G OOP 005 761 2 MEDICAL NOTES AND EEFLECTIONS. BY Sir henry HOLLAND, Bart., M.D. F.R.S. &c. &c. FELLOW OP THE ROYAL COLLEGE OP PHYSICIANS, PHYSICIAN IN ORDINARY TO THE QUEEN, AND PHYSICIAN IN ORDINARY TO HIS ROYAL HIGHNESS PRINCE ALBERT. oAAtj aei (paiverai apx^' M^'* '''^ '''V TeXeuT?)/', Irfpa OwoXenrofievri TeXevrt). — Pi.ATO {ih Scientia). THIRD EDITION. LONDON: LONGMAN, BROWN, GRP:EN, AND LONGMANS. 1855. LONKON : A. anrt G. A. SponiswoonE, Ncw-strect-Squarc. IY5 7 If55 PREFACE TO THE THIRD EDITION. A Third Edition of this work having been called for, it is necessary to preface the volume by a few re- marks, explanatory of certain alterations which have been made in its contents ; both as respects the several topics treated of, and the manner of their present arrangement. In the two former Editions, a few chapters were included on psychological subjects — the mutual actions and relations of mental and bodily pheno- mena, which constitute the life of man. Closely blended though these topics are with every part of physiology and medical practice, they yet involve peculiar methods of discussion, which separate them in some sort from the other parts of the work. This consideration led me, three years ago, to detach these particular chapters, and to embody them in another volume, under the title of "Chapters on Mental Physi- IV PREFACE TO THE THIED EDITION. ology;" — enlarging them generally, and adding others, which might give more of unity and completeness to the treatment of the subject. The removal of these chapters has led me to supply their place by a few others, taken from among the papers I had originally designed for a second volume of this work. The parts thus added have more explicit relation to practical medicine, and come therefore into closer accordance with the other topics treated of in the volume. In the prior editions, from causes stated in the preface, the arrangement of the subjects was desultory through- out ; a fault, doubtless, in itself, yet one which the nature of my plan and materials scarcely permitted me to avoid. In the present edition I have sought (aided by the change just mentioned) to bring the chapters more into series as regards the relation of their subjects; and, I trust, not without some ad- vantage to the reader. In the earlier parts of the volume, they will be found to relate chiefly to certain pathological prin- ciples, through which I have sought to associate together various morbid conditions, not usually thus connected in our systems of nosology. This method of inquiry, which I believe to conduct to many valuable results, I have further carried into the con- sideration of some particular disorders (Gout, In- fluenza, Dyspepsia, &c.) which at once illustrate the method in question, and are themselves best illus- trated through it. The chapters comprised in the latter half of the volume relate more especially to the treatment of disease ; including under this term PREFACE TO THE THIRD EDITION. V not solely the consideration of particular medicines or remedial means ; but also the methods in practice which a physician may expediently follow, and the duties he is bound to fulfil. Sixteen years have now been added to a period of practice, already long when the first edition of this work was published. In these times of rapid and incessant change — of medicine as of other sciences and professions — such a period becomes a little his- tory in itself; and no one of common observation can have gone through it without gathering up, not merely insulated cases and facts, but also many general conclusions and principles, of still greater concernment to the interests of the profession. Such knowledge, as derived from my own experience, it has been my endeavour to convey in the clearest and most practical form in the following chapters ; which must be regarded, however, not as formal treatises on the several topics discussed in them ; but simply as selections from what I have noted in practice ; embodjdng in this form some out of the numerous materials which are yet required for future and more complete research. The chapter on " Animalcule Life as a Cause of Disease," illustrated by the history of Cholera, I have considerably enlarged ; placing it, however, at the end of the volume, as being in some measure de- tached by its more hypothetical character from the other subjects of which I have treated. London, August 18, 1855. A 3 PREFACE TO THE FIRST EDITION. The title of this volume is chosen as being that which most nearly expresses its contents. Though appearing now as detached papers, they are founded chiefly upon notes made in the course of twenty years of medical practice in London. During nearly the whole of this time, I have been accustomed to preserve notices, not merely of particular cases, but also of such general reflections as were suggested to me by actual observation. At the expiration of the period named, I have thought it well to look back upon these various memoranda ; to give something of more definite form to those which seemed worth preserving ; and to compare the whole, as well with my own present impressions, as with the actual state of knowledge on the several subjects in question. This volume is the result of a revision and selection so made. But as its form, though sanctioned by precedents of high value, is not altogether common, A 4 Vni PREFACE TO THE FIRST EDITION. it may be right to add a few words more, in explan- ation of the motive and manner of publication. It seemed to me, looking at them as impartially as 1 was able to do, that there were among these papers so revised, a certain number which might be likely to contribute in some degree to medical knowledge or to the exactness of our views in practice. I have had regard to these objects only, as justifying pub- lication ; and as a principle of selection out of the materials before me. In making this selection, I have put aside a great deal as relating to subjects of in- ferior importance; still more, from finding that many of my notes related to facts or opinions no longer new. What I have retained includes much that will be familiar to all who have carried observation and study into their medical life. But this was inevitable, without wholly omitting many subjects of great in- terest ; and it would have been presumptuous to offer a work composed, as this has been, from ma- terials acquired in the course of active practice, as one of original research. Every physician has, in his progress, some par- ticular occasions or facilities capable of being con- verted to good. The opportunities of private practice, from which almost exclusively my own observations are drawn, do not furnish the same striking conclusions as those of hospitals ; nor the larger classes of facts, which form the statistics of medicine, and are so fruitful of results. Yet such is the scope of the subject, that a prolonged expe- rience, with due regard to the nature and sufficiency PREFACE TO THE FIRST EDITION. IX of the evidence, may from this more limited source derive much to aid other methods of research, and to enlarge the general amount of medical knowledge. What I would fain hope may be found in this volume is, a just view of some of the relations of diseases, as well to each other as to the healthy functions of the body ; — the correction of some doubtful or erroneous views in practice; — suggestions which may be useful as regards particular classes of remedies ; — and reflections on certain points of physiology, in Avhich, without any pretension to ex- perimental inquiry, it appeared to me that something might be gained by arranging the facts and inferences in a new form. On topics of the latter class I have sought especially to associate pathology with phy- siology, the morbid with the natural and healthy states of the body ; believing this principle of modern inquiry to be above all others fertile in sound con- clusions, and far from being yet worked out to its full extent. If I might venture on giving any distinctive character to the volume, it would be that of aiming throughout at this object. In one instance only have I indulged in any mere speculation ; and this only interrogatively, as to an old hypothesis, regarded in its relation to modern science, and to the history of a remarkable disease. Many other points I have put as questions ; finding them as such in my notes; and thinking it well, whenever it could be done, thus to mark the objects most open to inquiry. I have further taken the privilege (which experience may perhaps be allowed X PREFACE TO THE FIRST EDITION, to sanction) of commenting on certain usages and details of practice, in which the character and useful- ness of the profession, and through them, the welfare of the public, are materially concerned. On each subject treated of, I have brought to- gether my notes in the manner best suited for per- spicuity ; adding whatever seemed necessary to give greater completeness to the reasoning, or to connect it with the inquiries of others on the same topics.* In effect of this, much of the volume has been wholly written anew. I had at one time proposed the in- sertion of a greater number of the cases upon which its materials were founded ; but I abandoned the intention, from a wish not to increase the size of the work, which this must largely have done. And for the same reason I have abridged into the form of notes many topics on which I had originally written at greater length. As respects the arrangement of the subjects, it will be found a very desultory one ; such as naturally arose out of the miscellaneous materials employed. In a few instances only have I thought it worth while to bring topics expressly together for their mutual elucidation. To have attempted this further would imply a more complete and consecutive work than that now offered to the public. * On the latter point great deficiencies are inevitable. In these da}s of various research, actively pursued in so many countries, it would re- quire more reading than is coni[)atible with actual [)ractice to collect together all that has been done on these subjects ; nor would a single volume suffice Ibr the mere references needlul to such a work. PREFACE TO THE FIKST EDITION. XI These, I think, are all the circumstances which need be stated in explanation of the form and matter of the volume. It will deeply gratify me, if here- after I find cause to believe that it has contributed to science by any right views in the philosophy of medicine, or to practical good by any suggestions of value regarding the treatment of disease. Lower Brook Street, March 13. 1839. CONTENTS. CHAPTER I. Page On Medical Evidence ...... i CHAP. II. On Hereditary Disease - - - - - -16 CHAP. ni. Itlethod of Inquiry as to Contagion - - - - 54 CHAP. IV. On Diseases commonly occurring but once In Life - - 61 CHAP. V. On the Connexion and Classification of certain Diseases - - 91 CHAP. VI. On disturbed Balance of Circulation, and Metastasis of Disease - 1 ] .3 CHAP. VII. On the Influence of Weather in relation to Disease - - 149 CHAP. VIII. On Diet, and Disorders of Digestion ..... 202 CHAP. IX. On Gout as a Constitutional Disorder .... 239 XIV CONTENTS. CHAP. X. Page On Morbid Actions of Intermittent kind - - - - 270 CHAP. XI. On the Medical Treatment of Old Age - - - - 299 CHAP. XU. On the Epidemic Influenzas of late years ... 322 CHAP. XIII. On Prognosis, as a part of Practice .... 355 CHAP. XIV. On Pain, as a Symptom of Disease . - » - 364 CHAP. XV. On points where a Patient may judge for himself - - 377 CHAP. XVI. On Methods of Prescription ... - . 383 CHAP. XVII. On Internal Haemorrhages and Morbid Secretions as the Subjects of Medical Treatment - - - - - 391 CHAP. XVIII. On some supposed Diseases of the Spine . _ . 403 CHAP. XIX. On Hypochondriasis - - - - - -410 CHAP. XX. On the Exercise of Respiration ----- 422 CHAP. XXI. On some Points in the Pathology of the Colon ... 434 CONTENTS. XV CHAP. XXII. Page On the Abuse of Purgative Medicines - - - - 119 CHAP. XXTII. On Bleeding in Affections of the Erain - - - - 462 CHAP. XXIV. On the Use of Emetics -.---- 478 CHAP. XXV. On the Uses of Diluents - . . - . 491 CHAP. XXVI. On Sudorific Medicines ------ 504 CHAP. XXVII. On the Use of Oitiates - - - - - -516 CHAP. XXVIII. On Mercurial Medicines -----. 531 CHAP. XXIX. On the Use of Digitalis - - - - - - 543 CHAP. XXX. On Antimonial Medicines _ . . - . 553 CHAP. XXXI. On the Hypothesis of Animalcule Life as a Cause of Disease ? — On Cholera --..... 562 Conclusion ------- 609 MEDICAL NOTES AND REFLECTIONS. CHAPTER I. MEDICAL EVIDENCE. There can be few better tests of a sound understanding, than the right estimation of medical evidence ; so various are the complexities it presents, so numerous the sources of error. The subjects of observation are those in wliich Matter and Mind are concurrently concerned ; — Matter under the complex and subtle organisation, whence vitality and all its functions are derived ; Mind in its equally mysterious re- lations to the organs thus formed ; — both subject to numerous influences from without, both undergoing very various changes from disease within. Individualities of each have their effect in creating difficulties, and these amongst the most arduous which beset the path of the physi- cian.* Few cases occur strictly alike, even when the source * Idiosyncrasy, as arising In most cases from inappreciable causes, is the most absolute and inevitable difficulty In medical evidence ; since no accumulation of instances, such as might suffice for the removal of all other doubts, can secure us wholly against this source of error. B o 2 MEDICAL EVIDENCE. of disorder is manifestly tlie same. Primary causes of disease are often wholly obscured by tbose of secondary kind. Organs remote from each other by place and function are simultaneously disturbed. Translations of morbid action take place from one part to another. Nervous affections and sympathies often assume every character of real disease. While remedial agents are rendered uncertain in effect by the various forms of each disorder, by the idiosyncrasies of the patient, by the difficulty of securing their equal application or transmission into the system, and finally by the unequal quality of the remedies themselves. These difficulties, the solution of which gives medicine its highest character as a science, can be adequately conceived by the medical man alone. Neither those accustomed to legal evidence only, nor such as have pursued physical science in its more simple material fonns, can rightly apprehend the Aast difference made by the introduction of the principle of life ; or, yet more, of the states and phenomena of mind, in connexion with bodily organisation. We have here a new Avorld of relations, occult and complex in their nature, to be reasoned upon and resolved ; with a principle of change, moreover, ever operating among them, and deviations from nature under the form of disease, which render all conclusions liable in a thousand ways to error. It is the want of this right understanding of medical evidence, which makes the mass of mankind so prone to be deceived by imposture of every kind ; whether it be the idle fashion as to particular remedies ; or the worse, because wider, deception of some system, professing to have attained at once, what the most learned and acute observers have laboured after for ages in vain. It must be admitted, indeed, that this matter of medical testimony is too lightly weighed by physicians themselves. MEDICAL EVIDENCE. 3 Else whence the frequent description of effects and cures by- agents put only once or twice upon trial; and the ready or eager belief given by those, who on other subjects, and even on the closely related questions of physiology, would instantly feel the insufficient nature of the proof.* Con- clusions requiring for their authority a long average of cases, carefully selected, and freed from the many chances of error or ambiguity, are often promulgated and received upon grounds barely sufficient to warrant a repetition of the trials which first suggested them. No science, unhappily, has . abounded more in false statements and partial inferences ; each usurping a place for the time in popular esteem ; and each sanctioned by credulity, even where most dangerous in application to practice. During the last thirty years, omitting all lesser instances, I have known the rise and decline of six or eight fashions of medical doctrine or treatment ; some of them affecting the name of systems, and all deriving too much support from credulity or other causes, even among medical men themselves. Look at what is necessary, in strict reason, to attest the action and value of a new remedy or method of treatment. The identity or exact relation of the cases in which it is employed ; — a right estimate of the habits and temperament, moral as well as physical, of the subjects of experiment; — allowance for the many modifications depending on dose, combination, quality of the medicine, and time of use; — due observation of the indirect or secondary, as well as direct, effects; — and such observation applied, not to one organ or * " Id credunt esse experientiam, quando semel vel bis faustam, vel infelicem, in certo niorbo a sumpto medicamento annotarunt efBcaciam." — Hoffman. B 2 4 MEDICAL EVIDENCE. function alone, but to the many Avhicli constitute the material of life. All these things, and yet more, are essential to the completeness of the testimony. All can rarely, if ever, be reached; and hence the inevitable imper- fections of medicine as a science. But much more, doubtless, of truth and beneficial result might be attained, were these difficulties rightly appreciated, and the fit means of obviating them kept more constantly in view. * In no class of human events is the reasoning of "])ost hoc, propter hoc, " so commonly applied by the world at large, as in what relates to the symptoms and treatment of disease. In none is this judgment so frequently both erroneous and prejudicial. It would seem as if the very complexity of the conditions necessary to sound evidence, tended to beget acquiescence in that which is lightest and most insufficient for truth. The difficulties occurring in practice from this source are great, and require a right temper as well as understanding to obviate them. Nor is there any subject upon which words and phrases, whether applied to diseases or remedies, exercise a larger influence. Terms have descended to us, which we can hardly put aside, — maxims, which fetter the understanding and power of action, — and methods of classification, which prevent the better suggestions of a sound experience. And these are among the evils most aggravated by public opinion, ever prone to be governed by names, and particularly in all that concerns the symptoms and treatment of disease. The deeper the interest belonging to the subject, the greater the liability to error. * Amongst the other difficulties of evidence in such cases must be noticed the ambiguity of all language as applied to denote and distin- guish sensations ; an evil familiar to every medical man, and only to be obviated by watchful experience. MEDICAL EVIDENCE. O It needs to be called to the mind of medical men them- selves how many organs of the body are still without any certain interpretation of their part in the animal economy. Even that great organ, the Liver, though now known to us in its most minute anatomy, offers many problems for more complete solution ; — the conclusions of Liebig and Bernard (themselves recent in date) differing as to the nature of its functions, and their relation to the respiratory organs. The uses of the ductless glands — the spleen, thyroid, thymus, and supra-renal bodies — are yet only vaguely conjectured. The physiology of the brain and nervous system, though largely elucidated by the researches of the last forty years, still abounds in difficulties, many of which time may over- come ; while others are probably for ever insuperable. These few instances indicate one great source of error and embarrassment to which all medical proof is exposed. But in pathological doctrine also, there is similar and equal difficulty from the character of the evidence concerned. If example were needed to illustrate this, it might be di-awn from what relates to the history of Fever, whether idiopathic or symptomatic in kind. Here centuries of research, amidst facts of daily occurrence, have yet left some of the most important questions wholly vmresolved; — such is the dif- ficulty of obtaining unequivocal proofs of nature essential to a just theory. The same with respect to the true doctrine of Inflammation ; a question which spreads itself, directly or indirectly, over every part of pathology. Here the most various and diligent inquiries long left it uncertain whether there occurred an increased or diminished action of the capillaries of the inflamed part ; or in what mere turgescence differs from inflammation. It is only of late years that the improved power and refined use of the microscope has given us more assurance as to the nature and succession of these B 3 6 MEDICAL EVIDENCE. changes ; still leaving, however, various points open to future determination. * The history of contagious diseases furnishes another in- stance not less remarkable. It is the common belief of the world, and one plausible enough in its first aspect, that the laws of contagion are simple and readily learnt. No mistake can be greater than this. All parts of the subject, even the circumstances most essential to practice, are wrapt up in doubt; and the evidence is of so intricate a kind, and so much disturbed by seeming exceptions, that the best judg- ments are perpetually at fault upon it. The same remark may be extended to other classes of disease, where time and the most acute observation have hitherto failed to extricate truth from the multitude of conditions present; but where, nevertheless, we have the certainty of relations hitherto un- determined, the fixing of which belongs to future research, and will well repay it in the result. The observations just made are not less true in relation to the internal remedies we employ, even those most familiar, and seemingly simplest in use. The difficulties already noticed as belonging to the evidence of their effects, extend yet further, and more remarkably, to the theory of their action ; and our knowledge, though augmented of late years by the wonderful advance of Organic Chemistry and Phy- siology, can scarcely yet be said to have passed the threshold of the inquiry. We must avow that this whole department of medical knowledge, so important in all its bearings, is the one where most remains to be done to raise it to the character of a science. The real amount of the deficiency can only be understood by a candid examination of the results of ex- * I allude here especially to Kaltenbreiiner's microscopic researches. The frequent revival of controversy on these points among modern writers shows at once their importance, and the incompleteness of the knowledge yet obtained on the subject. MEDICAL EVIDENCE. 7 perience, and a fair comparison with other branches of phy- sical knowledge. To many, indeed, even of those conversant with practice, this will seem too disparaging a view of the science they profess. And, in truth, the accustomed way in which the uses of medicines are taught, and the methodical forms under which they are classed and named according to their alleged effects, do favour the persuasion of a more advanced state of knowledge than that just described. It might be enough, perhaps, to refer those who doubt the reality of the view I have taken to what has been written on medicines in general, and to what is unequivocally known of each one in parti- cular. It will be found that ambiguities of language crowd round every part of the subject — that classification, while clearing away some difficulties, has created many more — that evidence, feeble in its origin, has often gained weight by mere transmission from one hand to another — and that this matter is peculiarly one where the prejudices and cre- dulity of the world usurp upon the sense of the practi- tioner, and warp his practical judgment. If the truth be really as here stated, in regard to our knowledge of internal remedies, it is a feeble and useless policy to disguise what is thus deficient. The avowal may more readily be made; — first, because the difficulties to be overcome are greater than in any other science of observation or experiment ; — and secondly, because, despite these diffi- culties, the scope and prospect of future attainment are ample and certain, and the connexion such with other branches of physics, that the progress of each is fitted to throw light upon what is here doubtful or obscure. Al- ready it may be affirmed that the recent methods of research in medicine have gained greatly in exactness, and the just appreciation of evidence, upon those of any previous period : B 4 8 MEDICAL EVIDENCE. — a natural effect of increasing exactness in all other branches of science; and, it must be added, of increasing and well-directed energy amongst those engaged in the pro- fession. The deficiency just stated is greater, perhaps, than any other, and more difficult of redress; but time and various new means and appliances are in our hands, and it would be an injury done to the cause of science to doubt their effects.* A very especial advantage we now possess consists in the application of numerical methods and averages to the history of disease ; thereby giving it the same course and certainty of result which belong to statistical inquiry on other subjects. We do not exceed the right expression of fact, in terming this method of averages one of the most important principles and instruments of philosophic research. Little, if at all, recognised as such in former times, it has now become a law in itself, and the index and interpreter of truth in every de- partment of human knowledge. Under the guiding genius of Herschel and Struve it has been applied to the most pro- found questions in sidereal astronomy ; while under a widely * Some may think the view here given of the progressive advance of rational medicine to be contradicted by the recent growth of Homoeopathic practice in this country. It is true, indeed, (apart from what may be called the hcmceopathic principle,) that no case exists of more faulty evi- dence than that upon which the founder of this system and his followers have catalogued together symptoms (amounting frequently to some hun- dreds, and derived from parts wholly diverse in structure and function,) as produced by inappreciably small doses of substances which are utterly inert when largely augmented in quantity. In another chapter (On Disorders of Digestion) I shall speak of what I believe to have been the main causes of the spread of this practice in England. Depending for its success upon practical abuses still not wholly removed, it may main- tain for yet longer time a repute thus acquired ; but, like many other fashions of earlier date, must eventually yield to the conclusions of a sounder science, and better principles of evidence. MEDICAL EVIDENCE. 