SLIGHT AILMENTS NEW ENLARGED EDITION. BE ALE HC 50 356 Scale- On slight ailrronts . University of California Form L 1 50 This book is DUE on the last date stamped below. 5m-8,'21 ON SLIGHT AILMENTS: THEIR NATURE AND TREATMENT. OTHER WORKS BY LIONEL S. BEALE, M.D., F.R.S. HOW TO WORK WITH THE MICROSCOPE. A Complete Manual of Microscopical Manipulation, con- taining a full description of many new processes of in- vestigation, with directions for examining objects under the highest powers, and for taking photographs of mi- croscopic objects. Fifth Edition. Containing over 400 Illustrations, many of them colored. 8vo. Price $7.50 THE USE OF THE MICROSCOPE IN PRACTICAL MEDICINE, for Students and Practitioners, with full directions for examining the various secretions, etc., in the Microscope. Fourth Edition. 500 Illustrations. Much enlarged. 8vo. Price $7.50 " As a microscopical observer, and a histological manipu- lator, his (Dr. BEALEI skill and eminence are generally con- ceded." Popular Science Monthly. BIOPLASM. A Contribution to the Physiology of Life, or an Introduction to the Study of Physiology and Med- icine, for Students. Illustrated. Price $2.25 PROTOPLASM; or MATTER AND LIFE. Third Edition, very much enlarged. Nearly 350 pages. Six- teen Colored Plates. Part I. DISSENTIENT. Part II. DEMONSTRATIVE. Part III. SUGGESTIVE. One Volume. ON LIFE AND. VITAL ACTION IN HEALTH AND DISEASE. i2ino. Price $2.00 LIFE THEORIES; Their Influence upon Religious Thought. Six Colored Plates. Price 2.00 P. BLAKISTON, SON & CO., Publishers. ON SLIGHT AILMENTS: n THEIR NATURE AND TREATMENT. BY LIONEL S. BEALE, M.B., F.R.S., FELLOW OP THE BOYAL COLLEGE OF PHYSICIANS; PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE IN KING'S COLLEGE, LONDON, AND PHYSICIAN TO KING'S COLLEGE HOSPITAL; LATELY PROFESSOR OF PATHOLOGICAL ANATOMY, AND FORMERLY PROFESSOR OF PHYSIOLOGY AND OF GENERAL AND MORBID ANATOMY IN KING'S COLLEGE. SECOND EDITION, ENLARGED AND ILLUSTRATED. PHILADELPHIA: P. BLAKISTON, SON & CO., No. 1012 WALNUT STREET. 1885. 1 W .J| V .... PUBLISHERS' NOTICE. This new re- vised edition of Dr. Beales ''Slight Ailments " is published simultaneously with the London Edition, by special arrangement between Dr. Beale and P. Blakiston, Son and Co. It is, therefore, the only authorized edition, and contains all the Additions,, Illustrations, and a complete Index, as in the Lon- don Edition* so 33k TABLE OF CONTENTS. Introductory. Slight ailments and civilization; Interest in the patient ; Attention and kindness; Tact and treatment; Quackery and tact; Humbug; Vulgarity;. Decillionths of grains ; Credulity and imposition ; Imposture and nonsense ; Principles of con- duct; Studying slight ailments; Self-supporting dispensaries; Remedies in- slight ailments; Knowledge derived from microscopical observation ; Intermolecular circulation 17-41 Of the Tongue in Health and in Slight Ailments. Characters in health; The dorsum of the tongue; Funglform and filiform papillae and their covering; Epithelial cells; Fungi and low organisms in the mouth; Bacteria ; Tongue in various derangements; Importance of secretion ; Dry and moist states of the tongue; Exciting the flow of saliva; White moist furred tongue ; Bright red tongue ; Dry brown tongue; Haemorrhage ; Cracks and fissures ; Changes in the mucous membrane of mouth and fauces ; Inhalers, bronchitis kettle; Of the use of spray; Metallic and other tastes in the mouth; Aphthae, thrush, sores, and ulcers in the mouth ; Treatment of aphthae ; Offensive breath; Use of purgatives; Use of mercury 4 I ~75 Appetite Nausea Thirst Hunger. Impaired appetite; Loss of appetite ; Voracious appetite, bulimia; Nausea; Treatment of nausea ; Objections to alcohol ; Thirst 75~^4 Indigestion: Its Nature and Treatment. Indigestion, dyspepsia ; Nerve-fibres of intestinal canal ; Nerve-ganglia and plexuses; Gastrodynia-; Heartburn, pyrosis, or vvalerbrash ; Flatulence, wind in the stomach ; Treatment of ordinary forms of indigestion ; Of condiments ; In- fluence of cold ; Indigestion from failing glands, as in old age ; Of pepsine and its uses Method of preparing pepsine 84-111 Of Constipation. Importance of regular action of bowels ; Impaction of faecal matter in large intestine ; Influence of the reabsorption of fluid in causing constipation ; Haemor- rhoids or piles 111-122 Treatment of Constipation. Of the action of enemata ; Hygienic and dietetic treatment of constipation; Exercise, cold-bath, rubbing, moist applications, etc.; Diet; Of taking fluid; Smoking tobacco ; Of purgatives in' constipation ; Drastic and hydragogue purga- tives ; Saline purgatives; Friedrichshall and other waters 123-144 2 xiii Xiv CONTENTS. Diarrhoea. Ordinary diarrhoea; Nature and causes of diarrhoea; Treatment of diar- . rhoea 144-152 Intestinal Worms. Threadworms; Large round worm ; Remedies to be used 152-154 Vertigo Giddiness. Vertigo, swimming in the head; Causes; Aural vertigo, treatment, etc*... 154-157 Biliousness Sick Headache. Biliousness; Derangement of the liver ; Treatment of biliousness; Action of east wind; Jaundice* Yellow atrophy; Sick headache ; Treatment of sick head- ache ; Treatment of sick headache during the attack; Starving; Treatment of sick headache in the intervals between the attacks; Of the management of sick headache when the patient continues at work ; Drowsiness ; Wakefulness and restlessness 157-186 Neuralgia Rheumatism. Nervousness; Neuralgia; Treatment of neuralgia; Rheumatic pains ; Treat- ment of rheumatism ; Free sweating; Diet in rheumatism; Warm clothing. 187-202 On the Feverish and Inflammatory State. Of catching cold ; Preliminary changes and attendant phenomena ; Rise in the body-heat in all fevers and inflammations ; Is there increased oxidation in fever and inflammation? Method of ascertaining the temperature of the body; Fever, rigors, hot stage, sweating stage ; Of free secretion leading to recovery ; Princi- ples of treatnlent of a cold; Management of affections beginning like a cold. 202-219 Of the Actual Changes in Fever and Inflammation. Phenomena of fever and inflammation; Of a flea-bite; Alterations of calibre of small arteries; Influence of nerves in determining the degree of contraction; Of the ganglia governing the calibre of small arteries ; Nerves to capillary ves- sels; Demonstrating the nerves distributed to capillaries; Mechanism by which the capillary circulation of man and animals is regulated; General vascular dis- turbance resulting from local injury ; The formation of pus in and near the capil- laries in inflammation and fever; The passage of blood and living particles through the walls of capillary vessels, Diapedesis ; Haemorrhage,; Spontaneous movement ; Vital phenomena 219-248 Common Forms of Slight Inflammation. Formation of mucus, mucus corpuscle; Bioplasm of mucus; Dryness of the mucous membrane ; impaired sensibility ; counter-action ; counter-irritation ; Cracks and fissures about the lips ; Principles of treatment ; Conjunctiva, inflam- mation of; Treatment of inflamed eyes; Sore throat; treatment of sore throat; Gargles ; Running from the ears ; Inflammation of stomach and intestinal canal ; Chilblains; Treatment; Boils; Carbuncle; Changes preparatory to the occur- rence of disease ; Concluding remarks 248-276 INDEX 277 CORRIGENDIUM. On page 202, between the second and third paragraphs, the follow- ing heading has been inadvertently omitted : ON THE FEVERISH AND INFLAMMATORY STATE. SLIGHT AILMENTS: THEIR . NATURE AND TREATMENT. INTRODUCTORY. EACH one of us has, no doubt, suffered at times from slight derange ments of the health derangements which are not dependent upon 01 likely to determine structural change in any tissue or organ in the body due to temporary disturbance, to an alteration in the functional activity of tissues and organs, which may be soon succeeded by a return to the healthy state. In many instances the derangement depends upon the altered rate at which normal phenomena are performed. Perhaps, in consequence of changes in the blood itself or in the tissues outside the vessels, the blood flows too slowly or too quickly through the capillaries. These tubes often become unduly distended or relaxed. Disturbed action in the adjacent nerve- fibres is thereby occasioned, and pain or discomfort is in consequence experienced. Among civilized nations a perfectly healthy individual seems to be the exception rather than the rule. I do not remember having seen more than two or three men in the course of my life who had never experienced any form of illness, and did not know what it was to feel out of sorts. It is indeed very rarely one meets with any one who has reached the age of thirty who will not admit that at various times he has suffered from many different, though slight, derangements of health. We are indeed often told by persons, whose prospects of longevity are nevertheless good, that they have scarcely passed a week without the occurrence of a very decided departure from the healthy state. The most healthy among us occasionally feel unwell and are less up to work than is usual. Some complain of feeling fatigued, others tell you they are 2* B 17 1 8 SLIGHT AILMENTS AND CIVILIZATION. uncomfortable, or complain of being irritable and annoyed at slight troubles, which would not ruffle them in the least if they were in ordinary health. How few of those who take a very active part in the work of the world know what it is to enjoy uninterrupted health ! Most have to work on in spite of lassitude, or headache, or muscular or nerve pains, or indigestion, or some other discomfort which continually troubles them. How many of us experience a confused feeling, an indisposition to mental exertion, a distinct sense of fatigue after what we cannot but regard as very moderate mental application ! Many people take dismal so-called constitutional walks, not because they enjoy the exercise or from necessity, but because they have heard that this sort of penal servitude walking for walking's sake is necessary to keep themselves in a con- dition which some call health. Many a man thus imposes upon himself the regular performance of the most dreary form of task-worl^ and forces himself to go through his monotonous labors when his inclination would lead him to take rest and probably to go to sleep. In many instances the inclination would have the support of the reason. Some, again, who are considered to be in perfect health, scarcely know what it is to sleep soundly and rise refreshed, with spirits buoyant, ener- getic, with a desire for work. Men and women there are, and in every class of society, poor as well as rich, hardworking as well as idle, who scarcely ever eat without discomfort, and suffer still more if they do not take their usual meal. Few, indeed, of those who live in cities pass through life without being troubled with various derangements connected with the action of the stomach and intestinal canal. You will, of course, desire to know whether all these disturbances are necessary consequences of our civilization of our somewhat artificial mode of living or whether by altering our habits we could acquire and maintain a state of perfect health. Unquestionably not a few suffer because they 'are ignorant of the proper way of managing themselves in order that they may work most advantageously, or because they give way to habits of self-indulgence as regards the quantity and character of their food and drink. Many probably, from inherited weakness of various organs, would suffer more or less under any circumstances, and it is our duty to study the many ordinary slight ailments, in order that we may be able to mitigate the sufferings of our patients, if we cannot make them strong and vigorous. In this direction there is much to be done, and I cannot help thinking that of late years, in our zeal for pathological dis- covery, we have devoted less attention to functional disturbance than for the interests of the community might reasonably be looked for from us, and for the interests of true medicine might be expected. What is the meaning of these slight, but perhaps very frequent, disturbances or derangements of the changes which take place in an organism whose tissues are in a perfectly normal state? When any DERANGEMENTS AND DISCOMFORT. ig departure from the healthy state occurs, it is obvious" that the processes by which the equilibrium of physiological action is preserved are tempo- rarily deranged and out of order. An unusual or exceptional change- increased or diminished ordinary action results. In many instances some time must elapse before the exceptional gives place to the ordinary activity, and by slight excess of action in one or other direction the balance is restored. A little too much food, or food of a bad kind, or badly cooked, or food eaten at the wrong time, or too quickly a glass of bad wine, bad milk, or bad water, to say nothing of a dry east wind, or a cold damp atmosphere, has occasioned such disturbance in the normal changes in the body, as to cause even the strongest and exceptionally healthy to feel for a time far from well. Every generation has thus suffered, and we have no yet discovered exactly how a healthy person should proceed so as to keep every organ and every tissue in his body in a perfectly healthy state under the necessarily varying conditions to which it is exposed, so that each may continue to act for the longest possible time, and all gradually fail together in old age, until at last action ceases in natural and inevitable death. As it is our particular work in life to reduce disease and suffering to the utmost extent that is possible, it is undoubtedly our duty to care- fully study and investigate, as far as we are able to do so, the nature of such slight aches, pains, discomforts, and derangements from which nearly all suffer. Not a few people magnify their slight ailments, but, on the other hand, some persons are no doubt inclined to under-estimate the import- ance of, or to ignore altogether, aches, pains, and disturbances, the early recognition of which might be of great advantage, by enabling the doctor to interfere at once, and perhaps prevent serious illness, or even save that particular life. You will certainly be very frequently called upon to prescribe for slight ailments, and you will often be asked how this and that bodily derangement or discomfort may be avoided, upon what it depends, and whether it is not indicative of some change more serious than mere temporary disturbance of ordinary action. You will be expected to fully explain how many a slight ache or pain is caused, and you will often be asked to lay down rules of health, by the practice of which it may be avoided in the future. Very disappointed will the sufferer feel if you make light of his suffering, and dismiss him with the suggestion that, being only functional derangement, it is of no conse- quence. A little study and intelligent observation among sick people will teach you not to be too off-hand in giving advice, and will suffice to impress upon you the fact that very grave symptoms and the most excruciating pain may result from temporary derangements of no real consequence, and that, on the other hand, the most terrible morbid 2O GENERAL REMARKS. changes in important organs may exist for years, and run their course without the patient being cognizant of any unusual symptoms, or con- scious that anything in his organism had been going wrong. I propose, then, that these lectures should be devoted to the considera- tion of the nature and treatment of slight ailments. Could we examine the tissues ever so minutely, it is doubtful whether we should discover the slightest departure from the healthy state. No structural change whatever is induced, and even in cases in which there is decided depart- ure from the normal physiological action, and where considerable pain and distress may be experienced, the accumulation in the blood of some product that should be quickly eliminated, a slightly altered state of the fluid that transudes through the capillary walls and bathes the tissue elements, is probably all that would be found, and would indeed be quite sufficient to account for the symptoms. In the course of our inquiry questions of the greatest interest will present themselves, and although the present state of our knowledge does not enable us to give a full and satisfactory explanation of all the phenomena, say, of an Ordinary Cold 'or a Sick Headache, I feel sure that a more full consideration of the slight disturbance of physiological actions which are continually occurring even in the healthiest among us, will assist us in understanding those more complex changes which occur in actual disease. The plan I propose to adopt will not only enable me to bring under your notice thus early in my course some of the simplest and most common derangements you will be called upon to correct, but I shall be able to direct your attention to practical matters of great importance with regard to the action of remedies and methods of prescribing and administering many ordinary medicines matters of greater importance than ever in these days, when so few among you enjoy the advantages formerly gained by apprenticeship, and become acquainted with the art and mystery of preparing drugs and compounding medicines and dis- pensing pills and potions. I shall make use of very few learned terms, and when obliged to employ hard words shall give their exact meaning and derivation, and I shall try to describe the derangements I have to consider in the simplest manner possible. In case any of you should think I am too outspoken as regards the confessions I shall have to make of ignorance concerning the real nature of some of the simplest and most common of the slight ailments, I would only remark that, as there is so much real knowledge in medicine, and as the labors of our predecessors have established so many great truths and principles, we may surely freely admit that there are many things which we do not know, without fear of losing the confidence of the public. In my opinion, it is the very ON SLIGHT AILMENTS. 21 worst thing for the interest of true medicine when any of her followers act in such a way as to lead those who are completely ignorant of our work to suppose that we have acquired in some mysterious way knowl- edge that we cannot communicate to others, or that we have means of investigating disease which cannot be pursued or understood by ordinary mortals. We have no remedies of a secret nature, no occult arts of preparing or combining them so as to increase their virtues. All that we know can be learned by any one who chooses to spend the time and take the trouble requisite for mastering our art and the branches of science upon which it is based. There is no doubt still manifest a slight tendency here and there to credit some of us with the possession of mysterious power to control disease, but there is no excuse for this. Whenever naturally self-reliant enthusiasts act as if they were really the fortunate and favored pos- sessors of a power of detecting and controlling morbid processes that was not to be acquired by other men, the advance of medical truth will be retarded. In every age self-confidence has commanded faith and devo- tion, and with the aid of these the evolution of the extraordinary and marvellous from the ordinary and intelligible is not difficult. I should feel very sorry if in after days I should discover that any of my pupils have deviated from the right path, as some who have studied medicine had done, and had tried to make people believe they possessed powers and influences over disease which they did not possess. So terrible a falling away from the high standard raised by our predecessors and handed down to us would be a sad disgrace, and is most painful to contemplate. Of the patients who come under our care, many will be the subjects of but slight ailments, with the general nature of which any well-educated and experienced practitioner would no doubt be well acquainted. But if you go into practice fresh from the wards and the pathological depart- ment, and at once undertake the treatment of sick people, if you pass from the investigations of important structural changes to the prac- tical consideration of functional disturbance, and especially if you look too exclusively from a purely scientific stand-point, you will meet with many things that will puzzle you. The patients you treat will not be satisfied, and you will be disappointed and annoyed, because they are not contented with the advice you give. Perhaps you will feel in conse- quence out of heart or thoroughly disgusted with practical professional work. It has been said that the physician should be a consolation to the patient, but many a physician fresh from the study of severe forms of disease would, I fear, afford poor comfort to a dyspeptic, or to a person suffering, say, from functional nervous disturbance, and would hardly know what to say to a patient in whose body he could discover no actual 22 INTEREST IN THE PATIENT. disease of tissues or organs. The patient might describe many unpleas- ant and even alarming sensations and symptoms, which to him were of course of grave consequence, and all the comfort that he could get from such a medical adviser might be that, as there was no organic disease, he might go away and bear his complaints as best he could. Medical advisers of purely anatomical and pathological habits of mind are cer- tainly apt to disappoint or even offend unscientific patients, and, without deserving it, gain for themselves the unenviable reputation of being thoughtless and unkind regardless of others' suffering, and, if not objectionable, very far from agreeable ministers of relief. People do strongly object to follow the advice of such advisers, however correct it may be ; and perhaps the least unfriendly among the patients of such a doctor would, out of kindness and in the most quiet and confidential way, recommend him as soon as possible to change his vocation. You ought, therefore, to learn how to investigate the nature of slight ailments and how to relieve them, and, if the conditions which give rise to them are beyond our means of control, how to reduce the severity of the patient's sufferings. If the patient's malady is, unfor- tunately, ever so intractable or incurable, he will be much more grateful to you for your attention, and for doing what you can to relieve him, than he would be if you favored him with the most learned and elaborate disquisition concerning his case, even if it was accompanied with the demonstration that his illness was profoundly interesting and afforded an exceptionally perfect illustration of very remarkable patho- logical phenomena. You will generally find that if a man has pain in his stomach, especially if accompanied with excruciating spasm, he will not be satisfied with the assurance that he will be better when the wind is dispersed. However interested we may be in studying the natural history of disease, the patient desires our assistance to disperse wind that torments him, and wants remedies which will relieve his sufferings as soon as possible. I think you will agree in the opinion that such a patient is not more unreasonable than most doctors themselves would be under similar circumstances. If you know your work, you can be of use both in getting rid of the flatus and in relieving the pain. If from ignorance of the use of simple remedies you tell the patient that nothing can be done, the chances are that he will go to some intelligent person, professional or non-professional, who may, perhaps, give him a close of Bicarbonate of potash or some Sal volatile. He is at once relieved, gets well in the course of a few hours, and loudly praises the adviser of the successful treatment. On the other hand, anything but praise in such a case would fall to your share. I fear that the patient would give you a very bad character, and he might possibly speak of you as a most ignorant person and incompetent practitioner. Though, per- haps, not acquainted with the great value of such simple, commonplace WE SHOULD BE IN GOOD HEALTH. 2$ things as Bicarbonate of potash and Sal volatile, and some other simpfe medicines which are very efficacious in curing various unpleasant aches and pains, you might nevertheless be well informed as regards the manage- ment of serious cases, and, in fact, a well-informed and good practitioner. Those of you who are going to take part in country practice ought to be especially careful to try to do all you can to please as well as to help your patients. There may be no other medical adviser within many miles, and it is most unfortunate if any of the people in your neigh- borhood should be prejudiced against you. You must, indeed, think over people's individual peculiarities, be ready to pardon their suscepti- bilities, and try your utmost not to offend them. The most painful differences have been occasioned from want of care on this head ; and many a coolness between patient and practitioner, which has lasted for years, and has caused much suffering and misery, might have been altogether avoided, if the practitioner had exhibited a little amiability and exercised ordinary caution and self-control early in his acquaint- anceship. Not a few differences with patients may sometimes be traced to the practitioner's ignorance of common things he ought to know, or to an attempt upon his part to introduce new customs in dealing with his patients with which they are not familiar. You will find some useful hints to guide you in country practice and much information on conducting different branches of practice in a very useful little book to those about to enter upon the practical duties of professional life, lately written by Dr. Diver, entitled "The Young Doctor' s Future ; or, What shall be my Practice? " But, further, the study of the slight ailments is of no small import- ance to medical men, for it is of the greatest consequence that we our- selves should be in good health. Attendants of the sick should them- selves be well, and each one of us should recognize the importance of keeping himself in a healthy state, that he may be cheerful and hopeful in the presence of the sick. It never does for the doctor, while listening to the sorrows of his patients, to be continually reminded of his own discomforts, and constantly thinking, if he does not actually say, that he is far worse than his patient, and more worthy of attention, sympathy, and commiseration. The sufferer suffers less if he has healthy, cheerful people about him. Dwelling on the fact of pain, and talking about it, seems to increase it. Many patients suffering from temporary derange- ments are in a low, despondent state. Such a frame of mind is more commonly due to temporary deranged action of the stomach and liver than to any other circumstance. Though you may be equally or even more dyspeptic and may feel very wretched, you must be careful not to add to the general depression by discoursing about your own ailments, but must encourage and cheer the patient, and speak hopefully. All 24 A TTENTION AND KINDNESS. this is not very easy to do if we are not well. The doctor who is suffer- ing aches and twinges is to be pitied, for he must not allow himself to complain. He must not make wry faces while he is inquiring into his patient's case. An ailing or hypochondriacal doctor will be of little use, will get into discredit with patients, and will be disappointed with himself; and it will probably happen that some, it may be, ill-informed, but more worldly-minded medical authority in his neighborhood will get the patients who ought to be in his more deserving hands. This, I fear, is not unfrequently the secret of many a failure in practice. Those of you who, like many excellent men who have preceded you, feel inclined to condemn the delicate attention, the excessive care, the extreme solicitude for minute perturbations of sensation or emotion of the invalid, characteristic of some very successful and favorite doctors, should pause, and try to look a little from the patient's point of view. Even a philosopher who feels ill, though he may be sure that there is not much the matter with him, may nevertheless desire some skilled and experienced medical adviser who will appreciate his aches and pains, who will consider his complaint, and listen patiently to the story of his woes, -who will take a cheerful view of his case, and express him- self accordingly, instead of suggesting possibilities of pathological degeneration in the gloomiest phraseology. You may be able to relieve many a sufferer by suggesting some very simple remedy. A dose of bicarbonate of potash or lime-water after meals may be all that is requisite to restore him to health. Little may be needed, but still that little assistance is required. Many of the apparently slight disturbances or ailments may be due to some grave pathological change, which would be entirely passed over by one who had had little experience in medical observation, but would be full of significance to the well-informed practitioner. On the other hand, we often find that apparently serious illness is really due to tem- porary and functional derangement only. Do not, therefore, be too hasty in giving an opinion concerning the import of uncertain and in- definite symptoms. You should remember that the most perfect machines sometimes go wrong without a flaw being discoverable just before the occurrence, it may be, of a complete breakdown. No wonder that %he tissues and organs and the marvellously minute and delicate structures of a living being may fail in a hundred ways without giving any notice even to their owner. The most careful scrutiny and minute examination may fail to demonstrate any fault or flaw; nay, even after the body had ceased to work, after its death, the changes resulting in its destruction may elude the most careful investigation. We know that, for example, hydrocyanic acid, by its action on the nervous system, will kill a living organism in a few seconds, but as to tne exact changes which the acid works in the nerve structures and TACT AND TREATMENT. 2$ their living particles, we know nothing. The same is true of many other modes of death. The flaws existing in tissues in disease are not always to be demonstrated, though possibly many at least may be demonstrable, if we only knew exactly how to render them evident and distinct. Practitioners who will not endeavor to help their patients who are suffering from slight ailments had better not attempt to practise medicine at all, because they will almost certainly fail, seeing that a large percentage of our patients, fortunately for themselves, do not suffer from grave pathological changes. Nevertheless they require intelligent medical assistance. There is not one amongst us who gives his attention to those patients only who are suffering from very serious forms of disease. You must therefore understand the nature of slight derangements, and you must know how to relieve them. You must not treat the complaining patient with contempt, and tell him there is nothing of any consequence the matter, and that he may go about his business. If we behave in this manner the public will lose confidence in us, and great numbers of people will seek and accept advice from mere pretenders, and from wiseacres who profess to discover the most wonderful and exceptional phenomena in very ordinary cases, or who, while thus trying to gain the ear of the patient, make the most of every opportunity of casting a slur on those who have honestly studied and practised their profession. Knowing little or nothing of morbid changes, and of the sciences upon which the investigation and treatment of disease rests, many of these professing healers are, in a way, extremely clever, and not a few have the advantage of a marvellous development of that peculiar mental endowment called "tact" a most desirable possession for every one who has to treat and take care of sick people, if, in addition, he is honest and good. I would have you take note, how- ever, that this word " tact " has a very comprehensive and elastic mean- ing, and is in these days equally applied to an honest desire on the part of any one to avoid wounding the feelings of a sensitive person, or need- lessly vexing such an one when it is necessary to communicate un- pleasant things, and to the successful exercise of glaring imposture and pitiless humbug. One now and then gets, in a sense, an instructive, though a very painful and profitless lesson, as to the means by which the good opinion of people unlearned in medical ajid other matters may be gained by a practitioner who is sadly deficient in knowledge and in experience, and who is perfectly conscious of his defects, but knows well how to make up for them. A master of tact, and determined to avail himself of the advantage he thus possesses in the struggle for existence, he convinces, he persuades, and, in short, flourishes where many a good man would fail, and, perhaps, where many such have already failed. Nevertheless, do not let me lead you to conclude that 3 26 QUACKERY AND TACT. tact is another name for humbug, any more than that kindness and politeness imply insincerity; but it is only too true that some makers of fortunes have been indebted for their success to cunning, cuteness, and tact, rather than to hard work, goodness, or intellectual power ; and he who thinks very highly of tact, and acts upon his opinion, must be very careful lest he slide too far down the incline, which may lead him on from the display of tact to the habitual exercise of humbug, and at last to giving way to utter heartlessness and selfishness of the lowest order. Unless the highly competent and intelligent practitioner exercise due care as regards what he says and what he leaves unsaid, he may entirely fail to gain the confidence of his patient. Many a good, honest, and intelligent man unconsciously helps to drive the patient into bad hands. Grave pathological changes may be overlooked, and trifling aches and pains magnified by the patient into indications of serious and danger- ous disease from want of care and attention as regards the manner in which the practitioner expresses himself concerning aches and pains. But there are persons who would be easily influenced by what the quack says, who would go away from the honest, well-informed medical practitioner, with the idea that he knew nothing whatever about his business, and was quite ignorant of the nature of the changes taking place in the organism, and of the method by which these changes might be modified when they were not properly performed. This is unfor- tunate, but there is no help for it. Every upright practitioner has been placed in this most unhappy position more than once in his life. Should you find yourselves so situated, the best thing is to say very little, and be as patient as possible, leaving matters to be set right by time. While doing our utmost to preserve and extend the high repute always enjoyed by the medical profession, we must be careful not to play into the hands of pretenders, and this we shall certainly do if we need- lessly offend fanciful and crotchety patients, for by thus acting we prac- tically dismiss them to be preyed upon by quacks. There are few matters of greater interest or consequence to us than the consideration of the manner by which we may succeed in gaining the confidence of our patients, without making promises which cannot be fulfilled, and, indeed, without saying anything of which an upright, intelligent, and high-minded gentleman of kindness and consideration could in the least degree feel ashamed. Some men have the natural gift of inspiring confidence at once, just as others have unfortunately to contend with natural defects resulting in exciting in the minds of others anything but confidence. Still you must bear in mind that he who is to afford real help to people as a medical adviser, must be trusted and believed in by his patients. It is, therefore, our duty to study and train ourselves so that we may inspire confidence in those who place themselves under our care. In this endeavor we are, so to say, often MEDICAL HUMBUG, 27 heavily weigh'ted. To gain the esteem, especially of people unlearned in matters medical, it may, indeed, be necessary to promise more in the way of cure than truthfully a man of sound judgment would be able to do. We are often placed at a disadvantage, and a vulgar, ignorant pre- tender, brimful of assurance and conceit, will sometimes succeed in gaining the confidence even of an intelligent patient, when men of a higher order of mind -have hopelessly failed. In not a few instances the patient pays most dearly for the mistake he has made, but it may be long before he finds out that he has made a mistake at all, and still longer before he confesses he has done so when he does find it out. It is the conceit rather than the ignorance of the dupe which renders him an easy victim of the quack. On Quackery and Medical Humbug. To those of us who have passed thirty years or more working and thinking amongst sick people, and studying with the aid of accurate scientific instruments the nature of the actual phenomena occurring in the tissue elements, and in the fluids of the body in departures from the healthy state, it seems as extraor- dinary as it is disappointing, that men of undoubted intelligence and well acquainted with the ways of the world, should sometimes select for their medical adviser, not only an ignoramus, but a medical pretender an impudent fellow, who acts up to the conviction that if he only talks non- sense with sufficient audacity he will prevail, because even among highly educated people, it is very exceptional to meet with one who is suffi- ciently acquainted with anatomy, physiology, and chemistry to detect the true character of his insolent balderdash. But such complaint is not new. Galen (" Meth. Med.," 1. i.) remarks in the time of the Roman Empire, " What gives vogue to a physician is not science, but skill in flattery. To him who is the best sycophant, everything becomes easy. To him every door is open. In a short time he becomes rich and powerful." " The asses of Thessalus had parcelled out the art of healing into the most minute subdivisions of practice. Rome swarmed with special curers. Some, for instance, confined their practice to the treatment of the uvula, or the eyelashes, or certain kinds of cutaneous eruptions. Some restricted their attention to the treatment of ag,ed men, others to that of the strong and robust. Some would cure only with herbs, others by means of gymnastic exercises." One would, however, have thought that certain people of intelligence and culture would have preferred as their medical attendant one whose position alone rendered it evident that he could not be a quack or an ignoramus, and at least take the very little trouble required to discover among the four or five hundred public medical officers, whose work and repute are known, or at least among the two or three thousand medical practitioners whose training and character are recognized, one adviser who would not only treat them with judgment and intelligence, 28 VULGARITY MISTAKEN FOR GENIUS. but satisfy and please them in other ways. Instead of taking the little trouble required, how often is the recommendation of some old woman, who declares she has been cured of the most serious and extraordinary maladies after the most distinguished members of the profession had completely failed, taken and acted upon without further inquiry. It is quite extraordinary what large practices may be made in a short time by the puffing of influential people, not one of whom has perhaps taken the trouble to ascertain whether the practitioner so extolled is really deserving or not of the high praise and recommendation he has had the good luck to enjoy. Sometimes it would appear that some extraordinary vulgarity of manner on the part of the fortunate doctor had been set down as indicating originality of mind or unusual genius. The art of looking wise and saying nothing seems to be the secret of success in not a few instances. Sometimes success in small talk, a bustling manner indicative of overwhelming business; while, occasionally, peculiarity or perfection of dress appears to have won the respect and confidence of patients, and secured to the elegant doctor a considerable practice. You will not, however, feel astonished at all this if you consider how very ignorant of all subjects bearing in any way upon physiology and medicine are the generality even of so-called well-informed people. Not a few of the intellectual classes, the leaders of thought, great classics and mathematicians, lawyers, public speakers and writers, do not take the slightest interest in any department of natural knowledge, and are so incapable of entering into scientific modes of thought and work, that they can be deceived and cheated by the most commonplace pretender. The efficacy of the thousandth, or millionth, or decillionth of a grain of charcoal is deemed by them a question open to inquiry and to be determined by experiment. The utter suppression of ex- periments upon the lower animals seems to them but reasonable, mag- nanimous, and right. The ignorance and prejudice fostered by the teaching and advice of persons wholly ignorant of science and by nature strongly opposed to all attempts to inquire into the nature of things, constitute the chief obstacles to sanitary improvement, and encourage the maintenance of conditions adverse to health and the per- petuation of diseases still annually destroying thousands, but which ought long ago to have become unknown in England. It is easy for those who make light of the facts of medical and sani- tary science, and who pretend to believe in the virtue of minute globules, to retort by accusing us of attempting to constitute ourselves into a sort of trades-union, which condemns all who do not fall in with its views. The writers in our public journals, however, ought to be able to see through such false charges and commonplace cries, and expose them. But to condemn as a trades-union a body of men engaged in the fur- DECILLIONTHS OF A GRAIN. 2g therance of the greatest of all blessings, the health of the community, is most unjust. Our profession encourages and rewards individual merit, and allows and sanctions individual success, permits the freest com- petition between its members, limits neither the hours of work nor the freedom of thought, encourages all to aspire to equal, and, if it may be, to excel the greatest of those whose lives and works are recorded in its annals, endeavors to protect the unlearned and uninstructed from imposition and wrong, and refuses to sanction on the part of its members any secret method of healing, however useful it may be, or the use of any medicine the ingredients, composition, and method of pro- ducing which are not published to the world for the advantage of all. There is not the faintest justification for urging a complaint of the kind against the medical profession. Anything like what is called trades- unionism amongst us, if possible, is one of the most improbable of improbable eventualities. We only insist that the real knowledge which has been handed down to us, and which is still being added to by the work of thousands of practi- tioners in all parts of the world, shall not be considered in any way comparable with or related to any so-called medical systems which are based upon the assumption that any effects result from the exhibition of quantities of various medicines supposed to amount to a millionth of a grain or less. We maintain that the dicta upon these and other medical matters received as true by a section of the public are opposed to facts of anatomy, physiology, and chemistry, to observation and experiments, by which, on the other hand, the principles upon which medicine is based are continually being tested and verified or modified. To ascertain whether such a quantity as the decillionth of a grain acts in any way is impossible, any attempt to do so would be foolish, since no one can be sure that one-decillionth of a grain of anything in the world can be obtained. Such supposed fractional part is beyond the limits of physiological, chemical, or other method of investigation. It is invisible, intangible, undemonstrable, and as a medicine exists only in imagination, and can be proved by assertion only. In fact, it is not even possible to imagine particles of a degree of minuteness con- siderably less extreme than these. But it is useless to attempt to reason on such absurdities. I am ready to admit that there are persons who believe that the decillionth of a grain of opium will produce an effect upon man's organism, just as there are people who hold that the earth is flat, that living things are machines, that spontaneous generation occurs, that vaccination is detrimental, and a number of things which may have been conclusively proved or disproved, as the case may be, or concerning which there can be no evidence one way or the other, or which are altogether beyond the reach of thought. In this country we are proud of what is called liberty of opinion, and 3* 3O THE DECEPTION OF INTELLIGENT PEOPLE. we cannot prevent our friends and neighbors from holding and propa- gating beliefs, views, and doctrines which from the stand-point of fact and reason may be inadmissible. Many of the questions upon which there is wide difference are really open to discussion, and where there is doubt all ought to keep their minds open to conviction if evidence should be adduced, but many assertions which are commonly and frequently advanced are not reasonable, not open to discussion. The assertion, for example, that the decillionth of a grain of opium produces an effect on the human organism is one of these. Many years ago I saw in a hospital in the south of Europe a poor woman who was dying of cholera was indeed obviously within an hour or two of death. The attending physician examined her and prescribed " Opium." I asked him what quantity of the drug he had ordered the patient to take, and after some calculation he said, "The decillionth of a grain." Now, I shall no doubt be con- sidered by some who prescribe millionths and decillionths a very prej- udiced person, but I decline to discuss with a man who believes, or professes to believe, either that he was actually giving this quantity of opium, or that such an imaginary amount of that drug would, if it could be introduced into the body, produce any effect whatever upon the organism It would not be reasonable to expect that the public generally should be sufficiently informed concerning medical and scientific questions to enable them to form a judgment as to the relative merits of different systems of medical treatment, any more than we can expect them to investigate such questions as spiritualism or to determine the nature of, and right method of dealing with, certain forms of contagious disease. All thoughtful and reasonable professional men have, however, strong cause of complaint when they find that persons of intelligence holding positions of authority law-makers, ministers, and distinguished political chiefs so express themselves as to lead the public to suppose that it is as reasonable to place confidence in a man who prescribes the millionth of a grain of charcoal or the decillionth of a grain of opium as in one who orders ten or twenty grains of the first or a tenth of a grain of the last.* I doubt whether anything in modern times is upon the whole more disgraceful to an enlightened community than the spread of a disease so certainly preventible as Small-Pox. Only think of the absurdity of having to provide, at enormous expense, accommodation for thousands of people suffering from and spreading this loathsome disease when every case might have been prevented by vaccination. And we go on year * It is remarkable how very few persons seem to realize the tremendous difference between such fractional parts as hundredths, and thousandths, and millionths, bill- iouths, and decillionths. CREDULITY AND IMPOSITION. 3! after year allowing people to pay fines for the privilege of enjoying the right to catch Small-Pox and to communicate it to others. Intelligence as regards one department of knowledge is often asso- ciated with extraordinary ignorance and credulity concerning others; nay, the same individual sometimes manifests the extreme of scepticism as regards certain things, while in others he is unsurpassed for his credulity. You will find some persons sceptical concerning demonstrable and demonstrated facts, and faithful and believing in respect of fictions of the imagination and dicta of the most nonsensical character. The most profound knowledge of logic, mathematics, law, classics, or metaphysics will not protect a man from imposition and quackery as regards the nature and management of the ailments of his body, and there are not a few persons distinguished for great intellectual power who have been duped by quacks, while they altogether mistrnsted the true statements of honest, straightforward medical practitioners. There is nothing more extraordinary than the trust often reposed in what is false, and the doubt, disbelief, and suspicion indicated concerning that which is true. In the matter of medical advice, and not uncommonly in high quarters, humbug sometimes rules supreme. Character, experience, unremitting work often go for nothing. In England and in America there is nothing more wonderful than the great success obtained by persons utterly ignorant of their calling. There still lurks much belief in mysterious and inexplicable actions as regards medicines and in, the wonder- working powers of some who prescribe them. This it is, possibly, which enables the self-praising, vulgar empiric to exert a favorable impression upon those who are at best but very ill-informed concerning . matters of health and disease. It is curious how some even of our very simplest prescriptions get handed about from one to another in consequence of some wonder-working power they are supposed to possess, which would, I fear, vanish in a moment if only they were trans- lated into English. Still we may hope that the time is not far distant when we may order Carbonate of soda, Hydrochloric acid, and such like simple medicines, which often afford the greatest relief, without envel- oping them in a cloak of mystery. People would often be much astonished if they knew what cheap and common drugs they some- times bought at extravagant prices in various highly-puffed patent medi- cines of secret composition, not a few of which simple remedies we are prescribing every day. It is hardly reasonable to expect that we should be able to persuade people, especially those who are well off, to live like reasonable creatures; but those who are completely ignorant of medical knowledge, and who come to us for advice and assistance, go a little too far when they suggest or dictate to us the kind of advice we are to give, the medicines we are to order, and the methods of treatment which we are to adopt, we 32 IMPOSTURE AND NONSENSE. having been studying during many years the nature and causes of disease, while they are utterly ignorant of the whole matter. And yet this is no imaginary picture ; there are people who know nothing of science, and who have never seen anything of sick people, who neverthe- less talk as if they were thoroughly experienced in the science and practice of medicine. Such persons sometimes condemn us because we decline to "consult" with men who practise according to con- jectural principles based neither on experiment, observation, nor experi- ence. Certain rich, inflnential, and fashionable persons having patronized and embraced some absurd medical conceits, profess to be grievously offended with some practitioner, who perhaps has been study- ing and teaching medicine for half a lifetime, because he declines to adopt measures which the patient himself desires out of mere caprice should be carried out. It has been my lot to study, on more than one occasion, the well- turned phrases and persuasive sentences by which a popular prescriber of decillionths, brimful of tact, managed to bring conviction to the minds of people of intelligence, and at the same time to impress them with his profound knowledge and intelligence, though all the time he was writing nonsense, and probably knew that he was doing so. But, as is well known, cleverly stated nonsense often hits the mark, and will continue to do so for many a long year. Men high among the most intelligent and most learned, nay, men who have been looked up to as men of the world, have often been humbugged in matters medical, and even profound lawyers have failed to distinguish medical nonsense from medical sense, and mere sham science from real scientific knowl- edge. Those who are always gauging the value of evidence, and devoting themselves to the extraction of truth, seem to be specially susceptible to medical and scientific imposition. But there is hardly a department of human endeavor in these days in which you will not find audacious humbugs influencing opinion, and gaining for a time notoriety and renown at the hands of their dupes. But if we raise our voice ever so gently against nonsense and imposture, some of the writers belonging to the organs of so-called public opinion hold up to reprobation what they denominate the pro- verbial jealousy, the intolerance, the illiberality, and the narrow-minded- ness of the doctors. The comments in the supposed interests of the public and the strictures passed upon us are sometimes most comical, but you will find sometimes, I fear, that your work is rendered very difficult in consequence. If you attend, through a very long and serious illness, a patient, who, from the badness of the times, is unable to afford you any remuneration for your services, and you hear that as soon as he was able to get about he placed himself under the care of a distinguished quack, who found it necessary to see him every WANT OF CONFIDENCE IN US. 33 day, and received a handsome fee each time, you are to consider your- selves fortunate in belonging to a liberal profession, and though you receive nothing for your work, you are not to feel jealous of the quack who is well paid perhaps for doing nothing, perhaps for the mistakes he has made. If, after having ridden over hundreds of miles of ground of the roughest country in the roughest weather to attend the sick pool around you, finding not only medicine for all, but food and medical comforts for not a few, you one day discover that the only people within ten miles of you enjoying an income of more than a hundred a-year have, out of the purest kindness, invited a celebrated homoeopath to visit them, and he, also out of kindness, has seen and prescribed for a number of your patients at half the fee he usually receives, and has been paid more money by your poor patients in a week than you will receive in a year, you are to feel thankful that you live in a free country, where opportunity is afforded to all. If, after having served the offices of House Surgeon, House Physician, and many minor appointments in a public Hospital, and qualified with honors, the wealthiest of your neighbors gives it out that you are very kind to the poor, and that the servants are well satisfied with you, while he and the members of his family, when there is anything the matter, send over to for a dis- tinguished eclectic doctor of philosophy who graduated abroad, and is supposed to have had great experience, but whose early history and training are involved in obscurity, patiently submft. If he neither knows the test for albumen, nor its import when present in the urine; if he discards as useless physical examination of the chest ; and disapproves of the stethoscope, microscope, and other "medical toys," because by prolonged inquiries into the mysteries of the magnetization of the solids and fluids of the body he, as he says, has detected molecular anti- gyrations of a most important character in the component particles of the brain and nerves, and if by the administration of gyrating "similars" in the shape of small globules, largely composed of sugar of milk, this celebrity professes to be able to combat pathological phenomena before they could establish disease, do not be indignant. You may be expected to preserve an attitude of deferential awe or respect whenever the distinguished and eminently successful authority is spoken of. You may not discover his name on the medical register, and you may find that as soon as any patient is indiscreet enough to become very seriously ill, some "ordinary" medical practitioner, perhaps your- self, is requested just to attend as "a matter of form." You may possess incontrovertible evidence that the distinguished person is utterly ignorant of the very elements of medicine, but you must not be sur- prised to find out, notwithstanding, that his important services have been judged to be worth m"re than five times as much as the county pays for your own conferred upon hundreds of poor people, and extending C 34 PRINCIPLES OF CONDUCT. over a much longer period of time. We may, no doubt, derive some consolation from the reflection that we belong to a truly liberal profession, and do not practise merely for the purpose of receiving pay. You may, perhaps, think it hard that unqualified and only partly legally qualified charlatans are not prevented by law from humbugging innocent people, as is the case in some countries which have not reached the high degree of civilization which we enjoy, but rather you should feel thankful that the Government does not pass laws which might conduce to the further impoverishment and degradation of legally qualified medical men who attend the poor of the district in which they live. No doubt many highly influential law-making persons agree with eclectics, animal mag- netizers, hydro-, homceo-, and other "paths," in the opinion that it is degrading for a genius, a conjurer, or a certain cure to submit to the ordeal of examinations on elementary anatomy, physiology, and medi- cine conducted by unpractical theorizers, and presided over by the narrow-minded supporters of " medical trades-unions " ! After all, it must be conceded that the most popular of quacks seldom enjoys more than a short-lived reputation. He has to make hay while the sun shines, for he may soon have to give place to a greater quack than himself, and pass into obscurity. On the other hand, although we may in every way receive far less than our due, we belong to a body rightly proud of its history and confident as to its future. Resting on science, medicine must progress as knowledge advances. As information spreads, respect for real work will increase. The regard for the medical practitioner will be higher in the future than it has been in the past, and by and by the numbers of those who appreciate our work and put trust in us will include as many as the most enthusiastic among us could desire. We are, as I have remarked, sometimes placed in a position of great difficulty, and much perplexed as to the course we ought to take. Occasionally, regard for the honor of the profession would seem to require a course of action which might not coincide with the interest of the patient or be in accordance with that consideration and kindness which, under all circumstances, should be extended to the sick and suffering. If we carefully bear in mind that the credit and honor of us all are of higher consequence than individual success, or personal loss, or even injustice if we explain that we have nothing to keep secret, no mysteries to protect or preserve that on the contrary we desire that the knowledge we possess should spread, and that all possible means of relief and all methods of preventing disease should be widely diffused ; that we court inquiry into the principles upon which our methods of investigation and treatment are based, and desire that our reasonings thereupon should be examined and criticised, we shall seldom, I think, SLIGHT AILMENTS AND OUT-PATIENTS. 35 experience difficulty in deciding how we ought to act in almost any case that may arise. We must, in short, endeavor. to apt for the advantage and honor of the profession without in the smallest degree, or in any way sacrificing the interests of the sick person, and without wounding the feelings of the patient or his friends. In these, and in all other difficulties we encounter, we shall act upon the maxim Fac recte nil time. Of Studying Slight Ailments in the Dispensary Department of the Hospital. Great principles as regards the treatment of disease may, without doubt, be learned and taught, and the influence of im- portant remedies illustrated in the case of slight ailments as well as in grave disorders. The circumstance that little attention, comparatively speaking, has been paid to this part of medicine in modern systematic works, makes me particularly desirous to bring it under your notice. You may learn a good deal about man's slight derangements if you study in the dispensary department of the hospital, or in public dispen- saries, and I strongly advise you to take advantage of the opportunities that may offer. Do not be deterred from spending time in this department, although you may hear disparaging observations concerning out-patient medical work, both from professional and non-professional people. It is now the fashion to condemn the system upon which the dispensary department of most of our hospitals has long been success- fully conducted. To those unacquainted with the facts, there seems much that is plausible in the objections raised, but it will be found that the desire, on the part of some enthusiasts in charity organiza- tion, to improve the out-patient department of hospitals is supple- mented by a much stronger desire to do everything to encourage the so-called self-supporting dispensary system, based on the hypothesis that working-men and others are degraded if they receive relief from their sufferings without paying something. The " facts " and the value of the arguments advanced may be judged by the oft-repeated assertion that a fourth of the population of London receives gratuitous medical treatment. There is a class of philanthropists whose dictum it is that every one ought to pay for medical advice, and that if he cannot pay enough to re- munerate a practitioner he should combine with others placed in a similar position, and so form a club to which a salaried medical officer is appointed. The "self-supporting" system is, however, in many instances, not a reality, while any one who knows much of the working classes, knows that the demand for medical help and medical comforts usually comes at a time when little or no money is being earned. Thousands of pounds are to be collected for starting these "self-sup- porting" dispensaries, which, therefore, are "self-supporting" only in name. Charitable persons are to give in order that certain members of 36 THE POOR AND HOSPITALS. the population may be doctored at half the usual cost, or less than that. I have seen a great deal of the poor and of out-patient hospital practice, and as I have not met with the so-called evils of the system, I cannot advocate the proposed remedies. Many of the energetic legislators in connection with medical charity seem to think that no one who suffers from a pain in his stomach should be relieved until he has either paid for help, or has proved that he is a really necessitous and impecunious person. I believe that if some of the new suggestions were carried out, the profession would not only receive less, but would have to give more advice for nothing than they do now. Up to this time the Dispensary departments of our hospitals have been of the greatest service to the poor, and of great advantage to those who are studying medicine. It is there we learn to interpret the curious descriptions given by people in so many different ways of the aches and pains theyexperience there we learn to recognize the difference between apparent and actual suffering there we are taught to quickly discern different forms of disease, and to acquire that ready method of investi- gation which is so 'valuable in after life. Moreover, some of the hardest workers among us prefer to give their services out-and-out rather than receive the pittance which seems to be considered by some reformers as payment for services rendered, and pitied and possibly despised as poor doctors whose services are valued at a very small summer annum, and to be obtained by right by those who promise to pay a few pence per week. Although complaints may be made of the rate at which people are gratuitously seen and dismissed, the out-patient hospital physician, in fact, seldom misses an important case of actual disease, while of his real use to the poor there can be no question whatever. Slight ailments are prescribed for and relieved, while serious cases of disease are detected and at once transferred to the wards, without those inquisitorial investi- gations which seem to form a very important factor in model sick-poor relief and" centralization and general organization. It is doubtful if, by any system that can be inaugurated, a poor patient will be more quickly relieved and cared for than by the one which has been gradually built up by members of our profession, and is now in useful operation in hun- dreds of institutions. To teach providence to all classes is very laud- able, but there is no good reason why this desirable lesson should be taught by lowering the status of the medical practitioner. We must never forget that our work is to relieve suffering as promptly and as efficiently as possible, and it is on all grounds better that we should sometimes give our services altogether than accept what is called remuneration of a very inadequate character. The Treatment of Slight Ailments conducted on the same Principles as that of Serious Diseases. There is, lastly, this very cogent reason which impels me to direct your attention thus early in my course to the Los Ai, e fa c REMEDIES IN SLIGHT AILMENTS. 37 consideration of slight ailments. It will be found that many of the principles upon which the treatment of trivial derangements is con- ducted obtain in the management of graver maladies. This is a matter of the highest practical importance, and in not a few instances you will find that attention to the relief of slight ailments will afford you great assistance in determining the proper course to pursue in the treatment of very serious forms of acute disease. For example, I shall be able to show you that the treatment of a grave disorder like acute rheumatism is based upon facts and reasoning which apply equally to slight affec- tions of a rheumatic nature. Fevers and inflammations of the very slightest character afford lessons of the greatest value concerning the management of every disease of that class. By observing carefully the action of remedies in slight ailments, we may gain knowledge which will be of the greatest use to us, and espe- cially in the treatment of slight derangements of our own health may we hope to gain very definite information concerning the precise action of some of the most important of the medicines we employ. I am sure that any one who has experienced the change in his sensations which occurs after taking a few doses of ammonia in the course of an ordinary cold, or has noticed the pleasant alteration which occurs during an attack of quinsy as soon as diuretic and sudorific remedies have com- menced to act, or is practically acquainted with the relief afforded in sick headache by a grain or two of gray powder or calomel, will be quite convinced of the usefulness of medicine, will not altogether despise the views and practice of forty years ago, or feel reduced to advocate the administration of colored water to his suffering contemporaries, or wilf propose to leave a number of cases of different forms of disease without any medical treatment whatever, in order that he may observe what has been naively termed the "natural history of disease," the patient, of course, not wishing to complicate the interesting inquiry by desiring the relief of his suffering and quick convalescence. There are many valuable points connected with prescribing, which are of the utmost importance, and which are to be learned from the practitioner who is well acquainted with the management of slight ailments. I have often heard the remark that our predecessors knew more about the treatment of disease than we of this generation do. There is some truth in this ; and I am sure that many old practitioners now living are more successful in relieving the aches and pains of their patients than some of the young ones, who may, nevertheless, have a far more intimate knowledge of the diagnosis of obscure forms of disease and of the minute pathological changes which have damaged tissues and organs. Those of you who have worked under country practitioners enjoy a great advantage in this respect, and will be aware of many things connected with the art of prescribing for symptoms, of 4 38 MICROSCOPICAL INVESTIGATION. which, even men who have highly distinguished themselves in our medical classes and medical examinations, may be in total ignorance. Nor do I see how this very desirable practical information can be gained in any better way. I may try to convey to you some of the wrinkles I have learned from my own masters, but shall only very imper- fectly succeed. To offer remarks on the details of treatment when prescribing for the sick person in the country surgery is advantageous, but to give in lectures or at the bedside at the hospital detailed in- formation as to the combination of remedies in pills and mixtures, and a number of things of considerable importance practically, would be tedious, and would take so long a time, that I could not expect a class to listen to such matters with attention. I shall, therefore, only venture to trouble you now and then with details as regards prescribing, but it will be well for you to take note of prescriptions, which I have frequently found of great value in the management of cases of deranged health. Importance of Knowledge derived from Microscopical Investigation. In all healthy changes, in all derangements, in all forms of disease, thousands of very minute particles, each of complex arrangement and composition, are implicated. It is by the united action of multitudes of these that the broad phenomena evident to us as healthy actions, derangements, morbid changes are occasioned. Do not, therefore, cast a slur on the consideration of minute details, do not neglect the facts arrived at by microscopical investigation. Rather, on the other hand, try to acquire the power of seeing in imagination the very particles which are involved, and of contemplating the phenomena proceeding in connection with them. Bear in mind that around and in the interstices between the molecules of matter composing each elementary part of a living organism changes are constantly taking place. Remember that of the matter of the elementary part the bioplasm only lives and is the seat of vital action. The formed material which results from the death of particles of the bioplasm is the seat of physical and chemical changes only. These elementary parts are so small that a thousand thousand of them might not occupy more than a cubic inch. Each of them during .life is the seat of incessant change. Towards the bioplasm of each, streams of fluid, holding various substances in solution, continually tend, and, having reached it, part with certain constituents, there to be made into living matter, while the fluid, deprived of these, again traverses the formed material, and is taken up by the blood or is otherwise disposed of. Thus the formed material or tissue of every organ of the body is being constantly bathed by fresh portions of fluid, bringing and taking away, dissolved in it, things required for use or things which must be got rid of. This continual movement of fluid characterizes everything living from the lowest to the highest. In every form of plant and animal it is INTER-MOLECULAR CIRCULATION. 