of life.   I have had as patients thus affected many
farmers and country gentlemen who had suffered since  youth,
though living Avith little apparent care or intellectual occupation.
  As before mentioned, it may lead  to the first form of heart-
burn; but in  symptoms, pathology,  and treatment it may be
considered as a transition from it to the next in order.   And I
shall therefore postpone speaking of the indications it affords till
I have brought before you the heartburn which arises,
  (3dly.) By too  much acid being formed.  To this the name of
"acidity" is applied with  propriety, because there really is an
excess of acid.  It  comes on at a period more distant from the
time of meals than the last kind, and may be considered, in some
respects, as  a  further stage of it.  The pain, however, is much
less intense  in  general, sometimes so  slight as to cause scarce
any inconvenience.   But the regurgitations are much greater;
sometimes true vomiting occurs, distinguished by spasmodic action
of the diaphragm; sometimes only a teaspoonful of intensely sour
liquid comes up,  roughening the teeth, and bringing tears into
the eyes; sometimes a gaseous acid (acetic and butyric) is belched
up spasmodically; sometimes it oozes up gradually, and its pres-
ence is shown by the saliva and breath being sour to the taste
and smell.
  These peculiarities will suffice to distinguish between " acidity "
or heartburn from real excess of acid, and those forms preA'iously
named where the  excess is only apparent.   A further test  may
be found in  the action of remedies: a small dose of alkali, a grain 
SLOW DIGESTION AND ACIDITY.           521
or two of  soda or potash will be  sufficient  to  appease them;
whereas, in this case, a very considerable dose is required.
  Acidity is often misunderstood.   I have  heard it spoken of as
"an excess of gastric juice," "excess of action in-the stomach;"
that is to say,  too much of a  vital act, too much life.  Such  a
mode of  speaking, if it leads  to  anything, must lead to faulty
thinking and bad treatment.
  Instead of being an excess of gastric juice, it is itself a proof
of deficiency.  You may prove by experiments on artificial diges-
tion, that an increase in the  quantity of  the solvent secretion
quickens the solution of albumen.   You will find, for instance,
that the amount of  pepsine contained in tAventy grains of Bou-
dault's powder  will dissolve a piece of hard-boiled white of  egg
much sooner than five grains.   The same thing would of course
happen in  the stomach; were there more gastric juice there would
be quicker digestion.  But in "acidity" such is notoriously not
the case; the aliments lie for a long time in the upper part  of
the digestive canal, and often are, after all,  passed undissolved
in  the faeces.   It is a chemical act of decomposition directly
opposed to the vital act of  digestion.
   I call a "vital" act any which forms part of the great circle
of  life, such as  is the conversion in the  stomach of albumen,
previously incapable of  solution  and absorption,  into peptone
capable of entering the circulation.   Now,  when this vital act
of  conversion  is carried  on with rapidity  by a stomach making
abundance of gastric juice  strong  in pepsine, then chemical de-
composition  is prevented;  nay, it  is even arrested after it has
commenced,  as may be seen by putrid meat  not becoming more
but less putrid as it passes through the body  of a healthy animal.
But Avhen the conversion  is slowly or imperfectly performed, then
chemical change has time to take  place, and does  so very soon,
being favored by the heat, moisture, and animal matter in a state
of change.  If  the food remain too long Avithout becoming chyme,
the protein compounds putrefy with extreme rapidity under such
circumstances.
   Compare this white of egg which has  been immersed in saliva
at  the temperature of 100° Fahr. for twenty hours, with anothe
      34 
522           SLOW DIGESTION AND ACIDITY.

portion from the same egg kept the same time in distilled water.
Your  nose warns you of the difference directly; the first is in-
tolerably fetid, the second quite sweet.
                    (Experiments shown.)
  Exactly similar is the fate of undigested albuminoid matter,
whether animal or vegetable, in contact with the  mucous mem-
branes inside the body.   But how  does that affect the case of
acidity ?  Thus: I have in this beaker some syrup of grape sugar,
quite  neutral and natural.  Here is some of the same Avhich has
been poured on a piece of putrefying albumen a few hours ago,
and kept at the temperature of the body.   You see that a piece
of litmus paper  I put  in  it is strongly reddened, showing the
copious formation of lactic  acid.  In another beaker, the form-
ation  of butyric  acid from fresh butter by the same means is
shown to you.
                    (Experiments shown.)
  Just so all the grape sugar and fat swallowed, when  it meets
in the stomach or intestines with decomposing animal food, re-
maining in a mass or glued to the  side by a too sticky mucus,
ferments quickly throughout, and forms lactic and butyric acids
in great quantity.
  Remember, the grape sugar swallowed means  something much
more  important  than merely the grape sugar  eaten.   See this
boiled starch; I  heat  some  of it with the potassio-tartrate of
copper, and  there is no  change in the blue  color of the salt.
Noav I put some in my mouth, and hold it less than a minute.
                    (Experiments shown.)
  See ! when it is again heated with potassio-tartrate of copper,
the metal is precipitated, and shows by its brilliant yellow color
an abundant quantity of  sugar.  The saliva, you see, begins to
convert starch into sugar immediately; very soon  it will trans-
form the whole mass.   A mouthful of boiled starch which I held
in my mouth for five minutes the  other day showed afterward
scarce a trace of starch remaining.  As, even  among meat-eat-
ing nations,  from half to five-sixths of the  solid food consists of 
                SLOW DIGESTION AND ACIDITY.           523

 starch,* it is evident that one of the most bulky contents of the
 stomach must  be the sugar which has been made by the saliva
 out of amylaceous food.   Here then is ample material  for the
 formation of lactic acid to almost  any amount.   Add to this the
 oleaginous substances which it is impossible to avoid  in any diet,
 and  which,  from  being  insoluble  in water, constitute a pecu-
 liarly acrid and  concentrated acid, and you will have no diffi-
 culty in accounting for acidity, without recurring to a theoreti-
 cal excess of gastric  juice.   Acidity then  is  an  evidence of
 chemical, and therefore of decreased, vital action, a proof of in-
 complete digestion, of deficient activity in  the stomach.
    On this rests the rationale of the hints for treatment which it
 gives.   The way to cure it temporarily is to neutralize by alkalies
 the excess  of acid which  is formed.   And  this may be freely
 done without fear of bad consequences; for you are not  likely
 by any reasonable dose to make it so far alkaline as  to interfere
 with digestion.   It is not in  this  form, where acid  is really in
 excess,  but in the first (or nervous) heartburn  that  alkalies do
 harm, for  the  reasons  there  stated.   Where  it arises  simply
 from temporary debility induced  by occasional  gluttony, " the
 remorse  of a guilty stomach," it may be left to  cure  itself.
 But a permanent cure can only be brought about by reagents
 which—
   (1st.) Strengthen the local poAver of the gastric solvent.
   (2d.)  Augment its quantity.
   (3d.)  Excite the peristaltic  motions.
   The local power of the pepsine secreted, although in diminished
 quantity, may be much increased  by neutralizing  the  saliva
 swallowed and  collected  in the  stomach  and  oesophagus just
 before the meal.  In laboratory experiments on artificial diges-
 tion, you will find that saliva  arrests the solvent action of pep-
 sine in a close proportion to its amount.  In  the laboratory you
 may set  the  action  at work again  by acidifying  the mixture,
 unless you have waited  so  long as to allow it to decompose.  So
 too in the stomach,  if you take it  in time, you may free the
  * See the dietaries of soldiers,  prisoners, laborers, and others, analyzed by Dr.
Hildensheim in "Die Normal-Diiit," p. 6, Berlin, 1856. 
524
SLOW DIGESTION AND ACIDITY.
pepsine from the alkaline saliva, and enable it to do its duty by
adding acids.   The best to select are those to which the viscera
are most used, hydrochloric or lactic.  A few drops of these
taken immediately before meals will almost always have a most
beneficial effect.
   The quantity of the gastric juice may be increased by supply-
ing one of its most important constituents,  water ; but in large
quantity at the meal it is  apt to dilute too  much the  sparine
secretion, and hence it is better to direct the  principal draughts
to be taken half an hour aftenvard.  An artificial gastric  juice,
in the shape of one of the new preparations of pepsine, may also
be given if the acids are not  sufficient; but  I  prefer to try at
first and  get  the patient  to be his own  pepsine maker.   The
colder the water  the better ; for the low temperature  acts as  a
tonic shower-bath to the local nerves, and removes the congestion
of the blood-vessels, while at the same  time it never quite stops
digestion, and soon acquires heat enough to let it go on with  full
rapidity.*
   Your patient will perhaps think that you are  blowing hot  and
cold, or rendering inert your  own treatment, by ordering acids
at one time and alkalies at  another; so you will find it a wise
plan to give him  a short physiological lecture on the subject,
explaining the reason of your procedure.  You may explain also
that the acids given as medicine do something more than in the
laboratory: they stimulate the mucous membrane, and so actually
increase the quantity of secretion while they increase  its power.
You need not have the fear, which I have heard some express,
that the use of these  substitutes  for the natural constituents of
the gastric juice,  or rather the supply of that which ought to
exist in the gastric juice,  will teach the stomach to be lazy—as
doing a servant's work for him makes him less  equal to doing  it
himself.   On the contrary, the new vigor put into the  system by
  * That cold retards the  action of the gastric solvent is shown by some ex-
periments on artificial digestion  I  published in " The Lancet" of May 23, 1857.
But at the same time it does not stop it.  Even the freezing temperature  does
not entirely do that, as is proved by Drs. Bidder and Schmidt.  " Die Ver-
dauungssiifte," Exp. ix, 1, 2 ; x, 1; xvi; xvii.  This is a comfort to the admirers
of ices. 
SLOW DIGESTION AND ACIDITY.           525
the healthier and more copious chyme  that  is formed, renders
the organ more active; so that it soon is enabled to go on secret-
ing for itself what is Avanted, and to do without the artificial sub-
stitute.   Do not, therefore let patients fancy that they might get
into a habit  of taking  these  medicines, so as  to  be obliged to
continue or to  increase the dose.   If they derive benefit from
them, they Avill be able soon to leave them off.
  ' The action of the peristaltic muscles of the  stomach can be
excited by most of the drugs which  act as purgatives.   But un-
fortunately, in the great majority of gastric complaints, purga-
tives are decidedly injurious, so that the good done to the stomach
is overbalanced by the injury done elsewhere.   The least hurtful
are rhubarb  and  aloes ;  but  even  they  somewhat  impede the
digestion in  many persons  who take them as a dinner pill.   A
better expedient is  strychnine.  Its small  bulk causes it to be
quickly absorbed, and to act locally on the stomach alone with-
 out affecting the rest  of the system; so  that where common
 caution is observed, I have never found it  necessary to leave it
 off on account of the occurrence of specific spasmodic effects ;  at
 the same  time  its beneficial  influence is most marked, and in
 many instances  it  acts  as a  bitter tonic also, increasing  the
 appetite and spirits. 
LECTURE  XLIII.
             PAIN  IN  THE  STOMACH.

Local weight, tightness, distention, dependent on excessive secretion
         of mucus—Gastric catarrh, acute and chronic.

      (Extra course, St. Mary's, Summer Session, 1857.)

   Weight, Tightness, Distention,  sometimes a feeling  ex-
pressed as  of being "blown out with wind," while on  examina-
tion the epigastrium  is found  not  more tumid than  that of  a
healthy person digesting, are  modifications of  a sensation pro-
duced in the nerves of the stomach itself.
   (1.) Alone.—Where the sensation exists alone, unaccompanied
by soreness, by pain on pressure, or  by  decided pain immediately
after  eating, it is possible to judge of the real meaning of  the
phenomenon. But in complicated cases the difficulties presented
are very great.  Putting aside for  the nonce  these latter, and
looking only to simple examples, I have come  to the conclusion
that it denotes simply the presence of an excessive amount of
mucus in the stomach.
   Like  other mucous  membranes, that of the  stomach may be
affected acutely or chronically.   The  first case may be called
"gastric catarrh;" the second, " mucous flux."  Both are liable
to be followed by vomiting, which relieves  temporarily the dis-
tress, and which in the acute form constitutes the most ordinary
form of " bilious attack," so called from the bile which the action
of the diaphragm in vomiting  causes to regurgitate  along with
the contents of the stomach.   When not rejected  by vomiting,
the aliments are  so enveloped in  mucus, that they cannot be 
                  PAIN IN THE STOMACH.               527

acted upon  by  the  gastric juice,  and are  passed  very little
changed  into the bowels, where they are  liable to ferment, and
by  their acidity cause  diarrhoea, flatulence,  and sometimes  a
copious discharge of mucus from the bowels.   This latter result
is  more  common in  acute  than in  chronic  cases,  where the
motions are often infrequent and irregular, and exhibit unformed
or scybalous faeces.
  When  vomiting occurs, the  ejected matters are mixed with so
much mucus that there is no difficulty in making  the diagnosis;
but where it does not, the case is liable to be mistaken for one
of disease of the bowels, on account of the flatulence and mucous
diarrhoea.  Certainty of diagnosis can in such cases be obtained
only by the administration of an emetic, which brings the source
of the evil into the light  of day.
  In  acute cases this excess of mucus is  often accompanied by
very intense headache, but in  chronic it seldom  goes beyond a
feeling of stupidity.   Flushing of the face, and heat at the back
of the eyes,  are also nervous symptoms  dependent upon  the
chronic condition, and seem quite  independent of any disturb-
ance of the circulation.
  " Acute catarrh  of the stomach," like all  other catarrhs,  is
excited by external,  and often by epidemic influences.  Changes
of temperature are its most frequent cause. Bu still,  as in other
catarrhs, the cause must have  been  a special  reason in the indi-
vidual for selecting  one mucous membrane rather than another.
And since the naturally warm position of the stomach, aided by
the usual habits of  dress, guard it* very efficiently against ordi-
nary variations of the weather, the idiosyncrasy of the individual
has a preponderating influence on its production, and often leads
the others to be overlooked.   But in the prevention of the com-
plaint more is to be done  by attending to these special  reasons,
and by protecting the stomach against such deleterious agents as
the habits of the patient expose it to, than by trying  to alter the
diathesis of his body.
  On the other hand, the mucous flux is much less dependent on
external  circumstances, and much more on organic changes either
in  the stomach itself or  some other viscus.   Tubercles in  the 
528
PAIN IN THE STOMACH.
lungs,  emphysema,  chronic  bronchitis,  and  enlarged  heart,
oftenest produce  it,  and it is associated with cancerous, tuber-
cular,  and  inflammatory  affections of neighboring parts, but
alone it is rare.   In this it resembles  bronchial flux or  chronic
bronchitis.*
   (2.)  With soreness on pressure, more especially if the soreness
exist also when the  stomach  is  empty, or if accompanied by a
decided pain  arising from  the ingestion of food, it denotes  that
the  secretion of mucus depends on some  local inflammation  or
ulceration of a chronic character in the mucous membrane. Where
a tumor can be felt, the  probability is that it is of a cancerous
nature.  Where there has been bloody  vomiting, the diagnosis of
ulcer, cancerous or non-cancerous, is almost  certain.
   I incline to think  that  the peculiar sensation just  described
depends on the general state of  the mucous  membrane,  and not
on the local injury to one  part or another of the stomach.  My
reason for thinking so is that it  is capable of so much relief  by
medicines even in patients where the spot  anatomically altered
is found afterward to have been  gradually progressing.  Some of
you  may remember a man  who  lay in Albert Ward  during
the greater part  of a year, with rapidly growing cancer of the
liver and pylorus. In spite of a  continuous increase of his neces-
sarily fatal tumors, the sense of distention and weight  after food
   *  In 25 post-mortem instances of excess of mucus adherent to the walls of the
stomach—
     6 had tubercles or vomica; in the lungs as chief cause of death;
     4 had diseased hearts as chief cause of death ;
     7 had oedema pulmonum or emphysema observed after death, or chronic
        cough-observed during life, as  chief cause of death.
   In the above 17 it may be considered as self-evident that there was an in-
creased secretion of mucus from the bronchi as well as from the stomach.
   Of the remainder—
     4 had diseased kidneys as chief cause of death ;
     1 pneumonia (in both of which chronic cough was not unlikely);
     1 had cancerous ; and
     1 tubercular disease of the peritoneum  ;
     1, a child of four months, had acute inflammation of the bowels, and the
        mucus was  an evidence of gastric  fever, not of chronic flux.
   (See " Digestion and its Derangements,"  by the author, p. 353, with the refer-
 0 ces to Dr. Jones' paper.) 
                   PAIN IN THE STOMACH.               529

diminished, the  patient rarely vomited his  meals, and was able
to eat largely.  His being able to take a large quantity of nutri-
ment much prolonged his life, and his illness on the whole was
not one of much distress.  So you see that the treatment of even
necessarily fatal cases is capable of adding  much to the comfort
of our fellow-men,  and is well worth the thought and attention
of a serious mind.
   It may be observed, that where distention with soreness is de-
pendent on local inflammation of the stomach, the pain is constant,
at no time entirely  absent, though  increased by the ingestion of
food.  You may see a well-marked  case followed out in " Case-
book"  xxxix, p. 424  (where  the complete  cure seems to  show
that there was no ulceration), and several others scattered through
the books and indexed as " haematemesis" (where the throwing
up of blood seemed to indicate that lesion), in all of which the
discomfort is described as never quite Avanting.
   The  excessive secretion  of mucus in  the stomach, whether
arising  from ulceration of the membrane, from chronic  inflam-
mation  of it or neighboring  parts, from adhesion of the  peri-
toneum restricting  the peristaltic  movements, from simple de-
generative thickening of the  secreting structure, from cancer,
from external pressure (as in the case of cobblers or tight-laced
women), is indicated  by the  sense  of distention  above named.
But the evil rarely  stops here.  The gastric juice that is poured
out cannot penetrate the  slimy layer that envelops, as in a bag,
the mass of aliment, which consequently ferments and produces
all the evils arising from chemical decomposition in the stomach.
And if the  solvent secretion could get  to them,  it  would be
neutralized by the alkali of the mucus,  and so rendered incapable
of dissolving albumen.  Hence heartburn and acidity arise, as
before explained ; and hence,  in some  constitutions, vomiting, in
others  a passage of  the  fermenting mass into the boAvels, and
diarrhoea.
   Mucus itself appears peculiarly incapable of being digested.
When children with  catarrhal coughs swallow their  bronchial
secretion, you may  often find it unaltered in the stools.  If you
try to  dissolve it  in  artificial gastric juice in the  laboratory, 
530
PAIN IN THE STOMACH.
small lumps undergo no change after several days.  Still more,
when the  extensive surface of the  stomach secretes a large ad-
herent mass  of a peculiarly  stringy and firm description,  it is
often passed in large quantities through the bowels, and induces
a suspicion that some  part of the latter organs  are the seat of
the evil.  And in  truth  the  diagnosis is  not easy.   The  best
guide to it is the observation  of the contents of these masses of
mucus—if you find enveloped in the glairy slime merely broAvn
granular matter,  hairs, threads, the  cellular tissue  and husks of
plants, bits of gristle or skin, bile,  or anything  developing the
natural smell of faeces, then  you may fairly  conclude  that the
mucus comes from the bowel; but  if there are bits of food un-
colored. by bile—if, instead  of smelling  like faeces, they are
putrid, or exhale an odor  like vomit, it is certain that some, and
probably the  greater part, of  the mischief  lies in the stomach.
Thus you see that the digestive function, in the cases we are now
considering, is  "painful"  and "imperfect,"  but by no  means
necessarily "slow;" indeed, in many cases, the  little digestion
that goes on is  performed  with too great quickness.
  The indications for treatment derived from a mucous condition
of stomach are as folloAvs: First, it must be remembered that it
is  not only the evidence  of disease  (like the flow from the  nose
in nasal catarrh, for example, Avhich does  no  injury after it has
once  flowed out), but  it  is also  the cause of  further evil, and
therefore it must be directly restrained by  astringents.
  Secondly, the place  of  the  patient's own gastric juice, which
cannot get at the food, must be supplied by artificial  solution of
their aliments,  and their decomposition must be prevented.
  Thirdly, alterative diet  and medicines, and local counter-irri-
tants must be used to relieve  the congested or  degenerated  state
of the organ at fault;  especially in  cases complicated with pain.
  Of astringents, I have found none act more directly  than
kino; and Avhere there is pain at  the cardiac extremity of the
stomach, heartburn, or pyrosis, the conjunction of opium  with
it, as in the pulvis kino  compositus of the pharmacopoeia, in-
creases its efficiency.   Larger doses of opium,  however, in quan-
tities sufficient to produce soporific effects, cause headache.  A 
                   PAIN IN THE STOMACH.               531

 good test of the extent to which it is desirable to give astringents
 may  be found in their  action  over  the  bowels.   While  doing
 good they cause  no constipation; and, in some  instances, even
 relieve that  symptom by removing the  general state of irrita-
 bility and  discomfort, and by checking the discharge of mucus;
 so that it may be made  k rule to continue them  only so long as
 they  do not constipate the bowels.
   Nitrate  of silver is a very powerful astringent.   But it is of
 no use  unless you prevent the  salt from being decomposed and
 converted  by the chloride of sodium of the mouth into the inert
 chloride of silver.  The best mode of securing it is to coA-er the
 pill thickly with  gelatine, so that it remains undissolved until it
 gets to the right  seat of action.
   The  sulphate of iron  is also a very valuable astringent, espe-
 cially in anaemic  cases.   I  have found it a good  plan to  com-
 mence Avith the nitrate of silver; and, when obliged to leave that
 off for  fear of turning the  complexion black, to commence the
 iron,  and continue that until complete re-establishment of health.
 Ferruginous   Avaters, especially those  containing  the  sulphate
 (such  as  the Moffat and Hartfell chalybeates),  or  any  others
 where the  metal  is made into sulphate by the addition  of  a few
 drops of sulphuric acid, will,  of course, be equally beneficial—
 indeed, often more so from  the addition of  change of air  and
 scene.
   Another form of iron which I have found very useful in gastric
 cases is "iron alum," but I cannot detect any difference in its
 action from the ordinary copperas above recommended.
   Gallic acid is  also useful, if  a variety of astringents is re-
 quired.  But, to  say the truth, I have  been unable to  detect
 any advantage Avhich one medicine of this sort has over another,
 and think the only use in having a long list is to  be able to ring
 the changes upon them, to prevent the patient wearying of uni-
 formity.
  The arrested solution of the aliments  may be partially com-
pensated for by  a diet  of  milk guarded from  coagulation by
lime-water, so as to postpone its digestion  to the intestines.  The
avoidance of  such articles as  are apt to form  a  solid mass will 
532
PAIN IN THE STOMACH.
do much;  and for this reason pastry, new bread, and hard meat,
or fish, must be strictly proscribed.  But the most complete sub-
stitute for the patient's own  natural  secretion is  pepsine  arti-
ficially prepared.   It enables  solid albuminous food to be taken
without distress, increases the appetite, and raises the strength.
In the milder  cases,  lactic acid, taken  before food,  is sufficient.
   The most  efficient agent in preventing  the decomposition of
albuminous food (evinced by  fetid evacuations, acidity, &c), is
sulphurous acid combined with  soda.   There  are  two forms of
this  salt,  the  sulphite and hyposulphite.   Of  these, the  former
contains most sulphurous acid, and certainly does the work re-
quired of it most readily.  But  then  it has the bad quality of
completely destroying the potency of gastric juice at  the same
time, so that while  you are preventing the chemical decomposi-
tion you are  also preventing  the vital digestion.   The hyposul-
phite has not  this pernicious  effect, and may also, from  its less
nauseous taste, be given in larger doses, so that by  its means you
are able to do the good without the harm.*
   By "alterative " diet I mean a restricted supply of nutriment,
so that the destruction of effete tissues should somewhat exceed
the supply.  This for  a short period  seems beneficial in  cases
Avhere there is an organic change in  the tissue of the stomach
itself.  But  the treatment must not be carried too far:  a  week
is, perhaps, the extreme period to which the starving  system
should be carried; if it  does  not do the good expected  in that
time, it never will.
   The  same  cases  are  benefited by  counter-irritants, such as
leeching, blistering, and long-continued  water-dressings to the
epigastrium.  The advantages of the first  are, that their appli-
cation is  soonest over, and gives relief most rapidly, while at the
same time it does not prevent  the use soon  after of the  other
local remedies.   The fear that this little loss of blood will lower
the patient is theoretical; for the increased power of digestion
adds twice as much  blood and flesh as the leeches can suck away.
In "Case-book"  No. li, page 223, you  will find  the case of a
   *  See " Experiments  on Artificial Digestion," by Dr. Chambers,  in " The
Lancet" of the 23d of May, 1857. 
PAIN IN THE STOMACH.
533
patient of mine  who  was leeched on the epigastrium for some
time every other night, yet gained tAventy-one pounds in weight
during her six weeks' stay in the hospital, so great was the relief
afforded in her form of indigestion.  The advantage of the  wet
compresses as a counter-irritant is, that they  do least harm,
though at the same time it must be confessed that they do least
good, and are scarcely adapted for  severe cases.   However, in
the milder, especially where the person is not so ill as to be kept
from ordinary business, this method of accomplishing your object
is very convenient.
  The use of mercury is beneficial just in about  the same degree
as the alterative diet above mentioned: immediately it has begun
to have any good effect it must be  left off, or it will begin to do
harm.   It is  excellent  as an inaugurator or introducer of good,
but it does not carry it on without the evil results showing them-
selves.  The  utmost care must be taken that it does not specific-
ally affect the system, or purge.  As a universal  rule, purgatives,
and especially mercurial purgatives, do  harm.
   "Oppression" is  often complained of at the same time with
the weight, tightness, or distention  at the epigastrium.  But it
means something more, and is by no means identical.  Indeed, in
those worst cases of mucus on the stomach, which relieve them-
selves by vomiting or by rapidly passing on with the  alimentary
mass, there is no oppression at all.  On the other hand, there
are frequent instances of much discomfort AA'here the patients do
not at all assent to the description of a weight  at the pit of the
stomach.   That is a purely local feeling, referred, in a former
part of this  lecture,  to the local nerves; whereas this  indicates
a general feeling  of morbid  lassitude  and physical incapacity
throughout the whole body. There is a confusion of ideas, some-
times an  unnatural sleep, sometimes faintness, irregular nervous
action, such as flushings of the face, palpitation of the heart,
fidgets, twitchings, or cramp.
   As I said before, these are often the accompaniments of gastric
mucous flux, but at the same time they often  exist  without it;
and, indeed, almost anybody may bring them on by getting  very
tired and then eating largely.   If  vomiting occurs, you see no 
534
PAIN IN THE STOMACH.
mucus in the egesta, but simply the food last taken unaltered in
quality or appearance.  Digestion is more than sIoav, it has com-
pletely stopped.
  Oppression shows an exhausted condition of the muscular and
nervous system of the stomach.   The peristaltic  motion is null
from want of power. The causes usually are those which exhaust
the nervous energies without stimulating the powers of life, such
as prolonged and severe  intellectual labor, annoyance 6f mind,
and overstrained attention.   Temporarily, and  in persons previ-
ously disposed,  mere corporeal exertion may  bring it on; but
this form of depression usually works its OAvn cure, and does not
become a chronic habit; for the excessive bodily toil either causes
a reactive stage of  increased nutrition,  or so much exhausts the
voluntary muscular system that it cannot be continued.
  This vieAV of the pathology  of the disorder obviously suggests
the appropriate  treatment, which is, to  tone and invigorate the
involuntary muscles of the stomach.  I have found  no remedy
do this so invariably as strychnine.   Should anaemia be present,
iron—if heartburn, acidity, or waterbrash be joined, then bismuth
can be added; but where  the  symptom named exists  alone, or
predominates above the  others, still more, if bark,  iron, or other
tonics in any way disagree, nothing  affords such satisfactory re-
sults as the alkaloid principle of nux vomica above named.
  Wearing  or  boring  pain  commences gradually soon  after
food; it  is  confined to the epigastrium, or extends itself over
the abdomen, and does not run up the oesophagus like heartburn.
It sometimes is relieved by vomiting, and if not,  continues with
more or less intensity till the stomach  empties  itself through
the pylorus.  The pain is increased by  pressure,  very  often not
immediately, but in the course  of a minute or  two,  as if the
sluggish sensation of  the part took  some time to  appreciate the
injury.
  Boring pain is nearly always sufficient to rouse  a suspicion of
ulceration;  even cancer does not cause it, so long as the  mucous
membrane  be whole.  The suspicion is  strengthened  if weight
and tightness of epigastrium be present to indicate the excessive
secretion of mucus which usually accompanies chronic ulcer; and 
PAIN IN THE STOMACH.
535
the diagnosis is further confirmed by the occurrence of bloody
vomiting.
  It can seldom be removed by internal remedies.   Those which
do  it most good  are bismuth, opium,  and  kino; but  counter-
irritants to the external surface of its seat, leeches, blisters, con-
tinuous poultices,  mercurial and opiate inunctions, are of much
more marked benefit.
  It is  in  these cases especially that the failing organ  requires
to be spared Avork.   The best dietetic  substance is milk made
alkaline Avith lime  or soda-water, given  in  small quantities as
frequently as possible. Next to that, a mouthful of mutton-chop
at a time, with a dose of pepsine to digest it. Meals are painful,
your patient tells you, so advise  none  to be taken, but a con-
tinuous sparing supply of  such food  as may pass  through the
stomach Avithout  distending it, and be digested by the small
trickling of peptic juice which there is in the stomach and bowTels.
The chief object of the lime-water is to prevent  the milk forming
a large curd, but it  also may be a  sedative  to  the  raw surface,
just as it is to a blistered or burnt skin.
   Cramp or spasmodic pain in the epigastrium appears to arise
from the pyloric sphincter.   It is often accompanied by cramps
in the  neighboring and remote muscles, thus affording an indi-
cation  of the tissue in which its seat is to be looked for. It occurs
chiefly in  old persons, during  the latter period of the stay of the
food in the stomach, and does not  show any organic disorder of
the part.  A moderate dose of an anaesthetic stimulant is the best
mode of relief: the  domestic  remedy" of a thimbleful of brandy
with two drops of laudanum is about the most  efficient that can
be administered. 
LECTURE   XLIV.
         ERUCTATION  AND  VOMITING.