9 different use, it has been brought to the solution of some of the most curious problems of human life and social existence. The vast interval between is replete with examples of its successful application. Averages may in some sort be termed the mathematics of medical science. It is obvious, indeed, that the value of inferences thus obtained, depends on the exact estimate of what are the same facts, — what merely connected by resem- blance or partial analogy. Pathological results, essentially different, may be classed together by inexact observers, or by separate observers under different views. These, how- ever, are errors incident to every human pursuit, and best corrected by repeated applications of the method. The prin- ciple in question is indeed singularly effectual in obviating the difficulties of evidence already noticed ; and the success with which it has been employed of late, by many eminent observers, affords assurance of the results that may hereafter be expected from this source. Thi'ough medical statistics lies the most secure path into the philosophy of medicine.* In looking further to the chance of overcoming these difficulties in the future, regard must be had to the principle now verified in so many cases, that in proportion to the complexity of phenomena, is augmented also the number of relations in which they may be surveyed and made the sub- * The inquiries which so greatly distinguish M. Louis as a pathologist, may be noted as eminent examples of this method, which is now pursued with great success by many physicians in our own country. The ma- terials furnished for it, under the new Registration Act, are of the most valuable kind ; and the volumes already published give full proof of what will be effected for medical science by such a system, so admirably con- ducted. Already numerous results and generalisations have been placed before us, wholly imattainable in any other way ; and, on the simple principle of averages, every year tends to enlarge and confirm these conclusions. 10 MEDICAL EVIDENCE. jects of experiment.* The application of this principle to medical science is every day becoming more apparent. The fine expression of Laplace, " Tout se tient dans la chaine immense des verites," is well exemplified here. Every new path of physical knowledge opened, each single fact dis- covered, has given guidance more or less direct towards the objects stUl unattained in physiology and the treatment of disease. The unexpectedness of some of the relations, thus determined and converted to use, is the best augury for further advances in this direction of pursuit. A due estimate among medical men themselves of the nature of the proofs with which they have to deal is more especially needful at present, when the older doctrines of physic and physiology are all undergoing the revision re- quired by modern science ; and when new medicinal agents are every day produced upon trial, many of them danger- ously active in their eifects, many suggested by analogies which need to be verified by the most cautious experience. Hasty and imprudent belief may here become a cause of serious mischief; — the wider in its spread, as the minds most prone to this credulity are those most ready also to publish to the world their premature conclusions ; and thus to mis- lead the many who found their own practice upon faith in others ; or who seek after novelty, as if this were in itself an incontestable good. And here I must advert to another circumstance which renders strict attention to the laws of evidence a matter of peculiar obligation at the present time. This is the ten- * M. Comte, in his " Cours de Pliilosopbie Positive," has defined this as a general law, through which compensation is made for the difficulty or impossibility of giving a mathematical form to certain branches of physics ; such particularly as relate to the phenomena of organic bodies. MEDICAL EVIDENCE. 11 dency, so marked in modern physiology, to carry its re- searches into the more abstruse questions connected with vitality, the nervous power, and the relations of mental and material phenomena, — inquiries justifiable in themselves, but needing to be fenced round by more than common caution as to testimony, and the conclusions thence de- rived. Yet here especially it is that such precautions have been disregarded ; — partly, it may be, from the real difficulty and obscurity of the subject — still more, perhaps, from the incompetency of many of those who have taken it into their hands. For these researches, no longer con- fined to a few as heretofore, have become the property and pursuit of many who wander merely on the confines of science, believing they are within its pale ; and whose spe- culations on what they see are little checked by collateral knowledge, or by a due estimate of the laws and limits of scientific inquiry. The mystery of the subject is in itself a charm and seduction to the mind. They see, and give attention for the first time, to those wonderful phenomena, which, though inherent in the constitution of man, and in the relations of his mental and corporeal nature, are not familiar to common observation. The feelings are thereby excited even more than the reason ; and belief is hurried on, and results accredited, with little care for the sufficiency of proof, or knowledge of the many facts which otherwise explain, or contradict, the conclusion. However earnest the desire for truth, imposture rarely fails to mix itself with inquiries so conducted ; and increases the practical evil wliich always more or less results from error. Every phi- losophical physician is bound to watch over these events as they pass before him ; never refusing inquiry, because what is put forward is new or strange ; but requiring evi- dence in proportion to the unusual character of the facts ; 12 MEDICAL EVIDENCE. sifting closely that which is offered, and rejecting all con- clusions not founded on this basis. Wliile speaking on the question of evidence as applied to these subjects, it is impossible not to advert to the fact — a very important one in the history of the human mind — of the great diversities of intellectual constitution as to this point. It is in truth one striking expression of the dif- ference of the reasoning power, testified on the most or- dinary occasions of life, and Very remarkably where the subjects rise to the character of science. Locke has well said, " There are some men of one, some of two syllogisms, and no more ; and others that can advance but one step further." The distinction here expressed applies closely to every question of evidence. One man concludes upon proof, which to another has neither weight nor pertinency. One mind pursues a subject throughout all its relations ; another follows but a single line towards the resvilt. " Some men in passing through the boundless ocean of disquisition, mistake fogs for land." There are others whom Lord Bacon calls " ill-discoverers, who think there is no land, when they can see nothing but sea." Such, indeed, are these natural disparities, as in many cases to preclude any mutual under- standing or communion of the reasoning power.* * A regard to this point seems necessary to explain certain records of Animal Magnetism, Clairvoyance, Lucidity, &c., honestly believed by many ; which would, if verified by sounder proof, alter all our views of physical phenomena, of the nature of man, and of the Providence ruling in the world. The defoult of just and unexceptionable evidence which we find here, is still more singularly shown in some recent works of higher scientific pretension, in which the views and alleged discoveries of Baron Ileichenbach are promulgated ; upon fiiith in experiments, so entirely wanting in all that gives exactness and truth to scientific re- search, that they would hardly be accepted for results of the greatest antecedent probability. The most obvious sources of error are unseen MEDICAL EVIDENCE. 13 In commenting on these subjects we cannot rightly exckide the remark, tliat a certain amount of speculation, duly guided, enters into the purest form of inductive science. Even could the mind be restrained from excursions beyond the strict bounds of evidence, such restraint would be a wrong done to that genius, which has often through these speculations opened a path to new and more certain knowledge. In- stances of success, thus obtained, might be drawn from the history of the most eminent philosophers, and from the records of every part of physical research. It is not hypo- thesis, but conclusions founded on false or faulty evidence, which are the bane of all philosophy. I must further add here, that in questions of medical evidence there may be an excess of scepticism as well as of credulity. Sometimes this occurs in effect of a temperament of mind (not uncommon among thinking men) naturally dis- posed to see all things under doubt and distrust. There are other cases, where the same feeling, not originally present, or unprovided for ; even such as vitiate the experiments in their first stage of progress. Yet these researches are conducted and related by men of honour and good faith ; but wanting in that perception of evi- dence which is essential to the attainment of truth. In another volume (" Chapters on Mental Physiology") I have had occasion to treat more largely on these subjects, in connexion with the several psychological and physical phenomena, out of the truth and reality of which these false conclusions have been wrested, in defiance of all just proof and reasoning. Still more recently, other analogous, but more puerile, deceptions (table-turning, spirit-rapping, &c ), have yet further played upon the credulity of the world ; tarnishing the name of science by assuming it, and rapidly superseding one another in the fashion of the day. In the relation of these ephemeral follies to the great dis- coveries which have shed lustre on true science during this period, one may find a striking commentary on the maxim of Goethe — " Where there is much light, the shadow is the strongest" {Wo viel Licht ist, ift starker Schalten). 14 MEDICAL EVIDENCE. grows upon the mind of physicians who have been too deeply immersed in the details of practice. The hurried passage from one patient to another precludes that close observation which alone can justify, except under especial circumstances, the use of new remedies or active methods of treatment. From conscience, as .well as convenience, they come to con- fine themselves to what is safe, or absolutely necessary ; and thus is engendered by degrees a distrust of all that lies be- yond this limit. Though such scepticism be less dangerous than a rash and hasty belief, it is manifestly hurtful in practice, and an unjust estimate of medicine as a science ; both as it now exists, and as it is capable of being extended and improved. No one can reasonably doubt that we have means in our hands, ad- mitting of being turned to large account of good or ill. Equally unreasonable would it be to distrust the knowledge gained from a faithful experience as to the manner of using these means — and others which may hereafter become known to us — safely and beneficially for the relief of disease. The actual progress of medicine during the last thirty years, in all that regards the principles of the science, as well as the details of practice, is the best testimony for the present and assurance for the future. As respects the two extremes, noticed above, it is certain that there is a middle course, which men of sound sense will perceive ; and to which they alone can steadily and consistently adhere, amidst the many difficulties besetting at once the judgment and the conduct of the physician.* I am the rather led to these remarks on the nature of me- dical evidence, and the causes moral as well as physical af- * Laplace happily expresses the middle course here designated : " Egalement cloigne de la credulitc qui fait tout admettre, et de la pre- vention qui porte h. rcjeter tout ce qui s'ccarte des idees revues." MEDICAL EVIDENCE. 15 fectlng it, looking at the wonderful advances wliicli have lately been made in all other branches of science ; not merely by the addition of new facts, but yet more by new methods and principles of research, by instruments of greater delicacy, and by increasing exactness of details in every point of in- quiry. The eifect of these changes has been (and it is a result the grandeur of which can be understood only by those who have pursued their progress) to bring the physical sciences into much closer relation with each other, pressing them on by converging paths towards that unity of principle which is the object and end of all true philosophy. I cannot here do more than allude to the profound researches through which dynamical forces — the phenomena of chemical, electric, and magnetic actions — and those of light and heat — have been submitted in so many cases to common laws ; and the whole associated with the great doctrine of atomic elements, acting and combining in definite proportions throughout every part of the material world. These generalisations, great though they are, do not narrow the field of future inquiry ; but give fresh space, new objects, and higher incitements to those who may pursue such researches hereafter. The dissimilarity of the proofs, and the greater difficulty of their certain attainment, must ever keep practical medicine in the rear of other physical sciences, notwithstanding its closer association with them through the laws of animal phy- siology and organic chemistry, so largely explored of late years. But its still wider scope of usefulness requires that this distance should be abridged as far as possible ; and no occasion be lost — by improved methods as well as by new facts — by more cautious observation and more exact evi- dence — of maintaining its place and connexions among the other great objects of human knowledge. 16 CHAP. 11. ON HEREDITARY DISEASE. The subject of hereditary temperament and tendency to dis- ease is still largely open to inquiry. Future research will un- questionably lead to an increased estimate of the influence of this cause on all the conditions of individual life, and not least on those of disease. Looking to analogy in plants and lower animals, we see in every direction the wide and various transmission of incidental varieties in each species; gene- rally depending on combinations of natural causes ; some- times eifected by human care and design. One general fact, as respects man, seems to be that so ably developed by Dr. Prichard ; viz. that all original or connate bodily pecu- liarities tend to become hereditary; while changes in the organic structure of the individual from external causes during life, commonly end with him, and have no certain influence on his progeny.* I know not that this principle could have been in any way anticipated, or otherwise derived than from actual ob- servation. It must be received, however, under certain limitations. Every hereditary peculiarity must have had its beginning in some amount of deviation, however small, from the normal condition of the species ; multiplied, it may be, by repetition in successive generations of the causes which first produced it. Examples illustrative of this may be * Researches into the Physical History of Mankind. HEREDITARY DISEASE. 17 found, as well in the wide circle of structural changes from the eifect of disease ; as also more notably in those instances where necessities of situation alter certain parts of the or- ganisation of animals, and where the continuance of such change is needful to their preservation under these new cir- cumstances. The effects of domestication come under the latter view, where changes originally individual to the animal are propagated to its posterity ; reaching gradually, as it would seem, a certain range of deviation for each, beyond which definite causes of original structure interfere to pre- vent further alteration.* Nevertheless, as a general expres- sion of fact, the principle just stated may be deemed highly probable, if not wholly proved ; and it is one fruitful of im- portant inferences, both in physiology and pathology. It comes in direct relation to the subject of hereditary diseases : and though the manner of their transmission is still a mystery, hidden in the same obscurity as the more general fact of the reproduction of the species, yet are we able to reason upon the effects, and to class them in certain relation to each other, and to the healthy and natural condition of the human frame. It would be needless, and beyond my purpose, to cite the numerous examples of hereditary peculiarities of conform- ation, function, and tendency to disease. Such instances are * If other animals than those now possessed were needed for the uses or luxury of man, there is little doubt that human care alone might greatly extend the number of such varieties ; and this in truth has been done, in many instances familiar to our knowledge. There would seem to be cases, where certain combinations of muscles, or faculties of action, habitually called into exercise for particular effects, may produce bodily results more or less permanent, and capable of being conveyed to offspring. The pace of cantering in the horse, the motions of the tumbling pigeon, and the habits of certain varieties of the dog, may be noted in illustration of this fact. C 18 HEREDITARY DISEASE. familiar to us in common life — in history and books — and yet more especially and frequently in the practice of medicine. I have, indeed, been led to put together these remarks on the subject, from the numerous examples I find among my notes and recollections; to which I am desirous to give a more definite form, illustrative of their relations to each other, and to the general laws of animal life. As I have already re- marked, we are still only partially acquainted with the number and singular variety of such cases. The greater exactness of modern observation is ever placing before us new and wonderful instances, in which the most minute peculiarities or defects, in structure and function, are transmitted from one generation to another.* Scarcely is there an organ or texture in the body, which does not afford its particular proof of these variations, so transmissible ; — and we might almost doubt the permanence of the type of our species, thus largely and unceasingly infringed upon, were we not per- mitted to see something of those more general laws, by which the Creator appears to have set limits to the change, and made even the deviations subservient to the welfare of the whole. For in considering this hereditary tendency to disease, whether arising from structural or less obvious cause, it is needful to regard it in connection with, or even as part and eifect of, that great general principle, through which varieties of species have been spread over the globe, with obvious marks of wise and beneficent design. That there are certain determinate laws, by which the permanence of species is * When Savage speaks, in his bitter vein, of "The tenth transmitter of a foolish face," he scarcely exaggerates what is often seen in fiimilies, where some strongly-marked feature or expression long continues dominant, or breaks out again in successive generations. HEREDITARY DISEASE. 19 secured, must be admitted as a general fact — the result of all observations hitherto made on organic forms, both living and extinct. The very circumstance of the frequent repe- tition of analogous and parallel series of forms, under dif- ferent physical conditions, and at different geological epochs, though admitting some doubt as to its interpretation, is never- theless most favourable to this opinion. Still we are not entitled to deny to the followers of Geoifroy St. Hilaire the possibility that it may be otherwise ; and that time may hereafter disclose to us some evidence that species are not immutable. It is, in truth, one of the great remaining problems of natural science, to determine whether the variations induced upon any specific form of animal life, can ever become such in amount and fixedness as to con- stitute a new species, in the complete definition of the term ; — a question not to be settled " within the hour-glass of one man's life," but requiring ages of continuous observation, even for the chance of solution. Our present inductions, thovigh chiefly founded on negative proofs, are, as I have said, strongly in favour of the per- manence of species ; and there is nothing yet entitling us to pass tliis boundary of our knowledge. I have always felt surprize, when reflecting on the question, that so little at- tention should have been given to the argument derived from perpetuation by sexes. Seeing the precise adaptation of the male and female of every species to their relative parts in the great function of generation, those who vindicate the notion of a transmutation of species must suppose this exact relation and adaptation to be continued for each sex, through every progressive step of change — a supposition stretching so far beyond all probability, and involving, indeed, such endless adverse chances, as scarcely to allow its being admitted within the scope of argument. If, however, proof c 2 20 HEREDITARY DISEASE. were attained of tlie mutability of species, tliis would in no wise affect the great argument of Natural Theology. A law presumed at one time to be absolute and universal, would be found collateral or subordinate to a still higher law ; — further removed, it may be, from our comprehension, but involving the same proofs of design as the basis of the whole. Kecurring to our immediate subject, we may remark that the conditions upon which the varieties in species of animal life depend, and by which they are limited, allow wide scope to their existence without injury or disorder of the general system. In the instances where such effects do occur, we can discern some part of the modifying causes, even amidst the profound obscurity which conceals from us their original source. And here again we come upon another of the great questions in physiology, which are still awaiting solution from more complete research. The subject of this chapter, indeed, cannot be rightly pursued, without referring to those recent inquiries into the original types and development of animal life, from the simplest to the most complex forms, which form a new field within the domain of human science. Such researches into what has been termed Embryology and the theory of types, though Hervey and Hunter prepared the way for them, have, until lately, engaged much less attention in England than among the naturalists of France and Germany.* The boldness, or * In France, Geoffroy St. Ililaire, Lamairk, Blainville, De Maillet, and Serves ; — in Germany, Meckel, Tiedeniann, Van Biir, Spix, Valentin, Oken, &e., have been the most conspicuous of those engaged in the inquiry. In the former country, Cuvier sought to stay the extremes into which these doctrines have occasionally been carried. The sound and perspicuous understanding of this admirable man, while ever pursuing the great generalisations to which facts conducted him, had the power, no less important, to resist all inordinate speculation, and to recognise the HEREDITARY DISEASE. 21 even rashness, of some of the generalisations attempted, particularly in the doctrine of fundamental unity of struc- ture and design, must not prevent us from looking to a large increase of sound knowledge from this discussion, based as it is upon a close and minute observation of facts. Its bearing upon the question of hereditary conformation and peculiarities — whether in families, tribes, or races of men — will be obvious to all who have studied this curious subject, and the controversies and conclusions which have successively grown out of it. Dismissing the notion of a single primitive germ, or ab- solute unity of animal type, as a thing not proved, and probably incapable of proof; and putting aside also some fanciful analogies which have defaced the inquiry, we yet must admit that comparative anatomy is ever carrying us back, by successive steps, to simpler and more fundamental types of animal life — to conditions of structure, common to large and seemingly remote classes of created beings. It is still a subject of dispute w^here this progressive approach to more general forms is stopped by essential differences of type, or whether such divisions do at any point in the series really exist — whether there are separate circles of analogous structure, as defined by the four great classes of Cuvier, or by the more complex systems of some later zoologists — or whether these are but artii&cial limits, subordinate to a com- mon type pervading all the forms of animal life. These are questions strictly within the scope of research, and the so- lution of which connects itself with some of the highest bounds as well as the capacity of human research. Such eulogiura is not incompatible with the admission, that he was in some cases too much limited by his own early conclusions ; opposing those attempts at higher generalisation, which, though more speculative in kind, were nevertheless the natural oflfspring of his own methods of inquiry. c 3 22 HEREDITAllY DISEASE. objects of natural science.* I have never, as already stated, seen cause to think the arguments of Natural Theology at all affected by these inquiries; even when pushed to the speculations of a primitive germ, or original unity of type. Its truth indeed is far above the reach of what, after all, are but subordinate researches, even if they could by possibility attain the proofs of what these terms express. The chain is lengthened, and its parts are connected together by new and unexpected links. But still it is a chain of designed or- ganisation throughout ; and if we simplify the first of these links, it is but to render more wonderful the number and perfection of the varieties which are evolved in definite forms from this elementary structure. If the parts in man liave all their analogies or models in lower animals ; or if, according to one view proposed, we regard the several organs of the human embryo as passing through all the gradations of lower types, before reaching their perfect development in man ; still the great argument remains the same. The pro- gressive elaboration throughout all its stages is definite and designed; — the points are fixed at which each deviation has its beginning from the more common antecedent forms ; — the limit, of change, as defined by species, is fixed in each particular case. If there be an argument for the unity of creation, more complete and comprehensive than another, it is that which is furnished by the recent progress of com- * In our own country, tills inquiry lias of late been pursued with ardour and success by many naturalists. The Master of Trinity in his History of the Inductive Sciences, Professor Sedgwick in his Discovirse to the University of Cambridge, Dr. Carpenter in his various physiological works, and Dr. Roget in his Bridgewater Treatise, have discussed these questions, as to general types and iinity of design, in a happy spirit of philosophical research. But above all we are indebted to the genius and labours of Owen, for the highest and most inijjortant illustrations which have been given to this branch of modern science. HEREDITARY DISEASE. 