39 present and essential. When the flow is impeded derangement results, and degeneration and decay may commence; when it stops, death takes place, and the portion of tissue thus losing the preservative influence exerted by the never-ceasing currents of fresh portions of fluid through its most minute interstices, undergoes chemical decomposition, just as a portion of tissue taken from a dead animal would do if kept artificially at a temperature of 100. The deleterious gases and other poisonous substances formed, if there is no vent by which they can escape alto- gether, may pass into the blood and contaminate or actually poison every drop of the nutrient fluid, or may, by transudation into adjacent tissue, destroy it by causing the death of its living matter. In this way a large portion of tissue may soon be involved, and the death of the individual must shortly follow. There is, in fact, a constant circulation a constant interchange of gases and certain solid matters dissolved in fluid, some of which are appropriated as nutrient material, while others are removed as products of decay. This never-ceasing circulation goes on around and amongst the smallest particles of tissues and organs. Slow-moving tiny streamlets bathe the very molecules of the cells or elementary parts, and thus minister not only to the growth and increase of the bioplasm, but by aid of these currents alone can the formed material of the different tissues be preserved in a healthy and active state. What may be correctly termed an active inter-molecular circulation is one essential condition of a healthy state of tissues, and it will be well for us to occupy a few minutes' time in its consideration. In plants the inter-molecular circulation is equally essential, and the constant removal of fluid consequent upon evaporation from the sur- face of the leaves is one of .the most important of the operations con- cerned in establishing and maintaining a very free circulation of fluid around and in and out of every living cell of the plant. Even in the lowest, simplest, and most minute of living forms inter-molecular circula- tion begins with existence and never ceases until death takes place. It is one of the phenomena constant in and characteristic of every form of life, but it is peculiar to living things. There is nothing like it in any non-living matter. The importance of the continual flow of fresh particles of fluid through all the formed material or tissue of every part of the organism cannot be exaggerated. The rate of flow changes from time to time, and though it may sometimes take place very slowly, the movement never stops as long as life lasts, without derangement, damage, or destruction of the portion of tissue involved. You must try to picture to yourselves these never-ceasing movements of fluid simultaneously proceeding in every ele- mentary part of every tissue of the organism, though it may be less than the thousandth of an inch in diameter. It is obvious that the activity of 40 MOLECULAR CIRCULATION OF FLUID. these movements will in some measure depend upon the quantity of ' fluid taken up by the blood. If the nutrient fluid is habitually deficient in water, more especially if it be surcharged with only slightly soluble materials, there will be slow molecular circulation and a tendency to the deposition of some of these slightly soluble matters in tissues where the circulation is slowest. It is in this way that urates are deposited in fibrous tissues where ordinarily the circulation is slow, in cases of gout. Substances may be introduced from time to time into the blood which have the property of exerting a solvent action on these slightly soluble compounds. In this way their deposition maybe prevented, or, if depos- ited, their resolution and reintroduction into the blood, and at last their excretion from the body, maybe effected. The knowledge of the phenom- ena proceeding in the interstices of tissues enables us to understand pre- cisely how many of our remedies act. The careful consideration of such minute changes may enable us to suggest methods of treatment in various cases of great importance and value. We may act upon the formed material itself, rendering it more soft or more firm, help or inter- fere with the deposition pf insoluble matters in its substance, influence the growth of bioplasm, assist the removal of products of its death, and bring about many changes of the greatest consequence in treatment. Many of the diseases we have to diagnose and treat are due to a dis- turbed state of this inter-molecular circulation, and not a few of the most serious morbid changes result from diminished activity of the flow. Thus many matters which ought to be washed away accumulate in the interstices of the tissues and impede their action. When we can restore this molecular circulation to its normal state derangements of various kinds are at once relieved, and in treating many forms of established disease our principal object is to increase the activity of the inter-molecular currents in the interstices of the tissues involved. This object may be fulfilled in several ways. In many cases free perspi- ration and indraughts of water will effect it ; sometimes the administra- tion of frequently repeated doses of alkali promotes increased activity of the inter-molecular circulation, and assists the solution of imper- fectly soluble matters which have been deposited, or are in course of deposition. Looking from the point of view I have indicated, it will be well to consider, for example, what is the precise action of quinine when it cures in a few hours certain forms of obstinate lumbar pain. What happens when local thickening of the subcutaneous areolar tissue and inflamma- tion of the sebaceous glands, that may have lasted for months, subsides in a fortnight or less under the influence of biniodide or other prepara- tion of mercury. In cases in which too much nutrient material has been day by day introduced into the blood for considerable periods of time, slow circula- OF THE TONGUE. 41 tion or stagnation of some of the molecular currents in various tissues and organs of the body will occur. Partial starvation, or at any rate a very moderate diet for several weeks, will again promote the flow. Free perspiration will have the same effect. The inhibition daily of several tumblers of water will, by favoring the transudation of fluid from the blood, also benefit the patient by washing out the tissues in their inter- stices, and interfering with the deposition of imperfectly soluble matters. Water containing alkalies or salts of vegetable acids, particularly the citrates and tartrates, will, by exciting free action of the skin and kidneys, also help to re-establish currents in the several tissues and organs in which the molecular circulation has become unduly slow or has even ceased. Further, when we consider the close proximity of the nerve-fibres distributed to the capillaries to the very thin walls of these tubes, we shall not feel surprised that nerve changes are among the prominent and con- stant phenomena of disturbed molecular circulation. Any change occur- ring in the composition of the blood, leading to a diminished tendency on the part of the fluid constituents to permeate the vascular walls, must produce an effect upon the nerve-fibres just outside the capillary vessels. If the capillary vessels are over-distended or insufficiently filled with blood, these nerve-fibres are disturbed and will transmit impressions to the nerve-centre, which may react upon the nerves distributed to the muscular fibres of the small arteries, resulting in dilatation or contrac- tion, and may cause a more general and more widely distributed nervous disturbance. But this part of the question will be more conveniently discussed when we have to consider the vascular phenomena of Inflam- mation and Fever. OF THE TONGUE IN HEALTH AND IN SLIGHT AILMENTS. I shall in the first place speak of the characters of the tongue. Few things it used to be supposed were of greater consequence than the recog- nition of the varied character which the dorsal surface of the tongue assumes in various cases of actual disease, and of slight derangements of health. That the importance of the characters of the tongue as an indica- tion of internal disease has been exaggerated by some physicians is undoubtedly true, but that it is altogether useless as an indication is certainly an incorrect inference. Any one who is at the pains to notice the alterations in his own tongue under varying conditions of health will convince himself that there is something to be gained by noting the changes of the tongue in disease. If you are to form a correct estimate of the value of the changes in the characters of the tongue, you must be well acquainted with the appearance of the surface of the healthy organ and .with the exact nature of the structures which exist upon its dorsal 4* 42 CHARACTERS OF TONGUE. surface. Now, I dare say that few among you have had the curiosity to examine the back of the tongue, and see what is to be discovered there by microscopical examination. If you scrape off a small piece of the soft matter from the surface of the dorsum of the tongue, place it on a glass slide, and, after adding a drop of water, cover it with a piece of thin glass, and examine it under a quarter of an inch object-glass, you will find, though the tongue be in a perfectly healthy state, a great many objects of interest, of which I shall have to speak presently. I dare say that many who tell patients to put out their tongues some- times do it as a matter of routine. I have known a rather absent doctor tell the patient to put out his tongue several times in the course of a few minutes' medical conversation. Patients are sometimes a little prosy, and if there is not much the matter with them, you may not attend as diligently as you ought to do. You lose the thread of the discourse, and while your wits are wandering you may cry out quite unconsciously, almost as if your command was the result of some reflex and habitual action, " Put out your tongue," although the organ has been already more than once displayed for your examination. General Characters of the Surface. The character of the tongue undoubtedly is very much influenced by the state of the stomach. The mucous membrane which lines every part of the alimentary canal is, as you know, continuous with that which lines the mouth and covers the tongue. Whenever there is a little gastric disturbance the tongue usually participates in the change. The relation between the two phenomena is, however, a complex one, and not very easily explained. Of the fact, in very many cases, there is no doubt, as many may easily prove by obser- vations upon themselves. The appearance of the tongue, as I shall explain more in detail further on, is also in some measure affected by the state of the circula- tion, by the character of the blood itself, as well as by the rate at which the epithelium (tm, upon, and rtfl^ut, to place) on its surface grows, arrives at maturity, and decays and falls off. Sometimes the epithelial cells remain intimately adherent to the tissue beneath upon which they are placed, and from which they seem to grow. The epithelium, or rather a layer of it, is frequently very easily detached, but sometimes it adheres very firmly. If the epithelium on the dorsum of the tongue is very thick and adherent, the tongue looks pale, and perhaps white. On the other hand, if the epithelial layer is very thin the tongue is red. If you look at the under surface and sides of the tongue in the looking-glass, you will observe that these parts have a deep red appear- ance. The epithelium upon the sides, and the deep aspect of the tongue, consists of a layer so thin that the color of the blood is seen through the epithelial tissue. The degree of redness varies according to the EPITHELIAL COVERING OF TONGUE. 43 distention of the vessels, and depends upon changes in vascular disten- tion like those which determine the redness or pallor of the skin. In blushing, the small vessels of the skin of the cheeks are suddenly distended in consequence of an inrush of blood permitted by the sudden yielding and dilatation of the little arteries continuous with them, and the same phenomenon under certain circumstances occurs in the vessels of the tongue. The Dorsum of the Tongue. On the dorsal surface of the tongue generally, the epithelium (f*t, upon, and n%u, to place) is arranged to form a layer of considerable thickness, so that in many places the red color of the blood is not seen. In health the general color of the dorsal surface inclines to pale red, but in certain forms of disease it becomes of a bright red color, almost like raw beef, and it is in con- sequence sometimes spoken of as "beefy." This seemingly raw con- dition depends partly upon the desquamation and falling off of a good deal of epithelium, so that the layer covering the subjacent structures is much reduced in thickness, and partly upon the capillaries being dis- tended with blood. You can see the deep red color of the blood through the epithelial layer, and the tongue looks raw. The mucous membrane of the stomach and of other parts of the intestinal canal participates in this change. There is desquamation of the epithelium and undue turgescence of the vessels beneath. On the Fungifonn and Filiform Papillae, and of their Epithelial Covering. In health there are to be seen here and there over the dorsal surface little spots, which are of a bright red color. Upon more careful examination, it will be found that the red spots are really small papillae with a constricted neck, in shape resembling that of a mushroom, and known as the Fungiform (fungus) Papilla. The epithelium investment of the fungi form papillae is extremely thin, and the blood-vessels and terminal nerve networks lie just beneath. The papillae in question always appear red, and can therefore be easily detected here and there amongst the filiform or conical papillae which are more uniformly spread over the dorsal surface of the tongue. The epithelium covering the surface of the filiform papillae is so thick that we cannot suppose sapid substances could quickly pass through it, or between the edges of the overlapping cells, and come in contact with the nerves beneath. These filiform {filum, a thread, and forma, likeness) papillae have probably nothing to do with the sense of taste, but are important organs of touch, much concerned, it may be, in the process of placing the food in the proper position for mastication and deglutition. It is the fungiform papillae and the soft red mucous membrane at the sides and back of the tongue, and that of the palate and fauces, which are concerned in taste. As regards the color of the tongue, it may be remarked, generally, 44 EPITHELIAL CELLS OF TONGUE. that if the epithelial layer on the organ is thin, the tongue will be red ; if very thick, it will be white ; if rather dry, of a dull brown or dark brown color; and if there is an abundant accumulation of soft and moist epithelium upon its surface, of a very opaque dirty white. Epithelial Hair-like Processes of the Filiform Papilla. In the cen- tral part of the dorsum of the tongue the epithelial sheaths of the filiform papillae are very long, and indeed form elongated thread-like filaments, closely resembling hairs in structure. . You may snip off a few of these hair-like bodies from your own tongue, or scrape portions of them from the central part of the back of the surface with a knife. The specimen is then to be placed in a watch-glass in a little weak glycerine. After the processes have soaked for a time they may be placed on the glass slide, covered in the usual way with thin glass, and examined under the micro- scope, first under an inch power, and then under a quarter of an inch object-glass. You will find these long hair-like processes are composed of layers of scaly epithelium imbricated and superimposed one upon the other. The longest of the epithelial filaments project from the dorsal surface of the tongue, perhaps, for more than the twentieth part of an inch. Small particles of food often become entangled amongst these epithelial extensions of the filiform papillse. If you scrape the central part of the back of the tongue a short time after you have taken a meal, and examine the matter as just described, you will almost in- variably find a number of oil globules, and very frequently starch globules, portions of muscular fibres, and other things, according to the nature of the last food taken. Of the Epithelial Cells. The layer on all the papillae of the tongue varies in thickness from time to time. The several epithelial cells com- posing the layer necessarily differ in age. The oldest of these cells are those which are outermost, or situated at the greatest distance from the surface on which they grow, and the youngest are those which are nearest the vessels. Passing outwards we meet with cells gradually advancing in age. The oldest are constantly decaying and falling off. These mix. with the food, and, no doubt, during every meal we swallow them in thousands. But the old epithelial cells upon the tongue and mucous membrane of the mouth undergo other changes, with the general nature of which it is important that you should be acquainted. The changes in the epithelium should therefore be carefully studied as opportunities of making the examination occur. Of Fungi and Low Organisms in and amongst the Epithelium of the Tongue and Mouth. If, then, you look at the old epithelial cells detached from the mucous membrane of the mouth, from the inside of the check or the tongue, under high magnifying powers (from three to twelve hundred diameters), you will find that the cells contain a number of very minute spherical or oval particles, while multitudes of very OF FUNGI AND LOW ORGANISMS. 45 delicate filaments are often seen amongst them. (" Microscope in Medicine," pi. XXXVIII. , fig. i, p. 272.) Now these minute spherical and oval particles, situated in the formed material of the cell, and most numerous at its outer, that is, in its oldest part, are very low and simple organisms in an early phase of development. They have been called micrococci (/uxpoy, little, and xoxxoj, a grain), and have received other names. In this state they have not reached their full development. They are the living germs of organisms which exhibit different characters in their fully developed state. Each is capable of producing millions of descendants in a few hours. Some of them, probably, under certain circumstances, become elongated, and evolve bacteria of various forms; others may form the long thread which used to be called Leptothrix buccalis. (" Microscope in Medicine," pi. LXXXL, p. 492.) Some, perhaps, m^y be the germs of Oidium albicans and other fungi. It is, probable, indeed, that many different species of fungi may be developed from the spherical or oval germ-particles, existing in con- nection with the older epithelial cells on the surface of the, mucous membrane of the mouth. The germ-particles themselves, although they closely resemble one another in appearance, may have been derived from different species of organism. The various species of germs grow and multiply under different circumstances. The growth and multipli- cation of such minute organisms has much to do with the appearance which the tongue presents in the same person at different times, as well as its character in different forms of derangement and disease. It has been stated by more than one observer that Sarcina ventricull is often present in the fur of the tongue, but I have never found it in this situation, though I have examined the fur in very many cases during the past thirty years. In cases in which sarcinse were found in the stomach, I did not find them on the tongue or in other situations. I am afraid that many mistakes have been made with regard to the identification of Sarcina ventriculi. Old epithelial cells, like other old and formed tissue or other dead organic animal or vegetable matter, are very soon invaded by the germs of low vegetable organisms, always very numerous in their vicinity, which grow at their expense and live upon their substance. Not only on the surface of the cells, but in their substance, the fungus germs are found, and frequently project from them, forming little collections, which may be detached from time to time. Amongst the hair-like epithelial processes projecting from the free extremities of the filiform papillae, are often found masses which have a granular appearance under low magnifying powers. When examined under objectives magnifying more than three hundred diameters, these masses will be found to consist of millions of spherical and oval fungi or micrococci, grouped together, each little mass of bioplasm being 46 BACTERIA AND DISINTEGRATION. surrounded by, and separated from, its neighbors by clear structureless material, which probably has been formed by it. Amongst the epithelial cells in every part of the mouth you will often find some very long extremely delicate filaments, which, if ex- amined under high powers, will be found to exhibit a number of trans- verse markings. These grow and freely multiply in the fluids of the mouth at the usual temperature of that cavity. Many are found between the teeth, and in the tartar you will meet with numbers of vegetable organisms. Indeed, it is probable that the deposition of the tartar is intimately connected with changes occasioned by the living vegetable organisms in question, which belong to the genus Leptothrix. ("Microscope in Medicine," pi. LXXXL, fig. 3, p. 92.) Many of the filaments, long and short, exhibit peculiar movements, some vibrating to and fro, others taking a spiral course. In many cases you will find whole forests of vegetable organisms consisting of many different species, and of the same species at different periods of growth, upon the dorsal surface of the tongue. These increase in number in cases of derangement of the digestive organs, and in many forms of disease. The growth and multiplication of these low organisms at the very entrance of our bodies, and so placed that they must pass in immense numbers into the stomach whenever we swallow anything, is a fact of great significance in connection with certain conclusions respecting the action of these low organisms upon the solids and fluids of man's body. Of late years, the idea that such organisms constitute the active par- ticles concerned in the propagation of contagious disease, are, in fact, the actual materies morbi, has been increasingly popular. The first question you will ask will probably be this : Do these germ-particles perform any distinct office or function in connection with the solution of food or digestion, or do they merely live and grow upon the old epithelial cells and the debris of the food which must needs undergo change in such a situation, and at the temperature of the inside of the mouth? We find such bodies in animals as well as man, and though they are found in greatest number in certain derangements, multitudes are constantly present in the most healthy individuals. They have no doubt grown and multiplied under similar conditions and without vary- ing in character for thousands of years. Wherever organic matter is undergoing change and disintegration in an organism, or outside it, at the temperature of man's body, or some degrees lower or higher than this, and in some cases at a much lower temperature, such organisms exist in countless multitudes, and grow and multiply at the expense of the disintegrating organic matter. In the autumn there is not a leaf in which you will not find millions of low vegetable organisms in various stages of development and BACTERIA IN LIVING PLANTS. 47 growth. As the organic matter of the dying leaf or plant undergoes change, and the decomposition of its more unstable compounds com- mences, the circumstances specially favorable for the growth and mul- tiplication of many of the microscopic fungi are established. Fungus germs exist in the air at every part of the earth's surface at all times. Though by no means constantly present in precisely the same amount, some are always to be detected in appreciable numbers, if the air is properly examined. Many coming into contact with the moist sur- face of the leaf about to decay, find there a surface favorable for their development. The spores germinate, and from the surface of the tissues of the plant the growth easily makes its way into the substance. But is it not remarkable that any one should believe, on the one hand, that the decay of the leaves is due to the fungi, or, on the other, that the decay is the cause of their development, growth, and multiplication? All that can be proved by facts and observation is, that as the leaf grows old, substances are formed which are easily appropriated by the fungi. The germs of fungi are present and are ready to develop just at the time when the appropriate pabulum is formed. The fungus does not spring from the leaf, neither is the leaf caused to grow old by the fungus, and its deterioration begins before the growth of the fungus commences. The fungus is in no sense either the cause or the conse- quence of the decay. And in the case of the higher animals and man, at least x in many instances in which low organisms are associated with morbid processes, these last are neither the cause of disease nor are they produced by it. Fungus germs and micrococci of various kinds, being present, will grow and multiply whenever the surrounding conditions become favorable for the multiplication of each particular kind. If these conditions remain for a considerable time unfavorable, the germs, if present, remain quiescent, and may at last die, though probably most of such germs retain their vitality in a quiescent state for many years, and some perhaps for centuries. Nor are microscopic fungi found only at this period of the year (autumn) in connection with dead and decaying vegetable tissue. In the vegetables and fruit we eat are countless multitudes of living grow- ing organisms. Look, for instance, at the cells of a piece of lettuce or of the leaf of the watercress, nay, even those in the leaf and stem of the young and rapidly growing mustard and cress. There you will find, if you examine thin sections or the separated cells under a magnifying power of three hundred diameters or more, millions of little bodies, each of which is capable of giving rise to countless multitudes in a very short time. If you carefully study the revolving living matter of the cell of the leaf of the Vallisneria, you will have no difficulty in discern- ing some of these very low organisms in close proximity to the living 48 BACTERIA IN LIVING ANIMALS. matter of the plant itself. So very near, indeed, is the lowest living particle to the highest during its life, that no wonder the material of the latter falls a prey to it at last. The instant matter ceases to live it is invaded and appropriated by the -ever-growing bacterium the most constant, the most unchanging and universal of all kinds of living things and of all the survivor; but whether this be of all things the most fit to survive, you may decide if you can. As it is with regard to deteriorating vegetable tissues, so it is with regard to decaying animal tissue. Whether the body be in a state of health or disease, wherever tissue is about to undecgo active disin- tegrating chemical change, wherever decomposition is taking place, or is approaching, the conditions may be favorable for the growth and multiplication of certain low organisms, the germs of which are present. Long before any changes akin to deterioration and decay are ordinarily supposed to commence, even from the very earliest period of construc- tion and growth, fungus germs are ever present, ready to grow and multiply should the death and disintegration of a living particle occur. No wonder, then, that we find so many low organisms growing in connection with the old decaying epithelium of the mouth and of the tongue, of the oesophagus, and other parts. Under certain circum- stances, the fungi grow and multiply to a vast extent lower down the alimentary canal, as I shall presently explain. We cannot suppose that such organisms do any harm ; for patients suffering from maladies in which the alimentary canal seems to be almost filled with bacteria recover, without damage to any textures having been occasioned. I have not studied the epithelium from the mouth of a savage who has never been in contact with civilized man, but, without having actually looked, I think I may feel pretty confident that low vegetable organisms would be found growing in the cells just as they grow in those of our own mucous membrane, and the species are probably pre- cisely the same. In lower animals, organisms of the same general character abound. If you examine the tongue of the dog or of the cat, of the sheep or of the ox, you will find that the same sort of changes are constantly going on. Everywhere the old epithelial cells are being invaded by low vegetable organisms, which grow and multiply as they do in the epi- thelial cells of man himself. Multitudes, of course, pass down into the stomach, and, under ordinary circumstances, many are probably de- stroyed during digestion by the action of the gastric juice and bile, and other fluids, which are poured into the alimentary canal. Those that are not destroyed certainly do no harm. In the healthy state they either do not grow and multiply at all during digestion and assimila- tion, or only to a very slight extent. In the case of the lower animals, the introduction of fungi into the BACTERIA IN THE INTESTINES. 49 stomach goes on constantly and upon an enormous scale. Every mouthful of water consumed by sheep, oxen, and other animals, teems with myriads of low vegetable and animal organisms in various stages of existence ; and in the food they take, fungi in various stages are present, as well as the sporules of many different species. These low organisms are, therefore, always passing into the bodies of the animals in count- less multitudes. But although millions of living fungi are always enter- ing the alimentary canal of man and animals without doing harm, and probably without growing and multiplying there to any great extent, there are circumstances under which a different state of things is observed. If the stomach is out of order, if the bile and other secre- tions are deranged, or from some temporary or permanent impediment to their escape are not poured into the alimentary canal in propei quantity, phenomena totally unlike those characteristic of the healthy state are induced. Many an infant has suffered from the extraordinary development of bacteria in its alimentary canal, and some children die from the state of things thereby induced. But the bacteria cannot cor- rectly be regarded as the cause of the departure from the normal, state. That is to be sought in the secretions and in the action of the glands prior to the multiplication of the organisms. I have seen every part of the cavity of the stomach, and the small and large intestine of an infant filled with curdled milk which had not under- gone the slightest digestion, and every particle of which, when under the microscope, seemed to be almost composed of bacteria, so abundant were these bodies. Sometimes, however, bacteria grow and multiply in the milk of the mother before it has escaped from the breast, and the changes effected in the milk by the growth and multiplication of the organisms, it need scarcely be said, render it quite unfit for the suste- nance of the infant ; and such milk, were it taken, would, except perhaps in the very strongest children, give rise to serious derangement of the digestive organs. In such a case the maternal secretion must have been out of order at the time of its secretion, or the bacteria would not have grown and multiplied in it. It is certain that in such secretions and in the glands that produce them, bacteria-germs are always present, but do not increase and multiply until long after the secretion has been discharged from the gland. In face of such facts, it is difficult to accept the doctrine that bacteria, fungi, and such like low organisms are morbific, or disease- producing agents, or are of themselves productive of harm to the organism into which they pass. It is astonishing that, notwithstanding, these facts, which can be verified by any one facts with which many of us have been familiar for the last thirty years and more should at this time be unknown to, or somehow escape the cognizance of, some who have been recently studying the life-history of these very organisms. 5 D 5, the augmentative particle, and /U,, to concoct or digest. The pain or discomfort consequent upon slow or imperfect digestion, or indigestion, may be induced by many different circumstances. There may be some deranged action of the mucous membrane of the stomach, and hyper-sensitiveness (jWp, over, or above) ; or severe pain may be occasioned by an altered state of the circulation, caused directly or in- directly (by reflected action) influencing the nerves of the stomach. Very many times one comes across cases of what may be called ordinary indigestion, where there is no actual disease, but still where a trouble- some and almost constant fixed pain, aching, heaviness, or sense of weight, or fulness, or of pressure is complained of, so wearying to the patient that it deters him from taking food. In consequence he gets thin and pale, and perhaps loses heart and becomes weak and de- spondent, and is much out of health. If we could see the mucous membrane in many cases of indigestion, we should no doubt find it unduly vascular. There would be a state approaching to inflammation over a limited area only, possibly over a portion of mucous membrane not larger than a sixpence. Here the vessels would be seen distended, the blood moving very slowly along the capillary tubes, and some exudation from the vessels would very likely be found in the surrounding tissue. The nerves distributed to the mucous membrane would have undergone those changes which result in their being unduly excitable. Their bioplasts and those of all the tissues in the neighborhood would be found enlarged. Partly from this last circumstance, and partly from the pressure upon them exerted by the undue distention of the vessels, the sensitive nerve-fibres would transmit impressions of a painful character. The state of the mucous membrane I have just referred to may soon give place to the normal condition, or it may persist and lead on to a state of things which may result in the formation of an ulcer, the nature and symptoms of which disease I shall have to refer to in another part of my course. Of Pain, and of the Arrangement of the Finest Nerve-fibres in the Stomach and Intestines. The whole question of pain is one of great interest and importance, and as the pain in indigestion and other derangements of the digestive organs is experienced through the in- strumentality of nerves which in the normal state transmit impressions only of which we are not cognizant, it will be worth while to consider the arrangement of the nerve-fibres concerned, and discuss their prob- able action. Nor can disorders of the intestinal canal be understood without the knowledge of the way in which healthy action is governed 8 86 NERVES OF THE INTESTINE. and carried out. Although the bowels in every part are very freely supplied with nerve-fibres, so long as the functions are properly dis- charged we remain quite unconscious of the existence of any exquisitely sensitive tissues in connection with the alimentary canal. Fortunate are all who pass through life without discovering that sensitive nerves are distributed to the intestines. We know nothing of the changes taking place in the stomach and bowels until something interferes with their due performance. Then indeed we become aware of the contrast between ease and certain forms of drs-ease as it affects these wonderful structures. The whole of the intestinal tissues are most abundantly supplied with nerves. You will find in some of the older anatomical books, descrip- tions given which would give you a very imperfect notion either of the number or arrangement of the nerve-fibres. In fact, the most important and most extensive portion of these nerve-fibres is known to few anat- omists even now, and only a few years ago it would have been impos- sible for us to form a conception of the true arrangement of the nerve- fibres of the digestive tract, or of the actual phenomena going on during life in any part of it. All the tissues entering into the formation of every part of the intestinal canal are most abundantly supplied with very fine nerve-fibres, although you might read much that would lead you to infer that the mucous membrane and muscular coat of the stomach and in- testines received very few. nerves. It used to be supposed that the con- traction of involuntary muscular tissue resulted from direct irritation or stimulation. And even now little attention is given to the highly im- portant part played by the nerves and nerve-centres which influence every action and every movement connected with every part of the digestive process. In every part of the digestive apparatus, from the mouth to the anus, the secreting and absorbing as well as the muscular apparatus receives an abundant supply of nerve-fibres. The muscular fibres which are distributed around the stomach and intestine, as well as those situated just beneath the mucous membrane, are frequently, though not constantly, in active movement, each fibre alternately shortening and lengthening undergoing contraction and relaxation, actions which occur at different times in different parts-of the alimentary canal, and in all alternate probably, with comparatively long periods of rest or quiescence. But invariably the contraction of the muscular tissue, like that of every form of voluntary and involuntary muscle, takes place under the influence of the nerves. Besides the nerves distributed in networks and plexuses to the mucous membrane and muscles in great number, there is a highly com- plex system of ganglia or nerve-centres little appreciated, and indeed hardly known to more than a few observers. You all know, of course, what multitudes of ganglia help to constitute the sympathetic system NERVE-GANGLIA AND PLEXUSES. 8/ Many of the large ones you see in the course of your work in vhe dis- secting-room, and the more skilfully you dissect, the more ganglia will you find. You are also well aware of the complex interlacement of coarse nerve-fibres and trunks in many parts of the abdominal sympa- thetic system, but from the most perfect ordinary dissection that can be made, you will form but a very imperfect idea of the vast number of minute ganglia and ganglion cells connected with what seem to be excessively fine nerve threads. If, now, from a piece of small intestine pinned out upon a strip of wood or cork, you will detach carefully the mucous membrane from the muscular coat, and soak it for a few days in equal parts of glycerine and water, replacing the solution from time to time with fresh fluid, and then gradually add stronger glycerine, you will find the tissue will assume a state favorable for the demonstration of the ganglia. Small pieces of the submucous tissue are to be snipped off, placed on a glass slide, and after being gently teased out with pins or needle points, and moistened with fresh glycerine, covered with thin glass. If you examine such a specimen under an inch object-glass, you will have no difficulty in demonstrating a vast network of ganglia and nerve-fibres. You will observe hundreds of little microscopic ganglia on different planes, and these you will discover are all connected with one another by numerous intercommunicating bundles of nerve-fibres, constituting quite a net- work or plexus of fibres and ganglia. The ganglia in question were discovered some years ago by Meissner; Auerbach had some years pre- viously described plexuses and ganglia close to the muscular coat. But of course these observations were contradicted by some and ignored by others, and long papers were written by great authorities to prove that the nerves, ganglia, and plexuses were really vessels, the points of diver- gence of which, in their opinion, had been mistaken for ganglia. There is, however, no difficulty in demonstrating these ganglia most conclu- sively. I have many times shown in connection with the course of physiological anatomy which I used to give in this college, the cells composing them, with the bioplasm of the nerve-cells and fibres arti- ficially stained with carmine, and I can assure you, with the greatest confidence, that the cells are true nerve-cells, and that fine nerve-fibres pass from them to supply with nerve-fibres the tissues of the mucous membrane, as well as the thick layers of muscular tissue which encircle the intestinal canal. So numerous are the fine nerve-fibres that there is not a portion of tissue the one five-hundredth of an inch in width which, does not receive an abundant supply. Every villas of the intestinal canal is supplied with nerve-fibres, and the action of each of its several component tissues is presided over by nerve-cells. Every gastric gland as well as every intestinal follicle is also abundantly supplied. Its structural connection with the nerve- 88 PAIN-CONDUCTING NERVE-FIBRES. fibres is a nerve-centre, or rather a group of ganglia by which nerve action is regulated, the changes resulting in the secretion of gastric juice and intestinal fluid governed, and actions emanating from other nerve- centres or groups harmonized. The nerves have also much to do with the simultaneous discharge of the secretion upon the surface of the mucous membrane from thousands of microscopic glands. But in spite of this marvellous nerve supply, as long as things go on rightly, you are not cognizant of any of the changes which are taking place. The intestinal tube is sometimes full and distended, sometimes relaxed, sometimes contracted, and yet all these alterations in volume, all this stretching and contraction, take place for the most part without our knowing anything about it. If, however, these same phenomena occur in an exaggerated way, or if anything interferes with their due performance, we very soon become conscious that things are not as they should be. We cannot always say exactly what part of the intes- tine is in fault, or what sets of ganglia are disturbed in their action, but we experience discomfort if not actual pain, and almost instinctively we so act as to give the whole digestive system little to do. We let it rest for a time. We take no food or confine ourselves to small quan- tities of easily digested slops, and in the course of a short time things generally right themselves. But surely it is very remarkable, seeing how unconscious we are in the healthy state, at least as far as feeling is concerned, of the existence of the intestinal canal, that when its action is much deranged, the pain experienced should be so very severe, and so difficult to bear, as is the particular pain which is developed at the peripheral distribution of the sympathetic nerve-fibres, the ordinary actions of which go on quietly and almost incessantly, but quite unconsciously. The peritoneum ("/-><', around, and reu'w, to extend) or thin membrane external to the muscular coat of the intestine, which is supplied with nerves from these same ganglia, and which in the healthy state is always sliding smoothly in contact with the moistened surface of another layer of the same delicate tissue, becomes exquisitely sensitive in inflammation. The pain of peritonitis (^cpi, around, rVw, to extend, and *-?f, rash, the suffix itis denoting inflammation) is one of the most terrible forms of pain that any human being can have to bear, and yet these same nerve- fibres which are concerned in the causation of most horrible suffering, act as a general rule quite unconsciously, do their work without our knowing anything of them, or of the action of the apparatus they govern. Pain-conducting Nerve-fiLres. The nerve-fibres concerned in the transmission of the sensation we call pain, are not, I think, those which have been regarded as special sensitive nerves, but the fine fibres which were first demonstrated by me close to the capillary vessels, and so sit- uated that any change in vascular turgescence would affect them. As GASTRODYNIA. 89 is well known, the pain of a bad sore throat is much less severe than the pain experienced in pleurisy, pericarditis, or peritonitis, and yet the number of sensitive nerve-fibres distributed over a given area of tissue is many times greater in the mucous than in the serous membrane. When the tonsil is inflamed the pain is very great, but it depends less upon the tension of the mucous membrane covering it than upon stretching of the vessels and nerve-fibres in its substance. Again, the pain we suffer from in rheumatism originates in tissues which are rich neither in nerves nor vessels, and yet it is more severe than many kinds of pain, the seat of origin of which is in parts more highly vascular. The pain in the lungs when pulmonary capillaries are congested, even if they be seriously damaged, is slight as compared with that which results when the capillaries of the pleura are involved. Nerve-fibres of the same kind are not only distributed close to the capillaries, but in many tissues, as for instance the cornea, are situated at some distance from any vessel ; but these nerve-fibres belong to the same order as those distributed to capillaries, and act as afferent nerves to centres, the efferent nerves of which are distributed to the muscular fibres of the little arteries. It is, I believe, when these afferent fibres are made to act violently, that/^z'tf is experienced. The pain associated with circumscribed inflammation of various kinds is due partly to the stretching and pressure to which the fibres of these nerves are subjected, and partly to the increased nutrition which proceeds in the nerve bioplasts, in consequence of the increased amount of nutrient pabulum which bathes them, and which has transuded through the vascular wall. Gastrodynia. If the vessels of even a small part of the mucous membrane of the stomach become unduly distended from any cause, discomfort results. If there is too much action of the glands or insuffi- cient action, pain in the stomach, learnedly called Gastrodynia (yaa-rjp, the stomach, and btivvq, pain), or Gastralgia (dAyof, pain), is occasioned. If the food we take does not digest, that is, if it does not gradually dissolve after it reaches the stomach, as it should do, but remains there, being moved round and round by the muscular action of the organ, we experience pain and sometimes extreme pain. If you take rich, im- proper food, and drink a quantity of bad champagne, more especially if your dinner comprises tough beef and concludes with a good supply of heavy pudding or pastry, you will probably learn what is meant by an attack of gastrodynia, unless you happen to have an unusually vigorous digestion. You will at the same time be thoroughly convinced of the existence of a vast number of extremely sensitive nerves in connection with the walls of your stomach. Not only so, but in all probability the action of the whole intestinal canal will soon be violently disturbed, and you will be fortunate if you get off with a sharp attack of vomiting and 8JL * 9O HEARTBURN OR PYROSIS. active diarrhoea : for in this way you may perhaps find a short cut to returning health. But thousands who eat moderately, and some even who eat immoderately, go on from year to year without the slightest discomfort of any kind in any part of the intestinal canal, and without discovering from any sensations they experience that they possess one. Indigestion may be due to altered gastric juice, or to the secretion being too acid or not sufficiently acid ; or the active dissolving substance, the pepsin, may be in insufficient quantity or imperfectly formed; or, on the other hand, the derangement may depend upon the pouring into the stomach of a considerable quantity of alkaline fluid, which probably neutralizes the action of the gastric juice, and in other ways impedes digestion and interferes with the changes taking place in the stomach. Strange to say, two fluids of opposite qualities are secreted by glands in different parts of the stomach. Heartburn, Pyrosis, or Waterbrash, There are certain glands at the cardiac extremity, near the point where the CEsophagus opens into the stomach, and called by some The Cardiac Glands, the secretion of which possesses an alkaline reaction. It seems that these glands in certain cases secrete a great quantity of a clear, somewhat viscid, alkaline fluid. Few of us are aware of the existence of the secretion of these cardiac glands in our own organisms, nor have we any actual experience of the formation of a fluid of the characters just mentioned. As is well known, the contents of the stomach, under ordinary circumstances, are extremely acid, and many suffer from the regurgitation from time to time of a small quantity of highly acid fluid into the pharynx, when its distinctly acid taste is experienced. Chalk or Magnesia is taken for the relief of the Heartburn, which, when physicians thought very much of hard words, was known as Ardor Ventriculi, or Cardialgia (KapJmdAyof, pain). The acid fluid will effervesce freely if bicarbonate of potash or soda be added to it. A similar action occurs if chalk is mixed with it, but as it is more slow the effervescence is not so easily observed. Some of the Dispensary patients of the Hospital will tell you that they frequently reject from the stomach a large quantity of clear liquid, which you will find will cause the blue color of reddened litmus to return. It is, therefore, of alkaline, not acid, reaction. This alkaline fluid is vomited or rejected in certain cases, which are termed Water- brash or Pyrosis (iri given to the mysterious agencies communicated to some of TREATMENT OF CONSTIPATION. 13! the chemical ingredients of the water during their solution or afterwards. The air, the simple, wholesome, and restricted diet, the substitution of water for alcohol, the exercise, the rest enjoyed, and peace of mind are the mere accidents attending the curative action of the special water. But those who drink good water in London, and live according to reason, may work hard and enjoy all the year round the advantages which some go so far, and at great expense and inconvenience, to try to find during what they call their holiday. Smoking Tobacco. Other unfortunate individuals, slaves to a bad habit, tell you they never can get their bowels to act without smoking the accustomed, cigar or pipe. Whether it be the force of habit, or whether the nicotine, the active principle of the tobacco, actually gets into the blood and excites the bowel to act through the nerve-centres, I do not know, but we are often assured that smoking does exert a purga- tive influence. Tobacco smoking in moderation certainly does no harm whatever, and he who finds that it is followed by the desirable consequences referred to, will be wise to smoke. THE MEDICINAL TREATMENT OF CONSTIPATION. Of Purgatives in Constipation. As I have shown, in cases of pro- longed insufficient action of the bowels, the general health is impaired, the blood becomes altered in composition, many substances remaining in it, and circulating with it through the vessels, which ought to have been eliminated, and the action of many secreting and other organs is, in consequence, more or less disturbed. This after a time may lead to structural change, and result in disease. It may be necessary to advise the patient who has been suffering from deranged health, resulting from a prolonged state of constipation, to submit to systematic medical treatment. In some instances the condition may be relieved by attending to the state of the secreting organs without giving any medicines having purgative properties. The character of the urine and other secretions is often much altered. Deposits of considerable quantities of urates are formed, and the urine itself may be of very high specific gravity, and in other respects may have departed, more or less, from the healthy state. In such cases a few doses of Bicarbonate of Potash (Potasses Bicarbonas) will set everything to rights in a day or two, without any purgative action being excited. In many cases of constipation in which the blood is in such a state that any little wounds or scratches do not quickly heal, an ordinary purgative that acts on the alimentary canal will not suffice, but you must select one which, besides 'producing purgation, also acts upon the secreting glands, particularly those which discharge their secretions at once into the alimentary canal. As soon as the medicine begins to act, and that is oftentimes hours before any purgative effect is ex- IJ2 MEDICINAL TREATMENT. perienced, the red and angry appearance of the wounds and scratches will subside, and the healing process will be proceeding satisfactorily within twenty-four hours after the dose has been swallowed. Where constipation has existed for a considerable period of time, 'and the general health has in consequence become considerably de- ranged, you must not expect that the patient is to be at once cured, and indeed generally you will find that purgatives administered from time to time, in moderate doses, act more favorably than a smart purge administered once only. Very free purgation is often followed by constipation, and the patient, instead of being permanently benefited, is only relieved for a very few days. You will often find it necessary to give moderate doses of certain purgative medicines at short intervals for a time, taking care, however, not to carry this system too far, so as to worry and irritate the alimentary canal, and give the patient much pain and discomfort. Again, it not unfrequently happens that an ordinary purgative will not properly act, or it acts only very slightly, without affording the relief which is expected. In such a case it may be advisable to repeat the medicine two or three days running, but some- times it is better to wait for a few days, and then repeat the dose. The same observation has been made as regards many other medicines. Bicarbonate of Soda or Potash often fails to relieve if given in single doses, though they be large, while if fifteen or twenty grains be taken three times a day, and continued for three or four days a week, a very distinct and highly satisfactory effect is produced. The same medicine administered to a person in precisely the same dose will sometimes act freely and sometimes will not act at all. The state of the bowel varies greatly as regards secretion, and its response to stimulants to secretion and muscular contractility. No doubt this depends to some extent on the appetite, and the kind and amount of food taken, but not entirely so, for sometimes after a person has lived sparingly for some time, a moderate purge will produce a very free action. The action of the intestinal, like that of other glands, is not uniform within corresponding periods of time, but sometimes it is very free, sometimes almost suspended for a while. If we can just hit upon the time when the glands are about to act freely, for the administration of the purgative, the effect will be exactly what is desired. Most glands form and discharge their secretions, and then rest for a while. It is, therefore, wrong in principle to be continually trying to excite them to action by giving remedies which excite free action, day after day, for a considerable period. This injudicious and unreasonable practice, which was much in favor fifty years ago, did weak people a good deal of harm, and to it we are indebted for the present unreasonable oppo- sition to the employment of one of the most valuable medicines (mer- cury) known to us. SLUGGISH BOWELS. 133 When the constipation depends upon sluggish action of the large bowel only, the daily or almost daily administration of a mild purge, containing Rhubarb, Aloes, Senna, Colocynth, or Podophyllin, is un- objectionable, and by adopting this practice, which has been solemnly condemned by some authorities, you will sometimes enable a patient to get through a great deal of work which otherwise he could not perform, and you will now and then succeed in transforming a thoroughly miser- able and discontented person into a happy one. See also the remarks on the use of mercury under the " Treatment of Sick-headache." One is often assured by a patient in answer to inquiries that his bowels are " regular," that is, that an action occurs every day, and he will perhaps tell you that he is quite confident no purgative medicine is required. Although from the first you suspect that he requires a purge, according to his wish you try various remedies to relieve the symptoms of which he complains, but without effect. He may go from doctor to doctor, and at last he is ordered to take a purgative, and gets almost immediate relief. Oftentimes it is necessary to order a mild purgative pill to be taken daily before dinner, for a week or longer, and the patient is not unfrequently quite astonished at the effect. Up to that time he had felt convinced that his colon was clear, although, in fact, faecal matter had been very gradually accumulating in it for a consid- erable time. You will often find small doses of purgatives, given just after food for several days in succession, of great use in imperfect action of the bowels, from which many persons engaged in sedentary pursuits in towns very commonly suffer. From three to ten grains of Rhubarb, with or without Carbonate of Soda, or five grains of Compound Rhubarb pill, will be sufficient. You must teach people to experiment a little on themselves, in order that they may find out the least quantity required to produce the effect desired. As before remarked, fruit taken daily is of use in such cases, but many persons do not try the plan long enough to obtain success. The digestive organs which act sluggishly require a good deal of humoring, so to say. Violent purgatives are worse than useless, and in such cases a moderate purge is often followed by a headache and general upset, lasting perhaps for many days, and suc- ceeded by the sluggish, torpid, imperfectly acting state. There is no diffi- culty in managing those who eat well and take plenty of exercise, but those who live very moderately, and whose work is intellectual rather than muscular, will require some thought and the exercise of a little ingenuity on your part to get them right, and to regain for them the much desired feeling of contentment dependent upon healthy intestinal action. As regards the doses of purgatives, you must be very careful, for you may order a patient a dose that will certainly clear out the whole 12 134 CALOMEL AND COLOCYNTH. intestinal canal, but which will also gripe him very severely, and make him for a time very weak and miserable ; while a dose which you might perhaps hardly believe would have any purgative action at all, would have been quite sufficient to effect the desired end, and without pro- ducing the slightest pain or discomfort. You must vary the doses of the drugs you prescribe, according to the state of the patient, and according to the sort of organism you have to treat. If you are pre- scribing for a highly nervous, anxious, excitable person, who thinks he has got all sorts of ailments of a very serious character, you must, as a rule, not give very violent purgatives, for, if you do, you may bring on pain and sickness, and much increase the intensity of the suffering you have been asked to alleviate. On the other hand, if you are treating a robust laboring man, accustomed to work hard and feed well, and in the habit of drinking three or four pints of beer a day, and more when he can get it who has a florid complexion and great muscular vigor, it would be foolish to order him a gentle pill or mild draught. To such a person two or three grains of Colocynth pill would be perfectly useless, and ten grains might be required to act at all, and if you were to add to these two or three grains of Calomel, the patient would probably feel the more grateful to you. Many of the chemists, in town and country, sell good strong pills, and which are most useful for those for whom they are prepared, though they would not suit many of your patients. This neces- sity for varying thedoses of medicines according to the individual patient, ought to convince all of the importance of each practitioner learning how to prescribe, and mix, and combine medicines, instead of exclusively relying, upon the pills and mixtures prepared for the profession in enormous quantities by large firms, and to be purchased by the gross and by the gallon, but which cannot be altered to suit individual patients, and combined so as to agree with peculiar temperaments. Moreover, there is no doubt that many extracts and pill constituents lose much of their virtue by being kept for a considerable time. Practitioners have, from time to time, discovered certain combinations of things which are very valuable, and the receipt for many a useful pill or mixture has been handed down from generation to generation. In these days, not only do we neglect to use many of the old prescriptions, but we no longer suggest new ones, and many combinations of drugs of tried value and in frequent use in former days, will soon be altogether forgotten. The old system of teaching such elementary but practically important matters has been entirely abandoned, and many a wrinkle of the greatest im- portance in practice, instead of being preserved and transmitted as formerly from master to pupil, has been lost. Let me advise you never to neglect an opportunity of picking up from old practitioners any receipts for medicines they are willing to give you, and not to CASTOR-OIL AND RHUBARB. 135 despise their teaching, especially as regards the treatment of many slight ailments difficult to manage and to cure. Do not receive with contemptuous indifference their 'suggestions for the treatment of func- tional disorders, the exact nature of which they may be unable to adequately explain. Castor-Oil, Oleum Ricini, which is the oily substance expressed from the seeds of the Ricinus communis, is one of the best and most frequently used of purgative medicines, and, were it not for its nauseous flavor would be yet more popular. It is at the same time one of the mildest and most certain. of purgatives, and is suitable to persons of all ages. You may give it to the infant as well as to the most infirm and delicate. It is usually given by the mouth. But Castor- oil may also be employed in enemata. It is one of the few purgatives that act upon every part of the intestinal canal, from the stomach downwards, but its action commences in the' upper part, and it is efficient in driving down imperfectly digested and other matters that may be irritating the mucous membrane and causing pain. The dose varies from a few drops to half an ounce or more, but most persons take more Castor-oil than is really necessary to produce the required effect. One teaspoonful is often sufficient for an adult, and sometimes acts as well as a larger dose. Not the least advantage of prescribing the smallest dose that will be useful is that it is so much easier to take. There are many receipts for taking Castor-oil so as to avoid tasting it. Upon the whole I think you will find the following one of the most efficient plans. You direct that a teaspoonful or more of " black coffee," that is, coffee without milk, be poured into a wineglass, the whole of the interior of which, including the lip, has been well wetted with the coffee. A teaspoonful or a little more of the oil is then to be steadily poured on the surface of the coffee, when it will form a large globule lying perfectly free and not in actual contact with any part of the glass, because the latter has been well wetted with the adhering coffee. The patient then opens his mouth wide and pours the oil and coffee down his throat, swallowing the whole in one gulp. If the operation has been successfully conducted, he will not have tasted the oil in the slightest degree. Tea, a little Ginger or Orange Wine and water, or Peppermint, Camphor or Orange-flower water, or Brandy and water may be used instead, but strong spirit being lighter than the oil will not do. Some strongly recommend that the dose of Castor-oil should be well shaken up in a bottle with twice its quantity of milk, and when well incorporated poured into a cup or glass and quickly swallowed. Rhubarb, Rhei Radix, Pulvis Rhei is one of the best of purgatives, and its virtues are very widely known. It has been a popular remedy for more than two centuries, and is one of the best purgatives for children. Mixed with Carbonate of Soda, Soda Bicarbonas, it is very 136 COMPOUND RHUBARB PILL. useful in derangements of digestion. From five to twenty grains of Rhubarb with twice as much Bicarbonate of Soda, will often give great relief. The dose may be repeated once every other day after food for a week or two in cases of constipation or imperfect action of the bowels. See also pp. 139, 141. Pulvis Rhei Composilus, formerly known as Gregory 1 s Powder, con- sists of Rhubarb, 2, Light Magnesia, 6, and powdered Ginger, i. It is an excellent and safe remedy and may be given in doses of from ten grains to a drachm, in water. Ordinary Compound Rhubarb Pill, Pilula Rhei Composita, and Compound Colocynth Pill, Pilula Colocynthidis Composita, suit most persons very well. You may order three to eight grains of either of these pills, and it is better to combine with them a grain or two of the Extract of Hyoscyamus or Henbane, Exlractum Hyoscyami, which will prevent any griping or discomfort. Three or four grains of either of the above pills with a grain of Extract of Henbane may be made into a pill, and one may be taken every night or every other night for a week or two, in many cases with great advantage. In this way the bowels may be thoroughly relieved and got into the way of working regularly. One of the great advantages of giving purgative medicines in the form of pills is that the particles of the drug are thoroughly comminuted and diluted, as it were, by less active ingredients. The importance of the minute division of active substances was known even to the ancients. A smaller quantity of the active material is sufficient, and it is far less likely to do harm, while its action is sure to be more moderate and equable, if intimately mixed with a quantity of inert or slightly active material, than if administered in a pure state. Many pills and powders have been compounded on this principle. Compound Ipecacuanha powder, Pulvis Ipecacuanha Compositus, Compound Jalap powder, Pulvis Jalaptz Compositus, and Compound Rhubarb powder, Pulvis Rhei Compositus, are examples. If there be much flatulence, or if you desire to give a little stimulus to the secretion of the gastric juice, you may add to the pill or pills half a grain or a grain of Capsicum, Capsici Fructus, or ordinary Cayenne Pepper, with advantage. You must recollect in administering pills not to order more than five, or at the most six grains in one pill, or you will astonish your patient by the size of the bolus you have ordered him to take. Five grains form a moderate-sized pill, but if blue pill or calomel should be one of the ingredients, the pill will be small, because a grain of these mercurial preparations occupies very little space. This matter of the size of pills must be borne in mind, for some people think it an insult to receive a large pill, and many will tell you they cannot swallow one of even moderate size. The professed inability to swallow a pill is often COMPOUND LICORICE POWDER. 137 mere affectation or determination on the part of the patient not to attempt to do so ; but some persons have a real difficulty. For them the pill may be silvered or gilt, or covered with a tasteless starch coating, and if neither of these plans will please, tell them to pack the pill up in a small piece of moistened " pastry-cooks' paper," when the whole will slip down whether the patient will swallow it or not. This pastry-cooks' paper can now be obtained at many of the large chemists, and is an excellent thing in which to give powders to children. Little capsules of this material have been prepared and made in separate halves. The powder or pill is placed in one and the cover applied, the edges being slightly moistened, the two halves adhere, and the little parcel with the included medicine can be swallowed without any difficulty. Nux Vomica is another remedy which may be given, by itself or combined with a purgative, in cases of imperfect action of the bowels. It is useful by giving tone to the bowel and stimulating, probably through its action on the nerves, the muscular coat of the intestine. It is now frequently prescribed. It comes from the plant which yields Strychnine, Strychnos Nux Vomica. You may give of the Extract of Nux Vomica, Exlractum Nucis Vomicce, from a quarter of a grain to a grain. If added to a purgative pill, it helps the action of the large bowel. The Tincture of Nux Vomica, Tinctura Nucis Vomica, may be prescribed in doses of from five to twenty minims with some Compound Tincture of Bark or other tonic. Decoction of Aloes, Decoctum Aloes Compositum, Tincture of Senna, Tincture of Rhubarb, are simple remedies which are often prescribed in doses of from a drachm to half an ounce. Scammony, Scammonium, a gum resin from the root of Convolvulus Scamrnonia, is a component of many purgative pills, and is a very active purgative. For children suffering from intestinal worms, Scammony is one of the best remedies. It may be given in doses of one or two grains, or from three to five grains of the Compound Scammony Powder, Pulvis Scammonice Compositus,w\\\c\\ consists of Scammony, 4; Jalap, 3 ; and Ginger, i, may be ordered instead of the pure drug. It may be taken in a little milk. Probably many patent purgative medicines con- tain Scammony. It is a rather searching purgative, which clears out the bowel well, expelling any hardened faeces and wind that may have collected. Compound Licorice Powder is now in the Pharmacopoeia. The pre- paration is much used in Germany and Russia, and is certainly one of the best and safest of ordinary purgative medicines. The Pulvis Glycyr- rhizcz Compositus of the British Pharmacopoeia contains two ounces of finely powdered Senna and the same quantity of powdered Licorice root, with six ounces of powdered sugar; but the German preparation, is made as follows: "Powdered Senna, powdered Licorice, of each 2; powdered Fennel, Sulphur, of each i; white sugar, 6: mix." 12* 138 OF THE USE OF ALOES. The dose of the powder is a teaspoonful, carefully mixed in a little water. Aloes is another purgative which has the property of acting upon the large bowel. It probably irritates the mucous membrane, and excites its glands to secrete ; but also, by reflex nervous action, it stimulates the action of the muscular coat of the intestine, and excites vigorous con- traction both of the circular and longitudinal muscular fibres. It is a very good purgative to give in cases of torpid bowels, but it is important for you to bear in mind that aloes has the effect in some cases of encouraging the formation or increase of haemorrhoids or piles, see p. 120. It seems to irritate the mucous membrane of the lower bowel, and those who suffer from an irritable state of this part sometimes find their sufferings much increased if they take any of the ordinary preparations of Aloes. There is the Socotrine Aloes, Aloe Socotrina, and Barbadoes Aloes, Aloe Barbadensis. The Compound Decoction of Aloes, Decoctum Aloes Compositum, is ordered to- be made of Socotrine Aloes, and contains besides, Myrrh, Saffron, Carbonate of Potash, Licorice, Compound Tincture of Cardamoms, and Distilled Water. This is a very valuable preparation, a"nd enters into the composition of many favorite draughts which used to be prescribed in former days, and which brought gain to the apothecaries of old. That once very fashion- able but rather nasty dose called a Black Draught was composed of Decoction of Aloes, with Sulphate of Magnesia, Senna, and Licorice. Its composition was modified by different authorities, and some im- provements, more nasty still, were made by ingenious physicmongers ; but the reputation of the black draught is gone, and, though an excel- lent purgative, it is seldom prescribed in these days. Forty years ago Dr. Chambers, who was then the fashionable physician in London, and other physicians only a little less fashionable, prescribed blue pills and black draughts for most ailments. It would not be easy now to persuade people to swallow a black draught. However, with a little ingenuity you may make something less nauseous and equally efficacious. The Decoction itself may be taken in doses of from two drachms to an ounce and a half or more. Probably the best preparation of aloes, to prescribe in the form of pills, is the Watery Extract of Aloes {Extractum Aloes Socotrina). This watery extract does not irritate the bowels, and acts very effectually. It may be given in doses varying from the one-sixth of a grain up to a grain or more, but it is better not to order a larger dose than is abso lutely requisite, and in prescribing, it is well to bear in mind that Aloes, as well as many other drugs, have their purgative action much improved .by being reduced to a state of very minute division, and mixed with other things. If small pieces of Aloes should stick in the mucous membrane of the large bowel, that particular part might be severely OF THE USE OF PODOPHYLLIN. 