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         THE PRACTITIONER'S







HANDBOOK  OF TREATMENT;




                   OR,





      THE PRINCIPLES OF THERAPEUTICS. 
^
         WORKS BY AUSTIN FLINT, 3I.D.
Professor of the Principles and Practice of Medicine and of Clinical Medicine in
             Bellevne Hospital Medical College, N. Y., etc.
A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDI-
    CINE; Designed for the Use of Students and Practitioners of Medi-
    cine.   Fourth Edition, Revised and Enlarged.   In one  large and
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PHTHISIS ; Its Morbid Anatomy, Symptomatic Events and  Complica-
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    AND TREATMENT OF DISEASES OF THE  HEART. Second
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A PRACTICAL TREATISE ON THE PHYSICAL EXPLORATIONS
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    Edition.  In one handsome octavo volume of 595 pages.  Cloth, $4.50.
HENRY C. LEA'S SON & CO., Philadelphia. 
-b
THE PRACTITIONER'S
HANDBOOK  OF  TREATMENT;
THE PRINCIPLES OF THERAPEUTICS.
                     BY

          J. MILNER FOTHERGILL, M.D.,
        MEMBER OF THE ROY A!"/ COLLEGE OF PHYSICIANS OF LONDON;
ASSISTANT PHYSICIAN TO THE CITY OF LONDON HOSPITAL FOR DISEASES OF THE CHEST, VICTORIA PAKK,
          ASSISTANT PHYSICIAN TO THE WEST LONDON HOSPITAL,
       ASSOCIATE FELLOW OF THE COLLEGE OF PHYSICIAN'S OF PHILADELPHIA.
 -1 The knowledge which a man can use is the only real knowledge, the only knowledge which
has life and groivth in it, and converts itself into practical power. The rest hangs like dust
ahout the hrain, or dries vp like rain-drops off the stones."—Froude.
       SECOND AMERICAN.

             FROM THE

SECOND ENGLISH EDITION, ENLARGED

      PHILADELPHIA:
HENRY  C. LEA'S  SON k CO
             1880. 
w

   PHILADELPHIA :
COLLINS, PRINTER,
   705 Jayne Street. 
                       TO







           J. M. DACOSTA, M.D.,







PROFESSOR OF PRACTICE OF MEDICINE, JEFFERSON COLLEGE,






                   PHILADELPHIA,






   WHOSE REPUTATION EXTENDS OYER TWO CONTINENTS,






               %\}\s <llarli is Jttatto





                       BY





                  THE AUTHOR. 
i 
PREFACE TO  THE  SECOND EDITION.
   The comparatively brief time which has sufficed to exhaust
a  large edition of this  work, proves  that  it has been found
acceptable  by the  profession.   The  London  Medical  Record
said, " a work of  this kind  has long been  urgently wanted;
and  the perusal  of a systematic treatise on the Principles of
Therapeutics will enable the student, all the more thoroughly
and with advantage to  himself, to study the works of Sj'dney
Ringer  and H. C. Wood.  Such a treatise gives him the broad
lines upon  wThich he must proceed  in his therapeutic efforts;
the basis upon which  he can rear  a  superstructure that will
embrace minutiae,  the importance of which may not  be  very
comprehensible without such underlying basis.  The practi-
tioner  can  compare his  own  practice with  the  lines here laid
down, and  note the points of agreement."

   This  rapid sale  further demonstrates  that non-teaching
hospitals may be  made useful beyond  their own  immediate
precincts.

  In teaching hospitals, the  energies are  necessarily mainly
bent towards teaching  students the  elements of  diagnosis:
where no students are present the  energies can  be devoted to
the study of each case from its therapeutic point of  view, and
the treatment of a patient be the main thing aimed at.  That
the experience so acquired may be  made to have far-reaching
consequences, the sale of this work here, and still more in the
United States of America, amply testifies. 
Vlii        PREFACE TO THE SECOND EDITION.
   Some additions have been made to the matter in this edition,
as, "When  not  to give  Iron," "The Functional Disturbances
of the Liver," " The means of acting on the Respiratory Nerve
Centres," " The Reflex  Consequences  of Ovarian  Irritation,"
and " Artificial  Digestion," which it is hoped will add  to the
practical value of the work.

  The author begs to record  his  thanks  to  Henry Sevill, Esq.,
for some remarks  on the Hygiene of the Teeth ; to Professor
Austin Flint for his  permission  to  reprint, verbatim,  his
remarks  on " The  Professional Conduct of Physicians,"  in  his
recent work on Clinical Medicine.   These additions, it is hoped,
will add  to the practical  value of  the work.

  His  best thanks are also due  to  Dr.  H. G. Orlcbar for  his
friendly supervision of the proof sheets.
23 Somerset Street, W.,
     April 12, 1880. 
PREFACE  TO THE  FIRST  EDITION.
   This work is not  an imperfect Practice of Physic, but an
 attempt of original character to explain the  rationale of our
 therapeutic measures.   First the physiology of each  subject is
 given, then the pathology is reviewed, so far as they bear  upon
 the treatment; next the action of remedies is  examined;  after
 which  their practical application in concrete prescriptions  is
 furnished.

   It is  not essayed to give prominence to new  remedies or new
 therapeutic measures, so much as to analyze  and elucidate the
 modus operandi of the measures in common use.  It is designed
 to  furnish to the practitioner reasons for the  faith that  is in
 him ; and  is a work on medical  tactics for the bedside rather
 than the examination table.

  For nine years the writer has been laboring with the definite
 design of producing the present  work.  In consequence of its
 original character much difficulty has been felt from  want of
 some  guide to indicate—not so much what  to insert, as what
 to leave out and where to stop.  A certain amount of repetition
 has been found unavoidable; but the plan of Sections has been
adopted to  reduce this to a minimum.  It is perhaps impossible
to generalize broadly, and yet to be accurate in minutiae: never-
theless the writer trusts that general principles have here  been
demonstrated without any violence to facts.. 
 X           PREFACE  TO  THE  FIRST EDITION.
   For advice and suggestions  how to improve the work  in
 future editions the writer will look  to  his  critics, adverse  as
 well  as  friendly—each alike valuable  to  him whose aim  is
 strictly to advance knowledge.

   The writer must here express his thanks to the Journal Com-
 mittee of the  British  Medical Association  for  their kind  per-
 mission  to reprint such portions of this work as have appeared
 as leaders in the British Medical Journal.

   He must also  acknowledge his  indebtedness to  Dr. Lauder
 Brunton, F.R.S., for much friendly counsel; to  Sir Joseph Fay-
 rer, K.C.S.I., and to Surgeon-Major A. R. Hall for  information
 on matters more especially connected with India ; and lastly to
 Mr. Herbert Page for revision of the manuscript, and to Mr. E.
 0. Bark  for his co-operation in the  correction of  the  proof-
sheets.

  22 Lower Seymour Street, Portma:n Square,  YV.,
          October 10, 187G. 
CONTENTS.
CHAPTER I.
                             INTRODUCTION.
SECT.
 1. The present position of therapeutics
 2. Aledicine as a science and an art
 3. The transmission of knowledge
 4. Alan as a man ; and as an individual .
 5. Individual peculiarities   ....
 G. Systemic impairment from bad environment.
 7. Health a balance of parts      ......
 8. Sequences in medical measures.—The building of a prescription
 9. Combined prescriptions   ....
10. Adjuncts......
11. Hygienic arrangements (accompaniments) .
12. Dietetic arrangements (accompaniments)  .
13. The choice of remedies   ....
-Imperfect organisms
PAGE
  17
  17
  19
  22
  23
  25
  27
  ■>H
  30
  33
  33
  34
  34
CHAPTER  II
                              ASSIMILATION.

14. The necessity for physiological knowledge.—Forms of food ; their desti-
       nation       .     .     .     .     .     .     .     .    .     .     .   3G
15. The effects of saliva ; of the gastric juice ;  of pancreatine.—Intestinal
       absorption.—The function of the liver  .     .     .    .     .     .37
16. Sialagogues    ...........   40
17. Digestion.—Artificial aids.—Pepsine      ......   41
18. Stomachics.—Alkalies.—Bitters.......42
19. Action of the pancreas.—Effects of ether.—Pancreatic emulsion     .   45
20. Intestinal action.—Purgatives........47
21. Haematics.— Lime. — Iron. — Combinations. — Specifics  in  specific
       anaemia      .     .     .     .     •    •     •     •    •      •     .48
22. ATalue of water.—Dilution.—Tissue-bathing.—Mineral waters   .     .   53
23. Tonics—mental, material.—Aromatic astringent.—Combinations of   .   54
24. Change of air.—Cold water........58
    When not to give Iron.........GO 
xii
CONTENTS.
C IIAPTER  III
excretion.
SECT.
25
    Characters of waste matters.—General excretory action of the surface.
      — Specialization of parts during evolution.—Community of function
      in secretory organs     ....•■
26.  Tissue-growth a form of excretion   .
27.  Compensatory action of organs      ....
28.  The lungs and skin.—Cutaneous respiration.—Skin and kidneys.—
      Urea in sweat.—Uraemie diarrhoea
29.  Treatment in unvmia     ......
30.  Effects of compensatory activity on the organs so engaged
31.  Anaemia from imperfect excretion.—Specific haematics
32.  Compensatory excretion of bile.—Lactic acid
33.  Alteratives.—Mercury.—Arsenic.—Iodine
34.  Use of alteratives.—Hydropathy    ....
GG
7<>
71
79
81
82
84
                          CHAPTER  IV.

                        BODY HEAT AND  FEVER.

35. Glycogen.—Heat  production.—Heat loss.—Regulation of  body tern-.
      perature     ...........   90
36. Normal temperature      .........   93
3 7. Collapse temperature ; its treatment.—Catching cold     .     .     .94
38. Febrile temperatures.—Fever.—The typhoid condition   ...   97
39. Effects of high temperature on tissues    .    .    .    .     .     .99
40. Effects of high temperature on the brain  .    .    .    .     .     .101
41. Treatment of the typhoid condition.—Apyretics.—Acids.—Salines.—
      Nauseants.—Baths    .     .      .    .    .    .    .     .     .104
42. Depressants.—Antimony.—Aconite.—Veratrum.—Action of alcohol as
      anapyretic   ...........  107
43. Quinine, and digitalis    .    .     .     ,    .    .    .     .     .113
44. Cold in various forms.—Jaborandi   .......  116
                           CHAPTER V.

                    INFLAMMATION :  ITS  VARIETIES.

45. What is  inflammation ? as a morbid process; as a means of cure.__
      Excessive nutrition    .......            J2()
46. The inflammatory process.—Means  of controlling it.—Vascular de-
      pressants         .........       JOr,
47. Treatment of  the stage betwixt the  inflammatory rise  and conva-
      lescence.—Therapeutic and dietetic management  ....  i9« 
CONTENTS.
Xlll
SECT.                                                                 PAGE
 48. Calomel and opium.—Local applications .     .     .     .     .     .129
 49. Convalescence; its management    .......  130
 50. Asthenic inflammation ;  its treatment    ......  132
 51. Specific inflammations and their management  .     .     .     .     .135
 52. Parenchymatous inflammations ; their course  .....  138
 53. Their treatment   ..........  141
 54. Inflammatory products ;  their indications      .....  142



                          CHAPTER  VI.

                  AN.EMIA___PLETHORA___CONGESTION.

 55. Anaemia; its forms and  associations     .     .     .     .     .     .145
 56. Indications for treatment      .    .    .     .     .     .     .     .147
 57. Specific anaemia   ..........  150
 58. Plethora ; its causal associations   .......  151
 59. Therapeutic indications.—Dietetic measures.—Purgation     .     .  154
 60. Congestion; its forms and causes    .    .    .     .     .     .     .157
 61. (Edema ; its causation in relation to treatment      .     .     .     .162



                         CHAPTER VII.

                          GROWTH AND DECAY.

 62. Disturbances of growth.—Dentition......164
 63. Troubles of digestion.—Infantile remittent fever   .     .     .     .168
 64. Bronchitis in children.—Colds.......169
 65. Imperfect tissue growth.—Oil inunctions.—Struma. — Tubercle.—
        Syphilis.—Indications for management.....170
 66. Decay.—Senile decay ;  its oncome and pathology  ....  175
 67. Indications for treatment.—Diet.—Alcohol.—Clothes    .     .     .178
 68. Nutrition, nervous and vascular.......181
 69. Fatty  degeneration      .........183
 70. Ilheums      .     .     .     •.......185


                         CHAPTER VIII.

                          ABNORMAL GROWTHS.

 71. Never truly heteromorphic—Hypertrophy, or Hyperplasia.—Dilata-
        tion of the heart and  hypertrophy......187
 72. Connective tissue,  normal and abnormal......192
 73. Pathological but perfect connective tissue.....193 
XIV
CONTENTS.
SECT.
 74. Degraded connective tissue.—Tubercle   ....
 75. Progress of tubercle.—Relations to treatment  .
 76. Importance of fat.—Food.—Cod-liver oil.—Climate
 77. Hectic fever;  its treatment.—Effects of rest.—Preventive me
 78. Malignant connective tissue.—Cancer; its varieties  .
 79. Therapeutic indications  .......
isures
CHAPTER  IX.
                 BLOOD POISONS---SPECIFIC POISONS.

80. Nature of blood poisons ;  effects of
81. Remedial agents ; their action.—Antiseptics
82. Specific poisons.—Malaria;  its seat
83. Quinine, how to be given.—Malarial dysentery.—Ipecacu
84. Cholera ; its nature and treatment  .
S5. Specific fevers ; their general management
S6. Special points to be attended to
87. Diphtheria ; its indications
88. Influenza;  its treatment
89. Dengue.—Yellow fever .
90. Pertussis.—Treatment
91. Erysipelas; its forms ;  their management
CHAPTER  X.
                     ACUTE AND CHRONIC DISEASE.

 92.  Acute disease.—The shock of pain.—Its treatment  ....
 93.  Hemorrhage; its management.—Other discharges ;  their treatment .
 94.  Syncope;  its treatment.—Asphyxia; its management
 95.  The theory of stimulants     ......
 96.  Circumstances modifying the action of stimulants.—Secondary effects
       of excessive stimulation    ......
 97.  Medicinal stimulation    ......
 98.  Alcohol as a food ; its other actions ; its use in convalescence
 99.  The relations of acute and chronic disease.—Acute disease becoming
       chronic ; its indications    .
100.  The  balance of parts in  power as well as in  function;  in chronic
       disease, and in convalescence
101.  Chronic disease becoming acute 
CONTENTS.
XV
                          CHAPTER  XI.

                   DIABETES__RHEUMATISM__GOUT.
SECT.                                                                  PAGE
102. Diabetes ; its origin ; forms  of; relation to Bright's disease    .     .261
103. Treatment—hygienic, dietetic, and medicinal .....  264
104. Rheumatism ; what is it ?      ........  266
105. Acute rheumatism.—Principles of treatment.—After-management  .  267
106. Chronic rheumatism.—Therapeutics of, gen eral andlocal .    .     .  270
10 7. Gout.—Lithiasis    ..........  274
1<)8. Origin and manifestations      ........  27G
109. Treatment of lithiasis    .........  -279
110. Suppressed gout; its management  .     .    .     .     .    .     .  283
111. Rheumatic gout     ..........  285


                          CHAPTER  XII.
                       DIATHESES AND CACHEXIA.
112. The constitution ; its  outward indications.—Physiognomical diagnosis  287
113. Diatheses ; their influence over ailments  ......  290
114. The gouty diathesis      .........  991
115. The nervous diathesis    .........  292
116. The strumous diathesis   .........  293
117. The bilious diathesis     .........  296
118. The lymphatic diathesis.      ........  297
119. Blends.—The hemorrhagic diathesis     ......  298
120. Cachexia.—The syphilitic cachexia ; its importance in treatment    .  299
121. Specifics      .     .     .     .     .     .     .     .     .    .    .301
122. Lead poisoning    ..........  304

                        CHAPTER  XIII.

                          ACTION AND INACTION.
1 23. Forms of neurotics ; their action    .......  306
124. Opium ;  its action on different centres ;  on the vascular system ;  on
       the nervous system ; in the relief of pain    .....  307
125. Effect on  motor and secretory actions     .    .     .     .    .      .312
126. Hydrate of chloral      .........314
127. Bromide of potassium    .     .     .     .    .     .     .    .      .315
128. The use of these several agents      .     .    .     .     .    .     .318
129. Astringents; their combinations with sedatives      ....  320
130. Inaction.—Belladonna.—Cannabis Indica    .....  322
131. Quinine and strychnine ; their use  .......  325
132. Combination of neurotics in practice     ......  328
133. Irritation  and counter-irritation.—External  use of sedatives    .     .  329 
XVI
CONTENTS.
SECT
134.
135.
136.
137.
138.

139.
140.

141.

142.

143.
144.

145.
146.
147.
14 la
                     CHAPTER  XIV.

                   THE CIRCULATORY  SYSTEM.
                                                                  PAGE
 Groups of maladies      .....-•••   ^34
 Blood pressure ; effect of agents upon     ......   335
 Compensatory changes in valvular lesions      .     .     •     •     .33 7
 Cardiac failure     ......••••   338
 Treatment of cardiac adynamy.—Rest and the removal of  causes of
  irritation    ........••'   340
 Cathartics.—Diaphoretics.—Diuretics.—Hot poultices    .     .     .   341
 Means of acting directly upon the heart.—Digitalis, its action and its
  use     ............   343
 Apparent objections to its use explained.—The so-called "cumulative
  action"      ...........   346
 Relief of consequential ailments.—Dropsy.—Diuretics ; their action ;
  combinations of   .     .     .     .     .     .     .     .     .     .347
 The dietary...........   349
 Secondary affections of the heart.—Angina pectoris ; imperfect forms
  of, treatment of   .........        351
 Neurosal affections of the heart.—Palpitation.—Irritable heart      *   356
 Irritable heart      ..........   358
 Amemic disturbances     .........   359
.  Aneurism    .     .     .     .     .     .     .     .     .     .     .361
CHAPTER  XV
THE RESPIRATORY SYSTEM.
148.  Respiration, in  relation to disease; to mechanical irritants;  to tern
      perature.—Catarrh     ........
149.  The treatment of catarrh     .......
150.  Affections of the air-tubes.—The theory of expectorants.—Forms of
      bronchitis.—Its treatment   .......
151.  Bronchitis and asthma    ........
152.  Affections  of the lung  structure.—Pneumonia,  its manao-ement
      Asthenic pneumonia    ........
153.  Localized pneumonia.—Nutrition   ......
154.  Treatment, general and special     ......
155.  Broncho-pneumonia     ........
156.  Affections of the serous  coverings
157.  Pleuritic effusion, its treatment
158.  Cough, its varieties and their treatment
159.  Dyspnoea, forms of and  treatment
160.  Haemoptysis .....
Pleurisy, its management
363
366

367
373

374
377
379
380
381
383
384
388
389 
CONTENTS.
XV11
                         CHAPTER  XVI.

                         THE DIGESTIVE SYSTEM.
SECT.
161. Dyspepsia, how occasioned    ........
162. The theory of emetics, direct and indirect    .....
163. Food in gastric  affections.—Medicines.—-Opium, in bulimia.—Alka-
        lies.—Bismuth.—External applications     .....
164. Points in diet.—Distant irritation   .......
165. Liver affections.—The action of mercury.—Superfluous bile
166. Tropical biliary  distui'bances (Sir Joseph Fayrer's remarks).—Intes-
        tinal acidity of Prout  .........
167. Constipation.—Purgatives—gentle, cathartic ;  points in each.—Mer-
        cury   ............
168. Purgatives in intestinal stricture, in the aged,  and at the menopause.
        —Purgative waters    .........
169. Diarrhoea, its varieties and their treatment.—From irritant matter.—
        From a chill. — Catarrhal. — Dysenteric. —Nervous. — Reflex.—
        From portal  congestion.—Tubercular.—Uraemic diarrhoea.—Colli-
        quative.—Thermic    .........
PAGE
 393
 397

 398
 401
 404

 415

 417

 420
422
170. Enteritis.—Opium  in.........430
CHAPTER   XVII
use of each
                          THE URINARY SYSTEM.
171. Function of the kidneys.—Formation of  urea.—Effects of sustained
        high functional activity     .     .     .    .     .     .     .     .432
172. Water excretion    .......
173. Diuretics.—Hydragogue diuretics.—Simple diuretics.—Tli
174. Acute nephritis, its treatment .....
175. Albuminuria, its management .....
176. Bright's disease (chronic)     .....
17 7. Its treatment.—Action of the skin  ....
178. The diet........
179. Fluids.........
180. Remedial measures      ......
181. In valvular disease of the heart     ....
182. Vesical maladies    ...•••
433
435
438
440
443
446
449
451
452
453
454
                       CHAPTER  XVIII.

                       THE REPRODUCTIVE  SYSTEM.
183. Importance of the ailments of women
184. In relation to the nervous system
185. Anaphrodisiacs     ......
18G. Blenorrhagia in both sexes—Its management   .
        B
456
45.7
458
460 
XV 111
CONTENTS.
SECT.
187. Puberty in girls.—Points in practice
188. The menopause     .......
189. Amenorrhcea.—Its forms, their treatment
190. Menorrhagia, its varieties and treatment .
191. Dysmenorrhcea     .......


                        CHAPTER   XIX.

                        THE CUTANEOUS SYSTEM.

192. Function of the skin.—Diaphoretics and anhidrotics
193. Skin diseases, their causation and general management
194. Their relations to the stomach, uterus, liver, and kidney:
195. Syphilidae.—Their treatment   .
196. Neurosal skin affections  ....
197. Injuries and parasites.—Their treatment .
198. Corns.—Warts.....
199. Ulcers.—Principles of  treatment
     Foetid feet    ......
TAGE
 462
 4G9
 470
 472
 476
479
485
487
490
491
492
494
495
496
CHAPTER  X X
applications in
                        THE LYMPHATIC SYSTEM.

200.  Its distribution and function   ....
201.  Theory  of absorbents.—Iodine.—Mercury.—Their
       practice    .......
202.  Inflammation of the lymphatics
203.  Glandular suppuration   .....
204.  Inflammation of the lymph spaces (serous sacs).—Their treatment
205.  Passive accumulations   ....
498

500
503
505
505
507
                        CHAPTER  XXI.

                         THE NERVOUS SVSTEM.

206. Importance of accurate diagnosis.—Anatomical  arrangements of the
       blood supply    ......
20 7. Hyperaemia.—Its treatment  ....
208. Vascular cerebral hyperaemia.—Its management
209. Cerebral anaemia.—Points in practice
210. Local cerebral anaemia.—Vaso-motor arrano-ement.-
211. Insomnia.—Its management  ....
212. Delirium.—Its varieties.—Their treatment.—Moral
       Remedial measures   .....
213. Headache, forms of.—Their treatment
214. Cerebral paralysis.—Indications in each case
		509
		512
		514
		516
		518
		519
I man	agement__	533 536 538
 
CONTENTS.
XIX
Sunstroke.—Treatment of     ......    .
Affections of the spinal cord.—Varieties of.—Treatment of each
Epilepsy.—Its production and treatment.—Night-terrors
Chorea.—Its forms      .....
Hysteria.—Its varieties and their management
Neuralgia.—General lines of treatment   .
Electricity.—-Its use
The Therapeutic instinct      ....
PAGE
 539
 540
 542
 545
 547
 548
 550
 551
CHAPTER  XXII
                PUBLIC AND PRIVATE HYGIENE

Public hygiene.—Its importance
Our houses.—Ventilation     ....
Water.—Effects of impure water   .
Sewage. — Sewerage.—Earth closets
Pathogenesis.—Disinfection.—Sewer gas.—Special
Infection.-—Medical men.—Nurses  .
Fever hospitals,  cottage and other   .
Private hygiene.—The healthy and the sick
Bathing resorts    ......
Mineral waters.—Their varieties and uses
Baths.—Cold, warm, hot, sand, mud, peat, etc.
Health resorts.—For the consumptive
Change of air in India (Sir Joseph Fayrer)
Change of air in America.—Tours   .
disinfection
552
553
555
556
558
562
563
564
568
569
572
574
578
583
CHAPTER  XXIII
              FOOD  IN HEALTH AND ILL-HEALTH.

Respiratory and plastic  foods.—Nitrogenized food
Hydro-carbons.—Force-producing material. — Effects  of  foods.-
   Forms of diet    .....
The relations of food to disease.—Bantingism
The diet in lithiasis      ....
In combined lithiasis and diabetes  .
Drinks.—Milk-, beef-tea, rice-water, etc. .
As stimulants  ......
As beverages.—As water
As a means  of affecting temperature
Diet cures.—Grape, strawberry,  milk,  whey, and  koumiss cures.—
   Substitutes for milk.—Artificial digestion.....
585

588
593
596
599
600
604
606
607

608 
XX
CONTENTS.
C H A P T E R  XXIV
           CONCLUSION___THE MEDICAL MAN  AT THE BEDSIDE
SECT
245. The examination of the patient
246. What to observe    ......
247. The manner of the examination
248. Our social conduct ......
249. The natural history of disease
250. As instanced in the relation of Bright's disease to the circulation
251. To be fore-warned is to be fore-armed
252. The future, and our duty      .... 
\*
                            THE

PRACTITIONER'S  HANDBOOK OF  TREATMENT.
                    CHAPTER.  I.

                       INTKODUCTION.

  § 1. The ultimate aim of all medical research is the treatment
and prevention of disease.  It is  eminently desirable that a
medical man be generally well informed; but what is to be still
more devoutly wished for is that he shall be a skilful practitioner.
It is quite possible to be the one without being the other.   The
combination is  what we hope to see commonly accomplished.
The tendency of recent teaching has been rather to produce the
first, leaving the second quality to develop itself, or to remain in
a condition of imperfect evolution, as might  fall  out.   This  is
not an individual opinion, in which case  it would  have  little
weight, but a general comment.   We constantly hear it asserted
that the highly-educated medical men of the present generation
are not more successful in practice than their less accomplished
but more  practical predecessors.   Even  members of  the pro-
fession are to be found who assert  that the  man under whose
treatment they would place themselves, if seriously ill, is the
old-fashioned general  practitioner.   This  is  a  very serious
reproach  to all  our recent advances in scientific  medicine; to
our modern instruments of  precision  in diagnosis; and even to
our progress in rational  therapeutics, with the  remedies added
to our armamentarium in late years.
  § 2. In order to understand how progress in one direction may
exist without corresponding advances in other directions, indeed
with a certain amount of retrograding in some respects, we must
clearly distinguish betwixt  medicine as an art and  medicine
as a science.   At  present,  the aspect usually  presented  to  us
      2 
18
INTRODUCTION.
by medicine is that of it as a science.   We are beginning to
have precise notions about the rational consequences of valvular
disease of the heart, and to see why one  set of consequences
results from a defect  in  one valve, and why a totally different
series of results follows  from  imperfection in  another valve.
We are learning to distinguish the locality of disease  in the
brain from the various disturbances produced in it, according to
the functions of the part affected.  We have learnt the lesson
that much of  the disease of advanced life is due to  imperfect
elimination of nitrogenized  waste.  • The relation of mental con-
ditions to bodily derangements is  just dawning  upon us in the
ordinary diseases  of  the  sane.   Physiological  inquiries  are
moreover  pointing out to us  the  right direction of our thera-
peutic measures, and lighting up areas  never to be successfully
illumined  by empiricism.   For instance,  the treatment of angina
pectoris by nitrite of  amyl was  the logical outcome of certain
physiological inquiries as to the  action of this drug, together
with some very exact  observations as  to the actual condition of
the circulation during the  attack.  The synthesis, thus erected
by Dr. Lauder Brunton,  and successfully  applied  in  the wards
of the Edinburgh Royal  Infirmary, is an excellent illustration
of the power of well-conducted  physiological inquiry to aid us
in practical medicine.  The experiments of Oscar Liebreich have
given  us  chloral hydrate, an hypnotic of  the  greatest value.
The observation that  strychnine and  atropine are direct stimu-
lants to the respiratory centre in  the medulla, promises us  the
means of  improving the respiration when embarrassed; just as
digitalis stimulates the action of  the heart when failing.  The
stethoscope, the laryngoscope, the ophthalmoscope, the  sphyg-
mograph, the thermometer, the urinometer and cognate diag-
nostic aids have done much for us in the recognition of disease.
The microscope has rendered services to medicine as an art as
well as a science.  It  has cleared up the nature of a whole class
of skin diseases hitherto shrouded in mystery;  while in the
recognition of certain internal affections it is simply invaluable.
Such are  some of the important  steps recently taken in that
division known as the science of medicine.
   In the art of medicine we cannot boast of such magnificent
advance.   As our instruments of precision have become more
numerous, as well as more exact and trustworthy, we have 
INTRODUCTION.
19
 insensibly come to regard the information thus furnished to us
 as of primary importance; until the information derived from
 a careful collection of rational symptoms, from a cautious con-
 sideration of the general condition, has been awarded a subordi-
 nate position.  In fact, we attach an exaggerated importance to
 one series of facts and under-estimate the value of others.  At
 present physical  signs  preponderate in the mind of  the practi-
 tioner over rational symptoms, to the detriment of the patient,
 and possibly to the discredit of the profession.  The public can-
 not be expected to estimate us by any other  measure than that
 of  our usefulness.  It is all very well  for a  patient to feel that
 his medical man is a  gentleman ; that he is carefully trained in
 physical examination, and capable of constructing a skilful diag-
 nosis ; who has added a residence abroad, and the observation of
 foreign schools, to his home-acquired attainments ; but the essen-
 tial thing after all is confidence in  his power to aid him when
 stricken and prostrated by disease or accident.  The latter is
 our actual business and occupation  in life ; and  it  is  here that
 success is most to be desired.   We can now perform the longest
 and most excruciating operations  without the  patient feeling
 one pang of suffering :  we can give relief by hypodermic injec-
 tions of morphia more speedily, efficiently, and perhaps  with
 less of those undesirable after-effects of morphia, than we could
 ere this invention ; to say nothing  of its value in  intractable
 vomiting.   We can enable an injured heart to develop compen-
 satory growth, and so, in many cases, preserve for years valuable
 lives, which until recently must have soon been lost to us.  By
 our improvements in  facilitating nutrition we can rear success-
 fully  myriads cf children who but a generation ago would  have
 swelled the death-rate of those who die under five years of age.
 By a carefully-selected diet, the diabetic patient can be preserved,
 a useful life, for years.
  The widespread use of antiseptics and disinfectants is already
 working much-needed reform in relation  to the arrest of the
 spread of disease, and in rendering our refuse less harmful.  In-
 deed there is much to render this centuiy memorable in the an-
 nals of medicine as an Art as  well as a Science.
  § 3.  On the minds of some, both in the profession and out of
 it, there is a firmly established fear that there is something dan-
gerous and unsafe in  too much  understanding of the nature of 
INTRODUCTION.
 things, including the nature of disease.  To such it seems much
 better and safer to rest contented ; that it is the best thing to do
 certain things under certain circumstances without being too
 inquisitive or curious as to the how and the why:  in fact they
 rather avoid being able to give a reason for the faith that is in
 them.   To those who search into the nature of things they affix
 the term unpractical.  If research has yielded positive informa-
 tion, and a  law has  been established, they call its elucidator a
 theorist.  A theory, no matter how well founded, has to them
 something dangerous about it, and  indicates unsoundness in its
 author.  "What an insult it  is to the chartered imbecility of
 industrial mediocrity that Shakespeare, Plato, Goethe, Hum-
 boldt, Bacon, indeed any one who possesses anything of inspira-
 tion, should not be a mere sense-machine for  registering obser-
 vations.  That some should declaim against  theory is no more
 than that an eunuch should inveigh against  lechery;  it is the
 chastity of impotence."  Such  leanings have done much to re-
 tard the progress  of medicine and have decidedly crippled its
 usefulness.   The carefully-acquired knowledge of one man, how-
 ever useful to himself and his patients, gave little or  no addi-
 tions to the general stock of information, because it remained
 individual knowledge derived from experience, which died with
 its possessor because he  could not  formulate it—could not so
 arrange it as to bring it within the sphere of the cognizance of
 others.  He could  treat one complex case admirably from his
 previous experience of like cases ;  but he could not enable an-
 other to treat such, or similar cases.  The knowledge existed__
 but not in a communicable  form.   It  has  always appeared to
 the writer that if such experience could only be rendered avail-
 able to others, a great step would be secured.   Much of the ad-
 vance of knowledge lies in the capacity of one generation to
 benefit by the experience of  its predecessor, in the power to ap-
 propriate the information gathered by those who have  o-0ne be-
 fore us,—knowledge which we in our time should leave elabo-
 rated and  enlarged to those who shall come after us.  Medicine
 is no exception to this rule.   A man  should not only  learn for
 himself, but  he should gather and garner for his  successors.
 The circumstances of having  undergone an  apprenticeship of
 being brought  up in a surgery, of being from childhood in the
society  of medical  men,  together with some  personal  fervor 
INTRODUCTION.
21
and a firm confidence in the future of medicine, may form some
excuse for the writer's attempting a  task which is  felt to be
difficult;  though it is hoped not insurmountable.  The manner
in which this  work has been  received at home, and even still
more in the United States of America, has more than justified
the hopes entertained at the time of writing the first edition.
  In  carrying into  execution  the scheme as  it now presents
itself, no attempt will be made to gather together all  the facts
of medicine, to collect  all the  information possible, nor indeed
to enumerate all the members of the pharmacopoeia.  Such aim
would tend to make this work encyclopedic instead of a treatise
rather inciting and suggestive.  The aim of the writer, if it can
but  be accomplished, is to supply  a digest of the general prin-
ciples of therapeutics, to arrange well-known facts of practice,
together with the explanations furnished by pathological research
and  physiological inquiry, in  such array and form, that  the
treatment of each individual case  shall  become a fairly intelli-
gent and  rational procedure, rather than a  groping empirical
guess.   Failure even may indicate to some one else a line wTorthy
of pursuit.  Especially is some such work indicated for the use
of those who receive  a scientific  education  without  anything
like a corresponding  acquaintance with actual  practice; and
who pass  into the ranks of the profession, and are brought face
to face with the care and  responsibility of grave and complex
cases, without that aid and supervision from teachers or seniors
to which  they have hitherto been accustomed.  It  is a serious
matter, both for patient and medical man, this  abrupt introduc-
tion to practical medicine, with all its difficulties and anxieties.
  Practice differs essentially from the examination-table.   An
examiner may temper the wind to the shorn lamb, and remember
that a  diploma only  guarantees  the possession of a  certain
minimum of knowledge ; but in practice the most  complicated
affections  are presented to the tyro.  Further,  too, there is this
difference:  in the hospital the  patient is  merely  a case  of
Bricjht's disease, or some other disease;  in actual practice  the
patient is to a certain extent a patron, and the management of
the case may exercise a distinct and powerful influence over the
professional reputation and prospects of his medical attendant.
Such a consideration alone is often sufficient to produce in  the
youno- practitioner a  certain  disturbance of  the intellectual 
22
INTRODUCTION.
equilibrium, and to interfere with that serenity so desirable for
calm investigation and decision ; to induce, in fact, perturbation
of a nature militating against perfect self-possession.
  § 4. It is soon apparent that a patient is not merely a subject
of interest as  the victim of some  morbid process, nor even as
furnishing an opportunity for individual  advancement merely ;
he is an elaborate  and interesting organism  possessing certain
definite qualities.   In fact he is a Man.   He is a Being who
possesses the attributes of humanity collectively; together with
some variations which form individual peculiarities.  In relation
to the first he  is an organism which has possessed  the  power of
growth, of evolution  until a  certain point is  reached.   After
that point is attained growth  ceases, and a condition of perfect
functional activity is established.  In time, however, the system
is no longer equal to maintaining its integrity, and certain
modifications of nutrition are produced, which we recognize as
evidence that  the system is becoming old.  Such changes are
often prematurely induced, and are then termed degenerations.
  One thing especially strikes the observer in relation to disease,
and that is the capacity of the organism to maintain its exist-
ence for several days without supplies of either food or drink.
Yet the excretions  are going on.  It  is also found that during
this time of fasting  there is a loss of body weight.   In fact it
becomes evident, as we shall see  in  another chapter  (XXIL),
that the body possesses a reserve fund within itself; and that for
some time it can exist solely  upon this reserve fund.  This pos-
session becomes a specially valuable matter in disease. The fund
takes its  origin in the  food we consume.  After  each meal  so
much is stored up; every day so much is  withdrawn from  this
body bank. If each day's food had to furnish ouch day's supplv
of force, we should have a most uneven existence ;  and anything
like a normal  state would be  impracticable.  By this system of
storage man  saves up under  favorable circumstances, and ekes
out his daily needs under less favorable circumstances.   There
exists a species of capital, or physiological fund, into which he
can pay, or from which he can draw according to  his necessi-
ties.  This store of force will keep a man alive, when  deprived
of food, for about ten days.   With slight daily subsidies it will
maintain life  for a much  longer period.   Thus  in acute disease
this reserve fund enables the system to tide over the time of 
INTRODUCTION.
23
 trial;  if this period be survived  the system is left weak, en-
 feebled,  and reduced  in  bulk and weight.  After  the  active
 disease is over there comes a period of convalescence, when the
 body capital is being restored and a new fund of force accumu-
 lated.   This period is not without its dangers.   The treatment
 of  the disease by stimulants  is alone rendered  possible by the
 presence of this reserve fund.  Stimulants enable the system to
 unlock some of its reserve stores.   Alcohol, too, is,  as we shall
 subsequently  see, a readily  oxidizable form of hydro-carbon,
 and as such is easily converted into force by the system.  Often
 indeed it is the only food practically  available.  But it  also
 enables the system  to  borrow from itself much more than it
 furnishes.   When the  person  dies exhausted, the real state of
 matters is this—the reserve  fund has been  reduced below  the
 point  compatible with survival.   This is death by exhaustion.
 This reserve fund of force exists in every individual.  In some
 it exists in a highly marked condition, and these persons  are
 said to  possess great "stamina."  Others  possess it in  a less
 degree;  they are said to have  little resisting power.  Systems
 broken by  disease,  or wrecked  by evil habits, possess  but a
 small  reserve fund.  It is a matter of vital  importance  in the
 treatment of  disease to be able to estimate fairly and correctly
 the extent and  amount of this reserve fund in each and every
 case.
   § 5. Then come certain  other matters which gravely modify
 the significance of objective phenomena of a more personal  or
 individual character, which are not  to be overlooked.  First
 among these is the diathesis.  The diathesis is the form or type
 of  constitution  inherited  from the parents.  Five such forms
 are described (see Chapter XII.):  the  strumous, the  gouty, the
 nervous, the  bilious,  and the lymphatic.   Each constitution
 carries with it certain tendencies  and leanings, of the greatest
 possible practical importance.  In each there is a distinct incli-
 nation to institute  certain symptoms,  and to  present certain
 complications.   The strumous are very often lacking in-vital
 force, and are the objects of much care during convalescence
from acute disease;  especially  if it  be of a zymotic character.
The gouty are very liable to ailments  in advanced life, often of
the most varied and even  Protean character; but in each  the
imperfect elimination of nitrogenized  waste forms the  basis. 
21
INTRODUCTION.
In the nervous  there is a distinct leaning towards complicated
diseases connected with  the  nervous system, requiring special
care and watchfulness: in this class we find the patients for
whom it is so difficult to prescribe; they are  either excessively
susceptible to all drugs which act upon the nervous system, or,
less commonly, they require very large doses.  The bilious are
always more or less troubled  with an accumulation of bile pro-
ducts in their portal circulation, and, with  them, attention to
the liver is indicated in the treatment of all acute, no less than
of chronic  affections.  In those of a lymphatic diathesis  there
is  alwavs  a feebleness of resisting power, and the unenergetic
system  requires much whipping up with stimulants, alcoholic
and other, to enable it to tide over attacks of acute disease.  In
addition to these points of diathesis the family history is often
most instructive.   The long duration of life in one family often
whispers hope under conditions of gloom.  The history of the
family will often put the practitioner upon his guard when there
is nothing apparently in  the case itself to arouse his  apprehen-
sions.   Amongst  personal characteristics  too is the  possession
of endurance.   In one system repeated attacks of disease may
have  shaken  it to its very foundations;  and the organism is
already tottering, waiting for the last and  perchance minute
disturbance which will result in total overthrow.  In another
repeated perturbations seem but to have' educated the system to
seek -a  new equilibrium under disquieting circumstances, and
this education enables it to recover from rude oscillations which
would be utterly  destructive to most systems.  There is also
the greatest possible difference in individual organisms as to the
amount of food, wine, etc., required to compass a certain effort,
or  to  evolve a given amount of manifested  energy.   Locomo-
tives apparently  identical vary much in the amounts of fuel
they consume in performing a certain amount of work.  Horses
notoriously differ in the amount of food they require ; the labor
executed being apparently the same.  All these different factors
must.be included  in the  correct appreciation of  each case  and
are quite as important matters as the objective facts ascertained
by stethoscope and urinometer.
   In certain combinations, varying widely in different systems,
these  individual  characteristics just  enumerated are so pro-
nounced as to form what are called idiosyncrasies.  Often quite 
INTRODUCTION.
25
unintelligible as to the why of them, these idiosyncrasies are
most important matters in the treatment of disease. .Thus one
person cannot take milk ; while others cannot eat an egg.  Such
peculiarities will  always receive attention from the wary and
far-seeing practitioner.  Then others cannot take quinine, or can
tolerate some forms of iron only.   To one few tonics are en-
durable, while another seems only to be the worse for every con-
ceivable form of neurotic.  The intolerance of opium and mercury
by certain persons is well known.  It is often found combined
in the same person, and especially in  the subjects, of chronic
Bright's disease.  In fact such  intolerance should always fur-
nish a strong hint to investigate the conditions of the kidney.
Chloral hydrate, hyoscyamus, and other neurotics are well or ill
borne by different individuals in a curious and almost inexpli-
cable manner.   In an aged couple recently under my care, both
of whom were subject to attacks of suppressed gout, chloral was
simply a poison to the  ladj', while her husband's  praise of it
amounted to eulogy.
   § 6. There are other  points, associated  with individual  cha-
racteristics, of much importance in practical medicine, directing
the prognosis and guiding the  line of treatment.   One is the
general deterioration of pln'sique, not always giving outward
visible indications, which is found in persons who have under-
gone much privation, or  who have lived under  unfavorable
circumstances for some space of time.  Bad or insufficient food,
impure and tainted water, and  foul, polluted air, singly,  but
more potently when combined, in time  produce a deterioration
which readily reveals itself in the course of epidemics.  The
different areas of individual water companies have been found
to give widely-varying results in the proportion of deaths occur-
ring during epidemics.   The high  death-rate clings to the im-
pure  water-supply.  Persons thus influenced, or  unfortunately
so placed, sink under disease  much more speedily than others
who live  under more  favorable  circumstances.  They possess
little resistive force, and what they have  is quickly exhausted
by serious disease.   In such persons it is necessary to commence
a plan of stimulation combined with nutritive food, in  anticipa-
tion of the hour of trial.  If this treatment be delayed till the
indications present themselves, it will usually be found inopera-
tive and unsuccessful; it has been too long deferred.   In such 
20
INTRODUCTION.
cases the medical  man must learn to see his evils far ahead and
prepare to. meet them.
  On the other hand there is a large  class of  people not quite
coming under the head of invalids, and yet not perfectly healthy,
for  whom a directly opposite line of treatment is indicated.
They are persons who have established an ideal of health  to aim
at—quite irrespective of their capacities.  They do  not possess
a normal amount of health and strength, or age is commencing
to lay upon them its enervating hand, yet they are loath to
acknowledge either.  They aspire to the habits and  practices of
perfect health, or of a by-past time, and bend all their energies
to the attainment of these aspirations.  Instead of reducing
their  self-imposed demands to  the capacities of their system,
they endeavor  to whip  themselves up  to  their ideal by large
supplies of stimulating food and liberal draughts of alcohol.  It
is of  no avail, however, and then a  complete breakdown, fol-
lowed  by protracted convalescence, is the  result achieved.  If
they can be prevailed upon  by  any  means to moderate their
aspirations, or be compelled to limit their demands upon them-
selves to their capacities, much  better health, and even  length
of days, would be practicable.   They form a large  and  impor-
tant class of  chronic patients;  with whose  peculiarities and
individual necessities the prudent practitioner will  do well to
make  himself familiar.   There is another  class of persons who
are chronic invalids of a different description,  with whom more
acquaintance on the part of the profession is  desirable.   They
usualty occur in the  more affluent classes; indeed, their exist-
ence is scarcely compatible with hardship and penury.   They
have  not yet found a biographer in the ranks of medicine: and
the best sketch of such a person  is the brief one by Georo-e Eliot
in Adam Bede, where she describes Miss Anne Irwine, the Rec-
tor's  invalid sister.   A poor wretched  spinster, with a small
wan  face, worn  and  sallow; with chronic headaches, necessi-
tating rest in bed with a darkened room ; the prey of neuralgia
and depression ;  utterly unacquainted with the sensations of
buoyant health and possessing but a minimum of energy ; bare
existence under the most favorable circumstances is all to which
such a system is  equal.   Great and tender consideration, a low
voice whose tones vibrate with  sympathy, and a noiseless  step,
are more desirable here than  extensive acquaintance with reme- 
INTRODUCTION.
27
dial measures.  Such cases do not furnish brilliant cures, as do
the hysterical; but they furnish grateful, attached patients,
susceptible and thankful  for your  consideration.  It  is the
height of cruelty to demand manifestations of energy from such
poor creatures—they are simply not equal to them.
  § 7. Then again there is still another and larger class of patients
— the chronic invalid, suffering from some incurable malady.  It
may be  chronic gastritis,  cirrhosis of the liver, a tuberculous
lung, a weak heart, or granular kidneys which  constitute the
weak spot of the otherwise fairly healthy organism.  If the in-
jured or defective  organ could but  be restored  to its  pristine
integrity, a return to  something like jjerfect  health would  be
feasible.   But  such restoration is simply impossible.  "Health
consists of a balance betwixt the various parts of the organism
in power as  well as in function."  Consequently if the disease
in one part be  incurable, the sooner a new balance is  struck the
better.  A general lowering, or levelling down is alone calculated
to preserve the organism in such cases; and attempts to improve
the  general condition too far by any process of  levelling up is
but too commonly followed by disastrous results.   An improve-
ment in the  general condition is not rarely productive of a still
further disturbance of balance  betwixt  the weak part and the
rest of the body; and then usually a new accession of disease in
 the injured  part follows as a consequence.  For instance, if the
 kidneys are injured, a comparatively high state of general health
 with  good assimilation and much nitrogenized waste, is not
 uncommonly the cause of an attack of suppressed gout, may be
 as bronchitis or even pneumonia, the consequence of  renal  in-
 adequacy; or an attack of acute nephritis may imperil the ex-
 istence of the individual—which attack might have been avoided
 if the general condition had not differed so remarkably from  the
 condition of the kidneys.   Or, again, a person  has a weak heart
 or an aneurism.   Here the condition of chronic invalidism is
 more consonant with  the continuation of existence than is that
 of a capacity for  exertion, which would test  too severely these
 injured  structures.  It is  a  great point in practice to distin-
 guish clearly when to cease our efforts  to improve the injured
 part by measures  directed towards  the general condition,  and
 when to inaugurate a line of treatment which shall bring  the
 condition nearer to that of the incurable organ.  Constantly in 
28
INTRODUCTION.
actual  practice such modification of our therapeutic measures
will be clearly indicated.
  Such are several  of the most important variations from the
norm  which  will present themselves in daily practice.   They
present problems not always easy of solution.   Sometimes we
are scarcely thanked for their solution ; at other  times they fur-
nish  us much credit.  They all need careful recognition, and
give  much valuable material  for  the elaboration of a line  of
treatment.  Practically the clear appreciation of these rational
indications often outweighs  the information afforded by instru-
ments of diagnostic precision.
  Very frequently the  information thus afforded  will put the
youthful practitioner upon his guard in seemingly trivial  cases,
and prompt him to leave no stone  unturned in cases where the
physical signs are  far from  alarming; at other times it will
whisper hope and encouragement where all seems dark and un-
toward; in either case it will exercise a most pronounced  effect
upon the line of treatment.  In order that our therapeutics may
be successful, a distinct recognition of the case  in its entirety,
in its  subjective as well  as  its objective phenomena, is   most
necessary; and a thorough appreciation of what is to be dealt
with must, or ought, to precede our measures for dealing with
it, otherwise  much  valuable time  may be lost, or opportunities
have passed away—never to return;  and an unavailing  regret
be left where a more guarded attitude at first might have changed
the whole aspect.  The view presented to the medical man after
his examination of the case should be such that  it will include
the past history of the case ; nay, more than that, it should em-
brace the family history on  both sides, and  should also furnish
useful  forecasts as to  the probable future.   This is a genuine
diagnosis, and is as widely different from the  mere physical
diagnosis—now so  fashionable—no  matter  how exact, as is a
fertilized from an  unfertilized ovum; the one  is, too often, a
mere series of barren facts, the other is pregnant with potential
h\Tpotheses.
   § 8.  Having decided upon the ailment and formed a careful
diagnosis, having satisfied the patient's friends as to the prognosis
—it is perhaps not always desirable to tell  the  patient what is
the matter or the gravity of the  position, but  never  leave the
friends in ignorance—the practitioner must proceed to construct 
INTRODUCTION.
29
his plan of treatment.  It is a golden rule never to prescribe in
an off-hand slipshod • manner; whoever does so will sooner or
later trip.  It is well always  to construct, as far as possible, a
distinct scheme and a definite plan of treatment.   Xo  matter
how slight or trivial the case, it is desirable always to act on an
intelligible and intelligent plan.  Always, as far as practicable,
we should  prescribe with knowledge as to what we expect our
remedies to do.  It is certainly fortunate that the agents are
not influenced  in  their  action by  any theories or  hypotheses
on  which  they  are administered.  If such  were  the case our
therapeutics would indeed be chaos.  Nevertheless it is  always
agreeable to give medicines with a lively expectation as to what
they will do.  Such prescribing always gives a greater sense of
satisfaction than when one is driven to prescribe secundem artem,
or according to  an unilluminated empiricism.  Often indeed it
is necessary to sketch out a scheme which will not only include
the immediate present, but which will map out a line stretching
far into the future.  It may be desirable to give, at first, sedative
or diaphoretic  remedies; to  be followed  in a day or two by
mineral acids and bark, and ultimately by steel and cod-liver
oil.   Or a case of  suppressed gout  may  require eliminant
measures wTith alteratives and a restricted diet for a  time;  after
which tonics, good food, and wine are desirable. These arrange-
ments are not contradictory, nor even inconsistent; each has its
turn of usefulness, and then gives way to another.  Such alterna-
tions do not indicate changes of opinion or caprice: they  demon-
strate a clear-sighted view of the case.  As wheat is sown, grows,
and  ripens ere it  is cut; so complex  plans  of treatment  have
their several stages.  For instance, in an acute catarrh it is well
to give depressant diaphoretics, as opium, antimony, and iodide
of potassium, first; and then, when the  skin  has  been  roused
into free action, syrup  of  squills  and phosphoric acid follow
rationally in their turn.  It is desirable first to throw the skin
into action and  lower the temperature, measures which  relieve
both the catarrh and the pyrexia; and then to give  well-chosen
tonics, and especially tonic expectorants,  when the catarrh is
bronchial:  if it be nasal, phosphoric acid in infusion of cascarilla
would rather be indicated.
  Whatever  line or plan the reader may adopt  it should be
rational  above all things:  if  there is really nothing else for it, 
30
INTRODUCTION.
let  it be selected by or from  a  well-chosen empiricism, either
personal  or  acquired.  How to meet the bulk of cases encoun-
tered in  practice will be described in the course of this work.
It is  a matter of the  greatest moment in grave and complex
disease that the  practitioner keep his head clear and his judg-
ment sound.   If he lose his head it is as disastrous to the case,
as it is to his army when a general loses his head in a battle or a
strategic movement.  And nothing can or will keep a man's head
clear so effectually as the consciousness that he knows his work.
  It is  no part  of the present  scheme to provide a complete
treatise on Practice of  Physic.   There are many such works of
great excellence which  can be profitably consulted. The attempt
here is rather in the direction of enabling the reader to wield
satisfactorily a great proportion  of our remedial agents, and to
guide him in his therapeutic  evolution ; teaching him  how to
educate himself,  and  how to apply remedial agents intelligently
and  successfully.  Some  learn quickly  for themselves how to
combine  remedies, how  to construct prescriptions exquisitely
adapted  to the case  before them; but others are not so fortu-
nate, and for them the combinations given  in a concrete form
throughout these pages may be useful.
  § 9. Our remedial  agents form themselves into a number of
classes.   Several members of different  classes may often  be
advantageously combined in one prescription.  Then there are
different  remedial measures.  They may be also united with
good  effect  at the same  time.   We may briefly  construct a
typical prescription,  and  then  may review combinations of dif-
ferent  measures.  Medicinal  agents  comprise  remedies either
possessing a general action, or acting chiefly upon one system,
or perhaps one excretory  organ.   These latter agents have  been
supposed to  possess this propertj' by virtue of some stimulating
effect upon  that organ especially.  For instance, urea is a true
diuretic,  acting powerfully upon the kidney when administered
experimentally.  Aloes acts  upon the  bowels if applied  to a
blistered surface, as  well as when given by  the  mouth.   It is
not quite certain how  far these  agents act simply as increasing
the blood-supply to the different organs, and so increasing their
functional activity—for  these two stand in strict  relation to
each other; or how far they are eliniated by these oro-ans  and
so stimulate them into action.   Of this more  anon.   Ao-ents 
INTRODUCTION.
31
may possess a general action like  mercury or iron.   It may be
necessary to give two agents possessing different actions together,
say as sulphate of magnesia and iron, in a case of anaemia with
constipation.  These are the two chief factors of the prescription.
It is necessary, however, to  give them in a vehicle which may
itself possess some value.  Consequently it does not follow that
they need  be given merely in water.   There  may be a certain
loss of  appetite which may indicate  some bitter infusion, as
quassia, as the best  vehicle.  Then it not unfrequently happens
that such a dose is  not very perfectly borne by the stomach ;  it
seems to be cold, or to be followed by a sense of nausea, or eruc-
tations  of Avind.    Under these circumstances a few drops of
tincture of capsicum will  form a  capital addition.  This  is
termed  an adjuvant.  Consequently  the prescription  Avill  stand
ultimately in the following form:—
                 U Magnesias Sulph. 9j.
                    Tinet. Ferri Perchlor.  TH. vj\
                    Tinct. Capsici TTT. iv.
                    Inf. Quassia? ^j.
This may  be  taken two  or three  times a day, from fifteen to
thirty minutes  before food ; either before breakfast and dinner,
or before dinner and supper, or before all three.   Medicines are
apt to be somewhat nauseous ; and the above forms a bitter and
warm chalybeate.   Consequently something is desirable to take
away the  taste.  A draught  of Avater  accomplishes this best.
Such draught  not  only removes  the taste,  but it  often acts
usefully,— is  indeed of material value.   Especially  is this the
case with chalybeate and  alkaline  medicines.   It is often re-
marked that natural waters of these two  classes effect good
results  when similar remedial agents  giAren medicinally have
distinctly  failed ; and that, too, after long and persevering trial.
The amount of water makes the difference.   Alkalies and iron
should  be taken before food, and be Avashed down  by copious
draughts of Avater; and it -will not often be  necessary to send
patients to spas for natural waters to  achieve Avhat home-treat-
ment has  failed to accomplish, if this  rule Ave re generally at-
tended  to.  This is an important practical "wrinkle."1

  1  I suppose such hints are called " wrinkles" because, like wrinkles, they indi-
dicate the presence of age, and, therefore,  of long experience. A lifetime may-
be spent, by no means uselessly, in the gleaning of such wrinkles. 
32                    INTRODUCTION.

  It may so happen, however, that it is found convenient to
modify the  prescription.  For instance, it may not be easy to
hit  upon the exact amount of purgative the patient requires in
order to keep the boAA^els gently open.  It is one of the  most
disturbing matters possible in prescribing to adjust the exact
amount of a purgative.  So commonly is this fact recognized
that it is usual to ask a patient whether he, or she, is easily-
purged or not.   This is a question that in many cases  it is
undesirable to omit.   Consequently, then, instead of sulphate
of magnesia in the mixture, a pill of aloes and myrrh at bed-
time, every night or second  night, may be desirable.   A slight
action  on the boAvels is almost always beneficial at the commence-
ment of a course of iron;  but it had  better be within bounds,
else  it  may be harmful, or it may disgust the patient.  Some-
times, too, quinine is indicated as a tonic in addition to the iron
as an haematic and tonic.  The  prescription Avould  then stand
thus:—
                 R Quiniae Sulph. gr. j.
                   Ac. Hydroehlor. Dil. HI iij.
                   Tinct. Ferri Perchlor. TH. v.
                   Tinct. Capsici TTJ, iv.
                   Inf. Quassiae §j.
AA'itfl
                   Pil. Al. et Myrrh, gr. v. p. r. n.
at bed-time.  There is nothing contradictory in  such combina-
tion.   Even more complex arrangements are sometimes needed.
As, for instance, supposing the patient has piles, it would  then
be necessary to resort to another remedial measure :
                        Ung. Gallae Co.
A small quantity to  be  applied on  the tip  of the finger to the
piles after each motion of the  bowels: taking  care  to bathe
them Avell, or rather  wash  them thoroughly with cold water
immediately after the boAvels have moved.   If it happens that
the patient is a female it is more than probable that under these
circumstances she will have leucorrhcea too, and then somethino-
more Avill have to  be added, viz., another  measure  also of an
astringent class:—
                     Aluminis Sulph. gij.
                     Aquae 5XVJ. 
INTRODUCTION.
33
to form an injection to be used twice a day, with the patient in
the recumbent position.
  § 10. Such Avould form  in  most cases a  comprehensive line
of treatment; and though looking at first sight a complicated
affair, is nevertheless clearly intelligible and consistent.  Another
therapeutic measure  even might  be  indicated if there also
existed, as there very possibly would, a certain amount of pal-
pitation.   Iu  that case it might  be Avell to add  an  external
application to the skin,
                     Emp. Belladonna? 6X4,
to be applied over the region of the heart.   The patient by this
time wTould be pretty effectually drugged, and it would scarcely
be quite prudent to start with all  this at once.  It might, Iioav-
ever, all  be necessary  if  the  patient had  been long  under
medical care  in other  hands, and nothing but a  thoroughly
effective  and comprehensive therapeutic  plan  will be of any
avail.   If the piles caused much distress and prevented sleep, it
might be necessary to add one more therapeutic measure, often
very serviceable—
                     Morph. Mur. gr. |.
                     Gallic Acid, gr. ij.
                     Cetacei 3j.
to be inserted nightly within the anal ring;  placing it upon the
tip of  the long finger of  the right  hand, in  order to pass it
easily through the sphincter.
   § 11. This Avould in its  entirety form  a fairly exhaustive
treatment, carrying with  it   the elements  of probable success.
But it might  not be wise to  cease even  here.  It might be
necessary to recommend a cold bath every morning;  or  if  this
Avas too severe,  or not practicable, a sponge  bath.  Also  it may
be desirable to advise  long  hours of rest  in  a well-ventilated
bedroom; with early hours to  bed, and late ones at  which to
rise.   A  protest might  be raised at this by some well-meaning
friend, who  has a sort of impression in  his or her mind that
long hours in bed are wicked.  Such a notion has retarded the
recovery  of many a  patient.   If it  were  only necessary to
count beads during waking  moments, such plan of short hours
of sleep might  be free from mischief; but with something more
to do, long  hours of sleep are often imperatively necessary to
        3 
34
INTRODUCTION.
insure a sense  of energy when awake.  They are still  more
necessary  in the  restoration of a  state of health.   The safest
rule is to permit patients to  sleep wherever, and whenever, and
as long as they  please and can, until they no longer feel sleepy.
It is even desirable that the patient lie down and sleep, if pos-
sible,  for a couple of hours after the  mid-day meal; especially
is this desirable if the patient  be at a spa  or watering-place,
where all  rise at an early hour.   This sleep breaks the long day
in two, and the evening is enjoyed.  Such rest does not, except
in a few cases,  interfere  Avith the night's rest; in  many cases
the night's sleep is all the sounder for  the  afternoon nap.   If
the practitioner have the time, and  the  patient craves atten-
tion, he might  substitute for the suppository mentioned above
a hypodermic injection  of a solution of morphia.   This is a
most efficient means of procuring sleep.
  It is further  requisite to direct the  diet.   This should be at
once nutritive and digestible.  It is commonly most convenient
to have a large portion of it in a fluid form.  Milk, to which
more  or less of  an alkali  has been  added, eggs lightly cooked,
meat-juice, sago, arrowroot, or corn-flour or  lentil-flour pud-
dings, custards, blanc-mange, etc., would form the chief dietetic
material.   To this might be added, according to circumstances,
some  generous Avine—sherry, burgundy, champagne, moselle, or
even  port.  Or a little brandy  and water some Avould prefer;
whilst others are the better  for some sound malt liquor in good
condition, as pale ale, stout, etc., in bottle and " Avell up."
  § 12. Of course the orders given -will  very much depend upon
the social position and  the means of the  patients, as well as
upon  the ailments.   There is in my opinion nothing more cruel
than to order patients what they or their friends cannot procure.
It matters little Avhether it  arise from  thoughtlessness or cruel
indifference, it  is equally heartless and useless to order patients
what it is impossible for them to obtain !
  § 13. Having calculated then so far as is possible—and in the
great majority  of cases in general  practice it is quite feasible to
do  this—the  means of  the  patient  as Avell  as his needs,  it
behooves the practitioner to  lay  down his line of treatment;
bearing in mind the condition of his patient, and the action of
the remedies about to be prescribed.   There is a something to
be learned by experience in prescribing,  which tells when the 
INTRODUCTION.
35
ammonio-citrate  of iron Avith  tincture  of nux  vomica Avill
succeed—and it does—where  the muriate  of  iron, and liquor
strychnise have failed, Avhich  it is impossible to transfer from
one person to another.  Careful perusal of the following chap-
ters Avill, it is hoped, do much to enable  the reader to do this
for himself; but this he must do for  himself, no deputy, how-
ever Avilling and  enthusiastic, can perform  this labor for him.
Education is not  mere information ; and it  is not  so much any
mass  of mere information afforded in the following chapters
Avhich can give this Avork any value it may  be found to possess;
but rather that there is such a selection made as will best illus-
trate principles, and so enable the reader to peruse, with more
profit and advantage to himself, the systematic  treatises  on
Practice of Physic and on Materia Medica,  which already exist
in no stinted number ; and whose place this  work  does  not
aspire to usurp, rather it trusts to be auxiliary or even ancillary
to their study. 
CHAPTER II.
                        ASSIMILATION.

  § 14.  The first subject which obviously calls for  our atten-
tion is that of assimilation, or the  means by which  what  is
taken in as food is  converted  into the  material by which the
system  is sustained.  The  different  morbid changes which in-
terfere Avith  assimilation necessitate careful  attention to the
physiology of this process, in order that  Ave may have an  intel-
ligent comprehension not only of the changes themselves, but
of the rationale of our therapeutic measures.  We shall find that
the subject, though difficult, is not by any means so insuperable
as many suppose.   The application of clear common sense and
the determination  to understand the subject  will enable most
men to surmount the difficulties.  The following sketch of the
physiology of digestion  and assimilation  is  not intended  for
teachers of that subject, but is  a broad outline for readers whose
physiology may not be very clear, or which  may have grown
rusty in practice.
  As said before, all force, all manifested energy,  is  derived
from our food.  This food  is chiefly that form which supplies
our animal heat, viz., the hydro-carbonaceous.   It is furnished
to us in starch, sugar, gum, oil, fat, butter, etc.  " The union of
these with oxygen, or  their combustion appearing to generate
the force which is  rendered apparent in locomotion or manual
labor."  (Carpenter, 7th  ed., § 58.)  Such food, however, will  ,
not support life for long if altogether dissevered from nitrogen-
ized materials. These nitrogenized  principles are requisite for
the formation  of tissues, and for the  evolution of force.  With-
out nitrogen the force  stored up in  the body  could  not be  un-
locked or  manifested.  The leopard  could  not run a race Avith
the antelope, but it can  catch the deer by a  sudden rush ; be-
cause its blood is highly charged Avith nitrogen-compounds, and
it can  generate  rapid if but  briefly sustained  motion.   The
antelope can  go  much further, but it cannot escape the rush, 
ASSIMILATION.
37
because it cannot discharge its force fast enough.  (Haughton.)
But hydro-carbons are also essential to the formation of healthy
tissue; Avhile nitrogenized materials evolve some force in their
oxidation.   Sufficient supplies of each are  requisite in order to
repair daily Avear and tear, and to give out force.  The hydro-
carbons are the fuel convertible into force in the body as much
as coal in the locomotive's  tender is  the driving-power  in a
static form.  The oxidation  of  the one  drags  the  train from
terminus to terminus; the oxidation of the other gives  us all,
or nearly all our body-force, intellectual or physical.  Various
salts, containing lime, chiefly in the form of phosphates, potash,
soda, iron, etc., are  also  required to  keep the body in health.
We will now briefly trace the coilrse of food.
   § 15. Food may be solid or liquid.  If the latter, the digestive
process is  someAvhat simpler, and mastication  is not required.
If solid, food is  rolled  over Avith the tongue, ground with the
teeth, and thoroughly mixed Avith  saliva, in the mouth.  Here
the first change  is undergone, namely, the conversion of some
of the starch into sugar by the action of the saliva.   A certain
amount of oxygen is worked in too, Avhich, along Avith the sali-
vary secretion, makes digestion  easier and more perfect.   Then
the mass is swalloAved.   In  the stomach it is turned over and
over, and the nitrogenized matters are  gradually dissolved by
the action of the gastric juice.  This juice is an acid secretion
formed in the epithelial  cells of the gastric tubules, and con-
tains a ferment  named  pepsin.   Pepsin is an  animal ferment
capable of digesting  meat out of the body if in the presence of
Avarmth and an acid fluid.  It is the only ferment of the body
with which we are yet generally familiar; but there are other
ferments in the body, which serve important functions  in the
animal economy.  In the stomach nitrogenized material is con-
verted into peptones, in which form it is absorbed into the blood.
Unlike other forms of albumen, peptone is very diffusible.  "It
diffuses Avith remarkable facility through animal membranes."
(Carp. § 104.)  During  the digestive process the pyloric ring is
pretty fairly  contracted, and only permits of the  passage of
digested  material until  the termination  of  the digestive act,
when it relaxes, and the  undigested  and indigestible materials
pass along the intestines  towards the anal orifice.  After pass-
ing  the pyloric ring the fat we consume is  brought under its 
38
ASSIMILATION.
own special digestive process.   It is brought in contact Avith the
pancreatic  juice, by Avhich it is  emulsionized.1  Fatty  stools
are almost pathognomonic  of cancer  of the  head of the pan-
creas.  In the intestines the different  products of digestion are
absorbed, either by the lacteals of the  intestinal  villi  and so
borne into the receptaculum  chyli, or by  the venules  of the
portal circulation.  The blood of the portal circulation contains
during digestion a relatively large amount of albumen, of sugar,
and of Avater.   After long abstinence it does not differ from that
of the venous system in general.  A  large quantity of bile is
also  poured into the chyme, as the  digested food is termed.
This bile is hoAvever usually reabsorbed, and  but  little  bile is
normally found in the loAver intestine.  Feces  consist of the
solid and indigestible constituents of food, chiefly, that is, Avith
certain salts, mostly phosphates,  and certain excretions from
the glands of the intestines.
  In connection Avith digestion must be included the function of
the liver.   The liver is a most important viscus, but the general
impressions as to it and  its function  are very vague, and e\Ten
erroneous.   The prevalent  idea is that  it excretes bile, as a
noxious product of digestion; and that biliousness indicates a
sluggish  liver.   This vieAV is essentially erroneous.  "The ulti-
mate source of sugar and of every other constituent of the body
is, of course, the food Ave eat; and this, as Ave may easily see in
a typical meal of beefsteak, bread, and pudding, consists of fat,
albumen, starch, and cane sugar.   The fat takes no part  in the
production of sugar within the organism, but the other three
do.  After they have entered the intestinal canal the starch is
converted into grape sugar  by the saliva and  pancreatic juice,
and the cane sugar into a mixture of glucose and another sugar,
called levulose, by the intestinal juice.   The albumen  is con-
verted into peptone by the  gastric and pancreatic  juices. The
sugar and peptones thus  formed by the intestinal canal are
absorbed by the intestinal veins;  but they are not all  at once
poured into the  general circulation and carried to the brain and
muscles.   If this Avere the  case, these structures would  get all
their nutriment at once, and  they would have to stow it awav
themselves for use during the intervals of fasting.  The liver
Starch and albumen are also acted upon by the pancreatic fluid. 
ASSIMILATION.
39
acts as a store-house in which the superfluous nutriment absorbed
during digestion is laid up, and gradually given out again into
the blood during fasting.  The sugar Avhich has been absorbed
from the intestines is conveyed by the portal vein into the liver;
and there  it is  coiiA-erted  into  glycogen, and  stored up in the
hepatic cells.  If  the portal vein be ligatured so that the blood
finds its Avay from the intestines to the heart and body by means
of the collateral circulation, without passing through the liver,
glycosuria occurs.  The first great function of the liver, then,
is to form glycogen from the sugar and  peptones supplied to it
from  the intestines,  and to store them  up till Avanted.  The
second great function of the liver is to gi\Te out, during fasting,
the nutriment which it has stored  up during digestion.  This
is effected by the glycogen, Avhich  has been stored up in the
organ, becoming gradually transformed  into  sugar again.   It
is then Avashed out of the  liver hy the blood,  and  carried with
it into the general circulation."   (Lauder Brunton.)  The bile
throAvn into the  intestines is, to a large extent, superfluous
matter.  It probably, however, serves some useful purpose  in
digestion.1  ^Normally,  it  is chiefly  reabsorbed.  In excess  in
the boAvels it produces diarrhoea.  When its outflow is checked
we have constipation, as in jaundice,
  This function of the  liver must be remembered  in our treat-
ment of various forms of ailments.   Mercurial purgatives  do
not increase the bile-secreting poAver of the liver, but they SAveep
out the bile products in the intestines and portal circulation  in
excess.   Thus they produce bilious stools, and give  relief to that
condition known  as  biliousness.  It is very important  to bear
this in mind.   It clears up a very  difficult subject, often ob-
scured by so-called explanations.
  In addition to the digestion described above, a species of diges-
tive poAver exists  in  the caecum, especially in  certain animals.
This and the power of absorption possessed by  the lower bowel,
are important matters  Avhen feeding by the  rectum becomes
necessary.
  § 16. After this brief sketch of  assimilation, Ave may iioav
profitably consider the different disturbances which mar or in-
terfere Avith these  various processes.   Firstly comes  the question

 1 Bile aids in the nitration of fat through membranes. (Hermann's Physiology.) 
40
ASSIMILATION.
of the changes undergone  in  the  mouth.  Very little can be
done  by drugs here, so Ave may dismiss them at once.   But it
does not necessarily follow  that therefore nothing can be done.
Much indigestion, and consequent imperfect assimilation, takes
its origin in decayed teeth.   In consequence of the condition of
the teeth the  food is not well masticated.  Not only that, but
as a result of the loss of  power to masticate, the food is swal-
lowed  without being fairly saturated with saliva.  It is thus
doubly unfit for  reception by the stomach.  When such a con-
dition obtains, the  dentist  may be of much service.   So far as
the medical practitioner  is concerned, he  can advise a suitable
dietary.  The food ought to undergo such culinary preparation
as will, to a great extent, do aAvay Avith the necessity for masti-
cation.  Light puddings, soups, minced collops, sausage meat,
various entrees, preparations of eggs and milk, furnish a not un-
varied, or unpalatable dietary for the toothless.  It must be im-
pressed upon  them  that  the rolling of the meat about  by the
tongue, and the mixing of it with saliva are important matters;
and the hard gums often  form no very imperfect substitutes  for
the missing teeth.  If the  craving for slices from the joint be
very strong, it may be indulged Avith a minimum of bad result
by the skilful and industrious use of the knife ere the meat is
conveyed to the mouth.
  Sialagogues.—This is a  class of agents with  which Ave are not
very familiar, and little can be said about them.   All sapid and
acrid tasting  materials cause the mouth to \vater by the flow of
saliva so occasioned.  The  smell of cooking usually produces a
similar result, if Ave are hungry.  If we are sated Avith food, the
same smell causes nausea.   The tasty materials Avhich are some-
times  consumed  at  the  commencement  of a long  dinner, as
caviare, &c,  probably act to some extent as sialagogues.  The
presence of food in the stomach causes a flow of saliva, as Dr.
Gairdner found in a case of cut throat.  Here the injection of
broth into the stomach  caused a distinct flow of saliva.  The
importance of the addition of saliva to food  is shown by the
experiments of Spallanzani and  Re'amur, who found that per-
forated tubes containing food placed in the stomach  of animals
gave the following results.  Food moistened  with  saliva  was
most quickly digested; then food moistened  with water- and
lastly, food not moistened at all.   Mercury is a sialao-o^ue  but 
ASSIMILATION.
41
the excessive flow of saliva serves no  useful purpose.  Neither
is pellitory ever used to increase the flow of saliva for admixture
with food; nor as yet jaborandi.
  § 17.  When the food is  passed into the stomach a change in
the condition of that viscus is at once  instituted.  Ere the food
is taken, the mucous lining of the stomach is pale, only slightly
moist, and possessed of an alkaline reaction.   On food  being
placed within the stomach, the gastric bloodvessels dilate, the
color of the lining membrane changes into a rosy hue, and the
gastric juice, freely secreted by the gastric follicles, is poured out
on the surface, Avhich becomes bedewed Avith the secretion.  At
the same time there is a  change in  the  muscular Avails.  No
longer quiescent, they commence to contract and dilate in such
a manner as to produce a rotation of the contents of the stomach
en  masse.  By this  means  the  whole contents are brought in
contact with the digestive  fluid, and are reduced  to pulp.   Such
is the action of the stomach in perfect normal digestion.
   There is, hoAvever, no more common disturbance than  imper-
fect digestion.   This may arise in various ways ;  each indicating
its oavu  proper remedial measures.  It not  uncommonly takes
its origin in either  an imperfect amount of  gastric juice, or in
an inferior form of  juice of impaired  solvent  properties.  It is
and must be a difficult matter  to settle, Avhich of these patho-
logical states of the gastric secretion obtains.  Consequently our
treatment is rather empirical than rational, and is really educated
guessing.  Tavo plans of treatment suggest themselves :  either
to increase the amount, or  to improve the character, of the gas-
tric juice.
   We will take the latter  first.  The  knowledge that the stom-
achs of animals digest food of various kinds just as perfectly as
do our own, has suggested the use of  the digestive fluid of ani-
mals.   The most suitable animal is the omnivorous pig.   When
properly prepared, pepsin  is a very active  agent.  It can either
be used  fresh, or  in  the dried  form of powder.  It is given in
doses of  from  five  to  fifteen grains usually,  Avith a  certain
amount of dilute muriatic acid  (5 to 10 drops), or it  may be
given on bread and  butter.  The  use of pepsin is far from being
as  yet  very explicit.   Wood {Treatise on Therapeutics, Philadel-
phia, 1874) says, " Evidently one of tAVO things is certain: either
the present practice is  ridiculously absurd, or else pepsin acts 
42
ASSIMILATION.
upon the stomach in some way as a stimulant."   He, hoAvever,
admits  that its utility in the treatment of imperfect digestion
with diarrhoea in children is much more certain.   He thinks
pepsin is much more powerful in the primae via? of children than
of adults.  Muriatic  acid and lactic acid  are also occasionally
used for the purposes of aiding the gastric juice to perform its
work.
  § 18.  If we do not feel quite assured of the utility of pepsin
in all cases, there exists no doubt about our capacity  to increase
the flow of gastric juice, and so to render digestion more  per-
fect.  The various pathological conditions of the stomach  Avill
be considered in their fitting place in Chapter XVI., at present
we are  concerned with assimilation only, and  the changes in
the stomach in digestion.   In fact Ave are here considering
imperfect digestion, regardless of its causes, only in so far as
the digestive  act is imperfect.  As  said before, the  functional
activity of an organ is in direct relation to its  blood-supply.
An increase in the blood-supply gives greater functional power:
a diminution in the  supply of arterial blood lessens the func-
tional poAver.  Many agents increase  the vascularity of the
stomach, and so improve digestion.  These are called stomachics.
  Stomachics.—This is rather  an  old-fashioned appellation, but
it will serve our turn Avell  nevertheless.  The list contains agents
otherwise possessing widely different properties.   Thus alcohol,
arsenic, ipecacuan, capsicum, and others find themselves together.
They all possess  this property in common—they increase the
vascularity of the stomach, in small  doses ;  in large ones  they
act like irritant poisons, and  produce inflammation of  the
stomach.  They all are apt to produce vomiting in excess;  and
certainly their continuous administration  in liberal  quantities
produces an irritable condition  of the stomach.   Hoav  they
produce their action we do not exactly know.
  Ere proceeding we will just glance at the arrangements of the
nervous supply of the stomach.   It contains fibres of the sym-
pathetic nervous system, and terminal branches of the pneumo-
gastric.   Speaking broadly, fibres of the sympathetic  produce
contraction of involuntary muscular fibre: cerebro-spinal fibres
produce dilatation.   Thus the brothers Weber found the vao-us
to inhibit the action of the cardiac ganglia, and irritation of it
delayed the ventricular contractions.  M. Bernard has found by 
ASSIMILATION.
43
various experiments that galvanism of the pneumogastric excites
a floAV of gastric juice: Avhile similar irritation of the sympathetic
arrests the secretion.  Section of the pneumogastric nerves stops
digestion, and the mucous membrane of the stomach, previously
turgid, becomes pale  and exsanguine after such section.  Thus
we see the pneumogastric fibres dilate the bloodvessels, the
sympathetic fibres contract them.   From this Ave can under-
stand how any great  emotion  acting on the  sympathetic may
at once produce indigestion.   Whether our stomachics act by
stimulating the  pneumogastric  fibres,  or by  paralyzing  the
sympathetic, we do not knoAv; there is no doubt, hoAvever, that
they increase  the  vascularity of the stomach.  In practice we
find that in many persons a small quantity of alcohol improves
digestion; and that by its means a meal can be digested which
Avould otherwise  be  undigested, and so Avasted.  But it must
be borne in mind that alcohol and artificial pepsin do not agree,
and therefore  should  not be given together.  Arsenic produces
a  vascular  flow in the  stomach, often  very useful.  In large
doses it produces  irritability and inflammation.   It is a differ-
ence of degree.  Like alcohol, a small dose increases the vascu-
larity of the mucous  lining of the stomach and a free Aoav of
gastric juice ;  a poisonous dose produces  inflammation  and total
arrest of the flow.  Ipecacuan  produces a vascular Aoav in small
doses;  in  larger  doses  vomiting  results.  Ipecacuan  formed
part of the best  old dinner  pill, Avhich  ran something like
this:—
                     Pulv. Ipecacuan. gr. j.
                     Ext. Cinchon. gr. j.
                     Pil. Al. et Myrrh, gr. ij.
and as such Avas very useful.  This pill is not so much in vogue
now ; but its turn may come again.
  Ere  prescribing arsenic as a stomachic  permit me to give a
quotation  from Ringer about the action  of alkalies.  " We Avish
to draAV attention in this place to one important  property of
alkalies—namely,  their power to increase  the secretion of the
gastric juice, itself an acid secretion.  We venture to think that
many facts warrant the following generalization:  that alkalies
applied to the orifices of glands with  acid secretions increase
their secreting poAver; while alkalies applied in a corresponding
way to glands with  alkaline secretions  lessen  or check  this 
44
ASSIMILATION.
 secretion."   Given, then, almost immediately before food, the
 following prescription contains promise:—
                     Pot. Bicarb, gr. v.
                     Fowler. Solvit. TTLij.
                     Inf. Gent. 5J.
 It might be given before breakfast and dinner.
   Next  to  the question of stomachics comes the  question of
 vegetable  bitters, commonly  known  as  tonics.   It  is  not as
 tonics they are described at present, but simply in their relation
 to the stomach and to digestion.
   Bitters.—Unfortunately it is not  possible to give such a clear
 physiological explanation of the action of vegetable bitters as it
 is in the case of stomachics.  There is, hoAvever, no better estab-
 lished fact in medicine than  the  action of vegetable bitters
 to increase  the appetite  and improve  the digestion.  They are
 in one form  or other  the  resort  of all  dyspeptics, and  the
 mainstay of  herbalists.   Marvellous  and  poetical  discourses
 have been written as to the action and effects of these bitters,
 and their beneficial action has been  chronicled by dyspeptics.
 As yet physiology has  little or nothing to say.   The facts are
 not to be  disputed, but no explanatory  voice is  yet audible.
 There  are   various forms of the bitters ;  some  simply bitter,
 others highly aromatic and partly astringent, from the presence
 of tannin.   Quassia is the simplest  bitter.   PoAverful, intensely
 bitter, and  free from tannin, it forms  the  vehicle Avhen iron is
 indicated.   It is  also  the chosen  agent in  the dyspepsia of
 drunkards.   It is  usually given with some acid, hydrochloric
 or nitric usually :—
                     Ac. Hydroehlor. Dil. Vf[x.
                     Inf. Quassia?, Jj.
 with or without a fevv drops of tincture of  capsicum, is a capi-
 tal appetizer to the stomach saturated Avith alcohol.  Gentian
 is agreeable, and forms  an excellent vehicle for  quinine, when
 not combined with iron.   Chiretta is a coarse gentian.  Casca-
rilla is a very pleasant aromatic bitter, and forms an excellent
vehicle for alkaline remedies when given without iron.
                     Sp. Chloroformi,  1T|.xx.
                     Pot. Bicarb, gr. x.
                     Inf. Cascarilla.', ^j. 
ASSIMILATION.
45
is a capital combination in the dyspepsia of the gouty, or even
where there is excessive acidity of other origin.
  The Avell-knoAvn cinchona  in infusion  is often much better
tolerated than is quinine in solution.  This fact is very apt to
be overlooked; but  it is Avell Avorth remembering, and its re-
membrance is often very useful.  We Avill consider these agents
again in their relations as tonics.
  The action of these vegetable bitters upon the digestive organs
is as inexplicable as  it is well assured.   In his Clinical Medicine
Dr. King Chambers gives a very pleasant account of them, Avhich
is worth quoting, though it  is quite imaginative, and utterly
unsupported  by any  valid evidence.   " Vegetable bitters brace
up and harden  the mucous membranes, as may easily be tried
by their effect upon the mouth.  Hence exosmosis is lessened
and endosmosis is increased.  Digestion is made more rapid and
effectual, nutriment  is taken  up more copiously  and quicker.
Even in a healthy person the remains of the 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.....When mucus
is in excess, it doubtless interferes much Avith the taking up of
nutriment by membranes,  and the  checking of its groAvth is
an indirectly constructive  aid.  Many of the vegetable  bitters
contain tannin, or other astringent  constituents, and are thus
peculiarly  suited to the leucophlegmatic   (or  mucogenous)
diathesis."
  This at least gives a notion of some kind about their action,
and that is not quite a useless matter in giving direction to their
therapeutic aim.   It fits in with the facts, and in so far is useful.
But it cannot be  regarded as a physiological explanation of the
action of  vegetable bitters.   There is  no doubt but that these
agents  do increase  the sensation of hunger; and these sensa-
tions  depend for their expression upon the stomach.   Conse-
quently these bitters must  haATe some action, if we only kneAv it.
Equally certain is it that digestion  is also furthered and ren-
dered more efficient  by their use.  They are of avail  in further-
ing digestion if given after a meal as well as before it.   But in
so doing their appetizing effect is largely lost.
  § 19. After the digestion  of starch and nitrogenized principles
Ave come to the digestion of fat.   Fat is emulsionized  mainly by
the juice  of  the  pancreas,  which broadly resembles saliva, but 
43
ASSIMILATION.
has a much more powerful action upon oleaginous matters.  It
is a gland about Avhich, in disease at least, Ave know very little.
In health, and  physiologically, it has been carefully examined.
M.  Bernard experimentally found  that  ether introduced into
the stomach determined soon aftenvards a considerable flow of
pancreatic juice.  This Avas a very valuable observation at a
very important  time.  The introduction of cod-liver oil by the
late J. Hughes Bennett is  a matter of our oavu times; and the
importance of a sufficiency of fat for the building up of truly
healthy tissues is a comparatively recent addition to our knoAV-
ledge.   The association of the  formation  of  tubercle  Avith a
dietary too defective in fatty constituents,  the repair so often
instituted Avhen fatty food Avas given and  assimilated, pointed
distinctly to an increased use of fat by the consumptive.  Cod-
liver oil is the  most easily digested of all fats; and as such has
come into almost universal use.  In convalescence from acute
disease, as well as in the palliative treatment of chronic disease,
and especially of consumption, in supporting  the system under
the severe trial of surgical fever, cod-liver oil has Avon for itself
a well-established position.
  One difficulty has always been felt, and it is this.   Even cod-
liver oil is not always digested, and therefore something else
was wanting.   Dr. Balthazar Foster, of Birmingham, conceived
the idea of utilizing Bernard's hint, and so combined ether YAath
cod-liver oil.   The increased flow of pancreatic juice so induced
led to assimilation of the cod-liver  oil, and thus another step
forAvard was made  in  practical therapeutics. Another effect
noticed by Dr. Foster was the return of a liking for  fat under
this plan of treatment, where previously a  strong distaste to it
had existed.  One method is to give from ten to thirty drops of
ether (sulphuric) in  the dose of oil; or  the  ether may be given
in Avater immediately before the oil.  In private  practice Dr.
Foster prefers to give the following mixture:—
                Potassae Bicarb, ^iss, ^ij.
                Acidi Hydrocyan. Dil. HI m xij-xyj.
                Spt. iEtheris ^iss-^iij.
                Aq. adjviij. Misce.
                §j ter in die sumat.1

  1 Clinical Medicine, 1874.  The whole of the paper  is well worth reading as
indeed are the other essays in the book. 
ASSIMILATION.
47
   This method of adding  to the usefulness of a course of cod-
liver oil deserves Avide  and general attention.  Since this AA~as
written, an American committee Avas formed to investigate this
action of ether upon the pancreas.  It corroborated Dr. Foster's
vieAA's entirely.
   The adoption of a pancreatic fluid derived from animals and
rendered  useful in relieving the necessities of man, has been
brought forward by Dr. Horace Dobell, and is often useful.
These preparations can be easily purchased  ready prepared and
directed at almost any chemist's.
   The changes in the pancreas of the calf, its large size and great
cell-activity during the suckling period of calf-life, and its grad-
ual diminution to a fixed size as this food is changed for a vege-
table diet, point to the close relations betwixt the function of
the pancreas and  the assimilation of fat.
   §  20. Assimilation is never  very perfectly performed if the
action of the intestines be sluggish and imperfect.  The waste
matters of food must be swept  away, out of the small intestines
at least, in order that  the nutritive material of  the next meal
may be brought in contact with the intestinal villi and absorbed.
In the large boAvel  some secondary digestion may take place,
but  it is of questionable utility;  and it is practically much
better to keep the large boAvel unloaded than to look for  any-
thing from secondary  digestion.   The accumulated feces are
very apt to become hard and pouched in the folds of the large
intestine, and so  become the cause of much disturbance.   The
mere load, and its pressure on parts around, are often sufficient
to interfere  sorely Avith the functional activity of a susceptible
and  feeble stomach.  In many persons digestion is  never com-
fortable nor effective Avhile the bowels are loaded.   The enor-
mous consumption  of  aperient pills, quack and  other, in this
country, to say nothing of aperient Avaters, testifies to the Avide-
spread conviction on this head.  The use of an aperient pill at
bedtime and a draught  of cold  Avater first thing in the morning
obtains largely;  and might Avith advantage obtain still more
largely.  The purgative in such cases may well be accompanied
by some mix vomica, Avhich excites the vermicular contractions
of the muscular  coat  of the boAvels.   A carminative may  be
profitably combined.  A good  pill  for  common  use would run
so:— 
48
ASSIMILATION.
                    Ext. Xucis Vom. gr. j.
                    Pulv. Piper. Nig. gr. j.
                    Pil. Coloc. Co. gr. ii. ss.
at bedtime every night, or  every second  night;  or  instead of
this  Pullna, Fredericshall, or Marienbad Avater maybe taken;
the dose apportioned to each  individual  and his exigencies,
according to the directions given Avith each bottle.  A certain
action upon the boAvels is often beneficial, especially  to those
who control their bowels from social necessities.  Such persons
are all the better for occasional purgation.  A slight amount of
purgation is almost always indicated  in  the commencement of
a course of haematics, especially chalybeates.
  § 21. Haematics.—This is  a very important  group of agents,
though its members are feAV.  Haematics furnish  to the blood
matters Avhich are defective  in  our dietary.  They are indeed
foods rather than medicines; though a haematic may of course
be used in Avhat is truly a medicinal dose.  Haematics go to
build  up  the  blood, to increase blood formation, and with it
the groAvth of every part that is fed by the blood, and that is,
in fact, the Avhole system.  One of the group is phosphate of lime.
Especially  useful is this agent  during the period  of growth.
" Wherever cell-growth is active, there is phosphate of lime in
excess," says Ringer.  Over-Avorked town individuals and over-
suckling mothers, as well as groAving infants, are benefited by
this  haematic.   It  is especially useful  in  rickety children.  It
controls morbid nutrition of the skeleton, while it supplies  the
lime  for proper ossification.  It is not needed in large doses.
In fractures of bones in pregnant Avomen lime is useful.  The
administration of lime during pregnancy in women whose pre-
vious children have shown tendencies to rickets is yet untried
but it seems to offer a good and hopeful  prospect.
  Of all haematics, however, iron stands first—pre-eminently
first.   It is rather a food than a medicine.  "Iron is a constant
and  necessary constituent of the body, and must  be  regarded
as an important food."  (Ringer.)
  Iron, though a normal constituent of the body, is chiefly  pre-
sent in the red blood corpuscles, though there only to  a limited
extent.  By its use we can increase the amount of hpemoo-lobin,
upon AA'hich the  chemical  interchanges  conducted  by the red
blood corpuscles depend.  Under  its use in ansemia, the cheeks 
ASSIMILATION.
49
grow rosy, the lips recover the  usual color, the eye brightens,
the tongue is  less flabby, there  is a general increase in bodv-
weight, a development of muscle, and a heightened  condition
of nerve action.   Tone  is given to every part of the system.
"Iron salts in anosmia possess important properties other than
influence over the groAvth of the corpuscles.  They act bracingly
in the relaxed mucous membrane of  the digestive canal, and
probably in this Avay tend to restore its functions.  Moreover,
it is highly probable that, after its entrance into the blood, the
iron exerts an influence beyond that of merely increasing the
quantity of red corpuscles.  Hence iron preparations are useful,
not simply as a food in promoting the formation of the blood-
discs, but on account, likewise, of their beneficial  influence on
the  tissues of the  body.   Iron, therefore, cannot be  regarded
merely as a food to the system ;  it is also an important curative
agent.  Large quantities of the soluble astringent preparations
should be administered where Ave desire to benefit tonically the
mucous  membrane of the digestive canal  and the tissues."   I
make  this quotation from Ringer in its  entirety, in order to
show that, while iron may be given as a haematic, it  may be
usefully given in larger quantities than can  be utilized in the
blood.  The excess acts as a tonic.
   When given to healthy persons for a long period, iron com-
monly produces plethora, or  an excess of red blood corpuscles.
When given to anaemic  persons, it raises  the condition of the
blood to that of health.  "But  after a time  the  blood appears,
as it were, to become saturated Avith it, and ceases to assimilate
it." (Wood.)   In  certain chronic conditions it is very difficult
to see any point of saturation ; and iron may in  many cases be
usefully  continued for years.
   What becomes of the excess of iron in  the  blood ?  It  is
chiefly cast out  in the  feces,  which become  black from the
union of the iron Avith the tannin in the feces, or the sulphu-
retted hydrogen  it meets there.  It is also  eliminated  in the
urine.   Briicke found that in  rabbits, after a time, nearly all
the ingested iron  could be recovered from the urine.  Quevenne
found it as a  normal  constituent  of urine;  and Becquerel has
observed the  amount found in the urine  to vary Avith the
amount given.
  Iron in all its forms is useful.   " Almost all of the preparations
       4 
50
ASSIMILATION.
of iron are  more or  less astringent,  and, when in the  blood,
very  probably they exert a direct influence upon the tissues,
contracting them, not merely by increasing their tone, but also
by acting on their vital contractility." (Wood.) Much difference
of opinion exists as to the best  forms of iron for common use.
Some advocate  iron  in  poAvder ; others as  haloid  salts; Avhile
some prefer Avhat  are called  the lighter preparations, as the
ammonio-citrate and the potassio-tartrate.  Personally, I prefer,
to commence, in convalescence,  Avith  the lighter preparations,
and  then go on to stronger  forms.   Much Avill depend  upon
Avhat it is desirable to combine Avith it.   For instance,
                    Amm. Carb. gf. v.
                    Ferri Am. Cit. gr. v.
                    Inf. Quassias, ^j.
is a capital form in  early convalescence, or in the treatment  of
amenorrhoea.   After a time  the folloAving  may be substituted
for it Avith advantage:—
                    Cit. Fer. et Quinias, gr. v.
                    Liq. Strychnias, TTliv.
                    Inf. Calumbas,  5J.
This forms  a beautiful tonic—effective, agreeable, and  pleasing
to the eye.
  A common form, much used in both public and private prac-
tice, is the following:—
                     Quin. Sulph. gr. j.
                     Tinct. Fer. Perchlor. TT1.X.
                     Ac. Hydrochlor. Dil.  THjij.
                     Inf. Quassias,  §j.

Often the iron is felt  to be heating, and then a little sulphate  of
magnesia is of service. The following is a typical prescription :—
                     Quin. Sulph. gr. j.
                    Mag. Sulph. 9j.
                     Liq. Fer. Persulph. V([v.
                    Ac. Sulph. Dil. m,v.
                    Inf. Quassias,  gj.

If this lies cold on the stomach,  a few drops of tincture of cap-
sicum may be added.
  For a permanent  prescription, requiring to be continued for
months, a pill is the  best form.   It admits of  a large suppjy  of 
ASSIMILATION.                    51
material in a small space; the nausea of the disagreeable taste
daily for  months is also avoided; it does not affect the teeth,
and it can be taken after food Avithout attracting  the attention
of  others—often so  trying to persons in Aveak  health.  The
following is a very favorite form Avith me:—
                     Ac. Arsenic, gr. j.
                     Fer. Sulph. Exsic. 9j.
                     Pulv. Capsici, gj.
                     Pil. Al. et Myrrh, q. s.
              in pil. LX. div. 1 semel aut bis in die.
Taken  immediate!}' after a  meal, this is  a  digestive and tonic
pill of the highest  value.
   One beautiful preparation of iron should not be forgotten ; it
is often Avell borne Avhen other forms  are  not tolerated, and
consists of the recent addition of the tincture of iron to acetate
of ammonia.
                   Tinct. Fer. Perchlor. Tu>.
                   Liq. Am. Acet. §j.
It is beautiful to the eye, palatable, and, in  consequence of the
decomposition produced, readily assimilated.
   There are man}7 excellent preparations of iron AAdiich can only
be  alluded to  now as  occasionally furnishing  a more suitable
form than any here given.  There  is the  fer rum redactum,
Vallet's ferruginous pills (carbonate of  iron),  Griffith's  mix-
ture (Mist. Ferri Comp.),  excellent with Decoct, Aloe Co.  in
amenorrhcea and  in low  forms  of gout, Blancard's iodide  of
iron pills, the  syrup of iodide of iron, Parrish's chemical food
(phosphate of  iron and lime), etc.  etc.  More recently a new
form of iron—dialyzed iron—has been introduced from France;
this is a beautiful preparation : it is readily digested, it does not
affect the teeth, and  its taste is not  objectionable.
  The addition of  iron to the food  often produces effects little
less  than  marvellous.   It  not only gives tone  to  the Avhole
system, but nutrition is markedly advanced by its presence  in
the fluids  of the body.  This is often Avell shown  in the im-
provement in a  feeble heart under a course of iron.  Digestion
becomes more perfect under the use of chalybeates.  "Digestion
cannot be normal Avhen the blood has ceased to be so."  (Stille.)
Every part seems to perform its function more efficiently under 
52
ASSIMILATION.
 the stimulus of iron, of blood once more rich in one of its most
 important constituents.  One remarkable thing about the action
 of iron is its effect upon the dyspnoea of chlorotic girls and others.
 In  these  cases there is pallor, amounting often to Avaxiness,
 from absolute diminution  in the number of red corpuscles, and
 marked shortness of breath on exertion, from lack of these oxygen
 carriers;  there is general loss of body temperature from imper-
 fect combustion or oxidation, while Avhat ought to have been
 burnt is  stored up as fat.   In  fattening cattle, farmers  often
 bleed an  animal Avhich is not  fattening  quickly, in order to
 artificially  produce anaemia.   Under  conditions  of anaemia
 changes take place spontaneously such as the farmer induces
 deliberately, especially in young and not fully groAvn persons,
 chiefly girls.  Iron soon induces a change, and restores matters
 to their normal condition.   It must, hoAvever, be borne in  mind
 that Avhen the blood is either broken down, or its formation
 hindered  by  some blood-poison,  iron Avill not  cure  the anaemia
 unless combined  Avith  some specific remedy to the poison in
 each case.  For instance, in lead-poisoning iodide of potassium
 is absolutely requisite  to  good  blood formation ;  in syphilis,
 mercury; in gout, potash ; in malaria, quinine should be added
 to the iron.  It is matter for surprise Iioav little  this fact is
 recognized.   Often, indeed,  these specifics are true haematics,
 by destroying  the  poison  which is  exerting so  injurious  an
 influence  upon  the blood.   The question of  the effect of im-
 perfect elimination and its consequences upon the blood will be
 considered in the next chapter.
  Iron Avill  be alluded to again in several chapters  as occasion
 requires, and Avhere its action as a haematic renders it  an im-
 portant factor in the treatment.
  There are other haematics, as soda, potash, etc.,Avhich require
 a word.  Soda is a natural constituent of the blood.  As chloride
 of sodium it forms an important addition to our food, and the
 consequences of its Avithdravral  are so baneful, that  it formed a
 terrible old Dutch punishment.  AVater and bread made Avithout
 salt was one  of their most exquisite tortures.  The decomposi-
 tion of common salt furnishes hydrochloric acid to our gastric
juice, and soda to our  bile-salts.   African tribes will, like the
 buffalo, travel  several hundred miles to procure this coveted
 addition to their food. 
ASSIMILATION.
53
   Potash is a  normal constituent of muscle, and is a valuable
haematic in lithiasis.
   § 22. Ere leaving the subject of  haematics a  feAv words are
essential as to the  value  of water  as  an adjunct.  All  the
haematics are soluble, and require Avater for their  solution.  Xot
only that,  but it is a well-known fact that systems often can be
brought under the influence of iron at chalybeate  spas which
have resisted all medicinal treatment, no matter  hoAV ingenious
or varied.  The difference has been found to lie in  the amount
of Avater.  In all natural AATaters the iron exists in a state of high
dilution, and a large bulk is required  to furnish any material
quantity of iron to the system.   The late Dr. Fuller  has pointed
out  hoAV chalybeate remedies  may be rendered much more
effective by adding to them  large draughts of water.   From a
fairly long experience, I can quite corroborate this statement;
and amidst the humbler  classes, Avhere a sojourn  at a spa  is
simply impossible, such addition is often of the highest service.
Especially is this the case where chalybeate and  alkaline reme-
dies are combined, and given before  food.  A draught of water,
varying  from half a pint  to a pint, after each dose, will often
make all the difference betAvixt no benefit and the most satis-
factory treatment.  The dilution has the most excellent effect,
and iron so diluted is absorbed Avhen in a concentrated form  it
is not assimilated.
   Under certain conditions,  Avater is a true haematic.  All sub-
stances Avhich  are held  in solution by the water of the blood
must escape Avherever there  is a free outflow of Avater, Avhether
by kidneys, skin,  or boAvels.  In cases of lithiasis this is espe-
cially noticeable, and furnishes an explanation of the excellent
effects often derived from a stay at hydropathic establishments.
Not only does  water wash aAvay the waste matters which have
accumulated, but in doing  so it  paves the Avay for the growth of
new material.  Ringer says, with much force, "If water drink-
ing exerted only  a  disintegrating influence, it  would merely
lead to loss of weight; but simultaneously with  this rapid dis-
integration, a corresponding increase of assimilation takes place
in the same tissues;  whence it happens that water, taken under
certain precautions, may increase both construction and destruc-
tion of tissue, and so act as a true tonic, improving the vigor
of body and mind."  This view I quite endorse.   Further, there 
54
ASSIMILATION.
is every reason to believe that too little water is drunk by most
persons, especially in the  upper classes.   The thirst  produced
by labor compels the drinking of  AArater.   Those Avho are not
compelled to labor are very apt to diminish their bulk of Avater
to an injurious minimum.   Doubtless its effect upon the bladder
is occasionally inconvenient, especially in certain places of com-
mon resort, and especially to ladies.  Also its tendency to ap-
pear through the skin as perspiration is at times  inconvenient,
Nevertheless the consumption of a fair amount of fluids per
diem is an  excellent measure, and  ill-health is  commonly the
penalty for the abstinence so practised.  A draught of cold
Avater every morning is an excellent hygienic measure; it stimu-
lates the action of the boAA'els;  it  is  a tonic to  the digestive
organs; and it is a true  haematic, by its  removal  of Avaste
matters which hinder histogenesis.  This effect is ATery much
increased Avhen  the  water  used  is from some  natural  spring.
Apollinaris  Avater is a delicious beverage alone, Avhile it mixes
Avell Avith  most things, notably red  Avine.  Other Avaters, as
Nassau Seltzer, are very good indeed.   Some can only be made
pleasant by adding them to Avine  or spirits.  The use of mineral
waters as beverages  is much on the increase.   This is good in
several Avays.  These mineral waters are often pleasant medi-
cines.  But  more than  that, these palatable  and  trustworthy
waters will  lead to  more water drinking—to the ingestion of
more fluids.
  § 23. The next class of remedies which claims our attention
is scarcely inferior in value to that  just considered.  This class
is that termed tonics.
  A tonic (from r»vW, I stretch) is an agent Avhich has a syste-
mic action.   The ruling idea is that it gives tone, just as the
tightening of a cord or wire causes it to give out a better  tone.
A tonic differs from  a stimulant in  that its action is not merely
temporary and exhaustiA7e, leading to  reaction.   The effect  is
more permanent  and lastingly beneficial.   Neither  does the
action depend upon astringency.  Doubtless tannic acid is often
a tonic, and that too by its astringency; but  quassia contains
no tannin, and quinine is as tonic as cinchona bark.  Nor ao-ain
does the tonic action depend on any aromatic qualities, for
many tonics  are decidedly not aromatic.  They do not merely
act on the muscular  system, though that develops under their 
ASSIMILATION.
55
use.   They act upon mucous membranes in restoring them to a
normal condition, and very frequently tonics add very much to
the efficacy of astringents.   What their action upon the mucous
lining of the intestinal canal is, Ave do not knoAV.  But we knoAv
Avell enough that under their use the appetite returns and diges-
tion improves.  "-The effects of tonics upon the general  system
are never rapidly displayed; but after they have been taken for
some time  their influence is obvious  by the  increased force of
the circulation, the greater energy of  the digestive  organs, the
improvement  of the  secretions, the  abatement of nervous sus-
ceptibility, and the augmented power in particular which is
communicated to  the muscular system.  The effect of a tonic
Avhen administered under proper circumstances, and Avhen it ope-
rates favorably, is, in fact, to place the system  in that state
Avhich characterizes health; and  from the mode by Avhich it
produces this  effect, the description of diseases in Avhich tonics
are indicated  is sufficiently obvious; they are  evidently those of
depressed poAver."  (A. Todd Thomson.)  Such is the brief but
vivid sketch  by one of the past masters of therapeutics.  There
is no more recent sketch which  in my opinion is so good.  Tonics,
indeed, have  been  but little lighted up by modern physiological
investigation.  All Ave know of them is derived almost solely
from empiricism.  But our knoAvledge is not stinted, and tonics
form one of the most important therapeutic  benefits  obtained
from empirical observations. Not only has empiricism given us
tonics, but it has also furnished us Avith many little hints as to
the  best means of securing their action, and of the  different
circumstances which should guide us in their use and selection.
  In the first place, tonics are both mental and material. Hope
is a capital  tonic.   Depressing mental conditions will often
neutralize the best plans for administering tonics and thAvart our
desires.  Nextly, the prospect of recovery will often bring about
satisfactory results almost in the absence of material tonics, and
certainly often helps  out Avonderfully  a lame line of treatment.
Mental tonics can usually be  advantageously combined with
material  tonics.
  Material tonics are usually bitter, often aromatic.  The aro-
matic principle is  commonly stimulant, and  consequently aro-
matic tonics, as cusparia, cascarilla, etc., are often given in early
convalescence.   Many are also  astringent, and this astringency 
56
ASSIMILATION.
often is  a useful  property.   Astringent  tonics  are  indicated
when there exists any tendency to excessive secretion, as undue
perspiration or  looseness in the boAvels.  Sometimes, if given
too early, they produce disturbances in the bowels.   " It is also
Avell known that if their dose is not proportioned to the suscep-
tibility of the digestive organs, they may not only cease to pro-
duce a tonic effect, but absolutely destroy the appetite and give
rise either to diarrhoea or constipation.  It is, moreover, a fami-
liar  fact, that a febrile state of the  system altogether contra-
indicates their use, because they then immediately  derange the
stomach  and augment the vascular excitement."  (Stille.) There
is much  truth in what Stille states, and  all writers  have held
similar vieAVS  about the undesirability of  giving tonics during
conditions of febrile excitement up to a recent period.  Of late,
hoAveA^er, both in France and Germany the plan  of giving large
doses of quinine—an  unquestioned  tonic—to lower the tempera-
ture in pyretic  affections has obtained with  many competent
authorities.  Nevertheless, the rule not to  give tonics during
conditions of febrile excitement is a good one.   During the pre-
sence of a pyretic condition, especially in connection with acute
disease, it is Avell to stick to mineral acids.  When the tempera-
ture has fallen somewhat, and the fever is defervescing in  its
other symptoms, then  an aromatic bitter  may  be given Avith
advantage. The prescription of dilute phosphoric  acid tt\,xa\
and cascarilla 3j. is a good and suitable one, or a certain amount
of a stimulant may still be necessary, and then  something like
the folloAving prescription is indicated :—
                    Sp. Chloroformi, TUxx.
                    Acid. Hydrochlor. Dil. IHx.
                    Inf. Cusparia;,
                    or Inf. Cinchonas,  §j.
   It  is often  a good plan to gently act on the boAvels at  the
commencement of a course of tonics after acute disease.  A dose
of aloes is very suitable either as pil. al. et myrrh, or decoct,
aloe co.   Aloes, indeed, itself possesses a bitter  principle of no
mean properties as a tonic.  Often, especially after  the violence
of an attack of bronchitis is over, carbonate of ammonia  is  a
good stimulant to  combine Avith tonics.  It goes specially well
Avith ammonia, citrate of iron, and quassia (§ 20).  Quinine may 
                      ASSIMILATION.                    57

often be given Avith advantage along with  some  acid in  an
aromatic tonic.
                   Quinias Sulph. gr. j.
                   Sp. Chloformi, TTLxx.
                   Ac. Hydrochlor. Dil. T)lv.
                   Inf. Cascarillae, ^j.
forms  a pleasant  and efficient tonic.   When tonics disagree
Avith the stomach several measures may be indicated.  A change
in the form of the tonic  is one; the addition of a carminative
is another.  At other times a slight  action  on the bowels is
desirable, and a little sulphate of magnesia removes the heating
sensation complained of.  Very often a mineral acid is indicated;
if a small  quantity be already added, it is well  to increase the
dose of it.
   Tonics are especially useful  Avhen given with  iron, and this
well-knoAvn  association  has made  the expression  " iron and
bark" one as Avell known in  the household as in the lecture-
room.   There also exists in the minds of many a strong im-
pression that the lighter forms of iron, as the ammonio-citrate
and the potassio-tartrate, given in quassia or calumba are better
agents to commence Avith than the more poAverful  and astrin-
gent preparations.  Taa^o  cases will  point this well.   A patient
recovering from an acute ailment Avas ordered quinine and the
muriate of iron.  This  disagreed with her, and  the ammonio-
citrate in calumba was substituted for it.  This agreed perfectly,
and at the end of a week the former mixture Avas resumed, and
then Avas taken without discomfort.  Another, and even  more
striking, case occurred  lately.   A patient suffered  much  frcm
anaemia  and debility.  I ordered  her the ammonio-citrate of
iron with  tincture of nux vomica in  quassia.   She improved
forthwith  most satisfactorily.   One day, when nearly well, she
brought me her old  prescription to look at,   She had taken it
for six months, not only Avithout benefit,but absolutely she had
lost ground under  it.  To my amazement, it consisted of the
muriate of iron and liquor strychniae.  What the difference was
it is not easy to say, but the result was Avidely different.  The
only possible source of fallacy  in the matter, to call in question
the difference in the form of the medicine in producing the
result, was that she was told to go into a larger bedroom.
   The combination of hydrobromic  acid Avith  quinine will 
t>o                    ASSIMILATION.

usually relieve cinchonism in those persons Avhere this is readily
provoked by medicinal doses of quinine.   (De Witt C. Wade.)
  Quinine is the type of tonics, yet it does not agree Avith every
one.  Many East Indians volunteer the  information that they
either  cannot take quinine, or it does not do them  any good.
There  is one matter of some importance about quinine not
sufficiently Avell knoAvn, and  that  is its tendency to produce
irritability in the bladder, especially in elderly people.  In fact
it is not so Avell suited  to  elderly  persons, as a rule, as to the
young, the adult, and the mature.  Stille says—" The elimination
of the salts of  cinchona with  the urine exposes these organs to
irritation.  If the  urinary tract be anyAvhere the seat of disease,
it is apt to be  aggravated by these medicines.   This effect  is
frequently  observed  in gonorrhoea.   Sometimes, independently
of such a cause, the patient is affected Avith irritation  about the
neck  of  the  bladder, with haematuria,  or with  retention of
urine." This is well worth remembering.  Experto crede.
  There is a large amount of acquired skill in the right selection
and combination of tonic remedies which cannot be transmitted
at once to another.  But by careful observation the young
medical reader  will  learn for himself what it is impossible to
communicate by writing.   The very fact that  there is some-
thing to be learnt  that  cannot be so conveyed  will  certainly
stimulate many to  find out what that something is.  Those who
succeed will find in their knowledge the  reward of their labor,
while those Avho decline to observe their experience intelligently
will have to go Avithout the benefits  they Avould  otherwise
receive.  That  something is the power to see  a relationship
betwixt a certain case and  one  previously encountered, which
indicates that the plan necessitated  in the previous case will be
the one best suited to the present  one.   This is a knoAvledge
which cannot be conveyed, but close  observation will enable a
man to learn it  for himself.
  § 24. In addition to the tonics described above, there are the
common tonics of pure air and water.  That persons who breathe
pure fresh air, and drink pure  and uncontaminated water, are in
a better state of health, have more tone about them, is demon-
strated by the effects of epidemics.   When the  air is foul and
the water  filthy,  their systems succumb  to the onslauo-ht of
zymotic affections more extensively than do systems existing 
ASSIMILATION.
59
    under better hygienic arrangements.   The establishment of con-
    valescent homes in the country, in connection Avith metropolitan
    hospitals, is a proof of the tonic effects of good air and water.
    In private practice it is the rule to send patients aAvay to health
    resorts, if  the conditions of life are  such that  their home sur-
    roundings  are  not quite Avhat they might be.  The change of
    air annually indulged in is a famous  tonic.
      Then there is also the effect of cold Avater upon the skin—no
    mean tonic.  The bracing  effect of the sudden chill, the  sense
    of energy  it gives, the gloAAr Avhich follows, all tell of the tonic
    effects of cold bathing.  Experience  has decided  that the good
    effects of cold  Avater are increased by  its being salt.  Conse-
    quently it  is very common for convalescents to prefer the seaside,
    Avhere they can have  sea-bathing combined with fresh air and
    pure Avater.  For  children, the addition of Tidman's sea-salt to
    the  water  in Avhich  they are  bathed  is  often beneficial ; and a
    substitute  for a sea dip is thus furnished, not altogether Avithout
    value.  Still it is  a substitute, and nothing more.
      Assimilation is  an important part of nutrition ; and the best
    energies of the medical man  are often  bent earnestly towards
    securing it by the various methods that have been just described.
    The necessity for good and perfect excretion, in order to permit
    of healthy tissue growth, Avill become apparent in the course of
    the  next chapter.  Hoav the body Avaste may check  nutrition
    Avill be shown ; and  the  proper combination of agents aiding in
•   excretion,  Avith those  conducing to better  assimilation, will be
    pointed out.
      Before leaving  this chapter, however, there  is one point on
    Avhich some stress must be laid ;  and that is the peculiarities of
    some individuals : There are  some  organisms which  seem to
    perform a maximum of Avork Avith a minimum of  Avaste.  There
    are others  again Avhich consume a large  quantity  of fuel, Avhile
    they leave a huge quantity of ashes, etc., and only perform a
    small amount of  Avork.   If these  latter are to be so fed  that
    there shall be but  little ash and Avaste, they will simply perform
    no work at all, they will  die out.   It  is  not  only  in animal
    organisms, so varied and diversified, that this occurs.  It is to
    be seen in furnaces, engines, and flues.   Some Avork with  very
    little waste, their combustion is perfect; while others always
    need to have their refuse removed, else they cannot get on at all. 
60
ASSIMILATION.
So it is in certain systems.   If Ave attempt to reduce their sup-
plies to what they can perfectly consume, Ave simply starve them.
Their supplies must be liberal, and the removal of their waste
constant.  There are many people Avho consume a large amount
of food—indeed Avithout it they could not work at all—Avho are
all  the better for  occasional, almost, in  some cases, persistent
purgation.  They are always having too much bile in their
intestines, and they seem to get on better Avith having it swept
away than Avhen it is reabsorbed and an attempt made to con-
sume it.   It would seem  that they do  better Avhen  their bile is
always freshly made than Avhen it is taken up from the chyme.
Limited quantities of food  do  not prevent these people being
bilious.    What they want is to haATe their spare bile got rid of.
Regular action in the bowels, especially by alkaline purgatives,
good food, and a tonic occasionally, enable these individuals to
reach a  much higher standard  of  health  than they usually
attain.  They are wasteful  organisms, it is  true;  but it  is no
good destroying them in attempting to make them more eco-
nomical.  They  require that plan which enables them to Avork
best.

  At this point it may be well to insert  some remarks on the
subject of " When not to give Iron," which Avere Avell received
by  the  profession when they appeared in the Practitioner, in
September, 1877.   They are as follows:—
  The conditions which call for the administration of iron are   •
par excellence those Avhere debility is combined with  anaemia.
In these conditions iron acts as  a general tonic as Avell as in-
creasing the number of the red  blood corpuscles.   But  there
are certain circumstances which contra-indicate the use of iron,
and which are deserving of note and remembrance.   It is not
enough  to say that in  conditions  of plethora and  vascular
fulness iron should not be  given.  There are other conditions
in which  it  is well to resort to other tonics, and even to other
remedial agents altogether.   Pereira says that the contra-indi-
cations  are  "great  strength and  activity of organs,  excessive
tonicity (characterized by a firm and tense condition  of the
solids), and redundancy of the red corpuscles of the blood__as
in  general excess  of the  blood (plethora),  in fever,  in  acute
inflammation, and  in the sanguine temperament.  To these may 
ASSIMILATION.
61
be added, congestion, or a tendency thereto of important organs,
especially of the brain and lungs, and intestinal irritation."
Again he says, "Administered in  large quantities, or when the
alimentary canal is in an irritable condition, all the compounds
of iron are liable to excite  heat, Aveight and uneasiness at the
precordia, nausea,  and even  vomiting, and sometimes purging."
  From  the  Avell-known  action of iron in increasing  the red
blood corpuscles no one  Avould iioav think of giving  iron in
states of vascular  fulness.  It is  unnecessary  to  say anything
further  on this subject.  Then  again conditions of vascular
excitement are unsuited for the exhibition of iron.  As long as
there is  rapidity of pulse combined Avith  rise of temperature,
so long must iron  be Avithheld in the treatment of acute disease.
AVhen the convalescence is Avell  established,  Avhen  the pulse
may be fast and small, but  is Avithout excitement;  Avhen the
temperature is perfectly normal or below it; when  the skin is
cool,  the face pale, and  the  tongue clean,  then, and  not till
then, should the administration of iron be  commenced.   If it
produce any gastric disturbance, or headache or feverishness, it
should either be totally abandoned for a time, or the  dose be
much  reduced.   Vegetable tonics, as  quinine or strychnine,
together Avith mineral  acids, the  hydrochloric, the phosphoric,
or the hydrobromic even  in some cases, should be given instead ;
and then the iron, in small  doses  at first—to be taken  after
meals, especially dinner.    So administered iron  can often be
tolerated, Avhen it disagrees given in the usual  Avay in combina-
tion with the vegetable tonics.   The same rule holds  good of
the resort to iron Avhen the pyrexial stage of ordinary  phthisis
has passed away.   The tonics and acids must be given before
food, and the iron after, either as the tincture of the muriate in
acetate of ammonia, the carbonate, or Niemeyer's pill of sul-
phate of iron with carbonate of potash in a drop of syrup.   But
as long as  the tongue is thickly coated, or red and  irritable, it
is wTell to withhold chalybeates altogether.
   This is  very true of phthisis.   However much the general
pallor, the lack of tone and loss of poAver seem to call  for iron,
it is useless, and sometimes  Avorse than useless, to give  it unless
the tongue be clean, Avithout irritability.  If the  tongue be red
and irritable, bitters with bismuth  are to be adhered  to, until
all intestinal irritability has  passed aAvay, of  which the condi- 
02
ASSIMILATION.
 tion of the tongue is the best index; if the tongue is loaded
 Avith fur, bitters  and acids are to be  preferred Avith  a  little
 sulphate of magnesia, or a vegetable pill at bedtime; or both if
 necessary.    The  gastro-intestinal  canal must be  got into a
 normal condition, neither  too  irritable, nor sheathed  with a
 layer of epithelium, as indicated by the fur upon  the  tongue,
 before either chalybeates or cod-liver oil  can be satisfactorily
 prescribed.   About  this  my experience at  the  Victoria  Park
 Chest Hospital constantly makes me more and more positive.
   In ordinary convalescence from acute  conditions it is Avell to
 commence  Avith the lighter preparations, the ammonio-citrate,
 the tartrate, or the citrate of iron and quinine;  afterwards the
 muriate or the sulphate will  be tolerated equally Avell.  But
 these latter  forms often disagree  during the  early stages of
 convalescence.   At times too  the  mixture of the  sulphate of
 iron, with quinine, and a few drops of dilute sulphuric acid, is
 found to be heating, and each dose to make the  patient un-
 comfortable, especially in Avarm Aveather;  here the  addition of
 a little sulphate of magnesia, not  necessarily to the extent of
 producing  purgation, will at once remedy the uncomfortable-
 ness so induced.
   In atonic gout also iron is commonly of no service, and makes
 the patient uncomfortable.  In the sanguine and plethoric forms
 of gout iron is neA'er indicated.  But where there is evidence
 of chronic  renal disease with anaemia, and even with  albumi-
 nuria, then it commonly seems desirable to  administer iron in
 some form.  Very often, however, it distinctly disagrees.  It
 is  Avell to see that there is no acute action going on anywhere,
 that the joints are cool, even if still enlarged, before commenc-
 ing  Avith chalybeates.  The bi-carbonate of potash,  or the
 potassio-tartrate of soda, Avith  a little mix vomica, in infusion
 of buchu, Avith a liberal draught of water after each dose, are
 the medicinal  agents to be adhered  to until  all is perfectly
 quiet.  When the tongue is clean, the skin cool,and there is no
 evidence of much  acidity, then small doses of iron may be com-
 menced with.  But for some time the iron and the potash should
be taken together; if the potash is left off the  iron disagrees.
Especially  is this the case  Avith elderly persons.   It  may  be
 laid down as a broad rule that the toleration of iron diminishes
as  the age  increases.   AVith old persons iron  comparatively 
ASSIMILATION.
63
rarely agrees, and then only in very small  doses: while young
children take  iron well, and it often is Avell borne  by them in
conditions Avhich in the adult distinctly forbid  its use.  But
as age advances the system seems  to  grow  less  tolerant of
the drug  in  any form ;  and  the  dose  must be  much dimin-
ished.  In advanced life, in convalescence after  acute disease,
or paroxysms of gout in  any of its forms, chalybeates have
often to  be abandoned, and  alkalies, as potash or ammonia,
Avith  vegetable  tonics and  bitters, substituted in  their stead.
It Avould seem that the power of the digestive organs to assimi-
late iron is strongest  in infancy—except it be very young chil-
dren and babies—and that it diminishes, until  in advanced life
the blood manufacture  often appears  to  be  interfered with
rather than  assisted  by chalybeates.  Consequently Avith old
people it is often better to give them tonics Avith alkalies and
easily digestible food, than to give iron, when it becomes desira-
ble to give a fillip to  their nutritive processes.
   There  is one  condition  where  iron is absolutely forbidden,
and  that  is the condition  knoAvn as biliousness.  As long as
there is a foul tongue, a bad taste in the mouth, and fulness of
the liver, Avith disturbance of the alimentary canal, iron is to
be prohibited ; it is not only that it is of  no service, it positively
does harm.   It aggravates all the symptoms and intensifies the
condition.  Iron undoubtedly increases the oxidizing processes,
but somehow or other in biliary disorders it does not suit.  De-
fective oxidation is at the root of these states, and yet iron does
not agree with such patients.  As long as any  of the symptoms
remain, and there is any fur Avhatever on the tongue, iron must
be Avithheld.  The patient may be anaemic and iron seem to be
urgently indicated, but it Avill do no good  until the system is
in the proper condition to receive it.   Sir  Joseph Fayrer's
Indian experience is in full accord with  this expression of opin-
ion.  (See § 166.)  The liver  must be thoroughly  unloaded by
alkaline salines first; then some  strychnia  and  nitro-muriatic
acid may be  taken in the day, the salines being only taken first
thing in the morning; and ultimately,  when  the  liver is once
more working efficiently, chalybeates may be prescribed.  But
it seems  that the oxidizing power of iron  embarrasses rather
than aids the liver Avhen working inefficiently ;  and when iron
is given,  the morning purgation  of salines, mineral waters, or 
64
ASSIMILATION.
other means, should still be maintained.   By attention to these
points much may be done for bilious patients; aye! and much
discredit avoided.  Whenever, indeed, there is disturbance of
the gastro-intestinal canal, bilious or other, chalybeates are con-
traindicated, and if given, cause  discomfort, nausea, and  not
uncommonly a pyretic condition.   The digestive organs must
be got into good Avorking order before iron is administered if
it is  to be  properly assimilated.  AVhen  given in large doses
iron always blackens the stools, but if given in moderate doses
and Avell  assimilated this blackening of the  stools is  not so
marked.  The color of the stools, then  may be  utilized as an
indication as to  how far chalybeates are assimilated and are
likely to be useful.
   There are tAA^o different states found in women Avhere iron is
either totally contraindicated or to be given with great caution.
The first is the condition of amenorrhoea in florid, plethoric per-
sons.  In such cases, especially if the patient be of tense fibre,
depletory measures are to be resorted to, as local bleeding and
free purgation.  The other is the opposite condition of menor-
rhagia in certain females.  Of course no one would think of re-
sorting to any form of  iron, however astringent, in those cases
of menorrhagia Avhich  are due to a state of general  plethora.
But there are cases of  menorrhagia  associated with pallor and
debility, Avhere the usual compound of iron and extract of ergot
is not so useful as is a non-chalybeate treatment.   In these cases
it is not any imperfection in the processes of blood-manufacture
 Avhich  is to  be remedied, for  the blood is made rapidly and
 quickly, only to be lost at each menstrual period.   An irregular
 process of rapid blood-making with  still more rapid blood-loss
 is established, and requires its appropriate treatment.  It  is
 undesirable to stimulate blood-formation  by chalybeates here,
 for the greater the increase in the bulk of the blood, the more
 excessiAre the catamenial loss ; and to give iron is but to aggra-
 vate the condition.  It  is  here  desirable rather to limit the
 rapidity of the blood formation, so that AAThen the general vascu-
 lar turgescence of the  menstrual  period comes, it will  not find
 the  bloodvessels too distended with blood.  This will lead  to
 diminished catamenial loss, and so the blood-waste will be econo-
 mized.  For in these cases  it is the proper practice to lessen
 the loss rather than to stimulate  blood formation.  During the 
ASSIMILATION.
65
interval a  little sulphate of magnesia, with  dilute sulphuric
acid in some infusion of a vegetable astringent, forms an appro-
priate  medicinal  agent, and  should  be given  along Avith a re-
stricted dietary.  At the periods  the dose might be increased
and  the patient kept quiet, Avhile all aliment should be cold.
By such a plan the irregular condition of rapid blood-formation
and  blood-loss Avill be converted into a steady state of sloAver
blood-formation Avith  diminished loss.  The  same  rule holds
good of other periodical hemorrhages, and especially of some
forms of haemoptysis.
   Even in cases of menorrhagia where it is necessary to encour-
age blood-formation during the interval, it is often Avell to cut
off the chalybeates a day or so before the menstrual molimen,
and to substitute for it the mixture just mentioned above.   By
such plan the blood-waste by the catamenia is economized, and
the necessity for great blood formation minimized.
   Finally, the consideration of iron here is confined to its use
as an  haematic, its use in pyrexial affections as  erysipelas  or
scarlatina not being included.  When used as an haematic, it is
clear that certain points must be kept in view.  First, that the
digestive  organs be  in fair working order,  and second,  that
certain precautions be taken as to its administration Avhen it is
necessary to resort  to it.
   Since  writing the  above, Dr. Hughlings  Jackson tells me
that at one time he did not acquiesce in Brown-Sequard's idea,
that iron does not suit epileptics, but that a more extended ex-
perience has convinced him that it  is so.   When iron is given
to epileptics who are anaemic, it may improve the condition of
the blood ; but that, while doing so, it increases the  tendency
to fits.  It may improve the general condition, but  it aggra-
vates the epilepsy.
5 
CHAPTER  III.
                        EXCRETION.

  § 25. Having just seen the importance of a healthy assimila-
tion in the  production  of normal  nutrition, Ave hoav come  to
the question of excretion.  This  is  a much more important
subject than is usually supposed.   We  have  for  long been
familiar with the gravity of imperfect nutrition; but  are not
equally intimate Avith the still graver subject  of defective ex-
cretion, and the evil effects of imperfect elimination.  It is not
merely that life soon becomes extinct if the different excretory
actions of the body are not carried out—a method of destroying
life much more rapid in its  action  than  the  Avithholding  of
ingesta—but it is  also the more chronic action of imperfect
elimination which  is fraught Avith grave  issues.  The import-
ance of the functions of egestion as compared to those of ingestion
Avas insisted  upon  by Alarshall Hall in 1842.   The system is
soon poisoned if it cannot  get rid of its OAvn  carbonic acid.
The excreta of the urine are powerful neurotic poisons, causing
coma and convulsions ; and bile is equally  destructive to life in
large quantities. It would appear indeed that the assimilation of
food is accompanied, or followed by the production of principles
of a  pre-eminently  destructive character, either as injurious
products of the food taken when split  up, or as Avaste matters
—the result of histolysis.  Very grave, indeed, are the ques-
tions relating to retrograde metamorphosis  Avithin the organism.
Especially is this the case Avith nitrogenized principles.  These
nitrogenized matters do not merely go toAvards tissue formation,
and then, by a  process of oxidation, pass from one  form of  his-
tolytic product to another.   They do  not break up in tissue
destruction into  creatin, creatinin,  tyrosine and  other early
products of tissue  decay, and then pass on  into uric acid and
urea  merely ; each form  being in large amounts a dangerous
poison.   They  also form within  the  animal  organism ferments
which exercise no unimportant function.  Pepsin, so pOAverful 
EXCRETION.
67
a ferment  in the  production of the digestion of albuminous
matter, is a secretion, and in so far an excretion of the stomach
by means of its follicles..  Ptyalin is the ferment of saliva, very
effective in the conversion of starch into sugar.  Pancreatine is
another albuminous ferment, formed in the pancreas, also pos-
sessing marked power as a digestive  agent.   These different
products are in so for excrementitious, that they are thrown out
of one part of the system, and yet  they are most  effective in
promoting digestion by their action upon the material Avhich is
furnished as food.  These excretions are valuable digestives and
ferments.  Carpenter, in his article " Secretion," in the  Cyclo-
paedia  of Anatomy  and Physiology—a  most  valuable  paper  to
which frequent reference will be made in  this chapter—says:
" Thus the salary, the  gastric, and  the  pancreatic fluids all
contain an animal principle  nearly allied  to albumen; but this
principle seems to be in a state of change, or of incipient decom-
position ; and  it Avould not seem improbable that  whilst this
very condition renders the  albuminous matter useful in pro-
moting the solution  of the  aliment, it renders it  unfit  to be
retained Avithin the circulating current."   This is a suggestive
paragraph.  It throws a ray of light  over the subject of the
relations of excretion to nutrition.
  There are also albuminous  ferments scattered through the
body, Avhich cause, it is  believed, the  changes Avhich give us
our body heat.  The glycogen stored up in our livers, and there
reconverted into sugar, is  broken up into  lactic acid, and this
acid, uniting Avith the soda of the blood, is gradually oxidized,
and the oxidation of lactic acid, as lactate of soda, causes our
body heat.  (Headland.)  The production of waste  matters in
excess, by the action of these ferments when  overactiATe, is  a
matter just coming within the range of our physiological vision.
There  are  already indications enough to give  us grounds for
good expectations from it.
  Before we go further Avith excretion  by the different organs,
we must first look at excretion  in its  entirety.  Thus, in the
loAATest forms of life, Ave find the surface  generally excretory,
as it is also generally tactile.   But as  certain portions in time
manifest greater activity in certain directions, and form the
rudiments  of  special senses; so  apparently there are certain
areas  which are more active than others in the excretion of 
08
EXCRETION.
waste products ;  and so Ave get the rudiments, the first shadow-
ings out, of special excretory organs.   As these develop,  they
come to possess certain specialties ; yet nevertheless they do not
lose altogether their primitive characteristics as part of a general
excretory surface.
  "In  all instances, then, the excretory organ essentially con-
sists of a limitary membrane, Avhich  forms part of the integu-
ment of the body, or of its involutions, and of cells covering the
free  surface  of  that  membrane,  and  consequently  in direct
relation with the external surface.  Thus we have the limitary
membrane of the true skin, and of the mucous membrane of the
alimentary canal,  which is directly  continuous with it, sunk
into follicular depressions;  and the free surfaces  of these are
lined Avith cells,  the  layers of which are continuous with those
of the epidermis and of the gastrointestinal epithelium respec-
tively.  We trace  inwards another extension of the same mem-
brane  along  the genito-urinary passages up to the  kidneys,
Avhere  ir forms the Avail of the tubuli  uriniferi;  and there, too,
its free surface is covered with an epithelial layer of cells, which
is the efficient instrument of the selection of the constituents of
the  urinary  fluid, and which,  when exuviated, is  conveyed
along the urinary passages to the exterior of the body.  So, too,
the hepatic cells, by Avhich the biliary matter is eliminated from
the blood, are brought into direct  continuity Avith those of the
external surface, through the hepatic ducts  and gastrointesti-
nal mucous membranes.  The case is not different, in  any essen-
tial respect, Avith regard to the  organs  by Avhich the recremen-
titious secretions  are  formed.   Thus the lachrymal, sali\rary,
pancreatic, and mammary glands are, in like manner, composed
of a continuation of the limitary membrane of the true skin, or
of the  mucous membrane lining the alimentary canal, involuted
into tubes and follicles, the free surfaces of  which are covered
Avith epithelial  cells.   These  cells,  draAving  into  themselves
certain constituents of the  blood, are cast off when they have
completed  their  full  development, and their contents, set free
by the disintegration  of the cell-walls, are  carried  off by the
ducts, which collect them from different portions of the glandu-
lar structure, and  deposit them in the situation where the pur-
poses of the secreted product are to be answered." (Carpenter.)
   This gives us  a  clear view of  the community of origin of the 
EXCRETION.
69
 different excretory  organs.   AVe can see how, gradually, the
 function of each has become  more and more specialized, until
 Ave have the different systems distinctly established.  The air-
 tubes are nothing more than involutions of the general tegu-
 ment, by Avhose means  the respiratory changes are  carried on.
 They also furnish the means by Avhich oxygen is brought within
 the system, to perform  its combined action of the production of
 force, by the oxidation  of material within the  body, and of the
 removal of Avaste.   AVhile  permitting of the  chemical inter-
 changes which furnish  oxygen, and  also of the removal of car-
 bonic acid, these air-tubes resemble the skin, in that they pro-
 vide  a large  surface from Avhich Avater may exhale.  The air-
 tubes, Avith their alveolar pouches in the lungs themselves, are
 an involution of the general  tegument, preserving many of its
 primitive  characteristics.  The  lungs and  skin give off  the
 water of combustion within the body.   The kidneys represent
 the ingested water  rather, and  their secretion varies with  the
 amounts of fluid imbibed.  There is a general  play, backwards
 and forwards, betAvixt these excretory organs in the elimination
 of water from the  system, occasionally interfered with or aug-
 mented  by the action of  the gastro-intestinal canal.  The skin
 and kidneys play backwards and forwards very much according
 to the temperature; in  hot Aveather  the  skin is most active, in
 winter  the kidneys.  Agents like potash  act as diuretics or
 diaphoretics very much according to the temperature surround-
 ing the organism.  It is not in the elimination  of Avater merely
 that the mutual action and reaction of the skin  and kidneys are
 demonstrated.   They each excrete,  along  with water, Avaste
 products and salt.   Long ago  Nysten observed that urinous
 products were given off by  various emunctories  when their
 passage  by the kidney  was  interfered with.  " The  passage of
 a urinous fluid from the skin has been frequently observed in
 cases  where the renal secretion  was  scanty;  and the  critical
 sweats, by  which attacks  of gout sometimes terminate, contain
 urates and  phosphates, in  such abundance as to  form a poAvdery
 deposit on  the surface.  It has lately been ascertained that in
 warm climates urea is  an element of the perspiration even of
 healthy persons."  (Landerer, quoted by Carpenter.)  At other
times a urinous  fluid is  cast out  by the gastro-intestinal canal,
 which possesses an  excretory as well as  an absorbent action. 
70
EXCRETION.
As excretory organs these involutions of skin, and their primi-
tive form the tegument, possess much in common.
  § 26.  Along the gastro-intestinal canal there are established a
series of excrementitious actions, resulting in the production of
numerous albuminous products Avhich are also recrementitious,
and are very useful in  the elaboration of our food.   Though
varied, they possess much action in common.   That is, along
the digestive tract,  the primitive tegument has undergone such
modifications as to excrete, or secrete, a series of products Avhich
fulfil no unimportant  function in assimilation.   And yet these
excretory  organs  give off other products Avhen the system is
charged Avith them  ; products too  far  advanced to possess any
nutritive power, and simply active poisons.  From the times of
Chirac and  Helvetius. who  noticed that a urinous fluid  Avas
passed off from the  stomach after ligature of the ureters, down
to the time of Wm. Roberts, this power on the part of the gastro-
intestinal canal to supplement the action of the other excretory
organs, has been observed and acknoAvledged. In the same Avay,
the biliary excretion is removed by different parts of the body
(not usually eliminating bile)  when  the  system is charged Avith
it.  The skin, the serous  membranes, the mucous membranes,
are often  penetrated with the  coloring  matter of  bile, Avhich
they have AvithdraAvn  from the blood.  The urine is  often so
charged Avith bile as not only to give bile  reactions in testing,
but even to stain the linen ; Avhile bile-stained tube-casts are
among the most  striking objects revealed to us by the micro-
scope.   The elimination of the catamenial flow by other organs
than the lining membrane of  the uterus, furnishing Avhat is
called vicarious menstruation, is a phenomenon to Avhich porten-
tous importance is attached by many savage  tribes.  Even  milk
has been found to procure an  exit by other  channels  than the
mammary gland-ducts.
  The relations of excretion to nutrition are very much involved.
AVe ha\-e seen hoAV  a great many products are excreted, and yet
not cast out, but fulfil  an important functional end.  Unexcreted
they might have been injurious; excreted  they are useful and
beneficial.   But  there  is something more  than this in  their
relations.  "As Avas first pointed out by Treviranus, 'each single
part of the body, in  respect of its nutrition, stands to the \vhole
body in the  relation of an excreted  substance;' in other Avords, 
EXCRETION.
71
 every part of the body, by taking from  the blood the peculiar
 substances Avhich it needs  for its  own nutrition,  does thereby
 act as an  excretory organ; inasmuch  as it removes from the
 blood that Avhich, if retained in it, Avould  be injurious to the
 rest of the body.  Thus the  phosphates  Avhich are deposited  in
 our bones are as effectually  excreted from  the blood, and pre-
 vented from acting injuriously on the other  tissues, as are those
 AA-hich are  discharged in the urine."  The effect of  each act  of
 tissue-formation  is to remove that Avhich, if  unremoved, Avould,
 or at least  might, have exercised  an injurious  influence; and
 Avhich, if accumulated, certainly would exert  a prejudicial action.
 What is requisite for  one part is injurious to another.   It is
 somewhat difficult to realize this fact fully, in an organism  so
 complex and so interpenetrated, as the body is,  by bloodvessels
 and lymphatics.   At first sight it would  seem that  every form
 of pabulum must be  carried to every  tissue; just as  small
 organisms are seen to  melt in  the jelly-speck—the  amoeba—a
 simple solutiou of the tiny  creatures being set up;  and a centri-
 fugal distribution of the solution throughout the mass of sarcode
 carries it at last, as waste, to the  external  excretory surface.
 But nutrition has become  a complex matter  as evolution has
 progressed ;  and  the development of the different  specialized
 areas, Avith their  varied functions, is not more compound than
 is the general nutrition, Avhich gives to one tissue as  food, Avhat
 Avould but be a poison to other tissues if  not removed.
   § 27.  And yet, through  all this, there remains, in each and
 every excretory organ, a sufficient amount of its  primitive char-
 acter to  render one organ  a  compensatory excretory agent for
 the  elimination  of Avhat  is  more  distinctly the province  of
 another organ. Consequently Ave get compensatory over-actions,
 Avhich are often  mistaken  for  disease.   Indeed, until physio-
 logical research came to illuminate  our  practice,  such a thing
 as ursemic diarrhoea Avas unthought of;  and  as a consequence
 its proper treatment remained undevised.   We had  simply no
 conceptions of any augmented  secretions or excretions, other
 than  as  morbid  actions.  In this  respect Ave have made great
 advances ;  and hoav Ave commonly recognize the secondary char-
acter of what is truly a compensatory action, and not a morbid
process.   Especially have Ave learnt  this lesson in regard to the
 recurring ailments of advanced life. 
EXCRETION.
  In early life most ailments take their origin in  imperfect
nutrition—in  failure in the nutritive processes; in  advanced
life, ailments usually arise from impaired elimination of Avaste
products.   Of course zymotic and accidentally acquired diseases
act alike in both extremes of life.
  Many valuable lessons in practice are to be learnt solely from
physiology, and it is only now becoming possible to  learn them.
It is only at the present time that we are in a position to admit
of an intelligent and  rational comprehension of much of  the
ill-health of matured existence.
  Ere proceeding to go practically into this question, it is desir-
able to make  one  more quotation  from Carpenter's suggestive
monograph.   It relates to the poAver of  one  excretory organ to
supplement the action of another,  Avhen  defective.   He calls it
"Metastasis of Secretion," and Avrites, "Although the number
and  variety of secretions become  greater in proportion to the
increased  complexity of the nutritive processes in the higher
classes, and although each appears as if it could be formed by
its  OAvn organ alone, yet Ave may observe, even  in  the highest
animals, some traces of the community of function  which char-
acterizes the general surface of the lowest.  It has  been shown
that, although the  products  of  secretion are so different, the
elementary structure of all glands is  the same; that wherever
tiiere is a free excreting surface it may be regarded  as an exten-
sion of  the general  envelope  of  the  body, or of the reflection
of it Avhich  lines the digestive  cavity; that its epithelium is
continuous Avith  the epidermis of  the integument,  or with  the
epithelium of the mucous membrane from Avhich  it is prolonged ;
and that the peculiar  principles of the secreted products  pre-
exist in the blood in a form at least closely allied to that which
they assume after their separation.  Now it may be stated  as a
general laAv in physiology, that  in cases where the different func-
tions are highly specialized, (that is, where every one has its special
and distinct organ for its own purpose alone) the general structure
retains, more  or  less, the  primitive  community  of function which
characterized it in the lowest grade  of development.  Thus although
the functions of absorption and  respiration have special organs
provided for them in the higher animals, they are not  altogether
restricted to these, but may be performed in part by the general
surface, which (although the special  organ for exhalation)  per- 
EXCRETION.
73
 mits  the passage of fluid into the interior of the system, and
 allows the interchange of gases  betAveen the blood and  the air.
 In the same  manner Ave find that the functions of secretion are
 equally performed in the lowest animals by the whole  surface,
 Avhilst in the highest there is a complicated apparatus of glandu-
 lar organs, to each of AAThich some special division of the func-
 tion is assigned ;  either the general muco-cutaneous  surface, or
 some one of its subdivisions or prolongations, is able to  take on
 in some  degree the function of another gland whose functions
 may be suspended.  This truth Avas Avell known to Haller, Avho
 asserted  that almost all secretions may, under the influence of
 disease, be formed  by each and every organ.  This statement,
 hoAvever, needs to  be received  with  some  limitation, and  it
 Avould probably be safest to restrict it to the  excretions whose
 elements  pre-exist in the  blood, and  accumulate there,  when
 the elimination of them by their natural channel is suspended."
 This introduction to the physiology of excretion will enable us,
 all the better, to take up the subject of its  abnormalities, and
 to see more clearly the indications for a rational treatment.
   § 28. Thus, for instance, Ave see how water is eliminated from
 the  system  by the different emunctories,  the  skin, kidneys,
 lungs, and bowels.  When  the  skin is very active the  bulk of
 urine is small ; and a similar decrease in the amount of water
 excreted by the kidneys, follows a sharp diarrhoea with watery
 motions.  Sometimes when the  action of the skin is  checked
 Avhile the kidneys are acutely congested, a condition often pro-
 duced by exposure, we see a general oedema  induced, a storage
 of the Avater in the areolar tissue only to be  removed by sweat-
 ing and purging.
   Carbonic acid is chiefly exhaled by the lungs, but a portion
 also escapes by the skin.   Under certain circumstances of  arrest
 in the action of the lungs, the amount passed off by the skin
 becomes  notably  increased.   Holding  the breath in  summer
 quickly induces perspiration  in many persons.  In fact  when
 the exhalation of carbonic acid by the lungs is interfered  with,
 the skin  passes it off.  " Moreover, it  has been observed not un-
 frequently that the livid  tint of the skin which  supervenes in
 asphyxia, owing to the  non-arterialization of the  blood in the
 lungs, has given place  after death to the fresh hue of  health,
owing to the  reddening of the blood in the cutaneous capillaries 
74
EXCRETION.
by the action of the  atmosphere upon them ;  and  it does not
seem improbable that, in cases of obstruction to the due action
of the lungs, the exhalation of carbonic acid through the  skin
may undergo a considerable  increase ; for Ave find a similar
disposition to vicarious action in other parts of the excreting
apparatus.   There is also evidence that the interchange of gases
betAveen the air and the blood through the skin has an import-
ant share in  keeping up  the temperature of the body  (Chap.
XII.); and Ave find the temperature of the surface much elevated
in many cases of pneumonia, phthisis, etc., in Avhich the lungs
seem to perform their function very insufficiently."  (Carpenter,
Human Physiology, §  309.)  Every  observant  practitioner will
agree Avith this last, as he must have had opportunities of noting
this fact about the consumptive patient Avhen far on his journey.
About 5 or 6 a.m. the  patient Avill usually do one of two things;
either waken up and beg for air, sitting gasping, from the dimin-
ished lung space, and  throwing into play all the auxiliary mus-
cles of respiration—breathing for dear  life indeed ;  or he falls
into a deep comatose  sleep, and  becomes drenched Avith perspi-
ration.  Sometimes one happens, sometimes the other.  In  each
case there is a desperate effort made to get rid of the carbonic
acid of the system. In some of the lower animals the cutaneous
respiration is an important matter.
  Even still more important, and  Avithal interesting,  is  the
subject of the elimination of nitrogen.  It is usually taken for
granted that nitrogenized Avaste  passes off by the kidneys only.
Few practitioners think of the other means of its exit, in their
practice and treatment.  The importance of renal  inadequacy
is being noAV very generally comprehended, and a short review
of the matter may be profiable.   Prevost and  Dumas Avere the
first to find that Avhen urea Avas  not cast out by the kidneys it
accumulated in the system.  Since then we know  that urea,
uric acid, and the earlier  products of histolysis, creatine  and
creatinine, are all to be found in the blood after ligature of the
renal artery.   Such being the case, these waste matters pass out
by different emunctories.   A quotation from H. C.  AVood will
show the attention paid to this subject.
  " In 1851 Dr. Schottin discovered urea in the sweat of patients
suffering from the collapse of cholera.  Not only has the dis-
covery of  Schottin been  confirmed by the researches of G. 0. 
EXCRETION.
75
Rees, of Fiedler and Jiirgensen, of Leube, and of G. Deininger,
but it has also  been abundantly proven that  the skin excretes
urea freely during the advanced  stages of Bright's disease, and
also during the partial suppression of  urine of scarlatinal  des-
quamation and  nephritis.   The urea in renal disease may eATen
form  a distinct crystalline powder on  the skin; but it is most
abundant  about the mouths  of the sweat-glands.   I believe
Landerer Avas the first to announce that urea Avas present  in the
sweat of healthy persons;  and although chemists of excellence
have  been  unable to detect  it, yet its presence at times can no
longer be denied, since it has been found not only by Landerer,
but also by Funke, in 1858, by Meissner, and by Leube ;  Four-
croy has found it in the sweat of horses.  By a series of elaborate
experiments Leube has rendered it probable, if he  has not
actually proven, that in health there is such a relation betAveen
the skin and the kidneys  that Avhen the  former is very  active
the latter excrete less than the normal amount of urea."  (Loc.
cit. p. 435.»)
   From this it would  appear that suppressed gout may arise
from  defective action of the skin as Avell as from renal  inade-
quacy.  Richardson found  that ammonia Avas given off by the
breath in uraemic coma (Asclepiad), and experience has made it
a common  observation.
   Zalesky  found in  serpents, after ligature of the ureters, that
all the organs and tissues Avere strongly infiltrated Avith urates,
Avhich formed thick white  crusts and patches on all the mucous
and serous membranes, in the joints, in and upon the kidneys,
liver, heart, and spleen.   By chemical  analyses uric acid  Avas
also  abundantly found  in  the lungs, muscles, and  throughout
the body.   (Roberts  on Renal Diseases.)  The same authority
says,  "When the vomiting is really uraemic it takes place Avith-
out reference to the nature of the contents of the stomach, and
is  oft  repeated or uncontrollable;  the vomited  matter is a watery
fluid, either distinctly ammoniacal  to the  smell,  or  (if acid)
evolving ammonia Avhen caustic potash  is added thereto.   The
alvine dejections are similarly characterized  when due to the

  1 I have omitted the references to these authorities given in the text.  Any
reader  wishing to go further into  the  matter will find  them  given in  Wood's
Treatise on Therapeutics, at p. 435. 
EXCRETION.
 same cause."  (Part  iii. Chap, iv.)   AVe are all familiar with
 the inflammations of serous membranes so commonly found in
 chronic Bright's disease.
   Thus we can see Iioav a Avhole array of so-called ailments may
 arise in consequence of imperfect elimination of nitrogenized
 Avaste;  and  that such, of  course, will  most  commonly  occur
 where the kidneys are no longer in  their integrity.  But these
 affections are not the disease itself.   They are forms of natural
 cure.  They are better  obviated, if possible.   If this  is  not
 feasible, they may be  aided by proper treatment.  A large  series
 of the affections of advanced life find their origin in impaired
 elimination  of  nitrogenized  waste.   They are  compensatory
 actions rather than diseases per se.
   §  29.  It is, from  the  foregoing,  very obvious that in  the
 treatment  of affections originating in the imperfect elimination
 of nitrogenized Avaste there are several points to be attended to.
 1. To reduce the amount of nitrogen consumed.  This needs no
 explanation.  2.  To give large quantities of fluids, in  order to
 bathe the  tissues, and wash aAvay the  sparingly soluble  salts.
 3. On no account to attempt to stop the compensatory excretory
 action, until the normal excretion is restored.   4. To act upon
 the different compensating organs, and set up vicarious elimina-
 tion through other channels.  For this last purpose, action upon
 the skin is at once  the most physiologically  rational, and  at
 the same time practically feasible.   In all cases, then, the skin
 may be kept in action Avith advantage.  Warm baths, Sir James
 Simpson's  bath (see  § 41), the  hot-air  bath,  etc., all  may be
 resorted to beneficially.  Especially are  they useful when  there
 is obstinate vomiting. When the stomach is  unaffected, large
 draughts  of Avater,  pure  or alkaline,  are indicated.    Such
 draughts  may  advantageously be used  to wash  down the fol-
 lowing dose: —
                   Pot. Iod. gr. v.
                    " Bicarb, gr. x.
                   Inf. Buchu, §j om. 4ta hora.
At the  same time, if there be  evidence of congestion of the
kidneys, hot sinapisms may  be applied  over  the loins, or dry
cupping resorted  to.   The bowels  may be smartly  acted upon by
drachm doses of compound jalap powder, or the following :— 
EXCRETION.
i I
                   Pulv. Cambogise, gr. v.
                   Pot. Bitart. 3ij.
                   Pulv. Pip. Nig. gr. x.
daily, followed by action on  the skin  and draughts of AArater.
Such  a plan of treatment must be pursued  intelligently  and
courageously; and if so followed out will often give very satis-
factory results.  When the plan of  treatment is decided upon,
it is not Avell to interfere with it to allow for some intercurrent
trouble, unless the newT trouble imperatively demand attention.
Affections demanding such a plan of treatment are much more
common among elderly people than is ordinarily supposed.
  Even after  the violence of  the outburst is quelled, it is very
important to remember the pathology of the morbid condition,
and to avoid vegetable astringents,  and still more opium.  This
last is of en a desperate poison in conditions of impaired elimi-
nation, and  must be scrupulously avoided.   If  the diarrhoea
persists after  the action of the  kidneys is fairly re-established,
the skin must be kept in action, and the following mixture may
be prescribed:—
                   Liq. Fer. Pernit. ulxv.
                   Pot. Nit. gr. v.
                   Inf. Buchu,  §j ter in die,
until  matters have become more normal.
  It is a matter of  much importance in  the treatment of such
cases  to put the patient on a slop diet, which  contains a mini-
mum  of nitrogen.  The error made by our predecessors, in their
adoption of  a slop  diet, was, that they applied it too exclu-
sively ; and did not, with sufficient care, discriminate  betwixt
the cases where such a diet Avas indicated, and those  where a
more  liberal dietary Avas desirable, and  even imperatively neces-
sary.
  For some time, indeed, after  any outburst  associated with
impaired elimination, the patient must  live very carefully.  The
diet must be largely farinaceous, the skin be kept Avell  clad in
flannel, and the bowels regulated with alkaline purgatives.  The
pathology  of  the  ailment shadows out  the true and rational
treatment.
  § 30. It  not unfrequently  happens  that  organs actively  en-
gaged in compensatory action, or vicarious  elimination  become
themselves  affected  from this  functional  activity.  Thus in 
78
EXCRETION.
chronic renal changes it is very common for the skin to become
chronically  diseased; and the skin affections, so  induced, are
very intractable if their origin be not remembered.   Numerous
chronic skin affections, eczematous and scaly, are cured, for the
time being,  by a course of Buxton or other waters.   The elimi-
nation of the  Avaste products, by  the action of the  alkalies dis-
solving them, and so  permitting  of their Avashing out  through
the different  Avater-channels of  the body, is followed  by the
cure or relief  of the affections, induced  by the  vicarious  func-
tional activity of the  skin.  But  they return again, usually in a
brief period,  unless  the drinking of  some  alkaline water is
continued.
  A very illustrative instance of the  effect of  Avell  directed
treatment is furnished by the following case:  Some years ago,
a friend of  mine asked me  about a case of very obstinate irri-
table ulcer in a lady patient, who had been troubled Avith it for
eighteen years, and, during  that time, had consulted many lead-
ing surgeons  at  home  and  abroad.  It had resisted  all, and
every form  of treatment  hitherto devised.  Remembering the
instructions of my excellent surgical  teacher, Joseph  Bell, of
Edinburgh,  that irritable ulcers were commonly found in gouty
persons,  I asked if there was  a  possibility of the lady  being
gouty.   He  thought it probable,  though she had never  suffered
from regular gout.  The ordinary mixture—
                     Pot. Iod. gr. v.
                      " Bicarb, gr. x.
                     Tinct. Sem. Colch. TTL x.
                     Inf. Buchu 3J.
was  given three  times a day, with copious draughts of water.
Simple water dressing Avas applied to the ulcer.  In  three weeks
the ulcer had healed, to the patient's immense satisfaction.
  Not only the skin, but the bronchial membrane is exceedingly
apt to become chronically deranged from vicarious action ; and
in these cases iodide of potassium, &c, is extremely useful.  In-
deed, these are the cases of bronchitis which yield to this reme-
dial  agent only.   In  many cases the  stomach seems to suffer
continually  from  the  irritant effects of the uric acid present in
the gastric  juice.  It may be merely a coincidence, but it has
occurred to  me, several times, to see cancer of the stomach de-
veloped  after  a  long  history of  gouty dyspepsia.  It  is quite 
EXCRETION.
79
possible that  the  irritation, so caused, ultimately leads  to  a
development of pathological connective tissue of a grave char-
acter, viz., scirrhus.
  Dr. C. J. B. Williams has clraAvn attention to the relations of
localized inflammations Avith general conditions of imperfectly
depurated blood.  He says: "  Irritation and  inflammation are
sometimes caused by excrementitious matter  retained in the
blood, Avhere the functions of the excernent  organs are im-
paired."   And again he Avrites: "The natural excretions of the
body become  most acrid  irritants  when  brought into contact
with serous membranes;  thus  urine, feces, and  bile, effused in
serous membranes, even in the smallest quantities, produce in-
tense irritation and  inflammation."
  Such being the  case, it  is quite possible that long-continued
irritation, by trifling quantities of these substances, may result
in tissue changes of  a chronic character; and in those advanced
in life, such  change may assume  the direction of  malignant
connective tissue.
  § 31. Another  important effect of impaired excretion is the
action of retained excreta upon  the  blood-formation.  These
poisons—for they are identical  in their effects  Avith  blood
poisons—so produced within the system  itself,  act in the  most
prejudicial manner upon  the formation of the blood, or, if not
that, they break the blood doAvn wThen made.   In  the London
Hospital it is quite common to see what they  there denominate
" fecal anaemia"—that  is, anaemia caused by  the action of the
excretions of the intestinal canal being again absorbed, during
persistent constipation, and exercising a destructive action over
the blood corpuscles.  Purgation at once  improves  this state of
matters, and the condition of anaemia is relieved ere chalybeates
are resorted to.  In  the same way Ave find the anaemia, so  com-
mon in the  course  of  kidney  disease, to be produced.  The
presence  of renal derivatives  in  excess  affects the  red blood
corpuscles in  reducing their number.   Anaemia  folloAVS,  and
iron alone will not relieve the  condition.   As in fecal anaemia,
iron Avill not increase blood-formation unless a specific be added
to it.  Purgatives in all cases aid the action of iron, and this is
the explanation of much  of the benefit derived from such com-
bination.  In gouty  anaemia, potash added to  iron,  and the dose
washed down by large draughts of water, produces at once a 
so
E X C R E TI 0 N .
pleasant  change in the  state of  matters.  Such combination is
furnished by the Mist.  Ferri Co.  It is perhaps better  to  com-
bine iron with potash thus:—
                    Pot. Bicarb, gr. x.
                    Ferri Am. Cit. gr. v.
                    Inf. Quassia' gj, ter in die,
gradually decreasing the potash  and increasing the iron, until a
good state of health is produced. It has fallen to my lot to see
gouty anaemia pass aAvay, and  the hue of health come  back to
the lips and cheeks, simply under the use of potash and diuretics,
before a single  grain of iron had been administered.   In this
respect anaemiae, the result of   systemic poisons,  resemble the
anaemiae of syphilis, of lead-poisoning, and of malarial  disease.
In each case the specific, mercury, iodide of  potassium, or qui-
nine, must be added  to the chalybeate, ere good blood construc-
tion can be induced.   Promoting the action of the skin  is often
useful  in bringing the system  under the influence of iron in
these cases.   This is brought  about by  its eliminant action.
Warm baths and purgatives are  very serviceable as adjuncts to
the haematic remedies in such cases.  Thus mercury, iodide of
potassium, or quinine are true haematics in these cases, because
they directly aid in inducing healthy blood-formation.   (§ 21.)
  In many cases of anaemia the ordinary methods of giving  good
food and  iron totally fail.   The treatment  is persevered with,
but is of no avail.   The blood-formation is prevented  by  some
poisonous material in the blood, and  all our efforts are futile.
When the specific remedy is administered then progress  is made,
and the  case goes forward.  When anaemia  is a consequence of
impaired elimination of nitrogenized waste a  spare diet, but
poorly supplied with  nitrogen, Avill  often  produce excellent
effects, and procure an improved blood-formation.  Such a plan
of treatment would  never  suggest  itself except under  two sets
of circumstances.  1. A good comprehension of the physiology
and pathology of assimilation.  2.  A close  and observant ex-
perience, which  can  guide the  treatment of one  case  from its
remembrance of the course of events in another.  Few are  equal
to the latter;  the former is easily possible.  Such a plan of
restricted diet  must always precede any restorative treatment,
in cas'es  of  inadequate  excretion.   HoAvever the  patient may
dislike it—and  some do rebel in earnest—it is the  only plan. 
EXCRETION.
81
 AVe might Avish to reap our corn as  soon as the ear is shot—
 and the folly of that is clearly apparent—without satisfactory
 results:  so sometimes patients wish to hasten processes, instead
 of  allowing them  their proper order;  and  the  folly becomes
 apparent in time.  The old trainers' plan of clearing out  the
 system, ere commencing to build it up, was sound and sensible.
   § 32. There is another product Avhich in its waste or excess
 is certainly an excretion, and that is bile.  Though the creation
 of  the liver, essentially, Avhen the flow through the gall-duct is
 obstructed, there is a general saturation of the body with bile
 products.  The  different involutions  of the  general primitiAre
 tegument are specially involved, as vicarious  and  compensating
 eliminants.  Bile may either not be secreted originally, if indeed
 this occurs at all, or it may be reabsorbed: the latter being infi-
 nitely more common.   Biliousness  usually  springs from  the
 reabsorption of  spare  bile  going round and round in the portal
 circulation.  "In either case, the urinary  apparatus is the prin-
 cipal  channel through which the  biliary  matter  is eliminated,
 the urine becomes tinged  Avith the coloring principle of bile,
 being sometimes of a  yellowish or orange hue, and  sometimes
 of  a  brown color, Avith a considerable sediment;  and the pre-
 sence of the most characteristic constituents of the bile has
 been  determined in the urine.  The same  result presents itself
 Avhen the  biliary duct has been artificially obstructed by liga-
 ture.  Other secretions have been found tinged with the coloring
 matter of  bile:   thus  the  pancreatic  fluid has been  seen of a
 yellow color in jaundice ; and the milk has presented not merely
 the hue, but the  characteristic bitterness of the biliary secretion.
 The cutaneous transpiration is not unfrequently so much im-
 pregnated Avith  biliary matter as to communicate  the tinge to
 the linen covering the skin; and even the  sputa of patients
 affected with bilious  fevers have  been observed to be similarly
 colored, and have been found to  contain  biliary matter.  The
 secretions of serous membranes, also,  have frequently been seen
to present the characteristic hue of bile; and  biliary  matter has
been detected, by analysis,  in the fluid of the pleural and peri-
toneal cavities."  (Carpenter, Art.  Secretion.)  This  quotation
demonstrates the excretion of bile by various organs, when its
escape from the  liver is interfered with.                 •
  In practice, however, Ave do not treat functional disturbances
      6 
82
EXCRETION.
of the liver by acting on  other  emunctories, so much  as  by
measures  which will be  detailed  in  Chapter XVI.  (§§ 165,
160.)
  We are also familiar Avith  disturbances Avrought in the system
by  the excess of a normal  product,  viz., lactic  acid.  It is a
normal recrementitious excretion  in  the gastric juice, and it
normally  exists " in  the parenchymatous juices and especially
in that of muscle."   It is apt to  be  found in excess in those
whose diet is too exclusively farinaceous.  It is formed  in great
excess by the organism in acute rheumatism, or rheumatic fever.
Indeed rheumatic fever has  been induced  by doses of lactic acid
given medicinally.1   In acute rheumatism the skin is bathed in
a sour perspiration, the saliva is usually sour, the intestinal canal
pours out sour and  offensive  feces, and the  urine is acid and
charged with lithates.  As  the patient recovers  the secretions
become normal.  This again shows how under certain  circum-
stances general excretory activity  is induced, Avith the effect of
cleansing  the system from  a normal  product Avhen in excess.
We act upon the excretions  in the  treatment of rheumatism, as
we  shall see when Ave come to take up the question of rheuma-
tism. (Chapter XL)
  §  33. Alteratives.—" There are employed by practitioners  of
medicine,  to affect certain diseases most  intimately connected
with the processes of nutrition, various substances which do not,
at least in the doses commonly employed, produce any very
obvious symptoms.   These drugs may perhaps neither stimulate
nor depress, so far as  can be perceived, any function of the body ;
their action may be silent  and imperceptible,  their mode of
influence  may be unknown, but their therapeutic  effects are
among the most assured of clinical facts. It is to  medicines
of this character that the  name of Alteratives has been applied,
because Avhen administered  they seem simply to alter  morbid
processes." (Wood.)
  Our inability, as yet, to explain the action  of alteratives by
exact physiological experiment, is  the less unfortunate that the
clinical facts so Avell support what empiricism has  taught us.  It
must not for one moment be supposed that all empirical facts
which physiology or  pathology cannot yet explain, are  to  be
See Balthazar Foster's Clinical Lectures. 
EXCRETION.
83
rejected accordingly.  What will become of all Avhich Ave trust
to learn, if we are to cast away e\Terything not  yet illumined?
AVe  should be cutting ourselves off from  some  most valuable
knoAvledge if Ave Avere to abandon the teachings of empiricism.
It is certainly much more satisfactory to be able, by the light of
physiological research, to elucidate what empiricism has demon-
strated to be a fact.  But where this cannot, as yet, be done, Ave
must acknowledge the facts, and in  doing so  perhaps pave the
Avay for forthcoming investigations, Avhich may tend to clear up
our  imperfect  knoAvledge.   " To deny, as  has  been  done, the
existence or value of medicines of this class because we cannot
tell Avhy mercury relieves syphilis, or why iodide of potassium
cures rheumatism, is as  absurd as to deny the existence of the
syphilitic or rheumatic dyscrasia, because Ave do not know their
ultimate nature."  (Wood.)
   Arsenic is a poAverful alterative. AVe have seen before that it
Avas  a stomachic.  The union of these two qualities renders it an
excellent adjuvant to haematics.   As an alterative it is found to
be eliminated by  the  kidneys  chiefly, then by the  intestinal
canal,  by the skin, and even by the saliva and tears.   Thus Ave
see that it is eliminated  by the  principal excretory organs, and
can understand its efficacy in procuring more perfect elimination
of Avaste, and so more perfect nutrition of the body.   The im-
proved elimination leads to a more thoroughly healthy state of
the secretions and excretions.  Consequently we find that arsenic
is used in some countries, especially Styria, to give robust health.
This it does, and endows the arsenic-eater with   ruddy cheeks,
the bloom of health, long Avind, and a good physique generally.
It has been  used  in other countries for its famous alterative
qualities, as a cosmetique, for both human beings  and horses.  It
can be added to haematic and  tonic remedies with advantage.
                 Fowler's Sol. TTL v>
                 Pot. Bicarb, gr. v.
                 Fer. Pot. Tart. gr. v.
                 Inf. Quassia1 Jj. ter in die,

before food is often a capital combination.
   Sometimes it  is  desirable to giA^e arsenic in  an acid solution
with iron, as
            Valangin's Sol. (Liq. Ars. Hyd. Chlor.) TTL iij-
            Tinct. Fer. Perchlor. TH. x. ter in die, 
84                     EXCRETION.

in water, or other vehicle, after food.  This is the best fluid form
of arsenic to be given with haematics, when wishing to build up
the blood and system generally.   Or it may be administered in
the pill given in § 20.  It is often very convenient to use the
terms  "Fowler's solution" and  " Valangin's  solution"  when
nervous patients would be alarmed to see arsenic in their pre-
scription.
   Mercury is a notable alterative.   It is found in all excretions.
It acts upon  the Aoav of  bile, it  is found in the urine, in  the
serum of ulcers, in the saliva, feces, and even in the seminal fluid.
It has a marked action  on the  skin.   Its  value  is generally
recognized, not merely as an antisyphilitic and antipyretic, but
as an  alterative.   AVhen  the  tongue is foul, the skin  dry, the
bowels loaded, and  there is a bitter  taste in the mouth in the
morning, calomel will almost at once make  a difference  in the
effects of purgation.   Purgatives may have been resorted to in
vain, but mercury produces a decided difference.  As an occa-
sional  purgative it is most useful, but its  severe after-effects
 render its  long  continuance undesirable except in syphilitic
 cases.  The  soluble  preparations, as the bichloride  and the
 iodide, are most powerful poisons, and must be given in small
 doses.   Headland has given somewhat  lengthy explanations  of
 the difference betwixt the soluble and the insoluble prepara-
 tions, which  may be profitably perused in his Action  of Reme-
 dies.  He thinks calomel, blue  pill, and others  are  rendered
 soluble—Avithout Avhich  they would be physiologically inert—
 in the gastric juice, or the alkaline chlorides of bile.
   Mercury may be given in powTder, pill, mixture, or by a plas-
 ter.   It can often be combined with iron with advantage, espe-
 cially in the anaemia of syphilis, whether acquired or congenital,
 Avhere it is most useful.   (Chap. XII. § 120.)  It is unnecessary
 to write out any forms for the administration of mercury, every
 one knows them 1   Some special combinations will be given from
 time to time as we proceed.
    Iodine is a powerful  alterative.   It  passes off  chiefly by  the
  kidneys, but is found in  the secretions of all mucous  membranes.
  I have tasted it in the mouth on Avaking after its local  applica-
  tion  to the knees.  R. W. Taylor thinks he has found evidences   t
  of its free escape by the  skin.  As iodide of potassium it is  one
  of our commonest and  most valued  remedies.   Its  absorbent 
EXCRETION.
85
power will  be considered hereafter.  (Chap. XX. § 201.)  Its
alterative action on the different emunctories, and especially in
getting uric acid  out of the system  as Avell as the  poison of
syphilis, renders its use very common.  Ararious combinations
can be made, several of Avhich have been already given.  As a
haematic it  is given Avith iron, in the avell-known syrup of  the
iodide of iron, or Blancard's unchangeable iodide of iron pills.
  The most powerful  alterative  known is  the  combination of
iodine, mercury, and arsenic, called Donovan's solution.   In all
cases where  the excretory organs, at  large, need  acting  upon,
this is a capital agent to employ :—
                    Donovan's Solut. Ttlxx.
                    Inf. Cascarillae §ss. ter in die,
is a  famous alterative,  especially in  tertiary or  congenital
syphilis.  Alteratives are commonly  and advantageously com-
bined Avith  purgatives; and often a liberal dietary becomes
necessary at the same time  that they are continued, especially
if there be much wasting.   Colchicum, sarsaparilla, and guaiac
are vegetable alteratives often used along with iodide of potas-
sium. Guaiac is a better vehicle and adjuvant than sarsaparilla
in most cases, especially in the rheumatic.
   § 34.  In actual practice the well-directed use of alteratives
will often give the most gratifying results.  Indeed  they are a
class of agents too little understood by the merely well-taught
hospital student:  but with Avhich  he will do well to make him-
self more familiar, if he desires  success  in private practice.
Their effect  not being explicable or demonstrable by actual ex-
periment, they are too often neglected, to the  injury both of
medical man and patient.  They were much more used by the
practitioners of the last generation than they are now ;  but Ave
are not quite certain that we are  better practitioners than our
predecessors.  Their neglect is one of the surest pieces of evi-
dence that while our profession  as a  science has distinctly im-
proved, in some  respects it has retrograded as an art.   There
really is no room for  doubt  but that the brief  mercurial course
—not to the extent of salivation, but a feAv grains of Plummer's
pill every night for four or  five nights—so commonly resorted
to  by the practitioners  of  the past, was  often very salutary.
Such means threw into action the  different  emunctories of the 
86
EXCRETION.
body, and so restored the blood to  a normal  condition, or in
homelier phrase "cleansed  the blood."  In the  treatment of
affections of the skin, so notoriously associated Avith imperfect
elimination, or the  formation of crude matters  by imperfect
assimilation, these alteratives  are chiefly  relied upon  for the
cure of many of the  most obstinate of these decidedly intracta-
ble diseases.  Of old it Avas quite common  to fall back  on  a
course of alteratives Avhen any affection was  more than  ordi-
narily rebellious; and now Ave resort to the  same  thing Avhen-
ever there exists a suspicion of syphilis.  But it is somewhat
irrational to assume  that the poison  of syphilis—be it Avhat it
may—i8  the only  one eliminated by agents acting generally
upon the excretory  organs.  There  are  systems,  about  which
experience alone can  give  much information,  Avhere  altera-
tives are distinctly indicated ; people  Avith  muddy complexions,
unctuous skins, a disagreeable odor in the breath, and generally
constipated boAvels.   Such persons are all the better of a course
of alteratives and purgatives, from  time to time, when  out of
sorts.
  It Avas a practice among the practitioners of the past to give a
dose of calomel and James's powder  at bedtime, with a Seidlitz
poAvder in the morning, to patients  Avho presented themselves
Avith severe colds.  Here  the  tongue Avas usually foul and the
skin dry, Avith some  thirst.   After the boAvels  had been freely
opened, acetate of ammonia  with ipecacuan Avine, as diapho-
retics, Avere given for a  day or tAvo.   Excellent  effects  were
thereby  produced, as my experience in  my  father's surgery
taught me.  Nevertheless, Avhen at  last a  graduate, in the ful-
ness of my knowledge, and after a hospital training, I took the
reins of practice, it seemed  quite proper to discard alteratives
as impostors, Avhose  claims  could not be substantiated.  Conse-
quently,  and logically, they were put aside.  But, as time  went
on, one case after another turned up  Avhere the administration
of the poAvder and purgative  produced better  results than the
diaphoretic treatment, without such preliminary preparation ;
until, at last,  a silent recantation Avas brought about, and the
powder and Seidlitz  resumed their place as of yore—after  their
temporary seclusion.
  All this may seem to some readers as simple twaddle; that
the results Avere coincidences ; and that the patients Avould have 
EXCRETION.
87
 done just as well without the alterative.  Of course there exists
 the  right of  private judgment  in  matters therapeutic, as in
 matters theological; and such persons have a right to their own
 opinion.  I thought at one  time as they may think now; but
 at present my opinions have changed, Avithout making me a
 worse practitioner,  I  trust;  and the right and skilful  use of
 alteratives is, to my mind, one of the best evidences of an ob-
 servent experience and of thoughtful practice.
   No  doubt habits of  cleanliness, better  ventilated bedrooms,
 more  regulation of the boAvels, and a systematic attention to
 the  general health, have altered matters much ; and that the
 appeal to the general excretory organs, once so necessary, is not
 now so strictly indicated among  the more affluent classes; but
 among the  humbler classes the  old  plan of commencing treat-
 ment is a sound one.
   So, too, in convalescence, the occasional use of alteratives is
 proper and beneficial.  It often happens that a steadily progress-
 ing  recovery  is suddenly clouded by a state of feverishness, a
 foul tongue, loss of appetite, and general malaise.   Under these
 circumstances it is  a good plan to give some Pil. Cal. et Colo-
 cynth  Co. at bedtime and some citrate of magnesia in the morn-
 ing ; or to give a few grains of calomel Avith jalap or scammony
 in the morning, if the patient be seen in the forenoon.  A gentle
 action on the boAvels generally restores the condition to Avhat is
 to be desired.  But  it must not thence be  conjectured that it is
 the  mere purgative action which is the whole  matter; like
 results Avill not happen if the mercurial be omitted.
  The alterative action of arsenic is well illustrated  in the ex-
 cellent effects  produced by its combination Avith iron.  In many
 cases of impaired health, where the hair has lost  its gloss, the
 skin is dry and harsh, the tongue always furred, and the assimi-
 latiAre  process is imperfect, a course  of arsenic and iron restores
 the lost  lustre to the hair, the skin recovers its pliability and
 softness, the tongue cleans, digestion and assimilation progress,
 the system gathers Aveight, and the person possesses once more
the characteristics of health.  In cases where  there has  been
mischief in  the  lung, as for instance Avhere an  acute attack of
pneumonia has degenerated into  tubercle,  or incipient tubercu-
losis exists,  then  the combination of arsenic with  iron, and a 
88
EXCRETION.
liberal dietary, seems specially valuable, and gives most  grati-
fying results.1
  The combination of iodine  with iron, as in  the syrup, has
been found most useful in the treatment of the  strumous, and
especially strumous  children.  Whether it  is  in  the  convales-
cence after some exanthem, or in imperfect  groAvth Avith  defec-
tive assimilation, the union of iodine with the chalybeate  is
usually adopted as a matter of course—as a consequence of expe-
rience merely, Avithout any investigation into the rationale of the
matter.  In fact, it is done as a  matter of habit, as a  conse-
quence of Avhat has been observed  and silently registered—the
outcome, indeed, of  experience.
  Neither  is it difficult, after the  physiological introduction to
this chapter, to comprehend  why a generally  improved  excre-
tion should exercise such a beneficial action upon assimilation.
AVaste must be removed ere new material can be deposited in a
tissue ; and waste products must be efficiently eliminated, if the
assimilative processes are to be carried on with normal efficiency.
This truth has found an expression in the Avonclerful growth of
a system of treatment now becoming fashionable and common.
It is only about a century since Vincent Priessnitz, a peasant in
Austrian Silesia, evolved the idea of modern  hydropathy.  In
spite of obvious folly in  some of  its practices, in spite  of the
neglect and disdain of the profession, in the face of the fact that
it has not  yet succeeded  in attracting the best men into its
ranks, that it is indeed tabooed by most orthodox  members of
the profession; hydropathy is  establishing itself and making
good its claims, not only  to  our  attention, but  to  our respect.
In  the treatment indeed of the ailments of mature life, especially
 of  the man who has kept  himself  up to his work by large sup-
plies of rich food and a liberal amount of alcohol, and in whom
 the system is saturated with the products of Avaste, this plan of
 liberal draughts of water is  excellent. The waste products of
 the body are soluble, if but sparingly soluble in water; and the
bathing of the tissues with water, and the washing out of  the
 system,  are applications of sound  physiology, even if  arrived at
by an uncultured empiricism.  By this means, by the powerful
alterative  action of Avater in unstinted quantities, the  aim of
1 It is of service even in spreading caseous pneumonia. 
EXCRETION.                      89
purifying the organism, by exciting its  different  emunctories
into high functional activity, is achieved.  To this is conjoined
an almost total abstinence  from alcohol—the beverage is water.
The food is simple, and not specially inviting, there is nothing
in it to tempt too free indulgence;  there is a total absence of
the entrees and various Avines that have led to repletion, as the
consequence of pleasant viands rather than of systemic Avants.
There is good food for the needs of the organism ;  there is plenty
of fresh air, with its Avaste-removing oxygen ;  many hours every
day out of doors in bracing air ; and finally, there are early hours
to bed, and an early hour to rise in the morning.  In fact there
are aggregated all the conditions under Avhich a jaded and over-
taxed system  may recover itself; where it may get thoroughly
rid of its Avaste, and inaugurate  a course  of healthy tissue-
formation: a process of which  it stands much in need.   Indeed
in  hydropathy Ave  see empirically achieved Avhat a scientific
physiology would ere long have indicated as the logical  and
rational plan of treatment  of numerous affections of mature and
adA'anced life, Avhich take  their origin in the  imperfect elimina-
tion of Avaste ; either the products of tissue change, of histolysis,
or the results of protein compounds imperfectly assimilated or
furnished to the system in excess of its needs.
   We are rapidly coming round to a point when the importance
of  proper, sufficient, and  healthy excretion, in the maintenance
of  health and the treatment  of disease, can be established by
scientific evidence, as well  as by the accumulated but undigested
facts of simple empiricism.  As a logical sequence, then, altera-
tives are again  being included in  our  armamentarium with
benefit to our patients. 
CHAPTER  IV.
                   BODY-HEAT AND FEVER.