23 parative anatomy ; enabling the observer, by the uniformity of general laws, to predicate from a single minute part of structure all the more important generic characters of the animal to which it belongs. If now, recurring to the subject before us, we make the progress of development the basis of our views, and follow this from more general forms to those which are successively subordinate — even as far as to families and individuals of the same species — we thereby connect the subject of here- ditary aberrations with this more general law; finding reason from analogy to expect that such aberrations should occur, and that they should be carried into extreme variety and minuteness. The different parts of structure and func- tion become more special, or individual, at each step of descent; never losing, however, their relation to the original common type; and in the instances at least of individuals of the same species, tending ever to recur to it, when the causes of change are modified or withdrawn. This manner of pursuing the inquiry, through the unity or analogy of structure in corresponding organs, is probably in closest conformity to nature, and the most likely to lead to correct conclusions from the facts observed. Among other results already obtained from it, is a more just view as to the nature of what have been termed monsters ; which, though still regarded as deviations, more or less, from the natural type, are so, for the most part, in the sense of an in- terference or arrest at particular periods of development ; displacing organs only partially evolved, or suspending the progress of structure in parts yet imperfect. The advance here, from the old and vague notion of a lusus natures, is obvious ; and the details into which the doctrine has been carried form a remarkable feature in physiological science. Though exceptions exist to the law propounded by some c 4 24 HEREDITARY DISEASE. naturalists, that every particular monstrosity in man has its analogy in the natural state of the same parts in some infe- rior animal, the fact is nevertheless so general as to justify its being regarded as a principle in the development of animal life.* It can scarcely be needful to say, that these views are simply illustrative of relation in a series of effects. While augmenting our knowledge in this way, and leading us up to the threshold of the mystery, they give us no power to pass beyond it. The insuperable nature of the limit is even rendered more obvious, when thus approached, than as it is seen from more distant points of view. While we find cause for wonder at the transmission of resemblances from parent to offspring, we must admit the wonder to be equal that there should ever be deviation from this likeness, and that such deviation should be so little governed by any apparent rule or law. The one case is in reality as great a miracle to our understanding as the other. The hereditary tendency to disease, regarding the subject in its most general light, shows itself either in the anormal conformation of particular organs or textures ; — or in the presence and transmission from parent to offspring of certain morbid products, either altogether new, or vitiated in kind, or faulty by excess. f Pursuing the subject more closely, it * The "Ilistoirc des Anomalies de TOrganisation et des Monstruo- sites," by M. Isidore St. llilaire (1832-36), contains all that is known on this subject ; — expounded according to Serres's doctrine of centri- petal development, in opposition to that which has been termed centri- fugal, from opposite views as to the progressive formation of organs. f I do not use the term monstrosity here, as this in common language expresses only extreme cases of mal-conformation ; depending, it may be, on the same causes, but for obvious reasons more generally prevented from becoming hereditary. HEKEDITAKY DISEASE. 25 may be inquired, whether these morbid products may not be all referrible, as effects, to variations in some part of organic structure, producing or evolving them ; so that the solids of the body alone, by their conformation and texture, carry on such peculiarities through successive generations? or, whether the animal fluids also, and particularly the blood, may not be concerned in the transmission thus taking place? This is a question involving much curious but doubtful speculation, nor does the actual state of our knowledge afford any certain answer to it. We cannot go further than to say, that the evidence as to the solid structures of the body, and the changes they severally undergo, is more distinct and complete ; but we are not justified in denying that the blood also may take on morbid conditions, directly transmissible to offspring. The question here, in truth, involves the origin of the blood itself, in relation to these solid parts ; and merging in this, its import to the subject before us is less than might at first be supposed. So close is the mutual connection between them and the blood, in growth, function, and change, that it is scarcely possible, even were it practically needful, to separate the two in this inquiry. The faulty organisation of certain parts of the former may probably produce morbid changes in the latter : or the fluids of the body, already vitiated from other cause, may as probably alter and deprave the texture and function of the solid parts. If there were reason for o-oino; further into this curious question, it might fairly be argued, that, however difficult to conceive a fluid like the blood, ever in motion and change, being capable of hereditary taint, yet is not this really more difficult to understand than a character or peculiarity con- veyed by descent to any part of the solids of the body. The blood has vitaUty in every sense in which we can assign 26 HEREDITARY DISEASE. such property to the solid parts. Under some views, it is the portion of the animal frame especially so endowed. Its first appearance in the area vascuJosa of the germinal mem- brane of the embryo, is prior to the existence of those very organs which, after birth, chiefly minister fresh materials to it. And though undergoing constant change, it has this condition in common with the animal solids ; all which (in- cluding those most frequently the subjects of hereditary affections) are unceasingly altered by growth, by waste, or by fresh assimilation of substance. The morbid changes, moreover, which the blood undergoes, are often the effect of inconceivably minute portions of foreign matter brought into the circulation ; as denoted in the effect of various poisons, in the exanthematous disorders, and other instances familiar in the history of disease. I might further allude liere to the remarkable facts lately disclosed by the micro- scope as to the forms and magnitudes of the Blood discs, or Corpuscles, as well in man as in other annuals ; — definite for each species, but with singular diversities in different parts of the animal kingdom. These facts are already numerous and well determined ; but at the same time, to our present knowledge, so completely insulated, and offering so many apparent anomalies, that it would be idle and unsafe to found any speculation upon them. It is a problem open to the future ; and which, if ever solved, will probably be found to disclose at the same time many other phenomena of animal life, now most obscure to our comprehension. This part of the subject, then, can be approached only through general views, and subject to the obscurity which overhangs the whole. Yet even these general views, as far as they are reasonably supported by analogy or otherwise, have their value to medical science. We are called upon to recognise certain constitutional diseases, continued from HEREDITARY DISEASE. 27 one generation to another, tlie material of which (if such phrase is permissible for what cannot be presented in se- parate form) can only be conceived as circulating in the blood, and conveyed thereby to the parts or organs which it affects with the characters of visible disease. These con- stitutional disorders, and their results, will be found to comprise under a few really specific differences, very many forms of disease, scattered through our nosologies under different names and distinctions. Their relations to certain common morbid principles (an inquiry of great importance in every way) are often expounded or confirmed by looking to the fact of hereditary transmission ; and to the agency of the blood, as containing in itself the elements of disease, or as conveying them to different parts of the body. Contemplating then, generally, this great principle of the transmission of bodily peculiarities from the parent to the offspring, it will be seen that we cannot yet rightly distin- guish what belongs to the blood — what to the solid textures of the body — what to the connections and mutual agency of both. All reasoning here merges indeed, and is finally lost, in the great mystery of generation itself. Neverthe- less, we may find in these questions a convenient basis for the general arrangement of facts, where the latter are so numerous and varied as to need some method for their fit observation. Our imperfect knowledge leaves much that cannot be submitted even to the broadest lines of dis- tinction; but in this, as in other sciences yet unformed, facts, truly determined, will best lead to correct classification and future laws. Looking first to examples of the anormal conformation of particular organs, transmitted by descent, and limiting the consideration to man, we find the variety almost beyond estimate. Here, indeed, a view occurs in the outset of great 28 HEUEDITARY DISEASE. interest to the inquiry, but which I do not think to have been hitherto sufficiently regarded. If peculiarities of external form and feature, whencesoever originally derived, tend so speedily to become hereditary, — affecting, as we see on every side, not families alone, but, by intermixture and descent, whole races of mankind, — we can have no doubt that deviations of internal structure (whether they be of deficiency or excess, or of any other nature) are similarly transmitted; and with them propensities to, or conditions of, morbid action In the parts thus organised. Though the direct proof is not equal for the two cases, and though the effects resulting are of such different importance, yet is it certain that the peculiarities, so carried on from one generation to another, have reference for both to one common law. Those deviations from the primitive or common type of the species, which occur chiefly in the bony structure, integuments, or muscular fabric, producing varieties in the outward form and feature, in the texture or colour of the skin, hair, &c., may exist to great extent, without affecting in any important way the health or natural functions of the individual. On the other hand, much smaller deviations from this type, in the internal organs of circulation, respiration, digestion, absorption, or secretion — or in the brain and nervous system — may produce morbid actions, painful in progress and fatal in result : each class of deviations alike transmissible to progeny, under the same general law. A faulty texture of skin, a hare-lip, or stra- bismus — all frequent hereditary defects — may be of little import to health ; while a morbid structure of internal membranes, a slight organic deviation in the heart, or a tendency to deposit in the crystalline lens, may inflict danger or distress upon every part of life. This view, if authentic, is obviously one of singular im- HEEEDITARY DISEASE. 29 portance in the history of disease, and capable of very wide application. It throws light upon the connexion of various morbid states, by giving the relation to a common physical principle in their cause ; and this principle one which is associated with others of the more general laws of life. Here, for example, we must look for explanation of the difference in the averao-e duration of life in different families ; — a fact well attested in itself, notwithstanding the many exceptions which the laws or social usages of mankind are ever inducing upon it. There is no just reason to doubt that hereditary peculiarities of structure are as frequent and varied — perhaps as extensive — in the internal organs, as in the external parts of the body. Analogy would suggest this as a probable truth. It is confirmed in great measure by obser- vation ; and more extensively as the examination is rendered more minute. On the same gi'ounds it may be presumed that there is a general relation between the resemblance of external features and that of internal parts of structure. The child most like its parent in traits of countenance and figure, has probably closest kindred with him in other and more minute points of conformation. The evidence here is chiefly that of similarity of morbid affections in such cases; — a fact almost indis- putably ascertained, and which, if the views contained in this chapter be correct, affords the best proof we can reason- ably seek for. In the instance of gout it has often been observed, that the children most resembling the gouty parent have greatest liability to the disorder in its common form. Admitting this, it can only be explained by supposing a corresponding likeness in those parts of structure which are chiefly concerned as causes or seats of the disease. It must be confessed, indeed, that this inquiry is very in- complete in many of its parts ; and, on first view, it might 30 HEREDITARY DISEASE. appear that such internal deviations were much less extensive than those of outward conformation. But we can scarcely name any organ of importance which does not aiford evidence of diseased actions, derived from structure and transmissible by descent. And looking to the textures more widely dif- fused through the body — as the different vascular systems, the nerves, &c. — we have every reason to suppose (though the proof is less direct and of more difficult attainment) that they are subject to hereditary variations of structure, not merely in detached parts of each system, but also in the structure of those minute branches and terminations where the most important functions of the body, both animal and vital, must be presumed to take place. On a subject of this nature, however, it is not sufficient to refer merely to the vague division of external and internal parts. The distinction between the animal and vital organs is at the foundation of every such inquiry, and each parti- cular question must be brought into connexion with it. The fact may be considered as ascertained, that the vital organs are subject to more frequent and extensive deviations from the natural type than those of animal life ; the principle of symmetry (essential it may perhaps be deemed) in the latter, requiring, for the integrity of the functions, that all such deviations should be limited in extent.* A presumption might hence arise, that the tendency to transmission by descent would follow the same law, and the parts belonging to organic life oifer more frequent cases of hereditary mal-conformation than the animal organs. I know not that this question of relative frequency has ever been explicitly * It is a remarkable attestation of this fact, that where anormal varieties of the muscles occur (a much rarer event than in the vascular system), there seems a strong tendency in these varieties to become symmetrical for the two sides. HEREDITARY DISEASE. 31 answered. There is, however, enough of proof to make it probable that no disproportion exists of the kind just indicated ; and that anormal structure in the parts of animal life is quite as liable to be transmitted as in the organic. Taking the obvious instances indeed, these may appear more numerous ; but as the difficulty of observation is much greater in the latter case, it is enough to rest in the fact that both the great divisions of life are liable to this general law, and probably not in very different degree. Though refraining, for reasons already given, from any long enumeration of the special instances of hereditary mal- conformation and tendency to disease, yet some must be noticed, either from their singularity, or in illustration of what may hereafter become more definite laws. One point deserving attention is the wonderful extent to wliich such congenital deviations are carried, not only as respects the variety of the parts affected, but also their individuality and minuteness. Some of the earlier examples I am about to cite will well illustrate this ; while others, less special, will show how largely the body, in its morbid as well as healthy conditions, is submitted to the general law. These examples are chiefly taken from my own notes ; without looking to the many, more or less authenticated, wliich might be drawn from medical works, or other sources of information. An instance is known to me of hydrocele occurring in three out of four successive generations, in one family ; — the omission adding to the singularity of the fact, from its depending on a female being a third in the series, in whose son the complaint reappeared. I am acquainted with a family, in which there are three examples, the father and two children, of inability to distin- guish red as a colour. Another example, resembling the 32 HEREDITARY DISEASE. last, is known to me, where three brothers, and two or three children of their families, have the inability to distinguish between blue and pink. Instances of hereditary defects of this kind are far from infrequent.* I have known sqviinting to occur in every one of five children, where both parents had this peculiarity. An example has recently occurred to me of that remarkable affection, the suffusio dimidians, existing in a father and his daughter ; and brought on in each by circumstances singularly alike. The frequency of blindness as an hereditary affection is well knoAvn, whether occurring from cataract, or other dis- ease of the parts concerned in vision. The most remarkable of the many examples known to me is that of a family, where four out of five children, otherwise healthy, became totally blind from amaurosis about the age of twelve ; the vision having been gradually impaired up to this time. What adds much to the singularity of this case, is the existence of a family monument, long prior in date, where a female ancestor is represented Avith several children around her; the inscrip- tion recording that all the number were blind. The repetition of cases of deaf and dumb cliildren in the same family is familiar to those who are concerned in in- stitutions for the relief of this congenital defect ; and will be afterwards noticed in reference to another singular modi- fication of this fact. In one family I have known four or five cases of the peculiar tremor tendiniim of the hands and arms, which is sometimes called the shaking palsy ; and which here occurred in young persons of sixteen or eighteen, as well as in those more advanced in life. In this case, too, as well as in * An interesting case of this congenital defect, where it was also here- ditary, is given in the Aled. Chirurg. Transactions, vol. ix. p. 363. HEREDITARY DISEASE. 33 another of the same affection, I had proof of the peculiarity having gone through at least three generations. Defects or peculiarities in the form and setting of the teeth, as well as in the hair and nails, are often hereditary : and lefthandedness, from whatever cause it proceeds, I have more than once observed to take the character of a family peculiarity. In a family where the father had a singular elongation of the upper eyelid, seven or eight children were born with the same deformity ; two or three other children having it not. I have known another family, in which five daughters resembled the mother in having large growth of hair on the Up and chin. In like manner I have seen enlarged tonsils occurring in almost every individual of a numerous family, without other cause by which to explain it. A case is recently known to me where the patella was wanting; both in father and son. I find many examples among my notes of what must be deemed hereditary tendency to Heart disease ; and such, in truth, are familiar to all observers. In one of these, four brothers died, between sixty and sixty-five, of organic dis- eases of the heart, with prior cases of the same kind in their family. In another instance, which I note here, as having most recently occurred to me, I find three cases, including one of the Morbus Coeruleus, in three successive generations. It is unnecessary to add others. Of hereditary obesity I have seen some very curious ex- amples ; — the most recent that of a family, in which, out of two generations, four individuals died of the results of excessive accumulation of fat, producing diseased action of the internal organs, and dropsical effusions, — two other cases of the same tendency existing in the family, under distressing though less urgent form. Several cutaneous disorders evidently tend to become 34 HEREDITARY DISEASE. lieredltary ; whether from peculiarity in the texture of the skin, or depending on the general temperament and state of the circvilating fluids. I have lately seen three cases of Psoriasis in the children of a family where there is strong predisposition to gout; a conjunction I have observed in many other instances. Certain impetiginous eruptions belong also to a family constitution, such as is often termed scor- butic, and are obviously transmitted from parents to children. Icthyosis is occasionally seen as an hereditary disorder. I may notice here another singular disease, the Pellagra of Lombardy, in which, together with the peculiarity of a local limitation, there occurs a very singular succession of symptoms ; beginning with a cutaneous affection of leprous character, passing through various stages of cachectic dis- order, and ending generally, after the lapse of a few years, in fatuity or death. I have had much opportunity of observino; this cvirlous disease in all its forms.* There can be no doubt of its hereditary nature, though there is difficulty in tracing it back in Lombardy for much more than a century, and equal difficulty in assigning the causes which give it existence in this district alone. The peculiar form of Leprosy, prevailing in certain parts of Norway, comes under the same description of hereditary disease, and Is * A paper I wrote on the Pellagra was published in vol. viii. of the Medico-Chiriirgical Transactions. There are many points of great interest in the history and pathology of this disorder. Its first appear- ance seems to have been in the Alto-Milanese; but in the early part of this century, it had spread increasingly over the greater part of Lombardy, and to the shores of the Adriatic Sea. I have seen the disease as far eastwards as Friuli, at the foot of the Carinthian Alps. There are some districts in the Alto-Milanese where the pellagrosi' fn-ni one fifth or sixth of the whole population. And at the time I visited the Lunatic Hospital at Milan, out of nearly 500 patients of both sexes, about one third had been brought thither in efiect of this disorder. HEREDITARY DISEASE. 35 further analogous to the Pellagra in the fatuity it often pro- duces. In the hospital at Bergen I have seen this singular disorder in all its forms and stages. Diabetes, from my observation (and Dr. Prout states the same fact) has sometimes an hereditary character. Eneu- resis in children, from whatever source arising, occurs some- times in so many individuals of the same family, as to make it almost certain that it has a common congenital origin. What is not less remarkable, as an instance of similar specialty. Emphysema of the lungs has been ascertained to depend in a great number of cases on hereditary influence, independently of any disposition to tubercular pulmonary disease.* Another instance, which may be termed special, though belonging to a part of structure diffused over the whole body, is the Htemorrliagic diathesis. Though I do not find in my notes any well marked examples of its hereditary nature, except where confined to the lungs and connected Avith phthisical constitution, yet some are recorded so explicit as scarcely to leave the fact in doubt; and remarkable further, from the seeminsc limitation of these instances to the male sex. Nor is there greater difficulty of explanation here, than where a more limited portion of structure is concerned. The points of question are the same in each case ; and the solu- tion, if ever obtained, must be common to both. Other diseases might be mentioned, offering questions of the same kind as those stated above. Asthma, for example, sometimes shows an hereditary character. I have known the complaint to occur in three successive generations ; and often so numerously in the same family as to make it certain *This fact we owe to the late Dr. Jackson, of Boston in America; a physician whose life was too early terminated. D 2 3G HEREDITARY DISEASE. that a common cause was concerned. This cause is pre- sumably one of structure: — yet it would be difficult to affirm it to be so, or to state in what part the peculiarity is likely to exist. It may be that some anormal state of the nervous system is chiefly concerned ; there being nothing to disprove the possibility that such state of certain parts of this system may be transmitted by descent, so as to become a source of the disordered actions of asthma. Or the cause may per- haps be sought for in connexion with the gouty diathesis, to which I cannot doubt from experience that some forms of asthma are closely related. Every physician will recognise the general tendency to hereditary character in disorders of the Brain and nervous system. This is a very remarkable part of the subject ; in- volving, as it does, every variety and degree of morbid affec- tion, from simple head-ache to the worst forms of epilepsy, apoplexy and palsy. I shall hereafter notice, in relation to another part of the svibject, some singular examples in its illustration. The topic is further one of deep interest, as including the various conditions of hereditary insanity — instanced not merely in particular families, but even in districts and communities, where from local circumstances there has been little intermixture with the rest of the world. From these facts, well attested to us, we gather the im- portant conclusion, that some deviation in physical structure, whether obvious or not, is the cause of the aberrations it presents. In no other way can we conceive the transmission of the tendency from one generation to another. It may be that a part of the fabric of the brain is concerned, far too minute for the most subtle research to follow : and this in- deed might be presumed, looking at the nature of the functions affected. But still, whenever the transmission occurs, we are bound by all analogy to infer the presence of HEREDITARY DISEASE. 