139 irritated, and in consequence the patient would experience great pain and discomfort ; while, if the medicine was very minutely divided and mixed with a quantity of inactive or less active material, there would be no danger of any such deleterious action. When you prescribe aloes, you should always order it to be intimately mixed with other and less active substances. Let the pill contain, say, a quarter of a grain of the Extractum Aloes Aquosum with two or three grains of common Extract of Colocyrith {Extractum Colocynthidis Compost futri), and a grain of Extract of Henbane {Extractum Hyoscyami}. Although in these days it is the fashion to prescribe one remedy only, and I believe some distinguished physicians consider it improper to order more than two drugs in one pill or mixture, there is not the least doubt that, as far as regards the action of the medicine upon the organism, considerable advantage is gained by mixing several remedies together. Medicines, like foods, affect different people in a different v/ay. If you prescribe several different things together, you may influence different idiosyncracies, while it would be almost impossible to determine the particular purgative suitable for each individual patient. I much prefer a pill consisting of a little Compound Colocynth, a little Nux Vomica, a little Henbane, a small quantity of Podophyllin, and perhaps a little of the Watery Extract of Aloes, to a full purgative dose of any one of these preparations by itself. By mixing these things together, you get a less painful and more efficient action than you do from a large dose of either of them separately. If you desire to test the truth of this observation, you may carry out a very instructive experiment on your own organisms. Take, for example, one grain of Podophyllin and see how it affects you, and the next time you require a purgative take three grains of the Watery Extract of Aloes alone. On another occasion try a very small dose (a quarter or the third of a grain) of Podophyllin or Aloes, mixed with three grains of compound Colocynth pill, and notice whether, upon the whole, you do not get a better result with less griping pain than when you took the larger doses of the simple drugs. Podophyllin has been much used during the last ten years, and was first employed in America. But it is a purgative of somewhat uncertain action, and those who order it should take care how they prescribe it. I remember the case of a child who was almost killed by half a grain of Podophyllin, incautiously ordered by the practitioner, who perhaps up to that time had been employing some weak and inferior preparation ; but this last prescription, being made up by a chemist who used good medicines, a much too powerful dose was administered. The drug varies much in quality, and it is, moreover, one of those things which acts very differently upon different people. I have patients who have been taking a small quantity of Podophyllin for many years, and who I4O DRASTIC PURGATIVES. say they have never taken anything which acts so satisfactorily. On the other hand, I every now and then get into disgrace for ordering the same thing to other persons. The drug sometimes gripes the patient so much that he does not wish to try the remedy again. You should always order Podophyllin first in small doses, mixed with compound Rhubarb 'or compound Colocynth pill, and if it causes no discomfort, you can easily increase the dose. Do not give more than one-quarter or one-third of a grain, unless you know by experience the patient can take larger doses with advantage. Drastic and Hydragogue Purgatives can hardly be included among the remedies for slight ailments, but a few of them may be prescribed in small doses for ordinary maladies. Thus Jalap, Jalapa, is a very old and useful purgative, which may be taken in doses varying from five to fifteen grains. It excites the flow of fluid from the blood into the intestine, and when prescribed should be mixed with an equal quantity of Bitartrate, Potasses Tartras Adda, or Sulphate of Potash, Potassa Sulphas. Jalapine is obtained from ordinary jalap by rectified spirit. It is the resin, in fact, Resina Jalapa, deprived of its coloring matter by animal charcoal. A small dose of from one to three grains will be found to act freely. It may be prescribed in a pill or as a powder, mixed with a few grains of sugar. Elaterium, Cretan- Oil, Gamboge, are all violent purgatives, which are very useful in the treatment of some diseases, but are not required in the management of slight ailments. They should all be prescribed in very small doses to begin with. In fact, the practitioner who uses these drugs should always ascertain whether the patient will bear them by ordering in the first instance a very small dose. Drastic cathartics all excite the pouring out of a large quantity of fluid from the blood through the walls of the capillaries into the bowel. In this place I ought properly to speak of the action of preparations of Mercury, but as this subject will come under consideration a little further on, I shall postpone what I have to say for the present. Saline Purgatives are very valuable in many cases of imperfect action of the bowels. Many of the salts used as purgatives act not only by pro- moting osmose of fluid from the blood by reason of the higher specific gravity of the saline solution in the intestine than that of the liquor sanguinis, and by their direct influence on the nerves of the mucous membrane, but also in consequence of being first of all absorbed into the blood, and then excreted by the glands and follicles of the mucous membrane of the colon. At the same time many other substances are removed from the blood with the salt, and in this way the circulating fluid may be freed from certain deleterious constituents which have accumulated in it, and which if they remained would seriously interfere with the action and nutrition of various tissues and organs. Most SULPHATES OF MAGNESIA AND SODA. 14! salines act partly as purgatives and partly as diuretics, and not a few of them have the effect of increasing the secretion of many, if not of all, of the glands of the digestive system. There are many salts in the Pharmacopoeia which you will find useful. Some of these are very ancient remedies, and well known in all countries. First of all, there is Epsom Salts, Sulphate of Magnesia, Magnesia Sulphas, and a capitaf remedy it is. It forms, as it were, the basis of a great many fashionable medicines, and many people fre- quently take it without knowing from what a common drug they derive relief. It is one of the cheapest of medicines, for a pound of it only costs a few pence. It may be given in doses varying from half a drachm to half an ounce or an ounce, in solution in water. The small dose, especially if dissolved in warm or lukewarm water, will sometimes purge freely and quickly. As a medical author has metaphorically remarked concerning a much advertised water, it is "speedy, sure, and gentle!" Sulphate of magnesia is not an unpleasant thing to take, especially if you mix it with about one-fourth of its weight of common salt and twenty drops of Aromatic Sulphuric Acid (Acidum Sulphuricum Aro- maticum), the whole being dissolved in an ounce and a half of lukewarm water. I often order ten minims of dilute Hydrochloric Acid, Acidum Hydrochloricum dilutum, and two drachms of Sulphate of Magnesia, to be dissolved in an ounce and a half of Cinnamon Water, Orange Flower Water, Aqua Aurantii Floris, common Water, or Infusion of Roses, Infusum Rosa Acidum. The last gives a rather pleasant taste and agreeable color to the draught, which should be taken in the morning before breakfast, or about two hours after that meal. If you consider it desirable to act upon the kidneys at the same time as the bowels, and often it is very important so to do, you may add a few grains of Nitre, Pulvis Potasses Nitralis, and in this way you make a saline draught which many of your patients will find useful. It may be taken day after day for three or four days, or twice or three times a week ; but its daily use should not be continued for longer than a fortnight at a time. Sulphate of Soda, or Glauber's Salt, Sodce Sulphas of the Pharma- copoeia, is not so strong in its purgative action as the Sulphate of Magnesia, but it is not nearly so disagreeable in taste. You may give two or more- drachms of Sulphate of Soda dissolved in an ounce and a half of water. Or you may prescribe two or three drachms of the Sulphate of Soda with a somewhat less quantity of the Sulphate of Magnesia with five or ten grains of Nitre and a drachm or more of common salt. The addi- tion of common salt you will find advantageous, as it certainly much diminishes the nauseous taste of the Sulphate of Magnesia. Salines generally, like many other medicines, act more powerfully if they are com- bined than if taken separately, and, as I have already said, their action is expedited and increased if they are dissolved in warm or lukewarm water. 142 FRIEDRICHSHALL WATER. Phosphate of Soda, Soda Phosphas, is another salt which acts w'ell as a mild purgative in doses of from one drachm to an ounce dissolved in water. It is not disagreeable, and has long been known as " Taste- less Saline Aperient." It is a good saline for children, and maybe given dissolved in weak beef-tea or other form of broth or soup. Soda Tartarata, a Tartrate of Soda and Potash, commonly called Rochelle Salt, used to be a very favorite saline purgative. It also acts on the kidneys. The acid of this salt, like Citric and many other vegetable acids, becomes changed in the system, alkaline carbonates being formed which render the urine alkaline. The dose is from one drachm to half an ounce or more dissolved in water. You may order a mixture containing half a dozen doses, and direct the patient to take an ounce, that is, two tablespoonfuls, with one tablespoonful of hot water. If the dose is taken before breakfast, it will generally act in the course of two or three hours, and many a patient will have good reason to thank you for the advice you have given him. Many such saline mixtures may be used instead of purgative mineral waters. Their action is much the same, but you will find that not a few of the most prosperous of your patients will decline to take such salines as you can prescribe. They require a more fashionable form of saline in the shape of a purgative mineral water from some wonderful spring war- ranted to cure all diseases, and patronized by the nobility of Europe. In these days there are, indeed, a number of potent natural mineral waters having purgative properties from which to choose. A few years since, almost every person was advised to take Pullna water. This after a time, like the once famous Epsom and Cheltenham waters, gave place to others. For years Friedrichshall has been credited with virtues of surpassing excellence, but now I suppose opinion is divided between this and the unpronounceable Hunyadi Janos bitter water. The latter contains much more of the purgative sulphates than Pullna, Seidlitz, Kissengen, or Friedrichshall, and therefore acts more freely. Friedrichshall water is a mild purgative saline. Its composition is shown in the following analysis, for which I am indebted to Mr. C. H. ANALYSIS OF FRIEDRICHSHALL BITfER WATER. Grains per gallon. Sodium 657-5 Potassium 6 - l Magnesium 200-8 Calcium 187 Silica 1 7 Chlorine .' 1003-1 Bromine 0-13 Sulphuric acid (S0 4 ) 739' 2 Carbonic acid not estimated. Piesse, Public Analyst, London. It seems to contain Sulphate of Magnesia and Chloride of Sodium. EFFERVESCING SALINES. l\$ Mr. Piesse remarks that if the "Chlorine" be calculated into "Chloride of Sodium," and the "Magnesium" into " Sulphate of Mag- nesia," and the amounts of the salts thus indicated be dissolved in one gallon of ordinary drinking water, we shall have a solution very like the natural Friedrichshall water, especially if the mixture be well charged with carbonic acid. You may tell the patient to take a wineglass of Friedrichshall or Hunyadi Janos water with as much warm water every morning before breakfast, and in many cases it may with advantage be prescribed with twice as much Carlsbad water made warm, or hot water added. For patients who object to the expense of mineral waters you may easily prescribe a substitute according to the principles already mentioned, page 141. Whether the Sulphate of Magnesia and Sulphate of Soda in the water obtained from a spring is in a state in any way molecularly different from the salts as sold by chemists has not been determined, but certainly the less wealthy seem to derive as much benefit from solutions of ordinary Sulphates of Magnesia and Soda, as the rich do from purga- tive mineral waters. Sulphate of Potash, Potassa Sulphas, is a very old saline aperient. It may be taken in doses of from ten grains to three scruples dissolved in water. It enters into the composition of many of our remedies in the Pharmacopoeia. Effervescing Saline purgative. But perhaps the pleasantest saline purgative is an effervescing draught. We have an excellent mild purga- tive in what is now called Granular Citrate of Magnesia. I believe that much of what is sold under this name is really Citrate of Potash or Soda. The ingredients are mixed, and the water of crystallization in part driven off by heat, but the preparation is a difficult one to make well. The dose is from one to two teaspoonfuls thrown into a tumbler two-thirds full of water, and the mixture is to be taken during effer- vescence. The granulated salts must be carefully excluded from damp, but if this be done they keep for a long period of time. Such effer- vescing draughts are very agreeable in hot climates. It is of course only a very mild form of purgative, but useful in a great many cases when a cooling saline is required. The urine is rendered alkaline by the salt. .Many different forms of granulated effervescing salts are now pre- pared by chemists, containing Quinine, Strychnine, Pepsine, Bismuth, Lithia, and many other substances. Granulated Effervescing Salts also constitute a very agreeable vehicle for many different kinds of medicine. In giving purgatives, do not forget that it is a great point to hit the exact time, for a very moderate dose will often produce a full and sufficient effect, although at another time, in the case of the very same 144 DIARRHCEA. person, a larger dose will have little or no effect, save causing severe pain. If the right time can be selected, a mild purgative will be of the greatest use, and may possibly have the effect of preventing an attack of illness. This variability in the action of the same medicine Is very remarkable in the case of mercury, an extremely small quantity of which has sometimes the most beneficial effect in dissipating symptoms which for several days may have indicated serious general disturbance and the derangement of more than one important organ of the body. DIARRHCEA. I pass now to the consideration of a condition the very opposite of constipation. Diarrhoea (&a, through, PJ, I flow), though a common ailment, is less frequent than constipation, and is seldom habitual and persistent, lasting perhaps for the greater part of a lifetime, like the tendency to constipation. Now and then, however, you do meet with people who seem to surfer very frequently from a condition to which the term diarrhoea would be generally applied. To your inquiry if the bowels are open the patient will perhaps reply "Too much so." On further questioning, you find that the bowels act three or four times every day. In some of these cases the patients do not appear to surfer pain, nor do they necessarily get thin and weak, or appear to be out of health. Whether the looseness depends upon a highly irritable state of the nerves of the mucous membrane, or is due to weak vascular walls, or to an altered state of the blood, or to a highly nervous dis- position, it is often difficult to decide. In some cases the condition results from a peculiar habit of body, and undoubtedly there are types of constitution which are remarkable for the great activity of various secreting glands, just as there are others as remarkable for slow ai>i imperfect action. In neither case is there any structural alteration : but one class is characterized by rapid, the other by sluggish, change. That diarrhoea may be produced through nerve influence only, is proved by a number of circumstances. Many nervous people are very subject to it. Fright, anxiety, and sudden joy may be immediately followed by diarrhoea. Many students who have been exceedingly anxious concerning examinations, have experienced the influence of the mind acting through the nervous system upon the secreting glands which discharge their contents into the intestinal canal. The action is due mainly to a relaxation of the muscular fibres of the small vessels, permitting dilatation and a free discharge of fluid from the blood directly into the bowels, as well as indirectly into the secreting glands. To those who surfer from constipation, an occasional attack of diarrhoea is very advantageous, and is not to be regretted. Probably diarrhoea carries off many noxious materials that have accumulated in the blood, and may therefore be beneficial to some organisms, provided CHANGES IN DIARRH(EA. 145 it only occurs now and then, and does not last for too long a time, and is not allowed to become very severe at a time when there happens to be an epidemic. But you must not forget that an attack of typhoid fever is often ushered in by slight and sometimes by severe diarrhoea. There is usually a very decided rise in temperature, which in many cases will en- able you to form an opinion as to the nature of the malady. There are times when diarrhoea must be guarded against, and, if it occurs, must not be allowed to persist. During an epidemic of cholera, a person suffering from diarrhoea must be very carefully watched, for, if the condition continue unchecked for even a short time, it may become choleraic. In cholera-times what appears to be ordinary diarrhoea may be succeeded in the course of a few hours by the collapse stage of chol- era. The disease usually begins with slight purgation, and you cannot tell whether a person is going to have a mild attack of ordinary diarrhoea or actual cholera. It therefore behooves us to be on our guard, and, dur- ing the prevalence of a cholera epidemic, it is important to at once check all cases of diarrhoea. The commonest form of diarrhoea is that which we meet with in hot summers, and often prevails to a great extent in autumn.' This is often called summer diarrhoea, and it is hard to say exactly what occasions it. Certain it is that it is more prevalent in hot, dry summers, than it is in cold, wet ones. Some would explain the fact by the superabundance and cheapness of fruit in the former, and its scarcity and high price in the latter. Plums usually get the credit of exciting diarrhoea, but the condition frequently shows itself before plums are obtainable. No doubt bad, unripe fruit, and decaying fruit are very liable to irritate the bow- els, and may excite diarrhoea. Neither is there any doubt that decom- posing vegetable and animal matter will bring on an attack of diarrhoea; but what the particular organic material may be which exerts the dele- terious influence, I do not know. On the other hand, it is quite certain that many of us can eat very considerable quantities of any ordinary fruit without suffering in any way, and even without the. ordinary half-consti- pated habit being relieved. In summer, the intestinal canal of many- persons seems to be in an unusually sensitive or irritable state, so that very slight errors in diet are apt to derange its action for a time. Even a little beer that is out of order, or sour milk, will sometimes set up a very troublesome attack of diarrhoea, which may last for days, and re- quire careful treatment to check it. Concerning the precise changes which occur in severe diarrhoea, little is positively known. It is generally supposed, as I have already remarked, that much of the fluid escapes from the capillary vessels; but at least, in some cases, it is more probable that the condition depends upon increased activity of many of the glands which discharge their contents into the intestinal canal. In sudden diarrhoea, depending upon the presence of some irritating material, I suppose transudation of fluid takes place from 13 K 146 IRRITATIVE DIARRHCEA. the vessels, as well as increased secretion from the glands. In many cases, for some time before the attack, it is probable that the blood has been in an unhealthy state, in which case the free discharge of watery matter will be of advantage to the patient, inasmuch as various noxious materials will be eliminated, which would do harm if they were retained in it in a state of solution. Thus by the attack of diarrhoea is the blood depurated, and may, in this way, be soon restored to its normal healthy state. Unquestionably, therefore, in such a case, diarrhoea may be re- garded as conservative and advantageous. Suppose a child has been eating a quantity of unripe fruit, and it is nothing very unusual for an English baby to eat half a dozen unripe and very uninviting looking apples, this will soon ^produce an effect, the stomach and bowels will be irritated, and a sudden, and it may be, vio- lent derangement will follow, often accompanied by feverishness, the temperature in such cases not unfrequently rising to 103 or 104, with perhaps violent abdominal pain; and these symptoms maybe sufficiently severe to excite alarm. If vomiting occurs relief is at once experienced, but more commonly purgation is excited, and may perhaps have existed for a few days before you are called in to see the patient. You must not expect the diarrhoea to cease until the whole of the irritating matter which excited it has been removed, and the sooner this result can be effected the sooner will relief be afforded. All the particles of half-masticated apples containing immature acids and other irritating organic compounds must be removed from the alimentary canal before the diarrhoea will cease. In such cases, therefore, it is bad practice to attempt to check the diar- rhoea unless you feel sure that the whole of the irritating substances have been entirely got rid of. It is even desirable to encourage for a time the flow of fluid from the intestinal canal, so that the noxious 'matters may be thoroughly washed away. For this reason you will often have to ad- minister a mild purgative to expedite the removal of the matter which excited the purgation. You purge to stop purgative action, and you will often find this the best and shortest method of checking the diarrhoea of children. Of all the purgatives that are known to remove irritating matters from the intestinal canal, oily purgatives are the most suitable. Common Olive-oil, Oleum Olivce, will act in this way, and for very young children is quite sufficient, but as a general rule you will find it expedient to give Castor-oil, Oleum Ricini, the purgative action of which is more decided. There is an active principle in the Castor-oil which affects the action of the stomach as well, as the glands and vessels of the upper part of the alimentary canal. In this way; Castor-oil in its action contrasts with Aloes, Colocynth, and Sulphate of Magnesia, which act mainly upon the lower part of the small intestines and the colon. I suppose Castor-oil ex- cites increased secretion in the stomach, the duodenum, the jejunum, and ileum, causing a quantity of fluid to be quickly poured out from the vessels and glands of the mucous membrane. Thus the alimentary canal is thor- CASTOR-OIL IN DIARRHCEA. 147 oughly flushed in every part; and the action takes place from above down- wards. Any irritating matters that may be present are thus swept away. For this reason, and for the further reason that Castor-oil is a substance which does not irritate the mucous membrane in any undue or uncom- fortable way, it is the best purgative to give in any cases in which you have reason to attribute the diarrhoea to injudicious eating. Particularly in the diarrhoea of infants and young children is Olive-oil or Castor-oil a safe remedy. As a general rule, you will find a much smaller dose of Castor-oil will act than is usually administered. To a child of ten years old you may give half a teaspoonful or a teaspoonful ; to an adult, two teaspoonfuls, but a single teaspoonful of Castor-oil will be sufficient for many people. The objection to Castor-oil is its nauseating, disagreeable flavor. I have already referred to the best way of taking it, and have offered some suggestions for disguising the taste. See p. 135. After diarrhoea has continued for some time, there may be a good deal of severe griping pain all over the stomach, or at least in its upper part. At the same time the patient feels chilly or very cold, and may actually shiver; very generally there is more or less flatulence, with acid eructations, loss of appetite, and occasionally distressing nausea. The tongue is usually furred, and there may be a nasty taste in the mouth, or the mouth may feel clammy and disagreeable. After diarrhoea has lasted for several days, there may be considerable depression of the heart's action ; and not unfrequently severe cramp in various muscles increase the distress. Acid eructations and the rising of acid fluid into the mouth will be relieved by the administration of alkalies and other so-called antacid remedies. You may give alkalies, such as Potash, Liquor Potassa, twenty drops in a wineglass full of water once in three or four hours, or the Bicarbonate of Potash or Soda. Preparations of Bismuth are also useful, as the Carbonate of Bismuth (Bismuthi Carbonas), or the Nitrate, the old Trisnitrate of Bismuth {Bismuthi Nitras], from ten to twenty grains for a dose, suspended in water with the help of a little mucilage, or, better, prepared chalk {Creta prceparata), or precipitated chalk (Cal- ais Carbonas precipitata). But one of the best as well as simplest reme- dies to give in these cases, and particularly in gastric and intestinal de- rangements occurring in infants and very young children, is Lime Water {Liquor Calcis}. This is an extremely valuable remedy, which is not used as much as it deserves to be. Infants are very subject to diarrhoea, and I fear that many a child has been lost simply from allowing diar- rhoea to continue, which would have been easily checked, if sufficiently early in the attack a few teaspoonful doses of Lime Water in milk, or sweetened Lime Water {Liquor Calcis Saccharatus], had been given. Anything of an irritating character will very soon disorder the delicate mucous membrane of the intestinal canal of an infant, and a very simple remedy administered at the proper time will stop it, but if the purging 148 TREATMENT OF DIARRHCEA. be severe, and it be allowed to continue for a few hours, extreme exhaus- tion may ensue, and be soon followed by death. In these cases, mothers often make the unfortunate mistake of feeding the child too much. Fearing lest it should be starved, they keep pouring in milk. The secretions, already out of order, get worse, and the milk, instead of being properly digested and assimilated, is either rejected in the form of curd, or the curd formed is passed onwards into the small intestine, where it excites irritation without being taken up and absorbed. Coagu- lation of the caseine, without subsequent solution, may persist perhaps for many days, sometimes for a week or more, each new portion of milk that is swallowed undergoing the same change. Thus the intestinal canal, in every part of its course, becomes filled with firm white coagula, which, it will be noticed, constitute the greater part of every evacuation. After death from violent diarrhoea it is not uncommon to find the intes- tines even distended with coagulated and undigested curd. Cases of diarrhoea in infants may often be relieved at the outset by small doses of Lime Water. A little may be mixed with the milk, in the proportion of a tablespoonful or less of lime water to half a pint of milk. Sometimes Potash Water answers better, and I have used Liquor Po- tassae, in the proportion of twenty drops to half a pint of milk. You must not allow the child to take as much milk as it likes. For a day or two, half a pint of milk in the twenty-four hours will be sufficient. It must be obvious that, as long as the disturbed state of the bowels continues, it will be worse than useless to push food. Time must be allowed for the alimentary canal to become partially emptied of its irritating con- tents before fresh nourishment is introduced. If the child is at all low, it must be supported with small doses of brandy from ten to twenty drops in a teaspoonful of water or milk and a little sugar,' once in two hours. You cannot be too careful in watching cases of infantile diar- rhoea, especially in weak children, for it sometimes happens that serious exhaustion comes on quite unexpectedly, and if you do not visit the patient every few hours, a sudden change may occur, and the case be hopeless before you come to its assistance. I have already drawn your attention to the fact that in these cases of diarrhoea, bacteria often grow and multiply to an enormous extent in the caseine clots. In many cases every part of the intestinal canal is per- vaded by millions of these organisms, which grow and multiply in the altered secretions and food which are continually being poured into the stomach. The changes which ought to take place in the food prior to its absorption and conversion into healthy blood are consequently pre- vented. Children may, under these circumstances, die of inanition, although they have been but too liberally fed during the whole period of the illness. The food they are plied with merely serves to encourage the growth of bacteria, and it actually undergoes changes which interfere with its digestion and absorption. If just at the right time you withhold CHARACTERS OF THE STOOLS. 149 food, perhaps only for a few hours, everything may right itself; the irri. tating matters may themselves act a little on the bowels, and thus get pushed onwards by the contraction of the muscular coat of the intestine. Diarrhoea may come on and last for a few hours or so, or even for a day or two, and then the secretions return to their natural state. The child will be out of danger and soon be well again. In treating diarrhoea in children, particularly infants, you must take care that the child is kept warm. One of the principal causes of diarrhoea is cold, and bathing in cold water, and exposure to cold and wet will sometimes bring on diar- rhoea even in adults. You should be aware of the different characters of the stools in different forms of diarrhoea. If they are of the natural color and odor, you may let the diarrhoea go on for a while, for it will probably do no harm, and will most likely stop without medicinal treatment. But if the stools should become much altered if they should emit a sour smell, and the secretion should have the appearance of rice water, it will probably be necessary to check the discharge. For such evacuations, as well as those which are colorless or almost colorless, consist wholly, or in great part, of secretions poured out from the glands, and from the vessels of the mucous membrane of the lower part of the small and of the large intestine. You will find in such evacuations much altered mucus, with numerous small cells (bioplasts) from the follicles as well as from the surface of the mucous membrane, chiefly of the colon. Not unfrequently you will find a little blood ; but there may be more albumen than the quantity of blood will account for. If the increased formation of mucus continue for a considerable period of time, it is often associated with a serious change in the tissues of the mucous membrane itself. After such exces- sive action has gone on for several days or weeks, there may ensue an excoriated and almost lacerated state of a small portion of the surface of the mucous membrane. A sort of superficial ulcer results, from the surface of which perhaps blood will from time to time escape. By the continual drain of nutrient matter, and general disturbance of the action of the bowel, a low state of health may soon be induced, which, with the local affection, may soon lead to the development of a very serious disease, not uncommon in many tropical climates, but, happily, rarely contracted here. The malady in question is Dysentery, but it cannot be included among "slight ailments." Not unfrequently, however, in this climate the colon is the seat of great uneasiness, often amounting to actual pain. In many of these cases it is unquestionably the mucous membrane which is affected. The capillaries of a limited area become congested. The congestion not unfrequently passes into ulceration, and we have an approach to that state of things which may, under certain circumstances, be soon followed by dysenteric symptoms. More commonly, if proper precautions be taken, the patient gets better before actual ulceration occurs. If we 13* 150 DIET IN DIARRIKEA. could see the mucous membrane in some of these cases, I have no doubt we should find it, in the immediate situation of the painful spot, swollen, red, and exceedingly sensitive. Every time the muscular coat contracts, the dull pain changes in character and becomes severe. The affection may occur in any part of the colon ; but I think the sigmoid flexure, the caecum, and one or other end of the transverse colon, are the situations to which the pain is usually referred ; and, as regards frequency, in the order in which I have named them. If small pieces of hardened faeces or the debris of food happen to be forced into contact with the spot, sudden attacks of exquisite pain, of a cutting or tearing character, may be experienced. Not unusually the state of mucous membrane I have described persists for a considerable period of time. This condition may last for weeks, or even months, just as a portion of skin may be deranged by congested ves'sels, and chronic changes induced in the epithelium, and continue for a long period. Such morbid changes may be stopped by judicious interference, but they may not yield to remedial measures for some time. In the case of the colon, it is of the first importance not to allow anything of an irritating nature to pass along it to restrain its action as far as possible and to prevent the formation of wind, and the consequent irregular contraction of the muscular coat. In some forms of diarrhoea, which are often spoken of as "bilious," you will notice a very peculiar alteration in the character of the stools, which are very dark colored, and not unfrequently may be fairly spoken of as black. Sometimes the color is such as to suggest the idea that bile has passed down the intestine without undergoing the usual changes, and forms the chief constituent of the faeces. In some of these cases it is probable that bile accumulates for a considerable period in the gall bladder, until at last this viscus, having become considerably distended, suddenly expels its contents, which are discharged in such considerable quantity that much passes almost unchanged into the large bowel. You must be careful not to mistake the color of the motions, which is produced by many preparations of iron for that caused by blood. If a person takes iron his motions will become almost black, owing to the action of the sulphuretted hydrogen of the alimentary canal producing a dark black compound with iron. Salts of bismuth and lead also impart to discharges from the bowel a very peculiar dark color. It is important to distinguish all these changes from those caused by the presence of blood, which is itself much changed in color by the action of the intes- tinal gases and fluids which act upon it. The diet is of the greatest importance in the management of all forms cf diarrhoea. Little liquid should be swallowed while the purgation continues, and everything taken should for the time be tepid or cold, for hot things, and particularly hot liquids, seem to keep up the diarrhoea. Ordinary diet must be withheld for a time. The patient may live upon ASTRINGENTS. 1 5 1 milk, thickened or not with flour, Indian corn, or lentil flour, arrow-root, sago, tapioca, or other bland, non-irritating starchy matter. Cream, puddings made with eggs, such as boiled batter, may be allowed, but any- thing containing hard particles that might get embedded in the mucous membrane, or irritate any tender spot that may exist, must be avoided. Treatment of Diarrhoea. In all forms of diarrhoea, particularly where there is much abdominal pain, it will greatly contribute to the comfort and relief of the patient if you at once apply warmth to the external surface, and recommend that he be kept in a warm room. He should lie down and rest, and if the attack be severe, he should be in bed. Cold unquestionably fends to keep up diarrhoea, and may in fact cause it. Cold also increases the sufferings of the patient. Hot fomentations to the stomach have been strongly recommended, and certainly afford relief. Various plans may be adopted. One of the simplest is to wring flannels out in very hot water, and have them quickly applied ; or two or three thicknesses of dry flannel, held before a good fire until it is quite hot, may be preferred. The wet or dry flannels should be covered with a piece of oiled silk or mackintosh, which will prevent rapid cool- ing ; or a large piece of spongio-piline, made moist with hot water, may be applied. A better plan is to procure, at one of the shops where India- rubber things are sold, a hot-water bottle, made of good strong vulcan- ized India-rubber. It should be eight or nine inches by fifteen,, and covered with woollen material. In cases even of very severe griping pains, great relief will be afforded if the bottle containing hot water be placed closed to the skin of the abdomen while the patient is lying on his side, and kept there for an hour or more. Those who are subject to troublesome attacks of diarrhoea should wear, during winter and sum- mer, a good thick flannel belt made for the purpose. There are many potent remedies for checking diarrhoea. We have alkalies, the action of which I have already referred to ; then there are many astringents, certain metallic salts, acids, and sedatives. Astringents (astringo, to bind) are often given in diarrhoea, and unquestionably check it. Amongst these maybe mentioned "Krameria" "Kino," "Catechu" "Logwood," and several more are in general use. The value of many astringent remedies used in diarrhoea is perhaps, in great measure, due to the Tannin they contain, and this substance itself may be prescribed. It is a powerful astringent, and prevents free transudation of fluid through the walls of the vessels. The precise action of the Tannin is not fully understood. It may act directly upon the tissues themselves, and per- haps alter the permeable or diffusible property of the fluids. At the same time no doubt it acts upon the afferent nerves distributed to the capil- laries, and through these causes contraction of the muscular fibres of the small arteries. Thus their calibre is reduced, and the quantity of blood flowing to the capillaries lessened. Logwood, Hamatoxylon, is much used in the treatment of ordinary diarrhoea. You may order the decoc- 152 INTESTINAL WORMS. tion of Logwood, Decoctum Hcematoxyli, in doses varying according to the severity of the illness. You may begin with small doses, say from two drachms to half an ounce of the decoction once in three hours, and if the diarrhoea continues the dose should be increased to an ounce, and the remedy given more frequently. Of astringent tinctures, like the Tinc- ture of Catechu, Tinctura Catechu, the Tincture of Kino, Tinctura Kino, and the Tincture of Rhatany, Tincttira Krameria, you may prescribe from half a drachm or a drachm to three drachms in a mixture, and you may give this once in three hours, or, if the diarrhoea is severe, once in two hours. Many practitioners order one of these astringent tinctures with chalk. Chalk Mixture, Mistura Cretcz, and* the Aromatic Powder of Chalk, Pulvis Cretce Aromaticus, are valuable remedies in ordinary cases of slight diarrhoea. If there is anything irritating the bowels, it must be removed, or the diarrhoea will continue. As I have already explained, p. 146, a purgative is necessary to expel the irritating mat- ters before the diarrhoea will cease. Next, with regard to the use of Opium. If the diarrhoea has lasted for a considerable period of time, and the patient is becoming weak and exhausted, and you have reason to believe that instead of the bowels being filled with irritating matter, they are empty or nearly empty, the mucous membrane irritable and sore, with constant and irregular con- tractions of the muscular coat, giving rise to severe griping and excruci- ating pain, you will find Opium a most valuable remedy. In such cases small doses frequently repeated answer best. You may give five or ten drops of Laudanum in each dose of a mixture for an adult, half as much in the case of young people, but bear in mind that Opium must not be given in any form to young children. I prefer to give Opium in severe cases of diarrhoea in the solid form. A quarter of a grain of solid Opium, or half as much of the extract, Extractum Opii, for a dose. The com- position of Dover's powder is known to most of you. Two grains will contain one-fifth of a grain of Opium. This quantity or more of Dover's powder, the compound Ipecacuanha powder, Pulvis Ipecacuanha Com- positus, may be given in the form of a pill once in three or four hours if the diarrhoea persists. Or you may give the patent medicine Chloro- dyne, which is so well known perhaps too well known to non-profes- sional persons. Chlorodyne is a mixture of many things, but it un- doubtedly acts beneficially, and agrees with some persons who cannot take ordinary preparations of opium. Many other remedies are fre- quently ordered, but I cannot refer to them in this place. INTESTINAL WORMS. I will here make a few remarks upon the important subject of intestinal worms, for some of these parasites are often the cause of slight ailments, and at many different periods of life. It is, however, during childhood that illnesses depending upon the irritation of intestinal worms are most TREATMENT OF WORMS. 1 53 commonly met with. The ailment may vary from a slight, but almost constant, uneasiness or pain in the stomach, occasioning or accompanied by irritability of temper, to a very serious disturbance of the nervous system, characterized by attacks of convulsions, and even unconsciousness, in fact, by the epileptic condition, a form of illness which cannot be regarded as slight, and classed under the head of slight ailments, although the affection almost always terminates in recovery. The intestinal worms most commonly observed in children are called Thread Worms, from their resemblance to small pieces of thread. Oxyuris vermicularis. The little Thread Worms are sometimes found in immense number in the faeces of children, and occasionally they trouble adults. The worms are male and female, the former being the smaller of the two. The female is seldom more than half an inch in length. They inhabit the lower part of the large bowel, and breed in immense numbers in the rectum. The eggs are oval, and are not more than the one five-hundredth of an inch in length in their longest dimensions. They are produced in countless multitudes, and can generally be demon- strated easily enough by microscopical examination of the matter passed by the bowel in cases in which thread worms have been observed. Children suffering from thread worms are often fidgety, fractious, and excitable. They generally complain of itching about the rectum ; and not unfrequently the mucous membrane of the nose and of the lips is in an irritable condition. Sometimes there is diarrhoea and discomfort referred to the lower part of the abdomen. In order to get rid of these minute pests you may begin with purgatives. A few doses of Castor-oil will often bring away hundreds of worms. Compound Jalap Powder, Pulvis Jalapa Compositus, in doses of from five to twenty grains, according to age. Compound Scammony Powder, Pulvis Scammonii Compositus, is still more efficacious, but must be given with caution in the case of weak children in doses of from two to ten grains. But of all the remedies for the destruction of thread worms, bitter infusions are the most potent; and Quassia is, I think, the best. An infusion of Quassia may be made by placing a tablespoonful of Quassia wood-chips or shavings in a jug and pouring upon them about a pint of Cold Water. In an hour it may be strained. A child may take an ounce or more of the clear bitter infusion twice or three times a day. But it is more efficacious to inject the infusion of Quassia into the rectum ; and if common salt be added, in the proportion of about a table- spoonful to a pint of the infusion, it will act more efficiently. In bad cases, about a quarter of a pint or more may be injected daily into the bowel with the aid of a little India-rubber ball syringe. If the worms are not very numerous, once or twice will be sufficient. Some cases will resist for a long time all the remedies that you may try ; but if you continue to use the injections steadily, the case will at length yield to treatment, though the patient may long have to exercise great care as 154 GIDDINESS. regards diet, if he would continue free from the troublesome parasites. The tendency manifested by the large bowel of some persons to favor the growth and multiplication of these little Ascarides is very remarkable, and cannot be easily explained. I feel sure that in some cases which have been completely cured by treatment, a fresh importation of parasites into the intestines has taken place months afterwards. Other persons, and even members of the same family, eating the same food and living under similar conditions, pass through life without being once troubled by worms. The large round worm, Ascaris Lumbricoides, is occasionally met with. The female is much larger than the male, and sometimes attains the length of twelve inches. It is of a pale-brownish color, round, about a quarter of an inch or more in thickness, and tapering off at each end to a thin rounded extremity. The male is only five inches long. These worms are seldom numerous, and usually not more than from two to four exist in one individual. They live in the small intestine, but often pass downwards and escape when the bowels act. Occasionally they make their way into the stomach, and are vomited or pass into the mouth or nose, to the annoyance, and perhaps terror, of the patient. Hundreds of thousands of eggs are formed and discharged by a single parasite. The eggs are oval, and about one three-hundred-and-fiftieth of an inch in the longest diameter; and multitudes are sometimes found in the matter passed from the bowel by the patient when subjected to microscopical examination. They may be seen by an inch or half-inch object-glass. One of the most potent remedies for the round worm (Ascaris Lumbri- coides) is Santonin, the active principle of Santonica, which consists of ttie unexpanded flowers of some species of Artemisia, or Wormwood. The dose of Santonin is two or three grains for a child, and double the quantity may be taken by an adult. Santonica is the unexpanded flower- heads, as imported from Russia, from which the active principle Santonin, Santoninum, is obtained. The dose of the flower-heads is from ten to fifty grains. The only other entozoon I need mention here is the Tapeworm, of which more than one species is met with in the human organism. The medicine which is the most efficacious in expelling the Tapeworm is the Oil or Liquid Extract of the Male Fern ; but the remedy requires to be given in a particular manner, after the patient has fasted for several hours. I shall have to consider Tapeworm and its treatment in another part of my course. VERTIGO, GIDDINESS. Vertigo, swimming in the head or giddiness, is an indication some- times of disturbed action of the stomach and liver, and sometimes of deranged circulation and disturbed heart's action. But this symptom VERTIGO. 155 may also be due to affections of parts of the nerve-structure of the brain, or the smallarteries which supply it. The exact seat of the lesion may vary ; but in animals, injury to the crus cerebri, as well as certain injuries to the cerebellum, are followed by vertigo. For one case, however, of vertigo which is due to serious disease of the brain or its vessels, we shall meet with ten or more which depend upon temporary derangement of the digestive organs. The giddy feeling after waltzing for too long a time, or turning round many times on one leg, is within the experience of most of us, and is a form of vertigo. You will find in some works on brain affections that vertigo is mentioned as a prominent symptom of serious cerebral disease. If, however, a patient comes to you complaining of vertigo, do not at once shake your head and look grave, even if you have read records of cases in which it undoubtedly was a symptom of some terrible disease of the brain or cerebellum, or was discovered to be due to some tumor or other incurable morbid growth; for if you do give a dismal opinion you may afterwards discover that you have given a foolish one. You ought to know that this, like many other symptoms, may be due to a \mere transient disturbance in connection with the circulation, or of the nerves presiding over the calibre of vessels, distributed to a very limited area of brain tissue. You must not forget that giddiness may be brought about by distal derangement, as well as by local temporary or permanent change. Temporary derangement of the stomach or liver, and probably very slight changes affecting both, will, as I have said, account for vertigo as it occurs in many cases which will come under your notice. There is a form of vertigo which is due to mere fancy or imagination. Having experienced the feeling of giddiness on one or two occasions, patients often fancy it is continually coming on. Violent attacks of coughing, especially in the case of weak persons, may occasion severe attacks of vertigo. Patients who have been ailing for some time, though not suffering from any definite malady, and those who have long been troubled with loss of appetite or impaired digestion, are frequently sub- jects of vertigo, and may often be cured by judicious management, as regards diet and wine or other stimulants, without any medicine. Small quantities of good soup, at intervals of a few hours, and two or three glasses of Burgundy or port wine daily, for a short time, may be ordered in such cases, and will often cure the giddiness and restore the general health in a week or two. There are some persons who are very frequently troubled with a curiout form of vertigo or giddiness, not arising from any organic lesion, or leading to any change which shortens life, or which may even seriously derange the health. In not a few instances vertigo is due to excessive nervousness. I have known highly nervous people of both sexes suffer from the most severe vertigo, preventing them from walking for many days, and for a time liable to come on if the head was only slightly raised 156 VERTIGO. from the pillow. Sometimes disturbed co-ordinating power of the mus- cles of the eye-ball is accompanied by giddiness. Vertigo occurs in many cases of blood-poisoning, and in some forms of fever. It may be brought on by sudden loss of a considerable quantity of blood, as from hemorrhage ; and it often occurs in anaemia. In some forms of epilepsy vertigo is a prominent symptom. The word vertigo comes from vertex or vortex, a whirlwind, which is derived from "Verfo, I turn." The sensation is sometimes described as a swimming in the head. Objects seem to be moving in a strange and irregular manner. Many cannot look from a great height downwards without feeling giddy. Vertigo may be brought on by taking certain substances. Opium will cause it, also Belladonna ; alcohol causes it very commonly. Any one who has seen a person a little tipsy knows how his power of co-ordinating the muscular movements of his body is impaired, and how he rolls about from one side to the other ; and in consequence of feeling giddy is unable to walk in a straight line. Tobacco will also give rise to a form of vertigo, especially when it is brought into contact with nerves and nerve-centres, which have not gradually become accus- tomed to its influence. A slight, temporary failure in the force of the heart's action may cause marked giddiness ; and the attacks may recur from time to time, causing much anxiety to the patient and his friends. A few doses of Sal Volatile or brandy frequently relieve this form of vertigo. Only a teaspoonful or less of the stimulant is required, diluted with not more than double the quantity of water. Peculiar disturbances in vision occur in many cases of vertigo. Things look crooked. Some see only a portion of an object. They can see the upper half without being able to see the lower half of a person, and so on: These disturbances of vision do not necessarily imply anything more severe than temporary functional disturbance, perhaps due to some irregular distribution of blood in the capillary vessels of parts of the central ganglia, consequent upon sudden alterations in calibre of the small arteries, caused by disturbed action of the nerve ganglia which regu- late and preside over the action of the coats of these particular vessels. Such symptoms may mean, it is true, something far more serious, but in many cases they certainly depend upon no more grave or important changes than may be determined by taking a little more wine than is good. Swimming in the head is by many considered a fo.rm of vertigo. Persons who have been for some time over-anxious, or who have been overtaxing the mind or body, may suffer in this way. In the last case, the unpleasant symptoms will sometimes disappear ten minutes after tak- ing a dose of Sal Volatile or an alcoholic stimulant. If, however, they do not do so, they will probably be relieved by a little attention to diet, by a dose or two of Calomel or Blue Pill. The general health may afterwards be improved by taking a tonic, containing acid and bark, for a week or two. BILIO USNESS. 157 Aural Vertigo. Disease and injury to the semicircular canals of the ear may cause a feeling of giddiness and a tendency to fall, as well as vertiginous movements, the direction of which, forwards, backwards, or from side to side, is determined by the particular semicircular canal which is affected. Men i ere, as long ago as 1861, directed attention to a class of cases in which noise in one ear, humming, buzzing, whistling, puffing, often associated with pallor, headache, faintness, giddiness, nausea, and vomiting occurred in connection with disease of the semicircular canals, or of other parts of the ear. The attacks at first are slight and occa- sional, but gradually the -noises in the head increase in intensity, and are almost constant. At last absolute deafness of the affected ear ensues, and in consequence of the nerve-structures being destroyed, the giddi- ness and other symptoms cease. You will, however, meet with the symptoms above enumerated in cases in which there is no reason to suppose that organic disease of the ear or any other organ exists. The attacks, after recurring several times at intervals during many years, will at last cease, leaving the patient per- fectly well. Some of these cases seem to belong to the category of sick headache, and the attacks will be relieved by a small dose of Calomel, Blue Pill, or Grey Powder, Hydrargyrum cum Cretd. In such instances it is very probable that there is temporary disturbance of the circulation in the internal ear, as well as in other parts. Moreover, very nervous, fanciful people will sometimes complain of the symptoms of Meniere's disease, but as they quite recover under the influence of tonics, good living, and change of air, it is more likely that the symptoms were due to slight and temporary nerve disturbance, than to definite morbid change affecting nerve or other tissue. BILIOUSNESS. It is difficult to adequately explain the various phenomena which con- stitute what is known as biliousness, although very many persons are well acquainted with the symptoms of the bilious condition, and have fre- quently experienced them. Whether there is congestion of the liver in all cases, I cannot tell, for I am glad to say that I never saw a post-mor- tem of any one who had died during an attack of biliousness. Whatever may be the essential nature of the malady, it is not fatal. Nay, bilious people are for the most part long-lived. Some physicians who have expe- rience in connection with life insurance business, so far from objecting to take bilious people, are desirous of insuring them. In this opinion I fully concur. There is no doubt that a tendency to biliousness makes people very careful as to their mode of living. They know that if they exceed they will suffer. Bilious persons are often very fidgety about their diet, for if they eat too much a bilious attack usually comes on, and for a time they are completely unfit for ordinary work. Although bil- iousness is anything but an agreeable malady, nevertheless you may gen- 158 PATHOLOGICAL CHANGES. erally recommend bilious patients with confidence for various occupations in which endurance is required. The capacity for going steadily on for a long period of time is in truth often associated with a bilious habit of body. I fancy a very large share of the best work of the world is per- formed by the bilious. Such a tendency is frequently characterized by much energy and determination to work in spite of the derangement, and although there may be also some irritability of temper or despond- ency, there is frequently a very remarkable degree of patience, persist- ence, and resisting power. Although I cannot give an accurate description of the pathological phenomena of biliousness, I may help you to form an idea of the sort of unpleasant sensations experienced by bilious people, if I describe in his own words, the sufferings of a gentleman who had been bilious all his life, but who nevertheless managed to live to a very advanced age. My friend was a man who might have done great things and left his mark ; but I fear he lost much, and perhaps the world more, in consequence of his not being obliged to work. As in some other cases, a fortune is after all a misfortune. He was, -moreover, unwise enough to allow himself to get into that habit of thinking too much about slight physiological de- rangements which occurred in his own organism, and he gradually got into the bad habit of frequently talking to his friends about his aches and pains. Being rich, he was listened to, and further was spoiled by the sym- pathy and pity foolishly lavished upon him. As age advanced, the inter- est of his environment seemed to him to diminish, while the growls and grumblings, excited by sensations within himself, became so loud that at length he determined to seek professional consolation. He consulted the most celebrated physicians, but no one succeeded in curing his bil- iousness, or in teaching him to bear it patiently. He grievously trou- bled his family by his reiterated complaints, and by his persistent anx- iety about himself. Though on occasions he felt pretty well for a day or two, during many years he failed to make himself contented or happy. Every kind of treatment was tried, but nothing cured the derangement or averted the attacks. Blue Pill afforded some relief, and was the only remedy persisted in from first to last. All his tissues were probably sound, and I doubt whether there was any serious morbid change in any organs after more than ninety years of work. This gentleman was seen by me many times, and wrote down for me a description of his sufferings. Here it is: "Flatulence, distention of the bowels, and painful sensa- tions between the shoulders; coldness of the feet, twinging pains occa- sionally under the right shoulder-blade, nausea after eating. Muscular pain about the head and neck particularly the muscles at the back of the neck." The last is a very common symptom, and a very painful one in many cases of biliousness, and recurs in almost every attack. This old gentleman ate too much, and no wonder he was disturbed at night, and had to complain of " harassing and long-distressing dreams." DERANGEMENT OF THE LIVER. 159 He also suffered, as very many old people do, from " irritation of the skin of the body generally, but of his legs principally, and from sore- ness and eruptions about the mouth, affecting chiefly the upper lip." Such was the long catalogue of recorded symptoms, and the list by no means exhausts all this old gentleman's complaints. Some who suffer from biliousness differ from my old friend, and seem to alternate between a state of misery and despair and a state of com- parative comfort and even hopefulness. You will sometimes find patients bilious and irritable and out of temper, and very indisposed to do what you may wish, unless indeed they have sufficient self-command to over- come their natural bent. Another time you will find the same persons in excellent spirits, and ready to do anything for you, and as agreeable as possible. We may have very contradictory accounts of the same indi- vidual ; one person tells us that he. is a most disagreeable, cantankerous person, while another affirms him to be a most pleasant and excellent man. The conflict of testimony is explained by the circumstance that one informant happened to see him when he was bilious, while the other came in contact with him just after he had recovered from an attack. It seems curious that we should not be able to fully explain such very prominent and persistent functional derangements as affect important organs in cases of biliousness, more especially as the condition is a com- mon one, and has been often experienced by well-trained scientific and thoughtful members of our profession. But I have never been able to get, from any physicians with whom I have conversed or from any books I have read, what seems to me to be a clear and satisfactory account of the disturbance which occurs in an attack of biliousness, or of the actual changes which affect the action of the peccant organs during the preva- lence of the attack. There is, however, no doubt that at the time there is actual disturbance in the liver. When biliousness is experienced, the changes taking place in this organ, as well as in the stomach, differ in important particulars from those which occur under ordinary circum- stances. The liver is not concerned merely in the secretion of that fluid which we know as the bile, but it has to do with many other changes. Among the most remarkable phenomena of the liver are its sugar- and fat-pro- ducing powers. It also effects great changes in albuminous matters and peptones, which have just been taken up by the vessels of the intestines and carried to it dissolved in the portal blood. Concerning any slight derangements which the sugar- forming func- tions of the liver no doubt undergo from time to time, we know com- paratively little ; but we do know that these functions may be so disturbed as to result in the establishment of a most serious change in the action of the organ which, when once started, usually persists, and at length, at least in the case of the young, ends in death. In Diabetes, particu- larly as it occurs in the young, many ounces of sugar are formed during l6o BILIOUSNESS. each period of twenty-four hours, and the kidneys are chiefly concerned in the removal of this sugar from the blood, although the tears and other secretions also contain sugar when the diabetic state is established. This formation of sugar, although varying in activity from time to time, and under the influence of remedies, cannot certainly be stopped. It con- tinues in the great majority of well-marked cases, and gradually exhausts the patient, until, after a period varying from a few months to two or three years, death results. On the other hand, I may confidently state that, under certain conditions, which cannot be exactly defined, the liver may be seriously deranged as regards its sugar-forming functions, not only without causing death, but even without apparently deranging the general health or nutrition of the patient. In old age it is not an uncommon thing to find a certain amount, and occasionally an enormous quantity, of sugar in the urine of a person, although its presence was quite unex- pected. It would seem that, in old age, the sugar-forming action of the liver may be greatly in excess of what it is in the normal state, and although the sugar pervades the blood and is carried by it to the various tissues and organs of the body, it scarcely seems to disturb their action. At any rate, it may continue uninterruptedly for more than twenty years, and the patient may die at an advanced age of some other malady. Not only so, but any healthy person may for a time form considerable quan- tities of diabetic sugar, if he will take more than a moderate quantity of cane sugar. A man who took a dose of a quarter of a pound of ordi- nary sugar passed diabetic sugar in his water for two or three days after- wards; but this temporary diabetic state is not to be induced so easily in every person. The liver is the organ by which the change is effected, and if you think over these facts you will, I think, agree with me in the conclusion that, in many slight derangements of the health, some other functions of the liver, instead of or as well as its bile-forming office, are at fault. The action of the liver-cells, in connection with their influ- ence on the formation and transformation of fatty, albuminous, and amyloid matters, must, therefore, not be lost sight of in our efforts to determine the causation of many slight derangements of the health which seem referable to the liver. But as regards " biliousness," it seems to me that the yellow tinge of the conjunctiva so commonly observed, the alteration in the color of the skin and its dryness, the disturbed action of the sebaceous glands, the sense of weight in the right side, the derangement of digestion all point to the fat- and bile-forming operations of the liver-cells as being mainly at fault. This view is confirmed by the fact that medicines which cor- rect the changes just referred to are those which unquestionably act upon the bile-forming process, and as soon as the action begins the patient who suffers from what is known as a bilious attack experiences relief. Some cases of severe biliousness approach so nearly to those cases of temporary jaundice, which I shall presently speak of, that I am almost inclined to ON THE TREATMENT OF BILIOUSNESS. l6l regard them as related to that condition. Possibly, it may be correct to consider biliousness a condition which initiates certain forms of jaundice. Biliousness may possibly depend upon an inactive state of the liver-cells, in consequence of which substances remain in the blood which ought to be separated from that fluid and converted into bile. The sluggish state of the circulation, the tendency to the accumulation of the blood in the capillaries and veins, as shown by the distention of the capillaries of the papillse of the skin and the bleeding which takes place if they are di- vided, the formation or increase of haemorrhoids, the turgid state of capillaries near slight scratches or wounds, and the indisposition of the latter to heal, indicate such disturbance of the capillary circulation gen- erally as would result from the accumulation in the blood of substances which ought to be thoroughly eliminated from the circulating fluid. The Treatment of Biliousness. The only medicine that relieves many bilious people is a small dose of some mercurial preparation. The old gentleman to whose case I have already referred discovered that blue pill alone gave him ease, and dissipated for a time the unpleasant sensa- tions from which he suffered, and which made him at times perfectly wretched. He took blue pill of his own accord, whether the doctors allowed it or not. For forty years he seldom went four days without the remedy. He tried over and over again to get out of the habit, and many advisers strongly recommended him to give up taking mercurials. He made many attempts, but in a short time his sufferings became so great, that at last he was obliged to return to his favorite remedy. He seldom, however, took more than a grain once in four or five days. I do not mean to imply that you will cure every case of biliousness if you give mercurials ; but certainly the great majority that come under your notice will be benefited. Many cases resist every effort to cure, them, but it is the exception to meet with a sufferer who cannot be in some degree relieved by treatment. The bilious habit seems to be due to an unusually sensitive, irritable stomach and liver, which discharge their functions fairly in a moderate degree, but which cannot be made to perform more than this moderate amount of work, without getting much out of order; so that where you have to treat patients suffering from biliousness, you must be careful to give directions concerning diet, which should be very moderate, *nd lay stress upon the importance of great moderation. Most of the organs taking part in the digestion and assimilation of the food seem to strike work when a decided bilious attack comes on. If food be taken, the suffering becomes greater. Moderate starvation is what is required in many cases. Bilious people often find advantage from giving their digestive organs partial rest for several days. In this way time is allowed for the return of the organs deranged to their nor- mal state. The fact seems to be that the digestive organs require rest for a time, and if, when an attack comes on, this rest is given, the bilious 14* L 1 62 ON THE TREATMENT OF BILIOUSNESS. state passes off, and then the patient feels extremely well, perhaps for a considerable time. In general, you will find that those who are liable to bilious attacks require very little meat. Free meat-eating will often bring on an attack. Generally, rich foods do not agree. Fatty matters in certain forms and in moderate proportion must be taken, but cooked and half-cooked fatty materials, as in many sauces, soups, fried fish, and meats, are not suita- ble. Cream or much milk sometimes precipitates an attack. Most forms of alcohol, and any form in quantity, will generally disagree with the patient. Vegetables and many fruits, on the other hand, agree well; vegetable acids seem to help the action of the liver and stomach. From half an ounce to an ounce of lemon juice daily for a time is undoubt- edly useful in many instances. Cider in moderation, that is, one or at most two tumblers daily, can be taken by some bilious persons. Citrates, Tartrates, Acetates, may also be given. Light puddings composed of starchy matters of various kinds, such as Rice, Indian corn, Sago, or Tapioca, made with milk and eggs in small quantity, and plenty of bread, may be enumerated among the articles of diet for the bilious. Generally, such persons are of necessity small eaters their organs rebel before it is possible to damage them by overwork, and so they seldom die of those diseases which cut short the life of so many who enjoy good living, and who possess strong digestive organs. Hence, as I have already remarked, the bilious often live to be old. When an attack comes on, benefit often results from the use of mild purgatives. Effer- vescing Citrates and Tartrates do good. Liquor Ammonia; Acetatis and Muriate of Ammonia have been also prescribed with advantage in many cases. I have often recommended grapes, in quantities of half a pound a day, when they can be obtained. Many persons have been relieved by taking from six to ten tumblers of fluid in the course of twenty-four hours, for two or three days at a time. Ordinary soda water, or seltzer, or Apollinaris water may be ordered. The kidneys are in this way made to act very freely, and relief soon follows. Of the deleterious action of the east wind upon the functional action of the liver there can be no doubt ; but it is not easy to explain precisely how this results. That the dryness of the air and the constant wind are potent in interfering with the due <*ction of the skin there can be no question ; but these effects do not afford an adequate explanation of the facts, since persons shut up in rooms artificially heated, and with the air supplied with watery vapor, nay, people who have kept their beds, are often aware when the wind blows from the east. Northerly and westerly winds may be as cold, and I think as dry, as the east winds, withou; giving rise to those very unpleasaat sensations experienced by the majority of the population who have passed their fourth decade, whenever the wind is in the east. As long as the wind blows from this quarter, people suffer; but a few hours after a change has taken place they feel perfectly JAUNDICE. 