  § 35. AVhether under the burning sun of  the Sahara, or on
an iceberg  in Davis's Straits, the  body temperature of  man is
practically the same.  There may be sometimes a slight differ-
ence, but it is only to be measured by tenths of a degree Fahren-
heit, or little more.   To a certain extent this result is  due to
clothes; and without  warm clothing, by Avhich the body heat
may be conserved, man could not maintain a temperature com-
patible with life in the  Arctic  regions.  But admitting that
clothes are  an  indispensable auxiliary in  cold  climates, this
body heat is maintained in the one case, and regulated in the
other, by most important processes going on within the organism.
  All our heat is the result of combustion,  of oxidation of the
material  consumed as food.   At one time it  was  thought this
combustion Avas  carried on in the lungs solely—that they Avere
the furnaces of the body.   We now know that oxidation goes on
in all the minute capillaries of  the body.  But the combustion
is much  more active  in some parts than in others.  The  chief
combustion goes on in the muscles.  The actual combustion is
said to consist chiefly of the oxidation of  lactic acid in union
with soda.   The hydro-carbons are stored up, for the time being,
in the liver as glycogen, Avhich, Avhen liberated, becomes sugar,
and is then  split up  into  lactic acid and as such is oxidized.
The muscles have each a little store of glycogen, but the great
storehouse is the liver.  The more permanent storage is in the
form  of  fat; and on  these stores of  fuel the body lives when
deprived of food. As  the reserves of glycogen become exhausted
the fat is utilized to sustain the body  temperature.  This tem-
perature is almost entirely maintained by the union of oxygen
with the carbon and hydrogen of  our food.  To a small extent
nitrogenized matters are oxidizable, and so furnish a small quota
of heat.  A certain combustion goes on in the viscera, and the
venous blood of the  kidneys and liver is  warmer than the 
BODY-HEAT AND  FEVER.               91
arterial  blood supplied to these  organs.   The  blood of the
inferior  vena cava is  Avarmer than that of the superior vena
cava, and even than arterial blood itself.  A greater amount of
heat is produced during the  action of muscles than when the
same muscles are inactive.  It makes a decided difference, Iioav-
ever, Avhether the muscular action is doing so much Avork, or
whether it is not so employed, as  to the amount  of heat  pro-
duced.   In  tetanus  very high temperatures are  reached.  In
ordinary muscular action a certain amount of what would other-
Avise be heat goes to produce  mechanical results; and there are
good grounds for holding "that the products of muscular con-
traction—i.e.,the heat and the mechanical results—are conjointly
the expression or equivalent of the chemical action which  goes
on in the muscle."  (Wunderlich.) Heat is also  furnished by
mental exertion ; this  is more marked in tropical climates thau
in cold  ones.  Very active mental exertion produces a rise of
temperature of from one-half to a degree Fahrenheit.  A large
supply of good food  also occasions a temporary rise of tempera-
ture, probably from  the increased heat  produced by the active
changes  of digestion and assimilation.
   On the other  hand,  heat is lost chiefly by the skin;  and to a
less  extent  by  the  respiratory tract.   The blood circulating
through  the skin is cooled  by heat-loss, by the radiation aAvay
of the heat in the surrounding cooler air.  The larger the amount
of blood circulating through  the  cutaneous vessels the greater
the heat-loss. Consequently, in cold weather, the skin is  cold
and  marbly; it is  also Avhite and anremic.  The  vessels are
contracted, and  the  heat-loss reduced to a minimum.   On the
contrary, when there is an excessive heat-production, the vessels
of the skin  dilate;  the skin  is high-colored and glowing;  it
is in  a highly vascular condition.  We have seen  that a free
blood supply leads to functional activity, and, if the heat  pro-
duction be maintained, Ave get the sudoriparous glands throAvn
into action, and perspiration ensues.  The consequence is  that
the cooling  effects of evaporation are called into play,  and still
further heat-loss is occasioned.1  By such means  the tempera-
ture is kept at or near the norm.  In tetanus, and  in rheumatic

  1 The evaporation of water produces much coolness, from the amount of heat
rendered latent, as water assumes a gaseous form. 
oo
BODY-HEAT AND  FEVER.
fever, there is free perspiration often found along Avith very high
temperatures; but all that this proves is that  the evaporation
and  heat-loss are unequal to neutralizing the  excessive heat-
production.   (The body-temperature often rises after death, and
continues high for some hours.  This is due to the fact that the
heat-production is no longer met by heat-loss,  by radiation of
heat away by  a blood-current through the skin.)   The play
backAvards and forwards betAvixt the production of heat and its
loss is not only very interesting, but is of the highest practical
importance.
  Rosenthal has divided the body into an internal, or heat-pro-
ducing area, and an external, or heat-losing area, with a mixed,
or intermediate plane betwixt them.   In the internal area heat
is being produced by combustion ; in the outer area  it is being
lost, or got rid of.  Now it is obvious that a great effect must
be produced  by the  amount  of blood circulating in  these two
opposite areas.   If the vessels of the skin  be contracted by the
action of  external cold, then the amount of blood circulating in
the  cutaneous vessels will be small, and the heat-loss will also
be small.  Further, if  there be  but little blood  circulating
through the outer area, there must  be more circulating in the
internal, or heat-producing area, and consequently greater heat-
production.  The combined  effect of this is increased heat-pro-
duction and diminished  heat-loss in cold  climates;  and so the
body preserves its normal temperature in the coldest regions—
aided, as we  have before said, by the action of clothes.
  In hot  countries this  process is reversed.  There is, in a sur-
rounding medium of high temperature, a fulness or dilatation
of the vessels of the skin.  By this means the heat-loss is brought
to a maximum, and heat production to a minimum.  The lesser
the amount of blood in the internal, or heat-producing area, the
less  heat is evolved.   Consequently, there is a lessened heat-pro-
duction, and  very  little oxidation  or wasting.  Under these
circumstances life can be maintained on a  very small amount of
food, as evidenced by the long fast of the crew of the Arracan
in the  Indian Ocean, from which  all  recovered.1  In  a  cold
climate they would have been burnt out in  a very few days.
In the high temperature  by Avhich they Avere surrounded, their

  1 Fifteen days of short commons, and then seventeen of  almost absolute fast. 
BODY-HEAT AND  FEVER.
93
reserve  stores of fuel were scarcely draAvn upon  to  maintain
their body heat, and so remained aATailable for mechanical results.
In order to be Avell  and healthy in tropical regions but a small
quantity of food is  absolutely necessary.   That people should
not lose their gustatory tastes in hot climates, and, as a conse-
quence,  eat a great deal more rich food than is either  necessary
or good for them, does not bear on  the  real question.  The ill-
health Avhich follows systematic over-indulgence, sufficiently
proves the desirability of maintaining a strict moderation in the
matter of diet.  It is unnecessary and undesirable  to furnish to
the system  in excess the material for combustion.   Where there
is such  indulgence there follow  discharges of Avaste fuel from
the liver, and the cooling effects  of  purgation.
   § 36.  For the maintenance of health it  is necessary that the
temperature  of  the body  be near  the  normal.  According to
Wunderlich  the mean  normal temperature is 98.6° Fahr. (37°
centigrade), and the  range of normal temperature in the axilla
is from 97.25° Fahr. (36.25°  centigrade) to 99.5° Fahr. (37.50°
centigrade).  There is a constant oscillation, back  and forAvard,
betwixt the two antagonistic areas of Rosenthal—keeping the
heat-production and loss  in  equilibrium.  Speculations  have
been  indulged in  as to whether or not there is a " heat-centre"
Avhich regulates the heat supply, like the governing balls of an
engine; or the steersman of a craft, Avho by gentle movements
of the wheel keeps the vessel's head steady.  Its existence can-
not yet be  regarded as proven.  Certainly there are good reasons
for holding that there are two sets of nerve fibrils running along
the Avails of the bloodvessels—at least of the arteries—by which
their calibre is maintained.  The one, the vaso-motor  nerves of
the sympathetic, tend to contract the calibre of the vessels; the
other, the vaso-inhibitory  nerves,  derived from  the cerebro-
spinal  system, are antagonistic  to the vaso-motor nerves, and
produce dilatation.
   Betwixt  these tAvo  sets of nerve  fibrils the calibre of  the
vessels  is  maintained in constant equilibrium,  by  perpetual
oscillations,  however;  and similarly the body-heat is kept at a
norm by constant back and  forward play betAvixt the antago-
nistic heat-producing and heat-losing areas ; but here also there
is probably some oscillation on each side of the straight line.
   By the resort to clothes man voluntarily aids in the mainte- 
94
BODY-HEAT AND  FEVER.
nance of the line of normal temperature.   At night, when the
surrounding temperature is cooler, he covers himself freely with
non-conducting materials, and so retains his heat.   This is the
more necessary in that the cutaneous vessels are dilated in sleep
—to permit of the requisite cerebral anaemia—and so there would
be greater heat-loss if not so restrained.1   In warmer climes the
clothes are lighter, and of less perfect non-conducting materials,
so as to interfere but little with  the  dispersion of heat.   If man
is careless about protecting himself warily in the daily changes
of temperature, where there are burning noons and chilly nights,
disease, the result of  temperature-disturbance,  will  certainly
result.
  In addition to his clothes man has the aid derived from fire,
and the protection from external influences furnished by build-
ings.  Further, he can, when exposed  to cold, derive much aid
from fluids artificially heated.   He draws from the fire, by the
heated drink,  so much Avarmth,  and  so saves his  OAvn consump-
tion in heat-production.  When  too  much hot drink is indulged
in perspiration follows.  By reversing this process, and by the
inhibition of cold  fluids in warm climates, or Avhen surrounded
by a heated  atmosphere, man cools himself down, or neutralizes
the effects of heat accumulated from insufficient heat-loss.  The
use of iced fluids is greatly on the increase, and the terrors of
a chilled draught, when heated, are  being dissipated.  By such
various means, and especially by skilful  combination of them,
man aids his heat-regulating processes to  maintain his tempera-
ture at or about the norm.
  § 37.  The variations from  the normal temperature are of the
greatest moment to us.   High temperatures, Avith Avhich Ave all
are so familiar, Avill engage our attention at considerable length,
but, before entering upon that side of the question, we will first
examine the subject of low,  abnormally low, temperatures.  A
lowering of temperature may be  variously induced: in  lesser
degrees it is the consequence of  exposure, especially  without
effort (heat-production), or of hemorrhages, or of free discharges.
AVhen more pronounced the fall  is called collapse.  Slight lower-
ings of temperature, down to 96° or 95° Fahr., are not in them-

  1 When exposed, unprepared, to  severe cold, it is well known that the man
that sleeps—dies.  Wakefulness alone can preserve life. 
BODY-HEAT AND  FEVER.
95
selves dangerous  to life.  Further  lowering, from 95° to 93.5°
Fahr., indicates danger, and needs active measures.  The loAver
the temperature the more active the measures required to main-
tain life.  If the limit 93.5° is reached the danger is great; and
if the temperature falls below 92° there is deep algide collapse,
from Avhich the patient rarely, if ever, recovers—except in cases
of acute alcohol  poisoning, where a temperature of  90°  is not
incompatible with recovery (Bathurst AVoodman).   Below 92°
survival for a brief period is possible, but recovery can scarcely
be looked for.  Too low a temperature is as incompatible with
the  continuation of  existence as is too high  a temperature.
States of collapse are  more readily  induced  in children than  in
adults; in Avomen than in men;  in the sick than in the healthy.
  The measures to  be pursued or adopted for the treatment  of
Ioav  temperatures are various.   The first thing to be done is  to
conserve the body-heat to the  utmost, and  to economize it by
the  use of  non-conducting materials.  In addition to this, ex-
ternal  heat can be utilized to  lessen the heat-loss, and even  to
give heat to the body.  Consequently it is desirable  to see that
the patient is surrounded by blankets, or other woollen material;
to have bottles of hot Avater placed  around him, taking care not
to burn the skin; and further, to furnish to the  organism heat
artificially, by  the administration of hot fluids.  These fluids
may contain alcohol Avith advantage;  its presence makes them
more palatable, Avhile it acts upon the heart, increasing its con-
tractions in frequency and  in  poAver (Binz).   The heat-loss,
however, must be obviated, else the alcohol will act mischiev-
ously.   AVe shall shortly see that alcohol is  a potent means  of
loAvering temperature.  As  to any  medicinal means of increas-
ing  heat-production, it is very questionable  Avhether we possess
them in any practically useful form ; and it is more questionable
whether Ave can avail ourselves  of  them in  practice.  Such an
agent is belladonna, in moderate doses, which notably raises the
temperature.
  Very frequently there occur  sudden, passing loAverings of tem-
perature known as "catching cold."   The essential starting-point
here is the quick  abstraction of  heat in  excess of heat-produc-
tion.  Thus colds are commonly caught by the sudden removal
of the body from a  persisting high temperature into a cold sur-
rounding medium.    The vessels of the skin are dilated and 
96
BODY-HEAT AND  FEVER.
partiallv paralyzed by the warm surroundings, and Avhen sud-
denlv exposed  to  the cold environment they, instead of con-
tracting, become still further paralyzed by the cold; and then an
immense current of Avarm blood is brought into contact Avith the
cool air.   Great heat-loss follows : but there is not a correspond-
ing sensation  of cold, because the current  of warm  arterial
blood prevents the cutaneous nerves from feeling cold, as is illus-
trated by the hands of the snow-baller, which  glow in spite of
the contact of the frozen mass.  There is, however, much greater
heat-loss with these dilated cutaneous vessels  than when  the
vessels are contracted; when the cutaneous nerves are not bathed
in a Avarm current of blood, and so register the sensation of cold.
The feeling of cold and  the amount of  heat-loss  are, conse-
quently, often in  inverse   proportion  to each  other.    Habit
endows  the system with a  certain power of regulating the heat-
balance, and  of giving off heat  Avhen  required to meet  great
heat-loss. This  is well illustrated in  the case of those  much
exposed to great variations of temperature ; they become inured
to such  changes—we say.   The system  is educated to look after
itself, and by habit the vessels of the skin are taught to contract
on contact with  cold, and so to  lessen  the amount of blood in
the cooling area and to increase the bulk in the internal or heat-
producing area.  This is  the  effect of the constant use of the
cold bath ; viz., to educate the system to develop its heat-regu-
lating actions.  AVhen the  cutaneous vessels are paralyzed  a
large mass of blood is in  the cooling area, and the heat-loss is
great.   Further, too, there is a correspondingly small amount of
blood in the internal heat-producing area; and the evolution of
heat is  proportionately small.   Consequently, in the combina-
tion of  the  two we find  that loss of  temperature known as
"catching cold."   The secondary fever, often amounting to no
more than feverishness, is the consequence of delay in the heat-
regulating processes, and  an  excessive  heat-production comes
on when too late—too  long deferred  to be useful.  It forms,
hoAvever, a pyrexia, often calling for  our aid  to dissipate, or
rather to aid in dissipating the excessive heat.  The pathology
of taking cold is at once  simple and highly interesting, Avhile
it clearly points out two  things.   Firstly, how to  so conduct
matters as to  lessen the primitive depression of the body-tem-
perature; for  usually the  secondary reaction  is in  direct  pro- 
BODY-HEAT AND  FEVER.
97
 portion to this  original depression.  To avoid  cold, then, it is
 necessary to keep the skin in good tonic action ; then it must
 be borne in mind  that if the exposure to cold after being lono-
 at a high temperature, as at a ball, for instance, be but brief, the
 excessive heat merely may be got rid  of; but if the  exposure
 be prolonged, then great heat-loss  is  experienced.   The less,
 too, the system is inured  the greater the  risk.  The second
 indication furnished is—to get rid  of the  superfluous heat,
 occasioned  by  the  delayed heat-production, the pyrexia, or
 secondary reaction, by measures to be described a little further
 on, § 41-44.
   § 38. An increase in the body-heat forms the condition knoAvn
 as fever.  A pyretic condition may extend from a mere  condition
 of feverishness, Avith a temperature of from 99°.5 Fahr.  to 101°.5,
 states often found  in children Avithout any sinister meaning
 Avhatever; up to  a high febrile state  of from  107°  to 108.5°
 Fahr., beyond which existence is possible for only a brief period
 and recovery impossible  ; though there are some isolated cases to
 the contrary, this statement of Wunderlich is almost universally
 true.   A  temperature of 113°  Fahr. has been found ere actual
 death ; while a sharp rise of temperature is a common  precursor
 of death in  febrile states.  In the notorious Scarborough high-
 temperature case, Avherethe thermometer rose to 122° Fahr., the
 explanation noAv largely accepted is,  that the thermometer was
 twirled in a portion of the night-dress ; and the friction so pro-
 duced caused the very high reading.
   The different  conditions under Avhich pyretic states  are found
 are so numerous, and these pyretic states are so common, that
 fever, in some form, is one of the most  familiar morbid conditions
 Ave are called upon to treat.  Not only in the ravages of fever
 known as epidemics, or  in its local  persistence  as an endemic
 affection, as on the Gold Coast; but in isolated cases, specific
 fever has for us,  as practitioners, a deep interest and a poAverful
 attraction.  As typhus it follows overcroAvding ; as typhoid, or
 enteric fever, it forms the  nemesis of  sanitary  negligence; as
 relapsing fever it hangs around periods of famine ; while in the
 form of the exanthemata it is the plague of our youth  ; as ague
 it  is the scourge of undrained  marshes; while  as malarial or
climatic fever it  streAvs the shores of the Gold Coast, of Guiana,
and of the Mexican Gulf with the  remains of the natives  as 
98
BODY-HE AT AND  FEVER.
Avell as of the Avhite man.  It is commonly found  in the form of
Avell-marked specific  disease; but  it  is  not essential  that  it
should be connected with anything specific.  A prolonged high
temperature—no matter how produced—will occasion that state
knoAvn as "the typhoid condition."  AVe see it produced by
hectic  in the  consumptive ; by surgical fever and pyaemia  in
other cases.    AYherever met, it  forms a characteristic and a
terrible condition ;  and this consequence of a persistent high
temperature is the chief danger of all fevers.
  The  typhoid  condition is thus  graphically  described  by
Tweedie, Avhose experience  of fever  enabled him to picture it
well:—"It is  announced  by the  decline of the previous more
acute symptoms; by the pulse becoming  more rapid and soft;
the tongue dry and broAvn, tremulous, and protruded Avith diffi-
culty ; by the incrustation  of the teeth  Avith sordes; by the
increasing intellectual disorder, indicated by the constant Ioav
muttering delirium, and the greater insensibility and deafness;
and by the condition  of the muscular  system, evinced by mus-
cular tremor  and  subsultus  tendinum, and  in some cases by
irregularity or intermission of the  pulse; by the patient lying
sunk on his back, or sliding to the foot of the bed, the  muscles
being  unable  to support the body even in the  horizontal pos-
ture."   AVith  this condition all medical men of any experience
are unfortunately but too familiar.   It is  a condition which, to
a greater or less extent, obtains in every Avell-marked attack of
typhus, and is common in severe cases of enteric fever.  From
its  frequent occurrence in specific  fever it has acquired the name
of  the typhoid condition, and was once supposed to be found
solely  in specific  fever.  Consequently,  when  this condition
shoAved itself in the course of any other affection, the practi-
tioners of old said, " The disease has turned to typhus ;"  because
they rocognized a condition, as they thought, pathognomonic of
typhus fever.  In this th?y were distinctly mistaken. It is true
that such a state is associated with a sustained  high tempera-
ture—a condition  most commonly supplied by specific fever—
but it  is not causally associated Avith  the specific fever per se,
but Avith the sustained high temperature.  They were,  then, in
error in supposing that the ailment had turned to typhus Avhen
they observed a typhoid condition coming on ;  but, ere the day
of  the clinical thermometer, the  recognition of the association 
BODY-HEAT AND  FEVER.
99
of this state Avith a persistent high temperature was simply im-
possible.   Even yet the Avell-worn formula, that such a person's
disease turned to typhus, Avhich killed him, is heard from time
to time.   Still are patients suffering under different maladies
sent into fever hospitals because they have passed into a typhoid
condition.   In  his very able  Avork  on medical diagnosis, the
Avell-known physician, Da Costa, Avrites, " No  blunder is  more
common  than to misconstrue into typhoid fever a typhoid con-
dition of the system."
  § 39. The  pathology of the typhoid  condition is a matter so
important that a section may well be devoted to its special con-
sideration.  Such examination of its pathology Avill both clear
up its origin, and point the direction of the  therapeutic agents
to be employed.   To commence Avith, it is necessary to point out
this fact, viz., that at the ordinary temperature of the body the
nitrogenized tissues Avear aAvay but  sloAvly, and their oxidation
is a trivial affair.  But as soon as the body-temperature rises the
nitrogenized tissues begin to melt doAvn by oxidation ; and there
is found a corresponding excess of histolytic products in the
blood.  The higher the temperature  the greater the Avaste of the
nitrogenized tissues, especially the  muscles.   After a fever, the
fat of the body is left comparatively untouched, but the muscles
are shrunken and Avasted.  A microscopic examination of the
muscles after death from  fever demonstrates  that  they are the
subjects  of extensive structural changes.  Zenker  has pointed
out these changes, and his observations haATe been  corroborated
by others.  The  changes are  not so marked where death has
taken place in the earlier  stages of the pyrexia, but if  it has
been delayed till the later period, they are very distinct.  " There
are two forms of degeneration, the granular and the Avaxy.  The
granular form consists in the  desposition of minute, highly-
refracting granules in the contractile tissue, giving to the fibres
a dark appearance by transmitted light, and obscuring the striae.
This  muscular  deposit  is not  wholly composed  of fat.   The
degenerated fibres are  very friable.   The Avaxy form consists in
the transformation  of the sarcous  tissue into a homogeneous,
colorless mass, glittering  like  Avax, and causing a complete
obliteration of the striae and nuclei of the fibres, the sarcolemma
remaining intact.  The  waxy cylinders thus formed crack up
into  numerous  fragments Avhich crumble doAvn  into  a finely 
100
BODY-HEAT AND  FEVER.
granular detritus, and this is gradually absorbed."  (J. Harley.)
Rindfleisch  gives  a  plate of  these  changes in the  muscular
structure of the heart after relapsing fever.  Such changes are
not only found in the dead, but, by a process known as " har-
pooning  the muscles," identical changes have been  found in
fever patients, alive, and Avho have  ultimately recovered.  They
are not, then, post-mortem changes; they are the changes Avrought
in the  muscle  by a sustained high temperature.  They  are not
confined to febrile conditions of  a specific nature;  they are
found also in the hearts of women who have died from  puerperal
septicaemia.
  Such being the actual condition of the muscular structures of
the body, Ave  can  feel no surprise at  the sense of prostration
which  is so marked in the typhoid condition.  Muscular weari-
ness is  an initial symptom of fever ; muscular prostration marks
its height.   "If you  could  place your fever-patient  at the
bottom of a mine twice the  depth  of the deepest mine in Corn-
wall, and compel the wretched sufferer to climb its ladders into
open day, you would subject him to less torture from muscular
exertion than that Avhich he undergoes at the hand of nature as
he lies before you, helpless, tossing, and delirious, on  his  fever
couch." (Haughton.)  Murchison says, "There is found too, on
the whole, a direct relation  between the temperature and the
amount of  urea.....According to  Brattler,  there is a
close correspondence between the amount of urea and the tem-
perature: the greater the amount of urea, the greater the tem-
perature."   The normal excretion of urea per diem is  about 400
grains, but as far as 1065, and even 1235 grains have been ex-
creted  in one day in pyrexia.  Some of this might  be due to
the albuminoid matters given to the patient as  food, or  there
may have been imperfect action of the kidneys for  some time
before; still, admitting all this, there is a large quantity of urea
remaining, which is, in all probability, the result of tissue-Avaste.
In cases of pre-existing kidney disease, the  elimination of urea
in fever is  impeded, and consequently the waste products of
histolysis accumulate, so that  Murchison  says:  "The gouty
diathesis, from its being so often associated with disease of the
kidneys, is a very  serious complication.  I have never known  a
gouty  person  attacked with typhus recover."  Urea not  being
found  in excess in the urine  may, then, point to a  still more 
BODY-HEAT AND  FEVER.
101
perilous  condition than its presence  in  excess would  indicate.
These  are important  points to be considered; not only in  the
estimation of the patient's danger in  a typhoid  state, but they
also bear directly on the remedial measures to be employed.
   A still  more important  matter  to  recognize is this:  The ex-
cessive waste of the nitrogenized  tissues in  febrile states, pro-
portioned, Ave have been told, to the rise of temperature, is  not
solely  connected with specific fever.   Thus Unruh found an ex-
cess of nitrogen in the urine in twenty-eight  cases of febrile
temperatures, of Avhich sixteen only were specific fevers.  In
all of them,  however, the amount of nitrogen  was high, amount-
ing to  half as much again as the average in health; while in
some cases it was tAvice as much. Naunyn found, by experiment,
that an increased body-temperature Avas produced by the simplest
of all  methods of raising  it, viz., by confinement  in  a heated
atmosphere  saturated Avith moisture; and along Avith  this rise
there was found an  increase in the amount of urea.  These
experiments corroborate the views of  Trail be, Vogel, and others,
that the excess of  urea is the measure of high temperature, pur
et simple, without relation  to  its cause.  The association of  the
excess  of waste products with the typhoid condition, Avhere, we
have seen, the  muscles undergo degeneration in life, and their
production,  in undue quantities, in the  simplest forms of high
temperature, close the circuit in this direction ;  and point to  the
conclusion that these  changes in the muscular structures, accom-
panied by the formation of urea in excess, are the consequences
of a sustained high temperature, without reference to its causa-
tion.
  It is a  matter, then, of the greatest practical importance that
we should clearly recognize these facts, as to the manner of  the
production of the  typhoid condition—Avhich  is  essentially  the
same  in  specific and non-specific pyrexia.   Its  treatment—
speaking broadly—is the same, whatever the form of disease
with Avhich  it is casually associated, or coexistent.  Its oncome
is of deep import, and indicates a condition of peril whenever
and wherever met.  Everywhere and ever, a  typhoid condition
is a condition of grave seriousness.
  § 40. We  have seen that the typhoid condition is associated
with a high temperature, no  matter  how produced.   We will
now see how far this  pathological  revieAV will  explain the con- 
102
BODY-HEAT AND  FEVER.
dition of the patient, and the peculiar symptoms of this state.
It is probable that the temperature  of  the blood going to the
brain has something to do Avith the production of that abnormal
condition—the  delirium.  There is  much  evidence tending to
sIioav this: viz., its association with  high temperatures, and its
removal by lowering the temperature by means of the application
of cold.  AVith the fall in the temperature the reason returns
and resumes it wonted sway.  This,  too, is quite irrespective of
ultimate recovery or death.   Delirium is extremely common in
children during febrile attacks, and sharp high temperatures are
common also: the tAvo commonly go together.  Of course, too,
an excitable brain is much more easily thrown off its equilibrium
than is a less mobile one.  The  functional disturbances of  the
nervous system are—nevertheless and admitting all this—in the
typhoid condition, chiefly produced by  the waste products in
excess in the blood.  Murchison says: " The observations which
have been made in relapsing and pythogenic fevers also support
the opinion that the head symptoms of  typhus are due, not to
inflammation, as wTas once believed, nor to the presence of the
original fever-poison in the blood, but to the circulation through
the  brain of urea, carbonate of ammonia, or  other products of
disintegrated tissue.  . . . As in other febrile conditions, the in-
creased formation of urea, notwithstanding the diminished supply
of food, is evidently the result of an exaggerated disintegration
of the  muscular and  other nitrogenized  tissues.  As long as the
urea continues  to be eliminated by the kidneys its effects are
comparatively  trifling; but if the quantity be excessive, and,
still more, if from any morbid condition of the kidneys, either
antecedent to or resulting from the febrile attack, its elimination
be interfered with, it accumulates in the  blood and gives  rise
to  uraemic  (typhoid) symptoms.   If the  urine  be completely
suppressed, as sometimes happens, death speedily ensues, under
symptoms of coma, and sometimes with  uraemic  convulsions;
but if the suppression be less complete, it may still give rise to
delirium, stupor, and coma."  In fact the brain is poisoned by
the  Avaste products  in excess in the blood, there  being direct
evidence to show that the blood does contain urea, etc., in this
condition; and the  congeries of symptoms, so produced, is per-
fectly  characteristic, especially  Avhen read in connection with
the peculiar muscular symptoms.  The oncome of the symptoms 
BODY-HEAT AND  FEVER.
103
of the typhoid condition ever indicates the presence of the pro-
ducts of histolysis  in  the  blood in  excess ; the  lighting up of
the intelligence  marks the cleansing  of the  blood, and an im-
provement in the condition of the patient generally.   Under
certain circumstances this  grave typhoid condition is compara-
tively free from  danger, as  in the course of specific fevers in the
young; but  Avhen  found  in  the elderly, and associated Avith
chronic renal disease, it is ever fraught Avith peril, and  is com-
monly fatal.
  As the  direct consequence of a sustained  high temperature,
the typhoid  condition indicates what measures should be em-
ployed for the arrest of its oncome, viz., means  calculated to keep
doAvn the temperature; it show's the dangers which accompany
a sustained  high temperature, and the importance of apyretic
measures.  At the  same time its OAvn production, or genesis, is
very instructive in  pointing out to us  Avhat measures Ave should
adopt in the  treatment of the condition itself.
  By careful and repeated  examination of the urine, along Avith
similar temperature observations, and  a general summing up of
the various symptoms, it is possible to  calculate fairly well Avhat
the exact position of the patient is ; and whether  the kidneys
are equal  to their Avork or not.   As the condition progresses—as
if unrelieved it certainly Avill—the general indications sIioav that
the system is becoming more and more poisoned by the products
of histolysis. There is  the persistence of the posture in bed,
viz., on the back, Avith the tendency to  slip to the foot of the bed,
indicating the muscular  prostration ; there is the starting of the
tendons, due to the clonic  spasms of the  muscles in connection
with them, which differ but in degree from general convulsions;
there is inertness of the  sphincters;  there are also  disturbances
of vision, indicated by the picking  of the bedclothes, and the
graver indications, disturbances of hearing, as imaginary ringing
of bells, etc.,showTing how deeply the nervous system is affected;
there is also a brown, chapped tongue,  Avell retracted, the brown
fur  consisting of an accumulation of dead epithelial scales—
significant of the condition of the Avhole intestinal canal; with
brown sordes on the teeth of similar origin, accompanied by the
formation of crusts upon the lips ; there is the hissing respiration,
so characteristic of this condition, and  contrasting with the
stertorous breathing  of  apoplexy ; and very often an urinous 
104
BODY-HEAT AND  FEVER.
odor of the breath  due to ammoniacal matters, which form
crystals of muriate of ammonia when a glass slide moistened
with hydrochloric acid is held under the nostrils.  Everything
goes to shoAV how deeply the system  is under the influence of
products formed from disintegrating tissue, by the effect of a
sustained high temperature.  There is much to demonstrate the
importance of preventing a high temperature being reached; or
if that be impossible, or we do not see the  case till a high  tem-
perature is already inaugurated, of lowering  it as speedily and
effectually as may be.
  § 41.  Antipyretics.—For the purpose of  lowering the body-
temperature various  means have been resorted to from  time to
time, according to the state of our knowledge, the fashion of the
day, and the progress of physiology ; consequently Ave have had
bleeding, diaphoretics, depressants, various applications of cold,
and a strictly scientific use of agents acting  upon the circulation,
and through it affecting the temperature. The manner of action
of* each is Avidely different;  the end reached in each  case  the
same.
  It is obvious that an increase of temperature must depend upon
one of tAvo things: (1) an increase in heat production, and (2) an
imperfect heat-loss ;  in some cases the two are combined.  Some
remedies act upon the heat-production, and lessen it; others act
so as to increase the bulk of blood in the heat-losing area, and
to set up perspiration with its cooling effects.  Bleeding belongs
to the first of these. Bleeding, or venesection, is now almost
obsolete as a general  practice, chiefly  in consequence of its abuse.
It is an effective measure for the loAvering of temperature, and
may still be resorted to beneficially in rural practice, when it is
desirable to produce an impression, quickly and decidedly, upon
a rising temperature.  Marshall Hall found  bleeding to lower
the temperature, but it rises again ; and bleeding should be con-
fined to making an initial  impression, and its effects should be
folloAved up by the administration of depressants.  Bouchut has
recently advocated the practice of bleeding, and has found that
a fall of two or three degrees Fahrenheit is quickly produced by
venesection  The error of bleeding Avas the excessive abstraction
of blood at one time, or the repeating it to  meet the after-rise of
temperature, instead of resorting to antipyretic remedies.  Where
its use Avas followed by  the administration  of salines, or the old 
BODY-HEAT AND FEVER.
105
 " fever mixtures," the effects of venesection were far  from un-
 desirable.
   Another method much in vogue at one time, and still in favor
 in many institutions, is the use of mineral acids to check high
 temperatures.   As to their practical efficiency  there  exists no
 manner of doubt.  As to their mode of action Ave, as yet, knoAv
 nothing.   Acids are nevertheless excellent febrifuges, and in the
 tropics, and sub-tropical climates, acid  and subacid fruits are
 largely used for their heat-loAvering properties.  The acid treat-
 ment of fevers is very extensively practised, and in the late Avar
 of 1870-71, the recoveries under the plan of fresh air  and sour
 Avines Avere very numerous and satisfactory.
                    Acid. Hydrochlor. dil. Tllxv.
                    Syr. Aurantii 3J.
                    Aquae |ij.
 every  three or four hours,  is a pleasant and grateful  mixture to
 administer to a fever-stricken patient; and it  may be continued
 through the Avhole course of an ordinary uncomplicated typhoid
 fever case into the coiwalescence, Avhen it may be exchanged
 for a tonic.   The aromatic sulphuric acid may be substituted for
 the  hydrochloric, if an astringent be indicated.  With some
 the dilute phosphoric acid is the favorite agent.
  In consequence of its sedative properties hydrobromic acid is
 indicated as the acid par excellence in simple continued fever,
 especially Avhere there is cerebral disturbance.
                      Acid. Hydrobrom. ^j.
                      Syr. Simplicis gij.
                      Aq. ad gj.
                      6ta quaque hora,
 will  probably constitute the " fever-mixture" of the future.
  Salines  of various  kinds have also been  much used for the
 treatment of febrile conditions.  Salines hoAvever  have  been
 resorted to  rather  in febrile conditions associated  Avith local
 inflammatory changes, and in the  exanthemata, than  in simple
 continued fevers.  Why, it is impossible to say!  Irrespective of
any action they may have upon the blood, they usually  act upon
the different excretory organs, as the skin, bowels, kidneys, &c.
Acetate of ammonia is a famous remedy in the pyrexia of chil-
dren, and in sub-febrile conditions in adults.  Along Avith iodide 
KM]
BODY  HEAT AND  FEVER.
of potassium, or  tartar emetic, it forms a capital agent for the
dispersion of accumulated  heat, dilating the cutaneous vessels,
and  increasing the action  of the sudoriparous glands, and so
encouraging heat-loss.
                      Pot. Iod. gr. vj.
                      Liq. Amm. Acet. 5J.
every six hours, is an excellent  fever  mixture, especially in a
severe cold.   An old formula, once in  most extensive use, Avas
something of this sort:—
                    Yin. Ant. Tart. TTfxx.
                    Tinct. Hyoscvami Tfl.xxv.
                    Liq. Amm. Acet. ^j.
every  four or six hours.   Probably this is  a standard  fever
mixture with hundreds of practitioners at this day.   It is fairly
effective.
   Citrate of  potash, the nitrate and  acetate of potash (neither
pleasant forms), the bitartrate of potash, sulphate of soda or
magnesia, have all been used in  the  treatment of pyretic affec-
tions.   All  forms of potash act upon  the  skin as well as the
kidneys ; and the effervescing citrate of potach acts powerfully
as a diaphoretic upon some persons in summer.  A sharp action
on the bowels also loAvers the temperature, at least for a time,
and so purgation may  be indicated ; and in  combination Avith
either of the formulae just given, a Seidlitz powder, or a draught
of laxative water, may often  be exhibited  Avith  advantage.
AVunderlich  states that  vomiting depresses  the  temperature
more effectually than purging, the reaction being  the same in
each case.  The nausea produced by  antimonial and ipecacuan
Avines has probably much to do with  their efficacy as febrifuges;
but of that anon.
   In ordinary colds, Avith a dry burning skin, it is often neces-
sary to give nauseants in full doses to produce a sufficient  im-
pression upon the skin ; and such doses disorder  the stomach
much, and not rarely interfere with the administration of other
remedies.  In order to  avoid this resort to  nauseant diaphor-
etics, the idea of acting upon the skin directly by warm baths,
and so exciting it to renewed action, has obtained extensively.
The ordinary Avarm bath, especially for children and  infants,
who  can be  readily put into a bath,  or even a bowl of  Avarm 
BODY-HEAT AND  FEVER.
107
Avater, is very convenient; but  such baths for adults  are  un-
attainable in the homes of the poor.  For their needs  the late
Sir James Simpson devised a most capital  bath.   It consists of
the simple apparutus of six or eight soda-water bottles, as many
Avoollen stockings, and  some hot Avater and corks.  Each bottle
is filled with hot  water, and tightly corked.   Then a stocking
is Avrung out of hot Avater, so as to be moist, but not dripping,
and draAvn over the bottle (as it is over the foot Avhen put on);
each bottle, so  encased  in the moist stocking, is put into bed,
and  the Avhole are placed around  the feverish patient.   So
packed round the sides and  betwixt  the  legs, &c, each bottle
steams aAvay, the moisture of the stocking making the air damp.
In from tAventy to thirty minutes a thoroughly free perspiration
is in full swing; and thirty-five minutes are usually enough for
one bath—at least  Avith most persons.  If the patient  be then
wrapped in a blanket and covered up for thirty or forty  minutes
more, the diaphoresis is kept up; and then the patient  may be
uiiAvrapped and left in  bed, with his skin moist and bedewed
Avith perspiration.  If the bed  be  improperly Avet the patient
may be removed into another bed, Avhich  has  been  previously
thoroughly Avell aired and warmed.   If only  one bed be avail-
able, the patient must be inclosed, along  with his bottles, in a
large blanket, Avhich can  be removed, leaving  him in bed after
the bath is over.   Combined Avith iodide of potassium and ace-
tate of ammonia, this bath forms a capital treatment for the first
stage of a simple pyrexia; it is at once efficient and safe.  Proba-
bly a dose of jaborandi  will be found a famous adjunct to this
bath ;  but as yet little can be said practically about this drug.
Further experience has established pilocarpine, its  essential
principle, as a useful diaphoretic.
  § 42. Ere proceeding further with  the  action of antipyretic
or febrifuge remedies, it may be as Avell to glance again at the
causation  of pyrexia, in so far as  it  gives us indications for
treatment.   A rise of temperature is generally associated w7ith
a lowering of the blood-pressure, a  dilatation of the peripheral
arterioles, and a rapid  action of the heart.   The consequence
of this rise is  that there is a free flow of blood through  the
capillaries, and an increased number of respirations per minute,
with possibly some action upon the tissues  themselves, about
which  Ave  can  only as  yet speculate; all of which combined 
108             BODY-HEAT  AND FEVER.
                                     i
bring about an  increase of oxidation, and keep  up the high
body-temperature.   In addition to this, Cullen held  there Avas
spasm of the arterioles  of the  skin, and  so lessened heat-loss.
Recently  Traube and  Senator have espoused Cullen's views,
Ley den thinks there is not diminished heat-loss, but that the
heat-loss is not sufficient to meet the increased heat-production;
and so the body-heat accumulates, causing a rise of temperature.
It is  obvious, then, that our  remedial measures must take the
direction of attempting to restore the lost  balance betAvixt heat-
production and  heat-loss.  AYe have just seen that  increased
action of  the  skin  exercises a most distinct  effect upon heat-
loss.    Consequently agents  termed diaphoretics  have been
rationally, and logically, resorted to in the treatment of pyrexia.
Experience, hoAvever, has taught, what our scientific knowledge
now  explains, that  the diaphoretics to be selected for the pur-
pose  of loAvering the temperature are those exercising a depres-
sant action ; that is, they not only act upon the cutaneous ATessels,
but they at the same time depress the circulation.  They are
the nauseant or depressant diaphoretics, of Avhich antimony and
ipecacuan are  the best known instances.   These agents not only
dilate the cutaneous vessels, and  act  upon  the  sudoriparous
glands; but they also depress  the action of  the  heart, and so
retard the circulation,  and Avith it lessen the  chemical  inter-
changes.
  Rasori,  in 1800, introduced the  plan of treating fevers and
inflammations by full  doses  of tartar emetic.  The plan was
very successful, but was  much  abused ; and  has now for some
years been out of general favor.   Nevertheless it Avas an  efficient
plan,  especially in small and oft-repeated doses, so  as to  produce
a steady effect, instead of the oscillations  of distinct depression
and  after-rise, which folloAv  any  one decided  blow by a large
dose,  or  a  repetition of  poAverful  blows at  long  intervals.
Hufeland  regarded bleeding with tartar  emetic and opium as
the basis  of all therapeutics (1830).  This plan of Rasori's led
to another step in the  same  direction by Fleming of Birming-
ham, Avho in  1844  struck the  key-note of  a new and most
successful treatment.  Observing the objectionable effects of an-
timony in large doses upon the system, and the gastro-intestinal
disturbance so produced, he  investigated  and  brought fonvard
the action of aconite as  a febrifuge.  Aconite had been  inves- 
BODY-HEAT AND FEVER.             109
  tigated to some extent  by Storck  in 1763, Avhen  the  apostle of
  homoeopathy, Hahnemann, Avas a child ; but it was left  to
  Fleming to establish its position.  He found that it lowered the
  pulse both  in force and rapidity—that the pulse was lowered
  sometimes thirty or forty beats per minute.  At  the same time
  the action upon the skin Avas to bedeAV it Avith  moisture.  In
  practice he often combined aconite  Avith  bleeding,  and found the
  aconite most beneficial in maintaining the action of venesection
  and preventing the reaction or after-rise of temperature. Ringer,
  Avho has every claim to be listened to Avith the greatest respect,
  in reference to  the action of aconite, says: " Aconite is to be
  most esteemed  for its power, little less  than marvellous, of
  controlling  inflammation and subduing the accompanying fever.
  It Avill sometimes at once  cut short an inflammation.  It will
  not remove the products of inflammation, but, by controlling the
  inflammation, it prevents their formation, so saving the tissues
  from further injury.  AYhen given in the earliest stages  of  the
  commoner and milder pyrex;ae, the skin—dry, hot, and burning
  —becomes in a feAv hours comfortably moist; and in a little
  time  longer is bathed in a profuse  perspiration, often to such an
  extent that drops of SAveat run dowm the face and chest.  With
  the SAveating comes speedy relief from many of the distressing
  sensations, as restlessness, chilliness, heat, and dryness  of  the
  skin, aching pains and stiffness; and at the same  time  the
  quickness of the pulse becomes much reduced in frequency, and
  in a period varying from twenty-four to forty-eight hours both
  pulse and temperature  reach their normal  state." He further
  says: " The method of employing the drug has much to do Avith
  its efficacy.   It  should be given, as already stated, at the  begin-
  ning of the disease ; the medicine should never be delayed ; every
  hour  is of importance.   Haifa drop or a drop of the tincture,
■-  in a teaspoonful of Avater, should be given every ten minutes or
  quarter of an hour for two hours,  and afterwards hourly ; and
  if there be  much  prostration, with a feeble and  Aveak pulse, a
  still smaller dose."
   To  some readers this suggestion  may be somewhat repugnant,
  as savoring  of a soupgon of homoeopathy ; but Ringer, Phillips,
  Ashburton Thompson, and others,  who  have made trial of this
  plan,  advocate it as much superior to that of giving  ten drops
  every four or six  hours.   Such  plan, they tell me, produces a 
110              BODY-HEAT AND  FEVER.

steadier action.  For those Avho are but feeling their way Avith
aconite and other vegetable febrifuges, the combination of small
doses of aconite Avith acetate of ammonia or iodide of potassium
may suggest itself; using the  aconite in small doses instead of
antimonial Avine.  The plan of controlling fever by aconite  is
much on the increase.
  Another pOAverful remedy for controlling the temperature in
febrile conditions is chloral hydrate.  This agent  exercises a
very distinct action upon the heart, as Avell as upon the peri-
phereal,  and  especially  the cutaneous  arterioles.   Liebreich,
B. AAr. Richardson, Hammond, and others have found that the
temperature falls  3° or 4° Fahr. after a full  dose of chloral
hydrate (40-80 grains).  And Lauder Brunton has found that
by Avrapping a rabbit in cotton wool, so as  to conserve its heat,
a dose of chloral will be survived, Avhich  is fatal Avhen no such
precautions against heat-loss  are taken.  It has  also been ob-
served that chloral acts very  powerfully upon both the respira-
tion and the circulation, the heart's  action  being gradually
reduced, so that in chloral poisoning  it is found  in  diastole.
(Wood.)  In consequence of  its hypnotic action, as well as its
other actions, it seems specially indicated in  those cases Avhere
of old antimony was added to opium.  It is par excellence the
hypnotic of pyretic conditions.  H. C. Wood  says :  " The phy-
siological action of chloral may be  summed  up as followTs:—
Upon  the cerebrum it  acts  as a most  powerful  and certain
hypnotic:  in full doses it acts as an intense depressant upon the
centres at the base of the brain and upon the spinal cord, caus-
ing slowing and Aveakening of the heart's action, probably vaso-
motor paralysis, sloAving of the respiration, and muscular weak-
ness, with  a  certain  amount of  anaesthesia; in fatal doses it
causes death  generally  by arresting, through  paralysis  of the
nerve-centres, first respiration, and  then the  heart's action in
diastole."   Chloral  hydrate may be  given  in  various  forms, of
which, hoAvever, the  syrup is the favorite.   It  may  be given
alone ; or if there be also acute pain, as  in rheumatic fever, it
may be combined with opium.  This combination suggests itself
Avhenever there is severe suffering.
   Veratrum ATiride is a remedy in  much repute in the  United
States.   Bullock  has obtained from it tAvo  alkaloids, both of
great activity as depressants  of the circulation, and thus useful 
BODY-HEAT AND  FEVER.
Ill
in the treatment of acute pyrexia.  Veratrum does not seem to
have much action upon the skin, but its action upon the circu-
lation is energetic.   Wood says: "When true sthenic arterial
excitement is to be combated in any disease, except it  be o-as-
tritis, veratrum viride may be employed as a prompt, thoroughly
efficient, and at the same time very safe remedy—very safe, since
it is almost  incapable of producing  death in the robust adult,
unless used Avith great recklessness, and in repeated doses.   In
the early  stages of sthenic pneumonia it offers, I believe, the
best known  method of reducing the pulse-rate and the tempera-
ture, and  of ameliorating  the disease."  Of  its administration
he writes, "In administering veratrum viride it should  ahvays
be borne in mind that  it will do no good in acute disease unless
given in increasing doses until its physiological action is mani-
fested.  In almost all  cases vomiting is to be avoided as far as
possible.  To do this,  small  quantities of the drug  should  be
given at short intervals, and corresponding doses of laudanum
(5 to 10 drops) should  be exhibited  fifteen minutes after  each
dose of the veratrum  viride.  An hour is  generally the best
interval between the doses."  The  addition  of the opium Avill
serve several good ends, especially in its action upon the nervous
system, and  in its effects upon the skin.
  A word upon the use of opium in the treatment of high tem-
peratures may not  be out of place.  Given alone in pyrexia, the
action of opium is unsatisfactory.  As Ave have seen in an earlier
section of this  chapter, high temperatures seem  to  excite the
brain, and the first  effects of opium would add to the existing
excitement.   Consequently the combination of opium with anti-
mony, a direct  depressant, has been found desirable and effica-
cious.  The  less the pyrexia, the less the antimony ; the greater
the vascular excitement, the greater the dose of antimony, was
the rule.  Graves, as abridged  by Ringer, says:  "Each drug
appears to assist the action of the other; and the relative doses
must be determined by the circumstances of the case.  In furious
delirium the tartar emetic  must be given in full, and the opium
in small quantities;  while  if wakefulness is the chief symptom,
the delirium being not  very boisterous, the dose of antimony
must be reduced and the opium increased."  This rule for the
combination of opium and antimony, here given, sho\ATs consum-
mate skill in the prescriber—skill, however,  which all ought to 
112
BODY-HEAT AND  FEVER.
aim  at, even if it  be given to a feAV to attain it.  Opium  and
antimony may often be given Avith advantage together at bed-
time, as a grain of opium Avith five grains of pulv. antimonialis,
along with  the fever mixtures  given  above.  If the fever be
very sthenic, something like the following may be given:—
                      Yin. Antim. TTLxx.
                      Tinct. Opii, Tflxv.
                      Liq. Amm. Acet. 3J.
every four or six  hours.   It will  be  found a pretty effectiA^e
mixture in sthenic  pyrexia.  Or opium may be given  alone in
pill, or Avith a few grains of Plummer's pill, or as Dover's poAvder.
  In addition to  the remedies given above  there are other
measures which  are useful in pyrexia  for dissipating heat:  one
of the  most effective is alcohol.  Since the days of Dumcril  and
Demarquay this action of alcohol has  been the subject of much
investigation, and  of no little discussion.   The conclusions of
these observers are now generally  accepted, chiefly through the
Avork of Binz, of Bonn.   It has been found that alcohol  acts
very powerfully upon the  cutaneous vessels, dilating  them, and
so increasing the  bulk of  blood in the external cooling area of
Rosenthal.  Whatever other points there  may be in the action
of alcohol  leading to the  lowering of  the temperature, there is
unanimity about  this.1  Binz says that if the heart be excited
by alcohol Avhile the vessels of the skin are dilated a  large mass
of blood must  be  driven  through  the cooling area.   BathUrst
Woodman states that at  the London Hospital he has several
times noted a temperature of 90° Fahrenheit (32.2° Cent.) in
alcohol poisoning,  Avhere the patient has recovered.   The effects
of alcohol  in predisposing  those under its  influence to die of
cold  in low temperatures are Avell  known.  Thus  in cold days
men under the influence of excessive doses of  alcohol often be-
come benumbed, and have to be put into Avarm beds, and  have
heat artificially administered, in  order to restore them.   The
plan of taking alcohol on  going  out into the cold is a most mis-
taken one.  It may produce a sensation of warmth by dilating
the vessels of the skin, and so bathing the cutaneous nerves in
a current of Avarm blood;  but in doing so it increases the heat-

  1 Schmiedeberg holds that alcohol interferes with oxidation, and in this way
also lowers the temperature. 
BODY-HEAT AND FEVER.
113
 loss.   In warm weather a dose of alcohol, Avith many people, at
 once  produces a Aoav of perspiration ; but this action upon the
 skin  may lead to serious depression of the temperature in cold
 climates.  As a means of dispersing accumulated heat alcohol is
 often very serviceable.
   § 43.  Such  are the different  measures to be resorted to in
 pyrexia associated with heat accumulation, from defective heat-
 loss.   AVhen  pyretic conditions are found with  a dry burning
 skin, and arrest of the action of the sudoriparous gland, the
 restoration of the function of these glands and the relaxation of
 the cutaneous A-essels are the ends to be aimed at.  Leyden has
 found that in increasing fever there is no evaporation of Avater
 to be demonstrated  under an impenetrable covering; while in
 defervescence  there is ahvays a  well-marked perspiration  and
 exhalation of Avater.  The effects of Avater exhalation  and the
 change of form from Avater to vapor, Avith its  cooling effects
 upon the body temperature,  are too much mere physical effects
 to permit of any doubtfulness about their action.   Consequently,
 Avith pyrexia under such circumstances, the agents to be employed
 are the depressants just given: there is defective  heat-loss, and
 this must first be increased.1
   When, hoAvever,  there  is pyrexia  with  a moist  perspirable
 skin other measures are indicated.  Here there is no defect in
 heat-loss, and, as  the  skin is already moist,  it is well to resort
 to antipyretic agents, which appear to strike directly at heat-
 production.   Such agents we possess  in  quinine and  digitalis.
 The antipyretic action of  these agents has been chiefly worked
 out by German observers.  AVunderlich has found that quinine
 in  pretty large doses, as from twenty to thirty  grains, divided
 into three doses, given within a few hours of each other, has a
 decided effect in lowering  the temperature in typhoid fever.  In
 some  cases a  fall of several  degrees Avas observed; in one the
 fall was from  10o.8° Fahr. to 97.25°.   Liebermeister has found,
 from  a large  number of observations, that  quinine distinctly
 loAvers the temperature  in typhoid fever. It is not in typhoid
 fever  only that  quinine exercises  this  antipyretic  effect, for
 Kerner and JUrgensen found  that quinine arrested the rise of

  1 In  his Handbook of Therapeutics, my friend Sidney Ringer subjects these
views to some gentle criticism, without, however, invalidating the position taken
up.
       8 
114
BODY-HEAT  AND  FEVER.
temperature which  ordinarily follows exercise.  As to  how
quinine exercises this action,  is not  quite  clear.  It has  been
held by some, as Ackermann  for  instance, that quinine, like
digitalis, raises the blood-pressure,  and so limits tissue-changes;
but other observers deny that quinine does raise  the blood-pres-
sure.  It is surmised  that quinine exercises its antipyretic action
by virtue of some effect upon  the nervous system ;  but this is
not yet demonstrated.   The elaborate  labor  of  Binz leads  to
the supposition that  the antipyretic action of quinine  lies  to
some extent in  its checking the ozonizing poAver of the blood.
AYhateArer the explanation, there is no doubt that quinine exer-
cises a  powerful action  upon  heat-production in  pyretic  con-
ditions.
  Digitalis has also been used for its  antipyretic action.  Wun-
derlich  found  digitalis to distinctly affect  the temperature  in
the latter stages of typhoid fever.  The fall lasts about twenty-
four hours, and is then followed by a  rise, Avhich never, ho\A7ever,
attains  the original  height.   Other  observers have noted the
antipyretic  action of digitalis.1  In  fever there  is partial vaso-
motor paralysis, with  dilated  arterioles, a  low  blood-pressure,
and increased tissue-change, in and around the dilated terminal
A^essels.  Digitalis contracts these vessels, raising  the blood-pres-
sure.   Ackermann states that as  the  blood-pressure  rises, the
temperature falls;  and that as  the  blood-pressure falls, the tem-
perature rises;2 that there  is,  in fact,  an antagonism betwixt
the temperature and the blood-pressure.  There is no doubt a
good deal of truth  in this, and such is probably the explanation
of the antipyretic action of digitalis.
  Digitalis  and quinine may be profitably  combined  in the
treatment of pyretic conditions Avhere the skin is moist.   They
may be prescribed with  mineral acids in the following form :—
                      Quin. Sulph. gr. v.
                      Tinct. Digital. fflxv.
                      Ac. Phosph. Dil. ulxv.
                      Aquae 5J.
  1 Bernheim found digitalis always to produce lowering of temperature in typhoid
fever ;  either complete defervescence or remission ; that the pulse and temperature
fell together, but not always in a parallel manner; and that the delirium often
ceases with the decrease of heat, and the respiration is calmer.
  2 This is in strict accord with the observations of Heidenhain, who found by
experiment that a rise in the blood-pressure caused a fall in the temperature. 
BODY-HEAT AND  FEVER.
115
every four or six hours.   In a case of post-partum pyrexia Avith
a temperature of 105° Fahr., and a skin bedeAved with perspira-
tion, this combination brought  the temperature down to 101°
in twenty-four hours ; and that too whilst the case steadily pro-
ceeded to a fatal issue in a few days.   This shoAvs that the fall
wTas  not due to any general improvement, but directly to the
antipyretic  action of the remedies.  The value of this plan of
treating pyrexia  is shoAvn by the following case.  A lady, five
Aveeks after confinement, became feverish and ill.   When seen
by me she had had a temperature of 103° for six days.  She
was  then  flat on her back, delirious, Avith sordes on her teeth
and lips, while  her tongue Avas covered with a thick brown fur.
Her  urine was laden Avith albumen. The typhoid condition was
well marked, while  the  skin was moist.  The above mixture
Avas  prescribed.  In forty-eight hours the temperature had fallen
to the norm, and the urine was free from albumen.  The case
made a steady recovery.
   When the typhoid condition is established, depressant anti-
pyretics are distinctly contra-indicated ; and  the measures just
described should be adopted.  The last formula may be used,
and  with it alcohol might be freely administered, together Avith
milk and other nutrient fluids.  But it must be admitted that
when the typhoid condition is pronounced, the chief hope lies
in the capacities of the organism, and it becomes largely a ques-
tion of stamina.  The  more need then to avert  its oncome, if
possible.  For the theory of the action of stimulants, and their
use under these circumstances, the reader must consult a later
chapter (Chapter X., §§ 95-98).
   From what has just been said, it is perfectly obvious that in
taking the  temperature the medical man must do something
more than merely note the rise of the  register.  In addition to
the  mere body-heat, there  are the equally important matters
of the condition of the skin, and the  amount of perspiration,
telling of the  amount  of  heat-loss going on,  to  be observed.
AYhile taking note of the actual temperature, it is necessary to
apply the trained intelligence, and to have a clear comprehen-
sion of the  hoAV and Avhy of the febrile  state, as to the relative
amounts of increased heat-production  or diminished heat-loss,
and  to calculate exactly the factors of  the febrile state, and to
select the remedial measures accordingly. 
11»)
BODY-HE AT AND  FEVER.
  § 44.  The application of cold in the treatment of febrile con-
ditions dates back beyond the days of Hippocrates, and seems
to have taken its origin in man's instinctive acts  long  ere  the
era of written letters.  "The use of cold in the treatment of
disease may be traced to the very earliest historical periods and
in the records or usages of every people.  Savage and civilized
nations have employed it, and it  has  been equally the instru-
ment of physicians and the resource of quacks." (Stille.)  Syden-
ham was the  first of modern physicians  to treat fevers syste-
matically by cool surroundings, cold water, and fresh air.  After
him Cullen advocated the treatment  of  pyrexia, and the dis-
persion of accumulated heat, by the external application of cold
in the form of baths.  It has been left, hoAvever, for  Lieber-
meister, of Basle, to introduce the use of external cold in  the
treatment of pyrexia on a well-established basis.  It is a rational
and sensible plan of getting rid of superfluous heat: and though
there are  some popular prejudices to be overcome, this plan of
treating hyperpyrexia will obtain more  and more.   Possibly
the fear that  wre do  not  yet knoAv exactly how far to go and
Avhen to stop, is not altogether groundless; and further experi-
ence in hospitals, under skilled supervision, may be necessary
ere this plan will or can be largely  introduced into private
practice; but that it Avill ultimately become a general, perhaps
even a universal, practice, there seems but little reason to doubt.
The feeling of comfort,  the loss of  muscular weariness,  the
diminished thirst and restored consciousness given  by a cold
bath, all testify to the relief afforded by the reduction of the
temperature.   The loss of body-heat, so brought about, relieves
the patient from the direct  consequences of a high temperature
enumerated above.
   Cold sponging Avith vinegar and water has long been a recog-
nized  method of relieving the  burning heat which obtains
during the coming out  of  the eruption in  the  exanthemata.
More efficient measures are uoav adopted.  Brand gives different
forms of  applying cold externally.   The  cold wet  compress;
frequent Avashings Avith cold Avater; an ordinary bath gradually
cooled; and the cold wet sheet are the chief forms.   The pack-
ing in a cold  wet sheet has found many supporters.  It forms
an effective measure, readily applied in the humblest houses.
The patient can be wrapped  in the Avet sheet and Avhen swathed 
BODY-HEAT AND FEVER.
117
 in a blanket be put into bed;  and this  could be repeated at in-
 tervals, four or six times a day, as long as the temperature keeps
 rising.   All would depend upon the progress of the case: and
 it is very desirable for  the interests of this method that every
 medical man, commencing this line of treatment, should  first
 put it into  practice in his immediate neighborhood, so that he
 can keep the patient under his OAvn eye.
   The method of putting the patient into a warm bath and then
 gradually cooling it doAvn is only suited to houses Avhere such
 a bath can be procured, and is best adapted to the regular bath
 where cold water can be turned on gradually.   Ziemssen and
 Immermann immerse their patients in a bath at 95° Fahr., and
 in  the course of twenty or thirty minutes gradually cool it to
 60° Fahr.   This bath is agreeable to fever patients.  (Ringer.)
   Such external application of cold ought to be generally adopted,
 and in most cases will be found  practicable in  some form.   The
 feelings  of  the  patient Avill  usually secure the  continuance of
 the treatment, even if the friends are somewhat  timid, and
 unnecessarily afraid of potential evil consequences.
   As to the treatment of  high  temperatures  by iced fluids
 internally, or pieces of ice to suck, it is  to be hoped that no one
 will be at once so ignorant and so  cruel  as to withhold them.
 They will usually relieve the sensation of thirst, and do not
 create nausea.   In a severe  attack of scarlet  fever  the Avriter
 looked anxiously for the basinfuls of lumps of ice, which were
 greedily  consumed, despite an  ulcerated  tongue and  throat.
 After a feast of ice, some cold water in the Avater-pillow, and a
 bladder of iced  Avater to the head, a feeling of comparative com-
 fort Avas  attained, which no concurrent  delirium could obscure,
 nor passage  of time obliterate.
  The cold thus taken  into the  body destroys or neutralizes so
 much heat, and in doing so aids to reduce the body temperature.
 In our treatment of pyretic conditions we should aim at keeping
 doAvn the temperature  on the one hand,  and dissipating the
 superfluous  heat on the other, by every means in our power.
 Consequently in addition to the measures above mentioned it is
 desirable to  place the patient  in a cool Avell-ventilated bedroom,
 in Avhich a current of air  can be maintained without exposing
the patient to a draught.  Unless there be lung  complications
the air may be  alloAved  to play about and  around the  patient, 
118              BODY-HEAT AND FEVER.
especially Avhile the  temperature is rising.   By  such means
several ends are served.  The cool air respired destroys so much
heat, while the cooler temperature  around the body increases
heat-loss from the general  surface.   In order to secure  this
latter the bedclothes must  not be too thick;  a sheet  or light
blanket  is often  sufficient  for the  day, especially in  warm
weather; but in cold  AATeather, and at  nights, a second blanket
may be desirable.  It is easy if any chill be experienced to give
some  Avarm fluid  or  to put on some  more " cover;"  but, as a
matter of fact, in a rising temperature Avith a dry burning skin
chills are not readily produced.  There is not here the same
risk of carrying  the cooling process too far that exists when the
body is heated and perspiring  freely: then the cooling is easily
carried  too far, and a serious chill is often the result of careless
or prolonged exposure to cooling agencies.  But there is all the
difference possible  betwixt such dispersion of accumulated heat
in a healthy organism, with a gloAving and perspiring skin, as
is safe;  and the exposure to cooling  influences Avhich may be
not only undergone Avith safety, but even Avith actual benefit,
Avhen there is excessive heat-production and a dry burning skin,
as is the case in the pyretic  rise of a severe attack of fever.   In
the latter case the increased  heat-production  soon meets  and
neutralizes any chill; in  the former excessive  heat-loss  is fol-
lowed by a subsequent  rise  of the temperature, and may easily
be induced unless  good care be exercised.
   The whole subject of body-heat, its production, its dispersion,
and their disturbances, call for more general attention than they
have yet succeeded in attracting.  The use of  the clinical ther-
mometer as a diagnostic aid is noAv  very general, but  a  like
interest in the rationale of hyperpyretic temperatures is far from
being equally general.  Men will use a thermometer assiduously
Avho cannot, hoAvever, be induced to give  much thought to the
how,  the why,  and the wherefore  of the pyrexia, and conse-
quently of the best means of reducing it.  And yet this is Avhat
the clinical thermometer, properly and intelligently used, ought
to be the means of attaining.   It should  not  only register the
actual temperature, but it should furnish  information as to the
amount of heat-dispersion, and  so yield  indications for the
selection of the antipyretic measures best adapted to the exi-
gencies of each  case. 
BODY-HEAT AND  FEVER.
119
  Note.—The new agent jaborandi seems to possess very pecu-
liar properties as a safe and yet effectual and Avithal rapidly
acting diaphoretic.   It has not yet been procured in sufficient
quantities to admit  of much  experience of it; but it promises
to be  a valuable addition  to our armamentarium as an aid in
heat-dispersion.
  Salicylic acid also promises to be an  efficient measure for
lowering the temperature.  In drachm doses it produces a de-
cided fall in most cases.  AYhether it acts by lessening oxidation
or by  modifying thermic conditions is not yet certain.  (Ewald.)
Nor is its action made any clearer by further experience ;  which,
however, has established its use. 
CHAPTER V.
                INFLAMMATION : ITS VARIETIES.

  § 45. The morbid  process  denominated  inflammation is  a
curious and often complex affair.  AVhether it be ahvays a dis-
ease, or always a reparative process is a question  which can be
more easily raised than settled.   Without it the injuries inflicted
by accident,  or deliberately by the surgeon,  would remain un-
repaired.  By its means a fractured bone  is united, and at the
same time the fractured ends are maintained in their place by
an inflammatory cell-formation around them, Avhich consolidates
the surrounding tissues  and keeps the parts at rest.  The less
perfect the appliances of man, the greater the efforts of Nature
to procure quietude.   Every reader of Hilton's charming Avork
on Rest and Pain will remember the case of the Avasherwoman
with the broken collar bone.  She persisted in working, uncon-
scious of the fracture ; and the movements of the arms, necessi-
sitated by her occupation, disturbed  the fractured  ends, and
nature threw out such a mass of callus that it A\ras mistaken for
a bony tumor.   Ultimately, having achieved the desired end,
this natural splint gradually disappeared ;  leaving an instructive
lesson  behind it.  The bands of plastic lymph Avhich form in
enteritis  are the  consequences of the movements of the intestines
which  they tend to arrest.  Their continuance, however, forms
a source of the greatest danger to the life of the individual in
Avhose  abdomen such  plastic bands  lie hidden.   If it were not
for an  inflammatory process  which forms a defensive wall, how7
commonly would gastric  ulcer lead  to perforation of the  stom-
ach !  By its means abscesses  find  their  way safely from the
interior of the body to the external surface, and so the organism
is preserved.
  At other  times, however, inflammation forms a very  serious
danger, imperilling the  system  Avithout any apparent  useful
purpose.   For instance,  pneumonia is often, especially in the
chronically  enfeebled, a  simple  unmitigated danger to life. 
             inflammation: its  varieties.          121

Under other circumstances there is much reason to believe, that
the process  knoAvn as  pneumonia is  really not the disease but
the process of repair.   As in bronchitis, some occult  injury has
been received, which the inflammatory process alone will or can
compensate, or cure. Put a  grain of sand into the eye, and soon
there is not only a flow of tears from the effect of the irritation
exciting the lachrymal gland into functional activity, Avith the
result at times of effecting the removal of the irritant; but the
vessels of the conjunctiva undergo a process  of dilatation, and
there is  an  increase of blood-supply to the part and  additional
cell-formation. The design, if  such expression  may be  per-
mitted, is not destructive and mischievous, but benevolent.  If
the case were quite successful, the grain of sand would be en-
capsuled in  a mass of lymph—unfortunately, however, the deli-
cate structures of the  eye are generally destroyed in course of
the process.   The inflammatory process often needs the guiding
hand of  man; indeed  the disturbance occasioned by it is fre-
quently a source of much danger.  Equally too the benevolent
but misdirected zeal of  man often  ends in  the  death of the
patient;  and the attemps to  regulate the  course of the inflam-
mation destroy the life of the organism.   If  Nature does not
ahvays work wisely and  well, if her attempts sometimes are too
energetic, the same charge can be equally substantiated in rela-
tion to the efforts of man.  AVhen  inflammation Avas regarded
as a raging demon to be felled at once, no matter what the risk
incurred by smiting it, the efforts of the medical man had to be,
abo\re all things, energetic and decisive.  Then it might be said
Avith some approach to truth, that nature and disease wTere tAvo
men fighting, and a doctor was a  blind man Avho struck with a
club, and cut down either the disease or the system. At present,
however, more correct notions obtain; the inflammatory process
has been followed up and tracked to its furthest retreats by a
legion of industrious workers, and  been found to be almost a
physiological  action.   As Ave have just seen, it is often really
benevolent—the natural process of repair.  We now  knoAv that
there is no sharp line of demarcation to be  drawn betAvixt that
process of increased nutrition which develops masses of horny
epidermis on the hands of the workman, and the process which
disturbs the valves of the heart;  nor  yet even betAvixt it and
the inflammatory action in the lungs Avhich so frequently closes 
122         INFLAMMATION:  ITS VARIETIES.

the career of pyaemia.  After all, they are processes of increased
nutrition, Avhich differ in degree rather than in  kind.   Unfor-
tunately the function of the lungs is so important, and essential
to the existence of the organism, that the extensive changes set
up throughout them kill the patient: and an effort, benevolent
in itself, becomes  directly destructive.  In the  same Avay we
must look at inflammation in order to clearly comprehend how
it is that it so commonly occurs  under circumstances of lowered
vitality; how it is that the impaired condition of the  system
generally is so associated with these local disturbances of nutri-
tion, that the  inflammatory process is  ill-controlled, and be-
comes a source of danger instead of a reparative action.  AVe
are not yet sufficiently acquainted Avith the actual processes of
nutrition to understand the relations positively existing betwixt
the tissues and their blood-supply.  Consequently we do not yet
know how it is that the combined action is instituted which
Ave recognize and denominate inflammation.  AVhether there is
merely a disturbed condition of the innervation of the  blood-
vessels of the part, leading to hypervascularity and consequent
cell-formation ; or Avhether  there is a starting-point located  in
the tissues themselves, Avhich  casually   induces  the  vascular
changes; Ave do not yet know, and can  only surmise.   In fact
the existence of trophic nerves is not yet established to general
satisfaction.  There appear to be  grounds for believing  that
bloodvessels have not  only  their  vaso-motor  nerves, derived
from the organic nervous system, which  produce  contraction of
the muscular Avail of the bloodvessels ; but  that  there are  cere-
brospinal fibres as  well, Avhich inhibit  the vaso-motor nerve
action and dilate the vessels.  Consequently when a part is much
exercised the vascular branches of its nerves—the trophic fibres
of its motor-nerves—are thrown  into action Avith  the rest of the
nerve-fibres, and Ave have as results the  w^ell-developed  calf of
the ballet-dancer  and  the  muscular  arm of the  blacksmith.
AYhen a motor-nerve is  irritated the bloodvessels of the  muscle
involved are dilated.  This dilatation of the vessels follows the
irritation of the nerve even when the muscle itself is paralyzed
by curari. It is apparently in the relation of the tissues to these
trophic  nerves that we see the commencement of the inflamma-
tory process in its most normal  aspects,  as in the healing of  an
amputation.  AVhere the starting-point, and what the initial 
             INFLAMMATION:  ITS VARIETIES.         123

action in visceral inflammation is, Ave must candidly admit that
Ave do not yet know. AYe can only trace the action going on after
disturbance of the bloodvessels has commenced.  The dilatation,
the increased blood-floAv, the retardation of the flow, the ultimate
stagnation, the cell-formation outside the minute bloodvessels,
are described and pictured in a legion of Avorks on physiology.
Not only is there a local process going on, but the action on the
bloodvessels  extends to the  Avhole circulatory system.  There
is general vascular excitement: but at  the same time, the nearer
the inflamed spot the greater the effect.  Thus LaAvrence found
in a case of whitloAv, that on bleeding from both arms the  blood
ran much faster from the arm connected Avith the inflammation.
In the case of  a gentleman  who crushed  a  finger and had it
amputated, and in whom there  was much constitutional dis-
turbance with  acute inflammation  of the Avhole  hand, I found
the radial artery of the injured limb Avas at least one-half more
in diameter  than  the  corresponding artery,  and  in its dilated
condition felt like a loose round cord.  Inflammation has been
much more Avorked at  by surgeons than by physicians, and it is
in surgical Avorks Ave  find  the  best articles on  inflammation,
except in the excellent, and now little-known  book the Principles
of Medicine by C. J. B. AVilliams; a Avork every thinking student
should procure  and peruse  carefully.  If  it is in surgical in-
flammations of the limbs and in experimental researches that
Ave find the little Ave yet know about the first starting point of
inflammation ;  Ave know enough of the  more advanced stages
to direct our treatment of the inflammatory process, and that
is the side of the question we are most engaged with here.
   § 46. In inflammation  there  is  great  local vascularity, in-
creased cell-formation  and  local evolution of heat.   The  old
phrase, pain, heat, redness, and swelling, gave a fair idea of the
pathological  changes going  on.  But  this local  action is not
Avithout effect upon the system generally ; and it is with these
systemic disturbances that we are here chiefly interested.  Any
operative and purely surgical measures are not included in the
scope of this work;  they Avould be out of  place even if I Avere
successful in putting them correctly.  Nevertheless an inflam-
mation Avhich best illustrates  the different measures  to be em-
ployed Avill be found in the surgeon's domain, and consequently
a little poaching may be permissible for once. Take tonsillitis, 
 124         INFLAMMATION:  ITS VARIETIES.

 or a AvhitloAv,  for  instance.   There is  first  local congestion,
 hypervascularity, SAvelling Avith  pain,  tenderness, and heat.
 Then  there is  the formation of pus, and after its evacuation
 the process of repair.  There is also much constitutional dis-
 turbance.  The pain interferes  with sleep.   There is  general
 vascular  disturbance and a  feverish  condition  of the Avhole
 system.   The appetite vanishes, the tongue  is furred, there is
 much  thirst, the boAvels do not  move, the  urine  is scanty and
 high-colored, there is general languor and muscular  lassitude,
 Avhile  the head is not uncommonly hot and painful.  The secre-
 tions and excretions are deranged.
   Noav Avhat  are the measures  to  be adopted to relieve  this
 condition?  The first indications are to lower the temperature
 and the vascular excitement.   To attain  this  end most persons
 Avould select acetate of ammonia, as it is diaphoretic and cool-
 ing.  Others again might choose nitrate or citrate of potash, or
 effervescing mixtures; Avhile a third might have  a preference
 for sulphate of magnesia, and utilize the cooling  effect of pur-
 gation.  (AVunderlich, pp. 136-137.)  Any of these  measures
 might be  adopted Avith good results.  Even  the simplest form
 of getting rid of superfluous heat, the  cold bath, might  not be
 at all a bad measure to adopt.  The thirst AA^ould probably indi-
 cate cool beverages, which would dissipate or neutralize so much
 heat.  If  the fever Avere  high, and the skin  burning, a little
 tartar  emetic might not be out of place.  There is also the pain
 to be taken into account.   It is not  usual to employ opium con-
 stantly in such a case, though it might be resorted to in some
 cases Avith benefit.  A dose of it is commonly  given at bedtime
 to try  to secure some sleep.  To be effective it  must be given in
 a full dose.  A grain and a half  or  two grains of  opium, with
 three grains of calomel and five of James's powder, might be
given  at night, and  a  seidlitz  powder, a black draught, or a
dose of the bitter Avater of Friedericshall be taken in the morn-
ing.  The opium would at least soothe if  it  did  not  procure
sleep (Chap. XIII.), and the purgation would cool.   Then there
might  be a mixture of this kind given every six hours:__
                     Yin. Antim. Tfl_xx.
                     Tinct. Hyoseyam. ^ss.
                     Liq. Am. Acet. %j. 
             INFLAMMATION:  ITS VARIETIES.          125

 Another might prefer to use aconite, or even better still, if there
 be no great pain, hydrate of chloral.  Personally I think chloral
 the most physiological.  It Avould loAver the vascular excitement,
 both in its action on the heart and the  peripheral vessels, espe-
 cially of the skin ; it would act to some extent on the neiwous
 system, and modify the  sensation of pain and the headache.   It
 might be combined with opium, thus:—
                      Chloral Hydrat. gr. xv.
                      Tinct. Opii,  m,x.
                      Mist. Camph. gj.
 every six  hours.  A dose of  Plummer's  pill, Avith a  grain of
 opium, at bedtime, and  a saline laxative in the morning, would
 be of service.   Such Avould be  the plan of treatment during the
 rise of the inflammatory process.  Or the chloral hydrate might
 be combined Avith scruple doses of bromide  of potassium, or
 Avith aconite.
   If it Avere a viscus  that was inflamed,  say the lungs for in-
 stance, another therapeutic measure  might be brought to bear.
 This is to reduce the bulk of blood either by venesection or by
 its equivalent—bleeding the patient into his OAvn vessels.  To
 do this it  is necessary to increase the general vascular area.   All
 agents achieve  this  end which dilate the bloodvessels, as anti-
 mony, aconite, chloral, etc.   The more  the bloodvessels  are
 dilated the less the blood-pressure on the inflamed  part.   The
 vessels of the inflamed area are  already dilated, and so there is
 no local action to  be feared in  the use of the depressants of  the
 circulation, Avhich usually loAver the heart's action Avhile dilating
 the peripheral bloodvessels.  A further enlargement of the vas-
 cular area is achieved by dilating the vessels of the skin by  the
 application of heat.   A large jacket-poultice dilates the vessels
 of the skin of  the trunk to such an extent that effects similar
 to venesection  are produced upon the  blood-mass; while  the
 blood remains  Avithin the organism, and  is still available  for
 future needs.   Its effects are seen in the relief afforded by such
 poultices in cases of inflammation of the lungs,  or cardiac dys-
 pnoea where the right ventricle  is  gorged to distension.  Such
 a method of affecting  the  circulation Avould  scarcely be suited
to a Avhitlow.  If a knee-joint is inflamed, the plan of ligaturing
the femoral artery, and so shutting off the blood-current at  the
main, is at once rational and successful in  practice. 
126         INFLAMMATION: ITS VARIETIES.

  § 47.  A whitlow, though an  excellent example of simple in-
flammation of fever of local origin, is not the best example that
could have  been chosen  for  illustrating the  type  of ailment,
with  its appropriate  treatment, which  intervenes betAvixt the
inflammatory  rise and the true  convalescence.   During this
period there is  still  some constitutional disturbance with an
oscillating temperature.  An example of what is meant is fur-
nished by the condition formed in an abscess,  when the tension
and extreme pain, with  accompanying constitutional disturb-
ance, are relieved by a surgical incision, or the bursting of the
abscess spontaneously ; and there  is left a free discharge of pus,
with some general irritation  and  an  irregular temperature, or
evening hectic.  After a whitlow, or  tonsillitis, the course  of
which is very identical, the relief afforded  by the escape of the
imprisoned pus is usually sufficient to at once admit of sleep, of
a returning appetite, etc. ; but where this is not the  case, and
there is an interval  betwixt the inflammatory rise and the con-
valescence proper, then a modification of the treatment is neces-
sitated.  The direct depressants of the circulation are to be laid
aside, having served  their turn—and often well—and a line of
treatment is to be instituted which  is tonic or stimulo-tonic,
and yet calculated to control any tendency to temperature dis-
turbance.  Such measures we shall find in  the union of mineral
acids  with  vegetable tonics.   Nitric, muriatic, or phosphoric
acids in combination with cascarilla, cusparia, gentian or calum-
ba, and still more quinine, are good measures.  Any tendency
to constipation could be  met  by a dose of sulphate of magnesia,
either in the form of mineral Avaters or in  some pharmacopceial
preparation.  A good form of combination of acid and tonic is
 furnished by  the folloAving prescription:—
                     Ac. Hydrochlor. Dil. TTlx.
                     Inf. Cinchon. Flavas, §j.
 or it might be varied in  this manner:—
                     Quin. Sulph. gr. j.
                     Ac. Hydrochlor. Dil. Tfl_x.
                     Inf.  Cuspariae,
                     Aut  Cascarilla?, 3J.
 This might be given three or four times a day.  By such mea-
 sures the tongue cleans, the  appetite returns, the skin becomes 
            INFLAMMATION: ITS  VARIETIES.         127

moist and cool, the bowels  begin to move again; and that con-
valescence is steadily approached Avhich Avill  require a special
treatment—meet and suited to its Avants.
  Ere proceeding however to discuss the period of convalescence,
a feAv words as to the diet suitable to the first and second stages
of inflammation may be not altogether out of place.  The loss of
appetite which usually marks conditions  of pyrexia, especially
when accompanied   by  sharp pain,  and  the condition of the
primae viae indicate that any food taken at the  time should be of
a bland and non-stimulant character.   The digestive power is so
feeble that any solid food is out of place.   At the same time a
certain amount of food, of  force-bearing food  or hydrocarbons,
is much more indicated than  is at present thought; if judged
by the prevailing treatment.  In it beef-tea and its congeners
take a foremost place.   In reality, hoAvever, there is  little or
nothing of actual food  in  beef-tea, or  solutions of Liebig's ex-
tract.  They form agreeable and grateful beverages, but they
are rather stimulants than true nourishment.   The cups of beef-
tea which are  noAV so sedulously administered to the sick, in all
stages from  the malaise of  commencing fever  to the establish-
ment of convalescence, are  a  measure  of questionable utility.
They procure  a sense of "feeling better" after  their introduc-
tion into the system. But this often serves no good end.  The
feeling is procured by borrowing so much of the reserve strength
of the system, which might more Avisely be economized till the
hour of need.   Such practice is a part  of  that meddlesome offi-
ciousness wdiich must always be doing something.  Such inter-
ference often takes its origin in the bustling mischievousness of
a self-satisfied  relative, in  the ignorant though well-intended
suggestions of an anxious paterfamilias; and not rarely in a
desire to please the  friends and relatives of the sick person on
the part of the medical attendant, Avho feels it  safer  to folloAv
the fashions of the day  than to map  out a distinct and rational
plan of treatment and to stick to it.  As our knowledge pro-
gresses it seems more and more probable that systematic plans
of treatment will largely supplant the present plan of treating
symptoms, or groups of symptoms, as they arise, and of varying
the medicines and the food according to some passing phase in
the case itself.
  In supplying food  it should be at once bland, nutritious, and 
12*          INFLAMMATION: ITS VARIETIES.

easily digestible.  Such  a combination  is found in milk and
seltzer-Avater.   This forms a pleasant and supporting beverage.
It can be  easily and  readily  chilled by  the addition of ice.
AYhen so chilled it  is a febrifuge medicine, destroying so much
heat.  Iced lemonade forms a pleasant beverage.  Some persons
cannot take milk, and then it is necessary to  fall back on some-
thing else.   Lemonade and claret might  be given, as a beverage ;
and  a cup of beef-tea or Liebig's extract may  be given, or blanc-
mange, or  chocolate in a fluid form.   The coffee and milk hoav
procurable in tins, may be prepared according to directions, and
be permitted to cool ere  being given.1  This last is especially
indicated in the second stage.  Water, aerated or otherwise, can
be administered, usually Avithout  stint.   It  may be chilled or
acidulated, or both.  AVater in Avhich rice has been boiled, may
be used as  a combined food and beverage with advantage.   The
question of hoAV far alcohol is useful in the first stage of the
fever-rise, may well be raised.  The action of the alcohol on the
heart Avhile the skin is dry and burning, perhaps forms a strong
objection to its use, as  tending to raise  the temperature still
farther.  AVhen  the first stage  is over, then  alcohol  may be
resorted to usefully.   It may be  used at bedtime as a hypnotic
instead of the opium, or  Dover's powder, Avhich are better suited
to the first stage.   Its action on the skin lowers the temperature
and  conduces to sleep.   It may be given along  with portions of
food, and both  stimulates the digestion and  spurs the appetite.
As a food  it is readily  available; as a stimulant  it promotes
the  processes of assimilating food for  the body-needs.  It is a
grateful beverage, and a valuable auxiliary in  the  treatment of
sub-febrile  conditions, especially when subsequent  to  acute py-
retic states.  In the form of the brandy-and-egg mixture of the
Pharmacopoeia, alcohol  is very serviceable in  these conditions,
and even  in the more advanced stages  of a  typhoid condition.
As  the  convalescence becomes established the dietary may be
varied, and the more ordinary forms of food added.  Little al-
lurement in the nature of the viands  is  required  to tempt the
appetite in convalescence from acute disease; it is usually eager

   1 Vogel, in his  work on  Diseases of Children, recommends coffee as a useful
 stimulant in the ailments of children ; with good  milk or cream it is a good food
in conditions of depression. 
             INFLAMMATION:  ITS VARIETIES.         129

 and active,  and plain food is taken with  avidity, and  lar^e
 quantities are digested and assimilated with surprising ease.
   § 4S.  Some  readers  may feel surprised that no reference has
 been made to a plan of treatment introduced by Dr. Hamilton of
 Lyme Regis.  This consists of the administration of calomel and
 opium in  inflammations, especially Avhen serous or fibrous.   It
 has been much in vogue.  Probably there are practitioners avIio
 yet regard it as their sheet-anchor in the treatment of inflamma-
 tory conditions.   The explanations of its action  are so contra-
 dictory  and  unsatisfactory, and their success in practice over
 those who do not use this combination so trifling—if indeed the
 balance  is  not  rather  the other way—that it cannot be recom-
 mended  to young practitioners ; save and except in the treatment
 of inflammatory conditions of a syphilitic origin, or occurring  in
 a system saturated Avith syphilis.  Afy personal experience of it
 in other conditions is chiefly confined to having seen harm, often
 grievous, done by it.   The opium without  the calomel is Avell
 enough: or an  occasional dose of calomel Avhen the tongue  is
 foul is not objectionable.
   The general plan of treatment of inflammatory states may be
 aided by local applications of  heat and moisture.   Linseed-meal
 poultices are grateful  and beneficial, especially Avhen  there  is
 local suppuration.  They are  also good in pericardial and pleu-
 ritic inflammations.  In peritonitis they are too heavy ; here hot
 cloths sprinkled Avith turpentine or laudanum, or both, are often
 of the greatest  service.  At other times, lead, acetic acid, and
 opium are very useful.  In the  inflammation often found in a
 bruised or  injured part, cool and evaporating lotions, or a con-
 stant dripping of cold Avater, are most serviceable in moderating
 the excessive reparative action, otherwise knoAvn as inflammation.
 Local bleeding, cupping, or leeching, are often very desirable in
 controlling localized action, and in moderating the vascular
 fulness.  In  mammary abscess belladonna ointment smeared on
 the  breast  often givres great  relief.   Some  remedies used by
 quacks and old  Avives are not  Avithout value, and malloAvs,
 turnips, and carrots boiled, mashed and made into hot poultices,
 often give much relief, especially in  inflammation of the veins.
 The  "draAviug" qualities ascribed to various remedies of this
order by  the vulgar are not demonstrable, nor is the confidence
reposed in  them  by  the laity  as  to  this  power enjoyed by the
      9 
130          INFLAMMATION: ITS  VARIETIES.

profession.  The action of blisters and counter-irritants Avill be
explained—so far as they can yet be explained—in a forthcoming
chapter.   (Chap. XIII. §  132!!)
  § 49. Sooner or later a period of convalescence is established
and there exists no longer a sub-febrile temperature.  The pro-
cess of healing goes on triumphantly from this point.   There is
undisturbed sleep, a restored appetite Avith a renovated digestion,
and a recovery of the body-Aveight, until the pre existing Aveight
is again reached, or even exceeded.   The different functions of
assimilation, of  secretion and  excretion, are  once more acting
Avith unimpaired vigor, and the pristine integrity of the system
is recovered.   Such  is an  ideal  progress;  commonly a less
perfectly satisfactory  state of matters exists.   At these  times
there may be impaired functional activity and loss of tone.  The
food taken may seem not  to benefit  the patient, or there may
exist much torpor in  the gastro intestinal canal.   For the  latter
a dose of medicine, containing more or less of a mercurial in
combination Avith laxatives, is indicated.  Especially is this the
case Avhere there is a  furred tongue, the fur  having a yellowish
tinge, and there coexists a foul  taste  in  the  mouth on awaking
(under such circumstances the  addition of a slight amount of
a mercurial  is certainly indicated).  If the appetite is capricous
and assimilation  imperfect, then a  combination of vegetable
tonics and iron, Avith or Avithout  mineral acids, suggests itself
as most appropriate.  Consequently a mixture more or less like
the folloAving will be found advantageous:—
                   Tinct. Fer. Perchlor. Utv.
                   Ac. Hydrochlor.  Dil. TH.x.
                   Inf. Calumbae, 3J.
three times  a day, half an hour before meals.   If the mixture is
palatable and grateful, probably it will do' good.  If the palate
rebels against it, it will be better to change it  for something
else.   Citrate of iron and  quinine,  in  a  bitter infusion, may
be indicated  instead.  The bitter  acts beneficially upon  the
stomach;  the tonic action does good generally ;  while the iron
helps in  the  blood-formation.  Such combinations, then,  are
very serviceable, and  if the  bowels be  inactive  merely, with a
fairly clean  tongue, a little Pil. Aloe et  Myrrh at bedtime every
night or  every second  night will be found  sufficient  to keep
matters going straight.  A gentle action on the bowels is almost 
INFLAMMATION: ITS  VARIETIES.
131
 always useful at the commencement of a course of chalybeates.
 It often happens, too, that the combination of a vegetable tonic
 with iron does not quite agree Avith the  patient, and each dose
 is followed by a  disagreeable  sense  of feverishness, or as the
 patient says, " the medicine heats me  too much."   Here the
 addition of a little sulphate of magnesia Avill usually meet the
 emergencyT.
                   Mag. Sulph. Qss.
                   Quin. Sulph. gr. ^.
                   Liq. Ferri Persulph. Tfl_v-
                   Inf. Quassia3, §j. ter in die,
 forms an excellent and useful combination, Avhere the ordinary
 quinine and iron mixture do not perfectly agree.
   In convalescence it is  a great matter to see that it  be not
 interrupted.  If it be interrupted, the second progress is never
 so satisfactory as the first.  It is ahvays and invariably sloAver,
 at the least.   This is a  matter  Avhich cannot  be too  strongly
 insisted upon.  There are two  sources of disturbance to Avhich
 the convalescent is susceptible, and Avhich are the usual  causes
 of such interruptions ; these are febrile conditions from loAvered
 poAver of resisting changes of temperature, and  digestive dis-
 turbances.   The first  is- a  very common  and Avell-known cause
 of illness in those recovering from acute disease; and as such is
 generally Avell guarded against.  Great care about exposure  is
 very  necessary, and brief  periods of exposure  often bring on
 baneful consequences.  Any chill, however slight,  should at
 once be met by a Avell-Avarmed bed, some hot fluids with alcohol,
 and confinement to bed for twenty-four hours.   By such  means
 the cold may be kept off altogether ;  or, if not that, it may be
 hurried through  its different  stages,  and  so be  brought to a
 close  in a brief time.
  The other source of disturbance is also very common, and the
 rise of temperature is also very sharp.  It is more apt to happen
 when the appetite is just becoming very brisk, and is the conse-
 quence of what our forefathers termed  "a surfeit."   Here the
 old-fashioned remedy of an emetic, followed by a purgative is
 most  efficient.  If the  form of  the disorder be  mistaken for
 cold,  and therefore the correct treatment  missed, this febrile
condition may go on for days and cause much disturbance and
some  dismay.   It  is in children chiefly that  this  form  of ailment 
 132         INFLAMMATION:  ITS VARIETIES.

 is most commonly seen ; and any very sudden rise of tempera-
 ture should aiAvays arouse  the suspicion of acute indigestion.
   Commonly the progress  is unbroken, and the patient steadily
 gains strength  and Aveight.  It is often desirable to send con-
 valescents, if in a  town,  into the  country or to the seaside.
 Excellent effects are  usually so secured ;  but sometimes the
 change disagrees.   (This subject Avill  be further discussed in
 a  later Chapter, XXIII.)   Fresh air,  good food, pleasant sur-
 roundings, and cheerful society,  are all good and useful  adju-
 vants, to strictly remedial  measures.
   Such is the progress of a simple, or sthenic inflammation.
 At other  times  the convalescence is disturbed by some patho-
 logical  changes, Avhich  will be revieAved  hereafter.   But  it is
 not in the stage of  convalescence only that  there  are variations
 from this simple course; the character  of the febrile state may
 be quite different, and need appropriate changes of treatment.
   § 50. The most important modification  of the progress of
 inflammation and of its constitutional accompaniments is  fur-
 nished  by Avhat is  termed  "asthenic" or "low" inflammation.
 This is an aspect rarely presented by the youthful, the robust,
 or the rustic.  It  belongs to exhausted  systems,  no  matter
 whether reduced by prolonged ovenvork, fast  living, drunken-
 ness,  or  life in  insanitary  neighborhoods.  Existence in un-
healthy, badly-drained,  and Avorse-sewered districts, amidst an
 overcroAvded population, with foul air  and impure  Avater, Avill
produce such modifications in the system, that, Avhen  it becomes
the subject of an inflammatory   or febrile  affection, it  takes
the following aspect:—the  pulse is sharp, but unsustained ; the
temperature is  high, but liable to fits of collapse ;  there  is a
tendency  for the tongue  to become furred, and the typhoid
condition readily manifests itself.  Careful  observation of one
case in actual  bedside  practice will teach  more—and that too
far more effectually—than  any information that picture-writing
will convey.  There is a Ioav asthenic type of disease, once recog-
nized by  the  eye,  never  to be  forgotten, and  needing little
description.  In  the wards  of  hospitals,  with  broken-down
patients, and in  those physiologically  bankrupt, such cases are
very common.
  They are  not to be treated by depressants.  Such  treatment
sinks them at once.   They  require alcohol, ammonia, bark,  beef- 
V
             INFLAMMATION:  ITS VARIETIES.         133

 tea, milk, etc., in liberal  and unstinted quantities, and at brief
 intervals.  They do not possess that reserve fund of force, dis-
 cussed earlier in § 6, on  Avhich they can  live during an acute
 pyretic attack; and  consequently the Avhole plan of treatment
 has to be  modified  accordingly.   The  enfeebled system  has
 above all things to be supported.  The most effectual means of
 influencing the inflammatory process is  to  endow the system,
 as far as possible, with the poAver to assume the usual control
 over it.  The ordinary plan of treatment has to be reversed, and
 instead of loAvering the general condition in order to depress the
 inflammatory action, it becomes necessary to improve the gene-
 ral condition in order to  affect the inflammatory process bene-
 ficially.   Consequently instead jsf antimony we give  ammonia ;
 instead of laxatiAres Ave give barks ; and instead of slops Ave give
 the most  stimulating forms of food.  Neither is it irrational or
 illogical to do so.  In speaking of this  form of inflammation
 Erichsen  expresses himself Avith such  incisive good sense that
 he must be quoted verbatim.  He says, " It is the type that is
 affected by this constitutional  disturbance, its sthenic  or its
 adynamic character, as indicated by the  pulse and the tongue,
 and not the mere diagnosis of the local disease, that must guide
 the surgeon"—and I may add the physician too—" in the adop-
 tion of his line of  practice.  AYe  may  advantageously treat
 Avith antimony and blood-letting acute inflammation of the con-
 junctiva,  or that which is the  consequence of a wound of the
 lung, in an otherAvise healthy and robust  man of thirty; whilst
 in a broken man of seventy, ammonia,  bark, port Avine,  and
 brandy, would be equally proper; but if Ave were (except under
 peculiar and exceptionable circumstances) to reverse this treat-
 ment—to  stimulate the young or  vigorous and to deplete  the
 aged or feeble—we  should act  contrary to common sense,  and
 probably  destroy rather than cure  our patients.  It is of far
 greater importance to be  able to estimate accurately the true
 constitutional condition of the patient, than to be able  to form
 a minute diagnosis of  the precise seat, extent, and depth of the
 local mischief.  It is a fatal error, too often committed, to attach
 too much consequence to  the recognition of the local malady,
and to attach too little importance to the character of  the con-
stitutional disturbance attending it.  The  surgeon Avho acts thus
runs the risk of treating  the  name and not the thing.  If Ave 
134
INFLAMMATION :
ITS VARIETIES.
treat erysipelas or pneumonia as mere affections of the skin  or
lung, on one uniform plan, Avithout reference to the type of the
constitutional disturbance accompanying it, Ave shall miserably
err in a considerable proportion  of  the  cases.   But if paying
but little attention  to  the  local affection, except so far as its
characters indicate the general type of the disease, Ave make the
constitution of our patient  our guide, and deplete  or stimulate
according to the  state in which  Ave find it, and thus, perhaps,
treat tAvo patients with the same disease, so far as name is con-
cerned, on totally opposite plans, we shall not act inconsistently,
but in strict conformity to the natural condition of  the  patient
and of his disease."
  These  Avords are pregnant Avith thought, and contain a deep
and  subtle insight into the  actual  requirements of patients.
They should be read and re-read  by the student, pondered over
and  committed  to heart.   They  should be incorporated with
him, printed distinctly on  his brain-cells, and  coloring all his
trains of thought as  they pass through them, gi\Te a direction  to
his observations, and guide  his treatment whenever brought  in
contact Avith disease.  To be able to  recognize the distinctions
just given by Erichsen  may not be very useful  at an examina-
tion  table ; but it is of paramount importance  in dealing Avith
actual disease at the bedside.   It  is the gradual diminution  of
such poAver, along Avith such  strict attention to mere physical
diagnosis, that is making the  more correctly educated student
of to-day actually less useful to the sick man than his less per-
fectly trained predecessor in physical diagnosis—Avho Avas, how-
ever, a superior antagonist  to  disease—and so  has  done harm,
not only to the profession but to humanity generally.
  AYhen the inflammation assumes an adynamic or low type, the
treatment must be suited to the change.
                     Amm.  Carb. gr. v.
                     Sp. Chloroformi, TTI, xx.
                     Inf.  Cinchonas, Jj.
may be given every four or six hours, Avith Avine, especially effer-
vescing Avine, milk, beef-tea, or egg and  brandy; and at frequent
intervals.  The ethers of Avine make  it  specially suitable to such
asthenic conditions.   Effervescent beverages, such as brandy and
water  with citrate of potash, are of service;  and indeed the
utmost possible union of stimulants with tonics and nutritious 
INFLAMMATION :
ITS VARIETIES.
135
food is indicated, to get the organism  through the period of
peril Avhich is hanging OATer it.  The typhoid condition will ob-
trude its  grim visage in spite of everything, in some cases; but
the faintest appearance of  it should ahvays put  the  Avise and
thoughtful practitioner on the alert.  There is danger  hidden
behind it, wherever and whenever it shoAvs itself.  Its  appear-
ance should at once call out  our  most strenuous and energetic
measures (§ 41).
  Such a modification of the ordinary inflammatory process is
far from  uncommon, and  its early recognition, and the conse-
quent adoption of appropriate measures, will form an excellent
test of the natural good sense, and of  the genuineness of the
training of the medical man.  If he has so studied disease as
to make bedside practice merely subservient to the requirements
of examinations, it  is very probable that he will  make  his ob-
servations, and form his conclusions too late to be of service to
his patients,  or of credit  to  himself.  Too much  insistence, it
may appear to some readers,  is being made here on this power
of discriminating betAvixt different forms of one morbid  change,
according to the organism in Avhich it shows itself;  but such
power is of so great value in actual practice, both to patient and
practitioner,  that it is  well-nigh  impossible to lay too much
stress upon it—especially"  in  a work designed to enable the
student to meet disease as it presents itself in real life, and not
in the antiquated types of some examination tables.
   § 51. Such are the commonest forms of inflammation  as they
reveal themselves to  the  physician; but there is still  another
form of inflammation which it is  of the  greatest moment to
fairly comprehend, and consequently to knoAV how appropriately
to treat it.   Such inflammation as Ave will now proceed to con-
sider is excited by the presence of abnormal constituents in the
blood, or by  the presence in excess of what is quite  normal.
Under the first heading will come the chest complications of
measles, the suppurative inflammation of the parotid  glands in
scarlatina, and the  various complications of smallpox.   Under
the second heading can be classed the inflammatory processes
of acute rheumatism and the numerous inflammations of  chronic
Bright's disease.
  It is at once obvious  that  in such inflammatory actions—no
matter where located, or in what  tissue—one great point is to 
136         INFLAMMATION:  ITS VARIETIES.
remember their causation and  the indications  for treatment
furnished thereby.   If the exciting cause can be removed, the
consequential disturbances will vanish, at least in the  majority
of cases.  If the exciting cause cannot be removed,  then the
case  must  be treated  on  general  principles directed by the
exigencies of the case.   In the exanthemata, for instance, Ave
possess no means of  evicting or neutralizing the  poison, which
forms the initial point, and therefore Ave fall back on general
principles, and  treat the complication—as it is termed—either
as a simple inflammation, in Avhich  case the remedies  for a
pyretic state are those indicated for the  treatment of the rise
of the inflammatory  process; or if an asthenic type be  assumed,
the line of  treatment which has just been indicated  as appro-
priate in such  cases, is to be adopted.  The character of the
inflammation will rarely or never be dissociated from  the  type
of exanthem ; and when  an asthenic  type  is assumed by one,
the other will be found to present similar indications; for the
rash and the inflammation are but part and  parcel of the Avhole,
and  the  measures indicated by the  one are the  measures best
adapted to the other. In other cases, hoAvever, the line of treat-
ment to be pursued is that of the  condition generally  Avith
special  reference to the  individual cause.    For instance,  in
syphilitic iritis energetic treatment of the  syphilis is the best
line of treatment of the iritis;  and saturating the system  Avith
mercury will ordinarily give the  best results.  At  the  same
time it must be distinctly understood that even  here  the  type
of the inflammation cannot be overlooked.  The mercurial ought
to be given  along with vascular depressants or Avith stimulants
and tonics, according as each line is indicated by the characters
of the case.  That is, Avhile a mercurial course is being admin-
istered, the  appropriate measures  are  to  be combined with it:
and  according to the system in Avhich the syphilis is, so  must
be the auxiliary measures with which the mercurial is combined.
The syphilitic  iritis must be met; but Avhether  it shows  itself
in a robust  youth, or a broken-down  constitution, is  a matter
of importance in selecting the therapeutic measures to be com-
bined Avith the mercurial.
   When the inflammation rests causally  upon the presence in
excess of Avhat is normal in the blood, as, for instance, of lactic
acid in rheumatism, and lithic acid  in gout, the originating 
INFLAMMATION: ITS VARIETIES.
137  •
cause gives at once a direction  to the line  of treatment.  If
pericarditis come on during  the course of acute rheumatism it
does not necessitate any change  in the plan  of treatment.  It
merely indicates  the necessity for perfect rest—Avhich includes
the avoidance of pulling the patient  about  in the nimia dili-
gentia of diagnostic ardor—and the application of hot poultices
persistently and assiduously to the pericardial region, or rather
the Avhole of the  front of the chest.  Very few men now-a-days
—and  those only the practical  men, who, according to  Lord
Beaconsfield, are the men who practise the errors of their pre-
decessors—Avould think it  necessary to give calomel because
pericarditis had shoAvn itself; no matter Iioav strong might be
their vieAvs as to the usefulness of mercury in the ordinary
inflammation  of  serous  membranes.   The alkaline treatment
AArould be pushed more actively, and fuller closes of opium given
than before;  that would be the line  to be  pursued, not any
radical  change of plan in consequence of the complication, as
it must simply be regarded.   The condition  presented to us is
that of rheumatic fever, and the different complications which
arise during its course are part of  itself, and  are to be  treated
accordingly.  If a complication came on, not causally associated
Avith the prevailing  disease, as, for  instance, a sharp diarrhoea
in the course of acute rheumatism, it Avould be simply stupidity
not to treat it Avith its appropriate measures merely because it
occurred during  rheumatic  fever.  The natural common  sense
must be the director as to whether  the complication is a part
of the whole, or is an adjunct to be individually arranged  Avith.
To one  the relations may be clear and the  line to be adopted
quite distinct, Avhile to another  all is misty and obscure, in
which case it is not so Avell either for the practitioner or patient.
The  knoAvn sequences of ailments Avill give a clue at least in
the worst times of diagnostic trouble.
  The  most unfortunate evidences of the lack of discrimination
in discerning betwixt simple and specific inflammations, are  un-
questionably furnished by the inflammatory outcomes of chronic
Bright's disease.   Again and again are inflammatory affections,
in people of middle age and  adAranced  life especially, treated as
simple inflammations ; Avhen in  reality they  are gouty exacer-
bations  Avith local complications.  In  the form of  bronchitis,
pleurisy, arthritis, &c, Ave constantly see the  outcomes of  renal 
# 138         INFLAMMATION: ITS VARIETIES.

  inadequacy.   Xo one would dream of treating gouty inflamma-
  tion of the great toe as he Avould treat a Avhitlow, for instance;
  he would at once proceed on a recognition of the gouty element,
  and administer colchicum and alkaline laxatives freely.  In one
  respect the treatment would in no wise differ from a simple in-
  flammation, namely, that the inflamed  part be kept at rest—in
  as near perfect rest as  is  practically attainable.  But if feAv
  would make a mistake about gouty arthritis, there are hundreds
  Avho Avould as certainly overlook  the  gouty element in a case
  of bronchitis, and in doing so would fail to treat the case satis-
  factorily.  The importance of such  recognition Avas borne in
  upon  me with much impressiveness during my connection with
  the Public Dispensary of Leeds, Avhere I met Avith many cases
  of chronic bronchitis in winter, which  were unaffected by the
  ordinary measures.  A little careful observation and comparison
  enabled me  to classify  the cases; and  a  class soon stood out
  vividly where colchicum and potash formed a far more efficient
  cough mixture than any combination of expectorants.  By treat-
  ing the causation of the mucous rheum results could be achieved
  which could  not be attained by measures merely directed to the
  rheum itself.  The  different inflammations of serous and other
  membranes, which  arise from uraemia—alike the consequence
  of disease and the result of ligature of the renal arteries—point
  to the causal  relations of the morbid  actions, and demonstrate
  that in the removal of the exciting cause lies the best means of
  treating the  morbid changes.   Whenever inflammation is re-
  current in those at or over middle age Avithout  some very ob-
  vious exciting cause—as, for instance, inflammation of the liver
  from excessive drinking bouts—the renal origin of it must never
  be  forgotten, as a strong  possibility at least. AYherever there
  is an obvious exciting cause for  an  inflammation, such cause
  must be borne in mind and remembered in the treatment, if the
  practitioner  wish to be successful.   Perhaps few of us, hoAvever,
  learn to see  these  relations  clearly until after the chagrin  of
  clear and demonstrable error has been experienced.   In all in-
  flammations of a gouty nature, treat  the  gout first of all, and
  the inflammation in the second place; is  a rule well worth ad-
  hering to.
     §  52.  Parenchymatous  Inflammation.— A most  important
  modification of the nutritive processes is that known as paren- 
INFLAMMATION: ITS  VARIETIES.
139
 chymatous inflammation (Virchow), which is essentially a cell-
 proliferation.   It  consists of an  increase in the cell-production
 from the connective  tissue.   Connective tissue, or basement
 membrane, is  the loAvest form of organized tissue.  It forms the
 packing Avhich keeps  together the vessels, tubes, and nerves—
 say of the kidney, for instance.   When from any cause there is
 excessive vascularity in a part, there is an increase of cell-groAvth,
 a true hyperplasia.  In a muscle it may lead to increased growth
 of  muscular fibre, or hypertrophy.  In other tissues the growth
 is by development of connective  tissue, as  in the valves of the
 heart, for instance.  In the different viscera this increase in the
 deA^elopment of connective  tissues is Avell marked, where there
 has been sustained functional  activity.  Thus there is developed
 excess of connective tissue in the granular kidneys of the gouty ;
 where excessive and long-sustained functional activity has led
 to structural changes.  It may be occasioned by repeated local
 hyperaemiae,  as in  the gin-drinker's liver.  At other times it
 arises from  venous  congestion, as in  the increased  connective
 tissue of the lungs, brain, liver, spleen, and  kidneys,  which
 results from mitral disease  and arrested circulation.  It would
 appear that cell-growth may arise from congestion of the venous
 radicles as well as from arterial fulness.   It may arise from local
 irritation, as  in the chronic  interstitial pneumonia associated
 Avith the respiration  of organic particles in the miller, the mason,
 the potter, or  Avorkers in certain  departments of woollen manu-
 facture, etc.  Or  it  may be occasioned by  functional activity
 prolonged and excessive.   We have seen that much activity of
 a part is accompanied  by an increased vascular supply, probably
 through  the agency of trophic nerves: if this be ill controlled it
 may proceed to inflammation.  " Habitual use or over-stimulation
 of a part, by producing determination of blood to it, may readily
 drive it into inflammation." (Erichsen.) So Ave actually see that
 inflammation of the aortic valves is a very common occurrence
 where the occupation, or  the voluntary pursuit, leads to sus-
 tained high arterial  tension, and consequently violeut closure of
the aortic valves.  Thus in men Avho wield  heavy  hammers,
called strikers, such  ailment is very common.   Aortic valvulitis
is also common in the sustained high arterial tension of chronic
Bright's  disease;  where  the valves are closed violently, and so
become inflamed.   The  loud  sound produced  by the forcible 
140          INFLAMMATION: ITS VARIETIES.
closure of the aortic valves is to be heard constantly during the
course of chronic Bright's disease, and is of most valuable diag-
nostic import.  In the same Avay atheroma, which is  really cell-
proliferation in the Avails of the arterial system, is found locally
at points subjected to great strain; or as a general condition in
renal disease from the same cause as the aortic valvulitis, viz.,
over-distension of the arterial system.  Such  cell-proliferation
is the means  by Avhich arteries may be  thickened Avhen  their
work is increased; consequently atheroma is usually found along
with hypertrophy of the ventricle and similar change of the
muscular Avail of the arterioles.
  Such parenchymatous  inflammation is nutrition run a little
Avild.  It is however a conservative process originally.  AYhen
very excessive it beecmes baneful, but often it must be regarded
as a modification of  nutrition far from simply  injurious.   That
it amounts to  Avhat Ave call disease does not militate against the
vieAv that it  is a mere modification of physiological processes.
A pathological process is often  but an excessive or  perverted
physiological process.  Such is atheroma.
  There is one most important  practical lesson Avell  taught us
by atheroma, and which quite bears out what Erichsen said in
the foregoing quotation.   It is this.  The progress of atheroma
is Avonderfully modified by the  organism in Avhich it is found.
If in a hale and so-called healthy old person  it Avill go on for
years, undergoing little  change, and  rarely  endangering life,
except by  apoplexy.  In another  of broken  constitution, and
especially if  a drunkard, or saturated Avith syphilis, the cell-
products knoAvn  as  atheroma quickly  undergo  degeneration.
The patches on the  inner  coat  of  the bloodvessels soften and
break down  into  the puree of  peas, and, washing  out in the
blood current, lead to embolism on the one hand, and atheroma-
tous ulcer (geschwur) on the other.  Each of these actions en-
dangers life; and especially the open ulcer in the arterial Avails.
At other times, in other constitutions, the atheromatous degen-
eration  is  markedly calcareous, and leads to gangrene of the
limbs by the loss of arterial elasticity ; or forms a serious source
of trouble to the surgeon in ligaturing the vessel for aneurism,
or in amputation for gangrene.  Yet nevertheless in  these
different cases the essential starting-point is a parenchymatous
inflammation, a cell-proliferation of connective tissue elements 
             INFLAMMATION: ITS  VARIETIES.         l4l

 under the tunica intima ; but if the  initial process is the same
 the ultimate course is Avidely different.
   § 53.  The treatment  of  parenchymatous inflammation is a
 complex matter.   To  use the language of Herbert Spencer, Ave
 have to adapt complex concatenated measures  to complex con-
 catenated actions.  The AAThole of the origin and course of the
 parenchymatous inflammation must be subjected to a bird's-eye
 vieAV, and then each part of the Avhole is seen in true relation to
 the rest.   At the same time  each  part  should have  careful
 special attention given to it and  its needs.  If it be interstitial
 pneumonia in a mason Avorking on fine stone, he must leave his
 occupation and flee for his life.  As a police officer, a soldier, or
 an emigrant he may live ; but if he remain a fine heAving mason
 he will surely die  ; and that too before long.  If the  striker, or
 boatman, on the  first evidences  of  aortic valvulitis, quit his
 occupation and take to some lighter form of labor, he may live
 to a fair length of days.  But if he adhere to what has produced
 disease in healthy organs, the morbid processes  will be aggra-
 vated and the end accelerated.   If the gin-drinker reform, his
 injured liver may yet last  for years Avith  care.  If  the gouty
 man reduce his  consumption of nitrogen  to Avhat his kidneys,
 aided by his skin, can fairly eliminate, length of days may not
 be absolutely out of the question; but such prolongation of life
 is incompatible with self-indulgence.
   The removal, or, if that be impracticable, the reduction to the
 least possible minimum, of  the exciting cause is the first and
 most  important step in the treatment of parenchymatous  inflam-
 mation.  Any especial action of remedies is not  very applicable,
 except Avhen the chronic inflammation is within the surgeon's
 reach.  When so within reach  and not complicated with any
 functional activity, so that rest is attainable, local applications,
 first of opium, to lower the vascular  activity, and then  of
 mercury or iodine to remove certain  products, are available.
 A thickened joint  when placed at rest in splints  may be reduced
 by the use of absorbents : but it is quite a different matter Avith
 internal changes, Avhere such rest cannot be first secured.   Con-
 sequently  the use of  ioduretted or  mercurial  applications  in
 cirrhosis of the kidneys, valvulitis, or atheroma, does not sug-
gest itself as containing the elements  of possible  success.   This 
142         INFLAMMATION :  ITS VARIETIES.
is  not therapeutic  faith :  it is  credulity.   Rest, physiological
rest, is Avhat  must be aimed at for recovery and the arrest of
the morbid process;  removal of the morbid products cannot be
attained in chronic changes in the viscera.
  Attention to the general health, strict hygienic arrangements,
and careful avoidance of the various and special exciting causes
Avill often give very gratifying results in the arrest of parenchy-
matous inflammation, and in  escape from the consequences of
the morbid changes.
  § 54. Inflammatory products  are  not ahvays to be regarded
as a disease per se.   Very  frequently that  proliferation  of con-
nective tissue  Avhich constitutes  an inflammatory product is
useful and  conservative.   Thus  in perforating ulcer  of  the
stomach the products  of  inflammatory action  are often  the
means of preventing  the  ulcer opening  a  passage  into  the
abdominal cavity, which Avould be fatal.    By like means an
internal abscess, as of the  liver  or kidney, may safely make its
Avay to the surface.  In  cases  where disease is disturbed by
motion inflammatory products procure rest.   This is Avell seen
in the thickening around  a diseased knee.   By cell growth  a
certain support is given, as it were by a natural  splint; at  the
same time that the stiffness, so occasioned, aids  to limit move-
ment in the joint, especially in connection Avith the pain elicited
by motion and friction of the diseased surface, or surfaces.  In
a broken  limb Ave  see  first a general  infiltration of the part
around the fracture; and then a growth of cells from the peri-
osteum knoAvn as callus.  The less perfectly the part is  kept at
rest the greater the call for these consenrative efforts; the more
perfect the treatment the less the necessity for the reparative and
protective processes of nature.  It is ahvays desirable to limit as
far as possible any excess  in  these  natural  efforts, as the neAv
groAvth, having served  its  turn, may itself become a source of
trouble, or be unsightly.  Thus, for instance, in strumous inflam-
mation of a joint the thickening Avhich conduced to give rest
and limit  motion, and so saved suffering and favored reparative
action, may remain an eyesore, if not actually troublesome ; con-
sequently it becomes desirable to  exercise a certain amount of
control over such groAvths, and by reducing  the necessity for
them to a minimum to  get their good effects Avithout the draw- 
            inflammation: its  varieties.         143

backs.   If a fractured limb be carefully and skilfully placed at
rest, there is often no more new growth than serves for efficient
repair, and in a year or so the point of union may no longer be
detectable: if perfect rest be unattained, or unattainable, a mass
of callus will  mark the site  of  the  injury.  If strumous, or
other inflamed joints be put at perfect rest in splints, or leathern
or other appliances, the cell-groAvth, or natural splint, is limited,
and  is  ultimately  so  slight as neither  to occasion impaired
utility nor even deformity.  The inflammatory products are not
to be regarded as hostile, but rather  as friendly, if indiscreet,
allies.   They require guidance, and then they are beneficial; if
unregulated they are apt to become excessive.   The great point
is to limit their groAvth ;  once established, they are  apt to be
unmanageable.   Rest, pressure, and the use of absorbents (Chap.
XX.) will frequently aid the natural process of absorption,
Avhich  is often spontaneously  instituted after the necessity for
the new growth has passed away, and in a number of cases the
deformity is by these measures much  reduced.
   In spinal disease, Avhether lateral or antero-posterior, it  does
not matter, the vertebral column  yields under the superincum-
bent weight of the  head  and shoulders.  As Air. Erichsen points
out,this may occur  from rapid growth in the vertebral column;
or from the increased Aveight of the developing bust.  It is most
common in girls.   All the attempts of surgeons and mechani-
cians to push the spine straight by lateral  pressure have failed,
taken as a Avhole.  Dr. Lewis Say re, of Xew York, has Avith
trenchant logic  pointed  out  the elements of failure in these
incorrectly devised  plans.  Further.he has demonstrated  that
the correct plan of treatment is  to  take  the superincumbent
Aveight  off the Aveak spine by means of an external skeleton.
The patient is hung by the armpits, and the Aveight of the body
pulls the spine straight, or at least straighter, even in the Avorst
cases :  cambric bandages prepared with plaster of Paris are then
carefully applied, and the body kept  hanging until this corset
is dry and firm.  AYhen  this is accomplished the weight of the
head and shoulders  is borne by the external skeleton  resting on
the pelvic girdle; and the spine so relieved grows  healthy and
strong.   For further particulars   the reader must consult  Dr.
Sayre's  little book  on the subject.   It is somewhat  painful to 
144         inflammation: its  varieties.

one's national pride to find that British  so-called improvements,
on Sayre's  plan  so  commonly lose sight of the essential  prin-
ciple, viz., a well-fitting external skeleton to take the weight of
the head and  shoulders off the  imperfect  spine.  This logical
application of  the principle of procuring physiological rest for
an injured or diseased part, does Dr. Say re  great credit.  Other
measures to improve the  general health- may be adopted syn-
chronously with this treatment. 
CHAPTER  VI.
               ANJEMIA--PLETHORA—CONGESTION.

  § 55.  There are various states of the system depending upon
an insufficiency, an excessive amount, or an  irregular distribu-
tion of blood, which are of  much  importance in practice.  The
two first form general conditions of the greatest moment when
dealing Avith  many affections; the third is  also a condition of
much importance, and  stands  in  such relation to each of the
foregoing that it can only be properly considered after the first
tAvo have engaged our attention.
  Anaemia.—This  is a condition of general diminution  of the
bulk of blood.  It is a  condition Avhich occurs very commonly
in connection Avith blood poisons.  Consequently, as  has  been
pointed out before, it is found along Avith syphilis,  gout, lead
poisoning, malarial, infection, &c.  It may arise from imperfect
supplies of food, from starvation, or  it may take its  origin in
mal-assimilation, in impaired digestion. At other times it is clue
to drains  upon the system, as lactation, menorrhagia, or  leucor-
rhflea, chronic  diarrhoea, haemorrhoids; or thegroAvth of a malig-
nant tumor, robbing the system  to promote  its own increase.
In the first cases there is a poison  existing which  either breaks
down the blood-corpuscles, or  hinders their formation.  In the
second series  the blood is not  sufficiently fed by  the  nutritive
processes.  In the  third there is a  drain upon the system which
is impoverishing the blood.  A proper recognition of the causal
relationships of  anaemia is  of  the utmost value in giving the
right direction to the remedial measures.  It is of little use to
give haematics to a menorrhagic woman, Avhose system is simply
drained every three or four weeks; if at the same time measures
are not taken to check the drain.  Very often, indeed, it  is a
more successful  line of practice to stop the blood-loss,  and so
permit of blood accumulation; than merely to build up so much
blood to  be periodically  lost.   The one  substitutes  a  steady
progress  for the violent oscillations  of rapid blood-formation,
      10 
146
A N M M IA .
alternating with severe losses; which is induced by the other.
Especially is such plan desirable in stout women given to rapid
blood-formation.
  Anaemic persons are not necessarily spare.  Chlorotic girls often
become very fat.  At the same time there is  much lassitude,
drowsiness, muscular inertia, defective  secretion, and general
loss of tone.  Every organ feels the lack of arterial blood;  espe-
cially does  the brain feel it.  With the large amount of blood
normally in the encephalon and  its  rapid Aoav, a condition of
anaemia, Avith  defective circulatory  force,  is soon felt by the
contents of the cranium.   The sense of energy, so delightful to
all, is gone; and languor takes its- place.   The person is drowsy
when up, and feels as if he (or  rather she) never could  sleep
enough.  In bed, however, the rest  is broken  from  the  blood
floAving more freely into  the brain Avhen the head is laid upon
the pilloAV.  Consequently it is no  uncommon thing for such
patients to sleep almost propped up in  bed.  There is a great
tendency to neuralgia, which may be cranial, facial, or intercos-
tal.  "Pain is the  prayer of a nerve for  healthy blood," wrote
Romberg: and very commonly it is so.   When the  pain is in-
tercostal it is usually found in the sixth or  seventh intercostal
nerve of the left side in  women.  When so found it is generally
associated Avith suckling, or with  discharges from the genitals,
and usually with leucorrhoea.  Where there is pelvic irritation
it Avould seem that the nerve currents coming  up the splanch-
nics especially affect the spinal nerves, springing off at the point
of entry of the greater splanchnic into the dorsal ganglia.  From
each dorsal ganglion pass fibres to the intercostal nerve, and in
some  occult way the  sixth and seventh intercostal  nerves be-
come  the subjects of neuralgia in uterine, or ovarian irritation.
Such  neuralgia  rarely yields to general  treatment, unless the
reproductive system be also attended to, and the drain, Avhether
leucorrhoea or suckling, be arrested.  Neuralgia, or, in others,
pain in the vertex of the head,  are the scourges of anaemic
women.
  Palpitation is a very  common occurrence in states of anaemia,
and arises chiefly from nerve disturbance.  The roots of the
vagus  nerves are imperfectly supplied with blood, and  conse-
quently, the vagus cannot exercise its  wonted controlling or
inhibitory action over the heart.  As the bulk of blood increases 
ANAEMIA.
147
 the palpitation vanishes.   Haemic  murmurs, either aortic or
 pulmonary, are very common;  but ought rarely to be mistaken
 for the murmurs of organic  change.  The veins often give out
 a hum, the bruit de diablc, Avhich  is commonly regarded as the
 most marked physical sign of anaemia.   These murmurs of the
 circulation are very common in conditions of impoverished or
 diminished blood-supply; they are very curious, but their origin
 is scarcely yet established.
   Breathlessness upon  exertion is a very common  phenomenon
 in anaemia.  It is not due  to debility in  the diaphragm, the
 respiratory muscles, nor yet in the right ventricle.   These differ-
 ent factors may have some influence, but  they do  not form the
 essential matter.  The  real source is the  diminished amount of
 red corpuscles, and the impaired chemical interchanges result-
 ing therefrom.   The supply of oxygen is too imperfect for exer-
 tion and effort; and if these are attempted breathlessness folloAvs.
 Upon this  condition  of diminution  of  blood-corpuscles and de-
 fective oxygenation depends also  the fatness so often found in
 the anaemic, and especially in the chlorotic.  These pallid, pasty
 creatures often become very obese;  becoming paler, more languid,
 and breathless as they Avax  fatter.  The  fact is that they groAv
 fat from lack of blood-corpuscles to supply oxygen  to burn their
 hydrocarbons, and the  fuel becomes deposited as fat.  As they
 recover from their anaemia, and regain the bloom of health, their
 stoutness diminishes,  until they once more possess their  pristine
 symmetry.  Not uncommonly  the coloring  matter of the cor-
 puscles, dissolved  in  the hydraemic blood, is deposited  in  the
 areolar tissue, as in the dark  suborbital  patches of anaemia, and
 the general staining of the skin in chlorosis;  or passes aAvay in
 the urine as urohaematine.
   When anaemia is very marked  it  not uncommonly happens
 that there comes on oedema of the lower extremities. It is most
 marked at night, and is relieved  by resting in bed ; and  the
 SAvollen ankles  of the evening, on getting out of bed  in  the
 morning, present a normal appearance.   Here  the oedema is due
 to fulness of the venous radicles and atony of the circulation.
 It also disappears with  improvement in  the  condition of  the
blood.
  § 56.  The indications for treatment furnished by anaemia are
varied and important.   It is  obvious enough that  the measures 
148
ANEMIA.
indicated are those which will tend to restore the condition of
the blood to the norm.   Animal food, soups, broths, etc., are
indicated in small quantities often repeated.  Farinaceous food
alone is not desirable.  The blood must be built up by an increase
in the formation of blood-corpuscles.  In order to secure this the
diet must be fairly rich in nitrogen.   It  is desirable  that it be
of a stimulating nature, and it may profitably be combined with
wines of a generous character, as Burgundy, port,  or Madeira.
Exercise in the fresh air, cheerful society, and glancing sunlight
are all valuable auxiliaries.  Not uncommonly the anaemia will
assume a phase of the most obdurate persistency, and defy the
best laid schemes of the  medical adviser.  Under these circum-
stances a residence at a chalybeate spring is certainly  indicated,
and Bath, Tunbridge AYells, Harrogate, Gilsland, Moffat, at
home; and Carlsbad, Kissingen, Homburg, Schwalbach,  Pyr-
mont, Tarasp, or Orezza, on the Continent; and BallstoAvn, New
York, or the Rawlcy Chalybeate  Springs,  Virginia, may be
resorted  to with advantage.  The amount of dilution is a matter
of the greatest moment in attempting to bring the system under
the influence of chalybeates in many cases.  This  fact alone
often makes  the difference betwixt failure at home  and  success
at a spa.  At the same time the change of place and scenery, the
psychical impulses so inspired, and the  direction given to the
thoughts are all very useful.  The habits of others  at these cha-
lybeate springs often form a great  incentive to invalids, who
 are inclined  to be despondent, to exert themselves and so to aid
 in their OAvn recovery.
   At  the same time it must be remembered that very commonly
 anaemic patients are most difficult to manage from  the effects of
 impaired nutrition on the brain.  As soon as ever the blood  is
 at all enriched severe headaches come on and harass the patient
 extremely.  There is often, too, such cerebral excitement  that
 some depletory measure seems indicated, and relief is  not un-
 commonly brought about by bleeding from the nostrils.  Many
 writers have  draAvn  attention to these  consequences  of too
 suddenly filling the cerebral vessels with blood.  Dr. Handheld
 Jones says:—"Nothing is more  common than  to find anaemic
 patients complaining of headache from the administration  of
 the necessary  tonics, because their nerve-centres  have  been
 brought into such a state of  hyperaesthesia  by  the impaired 
ANAEMIA.
149
nutrition that they can hardly tolerate anything of a stimulant
nature.  A little excess, therefore, even of spanaemic blood, may
cause  distress to a feeble  brain, Avhich, after it has acquired a
more healthy tone, Avill bear and be benefited by a much larger
amount of much better blood.  The case is similar to that of the
starved man, Avhose very  preservation depends  upon his  being
fed most sparingly for a time."   In such cases chalybeates may
be combined Avith  bromide of potassium, as they commonly are
united in the treatment of melancholies.
                  Pot. Brom. gr. v. aut x.
                  Fer. Pot. Tart. gr. v.
                  Inf. Quassia?, ^j. ter in die,
is a  good combination under such circumstances.   At  other
times these  effects of debility  of the nervous  system—where
irritability is so associated with adynamy—may be obviated by
the combination of purgatives with the haematics or tonics.  A
good form is  given in § 49.  At other times lighter forms, as the
ammonio-citrate of iron in some  bitter infusion, may be given,
and  the  bowels acted  upon by saline purgatives, or  an aloetic
pill.   AYhere the anaemia is  associated Avith amenorrhoea it is
very desirable that  the   iron  and aloes  be  given  together.
Griffith's mixture with the compound decoction of aloes  forms
a good combination.   It  is hoAvever only suitable to be  given
before food;  and it is a golden rule that iron, as a pure haematic,
should be given after food and digested Avith it.1  Consequently
iron in pill Avith an aloetic purgative, is here  indicated.  Arsenic
may be conveniently added.  The folloAving form is  a  capital
combination:—
                   Arsenic,  gr. j.
                   Fer. Sulph. Exsic. sjss.
                  Pulv. Pip. Nig. 3j.
                  Pil. Al. et Myrrh, 31J.
                  In pil. LX. div.  1 bis in die.
Each pill to  be swallowed shortly after food.   Half a drop  of
01. Sabinae is an excellent  addition in amenorrhcea—an addition
now too rarely made.

  1 Many readers of the first edition  of this work have privately written to me,
pointing out that I advocate, as  at p. 31, iron to be taken  before food.  It is
often convenient to give iron with a bitter before meals; but in the face of the
above sentence I think I am clear of the charge of advocating the plan of taking
hasmatics, and especially iron, before  food. 
150
ANAEMIA.
  § 57. AVhere anaemia  is found  Avith  some  specific  poison,
then it becomes necessary to neutralize, to  destroy, or to elimi-
nate the poison by some  agent Avhich exercises a specific action
upon it.  It is here of as much importance to meet the  specific
poison by its antidote, as it is to  use haematics.   This subject
has been referred to before in §  31, and so need be but briefly-
alluded to noAV.   Very often, however, there are  drawbacks in
the remoter effects of the  antidotes  themselves ;  and  then it
becomes very necessary to  obviate these  secondary actions of
remedies whose primary action Ave Avish to secure.   For instance
in using mercury for the treatment  of syphilis,  the  effects of
the mercury upon  the organism  are often far from pleasing.
What then is to be done?  It is obvious  that the mercury is to
be used for the treatment of the syphilis ; consequently the effects
of the mercury which are not desired, but Avhich  are unavoid-
able, must in their turn  be met by the administration of good
food, of iron, and if necessary, of cod-liver oil.  Such a plan of
treatment is A^ery commonly indicated in the children  so com-
monly seen in our out-patients' rooms, Avhere there exists a con-
dition of anaemia,  or of impaired evolution, often taking its
origin in  the action  of  some  inherited  syphilitic taint.   In
other conditions of specific anaemia—as these anaemic conditions
depending upon  the presence of some blood-poison might pro-
perly be denominated, in order to distinguish them from the
other forms of anaemia not so occasioned, and which may fairly
be termed simple  anaemiae—similar plans are indicated.
  At other times anaemia may be associated with some profound
impression made  upon the nerve-centres,  or the  nerve-centres
maybe the parts most seriously iiwolved in the general anaemia.
The most obdurate case of anaemia ever brought under  my oavu
notice was that of a very healthy  girl—healthy both in herself
and her family history—whose father dropped down dead at her
side at market.  He Avas a  strong, hale man, and  nothing could
have been more unexpected. The shock so affected his daughter
that she became markedly pallid and anaemic in  a brief time;
and no combination of remedies, nor perseverance  in their use,
ever produced any effect, Avorth speaking of, in this girl.  What
is the true pathology of this condition, and Avhat the effect of the
shock upon  the assimilative apparatus, it is  impossible in the
present state of our knowledge to say.  Whatever it is, its action 
PLETHORA.
151
 is enduring.   At other times the  condition of anaemia is much
 relieved, and the general nutrition  is good, and yet there remains
 an anaemic condition of the  brain.  The person, usually a girl,
 is still drowsy and listless, and her lack of energy is  commonly
 attributed to indolence.  Indolence it  may be ; but hoAV comes
 it to be there in the midst of returning health ?  It depends upon
 an imperfect supply of arterial  blood to the cerebral  centres;
 and Avhen such condition remains the administration of iron and
 quinine, or of Easton's syrup, must be long continued.   AYhether
 it is that the cerebral cells have not regained their pristine power
 of attracting blood at Avill, and in sufficient quantity, or that the
 blood supply is itself defective; it is clinically  certain that iron
 and agents which exercise a decided action upon the nervous
 tissue should be  still continued, until the  lingering cerebral
 anaemia is successfully combated, and a  feeling  of energy is once
 more present.
   In anaemia there is rarely any very marked tendency to local
 congestions, but such occasionally occur.  This Avill engage our
 attention in the last division of this chapter.   (In the treatment
 of pronounced anaemia in girls, especially in chlorosis, it is good
 practice to send the patient to bed at the commencement of the
 treatment.  Improvement Avill often  set in after the patient is
 confined to bed, under the same remedies that fail to do good
 before, while she Avas engaged in her usual avocations.)  This is
 an expression of opinion Avhich further experience corroborates.
   § 58.  Plethora.—This is a  condition Avhich does  not loom so
 largely  in the professional mind  now as it did a generation or
 two ago.  AYhether there is not so much gross feeding now as
 there used to be—as in the days of old, when Queen Elizabeth's
 maids of honor had so much beef and beer at breakfast, dinner,
 and supper; or Avhether  there has some inexplicable modifica-
 tion of  the constitution come over us, as some very careful ob-
 servers  assert, it is impossible to  say;  but plethora  is very far
 from being the prominent subject  now that it Avas of yore.  No
 reader of George  Eliot's  admirable works of  fiction can have
 failed to be struck by the frequent introduction of medical sub-
jects into her conversations, and by the perturbation of the
 minds of the subjects of George III. on  the important affair of
 the lowering  and feeding  methods  of treatment.  That the
 opposite method to that Avhich the individual really required, 
152
PLETHORA.
was  the one espoused by each in each  case; is one of those ex-
quisite delineations  of real life Avhich are so characteristic of
that gifted authoress.
  The most characteristic instances of plethora are furnished by
the type of individual which used to  be regarded as  the apo-
plectic par excellence.   Such individuals Avere short, stout, florid,
short-necked,  and  short-Avinded.  Christmas,  as old Father
Christmas, is a Avell-known instance of the plethoric individual.
It is commonly denominated the alderman type, and is certainly
associated Avith good living.  In fact  plethora depends upon a
redundancy of red blood-corpuscles.   The bloodvessels are full,
often turgid, and  the capillaries distended.  There is usually an
hypertrophied heart; but there is rarely palpitation, in men at
least.  In Avomen sometimes there is a certain amount of dila-
tation Avith the hypertrophy, and then there is palpitation.  The
bloodvessels of the face  are  dilated, atheromatous, and gorged
with  blood. Very commonly the arterial tAvigs are distinct and
wrell-defined.  The face approaches in appearance the face char-
acteristic  of the  old stage-coachman and the modern engine-
driver; but with this difference, that in plethora the condition
of the face  is only that  of the vascular  system generally.  In
consequence of their wealth of red blood-corpuscles, and their
full  supplies of nutrition, such  persons are  generally warm ;
they  Avithstand cold Avell,  and they do not readily suffer from
exposure.  But they are usually somewhat inactive bodily, not
always  from lack of energy  by any means,  but  from what  is
understood as fulness of habit.   They are to  be seen commonly
in charge of  brewers' Avagons, and about breAveries; though
the type exists in other  ranks of life, and in all grades.   Such
persons are not uncommonly mentally  energetic, in fact they
are often gouty, Avith the energy and  hasty temperament of the
gouty.
  There is in such persons  a strong digestive power, and a liking
for generous food and for alcoholic drinks. The tongue is rarely
clean.  The bowels may or may  not be active; but the motions
are  ahvays very offensive.  The urine  is usually laden with
lithates, and the liver is often  gorged ;  and  bilious purgiugs,
naturally instituted, are not uncommon.  The relation  of the
condition of plethora to the free consumption of animal food is
seen  in its frequent occurrence in butchers, pork-butchers, pub- 
PLETHORA.
153
licans, and butlers.   In women the  same type prevails, and, if
very pronounced, gives a bloated appearance.  Here its origin
is the same as in men.  It not rarely happens, however, that
such Avonien are  the subjects of amenorrhoea ; and that too of an
obstinate nature.  They are commonly sterile ; especially if this
plethoric condition takes place in early life.  Such  women are
very short-winded, and asthmatic, as they term  it.  It is  Iioav-
ever little  more than the shortness of  breath of  the  obese.
They are not  rarely the subjects  of palpitation.   As  to  their
secretions and excretions, they have the character given above.
  These plethoric individuals are very subject to apoplexy ; it
Avas a mistake, however, to associate apoplexy exclusively Avith
persons of this build and type.  The vascular turgescence, Avhich
exists, leads to different changes in the circulatory organs. The
heart is  poAverful and Avell-nourished, in Avhich respect  it re-
sembles the muscular  system  generally.   The bloodvessels are
Avell filled, and the blood is driven on by a poAverful  ventricle.
Consequently  the blood-pressure is high,  and an atheromatous
condition of the bloodvessels is, sooner or later, induced by the
over-distension.   It can be no matter for  surprise that the thin-
AATalled vessels of  the  brain  often give  Avay in  such persons,
especially under excitement—Avhen  the  smaller vessels of the
encephalon are dilated, and the current   of blood is large, and
driven by an energetic and active ventricle.  The association of
apoplexy with hypertrophy of the left ventricle was long ago
pointed out by Rokitansky ; and the observations of that great
pioneer in pathology have  been corroborated by  numerous  other
pathologists.   The strong action of the heart is exaggerated by
the condition  of the arterial Avails, and  the pulse  is Avell-sus-
tained, and the arteries are resistant and  incompressible.  This
form  of pulse  is usually  regarded as  a  typically good one
rather than as illustrating  an abnormal form.   It  is an  abnor-
mal pulse, however, and as such must  it  be  regarded.   The
fulness of the vessels of  the face is  not unlike the condition of
the vessels of the head, and  both are but  parts of a general
condition Avhich is knoAvn as plethora ;  and Avhich  requires a
certain line of treatment, suited to its needs and  adapted to its
exigencies.  No  matter Avhat the form of ailment to be treated
in the plethoric, the line of treatment must ever be that which
makes the plethora the most prominent and  leading object.  In 
154
PLETHORA.
some  there  is much abdominal fulness, Avith congestion of the
lh-er,  and not rarely haemorrhoids.   The discharge from these
haemorrhoids is often most useful, and forms an excellent drain
on the vascular system too turgid Avith blood.   Very frequently
the disinclination to exert themselves bodily  in  such persons
is  marked, and, the appetite  remaining  good, the plethora is
thus aggravated.  Often, too, in plethoric females the heart is
not equal to much exertion, and exercise cannot be taken ;  and
so the congestion and fulness of the abdominal organs is unre-
lieved, as it Avould to some extent be if exercise Avere  feasible.
  § 59. Enough has been  said to enable the reader to see that
this condition gives  distinct indications for treatment.  There
are two  lines of approaching  the condition of plethora;  both
effectual, but neither of them likely to  be  agreeable to the
patient.   The one is to diminish the blood-formation ; the other
is to loAver the vascular fulness by  measures of depletion.   The
effect of  either plan, in  reducing  the  vascular supply to the
brain, is to lessen the sense of Avell-being, bien-etre, Avhich takes
its origin in a good supply of arterial blood  to  the posterior
lobes  of the brain.  The free vascular supply to Avhich they have
been accustomed makes many of  these patients very susceptible
to any depletory measures; and  they readily cry out that the
plan of treatment is " too lowering." It is this sensation of bien-
etre Avhich has lured them along the path they have taken ; and
Avhen  they  feel at   all depressed or deprived of energy, they
commonly rebel at the treatment.   It is not difficult  to see  that
such should be the case.  If they feel the better of their food,
Avhy should they not go on taking  it, is their argument; and as
they cannot be supposed to be  familiar with chronic pathologi-
cal processes, they are easily induced to persist in their wrong
course.  The matter must be explained to them, and they must
be made to see  that a lessened sense of  energy and of feeling
Avell,  is directly connected with their  future Avelfare  ; and  that
it is undesirable to  subordinate the future to the present.
   Having taken this precautionary measure,  it  then becomes
expedient, firstly, to diminish their food  in  quantity, and  still
more in  quality. Such persons like good food and enjoy it, and
poor food they are averse from.   Their soups are good and their
sauces rich.   It becomes necessary, then, to alter the character
of their viands.  Instead of rich entrees they may profitably take 
PLETHORA.
155
 a little more fish, and in place of Marcobrunner and Burgundy,
 they should take vin ordinaire, or Niersteiner.  Port wine after
 dinner should be avoided, and claret substituted.  The quantity
 too may be reduced Avith advantage.  If the patient be a coach-
 man or a brewer's man, he must be instructed  to diminish the
 amount of  malt liquor he takes.  There must be a reduction  of
 both food and drink, and the amount taken must be proportioned
 to the Avants of the system, and not to the gustatory tastes  of
 the individual.  Rich animal  food  must be indulged in but
 sparingly, and those adjuvants to a good appetite, piquant sauces,
 are quite superfluous.   The  meat should be plain, so  as not  to
 be too tempting.  If the appetite be brisk, fish should form a
 large portion of the  chief  meal.  All  appetizers,  as  gin  and
 bitters, are  quite uncalled for;  and the frequent draughts  of
 alcohol in Avhich some plethoric individuals indulge, are to be
 strictly forbidden, or very much limited.
   Then it is very desirable that exercise should be  taken, so  as
 to meet and neutralize the  large amounts of  food consumed.
 One north-country squire Avell  known to the writer knew the
 value of exercise well, and  not  a laborer on his farm Avorked
 half so hard for his bread as he  did—in  order to indulge in the
 pleasures of  the table  Avitli impunity.  Some  years after the al-
 lotted span had been  reached, the plan  Avas Avorking famously.
 Where exercise  is not so taken —and Avith many it would be
 impossible—then abstinence and depletion must be its substitutes.
 The meals must be fewer, more sparing,  and of poorer quality.
   Then there must be  established a system of depletion.  At
 one time  bleeding was much in vogue,  and persons Avere bled
 periodically for  plethora.  But this  is a radically bad  plan.   It
 is well  knoAvn that losses of blood  are  often rapidly repaired,
 and the more often repeated the loss, the greater  the assimilative
 poAver.  Consequently  Avhen persons are bled  at frequent inter-
 vals the blood-formation is rapid; a  state of recurrent plethora
 is SAviftly induced, and the distension of the bloodvessels arising
 therefrom is a great source of danger, and especially of apoplexy.
 The same may be said  of any other form-of depletion, including
 intermittent  purgation.   The thing to be  aimed at  is a steady,
continuous drain.  This is often established by haemorrhoids,
and  in some plethoric individuals  the arrest of this loss from
any cause is followed by general vascular fulness, injected couir 
156
PLETHORA.
tenance, and dyspnoea; all of Avhich disappear Avhen the bleeding
from the piles recommences.  The same symptoms follow from
the temporary arrests of other drains.  Then the  boAvels must
be acted on ;  and this action must not be restricted to keeping
the bowels  open, or even  Avell  open, it  must amount  to free
purgation.  For  this purpose saline purgatives  are chiefly in-
dicated.   If vegetable agents  are used it must only be  in  con-
nection with mineral salts, as  in the Avell-knoAvn black draught.
Purgation, Avhen  continued,  forms an exhausting  discharge;
Avhen artificially induced in plethora it forms an excellent reme-
dial agent.  The bitter water of Fredericshall is one of the best
purgatives Ave possess for the relief of plethora.   The dose can
easily be  regulated so as to merely open the bowels, or to cause
active catharsis.  Other Avaters possess similar properties.  The
advantage of purgation is that it can be continued steadily week
after Aveek, and month  after month.  It is this that qualifies it
so Avell for the treatment of  plethora.  A brief residence at a
sulphur spring is a very good  measure, but then it is too often
temporary in character. It  is very instructive to see the number
of stahvart and full-fed plethoric individuals who gather together
at Harrogate, as soon  as the Avarm Aveather cuts  cIoavh their
poAver of  getting rid of their  food  by oxidation.   The bracing
air, charged Avith oxygen, and the  sulphur springs combined,
give Harrogate a great advantage over most other health resorts,
as the number of persons drinking the Avaters in the pump-room
every morning, and then, after a walk, besieging the numerous
cloacae, abundantly testify.  After such a course the pleasures
of the table resume their wonted attractiveness.   Without such
a course,  in many of these habitues life would soon  be extin-
guished.   Where this  line of treatment  is impossible, or the
necessity for purgation is continuous and persistent, such natural
waters can  be purchased  in  bottles and  drunk  at home.  If
mineral salts be used it is desirable that they should be diluted,
in imitation of the natural waters.  Waters charged with purga-
tive alkalies are specially indicated  where the tongue is foul, and
there are,other evidences of biliary  turgescence.  It  is scarcely
desirable  to take mercurials constantly, and alkaline purgatives
are the best for continuous use.  AVhere there is a weak and
dilated heart, such Avaters are indicated as contain both saline
constituents and a certain amount of chalybeate matter.  Very 
congestion.
157
often a little  chalybeate water goes Avell with sulphur water-
not combined before drinking—and the union of these two at
one  spa is a great advantage.   When  the  patients are of the
humbler ranks of life, and a summer at Harrogate and a winter
at Bath are out of the question, artificial substitutes for these
spas are quite feasible.  Salts of various kinds are attainable,
and  perhaps the best is furnished by sulphate of magnesia.
                      Mag. Sulph. 5SS.
                      Sod. Pot. Tart. 9y.
                      Inf. Gent. 3 ij.
taken warm every morning, or second morning, will be found to
relieve the portal circulation Avithout destroying  the appetite or
disturbing the stomach.  Often, however,  the loss of appetite
is the best thing  that  could happen—and  this natural loss of
appetite in plethoric individuals is an  instinctive action which
should not be hastily interfered Avith.
   Such is the line of  treatment to be pursued  in the cases of
plethoric  individuals.  But the discriminating medical man will
soon learn to distinguish  betwixt those cases Avhere depletion
simply  is indicated, as in  sthenic plethora, and those cases of
asthenic  plethora, where  the  florid  complexion  and SAvollen
capillaries are associated with a weak heart and a compressible
pulse—where iron and tonics may be profitably  combined with
depletory measures.  He will also bear in  mind that the treat-
ment must be persistent to meet an enduring condition.
   § 60.  Congestion. — Congestion  differs   from   inflammation,
though it may be very commonly an  early part of the inflam-
matory  process.  Congestion  means  dilatation  of  peripheral
bloodvessels, Avhether external or internal.  It is most commonly
seen in the act of blushing ; it has also been  seen in the tails of
newts after amputation from the body.  It may be chiefly located
in the arterioles, as in  general plethora ; or  it may be situated in
the venous  radicles, as in the venous congestion resulting  from
impaired circulation,  especially when  due to tricuspid insuffi-
ciency.  When congestion is  long continued various changes
take place.   If it be a  serous membrane, there is  usually effusion
into the serous sac.  If a viscus, there is usually a development
of connective tissue; as  is so frequent in the  venous congestion,
the backward flow, or ruckwirkung, of chronic valvular disease
of the heart.   Under these circumstances there is commonly 
15$
CONGESTION.
 albuman  in the urine, as there is after ligature of the renal
 vein.  Under all circumstances, long continued congestion leads
 to tissue changes, and so  should be obviated as far as possible.
   We have just seen Iioav much congestion of the viscera is asso-
 ciated Avith a condition of general plethora; and have further
 seen  how such congestion can  best be met.   Poor food and re-
 peated depletion by various measures are the means by Avhich
 it must be met under these circumstances.  They had better be
 guarded and  persistent than violent, and at  intervals  merely.
 When indicated, they had better  be set on foot Avithout delay.
 The result apprehended may occur before the plan of treatment
 is inaugurated ; as once happened to a patient of my own.   lie
 left my consulting room in jubilant spirits;  Avrote to his friends
 as to what he Avas going  to do.  He went to bed at his hotel,
 and could not be roused.   They broke into his room, and found
 him  dead  in  bed.  At the  autopsy there Avas found an hyper-
 trophied heart and a large blood-clot in his brain.  The means
 of relieving congestion of the  portal circulation in  such  cases
 have  been  given  in  the preceding section.   In addition to
 purgation, a few leeches to the anus are an excellent measure in
 congestion of the liver, etc.   If there be uterine congestion, a
 leech to the os uteri is often advantageous.  In this last affection
 Ave see one of the frequent causes of congestion, viz., irritation or
 sustained imperfect function   AYhere congestion of the uterus
 is due to ungratified sexual aspirations, to imperfect intercourse,
 or to substitutes  for intercourse, its pathology  is as follows:
 There is that arterial fulness which is normal and physiological
 —if the condition be also normally relieved  by orgasm, and
 secretion from the glands of Naboth synchronously Avith the
 secretion from the glands  of  Buvernay—that  is, if there be
 natural intercourse.   Under other circumstances the  natural
 relief is not obtained, and the gorged vascular condition remains.
 This acts upon the cranial centres, through the numerous spinal
 fibrils in the nerves of the reproductive system, and the cerebral
 excitation maintains a dilated  condition of the  bloodvessels of
 the part.  The consequence of this is that the uterus becomes
 enlarged, heavy, often hot, and subjectively a source of disturb-
 ance.   It is the subject of congestion Avhich is  vascular truly,
 but Avhich  takes  its origin in  nerve-disturbance first.  Such a
condition, alike in the spinster and the Avife,  is kept up by 
CONGESTION.
159
 ovarian  mischief (see  §  187).   Consequently, not only  must
 measures for the relief  of the circulation be adopted, but meas-
 ures for lowering the nervous action must also be had recourse
 to.  Therefore  not  only ought the uterus to be  unloaded by
 local abstraction of  blood—and this should be accompanied by
 a general depletion of the portal circulation by purgatives—but
 certain neurotics, known to possess an effect upon the nervous
 system generally, and on the nervous supply of the reproductive
 organs in particular, must be exhibited.  Bromide of potassium,
 hyoscyamus, and camphor are the agents in most repute  for
 such purpose.   The different measures  may be profitably com-
 bined.   But other  addenda suggest themselves;  such as the
 avoidance of any load in the lower bowels, any irritation in the
 rectum,  any local  irritation of Avhatever kind ;  or  anything
 which might lead to local  congestion from its effect upon the
 nervous centres  first, whether intrinsic or extrinsic. All strain-
 ing at  stool, horseback  exercise, which produces pelvic conges-
 tion, heavy clothes hanging from the waist and compressing the
 peh'ic  viscera, hot rooms, and soft and Avarm arm chairs should
 also be avoided.  No remedial measures Avould  be at all likely
 to be  successful if  the  patient  lay in a warm room, on  a  soft
 couch, and read French novels; or if she  worked  steadily at a
 double-treadle sewing machine.
  The  liver is especially liable to congestion, and here again the
 measures just enumerated for the relief of  a loaded portal circu-
 lation  may be profitably resorted to.  But  here it is desirable to
 avoid  another set of conditions Avhich would tend to- keep  up
 the congestion.   First  is the avoidance of alcohol; especially
 when in large quantities and undiluted.  If this agent be taken,
 the excessive vascularity of the liver will be kept up in spite of
 free  purgation.   Another  thing to  be avoided is indulgence in
 highly-spiced and rich  dishes.  By such  food a condition of
 biliary, as compared with true vascular, congestion will be kept
 up.  At the same time large hot poultices over the  region of
 the liver will often induce  those discharges of bile which give
 such relief  in congestion of the liver.   The  use of  poultices
 over the  liver is far from being as common as it ought to be.
  The  kidneys may be,  and often are, congested, and when this
is the case great relief will be afforded by free action on the
intestinal canal; for such  action not  only forms a derivative, 
160                    CONGESTION.

but the relief of the portal circulation  has been found to ease
the renal congestion.   The skin  must be freely acted upon by
Avarm baths.  Such action of  the skin produces the same effect
in depurating  the blood as  is achieved  by the action  of the
kidneys ; Avhile it loAvers the blood-pressure generally, by the
dilatation of the cutaneous vessels.   Alere local measures, such
as Avet or dry cupping  over the  loins, mustard, and blisters, or
hot poultices dusted over Avith mustard, are also efficacious.  All
these various lines of  treatment may be combined in cases of
acute congestion of  the kidneys, which so commonly threatens
the existence of man.
   Congestion of the  lungs is a common consequence of cold.  It
also arises from disease of the left side of the  heart.  Further,
it is frequently seen in the course of severe  attacks of  fever,
especially in asthenic systems. It becomes at once  obvious that
the treatment of pulmonary congestion must rest upon its causal
associations.  Where it arises from cold it  is usually necessary
to throw the skin into  free action, and as the cutaneous  vessels
dilate  the pressure is reduced in the pulmonic circulation, and
relief is obtained.  This plan succeeded admirably in a case of
haemoptysis recently under treatment.  Where it  is associated
with cardiac mischief, it is  desirable  to enlarge  the general
vascular area by dilating the cutaneous bloodvessels of the trunk
by a jacket poultice, thus taking off from the distension of the
right ventricle;1  and also  at the same time  to stimulate the
gorged right ventricle to contract upon its contents by admin-
istering digitalis, along  with ammonia,  spirits of chloroform,
or alcohol.  When, hoAvever, pulmonary congestion arises during
the  latter stages  of an adynamic type of fever,  it is Avhat is
usually termed hypostatic,?', e., the result of the action of gravity
merely.   AYhen the patient lies upon his back, as he does in the
typhoid condition, the posterior portions of the lungs are among
the  most dependent parts of the body.  The  blood collects  in
them,  from lack of tone in the vessels to prevent  such stagna-
tion.  It becomes at once apparent  that under these circum-
stances stimulants must be administered, and freely too, in order
to maintain the poAver of the circulation.  But more than that,

   1 The effect of heat upon the heart must not be altogether overlooked: it is a
not unimportant factor in the treatment. 
CONGESTION.                    161
mere  position is not Avithout its importance.  As long as the
patient can turn over on either side, the lung of the other side
is to some extent unloaded, and so relieved.  Old practitioners
are always hopeful of fever  patients so long as they can turn
over.   The same species of hypostatic congestion is found under
similar circumstances in the  kidneys; and  Avhen the power to
turn  over is lost, it is a good practice  to roll the patient first
on to one side  for an hour or tAvo, and  then on to the other, in
order to mechanically unload the congested viscera of each side
alternately, especially in advanced typhoid  states.  Such mea-
sures, combined with stimulants, are often successful in enabling
many fever-stricken patients to recoA^er from a condition which
ever gravely  imperils the existence of the organism.
  At other times there exists a state of congestion of the lungs
which commonly enough is the immediate precursor of tubercle.
If this condition of vascular congestion persists, cell-growth,
its  sequel, will usually  not be long deferred.  Sometimes this
congestion  is relieved by  local  hemorrhage, haemoptysis ; and
hoAvever alarming at the time, and to the subject of it, there is
no room  for doubt but that at times haemoptysis is one of the
very best forms of local  bleeding.  It can, however, often  be
obviated by purgation, or by increasing the action of the skin;
and these measures may often be advantageously aided by giving
a fillip to the driving power of  the  heart.   The haemoptysis of
early  or quiescent lung-mischief is usually associated with con-
stipation, and is relieved by purgatives.  It is quite common at
Victoria Park Hospital for patients to neglect to procure another
letter when much improved ; and  in a  feAV  Aveeks to find them
again in attendance.   Without the  medicine they became con-
stipated ; this led to  haemoptysis, Avhich drove them once more
to the hospital.  The lungs furnish distinct illustrations of the
various forms of congestion, and of the  different measures to be
adopted in each case, according to its causation and associations.
  Cerebral congestion illustrates Avell the  association  of local
determinations of blood, otherwise known as congestions, Avith
conditions either of  anasniia  or  plethora.   The feeling as if a
bolt Avere driven  through  the forehead, together with vertigo,
pulsation of the carotids, and a flow of distorted ideas, is charac-
teristic of cerebral hyperaemia Avith  plethora; as dull headache
       11 
162
CONGESTION.
and a feeble pulse, are indicative of asthenic  hyperaemia; not
uncommonly found along Avith states of general anaamia.   The
treatment of these allied  yet  dissimilar conditions,  is Avidely
different.   In each form hemorrhage  from  the Schneiderian
membrane will  often  give  relief:  and so far as local measures
are concerned, there is little difference betwixt sthenic and as-
thenic congestion.  It is in the general treatment that the differ-
ence essentially lies.  To treat asthenic congestion Avith a sharp
cathartic, might possibly be successful, but it will be much more
likely  to  be  harmful;  Avhile in  sthenic cerebral congestion, it
Avould form an excellent measure, indeed the first to be adopted.
Low diet, purgation, and the derivative action of mustard to the
calves of  the legs, or the foot-bath of  hot  Avater and mustard
are indicated in active hyperaemia.  Even bleeding may not be
altogether out of place. But in asthenic cerebral  hyperaemia,
stimulants and tonics, together Avith agents improving the circu-
lation, are just as certainly required.  The fulness may be arterial,
and need  depletion; or it may be venous, and need stimulation.
According to its pathological relations will  be its treatment, if
the practitioner be thoughtful  and wary.
   § 61. So closely is oedema associated with congestion that it
is necessary to consider it  here.  It may be of varied origin;
but it is rarely allied with sthenic congestion.  It may be occa-
sioned, and often  is, by  venous fulness  with  pressure on the
A^enous radicles.   As such, it is often  found in the loAver limbs
when  the circulation  is defective, either from cardiac failure;
obstruction to the circulation  through  the lungs; or general
debility, either in simple anaemia, or in conditions of advanced
disease.   It is found in either upper or lower limbs Avhere there
is pressure upon the venae cavae, or upon the main venous trunk
of a limb.  It is also  found in renal disease.  If chronic, it is
partial, but more or less extensive; if acute, it is general, form-
ing anasarca.  It indicates a condition of blood in which there
is hydraemia, or an excess of water.  Consequently the measures
best calculated to relieve it are those which  improve the circu-
lation, or aid in the elimination of Avater.   Often these may he
combined Avith advantage.  AYhen the circulation is at fault the
treatment for cardiac dropsy  (Chap.  XIV.  § 141) must  be
adopted.   AY here the  emunctories of  Avater are acting imper- 
CONGESTION.                    1^3
fectly, the bowels and the skin may be called into requisition as
auxiliaries to  the inadequate action of the  kidneys (Chapter
XVII. § 172).   At times relief may be  given by permitting
the effused fluid to find its way out  by prickings or incisions.
If the oedema  be cardiac, Avithout  renal complication, this last
plan is less effective than when there is a renal factor in action. 
CHAPTER  VII.
                      GROAVTH AND DECAY.

  § 02.  As  an apple groAvs, ripens, and then decays, so does
the human  organism.   It has its  three periods too:  1, the
period of growth;  2, the maintenance of integrity ; and 3, the
period of decay.  There  are  many matters  connected with the
first and third periods which  call for special attention.  The
middle  period has  nothing about it,  normally at  least, calling
for especial  remark.  But of the  other  periods  it is different,
During  the period  of groAvth there is not  only  the  repair, but
the groAvth  of the  tissues to be promoted.   Consequently the
appetite of  the child is active,  and its assimilative  powers are
not readily  overtaxed.   The tendency,  however, of childhood,
in its more special maladies, is towards failure,  more or less
complete, in the nutrithTe processes.  In this it presents a strong
contrast to advanced life, where the chief difficulties lie in the
inability of the  system  to dispose  satisfactorily of its  Avaste.
The food of the  child should  be  simple, should  be  satisfying,
and should contain  a fitting proportion of the material required
for healthy tissue-building.  In milk, combined with farinaceous
matters, Ave find the most appropriate  food for infancy;  and
the dietary of the nursery is a choice determined by long ex-
perience, of which, hoAvever, advancing knoAvledge  thoroughly
approves.  A certain proportion  of  fat is also essential.   At
present  there is  a  decided objection  on the  part of children
to eat fat; some of  this  is doubtless  in many cases due to an
inability to digest  fat in its ordinary forms, and consequently
the more easily digestible  fats, butter  and cod-liver oil, must
be resorted  to.  But in  other  cases the objection has no such
valid foundation, and is  rather due to fashion or caprice.  The
importance of a  sufficiency of fat  in the dietary of children
cannot  be over-estimated.  I am informed that in New Zealand
children—Anglo-Saxon—are commonly  seen with a piece of fat
in their hands, sloAvly eating it. There are good prospects in the 
GROWTH AND DECAY.
165
future for a race where this is common.  With a suitable dietary
children do not need, or ATery seldom, that drugging Avhich seems
to some  parents indispensable.  It is too much the fashion to
administer medicines of various kinds to children, most of Avhich
are quite uncalled for.  The chief medicines required by children
are those that act upon the intestinal canal, which is apt to be
disordered from  its functional  activity.   But even here it is
often Avell to let the child alone ; the loss of appetite is a natural
outcome of repletion, and the malady carries with it its own
cure.  A great portion of the ailments of children are natural
actions rather than diseases per se, and those children Avho are
left  most alone usually do best.
   There are, however, many troubles Avhich are inseparable
from this period: some are  unavoidable;  others again are more
or less due to causes Avhich admit of being met, or even of being-
avoided  altogether.  Among these latter are the different dis-
turbing causes Avhich act mediately upon the child through the
system of  the mother.  Such are mental disturbances.  After
a great fright a mother  has been known to  suckle  her child,
and forthwith the child has died.  AYhat the change was Avhich
made the mother's  milk a poison to her child Ave  do not knoAv.
Lesser effects are much more commonly induced, and a fit of
passion in the mother often so modifies her milk  that it purges
her infant.   Such are some  of the risks run by the baby Avhich
are  capable of being averted  by thoughtfulness  and  care.   In
Levana;  or, the Doctrine  of Education, Jean  Paul  Richter
says:—"One  scream of fear from a mother may resound through
the  Avhole  life of her  daughter; for no  rational  discourse can
extinguish the mother's scream.  You may make any full-stop,
colon, semicolon, or comma of life before your children, but not
a  note  of  exclamation!"  There are however numerous other
causes of disturbance which  cannot so easily be averted.  Among
these are the common disturbances  of babyhood which arise
from passing periods of acidity  to Avhich the digestive system
of the infant  is liable.  It  often "possets" its milk, which in
curdled lumps is vomited, or ejected by purgation.   In which
case  it is Avell to get rid of the indigestible mass; and the ejective
process  should not be rashly interfered  Avith.  To obviate such
curdling an alkali must be added to the milk, and of such agents
the best is  lime-Avater.  This not only neutralizes  the excess of 
106               GROWTH AND DECAY.
acid but it also furnishes lime to a system in need of it.  Alka-
line carbonates are apt to cause disturbance from the disengaged
gas given off in the stomach.   This renders them  unsuited for
permanent use.   As an occasional resort they are unobjection-
able enough; and  the folloAving forms a capital mixture for
children that are griped after their milk:—
                       Pot. Bicarb, gr. ij.
                       01. Cajeput. TTL j-
                       Aq. Anethi. 31J.
three or four times a day.   This usually gi\res relief, and speedily
too.  It  may  be advantageously preceded by a  dose  of castor-
oil.  At other times children seem  to suffer severely from  the
act of  digestion; it does not appear to them a painless proeess,
but one  Avhich  produces  suffering.   In such cases bromide of
potassium is indicated  :—
                   Pot. Brom. gr. vij.
                    Aq. Anethi. 31J-, ter in die,
Avill often give great and  decided relief.   In  the troubles of
teething some such medicament is indicated in order to deaden
the  painful sensations which accompany and arise  out of the
emerging of the  tooth from the gum.  This  irritation  often
causes a  febrile  condition, especially  if the  saliva secreted so
freely by the reflex consequences of the irritation  in the  gum,
is Avasted on  the bib. It  is a matter of observation that the
child which Avets its  bib  much, is  that Avhich  suffers most in
teething.  Vogel says that the saliva is  purgative, and that the
purgation lowers the fever temperature, and so  does the infant
good.  If this be  so,  it Avill not be  wise  to check  purgation
under these circumstances, unless it  be  excessive.   When how-
ever it is necessary to check diarrhoea in children, the measure
selected  must  be in accordance with  the  indications.  If the
secretions are acid and sour to the smell, and are accompanied
by griping,  then  magnesia in  a fluid or solid form  may be
administered.   If the diarrhoea is profuse and persistent, decoc-
tion of logwood is the best of all agents to  select.   Its taste is
not unpleasant, its use is not accompanied  by  danger; and its
chief drawback, its staining properties, is easily met by putting
an old cloth of any  kind  under the  chin Avhen it is  being
administered.   It  is  an advantage  to  combine it with chalk. 
GROWTH AND  DECAY.
167
Sometimes it  may be  necessary to  cut  the gums,  especially
if convulsions are threatening.   If the tooth is just  emerging
there may be  no objection to this.   But if the gum  is swollen
and congested over a tooth not yet at, or  near the surface, such
cutting is undesirable:  the cicatrix resulting forms an obstacle
to the tooth in  the future; an obstacle not rarely sufficient to
throAV the tooth out of the straight line of growth.   Probably
a slight purgative gi\Ten to the child, or to its  nurse if still
suckling, will relieve the congestion as well,  or better, than
the  gum-lancet.  AYe  Iciioav noAv that every little divergence
from ideal health does not call for immediate active interference.
  When  it becomes desirable to add some other food to the
baby's  milk, a varied choice is offered.   It is no part of my
scheme to decide upon the merits  of the numerous foods for
infants with Avhich the civilized Avorld is flooded.  Suffice it to
sav that, as Avell as hydrocarbons, a certain amount of nitrogen
and a certain  proportion of various  salts  are requisite.   Flour,
hoAvever prepared, is  an improper  food Avith  Avater alone;  a
little  meat-juice is better; but milk is  the proper accompani-
ment.  Milk  should form a great portion of the dietary till the
full growth is reached.  Oatmeal porridge and milk is the best
of  all combinations for growing children; though of course it
is not  absolutely  necessary to  adhere to this exclusively.  In
the abandonment of such farinaceous food, and in the now pre-
valent dislike to fat, do Ave find the explanation of much of our
modern disease.  Imperfect  evolution,  degraded or arrested
tissue-growth, and numerous others of the troubles  belonging
to  the period of evolution, take their origin  in  an  erroneous
 and mischievous dietary.  We now know distinctly that hydro-
 carbons play an important part in cell-formation  and in tissue-
 building. They are not less necessary for perfect histogenesis
 than they are requisite for the maintenance of  the  body-heat
 and the manifestation of energy.
   The aversion to fat, Avhich is often the precursor of consump-
 tion—which  leads to  imperfect tissue  formation and thus  to
 tubercle—is very often a foolish caprice and an ignorant  preju-
 dice; though doubtless at times it may arise independently of
 the will.  If the inability to eat  fat were  successfully opposed,
 many of those dangers of imperfect cell-growth might be avoided,
 Avhich aftenvards cause so much consternation, and subsequent 
16S
GROWTH AND  DECAY.
contrition.  When  tubercle  has once  established  itself, then
there is resort to cod-liver oil—which after all is nothing more
than the most digestible of fats—to medicine, a fixed  dietary ;
and  to numerous means which would have been  much more
effectual if adopted  as preventive, rather  than as remedial and
restorative measures.  Those very measures Ave adopt to restore
tissue-growth  to its pristine integrity  are  those Avhich should
have been used all along.
  § 63. The food of the child should  be  simple, and not such
as to unduly incite the appetite.   If a child is Avell it Avill usu-
ally eat sufficiently  freely Avithout any special temptation.  In
consequence of the demands of groAvth the  digestive system is
much exercised, and is a common source of trouble.  There  are
passing fits of constipation, needing a gentle laxative, as manna,
a fig, or a prune.  There are periods of diarrhoea which may be
treated as directed in the last section ; but there is another form
of diarrhoea than  those given  there Avhich calls  for its own
special treatment.  Here there is a certain amount of irritating
material in the bowels, and the diarrhoea is an abortive attempt
to get rid of the offending material.1   In such cases castor oil
is the best of remedies.  It may be ghTen in the following for-
mula taken from Ringer: —
                        01. Ricini, ^ss.
                        Mist. Acacia;, 3iij.
                        01. Mentha?, uliij.
                        Aqua? Destil. 3v.
This might be given in two doses at an interval of four hours.
At other times  children  are  liable to accumulations of bile,
Avhich generally  pass aAvay in "a sick fit."   There is vomiting,
soon bringing up bile, and then  spontaneous purgation follows,
which should not be rashly interfered with.  Sometimes there
is a sharp rise  of temperature at  the  commencement of these
attacks, as they are termed.  In  addition to  these troubles
children are very apt to  have attacks of acute indigestion, in
which  the temperature quickly rises to 105° Fahr.  The very
sharp rise, and its height, Avill  generally distinguish these

  1 The fluid poured out by the  natural effort is often below the seat of the
offending matter, and so  fails to remove  it.  A purgative excites action above a>
well, and the irritant mass is then swept away.  (Lauder Brunton.) 
GROAVTH AND  DECAY.
169
attacks from a commencing exanthem.  An  emetic, as  Pulv.
Ipecac, gr. a^., Cal. gr. iij., Avill often be found useful; after the
vomiting  spontaneous catharsis may come on ; if it does not,
a feAV  grains of jalap, scammony, etc., or a little senna may be
given.   It must be understood  that in speaking of children
here the term is meant to include the period of the second den-
tition, up to about ten or twelve.  The dose mentioned here is
adapted to an age of six or seven.   If younger, the dose must
be lessened ; if older, a little more must be given.
  In addition to the various ailments given above, and Avhich
are more  or  less found in every child, no matter  Iioav healthy,
there is a form of fever knoAvn as infantile remittent fever (of
old "AATorm fever") to Avhich children are prone.  In the morning,
in slight  cases, they are almost Avell, in the evening they are
feverish.  In more marked cases there may be one or two remis-
sions each day.  The old-fashioned plan of treating such pyretic
conditions by acetate of ammonia, etc., is very  far from satis-
factory.   Personally, I have found quinine with a mineral acid
give much more beneficial results:—
                    Quin. Sulph. gr. ^.
                    Ac. Hydrochlor. Dil. TTLiij.
                    Syr. Aurantii, "Hlxx.
                    Aq. ad ^ij.
three or four times a day has produced very good  effects.1   In
some children rapid growth  produces febrile conditions  with
much malaise; but Avithout the marked remission Avhich charac-
terizes the last form of fever.  Here mineral acids seem to give
relief.
  § 64. The  most marked characteristic  of the acute diseases
of children is the quickness Avith which they  usually come and
go.  If, hoAvever,  the  child is feeble or Aveakly, acute disease
commonly lays the foundation of a chronic ailment. In children
where  such  mischief  may be apprehended,  the  greatest care
should be taken to see that the convalescence  be  not checked
or interrupted.   Fresh air, good  milk, a little tonic, and then
iron and cod-liver oil, must form the routine  treatment of con-
valescence in such children.

  1 In some cases " infantile remittent" is probably really a more or less masked
attack of typhoid fever.  At other times it  is connected  with rapid growth.   I
have known it to cease at once on the vomiting of a round worm. 
170               GROAVTH AND  DECAY.
  There are some points of much importance about disease in
children  which  may be alluded  to here.  The first is this.
Children can often endure much, but if they get bronchitis it is
very apt  to  be fatal.   Bronchitis, which  very rarely kills the
healthy adult, is  a  very grave matter  at  the extremes of life.
It is commonly fatal in weakly children, and it  often  severely
tests the powers of  strong children.   In no ailment, Avhich  Ave
are  called upon to treat, is it so necessary for the  practitioner to
recognize  the dangers ahead, and to  learn to meet them.  Alilk,
beef-tea,  and Avine have often to be given freely before there
seems much need of them.   If their administration be delayed
till  the hour of need arrives, it will  be  found  to  be too late  for
them to be of use.  Very commonly the mother will  be  found
to protest against such  measures, as calculated to increase the
fever, so she says; but she must be instructed to follow out the
orders, and the result will usually confirm the vieAv taken,   In
tea-fed children bronchitis is most fatal;  and  a Avhole family is
sometimes swept  awTay, one  by one, by this malady.
  Children  are liable to acute colds  and passing  inflammations
in consequence of their tendency to lose heat readily on the one
hand ; and their  ignorance  of Iioav  to guard  against  such  loss
on the other.  Fashion, too, leaves the  child  often unprotected
against the blasts  to which  it is exposed ; and acts  in utter
defiance of the physiological fact that children lose heat rapidly.
Here the very helplessness of  the child  is  abused by those who
ought  to  be its guardians and protectors.  The plan of syste-
matically  " hardening" children is professedly abandoned; but
it nevertheless obtains yet.   It is  certainly  undesirable that
children should be made artificially  delicate and susceptible by
the "coddling" plan; but the  combination of this  latter plan
with insufficient clothing when out of doors, is very dangerous.
  § 65. The chronic affections of children are  often very serious,
and  are ahvays very troublesome.  One of the greatest evils
which besets early life is the tendency  to form  tubercle.   This
form of perverted growth  will be discussed  further  on, but a
few Avords iioav are not out of place.   This degraded form of
cell-life is very common in childhood, and  is chiefly found in
the bowels and in the brain. In the  latter it gives rise to hydro-
cephalus  (tubercular  meningitis).   As  such it  is very swiftly
fatal.  As however tubercular meningitis (hydrocephalus) is 
GROWTH  AND DECAY.
171
 not always to be distinguished from simple meningitis, it is as
 Avell  to  treat each case as  possibly tubercular, and the best
 remedial combination is that of iodide and bromide of potas-
 sium in  full doses  several times a  day.   Counter-irritation to
 the head has its advocates.  AYhen the tubercle is in the boAvels
 and  peritoneum, the disease  is  lingering  and troublesome.
 Astringent  mixtures, milk, iron, iodide of  iron,  etc., are all
 indicated from time to  time, according to the varying phases of
 the case.
   At other times  there is  softening  of  the osseous system,
 known as rickets.  This may  extend from mere curvature of
 the spine, especially if the child be borne almost exclusively in
 one arm  of the  mother, up to  the advanced  condition vividly
 pictured by Sir  William Jenner:—" It is strange to see a little
 child sitting  placidly on the bed, Avithout moving, for hours
 together,—its legs  placed so as to escape pressure, its spine
 bowed, its head  thrown backward, the chief Aveight of its body
 cast  on  its arms;  and to  know  that,  notwithstanding  the
 apparent calm, the  tiny thing is  indeed fighting the battle of
 life;  for it  is striving, with all the energy it has, to keep in
 constant action  every  one of its muscles of inspiration—en-
 deavoring so to supply the mechanical defects of its respiratory
 apparatus, clue to the softening of the  ribs.  It  Avants no toys.
 It is the best of children  if you only leave it alone; move  it,
 and you  inflict pain on  its tender frame ; show it the horse or
 the doll  that Avas once  its delight, and it  turns aAvay its head
 or stares vacantly :  to  notice  would  divert  its attention  too
 much from the performance of those  respiratory  movements
 Avhich are essential  to its existence."   In  its  most  aggravated
 form, rickets is an intractable affection ; but in the less marked
 cases much may be  done by phosphate of lime (10 grains ter in
 die) or syrup  of phosphate of  iron  and lime 38S-  (Parrish's),
 together  Avith  milk, fresh air, and salt-water spongings.
  Marasmus, or simple Avasting from mal-nutrition, is a common
 affection, and  the wasted, old,  and  even Avizened faces of the
 unfortunate babies  have a weird look about them.  There is
often too an unnatural calm about them Avhich is very appalling.
They  rarely benefit  much by medicines given by the mouth,
but they often improve surprisingly by inunctions of olive or
neat's-foot oil.  The child should be stripped before the fire and 
172
GROWTH AND  DECAY.
a tablespoonful, or tAvo, of oil should be Avell rubbed into its
skin with the hand.  This should be done twice a day.  After
the child has begun to improve, the syrup of phosphate of iron
and  cod-liver oil may be administered Avith  advantage.   If
olive-oil be not easily procurable other fats may be used.  AYast-
ing with green stools is often the result  of too prolonged suck-
ling.  Here the child should be weaned, and iron and cod-livet-
oil given as above; when it usually7 rapidly improves.   Some-
times children SAveat profusely, to an exhausting extent even ;
here sulphate of atropia (gr. T^)  three times  a day in  dill-
water is useful.   Children bear  belladonna  well.   In inconti-
nence of urine the above dose of belladonna is usually very
efficacious.  But  if there exist local  causes of irritation all
schemes of treatment are  useless until  these be removed.  Asca-
rides call  for  santonine.  Even  surgical  operations  may be
indicated.   Air. Teevan and myself had a capital case  of per-
sisting nocturnal incontinence in a boy  of thirteen, where cure
folloAved enlargement of a narrow meatus.
  At other times syphilis interferes with healthy evolution, and
manifests  itself in numerous and widely different forms.  In
skin eruptions, ulcerations, deformity of the nasal bones or of
the forehead,  in internal diseases, in amemia, or arrested  evo-
lution, the inherited taint manifests its baneful influence.  It
is  common  to  treat such cases with iodide  of  potassium, but
my personal preferences are  in favor of a  course  of mercury
combined  Avith iron, as follows:—
                    Liq. Hyd. Bichlor. ul xv.
                    Tinct. Fer. Perchlor. TTLiij.
                    Aquae 31J. ter in die.
Given after meals, this combination secures all the  good effects
of mercury, and yet obviates its evil  effects upon  the system.
The  iron and good nutritious food counteract the lowering and
destructive action of the mercury, while it engages  the syphilis
and destroys the taint—Avhatever it may be.
  Of all the diabetic affections of childhood, perhaps struma is
the Avorst  misfortune.   As scrofula, or  king's evil, it Avas sup-
posed to require the royal touch, and  great  was  the discussion
as  to Avhether AYilliam  the Third possessed the power to heal
it or not.   But iioav Ave have abandoned all such figments, and 
GROAVTH AND  DECAY.
173
have set to work, under the combined lights of pathology and
experience, to combat the perverted nutrition which Ave recog-
nize as the visible sign of the strumous  diathesis.   Our fairest
child—the little  piquant precocious fairy,  whose  pretty  im-
periousness compels all to yield to her caprices, with open eyes
and long eyelashes, the family pet—is usually not  a perfectly
healthy organism ; any more than is the  bright creature whose
neck becomes furroAved Avith the cicatrices of scrofulous ulcera-
tion.  The  intelligent, active boy  Avho  comes home one day
from school Avith a limp, complaining of his knee, and svho after
long suffering  Ave find at the seaside  crippled for life Avith hip-
joint disease, is  another illustration  of  strumous taint.   The
full-lipped pink  and white countenance, Avith a certain fulness
of the alse of the nose, often so attractive, especially  when com-
bined"  Avith  high intelligence, is also a modification  of  struma.
So  also are the marked features, earthy complexion,  and dense,
straight or highly-arched black eyebroAvs, Avhich often give such
character to a face.  AYhen black-haired  or red-haired  persons
once develop tubercle they usually go very rapidly ; much  faster
than the brown-haired, or even than blondes.
  In early childhood this taint frequently sIioavs itself in thick-
ening  of  the epiphyses and  fulness of the joints.   Often this
thickening is regarded as evidence of Avonderful physical poAver
in the future, and the child is said  to be  "double-jointed;" but
this is an utter mistake.  A little later the taint shows itself in
precocity, and the child is a prodigy of cleverness and learning.
This may be;  but it  is only, after  all, another evidence  of
struma.   It may grow very beautiful, and from love of praise
very good—" too good for this Avorld."  At puberty, in those that
survh-e, there is often rapid groAvth, which commonly terminates
in consumption.  When adolescence merges into adult life the
character of precocity remains:  but, though quick,  the  person
is too  often superficial.   These persons are generally anxious
to become parents; but they are not quite justified in their self-
elected task.  Their families are often large, but  individually
their offspring are Aveak and delicate.  Such  persons  form  a
large portion of mediocrity and of society ;  but  they are far
from ideal types of physical development.
  This brief sketch will  perhaps aid  the reader to  detect the
strumous diathesis  in its finer shades.   It is easily diagnosed in 
174               GROAVTH AND  DECAY.
its grosser manifestations.   AYhen  diagnosed it requires a dis-
tinct line  of  treatment.  First of all the secretions and excre-
tions  must be attended to.   The bowels are apt to be sluggish
or irregular, the liver does not ahvays do its work, but suffers
from passing  derangements: both of these must be attended to
and regulated—but the less mercury used the better.  There is
also a constant tendency to acidity, which requires lime-water,
seltzer, or A^ichy ;  the first  is best adapted to infants, the latter
for groAving children.  The perspiration is often acid, and  the
urine contains quantities of lithates, or even .uric  acid.  The
men of past generations, Brandish and Lugo], found potash the
best remedy for the relief of strumous affections.  They observed
that it possessed  no  truly  curative action ;  but it gave relief.
The effect of fresh air upon strumous  children is well knoAvn.
Doubtless it favors the combustion  of the imperfectly oxidized
products with which  the system is laden.   But in fresh air and
potash we find only aids to improvement, the excessive  forma-
tion of acid  finds its  causation in faulty  assimilation.   Dr.
Broadbent,  in a  sentence  full of suggestive  thought, says,
"When, therefore, we examine  the  excretions for  the products
of combustion, and thence  draw conclusions  as to the complete-
ness of the process, it  must be remembered that the more or less
perfect oxidation  may depend upon  the more  or less  perfect
antecedent nutrition,  and not merely on the supply of  oxygen,
or any intermediate  influence on  destructive metamorphosis.
Thus, the uric acid which  forms the urinary excretion  of birds
whose habits are active and temperature high, and whose blood
is highly oxygenated, cannot arise from insupply of oxygen, but
must depend  upon some peculiarity in the tissues; so also in
man, uric acid may be the effect of defective nutrition or pri-
mary assimilation, and not merely of imperfect  metamorphosis
or oxidation.  The clinical history of the  so-called uric acid
diathesis  supports this vieAV,  and shows that  the remedy in
many cases must be sought, not in the  promotion of the oxida-
tion,  but in modification  of the  nutritive processes."  From
this view it  is impossible to dissent, and in the pathology of
the ailment we find  a direction  given  to our treatment.   The
alkalies Ave administer may be given Avith advantage  in vege-
table-bitters, or aromatic  bitters.  To  these may  be added at
times some potassio-tartrate of iron.  When the assimilation of 
GROWTH AND  DECAY.
175
food is imperfect and ordinary fats are refused, cod-liver oil may
be given;  and if that disagrees, or if the patients think it too
commonplace, cream may be given ;  and for the  latter class
cream and  maraschino  form a capital combination.  The boAvels
also  should be attended to, and  the skin kept in action by baths,
with or Avithout sea-salt.  Such persons should be much in the
open air.  Their holidays  should  be spent at the sea-side in
some far-aAvay,  but bracing nook.  Their school-rooms should
be airy and Avell-ventilated.  Their hours of study should not
be long.   In fact they should  be  discouraged from study, and
any  temporary lagging behind  Avill usually be readily made up;
after the physique has been improved, and thus the brain better
sustained by an invigorated nutrition, the progress will be more
rapid and  yet more thorough.   In persons of this diathesis an
actiA^e brain is often let clown by its association Avith a defective
and  easily-exhausted physique.  In a lecture to " The London
School-Mistresses' Association," in  November, 1877, the  writer
pointed out Iioav cruel it is to force  children  to  complete their
tasks during the periods  of acute groAvth.  At these periods the
blood is drawn to the groAving parrs, and the brain is robbed of
blood, and is therefore functionally inactive.  When the acute
period is passed the blood returns  to  the brain, the child once
more becomes intelligent, and soon makes up the lost ground.
  So much for the  general indications as to the requirements
and  necessities of growth.  The different pyretic affections to
which youth  is liable,  and especially the exanthems, will be
given in  a  subsequent chapter (IX.).

                           DECAY.

  § 66.  After the attainment of maturity the organism main-
tains itself for many years in its integrity without much altera-
tion, unless it  be some increase in  Aveight.   But  in time there
commences a series of changes known as senile decay.   Such
changes are easily recognized in the  very old, Avhether old in
years or physiologically old ; but they are commonly overlooked
until their existence is almost  forced upon the attention  of the
observer.   This is  unfortunate, as it is often a matter of great
moment, in the recognition of the  true state of a case, to be
able  to detect the  early  evidences of impending decay.   The 
176
G R 0 AV T H  AND DECAY.
process  is normally a sIoav  one, and  consequently the  first
changes must be insidious and occult.  Not only that, but they
will usually be very slowly deA^eloped.  This however forms no
reason Avhy these changes should be overlooked, and thus their
significance  be omitted from our estimate.  Many people, too,
even medical  men, have irrational notions about their health
and  their tissues.  The  idea that there  may be commencing
atheroma in their bloodvessels; that there is a commencing hy-
pertrophy of the heart; or that their kidneys are no longer in
their integrity ;  is sufficient not only to perturb them, but to set
them to work at once to prove, at least to their own satisfaction,
that they are free from  anything of the  kind.  They quickly
persuade themselves that their tissues are perfectly healthy, and
that they are  free  from the slightest taint of commencing de-
cay.  If it Avere merely a subject of self-satisfaction to the indi-
vidual it would  matter little; but  unfortunately such attitude
and  conduct stand in the very Avay of a proper comprehension
of the sIoav and gradual progress of some chronic changes. These
prejudices foster ignorance; and that ignorance often assumes
an aggressive character.
  Long before they obtrude themselves upon the vision of the
unwilling observer, there are instituted changes which mark the
oncome  of age.  The hair commences to frost, or to fall off, and
loses its lustre.  The skin  becomes dry, and  no longer glistens
Avith the gloAv normal to youth.   The frame loses its elasticity
and the step is no longer springy.  The gait is stiff; the motions
are sloAver.  The mind is not so quick in  its operations, and  no
longer learns so  readily; it has lost much of its apprehensive-
ness.  Names, Avords, dates, and other matters which do not  lie
in the direct path  of associations, are elusive and not readily
recalled.  The  residua are still  in the cerebral cells; but they
are not so readily communicated Avith as of yore.  The thought
is not so nimble, though  it is more  deliberative and accurate in
its processes,—at least in the early stages.  The secretions are
less active, and a foul odor of the breath often tells  that excre-
tion is  no longer so perfect as it used to be.  There  is also a
tendency to  rheums from the different mucous surfaces.  The
boAArels are sluggish, and there is a marked inclination to accu-
mulate feces in the intestinal canal, together Avith torpor in the
muscular fibre of the gut.  The Aoav of urine is often increased 
GROWTH AND  DECAY.
177
 —except where there is disease of the heart; but the urine is
 either of  low specific gravity,  or,  at other times, laden with
 lithates, indicating imperfect oxidation. There are, too, troubles
 in connection Avith the making of Avater   There is an increased
 susceptibility  to  the  natural  calls,  while these latter  cause
 greater urgency, so that it is  no longer possible to evade com-
 plying Avith them.  This vesical irritability is  a great  source
 of annoyance to elderly  people, and  harasses them  at  public
 gatherings, or Avhen travelling, etc.  It is commonly associated
 Avith enlargement of the middle lobe of the prostate  gland.
 This forms an  obstruction  to the  complete emptying of the
 bladder; never empty, it  soon fills to the  point of creating a
 call  to void its contents  And that call must be attended to at
 once, it cannot be restrained ! At other times there is irritability
 in the vesical centres, Avhich is often very much  relieved by
 belladonna.  It  is commonly increased by strychnine or quinine.
 The  circulation is  no longer  so perfect, and effort produces
 dyspnoea, or shortness of breath, on slight  exertion.   The costal
 cartilages ossify, and the movements of the thorax are impaired.
 There is a tendency to emphysema from the violent efforts made
 at times, especially if there be a certain amount of chronic
 thickening about the bronchial tubes.  There is frequently a
 great tendency towards an abnormally profuse secretion from the
 air tubes,  not always of an  inflammatory, but sometimes of a
 degenerative  character.  It  is  not bronchitis, but  one of the
 rheums of age.  There is also a flow from the lining membranes
 of the nasal cavities.
   The whole  of the  tissues  are modified, and so is their func-
 tional activity.  The hand is  tremulous, and highly co-ordinated
 movements are being gradually impaired,  so that the hand and
 fingers fumble where  they  used to act almost unconsciously.
 The  application of  the attention is requisite for movements
 which were once almost intuitive. A long and tedious process
 is  required  to recall Avhat at one time almost leapt  upon the
 consciousness, so quick the act of memory.  A careful inspection
 of a  microscopic section of an aged  brain  shows that the spur-
 like processes of the cerebral cells, Avhich once formed a sort of
 interlacement, are Avorn through, and the cerebral cell is rounded
and club-shaped—its residua remain to each cell, but the com-
municating lines no  longer  exist ; and so the residua can no
      12 
178
GROAVTH  AND  DECAY.
longer be communicated Avith—in other words, the memory fails,
and then ultimately is lost.  The muscles lose their plumpness,
become lax, and lose their poAver.  The viscera are sluggish and
inactive, and  lesser  matters serve to disturb them than  has
hitherto been the case.  There is a lessened power to Avithstand
disturbing  influences; the loss of heat is more  easily induced,
and  the  intolerance  of a  low temperature is pronounced.   In
this last the old person once more resembles  the child.   There
is  a  gradual  tendency to  sleep more and more;  and the short
hours of sleep Avhich  characterize middle age merge insensibly
into  longer and longer hours, till the  hours of sleep once more
exceed the  waking hours.   The  petulance of childhood is again
approached, and elderly persons  brook  control little  better than
a  child.  The  appetite is impaired, and  is  often  capricious.
The  poAver to digest large quantities of animal food varies, and
in place of  underdone meat well-cooked animal food is preferred.
At last meat is little craved after, and milk-puddings, bread and
butter, and the non-nitrogenized diet of early days are again the
staple food.  The waning brain-power  no  longer  desires  the
stimulating nitrogen to spur its  lagging  action.   The  prattling
child becomes  once more the  most highly appreciated com-
panion ;  and garrulous age loves to pour into uncritical youthful
ears  long tales of a far by-past time.  In  habits, thoughts, taste,
food, in the obsolescence of the  sexual passion, age approaches
youth.   The process of evolution has  given  place to a reversed
action, or involution.  The  higher processes, Avhich are slowly
developed  and are to a large extent  outcomes of training and
education, gradually  fade out, and lose their controlling  power
—the last to develop and the first to go ;  and the most vivid and
enduring impressions of the doting brain are the experience of
its early days, the impressions of childhood.
   §  67.  This brief sketch of the changes of age will enable  the
reader to comprehend more clearly,  the indications  for treat-
ment in the ailments of advanced life.   It is obvious that  the
aged frame is unequal to anything approaching heroic treatment.
The defects in functional activity require to  be met by a steady
and  persistent medication, rather than some sudden  active effect
upon the sluggish organs.   It  is no  longer  desirable to purge
actively, except  in emergencies; but  the boAvels must be regu-
lated so as to keep them acting  from day to day.  Warm aloetic 
GROWTH AND  DECAY.
179
 purgatives, or confection of senna, are the laxatives best suited
 to the aged.   If salines are taken  it must be  in  combination
 Avith such vegetable allies and carminatives.  In  this respect
 old persons resemble women at the menopause, where carmina-
 tives must ahvays be given freely Avith purgatives.  All strain-
 ing at stool is to be deprecated, as putting stress upon  organs no
 longer fitted to bear it Avith impunity.  The bloodvessels are more
 or less rigid tubes, and any strain upon them is apt to produce
 rupture.  The structures  of  the heart are no  longer in  their
 pristine integrity, and are undermined by fatty degeneration
 or molecular  necrosis; consequently they are unequal to effort,
 and straining at stool  is not rarely followed  by cessation  of
 the heart's  action.   There  is  induced either rupture of an
 atheromatous  artery from the  heart being comparatively too
 strong; or the structurally decayed heat stops in an  imperfect
 attempt to overcome the resistance offered  to its  contraction
 —unequal to forcing its contents into  the  altered  arterial sys-
 tem.  Alany salines are too depressant  to the heart to be given
 alone, and if  it be desirable to administer potash  it  should be
 gh7en  Avith  squill,  digitalis,  or belladonna.   The  stomach  is
 unequal to the Avork of  digesting a large meal, so that food
 should be given in small quantities and not  at long  intervals.
 It should be so prepared  that it will require  little or  no masti-
 cation.  The taste  for highly spiced foods  is gradually dimin-
 ished, and the food  may be plain in character, as well  as simple
 and easily  digestible,  with  advantage.   As to  drinks—tea,
 coffee, and  cocoa are all  suitable; but alcohol in  some  form
 is usually the best  fluid.   It furnishes a readily available  food,
 it is an easily oxidized carbo-hydrate.   It  is stimulating  and
 refreshing.1  It gives a fillip to the digestive organs, and, by
 increasing the vascularity of  the stomach, aids it in its solvent
 and digestive action.  It prevents the spasms, or colic  to which
 elderly people are very liable.    It feeds  the starving brain, and
 once more gives it  sensations of well-being, and  enables  it to
 Avork pleasantly.  All this too is accompanied by little  fear of
 its becoming a tyrant, or  of  its  use being comTerted into an
abuse.  " Wine is the milk of the aged,"  is a Rhineland proverb;
and there  is much truth in the statement.  Its stimulant effect

     1  Chambers's Maimed of Diet, chap. x. "The Decline of Life." 
180
GROWTH  AND DECAY.
is  less seen  in the aged, while its qualities as a food  become
more  prominent.   It  forms an  excellent hypnotic; and some
alcohol and hot water, Avith some sugar, forms a famous " night-
cap" for elderly persons wheu getting into  bed.   They are apt
to be chilled from the slowness of their movements in undress-
ing ; and when they get into a cold bed the vessels of the skin
are chilled and contracted, and, not readily dilating again, the
sleep is broken, imperfect, and unrefreshing.  Consequently the
bed should  be aired, the room  should be warmed  by  a fire
lighted  some hours previously, and the loss of  heat  should be
met by  a draught of warm  fluid,  containing alcohol, etc., on
getting  into bed.  The alcohol is  quickly  burnt, giving heat;
it dilates  the  vessels, and produces sleep of a  refreshing cha-
racter.  It is obvious that the loss  of heat by the dilated cuta-
neous vessels must be met by good  bed-clothes, else the alcohol
may do more  harm  than  good.  At other times old  persons
prefer beef-tea or Liebig's extract.  This is a pleasant stimulant,
but it is inferior to alcohol as a food; and should be combined
Avith  some forcebearing  food, as starch, in the  form of sago,
arrowroot, corn-flour, or biscuit-powder.  In the case of the aged
teetotaller a cupful of this last combination, hot, and  if neces-
sary spiced, could  be administered on getting  into bed, if the
sleep be broken and  fitful.   Or a cupful of hot  milk might be
given.  It  is as well  always to respect  the  prejudices and con-
victions of patients; and many people have  their opinions  upon
alcohol  Avith Avhich it is not well to war.
   It has been said before that elderly persons easily lose heat.
Their clothes  should be warm, comfortable, and uninutating.
AYith old people  comfort usually  takes preference of appear-
ance: though such  is not invariably the case.  There should
ahvays  be flannel worn  next the  skin, from the  neck to the
wrists and ankles.  These flannels should not be worn too many
days consecutively, as the cutaneous  excretion of aged persons
is apt to become offensive.  The clothes of the old should ahvays
be well-aired  ere  being put on.   Their shoes,  too,  should be
lined with fur or  flannel.  Their rooms should  be comfortably
Avarm;  and they should  not be  permitted  to catch cold in
draughty, cold water-closets, or other conveniences.   In such
exposure, or in conducting their devotions  in a state of partial
nudity in cold bedrooms, do  we find  the origin  of  much of the 
GROWTH  AND DECAY.
181
illness  of elderly people.  Age  is tenacious of habit; and  in
some cases the old are more easily managed if induced to adopt
changes by some cajolement rather than by direct  opposition.
It is not possible to override the caprices of the aged as can  be
done in case of the fancies of children.   Their age entitles them
to respectful treatment.  Their Availing power however calls for
our attention; which must be Avell  directed and  cautiously
exhibited  There is no part of medicine, as an art, which better
tests the natural powers, and the educational cultivation, of a
medical man than his capacity  to successfully meet the require-
ments  of elderly patients.  In each and every patient the skilful
and enthusiastic practitioner will find a problem well worth his
while  to unravel and to  thoroughly comprehend: and this  is
especially true of disease in advanced life, where every case will
be found  to have its  own peculiarities, and to possess its own
individual indications and necessities.
   § 68. As  well  as  the clinical indications furnished to us by
the extremes  of life,  there  are other matters, connected Avith
growth and decay, Avhich deserve our attention.  The considera-
tion of them will enlighten  us  as to peculiarities in  each case
which are Avell worthy of our thought: and intelligent attention
to these peculiarities Avill strengthen our hands as practitioners.
   In youth we find that growth is active.   The vascular system
furnishes free supplies of pabulum, and the power of self-enlarge-
ment of  each  tissue is decided.  When developed  by exercise,
or the  demands of growth are active, each part attracts to it blood
in free quantity.   By what  peculiar  power the tissues do this
we do not yet exactly know.  So far as our knowledge extends,
something like the folloAving is shadowed out.   There is not
only a vascular  supply to each  part of the body, but there is
also a  nervous supply.  This nervous supply is something more
than the mere afferent and efferent nerves known as motor and
sentient  nerves.  It consists of  nerve fibres which are con-
nected Avith tissue nutrition.  These fibres are not the vaso-motor
of bloodvessels which contract  the vessel, and Avhose  section is
followed by dilatation of the distal vessels;  as Claude Bernard
found  to follow section of the  sympathetic  in the neck.   They
are antagonistic in action  to  the vaso-motor  nerves, so they
are termed vaso-inhibitory, or otherwise trophic nerves.   AYhen
J. Hutchinson's well-known case of ulceration of the little finger, 
182
GROWTH AND  DECAY.
from a cut involving the ulnar nerve but not the ulnar artery, Avas
published, it gave rise to much thought.   There is every reason
to believe that that ulceration took its origin in lack of nerve
supply, and  not in any defect in the bloodvessels.   But how did
this lack of nutrition  come  about ?  Schiff, Claude Bernard,
Ludwig, Goltz, and others have indicated that there are nerve
fibrils, belonging to bloodvessels, Avhich are cerebro-spinal in all
probability, and  Avhich  produce  active  dilatation  of  vessels.
When then  the ulnar nerve Avas cut  these fibrils Avere severed,
and so the vaso-motor nerves, no longer held in check, contracted
the bloodvessels, and  then followed loss of temperature  and
molecular death.  In a  case of Mr.  Hilton's,  where  a mass
pressing  on  a  nerve produced peripheral  ulceration, bandaging
the hand, so that  the mass no longer pressed  upon the nerve, led
to the healing process being inaugurated.   It is difficult to con-
ceive  Iioav this could be if there were not trophic fibres in nerve
trunks.   Disorganization of the cornea folloAvs section  of the
fifth nerve if the  least exciting cause of disturbance is in  action.
Disorganization of  the  lungs follows section of both vagi, but
not of one.  If a rabbit's head be cut off and  the secreting fibres
of the seventh pair irritated, the parotid will secrete fluid  freely ;
and yet there  is no possible increase of vascularity here.  (The
secretion of course  is limited to the fluid  in store in the lymph-
spaces of the glandular apparatus.)  We are only just beginning
to see that  nutrition is associated with something  more than
mere  vascular supply ;  but  it  is not yet possible to be more
precise.    The trophic  nerves  are in  all probability efferent
nerves to the parts  with  Avhich  they are associated.  Irritation
of them produces increased vascularity  of the areas wTith which
the nerves  are connected, and  a diminution of  calibre of the
rest of the bloodvessels of the body.   This  latter increases the
general blood-pressure, and  sends the  blood  with greater force
into the hyper-vascular area.   The synthesis we may construct
is possibly this.  The relation of tissues to their trophic nerves
is such  that when  much exercised, or when growing rapidly,
the trophic or  vaso-inhibitory nerves are put in action; and thus
growth is rendered  possible by a freer blood supply.  That such
trophic fibrils are usually part of motor nerves suggests  that as
the activity is great  in the  motor nerves going to the part, so
is the activity of the trophic fibrils of that motor nerve; and 
GROWTH  AND DECAY.
183
 thus increased  nutrition  goes to  functionally active muscular
 fibre.  Thus Ave have the  hypertrophy of the arm of the smith
 and  the legs of the  dancer.  In the same Avay paralyzed parts
 waste.  There  is no motor  activity leading  to  nutrition ;  and
 the palsied tissue  wastes.   It  may  even  disappear, as  in  the
 essential paralysis of childhood.   In  this last  instance the appli-
 cation of electricity to the palsied muscles, and so the exciting
 of action, is followed by nutrition and the maintenance of struc-
 tural integrity in the paralyzed  muscles.   Aluscles waste  in a
 limb after fracture.   Here the  nerve currents are not broken,
 only the muscles are kept passive, and so the relations  existing
 normally betAvixt acting  muscle and its trophic  nerves are dis-
 turbed.   After the  full  stature of  the individual  is reached
 nutrition still goes on, and the frame becomes well "set," broad,
 muscular, and fully developed.1
   This condition is  maintained  for some years;  and then  it
 yields  to a gradual deterioration known  as senile decay.
   § 69. The most familiar of all forms of textural decay  is that
 known as "fatty degeneration."   It is sometimes  regarded  as a
 species of atrophy: it is certainly a form of histolysis.   Chemi-
 cally it is allied to the formation of adipocere.  It is sometimes

   1 Dr.  Clifford  Allbutt makes some very interesting remarks on the relation of
 nervous  influence to nutrition in a paper in  the Practitioner for Nov. 1874.
 " We began to learn of trophic  nerves, and at the present time we are tempted
 to explain  that all tissues are  but elaborated nerve-endings.   Be this as it  may,
 we have learnt that in the  higher animals nerve changes  constantly precede
 changes  of other tissues, not only in normal function and in normal growth, but
 also in abnormal function and  abnormal  growth.  Perhaps  there is no  more
 striking instance of the results of withdrawing nervous influence from the tissues
 than the case of nerving for navicular disease.   The section of the nerve in the
 horse is followed, not by insensibility alone, but by a change in the nutrition of
 the skin  known as the hoof.  The nutrition of the hoof is so far deteriorated that
 in nerved horses the hoof, if submitted to any unusual strain, is not uncommonly
 dragged  off the foot, and  the horse will go forward upon the bared stump un-
 conscious of pain.  If the hoof should not be shod and the nerving be effectual,
 the whole of the tissues of the fetlock  and foot below the section degenerate ;
 they lose their definite structural characters, they become puffy and friable, and,
 ultimately losing  their histological features and their tenacity, pass into a quasi-
gelatinous condition.  Such are the effects of cutting off all nerve supply from a
set of tissues: and other instances might be adduced to illustrate the effects of a
partial withdrawal of nerve influence in deteriorating, or of irritation of nerves
in preventing, the growth and nutrition of tissues." 
184
GROWTH  AND  DECAY.
a normal action.  It is a part of the process of involution under-
gone by the uterus after parturition.  It is found in paralyzed
limbs.   It is equally common in the quiescent muscles of a limb
whose  bone has  been fractured.  Erroneous impressions  have
existed about it.  It has been confounded Avith fatty infiltration
into the connective  tissue  betAvixt muscular fibrillae, and been
supposed to have something to do with general obesity. Nothing
could be further from the mark.   Extreme  leanness  confers no
more immunity from fatty degeneration, than does  obesity in-
cline to it.  It  has nothing whatever to do with corpulence.
It is a form of structural  decay which, according to Rindfleiseh,
commences in  the germinal matter of muscular fibre, and then
extends throughout the formed material.   It consists of the fat
of the  dissolved  albuminous tissues.   If this were removed by
oxidation, and new pabulum freely furnished, possibly the mus-
cular fibres Avould recover their pristine condition ; in the same
way that they recover from the  degeneration found in them
after sustained pyrexia.  (§ 39.)  In fatty degeneration  of the
heart, that form  due to "failing hypertrophy" must be distin-
guished from that due to "climacteric decay," or senile change.
{The Heart and its Diseases, Chapter VIII.)   Certain it is, this
degeneration is  recovered  from in the  muscles of a fractured
limb, and also in  those associated Avith a paralyzed part.   Ham-
mond says that the degeneration is progressive in  the  palsied
muscles of organic infantile paralysis, and gives exquisite draw-
ings of the gradual  structural  decay.   He  also gives the im-
provement in  the condition of  the structures in a  case where
recovery took place.  In ordinary cases, where no cure is achieAred,
the muscle becomes ultimately a piece of connective tissue, after
the oil  globules  cf the  decayed  muscular fibre are absorbed.
The reader  should take the earliest opportunity of  consulting
Dr. Hammond's book, Diseases  of the Nervous System, Chapter,
wu Atrophy  and Disappearance of  Motor and Trophic  Nerve-
Cells.   Organic Infantile Paralysis."
  There is little to  be learnt therapeutically from the pathology
of fatty degeneration, or  tissue-necrosis, except  the negative
lesson of the futility of attempting to arrest it by mere nutri-
tion in the form of food ; and especially in an abstinence from
fat.  The idea that cutting off the fat Avould arrest fatty degen-
eration was  founded on the old notions as to its pathology.   It 
GROWTH  AND  DECAY.
185
 may possibly be useful in checking  the amount of fat  in the
 blood, and so leaving the oxygen free to prey upon  the degene-
 rate tissues.  But even for this removal of the old effete matter
 to achieve any good in the end, the capacity for improved nutri-
 tion must still remain.  AY here a limb is paralyzed galvanism
 or electricity may  keep the muscular  structure in its integrity,
 or something near it;  and a similar  plan is useful in infantile
 paralysis.  But of the means of arresting fatty  degeneration,
 especially in the terrible form of fatty degeneration of the walls
 of the heart in "failing hypertrophy," Ave know nothing. How
 it comes, and what are its causal relations and  its pathological
 associations, Avill be discussed in Chapter XIV.,  Avhich  relates
 to the vascular system.
  At the same time we must admit that it seems possible that
 in certain cases something may be done for fatty degeneration.
 These cases are of this kind.   After a long debauch, where the
 blood has been constantly saturated with the readily oxidizable
 alcohol,  and the respired oxygen has  been engaged with  the
 alcohol,  a  certain amount of fatty necrosis of muscular fibre
 may remain, and prevent the growth of neAv tissue. The per-
 sistence  of urea in the  urine would indicate  the splitting up
 of albuminous bodies,  the  hydro-carbonaceous portions either
 remaining as fat or being  burnt off.   But it  would be very
 difficult to detect  the presence of such unoxidized products in
 any tissue; and the possibility of  procuring its removal by  a
 diet highly nitrogenized and sparingly hydro-carbonaceous is
 at least hypothetical, and should never lull any one into a false
 sense of security about ordinary fatty degeneration  of  the
 heart.
  § 70. Rheums, or simple fluxes from mucous membranes, are
 far from  uncommon in aged persons.   They are associated Avith
 the processes known as general decay.  They may occur in any
 mucous membrane, either in the bladder or from the  bowels,
 but they are especially  frequently found in the lining membrane
 of the respiratory tract.  The fluid is thin, and devoid of acrid
qualities.   It forms the  drop so  commonly seen  on the tip of
the  nose of aged persons, especially in cold weather.  That it
should appear during low temperatures  rather than high ones,
is probably due to the effect of cold air in increasing the vascu-
larity of  the respiratory  tract, leading to the better Avarming of 
186
GROAVTH AND  DECAY.
the inspired air.  The local hyperaunia induees it.  At the same
time it is usually associated with fulness of the venous radicles.
In other old persons there is a free secretion from the bronchial
tubes,  which is not to be regarded as of an inflammatory char-
acter, or termed bronchitis, so  much  as bronchorrhcea.  It is
usually associated Avith a failing circulation and venous fulness.
By some Avriters such rheum has been regarded as  a degenera-
tive change, and so it can be vieAved.  It  is a degraded condi-
tion of  the  mucous  membrane, commonly associated  with a
languid circulation.  It is  a matter of much question Iioav far
astringents, or expectorants, do much good  in such cases.  Squill
often  is useful ; probably from its action on the circulation.  In
such cases the following formula Avould  at least be pleasant to
the palate, and probably of some use to the patient as well:—■
                      Sp. Chloroformi TTtxx-
                      Ac. Hydrobrom. Tu,xx.
                      Syr. Scillaj 3j.
                      Aq. ad 3J. ter in die.
If the pulse is failing or irregular, to this  may be addeu a few
drops of tincture of digitalis.   In the acute bronchial catarrhs of
very old persons, Avhich much resemble bronchitis, such mixture
is often of great service.
  AYhere astringents can be applied locally to rheum-producing
surfaces, they may be so applied, and may consist of vegetable
or mineral astringents.   Especially is  this the case  in  rheums
from  the intestine.  But in all  rheums the  condition of the
venous radicles and the circulation generally must be entertained
in relation to the choice and selection of palliative measures.
  (Atrophy will  be discussed under the heading of " Chronic
Disease," Chapter X.) 
CHAPTER  VIII.
                     ABNORMAL GROWTHS.