37 a morbid material cause, upon which the phenomena pri- marily depend. There is much that is curious in the tendency to head-aches thus transmitted by descent, and often going through whole families with similar character. The cause here presumably varies in different instances. Sometimes, and especially perhaps where they are periodical, the affection may belong to the gouty habit, and to the matter of gout in the circula- tion. In other cases, anormal structure of the vessels of the head may be concerned ; in others, again, some peculiarity in the nervous substance itself. In hereditary affections of the nerves, as in those of other parts, it is extraordinary in what minute peculiarities the tendency often shows itself. It is difficult indeed in some of these cases to distinguish what is due to imitation alone ; but in other instances, where this is excluded by circumstances, we find nevertheless nervous habits and disorders of the parents reappearing in the offspring to a singular extent. These entailed disorders are certainly more numerous than is generally supposed; and probably the source of many morbid states, apparently remote in kind. As respects their origin, they may all be referred to the general principles we have already laid down.* There are some examples of anormal structure or disease, which, though frequently occurring in detached instances, yet are so especially numerous in certain localities, as to afford suspicion, in the absence of other sufficient causes, that hereditary tendency is much concerned. Such is the Goitre of particular districts, no consistent explanation of which has * Among particular forms of hereditary mental disorder, the tendency to suicide is recorded on what seems to be sufficient evidence. Curious examples to this effect are given by Pinel, Dr. Burrows, and Dr. Rush of Philadelphia. D 3 38 HEREDITAllY DISEASE. yet been given, founded on local circumstances of climate or mode of life. The Plica polonica, prevailing almost ex- clusively along tlie course of the Vistula, is another instance to the same effect. I might apply the same remark, though with greater doubt, to that curious affection, the Trismus nascentium, prevalent in particular localities, and these widely different in all physical circumstances.* The great frequency of Urinary Calculi, in certain districts where there is no obvious peculiarity of air, food, or water, as a probable cause ; and the common tendency to lithic acid deposits in particular families, may admit of like explanation. And this is further sanctioned by the certain connexion of the calculous with the gouty diathesis. Seeking then for the most general expression of the facts just indicated, we may affirm that no organ or texture of the body is exempt from the chance of being the subject of hereditary disease. Or, in other words, every part is sus- ceptible of deviations from the normal type or natural structure, capable of being conveyed to offspring ; and of producing morbid actions, which are thus, under the name of disease, frequently propagated through successive gene- rations. Of the instances given, to which many others * When in Iceland, in 1810, I had the opportunity of collecting some facts as to the singular frequency of this disease in the Vestmann Isles, on the southern coast of this island. On these desolate rocks, the popu- lation of which does not exceed 160 souls, I found that, in a period of 25 years, 186 infants perished of this disorder, under the age of 21 days ; of whom 161 died between the fourth and tenth days after birth ; 75 on the eighth day. Though the condition of life of these poor people is sin- gularly destitute, fish and the eggs of sea-fowl being their sole aliment, yet Is it not so different from that of the Icelanders of the main land as to explain the frequency of this fatal disorder amongst them ; and it would seem as if some constitutional and hereditary causes were concerned. HEIIEDITAKY DISEASE. 39 might have been added, it will be remarked that all are per- fectly congruous with the common transmission from parent to offspring of external features of the body, in the pecu- liarities of which no diseased action is involved. The wonder and the difficulty are alike for the two cases. I have alluded to the distinction which may be made in treating this subject, between hereditary malconformations of particular organs or structures, and those diseases, not less certainly transmissible by descent, where the blood must be regarded as bearing part in the phenomena. Most of the instances hitherto cited belong to the former class ; but others can hardly be submitted to either, under the vague knowledge we yet possess on this obscure subject. All the questions, in truth, are of singular difficulty with regard to those diseases, where the hereditary evil is not of one organ or texture, but seeming to pervade every part of the body; — showing itself at intervals, and especially at certain periods of life ; and very frequently shifting its action suddenly from one part to another. Gout and Scrofula in their various forms, and perhaps also the Cancerous diathesis, will at once occur as the most familiar examples. The very difficulty of the research here affords presumption of the extent to which it may hereafter be applied, in extending and correcting our pathological views. In gout, for instance, admitting, what can scarcely be denied, a morbid ingredient in the blood as the cause of the disease, it may be asked whether hereditary gout depends on the transmission of some part of structure, favouring the formation of this matter ? or on some faulty texture of the kidneys or other excreting organs, whose office it may be to remove it from the body ? Or further, if it be that gouty matter is merely an excess of some ingredient natural to the blood, whether the determi- nation to the joints, forming the fit of active gout, is the » 4 40 IIEEEDITARY DISEASE. effect of hereditary conformation of these parts ; the absence of which peculiarity in others allows this excess to show itself in very different appearances of disease ? I have noticed these questions more in detail, when treating elsewhere of this disorder. They apply equally perhaps, though this relation has been less followed, to those forms of acute Rheumatism (a name unfortunately vague in its use), where there is every proof, from the nature of the symptomatic fever — from the peculiarity of the secretions and deposits — and from the metastasis to internal parts — that the disorder is one of the whole habit, and probably de- pending on some peculiar state of the blood. There is sufficient evidence to show that this disease is often here- ditary, and involving, therefore, the same questions as gout ; though perhaps more dependent on occasional exciting causes from without, and less marked as a general tem- perament of body.* " Many similar inquiries will apply to the Scrofulous or tubercular constitution ; admitting it, indeed, as a single form of cachexia. It may be asked whether this congenital temperament consists in a certain texture of solid parts, vascular or otherwise, giving liability to peculiar deposits at certain periods of life ? or in a specific morbid state of the circulating fluids, producing such deposits in the parts of the body most prone to receive them ? The latter view, as in gout, may be admitted as the more probable one, and for the same reasons. Indeed, however different tlic diseases in many respects, yet certain general analogies of character subsist between gout and scrofula ; — in their hereditary * The most amjile proof is that furnished by the large experience of Chomel, who rates as high as one half the proportion of rheumatic cases where the parents had suffered under the same disease. HEREDITARY DISEASE. 41 nature — in their respective connection with particular periods of life — in the proofs of a morbid matter peculiar to each — in the various forms under which the morbid cause shows itself in different persons — and in the frequency and facility of translation from one part to another. These analogies lead us to no common cause ; and it may be affinned that none such exists. But they show causes ope- rating by certain common laws ; and, in a case where there is still so much to be learnt, all such relations are of value. Hereafter we may be able, by these and similar means, to associate together diseases now widely apart in our noso- logies; — gaining thereby a classification more just, and of greater practical usefulness, than any we now possess. In the Scrofulous temperament, even more than that of gout, we have a remarkable diversity in the forms the disease takes, and the organs it attacks. But it is worthy of note, that there appears a general tendency to the same form in the same branch of a family thus aifected ; still, more in children of the same parents. I may mention, as a striking example, the number of cases of blindness, partial or complete, in some families where this temperament exists. In others, the disposition is as strongly marked to aifections of the joints; — in others, again, to pulmonary consumption in its more common form. These are instances of the tendency to specialties before noticed, extending to morbid structure or functions, as well as to those of healthy kind ; and, in this relation, attesting the principle to which I have alluded in the Preface, as fertile beyond all others in just conclusions as to the nature and treatment of disease. What has been just said of the scrofulous diathesis applies by parity of all essential characters to the Carcino- matous habit. Though the proofs are more limited by the comparative infrequency of the disorder, it is certain that 42 HEREDlTARi DISEASE. this also is often an hereditary disposition of body, tending to the production of morbid growths, more especially at certain periods of life. If, as alleged, the lymphatic tem- j)erament is that particularly disj^osed to carcinoma, the question again arises (but without any further facility for solving it), whether this connate tendency consists in a state of the solid tissues, or of the fluids circulating through them ? In using the term of lymphatic habit, we are not, indeed, entitled to carry our meaning beyond some of the more obvious eifects of a constitutional cause ; the nature of Avhich, whether affecting the solids or fluids, is still unknown to us. Certain general facts still remain to be stated on the sub- ject of hereditary disease ; some of them of deep interest, but of equal difficulty. One of these is, that singular variety in the general law which Duchesne and others have termed Atavism ; where a bodily peculiarity, deformity or disease, existing in a family, is partially or wholly lost in one gene- ration ; reappearing in that which follows, or even yet later in succession. A curious instance of this has been already mentioned, where the omission depended on change of sex in the series. There may be many analogous cases, in which the part of structure affected by hereditary disease admits of the malady being disguised, or superseded, by other casualties in the bodily conformation of the individual. Or, if the animal fluids be directly concerned in the transmission, we may conceive these liable to be more readily affected by causes of variation; so that the same morbid influence is directed to one part rather than another, assuming totally different aspects of disease. But these explanations, pro- bable though they may be in part, will scarcely apply to the numerous cases where, the sex and all obvious circumstances being the same, a disease or deviation from common structure HEKEDITAEY DISEASE. 43 is missing in one or more individuals of a family series, re- curring in their children. Here we pass at once into the obscurity which hangs over all that belongs to that great function of life, the reproduction of the species. But the same analogy, or rather unity of plan, is still present to us. If one generation escapes the transmission of an hereditary disease, so do we often find some strongly-marked feature of face or figure lost in one of a family, but reappearing in the children. The proof is hereby strengthened of that general relation which pervades all these phenomena, and which makes the simple resemblance of an external feature the ex- ponent of other cases, in which the most severe diseases are conveyed from parent to offspring. Connected with the foregoing is another curious variety in the transmission of disease, if so it may be termed, Avhich has been very little noticed by medical authors. I allude to the case of several children of a family being affected in common with some given malady, of which there has been no certain instance on the side of either parent. An example has lately occurred to me in one family, of three sons and a daughter, every one of whom underwent an attack of hemi- plegia before the age of forty-five, though neither father nor mother had been similarly affected. I find another instance in my notes, where three brothers severally suffered hemi- plegia, and about the same period of life, without any record of the like event in the family. I have recently seen a fatal case of cerebral disease, with epileptic fits, in a young lady of twenty-four; two sisters of whom had died about the same age with similar symptoms, though neither parent had been subject to such disordei'. I am acquainted with a family in which four children have died during infancy from affections of the brain, without any like instances in the family on either side. In another family, without any 44 HEREDITARY DISEASE. similar disease in the parents, three or four children had epileptic fits. I have notes of several similar instances; chiefly, as I think, but not exclusively, disorders of the brain and nervous system. I have known three cases of Diabetes mellitus in brothers, under ten years of age, in the same family ; one of them fatal in result. In another instance, four cases of ascertained disease of the heart, all fatal about the same period of life, occurred to my notice in the brothers and sis- ters of one family ; without any suspicion, as far as I could learn, of the parents having been the subjects of this disease. In the instance of the deaf and dumb, already referred to, the examples are frequent and curious of several children being thus affected (five out of a family of eight, four from a family of seven), without similar defect existing in the parents. In one family with which I am acquainted, three children out of five are dumb, and of deficient intellect, but without deafness ; there being here also no record of the like defects in the families on either side. At the School for the Deaf and Dumb in Manchester, in 1837, there were forty- eight children, taken from seventeen families; the total number of children in these families being 106, and giving therefore an average of nearly three such cases in each family. Out of these instances, there appears but one in which the defect was known to exist in either parent ; and we may rightly therefore consider this as one of the most striking examples of the fact under consideration. As a curious variation of the same general conditions, a case is known to me, where the children of parents, each deaf and dumb, are themselves free from that defect. In another large family I have known almost every child short-sighted, without either parent being so. Some of these examples may probably be referred to the HEREDITARY DISEASE. 45 condition last mentioned, of the revival of an hereditary dis- order ; absent, as far as outward appearance goes. In one or more generations. Bvit proof to this effect Is wanting In other cases : and the remarkable fact remains, of several children of the same parents being affected In common with a given malady, of which there are no certain prior examples in either family. The extent and sudden development of disease in these instances may in itself be taken as the proof of new elements being Introduced. All physiology is at fault as to the solution of this phe- nomenon. Nor in a matter so obscure, can we venture beyond the inference, that where each parent is capable of conveying certain characters of resemblance, physical and moral, to their offspring, the combination of these generative elements, whatever they be, must have effect, more or less, in modifying the result. This presumption does not go beyond the fair bounds of reason ; is justified by various experiments on other animals ; and may afford the clue, under future observation, to some of the most remarkable facts in the physiology of man. A yet further variety in the hereditary transmission of dis- ease is its limitation, more or less complete, to the males or females of the family affected. This fact is illustrated by two or three of the instances already given, and seems Avell attested in the case of the htemorrhagic diathesis.* In the more familiar example of gout, the same condition may be admitted to a greater extent. The circumstance most remarkable here is the evidence of transmission through the * Examples to this effect will be found in the Archives Generales, Oct. 1833, and July 1835 ; one or two of tliem made more remarkable by the transmission of the diathesis through females, themselves unaffected iu this way ; and further by the very frequent concurrence of the ha?mor- rhagic with the rheumatic constitution. 46 HEREDITARY DISEASE. female of a morbid tendency or action, not observable in herself in its more ordinary forms, during any part of life. This indeed may be only a case of the singular phenomenon of atavism, already noticed ; but it is more interesting to physiology, as being more special in kind ; and including the relation of the sexual peculiarities to the other functions and changes of the system. Considering the subject in its most general light, it appears certain that the material of morbid action in such cases cannot be altogether dormant, though not attested by the usual signs of its presence. We may best, perhaps, remove the difficulty by looking to differences in the seat and manner of action, Avhether depending on sexual structure, or on other less obvious conditions. It cannot be doubted that such differences exist, modifying the influence of every one material agent upon the body ; and thereby giving, it may be presumed, a totally different aspect, as well as reality, to the effects of the same physical cause. I shall have other occasions to remark on the wide application of this principle to the phenomena of disease. Looking at what may hereafter be learnt on these curious subjects, the most obvious source of knowledge is the obser- vation of corresponding facts in other animals. Here our means of inquiry are greatly increased by adding direct ex- periment to the mere observation of facts. The results ob- tained from breeding, especially in the domestic animals, are infinitely valuable in this respect; and replete with curious inferences, all more or less applicable to the case of man; though, from some cause or other, they have been less closely applied to this illustration, than their importance might warrant. The whole subject of specialties of structure and function, whether natural or obtained by artificial means, is full of the same interest; and forms the most direct line along which to carry research into the types and development of HEEEDITARY DISEASE. 47 animal life. The physiology of plants affords similar illus- trations ; though more remote, from the wider difference in their organs and mode of existence.* Much has been attained on these subjects ; but more yet remains behind. Though the principle of life and reproduction is still a mystery at the root of the inquiry, all the effects resulting from this principle may become better known, their connexions deter- mined, and the relations explained by which they take the forms of hereditary disease. In a former part of this Chapter, I have adverted to the strong hereditary tendency manifested in disorders of the brain and nervous system, and to the many remarkable results thereon depending. It would be impossible in a general view like the present, to pursue this subject through its multiplied bearings, interesting though they are to all the conditions of life and human society. Here indeed, as so often before, we are called upon to note the close relation of particular morbid phenomena to more general laAvs; and, in the present case, to those laws which determine the varieties of character in nations and communities of men. Hereditary deviations in excess, such as come under the character of insanity, are for the most part corrected or limited, as they arise, by the usages of social life. The lesser variations from the common type (if we may apply this term of type to mind as well as body) which are not so controlled, may, in the infancy of any community, and in combination with other causes, become * I may cite, as an excellent example of the mode of pursuing this research, the work of Galleslo, little known in this country, " Storia della Riproduzione Vegetale." Pisa, 181G. Gallesio takes the genus Citrus as his subject, and, from his experiments upon these plants, draws con- clusions which apply largely to the production of varieties, monsters, and hybrids, in vegetable life. 48 HEREDITARY DISEASE. the basis of those more permanent traits which we designate as the character of a people or a race of men. Diversities existing, as they actually do, under infinite variety, and in many cases created and perpetuated within human record, must be derived in some part from this source. Or if we could suppose it otherwise as to origin, we must at least admit that this cause is largely concerned in giving them permanence among races of men. I need not stop here to denote the deep interest which belongs to this argument, in its relation to the physical and moral history of Man on the globe. It is one of the great questions which modern science has put forth ; — incidentally and obscurely at first, but now better defined as a specific object of future research; and connecting itself with those various conditions of climate, of government and social usages, of migration and intermixture of races, and of diversities of language, which are all associated as integral parts of this inquiry, — illustrating each other, and ever converging to- wards common and higher laws. As another remarkable fact connected with the same subject, I may mention the frequent occurrence of an here- ditary temperament, in which are blended together the elements of various disease, both of body and mind, with some of the highest mental qualities and endowments. In- stances are frequent, where in the same family we find almost every individual possessing some strongly-marked peculiarity; — such peculiarities often very different in aspect, yet all having reference to some single point in constitution from which the several effects diverge. Or the life of one individual, so circumstanced, may itself afford example of the most singular extremes of state, equally to be referred to some common hereditary cause. Another fact still to be noticed regarding hereditary con- HEEEDITART DISEASE. 49 stltutlon, In its relation to disease, is, the disposition of indi- viduals of the same family and generation to be similarly affected under any given maladies ; even such as have no apparent connexion with the peculiarity of family habit. There are indeed various chances of error in observations of this kind ; and many exceptions will occur. Nevertheless, examples free from ambiguity must be familiar to every medical man, where disorders assume a certain marked character in the same family, as regards the severity of the symptoms, the organs especially attacked, and the effects they leave behind. Such is the case with hooping-cough and various infantile complaints, — with exanthematous and epidemic diseases, — and with others less definite In their course of symptoms. Among the exanthemata, scarlet fever may be especially noted as an example. In the instance of twins (the frequent occurrence of which is itself observable as a peculiarity in some families), these coincidences show themselves in still more remarkable degree. And it is likely, in general, that they should be most distinct in early life, when extraneous causes have yet done little to alter con- genital likeness in structure and habit.* I find In my notes some curious instances, where two children of a family, Avith strongest likeness to each other in feature, figure, and habits, have shown singular resemblance in the symptoms of the disorders affecting them, and in their idiosyncrasy as to particular remedies. No new difficulties occur in the explanation of these facts. Every morbid cause must have definite effect on certain parts of structure ; and. If these are alike in two or more individuals from family descent, the presumption Is, that any diseased * An instance is known to me, where, in the same family, three persons attacked with Cynanche parotidasa all underwent that singular metastasis of inflammation to the testicle, occasional in this complaint. E 50 HEEEDITAEY DISEASE. actions ensuing will exhibit corresponding likeness in kind and degree. What we might here expect on theory, we find to be realized in the facts. And connected with these is the result, well attested by experience, that there is a general tendency towards the same duration of life in those of the same family ; — often modified or subverted by individual constitution or by the incidents of life, but never perhaps wholly absent. In some instances this may be referred to the likeness in particular structures ; but we must probably look still further and deeper for the causes concerned in this remarkable effect. The research, in fact, brings us again to the great mystery of the transmission of life itself; — under the condition of a fixed average duration to each species, and with subordinate variations belonging to particular series in the same species. It is another fact in the history of hereditary diseases* meriting attention on various accounts, that many of these have a well-marked tendency to evolve themselves at par- ticular periods of life, differing for each. This is true, not only as to those which are termed constitutional, such as gout and scrofula, Avhere it might more easily perhaps be anticipated ; but ajiplies also to some cases where the here- ditary disposition seems limited to a particular organ, as the heart, the liver, or the brain.