163 well, both in body and mind ; for, as is well known, the temper is often terribly ruffled by a dry east wind. The seaside has the reputation of seriously impeding the action of the liver ; and deservedly so ; for we are assured by many persons that when- ever they go to the sea for a week or more, the motions are invariably scanty, and of a very pale yellow or of a gray color. But what is very remarkable is this : that for some time after their return from the sea the hepatic actions of the same persons is unusually free. Although they may consume much less food than when they were away, the motions are more abundant and the faecal matter properly formed. In these cases there is no doubt that there is increased formation of faecal matter that materials which had been accumulating for perhaps a fortnight previously are at length separated from the blood, and the patient in consequence feels greatly relieved and appears to be much improved in health. Where the bilious state is very severe and in some cases it is so severe as to incapacitate people from performing any kind of work for the time you will often afford relief, and in a very short time, if you give a grain or two of Blue Pill or Calomel. Some who suffer from biliousness also experience violent headache at the time ; and this symptom is also re- lieved by the Blue Pill or Calomel, and frequently in the course of a very few hours after the medicine has been taken. Indeed, some who suffer much, and who are, generally speaking, in anything but a good state of health, may yet be able to get through their work with the help of an occasional dose of a mercurial from one to three grains of Gray Powder once in five or six days. I am not aware that any deleterious effects are produced by this practice in persons who suffer much from biliousness. Of course it is not desirable for any one to be continually taking mer- curials, or any other drugs for that matter ; but it is better to take mercurials now and then than to be utterly incapacitated for one or two days out of every ten or twelve, as is the case with many who suffer from this most unpleasant ailment. From some experiments performed by Dr. William Rutherford on the dog, it appears that several vegetable substances act as stimulants to the secretion of bile; and it has been inferred that they act upon man as well as upon the dog. Among the most important of these cholagogues are Iridin, Baptistin, Juglandin, of each of which from two to four grains may be prescribed for a dose, Euonymin in doses of from one grain to two grains, and Phytolaccin, of which the dose is from one-eighth of a grain to a grain. Dr. Rutherford's observations will be found in the "British Medical Journal," February Sth, 1879. Jaundice is a rather common affection, particularly in summer. It may be due to many different causes, some of which are unimportant and transient, while others are serious and irremediable. The particular form of jaundice to which I am about to refer, may, with propriety, be included under the head of "slight ailments." It is known as ordinary 164 EXCRETION OF BILIARY COLORING MATTER. jaundice ; and I dare say that perhaps thirty or more per cent, of us have suffered from an attack of jaundice, or will do so before the age of twenty- five is passed. The physiological changes in the system must needs be very much modified if the bile, which is formed in such considerable quantity, instead of being poured into the intestines, is retained in the gall-bladder. In every form of jaundice the bile is formed by the liver, but does not escape by its usual channel. Most commonly the Common Gall-Duct, Ductus-Communis Choledochus, is plugged up; and the bile, which has been formed by the cells of the liver, and has passed into the gall-ducts, is obstructed in its further course towards the intestine. After accumu- lating to some extent in the ducts, and in the gall-bladder, it would appear that it gradually makes its way through their coats, and gains entrance to the lymphatics and veins which lie outside them. Hence the bile formed by the liver soon passes into, and circulates with, the blood. Tissues in all parts of the body become stained, and in some cases take a deep yellow color. Textures, both at the surface and in the interior of the body, are thus stained more or less intensely in cases of jaundice. Not only so, but the excretion of the yellow coloring matter which has been formed originally in the liver, and has been absorbed into the blood, is effected to some extent by the kidneys. Mucus, epithelial cells, casts, and even some crystals passed in the urine are tinged of a bright yellow color, while the urine itself contains a good deal of yel- low biliary matter. Sometimes it appears of a dar-k-green color, owing to the quantity of bile it contains. So quickly in many instances is the bile removed from the blood by the kidneys that the urine is often stained with the characteristic yellow color for some days before the skin acquires the slightest yellow tint. On the other hand, the secretions from the bowels will be found to lose the ordinary color, and after the jaundice has lasted a short time they will be clay-colored or colorless. Whether the impediment which 'interferes with the passage of the bile into the intestine, in these cases of temporary jaundice, is due to firm spasmodic contraction of the muscular fibres which surround the lower part of the common gall-duct near its opening in the duodenum, or to the accumulation of mucus and epithelium in the same situation, thus plugging the duct, is not quite certain ; but there can be no doubt that there is in all these cases an impediment to the onward flow of the bile, consequent upon some temporary obstruction, which after a period vary- ing from a week to three months or longer gives way without any per- manent change or derangement being induced. Patients suffering from temporary jaundice completely recover. Now I desire to ask your careful attention to the fact that in these cases the jaundice is due not to the accumulation in the blood of substances out of which bile might be formed by the action of the liver-cells, but SEVERE JAUNDICE. 165 to the passage into the blood of bile which has been already formed by the action of these hepatic elements, and has passed into the ducts. As I have already said, the stools appear more or less like clay, or of very light-brown color, in consequence of the biliary matter not having passed into the intestines, where ordinarily it undergoes those compli- cated changes which take place in its resinous acids and coloring matter, and which end at last in the development of the peculiar chemical com- pounds which are constantly found in normal faecal matter. Even in slight cases of jaundice the bowels are usually somewhat con- fined. The patient perhaps experiences slight nausea, with indisposition to take food. He gets thin. The nutriment matters he does take do not nourish him properly, and he feels weak and out of health. Some people suffering from jaundice are, however, able to do their work, and students have passed through a difficult examination although they were deeply jaundiced ; but the proceeding is not a wise one. You see, therefore, that a very large and important organ like the liver may be seriously derangedwithout the ordinary functions of the other organs of the body being very seriously disturbed. For a time at least we can get on not only without bile flowing into the intestine, but in spite of its distribution to all parts of the body. In these cases, the bile prevented from escaping from the liver is reabsorbed and taken up by the blood, and the coloring matter deposited in many of the tissues. The patient may, however, notwithstanding this great change, be able to perform a certain considerable amount of work, and may be able to use his mind efficiently, although the whole of the blood distributed to his brain is contaminated with a considerable proportion of biliary matter. But, as I have remarked, you must bear in mind that from time to time cases of jaundice are met with which end, and very quickly too, most disastrously. It is a fact which must not be forgotten, that some of these cases which may run on to a fatal termination in the course of two or three weeks, cannot at their commencement be distinguished from that almost trivial form of jaundice of which I have spoken. Ordinary jaun- dice may last for a period varying from one week to three months. Probably the average time will be from two to three weeks. When it persists for more than a month, even though there be no grave symptoms, we feel some degree of anxiety lest the case should be due to more than a temporary obstruction of the duct. The longest case of ordinary tem- porary jaundice which has come under my own notice lasted for upwards of twelve weeks. For the whole of this time the patient, a young man of eighteen, was deeply jaundiced, and no decided improvement began to take place until three months had passed. In cases where the malady is prolonged so considerably beyond the average time, we may suppose that the plug of mucus or modified epithelium in the common duct is firmer than usual. At last, however, the mass, having become softened, 1 66 YELLOW ATROPHY OF THE LIVER. slowly escapes, bit by bit, from the orifice of the duct, and gradually the organ returns to its normal state. That form of jaundice which is very fatal, and which may end quickly in death, is dependent upon serious damage to the secreting and other structures of the liver, and the liver-cells are often completely disinte- grated and destroyed. As I said before, I do not know how we can dis- tinguish the terribly serious from the slight ailment when the patient first becomes jaundiced. In the fatal form of jaundice, however, very grave symptoms are developed after the lapse of a few days, and we then become aware of the terrible disease with which we have to deal. But during the first few days of the attack it is, I believe, not possible in many instances to distinguish a case which will end fatally from a case which will termi- nate in recovery. I allude to this matter because it is really most impor- tant not to be over-confident and off-hand in forming a prognosis in this, and indeed in most other forms of, disease. You may perhaps be called to see one of these fatal forms of jaundice, due to what has been called acute yellow atrophy of the liver, and, if nof aware of the existence of such cases, you might make a very sad mistake in informing the friends confidently-thai a necessarily fatal disease was only a slight ailment. We ought never to allow ourselves to make light of a malady which may turn out to be very serious indeed. Under such circumstances, we might be deservedly accused of want of care, experience, apd knowl- edge, and regarded as advisers lacking discretion and wisdom, and want- ing in power of discerning a most serious disorder, which destroys life in a short time. On the other hand, you must be careful not to need- lessly frighten people by detailing all the possibilities of disaster in any given case. Happily, these serious forms of jaundice are not common. In the course of a year we seldom see in the hospital more than one or two of them, and several years may pass without a single case being admitted. Ordinary temporary jaundice may occur at any period of life, but it is most common between the ages of fifteen and twenty-four; and it is more frequently met with in males than in females. Whether it is that we are apt to exceed in diet more than the other sex at this period of life, or whether the way we live has anything to do with it, I cannot tell ; possibly we maybe more anxious and nervous about our work and exami- nations than female students; but it is certain that about adolescence' jaundice in men is not at all uncommon. Jaundice occurring in middle life and old age is not very likely to be of this kind. More probably it will depend upon some more serious change than catarrh of the gill-ducts and the obstruction of the common duct by a plug of mucus. A very common cause of jayndice in middle life is a gall-stone impacted in the duct. Jaundice of this kind is usu- ally associated with great, and not uncommonly sudden, excruciating pain, and its nature can often be at once detected. This form of disease can, SICK HEADACHE. l6/ however, hardly be included under the head of "slight ailments." You should be aware that jaundice may occur in very young children ; and I have known cases in which it existed in intra-uterine life. It is not an uncommon thing for the child at birth to be completely jaundiced, but this usually passes off. It is due to temporary change. I have seen one case in which life was destroyed at or about the eight month of intra- uterine life by jaundice, caused by the impaction of a gall-stone in the common gall-duct. What is the earliest period of development at which the embryo may become affected I cannot say, but it is certain that some months before birth biliary calculi may be formed. Urinary calculi also may be produced even before the development of the kidney in which they are formed is perfected. Treatment of Temporary Jaundice. With regard to the treatment of ordinary jaundice there is little to be said. The main point to be borne in mind is that the patient should live on a light diet. Do not let him feed heavily, or he will get worse, and may suffer much. Keep the bowels gently acting by giving small doses of Blue Pill or- Gray Powder at intervals of a few days. You may also, or instead, occasionally give a dose of some saline purgative. A drachm or two of Sulphate of Mag- nesia, Magnesia Sulphas, with a little Hydrochloric or Sulphuric Acid (p. 141) before breakfast, is of service in this condition, just to promote the action of the bowels. Do not, however, give violent purgatives or attempt to cure the disease off-hand by any course of special treatment. A mustard poultice may be placed over the region of the liver every day, or every other day, for twenty minutes. Another local application which seems to be of use, and which I learned from Dr. Blakiston, is Hydro- chloric Acid applied on rags. The strong acid is diluted with twice its bulk of water. A rag is carefully wetted with the lotion, placed over the liver, and then covered with some useless rags or an old towel. This application may be used each alternate day, care being taken that the acid is not allowed to spoil any linen or the clothes of the patient. It produces only a little tingling. The skin should be wiped with a soft, wet sponge when the rag is removed. I come now to another malady, reference to which may perhaps raise a smile. It is, however, an extremely disagreeable ailment to endure, and it may entirely prevent, or seriously mar, the execution of mental and bodily work. SICK HEADACHE. This is one of the most severe of the maladies I have included under the head of slight ailments. The affection is very common, and used to be known as Migraine. Some, who 'in other respects are perfectly healthy persons, with apparently sound constitutions, and whose tissues generally would seem to be not only healthy, but of an enduring char- acter, suffer from very frequent attacks, and may be for many years hardly ever free from the malady. Nevertheless, sick headache is to be 1 68 NAUSEA AND VOMITING. regarded as a very troublesome and inconvenient, rather than as a seri- ous, derangement. This curious disorder may affect people at every period of life. Some authorities assert with confidence that as we grow older we overcome the tendency to sick headache ; but I am sorry to say I know some who have grown old, and many who are growing old, who still suffer. One sees cases of sick headache occasionally in very young children, frequently in young people and adults, and not uncommonly in old age. I know persons of seventy-five and upwards who continue to suffer from well- marked forms of this intractable malady. However, there is no doubt that the tendency of the sick headache is to diminish in severity as age advances ; so that many who are martyrs to frequent and severe attacks up to the age of twenty-five or thirty, begin to improve after that period, and towards forty become troubled less frequently, or recover altogether. In others, the attacks become rare, but occur now and then as long as life lasts. Sick headache is a disease not dependent upon any actual pathological change, as far as can be at present ascertained. It seems to be due to some temporary, but widely-extended, derangement, influencing a number of different tissues and organs, situated at a distance from one another. I shall endeavor to lay before you the several phenomena of which this malady is composed, and shall try to point out in what respects there is a departure from the normal and healthy action of the several organs and tissues involved. In the first place, as to the headache. This is peculiar, for it is usually confined to one-half or less of the head, Hemicrania (^icrnf, half, upaviov, the head). A part of one lateral half of the upper part of the head is the seat of very severe pain, which is occasionally described as of a boring or penetrating character, and may be so circum- scribed that the painful spot could be covered by the top of the thumb. Sometimes the pain is situated immediately over one brow, the sensation experienced being like that which would be produced if a sharp and strong instrument was being forced into the head at that particular spot. The pain, varying much in intensity, and somewhat in character, from time to time, may last for a period of from twelve to twenty-four hours, or even longer. It may then shift to the opposite side, and, after lasting there for about twelve hours more, may gradually subside, until the patient becomes perfectly free from pain. In a short time he feels well, and, perhaps, for some days after the attack has subsided considers himself unusually vigorous. From the frequency of the occurrence of cases in which the pain is confined to the region above one or other brow, the condition has been called Broiv Ague. The term ague is, however, unfortunate, for the affection is far removed from maladies belonging to that class. Next, as regards nausea and vomiting, which frequently accompany this headache. The stomach derangement in sick headache is often very NAUSEA AND VOMITING. 169 marked and very distressing; but these symptoms are often preceded by an almost irrepressible tendency to yawn at frequent intervals. There is a sensation apparently situated in the soft palate which almost makes the person yield ; but as soon as he has yawned once the desire returns; and this often lasts for some hours, or until vomiting occurs or sleep is induced. There is, as I have said, almost always more or less nausea, and not unfrequently absolute vomiting, the depression accompanying the sickness being sometimes of the most distressing character. It is often as bad as severe sea-sickness. I have known people to vomit fifteen or twenty times in the course of the day, although they were merely suffering from what is called sick headache. In this condition, then, we have temporary, but very decided, and sometimes violent, disturbance of the digestive organs, inability to take food, nausea, and severe vomit- ing, associated with pain, more or less acute, on one side of, or, it may be, all over, the head. The vomiting is remarkable ; for there is not merely straining and contraction of the stomach, followed by the rejection of its contents, but a great deal of secretion is poured into the stomach from the blood or from the glands; and after this has accumulated so as to distend the organ, it is suddenly expelled. It is in this way that many of those who suffer from sick headache get relief. After the removal of the contents of the stomach, which are often of an intensely acid reaction, the distressing nausea and sense of oppression and exhaustion become relieved for a time, but recur if more acid fluid is poured out. What is very remarkable in many of these cases is this : that food may be digested shortly before the vomiting is excited, when an enormous quantity of acid fluid from the stomach is brought up. There can be no doubt that in these cases much acid is formed in the stomach, or secreted by the glands. Indeed, at the very time food is being digested and passed onwards to the duodenum, there is evidence of the formation of other acids beside the ordinary acid of the gastric juice. Oxalic, butyric, acetic, valerianic, are among the organic acids which are developed, owing to some unusual chemical changes taking place in the contents of the stomach. It is the accumulation of this acid mixture which causes the nausea and painful sinking experienced at the pit of the stomach. The nausea remains until the contents of the stomach have been expelled. Vomiting may, of course, be encouraged by the administration of a medicinal emetic, by drinking several tumblers of warm water, or by tickling the back of the fauces. The act of vomiting may be attended with instant relief. I have known cases in which, the moment after the stomach had rejected its contents, the pains ceased, and, for a time at least, the patient is in comparative ease, or feels perfectly well. In slight sick headache, as well as in more serious head affections, there is evidence of remarkable sympathy and association between the action of the brain and the stomach. The pain that we suffer in sick headache is not due merely to some affection of the cutaneous nerves I/O DERANGEMENT OF THE STOMACH. of the skin of the head and face, as has been held by some, but there is clearly a temporary disturbance in the brain itself, probably in connec- tion with the vessels at least of the surface of the gray matter of the con- volutions, for not only does the pain seem to be situated in the brain, but the action of the cerebral matter is unmistakably disturbed. The memory is for the time impaired. Attention cannot be given without conscious and even painful effort. Sustained thought is impossible for the time, and there is a decided longing for mental rest, which, being yielded to, soon results in dozing, or in actual sleep. It might be thought that cerebral disturbance generally, at least when ushered in by functional or organic disease of the digestive organs, would be due to deranged action of the upper part of the alimentary canal only. The most remarkable phenomena undoubtedly point to stomach and duodenal disturbance, and we know that in many diseases of the brain the action of the stomach especially is disturbed frequent and sudden vomiting being often present. The action of the stomach, as every one has expe- rienced, is much influenced by the brain, and the latter by the stomach. Digestion may seriously derange cerebral action, and may in its turn be modified or completely interfered with by mental or emotional disturb- ance. This indeed is admitted, but in many forms of sick headache the derangement is certainly more general than the consideration of the sub- ject thus far would have perhaps led you to suppose, and it is doubtful whether the lower, as well as the upper, part, and in some cases exclu- sively the lower part, of the alimentary canal is not implicated in the attack. I shall presently refer to this point more particularly. The disturbance of the nervous system in sick headache is so striking and widespread, that some pathologists have been induced to place sick headache among nervous diseases, and to support the conclusion that the derangement not only begins in the nervous system, but that the affection is exclusively nervous. To me, however, it seems more probable, and the conclusion is grounded partly upon personal experience, that the nerve phenomena are second in the order of their occurrence, and that the starting-point of the malady is abnormal functional disturbance in the digestive organs, and, through these, in the blood itself. That the blood is deranged in cases of sick headache is probable from several circumstances. It has been noticed that any wound or scratch that there may be on the surface of the skin looks angry. The processes of healing and the nourishment of tissues do not proceed as in perfect health. Another reason for concluding that the blood is more or less out of order is that, when the sick headache disappears, very free action of excretory glands sets in. A considerable quantity of urine, often rich in uria and urates, and of high specific gravity, is voided, and this is suc- ceeded by the free secretion of large quantities of pale urine containing a small proportion of solid matter. Gradually the ordinary -actions in the several tissues and organs are resumed. DERANGEMENT OF THE LARGE BOWEL. I? I The composition of the blood is also much altered during the attack by the free discharge of certain substances from it into the stomach. The glands, instead of pouring out ordinary gastric juice to digest the food, secrete, and in considerable quantity, a fluid which, instead of qui- etly digesting the food, irritates the nerves distributed to the mucous membrane, and causes vomiting. The fluid is frequently highly acid, but, as I have remarked, the acidity is due to a number of organic acids which are not to be found in health. Under these circumstances it is useless to introduce food into the stomach, -for little or no digestion will take place. The stomach must be allowed to rest for a while, until its contents are rejected, or by degrees driven downwards into the small intestine. It seems, then, probable that certain materials which yield these substances when discharged into the stomach have been accumu- lating in the blood for some time before the attack of sick headache occurs that, indeed, the malady depends upon this accumulation in the blood, and that the "attack" corresponds to their discharge into the stomach. The salivary glands, the little labial and buccal glands, are elso affected. Saliva is very sparingly secreted, and the mouth is often in a dry or clammy and uncomfortable state; the mucous membrane dries very quickly; there is often a very unpleasant taste, and instead of the mucous surface being soft and moist, it seems to be besmeared with viscid mucus, and the patient will tell you his mouth is quite out of order. In many cases the action of the salivary glands is certainly suspended for a time, and when the attack is passing off, one of the first points noticed is the pouring of a quantity of saliva into the mouth. With the return of salivary secretion, the unpleasant sensations about the mouth, the dry- ness, the disagreeable taste, and the clamminess disappear. The liver is out of order in "sick headache." Its action in many cases seems indeed to be almost suspended for a time. The excrements are sometimes, but not invariably, pale and altered in consistence. The intestine is not stimulated to perform its ordinary contractions, and in many cases flatus collects. Moreover the surface of the liver is some- times tender to the touch. Not unfrequently there is a feeling of fulness or actual pain in the right side; and often there is distinct yellowness of the skin and the conjunctiva. The action of the alimentary canal is partially suspended, or the intestine scarcely acts at all. Its contents, in many instances, seem to remain almost still for a time during the attack, or are very slowly urged towards the lower bowel. The action of the colon is suspended. No accumulation of faecal matter goes on during the attack, for faeces are at the time not being formed. In some cases of sick headache, I think the derangement actually begins in the large intestine. Sometimes there is evidence of moderate, but not excessive, faecal accumulation, with a passive state of the mucous membrane and its glands, and sluggishness of its muscular coat. The caecum and 1^2 MEMORY AND TEMPER. ascending colon are very commonly at fault ; and I have often succeeded in feeling the accumulation at this part of the bowel. The patient him- self is frequently aware of some discomfort or unpleasant sensation in the right iliac fossa. By palpation you may detect the fulness, and by the tympanitic percussion over this part of the bowel you demonstrate the presence of gas, much of which probably arises from decomposition of materials which ought to have been expelled long before. It does not follow that actual constipation has prevailed, but the bowel has not com- pletely emptied itself. For -some time, perhaps for weeks and months, it has not driven down the fsecal matter towards the rectum as fast as it was formed. The lower part of the ileum, as well as the caecum, is at fault in many instances. Probably Peyer's patches and the solitary glands do not act freely; and oftentimes their action is further disturbed by the constant presence of faulty secretion, and possibly of the products of fermentation and unusual chemical action in the slowly-moving and almost putrefying mass. The action of the glands themselves is then interfered with; and the uneasiness and pain which are sometimes ex- perienced may be due to this cause. You must not forget these points, for they are of interest in connection with the causation of many derange- ments of the health, some of which are by no means slight. I believe that a prolonged, and perhaps almost constantly disturbed, action of this part of the alimentary canal leads to important changes in the blood, and may establish a state of system favorable to the development of important diseases of different kinds. Neither must it be forgotten that when mate- rials remain for some time in contact with the mucous membrane of the large bowel, reabsorption occurs, and thus many noxious matters, which ought to be discharged from the system, find their way in an objectionable form into the blood. You see, then, in sick headache there is evidence of very widespread, but, at the same time, slight, derangement in many organs and tissues of the body. There is general disturbance of the intestinal canal, alterations in the composition of the blood, and disturbed action of many parts of the nervous system. There are derangements of touch, perverted taste and smell, often disturbance connected with vision, and, not unfrequently, singing in the ears, and other departures from the normal state as regards the action of the organ of hearing. The action of the heart is depressed. The capillary circulation is deranged, there being too little blood in some parts, congestion in others. Digestion is much deranged, and the action of the liver and other secreting organs is seriously impaired for the time. The muscles do not work as they should do. Delicate movements cannot be executed with the usual precision, and sustained muscular effort is difficult or impossible. The body is fatigued. The memory is more or less affected for a time, and in many instances the temper becomes " bilious." To attempt brain-work when you suffer from sick headache would be useless, for the mind will not work to any advantage. Some- SICK HEADACHE AND EPILEPSY. 173 times there is a very distressing faintness, and a feeling of terrible exhaustion ; the heart's action being often very feeble for a time, and sometimes so very weak as to cause alarm. Rest in the recumbent posture for a few hours may be necessary ; but, generally, the heart soon regains its usual power if let alone. Stimulants sometimes increase the stomach disturbance, and prolong the attack; but if the heart's action is very depressed it may be desirable to administer Ammonia or brandy, in very small quantities, at short intervals, until the organ regains its natural strength, as indicated by the character and intensity of the heart's sounds. When the attack of sick headache begins to pass off, urine, often loaded with deposits of Urates of Soda, Ammonia, and Lime, and of high specific gravity, is excreted. Then the kidneys begin to act freely; the bowels also act slightly, and in a few hours more the patient will feel well. It is remarkable that, after all this disturbance in the system, the individual who has suffered should be for a time in better health than usual; and he may feel exceptionally well and vigorous. Indeed, you will find that many of the victims of this derangement have considerable powers of endurance, which enable them in a great many instances to work on energetically, far into old age. Many who suffer severely, though not fit to work, by great effort may get through their duties, and, perhaps, during a long lifetime may not have been forced to absent themselves for a single day. As far as I know, no harm results from working on through a sick headache, in cases in which this can be done, but, of course, certain kinds of work cannot possibly be executed under the circumstances. Attacks of sick headache may occur once a week and oftener, or the affection may recur not oftener than once in a fortnight, or once- a month, or still less frequently. You will sometimes find that the suffering returns almost to the day, after a week or a fortnight, or other interval. In spite of this almost continual disorder, the general phenomena of the system, essential to the continuance of life, proceed as usual. I think that some of those who surfer, and who take moderate care of themselves, really enjoy certain advantages as regards the prospect of longevity. Their tissues do not seem to grow old as fast as those of many of their more vigorous contemporaries. Periodical sick headaches may, after all, be conservative in their action, and may protect the organism from more serious pathological derangements, thus perhaps enabling persons to live long who might under other circumstances die early. Although the digestive organs may be seriously wrong for a certain time, they get the advantage of resting from time to time for periods varying from twelve to twenty-four hours. If in the affected organism anything happens to be wrong in connection with the alimentary canal, there is the advantage of time being allowed for the derangement to right itself instead of per- sisting until actual morbid change has resulted. There appears to be hyper-sensitiveness in connection with the nerves of the digestive organs 15* 174 NEUROSES AND NERVE STORMS. in many who suffer from sick headache, which, by favoring severe tem- porary disturbance of a functional character, may prevent damage and permanent structural changes in important tissues. Possibly this may be the reason why many people who suffer from sick headache not only live to be old, but retain their vigor in old age. Some physicians have thought that an intimate relationship existed between sick headache and the epileptic state, but we meet with so many instances of each condition without the slightest indication of tendency to the other, that I cannot, without some further evidence, accept this opinion as correct. Undoubtedly you will now and then meet with a case which might seem to justify such an inference, but you will also come across cases which, considered alone, might suggest a relationship between epilepsy and many other forms of disease usually considered quite distinct. Indeed, there are few morbid conditions in which nerve derangement exists which might not be adduced as supporting the view of their affinity to the epileptic state. Hysteria, nightmare, waking up suddenly in the night and calling out, nocturnal expulsion of urine, twitchings occurring in the muscles, may all be regarded as belonging to the category of epileptic affections.' But if I admitted this view to be probably correct, I should still be disposed to doubt whether any con- nection between sick headache and any form of the epileptic state had been proved to exist. Some cases that come under our notice would seem to justify the notion that, in certain instances, attacks of sick head- ache take the place of attacks of gout, and that the two affections are related. But it must be admitted that there are many persons who suffer from sick headache who have no tendency to gout, while many who have gout hardly know what it is to suffer from headache of any kind. Nev- ertheless, there is reason to think that in both affections the blood is deranged, and possibly by the accumulation in it of nitrogenous mate- rials which ought to be eliminated. Both affections come on at inter- vals, and often suddenly. Both are relieved by the same general treat- ment. Both are aggravated by a full meat diet, and mitigated by a diet largely composed of vegetables and fruit. In both there is derangement of the liver, and Calomel and other remedies which act upon that and other excreting organs relieve those who suffer from gout as well as those who suffer from sick headache. We cannot, I think, accept the generalization that sick headache belongs to the class of neuralgic affections ; for those who suffer from severe forms of neuralgia do not seem to be more susceptible of sick headache than other persons ; nor, on the other hand, are the victims of sick headache unusually prone to neuralgic pains. I do not see what we gain by calling this, and many diseases in which nerves are affected, " neuroses," or by referring them to " nerve storms," for no one knows what he means by the phrase "nerve storm." Nor has the supposed conr.ection between sick headache and ague, and maladies of that class TREATMENT OF SICK HEADACHE. 175 been proved. There seems to be an alliance between many different diseases, but it is most difficult to do more than point out the connec- tion in general .terms. As time goes on, I have no doubt many affections which have received different names, and are now regarded as distinct diseases, will be shown to be much more closely related to one another than we should be led to suppose from the accounts given in our system- atic works on medicine. For reasons to which I have already adverted, I should rather place ordinary sick headache under the head of derange- ments of the digestive organs than include it in the disorders of the nervous system. This question of the nature of the malady has an important practical bearing, for it must influence our views as regards treatment. Now I think I may go so far as to commit myself to the opinion, that if the digestive system and the most important organs of excretion could be made to work properly, and could be kept working properly, the subjects of sick headache would be cured, and, from the time when these results had been obtained, would be free from attacks. It appears to me probable, for reasons which I have set forth, that some material gradually accumulates in the blood, and by its deleterious action on the nerve-cells of the brain gives rise to the headache, and causes the inability to think, or at any rate renders it impossible to sus- tain connected, thought for many minutes at a time. This inability to think is probably caused by an indirect action leading to dilatation of the capillaries of the pia mater and those in the superficial part of the gray matter of the convolutions. At the same time it is probable that the fluid effused from these vessels, laden with matters which ought to have been eliminated, bathes the nerve-cells, and exerts a deleterious influence upon them. A small dose of Calomel within two hours, or even less time, completely alters the state of things for the nausea, the headache, the misty confusion of intellect, all disappear. The kidneys soon begin to secrete actively, and in this way the blood is depurated. The stom- ach and the intestinal canal participate, and then the peccant matter which has accumulated is removed and the healthy function restored. Treatment of Sick Headache. I believe we may often succeed, by judicious management, in reducing the number and severity of the at- tacks of this disorder. You must, in the first place, inquire very minutely into the general habits of the patient, and, of course, advise him to correct any irregularities he may have committed as regards quantity and quality of food, and the times of taking it. To lay down a strict dietary is, however, useless, nay, it might be mischievous, and more harm than good result. Many doctors make themselves ridiculous, and their patients miserable, by the absurd importance they attach to severe restrictions as regards particular articles of diet. The victim of sick headache will not gain anything by feeding as if he was in prison, and exercising as if he were under sentence of penal servitude, or undergoing the " cure " at some strict German bathing establishment. You may cut off his beer, i;6 TREATMENT OF SICK HEADACHE. wine, and all things containing sugar; you may order him to take so many pieces of dry toast at breakfast, without a particle of butter, and only allow him skim milk and lime-water to drink. You may limit him to a biscuit for lunch, and allow a small chop, with bread pudding, made without any sugar, for dinner, and a cup of water arrow-root for supper, or no supper at all. You may make him walk so many measured miles, rise at a certain hour, and retire at a time when most people consider the hour for a little quiet reading or other harmless enjoyment has arrived, and all to no purpose ; nay, instead of getting better, he may tell you that he is worse, and feels less happy and contented than before, and less able to be^tr his suffering. Your advice, as regards living, should be considerate, but not too strict ; for, in the first place, we do not know enough about the real nature of the malady to justify us in accurately and arbitrarily laying down the law of living ; and, secondly, experience has incontestably proved that persons who suffer from sick headache get on better, upon the whole, if they live fairly well in the intervals, and starve for the short period during which they have to suffer. As regards wine, it will be generally found that light wines, such as hock, suit the sufferers, if they require stimulants at all ; but many who suffer from the malady do not require any form of alcohol whatever. There are many cases of sick headache that have resisted every attempt to cure them; indeed, it must be confessed that, up to this time, no certain method of "cure" has been discovered. While the headache lasts, and the action of the stomach and liver, and, indeed, of the secret- ing organs generally, is suspended, even the most digestible substances do harm, and I know of no medicine that invariably affords relief to the patient. Some of those who suffer from this unpleasant affection can tell, some days before the derangement begins, that they are about to have an attack. There is a disagreeable taste in the mouth, with a degree of dryness, particularly at the tip of the tongue ; a feeling of distention or fulness over the stomach ; sluggishness or inaction of the bowels ; lassi- tude, and an indisposition to take active exercise ; slight or considerable depression of spirits, and an inclination to sleep. The appetite may still be good ; but there is often some degree of discomfort after taking food, and very frequently a feeling of regret that anything in the shape of food had been taken at the time. Now, if the patient, by whom the import of these premonitory symptoms is understood, takes two or three grains, or even one grain, of Gray Powder, with a little Colocynth, and, perhaps, a saline draught the following morning, he may completely escape the impending attack. He may feel more or less out of sorts for a day or two, but he does not get the severe headache, and, perhaps, also escapes the sickness, though very likely he experiences a slight degree of nausea. This surely indicates that matters which had accumulated in the blood have been removed by the purgative, and have thus been prevented from TREATMENT OF SICK HEADACHE. . 1?? exerting a deleterious influence, culminating in the headache, and causing other, symptoms. But what should be done in these cases? What methods of treatment afford the best chance of relieving the patient who actually suffers? If you cannot always cure the patient you may do something to prolong the interval between the attacks, and to mitigate the severity of symptoms when they occur. If the sick headache is not severe, persuade the patient to think as little about it as possible. Recommend him to go about his ordinary work, and tell him to try by his manner to prevent people from discovering that he is ill ; for too much sympathy and kind inquiry con- centrates his attention upon the malady, and makes him feel worse. If anything appears to annoy him, he should keep quiet, and restrain him- self from expressing any decided opinion until he is well ; otherwise he may get the character of being a very ill-tempered or cantankerous person, when, in truth, he is nothing of the sort. It is his headache, not himself, that does the wrong. I. TREATMENT DURING AN ATTACK OF SICK HEADACHE. Rest. During a severe attack of sick headache, the patient, if this be possible, must have complete rest, so that the organs which are deranged may be allowed to gradually right themselves. The mind and the ner- vous system need repose as well as the stomach, liver, and other organs. When the suffering is very great, and particularly in cases in which there is that distressing feeling of nausea, and frequent or occasional attacks of actual vomiting, the patient must lie down. But one meets with many instances in which he is able to continue his usual avocation, in spite of the headache ; and I am not aware that any one has discovered that his sufferings were actually greater, or lasted longer, than when he adopted another plan, and gave way as soon as the headache came on, and lay down in a darkened room until the attack passed off. In bad cases, however, and especially if the patients are weak, and in other respects out of health, absolute rest in the recumbent posture must be recom- mended from the commencement of each attack. Starving in Sick Headache. The patient who is suffering from an attack ought to starve for the time, and thus rest the stomach until the attack passes off. It is very remarkable that many who suffer from this troublesome disorder are able to discharge even active duties without taking any food at all for perhaps twenty-four hours or longer, although in ordinary health the same person would get completely faint if, fasting, he attempted to do the same amount of work. A person may get up with a sick headache and be quite unable to eat any breakfast, and yet he may perform the ordinary duties of the day, and perhaps continue working up to nine or ten o'clock at night without having taken a par- ticle of food, and yet without suffering. The same man in his ordinary health might not be able to postpone breakfast for an hour without feel- Id 1/8 INFLUENCE OF WARMTH. ing faint and exhausted. This peculiar state in which abstinence from food does not occasion exhaustion may last for forty-eight hours, during which period not an ounce of solid matter may be taken, and yet it does not follow that the nutrition of the body will be in any way impaired, or the health damaged for any length of time. The patient will not lose in weight, because the organs soon resume their natural functions. When the appetite returns, and the victim is able to eat again, plenty of nutri- ent material will be poured into the system and rapidly appropriated. Abstention from food for twehty-four hours is usually long enough to allow the organs which are deranged to right themselves. But in any case during an attack of sick headache, it is not of the slightest use to attempt to force the patient to eat. Even bread and butter is apt to dis- agree. The starchy matter of the bread instead of being digested is apt to undergo other changes, and butter and other fats suffer decomposition, various organic acids being formed, which, after a time, irritate the stomach, and cause it to reject its contents. Even meat is not digested, but if the patient feel exhausted, a little cold beef-tea may be absorbed, or beef-tea which has been artificially half digested with the acid of pepsine, p. no. If patients object to starve from the fear that they will get very weak, you may tell them to try a little mutton broth or beef-tea, which should be entirely free from fat, and should be sipped. Of course, as far as any real advantage is concerned, they might just as well take nothing, for the little that is introduced under these circum- stances cannot in any way help nutrition, although it may, on the other hand, somewhat interfere with the return of the stomach to its normal state. The fact is, that temporary abstinence from food, as above sug- gested, can do no harm whatever, and this course is necessary if the patient desires to gain his normal state of health in the shortest time possible, and with the least degree of suffering. Warmth. Exposure to cold often precipitates an attack of sick head- ache if one is about to come on. Indeed, many sufferers attribute the illness to the direct influence of cold. I have thought on some occasions that instead of catching an ordinary cold from undue exposure, I had contracted the greater, if less lasting suffering, sick headache. Sick headache is certainly relieved by warmth. A warm bath sometimes removes, the headache, and almost always gives relief for the time. In slight attacks of sick headache complete relief may be obtained by put- ting the feet into hot water, or even by simply well warming them before a good fire. An ordinary hot-water bottle, or, better, a vulcanized India- rubber bottle filled with hot water and applied to the stomach, some- times appears to be of use, and is at any rate very pleasant under the circumstances. Counter- Irritation. There is no doubt whatever that considerable temporary relief is afforded during an attack of sick headache by the employment of counter-irritants. A mustard plaster (half mustard and ADVANTAGE OF TEA-DRINKING. 1/9 half linseed) to the back of the neck or to the pit of the stomach will relieve the pain, or half of one of Rigollot's mustard leaves, a piece of writing-paper intervening between the mustard and the skin, may be applied in one or both situations ; but one of the best applications to be used in these cases is described on p. 97. In recommending the external application of strong Hydrochloric Acid, you must, however, always be very careful to give explicit directions, or you will get. into great disgrace in consequence of the destruction of bed-clothes and the serious damage to wearing apparel. Acids. It is curious that in many cases in which acids are produced in undue proportion by decomposition of various materials in the stom- ach, there should be a natural desire for things having an acid taste. Many persons certainly experience a distinct longing for acid drinks, which undoubtedly afford relief in some cases. Lemon or Lime juice and water is very grateful to some, and seems to allay the distressing nausea often present. Tea- Drinking in Sick Headache. Some persons sustain themselves during an attack of sick headache by drinking several cups of tolerably strong tea in the course of the day. The tea seems to keep them up, to mitigate the severity of the headache, and to relieve the nausea. Tea is condemned in the most unqualified manner by many members of the profession; but I cannot help thinking that the public forms a more cor rect estimate concerning the value of this celebrated infusion. I doubt whether it would be possible to persuade old women or old men, or even young men, as a class, to give up tea. The majority of people do not believe that tea does half the harm attributed to it ; and with this opinion I am inclined to agree. If, however, you were ailing, and were to consult many of the most distinguished members of the profession on the matter, you would almost certainly be enjoined to give up tea, whether the malady was dyspepsia, constipation, or sick headache ; and, indeed, for many slight ailments, the most important curative measure would seem to be to abstain from tea. Some practitioners express this opinion with amazing confidence and absolutism. Milk and water or wine and water are sug- gested as substitutes substitutes for tea ! Your medical adviser fairly argues that something or other must be wrong, and infers that you take something that you ought not to take ; that this something must be at the root of the evil ; and then concludes, but not, in my opinion, with good reason, that the particular peccant matter is nothing less than tea. Now, it is almost hopeless to attempt to alter the views of those whose minds are " made up " upon such a matter as this; and, as regards the deleterious effects of tea, not a few medical minds will be found in this happy state. No one is to be allowed to say a good word for tea. Tea is held to be the almost universal cause of dyspepsia, and there is an end of the matter. But, in spite of its condemnation, tea is at this time more largely drunk than ever. Probably more than two hundred million I SO TREATMENT IN THE INTERVALS. pounds of tea per annum are consumed in the United Kingdom alone: and, if its influence is as bad as some assert it to be, it is wonderful how few people discover its deleterious qualities. Seldom, I believe, does tea do the harm that has been attributed to it. In many cases of sick headache, four or five cups of good tea, at intervals during the day, will unquestionably mitigate the severity of a bad attack, and, perhaps, enable the sufferer to pursue his ordinary avocations in a way that he could not otherwise carry out. Strong coffee seems to suit some persons who cannot take tea. Vomiting sometimes goes on for four and twenty hours, and sometimes for a longer period. The patient may be much exhausted, and the stomach become weak and very tender. Three or four days often pass before the patient regains his normal state of health, and is again able to digest food. 2. TREATMENT IN THE INTERVALS BETWEEN THE ATTACKS. Now, as to the treatment in the intervals between the attacks. After having tried many different systems of diet, with the view of preventing attacks of sick headache, as I have already mentioned, I have come to the conclusion that, upon the whole, the best plan is to live pretty well, and not to be too fidgety as regards food. In one or two days after the attack has passed off, the stomach begins to digest, and, in most cases, it will readily digest the ordinary things taken in health. I do not think that a restrictive diet, of any kind, is of much advantage ; and if the plan adopted lowers the general health, there is no doubt that the attacks of sick headache will not only come on more frequently, but they will be more severe. I should say to those who suffer from this troublesome ailment, "Live fairly well while you can, and when the sick headache comes on, entirely abstain from food for a time. As soon as the attack has passed off, live as usual, and think as little as possible of the malady." A great many persons are certainly too careful, as regards diet, in sick headache as well as in many other slight ailments. I fear, too, it must be confessed that many doctors encourage this, and give minute directions, as to food, which are as unpractical as they are meaningless and useless. A parcel of very absolute rules is laid down for patients' guidance, many of which rest upon no principles whatever, and are but needless arbitrary enactments. If they were called upon to give their reasons for the rules they have made, they would find themselves in a very serious difficulty. Many of the very precise directions that have been given to people suffer- ing from slight ailments are really quite ridiculous. Even if some patients are a little silly, it is certainly not our duty to treat them as if they were utterly devoid of sense. Give reasonable and necessary directions as to diet by all means, and see that patients do not exceed in any way, but do not write minute directions concerning the precise thickness of the bread and the exact quantity of butter, and do not give written orders BETWEEN THE ATTACKS. l8l as to whether the toast is to be taken hot or cold, buttered or without butter. Such trumpery minutiae will be regarded as feeble affectations by all sensible patients. If people, who are merely dyspeptic or bilious or inclined to headache, are allowed to be too particular as to what they may or may not eat, they get very fidgety, and, perhaps, at last loathe almost all food. In consequence "they lose in weight, simply because they do not get food enough to sustain them. Thus such persons often get into a low hypo- chondriacal condition, and some real, and perhaps serious, illness may come on. Many who suffer from sick headache discover, if they will only try the experiment, that they can eat pretty much as other people do .in the ^intervals between the attacks ; and, if they can manage to eat fairly well, they will find that, instead of suffering from a greater number of attacks, they escape with fewer. Most who suffer from sick headache require, and can take, but very little stimulant. Many are better without any stimulants whatever. Beer will, often precipitate an attack, and wine generally disagrees. A teaspoonful of sherry, taken between meals, is sufficient to bring on an attack in one predisposed to the ailment. There are, however, exceptions to this ; for I know some who find that a little sherry or beer helps them in the intervals between the attacks, and does not seem to bring one on unless it happens to be imminent. All sufferers from sick headache should do all they can to avoid worry. Peace of mind and freedom from anxiety are of course to be desired for every one, but those prone to the malady we are considering should be doubly careful, and should avoid undertaking responsibilities which make them anxious. So also they should exercise as much self-control as possible, and endeavor not to give way to a feeling of restlessness and fussiness, which only increases the severity of the attacks which they have to suffer. Many saline medicines, which increase secretion, seem to be useful to those who suffer from sick headache. Small doses of Nitrate of Potash, Potasses Nitras, Bicarbonate of Potash, Potassce Bicarbonas, the so-called effervescing Citrate of Magnesia, or Liquor Ammonia Acetatis, or Liquor Potassa, may be ordered to be taken in a largely diluted state early in the morning before the breakfast, and the last thing at night. Or you may give half a tumbler of Vichy Water, or Lithia Water, or German Seltzer Wafer at the same time of the day, for a few days at a time, in the intervals between the attacks of sick headache. Some bitter preparations also seem to be of use. You may give Infu- sion of Orange, Infiisum Aurantii, or Infusion of Quassia, Infusinn Quas- sia;, or Quinine ; or, as I have suggested before, you may try the effect of tea or coffee in somewhat larger quantity than they are usually taken. A good deal has been said lately about Guarana. It is prescribed in powder, in doses of from ten to thirty grains twice or three times a day. 16 1 82 EFFECTS OF CALOMEL. Its active principle has also been extracted, and may be prescribed in doses of from one to three or four grains. I am indebted to Messrs. Savory and Moore for a specimen of Guaranine. It looks something like quinine, but is more flocculent. The taste, though bitter, is very unlike the taste of that substance. There is also a Liquid Extract of Guarana, Extractum Guarance liquidum, the dose of which is from twenty to thirty minims. I am sorry to say that, although benefit seems to have been t derived by some, many have tried this remedy without gaining the hoped-for advantage from its use. General treatment in the intervals of comparative good health must not be forgotten. Tonics of various kinds are often useful. You may give Quinine in one- or two-grain doses twice daily, about eleven and four o'clock, or Quinine Wine, or Tincture of Quinine. Various other bitter tonics and the mineral acids maybe prescribed in many cases with advantage. The above remedies must, however, be withheld as soon as the headache begins and while it lasts. If the patient suffers from constipated bowels, you must give mild purgatives. If the various excreting glands do not sufficiently freely perform their work, you must prescribe those remedies which act upon the liver, kidneys, or other organs at fault. Whether Calomel should be given now and then is a point upon which there is much difference of opinion. Some patients undoubtedly derive great benefit from small doses of this drug. From one to two or three grains, taken at intervals of three or four days, is, as I have before remarked, treatment which really deserves in certain cases to be called curative. There are, how- ever, a few persons who cannot take Calomel. If you give even half a grain, the salivary glands- will begin to act within three or four hours, and soon secrete violently. The saliva flows from the mouth, the tongue and cheeks swell, the teeth become loose, and the patient is in too much suffering to talce food, and too ill to digest it properly if he could take it. You must be aware of this extraordinary susceptibility to the action of Mercury, and do not order it if the patient or friends assure you that it has this effect. Sometimes Calomel seems to weaken patients terribly. Small doses purge them too much, and harm, instead of good, results. On the other hand, I can assure you that the confident unqualified con- demnation of mercurials that has lately been so fashionable rests on no foundation of fact. It is one of those fads or fancies which, being acted upon, are very interfering with our usefulness to the sick. It is, of course, easy to bring forward numerous instances where persons have been known t'o take Mercury almost daily for thirty or forty years, not only without suffering, but, from their own account, with great benefit. Indeed, some will tell you that they cannot get on without an occasional small dose. Many Mercury-takers have lived to be very old. I could give examples of life being prolonged beyond eighty-four years, although one or two grains of Blue Pill had been taken every fourth or fifth day for forty MANAGEMENT OF SICK HEADACHE. * years. I have been told by people that they had been distinctly warned by their medical adviser upon no account to take Calomel, on the ground that if they did take the drug, it would almost kill them, or would at least provoke some serious and lasting injury to tissues and organs, and damage the constitution. Such assertions are merely arbitrary utter- ances. It is a fact, as I have told you before, that Calomel enters into the composition of many powders which have a great reputation for ex- erting a soothing effect upon irritable children, and which are given even to young infants for the sake of improving the temper. It is wrong for practitioners to lay down the law against the use of such a remedy as Mercury. The public are sufficiently capricious to make it difficult to advise them for the best, and it is very injudicious on the part of a skilled practitioner to encourage fancies and prejudices. Calomel, by helping the action of the stomach and liver, restores digestion, and even an infant soon regains its good humor. Adults experience a pleas- ant sensation if digestion goes on quietly and effectually; while, on the other hand, if the digestive process is interfered with, the most amiable persons will find it difficult to keep themselves in that desirable state. If they do not feel out of temper, they probably experience despond- ency, and feel melancholy and out of heart. So far, the reputed substitutes for mercurials which I have tried have not succeeded -as I could wish ; but I have not yet had an opportunity of giving in a sufficient number of cases of sick headache and other maladies where the liver is at fault, the new remedies recommended by Professor Rutherford. 3. OF THE MANAGEMENT OF SICK HEADACHE WHEN THE PATIENT CON- TINUES TO WORK. The following plan has been found to answer, in several instances, in mitigating the severity of the attack while the patient continued his usual avocation. The victim may become conscious of the attack as soon as he wakes in the morning, and, instead of attempting to eat any breakfast, he should .take only a cup of rather strong tea. In the commencement there is a feeling of weakness and lassitude, often accompanied by giddi- ness ; but the patient can, nevertheless, walk about, and so far from feeling exhausted, as he certainly would do if, under ordinary circum- stances, he was deprived of the first and, with some, most important, meal in the day, he will, very probably, not feel the slightest demand for food. In an hour or two he may take another cup of tea ; and the dose may be repeated at intervals through the day. A little milk and sugar may be allowed ; but, probably, the simple infusion of a good tea, taken warm, would be best. In this way the patient may get through his work, with difficulty, no doubt, and, perhaps, he may feel somewhat miserable; but the time passes more quickly than if he were lying down and contemplating his 1 84 DR O WSINESS. pain. Towards evening, in many cases, the discomfort becomes less, a sensation of emptiness, not difficult to bear, is experienced, and this is gradually followed by an actual desire for food. But the most striking change which sets in about this time, and which is an invariable indica- tion of a favorable turn in the progress of the malady, is the free secretion of urine, after the action of the kidneys has been nearly suspended for four-and-twenty or forty-eight hours, or more. At first, a small quantity of very acid urine, of high specific gravity, makes its appearance in the' bladder ; but this is soon followed by a very free secretion of pale urine, of low density, and great relief of all the distressing symptoms is at once experienced. The stomach will now bear a little light food. The large bowel begins to resume its function, and next morning the patient will probably wake up feeling nearly well. If, however, the headache still troubles him when he -rises, it usually passes quite away during the day. It is true that in many cases the attack is often more severe, and its duration longer, than I have indicated ; but the general plan of treatment suggested should be the same complete abstinence from solid food, the administration of tea, coffee, or even plain water, at intervals of two or three hours, until the headache nearly ceases and the nausea disappears. Some people like warm water flavored with lemon-juice ; and you may add, with advantage, Supertartrate, or Nitrate, or Citrate of Potash, or some other salt known to act as a diuretic. It would appear that during the attack of headache most organs of the body, and notably the secreting organs, strike work. It is useless to try to violently and immediately excite them to action, for you would do harm by such attempts. You must wait for a few hours ; and as soon as you see the slightest tendency of a return to activity, I believe you may be of use in saving time and hastening the return to convalescence. A free flow of urine, I am sure, is advantageous, and lemon-juice, nitre, with plenty of water, will often effect this object. Purgatives do harm if given too soon; and I have not been satisfied as to the advantage derived from many other remedies that have been warmly recommended during the attack. Neither warm baths nor cold baths seem to be of use ; and with the exception of tea or water flavored with lemon-juice, with, perhaps, some simple saline diuretic, the less introduced into the stomach during the twenty-four or thirty hours of suffering the better. In conclusion, let me impress upon you the inference that sick headache is not an unmixed evil. The condition has its advantageous side, for he who is subject to the malady generally finds no difficulty in keeping temperate, and the delicacies of the table are to him scarcely a temptation. Thus he is less likely to suffer from early failure and degeneration of important organs than many apparently healthy persons who may over- work them and subject them to undue strain. Drowsiness. Patients sometimes come to consult us in consequence bf a persistent sleepy state. They will tell you that they feel as if they RESTLESSNESS. 