   § 71. Pathology, simply as pathology and as devoid of prac-
tical therapeutic interest, is no part of the scheme of this work.
Consequently  in  treating  of abnormal groAvths there is  no
attempt  made to go  into  recondite morbid  anatomy.  If the
reader desire to do that he wi 11 find the work of Rindfleisch,
translated  by the Sydenham Society, such a book as he wishes.
Here pathological  developments  Avill  be entertained simply
from a clinical point of view ; and only that amount of patho-
logical anatomy will be  lent to the subject which is absolutely
demanded for something like a fair comprehension of the mat-
ter.
   In the first place, Ave are  not acquainted writh truly hetero-
morphic growths, unless indeed tubercle be such, though it  is
to be  regarded rather  as  degraded  connective  tissue.  Even
the forms of cancer, which seem so far removed from anything
with Avhich we are  ordinarily acquainted, are found only to be
heterotopic, or heterochronic; that  is, out of place, or out of
time.  It is a matter of considerable importance to have definite
ideas about abnormal  growths.   They Avere most erroneously
regarded prior to  the time of careful histological investigation.
   Hypertrophy.—Hypertrophy, or hyperplasia, is common  in
many textures; but it is AVith hypertrophy in muscular fibre
that we are chiefly therapeutically interested.  Excessi\re growth
or hypertrophy of organs is a term rather indefinitely used.  It
is alike applied to epidermal thickenings on a workman's hands,
to enlarged  cerebral cells, to  the  increased bulk of one kidney
or one lung, when the other has been disabled; as well as to
the highly developed  state of muscles due  to excessive Avork.
It has  been variously regarded  as  a harmless overgrowth, a
disease, and finally and  more truly, as compensatory growth.
There was a time, not very  far  distant, when  hypertrophy of
the heart Avas energetically assailed as a disease per se.   Hyper- 
188
ABNORMAL GROWTHS.
trophy Avas a disease, an excessive groAvth, and  palpitation, its
objective symptom, Avas over-action.  Hoav erroneous such views
are Ave shall shortly see.  Remains of such obsolete impressions
still linger in many of our text-books.  They are the vestigia of
past thought, interesting from a retrospective  point of view.
They  have been preserved, hoAvever, as much from indolence as
from any conservatism in the minds of the Avriters.  Their pre-
sent use is to indicate the line of our progress in knoAvledge.
  Hypertrophy of muscular fibre is a thickening  of already
existing  fibres;  probably by multiplication  in  number rather
than an increase in bulk of the fibrillse.   The consequence is an
augmentation of volume in the hypertrophied part.   Such aug-
mentation in bulk we have just seen in the last chapter to be a
complex  result of functional activity and increased supply of
arterial blood, linked together  by some subtle nervous action.
Thus we find that there is hypertrophy of the bladder, or rather
of its muscular fibres, Avhen a stricture, or an enlarged prostate
offers an obstruction to  the flow of the urine from the bladder.
A similar development of muscular fibre takes  place  in  the
large intestine when a stricture  in the boAvel forms an obstacle
to the forward progress of the feces.  There is no  difference
Avhatever  betwixt  such hypertrophy,  such  groAvth, and  the
enlargement  of  the  ventricular  chambers of the heart Avhen
the orifice, or ostium, through  which such chamber  expels its
contents  forwards, is narrowed, or partially closed,  by valvu-
litis gluing  together the free  edges of the  semilunar valves.
After impregnation  the uterine growth is a  mere development
of fibres already existing in  an embryonic form in  the virgin
uterus.  After impregnation  they grow and  become, according
to Kolliker, from twice  to five times as thick, and from seven to
eleven times as long as they are in  their primitive  state.  In
the case of the development of the muscular fibres in the bladder
and in the bowel, to overcome an obstruction in  front, no  one
would call the growth a disease.  And yet a precisely identical
growth in the heart has  been regarded as a morbid  process.
Not only that, but  it  has  been thought to require remedial
measures.   AYhen the  aortic orifice is narrowed,  and aortic
stenosis exists, the Avails of the  left ventricle  grow in thickness,
and the effect of such  growth  is an accession of power; until
the A^entricle can once more drive an equal quantity of blood in 
ABNORMAL  GROWTHS.
189
 an equal space of time through the narrowed orifice.  It  is
 obvious that such a result  could only be obtained by an increase
 in the driving-power.   That driving-power is the muscular wall
 of the  heart, and by hypertrophy of it  alone  could  such com-
 pensation be secured.   And yet such compensatory growth has
 been denominated disease!  (See § 68.)
   In the same way the  enlargement of  the  left ventricle in
 aortic regurgitation has  been regarded as a morbid process.
 But Avhat are the  real facts  of the case?  AYhen  the aortic
 valves  are no longer competent, and a thin stream of blood is
 driven  backwards through  the  imperfect valves, and that too
 forcibly from the recoil of the  elastic aorta, the muscular cham-
 ber is subjected to an unwonted  distended force.  The effect of
 such increase in  the distending force to which the ventricle is
 now subjected Avould be to dilate it immoderately, if hypertrophy
 of the muscular wall did not come in to  arrest the dilating pro-
 cess.  Under  such  circumstances do Ave  find  the most marked
 hypertrophy of the heart, the  cor  bovinum.   So susceptible to
 any  distending force is the muscular chamber known as the
 left ventricle, that enlargement of it takes place very commonly
 in mitral regurgitation.   Here  the blood is driven  in  Avith
 abnormal force  from the gorged pulmonary  veins (and the
 hypertrophied right ventricle  behind them), and the left ven-
 tricle becomes dilated—unless the dilating process be stayed
 by muscular growth.  Hypertrophy's arresting hand alone can
 limit the dilating action.   Here we have hypertrophy to arrest
 distension:  that  is clear enough.   When the ventricular cham-
 ber enlarges from inability to  expel  all its contents, whether
 this  arise from debility in  itself  or some increased obstruction
 now offered to its  contraction by a heightened  blood-pressure
 in the arteries, dilatation  is  checked by hypertrophic growth.
 When a hypertrophied heart  is being undermined by  structural
 decay, or fatty degeneration, dilatation sets in.  Hypertrophy
 has arrested the dilating action ;  but  when it is itself cut down
 in time, the dilating process is again inaugurated, and  progresses
 without further check.   Dilatation and hypertrophy are more
 closely linked together, and Avithal are much more intelligible
 so linked, than Avhen treated  as separate processes.  There is no
 deep mystery about them.  When there is disturbance in the
equilibrium  existing betwixt the driving-power of  the heart 
190
ABNORMAL  GROWTHS.
and  the  Avork  it has to perform, the ventricular contraction is
incomplete.  A small quantity of blood is left unexpelled and
remains  in the ventricular chamber.  At the  same time  the
blood is coming in from the pulmonic circulation, and the con-
sequence  is the  ventricle yields, or  becomes dilated—unless
hypertrophic groAvth enables  the chamber  to contract com-
pletely and thoroughly expel its  contents.  In systems of  im-
perfect reparative poAver dilatation becomes  established under
the very identical circumstances  which evoke hypertrophy in
others of better reparative capacity.  The causation of hyper-
trophy and dilatation is the same; the presence of one or other
indicates the capacities  of the organism.   Consequently Ave have
dilatation  at the commencement and at the  end of the hyper-
trophy.   The  two  conditions  are  so intimately blended, and
developed  in such  varying proportions  in different cases, that
sometimes the  dilatation in one case, and the  hypertrophy in
another case,  may  be  scarcely, if at  all, discernible.1  Also
when hypertrophy  is wearing out  and being undermined by
molecular necrosis, dilatation recommences, and can never again
be arrested.  The true and just diagnosis of the different  ele-
ments of the [>articular  stage of the case, where there are found
hypertrophy of the heart Avails, Avith dilatation, is a matter of
the greatest moment in  prognosis.   It is no unimportant matter
therapeutically.  If it be a mixed case Avhere dilatation is being
arrested  by hypertrophy,  the  case  has Avithin it  elements of
promise.   But  if, on the  other hand,  it  be  a case Avhere  old
standing hypertrophy  is yielding, and dilatation  is a matter
rendered possible by structural decay, then the patient is going
down hill  hopelessly, and  usually SAviftly; and no poAver other
than supernatural can arrest the downAvard progress of the case.
  It is perfectly obvious to all thinking minds that hypertrophy
of the muscular Avails of the heart, bowel, or bladder must  not
be regarded  as a morbid process.   That it  may have some
consequential  outcomes not  altogether beneficial  is  possible
enough.   Unalloyed good is not to be sought in the domains
of pathological  anatomy.  Supposing that it  Avere possible to

  1 These views are given at length in  an article on Hypertrophy and Dilatation,
British Medical Journal, 1872, first half year, p. 236 ; and still further in the
Second Edition of The Heart and its Diseases ; with their Treatment; including
the Gouty Heart; Is79, ehap. v. 
ABNORMAL GROAVTHS.
191
remove this hypertrophy by any remedial measures whatsoever,
Avhat substitute for it could man devise?  If  it Avere  possible
to undo the compensatory growth, Avhat good Avould have  been
achieved?  The Avorst cases are  those Avhere the hypertrophy
is imperfect ; not those  Avhere it is well marked.   AYithout the
tissue-growth  the case Avould go wrong forthwith ; the hyper
trophy is the saving of the system.   The only  rational method
of affecting the hypertrophy is to strike at its causation.   If it
is practicable  to  do aAvay  Avith the exciting cause, the hyper-
trophy Avould pass away, just as does the hypertrophy of the left
ventricle of pregnancy after parturition.  Unfortunately, Iioav-
ever, it is but rarely possible to reach the originating cause, and
so the hypertrophy remains—fortunately not to be done away
with by any therapeutic  measure.   If the  attempts to reduce
hypertrophy were successful  the  patient  would have little
room for gratitude to his  ill-advised and mischievous medical
attendant.  Many cases of such  reduction of cardiac hypertrophy
have been  recorded, and still figure  in some works Avhich are
not  yet obsolete.   It is recorded that the late  Dr. Elliotson
announced to his class upon one occasion the successful treat-
ment of tAvo cases of cardiac hypertrophy byr iodide of potassium
with such  emotional disturbance as brought tears to  his  eyes.
I do not sneer at  the doctor's enthusiasm, but honor and respect
it.  He Avas simply mistaken.  Simple hypertrophy of the heart,
Avithout any valvular disease,  is almost  invariably connected
with the presence of nitrogenized waste in  excess in the blood.
A spare diet of slops and full doses of iodide of potassium would
strike directly at  the cause of the high arterial tension ; and, by
restoring the  blood to its  normal quality, relieve the  vascular
system, and with  it the chief  evidences of hypertrophy.  But
not  the hypertrophy itself; at least, not directly.   The recog-
nition of hypertrophy in a heart moderately enlarged and Avork-
ing  quietly and steadily, and well  covered by lung, is not by
any  means an  easy diagnostic feat.   This  is  a  very  different
matter from  the  excited  action of a  hypertrophied heart not
quite equal to its work.  A well-knoAvn authority on the heart
Avrites:  "For my own  part, I have  never  knoAvn the cure of
indubitable hypertrophy proved  by physical signs, and hold it
unwise to promise any such result from treatment." (Walshe.)
Instead, indeed, of attempting to do away with hypertrophy, it 
192
ABNORMAL  GROWTHS.
is our business to do our very besf to conserve it.  By good food,
iron, digitalis, and, if necessary, cod-liver oil, must Ave strive to
prevent its dissolution.  By similar measures, indeed, do  we
hope to inaugurate it where the system is unequal to instituting
it.  Its treatment lies in the  removal of its originating  cause.
In cases of hypertrophy of the  bladder and  bowel, something
may be done by the catheter, and by laxatives.  In hypertrophy
of the heart with valvular  disease, the only palliative  is a gene-
ral  quietude.  AY here the  hypertrophy  is associated with a
condition of the blood in which nitrogenized excess is present,
then a low  diet, alkalies and purgatives are indicated ; but not
as measures acting directly upon the hypertrophy, but as strik-
ing at its cause.   This part of the subject will be resumed in
Chapter XIV.  The chief  therapeutic lesson to be learnt about
hypertrophy is a purely negative one.  It is this :  it is equally
foolish and futile to  treat it as a disease.
  § 72. Connective Tissue.—Connective tissue is primitive tissue,
from  Avhich the higher tissues are  evolved, and  it still forms
the packing, or padding of the body.  In the lungs for instance,
are bloodvessels, air tubes, nerves  and lymphatics, all held
together by connective tissue.   When a solution  of continuity
occurs, it is by means of this connective tissue  that the breach
is  healed and the solution bridged over.  In inflammation of
the bowels an albuminous effusion, which  becomes ultimately
connective tissue, is  poured out; and so  the  inflamed surfaces
are first kept asunder, and  the vermicular action of the bowels,
Avhich disturbs the inflamed parts, checked, partially at  least.
The bands  which often tie  down the visceral to the costal pleura
after pleurisy, consist of similar histological elements.  Of like
nature is the growth Avhich constitutes the changes wrought in
the valves of the heart.  The  process which distorts and unfits
them for the full performance of their function is a growth of
connective tissue, the result  of valvulitis—a  parenchymatous
inflammation.  The changes Avhich  ensue in  the different vis-
cera, from the brain doAvn to the kidneys, in the venous con-
gestion which follows upon valvular disease of the heart, are due
to the excessive production of  connective tissue.   It is this tissue
which is thrown  out round the fractured ends of a broken bone,
and Avhich  keeps the two ends quiet, and also together.  If there
be  much  movement  this  growth is  developed in the tissues 
ABNORMAL  GROWTHS.
193
 around the callus, and so gives  more complete immobility.   It
 is by means of connective tissue that the two ends are ultimately
 united.  Cicatrix is connective tissue; so is keloid, but here the
 connective tissue is distinctly pathological.  Connective tissue
 may remain as it is: its histological elements may undergo no
 change, and for years it remains in itself harmless.   But under
 certain circumstances while so  harmless  it may be a source  of
 danger to  life, as in the bands remaining after enteritis, which
 so  frequently lead to strangulation.  The more normal is the
 tissue, the more likely is it to remain unchanged.  Frequently,
 however, a species of mineral infiltration goes on in it;  and we
 get the so-called ossification in parts, which is really rather a
 calcareous degeneration.   There is a quantity of  lime  salts
 deposited  in  the new growth,  just  as they  are found in the
 costal cartilages of elderly men.  Such  a  calcareous ring has
 been formed round the heart, from the infiltration of lime into
 a pericardial  band.  Lime salts are also  commonly  deposited
 in  the  connective tissue of valvulitis, and  give  a  species  of
 stoniness to  the altered vela.   This is in all  probability the
 true pathology of what used, a  generation ago, to be so  often
 heard of—viz., " ossification of the heart."  Similar changes go
 on  in arteries  Avhich have undergone atheromatous changes,  in
 certain organisms;  and the elastic artery is converted into a
 rigid and  brittle  tube.   This  condition  is  not  rarely  very
 general ; at other times it is more or  less localized.  It is a
 common cause of gangrene in  the extremities, and  gives the
 surgeon much trouble  when attempting to secure the  vessels,
 Avhich break up  when subjected to compression.  It is found
 also in the articular cartilage  of bone, as for instance, in the
 porcellanous deposit of arthritis.
  § 73. Connective tissue is at once an indispensable necessity
 and a disease,  according to circumstances.  It may or may not
 be  permanent.  Frequently large masses  of it are absorbed, as
 is especially seen in the removal of callus after the union of a
 broken  bone is complete.  At other times it is useless to attempt1
 its  removal, as in the valves of the heart  for instance, or the
 bands formed on  serous membranes.
  The different measures resorted to for its removal are  usually
combinations of iodine and  mercury.  The effect of these reme-
dies upon  some formations is very curious, and even in  some
      13 
194
ABNORMAL  G R O AV T H S .
cases almost magical.  There is, hoAvever, a marked difference
betAvixt the  ordinarv masses of  connective tissue  and those
groAvths of elements not far removed histologically, which are
denominated tumors.  There is little if anything to lead us to
hope that true tumors are ever removed by absorbent remedies.
For them  there is nothing but removal by operative interference.
On the other hand, masses of connective tissue are often success-
fully removed by the exhibition of iodine.   In superfluous pro-
duction of connective tissue-elements absorbents are  often very
useful, and much  depends upon the nature of the  mass, as to
Avhether it is  desirable to  attempt its  removal  by  medicinal
agents, or not.   The high hopes originally entertained are now
much modified, and Ave hear little  of the  reduction of hyper-
trophied organs by iodine compared to what Avas said a genera-
tion  ago.   Now there are no  surgeons who would hopefully
treat a scirrhous tumor with iodine.
  True  pathologically  connective  tissue  is  often  injurious
mediately from  the  consequences  of its presence.  Thus when
developed in excess in the kidneys it contracts and shrivels, as
is its nature, and so compresses and destroys  the tubules and
Alalpighian bodies,  and  ultimately ruins the  kidneys.  In  a
similar way it  grows round the lobules of the liver, and com-
presses and destroys that viscus, lobule  by  lobule.  In  the
chronic pleuro-pneumonia of oxen it creeps round the lobules of
the lung, and then, as it itself is transformed from a moist plasma
into something like  cartilage, it compresses the lobule of lung
till it  is  as dense as india-rubber.   In many of our chronic
complaints, especially in that form of disease of  viscera known
as cirrhosis, there is a gradual development of connective tissue
which slowly spreads; first throwing a series of soft cells  round
a part, and then, as they grow and harden, clasping the part in
its inexorable grasp, and rendering it utterly useless functionally.
As this  new  growth spreads  and  groAvs,  the viscus  becomes
practically destroyed for useful purposes.   Such is the effect
of healthy connective tissue upon  viscera.   Here it produces
untOAvard consequences merely by its presence, and  the  effects
of that presence upon the structures of the viscus.   The conse-
quences are certain—sure; but  at any rate the progress is slow
usually.   A very  different  state of matters is instituted Avhen
the connective tissue is itself the source of trouble, as when it 
ABNORMAL  GROWTHS.                195
 is too degraded to preserve  its integrity,  as  in  tubercle;  or
 assumes a malignant form, as  in scirrhus.  As consumption and
 as cancer, connective tissue furnishes  in  its abnormal aspects
 tAvo of  the  gravest  and most terrible maladies to which hu-
 manity  is subject.

                         Tubercle.

   §  74.  To Laennec we owe the introduction of the stethoscope,
 a most  valuable aid  to diagnosis; to him  also  Ave owe  most
 erroneous views about  tubercle—vieAvs Avhich  have done much
 to retard our progress,  and especially in the direction of treat-
 ment.  Laennec held that  tubercle Avas a special groAvth unlike
 any other tissue, and CarsAvell held  that  it Avas a secretion sui
 generis.   Nothing could have been further from the mark, nor
 yet more obstructive to real advance in knowledge about tubercle
 and  its  associations—except as to the tubercle of acute tuber-
 culosis.   Tubercle is modified connective tissue—nothing more
 or less.1   It varies from Avhat  is called "fibroid phthisis," that
 is, a form of pulmonary tuberculosis differing but slightly  from
 intestitial pneumonia—cirrhosis of the  lung, to masses of cell-
 groAvth  Avhich  swiftly  undergo retrograde  metamorphosis,  or
 even smaller or miliary  tubercles,  not  unlike  frog spaAvn,
 scattered throughout the lungs.  In the formation of the higher
 forms of tubercle the new growth springs from the connective
 tissue;  but, in  addition,  in  graver  cases,  the cell-growth is
 associated Avith the lining of the alveoli, and of the lymphatics,
 which accompany the terminal bloodvessels.   The lower the
 form of tubercle, and the Avorse the case generally, the more
 does  the growth involve  the latter structures.   Where the
 groAvth is confined to the connective tissue chiefly, the condition
 is rather that of cirrhosis.  Where there is free growth from
 the other sources of tubercle cells, the tubercle increases more
 quickly in bulk, and  its cell-elements are of  lowlier forms ; too
 often so slowly that  they  cannot  maintain  their vitality, but

  1 " The form is produced by the growth of the tubercle from single cells of
connective tissue by the degenerative proliferation of single  groups of connective
tissue corpuscles."—Yirchow, Cellular Pathology.  At Fig. 140 he shows the
"development of tubercle from connective tissue in the pleura."  Translated by
Chance. 
196
ABNORMAL  GROAVTHS.
soften and decays.   These  miliary  tubercles  are by  far  the
gravest form  of tuberculosis, Avhich is usually fatal in a  few
weeks.   Some  Avriters have preferred to call it  tuberculous
inflammation  of the  lung.  It  is indeed a species of inflam-
mation, or cell-proliferation; but it  differs  from ordinary in-
flammation in the quality of its products, and  in its fatal charac-
ter.   Both possibly it owes  largely to  the general condition of
the  organism in Avhich it shows itself.   Aliliary tuberculosis,
from its hopelessness, need not engage much attention in a work
on therapeutics—except from a preventive point of view.  Of
which anon.
  It  is rather as yellow tubercle, the bronchial tuberculosis of
Rokitanski, that tubercle interests us  here.   But though  we
associate tubercle with the lungs, it is not because it is in rela-
tion  only with  the lungs ;  it may be found  in  different locali-
ties  indeed, but it finds its  most marked forms  in  the lungs,
and  as such has been most  studied.  Perhaps the simplest Avay
to give a vivid, and yet fairly true impression of tubercle, as it
appears in masses, is to follow Niemeyer, and say that  it is  an
inflammation whose products are  imperfect or  degraded.  The
most perfect form of inflammation is folloAved by perfect resto-
ration of the lung—that is in  acute croupous  pneumonia.  If
there be a tendency for the cell-elements Avhich are the products
of the inflammatory condition to become organized into fairly
healthy  connective   tissue,  then  " fibroid   phthisis"  results.
Commonly certain portions—possibly from some local condition
Avhich Ave cannot appreciate—are of lower forms of cell-growth
than others, or undergo a degrading transformation more readily
than others.  Consequently in a lung which  is  generally in the
state knoAvn as  fibroid phthisis there may be masses of lowlier
cell-growth known as caseous tubercle.   At other times a local-
ized  inflammation Avill result in  the  production of a  mass in
Avhich the lung structure is infiltrated with a loAvly  form of
cellular elements, and which is called  caseous  pneumonia.  In
still worse cases there is a more Avidespread inflammation, impli-
cating several portions of the lungs,  very commonly  the two
apices.  Such  inflammation may  eventuate  in several cheesy
masses surrounded by fairly healthy inflammatory products; or
each   mass  may  be surrounded  by a wall of degraded cellular
elements, Avhich itself undergoes early  degenerate changes, and 
ABNORMAL  GROWTHS.
197
 so cause matters to go from bad to worse.  C. J. B. Williams has
 divided connective  tissue into—1,  Euplastic deposits, that is,
 healthy connective tissue, as cicatrices; 2, Cacoplastic deposits,
 Avhich are more or  less defective in organizability, as ordinary
 tubercle; and 3, Aplastic  deposits,  which  are too  degraded to
 possess any organizability, and which  simply pass  along in  re-
 trograde changes Avithout any  attempt towards organization.
 They do not constitute differences  in  kind so much as  differ-
 ences in degree.  They are all of like descent, but they differ,
 often profoundly, in their course and career, and that, too, much
 according to conditions and circumstances  iioav becoming fairly
 understood.  No respectable  comprehension of tubercle  in any
 of its relations can exist, or ever will become practicable, so long
 as the vieAvs of Laennec and  CarsAvell  obtain, that tubercle is a
 heteromorphic neoplasm.  It is not  a strange intruder of foreign
 race and blood amidst  the mild  and inoffensive  cell aborigines
 of  a  viscus, with  grim  front and lowering mien—a  sort of
 Spanish conguistadore amidst inoffensive and harmless Indians—
 exerting a destructive and malign influence on all sides and
 everyAvhere; it is the " ne'er-do-Aveel" of the tissue family,1 the
 degraded " naught-AA^eel," of Avhom there is  little hope of  re-
 generation; Avho Avill scarcely ever  be  converted into anything
 more than a harmless tax upon its  blood  relations; and Avhich
 not  unfrequently  becomes  a source of great danger  to them.
 Tubercle is a degraded form of connective-tissue, and  there are
 various forms of degradation—some higher, someloAver—but all
 below the standard of health.  This is  a broad view of tubercle,
 true in  the main, if not actually correct, or described as it should
 he in a  work purely devoted to pathological anatomy.  The less
 degraded the type, the  less unfavorable the prognosis ; the more
 degraded, the more hopeless.
  § 75. What  is of much  more importance  to  us here is the
 question of Avhat are the  circumstances which affect tubercle;
 which keep it aAvay or encourage its advances, or Avhich arrest
 its progress Avhen established, and stay its  ravages.  The hope-
 less pathology of Laennec and CarsAA^ell had nothing but a grave
as the future of those who Avere smitten with tubercle.  Now Ave

  1 " Tubercle is always a pitiful production,  a new formation  from its very out-
set miserable."—Virchow. 
198
ABNORMAL  GROWTHS.
knoAv that recovery from conditions either actually tuberculous,
or tending to tubercle, is very common.   "In nearly the half of
all cadavers Ave find traces of the nutritive disorders from which
pulmonary  consumption  proceeds."  (Niemeyer.)  There  are
various forms  or modes  of recovery in the case of tubercles.
They are  thus arranged  by Rokitanski.1  (1) Obsolescence, or
the Avithering up, the cornification of the tubercle, only too rare.
(2)  The  cretefaction of yellow tubercle-masses, in Avhich  the
organic matter is ultimately absorbed, and masses of inorganic
matter, like bits of mortar, are left; and not rarely expectorated
long after all evidences of constitutional  irritation  connected
Avith the tubercular deposit have  passed aAvay and almost been
forgotten.   (3)  Elimination by a process of softening of the
tuberculous mass, together Avith an ulcerative process around its
periphery by Avhich an outlet—as by perforation of a bronchus
—is formed, and the softened  tubercle got rid of. This last is
the form that gives us the well-known consumptive eases with
which all are so familiar    Many cases do badly, and the system
sinks  under the long  process  to Avhich  it is subjected.   The
hectic fever, the  night sweats, the harassing cough, the general
constitutional  irritation ; the loss of appetite  and of digestive
and assimilative power, which, combined, Avear out the powers
of the system ; are all but too familiar to us.   Yet there are
many recoveries  from this  terrible condition ;  so many indeed
as to encourage us to  inquire  into the factors which  lead to
recovery.   If there are conditions which render recovery feasible
it is our first duty to discover what those conditions are;  how
they  are  brought  about;  and  by what means  they  are  best
secured.
   We must start off by understanding distinctly that tubercle
is but a modification of  ordinary inflammatory products, not a
true neoplasm.   Niemeyer  lays doAvn the following in clear and
impressive language:  "The consolidation  and destruction of
the  lungs, Avhich form the anatomical  basis for consumption,
are usually the products of inflammatory action, and the greater

  1 Some apology may seem due to the reader for following an authority usually
regarded as alread}- antiquated, but Rokitanski is not yet laid on the  shelf, and
is a bright, cordial, active-minded man still; though he is the father of modern
pathology.  Now in 1880, we must speak of him in the past tense. 
ABNORMAL  GROWTHS.
199
the quantity of cellular elements collected in the vesicles, and
the longer the duration of the inflammation, so much the more
readily will pneumonia lead to consumption, since these are the
conditions most favorable for the production of caseous infil-
tration.  Secondly, pneumonia resulting  in  caseous infiltration
occurs most frequently,  but  not exclusively, in  puny, badly7
nourished subjects.   This is  partly because such persons are
especially delicate, and in part  because all inflammatory nutritive
disorders by Avhich  they may be  affected sIioav great tendency
to copious cell-formation, Avith subsequent caseous degeneration."
The production of the cellular elements is in inverse  proportion
to the quality—the  higher the fewer, the loAver the greater in
quantity.  And again, "The caseous masses  upon  which the
consecutive (secondary) development of tubercles in the lungs
depends  are situated in the great majority of cases in the lungs
themselves,  and consist of the products of chronic pneumonia
in a state of caseous degeneration.  We  have no hesitation in
stating that the greatest danger for the majority of consumptives
is, that they are  apt to become tuberculous."   It is in this that the
course of simple chronic pneumonia—probably  a very much
commoner complaint than Ave imagine, because it is  not sought
for by systematic  investigation—differs from that pyretic state
of hectic fever described in  common parlance as " going con-
sumptive."
  It is obvious  that the rational method of treating tuberculosis
is to restore matters to that condition which existed before the
patients  became tuberculous;  and which obtains in  those who
do not become  tuberculous.   In order to do this it is necessary
to consider  the different  circumstances which  lead  to the
patients becoming tuberculous.  First there  comes the question
of heredity.   It is notorious that in some families the tendency
of every  form of ccll-groAvth,  especially cell-formation of rapid
growth,  or  of  inflammation, is  to degenerate into tubercle.
They are known as  consumptive  families.  Their tissues bear
the brand of inheritance.  They readily yield and become tuber-
culous if placed under the following circumstances ; which have
much to do with the  production of tuberculous  degeneration.
Imperfect nutrition, unhealthy surroundings, and especially an
insufficient  dietary  are the factors which lead most  directly
to the formation of tubercle.   The want of fresh air, the imper- 
200
ABNORMAL GROWTHS.
feet removal of oxidized, or rather  partially oxidized products,
have  much  to  do with tuberculous degeneration.  The effect
of fever, and especially enteric or typhoid fever upon the nutri-
tive processes, is such that tubercle commonly follows any chronic
pneumonia in the convalescence  of these patients.  Long con-
tinued inflammatory action may lead to similar results.  Some-
times the effects of inflammation of the lungs upon the system
in a perfectly healthy subject are so grave as to lead to degene-
rative changes in the inflammatory products.  One of the com-
monest causes of general constitutional debility favoring tuber-
culous degeneration is rapid growth.   The tax upon the powers
of the system is commonly manifested in  the tendency which
then obtains for any cell-growth to develop a tuberculous char-
acter.  Long periods of partial  starA^ation, of imperfect  nutri-
tion, also render the tendency to such change very marked.   It
is a matter of personal observation that tubercle in a retrograd-
ing condition, on  its road towards one of the forms of  repair
given above, is common in the lungs of sheep or of cattle, Avhich
have  been  previously underfed  during  the preceding winter,
but which have fattened sufficiently for the market during the
ensuing summer.  Alasses of tubercle, the size of a billiard ball,
encapsuled by healthy connective  tissue, together with  similar
masses undergoing cretefaction, are far from uncommon in the
lungs of young cattle  slaughtered for the  food of man—and
perfectly good, wholesome fat meat they furnish.  In sheep the
tubercular masses  are rather those of millet-seed shape and size,
and  masses of  the size of a hazel-nut are rare.   Occasionally in
both  animals, cavities, lined with a species  of membrane, and
surrounded by  healthy lung tissue, are found ; marking the pro-
cess of elimination by softening and expectoration.
  § 76. The foregoing series of factors, standing  in a  causal
relationship to tuberculous  degeneration of inflammatory cell
elements, points very clearly in the direction—that imperfect
cell  elements  are  due to a low tissue-producing poAver in the
organism, either congenital  and inherited,  or acquired; occa-
sionally both combined.  Especially, then, Avill  tubercle mani-
fest  itself in those Avho, naturally delicate and predisposed to
tubercle, reject all fat.  It is Avell known that fat is wanting in
tubercular tissue—that  in  other words  the absence of fat is a
great cause of tuberculous degeneration in inflammatory pro- 
ABNORMAL  GROWTHS.
201
 duets.  Consequently a rapid cell-formation in such individuals
 is commonly folloAved by tuberculous degeneration.  Such is the
 actual  history of much  of the  tubercular consumption Ave see
 around  us.  Dampness of subsoil may exert  much  influence;
 but the unAvise yet prevalent custom of permitting children to
 leave all the fat of their  meat on their plates untouched, is a
 much more powerful factor.   It is just  those slight, fragile
 forms, to whose systems fat is so absolutely necessary for healthy
 tissue-building, that reject fat most persistently ; and where the
 parents should most steadfastly insist upon  their taking fat—
 in  some form  or other.   When once they can  be induced to
 take fat the  dislike  to  it vanishes, and  not  rarely becomes
 transformed into a positive craving for  fat, in  Avhich case a
 cure, or its equivalent,  is not  rarely achieved.  Such  is one
 of  the greatest of our curative agents ;  it is equally potent as a
 preventive  measure.
   When, then, Ave find good reason  to suspect the presence of
 tubercle, or a tuberculous tendency in a patient,  it becomes
 imperatively necessary to institute a distinct line of treatment.
 In  passing  it may be observed,*that it is very unwise  to rest
 the diagnosis of tubercle too exclusively  upon  physical signs
 in the lungs, as too many practitioners, and  especially juvenile
 ones, in their full-blown  zeal for physical examination, are apt
 to  do;  to the neglect of the  many other equally important
 factors Avhich only reveal themselves to the much more difficult
 observations of a brain trained  to observe and reflect—to esti-
 mate the tout ensemble of the  case, and correctly appraise the
 family  and the  individual  history  of the  patient.  Having
 arrived at the conclusion  that  there  is present  in  the organism
 connective  tissue of a loAvly  form, or undergoing tuberculous
 change, the  next question is—How  to treat  that patient?   If
 there be no  rise of temperature, or it be only  a fifth of a degree
 or so, it is desirable  at once to commence a plan of improving
 the nutrition.  The food must be easily digestible, and furnished
 to the system in liberal quantities.  It must be sloAvly consumed
 and where necessary sloAvly and deliberately masticated.   There
 must be a period of quiet maintained  after  each meal.  The
 boAvels must be  kept open ; and  the digestive  powers be well
sustained.   Frequently there is  some gastric  irritability inter- 
202
ABNORMAL  G R O AV T H S .
fering  Avith digestion and assimilation.   Here the  folloAving
forms a capital mixture :—
                       Bisin. Trisnit. gr. x.
                       Pot. Bicarb, gr. v.
                       Mist. Aeaciae 3j.
                       Inf. Calumba? ^j.,
three times a day before food.   Many practitioners regard such
mixture, or bismuth with tragacanth, as their sheet anchor in
incipient  phthisis.   The  food  should be such  as not  to tax
unduly the digestive powers.   It might  consist of milk  with
farinaceous foods, as tapioca pudding, arrowroot, maccaroni, or
bread  puddings, various nutritive soups, fish in various forms,
and  still more oysters and  other bivalves ; meat, either cut very
thin, Avith a fair quantity of fat, or carefully minced and not too
highly seasoned, poultry, game, etc.  Eggs in various forms are
very pleasant, especially Avhen  done  with butter, as folloAvs:
" Break four eggs into a basin, beat them well.  Put a teaspoon-
ful of  cream, or of milk Avith a  piece of butter in it, into a pan,
with a little  salt; when the cream is warm  add the eggs, and
keep stirring until the mess thickens, and  then pour it into a
dish, Avith or without buttered toast at the bottom.  The mixture
should not boil.  (Time five minutes.)"  Various glandular bodies,
as SA\reetbreads, etc., may be tried ; plain  boiled, and eaten  with
butter, pepper,  and salt, they form an  eligible article  of diet.
Marrow is also very suitable.   The leading  idea is to give fat,
or fat-forming material, in such guise as shall be least objection-
able to the patient's tastes, and  at the  same time most easily
assimilable ; and thereby to modify the  cell-formations  taking
place in the body.  If there already exist masses undergoing
a process of degradation, they may be surrounded by a Avail of
healthy connective tissue,  within which they are comparatively
harmless.  A glance over  Chapter II. may be desirable for the
reader at this point.  There he  will find  the  matter of assimila-
tion explained at length ;  and will  see hoAV  iron may be given
Avith advantage after food  in different forms, but especially with
arsenic in pill.   He will also see that cod-liver oil is stated to
be the most readily and easily digestible  of all forms of  fat.  It
was  in the recognition of  this fact that J. Hughes Bennett laid
the Avorld  under.a debt of thanks to him, and demonstrated so
palpably the aid physiological investigation can give to practical 
ABNORMAL  GROWTHS.
203
medicine.  Cod-liver oil should be given after food, and then it
is acted upon by the pancreatic secretion and emulsionized.  It
is also best borne  by the stomach  Avhen so  given; and  very
frequently if given before food, a most unphysiological time to
administer it,  it disagrees, and  often it is not tolerated, but
rejected.  It is further an  excellent plan in practice to  com-
mence Avith a plain and comparatively tasteless oil; and  only
after the  toleration of it is perfectly  assured, to proceed  with
the  stronger-flavored broAvn oils, Avhich  are alleged to be more
serviceable.  There are various vehicles in  which the oil  may
be taken.  Milk, solutions of gums, orange Avine, lemon juice,
cinnamon Avater, etc., are all recommended.  Cod-liver oil  may
be taken in quantities varying from  a  feAv teaspoonfuls to  four
or six ounces, daily, according to the  requirements of the case
and  the digestive powers of the patient.
   It frequently happens that  the appetite  of the tuberculous
patient is A7ery  capricious in the morning, and that breakfast is
not a good meal.   This is a graATe matter, and it is ever better
Avhen a good meal is  taken  and digested to commence the day
Avith.  Every means should be taken to secure a good breakfast
if possible.  One of the best measures is to give the well-known
rum-and-milk in the morning, ere dressing.  The following is
the best formula for it:  "Take half a pint of neAv milk  and
add  to it an egg, a teaspoonful of powdered sugar, some grated
nutmeg, and one or tAvo teaspoonfuls of good old Jamaica rum ;
stir all together well, and let it be taken by the patient in bed."
It is desirable that a little  further  rest in bed should precede
the process of  dressing.  After such  preparation  breakfast is
commonly enjoyed and assimilated.
   It is often desirable to Avhet the  appetite  with some bitter
infusion with acid, about half an hour before each meal.  Phos-
phoric acid with gentian does  very well.  Chalybeates are  best
taken after food when  used as a hrematinic.  By  such a course
of treatment, combined with AA-ell-ventilated bedrooms, plenty of
fresh air free from impurities, and good warm clothing, many a
case  can  be turned from its downward progress, and a process
of repair be instituted.  The question of climate is one of much
importance.  There is no doubt that a change of climate is
often very beneficial.   It is not ahvays easy to say what  that
change shall  be.   To many the shores  of  the Mediterranean 
204
ABNORMAL  G R O AV T H S .
are distinctly preseiwative, and their  Avinters  should be spent,
when practicable, amidst orange groves.   Others again require a
different climate, and the slopes of the Himalayas, the Califor-
nian Sierras, the Blue Mountains  of  Virginia, the high Swiss
valleys, &c, give them the best chance of life.   A long sea voy-
age to Australia is the salvation of others.  How to decide in
each case is very difficult, and  the young practitioner Avill be
prudent Avho defers the selection to some Avell-known authority.
Whether the mild climate, furnishing  a soothing air  to the dis-
eased lungs, or a bracing  climate, improving the  general tone,
shall be chosen, is  often a matter not  easy of solution.   It is a
still graver  matter often to decide whether  an invalid shall be
sent away Avith the prospect of dying  among aliens in a foreign
land, on the chance of a very hypothetical possibility of recov-
ery ; or let the sands of life run out at home.   I am glad to say
that a reaction is setting in in faA^or of the latter.   A  foreign
tour is very Avell in some cases : in others its recommendation is
simply cruel.   (Chap. XXII. § 232.)
   § 77. When the tuberculous degeneration is producing hectic
fever, and the softened  mass is being expectorated by means of
an opening into a  bronchial  tube, another series of symptoms
is  developed.  The ulceration around the periphery  of the
tuberculous  mass,  which  opens  the  way out, usually creates
some fever.   Frequently the fever is sharp.   The  mass too acts
like a foreign body, and  produces irritation which  evokes the
reflex act knoAvn as cough.  The irritation being persistent, the
cough  is frequent, harassing, and often so continuous  as seri-
ously to interfere with the rest at night.  Indeed, ere a way out
is  secured  for the softening  mass, by Avhich the system is re-
lieved, very commonly a period is passed through which gravely
threatens the existence of the organism.  Great emaciation and
exhaustion mark the time of  trial.  Here stimulants, nutritive
food, and alcohol are required, often  urgently.  Wine  is espe-
cially serviceable:  it  is  a stimulant, while the alcohol is a
readily available food.   In full doses, too, the alcohol loAvers the
febrile temperature, and so is  still further useful.   Cream with
sherry, or a liqueur, eggs and  brandy, milk and seltzer-water, as
a  beverage, Avine, Avhey,  coffee Avith  rich milk,  or  cocoa and
milk, are all indicated, and in liberal quantities too.   The ques-
tion is whether the storm that is brewing, or  already blowing, 
ABNORMAL GROWTHS.
205
 can be weathered or not;  if the organism can be sustained till
 the gale has blown over, all may yet be well.  For this end free
 supplies of easily assimilable food are necessary—absolutely neces-
 sary.
   Another great point is the question of what to  do when the
 sleep  is  much broken  by  cough.   When  the cough is very
 wearing it is highly desirable that  something be done.   Unfor-
 tunately the means of palliating the cough are often very objec-
 tionable.  Full doses of opium or morphia, however adminis-
 tered, are very apt to destroy the appetite and ruin the digestive
 powers.  It is  only when compelled to resort to them that they
 should be given.  If necessary, then "  must be" must.   A grain
 and a half of opium  in extract of aloes  may be given.1  Hypo-
 dermic injections  may be resorted to,  or a morphia suppository
 given.   At  other times the following is a good  form of night
 draught:—
                    Pot. Brom. J)j.
                    Tinct. Hyoscyami,  ^ss.
                    Mixt. Camph.  ttj.
 This often affects the  reflex mechanism, and lessens  the cough
 very satisfactorily.   At other  times  ammonia  and Cannabis
 Indica seem beneficial.   Often the night sweats are profuse, and
 then belladonna and  phosphoric acid  in free quantities may be
 resorted  to.2  Fuller was fond  of giving  food and alcohol at
 bedtime.  A large bedroom well  ventilated is ever  desirable.
   Under all circumstances  it is very necessary  that rest, as far
 as is possible, be given to the diseased  viscus.  In all inflamma-
 tory conditions rest is clearly indicated.  Quiet permits of the
 reduction of the hyperaemia which is the  initial step of the
 inflammatory process, Avhether simple  or tuberculous.   It is the
 impossibility of securing perfect rest  that renders  the presence
 of tubercle in  the lungs and  boAvels  so  much graver  than is

  1 The addition of a sixth of a grain of sulphate of copper will check the night
 sweats to which the opium alone might give rise.
                  2 Tinct. Belladonna?,  TT|.xv.
                    Ac. Phosph. Dil. ITl xv.
                   Mist. Camph. §j.,
every night at bedtime, gives very satisfactory results in the writer's hands.  At
Victoria Park Hospital atropine in  pill is  given at bedtime, and the effect on the
night sweats is very pronounced.   (From a 75th  to a 25th of a grain.) 
206               ABNORMAL GROWTHS.
 its appearance in an ordinarv gland.   The constant movements
 of the lungs, and of the boAvels, cause a further development of
 connective tissue, just as does the  movement of a broken limb
 call out callus; and this iioav formation takes on in its turn tuber-
 culous degeneration.  If rest could be  secured  this secondary
 formation might be avoided.  The objections to opium have
 been  given  above, but  other means  of securing rest may be
 tried.  In tubercle of  the bowels rest may be partially secured
 by cheeking any  tendency to  diarrhoea, Avhich  increases the
 vermicular action of the intestines, and for such purpose myrrh
 is often useful.  It may be given with bismuth  in powder, ten
 grains of each, at bedtime, especially with a grain and a half of
 powdered opium.  Strapping that  half of the thorax in Avhich
 the tubercle  has  shoAvn  itself, is an excellent plan for securing
 partial rest to the lung in pulmonary tuberculosis.  Cough, too,
 irritates  the affected parts mechanically,and should be avoided.
 Perhaps  some day Ave may  discover  a  remedy  Avhich Avill  so
 deaden the nerve centres as  to  arrest to a large extent those
 reflex actions which, though often useful—as  when a crumb
 is in the larynx—at other times are an unmixed evil.  If such
 an agent could  be discovered  it  would  be  most precious  in
 the relief of  cough of  pulmonary tuberculosis.1   For the cough
 is very irritating as well as  exhausting, and  there is  no hope
 of  the irritant mass being  expectorated, until it  is  softened
 and has  a way prepared for  it ;  after  which the  cough is very
 useful.
   Since  the  publication  of  the first  edition of this  work, a
 further experience, on an extensive scale, of phthisis, inclines me
 to  make some more extended  remarks upon  its  treatment;
 especially of  the  early stage, before there is any breaking down
 of the lung,  and  where there are  cough, night  sweats, loss  of
appetite, and failure  of strength, with shortness of breath,
markedly on  exertion, from the lungs being crippled.  It is at
this stage that treatment is most urgently required, and is most
successful.  There may or may not be haemoptysis; if there  is,
it often  is most  useful  as a form of local bleeding  relieving
vascular  congestion.  To administer tonics and good food  is the
aim of every  practitioner; but in many cases the patient can-

  1  Such an agent, some think, is to be found in the Gelsemium sempercirens. (?) 
ABNORMAL  GROWTHS.                207
 not tolerate such measures, and the practitioner is at a loss what
 line to try next.
   Every case has its oavu peculiarities and its own exigencies,
 and must be studied  in  detail.   In the first place all drains
 must be  stopped.  If a woman Avith vaginal discharges, they
 must be met by the measures given in § 190.
   Then there are the night sweats—of primary importance.  To
 arrest these, and Avith  them the terrible  loss of blood-salts en-
 tailed thereby, is the very first step to be taken—and earnestly
 taken too.  For  this end  belladonna  stands facile  princc.ps.
 Sulphate  of copper  is  good  where there  is  also diarrhoea,
 Sulphate  of magnesia is valuable where  there is a tendency to
 constipation.   Oxide of  zinc  and  hyoscyamus are precious,
 especially where there is a marked intolerance of belladonna__a
 very rare occurrence.  Sulphate of atropia is tasteless, and can
 be accurately measured.  It  acts  upon the terminal endings of
 nerves in  the sudoriparous glands, and as an anhidrotic is un-
 rivalled.   But it  must be  given in larger  doses  than those
 commonly administered, to be effective.   Many practitioners, I
 fear, declare the drug to have failed, when really they have failed
 to give it a proper trial.  No  one would assert  that  sulphate
 of magne'sia was not an effective purgative, because the ordinarv
 dose fails  to produce  loose  stools in certain persons.  It is well
 to commence Avith  one  seventy-fifth (^-th) of a grain in adults.
 With children, Avho are like rabbits almost in their tolerance of
 belladonna, it is desirable  to commence Avith  one-fiftieth (g^th).
 It may be given in pill or in solution, and is preferable to the
 galenical preparations, the extract and the tincture of belladonna.
 Not uncommonly the dose must be increased to a  twenty-fifth
 (.j'gth) of a grain.   Beyond this I haA^e not yet gone, but intend
 going up to one-tAvelfth (j^th)  in hot relaxing Aveather.
  In  measuring the  effect of  belladonna the pupil is a worth-
 less guide, utterly  worthless in my experience.  In some cases
 dryness of the  throat and dimness of vision are  produced by-
 small doses, and the judicious practitioner Avill not lose his head
 and stop the drug on the first appearance of  these  toxic  symp-
 toms.  Belladonna is a poison,  like strychnia, Avhich keeps its
 danger-signals well up and far  out, and gives distinct Avarnijig
 long before any serious risk  is  neared.  It is open to question
Avhat the lethal dose of atropia  is ; but probably half a grain is 
208               ABNORMAL GROWTHS.

perfectly safe with most people.  When then these evidences of
its physiological action are manifested, the anhidrotic  effect
may be looked for with  much  confidence.  The patient should
not be taught  to  regard these symptoms  as something  to  be
alarmed at, but  should be told, "If your throat becomes dry, or
the eyesight is  affected or impaired, it sIioavs  the medicine is
taking hold, and doing you  good."  Usually  the  sweats will
stop in three or four days;  and this arrest of the outflow of
blood-salts is very commonly followed in forty-eight hours  or
so longer by a return of the appetite and of the digestive capacity.
There are certain points about belladonna which deserve further
consideration in regard  to  pulmonary phthisis.  It is a direct
stimulant to the respiratory  centre  {The Antagonism, of Thera-
peutic Agents, and  what it Teaches.  Foihergillian Prize Essay of
the Medical Society of London,  1878), alike  Avhen failing under
the influence of a  toxic agent and Avhen exhausted by disease.
It acts powerfully on the  sentient  peripheral endings jof  the
vagus  nerve in the lungs.   It therefore can  often be  combined
with opium Avith the very best effects in the treatment of the
cough of phthisis.  It does not antagonize the effects of morphia
upon the hemispheres, and so  does not  interfere Avith the hyp-
notic action  of morphia;  Avhile its  stimulant  effect  upon the
respiratory centre wards off that failure of the respiration which
is not  very rarely  met with as the  consequence  of an ordinary
dose of morphia in a person Avasted by consumption.  The addi-
tion of a  dose  of  atropia  to  the dose of morphia required  to
procure sleep  in the  racking  cough of phthisis will make the
effect more certain, and will  get rid of two  undesirable, but
unavoidable, effects of the morphia, viz.,  the increase  in  the
night sweats and the danger of failure of the respiration.  It ia
a Avell-known clinical fact in  phthisis that a dose  of morphia,
which  is sufficient to exercise any useful effect  upon the cough,
is usually found to produce still more profuse perspiration, or
even to excite free perspiration where it has not existed  before.
When, then, it becomes necessary to give a  full  dose of morphia
every night, it is very desirable to add thereto a dose of atropia.
The result of this combination is  to maintain the respiration
and to arrest the profuse night sweats.  (Here the double action
of atropia is Avell seen.  It is scarcely the place here, however,
to discuss the relations of  the cutaneous and pulmonary respi- 
ABNORMAL  GROWTHS.
209
 ration.  When the blood is deficiently aerated, and  there  is
 excess of carbonic acid in it, the sensory nerves of  the sudori-
 parous glands are throwm  into action and  sweating  follows.)
 (P. 73.)   The pill in common use with  me at my hospitals con-
 sists of
                     Morphia Mur. gr. £.
                     Atropia? Sulphat. gr. Jg.
                     Pulv. Capsici, gr. j.
                     Pil. Aloe et Myrrh, gr. iij.
   Where there is great sensitiveness in the bowels, the dose of
 Pil. Aloe et Myrrh, may be reduced to one-half, or even omitted
 entirely in some rare cases, extract of gentian being  substituted
 for it.  The bitter of the aloes  keeps  up the appetite, and its
 laxative qualities prevent constipation from the action of the
 morphia.   This  pill  may  be  continued for Aveeks,  or even
 months, without any of the evil results usually seen to follow
 the  free  administration of morphia  alone.  Here our most
 modern knowledge is utilized to get rid of those actions of the
 morphia Avlijch are undesirable; but which  are, otherwise, un-
 avoidable.  Where the  patient cannot  sAvalloAV a pill, then the
 morphia and atropia can be  given in Decoct. Aloe Co.   In cer-
 tain cases of phthisis, especially in those cases  where  there is
 much pallor with a greasy shining skin, so justly regarded as of
 bad prognostic omen, the active exhibition of belladonna is  not
 ahvays sufficient  to  check  the exhausting  night  sweats, on
 Avhose arrest or persistence the prognosis hangs.   Here it is Avell
 to use a local application which was first described to me by Dr.
 Louis Sayre, of ~New  York, as having been practised by an  old
 irregular  practitioner over there, and who  bad, by  its  means,
 gained a high reputation for the treatment of phthisis.   It con-
 sists in sponging over  the patient with hot vinegar,  holding in
 suspension a quantity of powdered capsicum.   A teacupful of
 vinegar made hot and a teaspoonful of cayenne pepper were  his
 quantities.  About an hour before the usual  oncome  of the pro-
 fuse night or morning  sweat, the  patient should be sponged
 over freely.   The effects really are very satisfactory ;  nor do the
patients so treated  complain that  the  process is disagreeable.
So much, then, for arresting the night SAveats.  I may add, that
only once in many hundreds  of patients to whom this  pill has
been prescribed, has there been any complaint of active distur-
      14 
210               ABNORMAL  GROAVTHS.
bance of vision from  the above pill, and that Avas  in  a  very
hyperaesthetic Avoman.  At times the dose of aloes and myrrh
seems too great.
  Then sometimes the patient  shows a  special  intolerance of
belladonna, the dryness  of throat and disturbance of vision
being so great that the drug must be suspended.  In these rare
cases it is Avell to give oxide of  zinc and  hyoscyamus, or a pill
of sulphate of copper and  opium. This last is very useful where
there is also diarrhoea.
                   Cupri  Sulph. gr. £.
                   Pulv.  Opii, gr. H.
                   Confect. ltosae, q. s.
is the formula for it.
  Sometimes a tonic (vegetable) with some acid, as
                   Liq. Strychnia?, Hfiv.
                   Ac. Phosph. Dil. Hlxv.
                   Inf. Gentian, ^j. ter in die,
may conveniently be taken before  meals. But at other times
the tongue  is  raw and irritable, or denuded of epithelium in
patches. Here it is necessary above all things to attend to the
state of the  stomach.   Milk, sheathed  with alkalies, must be
the food ; the alkaline bismuth  mixture  with or without bro-
mide of potassium, the medicine.  Until the tongue indicates a
more normal condition of the primae vise, the greatest care  must
be taken, and no movement be made carelessly.  At other times
the tongue is  furred,  and then  it  may be  necessary to give a
mixture of nitro-hydrochloric acid and  infusion  of cinchona
thrice  daily; with a compound  colocynth and calomel pill at
bedtime every alternate night.  Or at times ten drops of  Tinc-
ture of Xux Vomica in an ounce of the Mist. Rhei et Gentian.
may be indicated  instead of the acid mixture.  So long as the
tongue is  raAv and irritable, or covered  with a broAvn fur—a
layer of dead  epithelium  cells—it is useless to  give iron and
cod-liver oil.   The tongue is  the index of the intestinal canal,
and it is often more essential  to study the tongue carefully than
to make minute observation as to the physical signs in phthisis.
After the night sweats are arrested and Avhen the  primse vise
have  been placed  in  a normal state, then it may  be  well to
administer haematics and  to order cod-liver oil—but not  precipi- 
ABNORMAL  GROWTHS.
211
tately, nor with undue haste.  Hoav often this mistake is made,
time lost, often  never to  be regained ; a backward step taken,
and slow onward progress alone attainable  in the future; is not
a pleasant matter for retrospection.  The ground lost by hasty
adoption of a tonic treatment is sadly  too  often never regained.
Still too great timidity may also lead to untoAvard results.
  Then as to haemoptysis.  In the early stages, when there is
consolidation Avithout softening,  the  bleeding does good  and
relieves the vascular  congestion,  often with  markedly good
results.  Such haemoptysis, Avhich  is very variable in amount,
is prognostically very different from haemoptysis due to a soften-
ing mass  opening  a  pulmonary bloodvessel, or that from an
aneurism  in an  old cavity;  the  first is  salutary, the others
fraught Avith imminent danger  to life.   In  the first form  of
hemorrhage it will commonly be found that there is coexistent
constipation.  Nothing is more common than  to find a patient
returning to the hospital, complaining of haemoptysis, after a
brief absence.  Especially is  this the  case Avhere  the  mixture
has contained some sulphate of magnesia,  and constipation has
followed its discontinuance.  As  to  the  other two forms  of
hemoptysis, recurrence is  not usually possible ; nor have we any
means  of controlling  such hemorrhage except by alloAving  syn-
cope to come on naturally, and then permitting the patient to
remain perfectly quiet.   To  arouse such  patients from their
syncope by stimulants  is to reinaugurate the bleeding;  to move
the patient is  to run the risk of disturbing  the blood-clot
formed.
  The  application of ice to the chest is unobjectionable.
  Blistering the chest may be adopted, and some  practitioners
attach  value to it; others  repudiate its  utility entirely.  When
there are sharp pleuritic pains, blistering seems to me to  furnish
relief.  Strapping the  chest, so as to abolish as  far as possible
all movement of the affected side of the thorax, after the plan of
Dr. Fred. Roberts, often gives great relief.  All mechanical  irri-
tants, as flour, dust, feather  particles,  steel-particles, dust from
pot-making, woollen particles, etc., should be studiously7 avoided,
as calculated to further disturb a diseased lung.  Air, pure  and
fresh,  and  free from  the presence of  mechanical irritants,  is
very beneficial.
  All cough medicines are to be avoided except to procure sleep 
212
ABNORMAL  GROAVTHS.
at nights.  The use of a  morphia tincture during the day to
allay  cough is,  to  my  mind, most objectionable.  Of all  the
insidious paths to the grave there is none so sure, so dangerous,
so fraught Avith immediate peril, as that Avhich is streAvn with
opium.  For disease beloAV the diaphragm opium is invaluable;
but in thoracic mischief it should be prescribed writh the utmost
caution.   It relieves the cough often only too effectually, for it
arrests all  action—reflex  and other—by death.   It  ruins  the
appetite, locks up the boAvels (unless guarded as described above),
and  in  every way  smoothes  the patient's path to the grave.
Chloral  is Avorse, if possible.   Bromide  of potassium, or hydro-
bromic acid, are comparatively free from ill after-consequences.
Where  there  is a  history of  syphilis its association  Avith  the
lung mischief must not be overlooked, and some of the solution
of the bichloride of mercury  may be indicated  Avith  the iron.
With a careful attention  to  the dietary, and the measures de-
scribed  above, many patients  will  recover, or  at least make a
temporary stand, Avhose cases, at first sight, present apparently
little  prospect of any good being attained.
  Finally, if a tithe of that care, of the good  food, and of the
fresh  air of convalescent homes in the country, could be given
to tuberculous cases at the outset, Avhich sentiment provides for
the closing of the scene, hoAV different Avould be the end achieved.
It is  not  my  desire to undervalue these  solaces to  the dying
which are furnished in no stinted quantities, even by Philistine
boards of guardians ; far from it.  What I would do is to point
out how inestimably valuable the same measures Avould be, if
available before the cases  became markedly tubercular.  Often
sentiment furnishes, Avhen too late, what would  have been price-
less at an earlier period.   When the Senior Resident Medical
officer of the Leeds Public Dispensary, it Avas very heartbreak-
ing to see case after case merging into tubercle Avhich might
have  been arrested  possibly, if any power to procure such things
as these cases require, had existed.  Medical advice, medicine,
and cod-liver oil could be given; but  wine, stout,  meat, etc.,
were  only to be procured  by  making the  patient a pauper, and
that only was done Avhen the case was hopeless; and then every-
thing was furnished to prolong  the last scene—in  order that
they  should not die unsuccored.  Had  that  succor  come out
of intelligence, and been given  in time, a life might have  been 
ABNORMAL  GROWTHS.
213
 preserved ; instead of merely a death-bed being made somewhat
 less repulsive than it otherwise would have been.

                           Cancer.

   § 78. If tubercle be infinitely more common  than cancer,
 cancer  is still more hopeless, and  still  more dreaded.   It is
 indeed  an intruder of grim mien, and of grave import.  Never-
 theless  it is but a modification of connective tissue.1 Rokitanski,
 in labored phrase, says of cancers: "Heterologous growths not
 distinguishable from sarcomata by definite generic marks, and
 like these, to be dealt  Avith only as species;  but contrasting,
 Avith sarcomata in the single feature, common to them all, of
 malignancy.   Carcinomata originate and subsist  not rarely as
 local evils.   Far more commonly, hoAvever, they are associated
 with a dyscrasia, Avhich,  in  point of fact, often precedes and
 engenders the cancer. .  Hence the  multiple appearance of car-
 cinoma as the sequel to a single one, as  the  sequel to the ex-
 tirpation of  a voluminous and  hitherto solitary one.  Hence,
 in other cases, the original appearance  of  cancer  in several
 organs  simultaneously, or in rapid  succession."   Cancer is a
 modification  of connective tissue,  which shows  itself  under
 certain  peculiar circumstances  often of a puzzling character.
 It is common at the junction of  skin and mucous membrane at
 the lip, and anus.  And yet it almost never attacks the upper
 lip.   It is common in the  uterus and in the mammae, and often
 arises at the  change of  life, Avhen there is a certain hypervascu-
 larity of these organs present.   At  a  corresponding age it is
 common in the  stomach  in  the male.  It is induced in the
 scrotum by soot, as chimney-sweeper's cancer.   At other times
 it is  more diffused, as if a cancer-building tendency existed
 throughout the  organism.   It is even  supposed that such ten-
 dency lurks in many cases, without actual existence  of cancer-
 cells, until a Moav or other injury develops them locally.
   Cancer will proceed from its  primitive seat along the lym-
 phatics, as is well shoAvn  by the secondary glandular enlarge-
 ments which so  often follow mammary cancer.   Cancer-cells,

  1 That is of those tissues enumerated as connective tissues by Carpenter in the
third chapter of his Principles of Human Physiology. 
214
ABNORMAL GROAVTHS.
when washed off into the  blood-current of a  vein, Avill float
along until arrested ; and  then Avill at once groAv and set up a
cancer colony.  Thus in  cancer of  the pylorus a  tiny speck of
cancer often breaks off into the gastric vein, and then becomes
arrested, in the subdivisions of the portal vein, in the liver ; the
point of its arrest becomes a nodule of secondary cancer.  A
cancer-cell  may Avash aAvay from  this secondary nodule, and
become  arrested in the subdivisions of the pulmonic circulation,
and so become a secondary cancer colony in the lung.  In some
cases cancer-cells form a mass in the lung, wash into the pulmo-
nary veins, and passing through the left heart,  drift along the
arterial  current into the cerebral vessels, and establish another
cancer-colony in  the brain.  Another curious and interesting
fact about  cancer is this: The  histological elements of cancer
are not  neoplasms, not neAv growths.  They are a development
of textures, normal in their place, or at their own time, but
forming under other circumstances malignant growths.   Thus
scirrhus is scarcely, if at all,  distinguishable  from cartilage.
The  rapidly-groAving osteo-cephalomatous,  or  cerebral cancer,
Avhich is connected with bone, is the growth of a tissue in adult
life, which is normal in foetal life as  the marrow cells of bone.
Colloid  cancer, a  gummy mass, common in  ovarian disease, is
nothing more than the sarcode of the umbilical cord ; Avhich is
useful in its  place.  Charles Creighton has demonstrated that
the cells in  mammary cancer  are allied closely with  the cells
formed  in the breast of the impregnated female before the secre-
tion of  milk is set up ; and Avith those cells found in the still
large  mammas after the flow of milk has ceased.
   Another thing about  cancer is this—any abnormal growth,
as a fatty tumor, for instance,  is in  mature life apt  to become
cancerous, just  as Ave saAv that  inflammatory masses  in certain
organisms become tuberculous.   Consequently it is very desira-
ble to remove such tumors, in order  that they may not become
the subject of cancerous change.
   § 79.  Looked  at from  a therapeutic point  of vieAV,  those
modifications of  connective tissue known as  the A'arieties of
cancer,  are of a depressing and  hopeless character.  When they
present themselves in situations Avhere the surgeon can reach
them, their removal by operative measures is clearly indicated.
In many cases such removal is effective.  In other cases,  where 
ABNORMAL GROWTHS.
215
there seems to be a general constitutional tendency to cancer,
such extirpation is of  little avail, and is folloAved by cancerous
manifestations elseAvhere.  Whatever means for the removal of
the cancer be adopted, the extirpation must be complete.  If
the end of a cancer prolongation, often very like a crab's cLaw,
be left, the cancer Avill grow again.  If a  cancer-cell be travel-
ling up a lymphatic, and is not included in the operathTe meas-
ure, it Avill institute a secondary cancer in the first  lymphatic
gland it  reaches.
  There are two  points Avhere a medical opinion affects the
purely surgical question of removal.   One is, that in very old
persons hard  cancerous  growths  are  as Avell let alone.   The
sufferers Avill probably die off ere the cancer itself is fatal.  The
removal of the  cancer may, however, become desirable in con-
sequence of the pain  it occasions.  Another is  this: if there
exist any evidences of  the presence of cancer in the viscera, then
surgical interference is clearly contra-indicated.  Recently a case
came before me where on  excmination it was possible to pro-
nounce the left lung quite normal.  It was probably cancerous,
as the subject  was a hale woman of over forty years of age with
a gouty diathesis.  She had had one mamma removed for cancer,
but the operation was not quite successful.   An opinion against
further operation  Avas given accordingly.   Ultimately the case
fell into the hands of a cancer quack, who inflicted much torture
by his measures for removing the cancerous cicatrix.   The lung
symptoms rapidly  increased, and the dyspnoea became intense,
and ultimately killed the patient.
  Cancer is usually regarded as a painful  ailment.   There are,
howTever, no nerve fibrils in the cancerous mass, and cancer is
painless  where it  does not involve pressure on a nerve.   So
strong is the popular impression that if there be  no pain the
tumor is not malignant, that it is sometimes simply impossible
to convince the patient that he, or she, is the subject of cancer.
Yet cancer is in itself  absolutely painless, and, if it develop in
a part free from nerves, occasions no pain.  If, hoAvever, a nerve
becomes  implicated, especially  if inclosed in the remorseless
grip of scirrhus, then  persistent, enduring pain is induced.   So
severe  and excruciating is  the  agony inflicted  by cancer, that
Montgomery wrote of  uterine cancer, "There is no  temporary
relief but in opium; no permanent rest but in the grave."  Few 
216
ABNORMAL  GROAVTHS.
diseases are more  terrible than stricture of the oesophagus, or
cancer of the pylorus.   The subcutaneous injection of morphia
and rectum-feeding may prolong a life which must have become
a burden ;  and relieve an existence otherAvise intolerable.  In
the last stages of gastric cancer ice often gives great relief to
the vomiting.   When  cancer  assumes a  phase of rapid growth
emaciation is  marked. The  system is  robbed to feed the in-
truder, and drained that its destroyer may wax and grow.  This,
however, is a less agonizing mode of death  than that produced
by pain alone—'by the torture which results  when nerves  are
caught by masses of malignant connective tissue.
  The questions  of fatty  tumors, of  adenocele, of recurring
fibroid, and other growths  are too purely surgical  to demend
our consideration here.  The  more special  requirements of ab-
normal growths, according  to  their individual exigencies due
to their position, Avill  be given in the chapters to be devoted to
the diseases of the different systems. 
CHAPTER.  IX.
                BLOOD-POISONS—SPECIFIC POISONS.

   § 80. This is perhaps the most difficult chapter to write of any
 in this Avork, from the fact that what has been collected on the
 subject is so unsorted, and views vary so much, that it is simply
 impossible to Avrite anything  that  will be in agreement Avith
 every hypothesis.   It is not about the gravity, or the course of
 the  maladies, when once established, that  much difference of
 opinion exists.   It is rather about the origin and commencement
 of the affections, denominated  blood-poisoning, that there is so
 much  confusion.  In attempting to  set forth what it is trusted
 will be an approach to a lucid statement to the youthful student,
 some offence may possibly be given to more  highly instructed
 readers, Avho may think the  matter to be put too definitely.
  In the  first place a blood-poison,  in the sense in Avhich the
 term is used, is a material Avhich finds  its  way into the blood,
 much after the  manner of what are known as specific poisons.
 But there does not follow  a definite group of symptoms and
 changes such as characterize each of the exanthems, and  make
 measles and  smallpox so distinct and distinguishable, in the
 case of Avhat are known as blood-poisons; though pyaemia and
 erysipelas possess  some fairly special characteristics.  The ten-
 dency is ever towards an asthenic type of pyrexia, a quick  pulse,
 a high temperature,  both  increasing towards evening ;  a dry-
 skin, a loaded  tongue with  a foul  breath, much  depression of
 the nervous centres, together with a generally ominous appear-
 ance, which must be seen to be understood—but once seen ever
 again recognizable.  It is very noticeable in cases of erysipelas
 in persons of broken-down constitutions ; in some children with
 ulceration of the  throat; in those  Avho, having  assisted at  a
 post-mortem  where  there  was erysipelatous  peritonitis, are
 struck doAvn by blood-poisoning; or, again,  at  times  after  a
puncture  at  a  post-mortem.   There  is a  rapidly advancing
adynamy Avhich, quickly following  the  first initial symptoms, 
218        BLOOD-POISONS—SPECIFIC  POISONS.

causes the  case to look serious;  and too often  soon renders the
prognosis hopeless.  The progress of these cases  is swift, and
a fatal  issue is but  rarely averted.  It  is the rapid progress
that gives to blood-poisoning an  aspect  so  grim, and Avhich
distinguishes it  from pyaemia—at least, as  pyaemia usually
manifests itself.
  There is much difference of opinion  as to the nature of the
infecting  poison.  To put the  matter  broadly: the poison is
either a decomposing particle wafted from the putrefying ma-
terial of one organism aAvay to some surface on another organism
previously healthy, in Avhich it sets up oxidizing processes such
as it itself is undergoing; or there is some lowly form of life,
bacterial or other, which breeds  in putrefying fluids, and Avhich
sets up putrefaction in other fluids if they gain access to them.
It is not the place here to attempt to  analyze  the evidence
for each view, nor is it of much practical importance, apparently,
to do so.  A large  number of names of  the  highest  eminence
might be adduced in favor of the latter view;  while the former
is the vieAV of those Avho have not  yet given in their adhesion
to the germ theory.  The chief practical result from the differ-
ence of opinion is the stimulus it gives to the investigation and
discovery of materials called antiseptics, or disinfectants, which
possess alike the poAver of arresting putrefaction and of destroy-
ing lowly forms of life.
  The strongest clinical evidence of the existence of such poison
is furnished by the wards of hospitals, where a gangrene in one
patient  will cause  the Avounds  of other patients to assume a
gangrenous character; or where pyaemia  has  located itself and
seizes remorselessly every patient who  is placed  in the  death-
stricken chamber. In the disease known as charbon, or malignant
pustule, the  slightest contact of the fluids of a diseased animal
Avith the fluids of another animal, previously healthy, will cause
that animal to be affected in turn.  These blood-poisons are apt to
produce rapid suppuration in the great intermuscular planes of
areolar  tissue, or very destructive suppuration in the interior of
viscera  : the first is known as phlegmonous erysipelas, the latter
as the pyaemic  abscess.   But  still the changes in the solids of
the body  are far  from being so constant  as  the changes in the
blood.  The most vivid sketch,  with which I am  acquainted, of
the  changes wrought by a blood-poison is given  by C. J. B. 
           BLOOD-POISONS—SPECIFIC  POISONS.        219

 Williams in his Principles of Medicine: it is  so graphic that it
 must be given verbatim, it Avould lose by any attempt at cbm-
 pression.  " Necroemia, or death beginning Avith  the blood, are
 terms,"  he says, " which I venture to give to  those fatal cases
 in Avhich the chief and most remarkable change is exhibited by
 the blood.  In typhoid fevers and others of the malignant or
 pestilential kind, none of the solids of the body  constantly ex-
 hibit such an early change of function or of structures as would
 Avarrant us in tracing disease and death to them.  It  is true
 that the functions of  many  solids are impaired—the muscular
 and nervous systems, secretion, digestion,  assimilation, and
 nutrition, all suffer, but  the very universality of the affection
 seems itself to point  to some cause  more general than  can be
 found in any individual function ;  and  such a cause  may be
 found in the blood.   The blood  at  an  early  period of these
 diseases, when they occur in their Avorst form, exhibits changes
 which show  that disorder begins AATith it, and this disorder may
 reach to a fatal degree.   The appearance  of petechias and vibi-
 ces on the external surface, the occurrence of more extensive
 hemorrhages in internal parts, the general fluidity of the blood,
 and frequently its unusually dark or otherwise altered aspect,
 its poisonous properties as exhibited in its deleterious operation
 on other animals, and  its proneness to pass into decomposition,
 point out the blood  as the first seat of disorder, and by the
 failure of its natural properties and functions as  the vivifier of
 all structure and  function, it is plainly the medium by which
 death begins in the body.  How far  the  change in the blood
 is in its structure  and vital properties, or in  its chemical com-
 position, further research  alone  can   determine ;  the vivifying
 function of the blood  depends on all these combined, and it
 is this function which obviously fails.  Hence the complete
 adynamia, or  general  prostration,  of all  living poAvers,  Avhich
 occurs Avhen this cause of death is most poAverful.  The blood,
 the natural source of life to  the Avhole body,  is itself dead, and
 spreads death instead of life.  Almost simultaneously, the heart
 loses its  poAver, the pulse becoming  very Aveak, frequent, and
 unsteady ; the  vessels  lose their tone, especially the capillaries
of the most vascular organs, and congestions occur to a great
amount; the  brain becomes inactive, and stupor ensues; the
medulla is torpid,  and  the poA\Ters of  respiration and excretion 
220       BLOOD-POISONS — SPECIFIC  POISONS.

are imperfect; voluntary motion is almost suspended ; secretions
fail* molecular nutrition ceases; and, at a rate much more early
than in other modes  of death, molecular death follows close on
somatic  death—that  is, structures  die and begin  to  run into
decomposition as soon  as  the  pulse and breath have ceased;
nay, a partial change  of this  kind may even precede the death
of the  Avhole body  (somatic death—Dr.  Pritchard); and  the
fetid aphthous patches  in the throat, the offensive colliquative
diarrhoea of persons in  the last stage of various fatal diseases;
parts running into gangrene, as in the carbuncle of plague, the
sphacelous throat of malignant scarlatina, and the sloughy sores
of the  worst form of typhus, and  in  the large intestines in
dysentery, and the putrid  odor exhaled even before death by
the bodies of those avIio are  the  victims of similar pestilential
diseases—are so  many proofs  of the early triumph of dead over
vital chemistry."
   Such  is the course of blood-poisoning in its Avorst and most
rapidly  fatal forms.   At other times there may be but a sharp
fever with depraved excretions folloAved by recovery.  It may
result from  extreme saturation  Avith scarlatinal poison, and so
spring from Avhat  under other  circumstances  is but a simple
exanthem, causing in its mildest form a slight fever for a couple
of days.  We can scarcely  yet  say that the effect is but the
result of the amount of the poison ; though  there is much to
favor such vieAv.  What the nature of the poison is in various
zymotic diseases and blood-poisons we  do not  yet know, but
many advances  are being made which in a few  years will give
us, in all probability, certain and definite information.
   § 81.  When the day comes that each poison, or the germ
which bears it, can be recognized, then special specific measures
against each may be available; but until the arrival of that day
we must trust to less precise information.  Up to  a comparatively
recent period all putrid or very adynamic fevers were treated
v»ath wine, bark, and carbonate of ammonia, given  in no stinted
quantities.   In  this  there is nothing of a specific character un-
less it be the quinine in the bark—as the recent experiments of
Binz, of Bonn,  as to the effect of quinine upon bacteria  Avould
tend to suggest.  The plan, however, is not ill grounded, and
may be pursued with  advantage in many cases.   Then came
the use of chlorate of potash  in septic conditions.   It was found 
BLOOD-POISONS
— SPECIFIC  POISONS.
221
that the administration of this agent Avas very commonly fol-
loAved  by the disappearance of the fetor which marks a depraved
condition of the fluids of the body ;  and the ease passed from
that of a septic form of disease to that of an ordinary pyretic
affection.   In  more marked  cases the  effect was  not so pro-
nounced, and only a modification, amounting to degree, Avas the
result.  Chlorate of potash is best given  along with  lemon-juice
In the following form:  Chlorate of potash, 5ss, the juice of two
large lemons,  to a  Avine-bottleful  of Avater  (Oiss), forming a
palatable  beverage which can be  taken at the rate of a wine-
glassful three  or four times a day.   It  forms a useful  measure
in ordinary exanthems, especially scarlatina, and is an excellent
prophylactic for nurses and others in attendance on scarlatinal
and other  patients.   Combined with the muriate of iron chlo-
rate of potash  is an excellent remedy in diphtheria, in severe
cases of scarlatina Avith pronounced throat symptoms, and in all
forms of fever  assuming a distinctly septic aspect.
   More recently the idea has arisen of directly nutralizing the
septic material in the blood.   For this we are indebted to Prof.
Polli, of Milan, who introduced sulphurous acid in  the form of
sulphites of soda, as an internal  antiseptic.  " It Avas found that
animals could, without any  apparent  ill-effects, SAvallow and
absorb large doses of the sulphites.   It Avas then observed that
when the animals Avere killed they long resisted the putrefactive
process—that Avhilst an animal killed under ordinary circum-
stances exhibited rapid and marked signs of putrefaction,  an
animal Avhich  had  previously absorbed  doses of the  sulphites
betrayed no sign of putrefaction whatever.   Another  series of
experiments, and in  this series three hundred dogs  were the
bases of the deductions,  shoAved that the  sulphites exerted a
prophylactic and curative power when septic poisons were intro-
duced into the  economy'.   Then, as regards the  human subject.
It Avas found that the stomach would tolerate  large doses of the
sulphites of soda or magnesia.  They Avere  tried in  the various
eruptive fevers, intermittents, typhus, typhoid, pyaemia, puer-
peral fevers, dissection avouikIs, malarial fevers, etc. The records
of cases treated in this way show an extraordinary amount of
success."  {The Antiseptic System—A.  E.  Sansom.)  Of course in
the worst cases  all measures unfortunately are futile.  The blood
seems to die, to lose  its vital properties, under the influence of 
222        BLOOD-POISONS — SPECIFIC POISONS.

the poison  imbibed, and then all  measures are unsuccessful and
unavailing.  In the less pronounced cases sulphite of soda in
doses of ten or fifteen grains every three or four hours is indi-
cated, and  in many cases will produce very gratifying results.
So powerful is the antiseptic action of sulphurous acid Avhen so
introduced into the system,  that " sulphites, administered by
the mouth, will, it is  said, prevent decomposition and putre-
faction of  urine in the bladder."   (Ringer.)
  There is  indeed  a great deal of evidence tending to demon-
strate, and  in no indistinct  manner too, that there are agents
which  possess  in  the  body much  the  same action that  they
possess out of the  body upon putrefactive processes, viz., that of
arresting them, or of neutralizing the poison.   Before anything
more definite can  be  done  in  the  Avay  of selecting certain
remedial agents, in particular  forms  of  blood-poisoning, the
nature of the various  poisons must  be indicated, after which
more special treatment may become practicable.  Modern research
is rapidly collecting evidence on this matter and specializing the
different forms in certain  zymotic affections; after which may
come the  specific  therapeutic remedy.   Of  course a  liberal
dietary  and  wine  in free quantities are  indispensable  to the
treatment of all blood-poisoning.

                      Specific Poisons.

  § 82. Under this heading may be properly placed first a class
of ailments Avith which Ave are but  slightly acquainted in England,
nowadays,  at least.  Here there  is a specific poison, known as
malarial poison, Avhich  institutes a certain set of marked and
characteristic symptoms.   Under the  name  of intermittent
fever, or " fever and ague," as  it is popularly termed, or in  more
marked cases " remittent fever,"  Ave have a recurrent disease of
a peculiar  character.   During the  interval all appears more or
less Avell, even in the quickly  recurrent form of quotidian ague.
Then comes on an algide stage, accompanied by severe shivering,
and  a  temporary  enlargement of  the  spleen  with contracted
arteries,  passing into  sharp pyrexia, also lasting for a  brief
period.   In remittent fever the intermission is brief, and a high
pyrexia is  almost constantly present.   In other cases, as the
returned East Indian, for instance, the sufferer will know but 
           BLOOD-POISONS — SPECIFIC  POISONS.        223

little of his malady, except at long  intervals,  when  he will
experience short attacks of the familiar fever.  At other times
periodical attacks of neuralgia aa ill take the place of the febrile
accession, and the intimate connection of the tAvo is shown by
their amenability to the same remedial agent.
  At other times instead of an attack of fever, an  attack of
dysentery is the consequence of malarial poisoning.  It is  dis-
tinguished from  the dysentery of armies  and  camps  by  its
symptoms, which are those characteristic of malarial  fevers, by
its  coming on  under circumstances Avhich  ordinarily produce
malarial fevers.  It is found, too,  that quinine  is much more
effecti\Te in  malarial dysentery than  is  ipecacuan (Maclean).
The diagnosis of these ailments cannot be considered here ; they
are known  to  depend  upon a poison which is produced  in
swamps, fens, marshes,  jungles,  etc., and  at  Hong Kong from
disintegrating granite.  What the poison is, is  yet unknown.
Whatever  it be, it  possesses certain peculiarities.  It  is most
powerful at night;  it is the more certain the nearer the ground
the person is at  night ; a circle of pines  forms a great protec-
tion, while the blue  gum-tree, the Eucalyptus globulus, is even
still more effective;  immersion completely  under water will
arrest the  poison-producing properties of a  marsh; while in
more solid fens drainage destroys the malarial miasm.
  The pathological  sequences of malarial poison are found in
the  portal circulation  and  its viscera.  Casorati thinks  the
stomach presents the most marked evidences of morbid changes.
Usually there  is hyperaemia, and  in  the notorious Walcheren
expedition there were also circular ulcers in  that viscus.  The
liver and spleen  are also  affected ;  the latter is especially  in-
volved.   During the cold stage of  ague the spleen enlarges  and
contracts again when the  paroxysm is  over (Maclean); while as
the case becomes  chronic  the spleen permanently enlarges  and
is known as " ague-cake."  The liver is similarly affected  and is
congested and  enlarged.  At the  same time  there is increased
cell-formation as well as  vascular  congestion in these viscera.
A black pigment is commonly found  in  the spleen, liver, and
kidneys of those persons who have long been resident in malarial
regions.
  Recently Lussana has given it as his opinion that the poison
of  malarial fever is confined to the portal circulation.  This, if 
224        BLOOD-POISONS — SPECIFIC POISONS.

true, is no unimportant matter from a therapeutic point of vie\Ar.
It is Avell known that in many regions Avhere quinine is not pro-
curable the treatment of malarial feATer has chiefly consisted  of
emetics and  aperients.  Ringer says: "In some cases Avhere
this medicine (quinine) appears powerless, the administration of
an  emetic  each morning  sometimes brings  the  disease at once
under  the control of quinia."  In many cases the administration
of an  emetic at the commencement of the paroxysm, or just
before  it is expected, is a very useful measure in the treatment
of malarial fever.1
  § 83. In the different manifestations of malarial poison our
great remedy at the present day is  undoubtedly quinine.   Per-
haps, indeed, the confidence in quinine is rather too pronounced,
as in many patients there is a marked intolerance of this agent.
Especially is this last the case in patients from the tropics. Dr.
De Witt  C. Wade has found hydrobromic acid to effectually
relieve the unpleasant effects of quinine, in the great majority
of cases.   It forms a good solvent of quinine.  In such patients
arsenic, strychnine, bebeerine, and the tincture of the Eucalyp-
tus globulus may be resorted to in lieu of  quinine.   Arsenic is a
measure  Avhich has  been long  in use in the East for the treat-
ment of ague; but its utility Avas best seen in the French army
under  Napoleon, when the  mastery of the seas by England cut
France off from quinine  altogether.  In  persons who  are the
subjects of malarial poisoning  there  is a marked  tolerance of
arsenic ;  and it requires  to be given here in much  larger doses
than when it is used as an alterative.  It is also  desirable  to
continue its use for some time after the  cessation of the  fever;
just as is the case with quinine.   The other remedies, of course,
are given in their usual doses.  They are uncertain, but may be
useful  Avhen quinine disagrees or has failed.
   As  to quinine, the evidence is  overwhelming in  its  favor.
In  fever-stricken  districts  quinine  rises in price in proportion
to  the supply of the  remedy and the severity of the malarial
outbreak.   This  association is  the  more marked  now that
quinine is given in doses of from half a drachm to a drachm;

  1  The old empirical treatment in the English Fens was first an emetic, then a
sharp purge, followed by quinine and arsenic.  It may be questioned if any im-
provement can be made on this plan. 
          BLOOD-POISONS — SPECIFIC  POISONS.       225

the more ordinary dose being  from ten to twenty grains. Thirty
grains  per diem,  in three doses, is the ordinary plan of giving
it;  taking care that one close be given a couple of hours or so
before the paroxysm is expected.  By such means the paroxysm
is delayed and diminished.  Sometimes the arrest is very dis-
tinct, amounting to so much each  day,  enabling  the delayed
advent of the paroxysm to  be  closely calculated.   Quinine is
best given in ague in an acid solution.
                      Quin. Sulph. gr. x.
                      Ac.  Sulph. Dil. tt1x.
                      Syr. Aurant. jij.
                      Aq. ad gj.
forms an agreeable dose three times a day.  When the case has
passed from an acute to a chronic  form,  it is  not  necessaiw to
continue the quinine  in such large doses; though  when  an
aguish attack is  felt to be  coming on  in a  patient familiar
with it, ten grains of quinine will  often arrest the threatening
paroxysm.
  When the pyretic attack is very marked, as in those cases
Avhere the feA^er is termed remittent, the  ordinary  measures for
reducing body-heat given  in Chapter IV., such  as ice, cold
affusions, etc., may usefully be resorted to.  At the same  time
the congested condition of the viscera of the portal circulation
must be  remembered, and purgatives must be given along Avith
the quinine.  But the administration of quinine must not AATait
upon the other measures—they are but  the auxiliaries of the
quinine.   Maclean advocates the administration of quinine by
enemata  in cases  Avhere there is much gastric  irritability  with
vomiting.  My friend  Surg.-Major  Hall, of the  Royal Artillery,
has found the subcutaneous injection of quinine very serviceable.
"In 1866,at Barrackpore, nine fine young men  out of a force of
130 died of remittent fever.  The tongue in each  case Avas
covered with  a   thick yelloAv fur, and  tAATenty-five grains of
quinine three times a day Avere of no avail.   Thinking the
failure due to inability of the quinine to pass through the thick
layer of dead  epithelium cells forming this fur, I adopted the
plan of introducing the quinine into the system by subcutaneous
injection. It was quite satisfactory, and all after the adoption
of this plan recovered.   Too strong a solution  caused ulcers to
form at the point of injection.  Ten grains of quinine dissolved
      15 
226        BLOOD-POISONS — SPECIFIC POISONS.

in ten minims of dilute sulphuric acid and 100 drops of water
formed a solution which could  be injected Avithout  producing
ulceration.  The neutral sulphate of quinine is even to be pre-
ferred to this solution for future use."   It has advantages over
the plan of giving it in enemata.
  Mercury, bleeding, and starvation, the old murderous plans of
treating malarial fevers, are noAV passed into the realms of the
dead past.  At least Ave may hope so!  In the form of  inunctions
to reduce the size of an "ague-cake," Maclean advocates the use
of the biniodide of  mercury.   Preparations of iron, especially
solutions of the sulphate, are in much favor for the  treatment
of enlarged spleen along with the malarial cachexia.
  A ATery useful measure in severe cases of malarial fever is the
secret  preparation knoAvn as Warburg's Tincture.   Among its
other  properties it is perhaps the most  poAverful sudorific Ave
are acquainted Avith,  unless it  be jaborandi.   It is especially
indicated in those cases  Avhere  there is intolerance of quinine.
It is Avell to commence its administration byr opening the boAvels
pretty effectually.
  In malarious dysentery quinine must be combined Avith the
ipecacuan treatment.  If desirable it can be given subcutaneously.
It may Avith advantage be pushed to cinchonism  ere the com-
mencement of  the ipecacuan treatment.  The treatment  of
dysentery by large doses of ipecacuan Avas introduced, or rather
reintroduced, by Dr. Docker, and has been a great boon to the
inhabitants of India.  Usually a dose of tAvo grains of opium, or
from half a drachm to a drachm  of tinctura opii, is given in the
morning;  and  then  in about tAvo hours afterwards,  when  the
patient is pretty Avell under its influence, a drachm of poAvdered
ipecacuan is given in mucilage.   The opium  tends  to hold  in
check  the vomiting  induced  by  the ipecacuan.  The  treatment
is not pleasant, but  it is effective.  Xext day the stools are of
normal character, and the patient is much better.
  In the treatment of the malarious cachexia, which forms such
a terrible outcome of acute  malarious disease, large doses of
ipecacuan  are most  serviceable  Avhere  there is dysentery in a
chronic form.   Surg.-Major  Hall  informs  me that it is his
custom to treat such cases after the following fashion:   "The
patient is kept  in bed a day and is fed Avith milk solely.   Xext
morning a drachm of ipecacuan  povvder is given in twelve pills, 
          BLOOD-POISONS—SPECIFIC POISONS.       227

each containing five grains  made up with mucilage.  For  a
couple of hours ere giving the medicine the patient is requested
to keep as still as possible  lying on his  back.   Then  the pills
are given Avith the least possible disturbance and Avithout any
fluid, unless a sip of Avater be imperative; but the  less the bet-
ter.   The patient  is encouraged  to resist the  inclination  to
vomit, and  usually can  do so for a sufficiently long time  to
secure the effect of the ipecacuan."  Since the  introduction of
these large  doses  of ipecacuan, the number of  broken-down
dysenteric invalids  in India has  been  very notably reduced.
When the bowels are steadied by  this treatment, then quinine
in combination with iron may be systematically folloAved out
for some considerable time.  The  reader Avill remember that in
speaking of the relations of anaemia to specific affections, much
stress has been laid upou  the necessity for combining with the
iron the specific remedy for each form of anaemia (§ 57).  Conse-
quently, in  treating the malarial cachexia, quinine must  be
ghTen freely7 along Avith the chalybeate ; or if it be not tolerated,
arsenic  may be substituted for the quinine.  But it is  highly
desirable that such patients be ahvays sent away from malari-
ous to healthy districts.   They must also be careful about their
food and drink.   Pure AArater, pure  air, nutritious food, espe-
cially milk,  are all indicated  as important matters.  The cloth-
ing should  be Avarm and abundant, especially in cold climates.
By these measures combined, a fairly comfortable existence can
be secured instead of the miserable condition Avhich obtained of
old, Avhere death formed a happy release.
  As " broAv ague," a form of malarial disease  is far  from un-
common in England.  Xot unfrequently it is  regarded  as con-
gestive headache, and treated  by blisters, evacuants, etc., without
any good effect resulting.  It can, however, be recognized  by
its  regular recurrence at or  about  the  same hour every day.
Full doses of  quinine speedily give relief.   In frontal headache
the young practitioner should ahvays be on his guard as to the
possibility of its being " broAv ague ;" and by his recognition or
non-recognition of it he may seize  or lose a good opportunity
for displaying his  knoAvledge.  Its true treatment is that appli-
cable to the other forms  of malarial mischief.
  § 84.  Cholera.—This  is a  matter of no  slight  difficulty  to
treat  of from any point  of vieAV.   It  is surrounded  indeed  by 
228        BLOOD-POISONS — SPECIFIC POISONS.

difficulties,  and has  been written about  ad nausccun.   It has
been regarded as an evacuation to be arrested by lead and
opium,  etc.  Another vieAV lfas been  to  regard the choleraic
discharges as an eliminative process, and to encourage them by
castor-oil.  The latest  plan has been  to  look  at  it from its
physiological  point of vieAV.   Surg.-Major  Hall found from
observation,  including  a personal experience,  that there Avas
much evidence pointing  to the conclusion that there Avas in
cholera spasm of the arterioles, often so great as to cut off all
secretion of the kidneys, with labored  action of the heart, etc.,
and much venous  congestion ; so that there Avas great effusion
from the  portal  circulation.  Accordingly  he  injected  subcu-
taneously hydrate of chloral, of the strength of ten grains to
the ounce, with very  satisfactory results.  His observations are
to be found in the Practitioner, July, 1875, and elsewhere, and
are Avell  worthy  of  the notice of  all practitioners Avho are
intending to seek  their occupation in India, and other districts
Avhere cholera is rife.  The noAv generally acknowledged starting-
point  of the pathological processes  in  cholera is spasm  of the
pulmonary  arterioles.  (Parkes and G. Johnson.)   Elaborate
experiments as to  how to relax such spasm ending in clinical
applications of various agents, as belladonna, etc., have not yet
hoAvever attained any practical results of moment.
  g 85.  In addition to these products  of  eastern and tropical
climates we  have certain other  specific poisons which do not
belong to any special areas, but Avhich are scattered over the
face of the globe.   Those Avith which Ave are most familiar are
enteric fever, typhus, relapsing fever, and  the various exanthe-
mata.  The aid given by physiology and pathology to thera-
peutics  in these  affections  is very great;  but it is not towards
the treatment of  any one of the group, so much as to the gene-
ral question of the management of the rise of body-temperature.
The various means by which  such rise  may be brought  about,
and the different measures by which it may be reduced, have
been given at length in Chapter IV., and what is said there will
apply to every specific  pyretic  affection—not  being malarial.
The general line of treatment  is to give mineral  acids at fre-
quent intervals.
                    Ac. Hydrochlor. Dil. Hlx.
                    Syr. Aurant. 3ij.
                    Aq. ad =j. 
           BLOOD-POISONS — SPECIFIC  POISONS.        229

every four or six hours is a good form of fever mixture.  The
use of acids, of sour wines, or of chlorate of potash Avith lemon
juice, or sulphites of soda, has taken the place of the old  fever
mixtures—such  as acetate of ammonia with hyoscyamus—with
advantage.  So long as there are no complications, to  render the
treatment accordingly complex, such management may be con-
tinued throughout the case.  In such complications as diarrhoea,
melaena, or a  purpuric state of  the  cutaneous rash, astringents
are indicated.   In the form of  from fifteen to thirty drops of
aromatic  sulphuric  acid,  or of a  fluidounce  of infusion of
haematoxylon  (in some cases they may Avell be combined), or of
gallic acid or tannin, five to ten  grains each, astringents are use-
ful and may be administered at frequent intervals.   When  a
typhoid condition threatens, the different measures given in the
consideration of that state  in Chapter IV. (§§ 38-41) must  be
exhibited—no matter Avhat the specific ailment with which it is
associated.  In all ordinary febrile conditions the general  rules
are to secure  good ventilation, efficient nursing, a suitable die-
tary, a Avatchful and observant medical attention, ever on the
outlook;  rather than  therapeutic rules of  thumb.  All  these
various matters haATe  been described  before, and  need not be
repeated here.
   § 86.  There are some points which deserve special attention,
such as  the prevention of  pitting in smallpox, etc.  A solution
of nitrate of silver, a drachm to the ounce of water, is useful,
and the surface may be washed Avith it in preference to Velpeau's
plan of  touching each  vesicle Avith a point of  the solid nitrate,
on the third or fourth day of appearance.  A mercurial plaster,
consisting of mercurial ointment tAventy-five parts, yelloAv Avax
ten parts,  and black pitch six parts, is useful in semi-conflueut
cases.  The plan of dissolving gutta-percha in chloroform and
putting a coating of the solution over the face  has not been
found to ansAver.  Cold cream and oxide of zinc combined form
a good application.  Collodion  has  its advocates,  while others
rely upon  a darkened room to prevent pitting, as the pits are
most  prominent Avhere the parts are exposed to light.  Others
cause a  light blister to be applied to parts not usually seen, in
order to direct the eruptive explosions to  these points, and so
draAV them away from the face.
  In scarlatina the throat requires careful attention  With some 
230        BLOOD-POISONS — SPECIFIC POISONS.

practitioners it is the rule to give borax in honey, Avhich comes
in contact  with the ulcerated  throat  as  it  dissolves and  is
swalloAved.   Others  prefer to SAvab the surface with nitrate of
silver solution,  5ss.  to  3j« to the 3j.  of water.   Others prefer
chlorate of potash.   In the treatment of severe anginose scarla-
tina personally I have found the following combination give the
best and most satisfactory results:—
                  Pot. Chlorat. gr. x.
                  Tinct. Fer. Perchlor. TTLV-
                  Syr. Zingib. 3j.
                  Aq. ad 5SS. o. Gta ant 4ta hora.
for a child from eight to ten years of age—the dose to be modi-
fied for those above and below that age.  The addition of the
iron gave better results than the chlorate of potash Avithout it.
In scarlatina a cool room and free ventilation in warm weather
are most  desirable.  Coolness is most grateful in the burning
sensation of the coming out of the rash ; but  when desquama-
tion has  commenced, the skin, having throAvn  off an epidermal
layer, is extremely sensitive to any change of temperature, and
a chill readily results.  Chilling is as  disastrous, and is  to be as
Avatchfully guarded  against at that time, as coolness, including
sponging Avith cold Avater and vinegar, is grateful and beneficial
Avhen the rash is coming out, or being well established.
  During peeling, too, it is Avell to have the body rubbed  over
with oil containing some carbolic acid ; this catches and detains
the epidermal scales, which Avould otherwise become detached,
and, floating off into the air, become  causes of infection; while
the carbolic acid destroys the infecting  poAver.  This should be
done daily after a warm bath.
  In measles  the great danger lies in  the chest complications
being  overlooked, or not  sufficiently  attended to.  There is  in
measles much tendency to inflammatory affection of the thoracic
viscera; and Avarm poultices to the chest are as needful in measles
as is a cool  temperature in the early stages of scarlatina.   In
fact, in both  these  exanthemata it must ever  be borne in mind
that Avhen the  rash is either originally imperfectly developed,
or is from any cause arrested, the internal complications are apt
to become more pronounced;  Avhile at other  times as the rash
fades the internal affection is aggravated. 
          BLOOD-POISONS—SPECIFIC POISONS.        231

  Iii both maladies, and especially in  measles, there  are after-
effects which  must  be  carefully guarded  against.  These  are
most common  in patients of a strumous diathesis, and are to be
met by cod-lh7er oil, steel, good  food, fresh air in  the country,
and better still at the seaside.  If such measures be commenced
in time  many unpleasantnesses might  be warded off which
cannot be arrested if the measures  are delayed until  the abso-
lute  necessity  for them becomes imperative.   No Avriting will
compensate for the lack of iiidividual knowledge and thought-
fulness on the part of a medical man in the  proper  treatment
of each case, according to its individual  exigencies, in  those
who are emerging  from an  attack of  measles or of scarlatina.
The general treatment of the pyretic stage has been laid doAvn
in its principles (Chapter IV.), and after careful perusal of these
principles the  intelligent student will be able to apply them for
himself.  The treatment of complications will still further test
his grasp of principles and  capacity to apply them.  A bare
enumeration of the more common complications and of the mea-
sures usually employed in them Avould  not  create any clearer
impressions, and Avould be out of place ;  if the principles given
above in the  various chapters do not make the matter intelli-
gible, it is to be feared  nothing can be done  here  but to refer
the perplexed  reader to different special treatises in which  the
complications are dealt Avith  at length.
  § 87. Diphtheria.—This  is an ailment Avhich resembles  the
maladies described under the head of " blood-poisons" in many
of its characters.  There is a great tendency to sink by  adynamy,
and  for a septic  condition of  the  fluids to obtain.  Death as
commonly occurs from  failure of the powers  as from the local
mischief in the throat.  The membrane in the pharynx may be
continued down into the larynx, and so cause death. Personally
it has appeared that where nitrate of silver  solution could be
applied below  the  margin  of the diphtheritic membrane its
doAvnward progress Avas arrested, and so that  source of danger
at least obviated.  But this vieAV is based on a limited experience
of the malady.  Nitrate of silver ought to be freely applied to
the throat.   The chlorate of potash and iron mixture given
above will often be found most useful.   Others prefei*  carbonate
of ammonia and  chlorate of potash. Beef-tea, milk, and alco-
holic stimulants are very clearly indicated in the treatment of 
232        BLOOD-POISONS — SPECIFIC POISONS.

diphtheria.   Tracheotomy  may  be required,  and is doubtless
too often delayed.   In the  treatment of the after-effects, iron,
quinine, bitter beer, generous Avine, are  all  desirable, especially
Avhere there is any tendency to paralysis.   Diphtheria is not a
markedly infectious  disease,  but if any of the membrane is
expectorated and reaches a mucous surface it will quickly spread
and develop Avell-marked  diphtheria.
  § 88. Influenza.—This is an epidemic  catarrh of the air pas-
sages with adynamic accompaniments, so that to the aged and
the feeble the ailment is not rarely a cause of death.  It differs
in its characters from simple catarrh, and partakes of the  nature
of specific pyretic affections.  The expectorants and other mea-
sures should never be of  a distinctly depressant character, and
acids, with syrup of squill,  are to be preferred.
                     Ac. Phosp. Dil. m>v.
                     Sp. Chloroformi, TTt.xxv.
                     Syr. Scillae, 3j.
                     Aq.  ad sj.
four or six times every tAventy-four hours is a good therapeutic
measure.  At other times the folloAving mixture may be prefer-
able, especially in the later stages preceding convalescence.
                     Ac.  Nit. Dil. m>.
                     Sp. Chloroformi, gss.
                     Inf.  Cinchonas, Jj.
three or four times a day.  Influenza is not  very much benefited
by  ordinary  cough mixtures, unless of a  tonic or stimulant
character.  Headland  is in favor of treating it Avith vegetable
acids.
  § 89. Dengue, or Dandy Fever, is a disease of tropical climates
characterized  by suddenness  in  the attack, a scarlet rash, Avith
intense pains in the joints, simulating acute rheumatism.  It
occurs  in remissions, and has been by some  regarded  as of a
malarious nature.  It does not, however, appear to be amenable
to quinine like  malaria in  general.   The method of treatment
most approved of is to give emetics, and then purgatives, con-
sisting of sulphate of magnesia  and senna, with a little jalap.
The free discharge of bile is folloAved by much relief to all the
symptoms.  When  the attack is over, tonics, such as quinine,
strychnine, and steel, are indicated. 
           BLOOD-POISONS—SPECIFIC POISONS.        233

   As to the terrible tropical fever, " YelloAv Jack," it does not
appear  that any light  has been thrown upon it  which  gives
therapeutic indications of any kind.  The yelloAvness of skin
has been ascribed to liver complications, but this has given no
clue as to the treatment  to be  pursued.   It  is a very curious
fact that yellow fever never obtains beyond a certain  latitude.
If the fever-stricken ship can reach a certain latitude  its creAv
are safe.
   § 90. Pertussis, or Hooping  Cough, comes under the heading
of specific poisons.  It  is an infectious  complaint usually con-
fined to the earlier years of life.   It is characterized by dis-
turbances of the respiratory nerves of  a spasmodic character,
and is a most troublesome affection.  An  emetic at bedtime often
renders the cough less persistent  in the  night.   Many remedies
of an  antispasmodic  character have been  tried, and  of  these
bromide of potassium, or ammonium,  in free doses is  the  best;
but none are entirely satisfactory.   When  much emaciation  is
the consequence of the cough, leading to vomiting, the best thing
to be done is to feed the child immediately after it has been sick,
Avith milk, beef-tea, &c, so that the ingesta may be assimilated
ere the next attack comes on.   Perhaps this  is the  most im-
portant part of  the  treatment of  hooping cough.   Opinions
differ as to the value of belladonna  in pertussis.   After the true
ailment is over, usually lasting about three  weeks, a convulsive
cough often remains, the consequence of habit upon the different
nerves implicated in the act of cough.  Here, quinine, steel, good
food, and  fresh air  are indicated.   It is  often Avell to  give the
quinine in  hydrobromic acid.
   § 91. Erysipelas.—This is an affection about Avhich there  is
much  confusion.    True erysipelas  is a well-marked  form of
pyretic disease characterized by much adynamy, and not  rarely
by distinct blood-poisoning.   It  is  especially fatal  to persons of
broken-doAvn constitution.   It is usually found in the  neck and
head.   In such erysipelas, tonics, stimulants, and  half-drachm
doses of the tincture of perchloride of  iron every four hours,
together Avith  milk and nutritive  food, form  the  best line of
treatment.   As external applications  flour, oxide of  zinc, and
other  powders, or cotton-wool, are useful; while  some  prefer
warm solutions of lead  and opium.  The tendency is  to death 
23-1        BLOOD-POISONS — SPECIFIC  POISONS.

from asthenia; and if a typhoid state sets in the aspect of mat-
ters is very gloomy.
  A totally different affair altogether is the  erysipelas which
sets  in near  injuries  to  the skin.  This is not dependent on
a specific  poison—it  is a true dermatitis.   It is apt to occur in
persons Avliose vaso-motor nerves are much shaken by  excessive
consumption of alcohol.  It is to be treated by cooling medicines
and  applications of lead  and  opium, or of the solid nitrate of
silver around the blush, which often arrests its spread.
  At other times erysipelas is of a wandering character, and is
seen in scrofulous children.  It commonly travels from head to
foot, and back again, and, according to Lugol, is often followed
by general improvement in the condition of the child.   In one
case Avhich came under my notice such certainly was the case.
  When  phlegmonous erysipelas  occurs  it is a  very  serious
affection.   It is a dermatitis Avith rapid formation of pus in the
subcutaneous areolar tissue,  usually  of  the limbs and of the
intermuscular planes.  It is ordinarily casually connected with
grave  and fatal blood-poisoning ;  and when so occurring  it re-
quires all  the stimulo-tonic measures and antiseptic treatment
that are a Available: too often with  no good results.   At other
times, Avhen  rather a localized  disease than an expression of a
general condition, recovery takes place ; but only after long and
terrible incisions made for the purpose of evacuating the differ-
ent depots of pus Avhich forms so freely in this malady.  Carbo-
nate of ammonia, wine, steel, beef-tea, milk, etc., are all requisite
in unstinted  quantities, in order to  give the  system  a chance
of tiding  over the period of peril.   In a case of carbuncular
inflammation of the lip the pronounced asthenia setting in Avas
successfully combated by  the  resort to digitalis in addition to
the measures just mentioned. 
CHAPTER  X.
                 ACUTE AND CHRONIC DISEASE.

  § 92.  There are  many reasons Avhy a  chapter should be
devoted to the peculiarities of acute and of chronic disease—
contrasting Avith each other as they do—and to the consideration
of their relations.  We shall find that acute disease of a part
may persist in a chronic  form ; Ave shall also find that chronic
disease has a  tendency to assume an active form, at certain
times and under certain circumstances.  From the consideration
of these matters we shall be enabled to see how to so conduct
acute disease as to reduce to a minimum the tendency for itto
linger in a chronic form ; and also Iioav to treat chronic disease
so as  to obviate  to a  great  extent the development of acute
manifestations.
  Acute disease is a brief affair, which, if survived, often leaves
the system but little altered.  For the most part  it consists of
acute inflammatory conditions or zymotic  affections; but it is
not confined to these tAA^o genera of disease; it may result  from
some brief passing condition, as shock, disturbed innervation, etc.
The indications most manifest are such as point conclusively to
the imperative necessity for tiding the patient over the dangers
of the hour.   In a few days the danger to life usually passes
aAvay; sometimes, hoAvever, not  until the existence  of the
individual has been most gravely imperilled, and  the question
of a satisfactory  coiwalescence  has been made a complicated
matter.  In  the  phraseology of the past, our duty in  acute
disease is to obviate the  tendency to death.  In order to  do so
with anything like an  approach to  success, Ave must clearly
distinguish the side upon Avhich death is threatening.  Having
recognized the nature of the most imminent danger, it  then
becomes practicable to select measures  calculated to arrest, or
modify the impending risk to life.   At one time a patient may
seem to be sinking from  sheer pain.  The  condition  is that of
cold extremities,  a small or failing pulse, of agonized features, 
23G          ACUTE AND CHRONIC  DISEASE.

and a general approach  to collapse.   The impression  made by
the painful sensations  upon  the nerve-centres is such  that a
condition not Avidely different  from that of shock is  induced.
Indeed, there is little difference betAvixt the condition produced
by severe pains, inflammation  of serous surfaces, not  in  other
ways immediately dangerous to  life, and that induced by tor-
tures or punishments deliberately  inflicted  for  any  purpose.
There is a certain amount  of nausea involved in the pain Avhich
is apt to be fatal.  It is that form of  pain Avhich  folloAvs when
a cricket-ball strikes a batsman  on  the genitals, and Avhich  is
quickly fatal when  prolonged  ; as in the form of murder not
uncommon in India, Avhere the testicles are  firmly grasped until
the victim is dead.   The pain  would  seem to arrest the action
of the ganglia of the sympathetic, and first to cause syncope and
then actual death.  It is especially associated with affections of
the viscera, and differs from the pain produced by neuralgia or
affections of  the  limbs, especially those osteal affections which
are very painful.   It is perhaps  in degree  rather than in kind
that these  pains differ, for  collapse is not rare under the punish-
ment of the lash, and the severe agony produced by the torture
of " the boot," as  in  the case  of Maebriar in  Old  Mortality,
so vividly sketched by  the author of Waverley.  In despite
of the  stern  and  unflinching heroism of the* man, syncope
folloAved a certain  measure of torture.  We are  not yet in a
position to know or to be able  to estimate hoAV far such syncope
and  unconsciousness may not be directly preservative  Avhen
acute  agony is present.   Unconsciousness  may  be  the only
means of averting  death,  or it may be an approach to death—
a difference  of degree only.   " The reflex inhibitory  fibres of
the A7agus are those which cause syncope under shock, injury,
or emotion.  Such  syncope leads directly to unconsciousness,
and  by this the brain is  saved  from  the lull force of the shock:
Avhich if it fell upon a brain not anaesthetized by unconscious-
ness would do severe and  serious injury.   Syncope then saves
the brain from the full  force of  shocks, either material or emo-
tional."  {The Hart and Its Diseases.)
   When fainting  results  from  a brief temporary pain, as the
extraction of a tooth, or the opening of an  abscess, it may be
safely left  to itself.  A  few minutes in the recumbent posture
is usually sufficient to restore  consciousness.  The pathology of 
             ACUTE AND  CHRONIC DISEASE.           237

syncope is this.  The heart fails to propel the blood into the
encephalic vessels,  there  is  a  state of acute cerebral anaemia
induced, and failure of brain function follows, accompanied by
loss  of  motion  and of sensation.   By the  latter, relief  from
suffering is obtained.   When  the  causation is  but temporary,
the effect  is but brief, and the  heart soon  commences again to
beat.  As soon as the arterial blood once more courses through
the brain, functional activity returns ;  this  is  much  aided by
the recumbent posture, Avhich permits the blood to run through
the head equally Avith other parts, instead of having to be lifted
up  by the ventricular contraction ; as  is necessary when the
head forms the highest point of the organism.   At other times,
when the  pain is less acute and more persisting, as in the pas-
sage of gall-stones,  for instance, a condition is induced which is
rather that of imperfect or partial shock ;  Avhere  unconscious-
ness is not reached.  Such is the consequence of severe shock,
Avhich we are often called upon to relieve or treat.   Our princi-
ples of treatment run  as folioavs.  In acute shock, or syncope,
stimulants,  the  more rapidly acting and diffusible the better,
are indicated.  Sal volatile, eau de Cologne, alcohol, or spirits
of chloroform  are  all useful and  serviceable.  The  following
combination is very frequently desirable:—
                    Am. Carb. gr. v.
                    Sp. Chloroform. 3ss.
                    Aq. ad gj.
It may  be repeated.   A teaspoonful of sal volatile forms a
pleasant stimulant in water.  When the  patient is unconscious
the fumes of ammonia are  very useful.  One  point, however,
must be borne  in  mind  in  connection  with the holding of a
bottle of ammonia to the  nostrils of a syncopal patient, and it is
this,—the unconscious patient  cannot turn  away the  nose from
the fumes, and  if  the  bottle  be held  too  persistently to  the
nostrils, inflammation of the air-passages  may be caused.
  When the condition is  that  of partial  or imperfect shock, as
in the condition which obtains in the passage of gall-stones, of
calculi along a ureter, or  inflammation of that  great  serous
surface,  the  peritoneum,  it  is a matter of question how  far
stimulants are  desirable.   They will arouse the patient to a
fuller and more vivid consciousness of his suffering; but this
is  itself undesirable.  Under certain circumstances it  may be 
238
ACUTE AND  CHRONIC DISEASE.
necessary to rouse an individual out of lethargy, even if acuter
comprehension of pain  be  the consequence, as  in  accidents,
Avhere the sufferers must be moved.  Here stimulants may be
indicated.  When the patient can rest in bed and the pain is very
severe, the more rational plan  is to deaden the  receptivity of
the nerve-centres  by full and  repeated  doses of opium.  The
Avhole question of analgesics and narcotics will  be  given in a
subsequent chapter, to Avhich the reader is referred.   (Chapter
XIII.)
  Where violent  pain exists,  very large  doses  of  opium are
borne  with impunity—the  tAvo being  antagonistic  in  action.
As soon as the pain is relieved, the opiate must  be  stopped, or
much reduced in dose, else fatal consequences may folloAV.
  § 93.  At other times death  may threaten from hemorrhage.
The bleeding may be continuous, as in the oozing from persons
of  a  hemorrhagic  diathesis; or it  may be from some larger
vascular trunk.   Whenever  it  is practicable, pressure must be
applied to the bleeding part, in  accordance with rules laid down
by the  surgeon.  Where pressure  can be  applied by ligature,
tourniquet, or finger,  arterial hemorrhage can ahvays be con-
trolled.  Sometimes the actual  cautery may be indicated.
  In other cases, such as hemorrhage from viscera, far different
means are alone feasible.  They consist of  astringents, styptics,
etc., as alum, perchloride of iron, zinc, acetate of lead, opium,
matico-leaf, etc.  These may  be  given internally,  or, if the
bleeding can be reached, applied locally.   Cold  is often of the
greatest seiwice in the treatment of severe hemorrhage.   It may
be given by the mouth, injected by the  rectum—in impassable
urethral stricture, from congestion, packing the rectum Avith ice
soon  gives relief from  its  effect  upon the bloodvessels,—or
applied  locally,  as  to the  right groin  in the  hemorrhage of
typhoid fever.   At  other times it may be  necessary to resort
to venesection, especially in haemoptysis.   In the Avell-knoAvn
case of George  the  Fourth, this Avas the  only  measure which
arrested the hemorrhage from the lungs.  When bleeding is the
result of  high  blood-pressure, venesection,  or  its equivalents,
viz., bleeding  the  patient  into his oavh vessels by  vascular
depressants, are the measures clearly indicated.1

  1  In a case of haemoptysis recently  (February) under care,  the cutaneous
surface and the hands and feet were very cold.  By putting the patient to bed 
             ACUTE AND  CHRONIC DISEASE.          239

  In hemorrhage stimulants are  highly undesirable.  The syn-
cope which  checks the hemorrhage  is  a condition of arrest,
more  or less complete, of the  ventricular chambers, with Ioav
arterial tension.  When a stimulant  is given, and especially an
alcoholic one, then the heart's action is restored, blood is pumped
into the .elastic  arterial system and  then the bleeding recom-
mences.  This goes on till syncope is again induced Avith arrest
of the blood-flow.  More stimulants are given, the pulse returns;
and with it the hemorrhage.  This  goes on until the system
Avill no longer  react to the stimulant, and so the organism is
preserved ; or if the  stimulant treatment be persisted in, it may,
and it is to be feared  often does, result in fatal loss of blood.
This last untoward  result is attained when the  persons around
the patient  are  sufficiently  wilful and ignorant—or frightened
out of their wits, and so rendered murderous in their well-meant
but unfortunate measures.   When the young  medical man is
called in to such a state of  matters he must be prepared to find
his plan of intelligent withdrawal of stimulants  meet with a
stern  and indignant reprobation from the  alarmed friends.  To
see the poor patient pale, blanched, unconscious, and tossing his,
or more often her, arms about, and to withhold  stimulants ; to
leave the poor  thing in a drenched bed, cold  and  chilled, and
not only that, but  often to apply ice or cold to the gelid creature,
seems heartless and repulsive.  Often, indeed, in their sentiment-
alism, the affrighted friends Avould prefer a sympathetic med-
dlesomeness, even if the results are  disastrous.   It may  be
difficult to pursue a rational course under these circumstances,
and, unmoved,  to  turn a deaf ear to the entreaties, but in the
interest  of  the  patient  it  must  be  done.  In  luemoptysis, or
hsematemesis, ice may be applied  externally over the chest or to
the epigastrium  with advantage.    Small  chips  of ice Avith
astringents  may be  given—but cautiously.  If  the  bleeding is
in the stomach, any distension of it  will be apt to dislodge the
clot and start  up  further  hemorrhage ; if from  the thorax,
cold ingesta need not be  so withheld, but vomiting must be
avoided, as that might at once reinstitute the blood-flow. When

and packing her with  hot bottles, the bloodvessels of the external areas Avere
dilated, the pressure on the  pulmonic circulation relieved, and the hemoptysis
ceased.   The case  did well.  1876. 
210
ACUTE  AND  CHRONIC DISEASE.
the flow is from a hollow viscus, ice or cold Avater with astrin-
gents may be injected.
  Plugging is only permissible in uterine hemorrhage, and that
too when the uterus is either unimpregnated or only at the early
months of gestation ; otherwise the internal hemorrhage which
results is dangerous and not rarely fatal.
  Quiet and cold are the great requisites in the treatment of
hemorrhage   Post-partum  hemorrhage is, hoAvever,  an excep-
tion to  this rule.  It has been found that injections of hot water
into the uterus arrest the bleeding.   The hot Avater throAvs the
muscular fibres of the uterus into tetanic spasm.  Teaspoonfuls
of salt  are a measure which may be  resorted to Avhen other
remedies are not at hand, or are not available.
  At other times there  may be free discharges, usually from the
boAvels, Avhich may threaten the existence of the individual.  In
such cases it often happens  that the measures resorted to must
be very vigorous.   When diarrhoea is colliquative and profuse,
the combination of stimulants and astringents Avith opium is
clearly indicated ;  the first two in no measured quantities.  The
combinations in most use in such case are the following:—
                    Am. Carb. gr. v.
                    Tinct. Opii, Tn_x.
                    Inf. Hajmatoxyli, ^j.
every three or  four hours.   At other times the combination of
the logwood Avith acids is indicated: —
                    J^th. Sulph. ITIxx.
                    Acid. Sulph. Arom. Ttlxx.
                    Inf. Ha3matoxyli, 3J.
Avith  or without opium, may often be given  with advantage.
At other times acetate of lead Avith opium in pill may be given,
especially when there is  much tendency to vomiting, and the
stomach rejects readily anything which distends it.  The young
student will not give acetate of lead along  with  mineral acids,
especially sulphuric acid, as the insoluble and inert sulphate of
lead would be thus formed in the system ; but will substitute
sulphate of copper  for  the lead.   Colliquative  SA\Teats often
endanger life.   They may be met by the measures given above,
or by quinine  and  sulphuric acid, or again by the free use of
phosphoric acid.   Ringer has  pointed  out  the efficacy of bella- 
              ACUTE  AND CHRONIC  DISEASE.           241

 donna in profuse sweating, Avhich is indisputable.  It may be
 applied locally Avith  advantage, as well as given by the mouth.
 Ten drops of the tincture three times a day, or oftener, will not
 uncommonly arrest or greatly diminish profuse perspiration ; or
 better still, atropine, from an eightieth to a fortieth of a grain
 in  pill at bedtime, is often very good.   Oxide of zinc  in tAvo-
 grain  doses  at  bedtime often checks colliquative  sweating.
 (Ringer.)  It is commonly given along with hyoscyamus, which
 is not without a value of its oavii.
   § 94. At other times death threatens from impending stoppage
 of  the heart or of respiration.   When  the action of the heart is
 failing, stimulants of any and  every form are indicated.   Those
 given in § 91 are applicable here; and veryT often they may be
 advantageously combined with  digitalis or belladonna.  Failure
 of  the circulation  is one of the commonest causes of death in
 diseases of the respiratory organs.  The obstruction offered to the
 floAv of blood through the pulmonic circulation produces disten-
 sion of the right heart; as the ventricular chamber becomes over-
 distended so its poAver Avanes, and then exhaustion is imminent.
 In  such  cases there is a fast, compressible, and irregular pulse,
 becoming gradually intermittent, and  after death the left ven-
 tricle is found small and contracted, Avhile the right ventricle is
 distendedand full of black blood. The administration of digitalis
 in these cases often averts a fatal result.  The pulse just described
 is the measure of the condition of the right heart  really, not of
 the  left—which  keeps time Avith  the right  side and passes on
 the amount of blood which comes over to it.  When digitalis is
 given here, the right  heart contracts more powerfully upon its
 contents as it recovers from its over-distended condition ; once
 more a fair amount of blood is  passed over to the left heart, and
 the pulse becomes  fuller; the  right ventricle on recovering its
 normal size contracts less frequently, consequently the pulse is
 not so frequent; the arterial system  becomes better filled Avith
 blood, and, correspondingly, the venous system is not so much
 distended, and  a general  improvement results.   Again and
 again will a fatal  result  be  averted,  A\Then threatening from
 failure of the right side of the  heart, if digitalis be given along
with diffusible stimulants.  Hot poultices to the chest, especially
if dusted over Avith mustard or capsicum, will often aid in giving
relief to this condition.
      16 
242          ACUTE AND  CHRONIC DISEASE.

  At other times death threatens from  the side of asphyxia.
Thus it occurs in pneumonia, especially Avhen the space of lung
remaining unaffected is insufficient for the purposes of respira-
tion ; or it is present in bronchitis Avhen the air-tubes are filled
with mucous secretion, and the chemical interchanges conducted
in the lungs are becoming arrested.  Under such circumstances
a condition of the gravest peril is induced.  The action of the
skin may  be called  into play by the different measures enume-
rated in Chapter III., and the compensating effects of exhalation
from the cutaneous surface  may be secured.   If there be much
accumulation of mucus in  the air-passages, vomiting  may  be
induced ;  and  in the  Avorst cases, Avhen  apparently  the  very
effort of vomiting Avould seem  enough  to asphyxiate the ex-
hausted patient, emesis  is  folloAved  by such cleansing of the
air-passages that a little sleep is secured, and the turning-point
is safely passed.  Especially is this true  of children, and  the
young practitioner must never be deterred by fear  from trying
the effects of emetics in the bronchitis of children.  They can
do no harm, and often do much good.  As an emetic, sulphate
of zinc combined Avith ipecacuan wine has proved in the writer's
hands a very efficacious  remedy:  much  better, indeed, than
either singly.   If the  case  is very desperate, irritation of  the
fauces may be resorted to, and the finger is much better than a
feather.  Of the more special matters of diseases of the respira-
tory organs and of  failing circulation, they will be discussed at
length Avhen the diseases of these systems are considered.  (Chap-
ters XIV. and XV.)
  Death may, and often  does, result from collapse, and oftener
from an exceedingly high temperature.   These conditions and
their indications for treatment have  been given at length in
Chapter IV. (§§ 37, 41-44),  and to them the reader must refer.
  § 95. The Theory of Stimulants.—There is nothing Avith which,
as medical men, we are more familiar than the  fact that there
are agents which possess what are termed  stimulant properties,
i. e., they produce a distinct effect in calling out more marked
evidences of  vital action.   Under the  influence of a stimulant
the pulse rises in frequency, Avhile its beats are  more powerful;
the  extremities  become  warmer,  the  cheek  flushes,  the  eye
brightens, the thoughts Aoav readily, and the hesitating  tongue
is loosened.  Such are the ordinary phenomena of limited stimu- 
ACUTE  AND CHRONIC DISEASE.
243
 lation by alcohol.  It is in Avatching the effect of alcohol that
 Ave  are  most familiar Avith  the action  of stimulants.   Other
 stimulants, as ammonia, spirits of chloroform, ether, Cannabis
 inciica, etc., produce like but  not identical effects.  In speaking
 of ammonia, Ringer says, "Ammonia induces a slight increase
 in the force of the pulse, some excitement of the brain, and a
 general  sensation of warmth.  Being a slight stimulant to the
 heart, ammonia is used in fainting and exhaustion.  Ammonia
 is frequently administered as an antispasmodic—an action de-
 pending probably, in part, on  its power to strengthen the heart's
 action, but, like  all other antispasmodics, its influence is  but
 brief."  There is also a distinct rise in the force and frequency
 of the pulse after taking a dose of spirits of chloroform, or of
 ether.
   In considering the action of stimulants there are  tAvo points
 that strike one strongly: they are (1) the effect upon the heart,
 and (2)  the  effect upon nerve-cells.  Hoav far  the  first effect
 depends  upon the action of the  stimulant upon the ganglia of
 the  heart  is not yet  demonstrated; but at least it is probable.
 There is certainly an increase in the vigor and frequency of the
 contractions of the heart after the administration of a stimulant,
 and this may take its origin either in direct stimulation of the
 cardiac  ganglia,  or in some  remote action upon the complex
 nerve-supplies to  the  heart.  From  the  readiness with  Avhich
 stimulants act, the first seems the more probable.   Certainly
 they do  affect the  heart, and pOAverfully,  as is seen in their
 administration in  fainting.  In addition to this effect upon the
 heart there comes the action  upon the cerebral cells.   That the
 cerebral cells are influenced by stimulants is unquestionable; but
 Avhether  this effect is produced by some direct effect upon the
 cells, or merely by an afflux of arterial blood, or both combined,
 is not yet quite settled.  We  know that the functional activity
 of the brain is in direct  proportion  to  its blood-supply.  In
 stimulation it is not yet ascertained Avhether it  is an afflux of
 blood to the cerebral cells which heightens their activity, or
 there is a condition  produced  in the cell  which  induces it  to
 attract more blood to itself.   Probably both factors act.   The
capacity to attract more blood would exercise but little effect if
an increased supply of blood Avere not forthcoming in answer to
the demand : while  an increased  blood-supply to a part  Avould 
244
ACUTE AND  CHRONIC DISEASE.
have but little effect if  the tissues did not have an increased
capacity to attract blood.   In the case of alcohol it has  been
shown by Dogiel that along with increased action of the heart
there  is also dilatation  of the carotid  arteries,  and, thus, an
increased blood-supply to the brain.  There  is  also increased
functional  activity of the brain.  If the  stimulation  be  con-
siderable, a condition of intoxication is produced.
  In intoxication  Ave find  several stages.   At first, "The effect
of this increased  blood-flow through the brain is to cause the
brain to be more active.  The thoughts flow rapidly, the halting
speech loosens into eloquence; coldness of feeling gives way to
affection, passion,  or sentiment;  despair becomes blended with
hope, courage is reanimated;  difficulties  melt away, and the
impracticable is almost  realized.   These  are  the sensations
Avhich have impelled  men  in every clime to devise some means
of exalting the  nervous life; and a  fearful price is paid for it,
Soon  the ready  speech grows muffled, the  thoughts confused,
the impressions blurred; the higher feelings become submerged
under  the  rising animal impulses; hope becomes a disfiguring
conceit,courage  merges into recklessness and boasting, exhilara-
tion into boisterousness, and sentiment into maudlin.  At last
the human frame lies unconscious, poAverless; all is  oblivion ;
the awakening is, however, a grim reality."1  At first  there is
increased functional  activity of the brain, and at this stage
there  is an increased  blood-supply to it.   There is, too, every
reason to  believe, as  said before, that the cerebral cells are
themselves stimulated into increased activity while the afflux
of arterial blood  renders  such activity feasible.  After much
activity of the cerebral  cells there  comes on exhaustion.  At
first the nerve actions cease to  be perfectly  co-ordinated, the
action of different parts is no longer accurately adjusted, and the
more complex movements, as talking and Avalking, are impaired.
An effort  of will can,  however,  supply  what is Avanting or
defective in the  ordinary automatic  action, and the appearance
of sobriety may be maintained by an effort: but this is only so
long as a certain point is not passed.  After that, all the most
active cerebration then  possible is  insufficient  to produce co-
ordination ; and then is exhibited the spectacle, far from un-
common, of an  intoxicated  person, conscious  of  the  condition
1 The Maintenance of Health, p. 150, 1874. 
ACUTE  AND  CHRONIC DISEASE.
245
Avhich obtains, making the most determined efforts to maintain
an equilibrium or to walk steadily, without  the desired  result
being obtained. A little further on and all volition is abolished ;
and  the medulla  oblongata is alone in action, carrying on the
circulation and respiration.  At the time that the manifestations
of brain activity are beginning to flag, the carotids are found to
contract—not to their normal calibre, but to something beloAv it
—to a calibre less than normal (Dogiel).   There is less arterial
blood  passing to the brain than in its unstimulated  condition.
At the same time the peripheral vessels of the system  generally
are dilated, and so there  may be a Avithdrawal of blood away
from the brain, as well as a diminished  demand  for it on the
part of the exhausted cerebral cells.   But Avhen the functional
activity of the brain is flagging, and pronounced intoxication by
alcohol is present, the administration of ammonia will usually
produce sobriety.  That  is, it Avill  restore such a condition of
brain  as is compatible with comparatively sober action.  It is
not supposed by any one that ammonia exercises any antagonistic
action  upon alcohol within the system, except such as Fraser,
Hughes Bennett, and others have demonstrated to exist betwrixt
certain agents, as  belladonna and Calabar bean, for instance, that
is, an antagonistic physiological action, not a chemical action of
neutralization.  When, then, the cerebral  cells are exhausted
and  the arterial blood supply to the brain is impaired, and the
venous radicles of the  brain are probably  full  of blood, the
administration of ammonia excites the cells into action, increases
the supply of arterial blood, and with it the circulation through
the  brain,  including  the  venous  radicles,  and  so  restores  a
condition of brain activity.  That is, one stimulant will produce
an effect Avhen the nervous system  has been exhausted by the
action of another  stimulant.  A condition of  exhaustion of the
nervous centres having been artificially produced, then another
stimulant is given Avhich again rouses them into action.  It must
ever be  borne in mind that conditions of exhaustion  require
doses of alcohol  which under ordinary  circumstances would
produce a drunken state, in order to procure the desired stimu-
lation.1

  1 When exhausted  the system will tolerate with only good effects doses of
alcohol which would in unexhausted states produce  advanced intoxication ; and
at critical times the amount required is far beyond what is ordinarily prescribed. 
24(5          ACUTE AND CHRONIC  DISEASE.

  § 96.  There are one or tAvo points to be further alluded to
in this  account of the history of a fit of intoxication.  One is
the readiness Avith which intoxication  is  produced after  long
abstinence  from food.  Every one knoAvs  how sAviftly the first
stages of intoxication pass into  the  more  advanced ones Avhen
there is no food  in  the  stomach.  Further, we are equally
familiar Avith the  fact of the power of a good dinner to endow
a man Avith capacity to " carry" alcohol.  It is Avell known that
when a man Avho has long drunk hard, but Avith his assimilative
powers  unimpaired and  appetite  keen, begins to diminish the
amount of food, that man " is giving Avay," as it is termed ; or
in other words, that his capacities are becoming impaired.  To
what does all this point?  To me it indicates that when pabu-
lum is freely offered to the cerebral cells during alcoholic stimu-
lation they do not become exhausted readily—that the advanced
stages of intoxication are not so easily reached.  Especially is
this the case when coffee and tea are taken amidst the alcohol.
These agents act upon  the vaso-mortor centre  and excite  the
heart into firmer  contraction, Avhile the peripheral vessels  are
induced to contract, or maintained in contraction ; and so the
blood-pressure in the  arteries is increased and the blood-supply
to the brain sustained.  The Avhole of the arrangements of a
dinner-party are so constructed  as to enable the guests to take
a maximum of alcohol Avith a minimum of risk of the  earlier
stages passing  into the later  stages of  intoxication.   In conse-
quence  of  the abundant supplies of nutriment in the system,
the tired nerve-cells are well  nourished during  the sleep which
follows, and  in the morning they are again ready for Avork.
They may be played upon by  alcohol with comparative  im-
munity if they are  well  fed, and  the effects of stimulation
repaired by good supplies of nutrient material.  In fasting,
hoAvever, it must not be forgotten that alcohol is most quickly
absorbed by the stomach.
   If, however, the stimulation has gone on to the latter stages
—whether to a greater or less extent it does not matter, it is
a difference of degree merely—the effects are well demonstrated
next day.  The nervous system is unstrung, the hand is tremu-
lous, the thoughts are erratic, the emotional  condition  is that
of depression ; the digesti\Te powers are impaired, the secretions
are scanty and  depraved, and the capacity  for labor of any kind 
ACUTE  AND CHRONIC  DISEASE.          247
is diminished.  There is craving for fluids—the temperature is
generally high—and a desire to remain in bed, the consequence
of the feeling of exhaustion.  If it be  absolutely necessary to
get up and go about the duties of the  day, further stimulation
by alcohol  is usually unavoidable.   If this condition of exces-
sive drinking at nights, followed  by resort to alcohol early next
day, be continued, a condition of systemic exhaustion, or ap-
proaching  physiological bankruptcy  is  induced.  The   vital
powers are so exhausted that Avhat would otherwise be trivial
demands upon  the system  become  important;  and what is
termed the resistive power of the system is loAvered.  Slight
acute attacks in  such systems commonly  lead to fatal results.
  § 97. Such are the consequences of chronic alcoholic indul-
gence, of persistent  stimulation.   They  will enable us to com-
prehend all the more clearly the points to be attended to in the
administration of stimulants Avhen it beomes desirable to pre-
scribe them medicinally. One of the first lessons taught is  this:
The stimulation  must bear a distinct  relation to  the forces of
the system on the one hand, and to the habits of the individual
on the other.  If the stimulation be  out of proportion to the
forces of the individual, stored up in a static form—the reserve
fund of the system on which we subsist during enforced starva-
tion—then exhaustion is  directly  induced ;  the strength is
called out in useless displays of  energy, and  dissipated ere the
hour of need arrives.  This is very common in the over-stimu-
lating present time.   It is seen  in the  exhaustion  produced,
amidst the ignorant lower classes, in  parturient Avomen, Avhose
energy  is dissipated by draughts of  alcohol  during the first
stages of labor ; and then, when  the  second  stage arrives, the
strength that should  have carried them through the active
efforts then required is gone—having  been Avasted Avhen useless
and  inoperative.   This is  equally  obvious  in the process of
stimulation by alcohol and beef-tea in  the early stages of  acute
disease, especially fevers, when an officious attendant dissipates
the body reserve fund  ere  the hour  of  need  has approached.
When the  time for resort to stimulants comes, the force the
stimulant can, and otherwise would evoke, is wanting ; and the
patient sinks—slain by good intentions.  If  the  reserve  fund
cannot be maintained  by supplies of easily assimilable food, to
some extent at least, stimulation  is exhausting, and should not 
248
ACUTE AND  CHRONIC DISEASE.
be resorted to prematurely, nor be unduly persisted in ; the time
may and often will  come, Avhen  it may  be simply " neck or
nothing," Avhen a point  must be rounded  at  all risks.   If the
reserve fund has not  been unduly  drawn  upon, success is often
practicable;  but if it has  been  already dissipated, then  success
is no longer feasible.
  In the same  Avay individuals  who  have  rendered  themseh'es
physiologically  bankrupt  by  chronic stimulation readily sink
under the demands of acute disease.  In such persons stimulants
have to  be  given in enormous quantities  to  produce ordinary
effects, and  then, too, often  without the  desired results being
attained.  There is a close analogy  betwixt  the condition of
these last-mentioned  individuals  and  those whose  stores of
energy have been dissipated by  stimulants  in the early stages of
acute disease.
  § 98. In attempting to fairly estimate the action of stimulants,
and  especially of alcohol, one point it  is of the  utmost import-
ance to remember.   It is  this—alcohol is a food !   If alcoholic
stimulants were mere disengagers of static force, early exhaustion
Avould be the rule.   But as alcohol is a readily oxidizable form
of hydro-carbon, it is also  a food as well as  a stimulant.  In fact
it is one of the  most  easily assimilable forms of food, and very
frequently it can be taken and  utilized when no other form of
food is aATailable.  While it is a stimulant, an evoker of force, it
also  supplies to  some extent  that force in its readily oxidizable
self.   The recent experiments of the late  Dr. Anstie and  Dr.
Dupre" have  placed beyond all question, or honest doubt, the fact
of the oxidation of alcohol Avithin the organism.  If alcohol is
oxidized in  the body, then alcohol is a true food or furnisher of
force.1  It is of great importance to  have definite ideas on this
head.  In administering  alcohol as a stimulant we  also give a
food;  if it  Avere not so we  should often exhaust  the  patient
whom we really conduct through a time of peril into the haven
of convalescence.  When other stimulants, as ammonia or«ether,
are given, Ave must remember that  they are not foods ;  and their
administration must be accompanied by food  and alcohol.

  1 "It is essential, in order that the  organism should continue to exist, that
it be continuously supplied with free oxygen and oxidizable substances.  Tin'
latter are called the organic constituents of food." — Hermann's Physiology, p. 2. 
ACUTE  AND  CHRONIC DISEASE.
249
  Beef-tea is a useful  stimulant, but it is only to a very slight
extent a  food.  As ordinarily given, it is scarcely a food.  It
contains nothing out of which tissues may be built, for its pro-
ducts are too far advanced for histogenesis : Avhile its oxidizing
poAver is so small as to furnish little or no force to the system.
Beef-tea as a stimulant is much abused, to the detriment of sick
persons.
  Alcohol, being at once a stimulant and a food, naturally takes
its position, on its merits,as the agent required par excellence for
the treatment of acute disease  in  its later stages; and also for
the inauguration of convalescence.  It can be combined  with
readily assimilable forms of food, Avith milk, farinaceous prepa-
rations, especially Avhen given along with infusions of meat; and
as such is an excellent agent. It furnishes by  its  stimulant pro-
perties that  condition of the system Avhich is necessary to the
assimilation  of other foods.  What those stimulant properties
consist in Ave have just seen.  There is an action on the heart by
which its  activity is increased, and a more rapid  propulsion of
blood into the arterial system achieved. There is also an action
upon the peripheral arterioles, Avhich still  further aids the rapid
flow of arterial  blood.   This is seen in the effect produced by
alcohol upon the encephalic circulation, upon the kidneys, and
upon the skin.   There  is also, as seen in  Chapter II., § 18, an
action produced upon  the  lining  membrane of  the  stomach,
Avhose vascularity is increased by alcohol.  There is every reason
to believe that a condition of hyperemia of the organic nervous
system  is  reduced by  alcohol,  similar to its action upon the
cerebro-spinal system.   Indeed,  it  is  strange if the organic
nervous system  alone escapes from  the action of alcohol upon
the arterioles. As a condition of arterial vascularity is intimately
associated, causally associated indeed, with functional activity,
there is, in the absence of direct proof, every  reason to  believe
that stimulants,  and especially alcohol, act upon the organic
ganglia, and  increase the activity of the organic processes.  By
means, then,  of the combination  of stimulants Avith  easily
digestible food, we secure assimilation in debilitated conditions,
while we procure a  loan from  the  reserve-fund  of  body-force,
and so Ave are enabled to tide our patients  through times of
peril, and to inaugurate a satisfactory convalescence.  As con-
valescence proceeds,  the stimulation gradually  gives Avay to 
250          ACUTE AND  CHRONIC DISEASE.

liberal supplies of food, and to the action of those agents termed
" tonics."
  The effect of alcohol upon the cutaneous vessels is such as to
produce a free blood-current through the skin, and so to get rid
of some of the excessive heat in high temperatures.   This action
is often very beneficial, and, added to the other effects of alcohol,
points to its  eminent  usefulness  in the treatment  of acute
conditions associated  Avith  high  temperatures:  alcohol also
diminishes the chemical interchanges.  This action upon the
skin is  much affected by the influence  exercised by the other
remedial  agents given  along with  alcohol;  and so its use in
pyretic conditions, or apyretic conditions can be regulated, and
the maximum of good effects secured.
   The proper combination  of alcohol Avith food and Avith tonics
as the convalescence proceeds is a matter  involving thought in
each individual case.  Very often the necessity for the adminis-
tration of alcohol, except at meals, becomes  abolished; but the
custom lingers from the liking for the effects of alcohol, or from
Avant of  attention  to  the  case  on  the  part of  the  medical
attendant.  There is, unfortunately, much reason to fear that in
some cases  habits  of indulgence in  alcohol have  taken  their
origin in some carelessness  or Avant of caution  in the medical
man, Avho permitted the imbibition of alcohol to continue after
it Avas no longer indicated.  In early convalescence a glass of
wine and a biscuit during  the intervals of meals  may be very
proper, and be  clearlyr indicated ;  but as  the digestive powers
become restored, and a larger bulk of food  can be assimilated
at one time, such irregular meals become less necessary.  But
too often the glass of wine remains, and is taken before or after
a Avalk or a drive.   "You  had better have a glass of wine, dear,
before you go out;  you are not strong yet;"  has laid the founda-
tion of many a ruined life.  The alcohol  is, however, not only
permissible  at meals, but is desirable, and may take the form of
sound malt  liquor,  or some generous wine.  But as a rule there
should be no other consumption of alcohol except it be at bed-
time, Avhen  it  may be taken for its direct  hypnotic qualities.
The effect upon the cerebral cells is first to  gently excite them
into  action, and especially to produce that pleasant emotional
condition associated with a sufficient supply of arterial blood to
the  posterior cerebral  lobes, and after  such  a condition sound 
             ACUTE  AND CHRONIC  DISEASE.          251

sleep, either dreamless or free from unpleasant dreams, is achieved.
Too  frequently at  bedtime the cerebral cells are wearied, and
evoke triste or deeply-shaded thoughts  as the outcome of their
anaemic condition, and unhappy impressions  tint  the  dreams
and take away from the good effects of sleep in the convalescent.
A draught of alcohol dispels the gloomy thoughts, and in this
agreeable emotional condition sleep comes on, and is sound and
refreshing; and no  shadow of unhappy dreams is projected
across  the  waking thought of the morrow.   More  extended
experience  convinces me more and  more of the truth of what
has just been stated  above.  That dilatation of the  encephalic
vessels which is part of the first action of alcohol  is quickly
followed  by the dilatation of the  vessels of the  body generally ;
and this is  succeeded by contraction of the carotids and lessened
cerebral activity, and in this condition of cerebral anaemia sleep
comes and Avraps the patient in oblivion.
  The two chief dangers to be  kept  carefully in view  in the
medicinal use of alcohol are these.  Firstly, the administration
of alcohol during the acute stage of the disease, and when there
is great exhaustion, at  times produces great gastric irritability.
This leads to  much evolution of gas in the stomach ;  this accu-
mulates, and, by pressure, interferes  both with  respiration and
the action  of the  heart.   The patient  is extremely ill, and an-
other dose  of alcohol follows, which aggravates  the condition.
In such cases  alcohol should not be given by the mouth ; it is
doing more harm than good.   Only the blandest matters should
be taken into the  stomach, and the brandy should  be adminis-
tered per rectum.  This is the great immediate danger in the
use of  alcohol.  (The risk of too early and of excessive stimu-
lation, whatever the stimulant  resorted  to, have  been given
already in an earlier part of this  section.)  Secondly, there is a
danger of the use of alcohol  being continued as a habit.  Of
course  this danger is much greater with some persons than Avith
others.  The  feelings created  by alcohol  are such as Avith some
to form a dangerous allurement  of a  seductive  character, and
this possibility must never be forgotten by the medical attend-
ant.  Drinking habits  are commonly attributed to medical ad-
vice as the least unpleasant explanation of their origin, by those
who are  so unfortunate  as to  have contracted such  practice,
Avithout any such foundation in fact in many cases.   Still there 
252          ACUTE AND CHRONIC  DISEASE.

is room for grave fear that in some cases the statement is abso-
lutely true; and that ever such a small  proportion of drunken-
ness should so originate is a matter for deep regret.  It may be
absolutely necessary  in the patient's interests to give alcohol,
and freely too, at critical periods ; but if this  resort to alcohol
degenerates into an evil practice, then it may be questioned how
far it might  not have been well to have let the case take its
chance Avithout this remedy, so potent for good or evil.  Where
the inclination to take alcohol lingers in too pronounced a form
it appears to  me to be the bounden duty of  the medical attend-
ant to warn the patient and the patient's friends, in  unmistaka-
ble language, of the dangers so incurred.  As the convalescence
proceeds, and ordinary food can be  taken in  increasing quanti-
ties, the amount of alcohol should be distinctly diminished.   In
advanced convalescence alcohol should be abandoned, except at
meals—when taken with food, or  at  bedtime.   If indulged in
at other times, it may turn out to have been a most unfortunate
thing for the patient that the  illness was survived.   To pursue
further the question of stimulants : More extensive observation
has revealed  to us the utility of agents which act upon the respi-
ratory centres  in  the medulla and upon the cardiac ganglia.
Thus we now know that ammonia is a direct  stimulant to the
respiratory centres.   Strychnine and belladonna both act on the
respiratory and cardiac centres, and are both  useful in cases of
collapse.  Even the collapse  of burns  is influenced by these
agents.   Then  digitalis  acts  upon  the cardiac  centres.   The
following are useful stimulants, Avith a more  persisting action
than alcohol ; though they may be given with alcohol, they may
often be usefully substituted for it.
                    Amm. Carb. gr. v.
                    Tinct. Nucis Vom. Tn>.
                    Inf. Cinchona;, ^j.
is a good form of stimulant blended Avith a tonic ; or at other
times, especially when there is much perspiration, the following:
                    Atropiag Sulph. gr. TJfl.
                    Liq. Amm.  Anisat. TTLxv.
                    Aq- Si-
Li iq. Ammonise Anisatus (Prussian Pharmacopoeia).
                    Liq. Amm.  Fort. ^iij.
                    01. Anisi, 3iij.
                    Sp. Vini Rectif. §xij. 
              ACUTE AND  CHRONIC DISEASE.          253

  § 99. The Relations of Acute and Chronic Disease.—There is
much  that is instructive and  suggestive in  the  careful con-
sideration of the relations Avhich exist betAvixt acute and chronic
disease.  We  are all  familiar Avith the tendency for  acute dis-
ease to become chronic, or rather to persist in a modified form
as a chronic affection ; and, as such, to  require a totally different
method of remedial procedure.  On the  other hand, as  Wilks
is fond of pointing out, it is a matter of much importance to
prevent chronic  disease from  assuming an acute form.   Of the
tAvo certainly  the  latter is much the  more common, especially
in the recurrent  inflammatory, or other acute ailments  of  ad-
vanced life.  The  consideration of both forms of the relations of
chronic to acute disease is Avell Avorthy of our attention.
  The most familiar instance  of acute disease becoming chronic
is the gradual merging of a  gonorrhoea into a gleet.   At first
there is an acute inflammatory condition Avith  pretty profuse
cell-proliferation, the result of a sustained hyperaemia.  This in
time becomes  a simple mucous discbarge from the affected sur-
face, holding its ground tenaciously ;  and not easily dislodged
by the most persevering treatment.  The acute cell-proliferation
and hyperaemia have declined into a less active condition ;  which
differs from the first in degree, but not in kind.  There still
remains a condition of exalted local nutrition, Avith degeneration
of cell-products.   Instead of  a quiet  and normal formation of
epithelium cells to line the urethral tract, there is a production
in excess of mucous corpuscles—imperfectly developed epithe-
lium cells—Avhich forms a discharge from  the  meatus.  The
condition is precisely analogous to the chronic  bronchitis which
frequently folloAvs an acute inflammation of the bronchial mem-
brane.   It is often most difficult to get  rid of these lingering
perversions of nutrition.  They may depend upon  some pecu-
liarly irritable condition of the mucous  membrane ; at other
times  there is some constitutional condition,  as  syphilis or
suppressed  gout, Avhich may  maintain  an  abnormally  active
condition of nutrition in the  membrane  over which an inflam-
matory storm  has passed, and which has been altered  thereby.
Certainly  the  function of either membrane  is scarcely com-
patible Avith physiological rest.
  The  methods of approaching the cure of these lingering modi-
fications  are various.  There  are  two Avays  of laying  siege to 
 254          ACUTE AND  CHRONIC DISEASE.

 them: (1) general measures, and  (2) local  measures.  To take
 the last  first, there is the plan of applying astringents directly
 to  the diseased surfaces.  In  chronic urethritis  this is easily
 done.   In  bronchitis it is  more  common  to  try the effect of
 medicated inhalations, though by means of the  spray astringents
 may be inhaled, and so be brought into contact with the bronchial
 membrane.  Other different local  measures may be  resorted to
 under different circumstances, according  to the indications fur-
 nished by the exigencies of each case.  The effects of balsams
 and resins on chronically inflamed mucous  membranes are well
 known.   Thus copaiba,  excreted  by the kidneys, soothes the
 urethral  mucous  membrane;  inhalations of allied substances,
 as terebene, spirits of juniper or tar, from an inhaler or sponge
 Avrung out of hot water, are often very serviceable  in chronic
 bronchitis.  At the  same time general  measures may also be
 resorted to Avith manifest advantage.  In all cases of lingering
 changes  in organs, the result of some acute disease, the constitu-
 tional treatment is of the utmost importance. JNTot unfrequently
 a condition of low persistent cell-proliferation will  obtain simply
 as  the result of general  debility, especially in the  strumous.
 There Avould appear  to be a  lack  of capacity for  perfect repair
 in an injured organ, depending upon general adynamy.  In such
 cases good food, Avarm clothes, chalybeates, tonics, cod-liver oil,
 careful attention  to  the general health,  and  especially to  the
 prima? viae ; together with a residence under suitable hygienic
 conditions and favorable surroundings ; are indicated.  Change
 of air, especially to some seaside resort, is often most serviceable;
 though it is not at all easy to say how such change acts.  It is,
 however, a Avell established  empirical fact.   In bronchial affec-
 tions, or affections  of other  respiratory organs,  a  mild and
 soothing atmosphere  is often most beneficial; and  residence in a
 cold region, where the air is also laden with mechanical irritants,
 is proportionately injurious.  At all times it is a  matter of  the
 gravest importance to secure for the part as perfect physiological
 rest as is  practically  attainable.  If  the part be exercised, it is
 almost impossible for it to  be thoroughly repaired  in a short
time.  This it is which interferes Avith perfect  recovery in parts
 Avliose functional  activity  is  absolutely  essential  for the con-
tinuation of the existence of the organism.  If the vela of the
mitral value  could be placed  at  rest after an attack of acute 
ACUTE  AND CHRONIC DISEASE.           255
 rheumatism involving the endocardium, we should see much
 less of the mitral disease so provoked.   If we could relieve the
 kidneys  of their labor, an attack  of tubular nephritis would
 soon pass away completely ; but unfortunately this is impossible.
   In acute affections of the stomach nutrition may be effected
 by the rectum.   When there  has been an attack of meningitis
 or acute cerebral congestion, great  quiet and inactivity on the
 part of the brain produce satisfactory repair.   When a limb is
 fractured rest permits of union; and in inflamed joints splints
 and immobility are  the great means for bringing the nutrition
 of the part back to its normal state.  When such physiological
 rest  is unattainable, the progress of a part  towards recovery,
 when injured or diseased, is far from satisfactory or Avhat Ave
 could desire; and such progress forms a  strong  contrast with
 the ready repair of parts Avhich  can be completely  put  at  rest,
 and  where  the  process  of reparation  is  not modified  by  that
 hyperaemia  Avhich is necessary  to functional activity.   Conse-
 quently absolute rest for the  nervous  system is necessary after
 railway accidents.  If the injured person does not attend to this,
 the raihATay companies ought  to  plead the fact in mitigation of
 damages; just as they do in  injured  limbs if the recognized
 rules of surgery have been violated.
   At other times a  general  condition  may obtain that inter-
 feres with  the  repair of any part  which has  been affected by
 acute disease.  Such conditions are notably found in gout, rheu-
 matism, and probably syphilis.   The local action  is  modified by
 the constitutional condition ; and a state of persistent activity is
 kept up,  Avhich  is most undesirable.   Whenever  it  becomes
 manifest that there is such a general condition, and that this is
 the reason of the intractableness of the malady, then it behooves
 the practitioner  to appeal to that general condition ; to  treat it,
 and so to remedy the local affection.  Experience  has taught me
 the value of the recognition of constitutional  conditions in the
 treatment of persisting local  affections:  and the recognition is
 usually the first  step towards satisfactory treatment.1 Of course,
at times the exactly correct treatment is accidental and fortui-

  1 See Sir  James Paget's papers  " On Gout in its Surgical  Relationships"
(British Medical Journal, May and June, 1875) for some excellent remarks on
this matter. 
25G           ACUTE  AND  CHRONIC DISEASE.

tous in its origin ; and then the rationale, the connection of cause
and effect, is not so palpable.
   Bv such measures and  means  as have just  been detailed do
Ave strive to improve an injured organ and to secure for it com-
plete and perfect repair—with more  or less success.  Our dis-
tinct  aim is to give the injured part  the best  opportunities for
repair by freeing  it as far as possible  from any functional ac-
tivity  that it can be spared, to secure for it physiological rest as
far as is practicable ; and at the same time to aid the reparative
poAver of the system by placing it  under  the most  favorable
conditions, hygienic and other;  and  improving  the  general
nutrition so as to enable  the  reparative processes to be carried
on in a thoroughly efficient  manner.  In fact we try to "level
up," to bring all parts to an equal condition of perfection.
   § 100. At other times, hoAvever, a very different plan of action
must  be adopted.  Health, practicable health, consists  in  a
balance of parts in poAver as Avell as in function.  If there exist
a distinct disproportion betAvixt the body generally and one part
in particular, the existence of the organism is imperilled by that
very disproportion.  To illustrate my meaning  I may  adduce
this instance: A person has got  a heart far advanced in fatty
degeneration, and yet is generally active and vigorous.   Such a
condition  not  rarely obtains  as  the  consequence of disease of
the coronary vessels.   His muscular efforts and capacity to exert
himself are much more liable to bring that heart to a standstill
from  sheer adynamy ;  than is the case  in  another who is  a
general invalid, and therefore less liable to tax his degenerated
heart.   The case of aneurism furnishes  a precisely  similar pre-
dicament.  No  chain  is  stronger  than its weakest link ; and
practically the  capacity of  the elastic arterial system to resist
distension by the contained blood is loAvered to the point of the
capacity of the  walls of the aneurismal  sac.   Any rise in the
blood-pressure might easily rupture the sac and at once suspend
the existence of the individual.  Again, if a person  be  the sub-
ject of advanced renal disease, hoAV much more likely is he to
survive if  the appetite be defective and the assimilation of ani-
mal  food, especially lean  meat,  be correspondingly impaired.
The  instinctive choice of  such  persons is usually  in favor of
farinaceous and other non-nitrogenized food.  At  other times
loss of appetite comes  on, and so  permits of the oxidation of 
             ACUTE  AND CHRONIC  DISEASE.          257

the nitrogenized materials in the body ;  and  consequently of
their escape from the system.  If these were permitted to accu-
mulate, and instead of  natural anorexia  the  normal appetite
remained, the system Avould  be imperilled, and uraemia would
threaten ;  or some other affection,  the outcome of lithiasis,
Avould come  on, and though essentially a cleansing process,
mio-ht vet  be fatal through its rigor.   These losses of appetite
in elderly persons with  renal disease are often most beneficial,
and are not to be regretted ;  neither should the patient  be pre-
vailed upon to drink beef-tea, soups, etc., measures Avhich  may
be simply destructive.   Rest in  bed with slops, tea, arrowroot,
and gruel are infinitely preferable.   Such rational practice,
however, is unfortunately only too rare at present.
   How often, too, in  our attempts to hasten a convalescence
which is  progressing satisfactorily, do Ave not do harm  in  our
well-meant efforts?  One such  case  occurred to me in my early
days  of practice in Westmoreland.   The following extract  is
from a paper on " The Preservative Agency of loAvered Vitality,"
read  by me  at the annual meeting of the  British Medical
Association in Newcastle-upon-Tyne, 1870: "About a year ago
I attended a young lady for an attack of acute nephritis, with
dense albuminuria and general anasarca.   Active purgation,
the free use of the warm bath, and  gentle diuretics  (potash
and buchu), were producing the most desirable amendment, and
 in the minds of the consulting physician  and myself  we felt
 we Avere securing a most rapid and satisfactory convalescence.
 We permitted a  moderately free  use of  animal food.   One
 afternoon  the  patient felt so well that she sat down to write
 to the physician to thank him for his kindness, but in doing so
 she laid the pen aside.   She began to feel  unwell, the bath Avas
 resorted to, and active spontaneous catharsis came on, but, in
 spite of all, uraemic coma with  convulsions appeared.  I tried
 B. W. Richardson's plan of bleeding as  a forlorn hope.  All
 was  in vain, and the  patient was  soon  out of her troubles,
 leaving on my mind a most  painful conviction that if  we had
 only  remembered the function  of the kidneys and their duties,
 been  more cautious in  our  treatment, and attempted  a more
 gradual and guarded  improvement,  this unfortunate result
 might haA'e  been averted."  The memory of that young lady
often  rises up and  points the warning  lesson very apt to be
       17 
25S          ACUTE AND  CHRONIC DISEASE.

forgotten, viz., ahvays to consider the physiological function of
oro-ans which  are  the  subject  of disease ;  and also never to
hastily interfere  with  the  progress  of  convalescence  in  well-
meant but mischievous attempts to accelerate the rate of pro-
gress.
  Whenever there is incurable disease in an organ Avhose func-
tion is very important  to the  microcosm, it behooves a wary
medical adviser to  u level down," to secure a new equilibrium
bv reducing the general condition until a balance of parts once
more exists;  in  fact, to insist  upon  the habits of the invalid.
If this can be done sufficiently thoroughly, then existence—an
imperfect existence truly—may be maintained  for some time
 (p. L7).  If, on the  other hand, the general  condition bears no
relation to the injured part, and that part is an  important part
from its physiological  function, then some sudden catastrophe
may  be  expected to occur  at  any time, and it  may endanger,
and often even cut  short, the existence of the individual.  In
the same Avay in convalescence from  acute disease in important
organs, the relation of the organs to the body generally ; the
condition  of  these organs, their capacity, the necessity  for
remembrance of  their function; the danger incurred by forget-
fillness of  these  different matters: all must be  borne  in mind
 vividly if the management of the case  is to be satisfactory and
 disaster avoided.  Very necessary too  is it to remember the
 mutual relations of parts in function  in the treatment of various
 maladies.  If  in uraemic diarrhoea, for  instance, the  condition
 of the kidneys  be overlooked, and the  diarrhoea be arrested
 Avithout the normal channel for the excretion of azotized matter
 being reopened, a general explosion of uraemia may be expected
 Avith confidence.
   It will not  do in practice to aim at  too  high a general con-
 dition in certain systems.  Where chronic  disease lurks in an
 important organ it is apt to be overlooked ; and that oversight
 may be fatal, especially when  the different viscera are affected.
 If chronic renal disease or fatty degeneration of the heart be
 not detected;  their importance carefully appraised; and the line
 of treatment laid down in accordance therewith  ; sooner or later
 the grim importance  of the  oversight will  become apparent.
 Sometimes it  is necessary  to  "level down;" just as at other 
ACUTE  AND CHRONIC  DISEASE.
259
 times and under  other  circumstances it becomes  desirable to
 "level up" as far as is practically attainable.
   § 101. In a preceding section of this chapter the subject of
 acute disease becoming chronic has been discussed, and certain
 indications to be attended to in order to avert such result have
 been given.  Now something may be said on the  reverse, viz.,
 on the tendency of chronic disease to become acute.  This is a
 matter on which S. Wilks lays much and deserved stress.  In
 his opinion it is a much more important matter than the ques-
 tion of acute disease becoming chronic.  It is also Avhen acute
 disease is the outcome  of chronic  conditions that it is most
 likely to be perpetuated, in a persistent  if less  active  form.
 Thus, for instance, a condition of chronic renal disease may lead
 to an acute attack of a  serous  membrane—a common  outcome
 of such a condition of the system—and that serous inflammation
 may endanger or terminate the existence of the individual.   It
 is obvious that if  the  chronic condition  could haA^e been so
 managed that the acute outbreak could have been averted, much
 suffering and no little danger  might have been avoided.  Or
 in another case the victim  of  constitutional syphilis  becomes
 hemiplegic from a syphilitic tumor in his cerebrum.  Noav it is
 pretty certain that if the management of the syphilitic cachexia
 had been more efficient this  acute manifestation of its  presence
 might have been avoided.   It is in the  danger of  chronic mis-
 chief assuming an acute form  that  the chief risk to life lies;
 and it is by  such outbreaks, inseparable  from the condition
 Avhich obtains, and liable to occur  almost at  any time,  that the
 patient commonly dies.  Here I mean the acute manifestations
 Avhich are directly  and causally connected with  chronic con-
 ditions; and not the inflammatory conditions, especially pneu-
 monia, which are liable to break out in debilitated  systems, and
 Avhich are so frequently fatal.  The termination of many chronic
 maladies in Avhich there is no blood-poisoning is by intercurrent
 pneumonia, as in general paralysis, aortic  valvulitis, locomotor
 ataxy, etc.  In such acute  affections, arising  during the course
 of fixed  maladies, the danger to life is extreme ; and the most
 Avatchful attention, and  the  most energetic as well as skilfully
 directed  treatment, are  often,  indeed  usually, insufficient to
avert a fatal result.
  It is obvious that the best  plan of treatment of acute ailments 
20)0           ACUTE  AND  CHRONIC  DISEASE.

arising out of chronic  conditions  is that of prevention.  How
this  may best be done entails  the consideration of the more
chronic diseases to which we are liable, as to their nature, their
course, and  their outcomes.  Firstly we  may consider  those
ailments all  distinctly  associated  with  assimilation,  and  so
naturally arranging  themselves  into  a group, viz., diabetes,
rheumatism  and gout.1   After their consideration  something
may profitably be said about the two  great cachexiae—syphilis
and  struma;  and the question of  diatheses—a very important
matter.

  1 Garrod points out that diabetes may alternate with attacks of gout;  and
further experience corroborates his view. 
CHAPTER  XI.
                DIABETES—RHEUMATISM—GOUT.

  § 102.  These  are three different affections more or less asso-
ciated Avith the assimilative processes; and being so connected it
is most  profitable to consider them  in a special  chapter.  The
two first are connected Avith the assimilation and combustion of
hydrocarbons in the body; the third is related to the excretion
of waste nitrogenized  matter,  but  is  nevertheless  very  com-
monly associated with imperfect or modified nutritive processes
(p. 166).
  Diabetes.—As we  have seen  in Chapter II., the  nutritive
material taken  up by the portal circulation is  stored  up in
the liver in the form of glycogen.  It  is formed  directly from
the  saccharine  food  of man,—or indeed  any animal,—from
farinaceous matter converted into grape-sugar by the action of
the saliva and the pancreatic fluid ; and also from nitrogenized
materials Avhich are split up by the liver into glycogen and
azotized Avaste matters, which latter by uniting with oxygen be-
come changed into uric acid  and urea, and are excreted as  such.
In  fact the liver is  the great  storehouse  of fuel, Avhere the
products of food are garnered and given off  according to the
requirements of the system.   This glycogen is gradually given
off  and is  reconverted  into  sugar, and  then  burnt  up in the
body ; producing in its oxidation  carbonic acid and water, and
evolving in its combustion  mechanical results  and heat.  In
ordinary and  healthy  individuals the  sugar so furnished to
the blood is perfectly consumed ;  but in others such is not the
case.   Persons may Avaste to  death, and yet  no sugar sIioav  itself
in the urine; at other  times sugar may be found in the urine
in persons in  perfect health.  The youthful  reader must not
imagine that because he has detected sugar in a patient's urine,
that therefore the sugar-producing individual is going to die;
or even necessarily be ill.  If a person be obviously very ill and 
202
DIABETES.
AA'asting, and sugar be found in the urine, then its appearance is
ominous.
   In order  to comprehend pretty fairly  the importance of
sugar-laden  urine,  Ave must review the circumstances  under
which glycosuria is produced.  In many cases it  is only found
shortly after meals, and is absent during  fasting.   Here the
sugar Avhich  should be stored up  in a glycogenous form  is but
imperfectly  restrained from entering the  general  circulation,
and  there is an excess at one time with deficiency  following
after.  In such cases the liver is  but imperfectly functionally
operative.  At other times  there is some irritation at the roots
of the pneumogastric nerves, as  in Bernard's experiments of
puncturing  the floor of  the fourth  ventricle, or in  the cases
related by George Ilarley and Dickenson of diabetes  the result
of excessive brain-labor.   The formation and garnering of gly-
cogen is connected with the portal vein ; its disengagement and
restoration to the blood are associated Avith  the hepatic artery.
When the hepatic artery  is  dilated, sugar is quickly given off in
large quantities from  the  liver  stores.  By such  mechanism
irritation of  the vagus produces  an excessive amount of sugar
in the blood.  Conditions  of high arterial tension,  causing a
rise of pressure in the hepatic artery, give rise to an  excessive
disengagement of sugar.   Consequently  glycosuria is  very com-
mon in persons suffering from Bright's disease, and in  con-
ditions Avhere the blood-pressure is raised temporarily, as in the
accession of cold in early Avinter.   In this last form it  is usually
connected with a sedentary occupation ; if active  exercise be
taken in the cold the sugar is burnt up, and in doing so raises
so much  body heat. In  other persons again glycosuria  is the
consequence of simple excessive formation  of glycogen, or of
sugar not converted into glycogen, beyond the necessities of the
system, Avithout  conversion into and  development  of fat, in
Avhich case it drains aAvay  in the urine  and is only discovered
by  accident.   In  some   cases  it  folloAvs the consumption of
certain articles of diet and passes a\vay when they are given up.
In all these cases the presence of  sugar in the urine is compara-
tively unimportant.
  A much more serious matter  is  diabetes, the result of in-
capacity of the livTer to   transmute the sugar in the blood of
the portal vein into glycogen, so that  it remains in  the blood 
DIABETES.
263
 as sugar ;  or of loss of capacity to oxidize the sugar assimilated,
 from  some  peculiarity  in the sugar itself, or  other  cause, or
 Avhere there is defective  assimilation.   In  such cases there  is
 muscular Aveariness, the result of defective combustion of suo-ar
 in the  muscles; Avhere it  is normally  burnt  up, after  beino-
 broken  up into lactic acid  and oxidized as a lactate of the
 alkalies, chiefly  of soda.  There  is much Avasting, because the
 body  temperature and muscular action (mechanical results)
 must  be maintained by the  combustion of other hydrocarbon-
 aceous material, as the stored-up fat of the body.   There is much
 thirst from the presence of sugar in the blood in large quantities;
 and the bulk of urine is large, for the sugar in solution by this
 means is got rid of.  It is, however, much better that the sugar
 be so got rid of,  when in the blood, than if it were not so elimi-
 nated.   It  is not the presence of sugar in the  urine—though
 of course it is a  Avaste of raAV material—Avhich should occasion
 anxiety; it  is the circumstances under Avhich sugar so shoAvs
 itself  that  should  excite  our apprehension.  The loss of body-
 weight  is  often  more important than the presence of sugar in
 the urine.
   There is much investigation yet required on the subject of
 the different ferments in  the body  by  which, among  other
 actions,  the sugar given off by the lhTer into the general circu-
 lation is broken up into lactic acid.  These ferments are found
 most  largely in  the pancreas, and probably thence find their
 way into the  portal  circulation.  They also  exist  in muscle.
 Lauder Brunton thinks Avhen diabetes arises from lessened com-
 bustion  rather than  from  increased  formation  of sugar,  it is
 caused by three different factors.  " It is," he says, "due either
 {a) to  insufficiency of the ferment Avhich should convert  the
 sugar into lactic acid and  glycerine, {(>)  to an altered quality of
 the sugar, Avhich enables it to resist the  action of the ferment,
 or {c)  to diminished circulation through the muscles, preventing
 the sugar  from  coming  sufficiently  into  contact with the
 ferment."
  At times sugar is found  in urine that is albuminous.  This
 may be the result of some  nerve irritation standing in a causal
 relation  to  both.  At other  times  they are found  together
towards  the  close of chronic  renal disease, Avhere the patient
begins to Avaste ;  and in such cases a fatal result  is usually not 
261
DIABETES.
far distant.   Whether the elimination of sugar in the course
of time produces organic changes in the kidney, or disease in
the kidney permits of the sugar  in the  blood draining away
and  so  being  lost, it  is not yet possible  to  say.  Certain it is
that the tAvo  are commonly found together.   Sometimes  the
indications so given  are of the worst  import; at other times
they form no serious  omen.  It  is of  much importance  to
examine the  urine of patients in the latter stages of chronic
Bright's disease for sugar; and if it be found the prognosis is
very bad.
   § 103. In the treatment of diabetes there are many points to
be attended to.   Too commonly it is thought sufficient to put
the patient on gluten-bread, and cut down the consumption of
saccharine and farinaceous material to  the minimum.  Doubt-
less  it  is very desirable  to give  the  patient food that he  can
oxidize; and to  relieve  him from the sugar  which is no longer
useful  to him, but Avhich entails  upon him  thirst and other
troubles ; but there are other important points to  be attended
to.  The  skin should be  kept Avarm,  and  the circulation of
blood in  the  cutaneous vessels be well maintained.  By  such
means  the blood-pressure is lowered  and the disengagement of
glycogen diminishes.  Exercise is a good means of securing this
end, and should be combined with warm clothing.  Exercise,
too, brings the  blood freely to muscles, and  Avith it brings the
sugar more in contact Avith  the ferments in the muscle.  The
late Dr. William Richardson, Avho had a personal experience
of diabetes, found exercise to be the most  efficient treatment
of his own case.  It required  great determination in the face
of the existing languor  to continue to make  muscular efforts,
but the results  Avere  very satisfactory.   " To  carry into effect
regular and sustained daily exercise,"  he says, "requires great
moral  courage and energy, the  languor  and  weariness are so
great;  but, if the exercise be only carried  out patiently  and
perseveringly, the task  Avill not  only  become more and  more
easy, but soon no longer a task, but positively a pleasure."   The
glycosuria of a sedentary, intellectual life  may  possibly be
nothing more than unconsumed sugar  draining aAvay.   At the
same time that exercise and a warm skin loAver the blood pres-
sure in  the hepatic  artery, it must  not  be  forgotten  that the
thirst of diabetes, Avhile it secures plenty of fluids to Avash out 
DIABETES.
265
the sugar  in  the blood, also fills the  bloodvessels Avith water,
and  so increases the general blood-pressure; and with it the
pressure in the hepatic artery.  It is certainly desirable that the
consumption of fluids when very great should be moderated.
  The diet  should consist of  meat, especially  fat  meat,1 of
vegetables not containing starch, of various breads and biscuits,
prepared by several makers, of dry Avines, and spirits and Avater
instead of malt beverages.   The different alkaline Avaters, natu-
ral or artificial, are also very useful.   The skim-milk treatment
suits some cases admirably, but butter-milk is even better;  and
in rural districts Avhere butter-milk is procurable it should form
a staple of the dietary.  Koumiss is also  a suitable  beverage
The lactic acid of milk so  treated is an oxidizable food, and so
is useful to the  diabetic patient.
  Of the remedial treatment of diabetes much  may be  said.
The plans of treatment  are various.  Some  give  large doses
of arsenic; others pin their faith on alkalies ; Avhile Avith  most
it is the practice to give opium, or its principle, codeia.  Opium
may be given in half-grain  doses three times a day to commence
with, and the dose may be  gradually increased.   Codeia may be
given in similar doses, or even as far as five grains three times
a day.  These sedatives are specially suited to those cases Avhich
are dependent upon some nerve irritation.   George  Harley pre-
fers conia as  his remedy Avhen  the  irritation is  in the pneumo-
gastric.  It is quite possible that the action of opium upon the
skin is very  useful  in many cases ; and  this action may be-
aided by Turkish or other  warm baths.  Attempts  have been
made to directly oxidize the sugar by giving peroxide of hydro-
gen (ozonic ether) Avith some success.
  Iodide of iron, combinations of quinine and  iron, and other
tonics  are often indicated  ; and  the diabetic patient may be
treated on general principles Avith  advantage at times, Avhile
his special malady is met  by appropriate diet merely.  Tonics
and cod-liver oil are  as good  for  him  as  for others suffering
from Avasting disease.  If the nutrition fails on  a too restricted
diet, modify it by all means.   It is of  no use to  kill a patient
or make  him  worse in well-meant but unfortunate attempts

  1 Particularly in the glycosuria of the lithremic, where the waste products of
nitrogenized foods will themselves be a source of trouble. 
266
RHEUMATISM.
to do him good ; and in the treatment of diabetes it  is of the
greatest moment to  watch and  follow the indications of each
individual case.
  The dietary of diabetic patients  is not to  be  laid  down by
rule  of thumb.  If the patient wastes on any dietary, then that
dietary should be altered.  AVasting is the index for treatment
rather than the amount of sugar  in the urine.   In one case,
which came before  me  lately, sugar was accidentally  found in
the urine.  The patient felt well, but nevertheless he went to a
Avell-knoAvn authority on diabetes, who put him on a rigid
dietary.  On this he wasted rapidly ; and became so ill that he
returned to his ordinary food, farinaceous and saccharine.  On
this  he quickly improved, became hale and strong, and has re-
mained so for twelve years.   A certain amount of glycosuria is
common  with stout  persons, and is probably  merely a sort of
" Avaste-pipe" getting rid of superfluous food.
  § 101.  Rheumatism.—It is somewhat  depressing  to have to
acknowledge that very  little is  known about the pathology of
rheumatism.  Considering how common acute rheumatism is,
and  Iioav general  it  is  to denominate all pains Avhich  are per-
sistent and yet unaccompanied  by general constitutional  dis-
turbance " rheumatism," it seems strange that Ave  should have
so little real  knowledge as to its causation.  As  to acute rheu-
matism,  it is a fairly  Avell-defined disease.   As  to "rheuma-
tism," it covers an immense range of pains, extending from the
lightning pains of locomotor ataxy to the periosteal affections
caused by  syphilis.   The term  " rheumatism" ought  to be ex-
punged from our vocabulary.   It  is a great  comfort to those
who  are diagnostically weak;  and has  given a  false sense of
security  in many grave diseases, and tended to hide the real
nature of  the  malady.  As to the use of the  term by non-
professional  people,  it  is excusable; they  are  not  expected
to knoAv  better; they  use it  in ignorance,  but Avith perfect
bona-fides.
  There  are  no means  of ascertaining how much of so-called
rheumatism, and especially articular and muscular rheumatism,
is gout, or  rather lithiasis.  The people Avho have  accumulations
of uric acid in their blood and tissues, are persons who  complain
of rheumatic pains.   After long  and careful consideration of the
matter, it becomes more and  more difficult to distinguish any 
RHEUMATISM.
267
 differential characteristics  betwixt chronic  rheumatism  and
 lithiasis.   In symptoms, in prognosis,  and in treatment, they
 are  identical, and  the question  resolves itself into a choice  of
 terms; and in this respect  rheumatism carries the preference.
 Lithiasis,  and still more the term " gout," at once  arouses a
 Philistine opposition; it savors of good  living and self-indul-
 gence—tAvo things which many instinctively turn aAvay from  in
 speech—and turn  towards in practice.  Any allusion to gout
 is in itself sufficient  to cause many persons to  seek another
 medical adviser, who will be discreet enough  not to give objec-
 tionable names to painful maladies.  Rheumatism is innocent
 and free from suggestiveness, and consequently holds its ground ;
 indeed is  rather a general  favorite.  Rheumatism as a malady
 is supposed to stand  in a certain  relationship to lactic acid.1
 When glycogen is given off into  the general circulation, it is
 converted  back again into sugar.   This sugar  is broken up into
 lactic acid, Avhich unites Avith  the alkalies  in the  body, and
 forms lactates.  Headland supposed that it is the oxidation  of
 lactates Avhich gives rise to  the  body heat,  and  these views are
 borne out  by the researches of LudAvig and  others.   Each mole-
 cule of soda burns off many different relays of  lactic acid during
 its residence  in  the organism.  Prout evolved  the idea that
 rheumatism was connected Avith lactic acid, and B.  W. Richard-
 son folloAved up the idea by giving lactic acid  to dogs, injecting
 it into the peritoneum, and  found endocarditis to follow.   The
 proof is insufficient, but is enough to give an  air of probability
 to the hypothesis ;  for Balthazar Foster  found  acute rheumatism
 produced  by  medicinal  doses of lactic acid  given to diabetic
 patients.   Rheumatism  must  be considered in relation  to its
 acute form and its chronic form.
   § 105. Acute Rheumatism, or Rheumatic Fever, as it is called,
 is a very common  malady, and though  rarely fatal at once, is
 very frequently the cause of early death  from its effects upon
 the heart.  The different joints and the outer and inner surfaces
 of the heart are  the seats of inflammation  in rheumatic fever.
 There are—as in gout—localized inflammations associated with

  1 That there is also a nervous factor is maintained  by some, and the spinal
arthropathies  of Weir Mitchell would by most practitioners be unhesitatingly
classed as rheumatism. 
268
RHEUMATISM.
a general  condition.  Another point connected Avith rheumatic
fever is this, if the action going  on in one  part  is checked,
increase in the action elsewhere is very liable to occur; i.e., if
the inflamed joints are wrapped in  cold lotions, the cardiac com-
plications Avill be increased ;  or induced, if not already existing.
  There is much  difference of  opinion as to the  measures to be
adopted in the treatment of rheumatic fever.  Up to a recent
period this malady  very commonly persisted for fifteen or
tAventy weeks,  leaving the patient a Avreck, and often a cripple
as well, in spite of every measure:  now it takes itself off on  the
slightest summons—mint-Avater being sufficient to dislodge it,
according  to some Avriters.    For my  oavu part, the alkaline
treatment  appears  to be  the best  one,  and furnishes the best
results. It is well to commence the treatment in this fashion :—
                      Pot. IJicarb. gr. xxx.
                      Tinct.  Opii, Tfl.xv.
                      Inf. Buchu, 3j.
every  four or  six hours, varying the  dose according to  the
patient's age, sex, and bulk.   To this may be added :—
                      Pulv. Opii, gr. H,
                      Pulv. Al. Co.  gr. v.

every  night  at bedtime; or  ten  grains of  Dover's poAvder.
There is much doubt existing as to Avhether colchicum is of
use in the  treatment of acute rheumatism or not.  There should
be a liberal supply of milk  and seltzer-water, as  the thirst is
great and the temperature often very high.   Indeed, the high
temperature and the profuse  perspiration  are often alluded to
as sufficient to excite  surprise.   The  question  is really how
much  higher would the  temperature be if it Avere not for  the
perspiration?   Probably  so  high  as to  be incompatible with
the continuation of the  existence of the organism.  The per-
spiration is often intensely sour, and this sourness is perceptible
to the olfactory organs.   The urine is often laden Avith urates,
probably to some extent  the  result of  the effect of the high
temperature upon  the  muscular  structures.  There  are some
points to  be attended to, and others to be kept in mind and
avoided, in the treatment of  acute  rheumatism.   The first is
to keep the patient in blankets—no sheets.  Next, to put him
or her into a woollen garment, as a woollen night-dress—amidst 
RHEUMATISM.
269
 the poor the flannel  shirt of a male relative is a capital thing.
 Then all movement  is to be avoided ; consequently it is not
 desirable to cause free purgation.   Nothing can  be Avorse than
 exposure of the thorax, and unnecessarily repeated examination
 of the chest is  to be  reprobated.  Physical examination is not
 often productive of good, and tends to turn the attention aAvay
 from the real  needs  and necessities of the case.  It is often
 directly  productive of harm.   In  my experience diagnostic
 inquisitiveness has  often stood in  an inverse ratio to a rational
 plan of treatment:  in Vienna it may be seen in its most highly-
 developed form.  It  is not confined to Vienna, however, and
 the treatment of acute rheumatism in this country needs much
 modification.   Every  examination as to the condition of the
 heart should be conducted Avith the least possible disturbance
 to the patient, and  with the very least exposure to  the chest,
 and  the  search  after obscure murmurs which  may  be  proper
 enough in a teaching hospital is not often required elsewhere.
 The  chest should be Avell covered, and if any pain be  felt in the
 neighborhood  of the  heart, or a murmur be heard, hot linseed-
 meal poultices should  be placed, over the whole of the front of
 the chest and kept there constantly, being repeated at frequent
 intervals ; each  change being effected  with the least possible
 disturbance of the patient.  The painful joints should be wrapped
 up in cotton-wool, or kept in flannel saturated with alkaline solu-
 tions, always as warm as can be  borne, or as circumstances will
 permit.   Such is the line of treatment to be pursued.   Warmth
 and quiet are the two things to  be aimed at.  If there be peri-
 carditis it is quite unnecessary to  give calomel, or any prepara-
 tion  of mercury. Large doses of opium are tolerated especially
 when given along with  alkalies,  and the action of  opium on
 the skin  is almost as important as  are its analgesic properties.
  When  the pains  are somewhat subdued the  opium may  be
 Avithdrawn.  After a Avhile the  dose of potash may be reduced
 and a feAV grains of iron added :—
                   Pot. Bicarb, gr. xv.
                   Fer. Am. Cit. gr.  v.
                   Inf. Quass. 3J.,
three or  four  times a day, is a good  combination  when the
brunt of  the malady is over.   This plan of making the alkaline
treatment and that of haematic  chalybeates overlap each other 
270
RHEUMATISM.
 is often very useful in practice ;  and should  form a rule for
 ordinary use.  In  one case where the  heart had been  already
 injured in a previous attack of acute rheumatism, the addition
 of digitalis to the  remedies produced an improvement at once.
 Its use under such  circumstances  is clearly indicated, especially
 if the lips be blue.
   If the  subject of rheumatic fever be  delicate, or  of the
 strumous diathesis, it  is a good  plan to continue  the combi-
 nation  of alkalies  and iron for some weeks; and to give cod-
 liver oil, liberal  supplies of food, especially hydro-carbonaceous,
 and to keep the  body Avell clad  in flannel.  A change to the
 seaside may be useful; but the diet and clothing must be doubly
 attended  to then.   By such means the troublesome affection of
 the  small joints, known as  rheumatic gout, may be usually
 avoided,—and that is no small matter for the patient. Next to
 the alkaline the blistering treatment of Herbert  Davis is most
 Avorthy of  confidence  in  acute rheumatism.   If  the  mitral
 Active be injured, a  course of digitalis and iron combined should
 be commenced Avith at once, general quiet  being observed ; and
 the  plan  should be continued for Aveeks or months.  By such
 means the ventricle may be brought back to its normal dimen-
 sions, the vaWes may  once  more be  competent to close the
 ostium, the murmur may disappear, and the patient may  be to
 all intents and purposes cured—except that the mitral valve has
 lost  its  spare or redundant  closing  power, and in any future
 dilatation of the left ventricle Avill  readily become insufficient.
 No amount of dilatation will  render the valve incompetent, if
 its valvular vela are not restrained by pathological connective
 tissue from  themselves stretching  along with the dilated ven-
 tricle (Rokitanski).  Often  the murmur is lost  after rheumatic
 fever, and only reappears when dilatation of the left ventricular
 chamber Avith enlargement of the auriculo-ventricular ostium
 has revealed the insufficiency in the valves ; which  have  been
 injured  by the fever, but were equal to closure of the ostium
prior to the dilatation.
  § 106. Chronic Rheumatism.—This term is applied to  many
forms of pain unaccompanied by general constitutional disturb-
ance.  In its more  precise  sense  it includes a series of pains
confined to the limbs and  the shoulder and  pelvic  girdles.
Lumbar pains are either gouty or rnyalgic usually.   Rheumatic 
RHEUMATISM.
271
 pains are felt  in joints, in muscles or their fasciae.  They are
 persistent and unintermitting.  In  this  they differ from  the
 gusty intermitting pains of true neuralgia.  Frequently they
 cover a certain area—not being the part over which any nerve
 is distributed,  nor possessing any natural boundaries.
   Rheumatic pains also depend much on changes of temperature,
 and are common in parts  that have been chilled by exposure.
 The thigh especially exposed to the rain  during a stormy ride,
 or the shoulder Avhich is in a draught, are the common  seats of
 chronic  rheumatic pains.   If the pains  are  restricted  to  the
 collar-bone, humerus, and the shin, they  suggest the probability
 of a syphilitic  factor.   When instantaneous they are ataxic.
   When, then, we have  such pains as  come fairly under  the
 category of chronic rheumatism, the next  question is  that of
 the  remedial  measures to be  employed.  One thing is pretty
 certain about  the class of cases iioav under consideration, and
 that is, they are almost invariably accompanied by  an inactive
 condition of skin.  Consequently a distinct part of the treat-
 ment includes diaphoretic remedies, and especially stimulant
 diaphoretics.   Guaiacum is perhaps the most typical of these.
 Muriate of  ammonia is another.  They  form an excellent com-
 bination in  the rheumatism of young men and women :—
               Am. Chlor. gr. xv,
               Mist. Guaiaci, ^j., ter aut quater in die,
 often give  excellent  results.   Whenever  there is a history of
 exposure in  elderly persons, especially Avhen  associated with
 florid complexions, guaiac with potash is good:—
               Pot. Bicarb,  gr. x.
               Pot. Iod. gr. v.
               Mist. Guaiaci, 3j'., ter aut quater in die,

 is a capital remedy.  At the same time  the skin must  be kept
 Avarm and covered Avith flannel.  Warm drinks are indicated,
 and  should  largely take the  [dace of solid food.   It  is  also
 desirable to give  some diaphoretic at  bedtime.   The  poAvder
given in § 105  is often useful.  If the  liver be loaded, then a
grain and a half of opium in four grains of Plummer's pill is
indicated, to be followed by  a draught of  alkaline purgative
water next morning.   By such means faulty7 assimilation is cor-
rected.  At  other times the following may seem indicated:— 
272
RHEUMATISM.
                   Pot. Bicarb, gr. x.
                   Pot. Iod. gr. v.
                   Tinct. Sem. Colchici, Tfl.x.
                   Inf. Cascarilhe, £']., ter in die.
In all cases a good  draught of Avater should be taken after the
medicine ; it not only serves to wash  it down, but it  fulfils a
very important function in the economy. Whenever,as remarked
before, alkalies are given either along Avith, or Avithout, chaly-
beates, free dilution is ever  desirable.   In speaking of chronic
rheumatism  the late  Dr.  Fuller Avrote:  "There cannot  be a
doubt  that  free  dilution exercises a most important influence
on the action of almost all the remedies Avhich prove useful in
this  class of  disorders, and  that a  dose Avhich would excite
nausea and  irritation of  the stomach  when  taken in a concen-
trated  form, is often productive of excellent results Avhen aided
in its action by water.  Hence, probably, the Avonderful efficacy
of the natural  mineral Avaters;  and  hence, also, the superior
effects Avhich often ensue after taking the  weak  infusions or
teas  Avhich are the favorite remedies of the poor and the nostrum
of so-called herbalists.  I am firmly convinced  that our  medi-
cines frequently fail in their  operation for lack  of sufficient
dilution ; and although I do not counsel  their administration
in an  inconveniently  bulky form, I do most strongly urge the
taking of a copious draught of  water, or some harmless diluent,
after each dose  of the remedy."  The remembrance of  this
counsel has often stood me in good stead in practice; and amidst
my out-patients  it is  my  habitual practice to order and  insist
upon such draught of Avater after each  dose.  Whenever the
means of the patient admit of it, natural waters should be freely
taken—Vals, Vichy, Carlsbad, or Buxton waters are all suitable;
and  with them the bitter water of Fredericshall, or Marienbad
Avaters, may be taken in the morning as  laxatives.  Very fre-
quently barley-water and bitartrate of potash  (§j. to the Oij.)
may  be  drunk Avith advantage.   In  very  chronic  cases  this
combination may be taken along Avith the well-knoAvn  remedy,
" the Chelsea Pensioner."  Its  formula is as folloAvs:—
                   " Flowers of Sulphur, ^ij.
                    Cream of Tartar, 5J.
                    Powdered Rhubarb, 3ij.
                    Guaiacum, 3j.
                    Clarified honey, lb. j.
                    One nutmeg finely powdered. 
RHEUMATISM.                    273
Mix the ingredients.   Two large teaspoonfuls to be taken night
and  morning." (Fuller.)  When in practice in  Westmoreland,
where chronic rheumatism is very prevalent, it occurred to me
to combine arsenic Avith guaiacum instead of the sulphur, whose
diaphoretic  poAvers are unquestionable.  The  results Avere very
satisfactory.   My formula runs so :—
                   Ac. Arsenic, gr. iij.
                   Pulv.  Guaiaci, 5iij.
                   Pulv. Capsici, ^ss.
                   Pil. Al. et Myrrh, giij.
                   In Pil. cxx. div.  1 bis in die.
This is a convenient form  in a chronic case. The value of fatty
food in the treatment of these cases should never be forgotten,
and  if necessary  cod-liver  oil even should be given.  The com-
binations of  iron Avith alkalies given  before (Chapter II.  § 21)
may often be resorted to  Avith advantage when the pains are
distinctly diminished, and improvement of the general health
is indicated.
   In addition to the general measures it is  customary to use
local applications in the treatment of chronic rheumatism.  The
most favorite of these consists of the  application of hot irons,
plasters, and liniments.   The  Emplast. roborans, Emp.  opii, or
Emp. ammoniaci c. hyd.  are good  plasters, Avhich  the  shreAvd
practitioner  will do well  not to discard.  At  other times lini-
ments, as the lin. sapo. co. Avith iodide of potassium, are far from
useless.  When the pain is chiefly confined to  the sciatic nerve,
whether it be rheumatic, gouty, or truly neuralgic, the folloAv-
ing is very satisfactory:—
                       Lin. Aconit. gij.
                       Lin. Belladonnas, .^ij.
                       Glycerine ad ^ij. ;
or it is  even better if treacle  be substituted for the glycerine.
This should  be spread upon a long V-shapel piece of lint, and
placed upon  the  thigh.   Over it should  be laid a piece of oil-
silk, large enough to overlap the lint, and then the Avhole should
be kept in its place byr a bandage, or a  stocking from which the
foot  has been  removed.   This should be done every night at
bedtime.  The lint  should not be  removed  every  night, the
repeated saturation of it by the liniment renders it more povver-
       18 
271
GOUT.
ful and efficacious.  In using this potent  measure care must be
exercised  to  see that  the skin is Avhole, else  dangerous absorp.
tion  may take place.   One great  object of our aim in the treat-
ment of chronic rheumatism is to excite the action of the skin.
By this means the lactic acid is got rid of.   Alkalies are very
useful in  uniting Avith it and so procuring its elimination, by
oxidation or otherwise.  The use of local analgesics is obvious.
When these measures fail or are but partially  successful, change
of air is most desirable.  The effects of such  change, especially
when it can be combined with alkaline Avaters, both as beverages
and as baths, are often very satisfactory.
  It  is always desirable to maintain the action of the  skin by
the  use of Avarm clothing ; and  the rheumatic person should
be clad from  top  to  toe in flannel, or even  in what is termed
" fleecy hosiery," or in chamois leather.   By  these measures an
existence  may be rendered tolerable Avhich would othenvise be
simply insufferable.
  Recently I have tried a " movement cure" for chronic rheu-
matism Avith  stiffness, and when the deltoid is too sore to permit
of the patient lying  on it  in  bed.   Here the  arm  should  he
grasped by the elboAv  or  Avrist, and moved in various directions,
Avhile the left hand is engaged in kneading the  muscles, especially
the deltoid.   At first the movement is very painful, but soon
becomes  less so.  Adhesions  will be heard  to crack, and  the
patient can  move  the arm more freely and Avith  less pain.
This should be  continued for ten minutes; stopping whenever
the muscles  are throAvn  into spasm.   This  treatment  is very
painful to the sufferer and is not light work for the operator;
but of its efficiency no doubt can be entertained.   TAvice daily
the movements and the massage  should be continued until nor-
mal painless movement is attained.  This treatment has a great
future before it.
  § 107.  Gout.—This  affection is much better understood than
the immediately foregoing  complaint.  Its nature  is hoAvever
much obscured,  and the proper comprehension of it hindered by
preconceived impressions and prejudices.   From its association
with good living and the habits of " the  Regency," there is a
very  decided impression in the  minds of many persons that
gout  indicates some  self-indulgence ; if not  ostensible, all  the
worse; or a  descent incompatible Avith their surroundings—a 
GOUT.
275
 still more objectionable matter.  It is highly desirable that the
 term " gout" be confined to ostensible ailments in the upper and
 lower  extremities, and that  the term " lithiasis,n be preferred
 for other maladies taking their origin  in the presence of  lithic
 or uric acid.  "Irregular," "suppressed,"or "latent" and "retro-
 cedent," are adjectives Avhich are  applied  to  gout, and which
 explain, to  some extent, the  peculiarities  of  each case.   It is
 obvious  enough  that  Avhen ailments  depend  upon a certain
 materies  morbi circulating in  the blood  and fluids of the  body,
 they Avill  be both  numerous and  Protean.   Consequently it
 Avould be much better to use the term lithiasis to signify the
 general condition on Avhich the malady depends.   Being a com-
 paratively  new term,  it  will not possess the  disadvantages of
 having any preconceived opinions  about it  to create objections
 or wrong impressions.   It will carry a  correct  conception  of the
 condition, viz., that it is a saturation  of the  body fluids Avith
 nitrogenized Avaste,  in its most persistent form—lithic or uric
 acid.  Such being the case, it may manifest itself as muscular
 rheumatism (so-called), as a skin  eruption, as  dyspepsia, bron-
 chitis, or inflammation of a serous membrane, as Avell as  affec-
 tions of the articulations.
  We  are  much indebted  to Professor Garrocl (late of King's
 College)  for a more accurate knowledge of the nature of  gout.
 Uric acid calculi, and the  composition of " chalkstones" (urate
 of soda) had prepared  us for the announcement that  in gouty
 conditions  the blood  contains uric acid.   The amount of uric
 acid in the urine previous to and in the early stages of an  acute
 attack of gout  is much  diminished.  " At the time  that the
 urine is deficient in this principle  it exists  in the  blood in
 abnormal quantities."   "In chronic gout the blood, even in the
 intervals between the exacerbations, Avas  ahvays rich in uric
 acid."  Such are the expressions of  Garrod.  Since the patho-
 logy of lithiasis, or gout,  has  been  cleared up, a great improve-
 ment has taken  place in our remedial measures.  As yet, how-
 ever, Ave  do not quite  knoAv hoAV far the accumulation of uric
acid  in the blood is due  to imperfect  oxidation ; to  impaired
renal activity; or to  diminished action of the skin.  Recent
obserA^ations  would  tend  to lead to the opinion that  defective
Murchison used the term "lithaemia." 
271!
GOUT.
action of the skin may not  be Avithout effect in the accumu-
lation of nitrogenized  waste  in  the  system  where there is
inadequate renal action (p. 74).  In the subjects of chronic renal
changes  it is quite common to find an inactive  and dry skin.
Potash, especially, as iodide of potassium, passes off by the skin
as Avell as by the kidneys.  It also renders  uric acid  highly
soluble;  and as uric acid has a  stronger affinity for potash than
for soda  or  ammonia,  its  administration  converts sparingly
soluble urates into a highly soluble  urate of potash.  When so
dissolved, uric  acid  finds  its way  out of the body by  every
emunctory of water.  Lithia alone excels potash in its power
to render uric acid and urates soluble.
   § 108.  Before, however, we can proceed  further in the con-
sideration of lithiasis, it becomes absolutely necessary to  run
over  its most common  manifestations.  The  matter has been
alluded to before, in Chap. III., but it must be considered again
at the risk of some  reiteration ; as  its  right  comprehension is
a matter of the utmost importance in the proper  recognition of
the multitudinous ailments of advanced life.
   Firstly, excess of uric acid does not  necessarily depend upon
very  high living.  This idea must  be dispelled.   At the same
time  it can be, and very often is, so originated.  At other times
it takes its  origin in imperfect  oxidation of the nitrogenized
matter which results from the splitting  up  of  peptones  in  the
liver  into glycogen  and waste azotized matters.  Very com-
monly it is the consequence of impaired functional activity in
the kidneys ; not, perhaps, necessarily due to structural changes,
but still commonly so associated.1   Consequently, lithiasis may
shoAv itself in a working Avoman (as  in a patient long under  care
at the West London Plospital) as Avell  as in a wealthy squire.
AVhatever the difference in the causation the result is the same,
viz.,  an  excess of uric acid  in the  system.   It will  not neces-
sarily follow that the treatment Avill  not  be  modified by the
mode of origin:  far from it, it Avill vary very much with the

   1 Garrod "noticed the constant occurrence of a morbid state of the kidneys in
advanced gout," and from a series of  observations "was then enabled to speak
more positively on the subject, and to show that, even  in the slighter forms and
early stages of gout, the renal organs sometimes become seriously implicated."—
Pp. 195-199, 3d edit. 1870. 
GOUT.
277
causation of the condition.   In the squire, colchicum, partial
starvation, and free purgation with  alkaline salines, will  pro-
bably form  the first line of attack.  In a working  seamstress
potash Avith iron, Avell diluted Avith water, and cod-liver oil, will
be the measures most indicated.
  Nextly,  lithiasis may  manifest itself  in  the articulations.
This is its best known  form.   Xot uncommonly the  local depo-
sition of uric acid as  urate of soda, leads to  much  deformity,
and not  rarely to the formation of abscesses Avhere  the pus is
highly charged Avith urate of soda.  At other times there is
effusion  into joints, especially the larger ones, Avith modifica-
tions of  the synovial membrane.  At other times the ligaments
become  infiltrated Avith  lithic  acid,  and  become  rigid  and
immovable, entailing much loss, or even  abolition, of move-
ment in  a joint.  At  other times, tophi, or chalkstones, form
elseAvhere, as  on  the helix of the ear.  Microscopically these
consist of crystals of uric acid in  combination with a base,
usually  soda.  These  external  changes, recognizable  by  the
eye, often furnish the diagnosis of the  malady  before any more
special investigation is commenced, and ahvays give indica-
tions for treatment.  Xot uncommonly the lobe of the ear gives
evidences of a tendency to lithiasis; it  is full, glistening, and
red, and  seems, in very marked cases, to be on the point of
bursting, so  tight is the skin.  Affections of the  respiratory
organs are very  frequent, bronchitis  being the most common
manifestation of gout  next to arthritis.   In  winter there is
usually more or less of it, and the bronchial lining  membrane
becomes  an excretory organ Avhen the fall of temperature checks
the  action of the skin.   Attacks of  dyspnoea,  the result of
bronchial spasm,  are also  not unfrequent.  Even pneumonia
may have a gouty origin.  The organs  of  the circulation  are
very commonly affected, and  attacks of palpitation  and inter-
mittency of the pulse are commonly the result of lithiasis.  The
changes  in the circulation  are so distinct and  well  marked in
chronic  renal disease,  where  a condition  of  lithiasis  almost
necessarily obtains, that the affections  of the symptoms patho-
logically  associated Avith such renal change, will be given at
length in a future chapter (Chap. XIV. § 143).   The brain and
nervous  system generally are also affected in lithiasis;  and
vertical  headache  is often very  suggestive  in atonic cases. 
278
GOUT.
There  are also psychical changes  very commonly found  in
chronic latent gout.   They  consist  of a certain  amount  of
brain activity Avith irritability  out of all  proportion  to the
exciting  causes,  together  with depression.   These   mental
symptoms are usually present, and  should  ahvays be inquired
into; and Avhen found are very suggestive.  Neuralgia  is very
common .in lithiasis.  Such neuralgias are found  in advanced
life, and are very  intractable, especially  if their systemic  asso-
ciations be forgotten.   Serous membranes are A^ery liable  to
become inflamed in latent gout.  At times there  is no effusion
as in the dry pleurisy, often denominated pleurodynia. Mucous
membranes, bronchial, intestinal, and vesical, are  all  apt  to
become inflamed from the presence of  uric acid in excess in the
fluids of the body.  Affections of  the skin are  frequently  of
gouty  origin;  eczema,  prurigo,  and  psoriasis, are the forms
most commonly met Avith.  Boils and carbuncles  are supposed
by the Germans to be common in the subjects of lithiasis.  The
changes in the kidneys  are  the casual  associations very com-
monly  of  lithiasis; and in well-marked cases the kidneys are
always involved.   There is a liberal elimination of AA^ater, which
is, however, usually of low specific  gravity.  It  may at times
contain small quantities of albumen, but this is mostly  absent.
In  fact Ave may see  that  such a condition of the fluids of the
body can originate the most varied ailments, and of all maladies
lithiasis is undoubtedly the most Protean.  No matter Avhat the
outward form, the iinvard thing is ever the same, and the line
of treatment is to  remove the uric acid, though the necessities
of different cases  may call for modifications in  the plans for
doing so.  Again and again in out-patient practice has it fallen
to my lot  to be successful  in the treatment of cases of dyspepsia
and bronchitis Avhich ha\Te resisted all  attempts to cure them by
such measures as bismuth mixture and expectorants, but which
have yielded  readily to fifteen grains of bicarbonate of potash
three times a day in a bitter infusion,  or infusion of Senega.
At other times cardiac  troubles of  an apparently alarming
character  have vanished at the solicitation of potash and  buchu.
Skin affections of an  obstinate  nature have likewise  passed
aAvay on  the  adoption of remedial measures Avhich struck at
once at the causation of the affection.   In affections depending
upon the presence  of uric acid more than in any other—unless, 
GOUT.
279
indeed, it be syphilis—is the mere recognition of the ostensible
malady subordinate and of secondary  importance to the clear
comprehension of the casual  relationships, for success in treat-
ment.  Careful attention to the  external indications, or what
haycock  calls physiognomical diagnosis, will enable the student,
especially if he be fortunate enough to see the matter practically
illustrated by some of Lay cock's  pupils, to distinguish .for him-
self by the eye many of the patients  who are  the  subjects of
lithiasis.   Such knowledge, when acquired, will  often light up
the nature of a case otherwise most obscure, and give indications
for successful treatment which would not,  and could not, be
furnished in any  other way.   Of  course  those  who have  not
learned to see these indications do not see them,  because, as the
Italian painters say, "the eye can  only see what it has learned
to see;"  it is, however, of much  importance that the teaching
of the eye in  these matters be  at once commenced, and  the
special education perseveringly pushed.  The knowledge  is well
worth the trouble of acquiring it.
   Surmising that such knowledge exists,  or is about to be
acquired, by the reader, and  that diagnostic power will  enable
the observer to select his cases—the question of the treatment
of them  Avill next engage our attention.
   § 109. Treatment of Lithiasis.—-This is a matter which  is  now
much more simple than it was in the days of Sir Charles Scuda-
more, for instance; though his work  is well worthy of perusal
yet bv those whose practice furnishes  them with many cases of
lithiasis, especially in its rarer manifestations.  There is present
in  the fluids, and often too in  the tissues, a distinct and well-
known product of retrograde tissue-metamorphosis and of excess
of peptones, viz., uric acid, possessing equally well-known  pro-
perties.  For some time before  an outbreak of  acute gout the
amount  of uric  acid  passed off by the kidneys is distinctly
diminished: but  it is  still  formed and retained in the body,
especially in the blood.1  It  saturates certain  tissues, especially
the articulations, and  then, at intervals, ensues a condition of
heightened temperature accompanied by severe  pain.  These
acute conditions are rather the cure than  the disease, however.
The effect of the high temperature is to reduce the uric acid into
1 Garrod, On Gout and Rheumatic Gout, 3d edit., 1876. 
280
GOUT.
urea and carbonic acid, and so to get rid of it.  In the language
of the late Pence Jones, for the time being the joints are con-
verted into supplementary kidneys.  There is a process of oxida-
tion going on in the tissues, which results in the perfect elimi-
nation of the morbid product and the restoration of  the action
of the joint in its integrity.  Again and again will such inflam-
matory storms pass  over a joint, leaving  it  unscathed and  un-
injured thereby.  In time, however, distinct  structural changes
result.  This  consideration is an important matter in relation to
treatment. Experience has long pronounced against  repressive
measures, having found them harmful and pernicious.  The
uric acid  must be got rid of; and  the more quickly the better,
the more slowly the  worse.  The inflammatory action, the high
temperature,  and the increased amount of oxygen  furnished  in
the highly vascular condition, is really essential to such removal.
Cold applications, though giving relief at the time, purchase it
at  the  cost  of  future  suffering.   Local  blood-letting, as  by
leeches, is still  more reprehensible.  Garrodsays:  "I have  fre-
quently seen  great toes stiffened after a few attacks, when local
depletion has been resorted  to;  and within the  last eighteen
months two remarkable cases, in which the patients have com-
pletely lost the use of both knee joints from tAvo or three attacks
only; in both instances  leeches had  been  applied very freely;
in one, more  than thirty to each joint.  I can with confidence
warn those engaged in the  treatment of an acutely inflamed
gouty joint never to have resort to this mode of combating  the
disease.  It would seem that the abstraction  of  blood  from  the
joint allows or favors the free deposition of urate of soda in  the
tissues, and thus the ligaments  become rigid, and anchylosis
results" (chap. x. 2d ed.). How different  is this from the prac-
tice requisite in an  ordinary inflammation of a joint!  There
local bleeding and cold applications are most desirable; in gouty
inflammation they are to be strenuously avoided.  The only
local treatment of service is to keep the joint at rest—the pain
occasioned by movement usually secures that  pretty Avell—to
keep it warm  in cotton-wool or  flannel, and, in addition,  the
application of warm solutions of potash or lithia may be  re-
sorted to.
   In acute gout this local  treatment is of  comparative unim-
portance ; the general treatment is the great  matter.  It is usual 
GOUT.
281
to commence with purgation of an active character.  This gives
relief to the general disturbance and loAvers the pyrexia.   For
such purpose it is  usual to resort to alkaline salines.  If the
tongue is  laden, the secretions foul, and the liver congested, a
pill containing  mercury Avith  vegetable aperients may be given
at bedtime, and be followed by a sharp cathartic in the morning,
as a black  draught, a seidlitz powder, or a dose of mineral Avater.
It is requisite, hoAvever, to be cautious about  the use of mer-
curials; in chronic  renal changes there  is much  intolerance of
both  mercury and  opium.  Consequently other  sedatives  are
given .in lieu of  opium, and  other cholagogues  than mercury.
The following is a good measure:—
                    Mag. Sulph. 3ij.
                    Pot. Bicarb, gr. xv.
                    Tinct. Sem. Colchici, Tfl. x.
                    Inf. Buchu, ^j.
every four or six hours. It should ahvays be followed by a large
draught of Avater, not too cold.  After free catharsis is induced,
then the  sulphate of magnesia may be omitted  in favor of a
cathartic at intervals.  The action of colchicum is  a  mystery
yet.   It does not increase the amount of solids in the urine, as
has been  thought:1 but it is  agreed that  it is most  efficacious
in the relief of acute paroxysms of gout.  An impression is
forming in  my mind that colchicum arrests the active symp-
toms; but in so doing favors  depositions in the joints.  Really
it appears to suppress the gout.   Consequently I never prescribe
it for private patients;  though  recognizing its value in  the
workman  Avho Avants immediate relief in order to earn his bread.
Colchicum gives  immediate relief, but its action  is injurious to
the patient's permanent interests.  The potash renders the uric
acid or the urates soluble, and  so they can leave the inflamed
parts and enter the blood-current.  The buchu probably increases
the excretion of the solids by the kidneys.  The large doses of
fluids help  to  wash  the soluble  matters  out at the different
emunctories in  the  excretion of water.
  Such is the treatment of a gouty inflammation, Avhether in the
articulations or elseAvhere.   It is the  gout, not the local mani-
festation, that we have to treat: and consequently the measures
Garrod, loc. cit., 3d edit. p. 334. 
282
GOUT.
most effectual against the gout are the most suitable, no matter
what  the part affected.  Very frequently it is desirable to use
iodide of potassium, especially in the  less acute forms of the
attack.   It would seem to arouse absorption from the tissues;
at least it has fallen to my lot to see it, and feel  it too, to make
a Avonderful difference in the progress of a case ; and the urine,
Avhich Avas very pale colored  under the use of  bicarbonate  of
potash and colchicum, greAV deeper  colored and  had a stronger
odor Avhen the iodide was added ; at the same time the symp-
toms were very much  ameliorated.  When the outbreak is but
subacute, instead of the sulphate of magnesia in the above for-
mula, five grains  of iodide  of potassium may be advantageously
substituted for it, and an occasional seidlitz poAvder given.
   The diet should consist largely of Avarm fluids, as  milk alone
or Avith arrowroot, gruel, etc., and but small quantities of beef-
tea.   Milk and seltzer-water, Vichy, or Carlsbad water, should
form the staple diet.
   In  subacute cases, rousing the action  of the skin by warm
baths, etc., is desirable.  This may be done  in  any of the in-
flammatory actions  of acute  gout.  It is very  serviceable  in
gouty bronchitis, Avhere the  mixture  of iodide of potassium,
potash, and colchicum with senega is  indicated.  Gout is very
apt to linger in a subacute form, as Avell as to  manifest  itself
primarily in  the form of bronchitis.  Here this formula—
                     Pot. Iod.  gr. v.
                     Pot. Bicarb, gr. x.
                     Mist.  Ammoniaci ^j.
three times a day is very useful.   "Where the acidity is slight—
as is found by  testing the saliva Avith  litmus paper—five grains
of carbonate  of ammonia may be substituted for  the bicarbonate
of potash.  Where  there  is a gouty  dyspepsia the following
mixture is idicated :—
                     Tinct. Xuc. Vom. TTtx.
                     Pot. Bicarb, gr. xv.
                     Inf. Calumbae 3J.
three times  a  day  before  food, and followed by a  draught of
water.  This simple combination has done me yeoman's service
many a time and oft.
   In certain  cases local applications are useful, as in  the effusion 
GOUT.
283
which occurs in joints ; and here the Viennese plan of combining
tincture of nutgalls with tincture of iodine in equal parts, or the
nutgalls preponderating, is capital.  It gives  much relief, and
does not usually, indeed rarely, blisters, and thus the application
can be continued.   When the joints of the hands are thickened,
iodide of potassium in soap liniment is very useful.  At other
times there is an acute affection of the  skin, usually eczematous.
In such cases  the use of alkaline lotions is  indicated, and often
givres great relief.
  The question of soporifics in lithiasis, acute or chronic, is one
of much practical  importance.  Opium and morphia, either by
the mouth, rectum, or subcutaneously,1 are to be  avoided.   If
there be much restlessness from the suffering in lithiasis, other
remedies are indicated.  These are  hyoscyamus, cannabis indica,
and tincture of hop.   They may be combined with  the mixture,
or given at bedtime merely.
                      Pot. Brom. gr.  xx.
                     Tinct. Hyoseyami 3ss.
                     Tinct. Lupuli gj.
                     Mist. Camph. 3j.
is a good draught  at bedtime; or tincture of cannabis indica
(fifteen  drops) may be substituted  for  the hyoscyamus, and the
dose  increased  if  necessary.   We have  not  improved  much
upon the measures of the past generation in finding a suitable
hypnotic in gouty  states, and it is not yet certain  that hydrate
of chloral, or even croton-chloral  hydrate, is the agent desired.
Chloral hydrate is indicated, however, Avhen insomnia is  found
to be accompanied by a tense artery.  Here the loAvering of the
blood pressure is essential to  sleep.
  § 110. In the more chronic forms of lithiasis, otherwise called
latent or suppressed gout, our treatment varies no little with
the  patient  presented to us.  If he  be a high-colored,  "old-
father-Christmas"  sort of a  man, with  a strong  pulse and  a
powerful  heart, it will be desirable to administer potash freely,
and to resort  to steady action on the bowels by mineral waters.