* These circumstances find their explanation in the general views already stated. When the disease depends upon anormal conformation of some par- ticular organ, it may be brought into activity, either by the * I find some curious instances to this effect recorded by Boerbaave ; " Novi in hac urbe familiam, in qua omnes certa ajtate schirrura accipiunt, et hoc malum ab ovo parenti liberis est communicatum; — uti et familiam, ubi omnes certa aetate icterum accipiunt, et sic orto postea hydrope, mo- riuntur. Novi etiam aliam familiam ubi omnes primb satis faceti, sed certa astate in melancholiam incidunt." — Boerhaav. Frax. sect. 485. HEREDITARY DISEASE. 51 accumulated effect of exciting causes long continued, or by the operation of new causes, coming into operation at certain periods of life. If there be cases in which we may suppose the blood concerned in transmitting hereditary taint, a point already considered, still it is conceivable (especially as we know that this fluid undergoes actual alteration at different ages) that some changes in its quality or distribution may bring the morbid jDrinciple into activity at one time rather than another. Or, without referring to such direct alteration in the blood itself, the changes successively taking place In the solid tissues of the body, particularly those of secretion, may so operate upon this fluid as to cause the commencement at a certain period of morbid changes, whether of deposit or other kind of action, which had not before occurred. To attempt explanation beyond these very general views would be merely to substitute vague phrases for real knowledge. I have not hitherto alluded to the question, which has been discussed and differently answered by different authors, from which parent the predisposition to disease is more frequently derived ? The difference of opinion here probably results from the actual approach to equality in the occurrence of the respective cases. The question. In fact, merges in the more general one as to the transmission of physical resem- blances from parent to offspring; these being, as we have seen, the chief source of similarity in morbid affections. And as such resemblances, both of lineament and structure, pro- ceed from each parent, according to laws of which we are ignorant, but seemingly in proportion nearly alike, the diseases therewith connected must be considered under the same relation, and as being probably derived equally through the two sexes.* * Dr. Nasse, of Bonn, treating of the tubercular diathesis, considers B 2 52 HEREDITARY DISEASE. Viewing the subject of hereditary disease in all its parts, one question still arises, viz. whether, and to what extent, there may be a continued progress of change in the organiza- tion, or other material cause of disease, through successive generations? — or, what are the limitations to such changes, and whence derived? The general answer to this question may be drawn from the views already stated ; and particular facts in illustration of it are best deduced from the growth of varieties in animals and plants, whether casual or designed. Natural History, in its present state as a science, furnishes exuberant evidence upon most points of the question ; and future research in the same direction is sure to enlarge and better define this knowledge. The general conclusion pre- sumably is, that the repetition of circumstances producing variation tends in itself to augment or confirm this, Avhether disease be the effect or not ; — but that the original type of the species is ever present in opposition to the changes thereby induced; defining their extent, differently perhaps for dif- ferent parts of the structure, but still with an eventual and certain limit to all. It is unnecessary to point out the important relation to practice of all that concerns hereditary tendency to disease. The subject is one which meets us at every steji, and to which our attention is perpetually required, as an exponent of symptoms, as affording some of the most certain means of prognosis, and as directing us in many particu- lars to the right course of treatment. No judicious physician will neglect the resources hence derived, which are in truth essential to sound and successful practice. It is probable tliat tlie disposition to disease is more commonly derived from the mother than the father. The general opinion seems to have been the ro\ erse of this ; but neither view, as far as I know, is supported by such amount of averages as to warrant its adoption. HEREDITARY DISEASE. 53 they will be largely augmented in future^, both by more exact and amj)le observation of facts, and by the extension of our knowledge of principles in this remarkable branch of phy- siology. There is yet wanting to our medical literature a work which may embrace the subject in its whole extent, and with the aids derived from other departments of science. What I have given here is but an outline of this ; and the examples are drawn chiefly from my own observations in practice. These of course might be greatly extended in number and variety, as well from the results of individual experience, as from research, even the most superficial, into the writings of medical authors.* I must add, however, that an inquiry so instituted, would require much more specification and ex- actness than I have been able to give in this general view. It is not enough, for instance, to speak of diseases of the heart collectively, at a time when the morbid anatomy of this organ is minutely investigated, and averages of Aveight and ad- measurement obtained for its condition in different individuals, and at diflferent periods of life. It will be readily per- ceived that the more precise and minute the definition of all parts subject to hereditary affection, the greater is the hope of further insight into this remarkable phenomenon, — the more certain the aids afforded thereby to the treatment as well as theory of disease. * In looking over the works of Morgagni, for instance, I have been struck by the number of cases of hereditary disease to which he inci- dentally refers; rendered more valuable as examples by his exactness as a narrator. E 3 /i4 CHAP. III. METHOD OF INQUIRY AS TO CONTAGION. After all that has been written upon contagion, in angry controversy or sober reasoning, I cannot but think that the question still admits of greater precision in the methods of inquiry ; whereby to reconcile the contradictions, and remove in some part the difficulties, which still perplex it in so many particular cases. I take the subject in its most general form ; and the term contagion in its broadest application ; as implying the com- munication of disorder in any way from one person to another, without reference to time, or medimn of communi- cation. The term infection, being less limited in its deriva- tive meaning than contagion, may be preferred by some ; but using the latter word in the wide and popular sense just stated, it cannot well be misunderstood. The particular proofs by which the contagious nature of certain diseases is established, and the enumeration of these diseases, important though the topics are, do not enter into my present object. I believe it may be assumed, that in every instance of com- municated disorder of the same kind (except the ambiguous case of certain nervous complaints, where other principles are concerned) there is a materies morbi, a material cause — what- soever, and however subtle, its nature and manner of trans- mission — which is directly concerned in the communication. This assumption, though large, is justified by observation as far as it goes ; — by strict analogy and probability, where METHOD OF INQUIRY AS TO CONTAGION. 55 observation cannot be had. It is likely that future re- search will rather augment than lessen the number of in- stances where such miasma or material cause of contagion may be presumed to exist. And it is further probable that we shall hereafter acquire more intimate knowledge of the nature of these morbid matters ; of their relations to each other ; and the manner in which they are transmitted so as to propagate disease. The course of modern inquiry directs through many channels to these important results. Looking singly, however, to the principle just stated, and admitting its truth, we shall find basis in it for all reasoning on the laws and anomalies of contagion ; that is to say, for all the conditions which determine and modify the communi- cation of disease from one person to another. A disease is communicated by some morbid matter, thrown oft' from the first, and capable of producing like symptoms in the second — when conveyed either by inoculation, by simple contact, or in- directly through some medium of transference. Here then three main conditions present themselves, each open to many variations ; and, in their combination, capable of producing the numberless varieties and apparent anomalies in the laws of contagion. These conditions are — First, the state of the person giving the infection ; — Secondly, the state of tlie person receiving it ; — and. Thirdly, the condition of the medium through which the transference is made. I believe that reflection will show the whole subject to be comprised under these three heads ; and that we are bound to refer to them severally in all particular questions or instances which come before us for solution. The first is very important ; inasmuch as it includes all that relates to the varying quantity and intensity of the virus itself. This forms a part of the condition of the patient giving the infection, and the most essential part : — one, how- E 4 56 METHOD OF INQUIRY •ever, by no means duly appreciated in the ordinary methods of viewing the subject. Though we have no present method of estimating either the absokite quantity, or the energy of quality, of the material cause, or the relation which these conditions bear to one another, this does in nowise lessen the certainty that variations exist in different cases, and have effect, directly or indirectly, in every example of infection. In the case of inoculated disease, we have evidence as to this point, from the influence of dilution in altering or annulling the effects of the virus employed. The modifications arising from the particular period of the disorder ; from idiosyncrasies of constitution in those affected ; and especially from the variety of the parts or textures through which communica- tion takes place, are all concerned in this view ; and have severally their influence in determining the power of the virus, and the course of propagation of the disease. Under the second head, viz. the state of the person receiving the infection, we have modifications derived from the previous condition of temperament and general health — from the actual health at the time, and particularly from the presence or absence of other specific disorder, counteracting or modifying the virus received — and from the state of the organ or tissue first or most intimately affected by it. All these circumstances needfully enter into a just and complete view of the subject ; but none of them, as I think, are suffi- ciently regarded in our common methods of dealing with it. The latter point in particular has been almost wholly kept out of view, from the great difficulty of reaching it by any distinct proofs. Yet we cannot for a moment doubt that the con- dition of the i^art which habitually, or casually, receives any given infection, must determine the degree of the eft'ects joro- duced, and probably in many other ways modify their cha- racter and course. AS TO CONTAGION. 57 Under the third head, of medium of transmission, still more numerous variations may be presumed to exist. Put- ting aside the obvious cases of inoculation and contact of surfaces, and looking to the atmosphere as the medium in the great majority of instances, we have here the endless variety arising from changes of weight, temperature, humidity, elec- trical state, and direction of currents — cii'cumstances ever fluctuating in themselves, constantly changing in their com- binations with each other, and capable therefore of modifying infinitely the action of any virus thus conveyed, even without regard to the chemical changes which it may possibly undergo during transmission. And further under this head, we have the case of fomites or virus thrown off from diseased sur- faces, imbibed by porous bodies, and again emitted — occa- sionally, as some assert, in a more concentrated form, from this previous absorption. Duly considering these several points, they will be found, I think, to show adequate cause for all the strange and per- plexing appearances of contagious disease. So far from it being difficult to explain why a given disorder should occasionally appear infectious, at other times not ? — why it should spread rapidly and virulently in some localities, and not at all in others ? — why it should affect some persons, and leave others free? — why the cases should be violent at one period, mild at another? — it is rather perhaps matter of wonder that the circumstances are not still more varied and irregular than we find them to be. When there are such numerous and ever-changing elements of difference, the combinations of these may well give scope to every assignable variety of result. It is clear that very many of the contradictions of opinion and statement, as to the contagious nature of certain diseases, may be solved by a reference to these considerations. In all 58 METHOD OF INQUIRY common reasoning on the subject, and even in what has been written upon it, infection is too much regarded as a simple and uniform act ; and the virus transmitted as the same in quantity and intensity. Such views, however, carry error into every part of the discussion. If we can dilute the matter of Small-pox, so that it is no longer capable of giving the disease by inoculation, equally may the effluvia of certain fevers, capable of communicating the disorder in one degree of concentration be so diluted in other cases — either in their original emission from the sick body — or by distance — or from the state of the atmosphere — or by the intervention of other matters — that they lose their power of reproducing the disease in its complete and specific form. Accordingly we find that in these fevers, as well as in diseases more undoubt- edly and actively contagious, the proofs of infection multiply in proportion as the causes exist which are likely to concen- trate, or give direction to, infectious matter ; as stagnant air, want of cleanliness and fresh clothing, proximity of place, particular currents of air, &c. And what is true as to these disorders, will equally apply to many other doubtful or ano- malous cases in the history of disease. In Erysipelas, for example, though its occasional contagious nature is sufficiently proved, the instances of this are com- paratively so rare, that it occurs in the light of an anomaly to common observation. The controversy still existing as to infection in Puerperal fever, may probably best be solved by a close regard to the circumstances stated above. Nor can I doubt (having seen cases which go far to prove it) that a patient labouring under genuine Measles may be present to another, perfectly susceptible of the infection, without the latter receiving the disorder ; in default of the quantity or other peculiar state of the virus, needful for its passage through the intervening air. And this point receives further AS TO CONTAGION. 59 illustration from those singular cases, where an imperfect and irregular evolution seems to occur of an infectious disorder, the actual nature and presence of which cannot be doubted. These various conditions can in no way be so well explained as by looking to the difference in quantity or concentration of a siven virus, and to the manner of its introduction into the system — diversities which must be of constant occurrence, and can never occur without some change of effect. It is another and frequent mistake, in reasoning upon con- tagion, to consider that the infectious nature of a disease may be disproved, by showing that it has been spread with- out any obvious communication through man or human means. The two conditions brought into the question, instead of being opposed, are in fact perfectly compatible with each other. If a virus can be transmitted from the body through a few feet of air, we are not entitled from the partial experi- ments hitherto made to set any limit to the extent to which, under favourable circumstances, it may be conveyed through the same or other medium. This virus, as already stated, must in every case be regarded as a material agent', and as such, susceptible of various influence and modification. Common reason here concurs with our actual experience of the transmission of the virus of certain diseases in various ways, and to remote distances. Notwithstanding all the labours of the time past, the sub- ject of contagious disease still offers a spacious field for discovery — perhaps more extensive and curious than any other part of medical science. In the remarks just made I have sought partly to remove two or three common errors — principally to put into a precise form those considerations or methods which must, I think, be the groundwork of all inquiry on the subject. I have purposely abstained from any but the simplest illustrations, though others might be 60 METHOD OF INQUIRY AS TO CONTAGION. copiously drawn from all parts of pathology. The methods of research now suggested will apply to every view of the nature of the virus of particular diseases, whether we suppose them of chemical origin, or derived from animal or vegetable life ; and, under the scanty amount of our actual knowledge, this general application is, perhaps, the best test we can have of their value.* Neither the laws of contagion, nor the many collateral questions which have perplexed and angered medical authors, can be rightly settled without some common principles to which to refer for classification of facts, and guidance amidst the seeming anomalies they present, f * It will be seen that I have, in this chapter, avoided every question as to the nature of particular miasmata; my object being merely to suggest those principles of research which are applicable to all. In other chapters, and especially in the last of the volume (" On animalcule life as a cause of Disease "), I have taken up some of the particular questions on this subject ; though chiefly interrogatively, as befits an inquiry in which so much is still hidden from us. f A valuable paper on the laws of contagion, by my lamented friend Dr. Henry, is contained in the Fourth liejiort of the British Association, in which will be found the notice of nearly all that forms our present knowledge on the subject. 61 CHAP. IV. DISEASES COMMONLY OCCURRING BUT ONCE IN LIFE. The title, thus including only a single character of these remarkable diseases, might be extended to other circum- stances in their history; which, though not exclusively limited to this connexion, are still so closely associated that it is im- possible to view them asunder. Such are, the perfectly definite course of their symptoms in the ordinary form; — the frequency of an external or eruptive stage in each ; — and the well-marked power of conveying infection by the reproduc- tion or diffusion of the virus respectively peculiar to them ; — all points of the highest interest in pathology ; and which, under the relations just expressed, involve some of the most abstruse questions in the whole range of science. Controversy, as might be expected, has made itself busy with various parts of the subject; but has yet done little to remove the obscurity which hangs over it. In pursuing the above connexions, even in their most general form, we seem ever on the verge of some discovery, giving new inlet to the more mysterious parts of the animal economy, whether in health or disease. Such discovery indeed, if hereafter made, is not unlikely to be derived from methods of inquiry in which these relations are directly involved. In their nature it is scarcely possible they should be unpro- ductive to research, however great the difficulties attending: it. The simple enunciation of the fact, that certain diseases of definite course, and communicable by some manner of specific infection, do generally occur but once in the term of G2 DISEASES COMMONLY OCCURRING human existence, abounds In the most curious suggestions, and carries us at once Into the higher and more hidden parts of the philosophy of life. The familiarity of the facts prevents Indeed an Immediate conception of the great wonder they involve. What in Itself more strange, than that a minute speck of matter (if indeed what is actually the virus of disease be ever the object of sight) — in other instances, agents wholly imperceptible by any sense, and admitted Into the body through unknown channels, — should be capable of exciting there certain trains of morbid actions, determinate In their character and duration ; reproducing or perpetuating, if so it may be termed, that which is the principle of infection and element of disease ; and, above all, giving exemption more or less complete to the remainder of life, from the action of this principle, or the recurrence of the symptoms depending upon It ! What again is the nature of that definite change In the body which makes it thus far Inaccessible to a certain disease, yet apparently does not affect any other property or function of the animal economy? Though processes of diseased action are con- cerned In all this, yet Is it a mystery of the same nature as that of generation and growth, and creating similar diflficulties to our comprehension. The consideration of these topics involves certain general views as to the course and changes of philosophical inquiry, at different periods in the history of science. It Is impossible not to be struck with the fact, that modern research, armed with all its powers of experiment and exactness of induction, has carried, and Is yet carrying us back, in the direction of certain ancient opinions, which have hitherto been viewed only as vague hypotheses, without other sanction than the hardi- hood or ingenuity of thought which first suggested them. The inquiries respecting the ultimate particles or atoms of BUT ONCE IN LIFE. 63 bodies, their forms, relative weights, and manner of combina- tion — though accredited to us now by the most exact evidence which number or geometry can furnish — do yet represent in a more substantial form certain theories which may be termed the poetical dreams of antiquity, and were apparently so re- garded by many of those who first propounded them to the world.* Even on points, however, where no such stable foundation is yet secured, the tendency is strong at the present time to carry speculation forward beyond the bounds of actual know- ledge. The very advance of science itself — the application of new methods of analysis — the discovery of new and subtle agents, universal as the more palpable forms of matter on which they act — the assignment of definite proportion, forms, and polarities, to matter in almost all its combinations — the successful research into conditions of the earth and of organ- ized life anterior to those which noAV exist — and, further, the high perfection and poAver given to instruments wherewith to work in these deeper mines of knowledge ; — all such attain- ments may be said to have forced philosophy upon bolder conceptions than heretofore, and nearer to what seem the ultimate bounds of human research. Still it is the wider * There is much that might tempt one to enlarge further on this subject and to fetch from the incomparable poetry of Lucretius, passages (stript of their conclusions) which stand in singular relation to the most recent speculations of the present age. But this belongs rather to the history of the human mind, and of general philosophy, than to the subject before us. All indeed who read, as well as write, on medical topics, will find how difficult it is to attain any opinion or truth that has wholly escaped the genius or labour of those who have gone before. This is especially true on every point of theory and general doctrine. Little that is new can here be looked for, except what is expressly founded on further discoveries in anatomy and physiology ; and on fresh relations, thereby disclosed, to what was already known. 64 DISEASES COMMONLY OCCURKING generalization of facts which serves as starting-place to these speculations; and they are speedily lost again, if not sup- ported by extension of the evidence on which they depend. The fortunate, but unproved and fruitless, anticipations of a former age curiously approach them on this still uncertain ground ; gaining admission into the domain of science through this connexion, and thus completing the record of human thought and labour, so directed, down to the present time. These remarks apply to medicine not less than to other sciences; and in singular manner as respects the relations of the blood to the production and progress of disease. Here modern research, by showing the very compound nature of this fluid ; the frequent changes it undergoes in the propor- tion of its component parts ; the generation of morbid matters within the circulating system ; and the extraordinary influence of even the most minute quantity of certain substances intro- duced from without, has sanctioned to an unexpected extent doctrines which, after centuries of reputation and general adoption, had fallen almost wholly into disrepute. There is no more striking feature in the history of medicine than the rapid recurrence to these opinions ; — in very different form and phraseology indeed, and now based upon the most minute analysis which modern chemistry can furnish ; but still involving the same principle, and even conducting to many similar practical results. It is difficult, in truth, to conceive how a doctrine, which, even in the infancy of [)hysical science, forced itself into acceptance by its obvious nature, and by the very necessity of the principle it involves, should ever have been so far neglected, or supplanted by other views. When the cir- culation of the blood was unknown, and its uses in growth, reparation, and secretion — in the production of animal heat and of nervous power — scantily defined, still was there evidence enough to show that its alterations in quantity BUT ONCE IN LIFE. 65 and quality formed a great part in all the phenomena of disease. What has been done by chemists and physiologists of late years, in the examination of its healthy and morbid states, renders this now, if not the richest department of medical science, at all events that which gives largest augury of future advancement. It would be impossible, and useless from their familiarity, to recite here all the ascertained facts which have connexion with the subject of this chapter. In the note below I have referred to a few of the number, which are most necessary to be kept under consideration ; and to these I Avould entreat the attention of the reader, as explaining at once the difficulties of the subject, and the methods of research through which they may best be overcome.