Anatomy and physiology of Eructation—Relaxation of oesopha-
     gus—Spasm—Analyses of gases by chemists—Deductions
     therefrom—Secretion of air by mucous membrane {?)—De-
    fective absorption—Decomposition of food — Fermentation
    prevented  by aciditu—Classification of  morbid states  in
     which eructation  occurs—Indications of treatment in the
     several classes—Antacids — Astringents— Valerian— Am-
     monia— Sulphurous  acid—Charcoal—Vomiting—Causes
     of—Indications afforded by  the contents  of  the  vomit—
     Remedies for—Hydrocyanic acid—Carbonate  of magnesia
     — Opium—Chloroform—Leeches—Lime-water  and milk—
     Brandy—Creasote— Valerianate of zinc—Ice—Possibility
     of starvation from vomiting of a purely functional charac-
     ter—Sea-sickness  and its remedies.

      (Extra course, St. Mary's, Summer Session, 1857.)

  Eructation is the passage upward through the oesophagus of
air  contained in  the stomach.   It  must be remarked that the
gaseous contents of the hollow viscera are differently circum-
stanced from  the liquids and solids ; their great expansibility by
heat, and their Ioav specific gravity, give them an inherent force
which  enables them to find  their way out without any aid  from
the  muscular system.   There is no fluid so light but it requires
the  action of the expiratory muscles to expel it from  the stomach,
whereas no gas  is so heavy but that, when Avarmed by the body,
it will  not rise  through the  oesophagus directly that tube is re-
laxed. 
ERUCTATION AND VOMITING.
537
  The first condition of eructation is the relaxed and open state
of the cardiac end of the gullet.  The air, instead of being re-
tained by the  natural  contraction  of this powerful  sphincter,
finds its way upAvard in greater or smaller quantity.   The pas-
sage of the  bubble toward the mouth almost always, except in
completely paralytic patients, causes a reaction, and by the time
it gets to the fauces it is  compressed  by the stimulated muscles,
and expelled Avith considerable force.  Hence the noise is greater
than is caused  by the mere bubbling of air up the gullet, such as
you produce in moving a dead body.  There is a compound of re-
laxation and reactionary spasm, the former taking the initiative.
  The analyses of the gas contained in the stomach, by Chevreul
and Chevillot,  show that more than four-fifths of it is atmospheric
air and the  rest  carbonic  acid in much less proportion than in
the breath which is passing out of the mouth by expiration.* So
that Ave have clearly not to seek far for a  source of the air; it  is
evidently swallowed with the food and saliva in the  great  ma-
jority of cases. Some persons also have a trick of half-consciously
swallowing air, like crib-biting horses, especially when suffering
from some uneasiness  in the digestive organs ; and in the par-
oxysms of sobbing, of hysteria, and of epilepsy, large quantities
are gulped  down.   And it is not impossible that gas  might be
secreted by  the  mucous  membrane, though I am not aware of
any case that proves the  occurrence.
   Another morbid condition that helps to  produce the flatulent
collection of gases is defective absorption.   In health  gases are
very  easily  absorbed by the alimentary canal.  It is the normal
thing for the abdomen to be dilated during digestion with several
pints of air,  Avhich disappear in a short time without passing up-
ward or doAvnward.  To be convinced of this fact is exceedingly
easy, by observing the extent to which the parietes of the belly
are distended and the descent of the diaphragm is impeded, so
as  to shorten the breath, after even  a light meal of  only a few
cubic inches of victuals.   In an hour or so the distention has all

  * See a comparison of the different gases of the alimentary canal as analyzed
by Chevreul, Alarchand, and Chevillot, in the  author's work on "Digestion and
its Derangements,'' book i, chap ix.
       35 
538
ERUCTATION  AND VOMITING.
gone, without making any sign of sudden departure, in a healthy
person. But in an invalid body absorption is not so active.  The
gas normal to digestion is not taken up, and remains to disturb
the patient  by its continued presence.   Should the oesophagus
be in its natural state—that is to say, equally contracted through-
out—the aerial contents of the stomach may be passed on through
the pylorus, to produce, perhaps,  the state of flatulence,  which
will be considered in a future  lecture.   Should that tube  be re-
laxed,  then  they break upward in eructations.
   So far, the bulk of  air swallowed has been  supposed to be in-
creased only by heat and  expansion.   But in some  cases  it is
further augmented  by gases disengaged from  the decomposing
organic matters of the food.   The occasional occurrence of the
alcoholic fermentation in the digestive canal is proved by instances
of vomiting, in which the matters ejected are seen actively under-
going this chemical change.  They are frothy and tumid, continu-
ally  swelling up and throwing off bubbles of carbonic  acid, like
yeasty beer.  You  have lately seen  a man in Cambridge Ward
in whom this condition of the  ejecta was very conspicuous.  Half
a pint  of vomit, left to stand, soon frothed up and ran  over the
edge of a vessel  holding two  quarts.   You  can easily imagine
what a disturbance  in the stomach all  this  frothing and boiling
must make, and are not surprised  at the rejection  of such a tur-
bulent guest.
   Fortunately the spread of alcoholic fermentation through the
saccharine contents of the  stomach is  a rare occurrence.  Its
features are so marked, and the discomfort it causes is  so  great,
that we should hear a great deal more about it were it common.
The fact is, that even where it begins and gives rise to the dis-
engagement perhaps of some carbonic acid, it is rapidly stopped
by the conversion of  the sugar into  lactic  acid, Avhich is more
congenial to the temperature of the body.  So that the " acidity,"
which  in a former lecture has  been  spoken about as an evil, is
the guardian against a still more serious evil.
   It will  be easily seen, from what  has gone before,  that the
morbid states of which eructation is a phenomenon,  naturally
arrange themselves into three groups: (1) where there is simply
a relaxed oesophagus; (2) where there is an increased  quantity 
ERUCTATION AND VOMITING.
539
of atmospheric air SAvallowed;  and (3) where foreign gases  are
formed from chemical decomposition.
  In  the first may be included many cases of heartburn.   The
quantity of air  brought up is small, but it seems to relieve  the
discomfort, probably by its stimulating the painful organ to con-
tract—just as moving a cramped limb cures the spasm.   It may
be observed that these cases are made much worse by motion.  I
have  been told by several patients that  if they kept quiet after
a meal they experienced  scarce any inconvenience, Avhile exer-
cise at such a time invariably brought on eructations, hiccough,
and heartburn.   Sometimes the eructations are the most promi-
nent  symptom, and the heartburn  is very slight.
   Under the same category may be classed cerebral diseases of
a paralytic kind, where the partial loss of power in the oesophagus
frequently causes eructation.
   In  these instances the eructations usually occur very soon after
meals, and have  very little explosive character.
   In  the  second  group   come hysteria, epilepsy, and chorea.
Watch a patient in  an  hysterical or epileptic fit, and you will
see great  gulps  of air bolted  down.   In chorea, too,  you may
often detect by  the  eye  or touch  the involuntary spasm of the
gullet, which gulps  and  swallows whether rtny solid matter is
present  or not.   There is often,  too, at other times, especially
in hysteria, a spasm of  the oesophagus, well known as  globus
hystericus.  And  less marked manifestations of the same phe-
nomenon,  uncomplained  of by the  patient,  or  called  simply
" heartburn,"  occur  constantly  during  the   day,  and fill  the
stomach with air.
   The excessive swalloAving of air  is often associated with a large
or dilated stomach,* but I cannot satisfy myself whether it is

  * In 13 cases of dilated stomach which I have noticed—
       3 had gastric cancer (Si. George's post-mortem  book).
       2 had chronic ulcer,            ditto.
       2 had dropsy and diseased liver,   ditto.
       1 had ulcerated oesophagus and  distorted ribs (St. Mary's post-mortem
           book).
       1 has a pendulous tumor attached to the pylorus (alive).
       ? have very fat omenta dragging  down the stomach (alive).
       3 have albuminuria (alive). 
540
ERUCTATION AND VOMITING.
cause or effect; I am inclined to think the latter, for the follow-
ing reason:  you  find these  dilated stomachs principally as the
result of some mechanical pressure or drag on the organ from
without, and therefore I do not  know whether  repletion from
Avithin alone would cause a permanent increase of area,  more
especially repletion with a substance so easily got rid of as air;
while at the same time it is easy to imagine that  a  large, heavy
empty stomach, dragging upon the cardia, should give rise to an
instinctive gulping.
  In  this  class of cases the explosions of air occur  at various
times, but most markedly and most inconveniently immediately
on swallowing food or drink.  The air thrown up has little or no
taste or smell.
  In  the  third group, where the  gas  is really generated in the
alimentary canal, the eructations occur much later after eating—
sometimes not till the  time  Avhen, normally, the stomach ought
to be  empty; and if they do  come  close upon the meal, they con-
tinue  much longer, and do not give the apparent relief which is
experienced in the other cases.
  The gases thus eructated are  nauseous and fetid, sometimes
with the odor of sulphuretted hydrogen.
  In  these  cases  there is  almost always mucous flux of the
stomach,  sometimes  from anatomical  changes in some part  of
the organ, sometimes  without.    The rationale  appears to be,
that organic matters in a state of decomposition remain adherent
in the mucus, and act as ferments to the newly received food.
Perhaps, too, the mucus itself may decompose.   You know how
quickly that takes place in urine, and how soon its decomposition
is communicated  to the rest of the fluid  in or out of the body;
and the same is likely enough to happen in the alimentary canal.
The ^decomposition of the  mucus  is confirmed by the frequency
with which  different sorts of low  organic growths (moulds) are
found in it.   The cryptogam sarcina ventriculi is the most dis-
tinctly marked of these, and, though detected occasionally else-
where, certainly finds its most  congenial home in the stomach.
In other places  it has been found a floating wanderer in fluids,
but in the mucous membrane of the stomach it may be  seen fixed 
ERUCTATION  AND VOMITING.
541
and growing in the mucus.  It is not often that an opportunity
occurs of proving  to the eye that such is the habitat of the sar-
cina—Ave frequently  find it vomited, but the patients seldom die
during their  illness, the complaint not being a fatal one.   One
such rare opportunity offered itself tAvo  years ago, in a girl of
thirteen, Avho died in this hospital of enlarged heart.   She had
frequent attacks of mucous vomiting Avithout sarcinae a few weeks
before death, and at  the autopsy Ave found the seemingly healthy
great curvature of the  stomach thickly clothed with a stringy
mucus, very difficult to detach, in the outer layer of which a great
quantity of sarcinae  were  imbedded.
  Being fixed thus in a permanent home, as shown by the above-
quoted rare case, and rapidly replacing with  new growths those
which are wiped away by  the food, the sarcinae is, unfortunately,
by no means idle.  A great number, perhaps  all, of those crypto-
gamous plants whose nature is to grow upon decomposing organic
matter, have  the property of promoting decomposition, so that
they are not only the consequences, but the causes also of decay.
It is  found that the gutta-percha covering to electric-telegraph
wires, when laid down  near  the roots of oaks, becomes rapidly
rotten from the presence of a fungus peculiar to that tree.  Put
jam in a new cupboard, and it will keep much longer than in an
old one where mould has  previously grown.   Economical house-
Avives have sometimes what they call a "vinegar-plant;" it is, as
I show you here, a fungoid vegetable  found in vinegar casks.  If
placed in sugar and  water, it makes the whole undergo the ace-
tous fermentation in two or three weeks, instead of the process
occupying  several months. The mould found in yeast, the torula
cerevisi;e,  though not  essential to alcoholic fermentation, cer-
tainly augments the rapidity of its induction; so that it is entirely
in accordance A\dth known physical laAvs if the presence of sarcinae,
or of the yeast-plant, on the  mucus of the stomach should bring
on fermentation  in  the food before  the obstructed absorbents
have  time to  take it  up.  Both  have  been found in the contents
of the stomach ejected; and  it is shown by the case  I quoted,
that sarcinse  at least may exist adherent to the mucus without
bein<r throAvn up.  Probably  very often these plants are unseen 
542
ERUCTATION  AND VOMITING.
promoters of the rapid fermentation  which takes place so mys-
teriously in the stomach of invalids.
   Besides producing eructation, the fermenting of organic mat-
ters in the stomach is almost always followed by vomiting; while,
if it takes place in the bowels, the consequence is diarrhoea; two
phenomena which will be considered shortly in their own place.
   The indications of treatment afforded by eructation are differ-
ent in the three groups of cases in which it occurs.   In the first,
antacids are often sufficient for temporary relief.  Four  grains
of rhubarb pill, with a grain of gallic acid, taken before dinner,
will be  found still  more useful, for the tone  thus  given  to the
mucous membrane prevents the recurrence of the inconvenience.
In more severe cases I have found a rhubarb draught with gallic
acid,  taken three times a day, a very efficient remedy.
   In  the second group, where excess of air is swallowed, valerian
and ammonia  are very  beneficial.  Where there is nausea or
vomiting, the valerianate of zinc may take their place;  but it is
not so certain  as the  infusion or tincture of the herb.   Where
this fails, use strychnine, which you have seen in the wTards to be
the most powerful agent we have to steady such  irregular nerv-
ous action as hysteria, chorea, &c.
   In  the  third group, the great object  must be to prevent de-
composition.    In the  laboratory you find that no  agent is so
powerful in this respect as  sulphurous acid; and,  accordingly, it
is  much used in various processes of the arts for  the purpose.
Sulphur is often burnt in casks to arrest the fermentation which
is apt to be going on  in the liquids soaked up by the cracks or
porous parts of the wood, and the sulphurous  acid vapors effect-
ually  do their duty.   The Board of Health finds no disinfectant
for fetid sewers so instantaneous in its  action as Macdougal's,
the chief ingredient in which is sulphite of lime.   Meat may be
preserved on  the same  principle, and  keeps as  well as  when
salted or dried;  and you  may  test even  on such a  delicate
substance as yelk of egg how fresh it keeps Avith any sulphite salt.
The same  effect  is produced by taking as  a medicine hyposul-
phite  of soda ; the fermentation of the contents  of the stomach
is  arrested, and the evil effects of  that fermentation prevented. 
ERUCTATION AND VOMITING.
543
  Another powerful arrester of chemical changes is charcoal.
When soup has begun to turn sour in hot Aveather, clever cooks
boil it again with a little bag of charcoal in  it, and  it becomes
quite sweet.  The same agent will prevent decomposition in the
alimentary canal.  I  have used it,  I  must say,  only in cases
where decomposition occurs in the intestines, producing flatu-
lence ;  but I should not hesitate  to employ it  in gastric fer-
mentation also, if hyposulphite of soda chanced to disagree or
was not beneficial.
  Vomiting  seems  less  than any of the phenomena previously
discussed dependent upon the peculiar condition of the stomach,
and more upon the idiosyncrasy of  the individual.   There are
those who, whatever may be the matter with them, never vomit;
while others  do so on  the  slightest occasion.   Even pleasant
associations will, in some people, bring on this most  unpleasant
consequence:  a patient of mine, a healthy young lady, is fre-
quently seized with retching on entering a ball-room where she
expects an agreeable evening; while  it never happens in going
to a stupid party.   On the other hand, I have had patients  with
cancer of the stomach, and others with various sorts of severe
dyspepsia, who could take the most nauseating  drugs without
inconvenience.    The mere  fact of vomiting, therefore, affords
in itself no clew to the local condition of the  stomach.   But the
time of its occurrence, the circumstances which increase it, and
the nature of the matters thrown up, may be most suggestive to
the practitioner.
   Vomiting which occurs when the stomach is empty, or which,
thouo-h it occurs at  other times, is most frequent and distressing
then, may be  safely set  down as arising  not from any fault of
the viscus itself.   Such is the morning vomiting frequent  in
pregnant women, in cases of diseased heart, of abdominal tumor,
and sometimes of pulmonary consumption.  This is  no doubt  a
reflex action  of the vagus nerve excited  by the irregular irrita-
tion of  some of its branches; and on the same principle I can
easily understand the more rare cases where vomiting has  been
caused  by foreign bodies in the ear or nose, by tumors in the
neck, ccc.
t 
544
ERUCTATION AND VOMITING.
   When vomiting occurs with a replenished stomach, it may be
 considered as a general rule that the smaller the quantity of food
 that produces it, and the sooner it takes place after eating, the
 nearer  to  the mouth is the  seat  of  injury.    Disease of the
 oesophagus causes rejection of the food before it  has got down;
 of the cardia, or smaller curvature, very soon  after it  has got
 down; and disease of the pylorus, or pancreas, or liver,  after an
 interval sometimes of as much as several  hours.
   When vomiting arises from congestion  of  the brain,  as in
 apoplexy, drowning, concussion, or in dead drunkenness, it is
 increased by the horizontal posture; when it arises from  deficient
 supply of blood,  as  in fainting, anaemia, and sea-sickness, that
 position relieves it.
   The  contents of  the vomit, which can afford  practical sug-
 gestions to the practitioner, are the following:
   Mucus, if it is in  large stringy masses, shows a generally dif-
 fused morbid condition of the stomach itself; if it is  in small
 round lumps, it has most probably been secreted from the bronchi
 and swallowed.
   Blood, when it comes  from an open vessel  perforated  by an
 ulcer, always is  in  considerable quantities,  and contains black
 clots  ; if  it  is mixed up with mucus, brown  and shreddy, it
 denotes a  high state of congestion of  the gastric walls, with
 rupture of some small capillaries, or  what is commonly called
 " exudation."
   Saliva, readily distinguished by its alkalinity, and the abund-
 ance  of buccal  epithelium   contained  in it;  when  in  large
 quantities, it denotes an  irritable state of oesophagus and fauces;
 when it constitues   the bulk  of the vomit of  pregnant women,
 you will often find  associated with it a sort of salivation in the
 mouth.
   Faeces or faeculent smell.  This  is usually referred to a reversal
 of the peristaltic motion ; but I do not think  it necessary to
resort to  such a strained explanation.  When  we reflect that
about twelve quarts of secretion  are  daily poured into the in-
testines, it is easy to see that you have only to stop the onward
peristaltic wave and absorption, for the ilia to  get overfilled, 
ERUCTATION AND VOMITING.
545
 and for their  contents  to  overflow upward into the stomach.
 There  they  naturally produce vomiting,  just  as they would if
 swallowed.   Such a paralysis of muscles and absorbents takes
 place in peritonitis, as well as in mechanical obstruction of the
 ilia, and consequently in  peritonitis  you have sometimes faeculent
 vomiting.
   Fermenting matters in the vomit show the continuous  reten-
 tion in  the stomach of some remains of the food  or of vegetable
 growths in a constant state of chemical change.   There is there-
 fore present  a quantity of adherent mucus  capable of retaining
 them there.
    Acid matters  in excessive  amount  may arise from  a  similar
 state of things;  but it seems as if  simple torpidity of stomach,
 without the necessary presence of mucus, can occasion  it.
   Pure unchanged food  shoAvs that the vomiting arises from the
 state of the nervous system, which is either locally irritable, from
 neighboring  anatomical  changes;  or  secondarily, as in preg-
 nancy ; or generally, as in hysteria.
   The remedial measures which I have found most useful in cases
 of vomiting are the following :
   Hydrocyanic acid, where it arises not from any fault of the
 stomach itself, but from  the secondary condition  of the nervous
 system, as in pregnancy, diseased heart, and  abdominal tumor,
 in pulmonary consumption,  in peritonitis.
   Carbonate of magnesia, in the vomiting accompanying gastric
 flux, with copious formation of acid.
   Opium, in acute vomiting from gastric  ulcer, from malignant
 tumor, in faecal vomiting from perforation,  peritonitis, internal
 hernia—in short, wherever the vomiting is accompanied by much
 local pain.
   Chloroform, in  the vomiting at the  commencement of  fevers.
 It maybe applied either on a cloth to the epigastrium, especially
in choleraic vomiting, or  taken by the  mouth.
  Leeches.—Very often  the vomiting  in cases of gastric ulcer
 will not be appeased till  some leeches  have  been  applied to the
epigastrium.
  Milk and lime-water, as a sole diet, will  often  alone  stop 
546
ERUCTATION AND VOMITING.
chronic vomiting.  Complete rest and absence from excitement
must accompany its use.
  Brandy, in  teaspoonful doses, is a favorite domestic remedy.
It is suitable  in acute cases for the nonce, and will  often stop
nervous vomiting  from mental causes,  but is obviously not
adapted for chronic disease.
   Creasote.—This is an uncertain remedy, and I confess I cannot
at all satisfy myself what  cases it  is suited to.  The vomiting
certainly seems  checked by it sometimes, sometimes is aggra-
vated, more commonly is uninfluenced.   The cases where it has
done good  have  appeared to me generally dependent on nervous
causes.    For example,  it has  been beneficial in  hysterical
vomiting.
   Valerianate of  zinc I tried  once  in hysterical vomiting with
good effect.  But  in these  patients the most powerful remedy is
the shower-bath.
   Ice is often most useful  in acute vomiting  in fevers, in chronic
cases of gastric  ulcer, and  in all cases is  an  agreeable remedy in
warm weather.
   The administration  of food in  cases of chronic vomiting is a
matter of much  importance.   You must not let your  patient be
 starved.   Even when  milk and lime-water  does not check  the
 vomiting,  it is by  far the best diet.  In  teaspoonfuls at a time,
 it can almost always be kept down.
   The risk of being starved  to  death from vomiting is not  an
 hypothetical fear.  A young woman came under my care at this
 hospital a few months ago who had been deserted by her  lover.
 She had violent hysteria, and an utter inability to keep anything
 on her stomach for some  days; the pulse Avas  failing, and  the
 tongue getting dry and brown.   An attempt was made to retain
 life by means of  nutritive enemata, but in vain.  At the post-
 mortem examination  every organ  was in a completely normal
 state, and the catamenia were still flowing from the uterus.  She
 had died of starvation only.
    When sea-sickness goes to the extent of  making a person se-
 riously ill, it is worth while to stop it or prevent it,  as you  can
 often do by a large dose of opium.  But  it is very far from being 
                ERUCTATION AND VOMITING.             547

worth  Avhile  for healthy persons, or even  invalids, in ordinary
cases, to take this preventive ;  for a small dose is useless, and the
requisite large one makes the patient endure much more dis-
comfort afterward than the sickness  during  the voyage Avould
have caused.   Chloroform does not arrest the nausea, but it cer-
tainly  does seem to control the violence of the straining.  Effer-
vescing stimulants are the most  effective palliatives for healthy
persons.  In some rough rolling Aveather off the coast of Portugal
I once tried  on  myself and several companions champagne and
highly deviled biscuits with complete success. But the  panacea
is not  always accessible; the  best imitation of it generally  at
hand is frothy bottled  porter: if it does not in  every case  pre-
vent the vomiting, yet the prostration afterward is avoided, and
the ejecta are not so disagreeable as when they consist  only  of
bile and acid mucus.  Warmth is also very  important: landsmen
will often expose themselves as much  as possible to the  breeze,
thinking that the freshening air will revive them and keep them
well.   This is a great  mistake ; they should clothe themselves  as
warm as possible, put a flannel band or faja round the Avaist and
abdomen,  and above all things, keep  dry  and quiet, and when
they feel miserable,  go and  sit with their backs to the funnel. 
LECTURE  XLV.
                      DIARRHCEA.

Pathology  of diarrhoea—Difference of it from mere frequency
     of evacuation—Division of diarrhoeas—Bilious— Watery—
     Muco-purulent—Bloody—Putrid—Their causes and indi-
     cations—Supplementary and reflex diarrhoea—Infantile—
     In fever— Ulceration of  bowels — Mucous flux—Copious
     solid matter—Acid diarrhoea—Use  of  opium—Riding—
     Cautions about traveling—Flatus  in ilia—Charcoal, fyc.

     (Extra course, St.  Mary's, Summer Session, 1857.)