  1 The reader may perhaps wonder that I do not allude more commonly to the
subcutaneous administration of morphia.   My line  of life and  practice  has not
been favorable to personal experience of it. It is, in my opinion, a most excel-
lent measure, especially when the stomach  is irritable—where it is invaluable. 
281                        GOUT.
At  the same time the amount of nitrogenized food consumed
must be diminished, and fish without rich sauces substituted for
it.  The amount of generous  Avine and  malt liquor must  be
looked to, and  the consumption limited.   If these  measures
produce much depression, as they are apt to do even in stalwart
men at times, the  patient  must be  kept quiet for a few days,
until the more active part of the treatment  is over.   The treat-
ment doubtless has some effect, but the Avithdrawal of the stimu-
lating  food and the supplies of alcohol  have more.  If the vas-
cular  depression  be marked,  squill or digitalis  may be given
with the other remedial agents.
  At other times there is a  much less sthenic type of patient to
deal Avith.   Here it may be  necessary after a brief course of
pure alkalies to combine iron and potash, or even to give both
Avith a little arsenic.
                      Fowler's Sol. TTfv.
                      Pot. Bicarb, gr. v.
                      Ferri Pot. Tart. gr. v.
                      Inf. Quass. §j.
three times a day is a capital combination.  If it rather irritates
the stomach when given before meals, it may be  given when
digestion is well  advanced,  say t\yo hours after a meal.
  When gout is prominently atonic, it is  sometimes very  de-
sirable to give cod-liver oil  and good nutritive food along with
alkalies  and chalybeates   Very often indeed is it  necessary so
to  proceed; the Avaste  nitrogenized matters being  met by the
constant  resort  to alkaline Avaters  and occasional purgation.
The iron and guaiac pill given in § 106, together with the use
of  Vals  or  Vichy  waters,  will  often give excellent  results in
chronic and atonic  conditions of lithiasis.  When there is much
debility in the heart, and the circulation is languid, digitalis in
small  doses  may be given  continuously Avith advantage.  The
arsenic and  guaiac pill may contain half a grain of digitalis
poAvder, the  guaiac being diminished to admit of it, and cha-
lybeate and alkaline waters used at the same time in such cases.
A  residence  at Vichy, Ems, Saratoga, and  similar spas Avould
admit of this.
   The treatment of lithiasis,  in  its pronounced  and chronic
forms, is a matter  as  complex as is the  malady to be treated ;
and no written instructions can do more than point  the direction 
RHEUMATIC GOUT.
285
in Avhich the medical attendant must proceed, in order to think
out for himself the  treatment of each  case.  Many  cases will
often give much trouble, but will amply reAvard the practitioner
for the trouble so taken.  In  my personal experience there is
no more satisfactory practice  than that afforded by the careful
and honest study of the multitudinous and  varied  conditions
assumed by lithiasis;  not only to recognize them, but to treat
them with a good knoAvledge of their nature, and  to know how
to vary the treatment to the exigencies of each case.1
  § 111. Rheumatic Gout.—This is an affection Avhose nature is
very obscure.   The name Avould imply a hybrid  betwixt gout
and rheumatism.  It is scarcely that, hoAvever ; and no special
product either of malassimilation or of  hystolysis, can be found
in connection Avith it.  If this is the  case as to  its pathology,
Ave are at no loss as to  the circumstances under which it mani-
fests itself.  It is the offspring of debility.  It may show itself
in the form of rheumatoid arthritis, first attacking one joint,
then another, until the individual is most effectually crippled;
or it may linger around and permanently attach itself to one
joint in particular.
  Under  these  circumstances it is  a very serious matter, and
forms an  obstinate and  intractable malady.  Very commonly,
hoAvever, it forms a sequel to  acute rheumatism  in  persons of
strumous diathesis,  or Avhere the general  health is impaired.
When so associated it is chiefly confined to  the small joints of
the hands and feet.  It also is found in the  subjects of atonic
gout, especially when they are placed under debilitating circum-
stances.  Xo matter how originated, it has ever  to be met by
measures calculated to improve the general health.  " Our great
object throughout the treatment should  be to restore or maintain
the health of the system" (Garrod).   There is a certain  class of
persons—persons of the strumous diathesis, usually—in Avhom,
Avhen  the subjects of acute rheumatism, this aspect  of matters
may be anticipated ; and then iron must be added  to the alkalies
employed at an early period, and the combination  must be exhi-
bited for several Aveeks.  At the same time good food in liberal
quantities, cod-liver oil, and sound malt liquors must be given.

  1 "The treatment of gout, founded on Cullen's aphorism of trusting to patience
and flannel, is to be highly deprecated."—Gakkod, 3d ed. p.  298. 
2*6
RHEUMATIC  GOUT.
Garrod is very confident that alcoholic beverages are harmless
in rheumatic gout.  He goes so far as to say "Avhichevcr kind
of alcoholic beverage causes the patient to eat Avith most relish
and  digest Avith  most  comfort should be selected."  (Second
Edition.)   When  the  case  goes on, and cannot be arrested by
these measures, it  becomes desirable to resort to  the  iodide of
iron, either the syrup, or Elancard's pills ; or the combinations of
arsenic and iron given in earlier sections of this work may be
used instead.   Fresh  air, especially at the  seaside, and other
means  of improving the general health, are very useful.  If the
general health can be  improved  the local  malady will be im-
proved.  As  to  the local measures to be used,  iodide of potas-
sium in soap liniment  is the favorite method ; or the iodide may
be dissolved  in glycerine,  and then  gently rubbed  in.   The
question of motion in  the  affected joints  is a  complex  one.
Often gentle passive motion is  highly desirable, at other times
active  motion may be permissible.   The  best rule in  reference
to motion is to desist from that amount Avhich  makes the  part
painful next day.   If  this rule  be carefully adhered to no  mis-
chief will be done, and much good may often be effected.
   Such are the  constitutional or general  diseases associated
with assimilation and excretion.   Very frequently they  are to
a  certain  extent  inherited, or more  properly speaking, the
tendency to them is transmitted  by descent.   At  other times
theyr may be acquired.1  Their progress too Avill  often depend
much  upon the individual in  whom  they are  found.  It Avill
tend to elucidate matters briefly to discuss in the next chapter
the questions of  inherited  constitutions, or diatheses, and of
acquired modifications  or  cacbexise, as  they are of the very
greatest importance in practice, and  ever give a direction  to our
remedial measures.

  1 "According to Dr. Quarrier, negroes serving as sailors in  the British Navy
are apt to become gouty."—Garrod.  I had recently in a negro cook, a patient
at Victoria  Park Hospital,  a well-marked instance of "The Gouty  Heart,"
including aortic valvulitis. 
CHAPTER  XII.
                  DIATHESES AND CACHEXIA,

   §  112.  Great importance has  ever been attached  to that
 acquaintance with families and individuals Avhich is summed
 up as "knowing their constitution."   There is some  ground
 for a sceptical doubt as to Avhether this form of  knowledge has
 not  at times been  made a great mystery, and been utilized
 accordingly.  Still nevertheless there  is much  in  such knoAv-
 ledge when it exists—and that is very commonly.  From long
 experience the medical  attendant  has learnt,  slowly  and  by
 degrees, that there are certain  tendencies in a family; that in
 their ailments certain peculiarities are apt to show  themselves ;
 that their convalescence is liable to modifications, and  that they
 suffer from allied or  recurrent disorders.  Empirically he has
 recognized the necessity for certain methods of treatment to
 meet these family tendencies  and idiosyncrasies ; and  learnt
 when and where to make a special movement to counteract a
 knoAvn modification  in his patient, and by doing so  to benefit
 him very  much ; in fact, often a life  is thus preserved that
 under another practitioner, perhaps much better  informed gene-
 rally, but  lacking this particular information about the patient
 and  his family, would  have been  endangered.  The Avidespread
 confidence in  the old family  practitioner  is a proof of the
 existence of a belief  in such special knoAvledge; and it is often
 of real importance  to families Avhen selecting  a new medical
 attendant  to feel assured that he will  remain among them, and
 that the special knoAvledge acquired by long acquaintance Avith
 them shall be available  as long  as he shall live.  When the
 medical attendant is a shrewd, clear-sighted man, his experience
 is  truly valuable; and  even where these tAvo  adjectives can
scarcely be applied to him, he ahvays  learns something Avhich
is not altogether without value.   Granting that "a knowledge
of the constitution" is an important matter, it becomes all the
more necessary to have  some means of acquiring  information 
288
DIATHESES  AND CACHEXIA.
as to the peculiarities of a patient, Avhen circumstances render a
consultation necessary Avith a medical man, avIio has no previous
knoAvledge of the family, and the best must be made of the
matter.  If " the knoAvledge of the constitution" possessed by
the family doctor Avere ahvays as genuine  an article as  it is
assumed to  be, and did not  quite so often  confine  itself to a
thorough acquaintance with the mental peculiarities, each lar»e
and Avealthy family would tind it almost indispensable to have
their medical attendant ahvays with them.   It  is found, Iioav-
ever, that such a practice is  not  necessary ;  and that a perfect
stranger may be quite competent to undertake the management
of their ailments and  to  conduct them  to  a successful issue.
That is ordinarily ; at other times it becomes highly desirable
that the old family attendant  be called in, no matter  at what
inconvenience,  nor how able  the  medical man in charge of the
case.
   So truly important is this  matter of  recognizing the family
or individual characteristics that systematic attempts to classify
diatheses and cachexias, and  to give the characteristics of each,
have been made.  The most  notable attempts in this direction
are those  of  Professor  Laycock, of Edinburgh,  and of  Mr.
Jonathan Hutchinson, of London.  The researches of this latter
gentleman as to the modifications produced by inherited syphilis,
especially in the  development  of the  teeth, are well known.
The more extensive Avork of Laycock is less familiar to the bulk
of practitioners.  Yet there  is no more valuable acquisition for
a medical man  than a fair acquaintance with the physiognomy
of disease.  The hue of  anaemia ; the facial oedema of chronic
renal disease ; the florid complexion of plethora ; the nose of the
drunkard ;  to say nothing of the cutaneous indications of the
exanthemata, on Avhich indeed their  classification rests; are all
Avell recognized, and their diagnostic utility admitted.  Finer
outAvard indications of  internal  changes reveal themselves to
the watchful observer; and when years of close attention have
developed the  faculties, the  knowledge acquired by a careful
observation of the patient is sometimes  almost  incredible.  Of
course what becomes obvious enough to the eye so trained may
remain unseen, and therefore incomprehensible, to the eye which
has not yet learnt so to see.   The negative  evidence  thus fur-
nished by ignorance weighs but little in the scales  compared 
DIATHESES  AND CACHEXIA.            289
 Avith a little positive evidence.  Very often indeed the youthful
 reader will find himself  brought face to face with sick persons
 of Avhom  he knows  nothing and from  whom  he can  learn
 nothing: say, for instance, when called in to a case of  uraemic
 coma:  and yet it is  highly desirable that he  should make a
 diagnosis, and if possible distinguish this form of unconscious-
 ness  from other similar  conditions.   Highly important indeed
 as regards the  line of treatment.  If he have paid some atten-
 tion, so far indeed as his  opportunities will permit, to physiog-
 nomical diagnosis, suspicions will flit across his mental horizon
 as to  the  possibility of the causation of  the unconsciousness;
 and a microscopic slide moistened Avith hydrochloric acid held
 under  the patient's nose  will  usually  render the  diagnosis
 clearer; when he has time to put it under the microscope, then
 crystals of hydrochlorate of ammonia, characteristic and dis-
 tinct, will clear up the matter.  But very probably slides and
 hydrochloric acid, to say nothing of microscopes, are not among
 the armamentaria of his ordinary walk; so he must forego this
 evidence, and act upon what is revealed to the unaided senses.
 If those senses are uncultivated they  will not tell much ;  if they
 have been sedulously educated  they will  give  most valuable
 indications: in  Professor  haycock's  case there  was something
 almost Avizard-like about his powers  of diagnosis from external
 indications merely, and no pupil of his questions his remarkable
 ability in this direction.  He himself writes: "Study well the
 physiognomy  of disease—that  is to say, all those external char-
 acteristics  in  the  patient that reach the   unaided  senses, and
 which are associated with morbid states, whether they be sounds
 or odors, or visible and  tangible  modifications of form, com-
 plexion, expression, and modes of functional activity;  taking
 cognizance of minute  modifications as well as  of the more
 obvious, for they are only minute in a popular  sense.   Techni-
 cally, a shade of tint of the skin, a quickly passing change in
 the expression,  an almost  imperceptible  modification  in the
 breathing or mode of  speaking,  the  ring of a cough, a local,
 and in  itself  trivial, development of a  capillary network,  a
 slight  twitching of a muscle, or a tremor, may  be as  clearly
significant of structural disease as the most characteristic and
undoubted  physical  signs."  By such education, persevered in
for years, the  eye becomes  enabled to assist, or even to direct
      19 
 200            DIATHESES  AND CACHEXLE.

 the physical examination in a Avonderful manner.  It is often
 of itself sufficient to exclude a large number of sources of error
 and to give a valuable clue  to the right direction in Avhich to
 go. In chlorosis, for instance, the eye makes the diagnosis ; and
 with  it  embraces  the pathological conditions existing, and
 sketches  out the  line of treatment  to  be pursued.   A limited
 number of questions as to certain minor but not unimportant
 points is  amply sufficient to complete the survey ; and  physical
 examination as to  haemic murmurs  and bruits de diable rarely
 gives anything but corroborative information.
   The application of such trained vision to  the question of the
 outward indications of inherited peculiarities has revealed groups
 of diatheses, distinct and characteristic ; each possessing charac-
 ters and tendencies of its oavii, well worthy of the careful study
 of the medical observer.  By painstaking observation of these
 matters, as a general rule of practice, and quick application of
 the knoAvledge to each individual case, together Avith a search-
 ing examination into the family history, an  approach can often
 be made to that knoAvledge of the family constitution which has
 been supposed to be the peculiar property of the family attend-
 ant alone.  In  fact very often such  investigation will reveal
 much  that the family doctor never thoroughly comprehended,
 and lighten  up  much that hitherto has lain in comparatively
 unillumined  darkness.  Such being  the  case, it is eminently
 desirable  that  all students  of medicine should for their oavii
 sakes, as  Avell  as  their patients', familiarize themselves with
 those  external indications Avhich are characteristic of consti-
 tutional conditions;  or in  other Avords,  of  those  inherited
 peculiarities  Avhich,  grouped  together, form the diatheses.  This
 knowledge is ever at hand, and can neither be forgotten at home,
 nor found out of order on  an emergency.   It will endow  its
 possessor Avith information that is otherwise unattainable, and
 Avill often strengthen his hands very materially.
   §  113.  Diatheses  may be divided  into  five  large  groups,
 which may be found either  as typical forms or in every stage
 of blending.  These five forms are, (1) the gouty, (2) the nervous,
 (3) the  strumous, (4) the bilious,  and  (5) the lymphatic. Very
 frequently persons are to be found who  are distinct and typical
 instances of each form ;  while in other cases there is one diathesis
forming as it Avere  the foundation, and another superimposed 
DIATHESES  AND  CACHEXIA.
291
 upon it;  for instance, the nervous or the strumous often possess
 gouty characteristics.  At other times the diathesis will deter-
 mine the direction of a general cachexia.  In those of a nervous
 diathesis lithiasis will commonly manifest itself  in  nervous
 affections, and especially  so in the  neuralgias  of advanced life.
 In the bilious person a cold Avill be apt to induce biliary disorder,
 eATen to catarrh  of the bile-ducts.  The strumous are  liable to
 glandular troubles, and their articulations are apt to become the
 seat of disease from slight provoking causes.  To be able indeed
 to recognize the  strumous diathesis when called in to  an  appa-
 rently trifling injury of a joint, is often to  be  enabled to guard
 against an otherwise most erroneous prognosis; and further to
 take proper measures for the successful treatment of the subse-
 quent changes Avhich  will in all probability follow the imme-
 diate consequences of the injury.   In the bilious it is commonly
 advantageous  to  attend specially to the liver in  any form of
 disorder  or ill-health Avhich  may occur in  persons of  this dia-
 thesis.   The  lymphatic are  specially liable  to low  forms  of
 adynamic ailments, are  listless,  and  unenergetic;  and  very
 commonly require a pronouncedly stimulant line of treatment.
   Some description of  each form of diathesis is  now desirable,
 and  in each  case the  typical  form  will  be  delineated—the
 crossings and  blendings cannot  be folloAved out here;  and  the
 reader must learn to decipher such forms for himself from  his
 acquaintance Avith the several component  parts.
   § 114.  The  Gouty  Diathesis.—Persons of this  diathesis  are
 commonly AATell made, with a tendency to breadth.  The osseous
 and  muscular systems are well de\Teloped :  the teeth are  even,
 Avell shaped, and remain " undecayed in advanced life."1   The
 vascular system is highly develojDed, the vessels are numerous,
 and the heart strong and large.   The nervous system is  very
 stable, and not easily  disordered.   The  digestive poAvers  are
 very good, and the  reproductive  powers are active.  They are
 usually healthy persons  until the changes of advanced life  be-
 come pronounced.  This class  furnishes those  hale individuals
 Avho at sixty years of age can boast that they never took a dose

  1 The large, massive, heavily-enamelled front teeth of the gouty will often
give a direction to the diagnosis of the greatest service,  as well  as suggestions as
to the treatment to be adopted in many cases. 
292
DIATHESES  AND CACHEXIA.
of medicine in their lives.   Xe\rertheless in advanced life they
are apt  to have  some acute ailment Avhich either carries them
off someAvhat unexpectedly, or leaves them in a much impaired
general condition.
  In persons of this diathesis affections usually assume a sthenic
type : lowering  measures are  generally indicated early in the
ailment, and in convalescence the recuperative powers are usually
active.  In acute ailments depressants are commonly indicated,
and the vascular tension is usually high, and the pulse incom-
pressible.   Purgation by alkaline salines, low diet, and slopsare
the measures best suited to these individuals.  When advanced
in years they become more liable to  ailments than they are in
early life and in maturity ; they are  the subjects of lithiasis in
its varied forms, and Avhatever their  ailment its probable asso-
ciation  with uric acid  must  never be forgotten.   Even if the
malady has a  distinctly separate origin, the diathesis is apt to
modify it, and  by so modifying the functional activity of the
part to maintain the ailment  in a chronic form, especially if it
be situated  on an eliminating surface.  All that has been said
from time to time before about lithiasis applies with much fit-
ness to persons of this diathesis.
   § 115. The  Nervous Diathesis.—Persons of this diathesis are
rarely of great  bulk.   Their osseous frameAvork is small, but
Avell proportioned; their muscles are not large, but  they possess
more power than the mere size would  indicate.  Usually such
people are small, active, restless, and  unwearying.   Their skulls
are  Avell  formed, and  at  times comparatively large and well
vaulted ;  and the development of the  nervous  system exceeds
that of any other part.   Their senses are usually acute, and they
are indefatigable and energetic.  They ahvays seem able  to do
something more than they are doing, no matter how heavy their
duties; in any emergency they are usually prominent, and not
only are active themselves, but inspire others to exertion.  Very
frequently they require but few hours of sleep; and  usually they
can thoroughly overwork  themselves without having resort to
stimulants.   In them  the  highly developed  nervous system
tyrannizes  over the body in  reiterated  demands: while the
chylopoietic viscera are not rarely  unequal to  supplying the
calls upon the nutritive processes.   Tea is their favorite stimu-
lant.  In persons of this diathesis  rest and sedatives, or tonics, 
DIATHESES AND  CACHEXIA.
293
 are chiefly indicated in their maladies, Avhich are largelv asso-
 ciated with over-exertion.   Some of them are singularly suscep-
 tible to small doses of narcotics ;  Avhile others  again require
 unusually large doses to produce the Avonted effect.   This class
 too furnishes a large number of the persons Avho display Avhat
 are called " idiosyncrasies," and Avho are consequently a very
 difficult class of people to treat, and constantly defeat the most
 carefully-laid therapeutic schemes by their peculiarities.   There
 is no class of beings about  whom  it behooves the young  prac-
 tioner to be more cautious: the more so that they are apt to
 preserve a singularly clear remembrance of everything, mistakes
 as well as hits, and are therefore  either good friends  or aAvk-
 ward enemies of the practitioner.   This diathesis is commonly
 found blended with  others—except the lymphatic, which is its
 antithesis.  It  is found  not rarely Avith the  bilious, and very
 frequently with the gouty;  but most largely Avith the strumous.
 Whenever  it exists it gives a  direction to maladies.  It  fur-
 nishes, according to Laycock, predisposition to insanity, anoma-
 lous hysteria, to eccentricity, to vinomania,1 to  epilepsy, and to
 chorea.  In practice the recognition of a nervous element in the
 constitution is a great  step  towards appropriate  and successful
 treatment.
   § 116.  The Strumous Diathesis.—Under the name of scrofula,
 Avith its numerous  modifications, this diathesis ha3 long been
 recognized  and its  importance appraised in the  treatment of
 disease.  In such persons the vitality is weak.  The circulation
 is defective and liable to disturbance.  Assimilation is imperfect,
 and nutrition is deficient.   The osseous system is far  from  being
 highly developed, and according to Laycock it is " of a retrogres-
 sive type, either towards the  infantile or a lower ethnic form,
 both as to cranium and other bones."   The epiphyses are often
 excessively large in the young, and are specially liable to disease.
 Even when healthy there is  a tendency in these epiphyses to be
 large and  unsightly in adult  life; especially is  this  the case
 Avith the small joints of the hands and feet.  Very  frequently
 the extremities contrast  strongly with the petite and beautiful

  1 Usually, as said before, persons of this diathesis prefer tea to alcohol ; but if
once drinking habits become  formed, they grow, and many of the  most hopeless
inveterate drinkers are furnished by members of this group. 
 201           DIATHESES AND CACHEXIA.

 features found in the strumous.  In consequence of the imperfect
 osseous development it is rare to find a thoroughly well-shaped
 thorax in persons of this diathesis; the chest is  apt to be flat,
 the ribs are drawn downAvards in inspiration ; and the configura-
 tion is one that one learns to dread, as being so closely associated
 Avith the development of tubercle, Avhenever there  is any inflam-
 matory action going on in the thorax.  The muscles are usually
 soft, and contract Avithout energy, except Avhen this diathesis is
 blended Avith  the nervous.   The functions of organic life are  far
 from active.   The appetite is  capricious, and the assimilation,
 especially of fatty matters, is defective.  Circulation and respira-
 tion are feeble;  they are prone  to precocity,1 while the nervous
 system is irritable, and is often imperfectly developed, and if the
 mental powers are good they are usually easily exhausted.   This
 diathesis furnishes those children who are too good to live, the
 bright precocious little angels described in Chapter VII.   Most
 of the troubles, especially of the chronic troubles of infancy and
 of groAvth, are furnished by the tendencies of this diathesis.  Any
 IjIoav to a joint is apt  to be followed by arthritis, not rarely of
 a suppurative character.   The  exanthems, though perhaps less
 severe at  the  time,  are  extremely liable to be followed by low
 chronic maladies of an intractable character.  Persons of this
 diathesis are commonly the subjects of rheumatic arthritis  after
 an  attack of acute rheumatism unless the greatest care is ex-
 ercised ; and  iron, iodine, cod-liver  oil, nutritive food, good air,
 and all other preventive measures resorted to.   Indeed the
 recognition of this diathesis is  perhaps of more importance than
 that of any other form in actual practice.  The  injured joint,
 Avhich in another person would merely require a  cooling lotion
 and temporary rest  for  its repair, will,  in persons of this dia-
 thesis, demand prolonged rest  in splints; together Avith all the
 measures mentioned in the sentence immediately  above.   Even
 with all care  an imperfect repair alone is often all  that is practi-
 cable.  If these persons have any mischief in their thorax it is
 very apt to assume a  tuberculous  character, instead of under-
 going normal resolution.  It is from them  that the recruits of
the ranks of  the consumptive  are  largely drawn. In infancy
the glands of  the chylopoietic viscera are apt to become diseased,
1 In this they seem to revert to primitive and early eth nic forms. 
DIATHESES  AND CACHEXIA.
295
Avhile inflammatory affections of  the serous membranes are
common, and also assume a tubercular form.  There  is a per-
sistent tendency to set up  lowly forms of cell-growth, Avhich
call for energetic and sustained treatment.  Indeed the majority
of the chronic diseases of early life is furnished by individuals
of a strumous diathesis.   There is a  marked  inclination to the
formation of uric acid ; and vesical calculus is the not infrequent
result.  It  is in the  families of this diathesis  that syphilis
mostly shoAVS itself as  a congenital affection, and produces those
modifications  which  are recognized as the syphilo-strumous
diathesis.    In  fact Avhere  there  is  a strumous  diathesis the
tendency to degeneration in every form is marked and decided.1
Consequently, Avhen the subjects of syphilis they are very liable
to have groAvths of a loAvly form of cell life in their lungs, little
removed from tubercle  histologically;  in  other parts  these
groAvths are known as  gummata  or syphilitic tumors.   One
curious matter  illustrating  the  imperfect nutrition which goes
along Avith the  strumous diathesis  is this, the formation  of
tubercle is commonly  in  abeyance during pregnancy—a period
of amplified nutrition.   Another matter of moment  is  that
an  organism with  but a slight  tendency to struma, if placed
under unfavorable circumstances, will give birth to children in
which this diathesis is pronounced; and  in  a similar way the
process may be reversed  by placing  the strumous  under more
favorable circumstances.  Struma grows up in town-bred fami-
lies, and Lugol asserts that scrofula Avas rampant in the third
generation  of  those who entered Paris  as  perfectly  healthy
provincials.  There is a  tendency to variation  in every organ-
ism, and when placed amidst unfavorable surroundings,  espe-
cially, if, at the same  time there be any insufficiency of food,
the modification so induced is towards the type termed strumous.
  For Avhat has just  been said it is abundantly demonstrated
that in persons of the strumous diathesis the thing to aim at, in
their ailments, is to keep up and improve the nutrition ; and to
obviate the tendency to chronic disease, Avith  exuberant groAvth

  1 "A gouty inflammation in a man who has scrofula by inheritance may drift
into true scrofulous inflammation. ... It may be doubted whether syphilis im-
planted in any other than a tuberculous or scrofulous person will ever produce
destructive ulceration of the soft parts of the nose."—Sir James Paget. 
296
DIATHESES AND  CACHEXIA.
of lowly forms of cell life—no matter Avhat the form of ailment,
or wdierever seated.
  § 117. The Bilious Diathesis.—This  is not  quite  so much  a
distinct type as the forms we have just been considering, but  is
often rather a modification found along Avith one of the former.
It consists essentially in a tendency tOAvards biliary disturbances
from causes which Avould in others be regarded as slight.  It
is not yet possible to say Avhy this  is, Avhether or not it is an
excessive  production of bile; but certain it is, bilious persons
are not usually inclined to  be corpulent, though  that is by no
means a rule absolute.   These persons  often  grow  stout Avhen
they cease to be  bilious.   It would  seem  that there is  some
antagonism betwixt biliousness  and  the deposition of hydro-
carbons as fat.  There is a  dark complexion usually in persons
of this diathesis, and  the  skin lacks  transparency.   When
engrafted on the typical gouty diathesis, the product is a large,
tall, energetic individual of a  someAvhat gloomy temperament.1
At other times it is  found along with the nervous diathesis, and
then we have the small, dark, active beings with Avhom Ave are
all familiar.  Very commonly it is found associated Avith struma;
and  of  all strumous persons, who go steadily and swiftly down-
wards  under  tuberculosis, the bilio-strumous are  the most
marked.  Whenever tubercle shows itself in uncommonly dark
persons with jet-black hair, very marked  eyebrows  and long
black eyelashes, it  Avill run its  course  speedily; in  a manner
much resembling its  career in  the dark races.  Whether it is
that the  bilious tendency interferes with  that assimilation  of
fat and other hydro-carbons so desirable and  even  necessary  to
the  strumous, when tubercle is threatening, or not, it is impossi-
ble  to say.   Nevertheless the fact remains.  This diathesis may
also be blended with the next form—the lymphatic.
 ,  In all maladies in the bilious, attention  must be paid to the
functions  of the  liver, and a good discharge of bile into the
bowels is desirable.   Alkaline purgatives are usually  advisable,
and they may  be combined  with   rhubarb  and aloes  with
advantage.  Such medication  is more  or  less necessary in  all

   1 These individuals are by some writers classed as energetic forms of  the
lymphatic diathesis, which implies a contradiction as marked as if one were to
 speak of listless individuals of the nervous diathesis. 
DIATHESES  AND CACHEXIA.
297
maladies in the bilious, especially when it becomes desirable to
improve the general nutrition.  Bilious persons can assimilate
more nutrition, and more thoroughly too, if they are kept  on
libera] supplies of food combined with purgation, than if they
attempt to avoid biliousness by starvation.  This  should never
be forgotten in the treatment of persons of  a bilious diathesis.
There is a large amount  of  waste in their  furnace, no  matter
how small the quantity of fuel; and the only effective plan of
treatment is to keep the flues swept, and at the same time to be
liberal with the fuel.
  Whenever the  bilious diathesis  is  found  combined Avith
another diathesis, the treatment of it must be blended Avith the
treatment of the associated  diathesis.  To recognize such com-
bination in practice and  in  the selection of remedial  agents is
often more practically useful than  an elaborate  physical diag-
nosis; and is  especially useful where physical diagnosis  is not
readily attainable.
  § 118.  The  Lymphatic  Diathesis.—This  is  the  last  of  the
forms of true diathesis.   It gives large, unenergetic, phlegmatic
and listless persons.  It is the  exact antithesis of the nervous
diathesis.  It  is  most commonly found in  women.  It gives a
marked  tendency to  passive  hemorrhages, especially uterine.
Such  women suffer  from  chronic  menorrhagia, associated Avith
persistent  leucorrhoea, and  they usually have heavy  losses of
blood after each parturition ; it is not flooding, but a draining
loss analogous  to  the  bleeding in  the  hemorrhagic  cachexia.
They also often have large supplies of lacteal  fluid, but  it is of
indifferent character.1   Indeed all their secretions are free, and
the use of astringents is often indicated in  the treatment of
ailments in persons of this diathesis.  They are liable to suffer
from dilatation of the heart, with palpitation, especially about
the menopause; and are most difficult patients to treat satisfac-
torily.  These  large unenergetic  beings of either sex require
active treatment in their  maladies, and  especially active stimu-
lant treatment, Avithout which, if they do recover, they are liable
to make a slow and  unsatisfactory convalescence; and are very
subject to remain  invalids for a long time, Avith some  low form

  1 Consequently they do not make good  wet  nurses,  though to the eye appa-
rently admirably adapted for that purpose. 
298            DIATHESES  AND CACHEXIA.

of chronic ailment, or Avith general adynamy.   Depressants are
rarely indicated Avith them.   These persons are much affected
by locality; in low-lying districts they are scarcely ever well;
in high-lying, bracing localities, they are much better.  This ia
especially seen  where  the  lymphatic diathesis  is blended with
the bilious.   Persons of the lymphatic diathesis are often  said
to be good-natured, when  they might with equal  truth  be de-
scribed as indolent: if listless, however, they are not capricious,
and  often furnish the steadfast,  unwavering friend.  There  is
one type of  the lymphatic  diathesis which  is most troublesome
in practice.   The patient is  usually a woman, broad-faced  and
corpulent, and not really pallid ; there is a large development of
fat over the abdomen, and  a tendency  to  flatulence, and almost
ahvays some uterine  affection is  present, either hypertrophy or
misplacement,  with menorrhagia and leucorrhoea.   They are
chronic invalids, who complain   much, probably  not without
reason ; they are ahvays grateful for  what is done, but they
never improve much.  I have tried several plans  Avith them—
chalybeates with  stimulants; astringents, Avith  and Avithout
chalybeates; vegetable tonics, etc.; without any results worth
mentioning.   The  reader  may   perhaps  be  more  fortunate.
Change of air at a chalybeate spa is worth trying.
   § 119. Such  are  the leading classes of diathesis.   They  con-
stitute distinct groups of individuals, and, perhaps less often,
pronounced groups of families.  In some cases the family pre-
sents a very marked type of one  or other diathesis.  At times
the type is not so pronounced in  some members of the family
as in others; Avhile occasionally  one individual will differ  con-
siderably  from all  the rest.   When  the  tendency towards a
certain  diathesis lurks in  both parents,  it will come out very
strongly in  their offspring.   In this  lies the sting of inter-
marriages.   It is very  undesirable that two  persons  of  like
diathesis  should marry ;  and  especially  is this  true of the
strumous.
   There are few things of more  importance in actual practice
than a fairly good appreciation of the varieties of diatheses, and
of the tendencies given by each ;  together with a knoAvledge of
the therapeutic indications so furnished.
   To the  above list  of diatheses  some add  the hemorrhagic
diathesis, classed by Laycock as  a cachexia.  It really may  be 
DIATHESES  AND CACHEXIA.
299
 found along with  any diathesis, single or blended.  It consists
 in a tendency to passive hemorrhage, Avhich may  render  the
 most trivial wound a very grave matter.  It gives no outward
 indications of its existence, and is only found out empirically.
 Whenever it is  discovered, it then behooves the  individual to
 be constantly on guard against any solution of tissue-continuity;
 and it also puts the medical man on the qui vive in any surgical
 interference.  Usually the hemorrhage is not arrested  until the
 system is blanched and  the blood-pressure brought very Ioav  ;
 and, at the same time, until some very energetic  measures for
 the repression of the bleeding haA-e been resorted to.  The French
 also speak of a dartrous  diathesis;  but of this I am not yet in
 a position to say anything either Avay, except that it has not yet
 forced itself upon my attention.

                          Cachexia.

   § 120.  Allied to  diatheses in their modifying power over the
 constitution, and in their tendency to give a direction to mala-
 dies, stand  the cachexias.   A cachexia is an acquired modifica-
 tion, as compared to a diathesis, which is inherited or congenital.
 Or the two conditions may  be combined, as in gout, for  instance,
 where we have  both a gouty diathesis and  a gouty cachexia.
 The gouty cachexia  may, however, be  found along Avith  any
 form of diathesis.  Wherever a cachexia is found, it behooves
 us, as practitioners, to attend to its indications.  Syphilis  also
 may exist either as an acquired cachexia, or  an inherited  dia-
 thesis : in either  case its  presence is most  important in a thera-
 peutic sense.  Hitherto little allusion has been made to syphilis,
 but iioav it must engage our attention.   Other cachexias, as  the
 malarious cachexia, the cancerous cachexia, etc., have been con-
 sidered from time to time in other sections;  now it is  the turn
 of syphilis to become prominent—as the most striking illustra-
 tion of a cachexia.
  A cachexia, as said aboAre, is an acquired modification of the
 constitution Avhich  may  or may  not be  outAvardly apparent.
 Except, indeed, in the anaemia which is so frequent in the course
of cachexias, there  are no  pathognomonic  indications.  The
modifications may be most profound, hoAvever, and may exercise
a distinct  influence over  the most trivial as vsrell  as the most 
300
DIATHESES and  cachexle.
important  maladies.  Its presence is  indicated  rather by such
effects than  by visible  signs.  Syphilis,  as  just said,  may  he
either acquired or inherited. It is the effect of an animal poison,
usually communicated  by impure intercourse.  Its origin  is
shrouded in mystery Avhich no application of intellectual energy
has yet been able  to  penetrate.  It  at first  sIioavs itself by a
local  ailment,  usually a hard  chancre.   The soft  chancre,  so
called, terminating in inguinal  bubo, may  be pretty well ex-
cluded from  the  present inquiry ;  though at times it develops
a hard base, Avhen it is folloAved by constitutional manifestations.
This  local sore  is characterized by a hard  cartilaginous  base.
Within a few Aveeks ordinarily there follow general evidences
of constitutional infection.  There is ulceration of the throat,
together  Avith characteristic  copper-colored  eruptions on the
skin,  sooner  or later  becoming scaly; while the hair usually
falls off, but  grows again.  In some instances the poison seems
to be  eliminated  by this eruption, usually  termed "secondaries,"
and no other evil consequences follow.  More commonly, how-
ever,  another series of ailments sooner or later show themselves,
which are termed " tertiaries."  These are  very commonly osteal
or periosteal  affections, but not rarely the  nervous system  is the
seat of disease, usually a neoplasm or growth of connective tis-
sue in the neuroglia, Avhich affects  the  nervous tissue by its
pressure;  or  new growths (gummata) may form in  the muscles.
Rheumatism, paralysis, cutaneous ulcerations of an eczematous,
or of  a serpiginous character, as well as conditions  of profound
anaemia, &c, all are the  direct outcomes of syphilitic infection
in its remoter manifestations.
  It is no part of my scheme to go into the  minutiae of syphilis
in its varied  manifestations:  they  are to  be found in  many
books, and are amply illustrated  in  every one  of  our  medical
charities.   What I do wish  to  insist upon  is this:  Wherever
an ailment can be discovered to have  a syphilitic origin, then it
becomes our bounden  duty to  treat  the  cachexia in the first
place; and to relegate the local  mischief to a subordinate  place
in the remedial measures.  Empiricism has declared in clear and
unmistakable accents that it is useless to treat syphilitic sequelae
without  directly treating the syphilis.  Chlorate of potash and
cinchona gargles are all very well in  the pharyngeal  ulceration
of secondary syphilis, but they are not curative; while a mer- 
DIATHESES  AND CACHEXIA.
801
curial course is.   Tar ointment may palliate the syphilids, but
it is inadequate  to  their cure.  Haematics are indicated in the
treatment of anaemia; but in the syphilitic cachexia mercury
must be added to the chalybeate, if it has to  be truly effective.
Whenever and wherever it  manifests itself,  syphilis must be
treated by  its  specific measures ; modifications and additions
however being  made according to circumstances and the  exi-
gencies of each case.  The specific remedies of syphilis are mer-
cury, in all its forms, and iodine.  How these agents act Ave do
not yet truly know.
   § 121.  That they do act, and most efficiently too, is admitted
by the most  confirmed sceptics;  and their  remedial powers no
competent authority would think of disputing.  Though we do
not  yet know how they produce their effect, we know empiri-
cally how to apply them.  In the earlier manifestations of syphi-
lis mercury is the  chief agent employed, either in  continuous
small doses  by the  mouth, or by repeated inunctions.  For the
first it is desirable to select some soluble solution of mercury, as
the solution of the bichloride, or of the biniodide; for the latter
blue ointment is  preferred.   There is one fact which Avill  soon
strike  the most careless observer, and that  is the  protection
against the evil effects of mercury which syphilis confers upon
the system.   Doses of mercury, which would  assuredly produce
havoc in other systems, are not only tolerated by the  subjects of
syphilis, but  seem  positively to  do great good.  Under them
rashes  disappear, ulcerations heal up, paralyses pass off,  and
morbid groAvths melt away.  No  matter Avhat the malady, from
rheumatic, nocturnal, persistent pains, to masses of lymph on the
irides, it yields to mercury.   It has been laid down as a general
rule  that syphilitic growths need  mercury, while syphilitic ulce-
rations require rather iodide of potassium in full doses.   This
may be a good general  rule, but it  has fallen to my lot to see
many undoubted  cases  of syphilitic  ulceration, in  Avhich  full
doses of iodide potassium have exerted but little influence, clear
up after the administration of mercury combined with iron.  I
was led to this combination by first noticing that many cases of
anaemia, which were entirely  unaffected by chalybeates, at once
began to  improve on the addition of mercury.   In these cases
there were evidences of the  presence of  syphilis, inherited or
acquired.  It has now become a regular practice with  me to give 
 o02            DIATHESES AND CACHEXIA.

 mercury in cases of anaemia  or imperfect evolution associated
 with syphilis.  Not  rarely, if the nutrition  he very inperfect,
 cod-liver oil may be given at the same time Avith advantage.  It
 has fallen to the lot of many to see the subjects of syphilis com-
 mence  to  fatten under a mercurial  course Avithout any chaly-
 beate remedy being exhibited.  As soon as the syphilitic virus
 is met and neutralized by the mercury, the processes of nutrition
 begin to improve fortliAvith.   At other times it  is desirable  to
 meet the original disease by mercury, and the marasmus or anas-
 mi a by iron.
   The  combination  which seems to me the  most generally
 serviceable is the following:—
                    Liq. Hyd. Bichlor. TUxxv.
                    Tinct. Fer. Perchlor. 1TLx.
                    Inf. Quass. 5J ter in die.
 It may be given before or after food, according as it is desirable,
 or  not, to  give a fillip  to  the appetite.  It  may be continued
 steadily for months not only without ill effect, but with advan-
 tage.   By  such conbination we secure the good effects of a mer-
 curial  course; and yet protect the system from the effects of
 the mercury itself.  While it is quite  true that patients do some-
 times fatten under mercurials given alone, it more commonly
 happens that some of the ill effects of a mercurial course manifest
 themselves sooner or later.  The administration of a chalybeate
 along Avith the  mercury obviates  these evil  consequences, and
 Avhile the  mercurial is engaging the  syphilis, the iron supports
 the blood-formation,  and protects  the system against the evil
 consequences of  the mercurial.  At  other times it is desirable
 to give the mercury  in the  form of pill, especially when the
 bowels  are  somewhat constipated.   Every one familiar with
 out-patient work must have noticed again and again how much
 better the  Pil. Cal. c. Col. Co. has agreed  with anaemic  women
 than a  pill not  containing mercury.  Rheumatism  ordinarily
does not require  mercury for its successful  treatment; but when
it occurs in subjects not of  a rheumatic character, is nocturnal,
and is found  along the collar  bones, in the  upper arm, and in
the shins, then mercury at once is beneficial; for this form of
rheumatism is a syphilitic  affection of the periosteum,  usually
worse at nights on  getting warm in bed. 
DIATHESES  AND CACHEXIA.            303
  Whenever, too, hemiplegia  occurs in young and healthy sub-
jects, or any symptoms of interference Avith a nerve tract, the
more irregular the better, show themselves, the syphilitic nature
of the malady at once  is suggested;  and  under appropriate
treatment the most apparently formidable maladies pass  aAvay.
This is a point of much importance for the young practitioner,
and he should ever bear in mind the nervous affections produced
by syphilis; by so doing he  may not  only save  himself from
falling into error, but he may  be enabled to be of  much service
to patients Avhose ailments have hitherto not  been  properly com-
prehended, and so to gain much kudos for himself.
  In children, Avhere syphilis is congenital, as sliOAvn by affections
of the nasal bones Avith " snuffles," or skin affections, especially
copper-colored nates,  mercury, chiefly in  the  form of gray
poAvder, has been found most serviceable.   Here again we get
a capital  illustration  of  hoAV important is  the constitutional
condition, and how comparatively insignificant the local ailment,
when syphilis underlies the ostensible malady.  When children,
whose teeth indicate the taint they suffer  from, are anaemic,
stunted, or arrested in their evolution,  the addition of mercury
to the ordinary measures will  produce all the difference possible
and convert an eminently unsatisfactory treatment into a very
gratifying one.
  It is no part of my business here to teach the youthful reader
how to distinguish  syphilis in its thousand varied forms; that
he must learn by the sweat of his broAv;  but in telling him by
Avhat principles  he must conduct its treatment, it may not be
out of place to insist that the  diagnosis of syphilis must  rest
but little, if at all, upon any  statements of the patient, and in
no Avay upon the position in life of the sufferer.   If these influ-
ences exist, the vision will often be clouded to the prejudice of
the remedial measures.  The  coppery tint of a rash, or the ser-
piginous nature of an ulceration, must outweigh the bluest blood
or the most perfect Avalks in life;   in comparison with such
Avitnesses  the noblest  descent  and  the  most  far-reaching of
genealogies are trifles light as  air.  The austere life of an arch-
bishop or a cardinal is not  incompatible  Avith early self-indul-
gence,  Avith its  consequences.  Such  being the  case,  it must
never be forgotten  that the  purest and best of women may be
the unwitting and  unfortunate sharers of the  taint.  The in- 
304
DIATHESES  AND CACHEXIA.
exorable Liavs of nature knoAv nothing of extenuating circum-
stances ;  and syphilis may be the lot of a  princeling as Avell as
of a pauper's bantling.  Hebra is  right  in insisting that the
diagnosis of syphilis shall rest upon its  objective phenomena
alone, and that the question of past history must be excluded—
if Ave Avish to be correct.  The importance  of a right diagnosis is
made all the more manifest from what has just been said about
the necessity for treating the cachexia irrespective of the form
of the leading outAvard manifestation. There is one point about
syphilis Avhich has not attracted the attention it deserves, viz.,
the occurrence of acute  outbursts of syphilis.  Like  gout and
malaria, syphilis  may  be long quiescent, and then  suddenly
burst out.  During these acute manifestations the syphilis must
be actively treated; just as in  the  other  cases the gout or the
ague are treated.  On  talking to Mr. Hutchinson on this topic,
I found he held similar views.
   § 122. Lead Poisoning.—Still  more vividly even  is the im-
portance  of  the cachexia in proportion  to  the  local  malady
brought  out in the case of lead-poisoning. Once the diagnosis
made, then it is of small moment what the peculiar manifesta-
tion of  the poison ; the treatment  is the same.  No matter
Avhether it be the well-known colicky pains, the  wrist-drop, or
paralysis of the extensors of the wrist; or  the less-known forms
of cerebral disorder, general tremor, amaurosis, albuminuria, or
even of uterine disorder ;  if the blue lines on  the edge  of the
gums be present, the diagnosis of lead-poisoning is  rendered
probable.1   In  this cachexia  the  past   history is valid and
valuable ; here  there  is nothing  calling  for concealment, and
it may fairly be admitted  as  evidence.   If  the  association of
the malady can be clearly traced, and there has been contact
with lead, then it behooves us to treat the cachexia.  One plan
much in A^ogue is the administration of sulphuric acid in order
to form in the system the insoluble, and therefore inert, sulphate
of lead.   The acid is  usually given  along with the sulphate of
magnesia either with syrup, or in  some  bitter infusion.  This
forms a  common draught in  manufactories where lead is much
used.  The  more favorite plan in medical practice is to dissolve
the lead out of  the body by giving iodide of potassium.  This

     1 Garrod thinks the gouty especially sensitive to lead, p. 474, 3d edit. 
DIATHESES  AND CACHEXIA.
305
forms a combination Avith the lead, and the resultant, iodide of
lead, passes out of the body in solution, chiefly byr the kidneys.
It is desirable to combine with it a course of purgation.  Very
commonly attacks  of gout, of various forms, are due  to  the
action of lead, Avhich appears to arrest the elimination  of uric
acid.  But the form of malady matters little ; it is the cachexia
—the lead-poisoning, that we have to treat.  The importance of
recognizing a cachexia when present, no matter Avhether syphi-
litic, lead, or  other poisoning, gouty, strumous,  malarial, etc.,
can but be imperfectly conveyed by Avords ; the student must
observe it for himself in practice.  All that can be done here is
to sketch out the matter in outline, and leave it  to be filled up
as experience dictates.  It is not  however a trivial matter to
sketch  that  outline  correctly; and  the sketch  is as correct—
it is hoped—as it can, in the present state  of our knowledge, be
made.
20 
CHAPTER  XIII.
                    ACTION AND INACTION.

  § 123.  In this chapter "will be considered the various measures
by Avhich Ave  act  upon the nervous system, and the means by
which Ave can  control that system, or excite action in it, when
it becomes desirable to do so.  That  we possess  such agents is
familiar to every one; but how they exert their influence, how
they produce their action, or in other words, their modus ope-
randi, is not so clear.   Physiological  research and experimenta-
tion are doing  much to dissipate the darkness which has hitherto
shrouded this  subject.  Of the agents which control nerve-action
Ave have several classes, as sedatives, clepresso-motors, analgesics,
anti-spasmodics, and agents Avhich check secretion.  The differ-
ent members of these groups possess varying degrees of potency.
The action of  some is  very  pronounced, Avhile others again
are useful rather as adjuncts to the more  powerful  members.
Of the neurotic agents Avhich  diminish action  in the  nervous
system, opium, chloral hydrate, and  bromide of potassium are
the chief  in  common use: calabar bean, conium, and others
are potent, but not so commonly resorted to ; Avhile hyoscyamus,
camphor, etc.,  are less powerful, except in doses far beyond those
of the pharmacopoeia, and are chiefly used  as adjuncts to other
remedies.   Another class of agents, as belladonna and cannabis
indica, lie across the borderland of depressant and excitant  neu-
rotics, and had best  be  considered under  the latter heading.
Even opium is not free from excitant properties, Avhich counter-
balance and even preponderate over its sedative properties, Avith
some individuals.   Much depends,  too, upon  the manner in
Avhich it  is given: if administered in  frequently repeated but
small doses its  excitant properties  are brought out; if given
in full doses its sedative  action is most pronounced.   By habit
and long indulgence in it opium may be converted into a nearly
pure excitant, as in the Avell-known instance of De Quincey.
  This combination of properties in a drug of so pronounced a 
ACTION  AND INACTION.
307
 character as opium demonstrates hoAV difficult it is to form anv
 arrangement or classification of neurotic agents which shall not
 at some point or other clash Avith  acknoAvledged  facts  In the
 present state of our knoAvledge a strictly accurate classification
 is unattainable:  still  it is .possible  to  adopt an arrangement
 which will so  group  neurotic agents as to make their action
 somewhat clearer  than before, and, to a great extent, to eluci-
 date their use in actual practice.
   In order to clear up this complex subject, to some extent at
 least,  it may be as Avell to commence by  reviewing a  few of the
 leading facts already gathered, in  reference  to the  recognized
 action of certain neurotic agents Avhich control nerve activity.
   § 124.  Opium  first  claims  our attention.   The effect  of a
 moderate dose  of opium, in ordinary individuals, is to induce
 sleep after a  brief period of excitation.  Max Schuler  found that
 opium first produced a slight dilatation of the vessels of the pia
 mater, folloAved by contraction  and brain-collapse;  the vessels
 recovering their calibre, Avith  slight dilatation even, when the
 narcosis Avas over.  If  a larger dose be given  a death-like coma
 is produced,  Avith a fast, feeble pulse, and irregular respirations,
 If the dose be fatal, " death occurs generally by failure of the
 respiration, but amid an almost complete extinguishment of the
 vital functions."  (Wood.)   The action which in moderate doses
 controls and diminishes nervous action, in lethal doses abolishes
 functional activity in  the nervous system.  First  the higher
 cerebral faculties  are  acted upon ; leaving the lower, but, as
 regards mere life  more vitally important  centres at the base of
 the brain, but little affected.   In larger doses  these, too, are in-
 volved ; and  respiration and circulation are arrested, causing the
 death  of the  organism.
   One of the difficulties experienced in attempting to trace out
 the action of opium upon the nervous system has arisen from
 the fact that in frogs opium  excites  convulsions.  This is ac-
 counted  for  by the comparatively high development of  the
 spinal  cord in  frogs and the  imperfect  evolution of the  cere-
 brum ; Avhile in man  the cerebrum  attains its highest develop-
 ment.   Consequently in the frog the effect is to produce  con-
 vulsions, chiefly the result of excited  reflex irritability ; while
 in man the resultant phenomena are sleep and stupor, the  eA'i-
dences  of the effect upon  the cerebrum.   Opium, however, acts 
308
ACTION AND  INACTION.
upon the spinal  cord  of man, as seen in its influence  upon the
centres Avhich regulate the emptying of the bladder ; and reten-
tion of urine is not uncommon after a full dose of opium.  Here
opium probably acts  by blunting the sensibility of the centres
Avhich are connected  Avith  the reflex relaxing  of the  vesical
sphincter, from sensory impressions  created by the full bladder.
  But opium and its  derivative, morphia, do not act only upon
the cerebro-spinal system, but  upon every nerve-cell,  and  pro-
bably every nerve-fibre.   Gscheidlen found that  morphia acted
upon  both the respiratory centres and the intra-cardiac ganglia.
In its influence upon  these centres it displayed the same action
as it produces over the cerebro-spinal system, viz., a brief period
of excitation, followed  by diminution and final abolition of all
action.   Opium, too, as  is well known, arrests action  in  the
intestinal canal, at the same time checking  the flow of  gastric
juice and the intestinal  secretion, causing constipation.  Thus it
is useful in certain forms  of irritable dyspepsia and in diarrhoea;
especially in that form Avhere, from hyperassthesia and irritability
of the intestinal canal, the food is swept away before it has had
time  to  be digested and  assimilated.  It is very important to
discriminate carefully the form of  diarrhoea  in adjusting  the
proportions of opium and the astringent selected.   Where the
secretion is profuse full doses of the  astringent  are indicated;
Avhere there are many motions in the  day, yet the  quantity
passed is in the  aggregate  but small, then opium should be
given freely. In colic, and  other spasmodic affections of the
intestines, opium, especially  in  combination with carminatives
and stimulants, is very  useful.  In  peritonitis opium  is  the
favorite  remedy.   Xot only does it  deaden the receptivity of
the nerve-centres  to impressions, including, of course, pain ;  but
it also has a poAverful effect upon the bowels, limiting peristaltic
action and lessening the friction of  the inflamed membranes.
In uterine diseases, and  after  operations in the neighborhood
of the intestines, opium is very serviceable from its effect upon
the movements of the bowels.  Opium, too, limits the activity
of the viscera, and is useful in diabetes and azoturia;  probably
in each case even more by its action  upon the liver than upon
the kidneys.
   Opium is used  to limit motor action, but not nearly to the
same extent as  it has  been resorted  to  to relieve pain.  This 
ACTION  AND INACTION.
309
last opium does most effectually, and in this  respect it differs
markedly from chloral  hydrate, though they are both poAverful
hypnotics.  In many cases where the dose of  opium is insuffi-
cient to produce sleep, it  Avill so far diminish the receptivity
of  the sensory centres as to relieve  the  sensation of  pain  in
painful conditions.  Thus opium is an analgesic as well as an
hypnotic.  In all forms of pain, except  neuralgic states, opium
is our favorite remedy and our most trusted  analgesic.  How
it exercises  this action Ave can inquire  after Ave have revieAved
its hypnotic action, Avhich will next engage our attention.
   In  the production of sleep there  are tAvo factors requisite:
(1) an action  upon  the vascular system which will permit  of
cerebral anaemia ; and (2) an effect upon  the cerebral cells, Avhich
results in their diminished activity.
   The vascular conditions requisite for sleep may be taken first.
At one time it Avas supposed that sleep was due to congestion of
the brain, and  that opium produced its somniferous effects by
inducing cerebral congestion.   But as it became more and more
clearly evident that functional activity of any part is  strictly
related to its blood-supply, that is, its supply of arterial blood,
careful observations and experiments were  made, especially by
Mr. Arthur Durham, Avhich resulted in modifying very materi-
ally our vieAvs  as  to the conditions under Avhich sleep occurs.
Sleep is a condition of cerebral  anaemia: coma one of venous
congestion.   Sleep  passes into coma  Avhen venous fulness  is
supperadded to arterial anaemia Avithin the cranium.  In poison-
ing by opium there is much venous fulness.  In moderate doses
opium produces sleep:  in  fatal, or even in large but not neces-
sarily lethal doses, it induces coma.  The chief effect of opium
in the production of sleep is upon the cerebral cells, but never-
theless there is also an influence upon the vascular system.   At
first opium increases the pulse-rate and the arterial tension ; but
afterwards both are lessened  beloAV the normal point.  (Xoth-
nagel, Gscheidlen.)  The  first action of opium, then, is that of
the production of excitement, during which  there  is  also in
creased vascularity of the  encephalic arterioles. (Max Schuler.)
Then  follows contraction  of the cerebral vessels, a fall in the
blood-pressure generally, and, Avith  these, lessened activity  in
the nervous system takes the place of excitement.  This lethargy
following activity Avas  at one time  attributed to exhaustion of 
310
ACTION AND INACTION.
the stimulated nerve-centres.  (A. Todd Thomson.)  We should
scarcely say so iioav; but Ave  know that this  diminished func-
tional activity is accompanied by distinct reduction in the cere-
bral vascularity—partly the consequence of the fall in the blood-
pressure and the contraction of the encephalic arterioles ; partly
the outcome of the effect upon  the cerebral cells, so that they
do not attract blood so actively.  When  Ave wish  to procure
sleep in conditions of vascular  excitement Avith a full and bound-
ing pulse, it becomes necessary to administer opium in  combina-
tion Avith some distinct vascular depressant, as  tartar emetic,
aconite, or chloral hydrate; otherwise those changes in the cir-
culation indispensable to sleep cannot  be  procured.   From its
very decided effects  upon the circulation,  chloral is to be pre-
ferred  to  opium  in  conditions  of vascular excitement, either
inflammatory  or febrile; or they may be given together if pain
also  be present.
  Both opium and chloral hydrate act upon the cerebral cells—
the second  part of the action of  hypnotics.  We cannot yet
speak very explicitly about this  action ;  all Ave may say is that
they produce  their effects, Ave have e\rery reason  to believe, by
an action upon the  cerebral cells, lessening  their functional
activity, and,  with it, their demand for arterial  blood; at the
same time that the blood-supply7 to the cells is diminished.  By
this  combined condition—of  arterial anaemia and lethargy in
the cerebral cells—sleep is brought about.
  From this consideration Ave may iioav pass on to the examina-
tion of the action of opium as an analgesic.  We are all familiar
Avith the fact  that pain puts away sleep until  sheer exhaustion
Avraps  the sufferer in oblivion.   It is said that Damiens slept
during the intervals of the rack.  The  activity of the cerebral
cells is maintained and kept up by  impressions of pain coming
in by the  afferent nerve-fibres.  The arrest of pain, the  cessation
of these painful  sensations conveyed by centripetal nerves, as
by the extraction of an aching tooth, or the opening of a  whitlow,
is at once folloAved by sound, dreamless sleep.   A state of ex-
haustion is induced by sustained persistent  pain, and relief from
these painful impressions is folloAved by a state of quiescence in
the cerebral cells; the evidence of Avhich is furnished by long,
sound sleep.   Several days indeed may elapse after a period of 
ACTION AND  INACTION.
311
 sustained acute pain, either bodily or mental,1 ere the cerebral
 cells recoA^er themselves, and the normal sensations of vigor and
 elasticity in the  nervous system  are  again experienced.  An
 analgesic is an agent Avhich diminishes painful sensations.  This
 poAver opium possesses very markedly.  If, in conditions of acute
 pain, it be given in moderate doses, it will merely palliate the
 condition, reduce its  intensity, and no more.  A larger dose,
 hoAvever, Avill subdue the sense of pain, though it may not be
 sufficient to  produce sleep under these  circumstances ; i. e., the
 impressions coming in by the afferent nerves, though no longer
 equal to producing painful sensations, are still poAverful enough
 to maintain  a condition of activity in the cerebral cells.  A still
 larger dose of opium will  annul these last remaining effects upon
 the cerebral  cells, and procure sleep.
   There are  some direct experiments (C. Bernard and others) to
 demonstrate the analgesic action of opium ;  but the bulk of evi-
 dence is furnished by the conclusions which may be draAvn from
 careful clinical observation of its action.  It is abundantly evi-
 dent  that the effects produced by opium are in a manner antago-
 nistic to the action by7 which pain  is manifested.  The sensation
 received in the brain as pain—say in onychia of the great toe—
 has passed from the periphery, along a nerve-tract of cells and
 fibres, until it is received in the sensory cells of the gray matter
 of the brain, probably in the optic thalami.  It Avould appear
 that opium  lessens  the conductivity of nerve-matter, of fibres
 probably as Avell as  cells, and so  diminishes  the  force of each
 impression—as seen  in the lessened pain prpduced by a compara-
 tively small  dose of opium, even  Avhen not equal  to  arresting
 entirely the transmission of  the  impression.  In  larger doses
 the impression becomes so lost in the transmission  that it is no
 longer felt as pain, though  still sufficient to maintain a condi-
 tion of Avakefulness in the cerebral cells.  Pain raises the blood-
 pressure generally (Von  Bezolcl)—except  when amounting to
 shock.  It would  seem that the effect of opium is felt in the
 receptive nerve-centres as  Avell as in each and every part through
 Avhich the pain producing message passes; and the force of the
 original excitant is so diminished  that it falls beloAV a pain-pro-

  1 Such was the case with Audubon,  the naturalist,  after discovering that mice
had eaten all his drawings of birds, the fruits of years of labor. 
312
ACTION AND  INACTION.
ducing  point when ultimately  received  in the brain.  A still
larger dose of opium is sufficient to neutralize all consciousness
of the pain-exciting impression,  and to arrest the unfelt pertur-
bations in the cerebral cells; and then sleep is secured.
  In this analgesic action opium is markedly superior to chloral.
In the conditions of sleeplessness due to pain chloral is of com-
paratively little or  no  value, and opium is the agent to be relied
upon.   The  Easterns  print  " Mash  Allah" (the Avork of God)
upon the cakes of opium, in consequence of its special properties.
(Pereira).  When, however, the  painful state is due to an inflam-
matory condition, then  the addition of direct vascular depres-
sants is indicated (p. 108).  If the painful state be due to inflam-
mation  of the brain itself, the depressant must be given Avithout
opium.
  As said before,  opium is not much used to subdue morbid
motor activity, as tetanus, chorea, epilepsy,  or paralysis agitans.
In  these conditions other  sedatives are more useful.  In con-
ditions of spasm, however, especially in the  intestines or badder,
opium is very effective; and its action on the muscular fibre of
the gastro-intestinal canal is pronounced.
  § 125. The effects of opium  are  felt in  other  parts  of  the
nervous system  than the intra-cranial  centres—in the periphery
as well as the centre.   (W. Baxt.)  This is shoAvn by the relief
furnished Avhen  opium  is applied locally, as to a blistered sur-
face, a painful ulcer, or to piles.  It seems  to  exercise an anass-
thetic effect upon the  terminal distribution of nerve-fibres in
the  tissues, and not only affords relief; but  by lessening  the
irritability  of the part affected, aids  in  repair  and  recovery.
Thus, in affections of the pelvic organs, the local application of
opium,  or its use  as a suppository, is  to be preferred  to  the
administration  of it by the  mouth.  In localized pain the appli-
cation of opium endermically, or, better still often, hypodermi-
cally, is very desirable.  In cases of gastric irritability, where
the stomach rejects everything, these means of administering
opium  are invaluable.
   Opium possesses another action often very useful, and that is
its poAver to arrest excessive secretion.  Thus in diarrhoea we
find it  not  only controls the peristaltic action of the intestines,
 but it checks secretion. How far it achieves this effect by action
 upon the peripheral  nerve-fibres in  the  glandular  structures 
ACTION  AND INACTION.
313
 solely; or Avhether it also  acts through the blood-supply, is  not
 quite clear.  There have  not  yet been a sufficient  number of
 observations and experiments made to decide the matter.  Lau-
 der  Brunton found that opium  exercised a very decided  effect
 in  Aveakening or destroying the  effects of a stimulus to sensory
 nerves, thus  diminishing the blood-supply to the  part.  From
 this he  Avas led to suppose that a part  of  the good effects of
 opium in inflammations is due to such action ; for limiting  the
 blood-supply to  an inflamed part will give the same relief as
 raising the hand  does in  lessening the  pain of  an inflamed
 finger.   This action of opium is important, especially in  such an
 inflammation as peritonitis.  If, indeed, to  the analgesic  effect
 of opium, on the  periphery as  Avell  as  the centres, be added
 its effects in controlling the vermicular action of the intestines,
 and so limiting motion;  and beyond these actions, again, its
 power to restrict  the vascular dilatation of an inflamed  part;
 then there can be no difficulty in estimating  its utility in  the
 treatment of peritonitis.
  Brunton has  also found that when a large  dose of opium is
 given to an animal it completely abolishes the secretion in  the
 submaxillary gland, Avhich is  excited  reflexly by  irritation of
 the lingual nerve.   Not only so, but he is inclined to the opinion
 that opium acts upon the secretory nerves themselves in  the
 gland.  If the narcosis be deep it appears that unusually strong
 electric currents are  necessary  to excite  secretion; and  the
 quantity of fluid obtained under the circumstances is less than
 that which is furnished when woorara is employed instead of
 opium.   From  this it Avould appear that opium exercises some
 direct  effect upon secretion  by  an  influence over the nerve
 elements of a  secretory organ ;  and  this action explains  the
 utility of opium in  the control of excessive secretion.  This
 matter will be referred to  again  Avhen considering astringents.
 (§ 128.)
  The  activity of one secretory  apparatus, however, is stimu-
 lated rather  than  arrested  by opium,  and this is that of  the
 sudoriparous glands.  Excessive perspiration is one of the effects
of a full dose of opium ; and opium is in many cases a valuable
diaphoretic, especially in combination Avith other members of
that class of remedial agents.  In this its antagonism to bella- 
314
ACTION AND  INACTION.
donna is  Avell  seen; for belladonna  is as  useful  in  arresting
excessive perspiratiou as opium is in exciting it.
  § 126.  Chloral  hydrate  is  a drug which  stands second to
opium only as an agent Avhich depresses nervous action.   There
are differences, hoAvever, betwixt the actions of these two agents,
which are far from  unimportant.   We have just seen that for
the induction  of  sleep two factors are requisite, viz., cerebral
anasmia and a quiescent state of the cerebral cells.   Opium  acts
more pronouncedly upon the cells than the circulation; whilst
the effects of chloral are most markedly felt by the circulation
and to a less extent by the cells.   Thus in old days a depressant,
as tartar  emetic,  was  combined with opium in  conditions of
sleeplessness due  to vascular  excitement.   In such conditions
chloral is  the hypnotic par excellence.  As an analgesic  chloral is
far below opium;  but in  conditions of  sleeplessness  due to
arterial fulness chloral is far superior to opium.  Where vascular
excitement and pain coexist, then chloral and opium should he
combined.  It must not, hoAvever, be  supposed that chloral does
not possess a very decided  effect upon the nervous system.   In
fatal  doses it arrests both respiration and the circulation by its
effects upon the  nerve-centres  of these systems.  It also  acts
upon the  cerebrum  and the  centres  at the  base of the brain;
Avbilst it  has a decided effect upon reflex irritability.  From its
double effects upon  the nervous  system directly and  upon the
circulation, chloral has been found very useful in  the treatment
of mania—much  more  useful than opium.  Chloral, too, is an
excellent  remedy  in cases of cerebral irritability from overwork,
giving calm, refreshing sleep.  There is much  room, hoAvever,
for anxiety as  to this  last use of chloral.   For  such end  it is
often taken Avithout professional advice, and great mischief has
folloAved  its abuse.  Properly used, no doubt, it is of the greatest
utility, and by its means serious injury has often been averted;
but it can cut  both Avays,  and it is  not an  agent to be trifled
with  Avith  impunity.   By its combination of qualities,  as a
powerful vascular  depressant and  a sedative  to the  nervous
system, chloral is indicated in all cases of  cerebral irritability
with encephalic vascular activity, especially with a tense radial
pulse.  Where there is high arterial tension  chloral  may be
continued without danger; but Avhen the  pulse is feeble and
 the extremities are cold, its  use is fraught Avith danger.  It is 
ACTION  AND INACTION.
315
 in such cases that fatal results sometimes folloAv an ordinary dose
 of chloral in those habituated to its use.  Chloral, too, exercises
 a powerful influence over the body-temperature, and is distinctly
 indicated Avhen the above condition is associated Avith  pyrexia.
 (P. 110.)
   In consequence of its poAverful effect upon the heart, Da Costa
 advises caution  in  the administration  of chloral  in  cardiac
 debility ; and this caution is well Avorthy of attention, especially
 Avhere a muscular chamber is struggling against a tight stenosis.
 Chloral has been found to diminish the pain which accompanies
 uterine contraction.
   Chloral is useful vey commonly in  the treatment of  convul-
 sions in children, and in  some  cases  of chorea; and  even in
 tetanus it has been found to furnish some relief.
   Altogether chloral is a potent remedy,  and as an hypnotic, in
 certain conditions, it is unequalled.  In cases of  sleeplessness it
 is by no means a matter of indifference Avhether opium or chloral
 be chosen as the hypnotic.   The choice in each case ought only
 to be made after a careful consideration of the indications, Avhich
 we have just seen may  differ considerably  ; under certain circum-
 stances these agents are best  given together.
   As illustrations of the evil effect of chloral we may refer to
 its employment in the sleeplessness of  melancholia, Avhere  it
 seems  to  still further  starve the anaemic brain, and tends to
 transfer the condition from that of temporary melancholia to the
 more advanced and permanent condition of chronic dementia
 (Crichton Browne, Hammond); and to the intellectual prostra-
 tion AArhich ensues from resort to it in the sleeplessness of over-
 work ; especially in those persons  Avhose circulation is not A7ery
 vigorous.   Chloral has been  found in  some cases very useful as
 a local application in certain painful conditions.
  § 127.  Another  poAverful remedial agent is bromide of potas-
 sium.  This  agent has been used both  as  an hypnotic and  anal-
 gesic, but still  more   largely in order to control disorders of
 motility—Avhether direct or the  result of reflex irritation.  It
 unquestionably exercises a poAverful influence over the nervous
system, and in cases of poisoning by bromide of potassium the
chief  symptoms have  been  cerebral—such as loss of memory,
confusion and torpidity of thought, a tardiness of comprehension
and answer, with  lethargy.  (Xothnagel.) The symptoms pro- 
316
ACTION  AND INACTION.
duced bv toxic doses of this  agent are those of a diminution of
cerebral activity.   But  other portions  of the nervous system
are affected by bromide of  potassium.   The  nervous arrange-
ments  of  the  circulation are affected by it;  the action of the
heart is lowered by large doses, and  the heart is  brought to a
standstill  in diastole by fatal doses.  (Here the action of potash
as a muscle-poison must not  be overlooked in the production of
these results.)  Toxic  doses  of bromide of potassium loAver the
body-temperature; but Avhether  this is solely due  to  the  effect
upon the circulation, or in part to some arrest of tissue change,
is not  yet determined.  Though the bromide does  affect the
circulation and the temperature, it is rarely if ever ghTen as an
antipyretic, but is mainly  used for its direct  action  on nerve-
tissue.   It exercises a decided effect upon sensation, even  when
applied locally, as to the pharynx ; but still more when admin-
istered internally ; and Waring refers to a case where a sclerotic
and  cornea, into which some grains of gunpowder  had been
bloAvn, Avere thus rendered so insensitive that  the  grains could
be removed.  In cases of  hyperesthesia, or irritability of the
reproductive organs, the effects  of bromide of potassium are
Avell known.  Where  the  system is suffering  from suppression
or repression of the sexual instinct, as in involuntary celibacy,
this drug possesses an almost unique poAver.  Consequently it is
very useful in the treatment of menorrhagia in girls and young
Avomen, and again at the menopause, Avhere there is often  much
sexual excitement, indeed a recrudescence of the  generative
instinct;  but in other forms of  menorrhagia, and in flooding
from uterine tumors, it is useless.  (Ringer.)
   In convulsive disease of  all kinds  it is most valuable, and
especially when associated with  some distant irritation, or of
reflex origin.   According to our best authorities it has entirely
changed the prognostic aspect of epilepsy.   In small doses it
usually exercises but little influence;  but in half-drachm doses
three or four times a day it is a powerful  remedial  agent, often
keeping the fits away for months.  The return of the fits after
its use is discontinued, and their suppression again by resort to
it, demonstrate, and  place  beyond  doubt, its unquestionable
utility.  Its action is, in the  experience of  the  Avriter, most
marked in cases of epilepsy  linked Avith excitement about or in
the reproductive organs.   It is also especially  useful Avhere con- 
ACTION  AND INACTION.
317
 vulsive movements are the result of habit; as, for instance, in
 the  cough which remains after  pertussis, when the specific
 element  has vanished.  It is  of  service in  the  treatment of
 laryngismus stridulus; and is often effective in the treatment of
 chorea.  Xot only does it produce these fairly generally known
 effects, but it exercises a powerful influence over  secretion the
 result of reflex irritation.   Thus Ferrier  found it arrest a diar-
 rhoea in a pregnant woman, where  all ordinary measures  had
 signally  failed.   I have  myself found it  useful in  arresting
 profuse salivation from a decayed tooth ; and in the salivation
 often met with in pregnancy it Avill  probably be found to be of
 similar utility.  As to the vomiting of pregnancy, so intractable
 to ordinary measures, it  usually yields  to the bromide quite
 readily;  and, in my experience, the vomiting ceases not  unfre-
 quently Avithin twenty-four hours from  the commencement of
 the use of this agent;  any7 passing excitement in the generative
 organs may however induce a temporary return of the vomiting,
 even when the arrest  of it by this drug is Avell  marked.  Thus
 we see that bromide  of potassium, or ammonium, possesses  a
 very marked  poAver in diminishing  nerve-activity; and even
 still more in arresting nerve-conducticity, so that in all cases of
 action of reflex  origin it  is invaluable.  That portion of the
 cord which receives and transmits reflex impulse seems  espe-
 cially under its influence. (Wood.)
  The effects of bromide of potassium upon  the cerebrum are
 also very decided.   In the irritability of young children, Avhere
 there is general hyperas3thesia, so that the  peristaltic movements
 even  give pain; in night-terrors, nightmare, and night-scream-
 ings it is very useful.   In all cerebral  excitement,  either in
 children  or adults, it is of service.  Ringer  says, "Sometimes
 in the later months of pregnancy a woman becomes at  night
 the prey of the most  frightful  imaginings,  laboring under the
 impression that she has committed, or is about to commit, some
 great crime or cruelty, as the murder of her children or husband.
 The bromide dispels these illusions, and induces calm, refreshing
 sleep."  In cases of cerebral  excitement,  as in the delirium of
 febrile affections in children, where  there is some vascular ex-
citement  also present, the bromide may be  combined with chloral
hydrate Avith  advantage.    The folloAving  formula  would be
appropriate for a child of six:— 
318
ACTION  AND INACTION.
                      Pot. Brom. gr. x.
                      Chloral Hvdrat. gr. v.
                      Aq. Anethi, 31J.
                         6ta. quaque hora.
In the insomnia of ovenvork, or of mental tension, the bromide,
if less potent,  is infinitely  less dangerous  than chloral;  and,
along Avith camphor or hyoscyamus, is to be preferred to that
hypnotic.
  Finally,  there is another action of bromine, Avhich is  A'ery
valuable, and that  is its power to check the headache, and other
uncomfortable  feelings in the  encephalon, which are produced
in many persons by the use of quinine, or of iron.  The potassio-
tartrate of iron and bromide of potassium  together  can  often
be tolerated Avhere iron alone disagrees; and by giving bromine,
in the  form of hydro-bromic  acid, as a  solvent of quinine,
instead  of some other acid, quinine can be borne by those Avho,
under other circumstancs,  would prefer their malady  to the
effects of the quinine.
   § 128. Such  are the most notable and energetic members of
a  very  important  group of remedial agents.   There are  other
members of this group possessed of similar properties in a less
degree,  as, for instance the  hop, which in the  form of tincture
is often very useful in  insomnia  in gouty conditions Avhere
opium is usually inadmissible.  Commonly the less potent mem-
bers of  this group  may  be  used as vehicles for the more ener-
getic forms with  advantage.  Thus an excellent  anodyne is
formed  by combining  the tincture of opium Avith  the tincture
of hyoscyamus, one part of the former to two of the latter.
   A feAv practical combinations may iioav  be  given.  In  cases
of cerebral excitement with vascular fulness, as in acute pyrexia
or inflammatory affections, not being situated in the brain itself,
opium may be  given with antimony, and
                      Tinct. Opii, TT|,xv.
                      Vin. Antimon. HLxx.
                      Mist. Camph. ^j.
every four or six hours, will be found a good combination  ; or a
grain, or a grain and a half, of powdered opium may be given
Avith five grains of James's poAvder at bedtime  usefully in many
pyretic  affections.
   According  to Fuller, opium acts more powerfully in  the 
ACTION  AND INACTION.
319
 presence of acids  than of alkalies;  consequently in rheumatic
 fever, Avhere the alkaline plan of treatment  is adopted, opium
 may be freely given Avithout fear.   Opium, too, may be admin-
 istered  in  toxic quantities  in severe pain without  danger, and
 in chronic painful maladies, usually, huge doses alone are of any
 service; but on the removal of the  pain the opium  must either
 be  totally  withdrawn  or greatly diminished in quantity7.   A
 full dose of opium may often advantageously  be administered
 half an hour  before any painful  operation, such  as  dressing
 a Avound, passing a bougie, etc.   When given at  bedtime,  as
 Graves  has pointed out, opium should be taken half an hour or
 so before the usual hour of sleep  ; so that its primary stimulant
 action  may get over, and  its secondary sedative action be  in
 force, when the natural  desire to sleep comes on ; and thus the
 soporific effects may unite with  the force of habit. By atten-
 tion to  this rule the action of the opium and the natural incli-
 nation to sleep will harmonize and not clash ;  and the minimum
 dose will so secure sleep.
  The forms in Avhich  opium may  be administered are legion.
 As a fluid, as a poAvder, in pill, as a suppository, hypodermically,
 or endermically, it, and its derivathTes, may be  used.  The plan
 of giving morphia hypodermically is now very  general, and the
 effects of the  drug Avhen so given are very certain and Avithal
 very speedy.   Opium may be applied locally by this means ;  or
 by blistering a surface and  sprinkling it Avith poAvclered  opium
 or morphia; or as a liniment, or  plaster applied to  the general
 surface.   Opium and chloral may often be  combined  with ad-
 vantage, and
                     Tinct. Opii, ufx.
                     Chloral Hydrat. gr. xv.
                     Mist. Camphorae,  §j.
 three or four times a day is an excellent combination in painful
 conditions,  Avhere  there  is also a febrile temperature and  vas-
 cular excitement.   In cerebral excitement, where  the pulse is
 not very feeble, such combination Avould be  useful.  Either
opium or chloral may be combined  Avith bromide of potassium
in certain cases with good results, especially in cerebral excite-
ment in  children, as in the delirium of the exanthemata.  Thus—
                     Pot. Brom. gr. x.
                     Chloral Hydrat. gr. v.
                     Aq. Mentha;, 3ss. 
320
ACTION AND  INACTION.
may be given to a child of sixty pounds Aveight, at intervals of
four or six hours, for tAventy-four  hours, with good  effects in
acute febrile delirium.  The effects of combining two agents
of allied action are often, indeed usually, very satisfactory.  In
cases of excitement  about the generative  organs bromide of
potassium  may be given with hyoscyamus,  Avith good expecta-
tions.
                     Pot. Brom. ,^ss.
                     Tinct. Hyoscyami, 3ss.
                     Mist. Camph. ^j.
given at bedtime in chordee, in nocturnal  orgasm, and sexual
excitement, usually produces excellent results.   Dr.  Clouston
has found  tincture of cannabis indica, of hyoscyamus, and  the
bromide of potassium,  in half-drachm doses each, at bedtime,
a satisfactory  means of  inducing  sleep in restless  talkative
mania.1  In cases of  chorea  Ferrier prefers the bromide of
potassium  to all other remedial agents. Where  there is coex-
istent anaemia,  the addition of iron is indicated ; and in my own
experience bromide of potassium and the potassio-tartrate of
iron in  ten-grain doses  each form a  useful measure, even where
chalybeates in  other forms have failed.
  These are but a few examples of the combinations which may
be used to  control nervous activity.
  § 129. We may now proceed to discuss the subject of morbidly
active secretion,  and the most  successful means of allaying it
We have already seen Iioav neurotic agents Avill affect a secretion
excited reflexly by far-away irritation ; and how opium arrests
certain  secretory actions.  Consequently the use of  opium in
hyper-activity of the secreting surfaces becomes quite intelligible
and  its use  is  rational.  In  all cases of catarrh  from mucous
membranes opium  is serviceable, except Avhen it  is bronchial;
where this agent is to be shunned, except under watchful intel-
ligent care.  In free  secretion from the intestinal canal opium
is ever of service, except where  the diarrhoea is vicarious, com-
pensating  discharge in renal inadequacy, as shown  in Chapter
III. (§ 29), or excited by an irritant mass
  Antrim gents.—This group of agents arrest  the action  of secret-
ing organs, and also check hemorrhage.  Up to a recent period
1 Foihergillian Prize Essay, 1871. 
ACTION  AND INACTION.               321
it Avas asserted that astringents exercised their poAver by virtue
of their action upon muscular fibre, producing contraction of it;
Avhile others held that their action depended upon their capacity
to coagulate albumen.  Neither  of  these hypotheses is iioav
entirely accepted ; and  the  action of astringents  is at present
thought to depend chiefly upon some yet undiscovered action
upon the  soft tissues.   Like tonics, their practical  application
is far advanced beyond our knoAvledge of their modus  operandi;
and the actual efficiency of both these groups of agents  is Avell
established  and notorious.   Astringents  are of  tAvo kinds—
mineral and  vegetable.  The vegetable  astringents are  tannin
and  gallic acid.   Tannin is converted into gallic acid in the
system ; and both are excreted  by the kidneys as gallic  acid.
They both coagulate albumen.   In gastric catarrh the combina-
tion of tannin Avith opium, as  in  the form of compound kino-
poAvder, is ever of service.  Tannin will at times check the loss
of albumen by the kidneys. In  hemorrhages gallic acid and
opium are commonly resorted to, as in menorrhagia, in melasna,
in haemoptysis, or hasmatemesis.   In the  uterine hemorrhages of
anaemic and  atonic individuals, especially in  those of the lym-
phatic diathesis, such combinations are frequently indicated.  In
intestinal  catarrh, opium—with catechu;  with sulphuric acid
and  hasmatoxylin (an  excellent measure); or Avith acetate  of
lead, or sulphate of copper  in pill—is our universal remedial
agent.  In regarding the action of opium in the various forms
of diarrhoea, or rather intestinal fluxes, as  they should be called
here, its effects upon the cutaneous vascularity and  the  sudori-
parous glands must not  be overlooked; the derivative action
may tend  to lessen the flux as Avell as  by its direct action  upon
the  intestinal canal.   (§ 123.)   Be this as it may,  opium  in
conjunction Avith  astringents, vegetable  or mineral, is signally
useful in all excessive secretion from the bowels.  Mineral astrin-
gents are of various forms.   Most of  the bases form astringents
in union with sulphuric acid—the astringent action of the acid
being preserved in the  sulphate.  Glauber's  salts (sulphate of
soda) and  Epsom salts  are, though  purgatives, not without
astringent properties, and may often be  most advantageously
combined Avith  other  astringents.  Thus  in  menorrhagia they
are very useful, the action on the bowels here being an advan-
tage Avhen added  to opium and sulphuric acid.  Even  hemor-
      21 
322               ACTION  AND INACTION.

rhage  from the  boAvels does  not contra-indicate  sulphate of
magnesia in small  doses, especially in passive rectal hemorrhage.
In this troublesome affection, not rare in women, Avhere Avithout
warning they find a gush of blood from  the  boAvels, either at
stool or just on leaving it, a small quantity of sulphate of mag-
nesia along with dilute sulphuric acid is indicated.
                      Mag.  Sulph. gr. xv.
                      Ac." Sulph. Dil. TTL xv.
                      Inf. Cinchon. ^j.
three times a day will usually arrest this loss, as well as other
forms of passive hemorrhage.  Some very  active astringents are
formed, hoAvever,  by the union of  bases with  other acids than
the sulphuric, as the perchloride of iron, acetate of lead, etc. etc.
  In the arrest of secretion belladonna possesses peculiar pro-
perties, especially over the salivary, the mammary, and  the
sudoriparous  glands.   Dryness of the fauces, too, is  the most
marked  symptom of  belladonna poisoning.  The arrest of  the
secretion of the submaxillary gland by belladonna is due, Schiff
thinks, to its paralyzing the chorda tympani.  It has long been
an empirical practice  to paint  belladonna over the  mammary
glands when the lacteal flow is excessive, and satisfactory results
often ensue therefrom.  Recently Ringer  has advocated  the
employment of atropine in excessive perspiration.  He uses from
a sixtieth  to  an eightieth  of  a grain of sulphate of atropine
hypodermically.   It may also be given by  the  mouth, or applied
as an ointment.   The  tincture of belladonna  has yielded good
results in my  hands, both in phthisical and other severe perspi-
ration, given at bedtime in sufficient doses.  (See p. 207.)
  The antagonism of belladonna and jaborandi, as regards their
action over the different secretions, is very marked.

                           Inaction.

  §  130. Under other circumstances, especially in general de-
bility, and, still more, when the activity of the  nervous system
is impaired, Ave administer a class of agents of totally different
character to those just described.   The narcotic agents now to
be  briefly considered  are  those Avhich excite  nervous action.
They consist  mainly  of the deliriant poisons,  of  quinine  and 
ACTION  AND INACTION.
323
 strychnine.  There  is a large amount of evidence  pointing in
 the direction that these different agents increase nervous action
 and stimulate  the cerebral cells to attract more blood, so that
 their functional activity is increased and maintained. Probably,
 to some extent, they also act  upon  the  heart and increase  the
 activity of the circulation.   In belladonna poisoning there is
 extravagant delirium of Avhich no  memory remains; but there
 is no sleep, because the brain is rendered hyperasmic rather than
 anaemic by this agent. (J. Harley.)  The delirium of belladonna
 poisoning, Handtield Jones holds to be due to arterial dilatation
 and afflux of blood to the brain.   Belladonna lias been found
 useful  in  the  treatment of some cases of  melancholia  where
 there  is cerebral anaemia.  Crichton  Browne holds that its
 effects are most marked in the early stages of emotional melan-
 cholia. In conditions Avhere the amount of arterial blood passing
 through the brain falls below  the  norm, belladonna certainly
 seems indicated; for it also increases  the ventricular contractions,
 and raises the  blood-pressure.  In  this it  is the antagonist of
 the calabar-bean, which lowers the heart's action,  and  conse-
 quently is given in conditions of cerebral excitement—as in the
 exalted stage of general paralysis, as well during the paroxysms
 as in the intervals of comparative quiescence—Avith very power-
 ful effects.   In these different and opposite effects  upon  the
 encephalic circulation we see two  classes of agents shadowed
 out which will exercise a profound influence  over the  thera-
 peutics of the  future.   Belladonna acts poAverfully upon  the
 heart, increasing its contractions at the same time  that it con-
 tracts the peripheral  arterioles in many  parts  of the  body.
 This  contraction  has  been seen in the frog's  foot  under  the
 microscope.  By  these  means combined the blood-pressure is
 raised, as it is by digitalis; with this  difference, however, that
 digitalis is not  a deliriant poison.  Digitalis is not, however,
 Avithout an influence upon the brain, and Lauder Brunton found
 visual disturbances  among the phenomena induced by toxic
 doses  of this drug.   In many respects there is  a similarity
 betwixt the action of belladonna and alcohol; only that alcohol
 ultimately dilates the  arterioles of  the  body generally, and so
leads to cerebral anaemia as a sequel to the cerebral  hyperaemia
first produced by7 it.   No  such  secondary action  has been de-
monstrated to belong to belladonna  except in very large doses. 
324              ACTION AND INACTION.

We are not yet, hoAvever, sufficiently acquainted Avith the effects
of belladonna upon the intracranial circulation to lay doAvn exact
rules  for its  administration in cerebral  anaemia.   As a remedy
in certain neurosal affections belladonna has long enjoyed an
empirical reputation, especially in the treatment of  Avhooping-
cough and in the nocturnal incontinence of urine in children.
In the latter case it is supposed to affect those centres in the
spinal cord which  are associated  Avith  the vesical  sphincters.
Possiblv it affects the susceptibility of the centre Avhich relaxes
the sphincter, so that  stronger  stimuli, or impressions received
by the sensory nerves of the bladder, are  requisite  in order to
induce it to relax.  HoAvever this may be, spasmodic contraction
of the vesical sphincter has been  found in cases of  belladonna
poisoning.   Belladonna is as  useful in  allaying the  vesical
irritability of old men, as it is  in  the incontinence of urine in
children.  Where there is chronic bronchitis Avith emphysema
and much nocturnal disturbance from calls to empty the bladder,
belladonna  or atropine  is  the agent indicated  par excellence.
Belladonna stimulates the respiratory centres  in the  medulla,
Avhile it is a sedative to the vesical centres in the spinal cord.
The value of belladonna in painful states, especially neuralgic,
is variously estimated.  Ringer, folloAving Trousseau and Anstie,
regards it as  serviceable;  Avhile Wood holds that it is of little
value in such conditions.   As a local application its analgesic
properties are much more certain and marked.
   A similar diversity of opinion obtains as to the analgesic and
hypnotic properties of cannabis indica.   Our experience of this
drug as a therapeutic agent does  not do much  to  explain its
action ;  though it is Avell known  in the East as a deli riant poi-
son, and is alike used  by the Malays when " running an amook,"
and by the Dacoits of India, who give it in  SAveetmeats; by
means of which they can commit offences Avithout the poisoned
person being able to remember anything, and so being unable to
give  evidence against them.  As such, it is largely  used to rob
persons of their  personal ornaments with impunity.  The tem-
porary condition into which persons are thus thrown by haschish
is  identical with  that  produced  by belladonna poisoning, as
practised by  thieves  in the  middle ages, viz., a condition of
which no memory remains; and  that brought about by stramo-
nium, where  assaults upon the  person  may be  practised with 
                 ACTION  AND INACTION.               325

impunity.1   Medicinally it has been  used to limit  the flux of
menorrhagia and to relieve  neuralgic  pains.  It is also often
serviceable in advanced phthisis, relieving the cough and the
perspiration; though my experience  of it in such  cases  is not
yet extensive enough to enable me to classify the cases in which
it will be found useful.   It is often resorted to as an intoxicant;
the intoxication produced by it  being of  a singularly agreeable
character.
  The whole question of deliriant poisons  is yet sub judice as
regards their use as remedial agents: and there is too  much
diversity of opinion about the action of conium and hyoscyamus
to warrant their consideration here.
  § 131. A somewhat less difficult subject, though far from clear
or simple, is the action of these two prominent members of the
pharmacopoeia — quinine and strychnine.   That these agents
possess a poAverful influence over the  nervous  system is a fact
too Avell known clinically to admit of any question being raised
as to the facts; though Ave  are not yet quite clear as to the
interpretation of them.  Further, Ave ha\7e learned empirically
what are the conditions  Avhich indicate their administration, at
least fairly well.  We use them in certain adynamic conditions
as tonics.  (§ 23.)  Here Ave are concerned with them only in
so far as  they are  neurotics, and with  their action upon the
nervous system.
  To take quinine first: It is Avell known that this agent pos-
sesses  the poAver of giving a sense of  fitness for exertion  of
energy, to persons  lacking  these feelings;  Avhich  it  probably
effects by some invigorating effect upon the nervous system.
Thus it is most  useful in cases of nervous debility, in  convales-
cence from  low forms of fever; it is  also resorted  to  in condi-
tions of fatigue and exhaustion, as a  species of dram, only its
effects are more enduring and persistent  than those induced by
alcohol.  For such  purposes  it is  largely consumed by persons
on  their own  responsibilityr, Avithout medical  advice, as  the
large sale of quinine wine testifies.   It forms a nervine  stimu-
lant and tonic of no mean properties, and is free  from several
drawbacks Avhich attach to alcoholic stimulation.  When  given

  1 It is also used in Hindostan when cruel and painful operations are about to
be performed. 

ACTION  AND INACTION.
in full doses, quinine produces marked  effects  upon the con-
tents of the encephalon  called " cinchonism."  In  this state
there are disturbances of hearing, notably the ringing of bells;
and  disturbances of vision, as flashes of  light;  delirum, and
headache Avith a sense of constriction, often relieved by epis-
taxis.  In fact these are the evidences of encephalic hyperaemia.
The  action of quinine has been subjected  to much observation
and experiment, and any remaining doubts as to its action have
been dissipated by the experiments of Hammond.  {The Psycho-
logical Journal of New York, October,  1874.)
  After long and careful experiment  it Avas conclusively demon-
strated that  quinine  dilates  the cerebral vessels and produces
vascular  congestion of the contents of the encephalon.   There
were increased  action in the carotid and temporal arteries, and
heat of head, Avith congestion of the retina,  and tympanum.
These results Avere such as might have  been anticipated from
our  previous acquaintance with quinine, as furnished by our
clinical experience.   In cases of cerebral anaemia accompanied
by a craving for alcohol—often quite irresistible—quinine is
very useful, and combined with iron  and strychnine often puts
aAvay the craving entirely ; but it commonly returns  in its pris-
tine  intensity Avhen  the action of the  quinine  wears off.   It
is also a potent remedy in  cases of  nervous exhaustion  or  of
ovenvork, but if resorted to merely to Avhip on a flagging  brain,
its use may  be  detrimental; and if  it postpones the collapse,
may make  it all the more severe Avhen it does come.
  In strychnine Ave possess an  agent  of  unquestioned power as
a neurotic.  In toxic closes this drug produces severe and pro-
longed spasms, in Avhich the body  is arched, resting upon the
head and heels.  So  terrible are these convulsions, that  death
is commonly induced in an hour or so.   It is noticed, however,
amidst all  this motor perturbation, that the  intelligence  is
unclouded  and that  consciousness  is unaffected.  This leads to
the conclusion  that  the spinal cord  is the part chiefly affected
by strychnine.  A medical friend of mine once took an overdose
of Easton's syrup.  He says he never felt so  happy as he was
when his legs  were jerking under the  influence of strychnia.
In conditions of degeneration of the spinal cord, especially Avhen
of an anaemic character, strychnia is  very  valuable;  and in cer-
tain conditions of  adynamy, as in incontinence of  urine, it is 
                  ACTION AND  INACTION.               327

 very useful, and  most  so  in  the dribbling of  elderly persons.
 In this it contrasts Avith  belladonna, AAThich seems to diminish
 the susceptibility of the  vesical  centres  in children ;  while
 strychnia appears to stimulate these centres, connected with the
 sphincter, in  elderly persons.   Its effect upon  the cord too is
 to stimulate  the  nervi-erigentes  which inhibit the  ganglia of
 the penis.  Ordinarily these centres, Avhich seem little detached
 pieces of the vaso-motor  centre—centres which have retained
 their original locality while the others  have travelled up to the
 medulla oblongata—keep the vessels of the penis contracted,
 and then the organ is flaccid ; but when the nervi-erigentes are
 throAvn  into  action the influence of these  local centres is sub-
 dued, or inhibited, and the vessels of the corpus cavernosum
 dilate, and the penis  becomes  turgid  and erect.   After  the
 administration of strychnine in many persons this state of erec-
 tion  is persistent.  Strychnia, too, seems  to possess a decided
 action upon the heart, and from this action is often given along
 with digitalis.1  It also acts  powerfully upon  the respiratory
 centre; and  is a true stimulating  expectorant; valuable alike
 in the prostration of acute bronchitis,  and in  the respiratory
 embarrassment  of chronic conditions.   As  a true stimulating
 expectorant, strychnine has a great future before it.  It also
 induces contractions of  the uterus; and is used by some  practi-
 tioners instead  of ergot;  while  its effect  upon the  intestinal
 muscular fibre is  such  that  it is  largely  added to cathartics
 in cases  of constipation allied with inertia of the bowels, and
 in cases  of intestinal dilatation  Avith  partial paralysis  of  the
 muscular fibre.  From  the rapidity of its action, strychnia is
 regarded as lying  midway betwixt  stimulants and tonics.   Per-
 sonally I have  found strychnia  in the form  of  the  tincture
 of nux vomica (tifteen drops), and  carbonate of ammonia (five
 grains), three or four times a day, a capital substitute for alcohol
 in the treatment  of adynamic conditions, and  in commencing
 convalescence.   Strychnine is often administered along with
 quinine and  iron, either in the form  of Easton's syrup, or in
 the folloAving  well-known formula :—

  1 Strychnia acts powerfully  upon the vaso-motor and respiratory centres, in-
creasing their activity.  (Prokop Rokitanski.) 
328               ACTION AND INACTION.

                   Fer. et Quin. ('it. gr. v.
                   Liq. Strychnia;, Tfl,iv.
                   Inf. Quass. 3J. ter in die.
The action of stimulants proper has been given  in Chapter X.
(§§ 95-98), and  need  not be  referred to again here.  ^Ye saw-
there that alcohol increased the vascularity of the nervous sys-
tem, both cerebro-spinal and organic; and that other stimulants
(as ammonia and ether) acted  in  an allied  manner.  Alcohol
even stimulates the movements of protoplasm, in  which there is
no trace of nerve.
   §  132. We  have now seen  that Ave  possess  agents  which
depressor  lower nervous Action; as well as an  opposite series
which will exalt nerve action.  It is true the review here given
is but brief, and that the action of the agents  is sketched in
outline merely.   Many more experiments are required, not only
for Avhat they may directly reveal, but for the information they
may furnish  indirectly in giving aim to clinical observation.
Much indeed has to be done before we can  venture to say defi-
nitely what are the exact actions, often complex  and sometimes
apparently contradictory, of these powerful neurotics whose aid
Ave have so often to invoke.  We can see that  Ave possess  one
group by which we can simultaneously depress nerve action and
lower the circulation, and Avhich  consequently  Ave can wield
with effect in cases of abnormal and undesirable  activity in the
nervous system; while Ave are equally clear that there is also
another group Avhich excites  nervous action, while at the same
time the supply  of arterial blood to the nervous system is in-
creased, and so the action is maintained.   As yet our employ-
ment of these neurotics has been rather empirical than rational;
but, as our knowledge as to  the physiological actions of these
remedies becomes more  precise, so we  shall be able to wield
these agents in practice with more  definite aim  and  greater
certitude.   Even now Ave can calculate with some certainty the
effect that will be produced by several agents, as in the case of
the ordeal bean of Calabar  in the wild paroxysms of general
paralysis; of bromide of potassium in epilepsy and other affec-
tions the result of  reflex  irritation ;  and  of quinine  and
 strychnine in debility and anaemia of the cerebro-spinal centres.
 Further, we can already combine agents possessing opposite or
 even antagonistic properties with advantage, by differentiating 
ACTION  AND INACTION.
329
the exact action of each remedy:  thus in  delirium tremens,
where there is a rapid feeble pulse Avith insomnia and agitation,
digitalis may be combined Avith the bromide of potassium Avith
excellent results; Avhile in cases Avhere quinine produces head-
ache,  often  of a very  distressing character,  the addition  of
bromine, in  the form of the hydro-bromic acid, will usually give
entire relief: so  that the good effects of the quinine  may be
secured Avithout this unpleasant drawback.  So too in the hack-
ing cough of phthisis Ave can give a full dose of opium  or mor-
phia, and by the co-administration of atropine we can  at once
prevent the profuse SAveats, Avhich are so exhausting, and the
dangerous  depression  of the  circulation and  the respiration
Avhich result Avhen  a full dose of opium is given alone; Avhile
the other effects of the narcotic are not interfered with.
  The above consideration of neurotics will not be regarded  as
exhaustive by any reader ; it is very undesirable that it  should:
but it is hoped that what is Avritten here will enable the reader
to classify and arrange  his own views on the matter; and then
perhaps instigate him  to inquire into  and examine  more criti-
cally the action of these powerful agents—and in doing so not
only to inform himself but to instruct others.
  § 133. Irritation and Counter-irritation.—It  has long been a
practice  in  the  art of  medicine  to resort to agents  capable  of
exciting activity,  and especially vascular  activity,  in a part,
when applied locallyT, to relieve abnormal action going  on  else-
Avhere.   This  artificially-excited action was supposed to relieve
and reduce the pre-existing malady; and this line of  treatment
has been denominated  \7ariously, according to circumstances,
irritation and counter-irritation.  It took its origin probably in.
observations of the following kind : in the exanthemata the more
copious the eruption the less the internal complication,ordinarily
at least; and that any retrocession of the eruption was followed
by gravescence  in  the  internal affection; in the metastasis of
gout,  of mumps, etc., as soon as another part became affected the
part originally implicated Avas relieved ; and in the relations of
cutaneous maladies to internal diseases in chronic disease, the
disappearance of the rash often being  folloAved by  a  distinct
exacerbation in the visceral ailment.   By a far from  unintel-
ligible induction our  predecessors concluded that  to set  up
artificially some irritation elsewhere would exercise a beneficial 
330
ACTION  AND INACTION.
effect over the disease they were essaying  to treat.   There Avas
an element of truth in their conclusions ; and unquestionably hot
pediluvia do often relieve head symptoms, and blisters to the
legs are found useful in diminishing congestion of the contents
of the cranium.  The advocates of blistering could  also take a
pretty firm stand on the ground that such  treatment did relieve
and diminish accumulation in the serous sacs, as of the thorax,
the abdomen, and the articulations.  The  good effects here are
distinctly intelligible by the la\v of Schrceder van der Kolk, that
the vascular supply of the deep-seated parts is derived from the
same  arterial  trunks  as  that of the superficial parts.   Any
dilatation of the cutaneous branches  and increased blood-flow in
the superficial distribution Avill diminish directly the current in
the deep-seated vessels.  Thus in inflammation  of the pleura for
instance—the  costal pleura, that is—the application of dermal
irritants, either heat or vesicatories,  Avill  dilate the cutaneous
terminations of the intercostal arteries, and diminish the blood-
supply to the pleural arterioles, and so lessen the vascularity of
the inflamed  area.  This is clear enough. In the same Avay
dilatation of the cutaneous  vessels of an  articulation, say the
knee, will be  followed by a lessened blood-flow in  the  deep
articular  branches of  the  arterial  trunk common to  both.
Further, Brown-Se'quard found that the renal arteries contracted
on irritating the skin  over  the kidneys.   This indicates that
there is something more in this  matter than the mere hydraulic
side of the question.  Max Schuler has found  that  the applica-
tion of large mustard blisters to the cutaneous surface produces
first a passing dilatation of the vessels of the pia mater, and then
a more persisting  contraction  of them;   the  latter  being so
prominent that the contraction  withstood  the  effects of agents
Avhich normally produced dilatation of these  vessels.  We all
know that plunging one  hand  into col 1 water will lower the
temperature of the other hand ; and that " cold applied to part of
a bat's Aving causes contraction of the  vessels of the  correspond-
ing part of the opposite wing."   From all this Ave can compre-
hend  hoAV it may be that counter-irritation may exercise a bene-
ficial  effect  in cases of inflammation  even where the vascular
supply of the inflamed part is not derived from the same arterial
trunk as is that of the  cutaneous surface operated upon.   But,
while admitting this, Ave must OAvn that the modus operandi here 
ACTION  AND INACTION.
331
 is far from being so clear as it is in those cases where the common
 vascular  supply exists, as in counter-irritation in inflammations
 of the  pleura, peritoneum, or the serous sacs of the articula-
 tions ; or in those more chronic affections of joints where there
 is deep seated hyperaemia, which not rarely produces elongation
 of the diseased limb  from the  continued  vascularity  of the
 epiphyses.
   The  laAV of Schrceder van der  Kolk  also  holds good  of the
 nervous distribution ; and as the  costal pleura and the  skin of
 the thoracic parietes are alike supplied  Avith blood  from the
 intercostal artery, so are they furnished Avith their nerve supply
 from the  intercostal nerves.  Thus in the articulations, the deep-
 seated and the cutaneous nerves  spring from common  trunks.
 Consequently the  application of analgesic agents to the  periph-
 eral extremities of the superficial  distribution exercises an effect
 upon the  deep-seated terminations.  That such is a fact is un-
 questionable ; but  it is not yet clear  hoAV the end is brought
 about.  Either there is some reflex  action induced; or some
 deadening effect  is  achieved which  counteracts the  pain-pro-
 ducing irritation of the deeper-seated terminal fibres, possibly
 iu the common trunk.   Be this as it may, there  is no question
 as to the utility of the application of sedative  and  analgesic
 agents to  the surface  over  an affected part—in practice.  In
 neuralgia, gout, rheumatism, as well  as  structural lesions, the
 application externally of opium, aconite, belladonna, chloroform,
 and even chloral hydrate, produces  desirable effects.   It is, in-
 deed, by first recognizing the fact that good does actually result
 from these therapeutic measures, that we shall be led to investi-
 gate the working of them ;  and then  perhaps  some  day even
 understand hoAV the results are achieved.
  As well as these more localized effects of external applications,
 there are wider and more general  consequences of their employ-
 ment which may well occupy out attention for a moment.  The
 application of epispastics to large  areas of the surface for  a brief
 time, so that they are  rubefacients rather  than vesicants, in
 cases of collapse, shock, or even the typhoid condition, is  a well-
 established practice.  The  results are  scarcely the consequences
of the pain  inflicted solely—for pain, when  not  too excessive,
produces a  stimulant action—there  is probably  some effect
produced upon the vascular system generally.   " Dermal irri- 
332
ACTION AND  INACTION.
tants," avrites  Wood, " have a  direct  tendency to  arouse  or
excite the system, and may  be used as  general  stimulants."
When so  used as passing rubefacients, probably the action upon
the intra-cranial vessels is  limited  to that dilatation, which,
Max Schuler observed, occurred in the vessels of the pia mater
on the first application of blisters ; but Avhich Avas followed by
subsequent contraction on the persistent application of the vesi-
cant.   There is nothing in  such  view inconsistent with Avhat
Ave have seen  as  the primary and  then the  secondary effects
of several  neurotic agents, as opium and alcohol  for instance.
The use of dermal irritants  as stimulants is indicated in states
of depression rather than adA'anced exhaustion ; their application
should be  brief, and be accompanied by the exhibition of other
stimulants somewhat freely.
   That cutaneous irritants will  affect  the circulation generally
is admitted by  many men, and some even go  so  far  as  to use
blisters in the  treatment of irritable conditions of the heart.   In
this case, however, there is no attempt at reasoning made, it is
pure  empiricism ;  and the practice obtains most strongly amidst
those whose physiological knowledge and acquaintance with the
circulation least entitle them to form positive opinions.   In the
following  case, dermal irritants were  used Avith an intelligent
idea of Avhat they might achieve, and Avith satisfactory results.
B. W. Richardson, F.R.S., in speaking of intermittency of the
heart, a subject on which he is entitled to be listened to with
every respect, says, " In one instance of intermittency with
palpitation, where morphia could not be tolerated, OAving to the
nausea and depression it  produced, and Avhere quick relief Avas
demanded, it occurred to me to aPP!y a  blister over  the whole
of the  front part of the  neck (the  throat), so as  indirectly to
 influence the sympathetics.   The  effect  in  this case was  simply
immediate for good.  So  soon as the counter-irritation began to
be felt, the action of the heart became quieter, the intermittency
Avas  reduced, and  sleep, Avhich  had  for  several  nights been
absent, became the welcome visitor.  In a second case  a sina-
pism applied  to the throat was instantly beneficial.  'I passed,'
said  the  patient, ' as  the sinapism took effect, from incessant
 restlessness, OAving to the irregular action of the heart, into deep
 sleep, and that so insensibly and rapidly, I Avas not conscious ot
 going to  sleep.'"   In these cases  the good effects  might be ex- 
ACTION  AND INACTION.               333
plained on two separate hypotheses:  (1) direct stimulant effect
dowuAvards to the heart,  increasing  its power; or (2) an effect
upon the peripheral  arterioles, dilating them  and loAvering the
blood-pressure in the  arteries, and thus enabling the heart to
contract more easily in the face of a lessened resistance.   Either
of these  effects, and still  more their union—an hypothesis far
from incredible—would account for the relief experienced.
  This brief  survey Avill someAvhat clear the ground and render
the adoption  of  irritants less a matter of sheer empiricism Avhen
their use is recommended in the ensuing chapters.

  Here  terminates the first half  of this Avork, which so far has
consisted of the inculcation of general principles—either derived
from the laboriously accumulated  stores of  empiricism ; or the
direct outcomes of physiological research—which principles will
be applied in a distinctly  practical manner in the consideration
of  the  various  maladies, of  the different  systems  and  their
treatment, Avhich will next engage our attention. 
CHAPTER  XIV.
                   THE CIRCULATORY SYSTEM.

  § 134. In considering the different  systems of the  body and
the ailments of each—the  practical  application of  what has
been Avritten before—it is obvious that the affections must be
regarded rather according to their indications as groups, than as
individual maladies.  If the latter plan Avere to be adopted, the
second half of this Avork Avould become a mere brief practice of
physic; and that is not  the design at all.  It will, it is believed,
be much more instructive to the reader, and tend more to make
his treatment rational at least, if no other advantage should arise
therefrom, to take groups of maladies and  give  the treatment
of them as a class.   By this means, the reader will have but to
relegate  the case before him to  its proper  class; and then its
treatment, as regards its  coarse  adjustment, will unfold itself.
How to enable  any one  to recognize the peculiarities of a case,
and its individual as compared  to its generic characteristics,
and so to  attain the fine adjustment of  the treatment, except
by the sweat of his OAvn brow, is, to me at least, unknoAvn.   But
there  are good reasons for  believing that by grouping mala-
dies, the individual  reader  may be assisted to perform a series
of generalizations, not  in every case attainable single-handed.
  Before  considering the ailments of each system, it Avill be
necessary to revieAv briefly the  physiological  action of  the
different parts of such system, and the relations existing betwixt
one part  and another.    For many reasons it is desirable to
commence with the vascular system ; and in considering its
maladies, it will be found that they form  natural groups, and
illustrate the propriety  of the principles (just announced), upon
which the latter half  of this work will  be carried out.   The
treatment of each  group will follow ;  and by this means there is
a reasonable hope that the treatment of diseases of the vascular
system will approach, to some extent at least, our present knowl-
edge of these maladies  as regards their diagnosis. 
THE CIRCULATORY SYSTEM.             335
  § 135. The vascular system  consists of a  central  organ, a
hollow  muscle—the heart.  By the rhythmical contraction of
this muscular chamber so much blood  is thrown into the aorta
at each  ventricular contraction ; and  this blood is preA^ented
from  regurgitating into the heart by the aortic valves.   The
arteries  are  elastic and contractile.  The larger arteries  are
rather elastic than contractile; while  the  Avails of  the  smaller
arteries  are  very decidedly contractile, or muscular.  This ar-
rangement permits of the blood throAvn at  intervals into  the
large elastic  arteries being given out by the recoil of the vessels
iu a steady and  continuous flow; Avhile the muscularity of  the
small arteries regulates their calibre, and with it the blood-sup-
ply to the different parts.  Thus, for instance, Avhen food passes
into the stomach the gastric vessels dilate, and so permit of that
free Aoav of arterial blood which is indispensable to good diges-
tion.  Under certain circumstances these peripheral and  muscu-
lar-Avalled arterioles may become generally dilated, as in acute
pyretic  conditions; where Ave find  dilated compressible vessels
with  more or less rapid action  of the  heart.  The blood easily
escapes  out  of  the elastic arteries by  these dilated terminal
vessels,  and the pressure of the  blood within the arteries is  low,
Avhile the ventricular contractions are rapid.   By these frequent
contractions  more  blood is passed into the elastic arteries, and
so they  are kept partially filled in  spite of the quick outgoing.
On the  other hand, in certain conditions, Ave find the terminal
vessels contracted, the outfloAv of  the blood  from the  arteries
much arrested, and therewith a high blood-pressure within the
elastic arteries, and a slow but powerful ventricular contraction.
As a broad  rule, generally true, it  may be said  that the rate of
the pulse and  the blood-pressure  are  in inverse  proportion to
each other:  the higher the blood-pressure the slower the pulse.
At the  same time a more powerful ventricular contraction is
required to  force the  blood  into the arterial system when the
blood-pressure is high, than when there is less  resistance to be
overcome.  Consequently we  find that a persistent high blood-
pressure  Avill induce cardiac hypertrophy, and will also at times
occasion palpitation—a laborious effort of the heart—as a symp-
tom.  It  is very necessary to bear this in mind—palpitation may
indicate  a fairly strong heart struggling against a heightened
blood-pressure;  as  well  as a partially  disabled heart fighting 
330
THE CIRCULATORY SYSTEM.
aAvay with a normal or eA^en low blood-pressure.  The treatment
in the two cases, hoAvever, will be widely  different.
  The blood escapes  from the peripheral ends of the arterial
system into the veins, and so returns to the right heart by which
it is pumped out into the pulmonary circulation, where the blood
is oxygenized ; from Avhence it once more finds its Avay into the
left heart.   It is at once obvious that when the arteries are well
filled Avith  blood the veins Avill be less full; Avhen the arteries
are comparatively empty, the veins will be proportionately full.
Venous fulness then indicates arterial anaemia;  and our line of
treatment, under such circumstances, is to fill the arteries and
so to empty the veins.  In order to accomplish this we admin-
ister an agent which Avill increase the vigor of the heart, while
restraining the outflow from the arteries,  by diminishing  the
calibre of the arterioles: such an agent Ave possess in digitalis.
Consequently, Avhen from  any cardiac  impairment  the  blood is
insufficiently pumped  out of the veins, and the arteries are un-
filled and compressible ; the administration  of digitalis  tends to
restore the lost balance.  It is obvious that this is not the agent
to be chosen Avhen we desire to lower the action of the  heart, or
to decrease the pressure Avithin the arteries.  Yet, from mistaken
notions, digitalis is still used by some for the latter purpose.  No
Avonder is there, then,  that the use of so powerful an agent
should be folloAved by disastrous results if it be given in  the
very cases where its use is  contra-indicated ; or that the drug
often gets a bad name, when really it is the knowledge of the
administrator  that is  at fault.  When we desire  to  lower  the
circulation Ave must select such agents as  aconite, tartar emetic,
&c, which dilate the terminal vessels while lowering the activity
of  the  cardiac movements (p. 107).   These latter agents are
never necessary in disease  of the heart, unless it be in some of
the complications of aortic regurgitation, in its earlier  stages of
massive hypertrophy.   In actual disease of the heart,  what Ave
must eArer strive to attain is a restoration of the normal condi-
tion of the circulation, or an approach to it, by increasing the
capacity of the crippled heart.
   The ordinary forms of primary disease of the heart, i. e. Avhere
the heart  is itself at fault, are those of valvular disease  and
muscular failure.  The valves are folds of the lining membrane
of the heart, Avhich prevent regurgitation of the blood on the 
THE CIRCULATORY SYSTEM.
337
contraction, or recoil, of the Avails of the chamber in front of
them.   If  these vah^es become incompetent to arrest the regur-
gitation, there follows a certain  obstruction to  the blood-flow,
and if this is not met by increased muscular growth—carrying
with  it an accession of power—the  circulation is  so  much
retarded.   Or,  on the other hand, if  from agglutination of the
free edges of these valves the ostium is narrowed, also an arrest
in the circulation is established ; and muscular hypertrophy can
alone restore the lost  balance, and enable an equal quantity of
blood to be driven through a narrowed orifice in an equal time;
an  operation absolutely necessary to  maintain  the working of
the organism unimpaired.  This is well  seen in aortic stenosis,
Avhere there is usually  hypertrophy of the left ventricle, by
Avhich a new balance is  attained.  If  the ventricle is faltering
before the  obstruction, digitalis will  give relief.
  In  aortic regurgitation  the hypertrophy is rather to  arrest
the dilatation of the  left ventricle than to overcome any  resist-
ance offered  to the Aoav of  blood, and in the early stages is
usually sufficient for  this purpose.   But this hypertrophy has
the effect of causing an unusually and  abnormally large bulk of
blood to be thrown into the arterial  syrstem at each ventricular
contraction, Avith the  consequences of overdistending the arteries
and establishing in them atheromatous changes.   Here digitalis,
and its allies, are contra-indicated.  But in the later stages, Avhen
the muscular structure is being cut down by fatty degeneration,
and the power  given  by the hypertrophy is melting away ; then
digitalis may be given as a  palliative, and an agent giving tem-
porary relief,  with advantage.   By attention to the action of
digitalis, and   a careful consideration of the course of  aortic
regurgitation, the  administration of the drug in this form of
heart disease should not be the subject of such diverse opinions
as at present exist.   Whenever  the arteries are insufficiently
filled Avith blood and the heart is faltering, digitalis is indicated,
no  matter  what the  form  of cardiac lesion—unless  it  be in
aneurism, either of the arteries or of the heart itself.
  § 136. In mitral disease Ave  never  have the arteries too fully
distended with  blood.  Here the tendency is ever toAvards arterial
anaemia: no matter  whether the flow of  blood into the  left
heart is obstructed by mitral stenosis ;  or there is regurgitation
through incompetent  valves at each ventricular contraction. In
      22 
338            THE CIRCULATORY SYSTEM.

regurgitation the left veutricle  is very commonly enlarged and
hypertrophied through the rush of blood into it from the gorged
pulmonic circulation and  the hypertrophied right heart.   In
mitral stenosis such enlargement of the left ventricle is never
found.  Though this statement is generally true, it does not hold
good of the mitral disease which comes on  in the latter stages
of " the gouty heart."   But there  the hypertrophy of the left
ventricle precedes and  is causally  related to the mitral valvu-
litis ; and is not secondary to, or the consequence of, the mitral
mischief.  In mitral disease  the compensatory changes consist
in hypertrophy of  the  muscular Avails of the  right  heart with
thickening  of the Avails of the pulmonic vessels.   Where the
heart is fairly hypertrophied, much capacity to  undergo exertion
is furnished thereby ; where  there is dilatation without hyper-
trophy the condition is serious, and the capacity for exertion is
lacking  Our  indications for treatment are then to reduce, if
possible, the demands upon the right heart, and, at the same
time, to encourage its  growth.  The same holds good of right
side  changes,  induced by disease in the  respiratory organs,
obstructing the blood-flow in the  pulmonic circulation.  It is
obvious  that if  the tricuspid  valves become  the subject  of
disease, then little can be done ; any action upon the right auricle
is comparatively useless,  and  there  is  no efficient muscular
chamber behind the right auricle,  i. e. that  is strong enough to
be made practically available.1  Here we may relieve the venous
congestion by appropriate measures, and improve the quality of
blood entering the right heart; but our powers are limited by
anatomical  conditions which we cannot modify.
   § 137. At other times there are  conditions of cardiac debility
without any valvular failure.  Here there  is simply muscular
atony with dilatation of the heart-walls from inability on the
part of the chambers  to  contract efficiently, and  to overcome
successfully, the resistance offered by the  blood already in the
arteries.  At each  contraction a  quantity of blood remains in
the chamber unexpelled, and gradually a condition of dilatation
of the chamber is induced.   In these cases the muscular failure
is due to imperfect nutrition ; not uncommonly combined with

   1 Though there are  strongly contractile muscular  fibres in  the vena cava,
especially the  ascending branch. 
THE CIRCULATORY SYSTEM.
339
 an insufficient amount  of rest, and often with habits  Avhich
 increase the amount of daily demand upon the heart.  At other
 times there is some myocarditis, usually associated Avith peri- or
 endo-carditis,  and the  softened muscular  fibre  stretches  and
 yields before the  demand upon it.  Under  the  circumstances
 hypertrophy Avill often arrest  the dilatation  and endow  the
 dilated heart Avith power.   (Chapter VIII. §§ 71-72.)   In these
 muscular conditions the same line of treatment is indicated as
 in imperfect muscular growth in valvular disease.
   In acute affections of the heart, the  same  line of practice is
 clearly  to be adopted—for acute affections are ever conditions of
 adynamy.  These affections may be either conditions of acute
 heart-failure, as syncope ; or inflammatory states, as pericarditis.
 In the first division no  one would  dream  of resorting to  any
 other than  restorative  measures, alcohol, sal-volatile, etc.   In
 the acute inflammatory states of the heart, depletory or depres-
 sant remedies  Avould not  now  suggest  themselves to  any  un-
 prejudiced mind.   To be sure it is possible that the question of
 meeting the  rising  inflammation might suggest  itself to   the
 mind ; but a little reflection Avill tell us that, as a matter of fact,
 inflammatory conditions of the  lining or external  membrane of
 the heart are never, or almost never, simple inflammations ; but
 rather local expressions of general conditions, as acute rheuma-
 tism, pyaemia, or lithiasis.  Their treatment then belongs  to,
 and is a part of, that of the general condition ; so far as they are
 affections of the heart only do they call for anything especial;
 and in so far they demand the treatment proper to cardiac ady-
 namy, and Avhat such treatment is Ave may noAV inquire.
   Further consideration of the treatment of acute endocarditis
 has convinced me that there is a fallacy in the above reasoning.
 When there is a growth of connective tissue-corpuscles  in the
 fibrous structure of the valves—lighted up  by the acute inflam-
 matory  storm Avhich has passed  over the endocardium, but per-
 sisting after the storm itself has  passed aAvay—it is  desirable
 that the vascular system be kept  as quiet as  possible; so as to
avToid all strain on the inflamed  valves.   To get  the patient up
and to administer tonics  is to increase the blood-pressure within
the heart and arteries ; and Avith them the pressure upon the in-
tracardiac valves.   The rational treatment is to keep the patient
in  bed a week  at  least  after all inflammatory symptoms have 
340
THE CIRCULATORY  SYSTEM.
passed away: and to give chloral or other vascular depressant, to
keep  the  blood-pressure low.   A feAv days more or less in hod
is  of  little consequence compared  to a mutilated  valve and  a
crippled existence. The subject is discussed at length in Chapter
VI. of The Heart and its Diseases.  (Second Edition, 1879.)
  § 138. In the first place, in an organ acting so purely mechani-
cally  as the heart it is absolutely necessary to reduce  to a mini-
mum the  demands upon it.   In order to do this most efficiently
a brief rest in bed for a day or tAvo is  desirable at the commence-
ment of the treatment in most cases.  If the case be  an  advanced
one, the rest in bed must be more prolonged, and  all  exertion
avoided, including straining at stool ; this last is  of  great im-
portance.   The gradually failing heart, losing  ground day by
day under the  necessity for  exertion, w'\\\ commonly, Avhen the
individual is put to bed, commence to regather strength  and
force  ; as is often seen in hospitals, without any other treatment
being adopted.  If the condition be  such as to permit of exer-
tion,  and  the sufferer must make a living, then the lightest form
of labor should be chosen   But in making the selection it must
not fall on a form of labor which, though light in  the main, is
apt at times to call  for severe  effort.  That  is very pernicious.
The effect of rest  in heart affections is such that there is a very
painful difference in the prognosis according  to  the circum-
stances of the  patient:  the  inequality between  rich and poor is
here vividly demonstrated.1
  iSTot only is labor to be avoided, but anything Avhich tends to
tax the poAvers must be shunned.   A debauch is very objection-
able ; and the question so frequently put to one,  about a sufferer
from  organic disease of the heart, " may  he, or she,  marry ?"
must ordinarily  be ansAvered in  the  negative—except in those
cases  of valvular disease where the  valvulitis was  acute, and
there exists no tendency in the  valvular  mischief to progress.
But in the  contracting or  progressive forms of valvulitis mar-
riage is contra-indicated.  Mental strain  and anxiety are also to
be avoided, and the  cares of business are injurious.  If the dis-
ease be pronounced, the sufferer should be ordered to quit busi-

  1 A very common cause of strain upon the weakened heart is that of running
to catch a train or omnibus, especially with a bag in hand.  With elderly persona
such exertion is frequently fatal at the time.  In other cases persisting dyspnoea
on effort is so produced, and the effects remain often for weeks. 
THE CIRCULATORY SYSTEM.
341
ness ; and this may be insisted on with less compunction, as any
grave disease of  the  heart enfeebles the intellect, and renders
the brain incapable of sustained effort.
   All intercurrent maladies should be carefully attended to, as
much less is sufficient  to  kill the patients than is the case in
healthy persons.   Thus all acute ailments  test  the system, es-
pecially if they are affections of the respiratory organs ;  in Avhich
case the  right  heart is  very apt to become exhausted.   All  and
every form of disturbance  and source of irritation must be done
aAvay with as  far as possible.  Botkin, of St. Petersburg, says
that  the severe Russian winter is very trying to patients with
heart disease, and recommends a milder climate  in winter.   A
similar change would be good in the case of the inhabitants of
the colder regions of North America.   The same writer tells of
the irritation caused  by a  floating kidney, and insisted strongly
on the disturbance in the heart's action occasioned by any coex-
isting ailment. In females, affections of the reproductive organs
should ahvays be attended to, and they are  common  in sufferers
from heart disease.1   Hernias should be kept well attended to by
trusses, etc.  The condition of the intestinal canal should always
be carefully watched  and  any disturbance of the health should
be attended to  at once.   There is one point, however, to be well
minded,  and that is  not to interfere with  discharges  too dili-
gently ; they are  often  modes of relief to the congested venous
system.  Thus  hemorrhoids frequently are a means  of  much
relief; and the absence of  bleeding is, in many subjects, accom-
panied by attacks of dyspnoea, which pass away on the return
of a little bleeding from the piles.  Also a certain looseness of
the bowels is often to  be  encouraged rather than  checked; it
relieves the portal circulation.  No rules of thumb can be dog-
matically laid down for the treatment of such intercurrent ail-
ments ; each must be made the subject of deliberate  thought,
and the decision formed accordingly.
   § 139.  As has  been said before, in  disease of the heart  the
tendency is for the veins to become too full of blood, while the
arteries are but  insufficiently filled.   The more marked  the

  1 In a case at Victoria Park Hospital, the attacks of palpitation are more
constant and more severe  during the time a prolapsed uterus extrudes beyond
the vulva. 
342
THE CIRCULATORY SYSTEM.
disease  the  greater the  tendency to venous congestion.  This,
hoAvever, varies much, according to  the form and locality of the
disease.   In aortic  disease, so long  as  the Avails of  the  left
ventricle are sufficiently hypertrophied and  structurally sound,
and the mitral valve is not secondarily affected, venous conges-
tion is not present; and  the mode of relief now under considera-
tion is not indicated.   But under all other circumstances much
relief may  be afforded  by unloading the  venous congestion.
This is often done by spontaneous catharsis ; and purgation  is a
much more  valuable  measure in the treatment of heart disease
than is commonly credited.  The relief afforded by free catharsis
more than compensates for any exhaustion that it produces ; and
the different effect of several copious discharges  from the bowel
in a healthy person and one suffering  from venous congestion is
very marked.  T\vo-scruple doses of compound jalap powder at
frequent  intervals, or some cathartic equivalent,  produce  ex-
cellent  results.1  The possibility, however, of partial  syncope
should be kept in mind, and alcohol and diffusible stimulants
should be at hand, in case of any emergency.
   Relief is  often furnished  by diaphoresis, and  this means of
relieving  venous congestion may be  resorted  to at times with
advantage.   The form of diaphoretic best adapted to heart cases
is that of the application of heat externally.  The bath, how-
ever, should be such as  not to  include  the head, and  nostrils.
Consequently Turkish baths are objectionable as a rule.  Those
baths by  which a patient  may be sAveated in  bed or in  the bed-
room are  the best ; and  Sir James Simpson's bath  may be used
in  the  humblest households (p. 107).  But diaphoresis is best
suited to those  heart cases Avhich are complicated with renal
disease—a very  large class—and  in  this  respect  it resembles
puncture, or tapping.  In pure heart cases I have never seen
punctures do anything  but harm ; in the dropsy of combined
heart and kidney disease they are often useful.
   Diuretics have always been held in high repute in the treat-
ment of dropsy; and an increase in the  bulk  of urine passed is
ever hailed  as a good indication, not only by  the scientific phy-
sician (like  the late Traube), but by the laity  generally.

  1 It has not fallen  to my lot to see any evil consequences follow from this plan
of treatment.  The patients all take digitalis and iron at the same time—a not
unimportant matter. 
THE CIRCULATORY SYSTEM.
343
  The question of diuresis in cardiac dropsy is  so bound  up
 with an increased arterial tension and a more powerfully acting
 heart, that it must be included in the consideration of the means
 of acting directly upon the heart—a subject to be revieAved at
 some length immediately.
  In the attacks of dyspnoea Avhich are so  common in the course
 of disease of the heart, and especially valvular disease, large hot
 poultices of linseed meal faced Avith  mustard, and applied over
 the front of the chest and betAvixt the shoulders, are often most
 serviceable.  The good  effects are produced in tAvo Avays.  One
 doubtless is  the effect of the heat  and  mustard together in
 dilating  the  cutaneous vessels of the  trunk, and in so doing
 lessening  the venous congestion  and engorgement of the right
 ventricle;  and so practically affording the same  relief that  is
 obtained by venesection,  without, however,  the loss of blood.
 The second is the  effect of the warmth upon the heart directly.
 All those who have seen the effect of warmth upon a frog's heart
 Avhen becoming motionless in diastole, will have no difficulty in
 understanding this second factor.1
  § 140.  We  have now come to the means  of acting directly
 upon the heart—one of the most  important matters of modern
 therapeutics.  By increasing physiological knowledge and care-
 ful clinical research, combined with  more accurate observation,
 Ave are beginning to learn something of the means of acting
 directly upon  the heart and increasing the vigor of  its contrac-
 tions.  The chief agent which we use  for this end  is  digitalis.
 This drug has a notable  history, and perhaps  more than any
 other marks  the  passage of therapeutics from the regions of
 empiricism to the  surer ground of the domains of rational medi-
 cine.  Additional interest has gathered  round it from the an-
 tagonistic opinions which have been  and  are still held  by some
 as to its real action.  In past days, when palpitation of the heart
 was held to be over-action of the  organ, and hypertrophy was a
 disease to be subdued by active measures, digitalis was  held to
 be a cardiac  sedative, because it allayed the palpitatiou.  It
 received the  name of " the opium of the  heart."  Nothing can
 be more assured than the fact that palpitation  may usually be
subdued by its use.  But we  noAv know that palpitation is—ex-
1 Hot poultices are good in the palpitation of muscular failure. 
344            THE CIRCULATORY SYSTEM.
cept in  its neurosal forms—the  outward visible sign of cardiac
embarrassment, an active indication of debility  indeed ;  and
that hypertrophy is a conservative and compensatory growth, to
be  encouraged rather than  othenvise.   Consequently  the old
ideas of the Avay in Avhich digitalis produced a quieter action of
the heart have been abandoned ; and truer views of its action
have taken their place.  So early as 1785, Dr. Withering had
observed that as a diuretic it was of little avail in persons with
a tight and cordy pulse.   "On the contrary, if  the  pulse be
feeble or intermitting, the countenance pale, the lips livid, the
skin  cool, the belly swollen, soft, and fluctuating, or  the ana-
sarcous limbs readily pitting under  the  pressure of the finger,
Ave may expect the diuretic effects to follow in a kindly man-
ner."  While Sir Henry Holland found that " the enlarged and
flaccid heart" Avas the condition in which digitalis was valuable.
More recently digitalis has been made the subject of numerous
observations and experiments at home and abroad.  Drs. Fuller
and llandfield Jones maintained strenuously that digitalis acted
as a tonic  to  the  heart, and their  vieAvs are corroborated by
Ringer, Lauder Brunton, Balthazar Foster,  in  this country;
by  Traube, Ackermann, and others, in  Germany; Wood in
America: and indeed by a  host  of other authorities.  When
administered experimentally to animals it is found to bring the
heart to a standstill in systole; and in  my own  experiments I
have found that in the hearts of frogs paralyzed  and flaccid in
diastole, from the effects of aconite, the administration of digi-
talis brought back the contractions;  and,  if the dose were large
enough, produced the opposite condition of firm contraction in
systole.  About this time an opportunity occurred to my friend,
Dr. Wm.  Dobie, of Keighley, of trying  digitalis  in a case of
aconite poisoning Avith complete success.   Digitalis produces its
effects upon the nerves in  the  heart itself, as  Eulenberg and
Ehrenhaus ascertained by an experiment made on a frog's heart
removed from the body.  Opinion  has  been, hoAvever, divided
as to  whether the results are attained by a stimulant effect upon
the intra-cardiac ganglia, or  to a paretic  effect upon the termi-
nal fibres of the vagus nerve in the heart—probably both factors
are  in action, but mainly the first.
  ]Sro doubt, hoAvever, exists now but that digitalis excites more
perfect contraction of the muscular walls of the heart.   The 
THE CIRCULATORY SYSTEM.            345
ventricular systole  is more perfect, and the beats of the heart
are reduced in frequency.   " The diminution in the frequency of
the heart's beat under digitalis ahvays means an increase of the
period of the dilatation of the ventricles.   Pulse-traces readily
show this."  (Balthazar Foster.)  The consequence  is that the
heart's brief sleep is lengthened; and the addition thus given to
its aggregate rest in twenty-four hours is considerable.   This is
one point of much  importance.  Another is, that by its effects
upon  the peripheral arterioles  the outfloAV of blood from the
arterial system is checked, and the arteries are better filled Avith
blood.  This arterial fulness produces a general effect on every
part;  it fills the brain Avith blood, Avhile it increases the blood-
pressure  upon the  glomeruli of the  kidneys, of which the in-
creased flow of urine is the outward visible sign.   The heart
itself  partakes of  the  advantages  derived from the  arterial
fulness; especially as the  aortic recoil is the propelling poAver
into the coronary arteries.  The increased  arterial tension pro-
duces a better Aoav of  arterial  blood to the heart itself; and
betwixt a longer sleep and a better nutrition the  heart often
recovers  its  lost poAver and  regains its  normal condition.   By
such means, together Avith haematics, we  can build up artificially
a  conservative hypertrophy  Avhere nature, single handed,  is
unequal to  the  effort.  Reducing  the  call upon the  heart by
enforced  rest; improving  the quality of blood by  appropriate
measures; and procuring for  the  heart a  longer sleep and a
better supply of arterial blood ;  are  the means by  which we can
enable a failing heart to  recover itself; and postpone the evil
day Avhen recovery  is no longer possible.
  In no  class of diseases has there  been  so  much  improve-
ment wrought in treatment by physiological research as in the
diseases of the heart.  In valvular affections Ave  can do much
to compensate the  mischief done by fostering muscular hyper-
trophy.   In  stenosis, by increasing  the  driving poAver, Ave can
have an  equal quantity of blood  passed  through a  narrowed
opening in  an equal time, and thus the equivalent of a  cure
reached—as  long as that  hypertrophy  can be maintained in
structural integrity.  In regurgitation Ave can partly arrest the
backAvard flow by increasing the blood-pressure, and by develop-
ing the muscular walls  of  the chambers, behind the lesion.  In
cases of simple dilatation of the heart Ave can often restore the 
346
THE CIRCULATORY SYSTEM.
chambers to their normal size; and even Avhen  that is  not
attainable Ave may induce  hypertrophy, and so stay the dilating
process ;  we can build up hypertrophy, and so endow the dilated
heart once more Avith  poAver.  These are not day-dreams, nor
the creations of a vivid imagination; but the  sober facts of
real life.
  § 141.  There  is one  apparent objection to be raised to the
use of digitalis in cases of cardiac debility, and it is this: if
digitalis  contract the peripheral arterioles, and so raise the blood-
pressure  in the arteries, the Aveak heart has a greater resistance
to overcome.  This seems  a grave objection;  but in reality such
objection does  not  exist.   One of the  sensory nerves of  the
heart is  the vaso-inhibitory, or depressor  nerve; and when  the
heart becomes  distended  in  its adynamy, this nerve is, in all
probability, thrown into action and the terminal arterioles are
dilated.   If  this latter condition were not effected by digitalis,
the blood pumped more vigorously into the arteries by the reno-
vated heart would still very readily escape out of them, and the
condition of arterial fulness would be  unattainable—AArhich after
all is what Ave chiefly Avish to obtain.  Consequently the action
upon the peripheral vessels  is  as  important as the action upon
the heart; and the effect of the digitalis is to restore the dilated
arterioles to their normal calibre, not to set up a condition of
arteriole  spasm.  The  digitalis probably only  counteracts the
condition produced by the vaso-inhibitory nerve being thrown
into action.  In those cases Avhere it is desirable to increase the
action of the heart  without  much action upon the arterioles,
then atropine is to be preferred to digitalis.
  Another  ideal  objection is that of  the cumulative  action of
digitalis.  We  hear comparatively  nothing  of  it iioav in the
works of those who have given attention  to the drug:  it figured
conspicuously in the writings of  those who  gave digitalis as
a cardiac depressant.   It  is quite  conceivable that by repeated
doses of this powerful agent, in  conditions  of  cardiac hyper-
trophy,  dangerous, and even  fatal, toxic symptoms  might he
induced.  But surely it is  rather hard that the drug should bear
the  blame which really attaches to  lack of judgment. It has
never fallen to my lot  to see any evidence of the  cumulative
action of digitalis.  If a  drug be given in such doses that it is
taken into the  system faster  than it is given out, there will be 
THE CIRCULATORY SYSTEM.
347
 an accumulation of it in the system, and toxic symptoms in-
 duced; but that surely is no unique action pertaining to digi-
 talis.  In the AAdiole of my experience I have only met with two
 cases in Avhich the drug decidedly disagreed with the patient.
  When this agent Avas given freely in the very cases to Avhich
 it Avas  unsuited, or where  its administration requires the greatest
 caution, it can be no  matter for surprise that  the  consequences
 of its  use, or rather of its  abuse, should be uoav and  then un-
 pleasant.   In several  instances knoAvn  to me, notably7 in a case
 of my own, Avhere  digitalis has been taken uninterruptedly for
 eight years (iioav eleven years), nothing bearing any resemblance
 to what has been described as the cumulative action of digitalis
 has ever been seen.  The cumulative action of digitalis, as  ordi-
 narily  described, has  been greatly exaggerated.   If the adminis-
 tration of  digitalis do not overrun the capacity of the kidneys
 to eliminate it, all  risk  may be avoided.  The  continuous use
 of small doses is the best plan of  treating chronic disease.
  § 142. Digitalis is very useful  in  cases of cardiac adynamy
 for the relief  of the symptoms and consequences of  such  heart
 failure.  This is Avell seen in the relief afforded by it in the free
 bronchial Aoav found in advanced mitral disease.  In no  class
 of cases is there such unanimity of opinion as to the good effects
 to be secured  by digitalis as in mitral disease: and yet if  this
 flux Avere really the measure of the congestion of the pulmonary
 vessels, digitalis  ought to  increase it.   As  a matter of  fact,
 however, it does not do so;  indeed, it is  a most efficient measure
 for the relief  of this condition.   The flux comes from the dis-
 tended bronchial veins—is part of the general venous congestion;
 the inosculations betAvixt the pulmonary and bronchial  veins
 being not nearly so complete as some suppose.
  In cardiac  dropsy digitalis is very serviceable Avhen  given in
 full doses.  In conditions of heart-failure and unfilled arteries,
 Avhere the small bulk of urine is the indication of a Ioav blood-
 pressure;  then digitalis  becomes a  most  poAverful  diuretic.
 Here it acts rather by its effects  upon the circulation than by
 its action upon the vessels  of the kidneys.  As the falling off
 in the bulk of urine is one of the gravest  symptoms of increasing
advancing  heart failure;  so increase in  its bulk is hailed as an
indication of  improvement.  EA^en  those Avho  have still  their
doubts  as to the action of digitalis upon the  heart, admit  that 
348
THE  CIRCULATORY SYSTEM.
its  effects are most gratifying Avhen  there is  a good  flow of
urine induced by its administration.  The explanation is obvious.
In  many cases  real  and  true diuretics may be required, as in
cases where the action of digitalis in increasing the blood-pressure
is also absolutely necessary ; and then digitalis may be combined
with compound spirits of juniper, or nitric ether, or buchu, with
advantage.
  In simple cardiac  debility with scanty Aoav of urine the  fol-
lowing is a pleasant combination: —
                    Tinct. Digitalis,  m_ x.
                    Sp.  .10th. Nit. 3ss.
                    Inf. Buchu, 3j. ter in die.
At other  times potash  in any of its  forms, but especially the
citrate, may be added to this mixture.   In cases where there is
atonic gout combined Avith heart disease, or with debility, potash
and iron Avith digitalis  are indicated.
                    Pot. Bicarb, gr. x.
                    Fer. Am.  Cit. gr. v.
                    Tinct. Digitalis, Til x-
                    Inf. Buchu, t^j.  ter in die,

to  be followed by a good draught of water, and taken half an
hour before meals, is a prescription in constant use in my hospital
practice.  In acute anaemia, Avith palpitation, digitalis may he
given with ammonio-citrate of  iron (grs. v), Avith or  Avithout
 five grains of carbonate of ammonia.   At other  times  digitalis
may be given with astringent per-salts of iron, the per-chloride,
the per-nitrate, or  the per-sulphate;  the little discoloration
which folloAvs  forming no valid  objection  to the combination.
In the  complex condition of cardiac  debility, gastric  catarrh,
copious eructations of wind, and inactivity  of the  boAArels, so
commonly found together in chronic heart disease, digitalis may
best be given in pill.
                     Pulv. Digitalis,  gr. xxx.
                     Fer. Sulph. Exsic. gr. xv.
                     Pulv. Capsici, gr. xl.
                     Pil. Al. et Myrrh, gij. M. fiat.
                     In pil. lx. div. 1 bis in die,
 is  a favorite form with me ;  and  is a good and vet not cumbrous
 combination of agents.  In coated pills the medicine may he 
THE CIRCULATORY  SYSTEM.
349
continued  for  months without the  stomach  rebelling  at  the
nauseous medicine, Avhich digitalis and iron in  mixture  really
are; in this form  it  can  also  be  carried about Avithout obser-
vation, and does not readily spoil; Avhile in such form the iron
does not affect the teeth.   A pill can be quietly swalloAved tAvice
a day after food Avithout trouble or inconvenience.
  In  cases of advanced dropsy it  has been  found desirable to
apply digitalis externally, as a  poultice of the leaves over  the
abdomen and thighs; and excellent  results  have folloAved this
use of the  drug.  In such cases powerful but unmeasured doses
of this agent may be absolutely necessary, and there may be  no
choice; but for my own part,  the cautious  and  yet persistent
administration  of  the remedy in  small  doses, along Avith  hae-
matics and nutritive food, appears the most  satisfactory on  the
Avhole.1  Nevertheless, in  certain conditions of acute asthenia,
or anaemia, it must be given  more freely.  In  states of  cerebral
anaemia it raises the  blood-pressure, and so  fills the  cerebral
vessels.  The  symptoms  of  cerebral anaemia, including even
delusions, Avill be  relieved by its  use.   In delirium tremens it
has been found  useful in full doses;  but  it is  when the pulse is
fast, irregular, and  feeble that its good effects are most apparent.
Where there is  insomnia and  much restlessness  it may be ad-
vantageously combined Avith full doses of bromide of potassium.
  The correct understanding of the  action of digitalis  ; of the
class of cases to which it  is suited;  and  those Avhere its  use is
contra-indicated ; form a subject upon Avhich every  practitioner
and every student ought to have definite and distinct ideas; that
is, if he wish to hold his oavii in the present arduous struggle for
existence.  (For further consideration of the action of digitalis
the reader  is referred to the chapter on Treatment in the writer's
book,  The Heart and its Diseases, with their Treatment: including
the Gouty Heart, 2d edition, 1879.)
  § 143. The different measures detailed above for the  relief,
and  even, in more fortunate cases, cure  of  primary heart  dis-
eases, must all be supplemented by a  liberal supply of nutritive

  1 It is well, too, to give hydragogue  cathartics in persisting dropsy.   They do
not exhaust, but really give great relief.  It has appeared to me that in many
cases of cardiac dropsy the temporary cure has hung on  the administration of
cathartics. 
350
THE CIRCULATORY SYSTEM.
 and easily digestible food.   This combination is most necessary.
 The food must be nutritive, else the improved tissue-nutrition—
 Ave wish to bring about—will  not be secured; and our good
 intentions will fail to attain permanent benefit for the sufferer;
 the good we succeed  in doing Avill be temporary and evanescent.
 If nutrition be defective, cod-liver oil may be given Avith advan-
 tage, when the stomach will  tolerate it.  The food should he
 given in small quantities at once, and at frequent intervals; and
 the  appetite, if defective or capricious, may be stimulated by
 vegetable  bitters, either taken in addition to,  or as the vehicle
 for, the other remedies.   Digestion may be aided by small  doses
 of alcohol ; but the rule of T. King Chambers had  better be
 followed, viz., to regulate the amount of alcohol by its poAver to
 aid in the assimilation of  food ; so long as it increases assimila-
 tion, it is good ; Avhen it diminishes it, it is injurious.   Broadly
 stated, Ave may say that alcohol is  rather indicated during the
 times  of acute failure, than as a permanent  part of the dietary
 in heart affections.
   Then  the food  should be easily digestible.   Little  need he
 said upon this head.   If it be not so, then indigestion is readily
 induced, and added  to the other troubles.   It must  be  ever
 borne  in mind that in heart-failure there is a marked  tendency
 to venous congestion, and  that  this is  especially felt in the
 valveless portal circulation.  The viscera in connection Avith the
 portal circulation share in the  venous congestion; and amongst
 others the  stomach.   There is a flow of mucus, which forms
 gastric catarrh ; and gives rise to that seuse of  fulness of which
 heart sufferers so constantly complain.  The  venous congestion,
 too, obstructs the flow of blood through the  stomach Avhen the
 arterioles dilate in the act of digestion ;  and so interferes  with
 the free secretion of gastric juice.  Consequently the food should
 be of such  a quality  and in such a  form that it shall tax but
 little the  enfeebled stomach.   It is  further obvious that any
 improvement in  the circulation generally will be felt in the
 stomach.   There is also another matter in connection Avith the
 question of food in heart disease ; and it  is this.  The heart is
 only separated from the stomach by the thin diaphragm; and
 any accumulation  in the  stomach, no matter Avhether  solid,
fluid,  or  gaseous,  presses  up the diaphragm, and, diminishing
the thoracic space in which the  heart beats, gives rise to very 
THE CIRCULATORY SYSTEM.
351
 unpleasant  sensations — not rarely forming  grave attacks of
 dyspnoea and palpitation.   Especially is this the case Avhen the
 right side of the heart is taxed and failing.  In  the same way
 distension  of the colon  affects the heart.   These  attacks are
 most common when the  patient  is  in  the  recumbent posture;
 apparently because then the contents of the  abdomen press more
 against the diaphragm ; from Avhich they tend  to fall aAvay by
 their OAvn Aveight Avhen the erect posture is assumed. Supper with
 such patients should ever be light, and taken some hours before
 going  to rest.   The morning meal  may be more substantial in
 character with impunity ; or a small quantity of fluid food may
 be taken toAvards morning.
   Such are the broad principles of the treatment to be pursued
 when the heart  is  itself affected  primarily.  A large  portion,
 hoAvever, of the cases of heart  affection,  for  which  relief is
 sought, are not true ailments of the heart;  but really secondary
 affections of it—consequent upon some disturbance in  the cir-
 culation.  They can iioav be considered after  the actual affec-
 tions of the heart have been reviewed.
   § 144. The secondary affections  of the heart may be defined
 as more or  less complete heart-failure, due  to a  rise  in the
 arterial tension.   It is  clear  enough  that a rise in  arterial
 tension may occur Avhere  the heart is not structurally sound,
 and  then the effects are very serious, as  in angina pectoris :
 Avhich  is often fatal Avhen it occurs in a patient Avliose  heart is
 structurally  unsound, and  whose coronary vessels are much
 diseased.   But  the complaint itself   is due  to an increased
 arterial tension  (as demonstrated  by  the  sphygmograph), oc-
 casioned by arteriole spasm.   This Avas first shown by Lauder
 Brunton (in 1866), to  whom belongs the further merit of
 clearly inferring how the attack  was produced and by what
 means  it Avould be  relieved—viz., by  an  agent Avhich  would
 dilate the peripheral arterioles.  From the physiological experi-
 ments of B. W. Richardson and A. Gamgee he  knew that Ave
 Avere already in  possession of such  an  agent in  nitrite of amyl.
 In a  severe  case of  angina pectoris in the  Royal Infirmary of
 Edinburgh, Avhich Avas unrelieved  by  any  measure Avhich em-
piricism could suggest, the administration of amyl gave imme-
diate relief.  This correct application of physiological knowledge
to the needs of practical medicine by Dr. Brunton is one of the 
352            THE  CIRCULATORY  SYSTEM.
best marked and best known instances of the services scientific
research  has rendered to the art of medicine.  But the line of
thought  so opened up Avas destined to  bear  fruit in  a  much
wider  sense  than, at the time, Avas anticipated by that  thera-
peutic pioneer.  This observation of Iioav to dilate the peripheral
arterioles, and  by doing  so  to lower arterial tension, and thus
relieve an embarrassed circulation,came at an opportune moment,
The early observations of James, of Exeter, and of Bright, that
in chronic renal disease  there  is  a well-sustained and incom-
pressible pulse, together Avith hypertrophy of the left ventricle,
both of which are due to obstruction to the blood-flow  in the
arterioles, had  been further elaborated by George Johnson in
this country, and Traube in Berlin ; both of Avhom, indepen-
dently of each other, had found that  in these cases there Avas
hypertrophy of the muscular Avail of the arterioles.   Here then
Avas the  secret of the obstructed blood-floAV.   The well-known
but  mysterious "gout at  the heart"1 stands noAV unveiled  before
us—it is cardiac embarrassment owing to spasm of the arterioles;
Avhich in its turn is  due to the accumulation of  nitrogenized
Avaste in the blood.  Not only so; but the frequent occurrence
of aortic mischief in chronic Bright's  disease becomes at once
comprehensible, the increased arterial  tension closes the  aortic
valves Avith unwonted force, and valvulitis  is the  consequence.
The forcible closure of the aortic valves gives rise to an abnor-
mally loud  aortic second sound;  and that  accentuated second
sound  is a diagnostic sign of the very greatest value.   Gout at
the heart and gouty inflammation of the valves of the heart are
no  longer  the  mysteries  they have  been, since empiricism first
detected their associations.   In the form of  angina  pectoris—
the  true angina vaso-motoria of  Xothnagel  and  Eulenberg—
this effect of an  increased arterial  tension upon the heart pro-
duces  a terrible and well-marked disease.  In the less perfect
and more  obscure  forms the effects upon the heart are  much
more frequent;  though  less readily recognizable, and  conse-
quently  less  generally  understood.  Xoav, however, that the
secondary  affections of  the  heart have  come within our diag-

  1 The persistent presence of uric acid in the blood of the gouty,  even when
free from manifestations of gout, is amply demonstrated  by Garrod in his work,
chap. vi. op. cit. 
THE CIRCULATORY SYSTEM.
353
nostic ken, they are found to form a large portion of the heart-
affections in which no organic disease is present.  The evidences
of cardiac embarrassment are exhibited ; but Avithout the Avit-
nesses of organic change.
  It is needless to  say  that up to a very recent period  these
cases were but imperfectly recognized ; and  though  the vague
diagnosis of gout at  the heart led to a fairly correct line of
treatment in  those who Avere obviously gouty; in those Avhose
wout was  not apparent  an  imperfect diagnosis led to a  less
successful  practice.   These  cases formed a class of their own,
very troublesome and very  intractable until their nature  was
detected and their pathology correctly interpreted.  Xoav, Iioav-
ever, it has become  possible to recognize these cases, and, Avhat
is more  important to the patient, to treat them  satisfactorily.
Here the palpitation, the irregularity, or intermittency, Avith
their subjective symptoms,  are  not  to be treated so  much by
measures intended to invigorate the heart, as by the removal of
the condition on which they causally depend :  that is, until  the
heart has begun  to palpably fail.   The state of the arteries
must  be our guide in  treatment;  Avhere they are  tense  and
tendinous to the touch, then the line of treatment is distinctly
to loAver the  blood-pressure in  the  arteries.   The reader must
bear in mind, however,  that an atheromatous  condition of the
arteries exaggerates the pulse, and so often misrepresents the
actual condition of  the  heart:  especially is this  the case in  the
failing hypertrophy of " the gouty heart."
  In this class of cases the cardiac troubles are the consequences
of a heightened arterial tension interfering with and opposing
ATentricular contraction, and the removal of this abnormal tension
is indicated.  It again rests causally upon an obstruction in  the
peripheral arterioles, taking  its origin in the presence of excessive
nitrogenized Avaste.   To remove this waste is our obvious duty,
and forms the only means of approach to successful  treatment.
For this end tAvo things are requisite: (1) To remove the waste;
and (2) to prevent its production.   For the attainment of  the
first end Ave  resort to  agents  which  increase the activity of
the kidneys and the other depurating organs, the skin and  the
bowels.  These ends may be attained by the  use of diaphoretics,
cathartics,and diuretics.  The diuretic here to  be selected is  not
an agent which Avill increase the bulk of urine so much, as one
    "" 23 
354
THE CIRCULATORY SYSTEM.
Avhich Avill increase the  amount of solids  in  the urine.   We
desire to cleanse  the blood of its  nitrogenized Avaste; and in
doing so, must remember that the  most permanent form such
waste assumes is uric acid, or the  urate of soda  or  ammonia.
These are all but  imperfectly soluble salts,  whereas the urates
of potash and of  lithia are freely  soluble.    Consequently Ave
must administer these agents, and,  by so rendering  the waste
soluble in the blood serum, permit of its escape by every Avater
emunctory.  The  various natural waters Avhich contain potash
are here  very valuable; and especially so if they are  purgative
as well.  As medicines, the potus impcrialis, and the bitartrate
of potash in barley Avater,  are very useful,  and may  be taken
freely to  the point of purgation.   When  more  concentrated
medicines are prescribed, it is a matter of the first importance
that each close be accompanied by large draughts of water, so as
to imitate the  natural Avaters ;  this makes them much  more
effective.  A good form of mixture is furnished by  the following
combination :—
                Pot. Iod. gr. v.
                Pot. Bicarb, gr. xv.
                Inf. Buchu, gj. ter aut quater in die.
This  should be taken on an empty stomach, and Avashed down
with  a tumblerful of Avater.   If  the pulse be strong and incom-
pressible, and the first sound of the heart good, then ten drops of
colchicum wine may be added Avith advantage.  If, hoAvever, the
pulse be compressible and  the  heart's contractions lacking in
poAver, as where there is dilatation and not  hypertrophy of the
left ventricle, then as many drops of digitalis may be substituted
for the colchicum; this will maintain the vigor of the heart
under the depressant action of the alkalies.   Under a line of
treatment of this kind  secondary affections of the heart will
progress more satisfactorily, both for patient  aud practitioner,
than under  the plan of strengthening the  heart  by the  usual
measures.   When  digitalis and iron  are  given alone for  the
treatment of affections of the heart Avhich are really secondary
in their  nature, the results are either no relief, or even a more
marked  condition;  not uncommonly a hard hammering of  the
heart against the chest Avails, the  consequence of its inability
to struggle successfully against the  opposing arterioles  and the
obstructed blood-flow.  The treatment here  rests very obviously 
               THE  CIRCULATORY  SYSTEM.            355

 upon a clear and  distinct diagnosis.  The use of amyl inhala-
 tions in  such cases is indicated ;  and jaborancli may be found
 very useful, especially in connection Avith hot baths, purgation,
 and the measures just mentioned.
   The relief afforded to the heart by the line of treatment just
 ghTen is often most marked; and the combination of the iodide
 and bicarbonate of p>otash may often be changed to that of iron
 and potash (given in § 141) Avith advantage, after a few days.
 In my oavii personal  experience it has  seemed very clear  that
 the gradual progression from an alkaline to a purely chalybeate
 and tonic treatment, by means of a compromise, is very desira-
 ble, and furnishes the most satisfactory results.
   In addition to these measures, alkaline purgatives, as Seidlitz
 poAvders,  Pullna   Avater,  or, better still,  the bitter  Avater  of
 Fredericshall, or  the Hunyadi Janos Avater, or that of Marien-
 bacl, or Saratoga, or Hathorn Avater, are very useful adjuncts;
 especially if there be  anyT overt evidences of gout manifesting
 themselves.  Such purgation, along Avith  colchicum,  is  often
 very advantageous.
   To fulfil the second indication, it is necessary to regulate the
 diet.   Slops, bland fluids, as milk  and seltzer Avater, or arroAv-
 root,' or   sago, variously  flavored, should  form  the  dietary.
 Kitrogenizecl foods, as meat, soups, and beef-tea, Avhose use often
 passes into abuse, are to be Avithheld ; during the early part of
 the treatment at least.  Nowadays it is fashionable to resort  to
 beef-tea in season  and out of season ; and to ignore the fact that
 its nutrithTe  poAver is Ioav, the amount of nitrogenized matter
 comparatively high, Avhile most of it is  too far advanced  to
 undergo anything but retrograde changes.  Of extract of beef
 this last is still more  true; and its value as a food is almost nil
 — it is an  agreeable stimulant.  Light puddings, as tapioca  or
 vermicelli, and Avhite fish, Avith vegetables or fruits, should form
 the diet for some time; and  it is only when the  brunt  of the
 affair is over, and the consequent debility is the chief matter to
 be attended to, that a more liberal dietary is indicated.  For
 some time, hoAvever, the alkaline, and often the mixed  alkaline
and chalybeate treatment, must be continued after convalescence
is established.
  The reader may refer to  Chapter III., §§ 31, 32 ;  Chapter XL, 
353
THE CIRCULATORY SYSTEM.
§§ 107-111 ;  and to Chapters XVII. and XXIII. in connection
Avith this subject.
  The success which attends the treatment of secondary affec-
tions of the heart  by measures which Avould prove but simply
disastrous in primary affections of that  organ, being, as they
are, direct depressants, is all that  is required to vindicate the
diagnosis, and to justify  the separation of heart affections into
the divisions made above.   Of course if there be also present
some  primary debility, or organic  disease of the heart, then a
complex treatment must be adopted to meet a complex malady.
  It is much to be regretted that the division here given is not
more  generally and universally recognized.  Xot only  Avould
patients  benefit thereby ; but those differences of  opinion as to
the existence of actual heart disease in these cases, Avhich con-
stitute one of the  opprobria of our  profession, would be avoided.
In cases of secondary disease of the heart, exercise  and effort, so
objectionable and  injurious  in  primary heart  disease, may be
indulged in not only without injury, but with advantage.  The
attacks of cardiac embarrassment in these cases are not associ-
ated Avith effort; while exercise, by leading to more perfect oxi-
dation, tends to diminish the amount of uric acid in the system.
Of course Avhen the hypertrophied heart is failing  then  effort
affects it, and digitalis is indicated.
  § 145.  Another division of affections of the heart is that Avhich
may fairly be denominated the  neurosal.
  Many conditions produce an  abnormal Avorking of the heart,
especially in persons of a nervous  diathesis, or in those reduced
to an anaemic or debilitated state; there are also other conditions
Avhich also give rise to palpitation and disturbed  action of the
heart.
  In  persons  of a  nervous diathesis  hysterical palpitation  is
common.  It is due apparently  to a contracted condition of the
arterioles; and in some persons there is  a certain amount of
hypertrophy produced in time.   The  subjects of this  class  of
ailments are usually Avomen, mostly spinsters, and but compara-
tively rarely mothers, and  there is not unfrequently an ovarian
element in the case.   Bromide  of  potassium with iron, and the
external application of  a belladonna' plaster, are  the  measures
best suited to this division of heart ailments.   The occupation
of the mind in some useful  Avork is also  very desirable. 
THE CIRCULATORY SYSTEM.
357
   It, hoAvever, happens that in some cases  the affection is dis-
 tinctly neurosal, and yet it is in no Avay related to Avhat Ave term
 hysteria.  Here quinine and iron, with strychnine, as in Easton's
 syrup, form a suitable measure to be adopted.  Such an affection
 is often associated Avith constipation or abdominal fulness, and
 this should be attended to forthwith.  Botkin, of St. Petersburg,
 advocates the use of nitrate of silver in cases of cardiac irrita-
 bility;  and recommends, at the same time, the relief, or, better
 still, the removal  of every form of coexisting or intercurrent
 malady Avhich may possibly form an exciting cause of this irri-
 table action.  The palpitation Avhich coexists Avith prolapsus of
 the Avomb is at  once greatly  relieved on the Avomb  being pro-
 perly replaced, and Avithout it  the ordinary treatment is ineffi-
 cacious.  This has occurred to many of my patients at Victoria
 Park Hospital.   Frequently excited action and palpitation are
 found in Avomen associated with  an irritable  condition  of the
 ovaries.  Here  the treatment  must be conducted on  the lines
 laid down in § 187.
   It  must neA'er be forgotten, however, that irritability of the
 heart is most commonly  associated Avith  indulgence in two
 neurotic poisons, tea and tobacco.  The  first is very common in
 women, very common  indeed;  while the  second is  far  from
 uncommon in men; indeed,the ailment used to be denominated
 in the Edinburgh Royal Infirmary " smoker's heart."  For the
 successful  treatment of these neuroses  the  removal of the ex-
 citing cause is the first and most necessary step.  A little  careful
 attention to the case  will usually determine  it  to belong  to
 neither  of  the preceding divisions: so that it falls by exclusion
 into this last class.  The  action of the heart in these cases is
 irregular in force and rhythm, and there are attacks of palpita-
 tion at intervals; as also times when the heart's action seems to
 be temporarily arrested.  In  these cases the favorite  neurotic
 must be abandoned, or its use much restricted ;  and the general
 health must  be attended  to.   The results of treatment will
 usually speedily  allay any apprehensions Avhich may  exist as to
 the possibility of actual organic disease of the heart.
  At other times a  similar  condition of the heart Avill be found
 in connection Avith  much indulgence of the generative  instinct;
and here restriction, with  attention  to  the general health, is
necessaryr. 
358
THE CIRCULATORY SYSTEM.
  In all these cases the rules and principles of treatment are to
be arranged according to the exigencies of each individual case.
In the treatment of neurosal affections of the heart Clifford
Allbutt, Da  Costa, and  others  have spoken  highly of opium.
Unfortunately they have not sufficiently discriminated the cases
in which it may be resorted to with  advantage to furnish any
rules for its use, and I cannot supply them; the more  that my
OAvn experience goes  strongly  against the use of opium and
morphia in heart affections; except in  the less pronounced con-
ditions of functional disturbance of the heart.  In actual disease
its use is inadmissible; and  the late Hyde Salter denounced,Avith
much eloquence, the administration of opium in the distressing
insomnia  of advanced  heart  disease.  Here  its  use is simply
fatal: it is all the patient can do to maintain respiration by the
most energetic voluntary efforts:  arrest those efforts by opium,
and  the  patient Avill  sleep—but it will be the long, dreamless
sleep which Icuoavs no awakening.
  § 140.   "Irritable  heart" is  the term  Da  Costa has  aptly
applied to a large series of cases  of disturbance of the heart
which first attracted his attention  in the recent American civil
Avar.  lie says:  "The general clinical  history of many of these
cases was this—A man Avho had been for some months or longer
in active service would be seized Avith  diarrhoea, annoying, but
not severe enough to  keep him out of the field ; or, attacked
Avith diarrhoea or fever, he rejoined, after a stay in hospital, his
command, and again underwent the fatigues of a soldier's life.
He soon  noticed  that  he could  not bear them  as formerly ; he
got out of breath, could not  keep up with his comrades, Avas
annoyed with dizziness  and palpitation, and Avith pain in the
chest:  his accoutrements oppressed him, and all this though he
appeared Avell and healthy."  It Avas not connected with indul-
gence in  tobacco or the  injurious  agents just alluded to above;
though they aggravated the mischief and kept it up.  It Avould
appear that the  ailment  was  induced  by some intercurrent
depressing affection, shoAving itself in a person previously sub-
jected to  excessive demands  upon the poAvers.   In such cases
the heart  becomes disturbed and enfeebled, and this condition of
it is apt to be persistent and intractable to treatment.  Da Costa
has carried his iiwestigations on this subject into other fields of 
THE CIRCULATORY SYSTEM.
359
inquiry, and has found that excessive exertion is apt to induce
a disordered  heart.  This  is especially  the  case amidst  those
who lead a high-pressure life, and avIio are also mentally  much
engaged.   Consequently Ave cannot  be  surprised  that  heart
ailments—if not actually heart diseases—are growing more and
more frequent, and that they will continue to grow in frequency.
These are important subjects for our consideration in the matter
of prevention as well as cure : this class of ailments is a growing
one, as well as  a difficult one  to  treat  successfully.  In cases
Avhere  there is little  or  no  anaemia, digitalis, especially with
bromide of potassium, is indicated in small but continued  doses.
A belladonna plaster  might be employed externally, or even
some counter-irritation resorted to.  Da Costa says "the  treat-
ment  is never  a  short one."   Rest, quiet, good food,  bracing
atmosphere, and cheerful surroundings are all desirable adjuncts
to the  strictly medical treatment in these cases.  Much of the
cardiac disorder Ave are called  upon to  treat presents many of
the features of this "■ irritable heart,"—often associated Avith
the consumption  of much lean meat, under the impression that
there  is debility  present  which  must  be  met by nourishing
food—and the treatment must be directed to the different factors
of the  case.  When  the case  is  complicated with imperfect
blood-depuration, this last  must be attended to and corrected.
Irritable heart is certainly  becoming  more common.   In my
own experience it has occurred most frequently among doctors
themselves.   Men of  a  neurosal  temperament and in large
practice: men Avho carry a part of their patients' cares as Avell
as their oavii.
  § 147. At other times there exists a tendency to palpitation,
especially on  effort,  with accompanying dyspnoea, in young
persons, mostly females.   In this  class of cases  there is also
pronounced  anaemia.   There are venous hums and very often
a systolic bruit, aortic, or more often pulmonary.   The hremic
murmurs  cause these  cases  not uncommonly to  be mistaken
for organic disease of  the heart; and much uncalled-for anxiety
and alarm are occasioned thereby.  Whatever the cause of the
anaemia, whether imperfect food,  impaired  assimilation, or an
exhausting drain, the exciting cause must be removed;  and
good food, tonics, and chalybeates must be  given.   The treat- 
360
THE CIRCULATORY SYSTEM.
ment of the anaemia is the treatment of the cardiac trouble;
and  the heart itself is not to  be treated, unless a belladonna
plaster be indicated by piersistent palpitation.   Ln  these cases
it is  often well to put  the  patient to bed for a Aveek or two at
the outset of the treament.
  Such are the different morbid conditions of the centre of the
vascular  system and their indications for treatment, so far as
they permit of being sketched  out in this brief manner.  In no
ailments  Avhatever  does  the  successful  treatment  rest more
distinctly upon  the  accuracy of the diagnosis—not only as to the
exact pathological condition, but as  to its Avhy and Iioav, and as
to the general conditions with which it is associated.  Take the
condition so commonly found, viz., dilatation Avith some hyper-
trophy.   It may occur in a young man who has persistently
ovenvorked himself; Avhere it is readily amenable to treatment.
It may be found in a  middle-aged woman, who  has had it for
years, and in Avhom palliative treatment is  fairly successful;
but Avhere anything like cure is out of the question, though life
may  be preserved for a long time.  Finally, the dilatation may
indicate the yielding of an hypertrophied heart, whose structure
is  being  cut down  by advancing fatty degeneration, and  the
indications so furnished point to a hopeless downward course—
but  little affected by  treatment in  most cases, and Avith  the
inevitable end  not  far distant.   Xoav it is obvious that it is of
the utmost importance to discriminate betwixt these similar but
really unlike conditions;  to be able to distinguish those cases
which  admit of being benefited by  treatment, from those that
do not.   In palpitation, too; how different  are the measures to
be adopted  in the  palpitation of muscular failure, and in the
neurosal  palpitation with  unfilled vessels Avhich  is common in
girls, and Avhere there seems to be  a discharge of accumulated
energy in the cardiac  ganglia.  The man Avhose creed is that
heart diseases  are  not to  be  improved by  treatment is  not
likely to be successful in  his practice;  the man who does not
discriminate his cases will also  bring  much  discredit upon
measures  Avhich are signally useful Avhen properly employed;
but  powerless, if not  actually mischievous, when  misapplied.
It is to be trusted that  the reader will belong to neither division;
but  Avill  be one of that rapidly  growing class  Avho recognize 
THE CIRCULATORY SYSTEM.
361
that the treatment of heart affections is often most satisfactory ;
and who further cle\7elop  their usefulness  by educating them-
selves to detect and  distinguish those  cases which admit of
treatment;  and Avho are also learning how best to treat them :
and so are  enabled  to separate  a large class of affections ad-
mitting of  beneficial treatment, from another class of maladies
for Avhich little or nothing can  be done—except in the way of
euthanasia.
  § 147a. The only ailment of the vascular system, not cardiac,
of which it  is necessary to say anything  here  is  aneurism.
Here a certain portion of  the Avail of the elastic arterial system
is weakened and impaired; and  a sac is formed, Avhich  sustains
the same pressure  as the  arteries  generally.  If  the blood-
pressure be high, the aneurism is prominent and pulsates power-
fully ;  if the blood-pressure be  lowered, the aneurism recedes
and its pulsations are  less  distinct.  It is obvious then that the
best means of avoiding rupture of the ansurismal sac is to  keep
the blood-pressure Ioav.  The Avell-knoAvn plan of Albertini and
Valsalva was to starve the patient by hunger and venesection.
This lowered the blood-pressure and the  patient, both.   Xow
we can loAA^er the blood-pressure by aconite or hydrate of chloral.
This is  an  important  part of the treatment.   The other part of
the treatment is directly  curative—to procure layers of fibrine
within the sac until it is filled and the aneurism is cured.   For
the attainment of this end it has been found useful to administer
iodide of potassium.   To Dr.  Balfour  belongs the credit of
strongly advocating this  plan of treatment first  suggested by
Graves, in  addition to a restricted diet and general quiet.   The
importance of the latter is obvious.   If to  this be added small
doses of chloral hydrate, a treatment will  be adopted which is
theoretically perfect;  and  further it is practically useful.   The
utility of such union is well seen in a case of thoracic aneurism
for many months under care at the West London Hospital.  It
is in the ascending aorta  in a hale, muscular man with a power-
ful heart, and by these combined measures a cure is apparently
being brought about.  He is still an active man ; and the aneu-
risrn is  certainly no worse.  (Second Edition.)  In defiance of
Avhat Ave now know of the action of digitalis and its effect  upon
arterial  tension, unreflecting persons still  give  it in  cases of 
36:2               THE  CIRCULATORY  SYSTEM.

aneurism;  and  so add  to the already existing  danger of rup-
turing the  sac.