185 could sleep all day as well as all night. If they sit on a chair for a few minutes, they drop off to sleep ; if they take up a book or a paper, it soon falls from their hands in consequence of an irresistible drowsiness. If they go out for a walk, they soon begin to experience a strong inclination to lie down and yield themselves up to sleep. Patients who suffer in this way sometimes come for help to their medical adviser. They may feel pretty well, and in good health, with the exception of this irrepressible drowsy feeling, and they ask you what they can do to get rid of a ten- dency so very troublesome and inconvenient. In many cases this drowsy state seems to depend upon some imperfect action of the digestive organs. Sometimes it may be traced to over- feeding. Sometimes to taking too large a meal in the middle. of the day. Sometimes beer or a too liberal allowance of wine seems to be the cause of it. If you give mild purgatives and mineral acids before meals, and saline medicines which act upon the intestinal canal, you will often suc- ceed in curing the patient. When the liver is in fault, as is not unfre- quently the case, you will find the advantage of giving a small dose of Calomel, Blue Pill, or Gray Powder (from one to two grains will be suf- ficient) every third .or fourth night for three or four courses. Cold bathing also is often useful. As soon as the patient rises in the morning he may have a cold shower-bath. There is no need of a large quantity of water. A shower-bath of two or three pints will be sufficient. If the drowsiness is very troublesome, two moderate shower-baths a day may be tried one at about eleven, the other at four o'clock cold or tepid, according to the time of year. In some cases, in addition to the cold bathing, a mild purgative every night for a week will be found useful. Wakefulness and Restlessness. The very opposite condition to drow- siness afflicts some patients. They come to you complaining that they cannot sit still or rest quietly for a time. They experience a strong desire to be continually walking about. They cannot stay for long in one place, and do not feel satisfied unless they get constant change of scene. You inquire if there is any cause for this restlessness, and, as a rule, the invalid assures you that, although everything is going on in its usual way, he cannot feel satisfied, quiescent, or composed. Sometimes vague frights harass the patient. When he goes to bed at night, instead of dropping off to sleep in a natural way, he lies tossing about. The pillow seems uncomfortable, and soon gets too warm for the head. A very miserable- night is passed, and the patient only gets a little sleep towards morning, and perhaps wakes up feeling tired, exhausted, and unrefreshed. The mental disturbance in these cases depends upon some temporary derangement which cannot be accurately defined. If upon inquiry you learn that the restless state has existed for a considerable time, you must induce the patient to thoroughly change his mode of life. If he is in business, recommend him to get away and take a holiday for 16* 1 86 TREATMENT OF WAKEFULNESS. a time. Send him to some place where he will get complete change of scene for a month or more. The diet must at the same time be carefully regulated, and in all probability the patient will return home well, and able to go on with his daily round of duty just as steadily as he did before the illness commenced. Persons who suffer from wakefulness are often ordered to take Chloral, and after finding out the efficacy of the remedy, some very imprudently continue its use without consulting their medical adviser. In a short time they discover that they cannot sleep at all without the drug, and at last they become complete slaves to its use. It has happened that from want of due care an overdose has been taken, and death has resulted. It is important to caution all persons for whom you prescribe Chloral, never to take this drug unless it is specially ordered for them. More dangerous even than Chloral-taking is the hypodermic injection of nar- cotics, and it seems to me that this method ought never to be employed in cases of occasional wakefulness, and I think that in all cases the rule should be observed of never leaving the syringe and morphia solution in the patient's custody, nor should any one be allowed to perform the oper- ation for you. In those cases only in which, owing to chronic incurable disease, accompanied by constant severe pain, the unfortunate patient can get no sleep or peace without the aid of morphia, and only very exceptionally, should this rule be relaxed, and non-professional persons permitted to inject the narcotic. , Patients oftentimes complain of feeling tired and exhausted as well as restless, and sometimes they will tell you that they cannot walk half a mile in consequence of being muscularly weak. You must carefully inquire into the state of the various functions of the body, and suggest what you can to rectify the action of any which are improperly dis- charged. (See p. 113.) Generally, you will do well to send such patients for a moderate tour in a pleasant part of the country, where they can see a good deal without walking very far. You must particularly caution them against over-fatigue. Many persons suffering from this or other conditions requiring change, are advised to take a walking tour in Swit- zerland or the Tyrol. So they go with all despatch, and having arrived at their destination, begin their pedestrian cure. Not having been accus- tomed to much exertion for many years, they set to work and, perhaps, walk twenty miles or more a day. Instead of feeling better, and gain- ing strength, they soon feel terribly tired and exhausted, and return home in every respect worse than when they set out. Such an expedition, under the circumstances, is a mistake. You must strongly impress upon such patients that they are not to walk more than a mile at first, and if they are tired, they are to sit down, or, better, lie down on a sofa, and read a novel, or otherwise amuse themselves. They should, as we say, moon about, or potter about in the open air several hours daily, without taking any active exercise. In this way, most sufferers will soon begin to im- NER VO US NESS. 1 8/ prove, and when this is the case, they may by degrees extend their daily walk until they are restored to health. Nervousness. There is another condition, which is usually called "nervousness." In this state there can be no doubt that the mind is, in some degree, temporarily affected. There may be undue emotional excitement. The least thing may arouse fear or dread ; but instead of the nervous, excited state impelling the patient to be more active in his work, he finds it almost impossible for him to discharge his ordinary .duties. A large proportion of the population seems never to have experi- enced anything approaching to nervousness, but some people suffer from it in a terrible degree. I have been told by patients that for some time they had been -conscious of an indescribable anxiety, for which they could not account, and from which, by no reasoning with themselves, could they get relief. They know and acknowledge that there is no reason for anxiety ; but, nevertheless, a sort of ill-defined dread seems to hang over them. They fear that something or other is about to hap- pen ; and this most painful state of mental disturbance sometimes lasts for a considerable time, causing the patient great suffering. With this state is frequently associated considerable depression of spirits. The subject of it feels as if everything was going wrong with him. He may be getting on just as well, and making quite as much, or even more, money than usual, but nevertheless feels discontented and depressed, as if something terrible had happened. People who suffer in this way some- times tell you that they are certainly going to the workhouse, and all this sort of thing, although they know themselves to be prospering. If a patient in this state of health should happen to lose a few shillings, he will feel quite convinced that everything is going to the dogs, and nothing will persuade him to give up the despairing views of life which have somehow arisen in his mind. People w,ho suffer from extreme nervousness, combined with a restless, unsettled state of mind, occasionally do very curious things. A man may wake up suddenly in the middle of the night and with the conviction he smells fire. He gets out of bed, strikes a light, goes over the house, finds nothing the matter, and goes to bed again. In another hour or two, perhaps, he wakes up a second time, and goes through the same proceedings as before. Many people whose nervous system is a little overwrought, wake up at night, and jump out of bed, and, perhaps, light a candle before they are quite aware of what they are doing. A further development of the same tendency may lead to sleep-walking, of which condition again there are many different degrees. Children of highly nervous temperament are likely to suffer from attacks of chorea. These and many more severe disturbances of the nervous system seem to depend upon a highly sensitive or excitable state of certain parts of the central nerve organs, rather than upon any abnormal or morbid change. They are, however, often associated with a special type- of organism; and 1 8 8 NER VO US NESS. frequently it will be found that cardiac disease, affecting either the mitral or aortic orifice, or both, also exists, or is developed before the period of adolescence. But sometimes an unusually restless and excitable state of the nervous system temporarily troubles people, and may come on at almost any period of life. The patient in such a state should be advised to visit friends, or take a holiday abroad. You should urge him to leave for a time his ordinary avocations, and very likely in a few weeks he will recover from his nervousness. Upon careful inquiry, you will find that, many who suffer in this way have been long in the habit of taking too little sleep. There is hardly anything in which individuals more widely differ from one another than in the time required for sleep. Some can do with six or seven hours, but it is quite certain that many require nine hours. Nervous people, as a rule, are benefited by a long night's rest now and then, and require an average of eight or nine hours. Of late years, very much has been written on the subject of nervousness, and attempts have been made to show that we are much more " nervous" than our fathers were. It seems to me that the evidence adduced in favor of the statement is, to say the least, very far-fetched. The so-called brain-workers are supposed to be great sufferers. It is said that people are more sensitive to heat and cold, and require to live in rooms more highly heated than was the case even a few years ago. It must, however, be borne in mind that a far greater number of the existing population are able to have the advantage of warm rooms in cold weather than for- merly, and, in consequence, the majority enjoy better health, and live to be older. That large incomes engender a good deal of fussiness, and little aches and pains which are made too much of, is, I dare say, true ; and if this is "nervousness," an increase no doubt exists, and such "nervousness" will increase as prosperity increases. But I cannot help thinking that if our fathers had been as prosperous as we are. as large a percentage would have suffered from " nervousness." However this may be, it is quite certain that if our modern habits and systems are productive of increased nervousness, they are at the same time conducive to health and longevity. There is no doubt whatever that the general health of the population has improved, and is improving, that the average duration of life is on the increase, and if the sum of human happiness is not much greater every succeeding decade, it ought to be so ; and the fault lies in the circumstances that individual evil inclinations are capable of counter- acting the natural influence of highly advantageous external circumstances. Upon the whole, I doubt very much whether there is anything to justify many of the statements made about the increase of nervous disorders. Whenever money is made rapidly, luxury and folly will increase ; but the silly rich, after all, constitute but a very small part of the popula- tion so small a part that, in the life of a country like England, their existence is hardly noted, except by themselves and the few whose inter- NEURALGIA AND 'ITS TREATMENT. 189 est leads them to minister to their requirements and to pander to their caprices. Dr. G. M. Beard, of New York, has lately called attention to the increase of nervousness in the United States, but I think his remarks can only apply to a very small fraction of the population of some of the large cities. This author seems to think very much of pork as a food, and to have formed a low estimate of those whose stomachs are not strong enough to digest it. The dethronement of pork, says Dr. Beard, is having a disastrous effect upon the American people " Pork, like the Indian, flies before civilization." Really it seems very hard that people who cannot digest pork should be put down as unduly nervous, over- sensitive, and the like, and be accused of undergoing deterioration and decay. I have no doubt that the American nation will survive and increase in numbers and in vigor, "the dethronement of pork" not- withstanding. As regards the effects of overworking the brain in the case of the young, while it may be admitted that, now and then, instances of men- tal strain are met with, such cases are exceedingly rare, even in these days, as compared with the number of persons, young and old, who are suffering from the very opposite condition from too little mental exer- tion. I should say that, as a fact, far more disease is caused by too little brain work than too much. Neuralgia. I will now offer a few remarks concerning a very impor- tant condition which is well worthy of attentive study, but of which I can now treat only very briefly and imperfectly. Every one of you must have heard something about Neuralgia and Neuralgic pains-, though no one has yet been able to give an adequate explanation of their causa- tion in many cases. Sometimes these pains are no doubt due to a tem- porary change induced in the nerve itself, which may possibly be beyond the means of investigation. Perhaps the capillaries distributed to the nerve-fibres constituting the trunk of a large nerve may be unusually distended with blood. Possibly the circular muscular fibres of the little arteries ramifying amongst the bundles of nerve-fibres may be tempo- rarily relaxed through nerve influence; and thus the capillaries distrib- uted to the particular nerve or particular part of the nerve may become much dilated, and thus pressing upon the adjacent nerve-tubules, very severe pain may be occasioned. That the trunk of the nerve is the seat of attack in certain ordinary forms of neuralgia is certain, and pain like that of neuralgia may often be produced by pressing or stretching or squeezing a nerve-fibre. If a sensitive nerve-fibre be pressed upon by a tumor or growth of any kind, or be stretched over a tumor, great pain generally results, and it may continue perhaps for months if the circumstances causing the alteration in the nerve persist. In certain cases, on the other hand, the precise seat of the affection is undoubtedly in the peripheral distribution of the TREATMENT OF NEURALGIA. nerve where it breaks up into expansions, plexuses, or networks of ex- tremely delicate fibres. Neuralgic pains, then, are generally associated with branches known to consist principally of sensitive nerve-fibres. Perhaps the fifth nerve is the greatest offender in these cases. You may have neuralgic pain closely resembling that of toothache, and affecting the very same nerve- fibres, the tooth itself being free from disease. The pain may be so acute as to lead both the patient and his adviser to conclude that some morbid change is going on in the pulp of the tooth. The dentist is consulted, and, unless he is thoroughly up to his work, the tooth may be injudiciously extracted, and upon examination found to be in perfect health. The patient, however, goes away with the conviction that, al- though he is minus a sound tooth, he has at any rate experienced the last twinge of pain. But, alas ! before many hours have passed the suf- fering returns as bad as ever. Torture as severe in all respects as that from which he had previously suffered is again experienced, though per- haps to the sufferer the pain may seem to be situated in an adjacent tooth. The patient might have one tooth extracted after another with- out the neuralgic pain being cured. Extraction is not the proper expe- dient in these cases. In some instances it is probable that the attack depends upon some change taking place in the circulation, and that in consequence partly of the pressure exerted by the distended capillary vessels, and partly in consequence of changes produced in consequence of exudation amongst the ultimate ramifications of the nerve-fibres, or around their bioplasm, pain results, and may persist for some time until the conditions become slowly altered. In a few very intractable forms of toothache, or rather of neuralgic pain apparently originating in the tooth-pulp, it is probable that the nerve-centre is the seat of disturbance due to vascular conges- tion, brought about by reflex action. In cases in which the pain depends merely upon some temporary dis- turbance in the branch of the fifth nerve which supplies the tooth, or in the tooth papilla itself, the probability is that it will yield to very simple treatment. Treatment of Neuralgia. Sometimes a good sharp purgative will cure the patient at once, but more frequently it is necessary to follow up the purgative with tonics, and especially preparations of bark, or Quinine itself, a mild purgative being also given every few days. In this way you very often cure obstinate neuralgic pains. You must, however, bear in mind that it sometimes happens that if Quinine is given by itself it may under some conditions of the system increase the pain, even for some time; while if you give a purgative in the. first instance, or combine purgative medicine, such as Sulphate of Soda or Sulphate of Magnesia, with it, the Quinine will often act perfectly well and cure the patient. When the pain is intense, and is decidedly a neuralgic pain, coming on HYPODERMIC INJECTION. 1 9! at about the same time of the day, and lasting about the same length of time, you must order a considerable dose of Quinine at once five or ten grains, and then from three to five grains twice or three times a day. Some people can take as much as ten grains of Quinine twice or three times a day for several days with great relief to various nerve ail- ments. Quinine may be given in the form of pills, or you may place the bitter powder on the tongue, or it may be diffused through water, or dissolved in water containing a few drops of free Hydrochloric, Sulphuric, Nitric, or Phosphoric Acid. The usual way of giving Quinine is the last. We order a six-ounce mixture as follows : Aromatic Sulphuric Acid, three drachms; Quinine, thirty-six grains; Syrup of Lemon, half an ounce or more, and water to six ounces. The dose will be half an ounce, cr one tablespoonful, with an equal quantity of water, three times a day, between meals, for a fortnight. The old Muriate of Ammonia, Chloride of Ammonium, Ammonii Chlo- ridum, is a very valuable remedy in certain cases of neuralgia which are not relieved by Quinine. Some consider it as a specific, and say that it seldom fails. The remedy should be given in good doses, and it is often useless to order less than twenty grains or half a drachm. It is not pleasant to take, as it has a peculiar salt taste which is di-sagreeable to most palates. However, those who have suffered much from neuralgia are usually ready to try anything that affords them prospect of relief. Salicine is sometimes of use, and may be given in doses of from five to eight grains every three or four hours for one or two days. Salicylale of Soda has been largely prescribed in the treatment of severe forms of rheumatism, and has been given for neuralgia. It is not much used in slight forms of either disease, but occasionally it does good. In many cases of acute rheumatism it acts admirably in lowering the quick pulse and high temperature. It must be given with care, and the patient taking it must be well looked after, as sometimes it lowers the pulse and de- presses the heart's action to a greater degree than is desirable. Iron. Arsenic. Many preparations of iron may be ordered in cases of neuralgia, particularly if there is reason to think that the state of the blood is at fault. Arsenic in small doses, and given with due care, may be prescribed if the pain is very severe. It is well not to continue arsenic for more than a month at a time. You may order from three to five minims of Fowler's solution of arsenic, Liquor Arsenicalis, with a little syrup of ginger and an ounce of water, three times daily, soon after food has been taken. Opium. There are several forms in which opium may be given. A small dose of Dover's powder, Pulvis Ipecacuanha Compositus (from two to five grains), at bedtime, followed in the morning by a mild saline purgative, if persisted in for a few days or a week, will relieve and sometimes cure certain forms of neuralgic pain. Hypodermic Injection. You may, too, inject a solution of Morphia 192 CHL ORAL-HYDRA TE. under the skin if the pains are very severe. The sixth of a grain, or less, of this drug is sufficient for subcutaneous injection. The operation is performed with the aid of a little injecting syringe made for the purpose, one of many forms of which I show you. In this way, for the time being, you may relieve the most exquisite nerve pain ; but too often it happens that, as soon as the effects of the Morphia have worn off, the pain returns. You must know that people are nowadays too apt to get into the way of prescribing sedatives for themselves after they have found relief, and thus they may do themselves great harm. You must, therefore, always exer- cise caution in prescribing and recommending this class of remedies, and be careful to tell patients they ought never to prescribe them for themselves. More particularly as regards hypodermic injection it is my duty to impress upon you the importance of not allowing the patient, under any circumstances, to get into the way of operating upon himself. There is really great danger in this, for the process is very simple and easily performed ; and as the relief is great, patients are very apt to assist themselves without waiting for the doctor. Of those who take this injudicious course, not a few get into the habit of narcotizing them- selves on the slightest excuse. Whenever they suffer slight pain they at once resort to hypodermic injection. As soon as the effects begin to- wear off, the pain recurs, and the dose is repeated. A vicious habit is soon acquired, and it is difficult indeed to prevent many of those foolish persons from going to extremes and making themselves slaves of the rem- edy. Very painful cases of the kind come under our notice from time to time, and every now and then death results from an overdose. Pa- tients who have contracted this habit of self-injection not uncommonly lose all control over themselves, and introduce narcotics hypodermically, just as other weak-minded individuals become a prey to drink or indulge in other vices. We shall before long have societies for the entire sup- pression of hypodermic injection, if this treatment becomes much more fashionable than it is. Dr. Sansoni 1 s Disks. Of late years. some excellent little disks of gel- atine have been prepared, each of which contains a given quantity of the drug we may desire to inject. All that is necessary is to dissolve the gelatine disk in a few drops of warm water at the time when it is required. The solution may then be taken up by the syringe and injected into the subcutaneous areolar tissue of the patient. I believe my friend, Dr. San- som, was the first to suggest the employment of these disks, which are also used when it is required to apply atropine and other remedies to the conjunctiva. Chloral-Hydrate and Croton Chloral-Hydrate. Chloral is of great use in procuring sleep in many cases of severe neuralgia, especially when the patient has been kept awake night after night ; but you must give it with the greatest caution, and only order one, or at most two, doses on the prescription. Take care also to write full directions how and when the RHEUMATIC PAINS. 193 draught is to be taken. The dose of Chloral is from ten to twenty grains, with a little syrup, and Peppermint or other water. The most convenient form is the syrup of Chloral-Hydrate, one drachm of which contains ten grains of the drug. Peppermint or Ginger covers the taste of the Chloral better than anything else. In cases of old catarrh and emphysema it should not be given. I have seen it do harm in several instances in which the heart was weak and the right ventricle dilated. Croton- Chloral or Butyl Chloral-Hydrate, which was much used a few years ago, when it was first discovered, has not been heard of so much lately. It is prescribed in doses of one or two grains, to be taken every two or three hours. In the " Lancet," for January 31, 1874, Dr. Burney Yeo reported some cases in which the remedy rjad been of great service in relieving very severe neuralgic pain ; and in the same journal, for December 2, 1876, you will find some cases recorded by Dr. Skerritt, of Bristol, in which the remedy relieved bilious headache, facial neuralgia, and giddi ness. Five grains were given twice a day. Rheumatic Pains. I must now say a few words about another kind of pain which is very common. It is, perhaps, not so severe as bad forms of neuralgic pain, but it nevertheless occasions much suffering, and in some cases is so severe and so constant as to prevent the patient from following his avocations. I allude to the so-called Rheumatic Pains, which affect various tissues and occur in many different parts of the body. The character of the pain differs somewhat in different cases, sometimes occurring as sharp, evanescent twinges, which either flit about, as it were, from place to place, or seem to be obstinately fixed in certain joints, the severity of. the suffering altering only in degree. A good many old men and old women, living in damp, cold, country places, will . tell you they have been martyrs to rheumatism for more than half their lives. When the blood is in a state favorable to the development of those changes which result in rheumatic pains, you may be exposed to cold, damp air for a short time, towards sundown, conscious of a slight chilly feeling, and in two or three hours you feel very decided aching of the muscles of the forearm, or upper arm, or of the leg, back, or other part of the body. Perhaps some of the tendinous structures about the wrist or ankles are the seat of fixed, continuous pain, which becomes worse on exertion, and makes it a matter of great difficulty to lift anything, or to perform the ordinary movements. Very commonly the muscles at the back of the neck, from their insertion in the occipital bone downwards, are so painful that you cannot turn or bend the head. Partly from the pain and discomfort experienced, partly from the effect of the altered blood on sensitive nerves of the body generally, you feel quite ill and must lie down. Now you soon find out that external warmth gives great relief. Sit before a good fire, wrap yourself up in a railway rug, take a warm bath, or hot-air bath, or a Turkish bath, and the pains will soon 17 N 194 MUSCULAR RHEUMATISM. disappear. If you go to bed and freely perspire, you will feel better within an hour. But, perhaps, after a few hours more you have evidence that the pain has not gone, showing that the changes which caused the pain in the first instance have been followed by phenomena which deter- mine a more lasting departure from the normal state. Rheumatic pains are often preceded by, or are associated with, flatu- lence, heart-burn, and other symptoms, indicative of deranged digestion. Some suppose that the peccant matter, which causes the pain, is actually secreted by the stomach, while. others consider that it results from the occurrence of unusual chemical changes occurring in the recently absorbed constituents of the food. In favor of this latter view may be adduced the fact that the subjects of rheumatisrn are almost invariably made worse by beer, while rheumatics who can be persuaded to give up this popular beverage, almost invariably improve. The rheumatism, however, returns whenever the beer is resumed. Rheumatic pains differ from neuralgic pains, inasmuch as they com- monly arise in muscles and fibrous tissues, while neuralgic pain is generally seated in a nerve-trunk or its ramifications. The dental nerve and its branches, or the superior maxillary, or frontal, or certain cutaneous branches in various parts of the body, are more frequently affected than other nerves. Rheumatic pains, on the other hand, seem to be situated deeper, more in the substance of tissues, and to emanate from the ultimate ramifications of the nerves, distributed to tendons or fasciae, or to the muscles themselves. Lumbago is a form, and a very unpleasant one, of muscular or fibro- muscular rheumatism. Sometimes it is very obstinate and very difficult to cure. The patient is obliged to rest in bed ; and it may be a fortnight or more before he is able to bend his back without great suffering. Rheumatic pain seems in many cases to arise near the insertion of a muscle. The .point of attachment of the deltoid to the humerus is a frequent spot for the development of rheumatic pain, which may be so severe as to interfere with the raising of the arm, and to render the put- ting on of a coat without assistance a most difficult proceeding. Some- times the pain persists in this situation for several weeks. The intercostal muscles are not unfrequently the seat of very severe rheumatic pain which is sometimes mistaken for pleurisy. The muscles of the side and of the hip are also frequently affected. Rheumatic pain' in some of the fibres of the diaphragm and of the abdominal muscles lias unfortunately led the practitioner to express the opinion that a patient was suffering, from peritonitis, and some days perhaps will have elapsed before this terrible and erroneous diagnosis has been controverted. The nerve-fibres distributed to the muscular fibre cells (organic mus- cle) may be the seat of organic pain as well as those distributed to vol- untary muscle. It is to be remarked with reference to the latter, that those parts of the muscle situated nearest to the tendon are most fre- NATURE OF RHEUMATIC PAIN. 195 quently the seat of the pain. Here, of course, the circulation through the vessel is slowest, and there would be the greater chance of any exu- dation poured out from the blt>od producing a deleterious influence upon the finer branches of any nerve-fibres with which they may come into contact. In various forms of rheumatism, then, we infer that certain of the fibrous tissues are the seat of pathological change. Exudation is proba- bly poured out from the blood as the circulating fluid slowly traverses the sparsely scattered capillaries of the tissues; The nerve-fibres close to the capillaries (see p. 230) suffer. The exudation coagulates, and part of it is at length converted into fibrous tissue, so that the affected textures become thickened, and the movements of the joints and of the tendons and muscles in their neighborhood seriously impaired. In many old cases of chronic rheumatism the patient becomes seriously crippled, and the movements of some joints are greatly impeded if not altogether stopped. It would almost seem as if in bad cases of rheumatism the fibrous tissues were the seat of a sort of slow inflammation ; and that the exudation poured out in the interstices of the bundles of the fibrous tis- sue gradually increased in amount as the disease advanced, and that the resulting fibrous tissue underwent condensation and contraction, greatly interfering with the action of the tissues in question. The movements of the large joints at last cease altogether; this change being partly due to the pathological phenomena I have described, and in part to the cir- cumstance that the pain accompanying every effort to move has gradu- ally discouraged the patient from making any attempts. The limbs become quite stiff, and the patient is dependent upon others, even for every mouthful of food he swallows. We often see extreme cases of the kind in work-houses in the country. If you visit some of these institu- tions, you will almost certainly discover several persons who, for many years, have been complete cripples from rheumatism, and are bedridden and incapable of moving any one joint in the body. The inquiry as to the actual state of things at the seat of pain during the early stages of the disease in ordinary rheumatic affection, is an inter- esting one, but I am sorry to say I cannot tell you what are the essential differences between a slightly rheumatic and a perfectly healthy tissue. The facts of the case justify the conclusion that certain materials, proba- bly soluble, are formed in undue quantity in the blood that the solu- tion transudes through the walls of the capillaries in situations where the vessels are few and the circulation is slow, that the contact of the fluid with the fine ramifications of the nerves close to the capillaries causes pain, that in consequence of the formation of more fluid of the same character in the blood, that which has been already poured out cannot be absorbed. The accumulation thus brought about accounts for the persistent character of the pain. Whether the pain is caused by the direct influence of the effused fluid on the fine nerve-fibres, or upon the 196 TREATMENT OF RHEUMATISM. bioplasm or living matter connected with them, is a question which is open to discussion. There can be no doubt that stretching of the ter- minal ramifications of nerve-fibres or pressOre upon them will 'give rise to pain, and it is not unreasonable to infer that fluid differing in its composition from that which bathes them in healiji would also cause pain and disturbance of nerve action. The mere stretching and press- ure to which the nerves are subjected are not, it may be fairly objected, an adequate explanation in many cases, as for instance, in those where there is persistent rheumatic pain not associated with any tension or swelling of the tissues. The views above suggested, however, receive support from the fact that in many cases after very free secretion has gone on for some time from skin, kidneys, and bowels, the reabsorption of any exuded fluid does take place and the rheumatic pain ceases. With regard to the muscles there is almost invariably imperfect action, and some muscles during an attack pass into a state of complete inac- tion. The muscular tissue which has been many times affected by the rheumatic state, gradually wastes, and the muscle itself after becoming very weak soon exhibits structural degeneration. Near the tendon the contractile tissue undergoes condensation, and slowly degenerates into fibrous tissue, while in the fleshy parts adjacent, fatty degeneration often occurs. Shrinking, wasting, thickening, and contraction proceed until muscle after muscle deteriorates, when the limbs fail to execute their ordinary movements. I need hardly say more concerning the very seri- ous results consequent upon the long continuance or frequent recurrence of the rheumatic state. Every one must see the importance of doing aH he can to check the pathological changes, or failing this, to cause them to take place as slowly as possible, and to retard the development of that dreadful state of helplessness and incapacity which are too often the consequence of rheumatism. MEASURES TO BE ADOPTED FOR THE TREATMENT OF RHEUMATISM. General Hints concerning the Prevention and Relief of Chronic Rheu- matic Affections. All who suffer from rheumatic pains should be made to understand that by acting in a certain way they may greatly diminish the tendency to rheumatism if they cannot completely check it, while by acting in a different manner they may greatly encourage the progress of the morbid change. All rheumatics should be instructed concerning the great importance of promoting the free action of the secreting organs generally. Their medical adviser should particularly direct their attention to the great importance of frequent and free action of the skin, kidneys, and bowels, in order that the materials which tend to accumulate in the blood, and which are concerned in the causation of the rheumatic state, may be removed as fast as they are formed, and expelled from the system. In our climate a tendency to slight rheumatism is so common that I should say at least half the population suffered more or less. It is noticed, TURKISH BATHS. 197 too, at every period of life. The so-called nervous, neuralgic, and mus- cular pains are very often of a rheumatic nature. These may get well of themselves, or be relieved or removed by a purgative, by a few doses of Bicarbonate of Soda or Potash, or by one of those effervescing salines now so commonly sold, or by a few ordinary warm baths, or, in the case of the young, by active exercise followed by free perspiration. A some- what more decidedly developed rheumatic condition often brings patients to us for advice ; and here and there, I am sorry to say, we find this to be but the state precursory to a severe attack. In the great majority of cases, however, the morbid condition yields, in a few days or a week or two, to remedial measures based on the principles already brought under your notice. The first thing to bear in mind in the treatment, I might say of every form of rheumatism, is that free action of the skin should be encouraged. Warm baths of various kinds, and in- many parts of the world, have been held in great repute for their curative properties. The Turkish bath is often of great use to those who are troubled with rheumatic pains. It is, however, a rather long business, and the' patient who adopts it must have two hours or more at his disposal. I know people who take a Turkish bath twice every week with advantage, and consider that they could not get on without it. Those who cannot, or will not, adopt the advice given them to take Turkish baths may, perhaps, not object to an ordinary warm bath, twice or three 'times a week, staying in the water from twenty minutes to half an hour, or until they perspire freely. I think the action of the ordinary warm bath in rheumatism is improved if the water be made alkaline. This may be done by dissolving in it a quarter of a pound of washing- soda. The vapor bath is also of great use, and so is the hot-air bath. Very simple arrangements for vapor or hot air may now be obtained. By free perspiration, the removal from the blood of a large quantity of water holding various substances in solution is effected. Thus thirst is excited. The patient drinks freely of aerated or other water. In this way those noxious materials which would otherwise accumulate in the tissues are gradually removed, and the patients, perhaps, escape much suffering. Shampooing is also of great use in slight cases of muscular and fibrous rheumatism. By judiciously pressing and squeezing the muscles, and by rubbing the skin, the removal of fluids from the interstices of many tissues is promoted. You know it is very important for the free action of the muscles that the fluid which bathes the contractile tissue, and which undergoes alter- ation during the action of the muscl-e, should be frequently changed. If some portions of the fluid remain in contact with individual fibres, the materials resulting from the decomposition taking place during the action of those fibres will accumulate and, necessarily, interfere with their free 17* 198 REMEDIES FOR RHEUMATISM. action, probably also affecting the action of the nerves, and thus occasion- ing rheumatic pains. You will find that, generally, muscular pains may be relieved by exciting the action of the skin, the bowels, and the kid- neys. Alkaline remedies have this effect, and are invariably useful to those who suffer, perhaps because in this condition there is an invariable tendency to the development in the system of organic acids, particularly lactic. Alkalies maybe given in all forms of rheumatism. You may order Bicarbonate of Potash, or Liquor Potasses, or Bicarbonate of Soda. These are very old remedies, and concerning their influence in relieving rheumatic pains there cannot be the slightest doubt. In many slight cases of pain, twenty or thirty grains of Bicarbonate of Potash, dissolved in two ounces of water, will be found to relieve in three or four hours. Sal Volatile helps its action, and also stimulates the heart a little, and thus the blood is driven more quickly through the capillary vessels, and absorption promoted. You may order the alkali to be taken about half an hour after meals, for a week or a fortnight at a time. But you must take care not to let a patient go on taking Liquor Potasses or Bicarbonate of Potash from one year's end to another, or you will probably be con- sulted on account of the appearance of phosphates in the urine, with, perhaps, irritable bladder. Retention of urine may follow, and con- siderable quantities of pus may be formed. Sometimes the patient becomes very low and weak; and I am not sure that serious changes in the blood, and even purulent inflammation of joints, have not resulted from the too long continued use of alkalies. Potash and Soda are very valuable remedies, if given with judgment, and if people are not allowed to go on taking them as long as they like. You must not forget to ex- plain to patients how long you wish them to continue taking any medicine you prescribe, or you will sometimes be astonished, if not alarmed, to find that a somewhat obedient patient, for whom you have prescribed a pill, has been daily taking it for years. If a patient suffering from rheumatism finds that alkalies disagree with him and disturb his digestion, you may try salts of vegetable acids, particularly the Citrates and Tartrates, for these become converted into alkalies in the system, and the urine may even be rendered alkaline by them as well as by the ordinary alkalies. Lemon and orange juice, and many fruits, also act beneficially in some cases. Among diuretics, the ordinary Nitrate of Potash or Common Nitre, dose from five to ten grains, in water, three or four times a day; the Acetate of Potash, in doses of from ten to fifty grains, in two ounces of water, three or four times daily; the Bitartrate of Potash (Potasscz Tartras Adda], in doses of twenty to sixty grains or more, in two or three ounces of water, three or four times in the twenty-four hours (sometimes also acts as a purgative), and the Citrate of Potash, in the same doses as the Acetate, are the most generally useful. BROMIDE OF POTASSIUM. 199 Guiacum. In former days, Guiacum was much in favor in the treat- ment of chronic rheumatism, and I have found benefit result from its use. You may prescribe the resin, Guiaci Resina, in doses of ten grains made into pills, or finely powdered and mixed with milk, three or four times a day, or the Mistura Guiaci, an ounce of which may be ordered twice or three times daily. Perhaps the least unpleasant form in which to take Guiacum is as the Ammoniated Tincture, Tinctura Guiaci Ammoniata, in a mixture with some bitter tincture or infusion. Mucilage and a few drops of Spiritus Chloroformi, with water ; or peppermint, mint, or other water, may be used to cover the taste. Iodide of Potassium. You will often find that severe lumbago pain, fixed pains in the muscles and fibrous tissues in many parts of the body, and severe chronic aching about various joints, which have troubled people for months, will be relieved by a few doses of Iodide of Potassium (Potassii lodiduni). You may begin with three grains, three or four times a day, and gradually increase the dose to five, six, eight or ten grains. The Iodide should be dissolved, in a considerable quantity of water, and should be taken about an hour or more after meals. You may also give with it half a drachm of Liquor Cinchonce (Battley's), and a few drops of Tincture of Ginger. Although I cannot justify the practice, on scien- tific grounds, I often give with the Iodide, Nitrate of Potash (five grains). The Iodide probably acts upon the painful textures, partly by promoting the absorption of exudation, but I think chiefly by taking the place of Chloride of Sodium, driving this out, and thus promoting free circulation of fluids and saline matters through the interstices of the textures. Don't accept the conclusion, implicitly received by many, that the beneficial action of Iodide of Potassium is evidence of the syphilitic origin of the malady. This is one of the new delusions. Some authorities attribute half the ills we suffer from to syphilis, and even think that a syphilitic taint accounts for the majority of ailments they cannot otherwise explain or account for. If neither you nor your father nor your grandfather had syphilis, the origin of disease is to be discovered further back in your ancestral line, if, indeed, it is admitted possible by syphilitic authorities that three' generations can exist without having acquired the disease. Some authorities seem to think that no one exists who is entirely free from syphilitic taint. Both Iodide of Potassium and Bichloride of Mer- cury (from the ^ to the j g of a grain for a dose) are extremely valuable remedies in very many affections which are not in any way due to syphilis. Bromide of Potassium, Potassii Bromidum, is useful in cases in which the rheumatic pain is, in part, neuralgic in character. It may be given alone, or with the Iodide, in doses of from ten to thirty grains. Salicine and Salicylic Acid and Salicylate of Soda (see p. 191) are useful in some cases cf chronic rheumatism, and quinine is frequently of advantage. I have observed, and in many instances, that after the persistence of slight but evidently rheumatic pains for many days, perhaps for two 200 ACTION OF THE SKIN. or three weeks, the patient, without resorting to any special treatment whatever, experiences unusually free action of the skin at night. Even in midwinter, as soon as he gets warm in bed, he sweats profusely, and for the whole night, finding his nightshirt quite moist and his skin thoroughly soft and soddened in the morning,' although no change had been made in his bedclothes nor in his diet, and he had not taken any medicine whatever. The free sweating had not only come on of itself, but, perhaps, persisted night after night for some time. So remarkable and unusual is the free action of the skin that oftentimes a patient is alarmed, and seeks advice with 'the object of stopping the cure. On inquiry, it is found not only that the rheumatic pains have been much less severe since the free sweating at night came on, but that the patient feels in much better health. He is in better spirits lighter, as he says and stronger and more active. His mind clearer. His bowels act un- usually well, and his water is excreted freely, and is perfectly clear and destitute of the accustomed sediment. The tongue is clean and the appetite is good. But notwithstanding his conviction that he is in better health than usual, he fears the very free sweating may weaken him, or in some way do harm, and therefore seeks advice. Now, so far from inter- fering with the free perspiration, you may assure your patient that a natural cure is being effected, and that it is desirable not to stop it. After a week or two the perspiration will diminish, and the patient will feel well, and will not be troubled with rheumatic pains for some time to come. Such facts are of the greatest interest, and are well deserving of your careful contemplation. We may learn from them even more than we can learn from many serious cases of disease. And though, if we act rightly, we may object to interfere, our attention is forcibly directed to certain phenomena, from the consideration of which the principle of treatment to be pursued, in the case of those who are not so fortunate as to suffer a spontaneous cure, may be deduced. Moderate, but habitual, natural action of the skin, liver, and other emunctories, probably prevents altogether the development of the rheu- matic state. Free action for a time cures the rheumatic condition, if present, and this free action may be brought about by changes within the body. In the absence of this action, however, we endeavor by arti- ficial means to excite it. And if the rheumatism is really severe, we should resort to the best means we possess to bring about these curative influences as soon as possible. Questions like the following will doubtless occur to some, but I regret to say that I cannot adequately answer them : " Why in some orgamsms only this spontaneous cure is observed? Why some never suffer from rheumatism, and so need no cure? Why some suffer terribly in spite of all measures adopted for their relief, and why some die in consequence of the extreme degree and inveterate character of the rheumatic phe- nomen.4? " Some would refer the difference to nerve action only, and DIET IN RHEUMATISM. 2OI there can be no doubt concerning the amazing variation in rapidity and intensity of nerve action in different individuals. Some people seem to be "all nerve." Others appear to get on, and very well, with extremely slow and apparently blunted nerve action. Between these two extremes many degrees of difference are to be noticed. If the nerve mechanism presiding over the physiological changes in the system is well developed and highly active, derangement will be corrected ere there has been time for its existence to have been made evident to the consciousness of the individual ; but when nerves and centres are dull, and small and sparse in proportion to the extent of area they have to govern, response is slow, and physiological derangement may even pass into pathological change, and result in structural alteration of a most serious and irreparable char- acter without the patient being aware that he is even out of health. Nay, we see the most grave morbid changes running a long course, damaging in the most decided manner, it may be, many important tissues and more than one organ, and at a comparatively early period of life, al- though the patient has not experienced even discomfort. On the other hand, sensitive, constantly ailing people often lead long, complaining lives, and die in old age, without a single organ having passed into a state of actual disease. In such instances as the last, the patient is en- dowed with highly active nerve organs. In the first, very decided patho- logical change fails to exert any influence upon slowly acting and blunted nerve organs. In the one, broad and obvious lesions progress until action is greatly deranged or death results ; in the other, illness is prevented or is self-cured before it progresses to any extent. Very decided and well-timed interference at an early period, and the utmost care all through, would alone save patients of the first class from serious disease, and perhaps death ; while no treatment, or only treatment of the sim- plest character, would be needed by the more sensitive nervous person. Slight ailments in some organisms cause much ado, while in others grave pathological actions of great intensity may occur, and serious structural morbid changes run their course for a considerable time without being discovered, and without giving rise to any symptoms sufficiently distinct to attract the attention of the patient. The Diet in Rheumatism must be nutritious, but care should be taken that the patient does not exceed. All rheumatics should be careful not to partake too freely of meat and allied substances. Farinaceous substances and fatty matters do no harm, but while many ripe fruits agree well, and some oranges, lemons, cooked apples, prunes, and some others are useful, sugar in large quantity is certainly not desira- ble. Milk is excellent, and rheumacics may take it in quantity. Vari- ous puddings, such as batter, sago, tapioca, etc., made with milk and an egg, may be recommended. Acid wines, like the commoner forms of claret, often do harm, and indeed may occasion rheumatic pains. Beer is especially hurtful, and should invariably be withheld. In treating 202 OF CATCHING COLD. cases of rheumatism you must impress upon patients very strongly that beer, as well as claret and some acid wines, seriously interferes with the improvement which otherwise would probably result from the remedies you prescribe. If stimulants are required at all, you may allow in the twenty-four hours two or three tablespoonfuls of brandy with seltzer or other mineral water, or the same quantity of whiskey with lemon juice and water. Importance of Warmth and Warm Clothing. Cold, damp, ill-venti- lated rooms are especially hurtful, and exposure to sudden changes of temperature often gives rise to very severe and acute attacks of rheuma- tism. Those who are prone to 'rheumatism may feel annoyed if they perspire much, and are too often unwise enough to try to check the ten- dency to perspiration by wearing very light clothing, and thus not uncom- monly they precipitate an attack. Not only should all persons who have even a slight tendency to rheumatism wear woollen next the skin during the day, but at night they should either have a flannel night-dress or a flannel jacket over their cotton garment. If the shoulders and arms be exposed at night with insufficient covering, very obstinate rheumatic pain, which may last a considerable time, is sometimes the consequence. A departure from the healthy state of the blood may originate either in the circulating fluid itself, or may be determined by changes in the tissues and organs which it nourishes. The change in the blood may, in its turn, react upon and influence the action of some, and, indeed, almost all the tissues and organs in the body. When this is the case, the phe- nomena are said to be "general," to distinguish them from phenomena of the same general nature which are restricted in area, and are spoken of as " local." We may speak of general tissue changes, general fever, general inflammation, as contrasted with changes of phenomena similar in their nature, but which are local, and affect only a very small portion of the body. Among the most important and most common general changes are those departures from healthy action known as fevers and general inflammations. So common is febrile and inflammatory disturb- ance that it is doubtful whether a single example could be adduced of a mammalian organism which had reached maturity without having suf- fered more or less from some such pathological changes. Few of us pass a month without experiencing, in our own bodies, some degree of febrile or inflammatory disturbance, and many are seldom entirely free for many weeks at a time from phenomena of the kind. Of Catching Cold. Before bringing under your notice the actual phe- nomena which characterize all fevers and inflammations, I propose to direct attention to the consideration of that most common of all febrile disorders, and the best known of all slight ailments an ordinary cold in the course of which a certain degree of febrile and inflammatory action invariably occurs. Most people have ''caught cold " probably many times in the course ACTUAL CHANGES IN CATCHING COLD. 203 of their lives, and though they may have suffered on some occasions severely, there is no reason to suppose that any tissue in the body has been damaged in the slightest degree, or that any Structural disease has resulted in consequence. Whenever you are unfortunate enough to take cold, you should make the most of the opportunity, and carefully study the changes as they go on in your own organism. When the cold is coming on, you may perhaps shiver a little, or you may experience a creeping sensation, apparently in the skin of different parts of the body. Although you may feel quite chilly, if you place a clinical thermometer in your arm-pit, you will be surprised to discover that it indicates a rise of three or four degrees above the normal in the temperature of your body, and the very striking and important fact will be impressed upon you that, although you feel extremely chilly and in- clined to shiver, and desire warm clothing, or to sit by the fire, with a good blanket over you, the temperature of the body is decidedly higher than it ought to be, and in fact may have risen from a little under 98 Fahrenheit, the point at which it stands in health, to 100, 101, or 102. You need not be very much disturbed or frightened if you should find that it marks 103. You will also notice that, as soon as you get into a free perspiration, all the uncomfortable sensations which you have expe- rienced during perhaps several hours, will disappear. If, as soon as you feel warm, and especially if you have perspired a little, you again use the thermometer, you will find that the temperature has fallen a degree or two. After you have perspired very freely, it will fall lower still, and probably stand at the normal. I shall endeavor to show not only that a cold is a form of fever, but that in many colds there is evidence of a certain, and in some a consid- erable, degree of inflammatory action. The mucous membrane of the nasal passages, of the larynx, trachea, and bronchial tubes, of the pharynx, and many of the small glands connected with these surfaces, are red and "inflamed." The capillary circulation in them is impeded, and if a minute examination be made we shall find evidence of undue growth of the bioplasm of the epithelium and adjacent structures. Many of the symptoms which usher in an ordinary cold precisely resemble those which occur when some special form of fever or, it may be, severe inflammation is about to attack the patient. In the last case the shivering and other phenomena may be more severe, but the differ- ence is one of degree; in fact, a cold must be included among the Fe- brile Diseases. But let us for a moment go further back in our inquiry as to the nature of the malady, and try to discover the change which, so to say, consti- tutes the first departure from the normal state in the case of a common cold or other simple form of febrile attack. The event in question usu- ally precedes by hours, and it may be days, the manifestation of any symptoms. The actual process of taking cold is never immediately fol- IMPORTANCE OF EXCRETION. lowed by any phenomena which disturb the health or which indicate to the patient himself that he has passed, or is about to pass, from the healthy into an abrformal state. This fact alone the existence of an interval between the commencement of the operation of the disturbing cause and the development of distinct derangement in the physiological actions of the body L seems sufficient to show that the symptoms are not due to nervous disturbance alone, and conclusively points to the conclu- sion that the change excited is of such a nature that it does not result in immediate consequences. The condition of the organism which favors " taking cold " is not one of perfect health. The circulation at the time is feeble, and the blood itself not in a perfectly healthy state. Instead of passing quickly through the cutaneous capillaries, the circulation is retarded in the surface-vessels, partly on account, as above suggested, of feeble heart's action, but mainly, I think, owing to the muscular fibres of the smallest arteries being re- laxed, and the consequent dilatation of the tube of the vessel. The blood, very slowly traversing the cutaneous capillaries, being far too long a time exposed to the cooling influences perhaps of a draught of cold air, becomes the seat of chemical changes which differ from those ordinarily taking place in the blood constituents. The particular chemical com- pounds formed under these circumstances are not readily excreted. Remaining in the blood, they accumulate, and minute bioplasts grow and multiply. At length an influence upon the nerves is exerted, and then ensues the chilliness and other symptoms due to the derangement of the action of many tissues and organs of the body which mark the invasion of the illness. After a time 'the materials in question begin to be eliminated, and the patient gets well. If we promote the action of the excreting organs, we follow the "sug- gestions of nature" and expedite recovery. Now some may think all this a rather fanciful explanation ; but if we consider what happens in slight rheumatism, we shall, I think, be convinced that the conclusions arrived at are supported by facts. When the rheumatic state comes on, the patient experiences pain in the muscles and fibrous tissues in many parts of the body distant from one another, which pains are relieved in a very short time if free action of the skin, kidneys, and bowels is established. There is no doubt whatever that certain alkaline, diuretic, and purgative medicines excite the desired action, and thus the morbid condition is relieved or cured. The increased flow of urine, caused by giving diuretics, is followed by thirst, to quench which the patient resorts to cooling drinks. Thus the tissues get well washed out, and the peccant materials which, by their action on the nerves, cause the pain, are by degrees highly diluted and dissolved away, or in the blood are con- verted into materials which are readily removed from the body by different emunctories. We have thus accounted for the formation of morbid materials in the body, and have explained how these derange many SYMPTOMS OF A COLD. physiological actions and occasion pathological phenomena. Further, it has been shown how these noxious substances are removed, and by what means their removal, or, in other words, the recovery of the patient, may be assisted and hastened. Preliminary Changes and Attendant Phenomena. As regards the accession of a cold, or other febrile or inflammatory attadk, the first indications of derangement in the ordinary physiological processes are much the same ; but the intensity of the changes varies greatly in different fevers and inflammations. For some little time before you " catch cold," you are conscious of not being in the ordinary state of health. Without feeling very weak or low, you are inclined to lie down ; and, perhaps, if you followed your own inclination, you would go to bed, and in this way try to obtain relief from the discomfort and sense of oppression and general uneasiness. In a short time some degree of soreness about the nose is usually experienced, and this is often associated with dryness of the nasal cavity and of the throat. The tongue feels more or less dry and uncomfortable. Little or no saliva is secreted ; the skin, too, often feels hot and dry. When the skin is perfectly healthy, it is smooth and supple, but when a cold, or any general fever or inflammation, is coming on, a change usually takes place. It becomes more or less harsh, and even rough, small particles of the outer layer of the cuticle being partially detached. The surface, in consequence, feels dry and rough, and when rubbed, bran-like particles, consisting of the scales of old cuticle, are removed. Very frequently the patient experiences slight uneasiness about the head, perhaps not amounting to actual headache, but a little pain, it may be, over the brow, or heaviness there or at the back of the head, or in the back of the neck, or in all these situations. The pain in the neck is probably caused by some derangement affecting the nerves distributed to those muscles by the action of which the head is raised and drawn backwards. This pain just below the occiput often lasts for several days and is very troublesome, the slightest movement of the head being difficult in consequence of the pain which is excited. When a cold or fever is imminent, you usually feel weak and disin- clined to take exercise. If it is necessary to walk, you have, as it were, to force yourself to do so. There is little appetite, and perhaps no desire to eat an ordinary meal. Rather than solid food, you feel inclined to take a cup of warm soup or strong beef-tea, or ordinary tea or coffee, or gruel, or hot wine and water. There is very generally indeed a demand for fluid when a cold is coming on. You feel dry and thirsty, and almost instinctively seek for water, iced water, or lemonade. It is unquestionably advantageous to take fluids when these sensations, which usher in a cold in the head or other febrile attack, are experienced. For although, as Dr. J. C. B. Williams long ago showed, by resisting the longing for fluid, and bearing with the thirst for two or three days, 18 2O6 BODY-HEAT OF MAN. the catarrhal symptoms may be lessened, at least for a time, the dis- comfort and distress are often so great that the patient prefers the in- convenience incidental to the cold to the suffering which results from carrying out this dry system of treatment for its relief or cure, and it is doubtful whether the duration of the illness is by this plan in any way shortened. I have thought that in some cases the cold has been cut short by taking plenty of fluid, and thereby exciting free action of the skin and kidneys. The premonitory symptoms of a cold are unques- tionably often much relieved by a basin of hot soup, or even warm tea or coffee. As you are probably aware, the treatment everywhere most popular is a glass of hot wine or spirits and water. You will hear in every part of the country of cases of various terrible forms of disease which have been at once stopped or cut short by a stiff glass of hot brandy, whiskey, or gin and water. Although the secretion from the mucous membrane may be diminished by withholding fluid for a time, it is also quite certain that general relief of the discomfort and unpleas- ant symptoms may be obtained from the very opposite system, that of drinking freely of fluids which excite the action of the skin and kidneys, and thus wash out of the system various deleterious matters which have accumulated in the blood. The Body-heat of Man and Warm-blooded Animals Fixed and Defi- nite. The temperature of man and the higher animals in a state of health is fixed within a very limited range, and, as I mentioned in one of my early lectures, it is worthy of note that this fixed and definite tempera- ture of the blood in the case of warm-blooded animals is maintained at the uniform standard, although the temperature of the medium in which the animal lives may vary greatly from time to time. The temperature of our body is the same in summer and winter, or at the most varies little more than a degree of Fahrenheit's scale. A man in the polar regions will have the same internal temperature as one living at 'the equator. In the cold climate there is very little sensible perspiration. In the hot one perspiration never ceases, and the cuticle is always wet and soddened. By constant changes in the rate at which heat is evolved in and carried off from the body, the internal temperature of the blood is kept very nearly uniform. It is remarkable that the limit of variation in health is so slight, for we may regard it as proved that -the blood cannot vary to a greater extent than is represented by two degrees of Fahrenheit, without a departure from the normal state of health. Whether the air be cold or hot, whether a person take violent exer- cise or lie quietly in a warm bed, whether food be taken frequently or withheld for many hours, the temperature will not exhibit more than a very slight temporary disturbance, and whenever a change does occur, the temperature will very soon return to the normal point. Rise of the Body-heat in all Fevers and Inflammations. In every form of fever and in every kind of inflammation the temperature of INCREASED OXIDATION IN FEVER AND INFLAMMATION. 2O/ the body or of the affected part, and therefore the blood, rises. You must not forget that, although, as I have said, the patient may feel ex- cessively chilly, nay, though he be seized with decided rigors, so that he is excessively pallid, the face being pinched and destitute of color, or actually livid and cold to the touch, his limbs trembling and his teeth chattering, the temperature of his blood will be higher than in the ordinary condition of health. So far from the blood being entirely or only affected, it is more probable that in many cases the rise in temper- ature begins in the tissues outside the vessels. The blood-corpuscles, as they pass through the capillaries, take heat from one place and distribute it to other parts, so that a considerable rise in one spot may be soon reduced, and the heat diffused over a wide area, and thus cause a slight rise in the temperature of the body generally. Even in the flea-bite, if it were possible to place an instrument among the distended capillaries and tissues of the affected part, the temperature, I venture to say, would be found higher than in the tissues just beyond the affected area. In extensive inflammations, as was shown by Mr. Simon, the temperature of the blood which leaves the inflamed part is always decidedly higher than when it passes into it. There is not a fever known to us in which the temperature does not rise above the normal ; neither is there any inflammation which is not characterized by phenomena which occasion the development of an increased degree of heat in the inflamed part. This generalization is to be extended to all the higher animals. Every creature capable of suffering inflammation or the feverish condition exhibits, during the attack, elevation of temperature. There is, in fact, a very intimate con- nection between the increased development of heat and the states Fever and Inflammation, and we may go so far as to affirm that the existence of either of these pathological processes without a rise in the tempera- ture is not possible. In both fever and inflammation it would seem that the circumstances which determine the maintenance, of the equable body-heat of health are deranged, either generally, as in the fever, or locally, as in the inflammation. Heat is developed faster than it can be carried off, or the processes by which it is carried off are for the time interfered with, or both circumstances are concerned in determining the rapid rise of temperature which is often observed in various fevers and inflammations of marked- intensity. Is there Increased Oxidation in Fever and Inflammation? This question is one of much importance in reference to the consideration of the real nature of the febrile condition. It would be answered directly and most positively in the affirmative by most pathologists, but, as we shall see, the facts known by no means justify an off-hand and confident answer. The secretion from the kidneys of a person suffering from feverishness is usually concentrated and of high specific gravity. You will frequently find it loaded with urates, and often there will be Excess 208 INCREASED OXIDATION IN FEVER AND INFLAMMATION. of Urea. Deposits of uric acid are common. The Excess of Ure.a is shown in a very simple way. To about half a teaspoonful of the urine in a test-tube you add an equal bulk of strong nitric acid, and plunge the lower part of the tube at once into cold water, shaking it from time to time. In the course of a few minutes crystals of Nitrate of Urea will begin to form, and if the specific gravity of the urine is 1.030 or higher, it may become almost solid from the quantity of crystals formed. The circulation of the blood and the action of the various organs in the body are greatly disturbed, and there is departure from the -normal state in many respects, both as regards the chemical processes going on in the blood, and the presence and accumulation in quantity in the circulating fluid of substances which ought to be removed from it in a very dilute state as fast as they are formed and passed into it. Instead of this, many of the excrementitious matters are in such a high degree of concentration that they readily separate from the fluid in which they are dissolved, and in the case of the urine some are deposited soon after the secretion has been passed and has become cool. These and many other phenomena, which are undoubtedly due to exceptional chemical change, are often set down to excessive oxidation, although a careful consideration of the facts would lead us to entertain the opposite conclusion, that oxidation was deficient instead of being in excess. In many books you are told that body-heat is invariably the result of the combination of carbon and other elements with oxygen that the increase of temperature in all fevers is due to increased oxidation. There is, however, evidence of a most striking kind that in various morbid conditions in which the temperature of the body considerably exceeds the normal standard the process of oxidation is much interfered with. If, for instance, a man has one lung solid from the air-cells being plugged up with lymph poured out from the blood, as occurs in pneu- monia, is it not unreasonable to maintain that oxidation is going on to a greater extent, or is more complete, than in health? In this case are not the air-cells filled with solid matter, which renders the entrance of air less constant and its renewal quite impossible ? And yet we are assured that the elevation of temperature in pneumonia, and in all other febrile and inflammatory states, is due to increased oxidation, and to that alone. Again, the body of a person who has died from a terribly severe attack of acute rheumatism can hardly be considered to be in a state favorable to free oxidation. Nevertheless the temperature, which at the time of death may be as high as 107 or 108, often rises three or four degrees of Fahrenheit during the first hour or two after death. How, then, can we reasonably attribute this rise of temperature to in- creased oxidation ? Consider not only that the rise continues for some time after the lungs have ceased to act at all, and the heart can no longer propel a drop of blood along the vessels, but that for many hours, or ASCERTAINING THE TEMPERATURE. 2Op even days, before death the conditions of the system had been most unfavorable to the introduction of air and its free distribution to distant parts, as also to its absorption by the tissues and fluids. We can show that in all probability the high temperature is due to the increased growth of bioplasm, not to increased oxidation. The generalization that the elevation of temperature in fever and inflammation is due to increased oxidation is, I think, a grave mistake. It is more probable that the phenomenon is occasioned by changes in the bioplasm or living matter of the blood and tissues of a nature far removed from the process of oxidation. I shall have again to refer to this very interesting subject, and hope to consider it more in detail. Method of Ascertaining the Temperature of the Body. The actual temperature, as indicated by the thermometer, is found to vary slightly, according to the part of the body which is selected for observation. If, 'for example, you place the thermometer under the tongue, you wi'l find, as you would anticipate, that it will mark a degree or so higher than if the same instrument is placed in the arm-pit. In medical observations on the body-heat we restrict ourselves to observations in two places, the mouth underneath the tongue and the arm-pit. But if you try the mouth, in the case of children, you will not unfrequently have the bulb of your instrument bitten off. Such an accident is serious, for good clinical thermometers cost from twelve to sixteen shillings each. It is, therefore, upon the whole, better to take the temperature in the arm-pit only. In order that you may be able to compare the records of different cases, you must take care to work in precisely the same way, and to place the thermometer in the arm-pit for at least two minutes, if the bulb is a very small one, and for double that time if it is not of the smallest size. You, will have little difficulty in using the small thermometer, even in the case of the most irritable and violent children ; for you can always put it in the arm-pit and keep the child's arm nearly still for the length of time required. Thermometers for medical observation, clinical thermometers as they are called, maybe obtained of all the instrument makers. Those with the smallest bulbs respond very quickly, and the index comes to a stand in two minutes, or even in less time ; but the degrees are small and more difficult to read off than those of larger instruments, which require to be inserted in the arm-pit for four or more minutes before you can feel sure that the mercury has come to a standstill. Of late a great improvement has been made in the construction of the very small thermometers. The bore is so fine that observers whose eyesight is not the most perfect often find it difficult to see the index. By grinding the glass away somewhat at the sides and making the front of a greater convexity, the effect of an elongated lens is produced, and the almost invisible mer- curial thread is made to appear as a broad band of mercury, which can be seen without the slightest difficulty. 18* O 2IO COLD, HOT, AND SWEATING STAGE. Further Consideration of the Essential Phenomena of Fever and Inflammation Rigors and Cold Stage Hot Stage Sweating Stage. When a severe form of fever or inflammation is about to attack a patient, instead of mere chilliness and a sensation of creeping or tingling of the surface skin, an actual rigor is experienced. This is often so intense that the patient trembles in every limb, his teeth chatter, and he feels dreadfully ill. The very bed on which he lies may be perceptibly shaken, so violent and so general is the nerve and muscular disturbance. Among severe inflammations, a sharp attack of inflammation of the lungs, Pneumonia, and among fevers, small-pox, Variola, and scarlet fever, Scarlatina, are ushered in thus. If you were called to the patient as soon as he was taken ill, you would see his limbs trembling violently, his face pale and anxious, the patient himself would be considerably depressed, suffering from nausea, and probably every now and then violent retching would add to his distress. If you put your hand on his pulse, you find it quick, feeble, and small; and if you place the ther- mometer in his axilla, you will find the temperature higher than normal, perhaps by four or five degrees. It would seem that the blood is diverted from the general surface of the body, and is driven in -greater proportion to internal parts to the lungs, to the intestines, to the liver, and to other internal organs. These preliminary symptoms, with the shivering which is developed in a re- markable degree, represent what is known as the "cold stage" of an '' intermittent fever." Ague is a very remarkable form of feverish attack, inasmuch as the several special stages which are to be traced with more or less distinctness in all fevers and inflammations are very manifest, and are well defined and sharply marked off from one another. In the cold stage, blood not only leaves the surface, but temporarily parts with much of its water, which then occupies the interstices of the tissues. After a. time it again enters the blood or passes off by the intestines, in which case it may be altogether removed from the body, as in Diarrhoea, or in Cholera, in which disease the blood becomes of a thick and tarry consistence, and stagnates in many of the vessels, scarcely moving at all in some of the capillaries which are distributed to very important organs of the body. The shivering and other symptoms which constitute the first indica- tions of derangement in febrile diseases are referable to conditions favoring the formation of deleterious matters in the blood itself. In some cases these are due to changes originating in the organism, in others to the introduction of a poison from without. The phenomena which mark the accession of a common cold corre- spond to the cold stage of the ague-fit. I think it probable that the so-called collapse stage of cholera is also analogous to the first stage of the ague-fit, and consider that it represents, only in the most severe form, the general phenomena which usher in every form of febrile and inflam- FEVER IN CHOLERA. 