  When the absorbing power of the intestines is defective, the
consequence is an  excess in the quantity of matters which pass
through them ; that Avhich ought to be  taken up is carried along
with the normal draught, and so constitutes a true diarrhoea.
  It is of great practical importance to distinguish this  from the
mere frequency of evacuation, which is quite consistent with a
natural or even deficient amount of faeces.   The number of mo-
tions, or the  number of times an inclination is felt to  void them,
is often increased when less  than the  average quantity may be
passed in the twenty-four hours.  This is of the nature  of tenes-
mus, and arises from an abnormal state, sometimes  ulceration,
sometimes  piles,  sometimes  cancer of even  colon or  rectum;
Avhereas  true diarrhoea as aforesaid,  depends upon  defective
function of the ilia.
  The arrest of function, as declared by the prevailing contents
of the stools, constitutes the  best  principle  of  division; and
according to it we may speak, without being  misunderstood, of
crapulous, bilious, serous, dysenteric diarrhoea, and cholera. 
DIARRHCEA.                     549
  Crapulous diarrhoea  is simply an  excessive quantity of food
taken, or arrested  in its normal solution by suspension  of  the
gastric function.  It is called crapulous, because it is most usual
after a debauch ;  but in Aveakly persons it is not necessary that
the intemperance should  be absolute;  that which is moderation
for  others may be an excess in them.   An  examination of the
faeces exhibits a quantity of undigested  food as the prominent
feature,  sometimes acid, sometimes  fetid and fermenting,  and
rarely Avith  enough bile mixed with it to  prevent decomposition.
  Bilious diarrhoea is  the next simplest form  of the  disorder.
Bile,  normally poured out by the liver to the extent of from three
to four pints a day, if not concentrated by the intestinal absorp-
tion,  adds very largely  to  the  quantity of excrement, where its
presence is  declared by  its well-known  smell, and  by a color
exhibiting  various shades  of yellow,  brown, and  olive-green,
according to its absorption of oxygen and mixture Avith faeces.
   This arrest of the absorbing powers  of the intestines and  con-
sequent rejection of bile mixed at first with faeces, and when the
bowels  are  emptied  augmented by the exudation of  water  from
their parietes, is what so often takes place temporarily from the
impression  of cold, from  irritation  of the alimentary canal by
unwholesome food and  from mental emotion.   It is possible also
that the qualities of the bile itself may be altered in some cases,
or  its quantity increased.   It  may be  changed by medicines, as
by calomel  or by senna, and so rendered incapable of absorption,
 and  be poured  through the ilia without their being  in fault.
 Congestion of the portal system, such as is  especially frequent
in  Europeans resident in warm climates, causes the bile to be at
 one time deficient,  and  afterward  to be poured out in excess.
 Irritation of the stomach  and duodenum causes it to be retained
 in  the  liver and gall-bladder till it is unfit for absorption.  In
 both these  cases it is rejected by  the  bowels, and constitutes
 bilious diarrhoea.
    You must be very careful to distinguish this  symptoms from a
 different one, often confounded with it—viz., the presence of a
 bright crass-green matter in the stools.   This  is not bile at all,
 but in reality altered blood, and denotes congestive inflammation 
550                     DIARRHCEA.
of the mucous membrane, a state requiring very opposite treat-
ment  from that proper for  bilious diarrhoea.  Your best aids to
diagnosis  are first, the smell: in real bilious stools the  odor of
the hepatic secretion can always be perceived, in spite of the
faeces mixed with it; and at the same  time it  always  prevents
putrescence, or even counteracts the incipient putrescence of the
undigested aliments; while in the grass-green stools the smell is
not of bile, but  more or less  cadaverous or putrid.  Secondly,
the microscope exhibits in the mucus, Avhich always is present in
congestive inflammation, the usual globules of pus mixed with
small shreds of fibrin and blood-globules.
  In  serous or watery diarrhoea it is probable  that there is an
increased  exhalation of aqueous fluid from the blood-vessels of
the intestines, as well as an  arrest of its  absorption.    In  this
form, when pure, if the faeces are retained by a voluntary effort,
they may  be concentrated nearly to their normal  condition by
the removal of  the water, and  thus  a  test afforded that their
state  depends mainly  on the addition  of this  constituent; for
that which can be so readily taken up again into the blood can-
not be of  a nature very foreign to it.   Thus, for instance, if you
take a saline purgative, you may feel several pints of fluid rolling
about in the bowels ; but if you resist the inclination to stool, it
goes off at  last, and  you void  afterward little more than  the
ordinary amount of  semi-solid faeces.   It is not so in bilious or
inflammatory diarrhoeas.
  Watery diarrhoea, when not arising from the antiosmotic action
of neutral salts,  indicates a congested state  of the venous plexus
of the alimentary canal, and a consequent  morbid proneness to
exhalation and  deficiency in absorption.  The vitality of the
mucous membrane is deficient;  and if  it is not restored, local
death, exhibited in  the form of ulcers and  sloughs, must be the
result.
  The exhalation, however, tends to become  habitual,  and so
continues  beyond the  period of congestion, so that the whole
mass  of blood is relieved of its water, and in this way sometimes
dropsical  sAvellings may be  reabsorbed  and  pass off through the
bowels. 
DIARRHCEA.
551
  In dysenteric or muco-purulent diarrhoea, water is in excess,
but the  characteristic is  the presence of mucus  or  pus mixed
with it;  in which also there  are, in cases seen early, shreds  of
fibrin,  blood-globules,  and flakes of  the peculiar epithelium of
the bowels.
  Should any of these products of inflammation be alone, sepa-
rate and unmixed with faeces, then it is probable they come from
the  colon or  rectum ; but if they are  mixed up with  a large
quantity of watery fluid, and still more, if that watery fluid shows
itself to  be the serum of the blood by coagulating with heat, then
there is  little  doubt of their  source being the mucous membrane
of  the  ilia, whose morbid condition  it consequently indicates.
The fluid in muco-purulent  diarrhoea is always highly alkaline,
and if it is examined with the microscope, crystals of ammonia-
magnesian phosphate are found scattered through it. If allowed
to  stand, it separates into  two  distinct parts: the  one serous,
varying in color  from complete whiteness and transparency
through all the shades of yellow  to deep brown,  or where blood
is present, to red and black, in which are the flakes  of fibrin,
 the ammoniacal crystals, and floating globules;  the other sedi-
 mentary, consisting principally  of  gray, granular  matter,  the
 ddbris of food mixed with more or less of the coloring matter of
 the bile and half digested blood.
    The degree of serosity and the proportion of the products of
 inflammation in the first, show the extent to Avhich inflammation
 has gone in the mucous membrane;  whiteness, bloodiness, putri-
 dity, alkalinity, being bad signs ; yellowness, opacity, the smell
 of bile,  and the absence of putridity, being good.
    The second or sedimentary portion proA'es the condition of the
 general system rather than of the ilia in particular.   If it is
 copious in  proportion to the fluid, then the normal function of
 destructive assimilation is shown to be little interfered with; if
 it  is scanty,  then we know  this important process to be arrested,
 the effete morbid  tissues are not being removed  from  the body,
 and a more grave state of  affairs exists.   The quantity of solid
 sedimentary  matter is the best test  you can have of an advance
 toward health, or departure therefrom, in all cases  where there
 is this state  of bowels. 
552
DIARRHCEA.
  The most  common examples of muco-purulent diarrhoea are
found among acute diseases, in low fever, in cholera, enteritis,
and dysentery, especially in the teething dysentery of children.
Among chronic diseases, ulceration  of the  boAvels,  whether a
consequence of phthisis or Ioav fever,  is the most usual cause.
  Bloody diarrhoea, where the  blood  is in  small streaks  in the
mucus, or  slightly mixed with the  serum,  or  mixed with the
grass-green mucus above described, indicates a recent inflamma-
tory state.  When it  is in clots, either  black or fibrinous,  with
the globules partially washed away, it shows that a blood-vessel
of notable size has been opened  into, probably by ulceration.
Should pus be  mixed  with it, the diagnosis of ulceration  is  con-
firmed.   Black, semi-digested  blood, precipitated by standing
with the  sediment of fluid stools, comes from  high up  in the
ailmentary canal, as it indicates its exposure to the gastric juice.
It not unfrequently comes from the stomach  itself.
  Putridity of  the stools in diarrhoea always shows that there is
an imperfect quantity of bile in them, one of the most  clearly
ascertained functions  of  the hepatic  secretion being to prevent
the chemical decomposition of  albuminous  matters.   Putridity
may arise from two  sources—namely,  the  food taken,  or the
albuminous secretions into the  alimentary canal.  A close ex-
amination of  the stools will generally distinguish one from the
other.   If it is non-digested food Avhich is  decaying, then the
solid constituents of the faeces are bulky, pale, containing large
lumps of still paler substance visible to the naked eye.   And if
these are examined by the microscope, they will be found to
consist of muscular fiber, fat, and other parts of victuals, often
swarming with  live infusoria and vibriones.   This occurs  from
time to time in all cases of deranged digestion.  If the  fetor
arises from the decomposed albumen of the exhaled serum, it Avill
be observed  to be exhaled  from the more fluid part  of the
motions,  which are like  the Avashings of macerated flesh, while
the solid part  is  scanty and  comparatively unaffected.   This
shows a much more serious state of the vital powers, and in severe
complaints, such as low fever, is usually the  harbinger of death.
It is often joined to a peculiar  mouse-like smell in the sweat. 
DIARRHCEA.
553
  In choleraic diarrhoea the Avhole mass of the blood is poisoned,
and it is so altered in its physical qualities that very little of it
remains  capable of supporting life, or of absorbing  the where-
withal to support life either  in  the shape of food or medicine.
The functions of the liver and kidneys are suspended for Avant of
live blood, no bile appears in  the stools or vomit, no urine in the
bladder.
  For the purpose of understanding clearly  the degree in which
life is deficient in the different forms of  diarrhoea, we may con-
struct a table in which the first column is occupied by the several
functions, the loss of one or more of which  characterizes those
different forms.   It will be seen that  the sign  of minus  may be
placed against one after the other till the normal condition of all
is finally lost, as an essential,  not accidental, part of the disease.
36 
Full life.	Crapulous diarrhoea.	Bilious diarrhoea.	Serous diarrhoea.	Dysenteric diarrhoea.	Choleraic diarrhoea.
1. Blood healthily suffi-	1. Normal.	1. Normal.	1. Normal.	1. Normal.	1. —
cient for the support of					(Mass of blood
the whole system.					poisoned and half dead primarily af-
2. Coats of capillaries	2. Normal.	2. Normal.	2. Normal.	2. —	fects the whole
elastic and retentive of				(Coats of capilla-	system.)
the contained blood.				ries wanting in elas-ticity, becoming	
3. Exosmosis and en-	3. Normal.	3 Normal.	3. —	congested and rup-	
dosmosis of serumthrough			(Exosmosed se-	tured, let out the	
the mucous membranes			rum passed away by	blood. The other	
equal to one another.		•	stool, instead of be-ing reabsorbed.)	stages of inflamma-tion may or may not	
4. Bile made in full	4. Normal.	4. —		follow.)	
quantity; its fluids re-		(Constituents of			
absorbed by intestines,		bile not absorbed,			
and its colored solids only		but passed away,			
rejected per anum.		forming the bulk of the dejections, and			
5. Food fully digested.	5. — (Undigested mate-rials of diet passed away with faeces, and hurrying downward the bile and other contents of the in-testines.)	shown by the smell to be unaltered.)		*	
 
DIARRHCEA.
ooo
  In some instances of mucous flux and indigestion in the upper
part of  the alimentary  canal, the stools are acid  from time to
time.   There  is nothing  special in the pathology of this.  It
arises simply from so much  acid  being  formed  from the decom-
position of food, that it cannot  be neutralized by the  alkaline
juices.  Sometimes the  acidification takes place in the stomach,
sometimes  in  the caecum,  during the  delay of  the decomposing
aliments there.   In the  latter  case considerable  pain  is  often
experienced in the  right iliac region, and in the  course of the
colon just before the evacuations.
  In all forms of diarrhoea from affections of the small intestines
the evil is  twofold : first, the aliment, which ought to contribute
to the support of the system, is  hurried through the abdomen,
and so  the supplies  are  cut off;  and  secondly, destruction is
carried  on  at an increased rate  by exhalation from  the mucous
membrane  of  the bowels.   The  stick  is being cut away at both
ends,  and  hence  there  is nothing which produces  such rapid
emaciation.  Where so-called " diarrhoea" is reported to you as
lasting  for any length  of time  without emaciation,  always let
your suspicions of the correctness of the nomenclature be roused,
and observe carefully whether the quantity of excrement be really
in excess,  or whether the ailment have not  rather the nature of
tenesmus, and arise from the colon or rectum.  You will gen-
erally find  such to  be the fact, and must vary your treatment
accordingly.
  Sometimes diarrhoea seems to be the transference of a  tend-
ency to exudation of  serum  from another tissue to the  aliment-
ary canal.   Such is that which sometimes  comes on of its own
accord or  may be artificially induced  in ascites, and  which cer-
tainly diminishes the abdominal  effusion.  Such is the diarrhoea
of uraemia, which, hoAvever, does not  usually relieve  anarsarca,
but rather increases it  from the weakening of the blood Avhich
folloAvs.  Hence it  is a  very bad, almost a fatal symptom in the
latter disease.
  The most important indication of treatment is connected with
the diet.   It must be such as does not require a perfect state of
the digestive organs for its absorption, while at the same time it 
55G
DIARRHCEA.
is  nutritive to the patient.  The best of  all is milk  and lime-
Avater.   In feverish cases it may be iced, and soda-water may be
occasionally substitued for the lime.   Keeping a person solely
on this diet is often sufficient alone to cure all sorts of diarrhoea
not dependent on a permanent chronic cause; and even Avhere
there is  such a cause for it, very great temporary benefit is
derived,  which forms  a better  starting-point for medicinal treat-
ment than the previous state.
   In a temporary diarrhoea without other disease, the loss of the
normal supply to the body is not of so much consequence ; a short
starvation perhaps does  good to a person  otherwise healthy.
But in  severe acute  disease, or in long-continued chronic diar-
rhoea, this is an important consideration, and care must be taken
to alloAV  for it.  Since food in the usual quantities at once  can-
not be borne, and is rejected undigested, give it very frequently
and in small portions. The alkaline milk  diet I have just recom-
mended  alloAvs this to be done most conveniently.  A jug of the
liquid may be kept close at hand, and sipped from time to time,
so that as much nutriment may be taken in the twenty-four hours
as would be  done  by a  healthy person without  the  alimentary
canal ever being overloaded.
   When there are  lumps of faeculent matter in the stools, and  a
smell like that of normal excrement, give purgatives.  Until you
get rid of these remains of previous constipation,  you  will be sure
to have  a relapse of diarrhoea, though your medicines may check
it for a  time.  When there is no  normal smell present, I  have
never found purgatives beneficial.  This is a better rule than the
routine  practice of ahvays commencing the treatment with a pur-
 gative—a plan which I have known very injurious  in  cases of
 chronic  diarrhoea.
   Where the products of acute inflammation are found mixed in
 the stools,  such as white and opaque mucus, flakes of fibrin,
 epithelium,  blood-streaked mucus, bright-green  matter, &c, as
 above described,  leeches, fomentations,  AAarm  hip-baths,  and
 poultices to  the  abdomen are  the appropriate treatment, and
 should not be delayed.  In the case of babies, the whole abdomen
 and loins may be fastened up in a large circumambient poultice, 
DIARRHCEA.
557
which they cannot wriggle away from, a leech put on near the
navel, and the bite allowed to bleed for a little time.  The drugs
I have most trust in are calomel, ipecacuanha,  and carbonate of
soda.  Of the first  and  second equal quantities,  and a double
quantity of  the third may be made into powders, of which from
four to six  grains, according to the child's age, may be given
every three  hours.  This  is a traditionary powder,  but it is right
to say that I have in a good many instances lately left out the
calomel, and the case has done just as well if not better  Avith-
out it.
   Be very careful in infants to look to the teeth.   The state of
the bowels may very likely be dependent on reflex irritation from
the dental nerves.  Lancing the gums will sometimes stop a most
violent diarrhoea where the stools  show evident proofs of the in-
flammatory condition of the ilia.   The action of  the  lancing is
probably  much the same as that of leeches, viz., a relief  to  the
 congestion of the mucous membrane.  Upon the development of
 the  teeth themselves it can hardly be supposed to have any influ-
 ence, but that  it alleviates toothache any adult can experience
 on himself,  though it is  difficult to get an account of  the action
 of the remedy from his little patients.
   In teething infants opium is of striking utility.  I begin Avith
 half a grain of Dover's powder every  three hours, increasing the
 dose by half a grain every  three hours  till a decided excess of
 sleepiness is produced by it.
   But there is no doubt that the most important cure in infantile
 diarrhoea is change of diet.  Bringing up by hand  or an umvhole-
 some  state  of the breast-milk are generally  at the bottom of the
 ailment.   No remedy is  equal to a  healthy AAet-nurse,  or, where
 circumstances forbid that, as near  an imitation as can be made
 of human milk by that of animals.  The old fashioned  donkey's,
 or the cow's diluted and  slightly sweetened.
   In  low fever the  presence of diarrhoea indicates to many prac-
 titioners the employment of mercury in the form of mercury with
 chalk. The effect'of this drug is the increase of solid sedimentary
 matter in  the stools;  in other words,  a restoration of  the de-
 structive assimilation going  on in  the body.  The  motions are
 diminished in number and in fluidity, but not in actual quantity. 
 558                     DIARRHCEA.

 Thus the tissues devitalized by the typhoid poison  are  removed,
 and can be replaced by new nutriment.  This increase of solid
 matter is taken as an evidence and test of benefit accruing from
 the use of mercury, and as a prognosis of good.   But  I confess
 I prefer the chalk without the mercury in the shape of mistura
 cretae or the employment of mineral acids.
   Where in the absence of fever blood  is passed by the bowels,
 the two most powerful means of checking  it I have found to be
 turpentine and acetate of lead, especially the latter.   Its direct
 influence as a poison on the bowels would have led to an expect-
 ation of  this.   If the haemorrhage has  gone on for some time, I
 am  inclined to think it must be sometimes  due to a clot distend-
 ing the boAvel, and preventing it contracting upon  the  bleedin^
 spot, for certainly a  dose of castor  oil, in the results of whose
 action a quantity of pale clots Avere exhibited,  has seA'eral  times
 in my experience stopped haemorrhage from the bowels.
   The long continuance of diarrhoea from  ulceration  of the ilia
 must starve the patient.  It tends also to prolong itself; for the
 weaker the system is the more irritable  are  the sore places, and
 the  less  can the morbid  actions they set up be resisted.   It  is
 right, therefore, to use direct means for arresting the diarrhoea.
 The best are such as blunt the sensibility of the ulcerated spots.
 The milk-and-lime-water diet should be used first, then chalk and
 opium, which appear to act  on the sore mucous membrane just
 as they do on a raw blistered surface of  skin.   If these fail, sul-
 phate of copper should be used in doses increased from a quarter
 of a grain up to tAvo  grains.  If no  good accrues after this, I
 suspect an error has been made in the diagnosis.
   Where there  is a  simple  flux of transparent mucus  without
 fever, pain, or  pressure, or any fibrin or blood in the motions,
 the vegetable astringents, such as logwood, bark,  kino, and tan-
 nin,  are often of great use.  In such cases, too, I have prescribed
 iron with seeming benefit.    I  must, however, say that I  feel
 doubtful in the great  majority of instances  whether this form of
 flux  is not rather due to the colon than to the small intestines.
  Where the solid matter is  copious, pale, and fetid,  consisting
mainly of undigested food,  inspissated bile may be given  with
benefit; the stools become darker, less fetid, and less frequent 
DIARRHCEA.                     559
under its employment.  This is particularly the case in children
whose mesenteric glands are diseased.  I am hopeful, too, that
pepsine will prove a still more efficient remedy in the same cases,
as it certainly diminishes the fetor of the motions in the best
way; namely, by promoting the normal solution of the food.
  Acid diarrhoea indicates the free employment of chalk.
  The use of opiates in diarrhoea  must never be  made a matter
of routine.  As  a general rule, I have  found them  beneficial
without consequent harm, in cases where  there  was tenesmus
and frequent stools;  but where the faeces are bulky and copious
they appear to impede the natural secretion.   Where the stools
also are putrid, caution is required in their use. In the diarrhoea
which  so  often accompanies and  proves  fatal  in  uraemia, they
cheek, indeed, the debilitating flux, but they are apt to bring on
coma.
   In some cases of diarrhoea from chronic  mucous flux  of the
intestines, without ulceration or acute inflammation, I have found
horse exercise serviceable.  I suppose it  is the gentle agitation
of the  abdomen, combined with the air  and  amusement, that
proves of use.
   In recommending the recreation of traveling to invalids sub-
ject to diarrhoea, you  must be very careful of  the route you
select.  The epidemic influence of cholera which  has overspread
Europe during the  present  generation, visiting almost every
square  mile of its surface several times during the last few years,
has, in many places, left behind it  a  chronic endemic poison.
The natives  are, indeed, insensible to it, but few strangers escape
becoming affected more or less, according  to their idiosyncrasies.
Strong persons find  it only an inconvenience, but an invalid is
put in some  danger,  and certainly loses all the advantage of the
tour.   This  is especially the case in the mountainous districts of
the  south of France, the  Pyrenees,  and  Dauphiny, and  in the
volcanic  regions  bordering  the Rhine,  the Eifel and Moselle
country, as well as those in the center  of France, the ancient
province  of  Auvergne.  All these  places are attractive from
their picturesque beauties, and therefore it is necessary that you
should  be  warned of this evil attendant  upon  choosing them  as
the  scene of a tour.  You will see sometimes the whole of the 
560                     DIARRHCEA.

strangers at a table d'hote obliged to leave the room  at once,
and cause one another no  slight inconvenience by tending all
together in the same direction; and in the Pyrenees I have seen
poAvders of chalk  and opium packed  up as the regular concomi-
tants of a day's walk.  It must not be supposed that this is the
result of the foreign modes of  cooking.  I have known English
biscuits  and porter, and boiled eggs,  adopted as a diet Avithout
relief, though of course nothing foreign could have got into them.
I believe the  cause to  be as  I have  represented it; namely, a
poison left endemic since the  passage of cholera  through the
country, but to which the natives have become  acclimatized.
That it is of late years only that this diarrhoea has been prevalent
is shown both by local report and the omission of all mention of
it from the well-known work on "Climate," by Sir James Clark.
  One source from Avhich strangers contract this diarrhoea is an
evil capable of, and rightly demanding, an amendment: I refer
to the filthy privies in continental inns.  A gentleman, eminent
in his profession and of good judgment, told me that, during a
Pyrenean  tour lately, he entirely escaped the  diarrhoea which
everybody else without  exception suffered from, by adhering to
a strict rule of never entering one of  these disgusting holes, but
worshiping Cloacina under the pure light of the stars.   Invalids
and ladies cannot so well manage this unless they are rich enough
to  travel with carriages  and servants  and peripatetic water-
closets.  With  few exceptions, I think patients  with diarrhoea
had better stay at home.
  Flatus in the small intestines is  one of the most trouble-
some forms of wind.  If it escape into the stomach, which is for-
tunately rare, the taste  and smell are  peculiarly nauseous; while
it seems to have considerable difficulty in passing the ilio-caecal
valve.   Hence it rolls about in the abdomen from  the changes
in position which the motion outAvard of the alimentary masses
involve,  and causes the  well-known  and distressing  " borbo-
rygmi,"  till it can get absorbed.  The  abdomen will  often be dis-
tended for several  days with it, without its being able to escape.
  The persons most liable to this troublesome  affection are fat
anaemic and hysterical women ; it folloAVS also the small and con-
tracted liver of spirit-drinkers,  and sometimes  is very annoying 
DIARRHCEA.
561
in cases of dilated heart.   Some  persons, in apparent health,
are habitually much troubled with  it.  I am inclined to attribute
it under these circumstances to a naturally sluggish portal circu-
lation, Avhich does not so quickly absorb  the contained air as a
freer current through the blood-vessels Avould enable it to  do.
  Flatus in the intestines is troublesome during the day, from
the tumidity of the abdomen, and noise on motion, and pain in
the side;  but when it comes at night it  causes still more incon-
venience by preventing  sleep.   I  cannot explain why this is;
there is not enough pain or discomfort to account for it,  yet a
complete wakefulness and apparent want of desire for sleep com-
monly prevails.   It is to be remarked,  also, that it  is in most
instances made worse  by opium.   Sometimes the patient will go
to sleep easily and naturally on  first lying down, and Avill then
wake up in an hour or two, finding his abdomen tumid and  un-
comfortable,  and will  remain entirely without rest  for the re-
mainder of the night;  or if he drop off for a few minutes into
unconsciousness,  it seems rather to aggravate than  relieve  the
feverish restlessness, and to cause headache.
   The most serviceable remedy is  finely-powdered animal char-
coal, in doses of from ten to twenty grains, and of the aloes-and-
myrrh pill just enough nightly not to  act as a purgative.  The
air seems  to be absorbed, and the peristaltic motions quickened,
by this treatment.  Should that not be  effectual,  you can employ
strychnine in small doses in the pill.
   It is scarce needful  to  say that indigestible  articles of diet
must be shunned, if the patient would avoid a recurrence of the
complaint; and it stands to reason that cold sponging and bath-
ing, sea-Avater—and in short all hygienic remedies which improve
the general health—will conveniently accompany the  treatment.
   I have knoAvn two cases of habitual looseness  of bowels cured
by marriage.  In one of these the  change Avas  sudden and  im-
mediate :  a gentleman  from boyhood  to the  age  of thirty-five
had been used to have the bowels  opened at least  five times a
day;  a week after his  wedding the number of  evacuations  Avas
reduced to tAvo, and before the  year was out to one  daily.   I
presume it is requisite for the marriage  to be  a happy one—a
Xantippe  would not, probably, lead to  the same soothing result. 
                LECTURE  XLVI.

     COSTIVENESS   AND  CONSTIPATION.

The difference between costiveness and constipation—Costiveness
    dependent  on retained excernible  matter—What diseases
    it accompanies—Cause, defective  vitality—Effect  on the
    nervous system  and mind of retained excernible  matter—
    Indications of treatment—Inconveniences of purgatives—
    Sort of purgatives to be adopted—Dietary— Water— Water-
    ing places—Cautions in use of them—Hydropathy—Consti-
    pation — Causes — Irritating food — Un absorbable  food—
    Remedies—Flatulence  in  colon—Distinguished from  that
    in ilia—Remedies—Slight cases  difficult to relieve.

      (Extra Course, St. Mary's, Summer Session, 1857.)