  Note.—At p. 355 it is stated that the use of nitrite of amyl  is indicated in
secondary affections of the heart.  This is not a mere surmise.   After the inhala-
tion of five drops of amyl the hard,  slow stroke of the heart and incompressible
pulse of such conditions, are converted into the rapid, light stroke and compres-
sible pulse of pyretic states.   This  change continues two  or  three minutes.  In
the treatment of palpitation so associated, and in imperfect attaeks of angina, the
inh.alation of amyl will, there is ever}' reason to believe, be as effectual as it is in
well-marked anginose attacks. 
CHAPTER  XV.
THE RESPIRATORY SYSTEM.
  § 118. By meams of respiration the system gets rid of most of
its carbonaceous waste, and of a quantity of Avater, while at the
same time oxygen is freely taken up by the haemoglobin  of the
red blood corpuscles.  In order to admit of these interchanges
air is drawn into the thorax;  mainly by the  sucking power of
the diaphragm and  intercostal muscles,  through the trachea,
which  divides  ultimately  into myriads  of terminal  air-tubes
with alveolar dilatations at their termination, over which are
spread  the pulmonary capillaries.   In animals who live in water
the respiratory  organs float in  the  fluid, and  often are pro-
trusions outwards of the pulmonary vessels.   When the respi-
ratory  changes are wrought in air, the  air  is  sucked in. In
consequence of this  the respiratory organs are  affected  by the
temperature of the inspired air;  and are also liable to mechani-
cal irritation from jninute particles in that air.   From the first
.Ave get colds;  and in the second we find a very  effective provo-
cative  of tissue changes.   The  mucous membrane of the respira-
tory organs is also liable to be affected by general conditions, as
the presence of gout-poison in the system.  Such are some of the
reasons why the  respiratory  organs are so often the  seat of
disease.   The  constant  necessity for  motion  and functional
activity in the organs of this  system, furnishes an explanation
Avhy diseases in them  are persistent and often  intractable.  If
the parts could  be  rested, their repair  would be wondrously
facilitated.  When laryngeal  disease is about to asphyxiate the
patient,  tracheotomy  not  only  gives  immediate relief, but
commonly leads to the cure of the laryngeal disease.  This it
accomplishes by the rest  it  furnishes.   That the rest is the
curative agent is shown  by  the fact that if the person upon
whom  tracheotomy  has  been  performed is a talkative person,
the repair is much slower than where more perfect rest is given
by taciturnity.   The application of the principle of rest to the 
3«U
THE RESPIRATORY SYSTEM.
treatment of disease Avithin the  thorax has been  successfully
attempted.   Dr. F.  Roberts advocates the strapping of oncdialf
of the thorax, in cases of  unilateral  disease, so as to render it
more immovable; and the results of  such treatment  are  satis-
factory.   The  plan  is  eminently  rational; and  has long been
practised in the  case of a broken rib, where the fractured por-
tion, in  the  movements of respiration, rubs the pleura into an
inflammatory state.   The painful  or  unpleasant  sensations pro-
duced  by exertion in extensive disease of the respiratory organs
usually secure for them the modified and  partial  rest of general
quiet.
  The irritation caused  by inspired particles is the  cause of
most of  the chronic interstitial pneumonia, with dilatation of
the  bronchi, Ave  so  commonly meet Avith ;  and Avhich is often
mistaken for phthisis Avith cavities.  As Ave have seen (Chap.
VIII.  §  74\ tubercle is but a lowly form  of tissue-groAvth; and
this condition of cirrhosis differs from that  of pulmonary tuber-
culosis chiefly in the better  chance  of life it gives.   In  each
case, Avhether a miller  Avith  chronic  inflammatory  changes
in his  lungs, or a needleAvoman in  a garret Avith phthisis, Avhere
smuts, &c, are inspired to the great irritation of the  diseased
surfaces, avo insist upon a change of air.  It is not only that an
atmosphere largely  charged Avith  oxygen in an  active form  is
to be preferred to one Avhich has been breathed and rebreathed
until its active oxygen is exhausted, for its  general tonic effect;
but also that the air of the country, and especially the sea-side,
is comparatively free from the  organic particles Avhich act as
direct  irritants to diseased  lungs.   Where change of air is not
practicable, respirators of cotton-Avool, Avhich arrest these parti-
cles, are  very  useful.    The hopelessness,  which hangs  OA'er
diseases of the respiratory organs  in  the  poor in towns, is due
very much to the air they breathe; laden as it is Avith  irritant
particles—sometimes, too, also irritant by their chemical quali-
ties, as well  as  to  their systemic  deficiencies.   Everything  is
against them!
  In consequence of their being  the means by AAThich air  is
respired, the organs of respiration are specially liable to  be
affected  by changes  of temperature.   We see in the  gloAving
hands of the snow-baller the consequences of a sustained appli-
cation  of cold in the resultant hyperaemia, and Avhen cold air is 
THE RESPIRATORY  SYSTEM.
365
respired  the  lining  membrane of  the  turbinated  bones,  etc.,
becomes  turgid with arterial blood.  By this means the air is
warmed in its passage into the thorax.  The importance of this
warming of the respired  air is seen in the tendency to pneu-
monia in persons upon Avhom tracheotomy has been performed,
unless a  Avarm temperature surrounds  them ; and  also  in the
tendency to thoracic inflammation  in infants after exposure to
cold, if they cry and so breathe the cold air through their mouth.
Who has ever watched an unhappy infant crying with cold,
and seen  the uiiAvarmed air entering its  thorax, without feelings
of keenest apprehension as to the consequences ?   It is also  seen
in the fact that Avhen nasal catarrh—itself the consequence of
acute hyperaemia—has obstructed our ordinary channel  of res-
piration,  and Ave breathe through the mouth, then inflammation
of the lining membrane of the thoracic portion of the respiratory
track is commonly instituted. The exact point when hyperaemia
of the-air-passages passes into inflammation cannot be defined;
and there is a difference of degree only betwixt the  rheum from
the nose,  occasioned by breathing very cold air, and the catarrh
of inflammation.  The normal hyperaemia occasions the one; the
more pronounced condition of inflammation furnishes the other.
In the same way the condition of the individual often determines
whether  of these  tAvo results  shall be produced by a certain
amount of exposure.   If the individual be perfectly healthy, and
the organism  be in good condition, then only hyperaemia with
its consequences will  be induced ;  if the  person be out of health,
and the system impaired  as regards its resistive and self-pro-
tective poAver,  then  inflammation and  its  sequels  will  be the
consequence.   The question is  one of degree in different indi-
viduals, or of times and states in the same individual.   If the
body  be heated by long exposure to a  high temperature, com-
bined Avith exercise,  the cutaneous \ressels are full of blood, and
heat is rapidly lost on exposure to cold.  If that exposure but
dissipates the accumulated heat, it is pleasant, and not injurious;
but if it be carried further, then such heat-loss may be induced
as shall depress the  body-temperature—the catarrhal pyrexia.
If the tone of the cutaneous vessels  be lost by reason of general
exhaustion  or tire, such a result is  more likely  to  follow than
in the case of an  unexhausted  person.   One avIio is  not quite
well,  or avIio  has  been ovenvorked, Avill  be  more  likely to 
OUO
THE RESPIRATORY SYSTEM.
undergo much heat-loss on such exposure than a perfectly healthy
individual.  The general loAvering  of  temperature Avill  deter-
mine often whether the hyperaemia of the air-passages shall pass
into inflammation, or not.  Hence the readiness Avith which
the Aveak and those  unaccustomed to  exposure catch cold, as
compared to the strong and inured.
  § 119.  The treatment of an acute catarrh must be conducted
on principles which are founded on a knowledge of the pathology
of the affection. At first there has been an abnormal depression
of temperature, a lowering of the body-heat; then follows a rise
of temperature and a pyretic state; this  gradually defervesces,
and the wonted health is recovered.  In our treatment, then, we
must  aim  at  aiding  these natural processes.  If  the catarrh
could be caught at the outset, then some hot fluids, more or less
alcoholic, and a full dose of paregoric, or Dover's powder, at bed-
time, and a Avarmed bed, might be sufficient for the restoration
of the patient.  More commonly, however, we are not consulted
until a more advanced condition is reached ; and there is a dry,
imperspirable skin, a pyretic state, with a congested condition of
the lining membrane of the respiratory track, in some part of
it.  There may, or may not be  any cough.  There is always,
hoAvever, some difficulty  in  breathing.  For the relief of this
condition of vascularity, it is necessary to relax the skin, as the
old phrase ran ; or, in more recent  phraseology, to excite cuta-
neous action, and dilate the cutaneous vessels.   It is well to com-
mence Avith either five grain  of James's powder or of Plummer's
pill, Avith or without a grain of opium, at bedtime; and in the
morning a seidlitz powder, or some of the bitter Avater of Fred-
ericshall, until a gentle action of the boAvels is set  up.  But
much purgation is studiously to be avoided, especially if the
patient be weak, or the attack severe ;  in these cases the powers
must  be husbanded, for they may  come to be severely taxed,
especially  if  the  catarrh  be intra-thoracic.   There are  many
patients  who  catch still more cold from  the exposure  during
purgation, especially in  country districts, where  there is not a
night-chair in the house;  this is a matter the young practi-
tioner Avill do well to heed.  The next measures usually adopted
in these  cases are something of this kind :—
                     Yin.  Antimonialis, Tfl. xv.
                     Liq. Am. Aeetat. 3J. 
THE  RESPIRATORY  SYSTEM.
367
every four or six  hours, and to give hot slops.   At other times
it may be desirable to give the following:—l
                      Pot. Iod. gr. v.
                      Liq. Am. Acet. ^j.
instead of the first, especially where the  patient is Aveak or the
system  impressionable to  depressants.    The  best  household
remedy is ipecacuan  Avine, Avhich  is  infinitely less  hazardous
than antimonial wine ; for the latter  may be given beyond its
emetic action, Avhile large doses of ipecacuan  are free from such
danger.   If  vomiting be induced,  especially in  children, it  is
useful.  After free  action  of the skin has been induced, then
something like the folloAving mixture may be given:—
                      Ac. Hydrochlor. Dil. TH x.
                      Sp.  Chloroformi, HI xx.
                      Syr. Scillaa, gj.
                      Aquas  ad §j.,  ter in die;
                  or
                      Ac. Phosph. Dil. m xv.
                      Inf. Cinchonas, §j.
if there  be nasal catarrh  only;  and Avhen more  convalescent,
some of the numerous combinations of iron and vegetable tonics
already given may be prescribed.
  It is often  desirable to inhale steam in affections of the lining
membranes of the respiratory tract;  and  for  this  purpose an
inhaler may be  used, or, in humbler homes, a jug of hot water.
How far the good effects of the  steam may be aided by adding
medicinal  agents  to the hot water  it is scarcely possible to say.
In  croup the room  should  be  filled  with  hot vapors, Avhich
produce excellent effects.  In croup an active emetic should be
administered at once,  and then depressant diaphoretics, as anti-
monial Avine, in guarded doses, hoAvever, given after; the strength
being kept up by free supplies of milk.
  § 150.  It may tend to facilitate the consideration of the
thoracic affections connected with the respiratory system if the
subject  be separated  into  three diArisions:  (1) the air-tubes;

  1 Probably in jaborandi we shall find a most  efficient  agent in reducing the
temperature and exciting cutaneous  action in the early stages of catarrh.   This
anticipation has, however, been but imperfectly realized. 
308
THE RESPIRATORY SYSTEM.
(2) the lung-structures; and (3) the serous coverings: and the
ailments of each described generically.
  Affections of the air-tubes  may  be acute or chronic.   The
acute forms differ but little from the sketch just given of an
acute catarrh, and vary from a mere  cold to a most dangerous
illness.   In acute  bronchitis, in addition  to  the  measures  just
mentioned, it is of great importance  to keep the chest enveloped
in large and hot poultices.  They should be repeatedly changed,
so as never to be allowed  to become  cool, let alone cold.  They
should  be  large and thick, so as not to  require very frequent
changes; and the best material for retaining its heat long is
linseed meal.  In severe cases, Avhere there is much exhaustion,
the surface of the poultices may be dusted Avith mustard.   The
heat keeps up the action of the heart, especially  the right  ven-
tricle, Avhich is  apt to become exhausted, and by dilating the
cutaneous  vessels  of the trunk  relieves  the vascular system.
But, as Dr. Brunton has  pointed out, two or three thicknesses
of flannel  should  intervene betAvixt the poultice and the skin,
so that the poultice may be applied at once.  When the poultice
must cool till the  unprotected skin  can bear  it, more than  half
its utility  is done  away with.  The great danger in bronchitis
is exhaustion, and in persons  at the  extremes of life  it is a very
fatal affection;  in strong adults the most  severe attacks are
compatible Avith recovery.  In addition to these  measures  it is
desirable to resort to some form of expectorant.
   The   Theory of  Expectorants.—Any  one  Avho  suffers  from
bronchitis  realizes for himself quickly the benefit to be derived
from  expectorants.   These agents  have  been arrived at  em-
pirically ;  and are  used  because they do good.  What  they
achieve is a loosening of the phlegm—that is, the secreted mucus
is more easily dislodged, and so  expectorated.   There is no
doubt about that  fact.   But  it is not a matter of indifference
which  one  of the  agents  known as expectorants be  resorted to.
In the first stages of the  case the bronchial  mucous membrane
is SAvollen, congested, turgid, and  dry;  it  is hyperaemic, but
secretion is arrested, and  the mucus is scanty and  tenacious, and
got up only with  the  greatest  difficulty.  It is obvious  that
here one part of the treatment must  be to relieve the vascular
system, to  reduce  the turgescence, Avithout Avhich free secretion
cannot be attained.  To  give ammonia and  senega  Avould not 
THE RESPIRATORY SYSTEM.
369
 achieve the  desired  end.   The  agent to be  used must be one
 which will affect the circulation ; Avhich Avill relax the cutaneous
 vessels and depress the circulation.   Such  an agent Ave find in
 tartar emetic, in  iodide of potassium, or ipecacuan.   The ad-
 ministration of  these agents is the line to be pursued until tur-
 gescence passes  into  free bronchial secretion, and a moist con-
 dition of the skin is secured ; then, and after then only, are the
 stimulating expectorants to be resorted to.  The effect of these
 remedies, where the first stage is strongly marked and  intracta-
 ble, will be much aided by producing an eruption on the chest:
 this may be done by tartar emetic  ointment,  or  croton-oil lini-
 ment, Avhich are powerful measures for good Avhen  skilfully
 wielded.   Even venesection may occasionally haATe to be re-
 sorted to Avhen these depressant measures fail,  as  my experience
 has taught me.1  Whatever the amount of  pains  required to
 procure relief, the first stage must be got over before the stimu-
 lating expectorants are of any avail.  I Avell  remember a case
 recorded in one of the journals many years ago.  A man had
 attended at  a London hospital  Avith bronchitis, and  had had
 carbonate of ammonia and senega prescribed.  After many days
 he  tried another hospital, as he  Avas utterly  unrelieved.   His
 lips were blue, his face congested, his breathing very difficult,
 and his expectoration scanty.   He was then given some tartar
 emetic, ipecacuan and  acetate of ammonia ; in a few  days he
 Avas much relieAred ; the first stage gave place to the second, and
 then  carbonate  of ammonia and senega  did  him great good.
 The case impressed me much.   The treatment Avas Avrong in
 the first  place—because it was mistimed.   This  was a lesson
 ahvays strongly insisted upon by  my late father Avhen I Avas
 assisting him to  dispense in the country.   Whenever the bottle
 of syrup of squill appeared instead  of the  ipecacuan Avine:
 "Never give squill until the skin is moist and the phlegm  loose
 —it will do no  good ;  you must give ipecacuan  and relaxent
 expectorants as long as the skin is dry and  the phlegm tough :
 squill  is very useful  in  its  place, and will be all right  in a day
 or two," Avas the phrase which greeted my youthful ear, much

  1 In one man no efforts of my father's, or afterwards of mine, could procure
relaxation in the turgid bronchial  membrane, until a few  ounces of blood were
drawn from the arm : after that the case moved on satisfactorily.
      24 
370
THE RESPIRATORY  SYSTEM.
to my benefit.  The principle  Avas  sound, and  the  maxim is
worth remembering.  When secretion is free, then squill, sene^ji,
carbonate of ammonia, benzoin, etc., may be given Avith advan-
tage.   The indications  for  treatment noAv are to sustain  the
system during the exhaustive process of  breathing  through the
obstructed air-tubes and expelling the phlegm.  This taxes  the
powers greatly ; and milk, beef-tea, wine, etc., must be given in
no stinted quantities.  The prescription of squill, acid, and
chloroform  given  in  the last section is a very palatable and
Avithal poAverful expectorant, and is easily rendered more stimu-
lant, when required, by increasing the dose of  spirits of chloro-
form.  Another still  more poAverful but disagreeable mixture is
the folloAving:—
                   Am. Carb. gr. v.
                   Sp. Chloroformi, TTixxx.
                   Inf. Senegas, gj.
  It may be given every four or six  hours.  If the circulation
be failing, the tincture of digitalis must be  added to the mix-
ture.   If the heart be already the subject  of structural disease,
the bronchitis will usually go very hard  Avith the patient; and
digitalis must be given  early  and  continued throughout  the
case,  else  the  patient  will  probably die.   As convalescence
proceeds, the carbonate of ammonia may be  continued  along
Avith the ammonio-citrate of iron and bitters.
  It is far from  being a well-ascertained  fact hoAV  expectorants
act.   Many agents,  especially  the  liliaCeae, are found  in  the
breath after being taken by the mouth; they are thus partly
given off by the bronchial membrane.  That they cause a certain
hyperaemia of this membrane and stimulate secretion  in  it is
more than probable, so that the secretion is freer; and then under
the cover of this layer of mucous cells the bronchial membrane
recovers itself.  But free secretion  must precede repair, and so
depressant  expectorants must  precede  the  stimulating and
restorative members of this group.
  Since the publication of the  first  edition of this Avork much
has been added to our knoAvledge of the action of drugs upon the
respiratory centres.  The writer conducted a series of experiments
for theBritish Medical Association asto theantagonismof certain
powerful poisons.   Experiments upon the frog had demonstrated
the antagonism of aconite and digitalis in relation to the heart. 
THE RESPIRATORY SYSTEM.            371
{Digitalis; its Mode of Action and its Use.  Hastings Prize Essay
of the British Medical Association, 1870.)  Further experimen-
tation  upon Avarm-blooded  animals seemed indicated, and Avas
performed with instructive results.   It  Avas soon found that
digitalis did not prevent death from a lethal dose of aconite in
the rabbit.  It maintained  the  action of  the  heart;  but  the
respiration failed,  and  death ensued.   Further  experiments
demonstrated  that belladonna and strychnine both  perfectly
antagonized the palsying effect of aconite upon  the respiratory
centres.  The failing respiration Avas restored ; just as  Professor
Fraser found  to  be the case in  calabar  bean poisoning, where
the pulse and respiration both improved  immediately after  the
injection  of  a solution of  atropia.   The experiments  Avere
repeated  and confirmed.   A  little  later   The Antagonism of
 Therapeutic Agents Avas selected as  the subject for  the  competi-
tion for the Fothergillian Prize of the Medical Society of London
for 1878.  The subject of  the action of  different  agents  upon
the respiratory centre was further worked out by the  writer in
his Essay Avhich gained the medal.  Belladonna has  a  most
powerful  influence over the respiratory centres in the medulla
when exhausted and failing in  disease;  as well as Avhen  para-
lyzed by a toxic agent.   Instances  have occurred since then of
testing  the action of atropia in opium  poisoning, where  the
respiration was failing.  In a case  which occurred at  the West
London Hospital on  February 11, 1878,  this antagonism was
well illustrated ; and the respiration was restored in a few minutes
after the injection of one grain of sulphate of atropia under  the
skin of the arm.   The  recovery was  perfect,  the respiration
being restored and the pulse and temperature rising, while the
patient was still Avrapped in her opium sleep.  A similar suc-
cessful case occurred last spring at the Leeds General Infirmary,
Avhere  the house-surgeon,  W. H. Brown,  administered  one-
quarter  of a grain  of atropia after the  galvanic  current had
failed to maintain  the respiration.   Belladonna, or better  still,
atropia, which can be given  in exact dose and strength, is a very
useful agent when the respiration is embarrassed ; and  it is well
to give it along with opium in phthisis (§ 77).  It paralyzes the
ends of the sentient vagus fibres  in the lungs, and so aids the
action of the opium in allaying the  reflex  act—cough ;  and does
not  practically interfere  Avith the action  of the opium  on the 
872
THE  RESPIRATORY SYSTEM.
hemispheres.   From its effects upon the respiratory centre, and
its effects upon the sudoriparous glands, it is a good tonic in hot
Aveather in patients Avhose breathing  is  embarrassed  and avIio
SAveat very freely and 30 lose their blood-salts.  Here the follow-
ing combination is very useful:—
                    Atropia? Sulphat. gr. T£5.
                    Liq. Amm. Anisatus, TTlxv.
                    Aq. Jj., ter m die-1
It also by its action upon  the respiratory centres prevents their
failure under full doses of opium.
  Strychnia also acts poAverfully upon  the respiratory, as on all
motor centres.  It is very useful in cases of chronic bronchitis
with emphysema and embarrassed breathing.  It stimulates the
respiratory centres when failing, in the same way that digitalis
acts upon the cardiac ganglia.   Where the breathing is labored
and painful, or failing, strychnia will often restore it and  make
the patient comparatively comfortable.   In acute bronchitis, in
the later stages, when death is impending  from exhaustion of
the respiratory centres—worn out with the sustained respiratory
efforts Avhich  alone can maintain life—then strychnia will  often
save life; given more freely and in larger doses than are  usual
Avhen it is merely given as a tonic.  Cases of acute bronchitis
rarely come before my notice; but if  they did I  should not
hesitate to push  strychnia till the limbs twitched ;  starting
Avith ynth of a grain every six or four hours, and increasing the
dose if  necessary.   Where the patient  is  evidently sinking,
heroic measures are not only justifiable, but are actually called
for.   The ordinary prescription for chronic bronchitis Avith em-
physema, and  for acute bronchitis when  the first stage is over
and the secretion is free, is—
                    Am. Carb. gr. v.
                    Tinct.  Nuc. Yom. TTLx.
                    Tinct.  Scillae, £ss.
                    Inf. Serpentaria;, 3j. ter in die.
To Avhich ten  drops  of tincture of digitalis may be added when
the right side of  the heart is  severely taxed.  In  embarrassed

  1 The  Liquor Ammonias Anisatus is  taken from the Prussian  Pharmacopoeia,
and is prepared by adding 01.  Anisi, giij. Liq. Ammonia Fort. 3iij. to Spirit.
Yini Reet. 3xij.  Dose Tu.xv. 
THE RESPIRATORY  SYSTEM.
373
 respiration  due to disease, strychnia is very useful, and  often
 soon  removes the attacks of dyspnoea Avhich come on in deep
 sleep.   Three well-marked instances of its efficacy in such cases,
 complicated by the persistent resort to narcotics, are given in my
 Foihergillian Prize Essay, Chap. VII.   The  use of belladonna
 and strychnia as stimulating expectorants is still in its earliest
 infancy.
   Sometimes, however, an attack of acute bronchitis, instead  of
 passing away, persists  as a chronic affection.   If there be a
 history of gout or rheumatism, potash, iodide of potassium, and
 balsamic  remedies, as benzoin, ammoniacum, and  guaiac, must
 be given.  The use of astringents is of doubtful  desirability.  If
 there be anaemia and  debility iron must be given, and astringent
 forms of it will be found  preferable.  In many  cases change  to
 a Avarm climate  may be  distinctly indicated ;  and cold  air  is
 found to  keep up and aggravate  the lingering  mischief.   A
 respirator is a most comfortable  and effectual means of aiding
 the convalescence.  In those Avho suffer from winter cough the
 resort to a respirator  as a  preventive  measure will  be  found  to
 often preserve the A\Tearer from the wonted trouble.  When
 bronchitis remains in a chronic form from sheer debility in the
 patient, then cod-liver oil  (often simply invaluable), chalybeates,
 tonics, and  good food are  the measures which will  be  found
 most  satisfactory in  enabling the diseased mucous membrane
 to recover its normal  condition.  Where the  right ventricle  is
 much  distended, as  is the case Avhen chronic bronchitis  is
 accompanied by emphysema, then digitalis is indicated, and  is
 of much service.  In accumulations of phlegm emetics are often
 followed by  great relief.   The use of inhalations, as a few drops
 of Cleaver's Terebene on a sponge wrung out of  hot  water, in
 these  chronic conditions, is on  the increase.  Many  cases are
 much benefited by inhalations.
  § 151. Inflammation of  the bronchi and bronchiae may be
 complicated  Avith  spasmodic action of the  muscular fibre of
 those tubes; and  then the  case is very severe and distressing.
 When this complication occurs, lobelia or the bromides are the
 remedies in  most  favor.  Lobelia is, however,  a  poAverful de-
 pressant, and must be used cautiously.
  At other times the  spasm of the air-tubes comes on without
any connection Avith inflammatory changes.  Here it is known 
371
THE RESPIRATORY SYSTEM.
as asthma.  The spasmodic nature of genuine asthma renders its
treatment very different  from that of the dyspiuea of heart-
failure, of bronchial inflammation  or thickening,  or  that of
anaemia.   It conies and goes in the individual, leaving him well
in the interval;  it  may  sIioav itself once or twice, or persist
through  a lifetime;  usually it disappears Avhile  the  system is
under  the influence of any intercurrent malady.   It  is very
difficult  to approach rationally the  question of  Avhat is to he
done in asthma.  Inhalations  of nitre fumes, of nitrite of amyl,
the smoking of  datura  tatula, are  direct applications to  the
affected parts.  At other times depressants  pushed very far are
the best means of relief, and tobacco, taken  until its toxic
symptoms are  induced, is a favorite  measure.   Sometimes it
must be  met by agents which  lower  nerve action, as bromide of
potassium.  Finally, it is Avell to avoid those exciting causes
which experience has shown to be provocative of an attack.  In
hay-asthma, for instance, flight from the pollen  of the anthox-
anthum  odoratum is  absolutely necessary.   Yachting Avhere
permissible  is  an excellent preventive.   At other  times  the
attack is found to follow intestinal derangement, or to be  pre-
ceded by a thick and high-colored condition of the urine.  The
treatment of the patient during the interval is no unimportant
matter;  but this depends on the  peculiar necessities  of  each
case.   Thus in asthma occurring at  the catamenia the bromides
are indicated; where each attack  is preceded  by a voracious
appetite, moderation in diet is as effective as in epileptic attacks
of like associations.  Where  attacks are set up by the  vascular
turgescence in the bronchial lining membrane caused by a cold,
avoidance of cold is very desirable.
   § 152. Affections of the lung structure—the second division—
furnish—Avhether in the acute or chronic forms it matters not—
perhaps  the most complete debatable grounds of medicine.   In
the acute form our immediate ancestors bled to death's door,
Avhile Rasori gave huge  doses of tartar emetic; more  recently
Hughes  Ben net  has advocated the expectant treatment,  "with
liberal supplies of food.  Every new remedy almost  is tried in
turn for pneumonia, and found to be followed by a large propor-
tion of recoveries ; but in hoAV many cases the recovery  is rather
in spite  of, than in consequence of, the treatment  employed, may
be open  to question.   It  is now, however, generally recognized 
THE RESPIRATORY SYSTEM.
375
that pneumonia presents in itself no especial indications for
treatment; and consequently it must be treated according to
the indications of each case, and of the system in which it occurs.
If the patient  be stout and  strong, and  the pulse full  and
incompressible, a  depressant line of treatment is indicated ; and
as the pulse becomes  softer relief Avill be experienced.   On the
other hand, where there is obvious  debility, and  the  pulse  is
small, compressible, and fast, then  stimulants, tonics, and liberal
supplies of easily assimilable food are the measures to be adopted.
It is very questionable, hoAvever,  hoAV far by any  measures we
can hasten the natural processes of pneumonia, or  exercise any
influence over the progress of the ailment.   But  it is certain
that Ave can aid  the system to tide over the  attack;  and also
that Ave can moderate its severity, by attending to the different
indications furnished  to us in  each case.  We can give aid in
each stage of the malady ; in the first stage we can moderate the
inflammatory rise, and control  to some extent the pyrexia.  In
the second stage Ave can attend to  the general  indications, and
can, at any  rate, treat  symptoms  if  Ave can do little  for the
malady itself.  While in the third stage stimulants and tonics
Avill often enable  the  patient to pass  through a period of peril,
and to round in safety  the critical point.  This may seem but
little; but in reality it is  much.   By moderating the pyrexia,
etc., of the early stage Ave lessen the amount of exhaustion which
may come to constitute the prominent danger of the later stage.
In that later stage Ave  may give  such aid  as shall  enable the
patient to survive till the disease has run itscourse into conva-
lescence.  It is also equally certain that by injudicious measures
the natural  efforts may be thwarted or opposed ; and so the
patient's life may be imperiled, as a consequence of our well-
meant but ill-designed measures for his benefit.  If  both lungs
be affected so that the pulmonic circulation is much obstructed,
it is good treatment to bleed freely ;  so as to diminish the bulk
of blood, and secure a nicer adjustment of balance betwixt the
blood and the respiratory powers, than existed before.   Such
practice  is  neither  inconsistent  nor  incompatible with the
administration of stimulants even at the time of bleeding; the
bulk of  blood must  be reduced  at  all risks, and the hazard
involved in doing so,  must be  met and obviated by all means in
our power.  It is  the standard practice now in pneumonia to 
37il
THE RESPIRATORY SYSTEM.
resort to that  modified form of bleeding  involved  in the appli-
cation of large hot poultices to the trunk.  The jacket-poultice
of the French is the best thing.  It reduces the  blood-pressure
in the veins and right heart; its heat stimulates the  heart; while
the blood is conserved  and  is useful for future needs, Avhen the
powers of the system may be strained  to the  utmost limits of
endurance.   The utility of blisters  in  pneumonia is doubtful.
The advocates of such plan  have failed to furnish convincing
evidence of the beneficial effects produced thereby.   The use of
venesection, either general or local, as  by cupping or leeches, is
merely to reduce the congestion of the right heart and the veins;
and this can be done, Avithout removing the blood from the body,
by means of the jacket-poultice.   In sthenic pneumonia I have
seen venesection, as  practised by my father, followed by good
results in severe  cases; but it is a measure obviously unsuited
to the large majority of the cases of pneumonia that come under
our notice.
  Especially is this the case in  those  low forms of pneumonia
Avhich are  so prone  to show themselves in conditions of great
debility, or in  the course of continued fevers, etc.  Why and
wherefore the  lungs  should under  such circumstances  become
subject to inflammatory change it is not for us to inquire here.
The fact remains that it is so ; and the treatment of pneumonia
here is the treatment  of the condition on which it  depends.
Consequently free stimulation is  often  imperatively called for;
and the patient must be tided over the danger of the hour CAren
if the treatment necessary for this end be not entirely free from
some risks  of its own.
  Pneumonia is a common cause  of death in  chronic maladies,
which are  themselves  but sloAvly fatal; and  all our efforts in
these cases are commonly unsuccessful.   At other  times pneu-
monia is associated Avith the development of a lowly form of
tissue-groAvth ;  and then it forms a tubercular pneumonia, or
acute tuberculosis, which is fatal in three weeks or less.
  If this Avork were chiefly pathological,  pneumonia Avould  call
for  a very  long and elaborate description; but as its  aim is
mainly therapeutical, a  brief consideration is all  that  can be
given to it. There is no treatment for pneumonia in itself.  Its
treatment in each case is a good touchstone of the general infor-
mation and skill of the practitioner; and of his power to observe 
THE RESPIRATORY SYSTEM.
377
 and to apply general principles.  jSTo description of pneumonia,
 or lengthy survey of our remedial measures, will, or can, take
 away the necessity for resort to individual thought.  The treat-
 ment of pneumonia is  the  application  of  the  principles laid
 cIoavii in the preceding chapiters; and especially Chapter V.
   § 153.  If these remarks hold good of acute pneumonia, they
 apply still more aptly to those chronic conditions of limited in-
 flammation of the lungs, which in their course and conclusions
 vary so much.  In  acute  ailments  careful examination will
 reveal in many cases a patch  of pneumonia.  This  may  be  of
 no moment Avbatever ; or it may be of the most serious import:
 its existence must be noted, and its progress watched.   It may
 quickly disappear, as is  doubtless  the case  in most instances;
 but it may persist, either as a limited area of chronically thick-
 ened lung from growth  of connective tissue, sufficiently elabo-
 rated to maintain its vitality unimpaired ; or it may consist  of
 a too loAvly form to  live,  and then  fatty degeneration of the
 neoplasm  may be accompanied by ulceration  around  its peri-
 phery;  in Avhich case the patient  usually has to  swim for his
 life.  The hectic fever Avhich  may coexist with  this ulcerative
 process  may Avear out the patient, assisted by the terrible and
 persistent cough excited  by the presence of this foreign body in
 the lung, this " thorn of Yal Helmont;" and aided by the  sleep-
 lessness, the exhaustion,  and expectoration Avith night sweats,
 which mark this condition.  Not only so ;  but the inflammatory
 margin of lung along the ulcerating process may itself no longer
 furnish  a  healthy pyogenic  membrane;  the connective  tissue
 here may be of so loAvly  a form that  it must in  its turn soften
 and  necrose, entailing another period of hectic  fever with its
 terrible associations.
   It is obvious then that in  chronic pneumonia it is of the
 utmost importance to prevent if possible the altered lung-tissue
 from becoming tubercular, to  Avard  off as far as  may be any
 tendency to  degradation  in the cell-elements of the neoplasm.
 Such must be our first aim;  and in all cases of  disturbance of
 health, especially in young persons, the lungs should be  care-
fully examined again and again for  these localized  patches of
parenchymatous inflammation.  When they are found they  must
be noted and their progress carefully observed ; and at the  same
time the general condition, and especially the temperature and 
378
THE RESPIRATORY SYSTEA1.
pulse, must be watched.  The general nurtrition is the point to
be attended  to, for if it be defective the repair of the inflamed
area Avill be but  imperfect.  Consequently food in  liberal sup-
plies, and of an easily  assimilable character, must  be given at
frequent intervals; and the appetite  must  be Avhipped  up  by
bitters ; if there be any irritability about the stomach, it  is well
to give
                    Bis. Trinsnit. gr. x.
                    Mist. Acacia1, 3J.
                    Inf. Calumbae, 5]'.
three times a-day before  food.   If there be  much  acidity, ten
grains of  bicarbonate of soda or of potash may be added with
advantage.  Some practitioners  prefer the mixture of calumba
with compound tragacanth powder, in these cases.  There can
be no doubt that in many cases the first  matter is to keep the
stomach in good condition, so that the assimilation  of food is
sufficient  and  effective: by this  means the  necessary nutrition
is secured for  the  growth  of healthy connective tissue. The
other measures, as the arrest of the hidrosis, moderating the
cough, correcting the boAvels, and securing sleep, are  secondary
to this ; though important enough themselves.  For the securing
of sleep and the alleviation of cough, the measures described in
the earlier half of Chapter XIII. are to be applied here—as are
also some remarks upon cough, Avhich  will be made further on
in this chapter.  The  regulation  of the  bowels,  the relief of
constipation, and the arrest of diarrhoea, are of much moment.
Where diarrhoea coexists with night-sweats, it is well to give a
pill  of sulphate of  copper (gr. J) with opium (gr. ij.) in extract
of cinchona  at bedtime.   If the patient be but  temporarily
reduced, and the patch of chronic pneumonia is  the result of
passing adynamy in  a healthy person of good family history,
the prognosis  is  good ; though there may be no arresting the
process until  the mass be expectorated and a cavity formed.
In some cases  the  walls of the  cavity fall  in; and a puckered
cicatrix is all that remains of Avhat Avas once a dangerous mass
of degraded tissue, whose expulsion had almost  exhausted the
poAvers of the patient.
   At other times there may be found a condition of numerous
small  masses  of tubercle  surrounded  by  healthy  connective
tissue, so  that the encapsuled mass softens, its organic matter is 
THE RESPIRATORY SYSTEM.
379
absorbed,  and  ultimately small  mortar-like masses—the inor-
ganic constituents  of tubercular growths—are either expec-
torated, or are found in the midst of hardened  lung-tissue after
death.   These are the cases  over Avhich young  practitioners are
so apt to trip.  They  discover that there is an area of  dulness,
where the breath-sounds are altered ; but they fail to distinguish
Avhether the mass is that of neAv growth, or the remains of some
long by-past mischief.   Yet it is  most important prognostically
and therapeutically that such diagnosis be made ; and correctly
made too.  By a sufficient amount of care and knowledge this
may usually  be determined.  If, however, the patient's health
he thoroughly broken; or the family history tells unquestiona-
bly that there has been a strong tendency to the formation of
tubercle, especially  on  the  father's side,  then  these  localized
patches of pneumonia must excite the  most apprehensive atten-
tion; and no stone must be left  unturned to avoid the degene-
rative changes  Avhich will be accompanied by so  much  danger
to life.
   § 151. When the  diagnosis has  been  made, that there is
present  in the lungs a certain amount of pathological connective
tissue of a degraded character, the treatment divides itself into
two lines.  The first is directed to the cure of the patient;  the
second is that of relief in incurable disease and the procuring
of euthanasia.   As long as hope remains, the first is to be
sedulously pursued ; and it is a complicated matter.  For there
are tAvo points to be  attended to Avhich are someAvhat antago-
nistic.   These are the maintenance of the general health, and
the securing of an atmosphere which is agreeable to the  diseased
lungs.   The pursuit of the latter has studded the shores of  the
Mediterranean  Avith  villas,  Avhere  the Anglo-Saxon  and  the
Sclave  stay during  the winter season, and so avoid the severe
Aviuters of their OAvn lands; the necessity for the former has
established health  resorts  in high-lying tablelands, and filled
Swiss chateaux and Californian sierras in summer with phthisi-
cal patients.  It is  not  caprice  or fashion  merely Avhich  has
determined two such  apparently  antagonistic lines of practice.
The choice depends upon the case.  In  one, a  hot summer so
enervates the patient  that  the benefits of Avarm air are more
than  counterbalanced  by the general depression  and loss  of
appetite; and consequently summer must be spent in a bracing 
380             THE RESPIRATORY SYSTEM.

situation at a high altitude.   In the other the irritation of cold
overrides  the  good  effects  of the Ioav  temperature upon  the
general condition; here a Avarm winter resort is indicated.  In
some phthisical patients quiet exercise in the open air is all that
can be undergone ; Avhile others are  the better for pretty severe
exercise.  In these latter the good effects of exercise outweigh
the evil effects  upon the  lungs  of their  increased functional
activity :  Avhile in the former, rest, as far as it is practicable, is
sought for the impaired respiratory organs.  Some persons again
must lead an outdoor life if  they Avish to survive; and  a return
to an indoor life in town is at once folloAved by a return of the
ominous symptoms.
   In others, again,  there seems to be a certain intolerance of
ordinary foods, Avhicn are not assimilated, and in these persons
certain preparations of milk are often of great service.  Hence
Ave find the koumiss cure,  the Avhey cure, etc. etc., in many
cases, undoubtedly useful.  In North America it is found that
a youth who is inclined to be phthisical is often much benefited
and even  cured, by  "lumbering," in winter.   This  means long
hours  in  the open  air, Avith  the steady use  of  the  axe, and
unlimited supplies  of  fat  pork—no longer  repugnant to  the
avbetted appetite.  Under these  circumstances many consump-
tives recover.   Fresh air, a keen  appetite, liberal  supplies of
food largely hydro-carbonaceous, and  sleep, the result  of exer-
cise, are the measures by which the first line of practical treat-
ment is to be secured.
   When, hoAvever, it becomes apparent that the malady is not
to be conquered, the second line of  treatment is to be folloAved.
An agreeable temperature, gentle exercise in the sunlight in a
carriage,  or a  brief seat in  the sun during mid-day in winter,
and at morning and evening in summer; a cheerful bedroom and
pleasant surroundings, to be accompanied by the administration
of narcotics, analgesics, and anhidroses, for  night sweats, are
what  must be  secured  as far as possible.  For further  informa-
tion on this matter  the reader must refer to § 77.
   § 155.  When there are good grounds for the opinion that the
connective tissue in the  lungs is of fairly good character—of a
sufficiently high vitality to maintain its  existence, the prognosis
as to life  is much better than Avhen it  tends to degenerate into
tubercle.   In such cases there is generallv a history of  exposure 
THE RESPIRATORY SYSTEM.
381
to the inhalation of dust, as in masons, especially in the more
hio-hly-paid  fine  hewers, in potters,  in  colliers, and  in steel
grinders;  the finer the particles  ground the  Avorse for the
grinder.  In a large majority of these cases, Avhere the disease
is a form of chronic broncho-pneumonia, the result of mechani-
cal irritation by the respired particles, a brief respite from their
ordinary employment will give much relief.   In all, however,
the adoption of some other form of industry is  very desirable.
Emigration, the army, or police force, game-preserving, or agri-
cultural labor are the lines of life to be aimed at; and such
changes of occupation often give  the most gratifying results.
Persistence in their pursuits will have the effect  of anticipating
or precipitating the final change.   Good food, cod-liver oil, out-
door exercise, are as necessary for these cases as they are for the
tubercular.
   There is  one point which may be raised  about all chronic
diseases of the respiratory organs, and  that is the desirability, or
otherwise, of the use of  wind instruments.  Where  there is  an
imperfect chest development the  use of such instruments has
often produced  a very  satisfactory change;  but, on the other
hand, such functional activity  of the lungs has too frequently
but baneful consequences.   Where acute mischief is going on,
rest and quiet rather are indicated  ; where a growing youth has
a badly-developed chest  a cornopean may not be  out of place.
   § 156. The third  division—the serous  coverings of the lungs
and their affections—iioav demands our attention.  The serous
sacs are dilatations of  the lymphatics—they are lymph-sacs,
whose smooth surfaces glide easily upon each other, lubricated by
their fluid  contents.  They usually contain but a slight amount
of fluid, just enough to keep the surfaces moist;  but under cer-
tain conditions the balance betwixt the outpour  and the absorp-
tion is disturbed by disease, and then there are accumulations of
fluids, and diminution of the thoracic space.   Such  effusion, as
the accumulation of fluid  is termed, may be either  active or
passive.  The  first  is the  result  of  inflammation,  the  second
usually of venous congestion.   In  the simplest form of pleurisy,
viz., that occasioned by the friction of a broken rib, there is first
acute hyperaemia with  sharp  pain, aggravated  by motion  and
relieved by rest; and then effusion of fluid, by which the pleura
and its source of irritation, the sharp point of bone, are separated. 
82
THE RESPIRATORY SYSTEM.
By this last means physiological rest is secured, the cause of the
inflammation in the pleura is remoA^ed, Avhile the effusion limits
the movements of that side of the thorax; and the rest so secured
admits of the broken rib becoming united.  Surely such action
is rather a reparative process than a disease per se.   It is obvious,
hoAvever, that if Ave place that  fractured rib at rest by a firm
bandage, which limits thoracic movement,  and leaves  respira-
tion  almost abdominal;  and at the same time relieve  the irri-
tated pleura by full doses of opium, so as to bring out both its
analgesic action and its effects upon secretion; we  may secure a
better line of treatment than that Avhich is instituted by the
unaided efforts of the system.
  At other times, from some cause or other,  the pleural surfaces
become inflamed.  Secretion is  arrested, and instead of gliding
smoothly, these dry serous surfaces rub upon each other at every
respiratory movement; there is acute pain, and arrested thoracic
motion gives partial  relief, while sooner or later effusion and
separation  of  the  inflamed surfaces  follow.  At  other  times
there is pleurisy Avithout effusion.  Especially is this  the case
in the apices of the lungs when the subject of tubercle.  A little
mass just  underneath the  visceral  pleura  irritates the costal
pleura on every respiratory movement; a localized inflammation
binds the two pleurae together, and then relief is obtained.  Such
are the sharp  pains  about the clavicles  so often complained of
by the phthisical, often  long before there is any serious percep-
tible disease.
  The line  of  treatment to be  pursued in  pleurisy is  to check
the hyperaemia, which may be  done by the  use of depressants;
to ease the p>ain by the  use of opium—antimonial wine, fifteen
drops, and  twenty drops of laudanum every four or six hours—
and  to affect the costal  pleura, at least, by  the  use of external
applications.   These may be of tAvo  kinds.   One is that of the
application of some agent Avhich will divert the Aoav  of the
blood in the intercostal arteries into  the cutaneous vessels, and
so tend to starve the inflamed pleura beneath ; and this end Avill
be secured as well by hot poultices as by blisters.  If such com-
bination be boldly followed out, venesection will rarely be needed,
and  local depletion will be avoided.   The other external appli-
cation is that of analgesics.   By the same laAv that  regulates
the blood supply of the  deep-seated parts  and the surfaces over 
THE RESPIRATORY SYSTEM.
383
 them—the laAv of Schroeder van der Kolk—is the nerve-supply
 regulated ; and by applying analgesic agents to the cutaneous
 peripheral distribution the pain is diminished : either a reflex
 effect being produced  upon  the  nervous distribution beloAv the
 surface ; or a condition of  impaired conductivity in the nerve
 fibrils being effected.  In painful dry pleurisy an opium plaster,
 aconite liniment, or subcutaneous injection of morphia Avillgive
 relief.  A third measure, that of  strapping  the chest, so as to
 procure physiological rest, is worth trying.
   When acute pleurisy is the consequence of some blood-poison,
 the special measures must be kept subordinate to the treatment
 of the causal condition.
   § 157.  When there is  fluid in the pleural  cavities  there are
 several plans of treating the case.  Of old it Avas the rule to use
 blisters round the diseased side, repeating them  as often as was
 necessary ; and to give absorbents,  together Avith diuretics; and
 these diuretics were those which affect the circulation, as digi-
 talis  and squill.  By  such  means  good  results were  often at-
 tained.  At  other times the lung becomes  bound  doAvn by
 adhesions, and  instead of expanding at each  respiration  as the
 effused fluid  is absorbed, the thorax  falls in,  until  great de-
 formity,  with accompanying loss  of respiratory poAver, results.
 If blisters succeed in producing rapid absorption, good and well ;
 but if they make  little or no impression, then the more direct
 means of getting rid of the fluid,  viz., tapping  the chest, must
 he resorted to.   This is now easily and pleasantly performed by
 the aspirator.   Commonly the removal of some of the fluid  is
 followed  by absorption of the remainder.  In other cases  the
 operation has to be  repeated, may be, several  times.  If  the
 pleural contents become purulent,  then  a drainage tube may
 have to be inserted, and the case  treated as an  abscess.
  When, hoAvever, the accumulation of fluid is of passive origin,
 then these active measures are not  indicated.   Passive effusions
are usually due to venous  congestion  in heart  failure, to  ad-
vanced renal disease, or conditions of great  debility, and  to
scarlatina.  In  such cases the treatment of the pleuritic effusion
is  involved and embraced  in  that of the  general  condition.
(§  61, Chapter VI., and §  205, Chapter XX.)
  In diseases  of the mediastinal spaces,  as  tumors, hydatids, 
381
THE RESPIRATORY SYSTEM.
etc., the  treatment of the  case must be conducted on general
principles.
  § 158.  In affections of the respiratory organs  there  are two
chief phenomena  produced, viz., cough  and  dyspnoea.   So ini-
portant are these tAvo symptoms, and yet often so different in
their causations, and consequently their importance  and their
indications for treatment ; that they must be considered at some
length.   By such special consideration  the lines of  treatment
to be folloAved will  be  more clearly marked out  than by the
arrangements  usually adopted—at least it is hoped so.
  A cough is  usually an  attempt to remove some irritant matter
from the thorax by  means of the respiratory tract.   When  a
foreign body gets into the larynx, or air-tubes,  violent and con-
vulsive cough ensues, until either the intruder is expelled ; or, in
rare cases, till  the parts have become accustomed to  its presence,
and  the  efforts to expel  it  subside, and are  no longer  evoked.
Tlie cough is  a  reflex act set up  by some  exciting cause; the
irritation so  excited putting in force the complex  muscular
actions called  a cough.   In  doing so the chest is well filled with
air, and then a strong expiratory effort folloAvs Avhich may carry
off  the   irritant  cause;  if it  is  unsuccessful,  another cough
folloAvs.  Sometimes  there is induced a fit of coughing.  Here
there is  imperfect inspiration and  futile  efforts at expulsion,
often until exhaustion is produced.   Such is  especially the case
Avhen the exciting cause is of such  a nature that it does not
admit of expulsion.  Under these circumstances cough is often
teasing,  persistent, and  exhausting.  As  regards affections of
the organs  within the thorax, cough is usually associated with
the air-tubes, the lung-tissue, or the pulmonic circulation.  The
simplest  form of cough  is  that associated Avith  the air-tubes
when there is  something irritant present whose expulsion gives
relief.  This is well seen  in the common expectoration on getting
out of bed in a  morning.   During  the  hours  of sleep mucus
has  accumulated  gradually upon  spots Avhich  have  become
accustomed to the presence of these groAving  masses.   In the
movements of dressing, especially in  stooping,  these  masses of
mucus slide on  to other parts of the air-tubes.   In this new
locality the irritation induced is  sufficient to cause  a series of
expulsive efforts until the masses are got rid of. After a cold thi.-
is very well shown ;  and repeated series of coughs  are required 
THE RESPIRATORY SYSTEM.
385
 to dislodge one mass of phlegm after another.   If the  mucus
 be dry and tenacious, great and repeated efforts are requisite for
 the expulsion of any accumulations: here we give expectorants
 Avhich increase secretion, or  loosen the pihlegm, as it is termed.
 Where there is  a  considerable  secretion, brief sleep is folloAved
 by expulsive efforts, which clear the  air-tubes; and then sleep
 follows, again to be  disturbed.  This is one of the sources  of
 danger in bronchitis; the patient may become worn out  by the
 disturbed rest and the exhaustion  so  induced.  At other times
 there is much cough Avith but little or no expectoration, and yet
 it is one phase merely of cold.  Instead of increased  secretion
 there is rather  an  irritable  or " raw" condition of the lining-
 membrane of the air-tubes  induced.    Here cough is useless,
 though often very distressing.   Consequently it must be met by
 sedative neurotics, as Tinct. Camph. Co. ("Ixx.) and Pot.  Brom.
 (gr. x.) in Mistura Ammoniaci (3j.)> or Inf. Serpentariae, three  or
 four times a day; or  a morphia pill Avith benzoin may be given.
 This  is  one of  the  few forms of  cough  where opium  is not
 contra-indicated.  Where there is much secretion, opjium tends
 to arrest the secretion.  In these cases counter-irritation  by the
 application of liniments—as croton-oil liniment to the anterior
 surface of the chest—is  often  most satisfactory in its results.
 When the irritation is in the larynx it is often possible to reach
 it and apply remedies directly to the  irritated  surface; thus
 nitrate of silver may be applied in the form of spray, or morphia
 Avith  powdered  starch  may be blown  in upon  the  diseased
 laryngeal surface.
  At other times  cough is due to an alteration in the lung-
 structure, and especially to  the growth of a mass of tubercle.
 Here there is an ever-present source of irritation to some  of the
 terminal ends of the  pulmonary nerve-fibrils, which excites the
 reflex action—cough.   Consequently a persistent dry cough has
 ever  been held  as one  of the heralds of consumption.  Even
 when too small to be detected by physical  signs, a tubercular
 mass  may declare itself by the pneumonia  which  it  induces.
 The hacking cough  of  such a  state of affairs is well known.
Here morphia gives much relief; but  to be efficient it must be
given constantly, and so  becomes  itself harmful, as it may
destroy  the appetite, if  not combined  Avith vegetable bitters
and a laxative.  When the  mass  has softened, then  cough  is
      25 
386
THE RESPIRATORY SYSTEM.
useful in expectorating the foreign material and  relieving the
lungs of its presence.  Cancer nodules  will also give  rise to
futile cough in consequence of their presence, acting as  foreign
bodies in the lung structure.1
  Cough is  not  rarely induced by pulmonary congestion, by an
hyperaemic  condition  of  the pulmonic  circulation.  Here the
fulness of the blood\7essels is the causal irritation Avhich  sets up
a dry, hard  cough.   It is  readily recognizable  as the cough of
heart disease.   Most persons can induce it by running up stairs.
The characteristics  of this form of cough are  not  lost  by its
being accompanied by free secretion in advanced cases.   In this
form of cough morphia must  never be  administered, as it too
often is.  This  cough much  resembles in  character the cough
of dry bronchial irritation, for which paregoric has just been
prescribed.  But as it differs from this  cough in  causation, so its
treatment varies.  Heart cough should be  met  by relief of the
Avascular condition, and not by sedatives.  Again  and again it has
fallen to my lot to see  great mischief done by the administration
of opium and morphia in the cough of pulmonic vascular fulness.
The cough must be left alone if possible; and certainly it must
not be allayed by repeated doses of morphia.
  The less common intra-thoracic causes of cough are aneurism
and mediastinal tumors.   In such  cases  there is no prospect of
the expiratory efforts succeeding in expelling the irritant cause,
and here again  it is possible to give  opium, bromide of potas-
sium, chloral, or camphor with advantage.
  At other  times cough  is excited  by irritation, which  is not
intra-thoracic, as in the Avell-known stomach cough, ear cough,
liver cough, etc.  The commonest  of  all of  these reflex move-
ments due to comparatively distant irritation is that of pharyn-
geal follicular  ulceration, so well  described by the late Dr.
Horace Green, of Xew York.  This observer found that  a large
number of cases which were put doAvn as phthisical, were really
cases of such  pharyngeal ulceration.   By  the application of
local measures, and especially nitrate of silver, the ulcerations
Avere induced to heal up, and the  symptoms then disappeared.
Doubtless Avhen unrelieved  these  cases have  often led to  a

  1  The agents which check reflex action, given  in Chapter XIII., may each and
all be tried in such cough.  The bromides have the least after ill-effects. 
THE RESPIRATORY SYSTEM.
387
 gradual death by Avasting.  In all cases of pharyngeal irritation
 the  use of local sedatives  is indicated.  Lozenges of various
 kinds—demulcent, opiate, or astringent—-are largely used.  Then
 there are household  remedies, as linseed-tea, etc.; jujubes, acid-
 drops, etc., are  useful.  By increasing the  flow of saliva they
 cover the irritable part and lessen the irritation, and Avith it the
 consequent cough.   There is also the  further matter of adding
 sedatives or astringents to the soluble  mass, which increase the
 efficacy of the Aoav of moisture over the affected  part.  If the
 irritation be excessive, and the paroxysms of cough distressing,
 then something of this kind  is indicated :  Acet. Morph. gr. j.,
 Syr. Rosae  3j., Mucilag. sss.; 5ss. at  repeated  intervals.  This
 should be slowly s\ATalloAA^ed, so as  to  be as long as possible in
 contact with the  sensitive membrane.  In the same  way  the
 cough of gastric irritation is to be met by putting the stomach
 in order;  and  especially is  this  the case Avhere the gastric
 irritation is associated with dram-drinking.  Unloading  the
 liver thoroughly will also relieve the cough  which takes its  rise
 in hepatic congestion.   Peripheral irritation Avill often  give  rise
 to cough, as  in chest  exposure for instance.  Here any cold
 playing upon the chest will excite cough, Avhile a warm poultice
 will relieve it;  and a chest-protector will'give great and con-
 tinuous relief.  In addition, hoAvever, to these measures, Ave may
 resort to those remedies given in Chapter XIII. for the lessening
 of nerve conductivity and  the  checking of reflex action, with
 decided advantage.
  At other times cough is a true neurosal  affection, and must
 be met by the ordinary measures of chalybeates, tonics, etc., and
 occasionally by  the  union of these  measures Avith bromide of
 potassium.   There is often a brazen  or ringing  character about
 a neurosal cough.   Sometimes the neurosal cough has certain
 especial surroundings, as in the so-called hysterical cough.  This
 is common in girls  and young women.  It is  very frequently
 associated with  the  changes of  puberty; and again and again
 does such cough  excite unfounded apprehension, being mistaken
 for the cough of tuberculosis.  It is  a cough Avhich is almost
 incessant: it  is  often a dry " hemming" cough.  Its origin is
either central in the  deeper seated portions of the basal cerebro-
spinal ganglia;  or it is due to some  peripheral  irritation, as
uterine or ovarian excitement.  It is  often found with hysterical 
388            THE  RESPIRATORY  SYSTEM.

paralysis or spinal irritation.  In  all cases of persistent cough
with little or  no expectoration it  is ever desirable to examine
the uvula, to make sure that the cough is not due to the tick-
ling produced by this organ Avhen  elongated.  If necessary the
uvula should be amputated.
  A distinctly characteristic cough is that of pertussis, or hoop-
ing-cough.  It is distinguished by the long  inspiration, recog-
nized as  the  " hoop,"  which  terminates  the repeated violent
expiratory efforts that precede it.  In these efforts the stomach
is commonly  emptied  of its  contents, and the great danger
looming is death  from  inanition.   Here the best  thing to be
done is  to feed the little sufferer immediately after the attack,
so that the food may be assimilated ere the next attack of cough-
ing  comes on  and empties the stomach.   The treatment of
hooping-cough is  very  unsatisfactory.   Sometimes the reflex
action  can be stayed  by bromide of potassium in a magical
manner;  more frequently, however,  it fails.  At other times
quinine seems useful ; or steel or zinc may be tried.
  Such  are the leading varieties of  cough which come before us.
It is clear enough that cough has  to be met by  different meas-
ures, according to  its causation and the conditions  Avith Avhich
it is associated.  The elixir which is all-poAverful in one form is
useless in  another.
  § 159. Dyspnoea  is the  other phenomenon so commonly met
Avith in diseases of the respiratory organs.  It, hoAvever, is often
due  to  enlargement of  the abdominal viscera, Avhich, by press-
ing the  diaphragm upwards, diminishes  the thoracic space.  It
does not  matter  Avhether the  disease  which  diminishes  the
breathing space within  the chest be.thoracic or  extra-thoracic,
the result is the same.  The intra-thoracic causes of diminished
space are pneumonia, pleuritic  effusion, congestion, mediastinal
growths,  aneurisms,  etc.   In  such  cases  the  only  measures
which will give relief are  those which Avill remove the cause of
the diminished space.   At  other times there is  obstruction to
the passage of air in the larynx, the trachea, or in the bronchial
tubes.   These are  mainly constant, as when an aneurism presses
on the  trachea—though this may  also give rise  to intercurrent
severe paroxysms—Avhen there is laryngeal cicatrization follow-
ing  ulceration, or  Avhen there is  thickening of the  bronchial
lining  membrane.   It may be continuous,  but  temporary, in 
               THE RESPIRATORY  SYSTEM.            389

bronchitis, especially if capillary.  In such cases there is little
to be done,  except  the  general  measures of stimulants, with
inhalations of steam, with which may often be profitably com-
bined some  balsam  or pine resin, as terebene.   At other times
the dyspnoea is paroxysmal, and  due to spasm of the bronchial
tubes.  Here the affection is neurosal, and has  been spoken of
before in § 150.   Dyspnoea is often cardiac  in  its  origin, and
associated Avith  congestion of the pulmonic  circulation.  Con-
sequently it is  common when there is mitral disease and the
rio-ht heart is failing.  These attacks of cardiac asthma are often
severe and ahvays  distressing;  they must be met by the meas-
ures  given in detail in the last chapter.  In  that form of dys-
pnoea where  the patient  can only breathe when propped  up,
known as orthopncea, there is usually disease of the right side
of the heart, with or Avithout left-side disease.  There have been
many explanations offered as to  the causation of this condition.
The  only one about which there is absolute certainty is an ana-
tomical one, viz., that Avhen the abdominal viscera fall aAvay by
their mere weight from the diaphragm, they give the heart more
room to play in, as well as increasing the thoracic space  for the
play  of the lungs, when in the recumbent posture the Aveight of
the abdominal viscera presses against the diaphragm as  well as
against their other parietes, and pushes it up into the thorax.
In such  dyspnoea change of posture as Avell as the administra-
tion  of digitalis and stimulants are indicated.
  As cough may have an origin in which the  respiratory organs
have no share, so dyspnoea  may  arise from conditions not asso-
ciated with  lung disease.   Thus  poverty of the  blood by its
reduced number of  red corpuscles and corresponding reduction
of haemoglobin, diminishing the  chemical interchanges, may
give  rise to dyspnoea.  This  is easily increased  by  exertion.
Chlorotic girls  furnish  the best and commonest forms  of this
"air-hunger," as the Germans  call it.  Here the relief of  the
anaemia is the most, and indeed only, efficient means of treating
this phenomenon.  (P. 146.)
  § 160.  We must not altogether overlook haemoptysis ere con-
cluding this chapter.  It is often a most alarming symptom of
a most grave condition.   At other times, even when not a vica-
rious catamenial Aoav, it is not  to  be regarded as  a  serious
matter. 
390            THE  RESPIRATORY SYSTEM.

  Ordinarily it is to be met by cold  fluids, perfect quietude and
silence, and astringents—ergot, sulphuric acid, etc., with opium.
When dependent  on  cardiac disease, on disease of the mitral
valve leading to pulmonic congestion, bleeding from  the arm
often gives immediate relief.  Under one set of circumstances
haemoptysis occurs as a sort of leakage.  In these persons there
is a tendency to make blood rapidly, and then the Aveakest spi>t
in the vascular system gives Avay.   If this locus minima: rexis-
tentiaz  be  the lung, the  recurrent haemoptysis will  go on for
years; but if sonic other point become least resistent, as the
uterus, for instance, then the  haemoptysis  vanishes—to return,
however, in the instance cited—on the occurrence of pregnancy.
In such cases a most restricted diet will produce but little blood,
and sIoav and retarded blood-formation  Avill lead to a gradual
filling of  the vascular system, by  which haemoptysis may  he
avoided.   A remarkable case of this kind occurred in the prac-
tice of my friend the late Dr. Greene, of Kendal, and the patient
is a very fine, stalwart gentleman, bearing  no traces of the re-
current haemoptysis, which apparently kept his life in jeopardy
many long years ago.
  It is not the mere haemoptysis—for  loss of blood is loss of
blood, no matter whence it conies—it is the circumstances under
which it occurs Avhich lend the gravity to this form of hemor-
rhage (Chapter X., §  93).  Haemoptysis not  rarely gives great
relief  to an acutely  congested lung, and  in so far is useful;
though it may thus be a good  form of local bleeding, it is always
Avell to do away as far as possible with the  necessity for such
an alarming auxiliary.   The cessation  of  the haemoptysis can
ever be hailed as a sign  of  better things, and of the success of
the  treatment  adopted.   The relief afforded by haemoptysis is
well shoAvn in a lady at present under care.  On two occasions,
now, the cough, the uncomfortable  feeling in the affected  lung,
the high temperature, and  the rapid pulse  have been relieved
by a free  haemoptysis.  Each time, after this local depletion,
relief of the general condition has been accompanied by a change
in the lung, which  forthwith commenced  to  clear  up.  Since
the  publication of  the  first  edition of this work, thrice  more
has haemoptysis given pronounced  and immediate relief.   The
cold spring of  1879, however, reduced her very much, the mis-
chief  in the lung spread, and she  became very feeble; at last 
THE RESPIRATORY  SYSTEM.
391
came the haemoptysis, but this time she was too Aveak to stand
the hemorrhage, which Avas almost instantly fatal.
  It  may  be Avell to conclude this  chapter Avith  a warning.
Opium kills by paralyzing first the respiration and then the
heart.  Whenever there is serious mischief in the thorax and
opium  must be given, it should ahvays be combined with atro-
pine.  Whenever the respiration is seriously embarrassed opium
is a  most dangerous  remedy to  prescribe; the already taxed
respiratory centres may  be palsied by a moderate dose and death
result.   I have known death to result from a quarter of a grain
of morphia, in a man  nearly worn out  with rapid phthisis.
Opium in thoracic disease should never be administered wuthout
the most Avatchful caution. 
CHAPTER  XYI.
                    THE DIGESTIVE SYSTEM.

  § 161. As the question of the assimilation of food, and the
means of assisting in the production of good digestion, have been
discussed at length in Chapter II., the reader may profitably
refer to  it again ere  reading this chapter.  Here it is designed
to review  the  various affections of the digestive tract and to
point out the means,  rational and empirical, by which they may
best be treated.  A large section of these ailments is comprised
under  the head of indigestion.
  Dyspepsia, or indigestion, is a term which  covers a number
of separate and distinct pathological conditions.  As the term
implies, there is present difficulty, imperfect, or painful digestion.
Dr. Leared thinks that where  there  is pain present there is
lack of gastric  juice ; where there is a sense of distension there
is imperfect muscular  movement in the  stomach.  Both may
be present.  The treatment is regulated accordingly.   After
food is taken  there is a sense of discomfort,  either immediate,
or not for an  hour  or so.  This is  accompanied by general
malnutrition, spareness, and general ill-health.  In some cases
there is much  toleration  of some  forms of food, with equally
marked  intolerance of other forms.  Consequently the form of
food, its manner of preparation, the quantities  in  which it is
taken, are  all important matters to be attended  to.  Whatever
the exact pathological form of the malady and the indications
for treatment as regards medicines, in every case the diet must
be carefully regulated.  What rules  shall guide the youthful
practitioner  in  the matter of diet will  be given after a brief
consideration of the leading forms of gastric maladies, and of
their remedial measures.   In  the first place, however, the im-
portance of  carefully chewing all solid  forms of food cannot
be sufficiently  insisted on.   Bad teeth  are  fertile  sources of
dyspepsia.   The  stomach may be  able to do its OAvn share of
Avork fairly well.   But it  may break  doAvn  under the test of 
THE DIGESTIVE  SYSTEM.
393
 haAring to make up for imperfect mastication.  If the food taken
 be not fairly prepared  by mastication and admixture of  saliva
 ere it enters the stomach, the act of digestion is rendered much
 more difficult.
  For the folloAving remarks upon the proper care of the teeth
 I am indebted to my friend Henry SeAvill, author of The Student's
 Guide to Dental Anatomy and Surgery:—

  "Caries, or decay of the teeth, consists essentially of a process
 of gradual softening and disintegration of the tissues, due mainly
 to the action of acid.  The  onset of the  disease is favored and
 its progress  hastened primarily by certain  structural  defects in
 the enamel  and dentine; and  secondarily by some diseases of
 the oral mucous membrane and some derangements of the gene-
 ral health.
  Commencing invariably at the exterior, it advances towards
 the interior  of  the  tooth, forming a cavity, which increases in
 size until  the crown and even the greater part of the root also
 are destroyed.
  The acid, the active agent  in caries, may be derived from
 several sources.  It may be secreted by the mucous membrane.
 The normal  secretion of the membrane is small in quantity and
 slightly acid.   In health the acid is at once neutralized  by the
 alkaline saliva Avith which it mingles ; but Avhen the membrane
 is congested or  inflamed, the mucus increases in quantity and
 becomes more  strongly  acid in character, and  is sufficiently
 powerful to  slowly dissolve enamel and dentine.
  During  the decomposition of particles of food, which, mingled
 with shreds  of mucus and other such substances, lodge about the
 teeth, acid is formed capable of producing the same effect.
  Caries may commence on  a  sound unbroken surface  of  the
 tooth, especially on the lateral aspects, close  to  Avhich acid is
 commonly generated by decomposition of particles of food  lodged
 between the teeth, and by irritation of the mucous membrane.
 It frequently has a starting-point at some part of the enamel and
 dentine the seat of structural defect.  Imperfections in structure,
 from which feAV sets of teeth are altogether free, may  be  OAving
to defect either  in the quantity or in the quality of the tissues.
Defects in  quantity consist of pits and Assures in the enamel and
dentine. 
391
THE DIGESTIVE  SYSTEM.
  These vary in extent between minute cracks perceptible only
under  the  microscope, and cavities plainly visible to the naked
eye.   They may penetrate the enamel alone, or may extend to a
greater or less depth into the dentine also.  Their most common
situation is in the depths  of the  natural depressions in the con-
tour of the teeth—as, for example,  between the cusps of the
molars.
  The durability  of the  dental  tissues varies  considerably in
different individuals: in one the teeth withstand the extremest
hard usage combined Avith neglect; in another they show traces
of disease within the earliest years of childhood, and are destroyed
sooner or later, even in spite of active treatment. If the enamel
and dentine of such delicate teeth be examined, it will be found
that they present well-marked evidences of imperfect formation.
The enamel, instead of appearing a densely hard, almost homo-
geneous  mass, is comparatively soft, owing to imperfect calcifi-
cation, and porous in consequence of imcomplete coalescence of
its formative elements.  It retains a marked  fibrous character.
The fibres are imperfectly blended, their transverse  stria' are
clearly evident, and  they are often penetrated  at  their centres
by tubes or small cavities.  At parts the fibrous character may
be altogether lost, the tissues consisting of an incompletely united
granular mass.
  The dentine, in addition to undue softness, exhibits at various
points throughout  its structure, and especially  immediately
beneath  the  enamel, patches of tissue of a granular formation
containing numerous spaces.
  It does not ahvays happen by any means that all the structural
defects which  have  been just mentioned in the quantity and
quality of  the  dental tissues exist together in one tooth.  It is
not uncommon to find in teeth, of otherwise good organization,
one or two pits or fissures, or small patches of  defective tissue;
whilst in teeth of generally inferior structure there are often to
be discoArered portions of still  feebler formation.
  The local  and constitutional diseases which  favor the onset
and progress of caries are  those which are accompanied by or
Avhich tend to aggravate inflammation of the oral mucous mem-
brane, and those which give rise to  the formation or deposit of
acid Avithin the mouth.  Among the former may be particularly
enumerated all the varieties of stomatitis; among the latter, gout, 
THE DIGESTIVE  SYSTEM.
395
 scrofula, syphilis, phthisis, chlorosis, and  chronic  alcoholism.
 These constitutional affections exert their  baneful  effect  upon
 the teeth in great part by reason of the chronic inflammation of
 the gums, and vitiation (eAren general  acidity) of the secretions
 of the mouth, and the  dyspepsia  with  Avhich  they are all so
 commonly accompanied.   For the same reason, caries is fre-
 quently active during pregnancy.   During febrile  diseases, in
 which  the secretion of saliva is scanty, and the teeth  remain
 coated with sordes, accumulations of epithelial  scales, viscid
 mucus, and other foul secretions, caries, as  might be expected,
 is often  originated, and,  when  previously present, is  ahvays
 aggravated.
  The facts that enamel and dentine are readily soluble in the
 acids, the presence of which in the mouth commonly arises from
 various sources, and that  structural defects in the enamel and
 dentine not only furnish places  favorable for the  lodgment of
 acid-forming substances, but at the same time render some por-
 tions of the teeth more readily acted upon than others, suffice
 to explain both  the origin  of caries and  the reason why the
 disease commences at certain isolated  spots, and does not affect
 uniformly and at once the entire  surface of the crowns of the
 teeth.
  The pathology and etiology of dental caries being  understood,
 it will be obvious that  much  can be done to prevent the  attacks
 of the disease and to delay its progress. Too much stress cannot
 be laid upon the importance of the treatment of constitutional
 conditions predisposing to decay of the teeth. If it  be omitted,
 the most  active  local  measures  may prove  in some cases  in-
 effectual.
  Locally, the prophylaxis of caries in part consists in combating
 diseased conditions of the mucous membrane of the mouth Avhich
 are attended Avith vitiation of the secretions; but as these con-
 ditions are discussed in other parts of this work, there need be
 considered here  only the means which are available locally in
 preventing the formation of acid, the active agent in caries, in
 neutralizing it, and in preventing  its hurtful effects upon the
teeth.  Foremost among these means must be placed the main-
tenance of the mouth in perfect  cleanliness.  The teeth should
be carefully brushed at least twice daily, and the patient should
be taught not only to cleanse the more exposed  surfaces, but to 
396
THE DIGESTIVE SYSTEM.
apply the brush to every part to Avhich it can reach.  The spaces
betAveen the teeth should be frequently freed from the particles
of food Avhich lodge there.   For this purpose a feAv threads of
floss-silk, or a fold of any similar soft material, or a thin flexible
quill toothpick, slipped into the  spaces and rubbed briskly to
and fro, answers Avell.  Tooth poAvders and lotions are of con-
siderable value.  Tooth poAvders ought not  to be made of mate-
rials like  levigated pumice, Avhich are often used to whiten the
teeth, and Avhich produce the effect by grinding aAvay the enamel,
but should be composed of alkaline bland and soluble substances,
having no more mechanical poAver than enables  them to remove
the Avell-knoAvn soft fur Avhich coats the surface of the teeth, in
most  mouths, even within a  feAv hours after every application
of the  tooth-brush.   The  desired  objects are Avell fulfilled by
such a mixture as the following: —
                  U Pulv. Iridis Flor. ^ij.
                      "  Sapon. Castill. ^ss.
                      "  Crete Precip. §j.
                      "  lioraeis, ^ss.
                   Otto Rosa,', TTfij.
                   01. Lavand.  ulxij.
A poAvder having as its principal  ingredients chalk and carbon-
ate of soda is almost equally efficacious.
   Mouth-Avashes may be composed  with advantage of tincture
of myrrh  or  of rhatany.   The  spirit Avhich  these  tinctures
contain, besides rendering them more astringent, is  antiseptic,
and it is  a good plan to  use them to moisten  the  floss-silk or
other material Avhich is  employed in cleansing the spaces be-
tAveen  the teeth.  With the same design eau-de-cologne, lavender
Avater,  and similar perfumes are pleasant  applications.  With
these lotions there may be combined carbonate of soda or other
soluble alkalies Avhen the  acidity of the  secretions is great, or
when the patient is obliged to take acid medicines.
   In  fevers  or other diseases, Avhen the patient is either too
feeble or too listless to  clean  his  teeth  for  himself, this should
be done by an  attendant, using a  soft tooth-brush  frequently
dipped  in a Aveak lotion of permanganate of potash or carbolic
acid,  with which also  the mouth should be  frequently well
Avashed out.   These measures not only tend  to preserve the
teeth, but at the period of early convalescence, Avhen the appe- 
THE DIGESTIVE  SYSTEM.
397
tite is feebly reviving, often by refreshing the mouth stimulate
the patient's desire for food.
  Perhaps the most beneficial procedure that can be adopted for
the prevention  of caries, in cases in Avhich the teeth are of a
generally defective structure, and especially Avhere great crowd-
ing of the teeth exists, is the extraction of tAvo  or more per-
manent teeth from  each jaAv  during the period of the second
dentition.  In such cases after the  second molars are in place,
the first molars, Avhich are the  most liable of all  the teeth to
decay,  and Avhich are by this time  often  extensively carious,
can be  Avell spared; but even Avhen sound, their sacrifice will be
rapaid  in many instances  by the  improved condition  of the
remainder of the set.  Xot only does the room afforded by the
consequent equal spreading ap>art of the  teeth render the origi-
nation  of caries less possible, but it enables the cleansing of the
interstices to  be easily performed, and affords the dentist the
opportunity of detecting and dealing Avith decay in these situa-
tions in its incipient and most tractable form."

   When food  is obviously unsuited to  the stomach, or  from
some suddenly acting cause the digestion is arrested, as by some
shock,  then one of two things happens—sometimes both.  The
contents  of the  stomach  are either immediately  ejected  by
vomiting ; or are passed into the intestines, and then got rid of
by purgation.   It is obvious that such a " sick fit," as this acute
indigestion is not inaptly  termed, is not to be arrested ; but
rather  encouraged.   After the brunt of the attack is over some
bland and fluid form of food is very desirable, such  as boiled
sago, Avith  milk or  beef-tea.  In milder cases these measures
may be  all  that  is  required.  In  other  cases,  hoAvever, the
suffering is such that it becomes necessary to  resort to emetics
to unload the stomach, by exciting vomiting.
   § 162.  The Theory of Emetics.—Emetics are of tAvo kinds, the
direct  and  the specific.   The first  division comprises agents
like mustard, sulphate of  zinc, sulphate of copper, &c, which
excite the act of vomiting as soon as they are brought into con-
tact with the lining membrane of the  stomach.   The specific
emetics are those Avhich also excite vomiting when administered
by other means than given  by the stomach.  Such agents  are
tartar  emetic, apomorphia, and  ipecacuan; they  will produce 
398
THE DIGESTIVE SYSTEM.
emesis  if  injected subcutaneously.   This division  of emetics
produces distinct impressions on the system generally.  The so-
called nauseant emetics are used rather imconditions Avhere vas-
cular depressants are indicated than for  the mere purpose of
unloading  the stomach ; for this last end mustard or sulphate of
zinc rather is to be selected.  By the  administration of mustard
in hot Avater, or the zinc in scruple doses, emesis is usually pro-
duced satisfactorily.  It is not bad practice to give the zinc with
ipecacuan  Avine—a scruple to a drachm of the Avine; this forma
a very certain and not too depressant emetic.
  When,  then, the  stomach has  in  it  an unmanageable and
troublesome  mass, it  is Avell to get rid of it at once.  If there is
any intestinal  disturbance  remaining, then a dose of castor-oil,
or other gentle purgative, may  be  given  with advantage.  It is
Avell ahvays  after such acute disturbance in the digestive tract
to be guarded about the nature of the food for some few days.
  § 163. Acute  affections  of the stomach  are  readily treated
at  the  time, but the permanent conditions upon Avhich  acute
derangements causally depend  are often troublesome, and not
rarely incurable.  Gastric catarrh, ulcer, and cancer are affec-
tions whose  treatment requires great consideration and  much
thoughtful application of  physiological  knoAvledge.   Firstly,
because the stomach  is an organ whose complete rest is scarcely
compatible with a prolonged existence: in those  cases Avhere the
irritability is  excessive, it  may be necessary to give  complete
rest to the stomach  by feeding the patient by the rectum; but
this is a tiresome and unpleasant method of feeding.  It becomes
necessary then  to give food in  such form that it shall tax the
stomach as little as possible.  Next, it is of importance to give
this viscus its  proper intervals of rest; that is, brief periods
when it is  not functionally active.  This is somewhat  difficult,
as in all cases of gastric debility it is very desirable to give food
in  small quantities, and  consequently  at  repeated intervals.
Nevertheless if  the food be such that  it  readily passes into the
intestines,  these intermittent periods of rest may be secured.
In gastric catarrh the food should  ahATays be fluid.  If there are
any solid particles in it, there is ever present the clanger that in
being rolled over and over by the stomach the mass will become
covered  with the mucus, too freely  formed ; and thus,  being
removed from the action of the gastric juice, rendered-useless, 
THE DIGESTIVE  SYSTEM.
399
 because indigestible.   Not  only that, but the mucus enveloped
 mass has to be got rid of either by vomiting or by purging.  The
 food, then, must not be solid.  In gastric  ulcer the food should
 be of similar character for the following reasons.  All movement
 of the stomach is  liable to  disturb  the  base of the ulcer, and
 so give rise to pain ;  consequently the  briefer and  slighter the
 movements required the  more this source of suffering will be
 aA^oided.   Then again the presence of the  acid gastric juice
 offends the  ulcerated  surface, and  consequently the briefer the
 act and  the  earlier  the quiescent and  alkaline  condition  is
 resumed the  better ;  furthermore,  repair  goes on during the
 time the stomach  is functionally quiescent, and the more such
 physiological rest can  be secured  the better for the patient. All
 this holds equally good of gastric cancer; though unfortunately
 here all measures  are  but palliative.   An impression exists in
 my mind  that many cases  Avhich ultimately become undoubt-
 edly cancerous had for years previously presented the features
 of chronic dyspepsia.  Even when  cancer is  gravely suspected,
 appropriate treatment  Avill often afford much  relief for a time.
  Much  may  be  done  in  these cases by proper  therapeutic
 measures.   First of these  stands  opium.   We have seen in
 Chapter  XIII. that this agent  checks nerve action not only
 in the centres, but in the  peripheral  portions of the nervous
 system.  It acts as  a sedative to  terminal nerve-fibrils.  In the
 stomach  this  is markedly seen.   If opium for any reason be
 given continuously for  some time,  by the  mouth especially,
 there folloAvs loss of appetite  and constipation.  This latter is
 due partly to the  arrest of secretion, and partly  to checking
 the muscular  movements of  the digestive tract.   The loss of
 appetite is due to a similar action.   The sensation of hunger is
 simply manifested  by the stomach, and  in cases of disease of
 the lining  membrane  of  the digestive tract  the sensations of
 hunger are  often so aggravated as to lead to  bulimia.  This is
 well seen  in cases of  muco-enteritis, often following measles,
 Avhere  a  child is  ever eating;  a  little  only of the  food so
greedily consumed is digested, and the  more the child eats the
worse it thrives aud the sooner it dies.  This  species of gastro-
intestinal irritability is not  rare in advanced  phthisis; and the
development of an inordinate appetite in these cases is a symp-
tom of'the Avorst omen.  In  such  cases opium is  clearly indi- 
100
THE DIGESTIVE SYSTEM.
cated.   If there  be much catarrh it may be given with astrin-
gents, as in the  form of compound kino poAvder.  It would at
first sight seem that the opium and astringents would lock up
the bowels too much ; but in actual practice it is not so.  These
agents seem to  act especially on  the  diseased surface and less
upon the boAvels than Avould be  the case if no gastric catarrh
existed.   We have seen before that  opium  also  tends to check
secretion, and is good for  that action  also when excessive.  In
gastric ulcer, by arresting the digestive movements, opium also
gives physiological rest ; and so is eminently useful.  Its local
action on  nerve-ends  soothes the ulcerated  surfaces.  It gives
relief in gastric  cancer, locally as well as  generally; but here
it  must  be gwen in different doses, for Ave wish to secure  its
general analgesic effects as well as the  local action.
  The proper use of opium in affections of the intestinal canal
is a matter of much  importance,  and the youthful reader Avill
do Avell to ponder over the subject at some length.
  Alkalies  are also of much service in the  treatment of these
ATarious  affections.   They  may be used with  success in neu-
tralizing  the  excess of acid in very acid digestion.   In  gouty
dyspepsia potash is of the greatest  service.  In some cases it
may be necessary to give alkalies during digestion to relieve the
excessive acidity ; even when acids and bitters are being admin-
istered  before meals.   There is  nothing  inconsistent in such
practice, and it is often followed by the happiest results.  Some-
times the acidity is found  far doAvn in the  intestines, and then
fixed alkalies, and especially chalk, are indicated.   If soda or
potash be given they may  be absorbed, but the various prepara-
tions of  chalk not being rendered  soluble, or  but very partially
so, are useful even  Avhen the acidity is  in the colon.  Thus milk
and lime-water is a famous old-fashioned combination, especially
useful for infants Avith gripings from excessive acidity: or chalk
may be added to the milk.
  Bismuth is a most useful agent in the treatment of all chronic
affections, especially where  there is  excessive secretion with
irritability, in the  gastro-intestinal tract.  This has long been
knoAvn ; but  we are  as far  as ever from knowing  how these
results are brought  about.   Most of the bismuth passes out by
the feces, consequently one is inclined to the belief that it exer-
cises some  local  sedative  action  upon the mucous tract.  This 
THE  DIGESTIVE SYSTEM.
401
view is confirmed by its use in gonorrhoea as a local application ;
and  its good effects in some persistent ulcerations, especially of
the face, in the form of bismuth ointment.  In gastric ulcer it
is useful, in catarrh it  is also useful ; it relieves gastric pain and
intestinal irritation.  Consequently it is of much  service in all
cases where there  is  irritative dyspepsia with  malnutrition.
The old form,
                       Bism. Trisnit. gr. x.
                       INIist. Acaeiae, 3j.
                       Inf.. Calunib. ad 51'.
three times a day before  food is an  excellent measure,1 and is
often to be preferred to the more  modern soluble  forms of bis-
muth. In many cases it is Avell to add ten grains of bicarbonate
of soda to  each  close, especially where  there is much  gastric
irritability, and  the tongue is raAv and denuded of epithelium.
Bismuth  may be  added  in a dose of ten grains to an equal
quantity  of compound  kino  powder  in gastric  catarrh.  In
troublesome irritative diarrhoea ten grains of bismuth with an
equal quantity of myrrh  is a good combination.   Indeed bis-
muth is a most valuable drug in many ailments.   Hydrocyanic
acid is also often of service.  In some cases of irritative dyspepsia
bromide of potassium is  of great use.   When  there is much
irritability of the stomach a mustard blister, or one of Rigollot's
leaves, applied to the  pit of the epigastrium every  night at bed-
time, is an excellent measure.   In cases of intestinal irritability
turpentine stupes, and  similar applications to the abdomen are
often of  service.  Subcutaneous  injection of morphia, or the
formation  of a  blister over  the  region of  the stomach, and
subsequent  dressing Avith morphia, may  be indicated in  some
severe cases.  (Bitters have been referred to at p. 44.)
  § 164.  The greatest matter in all these cases is the food.  This
must be bland, that is, pleasant and free from irritating  proper-
ties, even  when  spiced food is craved after.   It must be fluid,
in order to pass readily through the stomach, and  to call out as
little functional  activity  in the diseased organ as possible.  It
must be nutritive and readily  digestible, that  is obvious.  Con-
sequently  milk and seltzer-Avater, especially where the milk is

  1 In middle-aged persons it is often well to add  ten grains of bicarbonate of
potash to each dose, markedly so where there is present a condition of lithiasis.
      26 
402
THE DIGESTIVE  SYSTEM.
too constipating, or lime-Avater, is an excellent form of food; or
even prepared chalk, or magnesia in poAvder or in other cases may
be added to the milk.   Or milk may be thickened by having the
poAvder of  a  plain  biscuit stirred into it;  this is very nice in
gastric ulcer.   Or sago or  arroAvroot may be boiled and then
mixed Avith the milk,  or  they may be  thoroughly boiled and a
little beef-tea or meat-juice may be added.  Beef-tea or chicken-
broth alone  are  not desirable;  they contain  almost no force
bearing food, but Avith  sago, arroAvroot, or  biscuit powder they
become suitable  articles  of dietary.   The great thing to he
aimed at is to procure a food Avhich will readily pass through
the stomach, either giving the stomach no trouble or very little.
Nitrogenized  food  must  ahvays be in a fluid form ;  and the
hydrocarbons to be acted  upon by the saliva and  the pancreatic
fluid, should  be given  in  that form that  shall  least task the
stomach, and be least likely to be covered by mucus in catarrhal
conditions.   It has not happened to me to meet with those cases
where raAV meat pounded has  been  imperatively called  for.
Certainly  meat-juice, in the  many excellent forms  now in the
market, is  very digestible,  even by a very  feeble stomach, and
meat already digested  is very useful ; but that starch is contra-
indicated  in  dyspepsia is foreign to my experience.   Until avc
knoAv something more of indigestion from  defect in the saliva
or pancreatic secretion, we can  only  think of  the  digestive
processes going on in  the stomach, more  or less imperfectly.
The  stomach  hoAvever  is a  mere moving  bag as regards the
digestion of starch.  If the starch be given in boiled form, or
better still, after having  been baked, as is  the  case Avith many
excellent foods noAv in the market, it is readily digested.   Such
foods are as  desirable  for dyspeptic adults as they are for the
feeble digestive power of the infant.   Intractable dyspepsia is
usually as much the  result  of defecthTe  knowledge  in  the
practitioner as defective poAver in the assimilative processes of
the patient.  Beef-tea and meat-juices are all very Avell, but they
possess small value  as  foods—either for  the production of heat
or mechanical poAver;  and they should always be combined with
some form of partially digested starch, in  order to raise  their
food-value.  A small  quantity of baked starch,  added to beet-
tea or meat-juice gives it increased value, or  a pinch of sugar
may be added.  But much pains as well as acquired skill from 
THE DIGESTIVE  SYSTEM.
403
 practice are requisite in the treatment of dyspepsia; as Avell as
 patience.  Of all things to be avoided is meat cooked a second
 time.   To a dyspeptic, a hash made with cold, previously cooked
 meat is simply poison.
   The  food must be given in small quantities and at  repeated
 intervals.   If a tablespoonful of milk is rejected by an irritable
 stomach, a dessertspoonful should  be tried ;   if that is too large
 a quantity, a teaspoonful.   Any one of  much experience knoAvs
 hoAV desirable it is to so treat an irritable stomach, and of the
 hairbreadth escape  of many  a patient.   Another point to be
 remembered in  the treatment of these cases is this: a fort-
 night's careful self denial and  strict  dieting may be neutralized
 and thrown aAvay by one single act of indiscretion ; and all has
 to be  done over again.  Especially  is  this apt to occur when
 cases are doing Avell, and the patient is becoming too confident;
 after one or tAvo mistakes  the patient is more careful, but then
 the convalescence is apt to be very tedious.  Another point bears
 upon what has  been said  a few sentences back, and that is to
 remember that the stomach is a IioIIoav muscular viscus ; and so
 not to distend its Avails more than is necessary.   In febrile con-
 ditions and in the thirst of advanced cancer the patient will, if
 permitted, gulp  cIoavii  considerable  quantities of fluids, which
 are  immediately rejected.   Here pieces  of  ice relieve  the dry
 pharynx and the consequent sensation of thirst;  while the cold
 fluid, sloAvly trickling into the stomach, is grateful, and does not
 excite vomiting; but is absorbed  as  fast as it passes  into the
 stomach.
   Sometimes gastric irritability and vomiting are the conse-
 quences of distant irritation, as an  irritable ovary, the vomiting
 of pregnancy, or that caused  by calculus in the kidney, or a
 Woav on the genitals.  In such cases it is desirable to treat the
 stomach carefully ;  but at the same time it is very necessary to
 resort to those agents which lessen nerve conductivity, as bro-
 mide of potassium.  Also  removal of the irritating cause is a
 very proper measure.  All that has been said about reflex cough
 applies here to vomiting.   (Also  see § 187.)   Finally, no condi-
 tion  of dyspepsia or  intestinal  irritability will ever be relieved,
and got rid of, if the  boAvels  are  not properly unloaded.  As
long as a constipated and  loaded condition of the bowels, and
especially the colon,  exists, so  long  will the dyspeptic state per. 
101
THE DIGESTIVE SYSTEM.
sist.  A pill at bedtime, some bitter Avater of Friedrichshall, or
other laxative, on  getting out of bed in the morning, or even
a  tumblerful of cold  Avater  alone,  especially for ladies  who
habitually  take  too small  quantities  of fluids, are  excellent
measures;  or an enema may be resorted to if preferred, or more
desirable.  In Avomen dyspepsia is usually complicated by vaginal
discharges, Avhich must ahvays be  energetically treated.1  l>vs-
pepisia is often of reflex origin, and is almost invariably of this
nature Avhen found  along  Avith a perfectly clean tongue.  Such
dyspepsia is found  in women almost solely, and is of ovarian or
of uterine origin.   Such reflex disorders of the stomach are very
frequent, and are often obstinate and intractable, because their
nature  and  origin  are  forgotten or overlooked.  The subject
will be  discussed in § 187  as a result of ovarian disturbance.
   § 165. We may now  proceed to consider those disturbances
of the digestive canal Avhich are associated Avith the liver.  And
at  this point may  be discussed  profitably the function of  the
liver and the disturbances of that organ.   The liver performs
three distinct functions: (1) the storing up of glycogen ; (2) the
oxidation of albuminoids; and (3) the formation of bile.  It is
at once a storehouse and a furnace.   Without attempting to
pursue  very far the subject of the functions of the liver, it may
be said  that the liver is found  in lowly forms of animals, and
is a very important organ.  In  its loAvest form, it  consists of
glands  attached  to the  mid-gut beknv  the   stomach, while
colored epithelium called  the "liver," is  found in  the crelenter-
ata.  In the higher mollusks  the  liver is a separate organ con-
nected  Avith the digestive tube by  its ducts.   Placed beloAv the
stomach, it is probably as important that  the food  taken  be
properly digested in that organ before the  liver takes its part,
as it is important for the stomach that the food be sufficiently
masticated before being received by it.  As bad teeth frequently
cause indigestion, so imperfect  assimilation may be a cause of
hepatic disturbance.  The sugar  taken up  by the portal vein is
converted  by the action of the liver  into  glycogen, a substance
like dextrin in  composition, and which is an insoluble form of

   1 Unless this be done, no improvement can be achieved, that is, usually.  The
body-ineome is insufficient for improvement if the heavy body-expenditure be
not checked.  There is, as Mitchell  Bruce happily phrases it, " poverty  from
waste, and poverty from want." 
THE DIGESTIVE  SYSTEM.
105
 sugar.  It is found in greatest quantities after meals.  Without
 the liver the blood Avould be constantly surcharged with suo-ar
 or famishing ; by means of it the sugar furnished from a meal is
 stored up in an  insoluble form  and gradually given off as the
 organism  requires it.   It is like a reservoir which  gathers  the
 waters of floods, stores them, and gives them off during rainless
 periods.   By means of the liver, instead of one sIoav meal ani-
 mals are enabled to eat at intervals; without Avhich the higher
 forms of  life would be  unattainable.  The liver is  then, in  one
 sense, the coal cellar of the organism.   This is its first function.
 If sugar be produced more rapidly than the liver can re-hydrate
 it into glycogen, then  it finds its Avay out by the kidneys, and
 constitutes one form of glycosuria.  This sugar  is common in
 the urine after meals, especially with  stout  persons.  If it  be
 present in small quantities, it  produces no indications of its
 existence  ; but if in considerable quantities, it  produces  the
 symptoms associated with diabetes.  When the liver is unable
 to convert the sugar into glycogen, then genuine diabetes is the
 result, and the  body Avastes—unless other food be provided in
 sufficient  quantities.   Thus glycosuria may be of no significance
 —be indeed a species of waste-pipe—or it may be the consequence
 of a very grave disturbance in the  hepatic function endangering
 life.  Diabetes  is then a disturbance in the glycogenic, or first
 function of the liver.
  The oxidation of albuminoids is the second function of  the
 liver.  The albuminoid materials of our diet are converted into
 peptones by  the  action  of the gastric  and pancreatic juices;
 from these peptones the tissues of  the body are fed, the surplus
 is broken  up by the liver into glycogen, and nitrogenized waste,
 as leucin and tyrosin, Avhich  by further oxidation  are converted
 into uric acid and urea.   In  the liver, too, worn-out blood cor-
 puscles and  tissue  debris are burnt, more  or less  completely.
 The destruction of spjare and Avaste albuminoids  is the second
 function of the liver; in this respect it is a furnace.  In his in-
 valuable work on " The Functional Disorders of the Liver,"  the
 late Dr. Murchison points out these two facts: (1) that in func-
 tional disorder of the liver  lithates are found in considerable
quantities  in the  urine ; and (2) that when a large  portion  of
the liver is destroyed, as by cancer, for instance, the amount of
urea is largely diminished.  The liver then is involved in  all 
406
THE DIGESTIVE  SYSTEM.
those disturbances Avhieh are associated Avith defective oxida-
tion of albuminoids.  Consequently, where there is a large sedi-
ment in the urine there is imperfect oxidation, either  from the
liver having more albuminoids to burn than it is equal to, i.e.,
a large surpdusage of food ;  or from  inefficient action, so that it
cannot perform its duties in a perfect  manner.  Lithiasis may
be induced  in a person Avith a good, well-acting  liver, if it he
persistently  overtaxed by an excess of nitrogenized food, as of
broAvn meats ; or it may be the outcome of a fairly well adjusted
dietary Avith an insufficient  liver, or a liver not very active func-
tionally.  Where the liver action is imperfect, large functionally
active kidneys may cast out lithates freely, and so depurate the
blood and Avard off that waste-laden condition of blood known
as lithiasis.   In all cases of lithiasis it  is well then to reduce the
albuminoids taken as food  to the minimum  of tissue Avants.
Lithates cannot be  produced  from a dietary of  hydro-carbons
without nitrogen; on the other  hand,  Avhen the dietary is rich
both in hydro-carbons and albuminoids, then lithiasis is readily
produced.   Hydro-carbons oxidize but sloAvly when in combi-
nation Avith  nitrogen.  Consequently the more readily oxidiz-
able hydro-carbons burn readily and consume the oxygen of the
blood, leaving the albuminoids in an imperfectly oxidized form.
In some countries, as on the pampas of South America, the food
consists almost entirely of  flesh, yet  lithiasis is not common.
The gaucho  has  no hydro-carbonaceous  food  to prevent or
obstruct the oxidation  of the  albuminoids, and,  though a flesh
eater in a hot climate, does not suffer much from  lithiasis.  In
most tropical countries the dietary is very free from albuminoids;
it is Avhen the European  takes with him  his craving for albu-
minoids that his liver in  time becomes  the seat  of disease.
Where  the  dietary  consists exclusively of hydro-carbons, the
second function of the  liver is not  overtaxed in a hot climate,
Avhere oxidation is  imperfectly  performed. Tropical  liver dis-
ease and functional  liver disorder in all  climates are associated
rather with the second function of the liver than with the first,
or third.  I  am  aAvare  that  this  statement will be met by
another, viz., that a little rich food, that is, rich in either sugar
or fat, is very commonly  the cause of liver disturbance.   Quite
so, but it is  the impaired oxidation of the nitrogenized elements
of food by  the surfeit of hydro-carbons Avhich  causes the dis- 
THE DIGESTIVE  SYSTEM.
107
 turbance; if the excessive meal contained no albuminoids, the
 disturbance Avould not have folloAved.
   And this leads up to the question of " biliousness."  There
 are  tAvo  forms  of biliousness occurring in  totally different
 classes of beings.  There is that form of biliousness Avhich really
 is indigestion, and where  t\vo  hours after a meal the urine is
 laden with lithates. Such is not uncommon  in persons of florid
 complexion Avho live  too  freely—that is, for them, and where
 the oxidation is insufficient.   In such cases there is dyspepsia
 present.   This is one form of liver disturbance, where the liver
 functions and  the kidney functions overlap.  The kidneys  can
 supplement the  defective  liver-action if  they  are  very active,
 and throw out  of  the blood imperfectly oxidized nitrogenized
 waste very freely, and so efficiently depurate the blood.  Then
 there is  the well-knoAvn form  of biliousness, chiefly occurring
 and most marked in  persons of the  bilious  diathesis—persons
 Avith yellow skins  and  dark hair.   Here  the digestive tract is
 chiefly disturbed; and  Ave  find  the typical bilious  attack—
 headache, furred tongue, disturbance of  the alimentary canal,
 loss of appetite, vitiated stools, a bad taste in the mouth, Avith
 fulness over the hepatic  region; the urine not  throwing down
 a sediment, but being high colored  from the presence of bile-
 acids.  The bile-tinged hue  on the glossal epithelium tells of
 the bile acids circulating in the blood in excess.  It seems curious
 that the  chemical composition  of these bile acids has not pro-
 voked  more thought as to their origin than has actually been
 the case.  "The bile acids in human bile  are tAvo—glycocholic
 acid (C26H43X06) and taurocholic acid (C26H,sX07S).  Both acids
 are derivatives  of albumen, and contain  nitrogen; and tauro-
 cholic acid,  to which the bitter  taste of bile is due, contains all
 the sulphur of the bile" (Murchison).   These bile-acids are formed
 by the liver, and their production is part of the third function
 of the liver; but the different functions overlap each other, and
 the bile-acids,  as  nitrogenized  debris, are connected  with  the
 second function of the liver.  The bile-acids are forms of albu-
 minoid waste;  both contain nitrogen and  one contains sulphur.
 As urates and  urea circulate in the blood, when not in  excess,
Avithout causing disturbance, so the  bile-acids also, Avhen not in
excess, do not make their presence felt.   But when-in excess—
when the bile is not poured freely into the digestive canal, or is 
408
THE DIGESTIVE  SYSTEM.
reabsorbed, so as to circulate in the portal circulation in excess
—then  they  cause the well-recognized symptoms.  But their
parentage and that of lithates is the same, viz., the albuminoids
of food; and if the food be not rich in albuminoids the patient
cannot be "bilious," though  rich  hydrocarbonaceous food may
apparently be the exciting cause of the attack ; really, as pointed
out  before, the biliary  disturbance  is  brought about  by the
hydro-carbons  combining with the oxygen,  leaving  the less
readily oxidizable albuminoid matters unoxidized.   The chemi-
cal  composition of the bile-acids, like  that of  lithates, points
whence they  are derived, and gives indications  for striking at
the root of the condition by regulating the dietary.  When the
liver is injured by disease  slight errors in diet are followed by
distinct biliary  derangement, as  in those bilious  persons now
under consideration.  They probably possess congenitally small
livers,  or livers  imperfect in  function, and  consequently are
deranged by an  amount of food which most persons can dispose
of Avith facility.  Murchison throws out the thoughtful sugges-
tion that " most people have more liver, just as they have more
lung, than is  absolutely necessary for the due  performance of
its function.   But in others, not unfrequently the offspring of
gouty patients, the organ  in its natural condition seems only
just capable of performing its healthy functions  under the most
favorable circumstances, and functional derangement is at once
produced by articles  of  diet which  most persons digest with
facility."   Where there  is a  small  or functionally imperfect
liver Avith small or inactive  kidneys, then the condition is one
calling  for much sympathy; but admitting only of very little
in the  Avay of treatment, except the negative treatment of rest.
Such defective organisms, or " poor creatures" as they are some-
times  termed, can only  exist  under  favorable circumstances.
Probably Mr. Irwin's "Sister  Anne"  in Adam Bede  was an
organism of  this description.
  Where the assimilative powers are so feeble and  the excretion
of  waste so  imperfect, the organism can do little  more than
exist;  it has no spare power for the performance of work.
  The practical lessons taught by this consideration of the dis-
turbances of  the liver,  in relation to  its second  function, are
these.   First, of all  things, all substances containing  nitrogen
must be avoided, whether lithates or  bile-acids are the source 
THE DIGESTIVE  SYSTEM.              409
of the systemic derangement; and the dietary for the bilious
is the dietary of the gouty—if they could  only be brought to
think so.  Their disturbances, hoAvever, are  so associated Avith
food rich in sugar or fat, that it is next  to impossible to con-
vince them.   Yet it  is  essentially the albuminoids, not  the
hydro-carbons, Avhich  upset  them.  In those cases Avhere  the
stomach  will  tolerate  albuminoids only,  then of course they
must be  taken; not because it is desirable, but  of  necessity.
Consequently all meats should be  avoided, and fruits and  fari-
naceous foods, as stewed  fruit Avith cream, or a milk pudding,
should be taken: easily digestible fats  being good. It is clear,
too, that exercise—leading to more perfect oxidation—ought to
be taken as far as the poAvers  permit.   More food  can be taken
in a Ioav  temperature than in a high one.  In tropical climates
the food of natives is almost entirely hydrocarbonaceous; and
if albuminoids are taken they  are mostly derived from vege-
tables, or from milk.  Limited quantities of food of any de-
scription are  best suited to  tropical climates, where  the body
requirements are small.   Careful,  sIoav mastication, digestible
articles of food, and rest after meals so as to permit of as perfect
assimilation as  is attainable, are  desirable,  in order to reduce
the demands upon the liver to a mini mum.  Imperfectly elabo-
rated peptones probably increase the Avork of the  liver.  Then
as to beverages.   It is  notorious that small  quantities of appa-
rently simple food,as eggs, or milk,Avill disturb bilious persons,
whether  from bile-acids or lithates; equally well known is the
effect of  alcoholic beverages.  A glass of port in  one, a single
glass of Champagne, or Sauterne, in another, a glass of malt in
a third,  will  set up serious  hepatic disturbance.   Each  must
learn to avoid his own poisons.
  As  for  medicines, alkaline saline  purgatives are indicated.
They  should be taken in the form of Carlsbad salts, Vals  or
Vichy Avater, Friedrichshall or Hunyadi Janos, or a combination
of Rochelle salts and sulphate of soda every morning on rising;
together Avith a tumblerful of water, cold, luke-warm, or Avarm,
according to the patient's tastes  and  requirements.   After a
copious liquid motion before breakfast, and a second one after,
a  bilious person usually feels  light and fit for work; and, more-
over, can digest his food better,  and  take  greater  quantities
without disturbance.   Such treatment  requires a little time to 
110
THE DIGESTIVE  SYSTEM.
make its good effects manifest, and the patient must be encour-
raged to  persevere.  So long  as there is a bitter taste in the
mouth in the morning—probably due  to  taurocbolic acid—the
purgation must  be continued.  AVhen the tongue is clean and
the bitter taste gone, then  the purgation need only be occa-
sional.  However anremic such  patients are,  iron is generally
contra-indicated.  After the bowels are put  right, then some
chalybeate may do good;  but it must be in small quantities.
Vegetable tonics, quinine  or strychnine  in  gentian,  with or
Avithout a little  aloes, and some carbonate of ammonia, agree
with  bilious persons  much  better than chalybeates, as a rule.
As to the utility of mercury in these cases there does not exist
much doubt.  A reaction has set in from  the abuse of mercury,
but it has not gone too far.   Dr. Murchison thought that mer-
cury acted on the waste albuminoids  in  the  liver much as it
does on syphilitic gummata and effused fibrin, making such
change  that the material is more easily removed.  Further, too,
mercury sweeps away the  bile from the upper bowel and so
prevents its re-absorption.   A dose of calomel  occasionally, or a
little  calomel and colocynth pill at night, folloAved by the alka-
line saline purgative  on  rising, are desirable.  One unfortunate
effect of the blue  pill  and  black draught arrangement Avas the
immediate relief furnished, so that the patient Avas  indifferent
as to his food.   It is  better to do aAvay Avith the necessity for
the pill and draught by a careful dietary.  In these last remarks
the third function of the liver has been included as inseparable
from the right consideration of the matter.
  Xoav  as to the third function of the liver itself—the secretion
of bile.   This complex body is alkaline in its reaction, the bile-
acicls  being combined Avith  soda.  What its action is, is not yet
thoroughly knoAvn ; it has some effect upon sugar and upon fat,
and it aids the action of the pancreatic juice upon albuminoids.
M. Foster says, in speaking of the digestion of the proteids
formed  in the stomach: "Thus during their transit through
the small  intestine, by  the action of the bile  and pancreatic
juice, assisted probably to some length by the succus entericus,
the proteids  are  largely dissohTed and converted into peptones,
and other products, the starch is converted into sugar, the sugar
possibly being in part further converted into lactic acid, the fats
are largely emulsionized, and to some extent saponified." Such, 
THE DIGESTIVE  SYSTEM.
411
 then, are the  uses  of  bile  in  assimilation, Avhile  it corrects
 putrefying fermentation and is a stimulus to the bowels ;  con-
 stipation of an obstinate character being the common result of
 arrested  hepatic  action.  The composition of the bile varies in
 different animals; taurocholic acid is  the characteristic of the
 bile of earniA'orous, glycocholic acid  of herbivorous, animals.
 The sulphur products of taurocholic acid are linked with the
 offensively smelling feces of meat-eaters,  Avhether human  or
 animal; and also pirobably the difference in the urine of animals
 is due to the absence of sulphur-carrying materials.  In certain
 cases in  old  women the urine is very  offensive  immediately
 VAdien  passed.  This is usually accompanied by  drab-colored
 stools  and inactivity of the boAvels;  there  is generally pallor
 found  thereAvith.  Probably some sulphur product of bile is the
 cause of the offensive odor.  Bile has its uses; even that portion
 of it which is cast out as excrementitious.
   So much for the  third function of  the liver.   Xoav hepatic
 disturbance with  this  third function  demands our  attention.
 As to those conditions termed " biliousness," they were included
 in the  second section, and do not require to be described  again.
 The functions of the liver overlap each other at  some  p>oints.
 There  are other derangements associated with the presence of
 bile in excess, especially jaundice.   Here  the  tissues  of the
 body are  stained with  bile, Avhile the stools are pale for want
 of it.  The urine is laden with bile  so as  to stain the linen ;
 the  milk  also  leaves a stain.  The conjunctivae, the mucous
 membranes, and  the skin,  all are tinged yellow.   As  to the
 causes  of jaundice, one is mechanical  obstruction  of the  gall-
 duct, as by a gall-stone or  the  pressure of a tumor.  For the
 latter little can be done.  For the removal of gall-stones, which
 largely consist of cholesterine, chloroform and ether have  been
 advised, as they dissolve cholesterine out of the body ;  but  they
 have failed, as may be supposed, when  given internally.  Alka-
 lies, as soda or potash, and especially sodic salts, either as mineral
 Avaters or in medicinal  solution, are chiefly relied upon for the
 removal of gall-stones.  Strong lotions  of opium, or belladonna,
 or chloroform liniment applied  over  the  gall-bladder,  afford
 relief.  Then  there is catarrh of the gall-ducts where jaundice
 follows a cold.  Mucous inflammation  may follow  a cold in the
lining of the gall-ducts  as it may in the bronchial  lining mem- 
412
THE  DIGESTIVE SYSTEM.
brane, or that of the stomach or bladder; and probably this is
the form of jaundice of  a temporary character  seen  in young
healthy subjects.   Then  there is jaundice commonly Avithout
much disturbance of the  general  health.   Of all plans of treat-
ing jaundice of this character emetics are the most successful.
A scruple of ipecacuan powder, or an ounce of the Avine, with
a quarter of a grain of tartar emetic and a few grains of calomel
every morning, Avill produce free emesis.  The pressure on the
liver  in the act of vomiting is  good.  What  other effects are
produced  Ave do not know, but good results folloAV.  Then some
hydrochloric acid Avith strychnia three time a day, is  useful;  it
is supposed from the action of the free chlorine.  By such meas-
ures the jaundice disappears and  the stools become darker.  The
strychnia is desirable to counteract the depressing effects of bile
salts  in the  blood in any quantity.   A good combination is as
folio avs: —
                 Acid. Nitro-Hydrochloriei Dil. Tlfx.
                 Sodas Sulphat. gj.
                 Liq. Strychnia?, TTfiv.
                 Sp. Chloroformi, ^ss.
                 Aq. ad ^j. ter in die.
The food to consist of slops, gruel, milk, or light  broths.  When
jaundice is due to chronic disease of the liver, it is less tractable;
but the same  measures afford relief even when cure  is  out of
the question.   Jaundice  is not  rare Avith the enlarged nutmeg-
liver  or hob-nailed liver  of  alcoholism;  at other times it is the
outcome of hepatic congestion leading to a growth of the con-
nective tissue from  valvular disease of the  heart; or it may
arise  from sypmilitic growths in the  liver.   In elderly persons
it is not uncommon as one of the outcomes of chronic cirrhosis
of the liver Avhere there  is a general development of interstitial
connective tissue in the different viscera.  Here  there are gene-
rally  to be found tube-casts stained with bile—very pretty micro-
scopic objects.  In such cases a mixture as follows is good:—
                 Sodae Sulphat. 3j.
                 Sod. Pot. Tart. ^ss.
                 Tinct. Nuc. Yom. TTLx.
                 Inf. Gentian, ^j. ter in die,
to be folloAved by a draught of water.  A pill containing some
iodide of mercury at bedtime is often of service.  Murchison, 
THE DIGESTIVE  SYSTEM.
413
in speaking of enlarged  liver,  Avrites:  "Marked results often
follow the internal administration of the green  iodide of mer-
cury in doses of a grain, or half a grain,  three times  daily."
Here the treatment of the jaundice is  that  of the disease upon
Avhich  it depends.  Nitro-hydrochloric acid baths are often of
service.  Jaundice  may arise from   mental causes.  It  may
appear acutely from  rage, fear, or mental  anxiety.  An increas-
ing experience is teaching, Avith  some  very cogent arguments,
that mental anxiety, ovenvork, and Avorry affect the viscera and
their functions; and, when long-continued, lead to permanent
changes.  Clifford Allbutt's vieAV that renal cirrhosis may have
a nervous origin in  mental conditions, may fairly be extended
to the chronic  diseases of other viscera.  It is  not part of my
intention to go into the diseases of the  liver;  but  merely to
consider them so far as they furnish indications for  treatment.
If the bile circulating  in excess  in the intestines and liver be
removed by spontaneous purging, or  by mercurial  cathartics,
great  relief is  experienced in  bilious  conditions.   Very often
vomiting leads to bilious discharges by the compression to Avhich
the liver and gall-bladder are subjected in the act of vomiting.
Such bilious attacks of sickness and purging are frequent Avith
certain persons, who are denominated  by  their friends "bilious
individuals."  They  are  natural curative efforts, by  Avhich the
system is benefited.  When these attacks do not come  on, and
there is malaise, headache, depression, a foul tongue Avith a bad
taste in the mouth in the morning, and a high-colored condition
of the  urine—partly due to  excess of lithates, partly  to bile-
coloring matter—purgation with mercurials gives much relief;
and brings aAvay bile-laden stools.  The action of  the mercury
is to sweep aAvay this bile, going round and round in the in-
testino-hepatic  circulation, and so at  once to get  rid of the
offending matter.  By its action  on the  duodenum  and upper
part of the  small intestines we can understand its efficacy and
the resort to its use by the bilious.  But unfortunately it is not
possible to secure one  action  of  a drug, and  evade its other
actions; and the consequences of indulgence in mercurials render
it desirable that the bilious should be chary about resort to them
—though the relief ghTen by them is decided and unquestionable.
  WhateA^er the formation of bile  and its uses  in the economy,
we knoAv that it  is intimately  connected  with the assimilation 
411
THE  DIGESTIVE SYSTEM.
of food, and that indulgence in rich dishes, either fatty or sugary,
produces  a  bilious  condition.1   Conversely, abstinence  from
such  dishes  furnishes  relief from the  wonted bilious  attacks;
and  if  the  European in India Avould  live on the food of the
native, in the same scanty proportions, he would  know compara-
tively little of the bilious disorders so common in  that country.
Exactly the same  occurs in England, and  biliousness usually
implies the possession of sufficient funds to produce the disturb-
ance.  In all cases there is an excess of bile;  and it must either
be got rid of by purgation, or its formation must be arrested by
abstinence.   In very many cases it is desirable to combine these
measures.  If the mercurial purgation  be not accompanied by a
restricted diet, the condition may persist, until organic changes
in the liver will ultimately be set up.   If the bilious individual
be a  spare  Avoman, who says, in  her oavii vernacular, " Every-
thing I take  turns  to  bile," and Avhose speech  is  not  very far
from the  mark, it is very desirable to purge  this poor creature.
It will  be found, as a matter of fact, that to reduce the food in
such case till bile is no longer freely produced, means a practical
partial  starvation of a miserable character.   If  food be allowed
in fair  quantities, and at the same time  free action upon the
boAvels  be maintained, so as to get  rid of the superfluous bile,
the power of  assimilation in the patient will improve, and the
general condition Avill be benefited.   For such purpose a pill at
bedtime,  not  necessarily  a  mercurial  one, and  some alkaline-
saline purgative in  the morning, are the  best means, and they
may be continued for Aveeks with advantage.
                 R  Sod. Sulph. 3j.
                    Sodae Pot. Tart. 3J.
                    Inf. Cascarilla:, §j. ter in die,
will often produce  very good  effects.  Indiscretions  of  diet,
hoAvever, are  to be avoided.  Such are the  measures most suit-
able in my experience to the  needs of the  habitually bilious.
Xitro-muriatic acid is often of very great service; and strychnine
best relieves the mental depression.

  1 From what has been said it seems that it is really the albuminoid food which
produces biliousness.  The  nitrogenized waste  gives the lithates, the sulphur
waste is found in the bile-acids.  Rich hydro-carbonaceous food will interfere
with the due oxidation of albuminoid matters. 
THE DIGESTIVE  SYSTEM.
415
   § 166. My experience being limited to Europe, and altogether
 free from any of that special knoAvledge given by a residence in
 the tropics, it has occurred to me to consult Sir Joseph Fay re r,
 K.C.S.I., whose Indian experience gives weight to his opinion
 on tropical affections of the liver.   He kindly Avrites me  to
 the folloAving  effect:   " In reference to the  treatment of the
 functional derangements of the  liver that arise from congestion,
 and I think more especially in that form  in  which it  is some-
 what chronic and accompanied by anaemia, such  a condition,
 in  short, as is  so frequently seen  in persons who have lived
 long  in  hot malarious  climates, like India, the AVest Indies,
 and the coast of Africa, I may say this.   Beyond mere swelling
 of the liver from engorgement with blood, other changes—fatty
 or  amyloid—will  no doubt supervene, and it is often  difficult
 to  determine  how far the  functional is due to the structural
 change.  The treatment I generally find most  effective is atten-
 tion to diet and drinks.  Avoid much  fatty,  sugary, and alco-
 holic  fluids.  No beer.  Claret and water for  drink.  Warm
 clothing,  so  as  to keep the  skin moist.   An occasional dose
 of colocynth and  calomel, or blue pill, and every morning,  or
 every other morning, a dose of saline aperient, such as sulphate
 of magnesia, Avith quinine, or gentian, sufficient each  time  to
 produce  two  or three  loose motions.   Counter-irritation by
 tincture of iodine over  the loins.   When the  portal circulation
 is relieved some  preparation of  iron  may be very  useful.   The
 urine  is a good  test of the hepatic condition  ; it Avill improve
 under the above treatment, but  it is Avell  to  give the patient
 some alkaline Avaters—Vichy, Vals, or Carlsbad.   Albuminuria
 will be present at  times, Avhen the kidneys, like other abdomi-
 nal viscera, are congested, or are irritated by lithic acid.  In my
 opinion too  much  importance is attached to  this  symptom  in
 some cases.  Indeed, I think the subject of albuminuria would
 bear re-writing.  Albuminuria may be functional in such cases,
 and pass away  like the other  symptoms."  Such practice  is
 the result of long experience in a  very careful  observer ; and
 the necessity for unloading the liver,  especially ere iron can
be given satisfactorily,  is clearly  laid  down.    It agrees en-
tirely with Avhat has been insisted upon  so strongly in Chapters
II. and III., viz.,  that  in  imperfectly depurated conditions  of 
416
THE DIGESTIVE  SYSTEM.
blood chalybeates are comparatively useless, and until such con-
dition is remedied it is of little avail to give them.
  The recent vieAvs of  Lusanna as to the accumulation of mala-
rial poison in the portal circulation give an additional interest
to the subject of purgation in biliary congestion, especially in
malarial subjects.  Possibly even  an  occasional emetic might
not be out of place  in these cases.
  The great  matters  in  the treatment  of the  bilious  are  the
regulation of the amount and the character of  the food, and the
systematic use of alkaline saline purgatives.   By such means
the headache, the languor, the sense of misery, are all relieved.
The p>atient  eats more, assimilates more, and becomes  a  new
person by judicious yet energetic purgation, especially in  the
morning.
  The above account of Avhat is to be clone in a large class of
patients may seem unduly  short, but  there  is no alternative
betwixt  a brief summary, which, if brief, is distinct however,
and a lengthy dissertation, for which there is not space.  Popular
as Avell as professional experience has pronounced its verdict as
to the association existing betwixt biliousness and the necessity
for purgatives.
  Ere leaving this subject  it may not be out of place to describe
a form of ailment often mistaken for  biliousness.  Prout says,
"When acidity prevails in the lower  portion of the intestinal
canal, and particularly in the  caecum, the  treatment must be
modified to  meet the circumstances.   The soluble antacids in
this case have comparatively little  effect, from  their being
neutralized and absorbed  before  they reach the  seat  of the
affection; hence the insoluble antacids, and especially magnesia,
will  in  general be found more useful  in  such  cases.   The
shortest  mode,  hoAvever,  of getting rid of the immediate in-
convenience of acidity in the  loAver boAvels is usually to inject
a pint or two of warm water (or of soap and water), and thus
of removing the offending  cause.   By this  simple remedy I
have  often seen  the  severe  nervous headaches and  other un-
pleasant symptoms usually accompanying acidity in the lower
boAvels immediately  removed.   Those  Avho  suffer from such
causes usually require  the aid of purgatives,  which in  general
are better taken at bedtime.  Purgatives of a mild but effectual
kind, such as the Decoct. Aloes Comp. Avith magnesia  often suit 
THE DIGESTIVE  SYSTEM.
417
 well; as do pills taken at a  late dinner, if duly adjusted to the
 circumstances of the case."   This class of case  in adults is not
 sufficiently noted, Prout observes, and it  is impossible to differ
 from  him.  All are familiar with acidity in the intestines of
 infants, and of  the numerous combinations of remedies to meet
 it.  Gregory's powder, Dinneford's fluid  magnesia, Pulv. Cretae
 Aromat., and  dozens of quack remedies of unknown composi-
 tion, but  all  containing alkalies  with carminatives,  testify to
 the widespread acquaintance with acidity in  the primse viae of
 infants, and of the  measures  best calculated  to relieve it,  In
 young infants bicarbonate of potash (gr. ij.) with Cajeput oil
 (nij.) in dill water (3ij.) is my favorite measure ; together with
 some fixed alkali in the milk.
   §  167.  One  of the  commonest of maladies is constipation.
 This must be kept distinct from costiveness, Avhich means merely
 scanty feces ;  Avhere forms of food furnishing more bulky waste
 material are indicated.   Constipation is a  troublesome malady.
 When present, all the functions of life are languidly performed;
 the brain  is sluggish, and the digestion  impeded.  It may be
 itself a consequence of  brain disease ; and all cerebral affections
 combined Avith  obstinately constipated boAvels are serious.  In
 these cases an open  state of the bowels is a sine qua non, but
 sometimes it is very difficult to move them.  Free action of the
 bowels gives relief even when cure is unattainable.   In  many
 cases very  large doses of purgatives  are  required, much larger
 than those in ordinary use.   In such cases the practitioner must
 g'o on increasing the dose until a point is reached that is effective.
 Many stopAvhen the maximum dose in the posological  table has
 been given; but this is pusillanimity.  Sometimes constipation
 is folioAved by diarrhoea,  the  inaction of the bowel being suc-
 ceeded by  a period  of  excessive activity ; and  this condition
 is apt to become permanent.  Here  the  loading of the boAvel
 must be prevented by  laxatives, and then the diarrhoea Avill
 cease of itself.
   Purgatives.—These are agents Avhich act upon the boAvels in
 such a manner as to  increase peristalsis, and  cause a freer flow
 of intestinal secretion ;  the consequence of which is  that the
 motions become more numerous and of less solid consistency.
Much discussion has gone on as to Avhether purgatives merely
increase peristalsis, and  so SAveep aAvay the contents of the small
      27 
lis
THE DIGESTIVE  SYSTEM.
intestines in their fluid state ; or Avhether they increase the secro-
tion from the intestines.   It is iioav ascertained  beyond doubt
that they do both.  To aid their action  upon the intestines mix
vomica is often added to  purgatives.  Purgatives are furnished
by both  the  mineral  and vegetable kingdoms.  They may he
given alone or together.   They differ much in action, and there-
fore it is not ahvays a matter of indifference Avhich is selected.
Still the  amount of dose makes up for much of the difference.
  When  it is merely desired to maintain the action of the
boAvels at about the normal state  it  is common to order a fig,
prunes, oatmeal  porridge,  manna,  and similar matters.   All
oleaginous bodies increase the action of  the bowels; while milk
and farinaceous foods have an opposite tendency.  Consequently
Ave  eat starch and fruit together.   Olive  oil is a most gentle
purgative, and the best of all in very irritable conditions of the
bowels ;  next to  it comes the  universal  castor oil,  too often
rendered more powerful  by a  certain admixture of its potent
congener, croton oil.   Other  gentle purgatives are  found in
magnesia; and combinations of this  agent Avith potash and soda
in the forms of mineral Avaters.  These  last can be so arranged
that patients can find out what is the dose required in their own
case, and regulate  it accordingly.   The sale of mineral waters
is much on the increase.   Such natural combinations  may be
simulated by medicinal agents; it is often found, however, that
these artificial substitutes are not  so efficacious as the  natural
Avaters.  The explanation  of this lies in   the dilution—in the
amount  of water.  If a  good-sized  tumblerful of  AArater he
SAvalloAved with each dose, the desired effects Avould more com-
monly be secured.   Seidlitz-powders, citrate of magnesia, and
many other pleasant laxath'-es are largely in use. These mineral
purgathTes are used rather to procure easy  and  regular motions,
than for the purpose of producing catharsis. When  this latter
is sought, then the vegetable agents senna, jalap, scammony,
■colocynth, elaterium, gamboge, etc., are resorted to.   In  small
doses  these  agents increase the action of the  mineral  laxa-
tives,  as  in  compound jalap poAvder, senna and  Epsom  salts,
gamboge and cream of tartar, etc. etc., all excellent and useful
measures.
  There are, hoAvever, some points  about  the use of purgatives
which .are of importance in  practice.   First comes the use of 
THE DIGESTIVE  SYSTEM.              119
 rhubarb.   Of all agents to be selected for an habitual purgative
 this is the worst.  If once resorted to, its use is necessitated
 in consequence of its secondary action; Avhich is to cause consti-
 pation.  It is an excellent purgative Avhere any operation on
 the bowel, or pielvic viscera is to be performed; for it first opens
 the boAvels and then locks  them up.  A full dose  of rhubarb is
 the thing here par excellence.  Xext, aloes has  its peculiarities.
 Its action is chiefly upon the loAver  boAvel, and, therefore, its
 use is  indicated to unload the pelvic circulation in cases of con-
 gestion there.  From this action too it is very useful in ordinary
 habitual constipation from inertness in the loAver  bowel;  for
 Avhich it should ahvays be selected  as  one  agent at least.  It
 also has some action upon  the duodenum ; and so is useful in
 biliousness, and as a part of a dinner-pull.  Aloes goes well Avith
 alkalies  and  Avith  iron.   It is ahvays used  in first bringing
 patients under the action of chalybeates; it being  a Avell-kuoAvn
 fact that slight catharsis is  desirable at the commencement of
 a course of iron.  In allaying  excitement  in  the reproductive
 organs of  Avomen aloes Avith  potash  or  soda is very useful.1
 Fordyce Barker  on reading this footnote presented me  Avith a
 copy of his well-known Avork on Puerperal Diseases, in Avhich
 he  combats the opinion of Fuschius that aloes produces piles.
 He first gives the names of several accepted authorities Avho have
 questioned this view of Fuschius ;  and then writes: " It would
 seem, therefore, that the  use of aloes  for the  cure of haemor-
 rhoids in pregnant women  would have been suggested by ti priori
 reasoning,  but I am not aware, from anything I have read, that
 it ever has been.   I suppose that  the general impression that
 aloes  is contra-indicated where there is any tendency to piles,
 and that it possesses emmenagogue properties, has  had great in-
 fluence in  preventing this.  In my OAvn case,  the use of aloes
 for  this purpose  was the  result of  gradually-accumulating ob-
 servation, rather than from any reasoning on the subject" (p. 33).
 Then Ave have mercury, especially calomel, the  most subtle and
 dangerous of all laxatives.   It is scarcely possible  to  write dis-
 passionately on this subject.  The  freedom from pain in  the
 action of calomel; its " toleration" by the youthful system; and

 1 The charge brought against aloes of producing piles is not borne out by my
experience. 
420
THE DIGESTIVE  SYSTEM.
the remoteness of its  pernicious consequences:  have caused it
to be a constant visitor, and even occupant, of the nursery.  Yet
it  should be admitted under skilled medical supervision only.
Mercury is invaluable  in the treatment of congenital syphilis, no
matter Avhat the form of manifestation.   But to the other ail-
ments of infancy it  is unsuited.  hife-long misery, a  hypera's-
thetic  nervous system, erethism, defective teeth, and a whole
host of evils follow in  the train of  mercury, when administered
freely to children.   Calomel and gray powder  are excellent in
their place, but  when  improperly used they are  very objection-
able.
   § 168.  Then  again  certain special conditions  call  for special
treatment.  For  instance, in the  acute  suffering often found
along Avith constriction of the boAvels, Avhen the pouched gut
above the constriction is in great activity to force the contents
through  the narrow opening, the proper thing is to give a full
dose of laudanum along  Avith large doses of sulphate of mag-
nesia.  The opium soothes the active pains of forcible contrac-
tion ;  while the  salts  liquefy the  contents of the pouch, after
which they readily  pass  the  narrow portal.  This  is rational
medicine, and in practice it is  successful.   In cases of  constipa-
tion from ileus, the administration of purgatives is very repre-
hensible.   In  other cases catharsis  is indicated to affect  the
general condition.  It loAvers  the blood-pressure (Mahomed);
it loAvers temperature  ; it relieves venous  congestion, especially
in the portal circulation ; Avhile it is useful  in  defective renal
action as a compensatory eliminative process.  Lauder Brunton
says of purgatives :  "  They puove useful  in many Avays.  They
hurry  the  food out of the alimentary canal, and thus lessen
the injurious effects  of  over-eating.  By expelling  irritating
substances from the intestine  they arrest diarrhoea, and remove
headache and other pains, caused either  by the abdominal irri-
tation, or  by the  absorption of poisonous matters produced by
imperfect  digestion and decomposition  of food.  They relieve
biliousness by removing bile, and  are most efficient aids in the
treatment of chronic poisoning by lead, mercury, or other metals.
It is probable that pepsine and pancreatic  ferment are absorbeil
from the intestine, and circulate in the blood, where the latter
assists in the production of animal heat.  They are then secreted
aneAv  by the stomach and pancreas, and do their work again. 
                 THE  DIGESTIVE  SYSTEM.              421

 Purgatives lessen their quantity as Avell as that of the bile, and
 they are thus useful in fevers; but they injure old and feeble
 persons, both by diminishing their calorific poAver, and  impair-
 ing their  digestion.   They relieve inflammation  by lowering
 the blood-pressure, and thus diminishing congestion; and they
 prove beneficial in dropsies, both by abstracting water from the
 blood, and diminishing congestion in the kidneys."
   In the administration of purgatives in the old and the feeble,
 it is of much importance to select the proper  laxative  agents;
 they should not be too depressing, and they should be combined
 Avith carminatives.   Mineral laxati\Tes do not suit the aged ; old
 people say that they are too chilling.  If given, say, as sulphate
 of magnesia, they should  be  given Avith spirits of chloroform,
 tincture of ginger, or cayenne, in cascarilla.   Such also  are the
 combinations best  suited  to  the constipation  common at the
 change of life in women.   Carminatives—whatever their action
 certainly take aAvay griping, and for this end they are often to
 be preferred  to  hyoscyamus; though this latter is a pleasant
 adjunct to cathartic pills.  Such carminative laxatives taken
 warm  are  good in  aged people, and do not depress them too
 much.   It is attention  to  these comparatively trifling matters
 Avhich  helps to make the  successful practitioner—just as much
 as more solid attainments.
   In many instances constipation is associated with an  atonic,
 torpid, and dilated  intestine, and then  minute doses of  strych-
 nine, or nux vomica,  are  indicated.  I remember well a case
 AAThere  01. Croton. "ij.;  Gamboge, gr. If;  Pulv. Capsici, gr. j.;
 Strychnia, gr. g'o ; Ext. Al. Aquos. q.s., in  each pill, Ave re taken
 twice a day for tAvo months.  Then the oil was reduced to half
 a drop, and the strychnine increased, for tAvo months; after
 which the oil Avas stopped, the gamboge reduced to one grain,
 and a quarter of a grain of dried sulphate of iron  added.  This
 AATas taken for two months more; after  that the man ceased to
 be a pauper, and hired off as a farm servant, which he remains.
 Here there Avas great  abdominal  distension,  implicating  the
 small intestines,  which unfitted the man for labor; and  further
 impaired a limited  intelligence:  the  relief  of this  condition
 restored the man to a state  in Avhich he could again labor.  His
mother took one of  the first series of pills one night, Avhen not 
422
THE DIGESTIVE  SYSTEM.
very Avell;  but she did  not do it a second  time, though she ob-
served they suited her son " uncommonly."
  In the ordinary economy of life the condition of the IjoavcIs
is a matter  calling for considerable attention.   To many people
constipation is the plague of their lives; it and its consequences
embitter their existence.  Constant and unintermitting resort to
medicine is Avearisome and  objectionable, but  nevertheless un-
avoidable.   The numerous quack pills, from Cockle's doAvnwards,
testify to the  general necessity for such agents.  The introduc-
tion of granular effervescent salines has  been a great boon to
many.  A  teaspoonful of them in a morning, on getting out of
bed, in half a tumblerful of Avater is to many an effectual laxa-
tive.   To others, again, all  that is needed is  a tumblerful of
cold Avater, and  especially is this desirable for  ladies, Avho for
social reasons  consume much less of fluids  than is good for them.
  From  experimental research, Professor  Rutherford has found
that sulphate  of soda acts much more pOAverfully upon the  liver
than does  sulphate of  magnesia.  This conclusion is in accord-
ance Avith Avhat clinical observation has  taught us.  Sulphate
of magnesia is  an  excellent laxative, increasing the intestinal
secretion, and "liquefying the  stools," as older Avriters put it.
There is an impression  prevalent in the profession that sulphate
of magnesia  is not suited  to children.   Hoav this impression
commenced I do not knoAv in the  very least.  That it is an
utterly baseless impression experience has taught me.
   Many persons take annual  excursions  to Avells of purgathe
waters,  at  Harrogate,  Carlsbad, etc., where they  go  in for  a
course of  purgation, to their great  benefit and comfort.  For
many this is  a good  and useful practice; and enables them  to
live the  rest of the year in comparatively good health.  A course
of mineral Avaters at  home is  a good practice for those Avho
cannot  get to  these Avells;  or Avhen it is Avinter and it is not
convenient to visit a spa.  HoAvever attained, it is ever desirable
that the boAvels be kept open; and for  this  end  it is well to
have  fixed times for defecation, so as to  secure the advantages
of the force of habit.
   § 169. One of the commonest troubles of life is  the opposite
 condition   of the  bowels, viz., diarrhoea.  It is not a  chronic
 trouble, usually at least, like  constipation; but it is frequent,
 and sometimes unmanageable, requiring  for its successful  treat- 
THE DIGESTIVE  SYSTEM.
423
 ment measures Avhich  shall be in accordance Avith its causation.
 It is desirable to consider the varieties  of diarrhoea, and the
 remedial measures suited to each form.
   Diarrhoea may be a salutary p>rocess;  or an ailment serious
 enough to endanger life.  Even Avhen commencing as the first,
 it may eventually be fatal.  The boAvel is not only the means by
 Avhich absorption of our food goes on; but it is also a means of
 getting rid of  excrementitious material.  Moreover, Avhen a
 mass of objectionable or indigestible food is consumed, diarrhoea
 is the natural means of getting rid of it.  Such diarrhoea is very
 common among children, and is often  preceded or accompanied
 by emesis.  In  the same way bilious diarrhoea is a natural
 means of removing superfluous bile.  Here diarrhoea is decidedly
 a salutary, and not a morbid ptrocess.
   Such is  the diarrhoea Avhich is  occasioned in infants by the
 excessive curding of their milk ; a hard, firm, indigestible curd
 being formed, Avhich no infantile stomach can break down and
 digest.   This  morbid curding is at times  the result of too hasty
 consumption of  milk,  so that it is not well mixed with saliva;
 at other times it is the result of a preternatural acidity in the
 little piatient's digestive organs ; Avhile at  other times, again, it is
 the consequence of some  disturbance in the mother's  economy.
 When the morbidly curdled milk is rejected by vomiting and by
 purging, it is wrong to attempt to arrest the diarrhoea  by astrin-
 gents, chalk, and opnum ; such practice is bad.  This is commonly
 seen  in the  diarrhoea of  calves, Avhere  the busy, interfering
 farmer's wife tries to check the discharge; and if  she succeeds
 in doing so, locks up an  indigestible mass in the intestines, and
 produces enteritis.  The same occurs in human infants.  Instead
 of checking the  diarrhoea it is advisable to give a dose of castor
 oil, which sAveeps aAvay the offending mass.  The administration
 of such a purgative is often better than leaving the diarrhoea to
 itself, for this reason.   The increased secretion excited by an
 irritant mass in  the bowels is very often set up below the  source
 of irritation, so  that it is not  successful in  removing it;  if a
 purgative be  given, it sets  up increased secretion above the
 offending  matter, and so  sweeps it aAvay.  By such  means a
 troublesome and ineffectual discharge may be at once done aAvay
 Avith. Having so removed the indigestible curd, the next thing
is to  prevent its formation by the administration of alkalies; if 
424
THE  DIGESTIVE SYSTEM.
necessary, to the mother as avcII as to the infant.  If the child
be bottle-fed it is Avell to stick to the milk of one cow; and hy
such a change good  often results in  intestinal  troubles.  The
Swiss condensed milk is a great boon to the children of towns;
town-kept coavs being so fed that their milk is often •unsuitable
for the purpose of infant feeding.  This Swiss milk may often
with  advantage be mixed with  lime-Avater instead of  ordinary
Avater, especially in  infants  where the excessive  acidity is per-
sistent and intractable ;  or ordinary milk with  chalk, or mag-
nesia may be tried.  It  sometimes  happens, hoAvever, that the
diarrhoea thus  instituted persists as an  intestinal catarrh  re-
quiring  its appropriate treatment;  but  before  this subject is
considered it may be well to revieAV another form of diarrhoea
which may persist in a like manner.
  Diarrhoea is not rarely  the consequence of a chill.  Instead of
the ordinary cold a sharp action of the boAvels comes on; most
commonly in those  whose intestinal canal is  easily deranged.
Frequently there is  brief, brisk action ; but at other times the
discharge persists.   This, like the catarrh remaining after the
removal  of offending matters,  requires treatment.  A dose of
opium is often all that is  required.   At other times the  action
of opium is not sufficient alone; and then the favorite  adjuncts
are either alkalies or astringents.  Where there is a condition of
follicular ulceration of the bowels, and each motion is preceded
by severe griping pains, ceasing with the evacuation of the acrid
and offensive matter, then the old-fashioned remedy:—
                     K Cret. Pp. gr. xv.
                       Tinct. Catechu, gss.
                       Tinct. Opii, TTLx.
                       Aq. Cinnamomi, ^j.
after each motion is to be chosen, Avith a reduction of  the dose
for children ; or some similar alkaline mixture with astringents
may be given.   When  the motions  are loose and copious the
union of opium Avith acids and astringents is to be preferred.
                    R Tinct. Opii, Kfl,x.
                      Ac. Sulph. Dil. 1TI xx.
                      Inf. Hssmatoxyli, 3J.
four or six times a day is an excellent remedy, especially when
diarrhoea has been persistent and profuse.  Hematoxylin is a 
THE DIGESTIVE  SYSTEM.
125
 capital astringent and easily taken ; but it possesses the drawback
 of being a decided dye.  .Nevertheless, Avhen  diarrhoea has run
 on some time it forms the best remedy to select, especially Avhen
 others have failed.   Some medical men  prefer pills of acetate of
 lead and opium, Avhich form undoubtedly a powerful astringent
 measure.   It is much more convenient, and rational, to use
 sulphate of copper than  acetate of lead.  The copper does not
 interfere with the co-administration of acid astringent mixtures.
 Whatever- the  form of astringent selected, enemata  of starch
 and opium  are  often  very useful and  grateful to the  patient.
 Especially is this the  case where there is follicular ulceration.
 Sometimes a little prepared  chalk may be added to the enema
 with advantage.  The food should consist of milk Avith ground
 rice, sago, or arrowroot in  these cases ; and all food Avhich might
 give rise to irritation should be carefully avoided.
   Very often, in addition to the mixture given, a poAvder  at
 bedtime is serviceable.   This may consist of compound kino
 powder (gr. x.), Avith or without ten grains of bismuth.  Bismuth
 is often as useful in the treatment of intestinal disturbance  as
 it is in gastric affections.  In some cases of persistent looseness
 of the bowels, scarcely amounting  to diarrhoea, bismuth Avith
 myrrh may be given \Anth much benefit.  Ipecacuan is a remedy
 of Avhose value Ave  are all convinced.  In dysentery it is found
 that ipecacuan in  drachm  doses produces  a totally different
 condition of  the intestinal canal to that previously existing; a
 normal motion, free from patches of morbid mucous membrane
 taking the place of the  dysenteric discharges, in tAventy-four
 hours usually (p. 226).  Prof. Rutherford  thinks  this  may be
 clue to the effects of ipecacuan on the biliary secretion.
   Nervous  diarrhoea is a variety Avith Avhich Ave are all  more
 or less familiar; an uncontrollable  action of the bowels  is an
 outcome of mortal terror in animals as well as in man.   Increased
 secretion and activity  in the intestinal canal is Avith many
 persons the consequence of mental perturbation; in such persons
 diarrhoea takes the place of the palpitation experienced by others
 when under mental  agitation.  Thus with many individuals the
 necessity for  a  long journey will  excite diarrhoea.   This has
 become more markedly the case since  the introduction of rail-
Avays Avith express trains only stopping at distant intervals; and
then making so brief a stoppage as scarcely to afford  an oppor- 
426
THE DIGESTIVE  SYSTEM.
tunity to empty the bowels.  In some persons the very idea of
such a journey will excite diarrhoea even before the journey is
commenced, so that railway travelling  is abandoned.   In  less
marked cases there is ahvays diarrhoea as the hour of  starting
approaches, and some brandy  and  hot  water  with a dose of
laudanum  have to be taken; and repeated pulls at a flask are
requisite during the course of  the journey.  In such persons a
preventive plan may be put in force Avith advantage.  The  day
before travelling the bowels may be Avell opened with rhubarb,
and at bedtime a dose of opuum Avith some myrrh  or bismuth
may be given, or a  feAv grains of  compound soap pill  may he
taken instead.   The diet should consist of milk and farinaceous
foods, or macaroni au gratin, for those Avith Avhom cheese agrees.
In such persons the combination of bromide of potassium with
some vegetable tonic or chalybeate is a good measure, and might
be taken for some time ere  commencing to travel, or during a
course of travel.
  At times  diarrhoea is  the reflex  consequence of irritation,
under  Avhich circumstances it is to be treated by the means laid
doAvn  before (Chapter XIII.) as best  adapted to the arrest of
reflex action.  Such is the case related to me by Dr. Ferrier.  A
pregnant woman applied to him at the West London Hospital
Avith diarrhoea, which remained unchecked after the administra-
tion of various forms of astringents. At last Dr. Ferrier thought
of its being a reflex secretory action, due to some exciting cause
in connection with the gravid uterus,  so he gave bromide of
potassium; whereupon the diarrhoea  ceased.  (§ 126.)   This is
a most instructive and suggestive  case, and  gives us a hint
Avhich may often stand us in good stead; as well as furnishing
an  excellent illustration  of the poAver  physiological  research
possesses to aid us in practical  medicine.
  In other cases diarrhoea is the  consequence of congestion or
obstruction in the portal circulation.  It may arise from the ob-
struction offered by cirrhosis of the liver, with consequent ascites;
or it may take its origin in general venous fulness, the result of
obstruction to the blood-tioAv through the right heart.  In the first
case the substance of the  liver is bound down and compressed
by contracting  bands of connective  tissue, and the  circulation
obstructed, Avhich forms  a  chronic obstacle;  Avhile a  passing
phlebitis in the portal veins causes a sudden increased  obstruc- 
THE DIGESTIVE  SYSTEM.
427
tion.  Here the venules of the intestinal canal  are  turgid  and
full, and a serous fluid drains aAvay from the mucous surface of
the bowels.  Very commonly at  the same time there is an
accumulation of fluid in the  peritoneum, from a like condition
of the venules of the peritoneum.  The diarrhoea which shows
itself under these circumstances is a natural discharge affording
relief; and instead of attempting to check it, it must be en-
couraged ;  and in  some cases it  may be desirable  even to  in-
crease it by the administration of cathartics.   The same rules
apply to congestion of the portal  circulation from heart disease.
In both  these conditions, indeed, it  is our  common practice to
institute artificially a brisk action of the bowels where it is not
set up naturally.   With many people, and especially those who
have not made  much progress in matters medical, every  dis-
charge  is a disease to be dealt with ; just as they insist that if
the bowels  do not  act purgatives must be administered, even if
there be ileus.   As purgatives do harm in the latter case, so will
astringents be  simply injurious  in  many  forms of diarrhoea.
Little can be done  to  relieve diarrhoea arising from the effect of
a diseased liver upon the portal circulation ; but Avhen the con-
gestion is due to heart failure, much may often be achieved by
the administration of digitalis and  iron, so as to improve the
circulation  generally.
  It is said by writers that  the  diarrhoea of trichinosis should
be encouraged by  purgatives rather than arrested.   There are
still several forms of diarrhoea  to  be  considered; these  are
tubercular,  typhoid, uraemic, and  colliquative diarrhoea.
  In tubercular ulceration of the  intestines  diarrhoea often
occurs.   It  is obstinate and intractable.   Of course there is no
chance of removing the cause  here, and all that may be clone
is  to give relief by opiates, combined with fixed alkalies  and
bismuth.   Milk  diet with  farinaceous  food  should form  the
chief sustenance.
  The diarrhoea of typhoid fever  is not to be rashly interfered
with.  In ordinary cases where it is not excessh-e it is  best to
let it alone.  If blood be passed in the stools, or the discharges
become numerous  in  the twenty-four hours, then astringents,
with some  opium, may be  given with  advantage.  Sulphuric
acid, with opium,  is a favorite form with some; the lead  and
opium pill Avith others ; Avhile cold is approved by all.  There is 
128
THE DIGESTIVE SYSTEM.
little to choose in such cases, and the discretion with which the
remedies are Avieldecl is probably a much more important matter
than  the mere form of the drug.  When there  is a typhoid con-
dition coming on in the course of any sustained  pyrexia, then
diarrhoea must be watched rather than interfered  Avith.   When
slight, it  may be encouraged; Avhen excessive, it may require
astringents, of which chalybeates are the safest.
   Uraemic diarrhoea is a compensatory action, and not a morbid
process.   Throughout this book, in Chapters III.  and XI. espe-
cially, great  stress has been laid upon  the capacity possessed by
the different excretory organs to supplement each  other's action
when defective.   Thus Ave  saAv that  in conditions of uraemia
the intestinal discharge was a useful and beneficial action; and
that it Avas umvise to arrest it until  some other excretory chan-
nel was established.  In one case Avhich I remember. well, the
back and  forward  play  of  the bowels and kidneys was well
illustrated.  The patient Avas an old man, and during a sharp
diarrhoea no  Avater was  passed all  day.  Percussion said the
bladder Avas empty, but to  make perfectly  certain a catheter
was passed—there was no fluid in  the bladder.  In a few hours
some water Avas  made, the diarrhoea declining.   After several
days  of most instructive oscillation, the diarrhoea gradually less-
ening, while the  Aoav of urine became  steadier, matters settled
down to  their ordinary condition.   If this diarrhoea had been
thoughtlessly checked, the man Avould in  all probability have
died; as one painful experience in my early clays told me.  In
diarrhoea  of  this kind, a form commonly found in persons ad-
vanced in years as a recurrent  ailment, it  is desirable to excite
free perspiration by the use of the bath ; to apply large hot poul-
tices faced with  mustard  to  the loins, or even to cup.  When
the skin is well roused and the action of the kidneys is restored,
then  some astringent, especially an astringent form of iron, may
be given.   There  is ahvays  a lurking  danger  that opium and
vegetable astringents might  arrest the  neAvly-restored action of
the kidney, and the nimia diligentia be unfortunate.  Better far
is  it to allow the diarrhoea to persist, than to be led to kill the
patient in attempting to cure the ailment.   When the action of
the kidneys  is once well re-established the diarrhoea will com-
monly die out of itself; if not, careful dietary and the pernitrate
of iron will usually finish it off. 
THE DIGESTIVE  SYSTEM.
429
  In that form ot diarrhoea known as colliquative, Avhere  there
is rapid emaciation, and where of old it Avas said that the solids
of the body Avere melting aAvay into liquids  and taking the
forms of diarrhoea, or  in  other cases of colliquative SAveats,  it
is necessary to  take measures as active, as in other forms  of
diarrhoea the  measures are  to be expectant.   In  colliquative
diarrhoea the  patient will soon  become exhausted if the dis-
charge be not arrested.  Here opium must be given Avith astrin-
gents, as sulphuric acid and  cinchona-bark—or opium, hema-
toxylin and carbonate  of ammonia, together Avith  Avine, ether,
beef-tea,  milk, and, indeed, everything calculated  to sustain the
patient.  Sometimes  it becomes  a  neck  or nothing race, and
heroic  stimulation may  afford  the  only  chance  of  averting
death.
  In addition to these different varieties  of diarrhoea, a neAv
form has just been brought under  notice.  Drs. II.  C.  Wood
and C. G-. Comegys have  described in the  Philadelphia Medical
Times a variety  of diarrhoea  due entirely to a very  high sur-
rounding temperature.   Summer  diarrhoea is, according to them
often really thermic, or heat diarrhoea.  In such cases wdiile the
purging persists  the temperature keeps high. Drugs fail to give
relief;  but the application of external cold, so as to loAver the
temperature, is effective and curative. Enforced cold bathing
every three or four hours is the best  antipyretic measure.  " The
sudden SAveet sleep, replacing, after the bath, the  fretful nights
and days of unrest, is a thing never to be  forgotten Avhen once
seen, and the arrest of  the diarrhoea is certainly no  less remark-
able."  When the thermometer records a temperature running
up from 101° to  104° Fahr. in infantile diarrhoea in hot weather,
then antipyretic measures are to  be  adopted ; either alone or  in
conjunction  Avith astringents, especially the mineral acids.   It
is easy  to distinguish thermic diarrhoea from other forms by the
thermometer.  Purgation loAvers the body temperature as a rule,
and in other forms of diarrhoea the tendency is to  a low and not
to a high temperature.   In warm climates children  are liable in
hot Aveather to  a form of diarrhoea  knoAvn as " white scour,''
where there is an absence  of  bile  in the intestines.  Here a feAv
grains of calomel night and morning soon affords  relief, the bile
reappearing in the stools. 
480
THE  DIGESTIVE SYSTEM.
  § 170. It  now remains  to consider the question of inflam-
matory conditions of the gastro-intestinal canal.   Those of the
mucous surface are pretty avcII  included  in the  consideration
of diarrhoea, except that*of proctitis, or inflammation of the
mucous membrane of the rectum.   Here in consequence of the
exquisite tenderness of  the parts all expulsive action is reflexly
arrested whenever set up; and enemata must be  resorted to in
order to liquefy the contents of the bowel and to permit of their
escape.  After that the form  of diet so often insisted upon in
this chapter must be resorted to,  Avith frequent enemata of bland
and soothing character, and opium.
  When there is  inflammation  of the serous covering of the
boAvels, the bowel must  be kept empty—that is, have physiolocn-
cal rest—and  be kept quiet by  opium.   Not only do Ave Avish
here to call out the  general analgesic effect of opium and its
sedative action; but also to  secure its localized effect  upon the
intestines.   It deadens  sensibility as Avell as sensation ; it keeps
the inflamed parts at rest, and  so diminishes their  friction upon
each other, thus limiting the necessity for effusions to separate
the inflamed surfaces, or of bands  of lymph to glue  them to-
gether ; Avhile  it soothes the system generally.  No wonder then
is it that in inflammation  of the abdominal and pelvic viscera
experience has  decided in favor of opium, given in  full and
repeated doses.   In general inflammation  of the peritoneum,
visceral and parietal, to keep the patient on the verge of death
by opium is often the only Avay to escape the fate  which would
otherwise lie before him.   In the convalescence from any form
of enteritis the greatest care in diet  is  to be maintained for some
time, as the boAvels remain  sensitive  and are easily disturbed.
In piles it is well to  keep the boAvels regularly open, and after
each motion to bathe the anus well with soap and Avater; next
to apply some cold or  even iced Avater, or astringent lotion
(ointments are dirty here) and then  return  the mass.  An as-
tringent opium and  gallic acid suppository may be used  at
bedtime.
  In  rectal hemorrhage small  doses (gr. xv.)  of sulphate of
magnesia Avith dilute sulphuric acid ("l xv.) in inf. cinchona?
(3j.) three times every day are  very effective.
  Dysentery is found under  tAvo totally different sets of circum- 
THE DIGESTIVE SYSTEM.
131
stances.   It may be malarial, or  it may develop in  camps from
foul surroundings.   In each  the local treatment of the boAvel is
of value for  relief as well as cure.  While full doses of opnum
and ipecacuan (p. 226) are to be  given by the mouth, it is Avell
to Avash out the  boAvel Avith warm Avater enemata, and  then to
inject bismuth (5ss.) and opium  (2 grains), Avith poAvclered gum
arabic 3j- and Avater |ij. two or three times a day.   The severe
tormina and tenesmus can thus be relieved in a short time, and
the patient is made much  more comfortable. 
CHAPTER  XVII.
                     THE URINARY SYSTEM.

  §  171.  In no part of this work do greater difficulties present
themselves as to the drawing of the limits, than in this chapter.
Anything like a complete sketch is simply out of the question;
and  consequently a  brief revieAV of the subject, as  regards the
principal  indications for treatment, is all that can be essayed.
  The chief matter of interest is the  kidney and its function;
the other ailments of the  urinary system, however important
surgically, are of comparative unimportance to the physician.
  The function of the kidney as the  chief  means of removing
nitrogenized waste; and the serious consequences of accumula-
tion  of such Avaste matters in the system, cause disease and dis-
turbance in  these important little  organs to  be matters of the
deepjest interest.  The secretion of the kidney contains azotized
waste, certain salts, especially potash, and Avater, together with
numerous other matters  in trivial quantities; while  at other
times it contains neAv and strange material which has been given
medicinally.   There are some  points  about the renal secretion
which need special  attention from the  practitioner's point of
view; and these are the origin of urea, and  the relations of
water excretion to the condition of the circulation.
  To take urea first is the best method.  Urea  is  said  in the
older textbooks to be the result of  tissue metamorphosis, and it
is asserted that the earlier products of  histolysis, as  creatine,
creatinine, tyrosine, etc., are changed in the kidney into the more
advanced substances, uric acid and urea.   The presence of urea
and  uric  acid  in the blood and tissues  was  accounted for  by
the hypothesis  of reabsorption from the kidneys.  Then it wan
found that urea Avas largely manufactured  in the liver, by the
breaking  up of albuminous matters  into glycogen  and nitro-
genized waste.   Now Ave know that urea is largely derived from
this  splitting up of albuminous material in  the liver, as well
as its formation from disintegrating  tissues.   This knowledge 
THE URINARY SYSTEM.              433
 has borne fruit practically in  directing the dietary of persons
 suffering from renal inadequacy.  It has enabled us to relieve
 impaired kidneys by diminishing the amount of Avork they have
 to do.  It is of the greatest importance that clear ideas should
 exist on this head.  A large amount of the nitrogenized food Ave
 take is unnecessary, and is not required for tissue building: a
 comparatively small amount only of  nitrogenized matter daily
 is sufficient for that purpose.   We take it because Ave like this
 form of  food ; and because the stimulating properties of nitro-
 genized substances render  them agreeable.  The energy of  the
 meat-fed man as compared Avith the vegetable eater is distinct
 and marked ;  but gout and other troubles  are  the inseparable
 alloy.  There is a Nemesis behind the force-manifesting animal
 food !  Lithiasis in its Protean  forms  may be successfully culti-
 vated ; and though gout  may be more readily induced in some
 persons than in others, it can be produced  by persistent effort
 in all.  The  presence of  large  quantities of waste nitrogen in
 the blood maintains the  kidneys in  a state of high functional
 activity ;  and the  hyperaemia of active function leads in time
 to the production of connective tissue in excess.  Such is  the
 origin of the majority of the cases of chronic renal disease ; such
 indeed is the  natural  history  of interstitial  nephritis,  of  the
 contracting, granular, cirrhotic, or gouty  kidney. Long before
 the disturbance of balance betAvixt the Avaste to be excreted and
 the power of the eliminating organs to excrete it, is forced upon
 the attention,  a silent gradual process has been in action, sloAvly
 but  steadily destroying  the kidney, and  rendering it less and
 less equal to the duties  demanded of  it.  It is only when some
 of the evidences of imperfect depuration of the blood become
 manifest that Ave rouse up to the consciousness  that the kidneys
 are no longer in their structural integrity; and that a slow and
 insidious form of disease has been stealthily undermining them.
 Further, too, Ave must clearly recognize the fact that the excess
 of duty thrown upon the kidney—the direct cause of the tissue
 changes in it—is the result of indulgence in nitrogenized food
 beyond the absolute needs of tissue repair.  About this there
should be no doubt—no  haziness of opinion.
  § 172. The excretion of water by the kidneys  is a subject  on
Avhich it is desirable that a more  distinct knoAvledge should exist
 than generally obtains.  It varies very much with the condition
      28 
40.4
THE URINARY  SYSTEM.
of the  circulation.   If a large bulk of fluids be  swallowed,
rapid dialysis increases the volume of blood generally ;  there
is greater  pressure Avithin the arteries, and  a  rapid  secretion
of pale-colored urine follows.   If it  he  summer,  or, from any
other cause, the skin is acting freely, the accession of Avater to
the blood finds its Avay off by the perspiration ; and the bulk of
urine is but little affected.  When, however, the  skin is not so
active, then the inhibition of fluids results  in free secretion of
water by the kidneys; by Avhich means the bulk of the  blood
is maintained at a normal point.  When the blood-pressure is
increased, as in hysterical attacks Avith contracted arterioles, and
in the middle stages of Bright's disease, there is  a  free secretion
of Avater: Avhen the blood-pressure is lowered, as in disease of the
heart, the secretion is lessened ; the gradually diminishing bulk of
urine in a case of disease of the heart  is a symptom of the Avorst
omen.   The  relation of Avater  excretion by the kidney to the
condition of the vascular system is a subject too  little insisted
upon, though its practical value clinically is  almost inestimable;
it throAvs a flood of light frequently  upon  the course of a dis-
ease; Avhile it not rarely furnishes the  most pregnant sugges-
tions  for the line  of therapeusis to be adopted.   The arrange-
ment of the bloodvessels in the kidney is very interesting.  " It
Avould indeed be difficult to conceive a disposition of parts more
calculated to favor the escape of Avater from  the blood than that
of the Malpighiau body.   A large artery breaks  up in a very
direct manner into a number of minute branches, each of which
suddenly  opens into an assemblage  of vessels  of far greater
capacity than itself, and from which  there  is but one narroAV
exit.  Hence must arise a very abrupt  retardation in the velocity
of the current  of blood."  (Bowman.)   There is indeed rather
an exosmotic than a vital action  going on in the Malpighian •
tuft, and the flow of  water, through the thin-Availed glomeruli
is almost a question of hydraulics—the  greater the pressure on
one side the more rapid the flow ; the loAver the pressure the
slower; but if the pressure on both sides be equal, as when the
Aoav of urine through the kidney is arrested by a calculus in the
ureter, then the Aoav ceases, and there is a standstill of excretion.
  The secretion of water and the excretion  of renal solids have,
speaking broadly, nothing whatever to do with each other; the
urine may be scanty, and of high  specific  gravity, laden with 
THE URINARY SYSTEM.
135
 solids indeed; Avhile at other  times the flow is profuse, but the
 specific gravity  is  low and the  urine  is  almost colorless,  is
 indeed nearly pure water.   As a matter of fact more solids are
 often  eliminated when the bulk of urine is small than when
 the Aoav is profuse (Parkes on Urine, p.  385) in the subjects  of
 chronic renal disease;  Avhere these variations in  the  urine are
 common, and so decided as to  compel the attention of the indi-
 vidual, the matter of Avater  Aoav and the excretion of solids
 becomes a subject of the greatest importance in practice.
   § 173.  Diuretics.—By diuretics  are  meant a class  of agents
 which increase the Aoav of urine.  From Avhat has just been said
 it will be obvious that diuretics are to be classed under two divi-
 sions.  (1) Those Avhich act upon  the vascular system, and (2)
 those Avhich act upon the kidney.  Those of the first division are
 sometimes entitled hydragogue diuretics.  This division includes
 digitalis, squill, and broom.  These are  the diuretics Ave resort
 to in dropsy, Avhen the vascular  tension  is low.   They are diu-
 retics by their action upon the circulation generally ; rather than
 by their action upon the kidney or the renal circulation.  They
 increase the force of the  ventricular- contractions, Avhile  they
 tighten the arterioles by diminishing their lumen, and so they
 increase arterial tension ; Avhile the increase in the pressure Avith-
 in the arteries produces more rapid exosmosis in the renal tufts,
 and an augmented Aoav of urine folloAvs.  This is the mechanism
 of the improved Aoav of urine Avhich folloAvs the administration
 of a series of doses of digitalis in cardiac disease, as in mitral
 regurgitation  for  instance.  Such  are  the means  by Avhich the
 bulk of urine is increased in certain morbid conditions.  When
 given to a person in health, digitalis produces but little increased
 floAV of urine; in toxic  doses  there  is  suppression of urine.
'There is no notable increase in the bulk of urine solids after the
 exhibition of digitalis; this agent is not a diuretic in that sense
 at all.  It is  often  desirable to  increase  the secretion of urine
 solids  at  the same  time that  it is necessary to  act upon  the
 circulation ; then digitalis  may be given with  some of  the
 second division of  diuretics.  Consequently Ave  can  combine
 these agents, and the following is a very  agreeable mixture:—
                      Sp. Chloroformi, TuLxx.
                     Tinct. Digital, ufx.
                     Inf. Buchu, |j. 
436
THE URINARY SYSTEM.
The addition of potash, in the form of the citrate, to this mix-
ture makes it a complete diuretic, combining the various forms
of diuretics ; especially Avhen folloAved by a good drink of water.
Such combination is indicated in suppressed gout Avith a feeble
circulation.
  By such a combination Ave get an improvement in the cir-
culation,  at  the same time  that we stimulate the  functional
activity of the kidney.  Without the vascular diuretic  the cir-
culation Avould remain  languid; this agent not only increases
the  exosmotic consequences of heightened  blood-pressure, but
it improves the circulation generally,  and as part of it, the  renal
circulation.  The buchu acts, it is held, upon the secreting cells
of the  uriniferous tubules,  and  increases the bulk  of  solids;
Avhile the potash dissolves the uric  acid in the body,  and as the
soluble  urate of potash, the  uric acid finds a ready exit in the
renal fluid.   Such combination of diuretics is rational in theory
and  successful in practice.
  The second division of diuretics is that of agents  Avhich act
upon the renal circulation,  dilating the renal vessels  and so
permitting of a free Aoav of blood, Avhile stimulating the secreting
cells.  Juniper, buchu, cubebs, turpentine, etc., form  this group
of diuretics.  But  as digitalis  has some effect upon the  renal
circulation, as shown by the experiments of Brunton and  PoAver,
so the ordinary preparations  of these drugs  contain some agent
Avhich acts  upon the circulation.  Thus gin contains alcohol,
Avhich stimulates the heart;  as Avell as the juniper, Avhich pro-
duces renal  hyperaemia, increased functional activity,  and larger
volume of urine, with an augmented  bulk of solids.
  These diuretic agents seem to  have a soothing effect upon the
kidney, and to facilitate its  Avorking.  Buchu, indeed, seems to
possess  similar properties over the urinary tract that bismuth
has over the intestinal tract: though the action of each does not
yet admit of an explanation.   In conditions of vesical irritability
its excellent effects are undisputed and indisputable.   In con-
ditions  of excessive lithates and  attacks of suppressed gout, all
Avriters on therapeutics speak  Avell of  buchu.  It may not be
asserted positively, in  the absence of direct observation, that
buchu increases the solids in the urine,  but the general  impres-
sion  produced  by the use of buchu is pretty distinct, that the
cases so treated do better than when the  buchu is Avithheld. 
THE URINARY SYSTEM.
437
In my oavii  practice buchu is almost invariably the vehicle in
Avhich other diuretic agents are given.   It certainly is agreeable
to take, it is Avell borne, and  its volatile oil is readily found in
the urine; shoAving the probability at least of its having some
local  action upon the kidney.   Consequently citrate of potash
and buchu  form a pleasant mixture in  lithiasis, and constitute
an agreeable medicine in gently acting  upon the kidneys after
an attack of acute nephritis, Avashing out the blocked tubules;
which Dickinson insists upon as the correct treatment of tubular
nephritis, when the acute stage is over.   With iodide of potas-
sium (fiVe grains),  bicarbonate  of  potash (five grains), and  ten
drops of colchicum Avine, an  ounce of infusion of buchu forms
an excellent remedial  measure  in  suppressed gout or lithiasis,
especially Avhen folloAved by a draught of water.   Here we
require a combination of diuretics suited to the patient's needs,
and forming a complete contrast with Avhat is required in heart
failure.  In lithaemia  there is commonly a large  flow of urine,
pale and of low specific gravity;  here  Ave Avish to increase  the
bulk  of urine solids:  in heart failure the urine is high colored,
dense, and  laden  with  solids; here Ave Avish to  augment  the
bulk  of urine.   According to the circumstances of each case do
Ave select our diuretic.  A brief consideration of the physiology
of the renal secretion Avill tell us that  digitalis  is unsuited to
lithaemia, that is in the earlier stages  before the  hypertrophied
heart begins to undergo fatty  degeneration; and that potash and
buchu are equally unsuited to  relieve cardiac debility.  Of course
in a case Avhere both exist together a combination of the reme-
dies may be indicated.  But it is abundantly clear that it is  not
a matter of indifference Avhat  agent, classed as a diuretic, Ave
select in our treatment of a case, nor yet  Avhat combination even
Ave choose.  Certain members of this group are suited to certain
necessities, and others  to other needs.   For successful practice
it is necessary to know Avhen to  prefer squill to juniper, and
broom to  buchu.   Unless  the youthful reader  makes himself
perfectly familiar Avith the different actions of vascular and simple
diuretics, he will often blunder in his selection of remedies ; and
fail in giving relief in  a very  large and important class of cases.
He may by accident hit upon a successful  combination by putting
several diuretic agents into one mixture—a sort of practice which
has  no doubt often been followed  by excellent  results; but he 
438
THE URINARY SYSTEM.
will find a distinct and clear comprehension of the action of each
agent a much better and surer plan ; both for the patient's and
his oavii  interests.  A diuretic Avhich acts upon the circulation
may often be added to diuretics Avhich act upon the kidney itself
with good effects; and such combination is easy if Avhat has been
written above is not only read but imvardly digested.   For renal
ailments form a large  part of the diseases and troubles of the
wealthy  and the influential, as Avell  as of the indigent; and the
lessons learnt from the treatment of the one may be made very
useful in the relief of the other.   There is no surer  nor more
deserving road  to success in practice than a sound knoAvledge of
those ailments  Avith Avhich the various  classes of diuretics are
associated; and the man who knoAvs when a vascular diuretic is
to be preferred to one of the other class, has a decided advantage
over the man that does not.
   § 174. Acute nephritis is an ailment which commonly results
from exposure to cold, or  other sudden  arrest of the action of
the skin.  A little reflection will soon demonstrate how  this
comes about.  In the involutions of the general external surface,
as evolution proceeds, none retains so completely as the kidney
the functions of the general excretory surface; consequently,
Avhen the action of the skin is arrested an extra demand upon
the kidneys  follows.   The action of the skin in blood depura-
tion is very considerable,  and Avhen this  is  lost Ave have great
hyperaemia  of  the kidney Avith  increased functional  activity;
Avhich not rarely passes on into a true inflammatory condition.
That there  is another factor, in the general congestion of the
internal organs, which occurs when the cutaneous vessels are
contracted, must be admitted ; as is also the case in pneumonia:
but, nevertheless, the inflammations which most commonly result
from  cold are situated in  those organs Avhich  have a similarity
of function with the skin ; and that this is an important matter
cannot be doubted.  When the  kidneys are acutely  congested
or inflamed, their functional  activity is so impaired that there
is an  accumulation of waste matter and of Avater in the system.
The whole areolar tissue is not rarely filled with  fluid, and there
is general anasarca more or less pronounced.  This accumulation
of Avater furnishes the most prominent symptom in the altered
appearance of the  individual; but  the retention of the nitro-
genized  waste is the  really serious matter.  When the kidney 
THE URINARY SYSTEM.
439
mischief is due to scarlatina (where the relation of the skin and
kidneys is Avell seen in the pathological process of inflammation
and desquamation) convulsions of  uraemic origin are very com-
mon ; but in all cases of nephritis they are liable to occur.  At
other times  this azotized waste excites inflammation of serous
membranes; which is very grave Avhen the cerebro-spinal serous
membranes are those chiefly implicated.
  The indications for treatment in such conditions are as folloAvs.
First  to procure fair depuration of the blood by exciting  the
action of the skin and the intestines.  The first may be attained
by rolling the patient in blankets Avrung out of hot Avater, or
by the bath previously described as Sir James Simpson's bath
(p. 107).  This should be followed out vigorously ; at the same
time the bowels should be acted on briskly by tAvo scrupde closes
of compound jalap poAATder at repeated  intervals;  or five grains
of gamboge  in twTo drachms of bitartrate of potash,  the griping
being ameliorated by  ten grains of black pepper.   The sweating
and purging are folloAved by a sense of general relief, while  the
kidneys are  specially relieved.  By such plan not only are  the
inflamed kidneys  eased by lessening the demand  upon them
functionally, but the  refilling of the cutaneous vessels lessens
the blood pressure in the arteries ; -while the purging relieves the
venous congestion, and especially that of the portal  circulation,
and so the renal hyperaemia is reduced.  Such vicarious action
and effect  upon the circulation combined must be  maintained
steadily, according to the needs of the case and  the changes in
the renal  secretion.   If the case be slight, the urine  will be
smoky, from the presence of coloring  matter derived from the
blood, and will be merely albuminous.   If  the case be severe,
the urine will  resemble blood.  According to the appearance of
the urine  Avill be the  activity of  the  remedial measures:  in
some cases gentle measures, in other cases heroic ones are to be
adopted.
  This relief of the kidney by acting upon the skin and boAvels
is self-evidently the plan to be pursued in acute nephritis ;  and
about its propriety there exists no doubt.  There is some  dif-
ference of opinion about the use of  diuretics during the inflam-
matory process.   Many excellent authorities  are  in favor of
the administration of potash  in acute nephritis ; the purgatives
in most favor contain potash, and not only that, but it is found 
140
THE URINARY SYSTEM.
that citrate of potash  is  useful  in  addition to the cathartic
measures.  It forms a  pleasant beverage, very grateful  to the
thirsty feverish patient, and seems to exercise a beneficial effect
over the progress of the malady.   W.  Roberts Avrites:  "In a
disease  which  tends to  spontaneous  recovery  under  simple
hygienic and prophylactic treatment, it is necessarily a  matter
of extreme difficulty to  bring home the evidence of the curative
piOAver of drugs ; but in a'considerable number of cases of acute
Bright's disease coming under treatment early, I have obtained
almost invariably the  best results by  the free administration
of citrate of potash.  And in  no  instance Avhere the urine has
been rendered alkaline  in the  first week of the complaint have
I  observed the  more severe uraemic symptoms, or secondary
inflammations."  This  last sentence is  very  important  coming
from so cautious a Avriter  as W. Roberts.  My oavii experience
goes to corroborate his  statements as to the utility of citrate of
potash in acute renal disease, especially Avhen given in buchu.
   Such are the remedial measures which call  for our confidence
in acute  nephritis ; Avhile the dietetic measures are to give milk
and  seltzer Avater, lemonade, thin fluid preparations of  farina-
ceous foods, and other forms of food and drink which shall not
contain nitrogen ;  duly bearing  in  mind the function of the
kidney, and the chief dangers surrounding the patient.
   § 175. Albuminuria  is an indication  of renal disturbance Avell
deserving of our attention ; the more so that its real significance
is far from being clear.   The urine may be laden Avith albumen
in cases Avhere no symptoms of ill-health are present, and Avhere
the morbid state of the urine passes aAvay Avithout any illness
on the part of the individual; while on the other  hand Grainger
SteAvart Avrites : "Albumen  is rarely present in any considerable
quantity, and its presence—fitful in  its appearance, and varying
in its amount—is also  difficult of explanation," in  cirrhosis of
the kidney ; which, he  says, u is the most hopeless of all forms of
Bright's disease in relation to treatment."  Certainly the amount
of albumen in the urine is  no measure  of the amount of renal
mischief;  and my experience induces me to say that very often
its appearance gives no occasion for alarm,  and its absence in
other cases confers no  comfort.   The  simplicity of testing  the
urine for albumen, and so settling the  question of the presence
or absence of kidney disease, is  so  alluring that many forget 
THE URINARY SYSTEM.
441
 that it is only one  symptom of renal  disease ; and that, too, a
 symptom about  Avhose  value  there  is the  greatest variety of
 opinion.  It is  not certain Avhether albumen is not normally
 present  in  the  fluid  Avhich  drains out  into  the uriniferous
 tubules, and is absorbed by the epithelial cells Avhich  line these
 tubes, or not; indeed the subject is shrouded in mystery.  And
 yet there are many who Avould base their diagnosis  as to  one
 of the  most compuex  matters  in  all medicine, on the physical
 characters of the urine.   The diagnosis of chronic renal disease
 during its quiescent pieriods (that  is during  the greater  portion
 of its existence) is a matter involving  much thought and care ;
 much  knoAvledge  and  observation,  Avatchful attention, and
 thoughtful pmthological  research,  ere an opinion entitled to any
 Aveight can  be reached; and yet there are those Avho will at once
 decide the matter by testing the urine for  albumen, and if it be
 not present  throAv  over forthwith  all the  other evidences—a
 plan calling for stern reprobation.
   Albuminuria is a valuable symptom Avhen carefully appraised ;
 but it Avill  not  settle the question  of renal disease.  It is a
 symptom not to  be neglected, but  it has been  sorely abused ;
 it has covered much culpable carelessness,  and occasioned much
 mischief. The man Avho Avould make  the diagnosis of  chronic
 renal  disease turn on  the presence or absence of albumen, is a
 man whose patient I should not like to be.   The silent progress
 of interstitial nephritis  is often Avithout albuminuria for long
 periods; the absence  of albumen, therefore, does  not  contra-
 indicate the presence  of disease,  even  Avhen far  advanced ; at
 other times  albuminuria is  a  temporary  condition of  no real
 importance.   Albuminuria derives its significance from the
 conditions under which  it occurs; and the great matter is to
 arrive at a knoAvledge of these  conditions ;  after Avhich only can
 Ave appraise  the  value of this symptom.   This view of the
 matter is too little insisted upon, even by those Avho knoAv well
 the value of  the testimony furnished by albuminuria.
   If  its diagnostic  import  is surrounded  by difficulties the
 treatment of albuminuria is  no simpler matter.  That the loss
 of albumen  may  impoverish the  blood, if excessive, must  be
 admitted; but the  means of restraining its  loss  are  far  from
 deserving of confidence.   It Avas once thought that astringents,
as gallic acid, tannin,  the astringent preparations of  iron, and 
442
THE URINARY  SYSTEM.
other metals, did good in checking the drain of albumen.  Now
much scepticism prevails as to the utility of astringents.  More
confidence is felt in feeding the  patient  and  meeting the drain
by quantities of albuminous food, and yet  there are objections
to this plan ;  for in the splitting  up of albuminous bodies in the
liver much nitrogenized Avaste is produced, Avhich is a matter  to
be avoided.  In  obstinate cases  of albuminuria in my  own ex-
perience, hot baths  have produced more effect than anything
else ;  Avhile cod-liver oil has improved the anae-mia. The effect
of opium in checking the Aoav of urine  would indicate its use;
AATere it not that  albuminuria i3  often associated Avith uraemia,
and there opium is strongly contra-indicated.   Warm clothing,
promoting cutaneous Aiiscularity and functional activity, occa-
sionally purgation Avith cathartics containing potash, a plaster
over the loins, or frequent application  of hot poultices  faced
with mustard, or perhaps dry cupping ; and potash, the potassio-
tartrate of iron in buchu ; together Avith a restricted diet, chiefly
of farinaceous, fatty, or fish food, are the remedial measures  to
be generally adopted.   When the albuminuria folloAvs scarlatina
careful protection  of the skin  is of the utmost importance,
especially in cold weather.   In all  cases the  use  of the cum-
merbund, or Avaist  belt  is to be  recommended.  Dr. Broadbent
informs me that in  the numerous cases  of albuminuria in the
London Fever Hospital, towards the decline of  the affection,
Avhen  only small quantities  of  albumen  remain, mercury  in
limited doses usually leads to the entire disappearance of the
albumen.   It is a remedy, hoAvever, Avhich  should be resorted  to
cautiously ; Avhile quite a safe measure in the hands of so careful
a physician as Dr. Broadbent, it may be  a very dangerous agent
in the hands of some practitioners.   If albuminuria persist, and
there are other evidences of renal disease, the patient should
seek a warm climate ; and even then be warmly clad.  Albu-
minuria is associated with anaemia, and in anaemic persons there
is little resistive or reparative pxnver; consequently colds should
be carefully  guarded against.   The  feet should  be kept well
protected.  If  the boAvels  require to  be regulated, something
like the following mixture might be given—
                       Fer. Sulph. gr.  xv.
                       Mag. Sulph. gij.
                       Pot. Bicarb, jiij.
                       Inf. Buchu, 3 viij. 
THE URINARY  SYSTEM.
443
a tablespoonful once or twice a day in a tumblerful of water as
required ;  or some of the chalybeate saline waters may be given
instead.
  Haematics  must he  combined according to the necessities of
each case ;  and in the anaemia of  imperfectly depurated blood,
potash and purgatives  are as valuable as iron.  This much may
be safely said about albuminuria, that its presence during the
course of  a chronic renal affection indicates the necessity for
special care.  It is not an  outcome of the healthy portions of
the kidney, ordinarily at  least; neither  is  it the outcome of
piortions totally destroyed  by  interstitial  growth of connective
tissue;  probably its presence  indicates active change in some
portion of  kidney hitherto  unaffected.  Possibly at times it is
an outcome of mere renal hyperaemia.  It is questionable Iioav
far the drain of albumen is ever sufficiently serious to endanger
life; and it is even more questionable if the drain can be checked
by astringents, unless they be  ferruginous.
  § 176.- Bright's disease is a term used to designate  a series of
chronic changes in the kidney  of the utmost importance in every
way.   Three very marked forms of morbid changes are found in
the kidney, viz., in the tubules; in the bloodvessels; and in the
connective tissue.  It is a disputed point  whether either of the
first forms ever exists long without the connective tissue  being
increased.   Some remarks of Sir William Jenner's in the Lancet
(1865) are well worthy of .perusal  on this  matter.  The purest
and most  chronic form of disease  is interstitial nephritis.  It
is the excessive development  of connective tissue, or basement
membrane, Avhich so commonly follows high functional activity,
with  hyperaemia of an organ.   The other morbid changes are
usually of briefer duration ; the tubular form of the disease not
rarely ending in recovery.  When the vessels  are affected  in
that form of  renal disease termed amyloid, it is questionable if
anything more than palliative  measures are ever attainable.  At
other  times the chronic changes take the  form of fatty growth
—not fatty degeneration, but  interstitial  growth of  fat.   This
change gives but  few indications  of its existence.  When the
chronic changes are somewhat accelerated in certain constitu-
tions,  there is  fatty degeneration  of the  albuminous casts; a
symptom of evil omen.  But  whatever the form of change the
great principles of treatment are the same in each case—modi- 
144
THE URINARY SYSTEM.
fled by individual necessities according to the judgment of the
practitioner.
  Ere proceeding to the consideration of the treatment of chronic
renal changes, it may be as Avell to revieAv briefly the causation
of the changes ; as that Avill be found to furnish useful indica-
tions for the prevention of such changes, and the sloAving of the
morbid action Avhen established.  The first great point is that
chronic renal diseases are commonly the outcome of indulgence
in a highly nitrogenized diet; excessive functional activity lead-
ing in time to structural changes.   Then the second great cause
is exposure to cold and  especially changes of temperature.  The
function of the skin is closely allied to that of the kidney;  not
only as regards Avater elimination, but also as regards the excre-
tion of nitrogenized Avaste(p. 74).  Repeated chills to the skin
not only produce renal hyperaemia by the  internal congestion
which  follows all contraction of the cutaneous vessels; but by
the action of the skin being  checked there  is  an accumulation
of Avaste in the blood, and then there is furnished another cause
of renal hyperaemia and increased  functional activity—the two
chief factors  in  the induction of interstitial changes.   Careful
thought over the relations of the skin and kidneys Avill not only
explain the association of acute nephritis with sudden exposure;
but Avill also  elucidate the connection which  exists betAvixt con-
stant exposure and chronic renal changes;  and illustrate an  im-
portant part of the treatment of this affection.
  Xot only so, but the question  may be raised as to  Iioav far
the renal changes are involved  in general  conditions, and  are
modified by the general conditions.  The gouty form of Bright's
disease with florid complexion so  common in England,  is much
rarer in  Germany, where there is a marked  tendency towards
anaemia and oedema; and yet interstitial nephritis is the form of
renal change in both cases.   The tendency of present thought
is too  much towards making the kidney the starting  point of
all  the changes found in chronic  Bright's disease; and conse-
quently of finding different sequelae, requiring various treatment,
according  to  the form of renal disease.  Xot that this is  not
good and proper, if kept within  certain and safe  limits;  but
it may be  overdone.  Hoav far  renal  disease is  an outcome of
constitutional changes in some of its forms, has been Avell shown
by Basham.  The very form assumed by the changes in  the 
THE URINARY SYSTEM.
445
kidney depends to some extent upon the age, sex, and diathesis
of the individual in Avhom they exist;  and the treatment Avill
be  modified  by such  concurrent  circumstances in each case.
Then again the renal disease may be but part of a general break
up  of the system.  "■ A certain number of  cases of  chronic
Bright's  disease present themselves," says Roberts, " in Avhich
the most searching analysis fails to indicate the exciting cause
of the disease.  In some of  these  the  renal affection is only a
part manifestation of some Avidespread cachexy, in  Avhich fatty
degeneration coexisted in the heart, great vessels, brain, and
kidneys."  In this last series of cases little can be done, and that
little is only palliative.  In other cases again, more  especially
of the more acute forms and in  young  subjects, the starting
point is clearly and  distinctly in the kidneys; and  if the meas-
ures taken are judicious and carried out firmly, much  good may
be done; indeed, an entire cure  may be effected.   What those
measures are Ave shall see immediately.  In order to  comprehend
renal disease clearly Ave must remember that " Chronic Bright's
disease, in  the great majority of  instances, begins  sloAvly and
imperceptibly.   It is rarely detected until  it has already existed
many months—it  may be  years.   The attention of  the  patient
is at length awakened  by the gradual failure of his strength, the
increasing  pallor or salloAvness of  his complexion, and his dis-
inclination to exertion ;  perhaps his suspicions are aroused by a
little puffiness  under the  eyes—" the  Bright  eye"—a slight
SAvelling of the ankles  at night, unusually  frequent calls to AToid
urine, or shortness of breath.  In other cases these premonitions
are altogether  \ATanting, or peril a pis they  pass  unheeded.  The
fatal  disorganization  of  the kidneys  proceeds silently,  amid
apparent health ; and  then suddenly declares itself by a fit  of
convulsions,  rapid coma,  amaurosis,  pulmonary oedema, or  a
violent inflammation.  Or, again, the disease creeps on stealthily
in the Avake of some  pre-existing  chronic  disorder—phthisis,
caries, necrosis, joint  disease, constitutional  syphilis,  chronic
alcoholism, or exhausting suppuration.   Or it may be a continu-
ation or sequela of acute Bright's disease.  Lastly, the  disease
may lie concealed for an undetermined period, and  then reveal
itself after exposure to cold, or a  fit of intoxication,  in the guise
of an acute attack—with rapid  general anasarca and  scanty al-
buminous urine." (Wm.  Roberts.)  Dickinson also,  in speaking 
116
THE URINARY  SYSTEM.
of granular kidney, says: " The change begins in disproportioned
growth, someAvhat of a rank luxuriance, in the fibroid tissue with
which the arterial channels are uniformly fringed.  Hypertrophy
of this part leads to atrophy of all the rest.   Creeping along the
arterial lines Avith sIoav and hesitating steps, involving the organ
not all at once, but  by little and little, the disease makes itself
felt not suddenly, but with so gradual a departure from health,
that  its  date  is  usually undeterminable,  and  its  existence
unsuspected  until  it  has  reached an  advanced  stage."  The
importance  of  understanding  the silent  unobserved course of
the disease ere it  becomes  apparent (here insisted  upon) lies
chiefly in the  learning to distinguish and appreciate the indica-
tions  of  such changes in their earlier stages.  This can only be
acquired by the  most careful  and  painstaking observations of
all  cases ; a thorough investigation of  the past  history of the
individual, and a minute registration of external changes, so that
an acquaintance with the natural history of the disease may be
attained.  Having so learnt to form a " presumptive diagnosis,"
much may be  done to prevent and  arrest the morbid changes
ere they have  become undoubtedly established.   It is in these
earlier stages, of Avhich there may be so feAv indications, at least
of the certain signs and symptoms; that our measures Avill be
most  valuable and protective; and the power to recognize these
earlier indications  is only given to those  avIio earnestly investi-
gate  and inquire.1  It  is a matter of much  moment both to
patient and  practitioner that such knowledge exist, for then
measures may be taken  to avoid irremediable changes.
  § 177. Whenever there exists a suspicion of renal disease, the
patient must be Avatched carefully for the less doubtful indica-
tions, Avhich may be long in showing themselves ;  all the longer,
indeed, if the treatment be justly and truly adapted to the case.
It is  not only the  avoidance, as far as may be, of any aggrava-
tion of the  already existing disease that is to be aimed at; it is
the  aAToidance of  any  acute  condition  that Ave must strive
against.   In these  acute conditions  lie most of  the danger to
life.  Wherever chronic disease pre-exists, there acute disease

  1  The reader, if so minded,  will find a paper on " The Systemic Indications of
Bright's Disease" in the Brit. Med. Journ., Jan. 1875, by the writer, in which
he has striven to give the means of forming " a presumptive diagnosis" in such
changes. 
THE URINARY SYSTEM.
447
is most formidable.   In the phthisical, acute pneumonia is ever
to be dreaded ; the old standing mischief is lighted up, as a fire,
by the acute  intercurrent disease.  In chronic  debility  of the
stomach acute indigestion quickly sets up grave disorder.  In
chronic disease of the liver acute hepatitis becomes most serious.
And so in chronic renal disease the great matter to be avoided
is those conditions of  acute congestion, or even  of nephritis,
Avhich  are  so apt to occur in  the subjects of chronic  renal
changes; and to which pre-existing  disease  renders them so
liable.  The means to be adopted lie largely in the connections
with the skin and with the diet.
  It is of much  importance to keep the skin Avarm ; both fron?
the  effects  of cold in producing internal  congestion, and from
the aid given to the kidneys by the functional  activity  of the
skin.   Consequently the subject,of  Bright's disease should ever
be Avarmly  clad.   The tendency of  this malady is to produce  a
dry and imperspirable skin; so  that the impaired  kidneys get
little assistance from cutaneous activity.  Indeed in many cases
of gout, and the other outcomes of lithiasis, in  cold Aveather it
may be made a matter of question how far the skin may  not be
the  exciting  cause of the outbreak, rather than the  kidneys.
From the large amount  of oxygen respired in low temperatures
more perfect oxidation goes on, and yet there is a large quantity
of unoxidized waste in  the system.   There ought to be greater
freedom from these manifestations of imperfect blood-depuration,
and yet the opposite is often the case.  Some gouty persons—I
here use the  term gout in  its  Avidest sense—are best in  cold
AAreather; while  others again are best in warm  Aveather.  It is
impossible to  put away a conviction that the difference in these
cases lies in the action of the skin versus  more complete  oxida-
tion.  At any rate it is of the greatest importance that the skin
be Avell covered.  Flannel  from the neck to  the wrists and
ankles, or eA^en " fleecy hosiery," must be Avorn in the daytime;
and  flannel night-dresses must be used for bed wear.  Changes
of temperature must be as carefully followed as  in India, Avhere
it is necessary at some seasons  to dress three or more times  a
day—for the cool morning, the hot  noon, and the chill evening.
The shoes  and boots must be stout and Avell lined, and contain
an inner sole of  cork, felt, or even  fur.  About  the importance
of stout shoes it is imp>ossible to be too explicit. All exposure 
448
THE URINARY SYSTEM.
 to Avet must be followed by a change  of  boots, even Avhen it is
 in no Avay necessary to change the clothes;  but all damp clothes
 should be changed without delay.  The subjects of chronic
 Bright's disease live as it Avere over a volcano: and the slightest
 carelessness may be folloAved by the most  grave  consequences;
 what Avould but produce  a  mere  cold in  others may induce a
 fatal attack of intercurrent  inflammation in them.  Xot only
 that, but there is the danger  of producing further destruction of
 those parts of  the  kidneys remaining sound, by  each  repeated
 attack of congestion ; it is the silent, gradual destruction  of the
 kidneys that is to be feared,as well as the general inflammatory
 attacks of various organs Avhich immediately endanger life.
  "The prospects of a patient suffering from  confirmed chronic
 Bright's disease are exceedingly gloomy.  The textural changes
 in the kidneys are  of a kind that do not admit of reparation.
 The Malpighian bodies become enveloped in an exudation of low
 plastic material, of  Avhich the only tendency is to progressive
 contraction, and the tubuli are either blocked up Avith fibrinous
 plugs or shrivelled  into  useless fibres.   The  gland, hoAvever, is
 not equally affected  throughout all its parts, and the less injured
 portions  carry on, imperfectly,  the depurative functions.  As
 the sounder portions become more and more involved—and there
 is an almost inevitable, though slow, tendency to this—the Avork
 done by the kidneys groAvs less and less, and  the  blood is more
 and  more  contaminated Avith histolytic and  urinous elements,
 until at length a limit is approached Avhich is incompatible Avith
 life.   Long before this extreme limit is reached, however, death
 is brought about in a  large  number of  cases by one or  other
 of the numerous complications to Avhich the subjects  of  renal
 degeneration are obnoxious."  (Roberts.)
  This vivid  sketch sIioavs  Iioav each exposure  to cold  may
 result in the implication  of another piece of the sound  kidney;
 how its destruction will still further reduce the capacity of the
 kidneys to meet the work  imposed upon  them; and so how by
 each new congestion the gradual process of destruction is accele-
 rated.  Nothing could  tell us  more forcibly the  necessity for
 the avoidance of all provocatives of further  mischief.  As the
destruction of the kidneys proceeds the depuration of the  blood
 must rest  more and more upon the skin  and upon vicarious
action.   The more need then  to   maintain  and  preserve the 
                  THE URINARY SYSTEM.              449

 functional activity of the skin!  This part  of the treatment is
 obvious enough.
   § 178.  At the risk of'being charged with repetition of Avhat
 has been  said before both in this Chapter and in Chapter XL,
 it is necessary to be explicit about the relations of the food Ave
 take to the function of the kidney.  As the  chief eliminators of
 azotized Avaste,  it is obvious that Avhen the  kidneys are under-
 going the gradual destruction just given, it is necessary in order
 to maintain a species of equilibrium betwixt the power of the
 organs and the  Avork to be done by them, that  the  amount  of
 nitrogenized food be reduced.   As the renal disease progresses
 this must be done; else  explosions of uraemia will be induced
 from time to time, which may act as  temporary auxiliaries  in
 blood-depuration, but which Avill distinctly  endanger existence.
 Not only is there danger from the accumulation of nitrogenized
 waste, Avhen the Avaste matter  is too  much for the excretory
 poAver of  the kidney ;  but the hyperaemia Avhich goes  along with
 excessive functional activity in the renal organs may proceed  to
 acute congestion, or eATen inflammation, in those parts remaining
 sound ;  and so the destructive processes be accelerated.   Conse-
 quently the  amount of nitrogenized  food must be gradually
 reduced in proportion to the diminishing structural integrity
 and functional  poAvers of the  kidneys.   If this be not done
 then further mischief will result.   It  has been  shown before,
 in § 171, that the great bulk of nitrogenized Avaste comes from
 the splitting up  of albuminoids  in the liver,  and the production
 of glycogen.  Small quantities only of nitrogenized  matter are
 required for mere tissue repair—for the absolute needs  of the
 system.   For the formation of glycogen farinaceous foods will
 do  equally well.  The only difference is  that the excess  of
 nitrogen acts as  a  stimulant to the nervous system, and gives
 a sense  of  energy: this, however, is a small matter, compara-
 tively,  but  as  many  persons  object   very  decidedly  to any
 diminution in their sense of energy, they  oppose  the  proper
 treatment  and speak of it as too lowering.   This is deep-rooted
 fallacy, which often  calls for very firm and decided  opposition.
 The patient is incapable of having any explanation given him
in consequence of his  ignorance of  physiology, and  must rest
satisfied, or unsatisfied, with dogmatic statements;—while he
remains  distinctly conscious of the loss of energy.  But,  never-
      29
y 
4o0
THE URINARY  SYSTEM.
theless, the plan must be insisted  upon in his own  interests—
i. e., if he wish to  preserve  his  life.  The diet should consist
largely of farinaceous matters, fish, vegetables, and fruit. Sniall
quantities  of lean meat alone may be safely adventured ; and
beef-tea and soups must be indulged in in very moderate quanti-
ties, the more so that their nitrogenized matter can do little but
undergo retrograde changes.   It is necessary to speak decidedly
on this matter: beef-tea and the azotized matters of soups are
rather stimulants than food, their quality as food  ranks very
Ioav; they may form  palatable adjuncts to boiled sago, arrow-
root, and other farinae, but they  are otherwise of little use, and
only embarrass the failing kidneys.   At  present beef-tea and
Liebig's extract are the fashion, and it is almost heresy  to have
doubts  about their  unalloyed  goodness;  ne\Tertheless, these
doubts are Avell founded.   In fish  Ave p>ossess a form of animal
food Avhich is, or  can be made, palatable, and  satisfies the crav-
ings of the appetite ; and the  sufferer from chronic  Bright's
disease can make a hearty meal of fish, with melted butter or
sauce, Avithout overtaxing the kidneys.  Fish then should form a
large portion of their dietary.  Farinaceous foods and puddings,
or blancmange, will  make with fish  a  satisfactory  meal, espe-
cially if folloAved by  salad and fruit.  Such a meal  will satisfy
any but a gourmand.   Doubtless it requires  some ingenuity on
the part of the caterer to prevent a certain amount of monotony
in such a dietary ; but it may be relieved  by  meats, which shall
be taken sparingly, and be accompanied by much fat.  It is not
necessary to restrict the diet as  regards articles, so  much as to
keep steadily to  the principle that  the food shall  not be too
highly nitrogenized.  If this be adhered to, the dietary need
never be felt to be too restricted.
  In many persons who are stout, and Avho are also the subjects
of chronic  renal  changes, the  matter  of diet  becomes very
complicated.  If they  consume  hydrocarbons their obesity  is
increased ; if they cut  down their hydrocarbons  in  favor of
albuminoids, then renal trouble is the  consequence. For such
persons a fish  dietary  Avith the more highly  oxidized hydro-
carbons, such as rice, etc., is admirably suited.  They  Avish to
have a certain  bulk of food in order  to satisfy their cravings;
and in these forms of foods, together  Avith  many  vegetables,
they may find what they seek.   When, on the other  hand, renal 
THE URINARY SYSTEM.
451
 changes  are complicated with  glycosuria, then  the  farinaceae
 must be avoided, and the more concentrated hydrocarbons must
 be taken instead, together Avith bran biscuits, etc., and vegeta-
 bles.  Doubtless in some  cases the absolutely correct diet is so
 limited in range that it is very difficult to adhere to it.  Never-
 theless it is  the medical adviser's duty to put  the matter plainly
 and clearly  before each piatient in every case, and  to leave the
 responsibility of action with the person Avho is chiefly interested ;
 urging, hoAvever, in season the adoption of the right dietary.
   § 179.  The matter of drinks is not unimportant in the regu- '■
 lation of the dietetics of Bright's  disease.  It is  Avell known
 that alcohol if taken in large quantities  and undiluted, has a
 very pernicious action upon the kidneys ; consequently if alcohol
 be taken, it must be in a state of dilution.   If taken as spirit,
 it must be taken Avith potash or  seltzer water, Vichy, Vals, or
 Apollinaris  water, and the water must be in good excess;  anv-
 thing like concentrated drinks are to be avoided.  The amount
 of alcohol consumed daily should nerve be large, otherwise the
 interstitial changes in the kidney may be stimulated.   When
 wines are taken it is a matter of importance  to choose the least
 deleterious forms.  Sherry and  Marsala, Avith a poor  and plain
 claret, are the only Avines at  all safe.  If a  good Bordeaux, a
 rich Rhone  or Rhine Avine, port  Avine, champagne, or Moselle
 are indulged in, the consequences are very disagreeable; espe-
 cially when  there exists a tendency to the accumulation of uric,
 or the production of oxalic  acid.  In consequence of the ten-
 dency towards the  formation  of oxalates  in  the subjects of
 lithiasis, articles likely  to furnish  these materials must  be
 avoided.   The sensations of a gouty  man next day, after being
 inveigled  into the taking of  rhubarb champagne, form a good
 test of the quality of the beverage.   A plain  Avine with mineral
 Avaters is the safest  drink.  As to malt liquors, they are mostly
 to be avoided ;  there are, however,  some  pale ales Avhich  are
 very free  from objectionable qualities.  The lighter  pale ales, of
 which there are  many excellent forms to  be  procured, and  the
 Bavarian beers, are  free from, or nearly free from  any objection-
 able properties.  They may be taken  in limited quantities Avith-
 out evil effects.   But drinks  should  be taken in very limited
quantities in those cases where the  filling of the bloodvessels
 with fluid is undesirable, as  in renal drop»sy ; while in other 
1">2               THE URINARY SYSTEM.

cases the  Avashing  of  the tissues  with  Avater  is eminent! v
desirable.  Where there is some  glycosuria, subacid fruits and
alkaline waters  are  to be  preferred ; a limiting of the amount
of fluids in  these cases, gives a counterbalancing relief from
certain  unpleasant  sensations, and  compensates  for the  self-
denial exercised in resisting the temptation to indulge in fluids
in inordinate quantities.   A careful restriction in the matter of
drinks  as Avell as foods is desirable in the  subjects of chronic
renal changes.
  §  180.  Having briefly  gone over  the proper clothing  and
dietary  suited to  these  patients, something may iioav be said,
as to the indications for the remedial measures to be resorted to
in cases of chronic renal disease.  It is  obvious that nothing
can be done to restore the  structural integrity of the kidneys;
the more need then to conserve what is  left of them.  IIow to
diminish the call upon them, and to prevent them from sudden
derangements, has just been given.  If there be albumen in the
Avater, and it is smoky or blood-stained, together Avith aching in
the loins and other evidences of renal congestion, hot poultices
to the loins, or dry cupping, hot baths, and alkaline purgatives
are to  be  resorted to, just as in attacks of acute nephritis ;
indeed,  there is no difference  but that of degree, betwixt  this
condition and acute nephritis.   All that  has been insisted upon
there is applicable here ; it need not be  repeated.  Something,
hoAvever, may be said about Avhat is requisite more permanently
in such cases, especially in the convalescents from acute attacks.
It is highly desirable that they should take potash in its blandest
and  least irritant forms. It may be so combined Avith purgatives
as to form a pleasant  domestic  remedy.  When given with
sulphate of magnesia and buchu it  is  eminently suitable for
those cases of constipation which  are  accompanied by a dense
mass of lithates in the urine.  Whatever the form used,  each
dose  should  be Avashed down  with a good draught of water.
Where  there is  a tendency to anaemia  this resort to potassic
laxatives, freely diluted, should ahvays precede the administra-
tion of  chalybeates ;  and usually they should be given together
afterwards. As convalescence proceeds the citrate of potash  may
give Avay  to  a  combination of the bicarbonate of potash with
the  potassio-tartrate of iron, which  must be continued some
time; the amount of  potash  being diminished gradually,  espe- 
THE URINARY SYSTEM.              453
 cially if mineral Avaters are also taken.  One of the great points
 to  be attended to in convalescence is to remember the function
 of  the kidney, and  to  be very  guarded in every step  taken.
 The amount of nitrogenized  food must  be limited, iron must
 be  accompanied by potash ; the boAvels must be kept open, and
 the action of the skin must be maintained, if dangers are to be
 aA'oided.  When there are grounds for supposing  that renal
 congestion is threatening, then quick  resort to smart catharsis
 and the use of the hot  bath will often avert the  impending
 state of peril.  Dr. Broadbent and Mahomed  have found that
 the condition of high arterial tension (Avhen the coloring  matter
 of  blood can be  found in the urine by the guaiac test)  which
 precedes albuminuria in  acute  renal  congestion,  is relieved by
 brisk purgation, and the use of the bath;  so that the presence
 of  albumen in  the urine can often be prevented.  It  is probable
 that this  vicarious depuration does  away Avith the  impending
 renal congestion, of Avhich albuminuria is the external evidence.
  In many cases of acute nephritis, and in  cases of passing con-
 gestion  in kidneys already structurally diseased,  it is  very de-
 sirable to  be sIoav and cautious during the convalescence: "the
 more haste  the less speed" is here  \Tery applicable; Avhen the
 case is doing well young  practitioners in their  anxiety are often
 wishful to accelerate the  progress; but it is not ahvays  desira-
 ble to do so.   Great caution and thoughtfulness  are the chief
 matters, and should be assiduously practised. (See p.  257.)
  Having thus sketched in outline the great principles of treat-
 ment to be adhered to in chronic renal ailments, the reader must
 fill  out for himself the details for each case from his acquaintance
 with Avhat has  been written before ;  and his poAArer to do so will
 form a good test of how far he has read attentively, and  thought
 intelligently over  the subject matter;  for it is  one of  those
 matters  where  no  explanations, however lengthy and detailed,
 can do away with the necessity for individual thought.
  § 181. When interstitial nephritis  is  the consequence, as it
 not uncommonly is, of valvular disease of the heart, it is obvious
 that the only treatment of any service will be that which  Avill
 relieve the venous congestion.  Obstruction  to the  circulation in
the  portal veins produces an arrest of the circulation in the
kidney; there  is venous congestion and  albuminuria, together
with jrroAvth of connective tissue.  At the same time the bulk 
454
THE URINARY  SYSTEM.
of urine falls ;  and the gradual diminution in the bulk of urine
with  the appearance of albumen in the fluid, furnishes a sign
of the worst omen in the course of heart disease.  Brisk pur-
gation and  hot baths, so as to relieve the venous fulness, and
agents which act  directly upon  the heart (§ 139-110) are to he
administered freely ; so as to  keep up the tone of the circula-
tion and the fulness of the arteries.  This  last measure is of
great utility in bringing the blood more steadily to the kidneys,
and so of its being better depurated.  The waste-laden condition
of the blood in the more advanced stages of  heart disease often
leads to arteriole spasm, obstructed circulation, and ventricular
failure—to  those  attacks, indeed, Avhich  are so dangerous and
fatal in advancing  cardiac decay.   The  condition of the heart
leads to changes in the kidneys, and these, in  their turn, obstruct
the heart; and so the vicious  circle widens.  Renal disease is
also a cause of  changes in the  heart. (§ 143.)
  § 182. The other troubles of  the urinary organs, not being
renal, come  but little within the province of the physician ; they
lie rather in the domain of a surgeon.   The most  troublesome is
incontinence of urine in children ;  and that  is rather an affec-
tion of the  nervous system.   Whether there is nocturnal incon-
tinence of urine in the child,  or great  vesical hyperaesthesia in
the bladder in  adults, especially  in  elderly men, it is equally
desirable that there shall be no local causes of irritation.  Feces
in the rectum or descending colon, ascarides, piles, fissures, etc.,
are all fertile causes of vesical irritability, and their removal is
very necessary.  In all cases the bowels should  be  emptied at
bedtime—a measure often giving much relief.  Local irritation
in connection with the generative organs also should be avoided,
any irritability or excitement in  them induces vesical irritability
—Nee castas frequens mingit is an old proverb which holds good
yet of both  sexes.  For the allaying of vesical irritability a com-
bination of bromide of potassium with hyoscyamus and camphor,
at bedtime,  forms a most excellent  remedy.  In addition to these
measures alkaline purgatives  are desirable, as well as the con-
stant exhibition of potash, which relieves efficiently the irritant
qualities of acid urine, in combination  with buchu, triticum
repens, pareira brava,  and uva  ursi.  These two latter agents
also contain tannin, Avhich makes them specially useful in cases
of catarrh of the bladder ; where they may be given with advan- 
THE URINARY  SYSTEM.
455
tage.   When the urethra is affected alkalies are generally given
together with  cubebs or copaiba ;  both of which are more or
less given off in the renal secretion, and  exercise a  beneficial
effect over the urethral  tract.  This, hoAvever, brings us to the
next chapter, on the affections of  the  reproductive  organs, to
which these ailments rather belong.
  In great irritability of the  bladder in catarrhal conditions the
injection of opium or morphia with astringents is often good
practice.  Here, and  in  urethritis also, it is well to render the
urine alkaline, and to give buchu  Avith camphor and hyoscya-
mus.   Since the publication of the first edition of this work, the
effects of  atropine  upon the  vesical centres have  attracted the
attention  of the Avriter.  In  the  incontinence of urine in  chil-
dren,  often very  persistent,  atropine,  given in  efficient doses,
often  procures the most  satisfactory results.
                    Atropiae Sulphat. gr.  ^g
                     Aqua? Anethi 31J. ter in die,
will usually be found to effect a change speedily.  If this should
not have the desired effect the dose of atropine may be  increased.
The treatment  is more successful with girls than boys ; the latter
not unfrequently require some surgical interference  for cure.   In
a number of  cases the  incontinence  has ceased on the second
night after taking the medicine.  Atropine is equally, or  nearly
equally, useful in the  vesical  irritability of elderly persons;
especially  during the night when their rest is much  broken by
the demand to  empty the bladder.  By its  stimulant effects on
the respiratory centres, and  its sedative effects  on the vesical
centres, atropine may  be given  with  advantage in cases  of
chronic bronchitis with  emphysema, where there is also vesical
irritability. 
CHAPTER  XVIII.
                  THE REPRODUCTIVE SYSTEM.