* * The main difficulty in this investigation, and bearing closeP^ on all its relations to pathology, is that of interpreting the state of the blood within the living body by its appearances and changes when withdrawn from the vessels. It is yet a question whether all the principles asserted to exist in this fluid (or even in the organized animal textures) do exist there in life ; or whether they are not produced, or their combinations wholly altered, when vital actions cease, and coagulation and the ordinary che- mical affinities supervene. The state of the fibrin, of the globules, and of the iron or other colouring matter in circulating blood, are particular in- stances of this difficulty ; but it extends to other ingredients and con- ditions also, which the most exact observations have not been able to determine or explain. The fact, however, is now well assured, that the blood does undergo great changes in the living vessels ; — that these changes may commence from within, or be excited by agency from without ; — and that they consist, not merely in fluctuations of quantity, or of proportion of the watery to the saline or coagulable parts, but also in alteration of these solid parts themselves ; and in the generation of new compounds, either by anormal combinations of the elements of animal matter within the circulation, or by direct absorption of substances not previously there. In regarding those causes of morbid change which belong especially to the body itself, the points chiefly to be noted are, — the absorption into the blood of animal products already found in the system — and the retention F 66 DISEASES COMMONLY OCCURRING To the views so re-established regarding the blood, we must mainly look for whatever partial solution may be given to the questions before us. It is impossible to seek from any other source the explanation of morbid changes, so diffused in their nature, so active yet defined in their progress; — in- volving the phenomena of fever, of metastasis, and reproduc- tion of the same virus from which they originated ; — and ana- logous in so many points to those natural functions in Avhich we consider the blood to be the agent. Even were the in- ference to stop here in evidence, and to be ever unfruitful of there, by deficient or disordered action of the secreting organs, of materials that ought to be separated from the body. It is ever to be kept in mind, in relation to the functions and diseases of the blood, that it contains some parts to be assimilated; others that have passed through assimilation, and are to be removed by excretion. And though the latter in the healthy state may be so incorporated as to lose all distinction in the uniform nature of the fluid (a point not Indeed well ascertained), yet under morbid conditions it is manifestly otherwise ; and products are found in the blood representing those which ought to have been eliminated from the body ; or sometimes, thou<;h more doubtfully, such as may have been absorbed from parts under disease. The curious evidence, lately obtained, regarding the occasional presence of pus in the blood, may be named as an instance to this effect. These and other analogous facts, now familiar to vis, show some of the ways in which the blood may become the subject of disease ; and all have reference to, though they do not explain, the phenomena which form the subject of this chapter. This is a topic, moreover, on which, as I have mentioned above, speculation may be allowed to pass somewhat beyond the limits of actual proof. Looking, for instance, at the specific differences of form and size of the globules of blood in different animals, and the immediate fatal effect of mutual transfusion in such cases, it is impossible not to suppose that vai'ieties in the number or state of these globules, whencesoever arising, may produce essential alteration in the blood, and through it in all the functions of the body. And again, with respect to tlie agents which affect coagulation, looking at the singular way in which electricity is found to operate through intervening tissues, we must admit the likelihood that certain definite effects from this cause may take phice even in the living body. All the phenomena of coagulation, BUT ONCE IN LIFE. 07 further results, I know not how this general conclusion could be avoided, or any other reasonably substituted for It. But the methods of Inquiry, just referred to, render it very un- likely that the proofs should remain limited as at present ; and though it would seem that there are parts of the subject wholly beyond attainment, yet the very narrowness of our actual knowledge gives reason for not drawing the line closely or arbitrarily around us. The remarks which follow are merely an outhne of some of the questions belonging to this remarkable inquiry ; with such comments as seem justified by what we have hitherto indeed, are of primary importance in the pathology of the blood ; see- ing the numerous causes which modify it; — that some of these, as for instance most of the poisons, produce their effect in quantities incredibly small — whUe others, the alkalies and certain alkaline salts for example, are of such simple kind as to give the liability to continual variations by their amount, and by the state in which they are present. Many other questions apply to the curious subject of the influence upon the blood of matters not duly separated from it, or re-absorbed into the circulation. As an instance, recognized by medical experience, may be noticed the effects of the semen, or the elements of it, retained in the habit ; or possibly re-absorbed again after being actually separated : — and, on the other hand, the results when excreted in too large quantity, or at periods of life unfitted for the activity of this function. Of the existence of such effects on the nervous system, as well as upon the functions of particular organs, there can be no doubt. The manner of their production is wholly unknown to us, but we have every reason to infer that the blood is the medium through which they severally take place. That there is, independently of what has been theoretically termed innervation of the blood, some constant influence of the nervous system upon the physical conditions of this fluid, seems highly probable, though the proofs are too vague to be admitted into any argument on the subject. This may take place indirectly, through changes in the capillary vessels ; or, directly, by some manner of action on the blood itself. But at all events it; must enter into all our views on this part of pathology, and in this light I have spoken of it in another chapter. F 2 68 DISEASES COMMONLY OCCUERING learnt in relation to it, or by analogies drawn from other parts of physical science. It might be made a preliminary question, what diseases are properly included under the title of the Chapter ; and medical opinions would not wholly agree on the subject. But this is a point of difference upon which I do not enter ; satisfying myself by taking for the argument those examples among the contagious exanthemata respecting which no doubt can exist. The Small-pox, Measles, and Scarlatina (admitting the latter name as c]escribing all forms of the disease) arc evidently the instances which best fulfil all the terms of the question ; and from which probably an answer will be derived, if ever we succeed in obtaining it. I do not include the chicken-pox and cow-pox in this enumeration, seeing the dispute which yet exists as to their nature and relations. Typhus, and possibly other forms of simple fever, have connexion with the subject, and the Plague a still closer kindred ; and illustration may be derived from all, though less definitely than from the three diseases named above. The hooping-cough is placed in the class of contagious disorders, occurring but once in life, and comes therefore within the terms of the inquiry ; yet with so much difference of character, and ambiguity in certain points of its history, that there would be difficulty in examining it with the rest. The great problem to be solved is that of the change in the living body, effected by a given disease, which prevents the same cause of disease from again producing the same morbid actions, except in rare instances, or after a certain lapse of time. All other questions connected with the subject must be considered subordinate to this. For, the fact being once recognized, it is a natural and almost necessary suggestion that the train of actions, whence this singular change results, must be definite throughout in course and character. And BUT ONCE IN LIFE. G9 on the same grounds the presumj)tion occurs, as more probable than any other, that the agent in every such disease must be a specific virus, received into the system from without, and •evolving earlier or later the series of definite changes which ensue. No less determinate cause can be deemed capable of effects thus distinct and specific in their nature. The principle of contagion in these cases does not so directly suggest itself. Yet, when to the general statement of the problem just given, Ave add the fact, that, in certain of these disorders, there is an obvious and large reproduction of the virus whence they were derived, it becomes a ready inference (however difficult of explanation) that in all of them the train of morbid actions must tend to diffuse, by some manner of infection, that which is the essential element of the disease. Coming tlien at once to the main question — and basing it, as fa.r as possible, upon known phenomena, or physical analogies, Avhich can illustrate, however generally, this re- markable influence upon the body — we have to inquire, first, in what parts of the body (if in any especial parts) the changes take place which produce these extraordinary effects? And, secondly, in what the changes themselves may be pre- sumed to consist ? The former question is that in which we seem to make nearest approach to something like solution. I have already stated the strong presumption that the blood is the portion of the body most directly the subject of these phenomena ; — into which the material of infection is received, and through which the series of actions forming the disease is evolved and terminated. Were argument wanting to strengthen the pro- bability, it might almost be found in the question, whether any other part of the human frame can be conceived equally capable of fulfilling the conditions of the inquh'y? Unless we either avow total ignorance, or seek to veil it under phrases F 3 70 DISEASES COMMONLY OCCUKRING which convey no real meaning, we must admit that here alone can explanation reasonably be sought for, however remote the discovery from our present attainment. An altered state may indeed be produced throughout every part of the circu- lating system, from local irritation of a particular tissue, as is familiarly known to us in various disorders of inflammatory kind. But it is impossible to conceive of any other part than the blood being the agent in multiplying, by a long series of morbid actions, the virus or principle in which these actions commenced ; and secreting it afresh from all surfaces of the body, as happens in some of the diseases of which we are now treating. This is one of the instances where it is easier, from the nature of the topic, to apprehend the general inference than to express the reasonings on which it is founded. Even language is forced here to become hypothe- tical, to meet the obscurity of the inquiry. On this part of the subject, however, we possess more direct evidence in the actual introduction of the materials of certain of these diseases into the blood, and the production thereby of the specific maladies to which they belong ; — a result familiar to us in the cases of inoculation, and in two or three other disorders where an animal virus is obviously brought into the circulation ; but proved also experimentally in the communication of disease by the blood of the person infected, even where there is no virus secreted in any palpable form. Such experiments are hitherto indeed more limited and uncertain than might be desired. They afford, however, considerable proof that the measles have been produced by inoculation with the blood of patients under the disease; and that in other animals, glanders, canine madness, and the mange have been produced in similar manner. The argument with which we are concerned manifestly gains great weight by the double or reciprocal evidence thus BUT OXCE IN LIFE. 71 obtained. And if the proof be sufficient to show in certain cases that the blood is the seat of the combinations, as well as the active cause of the transferences, in which a disease consists, we can have no reasonable doubt in assuming this, where the facts are not yet equally ascertained. These experiments also, if duly admitted, apply to another doubt that may suggest itself, — viz. whether the series of changes, constituting what is called the disease in these cases, is really completed in the blood, so that the virus there formed is merely separated by the subsequent pro- cesses ? — or whether there are not specific actions of secre- tion going on upon the surfaces of the body, and connected with the eruj)tive part of each disease, by which its peculiar virus is reproduced, and becomes an element of fresh in- fection to others ? The difficulties with which these ques- tions are burdened, are the same in effiact as those which belong to the general doctrine of secretion. They are en- hanced by the peculiarity of this being a matter alien to the system, and morbid in its own nature; yet, as we are obliged to suppose, generated or augment^l in quantity, in the progress of the disorder, by some process for which we have neither name nor conception. The chief problem here is the true order of succession in the events, or that Avhich may justly indicate their relations of cause and effect; and a fair examination into what we reaUy know on this subject will show how scanty is the amount, even on points which seem essential to any reasoning upon it. In affirming the likelihood that the series of changes, from the reception of the virus to the complete evolution and decline of the symptoms, must take place principally within the blood, we are expressing all for which we have argument either from observation or analogy. But if this fact becomes even- tually well established, even without more intimate know- F 4 72 DISEASES COMMONLY OCCURRING ledge of the manner of operation, it will furnish a better basis for all future views as to these maladies. The same difficulties, equally inevitable, and even multi- plied in amount, affect the other part of the question pro- posed — viz. in what these changes actually consist? — How, above all, can it happen that a given series of actions, arising from a virus received, should thus preclude, except in rare or partial instances, the recurrence of similar effects from a similar cause applied ? The bare statement of this question carries with it, we must admit, a sort of interdic- tion to the hope of solution. AYhile avowing, however, that science hitherto affords us no definite answer to the inquiry, there are nevertheless certain facts and phenomena which seem to lie nearest the truth, or to furnish at least the most plausible methods of research. And upon these it is worth while shortly to dwell ; — the rather as they have them- selves great interest in the history of disease. The topics they comprise may briefly be thus enume- rated : — First, The leading fact already adverted to, that these diseases in their proper form, have a determinate course, from the first reception of the virus to the complete re-establishment of health. Secondly, The apparent insus- ceptibility of some persons to receive these infections at any time of life. Thirdhj, The susceptibility not existing at one time, but rcncAved at another; — sometimes without obvious reason, but in certain cases with general relation to periods of life. Fourthly, The deviations from the regular type of each disease ; occasionally in the length of interval between the infection and the first appearance of symptomatic fever ; more frequently in the interrupted and incomplete evolution of the symptoms. Fifthly, The occasional recurrence of each disease in the same person ; — in effect of this incomplete- ness of its first course, — of change in that state which gives CUT ONCE IN LIFE. 73 protection, — or of other cause wholly unknown to us. And, Sixthly, The facts, partially determined, regarding the in- compatibility of these several diseases, their degree and order of mutual interference, and their liability to be dis- turbed or prevented by other disorders existing in the body at the time ; — points all of great practical importance, and involving some of the most remarkable questions in medical science. These circumstances, moreover, may be regarded as the only elements we possess for inquiry on the subject. For it must be avowed that no certain analogy can be drawn from other branches of physics — none even from the general doctrines of life, or the phenomena of other disease — which will serve to explain the peculiar mystery of this case. We know, indeed, that incalculably small quantities of certain substances brought into the blood act as poisons there; producing occasionally trains of morbid actions of very definite kind. But these are wanting in the great pe- culiarity designated in the title of this chapter; nor do they, as in the instance of the diseases before us, reproduce a matter of the same kind, capable of perpetuating the disorder by communication to others. The closest approximation to a plausible theory on the subject, is doubtless to be found in Liebig's views regarding fermentation and putrefaction; as chemical processes, in which the introduction of a minute quantity of matter, in a certain state of chemical change, is capable of producing the same or analogous changes, throughout a large quantity of matter, esi)ecially if in a fluid state. The effects fol- lowing the introduction of putrescent animal matters into the blood (as so frequently occurs in dissection) may be ad- mitted in illustration of this view, which is undoubtedly one of very ingenious and curious application to the diseases 74 DISEASES COMMONLY OCCURRING before us. Still, while removing some difficulties, there re- mains the insuperable fact of the general exemption given by these diseases, once occurring, to the future part of life. Such immunity we can in no way conceive as belonging to parts which, whether fluid or solid, are in state of entire and un- ceasing change and therefore insusceptible, it might seem, of any permanent state, such as that of which we are now seeking explanation. Before commenting further on the subjects just stated, a condition may be mentioned, necessary as it would seem, and perhaps obvious, on any view of the subject ; viz. that the virus concerned in these phenomena must be of organic and probably of animal nature — the product originally of animal actions or changes, and propagated and diffused by the same. No other conception than this can well be enter- tained, however impossible it may be to vindicate it in detail. The same comment will probably apply to every case in which contagion is concerned. The regular period of maturation, the definite course of actions and metastases, and the multiplication of the matter of the disease — though not all equally cogent as reasons — strongly enforce the same view. The latter phenomenon especially, which has closest relation to some of the natural processes of life, seems insusceptible of other explanation. Admitting, then, that some animal poisons may enter into the blood without producing such effects, we cannot fairly contemplate the peculiarities of those in question without seeing that they have their source, as well as actual seat, in the functions of animal life. Upon this consideration arises the question (not indeed of recent date), whether the matters of infection in exanthe- matous diseases, thus designated by all their characters as animal products, may not be of other than human origin; — belonging in fact to some form of parasitic beings not cog- BUT ONCE IN LIFE. 75 nizable by the senses or other express observation, but capable of acting on the human body as a cause of disease, and evolving through their own vital changes the successive stages of these singular maladies. Unwarrantable though this speculation may seem in its boldness and want of direct proof, yet does it derive some support from the extension Avhich modern discovery has given to the principle of life under specific forms, where before only the relations of un- organised matter had been presumed to exist ; — from the almost innumerable conditions under which parasitic life has now been detected ; — and, further, from the peculiarities just recited as belonging to the diseases in question, and espe- cially the reproduction of the virus peculiar to each. In the last Chapter of this volume I have treated of this subject more in detail ; and will here only add, that were such opinion hereafter sanctioned by better evidence, it would not be incompatible with the views I have suggested as to the relation of these diseases to the state of the blood, and to the changes taking place in this fluid. Reverting now to the several points already stated as cha- racteristic of these disorders, an important remark occurs, viz., that, under admission of the truth of the first, all the others have a natural, or even in part a necessary, dependence upon it. If the morbid actions ensuing upon a virus received are, from any cause, perfectly regular and defined in their ordi- nary course, it may be inferred as likely that the suscepti- bility to undergo them will vary in different persons and at different times; — that any interruption to, or incomplete- ness of, the regular course of symptoms, may produce dis- orders of other kind, or liability to the oi'iginal disease ; — and that such diseases, for the most part, must be incom- patible mutually, or with other maladies present in the body at the time. These circumstances are suflficlently connected for mutual illustration ; though far short of showing in what 76 DISEASES COMMONLY OCCURRING that remarkable change consists, which, when complete, gives exemption for the remainder of life. The different degree of susceptibility to these disorders, and their incompatibility mutually, or with other diseases, are points which have been much examined. On the latter subject I will merely remark, that we may in every case con- ceive incompatibility to depend, either on some peculiar state of the blood existing at the time, or on some different virus of disease present in the circulation, and producing morbid actions there, which preclude, more or less, any other from co-existing with them. These general questions, im- portant to every part of the subject, are peculiarly interesting in their relation to the history of small-pox, to the modifying action of the vaccine virus, and to the whole tlieory of inocu- lation. As such, indeed, they possess a practical importance which belongs to few others in pathology. They have been multiplied in number, and have acquired fresh interest of late years, by the increased spread of small-pox, simple or modified, even among those who have undergone vaccination ; giving presumption thereby that the influence of this pre- ventive may be lost by time, or the vaccine virus itself be altered or impaired by unceasing use and transmission. In the first edition of this work I treated of these questions, and of the practical deductions arising out of them, in a separate chapter; but, for reasons stated in the preface to the second edition, I omitted this chapter, and do not enter upon the subject here, further than to show its bearing on the topic now before us. Its obscurity, in fact, would be in great part removed, were we ever to obtain an entire solution of these difficulties. The strong presumption now obtained from direct experiment, that the vaccine virus is but a modification of that of small- pox, and that the difference is due to the passage of the BUT ONCE IN LIFE. 77 matter of infection through an animal of another species^ may- be regarded as a great step in advance.* All assured facts as to the duration of the protection by vaccination, the causes which modify this, and the true nature of the varioloid dis- eases, are of equal value and similar application. Tlie rela- tion of chicken-pox to small-pox, whether a product of the same specific virus, modified by unknown causes in its effects, or of a different virus having some common principle of ac- tion, is another question, less important in practice, but equally bearing on the history and true doctrine of these dis- orders. And, above all, a knowledge of the circumstances which practically alter the susceptibility to the infection of small-pox, give occasional liability to its recurrence, and regulate the mutual interference of this and other diseases, would seemingly bring us nearest to the principles in the economy of life which govern these morbid phenomena, and determine their permanent effects on the body. The measles and scarlet fever afford similar illustrations, though less extended and less striking, from the absence of that singular connexion with another form of virus which has become so essential a part of the history of small-pox. The scarlet fever, hoAvever, has peculiar relations of its own, which long obscured the views of the most observant physicians, led to a disjointed nomenclature of the disease, and even still perplexes our opinions on the subject. Limited more than * The experiments of Dr. Sonderland of Bremen, and those more recently made by Mr. Ceely in this country, appear to have decided the identity of the virus, in conformity with the original opinion of Jenner himself. In the chapter on Vaccination, in the first edition of this volume, I have considered not only the problem, as it then stood, — and the further questions as to possible changes in the vaccine virus itself from a long series of transmissions, and as to the duration of the protective influence in the body, — but also the subject of revaccination, and the methods by which original vaccination may be best extended and rendered more secure. 