  The opposite states to diarrhoea are "costiveness" and "con-
stipation."  In the former  the quantity of faeces is too small;
in the second, the expulsive power is  in default.
  Costiveness arises from  deficient excretion in the alimentary
canal.  What  proportion of the  matters  that ought to  be  thus
got rid of comes from the  liver we  have not yet the  means  of
knoAving, but the main point, that they are derived  from portal
blood, we are justified in asserting;  so that the solution of the
former question is of the less importance.
  That a great deal of the  color of faeces is due to bile is  familiar
to us from the phenomena attendant on obstructed gall-ducts.
But even when there is complete occlusion of the communication
between the liver and intestines, the faeces by no means consist
entirely of undigested food; there is  in them a great proportion 
COSTIVEXESS AXD CONSTIPATION.          563
of a yellowish-gray granular  matter which appears also  in  the
healthy state, and  still makes up the bulk of the solid excreta.
   In deficiency, therefore, of the excretive poAvers of the intes-
tines generally (vulgo "costiveness" or  "biliousness"), there is
a different substance  retained than is the  case when local lesion
of the liver or gall-bladder obstructs the passage of bile.   There
is a partial retention of the whole matters destined for depura-
tion from these quarters, instead of a complete retention of  one
constituent.
   Hence there is not, as happens in mechanical retention of the
bile, the well-known stain of jaundice communicated to the blood
and  skin, nor are the stools clay colored.   But there is  a dingi-
ness and darkness of  complexion, and the stools are scanty. The
skin gets greasy and opaque, the  countenance sometimes puffy
and  bloated, sometimes thin and pale, the lower eyelid especially
sallow and discolored.   The sebaceous follicles on the alae nasi
are stopped up with black matter.
   There is  seldom  any decided emaciation, nor is there  always
even loss of muscular power; but still there is great sluggishness
of body and apathy of mind,  and often a miserable want of de-
cision and  energy.   Digestion is accompanied by a good deal
of discomfort and flatulence, but  rarely by actual pain, and  the
distress does not begin till several hours after eating, so as to be
with difficulty referred to any particular meal.
   In the least complicated cases of checked intestinal secretion
the stools are dark, hard, and dry; but their appearance may be
varied by several circumstances.   Sometimes there is an aug-
mented secretion of mucus, and then they are  intimately mixed
up with it, forming  a  black, slimy, almost  gelatinous  mass.
Sometimes, from the  appetite  not suffering, the patients will  eat
largely, and then there appears irregularly from time to time a
quantity of fetid, semi-digested food, constituting a sort of diar-
rhoea accompanied with pain and colic.   And this diarrhoea will
often be  the occasion of your patient's  first coming  to  you, so
that  you might be deceived into a false impression of  the case.
  The congestion of the portal vessels in the upper part  of the
alimentary canal is  often followed by the same state in the lower,
and thus piles are formed, which add much to the general distress. 
564          COSTIVENESS AND CONSTIPATION.
  Costiveness is a common accompaniment of anaemia, chlorosis,
debility in males and females, or diseased hearts especially where
the muscle is dilated rather  than hypertrophied, of  contracted
liver, and in short, of anything which makes the abdominal cir-
culation sluggish.   Sometimes it is found in cases of  pulmonary
tuberculosis, but hardly ever before middle age.   All those pul-
monary cases in which I have seen it last long enough to be a
marked feature have been examples of senile phthisis. It is often
the first and most  characteristic phenomenon of that change of
system which takes place in females after the cessation of the
catamenia.  The stools get gradually more and more scanty as
the uterine  secretion also diminishes, the pulse grows feebler,
the feet and hands more liable to  get cold.   There is evidently
lessened vitality throughout the whole body.
  No persons  more frequently suffer from costiveness and its
attendant " biliousness" (as the general appearance of the skin
is named) than old  Indians.  Their  sedentary routine life and
high feeding are partly chargeable with their  liability.   But in
addition to this, the endemic diseases of the country are  often the
exciting  cause.  I have  traced the  commencement of  a costive
habit of body several times distinctly to an attack of dysenteric
fever brought  on  by malaria.   So that the Anglo-Indian who
suffers in this way must not be  always accused  of previous
excess.
   The natural end of this state of things, if left unchecked, is
gradual progress from bad to worse.  The decrease of destructive
assimilation loads the tissues with effete matter, useless for the
purposes  of life, and a  constant  source of general  discomfort.
This  impedes  the constructive assimilation  of food as  well—
growth is arrested, the blood is not renewed,  and hence progres-
sive anaemia, weakness, want of  nervous and  muscular  power,
and probably in the end  the degeneration of  one or more of the
viscera, and death from that cause.
   One very striking attendant on the loss of destructive assimi-
lation is the depression of spirits ; melancholy is so named from
the dark, scanty stools which were observed by the Greeks to be
associated with it.  It appears to me to be a  universal rule  in 
             COSTIVENESS AND CONSTIPATION.          565

disease that the general discomfort  is proportioned to the arrest
of this vital  process, and I am inclined  to  attribute  it almost
entirely to the influence on the nerves of general sensation of
effete matter which is retained.  In all maladies, both  acute and
chronic,  you may  observe  the truth of this law.  Mark,  for
instance, the ushering in of a fever: the malaise  is excessive;
there are pains in the back, in the head and the  limbs, or, in
milder cases, a sense of what  the patients graphically call " all
overishness;" but when they get worse, and  destruction begins,
the effete matter  passing off as urea and  increasing the specific
gravity of the  urine,—then no aggravation of local symptoms,
however  much it may alarm their physician, and make his prog-
nosis graver, prevents the  general  feeling of relief.   Or watch
a case of consumption; the deposit of the tubercle may be in-
significant, and is at all events in its first stage; yet the patient
is despairing of recovery.   Why ?   Because the skin is sluggish,
the bowels costive, the urine of low specific gravity; because, in
short, there  is evidence of the  retention  of effete matter in  the
system. But let this patient's  tubercles soften, let there be night
sweats, copious expectoration,  diarrhoea—everything  that pro-
phesies ill—and Avho so full of hope as the poor blind sufferer ?
Morbid states where  destruction is  in excess  are the most fatal,
but those where retention preponderates are  invariably the most
distressing.
  Costiveness must be regarded as a disorder of the whole system,
and not of the intestinal canal  alone. The only effectual remedies
are those that are advised under that conviction.
  The objects of treatment must be : first, to relieve the body of
the immediate presence of  effete matter;  and, secondly, to  pre-
A'ent artificially its reaccumulation till such time as a complete
renewal of the  tissues has taken place.   Then the body ought to
be able to  take care of itself, and a cure may be  said  to have
been performed.   The attention to  local  disorders, arising from
the successful study of morbid anatomy, has too much made us
forget this main  object of all  medical advice—the replacement
of morbid tissue by healthy.   "Renew my age," was  the chief
earthly blessing prayed for by the  inspired prophet; and physi- 
I
 566          COSTIVENESS AND CONSTIPATION.

 ology teaches us it should be the motto of the rational physician;
 for if he omits to rebuild the healthy, his care for the destruction
 of the unhealthy is all thrown aAvay.
   Purgatives, then, may very fairly begin the  treatment;  for
 the immediate relief they give  to the feelings of discomfort is
 great.  But let not that relief be set doAvn to the mere " clearing
 out of the bowels;" it is the cleansing of the  blood which is  the
 real object of the remedy,  and the real cause  of the relief.   An
 inspection  of what comes away shows you it has  been newly
 formed;  it is fresh bile and other natural constituents of recent
 faeces ; not of those which have  rested long in the canal.
   Nothing is easier than thus Avith a vigorous  blue-pill and black
 draught to drive away, as with a charm, the patient's discomforts;
 and  he is  ready enough  to  cry out  that no  more  medicine is
 wanted.   But what is the consequence of leaving off treatment ?
 The reneAval of the blood and tissues not having had time to re-
 gain its  original activity—there not  being enough new-made
 blood to  carry on vigorous life—the  effete materials again col-
 lect, and the  disease takes a fresh starting-point.  Again and
 again the coarse expedient is called for, and at last fails to effect
 its object of giving relief.
   To avoid this evil consequence, it is best to give  no quickly-
 acting complete purgatives which directly deplete the abdominal
 plethora  by serous exudation, but rather such as  cause a gradual
 increase  in the solid matter of the stools.  Aloes and  rhubarb
 are the best  of these;  and I find it  also beneficial to  combine
 with the  drug resins Avhich act  as a tonic to the  surface of  the
 mucous membrane, and prevent the  exudation  of  serum  and
 mucus.   Four grains of aloes and-myrrh pill, every night, will
 in a week produce all the good effect of strong purgation ;  and
it will produce the good permanently instead of merely for a
 time.
  All accessory food that has the property of arresting destruc-
 tion  must be left off.   Wine, beer, tea, and coffee must, on this
 account,  be excluded from the dietary;  and milk, cocoa, whey,
 soda-Avater, Seltzer-Avater,  &c. substituted for  them.
   Perhaps it is on account of their temporary arrest of destruc- 
             COSTIVENESS AND CONSTIPATION.          567

tive  assimilation,  that  general tonics,  such  as cinchopa  and
quinine, rarely agree well in those cases.  I find it better to give
pure bitters, such as oak-bark, quassia, and gentian, Avhich seem
to act chiefly on the mucous membrane.  Their use is to increase
the appetite; and, when the object is attained,  I leave them off;
or, if it is attained without them, I do not begin.
   Water is a very accessible remedy, and certainly a very rational
one, when the destructive assimilation is  deficient.  The conclu-
sive  experiments of Dr.  Bocker and of Dr. Falck,* show the
increase of all interstitial  metamorphosis by this agent to be in
close proportion to  the quantity taken within  certain bounds;
and  all who have heard or read of the agreeable sensation ex-
perienced by patients  during the water  cure cannot doubt its
power of removing morbid accumulations of effete matter in the
tissues.   In this lies its strength; for, as Dr. Bocker observed,
" the demand for new tissue, as expressed  in  the sensation of
hunger, keeps  pace  exactly with the extent of the  metamor-
phosis."  And if this demand is rightly supplied, the result must
be a complete renewal of the body.
   The testimony of experience to the use of water as a remedial
agent is shown in the patronage  bestowed  from  the earliest
times upon numerous springs whose saline constituents are  even
less  abundant than  those  of ordinary drinking-water.   Pfeffers,
historically famous  for freeing  Martin  Luther of his demon-
haunted hypochondriasis, is still the resort of the invalid.  It is
situated in a most gloomy hole; and the  copious hot stream that
boils out of the rock is almost chemically pure.  So  really the
pure nymph of the  fountain, innocent of salt, should  have the
whole credit.   The same may be said of  the well-known Gastein
and Wildbad, the crowded Baden,  imperial Plombieres, of the
French Aix, and our own  long-frequented Buxton ;  for,  practi-
cally speaking, the influence of the saline particles they contain
must be reckoned for nothing. It is certainly nothing compared
with the effects of moderate doses of water in  Dr.  Bocker's ex-
periments.
  * See " Digestion and its Derangements," p. 21?: and " Zeitschrift der K. K.
Gesellscbaft der Aertze zu Wien," April, 1854; and Vierordt's  " Archiv.," i, p.
150, 1853. 
568
COSTIVENESS AND CONSTIPATION.
  As physiologists we cannot be surprised at the benefit derived
from the simple expedient of drinking water beyond the demands
of thirst, in all diseases of arrested metamorphosis. Taken several
times a day between meals it is a most efficient remedy.  Warm
hip-baths are also of great use, and can be borne even from the
first by those reduced to extreme anaemia and lifelessness. After-
ward, the cold sponge-bath, preceded and  followed by friction
to the skin, is a most active  promoter of life in  the  skin  and
capillaries.   The raising the specific gravity of the  water by the
addition  of salt prevents  the  chill which fresh water  is apt to
impart.  So that even persons with cold hands and feet, and very
great sluggishness of circulation, can bear to be sponged with
brine.
  Alkalies and neutral salts have the same  action  on the moult-
ing of effete tissues that water has.  Hence the repute of many
really strong mineral wells.  But care is needed  lest  the same
result should follow their use which is  threatened by the un-
guarded  use of purgatives.  In cases where there  is pure arrest
of metamorphosis, without organic change in any of the viscera,
I find that the weaker the spring the better it is for the patient.
Where,  hoAvever, any organ is chronically degenerated, general
consent seems to sanction even such waters as Vichy and  Sel-
ters, with their large amount of alkaline constituents.
  While pulling down an  old house, remember  to be building up
the new.   Let full supplies of albuminous material be continu-
ously kept up in such form  as  the absorbents  love.  Let milk,
mutton,  and  bread be the staple diet, with the  smallest quantity
of anything  else that human gluttony will submit to.   If your
patient be one of strong mind, the best and bravest thing is for
him to carry out your advice himself.  He will  then have gained
a victory, not only over the flesh, but over the spirit. But if he
is no Epictetus, and cannot attain to the dignity of being his own
jailor, do not be afraid of sending him to an hydropathic hotel.
You will generally find the proprietors of  these establishments
willing to carry out your directions, and the situations of most
of them  are  judiciously chosen for the advantages of air and.
amusement.  The principle of scientific hydropathy, the renewal 
COSTIVENESS AND CONSTIPATION.         569
of the body by water and food, the increase of growth secondary
to the increase of moulting, is no quackery.  It is not an under-
hand mode of doing nothing, but a bond fide use of a powerful
agent.
   I know that medical men are afraid that in sending patients
to water-cure  establishments they may be  aiding and  abetting
the pretensions which ignorant proprietors have put forth,  of
their treatment being a panacea for all ailments.  In my opinion
a contrary effect would follow;  for the very fact of regular prac-
titioners adopting the reagent as remedial, will show that science
ranks it as a physical power;  that, consequently, it will do  as
much harm in some cases as it does good in others; in fact that,
like  all  medicines, it will kill as well  as  cure.   This  is indeed
the truth, and patients are  as unwise  to  prescribe it for them-
selves, or on  the advice of a hotel-keeper, as  they would be to
take arsenic or strychnine,  or to cut their legs off, on the  same
grounds.
   Constipation  is often added to costiveness, but is not neces-
sarily connected with it.  In it  the faeces collect in some part of
the abdominal canal,  and give proof of that collection by being
occasionally passed in considerable quantities at a time.  In the
stools there are portions more  dried and  concentrated than the
general mass—scybala of various sizes and shapes, dark brown
or black, and  usually with less smell than ordinary faeces.
   The most obvious cause of constipation is mechanical obstruc-
tion, the nature of which, under  various  forms, has  been  fully
explained to you  in the ordinary courses of medical and surgical
lectures.
   Simple atony of the colon presents a much more frequent and
more curable   cause.   And not  rarely a  mucous flux of the
stomach or intestines will originate constipation by enveloping
the faeces in a slimy coat, and preventing their being moved on
by the muscular  contractions of the gut.   Atony of the colon
arises primarily  in those who  lead  a  sedentary life, and  have
that  pale look which  characterizes weak muscular fiber.   It  is
more frequent in the old than in the young;  indeed, a diminished
propulsive  force in the large intestines may be considered as a
       37 
570
COSTIVENESS AND CONSTIPATION.
normal consequence of advanced age.   It is very usual in con-
valescence after acute fevers  and  other  debilitating  diseases.
Neglect of the natural call to evacuate the bowels, and the re-
tention of wind in the  colon, also produces this sort of torpidity
by too long-continued dilatation.   Hysteria and nervousness in
either females or males often spasmodically contract the rectum,
so that the faeces are kept unnaturally back, and thus the same
state of things arises as from neglected evacuation.   The irrita-
tion of piles occasions  a similar result.
  Where  there  is a disposition in the colon to be atonic, this
disposition is much aggraATated, and sometimes first made evi-
dent, by some kinds of diet more than others.   It is a mistake
to suppose that indigestible articles of food ''irritate," as it is
called, the bowels; that is, pass on quicker than more soluble
substances.   The  contrary is the case;  and, as a general rule,
the gradual  and regular transmission, of the mass  is in  direct
proportion to the completeness of its digestion.  No sort of food
is so apt to be followed by constipation in atonic persons as that
which  contains  a large amount of matter  incapable  of  being
acted upon by the digestive juices, such  as the husks and stones
of fruit, stringy half-cooked vegetables,  in  which, besides  cellu-
lose, there is the equally impracticable body, unbroken starch.
All substances capable of being  squeezed into an  impenetrable
mass, such as puff pastry and new bread, come under the same
class of insolubles; and perhaps, too, gum and gelatine are liable
to the same imputation.
   The most successful practice in simple constipation is the free
use*of cold water enemata,  and a long-continued course of small
doses of strychnine.  When there are no piles, the latter medi-
cine may be  advantageously combined with aloes.   This treat-
ment does  not forbid the administration of tonics, or whatever
else may be needful to relieve the disease in which constipation
occurs;  which disease of course requires to be removed  before
the local symptom will be free from risk of relapse.  It is scarcely
necessary to say that no treatment will avail if the bad  habits
which have induced the constipation are persisted in.
   Where the constipation  arises from mechanical impediments 
COSTIVENESS AND CONSTIPATION.          571
to the movements of the bowels upon one another, such as adhe-
sions of the peritoneum, contraction from  old  ulcers, from  past
inflammation, or compression of the area of the gut, such as arises
from tumors, from retroversion of the uterus, and the like, a more
soothing treatment should be adopted.   Then the enemata should
be Avarm, and have an ounce of olive oil added to them.   If there
be localized pain, dissolve some opium in the oil, and put some
leeches to  the  spot  outside corresponding to  the  seat  of pain.
Hot fomentations and poultices containing fresh laurel leaves
also give great relief.
   The depending position of the caecum makes it the commonest
seat of fecal collections; and if you find it difficult to fix on any
other spot, it is Avise to take it for granted that this is the failing
one, and direct your local  application accordingly.
   Do  not  be satisfied with the one or two very copious stools
which will follow your efforts; the treatment must be persevered
 in until the bowel has recovered its tone, or there will  be  great
 risk of relapse.
   Flatulence in the Colon may be distinguished from that in
 the small intestines by the percussion, by the  absence of borbo-
 rygmi, and by its frequently passing freely out per anum.   It is
 a very usual accompaniment of  constipation, and in that case has
 the same pathology, being to the air what the other is to the solid
 faeces.   If the flatulence is a very marked symptom, a carmina-
 tive, such  as  extract of rue, or a few drops of ether, may be
 added  to the enema.
    Milder cases of  colonic flatulence, without marked constipa-
 tion,  are  often found more difficult  of  cure  than the severer.
  The reason is simply that which applies to all of  the less  incon-
  venient forms of  disease—namely, that patients  will not take
  the trouble to be well unless under strong compulsion. 
LECTURE  XLVII.
                       DIETETICS.

 Thesis of Dietetics based on the principle of sparing the weakest
     part—I.  Stomach—II.  Intestines—III.  Increase of ab-
     sorption—IV.   Delay of absorption—V.  Gradual return
     to normal diet.

      (Extra Course, St. Mary's, Summer Session, 1857.)

   As  a contribution  toward clearing  away the mistiness of our
 clinical dietetics, I purpose to set before you in one lecture cer-
 tain theses which are  my guides in this  matter, and perhaps,
 therefore, may help you also.
   The leading idea of the first-placed and most important rules
 is simply that of sparing weak members—working those that
 can work and resting those that cannot.

                              I.
   When the stomach is off work, spare it, and leave the digestion
 as much  as possible to the intestines.
   This applies to cases of weight  and pain after eating, heart-
 burn, acidity, haematemesis, vomiting of unaltered food, and fer-
 mentation.   Should the conjunction of symptoms enable us more
 definitely to diagnose gastric  ulcer, mucous  flux, cancer, or any
 other more definite anatomical change, the application is all the
 more imperative.
  Spare  the stomach both its  mechanical and its chemical toil.
  The first is the hardest, and  therefore the most necessary  to
be avoided.   A meal-—that is, the laying in of victuals to avoid 
dietetics.
573
future rather  than present  hunger—is a  labor, even to the
healthy; so do not impose it on a sick stomach.  In very bad
cases, do not divide the daily allowance into meals* at all, but
assign such  quantity  as appears  enough  for  the twenty-four
hours, and let the taking of it be spread over the whole  time,
as equally  and with as short  intervals  as  possible.   In milder
cases it will  be sufficient to "spoil" the meals—that is, to take
food between the usual times, so as to leave neither the necessity
nor the inclination for eating at once as much as other people.
One would be sorry to recommend  to  the  healthy an overcare
for their diet, but to invalids  subject to gastric  derangement,
you cannot do better than advise an  imitation of  a famous cen-
tenarian witness, examined by the scientific judge, who said he
attained his  great age by  always "eating before he was hungry,
and drinking before he was dry."
   But take care that your patients do not spoil their dinner and
eat it too: that last error would be worse than tire first.   Make
it a rule that the slightest sense of  repletion is to be a warning
to desist.
   Another valuable expedient for sparing  the organ, in cases of
slight indisposition,  is dilution of the  meal.   Copious watery
drinks  carry the food  on  quicker through  the pylorus, and give
great relief  to oversensitive, irritable stomachs.   But at the
same time it must be remembered  that thus the time for the
 action of the gastric juice is shortened, and its chemical strength
 lessened, so that  more is given for the  intestines to do.   It  is
 better, therefore, to let this dilution be practiced as long after
 the meal as the case admits of.  It  should be avoided also as a
 general rule where an obstructed  circulation impedes absorption
 of the water by the portal veins.  Patients with  dilated  heart,
 for example, and some cases of anaemia and of  diseased liver,
 suffer much inconvenience from a sloppy  diet.    Obese persons
 also should avoid dilution;  it washes  away the albumen which
 they do want, and allows of the absorption of fat, which they are
 better  without.
   * A Meal (as in Saxon " male," in German " mahl," and " mal") implies ap-
 portionment  of food, time, or anything else.  So Bacon-" the yearly rent is stil
 paid into the hanaper in parcel meal"—that is, "in lots." 
574
DIETETICS.
   The chemical toil of  the stomach may be spared  by giving it
less  to  digest, and  more to digest with.   Take  care  that  the
weak but well-meaning organ  is not driven to despair by solid
lumps of  albuminous food.   The best form of nitrogenous ali-
ment in these cases is whey, or milk prevented from coagulating
by a copious admixture of lime-water.   This fluid meat will pass
through  the stomach  unaltered, the  gastric juice  will trickle
through the pylorus at its leisure after it, and with the intestinal
juice  will digest the casein in the intestines.   Next in easy solu-
bility comes  soup, made fresh, weak, and  at a low temperature
—fresh,  that it may not decompose; weak, that it may be easily
absorbed; at a  low temperature, that  it may not be filled with
innutritious  gelatine, or with  hard-boiled albumen.   Meat is
suitable  in  proportion as it is soft, easily disintegrated, quickly
cooked, and  free from fat, which might oppose the soaking in of
the gastric  juice.   The well-known list of Dr.  Beaumont sets
in the order rjf these qualities a  great number of articles of
diet.  But I think it more useful for you to have the principles
of selection than a mere experimental enumeration of the articles
themselves.
   To mix starchy  food Avith the albuminous in cases of Aveak
digestion is  an  irrational practice.   It  soaks up the little that
there is of the valuable gastric juice, and then makes  no use of
it; for starch is quite unaltered by the peptic solvent.   This is
very bad economy indeed.   Moreover, if taken in quantity suf-
ficient to assist much as  a nutriment, it is  too bulky, and being
converted into sugar by the saliva, turns  acid  in a mass, and
puts a stop to further digestion.  This is particularly the case if
it  is in solid  coherent lumps, such as potatoes, soft bread, pastry
and the like.
   Starchy food, unmixed with albuminous, is a different  thing
altogether.   There certainly are some cases of gastric disorder,
which are much benefited by a temporary adoption  of such  a
diet.  It  is  the best during acute catarrhal bilious attacks, at
the commencement of treatment of even  chronic gastric cases,
and whenever a dusky complexion, hypochondriasis, or general
distress,  show that  arrested moulting  has caused a retention in 
DIETETICS.
575
the body of effete tissues.  It does good in fact as a temporary
starvation.  Hence you will see me occasionally begin the treat-
ment of such  cases  by our " simple  diet," and still oftener in
private  practice, where starvation for a time is more generally
wanted  than in hospitals, I give a patient nothing for two or
three days  but  arrowroot, panada, tapioca, gruel, etc.   This
enables  the congested portal system to  disembarrass  itself so
as to leave a clear space for the taking up fresh supplies.
  As you return  from a purely starchy, or purely animal diet,
to that mixture of the tAvo which is normal and necessary to the
healthy condition, or if you consider that  the case is  not bad
enough to oblige you to adopt either one or the other absolutely,
you may be of use by so arranging that the two sorts of aliment
shall not be together at once in the stomach.   For example, let
the  morning and  the evening diet be vegetable, and  then  let
several  hours pass before  and after a  mid-day meal of purely
animal food.
   Spare thus the stomach by giving it less to digest.  You need
not be afraid of starving your  patient by  diminishing the quan-
tity  eaten.  A  little digested goes much further than double the
amount  only swallowed.   For example,  you saw last  time we
went around the hospital a girl in the corner of Victoria Ward,
who had gained four pounds in weight during six days on the
sole allowance of three pints of milk and less than twelve ounces
of bread  per diem.   A man in Albert Ward  has also visibly
gained flesh in the same  time, though he has only a pint of beef-
tea beside what I  mentioned as the girl's  allowance.  He is too
weak to stand in the scales,  but the increase is apparent to the
eye.  Both these patients had,  till their admission  to St. Mary's,
been  trying to  strengthen themselves by meat,  and whatever
they could get, but  having gastric ulcers did not digest it, and
were rapidly emaciating.
  Spare it  also by giving it more to digest with.   I mean by
supplying an artificial gastric  juice.  This is  a mode  of treat-
ment so interesting,  from our being enabled to use it with novel
facility, that I shall make it  the subject  of  a separate  short 
576
DIETETICS.
lecture,* and  thus give fuller  details of its practical working
than I have time for to-day.

                             II.

   When the functions of the small intestines are off ivork, spgtre
them.
   Of acute diseases, this applies particularly to continued low
fever (during both its height and its sequelae), to enteritis, diar-
rhoea, and cholera; of chronic diseases, to ulceration,  tubercular
deposits, either in the peritoneum, Peyer's glands, or mesentery;
and, secondarily, to disease of  the liver.
   What are the functions of the small intestines in  relation to
different forms of aliment?  and  what colleagues have they that
can be trusted to take their duties during a temporary holiday?
The small intestines absorb all matters  soluble in  water  and
capable of endosmosis,  and have in that work  all the mucous
membrane of the  alimentary canal  to assist them.   They con-
vert starch into  sugar  before  absorbing it, in conjunction with
the saliva  and pancreatic juice.  They  dissolve albumen,  and
convert it  into peptone, in conjunction with the stomach.   But
in the digestion of fat they have none to help them.
   All ordinary fats and  oils, then, must be excluded from the
dietary  of patients affected with the last-mentioned diseases.
Even cod-liver oil, so peculiarly wanted in phthisical  cases, and
so easily digestible, will often become rancid in ulcerated bowels,
and aggravate the diarrhoea. If it does aggravate the diarrhoea,
depend  upon it more  harm than good is done by the remedy;
leave it off forthwith; the case  is an unsuitable one for it at that
stage of the disease. And if cod-liver oil disagrees, a  fortiori do
other less digestible fats.   I have known the mere skimming the
fat from broth make all the difference whether it were digested
or not,  and the leaving off such a simple article as butter render
a previously useless treatment immediately successful.
   Starchy food will agree only on the conditions that it is taken
in small quantities, and that the saliva is in a state to do alone
                       * See next Lecture. 
DIETETICS.
577
what generally it has the small intestines to help it in doing.
If the secretions of the mouth are deficient, it  will not agree.
Hence, in low fever, where the fauces and tongue are dry, you
will never see me order arrow-root, bread, panada, gruel, potatoes,
or any other amylaceous  article.  Where  they  are  eaten they
will be found unaltered in the faeces,  and not rarely cause con-
siderable  aggravation of the  symptoms.   I have  particularly
observed  this  in convalescent patients  after fever.   You  are
often surprised by an unexpected  relapse: examine the stools,
and there you see  lumps of potato, bits of pastry, or a mass of
starch granules.  The foolish friends have been disobeying orders
and giving these articles, which cannot act as a nutriment, and
do act as a poison.
   On  the other  hand, a phthisical patient, with a clean  moist
mouth, will  generally digest such things well,  in  spite of his
ulcerated  bowels, provided they are well cheAved  and not lumpy.
   Starchy food  is  exceedingly useful as a placebo to  persons
whom  you Avish  to keep  on low diet, such as rheumatic fever
patients, for  example.
   Albuminous food will agree, provided the stomach is doing its
duty.  But you must not forget that it has lost a potent colleague,
and be careful to prepare the food  so  as  to require only a short
time in digestion.  Milk must not  be  passed on  to the small in-
testines by being guarded Avith alkalies, but had better be soured
and made into whey.   Some of the curd,  broken up quite small,
may be taken with it.   Frequent  dilution with watery drinks,
and the use of artificial pepsine are of eminent use in these cases,
so as to insure the absorption of the food as quickly and as high
up in the intestinal canal as possible.

                             III.
   Where you wish to hasten absorption, dilute with water.
   This is so obvious a consequence of those hiAAS of osmosis which
almost every course of lectures—anatomical, botanical, physio-
logical, medical—has occasion to recite, that I will spare you the
repetition.
  The rule finds its chief application in  fevers,  but it must not 
578
DIETETICS.
be passed over in  ulceration of the  alimentary canal and  other
local disorders where protraction of  the process is painful, or in
emaciation and convalescence where we would not wish to  waste
time, but to give a person all the nutriment possible in the day,

                             IV.
   When you wish to delay absorption, dilute with solids.
  For  solids to act as diluents they must, of course, be incapable
of absorption; and the substance I principally refer to is  cellu-
lose in its various forms of chaff,  bran, husks,  skins, seeds of
fruit, and fresh green vegetables.   Cellulose being incapable of
chemical change there,  passes unaltered through the alimentary
canal,  carrying with it first the chyme prepared  for absorption,
and then adding its  bulk to  the faeces excreted.   Thus the ab-
sorption is  spread over a longer time and a  larger surface of
mucous membrane, the whole of which  is brought equally into
Avork.   A collateral  advantage is that the peristaltic wave acts
with more regularity when it has  a solid to propel  than when
the contents of the tube are fluid only.   The rule is useful, not
so much at the sick bed as for the prevention of sickness.  Many
persons are made ill by their diet being more immediately digest-
ible than they have been used to.  Scotch laborers on exchang-
ing oatmeal for wheat flour, Finn recruits on  getting bread at
headquarters without birch bark in it, country persons on coming
to London or  Paris,  often suffer from this cause.   The mode of
prevention is  obvious and  cheap;  cabbage, brown bread, and
charcoal offering types  of remedies readily altered according to
taste.
  In the administration of medicines something may be learned
from the same expedient.   Quinine occasionally will not  agree
where  powdered bark or decoction of bark will yet succeed very
well; and the  same may be said of the soluble and insoluble salts
of iron, of morphia and opium, and similar drugs identical  in all
but insolubility.  I believe the secret is  that a slower and more
graduated absorption is gained.
  I have elsewhere*  stated reasons for suspecting that gum and
          * " Digestion and its Derangements," book i, p, 260. 
DIETETICS.
579
gelatine may be classed among unabsorbable diluents of the food,
and are not really nutritious; but the argument is hardly suited
to a practical lecture.