  § 183.  Partly in  consequence of a certain feeling of repug-
nance to  enter into the subject, partly in  consequence of a con-
sciousness that their inquiries would point to nothing, and elicit
little of which they could  avail themselves practically, a large
majority of the profession are singularly ill-informed about the
treatment of the affections of the reproductive system.  They
form, however, a  large  and important class of maladies, and
cause not only local inconvenience, but excite disturbance, often
of a serious nature, throughout the organism.   How frequently
does it fall to the lot of piractitioners who have learned fully to
recognize the importance  of such maladies,  especially in  the
female, to  see  patients  sent  up to  them for grave ailments,
accompanied by pallor and Avasti ng, \A7here a profuse leucorrhoea
is the fons et origo rnali; and  yet not the faintest attempt to
ascertain the real  state of the case has been essayed.  It is ad-
mitted universally that modesty is a great ornament to woman,
and  her  privacy should not be  intruded upon  needlessly and
unnecessarily; but at the same time it  is worse than folly to
permit illness and  suffering to  go  unrelieved, the profession
brought  to discredit, and  money spent without  return, merely
because a sense of shame restrains the practitioner and binds his
tongue, when a feAv  well-directed  questions will solve the  mys-
tery.  To some men  this  is almost, if not quite, impossible ; and,
recognizing the fact, they should send their patients, for once,
at least, to some one aat1io Avill make  the necessary inquiries and
institute the much-needed line of treatment.  On the other hand,
there are men who put  their questions  so coarsely and rudely
that the instinctive modesty of  Avoman rebels  and makes her
dumb to her own detriment.  It is no unimportant matter to
learn how to put interrogatories on these  matters to Avonien
Avithout  making it awkward for them to answer.  If the prac-
titioner hesitates, then at once a difficulty arises: if he puts his 
THE REPRODUCTIVE SYSTEM.
457
questions in the same tone and manner in which  he asks after
the digestive  organs, then the ansAver will come readily, and
with a sense of relief to the answerer.  It is also very desirable
that the question should indicate that the inquirer knows what
he is about, and is  at home  Avith the subject; if aimless and
vague, a woman  quickly  discerns their Avortblessness, and an-
sAvers accordingly.   This is a little divergence from the matter
immediately in hand, but it  is not altogether unnecessary nor
without value.
  § 184. There are peculiarities connected Avith the reproductive
organs which  need consideration, and which separate them from
all  other  organs.  These peculiarities are  connected  with  the
functions of this system.  During a great portion of even adult
existence these organs are quiescent; but nevertheless they are
more  under the influence of  our  thoughts than any other part
of us.   Loose or lewd thought Avill induce an increase in  the
vascular supply  to  these  organs  in both sexes.   When  the
evolution of puberty converts the child into the man or woman,
the development of these organs gives a new direction to  the
thoughts of the individual, and  the mental horizon is croAvded
Avith vivid and novel images.  The consequence of this is that
in many cases  au  habitual unchasteness of thought is instituted,
though  this is by  no means the rule.   In all  except sexless
creatures, there are  general changes inaugurated which give
ultimately the characteristics of each  sex.  Vascular excitement
of these organs is often maintained to an abnormal degree, and
endoAvs the parts with an unwonted hyperaesthesia, far beyond
Avhat  is normal ; and this reacts again upon the nerve-centres
until a  condition of  irritability  is instituted of the most dis-
tressing character.   This  is communicated to the parts around,
and, as the old proverb said, Nee castus frequens mingit,so I have
knoAvn an  incontinent out-patient to be incapable of  retaining
her urine,  and obliged to partially  empty the  bladder Avhile
Avalking about in the streets in  consequence of the irritability
of the bladder-centres. Nor is it necessary that this should arise
from coition or the substitutes  for it;  it  is not unfrequently
found  amongst females Avho work Avith the double-treadle seAv-
ing machine, and who become so distressed thereby that they
often abandon this  form of industry altogether.  The exhaus-
tion of the system generally, and especially the nervous system, 
4f>8
THE REPRODUCTIVE  SYSTEM.
by this hyperesthesia and  morbid action  of  the  reproductive
organs, is such that a most pitiable  condition  ensues; which
frequently drives the sufferers to some medical adviser.  Thev
may come ready to reveal  the facts, morbidly voluble  about
their condition ; or they may come with some fictitious malady,
or outcome of their state, and  be resolutely determined to con-
ceal  the truth.   Xothing but Avatchful, observant  experience
will  or can guide the practitioner aright Avith the latter class of
patients; and yet it is most important to recognize the primal
mischief.
  §  185.  Anaphrodisiacs.—When  the  truth is revealed, and it
becomes apparent that the patient is  suffering from  debility or
nervous erethism, the result of abnormal erotic excitement how-
ever produced, it  becomes  necessary to  have  recourse to such
agents  as possess  the  poAver  of  reducing and  allaying this
abnormal state of matters.   For this end certain local measures
are necessary, and certain agents  given  by the mouth are desi-
rable.   As to the local measures, the cold hip-bath, the bidet, or
cold sponging, are all useful; indeed they should form as much
a part  of every woman's toilet as the washing of her face and
the brushing of her hair.   The modesty of English  girls often
leads them to neglect hygienic arrangements  of importance to
which  French women are  most  attentiA^e.  Even  injections of
cold  Avater in some cases would be  conducive  to comfort.   All
secretion  permitted to  remain  becomes  a  source of irritation,
Avhich  ought  not to be allowed to exist.  The boAvels, too, should
be regularly and  systematically unloaded, and  all irritation in
the rectum removed ; accumulations in the lower bowel ahvays
favor pelvic congestion  and excitement.  There should not he
too heavy skirts, etc., hung from the Avaist;  they prevent  the
return of blood from the parts  below the line of attachment,
and also heat the pelvis and its contents.  Soft luxurious beds
are also bad,  and  should  be avoided.    Horseback exercise,
though  otherAvise  healthful, in   many  girls  produce vascular
fulness in the pelvic viscera and a condition of unwonted activity
in the  generative organs which is undesirable.   (Mason Good.j
  Having taken such  measures  as affect the  parts locally,  and
relie\Ted  them from  the various sources of  excitation to which
they may have been subject, the  question  then arises of Avhat
to do remedially.   The first step  is to unload the bowels,  and 
THE REPRODUCTIVE SYSTEM.
459
especially the lower boAvels, for which  purpose aloes is specially
serviceable.  By its action, when given in purgative doses, upon
the hemorrhoidal vessels,  it relieves  the vascularity  of  the
reproductive  organs.   It  is  desirable, however, to combine it
Avith alkaline and  saline purgatives.  All saline purgatives are
anaphrodisiac, and more especially when alkaline.   In all cases,
then, Avhen there is erotic excitement Avith fulness and  tender-
ness of the ovaries, it is  desirable to give something of this
kind—
                     Soda? Sulph. jij.
                     Soda? Pot, Tart. ^ss.
                     Decoct. Aloes Co. 5J.
once or twice a day.   It should be given  until  the bowels are
rather freely opened,  and then continued  so  as to keep them
open without  actual  purgation.    In  a few days  the ovarian
excitement will  be much  relieved, and  Avith that  an  improve-
ment in the general condition will be inaugurated.  If it still
persist with local congestion and erotic excitement, then bromide
of potassium in  ten- or tAventy-grain doses may  be added to the
mixture; and this condition Avill be found sufficient to remove
the most obstinate congestion, if the treatment be energetically
followed out.
  In many  cases, however, the  pallor and  general debility
contra-indicate any depletory measures, and then the bromide of
potassium, or of ammonium, or hydrobromic acid, may be given
with a bitter tonic three times a day ; and the cold hip-bath, etc.,
be insisted on.   If purgatives are  inadmissible,  then cold water
enemata may be used to  unload the  bowels, especially at bed-
time.  If there  be any ascarides  in the rectum, then a weak
infusion of quassia may be used as an enema, and an occasional
dose of compound scammony powder may  be given ; this latter
treatment is often  necessary with young girls, where these seat-
worms are often the exciting cause  of irritation of the generative
organs.   Not uncommonly  they are the cause  of  much  erotic
excitement in elderly persons of both sexes.  Bromide of potas-
sium, or ammonium, are the best and most certain anaphrodisiacs
we possess.  Before their  introduction alkalies, colchicum, and
other less effectual measures, were in vogue.   In  addition to
these physical  measures, there are  moral measures of no mean
value. The avoidance of excitement and temptation, or removal 
160
THE REPRODUCTIVE  SYSTEM.
of residence, or travel, are often necessary.  The arousing of the
moral  sense is  very important.   In other cases idleness and
French novels must give Avay to more healthful excitement and
occupation, especially in those  where  the erotic  feelings are
rather central than peripheral  in  their  origin.  Matrimony is
often prescribed for those who actually suffer from involuntary
and constrained celibacy ; but it is a questionable piece of advice
to offer.  If there be a  perfect and thorough understanding
betwixt the contracting parties, then the objections fall to the
ground: too frequently there is an unjust reticence Avhich bears
bad fruit in the future.
  § 186. In consequence of the vascularity of the reproductive
organs, their position, and their function, the mucous lining of
these organs are specially liable to become atonic, and give forth
more or less profuse discharges.  In man this is rarely occasioned
otherAvise than  by impure connection, either during the cata-
menia,  or  when the woman is  suffering from leucorrhoea, or
gonorrhoea.  In  all these cases there folloAArs a form of urethritis,
generically  termed  blennorrhagia, in which  there is rather a
difference of degree than of kind.   At first there is SAvelling of
the mucous membrane, with  itching, burning, and smarting,
especially on  making Avater; then  folloAvs a  secretion, which
either gradually passes away, or remains for  long  in a chronic
condition, known as gleet.   The line of treatment of such cases
combines local  and general measures.   Soothing emollient in-
jections of warm water with a little  laudanum are useful in the
first stage ;  while the food should be bland and non-stimulating.
The boAvels should be kept open with  alkaline purgatives, and
invariably  unloaded at bedtime—a great  means  of avoiding
chordee, and other troubles in connection Avith the generative
instinct.  After each act of micturition the  urethra should be
Avashed out Avith warm water, slightly alkaline.  It is desirable
to render the urine alkaline by the administration of potash; and
also at the same time to  give certain agents Avhich  pass out by
the kidneys and exercise a beneficial effect upon the urethra, as
copaiba, sanclal-wood oil, or buchu.  If there be much nocturnal
excitement a morphia suppository in the rectum, or a  draught
of Pot. Brom. gr. xxv., Tinct. Hyoscyami 3j., Mist. Camphor. 3j.,
may be  taken  every night at bedtime.  After the secretion is
established  it is usual to resort to astringent injections.  It  must 
THE REPRODUCTIVE  SYSTEM.
461
 not be forgotten  that the discharge fulfils one  useful function,
 viz., it keeps asunder the inflamed mucous surfaces, which Avould
 otherAvise rub  on each  other, and  so cause much discomfort.
 The injection of a mixture of bismuth (trisnitrate) and Mistura
 Acaciae, so as to form  a soft  plug in the  male urethra, is in
 vogue in many of the  Continental schools of medicine,  and
 forms a plan  of treatment  much less  disagreeable  than  any
 other, Avhile it is very effectual.   When there remains nothing
 but  a gleety  discharge, astringent and  tonic  injections, with
 a liberal dietary, are the best measures to be adopted.  In many
 cases Avhere the secretion is profuse, antiseptic  injections  are
 often very useful.
   Much more frequent, and  more innocent  in their origin, are
 those discharges from the female genitals known as leucorrhoea.
 When the result  of  specific contagion, then they require  the
 same series  of  local measures  as are  requisite  in urethritis in
 man.  General measures, except cooling medicines, are obviously
 useless  in woman, as  the urine  does  not  traverse the affected
 surfaces;—Avonien, hoAvever, themselves think  differently.   In
 both sexes the ectrotic treatment of applying nitrate of silver to
 the inflamed surface, either in stick  or  in  strong solution, is
 undesirable,  being fraught  Avith untoward results.   In  the
 majority of women  leucorrhoea is the result  of carelessness,
 inattention to personal cleanliness, of excessive  use or irritation
 of the genitals ;  or of labor in Avarm rooms,  and of close, heated
 sleeping rooms.  With  many Avonien  the  hip-bath, or any sub-
 stitute for it, is probably never  used.  Industrious women in-
 habiting confined rooms  have intercostal neuralgia, the frequent
 accompaniment of leucorrhoea; they suffer  from perpetual  de-
 pression, and at the same time they are spare and pallid.   Such
 women almost  invariably have leucorrhoea,  and all attempts to
 treat them Avithout local remedies are  ineffective and futile.   In
 some cases the discharge is from  the uterus, at other times it is
 ATaginal.  Sometimes it is profuse and persistent, scarcely affected
 by the catamenia, except to acquire a pink tinge ; at other times
 it folloAvs the menstrual flow, or comes on  fitfully.  In all cases
 it is necessary to resort to injections.  If the discharge be slight,
 injections  of cold Avater merely Avill often  be sufficient to arrest
it, or a Aveak solution of alum  may be indicated.  When at all
profuse the vagina should be Avell Avashed out Avith cold or luke- 
162
THE REPRODUCTIVE  SYSTEM.
warm Avater ; after this the injection syringe should be filled with
a solution of some astringent, of which  alum  is the favorite*
and then the patient should lie down in the recumbent posture,
inject, and lastly  lie  still  tAvo or three minutes.  This last is
important, as if it be not practised the astringent fluid runs out,
and so does comparatively little good.  There is no subject con-
nected Avith themselves of which women are so  ignorant as that
of using an injection properly ; and yet it is often very desirable
that they  should  know.  Such systematic injection, first  of
water  and then of an  astringent solution, should be practised
tAvice  daily, as long  as any abnormal  amount  of secretion
remains; and then the daily practice of  injection Avith a weak
astringent  fluid should be continued for  some time afterwards.
The most scupulous ablutions of the genitals should be practised
by all.  Many, however, do not  know of its importance; some
are filthy and indifferent; Avhile others, as motherless girls, have
no one to tell them, and no one to ask.  To all  motherless girls
the medical man should ever be willing to give counsel, and to
give them Avhat they so much  stand in need of, viz., information
on these matters of personal hygiene.  Xot uncommonly barren-
ness  is  the consequence of leucorrhoea, and some women Avho
find this out are more anxious to retain it than  to do away with
it  It is not desirable that the injections be used  during the
catamenia.
  § 187. The entrance upon her reproductive period of life in
woman is  almost  invariably  accompanied by a certain amount
of disturbance of the general  health ;  its  cessation is not rarely,
if not  usually,  accompanied by a considerable amount of erotic
excitement, a period of active recrudescence of the generative
instinct.  Both periods  commonly produce such disturbance as
necessitates the calling in of medical aid.   The first change, or
puberty, is frequently accomplished under the circumstances of
rapid growth ;  and the double tax upon the system  produces in
many cases a distinct debility, Avhich may lead  ultimately  to
tuberculosis, or other wasting  disease.  Commonly  there are
recurring periods of lassitude, weight, and sense of dragging in
each groin, before the menstrual  Hoav is actually  established.
Under these circumstances it  is advisable to counsel the patient
to sit  over a vessel  containing hot Avater, or, if that be not
sufficient, to stay in bed and  have Avarm  cloths applied to the 
THE REPRODUCTIVE
SYSTEM.
463
 vulva;  this last is a powerful means of exciting a Aoav from the
 genitals, and is useful not only at puberty, but at  other times
 Avhen the catamenia have  been checked, as by cold ; and it is
 especially useful in any arrest of  the lochia.  (In the last case
 the application of hot cloths Avithout delay, on the  arrest of the
 lochial discharge, Avill often avert a grave condition.)  If these
 measures are  insufficient, it is  usual to give  iron  with aloes.
 There is no doubt that iron acts locally in these cases, as well
 as increasing the amount  and  improving the quality of the
 blood.  In many cases the addition of savine-oil is a satisfactory
 measure.  Savine is a poAverful  irritant and oxytoxic agent, and
 is used  in toxic doses to procure  abortion—a result which  it
 brings about, partly by its general  action as an irritant poison,
 partly by its local action.  In sniall doses it seems to maintain
 a condition of vascularity in the generative organs.   It is usual
 to combine  these measures in a  pill as follows:—
                      Fer. Sulph. Exsic. 9j.
                      01. Sabinaj, 3j.
                      Pulv. Pip. Nig.  5j.
                      Pil. Al. et Myrrh, ^iij.
 to be divided  into sixty pills, one to be taken twice a day after
 meals.  This is an  old and excellent formula.   It is desirable to
 give  such  a dose  of aloes  as shall produce slight  purgation,
 especially on commencing the course of iron.   This last is  an
 important matter for the attainment of success.   These pills may
 be continued until the catamenia are established, together with
 warm hip-baths;  and the  employment  of the measures  men-
 tioned above,  Avhenever there are the usual premonitory symp-
 toms of the  catamenial flow being about to come on.  The cata-
 menia, not  rarely, at first are irregular in appearance  and  in
 quantity, especially in some delicate girls; in others, again, they
 soon  are  profuse,and too frequent.  When the patient is a robust
 and plethoric girl, the induction of  the catamenia is often diffi-
 cult and  protracted, and  in such cases active general depletory
 measures, and the  application  of a leech  or two  locally, are
 indicated.
  In  other girls again, especially in those  that are delicate, or
anaemic, the delay in  the  appearance of the catamenia is rather
heneficial  than otherwise, and  need excite no apprehensions. 
464
THE REPRODUCTIVE  SYSTEM.
Mothers, especially of the humbler classes, are ahvays anxious
about the establishment of this function.  They know that the
non-appearance, or disappearance of  the menses  is often associ-
ated with the initiation of tuberculosis, or " decline" as they
term it;  and if the  flux is  initiated or restored it gives them
much comfort.  Important as the catamenial flow is in reality,
Avonien attach an undue importance to it and its  derangements.
  Where the pills given above  cannot be taken, then the old
mixture  of Mistura  Ferri  and  Decoct. Aloes Comp. may he
prescribed; this is  a piotent but nauseous  combination.  >so
purgative is so good as aloes for its  effects upon the  reproduc-
tive organs of women.  In small doses it excites the haemor-
rhoidal vessels, and Avhen so given Avith iron it is most useful in
anienorrhoeic states ; when given in full doses it acts freely on
these vessels, and when combined Avith other purgatives, espe-
cially  cooling  saline purgatives,  relieves  uterine  and ovarian
fulness famously.
  The reproductive organs of woman are the source of most
of her troubles during that pieriod of her life when  they are
functionally active.  Often Avill far-aAvay irritation in the womb,
or ovary, be  found to  be the  cause  of the most prominent ob-
jective and subjective phenomena manifested elseAvhere. Irrita-
tion is  not  always  felt  where  it arises;  the  pain is  very
commonly in the  knee Avhen the  disease  is in the  hip-joint; in
the right shoulder Avhen the liver is involved.   We know that
the pregnant uterus, especially in the early months before it has
escaped from  the pelvis, commonly  produces very troublesome
vomiting; or  it may  produce a persisting cough, known in
Scotland  as " a cradle cough."   Vomiting  is a  common out-
come of  injury to, or  acute mischief in the testicle ; as it  is a
pronounced symptom of a calculus  in the  kidney.  The old
term the " sympathetic nerve" was founded on the appreciation
of the fact that one part was influenced by, or sympathized with
another through the fibrils of this nerve.  Currents may arise
in the ovary and be  felt—not  there Avhere they  arise—but at
some far-distant point, Avhere they  run  out.  If  a  number of
ivory balls be suspended in a  row, touching each other, and a
tap be given to either terminal ball, it is the one at the other
end which flies from  its pil ace.   Consequently waves  of nerve-
perturbation, arising in the ovary, manifest themselves by dis- 
THE REPRODUCTIVE  SYSTEM.
465
turbances elseAvhere.   The  glittering flash  Avhich glances out
from some female hides is  the external indication of ovarian
irritation, and " the ovariau gleam" has  features quite its oavii.
The  most marked instance  which  ever  came  under my notice
Avas due to irritation in the ovaries, Avhich had been forced down
in front of the uterus, and been fixed there by  adhesions.  Here
there Avas little  sexual  proclivity,  but the  eyes were very re.
markable.  They Hashed and glittered unceasingly, and at times
perfect lightning-bolts  shot from  them.   Usually there  is  a
bright glittering sheen  in them Avhich contrasts Avith the dead
look in the hides of sexual excess, or profuse uterine discharges.
Cough, palpitation, face-ache,  usually on the  right side, infra-
mammary pain, usually in the left sixth or seventh intercostal
nerves, and  gastric irritation are the ordinary  outcomes  of
uterine flexion,  or ovarian  disturbance.   The most important
matters clinically are  the gastric symptoms  reflexly excited by
pelvic irritation.
   In § 164 reference is briefly made to " the reflex disturbances
in the stomach."   So  important  and so  common  are these
maladies, and so  utterly unsatisfactory  their treatment under
the usual remedies—as bismuth,  hydrocyanic  acid, oxide  of
silver, etc.—that they deserve to be treated at some length.   In
the first pjlace the stomach has different nerve-fibrils—those from
the vagus, and  those  from the sympathetic.   Claude Bernard
observed that the application of a galvanic stimulus to the vagus
fibres caused free secretion of the gastric juice; Avhile the same
stimulus apiplied to the sympathetic fibrils issuing  from the
semilunar ganglia, caused a diminution and complete arrest  of
the secretion.  The action of  sympathetic  nerve-fibrils is  to
excite  contraction in the arteries  and  arterioles; that  of the
pneumogastric fibrils  to dilate these vessels.  Consequently we
can readily  understand how currents coming in by the sympa-
thetic  tracts from pelvic, or other irritation, may contract the
gastric arterioles, and  arrest the Aoav of gastric juice.   If the
irritation be sufficiently powerful, then vomiting is set up.   In
ordinary digestion the gastric blooch^essels are  dilated and there
is a free Aoav of gastric juice.   The  irritation coming in from
without,  checks both  these  processes, and then imperfect diges-
tion with pain, or nausea, is the result.  This  may not  proceed
further than loss of appetite,  dyspepsia, and  nausea ; or there
       30 
460
THE REPRODUCTIVE  SYSTEM.
 may be severe persistent vomiting set up by the introduction of
 food  into  the stomach, till a  very serious  condition  may  he
 reached.  In  either case the tongue is clean, and there are no
 evidences of  disturbance  in  the gastro-intestinal canal, as  in
 primary gastric disturbance.  Such is the dyspepsia  so common
 in women.  Primary dyspepsia is no more frequent in Avonien
 than in men, and presents the same features in both sexes.  But
 reflex  dyspiepsia  has other and quite different associations,  hi
 both forms of dyspepsia there may be constipation, or diarrhoea,
 excited by  the  undigested food  irritating  the  intestines; but
 these are incidental or coincident collaterals.  In reflex dyspepsia
 there are usually the intercostal neuralgia, Avith the three tender
 spots of Yalleix, one under the mamma, the second  at the base
 of the left scapula, the third at  the exit of the posterior root of
 the sixth or seventh intercostal  nerve from the spinal column;
 and  palpitation.   Less  commonly face-ache  or cough, and in
 middle-aged women flushings.   Then there are the uterine out-
 comes  of the ovarian mischief—leucorrhoea, with or Avithout
 menorrhagia; while at times the menstrual  flux is  lost, or all
 but lost, in the profuse  leucorrhoea.  The generative organs of
 women become turgid with blood during sexual excitement, ap-
 proaching the erectile condition of the male organ under excite-
 ment.  Ovarian irritation sets  up vascular turgescence in the
 female parts which continues more or less  persistingly.  The
 consequence is that there is profuse secretion, often with excessive
 catamenial losses.  Frequently too there are  erotic dreams, re-
 current orgasms,  during sleep, " the period par excellence of reflex
 excitability."  In more pronounced cases, these discharges take
 place  in  the waking state, Avithout any reference to psychical
 conditions; being found alike in married women cohabiting with
 their  husbands, and in  spinsters and Avidows. That sexual ex-
 citement may be  produced or kept up by lewd thought may not
 be denied;  but this is not necessarily the psychical attitude here.
 The uterine centres in the cord and the centres presiding over the
 bladder lie in  close proximity to each other.  The irritable con-
 dition  of the lumbar centres of  the reproductive organs is com-
 municated to the vesical  centres, and then  a very  distressing
condition results, viz., a state of  weakness and irritability in the
bladder; and the call to  make  water is sudden and  imperative
and must be attended to at once, or a certain penalty be paid for 
THE REPRODUCTIVE SYSTEM.
167
 non attention.  Such are the objecthTe and subjective phenomena
 exhibited in a complete case of " reflex dyspepsia" of ovarian
 origin ; and it is by the study of such well-marked cases  that
 the student Avill learn to recognize the less marked or imperfect
 cases.   JSTor does it  necessarily folloAv that  the symptoms shall
 stand in a definite proportion to  each  other in each and every
 case.   Sometimes the  chief  disturbance  is  uterine, at other
 times  mainly gastric.   When the latter, the case often runs as
 folloAvs: a girl, usually of the neurosal diathesis, betwixt nine-
 teen and tAventy-four years of age, becomes the subject of intract-
 able vomiting.  This  goes on till such Aveakness is piroduced
 that the patient is confined to  bed  and  her life  apparently
 endangered.  The least particle of food is immediately rejected,
 more or less completely.  All sorts of combinations of drugs
 are tried, and fail to procure any alleviation of the condition.
 The medical attendant  is nearly worried out  of his life, con-
 sultants  are called in Avithout avail;  the friends of the patient
 are worked up to a state of feverish anxiety ;  the  sufferings of
 the patient are not inconsiderable ; and so the  case Avears  on for
 weeks.  Bismuth, hydrocyanicacid,opium,effervescing mixtures,
 champagne, milk and seltzer water, beef-tea, hot and cold, raw
 meat pounded, nialtine, all are tried and fail; sometimes enough
 is retained to support life; at other times it becomes necessary
 to resort to nutritive enemata.   All Avho have  seen  much prac-
 tice are familiar Avith  such cases, Avhich are very  trying to all
 parties concerned, and are unaffected by the different remedial
 measures resorted to;  and  which  seem at  last  to wear  them-
 selves out, and are folloAved by long and tedious convalescence.
 A year or two afterwards the patient is in good  health, often a
 happy  mother.   Here the absence of  local indications throAvs
 the medical man off  the scent  as to  the  real nature of  the
 malady with Avhich he  is brought in  contact, and the ovaries
 are unsuspected.  All the remedies are futile  and inoperative
 because not directed to  the origin of  the  trouble.  The case
 lingers on till it would  seem the general mal-nutrition starves
 down  the congested  ovary  into quietude, and  then  the  reflex
 disturbances cease.  Were the  true origin of  the  case known
 or discovered,  then the successful treatment  Avould soon  be
forthcoming.  As a  case  in point  I may mention a girl Avho
came under my care some time ago at the West London Hospital. 
468
THE REPRODUCTIVE  SYSTEM.
For  many months she  had been  under medical treatment for
persistent retching and vomiting.  The girl Avas pale and amende,
Avith lack-lustre eyes, and a peculiar but characteristic expres-
sion, Avhich may be observed but cannot be described, indicative
of ovarian trouble.   The left  ovary Avas found congested  and
exquisitely tender, pressure over it almost producing syncope,
and  exciting acute  nausea.  The ovary Avas treated and in ten
days the  girl left the Hospital—Avell;  but  I doubt  if perma-
nently cured.
  What is the  treatment of these cases?  It consists of several
factors  each  essential and complementary  to the others.   The
boAvels  should  be unloaded, so that  there shall be  no pelvic
congestion.   A small quantity of sulphate of magnesia in each
dose of medicine will  usually attain this end.  If  not quite
sufficient  an aloetic pill  at bedtime  is indicated.  In small
doses, as said before, aloes excites the haemorrhoidal vessels; in
fuller doses it depletes them.   The boAvels should be emptied at
bedtime.  A load in the bowels during sleep produces vascular
turgescence in  females whose  reproductive  organs are out of
health; just  as it produces chordee in  a man with gonorrhoea.
Then comes the other factor—the reflex manifestations.  Instead
of treating  the stomach, an agent must  be given Avhich  Avill
influence  the nerve tracts  over Avhich  the perturbatory Avaves
travel.  Bromide of potassium deadens the  nerve  fibrils, alike
along their course and at their peripheral endings.  Both at the
periphery in the ovary and at the  terminus in the stomach is its
influence  felt.   It blunts the  nerve endings while it  deadens
the conductive poAver of nerve fibrils.  (§ 125.)   Consequently a
combination like the folloAving is useful:—
                   Mag. Sulph.  9j.
                   Potass. Bromidi, 9j.
                   Mist. Camphorae, 3J., ter in die.
If the  stomach reject this a hypodermic injection  of half, or a
third, of  a grain of morphia  Avill usually produce such effects
that the stomach Avill tolerate the  medicines.  Xutritive enemata
may be needed for  a day or two.  As soon as the bromide is
tolerated and  retained, matters improve.   Sometimes it is well
to substitute infusions  of gentian for the camphor  mixture as a
vehicle ;  it acts beneficially upon the stomach, as do  all bitters,
and renders it more tolerant of the medicines.  Local treatment 
THE REPRODUCTIVE  SYSTEM.
469
 in the shape of a blister over the tender ovary is of much value;
 not only  does  it  produce a mental impression,  but Ave  have
 reason to suppose that  nerve-Avaves can meet and  neutralize
 each  other — like  rays  of light — under certain  circumstances.
 The ordinary Emplastrum Cantharidis 2x2 applied over the
 offending ovary, on  going to bed, Avill  usually be found to pro-
 duce  vesication by the morning.  Some slight  soreness follows,
 but the relief afforded to the internal pain far outweighs this.
 In some rare instances a crop of boils folloAvs the blister; but
 so rarely as not to militate against its use.   By these measures
 combined the reflex gastric disturbance is effectually  removed.
  There remains the leucorrhceal loss to be considered,  llio-o-in-
 son's  syringe, or the common  enema  syringe for infants, are
 preferable to the  glass syringe, which is brittle, and accidents
 sometimes occur.  First  an  injection of pdain water to remove
 all discharge, and  then of a little alum water, not stronger than
 an ounce to tAvo quarts of water, will  usually soon reduce the
 loss.  If there be  also menorrhagia  the usual  measures (§ 190)
 must  be adopited.
  § 188. The decline of woman's reproductive life  is  termed
 "the  menopause." It is a very important  epoch in  a woman's
 career.  It is then that constitutional  exhaustion, as repeated
 childbearing, &c, shows  itself in  broken, disturbed  health.
 Then it is that constrained celibacy reveals the strain to which
 the system has  been subjected; and nymphomania, or impru-
 dent and reckless attachments are common enough at this time.
 The insanity  to Avhich so many  spinsters become  subject at this
 period is  usually  erotic  in its  nature.   There is a flashing out
 of the  sexual instinct  before it  is extinguished, and  woman
 becomes once more a sexless creature.
  At  times  the disturbed health precedes irregularity in  the
 catamenia, at other  times menstrual  irregularity of various
 forms precedes any disturbance of the general health.  Women
 often  alloAv themselves to drift into a bad state of health about
 the  time of the change of life,  thinking it  is the change.   In
 this condition the actual change comes, and tells  hardly upon
 them  in their reduced state.  If there is any suspicion that this
 change  is at  hand—and an inquiry into  the history of the
patient's family in this respect will often  give useful infor-
mation—then it is desirable to place the patient under strict 
170
THE REPRODUCTIVE  SYSTEAl.
orders, and to guard the health most vigilantly.   Even if there
be no actual ill-health, it is Avell to take all measures to prevent
any breakdoAvn; the better the health of every woman on enter-
ing this period, the less Avill she suffer during it; if the health
be broken to commence Avith, then there will be much suffering
and ill-health ere it be accomplished.  In the majority of cases
the most Avatchful care is desirable, and the avoidance of illness
is as important as is its relief.   If the catamenia be profuse, it is
as Avell to restrain this by  astringent measures, as a little gallic
or sulphuric acid, with extract of ergot, in  infusion of cinchona,
a feAv days before the flux  is expected ; if this binds the bowels,
it is Avell  to  combine  Avith it a sufficiency of sulphate of mag-
nesia to keep  the boAvels  open.  It is often  more efficacious to
restrain the loss of blood, than  to make up  the blood during the
interval by ferruginous preparations.   There is one thing, how-
ever, to be borne in mind about the use of pmrgatives during the
menopause, and it is this: all  cathartics and laxatives must he
combined with carminatives in considerable quantities, else they
will certainly disagree Avith the patient.  There  is a great ten-
dency at this  time to flatulency, and, unless  the  purgatives are
accompanied  by full doses  of black pepper, cayenne, pepper-
mint, or some similar agent, each  dose of medicine will cause
flatulence and griping; the latter  often to a very troublesome
extent.   The  remembrance  of this fact will  often stand  the
young practitioner  in good stead  Avith an  important class of
patients.  There is very apt at this time to be much palpitation,
best treated by a little digitalis and bromide of potassium, and a
belladonna plaster; dyspepsia, requiring a avell-regulated dietary;
constipation, to be treated a3 above; and a good  deal of mental
depression and neuralgia.  If there is also, as not rarely happens,
a profuse discharge, then the measures to be shortly mentioned
as appropriate to menorrhagia, should be employed.  For two or
three years, in  many cases, the health at this time must meet
Avith the most  sedulous care,  and  the  results will  Avell repay
the attention so bestowed.  There is often a long period of good
health and enjoyment of life after this stormy epoch, well Avorth
the purchasing by a little  extra care at the time.
  § 189. Arrest of the menstrual flux is always an important
matter, and  needs  looking to.  Xot  unfrequently  there is a
vicarious Aoav,  complete or incomplete, as in haemoptysis, for 
THE REPRODUCTIVE SYSTEM.
471
 instance, or in haematemesis; and much needless alarm is often
 created thereby.   At other times it is the result of exposure to
 cold during the period, or perhaps even of deliberate stoppiage
 by some foolish girl in order to go to a ball or some other amuse-
 ment.   (Dr. Dewees.)  Under  these circumstances the disturb-
 ance of the general health is often considerable;  but whatever
 it is, and whatever the measures adopted to relieve it, it must
 ahvays be borne in mind that the most effectual of all measures
 is to restore the Aux.   If consulted sufficiently early the prac-
 titioner Avill do Avell to advise hot hip-baths, hot cloths  to  the
 vulva,  &c.; if the Aoav  can be re-established all  usually goes
 well.  If  too  late, or the efforts are unsuccessful, then the case
 must be Avatched, and when the  next pieriocl becomes due,  the
 same measures are to be repeated. If this Avere only sufficiently
 well known and practised, much ill-health and suffering Avould
 be saved.   At other times the arrest is due to general ill-health,
 or confirmed anaemia.  At times the loss of the catamenial Aow
 seems  to  leave the system undepurated, as it ought to  be, and
 normally  is,  thereby ; and these  retained excreta cause span-
 aemia,  or the anaemia spoken of in Chapter III. as the result of
 impaired  excretion.  Under these circumstances it is desirable
 to resort  to the measures given  above in § 187.   In cases of
 pronounced anaemia it is often Avell  to add arsenic to the ferru-
 ginous  medicines, in the form  of the ordinary Avhite arsenic, to
 the pill (last given), about a fortieth of a grain in each ; or in
 solution to  the mixture.  Sniall  repeated doses of arsenic  are
 often of the greatest Aralue in a course of steel and laxatives;
 and if  such course does not seem to be beneficial, arsenic should
 ahvays  be added.   In many cases amenorrhoea is an indication
 of failing health, and its treatment then merges into that of  the
 general condition.
   Scanty  menstruation  is  often  a normal condition,  which
 should not be  rashly interfered with.  During rapid growth, or
 pronounced anaemia, or early phthisis, the loss entailed by  the
 usual catamenial Aux forms a drain it is well to permit to remain
 limited; and attempts to restore the Aux until the system gene-
 rally is  equal  to it are unfortunate—when they happen to  be
successful.   If the  treatment  by  tonics, chalybeates, and a
liberal  dietary succeed  in restoring  the menstrual Aow,  by
producing general improvement, good and  Avell; the  reapi- 
472
THE REPRODUCTIVE  SYSTEM.
pearance of the discharge  is a sign  of good omen.   But any
attempt to restore the discharge pur et simple Avithout  regard
to the general condition Avith which it is associated is harmful
where it is not futile.
  If amenorrhoea be persistent in spite of Avell-directed measures
continued for some time, then it is as Avell to examine the patient
to see if she be normally formed.  It occurred to a friend of the
Avriter's to so examine a patient, Avho had been under treatment
for three years  for delayed menstruation under another prac-
titioner.  This at  once cleared  up  the difficulty—the girl had
no vagina.
  § 190. Menorrhagia is a serious as  AA^ell  as common ailment
among women.  It  arises  in a variety of ways.   It is casually
associated Avith soft, luxurious beds ; Avith the hanging of heavy
skirts around  the  waist;  with labor in moist, warm rooms, as
seen  in laundresses, and with  toil  in warm  or close rooms, as
seen in  mill-girls and  maids-of-all-Avork, avIio are more subject
to menorrhagia than the servants of large establishments, except-
ing  cooks:  it is found as  one  of the consequences of cardiac
failure Avith resultant venous congestion; it is not unfrequently
the consequence of erotic excitement in young girls, and of imper-
fect, or unattainable, as well as excessive coition in adults; or
it may be the result of some more  serious  condition, requiring
the manipulative interference of the obstetric physician.  In all
cases it must be regarded with relation to  its causation, if we
Avish our medicinal measures to be successful.  Amidst the bulk
of the profession,  especially of the  past generation, the  matter
of  menorrhagia Avas  too  commonly  ignored, or  women were
taught  to regard it as  a condition against which the therapeutic
art Avas p>OAverless.   Never  did a more pirofound mistake exist:
for this ailment is one of the  most tractable of maladies ordi-
narily; provided  the treatment  be thoughtful and  judicious.
What the different lines of treatment are will iioav be given.
   One of the commonest forms of  menorrhagia in out-patients'
rooms is that furnished by young girls, from fifteen to eighteen
usually, avIio are unwell, and freely so, from five to seven days.
There is nothing about them to indicate the necessity for, or the
desirability of such a drain.  It is the outcome of erotic excite-
ment, and not rarely of evil practices resorted to in order to pro-
cure relief.   Under these circumstances the use of the hip-bath 
THE REPRODUCTIVE  SYSTEM.
473
 and astringents are inferior  in value  to  the  use of anaphrodi-
 siacs, and especially of the bromide of potassium, or ammonium.
 These remedies lessen refiex conduction, and  act strongly upon
 the peripheral ends of afferent  nerves.   Consequently there is
 less local sensation and diminished erotic feeling, as Avell as less
 centric activity, and as a result of this, less vascular excitement
 of the  generative organs, and a moderate menstrual floAV.  In
 fifteen  or thirty-grain doses thrice daily, bromide of potassium
 will exert a most powerful effect  over the menorrhagia of the
 young, especially if at the same time the boAvels be attended to
 by sulphate of magnesia Avith alkalies, the vehicle being cam-
 phor mixture, or if desirable a vegetable bitter.  ISTot rarely a
 perfect suspension of the catamenia is  the result, and in  cases of
 rapid groAvth, etc., such a consequence is far  from undesirable.
 The Avithdrawal of the bromide is soon folloAved by the reap-
 pearance of the flux.   In many cases of anaemia in young girls,
 associated  with  heavy monthly  losses,  it is  desirable  to give
 some chalybeate  remedy together  with the  bromide.  The
 potassio-tartrate  of iron  goes Avell Avith  bromide of potassium
 in these cases; and  the  bromide seems  to prevent too much
 action of the  iron upon the reproductive  organs, Avhile the iron
 tends to improve  nutrition ;  or hydrobromic  acid Avith  quinine
 may be given instead.
   In more  mature  adults, and especially in married Avomen,
 menorrhagia  is more commonly the result of debilitating con-
 ditions, or occasionally of excess.  Under these circumstances
 another line of treatment from that described above is necessary.1
 The leading idea here is to moderate the  loss  by astringent and
 other measures, not anaphrodisiae. In order to produce the best
 effects,  it is Avell  to divide the treatment into  tAvo sections, viz.,
 the treatment of the period  and  the treatment of the interval.
 To commence Avith the treatment of the period : it is Avell for the
 patient  to avoid all  exertion, to keep  as  quiet as possible, and
 certainly to avoid all straining  at stool.   Then all food should
 be taken as cold as possible; tea, milk, soup, everything should
 be cold, or even iced.  It is the  common  practice of Avomen to

  1 Under certain given circumstances the bromide treatment is indicated in
elderly women, especially at the menopause : indeed, wherever there is ovarian
excitement. See §187. 
171            THE REPRODUCTIVE SYSTEM.

drink hot tea as a stimulant in the depression produced by the
loss; and the  consequence  is  that while  they experience an
immediate sense of relief of a brief character, in a few minutes
there is a profuse flow.  The well-knoAvn effect of heat upon the
heart, increasing its activitv, as Avell as its effect in enlarffino-
the calibre  of bloodvessels,  renders  this  result  intelligible
enough,  as Avell as  explaining the good effects of  cold fluids.
In addition to these measures it is Avell to give an astringent
mixture, as the following :—
                      Mag. Sulph. ^ij.
                      Ac. Sulph. Arom.  1u_xx.
                      Inf. Quass. 5J. ter in die,
regulating the amount of the magnesia to  the requirements of
each individual.1   If there be much suffering, a feAv drops of
laudanum may be added to the  mixture.  If the  loss be still
profuse it may be  desirable to add at bedtime this pill—
                      Cup. Sulph. gr. £-1
                      Pulv. Opii, gr. 1
                      Ext. Al. Aquos. gr. ij-iij.,
and even to take it again first thing in the morning, if necessary.
It is a.point  of moment to  so  combine  the astringents Avith
laxatives as not  to lock up the boAvels.   If the loss be  very
profuse  and persistent, the  application of cold cloths to the
vulva may be  indicated.  Just as hot cloths so applied increase
the discharge, so  cold  ones tend to arrest any flow from  the
genitals: it is  not desirable to apply  these cold cloths unless the
discharge has  persisted for  several days and is profuse.  Even
cold astringent  injections  may be  found  necessary.   If  the
menorrhagia has existed for some time, it may be found a  good
plan to* commence the  treatment of the period  a  day or  two
before its actual appearance, Avhether the case be one for astrin-
gents, or anaphrodisiacs.
  Xext, Ave come  to the treatment of the interval.   If there be
leucorrhoea, astringent injections must be assiduously practised,
as given in § 186, during the Avhole interval betwixt each period.
The patient must sleep on a hard bed, Avith  but light bedclothes;
no treatment is efficacious if the patient lie in soft feather beds,

  1 Sulphate of magnesia exerts an astringent action elsewhere than in the bowels.
It can thus often be profitably combined with astringents. 
THE REPRODUCTIVE SYSTEM.
475
 Avhich heat the pjelvic organs extremely.  The boAvels must be
 kept open, and in many cases, especially Avhere there is much
 neuralgia, facial or intercostal, chalybeates must  be combined
 Avith laxatives.  It is not improper to give iron in  menorrhagia,
 but it is desirable to restrict it to the interval, and to use some
 astringent form.1   In  many cases a few drops of digitalis, or a
 close of Liq. Ext. Ergotae, may be added  to the mixture, both
 during the period and the interval, Avith advantage.  Dickenson
 found digitalis very useful in such cases.   In the case of married
 Avomen it is often Avell to forbid  all marital intercourse;  other-
 Avise, the treatment is often inefficacious.  By the union of these
 different measures, and a Avatchful attention to  the case so as
 to make the different changes as soon as ever they are indicated,
 most cases of menorrhagia can be cured, or at least much relieved.
 When it is the result of heart-failure, then digitalis and  tonics
 should be exhibited freely.
   There is, however,  one class  of  menorrhagic women  whose
 malady is extremely intractable.  They are usually  stout Avomen,
 Avith large and full abdomens.  They  are usually troubled with
 flatulence, and have either constipation or diarrhoea.  They are
 either AvidoAvs, or their husbands are either partially impotent, or
 away for long intervals.   In some cases coition is imperfect from
 the  use of the condom.    In almost  all these cases there is
 enlargement of the Avomb, ahvays excessive menstrual flux, and
 usually leucorrhoea.  That  such  cases should be  intractable is
 no matter for surprise.  The patients, hoAvever, are generally
 little benefited by treatment; they are pleasant patients enough,
 but, in my experience, there is but little to  be done for  them.
 The  condition takes its origin in local derangements themselves,
 arising from causes Avhich do not admit of removal.  (See p. 298.)
  In the treatment of menorrhagia, no matter of what form, it
 is ahvays a good plan  to  relieve the  anaemia and improve  the
 general condition, by moderating the loss.  If this be not checked
 the state of anaemia is perpetuated ; the making of blood during
 the interval is rapid, especially under the spur of chalybeates,
and  thus a condition  of  alternating  loss and SAvift repair is
instituted.   For such a state  it is  much better  to substitute a
more even and regular condition; and this is often best secured

           1 Avcling finds arsenic very useful in menorrhagia. 
476
THE REPRODUCTIVE  SYSTEM.
by checking the loss, and not  spurring on blood formation in
the interval.   There is another point, too, worth  remembering
in the  matter of  menorrhagia, or  any uterine hemorrhage, and
it is this: syncope is the natural treatment of hemorrhage; and
Avhen there is profuse loss, this is not to be treated as an evil.
The patient should be allowed to faint, and to come round again
quietly.  It has fallen to my lot to see such hemorrhage met by
lifting the patient up, or propping her up, and dosing her with
brandy till she nearly died of loss of blood. The spirit acts upon
the heart, more blood is pumped  into the arterial system, and
then drains away; and  a much more profound blood-loss is so
secured than if the patient Avere to  be left alone, and  nothing
but iced water, or iced  lemonade, with a few drops of  dilute
sulphuric acid administered.   The raising of the head induces
cerebral  anaemia, by the falling  away of  the blood into  the
unfilled  \Tessels of  the trunk and  abdomen,  while the  blood
drains aAvay all the more from  so falling away by gravity.  The
head should be left  low, and the feeling of faintness, or  actual
syncope, should  not  be  relieved  by the exhibition of alcohol.
(P. 239.)  This rule  holds good of haematemesis and other forms
of  internal  hemorrhage.  The injection of cold Avater  into the
bowels is often of service in the  case of internal hemorrhages.
Astringents and  cold are excellent  agents, but these are much
more efficacious Avhen combined with thought  and a fair knowl-
edge of pdiysiology.
   § 191.  Dysmenorrhoea is  a painful  and distressing condition.
It may precede or persist through the menstrual p>eriod.  Usually
it precedes the appearance of the discharge.   The pain is often
so  acute as to cause  the sufferer to roll about the floor in  agony.
The treatment ordinarily adopted  in all countries  is to give
alcohol with hot water under these circumstances.  The relief so
afforded is often  very great, so much so that the late Sir James
Simpson asserted that this constituted  the Avorst feature in the
treatment.   The relief afforded by alcohol in this condition, he
asserted, Avas one of  the commonest causes of ultimate excess'we
indulgence in alcohol by Avomen.  Having learned to resort to
 it then, he declared they Avere led to resort to it at other times;
 and he  advocated strenuously the  use of any other stimulant
 than  that Avhich is at  hand in almost every sideboard.   Sal 
THE REPRODUCTIVE SYSTEM.
477
volatile, spirits of chloroform, anything, indeed, but alcohol, he
advised, as being equally efficacious, and being free  from the
dangerous allurement of the other.  Amidst Avomen there exists
a Avidespread  belief in the  virtues of pennyroyal in  painful
menstruation.   The Oleum  Pulegii is a harmless remedy in
ordinary doses, and  a feAv drops at  these times may be recom.
mended Avith advantage;  especially as orthodox  medicine has
nothing to substitute for it.  Hot drinks, the AA^arm hip-bath, or
warm cloths to the vulva, are all useful, to some extent at least.
When there  is a thick membrana decidua  throAvn off at each
period, a process like that of parturition is unavoidable.  For its
relief special obstetrical treatises must be consulted.   At other
times, clysmenorrhcea  arises from  too narroAV a cervix; the
treatment here also is  beyond  the  spdiere of the  piresent work.
Not rarely dysmenorrboea is the consequence of latent gout—is
one of its manifestations, indeed.  Here the treatment of gout is
necessary for the relief of the local malady.  At other times the
dysmenorrhcea is ovarian, and  the pain shoots doAvn  the thigh
in acute paroxysms, while the ovarian region is painful and
tender to  the  touch,  often  acutely so.   Here  the  measures
described in the last division of § 187  must be adopted.
  There is much more that might be said about  certain condi-
tions  of the reproductive organs in women, as about misplace-
ments of the uterus, etc.   It is obvious that when misplacement
of the Avomb is the cause of any unpleasant symptoms, its re-
placement is the rational practice.   Hoav this is to be done, and
Avhat  are the lines of treatment of  many maladies incidental to
pregnancy, the management  of the act of  parturition, and of
the puerperal state,  cannot be entered upon here.  All that may
be said is that in pregnancy  many  of the  troubles arise from
irritation  caused by the enlarging womb, and then—the cause
not admitting  of removal—it  is desirable to check nerve-con-
duction, and arrest reflex action by the administration of bromide
of potassium, hydrate of chloral, or those other remedies which
Ave have seen in Chapter XIII. to diminish action in the nervous
system.   In the vomiting of  pregnancy it is also of moment to
give the food in such small quantities  at once that the stomach
will tolerate its  presence, reducing the amount to  what the
stomach Avill tolerate, no matter to how small a quantity it must 
478           THE  REPRODUCTIVE  SYSTEM.

be diminished.   By perfect quietude in bed much toleration is
given; as Avell as the wants of the system being  thus reduced
to a minimum, and the necessity for food thus being lessened.
  The propeer management of the troubles  to which  Avomen are
liable in consequence of their  sex  is of the utmost importance
to all, and especially to young practitioners. 
CHAPTER XIX.
                    THE CUTANEOUS SYSTEM.

   § 192.  Before considering the diseases of the skin, it will be
 Avell to revieAv some  matters concerned with its physiological
 function  as a secreting  and excreting organ.  The skin is not
 merely the sensitive covering of the body, but possesses great
 functional utility.   'We saAv in Chapiter III. that  in loAvly forms
 of life the outer surface is also the general  excretory surface,
 and that  the various specialized excretory  organs of higher life
 are but involutions of the general tegument; preserving in the
 midst of  their specialized action more or less of their primitive
 function,  and so capable of supplementing each  other's action
 when  deficient or arrested.  The skin  aids  the lungs  in  the
 excretion of carbonic acid Avhen the  lungs are  disabled by
 disease.  It also possesses, to a large extent, the same power to
 excrete nitrogen  that is usually  assumed to be the peculiar
 property of the kidney.   The poAver of  the skin to  excrete urea
 has been alluded to at p. 71, and Carpenter says (§  420, op. cit),
 "There is reason to believe that at least 100 grains of azotized
 matter are excreted from it daily ; and  any cause Avhich checks
 this excretion must throAv additional  labor on the kidneys, and
 will be likely to piroduce disorder of their  function." Thus Ave
 act freely  upon the skin when  the  kidneys are insufficiently
 active, or  crippled  by disease, and so unequal to their duty of
 blood  depuration.   It will not be  necessary here  to  pursue
 further this subject of  acting upon  the skin as an excretory
 organ ;  it  has been  fully discussed in Chapter III.
   In Chapter IV. the utility  of the cutaneous surface  in dis-
 sipating heat, in maintaining a normal  temperature in  health,
 and in reducing pyrexia, Avas reviewed.   The loss of heat in the
 evaporation of the Avater thrown out by the sudoriparous glands
is very considerable; and consequently in piyretic conditions Ave
 not only attempt to reduce beat-production, but Ave also essay
to  increase the  heat loss by exciting further activity in these 
480
THE CUTANEOUS SYSTEM.
glands.   For these ends Ave resort to a class of agents  termed
diaphoretics.
  The Theory of Diaphoretics.—The means of acting upon the
skin, so  as to increase the amount of fluid excreted by the sudo-
riparous glands, are various.  They include the application of
external heat and the administration of certain medicinal agents.
H. C. Wood states,"The skin undoubtedly eliminates medicinal
substances," but Ave do not  administer diaphoretics so much on
the hypothesis that these agents produce diaphoresis by exciting
the sudoriparous glands  into activity for their secretion (the
mode of action of some diuretics on the kidney), as that  they
exercise some action through the nervous system, especially the
vaso-motor system, and so excite diaphoresis.  The nerve arrange-
ments of the  cutaneous vessels, and  the sudoriparous  glands,
have not been sufficiently thoroughly  investigated  for any very
positive statement on this head.  There is, however, no fact in
therapeutics better established  than the diaphoretic action of
aconite, antimony, opium, and guaiac, etc.   Some  diaphoretics
are also  nauseant and depressant agents, lowering the circulation
as Avell as increasing activity in the sudoriparous glands.  Under
conditions of depression there is a tendency to perspiration, and
in great anxiety there  is an increase in the amount of water
exuding through the skin ; as seen so frequently in candidates
for  examination  when  before the examiners.   "The secreting
action of the  skin is  influenced  by general conditions of the
vascular and nervous  systems, which are as yet ill-understood.
It is quite certain, however, that  through the influence of the
latter the secretion may be excited or  suspended ; this is seen
on the one hand in the state of  syncope, and in the effects of
depressing emotions, especially fear,  and its more aggravated
condition, terror; and on the other, in the dry condition of the
skin during states of  high  nervous excitement."  (Carpenter.)
In syncope and in angina pectoris beads of SAveat collect on the
pallid skin, and demonstrate that perspiration  does  not neces-
sarily depend  on a highly vascular condition of the skin, but
that it may be found Avhere  the skin is blanched and cold, from
lack of  arterial blood.   The nerve arrangements of the sudori-
parous glands have only yet been partially demonstrated, but it
seems very probable that these glands possess  secretory nerves
Avhich may be acted on, and excite secretion, Avithout any neccs- 
THE CUTANEOUS SYSTEM.
181
 sary apparent increase  of  vascularity in the skin.  The laro-e
 plexus of capillaries at the base  of each sudoriparous gland
 enables this to be brought  about.
   On the other hand, there may be great cutaneous vascularity
 Avithout  any  action of these sudoriparous  glands.   Leyden
 found  that there Avas no fluid given off by the skin in risino-
 fever (Wunderlich's Thermometry,  p.  190),  and  this  loss  of
 perspiration is one of the causes of the pyrexia.  It is quite
 clear that \-ascularity of the skin and perspiration do not neces-
 sarily go together ;  though they usually  do, as seen in the moist
 and gloAving skin produced by muscular activity.
   The most  powerful  medicinal diaphoretics  are depressant
 agents.  There are others Avhich are not so depressant, as acetate
 of ammonia, ipecacuan, sweet spirits of nitre, and salts of potash.
 But in pyretic conditions Avith a dry skin these agents possess
 little poAver;  there aconite  and antimony are far more potent.
 When  it is  desired  to  utilize  the action of the skin for the
 kwering of temperature Ave resort to these depressant diaphore-
 tics;  Avhen Ave wish to excite it for excretory purposes, the Avarm
 bath  is to be preferred.   The application of external heat is the
 best mode of  inducing perspiration  Avith normal temperatures,
 but is not much  resorted to in the treatment of pyrexia, except
 in children, and in conjunction with depressant diaphoretics.
 Diaphoretics  are used in all conditions of pyrexia, especially
 with  a dry skin, and are very useful  in the acute diseases  of the
 respiratory organs.   Thus in bronchitis great relief is experienced
 when the skin acts freely.  The state  of turgescence  in the
 bronchial  mucous membrane is relieved  thereby, and secretion
 follows.  It seems necessary in all cases of vascular turgescence
 in secretory surfaces to give vascular depressants in  order to
 secure secretion.  This is alike seen in the dry, swollen mucous
 membrane of the air-tubes in the first stage of  bronchitis, and
 the dry, burning skin of  febrile  conditions.   The secretino--
 nerves of the  sudoriparous  glands seem to be most poAArerfully
 acted upion by depressants, Avhether emotional or medicinal.
  Opium is a poAverful sudorific, especially Avhen  combined Avith
a depressant like antimony.  In opium  poisoning the skin is
blanched, cold, and  bedewed with  pierspiration.   On the  other
hand,  in belladonna  poisoning  the skin is vascular, dry, and
burning.  We saAv in Chapter XIII. that opium and belladonna
      31 
482
THE CUTANEOUS SYSTEM.
possess  opposite properties in their effects upon the  nervous
system.  It Avould appear  that all agents which excite  nervous
action piroduce a condition of the system unfavorable to  activitv
of the sudoripiarous glands.
  The application of external heat is a ready means of  excitino-
perspiration ;  but George Johnson says that in the dry, imper-
spirable skin,  of some subjects of chronic  Bright's disease, the
application of cold is required to paralyze the contracted blood-
vessels, and so lead to subsequent dilatation of them and cutane-
ous secretion.
  The most remarkable sudorific, Ave know of, is the newly-
introduced jaborandi.   It Avould  appear to be  a true specific
diaphoretic, possessing a special power over the secretory nerves
of the sudoriparous and salivary glands.   It is  a most potent
agent for the  purpose of producing perspiration.  Its essential
principle, pilocarpine, has  been employed  by different  authori-
ties Avith someAvhat varying results; but its position  as a power-
ful  diaphoretic is iioav pretty well established.
  Diaphoretics constitute a  large  class of remedies  of  much
importance in practice.   The depressant, or nauseous members
of the group are those best suited for the treatment of pyrexia;
while for  other  conditions  the  less  depressant members are
better fitted.   Thus in chronic bronchitis of rheumatic or gouty
associations, iodide of potassium,  with guaiac or serpentary,is a
very good  measure.   (This is one of the medicinal agents which
have  been found  in the  sweat.)  In conditions of renal inade-
quacy salts of potash are ahvays to  be combined Avith diapho-
retics ; and with many persons potash salts are as  diaphoretic
in summer as they are  diuretic in  cold Aveather.  They aid in
the efficiency of the hot  bath when  required in conditions of
uraemia, or lithiasis.
  At other times the skin acts too  profusely ; and the excessive
perspiration is objectionable, and a source of much  exhaustion.
SAveat is usually acid, but when profuse becomes neutral, or even
alkaline.1   "  With an increase in the quantity of fluid excreted
by  the skin there is also an augmented excretion of  solids; and
to  the deficiency which is  thus  produced in the salts  of the

  1  " That it is a true secretion and not a mere transudate, is shown by the entire
absence of albumen." 
THE CUTANEOUS  SYSTEM.              488
 blood may be partly assigned the debilitating effects of profuse
 perspiration."   We are all familiar Avith  the great exhaustion
 caused by profuse sweating in hectic fever, and especially when
 associated Avith phthisis.  In conditions  of great debility pro-
 fuse  discharges, especially of the skin and  boAvels, are apt to
 show themselves, and  are most  serious.  The term colliquative
 is applied to these discharges, and of old it was said that the
 tissues of the body Avere  melted down, and discharged from the
 system  in these profuse  excretions or secretions.  Even Avhen
 not so excessive, sweating and  purging  are  often troublesome
 matters, causing much exhaustion.  In affections of the lungs
 nocturnal perspiration is one of the most  serious matters Ave
 have to  contend Avith.   In very many cases the arrest of the
 profuse perspiration at once inaugurates an improvement in the
 general condition.  This  brings up the subject of anhydrotics.
   Theory of Anhydrotics.—It  is here necessary to make a Avord.
 (Hydrosis is  profuse  perspiration, and by the addition of the
 alpha (a) privative  we readily reach  the  adjective anhydrotic.)
 The  anhydrotics are  a very valuable and important  group of
 remedial  agents. This group includes astringents, vegetable and
 mineral, both salts and acids, phosphorus in various forms, and
 lastly and chiefly, belladonna.  We saw before (p. 320) that as-
 tringents piossess decided properties, but the explanation of their
 action is not yet furnished  to  us.  They are soluble matters,
 and wherever there is a  profuse  Aoav  there they are  of course
 found, and exercise an arresting influence.  Sulphuric acid, sul-
 phate of copper, pernitrate of iron, acetate of lead, oxide of zinc,
 gallic acid and tannin, are all useful in checking profuse perspi-
 ration.   The  action of phosphorus is  also pronounced, and  as
 phosphoric acid, and in the form  of hypophosphites, phosphorus
 is very useful in the treatment of phthisis.  But the  most pro-
 nounced anhydrotic we are yet acquainted Avith is  undoubtedly
 belladonna.  This drug may fairly be  termed a specific anhy-
 drotic ; and it is almost  certain that  it exercises its effects by
 some  special property and influence over the secretory nerves  of
 the sudoriparous glands.   Atropia arrests secretion in the sali-
 vary glands, and acts specially on the submaxillary gland through
 its secretory nerve—the chorda tympani.   Galvanization of the
chorda tympani is powerless  to  excite secretion in the gland
after the  administration of belladonna.  Heidenhain (Pfluger's 
4^4
THE CUTANEOUS SYSTEM.
Archiv,vo\. v. p>. 40) indicates  that other glands, the secreting
nerves of which  have not yet  been found out, may be a flirted
by belladonna, as is the  submaxillary gland.  Certainly bella-
donna arrests the action of the sudoriparous glands, even avIicii
a red rash is produced by it ; showing that even Avith increased
cutaneous hyperaemia  there  may be not only no  increase, but
actually an arrest of perspiration.  Ringer, to Avhom we OAve so
much of Avhat  Ave know  on this subject, found in  belladonna
poisoning jaborandi did not act.   The antagonism of action of
these tAvo drugs on the skin and  salivary glands is alike inter-
esting and instructive.  So is the opposite action of  opium and
belladonna  upon  the  skin.   That belladonna  possesses  some
direct action upon  the sweat-glands  is demonstrated by  its
utility as a local application, as in perspiring hands, etc.  Bella-
donna liniment, or a solution of atropine, produces an arrest of
the activity of the sudoriparous glands of the area to which it
is applied.
  Something here may be said as to the practical application of
belladonna in bydrosis.  During the intensely hot Aveek, July
16th to 23d, of 1876, at Victoria  Park Hospital, out of a total
of 300 out-patients, seventy-four were taking belladonna in the
forms mentioned at p. 207. The effects Avere most marked, and
any  doubt that might remain as to the connection betwixt the
use of this drug and the arrest of the perspiration, Avas dissipated
by the return of  the sweats in those avIio had omitted  their at-
tendance the previous Aveek,and so Avere Avithout their medicine.1
The doses given were from ^th to ^th of a grain of  atropine,
and  from  xx.  to  xxx. minims of tincture of belladonna.  The
larger doses Ave re not given at  first, but where the smaller doses
were found  ineffective.  Where  there is an apparent tolerance
of the drug, larger doses Avere required, and did not produce such
toxic symptoms as might have been anticipated.  Out of these
seventy-four patients  one only complained of some dryness of
the  throat;  one had  some derangement of the pupils; and  a
third  complained of some indistinctness of vision on first get-
ting out of bed in the morning, but quickly  Avearing off.  In the

  1 The profuse sweat did not return for two or three nights after the medicine
was suspended, showing that the effect of belladonna, as an anhydrotic, goes oft
slowly at pretty much the same rate as it comes on. 
THE CUTANEOUS  SYSTEM.
485
early stages of lung-consolidation, belladonna appears to  me to
alter the Avhole aspect of the case in many instances; and to
stand on an  equal footing Avith digitalis in weak action of the
heart.  By cutting down the exhausting perspiration, the case
altogether  changes its features.   In patients sinking in  the
more  advanced stages, belladonna exercises much  less  effect ;
but further experience may  sIioav that in larger doses than used
hitherto, it may be more effective—in giving partial relief at
least.
  It is not in the hydrosis of lung disease alone that belladonna
is useful;  it is equally  effective  in  profuse  perspiration Avith
other associations.  Hydrosis is ahvays found Avith conditions of
adynamy, Avhich it distinctly tends to aggravate.   Consequently
the use of anhydrotics should always go hand in  hand Avith the
exhibition of tonics and heematics.  Fuller counsels  some food
and an alcoholic stimulant at bedtime as useful in the nocturnal
perspirations of phthisis.   There  seems a greater  liability to
Avhat  are  called the toxic  symptoms of  belladonna  in private
than in hospital patients.   It is rare in my hospital  experience
to find the tricksy qualities of belladonna to manifest  them-
selves. As to any effect upon the pupil as a guide, I have given
up paying any attention to  the state of the pupil.
  Hyoscyanhne in composition and action is closely allied to
atropine.
  § 193.  The diseases of the skin, from  their ready  appeal to
the eye, have always rather been regarded as forming varieties,
allied to each other by  points of resemblance, than looked at
from  the  point of vieAV of  their  causation.  It is only recently
indeed that it  has become the rule to investigate  the  causal
associations of other maladies of the skin than those of syphilitic
origin.  And yet this is the only  plan by Avhich the student can
ever get beyond the mere recognition of the form of the disease,
and the proper  application of one of the many synonyms which
iioav exists for each form and even variety of skin affections ; or
the use of the  routine remedies as  mercury, tar, alkalies, sul-
phur,  or borax.  In order to comprehend the affections  of the
skin and the indications for the treatment of each, it is necessary
to remember and  recognize the  structure, the function  of the
skin;  and its liabilities to injury, and to parasites in consequence
of its  being our external covering. 
186
THE CUTANEOUS SYSTEM.
  The skin  is a  very vascular  organ and is thus  liable  to
variations in its blood-supply, to anamiia or to hyperemia, and
as a consequence, to many maladies Avhich take their origin  in
malnutrition, such as pemphigus; and to others the result of
excessive nutrition, as molluscum fibrosum, ichthyosis, corns, &c.
It is also liable to acute morbid conditions covering a considerable
area, as erythema  and erysipelas, or more especially localized as
furunculus and carbuncle.   As  to these acute conditions, they
have  to be  treated on the general principles  laid down in the
preceding Chapters IV. and IX.; and, then, if a large surface is
involved, either some agreeable  external application, as cotton-
wool, flour, or Avarm lead and opium lotion, or other soothing
mixture must be adopted ; or, if the disease be local, it is well
to pass a knife through and  through the  inflamed, mass, so as
to relieve  the different  nerve fibrils from the pressure of the
neAv groAvth, or cell  accumulations, and  the consequent pain.
The  acute  affections of the skin  present comparatively few
points of difficulty for the student, or young practitioner.  The
more chronic maladies of p>erverted  or  defective nutrition, and
of hypertrophic groAvth are much more troublesome affairs.  They
must be looked at from several  points  of view.   Defective nu-
trition of the skin is commonly associated Avith general defec-
tive nutrition, but not necessarily so.  On  the other hand, local
perversions of nutrition, even of a  hypertrophic  character, are
not  necessarily incompatible with  Ioav general  nutrition; nor
are they always associated Avith a full habit of  body.  In all
cases it  is as necessary to take into consideration the general
condition of the individual  as  it is  to recognize the peculiar
characters of the eruption, or to select a form of external appli-
cation.   It  is  simply impossible here  to attempt to give any
detailed account of  the  various affections of the skin ; and to
give a mere  list of names  under the headings of imperfect or
excessive nutrition  Avould be useless, if not  absurd and  often
incorrect.  The point here insisted upon is, that it will not be
found a successful practice to merely  refer the  disease to  its
propier position in the classification of skin affections, and then
to treat it by routine; according to Avhat is said to  be good in
that particular malady in the text-book  to which the practitioner
refers, or in  Avhich he places  his confidence.  Doubtless be will
find  there an account  of  Avhat external  measures  experience 
THE CUTANEOUS SYSTEM.
487
has found to be useful in each form of disease, and allusion to
general measures, as tonics, alteratives, and cod-liver oil.   But
he  will  easily recognize the fact that this information is of
slight value, unless he  can see Avhat portions of the general
directions apply to the particular case before him.  In impetigo,
for instance, it is often  well to give arsenic internally; but in
many cases this  will  be found inoperative unless at the same
time  the diet be liberal and cod-liver oil  be  added.  In other
cases, repeated small doses of mercury may be  requisite, especi-
ally if the ailment occur in the subject of congenital syphilis.
The  external application of some  mercurial  ointment here is
probably proper enough, Avhatever the special form of general
treatment indicated.   In the out-patients of hospitals the skin-
affections are exceedingly often  the  outcome  of  dirt, squalor,
and malnutrition.  Cleanliness and an improved dietary are as
necessary to the successful treatment of  a number of different
skin affections, AArhich are free from any parasitical origin, as in
those Avhose ailments  are so causally associated.
  § 194.  A large  proportion  of skin affections are,  as  the
French have  long insisted, linked Avith  disturbances  of  the
abdominal viscera, and  especially of  the  digestive tract.   The
late Tilbury Fox in his last edition of his work on Skin Diseases
says,  "There are four organs Avhose derangement  excites  or in-
tensifies skin  mischiefs.   The stomach, the liver, the kidney,
and the uterus.  In the \Tast  majority of cases it is rather in-
tensification than excitation that the practitioner has to deal
with.  First, as to the stomach ; of course, if the  stomach fails
in its Avork the general  health will  suffer, and  so  the skin will
be less able to resist disease or  to undergo repair; but there is
a more direct influence upon cutaneous diseases than this.   My
own belief is that wherever there is excess of acid secretion, or
where the secretion of  gastric juice  is altered from a healthy
standard, there,  probably, from  the circulation  of acridities
absorbed by the intestinal tract, cutaneous inflammations  and
bypersemias are intensified, as  in the case of the simpler ery-
themas  of children, which are thereby produced.  But again,
stomach  irritation, especially in subacute dyspepsia, is reflected
to the skin, especially that of the  face, and excites glandular
or erythematous changes, as in acne and erythema of the face.
The face flushes after meals where digestion is badly performed, 
488
THE CUTANEOUS SYSTEM.
and an exaggeration of this condition is observed in  acne  and
erythema, in connection with marked dyspepsia.  Of course a
predisposition to acne, Avith exposure  and irritation of the  face
by externals, are elements in the cause of acne, but practically,
if treatment removes the dyspepsia, the disease often goes.  It
is not difficult to see that if the face of the  patient is predis-
posed to  acne, dyspepsial troubles reflected to  the  face may
actually excite or determine the occurrence of the acne.  Pretty
much the same may be said, mutatis mutandis, as regards uterine
irritation in women.  It is a matter  of very common observa-
tion that uterine troubles aggravate erythema of  the face, urti-
caria, and so on.   Now as regards  the liver.  It  is needless to
give proof of the truth of  the statement that 'poisoned blood'
—blood, I mean, charged with any effete products—when passing
through  an inflamed skin,  say  that of eczematous persons, or
of an urticaria  patient, Avill  tend  to  still further derange the
skin of that particular subject;  and blood is often charged with
bile products, and tends, as in urticaria and eczema, to intensify
the inflammatory symptoms, and to retard  the cure.   This is
often  seen in  children avIio  have white stools and Avho suffer
from  eczema.   In the  connection • betAveen  phlegmonous or
carbuncular inflammation and the diabetic  habit, it is possible
again to trace the influence of a disordered liver—supposing
that to be the organ directly  concerned in the production of
sugar—on skin  diseases.  Lastly, as regards the kidney, there
are tAvo Avays  in which this organ may influence  skin diseases;
the first, by the  non-removal of watery fluid  in proper quan-
tities, whereby  the  occurrence of ceclematous  infiltration is
favored, as is often seen in eczema in the legs of the old; the
second, by  non-excretion of nitrogenous  matters,  leading to
impurification of the blood, and the circulation of urea, uric
acid, and the like, in unusual quantities, through the inflamed
or diseased skin, giving rise to increased hyperemia.  The latter
happens in psoriasis, eczema, and  other diseases.   Of course
organic  diseases  of  the stomach, liver, and kidney  involve
functional disturbances,  and so far bring about modifications
of skin diseases indirectly, as do purely functional disturbances
of  these organs.  From what I have  said the reader will have
no  difficulty in understanding  that skin diseases require to he
regarded, not only from a purely surgical point of view, an 
THE CUTANEOUS SYSTEM.
489
 some are Avont to assert, but also from  that of  the physician."
 (Third Edition, pp. 10-11.)  This  rather  lengthy quotation ex-
 presses almost exactly the vieAV it is desirable  to impress upon
 the reader.  Of  the relation of  the skin, and  its affections, to
 the stomach and digestive canal there is  no doubt, and our old
 empirical plans of treatment  have always insisted upon atten-
 tion to  the primce vice in skin  affections.  Laxatives, alkalies
 Avhere there is acidity, tonics,  regulation of the diet,  etc., all
 are of the  greatest importance in  the treatment of diseases of
 the skin.   AVhere there is a cachectic condition, then arsenic,
 some  preparation  of mercury,  or  the excellent  combination
 knoAvn as Donovan's Solution may be desirable, as Avell as ferru-
 ginous agents.  In strumous  conditions potash  and iron Avith
 coddiver oil are the best measures.
   As to the relation of  skin  affections Avith disturbance of, or
 inaction in, the liver and  kidneys, one is  inclined to hold that
 the affections of the skin are causally connected with the non-
 elimination, or excessive presence, of nitrogenized matters in the
 blood.  The skin has much to do with the elimination of these
 matters, and  it  seems  very probable that many  of  the skin
 affections, especially eczema, found  under these  circumstances,
 are the direct  consequences of this function of the skin.  These
 matters  either act as irritants  (Dr. Fox's  vieAv),  or  the skin
 becomes affected by its functional activity in  excreting them.
 In the latter case the skin disease finds its origin in the condition
 of the blood,  laden  with Avaste; and  not merely that already
 existing skin  affections  are  aggravated  by  the  imperfectly
 depurated  blood.   As  a matter of  fact, hoAveArer, the relief of
 the internal organs, and especially a reduction in the amount of
 nitrogen consumed, together with alkalies and chiefly potash, at
 once relieve these skin affections and often secure a speedy cure.1
 In some  disorders of the liver there is an excess of lithates in
 the  urine, and therefore in the  blood first, and these  no doubt
 irritate the skin;  so that in reality liver  disturbance  may" pro-
 duce the same consequences as imperfect action of the kidney.
 In each case the treatment usual in gout Avill  relieve the skin

  1  Such are the measures to be adopted for the relief of the terrible itching
found in many cases of jaundice, and  in the prurigo  senilis associated with  im-
perfect renal action.  For the latter strong solutions of  bicarbonate of soda
applied hot often give great relief. 
190
THE CUTANEOUS SYSTEM.
affection—no matter Avhether it be eczema, an irritable ulcer, or
prurigo.  Very often alkaline applications, as in eczema, aid the
general measures  in giving relief.   A large proportion of the
visitors  to  such  spas  as Buxton,  Aix-la-Chapelle, Carlsbad,
Saratoga, etc.,  suffer from  skin diseases, and are relieved by
the Avaters, as  effectually as are any of  the sufferers from the
other forms of  lithiasis.  The habits of the rich lead to certain
forms of skin affections, as certainly  and  surely, as the improper
food and neglect of  hygienic arrangements  of  the poor lead to
other forms.  In  cases of biliary disturbance  with  lithates  in
the urine the following will be found very useful as an internal
remedy:—
                    Sod. Sulph. >}j.
                    Sod. Pot. Tart. 3j.
                    Tinct.  Nuc. Vom. ir\,x.
                    Inf. Buchu 3J.
or
                    Decoct. Aloes Comp. ^j.  ter in die.
   § 195. The  association of the  cutaneous manifestations of
syphilis with the  saturation of the  system with the syphilitic
virus, forms material for  a good deal of thought about the rela-
tions of skin affections to constitutional conditions.  Hoav far
the disturbances of the tegument can be  regarded  as depurative
measures calculated to restore  the system  to  its integrity, is a
matter about which we cannot  at present be certain.  There is
no doubt that  syphilis is much milder in hot countries than in
cold ones;  indeed, Hebra points  out the excellent  effects of a
sojourn  in  hot countries  over the progress  of  an attack  of
syphilis; and also that hot baths are excellent measures during
the secondary manifestations of this disease.   When there is a
good eruption in the secondary stage there  is  frequently less of
remoter consequences than  Avhere  the eruption  is slight and
fitful.   Indeed it  would almost seem that  a good crop of  cuta-
neous secondaries  eliminates the poison  thoroughly and leaves
the system freed.  The cutaneous  outcomes of syphilitic infec-
tion are seldom  treated  by local  applications, but by general
treatment almost  entirely.  No one dreams  of applying mercury
outwardly only, but saturates the  system generally with the
drug.   In no form  of  skin  disease  do we  see more practically
exemplified  the dependence of these maladies upon a general 
THE CUTANEOUS SYSTEM.
491
 condition, than in the treatment  of cutaneous syphilitic mani-
 festations.  Of course it  is not asserted that local applications
 are utterly Avithout  value; but no one Avould dream of relying
 upon them, or even of attaching much value to them, as com-
 pared to  the  administration of mercury by the  mouth, or by
 inunction over a  limited area.  In  the same Avay, in cases of
 congenital syphilis, Avhere an infant will come out suddenly in
 almost one  sheet of eruption, the treatment is to give mercury
 internally ;  and to leave the erupition  alone as regards any ex-
 ternal applications.   In  the  remoter cutaneous  outcomes  of
 syphilis, the application of mercury locally is desirable ; but in
 all cases it  is subordinate and  ancillary, and  thoroughly so, to
 the general  treatment.  The lessons taught us by  the treatment
 of syphilitic eruptions, ought to lead us  to  think more exactly
 about the treatment of other skin affections, and of their con-
 nection Avith general conditions.
   § 196. At other times skin eruptions are distinctly associated
 with the nervous system.  This is most distinctly seen in herpes
 zoster, which  folloAvs  closely the  distribution of  an  intercostal
 nerve, or in more  severe cases, several nerves.  This form of
 vesicular disease  is  not only preceded in many cases by severe
 neuralgic pains, or pleurodynia, which sometimes remain after
 all eruption has passed away ; but Barensprung and others haA^e
 found distinct changes in the nerves going  to the part affected.
   This association of herpes zoster, Avith changes in the nervous
 system, must ahvays  be borne in  mind in  practice; and while
 the eruption may be treated Avith a solution of  the bichloride
 of mercury, or other external application, tonics,  iron,  and
 quinine must  be  given freely,  and the dietary must be liberal.
 If this general treatment be not folloAved out, not uncommonly
 the burning, stinging pain will  survive the disappearance of the
 eruption, to the great  suffering and annoyance of the patient.
 Herpes is not rarely found in  ague, and is conjectured to be
 due to some disturbance in the spinal ganglia.  It is also found
 underother circumstances, including the well-knoAvn association
 Avhich exists betAvixt herpes labialis and pneumonia, or catarrh.
 Clifford Allbutt is inclined to think  that several other forms of
skin disease, as acne, eczema, lichen, psoriasis, and urticaria, are
at times associated with visceral neuroses, and Avith asthma and
gastralgia.   He says, "We  have learnt that  in the higher ani- 
492
THE CUTANEOUS SYSTEM.
mals nerve changes constantly precede changes of other tissues,
not only in normal function and in normal growth, but also in
abnormal function and abnormal growth."  Many of the skin
affections are doubtless at times the consequence of interference
with nerve-nutrition rather than blood-nutrition ; and then it is
necessary to take into consideration, therapeutically, this asso-
ciation.   At present the tendency is to regard herpes as part of
a neurosis only and not the disease itself.  A localized neuralgia
may occur  Avithout  the vesicular eruption, Avhich  is  quite as
unpleasant as Avhen  the eruption is present.
   § 197. In consequence of its being our external covering, the
skin is liable to injuries and to the presence of parasites.  These
last are of various kinds, they may be animal or vegetable.  Of
the first, or animal parasites, there are  varieties ; there are those
which live outside the skin  and are visible to  the eye—the
pediculi; a large class of articulata, which infest all varieties of
creatures, fish, flesh, and foAvl.  There  is one curious peculiarity
about this objectionable and destested class, namely, that each
species of parasite will only survive on  its  oavu peculiar hunt-
ing  grounds;  the parasites  of the Lascar  will not live on a
European seaman, and vice versa.  The other and larger visitors,
the pulex and the cimex, do not manifest this fastidiousness; still
there are persons Avhom  they avoid.   Habits of cleanliness are
destructive to  these last-named parasites, and are hostile  to the
pediculi ; but in the case of the pediculus  pubis it is necessary
to solicit their departure by  the  application of blue ointment,
which, if applied  effectually,  leaves the  Avhole  host in the
morning dead or dying.   There is also another sadly common
parasite, the acarus scabiei.  Here the insect burroavs in the skin
and lays eggs along the  channel.   When  the skin  becomes
vascular, as when exposed to heat, or in bed, then these creatures
become  specially active,  Avhile the  vascularity  give3 greater
sensitiveness ;  the result is intense itching.   These animals have
a decided intolerance of sulphur, especially  in the  shape of an
ointment;  and  two  or  three  complete  applications of  this
unsavory compound is usually sufficient for their  annihilation.
In all cases the clothes must be subjected to a high temperature
in order to destroy the juvenile parasites, avIio are unusually
tenacious of life, Avhether the eggs of the acarus or the pediculus;
and a temperature  sufficient  to coagulate their albumen is the 
THE CUTANEOUS  SYSTEM.
493
only parasiticide Avhich can be thoroughly relied upon.   Some
insect powders are most potent in their effects upon these small
parasites.   In other cases, as in that of the Guinea Avorm, the
careful extraction of each invader is indicated.
  At other times the pmrasite is a vegetable groAvth, as in favus,
sycosis, tinea tonsurans,  etc.  In favus the scabs must be re-
moved by poulticing, and then the hairs must be extracted and
a parasiticide applied.  The agent of all others destructive to
vegetable parasites is sulphurous acid, either alone or in the form
of sulphite of soda.   In tinea tonsurans the destruction of the
parasite by repeated applications of  sulphurous acid is followed
by the groAvth of the hair, Avhich, hoAvever, may require some
stimulation.   In pityriasis  versicolor, the parasite is the micro-
sporon furfur, and it  also gives Avay before repeated Avashings
and the use of sulphites;  but its most ready departure is induced
by Goa powder, rubbed on  Avith the finger in  a  little Avater;
indeed the effect of Goa p>OAvder would seem almost magical.  A
curious form  of disease connected  with vegetable parasites is
the Madura foot, or  fungus foot, of  India.   The destruction of
the foot so produced is such that  amputation alone affords any
substantial relief.  This ailment is found only in certain localities,
and in this respect  resembles the Delhi boil  (Avhere, however,
there is no parasite) and Pellagra, or Italian  leprosy, Avhich is
due to eating maize  Avhich  has  become unsound or, rather,
mouldy.   Maize  so  changed produces skin  affections in horses
and  foAvls, as Avell  as man.   A species of measles  has been
induced in America  by mouldy straAv.
  At  other  times vegetable  growths, and especially oidian
forms, locate and flourish on mucous surfaces, as in the apbthas
or thrush, Avhich forms in the mouth and on the fauces of debili-
tated  infants;  and  which  also finds a suitable home in  the
vaginal mucous  membranes of neglected little girls,  or of dia-
betic women.  In the latter case these fungi keep up  the dis-
charge, and their destruction by sulphites  is a necessary step
toAvards the cure of the malady.
  The whole treatment of diseases of the skin of parasitic origin
is curious and special, and contrasts Avith those of constitutional
origin  in  that external  applications,  often of a very special
character, are the chief  measures to be relied upon, and  the
general measures are quite subordinate ; while in the other class 
494
THE CUTANEOUS SYSTEM.
of skin disease, general  treatment, often as a special character,
as mercury in syphilis, is the great matter, and  the local appli-
cations are comparatively unimportant.
  § 198. One of the  most  curious and yet universal  of  skin
affections is  the corn.  FeAv people Avho walk  much  are free
from these growths.   Their causation  and groAvth are matters
of practical interest,  furnishing hints for their prevention or
removal.  They usually—that is the hard corn at least—appear
at points exposed to friction, or to piressure.   A growth of epi-
dermal scales follows, like the groAvths on the  laborer's hands,
with this difference, in the latter case  the thickened epidermis
rises from the surface, and so protects the piarts beneath, while it
enables the hand to take a firmer grip ;  but in corns the surface
is kept flat  by the pressure, and so  the epidermal  growth is
pressed iiiAvards into the sensitive skin.  There are two ways of
getting rid of corns when established.  One is to apply a satu-
rated solution of sulphate of zinc to the mass until it is so dry
that it peels off; the  other is  to dig out the conical  mass with
its little nutrient artery and vein, called by the vulgar " the root."
By either plan the growth is got rid of;  but if the pressure be
still there the corn will grow again.  Consequently, Avell-fitting,
even tightly fitting shoes of soft leather are indicated; by having
them to fit closely the pressure is spread evenly over the whole
foot; Avhile if large,  loosely fitting shoes  are worn the  pressure
necessarily falls on a few points.  Relief  may also be obtained
by corn  plasters, Avhich  are perforated circles, and are applied
so that the corn  may  rise  up in  the central hole; and  thus the
tender part under  the corn be relieved from pressure.  A few
Aveeks in bed, from any cause, is folloAved by relief from corns
for a long Avhile after.   If the  pathology  of corns  were  only
more thought over, they Avould be found much easier to remedy
than is at present the cause.
   Another  troublesome skin affection is the  Avart.   Not the
congenital wart of the face, but the wart which flourishes on the
hands of groAving  children.   This growth  usually passes aAvay
when  adult life is attained, but this is not ahvays the case.  The
most effectual plan is to touch them with strong acetic acid, or
strong ammonia,  which  soon destroys  them.   The secret of
success, hoAvever, does not lie so much  in the peculiar form of
the different applications in favor, as in the method of  applying 
THE CUTANEOUS SYSTEM.
495
 them.   The fluid should be applied with a glass rod or stick, so
 that half a drop or so of the fluid may be located on the Avart.
 The hand should be so held also that  the fluid can dry Avithout
 running off.   If too much be applied the  fluid runs off, doing
 little or no good, and only irritating the skin around.   If applied
 properly, warts can be destroyed  most effectually by acetic or
 other acid, or strong  ammonia.
   § 199. The skin is liable to solutions of continuity, or breaches
 of surface, known as ulcers.  It  is  difficult to say anything
 briefly which is of any value about  these  maladies.  They are
 essentially surgical matters, and require very special treatment;
 nevertheless, there are points about  ulcers  which come  under
 the physician's province.   A sore, or ulcerated surface may arise
 from almost any form of skin affection in  debilitated  consti-
 tutions, especially if much scratching  has been practised.  Such
 ulcerations  are best  met by  tonics, by cod-liver  oil,  and good
 food.  Occasionally a little arsenic, or  mercury may be  given
 with advantage. Of  the ordinary ulcers there are  several varie-
 ties.  One is an indolent form  where the  raised  edges  of epi-
 dermal scales do not  furnish  ready growth.  Here the removal
 of the thickened epidermal layer, by the application of a blister,
 is folloAved by reneAved growth and  formation of cicatrix.   If
 there be a someAvhat large surface to  heal  over, bringing  the
 edges of the ulcer a little nearer  together by strapping the leg,
 so as to take off the tension, will  often induce further cicatriza-
 tion.  The discovery of M. Reverdin of the transplantation of
 bits of skin,  and their  subsequent growth, has done  much for
 the treatment  of large ulcers.  Good food, iron, fats, rest and
 warmth for the limbs, all  are useful  adjuncts.  Sometimes the
 ulcer is  very  painful,  and then it is termed  an irritable  ulcer.
 Here there is often a  network of nerves at the base of the ulcer,
 which are very sensitive and  interfere Avith  repair.  Their sec-
 tion with the knife gives relief and  institutes repair.  This is
 well known in fissures of the anus.   At other times  irritable
 ulcer is  connected Avith lithiasis,  and  then  it must  be met by
 constitutional rather than local measures.  When there is much
 standing, the veins of the legs are  apt  to become dilated or vari-
 cose.  An ulcer forming under these circumstances is very trou-
blesome ; but for the  measures required for its relief the reader
must consult  some  surgical treatise.   There  are minute atten- 
196
THE CUTANEOUS SYSTEAI.
tions to detail  required, AAThich do  not enter  into  the  scope of
this work.  In all cases keeping  the  skin Avarm is a matter of
moment.  The exposure of the  legs to cold is as much a cause
of ulcers as is their  dependent position, and  both these factors
must be taken  into consideration in any plan  of treatment.1
  At other times the skin, and especially that of the face, is
liable to a persistent change in limited areas.  Lupus is the term
applied to this  malady.  It may or may not go on to ulceration.
If an ulcer forms, nitrate of bismuth ointment is  often very
useful.  If the ulceration be persistent  until a condition not
unlike a cancerous sore is induced, then escharotics are indicated.
If there be no  ulceration and but a disfiguring blotch exists, it
may  be removed  by caustics.  Any  one  avIio has seen Ilebra
proceed to attack  lupus  must be convinced of the necessity for
active measures.  He first energetically rubs  caustic potash on
the  epidermis  of  the mass.   Then he  removes  the  loosened
epidermis with charpie, and  having thus exposed the  morbid
groAvth, he applies lunar caustic in stick.  As he remarks, it is
of no use to apply the nitrate of silver until  you have reached
the disease and tissue itself.
  Finally, skin diseases  and their  treatment  must be learnt by
actual practice; and arrangements are  now made  in most schools
for  their teaching.   At the same time there is much  to be done
by  rational  therapeutics even in   this domain,  specially ruled
over, though it be,  by  empiricism.  Even in the  matter of  a
scratch it is Avell to  shave  doAvn the raised edges Avith a razor,
so as to take off the projections which are sore to any touch;
and  by so removing  them, and thus putting  the parts at rest,
the scratch heals more kindly.
  A Avord, however, about  fetid feet.  This  is a very trouble-
some affection  with  some persons, and persists in spite of great
personal cleanliness.   Of the many plans of treatment in vogue,
there is none more successful than  that of washing  the feet with
soap  and  water night and morning, and  then  sAvabbing them
Avith a strong solution of sulphite of soda, about an ounce to the
quart of Avater.  If  this  be accompanied by the changing of the
socks, so that the same pair be not worn tAvo days consecutively;
and a similar arrangement be made with the  shoes, taking care

   1 Old persons  often have ulcers from burning their shins  before the fire. 
                THE  CUTANEOUS SYSTEM.             497

that during the time  they are not Avorn to expose them freely
to the air and still more to the sun; together Avith attention to
the general health, and especially to the boAvels:  this repulsive
affection may usually  be treated successfully.  When the feet
are always  bathed in perspiration it is well to apply a solution
of sulphate of atropia.
  Affections of those modifications of  the epidermis—nails and
hair—scarcely permit of anything being said about them here.
32 
CHAPTER  XX.
                   THE LYMPHATIC SYSTEM.

  § 200.  This system Avhich is iioav to  be considered is one of
much importance; but it is one ou Avhich Ave do not yet possess
a sufficient amount of information to be very explicit about the
rationale  of much of Avhich  Ave are assured by our  every day
practice.   When there is an enlarged thyroid gland, a periosteal
node, or  an effusion into a serous  sac remaining after an acute
inflammation, Ave resort to  iodine, with  or Avithout mercury; in
order, as Ave say, to rouse the lymphatics.  We all  know that
by these  means Ave shall be able to remove, more or less com-
pletely, the abnormal matters.  Early in the use of iodine it Avas
asserted  that the testes and the mammary  glands were not
unfrequently removed  by  the unusual  absorption excited  by
the use of  this agent.   Nowadays Ave do not hear of  these
occurrences.
  The system of lymphatics, by whose agency these ends  are
brought  about, is  a  widespread system.  It consists of multi-
tudinous tubules extending over the limbs and permeating the
tissues, which, at the axillae and groins, have placed upon them
glands, possessing, among other properties, a species  of filtering
action; after passing into the trunk the glands become more
numerous, and the lymphatic vessels of the loAver  extremities
open into the receptaculum chyli; and joining their contents to
those of the chyliferous glands, the common fluid is poured into
the venous system by means  of the thoracic duct.  The lymph-
atics of the left upper extremity and left side of head unite with
the duct as it opens into the left  subclavian vein.   The right
lymphatic duct, containing the fluid brought from the right arm
and  head, opens  into the  right subclavian vein.  Such is  the
anatomical arrangement of the lymphatic system.   Why there
should be collections of glands  on the  lymphatics at certain
points, as the glandulse concatenatse of the neck, is yet unknown.
Recent researches have  shown that these lymphatics are evolved 
THE LYMPHATIC SYSTEM.
499
from  mere  spaces in the connective tissue of the body, Avhich
have become elaborated into a distinct system of vessels  with
definite coats, and an arrangement acting like valves.   In rep-
tiles there are pulsating sacs in this system, denominated lympih-
atic hearts.   More recent researches have shown that the  great
serous sacs,  the peritoneum, the pleura, the pericardium, and the
arachnoid, are  not merely smooth  lubricating surfaces admit-
ting of movement Avithout friction ; but further are lymph spaces
in intimate connection Avith the lymphatic system.  There are
also lymphatics in  the sheath of each arteriole.
   So much  for  the anatomy of the lymphatic system.  To be
equally brief, the physiology  of  this system is as folloAvs: It
is by  means of this system  that  the excess of  nutrition to
various parts of the body  is restored to the  general circulating
fluid;  instead of being Avasted, or producing local anomalies of
nutrition.  Nutrition is furnished to the different parts of the
body by the arteries, and still more intimately by the capillaries,
from  which last the nutritive fluid actually escapes.   Some of
this fluid passes back into the venous portion of the capillaries,
another portion  is taken  up  by the lymphatics.   During this
process the fluid has parted Avith some of its nutritive material
for the support and repair of the tissues; and on the other  hand
has taken up the Avaste of these tissues.  Part of the tissue-waste
then passes  away in the fluid Avliich finds its  way into the veins,
the other part is carried off in the fluids of the lymphatics.  In
either case along with the Avaste there is much nutritive material;
which  is  thus  carefully economized and utilized  to  meet the
needs of the system.   It is obvious from  this  that in health, a
balance must exist  betwixt the supply of pabulum to the tissues
and the removal of the excess remaining over after their wants
are supplied.1   The arrangements for maintaining this balance
are curious  and  interesting.   They resemble, indeed,  pumping
arrangements.   "When a muscle is in great  functional activity
there  is a free  supply of blood to  it, and the liquor sanguinis
passes freely through its structure, supplying its wants and re-

  1 AVhen there is venous congestion of organs, and the  venous flow is retarded,
the lymphatics cannot remove all the fluid effused from the capillaries, and so we
ffet the development of connective tissue, so well seen in  the viscera, in confirmed
valvular disease of the heart. 
500
THE LYMPHATIC  SYSTEM.
moving the Avaste; upon whose presence the sensation of fatigue
depiends.  There is a much freer supply, indeed, than is the case
in rest, and this extra supply passes off* by the lymphatics in the
sheath of the muscle; Avhile the alternate  contractions and re-
laxations of the muscle exercise a species of pumping action, by
which the passage of the fluid in the lymphatics of the fascia is
accelerated and aided.   In the periotoneum the diaphragm acts
as a pump, and the  stomata  found on the under surface of the
diaphragm are the open mouths  of lymphatic ducts, into which
the fluid is forced.  Similar  stomata exist  in the costal pleurae,
and every act of respiration—in one respect—resembles the stroke
of a pumping-engine.1  Such are  the arrangements by which the
nutrition of the  system and the removal  of Avaste are accom-
plished;  the arteries supplying the nutritive fluid which  finds
its Avay back  into the blood-current by means of the veins and
the lymphatics.
   § 201.  Theory of Absorbents.—These  lymphatics then remove
in a great measure the excess of nutrition, laden  as it is with
tissue-Avaste.  Where there is a disturbance in the equilibrium,
normally existing betAvixt  supply and demand, excitation of
the lymphatics will tend to  restore it.   Such is the theory of
absorbents.   By means of iodine in its various forms, the most
distinct and poAverful  absorbent  with Avhich Ave are acquainted,
we excite the lymphatics into  greater  activity ; and so reduce
various tissue enlargements,  especially such as consist of certain
forms  of connective tissue.  Locally apiplied, too, these agents
act powerfully, especially in  connection with glandular enlarge-
ments.   Thus in enlargements of the thyroid gland, especially
those known as goitre, or bronchocele, the hypertrophy is readily
removed by the use of iodine in  many cases.  If, howrever, the
enlargement be due to a cyst, or if it consist chiefly of enlarged
bloodA7essels, then iodine is of little  use.   But if it be mostly
composed of adenoid elements, then iodine is efficacious. When,
too, there is an accumulation of  fluid in the great lymph spaces
after  inflammatory action, iodine is very  useful.   But in the
mere static  accumulation of fluid  in these spjaces, from venous
congestion due  to cardiac failure, absorbents are  useless; the
disturbance of the circulation is too  profound to be affected by
Ludwig and others. 
THE LYMPHATIC  SYSTEM.
501
 acting  on the absorbents alone.   If the heart can be  stimu-
 lated into greater activity, and the balance of the circulation
 be someAvhat  restored,  then  absorption may once more take
 place efficiently.   Also in those perversions of nutrition in the
 direction of excess, such as Ave see in the periosteal node, iodine
 is very useful; but, as  is Avell known  empirically, it  is of no
 avail to  resort to iodine so long as  there is much  vascular
 activity in the part.  As long as such activity exists it is useless
 to  stimulate  the  lymphatics;  the disturbance  of balance in
 nutrition is not at that period  to be remedied by acting upon
 the absorbents.   But Avhen the  vascular  activity has  passed
 aAvay, and  the nutrition  of the  part  has become once  more
 someAArhat normal, then iodine may be  used with advantage;
 very frequently the absorption is very rapid, and a normal state
 of matters is once more reinstituted.  Thus Ave can see the how
 and Avhy of what  empiricism has taught us.  The action  of the
 absorbents  upon  various  forms of  tissue  is interesting and
 instructive.  Over normal tissue they exercise but little effect;
 but over  neoplasms they exert more influence.   There is much
 difference  in   the  neoplasms, hoAA^ever.   Malignant  forms of
 connective tissue are in no Avay  affected by absorbent remedies.
 Cancer defies such action of the  lymphatics.   Ordinary growths
 of  connective tissue,  like fibroid tumors, resist the action of
 absorbents.   But  rapidly-groAving masses of young connective
 tissue cells, such as Ave see in  gummata  and other syphilitic
 growths,  are  readily  removed  by means  of these  absorbent
 remedies.   Nodes, gummata, growths in the nervous system, all
 disappear under the exhibition of iodine.
  There is, however, one important matter in connection with
 the removal  of these neoplasms by the use of absorbents, and
 that is  the effect  of mercury.   Probably  mercury acts  upon
 the lymphatic  system directly, standing in  that  respect next
 to iodine.   But  mercury has  another action, which in the
 removal of such growths  is most important, and that  is its
 destructive action  upon neAv groAvths.   John Hunter of oldr
 thought and taught,  that mercury acted upon abnormal and
 diseased parts Avith much energy, Avhile  it affected but little the
 healthy  structures.  There is a  great deal  in this, really and
actually.  Mercury does  break  doAvn such growths,  and  the
detritus is removed by the lymphatics.  Especially is, this the 
502
THE LYMPHATIC  SYSTEM.
case Avhere the syphilitic neoplasm is in intimate relations with
lymphatics, or  a lymph  space.   Witness  the  effect upon a
syphilitic tubercle in the iris, produced by  the  administration
of mercury.  The anterior chamber of the eye is a lymph space,
and under the effects of mercury this growth  can  be seen to
melt aAvay rapidly and thoroughly.
  By the combination, then, of mercury, to break doAvn struc-
turally  neoplastic groAvths,  and iodine to  stimulate the lym-
phatics, we can remove much excessive or perverted nutrition;
which may be objectionable, either from the pain it produces,
by  the pressure it exerts,  or from  the abolition of nerve-func-
tion which its presence may induce by pressure, or compression
of some  part  or  portion of  the nervous system.  Such  is the
explanation, so far as the  present  state of our  knoAvledge  Avill
permit, of the effects of iodine and mercury  upon the glandular
and lymphatic systems.1
  We have long ago abandoned  the  idea, that by the  use of
iodine Ave can remove either hypertrophic muscular fibre, or
the products of sIoav progressive parenchymatous inflammations.
The reduction of hypertrophic enlargement  of the heart by the
use of iodide  of  piotassium, which  so moved  our immediate
predecessors, is  iioav no longer  thought attainable.  That the
hypertrophy, or rather its  prominent objective phenomena, Avas
removed  by  a course of iodide of potassium,  combined Avith
Ioav diet, is  intelligible enough.  We ha\~e seen  that most of
the cardiac hypertrophy, unconnected  Avith  valvular lesions, is
associated Avith a lithsemic condition, and the removal of waste
nitrogenized  matters by  these  means would  lead  to a loAver
arterial  tension (§ 142), and so  relieve the  left ventricle; and
then  the objective signs of hypertrophy Avould pass away, and
only  a slight increase of bulk, no easy matter to determine  even
by careful percussion, Avould remain ; just as the hypertrophy of
pregnancy passes away after parturition.   But Ave know well
enough that this change did not, and does not occur by any action
of  the absorbents upion the muscular structure of  the heart it-
self.  In the  same Avay the lymphatics are unable  to remove

  1 The old idea that there were no lymphatics in the brain is now known to be
erroneous.  Lymphatics  are found alongside the arterioles in the perivascular
spaces. 
THE LYMPHATIC  SYSTEM.
503
 the products of slow parenchymatous inflammations ; and the
 recommendation to use ioduretted frictions in  valvulitis, in
 order to remove the connective tissue which  has  distorted the
 valves of the heart, though met Avith even in some recent works,
 indicates, not faith, but credulity.  We  now know that such
 statements are but the remains of that belief in the Avonderful
 potency Avith Avhich iodine Avas credited on its first introduction.
 In this respect iodine differs not in its history from that of other
 potent agents; the miraculous powers which  are  at first attri-
 buted to them, settle down in time into a sober estimate of the
 real value of each agent; and if  iodine is unequal to procuring
 the reduction of a  hypertrophied heart, or the restoration of
 crippled and  injured valves, nevertheless it is an agent Avhose
 potency over young connective tissue growth (of sypihilitic origin
 especially) no one Avould think of disputing.
  As to the practical application of iodine little  need be said.
 It is usual to  prescribe it in the form of iodide of potassium in
 doses of from  fh*e grains up to half a drachm, or even a drachm,
 three times a day.   It is also applicable in the form of an oint-
 ment, or a liniment of iodide of potassium in compound soap
 liniment,  or in  camphor liniment.  Many add  a dose  of the
 liquor hydrargyri bichloridi  to  the mixture containing iodide
 of potassium, so as to produce a soluble  biniodide of mercury.
 At  other times the mercury is used as an inunction along Avith
 the iodine mixture, or is given in the form of a pill, chiefly at
 bedtime.
  Such is the action of mercury  and iodine in the reduction of
 abnormal growths ; and a little experience will soon convince the
 student of  their potency, if they be used in a suitable form of
 morbid product.  If given in unsuitable cases they fail;  but
 that is  not  any fault  of theirs.   The extraordinary effects of
 such combination upon the secondary eruptions of syphilis can
 be accounted  for by the richness of the  lymphatics in the vas-
 cular  skin ; while the mode  of action of mercury  and iodine
 will readily explain to us their potency in  the treatment of those
 affections of the skin,  not being syphilitic,  Avhich take their
 origin in excess of nutrition.  The local application of mercury
and iodine aids in the effects produced by their internal  admin-
istration.
  §  202. The lymphatics of the body are  liable to acute  inflam- 
504
THE LYMPHATIC  SYSTEM.
mation.   This  usually  occurs  from some injury, especially  a
pioisoned wound ;  or it  may arise  from some suppuration in a
debilitated system,  or one  temporarily in an unhealthy condi-
tion.   In these cases the lymphatics  become inflamed by the
material they have taken up.   In  certain forms of dissecting
wounds  the  lymphatics  become  most gravely  affected, and
though usually the peccant  material  is  arrested at the first
gland, Avhich acts as a filter, in  such cases there is, not rarely,
a general infiltration of the areolar tissue on  the affected side of
the body, general  blood-poisoning, and death.  In the case of
soft chancre,  there is absorption of the poison by the lymphatics
of the penis, and arrest at the first gland, causing  that sup-
puration known as the " bubo." There are  tAvo points then to
be attended to in the ailments of the lymphatic system, and these
are the treatment of the inflamed lymphatics, and the treatment
of the affected glands.  Ere mentioning these varieties of local
treatment, it  may be well to  insist  upon  the lines of treatment
to be pursued for  the system generally.  In  cases of blood-pois-
oning by absorption, it is of the utmost importance to protect
the system at large, and for this purpose it is usual to resort to
antiseptics, often combined with tonics.  Thus
                   Pot. Chlorat. gr. xv.
                    Inf. Cinchonae §j.
every four to six hours, Avith or  without five grains of carbonate
of ammonia, or ten drops of tincture of steel, is an excellent
measure.  Others rely upon the  sulphites  of soda, alone or along
with chlorate of potash, with liberal  quantities of Avine (p. 221).
After the brunt of the attack is over,  and there remains a con-
dition of debility  combined with  an amount of putridity, then
the  chlorate of potash may be combined Avith the tincture of
steel.  As regards the local treatment of the  inflamed lymphatic,
the pink ribbon it forms on  the  skin may  be painted with nitrate
of silver Avith advantage.  If there be any local sore, or abscess
at the periphery of the limb, this ought to be cleansed thor-
oughly Avith Condy's fluid, or carbolic or salicylic acid; and if
irritable poulticed, some charcoal being dusted over the surface
of the poultice.  When a gland is affected here, it is undesirable
to attempt to arrest the process of suppuration—a plan not un-
desirable under some other circumstances—but to poultice it,
and lay it freely open as soon as fluctuation can be felt. 
THE LYMPHATIC  SYSTEM.
505
   § 203. The glands  are  liable to be  affected by  acute  and
 chronic diseases.   The acute form  is found under the circum-
 stances just referred to, but  is most commonly the  consequence
 of absorption of syphilitic poison from  a soft  chancre.  In the
 latter case  the attempt  to  induce resolution by painting the
 gland with  iodine is  rarely successful; and only renders the
 skin harder, and so  increases the necessity for the use of the
 knife.   When an inguinal, or other gland is inflamed from mere
 irritation, as in the case of the bubo found Avith gonorrhoea,
 then it may  not be undesirable to attempt resolution.
   At  other times the  glands undergo a more chronic form of
 suppuration, requiring  its peculiar treatment.   If the patient be
 scrofulous, no local treatment alone will affect the glands, and it
 is necessary to attend to  the general health ; to give iron, best
 combined Avith alkalies, and cod-liver oil with a liberal dietary.
 All  drains upon the system must be looked to.  In a patient at
 the  West London Hospital some time ago, the necessity for this
 was very distinctly  shoAvn  by the slow  progress of the case,
 until it AATas elicited that  the patient suffered from leucorrhoea ;
 this was attended to, and then the case moved forward swiftly
 and satisfactorily.  Very often a change of air to the country,
 and still more to the seaside, is necessary.   In other forms of
 chronic enlargement of glands, the use of iodine, and especially
 in combination with mercury, is indicated.   Not rarely pressure
 by strapping or otherwise, is useful.
   §  204. The great lymph spaces, the serous sacs, are commonly
 the seats of acute inflammation.   Of old it Avas the  practice to
 bleed freely under such circumstances; and wrhere there are not
 many other appliances at hand, this is a practice which may yet
 be resorted to with advantage.  In most cases, hoAvever, it is
 well to depress the circulation  by other means, as by antimony,
 hy aconite, or by the use of  the Calabar bean.  By so reducing
 the vascular tension the hyperaemia may be  affected in the in-
 flamed part, and one  element  of the  inflammation at  least be
 someAvhat controlled.   At the same time opium must be admin-
 istered freely.   There are no longer two smooth and well lubri-
 cated surfaces gliding pleasantly  upon each other; but two  dry,
 highly vascular  surfaces, Avhose friction upon each  other is ex-
quisitely painful.  Consequently opium in full doses is indicated.
It not only affects the terminal fibres, and so lessens the actual 
506
THE LYMPHATIC SYSTEM.
pain of the friction ; but by its action upon the nervous system,
deadening conductivity, and also lessening the  sensitiveness of
the nervous centres (Chapter XIII), it  relieves the system from
the effects of the pain.  Such  should be the plan of treatment
of simple inflammation of a serous surface.  If it be more spe-
cific, as in lithiasis or uraemia,  two common causes of inflamma-
tion of serous surfaces, then the treatment must be directed  to
the general condition ; and such apian will be found most effica-
cious in the relief of the local ailment.
  The local measures to be resorted to  are such as reason dic-
tates.  In the case of the pileura and peritoneum, their  parietal
layers  are fed  by arterial twigs arising from the same trunks as
the tAvigs Avhich supply the skin;  this is most clearly seen  in
the cutaneous and pleural twigs  of  the  intercostal arteries.
Consequently  if the circulation through the cutaneous branches
be increased, the blood-supply  to the serous layer beloAv will  be
diminished.   The application  of hot poultices or flannels to the
skin effects this end nearly as well as if the surface Avere covered
Avith  leeches,  after the old-fashioned  plan.  Free  circulation
through  the cutaneous branches, or local bleeding by leeches,
gives much relief  to the inflamed serous surface beneath ; and
by such means, and the free administration of opium, Avith some
depressant, much  relief is usually afforded.  Of course if peri-
tonitis be the consequence  of  rupture  of the  intestine, of  an
abscess, or of  an ovarian  cyst, etc., no  treatment will  be very
efficacious;  but relief at least  can  be afforded by giving opium
freely, and so  better euthanasia permitted. The exhibition  of
opium in large doses in all serous inflammations, except those
of renal  origin, is distinctly indicated.  As a rule these inflam-
mations  are not fatal, and it is very desirable  that  the painful
stage be  undergone in a state of more or less perfect  anesthesia.
The suffering may just as  Avell be avoided as not.
  In many cases such measures will be found efficient; but  in
other cases effusion takes place, as it is said—in reality the fluid
poured out into the lymph sac is not absorbed again as quickly,
and so accumulates.  The fluid is  useful in so far that it keeps
the tAvo  inflamed surfaces asunder, and relieves  them from
further friction.  This, Mr. Hilton, in his valuable  work  on
Rest and Pain, has clearly pointed out.   When once  there is
fluid  poured  out, as Ave  say, the active symptoms  cease; and 
THE LYMPHATIC SYSTEM.
507
then we are left to engage and disperse this fluid, which infringes
on and diminishes the  thoracic space.   The problem  Ave have
then to solve is the getting  rid of this  fluid ; and for  this end
Ave usually resort to the internal administration of iodine, Avith
small quantities of mercury.  The local measures in most repute
are blisters applied  around the thorax, first one, and then, in a
day or tAvo, another.   These produce a flow of blood to the cuta-
neous surface, and diminish the blood  going to the serous sur-
face beneath ; and, by so lessening  the  vascular supply, permit
of the absorption in the lymphatics  taking up  some  of  the
accumulated  fluid.   In  fact by checking the vascular supply,
and with it the  effusion of  lymph, the  absorption going on is
able to reduce the bulk of fluid ; the absorption being then in
excess of the outpouring.   The blisters are to be repeated until
a steady increase of the absorption over the influx is  instituted ;
after that is established matters soon become normal again.   If
the fluid  remains but little affected, it is Avell to  remove some
of it by the aspirator, after Avhich absorption will usually set in.
If the fluid be  not removed at a comparatively early  date, the
lung is apt to be bound  doAvn by adhesions to the costal pleura ;
as the fluid is absorbed  the chest-wall shrinks.  As soon as ever
the chest-walls  begin to fall in, the opportunity for successful
treatment has passed away—usually never to return.
  If the pleuritis has resulted  from a broken rib, it is obvious
that the treatment of such a case, par  excellence, is  to  put  the
parts at  rest by limiting the movements of the  fractured  rib.
This can be effected by  putting on a form of corset,  and lacing
it tightly.  These are the only circumstances under which tight
lacing is permissible.   At the  same time opium or  some other
analgesic may be exhibited with advantage.  In the same way
if the  pleurisy be the result of a  tubercle of  the lung imme-
diately under the surface of the visceral pleura, irritating the
costal pleura ; putting the parts at rest by checking the thoracic
movements, and leaving the respiration for a time to be purely
abdominal, is the plan to be adopted.  In fact the acute ailments
of the serous membranes demonstrate pretty distinctly how far
medicine can be rational Avith advantage; and also  how much
aid physiology can afford to practical medicine.
  § 205.  The more chronic  and passive accumulations of fluid
in the serous  sacs are troublesome  matters to  deal with.  The 
50^             THE  LYMPHATIC SYSTEM.

mere passive accumulations are most commonly seen in an a'nre
form during scarlatina;  and purgatives and  the warm  bath
u-ually procure the speedy absorption of the fluids.  In a more
chronic form they are usually the  accompaniment- of a failiuj
heart, with or without renal  complications.   In such ca-e- the
treatment t> be adopted is that of the primal and  cau-al condi-
tion, according to the rules  laid down in Chapter XIV.. local
measures being  utterly futile.  In  ascites where  there is accu-
mulation of fluid in the peritoneum, purgation, free and repeated.
followed by  stimulating diuretics, is the best method of giving
relief.   Often ascites is the consequence of an obstructed portal
circulation, due to cirrhosis of the  liver.  It may set in and be
stubbornly persistent  until the hepatic veins become inflamed.
as not  uncommonly  happens in  advanced  cirrhosis.   Under
the-e circumstances all treatment is but palliative, and the con-
dition does not admit of cure.  At  other times the  ascites is due
to some localized inflammation of the peritoneum, and yields
readily  to treatment.
  The function and anatomy of the lymphatic  system is nf im-
portance practically, and mu-t be borne in mind in a large cla-
of diseases whose connection  with the lymphatics  is not always
at first sight very apparent. 
CHAPTER  XXI.
                     THE NERVOUS SYSTEM.

   § 206. The functions of the nervous system are such as to
 render it  liable to many maladies  of  various kinds, and of
 different  characters, especially  as to severity.   Some of its de-
 rangements are sources of much discomfort rather than anything
 more; while others are fatal to life in the highest degree.  The
 successful  treatment of these maladies, that is  of such of them
 as permit of treatment—and  these  are  the majority—involves
 much reflection, and the application of physiological knowledge
 to  a very marked degree.  Thus in apoplexy—whether it be
 from rupture of a vessel, embolism, or sudden acute cerebral
 anaemia—most varied conditions, but  often resembling each other
 with a closeness Avhich only permits of their being distinguished
 by a specially-trained observer—the treatment involves a certain
 fulness of  knowledge to be really successful.  Of course  in  dis-
 eases of the nervous system, distinct and well-defined diagnosis
 is of the greatest importance, and yet this can scarcely be touched
 upon here  for obvious reasons.  Upon certain matters which are
 parts of a  diagnosis, or rather a part of the data upon Avhich a
 diagnosis is built, depends the  line of treatment to be adopted.
 If the apoplectic patient be found to have a full, well-sustained
 pulse, an hypertrophied heart with  forcible impulse, then it is
 eminently  probable  that depletory or depressant remedies are
 chiefly indicated, and best of all, their combination;  while if the
 apoplectic  sympitoms occur in a poor old  creature with  a very
 feeble  circulation, it is very probable that the  condition is one
 of acute cerebral anaemia,  where restoratives, to be followed by
 tonics, rather  are  indicated.   So too, in epilepsy, it  is  a matter
 of much practical importance  to discover if the attack, or series
 of attacks, be associated with some distant irritation, as a load
 in the intestinal canal, or is due  to central instability merely; in
 the first case a pretty effectual purgation would be indicated, in
the second  case  such treatment might be highly injurious.  So 
510
THE NERVOUS  SYST.EM.
too in neuralgia, a very decidedly different treatment is indicated
in the neuralgia? of young people, depending as they niostlv do
upon  defective nutrition of the nerves, either from insufficient
food or over-taxation of the system generally ;  and in the neu-
ralgias of advanced life, which are mostly gouty or degenerative.
In the first, good food  and tonics are to be given freely ; in the
latter a poor diet with  eliminant  measures would commonly he
required; in both, hoAvever, there might  be an equal necessity
for the liberal consumption of fat in any of its forms.
   In  the  consideration of the nervous system, one  important
fact  must ever be borne in mind, and  that fact is its  high
vascularity.   Xot only is the  supply of bloodvessels unusually
large, and their calibre comparatively great, but the Aoav of blood
through the brain is rapid and impetuous.  Though the brain of
man is but one-fortieth of his Aveight, one-fifth of the Avhole bulk
of blood passes through it.  Xot  only is the amount of blood in
and  passing  through  the brain very large, but there is also  a
great difference betAvixt the vascular condition of the encephalon
in sleep and  in great functional  activity of the brain.   The
amount of activity in  an organ  is in direct proportion to its
blood-supply;  and  the paresis of all the  cerebro-spinal system,
even  including that of  the  medulla oblongata  itself, is readily
produced  by cutting off the blood-supply.  In sleep the brain  is
comparatively anaemic  ; in intense cerebral activity  the vessels
are dilated, and the Aoav of blood  is large and  SAvift.  These
changes of the  calibre of  bloodvessels  are permitted  by the
perivascular spaces, or tunnels in the nervous  structure, along
which the bloodvessels  run.  A  serous fluid fills these spaces
Avhen the bloodvessels are contracted, Avhen they dilate  the fluid
it absorbed,1 and the vessels  till their tunnels.  By such arrange-
ment the amount  of  blood in the brain varies  Avithout com-
pression of the nerve-structure.  The brain is  also fed by two
sets of  vessels on each  side.   The cerebellum and the posterior,
or occipital cerebral  lobes, are fed  by the vertebral  arteries;
Avhile the  anterior and parietal  lobes are  supplied  by the
carotids.   The parts at the base of the brain are furnished with
blood from all four arteries by means of the circle of Willis.
These latter  parts are thus protected  in  the  most complete
Probably by the lymphatic which accompanies the artery. 
THE NERVOUS SYSTEM.              511
 manner possible from conditions of pronounced anaemia, which
 Avould be fatal.  It may, however, be seriously questioned if the
 anastomoses of the circle of Willis are equal to  maintaining
 functional activity in the hemispheres; though they do maintain
 respiration, etc., by keeping the medulla supplied with blood.
 A glance at the distribution of the vessels over the under surface
 of the brain will at once demonstrate how admirably the different
 structures at the base of the brain are fed with arterial blood ;
 and the richness of that supply, not only as an aggregate, but in
 the numbers of vessels also; so  that  the blocking-up of one  is
 of comparatively little moment.  The pia mater is very rich in
 bloodvessels; and  from it piass  myriads of little arteries  into
 the cortical  substance of  the brain, where lie the cerebral cells
 Avhich  are functionally so  important.   The  gray matter, the
 active  part of the brain, is more liberally supplied with blood
 than is the white matter.
   The  relations of the cerebral  cells  to their blood-supply are
 interesting.   There  is  no doubt that a well-sustained blood-
 supply to  the  cerebral cells is  a necessary  factor  in  active or
 long-sustained thought; and that on warm, moist, relaxing days,
 the cerebral activity is much diminished, no matter hoAV stren-
 uously the will determines that action shall prevail. The opposite
 effect of cold, bracing Aveather  in producing  a sense of energy
 and of fitness for exertion is Avell known. The amount of blood
 in the cutaneous vessels affects  the blood-pressure, and  with  it
 the amount of arterial blood in the encephalon,—perched as  it
 is at the top of the vertebral column.  In persons of the nervous
 diathesis, AArhen the nervous system is comparatively excessively
 deAreloped, and the brain bears an umvontedly large proportion
 to the general  bulk, mental   labor  under  unfavorable  cir-
 cumstances and surroundings  is  much more  possible  than
 Avith persons of other diathesis.  The inhabitants of  India are
 largely of the nervous diathesis; so are Arabs;  and we know
 how  comparatively active, both  physically and mentally, these
 creatures are  under tropical heat, to  those of a different type.
 The greater the brain in  proportion to  the body bulk, the greater
 its power; the richer the blood-supply the greater the activity;
 ceteris paribus, the larger (comparatively) brain has  it; ceteris
■paribus, the more active the vascular supply, the  greater the
 functional activity. 
512
THE NERVOUS SYSTEM.
  In the treatment of affections of the nervous system, Ave find
then that there are two  methods of acting upon the cerebral
cells, either directly  by neurotic agents, or  indirectly through
the circulation ; often the  two measures are to be combined.
The different agents Avhich act upon the nervous system have
been grouped into classes, and their action contrasted in Chapter
XIIL, to Avhich the reader  may turn and reperuse ere proceed-
ing with this chapter.  Such reperusal will render the following
sections much more lucid and readily intelligible.  It will be seen
that neurosal sedatives are also more or less vascular depressants;
and that nervous tonics also  tend to raise  the blood-pressure.
The affections of  the nervous system, however, are not to  be
approached from  their vascular side only—that would be very
absurd;  but  this  means of affecting them  must never be for-
gotten or neglected.
  § 207. Hyperemia.—Hypersemic conditions  of the brain are
very common, and mostly so in acute pyretic  affections, and in
forms of insanity  with  brain activity.    As a more  permanent
form, great  cerebral hyperaemia is often found  in  those who
persistently Avork  to excess  with their brain ; especially if there
be  also a condition of cardiac hypertrophy with high arterial
tension.   Hyperaemia of an organ  means, really and truly, not
merely  a large amount  of blood in that  organ, but a  large
amount of arterial blood passing through it.   Thus passive or
venous congestion of the encephalon belongs rather to cerebral
anaemia than hyperemia.
  Cerebral  hyperemia  is  found  in  maniacal conditions,  in
exalted conditions, and the delirium of acute pyrexiae. There is
an excited condition of the cerebral cells, in Avhich  they attract
an unwonted supply  of blood to themselves; and this increased
blood-supply maintains the  cell-activity.   But the alteration in
the cerebral  cells  here forms the starting point, and  the hyper-
aemia is secondary.  In addition to the exciting cause, whatever
it may be, Avhether a naturally unstable equilibrium, exciting
circumstances, or  an abnormal condition of  the blood itself,
there is often another factor, and  that is the increased tempera-
ture.   The hotter the blood and the brain,  the more the cere-
bral functions are disturbed ;  Avhile in great cold there is  aboli-
tion of brain function.   Consequently refrigerant and cooling
measures are ever indicated  in  cerebral activity Avith a high 
THE NERVOUS SYSTEM.
513
 temperature.  Xot only general measures, but the local applica-
 tion of cold is very useful.   Then there are nerve sedatives, by
 which nervous action may be lowered.  Chloral hydrate affects
 the  nervous  system generally, as Avell as  having a  powerful
 influence upon  the circulation.   Bromide of potassium acts
 readily upon the nervous system,  and to some extent affects the
 circulation.   These tAvo agents  then could be given  in cases of
 cerebral activity, together  Avith  opium ; or combined, with or
 Avithout it.   If  the circulation be pretty quiet a little opium,
 from its action upon the nervous system, is fairly indicated; and
 by combining it  with the other two remedies mentioned, a very
 certain and effectual action  will be produced.  Thus are ordinary
 states of excitement, or of insomnia—often due  to  cerebral
 hyperemia solely—to be met.
   When there is a pronounced condition of hyperaemia, as  in
 meningitis, then direct vascular depressants may require  to be
 added.   Before  the days of chloral and bromide of potassium,
 opium in small doses, together with full doses of such a vascular
 depressant as tartar emetic, or may be  venesection, Avas the
 plan  in  vogue; local depletory measures  also being practised.
 An  emetic of antimony generally loAvered  the  inflammatory
 changes ; or a full  bleeding was performed, and  then  repeated
 doses of antimony  kept  the circulation quiet.  Xor  Avere  such
 means at all  badly adapted for attaining the end in vieAV.  If
 practised thoughtfully and judiciously, great and pronounced
 good resulted  from such measures.  Often  doubtless these meas-
 ures ay ere abused; and the abuse commonly arose from the treat-
 ment being too  purely empirical, and because the practitioner
 thought too little of the rationale of what he Avas doing.  By
 keeping the tAvo factors of cerebral hyperaemia clearly before the
 mind's eye, the treatment Avill be guided and directed to what is
 required.   When the circulation is effectually quieted,  the pure
 narcotics may  be ghren to procure sleep.  As long as the circu-
 lation remains active, vascular depressants must form an essen-
 tial part of the programme.  Thus  in actual practice in moderate
hyperaemia, something like  the following prescription is indi-
cated :—
                    Pot. Brom. gr. xx.
                    Chloral Hydrat. gr. xx.
                    Mist. Camph. §j.
      33 
511
THE NERVOUS SYSTEM.
once, tAvice, thrice  a  day, or  may  be every six  hours.  If the
hyperaemia result from over-Avork or over-excitement, and the
circulation is rather quick, then opium might be  substituted for
the bromide.  The exact  proportions of each factor in the pre-
scription  Avould  be determined by  the  requirements of each
individual case.   The boAvels  should be kept freely open in all
cases; and smart purgation should be folloAved up by a slightly
active state of the boAArels for some time.   In referring to my
note-book for  the treatment of a Avell-marked case of subacute
encephalitis (resulting from an accident to the head, followed by
a bout of drinking), excellent effects resulted from full doses of
the bromide thrice daily ; accompanied by James's poAvder, and
compound scammony poAvder at bedtime.   This was before the
davs of chloral.  Xow chloral  Avould form at least one ingredient
of all prescriptions for cerebral hyperasmia.
  In  all cases Avhere the cerebral hyperaemia  commences in
alterations in the cerebral cells, the treatment Avill comprise two
factors, but the agents calculated  to allay cerebral excitement
take the first position ; vascular depressants and purgation being
ancillary and subordinate, but nevertheless  not to be neglected.
The temperature too  may be  important.
  §  208.  Vascular  Hyperemia.—Here another condition  of
matters exists, and our measures must be modified accordingly.
There is usually a full and bounding pulse, forcible impulse of
the heart, atheroma of the vessels, a state of general plethora, a
florid countenance, and an injected eye.    There is  no actual
delirium;  but there may be some excitement in the intellectual
functions, preternatural  sensitiveness to  all impressions, and
abnormal acuteness  of the special  senses,  together Avith  head-
ache.  Old Avriters often spoke of the  feeling being as if a
bolt Avere driven into the forehead.   In  such cases there  is
a high blood-pressure, and  the great danger is rupture of some
encephalic vessel.
   Arterial rupture here  ;s imminent, and  the  first thing to be
done is, perhaps, to bleed. Then an ample purgative of potassio-
tartrate of soda and scammony, jalap, or  gamboge should be
administered ; to be  folloAved by sulphate of magnesia, together
Avith small doses of antimony, so as to keep up the action of
the boAvels and  to  depress the circulation. If there be much
excitement bromide  of potassium in full doses might be added. 
                 THE  NERVOUS  SYSTEM.               515

A Ioav diet of rice-Avater and lemonade iced, and general quietude
are indicated.   A non-nitrogenized diet is most necessary (see
Chapter XXIII.) for some time.  The Avhole aim of the practi-
tioner Avill be directed to moderating the vascular  excitement
and relieving  the arterial  tension.   Such patients are usually
the subjects of chronic Bright's disease, the relations of which
to blood-pressure and the effects upon the circulation have been
described  at. length in several  chapters (XI. and XIV.); the
hypertrophied left ventricle and  the high  arterial tension form-
ing sources of  imminent danger to the thin-walled encephalic
arteries, no longer structurally sound.  In lowering the vascular
excitement venesection may be resorted  to, especially if drugs be
not at hand ;  but the tendency to reaction must be kept doAvn by
adding to it, as quickly as  may be,  vascular depressants and the
effects of catharsis.   In rural practice, and amidst the exigencies
of travel, and of remote colonies, bleeding may be indicated ;
and it may be necessary to repeat it if other means of subduing
the vascular excitement are unattainable.
  The consequences  of rupture must engage our attention in a
subsequent section.   (§ 211.)
  A  very  well marked condition of  combined cerebral cell-
activity Avith  high  vascular  tension is seen in the earlier stages
of the general  paralysis of the insane.   Xot only is there much
cerebral excitement, but there is hypiertrophy of the heart, Avith
loud  accentuation of the aortic second  sound, indicating high
arterial  tension.  In the.paroxysms of exacerbation  to Avhich
such  sufferers  are liable, there  is great excitement with a full
pulse.  Dr. Crichton BroAvne ingeniously appilied to the relief of
this condition  the Calabar bean ;  having noted that Dr. Thomas
Fraser in  his  experiments on  this agent, has  found vascular
depression and muscular relaxation to follow its administration.
This logical application of information derived from physiologi-
cal research to  the needs of practical medicine, has been quite
successful  as regards the immediate end sought.   Xot only that,
but it has been found that the continued use of the physostigma
tends to check the general progress of  the disease, and in some
cases even to bring  about a distinct improvement.   This is one
of the most striking illustrations of applied physiological knowl-
edge  on record ; and forms a matter of much interest outside 
.116
THE NERVOUS SYSTEM.
its importance as a therapeutic  measure of great value in  the
practice of psychological physicians.
   Such are the means then by which Ave can control conditions
of cerebral hyperemia.
   § 209. Cerebral Anaemia.—This is  the  opposite of the above-
described condition.  It  may be found in two  forms; the  one
simple  arterial  anaemia,  and  the  other arterial anaemia Avith
venous congestion.  The first is found well marked in cases of
general anaemia  and  in simple  dementia;  the other is found
most  markedly in advanced cardiac disease.  There are various
circumstances under Avhich  cerebral anaemia may manifest itself;
and these general conditions are of  much moment in selecting
the line of treatment to be adopted.  The  local condition of
cerebral anaemia may be found along Avith general anaemia; and
in chlorotic girls and delicate women a condition of cerebral
anaemia, with  droAVsiness, vertical or even frontal headache, and
depression of  spirits, Avill often  remain for some time after the
general signs and symptoms of anaemia have passed away.   At
other times it is associated Avith spanaemic conditions in various
forms of blood-poisoning, where the red corpuscles are broken
down, as in malarial  disease,  lithiasis, amenorrhcea, etc.  Here
the blood poison must be met by the specific remedies for each
form, as Avell  as by the  administration of  iron.   In cases of
lithiasis cerebral anaemia  is  common ;  especially in  the  more
advanced stages  of Bright's disease, where there is  arteriole
spasm in the branches of  the encephalic arteries, together with
a failing circulation.  In such conditions potash with digitalis
is indicated.   At other times cerebral anaemia is the outcome of
heart failure, where the blood-pressure is low and the vessels are
unfilled.  Here digitalis, by acting upon the heart at the same
time that it tightens doAvn  the arterioles on the blood column,
raises the blood-pressure and tills the cerebral vessels; and so is
most  useful.
  In all cases  there  are tAvo points to be attended to; they  are
the increasing of the  blood-pressure, and  the  supply  of liberal
quantities of arterial blood  of normal quality to the contents of
the encephalon.  Any deficiency in  quality as well as quantity
is felt by the cerebral  cells.   Whatever their potential activity,
a free  supply of healthy  blood is requisite  to  their proper
functional working.   Consequently there  are  several  points to 
THE NERVOUS SYSTEM.
51Y
 be attended to in the  treatment of cerebral  anaemia.   First,
 in all cases the blood must be of normal  quality and  rich in
 nutritive material.  Chalybeates are  almost always indicated;
 and in cases of spanaemia from the presence of  some poison the
 chalybeate  must, as  has been insisted on frequently before in
 these  pages, be combined with some  specific remedy; Avithout
 which iron is  often given in vain.  Then, while  giving  agents
 which increase the blood-pressure, it is desirable to administer
 nervine  tonics, quinine, strychnine, or belladonna.  The first
 tAvo all  are fairly familiar Avith ; but belladonna is not yet so
 well  known, for  this  purpose at least.   Yet  belladonna acts
 poAverfully  upon the heart at the same  time that it dilates the
 encephalic  arterioles.   Dr. Crichton  Browne has found  it very
 valuable  in the treatment  of emotional melancholia;  where
 there  is defective nervous activity,  the  result of some  shock,
 which depresses alike the cerebral functions and the circulation.
 Its use, too, is indicated in that stadium melancholicum which so
 commonly precedes actual  insanity.   Alcohol has an identical
 action upon the  circulation  and the brain-cells; and it is the
 relief  it affords to the miserable  depression of  cerebral anaemia
 which forms its irresistible  allurement  for  many persons, espe-
 cially  females.   If their cerebral anaemia be relieved by other
 measures the craving for alcohol is not felt; when the effects of
 other  remedies Avear off, then the craving comes back Avith all
 its terrible resistless force.
   This is one point to be attended to in the administration of
 tonics, and especially nervine tonics, in case  of cerebral anaemia.
 It is Avell pmt by Handfield Jones.  "Xothing is more common
 than to  find anaemic  patients  complaining  of headache from
 the administration of the necessary tonics, because their nerve-
 centres have been brought into such a state of hyperesthesia by
 the impaired nutrition that  they can hardly tolerate anything
 of a stimulating  nature.   A little  excess, therefore, even  of
 spanaemic blood, may  cause  distress to a feeble  brain, Avhich,
 after it has  acquired a  more healthy tone, will  bear and be
 benefited by a larger amount of  much better blood.  The case
 is similar to that of the  starved man, Avhose very preservation
depends upon his being fed most sparingly for some time."
  In such cases, and they are frequently met with, the  admin-
istration of  tonics and steel  may be combined Avith bromide of 
518
THE NERVOUS SYSTEM.
potassium and, even still  better, hydrobromic acid, Avith advan-
tage.   Such combination but very rarely disagrees, even Avhere
nervine tonics alone, or not so combined, are utterly intolerable.
Often, too, it is well to keep up a gentle action on the bowels ;
as is so Avell known in connection Avith the commencement of a
course of ferruginous tonics.
  There is also another point to  be  attended to in connection
with the treatment of cerebral anaemia, and that is its relation
to the production  of sleep.  If the more strictly  depressant
hypnotics, as chloral and bromide of potassium, be  given, the
tendency is to retard recovery in the convalescent melancholic ;
and in many cases of melancholia to transfer  it on to the more
pronounced condition of dementia.  Both Crichton BroAvne and
Hammond are strong upon  this point; and they arrived at this
conclusion quite independently of  each  other.   Opium  and
alcohol are either of them preferable; as not tending so strongly
toAvards  the production  of chronic  brain starvation  as  these
other tAvo agents do.   This point is of the more importance in
that there  is  often  persistent  insomnia  in cerebral  anaemia.
Whatever the medicines  ghTen  at  bedtime, nervine  tonics
should be given during the day.
  § 210. Local Cerebral Ancemia.—This is a subject of no slight
importance in  general practice, as Avell as in  asylum practice.
We  have  just briefly reviewed the  circumstances  of  general
cerebral anaemia; not, however, alluding to that form which is
apparently the result of vaso-motor spasm—not being gouty. In
many cases this spasm is the cause of cerebral anaemia, especially
in the demented forms of melancholia.  It is here where bella-
donna is often  so useful.  But there is also partial anaemia, as
in ordinary melancholia, when the intelligence is unaffected, and
the patient merely seems  to see  everything through sepia-tinted
spectacles.   Conditions of depressions in  the  sane are of like
causation.  Here  there is, in all probability, an anaemic con-
dition of  the posterior, or occipital cerebral lobes, which, as we
have  seen, are  fed  mainly  by  the  branches of the vertebral
vessels after their fusion into the basilar artery. Schroeder van
der Kolk  and  Laycock  ha\7e long taught that these  occipital
lobes  are in  connection  Avith  the  systemic  sensations and
the viscera—conclusions corroborated  by  the investigations of
Ferrier.   Consequently Ave can understand the melancholia of 
THE NERVOUS SYSTEM.
519
liver disease ; or even the more illustrative cases of melancholia
attendant upon  scybalae in the lower  boAvels,  or upon a mis-
placed uterus, coming on and passing away Avith these causal
conditions.  Xot only so, but there is  a point of much import-
ance, hitherto curiously overlooked ; and that is the vaso-motor
nerve-supply of the carotid and of the vertebral arteries.  They
are quite distinct.    The carotid arteries receive their nerves
from the superior cervical ganglion ; while the vertebral arteries
are supplied from  the inferior cervical  ganglion, Avhich is in
more intimate  relation  with  the thoracic ganglia  and  the
splanchnic nerves, Avhich supply the abdominal viscera.  Cyon
and Aladoff have traced nerve-fibrils from the vaso-motor centre
doAvn the vertebral arteries,  through the inferior cervical gan-
glion, the annulus of Vieussens, the thoracic ganglia, and down
the splanchnics to the liver.  This  of  course applies to efferent
descending  fibres piassing from the centres to the viscera; but,
judging from  analogy, the afferent fibres ascending from the  vis-
cera to  the nerve centres folloAV the same route.  Thus we now
comprehend hoAV disturbance in the abdominal viscera can  pro-
duce melancholia, Avithout the intellect being obviously affected.
There is anaemia of the  posterior cerebral lobes from arteriole
spasm, the result of  distant irritation ;  and  consequently the
remoA^al of this distant cause is as necessary to the treatment of
the case as is the administration of nervine  tonics and chalybe-
ates. In simple  melancholia, the motor centres—in the parietal
lobes—are not affected ;  in  general  cerebral anaemia, as  in de-
mentia, they are involved.  This corroborates the view taken
here.
   § 211.  Insomnia.—At  the expressed Avish  of several friends,
instead  of the  remarks  in  the first edition, I have  put here
verbatim  an article  on the causes and treatment of sleeplessness,
which appeared  some time  ago in  the Practitioner; Avhere the
subject  is pretty  completely  discussed.
   Sleeplessness is one of the most troublesome ailments Avhich
medical practitioners are called  upon to treat.  It is annoying
to the  patient—to  Iioav great an extent, probably,  only those
who  suffer  from it  can  appreciate ; it  is troublesome to  the
practitioner from its frequently  intractable character.  Much,
however,  of the  difficulty of treating insomnia  satisfactorily
lies in the complex associations of the malady.  The measures 
520
THE NERVOUS SYSTEM.
which will readily procure sleep under one set of circumstances
fail signally  when  employed under  other circumstances;  and
yet the causes of such failure often remain undiscovered because
they  are  not studiously  sought for.  In order to render the
subject more intelligible, it may be Avell  to glance  at the
physiology of sleep, and then to proceed to review the different
forms of insomnia, Avith the form of treatment appropriate to
each.
  Sleep is a condition of physiologically cerebral  anaemia.  At
one time—not so very long ago—it Avas thought that sleep Avas
connected Avith a state of vascular congestion of the brain ; this
vieAV took its origin  in the vascularity found after fatal doses
of opium.  In reality, in such fatal cases there is marked venous
congestion of the brain  ; but then the condition preceding death
here  is fatal  coma, not  normal  sleep.   The experiments of
Durham, Hammond, Donders, and others, have placed beyond
doubt the relations of sleep to cerebral anaemia. Such conclusion
might have been anticipated from the physiological laAv—that
the functional activity of an organ is in direct proportion to its
blood  supply.  This condition of anaemia  is produced  by the
co-operation of two factors : one, a modification of the vascular
system ;  the  other, a diminution of activity in  the  cerebral
cells themselves.  It is  the combination of  these two factors in
the production  of sleep that must  ever be  borne  in mind in
the treatment  of each  case of  insomnia.   According  to the
predominance of one or  other of these factors  must  the re-
medial measures be selected and  proportioned, if they are to be
successful.   The measures Avhich Avould be most appropriate
to  the relief of insomnia  in  the convalescence  after a fever,
would be most unsuitable in the sleeplessness of the gout.
   It  will, perhaps, be  Avell to take the simpler  forms of in-
somnia first, and  then to proceed  to the  more complex and
intractable forms.  With  many persons sleep is  unattainable if
their feet be  cold.  This condition, depending upon contraction
of  the arterioles of the  loAver limbs, is  not confined  to the
extremities of the limbs, though, of course, it is most pronounced
there.  It affects a large portion of the vessels of the body, and
by thus, as it were, driving the blood to the head, keeps up a
condition of arterial vascularity in the brain, Avhich effectually
prevents sleep.  Here the Avarming of the feet is often sufficient 
THE NERVOUS SYSTEM.
521
 to permit  of sleep Avithout  any resort to hypnotics.   In order
 to warm the feet, many resort to hot bottles ; but a much more
 effectual method, especially with young persons, is to immerse
 their feet  in cold water  for a  few moments, and then  to rub
 them Avell Avith a rough  towel until they become  warm.   If
 this be  done ere getting into bed, that  coldness of the feet
 Avhich is so inimical to sleep, will, usually, be no longer felt.
   Cold is often a cause of insomnia.  If  insufficiently clad, so
 that the cutaneous vessels are not relaxed, sleep is rarely sound,
 when attained at all.  It is only  Avhen stupefaction  from cold
 occurs that  the dangerous  coma-sleep comes on Avhich is  so
 often fatal.  With many persons sleepi is impossible if the bed
 be not Avarmed  previous  to  their  entering it.   In these cases,
 the arteriole contraction, induced  by the  contact with the cold
 bedclothes, does not pass readily  into the opposite  condition
 of relaxation, and so sleep  does not come on.   This state  of
 affairs is very commonly met with  among the aged, the most
 so in  those  Avho suffer from some  form  of heart-disease.  In
 such  cases it is not only desirable to Avarm the bed and the
 night-clothes, but even to administer some  hot fluid, all the
 better for  containing alcohol,  when  the  patient has got into
 bed, if any  sense  of chilliness remains.   In  the young and
 healthy, the chill on getting into bed, hoAvever, is often of great
 service  in  inducing a subsequent  relaxation of the cutaneous
 A'esscls,and thus conducing to more perfect cerebral anaemia and
 sounder  sleep.  Few persons will have failed to  note the deep
 and  usually refreshing  sleep  Avhich  follows  any disturbance
 during  the  night, Avhich has  exposed them briefly to cold.
 Getting upj to do some little service for  a sick friend,  or  to
 attend to  some  natural  call, will usually lead  to a sense  of
 chilliness, Avhich makes the Avarm bedclothes extremely comfort-
 able on again getting into bed, and Avhich  is followed by sound
 sleep.  Here  the brief contraction of the peripheral  vessels  is
 folloAved by  relaxation,  leading to more complete cerebral an-
 aemia.
  At  other times an increase of the body-temperature is the
 cause of disturbed sleep, sometimes amounting  to sleeplessness.
 This is most  frequently seen  in  febrile  states, where a delirious
 condition takes  the place of  natural  sleep. After the tempera-
ture has been  brought down by the application of cold, a fever 
522
THE NERVOUS SYSTEM.
patient will commonly fall into refreshing sleep, until a return
to a fever-temperature disturbs  it.  In slighter conditions of
restlessness, associated Avith too  great a body-temperature, the
dissipation of a certain amount of superfluous beat by getting
out of bed and drinking a draught of cold water, will usually
be folloAved by sound sleep.   At other times, throwing off some
of the bedclothes will achieve the same end:  though, if the
amount removed be  too  great, Avakefulness  may follow from a
too low temperature being brought about.   With some persons,
Avhen the  rest is disturbed, it is sufficient to protrude an arm
or a leg from under  the bedclothes, so as  to secure more loss
of heat ; and sound sleep Avill folloAV.
   At other  times  sleeplessness  is due to a  condition of high
cerebral vascularity, accompanied Avith excitement in the cir-
culation generally.   This associated condition  may be due to
inflammation someAvhere, which  sets up  the  usual  vascular
excitement of inflammatory conditions, together with excitement
in the cerebral cells, produced by the sensations of pain received
by them.  Or  it may be due to  an  inflammatory condition in
the brain itself; or to a condition of high cerebral vascularity
falling short of inflammation, as  in the paroxysms of excitement
in A^arious forms of insanity, or in acute mania.   Here there Avill
be found in varying proportions (1) local (cerebral) hyperemia,
(2) general vascular  excitement, and (3) a rise  of temperature.
When  sleeplessness  is found  under these  circumstances, the
treatment must embrace the different factors, and include each
in the remedial  measures  employed.  Opium  will not  alone
meet these complex  states.   In  order to  procure its hypnotic
effects, it is necessary to combine it Avith a  direct vascular
depressant.   The  rule laid  down by  Graves, as abridged  in
 Ringer's Handbook, for  the administration of  opium in excite-
 ment and furious delirium, Avas  to combine it Avith antimony.
 u Each drug seems to assist the  action of  the other; and the
 relative doses must  be determined by the  circumstances of the
 case.  In  furious delirium the  tartar emetic must be given in
 full, and the opium  in sniall  quantities;  while, if wakefulness
 is the chief symptom, the delirium being not  very boisterous,
 the dose of tartar emetic must  be  reduced and  the opium  in-
 creased."   Graves Avas evidently a  most sagacious physician.
 Of course it is not  supposed that these  rules  were solely due 
THE NERVOUS SYSTEM.
523
 to him, but they evidence a most practical grasp of the difficul-
 ties encountered in  practice, and the measures best adapted to
 overcome them.  When the  condition of wakefulness is little
 if at  all associated  Avith general vascular excitement, then the
 opium alone is sufficient  to produce quiescence in the cerebral
 cells.   When,  hoAvever, there  is much  excitement in the circu-
 lation along with the insomnia, then a direct vascular depres-
 sant is needed  to calm the vascular element in the isomnia.  At
 the same  time the antimony  affected the body temperature.
 Consequently, we see the measures employed struck at each and
 all of the factors of the sleepless condition.  In the piresent day
 Ave have chloral-hydrate, Avhich combines the  actions necessary
 for the relief of such form of insomnia.  It acts upon the nervous
 system ; it lessens the  heart's action ; and loAvers temperature.
 But if thus suitable to one form of sleeplessness, the very quali-
 ties Avhich here render it so valuable constitute the objections to
 its use in other forms of insomnia.
   There are some points to  be noted in connection with the
 relations of sleeplessness to pain and to pyrexia,  Avhich are de-
 serving of attention.  Pain excites  the cells of the sensorium,
 and such activity in them causes them to attract more  blood to
 themselves, by which their activity is maintained.  That, Iioav-
 ever, is not all.  Pain  has a stimulant effect  upon the circula-
 tion, and causes a rise  of  blood-pressure  in the  vessels of the
 body generally, including  those Avithin  the cranium.  If pain
 be not too excessive, it does not induce shock ; indeed, the pulse
 will be found  to  be fuller, and less compressible, Avhile its beat
 is slower, during the infliction of  pain.  In  an  article by the
 Avriter in the December (1875) number of the Practitioner,  it is
 written (p. 437): "The  effect of the  pain Avas to improve the
 pulse, which became  slower  and fuller  under the stimulus."
 Consequently,  then, in conditions of severe pain accompanied
 by vascular excitement, opium should be combined Avith a direct
 depressant, as aconite, antimony, or chloral-hydrate, in  order to
 successfully overcome the  resultant  insomnia.  The opium  will
 diminish the receptivity of the cerebral cells, but, alone, it is
 not sufficiently depressant to affect  the circulation.  Heat is a
 most powerful  excitant  of the heart's  action, and conditions of
pyrexia are ever accompanied by an  elevation  in the number of
pulse-beats in the minute.   Such stimulation of the heart causes 
521
THE NERVOUS SYSTEM.
an abnormal amount of blood to be pumped into the arteries,
and this arterial fulness is hostile to sleep.  The effects of a too
high temperature in disturbing sleep has been alluded to before,
and the effects of loAvering the body-temperature in inducing
sleep referred to.   In conditions of p>yrexia Avithout pain, opium
alone is unsatisfactory as an hypnotic; it is here  far inferior to
chloral.  Indeed, in the treatment of sleeplessness due to  too
high a body temperature, apyretics are distinctly called for; it
may not be amiss to combine them Avith the ordinary soporifics,
but they constitute the treatment essentially.
  All poAverful impressions made  upon sensory nerves not only
excite the sensorium, but they raise  the  blood-pressure.  This
holds good of sensations received  by  nerves of special sense, as
well as by those of general sensation.  The eyes are closed in
sleep, and the cutting off of the stimulant sensations, coming in
by the  optic nerve, conduces  poAverfully  to  that result.  Con-
versely, on aAvaking  the eyes are opened,  and  the inrush of
sensations caused thereby produces a more active state of Avake-
fulness.  If, Avhen  partially  aAvake, the eyes  are  kept closed,
sleep  more readily returns than  is the case  Avhen  the eyes are
opened : and similarly if the eyes are opened in the dark, there
is less stimulation experienced than occurs if  the eyes are opened
in daylight.
  Sleeplessness is a common symptom of lithiasis or suppressed
gout.  The patients compdain  that they cannot get off to sleep;
it is not pain that keeps them awake—they cannot " catch sleep,"
to use the expression they commonly resort to.   Their thoughts
traATel in a circle, and the process  is tiresome and  barren of re-
sult, and tends to keep up the feeling of irritation experienced.
When morning is far advanced sleep comes on, but it is brief,
and  the  sufferer  aAvakes Aveary  and unrefreshed.  Here  the
cause of  the sleeplessness  is almost  entirely the  high blood-
pressure; though  probably the effects of  nitrogenized  waste
upon  the cerebral  cells are of a stimulant  nature.  This  high
blood-pressure is due to the action of  the effete matter in excess
upon the  circulation ; of which  the accentuated second sound,
the incompressible  pulse, and the free Aoav of  pale urine are
Avitnesses.  In sleeplessness occurring under these circumstances
opium  is useless, and very commonly is harmful, increasing the
excitement instead of allaying it.  Chloral-hydrate often is very 
THE NERVOUS SYSTEM.
525
 useful, and Avith some gouty persons acts like a charm, though it
 disagrees Avith others.  Bromide of potassium is very serviceable
 here, and may advantageously be combined Avith hyoscyamus or
 Avith tincture of hop.   This last combination, or chloral, may
 be taken at bedtime  in such  insomnia, but a course  of alkaline
 waters, or potash and  buchu, with a non-nitrogeuized diet, is
 also most desirable.  The  elimination of the already existing
 uric  acid  by such  remedial measures, and the  arrest of its
 further  production  by a suitable dietary, Avill  be found most
 effective in the alleviation  of the sleeplessness of  the lithaemic
 —a sleeplessness Avhich is very intractable to ordinary hypnotic
 measures.  There seems  much  reason to  suppose  that  the per-
 sistent insomnia of the  more affluent classes, which impels them
 to resort to the most poAverful and dangerous hypnotics in order
 to procure sleep, has in it an element  of gout which is  not
 recognized, and which tliAvarts the measures ordinarily effective
 and  operative; so that remedies of umvonted  potency or  in
 unusual doses  are necessary in  order to secure sleep, or rather
 unconsciousness.
   A  totally different form  of sleeplessness is found along with
 cerebral anaemia.  Here there is sleepiness felt during the day,
 and  especially Avhen the upright  posture is assumed ; but  at
 night, on lying down, instead of the  inclination to slumber
 becoming more pronounced, a state of Avakefulness is instituted.
 Hammond explains this on the ground that the brain is anaemic,
 and consequently lethargic, when the skull is the highest  point
 in the organism, and  the  blood falls away into the  unfilled
 vessels by the force of gravity ; but that, Avhen  the horizontal
 posture is assumed, the head ceases to be  the highest point and
 then the blood returns  to it,  fills the intracranial vessels, and a
 state  of Avakefulness is induced.   These patients could sleep
 Avhen going about their duties in the day, but they cannot sleep
 when they go to bed at night.  Such a  condition is found in
 a  most pronounced  form in  melancholies.  It has been found
 that  in such patients  bromide of potassium, or chloral, however
 effective in procuring sleep, are unsuitable and indeed mischiev-
 ous from their tendency to  aggravate  the condition of anaemia.
 When administered to the convalescent melancholic they retard
 recovery, and  when given in  the earlier stages tend to produce
still further " brain starving," and to transfer the condition from 
526
THE NERVOUS  SYSTEM.
one of temporary melancholia into the more advanced and per-
manent condition of chronic dementia.  Both Crichton Browne
and Hammond decry the resort  to the above-named narcotics in
cerebral anaemia, and advocate instead the use of alcohol and
opium.  These latter agents first dilate the cerebral vessels ere
producing contraction of them, and  so  relieve the condition of
gloom ere the patient falls asleep.  Xor is the condition of cere-
bral anaemia induced by them  so persistent and mischievous in
its after-consequences as that produced  by chloral and bromide
of potassium.  In the sleeplessness of cerebral anaunia, alcohol
and opium may be  given alone or combined at bedtime, for the
purpose of procuring sleep ; but their administration must be
accompanied by a generous and  liberal dietary, and by the exhi-
bition of iron and of quinine in  fair quantities.  By such means
the brain recovers its normal vascularity, and  the  sleepiness of
the days and the sleeplessness of nights are exchanged  for  the
usual sensations.  In order to  give tone to the unfilled vessels
digitalis—though  it raises  the  blood-pressure—may often be
given with advantage along Avith the quinine and iron.  There
is nothing  inconsistent  about  the use of quinine under such
circumstances.
  Sleeplessness is, of course, a consequence of cerebral  hyper-
aemia.  We have already  considered its association  with con-
ditions  of active hyperaemia, accompanied by general vascular
excitement, and the appropriate  measures  for its treatment.
There is, however, another form of cerebral hyperaemia, in Avhich
insomnia is a prominent feature, that calls for remark.  This is
a form of passive hyperaemia from partial vaso-motor paralysis of
the intracranial bloodvessels, usually associated Avith mental over-
Avork.  It is described by Xiemeyer as a condition in  Avhich the
mental disturbance is so great that it stimulates melancholia, or
mania.  There is restlessness, anxiety, a general sense of dread,
and  such patients  "cannot stay long  in  one place, go  about
restlessly, are worried, and are conscience-stricken  about  slight
trifles."  This last is a very significant statement, and throAvs
a  light  upon some unfortunate actions otherAvise apparently
inexplicable.   In  speaking of  the  accompanying  insomnia,
Xiemeyer  Avrites:  "In such cases  the sleeplessness is  almost
absolute ; opiates have no effect, or, after  the exhibition of  this
remedy, Avhich is injurious and dangerous to the  patient, there 
                  THE NERVOUS SYSTEM.               527

is a short restless sleep*, from Avhich the patient aAvakes with all
the symptoms increased."   In such conditions it is obvious that
the line of treatment to be pursued is one Avhich will rest  the
excited and irritable brain, and in doing so embrace the con-
dition of the bloodvessels, which is  so  important a factor in
the malady.  That a brain  overtasked and approaching exhaus-
tion should show great irritability, is  in strict accord Avith Avhat
we  knoAv of the  symptoms of  commencing nerve-exhaustion.
That the Avearied brain should become  hypersensitive  about
trifles is  also in unison with our experience, and that the mental
symptom—a  morbidly exacting  conscience,   should  manifest
itself, is Avhat  Ave may readily believe.  In  such a state the
person is indeed to be  pitied, for all causes of pain or trouble are
magnified, Avbile the power to bear up against them is lessened.
Xor is the  suicide which  occasionally gives a  shock to society
unintelligible, Avhen Ave consider the number of individuals, and
those too the most sensitive, avIio are  reduced, more or less  pro-
nouncedly, to this pitiable condition.   In  estimating the  effects
of Avorry, of anxiety, of OA^er-sensitiveness upon any individual,
Ave must not either overlook  or  underestimate the peculiarities
and capacities of such  individual.  What may be  sufficient to
utterly break doAvn one person, may be borne  by another with
comparative equanimity,  or even perhaps Avith  ease.    But
hecause such is the case, it does not folloAV that the burden has
not been too great for  the person \ATho succumbs under it.
   What  the line of treatment to be  pursued  under these  dis-
tressing  circumstances should be  noAv calls for our attention.
Xiemeyer has told us that opiates are injurious. The vaso-motor
..paralysis Avhich folloAvs the use of this agent  evidently  aggra-
vates the already existing condition.   Chloral produces cerebral
anaemia,  but  from its enervating effects upon the circulation
it tends  to  make the general condition worse, Avhile it  affords
temporary relief.   It  is not merely a question  of regulating, so
far as may be possible,  the intracranial circulation ;  the condition
of the cerebral cells calls for attention. A great portion  of the
hyperaemia  is due to the persistent call of these cells for  blood,
until piassive congestion, from vaso-motor paralysis, is induced.
It is obvious then that one constituent factor of the treatment
must be  to  lessen this cerebral  activity by some suitable  agent.
Of all our remedies for such end, probably bromide  of potassium 
528
THE NERVOUS  SYSTEM.
is the most efficient.   It leads to cerebral anaemia chiefly by its
action upon the cerebral cells, lessening their activity and so
diminishing their call for blood;  Avhile it exercises some sedative
effect upon the circulation.   With it digitalis may be advan-
tageously combined.   The efficacy of such combination, in cases
of cerebral disturbance Avith a feeble circulation, is  no longer a
matter  of hypothesis, it is an ascertained fact.  Doubtless in
such cases it is the action of digitalis upon the peripheral vessels
rather than its effect upon the  heart  which  is valuable here.
The action of  digitalis  in contracting  the  terminal vessels is
pronounced, and such action  is very useful  in the  cases under
discussion.  Very possibly the allied action of ergotine may make
it equally serviceable; and the use of  ergotine in asylum prac-
tice to control  cerebral hyperaemia is on the  increase.   By such
a line of practice, then, Ave secure a condition of comparative
inactivity in the  cerebral cells,  and also give tone to the en-
feebled  encephalic vessels.  But Avhile  doing  so, the demands
upon the brain  should be reduced to a minimum, and all  out-
Avard and extrinsic sources of disturbance should be, as far as is
practicable, done aAvay with.  As complete rest as is attainable is
an important  matter.  Then  again the blood itself  should  con-
tain fair quantities of nutritive  material, in  order that the nu-
trition  and restoration  of the exhausted cerebral cells  may he
achieved and augmented.  For this end liberal supplies of easily
assimilable food, some generous Avine, and iron along with qui-
nine, or even strychnine, should be taken.  There  is no incon-
sistency in giving quinine and strychnine, powerful nervine
tonics, during  the day, together Avith hypnotics at night—cer-
tainly not.  By the combination of such measures good results
may be expected, Avith more or less confidence, according to the
state of the patient, the original  constitution, and the conditions
of the environment.  The treatment, hoAvever, requires time, and
compliance Avith it on the part of the patient. If  it be impos-
sible, or be thought to be impossible, to lessen the demands upon
the brain, and this latter will but too easily and readily occur
in  the  abnormal conscientious  state Avhich  iioav obtains,1 the
treatment will be unsatisfactory ; and  then  the patient  will

  1  Oliver Wendel Holmes, Avith his graphic and happy descriptions, tells us in
Elsie Tenner, Avhat a terrible and exacting affair a sick or morbid conscience can
be. 
THE NERVOUS SYSTEM.
529
 usually resort to those potent measures by Avhich sleep, or rather
 unconsciousness, may be certainly induced, and will  sooner  or
 later pay the price for it.
   When, hoAvever, in addition to the  condition just described,
 there  is added an element of  lithaemia, and  the cerebral cells
 are further  irritated by  the products of nitrogenized  Avaste,
 then the case becomes trebly difficult to manage.   The tendency
 to such complication  is furthered by the resort to  stimulant
 nitrogenized food by  such persons, in order to  increase their
 strength  and  improve  their condition ;  a very  natural error.
 In many cases, too, in addition to this excessive consumption  of
 albuminoid  matters, there is  imperfect  elimination  of Avaste
 matters from the sniall quantities of fluid imbibed, Avhich are
 insufficient to that  thorough  washing-out  of  the tissues,  so
 desirable Avhen there  exists an excess of effete matter.  This latter
 is  especially  the  case  with  ladies, whose social  requirements
 cause them to imbibe as small a bulk of fluids as is practicable.
 In such cases it is necessary, in addition  to Avhat has just been
 stated, to give the patients free supplies of  alkaline Avaters,  as
 Vals, Vichy, Carlsbad, Seltzer,  or others, so as to at  once secure
 the quantity of fluid necessary, together with the formation  of
 soluble urates, Avhich  Avill  readily find  their Avay  out  of the
 organism  by the  natural  emunctories.  Without attention  to
 this factor in the  case, the other remedial measures will be but
 inefficient, or even futile.
   Having  thus revieAved  the different forms of  sleeplessness,
 except perhaps that of acute mania, Avhich scarcely conies within
 the sphere  of this article, something may now be said about the
 chief forms of hypnotics in common use.   They cannot  be dis-
 cussed  at length, such treatment of the subject would  be out of
 place here:  the .chief indications only can be given.
   To take Op>ium first.   Its use  is rather indicated  in conditions
 of insomnia Avhich take their origin  in  pain.   When there  is
 vascular excitement  present, it is desirable to combine Avith  it
 direct  depressants of the  circulation, as aconite  or antimony.
 The subsequent cerebral anaemia induced by the resort to opium
 is not so pronounced as is that induced by chloral.
  Hyoscyamus takes  its place alongside of opium, and may be
resorted to in cases Avhere  opium or  morphia disagrees, as in
cases of chronic renal disease.   I^or these last class  of patients
      34 
530
THE NERVOUS  SYSTEM.
the tincture of hop is often very serviceable, though iioav rarely
prescribed; it is a very satisfactory agent in such cases.
  Hydrate of chloral is comparatively valueless in sleeplessness
due to pain, and  is inferior, in this respect, it is said, to the
croton-chloral-hydrate.   It is, however, very useful in conditions
of vascular excitement, either  alone, or in  combination with
opium.   In the delirium of acute pyrexia in children it may be
usefully  combined with the bromide of potassium.   In cases of
sleeplessness where there is a sustained high blood-pressure, or
Avhere there is distinct pyrexia, chloral hydrate is the hypnotic
par excellence.  It is, however, decidedly to be  avoided in cases
Avhere the  inability to  sleep  is due to Avorry and  to brain
exhaustion.   In  such case3, as in melancholia, the cerebral
anaemia Avhich folloAvs its use is  most  objectionable and mis-
chievous.  It amounts to u brain-starvation,"  in fact, and the
persons so affected  are reduced to  a  pitiable  condition. The
persistent resort  to  chloral-hydrate is  most disastrous in  its
consequences, and the temporary relief afforded  by it is not to
be set against its  after-effects.
  Bromide  of potassium  has a decidedly sedative effect upon
the brain-cells; and the cerebral anaemia produced by its admin-
istration is rather due to its sedative  action upon the cerebral
cells by Avhich they attract  less  blood  to themselves, than to its
effects upon the circulation ; though doubtless to some extent it
does diminish the activity of the  heart.   Its special adATantage
lies in its utility, where cerebral activity is kept up by far-away
peripheral irritation, especially Avhen that  irritation  lies in the
pelvic viscera.   It may be  given alone, or Avith  opium, or with
chloral, according to circumstances; and may often be usefully
combined Avith hyoscyamus in cases Avhere opium  is contra-
indicated.  Its constant use, however, leads to diminished brain
activity, and to intellectual lethargy.
  Chloroform is a most potent agent, but is rarely resorted to as
an hypnotic until other means of attaining the desired end have
failed.   The dangers attendant upon its use are so great that it
is only resorted to in dire necessity.  It is, hoAvever, occasionally
used  as  a narcotic by the profession, but  more frequently by
persons upon their  OAvn responsibility.   This  chiefly occurs in
those subject to sudden and unendurable pain, where nothing but
the narcosis of chloroform would be effective.   Probably indeed 
THE NERVOUS SYSTEM.
531
in these cases, all other and less objectionable means of attaining
relief have been tried and  have failed.  According to Claude
Bernard, by combining opium, or rather morphia with chloro-
form, the sensory nerves and centres are affected ere the intelli-
gence and the motor poAvers are  much  influenced.   But with
chloroform alone all are equally and alike affected.  The danger
of chloroform inhalation lies chiefly in the  risk of an overdose
being taken; as unconsciousness creeps on  the motor power is
involved, and then the amount taken  may  be, and too often is,
far beyond Avhat Avas intended.   In  another communication in
the Practitioner, February, 1876, Avill be found some account of a
most ingenious apparatus, by Avhich the supply of  chloroform is
cut off as soon as the  motor poAver is impaired.  If resort to
chloroform inhalation cannot  be avoided  by certain  sufferers,
surely it is not objectionable from any point  of view that the
danger attendant thereupion be reduced to a minimum.
  There is another hypnotic agent of undoubted potency, Avhich
cannot be overlooked in the present inquiry, and  that is—alco-
hol.   If  there be any use of alcohol that is free from  objection it
is its use as a narcotic in certain conditions.  With many persons
a dose of alcohol at bedtime is the very best nightcap they could
possibly resort to.  The cases  best adapted to its use are those
Avhere there  is mental worry and anxiety.   In such states the
first  effect of alcohol in removing gloom and substituting pleasing
sensations for unpleasant thoughts is eminently useful. A series
of pleasant mental images are brought up on the mental horizon
by its means, in place  of the triste  and sombre subjects which
before its use occupied the foreground of the consciousness ;  and
Avith such agreeable  objects uppermost, the  secondary effects
come on, and the patient is  wrapt in a refreshing renovating
sleep.  Probably the evil  after effects of  alcohol, so used, are
less  than those of any other agent which would achieve the
same end.  Unfortunately, however, commonly the very persons
for whom alcohol would form the best hypnotic are those most
opposed  to  its use;  and where a full  dose  of alcohol would
constitute the best  remedy that could be resorted to, prejudice
prevents its employment.
  So much  for the  ordinary narcotic agents in common  use.
Over and above these are some other means  of insuring sleep,
Avhich are not contained in the pharmacopoeia.  Nor are these 
532               THE  NERVOUS SYSTEM.

measures of little avail;  they might be more commonly resorted
to Avith advantage.
  The first of these is  bodily exercise, especially out of  doors.
Many cases of sleeplessness, as our common experience tells us,
are due to  this cause.   With a number of individuals the omis-
sion of  their Avon ted Avalk is folloAved by a restless and uneasy
nio-ht.  In such  cases it would seem that very probably there
are a number of motor centres in the cerebral convolutions Avhich
are still in  a state of high tension, highly charged and  unrelieved
by discharges.  It is not difficult to conceive that under such
circumstances  there should be such activity remaining  undis-
charged as shall  seriously interfere Avith the quiescence of those
centres  which have not only  been relieved  by discharges, but
Avhich are  in that state of irritability Avhich is the forerunner of
exhaustion.   Muscular exertion Avould relieve this condition of
matters, and so Avould  tend to the induction  of sleep;  not only
that, but, according to Preyer, the products of muscular exer-
tion  are directly hypnotic in  their action.1  If such a view
should  be substantiated, then muscular activity Avill take a
decided position in  the ranks of the means by Avhich sleep may
be secured.
  In addition to these measures already enumerated, there  are
the  mental means of attaining repose.   Just as  worry,  excite-
ment whether of a pileasant or of a disagreeable nature, anxiety,
and other  mental conditions do aAvay Avith and destroy sleep, so
psychical quiescence tends to establish  it.  Different individuals
seek this  quietude in various Avays  and by varied measures.
Thus in many families  it is customary  to abstract  the mind
from the distracting affairs of life by music ;  and such diversion
of  the  thought  is commonly productive of a mental condition
highly  favorable to sleep.   With  others again, Avhose  minds
are  cast in a sterner mould, family and private devotion  advan-
tageously  occupy the close of each day.   Such diversion of the
mind at the close of each day cannot be too highly recommended

  1 Preyer,  Centralblatt d. Med. Wissenschaften, Xo. 35, 1875.  has found that
lactate of soda injected subcutaneously, or injected in  large  quantities into an
empty stomach, causes sleep,  and that highly concentrated  sugar solutions, or
other substances which may give rise to the formation of lactic acid in the stomach
or intestines, also produce sleep. 
THE NERVOUS SYSTEM.
533
 from a physiological point of view.  Whether persons or families
 make their selection on higher or lower grounds, this is not the
 place to discuss their choice.
   Many contrivances to secure sleep have been devised which
 act through the mind.  Of these the counting of sheep  rushing
 through a gateAvay, or of their  leaping from a height iu single
 consecutive order; or the mental repetition of numerals; or of
 x, y, z,  are the  most common; when  there  is simple want of
 consentaneity  in  the different cerebral  centres, or a  certain
 amount of mental activity remaining unused  up, such plan may
 be successful in inducing sleep.  But sleeplessness is very often
 a much too serious matter for any such means to be efficacious,
 and  its successful  treatment usually entails some physiological
 knowledge of  the nature  of sleep, as  Avell as a Avide and com-
 prehensive grasp of the different factors in each case and of the
 means of  meeting and of combating them.
   §  212. Delirium.—This is a condition of cerebral  disturbance
 often of grave omen; always more or less alarming.  It is much
 commoner in children than in adults;  and is very much easier
 induced in children, and by lesser exciting causes than it is in
 adults.  It is more readily brought  about in persons of a nervous
 diathesis than in those of other diatheses.   It is very common in
 fevers, and still more in exanthemata, especially in scarlatina.  It
 arises under these  circumstances from the combined effect of the
 fever-poison, the excited circulation, and the increased tempera-
 ture.  When, hoAvever, it occurs in the  later stages of continued
 fevers, where the  typhoid  condition is pronounced, then it is
 due  in a great  measure  to  the  amount of tissue waste in the
 blood.  In the  early stages  of fever delirium  is scarcely serious
 in the  young;  though its import  is grave if the person be an
 adult, and still  more an old person, whose brain is  usually not
 easily perturbed.  When it occurs in the  typhoid condition it
 is serious, and frequently passes into coma and death.  In the
 management of delirium there are several points to be carefully
 attended to.   One, and a  very  important one, is  the piartial
 prevention of the  oncome of delirium by avoiding Avhat is cal-
 culated  to excite it.  This  is a matter  not sufficiently attended
 to by some practitioners.   AVhen a  person is severely  ill, and
 the brain   has  a tendency  to AA^ander, then  little  changes  in
the environment become very important.   If the aspect of the 
531
THE NERVOUS SYSTEM.
Avon ted room be much altered, the AA'andering eve and  unstable
brain, especially Avhen awaking from  slumber, fail to recognize
the altered surroundings.  The first  impulse is to escape from
the strange place, and to get home—an instinctive feeling when
very ill.  Consequently an outbreak of delirious violence occurs,
which  leaves the patient exhausted  and powerless.  It is not
this alone Avhich is to be avoided—though  it is not Avithout its
OAvn importance—it is the  uncomfortable feeling Avhich remains
in the patient's mind, that  those around him are opposed to him
and hostile to his interests. AVhat the patient Avishes to do is to
him quite intelligible and perfectly proper to be done; and when
he finds that instead  of being aided by  those around him—the
friends  and  relatives in  Avhom he has ahvays fondly trusted—
they tlnvart  and oppose him, a  sickening feeling of suspicion
and misanthropy pervades the mind, which is most undesirable.
Having  passed through  this  condition  himself, the  Avriter has
still a fairly vivid recollection of his sensations and  feelings,
distinct through the  haze of delirium and the debris of  confused
and broken memories.  If then it be  impossible to accede to the
patient's requests, the attendants must meet them by cajolement,
rather than by active resistance and the force of brute strength.
It is a matter of moment Avhen adults are  ill, and likely to be
delirious, not to change  the aspect of the room much, even if the
ailment be an infectious one; the exciting of delirium, and its
ill-effects upon the  patient, must  be set against the possibility of
infection being conveyed by the  ordinary furniture of the room
being  permitted  to  remain  in it.  With children it  is of less
moment, and every  removable  and   unneeded article may be
advantageously taken away.   So much  for the psychical side of
the management of delirium.
   The actual  therapeutic management rests much upon  the
circumstances of the case, and the conditions Avith  which  the
delirium is associated.   If there be cerebral hyperaemia, depres-
sants and sedatives  are clearly  indicated.   If there be also a
febrile  condition,  antipyretics and  other means of  lowering
temperature must be adopted. If the skin be dry and imperspir-
able, agents Avhich  excite free action in the  skin may be resorted
to; or the temperature may be loAvered and  heat abstracted by
the external  and internal use of cold.   AVith the head  on a pillow
of cold water, and  a  bladderful of iced  Avater on the head, sleep 
THE NERVOUS SYSTEM.
535
often can be induced in the excited and delirious  patient.  Mr.
KnoAvsley Thornton's  ice-cap is a \rery useful means of cooling
the head.  It is composed of coils of india-rubber tubing, through
which a stream of iced-water is  allowed to Aoav.   When  the
patient is packed in wet sheets, or placed in a bath and cooled
doAvn, the delirium passes a\vay, and reason  resumes  her seat,
showing that delirium is largely a question of temperature in
the blood and brain;  the  return of the delirium along Avith
a rise of temperature completes the argument.   Another point
is the state  of the pulse.  If feeble, fast, and intermitting,
digitalis and bromide of potassium in combination are indicated.
If full and bounding, or incompressible, chloral, or the bromide,
together with depressants, are the agents to be resorted to.  In
delirium tremens, large doses, half an ounce, of the tincture of
digitalis, have been  given by Mr. Jones, of Jersey, and others.
Such plan is only safe Avhen  the heart is very feeble or failing,
and the cardiac ganglia  are nearly exhausted ;  then it  is good.
When the delirium occurs  in  a typhoid condition, no  matter
Avhether connected with a speciflc fever or not (see Chapter IV.),
then it is desirable to procure  more  perfect  depuration of  the
blood  by the  use  of bitartrate  of potash, until the  bowels  are
opened ; or by acting sharply on the bowels or the skin, accord-
ing  to the circumstances of the case.  Subcutaneous injections
of chloral hydrate may be useful when the broAvn, furred tongue
indicates that a layer of dead epithelial cells lines the intestinal
canal, and hinders absorption through them; so that it  is use-
less to give remedies by the mouth.   Such injections should  not
ordinarily be  stronger than ten grains to the ounce, on  account
of the local disturbance  which  stronger solutions so often give
rise to; in emergencies, hoAvever, more potent solutions may be
indicated.
  At other times a form of delirium  is met with after the acute
pyretic stage  is over.   It seems  rather a form of cerebral  ex-
haustion than a form of active delirium.   Dr. Stokes enumerates
three such conditions:  (1) where there is persistent Avakefulness;
(2) Avhere  an  inAammatory condition of  the brain  has existed
and  been  subdued, but  delirium or other nervous symptoms
still remain ;  (3) Avhere an excited state of the sensorium exists
Avithout heat  of scalp  or  remarkable  throbbing of the arteries
of the head.   To these Copland  adds the condition  of there 
586
THE NERVOUS  SYSTEM.
being free discharges or  unrestrained  evacuations.  In all these
conditions  opium  is  indicated.  According to circumstances it
might be combined with chloral.   In coma vigil such combina-
tion is indicated.  In children the chloral might be given along
with bromide of potassium.
  §  213. ILadache.—This is a wide  subject, and  can  only be
treated of in a general way here for lack of space.   A bird's-eye-
vieAv of the matter is all that is permissible.   In the first place,
then, headache  may be associated Avith  vascular fulness and
congestion, as seen in the injected eye, flushed face, etc.  Here
cathartics,  hot mustard  pediluvia, and vascular depressants are
indicated.  I have known aconite  give perfect relief in obstinate
congestive  headache  of a most intractable character, with  cold
hands  and  feet.  Then there is the headache described in § 208
Avith  its treatment, as part of a state of high arterial  tension,
and differing from the headache of localized cerebral congestion.
Then comes  the vertical headache, so characteristic of  cerebral
anaemia, which  must be met by the measures adapted to its
pathology ; there  is too the occipital  headache of venous fulness
in the region  of the  torcula  Hierophili, indicating purgatives,
tonics, and chalybeates.  In cerebral exhaustion the pain may
be  frontal, parietal, vertical, or occipital.   It yields to cofl'ee,
guarana, to a draught of generous  wine, or some food ; according
to  the peculiarities  of the patient.   In bilious  headache, i'ree
purgation  jvith alkaline salines, especially  first  thing in the
morning, and continued every day, quickly  gives  great relief;
while  the patient soon  can  eat more, and improves  generally.
Ilemicrania is often  gouty or rheumatic; and brow ague has a
malarial origin.  Whenever frontal or temporal  headache pre-
sents  the  characters of rhythmical   recurrence,  ague must  be
suspected,  and  the  treatment is that  of  intermittent  fever
(Chapter IX., §§ 82  and 83).   Headache may be  due  to  some
distant irritation, as  liver disturbance, dyspepsia, especially acid
dyspepsia,  or some load  in  the intestines, especially in systems
Avhich are much  debilitated.  Poor  women  in  hospitals com-
monly have headache and depression from imperfect assimilation.
To keep the bowels  regular, and  to lay doAvn a system of diet,
are here as necessary as are tonics.  -Alkalies with iron are de-
sirable.  Often there is a condition of acidity  in the loAver bowels
Avhich is the cause of severe nervous headache, and here insolu- 
THE NERVOUS SYSTEM.
537
 ble antacids are  indicated, as magnesia or lime; while  the
 readiest method of giving speedy relief is to give an  enema of
 warm  water, or soap and Avater, and so to wash the offending
 matter away. (Prout.)  In headache from peripheral, abdominal,
 or pelvic irritation, bromide of potassium and regular unloading
 of the bowels are the best measures.   In the headache of gout,
 oxaluria, or rheumatism, alkalies freely administered, especially
 alkaline  purgatives, as  mineral waters, or  in other forms, are
 very useful.
   Then there are the headaches of organic disease of the head.
 There is the persistent nocturnal headache of syphilis, which may
 be osteal and destructive.  Here the treatment of the headache
 is  that of  syphilis.  It  may  be gouty, and then requires  the
 treatment of lithiasis; or there may be headache from organic
 diseases within  the head.  This form of headache is the  all-
 absorbing, terrible headache, where the patient seems mad Avith
 pain.   " The organic causes of great headache are never diseases
 of the  proper nervous system, but  always diseases of  its  en
 veloping textures."   (Moxon.)  This vieAV grows upon one with
 consideration of the subject. The brain itself is very insensitive,
 and extensive disease in it, as softening, sclerosis, a tumor, or
 an apoplectic clot, exists often Avithout pain at all, except the
 pyschical pain of mental misery.  Affections of the meninges,
 however, produce pain  very decidedly.  Tubercle of the cere-
 bral meninges, syphilitic diseases of them, or cancer, produce
 dreadful headache.  Aneurism at the base of the brain  produces
 acute  pain.   Abscesses  produce pain Avhen they  reach  the
 meninges, but not before.  In  all organic headache it is Avell to
 lookout for other evidences of nervous disturbance;  ptosis, a
 squint,  a  frown, a  palsy, hoAvever  slight, a  tAvitch,  are  all  in-
 structive.  The  " choked optic disk" is  even more  indicative.
 In organic headache it is most important  to make an  accurate
 diagnosis ; as on that diagnosis rests  the treatment.   If a syphi-
 litic growth, in young persons  especially, mercury and iodide of
 potasssium must be pushed vigorously and without stint.  Often
 the growth  produces other grave  symptoms, as paralysis  of
 various parts. They all yield to the specific measures.  If there
 be an abscess, the trephine  and the bistoury are indicated ;  if
 there be a blood-clot or a tumor, little remains but to lower the
vascular excitement, and  to take off the results of pressure upon 
53S               THE NERVOUS  SYSTEM.

the brain tissue.   Cooling purgatives, a  non-nitrogenized diet,
and the bromides in liberal quantities are  the  measures most
likely to attain this end.
  § 214. Cerebral Paralysis.—Under this  heading may be con-
sidered paralysis of cerebral origin, Avhether truly apoplectic,
or from embolism, or thrombosis.  It is impossible to enter upon
these questions  here further than as  regards their treatment.
In apoplexy the brain, or rather a  portion of it,  is ploughed up
and  destroyed,  more  or  less completely, by a blood clot.  In
addition to the injury so actually done, there is a certain amount
of anaemia of the  brain  substance in the neighborhood, from
pressure.  In such case the anaemia becomes less pronounced as
the blood  clot diminishes, as it grows smaller and paler, until
at last a feAv scales of haematoidin alone  mark  the seat of the
primitive  injury.  Here  a great  point is to prevent  another
attack by a suitable regimen.   In  embolism and  thrombosis, a
vessel is occluded, and the part  supplied by it becomes function-
ally  inactive from loss of its arterial blood.  In these cases the
establishment of a collateral circulation until a vascular condi-
tion sufficient to admit of functional activity is attained, is the
only thing Ave can look for.  It  is obvious that little can be done
to modify these lesions themselves.   Charlton  Bastian thinks
the nitrite of amyl might possibly be of service in helping  the
formation of a sufficient collateral circulation in embolism.  In
the various forms of cerebral piaralysis attention to the general
condition Avill do much to assist the natural process of repair. In
apoplexy, if  seen at once, and the  pulse  be full  and hard, vene-
section, followed by smart- purgation and the administration of
vascular depressants, might do something to limit the size of the
blood clot.  (In embolism  little  can  be done to mitigate the
original injury.)  Afterwards the treatment would be conducted
on rational principles.   Where  there is rupture of a vessel, the
blood-pressure must be kept low by alkalies and purgatives, and
the adoption of a non-nitrogenized diet.   (See Chapter XXIII.
for the full  consideration of this  subject.)  In embolism a  rich
and liberal dietary may be  indicated, and tonics  and steel be
useful. As regards the general management it must be conducted
according to the especial indications of each individual case.
In all cases, hoAvever, it is most desirable to keep  up the nutrition
of the palsied muscles by kneading, shampooing, etc., and also 
THE NERVOUS SYSTEM.
539
by  the  use of electricity.  Electricity cannot affect the causal
injury; but  it can  keep  up the  muscles, so that they  shall
respond to  the slightest  nerve-order; and maintain  them in
good condition to resume work when the  nerve-communications
are once more established.  The more readily the muscles respond
to electricity, the graver the prognosis in each case, as showing
the mischief to be purely cerebral.   As well as these  measures,
the muscles may  be firmly grasped and the blood squeezed out
of them by an attendant every day, so as to keep up a better
circulation in  them.  Many cases  of imperfect  recovery  from
paralysis  are due to the muscles being  allowed to atrophy, so
that when the  nerve messages once more reach  them  they can
no  longer respond.   Such atrophy  must  be avoided by the
measures  mentioned above.  Chalybeates,  nervine tonics, etc.,
may be useful,  and a liberal supply of rich  blood may  be neces-
sary to enable the injured parts to thoroughly recover.  A certain
action of the bowels is ever desirable.  Ludwigand Dogiel have
found irritation of the intestine, as in response to  the touch of
the  finger, to  increase the  rapidity of  the  blood-flow to the
encephalon.  In all cases of paralysis the greatest care must be
taken  against cold and intercurrent pneumonia, to which such
sufferers are so liable,  and  Avhich  is often so fatal  to  them.
(Bastian.)
  §  215.  Sunstroke,  or  Heat-Apoplexy, is  a  malady  of Avhich
little, or comparatively little, is seen in temperate climes; but in
tropical regions, especially when exertion  is called for, it is com-
mon.  Mental  depression  predisposes to it.  Conquering troops
suffer less than those who are not successful.   I am indebted to
Surgeon-Major  A. R. Hall, II. A., for a short account of sunstroke,
as well  as of a new and very successful method of treatment
originated by himself.  "There are tAvo forms of sunstroke met
Avith in India.  The most fatal—which generally occurs in the
field in those exposed for a long time to intense heat under the
sun's rays, after long marches, often Avith much mental excite-
ment, and  Avith  insufficient food, or, worse  still, alcohol instead of
food—is marked by sudden pallor of the  skin, and the patient
dies at once from  heart failure.   In less severe forms there is red-
ness of the face  and surface, burning heat of skin, and a full pulse,
often dilated pupils and complete coma—frequently Avith copious
micturition preceding it.  Such heat-apioplexy is more commonly 
510
THE NERVOUS  SYSTEM.
found in buildings during hot afternoons when men move about
absolutely gasping  for breath.  Here there is incomplete  vaso-
motor paralysis, Avith dilated vessels and really a feeble heart, so
that bleeding and tartar emetic  are  distinctly contraindicated.
Dr. Waller first suggested to me the use of quinine in large doses
in these cases, a hint I adopted. Finding, hoAvever, in many cases
that it was  not  easy to give it by the mouth, I resorted to the
hypodermic syringe Avith the very best results.   Even in cnses
apparently moribund this plan piroduced good effects, especially
when combined  Avith the cold douche and the free use of ice.
On the march,cold douches and ice are not ahvays at hand; but
the syringe  and  a small bottle of quinine  in solution  can easily
be carried about the person, and used at  once.   Ten grains of
quinine,as many drops of dilute sulphuric acid, and one hundred
minims of Avater form a good solution ; and this amount might
be injected in several  places, rather  than in one, with advantage.
If the temperature does not fall  someAvhat  in  half an hour,
other fifty minims had better be  injected.   Cold douches to the
head are good as an auxiliary, but they often fail Avhen employed
by themselves. After consciousness has returned milk and beef-
tea  in small  quantities at frequent  intervals may  be given.
Ulceration  does not  take  place  at the seat of  the injection."
These  remarks need no comment except that if the condition
really be  one of vaso-motor  paralysis, as seems very probable,
then digitalis, or ergotin,  might  be added to  the quinine if
necessary.
   §  216. Affections of the spinal cord are very difficult matters
to approach from a therapeutic  point of  vieAV.   Inflammatory
conditions must of course be treated  in a manner similar to like
affections of the intra-cranial contents.  Conditions of congestion
of the cord  are to be treated by purgatives and by ergot, Avhich
exercises a decided effect upon the  vascular system of the spinal
cord, producing  contraction of the  vessels.   The combination of
cathartics—Avhich themselves tend very directly to unload  the
spinal vessels—with ergotin, contains the  best potentialities of
success.  In cases of  anaemia of  the  spinal cord, Avith resultant
paralysis, more or less absolutely free from  spasms, either tonic
or clonic, strychnia is indicated.  It has been  found to increase
the vascularity of the cord, dilating the spinal bloodvessels, and
indeed exercising an influence the  opposite of ergot; and is con- 
THE NERVOUS SYSTEM.
541
sequently to be given Avith iron, good food, and general tonics.
Other conditions of the cord, as locomotor ataxy, are very little
influenced by treatment.1  Iodide of potassium has been thought
to exercise some influence, but everything is useless, or nearly
so, in a curative sense; Avhile  palliative treatment  is  very un-
successful, and even opium fails to relieve the terrible  pains of
this malady.   Sclerosis of the cord like similar  conditions of
the brain, is a malady over Avhich drugs exercise but little con-
trol; and the sole hope lies in improvement of the general con-
ditions;  and,  from  that, some  local improvement.  The  appli-
cation  of various agents to the spine, as liniments, plasters, heat,
or cold, exercises but little influence; but electricity is  often of
service in spinal  paralysis accompanied by auaunia.   In  some
conditions of spinal irritation  commonly seen  in   unmarried
ladies, and less frequently in spinsters of humbler grades, coun-
ter-irritation along the  spine, or large  opiium plasters from the
sacrum to the nape of the neck,  are often very useful.  But
their use is subordinate and but ancillary to measures calculated
to  reduce  ovarian  congestion and  allay  sexual excitement.
Hysterical paraplegia is best met by alkaline purgatives and the
bromides.  Here it would appear that the impressions coming
into the lumbar portion  of the cord arrest or inhibit the ordi-
nary motor  impulses ; and the diminution of these sensory cen-
tripital impressions, by the measures just mentioned, is  followed
by improvement  in  the paralysis.  If the patient be plethoric
it might also be desirable to adopt a low diet and  to  encourage
the menstrual flux.  Such at least are the measures Avhich have
been most satisfactory in the Avriter's experience.  Aloes, Avhich
induces congestion  of  the pelvic  vessels  in small  doses, acts
beneficially  in congestion of the  pelvic viscera  Avhen  given
freely.   Given  with sulphate of magnesia and bromide  of potas-
sium, aloes is a capntal  remedy in  ovarian congestion  ; that is
if the mixture  be pushed to the extent of Avell-maintained but
not too profuse catharsis, so as to secure three or four full motions
per diem.  (See § 167.)   Affections of the spinal c.ord do not
admit  of such,  classification—therapeutically  at least—as is
possible  in  affections  of some other organs;  and  each case

  1 Weir Mitchell thinks rest in bed gives the best results in this terrible malady.
This plan is Avell worthy of trial. 
512
THE NERVOUS SYSTEM.
demands long and careful thought, and  the  special application
of the rules laid down here, in this and previous chapters.
  § 217.  Epilepsy and Chorea.—These are tAvo common maladies,
Avhich are best considered by themselves.   The first, epilepsy,
consists of motor  disturbances of the most varied character from
general and  bilateral convulsions to a slight twitch, or the mo-
mentary  arrest of consciousness, the petit mul.  Truly epileptic
mental discharges are also  found.  For long  the  pathology of
epilepsy has eluded the search of those engaged in its pursuit;
but at length a circle is beiug drawn around it which is gradually
closing up.  The thorough investigation of the vascular relations
of epilepsy has done away with the theories which made epi-
lepsy rest upon circulatory disturbance; it is found that  there
is a sudden rise of blood-pressure at the commencement of the
fit, Avhich passes  off quickly.   Probably there is  some hyper-
vascularity  in the nervous matter involved in producing the
fit; but the  fit itself  is an explosion of nerve energy in over-
charged  or  unstable nerve-centres.  " In each epilepsy there is
an area of gray matter in  some portion of the cerebrum Avhich is
so abnormally nourished  that it occasionally reaches very high
tension and  highly  unstable  equilibrium.   It occasionally dis-
charges, or is discharged, by some excentric irritation, or during
some general bodily disturbance, as, for example, that attending
fright."   (Hughlings Jackson.)  The experimental researches of
Ferrier corroborate the vieAvs formed clinically by  Jackson, and
the application of electrodes to motor centres in the brain pro-
duces a discharge of nerve force; which is preceded, however,
by an instantaneous increase in the vascularity of  the part, and
folloAved by motor movement.   Consequently Ave can understand
that  the  nerve energy stored  up in the cerebral  cells may be
discharged from  some emotional cause,  as fright;  or from sonic
irritation Avithin the system,  as a tapieAvorm, or a decayed tooth,
or as the convulsions of teething, or still more ovarian or uterine
disturbance; or again the discharge may result from some high
tension, from excessive or abnormal nutrition in the hemispheres
themselves, especially in  a brain naturally unstable. There is a
discharge similar to, if not identical Avith, that of  other centres
in fits of  rage  or in hysteria;  where the explosions assume
another  expression.  From this very brief allusion  to the con-
ditions under which epileptic convulsions arise, a light is thrown 
THE NERVOUS SYSTEM.
513
upon the  lines of treatment  to  be  adopted in  each case of
epilepsy.
  It becomes obvious that one great matter is to relieve any
state of tension, and to lessen mobility in the nervous system,
and  so to reduce  the  tendency to  discharges from any exciting
cause.   Consequently it becomes desirable to administer agents
Avhich Avill lessen nervous activity Avhile controlling the circula-
tion, and  especially the encephalic circulation.  Such an agent
we possess in bromide of potassium.  It gives steadiness to the
nervous system by lessening its activity, and still more  its ex-
citability, and so diminishes the tendency to give forth discharges
from high  tension as Avell as from exciting causes; and Ave can
therefore  comprehend its  immense value in the  treatment of
epilepsy.   That the employment  of  bromide of potassium has
changed the aspect of epilepsy, or at least profoundly modified
it, can scarcely be denied.   In many cases the fits can be kept
aAvay for almost any length  of time by its free use ; though they
not  rarely return soon after its Avithdrawal, to disappear again
Avith the readministration of the remedy.  Xo neurotic agent Ave
are yet acquainted Avith  has received such universal acceptance
iu the  treatment of epilepsy, and held its ground so firmly, as
bromide of potassium.  It is quite certain that numbers of other
agents have  been vaunted  as useful and effectual,  and after
a temporary favor receded  into comparative obscurity ;  but the
bromide increases steadily in favor even with the most sceptical.
It is not only that it lessens nervous action in the centres, but it
diminishes nerve conductivity, and so is  useful in two Avays.  It
diminishes the tendency to explosions ; and it lessens centripetal
impressions coming in from a distance.
  The treatment of epilepsy is not, however, to be confined to
the  administration of bromide of potassium,  no matter  Iioav
freely.  There are other matters to be considered.  There is the
reduction of  tension in the nerve centres by modifications of
nutrition.   In many epileptics  the  discharge  is  preceded by
a ravenous appetite and  the consumption of large quantities of
food.  It  is  impossible  to  shut one's  eyes  to  the effect such
supplies of food  will have  in adding to the  vascularity and
nutrition of unstable nerve-centres.   There is, too, something in
nitrogen which increases nerve activity, and renders nerve-tissue
more explosive;  and free quantities of nitrogenized food add 
544
THE NERVOUS SYSTEM.
 to nerve susceptibility.   Consequently a non-stimulating diet is
 distinctly indicated in many cases.  A certain amount of normal
 discharge of nerve force is not  unimportant as Avell.   Brown
 Sequard's guinea-pigs, Avhich  had frequent fits in confinement
 when abundantly fed, lost much of  their convulsive tendency in
 liberty Avith a different regimen.   From such considerations Ave
 cau see a probable relation at  least betAvixt  nervous  discbarges
 and excessive nutrition in unstable brains, especially Avhere there
 is much nervous  inactivity.   Exercise in the fresh  air with a
 regulated diet Avill do much to reduce the liability to such  dis-
 charges in many brains.
   On the other hand, Ave know that convulsions are apt to occur,
 if they are not ahvays present, in sudden hemorrhage.  Con-
 sequently we can see Iioav, under  other circumstances, tonics,
 chalybeates, and liberal supplies of  good food may be beneficial
 in restoring some brains  to their  normal  equilibrium.  Many
 cases are permanently benefited by good nutrition, just as much
 as a loAvering of the diet is required for others.  Of  the tonics
 most resorted to iron is one of the first, often beneficially given
 with bromide of potassium ; zinc, silver, or gold are also com-
 monly used.  In true epilepsy Hughlings Jackson folloAvs Brown
 Sequard in thinking chalybeates contraindicated.   Phosphorus
 is sometimes useful ; Avhile the vegetable tonics, as quinine and
 strychnine, are also  serviceable.   Other agents  of neurotic
 character than the bromides are  also  useful  in some cases, as
 belladonna and cannabis indica; but it is impossible yet to dis-
 criminate the cases to which they are suited or to lay  down any
 rules for  the administration of these two agents in epilepsy
 proper or epileptiform seizures.
  Then again there comes the matter of  the removal of irritant
 or other exciting causes.   Extrinsic  causes  of such  nervous
 explosions are to  be guarded  against  and avoided, as  sources
 of fright, of excitement, etc.   All irritant matters Avithin  the
 organism itself must  be attended  to  and relieved.  Thus in-
 testinal or other irritation must be removed, and it is ever well
 to keep up the action of the intestines.  A loaded  state of  the
 bowels is a great provoking cause of epilepsy in unstable brains.
 A tapeworm also  has been  knoAvn to cause epilepsy;  and  the
recurrence of  the fits  Avas  the indication  of the  presence of
another Avorm in the same individual.   The sexual organs  are 
THE NERVOUS SYSTEM.
545
 very commonly,  indeed intimately  associated Avith  epilepsy.
 Thus Ave often  see  it  in women at  or  about their menstrual
 periods.  It is not only that in unstable brains peripheral irrita-
 tion sets up> centric discharges very readily; there seems some-
 thing in the brains of  epileptics which leaves them  more at the
 mercy of their  passions than  other persons are.  In such cases
 bromide of potassium  or ammonium are useful in  every way ;
 especially along Avith measures which keep the pelvis free from
 load or congestion.
   It is  also a matter of importance to attend to the secretions
 and excretions.  Especially  is it  necessary  to attend to the
 elimination of  Avaste  nitrogenized  matters.  The relations of
 nitrogen to nerve-explosions, as Avell as nerve-explosiveness, are
 Avell seen in the convulsions of urcemia.   An uraemic condition,
 especially Avhen  it occurs  in anaemic  subjects,  is commonly
 accompanied  by convulsions in normal brains; and consequently
 the disturbing effects of nitrogenized Avaste upon unstable brains
 becomes very  intelligible.  Free purgation Avith potash, laxatives,
 Avarm baths,  and  increased action of the skin, as Avell as kid-
 neys, are indicated.
   In many cases  counter-irritation  is  found  of service, and
 Romberg gives  some very striking  cases.  BroAvn Sequard and
 Van der Kolk also believe in  the good effects of counter-irrita-
 tion.  From what has been said of counter-irritation in Chapter
 XIII. this is not at all  unintelligible.
   The night terrors and the convulsions  of  children have to be
 treated on  the  same principles as  epilepsy; and in them  the
 condition  of  the  intestinal  canal  is all  important, as  the
 reproductive  organs exert  comparatively little action at this
 period of life.   Bromide of potassium is  the most useful agent
 to directly control the nervous system in  these cases.
   § 218. Chorea is as  much a spinal affection  as epilepsy is a
 cerebral one.  It occurs under various circumstances;  and, like
 epilepsy, may  be unassociated  with any organic change, or may
 occur under the  most unalterable circumstances.  As commonly
 seen in children  chorea is  often the evidence of arrested nerve-
 evolution.   It is apt to be  common in families of low nervous
development, or in those where there is nervous instability.   It
is found  in families where  there is also epilepsy, neuralgia, and
paralysis.  Commonly there is defective motor piower, impaired
      35 
546
THE NERVOUS SYSTEM.
sensation in the affected limbs, and limited intelligence in choreic
children.   In such cases nervine and general tonics, arsenic, iron,
etc., are indicated.  Then it may arise from embolism; and here
the establishment of collateral circulation alone gives relief.  All
measures, then, calculated to develop such collateral circulation
should  be resorted  to.   It  may arise  from  irritation in the
viscera, and has been found, like epilepsy^ to come and go with
a tapeAVorm.  Here the removal of the irritation is the treatment
of the chorea.  In the Exeter Hospital chorea is treated first by
santonine, so commonly is it found associated Avith seat-worms.
Where  the removal of the irritation is impracticable, as in the
chorea of pregnancy, nerve sedatives, as the bromides, are most
useful.  There is all the difference in the Avorld in the treatment
of chorea according to its causal associations.  But chorea gene-
rally  is an indication of  impairment  of nerve-power, of the
instability and  irritability which shows itself in the  nervous
system  Avhen  exhausted, or  insufficiently nourished.   "Chorea
is a disease  the essence of which is  impairment of  nervous
power,  and that this  impairment may  manifest itself in many
different ways, according to the nerve-centres especially affected.
One reason at least  Avhy  the  malady is so  frequent in young
children  is the greater mobility or excitability of the motor
department of the nervous system-in them than in older persons.
AVbat would  be a neuralgia in the latter, or some other form of
sensory disturbance, or perhaps emotional, takes that of muscular
jactitation in them."  (Handheld Jones.)  Consequently the plan
of giving tonics with liberal  supplies  of fat is a sound one in
many cases.   Zinc or iron are also useful; and I have  seen the
 specific of Stissero, sulphate of copper, do Avell in a most obsti-
 nate case. Strychnia is most useful Avhere the cord seems lagging
 behind in the general evolution of puberty—a common condition
 for the exhibition of chorea.  At other times belladonna is good,
 lessening apparently spinal excitability.  The combination of
 bromide of potassium with iron Avill often give very good effects
 in cases Avhich have resisted both singly; and Da Costa advocates
 the use of the bromide of iron.  Where there is simple irrita-
 bility  the bromide of potassium  alone  may be required.  In
 almost all cases of chorea, as in other functional disturbances of
 the nervous system, liberal supplies of hydro-carbons, especially 
THE NERVOUS SYSTEM.
547
fat (in the form of cod-liver  oil if necessary), and  limited sup-
plies of nitrogenized food, are indicated.
  § 219.  Hysteria is a very troublesome  and complex affection,
and the brief summary, here alone possible, is to the effect that
it is the  outcome of a susceptible nervous system, often  acted
upon by  the associations,  mental and other, connected with the
reproductive system;  but by  no means necessarily so.   It is
most common in spinsters from puberty to about six-and-thirty ;
but may be found  in  highly  strung  nervous systems  under
totally different circumstances.  In the case of spinsters it often
ceases with marriage, and  rarely persists  after the advent  of
motherhood.  In many cases  the  patient  manifests a morbid
self-consciousness,  and is  entirely absorbed in herself, her in-
terests, and her sensations.  In such cases the symptoms classed
as spinal  irritation are frequently found.   This is the commonest
form of hysteria;  but it has myriads of manifestations.   Joint
disease, paralysis, hypersesthesia, etc.,are amongst its mimicries;
but it  Avill simulate peritonitis, or at other times explode  in
oft-repeated convulsions.  In approaching hysteria from a thera-
peutic  point of view, it  is  necessary first to  discriminate its
causal  associations and  its  surroundings.   If occurring in a
person of high nervous development and mental  culture, it is
probably intimately related to some emotional  disturbance not
necessarily  involving  the passions.   In such cases camphor,
hyoscyamus, or other calmative neurotics, are indicated, with
rest ami  the avoidance of excitement.   AVhen associated with
ungratified physiological aspirations in the spinster or the widow,
hysteria  is almost always accompanied with, if not caused by,
ovarian fulness and congestion: indeed in many cases it is the
outcome  of some  disturbance in the ovary, or uterus,  acting
upon  a  very  sensitive  emotional,  or even  unstable  nervous,
system.   The impressions  arising therefrom either cause cerebral
disturbance, or disturb motor or sensory processes, or influence
the body temperature.  In  such cases it is necessary to unload
the pielvic  viscera by sulphate  of magnesia with  decoction  of
aloes, pushed pretty freely, and to give bromides.  On no account
must the alleged incapacity to empty the bladder lead to manual
measures of relief.  Quiet surroundings, with judicious, but not
ostentatious  kindness, and a firm bearing in those around the
I.atient, are absolutely necessary.  If the patient's mother is an 
518
THE NERVOUS SYSTEM.
 umvise woman all  treatment Avill be found ultimately to he
 useless, or next to  it.   The  ordinary measures of unpalatable
 remedies  are of little  real service.   " The Avhole list of anti-
 hysteric remedies—such as musk, castor, valerian, assafoetidn,
 and the like—appear to have this one property in common, that
 they do no good, and delay the real treatment of the case, which
 is not one of' nauseous gums,' but of mental, moral, and social
 management."  (Russell  Reynolds.)   In minor  cases nature's
 remedy—a good cry—often is of  much service and  gives great
 relief.  The  tout ensemble of the  hysteric  female is unfortunate,
 and requires the utmost skill for its correct management or
 amelioration. Firm and Avell-defined  measures alone are service-
 able ; and a hesitating, vacillating adviser may soon render a
 case incurably bad Avhich, under a wiser  counsellor, might have
 been largely amenable  to treatment.  In hysteric convulsions a
 deluge of cold water is  useful for its moral as well as its physical
 effects; but the most effectual pdan, and least  troublesome (that
 of C. J. Hare's), is to hold the mouth and nose forcibly,  until a
 vigorous inspiration is at last attained, which usually terminates
 the fit.   Inhalations of nitrite of amyl contain much promise.
   §  220. Neuralgia  is  a  most common ailment, indeed  one of
 the most universal plagues of humanity.  It occurs in tAvo pretty
 distinct forms: (1) that of anaemia and debility; and (2)  that of
 degenerative  change, especially  in  connection with  lithiasis.
 In the first form Romberg's idiomatic utterance  that "Pain is
 the pirayer of a nerve  for  healthy blood "—that is, healthy in
 quantity and quality  both — is almost  universally  true.   In
 order, however, to  discriminate  betwixt  neuralgic and other
 similar  pains the four  rules of Anstie must  be borne in mind.
 First, the one-sidedness; except in severe cases, where the pain
 becomes sometimes bilateral.   Secondly, its gusty character;  not
 a steady, continuous  pain, but coming in ebbs and Aoavs.  Thirdly,
 the association of  the pain Avith physical depression, imperfect
 nutrition, or  exhaustion. Fourthly, the effects of tonic treatment.
 In addition to these the pain is often sudden or fitful in appear-
 ance, Avith intervals of  complete freedom from pain; except in
 advanced  cases, where  the intermissions become more  or  less
 lost.  It also folio ays the track of sensory nerves.   It is often
associated with  a  family history  of neuroses  of various kinds.
Often, too, there are present sensitive points along the aftected 
THE NERVOUS SYSTEM.
549
 nerve, the tender spots of Valleix.  One of the very commonest
 forms of neuralgia  is the intercostal, the pain in the  side, or
 under the heart, so  frequently complained of by Avomen.  This
 form is  most commonly associated with leucorrhoea, next with
 suckling, and then with excessive tea-drinking or dyspepsia ; in
 some cases all these are found together.  Perhaps intercostal neu-
 ralgia points more strongly than any other form to the absolute
 necessity for the removal of all  debilitating or coexisting  con-
 ditions producing exhaustion or irritation; as Avell  as  the ad-
 ministration of food, tonics, and chalybeates.1   The cure of the
 leucorrhoea, and its frequent accompaniment,  menorrhagia, is the
 essential step in one case ; the abandonment of suckling is neces-
 sary in another ; and the avoidance  of tea  is as requisite in a
 third.  What is true of this form of neuralgia holds good in all
 others, facial or lumbar.  It is useless to attempt to feed up the
 patient if drains upon the system are left unchecked, or sources
 of nervous exhaustion are permitted to remain.  Every  form of
 deliberating action, mental  and  bodily,  should be  removed.
 Then iron, Avith  or  Avithout  ammonia  or arsenic, quinine, and
 strychnine, are the chief agents to be relied upon.   These drugs
 may be given in combinations of two or more with advantage.
 Then comes the absolutely necessary fat.   The influence of fat
 over  neuralgiae is unquestionable.   When  we remember  that
 nervous  tissue consists  so largely of fat and phosphorus, it  can
 be no  matter for surprise  that  fat, in  all its  forms, and phos-
 phorus should be so valuable in the treatment of conditions of
 nerve debility.  Phosphorus may be given in any of its forms ;
 but as phosphoric acid, either free, or in combination as a phos-
 phate, it is least useful; and as free phosphorus is most  service-
 able.   Fresh  air, exercise, and invigorating surroundings  are
 ever of service, and  the avoidance of surroundings of opposite
 character is equally desirable.   Such  are the means of cure.
 Tliere are also palliative  measures.   Opium is of use to  procure
 sleep ; Avhile it may be used locally.   The hypodermic injection
 of morphia, so as  to secure local and general effects, is  a great
 boon  alike  to patients and practitioners.   Chloral is of little
 use, and  is not desirable.  It  is too depressant, and loAvers  the

  1 it occurs at that intercostal nerve which comes off from the cord where the
great splanchnic runs in, and which is, therefore, most  affected by any visceral
disturbance causing irritation. 
550               THE NERVOUS SYSTEM.
nervous system too much.   For local relief aconite is most use-
ful, in the form of a strong tincture, or the liniment of the
British Pharmacopoeia, Avith or Avithout  belladonna liniment.
Often this may be painted on  merely, and yet give  effectual
relief.   At other times it is better to use a more poAverful meas-
ure, especially in sciatica.  For such end then aconite liniment,
5ij., and an equal quantity of belladonna liniment may be mixed
with  3ss. of glycerine, or better still, treacle.  This does not
readily dry.  The mixture must be spread liberally on a strip of
lint  of two or four folds in thickness, and  the prepared  lint
applied along the course of the affected nerve ; covering the lint
with oiled silk, sufficiently large to overlap the lint half an inch
all round.  This can  be  secured by a roller bandage, or the leg
of a stocking; and  left on for  hours.   When desirable a  new
application can be put on ; but it is even  better to spread some
more of  the mixture on  the  original lint,  until it  becomes com-
pletely saturated, and then reapply it.  This is a poAverful local
measure, often of incalculable service, and can be used along with
general measures, no matter Avhat the form of neuralgia (p. 273).
  Xeuralgia may be rheumatic, or gouty, or  degenerative.   As
such, it is most commonly found in advanced life and  in those
of a  nervous diathesis.   It is not incompatible with  great vigor
in such persons ; but  is more commonly found  associated with
overAvork. Such forms of neuralgia are generally best treated by
remembering the associations, and giving potash and colchicum
along  with tonics and chalybeates.   In such cases  the desira-
bility  of a diet containing much  fat and  little nitrogenized
food becomes of greater urgency than in other neuralgias even.
Alkaline purgatives are useful, and in atonic cases arsenic may
be added Avith advantage.  After the materies morbi has been got
rid of by such measures, then a cautious administration of potash
and iron Avith quinine may be commenced; and  for some time
the evacuant and tonic measures may be  combined and blended
ere tonics alone are given.   In  these forms  of neuralgia local
measures are more satisfactory than in pure neuralgia Avhich is
essentially a disorder of adynamic character.
   Local palsies  and  local spasms must be therapeutically con-
sidered in relation to their  exciting  cause and special associa-
 tions.
   Electricity  can have  no  lengthened notice  here, as its  use 
THE NERVOUS SYSTEM.
551
obtains chiefly among  those avIio do not require the perusal of
a Avork like the  present.  It is  useful diagnostically as well as
therapeutically.   As a remedial agent it is often most  useful:
mostly in  localized nerve affections, least so  in  maladies of
cerebral origin.  If the two poles can be placed on each side of a
nerve lesion, then the current may rouse the nerve fibrils, and do
good.  If used too soon much harm may folloAv its employment.
In all cases it may be used to maintain  the activity and nutri-
tion of muscles, so  that they are kept in such a condition as to
resume action as soon as nerve currents once more  reach them.
It may be also used in cases  of arrested development, as inca-
pacity to Avalk,  or  backAvardness  in Avalking, in infants.   And
it is equally serviceable in cases of loss of power from muscular
atrophy ;  but here  good nutrition is absolutely essential to im-
provement.
   With this chapter on  the  nervous system the second part of
this work concludes.   The second part is the practical applica-
tion of the general principles laid down in the  first section.
The whole  scheme is completed  by the two  folloAving  chapters
on Hygiene and Diet.   The perusal of this Avork will show that
there is a certain refinement, or fineness to be attained in thera-
peutic measures: such as the addition of strychnia to digitalis
in certain  cases of cardiac debility; of digitalis to depressant
alkalies in gout Avith a feeble heart; of colchicum to the  medi-
cines Avhen a gouty factor is  found present  in  the morbid con-
dition;  of  hydrobromic  acid  to quinine  in cases Avhere  that
drug causes headache;  or of belladonna to opium in  phthisis
Avhere night-SAveats are either  present, or  to be apprehended.
The power to recognize these subtle distinctions is an indhTidual
property quite independent of the acquired knowledge; just as
music or painting require certain natural qualities.   Like these
therapeusis is an art;  and for its highest expression there is  a
something required which no study can give.  This faculty may
be greatly developed by careful  study; but it is  after all an
individual possession, and the therapeutic instinct  stands in the
same category  as  the musical  faculty; and  just  as a  musical
person can almost at once detect the absence of that faculty in
others ;  so can the person Avho possesses the therapeutic instinct
note its absence in another after very few  words  haATe passed
on the matter of the remedial art. 
CHAPTER XXII.
                 PUBLIC AND PRIVATE HYGIENE.