78 DISEASES COMMONLY OCCURRING measles or small-pox to one portion of life, it nevertheless is subject to greater irregularities than either of them ; appears more frequently in incomplete forms, and seemingly blends itself more readily with other disorders of the body. I shall have occasion elsewhere to speak of some of these relations ; but meanwhile I refer to them chiefly in connexion with the curious topic of the frequent imperfect and irregular develop- ment of this disease. In speaking of the methods of inquiry as to contagion, in the last chapter, I have alluded to the influence which variation in the quantity or concentration of any given virus must have in determining its action on the body. Among the contagious exanthemata, none certainly illustrates this principle so well as Scarlatina. Looking at the disorders, among children especially, during the seasons when this disease prevails as an epidemic, Ave find many which strongly warrant the suspicion of their being derived from the same virus ; yet so incomplete and irregular in aspect that it is impossible to define them as really forming part of the malady. A great cause of perplexity here, as in every part of the history of scarlatina, is the peculiar form of cynanche attending it, which occasionally appears as the only distinct evidence of the constitutional disorder. These deviations from the regular type, if we may thus describe them, occur in several, and very different, forms ; all familiar to medical experience, though not always viewed in the connexion to which they belong. One class of these deviations, and the most difficult perhaps to identify, is that of febrile symptoms, generally of ady- namic kind, but very irregular in character and progress ; — sometimes a certain degree of angina alone, often none that is obvious; — occasionally partial eruptions, frequently none whatsoever ; — a general disturbiigi^cstions of Sir James Murray {Report of the British Asso- cialion, 1835) for the use of artificially rarefied or condensed air, in appli- IN RELATION TO DISEASE. 181 But in less peculiar cases than these, notable effects may occui', Avhen the changes in the weight of the air are frequent, sudden, and considerable, even within the ordinary range of atmospheric variation. Regarding merely the average pres- sure upon the whole body, it is to be supposed that any very sudden fluctuation, (to the amount perhaps of one-thirtieth,) may produce temporary changes in the balance of circulation between external and internal parts, of much influence on the latter. And these are particularly to be looked for, when there is individual liability to certain diseases, or close ap- proach to them at the time ; — a point requiring to be kept in mind more than it usually is, in estimating the influence of exciting causes, whatever their nature. This observation, as I have already stated, appears espe- cially to apply to aflections of the brain. I have made note of two or three periods, since I began practice, during which there has been a more than wonted frequency of apoplectic or paralytic seizures within my immediate knowledge ; so marked as to make it difficult to attribute the fact to mere casualty, notwithstanding the many circumstances which tend to invalidate such results when not verified by large averages. The same fact, observed by others, has generally been attributed to external heat alone. But allowing what has already been assigned to this cause, the particular character of the weather at these times will scarcely support the infer- ence ; nor has the result in question been equally apparent even under higher degrees of atmospheric temperature. While, on the other hand, I have observed at these periods frequent and rapid changes in the barometer, often with great depression of its level ; and have noticed at the same cation to the surface of the body as a remedial agent, deserve atten- tion. The cases are numerous, where changes in the local distribution of the blood, thus readily made, might be of much value in the treatment of disease. N 3 182 INFLUENCE OF AVEATHER time the very common occurrence of lesser affections of the head — vague and uneasy sensations, oppression, vertigo, and what may be termed a feeling of want of proper balance in the frame — all indicating some cause present which tends more or less to disturb the equality of circulation through this organ.* In fact, the ordinary phrases of heaviness and lightness of air (however misplaced or even inverted their use) prove the general consciousness of these changes in their slighter influence on the body. It may be difficult to say through what organ or function this feeling is chiefly conveyed ; but probably it is a compound eflfect of the changes in circulation, in which the sensorium, the lungs, and the muscular system, all participate. Even the organs of digestion seem to be affected, directly or indirectly, by the same causes. Without referring to the doubtful instance of vomiting produced in highly rarefied air (of which, however, I obtained some very curious proofs when visiting the Peak of Teneriffe two years ago), I think I have observed frequent disturbance both in the sensations and functions of the alimentary canal under any rapidly diminished weight of the atmosphere, or where its changes were more frequent than usual. I have remarked * Hippocrates mentions the greater frequency of apoplexies in damp and rainy seasons ; and Morgagni refers to several other physicians who have made the same remark. Looking to more recent information in our own country, I may mention the notice taken by dllTerent coroners in the month of December, ] 839, of the singular frequency of sudden deaths without obvious cause during the first three weeks of this month ; — a period when the baro- meter was generally very low, with almost continual rains, which ex- tended over France, Spain, and even the north of Africa — with much fog, and a singularly oppressive state of atmosphei'e — little wind, and this chiefly from the S.S.W. or S.E. — the temperature very high for the season. Bowel disorders and low fevers were at the same time very common in London and other parts of England. IN RELATION TO DISEASE. 183 in another place on certain indications of disturbance to sleep from the same cause. All these inferences, however, are rendered uncertain by the great difficulty of simplifying the conditions which belong to them, where the physical causes concerned are so unceas- ingly blended in their operation. It may be, for instance, that what is attributed to changes of weight of air really belongs to electrical changes in the atmosphere, producing or attending the former. Another more familiar case of ambi- guity, is that of the sensations exjDcrienced in reaching a high mountain-summit. Though often attributed to rarefaction of the air breathed, I doubt not (on my own observation as well as that of others), that they are chiefly owing to the ex- penditure of bodily power that has been incurred by muscular action, to hurried breathing, and quickened action of the heart. These sensations in great part subside, when the immediate causes of lassitude and disorder are removed. Or, if we yet need explanation of that singular sense of fatigue in the limbs, which is alleged to occur when walking in elevated regions, even without the toil of ascent, we may perhaps find it in a suggestion of Humboldt ; whose sagacity is ever awake to all natural phenomena, even such as pass unheeded by others from their seeming familiarity. He conjectures that this sen- sation may depend on the mechanism of the joints, and equi- poise of the bones, being disturbed by the low atmospheric pressure ; and the experiments of the two Webers, subse- quently made at his suggestion, have afforded a singular confirmation of this idea.* * Po^gendorfTs Annalen fiir 1837, No. I. These experiments, made upon tlie hip-joint after the two bones had been detached by cutting the capsular membrane through, show that the pressure of the air will still retain the head of the thigh-bone firmly in the socket, from which it sinks down when the air is artificially rarefied underneath ; the joint thus be- N 4 184 INFLUENCE OP AVEATIIER The observations in ascent by balloons, now become so familiar to us, show, even unexpectedly in degree, the extent to which the body can undergo the most sudden changes of atmospheric weight, without any very obvious effect, where the health is unimpaired, and no causes of bodily fatigue are conjoined. In the note below, I have related some facts de- rived from the best authority we now possess on this curious subject.* It is j)robable that most of the persons, included coming a sort of air-pump, in wbich the bead of the thigh bone acts as a piston. * I have been recently fiivoured with these observations by Mr. Green, whose boldness and ability as an aeVonaut have given him such general and well-merited reputation. Having now ascended in balloons with more than 400 persons, under every possible variation of height, rapidity, and state of atmosphere at the time, his evidence on the points in question is far more complete than any other we possess. Mr. Green informs me that he has found none of these individuals sensibly affected, otherwise than by the sudden change of temperature and by a noise in the ears, compared by some to very distant thunder ; the latter sensation occurring only during rapid ascent or descent of the balloon, and, when greatest in degree, far less distressing than that pro- duced by descent in a diving bell. He has never felt his own respiration hurried or oiDpressed, except when exerting himself in throwing out ballast, or other management of the balloon, or when suddenly passing into a very cold atmosphere. His pulse is occasionly quickened ten or fifteen beats, but this only when some such exertion has been sustained. He mentions to me expressly, that in no instance have his companions experienced vertigo or sickness ; thus rendering doubtful one of the statements current on this subject, and showing how little the two great functions of circulation and respiration are disturbed, under circum- stances where much effect might have been anticipated. Though the inference is limited to two persons, yet it may be worth while to mention the great experiment made by Mr. Green and jMr. Hush in September, 1838, in ascending to the height of 27,136 feet, or 5| miles above the level of the sea ; the greatest elevation ever reached by man, and very nearly approaching to the level of Kinchinjunga, the highest ascertained summit of the Himalaya mountains. The barometer fell from 30° 50' to 11° during this accent; the thermometer from 61° IN EELATION TO DISEASE. 185 under this statement, were in such state of health at the timej as to render them less sensible of sudden barometrical changes, than had they been of feeble respiration, or dis- ordered powers of circulation. These observations, however, may lessen any surprise at the great powers of accommodation by habit to a constant high degree of rai'efied atmosphere. The city of Mexico stands 7460 feet above the level of the sea ; and there are in- habited points in the Andes of Peru nearly 6000 feet still higher.* It must be admitted at the same time that we have no sufficient knowledge of the diseases in these localities, or of the average rate of mortality, to justify inferences as to effects on the body derived from this single physical cause, when forming what may be termed a constant condition of climate. On a general view of the circumstances stated, there is reason to conclude that the influence of the different degrees of atmospheric pressure in disturbing the bodily functions and general health is rather derived from the frequency of fluctuations, than from any state long continued, either above or below the average standard ; — that, of the two conditions, suddenly incurred in any extreme degree, the human frame is better capable of withstanding a rarefied than a condensed atmosphere ; — and that, in every case, the previous health, and proneness to disorder in particular organs, are greatly concerned in determining the results on the body. to 5°. The first 11,000 feet were passed througli in about seven minutes. Yet, under these remarkable circumstances, Mr. Rush suffered no incon- venience but from cold ; and Mr. Green little other than from the toil of discharging ballast and gas at different intervals, which hurried the respiration during the time. * Mr. Pentland, in 1826, ascertained the height of the town of Potosi to be 13,260 feet above the Pacific. Humboldt mentions inhabited places on the Cordilleras at equal elevation. 186 INFLUENCE OE WEATHER Little thougli Its influence has yet been defined, I believe that the Electrical state of the atmosphere is that of all its conditions which has most important and diffused effects on the animal economy; more rapid and pervading than any other ; and, as one of the vital stimuli, more intimately allied to the functions of the nervous system. It Is that, further, which most closely blends Itself, either as cause or effect, with all other meteorological changes; producing thereby many of the difficulties already noticed in estimating their relative amount of influence. When modern science has shown us that every chemical action Is attended by, if not identical with, electrical change ; — that the processes of vegetation, as well as those of animal life, involve unceasing alteration In its states ; — that no two bodies can be present to each other of different temperature, nor even separate parts of the same body be differently heated, without evolution of this agent ; — that every act of evaporation or deposition of water on the surface of the globe has similar effect of change, even the spray of a waterfall sensibly altering the balance of electricity around it ; — we may well understand how wide is the circle of these mutual changes, and how important in the economy of nature. Including in this the existence and functions of organic life Itself. It is difficult to advert to the effects of atmospheric elec- tricity on the body, either as a vital stimulus or cause of disease, without noticing the question, whether this great element of electricity is not itself directly engaged as an ao-ent in the functions of the nervous system ? If this were eventually determined to be so, the relation of the actions without, to those of the same agent within, would present itself under conditions still more difficult of apprehension, and little amenable to our present means of research. Hitherto, however, no proof to this effect has been obtained ; though IN RELATION TO DISEASE. 187 mucli research^ and still more speculation, have been directed to the inquiry. The striking results obtained by Matteucci, and those still more wonderful derived from the experiments of Du Bois Keymond, attest the presence of the electric element in the most minute portions of muscular or nervous fibre ; — its evolution in currents in the act of muscular con- traction ; — and the different direction of these currents in re- lation to the longitudinal and transverse sections of muscles. Still these researches, however ingenious or subtle in their methods, want an experimentum crucis to meet the question as to the identity of the electric and nervous elements. All the phenomena, thus exhibited, may be explained through the evolution of electric currents by other agents, chemical or mechanical, or by that very nervous element which we are seeking to identify ; and we can bring no certain proof that the electricity is not secondary in every such manner of its appearance and operation. The whole question is one, the obscurity of which makes it a favourite theme of speculation with those who are ignorant of the true principles of in- ductive science, and throw dice for discoveries which can only be reached by labour and long research.* Limiting ourselves, however, in this place to the simpler view of the influence of electrical states of air on the human frame, many circumstances occur, well deserving notice, though yet wanting the certainty needful to give them a place in science. The natural history of the animal kingdom through its whole extent furnishes numerous examples (ex- clusively of those in which there exists an especial oi'ganiza- tion for electrical purposes) of the singular susceptibility of different animal species to electrical changes in the media * In my volume on " Mental Physiology " (p. 292. et seq.), I Lave commeutcd at greater length on this question of animal electricity, and the researches of Matteucci, Du Bois lleymond. Person, &c. 188 INFLUENCE OF WEATHER Avhich surround them ; and many particular cases of instinct, hitherto unexphiined, may doubtless be traced to this source. As a particular instance of such effects, less familiar than many others, is the influence of a thunder-storm on the in- cubation of eggs.* In man the eifects are generally less marked, yet nevertheless certain. Without adverting to those singular cases, where the balance of electricity with external objects ''seems altered by the excess of one of its states within the body, it is obvious that changes of atmospheric electricity have much influence both on the sensations and voluntary powers, producing results variously analogous to those which attend certain morbid states of body more fami- liar to us.f A few maybe noticed in illustration from among those most easily recognised. An atmosphere, proved by other phenomena to be highly charged with electricity, produces in many persons sensations resembling those of slight incipient fever ; vague alternations of chill and warmth on the skin, general languor of the frame, debility and aching of the limbs, oppression or other uneasiness about the head. In other instances, the feelings created in the muscles of the trunk and limbs have more of rheumatic character; the resemblance being such as to justify a suspicion I have long entertained that some of the * This was remarkably testified, In the Exhibition for hatching eggs by artificial heat, during a violent thunder-storm, July 7th, 1839. t Of the Instances on record of the curious foct alluded to above, the most remarkable and best attested is that related in the American Journal of Medical Science for January, 1838. A lady, without any adequate cause, passed suddenly into a stnte in which she threw out electric sparks to any conductor around her, sometimes to the distance of an inch and a half, with the ordinary sensations attending electrical action ; this state continuing for several months, and subsiding gradually. Other singular details of this case are given, on authority which appears to be good, and without any obvious sources of fallacy. IN RELATION TO DISEASE. 189 muscular affections, often so termed, are actually derived from this cause. In some persons the suscejitibility is so great, that even the approach of thunder-clouds (especially, I think, such as are attended with heavy storms of hail) pro- duces bodily feelings akin to those just described ; together with a sense of fulness and pricking about the eyes, and a slight tingling over the whole body, which I have often noticed in such cases.* The effects of electricity, artificially applied, may be brought into illustration here. The feelings of numbness or aching that remain for some time in the muscles or joints, after the electric current has been passed through them, (whether derived from the machine, from voltaic, or electro- magnetic combinations) much resemble those which occur in the early stage of fever, or under other morbid conditions of the body : while the sensations on the skin which some persons feel in the vicinity of a powerful electrical machine in action — or in being electrified on an insulated stool, with much conducting material around — are very similar to others of familiar occurrence, observed especially in certain states of the atmosphere, Avliile electrical changes are going on. And in cases of this kind there is also a certain degree of languor, or even diminished frequency of the pulse ; varying in different individuals, but still uniform enough to prove the reality and nature of the effect. That the effects just cited vary greatly in different indivi- duals, and are very slight in some, is in accordance with what * In the very remarkable storm, wliicli in July, 1839, passed over the south of England, the northern provinces of France, Belgium, and Hol- land (and jjrobably was still more widely diffused), the sensations ex- perienced by those at all susceptible to them were very oppressive and singular. The precipitation attending the violent electrical changes in this storm mi";lit rather be called that of masses of ice than of" hail. 190 INFLUENCE OP WEATHER we know of the various action of other atmospheric causes upon different habits. And it may be matter of curious inquiry hereafter, what are the sources of this diversity ; and what its influence in giving liability to particular maladies, as well as upon the general functions of life. One of the best tests of the actual operation of atmospheric electricity on the body is, as I think, that mixed sensation of heat and cold which most persons must recollect at some time to have felt; — or rather, the consciousness of sensations which cannot clearly be defined to be either.* Concurrently with such state of atmosphere, which the thermometer does not in any way interpret to us, there generally occurs more or less of the lassitude before described ; — the muscles are readily fatigued ; some degree of headache is often present ; and other vague uneasiness of the bodily feelings, varying much in different habits, and doubtless influenced by the condition of health at the time. Though these effects are in general more distinctly expe- rienced previously to, or during, thunder-storms, yet are they sometimes also present in other states of weather where no such storms occur. Certain winds, very common in our own climate, will sustain, even for Aveeks together, this peculiar character of atmosphere ; in degree sufficient to be marked by the results just described, and having still more singular and obvious influence on other annuals inferior to man, and on vegetable life. These winds, which may be described, gene- * It is certain that the sensation of itching depends on several different causes acting on the extremities of the sentient nerves ; and it seems probable, from various fiimiliar instances, that one of these is the state of electricity on the skin, in relation to that of the air or particular articles of clothing without. If the assertion of Donne be correct, that there is an opposite electrical state of the two surfaces of tlie skin, it might lead to further inferences on the su1)ject. IN RELATION TO DISEASE. 191 rally, as coming from all eastern points of the compass, but more especially from the quarter lying between north-east and south-east, deserve inquiry under all the aids which modern science can afford. Their various effects on the human body, and on all living organization, are in no wise explained by the temperature or weight of the air. The great dryness of some easterly winds may give better reason for certain of the phenomena, but will scarcely explain the peculiar sense of muscular aching, uneasiness, and languor they produce in many habits ; the almost instant perception of their effects by some persons, even without any exposure to the external air; and as rapid consciousness of change when they cease. Such sensations belong much more to what we know of electrical agency than to any other cause we can assign ; but they need observations more exact than have yet been made, and a careful comparison of these with the physical properties of the winds in question, which future research may also better determine. Whatever the natural causes which render some of our easterly winds thus peculiar, that from the south-east may certainly be considered to have direct connexion with the Sirocco, as it sweeps with greater or less intensity over the southern half of Europe. This very singular atmospheric current, which on its more distant border has probable re- lation to the Simoom and Harmattan, the hot winds of the African desert, — and passes over the Mediterranean Sea under the names of the Levant wind and Sirocco, — reaches England on the opposite side; with its peculiar qualities much mitigated ; yet still showing the same origin in its general direction, in its hygrometrical conditions, and in what I believe to be its electrical influence on animal life. No sufficient explanation has yet been given of these pecu- liarities, nor are they perhaps definite enough as facts to 192 INFLUENCE OF WEATHER warrant mucli theory on the subject. I cannot doubt, how- ever, from my own observations, that the electrical state of these great atmospheric streams, whencesoever derived, is that to which their effects are mainly due. I have witnessed in different parts of the Mediterranean such singular and re- peated proofs of this as to give assurance of the general fact, though there are yet wanting the exact detei'minations re- quired to fix its place in the history of physical phenomena.* * In my Travels in Albania, &c. (2nd edition, 1819,) I have related two occurrences of this kind, in which the electrical phenomena at- tending the Sirocco, as seen at night, were very striking. One of these instances I cannot readily forget. It was when approaching the coast of Ithaca, under the obscurity of a dark evening in October, after a still and sultry day, the wind arose suddenly and strongly from the south-east, kindling almost instantly every part of the sky with gleams and flashes of electric light ; vivid enough at intervals to allow the reading of the smallest print ; and giving outline not only to the cliffs of Ithaca closely above us, but even to the distant mountains of Santa Maura and the Acarnanian coast. As in almost every instance in which I have witnessed such appearances from the Sirocco, dark masses of clouds speedily began to gather in the north-west, the quarter towards which the wind blew ; and amidst these the electrical discharges or interchanges were singularly splendid in effect, continuing till a late hour in the night. No thunder was heard during any part of the time, nor did rain fall ; but I found, from observations on this and similar occasions, that the quantity of moisture in the air was very great, and have generally noticed the wind to subside with a fall of rain. In other instances, where the Sirocco began to blow in the evening or during the night, I have observed appearances of the same kind, though none equally striking. They are generally, according to my experience, more marked at the beginning of the wind, as might be presumed likely from the blending of different portions of atmosphere unequally charged with electricity or in different states. In the work just alluded to, I have mentioned the position of Malta as very favourable for a series of observations on this remarkable wind. The best information we yet have from this island is that given in Badger's History of JNIalta. The effects of the Sirocco on the barometer and ther- mometer require to be noticed : still more those which indicate its IN RELATION TO DISEASE. 