                              V.

   When  the diet has been diminished, return gradually to the
normal in quantity and quality.
   I suppose mere instinct teaches this, for all acknowledge the
justice of it as a sort of  truism, and  agree that  a  convalescent
diet should  be  "light" at first, and afterward more "substan-
tial."  Perhaps,  in respect  of quantity error  is rare; but the
spirit of the rule in regard to quality is often lost by misinter-
preting the words  "light" and "substantial."   Scientific men
must  not think vaguely, and  you must have clearer ideas than
the old nurses, who so often hurt your patients by misapplying
these expressions.   I  shall  not, therefore, think I  am wasting
time by explaining what the rule really means.
   I formerly*  divided foods into such  as  are capable of direct
absorption without change, and such as require a previous change"
by the digestive juices;  and the same division has  also been
adopted by M. Bernard.  By subdividing the latter  class into
such as require only direct chemical change, and  such as require
disaggregation as well, we get three groups of aliments: the first
the "lightest" or most digestible;  the last the most  "substan-
tial;" the  second  intermediate,  M. Bernard observes that the
first necessitate but one physiological act;  the second, two acts;
and the last, three ;f  and, consequently, in that order demand a
proportionate amount of  labor from the system.
   Under the  first head  come Avater, essential oils, tea, coffee,
alcohol, ethers, salts,  sugar,  whey, gravy (containing osmazome);
asses' milk, with its small quantity of butter and casein, and its
large allowance of sugar, forms a transition, through cows' milk,

   * In " Digestion and its Derangements," book i, p. 195.
   f '• Memoire sur la Question suivante mise au Concours, par le Societe de
 Modecine de Lyon, pour Tannee 1856, &c, 4c,"  obtenue par M. le Dr. Bernard,
 fils.  Lyon, 1857. 
580
DIETETICS.
to the second class, in which some soups, lightly cooked ego-s,
well-boiled liquid starch; in the third class, tripe, oysters, sweet-
bread, and boiled chicken come nearest to the second, while the
power of digesting  hard meats (such as beef), or solid lumps of
starch (such as potatoes), shoAV that  the  full  normal powers of
digestion have been regained.  This  is something definite,  and
with this idea you will find  no difficulty in making a graduated
scale up which a convalescent patient may safely mount. 
               LECTURE  XLVIII.

                     CORPULENCE.

Obesity to  be  distinguished from fatty degeneration—Origin of
     adipose tissue from food either containing fat, or  elements
     capable of conversion into it, in excess over the respiratory
     consumption — Presumed possibility of  relief by  dietetic
     treatment—Tendency to obesity congenital and hereditary—
     Deductions from thirty-eight tabulated  cases as to the pecu-
     liarities of obese persons, and  the  exciting causes  of their
     condition—Obesity a comparative hypertrophy arising  out
     of a  comparative  vital deficiency — Principles of rational
     treatment thence  deduced—Difficulties in  enforcing their
     adoption—Specimen of detailed scheme of dietary—Limits
     to attempts at reduction—Drugs, such as liquor potassse, vin-
     egar,  iodine, and diuretics, discussed—Belts  and baths—
     Prognosis of obesity.

(St.  Mary's, Cc urse on Practice  of Medicine, part of Lecture, on
            "Hypertrophies."  December 1, 1862.)

   As Gulstonian lecturer, I delivered at the  College of Physi-
cians, in 1850, a course of lectures on Corpulence, and published
them in  a little duodecimo afterward.   As more than a dozen
years have passed by,  and the volume has been long out  of print,
I may be allowed to dish up  some old  matter, and to give you
an analysis of the  more practical parts  of what I  then  said at
fuller length before a more stately audience.
   In the first place, I carefully distinguished  obesity, or  the
inconvenient presence of a  large quantity of normal fat, from 
582
CORPULENCE.
fatty degeneration of existing tissues.  I traced the origin of the
true adipose tissue, shoAving, by well-established physiological
observations, that it is  derived entirely from the food eaten, in a
great measure directly, as fat previously ready made, and partly
from articles, such as  starch, readily converted chemically into
fat.  And I laid down the law, that for the formation of fat the
preliminary need is that the materials  be digested in greater
quantity than is sufficient to supply carbon in equal amount to
that consumed in the respiration.
   Thus you  see I  showed the probability that by modification
of diet we may be enabled to govern effectually at will the forma-
tion of fat in the human body.
   The next  point I aimed at making was that the excess of fat
which inconveniences a good many people OAved its  origin to  a
congenital, often hereditary, structure of body.   The peculiar-
ities of  this structure  of body are most  manifested in the  func-
tions of the assimilating organs,  especially in the intestinal ab-
sorbents, which  are more active than is  consistent with the size
of the body, and which are mostly concerned with  the osmosis
of oleaginous particles.  It is impossible of course to demonstrate
during life this important, perhaps  the  most important, pecu-
liarity.   But there are others which are capable of  being made
subjects of observation, and these 1 endeavored to make evident
and to base upon fact by a table of notes  I had made of the cases
of thirty-eight  obese persons then alive, or at least  alive when
the notes were written, and ranging in weight from about sixteen
up to thirty-six  stone (501 lbs.).
   From this  table I drew the  following deductions:
   1. That in corpulent persons the bony framework of the body
is  less massive than in the spare, as indicated  by the smallness
of their hands and feet.
   2. That the  skin  is  usually fresh colored and  thin, and  the
hair soft and fine.
   3. That in youth and middle age their digestive  apparatus
performs its  task  with rapidity.   The  action  of  the bowels is
generally natural,  and  in some cases loose.   But where the  ac-
cumulation of fat  is principally  in  the  omentum, a pendulous 
CORPULENCE.
583
state of abdomen is apt to be produced, causing a displacement
and dilatation of the intestinal canal that make it sluggish and
irregular.
  4. That their respiratory function presents a well-marked and
universal peculiarity.  The volume of air which they are capable
of containing in and expiring from their chest is considerably
less than the average quantity contained and expired by healthy
persons of equal height. The lungs,  instead of holding an amount
of air proportioned to the size of the body, seem of diminished
power.  "Thus the vital capacity  of H. T. (No. 35),  a man of
enormous  muscular strength, and in his youth remarkable for his
power  of  wind, ought to  have been at least 250 cubic inches;
instead  of that it is but 205.   Ch. S. (No. 9) held but 120 cubic
inches of  air, whereas she ought to have contained 206, accord-
ing to  the table* of healthy  averages published  by Dr. Hutch-
inson.   G. 0. R. (No. 18) when in  perfect health, in 1845, held
255 instead of 270 cubic inches."   The  lungs, therefore, in
obese persons are  small, and consequently their exhalation of
carbon  deficient.
   5. That the reproductive  powers  are by no means  defective,
some being very fertile and few barren.
   6.  That a tendency to obesity is  decidedly hereditary; though
the actual disease is not always developed in every member of the
family, and rarely  before adult  age.
   7.  That of the exciting causes in those predisposed to it, none
appears so  common as the occurrence of an acute attack of ill-
ness.   Next surgical injuries, and  next chronic diseases of such
nature  as to render confinement needful without injuring the '
constitution.
   8.  Taking a large quantity  of  liquid, of any description, is
another frequent cause of corpulence.   Of course, if  the liquid
be fatty at  the same time, such as  in the case of milk, still more
striking effects are produced.  And the mixture of alcohol and
sugar, such as we find in  beer and sweet wines, makes an equally
 deleterious drink.
   9.  Deficiency of sunlight has a similar effect.  A case is cited
 from the table (No. 13) of a man  employed in the cellars  of a 
584
CORPULENCE.
brewery, who, in spite of strict temperance, found  his bulk be-
come so great as to give him much alarm.  He obtained a situa-
tion as clerk in the same  establishment, and found the employ-
ment above ground cause a rapid reduction.
  It is made to  appear by what has  gone before  that the accu-
mulation of fat in the tissues is a partial and comparatiATe hyper-
trophy—comparative, that is, with the  proportions  of  the other
functions—connected with a comparative deficiency of the decar-
bonizing force of the lungs at least, and  possibly of other organs.
  Hence were deduced the principles of the treatment shown to
be rational by physiology and efficient by experience.
  1.  The dietary must be made the special  object of care; it
must be habitually different from that  of ordinary  healthy per-
sons, inasmuch as the obese  differ congenitally from others.
  2.  All  oleaginous articles  of  food should  be  rigorously ab-
stained from : fat, oil,  butter, milk, cream, maize, and  the  like,
must be entirely abstained from.   Sugar must be left  off.  The
amount of other hydrocarbons must be reduced to  the minimum ;
starch, in  the form  of  potatoes, bread,  &c, being looked upon
with extreme suspicion.
  3.  To avoid the transformation into fat of  starchy articles of
diet, Avhich it is impossible wholly to shun, it is  desirable  that
food should lie in the  stomach as short a time  as  possible, in
order that a fatty fermentation (so to speak) may not be set up
in it. Therefore very light meals at not too long intervals should
be taken, at times most favorable to  rapid digestion, and should
consist of substances easy of solution and assimilation.
  4.  Liquids should be taken at  the end, and not at the begin-
ning of the meal; so as not to impede the mixture of the gastric
juice with the mass.
  5.  The liquids taken  should be small  in amount.
  6.  Inasmuch as excess of alcohol  diminishes the  excretion of
carbon (as shown by Bb'cker's experiments) the quantity taken
should be limited to that found by experience in the case of each
individual to quicken the digestion.
  7. Exercise should be taken to sufficient extent fully to em-
ploy the muscles and lungs.  But it should not exhaust com- 
                       CORPULENCE.                    585

pletely the  strength,  otherwise  an  imperfection  of  digestive
powers is the result.
  8. The exercise should be taken in  the open air and  sunlight.
  9. As in the management of all congenital tendencies, medi-
cines  must  be looked upon  as wholly secondary  to  regimen.
Those  adopted should be  such as  tend to increase  the meta-
morphosis of fat and its habitual evacuation in the  form of car-
bonic acid.
  10.  The quality of the food is of more direct importance than
its quantity.
  The hourly watch over  the instinctive desires, which must  be
observed by one desirous of reducing his corpulence, makes it a
serious thing to advise the undertaking of the necessary regimen.
Many of us shirk  giving  our  advice, because we feel  confident
that the patient has not strength of mind to follow  it.   He that
commences it must be taught to vieAV himself as his Avorst enemy.
Like Epictetus'  philosopher, he must "mount guard and plot
against himself."   We must feel very sure we are doing Avhat is
right before we  take  such a  responsibility, otherwise hesitation
will produce wavering, and wavering shake the confidence of the
patient, and all hope of benefit be lost.  All advantages should
be taken of adventitious circumstances : to add importance to the
enforcement of the rules,  they should be written  out  clear and
exact,  and  enjoined as strictly as if they were moral  precepts.
If left  to general and verbal instruction, their chance  of being
observed is small indeed.
  At the same time the dietary prescribed and the hours fixed
for meals should not be such as it is  impossible for men actively
engaged in business to submit to.  In detail  you may lay down
some such scheme as this—
  Breakfast to be taken early and to form a substantial meal,
so as to prepare for the day's work.   The solid part of it to con-
sist of tAvo mutton-chops with the fat carefully removed, grilled
or plainly cooked, and captain's or ship biscuit.   Sometimes a
pigeon, a bit of game, or  a fish of about the same  weight, may
be substituted for the mutton-chops.   For liquid to follow, if the
patient will take soda-water or  plain water, so much the better.
       38 
586                     CORPULENCE.

If he cannot get over his craving for a cup of tea, let him take
it in the Russian fashion with a thick slice of lemon floating on
the top instead of milk.
   Luncheon at one may consist  of the same ingredients, only
instead of so much liquid,  a glass of half-and-half, sound claret,
or burgundy and water is more agreeable as well as more whole-
some.
   Dinner to be taken earlier than  is usual now-a-days.   Six
o'clock is the best hour.   Soup and fish must be  eschewed, and
plainly cooked  mutton and beef, especially the former, made the
staple of the meal.   A bit of  biscuit  may accompany it, and as
vegetables, those which contain much insoluble chlorophyll and
little starch, as cabbage, lettuce, spinach, French beans, or celery
in  small quantity; but no potatoes.  In short, the dinner should
be as much as  possible that of a carnivorous  animal.  Sweets,
pastry, eggs, and  beer, must  be  avoided like poison.   Next to
water, claret is the best drink;  champagne  (according to the
well-known writer on this subject, M. Dancel), the worst.*
   Here should  end the serious feeding for the day.  A cup of
Russian tea, or a water-ice, may  be taken during the evening,
but a glass of water or soda-water is better.
   The  emptiness  or  sinking  at the pit of the  stomach felt by
those who begin a diminished  diet,  and  which they often are
driven to remove by eating and often (still worse) by drinking,
is  best relieved by chewing a  bean or two of  coffee.   A supply
sufficient for all wants is easily carried in the  waistcoat pocket.
   I  do not think it advisable to  burden the conscience of the
patient by laying down the number of ounces of each food which
should be consumed.   The nature of the food is of more import-
ance than its exact quantity,  and the exhibition made by  eating
from scales is annoying to touchy persons.
   Some  persons are able to  do without the dinner  at all, and
indeed in 1850 I Avas  inclined to urge the adoption of this plan,
  * M. Dancel  cites an instance of  a young  lady who, with the intent of pre-
serving her symmetry, fasted four days every week upon champagne and " mpr-
rons glacees" alone. Her outline grew out of all drawing with frightful rapidity.
But she regained it on resuming a more rational diet. 
CORPULENCE.
5S7
and  to subsitute for it biscuits and water taken standing up or
while walking  about.   This is not  a scale  of  diet absolutely
unattainable.   A retired butcher and pugilist whose case I  had
tabulated (No.  35) had adopted it for some years with the great-
est comfort to himself.   He was able to work upon it in a most
violent manner in a small garden he cultivated for himself in the
suburbs.  He had reduced himself from 20 to 17 stone; whereas
his brother, who had not the same strength of mind, had increased
to 23 stone.   Persons of more refined education have, or ought
to have, the same power over their appetites.  J. R. (No. 7) re-
duced himself from 22  to 18 stone, and has  sometimes brought
himself down to 17.  But he found no particular advantage from
being of the lower weight.
   This  latter remark  leads me to observe that in all persons
there is a certain Aveight, to be found by experience, called by
trainers " the fighting Aveight," necessary to  full force, and  that
to be lighter than this tends to injury of body and mind.  And
I must also  say that  mental workers do not  bear abstinence so
well as bodily workers, and that I do not think it advisable for
a man Avhose mind is much  engaged to attempt the omission of
the usual evening meal.  But he may at it feed  his nervous sys-
tem with meat, and not his adipose tissue with starch and oil.
   As to more strictly medical remedies, I have found full doses
of liquor potassae at  the beginning  of  the treatment very bene-
ficial, especially in persons who are incapacitated  by bodily in-
firmity from taking  sufficient exercise.  I presume that  it  acts
by increasing the vital powers of metamorphosis, by saponifying
in part the fat contained in the blood and enabling it to be burnt
off as carbonic acid.   But I must  repeat again  that  the  pre-
scription of drugs is strictly secondary to that of diet.   Where
the  size of the abdomen impedes the walking, a  belt,  such as
pregnant women wear, is useful.  A feAV sweating baths are also
beneficial at the commencement, as they bring the skin into good
condition ; but as an habitual resource they are  debilitating.
   Of vinegar  and iodine as medicines I have  no good to  say.
The moderate use of iodine certainly does not  cause the disap-
pearance of healthy fat.  Indeed, it  has been noticed by Lagol,*
              * " Essays," translated by Dr. O'Shaughnessy. 
588
CORPULENCE.
and is matter of daily observation at our metropolitan hospitals,
that patients frequently acquire a considerable amount  of  em-
bonpoint during the time they are taking iodine.  The cases of
tumors and of fat are very distinct.  As Dr. Pereira remarks,*
" The enlargements Avhich these agents  (mercury and  iodine)
remove are not mere hypertrophies;  their structure is  morbid,
and they must  in consequence have been induced by a  change
in the  quality of the vital activity ; in other words, by morbid
action.   Medicines, therefore, which  remove  these abnormal
conditions, can only do so  by restoring healthy actions."   But
the action which causes the deposition of fat in the adipose tissue
is of a healthy nature,  and harm rather than benefit is to be
expected  from the  drug under discussion;  that harm  which
always accrues from a valuable remedy wrongly employed.
  Of diuretics, as recommended by the older physicians, I have
no experience.   But as there is no secretion by which less fatty
matter is excreted than that of the kidneys, they do not seem to
promise well.
  The prognosis depends very closely upon the age at which the
obesity has commenced.  To that form of the disease which begins
at birth,  and goes on increasing during infancy and childhood,
cure is unattainable. It is a sort of monstrosity, and the subjects
of it usually display some  other  bodily malformation  or a  de-
ficiency of intellect.  When it begins  in childhood or about the
time of puberty, we  must not be deterred, by the circumstance of
its being  hereditary, from trying to  remedy the inconvenience.
We cannot truly reduce our patients entirely to the average  size
and weight, but we  may enable them to pass life in comfort  and
usefulness.
  The later  the disease begins, the more controllable it is by
management; until the prime of life is passed, and then  old  age
impedes in some degree the benefit we  may confer, not by  ren-
dering our  measures inert, but by  preventing our employing
them quite so actively as Ave should have done earlier.
             * " Materia Medica," vol. i, p. 19-6. (edit. 1848). 
LECTURE  XLIX.
                      ON PEPSINE.

 History of the use of gastric juice in medicine—Difficulties of its
     use obviated by preparation—Experience of its use in a few
     typical cases—Limits of advantages gained—Details of ad-
     ministration.

      (Extra course, St.  Mary's, Summer  Session, 1857.)

   The  attempt to turn the peculiar poAvers of gastric juice to
 adA'antage in  medicine  dates  from  remote  antiquity.  Pliny
 mentions the fluids of the stomach of sucking animals as in com-
 mon use  for a variety of purposes, such as  curing disorders of
 the  intestines,  allaying  the  inflammation from spiders'  bites,
 stopping  bleeding from  the nose, preventing snakes  attacking
 you, and  in short against poisons in general.*  Asclepiades also
 recommended it as a means of dissolving milk which has clotted
 in the stomach in dangerous excess.f  Galen, arguing probably
 on his physiological theories, attributes a " digestive" and " dry-
 ing" power to it.   But he also mentions having felt in his own
 person the relief afforded by it to weight at the epigastrium after
 drinking  too much milk, and  advises a trial of  it in  abdominal
 disorders.  He remarks  that the stomach  of one animal differs
 from another only in degree of poAver. He gives a warning also
 that the boiling temperature destroys its virtues, as Ave noAV well
 know; for he found that  hens' and  cormorants'  stomachs, when
cooked,  were perfectly inert.!
  * See the places referred to in any good index to Pliny's " Naturalis Historia,"
article " Coagulum."
  f Quoted in " Galen on Antidotes," ii, ?.
  I  "Galen on Simple Medicines," x, 11; xi, 13. 
590
ON PEPSINE.
   On the strength of his rational advice the coagulated milk and
fluid taken from the paunches of several young animals Avas a
remedy sufficiently often used to retain a  place in European
pharmacopoeias up to the first  quarter of the last  century.  This
is the  explanation given  by Dr.  Schroder, a Dutch pharmacol-
ogist, who wrote in 1672,* of  the method of preparing, and  the
reason for using, " Coagulum  leporis,\ hcedi, agni, equi," &c.
   The disagreeable nature of the remedy in this  form probably
drove it out of  use, for the last London pharmacopoeia in which
it appears is that of 1677.   In the edition of 1721, the only re-
presentative of gastric juice is  the mucous membrane of the hen's
stomach—" Pelliculse stomachi gallinse interiores."%  In 1746
this also had vanished, along Avith " stercus bovinum, humanum,
pavonis," and various  similar  remedies Avhich  patients  had  got
too civilized to submit to, without at  least  knowing the reason
Avhy.  Thirty years later, the immortal experiments of the Abbe*
Spallanzani  threw a  bright neAv  light into  the subject of di-
gestion, and taught  the true nature of the gastric juice.   With
muchjuster views than of old,  its use in medicine was again rec-
ommended. Dr. Mongiardini, of Pavia, a pupil of Spallanzani's,
at his master's instance treated indigestion successfully with the
gastric juice of crows. Another pupil employed it as a lithontriptic,
to break  down calculi by destroying  the animal matter which
holds  them together.   M. Senebier, a  clerical pupil, suggested
that its antiseptic power  might make it  useful in  surgery,  and
advised a trial  of  sheep's paunch as  an application to ill-con-
   * " Pharmacopoeia Medico-Cbemica.''  Amstelodami, 1672.
   | The rennet of the leveret is now usually wasted, but the  Roman dairymaids
preferred it to that of any other animal for making cheese.  Varro ranks it as
the best, then that of the kid, then that of the lamb.  (Varro de "Re Rustica,"
lib. ii, xi, 4.) The Roman physicians also had the same preference. Sammonicus,
in a prescription for" Colus" (Colic), says, " Aut pavidi leporismadefacta coagula
pota."  ("Quinti Serini Sammonici  de Medicina, Prnecepta," ;' De Colo com-
pescendo.") This accounts for its  being named in pharmacopoeias which  omit
other rennets, as for instance in the Vienna priced drug list of 1613 and 1646,
in which its price varies from six to sixteen kreutzers the half ounce.
   J This is another Italian expedient for coagulating milk rarely used  now.
Paliadius recommends it for  making summer cheese, when you cannot get
leveret's rennet.  ("Paliadius de Re  Rustica,"  " Mensis Maius," ix.) 
ON PEPSINE.
591
ditioned  wounds.*  M. Boyer, of Strasburg, found that it  de-
stroyed the poison of the viper, and  thought it might be an
antidote to snake bites.f
   With all the obvious advantages Avith which the remedy rec-
ommended itself  to the physician, there was the insurmountable
difficulty of obtaining it in a form fit for general use internally.
It Avas of course necessary to administer it at the same time with
the food, and any nauseating substance then given does more
harm than good by taking away the already squeamish appetite.
Dr. Latham, who practiced in Paris some years ago, informed
me that Laennec had a  preparation  of concentrated  gastric
mucus, which he  recommended with great enthusiasm;  and Dr.
Haudfield  Jones at  this hospital gave in  some cases a cold in-
fusion of pig's stomach, acidulated with muriatic acid.   In this
form, however, the remedy is disagreeable and inelegant.
   But the  matter showed itself in quite a new light when an
ingenious French pharmacien, M. Boudault, at the instigation
of Dr. Corvisart, made the very elegant and agreeable prepara-
tion, called " Poudre nutrimentive."   It is  simply pepsine from
the sheep's stomach dried on starch, with lactic acid added or
not according to circumstances.  You have during the past winter
(of 1856-7) seen me prescribe  it to numerous  patients in the
Avards, and I have also employed it frequently in  private  prac-
tice,  so that I think we are  in a position now to form an  idea
of its value to the practical physician.
   These hospital cases in Avhich I have administered it with ad-
vantage are, six  of phthisis  pulmonalis, one of  cancer near the
 pylorus, two of gastric ulcer, one of hysterical vomiting, tAvo of
 nausea,  one  of hysterical  pain after eating, tAvo of  atonic  pain
 after eating, one of atonic gout, one of dilated stomach, one of
 gastric flatulence, three of low fever, and two of pneumonia. In
 these the full  benefit  Avhich physiological reasoning would lead
 us to expect from the remedy has followed.
   [These  cases fairly  represent my  since  experience of the
 remedy.]
   * "Experiences sur la Digestion de  l'Homme, par l'Abbe  Spallanzani, avec
 des Considerations," &c, par Jean Senebier.  Geneve, 1783.
   f Falck " Handbuch der Arzneimittellehre," vol. i, p. 275. 
592
ON  PEPSINE.
   I have also injected it per anum, mixed with food, in a case of
ulcerated oesophagus, and in a case of manio-hysterical vomiting
and  dysphagia.    But in  neither did it  appear  to delay death.
Probably the patients were already too far gone.
   Several  other  cases  of atonic pain after eating, in which I
have  given pepsine, I  have  not since   heard of, but probably
should have done so had any harm happened.
   In  one case of chronic dysentery it was stated to cause nausea
and loss of appetite.  In one case of consumption, and in one of
pendulous tumor of the abdomen, it  purged the  patient.   These
are the only instances of inconvenience that I have been able to
connect with the administration of the remedy.
   The  phthisical  cases have been  .those where  a  progressive
anaemia was accompanied by an inability to digest meat or other
albuminous food.   This inability is exhibited  in three ways:
first,  by meals of such diet, even in very small quantities, being
followed by a sense of great weight  and oppression at the epi-
gastrium, and sometimes  by actual vomiting;  secondly, by the
passage of loose fetid stools containing much unaltered muscular
fiber, lumps of fat, and such  like remnants of a recent meal;
thirdly, by entire loss of appetite  and an instinctive  nausea
roused by the bare idea of flesh food.  Often all three phenom-
ena exist together;  but each one may be found  separately, and
is of itself  a sufficient indication of the patient's  state.
   The  state of the stomach when  these  symptoms occur is
probably an excessive secretion in the upper part of the aliment-
ary canal of alkaline mucus, which envelops the food, and pre-
vents the action of the gastric juice upon it.  The consequence
is, either its rapid ejection unaltered, or its decomposition, and
the evolution of fetid gas.  If vegetable  food be mixed Avith the
meat, it ferments into  acetic acid, and thus you may have sour
eructations from  the stomach, and diarrhoea  arising out of the
want  of gastric juice.   If this excessive secretion of mucus is
recent and moderate, the  appetite  may  remain  uninjured, nay,
may sometimes be morbidly increased;  but a  long continuance,
joined to  progressive pulmonary disease, is sure to  induce  an
anaemic condition of the  alimentary canal, which results in a
disgust for food. 
ON  PEPSINE.
593
  Now this state of things it  is very important to check.  If it
goes on, the patient cannot take in sufficient quantities the meat
which  should refresh his degenerating muscles and  pale blood;
he cannot take the cod-liver oil which is to replace his emaciating
tissues ; he cannot, from weakness, take the exercise which might
renew  his  whole diseased  system.   And I do not know any
remedy which  more readily, obviously, and  directly does Avhat
it can  toward checking such a state than pepsine.   It does im-
mediately and surely what it can do ;  but then  that is not very
much.   Raise  not  your expectations of its power  too high, or
you  Avill  be disappointed.   Understand  clearly Avhat position
this  agent  holds in the rational  materia medica, and then you
will  know what good results  you may demand Avith reasonable
hopes  of obtaining them.  It is an  artificial,  and  therefore  a
partial, substitute for a natural process.  Gastric juice prepared
by a healthy  animal is mixed Avith  the  food,  instead of that
which  the patient's  stomach ought to prepare.  And  it acts in
the body just as it would out of the body under the same cicum-
stances of  heat and motion.   The chewed meat is  dissolved by
it just  as you see the white of egg suspended in this beaker dis-
solved  by it; and the putrefactive process is arrested by it in the
intestinal canal just as  you  perceive the putrefactive process  is
arrested by it in the experiment under our eye.  For  you may
observe that this albumen suspended in pepsine is  quite  sweet,
whereas that soaked  for the same time in saliva is most fetid.
It is, therefore, a substitute for the natural secretion, and to a
certain extent supplies  its place.
  But, like all  imitations of nature,  it is coarse and imperfect.
The  solvent, instead of being gradually and continuously poured
on to the outside of the mass of food, is mixed up in the middle
part of it,  and acts merely chemically, Avithout any of the me-
chanical and physiological helps belonging to natural digestion,
and  consequently soon  exhausts  its  energies.   The chyme, or
albumen prepared for absorption, instead of being wiped off and
SAvept  away by the stomach, remains  for some  time mixed up
Avith the pepsine, so that the latter is  not freed for the solution
of a neAV portion.   By  this imperfect  process only a very small
portion of meat can be dissolved at once. 
594
ON  PEPSINE.
  Hence, if you hope that by administering pepsine Avith it, you
can get a full and sufficient meal eaten at once by your consump-
tive  patient, you will fail  in  your expectations.  Give half a
mutton-chop with the remedy the first  day ;  and if that is  di-
gested Avell, a whole chop next; but then  you have got to the
end of your tether, and  the digestion of a larger quantity will
not be at  all assisted by artificial solvents.  After a chop has
been  digested  and  absorbed twice, or  even once a day by this
means for  about a week or ten days, the expedient  has prob-
ably done all the Avork that can be fairly asked of it,  and the
stomach has either recovered  sufficient energy to digest alone,
or Avill require different  remedies to enable it  to do so.   There-
fore, for the pepsine to be completely successful in these cases—
first,  it must be given  only to  those who  cannot digest half a
mutton-chop Avithout it;  secondly,  more than  a chop must not be
given at once;  thirdly, it must not be  required to go on alone
improving  the  patient's  condition for more than a week or ten
days.
  But for  the  time named I  advise its being given alone, and
the action not interfered with in general by other drugs.  Many
will  really prevent its chemical effect,  and all Avill confuse your
judgment  of the  advantage  gained.   In  this  time  you will
generally find that the repugnance of  the patient to meat has
been overcome, and that a small quantity of it at a time can be
relished and digested ; the morbid fetor of the stools diminishes,
and  the  flatulence and  distress  arising  during their  passage
through the bowels ceases.   A renewed strength  and a  renewed
power of assimilation commence, the sleep becomes more natural,
Avith  the diminution  of  night-SAveats and  hectic; while, at the
same time,  the  pulmonary symptoms  of  cough,  dyspnoea, &c ,
relax, and  a step  at any rate  is taken in  the right direction
toward the  cure of the  disease.  It  is  remarkable, too, what a
slight improvement in  the digestive  powers will often enable
iron and cod-liver oil to be taken.   These  drugs are, you know,
the main stays in  the treatment of tubercular consumption, and
any  expedient, hoAvever temporary, Avhich will pave the Avay  for
their administration, is a great boon.
   It would  not suit the  plan of the present lectures to  quote in 
ON  PEPSINE.
595
detail  these  consumptive cases.   They differ much from  one
another in their unessential characters—namely, in the stage
and  general  phenomena of the disease, in age  and sex of the
patients; while they all closely resemble one another in essential
points—that  is to say, in those which I have described as indi
eating a mucous condition  of  stomach, preventing  the  gastric
juice being poured out on the food, and finally leading to anaemia
and  atrophy of the secreting  membrane.   They resemble  one
another also in exhibiting an immediate and uniform ameliora-
tion  of limited extent.   In  one man  who had loss of voice, ap-
parently from crude tubercle in  the lungs, with ulcerated  trachea,
the amelioration of voice and cough continued so long, that I let
him remain three weeks taking pepsine alone without other drugs;
but,  then, he also continued to improve more aftenvard on cod-
liver oil, so that he might just as well  have commenced it sooner.
In another, Avho had tubercular ulcers in the bowels, afterward
fatal, there Avas an  idea that  the pepsine caused a relapse of
diarrhoea; but I suspect  the coincidence Avas  accidental.   These
are the only cases where it appeared to do  more good  or  less
good than I have attributed to it.
  The case I alluded to of cancer near the pylorus is an instance
of a disease  necessarily fatal being  still worthy of the careful
attention of the medical man.   When  the  patient came  under
my care, she Avas unable to keep anything at all on her stomach:
every solid, even an ounce of beef-tea, Avas vomited unchanged
within half an hour of its ingestion.   She had been taking prus-
sic  acid, soda, creasote,  opium, and  a variety of remedies with-
out benefit;  and, as might be  expected, Avas dying rapidly of
starvation.  I ordered her immediately half a mutton-chop, with
fifteen grains of Boudault's " poudre nutrimentiA-e," twice  a day,
and an ounce of milk and lime-water eArery two hours.  She kept
all that down ;  it passed the pylorus, and  nourished her so  far
that  she had a good night's sleep, and  the next day was able to
take  a whole mutton-chop.   So she went on for three weeks,
gaining flesh, losing her pain, and acquiring a cheerfulness about
the future unwarranted by the  gloomy prognosis which truth
compelled me to give her.   So far  all Avas  right;  reason  had
reasoned well.   But I feel it a duty to tell you the mistakes I 
596
ON PEPSINE.
make, as much as the occasions on Avhich  I act wisely.   And I
find recorded in  my note-book a warning, which I advise you to
profit by, of the importance of "letting well alone."  The patient
from the first had jaundice, with pale stools and bilious urine;
and now, I thought, had sufficiently recovered strength to bear
an endeavor to make  the liver clear the blood of its bile a little
more  briskly.   I therefore  gave her some  nitro-hydrochloric
acid, which  is often of  great  use under similar  circumstances.
But the result was  most unfortunate.  The vomiting returned
with violence.  The drug Avas left off, and the vomiting  stopped,
but not before the ground gained had been lost.  Then again,
contrary, I  must say, to my Avish, it was judged expedient to
give the patient  mercury,  and she rapidly sank.   The jaundice
was then proved to  be dependent on cancer of the gall-bladder.
Now, here it is impossible not to alloAV that life Avas lengthened
by artificial pepsine,  and  would  have been further  lengthened
but for a meddlesome propensity in  both physician and patient
for continuous improvement.
   In one case of hysterical vomiting, and tAvo of nausea prevent-
ing a due  quantity of  food being  taken  by hysterical persons,
this remedy has  appeared  to enable the patient to SAvallow meat.
The mere nutriment thus  imbibed has improved the appetite for
future meals; and the valerian and  salt sponge-baths afterward
administered seemed  to have a more rapid effect than without it.
The rational  explanation  of its good influence is, that both in
hysteria and  anaemia the secretion of gastric juice is apt to be
irregular and deficient,  and that the morbid processes  here act,
as is so often the case,  in  a circle; the non-secretion of gastric
juice still further starving the blood and aggravating the hysteria
and anaemia, and that further aggravation again  diminishing the
secretion.   But once breaking  the magic  chain, and  enabling
even a single meal to be  well digested, begins a march tOAvard
health which it is comparatively  easy to guide afterward.
   Closely connected  Avith the last-named complaints is, in  the
female sex, atonic gastralgia.  Indeed, I may say  it is practically
identical.  At the same  time that the gastric juice is imperfectly
secreted, the muscles of the stomach refuse to perform  the peri-
staltic motions with sufficient activity.   Hence not  only is  the 
ON PEPSINE.
597
alimentary mass a greater inconvenience than it ought to be, but
it actually lies longer than usual in the first portion of the canal,
as may be found on percussion of the epigastrium.   Atonic gas-
tralgia is a common consequence, in the educated classes, of ex-
cessive mental  and  sedentary labor.   Where this is very great,
I have found pepsine of some use; but in the slighter cases, which
more frequently come  before us, I have not  seen any apparent
benefit accrue from it.  A change of habits is here the only per-
manent remedy, and of drugs strychnine is the most efficacious.
I believe M. Boudault prepares a poAvder in which strychnine is
combined with pepsine and lactic acid.  I presume it is for cases
of this sort that it is intended, but I have not tried  the combi-
nation.
   In a case of diarrhoea  and  mucous vomiting occurring in an
old victim of atonic gout, the stools became more  natural and
less  frequent, and strength was regained, on  taking pepsine and
mutton-chops, instead of  opium  and  acetate of lead.
   As cases of acute disease have a habit of getting well of them-
selves, they are not, of  course,  such good tests of the essential
benefit derived from remedies; and it is only by comparisons on
a large scale that one could speak of fever and pneumonia being
benefited by pepsine.  There seemed,  however, in those alluded
to, an immediate improvement to  take place in the appearance
of the tongue and of the  evacuations;  and it  is impossible not to
think that the amelioration  in  the  alimentary canal thus made
evident would tend to lessen the mortality of these diseases.
   On the whole, then, I cannot but  conclude  that  Ave  have in
artificial  pepsine a valuable and safe remedy,  and  an important
aid  to rational medicine.
   The way in which I have  given  it  has  depended  on the diet
on Avhich the patient is placed.  If regular meals are  eaten, then
it is best taken spread as a  sandAvich between tAvo thin slices of
bread at the commencement of the dinner.   Fifteen grains of
 the  starchy powder  is the usual dose for an adult.  If the patient
is so ill  that  the food is obliged to be administered more fre-
 quently and in small  quantities, so  as to  keep up a continuous
supplv,  smaller doses of the  pepsine powder may be given in a
 draught every four or five hours. 
LECTURE  L.
                    ON  ALCOHOL.