  § 221. Public Hygiene.—As Avell as the cure of disease, there is
the matter of its prevention ;—a very important matter, and
one now much  better recognized than in times past.  The con-
viction that prevention of disease is a better method than cure,
even if cure Avere invariably attainable—Avhich  it is not—is iioav
generally prevalent.   This is partly the result  of better general
education  and the spread of information ; but also not a little
due to the fact that  the Avear  and tear of life, the direct conse-
quence of the pace at Avhich  Ave live, is such that feAv systems are
fit to bear fairly Avell the  test of acute disease.  This last applies
rather to  the dwellers in tOAvns than the denizens of hamlets
and villages; is more true in the hives of industry than in the
scattered population Avho follow agricultural pursuits.  The pace
at Avhich Ave now live is much faster than that of our immediate
predecessors, nor is there any prospect of immediate retardation ;
though it  may  well  be questioned Avhether  man will continue
indefinitely his  present feverish pursuit of Avealth.  It is not
merely to make ends meet that man, and  especially the Anglo-
Saxon, struggles so strenuously and persistently ; the early exer-
tions are continued and, if  possible, increased, in order to make
a  fortune—for  nowadays  it would  seem that  the  prevalent
opinion is that Avithout Avealth life is scarcely  endurable.  A
truer and  juster idea of happiness and comfort will ultimately
obtain; and  man will find himself more agreeably as AArell as
more profitably engaged  in other  questions than  the  gain of
mere material Avealth.  It is only of late years that wealth has
been readily  attainable by any considerable number of people;
and its dazzling  fascination blinds mankind  at present to the
evils and  the drawbacks which underlie the alluring surface.
Experience, hoAvever, is being rapidly furnished  to  demonstrate
that Avealth is  not the royal  road  to happiness; that money-
making may warp the intelligence  and dwarf higher qualities; 
PUBLIC  AND PRIVATE HYGIENE.
553
 that in material wealth we are not to find unalloyed good.   At
 present, hoAvever, we live in  an age which is pretty universally
 finding out the poAvers of  endurance of every individual by the
 searching test of over-exceeding them.   It is  not  in commerce
 only that this high-pressure existence obtains; in every Avalk
 of life noAv there is  a general pushing forward ; a great deal is
 required now to  enable  the  individual to hold  his own:  how
 much more then is  required in  order that  each  may pass his
 felloAvs in the race of life ? It is the sustained rate of life-speed
 which requires that the individual shall lose none of his head-
 Avay by intercurrent  sickness, that gives  a  stimulus to  public
 hygiene.  Man in his SAvift  pursuit of wealth does not Avish to
 lose ground by sickness.   He takes care of  his health in order
 that he may grow  wealthy ; but he does  not grow Avise  in
 proportion, and his care of himself in many ways  is more than
 counterbalanced  by  his gross neglect of himself in others. We
 are all inclined to look very sharply after any sources of ailment,
 except  the  noAv  common  one of  pihysiological bankruptcy, by
 too frequent and persistent  drafts upon the  body force.   The
 large increase of heart-disease,  and  still  more  brain-disease,
 amidst  the Avell-to-do classes,  of late, is the direct outcome of our
 impetuous excitement and anxiety, of " Avear and worrit."
  Such, however, being the case, it is desirable that the young
 medical man should recognize the fact, and  be prepared accord-
 ingly to advise his patients.
  § 222. First, then, about the house in Avhich we  live.   Much
 ill-health  is the  direct  consequence of ill-built, or  ill-planned
 houses; of Ioav rooms, of insufficient sunshine ; and, still more,
 of bad ventilation and worse seAverage.   The primitive arrange-
 ments  of  nomadic tribes  are utterly unsuited to  the existing
 circumstances of the day.   The magnificent  sanitary arrange-
 ments  of past civilizations  were  lost during the  dark  ages.
 Cloacal arrangements Avere entirely lost sight of, the streets were
 sewers,  while water Avas draAvn  from wells immediately under-
 neath and amidst this filth  ; the  floors of  houses were streAvn
Avith rushes, amidst which  refuse and  waste accumulated, a
fresh layer of rushes merely  hiding the  nastiness it concealed,
but did not remove;  in the churches lay the decomposing dead,
poisoning the living ; crusaders ignorant of, as Avell as fanatically
disreo-ardful of all sanitary  laAvs, spread pestilences in  their 
554          PUBLIC AND  PRIVATE HYGIENE.

marches ;  plagues and pestilences decimating, nay, depopulating
Avhole  territories, as any one avIio has read Ilaeckcl's Epidemics
of the Middle Ages well knows, Avere constant and persistent;
Avhile  the  ordinary heavy  death-rate at times  ascended to  a
terrible fatality.  From such  a state of matters  Ave are now
aAvakening;  not, hoAvever,  Avithout repeated reminders in the
forms of severe  outbreaks of preventable disease; and are set-
ting to work seriously to improve matters, and to entertain the
question of  hygiene, and  to  recognize the value of sanitary
arrangements.   Consequently houses are uoav built Avith careful
regard to their position, so far as is possible, to the foundations,
to the regular supply of Avater and of air, and the proper removal
of all  Avaste and fecal  matter.   The importance  of sunshine
to the  health of humanity is  uoav recognized.   We know from
barracks Iioav lack of sunshine and ill-health go together.  Then
we also have learnt that spacious  rooms, giving a large cubic
space to each individual, are of little avail unless that  air be
changed repeatedly ; and for this end ventilation is imperatively
necessary: by too carefully closing every aperture all the evils
of bad ventilation are artificially secured.  Xot only do many of
the wealthy classes  inhabit day rooms too carefully heated, the
air of  which is laden Avith the products of combustion ; but the
advantages of large bedrooms at night are lost and neutralized
by burning gas  for hours in these rooms in the evenings, closing
every  crevice against a draught, and  then often, too, lighting
a large fire.   By this  means the oxygen of the room is largely
consumed until the fire dies out; leaving the  human being in a
sleep Avhich is  partial  carbonic  acid  poisoning;  there  are no
means  for the  renewal of  air; the draught  caused by the fire
is no longer existing; and  under such circumstances  man seeks
to fit himself for days of toil and exhaustion.  The storing up
of  oxygen  at night, as Voigt has  shown, for the  needs of the
 waking hours, so necessary and desirable, is  as far as  possible
prevented by the very  individuals Avho need it most.  How far
such nocturnal  storing up of oxygen  by the humbler classes,
Avhose houses do not admit of proper ventilation, is simply im-
possible,  it is not easy  to say: their neglect of sanitary arrange-
 ments is  not merely an outcome of indifference, but is  largely
the unavoidable result of  poverty.  Plentiful supplies of fresh
air  are desirable for every living thing; and if,  under  certain 
PUBLIC  AND PRIVATE  HYGIENE.
555
 circumstances, they  are  unattainable, in a  great  many other
 instances their absence is the result of ignorance or  indifference.
 In a great many affections of the  lungs  the  disease arises from
 mechanical irritants suspended  in  the air; and  in all cases of
 disease, and especially chronic disease of the lungs,  the mischief
 is aggravated by the respiration  of such mechanical irritants.
   The importance of sufficient ventilation in our public build-
 ings  is  not yet  sufficiently  recognized.  Churches,  theatres,
 places of  public  entertainment, picture-galleries,  etc.,  are all
 liable  to produce  distinct  and tangible effects, as faintness,
 headache,  malaise, upon some individuals, Avho are very  suscep-
 tible to  bad ventilation and foul  air; while similar more per-
 sistent conditions are produced  in less susceptible  individuals
 Avhen  chronically  exposed  to such  conditions.   In  railway-
 carriages, in tramAvay cars, and  in omnibuses, this  disregard to
 the necessities of the system in the Avay of  a sufficient  supply
 of oxygen is painful to see, as Avell as to bear;  for those avIio
 do understand the subject.   An abject fear  of colds from free
 supplies  of air absorbs all the attention of  many individuals,
 and renders them  forgetful of other evils Avhich do not lie so
 immediately at the surface.
   § 223. The importance of a good  supply  of pure air is  not
 nearly so Avell appreciated  generally, as is the necessity for free
 supplies  of pure water.  Mankind has ever sought to get a clear
 and sparkling Avater, and objects to it if  its smell be unsavory ;
 but of the finer  and subtler contaminations he  has remained,
 until  recently, profoundly  ignorant.  The curious  relations of
 cholera  to Avater-supply  furnish  a  case  in point.   In  one
 outbreak in  London 37 per 10,000  of  those who drank  the
 Avater brought from the Thames near Ditton  died; but 130 per
 10,000 of those Avho drank water brought from the Thames at
 Chelsea died.  Here is an unquestionable piece of evidence that
 a  constantly impure AArater-supply  leaves the system less equal
 to resist  an epidemic form  of disease.  It is not that Avater is
 often  the  direct  source of  disease, as  diarrhoea and  typhoid
 fever; but it is commonly a cause of a gradual, steady deterio-
 ration of the  health, Avhich is revealed by the inability of  the
system to Avithstand  the strain of some  acute intercurrent dis-
ease.  If temperance, or rather teetotalism, be a good thing, its
advocates ought  at  least  to secure their adherents from  the 
556          PUBLIC AND  PRIVATE HYGIENE.

dangers to  which  they are  thus exposed;  for outbreaks of
typhoid fever have  been found to seize the water-drinkers of a
house, Avhile the beer-drinkers have been free from attack.  In
our relations to the public as medical men Ave must  be impartial,
and  sentiment must not Avarp our intelligence; Ave must be as
ready to acknoAvledge  the  dangers of Avater-drinking as Ave are
to admit  the destructive consequences of excessive indulgence
in alcohol.   It is  not in toAvns only that  the  evil effects of a
contaminated Avater-supply  is felt ; indeed  they have been too
rudely aAvakened by irrefutable facts to be any  longer oblivious
to the consequences ; but also  in the country, Avhere Avells  lie
close to sinks and middensteacls; Avhere the village stream fur-
nishes to those at one end of the hamlet as a  beverage, the sew-
age of the houses placed further up.  In  feAv villages  is the
AArater to be trusted, unless it be the product of some Avell-cared-
for spring, or some exceptional Avell.  Repieated outbreaks of
typhoid fever have  accumulated evidence on  this matter which
is sufficient to convince the most sceptical.
  § 224. Closely connected Avith our Avater-supply is that of our
seAvage.  The fact that in large communities the Avater-carriage
system is the only practicable one; and the  other fact, that if
the sewage Avere entirely removed from our waste water-supply,
the seAvers would no longer receive the benefits  of being flushed
by  the waste water in rainy  seasons and  in  thunderstorms,
cause the question to be more complicated than it would be, if
the axiom " the rainfall to the river and the seAvage to the soil,"
were capable of practical application.  As  it is,  the two matters
are bound up together in such a manner that they cannot be
separated.   We know, hoAvever, that many outbreaks of disease
are occasioned by our water-carriage of seAvage.  Xot  only is
seAver gas apt to diffuse itself from the Avater-closet trap, and so
to poison the inhabitants of the house; but leakage from seAver-
pipes is ap>t to penetrate the Avater-supply,  and so cause disease.
Especially is this the case where the nitrites of the  fecal matters
have eaten through the iron pipes, as they are apt to do, and the
water-supply is intermittent.  When the Avater-supply is cut off
seAver gas  finds its way into the empty tubes, Avhich exercise a
suction action as the water  runs out of them ; and then  follows
disease.  If there be any typhoid fever in the town the poison
will get universal diffusion when the water is again " on," and 
             PUBLIC  AND PRIVATE HYGIENE.         557

 an outbreak will result.  The possibilities of water contamination
 by our sewage are so  numerous that it Avould be simply impos-
 sible here to indicate a  tithe of them.   The  publication  of
 sanitary journals, as the Sanitary Record in England and the
 Sanitarian in XeAV York, is  doing much  to familiarize  not the
 profession only, but lay readers, Avith the manifold clangers which
 ensue  from  neglect of seAvage and seAverage.  The removal  of
 fecal matter by  the use of the  earth  closet is feasible in  large
 establishments, as sanatoriums, etc., where the system of Avater-
 carriage is likely to lead to the pollution of neighboring streams,
 or Avhere public institutions  are  liable to actions  at law in con-
 sequence of their sewage, or in private houses, for indoor arrange-
 ments in the country  ; but as a means for use in comparatively
 sniall  towns even, it must be pronounced unsuited and  imprac-
 ticable.   That towns, hoAvever,  can go  on polluting  adjacent
 rivers  and poisoning the Avater for their neighbors, as of  yore,
 is quite  out of  the question; especially in our manufacturing
 districts. There are immense difficulties  in the way, and vested
 interests  to  be  attended  to;  but,  nevertheless,  tOAvns where
 wealth is made must  set apart a portion  of  that wealth for the
 removal  of their sewage ; and of all plans the system of seAvage
 irrigation over meadows seems the most feasible,  and to possess
 the maximum of advantages Avith the minimum of drawbacks.
 By the different systems of  filtration and seAvage of  meadows
 combined, there seems a prospect  of getting rid  of sewage  in
 such a manner that the fluid shall fertilize the land, and, leaving
 there its fecal matters, return through the purifying soil to the
 river a fairly pure water.  In  all large  plains,  studded  with
 hamlets  and tOAvns, the contamination of water with sewage,
 in spite of eA-erything yet  knoAvn, is such that filters in  private
 houses are very desirable.
   The sewage difficulties are such in  every health-resort as to,
 as soon as ever  any place becomes popular, cause the greatest
 difficulties.   Look, for instance, to the health-giving valley  of
 the Wharfe, where Ben  Rhydding towers over one  of the
 healthiest of districts, near pure air of the  most bracing  char-
 acter, with  limpid AA^ater  from far-stretching moorlands;  and
yet Ilkley is  hoav a town with all the difficulties of aggregations
of individuals.   Whether in  such  districts as Harrogate, Ilkley,
etc.,  the  system  of only permitting so many acres, when being 
558          PUBLIC AND  PRIVATE HYGIENE:
sold, to each house and no feAver; so that for the Avealthy there
is  a  villa and grounds; and for the less AA^ealthy sanatoriums
under  professional and skilled superintendence, Avith  every
possible sanitary arrangement,—Avould be successful in gettino-
rid of many of the present drawbacks, or not, it is  impossible
to say.   It is hard that the poorer members of the community
should be cut off from the advantages of  health-resorts; and yet
the conversion of  rural districts of that character into  tOAvns
of second-rate lodging-houses,  Avith their sanitary defects, is a
questionable means of bringing such  health-resorts Avithin the
reach of these persons.
   § 225. The causes of diseases associated with decomposition
have been held to  be germs, Avhose origin and growth putrefac-
tion  encourages; or else to be tiny particles, in atomic  activity,
from one organism Avafted  to  or  otherwise  brought  in contact
Avith other organisms, in  Avhich they set up changes similar to
those being  undergone by themselves.   As to Avhich  of these
hypotheses is correct; or whether the true explanation has yet to
be discovered, I am not in a position to  say, nor, indeed, appa-
rently is any one else as yet; but  this Ave do knoAv, that a large
series of agents, knoAvn as disinfectants  and antiseptics, possess
the property of arresting the  activity of the infecting media.
That carbolic acid added to the offensive pea-soup  stools of a
typhoid-fever patient takes  away the offensive odor;  and not
only that, but renders them innocuous, Ave have every reason to
believe.  It must  not, however, be supposed  that the  offensive
odor is the poison  ; but, at the same time an odor of a  disagree-
able  character  is  usually found present where septic p>oison is
being generated.  By "his sense of smell  man  is Avarned to take
precautions; but the stench  is not itself poisonous, as is seen in
the offensive odors of tanneries, for the  popular belief is that
the  neighborhood of a  tannery  actually confers healthiness.
Wherever there is decomposing matter,  especially nitrogenous,
there is a disagreeable odor evolved; and Avith such decom-
posing matter  certain  fevers,  and especially typhoid,  are asso-
ciated   causally.    Murchison,  indeed,  called  typhoid  fever
"pythogenic fever," or "fever bred of putrefaction," and some
French  Avriters regard it  as procurable at will.  In consequence
of the vast  accumulation of  evidence that septic poisons  are
causally connected Avith  decomposition—an amount which no 
PUBLIC  AND PRIVATE  HYGIENE.
559
ordinary mind can resist—a great stimulus has been  given to
the  subjects of  disinfectants  and  antiseptics.  These agents,
Avhether derived  from vegetable  or  mineral sources, possess the
propierty of uniting Avith  bodies in  a  state of atomic activity,
and  forming with them staple compounds ;  Avhich, as  such, are
inert, and  so free from dangerous qualities.  The  decaying or
decomposing matter forms a species of base or basyle,  in  union
with the arresting acid, as seen in  the use of carbolic acid, for
instance.   In Condy's  fluid, hoAvever,  a  diametrically opposite
action takes place.  Here  the active oxygen, liberated from the
fluid, quickly  procures entire and  complete  oxidation  of the
particles  in  atomic  change;  and  so does aAvay Avith  their
dangerous propierties.
   It  is a matter of no small  importance for the  young prac-
titioner to have  distinct  ideas on  the subject of disinfection,
as at the  present time the subject  is  invested Avith somewhat
of novelty, as  Avell as possessing merits of its own.  There are
various forms of  disinfectants, some more suited to one require-
ment,  others  better  fitted for  different  needs.   To  take the
disinfection  of drains and  sewers first: here  is  required, as
regards the fluid  contents  of the channel, a  fluid form of disin-
fectant ; and a suitable form is found  in a solution of sulphate
of iron, in carbolic acid in  solution, or  chloride of zinc, or of
lime, etc.  Such  fluid should be  poured pretty liberally into the
offensive drain. At the traps, or  other openings, carbolic poAvder
may be used Avith advantage.  For the disinfection of privies,
urinals, the arrest of offensive  odor in  Avater-closets, etc., the
carbolic poAvder is very useful.   It should be used liberally and
freely.   It has the advantage of  liberating the  carbolic acid
gradually;  and  consequently  is useful  to  meet  a  persistent
giving off of putrefactive matter, or  offensive  gases.   Similar
antiseptics are useful  to  deodorize and render  harmless the
dejecta  from  typhoid-fever patients.   In  the country  these
dejecta  might, as speedily as  possible, be buried at some dis-
tance from any  water-supply, where  the antiseptic action of
the earth Avould soon render them free from all danger.   If in
towns, they ought  to be thoroughly disinfected ere being com-
mitted to the water-closets  A certain quantity of some soluble
disinfectant might be  added to  the water  in the  pan of each
closet, or  some powder scattered in Avith advantage.  A great 
560         PUBLIC AND  PRIVATE HYGIENE.
 source  of  danger in connection  Avith the Avater-closets is the
 liability to so introduce se\ver-gas into  the  house.   When the
 Avater-supply, or waste-pipe of closets in the upper part of the
 house are in communication  Avith those beneath, the rush of
 AATater to the lower outlets causes a rush of air to take the place
 of the vacuum so made, and sewer-gas often is thus introduced
 into a house.   At other times, especially in  houses at the sum-
 mit of each sewage-area, the  pent-up seAver-gases  rush up the
 waste-pipes, and  from the  Avater-closet infect the upper rooms
 of the houses.  Especially is this  the case if the sewerage opens
 into a tidal river.  The rising Avater  fills the outlet, and then
 compresses the pent-up  air in  the sewers ; under such  pressure
 the  seAver-gases  penetrate  where under other  circumstances
 they could not enter.  The waste water-pipe should be broken
 in its course, so that sewer-gas may escape without rising  into
 the house; or a  shaft should be carried up and out beyond the
 roof, so that if pent-up  sewer-gas should rise in the  pipes it
 would find a ready outlet into  a comparatively safe external
 air.
   So much for general disinfection.  We may iioav come to  the
 question of more special disinfection.  Supposing that there is
 already a case of fever in a house, the first  thing to be done is
 to isolate the  patient.   Xo one should see him  except  those in
 immediate attendance upon him.  All food  should be  brought
 into another contiguous  chamber, and be removed from thence
 to the sick-room  by the  attendants ; and all  refuse, etc., should
 be conveyed by the nurses into this room and thoroughly disin-
 fected, and then it  could be removed Avithout fear of infection
 by the ordinary  servants.  Thus all  direct communication be-
 tAvixt  the  sick  person  and the  household Avould be  avoided.
 All soiled linen should be immersed in a  disinfectant  solution,
 all slops disinfected, and the  clothes of the nurses should be
 disinfected on their leaving the room. In order  to prevent  the
 fever-poison passing out from  the sick-room when the door is
 opened, a sheet saturated with some liquid  disinfectant should
 be hung over the doorway ; and be  frequently moistened with
the disinfecting solution. Within the room Condy's fluid might
be scattered about freely, or some solution of carbolic acid, or
chlorozone. All  unnecessary articles ought to be removed from
the room, as they might  prove  carriers of infection. 
PUBLIC  AND" PRIVATE HYGIENE.          561
   As  to  the  patient, chlorate of  potash in lemon-juice  (very
 palatable), or sulphite of soda, may be administered internally;
 and if the case be smallpox  or  scarlatina, the patient  may be
 washed  with  Wright's tar soap,  or salicylic, or carbolic-acid
 soap.  At the latter stages, when the dried crusts of smallpox,
 or the exfoliated epithelial scales of scarlatina constitute special
 sources of danger, a  carbolizecl cerate, or oil, should  be rubbed
 over the body, and  the patient should be  bathed every day
 or second day, and  the  exfoliated matter removed ; then the
 disinfectant should  be smeared  over the whole  surface again,
 and at the regular time the bath  be resorted to. By such means
 the infective matter given off from the surface is rendered harm-
 less.  It is of as much importance to disinfect  the  cutaneous
 matters  in  these ailments, as it is to disinfect  the stools in
 typhoid  fever.
   After  the convalescent patient has left the  sick-room it ought
 to be cleaned  out; everything being removed, the empty room
 should have its Avinclows closed, and then, on  a thick layer of
 sand, should be placed a red-hot iron plate, and upon it sulphur.
 The fumes of  the burning sulphur then fill the  room, Avhich
 should be kept  closed  for tAventy-four  hours.   After  that  it
 ought to be  scoured out thoroughly, and then  the sulphur-
 fuming ought to be  gone through  agaiii.  After  this the win-
 dows should be open for a couple  of days, and then  the  room
 is safe enough.  If necessary the  Avoodwork could be scraped
 and repainted, the  ceiling  AvbiteAvashed, and the Avail-paper
 renewed, in addition.
   The articles which are in the  room might remain over the
 first fumigation, if they could not otherwise be Avell disinfected.
 If in the country, they should then be exposed freely to the air.
 All  feather beds and mattresses ought  to be teazecl out and
 made over again.  Things of no value should be burnt, as neAvs-
 papers, journals, etc.  Books  should be carefully  aired, or Avell
 shaken over some  fuming disinfectant.   In tOAvns  there are
 now large disinfectant chambers, Avhere Avearing  apparel, bed-
 ding, etc., can  be disinfected  for a sniall charge.   In villages,
 etc.,  the Avearing apparel might  be hung around a small  spare
room or outhouse, and then fumed with sulphur, or with iodine,
whose fumes are an excellent  disinfectant.
  If the patient die, then the corpse should be washed with a
       36 
562          PUBLIC AND  PRIVATE HYGIENE.

strong solution  of carbolic acid, placed as quickly as may be
in a coffin, disinfectants  being placed beneath and  over it; and
the coffin lid screAved down Avithout delay.  The burial  should
be proceeded with at once.
  Such are the measures to be carried out  Avhen fever has once
entered a house.   It is not  sufficient merely to see the  patient
through  the fever,  in  scarlatina,  smallpox,  and  typhus: the
most  infectious period  is that of early convalescence.   Such
convalescents  should be kept aAvay  from  the healthy  in  con-
A-alescent rooms or Avards;  until the  last scab  has  fallen off in
smallpox, and until  the last particle of skin has exfoliated and
come aAvay in scarlatina.
  § 226.  The  next point to be discussed is the  question of the
dissemination of disease by those \vho  attend upon the  sick, as
the medical  attendants, nurses, etc.   First, as to the medical
attendant.  AVhen  attending upon  fever cases, the ordinary
conventional rules ought to be put in  abeyance;  and the medical
man  should  see  his  patient without removing his macintosh,
and after leaving the room should  have it sponged with a solu-
tion  of Condy's fluid.  This  Avould  pretty effectually disinfect
him.   He should  also Avash himself  Avell  either Avith Wright's
tar soap or a solution of Condy ; hands, face, and  beard all
should be  disinfected.  After this he  might go on his round
Avithout  practical fear of being a poison-carrier.   It  is avcII,
Avhen possible,  to visit the  fever  patients last on  the daily
round. In rural practice, of  course, this  is not always practi-
cable.  Especially is it necessary and imperative upon the part
of the medical man to take precautions when he has midwifery
to attend.   There is no evading the conclusion that the vagina
readily takes up septic  matter when brought  in  contact  with
it; and the scarlatinal poison readily sets up puerperal  fever of
a hopeless character when  so conveyed to a parturient  woman.
The  hands should  be  carefully washed,  first in  a solution  of
carbolic acid, and  then in  one  of  Condy — but  not the two
together, as they neutralize each other. The carbolic acid solu-
tion  should be used  first ; then  the  bands may be rinsed Avith
simple Avater; and, lastly, Avashed in a solution of Condy: by
such  means they will be free  from dangerous  properties, as Avell
as odor.
   As to the disinfecting of nurses, the question  is a complicated 
PUBLIC  AND PRIVATE HYGIENE.
563
one.   In feA-er cases among the affluent  there should  always be
two nurses, so that they could have regular and sufficient sleep
in a large double-bedded room Avell ventilated.  It is  obvious
that if the nurses' room is attended to by the ordinary domestics
there  must  be some  considerable danger of  infection.   The
nurses then  ought to do the chambermaid's Avork of their own
room, carrying their slops, Avell disinfected, into the same room
as the slops from the sick-room are  carried; and Avhich should
ahvays and nnintermittingly be Avell disinfected.  Their changes
of linen should be brought about in the same Avay ; all soiled
linen  being immersed in  an antiseptic solution as soon as taken
off.  After it is done Avith, this nurses' room ought to be fumed
and scoured in the same  Avay as the actual sick-room—as given
above.
  In the dwellings of the  humble, hoAveA^er, it is simply impos-
sible to take efficient precautions  against the carriage of infec-
tion by the  nurses.  Where neighborly kindness  has to supply
the place of a  hired skilled nurse,  some  risk must be run by the
nurse:  and when a  neighbor sits up all  night Avith the sick
patient, it is not only the  self-denial and  exertion  undergone
that claim our respect; but  there is actual possibility of infec-
tion and danger to their oavii loved ones at home Avhich is risked.
Under such circumstances  the use of disinfectants and the  ex-
posure to the air in passing from  house to house, are almost all
that is feasible.   While  respecting neighborly kindness in the
humble, tliere is another form of neighborliness which is  to be
sternly  reprobated ;  and that  is  the reckless  and  thoughtless
visits of the gossip  to fever-stricken houses, "just to  see how
they are getting on."  This is useless and fraught with danger ;
and the medical attendant should set his face  determinedly
against all such practices.
  § 227. The  onlv prospect of improving matters, as  regards
the management  of fever among  the poor, is the  institution of
fever  hospitals in towns—in epidemics they may be of a tempo-
rary character—and the spread of the  cottage-hospital system.
The latter arrangement would  meet famously  the necessities of
sporadic cases  of infectious disease; and  would often prevent
the spread of such disease.  This is especially true of typhoid
fever, which is largely spread by  persons going from one  place
to another while the  fever is  latent in them; on arriving at 
564
PUBLIC  AND PRIVATE  HYGIENE.
their neAv residence the fever develops ; they are nursed by well-
meaning but ignorant persons;  the dejecta are not disinfected,
and, finding  their Avay into the water-supply, a local outbreak
of fever results.   If  the  cottage-hospital plan Avere in  general
use, the patient Avould be nursed under circumstances much less
favorable to the spread of the disease; and the nurse, knowing
something at least of nursing, would be less careless  about the
disposal of the dejecta, and so would limit the disease.
  It is by no means absolutely  necessary for the practical adop-
tion of the cottage-hospital system to have a handsome buiding,
etc.; a good Avell-aired cottage  standing alone, with  an  intelli-
gent Avidow in it, Avould  form quite a  sufficient hospital for a
village, except in special outbreaks of fever.  Such cottage and
nurse could easily be  secured by any board of guardians; while
the union medical officer aatou1c1 Avillingly give some attention
to the training of the  nurse.   Such an arrangement, Avith the
nurse under  the doctor's orders—a matter of no slight  impor-
tance—would often  check troublesome  outbreaks of typhoid
fever, and nip them in the bud.
  The importance  of having some similar  institution for the
recepition and detention of travellers  from  places  notoriously
affected with  infectious disease, until  their perfect healthiness
is demonstrated, it is easy to see; but it Avould not be easy to
carry such  arrangements  into  practice  Avith  Anglo-Saxons.
When, hoAvever, the liberty of the subject extends to carrying
fever-poison to others, and so endangering their lives, or, at any
rate, subjecting  them to expense  and suffering, that   liberty
seems certainly to call for some  restrictions.
  § 228. Private Hygiene.—This  important matter may most
conveniently be divided into two sections, (1) that of the healthy
individual;  and (2) that of the invalid.
  For a person in  health  the great question is Iioav to preserve
this condition of matters.  In order to do this it is necessary to
bear in  mind the circumstances  of each individual.  If he be a
wealthy man, tliere Avill probably exist a tendency toAvards an
unnecessary  consumption of food, that  is,  in excess   of his
absolute needs;  but this varies much with different individuals;
if the person  be in  humble circumstances, the amount of food
may be  insufficient.   The southern laborer, described  by the
late Charles Kingsley in  Yeast,  gets but  bread and cheese, and 
PUBLIC  AND PRIVATE HYGIENE.
565
 an occasional bit of bacon, or a dab of dripping, for his unvaried
 dietary, upon Avhich he has to labor as  best he may; with him
 a more liberal dietary Avould  certainly  be beneficial.   The  full-
 fed servants of  rich men's houses have too much of Avhat most
 poor  neeclleAvomen lack.   Some intellectual  excitement, some
 mental occupation is as necessary for the workman engaged  in
 monotonous pursuits, as  pin-head making or needle-grinding,
 in order to preserve him from insanity  or outbreaks of debauch,
 by AAdiich  his health may be imperilled ; as  is exercise  in the
 open  air for  the  clerk, confined for hours to close and heated
 rooms, or the merchant, avIio  is little better  off, except in the
 question of length of hours; or the  barrister or the literary
 man, avIio live sedentary lives,  and breathe an atmosphere by
 no means too pure, or too  highly charged Avith oxygen.
   At other times  the question of clothes becomes an important
 matter.  Especially is this the case Avhen autumn Avanes, and
 hot noontides are  combined Avith cool mornings and cold even-
 ings.   In  spring Ave  usually continue  our Avinter  clothing till
 advanced  spring compels us to  lay it aside; and colds from the
 too ready  adoption of summer costume, though  far  from un-
 common, are less frequent than  the various derangements  of
 health in the autumn.  In spring the form of ailment is usually
 an ordinary cold ;  in autumn a chill to  the surface is apt to pro-
 duce a catarrhal condition of the  intestines Avhich is set cIoavii
 to fruit.   With some persons fruit seems to be regarded as the
 means of producing diarrhoea rather than as pleasant, Avhole-
 some, refreshing food ; and is much too scrupulously avoided.
 It is  wonderful, too, to see Iioav carefully Eastern people, even
 in very hot countries, stick to their cummerbund, by Avhich the
 loins  and  abdomen are kept Avarm and protected  from sudden
 chills.   Many Europeans develop in time a similar attachment
 to this article of  attire.   It is  ahvays  Avell for immigrants to
 conform  to the  customs of the  places they migrate to; if they
 retain  too  conseiwatively their  old  habits, it is  probable  that
 illness will result, and after  this experience  they may become
 wiser; but then they may  be  killed  or  seriously injured in
 undergoing this species of  instruction.
   A great  matter at present is  the  question  of  the bath.  As
regards the use  of the bath, Ave have uoav reached a point not
far removed from  that of  ancient Rome.  Xot so much time, 
5)6         PUBLIC AND  PRIVATE  HYGIENE.

hoAvever, is  spent in the bath as yet; and  the  common form
is  that of the morning tub, iioav so universally in  use.  That
cleanliness is a matter of the greatest importance Ave  know Avell,
and an efficient action of the skin is a great promoter of health.
At the  same time the  free use  of  cold Avater  tends  to  brace
the vessels of the skin  and educates them  to contract readily
on the impingement of cold, so  that the risk of  taking cold is
diminished; nevertheless, there is something to be said on the
other side.   When the morning bath  is resorted to  in order to
create a sense of energy  and fitness for the day's Avork, which is
wanting from  imperfect hours of rest; it becomes no longer a
useful agent, but contains an element  of mischief.   It then  be-
comes a species of stimulant, which tends towards physiological
bankruptcy; in that it enables the individual to reach his fund
of reserve force, but does not itself furnish force, nor anything
Avhich  can  be converted into it.  The general use of the bath
cannot  be  too  highly commended, but like everything else,
the bath is not  an unalloyed good ; it contains some poten-
tialities for doing  harm  under certain circumstances.  With
many persons  the cold  bath does harm in this  Avay: It chills
them too much, and the skin does not readily react and glow,
even when  industriously and  perseveringly rubbed  Avith flesh-
brushes or Turkish toAvels.  For such persons it is  desirable
that the Avater have the chill taken off, and that the time spent
in the bath  be brief.  With  these precautions many persons
may take  baths with benefit who noAv cannot  do so, and Avith
Avhom baths are more injurious than beneficial.  George Johnson
thinks that too free indulgence in the bath not infrequently is
the cause of latent albuminuria.
  For women the use of the hip-bath  is very desirable; and if
that chills  them too much, or is inconvenient, the bidet should
never be neglected.  Our English women are chaste doubtless;
but  in  their chasteness they are apt to avoid all attention to
their reproductive organs;  and are  infinitely less careful about
their personal hygiene in this respect than are their Continental
sisters, especially the FrenchAvoman.  A great deal of feminine
ill-health arises in  or is fostered by neglect of ablutions round
the hips and pelvis; and as the subject is rather a delicate one,
it  is not pressed by the  bulk of medical advisers.   A woman
may be perfectly continent and chaste, and  yet be scrupulously 
             PUBLIC AND  PRIVATE  HYGIENE.         567

 particular about her personal  ablutions.   Not only is the use
 of the bidet desirable every morning;  but vaginal injections of
 cold water, alone, or Avith a  little Concly's fluid added, every day
 are beneficial for those who have a tendency to a free flow  of
 mucus from the vagina—and they are a large proportion of their
 sex—and in some cases these  injections of cold water should
 be followed  by the  injection of a weak solution of sulphate of
 zinc, alum, or other astringent.  Of course the ablutions must
 be sparing, and  the water not cold during the catamenial Aoav ;
 while  the injections must be stopped during that period.  By
 such  means women would  enjoy much comfort; and many of
 them better health.
   Considering  Iioav women  fasten their skirts from their hips
 and surround their  pelvis with clothing, so as to keep  it and
 its contents warm, indeed too Avarm ; and the exposure to heat,
 as in  cooks and  laundresses;  or the  Avarmth of exertion  in
 actresses, ballet-dancers,  housemaids,  and chambermaids; the
 action of the treadle in seAving-machines, especially the double-
 treadle form of machine; the close rooms in which  girls and
 Avomen have to live in commercial houses; and the Avarm rooms
 wealthy ladies  prefer; all  Avhich  tend  to produce  a relaxed
 condition of the  vaginal mucous  membrane: no wonder few
 women escape, at some time or other, a condition Avhich renders
 the use  of  the  bidet, and even the injection, indispensible  to
 health and comfort.
  Most modern  houses of any pretensions  contain a bathroom,
 and this is a most salutary arrangement.   After fatigue, mental
 or bodily, especially in Avarm Aveather, the  bath is a great com-
 fort, as Avell  as  an excellent hygienic arrangement.  They are
 now so fitted usually as to admit of warm or cold baths, or the
 shower-bath—a  famous  means  of producing Avakefulness  in
 those Avho are too fond of lying in bed in  the mornings.  Some
 also  are so constructed  as  to  give the needle-bath—a  rather
 powerful  agent, not  to be used  rashly ; but very  useful in asy-
 lums in  the treatment  of melancholia, or of  simple  dementia.
 The  Turkish bath, now  in  much favor, is a luxury to most  of
 those persons avIio frequent it;  it is also an excellent means  of
 treating a cold,  if caught  at  the  commencement.  After ex-
 posure to chill,  immersion in a  Avarm  bath, and then a sojourn
in a bed comfortably Avarm, Avill usually take aAvay all unpleasant 
5l)8         PUBLIC AND  PRIVATE  HYGIENE.

consequences.   Indeed, an hour or two in bed after a  bath is
usually very refreshing, and is  not nearly sufficiently adopted
in Great Britain.
  So  much  for  the  ordinary use  of the bath by healthy indi-
viduals.  We may now proceed  to the use of the bath, of baths,
and bathing-places by invalids, or those who consider themselves
to some extent  such.
  § 220.  The benefits to be derived from mineral Avaters, either
Avarm or cold, poured out by certain spirings, Ave re recognized by
old Avriters of medicine.  Hoav, and under Avhat circumstances
man first used such  Avaters Ave can only speculate;  probably
for some persistent forms of skin disease.  Empirically, and by
long experience, Avas it found Avhich baths did good in  certain
conditions.  Now baths have developed from their primitive
condition and  become  handsome  and  large  towns; where a
resident  population thrives on the profits derived from visitors
to these baths.   As many of these visitors are  there on the pre-
text of seeking the 'oaths and drinking the waters, as are there
for strictly  necessary reasons.  Consequently at most of these
places  there  is pleasant  society,  amusements to engage the
attention and relieve ennui, together with rules and regulations
ostensibly to secure all the possible benefits from the baths and
Avaters, and so impress the minds of the visitors; but Avhich are
at the same  time directly conducive to health. In sending pa-
tients  to baths and Avatering-places there are other  advantages
than those furnished by some peculiar form of mineral  Avater.
To the merchant who sticks too closely to  business and is en-
gaged  in crowded streets or thronged  Avharves the greater por-
tion of the day, it is as health-giving to be out for hours in the
open air; to  meet pleasant company, to hear an outdoor concert,
to rise early and to go to bed at ten o'clock, sleeping in a pure
bracing air; as it is  to take draughts of sulphurous Avater until
the liver is thoroughly unloaded, and  then to drink chalybeate
waters as a tonic.  All this time,  too,  there should be a  liberal,
but not too  luxurious dietary ; and the appetite should not be
tempted too far by the nature of the viands.   There are in such
arrangements many things conduce to health beyond the mere
mineral water.   To ladies of fashion, after a long and exhausting
season, which has turned day into night and produced the well-
kuoAvn depressing effects of exertion in heated rooms amidst an 
              PUBLIC AND  PRIVATE HYGIENE.          569

 atmosphere  fouled  Avith myriads of gas-lights; the  healthful
 quiet  of  a watering-place, its  fresh air and sanatory breezes,
 together Avith long hours of rest at night, furnish an opportunity
 of regaining the lightsome sense of energy Avith which recently
 they haA^e been but little acquainted ; Avithout there being any
 magical properties  in  the  nauseous waters they so faithfully
 drink. The life  led at  Avells  and Avatering-places  is  itself so
 conducive to health, that Ave iioav find sanatoriums springing up
 in places  Avhere the Avaters are not  vaunted as possessing any
 special properties; but where the claims of the institutions are
 founded on the other attractions the localities possess.  Having
 admitted the advantages to  be derived from the piosition and
 surroundings of most  of our best-known watering-places and
 baths, it  may  be advantageous to  review very briefly the dif-
 ferent forms of Avaters,and the different disturbance of health to
 Avhich each is best adapted.
   § 230.  First of  Avater—as Avater.  A  large portion of the
 body  is Avater;  and a  constant  Aoav of water  through  it is
 necessary to existence, to say nothing of health.  By means of
 water  in simple solution, a great many constituents of the  body
 find their Avay out of the system.  A constant bathing of the
 tissues with fluid is perpetually going on, and by such means
 the  Avaste is removed.   In  many persons the amount of Avater,
 in any and  every  form, consumed  per  diem is much  too  little
 for the efficient washing of the tissues.  The bulk of water then
 which is  insisted upon  at the various  baths is itself an agent
 of no mean therapeutic  power ; and if it be also charged  with
 various alkalies, the removal of Avaste will be facilitated. When
 there has  been a rather too  liberal dietary indulged in, and the
 patient suffers from suppressed gout in any of its protean forms,
 such free consumption of water is very useful, especially  when
 alkaline.   Such waters are to be found at Vichy, Vals,  Ileil-
 brunnen, Neuenahr, Bladon (Aa.), and Congress Springs (Ca.);
 and are suited to dyspeptic affections, thickening of the joints,
 gout, chronic affections of the respiratory organs, etc.   If  it be
 desired also to act upon the bowels and there is a sluggish liver,
 so called,  or  a loaded liver, with  engorgement  of the portal
circulation ; it is well to recommend the patient to visit  some
spa where the water  is purgative  as  Avell as  alkaline.   Such
water  is  furnished by  the springs  of Carlsbad,  Marienbad, 
570         PUBLIC AND  PRIVATE HYGIENE.
Tarasp, etc.   Purgative waters charged with  salt are  to  be
found  at  Cheltenham,  Leamington,  St. Gervais;  while  fairly
purely purgative Avaters are to be found at  Pullna, Friedrichs-
hall, the Hungarian Ilunyadi Janos, Estill  (Ky.), and  Bedford
(Pa.) Springs.  Such  Avaters are very useful in all  cases  Avhere
the digestive system has been systematically and regularly over-
Avorked.
  In  other cases, again, of broken  health, as  in  the  Indian
cachexia,  and the other debilitated  conditions  of the  system
produced  by residence  in  tropical climates, and also in many
cases Avhere no foreign  experience is  in action, salt springs are
very useful.  In these springs chloride of sodium is combined
Avith other constituents, may be carbonate of lime and carbonic
acid,  as  in the  Avaters of Homburg, Kissingen,  Wiesbaden,
Harrogate,  Baden-Baden,  Cronthral, Congress,  etc.; or  Avith
traces of iron, as is  the case with  several  of the  waters just
mentioned.   In some of these  springs  the proportion of salt is
much greater than in others, and for many persons the milder
waters of Baden-Baden, Canstatt, Charleston (S. Ca.), are to be
preferred  to the  highly-charged waters of  Mannheim, Soden,
Homburg, Saratoga (2s". Y.), and Ballston (X.  Y.).  Then there
are sulphur springs possessing their peculiar properties.   They
are said to act  Avell upon lethargic skins, to be  useful  in rheu-
matism ; being commonly purgative, they are beneficial  in ple-
thora, biliary congestion, etc.
  Aix la Chapelle is a mixed salt and  sulphur spring, thought
to be specially good in constitutional syphilis in the debilitated ;
it is  useful  of course  in  many other  maladies.   Wielbach,
Langenbrucken, Stachelberg, La Prese, Allevarcl, Enghien, the
old sulphur-well at Harrogate, Gilsland, Moffat, and Strathpeffer,
are among the  principal sulpihur springs of Europe;  while  in
the United  States there are West Baden (la.), Paroquet (Ky.)'
Sharon (N. Y.),  the  milder and pleasant waters  of Minnequa
(Pa,), Jordan's White  Sulphur  (Pa.),  Greenbrier's (West Va.),
and others; and in Canada the pjOAverful SandAvich  Springs, near
Ontario.  These Avaters are all unpalatable, but are very service.
able In cases Avhere the indulgence at the table has been rather
too free.   By means of  Harrogate and Buxton,  the  wealthy,
self-indulgent, high-living  manufacturers  of  Yorkshire and 
PUBLIC  AND PRIVATE  HYGIENE.
571
Lancashire  continue to  keep  themselves in moderately fair
health ; and in many cases even in redundant health.
  Then there are chalybeate Avaters of great  importance and
freely scattered.  These waters are either resorted to at once,
or after a course of some of the  Avaters  previously mentioned.
They are  either  themselves fairly pure, or mixed with other
constituents, as salt, carbonate  of soda, or sulphate of magnesia,
or soda.   If  situated at  some  height above the  sea,  they  are
more efficacious.  Thus Schwalbach  is 900  feet above the sea,
Spa 1000, Bagneres  de  Bigorres 1850, and St.  Bernardine and
St. Moritz over 5000 feet above  the sea.  Ferruginous  Avaters
are commonly found charged Avith other  mineral constituents.
Thus the Avaters of Giesshubel, Heilbrunnen, the Bailey Springs
(Aa.), Estill (Ky.), etc., are  also alkaline.  Those of Marienbad,
Franzenbad, Elster and Ocean  Springs (Mi.), are alkaline-saline.
Kissingen, Canstatt, Homburg, Harrogate, etc., are ferruginous
and  salt.  Pyrmont, Bagneres de Bigorres, Tarasp, St. Moritz,
Stribling  Springs  (Va.), etc.,  are  also vastly  saline;   Avhile
Sclnvalbach,  Spa,  Tunbriclge,  Harrogate, and Marienbad  are
comparatively pure iron Avaters.   Many of these waters  are
highly charged Avith carbonic  acid, and  so possess exhilarating
qualities.   One great matter, perhaps the  greatest matter of all
Avith  mineral Avaters, is their dilution.  The different substances
are largely diluted  Avith Avater, and thus are more readily  assimi-
lable  than Avhen given  from the medicine  bottle. Where pa-
tients are poor, and cannot  be sent to drink  mineral waters, nor
yet even purchase imported  mineral Avaters, much may be done
by  directing  them to  drink large  draughts of water with  or
after each dose of medicine.  This, as has been remarked before,
often makes all the difference betAveen the medicine doing little
or no good and  its being beneficial, especially in  combinations
of alkalies with iron.   The bicarbonate of potash with potassio-
tartrate of iron in a bitter infusion, with or without a little sul-
phate of magnesia,  will often  produce as  good effects as can be
derived from  some  fir distant  spring—if largely diluted.   Of
course it is not the  interest  of those connected Avith such springs
to admit this fact;  and on the other hand such home treatment
does not include the new scenery, the fresh air, the pleasant life
and gayety of a fashionable spring; and  in  so much is actually
inferior to a visit to a spa. 
572         PUBLIC AND  PRIVATE  HYGIEXE.

  There are also  Avaters  impregnated Avith iodine, as in  the
water of Wood hall  Spa,  in Lincolnshire, Avhere there is both
iodide of potassium and bromide of sodium in solution.  Similar
Avaters are found at Kreutznach, Wildegg, Aldehicls Quelle, etc.
They may be taken in large quantities, indeed  must be so taken,
in order to furnish  much of the medical  constituents to  the
system.  Lithium has been found in the Murg-quelle, and at
Elster.  For its solvent action  upon uric acid and urates, much
has been expected from  it in the treatment  of gout.  Large
quantities of Avater must  be drunk in  order to take in any  per-
ceptible or  medicinal amounts of lithium ; but  the cases thus to
be benefited often  need large quantities of water as  much as the
mineral constituent.
  Waters are now exported in large quantities, and vary from
the p>otent  Hunyadi  Janos water  to the delightful  Apollinaris
water, an exquisite  beverage.  Artificial  Avaters, seltzer, soda,
potash, lithia, etc., are iioav largely manufactured,  and are in
almost universal use, to add to spirits, Avine, beer, or even to be
drunk alone.  As lemonade, Avater simply charged Avith gas,  and
acidulated, has a most extensive sale.   The chief draAV backs to
these artificial  waters  are the carelessness with Avhich  many of
them are made—a supply of pure water not being  essential in
the eyes of some manufacturers—and still more their price.
  § 231. So much for the  various forms of  Avaters furnished
by our  best known baths  and Avells, and the indications for
drinking them.  Noav Ave may revieAv the more special  use of
them as baths, and for bathing purposes.
  First,  as  to   the effects  of  temperature.  In a bath  below
the temperature of  the  body there is a decided  loss of heat,
the surrounding water being a good conducting medium.  Con-
sequently even  cold baths are rarely below 50°  Fahr.  If  below
this the immersion must be brief; and even then they can only
be used by those Avho  are fairly strong.  The  more the bather
agitates the Avater the greater the loss of heat.   After  a  cold
bath  the bather usually  rubs the surface vigorously and  pro-
duces a glow over the skin;  this  is caused by the dilatation
of the cutaneous vessels and the rush  of Avarm blood through
them ; the  vigorous exercise of rubbing resulting  in  increased
heat-production. The tepid bath is from 85° to 95°.  Such baths
are suited  to delicate people, and such is the temperature of 
            PUBLIC AND PRIVATE  HYGIENE.          573

baths in which people reside  for hours  as  in Baden (Vienna),
or in the Avater under the Blocksburg at Ofen (Bucla).  At Leuk
men and women sit  for hours in Avater  " Avith  card-tables  and
drinks floated  to  them on trays."   The warm bath is from  96°
to 101°.  Here the pulse and respiration are not much quickened,
but the skin is induced to act  readily.  The hot bath runs from
101° to  110°, occasionally to 120°, which  is very hot.  Such
baths form powerful stimulants, and excite the  pulse and respi-
ration considerably.  They are obviously not adapted to weak
persons.   In hot  baths  the  skin  is  thrown very freely into
action ; and this transpiration through the skin, taken together
with the large draughts of  Avater  sAvallowed,  produces a flow
of water through the tissues  of the body,  which  exercises the
most beneficial effects.1  Baths and drinking the waters then
commonly go together ; occasionally it happens  that the patient
either cannot or will not tolerate one of them, and consequently
must go Avithout the benefits to be derived from the combina-
tion.   In many conditions such hydropathy is  very useful  and
health-giving, and is  much  to be  commended.  Personally, I
believe that hydropathy, rescued from quackery and under  pro-
per professional guidance and  superintendence, will form one of
the most universal  remedies of the future; especially in cases
where the system is laden with the deleterious products of waste.
   Vapor baths, Turkish, Russian, or natural, are also excellent
measures for exciting the action of the  skin and  inducing the
depurative effects of perspiration.   In addition  to  their general
application, waters and  vapors can be applied  locally to many
parts with advantage.  The  shower bath directed to the head
is a familiar illustration.
   Cold baths are often too depressing, and  hot baths too stimu-
lating to be indulged in safely by a large proportion of the
visitors at baths and bathing-places.
   There are other baths  than those of pure water, of any tem-
perature, and those of mineral waters.   Such are the sand baths
of Blankenberg and Xorderney.  A hole is  dug  in the sand, and
then the patient is placed in it, and the sand shovelled in around
him.   They are said to produce free action of the skin.  Such

  1  Jt is often well to go to bed after such baths, so that the  perspiration goes on
without fatigue, often with sleep ; by this means baths are made more effective. 
571          PUBLIC AND  PRIVATE HYGIENE.

proximity of damp sand must cause much heat-loss;  and these
sand baths were the favorite treatment of yelloAv fever by the
buccaneers of the  Spanish  Main.  In other places mud baths
are in vogue.  Peat or turf baths are common in many German
spas.   Such  baths  are  powerful cutaneous stimulants, and in
some  cases produce much  cutaneous irritation.   Partial peat
baths, or peat poultices, are also used  by some.   Peat Avater
forms the bath  at  other times.   Baths of pine balsam are in
vogue in some pilaces.  They also excite the skin Avhen inactive.
They are fragrant  from the resinous substances in the pine
balsam.  The dregs of the  Avine-tub  have also been utilized to
form a species of bath.  These  baths have the properties com-
mon to all baths.   Finally there are electrical baths; doubtless
useful at times, but too much  surrounded by quackery.  In
this account  of  baths and Avells the writer is much  indebted to
Macpherson's Baths and Wells of Europe: a Avork which may be
consulted by the reader Avith adwantage.
   § 232. There  are also health-resorts Avhich have nothing Avhat-
ever to do Avith Avells or springs, but Avhich  attract in conse-
quence  of their climate, position, etc.   Such are  Brighton,
Ramsgate, Torquay, Aberystwith, Westward Ho!  and Sear-
borough, Whitby, Silloth, and others.  These different places on
various coasts, east, south, and Avest, are good  and beneficial to
different cases.  In some cases the Avarm soft air of Devonshire
is as healthful as it is depressing to others ; Avhile these last are
benefited by  the bracing air of  eastern and northern localities.
It is a matter of no slight moment to many persons Avhere they
reside.   Some, however, are never Avell  at the seaside;  others,
again, never  so  Avell as when there; Avhile a third  series find a
sojourn  by  the  seaside  annually to exercise  a most  excellent
influence over them for the rest of the year.   In these different
cases varied  instructions must be given ; and if one place dis-
tinctly disagrees Avith the patient, let him or her resort to some
other locality.   We cannot yet find an explanation of the Avhy
and the Avherefore that some  organisms feel  Avell at Hastings,
Avith Avhich  Brighton  never agrees.  It  is useless to say that
this is  all imagination—though of  course in some  cases it is
little else, because Ave cannot  unravel and lay bare  the subtle
peculiarities  of individuals  Avhich Ave denominate idiosyncrasies;
Ave must boAv before the facts until Ave can explain them.  That 
PUBLIC  AND PRIVATE HYGIENE.
575
such individuals  should only be found in the affluent classes is
intelligible enough ; such organisms are incompatible with the
hardships of labor for an  existence, requiring residence, not
according  to  sensations, but according to  opportunities  for
making a livelihood.   But since they do exist, it is the business
of the physician to enable them to prolong their existence; and
to make that  existence as tolerable  and agreeable to them as
possible.  It is chiefly Avith respect  to the  consumptive that
health-resorts  have been studied.  Experience has  tan«lit  us
much in these  matters.  The first impression Avas to send  the
patient in Avinter to some warm  climate, Avhere the genial  air
and  mild temperature  Avould enable  the patient to be  out of
doors for hours  even in midwinter;  breathing an  air at once
pure  and fresh, and yet not so cold as to induce attacks of in-
flammation in  the diseased  lungs.  Madeira, from  its position
and its being on  the route of Indiamen, was a favorite place for
a  long  series  of years, and  Avas much resorted to; but iioav it
has fallen  from  its high estate,  apparently,  however, from no
demerits of its oavu.  The shores of the Mediterranean are iioav
the favorite Avinter resorts of the Anglo-Saxon, the Sclave, and
other races, whose oavii  Avinter  temperatures  are  too severe.
Egypt is also  uoav a popular resort, as steam  has made it more
accessible to the world.  Tangiers too has its  advocates ;  as also
has the Cape.
   On the other hand, it has  been  found that in a large propor-
tion  of phthisical cases it is not some warm  place  in Avinter
that is to be desired so  much as a cool place in summer; Avhere
a bracing air maintains  the  general  health in a desirable state.
Consequently  these cases seek the heights of Switzerland and
the Tyrol, where the summer air is chilled by the proximity of
snoAV-clad mountains.   In these elevated regions the consump-
tive  finds comparative  health during the  warm weather; and
descending on the approach  of cold Aveather  to  some healthful
region nearer  the sea-level, again finds a suitable resting-place
compatable with  existence.   By  such alternations life  is pre-
served.  It is even asserted by some that there are altitudes Avhere
consumption is never found, as in the Upper Engadine ; and
that  the phthisical can be  snatched  from the fate before them
by resorting to such places as lie Avithout the tubercular zones.
But  this is largely fancy, and it  will not be Avise to trust  too 
576          PUBLIC AND  PRIVATE HYGIENE.
 much to this avoidance of consumptive zones.   So far have avc
 advanced, or at least moved from  the  old  therapeutic position,
 that Avhile a low-lying Avarm  locality in winter was once  alone
 thought safe for the consumptive, Ave iioav advise the phthisical
 to winter  in comparatively high altitudes; and that, too, Avith
 apparent advantage.   In India also the hills  are  no longer for-
 bidden to the consumptive, avIio can find there a comparatively
 comfortable  existence, as Avell as other  invalids do.
   The  remarks of the late Dr. Fuller  are so much  to the  point
 that I shall quote them literally in  connection with  the question
 of the proper residence for the consumptive.   We  must ascer-
 tain "first, the sort of climate and the  degree of  temperature
 Avhich  formerly  suited the patient's constitution,  or, in  other
 Avords,  agreed  best Avith him when  he was  in health;  and
 secondly, the state of the patient's  bronchial  mucous membrane
 at the time Avhen his removal to another climate comes under
 consideration.   It is  obvious that if the  bronchial  mucous
 membrane is irritable the  invalid  cannot  bear the effects of a
 very dry and stimulating atmosphere, however warm the locality
 may be.  His symptoms require a soft  atmosphere,  and  its tem-
 perature and the precise degree of  necessary  humidity must be
 determined  by  reference to  his  constitutional peculiarities.
 Thus, if he formerly enjoyed  better health in summer than in
 Avinter, and  felt  greatest vigor in  very warm  weather, and in
 an  atmosphere  devoid of  markedly stimulating  or relaxing
 qualities,  the probability is that the climate of  Syria, Persia,
 Rhodes, Egypt, and other parts of Northern Africa  Avould  exer-
 cise an influence  on his system, the good effects of Avhich can
 be hardly over-estimated.
  "If, again, though  usually  better in  summer than in Avinter,
 he Avas  formerly oppressed by excessively dry heat,  but enjoyed
 a Avarm, humid  atmosphere,  such  as that of South Devon or
 Cornwall,  the  probability  is that  the  climate of  Torquay,
 DaAvlish,  Penzance,  or Jersey, of  Pau,  Rome,  the  Azores,
 Teneriffe, Madeira, Santa Cruz, the  Mauritius, or Ceylon, accord-
 ing to the degree of temperature required, Avould  be found to
 suit  his general  health, and assist  in subduing the irritability
 of the air passages.
  "And yet again, if be is constitutionally disposed to  general
languor, and has ahvays felt as much depressed and enervated 
PUBLIC AND PRIVATE HYGIENE.
577
   by heat as pinched  and prostrated by cold, then, notwithstand-
   ing the irritability of his bronchial mucous membrane, a medium
   climate must be sought—a climate such  as is  to be  found in
   QueenstOAvn, and other parts of the coast of  Ireland,  in the
   western coast of Scotland, at Buxton, Cheltenham, St. Leonard's,
   Ventnor, and Bournemouth ;  or, if a somewhat higher range
   of temperature is necessary,  in New Zealand,  or the Cape of
   Good Hope.
     "But a large class of consumptive patients  exist  in  whom
   there is little or no irritability of the  mucous  membrane.   In
   these a drier and more bracing air will generally prove of the
   greatest benefit; but nevertheless, as in  the former cases, the
   selection of a locality in each  particular instance must be regu-
   lated by the constitutional peculiarities of the invalid.  If his
   circulation is languid, and he  has usually felt more vigorous in
   summer than in Avinter,  the invalid  must  repair to a  warm
   locality, and in such a case the climate  of Mentone, Hyeres,
   Cannes, Malta,  Xubia, Algeria, Upper Egypt, the northern  dis-
   tricts of Syria  and  New  South Wales  are likely to  prove ex-
   tremely beneficial.  In some such cases the air of the Himalayas,
   the more elevated parts of the Andes, and other hill  districts,
   has been found remarkably serviceable.
     "If, again, the patient has an  active circulation, and  has
   usually enjoyed better health in winter  than in summer,  feeling
   braced and invigorated by cold, he  will probably derive  benefit
   from  a residence at Brighton, Margate,  Aldborough, Cromer,
   Harrogate, or Malvern; or if a cooler and  still keener air is
   required, from  the  climate of Montreal, or other  places  in
   Canada, or of certain dry  localities  in Russia, or other northern
   countries.   Some of the most  remarkable recoveries  from con-
   sumption  which have come within my oavii cognizance have
   occurred under the bracing  influence  of a  northern clime."
   {Diseases of the  Chest, Chapter  IV.)
     It is  noAv customary to 'send consumptive patients to high
   altitudes in Avinter.   It is asserted that the dry cold of  a high
   Swiss valley, together Avith fairly  constant  sunlight, is much
   more salutary for such  patients than the damp British climate ;
   and this may not be contradicted.  But it  strikes me the getting
„   away from unhealthy damp surroundings—the  negative  factor
   is often quite, if not more important than  the  positive  factor,
         37 
578         PUBLIC AND  PRIVATE  HYGIENE.
the high Swiss  valley.   The cases which do so Avell at Davos
are just those Avhich Avould do Avell at health resorts at home.
At least it may fairly be put  thus:  Is the superiority of tlie
foreign health resorts such as to meet the cost so incurred ?  In
many cases of phthisis  bracing health resorts at home would
give very excellent results.
  What is so well said by Dr. Fuller about the consumptive
patient Avill apply to a  large class of invalids, to whom, a resi-
dence suited to their individual necessities is quite as important
as it is to the phthisical.  In all cases indeed the answer to the
question  of the propriety of going abroad must be answered
carefully and  conscientiously.   It  will  not do in  so  grave a
matter to give  an off-hand ansAver, when the question  involves
residence amidst strangers in a foreign  land, Avho speak an un-
familiar tongue;  aAvay from friends and relatives whose kindly
sympathy is so dear to  the  invalid; with the  prospect perhaps
of a lingering death, Avhere no kindly hand will cool the fevered
broAv, no  Avell-known voice solace Aveary hours, no  familiar
presence  cheer the  chamber of. the sick  person.  To  send  an
invalid into exile Avithout a good  and valid reason is  very im-
proper.  Even Avhen  several  members of the family can accom-
pany  the invalid, it is a serious matter to order  Avhat may be
productive of  much inconvenience  Avithout  good  and  valid
reasons.  It is sad to reflect  upon  the number of cases where
all the good accruing from  a foreign  residence is allowed to
gradually slip away, because the patient is not put upon appro-
priate medicinal and hygienic treatment after  returning home.
I am afraid the  physicians of health  resorts do not sufficiently
insist upon this.
   § 233.  India.—The question of change of air in India is one
of  such importance that  it can scarcely be exaggerated, and in
order to do the subject justice, I have  applied to my friend Sir
Joseph Fayrer, K. C S. I., to givre me some information on  the
subject;  which  his long experience  and extensive acquaintance
with India so well enable  him to  do.   With this  request he
kindly complied;  and in the folloAving remarks points  out some
matters not generally understood;  but the gravity of  Avhich is
self-apparent:—
   "The subject of change of air and climate is a most important
one in India.  I really believe that it is  more so there than at 
PUBLIC AND  PRIVATE HYGIENE.
579
 home; and if the Calcutta medical men had it not to fall back
 upon, they would find great difficulty in restoring a number of
 their patients to health.  The most important means of obtaining
 change of air are the folloAving, (1) the Hills, (2) the  Sea, and
 (3) Europe. These are all extreme methods, and there are many
 slighter, but very effective changes—none so trivial as  to be un-
 important.  For instance, change to another house, or even to
 another  room in the  same house; to another  station, even if
 there be  no  very obvious difference in the climate; a feAv days
 or even  hours in a boat on a river, if the patient be near one;
 and in Calcutta a run  doAvn the  Hoogly in a small steamer  to
 the Sandheads, Avhere a  day or  tAvo may be spent actually in
 real sea  air; each and all of these are  valuable remedies, and
 contribute largely toAvards enabling our countrymen and women
 to fulfil  the period of their exile in the East, and to  return to
 Europe, damaged it may be in constitution, and compromised
 in their eapjacity for sanguification ;  but still free from Avhat is
 ordinarily termed structural disease.   Of course the change of
 climate adapted  to  one is not ahvays suitable  to another; the
 visit to  Simla, Missouri, Darjeeling, that would  restore  one
 man to vigor and health, might  prove fatal to another; even
 the health-giving sea air, if resorted to only in the Indian seas,
 might prove a delusion in those cases Avhere the more radical
 change to Europe is indicated, as I have often  found to be the
 case.  The difficulties of getting  aAvay, the probable loss  of
 appointment or business, the want of funds, the anxieties and
 care of an establishment at home and in India;  the temptation
 to complete the one or two more years Avhich will conclude the
 term when a pension becomes due, and India may be abandoned
 for ever—these and other motives have led many a one to trust
 to the lesser change of a voyage to Bnrmah or Singapore when
 the more radical  one of a visit  to Europe alone  could  have re-
 stored health, or, indeed, saved life.
   "These are sometimes difficult problems for the medical man
 to solve, and at times it is necessary to be very  firm in urging
 the necessity for a step that  is  so full of importance to the
 patient and his family.  The question will naturally arise as to
 Avhat are  the cases where this change of air is desirable, and
what variety of  change is suited to particular cases?  I believe
that such  change is needed  for Europeans in  India,  after all 
580          PUBLIC AND  PRIVATE HYGIENE.
attacks of disease  Avhich have amounted to more than mere
passing derangements of the bowels  or stomach ; or  perhaps
slight attacks of fever the result of heat and exposure, or other
corresponding trivial ailments, from which the young and other-
Avise healthy persons  recover  there as Avell  as  here; but in all
cases where the disease or ailment has lasted longer than this,
change  is generally needed  to restore  the patient  to his usual
health and pristine vigor.  I do not in the least mean to assert
that he will necessarily remain an invalid in all cases  Avithout
it; but that it is very desirable—that it is good economy in time
and money—for  the  mercantile  man, and also for the public
servant, Avho is thus  sooner fitted to resume his duties effectu-
allv, and to perform them Avith greater benefit to the State.
  "The complete change to Europe is the most important,  and
it is often very necessary.  Formerly under the old Honorable
Company's regime a period of three years' furlough was accorded
to officers avIio  had served  many years in India;  and  it Avas a
wise rule.   It has been contracted of late years, and the period
reduced to  tAvo years, and even  less ; but I  have frequently
observed that it is the third year at home that completes the re-
establishment of  health in  the cases  of many who have been
long exposed to the influence of the Indian climate. Eighteen,
fifteen, and tAvelve  months  are the periods of leave iioav gener-
ally granted on  medical certificate;  but these are too often
insufficient, and have to be extended.  As a general  rule,  one
might say that  a  visit to Europe for a  year at  least is desirable
after  six or seven  years' residence in  India, especially if that
time has been spient in the plains; and this even Avhere there
may have been no  illness, only that deterioration which takes
place  more or less in Europeans after  a protracted residence in
hot and malarious  climates.   But after attacks, and still more
if  they have been severe,  of the so-called  tropical   diseases,
change  to Europe is often the only means of restoring health ;
especially in those  who haATe  had  more than  one attack,  and
have also been long in India.  Such cases as chronic dysentery ;
enlargement, malarious or otherAvise,  of the liver and spleen;
abscess of the liver, and that dubious state in which no one can
feel sure  that  an  abscess  has or has not  formed;  malarious
cachexia, the result of frequent recurrence of fever, or of expo-
sure to malarious  influences, that have not caused fever, but 
             PUBLIC AND  PRIVATE  HYGIENE.         581

anaemia,  neuralgia,  local disturbances of venous or  arterial
systems, with the numerous evils that result from that condition,
according to the degree to Avhich they exist;  albuminuria, im-
perfect function or disease of the organs  concerned in the due
and proper elaboration of the blood, as evidenced by litbeemia
and all its attendant troubles;  the broken health Avhich often
remains after cholera and attacks of continued fever, insolatio,
and above all  that which is so commonly the consequence of
overwork, mental rather than bodily, when the mind more than
the body needs rest—such are  the cases, but  by no means  all,
that require the radical change to Europe.
  " Next to this comes a sea-voyage.   This may be to China, to
Singapore, to Ceylon, to the Andaman Islands, seldom iioav, as
used  to  be the case, to the Cape  of Good  Hope, or  even  the
brief  run to Madras, or  some  pilace  on the  coast; a  few days
on board a pilot brig or  light vessel at  the Sandheads, or a  run
doAvn the river in a steam tug just  to  meet the sea-air  and
return.   Such trips  are often of the greatest benefit, but unfor-
tunately they are frequently far from sufficient, and are only the
preludes to  the change to Europie.   Still every one in  Calcutta
knoAvs how  great  is the  benefit these trips  confer, and how
often, if taken in time, they serve to  stave  off or prevent  the
necessity of some more radical change.  After attacks of fever,
hepatic congestion,  bowel complaints, nervous irritability, the
result of heat, ovenvork, and imperfect action of the  liver, an
absence of this kind, say for a  fortnight, in a steamer crossing
the Bay of  Bengal, will  often  restore health ; while  in lesser
cases a run doAvn to the Sandheads,  or  a trip to Madras  and
back, Avill suffice.   The  fact is  that by medical treatment, with
all it  implies, a patient  may be got over the  worst part of his
trouble, and be restored  to a certain condition  of convalescence,
—but can be got no further.  Hitherto he has been getting on
in a direct line, but ultimately  he  gets into a species  of circle
and makes no  progress, and then it is  that the sea-trip does so
much good, and enables the invalid to  return to his work.  For
instance, take  the case of a young man who has been a  feAv
years in  Calcutta,  and  who  has already  begun to  feel  the
climate: he  has  an attack of fever with a certain amount of
hepatic trouble, or perhaps  even dysenteric complication.  The
early  treatment is perfectly successful, and the symptoms rapidly 
582         PUBLIC AND  PRIVATE  HYGIENE.

disappear ;  but he does not get on, and remains Aveak and de-
pressed, and unfit for Avork.  Tonics, food, etc., all do no good.
Send him for  a Aveek to sea, and he conies  back strong and
healthy,  with color in his cheeks and \rigor in his frame.
  " Now Ave come to the Hills.  They are valuable too, and often
do much good, but they cannot take the pdace of the change to
Europie, or  even the ordinary sea trip.  For many cases, Dar-
jeeling, Missouri, Simla,  Murree,  are  all too cold  and too ele-
vated,  and  they do  more harm than  good.   There is in  such
cases no  poAver of  resisting the  influence of cold and the  rare-
faction of the air ;  and diarrhoea of a most intractable character
results.  These Hill stations are useful rather as places of refuge
from the great heat, for  the mental  rather than  the  physical
(though  that  too  very often)  effects of change ;  and for the
bracing effects of cold air in those avIio are strong  Avith un-
sapped constitutions.  Those avIio  have suffered from overwork,
mental strain, malarious cachexia  in the slighter forms, or  have
a nervous system rendered irritable by responsibility and anxiety,
or exposure to heat,  may and often do benefit by it: but the bill
stations of the Himalayas are seldom  of use to those Avho have
suffered  from  hepatic disease, dysenteric affections,  or general
malarious cachexia.   As a general rule these cases should not be
sent there, but to sea, or  home  to Europe.   It  is not the  same
Avith the Hill  stations of the south, Ootamacund  and Conoor;
much  further south they have a different and  less  extreme
climate,  and are frequently of the  greatest benefit;  as I have
often recognized in  the case of patients of  my own  sent from
Calcutta.
   " As to minor changes, such rules as apply at home obtain in
India, only I think they seem to tell more strikingly there.  In
short,  change of air and climate  constitute the most powerful
curative agents, and often preventive measures, Ave have to fall
back  upon in  India, and  it is  impossible to say  too  much in
their  behalf.   This brief  note is insufficient  to  do even the
pretence of justice to the subject."
   These remarks, though all too brief, are most valuable and
suggestive:  pointing out as they  do so  forcibly, the limited
amount of benefit to be derived in  grave  cases from a resort to
the Hill sanatonums; Avhich, hoAvever valuable they really are, 
PUBLIC  AND PRIVATE HYGIENE.
583
appear to be overrated as to their potency by those avIio are not
so familiar with the subject in its entirety.
  § 234. The subject of change of air and climate  comes home
to most of those Avho are either naturally delicate, or Avho beo-in
to feel the tax of prolonged physical toil and exertion, or mental
tension, in tropical or sub-tropical climates.  In such cases the
sea-voyage, when  practicable, especially when it leads to neAv
lands, new topics  of thought, novel scenery and associations, is
very desirable; as Avhen the American takes a trip to Europe;
Avhen the  resident of the Cape, or the Australian, takes a similar
trip;  or Avhen the European visits their lands.  In each and all
cases  such change is  not  uncommonly of  inestimable benefit,
and ahvays almost of  some decided good.  When such  voyage
is not feasible, then a  sojourn  among the Blue Mountains of
Virginia; or iioav to the Rocky Mountains,and the  prairies that
lie  at their feet; or even to the Californian Sierras, is beneficial
to the denizen of the United States.  The northern spurs of the
Rocky Mountains in English territory, Avith the pleasant lands
known as "the fertile belt," Avhich lie around them, form a mag-
nificent site for sanatoriums ;  as well as health-giving resorts for
the naturalist, the artist, or the sportsman.  In South America
the slopes of the Andes are available for those  avIio need coolness
and quiet;  and the  lofty table-lands  of Quito offer sites  for
sanatoriums; though perhaps liable to the  objections which  Sir
Joseph Fayrer makes  to the Hill stations of India. Simla is
8000  feet above the  sea;  Quito is 9000 feet; Avhile the table-
land  of Mexico is over  6000 feet  above  the  sea-level.   Such
altitudes, while doubtless  securing  coolness,  must  necessarily
possess a rarefied air, and have other drawbacks.
  It  is not only the intervals of  convalescence in the  invalid
Avhich give importance to these matters; there is also the ques-
tion of prevention, of  the right and Avholesome use of holidays.
The tour  through SAvitzerland, the Tyrol,  or the Ilartz Moun-
tains, now so common Avith Europeans, are  excellent  health-
giving measures, Avhich can scarcely be too highly  commended;
but some caution  is necessary that they are not made fatiguing,
especially to the weaker and less enduring members of the party,
under Avhich circumstances they often do much more harm than
good.  For the residents in loAV-lying plains an annual  sojourn 
584         PUBLIC AND PRIVATE  HYGIENE.

to some elevated inland resort, or to the sea-side, is very desir-
able;  Avhile for  those  who  live in  elevated places a similar
annual sojourn by the sea in some mild neighborhood is equallv
beneficial.  It is not, however, ahvays the  mere change of air
that does all  the good ; there are other factors  often, as the
change of habits, of scenery, and of neAV surroundings generally,
Avhich are of no slight value. 
CHAPTER  XXIII.
              FOOD IN HEALTH AND IN ILL-HEALTH.

  § 235.  Scarcely, if at all, less important than medicinal agents
is the matter of food.   The subject is one Avhich  has attracted
much  attention at  all  times; and  varied  views have  been
expressed about it, from the whimsical  distinctions as to the
action and  effect of different meats given in  the Anatomy
of Melancholy,  to  the clearer  and more  exact  statements of
Physiological Handbooks.
  Liebig laid  doAvn  a broad  rule, which has been so Avidely
spread, that reference to it is unavoidable.   He divided foods
into tAvo classes: (1) nutritious or plastic food ;  and (2) respira-
tory food; not  forming .the  mineral elements  of food into a
distinct class.   This division had much to recommend it, but it
is far too absolute.  In the first place, plastic forms of food, to
a certain extent, are respiratory food ;  and hydro-carbons are also
requisite to  the formation and building up of  healthy normal
tissues.  Muscles, the very  type of plastic food,  contain a
certain amount of glycogen in health, and in so  far contain a
hydro-carbonaceous, or respiratory food.  In the  oxidation of
azotized matter on its road from  peptones to  urea, a certain
amount  of  heat, or force is  produced ;  independently  of any
hydro-carbon contained in the azotized food.  On the other hand,
tissues for their building and repair require a certain  richness of
hydro-carbonaceous matter; and if the food be too poor in this
respect, wasting follows, with a strong tendency to the forma-
tion of tuberculous growths.   Hence Ave strive  to  arrest the
tubercular habit by  giving the  patient  a plentiful supply of
hydro-carbons in the concentrated form of oil or fat; and in
order to  secure their  better assimilation, give Avith them tonics
and  stomachics; even an artificially-supplied pancreatic secre-
tion  is not without its value.
  Retaining, then, this division in a modified form—namely, as 
586      FOOD IN  HEALTH AND IN ILL-HEALTH.

(1) nitrogenized, and (2) non-nitrogenized foods, Ave can proceed
to consider the matter more in  detail.
  Nitrogenized foods are those Avhich in digestion are formed
into peptones, and from Avhich the tissues are built and repaired.
The amount that a  growing  boy will eat of thi3 material with
impunity, indeed Avith advantage, is  many times greater than
Avhat  is  required by  an  adult or aged  person.   In  growth,
tissues have to be built  as well as repaired, and in  health the
digestive poAvers  are fully equal to the task of assimilating the
required material.
  If a sufficiency of suitable food be attainable, and the assimi-
lative powers are healthy, a full-groAvn organism, structurally
sound, is the result.  But a much smaller quantity of nitrogen-
ized food is alone absolutely required  Avhen the full  groAvth is
attained.  In the face of this  fact, the consumption  of meat is
widespread, and largely indulged in. • There is a general impres-
sion that a diet consisting largely of animal food endows the
system Avith  a sense  of energy and capacity.   The  gillie who
lives ordinarily on  a diet  almost exclusively vegetable, quickly
increases in  power of endurance, and in capacity to manifest
energy in the shooting season,  when his dietary is  more liberal,
and contains a good proportion of animal food.  On a conscious-
ness of  the  capacity  to  increase a man's  power  of labor by
liberal supplies of food, of which  a large proportion  is derived
from  the animal  world, the farmer engages men to  live in his
house and eat at his table ; while their Avives and children eat at
their  own home.  The farmer knows Avell enough  that, if he
arranges so that  the bread-winner gets his meals at home, he
Avill share what he  can procure with his offspring ;  and in doing
so will diminish  his  oavii capacity to labor.  The  farmer gives
his horses an extra  quantity  of corn when  the duties  to be
performed are heavy ; he knoAvs that if he does  not do so his
horses Avill fall off in condition, and  have to  be fed up again;
so,  instead of taking from their stored-up force, he  meets the
increased Avear and tear  by  a  more liberal dietary.   Not only
does  a liberal supply of animal food  give  an  increment of
energy,  but  it also endows the  organism Avith  an  additional
amount  of vigor.   The meat-fed man is livelier, and his nervous
energy greater,  than  the vegetarian.  A bear Avhich Avas fed
upon  meat became unmanageable;  but a dietary Avhich  fur- 
         FOOD IN HEALTH  AND IN  ILL-HEALTH.      587

nished no excess of nitrogen kept him comparatively quiet and
submissive.   The energy of meat-eating races and of carnivora
contrasts Avith the quiet and more subdued Avays of vegetarians
and herbivora.   It is then  this sense of vigor which a dietary
of animal food gives, that makes  mankind crave after it;  and
induces humanity to consume an  amount of  azotized  material
far beyond the absolute requirements of their tissues. A highly
nitrogenized diet  is  conducive to  mental vigor:  about that
there can be no question.  "It  is certain that  three men, one
of Avhom has had a full meal  of  meat  and bread, the second
cheese or salt fish, and  the third piotatoes, regard a difficulty
Avhich presents itself from entirely different points of view.  The
effect of the different articles of food on the brain and nervous
system is different, according to certain constituents pieculiar to
each of the forms of food."  (Liebig.)  And it is equally certain
that the poAver of thought in an individual is very  different
according as to Avhether he is Avell and  liberally fed, or is in a
state of  partial starvation.  This is a matter,  however, Avhich
does  not admit of  demonstration ;  and yet there  is a  large
amount  of evidence  pointing to  it,  and indicating that there
are relations existing betAvixt  the different  forms of  food and
manifestations of nervous energy.
   We will now proceed to a part of this subject about Avhich
the proof is  more certain and  the matter more  demonstrable.
Azotized foods  furnish the material for our tissues, for Avhose
reneAval  they are  required.   But  this is much less than  is sup-
posed ;  and  tissue-repair requires but  a comparatively sniall
portion of our plastic food.  The rest of the peptones, Avhich
are produced in each act of digestion, are split up, as  has been
insisted  upon in Chapter II. (§ 15), in  the liver, into  glycogen
and  nitrogenized Avaste.   All, or almost all, of this nitrogenized
Avaste is  superfluous; and the requisite amount of glycogen for
the daily combustion within the  system could  be as Avell fur-
nished by farinaceous or saccharine material as by azotized food.
The  amount of urea passed daily does  not so  much represent
the waste of tissue, as the manufacture of glycogen  from albu-
minous matter in the liver.  Even  in  fever  much of  the  urea
passed, frequently in  large quantities, is derived from  the albu-
minous and other nitrogenized material furnished to the system
as food, in the shape  of milk, beef-tea, eggs, etc.  No doubt the 
588      FOOD  IN HEALTH  AND IN  ILL-HEALTH.

tissue-Avaste,  under a  high temperature, is very considerable,
but it must not be supposed  that all the urea is furnished  by
tissue-Avaste.   Much of the attention to  the  estimation of the
urea excreted in pyretic conditions is throAvn  away really, and
rendered comparatively valueless, because the estimates are not
accompanied by accounts of the  exact  amount of the patient's
daily ingesta.  The origin of  the urea is overlooked in the esti-
mates, and the conclusions are  radically invalidated by such
omission.  It may seem  to  some  readers  that  this matter is
unduly insisted upon throughout this Avork, but its importance
is a sufficient vindication  for the repeated references to it.
  These  products of nitrogenized ingesta are matters of much
moment  in the management of conditions of lithiasis.  In renal
inadequacy the first step, of course, is  to diminish the amount of
nitrogen consumed.  The effects of quantities of azotized matter
in the blood upon the nervous  system  have just been mentioned;
and certain it is that the nitrogenized  materials may be regarded
as manifestors of force, i. e., the man whose blood is  highly
charged  Avith nitrogen can evolve nerve-energy more  rapidly
and  freely than can the  vegetarian—the brain-power of each
being  equal—and  probably can maintain that evolution for a
longer time ; but,  nevertheless, the actual force is furnished by
the combustion of hydro-carbons.
   § 236. In  the hydro-carbons Ave consume as food Ave find the
chief supplies of our force-producing material.  All manifesta-
tions of force, muscular, nervous, and  glandular, are produced by
oxidation Avithin the system.   Each muscle has its little  store of
glycogen as  muscle-sugar; and, Avhen  functionally active, it is
that glycogen which is consumed and oxidized, not the struc-
ture of  the  muscle  itself.  It Avas supposed by Liebig,  and by
other more recent Avriters, that the muscle  itself  AATas worn out
in functional activity,but the experiments of Parkes and others
have shown that  sustained  muscular  activity is not so much
accompanied by an increased amount of urea, as by an increased
production of carbonic acid.   The muscle, in this respect, is  not
unlike the Avick of a candle,it burns the supply of hydro-carbon;
and as long as this is furnished in good quantity, it is but  slightly
consumed itself; when, hoAvever, the supply  of fuel fails, the Avick
itself  is  consumed, as in starvation.   As long as the amount of
urea excreted daily is regarded as the measure of  tissue-waste 
        FOOD IN  HEALTH AND  IN ILL-HEALTH.     580

only,  so long shall Ave have  erroneous  conceptions  as  to the
amount of nitrogenized matter required to meet—Avhat are sup-
posed to be—normal daily wear and tear.
  In hydro-carbons Ave find the great sources of our supply of
force-producing  material.  There is a store of glycogen in each
muscle, and  a granary in the liver ;  while in our adipose tissues
Ave carry, in  a permanent condition, much fuel in a concentrated
form.  When the supplies of food  are beyond the immediate
requirements of  the  individual, there is  an accumulation  of
stored-up  material, giving  an  increase  in  body-weight.  Not
only is there an increase of fat, but each muscle is plumper and
fuller; as is seen in the horse  when in good condition, or made
up  for market.   Tliere is, in fact, a reserve of force-producing
material  stored  up for the  needs of the system, and a man in
good  full  condition will outlive the. spare man if exposed  to
complete, or partial starvation.   Understand me distinctly, how-
ever: a fat man will not necessarily Aveather a fever better than
a lean man, the  clinical facts  are  rather the  other  Avay; nor
yet will  a stout man  necessarily  endure  hunger  better than
a spare one; but the same organism possesses  more endurance
Avhen in  good condition than it does when  previously reduced.
The excess of nutrition is stored up, and evidence of this is given
by increase of body-weight;  when the demands upon the system
are excessive, then the body-weight falls.  The ordinary reserve
store of man is equal to about eight or nine days' consumption,
as found by  the records of shipwrecks, etc.  If the  surrounding
temperature  be  low, the store is soon exhausted,  because  the
body temperature has to be maintained ; if  the exposure be  in
tropical regions, a longer period of abstinence is compatible with
existence, because there, little is required to maintain the body-
temperature, and so the reserve-store  lasts  longer.  Of  course,
too, much depends upon the amount of muscular exertion to be
performed ;  if it be great,  the reserve stores will be  all  the
sooner exhausted ;  if little, as  in a boat, or, still more, a raft,
and most when in  bed, the  stored-up  force-producing material
will be still  longer ere it is consumed.  When cold, Ave put our
muscles in action ; and in doing so produce more  heat, and  so
become warmer.  There is a greater combustion of muscle-sugar
so induced,  and thereby  more heat is produced.  So when 
590      FOOD  IN HEALTH  AND IN  ILL-HEALTH.

muscular  exertion  is required from a famishing man, he is so
much the sooner burnt up.
  In  sickness in bed  the reserve stores are not much draAvu
upon ; and if small quantities of nutriment are  furnished,  and
the needs of the system  are  reduced to a minimum, a person
Avill last several Aveeks on  a  very small  quantity of food,  and
yet ultimately  recover.   Seegen1  gives  such a case.  The  ob-
servations began after the piatient (avIio suffered from a gastric
affection) had  been taking  very little food for  several Aveeks;
and for  nearly  fourteen  days had  been living on thirty-five
grams of fresh  milk daily.   A  gram being fifteen grains,  this
gives  515 grains of milk per diem.  In  addition to  this  she
only took so much  Avater; which, of course, furnishes no force,
as it is not oxidized.  The thirty-five grams of milk contained,
according to the determination of Becquerel and Vernois, 1.0
grams of albumen, corresponding to 0.29 gram of nitrogen taken
daily, or 3.4 grams in tAvelve  days.   The urea excreted during
the same period amounted to 106.9 grams, containing 49.8 grams
of nitrogen ; and the excess of nitrogen excreted over  that con-
sumed, and  Avhich  necessarily must have  come from the tissues
of the body, Avas 46.4 grams.   From the  thirteenth  day of
observation  omvards,  to the twenty-fourth, a much larger quan-
tity of food Avas taken ; the milk  during this time being 2275
grams daily, besides an egg, and a little arrow-root.   The nitro-
gen taken into the body during this period in  the  milk alone
Avas 1.76 gram daily, Avhile  in the first tAvelve days it \vas only
0.2 gram.  The  excess of  nitrogen taken in the food during the
second period over that in the first Avas, therefore, not excreted,
but stored up in the body.   This case sIioavs Avell how  insuffi-
cient  supplies of food are eked out by tissue consumption, of
which the urea forms the cinders ; and then, again, hoAV tissue-
nutrition takes  up nitrogen from the food for  the  purposes of
repair.  It  illustrates  strikingly the requirements of convales-
cence; and  shows  how  liberal supplies  of food are  required,
the appetite and poAver of assimilation being remarkable at  this
time.   The  patient Avhose reserve-stores are small to commence
with, is  ill  prepared  for  any long or severe demand upon  the
1 Journal of the Chemical Society, vol. xxv. 
         FOOD IN  HEALTH AND  IN ILL-HEALTH.      591

system ; and  succumbs  to  demands Avhich could be  met with
safety from fuller and more abundant reserve-stores.
  From the hydro-carbon elements of our food, then, Ave get the
bulk of that material required for the maintenance of body-heat
and the manifestations  of  force.   Some glycogen is  furnished
by the splitting up of peptones ; and fuel  is also furnished in
starvation by the combustion of the tissues, of Avhich the amount
of unoxidizable Avaste is the measure.
  It is very desirable that  definite  and  distinct impressions on
this matter should exist, and that the importance of starch be
recognized.   Those popular books Avhich measure the amount of
nutriment contained in  any substance by the proportion of ni-
trogen present Avould  be very mirth-provoking, if they did not
create erroneous impressions on an important subject.
  For most persons a much larger proportion of farinaceous food
in their dietary is desirable ; and puddings of various forms may
advantageously  again  make  their appearance  on other than
nursery tables.  The tendency of the present  day is  too  much
in favor of a lunch of cold meat, accompanied by a draught of
wine, beer, or stout.  No doubt  in such a  luncheon there  are
combined nitrogenized and hydro-carbonaceous elements,  to-
gether with a stimulant; and Avherethe alcohol  in the beer does
not induce somnolence, such a luncheon perhaps  gives the  neces-
sary food in that form Avhich  best permits of an arduous after-
noon's work  being encountered.   But it may  be much  wiser
ultimately for younger men and growing boys to have a luncheon
of a less stimulant character.  " The best luncheon a growing
young man can  have is a  dish of roast  potatoes well buttered
and peppered, and a draught of milk.  Or the  same  vegetable,
with a little bacon  or  fish, may be made into a Cornish  pasty,
which  if wrapped up in flannel will keep hot for several hours."
So says one of our best authorities on diet (Chambers); the first
form is within the reach  of all  Avho follow sedentary or town
lives; while the latter is suitable for those who must go  a-field
to labor, or those avIio must take their noontide meal with them.
Such an arrangement furnishes the species  of food required for
the production of force, in a readily  assimilable and non-stimu-
lant form ; and  in doing so constitutes a most  suitable dietary
for a midday meal.  Of course such  a lunch  ought to be com-
bined with a liberal breakfast and a substantial dinner  in the 
502      FOOD  IN HEALTH  AND IN  ILL-HEALTH.

evening.  The  matter of breakfast is  very important.   After
a good substantial breakfast, long hours of labor can be under-
gone Avithout a sense of fatigue or exhaustion ; for hours can
arduous work be maintained after a breakfast of bacon, or ham,
with a good proportion of fat upon it; not only physical labor
but psychical toil  can be  avcII  undergone, and a long day's
Avriting, preceded by such a  breakfast, is sustained Avithout any
of that  feeling  of the thoughts no longer framing themselves
readily into concrete sentences, or that the Avords Avill no longer
readily  drop from the point of the pen, Avhich come on  after a
few hours Avhen only a  light breakfast  has been taken.  Those
Avho have made observations on the  matter, note  Iioav Avide is
the difference in endurance after  such  a breakfast  as that de-
scribed, and one of fish.  Fish is rich in phosphorus, and " ohne
Phosphor kein  Gedanke"  may have some  elements  of  truth
about it ; but after a breakfast of fish, comparatively feAv hours
of Avork produce the feeling of being exhausted ; while a break-
fast consisting largely of fat will give  umvearied  energy for
tAvice as long.  Phosphorus and nitrogen are very Avell in their
way, and enable the brain to Avork up to a higher pressure ; but
the hydro-carbons  are  the  fuel  after all, both in  the human
organism, and  in the locomotive; and  a certain proportion of
each should exist in the dietary of all.
  Perhaps a larger proportion of force-manifestors are desirable
where  the labor is chiefly cerebral, than where the toil of the
nervous system is confined  to keeping  the muscles in  action.
" And Avhilst on the one hand it may be  freely conceded to the
achTocates of ' vegetarianism' that  a Avell-selected vegetable diet
is capable of producing (in  the greater number of individuals)
the highest  physical development  of Avhich they are capable, it
may on the  other hand be  affirmed with  equal certainty that
the substitution of a moderate proportion of animal flesh is in
no Avay injurious, Avhilst so far as our evidence at present extends,
this  seems  rather  to favor the highest  mental development."
{Principles of Human  Physiology,  §  62.)   This expression  of
Carpenter's  falls in Avith my  oavii  views; and  perhaps a more
stimulant dietary, both alcoholic and nitrogenized, is requisite
for  sustained mental Avork  than  for  any other form  of  labor.
Barristers, literary men, actors, and others similarly engaged may
find that an indulgent dietary enables them better to get through 
         FOOD IN  HEALTH AND  IN ILL-HEALTH.      593

their intellectual toil; but if this is the case it also throws some
light upon the tendency in such persons to premature decay, or
demise in the midst of apparently perfect and unimpaired health.
It is the old story over again, " in order to live long it is neces-
sary to live slowly;" or that moderation  alone is conducive to
the prolongation of enjoyment. A diet may be stimulant even
without alcohol, though usually they go  together; but such  a
dietary is hostile to length of days, Avhile a non-stimulating dietary
is conducive to prolonged existence. The individual must choose
for himself in the matter; but where a large amount of intellectual
toil has to be and must be undergone, then the power of choice
is limited.  In thus speaking of a stimulant dietary Avith alcohol,
it must not be supposed that Avork can only be done under the
influence of stimulants—far from it.  The best and largest pro-
portion of work is done on such a breakfast  as  has been just
described; but then after the day's Avork  is over, and the work
done, a  dinner of animal food,  or largely so, Avith  some alcohol,
Avill secure the greatest fitness for the next day's toil.   By such
an arrangement it is found  that the maximum of work can be
done with the minimum of wear and tear.  The alcohol  under
such circumstances should  only be taken at meals, unless it be
a small  quantity  at  bedtime;  and scarcely ever before dinner,
especially if the labor has to be continued through the after-
noon.  Where, on the other hand, the labor to be undergone is
chiefly muscular, a diet largely  hydro-carbonaceous, and to a less
extent of azotized  material, is desirable, unless the labor  be
very severe; and  then it has been found  that a free supply of
animal  food  is beneficial, as has been seen in the comparative
capacities of English navvies on their Avonted diet, in the con-
struction of foreign railroads.
  § 237. Food, however, has other relations Avhich are far from
unimportant.   In the excess or diminution of certain constitu-
ents of  our  food  do we  find the explanation of  many of our
constitutional conditions.  For instance, in an excess of  nitro-
genized food we find the causation of much of the lithiasis, or
gout, Avhether regular, irregular, or suppressed, with which  we
are brought into contact.   In  an excess of hydro-carbonaceous
food does obesity take its origin; and abstinence is an effectual
treatment for such a condition.  In a deficiency of oleaginous
matters is found to lie the tendency to  those ailments which
      38 
594      FOOD  IN HEALTH AND  IN ILL-HEALTH.

are regarded as scrofulous, or as tubercular.  Consequently in
either tendency it is ever of the greatest importance  to flood
the system Avith oleaginous matter, so far  as it is possible to
procure its assimilation.  If one form of fat or oil is unpalatable
or indigestible, it becomes necessary to substitute  another;
until  some one is  found which can  be digested.  Neither is it
desirable that one  form be adhered to  until satiety is induced  ;
changes must be made, and fresh olive oil may sometimes be
substituted for cod-liver oil ;  especially in those seasons when
vegetables are procurable in plenteous  supplies and in good con-
dition, and with Avhich  large quantities of oil may readily be
taken.  At other times cream Avith  fruits, cooked or uncooked,
may be taken in large quantities; Avith stewed fruit or straAv-
berries it is Avell  borne, and as Devonshire cream is  delicious
Avith  preserved ginger;  while cream  and maraschina form a
nutritive  drink for the affluent consumptive.  It is not ahvays
the same thing, hoAvever,  to consume  food and to assimilate it;
and in many cases a liberal  supply of  oleaginous food, hoAvever
necessary for the system generally, produces biliary disturbance.
In these cases—and they are numerous—it is  well  to maintain
a gentle action on the boAvels, and  every three or four days to
induce purgation, especially by alkaline  saline purgatives ; by
such a plan, sAveeping away the superfluous bile, in these persons
the assimilation of oleaginous matter can be much furthered.
At the same time, open air exercise in some  bracing locality is
very desirable.  Not only  must the primal vice  be SAvept at inter-
vals, but the removal of  waste  products, by  liberal supplies of
oxygen, is to be encouraged, such removal of waste being essen-
tial to perfect tissue-repair.  As soon as oleaginous  matter is
supplied to  the tissues,  those changes known  as tubercular
growths give way to the formation of  healthy tissues.
  In obesity, on the other hand, it  is necessary to avoid those
fonis of food AA^hich readily develop adipose tissue.   The favorite
plan,  in vogue at present, is that advocated by the late Mr.
Banting.  It consists of cutting off all  hydro-carbonaceous food,
and substituting  for it a  practically unlimited  nitrogenized
dietary.  This is effectual in reducing the amount of fat; for
the glycogen so furnished  is insufficient for the needs of the
system, and, consequently, the reserve stores of fat  are drawn
upon, and diminution in weight  and bulk results.  This plan is 
         FOOD IN  HEALTH AND IN  ILL-HEALTH.      595

unphysiological, and is so far unwise that it takes no account
of the amount of nitrogenized waste produced by it:  and grave
renal  mischief often results therefrom.  It is much more pru-
dent to adopt a line of practice which  secures the same results
without the risk so run ;  and the best plan is  to fill the stomach
with material, which, while it satisfies the cravings of hunger,
furnishes  but little ailment.   Consequently vegetables, espe-
cially such  as have much  parenchyma, as  lettuces, cabbages,
greens, spinach, etc., are  very suitable.  The next best material
of diet is the use of cereals  and fruits, taken in limited quanti-
ties.  The cases  of the Abbe Cornaro; of Wood, the miller of
Billericay; of a patient  of the late Dr. John Fothergill; of a
Whitehaven man  related by Wadd ;  of  a baker of  Pye-corner
(Wadd), are quite  as  striking as  that  of Mr. Banting, or even
more  so.  Cornaro took daily but twelve ounces of food,  chiefly
vegetable matter, and fourteen ounces of light wine, for fifty-
eight years.   Mr.  Wood for eighteen years lived  on sixteen
ounces of flour daily, in the form of a pudding  made of sea-
biscuit; by which plan he reduced himself  some ten or eleven
stones, and was " metamorphosed from a monster to  a person of
moderate  size; from the condition of an unhealthy decrepit old
man to perfect  health  and the vigor and activity  of youth."
Dr. Fothergill's patient lived solely  upon  vegetables, with a
little  wine  or  light beer.   The Whitehaven gentleman  ate
brown bread, and  apples to fill his stomach ; by which means
he  reduced himself eight stones.  He purged himself thrice
a Aveek, but alloAved himself  a  pint  of port  or  sherry daily.
The baker took water gruel and brown bread, and lost fourteen
stones.  In the other case, related by Wadd, on a diet of  four
ounces of  animal  food,  six ounces of bread, and two pounds
of liquid, a gentleman reduced himself from thirty-two stones
nine pounds, to tAventy-three stones.  These cases are each of
them more remarkable  than that of Mr. Banting, as regards
the reduction  of  weight;  and  the  means  of attaining  this
reduction are  much  sounder  than  that gentleman's plan of
unlimited  meat;  not even  restricting the  diet to fish.  The
Banting dietary is not to be compared to that of abstinence;  the
food taken being vegetables and hydro-carbons in the least con-
centrated form  of farina.   No doubt, too, alkaline  purgatives
are of great moment in aiding reduction.  Except that it entails 
506      FOOD IN HEALTH  AND IN  ILL-HEALTH.

little that is disagreeable, Mr. Banting's plan is far  inferior to
those detailed above; and it is not creditable to the  profession
that for so long Air. Banting could get no  useful suggestions
for the reduction of his  bulk; and that Avhen he did  at  last
succeed,  so  dangerous a scheme  should  have  been  furnished
to him.   It is at once obvious  that a frugal meal  of  matter
largely carbonaceous is  more  effective  than a liberal supply of
azotized  matter;  Avhich latter furnishes a considerable amount
of glycogen, but Avith it a large quantity of nitrogenized Avaste ;
in the elimination of Avhich the kidneys are  kept functionally
active, and so in time become diseased.
   § 238.  The consumption of azotized food in liberal quantities
and  over long periods of time, as on  the Banting  scheme, is
a  great  factor  in the  production  of  chronic renal  disease.
Doubtless  there  is  much  difference   in  individuals and in
families; in some the tendency to renal mischief is such that
small provocation sets up>  abnormal changes ;  Avhile others again
practise the greatest  indulgence in eating almost with impunity.
Sooner or later, however, the sustained functional activity, with
its necessary hyperaemia, develops a groAvth of connective tissue
in the kidney ; just as such  interstitial  growth is set up in other
viscera by persistent hyperaemia.  . By  this impairment of the
kidney structure the work falls more  heavily upon the parts
remaining sound ;• and thus the disease is fostered.  It is obvious,
then, to  any thinking person, that  the first  step to  be taken
under these circumstances, is to reduce  the nitrogenized food to
a  minimum; and that  minimum is much less than is  almost
universally  supposed.  Very  small amounts of nitrogenized
matter are absolutely requisite for tissue-repair.  What has just
been said of the dietary of the Abbd Cornaro, and of the miller
of Billericay, proves this  to a demonstration; for these men did
not fall off  in muscular Aveight, and the energy they possessed
is full proof that their tissues, other than adipiose, Avere well and
sufficiently nourished.  No  doubt in both these cases, as Avell as
the others mentioned above, there Avas  a very perfect digestion,
and all  the food taken  was  assimilated—a  condition  by no
means the  rule; but, nevertheless, these cases  show hoAV small
is the amount of plastic material necessarily required for perfect
histogenesis.  In  laying  doAvn the  dietary of the gouty, these
facts must  be borne in  mind ; and the remonstrances  of the 
         FOOD  IN HEALTH  AND IN  ILL-HEALTH.      597

patient must  be gently, but  firmly met.  To a large number
of persons the pleasures of the table are the best part of their
existence; and  these  are the  very  persons  whose  kidneys
ultimately suffer  for their sustained functional activity; and
in whom it becomes so  desirable  to restrict their dietary.  Con-
sequently great  firmness is necessary, and no little caution, in
the management  of  them.   Even  while conscious, in many
cases,  of the  benefit  derived  from  a restricted dietary; these
persons will take  an early opportunity of consulting some one
else in the hope of prevailing upon their new medical adviser
to recommend a more liberal diet scale.  As it is a marked trait
in humanity to  believe readily what it is agreeable to believe,
the advice of  the  less skilled man  is  adopted ; and it is only
Avhen  the consequences folloAv, as in time they do, that a long
deferred repentance sets in—usually too late to be of service.
The question of such a dietary for  gouty persons  is  far from
being  generally understood ; and though a large proportion of
the profession recognize the importance of restricting the dietary
in such cases, still it is scarcely a living faith  Avith them, and
exercises little or  no influence upon their practice.   When the
subject becomes better  understood a stimulus Avill  be given to
the culinary preparation of fish, vegetables, farinaceous material,
fats, and oils; and the  cook's skill will render palatable what
science selects.
   This subject  becomes of great importance when  we bear in
mind the  changes in  the circulation which accompany chronic
renal disease.   The  consequences of  the blood being highly
charged (ueberladen) Avith  nitrogenized waste  are,  as Ave have
seen, hypertrophy of the muscular walls of the arterioles and of
the left ventricle ; high  arterial tension (ueberspannung) leading
to those  changes in the  arterial  coats  knoAvn as  atheroma;
and. as a  resultant sequel, a strong  tendency to apoplexy from
rupture of one  of the  intercranial  vessels,  and consequently
again to paralysis; or to the formation of aneurism, the result
of some incidental over-exertion or of  the giving Avay of some
portion of the arterial  coat, previously weakened by atheroma-
tous change.   When the  blood  is  more than  usually charged
Avith azotized waste, the usual high blood-pressure is increased,
and the liability  to  rupture in  the  atheromatous  arteries  is
doubled.  On the other  hand, Parkes {Lancet, May  23d  and 
598      FOOD  IN HEALTH  AND IN  ILL-HEALTH.

30th, 1871)  has shown  by the  sphygmograph, that  a non-
nitrogenized diet is  folloAved by a  loAvered blood-pressure, a
diminished  arterial tension.  These  tAvo facts stand in a most
suggestive relationship to each other, and point distinctly to the
necessity for a non-nitrogenized diet for  the gouty ; especially
where the vascular system is much implicated.  That on such a
non-nitrogenized dietary these persons should feel less energetic,
and  that they should  complain of it  as " too  depressing," is
only what Ave may fairly inductively expect; and Ave  must be
prepared to meet their murmurings, to be patient  Avith them,
and by  reiteration to induce  them to  keep their real  interests
in view.  By again altering their dietary such  persons  can at
once both gratify their palate and increase the blood-pressure
within  the encephalic vessels, and so experience greater cerebral
activity; but at the  same  time they must take the potential
consequences.  In the treatment of paralysis in those Avho live
well, and  in those  in Avhom  chronic  renal mischief with its
consequences exist, it is of equal importance to remember the
action of food upon  the vascular system ;  and so  to avert the
second  attack Avhich is looming in the distance. Much of  our
recent success  in the treatment of paralysis, of cerebral origin,
is due to our recognition of the importance of such regulation
of the  diet; as  is seen  in the  excellent paper of  Dr. Alfred
Carpenter (of Croydon) in the Practitioner  for May, 1875, en-
titled "The Rational Treatment of some  Forms of Hemiplegia."
It is not  only, however,  in those cases where the  vascular
 system gets the  brunt  of the effects of imperfect kidney action
 that such  a dietary  is  of signal  service;  its adoption gives
 relief, more or less perfect, to all and  every one of the myriad
 outcomes of the Protean malady—gout.   Of course, in all cases
 the use of mineral Avaters, especially of those containing potash,
 as a daily habit; the  regulation of the  boAvels, together Avith
 decided purgation  at brief  intervals;  and a Avell-maintained
 action  of the skin, by A\diich means the  imperfect action of the
 kidneys may be compensated ;  are all of service.  Nevertheless,
 the regulation of the diet scale is the first and foremost matter.
 Many correspondents  have asked me to  develop this section on
 the dietary for the gouty; but to do this Avould make the book
 lop-sided.  The subject  of gout in its  production, prevention, 
         FOOD  IN HEALTH AND  IN ILL-HEALTH.      599

and treatment, will be considered in detail in a work on " Gout
in its Protean Aspects," Avhich is being prepared for the press.
   § 239. Under the heading of Diabetes, in  Chapter XL, the
diet suitable to that  malady was given.  It need not, then, be
repeated ; but something may be said  here as to the  dietary to
be adopted by those who suffer from diabetes, Avhile at the same
time being the subjects of chronic Bright's disease—a very con-
siderable class.  With such patients the liberal amount of animal
food usually permitted to diabetic patients would be a source of
no small danger.  The farinaceous  foods in stinted quantities,1
vegetables,  salads Avith  oils;  or fish,  few potatoes, and much
butter, the fat of meat; and other aliment containing but limited
amounts of nitrogen, are here clearly  indicated.  Not rarely,
too, such persons are inclined to obesity; and then the problem
to be solved is indeed a complex one. Here there is the tendency
to put on fat to be taken into consideration ; and, on the Avhole,
the dietaries  of Cornaro  and  his  allies are  the fittest to be
adopted.
   However distasteful, abstinence must be practised,  both as to
quantity and  quality.  Boiled  rice Avith stewed fruit (though
containing small quantities of sugar-producing material), spinach,
salad, lettuces, fish, other  articles of food which will  give bulk
to  meet the cravings of  the stomach, and yet  do not supply
nutrition in too liberal  quantities,  are the forms of food to be
chosen.  Hoav far in such cases alcohol is desirable will perhaps
be a matter for the exercise of  the  right of private judgment;
but it is a form of food which  does not  furnish much combus-
tion-matter, and, from its stimulant properties, is desirable, as
it relieves the depressing and loAvering qualities of the  Spartan
fare indicated.  A limited amount of alcohol in these  cases then
is not objectionable.
  Such are the leading  indications for  the  medicinal  use of
food;  both in the treatment  as Avell  as in the pirevention of
disease.  The subject is one of high importance; and  this im-
portance is  being rapidly recognized.   It will  be forced upon
the attention of the profession ere long, as much by the highly
educated laity outside as by the persistent admonitions of physi-

  1  A watchful observer, the subject of glycosuria, has found that farinaceous
food does not aggravate his diabetic symptoms;  but sugar  quickly affects him. 
600      FOOD IN  HEALTH  AND IN  ILL-HEALTH.

ologists.   It Avill, however, be a stubborn battle betAvixt scien-
tific knoAvledge, on the one hand ; and the cravings of the palate,
the pleasure of a sense of intellectual activity, and  even the
necessities of the individual, on the other—a man  may have to
kill himself to get a living.  As life Avears on the capacity to
grapple successfully with large quantities of rich food declines,
while synchronously the poAver to purchase it usually increases;
the modified enjoyment of other pleasures leaves that of the
table more vivid ; and if  it Ave re not for the protection of indi-
gestion, of which  many so bitterly and ungratefully complain,
the lives of a large number of individuals Avould not attain their
furthest potential expansion.  As Age lays his heaATy hand upon
the organism the taste for animal food commonly undergoes a
natural and spontaneous reduction, and the diet of childhood
is usually instinctively adopted.   This is  part of the natural
conservatism of  the  system, which  often shoAvs  itself Avith
remarkable distinctness; and points out  to the careful  thera-
peutist, paths in which he may  Avisely folloAv.   The tendency of
the present age is toAvards the  keeping up and sustaining line
of practice; and Ave might in many cases adopt with advantage
some of the loAvering treatment and slop diet to which the last
generation inclined.   Then  there is a large class  of articles
consumed Avhose food-value is very Ioav, but Avhich are valuable
as anti-scorbutics;  and  without Avhich Ave would  suffer from
scurvy. Vegetables and fruit  are thus important matters of our
dietary, especially Avhen milk and frest meat are unattainable.
   § 240. After this consideration of food in its relation  to the
body force and the  requirements of various individuals, not only
in conditions of health, but in certain abnormal conditions, the
question  of  drinks may Avell  be entertained.  They present
different  aspects;  and  can  be  regarded from the different
standpoints, as of food in a fluid form, as stimulants, beverages,
pyretics, and apyretics, and again simply as Avater.
   To take them in the order  they thus stand ;  we come  first to
milk, Avhich contains in itself all that  is required for the Avants
of the organism.  There  is in it fat,  nitrogenized matter, sugar,
and salts.  It is palatable when fresh,  and usually easily taken
by most persons. To some, hoAvever, it is a subject of repulsion;
and for such persons  some substitute for it must be found.  To
others, again, it  is  constipating;  but this may  usually  be 
         FOOD  IN  HEALTH AND  IN ILL-HEALTH.     601

 corrected by mixing it with  seltzer-Avater;  so treated, it forms
 a  most agreeable beverage; and  many persons  who  find milk
 alone too heavy for  them can take it with a relish, and digest it
 well, when so treated. Ordinarily milk is best in its fresh state;
 but in diabetic  conditions the best  form  is that  of butter-milk,
 Avhere the milk-sugar has been broken up into lactic acid ; this
 is an  agreeable beverage when  properly prepared, and ought
 to  form a large portion of the dietary of the diabetic  in the
 country, or indeed anyAvhere where  butter-milk can be procured.
 During pyretic conditions milk, alone or Avith some mineral
 water, should form  the chief food; and recent  observations in
 various fever-hospitals bear out this strongly. In convalescence,
 especially in its early stages, and in  conditions of great debility,
 milk is  the food par excellence.  It  supplies nutriment, both
 plastic and respiratory, in suitable proportions ;  and is infinitely
 superior to beef-tea,  or alcohol as a food.  When something more
 substantial, but yet in a fluid form, is indicated; milk  may be
 thickened with  corn-flour, and  then have  an  egg beaten up
 with it and some sugar added.  This forms a famous  meal, and
 is excellent  in certain forms of gastric catarrh.   At times some
 preparation of alcohol may be added to  milk, either plain or
 combined, as just described.   Such is the famous rum and milk
 of Avorld-Avide repute.   To prepare  it properly, however, it  is
 necessary to add  some  other ingredients.  The best form  is
 given elsewhere.  Taken in  the  morning early, this draught
 enables the invalid  either to have another napi, or to  dress and
 then enjoy, and digest breakfast aftenvards.   In convalescence
 it is often very useful; while to many a phthisical patient it has
 simply been life.  As custard, egg and  milk form a pleasant
 food of a highly nutritive character.
  The next form of nutritive fluid is beef-tea.  I trust that the
 folloAving remarks upon  this valuable article may not seem to
 some readers disrespectful—no disrespect is intended ; but beef-
 tea, at present, holds a more exalted position than that to Avhich
 it  is lawfully entitled.  Many persons, too, think  it an  article
 which  cannot be abused ; but this is a mistake.  Its first abuse
 is, that it ranks far  too high as a  food ; its second abuse arises
from its stimulant properties.
  As a food, beef-tea ranks Ioav.  It contains meat-salts, a small
quantity of  albumen, and a little gelatine, together with some 
602      FOOD  IN HEALTH  AND IN  ILL-HEALTH.

advanced nitrogenized matters, useless in histogenesis.  But
there is little in  it to repair tissues, and less in it to sustain life;
so far as our knoAvledge yet extends.   There is little real force-
bearing material in the Protean compounds of beef-tea.   Tittle
actual  force  is  evoked by the oxidation of nitrogenized com-
pounds in  the body.   For the  starving  fever-patient, to give
him beef-tea  alone, is almost to give him a stone Avhen he asks
for bread.   It makes him feel better for the time  being ; but
that is due to its stimulant properties.  We have seen above
Iioav nitrogenized matter acts upon the nerve-centres and evokes
energy.  But  then it is not  Avise to  evoke manifestations
of  energy, without supplying  force-producing material—this
is a means of artificially inducing exhaustion.  Alcohol is a
force-producing  hydrocarbon as well  as  a stimulant; and  if
a manifestor of force, at least  brings something  to  the body
fund ;  but  beef-tea alone  does not do this last, or if so, only to
an infinitesimal amount.   To give beef-tea, as is often done, in
the earlier stages of fever or other ailment, is  often  to induce
exhaustion  sooner than  it  would otherAvise  have  come on.
Doubtless the sufferer feels refreshed  by the beef-tea—personal
experience leaves no  doubt  upon  that  head ;  but  then this
feeling is produced by the consumption of some  of the body-
store of force ; and in  so far is a loan, and not a gift.  It is here
that beef-tea falls so far short of milk, which furnishes force-
producing  material.   By the exhibition of beef-tea  in  liberal
quantities;  under the amiable delusion that, because the patient
feels better, brisker, and livelier after it, therefore he is better;
many  a patient  is exhausted,  and  rendered physiologically
bankrupt—his fund of body-force dissipated and squandered in
aimless and  useless manifestations of  energy—ere the hour of
need and the time of trial arrive.  Instead of  nursing carefully
and husbanding his force till the severe trial of the critical period
arrives, it is Avasted; and then exhaustion follows.  It reminds
one of the  well-meant, but vicious action of ignorant  neighbors
in a first confinement.  They smuggle  spirits in a cup of tea, if
they are afraid of the Avatchfulness of the medical attendant; or
on some pretext get him  out of the room, and then administer
alcohol; and encourage the patient to make voluntary efforts in
the  first stage,  when  they are simply useless; and then, Avhen
the second stage comes, and  these displays of voluntary effort 
         FOOD IN  HEALTH AND IN ILL-HEALTH.      603

would  be useful  and desirable, they are not forthcoming;  the
force that is then so desirable has been spent and Avasted:  and
often it becomes necessary in  such cases  to apply the forceps
to complete delivery; Avhen, if a better knowledge had existed
among the women in attendance, no such procedure would have
been necessitated.   Just in the  same blundering  Avay, some
well-meaning, officious attendant squanders the body-capital in
useless, profitless displays of energy in the  early stages of acute
maladies; and so ultimately wrecks the patient. These remarks
are not unnecessarily strong; and are certainly  called for by the
ignorance of some  persons, and the disinclination to think on
the part of others.  Beef-tea has become, in one sense, a trouble
at present ; not  only is harm done by its agency, but its use
prevents the more  serviceable  milk from  being  more largely
used.
   If, hoAvever, beef-tea  be  given Avith  sago,  or perhaps even
better  still with  arrowroot, which goes  thin on boiling and so
drinks clean, it then possesses  some force-producing material;
and so something is furnished to the fund of body-force, in  lieu
of that force which is expended by the stimulant action of the
nitrogenized  matter.  If biscuit-powder, and a little butter with
pepper and salt be added, or fine  bread-crumb, then  beef-tea is
a  food.  During a  piyrexia, especially if there be difficulty in
swallowing, arrowroot and beef-tea alternately Avith milk should
form the chief sustenance ;  sometimes  it  may be desirable to
suck the  fluid through a glas3  tube, if deglutition be difficult.
Another  pleasant beverage  possessing nutritive properties  is
rice-Avater, the  well-known "cungee-paAvnee" of Hindoostan.
Where there is  diarrhoea, rice as rice-Avater, or ground  rice
boiled  and mixed  with milk, beef-tea,  mutton-broth,  etc., are
very suitable.  Whey, cream diluted Avith  seltzer or rice-water,
or with soup, or beef-tea, are pleasant  forms of food  ; and with
these different fluid  foods  ice may be given,  so as  to convert
the beverage into an antipyretic.  When given with some form
of starch, with sugar, or with fat, beef-tea is a valuable addition
to the dietary of the invalid ; and loses the  objections which are
valid and well-founded against it in its simple form.   When
added  to the farinacese and  other foods, gelatine has been found
by Voigt to be capable of digestion ; but the conclusions  of the 
601      FOOD IN HEALTH  AND IN  ILL-HEALTH.

French  commission as to its  uselessness in the form of jellies
still holds good Avhen it is given alone.
  § 241. As stimulants, fluids are commonly administered to
the sick, the weak, and  those avIio have just  been exposed to
some shock, or injury.  In the giving of stimulants, as has been
pointed out in  Chapter X.  (§§  95-98), Ave  unlock  a certain
amount of  the  body-fund  of force.   This is unquestionable;
though  alcohol furnishes some force in  its oxidation within the
system.   In giving fluids  as  stimulants, this  must be remem-
bered;  and tea, coffee, sal volatile,  and chloric  ether do not
possess the force-producing  hydrocarbon of alcohol.  In combi-
nation Avith rich  cream and sugar, tea and coffee may often be
given Avith advantage, especially in convalescence.  Vogel  {Dis-
eases of Children, p. 193) speaks highly of coffee so treated as a
useful stimulant in the affections of childhood.  It is unnecessary
here to  go again into the action of stimulants at length ; suffice
it to  say that the administration of  stimulants, alcoholic or
nitrogenized, should ahvays be in proportion to the reserve fund
of the system, and the pressure of the emergency.   Sometimes,
it may  be neck or nothing; and  an apparent recklessness may
really be the most prudent and the wisest course—the patient
must  be tided over the perils of the hour, no matter at  Avhat
cost.  At other times, however, it is desirable to look forward
a little, and  not  to  subordinate  the future  too much to the
present. It is of  little use for a ship to round a point only to
drift helplessly ashore in the bay beyond.   Many patients sink,
Avhen the turning-point has been passed, from sheer exhaustion ;
for Avant of that force whidh  has been  expended already—may
be in useless displays of energy, in manifestations of force which
have  served no useful purpose.   Such, it  is to be feared, is too
much the case with  the modern  treatment of disease, and the
therapeutics of the present are far too saturated Avith the brandy
and  beef-tea theory.   What  is indicated  is the greater use of
force-producing food, and less of the mere manifestors  of energy,
in our treatment of acute disease.  AVe \ATant, in fact, better and
more trustAvorthy physiological notions than at present obtain.
The now fashionable Liebig's extract of beef  is a stimulant, or
a flavoring  agent, rather than a food.  It  gives a pleasant char-
acter to farinaceous preparations, or forms an agreeable beverage
Avhen mixed Avith cold Avater;  but it  is scarcely a food.  It is 
FOOD  IN HEALTH  AND IN  ILL-HEALTH.      605
useful to render food palatable, and in so far is not to be despised.
As a food it ranks beloAV well-made beef-tea, though it is supe-
rior as a  flavoring agent.   Stimulants  should be subordinate
and ancillary to food in cases of debility in the young, Avhose
evolution is retarded ;  in  the dyspeptic; and in the general
failure of senile decay.  In such cases it is much wiser to reduce
the demands upon the system to the capacities of the organism,
in proportion to its  diminished  poAvers; than to erect an ideal
standard to be aimed at, and then to Avhip up the bodily powers
with alcohol  and nitrogenized material until the patient feels
as he would wish to feel, or an approach  to it;  and can do more
or less what he wishes  to do.   By such  means the  system  is
exhausted before its time ;  and though, according to the ancient
saw, "It is better to wear out than to rust out," still, the latter
is usually much the slower pirocess.
  Finally, our treatment has  at present a decided  tendency  to
assume a character too distinctly stimulant,  and not sufficiently
nutritive and restorative.   Stimulants  should  be auxiliary  to
food, in whose assimilation they often assist; in themselves they
furnish little, and often no force-bearing material.  They  are,
however, a means  of reaching the physiological reserve  fund
of force, and consequently may be  advantageous or pernicious,
according  to circumstances;  and an  ill-regulated or excessive
process of stimulation may give results as disastrous, as a  pru-
dent and intelligent resort to stimulants may be beneficial and
preservative.
  The food-value of alcohol has been discussed in § 98, but the
subject may be briefly referred  to again  here.  There are con-
ditions of the system when alcohol is almost the only food the
patient can take, and  when  exhaustion is  threatening then  a
full dose of alcohol must be administered.   This will often also
allay the irritability which indicates and is the  precursor  of
exhaustion, and the patient will drop off to sleep.  This is " the
narcotic dose of alcohol,"  which however also furnishes a cer-
tain amount of readily oxidizable material to the system.  When
thoughtfully and  skilfully  used,  under these circumstances,
alcohol may  be  ranked  as one  of our most potent therapeutic
measures.  But to proceed from such consideration of the value
of alcohol in disease to that of its food-value when taken as a
beverage is to talk unmitigated nonsense.   Before a man could
lnv) 
606      FOOD  IN" HEALTH  AND IN  ILL HEALTH.

take a substantial meal of alcohol he would be simply dead-
drunk, if not killed outright.
  § 242. As beverages, fluids  are in universal use both for the
healthy and the sick.   They consist  of water with or without
other constituents. As rice-water, barley-water, etc., beverages
are also foods.   When consisting of vegetable juices as well  as
Avater, beverages are often useful as well as grateful.  Thus  in
grape-countries, grape-juice, or must,  is a  favorite beverage;
and from the amount of sugar contained  in  it, a small  quantity
of nitrogenized matter, and some salts, this must Avill often  be
found an agreeable beverage, possessing  high nutritive proper-
ties ;  and can be iced Avithout detriment to its qualities.  The
straAvberry and raspberry syrups in such vogue in  Dresden are
also pleasant beverages.  The potash in the strawberry renders
its juice a desirable drink for the gouty and  for strumous
children.   The juice  of  the  apple  and  pear Avhen fermented
forms most agreeable beverages, possessing stimulant properties
from a certain percentage of alcohol.   The various preparations
of  the grape  which Ave consume  as  wine are well knoAvn and
appreciated.  In pyretic  conditions acid Avines are very desira-
ble, and were largely used  in  the Franco-German Avar in fever
cases, Avith excellent results.   Taken with food, a glass  or two
of  generous Avine, as  Burgundy,  Marco Brunner, Sauterne,  or
sherry, are often  very useful in  aiding digestion; and cham-
pagne possesses, like  all  sparkling wines, stimulant properties
not to  be  measured  by the proportion  of  alcohol.  Often too
a glass of port after  a meal  is useful.   As beverages Ave also
use preparations  of malt, the well-known ales  and  stouts, of
every variety of  alcoholic strength.   They are also used with
meals by many Avith advantage; but Avhen prescribed for invalids
care should be taken to see  that they are in good condition,
fresh, if from the cask ;  well up, and Avith a head, if bottled:
stale malt liquors  and flat  bottled beverages are repulsive, and
consequently  objectionable to  the invalid.   Spirits are rather
pure stimulants, and are  not so much in vogue  at meal-times.
Nevertheless,  with some persons  a little brandy-and-water at
 meals is preferable to Avine or any other beverage.  Spirits  are
 often used as beverages now  Avith some form of  mineral Avater,
 and as such  may be taken  in conditions  of debility and  ex-
 haustion ;  though perhaps inferior to a draught of Avine.  In 
         FOOD IN HEALTH AND  IN ILL-HEALTH.     607

the evening ere going to bed they  form  a useful nightcap for
those Avho have not only worked hard during the day, but been
subjected  to worry;  and often secure for such persons sound
refreshing sleep.
  Water too, simply as water, is an  excellent beverage, in which
most persons might indulge more freely with advantage.  From
the effects of perspiration in warm weather, from the calls of
the bladder in society,  numbers of  persons take an undesirably
small amount of fluids;  not nearly  sufficient for the real needs
of the body  and for the removal of Avaste.   In adults the tissues
are often much in  need  of being Avell washed by the permeation
of water through their structure ; and the advantages which we
saAv, in  the last chapter, to attach to Avells and watering-places,
lie  no little in  the increased consumption of water  by those
visiting them.  The Missisquoi-water, once so famous in  the
U. S. A., Avhen analyzed by Dr. Squibb, Avas found to be simply
an unusually pure water. After the experience of a fashionable
season, of a festive time, or of a series of dinners, a course of
water with  abstinence is often most beneficial.
  § 213. Fluids too are often  a  ready and effective means of
affecting temperature.  In cold Aveather an increment of heat is
furnished by hot  fluids, as soups;  and so waste  of tissue for
heat-production is economized.   Especially after exposure  to a
low temperature, or when the body is chilled from any cause,
draughts of hot fluids  are  very  useful in restoring  the body-
temperature.  In collapse they are often of great utility ; and
they are equally serviceable in the piroduction  of perspiration in
addition to  the Avarm bath.   We have for generations been in
the habit of supplying  hot fluids in  a rational Avay; but it is
only since the importance of variations of the body-temperature
has been enforced upon us by the use of the clinical thermometer,
and the evil consequences of a rise  above the normal  body-heat
have been thereby demonstrated, that the use of chilled fluids
has obtained.  Of course for ages the practice of chilling waters,
and the use  of ice  for cooling beverages, have been indulged in
by the affluent;  but the application of ice  to the  reduction of
fever in the sick  in humble life is of modern, indeed  recent,
origin.  A pronounced  impression  can be made upon the body-
temperature by draughts of cold fluids, and this can be repeated 
608      FOOD  IN HEALTH  AND IN  ILL-HEALTH.

in pyretic conditions.1  In exposure to great heat, or after much
exertion, iced fluids are very grateful.  After much exertion in
a high temperature so  that exhaustion  is approached, it is  Avell
to drink iced or chilled fluids, but sloAvly and in sniall quantities
at once ; as large draughts are sometimes followed by disastrous
consequences.  Large  draughts of cold Avater at meals are  also
subject to abuse, especially in certain dyspeptics, Avhere the  cold
checks the digestive processes.
   On the other hand, in febrile conditions, in very hot Aveather,
etc., iced fluids are grateful and free  from objection.  There  is,
however, on  the part of imperfectly-instructed persons an  un-
founded  dread of cold fluids ; and a well-meaning mother will
often torture her fevered child in a negative, yet effectual Avay,
by Avithholding  from it the cool fluid for which it craves.  Such
conditions  are often combined Avith  anorexia, and under these
circumstances milk, rice-water, etc., chilled, are excellent means
of feeding  the child, by  taking advantage of  its thirst.   As
people advance in life they become  less tolerant of iced fluids ;
and Avith the aged they should be used  Avith caution, especially
if the heart be Aveak.
   This it is the more necessary to  insist upon since the greater
consumption  of  iced fluids has set in, as it  has done of recent
years.  Such iced fluids, especially if the material of the fluid
be some mineral water with an admixture of wine or  spirit, are
excellent in hot Aveather; especially where  there is some accu-
mulation  of  uric acid from  imperfect oxidation.   The daily
consumption  of a mineral Avater containing potash meets the con-
tinuous production of small quantities of uric acid, neutralizes
it, and renders it soluble ; and thus in solution it drains aAvay in
the fluids of  the body.  The excessive  resort to alkaline Avaters
by non-gouty persons is not uncommonly the cause of  much dis-
comfort and gastric debility.
   § 244.  Not  only is  the food we  consume of importance in
the  treatment of disease,  as  we  have just  seen, but it  has
further been  essayed  to  treat  diseases  solely by  a  diet-cure.
Such, for instance, are the grape-cure, the whey-cure, and the
koumiss-cure.
   Grape-juice contains a large quantity of sugar, some gum and

       1 "Wunderlich on "Thermometry," Syd. Soc.  Trans., p. 114. 
          FOOD IN  HEALTH AND IN ILL-HEALTH.      609

 albumen, Avith tartrates and  phosphates of lime  and potash.
 Consequently for a large class of cases, especially Avith a lithsemic
 element about them, grapes form an excellent form of food.  At
 first the grape-cure produces purgation, and this is often very
 useful, if not too pronounced ; and ahvays has a tendency to keep
 the boAvels open and to unload the portal circulation.  Knowing
 as we do the association betAvixt biliary congestion and a large
 amount of lithates in the Avater, such action of the grape-cure is
 most excellent.  As the grape-juice also acts upon  the kidneys,
 and other food is almost entirely forbidden, a perfect depuration
 of the system is induced ;  especially valuable where the amount
 of food taken has  been for long and persistently in excess  of the
 needs of the  system.   Consequently in abdominal plethora, in
 catarrh of the digestive organs, etc., the grape-cure is often very
 beneficial.  It is not adapted to debilitated conditions, especially
 in  children  and in delicate  Avomen ;  it  is  a  reducing  agent,
 chiefly adapted to men and  Avomen of  full habit.  Of course
 it can only be conveniently undergone during  the season when
 the grapes are ripe.   In Europe, America, the Cape, and Aus-
 tralia, Avhere  there  are vineyards, especially in healthy  places
 and amidst pleasant scenery,  such grape-cures are to be com-
 mended.   Strawberries are rich in potash, and contain iron ;
 therefore in similar cases of lithic  acid  tendencies the  straw-
 berry-cure of Interlachen  is often to be  advised, or prescribed
 Avith benefit.   By the addition of milk and cream, where the
 straAvberries alone  are  too reducing, or afford insufficient nour-
 ishment, a pleasant dietary  is  furnished, suitable  to many in-
 valids.
  Milk-cures are as old as the days of Galen, avIio sent strumous
 patients to the milk-cure at Stabice.  In SAvitzerland the milk-
 cure is common, and  there are several places where it is con-
 ducted  on a large  scale. When milk alone is too constipating it
 can be combined Avith  seltzer Avater.  This plan is rather  suited
 to cases of anaemia depending upon imperfect assimilation ;  and
 in such  cases often works marvels.  In  atonic gout it  also is
 useful.   In cases  of threatened tuberculosis the  milk-cure in
some   mountain-health  resort,  as in the Upper  Engadine, is
very good, and  often  wards  off serious  illness.  In  ulcer and
catarrh of the stomach milk may advantageously  be made the
sole food.
       39 
610      FOOD  IN HEALTH  AND IN  ILL-HEALTH.

  Preparations of  milk also are used.   Whey has long been in
favor.   It contains the  salts of milk and the sugar, freed from
fat  and  caseine.  It is especially adapted  to the gouty and
plethoric.  By combining it Avith milk it becomes more nutri-
tive.  Like most of these  cures, it secures a  small amount of
nutrition Avith much fluid, and  therefore suits  tAvo classes of
people:  the plethoric, who consume and digest too much ; and
those whose digestions are feeble, and who require their nutri-
ment highly diluted, and in a diffused rather than a concentrated
form.  Care, hoAvever, must be taken about these latter cases in
order that  no mistake be made ; for it is impossible ahvays to be
sure in  cases of weak digestion that a dry diet  instead of a
highly-watered one is not rather indicated.
  Butter-milk is also  used for dietetic and even therapeutic
purposes.   In it the milk  sugar is  broken up into lactic acid;
and therefore butter-milk is Avell suited to the diabetic, especially
if it contain numerous tiny flakes of butter in  it.  In some con-
ditions of chronic Bright's disease it is also useful.
  Milk  prepared as koumiss is a pleasant  fluid, containing fat,
caseine, milk  salts, lactic acid, some  alcohol and  carbonic acid
gas.  It agrees Avell Avith many cases of enfeebled digestion ; and
is well suited for the treatment of pyretic conditions, as Avell as
conditions of more permanent debility.  It is in vogue in Russia,
at several places in Germany, and at Eaux  Bonnes.   Koumiss
can also be  bought  in bottles in England and America, combined
with glycerine ; it forms an agreeable and most suitable bever-
age for most diabetics.
  Such  are the especial forms of cures accomplished by adapta-
tions of certain forms of ordinary food.  They are pleasant, and,
from the reasons given above, well adapted to the successful treat-
ment of many conditions.  Not only are these cures good in them-
selves ;  but they also point  out in a very distinct manner the
great importance of a Avell-adjusted and suitable diet for many
persons as  a preventive of  disease.   In diabetes and gout we
find that the question of diet is one of primary and  cardinal
importance; in  the treatment of struma and tuberculosis it  is
of no less  moment; and in many conditions of debility Avith
impaired digestion it  is no slight  matter to select  a suitable
dietary,  and to supply food in a form at once nutritive and
digestible. 
         FOOD  IN HEALTH  AND IN  ILL-HEALTH.      611

  As there are many persons avIio cannot  take milk  in  any
shape, and  yet  for Avhom  food in a  fluid form is  absolutely
necessary, it is often of advantage  to know of some other fluid
food to fall  back upon.   The following combination Avas almost
the sole food  of the late Duke of Gloucester for a long time.
Of rice,  well  avashed, of arrowroot, tapioca,  and pearl  barley,
take each an ounce: add tAAro  quarts of Avater, and boil down to
a quart;  then flavor Avith  candied eringo.   This is palatable,
and will often be found very serviceable.
  A still better substitute may  be made as folloAvs: Pour a
pint of rice-Avater upon a  tablespoonful  of a mixture of  fine
almond flour (4  ozs.) and prepared  sugar  of milk (2 ozs.).   The
latter consists of sugar of milk, 13 ozs., poAvdered lump  sugar,
2 ozs., and 1 oz. of a combination of salts, of Avhich  this is the
formula—chloride of potassium, 6 ozs., phosphate of soda, 3  ozs.,
phosphate of magnesia,  2 ozs., and phosphate of iron, 1  dr.  I
am indebted to  Air. Van Abbot, of Princes Street, for this for-
mula.  The rice-water should be poured on boiling hot, and the
mixture Avell  stirred ; after  this it should cool and  then be
strained through a sieve.   This forms a very milk-like fluid,
both to sight and taste.  It also contains  a good  quantity of fat
in fine emulsion, and is  almost identical with milk  under the
microscope.  Personally  I have  found it very digestible.
  As the sheets of this  edition Ave re going through the press,
Dr. W. Roberts, of Manchester, contributed to the British Medical
Journal (Nov.  1st and 8th, 1879) an  article  on the digestive
ferments—(1)  salivary;  (2) gastric;  and (3)  pancreatic.    Had
they appeared early enough  their consideration Avould have been
entertained in Chapter  II.  (Assimilation).  The subject enters
now on a new phase, and I  trust by the time another edition of
this work is called for, to be able to give  much further informa-
tion  on the subject.  The practical part  of Dr. Roberts's work
Avas how to solve the difficulties of procuring artificially digested
food at a reasonable cost.  Peptones themselves are inoffensive
to taste or smell, but the by-products of digestion are such as to
make artificially digested food offensive to the palate.  When a
poAverful pancreatic extract is added to milk, two-thirds of the
caseine is peptonized in the  first half hour, and three-fourths in
the first hour ; but it takes another hour and a half to peptonize
the remaining fourth.   At  first the milk thickens and becomes 
612      FOOD IN  HEALTH AND  IN ILL-HEALTH.

softly curdled, but in half an hour regains its normal appearance.
A temperature of 157° Fahr. arrests the action of the pancreatic
ferments.   The liquor pancreaticus  used by Dr. Roberts  is pre-
pared by Mottershead & Co., Manchester.  It is  a potent, well-
prepared preparation  containing four  principles, (1) diastase,
which converts starch into sugar;  (2) trypsin,  which digests
albuminoids  in an  alkaline  medium;  (3)  pancreatine,  which
emulsionizes  fat; and (1) a principle which curdles  milk.   By
means of such an agent,  milk can be digested  outside the body
without being made offensive, if the action be stopped at the end
of a certain time, by raising the mess to the boiling point.  The
proper temperature at which the milk so treated must be kept
is below 157° Fahr., else the ferment is destroyed.  No fluid can
be sipped even which has a higher temperature than 150° Fahr.,
so that a thermometer is  not  essentially necessary to correct
treatment of  the  milk.   Dr. Roberts  has found that this frac-
tionally digested  milk would remain on the stomach in some
cases where nothing else  could be retained.  His formulae are as
follows:—
  " A pint of milk is first diluted with half its bulk of  water,
and heated to about 150° Fahr.  It is then put  into a covered
jug with  a tablespoonful  of  liquor  pancreaticus and twenty
grains of bicarbonate  of soda  (in  solution).  The jug is then
placed in a warm place under  a ' cosey,' for one  hour.  At the
end of this time the milk is at once raised to the boiling point.
It can then  be  used like  any other milk, and  undergoes  no
further change until decomposition sets in."  It is well, how-
ever, to knoAv that peptonized milk  does not keep Avell,as might
be expected, and  that it  should be  used within twelve hours of
the time of preparation.   The  use of the thermometer may be
obviated by directing  the  milk to be  diluted with an  equal
quantity of boiling water.
  Another formula, which supjplies a more nutritious product,
and does not require the thermometer, is the folloAving : "To half
a pint of  cold milk, in a covered  jug, add half a pint of well-
boiled and boiling gruel.  This gives a temperature of 120° to
130° Fahr.  To this add  a dessertspoonful of the liquor pancrea-
ticus,  and a dessertspoonful of a  saturated solution of  bicar-
bonate of soda (which contains about ten grains).  Put under a
i  cosey,' as before, and heat to boiling at the expiration of an 
         FOOD  IN HEALTH  AND IN  ILL-HEALTH.      613

hour.  In this case the trypsin of  the pancreatic extract acts on
the casein of the milk, and (I presume) on the albuminoids con-
tained in the gruel.  The diastase of the extract also acts on the
starch of the  gruel and converts  it into sugar.  This  method
gives us a preparation similar in design to Liebig's food for
infants, but in which the piroteids, as well as the amylacea, are
subjected to digestion.  The making of it is exceedingly easy,
and it Avould seem Avell adapted for the nursery and  the sick-
room.   The gruel employed  should  be made thin ; it may be
prepared from Avheat-flour, or from oatmeal, or from any other
farina.
  "I have iioav used these fractionally  digested articles of food
in a considerable number of cases, and  in many with gratifying
results.  If the  process be properly performed, if  it be cut short
by boiling at the right moment—that is, after the curdling phase
has passed aAvay, and before ulterior changes have rendered the
milk unpleasant to the  palate—the resulting products are liked
as Avell as if  they Ave re simple milk-and-water, or simple milk-
gruel.   But if the process be carried too far—or if, on the other
hand, the milk  be still partially curdled when put  before the
patient—the  product is not  liked, and  is  even apt  to  cause
nausea."
  Such artificially digested food is indicated  in actual disease of
the stomach, in  dyspepsia, in convalescence  from acute disease,
as well as in acute disease itself, and in several other conditions
where it is likely to be  most useful. 
CHAPTER  XXIV.
         CONCLUSION—THE MEDICAL MAN AT THE BEDSIDE.

  § 245.  In this concluding chapter may be found a fitting place
for some remarks intended chiefly  for junior readers.  The first
matter to be  attended  to in  practice is of a proper demeanor.
Whatever  may be the  ordinary  manner  of  a medical  man, a
certain carriage in  the sick-room and at the bedside  is ever
desirable.  Such  carriage is looked for by the patient  and his
friends, and  a  sense of disappointment  "will be felt if  it be
Avanting.   The  medical man should avoid,  so  far as may  be,
attracting the attention of those around him to himself, instead
of to what he has to say.  The conduct  and behavior of  the
medical attendant will also exercise much  influence  in inspiring
the patient with confidence, and so encouraging him to folloAV
the directions given ; and thus to  give the advice  and  plan of
treatment a fair trial.  The young practitioner must remember
that he is the  subject  of a keen  and  critical survey, and  his
manner should be calm and self-possessed.   Nothing Avill enable
him so Avell to sustain the critical  examination,  and endow him
Avith  composure  under the  ordeal, as confidence  in his oavii
knowledge of his profession—in its social as well as its higher
and more important aspects.
  There  are also  some social points to be attended to,  and the
following remarks from Prof.  Austin Flint's Clinical Medicine
seem to  me  so appropriate  and  so aptly phrased, that I have
procured his  assent to my reproducing them verbatim:—
  "Cheerfulness  of  mien is an important element in  clinical
medicine.  It is  not  merely a politic  accomplishment; it  is  a
professional duty. Its moral influence upon  patients entitles it
to rank among the  measures of treatment.  In its cultivation,
hilarity and  frivolity are to be avoided.  The latter, in the in-
tercourse between, the physician and patient  are unprofessional.
  " It is a duty  to  manifest a propter degree  of  interest  and
sympathy in  cases of  disease.  This not only  wins the confi- 
CONCLUSION.
615
clence and attachment of patients, but an influence is thereby
secured Avhich, judiciously managed, may be made useful in the
treatment.   Discrimination in this regard among patients, ac-
cording to their station in life and their ability to remunerate
for medical services, brings justly a reproach on the character
of the profession.   Manifestations of indifference or harshness
towards patients in charitable institutions deserve to be stigma-
tized as brutal.  These  patients have claims of poverty added
to those arising from their diseases.   Moreover, inasmuch as
they are involuntary patients, that is, having no voice in select-
ing and retaining those to Avhom they  look for relief, inhumanity
towards them is taking an ignoble advantage.  Brutality is less
reprehensible when manifested towards those whose influence is
valuable, from Avhom fees are expected, and  who can terminate
at any moment professional relations Avith their medical advisers.
   "Patients are  entitled to all the  encouragement Avhich can
conscientiously be  given.   In this point of  view there is a
marked contrast in  the conduct of different  physicians.  Some
who are unfortunately disposed  to look upon the darkest side,
anticipating the  most  unfavorable events which can happen,
communicate their apprehensions and gloomy forebodings either
by word or  manner.  His  discouraging  influence on the minds
of patients is often baneful.  It is a duty to give the encouraging
points in any case, and  it  is a duty  not to  discourage by pre-
senting prospective dangers which  are  problematical.  Cases
which furnish an exception to the latter rule are those in which
it may be   necessary to alarm the patient in  order  to secure
measures of protection against events Avhich  are liable to occur.
For  example, the effect of phthisis on the mind is such that
patients sometimes insist  upon the inutility of taking  any  steps
to prevent the further progress of the disease.   As a rule, when-
ever  there  is any doubt  as to  the degree of existing danger,
patients should have the  benefit  of the doubt in  the way of
encouragement.
   " In cases of disease threatening life, shall this fact  be volun-
tarily communicated to patients in order to  give time for the
disposition of worldly affairs and other preparations for death?
With reference to this question, the  physician is often placed
in a  delicate  and somewhat difficult position.  It is rare  for 
616
CONCLUSION.
patients with mental faculties intact to ask, of their oavii accord,
a direct question as to immediate danger.  If asked, the physi-
cian is bound to answer without deception, but, if possible, Avith
qualifications Avhich will not take aAvay all hope.  If not asked,
it may be  the  duty  of  the physician  to suggest that some
friend of the patient communicate the fact of imminent danger.
Patients after becoming aAvare of danger, and having  made, in
vieAV thereof, every preparation, are sometimes  more tranquil
than before. Resignation at the near approach of death  is the
rule ; fear and dread of the termination of life, when encourage-
ment can no longer be given, are exceptions to the rule.  This
does not militate against the beneficial  influence of encourage-
ment so long  as it can be given.   In brief, knowledge of  the
character of the patient, and of all  the  circumstances in indi-
vidual cases, in  connection with the exercise of judgment and
tact, must determine the conduct of the physician Avhen diseases
approach a fatal termination. It may be added that the visits
of judicious clergymen are unobjectionable, either in the cases
now referred to, or when life is not immediately threatened.
  " Physicians are most apt to be asked respecting danger when
patients either imagine its existence, or suppose that it does not
exist.  The usual mode of asking is not  'Tell me candidly if I
am in  danger,' or ' What  are the chances of my recovery?'  but
' You do not think my case serious?' or ' You  have no doubt of
my  recovery?'   Most  patients who  infer from  circumstances
that they are considered to be in great danger, prefer not to be
told so in plain terms.  If there be danger, not  proximate,  but
more or less remote, the ansAver to the foregoing questions should
be such as to avoid deception, to secure any needed preparations,
and, at  the  same time, not to Avithhold  a proper degree of en-
couragement.  ' It is better to be prepared and not go, than to
go unprepared,' was the happy reply of  a medical friend of  the
author to a piatient who  inquired  Avhether his  condition Avas
sufficiently serious for a final disposition  of affairs.
  " Intimations to patients of a liability to sudden death should
be made Avith the greatest reserve.   The  cases  are rare  in which
the physician  is able to foresee this event with anything like
certainty; and it is a cruel act to intimate  the  liability on in-
sufficient ground.   The author has known repeated instances of
Avretchedness for years caused by the belief that apoplexy might 
CONCLUSION.
617
 be expected at any time ;  and that death might occur at any
 moment in  cases of purely functional disorder of the heart.
 Even in cases in which a liability can be recognized, as in cases
 of angina pectoris, fatty heart, and certain aortic lesions, the
 event may not occur for a long period, if the patient do not die
 of some intercurrent affection.  In  these cases,  the  physician
 should  inform  some discreet  friend of the patient of the re-
 cognized liability to sudden death.   It is well,  also, to make
 memoranda, Avhich may be referred to after sudden  death has
 occurred, as  a protection against the charge of either negligence
 or ignorance.
   "Communications in respect to danger may often be made to
 relatives or intimate  friends with less reserve than to patients.
 They are, however, to be made Avith discretion.   If  extremely
 discouraging they are apt  to be interpreted as taking aAvay all
 hope.  The patient is considered as ' given up.'  The effect is de-
 moralizing.  Either further  efforts are abandoned, or doubts arise
 concerning the propriety of the practice pursued ; both  telling
 against the welfare of the patient.  The physician  should  bear
 in mind that in certain  cases he may over-estimate the danger,
 and that instances are not very infrequent of recovery when the
 condition seemed as hopeless as possible. All physicians of much
 experience can cite cures illustrative of this fact.
   "Undertaking to predict that a patient will  live a certain
 number of days, Aveeks, months, or years, is injudicious to say
 the least. It is a hazardous undertaking as regards the sagacity
 of the physician,  and it may occasion mischief.   Giving  the
 percentage of the chances  of  death or recovery is also objec-
 tionable.   It does not confer credit on the profession for healthy
 persons to be able to say  that in years past they were pronounced
 incurable, and the time of death specified.
   "It should be a rule of professional conduct not to communi-
 cate information concerning the maladies of patients, except to
 those entitled to receive  it.  Patients have a right to the privacy
 of their  diseases, albeit it is but little respected by individuals
 or the public.  The  question  so often addressed to physicians,
 'What  is the  matter Avith' this or  that  patient?  is asked in
innocence of its impropriety, and therefore does  not  challenge
rebuke;  but  pains should be taken to have it generally under- 
618
CONCLUSION.
stood that such question is improper, and that the physician is
not at liberty to answer it, unless authorized by the patient.
  " Certain rules relating to professional visits may be mentioned.
The frequency of  visits, aside from the wishes of patients and
friends, is to be regulated by the importance of observing varia-
tions of symptoms, or the effects of  treatment;  and of this, of
course, the physician is the best judge.   The liability to err in
the number of visits is in making too feAv, rather than too many,
for the reason that physicians are  generally sensitive in regard
to an imputation of making more visits than are required.  This
sensitiveness, carried to an excess, not infrequently is of damage
to the physician, patients inferring  lack of interest or attention.
Too short intervals between visits are sometimes objectionable,
leading to injudicious  changes  in  treatment.  In general it is
not advisable to remain  constantly with  patients unless for the
purpose of carrying out measures of treatment AAdiich require
continued supervision.   Regular visits should not be  so brief
that full attention cannot be given to the case, and the physician
should not appear to be hurried.   The patient is apt to be left
in an uncomfortable frame of mind if there be occasion to think
that the case has not been Avell considered.   On the other hand,
visits should not be too prolonged.  After examining, prescribing,
and giving full directions, the  sooner the physician takes his
departure the better, if there be  no special  reasons for delay.
During a  professional  visit  the  first and  chief topics of conver-
sation should  have reference to the case.  It is a great mistake
to act as if the latter Avere of secondary consideration, the greater
part of the  time being devoted to  extraneous matters.  Physi-
cians sometimes fall into the error of occupying the  time Avith
a  recital  of other  cases,  and  telling  of  matters exclusively
concerning  themselves.  These  rules of  conduct are important
Avith reference to  professional  success as Avell as to the welfare
of patients.
   "The manners and appearance of the practitioner of medicine
are  by  no means  of so little  moment  as  to be  unworthy of
being alluded to  in connection with clinical medicine.  In no
profession or  calling are coarseness, vulgarity, untidiness, and
repulsive  habits more incongruous  than in medical practice.
These comprehensive terms wi 11  suffice  without going  into
details.   The physician should be ready to  overlook the Avay- 
CONCLUSION.
619
Avardness,  ill-humor, and prejudices  of  those to whom he  is
called upon to minister  in  disease.   He should not be over-
sensitive as regards  personal dignity, and, as far as possible, he
should refrain from exhibitions of irritability of temper. Sick-
ness claims forbearance and charity.  Still there are limits to
endurance  and  encroachments on self-respect.   If  a patient,
Avhose intellect  is  unaffected  by disease, refuse to  follow the
treatment which the practitioner decides to pursue, he should
at once decline any further responsibility in the case ; and  if
there  be other  manifestations of want of confidence, the case
should be relinquished."
  So pregnant  are  these sentences of Prof. Flint's that the
student should read and re-read them.  Their perusal will guide
him aright in many a moment of difficulty, and tell him the
right course to adopt.   Sometimes the relations betAvixt practi-
tioner and  patient become seriously strained, and then a con-
sultation is imperatively demanded to protect the practitioner
and  to allay the mind of the patient.   To decline a consultation
is often to  arouse the suspicions of the patient that the  medical
attendant is not so confident in his diagnosis and  measures of
treatment as he Avould like to have believed ; and the practi-
tioner should bear  this  in  mind as  soon as there  arises  any
tension in  the relations  betwixt him and his patient.  If the
consultant  agree Avith  him, then the patient is satisfied  ; if the
ordinary attendant has failed to grasp the case  in its entirety,
or to  appraise correctly some  neAV symptom, then the  piatient
gets  the benefit of the consultation.
  Bearing all the above in mind, and having been shown into the
sick-room,  it is very desirable for the medical attendant to take
up a position  where his own face and features  shall  be placed
in the shade;  while the light shall fall fully upon  the  counte-
nance  of the patient.   By  this  means various important ends
are  secured.   In the shade, and so comparatively veiled from
observation, the facial muscles  of expression may not betray
what is passing through  the mind ; for such expression might
readily do much ill-service.  At the same time  the light upon
the patient's features Avill often reveal a wavering eye, a tremu-
lous  lip, a quivering  nostril, or the frown of pain,  especially
when showing itself in brief intermittent twitches ;  or it Avill
brino- out  the configuration of  the teeth, the  contour of the 
620
CONCLUSION.
face, a tortuous temporal  artery, or  a dendritic atheromatous
arterial tAvig ; or perhaps  a fatty cornea and  an arcus senilis;
all of Avhich furnish valuable  indications to the eye which has
not only learned to note them, but also can interpret their signi-
ficance correctly.   All  this may be observed Avhile examining
the tongue.  Carefully-cultivated physiognomical  diagnosis, as
taught by Prof. Laycock  in Edinburgh, Avill often ghe  most
important hints, directing  the verbal inquiries, and pointing to
the necessity for certain physical investigations ; and pier haps,
more than all, often furnishing valuable  suggestions  as to the
line of treatment  to be adopted.
  As to  the questions  put, they  should  be brief,  and incisive
rather than discursive ;  especially if the case be a grave one.
They should, of course, ahvays be to the point.  If much talking
has to be  done, let it be done by the patient or his friends.   See
all about your patient;  and do not divert the attention of those
around from the matter in hand to the observation of yourself,
youthful  reader!  if you are  either  prudent or careful  about
producing impressions and  gaining confidences.  A  good knowl-
edge of practical psychology is invaluable: still it can scarcely
show to  advantage if unaccompianied  by a fair knowledge of
your profession.
  Spare no pains over your piatient: and carry yourself so that
you produce  the  right  and correct impression that  you are
taking pains, and not merely being fussy.  ShalloAv and ignorant
people are especially apit to  misinterpret  great pains.  Be on
your guard, then, with such persons,  or rather, perhaps, against
them.  With  such persons it  is never safe to be demonstrative.
It Avill often be necessary to be reserved in self-defence.  It is a
good test  of the natural good sense, as well as of the perfection
of training in  the observing faculties of a young medical  man,
to be able to  distinguish  betwixt the  sensible and intelligent
persons to whom he may be advantageously communicative,and
the opposite order of individuals in whose case silence is indeed
golden.
  §  1.46.  While this  scrutiny  is going on, inquiries may be
made as to the family history, especially if there be any tendency
to certain  diseases or special  peculiarities, as affections of the
nervous system, chest diseases, etc.  It is usually a  matter  of
the greatest importance to form  a sound  and clear conception 
CONCLUSION.
621
 of the diathesis, as manifested by the class of ailments to which
 the  family is liable.  By such means only can be acquired that
 information  which is called " a knoAvledge of the constitution"
 —a matter  highly^ prized as well as  of  real value.  Having
 gathered what  can be gleaned on these topics, it is necessary to
 go carefully, yet warily, over the patient's  past history.   In
 doing so the discretion Avill often be  severely tested.  Really
 curious  facts do occur in the histories of the lives of patients,
 Avhich should not be overlooked, or ahvays listened to in a spirit
 of incredulity.   To  act so would often be far from  prudent:
 and I trust  sincerely that every reader, no matter hoAV little
 advanced  in his studies, will be  conscious  how important a
 matter it  is for a medical man to be prudent.  At the same
 time,  facts  sometimes  array themselves  in  such  order  that
 certain  conclusions are forced upon  one,  and are irresistible;
 hoAvever the patient may Avish to arrange them to tell  some-
 thing  else.  For instance, if a slim woman of good physique,
 and naturally good  constitution, married, and  Avho has had
 several miscarriages,  complains of rheumatic pains in the collar-
 bones, upper arms, and loAver part of the legs, it is well to listen
 with mute and  unmoved countenance to  her story of getting
 Avet on going to church, and  having to sit  in her clamp clothes
 through the service, which is probably all true enough; or another
 will tell of having to Avork in a laundry;  but all the time we
 are conscious that syphilis  is at the root  of it  all, and see in
 mercury and iodide of potassium the best  cure for  such  rheu-
 matic  pains.  In fact it  is necessary to apply  one's  experience
 without annoying the patient.
   It is Avell also to mentally appraise  the  intellectual  poAvers,
 etc., of the patient and those around, and estimate their intelli-
 gence carefully.  Also try and test them as to how far they are
 likely to obey instructions to the letter, or  to neglect them.   If
 the latter is  to be apprehended, the directions  should  be  brief,
 to the point, and given with decision.  If the patient or  his
 friends are familiar Avith sickness, the  medical man  may fairly
 venture to be more explicit.  But it must  be  remembered this
 very experience makes them more capable of estimating him in
 turn. Avoid familiarity under all circumstances.  Be courteous,
 interested, and  sympathizing:  but be  on  your guard against
ptossible misinterpretation. 
622
CONCLUSION.
  § 247.  Having gathered together a  fair series of facts as  to
the past, concentrate  the intelligence  upon  the  immediate
subject-matter in hand.  Listen to the patient's account of the
origin of the ailment, throAving in a well-directed question from
time to time.  Go carefully over every organ and system seria-
tim.  Get into the habit  and  piractice of making a systematic
examination.  If a woman, after asking about her  boAvels, in-
quire about her reproductive system.  But, remember, ask about
it in the  same strictly business tone.  If you hesitate, as if the
inquiry Avere one of doubtful  propriety, your patient will feel
some hesitation in answering  it; and  the  position will be dis-
agreeable and  unpleasant for both.   This is a matter of much
moment.  If the patient is a spinster in the upper classes, it is
the proper thing to  make these  inquiries  of her  mother, or of
her maid, nurse, or other attendant.  Never omit that.  Having
made a careful examination, including  a close and painstaking
physical  examination, you will be then in a position to arrange
the material into a diagnosis consistent with the facts; this will
suggest  the prognosis, and give a  direction to the treatment.
Be cautious, and do  not  commit yourself rashly to a prognosis.
Often this  is the subject of your being consulted ;  and your
opinion is asked as  to the nature of the ailment  Avith much
empressement by  those Avho really do  not care  about  it.  They
are eagerly noting  the  ansAArer, as  furnishing to them some
guidance in the  formation of their estimate of the value of your
aiiSAver to their  next question.   If you do not succeed in im-
pressing  them that you  quite  understand  the case, they natu-
rally come to  the  logical conclusion that your answer to their
next  inquiry  will not be very trustworthy.  If your answers
as to the  nature  of the case are  satisfactory, then  they feel
confidence as  to the value of your  next answer.  If neither
answer inspire confidence, the mutual relations will not be very
agreeable.
  It is ahvays a good plan to  make a note, so soon as it can be
done unobserved, as to Avhat you have said to the patient or the
friends.  It is rather  unfortunate if at the second visit you
contradict what was  said on  the first;  or  give  conflicting
directions Avithout some  explanatory statement.  If this should
be done, and the medical man is reminded that he said so and
so on a  prior occasion, a truthful answer will best serve him. 
CONCLUSION.
623
Say  at once, " If I said  so then, there must have  been some
reason for it, else I should not have said it."   Try to remember,
and get your informant to  aid you in your effort.  But do not
leave the matter uncleared  up and in doubt ; make it straight
by all means.
  The medical  man is  also  often told  that some professional
brother has given an opinion different from  or opposed to his.
This  is an  unpleasant  matter.   If the people had  been quite
satisfied with this other opinion they would  not have sought a
second.  Kiioav  all the  circumstances.  If there be a change of
residence, or death, or sickness on the other medical man's part
to account for the change, then all may be fair and above board.
If the matter looks at  all " doubtful," be very cautious.  It is
not given  to all members  of every family to  be able to turn
everything over exactly as  they get it; indeed such poAver
is very rare.  They may not have heard correctly, nor under-
stood the previous attendant thoroughly.   They may even wish
to extract  from you some expression of opinion, which is con-
tradictory  to his, in order  to make  mischief.   The natural
opinion of every young practitioner is that the  patients Avho
call  him  in are  of a  high  order of intelligence, and  indeed
generally superior to those Avho do not so act; and he is inclined
to trust them accordingly.
  This is very natural ; but it is  too often an amiable delusion.
They may  be impelled  by sheer curiosity to  draAV you out and
lead you into some expression  of opinion.   Or they may wish
to extract from  you Avhat they wish to hear.  It is a marked
feature in  patients,  the  youthful reader will find, that  they
ahvays most readily accept and believe what they  Avish to
believe.   Culpable suppression  of certain symptoms is not un-
known in order to  induce an opinion favorable to their inclina-
tions.  For instance, do not be tempted to stake your reputation
on the integrity of the kidneys because one hasty  boiling has
not furnished traces of albumen.  Especially if  some one else
has  said  that   they  Avere affected.   Passing  periods  of total
absence of albumen are not at all  rare.1  Be prudent  and careful

  1 The reader may consult  a most striking case pointing this illustration, re-
corded by Basham in his work  On Dropsy, 3d edition, pp. 195-203.  This was
not a case of granular kidney, but of a much more grave type, rarely giving such
intermissions. 
621
CONCLUSION.
 that you  are  not converted into  a means  of  annoyance to a
 brother practitioner.  The people  avIio would behave so to an-
 other, Avill not hesitate to  turn round and  serve you  a  similar
 ill-turn if necessary.  Confine yourself as strictly as possible to
 the matter in hand ; and be cautious about making any state-
 ments or  admissions that may be  troublesome or disagreeable
 on some future occasion.
   Ahvays remember that you haAre to sustain the reputation of
 your profession,  as  AAell as your own.   The reputation of the
 profession is the  aggregate of the  individual reputations of its
 members!
   Another thing, too, it is as Avell  to bear in mind, and that is
 to avoid unnecessary fuss or superfluous measures, until you are
 in a position to  do  so with immunity—and usually only very
 fashionable physicians are in that  position.  There are Avealthy
 nouveaux riches Avho adore fuss; and it may be well enough in
 their case.  But  the majority of human beings do not.   So just
 adapt the  measures to the necessities of the case.   Often the
 simpler and less  complex the measures, the greater and more
 distinct  the impression piroduced.   For  instance, if a  patient
 comes Avith a persisting diarrhoea, which has resisted the differ-
 ent  measures tried,  and it is obvious that it is due to irritant
 material in the boAvels, a full dose  of castor  oil, or, still  better,
 of rhubarb powder, will at once end the matter.  Here the very
 simplicity  of the remedial measures will gain the prescriber
 credit.
  §  248. Wrherever you are, and under whatever circumstances
 you  are placed, never forget  two  things:  1.  Your own self-
 respect; and 2. The honor of your profession. The first is your
 duty to yourself; the second  is your duty  to  your neighbor.
 First see that you conduct yourself so as to insure the  respect
 of those with Avhom you  are thrown  in  contact.   Secondly,
 never speak of, or behave to  a professional brother so as to bring
 him  into discredit.  This last is very important.  The want of
 it has done much  harm, and  prevented us, as a body, from  taking
the position which Avould otherwise have long since been accorded
 us.   Each ecclesiastic asserts the dignity of  his office, however
unworthy he may think some others are to fill it.  It would  be
Avise if Ave followed  their example—in  this respect at least.
Another lesson, too,  we might learn from  them, and that is the 
CONCLUSION.
625
 air of respectful gravity they assume at once Avhen speaking of
 matters theological ;  and the  readiness with Avhich they check
 any levity of speech  on such  matters  on the part of any one
 present.  We all know Iioav cautiously  such  subjects are spoken
 of in the presence of ecclesiastics.  What a contrast the hushed,
 reverential tones of the laity discoursing of  matters theological
 before a minister form to the  readiness Avith Avhich even Avell-
 bred people rush into flippant observations about homoeopathy,
 hydropathy, and chloral hydrate, or electricity, to medical men;
 in season and out of it.  In fact, some people would seem never
 to alloAV a medical man any  social distraction from  incessant
 tales of bygone maladies.  No doubt to some extent such con-
 versation  is  umvittingly  encouraged by a medical man's  pride
 in  his profession.  It is  rare  to  find  medical  men voting the
 subject of their daily thought, and their lives' energies "shop."
 They knoAv  better than that; and  are apt  to  be drawn into
 medical talk in order to correct Avrong  impressions, or relieve a
 misapprehension.  Consequently there  is a  large  class  on the
 watch for  informal consultations.   And there is a larger class
 Avho follow their example in talking medicine to medical men ;
 not from any mean ulterior motive,  but simply because they do
 not know any better.   They mistake courteous attention for a
 professional interest in their conversation.
  It is quite time that we folloAved the example of the  other
 professions, theology and  the  Low.   The one in making profes-
 sional subjects matter for respectful speech  ; the other in not
 being led into informal consultations.
  At all times remember you ought to be a gentleman.  Also
 be a self-respecting man.  Never on  any account be led into any
 connections with your piatients which  are  dishonorable.   Our
 position  throAvs us in the  Avay of  many difficulties.   We are
 compelled to tread  Avarily;  and the man avIio trips, discovered
 or undiscovered, lives Avith a mill-stone round his neck.  Medical
 men occupy a position of honor.  See  that  you  are not led to
 sully it.  Traps will be laid for you.   You  will be caught at
 times suddenly.  See,  then, that you are ahvays on your guard.
  Thorough  self-respect and perfect self-restraint are  expected
 from you.  It is but your duty.  There is no credit attached to
the mere discharge of  duty.
  In  approaching sick persons, it is well to blend  cheeriness
      40 
626
CONCLUSION.
with sympathy.  The visit of the medical man should be looked
fonvard to by the patient Avith pleasure ;  and nothing  tends
more  to produce this  feeling  than a cheerful demeanor.   It is
all very Avell  to feel sympathy Avith the sufferer, but that  is not
sufficient; and the moral effect of the visit ought to be made to
aid the action of the  therapeutic measures.  Much, however,
depends upon the condition and the mental morphology of the
patient.  In  some cases the sympathy may preponderate  Avith
adA-antage; while with others the cheeriness is more acceptable.
  There is and can be no  question but that the usefulness of
every medical man, and especially of young men, is indefinitely
increased by  general prudence, thoughtfulness, and  good  sense.
The days are past when medical men Avere regarded as being all
the better professional men for a profound ignorance on  other
subjects.   It  Avas once  thought that such ignorance argued a
certain attention to their profession, and the absence of  distrac-
tion from it toother topics ; but such is not the present prevalent
opinion.  A  medical man, especially if he  holds a respectable
degree, and is in so far a university man, is iioav  expected to
possess much knowledge  on many topics; to be able to  speak
Avell upon them, and to indicate in his conversation  on ordinary
top>ics that his mind is trained and  cultivated; if such  is not
the case, the  laity will  naturally be sceptical about his culture
in matters professional. The manners and  conversation of the
man  on  subjects within  the  range  of  its cognizance can be
measured by  the Avorld at large; and upon these subjects  it can
form  an opinion, when it feels incompetent  to measure his
capacities on matters  purely  professional.   It gives  a man
Aveight with  others to be  generally well informed,  and  to show
good  sense in ordinary matters;  and if he be lacking  in these
respects, a medical  man will scarcely get credit  for the profes-
sional knowledge he may  really and actually possess.
  Indeed  this is no more than  might be fairly expected.   If  a
medical man indicate  that he is but imperfectly  informed on
current questions, and still more be unconscious of  his  ignor-
ance ; observant persons will  quickly take  a note, and suspect
his professional knowledge to be unsound.  Of course a medical
man may be  of such a turn of mind as to take little  interest in
current topics, but he  will be conscious that, he is unacquainted
with  them;  while  in  all probability he will give evidence of 
CONCLUSION.
627
full acquaintance Avith  the  subjects in which he does take an
interest.  If, on  the other hand, he talks confidently and  yet
loosely, Avith obviously imperfect knowledge, on ordinary topics,
his professional  utterances will not carry their proper Aveight
Avith them.
   § 219.  It is  also,  too,  a great matter to familiarize the mind
with Avhat is hoav called the natural history of disease, i. e., the
progress of maladies through their different stages.  There is
the initial stage, the middle, and then the more advanced stages.
As in consumption, for  instance, there is first the  stage of con-
solidation, then  that of softening, and  then that  of formation
of a cavity ; in very fortunate cases there is further a falling in
and  cicatrization of the cavity.   So, too, in Bright's disease,
tliere is the early stage,  of Avhich there are few indications;  and
those only recognizable  by the  eye  that has carefully educated
itself to discern and note  the early  changes of Avhat, in time, is
distinct enough to a comparative tyro.  There are  the begin-
nings of  morbid changes  Avhich can only be observed by those
avIio have studied  the  marked and advanced changes,  and so
proceeded to a recognition of the earliest modifications.  To the
 trained eye these indications are as pronounced, though  hidden
 from others, as are the  early manifestations of insanity visible
 to the skilled  alienist physician, long ere they can  be recognized
 by the ordinary observer.   Then there are  objective and sub-
jective phenomena which  mark the establishment of the disease,
and  Avhich are more generally knoAvn, such  as a glistening ear-
 lobe, otolites,  the deformed knuckle, etc., attacks of arthritis, of
 dyspepsia, of  boils, of skin eruptions, or bronchitis, etc., with
 occasional fitful appearance of albumen in  the  urine.   Ulti-
 mately there  are atheroma, cardiac changes, with or without
 aortic  valvulitis, failure  of the circulation, the evidences of
"cardiac inability, as enlarged  liver and  spleen;  congestion of
 the kidneys, with persistent albuminuria ; general anasarca, etc.,
 etc.  It is as desirable that the medical attendant should think
out these changes in their order and rotation, as that the farmer
should recognize the growth and  changes in his crops in their
order, according as the  three or seven-year  system is adopted.
By such  study the  medical  man Avill learn to see these evils far
ahead  and learn to meet them ; and this is a matter of immea-
surable  importance.  Changes foreseen afar oft'  may be met, 
628
CONCLUSION.
headed, and  arrested even, by prudent, Avell-applied measures.
If the changes looming in the distance are recognized, suitable
precautions can  be taken; just as a ship may Aveather a point
only discernible  by a trained eye on the outlook, and not visi-
ble to ordinary ken, if seen early enough ; but if not recognized
or noted in time, there may be no means of avoiding the ship-
wreck then inevitable.  The eye can only see what it has learned
to see;  and the youthful gaze may see nothing, though the eye
is young and  the vision keen, where to the duller eye  of ad-
vanced  life the  face may be a written page, whose characters
are both familiar and distinct.  The tortuous temporal  artery,
its thickness  indicating the kind of atheromatous change going
on in it; the species  of arcus senilis ; the absence or presence of
degeneration in  the skin ;  the formation of the teeth ;  the ful-
ness under the lower eyelid ; the tremulousness  of the tongue,
or the twitching of a muscle—are to the trained eye all  indica-
tions pregnant with information ; but which convey no informa-
tion to  the eye which  has not  learned  to see and note these
matters, and to the mind which has not yet found their inter-
pretation.  It is indeed just  the  difference  betwixt Egyptian
hieroglyphics  to him Avho can read these characters, and  to him
that cannot.   To the one the  subject  matter is unfolded, to the
other there is merely  a  series of undecipherable characters;
Avhich, hoAvever, might give the most  valuable  information if
they could not be  read.  There is as yet no  Rosetta stone by
which young  medical  men can be taught to read readily  the
hieroglyphics  of degenerative changes:  and yet  hoAV strangely
some men have learned to  read for themselves these subtle
indications, and  taught themselves to  interpret  broadly their
significance—even while unable to spell them out alphabetically.
This forms a great portion of  that  individual  experience so
valuable and yet so  untransferable.  Careful observation and
comparison of cases  furnish  in time a repertoire of experiences
most valuable for the formation of prognosis, indeed
                  "Till old experience doth attain
                   To something of prophetic strain ;"

and by the light of  past experiences the old practitioner Avill
often shadow  out the future  progress of a case with wonderful
accuracy.  In the strange forecasts of observant  old men there 
CONCLUSION.
629
 is no " mystical  lore," but rather a full-stored  memory of past
 experience  well-culled;  which, hoAvever, speaks  out in the
 puzzling form of  unconscious cerebration rather than  in the
 intelligible form of conscious induction.   For the young man  to
 whom such experience is impossible, its  advantages can only  be
 supposited by piainstaking observation,  extensive acquaintance
 with the experience of others, as found in their writings—-for
 by such  study7 youth  may converse Avith the  aged and with
 those  Avho have passed aAvay—and, further, by thinking and
 pondering over the matter;  until the  subject  has become one
 consistent intelligible Avhole, which can be recognized  in  its
 entirety, and yet be studied  in  detail  in each  part.   Without
 such study, and  the scientific use of the imagination to bridge
 gaps Avhich  cannot otherwise be got over, no  young  man can
 meet and hold his  own Avith  an older  man of  riper experience
 as regards the formation of  a prognosis in  chronic maladies;
 and  still more, in that practically more valuable matter, in the"
 selection of  remedies and the laying down of a line of conduct
 to be folloAved, which  will keep at bay and  stave  off for long
 inevitable mischief ultimately.
   §  250.  As  an  illustration  of  the manner  in which careful
 observation  of the general surroundings of  a  malady may  be
 made  to supplement   the information   furnished  by  physical
 signs, and so enable a correct and  proper diagnosis and prog-
 nosis to be made, the  following quotation may be  permissible.
 "Forms of disease closely allied are found to take in a totally
 different progress under  divers associated conditions.   For in-
 stance, the pathological condition 'dilatation' of the heart Avith
 its objective  phenomenon ' palpitation  on effort' is a  very dif-
 ferent  matter Avhen found along  with  passing coexistent condi-
 tions than where  it is a permanent state in  a  chronic invalid :
 and  yet these do not differ so  much from each  other as they  do
 from the dilatation of  failing hypertrophy.  Aortic  stenosis and
 regurgitation differ so Avidely as regards their progress and the
 patient's prospects, that Ave might Avonder at such diverse effects
 of a  little connective tissue in the aortic valves, Avere it not for
 the  importance of  the situation of the  neAV  growth ;  and the
well-recognized  difference of  an obstruction merely offered  to
the blood-flow from a  muscular chamber and  regurgitation into
it__the influx of blood driven in  by the aortic recoil, and not 
630
CONCLUSION.
merely welling in, comparatively quietly, from the pulmonary
vessels.
  " In illustration of Avhat is just indicated, Ave may noAv proceed
to consider  in detail  the different  progress of the pathological
condition known  as  dilatation of the  left ventricle, Avith its
objective symptom, palpitation on effort.; according as it occurs
under different accompanying general conditions.  The pihysical
signs are diffused  impulse, increased area of percussion dulness,
a Aveak and irregular action of the ventricle, a Avant of volume
in the first sound ; Avhile the subjective symptoms are, dyspnoea
easily excited, and incapacity for exertion.  In so far the signs
and symptoms agree and are common to all; but Avhen Ave come
to consider the more  special peculiarities of each condition the
points  of difference come  out strongly, and illustrate vividly
the importance  of the general  conditions under  which this
pathological  change,  dilatation, is  found ; enabling us to esti-
mate  its significance, and to foreshadoAv the probable progress
of the case.
   " Firstly, Ave meet with dilatation  and  its usual signs and
symptoms  in young  men, with a distinct  history of sustained
overexertion, of  efforts  made  and  maintained beyond the
patient's physical powers.  Hence he has dilatation of his left
ventricle.  This form is  very amenable  to treatment.   Pest,
good  nutrition, digitalis  and  iron, and  in a feAv months the
patient is  Avell  and  returns  to  labor.   Imperfect  cure is the
exception and not the rule.   Experto credel
   " Secondly, we have dilatation in an elderly female, in Avhom
it has existed for  years.   She is more  or less of an invalid, and
her capacity for exertion is very limited.   It is unnecessary to
go into  any  detail  of a case  so  familiar to  all.   Here the
condition is chronic,  and  that very chronicity carries Avith it a
fair prognosis as  to life, though the case is hopeless as to cure.
It is like  the chronicity of phthisis; the length of  time the
patient has actually  lived with  it holds  out a prospect of life
for a fair time longer—i. e., in the absence of any new symptoms
indicating a change  from  the stationary condition.   Here the
treatment  is palliative;  rest is a sine qua non, for exertion
is simpily impossible; but quiet, a good  regimen, a  carefully
supervised medical treatment, following up each varying change,
and moderating each intercurrent ailment, will  usually enable 
CONCLUSION.
631
the patient to  live for years.  Recovery is scarcely  Avithin
hope; though Fuller tells us  that a course of iron, adhered to
for years, has often removed all evidences of dilatation.  The
progress of dilatation is very different here from its course in
the first division.
  " Thirdly, we  meet with dilatation under totally different cir-
cumstances from either of the above divisions—namely, where
pre-existing hypertrophy  is being  undermined by  structural
degeneration, and the  muscular walls are yielding.   It occurs
chiefly in the latter stages of chronic Bright's  disease, where
simple hypertrophy unconnected with valvular disease is mostly
found.  To  illustrate thoroughly the significance of dilatation
under these circumstances  will need a brief divergence from the
subject-matter in hand—a rapid bird's-eye view of the preced-
ing and causal changes.
  "The course of events is usually  in the following sequence:—■
  " 1. Renal inadequacy, Avith accumulation of histolytic pro-
ducts in the blood.
  "2. Spasm of the arterioles, from the effect of those products
upon the vaso motor centre.   (Traube, Ludwig.)
  " 3.  Hypertrophy of  the  muscular walls  of the  arterioles
from  the persistent, oft-repeated  spasm.    (George Johnson
Traube.)
  "4. Arteriole spasm  and  hypertrophy  lead to  obstructed
blood-floAv.
  "5. Obstructed blood-flow induces hypertrophy  in the left
ventricle.
  "6. The action of these two hypertrophied  muscular ends of
the arterial system produces over-distension (ueberspannung) of
the elastic connecting arteries.
  "7. This over-distensk>n produces atheroma.  (Szostakowski,
Moxon, the Avriter, and others.)
  "8. Atheroma entails loss of arterial  elasticity, and conse-
quently impaired aortic systole.
  "9. The aortic systole is the propelling power which drives
the blood into  the  coronary vessels during  the  ventricular
diastole; and impaired aortic systole leads to imperfect cardiac
nutrition, structural degeneration,  yielding  of  the decaying
AA-alls, and dilatation.
  "In the induction of these last changes we must not overlook 
632
CONCLUSION.
the assistance given by the degeneration of the coronary vessels.
The dilatation here is a condition of the greatest gravity.   It is
neither a temporary nor yet a stationary chronic condition, as
in the preceding forms: it is a degenerative change of the most
serious nature, and its prognosis is of the most hopeless char-
acter.  The  atheromatous  systemic arteries  are  not readily
distensible, and  the failing  heart is every day less equal  to the
work entailed upon it.  The hypertrophy which had maintained
in it the requisite driving power is melting away, and  nothing
can restore  it ;  indeed but little  can be done even  towards
arresting the decaying process.  Rest is  imperative, and, along
with  palliative treatment,  may for a brief  period retard the
downward progress;  but it is only for  a time.  A  process of
degeneration is established whose march is simply irresistible.
  " Thus Ave see that  one pathological condition" may be found
under totally different circumstances, the pirogress in each case
being of an utterly dissimilar character.   In each case, hoAvever,
the progress may usually be fairly predicted  if the different
factors are taken into account—the actual heart changes Aveighed
by the general coexisting condition.   The grim significance of
dilatation in the third division must never be underrated ;  and
though at first the dilatation  is distinctly bleuded with hyper-
trophy, it is not a chronic  condition of  combined  hypertrophy
and dilatation, the amount  of hypertrophy lending an equiva-
lent of hope ; it is  a decay  of  hypertrophy, whose arrest  is
impossible.   Every recurring  examination of the patient tells
of the progress of the new changes, and of  the  inadequacy—
indeed too often futility—of our attempts to  arrest them.
  "With  relation to its  possible constitutional origin should
dilatation of the left ventricle be looked at  on the  one  hand;
with  regard  to its  systemic consequences should it  be vieAved
on  the other: not  only the exact  form of the disease and its
complications, but  the reparative or resistant powers of the
patient, the necessity for exertion or the practicability of rest,
the exigencies of the  individual—all must be included and ap-
praised ;  if  our  estimate  of the probable progress is  to contain
the elements of success and not of failure, and the advice given
to the patient to be of value to him, and not a possible  source
of danger.  It is only Avhen our view embraces all these factors
that even  a  correct diagnosis is of any real value ; without them 
CONCLUSION.                    633
it  is little, if anything, more than a mere  feat of intellectual
legerdemain."1
  § 251. It may seem to some that the pathological process just
detailed briefly has figured a little too often  in these pages, and
the apology for its repeated  appearance  is, first its importance;
and secondly, that many readers, and perhaps most of those for
Avhom this Avork is more especially intended, will not ahvays
turn up Sections  to which   reference is  made and  given ; and
consequently some repetition on important  matters  is not only
excusable, but even desirable.  The whole subject of the changes
Avhich commence in imperfect blood depuration, the  effect upon
the circulation, the consequences and outcomes of that again,
forms the most complete and  illustrative morbid process with
its different stages and order of evolution, with which Ave are
yet acquainted*;  and so possesses  an intense  pathological  in-
terest : and something more than  mere pathological interest to
the far-seeing  practitioner,  who, recognizing the early changes,
knows Avhat will folloAV, and so takes his measures accordingly.
In such cases to be fore-warned is  to be  fore-armed indeed ;  ancl
as the knoAA-leclge  of our profession in the abstract grows, so will
each man in the concrete be more able  to  interpose, and more
or less effectually arrest morbid processes; instead of  merely
relieving imperfectly the disagreeable sensations and symptoms
of an  established  and irreparable condition.   It is this power to
prevent, which a good knoAvledge  of pathology, as distinct from
mere morbid  anatomy, gives, that makes it so valuable to the
practitioner.   If  the pathological  facts  exist as mere facts, they
are like beads unstrung ; or the varied materials  gathered to-
gether for the erection of a stately mansion, but which remain
hi more  or less chaotic condition because the architect  who
possesses the plan is absent.
   It  is  very  desirable  for many ends, prognostic as  well  as
therapeutic, that  a well-defined acquaintance with the progress
of chronic  maladies should exist.  Such knowledge will often
point  to something looming up in the future which may be met
and its  shock lessened, if  escape  be  impossible; on other occa-
sions it will indicate  that the time for certain  measures to be

   ' Lancet, May and June, 1874, "The Progress of  Heart Disease."  Trans-
lated into Echo'de la Presse Medicate, July to November, 1874. 
631
CONCLUSION.
useful has passed aA\ray.   As it  is  impossible for a young prac-
titioner to Avatch chronic cases for himself; and even if he chooses
to do so his knowledge must keep pace Avith the  sIoav progress
of his cases, and the advance of general knoAvledge will in the
mean time have left him far astern ; so it becomes imperative
that he should  erect for  himself a chart of  the progress of
chronic maladies, of which but intermittent fragmentary  and
transient views are permitted  by circumstances:  so that from
an occasional isolated view of a case he  may be able to construct
a  tolerably correct idea of the past history of the case before
him, and still more of its probable future.  No one can do  this
avIio has not labored hard as well as willingly  at the subject.
The darkness which hangs over the past, and shrouds the future
from light, must be illumined by acquaintance Avith the progress
of similar cases,—by knoAvledge of the  subject  in its entirety.
In the same way  that a geologist, when finding a certain fossil
in a shale bed, tells confidently from  its presence there that the
shale-bed  points to no  coal-seams beneath; because  he knoAvs
well that this fossil is found only in the earliest coal formations ;
and consequently knoAvs that the shale-bed in which it is found
points  to the exhaustion  of the  coal-seams,  and not  to their
commencement ;  so must the observant  medical  practitioner
learn to recognize by certain signs that the case before him has
passed certain  points, and entered upon  certain stages.   The
commencement of a mitral murmur in a  case  of old standing
aortic disease;  the inauguration of a tricuspid " whiff" in long-
established mitral disease, furnish such landmarks—are indeed
the milestones of morbid  progress.  By such  indications in the
course of many chronic maladies  Ave are enabled to calculate
the position of the disease as well as the prospects of the patient;
to  ascertain that the time has come Avhen curative measures
must give way, and palliative measures take their place; when
there no longer exists a foothold for hope that the injury can
be compensated, or that an approach to approximative cure can
be  entertained  as potential; and when all  our energies must
be  bent to  the delay of  the  end, iioav distinctly and clearly
inevitable.  All  therapeutics,  whether curative  or palliative,
must rest, if they aspire to be rational and successful, upon  a
sound  comprehension of the nature and  exact position of the
malady. 
CONCLUSION.
635
   § 252.  There is much still  to  be done, much to be learnt,
 much to be investigated, before therapeutics shall have attained
 their ultimate evolution and  their maximum of utility.   But
 if such is the case there exist also ardent minds, enthusiastic
 and  undaunted Avorkers, avIio  form an  undying guild, Avhich
 will, in time  and  with infinite patience, lay deep and firm the
 foundations  of a  rational  therapeusis; and  erect thereupon a
 structure which will comprise  and hold in intelligent array and
 serried order, the  facts gathered by a long-existing and indus-
 trious empiricism ; as Avell  as  the information  given  by enter-
 prising and well-maintained physiological inquiry.
   The prospiect. contains much to cheer us, much to encourage
 us to Avork and Avait.   If  the  work  of  the individual has no
 apparent fruition, and he passes away without the gratification
 of seeing  the  desired outcomes of his  labors, there exists the
 consolation and the  comfort that good  honest work is never
 ultimately lost ; and that  Avhat has been  done by  him will
 ultimately bear fruit  in the hands of another;  and  that the
 sum total of human  knoAvledge is the better for him and his
 work; even though the fruition be delayed until he himself is
 forgotten  in the silent tomb—unconscious of the busy life Avhich
 is reaping what he  has soavu.   We, living now, receive the
 benefits  accruing from the work of past  toilers; and so in
 return must Ave do something for  those Avho will folloAv us, and
 do it too Avithout a grudging or repining spirit, but simply with
 an honest consciousness of  duty—done and to be done. There
 is a certain element  and Avarp of  selfishness in the web of the
 life of those Avho take Avhat medicine has slowly accumulated,
 and  use it merely for their oavii advantage and their individual
 interests;  without a  thought of  making  some return. Those
 Avho fell the oak Avhen full-grown should strive at least to plant,
 even if they do not succeed in planting an acorn.  He that planted
 the acorn of the tree they profit by did not hope to see its mighty
 trunk on the wagon Avhich  conveys it to the timber merchant's
yarfl—but perhaps he witnessed the fall of oaks some  nameless
and forgotten  man had pilanted long before him.   So, if Ave feel
 that others must enter into the fruition of our  labors, we must
not repine; Ave reap  that  Avhich  others  before  us have soAvn.
The personal benefit is the consciousness of duty done, which is
far  more than  hope of reward—the consciousness  that we too 
636
CONCLUSION.
have added our brick, and laid it  fairly true and well, in the
building of the  temple of knowledge—that the Avhole is the
aggregate of individual bricks, and that each one has its place
and its value.
  There are those, however, Avho Avould say in the  matter  of
therapeutics:  "Generation  after generation  still sends forth
new speculators—ardent, sanguine, and  undiscouraged by the
failure of their predecessors—to toil at the same Sisyphean task,
to be met by the same impiassable bounds, to catch the same
vanishing and partial glimpses, to be conscious  of the same
incompetency, to  confess to the same utter and disheartening
defeat.  One after  another they retire from the voyage of dis-
covery weary and baffled—some in the exasperation of mortified
ambition—some having learned the rich lesson of humility; a
few in faith and hope—many in bewilderment and despair—but
none in knowledge—scarcely any (and those only the Aveakest)
even in the delusion of fancied attainment."  But in this scep-
ticism, too often  but the  thin veil Avhich scarcely cloaks and
utterly  fails to conceal their  ignorance, they are not justified
by  the  facts  of  the case.    Therapeutics  have  made  steady
advances  since the study of physiology has opened up for us a
knowledge, albeit  yet  very  imperfect, of the normal  processes
of the body ; and in doing so has given direction to pathological
research and a form and order to the facts of morbid anatomy ;
as Avell as permitted of the investigation of the action of reme-
dies by  the more precise method of experimental research ;  so
checking and correcting the vaguer conclusions  furnished by
clinical observation.   Already they occupy a comparatively
firm foundation of assured data;  and round this nucleus  an
accretion of facts is forming :  and if we have yet much to learn,
Ave are at any  rate conscious of our ignorance, and in possession
of some lines of research Avhich are  trustworthy and to be relied
upon.   There is a great future before us in the struggle Avith
disease; and Ave may reply to those who scoff in the following
sentences, from the Avriter just quoted—having some reservations
about the strict applicability of the first part of the commencing
sentence: "The  true solution is pierhaps no nearer to  us than
before,  but  false ones are  disproved and  discarded;  positive
science, which is ahvays advancing, lends  its aid  not so much
to disperse the darkness as  to expose the ignes fatal Avhich we 
CONCLUSION.
637
mistook  for  light;  and we are brought  into a more hopeful
state of pirogress and sent further on our way, in proportion as
Avider  knoAvledge and  exacter  observation  unroofs one  after
another of the errors in which Ave had sought a shelter, and
fancied we could find repose.   Perhaps, after all, our discom-
fitures hitherto  are  attributable less to the  inadequacy of our
speculative faculties  than to the poverty of our positive knoAvl-
edge ;  the problem may appear insoluble simply because Ave have
not yet accumulated the materials necessary for approaching it;
and the higher branches of physiology may yet  point  the path
to the great secret."1
Gregg, Enigmas of Life. 
 
APPENDIX.
  As  this work Avas passing through the press attention Avas
strongly attracted to several therapeutic agents.   As, hoAvever,
it seemed desirable to Avait for further  knowledge, their con-
sideration Avas deferred to an appendix.  The three agents are
salicylic acid, jaborandi, and hydrobromic acid.

                     I. Salicylic Acid.

  This agent is allowed to exercise a powerful antipyretic action
over many febrile  states, especially  rheumatic fever.  It  is not
yet  clear how it exercises this  action.  Not  having any oppor-
tunities for trying it, I have asked Dr. Broadbent, Avho has given
salicylic  acid an extensive trial in rheumatic fever, to furnish
me  with the results of his experience.  He writes:—

  "In doses of twenty grains repeated hourly for six hours on
two consecutive  days,  as recommended by  Strieker,  it  has
notably cut short acute rheumatism, at Avhatever  period of the
attack, early or late, it may have been  administered.  In  sub-
acute cases, where  the temperature was comparatively Ioav and
perspiration absent or slight, the effects have been less striking
than in the well-marked  acute  forms of  the disease, with high
temperature and profuse sweating.  On the evening of the  first
day the patient has generally slept comfortably.   The tempera-
ture invariably fell; and after the second series of  doses gene-
rally became normal.  Sickness Avas  occasionally  produced, and
in  some cases considerable depression,  so   that brandy  Avas
required.  The same doses of the drug given three or four times
a day, at the usual intervals, for several days, had  very little
effect ;  and though the  effects Avere more   marked when the 
640
APPENDIX.
doses were given consecutively, at intervals of an hour, no per-
manent impression Avas usually made on the course of the dis-
ease.  Relapses occurred in a considerable proportion of cases,
but this is usual in acute rheumatism, and the rencAved attacks
Avere  usually slight, and yielded readily  to  another course  of
the remedy.   They are much  less frequent, if not  prevented
altogether, by continuing the tAventy-grain doses three times a
day for a  week or ten days.
  " AVhen pericarditis has set  in salicylic acid is no longer  of
any apparent use.  It has no influence over the inflammation  of
the pericardium, and no appreciable  influence over the pyrexia.
This Avas shoAvn by several cases.  In one case of post-scarlatinal
acute rheumatism Avith pericarditis, the temperature went up
rapidly  to 107° while salicylic acid Avas  being administered:
and the patient  Avas only saved from imminent death  (from
hyperpyrexia) by the cold bath.
  " In pyamiia simulating acute rheumatism  salicylic acid has
failed to reduce the temperature or to control the disease.  One
case of the kind Avas so rapidly fatal as to give reason to fear
that death had been precipitated by the drug."

  Dr. Broadbent has no theoretical explanation to offer as to the
mode of action of the remedy.

                       II. Jaborandi.

  For some notes  on  the  use of this agent I am indebted  to
Dr. DoAvse, Superintendent of the Sick Asylum, Highgate.