211 matory attack. It is in a sudden and very severe attack of this most terrible disease, Cholera, that we see the cold stage of a fever in its highest conceivable degree of development ; for, in fact, the collapse is so severe and so widely diffused, so manifestly deranging the action of every tissue and organ in the body, that in too many instances death results in a very short time. But Cholera, like other febrile affections, has not only its cold stage. If the patient lives, the terrible state of collapse at length gives place to great heat and dryness of skin, and this hot stage in turn is followed by a crisis or critical change, when .the kidneys and skin again resume action. The blood regains its color and begins to freely flow along its accustomed channels, and the various glands and tissues gradually recover from the shock they have suffered and return to their normal state. The patient, in fact, soon becomes convalescent. The feverish condition which in cholera follows the stage of collapse, after a varying interval of time, is called Secondary Fever. Happily, few of you have seen either a case of ordinary cholera or the secondary fever, which was not so common, but not a few of your teachers have seen and done their utmost to save many a case. In most epidemics the disease was very fatal during the cold stage, and where very much water had been already drained off from the blood into the intestinal canal the patient died in collapse. In some of the cases which recov- ered the secondary fever was so slight that it attracted little or no atten- tion ; but occasionally I have seen it very marked indeed, and have lost patients from secondary fever who, some days before, had passed through severe collapse and were considered to be recovering. I believe that this febrile stage of cholera corresponds very closely to the prolonged feverish condition characteristic of typhus or typhoid, for example, and to the so- called hot or febrile stage of an intermittent. In an ordinary cold the feverish state usually lasts but a very short time, perhaps not longer than from ten to twenty-four hours. In typhoid fever, however, it may last for six weeks or more, and in acute rheumatism it may extend over two months. During the whole of this long period the temperature of the patient's blood may not once, even for a single hour, fall to the normal standard, though in many cases it falls and rises several times in the course of the attack, passing three or four degrees above the normal, and then perhaps going down to that point, again rising, and so on. In an ordinary cold or catarrh the chilly stage is usually followed, in the course of five or six hours, by free perspiration, which immediately affords great relief, and in many instances seems to cure the patient at once. In fevers and extensive inflammations the nervous system generally is affected. In some forms the action of the brain is very much dis- turbed. Soon after the preliminary phenomena of the common cold have occurred, the pulse increases in frequency, and there is, possibly, severe headache, the whole of the head, perhaps, feeling full, almost to 212 . COLD STAGE OF A CUE- FIT. bursting, as if it had been forcibly distended with more than it could properly contain. The action of the mind is affected. No one when he is attacked can perform much intellectual work. His memory suffers, and to think at all is a painful effort. He probably feels more inclined to lie down and do nothing. If he goes to bed, instead of falling asleep he tosses about from one side to the other in an uncomfortable way ; perhaps he dreams of all kinds of horrible things, and wakes up sud- denly, finding the mouth, fauces, and tongue dry and uncomfortable. There is still more or less feeling of fulness and distention about the head. The patient again tries to go to sleep, only to be disturbed by more unpleasant dreams and to wake again, perhaps frightened, in a short time. Oftentimes there is chilliness, or a creeping sensation is experienced over the general surface, the muscles seem fatigued, and there is a general feeling of lassitude. These phenomena indicate a wide-spread disturbance of the nervous system, cerebral, spinal, and ganglionic, caused probably by the action upon the nerves and nerve- centres of certain materials which ought to have been eliminated, but which have unduly accumulated in the blood. Such are some of the broad phenomena which almost every one has experienced who has taken a bad cold or has suffered from any form of fever. In severe and specific fevers and general inflammations all these nerve phenomena are more strikingly developed, and trouble the patient for a longer period of time. In any well-developed fever, for instance, the patients may pass many sleepless nights. They may be troubled with headache for a fortnight or three weeks, or even longer, and may be restless and wakeful during the whole of the time. The chilly sensation, like the cold stage of an ague-fit, is succeeded, after a varying period of time, by a very different state of things. The blood returns in volumes to the surface of the body. The little arteries dilate, the capillaries are distended, the color returns and is intensified, and the skin becomes hot to the feel, but it remains dry. There is often headache, and the patient will perhaps tell you that his head feels ready to burst. This is the hot stage, which is soon followed by the last or sweating stage. The skin is bathed with perspiration, which continues it may be for several hours, so that the cuticle becomes completely soddened and softened. In this way a quantity of water with certain organic matters dissolved in it, and often amounting to several pounds in weight, is very quickly removed from the blood. The action of the skin and other excreting organs of the body, which had been partially suspended during the accession of the attack, and in many cases for some days before, is a general fact of great importance, and marks the temporary abatement or actual cessation of all febrile and inflammatory disorders. If these phenomena can be caused to come on somewhat earlier than in the natural course of events, the duration of the febrile or inflammatory attack is to that extent reduced. As soon FREE SECRETION IN FEVER. 213 as the sweating comes on the patient may feel relieved, but until it has occurred he may experience much discomfort. Till then you may have felt very anxious about the case. We are unfortunately unable to ascer- tain at the commencement of the attack how bad the patient is likely to be ; we never know to what extent the grave symptoms of the malady may continue to increase, or for how long a time the patient will con- tinue to get worse. Until sweating and free secretion have occurred we can seldom judge as to the probability of recovery or the duration of the time of illness. Of Free Secretion which Leads to Recovery. Recovery is associated with the gradual removal from the organism of substances which prob- ably have been accumulating for some time in the blood and nutrient fluids. These substances are slowly removed by the agency of the kid- neys, skin, bowels, and other emunctories. When the skin acts pretty freely, you become thirsty and imbibe a quantity of fluid, which is again quickly removed by the kidneys. The bowels act freely, although per- haps for some time before the illness and during part of the attack they had been confined, or had only acted imperfectly, especially when febrile action was most intense. The glands of the mucous membrane of the intestinal canal, like other glands, do not act as freely in the early period of a cold as they do in the healthy state. When, however, the patient returns to the normal condition these glands act freely, and the tendency to constipation and defective action passes off. Moreover, as the feverishness abates there will be increased action of several glands as compared with their activity in the ordinary state of health. Not only do the kidneys and the cutaneous glands act in an unusual way for some time after recovery, but the glands of the mucous membrane of the nose and those of the mucous membrane of the air- tubes also continue to secrete freely for some time. Many of us while in perfect health might leave our pocket-handkerchiefs behind without experiencing inconvenience, but when suffering from a cold it is well not to be neglectful. A quantity of secretion is poured out from the mucous membrane of the nose, and in many cases also from that of the windpipe and bronchial tubes. The secretion is modified mucus. In the healthy state the mucus which is formed is extremely small in amount. This mucus is princi- pally produced in minute glands connected with the mucous membrane and which open upon its free surface. The same glands, when the fever of an ordinary cold is passing off, secrete an undue quantity of mucus. Exaggerated action proceeds in connection with all the mucous surfaces, and persists for a certain period of time, varying from twelve or twenty- four hours to many days. The patient then usually gets better, and everything slowly returns to its normal rate of action. Now this very free secretion, in certain cases, is a matter of serious importance. There are certain forms of inflammation of the mucous 214 TREATMENT OF A COLD. membrane of the air-tubes, including the nasal passages, in which there may be an undue secretion of altered mucus, amounting to six or eight ounces in the twenty-four hours. In some sad cases, happily not very common, an excessive quantity of secretion is so quickly poured out that it accumulates in the smaller air-tubes, and death may be caused by suffocation in the course of a few hours. The mucous membrane of some persons' air-tubes is constantly in so sensitive and irritable a state, that whenever the weather is either cold or damp they suffer more or less. Such patients ought to spend their winter in a warmer climate, where they can be out in the open air almost daily; for if they remain in London they generally have to be shut up in warm rooms for a great part of the winter, a course very detrimental to the general health, and likely to render the mucous membrane still more irritable and sensitive to adverse atmospheric changes as life ad- vances. Coryza is the scientific name for a cold associated with the secretion and removal of a considerable quantity of fluid secretion and viscid mucus from the secreting follicles and surface of that part of the mucous membrane which lines the nasal passages and adjoining cavities. Catarrh, Gravedo, are also terms applied to a cold in the head. The word Coryza, liopi^a, is supposed to be derived from K.6po$ or /capa, the head, and f, to boil. I am not, however, sure whether this derivation is perfectly accu- rate. The condition was, perhaps, so called because some people, suffer- ing from a very bad cold, say that they feel as if the blood in the head was in a boiling state. Of the Principles upon which the Treatment of a Cold should be Conducted. As regards treatment, I suppose many would say "let a cold alone; " "it will get well of itself; " "do nothing." I am quite ready to admit that an ordinary cold will get well without any active treatment. Nevertheless, a bad cold is a very unpleasant affection in many ways, and it is desirable to mitigate its intensity and shorten the attack, if we can do so. Besides, as I shall have to explain, many serious maladies in their early stage may be easily mistaken for an ordi- nary cold, and in many cases real, advantage does result from the early adoption of judicious treatment. We will, therefore, endeavor to decide as to the principles according to which the treatment of a cold and allied derangements should be conducted. The phenomena characteristic of an ordinary cold, as I have just re- marked, are present during the period of accession of many forms of fever, and sometimes in a greatly in-tensified state. You ought, there- fore, to know whether, and by what means, these symptoms may be modified, or the changes which usher in convalescence encouraged, so that the latter be made to occur somewhat earlier than they would do if the malady ran its ordinary course. Obviously, the thing to try to do in the treatment of maladies of the class we are considering is to bring on DIURETICS AND PURGATIVES. 21$ the period of perspiration as early as possible and to excite the action of the various glands of the body. The blood has been diverted from the surface to the internal organs of the body, and we want, if we can, to determine its flow towards the skin, in order that much of its water and some of its organic constituents may be removed by the glands and discharged in the form of perspiration. External warmth will relieve the feeling experienced when a cold is coming on, and I think that sometimes the malady, and possibly some severe acute affections, may be cut short in this way. The patient is told to get into a warm bed or to take a warm bath. But the applica- tion of cold externally has been as strongly recommended as warmth, for the very same purpose in the same cases ; and you might be led to suppose that here, as in some other instances, opposite and conflicting practices had been advised and adopted for the relief of the very same malady. But this is not really so ; for whether you wrap a patient in a sheet dipped in warm water or in cold water, it makes very little differ- ence, except that a cold sheet is somewhat more disagreeable to the patient than a warm one. Cold, wet packing will bring about just the same action as warm packing or a warm bath. For the chilly feeling produced by the first contact of the cold wet sheet is soon followed by reaction, and is replaced by a gentle glow, succeeded by free perspiration. Diuretics. But besides trying to excite perspiration, you may endeavor to cause various eliminating organs to act freely. You should give unir- ritating diuretic remedies, such as Liquor Ammonia Acetatis, Citrate of Ammonia, Citrate of Potash, Nitrate of Potash, and Chlorate of Potash. These all act, more or less, upon the kidneys, and increase the flow of urine ; some of them act upon the skin, and in other ways promote the removal from the blood of noxious substances which have accumulated in it. They and many other remedies are thus of use in the treatment of an ordinary cold and allied ailments. I often suggest the following prescription : Spirit of Mindererus {Liquor Ammonite Acetatis), two ounces ; Spirit of Chloroform (Spiritus Chloroformi"), from one to two drachms ; Nitrate of Potash (Potassce Nitras\ sixty grains ; or Chlorate of Potash {Potasses Chloras), from one to two hundred grains ; Syrup of Orange, of Squill, or of Tolu, half an ounce, and water to six ounces. The dose is half an ounce, or a tablespoonful, with as much water, once in two hours, or less frequently, for three or four days. Purgatives. And, lastly, the elimination of noxious matters which have accumulated in the blood may be further promoted by exciting to a moderate extent the action of the intestinal canal. In a cold the bowels are generally more or less confined, and in many cases there has been but imperfect action, perhaps, for some time previous to the attack. I therefore recommend you to make full inquiry upon this point, and, if necessary, order for the patient some mild laxative that will act upon the bowels and favor excretion. Thus you may, perhaps, shorten by a 2l6 ONLY !4 COLD. day or two the period of the duration of the cold. In the highly fever- ish condition which often comes on soon after a surgical operation, re- lief may be afforded in the course of a few hours by the administration of purgatives, sudorifics, and diuretics. One or two grains of Calomel will be found to act admirably in many of the most serious of these cases. The temperature falls soon after the dose has been taken, and the patient often experiences great relief long before the medicine be- gins to act on the bowels. The fact of improvement so immediately following the use of reme- dies which increase the action of the skin, kidneys, and bowels, favors the conclusion that the fever is due to the accumulation of certain mate- rials in the blood, the elimination of which is followed by relief, and, as we say, the resolution of the fever. It is important to consider these matters, the more so just now, because there is too great a tendency to altogether discard the use of many medicines which are of great value in the treatment of disease. Of the Recognition and Management of Affections which Begin like an Ordinary Cold. Some cases which at the outset seem to be nothing more than an ordinary cold or catarrh, do not prove to be of this na- ture, but issue in some form of serious acute disease. Those terrible fevers which occur in all the large cities of Europe, and which carry off so many thousands every year, may come on just as an ordinary cold does. During the period of accession the symptoms are much the same, and both the patient and his doctor may for some days think there is not much the matter. The patient feels so strongly convinced that he is suffering only from an ordinary cold that he goes about just as usual. When, however, he gets worse from day to day and feels decidedly weaker, he begins to be alarmed. At length he is obliged to take to his bed, his temperature is found to be and to remain above the normal, perhaps rising to 102 and 103. By this time the practitioner is able to determine the nature of the case. Instead of the attack being, as the patient himself supposed, an ordinary cold, it turns out to be a specific fever, of a kind which not un frequently destroys life. It may be that under the most favorable circumstances, and with the best nurs- ing and medical treatment, the rate of mortality will not be less than one out of every seven or eight attacked by the disease. It is a fact that many serious attacks of fever begin just like an ordinary cold. Now if you happen to be called in just when the fever is coming on, and you thoughtlessly remarkt that " this is only an ordinary cold ; I need not do anything," think of the dilemma in which you may be placed. When the severe nature of the disease becomes apparent, you will be, as it were, convicted of having made a very serious mistake. Very likely neither the patient nor his friends will have any further confidence in you, and you may be pronounced to be an ignorant person, who knows very little about his profession. You may in consequence get out of heart and feel IMPORTANCE OF TREATMENT. 2 1/ altogether dissatisfied with yourself. As a fact, it may have been impos- sible for anyone to make a diagnosis at a very early period of the attack; but the right course would have been to have waited until the premoni- tory symptoms passed off, or until some definite characteristics of a special malady had manifested themselves. You should always carefully inquire into all the facts of any given case, listen attentively to what the patient has to say concerning the symptoms which disturb him, and do all you can to relieve them, postponing any decided expression of opinion as to the precise nature of the disease until your next visit, when you may perhaps be able to speak with decision. Even if the disease should be only a common cold, you will, never- theless, find in practice that many persons who experience suffering, dis- comfort, or even mere inconvenience, strongly desire to be relieved of their troubles, and as quickly as possible. Of the sick who send for you, a considerable proportion will certainly expect that you will do something for them. Though if you were in the same condition yourself you might be inclined to leave the case to nature and not take any medicine nor desire to follow any course more unusual than indulging in a little more rest than when in good health, your patient will expect you to prescribe something that will relieve him or help him to get well. And unques- tionably you may help persons suffering from a severe cold if you give sudorifics, diuretics, and a gentle purgative. Especially in the case of children is it necessary to be very cautious in committing yourself to a positive opinion at an early period of a febrile attack. You may mistake a serious case for a slight one, or the reverse. You will be astonished at the very serious aspect sometimes presented by many a case of mere stomach disturbance. A child who has partaken of unripe fruit may be very ill indeed a few hours after- wards, with a temperature of 104, flushed face, quick pulse and respira- tion, with a suffering, anxious look. An inexperienced practitioner would perhaps tell the friends that some severe fever or other acute disease was certainly about to establish itself, when, perhaps, a few hours afterwards the bowels act, the temperature falls to the normal, and when he next visits his patient he finds him well, and the friends laughing about his gloomy prognostications. In children suffering from slight ailments, I have observed the temper- ature rise from the normal to 104, or even higher, and descend to the normal, within twenty-four hours, so rapidly may considerable changes in the temperature of the blood of children occur. Such cases, I need scarcely say, require simple treatment. A purgative dose of castor-oil is sometimes needed, and the patient is well again as soon as it operates. The child, as often happens, is very thirsty, and you may allow it to drink water. Plenty of toast and -water may be given, or plain water, if the patient likes it better, provided it has been well boiled. Water or milk and water will help the skin and kidneys and bowels to act freely, 19 2l8 IMPORTANCE OF TREATMENT. and in consequence the feverishness will subside and the patient regain the usual state of health. Sometimes, however, a feverish attack instead of subsiding continues for several days. The child may be ill for a. week or two, and require careful management, although no definite fever is de- veloped. Neither scarlet fever, nor typhus fever, nor any other specific disease may be manifested ; but a general feverish state may be estab- lished, and may continue for several days, and then gradually subside, leaving the patient thin and weak and out of health. It must be admitted that in former days many doctors gave too much physic and were somewhat too fussy. In these days, however, I fear there is a tendency, or more than a tendency, to err in an opposite di- rection. Some practitioners, having convinced themselves, seem to be most anxious to convince the public and 'the profession that the chief duty of a medical adviser is to study, note, and carefully watch the progress of a malady to observe, if he is qualified to do so, the minute changes taking place in the tissues of the sick man, in order that he may discover facts which will increase our knowledge of the nature of the pathological processes, and possibly lead to the enunciation of new prin- ciples of treatment for the benefit of sufferers in the next and succeeding generations. But this view of medical aspiration is not always appreci- ated by the patient, especially if the doctor's visits are not purely of an honorary character, and even then it will be found that there are some few patients so peculiar in their notions as to object to their bodies being used for observation, or their sufferings studied and noted as interesting pathological phenomena, which may be further elucidated as the case proceeds. You must really bear in mind that patients want to be relieved as well as watched, and unless you can be of some use to them unless you can advise and help them, they may regard you as a nuisance, in- stead of discovering in you a consolation. But, further, we really ought to do all we can not only to remove bodily aches and pains, but also to relieve our patients' minds. You will not reduce the mental anxiety of a sick man if you tell him you can do nothing to relieve his pain, noth- ing to expedite his recovery, nothing to avert impending morbid change or to mitigate the severity of the disease. I find that some doctors, if they get ill, even though the illness is obviously not a serious one, be- come very anxious, and of all sick people they are oftentimes the most difficult to manage. They usually think themselves worse than they are, and are almost invariably desirous that something practical should be done. I have sometimes ventured to discuss with a medical friend the actual nature and import of the symptoms from which he was suffering, but I generally find that my friend is sadly disappointed if I do not pro- pose to "do something" for him or suggest some operation to relieve him. If I suggest to a medical patient that the malady will probably get well of itself, he will, perhaps, feel disappointed, if not hurt ; but if I propose that he should take a few doses of the Liquor Ammoniae Acetatis, CHANGES IN TISSUES IN FEVER AND INFLAMMATION. 21$ Nitrate or Chlorate of Potash, and Sal Volatile, a practitioner of even a philosophical turn of mind will feel quite happy, and will take the med- icine ordered with regularity, and bear his ailments with cheerfulness. I advise you to bear in mind the principle upon which the treatment of a cold or an ordinary febrile attack is to be conducted, and I recom- mend you to be careful not to commit yourselves too hastily to a positive opinion as to the exact nature of a febrile attack which has only lately come on. It is important , not to make too light of it, on the one hand, or on the other to cause needless alarm by suggesting to anxious friends that what is probably only a most trifling and unimportant temporary derangement may turn out to be a grave disorder. OF THE ACTUAL CHANGES IN THE AFFECTED TISSUES IN FEVER AND INFLAMMATION. I now desire to consider more particularly the actual phenomena of Fevers and Inflammations, and the general nature of the minute changes upon which they depend. I have said before that in all fevers and inflammations there is an elevation of temperature. Whether the rise begins in the blood or in the tissues outside the capillaries, is a question concerning which some difference of opinion may be entertained. In some cases it is certain that the tissue elements exhibit the earliest departure from the normal state, and in all probability it is there that the rise in temperature begins. But the blood is soon affected, for in all cases the blood in the adjacent capillaries becomes hotter, and it is by the movements of the blood that the distribution of heat is effected. On the other hand there is no doubt that some fevers and inflammations begin, so to say, in the blood. In every form of marked inflammation and fever the vessels of the affected part contain more blood than they do in the normal state. Par- ticularly the capillary vessels and the small veins are distended. If you watch the phenomena of local inflammation in one of the lower animals, as for example that form which may be excited in the web of the frog's foot by the application to one spot of a small portion of mustard for a few minutes, and carefully observe the alteration in the circulation there- by induced, you will gain much important information concerning the nature of the process. You will notice in the first place that the vessels have become much dilated, while the movement of the blood along them gets slower and slower. At last the circulation completely stops. If at this stage of pathological change the mustard be removed and the web be kept perfectly moist, it will be found that the movement of the blood will begin again, and that much of it will find its way on to the small veins. In fact the disturbance will soon cease. The normal state of the circulation will be restored, and without any damage whatever to vessels, nerves, or other tissues having taken place. In fever there can be no doubt that the same sort of change occurs in 220 CHANGES IN TISSUES IN FEVER AND INFLAMMATION. fhe capillaries, but the degree of change is so slight that it is not in all cases to be demonstrated. You may look upon a cold as a slight fever, while a chilblain may be adduced as an example of a slight inflammation. Some authorities consider that febrile disorders should be classed among nerve disorders, and the arguments advanced in favor of this view also apply to the case of inflammations. But would it not be un- reasonable to include flea-bites, and boils, and abscesses in the class of nervous diseases? In point of fact, nerves and nerve-centres are invari- ably affected in all fevers and inflammations, however slight. Indeed, no changes whatever which involve alterations in the diameter of the small arteries can take place in the body without nerves being concerned, and the essential phenomena both of fever and inflammation are inti- mately connected with disturbed arterial and capillary action. Still these conditions cannot properly be regarded as nerve diseases. The patho- logical action does not begin in nerve structures, and the nerves and nerve-centres, so far from being the points of departure of the morbid change, are only affected in consequence of preliminary changes in other textures. The phenomena of some fevers and general inflammations are due to changes which have taken place in the blood, and there is, as I have re- marked, undoubted evidence of the blood being, as it were, the starting- point of all the phenomena. The disease begins in the blood. A poison, or materies morbi, may infect the blood in the first instance, and through the blood various tissues and organs may suffer. It is very probable, I think, that the afferent nerve-fibres distributed to the capillary vessels are disturbed either by the action upon them of the altered fluid which transudes through the vascular walls, or, in certain cases, by the growth and multiplication around them of minute particles of morbid bioplasm (disease germs) which also traverse the thin walls of the capillaries, thus leaving the blood in countless numbers and passing into the interstices of the surrounding textures. In Scarlet Fever (Scarlatina] the "rash" depends upon the capillaries of the surface of the skin being dilated to such an extent that the redness of the affected parts is as intense as that of the skin of the lips in the ordinary state. The bright red color of the skin of the lips is due, as you are probably aware, to the number and considerable diameter of the capillaries of the skin of the part, and to the circumstance that these vessels are covered by a thin layer of epithelium only. In scarlet fever the redness is due to a dilatation of the vessels, somewhat like that which occurs in those of the skin of the cheek when we blush. In the fever, however, the blush lasts for a much longer time. The period of vascular congestion of the cutaneous capil- laries is, in most febrile diseases, fixed and definite; but it varies con- siderably in duration, as well as in the course which it takes in different kinds of fever. In eruptive fevers, then, and in some general inflam- mations, the " eruption " or " rash " results from dilatation of the capil- THE ACTION OF EXTERNAL COLD UPON THE BLOOD. 221 lary vessels, which lasts for a certain time. The mechanism instrumental in bringing about the result and the precise changes taking place in the vessels are considered on page 231. I do not say that the redness of the skin is due to increased supply of blood, for probably a less propor- tion of blood goes to the part than in the normal state. In a given time less blood passes along the vessels, but they are distended, and more blood remains in them; their walls being stretched are much .thinner and more permeable than in the normal state. The blood is not actu- ally stagnant, but it circulates very slowly. Slight exposure of a part of the body to cold may cause a severe febrile attack. In considering how cold operates, I think we shall find the following explanation in accordance with the broad facts of the case : The heart's action being at the time feeble, blood will be flowing but slowly through the capillaries of the skin. The blood will, therefore, for a much longer time than usual, be exposed to the detrimental influ- ence of cold. No wonder that under such circumstances chemical changes of an unusual kind are induced. Substances are formed which injuriously affect the tissues and interfere with the proper performance of many of the normal phenomena of secretion and nutrition. The noxious materials dissolved in the fluid, transuding with it through the walls of the capillaries, would come in contact with the delicate nerve- fibres and mar their action. As long as such matters remain in the blood there must be in many ways a departure from the healthy state ; but as soon as these compounds have been eliminated, the organism will be restored to its normal condition. For these reasons the free action of organs concerned in excretion is, as I have already stated, of the first importance, and is associated with the subsidence of the fever and the discomfort which accompanies the attack. There are several affections which may be correctly termed either fevers or inflammations. If in many cases you looked at the local phe- nomena only, you would use the term inflammation, while to the general symptoms consequent upon the local change and varying with it in in- tensity, you would apply the term fever. Not only is inflammation the cause of fever, but fever in many cases leads to inflammation. In truth, there is no inflammation without a degree of fever, and there is no fever in which the phenomena essential to inflammation are entirely absent. That which is common to both, to all fevers and to all inflammations, is the increased growth of bioplasm, consequent upon increased facilities of access, or of the greater abundance or greater permeating property of the nutrient fluid. This increased growth of the living matter is in- variably associated with a rise in the temperature of the tissue or organ in which it takes place, above the normal standard. Erysipelas may be fairly called an inflammation, though in many respects it exhibits all the characteristics of a fever. In the slightest local inflammation, however limited its area 'may be, a flea-bite for example, the phenomena are essen- 19 * 222 THE MINUTE CHANGES tially the same as in a fever, only they are circumscribed to a partic- ular spot. If you consider the actual changes which occur in both path- ological states, you will find that they approach so nearly in their essen- tial features as to justify me in advancing the generalization that Inflam- mation is a local fever and Fever is a general inflammation. If we consider the actual phenomena of fever and inflammation, as they are revealed by careful microscopical examination of complex tissues involved, we shall find that we have : i. Temporary enlargement or dilatation of the capillary vessels, which soon become filled with blood. 2. If this state of the vessels lasts for a time, exudation of fluid occurs and minute particles of bioplasm pass through the capillary walls, and grow and multiply in the new situation. 3. The bioplasts of the vessels, nerve- fibres, and other tissues, being supplied with more nutrient matter than in the ordinary state, grow larger and tend to divide and subdivide. The particles of bioplasm, or living matter, in all the tissues and fluids affected are invariably enlarged in all fevers and inflammations. 1 be- lieve it to be impossible for fever or inflammation to occur without this enlargement of the bioplasts or particles of living matter, without the temporary increase of the living matter of the part of the body affected. The living particles always experience increased nutrition under the con- ditions present when fever or inflammation exists, and this phenomenon, this increase of the bioplasm, is invariably associated with a rise in the temperature of the part. Rise in body-heat in fever and inflammation is constant, and I must ask you to note the important fact that it is asso- ciated with slow and impeded capillary circulation, with the exudation of fluid and minute particles of living matter from the blood, and with the increased nutrition and growth of bioplasm. So far from depending upon increased oxidation, inflammation and fever often coincide with impaired respiratory function, and the introduction into the blood of far less oxygen than in health, and with the formation and removal of less than the ordinary proportion of carbonic acid. Slight fevers and inflammations do not necessarily result in permanent tissue changes. Many leave no traces behind them. There may be no degeneration of any tissue in the body, no structural change, no evidence left of the attack. After a fever or inflammation the organism may be left precisely as it was before the attack occurred. Nay, one or more attacks of feverishness during early life seem to be the rule. Almost every child suffers. Indeed, amongst young vertebrate animals, dogs for instance, attacks of feverishness occur in almost every individual, and the disease is often fatal. In many cases, however, the feverishness after a few days passes off, leaving no structural change or damage. Of a Flea-bite. If we thoroughly understood the phenomena which result from the "bite" of a common flea, we should know very much more about the exact nature of the changes which occur in such serious inflammations as erysipelas than we do at present. Possibly, also, such OCCURRING IN PUS-FORMATION-. 22$ information might enable us to suggest means by which an attack might be prevented, or at least the inflammation kept from spreading until a considerable extent of the surface of the body was involved in the dis- ease. You may remember that in one of my early lectures I described how, by the minute but exquisitely sharp lancet of an insect, the formed ma- terial of a cell of cuticle might be easily injured, and in such a manner that a part of the bioplasm in its interior would be exposed to the con- tact of the fluid which moistens the tissue. I showed that, under the circumstances, the access of the surrounding nutrient material to the bioplasm in the interior of the cell must be greatly facilitated. It is obvious that much more nutrient matter would reach the bioplasm in a given time when the so-called cell-wall was thus damaged than when it was intact. In the normal condition of the cell, every particle of nutrient fluid must slowly permeate the thick layer of formed material which con- stitutes the outer part of the cell, the so-called cell-wall, before it can reach the bioplasm and be assimilated by it. When the formed material has been torn, nutrient fluid will pass at once to the bioplasm and come into immediate contact with it. As the ordinary formed material or "cell- wall" consists of several layers of firm cuticular matter, not very per- meable, the ordinary passage of soluble nutrient substances through it must necessarily be a slow process. But when the formed material is injured so that the bioplasm is exposed, the access is free and the pab- ulum is at once appropriated. The result is the rapid increase of the bioplasm or living matter. Outgrowths or diverticula soon make their appearance at different parts of the circumference of the mass. Some of these are from time to time detached, and being freely supplied with pabulum they grow, and multitudes of separate masses of bioplasm quickly result. These &r& pus-corpuscles, many of which may in this way be formed from the bioplasm of an epithelium cell in a short time. Pus may result in the course of a few hours by the growth and sub- division of any form of bioplasm, if it be supplied with an unusual amount of pabulum. The appropriate pabulum coming into contact with the bioplasm, the latter must take it up and grow. If the excess of pabulum were not taken up by the bioplasm and converted into the quickly growing living matter, pus, it would become decomposed, and the products result- ing from decomposition would infallibly cause the death of every particle of bioplasm in the neighborhood. " Mortification " of a portion of the affected tissue would result. The bioplasm of any tissue, thea, as well as that of which white blood-corpuscles and lymph-corpuscles are com- posed, may give rise to a form of bioplasm, pus, a kind of living matter having general powers and properties, irrespective of the particular form of normal bioplasm from which the "pus" may have been derived. The formation of pus from the bioplasm of an epithelial cell may be studied in the epithelium of the skin, as well as in that of the air-tubes, the 224 THE MINUTE CHANGES bladder, and other mucous surfaces. If living pus be examined, active vital movements will be observed in almost every corpuscle ; and I beg you to study these wonderful movements for yourselves and ponder over them, for they are worthy of your thoughts. See p. 248; also " Disease Germs" or "The Microscope in Medicine," 4th edition. . We are just now, however, chiefly concerned with the changes which occur in the skin beneath the epithelial layer in an ordinary flea-bite. These involve the vessels and nerve-fibres, and are of the highest interest. The lancet of the flea, I need scarcely tell you, goes deeper than the deepest layer of the cuticle, for it penetrates the vessels and occasions changes in the capillaries as well as in other tissues of the skin. This is of importance, inasmuch as an excelle'nt illustration of the remarkable phenomena which occur in inflammation of a complex tissue is afforded. Here we have a comparatively circumscribed inflammation admirably adapted for the investigation of the actual phenomena which constitute the inflammatory process as it occurs in a compound tissue, like the true skin. In consequence of the wound inflicted upon the capillary vessels, there is of course slight escape of blood into the adjacent tissues. This haemorrhage gives rise to a very small deep red punctum or spot, which does not disappear on pressure, called zfetechia (from the Italian Pete- chio, a flea-bite). The important fact to which I now wish to direct your attention is not the petechia caused by the escape of a minute quantity of blood, but the less intensely red area around it, which does disappear when the finger is pressed upon it, so that the blood may be for a moment driven out of the distended capillaries. 'A short time after the lancet of the flea has penetrated the cuticle and subjacent tissues, there appears this bright red blush around the point which indicates the position of the wound. The area forming the round red spot, with the appearance of which most of us are familiar, is, I suppose, of the same diameter in all cases where the lancet of the flea is of the same size, the wound of the same depth, and the irritating poison discharged the same in amount. In the case of an ordinary flea-bite, then, the injury is not confined to the particular portion of tissue transfixed and injured by the lancet, but the disturbance extends some distance around. Those who have not studied flea-bites should do so, and I need hardly assure you that you have abundant opportunities in the wards of the hospital for the observa- tion of flea-bites in every state of change from the most recently inflicted injury to the case in which the redness is disappearing and the bright red tint is giving place to the ordinary color of the adjacent skin. If in a recent bite you carefully notice the redness, you will observe that the red blush ceases at a definite line; the red tint does not grad- ually shade off into the hue of the surrounding skin, but the red limit- ing line is abrupt, and, if the skin happens to be pale, what is seen is a little circular patch about the one-eighth of an inch or more in diam- eter. This area is of a bright red color, almost as red as the cheek, and OCCURRING IN A FLEA-BITE. 22$ if you look closely you may often see a dark spot in the centre, which, as I have said, is the perforation made by the lancet of the animal, ren- dered evident by the passage into it of a little blood. Now there is no doubt that the redness depends upon the distention of the capillaries by blood. These little vessels obviously contain much more blood than they do in their usual state. As regards the precise manner in which this redness is produced there is, however, room for some difference of opinion, and we have, indeed, yet much to learn in connection with this interesting phenomenon. There can be no doubt that the capillaries of the red area contain twice or three times as much blood as the adjacent capillaries of the skin. Now you are probably aware that when we blush, the cutaneous capillaries of the cheeks are suddenly distended, and their diameter, of course, is considerably increased. If it were not so, the difference in the quantity of blood would not be sufficient to produce the intensity of color which is so remarkable. You see, then, that an instrument which is much less than the smallest needle, having passed directly through the skin, has quickly led to dila- tation of the capillary vessels for a certain distance, perhaps the one- sixteenth of an inch or more, around the line of perforation ; but none of the vessels beyond the circumscribed line are dilated, though they freely communicate with the dilated vessels. Does this action depend upon some influence exerted upon certain fine nerve-fibres lying in the course of the wound, or is it due to any direct influence upon the vessels themselves? This last suggestion may be dismissed at once, because by. no direct influence upon vessels, of which we have knowledge can such a phenomenon be produced. There is no doubt, whatever, that the change in the diameter of the vessels is occasioned by injury to the nerves, and it is probable that the congestion of the capillaries depends, not upon injury done to nerves by the passage of the lancet of the flea, but upon the influence exerted on the nerves in consequence of the escape of a small quantity of irritating poisonous, material, which is extruded at the same time, and poisons and irritates the nerves in the course of the wound and those at a short distance around the line' of penetration, and thus causes change in the nerve-centre. Alterations of Calibre of the Small Arteries. The redness of the flea-bite is due to dilatation of the capillaries ; but what is very remark- able and of great interest is this, that the little arteries which communi- cate with and supply the capillaries with blood must be dilated to a cer- tain definite extent. Of this you may convince yourselves by trying the following little experiment. Press the finger firmly upon the skin cor- responding to the flea-bite and skin around it, so as to drive the blood from the distended vessels into the neighboring capillaries. The whole of the skin subjected to pressure of course becomes perfectly pale, the area corresponding to the flea-bite being as pale as the skin around, from the capillaries of which the blood has been temporarily driven. Now a P 226 DEGREE OF CONTRACTION OF ARTERIES few seconds after the finger has been removed, the blood streams back into the vessels of the area of the skin rendered white by the pressure, so as to restore the exact tint which existed before. The flea-bite will re- sume the precise degree of redness it had before pressure was applied, being neither paler nor darker. The pressure has caused only a tempo- rary change. Although the blood had been completely squeezed out of the capillary vessels, the moment it is allowed to return it fills 'these ves- sels and distends them to precisely the same degree of dilatation as before. By this simple experiment we conclusively prove not only that the capillary vessels are dilated, but dilated to a definite extent, so that every capillary will resume the same diameter, and is capable of retain- ing this, at any rate, for some hours, though the blood may be thoroughly squeezed out and allowed to run back as often as you please. How is this brought about ? By what mechanism is it effected and how can the phenomenon be accounted for ? The change is complex and not to be explained in a few words ; but as it illustrates some very important phys- iological and pathological principles the matter is well worthy of atten- tive consideration. In the first place, we must take note of the condi- tions which determine and regulate the flow of blood at a certain rate through the capillary vessels, and these are somewhat complex. The capillaries are elastic tubes, which have no power, as far as is known, of active contraction. They can be distended, and they will recoil or contract so as to be very much less than their ordinary diam- eter, indeed, they may be so reduced as to appear like mere lines, their cavity being for the time obliterated, and not a blood-corpuscle passing through them. Nevertheless the capillary has no active power of con- traction or dilatation. Its thin walls are eminently elastic, and yield if blood or other fluid is forced into the tube by pressure. If they are allowed to react, the fluid will be gradually expelled and the cavity of the tube almost obliterated, the capillary vessel looking like a fine cylin- drical cord. If the little arteries are distended and enlarged, more blood will be permitted to pass into the capillaries, and these tubes will be distended and their walls stretched. If the diameter of the arteries becomes reduced, the capillaries will shrink. These phenomena are repeated whenever the pressure by which the blood is forced into the vessels is reduced or increased. The Degree of Contraction of the Minute Arteries deter?nined and maintained by Nerve Action. And now as to the vessels which pour their blood into the capillaries. The smaller arteries, we know, are capable of undergoing very great alterations in calibre, the alterations being of an active character. By active I mean that the diameter of a small artery can be maintained for a time at a certain uniform standard, the canal being completely obliterated, or increased to twice the area of its usual section, or half the area, as the case may be, and this irrespec- DETERMINED BY NERVE-ACTION. 22/ tive of any temporary changes produced by mechanical pressure applied from time to time. The smaller arteries are encircled by numerous muscular fibres, placed as close as possible to one another, often arranged in very many layers. This muscular tissue constitutes the greater part of the thickness of the arterial walls. An idea may be formed of the arrangement of the mus- cular fibre-cells of a small artery, and of the manner in which, by con- tracting, the tube of the vessel may be constricted, and of the mode of distribution of the nerve-fibres, if the accompanying figure, p. 229, be carefully examined. When the encircling muscular fibres contract, the tube of the artery is, of course, diminished. When the muscular fibres undergo relaxation, the tube of the vessel will be enlarged. The calibre of the artery is entirely dependent upon varying degrees of contraction or relaxation in the contractile fibres, and the change takes place in all little arteries from time to time. This is not a passive change, like the mere dilatation and recoil of the elastic capillary vessels, but a change due to varying degrees of contraction or relaxation of the muscular fibres which encircle the tube, and which may be retained at a precise point without the least variation in extent or vigor for a con- siderable time. The contraction of the muscular fibres may even remain constant in spite of an alteration in the pressure by which the blood is driven into the tubes. Next, we must inquire by what means a definite degree of contraction and relaxation of the muscular fibres of the little arteries is determined. It has been conclusively proved, partly by the results of experiment and partly by reasoning based upon the fact of the arrangement and distri- bution of nerves to muscular fibres, which has been demonstrated by microscopical investigation, that the Avonderful changes in question are brought about through the instrumentality of nerves and nerve-centres only. For every set of minute arterial vessels there is a nerve-centre, and by alteration in the condition of this nerve-centre the calibre of the little arteries, or, in other words, the degree of contraction of the mus- cular fibres of their coats, will be determined. Each nerve-centre is connected with other centres by intercommunicating fibres, so that a very few arteries only may have their calibre altered, or the change may occur in hundreds and thousands of vessels, distributed to a large extent of tissue at the same moment. Everything I am telling you is based on observation and experiment, and I shall be able to show you in microscopical preparations the actual nerve-fibres concerned. We can easily demonstrate the muscular fibres of the minute arteries of the body of man and vertebrate animals gener- ally. We know, too, that there are nerves abundantly distributed to these arteries, and that the nerves are connected with ganglia. Of the Ganglia governing and regulating the Calibre of the small Arteries. In manv instances I have followed fine nerve-fibres distributed 228 DISTRIBUTION OF NERVES TO ARTERIES. to the muscular fibres of a minute artery for a long distance, and have traced them to their origin in an individual nerve-cell in the nerve-centre. The nerve-centres connected with these and other nerve-fibres con- cerned in governing and regulating the flow of blood through the arte- ries and capillaries are extremely numerous. The arrangement of the centres or ganglia and of the entering and emerging nerve-fibres can be most easily studied in the coats of the intestine of any small animal; but for investigating the structure of the nerve-cells themselves, the little green tree-frog (Hyla viridis) should be selected. If you examine the .mesentery near the intestine of this animal and the areolar tissue in the back part of the abdominal cavity, you will find the ganglia as numerous as is indicated in this drawing. If you take a portion of the mucous membrane of the small intestine of man, or of one of the higher ani- mals, say not more than a quarter of an inch square, and prepare it care- fully, you may find from half a dozen to a dozen or more ganglia. Each ganglion will contain from two or three to two or three hundred cells, and every individual cell will have at least two fibres issuing from it.* By this investigation you will be able to gain a correct notion of the general nature and structure of the nervous apparatus which exerts an influence upon every part of the vascular system, and particularly of the finest ramifications of the nerves distributed to the walls of the small arteries, veins, and capillaries, and, in certain cases, to the tissues which intervene between the capillaries. Ganglia and intercommunicating bundles of nerve-fibres exist in every part of the intestinal canal of man and the higher animals. Although no nerve ganglia exist very near the ultimate distribution of the nerves to the small arteries of the skin of the body and to the tissues of the limbs, we know that these nerves are all connected with, nerve-centres exhibiting the same general structure and arrangement as those found in connection with the mucous membrane of the intestines and other viscera of the abdomen and thorax. All belong to the so-called Sympathetic system. Nerve-centres or ganglia are placed in certain special parts of the trunk, and from these bundles of nerve-fibres are derived which are distributed to the vessels of the head and extremities. The minute arteries by which blood is distributed to the muscles of the limbs, to the large nerves, to the brain and spinal cord and their membranes are as fully supplied with nerves, and are as much under the influence of nerve ganglia of the sympathetic system, as are the arteries of the lungs or the heart, or those of the liver, kidney, or other secreting organs. I propose now to describe more fully the mechanism by which the varying calibre of the small arteries is determined. You will form a correct idea of the degree to which little arteries may contract if you take note of what is represented in this drawing (not introduced in this * " Phil. Trans.," May, 1863. DISTRIBUTION OF NERVE-FIBRES TO SMALL ARTERY. <* FIG. I. A small artery from the bladder of the hyla or green tree-frog, showing the distribution of fine nerve-fibres to the muscular fibre cells of the vessel. The nerve-fibre can be followed from the nerve trunk a to the vessel. In the connective tissue to the left are seen two muscular fibre cells with nerve- fibres distributed to them. These belong to the tissue to which the artery was distributed, and are not connected with the vessel. X 215- About the middle of the figure the tube is somewhat constricted, in consequence of slight contraction of the muscular fibre cells in this part of the artery. nfas of an inch X 215- 2O 229 230 THE NERVE-FIBRES OF CAPILLARIES. work) of the arteries of the Pia mater of the common sheep, which were injected, immediately after the death of the animal, with Prussian Blue fluid. (For the composition of this fluid and the method of injecting, see " The Microscope in Medicine," or " How to Work with the Micro- scope.") The walls of the vessels, with their muscular fibre-cells, are well shown. The little arteries at the time of death have contracted, so as to produce great irregularity in the calibre of the arteries. You see in one place the muscular fibres of a considerable length of the vessel have vigorously contracted, so as to obliterate the canal. Very few blood-corpuscles could have passed through this part of the vessel at the time of the contraction of its muscular fibres. This firmly con- tracted portion of the little artery is immediately continuous with another part of the vessel where the coats are relaxed, and the diameter of the tube here would be perhaps twenty times that of its continuation in the contracted portion of the vessel. Many different portions of small arteries in various degrees of contraction are represented in different parts of the drawing. (A very slight degree of contraction is seen in the little artery figured on page 229.) We must yet go somewhat more into detail before we can expect to find an adequate explanation of the changes which take place in the coats of the small arteries during life, by which variations in their calibre are determined, and which are intimately connected with the causation of the phenomena of the flea-bite. It must be borne in mind that the arteries are not the only small vessels which are supplied with nerve- fibres. It has long been known that to the coats of the small veins nerve-fibres are abundantly distributed, but the general arrangement of the finest fibres has not been fully investigated. They exist in great number, and, indeed, in much greater number than would be expected, considering the paucity of the muscular fibres of the veins and the thin- ness of the coats of these vessels. From the great number of the nerve- fibres one would incline to the notion that some were concerned in transmitting impressions to the nerve-centre. If all are motor fibres, their number in proportion to the amount of muscular tissue is far greater than elsewhere. But besides the distribution of nerves to small arteries and veins, I must beg you to pay attention to the arrangement of the nerve-fibres which belong to the capillary vessels. Of the Nerves of Capillary Vessels. You will not find it stated in any of your text-books, even at this time, that nerve-fibres are distributed to capillaries. Not only is this the fact, but upon many capillaries a considerable number of fine nerve-fibres may be seen to ramify. As long ago as 1860 I succeeded in demonstrating this new set of nerve- fibres, distributed to the capillary vessels, which had not been previously described. Numerous observations upon the capillary vessels of various vertebrate classes have convinced me that the capillaries of vertebrate animals generally are freely supplied with nerves; or, to speak more NERVES OF CAPILLARY VESSELS. 231 accurately, that just outside, or at a short distance from the 'outer sur- face of the walls of the capillaries, very fine nerve-fibres exist, which in many cases form a lax network or plexus of extremely delicate nerve- fibres on the outer surface of the vessel. The fact is not of anatomical interest only, but the distribution of the nerve-fibres in question has an important bearing upon questions concerning the action of the minute vessels during life. Upon carefully examining capillaries in many tissues of the frog, according to the plan I have described in "Microscope in Medicine" and "How to Work with the Microscope," you will meet with little difficulty in demonstrat- ing the nerve-fibres to capillary vessels. I could show you more than FIG. 2. From an interval between the fibres of the mylohyoid muscles of the hyla, a. Trunk of fine dark- bordered nerve-fibres with fine fibres coming from them, one of which may be traced to the capillary b, while others are distributed to the muscular fibres, which are not represented in the drawing. Th ; arrangement of the nerves supplying the capillary vessel is well seen. From a specimen mounted in glycerine and more than ten years old. X 2I 5' twenty preparations from the frog in which branches of nerve-fibres to the capillary vessels are seen, without the slightest doubt. The fact can- not be explained away. There is no question whatever about the deli- cate fibres in question being nerves, because in many instances I have been able to trace the fibres from their distribution outside the capil- laries to their connection with the ganglion cell, without one break in the continuity of the matter of which they consist. But many will not believe that a structure which may be demonstrated in a cold-blooded vertebrate animal like the frog necessarily exists in the higher vertebrata and in man. I have, however, succeeded in demonstrating nerves to capillary vessels in several mammalian animals and birds, and have been able to permanently preserve several of the specimens. One of the best animals for the investigation is the white mouse, because there is very little connective tissue in this animal to obscure the extremely delicate nerve-fibres. Upon the whole, however, I prefer the bat's wing ; and of the arrangement of the nerves upon the capillaries and in other tissues 232 MECHANISM OF CAPILLARY CIRCULATION. connected with the thin membrane of this wonderful organ I have pre- served several specimens. I have represented a very clear specimen in the accompanying figures 3, 4. It has been magnified only 215 ; but to see the points clearly a magnifying power of 700 is required. Of Demonstrating the Nerves distributed to Capillaries. In order to see the delicate nerve-fibres and the capillary vessels, it is necessary to obtain a structure in which the capillaries themselves can be seen with- out much dissection or the necessity of section cutting ; for if you have to dissect the tissue, you will tear the capillaries, and then you will not be able to follow the nerve-fibres for any great distance. In the bat's wing, and also in the bladder of the frog, you have a natural dissection almost ready for observation. (Arrangement shown in several enlarged copies of drawings.) Of the arrangement of nerve-fibres in a tissue, a considerable extent of which is altogether destitute of capillary vessels, one can hardly point to a better illustration than is afforded by the cornea of a small animal, particularly the hyla or little, green tree-frog. The nerve-fibres in this transparent fibrous tissue are exceedingly numerous, forming extensive networks of wonderfully delicate nerve-fibres, with which, at short in- terval's, small masses of bioplasm are connected. From these the fibres grow, and the net-work of nerve-fibres increases in extent a's the cornea expands in dimensions. A thin section, which includes the anterior surface of the cornea (placed uppermost so as to be just beneath the thin glass cover) is most favorable for observation. High powers ought to be used (from 300 to 1,200 diameters). In such a specimen you can trace all that is represented in my drawings. The nerves divide and subdivide at short intervals, and extensive networks of excessively fine fibres are formed, which lie on different planes, and are to be found in every part of the corneal tissue, though the networks are more numerous near the anterior surface than in other parts. These nerve-fibres might be regarded as extensions of those belonging to capillary vessels. At the margin of the cornea some are undoubtedly continuous with the latter, but many of the nerve-fibres of the corneal tissue may be fol- lowed to bundles of nerve-fibres at the margin of the cornea. Of the Mechanism by which the Capillary Circulation of Man and Animals is regulated. My chief object in troubling you with this some- what detailed anatomical description is that I maybe able to explain the probable action of these fine nerve-fibres distributed to the capillary ves- sels, and give some account of the very important office they discharge during life. It is true that much of this discussion strictly belongs to the province of physiology, but inasmuch as the inquiry has a most im- portant bearing in connection with the determination of the nature of the phenomena occurring in the simplest pathological changes, in a flea- bite for example, I shall make no apology for referring to it here. With- out the facts above referred to, and deprived of the inferences deduced CAPILLARY VESSELS AND NERVE-FIBRES FROM THE BAT'S WING. FIG. 3. Capillaries and very fine nerve-fibres distributed to the bat's wing. In many parts of the specimen the nerve-fibre could be followed from a bundle of fine nerve-fibres to the capillaries. Two instances of this are shown in the drawing. f^fj, of an inch X 215. FIG. 4. A small part of Fig. 3 highly magnified. The distribution of the nerve-fibres to the capillary and their relation to its walls are well seen. The mode of branching and division of some of the finest nerve-fibres are also well shown in the lower part of the drawing. X 7. 20* 233 234 ARRANGEMENT OF NERVE-FIBRES. from these observations, I should be unable to explain to you the phe- nomena of inflammation or fever as these pathological changes occur in man and warm-blooded animals. In order to make my meaning clear, I must refer to this diagram, which is, as it were, made up from obser- vations actually carried out on several different specimens. FIG. 5. I. 2. Diagram to show self-regulating mechanism connected with the minute arteries and capillaries. a, artery with muscular fibre-cells; the dark lines show its diameter when dilated, b, small vein. c, capillary net-work. Over No. I the capillaries are dilated and over No. 2 they are contracted, d is a ganglion cell with at least two sets of nerve-fibres connected with it, one of which, e, divides and subdivides, giving off nerve-fibres, which are distributed to the artery a, while the other,/", is contin- uous with the plexus of nerve-fibres ramifying clse to the capillary vessels. Nerve-fibres are also distributed to the small vein, b, but these are not represented in the drawing. The bioplasm of the vessels and nerve-fibres is shown. The vessel to the left, b, is intended to represent a small vein, while that marked a is a small artery, and the net-work of small tubes below, which are continuous with both vessels, are the capillaries, outside which you see here and there delicate fibres, nerve-fibres. These are really distributed to the capillary vessels in very much the same manner as is represented here. The nerve-fibres distributed to the capillary vessels join to form a fine nerve-trunk, and are by continuous fibres connected with a cell, d, of the nerve-centre, e is the nerve-fibre distributed to OUTSIDE THE CAPILLARIES. 