Experiments showing the action of alcohol on the vital metamor-
    phosis of the  body,  with a running commentary on each—
     Opposite opinions about the use of alcohol—Best  guide to
     therapeutical  use is physiological observation of its action on
     the  healthy body—What is a  stimulant?—The  effect of
     alcohol is arrest of nervous function—How it comes to be an
     indirect restorative—Rules for the administration of alcohol—
     Form of administration.

                     (St. Mary's, 1861.)

  The porter of our school and the late Mr. Hall Smith assisted
me, in 1860, in a series of experiments on the  effects of alcohol.
The melancholy circumstances of the latter's death brought them
to an abrupt  termination,  and made the prosecution of the in-
vestigations  painful to  me.  But still let us  see  what can be
done with the facts already collected, and try whether  they  can
be made of serA'ice to clinical medicine.
  I.—W. M.  Age thirty-eight.  Weight 254 lbs., taken at noon
every day.  Habits of life extremely regular.   He walks half an
hour before breakfast, daily; breakfasts at eight on tAvo cups of
coffee, bread and butter, and a slice of cold  meat; dines at  one
on beef and mutton in regular  quantity, potatoes, and pudding;
has tea at five, two cups, with bread and butter; sups at nine,
on  bread and butter, or cheese, with half  a  pint of ale.   He
sleeps six and a half to seven hours.   His boAvels are open once
daily. 
ON  ALCOHOL.
599
  A view of the normal amount of metamorphosis in the body is
afforded by this table:
	Quantity in cibic centi-metres.	Specific gravity.	Urea in grammes.	Chloride of sodium in grammea.	Sulphuric acid in grammes.	Phospho-ric acid in grammes.	Uric acid in grms.
Amount of urine and its several parts made in 23 days, in perfect health and on usual diet, . . Ditto in 15 days, Mean daily amount, .	24,970 1,085	23-518 1-022	728-437 31-671	174-625 7-592	51-307 2-230	44-719 1-944	2-813 •187
  The effect of the addition of a moderate quantity of alcohol to
the daily meal is shown by the next:
Date.	Quantity in cubic centi-metres.	Specific gravity.	Urea in grammes.	Chloride of sodium in grammes.	Sulphuric acid in grammes.	Phospho-ric acid in grammes.	Uric acid in grammes.	Daily quantity of be«t French brandy added to meals in ounces by mea-Bure.
Sept. 13 li 14 " 19 " 20 " 21 " 22	1,020 1,570 1,050 1,200 1,110 770	1-024 1 022 1-026 1025 1-023 1-026	30-708 39 746 38-795 42-695 37-974 30-030	7-140 10-990 8-400 9-600 6-937 6-160	2-017 2-579 ^•456 2-622 .2-212 2-065	1.469 •848 1-890 1-944 1-798 1-386	■■! • • i • -J	4* 3 6 viz., IJ at breakfast, din-ner, tea and supper.
  On the next day the appetite for food was observed to be some-
what less than usual, and the experiment ceased; for any change
of usual weight, health, feeling, or habits, of course would vitiate
the  result of an investigation conducted in this form.
  These few experiments lead to the belief that  the taking a
moderate quantity of alcohol with food—
  (1st.) Increases the quantity of urea  daily excreted, and in a
much minor degree that of the chlorides and sulphates.
  (2d.) It does not increase the aqueous part of the urine.
  (3d.) It decreases the quantity  of phosphates.
  (4th.) The augmentation is temporary, and after a time is fol-
lowed  by a reduction to the normal measure, which reduction  is
coincident with a loss of appetite.
  The increase in the quantity of urea  excreted would  seem to
show that the renewal of the muscular tissues, the appropriation
of neAv flesh, and the removal of old flesh, go on more  actively 
600
OX ALCOHOL.
for making a moderate  quantity  of  alcohol part of the daily
food.
   The non-increase  in the  aqueous secretion, and the decrease
in the phosphates, would seem to show that this change is not
merely a general augmentation of the  destructive metamorphosis
of the body; for if it were, the whole of the constituents of the
urine  would be equally affected.
   In short, the circumstances seem to indicate  that a moderate
dose of  alcohol acts by temporarily augmenting the digestive
power of the stomach, helping it to appropriate more thoroughly
the food.
   The decrease in the excretion of  phosphates is an interesting
observation.  The  chief source of phosphorus in the  urinary ex-
cretion must be nerAre tissue, and it is  certainly  something more
than a mere coincidence Avhen Ave  see a reagent, Avhose effects
are most peculiarly  manifest on the  functions of the nerves,
diminishing Avhat we believe to be the metamorphosis of that
portion of the body.   We can hardly hesitate to call alcohol  an
arrester of nerve-life, and consequently a controller of nervous
action on the rest of the  frame; and it would  be wise to cast
about for explanations which would  harmonize this with its other
operations.
   II.—Letitia C,  a  prostitute, aged twenty-three, acquired the
habit, during a year  of her being on  the town, of frequent tip-
pling to drown care.  Standing by her  bed on the 14th of August,
she suddenly fell on  to it, not from  apoplexy, but from complete
paralysis of the right leg and arm without a fit.   On her admis-
sion to St. Mary's, tAvo days afterward, the power had returned
in a great measure to the limbs, but the right lingual and facial
muscles were still  quite  paralytic.   As far as  one could judge
by external phenomena, all the viscera except the brain were in
a healthy state.   She stayed in the  hospital till  September 6,
when  she Avas offered a place  as servant, and a slight impediment
to speech remaining I considered  not sufficient reason for her
passing  over so good a chance of bettering her social  state.
During the time she  was under observation  no  drugs Avere pre-
scribed for her;  she rested on her bed the greater  part of the 
ON  ALCOHOL.
601
day, and sauntered about the ward and garden the rest; she was
kept on "broth diet."*
  The amount of urine and of its chief constituents excreted by
her on all the days Avhen circumstances allowed it to be all col-
lected is shown in this table:
Date.	Quantity in cubic	Specific	Urea in	Chloride of sodium	Sulphuric acid	Phosphoric acid
	centimetres.	gravity.	grammes.	in grammes.	in grammes.	in grammes.
Aug. 17	252	1-018	5-915	1-389	?	■409
" 19	880	1-006	12-729	4-400	?	•396
" 20	240	1-014	4-529	2-040	?	None.
« 21	270	1-007	3-429	•337	•206	•061
" 22	360	1-011	5-280	2-340	•212	A trace.
" 23	1,000	1 007	15-353	3-500	■878	•540
" 24	1,280	1-007	14-504	4-480	•715	A trace.
" 27	570	1-008	9-405	1-425	•436	A trace.
" 28	1,030	1-007	10-979	3-862	•596	•494
" 29	730	1-010	9-252	3-285	•423	A trace.
" 30	1,320	1-008	13-645	5-120	1-039	?
Sept. 1						
2 " 3	1,650	1-008	22-027	1-358	7-425	?
" 4 " 5	900	1010	13-231	2-925	>790	•162
  It will be  noticed that in the last three observations there is
an improvement in the amount of those solid constituents of the
urine which are an evidence of the force of vital metamorphosis.
This improvement  was  coincident with  the  addition  of three
ounces of brandy to her diet card, an ounce and a half at dinner,
and an ounce and a half at supper daily.
  In this case, then, Ave again find alcohol appearing to aid vital
force of metamorphosis when taken with food.   The quantity of
urine, of solid matter in it, of urea, of chloride of sodium, and
of sulphuric acid  is augmented.  The phosphates, truly, are
remarkably deficient, but that probably depends  on the arrest
to the reneAval of brain  substance which the injury to her brain
entailed.
  III.—The first subject, W. M., at another time tried the effect
of alcohol taken in another way, namely, in small  divided doses.
  * Tea, 2 pints, with 3 oz. of milk, and sugar q. s ; Bread, 12 oz.; Butter, f of
an oz.; Broth, 1 pint, with 4 oz. of boiled meat; Gruel, 1 pint.
       39 
602
ON ALCOHOL.
Six ounces of brandy were drunk daily in drams of half an ounce
every hour from 9 a.m. to 9 p.m.
  This is a record of the results:
Chloride of	Sulphuric	Phospho-	Uric
sodium	acid	ric acid	acid
in	in	in	in
grammes	grammes	grammes.	grammes.
5-320	2-210	1-299	•008
6370	2 375	1-474	■259
6-687	2-246	1-637	•193
6-750	1-897	1-440	•135
7-205	1-649	1-061	•196
9-946	3-064	2-203	■390
  One day  was an  interval in the experiment, and  only  the
usual amount of daily diet, without extra alcohol, was  taken,
when the numbers stand as follows:
Date.	Quantity in cubic centi-metres.	Specific gravity.	Urea in grammes.	Chloride of sodium in grammes.	Sulphuric acid in grammes.	Phospho-ric acid in grammes.	Uric acid in grammes.
Aug. 19	920	1-026	35-88	5-750	2-374	1-904	•281
   It is very clear from these observations that alcohol taken in
the dram-drinkers'  fashion, namely, in  small  divided doses, by
no means increases  metamorphosis.  It rather tends to diminish
it, and this diminution is  not sudden or immediate, but is more
and more for a certain period, till the retention reaches a point
at which  a  critical discharge takes  place in healthy persons.
This discharge may take place either in consequence of the alco-
hol being left off, as may be observed in the day of interval; or
from  an idiopathic reaction, as on the  24th  of August.   This
idiopathic reaction was in the present instance doubtless enhanced
by the excitement of packing up for a short visit to the country
which began  on the  next day,  and  removed the subject from
observation.
   On the whole, we may conclude that the effect of continued
small doses of alcohol is  to diminish vital metamorphosis, to make
it  irregular,  and to induce, in  healthy people, the necessity for
Date.	Quantity in cubic centi-metres.
Aug. 18 " 20	1,520 910
" 21	1,070
" 22	1,000
" 23	1,310
" 24	1,530
Specific	Urea in
gravity.	grammes.
1-013	30-465
1-025	33-077
1-022	32-945
1-021	23-735
1-015	25-097
1021	41-867
 
ON ALCOHOL.
603
crises of evacuation.  Its first action  is upon the stomach, ena-
bling more food to be digested, and increasing vitality; but if
advantage  is not taken of this first action, its secondary effect is
a  diminution of  vital functions  in general,  and  of digestion
among their number.
   IV.—These opinions  are further supported by the following
set of experiments:
   T. K. C, aged  forty-three, healthy, though not  muscular, of
regular life and habits, took daily during  the days averaged in
the table a quantity of food proportioned to appetite,  viz., about
a pound and a half of meat, half a pound of bread, a  pint and a
half of tea, Avith milk, sugar, butter, saucee, &c, q. s.,  half a pint
of water, and from five to seven glasses of port or sherry ;* care
being always taken- not  to annoy the temper, and so  nullify the
experiments, by overstrictness.
	Quantity in cubic centi-metres.	Specific gravity.	Urea in grammes.	Chloride of sodium in grammes.	Sulphuric acid in grammes	Phospho-ric acid in grammes.	Uric acid in grms.
Amount of urine and of its seve-ral parts made in 15 days, in perfect health and usual diet, Ditto in 14 dajs, Mean daily am't.	18,800 1,253	15337 1-022	493-852 32-923	137-655 9-177	26-487 1-891	27-683 1-977	3-839 .275
  The effect of taking  in  addition  at  times  betAveen  meals a
moderate amount  of alcohol, in divided  doses, is shown in the
following table:

  *  Which may be reckoned to contain from 33 to 35 per cent, of proof spirit. 
604
ON  ALCOHOL.
Date.	Quantity in cubic centi-metres. 1,180 1,800 1,150 980 1.060 1J320 1,110 1,180	Specific gravity.	Urea in grammes.	Chloride of sodium in grammes.	Sulphu-ric acid in grammes 1-954 1-906 1-785 1-865 1-713 1-586	Phospho-ric acid in grammes 1-770 1-800 1-696 1-980 1-665 1-652	Uric acid in grammes	Daily quantity of best French brandy taken between meals.
Nov. 16 " 19 " 22 " 23 Dec. 3 " 5 " 6 " 17		1021 1-013 1-025 1-025 1-023 1-019 1-021 1-020	30-090 28-854 32-775 27-930 28-620 30-875 30-025 30-208	11-210 9-900 12-075 9-310 9-540 9-900 9-435 9-440			Trace •258 •339 •330 •299 •343	3J fid. ozs. 8 " n " n " 3 " 8 " 8 " 4 "
  It is very clear from these figures that vital metamorphosis,
as eA'idenced by the amount of the principal solids of the urine, is
diminished by thus  taking  more  alcohol than  the  healthy  in-
stinct prompts.  Not only are the  whole  mean amounts low, but
on no' day do they come up to the average. The  only exceptions
are  the chloride of sodium, which is slightly increased, by what
agency I cannot tell, and the uric  acid, whose augmentation  is,
probably with justice, considered an indication of an approaching
abnormal state.
  It may be remarked  that a greater quantity  of brandy than
that recorded above spoilt the appetite and prevented  the usual
diet being taken with pleasure, thus nullifying the experiments.
  I have often given you at the bedside reasons for administer-
ing or withholding alcohol in special cases;  but I have  been
cautious about reducing these reasons to  general rules without
going into the subject more fully than is possible in the wards.
  As you are well aware, extreme opinions  may be, and  have
been, held about this indubitably powerful reagent.  Dr. Brown
(the  author of the Brunonian theory) persuaded himself that it
was a panacea for all human ills, and  a direct prolonger of life;
but by dint of frequent experimenting, and lecturing with a bot-
tle of brandy by his side, he soon succeeded in giving a practical
refutation to  his own words by ruining his  health and shortening
his existence.  Others, again, Avould persuade us that it is a pure 
ON ALCOHOL.
605
poison, whose degree of antagonism to life is in a direct ratio to
the quantity  used. I shall take for granted that your experience
in the  hospital  has not made you advocates of either opinion ;
but that }'ou, by this  time, have seen, or  seemed to see, it in
many cases saving and prolonging life, in many saving and pro-
longing health,  in many others destroying  and shortening  both,
and, again, often conceded by indulgent doctors as an innocent
luxury likely to do neither good nor harm.
   The best  guide to the effects to be expected from a reagent
on a diseased body is the intelligent observations of its effects on
a healthy body; and  I think that alcohol is  no exception, but
that a knowledge of its physiological action leads directly to its
therapeutical application.
   The experiments of Rudolf Masing, since repeated and con-
firmed by MM. Lallemand, Perrin, and  Duroy, have taught us
that alcohol passes through the body unaltered in chemical con-
stitution,  and  does not, so far as we know, leave any of its
substance behind.  It remains in the body for some hours, and
during that time exerts an influence for good or for evil.
   It is not strictly an " aliment;" but if it aids the appropriation
of aliment, it may be looked upon as an  "accessory food" in
health, and as a "medicine"  in disease.
   What is the nature of the influence which it exerts ?   What is
its action upon  life ?  It is usually defined as a " stimulus to the
nervous system;" and so  long as "stimulus"  is held to mean
only something Avhich makes one feel comfortable, we may be
satisfied with the explantion; while upon the nervous system all
experimenters,  from  the  first patriarch downward, will agree
that it acts.   But if led by the etymology we infer that it directly
augments the developed force of the  nervous function, we shall
fall into the error of poor  Dr. BroAvn.
   Let us be a little more particular in our inquiries, and then I
do not think we shall be  able to trace any direct  increase of
force to alcohol, even in the smallest  doses, or for the minutest
periods of time.  The sort  of researches of which those detailed
are an example, shoAV pretty clearly that its continuous use (z. e.
in small divided doses) does not add poAver to vitality, and I 
606
ON ALCOHOL.
think we shall not fail to come to the same conclusion from ob-
servations made upon its more immediate effects.
  In a series  of experiments, conducted with another object, Dr.
Edward Smith has recorded very minutely the  sensations expe-
rienced after  brandy,  by a  temperate  man,  with  a  fasting
stomach.*
  What are the first effects noticed there ?  Increased life ? In-
creased function ?   No—lessened consciousness, lessened sensi-
bility to light, to  sound, and to touch.
   Then there comes a peculiar sensation of stiffness with swell-
ing of the skin, which is noticed particularly in  the upper lip
and cheeks,  evidently due  to  arrested sensation and motion.
These are very unlike spurs to extra exertion.
   In a patient lately under my care the same peculiar sensation
of stiffness, and also the objective phenomena of rigidity of  skin
without loss of sensation, Avere produced by the pressure of dis-
eased bone on the fifth nerve inside the skull.f   If we  call this
symptom a partial paralysis from partial  obliteration of nervous
function (to which I suppose nobody will demur), we must call
the effects  of  alcohol also a partial obliteration  of  nervous func-
tion, for the phenomena are strictly identical.
   Dr. Smith  further records among the " early effects" of alco-
hol a relaxation of  the  dartos and other muscles connected  with
the reproductive  system,  for which Ovid elegantly,  and Shak-
speare coarsely, blame the later  and more  obvious influences of
drink.   The  sphincter  also of the bladder was relaxed, and  to
this the  observer  lays the increased  micturition  during in-
dulgence.
   The pulse also  is  quickened.  At first blush you might be dis-
posed to view this  as an  indication  of an increase of nervous
force.   But do not  be hasty.  Observe with Dr. Bedford Brown
  * "Transactions of Royal Society," 1859, p. 732.
  f In this lady another facial characteristic of incipient drunkenness was
simulated.  Ordinarily the affected side had a slight diffused fixed color, the
other being pale ; but when she blushed  the healthy cheek was colored quickly
and deeply, while the diseased one remained unchanged in hue.  This is the
same physical phenomenon which is exhibited in the half-flushed but unabashed
fro at of a toper. 
ON ALCOHOL.
607
the circulation in the  cerebrum, during an operation on the
skull, when the pulse was quickened by chloroform ; and you will
see the  heaving and bulging of  the brain quieted, the surface
becoming pale, and the haemorrhage arrested.   The quickening
of the pulse must  therefore have been contemporaneous with
diminished force of the heart's beat.*
  Again, observe  that  in  disease those patients especially ex-
hibit the phenomenon of quickened pulse whose hearts are most
enfeebled.
  No—it would appear that in motion of an entirely involuntary
character,  quickness  indicates diminution and not increase of
force.
  It is unnecessary to go through the symptoms of advanced in-
toxication by  alcohol :  all observations  agree  that large doses
immediately, and small doses more remotely, depress  the nerv-
ous  centers, and  that  in cases of absolute poisoning the cause
of death is  a cessation of the muscular respiratory movements.
What I wish particularly to mark is, that the primary as well as
the secondary action is a diminution of  vitality in the nervous
system.
  Life and warmth are so closely connected together in scientific
as well as in popular notions that perhaps the most striking evi-
dence of diminished vitality is the lessened capacity to generate
heat.   We have this evidence  in  the  case  of alcohol.   MM.
Dumeril  and Demarquay  published in  1848 their observation
that intoxicated dogs exhibited a great loss of  temperature, and
Dr. Boecker and Dr. Hammond find the same  result from eAren
moderate doses of spirits.   This accords with and  explains the
experience of Dr. Rae, that alcoholic drinks give  no satisfaction to
Arctic voyagers, and of Dr. Hayes (Surgeon  and Commander in
U. S. second Grinnell Expedition), that they actually lessen the
power of resisting cold.f The " warming of the stomach" wdiich
tipplers  speak  of with  delight  is  in  fact  a  mere fallacy of
insensibility to external influences.  We may  I  think fairly come
        * "American Journal of the Medical Sciences," Oct., 1860.
        f Ibid. 1859, p. 117. 
608
ON ALCOHOL.
to the conclusion, that alcohol is primarily and essentially a
lessener of the power of the nervous  system.*
  How then can it be a restorative ?  How can that which loAvers
one of the chief manifestations of  life be a renewer of life ?
  In this way:  in lowering the power of the nervous system, it
lowers its action on destructive metamorphosis,  and thus it  saves
the substance of the body.  We know that the  exercise of nerv-
ous functions, bodily or  mental, increases destructive metamor-
phosis.  We know, too, that when either bodily or mental action
is in excess, there is an arrest of the constructive appropriation
of food by the stomach.   Our own personal experience, without
the aid of Shakspeare, teaches us that passion and  emotion  as
well as overstrained muscular labor put a stop  to digestion and
appetite.   Well,  then,  anything  which  either  sensibly or in-
sensibly interposes between this sensible  or insensible  nervous
action and the digestive viscera must tend to restore that balance
of the two in which healthy life consists.   Thus Dr. Hammond,
having placed himself on an insufficient allowance of food, found
his mental and  bodily powers  deficient—the balance Avas  over-
thrown.   He afterward took  a small quantity  of alcohol -with
each  meal,  and  then, without any increase  of  diet, he gained
weight of body, and his mind was  more vigorous.  On the  other
hand,  if he added alcohol to a full diet,  the blunting of  the
mental powers was very perceptible,  and  there was feverishness
of body.  We cannot doubt that the  essential action of  the alco-
hol was identical in both  cases, but in the first the blunting of
the nerve force  was requisite for perfect life, in the second it
was not wanted and was therefore injurious.
  The effect of  small  wholesome doses upon the mind is to blunt
the sensibility to the slight half-felt corporeal pains which  the
  * We may call it an " anaesthetic," if it is allowed us to extend a little the
application of the term, and to let it include  all reagents which tend to inter-
rupt the connection between the material and immaterial of our being, between
force and visible nerve, whether our memories are  conscious of the interruption
or not.  It is only when it is taken in considerable  doses that our direct feelings
note the anaesthetic action of alcohol. Its action on the involuntary nervous
system, more important in a physiological  point of  view, is anterior to that, but
can be traced only by inference. 
ON  ALCOHOL.
609
want  of balance  had produced.   It removes the chains of the
corruptible body from the soul.   Hence a freedom and  bright-
ening of the intellect.  But it  is only the moderate  man that
can enjoy this luxury; the attempt to drown a care too tall for
a shalloAV bowl, or  to soothe a pain too sharp to  be forgotten,
induces  an  excess.   Then  the  scale is inclined too much the
other Avay ;  the influence  of the nervous system on the body  is
owrblunted, and the just degree of its action requisite to  perfect
health is arrested.
  In truth, this balance is not easy to adjust.   And  therefore  it
is lucky for us that  alcohol passes so freely out of the body, as
Dr. Percy, Mr. Masing, and the French physiologists  who have
repeated their experiments have shown to be the case.   It  is
lucky for us also that any slight harm it may have done during
its sojourn is set right by a  reaction of increased metamorphosis
or evacuation, of which an  example has  been  given in the ex-
periments detailed at the beginning of this lecture.
  Thus do I interpret the  effects of alcohol;  and  taking  this
interpretation as a basis, I Avould deduce therefrom the  folloAving
clinical rules for its administration :
  I. Give alcohol whenever you find the  nervous system is ex-
hausting itself and the body by an activity in excess of the other
bodily functions.
  Examples:
  In  delirious fever, especially in typh-fever.   Here  the high
specific gravity of the urine is a  warrant to  you of the great
amount of destructive metamorphosis going on, and the failing
strength shows how low the constructive  life is.   Continue the
alcohol as long as the tongue is dry, and  the mind raves  instead
of sleeping, and the  hands tremble.
  In  pneumonia, in surgical injuries, in  erysipelas, &c, under
the  same regulations.  Here, however, our path is not so clear
nor so well enlightened by physiology ;  we must feel our  way by
actual obsenration of the effects produced on the patient under
our eye.
  The poAver of  resistance to  some poisons,   such  as malaria,
seems increased by  alcohol.   Thus  aguish and  neuralgic cases, 
610
ON ALCOHOL.
in their Protean forms, bear Avell and are benefited by it in very
considerable  quantities.   Strangely enough, these patients  on
recovery cannot stand it,  and usually of their OAvn accord leave
off the habit of taking  it.  So  that  we need not fear that  we
shall make them tipplers by administering the remedy.
   After violent shocks produced by mental emotion, or extreme
bodily  labor.  It may be doubted whether  the prejudice  felt
against serving out  spirits to soldiers or sailors before a battle
is justifiable; the courage or apparent strength given may be
tinsel,  but the power of resistance to wounds, mental and bodily,
is something  real.
   Where the patient has been  accustomed  to  excess.  It will
not do  to let  the body have to endure the natural  reaction and
the disease at the same  time.  The reaction must be postponed
to a more convenient  opportunity,  when  the  body  is  ready
for it.
   II.  Give it, increase it, leave  it off under the guidance of the
appetite for food.   As long as  a sick person takes and digests
food better with alcohol than Avithout, so long it is doing good.
Beyond that  we have no evidence.
   III.  When the marked feature of the disease consists in re-
tention of effete matters Avhich ought to be  discharged,  abstain
from the use  of alcohol altogether.
   Examples:
   In Uraemia I have always found any effects which could be
traced  to alcohol  to be  of an  injurious character;  under  its
employment  the giddiness, the  blunted intellect, the  faintings,
the tendency to coma, all  increase, the urine sometimes becomes
more scanty, always of lighter  specific gravity; and  I cannot
say that even the dropsy, for Avhich the alcohol is most  usually
administered, is often benefited.
   Jaundice also seems to  be aggravated bv alcohol.
   The uric acid diathesis also presents an objection to the  use
of alcohol ; but there are exceptional  complicated  cases which
appear to receive benefit from occasional doses.
   IV.  Divide the  daily allowance  into two or three doses only,
giving  enough at once to  produce a decided  effect.   The  action 
ON  ALCOHOL.
61L
of frequent small divided drams is  illustrated by the experi-
ments I  have detailed—it is to produce the greatest  amount of
harm of which the  alcohol is capable, combined Avith  the  least
amount of good.
  In fever I usually order three doses a day, and find even that
division  not  ahvays advisable, and that the patients do better
with two larger doses.
  The  shape in which alcohol is  administered is in many cases
not  a matter of choice.   The mighty force of the purse-strings
often restricts us to the coarsest compounds.  New whisky and
gin and British brandy are better than nothing, but  let us not
forget that they contain a very hurtful, nay almost poisonous in-
gredient,  fusel oil, which  is abundant  in  direct proportion to
the youth and low price of the article.   Age changes this into
more wholesome as well as more agreeable ethers.   Any of the
full-bodied wines are  better for acute cases than spirits.   Port
perhaps  exhibits in its  commoner varieties more  of the good
qualities  that  a wine  should  have than  the  produce of other
grapes.   I mean to say that second and third-rate port, or even
sham port, is a wholesomer beverage than second and third-rate
and  sham articles with other names.  But if the expense is no
object,  thoroughly good  champagne exhilarates  more, is easier
digested, and does  the good without  the harm better than  any
of its rivals.   Of course a high price  must  be paid  for a genuine
specimen of a wine so restricted in quantity. 
LECTURE  LI.
                ON BLOOD-LETTING.