  "I have found it of most service in cases of suppressed gout
and rheumatism, Avhere the kidneys and skin are both inactive,
the heart  irritable, and the membranes inclined to take on a Ioav
form of inflammatory change ; but its action is greatly increased
by combining it with large doses of bicarbonate of potash. Dr.
Laycock, of Edinburgh, found it useful in some cases of polyuria;
but it has not been efficient in my hands.
  " The effects are usually constant.  First  profuse  salivation
Avhich comes on  in from  five to ten minutes, quickly folloAved
by profuse sweating; both of which usually  pass away  in an 
APPENDIX.
611
hour.  This dose has been increased to twenty grains, every four
hours, without any serious bad effects."

                   III. Hydrobromic Acid.

  This is formed by adding Tartaric Acid sxiij. 3j- gi*- xxxvij.
to Potassium  Bromide sx. 3yj. gr. xxviij., Water Slxxx.  The
tartrate of potash falls as a Avhite precipitate, the hydrobromic
acid remaining as a clear  fluid.  Dose, 3ss to 3j.
41 
 
INDEX.
                 A.

Abnormal growths, 187
Absorbents, theory of, 500
Acidity in children, 165
Acids as febrifuges, 105
Aconite, action of, 109
Action, abnormal, 307
Acute  disease, 235 ;  relations of,  to
  chronic, 253
Ague,  222 ;  relations of, to portal cir-
  culation,  223 ;  emetics   in,  224 ;
  treatment of, 224 ; injection  of qui-
  nine in, 225 ; relations of dysentery
  to, 226 ; brow,  227
Albuminuria, 440 ; treatment of,  441
Alcohol,  in pyrexia,  112;  in  acute
  disease, 248 ;  effect  on circulation,
  249 ; risks attached to, 250
Alkalies, on acid surfaces, 43;  in dys-
  pepsia, 400
Aloes,  419
Alteratives, 82
Amenorrhoea, 470
Anaemia,  145 ;  effects  of, excreta on,
  79;  fatness  produced  by,   146 ;
  treatment of,  147; use of  water in,
  53
Anaphrodisiacs, 458
Aneurism, treatment of, 361
Anhidroses, theory of, 483
Antimony in pyrexia, 108
Apoplexy in plethora, 155; treatment
  of, 514
Antipyretics, 104
Arsenic, 83
Assimilation, 36 ; disturbances of, 41
Astringents, 320
Atheroma, 140
B.
Bile, vicarious elimination of, 81
Bismuth, 400
Bitters,  45
Bladder, affections of the, 454
Blisters, 329
Blood-poisons, nature  of, 217;  C.  J.
  B. Williams on, 219 ; treatment of,
  220
Body temperature, 90
Brain, blood-supply of,  510 ;  hyper-
  aemia  of, 512 ;  vascular hyperaemia
  of,  514;  anaemia of,  516;  local
  anaemia of,  518
Breathlessness in  anaemia, 147
Bright's disease,  chronic, 443 ;  treat-
  ment  of, 446 ; dietary in, 449 ; with
  obesity, 594 ; with glycosuria, 443 ;
  remedial measures in, 451
Bromide of potassium, 315
Bronchitis, 368
Brow ague, 227
Buchu,  436
Building a prescription, 30
Bulimia, 399
                 C.

Cachexia, saturnine, 304; syphilitic,
  300
Calomel  and opium in  inflammation,
  129
Cancer, nature of, 213 ; treatment of,
  214
Cannabis indica, 324
Carbonic acid given off by the skin, 73
Catching cold, 95, 365
Cerebral  anaeinia, 516 ;  treatment of,
  516 ; local, treatment of, 518
Cerebral  circulation, effects of alcohol
  on, 244
Change of life, 469
Children, food of, 167;  in bronchitis,
  170 ; in diarrhoea, 168 ;  in  rickets,
  171 ; in  syphilis,  172 ;  in struma,
  171 ; with uric acid, 174
Chloral hydrate, in pyrexia, 110 ; as a
  nerve depressant, 314
Cholera,  227
Chorea, 545
Balance of parts, 27
Bantingism, dangers of, 596
Baths, use  of,  567 ; hip, for  women,
  566 ; varieties of, 572
Beef-tea, objections to, 601
Belladonna  in  night sweats, 207 ;  ef-
  fects on nervous system, 322 
611
INDEX.
Circulatory system, the, 334
Climate,  for  phthisis,  574 ; in India,
  579 ; change of, 583
Cod-liver oil, 202
Cold, external,  in  pyrexia,  116 ; in-
  ternal, 117
Community  of  origin of  excretory
  organs, 67
Compensatoiy action in excretion, 71
Conduct at the bedside, 615
Congestion,  157;  cerebral,   161;  of
  kidneys, 161 ;  of liver, 159 ; of lungs,
  160 ; of uterus, 158 ; venous, 160
Connective  tissue,  192 ; modifications
  of, 193
Constipation, 47, 417
Convalescence,  cautions as to, 127
Corns, 494
Cough, 384
Cutaneous  system, 479;  dieases  of,
  485
D.
Dkcay, characteristics of,  175 ;  man-
  agement of, 198
Delirium, 533
Dengue,  or dandy fever, 232
Diabetes, 261 ;  treatment of, 264
Diaphoretics, the theory of, 480
Diarrhoea,  422 ; nervous,  425 ; reflex,
  426; uraimic, 428 ; colliquative, 429 ;
  thermic, 429
Diathesis, 287; the gouty, 291 ; nerv-
  ous, 292 ;  strumous, 293 ;  bilious,
  296 ; lymphatic, 297 ;  hemorrhagic,
  298
Diet cures, 608
Digestion, disturbances of, 41
Digestive system,  the, 392
Digitalis, in pyrexia,  114;  in  heart
  disease, 343
Dilatation of the heart, forms of, 629
Diphtheria, 231
Disease, acute,  235 ; heart failure in,
  236; chronic, 253
Diuretics, 435
Dysmenorrhoea, 476
Dyspepsia, 399
Dyspnoea,  388
E.
Effects of excreta on different organs,
  73
Emetics, 397; in ague, 224; in jaundice,
  412 ; in thoracic disease, 242
Epilepsy,  542
Erysipelas. 233
Exanthemata, treatment of, 229
Excretion, 67
Excretory, general surface, 68
Expectorants, 368
F.
Fat, how  digested, 45 ;  value of, in
  tubercle, 202 ; value of, in neuralgia,
  549
Fatty degeneration, 183
Fayrer, Sir Joseph, on hepatic conges-
  Son, 416 ; on change of air in India,
  578
Fetid feet,  496
Fever, how produced, 97 ; how treated,
  108
Fluid food, 600
Fluids to affect temperature, 607
Food,  in  health,  585 ; azotized,  585 ;
  hydrocarbonaceous, 588 ;  in a case
  of  incomplete  starvation,  590 ;  in
  inflammations,   127;  in dyspepsia,
  398 ;  in  obesity, 594 ; in renal dis-
  ease, 595 ; for   brain-workers,  592,
  for  muscle-Avorkers,  591 ; reserve
  stores of, 589
Fox, Tilbury, on  diseases of the  skin,
  487
G.
General excretory surface, 66
Glycogen, 38
Gout,  its nature, 274;  acute,  treat-
  ment of, 279 ;  chronic, treatment of,
  283
Growth,  164;   relations  of  trophic
  nerves to, 182 ; abnormal, 187
H.
H^EMATEMESIS, 238
Haematics, 48
Haemoptysis, 389
Hemorrhage, treatment of, 238; stimu-
  lants in, 239
Hemorrhagic diathesis, 298
Hall, Surgeon-Major, A. R., on cholera,
  228;  on  dysentery, 226 ;   on  sun-
  stroke, 539
Headache, 536
Heart, primary  disease  of, 336 ; treat-
  ment of, 337 ; digitalis in, 343 ; food
  in, 350 ;  secondary diseases of, 351 ;
  treatment of, 353 ; neurosal affections
  of, 358
Heart cough, 386
Hooping cough, 233. 388
Hospitals,  cottage, for fever cases, 564
Hydrocarbonaceous  food.. 588 ; effects
  on blood-pressure, 588 
INDEX.
615
Hygiene, public, 552 ; private, 564
Hypertrophy,   or   hyperplasia,  187;
  nature of, 188 ; of the heart  in val-
  vular disease, 189 ; relations  to dila-
  tation, 190 ;  treatment  of, 191 ;  in
  aortic regurgitation, 337
Hysteria, 547
Ice, in pyrexia, 117; in hemorrhage,
  239
Idiosyncrasies, 24
Inaction, 332
Indigestion, 41, 393 ;  acute, in conva-
  lescence, 131
Infantile remittent fever, 169
Infectious disease,  management of, 559
Inflammation, nature of, 120; simple,
  treatment of, 124 ; after the pyrexia,
  126 ; in convalescence, 130 ; calomel
  and opium in, 129 ; local treatment
  in, 129 ; asthenic, 132 ;  due to gene-
  ral conditions,  135 ;  parenchyma-
  tous, 138 ; its treatment, 140
Inflammatory products, 142
Influenza, 232
Insomnia, 519
Intestinal acidity,  416
Iodine, as an  alterative, 84; as an ab-
  sorbent, 500
Ipecacuan in dysentery, 226
Irritable heart, 358
Irritation and counter-irritation, 329
Iron, its action, 48;  forms of, 50, 57;
  when not to give, 60
Jaborandi, 482
Jaundice, 411
J.
K.
Kidneys, congestion of, 159 ; disease
  of, in gout, 276 ;  function of,  432 ;
  inflammation of (acute), 438; in-
  flammation  of  (chronic), 443; in-
  flammation of, with valvular disease,
  453
Kidney disease, sequelae of, 631
Lead poisoning, 304
Leucorrhoea, 461
"Levelling up," 256
"Levelling down," 257
Lithiasis, 276 ;  treatment of, 279
Liver,  use of, 38; congestion of, 159;
  diseases of, 412 ; diseases of, in India,
  414; function of, 404
Local inflammations in general condi-
  tions, 136
Lupus, 496
Lymphatic system, 498
Lymphatics, inflammation of, 503
Lymph spaces,  inflammation of, 505 ;
  accumulations in, 507
M.
Max, as an individual, 23 ;  as an organ-
  ism, 22
Management of  advanced life, 178;
  of exanthemata, 229
Measles, 230
Menopause, the (change of life), 469
Menorrhagia, erotic form of, 472 ; other
  forms, 472
Mercury, action of, 83;  as an absorb-
  ent, 500
Milk, 600 ; cure,  609 ; substitutes for,
  610
Mineral waters, 569
Mitral disease, 337
N.
Natural history of disease, 627
Nauseant remedies in pyrexia, 108
Nephritis, acute, 438 ; chronic, 443
Nervous diathesis, 292
Nervous origin of anaemia,  151 ;  of
  skin affections, 491
Nervous system, the, 509 ; diseases of,
  512
Neuralgia, 548
Neurosal cough, 387
Nitrogen, its use,  36;  elimination of,
  74
O.
Obesity, food in, 594
(Edema, 162
01. sabinae, 149
Opium, action of, 307 ;  action of, as an
  analgesic, 311 ; effect of,  on secre-
  tion, 312 ; in gastric  affections, 399 ;
  in pyrexia, 111
Ovarian dyspepsia, 465
Pain, treatment of, 236
Parenchymatous  inflammation,
  treatment of, 141
138; 
616
INDEX.
Paralysis, 538
Parasitic skin affections, 492
Pathology, of cancer, 213 ; of cholera,
  228 ; of fatty degeneration,  183 ; of
  tubercle, 197
Pepsin, 37, 41
Pertussis, 233, 388
Pharyngeal cough, 886
Phosphate of lime, 48
Phthisis,  climate in, 575; pathology
  of, 195 ; treatment of, 201
Physiognomical diagnosis, 288
Plethora, 151 ; treatment of, 154
Pleurisy, treatment of, 382
Pneumonia, 374
Poisons,  blood, 217 ;  chlorate of potash
  in, 221 ; sulphites in, 221 ; C.  J.  B.
  Williams  on, 219;  malarial,  223;
  specific, 522
Position in congestion, 161
Prescriptions, how to build, 30
Profuse perspiration, means of check-
  ing, 483
Progress of disease, 627
Puberty in women,  462
Purgatives, 417
Pyrexia, 97 ;  effects of, on tissues, 99  ;
  treatment of, 104 ; nauseant remedies
  in,  108; quinine  and digitalis in,
  113 ; cold in,  116
Q.
Quinine, as a neurotic, 325 ; as a tonic,
  57 ;  effect on the bladder, 58 ;  in
  pyrexia, 113 ; subcutaneous injection
  of, 225 ;  subcutaneous injection of,
  in sunstroke, 539
R.
Rectal hemorrhage, 430
Relations of hypertrophy to dilatation
  of heart, 189 ; of acute  and chronic
  disease, 253;  of kidney disease to
  circulatory changes,  631
Reproductive  system,  the, 456 ;  ex-
  citement in, 457
Respiratory system, the,  363 ; effects
  of cold on, 364; disease of air-tubes
  of, 373 ; disease of lung structure of,
  374 ; disease of serous membrane of,
  384
Rheumatism, acute, 266 ; chronic, 270 ;
  local applications in,  273
Rheums, 177
Rhubarb, 419
S.
Salines as febrifuges, 105
Sanatoriums, 564
Scarlatina, 230
Secretion, metastases of, 67
Septic matters,  558
Sewage, 556
Sialagogues, 40
Sir James Simpson's bath, 107
Shock, 235 ; treatment of, 236
Skin, action of, 483 ; diseases of,  485 ;
  urea given off by, 74
Sleeplessness, 519
Spinal cord, affections of, 539
Stimulants, action  of, 243 ;  the  theory
  of,  242;  cautions as to  use of in
  hemorrhage,* 239
Stimulation, after effects of, 251
Stomach, changes  of, in digestion, 41 ;
  affections of, 397
Stomachics, 41
Struma, 172
Strychnine,  326
Sunstroke, 539
Syphilitic cachexia, 299;  skin affec-
  tions, 490
T.
Tartar emetic in pyrexia, 108
Tea, beef, 601
Teeth, hygiene of, 393
Teething, treatment of, 166
Temperature,  body,  how  maintained,
  92 ; how regulated, 93
Temperatures, low,  treatment of,  95 ;
  high, effects on tissues, 99 ;  high,
  amount of urea, 100 ; high, treatment
  of, 104;  high, effects of, in delirium,
  533
Therapeutic instinct, the, 551
Tissue,  connective, 192 ; modifications
  of, 194
Tonics, 54
Trophic nerves, in inflammation, 122 ;
  in growth, 181
Tubercle,  195; nature of, 197;  pro-
  gress of, 197 ; treatment of (curative),
  199 ; treatment  of (palliative), 204
Tubercular inflammation of the lung,
  377
Typhoid condition, the, 98 ; treatment
  of, 104
U.
Ulcer, gouty, treated successfully, 78
Ulcers,  495
Urea, elimination of, 74; source of,
  405 
INDEX.
617
Uraemia, treatment of, 76
Uraemic diarrhoea, 428
Urethritis, 460
Urinary system, the, 432
Uterus, diseases of the, 461
                 V.

Vaso-inhibitory nerves, 181
Vaso-motor nerves, relations of, 182
Venesection, effects of, on temperature,
  104
Ventilation, 555
Veratrum viride, 110
Vicarious action, 68
Visceral  associations of skin  diseases,
  486
                 W.

Warts, 494
Water, as a beverage, 569 ; as a diluent,
  31, 53 ;  its utility,  53 ; its utility in
  constipation, 422 ;  excretion  of, by
  kidneys, 433
Waters, mineral, 569 ; as baths, 572
Water-supply in  relation to disease,
  555
THE  END. 
 
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ous elaborate Analytical and  Birjliogr<.phical  Notices, giving a faiily complete sur-
vty of medic  1 literature.
  Then follows  the Quarterly  Summary of Improvements and Discoveries in
the Medical Sciencks, classified and  arranged  under different heads, and furnish.
ing a digest of medical progress, abroad and  at home.
  Thus during the year 1878 the "Journal" contained  77 Original Communica-
tions, mostly  elaborate in character, 133 Rev.ews and Bibli graphical Noticee, and
255 ai tides in  the Q  arterly  Summaries, illustrated with 48 maps  and wood en-
gravings.
  That  the efforts thus made  to maintain the  high reputation of the "Journal" are
successful, is shown by  the position accorded  to it in both America and Europe as a
leading organ of medical progress:—
 This is universally acknowledged  as the leading!  The Philadelphia Medical and Physical Journal
American Journal, and has been conducted by  Or. issued its first number in 1820, and. after a brilliant
Hays alone until 1S69, when  his son  was associated I career,  was succeeded in  1827  by the American
with him.   We quite agree with the critic, that this I Journa^ of  the Medical Sciences, a periodical of
journal is second to none in the language, and cheer-
fully accord to it the first place, for nowhere thall
we find more able and more impartial criticism, and
nowhere such a repertory of able original articles.
Indeed, now that the ''Brilish and Foreign Medic.i-
Chirurgical Review" has terminated its career, the
American Journal stands without a rival.—London
M*d. Times and Gazette, Nov. 24, 1877.
  The best medical journal on the continent —Bos-
 on Med  and Surg. Journal, April  17, 1879.
  The present number of the American Journal is an
exceedingly good one, and gives e\eiy promise of
maintaining the well earned reputation^ the review
Our venerable contemporary has our best wishes,
and we can only express the hope that it may con-
tinue its work with as much vigor and excellence for
the next  fifty years as it has exhibited in the past.
—London Lancet, Nov. 24, 1877.
And that it was specifically included in the award of a medal of merit to the Publishers
in the Vienna Exhibition in 1873.
   The subscription price of the "American Journal of the Medical  Sciences" has
never been raised during its  long career.  It is still Five  Dollars per annum ; and
when paid for in advance, the  subscriber receives in addition the "MedicalNews and
Abstract," making in  all  near.y 2000 large octavo pages per annum, free of postage.
                                        II.
                   THE  MEDICAL NEWS AND ABSTRACT.
   Thirty-seven years  ago the "Mtdical  News" was  commenced as a monthly to
convey to the subscribers  of  the "Amkrican  Journal" the clinical instruction and
  * Communication!; are invited  from gentlemen in all parts of the country. Elaborate articles inserted
by the K.litor are paid for by the Publisher!).
world-wide reputation ; the ablest and one of the
oldest periodicals in the world—a journal which baa
an unsullied record.—Gross's History of American
Med. Literature, 1876.
  It is universally acknowledged  to be the leading
American  medical journal, and, in our opinion, it
second to  none in the language.— Boston Med. and
Surg. Journal, Oct. Is77.
  This is the medical journal of our country to which
the American physician abroad will point with the
greatest satisfaction, as reflecting the state of medical
culture in his country.  For a great many years it
ha* been the medium through which our ablest writ-
ers have made known their discoveries and observa-
tions —Address of L. P Yandell, M.D., before Inter.
natiimul Med. Congress, Sept. 1876. 
r
     Henry C. Lea's Son  & Co.'s Publications—(Am. Journ. Med. Sci.).  3

   current information which could not be accommodated  in the Quarterly.   It con-
   sit t d of sixteen  pages of such  matter,  together with sixt en more known as tie
   Library Department and devot<d to *he  publishing of books.  With the increased
   progress of ecierce, however, this was found imufficient and some years since an-
   other periodical,  known as  the  "MoNTtLY Abstract," was started, and  was fur-
   n shtd at a  moderate  price  to  subscribers to  the  "American Journal."  These
   two monthlies will  hereafter be consolidate, ULder the title of "The Medical
   Nfcws and Abstract," and will  be furnished free of charge in connection  with the
   "American  Journal."
     The "News and  Abstract" will  consist of 64 pages  monthly, in a  neat  cover.
   It will contain a  Clinical Department  in which will be continued the series of
   Or o nal American Clinical Lecturfb, by gentlemen  of  tbe highest reputation
   throughout the United States, together wi h a choice selection of foreign Lectures
   and Hospi al Nott-s and Gleanings.  Then will follow the Monthly Abstract, sys-
   tematically arranged and classified, and presenting five or six hui died articles yt arly ;
   and each number will cmclude with a  News Department,  giving current j rofes-
   gional intelligence, domestic  and foreign, the  whole fuiiy indexed  at the  ^ose of
   each volume  ieude  ing it of permanent v lae for re'e erce.
     As  stated  above,  the  subscription price to lhe "News and Abstract" will be
   Two Dollars and a Half per annum, invariably in advance, at which  rate  it will rank
   as one of the cheapest medical peri dicals in the country. But it will also be  fur-
   nished, tree of all charge,  in commutation with the "Amer can Journal of  this
   Medical Sciences " to all  who remit Five  Dollars in  advance thus giving to the
   su scriber, for that very  moderate sum, a complete record of medical progress
   throughout the worli, in the compass of about two thousand large octavo pag s.
     In  this effort to  mrni^h so large an amount of  practical information at a  price so
   unpriced ntedly low, and thus place it within the  reach of every member of the
   profession, the publishers confidently anticipate the friendly aid of all who feel an
   interest in the dissemination of sound medical literature.   They trust, e pecially, thac
   the subscribers to  the "American Medical Journal" will call the attention  of their
   acqua;ntances to the advantages thus offered, and that they  will be sustained in the
   endeavor  to permanently establish medical periodical  literature  on a  footing of
   cheapness never heretofore attempted.

    PREMIUM  FOE OBTAINING NEW  SUBSCRIBERS TO  THE "JOURNAL."
    Any gentleman who will remit  the amount for  two subscriptions for 18.0, one of
   which at least must be for a new subsrrtbtr, will receive as a premium, tree by mail, a
   copy of any one  of toe  following rcc nt works:
      '•Barnes's M  nual of M dwjfery" (  ee p. 24),
      "Tubury Fox's Epitope of Uis ases of the Sk n," new edition, jutt ready,
            (see p. 18)
      " FoTHEaGii.L's Antaoonism of  Me icines" (see p. 16),
      " Holdbn's Landmarks. Medical and Surgical" (see p  6),
      " 1JROWM! ON THE USE OF THE OPHTHALMOSCOPE" ^Stfe p. I'.'),
      "Flint'sEssays  on Conservative Medicine" (see p, 15j,
      "sturges's Clinical Mkdicine" (see p. 14)r
      "Swayne's Obstetric Aphorisms," new edition (see p. 21),
      "Tanner's Clinical Manual"  (see  p. »),
      "West on Nervous Disorders of Children '' (see p,. 2.0,.
    * * Gentlemen desiring to avail  themselves of the advantages thus offered will do
  well to  forward their subscriptions at an early day, in ordei; to. insure ine receipt of
  complete sets  for the year ibesO.
    Jgg*  The safest mode of remittance is by bank check or postal money order, drawn
  to the order of the undersigned.  Where these are not accessible, remittances for tlie
  "Journal" rnay be made ai  the risk of the  publishers,, by forwarding in registered
  letters.   Address,
              Hknry C.  Lea'.- Sok  & Co., Nos. 706 and 708 Sansom St., Phila., Pa. 
Henry C.  Lea's Son & Co.'s Publications—(Dictionaries).
 TjUNGLISON  (ROBLEY),  M.D.,

         Late Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia.

   MEDICAL  LEXICON;  A  Dictionary of  Medical  Science:  Con-
    taining a concise explanation of the various Subjects and Terms of Anatomy, Physiolcgy,
    Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medicnl
    Jurisprudence, and Dentistry.  Notices of  Climate  and of Mineral Waters; Formulae fer
    Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of
    the Terms, and the French and  other Synonymes ;  so as to constitute a French as well as
    English Medical  Lexicon.  A New Edition.  Thoroughly Revised, and very greatly Mod-
    ified and Augmented.  By Richard J. Ddnolison, M.D.  In one very large and  hand.
    someroyaloctavo volume of over 1100 pages.   Cloth, $6 50; leather, raised bands,  $7 60.
    (Just Issued.)

  The object of the author from  the outset has not been to make the work a mere lexicon or
dictionary of terms, but to afford, under each, a condensed view of its various medical relations,
and thus to  render the work an epitome of the existing condition of medical sciei- e.  Startirg
with this view, the immense demand which has existed forthe work has enabled him, in repeated
revisions, to augment its completeness and usefulness, until at length it has attained the position
of a recognized and standard authority wherever  the language is spoken.
  Special pains have been taken  in the preparation of the present edition to maintain this en.
viable reputation. Duringthe t»n years which have elapsed since the Inst revision, the additions
to the nomenjlature of the medical sciences have been greater than perhaps iD any similar period
of the past,  and up to the time  of his death the authorlabored assiduously to incorporate  every-
thing requiring the attention of the  student or practiioner.  Since  then, the editor has been
equally industrious, so that the additions to the vocabulary are more numerous than in any pre-
vious revision. Especial attention has been bestowed on the  accentuation, which will be found
marked on every word. The typigraphical arrangement has been much improved, rendering
reference much more easy, and evjry care has been taken with the mechanical execution.  The
work  has been printed on new type, small but exceedingly clear, with an enlarged page, so that
the additions have been incorporated with an increase of but little over a hundred pages, and
the volume now contains the matter of at least four ordinary octavos.
                                              may safely confirm the  hope ventured by the editor
                                              " that the work, which possesses for him a filial as well
                                              as  an individual interest, will be found worthy a con-
                                              tinuance  of the position so long  accorded  to it as a
                                              standard authority,"'— Cincinnati Clinic, Jan 10,1874.
                                               It has the rare merit that It certainly has no rival
                                              In  the English language for accuracy and extent of
                                              references.—London Medical Gazette
                                               As a standard work of reference, as one of the best,
                                              if  not the very best, medical dictionary in Ihe  Eng-
                                              lish language, Dunglison's work has been well known
                                              for about forty years, and needs  no words of praise
                                              on our part to recommend it to the members of tbe
                                              medical,  and, likewise, of the pharmaceutical pro-
                                              fession.   The  latter especially are in need of such a
                                              work, which gives  ready and reliable  information
                                              on thousands of subjects and terms which they are
                                              liable to encounter in  pursuing their daily avoca-
                                              tions, but with which they cannot be expected  to be
                                              familiar.  The work before  us fully supplies this
                                              want.—Am. Journ. of Pharm., Feb. 1874.
                                                A valuable  dictionary of tbe terms employed in
                                              medicine and the allied sciences, and of the rela-
                                              tions of the subjects treated under each head.  It re-
                                              flects great credit on its able American  anthor, and
                                              well deserves the authority and  popularity it has
                                              ob:ained.—British  Med. Journ.,Oct. 31, 1874.
                                                Few works  of this class exhibit a grander monu-
                                              ment of patient research and of scientific lore.   The
                                              extent of the sale of this lexicon is sufficient to tes-
                                              tify to its use ulness, and to the great  service con-
                                              ferred by Dr. Robley Dunglison on the profession,
                                              and indeed onotliers, by its issue.—London Lancti,
                                              May 13 l*-75.
  A book well known to our readers, and of which
every American ought to be proud. When the learned
author of the work  passed away, probably all of us
feared lest the book should not maintain its place
in the advancing science wbo«e terms it defines.  For-
tunately, Dr. Richard .1. Dunglison, having assisted his
father in the revision of several editions of the work,
and having been, therefore, trained in tbe methods and
Imbued with the spirit of the book, has been able to
edit it. not in  the patchwork manner so dear to  the
lieart of book  editors, so repulsive to the taste of intel-
ligent book readers, but to, edit it as a work of the kind
Bhouldbe edited—to  carry it  on  steadily, without jar
or interruption, along the grooves of thought it  has
travelled during its lifetime.  To show the magnitude
of the task which Dr Dunglison has assumed  and car-
ried through, it is only  necessary to state that more
than six thousand new subjects have been added in the
presentedition.—Phila. Med. Times, Jan. 3, 1874.
  About the first book purchased by the medical stu-
dent is the Medical Dictionary.  The lexicon explana-
tory of technical terms is simply a. sine qua non. In a
science so extensive, and with such collaterals as medi
cine, it is as much a necessity  also to the practising
physician. To meet the wants  of students and most
physicians, the dictionary must be  condensed while
comprehensive, and practical while perspicacious. It
was because Dunglison's met these indications that it
became at once the dictionary of general use wherever
medicine was studied in  the English language.  In nc
former revision have the alterations and additions been
so great.  More than six thousand new subjects and terms
have been added. The chief terms have been set in black
letter, while the derivatives follow in small caps; ar
arrangement which greatly facilitates reference.  We
 fJOBLFN {RICHARD  D.), M.D

    A  DICTIONARY OF  THE TERMS USED IN MEDICINE  A*D
      THE COLLATERAL SCIENCES.  Revised, with numerous additions, by Isaac Hays,
      M. D., Editor of the " American  Journal of the Medical Sciences."  In one large royal
      l2mo. volume of over 500 double-columned pages ; oloth, $1  50 ; leather, $2 CO
  It te the best bo"k of d.nuitions we have, and ought always to be upon the student's taole.— Southern
Med. and Surg  Journal.
JDODWELL [G. F), F.R.A.S., frc.

     A DICTIONARY  OF SCIENCE:  Comprising Astronomy, Chem-
      istry,  Dynamics,  Electricity. Heat, Hydrodynamics, Hydrostatics, Light, Magnetism,
      Mechanics, Meteorology, Pneumatics, Pound, and Statics. Preceded by an Essay on th«
      History of the Physical Sciences.  In one handsome octavo volume of 694 pages, and
      many illustrations: cloth, $5. 
           Henry C. Lea's Son & Co.'s  Publications—(Manuals).         5

A  CENTURY OF AMERICAN MEDICINE.  1776-1876.   By Doctors E. H.
      Clarke, H. J. Bigelow, S. D. Gross, T. G. Thomas, and J. S. Billings.  Inone very hand-
      some 12mo. volume of about 350 pages : cloth, $2 25.   (Just Ready.)
  Ihis work appeared in the pages of the American Journal of the Medical Sciencesduring the
year 1876.  As a detailed account of the development of medical science in America, by gentle-
men of the highest  authority in their respective departments,  the profession will no doubt wel-
come it in a form adapted for preservation and reference.
£J~EILL (JOHN), M.D., and   CjMITH {FRANCIS  G.), M.D.,
                                         Prof, of the Institutesof Medicine inthe Univ of Penna
   AN  ANALYTICAL  COMPENDIUM  OF  THE   VARIOUS
     BRANCHES OF  MEDICAL SCIENCE ; for the Use and Examination  of  Students.  A
     new edition, revised and improved. In one very large and handsomely printed royal 12m<>.
     v&lume, of about  one thousand pages, with 374 wood-cuts, cloth, $4 ;  strongly bound in
     leather, with raised bands, $4 75.
 TJARTSHORNE {HENRY), M. D,,
        Professor of Hygiene in the University of Pennsylvania.

   A  CONSPECTUS  OF  THE   MEDICAL  SCIENCES;  containing
     Handbooks on Anatomy, Physiology, Chemistry, Materia -Medica,  Practical Medicine
     Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large
     royal  12mo. volume of more than  1000 closely printed pages, with 477 illustrations on
     wood.   Cloth, $4 25 ; leather, $5 00.   (Lately Issued.)
  We can say with  the strictest truth that it is the
best work of the kind with which w. art acquainted
It embodies ina condensed form ailrecent contribu-
tions to practical medicine, ana is therefore useful
to every busy practitioner throughout our country,
besides being admirably adapted to the use of stu-
dents of medicine.  The book is faithfully and ably
executed.—Charleston Med. Journ.,  April, 1875
  The work is intended as an aid to the medical
stulent, and as such appears to admirably fulfil its
object by itsexcellent arrangement,the full compi-
lation of facts, the perspicuity aud terseness of lan-
guage, and the clear and  instructive illustrations
in some parts of the work —American Journ. of
Pharmacy, Philadelphia, July, 1S74.
 The volume will be found useful, not only to stu-
dents, bat to many others who may desire to refresh
their memories with the smallest possible expendi-
ture of time.—N. T. Med. Journal, Sept. 1874.
 The student will find this the most convenient and
useful book of the kind on which he can lay hit
band.—Pacific Med. and Surg. Journ., Aug. 1874.
 Thisi6 the best book of its kind that we have ever
examined.  It is an honest, accurate, and concise
compend of medical sciences, as fairly as possible
representing their present condition.  The changes
and the additions have been so judicious and tho-
rough as to render it, so far a.- it goes, entirely trust-
worthy.  If students must have a conspectus, they
will be wise to procure that of Dr Hartshorne.__
Detroit Rev. of Med and Pharm., Aug 1874
  The work before us, however, has many redeem-
ing features not possessed by others, and is the best
we baveseen. Dr. Hartshnrne exhibits much skill in
condensation   It is well adapted to the physician in
active practise, wbo can give but limited dine to  the,
familiarizing of himself with the important changes
which have been made since he attendtd  lectures.
The manual of physiology has  also been improved
and gives the most comprehensive view of the late t
advances in the science possible in tbe space devoted
to the subject. The mechanical  es3cution of  the
book leaves nothing to be wished  'or.,—Peninsular
Journal of Medicine, Sept  1874.
  After carefully looking  through this conspectus,
we are constrained to say that  it is the most com-
plete work, especially in its illustrations, of its kind
that we have seen.— ,'incinnati Lancet, Sept. 1S74.

  The favor with which the  first edition of  this
Compendium was received, was an evidence of its,
various excellences  The present edition bears evi-
dence of a careful and thorough revision.  Dr. Harts-
home possesses a happy faculty of seizing upon  the
8-t ient points of each subject, and of presenting them
in a concise and yet pers jicuous manner.—Leaven- '
worth Med. Hera.d, Oct. 1S74
 fUDLOW {J.L.), M.D.
   A  MANUAL  OF  EXAMINATIONS  upon  Anatomy, Physiology,
     Surgery, Practice of  Medicine, Obstetrics, Materia  Medica, Chemistry, Pharmacy, and
     Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised
     and greatly  extended and enlarged.   With  370 illustrations.   In one handsome royal
     12mo. volume of 816  large pages, cloth, $3 25 ;  leather, $3 75.
  The arrangement of this volume inthe form of question and answer renders it especially suit-
able for the office examination of students, and for those preparing for graduation.
subs
 BANNER  (THOMAS  HA WKES), M.D., Sec.
  A MANUAL OF  CLINICAL MEDICINE  AND PHYSICAL DIAG-
    NOSIS.  Third American from the Second London Edition. Revised and Enlarged by
    Tilbubt Fox, M. D., Physician to the Skin Department in University College Hospital,
    4c. In one neat volume small 12mo., of about 375 pages, cloth. $1 50.               , ,
#  * On  page 3> lt wi"  be seen that  tnis W0T^ is offered as a premium for procuring  new
bscribers to the "American Journal of the Medical  Sciences." 
6         Henry  C. Lea's Son & Co.'s
 Q.RAY  (HENRY), F.R.S.,
         Lecturer on Anatomy at St. George's Hospital, London.

   ANATOMY,  DESCRIPTIVE   AND SURGICAL.   The Drawings  by
       H. V. Carter, M.D., and Dr  Westmacott.  The Dissections jointly by the Author and
       Dr. Carter.  With an Introduction  on General  Ana'omy  and Development by T.
       HoLMtS, M A., Surgeon to St  George's Hospital.  A new American, from  the  eighth
       enlarge* and improved London edition   To which is added " Lam>mahks, Medical and
       Surgical," by Luther Holden, F.K.C S., author of " Human Osteobgy," " A Manual
       of Dissections,"  etc.  In  one magnificent  imperial octavo volume ot V183 pages, with
       522 large and elaborate engravings on  wood.  Cloth, $6 ; leather, raised  bunds, $7.
       (Just Ready.)
  The author has endeavored in this work to cover a more extendedrange of subjects than is cus-
tomary in the ordinary text-books, by giving not only the details necessary forthe student, but
ulsothe application of those details in the practiceol medicine and surgery, thusrendering it bott
a guide for the learner,  and an  admirable work of reference for the active practitioner  The en-
gravings form a special feature in the work, many of them being the size of nature, nearly till
original, and having the names of the various parts printed on the body  of the out, in place of
figures of reference, with descriptions  at the foot  They thus form  a complete and splendid series,
w.iich  will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve tc
refresh the memory of tnose who may find in the exigencies of practice the necessity of recalling
uhe details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, wit b
a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of
essential use to all physicians who receive students in their offices, relieving both preceptor and
pupil of much labor in laying the groundwork of a thorough  medictil education.
  Since the  appearance of the last American  Edition, the work has received three revisions nt the
hiinds of its accomplished editor, Mr. Holmes, who has sedulously introduced whatever has seemed
requisite to  maintain its reputation as acomplete and authoritative standard text-book and work
of reference.  Still  further to increase its usefulness, there  has been appended  to it the recent
work by the distil guishtd anatomist, Mr. Luther Holden—"Landmarks. Medical and burgicnl"
__which gives  ii a clear, condensed, and systematic way, all the information by  which  the prac-
titioner can  determine from the external surface of the body the position of internal parts.  Thus
complete, the work, it is believed, will furnish all the assistance that can be rendered by type and
illustration in  anatomical study.   No pains have been spared in  the typographical execution of
the volume,  which will be found in all respects superior to former issues.   Notwithstanding the
increase of size,  amounting to over 100 pages and 57 illustrations, it will be kept, as heretofore,
at a price rendering it one of the cheapest works ever offered to the American profession.
  The recent work of Mr Holden, which was  no- i to consult  his books on  anatomy. The work is
ticed by us on p. 53 of this volume, has been added  simply indispensable especially this present Amer
a« an appendix, so that, altogether, this is tbe mo»t J ican edition
practical and complete anatomical treatise available
to American sndents and  physicians. The former
fluds in it the necessary guide in making dissec
Va. Med. Monthly, Sept. 187P.
tions; a very comprehensive chapter ou  minute
anatomy ; and about all that can be taught him on
general and special anatomy; while the latter, in
its treatment of each region from a surgical point of
view and in the valuable edition of Mr  Holden,
will  find all that will be essential to him in his
practice—New Remed'es, Aug 1S78.
  This work is as near  perfection  as one could pos-
sibly or  reasonably expect any book intended as a
text-book or a genera) reference book on anatomy
to be  The American pnblisher deserves the thanks
of th» profession for appending the recent work of
Mr. Holden, ''Landmarks, Medical and S*r gieal,"
which has already been c .mmended as a separate
book. The  latter work—treating  of topograph,cal
anatomy- has become «n essential  to the library ot
every intelligent practitioner.  We  know of no
book that  can  take its place, written as it is by a
most distinguished anatomist. It  would be simply
a waste of words to say an/thing further iu praise
of Gry's Anatomy, the text-book in almost every
medical college in this country, and the daily refer
ence  book of every practitiontr who  has  occasion
  The addition of the recent work of Mr. Holden,
as an appendix, renders this the most practical and
complete  treatise available to American students,
who find in it a comprehensive chapter ou myiu'e
anatomy, about all that can be taught on general
and special anatomy, while Its treatment of each
region, from a surgical point of vie v, in the valu-
able section by Mr  Holden is all that will be essen-
tial to them in practice.— Ohio Mtdieal Recorder,
Aug  1S78.

  It is difficult to speak in moderate terms of thia
new edition of "Gray."   It teems to he  as nearly
perfect as it is possible to make a book  devoted to
any branch of medical science.  The labors of the
eminent men wbo have successively revised  the
eight editions through which it has passed, would
seem to leave nothing for future editors to do.  The
addition of Holden's  " Landmarks" will make it as
indispensable to the practitioner of medicine and
surgery as it has been heretofore to the student  As
regardr  completeness,  ease of reference, utility,
beauty,  and cheapness, it has  no rival.   No stu-
dent should enter a  medical school without it ;  no
physician can afford to have it  absent from his
library — Si. Louis Clin. Record, Sept 1878.
H<
H
     Also for sale separate—
 'OLDEN {LUTHER), F.R.C.S.,    '
      Surgeon to St. Bartholomew's and the Found!ir g Hospitals.
LANDxMARKS,  MEDICAL  AND SURGICAL.  From the 2d  London
   Ed.  In one handsome volifme, royal 12mo., of 128 pages : cloth, 88 cents.  (Now Ready.)

  EATH  (CHRISTOPHER), F.R.C.S.,
      Teacher of Operative Surgery in University College, London.
  PRACTICAL ANATOMY:   A  Manual  of Dissections.   From  the
   Second revised and improved London edition. Edited, with additions, by W.  W  Keen,
   M. D.  Lecturer on Pathological Anatomy in the Jefferson Medinal College, Philadelphia.
   In one handsome royal 12mo volume of 578 pages, with 247 illustrations  Cloth, $3 cO ;
   leather, $4 00. 
Henry C. Lea's Son <fc Co.'s Publications—(Anatomy).
J^LLEN  {HARRISON). M.D.
        Professor of Physiology in th» Univ. of Pa.
  A SYSTEM OF HUMAN ANATOMY:  INCLUDING ITS MEDICAL
      and Surgical Relations.  For the Use of Practitioners and Studentsof Medicine  With an
      Introductory Chapter on Histology By E. 0. Shakespeare, M D , Ophthalmologist to the
      Phila. Hosp.  In one large and handsome quarto volume, with several hundred original
      illustrations on lithographic plates, and numerous wood-cuts in the text.   (Preparing.)
  In this elaboratework, which has been in active preparation forseveral years, the author has
sought to give, not only the details of descriptive nnatomy in a clear and condensed form, but also
the practical applications of the science to medicine and surgery. The work thus has claims  upon
the attention of the general  practitioner, as well as of the student, enabling him not only to  re-
fresh his recollections of the dissec.ing room, but also to recognize  tbesignificanee of all varia-
tions from normal conditions  The marked utility of the object thus sought bv the author is
self-evident, and his long experience and assiduous devotion to its thorough development are a
sufficient guarantee of the manner in which his aims have been carried out. No pains have been
spared with the illustrations  Those of normal anatomy are from original dissecti >ns, drawn on
stone by Mr. Hermann  Faber, with the name of every part clearly engraved upon the figure,
after the manner of " Holden" and " Gray." and in every typographical detail  it will be  the
effort of the publisher to render the volume worthy of the very distinguished position which is
anticipated for it.

  J?LLIS {GEORGE  VIXER).
 J-J    Emeritus Professor nf Anatomy in University College, London.

   DEMONSTRATIONS  OF  ANATOMY;  Being  a Guide to  the Know-
       ledge of the Human  Body by Dissection. By George Viner Ellis,  Emeritus Professor
       of  Anatomy in   University College,  London.   From the Eighth and Revised  London
       Edition.   In one  very handsome octavo volume of over 700 pages, with 256 illustrations.
       Cloth, $4 25 ; leather,  $5.25   (Jvst Ready )
   This work has long been known in England  as the leading authority on  practical anatomy,
 aid the favorite guide in the dissecting-room, as is attested by the numerous editions through
 which it has passed.  In the last revision, which has just appeared in London, the accomplished
 author has sought to bring it on a level with the most recent advances of science by making the
 necessary changes in his account of tbe microscopic structure of the different organs, as devel-
 oped by the latest researches in textural anatomy.
 Ellis's Demonstrations is the favorite text-book
of the English gtudent of  anatomy.  In passing
through eight editions  it has been >-o revised and
adapted to the needs of the  student ha» it would
seem that it had almost reached perfection in thi-t
special line.  The descriptions are clear, and  the
methods of pursuing anatomical investigations are
given with such detail that the book  is honestly
entitled to its name.— St. Louis Clinical Record,
June, 1879.
 The success of this old manual seems to be as well
deserved in  the present as in the pa*t volumes
its leadership over the English manuals upon dis-
secting.—Phila. Med. Times, May 24, 1879.

  As a dissector, or  a work  to have in hand and
studied while one is engaged in dissecting, we re
gard it as the very best work extant, which is cer-
tainly saying a very  great deal.  As a text-book  to
be studied in the dissecting-room, it is superior  to
any of the works upon anatomy.— Cincinnati Med.
New*, May 21, 1879.

  We most  unreservedly recommend  it to every
practitioner  of medicine who can possibly get it.—
The book seems destined to maintain yet for jears I V«. Med. Monthly, June, 1879.
UTILSON (ERASMUS), F.R.S.
    A  SYSTEM OF HUMAN  ANATOMY, General and Special.  Edited
     by W. H. Gobrkciit, M.D ,  Professor of General and Surgical Anatomy in the Medical Col
     lege of Ohio.  Illustrated with three hundred and ninety-seven engravings on wood.  In
     one large and handsome octavo volume, of over 600 large pages ; cloth, $4 ; leather. $5.

UMITH (HENRYH.), M.D.,     and JJORNER ( WILLIAM E.),M.D.,
  Prof .of Surgery inthe Univ. of Penna.,&c.        Late Prof. of Anatomy inthe Univ. ofPei.na.
  AN   ANATOMICAL  ATLAS ;   illustrative  of  the Structure of the
     Human Body  In one volume, large imperial octavo, cloth, with about six hundred and
     fifty beautilul figures.   $4 50.

  CHAFER  (ED WA RD  A LBERT), M.D.,
       Assistant Profetsor of Physiology in University College, London.
  A COURSE OF PRACTICAL  HISTOLOGY: Being an Introduction to
     the Use of the Microscope.   In one handsome royal 12mo. volume of 304 pages, with
     Dumerous illustrations: cloth,  $2 00.   (Just Issued.)
S
HORNER'S SPECIAL  ANATOMY AND  HISTOL-
  OGY   Eighth edition, extensively revised and
  modiflo<l  In 2 vols. 8vo., of over 1000 pages,
  with 320 wood cuts : cloth, $6 00
KH4RPEY AND  QUAIN'S  HUMAN ANATOMY.
  K vised  by Joseph  Lkidt, Ml)., Prof of Anat.
  .  r,  iv' 0| Penn. In two octavo vols, of about
  l°0 pages, with 511 illustrations  Cloth, $b 00.
BELLAMYS STUDENT'S GUIDE T1 SURGICAL
  ANATOMY:  A Text book for Students prepa irg
  for their Pass Exanilr, ation. With erg avings ou
  wood  In one handsome royal 12mo. volume.
  Cloth, $2 25
CLELAND'S DIRECTORY FOR THE DISSECTION
  OF THE HUMAN BODY.  In one  small volume,
  royal 12mo. of 182 pages: sloth $1 2ft. 
8         Henry C. Lea's Son & Co.'s Publications—(Physiology).
 fiARPENTER (WILLIAM B.),  M.D., F. R. 8., F.G.S., F.L.S.,
 ^      Registrar to University of London, etc

  PRINCIPLES  OF HUMAN PHYSIOLOGY; Edited by Henry Power,
      M.B. Lond., F R.C.S., Examiner in Natural Sciences, University ot Oxford.  A new
      American from the Eighth Revised  and Enlarged English Edition, with Notes and Addi-
      tions, by Francis Q. Smith, M D., Professor ol tht Institutes cf Medicine in the Univer-
      sity of Pennsylvania, etc.  In one very large and handsome octai o volume, ol 1083 pages,
      with two plates and 373 engravings on wood; cloth, $5 50 ; leather, $6 50.  (Just Issutd.)
  We have been agreeably surprised to find the vol
ume so complete in regard to the structure and func-
tions of tbe  nervous system in all its relations,  a
subject that, in many respects, is one of the most diffi-
cult of all, in tbe whole range of physiology, upon
which to produce a full and satisfactory treatise of
tbe class to which the one before us belongs.  The
additions by the American editor give to the work as
it is  a considerable value beyond that of the last
English edition.  In conclusion, we can give our cor-
dial recommendation to the work as it now appears
The editors have, with their additions to the only
work on physiology in our language that, in tbe full-
est sen-e of the word, is the production of a philoso-
pher as well as a physiologist, brought it up as fully
as conld beexpected, if not desired, to the standard
of our knowledge of its subject at the present day
It will deservedly maintain the place it has always
had iu the favor  of  he medical profession.—Journ.
of Nervous and  Mental Di-ease, April, 1877.
  Such enormous advances have recently been made in
our physiological knowledge, thHt what was perfectly
 new a year or two atto. looks now as if it had been a
 received and established fact for years.  In this enry-
 dopspdic way it  is unrivalled. Here, as  it seems fen
 us, is tbe urea t value of tbe book; one is safe in sending
 a student to it  for information on almost any  given
 ■lubject, perfectly certain of the fulness of information
 it  will convey, and well satisfied of the accurscy with
 which it will there be found stated.—London Med.
 Times and Gazette. Feb. 17, 1877.
  The merits of-'Carpenter's Physiology "are so wide)j
 known ari4 appreciated ihat we need only allude briefly
 to the fact that in the la test edi'ion will be found a com-
prehensive embodiment of the results of recent physio-
logical investigation Care has been taken to preserve
the practical character of the original work  In fact
the entiie work has been brought up to date, and beart-
evidence of the amount of labor that has been bestowed
 upon it by  its distinguished editor, Mr. Henry Power.
The American editor has made the latest additions, in
order fully to cover the time that has elapsed since the
last English edition.—iV. Y Med Journal, Jan.1877.
F
    OSTER  (MICHAEL),  M.D.. F.R.S..
         Prof of Physiology in Cambridge Univ , England.

   TEXT-BOOK  OF PHYSIOLOGY.   A new American, from  the third
      English  edition.   Edited  with  notes  and additions  by Edward T. Kkichert. M.D ,
      Demonstrator of Experimental Therapeutics  in Univ. of Penna  In one handsome royal
      12mo. volume of over 1000 pages, with over  250 illustrations.   Cloth, $2 50.   Leather,
      $3 25.   (Just Ready.)

                              American Editor's Preface.

  The high  reputation acquired on both sides of  the Atlantic  by Dr. Foster's "Text-Book on
Physiology," as a lucid exposition of functional physiology, in its most  modern aspect, ha.- seemed
to call for an edition more thoroughly adapted to the wants of the American student.  The plan
of the author has presupposed an t-cquaintaLce with the details of phys;oiogical anatomy tuch as
tbe student is  accustomed to  look  to  in his treatises  on physiology.   The  absence of these
details has rendered many parts  of the  work vague, if not altogether incomprehensible, and has
therefore proved a seiious drawback to the usefulness of the boik as an accompaniment to lec-
tures  on physiology, as it is usually  .aught in our  schools, and this  deficiency the editor has
endeavored to supply,  by brief notes unci the  introduction of  a  large number of illustrations.
  The almost limitless amount of matetial accumulated by modern  research has rendered  diffi-
cult the task of selection and compression, wi hout  exceedirg the reasonable limits of a conve-
nient text-book.  In his selection the editor  has been guided by his experiet.ee in  the wants of
students, and has endeavored merely to present, in  the mott concise form, such facts as would  seem
to be  indispensable to a  correct appreciation of the struetue and  function of the  important
organs.   In accomplishing this, his additions  have  consideraby  exceeded his expectations,
amounting to about 140 pages, includirg trie  illustrations which have  been increased in number
fom 72 to 25t).  If he shall thus have  succeeded  in rendering this admirable work better fitted
for the wants of the American  student, he will feel abundantly  rewarded.
  .Nothing has  been omitted  from the English edition, and a 1 additions have  been distin-
guished by insertions in  brackets [—J.
  On the whole the book can be called the standard  the   subject, can little appreciate what advances
wotk in  the English language, while it has  noiie su-  have been mace, and can do nothing b> tter t ban to
pei tor in any other tongue.  It i.-, perhaps, ths only  g ve Dr. F .s.er's wi rk  oome careful readi ng —New
work in our language which represents physiology , Remedies  Jan 1S80.
fully as an experim utal science.  Its completeness    The iU-]tor 0f this  b ok is too well known to
isadmiiable. Theauxions student can find not only ' phy„iolog stg  to require an introduction.  His con-
the actual facts of the science, but also the mode in
which they were obtained. The author proven  olhe
student not only a compiler but a judicious ciilic —
Ji. urn. of Nervous and Mental Diseases, Jan  1880

  The work, since its first appearance,  has  con-
                                              tributions to this branch of eci nee bavesec'ned for
                                              him lasting fame.  As  an advanced thinker and
                                              writer his v;ew« and teacb'ng are  regarded as  the
                                              highest authority, and may be accepted as ihe late  t
                                              outcome  cf physiof gical  retearch aud  study —
tinned to'be'one of the nwt saUsfacTo7y te"x"t-b("oks ! Maryland Med. Journal, Feb. 1*8).
on the sulject that we have met with, and in in !  An elab rate  review at present is not required;
many respects peculiarly adapted to the  use of, it is only necessary to say that it is the best book
piaccition>-rs.  Those whose knowledge of the func- | of its immediate scope in any of the three 1  uguages,
tions of organs was chiefly acquired a decade ago, ; so  far, at least, as  our knowledge goes.—PhUuaa.
and who  have not since been  clligeut students of Mid.  Times, Jan. 3, 1 80.

HARTSHORNE'S HANDBOOK  OF ANATOMY AND |  and Additions, by J Cheston Morris, M.D. With
  PHYSIOLOGY.  Second  edition, revised.  In one   Illustrations on wood.  In  one octavo volcme of
  royal 12mo. vol., with  220  woodcuts;  cloth,   336 pages.  Cloth, $2 25.
  *1 75.                                       LEHMANN'S PHYSIOLOGICAL CHEMISTRY. Com-
LEHMANN'S MANUAL OF CHEMICAL PHYSIOL- j  plete in two laige oetavo volumes ol  1200 pages,
  OGY.  Translated  from the German, with Notes ;  with 200 illuMratijn«: cloth. 46. 
Hexhy  C. Lea's Son  &  Co.'s Publications—(Physiology, Chemistry).  9
 J)ALTON (J.  C), M.D.,
          Professor of Physiology in the College of Physicians and Surgeons, New York, Ac.

    A  TREATISE ON HUMAN   PHYSIOLOGY.  Designed forthe use
      of Studentsand Practitioners of Medicine.  Sixth edition, thoroughly revised and enlarged,
      with three hundred and sixteen illustrations on wood.  In one very beautifulootavo vol-
      ume, of over 800 pages.   Cloth, $5 50 ; leather, $6 50.  iJust Issued.)
  During the past few years several new works on phy-
siology, and new editions of old works, have appeared,
competing  for  the favor of the medical student, but
none will rival this new edition of Dalton.  As now en-
larged, it will be found also to be. in general, a satisfac-
tory work of reference for the practitioner.—Chicago
Med. Journ. and Examiner, Jan. 1876.
  Prof. Dalton has discussed conflicting theories and
conclusions regarding physiological questions with a
fairness,  a fulness, and a conciseness which lend fresh-
ness and vigor to the entire book.  But his discussions
have been so guarded by a refusal of admission to those
speculative and theoretical explanations, which at best
existin the minds of observers themselves as only pro-
babilities, that none of his readers need be led into
grave errors while making them a study.—The Medical
Record. Feb. 19,1876.
  The revision ofthis great work has brought it forward
with the physiological advances of the clay, and renders
it, as it has ever been, tbe finest work for students ex-
tant.— JNashville Journ. of Med. and Sui>g., Jan. 1876.
  For clearness and perspicuity. Dalton's Physiology
commended itself to the student year? ago. and was a
pleasant  relief from the verbose productions which it
supplanted. Physiology has. however, made many ad-
vances since then —and while tbe style has been pre-
served intact, the work in the present edition has been
brought upfully abreast of the times. The new chemical
notation and nomenclature have also been introduced
into the present edition. Notwithstanding the multi
plicity of text-books on physiology, this will lose none
of its old time popularity.  The mechanical execution
if the work is all that could be desired.—Peninsular
Tnurnal nf Medicine, Dec. 1875.
  This popular tex'-book on physiology comes to us in
its sixth edition with the atdition of about fifty per cent
of new matter, chiefly in  the departments of patho-
logical chemistry and the  nervous system, where the
principal advances have been realized.  With so tho-
rough revision and additions, that keepthe work well
up to the times, its continued popularity may be confi-
dently predicted, notwithstanding the competition it
may  encounter.  The publisher's work is admirably
done.—St. Louis Med. and  Surg. Journ , Dec. 1875
  We heartily welcome this, the sixth edition of this
admirable text book, than which there are none of equal
brevity more valuable. It iscordially recommended by
the Professor of Physiology in the University of Louisi-
ana, as by all competent teachers in the United States,
and wherever the English language is read, this book
has been appreciated. The present edition, with its 316
admirably executed illustrations, has been carefully
revised and very much enlarged, although its bulk does
not seem Derceptibly increased.—A'ete Orleans Medical
and Surgical Journal, March, 1876.
  The present edition is very much superior to every
other, not only in that it brings the subject up to the
times, hut that it do<*.= so more fully and satisfactorily
than any previous edition. Take it altogether it remains
i n our h urn We opinion, the best text book on physiology
in any land or language.—The Clinic, Nov. 6, 1875.
QREENE (WILLIAM  H.), M.D.,
^      Demonsirntor of Chemistry in Med. Dept , Univ of Penna.
  A MANUAL  OF MEDICAL  CHEMISTRY.  For the Use of Students-
     Based upon Bowman's Medical Chemistry.   In one royal 12mo. volume of  312  pages.
     With illustrations.  Cloth, $1 75.   (Just Ready.)
  It i? well written, and give« the latest views on
vital chemistry, a subject with which mist phy-i
cians are  not sufficiently familiar.  To those who
may wish  to improve their knowledge in that direc
tion, we can heartily recommend this work asheitig
worthy of a careful perusal.— Phila Med. and Surg.
Reporter, April 21, 1SS0.
 HLASSEN (ALEXANDER),
 ^     Professor in the Royal Polytechnic School, Aixla-Cha.pelle.
   ELEMENTARY  QUANTITATIVE  ANALYSIS.   Translated  with
      notes and additions by Edgar  F   Smith, Ph.D.,  Assistmt Prof,  of Chemistry in  the
      Towne Scientific School, Univ, of Penna.   In one handsome royal 12rao. volume, of 324
      pages, with illustrations; cloth, $2 00.  (Just Ready.)
  It is probably the best mmual of an elementary | advancing to the analysis of minerals and such pro-
nature extant, insomuch as its methods are the best,  ducts as are met with in  applied chemistry   It ig
It  teaches  by examples,  commencing  with single ' an indisoensable book for students in chemistry.—
determinations, followed by separations, and then ! Boston Journ. of Chemistry, Oct. 1878.

 Q.ALLOWAY (ROBERT), F.C.S.,
 *-*      Prof of Applied Chemistry in the Royil CoVege nf Science for Ireland, etc.
   A MANUAL OF QUALITATIVE  ANALYSIS.  Prom the Fifth Lon-
      don Edition. In one neat royal l2mo. volume, with illustrations; cloth, $2 75.  (Lately
      Issued.)_________________

 ~DO WMAN (JOHN E.), M.D.
    INTRODUCTION TO  PRACTICAL CHEMISTRY, INCLUDING
      ANALYSIS. Sixth American, from the sixth and revised London edition. With numer-
      ous illustrations.  In one neat vol., royal 12mo., cloth, $2 25.

 pEMSEN(IRA), M.D., Ph.D.,
         Professor of Hhemi»try In the Johns Hopkins University, Baltimore.
   PRINCIPLESOF TflEOllETICALCFIKVIISTllY, with speoial reference
      to the Constitution of Chemical Compounds. In one handsome royal l2mo. vol. of over
      232 pages: oloth, $1 50.   (Just Issued.)

     'OHLER AND FITTIG.
      OUTLINES OF  ORGANIC CHEMISTRY.   Translated with  Ad-
      ditions from the Eighth German Ed.  By Ira Remsbn, M.D.,  Ph.D., Prof, of  Chein.
      and Physios in Williams College, Mass. In one volume, royal 12mo.of 550 pp., cloth, $3.
W' 
10       Henry C. Lea's Son & Co.'s  Publications—(Chemistry).
pOWNES (GEORGE),  Ph.D.

    A MANUAL OF  ELEMENTARY  CHEMISTRY; Theoretical and
      Practical.  Revised and corrected by Hknky Watts, B.A., F R.S., author of' A Diction-
      ary of Chemistry," etc.  With a colored plate, and one hundred and seventy-seven illus-
      trations.  A new American, from th< twelfth and enlarged London edition.  Edited by
      Robert Bridges, M.D.   In  one larpe  royal 12mo.  volume, of over 1000 pages;
      cloth, $2 75;  leather, $3 25.  (Just Ready  )
  Two careful revisions by Mr.  Watts, since the appearance of the last American edition of
" Fownes," have so enlarged the work that in England it has been divided into two volumes   In
reprinting it, by the use of a small and exceedingly clear type, cast for the purpi se, it has been
found possible to comprise the whole,  without omission, in one volume, not unhandy for study and
reference.  The enlargement of the work has induced the American Editor  to confine his additions
to the narrowest compass, and he has accordingly inserted only such discoveries as have been an -
nounced since the very recent appearance of the work in England, and has added the standards
in popular  use to the Decimal and Centigrade systems employed in  the original.
  Among the additions to this edition will be found a very handsome colored plate,  representing
a number of spectra in the spectroscope. Every care has been taken in the typographical execu-
tion to render the volume worthy in every respect  of its high reputation  and extended use,  and
though it has been enlarged by more than one hundred and fifty pages, its very moderate price
will still maintain it as one of the cheapest volumes accessible to the chemical student.
  This work, inorganic and organic, is complete in
one convenient volume.  In it- earliest editions it
was fully up to the latest advancements and theo-
ries of that time.   In its present form, it preseuts,
in a remarkably convenient and satisfactory man-
n r, the principles and leading facisof thecuemi*trj
of to-day.  Concerning the manner in which  tbe
various tubjects are treated, much de-erves to be
said, and  mostly, too, in praise of  the book.  A re
view of such a work a^  Foumes's Chemistry within
the limits of a  bcok-notice for a medical weekly is
simply outofthe question.—Cincinnati Lancet and
Clinic, D. c. 14, 1878.
  When we state that, in our opinion, the present
edition sustains in every respect tie high reputation
which its predecesso'8 have aiquiied and eujoyed,
we express therewith our full belief in its intrinsic
value as a text-book and work of reference.—Am.
Journ. of Pharm., Aug. 1878.

  Tbe conscientious care which has been bestowed
upon it by tbe American and English editors renders
It still, perhaps, the best book for the student and the
practitioner who would keep alive the acquisitions
of hib student days. It has,indeed, reached a some-
what formidable magnitude with its more  than  a
thou and pages, but with less than this no fair repre-
sentation of chemistry a» it now is can be given. The
type is small but very clear, aud the sections are very
lucidly arranged to facilitate study and  reference.—
Meo  and Surg. Reporter, Aug 3, 1878.
  The work is too well known to American students
to need any extended notice; suffice it to say that
the revi ion by the English editor has been faithfully
done, and  that Professor  Bridges has  added some
fre*h aud valuable matter, especially in  the inor-
ganic chemistry.  The book has always been a fa-
vorite in this coun ry, and in its new shape bids
fair to retain all its former prestige.—Boston Jour.
of Chemistry, Aug 1878.
  It will be entirely unnecessary for ns to  make any
remarks relating to the general character of Fownes'
Manual For over twenty years it has held th* fore-
most place as a text-book, and the elaborate and
thorough revi-ions which have been  made from time
to time leave lit tie chance for any wide a wake rival  to
step before it.—Canadian Pharm. Jour.,  Aug. 1878.
  As a manual of chemistry it is without a superior
in the language.—Md. Med. Jour., Aug. Is78.
  A TTFIELD (JOHN), Ph.D.,
■*-*-      Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, Ac.
   CHEMISTRY, GENERAL, MEDICAL, AND  PHARMACEUTICAL;
      including the Chemistry of the U. S. Pharmacol ceia. A Manual of the General Principles
      of the Science, and their Application to Medicine and Pharmacy.  Eighth edition revistd
      by the author. In one handsome royal l2mo. volume of 700 pages, with illustrations.
      Cloth, $2 50 ; leather, $3 00.   (Just Ready.)
  We have  repeatedly expressed our favorable
opinion of this work, and on the appearance of a
new edition of it, little remains for us to say, ex-
cept that we expect this  eighth edition to be as
indispensable to  us as the seventh and previous
editions have been.  While the  general  plan and
arrangement  have been adhered to,  new matter
has  been added  covering  tbe observation.-  made
since tbe former edition  The present differs from
the preceding one chiefly in these alterations and
in about ten  piges of useful tables  added  in the
appendix — Am. Jour, of Pharmacy, May, 1879.
  A standard work like Attfield's Chemistry need
only be mentioned by its  name, without further
comments  The  present edi ioti contains such al
terations and additions as seemed necessary  for
the demonstration of  the  latest deveopments of
chemical principles, and the late-t applications of
chemistry to pharmacy.  The author has bestowed
arduons labor on the  revision, and the  ex'ent of
the information thui introduced may be estimated
from the fact  that th*  index   ontains three hun-
dred new references relating to additional mater
lal.—Druggists'  Circular  and Chemical Q itelte
Miy, 1879.
  This  very  popular and   meritorious work  has
now reached its eighth edition, which fact speak*
la the highest terms in commeud ition of its  excel
leuce.  It has now become the principa text-book
of chemistry in all the medical colleges in the
United States   The present edition  contains such
alterations and additions as seemed necessary for
the demonstration of tbe latest developments of
chemical  principles, and the latest applications of
chemistry to piarmacy  It is scarcely nece-sary
for us to say that it exhibits chemistry in its pre-
sent  advanced state.—Cincinnati Medical  Nrws,
April, 1879.
  The popularity which this work has enjoyed is
otving to the original and clear disposition  of tie
facts of the science, the accuracy of the details, and
the omission of much which freights many treatises
h>-avily without briuging cor responding instruction
to tbe reader.   Dr. Attfield writes for students, and
primarily for med cal students; he always bas an
eye to the pharmacopoeia and its officinal prepara-
tions; and he is continually putting  the  matter in
the text so that it responds to  the questions with
which each  section is provided.  Thns the student
learns easily, aud can  always refresh and test his
knowledge.—M»d a'dSurg. Reporter, Apri  19,'79.
  We noticed only about two years and a half ago
tbe  mblication of the preceding edition and re-
marked upon the exceptionally valuable charac er
of the wo'k.  The work now iiolndes the whole of
the chemistry of the pharmacopoeia of the Untied
States, Great Britain, and India.—New Remedies,
May, 1879. 
Henry C. Lea's Son  &  Co.'s Publications—(Chemistry).
11
 TILOXAM (C. L.),
         Professor of Chemixtry in King's College. London.

   CHEMISTRY,  INORGANIC  AND ORGANIC.   From the  Second Lor.-
       don Edition.  In one very handsome octavo volume, of 700 pages, with about 300 illus
       trations.  Cloth, $4 00;  leather, $5 00.  (Lately Issued.)
  We have in this work a completeand most excel-
lent text-book for the use of schools, and can heart-
ily recommend it assuch.—Boston Med.and Surg.
Journ., May 28, 1S74.
  The above is the title of a work which we can most
conscientiously recommend to students of chemis-
try.  It is as easy as a work on chemistry could be
made, at the same time that it presentsa full account
of that science as it now stands. We have spoken
of the work as admirably adapted to the wants of
students ; it is quite as well suited to the require-
ments  of practitioners  who wish  to review their
ehemistry, or have occasion to refresh their memo-
ries ou any point relating to it.  In a word, it is a
book to be read by all who wish to know  what is
thechemistry ofthe presentday.—American Prac
titioner. Nov. 1873.
  It would be difficult for a practical  chemist and
teacher to find any material fault with  this most ad-
mirable treatise  The author has given us almost a
c} clopaedia within the limits of a convenient volume,
and has done so without penning the  useless para-
graphs too commonly making up a great part of the
bulk of many cumbrous works.  The progressive
scientist is not disappointed when he  looks for the
record of  new and valuable processes and discover-
ies, while the cautious conservative does not find its
pages monopolized by uncertain theories and specu-
lations.   A peculiar point of excellence is the crys-
tallized form  of expression in which great truths are
expressed in very short paragraphs. One is surprised
at the brief space allotted to an important topic, and
yet, after  reading it, he feels that little, if any more
should have beeu said.  Altogether, it is seldom yo i
see a text-book so nearly faultless. — Cincinnati
Lancet Nov. 1873.
O
 LO WES (FRANK), D.Sc. London.
      Senior Science- Master at the High School, Newcastle-under Lyme, etc.
AN  ELEMENTARY TREATISE ON  PRACTIC AL CHEMISTRY
    AND  QUALITATIVE  INORGANIC ANALYSIS.   Specially adapted for Use in the
    Laboratories of Schools and Colleges and by Beginners.  From the Second and Revised
    English Edition, with about fifty illustrations on wood.   In one very handsome royal
    12mo. volume of 372 pages :  cloth  $2 50.  (Now Ready.)
  It is short, concise, and eminently practical. We
therefore heartily commend it to sf uden's, and e=pe-
eially to those who are obliged to dispense with a
master.  Of course  a teacher is in every way desi-
rable, but a good degree of technical skill and prac-
tical knowledge can  be  attained with no  other
instructor than the very valuable  handbook now
under consideration.—St Louis Clin. Record, Oct.
1877.
  The work is so written and arranged that it can be
comprehended by the student without a teacher, aud
the descriptions and directions forthe various work
are so simple, and yet concise, as to be interesting
and intelligible.  The work is unincumbered with
theoretical  deductionSf»dealing wholly  with the
practical matter, which it is the a>m of this compre-
hensive text book to impart.  The accuracy ofthe
analytical methods  are vouched for from the fact
that they have all been worked through  by tbe
author  and the  members  of his class, from the
printed text. We can heartily recommend the work
to the student of chemistry as being a reliable and
comprehensive one.—Druggists'  Advertiser, Oct.
15, 1877.
KNlPP'S TECHNOLOGY; or Chemistry Applied to
 the Arts,  and to Manufactures   With American
 additions by Prof. Walter R. Johnsok.  In two
very handsome octavo volumes, with 500 wood
engravings,cloth, $6 00.
OARRISH (EDWARD),
       Late Professor of Materia Medica in the Philadelphia College of Pharmacy.
 A TREATISE  ON PHARMACY.   Designed as a Text-Book for the
    Student, and as a Guide for the Physician and Pharmaceutist.  With many Formulae an 1
    Prescriptions.   Fourth Edition, thoroughly revised,  by Thomas S. Wiegand.  In one
    handsome octavo volume of 977 pages, with 280 illustrations ; cloth,  $5 50 ; leather, $6 50.
    (Lately Issued.)
  Of Dr  Parrish's great work on pharmacy it only
 remains to be said that the editor has accomplished
 hi* work so well as to maintain, in this fourth edi-
 tion, the high standard of excellence  which it had
 attai'nedin previous editions, under tbeeditorship of
 Its accomplished author.  This has not been accom
 p'ished without much labor,and many additions and
 improvements,  involving changes in  the arrange-
 mentof the several parts ofthe work, and the addi-
 tion of much new matter.  With tbe modifications
 thus efTecteditconstitutes.as nowpresented,acorn
 pendium ofthe  science and art indispensable to the
 pharmacist,  and of  the  utmost value to_ every
 practitioner  of  medicine  desirous  of  familiarizing
 himself with the pharmaceutical preparation ofthe
 articles which  he prescribe* for his patients.—Chi-
 cago Med. Journ., July, 1874.
  The work is eminently practical, and has the rare
 merit of beingreadableand interesting, while it pre-
serves astrictly scientiflccharacter  The whole work
reflects the greatest credit on author, editor and pub
lisher  [twill convey some idea ofthe liberality which
J K been bestowed upon its production when we meu-
rn thatthereare no less than 280carefully executed
Illustrations. In conclusion, we heartily recommend
the work, not only to pharmacists, but also to the
multitude of medical practitioners whi are obliged
to compound their own medicines. It vt ill ever hold
an honored place on our own bookshwlves.—Dublin
Med. Press and Circular, Aug. 12, 1874.
  We expressed our opinion of a former edition in
terms of unqualified praise, and we are in no mood
to detract from that opinion in reference to the pre-
sent edition, the preparation of which has fallen into
competent hands It is a book with which no pharma-
cist can dispense, and from which no physician can
fail to derive much information of value to him in
practice.—Pacific Med  and Surg. Journ.,  June,'74.

  Perhaps one, if not the most important book upon
pharmacy which has appeared in the English lan-
guage has emanated from the transatlantic press.
" Parrish's Pharmacy" is a well-known work on Ibis
side ofthe water, and the factshows us that a really
useful work neverbecomes merely local in its fame.
Thanks to the j udicious ed iting of Mr. Wiegand, the
posthumous edition of "Parrish" has been saved to
the public with all the mature experience  of its au-
thor. anH perhaps none th» worse for a dash of new
blood.—Lond. Pharm. Journal, Oct. 17,1874. 
12  Henry C. Lea's Son <fe Co.'s Publications—(Mat. Med. and Thcrap.).


 UIARQUHARSOX (ROBERT), M.D.,
        Lecturer on Materia Medica at St. Mary's Hospital Mulicnl School.
  A  GUIDE TO THERAPEUTICS  AND  MATERIA MEDICA.   Pe-
      c^nd American edition, revised by the Author.   Enlarged and adapted to the U. S.
      Pharmacopoeia.  By Frank Woodbury, M.D.  In one neat roj al 12mo. volume of 498
      pages : cloth, $2 25.   (Just Ready.)
  The appearance of a new edition of this conve-
nient and handy book in less than two years may
certainly be taken as  an indication  of its useful
ness.  Its convenient  arrangemen', and  its  terse-
ness, and, at the same  time, com >leteness of the
information given, make it a handy book of refer-
ence.—Am.  Journ. of Pharmaiy, June, 1879.
  This work contains in moderate compass such
well-digested  facts conceruirg the  pbysiolcg "al
and therapeutical action of ren edies as are reason-
ably es'ablished up to the present time.  By a con-
venient arrangement  the conespondirg  effects of
each article in health  and disease are presented in
parallel cilumns, not only  rendering reference
easier, but also impressing the facts more strongly
upon the mind of the  reader.  The book  has been
adapted to the wants of the American  student, and
  It is unnecessary to  do much more  than to an-
nounce the appearance  of-the fourth edition of this
well known aud  exc»llent work.—Brit, and For.
Med.-Ohir. Review, Oct lt>75.
  For all who desire a complete work on therapeutics
and materia medica for reference, in cases involving
medico-legal questions, as well as  for information
coucerning remedial agents, Dr. Stille"s is "par ex-
cellence" the work. Tbe work being out of print, by
the exhaustion of former editions, the author has laid
the profession under renewed obligations, by the
careful revision, importantadditions, and timely re
issuing a work not exactly supplemented by any
other in the English language, if in any language.
The mechanical execution handsomely sustains the
well-known skill and good taste of the publisher.—
St. Louis Med. and Surg. Journal, Dec 1874.
  From the publication of the first edition '' Still^'s
Therapeutics" has been one of the classics; its ab-
sence from our libraries would create a vacuum
which could be filled by no other work in the lan-
guage, and its presence supplies, in the t wo volumes
  To the druggist a good formulary is simply indis-
pensable, and perhaps no formulary has been more
extensively used than the well-known work before
us. Many physicians have toofflciate, also, as drug
g;8ts.  This is true especially of the country physi«
cian, and a work which shall teach him the means
by which to administer or combine his remedies in
the most efficacious and pleasant  manner,  will al-
ways hold its place upon his shelf  A formulary of
this kind is of benefit also to the city physician in
largest practice.—Cincinnati Olinic, Feb. 21. 1874.
CHRISTISON'S DISPENSATORY. With copious ad.
  ditions, and 213 large wood engravings  By  R.
  Eolesfiei.d Griffith, M.D.   One vol. 8vo., pp.
  1000, cloth.  $4 00.
-  copious notes have been introduced, embodying the
r  latest revision of t' e Pharmacopoeia, together wi h
  the antid  tes to the more prominent poisons, and
-  such of the newer remedial agents as seemed neces-
i  sary '.o the completeness of the  work.  Tables of
-  weights and measures, and a good alphabetical in-
  dex  end the  volume.—Druggists' Circular and
,  Chemical Gazette, June, 1879.
1    It  is a pleasure to think that  the rapidity with
-  which a second  edition Is demanded may be taken
-  as an indication  that the sense of appreciation of tbe
f  value of reliable information regarding the use of
l  remedies i- not entirely overwhelmed in the cultiva-
3  tion of pathological studies, characteristic of the pre-
r  sent day.  This  work certainly merits the success it
i  has so quickly achieved.— New Remedies, July, '79.
-  of the present edition, a whole cyclopaedia of thera-
*  peutics.—Chicago Medical Journal, Feb. 1875.
    The rapid exhaustion of three editions and the uni-
  versal favor with which the work has been received
s  by the medical profession, are sufficient proof of its
;  excellence as a repertory of practical and useful in-
i  formation for the physician.   The edition before ue
-  fully sustains this verdict,asthe work hasbeen care-
f  fully revised and in some portions rewritten, briug-
J  ing it up to the present time by the,admission of
e  chloral and crotonchloral, nitrite of amyl, bichlo-
  ride of methylene,  metbylic ether, lithium com-
7  pounds,  gelseminum,  and  other remedies.—Am.
.  Journ. of Pharmacy, Feb. 1875.
e    We can hardly admit that it has a rival  in the
"  multitude of its citations and the fulness of its re-
  search intocliuical histories, and we must assign it
s  a  place in tbe physician's library; not, indeed, as
-  fully representing the present state of knowledge in
i  pharmacodynamics, but as by far the most complete
-  treatise upon the clinical and practical side of the
s  qnestion.—BostonMtd. and. Surg. Journal, Nov. 5,
  1874.
i-   A  more complete formulary than it is in its pres-
e ent form the pharmacist or physician could hardly
e desire.  To the first some such work is indlspensa-
;  ble, and it is hardly less essential to the practitioner
i« who compounds his own medicines.  Much of what
s is contained in the introduction ought to be com-
n mitted to memory by every student of medicine.
I- As a help to physicians it will be found invaluable,
>f and  doubtless will make its way into  libraries not
n already supplied with a standard work ofthe kind.
1. — The American Practitioner, Louisville, July, '74.
CARPENTER'S  PRIZE  ESSAY  ON THE  U8E OF
  Alcoholic Liquors in Health and Disease. New
  edition, with a Preface by D. F. Comsie. M.D., and
  explanations of scientific words. In oneneat!2mo.
  volume, pp. 178, cloth. 60 cents.
1TILLE (ALFRED), M. D.,
      Professor of Theory and Practice of Medicine in the University of Penna.
THERAPEUTICS AND MATERIA  MEDICA; a Systematic Treatise
    on the Action and Uses of Medicinal Agents,  including their Description and History,
    Fourth edition, revised and enlarged. In two large and handsome 8vo. vols, of about 2000
    pages.  Cloth, $10; leather, $12.   (Lately Issued.)
RIFFITH (ROBERT E.), M.D.

A UNIVERSAL FORMULARY, Containing the Methods of Prepar-
  ing and Administering Officinal and other Medicines. The whole adapted to Phyeiciars and
  Pharmaceutists. Third edition*, thoroughly revised, with numerous additions, dj John M.
  Maisch, Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large
  andhandsome octavo volume of about 800pp., cl., $450; leather, $5 50.  (Lately Issued.) 
Henry C. Lea's Son & Co.'s Publications—(Mat. Med. and Therap.).  13
STILLE (ALFRED), M.D., LL.D.,and \fAlSCH (JOHN M.).  Ph.D.,
*-*   Prof, of Theory and Practice of Medicine     J-U-   Pr„f. of Mat  Med. and  Bot in  Phila
and of Clinical Med. in Univ. of Pa.
Coll. Pharmacy. Secy tjothe American
Pharmaceutical Axwciation.
  THE NATIONAL  DISPENSATORY:  Containing the Natural History,
      Chemistry,  Pharmacy, Actions  and Uses of Medicines, including those  recognized  in
      the Pharmacopoeias of the United Stutes, Great Britain, and Germany, with',numer-
      ous references to the French Codex.  Second edition, thoroughly revised, with numerous
      additions.  In  one very handsome octavo volume of 1692  pages,with  239 illustrations.
      Extra cloth, $6  75 ; leather, raised bands, $7 50   (Now Ready )
                             Prbface to the Second Edition.
  The demand which has exhaus-ed in a few months an unusually large edition of the National
Dispensatory is doubly gratifying to the authors, as showing that t ley were correct in thinking
that the want of such a work was felt by the  medical and pharmaceutical-professions, and that
their efforts to  supply that want have been acceptable.   This appreciation of their labors has
stimulated them in the revision to render the volume more  worthy of the very marked  fator
with which it has been received.  The first edition of a work of fuch magnitude must necessarily
be more or less imperfect; and though but litt'e that  is new and  important has been  brought
to light in  the short interval since its publication, yet the length of time during which it w:is
passing through the press rendered  the earlier portions more in  arrears than the la er.   The
opportunity for a revision  has enabled  th« authors to scrutinize  the work  as a whole, and  to,
introduce alterations  and additions whereve ■ there has seemed  to be occasion for improve-
ment or greater completeness.  The principal changes to be noted are  the introduction of seve-
ral drues under separate headings,  and of a .large number of drugs,  chemicals, and pharma-
ceutical preparations  classified  as allied drugs and preparations under the  heading of more
important or better known articles: these additions comprise in part nearly the entire German
Pharmacopoeia  and numerous articles from the French Codex.   All new investigations which
came to the authors1 notice up to the time of publication have  received due consideration.
   The series of illustrations has undergone a corresponding thorough revision.  A number have
been added, and still more have been substituted for such as were deemed  less satisfactory.
   Thf  new matter  embraced in the text is equal to nearly one  h jndred  pages of the first edition.
Considerable as are these changes as a whole, they have been accommodated by an enlargement
of the page without increasing unduly the size of the volume.
   While numerous additions have been mar'e to the sections which relate to  the physiological
action of medicines and  their use in the treatment of disease, great  care has been taken  to
make them as  concise as was possible without rendering them incomplete or obscure.   The
doses have been expressed in  the terms both of troy weight and of the metrical  system, for the
purpose of mak;ng those who  employ the Dispensatory familiar w.th the latter,  and paving the
way for its introduction into general use.
   The Therapeutical Index has been extended by about 2250 new references, making the total
number in  the present edition ab ut 6000.
   The articles  there enumerated as remedies for particular diseases are not only those which,
in the authors'  opinion, are curative, or even beneficial, but those also which have at any time
been employed on the ground of popular belief or professional  authority.  It is  often  of  as
much consequence to be acquainted with the worthlessness of certain  medicines or with the
narrow limits of their power, as to know the well attested virtues of others and the conditions
under which they  are  displayed.  An additional value posse  sed  by such an Index is, that it
contains the elements of a natural classification of medicines, f >unded upon an analysis of the
results of experience,  which is the only safe  guide in the treatment of disease.
  This  evidence  of success,  seldom  paralleled,
shows clearly how well the authors have met the
existing needs of the pharmaceutical and  medical
professions. Gratifying as it must be to them, they
have embraced the  opportunity offered for a thor-
ough revision of  the whole work, striving to era-
brace within it all that might have been omitted in
the former edition, aud all that has newly appeared
of sufficient importance  during the time of its col-
laboration, and the short interval elapsed since the
previous publication.  After hiving gone carefnlly
through the volume  we must admit that the authors
have labored faithfully, and with success, in main-
taining the high character of their work as a com-
pendium  meeting the requirements of  the day, to
which one can safely turn in quest of the latest in-
formation concerning everything worthy of notice in
connection with Pharmacy, Materia Medica, and
Therapeutics.—Am.  Jour, of Pharmacy, Nov. 1879.
  It is with great pleasure that we announce to our
readers the appearance  of a second edition  of the
National Dispensatory.  The total exhaustion ofthe
first edition in the short ►pace of six months, is  a
sufficient testimony to the value placed upon  the
work by the profession.  It appears that the rapid
  .  ofthe first edition must have induced both the
editors and the publisher to make preparations for
    w edition  immediately after the first had been
* ae  ,  f0T we find  a large amount of new matter
 <?ded'and a good deal of the previous text altered
*  1 improved, which proves that the authors do not
intend to let the grass grow under their feet, but to
keep the work up to the time.—New Remedies, Nov.
1879.

  This is a gr-at work by two of the ablest writers on
materia  medica in America  The authors have pro-
duced a work which, for accuracy and comprehen.-ivt--
ness, is unsurpassed by any work on th'» subject. Theie
is no book in the English language nhich contains so
much valuable information on the various articles of
the materia medica.  The work has cost the authors
ye*rs of laborious study, but they have  succeeded in
producing a dispensatory which \a not only national,
but will  be a lasting  memorial of the learning and
ability of the  authors who produced it.—Edinburgh
Medical Journal, Nov. 1879.

  k new edition of this great  work, only a few
mon'hs after tbe first, takes us by surprise   It in-
dicates  the high  appreciation of its value on the
part of.  physicians and  pharmacists,  by  whiph a
Urge edition has been so soon exhausted.  The pre-
sent is uot merely a reprint but a  revision, with
important additions and modifications,  requiring 100
pages of new matier, and an index increased by
22o0 references.  The doses are  stated in both the
ordinary and me'ric terms.  All the more important
material ofthe German and French Pharmacopoeias
is embodied.   It is by far more international or uni-
versal than any other book of the kind in our lan-
guage and more comprehensive in  every sense.—
Pacific  Med. and Surg. Jown., Oct. 1879. 
14     Henry  C. Lea's Son <fc Co.'s Publications—(Pathology, <bc).
PORNIL (V.),
V>    Prof, in the Fa
                               AND        ft AN VIER  (L.).
       Prof, inthe Faculty of Med , I'nris      -*-^    Prof in the Collrgeof France.

   MANUAL  OF  PATHOLOG.CAL HISTOLOGY.   Translated, with
      Notes and Additions, by E. 0. Shakbspbare, M.D , Pathologist and Ophthalniio Surgeon
      to Philada  Hospital, Lecturer on Refraction and Operative Ophthalmic  Surgery in Uni''.
      of Penna.,  and by Henry C.  S  mf.s  M D., Demonstrat  r of Pathological  Histology in
      the  Univ. of Pa.   In one very  handsome  octavo  volume  of over  700  pages, with over
      350 illustrations  Cloth, $5 50; leather, $6 50.  (Just Ready.)
   The work of Cornil and Ran  ier is so well known  as a lucid and accurate text book on its
important subject that no apology is needed in presenting a translation of it  to the American
profess on.  It is on'y necessary to  say that the  lahors of D-s. Shakespeare  and Simes  ha-e
been by no means confined to the task  of rendering tbe work into English.  As it appeared in
France, in successive potions,  betwten 1868 and  1876, a part of it, at least, w;is  fomewh  t in
arrears ofthe  p  esent state of scien"e, while the diffuseness of other portions ren 'er. d conden-
sation  desirable  The translators have, therefore, sought to  bring the work up to the day,
and, at the same time, to reduce it in  size, a.  far as practicable, without i nrniring its c  m-
pleteness   These  changes will  be found  throughout  the volume, the most extensive being in
the sections devoted to Sarcoma, Carcinma, Tuberculosis, the  Bloodvessels, the M.immse, and
the classification of turn  >rs   Corresponding modifications have been made in  the very exten
?ive and beautiful series  of illustrations, and every care  has been taken in  the typographical
executi n to render it one of the most attractive volumes which  have issued from the American
press.
  The translators have done their work very well
indeed, rendering it into smooth and excellent Eng-
lish, and in their selection  of new material they
have  iu tbe main used good dii-crimination. We
heartily commend tbe book as one ofthe best works
on the subject.—Boston Med. and Surg. Journal,
March 11, 1880
  This work, in the original,  hag  for ye<rs past
occupied a prominent place in the library of French
p tthologists, as  we should naturally be led  to be
tieve from the reputation of ihe  distinguished an-
th >rs   Now ,hat it has been  presented to the Eng-
li h student for t> e first time, it will be perused
with unusual interest.  The illustrations are  by no
means the least valuable part of  the work.   Indis-
pensable as they are to any work of this nature,
in the work  before us the artist  has succeeded in
producing cuts witch will prove unusually valuable
to the reader. The translation is well  done, and
g'ves evidence throughout the volume that it was
m ide by a person thoroughly conve^ant with the
subject.—N.  «-. Med. Gazette, Feb 28, 18SO.
  This  will  be  found  an exceedingly interesting
and valuable work by all who are engsged in the
study of or take an interest in, histology—normal
or morbid.  The material which was  utilized in its
preparation was delived from autopsies aud opera-
tions in the hospitals  of Paris, which are so very
rich in  it    No hiug  was taken for  granted,  but
everything verified by microscopical  investigation
by the authors themselves in their own laboratories
assisted by their pupils.  Ae an aid to  microscopies
in heir investigations it will be f'uud invaluable—
in fact,  the vary best wiih wbich we ara acquainted.
—Cincinnati Med News, February, 1880.
  We can conscientiously recommend ihis volume
to -he profession.—Maryland Jlf d. Journal, March,
1880.
F
    EN WICK (SAMUEL),  M.D.,
         Assistant Phyxician to the London Hospital.

   THE STUDENT'S GUIDE  TO  MEDICAL DIAGNOSIS.   From the
      Third Revised and  Enlarged English Edition   With  eighty-four illustrations on wood.
      In one very handsome volume, royal 12mo., cloth, $2 25.  (Just Issued.)

 fIREEN  (T. HENRY), M.D.,
 *•"      Lecturer on Pathology and Morbid Anatomy at Charing-Oross Hospital Medical School, etc.

    PATHOLOGY  AND  MORBID ANATOMY.  Third American,from
        the Fourth and Enlarged and Revised English Edition.  In  one very handsome octavo
        volume of 332 pages, with 132 illustrations;  cloth, $2 25.   (Just Ready.)
  This is unquestionably one of the best manuals on
the subject of pathology and morbid anatomy that
can be placed in the student's hands, and  we are
glad to see it kept up to the times by new editions.
Each edition is carefully revi-ed by the author, with
tbe view  of making it include the most recent ad-
vances in pathology, and of omitting whatever may
have become obsolete.—N. Y. Med. Jour., Feb. 1879
  The treatise of Dr. Green is compact, clearly ex-
press d, up to the times, and popular as a text-book,
both in England and America. The  cats are suffi-
ciently numerous, and usual y well made.  In tbe
pe>ent edition, such new ma: ter has been added as
was necessary to embrace the later results iu patho-
logical research. No doubt it will continue to enjoy
the favor it has received  at the hands of the profes-
sion.— Med and Surg. Reporter, Feb. 1,1879.
  For practical, ordinary daily u«e, this is undoubt-
edly  the best treatise that is offered to student* of
pathology and in irbid anatomy.—Cincinnati Lan-
cet and Clinic, Feb. 8, 1879.
GLUGE'S ATLAS of PATHOLOGICAL HISTOLOGY
  Translated, with Notes and Additions, by Joseph
  Leidt, M. D.  In one volume, very large imperial
  quarto, with 320 copper-plate figures, plain and
  colored, cloth. $4 00.

PAVY'S TREATISE ON THE FUNCTION OF DI-
  GESTION:  its Disoiders  and  their Treatment.
  From the second London edition  In one hand-
  some volume, small octavo, cloth, $2 00.

LA ROCHE ON YELLOW FEVER,considered in Its
  Historical,  Pathological, Etiological, and Thera-
  peutical Relations.  In two large and handsome
  octavo volumes of nearly 1500 pp , cloth.  $7 00.
HOLLAND'S  MEDICAL  NOTES  AND  REFLEC-
  tfoicb   1 vol. 8vo., pp. ">on. cloth,  %% so
BARLOW'S  MANUAL  OF  THE PRACTICE Ol
  H>?DICINE.  With Additions  by D. F. Con»m
  M D.  1 vol. 8vo., pp 600, cloth.  $2 SO.
TODD'SCLINICALLECTURESos CERTAIN ACT7T1
  Diseases.  In one neat octavo volume, of 320 pp.,
  cloth.  *2 fin
STURGES'S INTRODUCTION TO THE STUDY OF
  CLINICAL MEDICINE.  Being a Guide tothe In-
  vestigation of  Disease.  In one handsome 12mo.
  volume, cloth, $1 23.  (Lately Issued.)
STOKES' LECTURES ON FEVER  Edited by Johii
  William Moorb, M. D., Assistant Physician to the
  Cork Street Fever Hospital.  In one  neat 8vo.
  volume, cloth, *2 00.  (Just Issued )
THE CYCLOPAEDIA OF PRACTICAL MEDICINE:
  comprising Treatises on the Nature and Treatment
  of Diseases, Materia Medica and Therapeutics, Dis-
  eases of Women and  Children Medical Jurispru-
  dence, etc etc.  By Dunolisom, FoBBF.8, Twekdiii,
  and Co.nollt.   In four large super royal octavo
  volume*, of :V2/H double-columned p 'ge-, strongly
  and ^jflj""1* K"""'t;" JjQjijJ^rijji^mini*'' 
Henry  C. Lea's Son & Co.'s Publications—(Practice of Medicine).  15
&LINT (A USTIN), M.D.,
       Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. Y.

  A  TREATISE  ON  THE   PRINCIPLES AND  PRACTICE  OF
     MEDICINE ;  designed for the use of Students and Practitioners of Medicine.   Fourth
     edition, revised and enlarged.  In one large and closely printed octavo volume of about
     1100 pp.; cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00.   (Lately
     Issued.)
 This excellent treatise on medicine has acquired
for itself in the United States a reputation similarto
thatenioyed in England by the admirable lectures
of Sir Thomas Watson.  We have referred to many
of the most important chapters, and fiud the revi-
sion spoken of in the preface is a geuuine one, and
that the author has very fairly brought up his matter
to the level ofthe knowledge of tbe present day. The
work has this great recommendation, that it is in one
volume, and therefore will not be so terrifying to the
student as the bulky volumes which several of our
English text-books of medicine have developed into.
— British and Foreign Med.-Chir. Rev., Jan. 1875
 It isof course unnecessary tointroduce oreulogir.e
this aow standard  treatise.  The  present edition
has been enlarged and revised to bring it up to the
author's present level of experience and  reading
His own clinical studies and the latest contribu-
tions to m«dical literature both in this country a.Ld
in Europe, have received careful attention, so that
some  portions  have been  entirely rewritten, aDd
About seventy pages of new matter have been  ad-
ded. — Ctiicrgo M*d  Jour.,  June, 1873.

  Has never been surpassed as a text-book for stu-
dents and a book of ready reference for practition-
ers  The force of its logic, its simple and practical
teachings, have left  it without a rival in the field.
N. Y.—Med Record, Sept. 15, 1874.

  It is given to very few men to tread in the steps of
Austin Flint, whose single volume on mediciue,
though here and there defective, is a masterpiece of
lucid condensation and of general grasp of an enor-
mously wide subject —Lond. Practitioner,Dec.'7.'.
B
F THE SAME AUTHOR.
  CLINICAL MEDICINE;  a  Systematic  Treatise  on  the  Diagnosis
   and Treatment of Diseases.   Designed for Students nnd Practitioners of Medicine.   In
   one large and handsome octavo volume of 795  pages; cloth, $4 50 ;  leather, $5 iO.
   (Now Ready )
  It is here that the skill and learnirg of tbe great
clinician are displayed   He has given us a store-
house of medical knowledge, excellent for the stu-
dent, convenient for the practitioner, the lesult of a
long life ofthe moat faithful clinical work, collect-
ed by an energy as vlgi'ant pnd systematic as un-
tiring, and weighed by  a judgment  no less clear
than  his observation  is close.—Archives  of Medi-
cine, Dec. U79
  The author  of the above work  has anticipated a
want long felt by those for whom it was especially
written—the clinical student during  his pupilage,
and the busy  practitioner.  He has given to the
nudical profession a  very necessiry and  useful
work, complete in detail, accurate in observation,
br ef in scatement.—St. Louis Courier  of Med.,
Oet  1879.
  There is every reason to believe that this book
will  be well  received.  The active practitioner is
frequently in need of some work that will enable
him  to obtain Information in  the diagnosis and
treatment of cases with  comparatively little labor.
Dr. Flint has tbe faculty of expressing himself
clearly, and at the same time  so concisely as to
eoab;e the searcher to traver.-e the entire ground
of his search, and at the same time obtain all that
is es-entiil, wi hout plodding through an intermi-
nab'e space.—N. Y. Med. Jour.. Nov. 1879
  The eminent teacher who has writteu the volnma
under consi ieration h s recognized the needs of
the  American profession, and th. result  is  all that
we could wish.  The s'yle in which it i  writ en is
peculiarly the author's; it is clear and forcibU, and
marked by those characteristics which  have ren-
dered him one of the best writers and teachers this
country has ever produced.  We have not space for
so full a confederation  of this remarkable work as
we would desire.—S. Louis Clin. Record, Oct. 1879.
  It is venturing little to »ay that there are few men
so well fitted as Dr Flint to impart information on
these last mentioned subj-tcts.aud the present work
is a timely one a* relates both to the author's ca-
pacity to  undertake it and the Deed for it as an
accompaniment to the multitude now  issued, in
which tlie subject of treatmeut is but li.tle consid-
ered—New Remedies,  Aov. 1879.
Df THE SAME AUTHOR.
     ESSAYS  OX  CONSERVATIVE  MEDICINE   AND  KINDRED
     TOPICS.   In one very handsome royal l2rao. volume.  Cloth, $1 38.  (Just Iss >ed.)
 VTTA TSON (THOMAS), M.D., Sfc.
 nLECTURES   ON  THE   PRINCIPLES  AND  PRACTICE  OF
      PHYSIC   Delivered at King's College, London.  A new American, from the Fifth re-
      vised and enlarged English edition.  Edited, with additions, and several hundred illustra-
      tions by Hbnby HARTBHoaHB, M.D., Professor of Hygiene  in the University of Penn-
      sylvania.   In two large and handsome 8vo. vols.  Cloth, $9 00 ; leather, $11 0.0.  (Lately
      Published.)____________________

 EJARTSHORNE (HENRY), M.D.,
_TZ      Professor of Hygiene in the University of Pennsylvania
  ESSENTIALS  OF  THE PRINCIPLES  AND PRACTICE OF METI-
      CiNE.  A. handy-book forStudents and Practitioners.  Fourth edition,  revised and im-
      proved- «Witb about one hundred illustrations.  In one handsome royal 12nio. volume,
      of about 550  pages, cloth, $2 63 ; half bound, $2 S8.  (Lately Issued.)
D
AVIS (NATHAN S.\
     Prof. "/ PrinHples and Practice of Medicine, etc.. in Chicago Med. College.
CLINICAL LECTURES ON VARIOUS  IMPORTANT DISEASES;
  being a collection of the Clinical Lectures delivered in the Medical Wards of Mercy Hos-
  pital, Chicago   Edited by Frank H. Davis, M  D   Second edition,  enlarged.  In one
  handsome royal 12mo.  volume.  Cloth, $1 75.  (Lately Issued.) 
16   Henry C. Lea's Sox &  Co.'s  Publications—(Practice of Medicine).
 DRISTO WE (JOHN SYER), M.D , FR.C.P.,
J-J      Physician and Joint Lecturer on Medicine, St Thomax't Hospital.

   A  TREATISE  ON  THE   PRACTICE  OF  MEDICINE.   Second
       American edition, revised by the Author.  Edi'ed, with Additions, by Jamks II. Hutch-
       inson, M .D., Physician to the Pennn. Hospital.  In one  handsome octavo volume of
       nearly 1200 pages.  With illustrations.  Cloth, $5 50 ;  leather, $C> 50.  (Just Reidy )

   In  reprinting  this work  from the recent  thoroughly revised second English  edition,  the
 author has made such corrections as seemed  ad^ isable, and has  added n chapter on Insanity.
 The Editor has likewise revised his additions in the  lipht of the  latest  experience, nnd the
 work is presented as r« fleeting in  every way the most modern aspect of medicnl science, and
 as fully  entit'ed  ti  maintain  the  distinguished  position  accorded to it on  bo'h sides  of the
 Atlantic  as an au'horitntive  guide  for the student, and a complete though conc^e took of
 reference for the practitioner.  Notwithstanding the  author s  earnest effort  at  compression,
 the additions have amounted to nb  ut  one-tenth of tbe previous edition : but by the use of an
 enlarged  page these have been accommodated without increasing the size of the volume, while
 a reduction in  the price renders it one ofthe cheapest works acce sible to the  profession.
   A new edition of this well-known woik which increased emphasis, repeat concerning this: "Every
 has- had the advantage of careful revision not only page is cha r; cterized by the r.tteratice* of a thotight-
 by its author  but also by Dr  Hitchinson,  »han \ ful man. W lat has been said, has been well said,
 whom there is  no one in this country better fitted J and the book is  a fair reflex of all that is certainly
 for the ta>k__Phila. Med. Tim's, Jan  3, 1880     j kn-wn  on  the  sub ects  considered."—Ohit  Med.
  The  popularity of the work  depends no doubt, Recorder, J  n. 7, 1880.
 upon  the  clear  and incisive  way  in which  it is!   This is not only one of the latest and roo«f  com
 written, and the attention to details likely to occur
 in practice, rather than the discussion ot questions
 of theory.—New Remedies, Jan 1SS0.
   What we said of  the first edition, we can, with
prfhensive works out  on  the  general subject  of
Theory and Practice of  Medicine, but it is  nnques-
t;onably one of the best.—So  Med. Practitv ner,
Jan 7 880.
 WOODBURY (FRANK),  M.D.,
        Phyxivian to the German Hospital, Philadelphia, late Chief Assist, to Med. Clinic, Jeff. College
          Hospital, etc.
   A   HANDBOOK  OF  THE  PRINCIPLES  AND  PRACTICE  OF
      Medicine ; for the use of Students and Practitioners.  Based upon  Husband's Handbook
      of Practice.   In one neat volume, royal 12mo.   (In Press.)

 TJABERSHON  (S.  O.). M.D.
J--L      Senior Physician to and late Lecturer on the Principles and Practice of Medicine at Guy's
           Hospital, etc.

   ON THE. DISEASES OF  THE ABDOMEN,  COMPRISING THOSE
        of the Stomach, and other parts of the Alimentary Canal, (Esophagus, Caecum, Intes-
        tines, and Peritoneum.  Second American, from the third enlarged and revised  Eng-
        lish edition.  With illustrations.  In one handsome octavo volume of over 500 pages.
        Cloth, $3  50.  (Now Ready.)
  We can do very little to add to the favorable re-
ception which has already been given by the medi-
cal press of the world to this well known treatise
We commend to all practitioners a careful perusal
of Dr  Habershon's work More especially, wedraw
attention to the number of intestinal diseases re-
corded in its pages, cases of  extreme interest clini-
cally and pathologically. This careful record shows
that the work is no compilation but a careful exposi-
tion of the author's personal experience.—Canadian
Med. and Surg. Journ., May, 1879.

  This valuable treatise on diseases  of the stomach
and ahdon  en has been out of print for several years,
and is therefore not so well known to the profession
as it  deserves to be.  It will be found a cyclopaedia
of information, systematically arranged, on all dis-
eases ofthe alimentary tract, from the month to the
rectum  A fair proportion of each chapter is devot-
ed to symptoms, pathology, and therapeutics.  The
present edition is fuller than former ones in many
particulars, and has been thoroughly revised and
amended by the author.  Several new chapters havt
been added, bringing the work  fully up to the times,
and roabiDgit a volume of interest to the practitioner
iu every field of medicine and surgery.  Perverted
nutrition is in some form associated with all diseases
we have to  combat, and we need  all the light that
can be obtained on a subject so broad and general.
Dr  Habershon's work is one that every practitioner
should read and study lor himself.—N. Y. Med.
Journ., April, 1879.
F
  'OTHERG1LL (J.  MILNER), M.D. Edin., M.R.C.P. Lnvd.,
       Asst. Phys. to the West hond Hasp.; Asst. Phys. to the City of Land. Hoxp., etc.

 THE  PRACTITIONER'S  HANDBOOK OF TREATMENT ;  Or, the
     Principles of Therapeutics.   In  one very neat octavo volume of about 550 pages :  cloth,
     $4 00.   (Now Ready.)
Our friends will find this a very readable book; and , he knew how suggestive and helpful it would be to
that it sheds light upon every theme it touches,causing
the practitioner to feel more certain of his diagnosis in
difficult cases.  We confidently commend the work to
him.—Si. Louis Med. and Surg. Journ , April, 1877
  We heartily commend his book to the medical student
as an honest and intelligent guide through the mazes at
our readers as one worthy of careful perusal. It lights , therapeutics, and assure the practitioner who has grown
the way over obscure and difficult passes in medical '
practice.  The chapter on the circulationof the blood
is the most exbaustiveand instructive to be found. It
is a book every practitioner needs, and would have, if
gray in the harness that he will derrve pleasure and in-
struction from its perusal   Valuable suggestions and
material for thought abound throughout.— Boston Med.
and Surg  Journal, Mar 8, 1877.
T>Y THE SAME AUTHOR.
    THE  ANTAGONISM OF THERAPEUTIC  AGENTS, AND WHAT
     IT TEACHES. Being the.Fothergillian Prize Essay for 1878.  In one neat volume, royal
     12mo- of 156 pages; cloth, $1 00.  (Just Ready.) 
Henry C. Lea's  Son & Co.'s Publications—(Practice of Medicine).  It
 REYNOLDS (J. RUSSELL).  M.D.,
        Prof, ofthe Principles and Practice of Medicine in Univ. College, London.
   A SYSTEM OF  MEDICINE  with Notkr  and  A_ddtttons by HrnrtH^pts-
       horne, M D., late  Professor of Hygiene in the University of Penna.  In three large and
       handsome octavo volumes, containing about 3000 closely printed double-columned pages,
       with numerous illustrations.   Sold only by subscription.  Price per vol , in cloth, $5.00 ;
       in leather, $6.00.
 Volume I. (just ready) contains General  Diseases and Disease* or the Nervous System.
 Volume II.  (just ready)  contains Diseases of Respiratory and Circiilatoiiy Systems.
 Volume III. (just ready) will contain Diseases  of the  Digestive and Blood Glandular
     Systems, of the  Urinary Organs, of the Female  Beproductive System, and of the
     Cutaneous System.
   Reynolds's System of Medicine, recently completed, has acquired, since the first appearance
 of the first volume, the well-deserved reputation of being the work  in which modern British
 medicine is presented in its fullest and most practical form.  This could scarce be  otherwise in
 view of the fact that it is  the result  of the collaboration of the leading minds of the profession,
 each subject being treated by some gentleman who is regarded as its highest authority—as for
 instance, Diseases  of the Bladder by Sir  Henry Thompson,  Malpositions of the Uterus by
 Graily Hewitt,  Insanity by Henry  Maudsley, Consumption  by  J. Hughes  Bennet,  Dis-
 eases of the Spine by Charges Bland Badcliffe, Pericarditis by Francis Sibson, Alcoholism
 by Francis E. Anstie, Benal Affections by William  Roberts, Asthma by Hyde  Salter,
 Cerebra1 Affections by H  Charlton Bastian, Gout and Rheumatism by Alfred Baring Gar-
 rod, Constitutional Syphilis by Jonathan  Hutchinson, Diseases of the  Stomach by Wilson
 _ ox, Diseases of the Skin by Balmanno Squire, Affections of the  Larynx by Moreli, Mac-
 fenzie, Diseases of the Rectum by Blizard Curling,  Diabetes by Lauder Brunton, Tntes-
 tinal Diseases by John Syer Bristowe, Catalepsy and Somnambulism by Thomas King Cham-
 bers,  Apoplexy by J. Hughlings Jackson, Angina Pectoris by  Professor Gairdner,  Emphy-
 sema of the Lungs by Sir  William Jenner, etc etc.  All the leading schools in Great Britain
 have contributed their best men in generous rivalry, to build up this monument of medical sci-
 ence.  St. Bartholomew's, Guy's, St Thomas's, University College, St Mary's in London, while
 the Edinburgh, Glasgow, and Manchester schools are equally well represented, the Army Medical
 School at Netley, the military and naval services, and the public health boards.   That a work
 conceived in such a spiri', and carried  out under such auspices should prove an indispensable
 treasury of facts and experience, suited to the daily wants of the practitioner, was inevitable, and
 the success which it has enjoyed in England, and the reputation which it has acquired on this
 side of the Atlantic, have sealed it with the approbation ofthe two pre-eminently practical nations.
   Its large size and high price having  kept  it  beyond the reach  of many practitioners in this
 country who desire to possess it,  a demand has arisen for an edition at a  price which shall ren-
 der  it accessible to all.  To meet this demand the present edition has been undertaken.  The
 five volumes and five thousard pages ofthe original will  by the use of a smaller type and double
 columns, be compressed into three  volumes of about three thousand pages, clearly and hand-
 somely printed, and offered at a price which will  render it  one of the cheapest works ever pre-
 sented to the American profession.
   But not only will the American edition be more convenient and lower priced than  the English ;
 it  will also be better and more complete.  Some years having elapsed since the appearance of a
 portion ofthe work, additions will be required to bring up the subjects to the existing condition
 of science.  Some diseases, also, which are comparatively unimportant in England, require more
 elaborate treatment to adapt the articles devoted to them to the wants of the American physi-
 cian  ; and  there  are points on which  the received practice in this  country differs  from  that
 adopted abroad.  The supplying  of these deficiencies  has been undertaken  by  Henry Harts-
 horne,  M.D.,  late  Professor of Hygiene in the University of Pennsylvania, who will  endeavor
 to render the work fully up to the day,  and as useful to the American physician as it has proved
 to be to his English brethren.  The number of illustrations will  also  be  largely increased, and
 no effort will be spared to  render  the typographical execution unexceptionable in every respect.
 The  first and second volumes are now ready, and the completion of the whole may be expected
in  a few days.
                                             house of information, in regard to so many of the
                                             subjects  with which be should be familiar —Gail-
                                             lard's Med. Journ., Feb. 18o0.
                                              There is no medical work which we have in times
                                             past more frequently and fully consulted when per-
                                             p'exed by doubts as to treatmem, or by having un-
                                             usual or apparently inexplicable  symp'oms pre-
                                             sented to us tban "Reynolds' System of Medicine."
                                             Among its contributors are gentlemen who are as
                                             well known by reputation  upon this side of the
                                             Atlnntic as in Great Britain,  and whose right to
                                             speak with authority upon  the  subjects  about
                                             which they have written,  is recognized the world
                                              iver.  They have evidently striven  to make  their
                                             assays as practical  as possible, and while these are
                                             Mifflciently  full to entitle them to  the name  of
                                             monographs, they  are not loaded down with such
                                             m amount  of detail as to render them  wearisome
                                             to the general reader.  In a word, they contain just
                                             that kind of information which the busy practitioner
                                             frequently finds himself in need of.   In order that
                                             any deficiencies may  be supplied, (he publishers
                                             have committed the preparation of the book for the
                                             press to  Dr. Henry Hartshorne, whose  judicious
                                             notes distributed throughout the volome afford abun-
                                             dant evidence of the thoroughness of the revision to
                                             which he has subjected it.—Am. Jour.Med. Sciences,
                                             Jan. 1880.
  Really too much praise can scarcely be given to
this  noble  book.  It is a cyclopaedia of medicine
written by some of the best men of Europe. It is
full of useful information such as one fiuds frequent
need  of in one's daily  work ; for no one head can
possibly carry all the knowledge one needs in gen-
eral practice, and one must refer sometimes to one's
library. As a book of refereuce it is invaluable. It
Is up with the times.  It is clear and concentrated
in style, and its form is worthy of its famous pub
lishers —Louisville Med News, Jan. 31,  1880.
  "Reynolds' System of Medicine" is ju tly con
sidered the most popular work on the principles and
practice of medicine  in the English  language  Tb<
contributors to this  work are  gentlemen of well
known reputation on both sides of the Atlantic
Each gentleman has striven to make his part of the
work as practical  as pos>ible, and the information
contained is such as  is  needed  by the  busy practi
ti .ner. — St. Louis Med. and Surg. Journ., Jan. 20,
1880.
  Dr Hartshorne has made ample additions and re-
visions so far, all of which give increased value to
the volume and render it more  useful to the Ameri-
can  practitioner.  There is no  volume in English
medical literature more valuable,  and every pur-
chaser will, on  becoming fami^ar with it, conerat
ula>^____OU______-""
ou of th.s vast More-
^ 
18   Henry  C. Lea's Son & Co.'s Publications—f Prac of Med., <f-r.).
JPISLA YSON  (JAMES),  M.D.,
        Physician and Lecturer on Clinical Medicine in th« Glasgow Western Infirmary, etc.
   CLINICAL   DIAGNOSIS;  A  Handbook  for   Students  and   Prac-
      titioners of Medicine.  In one handsome 12mo. volume, of 546 pages, with 85 illustra-
      tions.   Cloth, $2 63.  (Just Ready.)
 The book is an excellent one, clear, concise, conve-
nient, practical  It is replete with the very know-
ledge the student needs when he quits the lecture-
room and the laboratory for the ward and sick-room,
and does not lack in information that will meet the
wants of experienced  and older men.—Phila. Med.
Times, Jan. 4, 1879.
  The aim of ihe author is to  teach a student and
practitioner how to examine a cas. so as to u.-e "all
his knowledge" in  arriving at a diagnosis.  All the
various symptoms of the several system* are grouped
together in such a mxnner as to mike their rela'ions
to  a final diagnosis clear and easy of apprehension.
This work has been done by men  of 1'nrge experience
and  trained observation, who have been long recog
treat.  There is a profusion of illustrations to illus-
trate subjects under di-cussion.  The application of
electricity, and instruments of precision in dlaguotiiH,
Is fully discussed.  This book is all good. We com-
mend It to all students and practitioners of mediciDe
*s a work worthy of a place in their libraries.—Ohio
Med. Recorder.  Dec. 1878.
  This i» one of the really useful books  It is attrac-
tive from pr face to the final page, and  ought to be
given a place on every office table, bee i use it contains
in a condensed form all that is valuable in semeiology
and diagnostics to be found in bulkier volunv k, and
becau-ein its arrangement and complete index, it is
unusually convenient for quick  reference in auy
emergency that may come upon the busy practitioner.
niztd as authorities upon the subjects which they 1 — N. 0. Med. Journ., Jan. 1S79.

 TJAM1LTOS (ALLAN McLANE), M.D.,
         Attending PhyHcinn at the Hospital for Epileptic* and Paralytics. Blackwell's Island, N. Y,
          and at the Out-1'atienls' Department of the Ne»  York Hoxpitnl.

 NERVOUSDISEASES;THEIR DESCRIPTION AND TREATMENT.
    In one handsome octavo volume of 512 pages, with 53 illus.; cloth, S3  50.  (Now Ready )
  This is unquestionably the best  and uio-t com
p'ete text-book of nervous disea-es  that h<is yet ap-
peared, and were international jealousy in scientific
affairs at all  possible, we might be excused fir a
feeling  of chagrin that it i^iould  be  of American
paientag". This work, however, has been performed
in New York, and has been  so well performed that
no room is left for  smything but  comtnendati'n.
With great skill,  Dr.  Hamilton has  presented 'o his
readers a succinct and lucid survey of all that  is
kn<-wn  of the  pathology of the nervous system,
viewed in the light of the most recent researches
From the preliminary description of the methods of
examination  and study, and of the instruments  of
precision employed in the investigation of nervous
diseases, up till the final collection of  formula), the
book is eminently practical. — Brain, London, Oct.
1878.
  From a very careful examination of the whole
work, we car justly say that the author has not only
clearly and fully treated of diagnosis and treatment,
but. unlik« most works of this class, it is very com-
prehensive in regard to  etiology, and  exposes the
pathology of nervous diseases in the light of the very
latent experiments ind discoveries  The drawings
are excellent and well selected.  After  this careful
revision, we can heartily recommend this work to
student" and general practitioners in particular as
being a full exposition of aiseases of the nervous sys-
letn. their pathology and treatment, to date.— N. Y.
Med.  Record, Aug. 3, 1878.
G
 HARCOT (J. M.).
    Professor to the Faculty of M".d Pa*is, Phys. to La Salpc'triere, etc.

LECTURES ON DISEASES OP THE NERVOUS  SYSTEM.  Trans-
   lated from the Second Edition by George  Siobrson, M.O . M Ch., Lecturer on Biology,
   etc.,  Cath. Univ  of Ireland.  With illustrations.  1 vol. 8vo. of 288 pages.  Cloth, $1 75.
    (Just Ready.)
CL'XTCAL  OBSERVATIONS  ON FUNCTIONAL
  NERVOUS DISORDERS  B»0. Hakdpiei.oJone*
  M. D., Physician to St. Mary's Hospital, &c. Sec-
ond American Edition  In onehundsome octavo
volume of 318 page*,cloth,*3 25.
 MORRIS (MALCOLM).  M.D.,
JJ-L     Joint Lecturer on Dermatology, St. Mary's Hospital Med. School.

   SKIN  DISEASES, Including  their  Definitions,  Symptoms, Dineriosis,
      Prognosis, Morbid Anitomy, and Treatment.  A Manual for Students and Practi'ioner*
      In one 12mOi volume of over 300 pages.  With illustrations.  Cloth. $ I  76.  (Just Ready )
  The bo^k is clearly and concisely written, and the I work neatly got up and of convenient size, and  the
subject iR handled in a way calculated to be readily I manual ought to b-> very usefu'  for the purpose or
intelligib.e to stud nts.  The type is excellent, the 1 which it is intended.—London L'incet, Jan 31,1880.
 ipOX (TILBURY), M.D.,F.R.C.P.,and T. C. FOX, B.A., M.R.C.S.,
         Phyxioian to the Department for Skin Diseases, University College Hosjntrl.

   EPITOME  OF SKIN  DISEASES.   WITH FORMULA.   For Stu-
      dbkts and  Practitioners. Second edition, thoroughly revised and greatly enlarged. In
      one very handsome 12mo. volume of 216 pages.   Cloth, $1  38.   (Just Ready.)
  The names of tbe  authors are quite snflVient  to ,   The present edition of the Epitome considerably
command this  book,  Dr  Tilbury  Fox being wet) I exoeed* in size, and surpesses iu n«, Its prfdeces-
bnown as occupying a pl-ce  in the front rank, of j xor.  The work is  -er ainly a valuable  addition to
dermatologists of the day.— Canadian Journal of j the «• h*ody v lume" department of medical lltera-
Med. S'i , May, 1?78.                            ture  — The Med. Bulletin, May, 1878.
WTTSriN-S  STUDENT'S BOOK O*  CUTANEOUS I HILLIERS  HANDBOOK OF SKIN  DISEASES  for
                                       In one    Students and . rac I tomrs.  S-cond Am  Ed  Io
                                             I   one ro' al  12 no. vol of338pp. With illustrations.
                                             |   Cloth, *2 23.
MSMHNE aud  Di f.a-fu op Thr Skim.
Very h_ud*ome royal 1-mo volume.  $3 30. 
Henry C. Lea's Son  & Co.'s Publications— Dis.ofthe Chest,dc.
19
PLINT (AUSTIN), M.D.,
      Professor of the Principles and Practice of Medicine in Bellevue Hospital Wed. College, N. Y.
  A  MANUAL OF  PERCUSSION  AND AUSCULTATION;  of  the
       Physical  Diagnosis of Diseases ofthe Lungs and Heart, and of Thoracic Aneurism.
       Second edition.   In one handsome royal 12mo. volume: cloth, $1 63.  (Just Ready.)
 Prof. Flint is so well known as a medical teacher  p'tysician's library. —Med.  and Surg. Reporter,
                                            March IS  1880
and writer that it seems  superfluous to state that
the subject has been treated in a thorough and sys-
tematic manner.  In  revising it for a second ed tion
the author has confined himself to such additions as
seem likely to render it  more useful, not only to
students engaged in the practical study of the sub-
ject,  but  also to practitioners as a hand book for
reaiy reference, and we do not hesitate in saying
[hat it would prove  a valuable addition to every
  The little  work before us has already become a
standard one. and has become extensively adopted
as a text-b^ok.  Th-re is certainly none better.  Tt
con  a'ns the substance  of  he le>sons which the
author has for m  ny >ear^ given, in con nee'ion with
praciical instruction in auscultation and percus-ioD,
to private classes, composed of medical students and
p actitiouers — Cincinnati Med. News, Feb. 1S80.
Df THE SAME AUTHOR.

  PHTHISIS:  ITS  MORBID  ANATOMY, ETIOLOGY, SYMPTOM-
     ATIC  EVENTS  AND COMPLICATIONS, FATALITY AND  PK0GN0S1S, TREAT-
     MENT, AND PHYSICAL DIAGNOSIS;  in a series of Clinical Studies.  By Austin
     Flint, M.D., Prof, ofthe Principles and Practice of Medicine in Bellevue Hi spital Med.
     College, New York.  In one handsome octavo volume : $3 50.   (Lately Issued.)
 T> Y THE SA ME A UTHOR.

   A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY,
      AND  TREATMENT OF DISEASES OF THE  HEART.   Second revised and enlarged
      edition.  In one octavo volume of 550 pages, with a plate, cloth, $4.
  Dr. Flint chose a difficult subject for his researches, , ind clearest practical treatise on those subjects, and
_nd has shown remarkable powers ot observation  ihould be in the hands of all practitioners and stu-
and reflection, as well as great Industry, in his treat-  lents It is a credit to American medical literature.
ment of it. His book must be considered the fullest I — Amer. Journ. of the Med. Sciences, July, 1860.

 T>Y THE SAME AUTHOR.

   A  PRACTICAL TREATISE  ON  THE  PHYSICAL  EXPLORA-
      HON OF THE CHEST  AND THE DIAGNOSIS OF  DISEASES AFFECTING THE
      RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume
      of  595 pages, cloth, $4 50.
B
 ROWN-(LENNOX), F.R.C.S. Ed.,
      Senior Surgeon tothe Central London Throat and Ear Hoxpi'al, etc.
THE THROAT  AND  ITS  DISEASES.  With one  hundred Typical
   Illustrations in colors, and fifty wood engravings, designed and executed by the author.
   In one very handsome imperial octavo volume of 351 pages ; cloth, $5 00. (Now Ready.)
 OE1LER (CARL), M.D.,
A>3     Lecturer on Laryngoscopy at the Univ.  of Penna , Chief of the Throat Dispensary at the
          Univ. Hospital, Phila., etc.

   HANDBOOK  OF  DIAGNOSIS  AND  TREATMENT OF DISEASES  OF
      THE  THROAT AND NASAL  CAVITIES.   In  one handsome royal  12mo. volume,
      of 156 pages, with 35  illustrations; cloth, $1.  (Just Ready.)
  We most heartily commend this book  as showing   A convenient little handbook, clear, concise, and
sound judgment in practice, and perfect familiarity : accurate in its method, and admirably fulfilling its
with the literature of the spec ally it so ably epl-  purpose of bringing the  subject of which it treats
tomizes.— Philada. Med. Times, July 5, 1879.      within the comprehension  of  the general practi-
                                            I tioner.—N. C. Med. Jour., June, 1879.
 WILLIAMS'S  PULMONARY  CONSUMPTION;  its
  Nature, Varieties, and Treatment.  With an An-
  alysis of One  Thousand Cases  to exemplify its
  duration.   In  one neat octavo volume of about
  350 pages; cloth, f2 50.

 BLADE ON  DIPHTHERIA; Its Nature and Treat-
  ment, with an account of the History of its Pre-
  valence in various Countries  8econd and revised
  edition.  In one neatroyal 12mo. volume, cloth,
  $1 25.

WALSHE ON THE DISEASESOF THE HEART AND
  GREAT VESSELS. Third American Edition.  In
  1 vol. 8vo., 420 pp., cloth, $3 00.

CHAMBERS'S MANUAL OF  DIET AND REGIMEN
  IN  HEALTH AND SICKNESS.  In one handsome
  octavo volume.  Cloth, $2 75.

T A ROCHE  ON PNEUMONIA. 1 vol. 8vo., cloth
*"     -   ■--   u-i-o *s no.
LINCOLN'S ELECTRO-THERAPEUTICS ; a Concis6
  Manual of Medical Electricity.  In one very neat
  royal 12mo. volume, cloth, with illustrations,
  $1 50.
PULLER ON DISEASES OF THE LUNGS AND AIR-
  PASSAGES. Their Pathology, Physical Diagnosis,
  Symptoms, and Treatment. From the second and
  revised English edition.  In one handsome ocatvo
  volume of about 500 pages : cloth, $3 50.
SMITH ON CONSUMPTION ; ITS EARLY AND RE-
  MEDIABLE STAGES  1 vol.8vo..pp.254  *2 2fi.
BASHAM ON RENAL DISEASES : a Clinical Guide
  to their Diagnosis and Treatment. With Illustra-
  tions In one l2mo. vol of 304 pages, clo»h, **? 00.
LECTURES ON THE STUDY OF FEVER.  By A.
  Hcnsox, M.D., M.R.I.A., Physician to the Meath
  Hospital  In one vol 8vo., cloth, #2 50.
A TREATISE ON FEVER.   By Robert D Lyons,
  K.C C. In one octavo volume of 362 pages, clotb,
  *2 2o. 
20   Henry  C. Lea's Son & Co.'s Publications—( Venereal Dinettes, (he).


 ftUMSTEAD (FREEMAN J),  M.D., LL.D.,
■*-*    Professor of Venereal Diseases at the Col. of Phys  and Surg., New York. Ac.

 . THE PATHOLOGY AND   TREATMENT OF  VENEREAL  DIS-
      EASES. Including the results of recent investigations upon the subject.  Fourth edition,
      revised  and largely rewritten  with the co-operation of R. W. Taylor, M D., of New
      York, Prof, of Dermatology in  the Univ. of Vt.  In one large and handsome octavo
      volume of 835 pages, with 138 illustrations. Cloth, $4 75 ;  leather.  $5 76  (Just Ready.)
  This work, on its first appearance, immediately took the  position of a standard authority on
its subject wherever  the language is spoken,  and the success of an Italian translation  shows
that it is regarded with equal favor on the Continent  of Europe. In repeated editions the author
labored sedulously to render it more worthy of its reputation, and in the present revision  no
pains have been spared to perfect it as far  as  possible.  Several  years  hav'ng elapsed since
the publication of the  th:rd edition, much material has been accumulated during the interval
by the industry of syphitoIogUts, and new views have been enunciated.  All  this   so  far as
confirmed by observation ami experience, has been incorporated; many portions ofthe volume
been  rewritten, the series of illustrations  has been enlarged and improved,  and the whole may
be regarded rather as" a new work than as a new edition.  It is confidently presented as fully on
a level with the  most advanced condition of  syphilology, and as a work  to which the practi-
tioner may refer with the certainty of finding clearly and succinctly set forth whatever falls
within tbe scope of such a treatise.
  However valuable the previous editions have been,
the  present is, to our thinking, decidedly of more
worth.  An air of completeness—of having h:id gar-
nered into its pages all the best frnit of the world's
experience and research upon the subject of which
it treats—has been given  to the book, without in
any way detracting  from  the pecnliarly practical
value of previous editions.  Ncne the less clinical,
the  treatise seems much more  cosmopolitan.  The
possession of old editions will be no excuse to the
progressive physician for not purchasing this edi-
tion, and we pred'et for it  a very speedy sale.  We
congratulate  Dr. Bum stead on the wisdom which
led to the selection of Dr. Taylor as colleague, and
we sincerely congratulate  the two  coworkers upon
the  results of their  labor.—Philadelphia Medical
Times, Dec. 6, 1879.
  As it now stands, this is the only complete mod-
ern  work devoted exclusively to the discussion of
venereal diseases.  It was needed, and will be cor-
dially welcomed  by all who desire to keep abreast
with the times in their knowledge of these su ijects.
It is one  of the  few really good books  needed by
every practitiorer of medicine or surgery, vhether
be be a general practiti mar or specialist.—Detroit
Lancet, December, 1879.
  Dr. Bumstead's successful labors entitle him now
to rank pre-eminently as the authority in this couq.
try  on  venereal  diseases. But not only does this
tact make his present treatise of interest, to practi-
tioners ; the  book is  fully  abreast with present
literature on  the subject of which it treats, is ex-
tremely practical  in  descriptions of  the several
venereal diseases and modes of treatment, and hence
should  be in  every  doctor's library.— Va.  Med.
Monthly  December, 1879.
 ffULLERIER (A.),         and     ftUMSTEAD (FREEMAN J),
 ^    Surgeon to the Hdpital du Midi.         ■*-*   Professor of Venereal Diseases in the College of
                                                       Phyxicians and Surgeons. N. Y

   AN ATLAS OF VENEREAL DISEASES.  Translated and  Edited  by
    Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns,
    with 26 plates, containing about 150 figures, beautifully colored, many of them the size of
    life; strongly bound in cloth.  $17 00 ;  also, in five parts, stout wrappers, at $3 per part.
  Anticipating a very large sale for this work, it is offered at the very low price of Three Dol-
lars a Part, thus  placing it within the reach of all who are interested in this department of
practice.  Gentlemen desiring early impressions ofthe plates would do well to order it without
delay.  A specimen of the plates and text sent free by mail, on receipt of  25 cents.
LEE'S  LECTURES  ON  SYPHILTS  AND  SOME
  FORMS OF LOCAL DISEASE AFFECTING PRIN-
  CIPALLY THE ORGANS OF GENERATION.  In
  one handsome octavo volume; cloth, ip_ 25.
HILL  ON  SYPHILIS AND LOCAL  CONTAGIOUS
  DISORDERS  la one handsome octavo volume;
  cloth, $3 25.
WTEST  (CHARLES),  M.D.,
         Physician to the Hospital for Sick Children, London, 4c.
  LECTURES  ON  THE DISEASES OF  INFANCY  AND  CHILr-
    HOOD. Fifth American from the sixth revised and enlarged English edition.  In one large
    and handsome octavo volume of 678 pages.  Cloth, $4 50 ;  leather, $5 50. (Lately Issued.)
T>Y THE SAME AUTHOR.  (Lately Issued.)

  ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD-
      HOOD; being the Lumleian Lectures delivered  at the Royal College of Physicians of
      London, in March, 1871.  In one volume small 12mo., cloth, $1  00.
DF THE SA VE AUTHOR.

    LECTURES ON THE  DISEASES OF WOMEN.   Third American,
      from  the Third London edition.   In one neat octavo volume of about 560 pages, clotL,
      $3  75;  leather, $4 75.      _____________

CONDIE'S PRACTICAL TREATISE ON THE DrS- \ SMITH'S PRACTICAL TREATISE ON THE WAST-
  EASES  OF CHILDREN.  Sixth  edition,  revised    INI DISEASES OF INFANCY AND CH LDH >OD.
  and auumented.  In one  large octavo volume of I   Second American, from the second revised and
  nearly  8r0 ctosely-^rinted  pages, cloth, J5 25 ; 1   enlarged Baalish edition.  In one handsome ou_-
  leather, $6 25.                              I   ▼<> volame, cloth, $2 50. 
Henry C. Lea's  Son & Co.'s  Publications—(Dis. of Children, &c).  21
jgMITH (J. LE WIS), M.D.,
        Clinical. Professor of Diseases of Children in the Bellevue Hospital Med. College, N Y.

   A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF
      CHILDREN.  Fourth Edition, revised and enlarged.  In one handsome octavo volume
      of about 750 pages, with illustrations.  Cloth, $4 50;  leather, $5 50.  (Now Ready )
  The very marked favor with which this work has been received wherever tie English lan-
guage is spoken, has stimulated the author, in the preparation of the Fourth Edition, to spare
no pains in the endeavor to render it worthy in every respect of a continuance  of professional
confidence.  Many portipns-of the volume have been rewritten, and much new matter intro-
duced, but by an earnest effort at condensation, the size of the work has not been materially
increased.
                                               This excellent work is  so well  known that an
                                             ex ended notice at this time would be superfluous.
                                             The author has tafcen advantage of the demand for
                                             another new  eoit on  to revise in a most  careful
                                             manner the entire book ; and the numerous correc-
                                             tions and additions evince a determination on his
                                             part to keep fully abreast  with the rapid progress
                                             that Is being made in the knowledge and treatment
                                             of children's diseases.  By the adoption of a some-
                                             what closer type, an increase iu size of only thirty
                                             pages has  been necessitated by the  new  subject
                                             matter introduced.— Boston Med. and Surg. Jour.,
                                             May 29, 1879.
                                               Probably no  other work ever published  in this
                                             country upon a medical subject has reached such  a
                                             heighth of popularity as has this well-known trea-
                                             tise.  As a text and  reference-book it is pre-emi-
                                             nently the authority upon diseases of children.  It
                                             stands deservedly higher in the estimation of the
                                             profession  than any other  work upon the same sub-
                                             ject.—Nashville Journ. of Med. and Surg., May,
                                             1879.
                                               The author of this work has acquired an immense
                                             experience as physician to three of the large char-
                                             ities of New  York in  which children are treated.
                                             These asylums afford unsurpassed opportunities for
                                             observing the effcts of different plans of treatment,
                                             and the results as emb idied in this volume  may be
                                             accepted with faith, and should be in the possession
                                             of all practitioners now, in vi» w of the approaching
                                             season when the diseases of children always increase.
                                             —Nat Mid. Review, April, 1879.
  In the period which has elapsed since the third
edition of the work, so extensive have been the ad-
vances that whole chapters required to be rewiitten,
and hardly a page could pass without some material
correction or addition.  This labor has occupied the
writer closely, and he  has performed it conscien-
tiously, so that the book may be considered a faith-
ful portraiture  of an exceptionally  wide  clinical
experience in infantile diseases, c rrected by a care-
ful study of the recent  literature of the subject.—
Med. and Surg. Reporter, April 5, 1879.
  It is  scarcely necessary for us to say the work be-
fore us is a standard work upou diseases of children,
and thatno work has a higher standing than it upon
those afFe*ctions.  In consequence of its thorough re-
vision, the work has been made of more value than
ever, and may be regarded as  fully abreast of the
times.   We cordially commend it to students and
physicians There is no better work in the language
on diseases of children.—Cincinnati Med. News,
March, 1879.
  The  author has evidently determined that It shall
not lose ground in the esteem of the profession for
want of tbe latest knowledge on  that important
department of medicine.  He has  accordingly in-
corporated in the present  edition  the useful and
practical remits of the latest study and experience,
b th American and foreign, especially those bearirg
on therapeutics.  Altogether  the  book  has been
greatly improved, while it  has not  been greatly
increased in  size. — New  York Mtdical Journal,
Jane, 1879.
 VWAYNE  (JOSEPH GRIFFITHS), M.D.,
        Physician-Accoucheur to the British General Hospital, Ac.

   OBSTETRIC APHORISMS-FOR THE USE OF STUDENTS COM-
      MENCING MIDWIFERY PRACTICE   Second American, from the Fifth and Revised
      London Edition  with Additions by E. R. Hotchins, M.D.  With Illustrations.  In one
      neat 12mo  volume   Cloth, $1 25.  (Lately Issued.)
  ** * See p. 3 of this Catalogue for the terms  on which this work is offered  as a premium to
subscribers to the " American Journal of the Medical Sciences."
CHURCHILL ON THE PUERPERAL FEVER AND
  OTHER DISEASES PECCLIARTO WOMEN. 1 vol.
  8vo., pp. 450, cloth  $2 50.
DEWEES'S TREATISE ON THE DISEASES OF FE
  MALES. With illustrations. Eleventh Edition
  with the Author's Iastimprovementsand correc-
  tions. In one octavo volume of 536 pages, with
  plates, cloth.  $3 00.
MEIGS ON THE  NATURE, SIGNS. AND TREAT-
  MENT OF CHILDBED FEVER.  1 vol. 8vo , pp.
  36'. cloth.  $2 uO.
ASHWELL'S PRACTICAL TREATISE ON THE DIS-
  EASES PECULIAR TO WOMEN. Third American,
  from the Third and revised London edition. 1 vol.
  8vo., pp. 528, cloth.  $3 50.
  TJODGE  (HUGH L.),  M.D.,
         Emeritus Professor of Obstetrics, Ac, in the University of Pennsylvania.

    ON DISEASES PECULIAR TO WOMEN ; including Displacements
      of the Uterus.  With original illustrations. Second edition, revised and enlarged.  In
      one beautifully printed octavo volume of 531 pages, cloth, $4 50.
  Professor  Hodge's work is truly an original one I contribution tothe study ofwomen'sdiseases.itierf
from beginning to end, consequently no one can pe-  great value, and is abundantly able to stand on its
raseitspageswithont learning something new. Am \ own merits—^. Y. Mtdical Record, Sept. 16, Ibbi.

    'HURCHILL  (FLEETWOOD), M.D., M.R.I.A.

     ON THE THEORY  AND  PRACTICE OF MIDWIFERY.   A new
      American from the fourth revised and enlarged London edition.  With notes and additioi s
      by D. Francis Condib, M.D., author of a "Practical Treatise on the Diseases of Chil-
      dren," Ac. With  one hundred and ninety four illustrations. In one very handsome octavo
      volume of nearly 700 large pages.  Cloth, $4 00 ; leather, $5 00.

uowTOOMERT'S  EXPOSITION OF  THE SIGNS I RIGBY'b SYSTEM OF MIDWIFERY.  With notes
  AND SYMPTOMS OF PREGNANCY.  With two    and Additional Illustrations.   Second Amerl. an
    anisitecoloredplates,andnumerouswoodcuts.    edition.  One volume octavo, oloth 422 pages,
  ?*i vol 8vo.,of_early600pp.,clotb,$376.       I   $2 50.
G 
22    Henry  C. Lea's Son  &  Co.'s  Publications—(Dis. of Women).
 rPHOMAS  (T.GAILLARD).M.D..
 *      Professor of Obstetrics, Ac. in the College of Physicians and Surgeons, N. Y., Ac

   A PRACTICAL TREATISE ON THE DISEASES OF WOMEN   Fourth
      edition, enlarged and thoroughly revised  In one large and handsome octavo volume of
      800 pages, with 191 illustrations.  Cloth, $5 00;  leather, $6 00.   (Just Issued.)
   The author has taken advantage of the opportunity afforded by the call for another edition of
this work to render it worthy a continuance of the very remarkable favor with which it  has been
received. Every portion has been subjected to a conscientious revision, and no labor  has been
spared to make it a complete treatise on the most advanced condition of its important subject.
  A work which  has reached  a  fourth edition, and  is classical withoutbeingpedantic,full in the details
that, too, in the short space of five years, has achieved  of anatomy  and pathology, without ponderous
a reputation which places it almost beyond the reach  translation of pagesof German literature, describes
of -riticism. and the favorableopinions which we have | distinctly the details and difficulties of each  opera-
alreidy expressed of the former elitions seem to re-  tion, without wearying and useless minutias, and is
quire that we should do  little more than  announce | in all respectsa work worthy of confidence, justlfy-
tbis new issue. We cannot refrain from saying that,) ing the high resrard in which Its distinguished an-
as a practical work, this is second to none in the Eng-  thor Is held by the profession.— Am. Supplement,
                                               Obstet. Journ., Oct  1874.
                                                 ProfessorThomasfairly took the Profession ofthe
                                               United States by storm when his book first made its
                                               appearance early in 1S68.  Its reception was simply
                                               enthusiastic, notwithstanding a few adverse criti-
                                               cisms from our transatlantic brethren, the first large
                                               edition was rapidly exhausted, and in six months a
                                               second one was issued, and in two yearsathlrd one
                                               was announced and published, and we are now pro-
                                               mised the fourth.  The popularity of this work was
                                               not ephemeral, and itssuccess was unprecedented in
                                               the annalsof American medical literature. Six years
                                               is a long period in medical scientific research, but
                                               Thomas's work on " Diseases of Worneo"is still the
                                               leading native production ofthe United States. Tbe
                                               order, the matter, the absence of theoretical dispu'a
                                               tiveness, the fairness ofstatement, and the elegance
                                               of diction, preserved throughoutthe entire range of
                                               the book, indicate that Professor Thomas did not
                                               overestimate his powers when he conceived the idea
                                               and executed the work of producing a new treat'se
                                               upon diseases of women.—Prof. Pallen, in  Louis-
                                               mile Med. Journal, Sept. 1874.
lish, or. indeed, in any other language.  The arrange
ment of the contents, the admirably clear manner in
which the  subject of the  differential diagnosis of
several of the diseases is handled, leave nothing to be
desired by the practitioner who wants a thoroughly
clinical work, one  to which he can refer  in difficult
cases of doubtful diagnosis with the certainty of gain-
in? light and instruction. Dr. Thomas is a man with a
very clear head and decided views, and there seems to
be nothing which he so much dislikes asbazy notions
of diagnosis and blind routine and unreasonable thera-
peutics.  The student who will thoroughly study  this
b >ok and test its principles by clinical observation, will
certainly not be guilty of these faults.—London Lancet,
Feb. 13, 1875
  Reluctantly we are  obliged to close this unsatis-
factory noticeof so excellent a work ,and in conclu-
sion would remark that, as a teacher ofgynsecology.
both didacic and clinical, Prof. Thomas has certainly
taken the lead far  ahead of his confreres, and as an
author he  certainly has met with unusual and mer-
ited success.—Am Journ. nf Obstetrics,  Nov. 1874.
  This volume of  Prof. Thomas In its revised form
 T>ARNES (ROBERT),  M.D.,  F.R.C.P.,
•*-"      Obxtetric Physician to St. Thomas's Hospital, Ac.
   A CLINICAL  EXPOSITION OF  THE  MEDICAL AND  SURGI-
      CAL DISEASES OF WOMEN.  Second American, from the Second Enlarged and Revised
      English Edition.  In one handsomA octavo volume, of 784 pages, with 181 illustrations.
      Cloth, $4  50;  leather, $5 50.  (Just Ready.)
  The call for a  new edition  of Dr. Barnes's work on the Diseases of Females has encouraged
the author to make it  even more worthy ofthe favor ofthe profession than before    By a rear-
rangement and careful pruning space  has been found for a new chapter  on the Gynaecological
Relations of the  Bladder  an! Bowel Disorders, without increasing th» size  of the  book,  while
many new illustrations have been introduced where experience has shown thetn to be nee led.  It
is therefore hoped that the volume will be found  to reflect thoroughly and accurately the present
condition of gynaecological science.
  Dr Barnes stands at the bead of his profession in
the old country, and it requires but scant scrutiny
of his hook to show that it has been sketched by a
master.  It is plain, practical common sense ; shows
very deep research without being pedantic; is emi-
nently calculated to inspire enthusiasm without in-
culcating ra-huess; points out the  daogers  to  be
avoided  as well as the success to be achieve  in the
various  operations  connected with th:s branch of
medicine;  and will do much to smooth the rugged
path of the young gynaecologist and relieve the per-
plexity of the  man  of mature years. — Canadian
Journ. of  Med. Science, Nov. 1878.

  We pity the doctor who, having any consider-
able  practice in diseases of women, has no copy o'
" Barnes"'  for dailv consulta'ion and instruction.  It
is  at once a book of  great learning,  research,  and
individual experience, and at  the same time emi
                                               the work is a valuable one, and should be largely
                                               ciin tilted by the profession.—Am. S-pp Obstetrical
                                               Journ. Gt. Britain and Ireland, Oci. 1S78
                                                 No other gynaecological work ho'd" a higher posi-
                                               tlon, having  become an authority  eveiywhe>e in
                                               disease-, of women.  The  work  has been  brought
                                               fully abreast of present knowledge.  Every practi-
                                               tioner of medicine should  have it upon the shelves
                                               of his library, and the student will find it a superior
                                               text-book—Cincinnati  Med. News, Oct. 1878.
                                                 This second revised edition, of course, deserves all
                                               the commendation given to its predecessor, with the
                                               additional one that it appears to include all or nearly
                                               all the additions to our knowledge of its subject that
                                               have been made since the appearance ofthe first edi-
                                               tion   The American references are. for an English
                                               work, especially full and  appreciative, and we can
                                               cordially recommend the volume to  American read-
nently practical.  That it has been appreciated by ] ers —Journ. of Nervous and Mental Disease, Oct.
the profession, both in Great Britain  and in this  1878
country, is shown by the gi-cond edition  following
so soon upon  the first.—Am. Practitioner,  Nov.
1878.
  Dr. Barnes's work is one of a practical character,
largely illustrated from c ises in his own experience
  This  second  edition  of  Dr. Barnes's great work
conneR to ns containing many additions «nd improve-
ments which bring it up to date in every feature.
The excellences of the work are too well known to
require enumeration, and  we hazard  he prophecy
bnt by no means confined to such, as will be learned | that they wi'l for many years maintain its high po-
from the  fact that he quotes from nolens than 628 I sltlon as a standard textbook  and guidebook for
medical  authors  in  numerous countries.  Coming  studens  and practitioners. — N.  O.  Med. Journ.,
from such an author, it is not necessary to say that, Oct. 1878. 
henry u. lea's son a vyv. o  Publications—(Dis. of  Women).     23
pMMET (THOMAS ADDIS). M.D.
        Surgeon to the Woman's Hospital, New Yo
                                            rk, etc.

   THE PRINCIPLES AND PRACTICE OF GYNAECOLOGY, for the
      use of Students and Practitioners of Medicine.  Second Edition.  Thorougly Revised.
      In one large and very handsome octavo volume of  875 pages, with 133 illustrations.
      Cloth, $5; leather, $6.  (Just Ready.)

                           Preface to the Second Edition.
  The unusually rapid exhaustion of a large edition of this work, while flattering to the author
as an evidence that his labors have  proved acceptable,  has in a great measure heightened his
sense of responsibility.   He has therefore endeavored  to take full advantage of the opportunity
afforded to him for its revision.   Every page  has received his earnest scrutiny; the criticisms
of his reviewers have been carefully  weighed ;  ard while no marked increase has been made in
the size of the volume, several  portions have  been  rewritten, and uuch new matter has been
added.   In this minute and thorough revision, the labor involved has been much greater than
is perhaps apparent in the results, but it has been cheerfully expended in the hope of rendering
the work more worthy ofthe favor which has been accorded to it by the profession.
  In no country of the world has gynecology re-
ceived more attention thin in America.  It is, then,
with a feeling of pleasure that we welcome a work
on diseases of women from so eminent a gynaecolo
gist as Dr. Emmet, and the work is essentially clini-
cal, and leaves a strong impress of the author's in-
dividuality.   To  criticize, with the care it merits,
the book throughout, would demand far more space
than is at our command.  In par ing. we can say
that the work teems with original ideas, fresh and
valuable methods of practice, and is written in  a
clear and elegant style, worthy of the literary repu-
tation of the country of Longfellow and Oliver Wen-
dell Holmes.— Brit.  Med. Journ , Feb  21, 1880.
  The wide reputation of tbe author makes its puH.
lication an event in the  gynaecological world ; and
a glance through  its pages shows that it is a work
to be studied wi*h care. .  . .  It must always he a
work to be  carefully studied  and frequently con-
sulted by those who practise this branch of our pro-
fession.—Lond. Med. Times and Gat , Jan. 10,18-0.
  No gynaecological treatise has appeared  which
contains an equal amount of original  and  use'ul
matter; nor does the medical and surgical history
of America include a hook more novel and useful.
The tabular and  statistical information which it
contains is rnarv«Uous, both in quantity and accu-
racy, and cannot  be otherwise than invaluable to
future investigators.  It is a woik which demands
not careless reading but profound  study.  Its value
as a contr bution >o gynaecology is, perhaps, greater
than that of all previous literature  on the i-ubject
combined.—Chicago Med.  Gat., April 6,1880.
D
UNCAN (J. MATTHEWS),  M.D., LL.D., F.R.S.E., etc.
CLINICAL   LECTURES   ON  THE  DISEASES  OF  WOMEN,
  Delivered in Saint Bartholomew's Hospital.  In one  very neat octavo volume of 173
  pages.  Cloth, $1 50.  (Just Ready.)
  They are in every way worthy of their author ;
indeed, we look upon them as among tbe most valu-
ab e of his contribuiions  They aie all op n mat-
ters of great interest to tbe general practitioner
S >me of th> in deal wi'h subjects that are not, as a
rule, adequately  handled in the text-books; others
of them, while bearing upon topics that are  usually
treated of at length in such works, yet bear such a
stamp of individnality that, if widely read, as they
Mrt&inly deserve to b", they cannot fail  to exe*rt a
wholesome restraint unon the undue eagerness with
which many yo-ing physici ins i-eem bent upon fol-
lowing the wild teachings which so infect the gy naj-
colot;y of the present  day.—N. Y. Med. Journ.,
March, 1880.
  The author is a remarkably clear lecturer, and
his discussion of symptoms aad treatment i>- full
and suggestive. It will be a tvork which will not
fail to be rend  with benefit by practitioner* as well
as by students.-Phila. Med. and Surg. Reporter,
Feb. 7,1880.
  We  have read  this book with  a great deal  of
pleasnre.  It is full  of good things.  The hints on
pathology and  trev ment scattered through the book
are  sound, trustworthy, and of great  value.  A
healthy scepticism, a large  expedience, and a clear
judgment are everywhere  manifest.  Instead  of
bristing  with ndvice  ot doubtful  value and un-
sound character, the book is in every respect  a safe
guide.—The London Lancet, Jan. 21, 1880.
(1RAD WICK (JAMES R.), A.M.,  M.D.
  A  MANUAL OF THE  DISEASES  PECULIAR TO WOMEN.   In  one
     neat volume, royal 12mo , with illustrations.  (Preparing.)
DAMSBOTHAM (FRANCIS H.), M.D.

   THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDI-
    CINE AND SURGERY, in reference to the Process of Parturition.  A new and enlarged
    edition,  thoroughly revised by the  author.  With additions by W. V. Keating, M. D.,
    Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia.  In one 1 ree
    and handsome imperial octavo volume  of 650 pages, strongly bound in leather, with raised
    bands ; with sixty-four beautiful plates, and numerous wood-outs in the text, containing in
    all nearly 200 large and beautiful figures   $7  00
 TXTINCKEL (F.),
 f T      Professor and Director ofthe Gynaecological Clinic in the University of Rostock.
  A COMPLETE TREATISE  ON  THE PATHOLOGY AND TREAT-
     MENT OF CHILDBED, for Students and Practitioners.  Translated, with the consent
     of :he author, from the Second German Edition, by James Read Chadwick, M.D. In
     one octavo volume.   Cloth, $4 00.   < Lately Is<ued )

/TANNER (THOMAS  H.),  M.D.
    ON  THE SIGNS AVI) DISEASES OF PREGNANCY   First American
      from the Second and Enlarged English  Edition   With four colored plates and illustra-
      t:^n<> on wood.  In one handsome octavo volume of about 500 pages, cloth, $4 25. 
24
Henry C. Lea's Son & Co.'s  rum ications—(luiawijcry).
    PLAYFAIR ( W. S.), M.D., F.R.C.P..
         Professor of Obstetric Medicine in King's College, etc. etc.

    A TREATISE OX THE SCIENCE AND PRACTICE OF MIDWIFERY.
      Third American edition, revised by the author.  Edited, with additions, by Robert P.
      Harris. M  D.   In one  handsome octavo volume of about  700  pages, with nearly 2(0
      illustrations.  Cloth, $4 ; leather, $5   (Just Ready )
                        extract from the author's preface.
  The second American edition of my work on Midwifery being  exhausted before the corre-
sponding English  edition, I cannot better show my appreciation of the kind reception my book
has received in  the United States than by acceding to the publisher's request that I should
myself undertake the  issue  of n third edition.  As little more than a year has elapsed  since
the second edition was issued,  there are naturally not many changes to make, but I have,
nevertheless, subjected the entire work  to carefol  revision, and introduced into  it a notice of
most of the more important recent additions to obstetric science.  To the operation of gastro-
elytrotomy—formerly  described  along with the Caesurean section—I have now devoted a sepa-
rate chapter.  The editor of the Second American edition, Dr. Harris, enriched  it with many
valuable notes, of which, it will be observed, I have freely availed myself.
                                             If inquired of by a medical student what work on
                                            obstetrics we should recommend for him, as par
                                            e&celltnce. we would undoubtedly advise him to
  The medcal profession  has now the opportunity
of adding to their stock of standard medica' works
one of the best volumes on midwifery ever published.
The subject is taken up with a master hand.  The
part devoted to laborin all Its various presentations,
the management and results, is admirably arranged,
und tbe views enterta'ned will be found essentially
modern, and the opinions expressed trustworthy
The work abounds with plates, illustrating various
ob-terical positions; they are admirably  wrought,
and afford great assistance to tbe student.—N. 0.
Med. and Surg. Journ., March, 18S0.
choose Playfair'a.  It is of convenient size, but what
is of chief importance, i's treatment of the various
subjects is concise and plain.  While the discussions
and descriptions are sufficiently elaborate to render
a very intelligent  idea of them', yet all details not
necessary for i full understanding of the subject are
omifted.—Cincinnati Med. News, Jan. 1880.
 "DARNES (FANCOURT), M.D.,
-D     Physician to the General Lying-in Hospital, London.

A MANUAL OF MIDWIFERY  FOR  MIDWIYES AND  MEDICAL
      STUDENT-5.   With 50 illustrations.  In one neat royal 12ino. volume of 200 pages;
      cloth, $1 25.   (Now Ready.)
  Tbe book is written in plain, and as far ac pos-
sible in untechnical language. Any intelligent mid-
wife or  medical student can easily comprehend the
directions  It  will undoubtedly fill  a want, und
will be popular with  those for whom  it has been
prepared. The exam'ning questions  at  the back
will be found very useful.—Cincinnati Med. News,
Aug 1S79.
  The style is clear, and the book will, doubtless,
be useful to the persons for whom it is intended.—
London Med Times and Gatette, Aug 30, 1879.
  The book is written with as little technical  lan-
guage as possible.  Any intelligent midwife or med-
ical studenr can  easily understand the directions.
It will  undoubtedly be found  very  useful.—Ohio
Med. Recorder, Sept. 1S79.
 HTHE  OBSTETRICAL JOURNAL.   (Free of postage for WW.)

    THE  OBSTETRICAL  JOURNAL of  Great Britain and Ireland;
      Including Midwifery, and the Diseases of Women and Infants.   A monthly of
      64 octavo pages very handsomely printed.  Subscription, Three Dollars per  annum
      Single Numbers. 25 cents each.
  With the January number will terminate Vol. VII. of the Obstetrical Journal.  The fir»t
No. of Vol. VIII. will be  issued about Feb. 1st; the  " American  Supplement" of 16 pages
per No. will be discontinued, and the periodical will thenceforth consistof 64 pages per number,
at the exceedingly low price of Three Dollu s per annum, free of postage.  For this trifling
turn the subscriber will thus obtain more than 750 pages per annum, cont ining an extent and
variety of information which may be estimateu from  the fact that Vol. VI. of the "Obststri-
cal Jodrnal" contains in
Original  Communications
Hospital Practice   .   .
G_neral  Correspondence
Reviews  of Books .   .   .
Proceedings of  Societies
44 Articles  In Monthly Summary, Gynecic
101
Pediatric
28A-ticles
 4   "
News
In Monthly Summary, Obstetric  73   "
and that it numbers am ing it* contributors the distinguished names of Limbic Atthill, J. H.
Aveling,  Robert Barnes, J. Henry- Bennet, Nathan  Bozeman, Thomas Chambers, Fleet-
wood Chubcbill, Charles Clay, John Clay, J  Matthews Duncan, Arthur Farke, Robert
Greenhalgh, W. M. Graily Hewitt, J. Braxton Hicks, William Leishman, Angus Mac-
donald, Alfred Meadows, Alex. Simpson, J. G. Swayne, Lawson Tait, Edward J. Tilt,
E. H. Trenholme, T. Spencer Wells,  Arthur Wigglesworth, and many other distin-
guished practitioners   Under such -uspices it  has amply fulfilled  its  object of presenting to
the physician all that is new  and interesting in the rapid development of obstetrical and gynae-
cological science.
  As a very large increase in the subscription list is anticipated under  this reduction in price,
gentlemen who propose to subscribe, and  subscribers intending to  renew their subscriptions,
are recommended to lose no  time in making their remittances, as the limited number printed
may at  any time be exhausted.
  This is certainly a very excellent journal.  It gives    We cannot withhold the expression ofthe admi-
ns the best obstetrical literature from across the  ration ihis rlegantjournal excites.— Western Lanctt,
water.— lad. Journ. of Med., .Nov. 1874.           March, 1876. 
Henry C. Lea's Son  &  Co.'s Publications—(Midwifery,  Surgery).
25
JjEISHMAN (WILLIAM), M.D.,
         Regius Professor of Midwifery in the University of Glasgow. Ac.
   A SYSTEM  OF MIDWIFERY, INCLUDING THE DISEASES OF
     PREGNANCY AND  THE PUERPERAL STATE.   Third American edition, revi.ed by
     the Author, with additions by  John  S. Parry,  M.D., Obstetrician to the Philadelphia
     Hospital, &c.  In one large and very  handsome  octavo volume, of 733 pages, with over
     two hundred illustrations.  Cloth, $4  50; leather, $5 50.   (Just Ready.)
  Few works on this 6n' ject have met with as great
a demand as this one  appears to have.  To judge
by the frequency with  wh ch its autln r's views are
quoted, aud its s atements referred toin obstetrical
literature, one would ju<ige that there are few phy-
sicians deviting much attention to obstetrics who
are without it.  The author is evidently a man of
ripe experience and conservative views, and  in no
branch of medicine are these more valuable th*n in
this.—New Remedus, Jan. 18S0.
  We are glad to call the attention of our readers to
this new edition of Or.  Leishman's well-knowu
work, which  has already established itself in  gene-
ral favor  both in this coun ry and in Amerca.  In
noticing this  thiid edition, we need  ony direct at-
tention to the diff<iences between it and its prede-
cessors.   Although carefully  revised  throughout,
with not a few auditions it various  places, the  net
enlargement amounts only toafewpages.- Glasgow
Medical Journal, Jan. IS  0.
  We gladly welcome the new edition of this excel-
 lent t> xt book of midwifery.  The former editions
 have been  most favorab y received  by the profes-
 sion on both s des of the Atlantic  In the prepara-
 t on of the presfnt edition the author has made such
 alterations  as the  progress  of obstetricil  science
 seems to require, aud we cannot but admire the
 ability with whicu  the  task has been performed.
 We consider it an admirable text-book for stuients
 during their attendance upon lectures, aud  have
 great pleasure in recommending it. As anexponeut
 ■ f ihe midwifery of  the present day it has no supe-
 rior in .he English language.—Canada Lancet, Jan.
 1S80.
  The book is greatly improv<d, and as such will be
welcomed by those who are trying to keep posted in
the  rapid advances which are being made in ihe
study of obstetrics.—Bostt.n Med audaurg Journ.,
 Nov  17. 1879.
pARRY (JOHN S.), M.D.,
        Obstetrician to the Philadelphia Hospital, Vice-Prest ofthe Ohstet Society of Philadelphia.
  EXTRA-UTERINE  PREGNANCY:  ITS CLINICAL  HISTORY,
     DIAGNOSIS,  PROGNOSIS, AND TREATMENT.  In one handsome octavo volume.
     Cloth, $2 60.  (Lately Issued.)
 TJODGE  (HUGH L.), M.D.,
         Emeritus Professor of Midwifery, <tc, in the University of Pennsylvania, Ac.

   THE  PRINCIPLES  AND  PRACTICE  OF OBSTETRICS.   Tins-
     trated with large lithographic plates containing  one hundred and fifty-nine figures from
     original photographs, and with numerous wood-cuts.  In one large and beautifully printed
     quarto volume of 560 double-columned pages, strongly bound in cloth, $14.
 The work of Dr. Hodge is something more than
a simple presentation of his particular views in the
department of  Obstetrics;  it is  something more
than an irdinarytreatise on midwifery; it is, in fact,
a cyclopaedia of midwifery.  He has aimed to em-
body in a single volume the whole science and art of
Obstetrics,   vn elaborate text is combined with ac-
curate and varied pictorial illustrations, so that no
fact or principle is left unstated or unexplained.
—Am. Med. Times, Sept, 3, 1864
  It is very large, profusely and elegantly illustrat-
ed, aad is fitted to take its  place near the works of
great obstetricians  Ofthe American works on the
subject it is decidedly the best.—Edinb. Med. Jour
Dec. 1864.
  %*% Specimens of the plates and letter-press will be forwarded to any address, free by mail,
on receipt of six cents in postage stamps.

 QT1MSON (LEWIS A ), A.M.,  M.D.,
^     Surgeon to the Presbyterian Hospital.

   A MANUAL OF  OPERAT1YE SURGERY.   In one very handsome
     royal 12mo. volume of about 500 pages, with 332 illustrations ; cloth, $2 50. (Now Ready )
  The work before us is  a well printed, profu-ely  performing them.   The work is handsomely illus-
illustrated manual of over four hundred and seventy j trated, and the de criptions are cle*r and well drawn.
pages.  The novice, by a  perusal of the  work, will ! It is a  clever and uselul  volume; every student
gain a good idea of the  general domain of operative | should possess one  The preparation of this work
surgery, while  the practical surgeon has presented  does away with the  necessity  of pondering over
to him within a very concise and intelligible form
the latest and most approved selections of opeiative
procedure. Theprecsion ar d conciseness with which
the different operations are described enable the
author to compress an immense amount of practical
information in a very small compass.—N. Y. Medical
Record, Aug. 3, 1878.
  This volume is devoted entirely to operative sur-
gery, and is intended' to familiarize the studeut with
the details of operations and the  different modes of
larger works on surgery for descriptions of opeia-
tions, a-< it presents in a nut-shell just what is wanted
by the surgeon without an  elaborate search to find
it —Md. Med  Journal, Aug. 1878.
  The author's conciseness and the repleteness of
the work  with valuable illustrations entitle it to be
classed with the text-books for students of operative
surgery, and as one of reference to the practitioner.
—Cincinnati  Lancet and Clinic, July 27,1S78.
SKEY'S OPERATIVE SURGERY.  In 1 vol. 8vo.
  el. of 650 pages ; withabout lOOwood-ents $3 2o

C)OPER'S LECTURES OK THE PRINCIPLES ANL
  PRACTiCBorSrjBOEEY. In 1 vol. 8vo. cl'h,750p. $2.
aiBSON'S INSTITUTES AND PRACTICE OF SUR-
  GERY. Eighth edit'n, improved and altered. With
  thirty-four plates.  In two handsome oc'avo vol-
  umes, about 1000 pp.. leather,  raised bandf. 96 50.
THE PRINCIPLES AND PRACTICE OF SURGERY.
  By William Pirrie.F.R S E., Profe^r of Surgery
  in the University  ofAheideen.  Edited by John
  31 bill, M.D., Professor of Surgery in the Penna.
  MedicalCollege,Surg'n to the Pennsylvania Hos-
  pital, .Sic.  In one very handsome octavo  vol. of
  780 pages, with 316 illustrations, cloth, $3 75.
MILLER'S PRINCIPLES OF SUKGERY FourthAme-
  rican, from the Third Edinburgh Edition.  In o_e
  large 8vo. vol. of 700 pages, with 340 illustrations
  cloth, $3 75.                                 '
MILLER'S PRACTICE OF SURGE1. Y  Fourth Ame-
  rican, from the last Edinburgh Edition Revised by
  the \merican editor. In onelargeSvo. vol.of nearly
  700pages, with 364 illustrations: cloth, $3 76. 
26
Henry  C. Lea's Son & Co.'s  Publications—^Surgery).
 /rROSS  (SAMUEL  D.),  M.D.,
 *-*      Professor of Surgery in the Jefferson Medical College of Philadelphia.
    SYSTEM  OF  SURGERY:  Pathological,  Diagnostic,  Therapeutic,
      and Operative.  Illustrated by upwards of Fourteen Hundred Engravings  Fifth edition
      carefully revised, and improved. In two large and beautifully printed imperial octavo vol-
      umes of about 2300 pp .strongly bound in leather, with raised bands, $15.  (Just Issued.)
  The continued  favor, shown.by the exhaustion of successive large editions of this great work,
proves that it has successfully supplied a want felt by  American practitioners and students.  In
thf present revision no pains have been spared by the author to bring it in every respect fully
up t<  the day.  To effect this a large part of the work has been rewritten, and  the whole en-
arged bj  nearly one fourth, notwithstanding which the price  has been  kept at its  former very
moderate rate.   By the use of a close, though very legible type, an  unusually large amount of
matter is iondensed in its pages, the two volumes containing  as much as four or five ordinary
octavos   This, combined with the most careful mechanical execution, and its very durable bind
ing render*, it one of the cheapest works  accessible to the profession.  Every subject properly
belonging to the  lomain of surgery is treated in  detail, so that the  student who possesses this
work may be said to have in it a surgical library.
  We have now brought our task to a conclusion, and
have seldom read a work with  the practical value ol
which we have been moreimpressed. Every chapter is
so concisely put together, that the busy practitioner,
when in difficulty, can at once find the information he
requires.  His work, on the contrary, is cosmopolitan,
the surgery ofthe world being fully represented in it.
The work, in fact, is so historically unprejudiced, and
s > eminently practical, that it is almost a false compli
ment to say that we believe it to be destined to occupy
a foremost place as a work of reference, while a system
of surgery like the present system of surgery is the
practice of surgeons.  The printingand binding of the
work is unexceptionable; indeed.it contrasts, in the
latter respect, remarkably with English medical and
surgical cloth-bound publications, which are generally
so wretchedly stitched as to require re-binding before
they are any time in use.—Dub. Journ.  nf Mtd. Sci..
 March, 1874.
  Dr. Gross's Surgery, a great work, has become still
greater, both in size and merit, in its most recent form.
The difference in actual number of pages is not more
than  130, but. tbe size of the page having been in-
creased to what we believe is technically  termed •ele-
phant," there has been roomforconsiderableadditions.
which, together with the  alterations, are  improve-
ments.—Land. Lancet,Nov. 16,1872.

  It combines, as perfectly as possible, the qualities of
a text-book and work of reference. We tbink this last
elition of Gross's "Surgery," will confirm bis title of
' Primus inter Pares." It is learned, scholar-like, me-
thodical, precise, and exhaustive.  We scarcely think
any living man could write so complete and faultless a
treatise, or comprehend more solid, instructive matter
in the given number of pages. The labor must have
been immense, and the work  gives evidence of great
powers of mind,  and  the highest order of intellectual
discipline and methodical disposition, and arrangement
of acquired knowledge and personal experience.—A. F\
Med. Journ., Feb. 1873.
  As a whole, we regard the work as the representative
"System of Surgery" in  the English language.—St.
Louis Medical and Surg. Journ., Oct. 1872.
  The two magnificent volumes before us afford a very
complete view of the surgical knowledge ofthe day.
Some years ago we had the pleasure of presenting'the
first edition of Gross's Surgery to the profession as a
work of unrivalled excellence; and now we have the
result of years of experience, labor.and study, all con-
densed upon the great work before us. And to students
or practitioners desirous of enriching their library with
a treasure of reference, we can simply commend the
purchase of these two volumes of immense research —
Cincinnati Lancetand Observer, Sept. 1872.
  A complete system of surgery—not a mere text-book
of operations, but ascientific aecountuf surjiical theory
and practicein all its departments.—Brit, and For,
 M"d Chir. Rev., Jau. 1873.
B
Y THE SAME AUTHOR.
 A   PRACTICAL  TREATISE  ON  THE  DISEASES, INJURIES,
   and Malformations ofthe Urinary Bladder, the Prostate Gland, and the Urethra.  Third
   Edition, thoroughly Revised and Condensed, by Samuel W. Gkoss, M.D., Surgeon to
   the Philadelphia Hospital.  In one handsome octavo volume of 674 pages, with 170 illus-
   trations: cloth, $4 50.  (Just Issued.)
  For reference and genera I information, the physician
or surgeon can find no work that meets their necessitiet
more thoroughly than tbi«. a revi.-ed edition of an ex-
cellent treatise, and no medical library should be with-
out it.  Replete with handsome illustrati ns and good
ideas, it has the unusual advantage of being easilj
comprehended,by the reasonable and practical mannei
in which tbe various subjects are syr,tematized and
arranged  We heartily recommend it to tbe profession
a« a valuable addition to the important literature of dis-
eases ofthe urinary organs.—Atlanta Med Journ., Oct.
1876.
  It is with pleasure we now again take up this old
work in a decidedly new dress. Indeed, it must be re-
garded as a new book in very many of its parts.  The
chapter.-  on -'Diseases of the Madder,"  "Prostate
Body," and '•Lithotomy," are splendid specimens  of
lescriptive writing; while the chapter on "Stricture'*
is one ofthe most concise and clear that we have ever
read.—iVetc York Med. Journ., Nov.1876.
 T>Y THE SAME AUTHOR.
   A  PRACTICAL  TREATISE   ON  FOREIGN  BODIES  IN  THE
      AIR-PASSAGES.  In  1 vol. 8vo., with illustrations, pp. 468, cloth, $2 75.

 T)RUITT (ROBERT), M.R.C.S., frc.

    THE PRINCIPLES AND PRACTICE OF  MODERN  SURGERY.
      A new and revised American, from the eighth enlarged and improved London edition Illus-
      trated with four hundred and thirty-two wood engravings.  In one very handsome octato
      volume, of nearly 700 large and closely printed pages, cloth, $4 00 ;  leather, $5 00.
  All that  the surgical student or practitioner could
desire.—Dublin Quarterly Journal.
  It  is a most admirable  book.  We do  not know
when we have examined one with more pleasure.—
Boston Med. and Surg. Journal.

  tn Mr.Druitt's book,though containingonly some
seven hundred pages, both the principles and the
practice of surgery are treated, and so clearly aBd
perspicuously, as to e lucid atee very important topic
We nave examined thebook most thoroughly and
can «ay that this success is well merited.  His'book
moreover, possesses the inestimable advantages of
laving the subjects perfectly  well arranged and
clafsified and of being written in a  stvle at once
clear and succinct.—Am. Journal of Med. Sciences 
's Publications— (Surgery).
27
 A SHHURST (JOHN,  Jr.), M.D.,
-£*-     Prof, of Clinical Surgery, Univ of Pa.. Surgeon to the Episcopal Hospital, Philadelphia.
    THE  PRINCIPLES  AND PRACTICE  OF  SURGERY.   Second
      edition, enlarged and revised.   In one very large  and handsome octavo volume ol over
      1000 pages, with 542 illustrations.   Cloth, $6; leather, $7.   (Just Ready.)
                                                  Ashhunt's Surgery is too  well  known  in  this
  Conscientiousness and thoroughness are two very
marked trails of character in  the  author  of  this
book.  Out of these traits largely has grown the
Biiccess of his mental fruit in the past, aud the pre-
sent offer seems in no wise an exception to what has
gune bt-fore.  The g neral arrangement of the  vol-
ume is the sameas in the first edition, but everypart
has been carefully  revised, and much  new matter
added.—Phila. Med. Time*, Feb. 1, 1S79.

  We have previously  spoken of Dr.  Ashhurst's
work in terms of praise  We wish to reiterate those
terms here, and  to add  that no more  saiUfactory
representation of midern surgery has yet fallen
from the press.   In point  of judicial  fairness, of
power of c >ndeusation, of accuracy and  conciSeuess
of expres-iou and thoroughly  good Eugli>h, l'rof.
Ashhurst has no superior among the surgical writers
in America.—Am. Practitioner,  Jan. 1S79.

  The attempt to embrace In a volume of 1000 page9
the  whole  Held  of  surgery, general and special,
would be a hopele-s ta k unless through ti.e most
liteless  industry in co lating and  arranging,  and
the wisest judgment in condensing and excluding.
Th<-se facilities have been abundantly employed by
the-author, and  he  has given us a most excellent
treatise, brought  up by the revision for  the second
edition to the latest d-ite.  Of course this book is not
de.-igned- for specialists, but as  a course of general
surgical knoulndge  aud  for general  practitioners,
and as a text-book tor students  it is not surpa  sed
by any that ha< yet appeared, whether  of h>aie or
foreign  authorship.—N.  Carolina  Med. Journal,
Jan. 1S79.
 country to require special  commeudation  from  ns.
 This, its second edition, enlarged  and thoroughly
 revised, brings  it nearer our idea of a model text-
 bo 'k than any recently published treatise.  Though
 numerous additions have been made, the size of the
 work is not materially increased  The main trouble
 of text  books of modern times is that they are too
 cumbersome.  The student needs a  book which will
 furnish  him  the most information in the  shortest
 time  In every respect this work of Ashhurst is
 the model textbook  full, comprehensive and com-
 pact.—Nashville Jour, of Med. and Surg., Jan. '79.
  The favorable r ception of the first edition is a
 guarantee of the popularity of this edition, which is
 fresh from  the  editor's  bands with many  enlnge-
 inents and improvements.  The author of this work
 is deservedly popular as an  editor and writer, and
 his contributions to the literature  of surgery La»e
 gained for him wide reputation.  The volume now
 offered the. profession will add new laurels to those
 already  won by previous contributions.   We can
 only add that the work is well arrang d, filled with
 practical matter, and  contains in  brief and clear
language all that is necessary t > be learneu by the
student  of surgery  whilst in attendance upon lec-
 tures, or the general practitioner- in his daily routine
 practice.—Mo. Med Journal, Jan. 1879.
 The fact th.it  this work has reached a second edi-
tion so very soon after the  publication of the first
one, speakc more highly of its merits than anything
Wf  might say in the way  of commendation.  It
seems to have immediately gained tbe favor of stu-
dents aud physicians.—Cinctn. Med. News,J&u. '79.
 BRYANT (THOMAS),  F.R.C.S.,
 U      Surgeon to Guy's Hospital.
    THE  PRACTICE OF SURGERY.    Second  American, from the Sec-
      ond and Revised English  Edition.   With Six  Hundred and Seventy two Engraving! on
      Wood   In one large and very handsome imperial octavo volume of over 1000 larg« and
     ' closely printed pages.  Cloth, $6;  leather, $7   (Just Ready)
  This work has enjoyed  the advantage of two thorough revisions at the hand of the author since
 the appearance ofthe first American edition, resulting in  a very notable enlargement of size and
 improvement of matter.  In England this has led to the division of the work into two volumes,
 which are here comprised in one, the size being increased to a large imperial octavo, printed on
 a condensed but clear type   Tbe series of  illustrations has undergone  a. like revision,  and will
 be found correspondingly impro  ed.
  The marked  success of the work on both  sides of the Atlantic shows  that the author  has  suc-
 ceeded in the effort to give to student  and practitioner a sou  d and trustworthy guide in the
 practice of Surgery;  while the simultaneous appearance of the  present edition in England and
in  this country affords to the American reader  the  benefit of the most recent advances made
abroad in surgical science.
  There are so many text>books of surgery, so many
 written by skilled and dist.nguished hands, that to ob
 tain the honor of a third edition in England i- no ii<:ht
 praise.  Mr. Bryant merits this, by clearness of style.
 snd good judgment in selecting the operations hr re-
 commends, in bis  new  editions he goes carefully over
 the (Id grounds, in light of later  research.  On these
 and many allied points, Mr. Bryant is a culm and un-
 partisan observer, and  his book throughout has the
 great  merit of maintaining the true scientific, judicial
 tone of mind.—Med. and Sui-g. Reporter, March 22,
 1879.
  The work before us is the  American reprint of the
 last London edition, and has the advantage over the
 latter in being of more convenient size, and in being
 compressed into one volume.  The author has rewrit-
 ten the greater part of the work, and has succeeded,
 in the amount of new matter added, in making it mark-
 edly di>tinciive from  previous edi ions.  A few extra
 pa"HB have been added, and also a few new  illustrations
 introduced.  The publishers  have  pre.-ented the work
in a creditable style. As a concise and practical manual
of British surgery it is perhaps without an equal, and
will doubtless always be a favorite text-book with the
Student aud prac itiouer.— _V. 1". Med. Jitcord, March
 22,1879.
   Another edition of this manual having been called
 for, the author has availed hiin.-elf of the opportunity
 to make no few alterations in the substance as we.l
 as in the arraugeuient of the work, and, with a view
 to its improvement, has rcea-t the maierials and re-
 vised the whole.  We ourselves are  of the op.uion
 that there it no better work on surgery extant —
 Ciucinnati Med. News, Match, 1S79
   Bryant's Surgery has been favorably received from
 the fimt, and evidenily grows in the esteem ot  the
 profession w th each succeeding edition.  In glanc-
 ing over the volume before ns we Hud proof in aimost
 every chapter of the thorough revision which  tue
 work has  undergone, m ny parts having been  cut
 out  and replaced by  matter entirely fresh.__N.  y
 Med.  ourn., April, 1879.
   Welcome as the new edition is, and as much as it
 Is entitled to commendation, yet its appearance at
 this time is, in a cer ain sense, a matter of regret  as
 it will be iu  competition with another work, lately
 issued from the  sine  press.  But, the difficult ta-k
 of forming a judgment as to the relative merit» of
 Bryant and Ashburst we will not attempt, but pre-
 dict that,  considering the  high excel.euce of both
 many others w.ll likewise be torced to hesitate Ions
 in unking choice between  them - Ci.icit.nuti LaiZ.
I cet and Clinic,  Match 22, 1S79. 
28        Henry C. Lea's Son  &  Co.'s  Publications—(Surgery).
PJRICRSEN (JOHN E.),
         Professor of Surgery in University College, London, etc.

   THE  SCIENCE AND  ART OF SURGERY; being a Treatise on Snr-
      gical Injuries,  Diseases, and Operations.    Carefully  revised  by the author from the
      Seventh and enlarged English Edition.  Illustrated  by  eight hundred and sixty two en-
      gravings on wood.  In  two  large and beautiful octavo volumes of nearly 2000 pages :
      cloth, $8 50 ; leather, $10 50.   (Now Ready.)

  In revising this standard work the authorhas spared no painsto render it worthy of a continu-
ance  of the very marked  favor which it  has so long enjoyed, by bringing it thoroughly on a
level  with  the advance in the science and art of  surgery made since the appearance of the
last edition.   To accomplish this  has required the addition of about two hundred pa^e" of text,
while the illustrations have undergone a marked improvement  A hundred and fifty additional
wood-cuts have been inserted,  while about fifty other new ones have been substituted for figures
which were not deemed satisfactory.   In  its enlarged and improved form  it is therefore pre-
sented with the  confident anticipation that it will maintain its position in  the  front rank of
text-books for the student, ana of works of reference for the practitioner, while its exceedingly
moderate price places it within the reach of all.
  The seventh edition is before the world as the last
word of surgical science. There may be monographs
which  excel it upon  certain  points, but as a con-
spectus upon surgical principles aud  practice it is
unrivalled.  It  will well reward practitiouers  to
read it, for it has been a peculiar province of Mr.
Erichsen  to demonstrate the absolute interdepend-
ence of medical and surgical science   We need
scarcely add, in  conclusion, that we  heartily com-
mend  the  work  to  students that they may be
grounded in a sound  faith, and to practitioners  as
an invaluable guide at the bedside.— Am.  Practi-
tioner, April, 1878.
  It is no idle compliment to say that this is the best
edition Mr. Erichsen has ever  produced of his well-
known book.  Besides inheriting the  virtues of its
predecessors, it possesses excellences quite its own.
Having stated that Mr. Erichsen his incorporated
into  this  edition every recent improvement in the
science and art of surgeiy,it would be a supereroga-
tion to give a detailed criticism.  In short,  we un-
hesitatiugly aver that we know of no other single
work where the student and practitioner can gain at
once so clear an insight into the principles of surgery,
and ■■» complete a  knowledge of the exigeticies of
surgical practice.— London Lancet, Feb. 14, 1878
  For the past twenty years Erichsen's Surgery has
maintained its place as the leading text-book, not only
in this country, but in Great Britain.   That it is able
to hold its ground, is abundantly proven by the tho-
roughness with which the present edition  has bein
revised, and by the large amount of valuable mate-
rial that has been added. Aside from  thiR, one hun-
dred and  fifty new illustrations have been inserted,
including quite  a number of  microscopical appear-
ances of pathological  processes,  so milked is this
change for the better,  that the work almost appears
as an entirely new one.—Med.  Record, Feb.  23,1878.
ASHTON ONTHEDISEASES, INJURIES, and MAL-
  FORMATIONS  OF THE  RECTUM  AND ANUS:
  with remarks on Habitual Constipation. Second
  American, from the fourth and enlarged London
  Edition.   With illustrations.  In one 8vo. vol. of
  281  pages, cloth,$3 25.
  Ofthe many treatises on Surgery which it has been
our task to study, or our pleasure to read, there is none
which in all points has satisfied us so well as the classic
treatise of Erichsen. His polished, clear style, his free-
dom from prejudice and hobbies, his unsurpassed grasp
of his subject, and vast clinical experience, qualify him
admirably to write a model te^t-book.  When we wish,
at the least cost of time, to learn the most of a topic in
surgery, we turn, by preference, to his work.  It is  a
pleasure, therefore, to see that the appreciation of it is
general, and has led to the appearance of another edi-
tion.—Med. and Surg. Reporter, Feb. 2,1878.
  Notwithstanding the increase in size, we observe that
much old  matter has been omitted.  The entire work
has been thoroughly written up, and not merely amend-
ed by  a few extra chapters  A great improvement has
been  made in the illustrations. One hundred and fifty
new ones have been added, and many of the old ones
have  been redrawn. The author highly appreciates the
favor with which his work has been received by Ameri-
can surgeons, and has endeavored  to render his latest
edition more than ever worthy of their approval.  That
he has succeeded admirably, must, we think, be the
general opinion. We heartily recommend the book to
both  student and practitioner.—N. Y.Med. Journal,
Feb. 1878.
  Erichsen  has stood  so prominently forward for
years as a writer on Surgery, that his  reputatlbn is
world wide, and his name is as familiar to the med-
ical student as to the accomplished and experienced
surgeon.  The work is not a reprint of former edi-
tions, but has in many places been entirely rewrit-
ten   Recent improvements in surgery have not es-
caped his notice, various new operations have been
thoroughly analyzed, and their merits thoroughly
discussed.  One hundred  and fifty  new wood-cuts
add to the value Of this work.—N. O. Med. and Surg.
Journal, March, 1878.
SARGENT ON BANDAGING AND OTHER OPERA-
  TIONS OF MINOR SURGERY. New edition, with
  an additional chapter on Military Surgery. One
  12mo. vol. 0l383pag38 withl8i wood-cuts Cloth
  $175.                                      '
 TJOLMES  (TIMOTHY), M.D.,
J-J.     Surgeon to St. George's Hospital, Londoi

   SURGERY, ITS  PRINCIPLES
       some octavo volume of nearly 1000 pages,
       (Just Issued.)
  This is a work which has been lookedfor on both
sides ofthe Atlantic with much interest. Mr. Holmes
Is a surgeon of large and varied experience, and one
of the  best known, and perhaps the most biilliant
writer upon surgical subjects in England.  It is a
book for students—and an admirable one—and for
the busy general practitioner It will give a student
all the knowledge needed to pass a rigid examina-
tion. The book fairly justifies the high expectations
that were formed jf it. Its style is clear and forcible,
even brilliant at times, and the conciseness needed
to  bring it within its properlimits has notimpairea
AND  PRACTICE.   In  one  hand-
with 411 illustrations. Cloth, $6; leather, $7.


its force and distinctness.—^. Y. Med. Record, April
14, 1876.
  It will be found a most excellent epitome of snr-
gery by the  general practitioner who has not the
time togive attention to more minute and extended
worksand to the medical student. In fact, we know
of no one we can more cordially recommend. The
author has  succeeded well in giving a plain and
practical account of each surgical injury and dis-
ease,  and of the treatment which is  most com-
monly advisable. It will no doubt become a popu-
lar work in the profession, and especially as a text-
book.—Cincinnati Med. News, April, 1676. 
Henry C.  Lea's Son & Co.'s Publications—(Ophthalmology).    29
 fJAMILTON (FRANK H.), M.D.,
■*-*     Professor of Fractures and Dislocations, Ac., in Bellevue Hosp. Med. College, New York.
   A  PRACTICAL TREATISE  ON  FRACTURES  AND  DISLOCA-
       TIONS. Fifth edition, revised and improved.  In onelarge and handsome octavo volume
       of nearly 800 pages, with 344 illustrations. Cloth, $5 75 : leather. $6 75. (Lately Issued.)
  This work is well known,  abroad as well as at home, asthe highest  authority on its important
subject—an authority recognized in the courts  as well as in the schools  and in practice—and
again manifested, not only by the demand for a fifth  edition, but by arrangements now in pro-
gress for the speedy appearance of a  translation  in Germany.  The repeated revisions which the
author has thus had the opportunity of making have enabled him to give the most careful consid-
eration to every portion of the volume, and he has sedulously endeavored in the present issue,
to perfect the  work by the aid of his  own enlarged experience, and to incorporate in it whatever
of value has been added in this department since the  issue ofthe fourth edition.  It will there-
fore be found considerably improved in matter,  while the most careful attention has been paid
to the  typographical execution, and the volume is presented  to the profession in the confident
hope that it will more than maintain its very distinguished reputation.
                                              of its teachings, but also by reason ofthe medico-legal
                                              bearings of the cases of which it treats, and which have
                                              recently been the subject of useful papers by Dr Hamil-
                                              ton and others, is sufficiently obvious to every one. The
  There is no better work on the subject in existence
than that of Dr. Hamilton. It should be in the posses-
sion of every general practitioner and surgeon.— The
Am. Journ. of Obstetrics. Feb. 1876.
  The value of a work like this to the practical physi-
cian and surgeon can hardly be over-estimated, and the
necessity of having such a book revised to the latest
dates, not merely onaccount ofthe practical importance
present volume seems to amply fill all the requisites.
We can safely recommend it as the best of its kind in
the English language, and not excel led in any other.
Journ. of Nervous and Mental Disease, Jan 1876.
B
   ROWNE (EDGAR A.).
        Surgeon to thehiv-rpool Eye and Kar Infirmary, and to the Dispensary for SJcin Diseases.

  HOW TO  USE  THE OPHTHALMOSCOPE.   Being Elementary In-
      structions in Ophthalmoscopy, arranged for the Use of Students.  W itb thirty five illustra-
      tions.  In one small volume royal 12mo. of 120 pages : cloth, $1.   (Now Ready.)

 ]\JETTLESHIP (ED WARD), F.R C.S.,
-*■ '       Ophthalmic S^rg. and Led. on Ophth. Surg at St. Thomas' Hospital. Lor don.
  MANUAL  OF  OPHTHALMIC   MEDICINE.   Jn  one  royal 12mo.
      volume of over 350 pages, with 89 illustrations.  Cloth, $2.  (Just Ready.)
  The hook is written in a careful and logical man-
ner, and though extremely concise, we have failed
to notice any evidence of ambiguity.  It is rendtred
more compact and homogeneous by frt quern refer
ences. by page  number, to other portions of the
work; repetitions are thus avoided, and we  have
been surprised to find how much information our
anthor has succeeded in conveying  iu so small  a
space. A careful study of the  book will well repay
the  general  practitioner, even  though  it  s>ould
serve only as a moi itor.  It  is particularly useful
in the latter regard,  as the subject of treatm nt  is
presented in a thoroughly conservative manner.—
N.  Y. M-A. Record, March 6, ^8d.
                                             acceptable book.—Cincinnati Lancet and Clinic,
                                             Feb. 7, 1&80.
                                               We are sure he has produced a useful volume. Its
                                             eighty-nine illustrations add much to its attractive-
                                             ness.  Full directions for exam ning the eye are
                                             given.  The descriptions of the various operations
                                             and suggestions for 1' cal and surgical  reatment, ar.d
                                             the etiology of eye diseases, are done full justice to.
                                             - Louisville Med. News, Jan 1F80.
                                               It is multum in parvo, containing all the leading
                                             points to be remembered in the pathology, descrip-
                                             tion, and treatment of diseases of the eye.  It will
                                             be lound especially valuable in  preparing for exam-
                                             inations   Practitioners will find it convenient as a
  The author has succeeded in touching upon about j work of reference, when they wish to refresh  their
all the points, operations, diseases of the eye in ; memories jn respect to  the feature*  of some  affec-
relation to general diseases, and has prepared a very tionB _Cincinnati Med. News,  Jan. 18t0
PAR TER (R.  BRUDENELL), FR.CS.,
^     Op'itnaln ic Surgeon to St George s Hospital, etc.

  A PRACTICAL TREATISE  ON DISEASES OF THE EYE.  Edit-
     ed, with test-types and  Additions, by John Green, M.D. (of St. Louis, Mo.).  In one
     handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $3 75.  (Just
     Issued.)
 It is with great pleasure that we can endorse the work  chapter is devoted to a discus>ion ofthe usesandselec-
as a most valuable contribution to practical ophthal
mology. Mr. Carter never deviates from the end he has
in view, and presents the subjectin a clear and conciw
manner, easy of comprehension, and hence the mori
valuable.  We would especially commend, however, a*
worthy of high praise, the manner in which the thera-
peutics of disease of the eye is elaborated, for here tin
author is particularly clear and practical, where othei
writers are unfortunately too often deficient. The final
tion of spectacles, and is admirably compact, plain, and
useful, especially the paragraphs on the treatment of
presbyopia and myopia. In conclusion, our thanks are
due the author for many useful hints in the great sub-
ject of ophthalmic surgery and therapeutics, a field
where of late years we glean but a few grains of sound
wheat from a mass of chaff.—New York Medical Recoid,
Oct. 23,1875.
w
     ELLS (J. SOELBERG),
        Professor of Ophthalmology in King's College Hospital, Ac.

   A TREATISE ON  DISEASES  OF THE EYE.   Third  American,
      from the Fourth and Revised London Edition, with additions ;  illustrated with numerous
      engravings on wood, and six colored plates. Together with selections from the Test-types
      of Jaeger and Snellen. In one large and very handsome octavo volume. (Preparing.)

LAURENCE'S HA.SDfBOOK  OF  OPHlHAL.MlC i LAWSON'S  INJURIES TO  THE EYE  ORBIT
  SURGERY, forthe u>e of Practitioners. Second    AND EYELIDS:  tteir Immediate  and Remote
  edition, revised^ and  enlaiged ^ With numerous |   Effocts.  With about one hundred illustrations.
                                                   one  very  handsome  octavo  volume,  cloth
illnslrations.
nine, cloth,
In one very handsome octavo vol-
75.
Effocts.
Iu
»3 
32
Henry C. Lea's Son &  Co.'s  Publications.

tn^scs C
INDEX  TO   CATALOGUE.
PAGE
   1
 American Journal ofthe Medical Sciences
 Allen's Anatomy .....
 Anatomical Atlas, by Smith and Horner
 Ashton on the Rectum and Anus
 Attfleld's Chemistry ....
 Ashwell on Diseases of Females
 Ashhurst's Surgery
 Browue on Ophthalmoscope .
 Browne on tbe Throat .
 Burnett on the Ear
 Barnes on Diseases of Women
 Barnes' Midwifery
 Bellamy's Surgical Anatomy
 Bryant s Practice of  Surgery
 Bloxam's Chemistry
 Blandford on Insanity .
 Basham on Renal Diseases
 Barlow's Practice ol Medicine
 Bowman's (John E.) Practical Chemistry
 Bristowe's Practice    .    .     .    .
 Bamstead on Venereal
 gumstead and Cullerier'sAtlasof Venereal
 Carpenter's Human Physiology
 C-trpenter on the Use and Abuse of Alcohol
 Cornil aud Ranvier    ....
 Carter on the Eye.....
 Cleland's Dissector   ....
 Classen's  Chemistry   ....
 Clowes' Chemistry    ....
 Century of American  Medicine  .
. Chadwick on Diseases of Women
 Charcot on the Nervous System  .
 Chambers on Diet and Regimen  .
 Christisonand Griffith's Dispensatory
 Churchill's System of Midwifery
 Ghnrchillon Puerperal Fever
 Condie  on Disease* of Children  .
 Cooper's (B.  B.) Lectures on Surgery
 Cullerier's Atlas of Venereal  Diseases
 Cyclopaedia of Practical Medicint
 Duncan on Diseases of Women  .
 Dalton's Human Physiology
 Davis's Clinical Lectures
 Dewees on Diseases of Females .
 Druitt's ModernSurgery
 Dunglison's Medical  Dictionary
 Ellis's Demonstrations in Anatomy
 Erichsen's System of Surgery
 Emmet  on Diseases of Womeu
 Farquharson's Therapeutics
 Foster's Physiology . .
 Fenwick's Diagnosis
 Finlayson's Clinical Diagnosis
 Flint on Respiratory Organs
 Flint on the  Heart
 Flint's  Practice of Medicine.
 Flint's  Essays
 Flint's  Clinical Medicine
 Flint on Phthisis  .
 Flint on Percussion
 Fothergill's Handbook ofTreatment  .
 Fothergill's Antagonism of Therapeutic Ag
 Fjwnes's Elementary Chemistry
 Fox on  Diseases of the Skin
 Fuller on  the Lungs. &c.  ■
 Green's Pathology and Morbid Anatomy
 Greene's Medical Chemistry
 Gibson'* Surgery.....
 Gluge's Pathological Histology, by Leidy
 Gray's  Anatomy.....
 Galloway's Analysis   ....
 Griffith's (R.  E.) Universal Formulary
 Gross on Urinary Organs  .
 Gross on Foreign  Bodies in Air-Passages
 Gross's System of Sureery .
 Habershon on the Abdomen .
 Hamilton on  Dislocations and Fractures
 Bartshorne's Essentials of Medicine
 Hartshorne's Conspectus ofthe Medical Sciences  6
 Hartshorne's Anatomy and Physiology
 Hamilton on  Nervous Diseases  .
 Heath's Practical Anatomy
 Hoblyn's  Medical Dictionary   .
nts
Hodge on Women.....
Hodge's Obstetrics
Holland's Medical Notes and Reflection* .
Holmes's Surgery ...        .
Holden's Landmarks      ....
Horner's Anatomy and Histology
Hudson on Fever......
Hill on Venereal Diseases  ....
Hillier's Handbook ot Skin Diseases
fones (C. Handfieid) on Nervous Disorders
Knapp's Chemical Technology  .
Lea'sSuperstition and Force       .
Lea's Studies in Church History
Lee on Syphilis   ....
Lincoln on Electro-Therapeutics
Leishman's Midwifery .
La Roche on Yellow Fever.
La Roche on Pneumonia, &c.
Laurence and Moon's Ophthalmic Surgery
Lawson on the Eye
Lehmann's Physiological Chemistry, 2 vols
Lehmann's Chemical Physiology
Ludlow's Manual of Examinations
Lyons on Fever  ....
Medical NewB and Abstract
Morris on Skin Diseases
Meigs  on Puerperal Fever  .
Miller's Practice of Surgery
Miller's Principles of Surgery .
Montgomery on Pregnancy
Nettlesbip's Ophthalmic Medicine
Neill and Smith's Compendium of Med. Selene
Obstetrical Journal
Parry on Extra-Uterine Pregnancy
Pavy on Digestion
Parrish's Practical Pharmacy  .
Plrrle's System of Surgery  .
Playfair's Midwifery  ....
Quain and Sharpey's Anatomy, by Leidy
Reynolds' System of .Medicine .
Roberts on Urinary Diseases
Ramsbotham on Parturition
Remsen's Principles of Chemistry
Rigby's Midwifery    ....
Rodwell's Dictionary of Science .
Stimson's Operative Surgeiy
Swayne's Obstetric Aphorisms .
Seiler on the Throat    ....
Sargent's Minor Surgery
Sharpey and Quaiu's Anatomy, by Leidy
Skey's Operative Surgery  .
Slade  on Diphtheria   ....
Schafer's  Histology    ....
Smith (J  L.) on Children
Smith (H. H.) and Horner's  Anatomical Atlas
Smith (Edward) on Consumption
Smith on Wasting Diseases in Children
Still6's Therapeutics   ....
Stille  & Maisch's Dispensatory .
Sturges on Clinical Medicine
Stokes on Fever.....
Tanner's Manual of Clinical Medicine
Tanner on Pregnancy  .
Taylor's Medical Jurisprudence
Taylor's Principles and Practice of Med J
Taylor on Poisons
Tuke on the Influence of the Mind
Thomas on Diseases of Females
Thompson on Urinary Organs
Thompson on Stricture .
Todd on Acute Diseases
Woodbury's  Practice   .
Walshe on the Heart  .
Watson's Practice ol Physic
Welle on the Eye .
West on Diseases of Females
Weston Diseases of Children
Weston Nervous Disorder*, of Children
Williams on Consumption  .
Wilson's Human Anatomy .
Wilson's Handbook of Cutaneous Medicine
Wiihler's Organic Chemistry
Winckel on Childbed.....
uris
HENRY C. LEA'S SON &  CO.- Philadelphia. 
 

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