235 the artery, and /is that connected with the branches distributed to the capillaries] those capillaries near the vein, over i, being distended, so that the nerve-fibres are nearly in contact with their walls; while those over 2 are contracted, and a considerable interval is seen to exist be- tween the outer surface of these and the nerve-fibres distributed to them. The greater part of the nerve-circuit, which I have endeavored to depict, has been demonstrated by actual observation, but there is a break or hiatus as regards the connection of the particular fibres distrib- uted to the artery and those to the capillary, with the nerve-cell. One cannot identify the afferent fibre and the efferent branch connected with the very same cell as is here represented. There is no doubt whatever as regards the existence of two fibres in connection with each nerve-cell in any nerve-centre. Nor, as I have already stated, is there any doubt about the connection of one of these fibres with the fine nerve-fibres which are distributed to the artery, for the continuity has been demon- strated. The ramifications of the fine nerve-fibres upon and amongst the muscular fibres of the artery have also been demonstrated in numer- ous specimens from representatives of the different classes of Vertebrata. I have not succeeded in tracing the nerve-fibres from capillary vessels to the same identical nerve-cell as that from which the nerve distributed to the little artery which subdivides into the capillaries takes its rise. I con- sider the arrangement to be as follows : The very fine nerve-fibres which I have shown to be distributed to capillary vessels are probably afferent. These transmit centripetally to the nerve-cell impressions from the sides and immediate neighborhood of the capillary vessels, and from the' tis- sues between the capillary vessels. In the cells of the nerve-centre a change takes place whenever the peripheral ramifications of these affer- ent nerve-fibres from the capillaries are irritated. In consequence of this change effected in the nerve-centre, an impulse to movement is trans- mitted by the nerves, which are at length distributed to the muscular fibres of the little artery, when the muscular fibres will contract, and the tube of the artery will be reduced in diameter. The calibre of the artery is at once reduced, and the blood stream which flows onward into the capillary vessels is diminished ; or, in other words, the quantity of blood passing to a given area of tissue in a given period of time is much re- duced. Under other circumstances the nerve-fibres distributed to the capillary vessels, instead of being irritated, experience a paralyzing influence, in consequence of which a corresponding action is produced in the nerve- centre, and, instead of contraction, we have relaxation of the muscular fibres of the little artery; and the quantity of blood passing through the vessels within a given period of time must be increased to an extent proportionate to the increased diameter of the vessel. Here, then, is a self-regulating nervous mechanism connected with the distribution and regulation of the blood-current in the capillary vessels of the body of a 236 CALIBRE OF ARTERIES most efficient kind, coming into action on the slightest disturbance of the equilibrium of activity either at the peripheral distribution of the nerves or in the nerve-centres connected with them. The quantity of blood passing through these vessels can be regulated to a nicety. The stream may be increased or diminished suddenly, or an uniform flow maintained for a considerable period of time. These changes are brought about solely by the influence of the nerves in determining the degree of contraction of the muscular fibre cells which encircle the artery. Let us now apply what we have learned to the phenomena of the flea- bite : When the lancet of the flea, after penetrating the cuticle, reaches the capillaries of the skin, some of the fine nerve-fibres distributed to the capillaries will be severed, others no doubt being stretched or pressed upon by the blood and fluid which escape from the vessels, and in conse- quence of the distention which the latter undergo. The result is -a relax- ing or paralyzing action upon the nerve-centre. The efferent nerves being thus influenced, the muscular fibres of the little arteries yield, and become flaccid and elongated. Hence the diameter of the tube of the vessel will become largely increased. A greater quantity of blood will flow into the capillaries, and these vessels will in consequence become distended. This action probably depends partly upon severance of fine nerve-fibres by the cutting action of the lancet of the animal, but it is in part due to the influence of poison expelled at the moment, which spreads for a short distance among the elements of the adjacent tissues, perhaps acting chemically on the nerve-fibres or on their bioplasm, and causing a paralyzing influence. But what is highly interesting and very remarkable is this : The relax- ing or paralyzing action is exerted to a definite extent, and maintained without variation at a given point for some time. The dilatation of the little arteries is effected, and the degree of constriction exerted by the muscular coat is altered for a time. The muscular fibres yield accord- ing to the degree of paralyzing influence produced upon the afferent nerves at the seat of injury. That the degree of dilatation does not vary from moment to moment may be proved in a very simple manner. If you squeeze the little vessels of the congested area of skin by pressing firmly for a second or two with one finger, so as to drive the blood out of the vessels, the whole of the skin subjected to the pressure will be seen at the moment when this is removed, to be uniformly pale. In a few seconds, however, after the pressure has been withdrawn, the blood will re-enter the vessels, and the inflamed area will resume its redness, while the surrounding skin will regain its original tint. The varying degrees of redness observed in different flea-bites are due entirely to the varying degree of dilatation of the hundreds of little arteries which sup- ply the capillary vessels of the inflamed area. The distention of the capillaries varies according to the calibre of the arteries, and is there- fore entirely under nerve control. If complete paralysis of the nerve- ALTERED BY LOCAL INJURY. fibres distributed to the little arteries, or of the centres from which they emanate, were to occur, the capillaries would become distended to the utmost limit, and the circulation through them would cease. The sur- rounding tissues deprived of their blood supply would become disorgan- ized, and might at once pass into a gangrenous state, or might slowly degenerate and waste. Such is the nature of the very important vascu- lar phenomena which occur in all cases of inflammation, and which, when affecting a considerable extent of tissue, may cause serious structural changes, and result in the development of chronic disease, or, where certain important organs are affected, may cause even sudden death. General Vascular Disturbance resulting from Local Injury. But in many instances, the result of the local injury is much more widely spread. In some cases this is due to poison being introduced into the blood, so that the whole mass of nutrient fluid is poisoned, and, through it, every tissue and organ of the body may suffer. But there are not a few instances in which the facts cannot be thus explained, but seem rather to be due to the same series of changes which occur in an ordinary flea- bite, the action being more intense. The bite of a gnat, the sting of a bee, wasp, or hornet, will occasion phenomena in connection with the vessels of the same kind, but more serious and extensive than the injury inflicted by the lancet of the flea. Such local injuries may cause dilata- tion of the little arteries and capillaries over a considerable portion of the body. In consequence of the bite of an ordinary gnat, the whole of one arm may become enormously swollen. So large a quantity of exudation may escape from the vessels, that the areolar tissue of the limb may be much distended, the elements of the tissues generally being in a state of tension, their action much deranged or entirely marred. In short, a condition of very acute and serious inflammation may result. In such a case, I think that the more extensive local mischief is per- haps due to a more severe and more extensive local change having been produced at the seat of injury. Instead of derangement of the action of the vessels of a very limited area of skin, as in the flea-bite, we have evidence of extensive disturbance in the circulation affecting small arter- ies, capillaries, and veins of the tissues, of part of a limb or of the entire limb. The influence is, however, still limited, and such a case must be distinguished from those in which the tissue-changes result from the whole mass of the blood being poisoned. As a general rule, a gnat- bite does no harm whatever. Most of us have been bitten over and over again ; and I dare say some have carefully watched the interesting opera- tion performed by the insect, and, when the instrument has been care- fully inserted through the cuticle, and into the true skin, have felt the pricking sensation which indicates the arrival of its point at the nerve- fibres adjacent to the capillary. Then follows the perforation of the capillary, and soon the blood will be seen to ascend, and you will notice the abdominal cavity of the insect becoming gradually distended by the 238 GENERAL CHANGES FROM LOCAL INJURY. inflowing blood. In a short time the creature is satisfied, and, after care- fully withdrawing his proboscis, he contentedly flies away, though slowly, for his body will be more than twice as heavy as it was when he first attacked you. With the exception of slight tingling, which lasts for a little while, no further effect, as a general rule, will be produced ; but I know persons who do not escape so easily. Sometimes a single gnat- bite will cause the whole of the hand and arm to swell enormously, and the state of inflammation may last for two or three days, and may be accompanied by much pain. A similar remark applies to the sting of a bee, or wasp or hornet. Some individuals will be seriously affected, while others will escape with very little inconvenience.* Such facts are not incompatible with the view of the phenomena being essentially due to nerve change, and we have ample evidence that some persons' nerves are much more susceptible to the same degree of irrita- tion, mechanical or chemical, than are those of others. A mechanical injury or a poisonous influence sufficiently severe to cause death in one case might scarcely produce any serious change in another. It is possi- ble that there may be some structural difference in the nervous system of the two persons, but it is perhaps more probable that the cause of dif- ference in the results is deeper, and depends upon some difference in the individuality and powers of the bioplasm of the nerve of a nature not to be rendered evident by physical investigation. We note correspond- ing peculiarities as regards the action of medicine. I have known in- stances in which the smallest dose of Morphia will occasion, within three or four hours of its being swallowed, dilatation of the capillary vessels of the greater part of the surface of the body, shown by a diffused red- ness in patches. Less than one-tenth of a grain of Morphia has led to this result, but such a dose, as a general rule, would produce only a very slight effect, or the person might be unconscious that any such drug had been * An interesting fact has been made out by Dr. Manson, in China, with regard to the transference by gnats of embryonic or immature entozoa from the blood of the human organism to water. The minute Filaria sanguinus hominis is the entozoon in question. It exists in the blood in certain cases in immense numbers, and has been removed from the circulating medium, and transferred to the situation where it is to undergo further change in the remarkable way just referred to. An excellent resumt of what is known concerning this entozoon will be found in a paper read at the Epi- demiological Society, by Sir Joseph Fayrer, and published in the "London Lancet" for February 8th, 1879. We have long known that many infectious diseases may be spread by the agency of insects, but here we have an insect extracting blood from the interior of the vessels, and carrying some of this very same blood, and diffusing any special living particles it may contain into other media, where these organisms may pass another part of their existence, and possibly grow and multiply. It is obvious that other living disease- causing organisms may be distributed far and wide in the same manner, and thus many special fevers, and inflammatory diseases occurring in man and animals, and depending upon a living poison, may be carried to a distance, and preserved for long periods of time, or undergo farther development. FEVERS AND INFLAMMATIONS. 239 given at all. The nerves and the nerve-centres connected with the vas- cular system exhibit very different degrees of sensitiveness or suscepti- bility in- different persons. In discussing the probable nature of the actual changes induced by such poisons, which act upon the fine ramifications of the nerves dis- tributed to capillary vessels, we have to consider: i. The direct local action of the poisonous material on the nerve -fibres and other tissues with which it comes at once into contact ; and, 2, the local action of the poison on the capillary nerve-fibres in many tissues and organs of the body at a" distance from the seat of injury, through the contamina- tion of the whole mass of the blood. In both cases, whether the action be local or general, circumscribed or diffused, the widest difference as regards the degree of action exerted by the same poison and the same amount of poison on different persons will be observed, and this must be referred to the peculiarity of constitu- tion of the individual, to the degree of tolerance his nerves may have acquired by the influence of previous exposure, and a number of other circumstances. The same amount of poison in the blood may be suffi- cient to cause the most grave symptoms in one person and not give rise to the slightest change in others. You see how large a subject' is opened for consideration by the dem- onstration of the nerve-fibres to capillary vessels, and what a number of important and widely separated physiological and pathological actions may be explained and accounted for by the influence of this important part of the nervous system. OF THE FORMATION OF PUS IN AND NEAR THE CAPILLARIES IN INFLAMMATION AND FEVER. I have already advanced arguments which, as it seems to me, fully justify the conclusion that fever is a General Inflammation, while inflam- mation is to be regarded as a Local Fever. Some among you who have considered the matter may, however, object to this inference, on the ground that what is known as " pus" is a very constant product in in- flammations, but is not generally formed in fever. Such an objection will, however, disappear if we study the mode of formation of this liv- ing matter, pus. Indeed, in most fevers the pathological phenomena are, happily, not sufficiently intense. The changes do not proceed to the extent necessary for the development of pus-corpuscles. There are, however, fevers in which the development of pus is common enough. In Erysipelas, which may be correctly included under fevers or inflam- mations, pus, as you are aware, is often formed to an extent sufficient to destroy important tissues and to cause death. Some of you of late years may have been assured that erysipelas, like many other fevers and inflam- mations, is due to the presence and growth and multiplication of bacteria. The process of suppuration itself, it has been said, is occasioned by these 24O BIOPLASTS PASSING THROUGH VESSELS. organisms. I have already treated of this question in " Disease Germs " and elsewhere. I shall, therefore, only remark here that, in my opinion, there is no reasonable ground for either hypothesis, and that The facts can be adequately explained without invoking the aid of bacteria. In the course of the changes taking place in erysipelas, pus, unfortunately, is very often formed. You may have suppuration of the tissues in the greater part of the affected limb. Indeed, in some cases the areolar tissue extending over a considerable part of the body may be the seat of the formation and multiplication of pus-corpuscles. In ordinary fevers life is usually destroyed before that degree of change which involves the process of suppuration has been reached. If, how- ever, severe fever lasted for a considerable period and life was sustained for a sufficient time, many of the tissues might pass into the state of suppuration. Such is, unfortunately, but too frequent in very severe cases of scarlet fever, in which disease suppuration sometimes occurs in several of the joints, besides which small abscesses are not unfrequently developed in many different parts of the body. It is easy to see why suppuration should be more commonly developed in connection with intense local inflammation than in the more widely spread, but less in- tense, action which occurs in fever. In inflammation the change is com- paratively circumscribed, and may, therefore, go to a much greater extent without destroying life than is possible in the case of fever, for the mass of the blood and every tissue in the body is more or less affected, while the action of some of the most sensitive organs is seriously deranged and the organs themselves damaged. Not unfrequently the brain and some parts of the nervous system seem to be poisoned by the altered blood. A huge abscess containing pints of pus may be formed in the course of a fever and the patient nevertheless get perfectly well, if only his strength can be sufficiently supported and the case be well nursed and judiciously managed. Anything like general suppuration of all the tissues of the body is impossible in fever, because death would take place long before such an event could occur. The formation of pus, and the manner in which the pus-corpuscles move and grow and multiply, have been already referred to on p. 223. Of the Passage of Blood and Living Particles through the Walls of Capillary Vessels. Diapedesis. I have now to say a few words about certain other phenomena of inflammation. When ordinary inflammation takes place in a part, the vessels, as I have already said, are more or less distended with blood, and as the walls of these capillary vessels are stretched and rendered thinner by distention, fluid will more readily transude through them than when they are in their usual medium state of tension. Suppose this outline (chalk diagram) to represent the area of a section of a capillary vessel in the ordinary state, neither contracted nor stretched. This larger circle with thinner outline (diagram) may stand for the same capillary vessel, with its walls much thinner and its THE PASSAGE OF PARTICLES 241 calibre greatly increased, as in the state of congestion, which gradually passes into inflammation. Now, it is obvious that, if the walls of this capillary are to be so stretched as to form a tube as much more capacious than the vessel in the ordinary state, as would be the tube of which this circle is the limit, than that indicated by the last outline, great thinning of the walls must take place. Whenever capillary vessels are distended with blood, there must be increased tenuity of their walls. The greater the diameter of the vessel the thinner will be its walls, and the thinner the walls the more readily will fluid permeate them. Now, in Inflam- mation and Fever, fluid, and often not only fluid, transudes from the blood through the walls of the capillaries of the affected parts into the tissues around the blood-vessels. The material which is poured out has long been called Exudation, and this material varies somewhat in character and composition in different cases. Certain changes taking place in the blood itself may cause the fluid to become more permeable than the ordinary fluid portion (liquor sanguinis) of healthy blood. In many forms of disease the quantity of matter dissolved in the fluid which permeates the vascular walls is'greatly increased, and probably the fluid itself is otherwise changed. But you must bear in mind that, beside the fluid which transudes through the capillary vessels in inflammation and fever, multitudes of excessively minute and very soft particles also traverse the capillary wall. Of these the great majority are less than the one hundred-thousandth of an inch in diameter, but some are very much larger than this. Indeed, particles as large as a red blood-corpuscle may find their way through the capil- lary wall without causing any rupture or permanent damage to the vessel, and through openings which it is not easy to demonstrate. Of this, instances have long been known in the case of what has been correctly termed capillary haemorrhage. After this haemorrhage has taken place, the stretched and distended vessels may return to their ordinary con- dition without any deterioration of the structure occurring in the walls which have been stretched. Such phenomena occur in every case of pneumonia. You will naturally ask how large particles like the red blood-corpuscles pass through the walls of vessels in which no fissures or openings can be discerned. When we study the changes taking place during develop- ment, we learn that the walls of the capillary vessels are, as it were, laid .down in such manner that the tissue of which they are composed, though exhibiting no 'definite indication of actual fibres, will tear much more readily in the longitudinal than in the transverse direction. Whenever the capillaries are distended by the accumulation of blood, and their walls stretched by lateral pressure, the fibre net-work, of which they may be supposed to consist, would have its meshes considerably widened in such a way that longitudinal rents or fissures would result, which would be large enough to permit the passage of more than one red blood-cor- 21 Q 242 THROUGH THE WALLS OF VESSELS. puscle at a time through them. The distending force ceasing, the elastic tissue of the capillary wall would react, and the vessel gradually return to its ordinary size, the rent slowly closing up. We can, therefore, readily imagine that a body as large as a blood- corpuscle would easily escape sideways through one of these fissures and pass amongst the tissues outside the vessel. Such escape of blood-cor- puscles, a few at a time, takes place from the capillaries of the walls of the air-cells of the lungs in every case of ordinary inflammation of the lung tissue, or Pneumonia. In cases, however, in which blood extrava- sates to any great extent, as where blood escapes from a surface in drops, a free tearing, or other solution of continuity, of the walls of the vessels undoubtedly occurs. Even where violent haemorrhage has taken place from vessels of considerable dimensions, it is often most difficult to demonstrate the opening. You need not, therefore, be surprised to learn that it is almost impossible to expose the actual holes, rents, or fissures in the walls of capillary vessels which have allowed the exit of a few blood-corpuscles. There are cases in which haemorrhage occurs from a vast tract of capillary vessels, as for example, of the mucous membrane of the small intestine, and yet the fissures or rents cannot be detected, though several pints of blood may have been lost in the course of half an hour, in consequence of capillary hemorrhage. This may cause faint- ness and death. In such cases of fatal capillary haemorrhage, no doubt, degenerative changes have been taking place in the walls of the capillary vessels involved, during a considerable period of time previous to the occurrence of the haemorrhage. When one comes to examine the mucous membrane after death, the whole of the surface is found suffused, and the tissues, so to say, infiltrated with blood which has issued from mil- lions and millions of capillaries, distributed over perhaps as much as six feet of intestine. I have seen several instances of death from almost sudden and profuse capillary haemorrhage from the mucous membrane, extending over many feet of the small intestine, consequent upon slow morbid changes pro- ceeding in the liver and resulting in the condition known as cirrhosis. In the course of this disease the circulation through the liver becomes greatly impeded, and in consequence congestion of the mucous mem- brane of the intestines ensues, and frequent slight attacks of bleeding occur, which may at last end in extensive and fatal haemorrhage. If you were to inject the vessels in such a case, the injection would ooze from multitudes of minute openings, but no large aperture would be discovered in any large or small vein or artery. The case is very different where a large vessel is opened in the process of ulceration, as frequently occurs in the course of ulcer of the stomach and in phthisis, or as sometimes happens in aneurism. There are certain forms of capillary bleeding or haemorrhage which are very common, and not indicative of any actual disease, and which COHNHEIATS RESEARCHES. 24$ may fairly be regarded as slight ailments. Bleeding from the mucous membrane of the nose is one of these. Some children frequently suffer from this affection, and in certain instances relief to headache or to a sensation of fulness in the head is afforded by the slight loss of blood which occurs. Haemorrhage of the same kind may take place from the back of the throat, from the gums, from the stomach, and even from the lungs. Occasionally bleeding takes place from the rectum, without pro- ducing more than temporary derangement, though, of course, it causes alarm to the patient and his friends. You must be very careful about giving a too positive opinion concern- ing the exact nature of many of such cases, for bleeding from one or other of the surfaces above mentioned may be a grave matter, and per- haps the first indication of serious disease. On the other hand, even several teaspoonfuls of blood may escape from capillary vessels without the general health being in any way deranged. After tension has been relieved by'this haemorrhage, the vessels return to their former state and the blood circulates in them as before. In cases of haemorrhage from the mucous membrane of the nose, I believe that the capillaries become much congested, and that actual longitudinal rents or fissures are made through which blood escapes. If the attacks are frequent and severe and the patient's strength fails, it may be necessary to adopt remedial measures even in a case of what appears to be ordinary bleeding from the nose. Perfect rest in the half- recumbent posture, the application of cold to the nose externally, suck- ing small pieces of ice, are usually effectual, but it may be necessary to use styptics or "plug the nostrils" in severe cases. This, however, is not the place to discuss the treatment requisite in cases of such gravity. It should, however, be borne in mind that bleeding not depending upon actual disease may take place from many other organs and surfaces as well as from the mucous membrane of the nose. Haemorrhage from minute vessels used to be spoken of -as haemorrhage by exhalation ; and the older observers believed the escape of blood from the vessels occurred in some mysterious manner not to be adequately ex- plained. They seemed to think that the blood passed through the walls of vessels in some strange and inscrutable way. By the aid of recent in- vestigations we can form a clear idea of the manner in which the haemor- rhage through the walls of the capillaries may occur without actual rup- ture. The phenomenon is of great interest, and we may conveniently consider under the same head a process which has been regarded by many observers as essential to more than one general pathological change, and which has been spoken of as Diapedesis. It was proved experimentally by Cohnheim, of Berlin, that colorless blood-corpuscles might pass from the cavity of the peritoneum into the vascular system, and that in the case of the membrane of the frog's foot and other tissues when in a state of inflammation, colorless blood-corpus- 244 MINUTE BIOPLASTS. cles made their way through the capillary walls, though no openings could be seen and the capillaries themselves were not unduly distended. Cohn- heim maintained that this migration of colorless blood-corpuscles was an ordinary phenomenon; that it was common, and constantly took place, to a great extent, in every case of inflammation. Nay, he went so far as to insist that pus itself consisted of colorless blood-corpuscles which had made their way out of the vessels. Of course it occurred to many that the last proposition was rather difficult to accept, for the number of pus-corpuscles in an ordinary abscess formed in the course of the twenty-four hours is so great, that had every colorless blood-corpuscle in the body made its way into the abscess a mere modicum of the total quantity of pus present would be thus accounted for. The pus-corpus- cles in a small abscess, or on the surface of an inflamed mucous mem- brane, outnumber by many times the whole of the colorless blood- corpuscles in the organism. Many observers in this country, however, advocated the above view, and it has in consequence formed a cardinal doctrine of more than one school of pathology. Of those who profess to have seen the phenomenon in question, not a few will tell you that it is easily demonstrated and occurs constantly. He who proceeds to study the matter for himself will, I think, find that only very occasion- ally can he feel at all sure that a colorless blood-corpuscle has actually passed through the vascular walls. The careful observer will not unfre- quently find that a corpuscle which seems to pass through the walls of a vessel does not really do so, and is, in fact, either in front of the capil- lary or behind it, and has not come out of the vessel at all. There is, however, no doubt that this migration of colorless blood -corpuscles does occur, but I believe it to be an exceptional, rather than a common or ordinary, phenomenon, while I feel sure that, in many cases, the proc- ess of inflammation may run its course entirely without the escape of a single blood-corpuscle. The corpuscles found outside the capillaries in great numbers in cases of inflammation, are produced not by the passage of colorless corpuscles from the blood, but by the growth of very minute particles which have escaped with the transuded fluid. These particles do not consist of col- orless blood-corpuscles, which, as such, have traversed the walls as has been supposed. So far from having been colored blood-corpuscles, it is doubtful whether at any time one of them ever circulated in the bloc.l as such. What, then, are these bodies, and how did they attain the position in which we find them? Some years before the above views were published and popularized in this country, I had described another process of migration, or rather pouring out, from the blood, suspended in liquor sanguinis, of minute particles of living matter or bioplasm, which no doubt play a very im- portant part -in the complex phenomenon of inflammation. I showed that, if a very thin layer of healthy blood was examined by a high mag- ' SPONTANEOUS MOVEMENTS 24$ nifying power, a n amber of corpuscles, infinitely smaller than either red or colorless corpuscles, were to be detected ; and not only so, but I proved that these minute corpuscles, varying from the one hundred-thousandth to the one ten-thousandth of an inch in diameter, and probably corpus- cles still more minute, consisted of bioplasm, or living matter. The. blood of man and the higher animals, while circulating in the living body, ought to be regarded as a fluid holding in suspension countless multitudes of minute particles of living matter which, at death, undergo a great change, and become converted into several different substances, among the most important of which is the matter we call fibrin. Similar minute particles of living matter are held in suspension in the circulating and nutrient fluids of every living organism, and are present even in the nutrient fluids of plants. In the large cells of Vallisneria spiralis, which you may easily grow in a glass jar in your sitting-room, you may see the rotation of the so-called "cell-contents." The most important of these contents being the ap- parently clear homogeneous fluid which passes round and round the cell, as long as the very minute particles of bioplasm suspended in it, but to be demonstrated only by the aid of very high powers, continue alive. No one has succeeded in accounting for these movements by physical and chemical change, though many have attempted to do so. Many more have affirmed that it can be so explained, and with the confidence and satisfaction characteristic of the new philosophy, have affirmed that, even if the explanation they have given is not quite adequate and satis- factory at this time, it will be found to be so at some future period. The power of moving resides in the minute particles themselves. As long as the matter of which these consist lives the particles may move, but when it dies the moving power is completely lost. This remarkable spontaneous movement, which cannot be explained, which we may see in the pus-corpuscles, in the colorless blood-corpuscles, and in other forms of bioplasm belonging to man, to animals, and to plants, has been attributed to certain reactions between the particles themselves and things in their environment, but if you will only look for yourselves and ponder over what you observe, you will soon be convinced of the incor- rectness of the hypothesis. At no period of history have such ridiculous statements been made concerning the nature and actions of living things as in our own time. So far from being in advance of old doctrines, the ancients would have ridiculed much that now passes for philosophy. It must be admitted that the most nonsensical views concerning many things have been received as true because they have been repeatedly urged in the strongest language. When people hear, an assertion re- peated again and again they think there must be "something in it." So they believe it, or act upon it, as the case may be. The confidence with which physical explanations of purely vital phenomena are insisted upon is most extraordinary. On the one side there is astounding audacity 21* 246 OF LIVING MATTER. and arrogance, on the other meek acquiesence, and an almost incredible credulity. Some teachers do not hesitate to tell the public that they know many things which have never been and cannot be proved. They are, we 'are assured, peculiarly strong and " privileged " to prophecy, and to do other out of the way things. Such persons affirm that they discern all sorts of wonderful things, but they cannot tell us how to discern, nor do they explain by what means they have been able to discern. They are "gifted spirits," and do not belong to the class of ordinary mortals. Some prophetic philosophers, without having earnestly studied the phe- nomena of any living thing in nature, nay, without being even practi- cally skilled in the ordinary methods of investigating the structure of any living thing, dare to wildly assault the whole world of life, and reck- lessly declare that all living things are produced and built up and worked according to the very same principles and laws by which the non-living world is fettered and confined in eternal helplessness. Let me persuade you to observe what happens as the simplest of liv- ing things grows. Take, for instance, ordinary mildew, wh*ich can be obtained easily enough, or which each can grow for himself, for its germs are always present in the air. You may grow it in a little acid urine if you like. By carefully watching it, you will be convinced that it grows by taking up nutrient matter, which is not deposited upon its surface but taken into its very substance, where it becomes converted into living matter, from every particle of which new particles may result. Ask the physicist to explain, if he can do so by any physical laws, the phe- nomena which have occurred while the organism has been under your observation. Up to this time, instead of telling us what is going on, instead of describing by what means matter is changed in composition and acquires new properties whenever it is caused to assume the living state, confident physicists assert, and with an air of superiority, what according to their powers of prevision is certainly to be achieved by physicists in the far- off future. Perhaps the materialist gifted with prophetic powers enlarges on the subject of ch'emical affinity and its possibilities in the future, per- haps he will tell you about properties and attractions, tendencies, molecu- lar forces, potentialities, and evolutions and laws, and discoveries con- cerning things that may be, or according to him must be, and which he, but no one else, can discern in his imagination. He will not, hoAvever, tell you what happens whenever lifeless matter is made to live, or when I'.ving matter dies. All the assertions made during the last ten years or more on the identity of vital and physical properties have but retarded real advance in biological science. No adequate explanation as regards the nature of the change from non-living to living, and from living to dead, has been discovered in the past. Nothing definite is known to the physicist at the present time, but what is not discovered by him no~v is, he asserts, to be rendered evident by his successors in the future, CHANGES IN BIOPLASM. 247 that future which is now very far off, and which ever gets dimmer and more remote as time passes. The truth is the materialist view of things is a mere absurdity, based on fancies and dicta instead of on facts. The vital phenomena observed in the case of the mildew or any other simple organism, closely resemble those which are observed in the case of living particles belonging to man and the higher animals, both in health and disease, and can be accounted for only by attributing them to the influence of a peculiar power or agency associated with the matter while it is alive, and which is absolutely distinct from any of the known properties or forces of ordinary matter. The minute particles of bioplasm or living matter which pass through the walls of the capillary vessels in cases of ordinary inflammation soon begin to undergo alteration. As long as they were being rapidly moved about in the blood-stream these particles would undergo little or no ac- tive change ; but as soon as they become still and quiescent, by their own inherent power of movement they begin to make their way through the walls of the vessels (p. 240), and soon take up and appropriate the nutrient material which surrounds them in great quantities. While in the blood, probably in those organs where the circulation of the blood goes on very slowly, these minute particles grow and slowly undergo conversion into the bodies known as the colorless blood-corpuscles. When outside the vessels, as in inflammation, the particles grow more quickly, and soon assume the form of the colorless corpuscles which we see in such immense numbers in the interstices of various tissues and just outside the walls of the vessels in inflammation. i. Under certain circumstances the bioplasts in question soon die, and the products resulting from their death are quickly re-absorbed. 2. Under other conditions they develop a delicate fibrous material. 3. If supplied with plenty of pabulum they may continue to grow and multiply very rapidly until the form of living matter known as pus results. Pus-cor- puscles are particles of living matter or bioplasm, which have been devel- oped by direct descent, but with modification in power, from the minute living particles under consideration, or more directly from colorless blood- corpuscles, or from the bioplasm of some tissue. From such particles of bioplasm every form of adventitious fibrous tissue which we find out- side the walls of the capillaries and in the interstices of the tissues, in various forms both of acute and chronic inflammation, is produced. The delicate fibrous tissue at first formed loses water, contracts, and gradually becomes condensed. The "thickening" and condensation which you often meet with in tissues which have been inflamed is thus brought about. As I have already remarked, the minute particles of living matter, or bioplasm, outside the walls of the capillaries may also grow and multiply until multitudes of " pus-corpuscles " result. Even at this time the fact that pus-corpuscles grow and multiply of themselves by the formation of 248 SLIGHT INFLAMMATION. little offsets, outgrowths, or diverticula, which' are from time to time detached, is not generally recognized. You may remember, in a former lecture, I described how the bioplasm of a cell might increase in size, and might give off diverticula, which being detached, form separate portions of bioplasm, each of which may grow and give off more proc- esses, until by the growth and multiplication of a few particles millions of the masses of bioplasm known as pus-corpuscles are formed, every one of which may be regarded as the descendant of the bioplasm or nucleus of an epithelial cell. The pus-corpuscles cannot, therefore, be looked upon as an individual colorless blood-corpuscle, which has simply mi- grated from the blood by traversing the walls of the vessel. The idea that the formation of pus is in any way dependent upon bac- teria or other forms of so-called micro-organisms is negatived by what maybe easily seen in the production of pus-corpuscles in epithelial cells. The growth of the bioplasm and its division and subdivision under con- ditions which involve increased nutrition will convince any one who observes the phenomenon how pus is produced in epithelium ; and as exactly corresponding facts are to be demonstrated by the examination of bioplasm in other tissues, cartilage, fibrous tissue, muscle, nerve, etc., when exposed to the influence of an unusual supply of pabulum, no room is left for doubt as to the exact nature of the pathological process of pus production. I cannot agree with my colleague, Professor Lister, in con- sidering that putrefactive materials maybe the cause of suppuration, nor can I admit that this process can be properly attributed to chemical sub- stances or to nervous disturbance. A state of things may be brought about by these which may indirectly occasion the free distribution of nutrient matter to bioplasm to which the production of pus is directly and solely attributable in all cases. SOME COMMON FORMS OF SLIGHT INFLAMMATION AND OF THEIR TREATMENT. We will now endeavor to determine what are the essential changes which occur in epithelium and in some other tissue elements in ordinary slight inflammations. These changes do not necessarily lead to any structural alterations ; but if the inflammatory process continues for a certain period of time, it may be followed by tissue degeneration and other pathological phenomena, from which return to the normal state, complete recovery, cannot be looked for. Not a few of the slight in- flammations are superficial, involving a very thin layer of the surface tissue only, and although most of them are by no means serious, some are very troublesome and many excessively painful. It is desirable, therefore, not only that you should know how to detect and distinguish them, but you ought to be fully conversant with the exact nature of the minute changes taking place and the methods by which a return to the normal state may be effected. INFLAMMATORY CHANGE. 249 The treatment of some of the inflammations in question has been already considered, but it seems to me very important that I should do my best to press upon your consideration the character of the changes effected by simple remedies in the vital actions which are proceeding in the inflamed tissue, the effects pf some of which have been rendered evident to us by careful microscopical research. He will be most suc- cessful, in the management of the disease who most nearly succeeds in picturing to himself the wonderful changes which proceed in such mar- vellous minuteness and detail, and which can only be revealed to those who have long and earnestly studied, and have taken full advantage of, the elaborate means of minute investigation now at their disposal. The mucous membrane of the nose and its many passages, as has been already stated (p. 214), is very liable to slight inflammation. In the changes which occur during an ordinary cold we have an illustration of the very gradual passage of physiological into pathological actions. There is a particular point in these changes when it would be impossible to decide whether it would be more correct to say that the membrane still remained in a healthy state or had just passed from this into a morbid condition. The difference between certain normal and inflammatory states unquestionably depends only upon an exaggeration of the activity with which normal changes are performed. In suppuration there is too much vital action, too much growth, and too rapid multiplication of living particles. It is by the careful study of inflammatory changes only moderate in degree that we shall be able to answer the question why in one case the healing, and in another, apparently similar in all general respects, the opposite and destructive process, occurs. A slight wound suppurates which we desire should heal ; an ulcer forms and increases in spite of all our efforts to stop its ravages. The observations made on p. 254. bear upon this most important question ; and while one set of inquirers would attribute the want of repair to some derangement of the nervous system, another set to some chemical poison in the air, another to the presence of bacteria of a malignant type, I would refer it solely to the state of the patient's blood to the presence in the circulating fluid of an abnormal quantity of material easily appropriated by low forms of bioplasm or living matter, and to the presence of multitudes of minute particles of these of bioplasm particles, which, passing through the capillary walls, grow and multiply, and actually prevent the slower changes which ordi- narily result in the formation of formed material, and which constitute an essential part of the healing process. If the matter upon which these particles live can be removed from the blood, we shall stop the growth and multiplication of the bioplasm particles and cause their death. Hence in cases in which the patient's strength is good, free purgation favors the healing process, and in the case of those who suffer from prostration, alcohol in the blood, and the application of alcohol, and 2$O FORMATION OF MUCUS. things which act like alcohol to the wound, acts in the same beneficial manner; for this substance interferes with the growth of living matter, and alters the pabulum in such a manner as to render it unfit for the nutrition of the living particles. Formation of Mucus. Mucus, as yo know, is formed in small quan- tity in the follicles and glands in connection with the mucous membrane of the nose, even in perfect health. When we suffer from a common "cold in the head," these particles of bioplasm which take part in the- formation of the tenacious mucus around them grow and multiply more quickly than they do in the perfectly healthy state. The viscid material (mucus) formed by them is in greater proportion, softer in consistence, perhaps disintegrated and broken down, or actually decomposed, and in it bacteria and low forms of life find materials favorable for their devel- opment and eminently suitable for their nutrition. Mucus-Corpuscle. I have many times spoken of the bioplasm which constitutes the so-called Mucus-corpuscle, but I have not told you how you should proceed to observe the wonderful vital movements which occur during its life, and especially at the commencement of a slight cold, when the activity of the movement is considerably increased. Having obtained, by coughing or sneezing, a small piece of the trans- parent mucus, about the size of a pin's head, place it on an ordinary microscope plate-glass slide. Next cover it with a piece of the thinnest covering-glass you can obtain, without adding water or any other sub- stance. Gently press down the thin glass cover with the aid of a pin or needle, and place the slide under the microscope, using first of all a quarter of an inch object-glass, and then a twelfth or higher power, if you are fortunate enough to possess one. If not, you can gain the req- uisite degree of amplifying power in another way, and at the cost of a shilling or two. A piece of brass tubing, of the same diameter as that of the tube of the microscope, and arranged to carry the eye-piece, is fitted to it, sliding in just as the eye-piece does. The total length of the tube, to one end of which the object-glass, and to the other the eye- piece, is attached, is in this way increased to about eighteen inches. The intensity of the illumination being somewhat increased, you will find the little particles of mucus so highly magnified that you will be able to see the slightest changes which take place in their form and con- tour from moment to moment. The minute oval particles in the thin layer of transparent mucus, and which 'consist of living matter or bioplasm, may be said to represent, and indeed correspond to, the " nucleus " of an ordinary epithelial cell, while the mucus that viscid material which surrounds them corresponds to the wall of the cell. If the epithelium of other mucous membranes grows unusually fast, a material which not only corresponds to, but re- sembles, mucus will be formed. If you select one of the oval corpuscles, the living matter of the mucus, NERVE-FIBRES CONCERNED 2^1 and examine it intently, you will soon observe changes in its outline. Here and there protrusions will occur, portions of the mass moving away from the remainder, and then being withdrawn and incorporated. The movements indeed very closely resemble those seen in an ordinary amoeba, and are vital movements of the same nature. They continue for a con- siderable period of time perhaps for twelve hours, or longer, if you can keep the mucus in a moist atmosphere, and so prevent it from drying up. Changes of the same kind occur in bioplasm generally, but it is only here and there that we are able to demonstrate them so satisfactorily as in the case of the living Mucus-corpuscle, Pus-corpuscle, and colorless Blood-corpuscle. In these living particles any one can study, and at any time he desires to do so, the vital movements of bioplasm or living matter. In an inflamed mucous membrane, besides those prominent derange- ments, increased redness caused by congestion of the capillaries, and in- creased dryness consequent upon the defective pouring out of the fluid from the blood to take the place of that which has been quickly removed from the surface by evaporation, we have to notice important changes in connection with the action of the nerves. Every one who has had a cold knows that the sensation of the part is affected. The mucous mem- brane is sore and painful, so that his attention is being frequently directed to itl He fancies something is adhering to it which requires to be re- moved, and is constantly making efforts to get rid of it. In some cases a certain quantity of mucus collects upon the surface and dries, in others the sensation experienced seems rather to be due to the tissues being in- filtrated with fluid. Sometimes the mucous membrane, particularly at the margin of the nose, becomes excoriated, or a superficial ulcer may form. In the last case it will be found that the ordinary protective hard- ened epithelial covering has been here and there removed, and a raw and highly sensitive fissure formed, at the bottom of which are capillarieS and nerve-fibres. From the capillaries fluid escapes holding in suspension numerous minute particles of bioplasm, and not unfrequently small quan- tities of blood itself are poured out. The pain experienced is due .to the exposure or incomplete exposure of delicate nerve-fibres. The par- ticular nerves affected are those which are distributed close to the capil- lary vessels, and which have been described in p. 228. But other nerve- fibres maybe involved, for, as I have already mentioned, there are tissues in which nerve-fibres are distributed, although no capillaries exist, which nerve-fibres are concerned in the pain experienced when the tissue is in- flamed. At the same time it is probable that the nerves in question be- long to the same system as those distributed to capillaries, while there is no doubt that the latter are concerned in transmitting to us the im- pressions which we call pain. I have already remarked that as regards many tissues to which numbers of nerve-fibres are distributed, we are quite unconscious of their existence so long as the normal or healthy 252 IN PAINFUL SENSATIONS. state lasts, but as soon as this gives place to inflammation, pain, it may be of the most exquisite kind, results. The nerves concerned being those of the capillary vessels which belong to that self-regulating system of nerves before referred to (p. 232). These fine nerve-fibres become, as I have said, stretched or pressed upon by the distended capillary ves- sels, and- perhaps otherwise affected* by the exudation which takes place. And in consequence of these derangements, this departure from the normal state, as respects the nerve- fibre, and the bioplasm which is con- nected with it, that disturbance of the nerve-current which we term pain results. The extreme pain accompanying pleurisy, that caused in the condition we recognize as a rheumatic state of the nerves distributed to the inter- costal muscles, and the pain excited during inflammation even of very small portions of the subcutaneous tissues, as in the formation of a boil, or even in the case of a chilblain, are illustrations of the exquisite sensi- tiveness of nerves in textures, of the existence of which in the normal state we are perfectly unconscious. In all these cases the actual nerve- fibres involved are probably those which r,un very close to the capillary vessels of the respective tissues. Eruptions, particularly of a vesicular character, often occur in the course of sensitive nerves, and particularly in the course of nerves which are very commonly the seat of neuralgic pain. Whether the sensitive nerve trunk is directly involved, or whether the fibres distributed to the capillary vessels of the nerve trunk and of the skin situated over the nerve only are affected, it is not possible to say. What, however, seems quite certain is that the vesicles of an eruption which generally is her- petic in its character follow the course of the nerve. The pathological disturbance resulting in the formation of the vesicles may be of a most complex nature, in which reflex nervo-vascular action plays a highly im- portant part. There must be increased nutrition, with pouring out of fluid from the capillary vessels, and this phenomenon is probably due to the relaxation of the muscular fibre-cells of the small arteries and consequent enlargement of their calibre. This change is caused by disturbance in the nerve-centre which governs the arterial contraction and dilatation. The central disturbance may itself be due to impulses emanating from the sensitive nerve itself, or originating in the skin situ- ated over its course and transmitted thence by afferent fibres connected with the centre. In this manner it is very probable that various pecu- liar eruptions and other disturbances connected with the nutrition of the skin and subjacent structures are occasioned. But besides the alteration in the sensibility of the mucous membrane in sore throat, important changes take place in connection with reflex nervo-muscular action. You are all no doubt aware that if the fauces be tickled ever so slightly, convulsive movements of swallowing will instantly follow, if the mucous membrane be in a healthy state. In CO UNTER-IRRITA TION. slight " sore throat " it will be found that the response to slight irritation is slow and imperfect, while in severe forms of inflammation no efforts of deglutition can be 1 excited even by severe irritation. The changes in question are dueQo an alteration in the sensitiveness of the mucous membrane, and probably depend upon pressure or stretching of the delicate nerve-fibres, in consequenoe of which they cease to conduct impressions from the periphery to the nerve-centres. The dry state of the surface which is induced by slight inflammation of the mucous membrane may last for a short time and then gradually subside, without any further pathological action. If, however, the dryness and diminished secretion should persist for some weeks, restoration to the ordinary condition takes place very slowly, and before the healthy state can be resumed a condition opposite to that of dryness supervenes. Secretion is poured out, it may be, in very considerable quantity. This tendency to secretion, being once established, may persist for days or weeks, and then begin to diminish in amount. By degrees the glands return to their normal state of slight activity, secreting only a very small amount of transparent viscid mucus. Counter- action, Counter-irritat : on. But we may reduce the secre- tion consequent upon exaggerated and abnormal a-\ion occurring upon a mucous surface by proceeding in another way. Instead of trying to act directly upon the membrane which is the seat o? the increased action, we may endeavor to establish increased action of surfaces or organs at a distance, situated in different parts of the body. In this way we may, for example, diminish the inflammation and undue acuon which are going on in the surface of the nose in many cases of catarrhal inflammation. I will now direct attention to an important principle connected with the treatment of disease a principle which has been acted upon for years, or even centuries, and concerning which we are much better informed than our predecessors were. That we can reduce the rate or degree of action in one part of the body by increasing it in another may be proved by a simple experiment. When a cold is coming on, you feel great dis- comfort about the nose, the mucous membrane of which cavity is so swollen that the nasal passages are obstructed, so that if you try to- force air down one nostril, you fail, or only a little air can be forced through if a great effort be ma le. You are obliged under these circumstances to breathe entirely through the mouth. The discomfort caused by the swollen state of the mucous membrane, depending partly upon exuda- tion into the submucous tissue and partly upon increased nutrition going on in the epithelial covering, may be ameliorated in a very short period of time and in a very simple way. Let the feet be put into water, as hot as you can bear it without severe pain. In the course of a quarter of an hour the disagreeable feeling of fulness and obstruction in the nose will cease. The air will pass through the passages of the nose quite freely. By increasing the flow of blood in the vessels of the skin 254 CHANGES TAKING PLACE. of the lower extremities, much of the circulating fluid will be diverted, for the time being, from the mucous membrane of the nose. Many cases of headache are also relieved by putting the feet into hot water. If instead of this a mustard poultice be allied to the back of the neck a similar effect will follow. As soon as the mustard poultice begins to act, the vessels or, more correctly, the nerve-fibres distributed to the capillaries ramifying just beneath the epithelium, after being first irritated and then poisoned by the oil of the mustard, take part in irri- tating changes, which result in the vessels becoming red and turgid from the increased quantity of blood which is driven into them. The blood in these vessels circulates more slowly and gradually accumulates in them, the surface becoming red and exceedingly painful. Corresponding with this increased action in the healthy part we have reduced action at the seat of the morbid change. In this way we are able to effect alterations which are of immense importance in the treatment of many different forms of disease. In cases where the morbid action is chronic, we keep up the counter- irritation to a moderate extent, or we repeat the application of the counter-irritant from time to time. Even in very chronic diseases there is good reason for adopting this principle of treatment. In some cases of phthisis, where there was reason to infer that tubercle was limited to a very small extent ofr pulmonary tissue, benefit seems to have resulted from keeping, a small open sore on the skin of the upper part of the chest on the same side of the body. This is a form of "issue." In these days, however, this system of treatment is now rarely, perhaps too seldom, employed. It is not uncommon to find slight pathological derangements of the skin and mucous membrane of the lips. This surface becomes more or less dry, and the epithelium of the red part of the lip which resembles that covering the skin, only forming a thinner layer, as well as the soft, moist epithelium lining the cavity of the mouth, becomes deranged in its growth. The surface, instead of remaining quite smooth, becomes more or less harsh. Under these circumstances the patient often attempts to make- the surface even by rubbing it, so as to remove the little project- ing pieces of ragged cuticle. In this way the derangement is kept up or intensified. The cuticle tends to peel off in thin laminae, and many people cannot resist the temptation to catch at the pieces and tear them away. But then the surface becomes raw and often bleeds. In conse- quence of the air coming into contact with it, the moisture soon disap- pears, and the soft, imperfectly-formed cuticle soon gets dry, and the surface becomes corrugated and more painful than ever. By the irregular growth of epithelium the arrangement of the finest nerve-fibres is disturbed, and constant irritation gives rise to irregular stretchirg or pressure. The sensations thus caused, and rapidly suc- ceeding one another, excite the patient's constant attention, and in PRINCIPLES OF TREATMENT. 2$$ consequence he continually rubs the affected part or keeps constantly picking at any loose portion of cuticle. Immediately around the irri- tated nerve-fibres are multitudes of particles of living bioplasm actively growing and multiplying, forming a mass of soft, very moist spongy matter, the constituent particles of which are always changing in posi- tion. The drying that is proceeding on the surface necessarily disturbs the nerve-fibres, as well as other structures beneath. Schoolboys are very prone to pick their lips when in this state and make them extremely sore, particularly at the line where the thin skin of the lip joins the ordinary skin, and at the angles of the mouth, where little cracks or fissures often form, which may remain for days or weeks, sometimes giving rise to ugly and troublesome sores. It is very desirable to pre- vent the irritation which so disturbs the patient and causes him to make the sore worse and retard the healing. Principles of Treatment. Now, upon what principles should the treatment of such simple excoriations and slight superficial ulcerations be based ? Our main object should be to reduce the growth and multi- plication of the particles of bioplasm which are instrumental in keeping the fissure moist and open. This cannot be effected by causing them to dry up, because in that case a little crust would soon form, which, in consequence of the contraction produced by desiccation, would after- wards be drawn away from the subjacent parts. In this manner a raw surface again appears, and is perhaps larger than the preceding one. At the same time we must try to prevent this drying up, and to reduce the growth of bioplasm and pouring out from the blood of fresh plasma containing more bioplasm particles. By effecting these objects, certain lotions and other local applications promote healing. Some of them lead to the quick formation of a dry scab, but so thin that it does not become detached. Other applications are employed for the purpose of reducing the rate of growth of the masses of bioplasm on the surface of the sore, which is at the same time kept moist. The formation of the more permanent tissues slowly proceeds beneath this temporary pro- tective covering. This latter process requires a considerable time for its completion. Much formed material has to be slowly produced by the bioplasts of the several tissues, and must subsequently become condensed. Alcohol. One of the most potent applications for healing such slight sores as I have referred to is alcohol. The sore place may be painted over once in an hour or so with pretty strong spirit, a camel-hair brush being used for the purpose. Of course, there is a sharp pain at the moment the alcohol comes into contact with the delicate nerve-fibres, but it soon passes off. In many cases it is well to dilute the alcohol with an equal quantity of water or rose-water. It matters little whether you use any of the ordinary spirits or Eau de Cologne, but pure spirits of wine diluted with one-third part of pure water is the best applica- tion. By this treatment the thin skin on the surface of the fissure or 256 NITRATE OF SILVER. ulcer becomes hardened, and the soft, new epithelium that is being formed beneath will become condensed, and the new cuticle will grad- ually assume the usual character of that tissue. Let us consider how alcohol acts advantageously under these circumstances. By its property of coagulating albuminous matters, alcohol tends to retard rapid growth and to interfere with the multiplication of those particles of bioplasm which are growing so rapidly just outside the capillaries. The bioplasm, as I have mentioned, is growing so very fast that there is not time for the development and consolidation of that firm, healthy-formed material which, with living matter within, constitutes a cuticle cell. By applying alcohol, then, you favor the formation of cuticular cells. Wherever the cuticle is thin, by painting it frequently with alcohol, you promote the formation of cuticle and assist the condensation and increase in thick- ness of the new tissue. If there should be sores in the mouth ; or if the mucous membrane of the gum should be soft and spongy from the infiltration of fluid in the substance of the mucous membrane, the surface of which may be very red and tender, the morbid action may be quickly counteracted by painting the part three or four times a day with spirits of wine, Spiritus Vini Rectificatus, or some other form of alcohol, or with spirits of Cam- phor, Spiritus Camphor &. Solution of Nitrate of Silver. Many lotions composed of metallic salts are employed in the treatment of sores. Most of them act by virtue of their property of coagulating and precipitating and forming com- pounds with albuminous matters. Among these salts is Nitrate of Silver, Argenti Nttras, which causes the sores to heal very quickly. With a small camel-hair brush you paint the fissure with a little solution of Nitrate of Silver, consisting of from five to ten grains of the Nitrate in an ounce of Distilled water. This will give pain for the moment, but the soreness soon passes off. The growth and multiplication of the masses of bioplasm are prevented. Time is allowed for the young cells of cuticle to harden. Gradually, new skin is formed, the growth of healthy epithelium is favored, and before long the healing process is completed. Conjunctiva. A good illustration of the pathological changes which occur when a complex tissue becomes inflamed is afforded by the mucous membrane which covers the front of the eye and lines the eyelids, the Conjunctiva, when in a state of inflammation. This moist mucous membrane is very highly sensitive, and, as all have occasionally ex- perienced, readily becomes inflamed. If you go out in foggy weather, and afterwards examine the conjunctiva, you will often find many of its vessels distended, and you will observe that it is much redder than it was before it was exposed to the deleterious effects of the irritating sub- stances which are suspended in the air in a fog. The pathological change in question is a reflex action due to disturbance in the nerve-centres INFLAMMATION OF THE CONJUNCTIVA. induced by the poisonous action of the irritating matter on the pe 'ipheral ramifications of the sensitive afferent nerves, and a consequent paralyzing influence upon the nerves of the little arteries. In the case of persons who are in a low state of health who have lived badly for some time, and especially in those who belong to scrofulous families, there is in- creased liability to inflammation of the conjunctiva, as well as the glands and other structures which are connected with it. When the mucous membrane is inflamed the little glands participate, and from them is poured out an abundant secretion- containing numerous particles of bio- plasm. The vessels are distended, and that part of the mucous mem- brane which lines the eyelids and covers the white part (sclerotic) of the eye is reddened and, as I have remarked, in a state which well illustrates the changes taking place in inflammation. The condition is called Ophthalmia or Conjitnctivitis, and is of great scientific interest, because a transition from the normal or ordinary state of health to the abnormal and temporary state of inflammation may be studied in its gradations. It is easy to examine the membrane from time to time with a lens, and without causing the slightest pain or inconvenience to the patient. The conjunctiva, especially in ill-fed, ill -nourished scrofulous children, not only readily takes upon itself this exaggerated action, but passes into a state of inflammation which, though slight for a time, may soon be- come severe, and be accompanied 'with an abundant formation of a yel- lowish secretion. If a little of the discharge is examined in the micro- scope, it will be found to consist of multitudes of particles of living matter, well known as pus-corpuscles. Such is the virulence of these particular living particles that if no more of the discharge than can be carried on the point of a needle, be transferred to the surface of the eye of another person, a similar pathological state is quickly established upon it. Serious inflammation is excited, and the same series of phe- nomena recur. From this case the poison may be transferred to a third, and so on. Now, if many children in weak health, who for some time previously have been badly managed as regards food, air, exercise, and cleanliness, are allowed to congregate, and especially if they are confined in close, ill-ventilated rooms, the disease may not only arise but soon acquire an extraordinary degree of virulence. It may spread so quickly in such a community of children, that in a short time out of four or five hundred, one-third or even a larger proportion may be suffering from the disease. Of the number affected many will suffer severely, and serious structural changes in the membrane and in subjacent tissues will result. The trans- parent part of the eye in front, known as the cornea, may ulcerate, and when after some time it heal?, the tissue will be so altered that the very transparent texture will become opaque, or the eye itself may be destroyed, blindness of course resulting in either case. This very virulent poison of purulent ophthalmia may, as I have re- 22* R 258 TREATMENT. marked, be evolved in the first instance without contagion. The con- tagious material may originate upon the membrane which during its for- mation passes from the normal into a pathological condition. A highly contagious poison may also be developed, in the organism of a person suffering from peritonitis and some other inflammatory and febrile dis- eases. In this case it *is to be remarked that the surfaces upon which the changes occur which result in the development of the contagious poison are not, and never have been, exposed to the air. The contagious matter once developed, however, may spread far and wide, and with a rapidity which is quite remarkable. You see, therefore, that an animal poison may be developed of a highly contagious kind, the most minute portion of which, not more than would remain on the point of the finest needle, would establish the same series of pathological phenomena in a comparatively healthy tissue if transferred to it. Probably many of the pus-corpuscles found on the surface of the conjunctiva in a case of purulent ophthalmia do not result from the particle inoculated. Some, no doubt, are formed from the young bioplasts of conjunctival epithe- lium. There are, therefore, two kinds of bioplasm growing and multi- plying at the same time, but so intermingled that it would not be pos- sible to obtain particles of each kind separately. In inflammation of the conjunctiva, not the least important of the phenomena is the dilatation of the vessels. Of the little arteries, many are dilated to three times their ordinary diameter, and the capillaries are also distended and choked with blood. Capillary vessels so small that hardly a single row of red blood-corpuscles would lie in them and quite invisible in the ordinary state, become so large in inflammation and are so filled with blood that through an ordinary lens they can be seen as distinct dark-red lines. The injection of the vessels may con- tinue for many days and then pass off, or it may become chronic, when other pathological changes take place in consequence. The influence of the nerves and nerve-centre in these vascular changes has been already considered in page 235. Treatment. Inflammation of the conjunctiva requires to be carefully treated. It is undesirable to allow this inflammation to go on, especially in children, because it may reach a stage in which there is danger of damage, not only to that very important structure of the eye, the cornea, the clearness of which is essential to distinct vision, but, as before re- marked, to the, whole organ. Good hygienic conditions are essential in the treatment of the disease as it occurs in children ; and it is very important to look for and relieve that preliminary state of inflammation and enlargement of the glands in the membrane, which almost invariably precedes an attack of purulent ophthalmia. Many astringent substances are of use in the treatment of inflamma- tion of the conjunctiva. These may be applied in various ways. In former days it was the practice to project a small quantity of some EYE-LO TIONS. 