 Part  I. — The power of renewal in the animal body exemplified
     by the quick restoration of normal blood in an anaemic girl—
     Application of these facts to the artificial ansemia induced
     by blood-letting—The necessary conditions for the repair of
     ansemia—Starving and bleeding at the same time bad practice
     —Reasons for bleeding—Fallacies  of the ancients.
 Part  II.—Cases  in which  loss  of blood  is beneficial—In some
     cases  of apoplexy—In  pneumonia—In the congestions  of
     typh-fever—In serous inflammations, in pleurisy, pericardi-
     tis, and peritonitis—In renal congestion and hsematuria—
     In paralysis  of the  circulating organs from over distention
     —In chronic  diseases of the skin—Conclusion.

          (Clinical, St. Mary's, November 29, 1861.)

  A fortnight ago I lectured about  an anaemic patient.*   She
was then showing a title to be no longer so called;  and now she
most certainly may claim  exemption, having fairly won our faith
in the  statement that her natural hue is  rosy.   She is leaving
the hospital to-day with  enough haematine to  color the  blood
throughout her body very sufficiently.
  Let  us  take  stock of what  Ave may learn from her agreeable
change of looks.
  What amount of  manufacturing industry does this new store
of haematine prove ?  Let us do a sum.   She weighs 8 stone, or
1792 ounces : of this weight f-ths, or  512  ounces, is  blood ; and
* See previous lecture on Anaemia.  Lecture XXVII, p. 3 61. 
ON BLOOD-LETT I NO.
613
of this blood tWuj or 60 ounces, should be red disks.   Now the
careful analyses of MM. Andral and Gavarret show that in cases
of anaemia of  a marked character (as  this was), we may expect
at least three-quarters of the haematine to be wanting; so that
when she came into our Avards it maybe fairly taken for granted
that she did not possess aboA'e 15 ounces;  and now I think with
equal fairness her stock may be reckoned to  have  got up to 45
ounces, Avhich  is  to allow that  she  still wants a quarter of her
perfect  health.   By this reckoning  she  must  have made 20
ounces of  blood-disks,—so much of the most important organic
constituent of  upwards of 150 ounces of blood,—in a month !
   Mark the vigor  of renewal  with which the  human body is
dowered.   Learn  from  this  to have faith in its power, and to
trust in  it, though  prospects  may  look  untoward.   Learn
especially the  curability of even the most  unfavorable specimen
of anaemia.  And learn too  not only its curability Avhen it is a
disease which  has come of its  own  accord, but also the facility
of repairing artificial loss of blood when it is  employed  as a
remedy.
   I  hope  you all by this time clearly understand that physio-
logically speaking all departures from  full health  are diseases.
The artificial states which many of our remedies produce, some-
times even as  a means of doing the patient good, but more often
as an incident unavoidable  and lamented by us,  are as much
diseases as any of  those on the roll of the  Registrar-General.
Diarrhoea is as much diarrhoea, whether it is caused  by Epsom
salts, by a felonious  poisoner,  or by a  poisonous malaria.  So
anaemia is as much anaemia when  it follows  our lancet  and our
leeches, as when  it arises we cannot tell how, and comes to us
for advice.  It must be equally thought of, guarded against, and
cured, in one case as the other.  But  what  I particularly wish
to insist on here is that it is as easily thought of, guarded
ao-ainst, and cured in one case as the other.
   It  has  been the fashion  lately among certain declaimers to
paint the  physician who draAvs  a few  ounces of blood from the
arm. or cups or leeches a sick man, as  a sanguinary villain, who
neeessarilv ex  vi  termini takes away the  life, or that which he 
R14
ON  BLOOD-LETTING.
cannot  replace.   Not  only novelists,  pill-dealers, and quacks
have raised this outcry, but it has been joined in by some whose
knoAvledge of physiology ought to have taught them  the fallacy
of the popular  notion  and the argument by which to refute  it.
You will clearly perceive from the calculations through which I
have taken you that by proper management no loss is easier re-
paired ; and consequently that if it only saves a patient two or
three nights' sleeplessness and pain, the price of a venesection
is Avell paid; and still more, if  it contributes in the remotest
degree to free him from  danger, it is blood  well spent.
  Nevertheless, note this, that if the loss is to  be  repaired, the
means of repair must be given.  When I bleed, you will observe
that I take doAvn  the diet card and suit it to the circumstances,
being very careful that the patient has the power to reinvest the
capital drawn out.  I  supply with one hand Avhat  I  am taking
away with the other.  I begin to try and cure the anaemia, Avhich
I feel myself called upon to produce, at the same moment that I
am  producing it.   "BloAving hot and cold," you will  say.   Pre-
cisely so—that is Avhat I intend.   I blow  cold Avith  my bleeding,
not for the sake of blowing cold, but because it is the inevitable
result of the remedy.  I blow cold not in order to induce anaemia,
but for other quite different  purposes, which I think are Avorth
the  cost.  And I blow hot to make up as well as I can for the
evil I am going to do,  on the principle—
           " Facere necesse est sumptum, qui quaerit lucrum."

  I  am  sure that the sad effects of the too zealous  practice of
our fathers,  Avhich with justice have been cast in the teeth of the
medical profession, were due quite as much to the  starvation as
to the bleeding.  I have a  most lively and painful recollection
of seeing, Avhen I Avas  a student in Paris, M. Chomel  and others
treating  pneumonia.   I could not  at  first understand  why  in
France so much more marked and more hurtful effects were pro-
duced by venesection than in England.  At that period we had at
home ample opportunities of seeing it practiced; but 1 never wit-
nessed such prostration folloAV at St. George's as  I  did at the
Hotel Dieu.  I Avas puzzled  for a  week or tAvo, till at last I 
ON BLOOD-LETTING.
615
noticed that the order for "saignee" was accompanied by "diete
absolue."  I almost doubted my knoAArledge of French, and was
obliged to ask of the  by-standers before I could believe that this
meant an utter deprivation of all food!  Here was an immediate
explanation of  the seeming toughness  of  my countrymen;  for
never in our Avorst days did we carry the Sangrado practice so
far as that.   Our teachers did not give food enough, but they
never bade it to be willfully kept beyond their patient's reach.
   The bad practice of starving and bleeding at  the same time
took its rise from the erroneous doctrine of antagonism.  Accord-
ing to this theory disease is an enemy to  be overcome—A Disease
with a proper name and a capital letter to  it, like a living con-
crete creature—a something to be combated by  a something
which is as opposite  to  it as possible.  Bleeding Avas found by
experience to  be useful  in certain morbid states; it was therefore
held to be useful in virtue of possessing qualities opposite to these
morbid states.  Ansemia and depression  of life are the most con-
stant effects of bleeding; therefore anaemia and depression, it Avas
argued, are the benefactors to be sought for, and whatever aids
blood-letting in  producing anaemia and depression is a good com-
panion to it.  Of course starvation was the first  agent thought
of, adopted in all its integrity by the logical French, and with
more hesitation by our countrymen, who  fortunately do not carry
out all arguments to their apparent conclusion, and therefore  are
often right without knowing why.  The  abuse has brought about
a reaction; and  that treatment which was considered at one time
so sovereign that  its gravest faults were viewed  as virtues, now
runs a risk of being denied all virtue, because of faults capable
of being compensated for.
   Against this I feel bound to raise my voice.   It is time now
to have  done with the  reactions for and against letting blood,
which have been going on throughout  the period of the Christian
era;* the  Avave, Avhich  has swelled backward and forward to a

  * A short sketch of the reaction in favor of blood-letting started by Galen, is
given by the author in the " Medico-Chirurgical Quarterly Review" for October,
1858.  The shrewd chatty Greek hits hard at his opponents,  and seems to have
had a single-handed fight with all the world of fashion against him, and yet came 
616
ON BLOOD-LETTING.
dangerous height, ought  to settle down  into  a steady  stream.
We ought to know clearly why we bleed, and then we shall know
when to bleed.
   The question  seems to me one to be answered by hydrostatics
rather than by physiology.   The most important early  effect of
external injurious action  on the  tissues is that the blood-vessels
lose their tone and  become  dilated, the "congestive  stage of in-
flammation" occurs.   At this conjuncture  the more  pressure of
fluid there is inside the more will their elasticity be impeded, and
the more dilated must they become.   Taking blood from them is
like emptying the  urinary bladder  Avith  a catheter when  it is
paralyzed by its retained  contents;  and the  more  locally the
remedy can be applied, the more like it is  to  that generally ap-
proved surgical  operation.  Dropping the  burden which weighs
doAvn their life,  the vessels are enabled to go again to their Avork
of regulating the stream  of the  circulation.   So that from this
point of vieAv, and  so far, the treatment is directly restorative
and reconstructive.    Blood-letting is a cure of local  congestion,
and to the local  symptoms it may be  expected to be  beneficial.
   The fault of  our forefathers was that  they went beyond this.
They pictured to themselves a  condition of  universal plethora,
or general excess in quantity of blood throughout the blood-ves-
sels—a condition which every observant  and practical physician
now sees can have no existence  in nature.*  Where  experiment-
out victorious in the end.  It is satisfactory to find him free from the vulgar notion
that human nature and its diseases are liable to changes of type, delivered from
the superstition that
                   .<Etas parentum, pejor avis, tulit
                   Nos nequiores, mox daturos
                        Progeniem  vitiosiorem.
He never suggests that any one generation could stand bleeding either better or
worse than their ancestors; but he notices a fact, which probably  explains  a
good many of the revolutions  of public opinion,  namely, that some races are
much more affected by it than others—the  Celtic, for example, more than the
Latin.  It would be interesting to trace historically how the  prominence of one
or other nationality as teachers of medicine  has altered the prevailing practice.
   * By "plethoric" old writers  do not mean "fat," but a  state in  which too
much blood and flesh were supposed to be made by too much nutriment being
absorbed.  It is the latter or primary meaning of  the word which I refer to in
the text. 
ON  BLOOD-LETTING.
617
ally they saw good results follow the emptying of the blood-ves-
sels,  they pronounced  the special disease  before them to be a
proof of this plethora, and hence inferred that the loss of blood
was directly beneficial  to  the system  at large by restraining an
excess of "violence of life."
  We know now that  a destructive agency keeps step with the
reconstructive one—that  our gain entails a loss.  By blood-let-
ting is brought about, temporarily or permanently, first a decrease
in those red blood-disks which  are the characteristic of health,
and then an increased proportion of fibrin which marks disease.
So that an injury is  done to the mass of the body for the sake
of a part—a temporary injury for  the sake of a permanent
benefit.
   The questions, then, which we have to decide in each several
case are—first, whether we can by our  art certainly  repair the
artificial injury; secondly, whether the  part to be relieved is of
sufficient importance to  the whole to justify the sacrifice; and
thirdly, what is the least amount of sacrifice that will  be  of use.
   As to the first question, the daily  occurring evidence of such
cases as those of which one has formed the text of to-day's hints,
is surely enough to give us faith in the means of renewal at our
command.  As to the second and third, more details are required
than we have time for to-day, and I must wait for another oppor-
tunity of enlarging  upon them.

        Part II.— (Clinical, St. Mary's, March 5, 1864.)

   Taking for granted that certain evils attend a loss of blood,
 while certain advantages may also be derived from it, the ques-
 tion  is, when does the prospect of advantage overbalance the risk
 of evil'? It is my purpose, to-day, to set before you a list of cer-
 tain  instances in which it appears to me to do so.
   1.  Some cases of apoplexy.
   The cause of apoplexy is obliteration of the cerebral nervous
 functions.  And this  may take place in two ways:
   1.  By actual destruction of the nervous tissue.
   2.  By impeded circulation of blood through the brain.
        40 
618
ON BLOOD-LETTING.
  To an inward wound of the nervous tissue, causing actual de-
struction, whether it  take  place by Adolence, by the pressure of
a clot of blood or of a tumor, or by the  more  usual  case of
atrophic softening, blood-letting can afford no  assistance.  The
immediate effect of the lesion is bad, and the more remote effects
worse.
  But to the impeded circulation a cure may be surely applied.
When from the filling up of the cerebral veins and  capillaries
with  venous blood, black,  effete, and useless,  room  cannot  be
found for the arterial quickener—when life is stagnant, so to
speak, from the stagnation  of its river of supply—then you may
restore the stream by the rough and ready means of an artificial
outlet.
  When the lips and tongue are tinted blue with venous blood;
when the pulse  is filled and sluggish; when  the heart,  either
from  chronic lesion or from repletion, has hardly room to strike
the ribs; then you may withdraw blood Avith advantage, for you
may relieve the congestion which  is  obstructing the sanguifica-
tion of the brain.
  When the lips are  pale or naturally colored; when the pulse
is free or empty,  striking the finger with a high sharp stroke;
when the heart  beats freely, even if it should murmur in your
ear that its  valves are imperfect; then the  lancet and the leech
are useless,  nay, hazardous.
  The indications afforded  by the  general symptoms  are less
positive.
  General convulsions may arise from congestion, as  often hap-
pens in the  apoplexy from drowning or hanging, and  are not by
any means a certain contraindication, as is sometimes stated.  It
is, however, as well not to  bleed during the paroxysms.   But I
think that where the  convulsion is local,  where it occurs  in one
or two limbs otherwise paralyzed, that then it usually arises from
local  lesion  of the nerve substance, and is an argument against
drawing blood.
  When the apoplexy has,  in a previously healthy person, come
on gradually, beginning with stupidity, giddiness, and headache
without local paralysis, and passing, in times varying from  an 
ON BLOOD LETTING.
619
hour to a day, into complete loss of sense and motion; when the
sphincters slowly  become relaxed, and continue so; when the
patient may by a  violent effort be a little roused, lapsing again
into unconsciousness; then it is not uncommon to find the symp-
toms depend on congestion and relievable by bleeding.  When it
has come on suddenly, a local paralysis being contemporaneous
with or  preceding the clouding over of the mind; when the
sphincters hold their OAvn, or are only intermittent  in relaxa-
tion ;  when the senses which have been suddenly lost  are either
completely  lost, or  completely recovered; then  you are wiser
to abstain,  for you  probably  have to do with broken  nervous
tissue.
   This is about as  much as you will have  time to think  over
with your patient  before you.
   It has been argued by Drs.  Munro, Kellie, Abercrombie, and
others that, the brain being inclosed in an unyielding case, and
thus excluded from  atmospheric pressure, the quantity of blood
in it cannot vary, and therefore that detraction of blood from the
whole bulk of the fluid in the body can make no impression on it.
But the experiments of Dr. Burrows, exhibited before the Col-
lege of Physicians,  have  shown that at least the  color of the
brain and the quantity of blood in its  veins may  be much af-
fected by external circumstances;  and that is the point  in  ques-
tion;  it is the  maldistribution of the blood,  the venosity in the
brain, that we Avant to restore  to its normal coMition, and I feel
sure that bleeding may temporarily contribute to that result in
the special cases of which I have spoken.
   2. In some cases of pneumonia.
   The reason for  blood-letting  in pneumonia is shortly stated
by the late President of the College of Physicians, when he  says,
" Although pneumonia is not cured by blood-letting, and may be
rendered fatal by excess of it,  yet a moderate loss of blood early
in the  disease has sometimes the power of determining favorably
both its type and its duration."*  That is to say, that though
the pneumonia is  not cured  by the  blood-letting, the patient
sometimes is.  Observe the experiments shown  us in the great
          * Dr. Mayo in "British Medical Journal," May 6,  1863. 
620
ON BLOOD-LETTING.
lecture-theater of nature.   You see that often great relief is ex-
perienced when blood is expectorated in the early stages of the
disease, that the inflammation ceases to spread over the tissue  of
the lung as soon as the mucus is stained with red.  Get the start
of this  by prevenient bleeding or cupping or leeches, when the
other circumstances on which I enlarge in lectures  on special
cases of pneumonia allow it.  It will diminish the dyspnoea, the
oppression and the pain.   And you will be quite safe as long  as
you will bear  in mind that you are doing a certain  harm at the
same time as a certain good,  and  anticipate the harm by proper
nutrition, and sustaining the strength  of the body.
   Observe also the experiments exhibited by nature in localizing
the blood-letting.   You cannot, as she does,  let blood from the
bronchial and pulmonic vessels, but you can make the nearest
approach in your power by  taking it from the exterior of the
chest-A\ralls through cupping-glasses or leeches.
   3.  In the typhous congestive inflammations of the  lungs and
bowels taking blood by leeches or cupping  from the nearest ex-
ternal surface  is  often judicious.  The relief is usually very rapid
and immediate, and the risk run from a small loss of  blood very
little.   The fluid you take away, though called by the common
name of blood, is not the  same as an equal quantity  circulating
in the veins of a  healthy man. It is more or less poisoned, more
or less useless for the purposes of life, and the loss is  far from
being in a directHitio to the amount taken.  It is more important
that the patient should regain the use of his bowels, or of a con-
gested lung, than that he should keep such imperfect stuff cir-
culating or stagnating in his blood-vessels.   Of this I have
spoken  at length in former lectures.
   4.  The same remarks will apply to  acute dysentery, in which,
indeed,  an indication  of  treatment is afforded by the natural
course itself of the disease.  The worst cases are those in which
there is no  loss of blood  by stool, and, alarming as it is, san-
guineous purging often saves the life of the sick.
   5.  In inflammations of serous  membranes, such as pleurisy,
pericarditis, and  peritonitis, a great part  of the  danger arises
from the quickness with which the continuous parts of the same 
ON  BLOOD-LETTING.                 621
tissue yield to the destructive influences of neighborhood.   This
quickness is certainly checked by the direct counteraction  which
loss of blood  affords  to  the congestive stage of inflammation.
The  local capillaries show their partial deficiency of life in loss
of elasticity, in dilatation, and  in  being  overfilled with  blood.
Leech the neighborhood, and you temporarily empty them, and
you postpone, at least for a  time, the coming inflammation;  you
gain time; and time is no mean gain, for it gives the smitten
body a period of  rest in which it can store up force to effect a
cure.  But it is only time that you gain, for when the first stage
of inflammation is over, when "its work is done, its path of ruin
past," then your detraction of blood is a robbery.
  As to  locality, the nearer you can  approach to  the part  in-
flamed the better; for the action is hydrostatic, and mechanical
forces lose by distance.   In peritonitis put your leeches on the
painful side of the belly—that  is, where congestion is going on,
for after  effusion of fibrin or pus, pain ceases at the point of effu-
sion.  In pericarditis, apply them close together  at the level of
the mammae,  or where the apex  of the heart beats,  according to
Avhere the chief pain on pressure  is found  to be.   In women
with full bosoms, shun the  mammary gland; not  because  you
Avill hurt it, but because it removes your leeches too far off.   In
pleurisy, leech as near the pain as may be; take  care, however,
to keep above the level of  the  diaphragm;  even although the
stitch, as often happens in diaphragmatic pleurisy,  should be
felt by misplaced sensibility below the ribs.  In this case espe-
cially you should mark for the nurse the spot where the leeches
are to be put on, for you must remember that she  is not an anat-
omist, and has not learned  where the  pleura ends  and begins;
she is likely,  therefore, to be led into error by the faulty  sensa-
tions of the patient.
  The amount of blood-letting must be  proportioned to the risk
run by the spread of the inflammation.  In peritonitis  this is
very great and immediate:  leech,  therefore, freely,  and  cover
the congested spot with  the remedy.   Two dozen leeches even
are not too many in pressing cases.  But  do not use so many in
case  of repetition.  Then cover the place (having first stopped 
622
ON BLOOD-LETTING.
 up  the  bleeding  bites with dry lint) with a linseed poultice, or
 Markwick's spongio-piline; keep the patient quite still, and pro-
 cure sleep with opium.   Thus you will make the best use of the
 time gained.
   Follow the same rules in pericarditis; only you will not wTant
 so many leeches,  as there is less space to be covered; six, eight,
 or at most ten, will be quite enough, according to the size and
 sex of the patient, and  the correspondent size of the exposed
 piece of pericardium.   Moreover, in pericarditis you  are  more
 likely to require  a second  application, as you cannot procure
 such perfect rest  to the heart as to the peritoneal viscera. Poul-
 tices and opium, however, are well spent here.
   Pleurisy, unaccompanied by pneumonia or catarrh, is not such
 a pressing complaint.  Half a  dozen leeches and a poultice are
 usually quite enough to manage it.
   6. Congestion of the kidneys is  apt to produce a continuous
 drain of blood by the urine; and from the great weakness thus
 arising, it seems not unlikely that the material thus lost is arterial
 and  vitally important.  Moreover,  protracted  congestion of the
 kidneys often ends in the permanent degeneration of Bright's
 disease—a result most unhappy.  When, therefore, after scarla-
 tina, exposure to cold, blows,  or other  causes, I find  visible
 haematuria, I almost always cup the patient on the loins. I can-
 not  say that the practice  is invariably successful in effecting its
 intention ; for the loins are  some way off the  kidneys, and the
 force of the remedy is much diluted by the  time it influences the
 point of  attack.   But it succeeds often enough in stopping the
 haematuria to make it worth while to lose eight or ten ounces of
blood in the trial.
   7.  The same considerations may  sometimes induce us to treat
by emission of blood a congestion unimportant in itself, but im-
portant from its neighborhood;  such as  swelling of the tongue
or tonsils, which we fear might suddenly compress the glottis.
   8.  When the heart is  temporarily paralyzed by overdistention,
either completely,  so as to produce  apparent death, or partially,
so as to produce Avhat is technically known as a " Arery oppressed
pulse," joined with anxiety and  dyspnoea, then bleeding and still 
ON BLOOD-LETTING.                  623
more cupping the cardiac region is often of signal service.   The
relief is of course mechanical;  the  dormant excitability of the
heart is roused by the artificial motion communicated to the cir-
culation ;  and  perhaps  also the  sensitiveness  of  the  nervous
system is heightened by the absence of blood, just as tonic mus-
cular  contractions  are induced by  excessive  haemorrhage, by
starvation, &c*
  9. Blood-letting  may sometimes be  employed in chronic skin
diseases, to render  more efficacious the action of certain specific
remedies for  certain  specific forms.   Thus in lepra, and in pso-
riasis, I have several times  arrived at  a point which arsenic and
sulphur did no further good, even in doses larger than are usually
considered safe.  After bleeding the patient, a smaller dose pro-
duced an immediate effect and a rapid  renewal of healthy skin.
I have  remarked  the same  fact in a  nearly  equal degree, as
respects the  action of alkalies in eczema.  Last week  I called
your attention in the  admission-room to the  arms and legs of a
gardener, as  exhibiting  quite a typical case of eczema in pic-
turesque distinctness: I had him  bled  to  six  ounces, gave him
a bran bath and only three doses of liquor potassse, and next day
Avhen  we saw him in bed he Avas so much better that I was obliged
to apologize to you for the departure of most of the characteristics
of the disease.  And last year in a case of extensive lichen no
good at all was done by emollient baths of bran and linseed, till
I bled the patient,  and then  these simple  agents were sufficient
to effect a cure. After these bleedings,  if beneficial, no weakness
is felt.
  These are examples of the principal circumstances under which
you will find  me in my practice think it advisable to take blood.
You will see  that they generally agree in  this,  that there is  a
Avant of due circulation, a true deficiency in that  important func-
tion of the vascular system.   The flow of blood restores this cir-
culation, for  though the blood flows out of, instead of flowing
      * See M. Chossat's observations, quoted in Lect. II,  pp. 45-49 
624                  ON BLOOD-LETTING.

through  the vessels, it is a  nearer representation of the living
act than the previous  stagnation. In all the concerns of organic
life,  as of social life, anything is better than stagnation.
   The physiological reasons  for  localizing as far as  possible our
blood-letting are  exceedingly well put by  Dr. Young.  " The
effect of venesection  must be not only  more  rapidly, but also
more powerfully felt in a neighboring than in a distant part; and
although the mean or permanent  tension of the vessels of any
part must be the  same, from whatever vein the  blood may  have
been drawn, provided  that they undergo no local alteration, yet
the  temporary change, produced by opening  a vein  in their
neighborhood, may have relieved them so  effectually from an ex-
cess  of pressure, as to  .allow  them to  recover their natural tone,
which they could not have done without such a partial exhaustion
of their neighboring vessels."*
   The history of  opinions on the subject  of blood-letting shows
us four sects or parties, each one of  which has at various times
outweighed  its rivals  in number of  adherents.   First, the fol-
lowers and predecessors (for  " vixere fortes ante Agamemnona")
of Hippocrates, who sometimes bled, but always fed, their pa-
tients.   Second,  the  disciples of Erasistratus, who denounced
bleeding as  robbery, and prescribed in its place a complete  star-
vation for several days—didrpirog aania.   Third,  the French prac-
titioners of  the two last centuries, immortalized but  not checked
by the satire of Moliere and  Le Sage, Avho both bled and starved
at once.   Fourth, the followers of Brown, wrho replaced bleeding
by alcohol.f
   From  what has been said it will  be seen that I should find
myself a member  of the first-named  sect, if  the unhappy mania
of party spirit were again to afflict our profession as it  has  done
of old.   And were hero-worship again to become one of our fail-
ings, I should probably select as the  Bible of  my medical  faith
  * Croonian  Lectures in " Philosophical Transactions of Royal  Society," 1809.
  f I do not  here include as a practical school "La Medecine Expectante,'
which objects  to bleeding just so much and no more as it  objects to  everything
else.   In an ignorant man this is merely unwarranted skepticism, in a wise man
it is a philosophical experiment.  Neither can suppose themselves  engaged in
an act of cure. 
                    ON  BLOOD-LETTING.                 625

Hippocrates' " Regimen of Acute Diseases."  For if it might be
allowed, out of consideration for the differences between Athens
and London, to substitute beef-tea for gruel, there  is  very little
in that capital course of lectures which does not accord with the
daily practice of those I think wisest among us in the present
day.
   But how different are the grounds on which our practice is
based!  The Greek had merely the limited guidance of empirical
observation, aided in his individual  instance by a remarkably
shrewd instinctive feeling of what the normal progress of disease
is, and how far it is modified by remedies.  We have  a crowd of
anatomical and physiological facts, which may be brought to bear
on the subject, and which may keep us from wasting our time in
unfruitful  experiments;  and we  have spread open before us in
our public  hospitals  a wide volume for those who will read it
aright, illustrating the natural history of disease and its conse-
quences.   It is not necessary for any one of  us to be  an Hippo-
crates for  us to cure disease much more safely than he Avas  able
to do, and  probably in no remedy is this so clearly shown as in
the application of blood-letting. 
LECTURE   LI I.
ANSWERS TO OBJECTIONS AGAINST THE THEORY AND
      PRACTICE  OF CURE BY RENEWAL OF LIFE.

         (Lectori benevolo.  Not delivered viva voce.)

  He that for the first time happens to hear it made an aphorism
of therapeutics (as it has  been in the preceding lectures) that
morbid phenomena are always evidence of deficient vitality, may
not unreasonably find a stumbling-block in the following obser-
vations Avhich a thoughtful student of nature Avill not fail to make
on the patients before him :
  First.   Morbid  excretions  and  secretions  are often  more
copious than natural.
  Second.  Morbid solid products  may add to the  size of the
parts  they are attached to.
  Third.   Morbid muscular motions may be excessive.
  Fourth.  Morbid  mental  phenomena  may be  apparently
excessive.
  Fifth.   Morbid temperature is often higher than  the normal
average.
  Sixth.   Sensibility is sometimes increased by disease.
  I will answer these objections in detail.
  First objection.—The copiousness of morbid  excreta will be
observed  to depend not on the  addition to them of such organ-
ized products as are useful in assisting vital processes, but of
such as are the result of the physical decomposition of the body,
or of  its deficient  resistance to external  cosmical agents.  In
diarrhoea there is not an extra formation of pepsin or other di-
gestive juices in the alimentary canal, but a flood of liquid re- 
ANSWERS TO OBJECTIONS.
627
suiting from the diminished endosmosis compared with exosmosis
—just  as you have a  flow of water doAvn the waste-pipe of a
cistern Avhen  you do not  use  so much  in  the  house  as usual.
Thus, also,  medicines and diseases which increase the  amount
of  hepatic  secretion found in  the  stools,  do so by poisoning
either the secretion  itself or the intestinal  absorbents ;  so that
not  the quantity made but the  quantity wasted is  in  excess.
Waste  is no  proof  of  life.  Again,  in  urine abnormally aug-
mented there is found  no  excess of its essential part, urea, but
in almost all cases  a deficiency; those  instances of apparent
excess formerly classed  as  azoturia, baruria, &c. really resolving
themselves  into irregular  retention  and consequently irregular
evacuation.   The urea is first retained, then thrown out  for tAvo
days  in one.   Again, in the bronchi, how can Ave call excessive
mucus an excess of life, when even popular observation takes its
superabundance (the "death  rattle") as a proof of immiment
death ?  It  is not the business of healthy mucous membranes to
be covered with mucus  at all,  and when they  are so it is a sign
of deficient life,  local or general.  Mucous globules consist of
young epithelium, or rather of matter which ought to have been
epithelium, which ought to have lived remaining adherent to the
basement membrane, and performed  the local duties, but which
has miscarried and become a tenacious  fluid instead of a con-
tinuous solid.*
  Second objection,—viz.   That morbid  products  may  add to
the size of the  parts  they are attached to.
  The fact that diseased parts are often increased in solid bulk
is  of serious import, and suggests tAvo questions both of very
practical bearing:
  Firstly, does augmented  bulk imply augmented general life in
the individual 1
  Secondly,  does it imply augmented local life in  the  part
affected ?
  To the first question  a sufficient answer may be found, which
a fcAv visits Avith the eyes open to either  medical or surgical
Avards of a hospital may show to be true; namely, that it is not
                    * See Lectures III, IV, X. 
628
ANSWERS TO OBJECTIONS.
the burly, full-pulsed, red-blooded  man of large  appetite  and
great muscular power that is most liable to exhibit a specimen
of solid morbid matter,  but the anaemic starveling, quivering at
a breeze or a blow.
   In what corpse do you find the largest weight of fibrin thrown
out in the peritoneum  in the shortest  possible time ?   In  one
dead of puerperal fever—that is, in the Aveaker sex  at the period
of its greatest weakness.
   In  whom is rheumatic fever most likely to cause pericarditis,
with its great masses of morbid matter ?   In the young over-
grown person, especially if a female, and more especially if an
overworked, underfed needlewoman or maid-of-all-work.
   In  whose heart do the consequences of this pericarditis  most
readily induce hypertrophy ?  Not in  the  well-fed and  well-
clothed idle  or  professional  man  or woman; but  at the same
time of weakness, in the same weakly sex, and  under the same
weakening circumstances as the original  disease came on.
   Cancers and other tumors again, are found most often and of
quickest growth  in  the least lively bodies,  in  the  least lively
parts, and in those  Avhich are half killed by wounds, injuries, or
previous disease.
   It is perhaps not  impossible that, while the general vitality of
the individual  is lessened, some  part  might exhibit an extra
amount.   But morbid processes are  not evidences  of  it:  they
rather resemble developments of a lower form of life : their  pro-
ducts, though abundant, are  less vital than  the normal growth
Avhose place they take;  their existence is temporary, and "they
are not capable of becoming permanent constituents of the body,
or of lasting as  long as the individual."*   Examine a  patient
with  thickened heart during  life, and the pulse does not strike
your  finger vigorously, the apex of the organ does not  beat
sharply against the  ribs; indeed, the thicker it  gets, the  less
powerful is both  pulse  and beat, and the less actively does the
blood course through the vessels.   Dissect it  after death,  and
you will  seldom  fail to find a pale tissue with  microscopical
evidences of commencing fatty degeneration.   Still more  evi-
              * Virchow's "Cellular Pathology," p. 456. 
ANSWERS TO OBJECTIONS.
629
dent is the same degenerative  tendency in cancer.   The tissue
of malignant tumors, directly it  ceases to groAV rapidly, begins
to decay, to shrink, and  to be converted into fat.   It is hard to
imagine local strength or local excess of life producing such a
weakling crop.
   In cancer, truly, there is  a continuous reproduction of new
foci  of groAvth, a new progeny of prolific cells, which certainly
does look like an extension of local  life over a larger space, if
not the production of fresh local life.  But then we should reflect
that the highest and  most vital function of nutritive growth is
the  retention of the form of  the  body or its  separate  parts ;
that in morbid augmentations of size  this is lost: the controlling
power is absent, and the more so the more morbid and the larger
the augmentation is.   The formlessness of cancerous and of the
so-called  hypertrophic tissues seems to refer them  to a lower
grade of organic life than normal growth.
   Third  objection.—That morbid  muscular  motions are often
excessive.
   It is the function of  muscular tissue to contract, and there-
fore when  it contracts oftenest and  most it  might at the first
blush seem to  be  fullest of  life.  But on  the  other  hand,  its
function is  to contract in obedience  to antecedent animal acts ;
the  voluntary muscles in obedience to  the will, the involuntary
in obedience to other  demands.  And moreover, it  does not
seem certain that  relaxation is  not an active state as well as
 contraction, for reflex muscular actions, such as winking, yawn-
 ing sneezing, laughing, &c, can often  be prevented by an effort
 of the will keeping the  muscles  relaxed.   The highest develop-
 ment  of life is the fullest submission of the muscle to its  natural
 master.
   Observe, in  excessive haemorrhage,  Avhich I suppose  nobody
 will call an exaltation  of vitality, there is spasm, convulsion,
 sometimes  epilepsy.  In diseases universally acknowledged  to
 be  debilitating  you  find that irregular  constant  motion called
 subsultus tendinum, and the nearer  death, the more marked it
 is.   When the limbs are wearied  by violent exercise,  they start
 and quiver, and cramps keep  us awake after a hard day's walk- 
630
ANSWERS TO OBJECTIONS.
ing.   The Aveaker the will, the  more frequent and more violent
are hysteric paroxysms.   In  short, the rule appears to be, that
as the debility is greater, the  more frequent and more uncon-
trollable are the muscular contractions, and the easier are  they
excited.
  Fourth objection.—That morbid mental phenomena may  be
excessive.  If Ave examine carefully the minds of those in whom
one or other mental faculty appears excessive, we find that the
apparent excess is due  to the deficiency of another  faculty,
which in the  normal state balanced or controlled it.  Thus, for
instance, the  draAvings and  handwriting of incipient  lunatics
sometimes  exhibit  a  delicacy  and  minuteness  almost super-
natural.  This appears to arise from want of imagination and
taste.   The  wonderful memory  for  little  things  which these
people exhibit is seemingly dependent on the emptiness of  their
minds of other sensations.  That intellect, judgment, poetical or
artistic power are ever really developed by insanity, is merely a
popular delusion.
  Fifth  objection.—Life and warmth are so wedded in men's
minds, that the heightened  temperature in inflammation and
fever has contributed more than anything else to beget the idea
of the phenomena of disease being due to excess of vital action.
  It  is true that the  heat of the  body is greater in fever; but
that is no positive proof that  more is elicited, only that  more is
retained, than in health.   Indeed, in  many  cases Ave can  show
clearly  enough  that the  quantity produced is  not augmented.
Chill an inflamed part and a healthy part to the same  point at
the same time, and Ave find that the healthy part the soonest ar-
rives at the normal temperature.   Leave a fevered patient Avith
his burning  skin exposed to the air, and he  will often  grow
colder than a healthy person  under the like circumstances. Prob-
ably a great deal of the heat of fever is  due to deficient evapo-
ration by the skin and lungs, and  under that aspect Avould pre-
sent itself as the direct result of deficient function.
   Sixth  objection.—When people  talk of  " hyperaesthesia," and
of " sensibility being  morbidly  increased," they mean that  more
pain than ordinary is felt in  certain parts.   I cannot hear that 
ANSWERS TO OBJECTIONS.
631
they ever find agreeable sensations augmented.  No patient ever
speaks of enjoying  his  morbid feelings; his capacities in this
respect are  not  raised.  Nor have I ever found the organs  of
special sense made really more perceptive by disease.  No sounds
inaudible to the  listening ear  ever fall on the invalid's auditory
nerve, nor are objects  beyond the range of vision pictured on
his retina.   It is true  that the pains they feel often make them
attentive  to  slight  sounds  and  distant sights,  which the by-
standers  have passed over; but  these latter never  fail also  to
hear and see them by a voluntary direction of the attention.
   Nor is common sensation  rendered more accurate or  delicate.
I have tried, several times, by the test of its appreciation of the
distance betAveen the two points of a pair of compasses, whether
a  spot inflamed  Avith gout  had  the  perceptive faculties of its
nerves heightened in comparison  Avith the corresponding part of
the opposite side.  I have never found it to be so.  I have tried
the same experiment on parts affected with hysterical so-called
" hyperaesthesia," namely the brow and the left hypochondrium,
and  the delicacy of touch  seemed, if  anywise altered, to be
lessened.
   Therefore  to  call  these pains an increase of sensibility is in-
correct.
   The increase of painful sensation in disease is of  two kinds:
first, the exaltation of  it in parts which  are  naturally sensitive;
and secondly, its establishment in parts Avhich normally have no
feeling.  Can either  be  viewed as an augmentation of life ?  Test
the first by  the  gradual production of indubitable local death in
a  part.  Burn a portion of skin with fire or a caustic, or pro-
duce a slough by pressure;—the entire death or mortification is
always preceded by  pain.  And this pain goes on getting worse
and worse the nearer to death the spot  approaches, till its sud-
den cessation at the period of the virtual disconnection  of the
part with the individual.  It seems unreasonable to suppose that
the nearer death a part is, the higher should be its life; and we
cannot therefore accept heightened capacity for pain as proof of
heightened life.
   The occurrence of pain during the inflammation of tissues des- 
632
ANSWERS TO OBJECTIONS.
titute of nerves and insensible under  ordinary  circumstances,
such as the alimentary canal, cartilages, &c, is  at first glance
an argument telling  strongly against the theories of disease and
cure which I have propounded.  It may be asked whether the
sensitiveness of normally insensitive parts can be viewed other-
wise than as the extension of a vital function beyond its natural
limit and therefore as an increase of life.  For where is the pain
felt ?   In the uninjured nervous  center.  And  where is the
nerve that communicates with the center ?  Not in the inflamed
painful cartilage but at its border.  By the disease, by the low-
ering of life a physical change is effected in the cartilage up to
its edge, and notice  of that physical change  is transmitted by
the nerve.

  Since the  publication of the second  edition I  have read ex-
pressions of dissent from a principle which I think an important
one, and Avhich runs  through the Avhole of my pathological  rea-
soning, namely that all departures from that normal state Avhich
renders a  man capable of his ordinary duties are diseases.  It
is argued, for example, by the  Professor of Physiology  at King's
College, that I have  no right  to class as diseases diarrhoea  and
diuresis,  which  may be  produced by  a medicine in  the  end
beneficial.
  A grave principle  is here involved.
  It seems to me of the utmost importance for the pathologist
to recognize that  every phenomenon Avhich is not  health is  dis-
ease, and essential to the proper understanding of morbid states
to see that the external motive cause makes no difference in their
true nature.   The state in question is the same whether induced
by a physician's drug, or by a  felon's poison, or an epidemic ma-
laria, climatic influences, or organic changes in a patient's body.
In fact it would obstruct all true progress if we called the state
when  intentionally produced by  one  name, and  Avhen  uninten-
tionally arising by another.   In point of fact the  Avorld does not
do so, and  when  they  are " ill of the doctors,"  patients call
themselves quite as ill as Avhen otherwise laid up.
  The Avords "health" and "disease" must be employed;  and 
ANSWERS TO OBJECTIONS.
633
if they are  employed, the line between them  must be drawn
somewhere, or each speaker will assign to them a different sense.
Where shall we find a line more convenient than that most in
accordance with common usage ?
  An objection has also been raised to my counsel to medical
men to turn  their thoughts  toAvard adding to rather than to
diminishing  the materials of growth in disease.   The instance of
pneumonia has been quoted, where it is said our aim should be
to diminish the lymph in the lungs.   Now I suppose nothing is
so calculated to diminish the materials of lymph as mercury and
frequent  venesection; yet mercury and  frequent  venesection
are  amply proved  by  experience not to be the most successful
means of treating pneumonia.  I am  sure that the mode of
managing the patient  by supplying the materials of which lymph
is made,  as set forth in the lectures on pneumonia, and possibly
practiced by the objector himself, is much more efficacious.
  I trust nobody will understand me to claim any exclusiAre prop-
erty of invention in the plans of treatment which  I  advocate.
They are those now adopted by the most earnest and  liberal-
minded hospital physicians.   As Dr. Hayes truly  says in the
"American Journal of the Medical Sciences," I try to "embody
into a system the common  sense of clinical experience."  Per-
haps this is  a less ambitious task than the building up of theories
anticipatory of experiment, but I am sure it is more likely to
lead to useful results.
41 
L'BNVOI.
   In saying farewell, I would take the opportunity of pressing
upon students the  importance of making physiology the key-
stone and  binding  link  of all their knowledge,  and the firm
foundation which they are to crown with  their future practice.
It is an error, deadly to the usefulness of our profession,  to say
or do anything to foster an idea that the organic laws of health
and  disease are  different;  it  is still worse to paint them as in
opposition.  On the modern principle of dividing labor we have
separate lectures on anatomy, physiology, pathology, and the
practice of medicine; but your instructors  and you should never
lose  sight of these  as branches of one study, as being in truth
all limbs of the  same tree, those who follow them one after the
other are still pursuing  the  same end—a knowledge of  man's
nature,  with a view to the culture  of his physical well-being.
Each special professor has no more right to claim the sole  teach-
ing of you to be medical  men, than  the shepherd, the weaver,
or the tailor can arrogate to  himself the credit of adorning our
backs.
   I  have studiously taught you that no new modes of nature's
acting are brought into  play by disease; its chemistry  is the
organic chemistry of health; the same mechanical laAvs are ex-
hibited; the relations of the material and spiritual world therein
are the  same.   The difference consists in the deficiency, that is,
the temporary or permanent subtraction, of substance or power,
and  not in  its unwonted increase.
   I will frankly grant that this teaching is at issue with certain
notions  about disease handed down from  ancient times, and in-
fluencing the practice even of our immediate predecessors.  Ac- 
L'ENYOI.
635
 cording to them disease appears in the light of a positive material
 or agency alien to the body, to cast out which must be our prin-
 cipal aim in our endeavors to restore health.
   This idea has several branches.   Some look upon the morbid
 phenomena as "an effort of nature to destroy some noxious mat-
 ter, and to recover the patient by expelling it from his body."*
 It would make the chief business of the physician consist in
 watching the proper moment for aiding this elimination, in setting
 it going,  or in substituting instead of  it an  artificial outlet for
 the "morbific material."
   Other  branches are the chemical and antidotal systems of
 treatment,  which  have  nearly the  same pathology;  they look
 upon disease as an active foreign substance, which only requires
 to be rendered inert for the patient  to be restored to health.  A
 materies morbi is presupposed in either case.
   That a few diseases are the result of the introduction into the
 body, or of the formation in the body of a foreign noxious agency
 may be frankly conceded; and if we could keep  this agency out
 we should keep the patient well.    But even in  those special
 cases we cannot but see that the morbid phenomena continue to
 be  displayed  after the  expulsion of the  excitant;  the  Avound
 remains after the sword is withdrawn, the burn  is as painful
 when the  fire is out, the  chill is felt after our return to warmth
 and comfort, the stomach is inflamed though the irritant poison
 may be neutralized.   The disease  we  have to cure is not the
 materies,  but its consequences.
   Besides which, this  noxious matter is in  most instances not
 foreign to the body at all, but a necessary part of it, only re-
 quiring the addition of a  fresh constituent, or renewed function,
 to render it again efficient.   Such is acid in  the  stomach and
 colon, super-alkaline blood, anasarcous  serum in the tissues. To
 expel them is to deprive  the body of its substance, and  certainly
is injurious  practice in most cases.
   To another physician the morbid phenomena present a different
 aspect.   He regards them solely as exhibiting a phase of nature
  * Sydenham (Obs.  Med., cap. i)  defines  disease to be  "Naturae conamenr
materia; morbificoe exterminationem in aegri salutem omni ope molientis." 
636
L'ENVOI.
different from, and opposed to, normal anatomy and physiology.
Disease  is to him  an active  and intelligent living foe, at war
with his friend the human body, Avith a military system of its
own, to be studied  and outmanoeuvred.   There is a contest be-
tween Ormuzd and Ahriman; the agencies under the command
of the normal life  are  arranged against the pathological life.*
On these grounds, it would seem the main duty of the medical
man to  "weaken life,"f for it cannot be denied that these patho-
logical  phenomena are in a great  measure  of  a vital nature.
What this physician fails to recognize is, that their vitality is
the deformed remains of the normal vitality, that they are an
evidence of deficiency,  not something in excess, in fact that dis-
ease is "something less than life."
   I am sure that physiology as  it is now taught in our schools
is enough  to clear aAvay the remaining mists of  these supersti-
tions.   They cannot  stand before the light.   To us now health
is that  nicely adjusted balance  of vital functions which is  con-
venient for the uses men put their  bodies to, or ease; that dis-
ordered balance which  is inconvenient is bad health or dis-ease.
There are no foreign forces to be studied,  but simply varied
relations arising from deficiency of one or other of the ordinary
functions of life, and  a consequent Avant of  balance  between
them.
   Is it  not, then, obvious that the only sure mode of arriving at
a knowledge of the deficiencies  of vital powers, or diseases, is by
a knowledge of those powers of which they are deficiencies ?  The
physiologist is the only true pathologist.
   And as to the use of medicines,  with which it is a student's
duty to be acquainted,  do you not  see  that the safest guide to a
knowledge of their effect upon  a disordered  body is the knoAvl-
edge of their effect  upon a  healthy body,  and that the most
certain way of advancing the art of healing  is to search out the
essential actions of physical agents?

   * "Krankheit ist der Kampf des egoistischen Princips (des besondern Lebens)
mit dem planetarischen, der schadlichen Potenz, die es zu zerstoren sucht."—
Schonlein's "Allg. Pathologie," s. 1.
   f See Lecture V in this volume, p. 86, note. 
L'ENVOI.
G37
  To the practitioner I will urge the  need of  gaining firm faith
in the work he is  busy upon, and using  only the tools he can
trust.   Without this he can look back with no conscientious joy
on his daily toil, his moral nature will become baser and baser
day by day, he Avill have but the slighting scorn of those whose
praise he should value  in  old age, and, worse than all, he will
deserve it.  The sooner a skeptic leaves our profession the better
for his peace of mind.
   Remark, that by a skeptic is not meant one who disbelieves
Avhat somebody else believes in, and  which reason shows to be
inconsistent Avith  that  which he himself  has  ascertained  to be
true.  The early Christians Avere not skeptics, when they rejected
the  idols which their  better faith told  them were false gods.
Galileo Avas not a skeptic, when he found the Ptolemaic astronomy
inconsistent with his own.  A skeptic is one who begins by pull-
ing down, wTho scornfully calls useless the means which  yet he
traditionally  employs, before he has got better to take their
place.  Such a turn of mind never has led to truth.
   The right-thinking  practitioner will,  as Sydenham  did, gain
with advancing experience more faith and confidence in physio-
logical and restoratiA^e  treatment, Avill be less driven to fly timidly
to destructive expedients.   Like that great and honest-minded
man  he will cease to resort to "vense seetio"  in  cases where he
has found the  effect of "serum ladis" sufficient.
   To non-professional  persons* I would  say, examine  for your-
selves and see that the art of healing is a true woik,  not a set
of rules,  not  a doctrine, but  a  real means of adding to life and
happiness.   See—for you can see if  you  like—that her founda-
tions are  not opinion  or traditional  notions,  but a sure knowl-
edge  of God's works.   Look and see  that  not cleverness,  or
knack, or habit learned from others  can  be the  chief virtues of
the  professor of this art.  There is scope in  it  for the  highest
and broadest intellects, for wisdom, prudence, and judgment, as

   *  These sentences are taken from a general school introductory lecture given
at St. Man's for the opening of the session* in October, 1856; to which, accord-
ing to usual custom, parents and other non-professional friends of students are
admitted. 
638
L'ENVOI.
well as for the moralities of perseverance and charity.  He in
our profession who is first  in  the  scale of humanity is the first
and best physician.
  I would call upon all to remember what a high matter it is that
we  take upon ourselves  to  handle.    Man's life!—-that which
makes him God's viceroy on earth; for divorced dust and spirit
cease to hold that lofty post.   To aid us in our duty we  are
dowered with dominion over not only brute matter which we  can
number and weigh, but over those unseen forces which our reason
makes known to us ;heat, electricity, vitality, and maybe other
yet nameless  "powers of the Lord." Our business is to use them
to lengthen and lighten man's earthly trial.  Every minute that
our ministrant zeal upholds it in  vigor fosters a fresh  hope of
working out salvation for himself and  others; every minute by
which it is shortened damps that hope. 
 





 

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