259 astringent powder on the surface of the inflamed conjunctiva, by placing a little of the powder in a quill or piece of straw and blowing it suddenly upon the eye, which was kept open for the moment. These powders were usually made of sugar and the potent substance, in the proportion of from ten parts or more of the former to one part of the latter, the whole being very finely powdered and carefully mixed. Oxide of Zinc, Nitrate of Potash, Alum, Sulphate of Copper, Nitrate of Silver, and other substances' have been used in this way. But the practice is a bad one, and has been almost entirely abandoned in favor of solutions, which may be applied as drops or by using an eye-glass or an eye-fountain. Strong astringent applications should never be used except under proper advice, or serious damage to the eye may result. Of Lotions and Eye Waters. One of the best is a weak solution of Sulphate of Zinc, Zinci Sulphas, in water ; or, if you wish to order a more elegant lotion, in Rose Water, Aqua Rostz. As regards the quan- tity, you may prescribe from a quarter of a grain to a grain to the ounce of water. A very dilute solution will often produce a favorable change in cases of mild inflammation of the conjunctiva, in a few hours. Sugar of Lead, Plumbi Acetas, or Sulphate of Copper, Cupri Sulphas, may be used in the same proportion as Sulphate of Zinc ; but the latter and Nitrate of Silver, Argenti Nitras, are probably the most useful. Of the last, the proportion should be half a grain or less to an ounce of distilled water. If the eye is very painful, a grain of Opium or two or three drops of Laudanum, Tinctura Opii, to the ounce of water may be prescribed. In all cases the solution should be carefully filtered before it is applied. A lotion consisting of Spirits of Wine, Spiritus Vint Rectificatus, or good brandy, Spiritus Vini Gallici, in the proportion of one part to thirty or more parts of water, has also been recommended ; and where the vessels are dilated without any production of pus, the careful application of a weak spirit solution may be useful. Lotions may be applied to the surface of the eye in two or three differ- ent ways. One of he best methods is to seat the patient in a chair and make him throw his head back. You then take a good-sized camel-hair brush which will take up two or three drops of the lotion, which may thus be caused to flow into the inner corner of the affected eye. Of course the patient will instinctively close the eye at the moment, but he must be encouraged to open the lids a little, so that some of the solution may pass in and the surface of the conjunctiva be thoroughly moistened by it in every part. Another plan is to bathe the eye with an ordinary sponge or rag, but you must always be most careful that the particular sponge or rag is used for no other purpose whatever. Where there are several patients, each must have his own sponge, towel, etc., kept exclusively for his own use. Another way of applying lotions to the conjunctiva is with the aid of an Eye-glass. This is a little glass made something like a small wine- 260 SO KB THROAT. glass, the free edge Leing shaped so as to fit within the margin of the orbit. The eye-glass is half-filled with the lotion, and the patient is directed to hold the glass steadily against the eye, while the head is to be moved about in such a way as to cause the fluid to splash against the surface of the conjunctiva. The glass acts so as to keep the lids open, and in this way you ensure the lotion coming in contact with the surface of the mucous membrane. Lastly, there is the little Eye-douche ar Fountain, by the aid of which a jet of lotion can be thrown against the eye. All these instruments may be obtained of surgical instrument makers. Astringent lotions generally by their indirect action upon the nerves of the part, and by their direct action upon the particles of bioplasm which are growing and multiplying, favor the formation of the firm material, upon which the consistence and the protective character of the epithelium depends, and its subsequent condensation. Thus a "raw," or nearly raw, surface again gradually becomes protected with a layer of ordinary slow-growing epithelial tissue. Sore Throat. In an early lecture I have adverted to some of the changes which occur in sore throat, but in this place I shall consider one or two questions in connection with the subject which were then passed by. Mo t of us have suffered more or less from this affection. In the case of those who are susceptible, there frequently occurs a certain amount of congestion and inflammation in the mucous membrane of the fauces, and of the back of the pharynx. If you look at the palate in suih a case, you will find it in very much the same state as I described when referring to ihe mucous membrane of the nose in an ordinary cold. Many of you will have opportunities of making the observation in your own persons. You may easily examine the fauces with the aid of an ordinary looking-glass. Instead of the membrane appearing moist, you \v.A find it near.y dry, and perhaps you may see a piece of half-dry viscid mucus intimately adhering to it. The sensibility of the membrane is also affected. Although it feels sore, you will, however, find that it is less sensitive than in the normal state, while certain of its nerves do not respond so readily to a stimulus as they do in health. If the throat is perfectly healthy, the process of swallowing, or deglu- tition, is easily performed, and almost unconsciously at least without any great effort; but if the throat is sore, deglutition becomes difficult, and you have to. make a very decided effort, perhaps more than one, be- fore the morsel of food can be successfully swallowed. Then there is another fact of some importance with regard to the action of the mucous membrane. Not only are the nerves which are connected with the capillary vessels, and which are concerned in the sensation of pain and discomfort, obviously affected, but those which are instrumental in exciting by reflex action the contraction of the pharyngeal muscles. If, in the normal state of health, you tickle the soft palate TREATMENT OF SORE THROAT. 26 1 ever so slightly with a feather, if the raucous membrane enjoys its proper sensitiveness, movements of deglutition almost instantly succeed. But if the throat is "sore," the mucous membrane red, and perhaps dry, you may tickle it very decidedly, and only feeble contraction will follow after an interval of time, or no contraction of the muscles will occur. In this action the muscular fibres fail to contract, because the nerve-fibres which carry impressions from the surface of the mucous membrane to the nerve-centre are deranged. Their action for the time being is pre- vented. There is, as it were, a peripheral paralysis. The motor nerve- fibres, the nerve-centre, and even the afferent trunks themselves, may be all right ; but the fine ramifications of the afferent fibres in the mucous membrane are so affected by the effusion in its substance and other changes, that they do not receive and transmit impressions. When sore throat attacks persons who have for some time been in a low state of health, or exposed to adverse influences, as sometimes hap- pens in the case of those resident in workhouses, hospitals, jails, and other places, it may run on very quickly to extensive superficial ulcera- tion, which may affect the substance of the tonsil, and progress for several days. The fetid products resulting from the decomposition of the secre- tion taking place upon or near the ulcerated surface, are sometimes absorbed into the blood and occasion a form of blood-poisoning. If swallowed, the discharges give rise to much disturbance of digestion. It is, therefore, most important in the treatment of such cases to apply substances to the surface which have the effect of completely changing the organic matters and destroying the infecting material. If Diphtheria exist in the neighborhood, persons in a low state of health, and those already suffering from sore throat, are very likely to take the disease, which sometimes runs its course so very quickly that life is in jeopardy in a few hours after the malady has declared itself, or even before there has been time for the formation of a false membrane, or for the development of any characteristic phenomena of the disease. It is, therefore, of the utmost consequence to very carefully watch cases of sore throat, especially when of an epidemic character. You should see the patient at intervals of a few hours, and you should give quinine and stimulants early, instead of waiting until the patient is very low. In some cases of what is called " hospital sore throat," as well as in Diphtheria, you will be surprised to find that persons may take in twenty- four hours from ten to thirty grains of quinine, and eight or ten ounces of brandy, divided into doses given every two hours, wfthout any indi- cation of the quantity of either remedy being excessive ; and it may be necessary to continue this treatment for many days, giving at the same time plenty of beef-tea or milk. The Treatment of Sore Throat. We are often consulted by patients who complain that they are almost constantly suffering from soreness of the throat. It is sometimes better, sometimes worse, but they will tell 262 APPLICATION OF ASTRINGENTS. you the throat always feels rough and uncomfortable. Many local appli cations are of great use. You may paint the fauces with a solution of Nitrate of Silver, Argenti Nitras, but a stronger solution may be em- ployed than was recommended for applying to the conjunctiva. A solution consisting of from five to ten grains to the ounce of distilled water answers well, or you may employ a mixture of solution of Per- chloride of Iron, Liquor Ferri Perchloridi, and an equal quantity of glycerine, Glycerinnm. This mixture is very valuable in the treatment of sore throat, whether it be mild or severe. The glycerine causes the Perchloride of Iron to adhere to the surface for a little time, and in that way increases its beneficial effects. In forms of sore throat in which there js a quantity of viscid mucus, accompanied with excoriations or ulcers on the palate or- tonsils, the mixture may be applied every two hours, or oftener. The solution is a potent antiseptic, and destroys any deleterious properties the secretion may possess. By its application efforts of vomiting are often excited, and thus much of the secretion is got rid of. I have successfully treated in this way many bad forms of sore throat, which by some would be called li diphtheritic ." The condi- tion is associated with great depression of strength, and, as I have before said, it is necessary to give quinine and wine or brandy in very decided doses. Any of the foul secretion swallowed by accident is rendered innocuous by the action of the iron. In this way stomach disturbance, so apt to ensue in these cases, and which so much increases the risk to life when it does occur, may be prevented. Tannin dissolved in glyce- rine, Glycerinum Acidi Tannici, is also a good application. In applying such local remedies, whether a solution of Nitrate of Silver, or Glycerine and Perchloride of Iron, or the Tannin, perhaps the following will prove to be the best plan. Take a good large camel's-hair brush, which must be carefully tied to the end of a stick. This latter point is important, because if the brush is simply placed on the stick, it may, unfortunately, fall off at a critical moment and be swallowed by the patient. The possibility of the occurrence of so awkward an accident may be thus prevented. The brush is to be thoroughly wetted with the applica- tion, and, a few drops being taken up in it, the wet brush is to be well smeared over the surface of the affected mucous membrane. After a quarter of a minute the patient may be allowed to gargle with a little cold water. Although severe forms of sore throat cannot certainly be included among "slight ailments," it is important that your attention should be directed to the general treatment of the patient. I have no doubt that by judicious management many cases are prevented from assuming a severe form. If the patient gets low with a quick weak pulse, especially if ulceration, which may be present, should be extending, and there is infiltration of the tissues around the tonsils, it is necessary to give wine or brandy and tonics, such as iron and quinine. One is often surprised GARGLES. 263 at the large amount of supporting remedies required in some of these cases. In what used to be called "hospital sore throat," we often find it necessary to give six or eight five-grain doses of quinine in the four- and-twenty hours, and as much as twelve or more ounces of brandy during the same period, and this treatment may have to be maintained during several days. Gargles. Various gargles are used in the treatment of sore throat and an inflamed or aphthous (p. 70) state of the mucous membrane of the mouth. The influence of some of these is due to the presence of matter having astringent properties, while others depend for their efficacy upon some form of alcohol. Port wine is an excellent gargle in cases of ordinary relaxed sore throat ; but some people do not like port or any other kind of wine, and in that case you may order a gargle consisting of one part of spirits o-f wine to four or five parts of water. Alum used to be a favorite remedy, dissolved in a little water in the proportion of one drachm to six ounces. A good gargle may be made by dissolving a drachm of Nitrate of Potash, Potasscz Nitras, or Chlorate of Potash, Potassa Chloras, in six or eight ounces of water. An ounce of glycerine or honey may be added. Some like gargles made acid ; for this purpose you may order a drachm of Dilute Acetic, Phosphoric or Hydrochloric acid, to six or eight ounces of water. Many persons derive benefit from the use of a stimulating gargle, which may be made by adding a little Cayenne pepper, or Tincture of Capsicum, Tinctura Capsici, in the proportion of one drachm or less to six ounces of gargle ; but this is not suitable in the case of a very sensi- tive, irritable mucous membrane, and, indeed, may do harm instead of good. Common Salt is valuable as a gargle. A weak brine may be made by adding a dessert-spoonful of salt, or less, to half a pint of water. The throat may be gargled with this solution once in two or three hours. In ordering gargles, it is necessary to give the patient exact directions to tell him to use the gargle frequently, for it is useless to gargle once or twice in the four-and-twenty hours. If the sore throat is at all severe, the gargle should be used once or twice in the hour. Of exciting increased action in distant parts. You may sometimes relieve a sore throat, as well as other forms of local inflammation and congestion, by causing increased action in other organs and tissues. The. action of a purgative is often followed by the relief 'of the throat affec- tion. Diuretics and sudorifics may be prescribed with the same object, and counter-irritation may be applied in some other part of the body. A mustard poultice to the neck, by establishing increased action on the cutaneous surface, often reduces the congestion of the mucous membrane of the throat. When slight, and not depending upon a general low 264 INFLAMMATION OF AIR-TUBES. state of the system, or altered blood, a sore throat may sometimes be cured in this way in a couple of hours. Inflammation of the Mucous Membrane of the Air Passages. Inflam- mation, as has been already remarked, very commonly affects the mucous membrane of the nose and all the cavities which open into it. There is increased secretion from all the glands and follicles opening upon the surface, increased formation of soft, moist, and imperfectly formed epi- thelium, taking the form of mucus, and undue turgescence of all the vessels. In consequence there is what is ordinarily called " running from the nose." When the mucous membrane of the large bronchial tubes is inflamed, and consequently there is an increased formation of mucus on the sur- face, we have an ordinary catarrh, the phenomena of which have been already referred to. There is in these cases also congestion of the fauces, increased formation of mucus, and increased action of the glands. The transition from the ordinary epithelial cell to the viscid material known as mucus, and from the mucus-corpuscle to the pus-corpuscle, may be observed and studied. In cases in which the inflammation continues for a considerable time, instead of viscid transparent mucus being formed, we meet with ordinary pus, or pus mixed with mucus, which is known as Miu'o-pus, the microscopical characters of which must be carefully studied, as well as those of other kinds of sputum formed in different cases of diseasj. What is termed false membrane, or croupous exudation, is frequently formed in cases of inflammation of the mucous membrane of the larynx, trachea, and bronchial tubes. I have seen cases in which a complete and firm membranous cast of these passages was formed on the surface of the mucous membrane, and was expelled entire after much suffering. The firm material consisted entirely of viscid mucus. Casts of the smaller bronchial tubes are also sometimes formed of mucus, but more commonly they will be found to consist of fibrinous material which has been poured out from the blood, and has coagulated in the air-tubes. Running from the ears is common among children of what is called " a scrofulous habit of body." The epithelium of the meatus undergoes change, and becomes soft, the new epithelium being imperfectly formed, and superabundant. The vessels of the skin are also congested. After the disturbance has existed for some time, the discharge resembles that from an ulcerated surface. Not unfrequently the discharge dries up and forms a crust, which in consequence of the itching and irritation excited, is often picked off by the patient. A raw and very sore surface is ex- posed, and from this fresh discharge escapes, which in turn dries, and then follows a repetition of the process. The condition is often very obstinate and difficult to cure. In most instances constitutional treat- ment by iron and other tonics and cod-liver oil is absolutely requisite. INFLAMMATION OF STOMACH. 26$ As the health improves, the discharge begins to diminish, and at last ceases altogether. Inflammation of the Mucous Membrane of the Stomach and Intestinal Canal. The mucous membrane of the stomach is very liable to conges- tion and inflammation, much more so, I think, than is generally supposed. From time to time these pathological changes probably affect small patches of mucous membrane, last for a time, and then pass off if the mucous membrane is soothed and allowed to rest from active work fofr a few days. In all our best works on Medicine, the subject of Ulcer of the stomach is fully treated of, but there is a -state of things allied to ulcer, and lead- ing to it, to which reference is seldom made. The state of mucous mem- brane to which I allude is not so serious as ulcer, but it is much more common, and, if not relieved, may be succeeded by the formation of an ulcer. The mucous membrane of the stomach, like the nasal and bron- chial mucous membrane, "takes cold." It becomes red and less moist than in the normal state. There is often great discomfort and very fre- quently severe pain. The glands are more or less affected, and the func- tions of the stomach are very seriously disturbed. The secretion of gastric juice is interfered with and its qualities changed. Digestion is of course deranged, and sometimes completely checked. There may be much flatulence, .which adds to the distress. Many patients, instead of allowing the stomach to rest for a while, are too prone to call for food when they experience any uneasiness. They feel exhausted, and think a good meat meal will certainly relieve their discomfort. This they take, and very soon find they have made a mistake, for their pain is increased. If they are fortunate, vomiting will be excited, and all that has been taken, with perhaps other matters already in the stomach, will be rejected, when considerable relief will be experienced. When you Have reason to think that a patient is suffering from this slight inflammation, it is de- sirable to at once carry out measures for his relief, and effect a return to the healthy state as soon as possible, for the stomach is an organ .whose work cannot be suspended for long at a time without the whole organism suffering. You order, therefore, nutritious, but unirritating, soft or liquid food for a while, and then take care that for the next few weeks only food of a soothing character, and which will be very easily digested, passes into the stomach. The patient must on no account be allowed to take ordinary diet, and you must tell him not to touch beer, and enjoin him not to take very cold or very hot liquids of' any kind. Every form of alcohol should, as a general rule, be withheld, because in a great many instances alcohol only irritates, and sometimes greatly increases the pain. It may do much harm, though it must be admitted that not unfrequently it relieves for the moment the discomfort and sinking feeling which some- times distress the patient. For this reason it is imperative to be cautious in such cases. We ought never to give people any excuse for perma- 23 266 CONGESTION OF SMALL INTESTINE. nently damaging their tissues, by acquiring the habit of taking too much alcohol. The digestion of meat almost entirely depends upon the secretion formed by the stomach glands. When this secretion is temporarily de- ranged, it is better to allow the mucous membrane of the stomach to do as little work as possible. Meat and fish should, therefore, be withheld for a time. The patients should be put on a milk diet. You may order them to take bread and milk, or arrowroot and milk, or rice, sago, tapioca, maccaroni, vermicelli, and cooked in such a manner as to make a very soft moist food. By adopting this course, the patient ap- plies something like a poultice to the disturbed mucous membrane of his stomach, and in many other cases, with great and immediate benefit. It does no one any harm to live on soft food of a farinaceous kind for a few days or a week. Indeed, not a few would gain in health if they sys- tematically adopted such a diet for a week or two once in every two or three months. A very good substance to recommend patients to eat under these circumstances, only you will find many will refuse to eat it, is lentil flour, well boiled and made thick like gruel. Any part of the mucous membrane of the small or large intestine may be affected by congestion and catarrhal inflammation. There are many cases in which there is severe pain " in the stomach," as the patient says, but which depends upon derangement of some part of the small or large intestine. The mucous membrane may be congested in patches, and the action of the follicles and of the villi for a time, becomes seriously disturbed. By taking care that only bland substances, and as little as possible of these, pass along the small intestine for a time, the mucous membrane will be soon restored to its normal state. It is important to check such disturbances as soon as possible. Though according to the patient himself, he maybe suffering only from pain "in the stomach," if he do not take complete rest, what is only a slight ailment may soon become a grave malady. In such cases, diet is of more conse- quence than medicine, but if the pain is very severe, it may be necessary to give small doses of sedatives. Advantage also results from employ- ing mild counter-irritants over the belly. The best counter-irritant is a poultice made of half mustard and half linseed-meal. This may be applied to the surface, near the seat of pain, and it unquestionably relieves the inflammation. A mustard leaf is more easily prepared, but a piece of writing-paper should intervene between it and the skin, or the action will be too strong, and the patient will remove it before there has been -time for the counter-irritant to have done good. The external application of warmth greatly relieves pain which results from a congested or inflamed. state of the mucous membrane of the intes- tinal canal. A linseed poultice,. or flannels wrung out in hot water, will be of service. If, however, this does not soon afford relief, the surface of the poultice or the flannel may be sprinkled with turpentine. The TREATMENT OF CONGESTION AND INFLAMMATION. 267 thick India-rubber bottle for hot water should find a place in every trav- eller's trunk. It is most useful in the treatment of abdominal and other pain. I have already referred to it on p. 151. Stimulating liniments are, as a general rule, not advisable. You do not want to move the bowels about in the least degree, or to disturb the parts at all. If you allow people to rub things in, the chances are they add to the sufferings of the patient, and do harm to tissues already tender and irritable, and in a state verging upon actual disease. This rubbing in of liniments is often adopted most injudiciously for every kind of pain, and you not unfrequently find a self-constituted and most self-con- fident medical adviser " rubbing away ! " the pain of an inflamed joint. Many nurses and ladies having a turn for doctoring require to be cau- tioned on this head, for many conditions are made worse by rubbing, and in some instances very serious inflammation may be excited by the operation. Congestion and inflammation of a portion of the mucous membrane of the large bowel is not uncommon. There is in such cases severe pain and the action of the bowel is much deranged. The condition may pass on to ulceration, which may endanger life. Ulcers frequently form in the lower part of the small intestines in cases of Typhoid fever, the heal- ing of which is always a very slow process. Every case of Typhoid fever requires the most careful management and constant attention, not only at the time ulcers are forming and the sloughs separating, but dur- ing the healing process. Though this disease cannot be included among "slight ailments," it is very desirable that you should know that health is only very slowly restored, and that three months sometimes pass before a patient suffering from Typhoid can with safety be allowed to resume his usual diet and habits of life. All attempts to hasten conva- lescence are unwise, and every now and then a patient is lost in conse- quence. Full time must always be allowed for the healing of ulcers in any part of the alimentary canal. There happens to be just now a case of mild dysentery under my care in the hospital. The man suffers much pain, and from the usual symp- toms. He passes liquid motions with a good deal of mucus. In this case we are adopting, with the greatest benefit, a mode of treatment which may be considered "empirical," (f^nsipia, experience;) for, although the remedy employed is undoubtedly useful, we do not know precisely how it acts. Ipecacuanha powder is of the greatest value in many such cases not only where there is actual ulceration of the mucous membrane of the colon, but where there is an approach or ten- dency to this condition. In India this drug is much used in the treat- ment of dysenteric affections. You may begin with doses of two or three grains of Ipecacuanha, in the form of a powder or pill, and you may increase the dose up to twenty grains or more, twice or three times a day; or five or ten grains may be given with a half a grain or less of 268 CHILBLAINS. opium, which will prevent its emetic action. Some persons cannot take opium, and in this case the Ipecacuanha must be given at first in small doses. The medicine may be continued until the symptoms are greatly relieved. In many cases the patient is completely cured in a month or six weeks. If you desire to study the mode of action of an emetic in your own organism, there will be no harm in trying the experiment with this drug. You may take twenty grains of Ipecacuanha powder, Pulvis Ipecacuanha (not Puhris Ipecacuanha Compositus], suspended in half a tumbler of warm or lukewarm water. The dose may be followed by one or two tumblers of warm water, and in the course of ten minutes or a quarter of an hour, you will have an opportunity of studying the violent con- traction of the muscular coat of the stomach, which will be excited by reflex action consequent upon the irritating effect of the Ipecacuanha upon the afferent nerve-fibres of the mucous membrane of the organ. Ipecac- uanha is one of the most potent, and in action on'e of the least dis- agreeable, of emetic. remedies. Congestion and inflammation occur in connection with other mucous membranes, as well as those to which I' have specially drawn your atten- tion. Thus, the gall-bladder and gall-ducts may suffer congestion, and inflammation of the mucous membrane of the urinary bladder, of the ureters, and of the pelvis of the kidney are unfortunately frequently met with, but these cannot, I regret to say, be classed among slight ailments, and they will come under our consideration in another part of the course. Chilblains. This troublesome and often very painful affection is due to local changes in the vessels of the skin of parts of the body most distant from the large vessels, notably the fingers and toes, and occa- sionally the ears and nose. These parts are more exposed to cold than the rest of the body, and to them the blood will be driven into the rami- fications of the arteries with less force than elsewhere. Anything that retards the return of the blood towards the heart, such as the pressure on the superficial veins by tight gloves or shoes or garters, increases the tendency to chilblains. On the other hand, anything that promotes the circulation, large and easy boots and gloves lined with wash-leather or other warm material, may prevent their occurrence in persons predis- posed to the malady. Chilblains seldom occur in the adult, and they are far more common among ill-fed, weak children than among strong and healthy ones. In- sufficient exercise, especially in the case of those, and in towns they are very numerous, who suffer from weak heart's action, sitting in cold rooms and sleeping in chilly bedrooms favor the development of chilblains, which are also encouraged by insufficient clothing. Warm woollen under- garments down to the wrists- and ankles often prevent the occurrence of chilblains in those who have been subject to them. Exposure to cold, TREATMENT OF CHILBLAINS, 269 more especially when the vessels of the skin have been for some time previously subjected to pressure, is usually the immediate cause of an attack. In the capillaries of the affected skin the blood flows slowly and re- mains too long in the vessels. The composition of the stagnant blood is probably altered by being too long exposed to the influence of cold, and in consequence does not flow onwards towards the veins. Soluble matters transude through the walls of the vessels, and the skin and sub- jacent textures in consequence become swollen. The afferent nerve- fibres running with the capillaries are necessarily affected, and their action becomes sluggish, and the muscular fibres encircling the minute arteries soon undergo relaxation. When the force of the heart's action becomes greater, and the activity of the circulation temporarily increased, as occurs after meals or when the patient gets warm in the evening or in bed, a rush of blood occurs to the extremities. The relaxed arteries and thin capillaries become greatly distended, the temperature of the part rising several degrees. The sensitive nerves at the same time being dis- turbed in such a way as to occasion the intense itghing and discomfort experienced by the patient. In some cases there is little or no itching, but, Nevertheless, the con- gested state of the vessels, and consequent soddening of the tissues, may result in damage to the cuticle which may be raised in bullse, which soon rupture, and the formation of troublesome sores, which heal very slowly, and add to the patient's suffering. In bad cases the skin around the vesicles becomes dark and soddened, and sloughs of considerable size may be formed, which often leave deep and bad ulcers, requiring a considerable time for healing. Treatment. Chilblains often give rise to very severe suffering, and are difficult to cure. Appearing to be a purely local affection, the dis- ease is too often treated by purely local measures only. In a great many instances it will, however, be found that improvement in the general health and strength is followed by a cessation of the painful inflamma- tion. Tonics, especially preparations of Bark and of Iron, should be given. One or two tablespoon fuls of wine daily often effect great im- provement without any local treatment whatever, and if this plan is adopted early in the winter season, the subjects of chilblains will some- times escape an attack. Great care should be taken to clothe all children who are tortured with chilblains in woollen next the skin. The rooms in which they live should be well warmed in winter, and everything done to assist the weak and very likely slow circulation. Gradual cooling down is likely to do more harm in the case of those subject to chilblains than sudden ex- posure to cold for a short time only. Local Treatment of Chilblains. If the skin is not very tender, it may be painted with Tincture of Iodine, or very gently smeared with a lini- 23* 2/O BOILS. ment composed of* equal parts of Soap Liniment, Liniment urn Saponis, and Tincture of Iodine, Tinctura lodi. Smearing the inflamed skin with a little Turpentine, Oleum Terebinthince, or Acetic Acid, Acidum Aceticum, or the Liniment of Turpentine and Acetic Acid, Linimentum Terebinthince Aceticum, or Camphorated Spirit, Spiritus Camphora, undoubtedly much relieves the itching ; but if the cuticle is tender or sore, such remedies do harm instead of good. In this case the tender part is to be painted over with several layers of Collodion, or the Col- lodion flexile, made of Collodion, Canada Balsam, and Castor-oil. In this way a sort of artificial cuticle is made, by which the tender parts beneath are protected until they recover their healthy condition, and time has been allowed for the formation of new cuticular cells beneath, and for the hardening process to be carried out by which the protective property of the cuticle is established. If the skin is actually broken, a small poultice is to be applied with or without some stimulating substance, such as Resin Ointment, Unguentum JResince, or Peruvian Balsam, B'al- samum Peruvianum. The health must at the same time be well sustained by good food, wine, Quinine, and Cod-Liver Oil. When the sloughing process has ceased, a stimula-ting zinc lotion, one or two grains to an ounce of water, or cSrbolic acid lotion, or one part of absolute Phenol to forty parts of water, may be used, or Lister's antiseptic gauze may be applied. Boils, although brought about by very different circumstances, some unimportant, others indicative of grave disease, may be fairly included among "slight ailments." The old name for boil is Furunculus. This affection played a more formidable part during and anterior to the middle ages than since and than it does now. In former days many very serious and fatal febrile conditions were characterized by the for- mation of boils. Although in these days boils may be associated with certain forms of blood-poisoning, usually fatal, they are much more common in states of the system due to temporary derangement of the blood than they are in serious blood diseases which soon destroy life. Pathologically the boil is of great interest, as the inflammation begins in one spot and quickly involves a number of tissues, including nerves, blood-vessels, and lymphatics, as well as all the textures forming the true skin. A small portion of the complex tissue is destroyed, in fact it dies, . and is cast off as a slough of dead decomposing tissue, the removal of which is soon followed by the healing process. The local inflammation thus ending in mortification and removal of a portion of the skin and subjacent structures, starts from within. It is difficult to decide whether the local change begins in a capillary or lymphatic vessel ; but in most cases it is probably in the capillary, which is the seat of the changes which result in the formation of the boil. Particles, probably of living matter, adhere to the wall of the capillary, and grow and multiply until the vessel is occluded partly by accumulation TREATMENT OF BOILS. of matter caused by the growth and multiplication of these tiny particles, and partly by fibrin from the blood. The capillary being thus plugged, exudation takes place from the adjacent capillary vessels; and with the fluid poured out minute particles of living matter also escape, and these multiply in the surrounding tissue. In this way the ordinary nutrition of the part suffers, and the usual flow of fluid to and from the living mat- ter of the several tissues which takes place in health is stopped. The nerves of the capillaries and other parts are stretched and pressed upon in consequence, and considerable pain is experienced. The rapid growth and multiplication of living matter, which occurs in every part of the affected region, as usual is associated with the increased development of heat. The inflamed tissues constituting the boil are sensibly warmer than the surrounding healthy tissues. A certain amount of pus is formed between the core of dead tissue and the surrounding healthy structures. By this process the disintegration of the affected tissues is assisted, and the separation of the slough of dead tissue from the surrounding healthy part is expedited. Boils may be caused by a poison developed within the system or in- troduced into the blood from without. The inhalation of infected air, eating diseased meat, over-eating, insufficient and 11 bad food, too much animal food, may establish a state of health favorable to the formation of boils. An actual alteration, no doubt, takes place in the blood, although it is not possible to determine its exact nature. Boils are liable to occur after recovery or partial recovery from fevers, and are very common in cases of diabetes; but the precise influence exerted by the diabetic state upon the tissue, which results in the development of the boil, has not yet been ascertained. The bites of mosquitos, if numerous, may occasion blood-poisoning and considerable derangement of the health, lasting for a considerable time, and ending in the formation of boils of an obstinate kind in different parts of the body. Carbuncle, Anthrax, is closely allied to boils, but is more serious from the much larger area and depth of the inflamed tissue, and from the more serious constitutional disturbance. The inflammation is more diffused ; the slough formed is often so very large that the patient's strength is exhausted before its separation is effected, and the reparative process can begin. This affection cannot properly be included among "slight ail- ments," and I therefore only refer to it as a farther development of the boil. Treatment. As regards the treatment of boils, the best advice I can give you is to leave them alone. Incisions are not needed, and any at- tempt to expedite the removal of the slough does harm by breaking down the temporary separation between the slough and the healthy tissue, thus causing some of the irritating discharge to pass into the surrounding areolar tissue, starting therein a similar inflammatory action leading to sloughing over a wider area. It is important, however, to prevent the 272 CHANGES PREPARATORY boil from being rubbed or pressed upon by the clothes. A small piece of thick Amadou plaster-like felt may be taken, and a hole cut large enough to receive the boil, the summit of which may be partially cov- ered by a piece of ordinary plaster. Yeast has been highly recommended internally, but its efficacy is doubtful. Quinine, mineral acids, and ton- ics of various kinds seem to be useful. Wine may be given in the case of patients whose strength has been worn out by prolonged exhausting disease, but in ordinary cases more harm than good results from stimu- lants. It has been remarked several times, in these introductory lectures on Slight Ailments, that illnesses which apparently come on suddenly are themselves but the consequence of prior changes which have been going on for some time previous to the attack. These preliminary changes are a necessary and essential part of the illness, and, but for them, the attack could not have occurred. The invasion, it is true, seems to be sudden, but the apparently rapid passage from comparative health to decided ill- ness is deceptive, for derangement even of a serious character has cer- tainly existed for some time, though the patient may not have been aware of it. In many cases very great disturbance only gives rise to mere dis- comfort, and the patient himself can form no conception of the serious changes which are going on in his tissues. In not a few instances, espe- cially persons about or past the middle period of life, the nerves are more or less numbed owing to structural changes in them. They do *ot re- spond as readily as they should do, and in consequence their owner does not experience the pain and discomfort which ought to warn him of the occurrence of derangement in action or alteration in structure. By paying attention to the signs and symptoms of derangements which may be correctly termed slight, and relieving them as soon as possible, we may succeed in preventing the occurrence of grave pathological changes. You will remark that many persons who will tell you they do not know what it is to feel well, have not in the whole course of their lives once been seriously ill, and such lives you will often find will be exceptionally long. The nerves are sound, and their peripheral ramifi- cations in a healthy and highly sensitive condition, so that the slightest change in their neighborhood is made evident to their owner by pain and discomfort, or by some form of nerve disturbance. The man who experiences slight derangements of health oftentimes takes steps to re- lieve his discomfort, and, by acting thus, very likely succeeds in remov- ing the condition which precedes the development of actual disease. It is also probable that the very means taken to remove slight symptoms are also effective in bringing about a state of the system which is not favorable to the development of severe illness, or the invasion of mor- bid poisons. It would seem as if some preparatory changes were neces- sary to render the organism fitted either for the reception of morbid TO THE OCCURRENCE OF DISEASE. 273 poisons, or for the initiation of the majority of morbid changes in tis- sues and organs. Even in the case of many purely local lesions it is probable that, for some considerable time before any actual structural change has occurred, there have been congestion and disturbed action. But for the persistence of these, the local disease would not have mani- fested itself. How important it is, therefore, that we should search for evidence of preliminary change, in order that, by altering the conditions of life for a time, by relieving local congestion, by promoting excretion, or by establishing some increased local action, we may succeed in bring- ing about a return to physiological health before any of those grave morbid conditions, which will occupy much of our attention in this course of lectures on the Principles and Practice of Medicine, can be established. I have already drawn your attention to the preliminary changes, which occur in the conjunctiva and glands connected with it, by which it be- comes fitted for the reception and propagation of the minute particle of that specific and poisonous bioplasm which is concerned in the develop- ment of a most formidable and destructive kind of inflammation. Al- though, undoubtedly, there are a few living poisons which are so virulent in their properties, and have such extraordinary power' of vitality that almost every one exposed to their influence is attacked with the disease they engender, this is so decidedly exceptional that one may fairly ven- ture to advance the conclusion that it is at least conceivable that indi- vidual human or animal organisms may exist, upon which the great ma- jority of contagious poisons known to invade might beat in vain. And, as time goes on, I think I shall convince you that the prospect of our being 'successful in discovering the means of enabling the individual organism to resist the assaults of contagion is far brighter than that of our discovering how to exterminate contagion itself, and to prevent new forms of contagious living matter from springing into life. The poison instrumental in carrying ophthalmia undoubtedly spares some exposed to its influence, and, amongst those attacked, varying degrees of severity of the disease will be observed v Even ringworm, and many other diseases invariably associated with the growth and mul- tiplication of a special vegetable organism, will not invade every indi- vidual indiscriminately, and those who have been long under bad influence as regards bodily health, are sure to be the first attacked, and to suffer most severely and for the longest time from the disease. Of a number of persons swallowing the poison of typhoid, or exposed for the same period of time to its baneful influence, some will escape altogether, some will be violently assaulted by the poison, but will escape without the specific disease being developed in consequence of a sharp attack of diarrhoea, some will pass through a mild form of the disease, and a small number will be severely attacked, of which perhaps one-eighth will be destroyed by the fever or its consequences. S 2/4 CHANGES PREPARATORY TO OCCURRENCE OF DISEASE. So, too, with regard to acute inflammations and various diseases of a non-contagious character, what seems to be a sudden illness is probably but the climax of a series of changes which have been going on for a considerable time, although the patient may not have been aware that anything was wrong. An attack of acute rheumatism is always referred to exposure to wet and cold, or to sleeping in a damp bed, or to a long drive or walk in the rain, or to some single unfortunate circumstance or want of caution on the part of the patient. But how many of us are exposed, over and over again, to adverse conditions of precisely the same kind with perfect impunity. The peculiar state of the blood which pre- cedes the attack of illness, and which alone renders the attack possible, has been produced after a prolonged course of pathological changes. But if this special state of blood exists not, instead of the person ex- posed to the adverse influences being attacked by acute rheumatism or pneumonia, or pleurisy, or some other acute inflammation, he experiences, perhaps, a sharp rigor, accompanied possibly by local pain and general discomfort, succeeded in two or three hours by profuse sweating, prob- ably diarrhoea, and the secretion of urine rich in urates, uric acid, and other matters. In the course of a day or two, except feeling a little weak, the patient regains his normal state of health. Perhaps, indeed, for some time afterwards he may even feel exceptionally well and vigor- ous. He has, in fact, been relieved by the removal of various substances which had been for some time accumulating in his blood to his detriment, and which at any moment might have been instrumental in the develop- ment of local disease in some important organ. These considerations, supported by many more to which I might advert, suggest the general* conclusion that the maintenance of each individual organism in a good state of health, the careful attention on the part of the practitioner to slight ailments, and the recognition by hini of any symptoms that may indicate slight derangement of function or action, are of far greater con- sequence than the hunting after and extermination of various species of hypothetical pathological organisms, even though it were actually possible to catch and exterminate legions. 9 I believe that if the organism be in a proper state, almost all disease germs coming in contact with it, or entering it, will certainly die, instead of growing and multiplying and deranging or destroying important con- stituents of the blood and tissues. Many of the poisons in question are round about us in the food we eat in the water we drink. The foot of a fly will carry enough poisonous matter to infect a household. It is, therefore, vain to be always seeking to annihilate contagion which you can only destroy to a most limited and probably useless extent. On the other hand, it seems exceedingly reasonable, and especially on the part of nurses and ourselves, who must be continually exposed to the assaults of disease germs, to do all that is possible to promote and improve the resist- ing power of the body. We always notice that of those exposed to the SLIGHT DERANGEMENTS PREVENTING SERIOUS' DISEASE. 2?$ same adverse conditions, but a very small percentage will be seriously ill. A moderate number only after suffering exposure will catch cold or ex- perience some slight derangement. The majority will entirely escape. No doubt such facts may, in part, be explained on the supposition of the existence of difference in constitution in the different individuals. Allow- ing amply for this, however, there is good ground for concluding that it is possible to preserve the body in such a state of health as would enable it to resist attacks of contagious poisons, to any one of which, in a dif- ferent condition, it would certainly succumb. In other words, there is good reason for the conclusion that it is possible to resist the onslaught of contagious poisons, and, therefore, that it is possible to still increase the health of the community. By detecting and treating slight derange- ments, I have no doubt whatever that we frequently succeed in establish- ing a state of the system which renders the supervention of serious disease almost impossible. The comparative immunity of those who are frequently troubled with various slight derangements of health has been frequently noticed. Per- haps it is to be explained by the existence, in particular individuals, of a highly sensitive and exceptionally active state of those nerve-fibres, and that part of the nervous system which is intimately connected with the healthy action of the circulating and digestive systems. In some persons these nerves respond to the slighest stimulus, and the least de- parture from the ordinary state at once occasions inconvenience or dis- comfort ; while in others, considerable variation, as regards temperature, quality and quantity of food, make little or no impression, and occasion *no immediate disturbance or derangement. But, in the latter case, pathological changes may take place, and may result in grave structural alteration, without the patient having experienced the least discomfort, or even being made aware that any departure from health had occurred in his system before the supervention of the serious illness which you are asked to investigate and treat. Perhaps, in some such manner, we may attempt to account for the fact that certain individuals are suddenly struck down by terrible disease while they seem to be in good health, and others, who never feel well, or look well, reach old age without ex- periencing one single attack of any illness so serious as to endanger life. Such persons, it must be noted, are often obliged to be very careful, as regards diet, and the feeling of tiredness, after great exertion, is in them so distinct that it must be yielded to. Thus they are forced to take rest before any damage whatever has been done to their organs. It is not probable that careful attention to the process of excretion, as well as to the quality and quantity of food that is taken, brings about and preserves a state of blood in which disease germs, instead of growing and multi- plying, would die? How many ailments may not be prevented by judi- cious starving, or by living for a day or two now and then on low diet ? How thoroughly may not the blood be depurated by a sharp purge given, 27-6 -...' CONCLUSION. perhaps, just before liquor sanguinis was about to escape from the vessels, to be poured, perhaps, into the air-cells of the lung? Might not the purgation be fairly considered to have prevented an impending attack of acute Pneumonia or Inflammation of the Lung, and thus to have really "cut short" the disease? May not moderate doses of Bicarbonate of Potash or Soda, taken in solution twice or three times a day for a week or two, avert an attack of acute rheumatism? Will not a small dose of certain preparations of Mercury, now and then, prevent attacks of gout or rheu- matism or sick headache or dyspepsia or biliousness ? Is it not reason- able to conclude that certain salts, by their action on the bowels and kidneys, by promoting free elimination, establish a general state of the tissues, which may for the time render it impossible that certain morbid changes of serious consequence should occur ? I have endeavored, in these few lectures, to show you why we should not fail to devote some attention to the study of those slight departures from the normal state which possibly, in these days, are sometimes passed over by the practitioner, although, on the one hand, their import may be strangely exaggerated, or, on the other, hardly noticed by the patient himself. As I have tried to impress upon you many times, slight derangements sometimes afford the first and only indications of com- mencing disease of a serious character. There is good reason for think- ing that by judicious management, not only may some troublesome though slight ailments be entirely relieved, but further and progressive morbid changes may be prevented or retarded. The principles upon which the treatment of many slight ailments may" be successfully conducted, are the same as those upon which the manage- ment of more marked developments of morbid phenomena is based. I have given illustrations of the simplest and slightest ailments, and have endeavored to show how their treatment may.be most simply and suc- cessfully carried out, and I have attempted to lead you on by degrees to consider more highly complex pathological changes, and to explain the principles upon which more complex methods of treatment are based. In no way, I believe, can you so quickly acquire that sound knowledge of pathological processes, and of the means of checking or modifying them, which are daily required in practice, as by adopting the course I have advocated. Let me, therefore, conclude by again impressing upon you the importance of not neglecting the study of the nature and treat- ment of " Slight Ailments" now, or at any period of your professional career. INDEX. A BSORPTION of fluid in constipation, I\ 117- Acid application to liver, 167. drinks in sick headache, 179. eructations, 147. of the stomach, 95. Action, increased, its effects in treatment, 253- Acute Jaundice, 166. Afferent nerves of capillaries, 235. Ague fit, 212. Ailments beginning like a cold, 203. Air-passages, inflammation of, 264. Albuminous matters, effects of alcohol on, 256. Alcohol, bad effects of, 81. causing vertigo, 156. in dyspepsia, 8l. its use in the treatment of fissures and ulcerations, 255. Alkalies in rheumatism, 198. Aloes in cases of offensive breath, 74. preparations of, in constipation, 138. _Alum as a gargle, 263. spray in sore throat, 69. Ammonia, chloride of, 191. Amoeba, 251. Anaemia, state of tongue in, 62. Anorexia, 75. Anthrax, 271. Appetite, impaired, 75. voracious, 77. Apples in constipation, 128. Aphthae, 70. Ardor ventriculi, 90. Area of redness in flea-bite, 225. Arsenic, 191. Arteries, alteration of, in flea-bite, 225. Artery with nerve-fibres distributed to it, 227, 230. Artificial teeth, value in dyspepsia, 101. Ascarides, 154. Ascaris lumbricoides, 154. Astringents in ophthalmia, 260. . in the treatment of diarrhcea, 151. in the treatment of piles, 122. Aural vertigo, 157. BACTERIA in blood in health; 50. as a cause of disease, 51. in intestine of infant, 49. Balsam, Peruvian, 270. Baptistin, 163. 24 Bat's wing, nerves to, 233. Beef-tea, peptonized, 109. Bilious diarrhoea, 150. Biliousness, 157. treatment of, 161. Bioplasm changes in outside capillaries, 247- growth of, in inflammation, 222. minute particles in blood, 245. Bite, flea, 222. gnat, 237. Black tongue, 64. Blood in fever and inflammation, 221. filaria in, 144. in constipation, 121. passing through vessels in fever, 222. state of, in sick headache, 171. Blue pill in biliousness, 161. Body-heat in fever, 222.' in man and animals, 206. Borax and honey for thrush, 71. Borborygmi, 93. Brain, overworking, 188. - and stomach, 155. Bread, 127. Breath, odor of, 72. Bright red tongue, 63. Bromide of potassium in rheumatism, 199. Bronchitis kettle, 68. Brow ague, 168. Brown bread, 113, 127. Bulimia, 78. affected in sick headache, 171. V_, Calibre of small artery, maintenance of, at a given point, 227. Calomel in dyspepsia, 93. - effect on secretion of saliva, 61. Camphorated spirits in the treatment of chilblains, 270. Capillaries in flea-bite, 225. - in inflammation, 222. - passage of corpuscles through walls of, 240. Capillary haemorrhage, 224. - capillary vessels, nerves of, 230. Carbolic acid as a gargle, 69. - in cases of offensive breath, 73. Carbuncle, 271. Cardialgia, 90. Carlsbad water, 143. Castor. oil for constipation, 135. - for diarrhoea, 146. 277 2/8 INDEX. Catarrh, 214. Catarrhal inflammation of stomach, 266. Catching cold, 202. Catechu, 151. Cayenne pepper in nausea, 86. Cells, changes in epithelial, in a flea-bite, 222. of liver in biliousness, 1 60. Chaff, 113. Chalk mixture, 152. Changes, minute, in fever and inflamma- tion, 219. Charcoal powder in cases of offensive breath, 72, 73. Cheltenham water, 142. Chilblains, 268. Children, constipation in, 120. high temperature in slight ailments, 217. Chlorate of potash in sore throat, 69. as a gargle, 263. Chloride of sodium in sore throat, 69. Chloral hydrate, 192. its dangers, 186. Chlorodyne, 94. Cholera, 145, 211. Chronic rheumatism, treatment of, 196. Citrate of magnesia, 143. Circulation, intermolecular, 39. capillary, mechanism for governing, 232. Civilization, slight ailments, 1 8. Clothing, warm, importance of, 99. Cleaning of tongue, 65. Clinical thermometer, 209. Clyster, 123. Coffee in constipation, 128, 135. COHNHEIM, on migration of blood cor- puscles, 243. Cold bath in constipation, 125. catching, 202. causing a febrile attack, 221. influence of, on blood and tissues,22l. its influence in diarrhoea, 149. sick headache, 1/8. stage in fever, 210. treated by counter-irritation, 253. treatment of a, 214. Collodion, 270. Colon, tenderness of, 149. Color of the tongue, 42. Complexion in those who suffer from con- stipation, 1 18. Condiments, 97. CONDY'S fluid, gargle of, 65. in offensive breath, 73. Congestion of capillaries in flea-bite, 224. of mucous membrane of bowel, 267. Conjunctiva, inflammation of, 256. Connective-tissue formed- by bioplasm, 247. Constipation, in. in jaundice, 165. in sick headache, 171. treatment of, 109, 131. Contagion, 275. Contagious disease, 46. Contractile power of bowel, loss ot', 116. Contraction of minute arteries, 228. Co-ordinating power in vertigo, 156. Corpuscles, mucus, 250. blood, passage through vascular walls, 241. outside capillaries in inflammation, 244. Coryza, 214. Counter-irritation, 253. in sick headache, 178. in stomach, 266. Cracks and fissures of tongue, 65. on lips, 254. Critics subject to constipation, 115. Croakings, flatulent, 93. Croton-chloral-hydrate, 192. oil in constipation, 140. Croupous membrane, 264. Curry powder in nausea, 80. in dyspepsia, 97. DEATH-carrying bacteria, 54. Decay, part played in by fungi, 44. Decillionths of grains, 29. Degeneration of muscles in rheumatism, 196. Demonstrating nerves distributed to cap- illaries, 232. Deranged action of glandular organs, 89. Diabetes, 77. causing boils, 271. Diagnosis, importance of being cautious in making, 217. Diapeclesis, 240, 243. Diarrhoea, 144. treatment of, 151. Diathesis, 76. Diet in constipation, 127. in rheumatism, 211. in diarrhoea, 150. in hot and cold climates, 98. in indigestion, 93. . Digestion, artificial, 109. in jaundice, 167. non-nutritious matters in, 113. in rheumatism, 205. Digestion in sick headache, 169. Dilatation of capillary vessels in fever and inflammation, 222, 232. Diluents in a cold, 218. Diphtheria, 261. Disease germs, 275. Disks for hypodermic injection, 192. Dispensaries, self-supporting, 35. Dissection of nerves of intestines, 87. Diuretics in a cold, 215. Dorsum of tongue, 43. Douche, eye, 260. Dover's powder, 191. Dried apples in constipation, 129. Drowsiness, 184. Dry mouth and fauces, 67. INDEX. 279 Dry tongue, 58. brown tongue, 63. Dust and disease, 50. Dysentery, 267. Dyspepsia, 84. treatment of, 94. EAST wind causing biliousness, 162. Eau de Cologne in treatment of cracks and fissures of lips, 255. Efferent nerves to arteries, 236. Effervescing citrate of magnesia, 143 saline purgatives, 143. Elaterium in constipation, 140. Emetics, 92, 268. Empirical treatment, 267. Endurance, powers of, in sufferers from sick headache, 172. Enemata, action of, 123. Epilepsy and sick headache, 174. Epithelial cells of tongue, 43, 44, 45. Epithelium, irregular growth of, 254. pus formed in, 224. Epsom salts, 141. Eructations, acid, 147. Eruption in fever, 221. Eruptions, 252. Examining mucus-corpuscle, 249. Excess of urea, 208. Ex oriations, treatment of, 255. Excretion, importance of, 204. Exercise in constipation, 125. External applications in indigestion, 96. Exudation, 241. in fever and inflammation, 222. in rheumatism, 195. Eye-glass, 259. Eye waters, 259. T7/ECAL matter, impaction of, 116. 1 False membrane, 264. Fasting girls, 77. Fauces, dryness of, 67. Febrile diseases, 203. Fever, local, 222. and inflammation, 207, 219. Feverish and inflammatory state, 202. Feverishness produced by irritation of stomach, 146. Feverishness, secretion in, 213. Fevers, formation of pus in, 239. Fibrin, bacteria in, 50. Fibrous matter, formed from bioplasts, 247. Filaria sanguinis hominis, 238. Filiform papillae, 43. Fissures and cracks of tongue, 65. Flannel for warm clothing, 99. Flatulence, 92. Flea-bite, 222. Fluid, quantity of, to be taken, 83. importance of taking, in constipation, 117, 129 Fog, its effects on conjunctiva, 256. Food, abstention from, in sick headache, 177- Food, importance of not taking too much, 19, 79- Fountain, eye, 260. FOWLER, DR., his case of the fasting girl, 77- Friedrichshall water, 142. Fruit causing diarrhoea, 145. in constipation, 128. Fungi, germs of, 45. growth and multiplication of, 45. on tongue, 44. Fungi form papillae, 43. Furred tongue, 6l. Furunculus, 270. f~^ ALL stones, 166. \J Gamboge, 140. Ganglia," 89. regulating calibre of small arteries 227. Gargles, 263. Gastric glands, nerves of, 87. Gastralgia, 89. Gastric juice, variation in quantity of, 57. Gastrodynia, 89. General changes from local injury, 237. Germs o* fungi, 4.4. in every part of body, 48. on tongue, 44. G Jdiness, 154. Glands o< conjunctiva, inflamed, 257. exciting action of, in offensive Dreath, 73- gastric, wasting of, 100. Glauber salts, 141. Glycerine and water, 64. Gn.u-bite, changes resulting from, 237. Gout and sick headache, 174. Granulated effervescing salines, 143. Gravedo, 214. Gray powder, 61, 70, 102, 167, 176. Growth of fungi, 47. Guarana in sick headache, 181. Guiacum in rheumatism, 199. TT HEMORRHAGE, 65. 11 capillary, 224. Haemorrhoids or piles, 120. Hair-like processes of papillae of tongue, 44- HALLIER on fungi, 53. Headache, treatment of, 175. sick, 167. Healing process disturbed in constipation, 119. Healthy individuals rare, 19. Heartburn, 90. Heat of body, 206. in fever, 206. Hemicrania, 1 68. Homoeopaths, 28. Honey and borax in aphthae, Jl. Horse radish. 60. Hospital, out-patients, 36. Hot climates, diet in, 97. 280 INDEX. Hot stage in fever, 210. water, India-rubber bottle for, 151. Humbug, medical, 26. Hunyadi Janos water, 143. Hydrocyanic acid in nausea, 85. Hygienic treatment of constipation, 125. Hypodermic injection, 186, 191. Hyposulphite of soda, 65. Hydrochloric acid, external application of, to liver, 167. Hydrocyanic acid, its effects, 24. Hy!a, nerve-cells of, 228. artery of, 228. Hysterical loss of appetite, 76. IMMUNITY to severe disease of those J suffering from slight ailments, 275. Impaction o fsecal matter, 116. India-rubber bottle for hot water, 151. Indian corn flour, 127. Indigestion, 84. in old age, loo. re-u'ting from loss of teeth, loo. treatment of, 94. warm clothing in, 100. Infant, growth of fungi in intestine of, 49. Infant le diarrhoea, treatment of, 146. Ingluvin, 108. Inflammation, 202, 219. heat of blood in, 207. minute particles of bioplasm passing through vessels, 247. slight, 248. Inhalers, 68. Injection, 123. hypodermic, 192. Iniury in case of a flea-bite, 226. hv.jrcostal muscles, pain in, 194. Intermolecular circulation, 39. In'estinal canal, ganglia and nerves of, 228. nerves of. 86. inflammation of, 265. worms, 152. Iodide of potassium in cracks of tongue, 66. in rheumatism, 199. Iodine in chilblains, 269. Ipecacuanha as an emetic, 92. in ulcers of colon, 267. Iron, its influence in darkening the mo- tions, 150. tincture of, in sore throat, 262. muriated tincture of, in thrush, 71. in neuralgia, 191. Irritability in biliousness, 158. of dyspeptic persons, 94. Irritation of mucous membrane, 253. ofstamach causing diarrhoea, 145. Issue, 254 Itching in chilblains, 269. JALAP in constipation, 136. I Jaundice, 163. Joints, state of, in rheumatism, 195. Juglandin, 163. T7" ETTLE, bronchitis, 68. lV Kino, 151. Kneading the bowels, 127. Krameria, 151. LARGE intestine deranged in sick headache, 171. Lavement, 123. Leaves, fungi of, 46. ^ '. Lemon-juice when mouth dry, 60. Lentils, 266. Leptothrix buccalis, 45. Licorice powder, compound, in constipa- tion, 137. Lime-water in diarrhoea, 147. Liquid taken, its influence on action of bowels, 117. Liquor sanguinis, 241. bioplasm in, 222. Lips, vascularity of, 255. Literary men, constipation of, 1 1 5. Liver, its deranged action in biliousness, 1 60. exciting action of, in offensive breath, 73. in sick headache, 171. Living matter, changes in, 247. particles, passage of, through ves- sels, 241. Local injury, vascular disturbances from, 237- Logwood, 151. Loss of appetite, 76. Lotion for eyes, 260. Lozenges, bismuth, in dyspepsia, 96. Lumbago, 194. Lungs, capillary haemorrhage from the, 241. ll/f ANAGEMENT of patients, 21. 1V1 Manson, Dr., on filaria, 238. Mastication, defects of, IOO. Materies morbi, 54. Meat in inflamed mucous membrane of stomach, 266. little required by bilious people, l6f. too much, 98. Mechanism for governing calibre of ar- teries, 232. for regulating capillary circulation, 232. Me'niere's disease, 157. Mercury in sick headache, 175. its use in offensive breath, 74. Metallic taste in mouth, 70. Micrococci, 45. Microscopic ganglia, 70. observation, 38. Mildew, vital phenomena of, 246. Milk and lime-water, 147. Mind in sick headache, 170. Mindererus, 215. Misery and despair in biliousness, 159. Moist application to bowels in constipation, 126. INDEX. 28l Molecular circulation, 39. Morphia, its influence on t"he circulation, 238. Mortification, 223. following boils, 270. Movements of mucus-corpuscles, 250. vital, 223. Mouth, aphthae in, 70. dryness of, 58. Muco pus, 264. Mucous membrane, inflamed, 249, 264. of stomach, inflamed, 265. Mucus corpuscle, 250. evacuations, 148. formation of, 250. of pig's stomach as pepsine, 105. secreted in a cold, 253. Muscular fibre cells of intestine, 86. of small artery, 227, 235. rheumatism, 195. Mustard as an emetic, 92. leaf, mode of using, 266. Myrrh, tincture of, in cases of offensive breath, 73. N'ARES, dryness of, 67. Natural history of disease, 37. Nausea, 79. in sick headache, 168. Nerve, action of, determining calibre of arteries, 227. cells and fibres governing capillary circulation, 228. circuit, 236. derangement in sick headache-, 173. disorders, relation of fever to, 220. disturbance in chill >lains, 269. fibres concerned in pain, 251. eruptions in course of, 252. of stomach and intestine, 85. storms, 174. Nerves of digestive system, 55. to capillary vessels, 230. and ganglia, stomach, 85. of hyla, 228. of intestinal canal, 86. Nervous excitement producing diarrhoea, 144. Nervousness, 187. Neuralgia, 189. treatment of, 190. Neuralgia and gouty affections, and sick headache, 174. Nitrate of silver in sore throat, 68. in treating sores on lips, 256. Nose, haemorrhage from, 243. Nucleus of a ceil, 250. Nutritive matters, 113. Nux vomica in constipation, 137. OATMEAL in constipation, 113, 127. Odor of the breath, 72. Offensive breath, 72. Oidium albicans, 45. 24* Old age ; accumulation of fsecal matter in, 116. indigestion in, 100. Olive oil, 146. Oozing of blood from capillaries, 241. Operation, fever after, treatment of, 1 19. Ophthalmia, .257. poison of, 273. Opium in diarrhoea, 152. homoeopathic doses, 28. Ostrich -pepsine, 107. Outgrowths from bioplasm, 247. Out-patient department of hospitals, 35. Over-sensitiveness in sick headache, 173. Oxidation not increased .in fever and in- flammation, 207, 222. DAIN, 85, 1 conducting nerve-fibres, 88. nerve-fibre concerned in, ii;i. neuralgic. 190. pleuritic, 252. in the stomach, 266. rheumatic, 193, 197. Palate, soft, dryness of, 67. Papillae of tongue, filiform, and fungi form. 43. Paralyzing action of nerve-centres and fibres, 236. Pathological changes, nature of, 52. Peculiarity of dress, 28. Pepsine, and its uses, 102. of the pig, 105. of the ostrich, 107. Peptones, no. Pericarditis, pain in, 88. Periodical sick headaches, 173. Peripheral paralysis, 261. Peritonitis, 88. Perspiration, free, in rheumatism, 197. Peruvian balsam, 270. Petechise, 224. Pharynx, changes in mucous membrane. of, 68. Phosphate of soda, 142. Physical views of vital aciion, 246. Phytolaccin, 163. Pig, pepsine of, 105. Piles or hcemorrhoids, 120. Pleurisy, pain in, 89, 251. Plexuses, nerve, 87. Pneumonia, 274. increased oxidation in, 208. PodophylHn in constipation, 139. Poison of disease, 274. Pork, its dethronement in America, 189. Port wine as a gargle, 263. Poultice, its use in treatment of ulcer of stomach, 266. in dyspepsia, 97. Preliminary changes in febrile attacks, 204. : various diseases, 273. Pressure in causing chilblains, 268. 282 INDEX. Principles of treatment of slight and severe ailments, 35. Prescribing, 36. Prunes in constipation, 128 Prussic acid in nausea, 83. Pullna water, 142. Purgative enemata, 123. Purgatives in cases of offensive breath, 74. in a cold, 21=;. in constipation, 131. in indigestion, 93. Pus from bioplasm of epithelium, 223. corpuscles, formation of, 223. in boils, 271. not altered < blood-corpuscles, 240. formation of, in and near capillaries, 239- Putrid fluids, bacteria in, 47. Pyrethrum, 60. Pyrosis, 90. QUACKERY, 27. its consequences, 32. Quinine, action of, 40. RASH in fever, 220. Reabsorption of fluids from intes- tine, 117. Rectum, bleeding from the, 243. Redness of skin in fever, 220. in flea bite, 224. Regularity of action, importance of, 96. Reputation of quacks, 33. Rest, importance of. 57. in sick headache, 177. importance of, in treatment, 266. Restlessness, 185. Rhatamy, tincture of, 152. Rheumatic pains, 193. Rheumatism, tongue in, 61. causes of, 274. treatment of. 196. Rhubarb in constipation, 132, 135. Rigors, 210. Rubbing in constipation, 126. in liniments, 267. Running from the ear, 264. Rocheile salts, 142. SALTCINE, 191. Saline purgatives in constipation, 140. Salines, action of, 57. Saliva, exciting flow of, 60. Salt as a gargle, 263. Santonin, 154. Sarcina ventriculi, 45. Scammony in constipation, 137. Scarlet fever, rash in, 220. Scepticism, 31. Scrofulous children, ophthalmia in, 257. Sea-side causing biliousness, 163. Secretion, free, 213. importance of, in preventing illness, 273- Self-supporting dispensaries, 35. Senses disturbed in sick headache, 173. Sensitiveness of inflamed mucous mem- brane, 251. of peritoneum, 88. Serious diseases, 36. Serous membranes, pain in, when in- flamed, 88. Shampooing in rheumatism, 197. Shrinking of muscles in rheumatism, 195. Shivering and rigors, 203. Sialogues, 60. Sick headache, 167. treatment of, 175- Slight inflammation, 248. Smoking as a remedy for constipation, I3I- Sordes, 64. Sore on lips, 254. on mouth, 70. throat, 260. state of mucous membrane in, 252. Spirit of Mindererus, 215. Spray in treating sore throat, 68. Starving in sick headache, 177. Steel, tincture of, 71. Stings or bites of gnats, 237. Stimulants in sick headache, 173, 176. Stomach, derangement of, in sick head- ache, I/O. poulticing the, 266. acids of, 91. capillary haemorrhage from the, 244. fungi in, 48. irritation of, producing fever, 146. of pig, 105. ulcer of, 265. wind in the, 92. Sudden illness, 274. Sulphate of magnesia and soda, 141. .Sulphurous acid gargle, 65. Swallowing, 260. Sweating in rheumatism, 200. - stage in fever, 210. Sycophants, 27. Sympathetic system, nerves of, 86. Syringes for injections, 124. '"PACT and treatment, 25. 1 Tannic acid, glycerine of, in sore throat, 68. Tannin, use in sore throat, 262. Tapeworm, 154. Tarlar emetic, 80. Tartrate of soda and potash, 142. Taste, metallic, in the mouth, 70. , Tasteless salt, 141. Tea-drinking in sick headache, 179. Teetotalism, 82. Teeth, loss of, causing dyspepsia, 100. Temperature of body, ascertaining, 209. rise of, in febrile states, 206. Temporary jaundice, 164. Tendons in rheumatism, 195. Thermometer, use of, 209. INDEX. 283 Thickening and condensation of connect- ive tissue, 247. Thirst, 83. Thought in sick headache, 170. Threadworms, 153. Thrush, 70. Tissues, changes of, in inflammation, 219. Tobacco, a cause of vertigo. 156. Tobacco-smoking in constipation, 131. Tongue, 42. cracks and fissures of, 65. dry and moist, 58. in various derangements, 55. in vegetable organisms on, 45. Tonics, in chilblains, 269. Toothache, 190. Trades, constipation dependent on various, 114. Transudation of fluid through vessels, 145. Treatment of aphthaj, 71. of boils, 271. of chilblains, 269. of a cold, 214. of drowsiness, 185. empirical, 267. of inflamed mucous membrane, 255. of rheumatism, 196. of sick headache, 175. of slight ailments, principles of, 36. of sore throat, 261. Turkish bath in rheumatism, 197. Turpentine in chilblains, 270. u LCER of bowel, 267. of stomach, 265. - in mouth, 70. of mucous membrane, 249. Urea, excess of, in fever, 208. Urine in sick headache, 173. VALLISNERIA, bioplasm of cells of 245. cells of leaf of, 47. Vapor-bath in rheumatism, 197. Vascular disturbance resulting from local injury, 237. Veins, state of, in haemorrhoids, 121. Vertigo, 154. Vessels in fever and inflammation, 2T2O. Villi, nerves of, 87. Virulent pus-corpuscles, 257. Vital movements, 250. Vomiting, 80. in sick headache, 168, 180. Voracious appetite, 77. Vulgarity of manner, 28. TT7AKEFULNESS, 185. VV Warm-blooded animals, 206, Warm clothing, importance of, 99, 2O2. W T armth, importance of, 149, 151,202. chilblains treated by, 268. in sick headache, 178. in treating pain in the stomach, 266. Wasting of muscles in rheumatism, 195. Water in treating biliousness, 162. Waterbrash, 90. Weakness as a consequence of dyspepsia, 102. White moist furred tongue, 61. Wind in the stomach, 92. Woollen clothing, importance of, 99. Worms, intestinal, 152. Wounds do not heal i.n constipation, 119. not healing in sick headache, 170. T7" AWNING in sick headache, 169. 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