193 Our knowledge of atmospheric electricity is, in truth, still in its infancy. The researches of Peltier, and the more recent and remarkable results obtained by Quetelet, from five years of continuous observation at Brussels, have indeed determined much as to the statical condition of the electricity of the atmosphere, and the changes it undergoes at diiferent seasons of the year, at different times of the day, and under different hygrometrical states of the air. But the causes of production, distribution, and change ; — its relation to that electricity which circulates in magnetic currents, or otherwise appertains to the earth, or may possibly exist in space beyond the atmosphere ; — its connexion with atmospheric heat, moisture, or weight ; with the formation of clouds, and the phenomena of wind, thunder-storms, and rain ; — and above all, the true theory of its positive and negative states, — electrical and hygrometrical states. The latter, too, need the comparison of inland observations (which must be obtained elsewhere) with those made by the sea-side. Though Dolomieus's assertion, that the atmo- sphere of the Sirocco contains less than the due proportion of oxygen, is liable to much doubt, yet ought the air to be examined eudiometrically also ; and particularly as to the proportion, if any, of Ozone contained in it. And to these notices should be added others, as to the frequency, periods of occurrence, and duration of the wind ; — the points from which it blows, and the changes in these ; — the external appearances attending it ; — and its effects in producing bodily disorder, whether of the sensations, voluntary power, or vital actions. A conjecture of Colonel Reid, in his very valuable work on the Law of Storms, would, if verified, afford a plausible account of the properties of this wind, hitherto so little explained by any local circumstances. He supposes, in conformity with his general doctrine, that the Levanter or Sirocco may be the south-west wind of the great Desert of Sahara, sweeping round so as to become an easterly or south-easterly wind in the Mediterranean, and still retaining qualities which it has acquired in passing over this vast region of sand. Any future observations in Egypt, or other eastern parts of Africa, which might show strong southerly winds, corresponding in time with the Levant winds of the Mediterranean, would furnish much confirmation of this conjecture. Q 194 INFLUENCE OF AVEATHER each of these conditions is still largely open to inquiry. The latter especially, which has most assured and closest relation to all the rest, is the great mystery still hanging over electrical science; the solution of which would not merely determine these particular questions, but probably, in its connexion with the general doctrine of polarity, enlarge our whole view of the attraction and combinations of matter whether in atoms or masses, throughout the universe.* What has been thus far said regards chiefly the influence of electrical states of the atmosphere on the sensations and muscular powers. Unless justified in considering as such the occasional effects of lightning on the body, I know no ex- press example of disease which we can affirm to be produced by this agency. Some authors, indeed, have attributed to it certain epidemics of singular character, and not easily refer- able to any known cause. But in this opinion they have hardly defined, whether it is to be considered as directly pro- ducing the disorder, or merely a state of body predisposing to receive it; leaving open still the third contingency of its simply evolving from other sources the virus or material cause of disease. I have elsewhere shown that it is difficult, if not impossible, to connect these erratic disorders with any state of weather or known quality of the atmosphere; and the reasons derived from their history apply as distinctly to electricity as to any other property of the element which surrounds us. We must, however, admit the possibility, both as to these and other disorders, of the two latter contingencies just stated. Electricity may be concerned in favouring the generation of malaria, whatever its nature; or it may in- * I may notice here the remarkable fact stated by Quetelet, that in daily observations 'for five years, the electricity of the atmosphere was only found negative in 25 instances; all these occurring in connexion with storms. IN RELATION TO DISEASE. 195 duce a state of body more liable to be affected by this, or by other causes of disease in activity at the time. We have no proofs on which even to approach towards assurance, but presumption from several sources that this great agent can- not be wholly inert as respects either of the conditions in question. Though unable then to affirm any one disease to be actually produced by electricity, yet, considering the subject in its whole extent, it is impossible not to see the likelihood of its influence on the body in many ways hitherto undis- tinguished, or not understood. If a stroke of lightning can in an instant destroy muscular irritability tlu'oughout the sys- tem, and prevent the natural coagulation of the blood, either directly, or indirectly by hastening putrefaction, — it is clearly to be inferred that lesser degrees of the same action must have definite effects, bearing proportion to the intensity of the electrical changes or transferences taking place.* The con- clusions, best warranted by the facts we possess, would direct us towards the blood and nervous system generally, as the parts of the animal economy most liable to be thus affected. The influence of atmospheric electricity on the latter is shown in the various effects, akeady mentioned, on the sen- sations and muscular power; and the proof is greatly strengthened, though indirectly, by the numerous experi- ments which prove the influence upon these two functions, of electric action from different sources, applied directly to the nerves themselves.f The quantity or tension of the agent, * Though these effects of lightning are generally recorded, and in part on the authority of Hunter, there is still some ambiguity attending them. See the Memoir of Dr. Davy on this subject in his Physiological Re- searches. t The researches of Humboldt, INlUller, Prevost and Dumas, Dr. Wil- son Philip, Becquerel, and other physiologists, might be referred to in o 2 196 INFLUENCE OF WEATHER as affecting the body through the ah', may be less, and its application not so direct on the nervous system. The low average intensity of animal electricity, as ascertained experi- mentally, must also be taken into account. But with all these allowances it is impossible that the effect should be wholly absent or different in kind; and circumstances may often greatly augment its degree, disordering in the same ratio that balance which is most conducive to the general well-being of life. The same reasoning applies equally to its influence on the blood; and though this part of the subject is even more obscure, yet is there presumption that here the effects occur which are of greatest import in the history of disease. All that chemistry has recently done to determine the nature and relation of parts in the blood (concurrently with that great fact which has now been established of the identity of electrical and chemical action) justifies the belief that every material change of balance between the electricity without, and that within the body, must have effect on the state of the circulating fluid ; — transient and wholly inappreciable, it may be, in the great majority of cases; in others, possibly, of longer duration and more extensive in degree. The general relation of acid and alkali, as important in the chemistry of life as in that of Inorganic matter; — obvious, not only in the blood itself, but in the materials and processes by which it is formed, and in the secretions and excretions derived from it ; — this relation is one in which we have peculiar and con- stant evidence of electrical agency. The coagulable property of the blood, in whatever it consists, is closely affected by the this place ; — not equally certain in results, nor conducting their authors to the same conclusions ; but concurring to show the remarkable nature of this agency as a stimulus on the nervous and muscular systems, if indeed it be nothinfj more. IN RELATION TO DISEASE. 197 same cause, even when acting through various intervening tissues. Though we have no equal proof as to the globules, yet their definite form, size, and other peculiarities (necessary as it would seem to the existence of each species), make it probable that they are liable to alteration from an agent, which seems more than any other to determine all definite combinations and changes in the material world.* The tenor and extent of the argument here must be rightly understood. We have no proof of the action of atmospheric electricity, in any of its ordinary states, upon the blood. But the effects of lightning, and the influence of the same prin- ciple, proved by experiment in other modes of application to this fluid, warrant the belief that such action may exist ; and, if existing, that it must be a frequent cause of disorder throughout every part of the animal economy. We cannot trace diseases with certainty to this source, but how rare are the instances in which we can affirm their real causes ! The actual void of knowledge justifies our seeking them through all the new agencies which physical science may disclose ; and none is more likely to afford successful results than that now before us. Two classes of facts, neither of them yet sufficiently ex- amined, are obviously very important to the inquiry. The * The action of electricity on the blood has been the subject of the same zealous research as its influence on the nervous system ; and directed ultimately to the same question, whether it is not itself the most essential principle in this fluid, ever present, and determining all the changes which take place within it ? The reasoning of Muller (Handbuch der Physiologie, p. 128.), in refutation of the singular experiments and inferences of Dutrochet, may be consulted as an example of the ingenious and minute inquiry given to this subject, as well as of the ambiguity which still surrounds it'; both as respects the chemical changes, usually so termed, in the blood, and the action of voltaic electricity in promoting or modifying them. The question concerning the relation of animal electricily and animal heat is a very curious part of this subject. o 3 198 INFLUENCE OF WEATHER first includes the indications which diseases themselves may give, in their progress, of alteration of electrical state in the body. The second involves the more general question as to the development of electricity in the animal frame ; its natural variations from age, sex, temperament, and connexion with particular bodily functions ; and its manner of relation to the electricity of the air without. With the exception of some curious observations of Humboldt and PfafF on the electrical state of rheumatic patients, we have nothing that approaches to certainty on the former subject. On the latter we possess more results, but all requiring revision and extension by further experiment. We still have no averages sufficient to show the relative frequency of positive or negative states of the body ; — or the causes which determine this difference, as well as the changes taking place in the same person at dif- ferent times.* And as respects the connexion of animal elec- tricity with that of the atmosphere, (though this question may have been made less difficult by the sagacity of Faraday in reducing all the phenomena of induction to functions of the conducting power,) it still requires much care and research for its complete solution ; and a regard, not merely to the changes of state within the body, but to those also constantly occurring in the positive or negative conditions of the atmo- sphere without ; of which the comparative excess of positive electricity during the day may be taken as a well marked example. I have dwelt so far in detail on this part of the subject of the chapter, as being that on which our knowledge is most deficient ; and from persuasion also of its future importance in solving many obscure questions in pathology. I might * The experiments of my friend Professor Pfaff of Keil, in conjunc- tion with Ahrens, are more complete than any others I know on this subject. IN RELATION TO DISEASE. 199 further plead its obvious connexion with all the uses, which may eventually be ascertained of electricity as a remedy in disease ; a point where it must be owned that much success- ful research is needed, to remove that imputation of failure which has been the result of the partial and often abortive trials hitherto made.* * It must be regarded, indeed, as strange, that an agent so general, so variously excited, and so powerful as a vital stimulus, should hitherto have lent such slender and doubtful aid to the physician. For this, however, some probable causes may be assigned. Applied chiefly as a stimulus to palsied limbs or torpid organs, or often with less definite purpose to cases where all other means have failed, it has had also the disadvantage of a general method of use, too gross, as we may suppose, for the subtle nature of its action on the living economy. The only concep- tion of its effect would seem to have been that of a stimulus, and this in the least defined sense of the term. Any action upon particular functions is either unknown, or so partially determined, as still to afford no assured inferences for practice. The researches of Dr. Wilson Philip, on the influence of voltaic electricity, transmitted through the pneumo-gastric nerve, on the function of digestion, may occur as an exception to this statement. But I would remark that his experiments require to be at- tested by more careful repetition, before they can be admitted as a part of physiology. The application of electricity to paralytic cases is a remarkable proof of the vagueness of all notions on this subject. Because the muscles of a limb, palsied from some affection of the brain, are convulsed under electric shocks, or when made part of a voltaic circuit, it is inferred that their action under voluntary power may be restored by this agency. An opposite practical conclusion might almost as reasonably be drawn from the same premises. In other cases, where electricity is passed through organs presumed to be in a torpid state, (as the uterus in amenorrhaea,) the practice is merely tentative, more frequently failing than succeeding in result. Such failure is readily explained (even allowing the principle to be just) by the manner in which alone the electricity can be supposed to make its passage throufh the organ. The same remarks equally apply to its use in cases of deafness, stiffened joints, and other disorders of still less determinate kind. o 4 200 INFLUENCE OF WEATHEK Throughout the whole of this chapter, I have been con- sidering the influence on the body of those atmospheric con- ditions which are commonly termed weather ; exclusively of all chemical changes in the air itself; of the admixture of other gases ; or of the presence of ingredients of animal or vegetable origin forming; the miasma of disease. Were I writing a treatise on the subject, I might enlarge much on all these points ; and in regard to the first particularly, might speculate — where all is yet mere speculation — on the pro- bable influence of oxygen, under its allotropic state of Ozone, existing in different proportions in the atmosphere around us. Even with these exclusions, and merely touching on the several parts of the subject, it will be seen how vast is its extent, and how important its relations to the history of disease. My principal object has been to indicate the latter, and to suggest some of the topics on which more complete knowledge is to be desired. Here, as already remarked, the In relation to future inquiry on this subject, the application of electri- city as a medicinal agent may best be viewed in the three following ways: firsty in its action on the nervous system ; secondly, on the blood ; and, thirdly, on particular organs under disease. The first two topics are the most important ; and all that has been stated above tends to show that we may look to these as a basis of future discovery. Many results already obtained (as those recently published by Dr. Addison, in relation to chorea, and the successful experiment of Matteucci in tetanus) make it probable that the use of electricity in nervous and spasmodic disorders, even when depending on the sensorium, may be greatly extended ; and though its action on morbid states of the blood seems much less within our reach, seeing the multiform conditions of this fluid, and the practical difficulties of application, yet is the object one well meriting diligent re- search. In each of these cases future success will probably be due to new and more refined methods of use, better according with the natural actions of this principle within, and upon, the human frame. Various suggestions to this effect arise out of recent discovery in electrical science ; and the whole question of methods of application is one of great im- jiortance in the inquiry. IN RELATION TO DISEASE. 201 progress of physical science is ever lending fresh aids to that of pathology ; and the unexpectedness of some of the results 18 the best augury of what may be looked for in future, from the enlarging scope of the inquiry, and the new instruments and means with which it is pursued. 202 CHAP. VIII. ON DIET, AND DISOKDERS OF DIGESTION. Looking over the notes I have made on this subject in the course of practice, I find them in various parts superseded by the many and valuable treatises which have been published of late years. These works, founded upon an improved phy- siology of the organs of digestion, have done much to give dietetics the character of a branch of science, which it cer- tainly did not possess before.* Even now it may be doubted whether our materials are ample or exact enough for method- ical arrangement ; and whether many of the rules founded on them are not calculated to foster, rather than repress, the vague and changeful fancies which prevail on this subject. It is certain on experience that no proportionate benefit has yet been obtained from all hitherto written upon it. For this there may be many causes. One doubtless is, the diffi- culty of establishing or applying positive rules for conditions so infinitely varied, that the evasion of these rules becomes easy, or is even apparently sanctioned by the peculiarities of each case. Nor can it be affirmed that the precepts of * I may mention particularly the works of Dr. Paris, Dr. Combe, Dr. J. Johnson, Dr. Wilson Philip, and the article on Indigestion, by Dr. Todd, in the Cyclopsedia of Practical [Medicine. The physicians of the United States, who now contribute so eminently to medical science in all its branches, have added to our knowledge on this subject. And their writings have the greater interest, as stating the result of manners of life differing in several respects from the ordinary habits of our own country, and of other parts of Europe. ON DIET, AND DISORDERS OF DIGESTION. 203 medical authors themselves are concurrent on the principles of diet, and the management of dyspeptic disorders. Many points are still disputed : and on few perhaps are the criteria of truth so complete as to possess the influence that is re- quired for their successful application to practice. These circumstances, and still more the habits of society among the higher classes, and the influence of dyspeptic com- plaints on the minds of those affected, render the treatment of such disorders a matter of great interest, even in a moral point of view. They unhappily furnish an arena on which all the worst parts of medical practice find their readiest display. Fraud, intrepid in its ignorance, here wins an easy triumph. Seconded on every side by prejudices, fashions, and foibles, and taking advantage of the mind and body in their weakest and most sensitive mood, it deals out precepts and drugs with a pernicious facility ; — sometimes altogether at random ; — sometimes, and even more injuriously, with one common scheme of treatment applied to the most variable and incongruous symptoms. These abuses indeed, in their worst form, exist only on the outskirts of the profession. But it will be admitted by all who have candour and experience, that there is no part of medical practice where knowledge and good faith are put to equal trial as in the management of dyspeptic complaints. Even the effect of the disorder in obscuring the judgment, and rendering impotent the will of the patient, bcomes an embarrassment to the physician. If his own judgment be slow and wavering, he is deprived of aid — if hasty and rash, of that control from the opinion of his patient which is fre- quently needful. The mind of the dyspeptic is uncertain and fickle. He interprets falsely his own sensations, and the effects of the treatment employed ; — is unduly confident at one moment and under a new remedy ; — at another time as 204 ON DIET, AND irrationally desponding ; — prone, moreover, to change his medical adviser, and to resort to any person or remedy where there is largest profession of relief. All these things, familiar in practice in this country, make the situation and conduct of the physician in cases of dys- pepsia hardly less difficult than in acute and dangerous dis- eases. Though the symptoms before him are not so critical in kind, they need sound moral management as well as dis- creet methods of medical treatment.* Forbearance and firmness are both required ; and, together with these, inte- grity and good faith. The admirable precepts as to upright- ness in practice, which came down to us under the great name of Hippocrates, obtain here their closest application ; and may well be impressed upon all who are entering on a medical life. The mind must be fashioned early and strongly in these professional principles ; as they are rarely attained afterwards, and not always easily preserved, amidst the many difficulties which beset the conduct of the physician. I dwell on the foregoing points the rather because experi- ence has convinced" me of the great abuses existing in this part of medical practice, from the excessive employment of medicines, where management of diet and habits of life would be of far greater avail for good. These abuses have been much lessened of late years ; but enough still remains to justify a reference to them, and the demand for their further control. I cannot doubt that to this cause in great part may be attributed the growth and continued prevalence of Homoeopathy in England ; while it has passed into com- parative neglect in the country which gave it birth. The * What Aretaeus says regarding the treatment of chronic diseases in general, applies singularly to dyspepsia, as one of the most frequent of them. EvBa di] apirri SiaeiSsrai av^poc; irfTpov^ Km ixaKpoOvi.iu]Q, kcu ttouci- DISORDERS OF DIGESTION. 205 love of novelty, and of all that is secret and unintelligible, doubtless contributed to foster tliis, as it has done so many- prior fashions, calling themselves systems, in the treatment of disease. But the contrast of the occasional Homoeopathic globule with the daily series of pills and draughts, affords more entire explanation of the fact. The public at large, little capable of judging rightly either as to the causes or treatment of disease, accepts as a boon the practice which exempts them from unceasing j)hysic ; and attributes to the infinitesimal dose effects which are really due to this ex- emption alone. Such is especially the case in dyspeptic dis- orders, where the malady is fed by excess of medicine, and often greatly mitigated by its removal. And here, accord- ingly. Homoeopathy, inefficient in all acute diseases, has found a wide field in which to work ; the abuses which had debased this part of practice, giving a specious sanction to any new system, free from similar reproach. I am persuaded that the experience of those physicians, who have been most observant of the medical history of the last thirty years, will be in accordance with this view of the subject. For the reasons already named, I shall not seek to give any method to the remarks which follow respecting diet and dyspeptic disorders. They are drawn from my experience, on no other principle of selection than that of appearing to be least regarded in proportion to their practical importance. If desultory, it may be truly affirmed that the subject to which they relate is so likewise. Even the term of dyspepsia is variously and vaguely used by medical writers themselves; and in truth is not readily defined, where so many organs are concerned, and such various causes of disorder. In a formal treatise, this difficulty requires to be met by some sort of arrangement of the cases and causes in question. It is not 206 ON DIET, AND necessary here, where the object is limited chiefly to practical views, and those of a general nature. It is needful to remark in the outset, that rules of diet may be pressed too closely, as well as too vaguely, in the treatment of disorders of digestion. Such rules may come to exercise a morbid influence over the mind of the patient, counter- acting all the good obtained. Attention to his sensations is already too much awakened in the habitual dyspeptic ; and often the greatest benefit wliich can be conferred is that of weaning it away from them. In another place I have alluded to the singular influence of the mind, simply dhected to the digestive organs, in altering or disordering their natural functions ; and this even where no morbid solicitude exists on the subject.* Every such effect is greatly aggravated in the case of the dyspeptic. His minute and anxious watch over his sensations generates the very evils which it is the object to remove. A system of rules for diet and other manage- ment of the digestive organs may be necessary in such cases ; but their effect on the mind must be observed, to see that they do not usurp too much upon it, and sanction injuriously those morbid habits which, arising out of the malady, augment the symptoms and retard their cure. A strict rule, good in itself, may often expediently be relaxed or dispensed with, if found thus to influence the temper of the patient. Austerity of system must bend before the variable conditions with which we have to deal in the treatment of disease. Many points of practice connect themselves with this state of mind in dyspeptic disorders. It may be well, for instance (though the rule is by no means an invariable one), that the bowels should act each day in such cases. But if the patient becomes morbidly intent on this object, as often happens, all * On the Effects of the Attention of Mind ou the bodily Organs. Chapters on Mental Physiology. Chapter II. DISORDERS OF DIGESTION. 207 value of the habit is lost in the anxiety it creates, and mischief is generally incurred in the means employed to promote it. Here every eifort must be made to disengage his mind from the presumed need. It is- often even expedient for this purpose expressly to advise that there should be action on al- ternate days only ; gaining thereby the chance of some inter- ruption to these habits of morbid feeling. The disorder they produce in the various parts and stages of digestion does generally itself, indeed, prevent that regularity which is so anxiously sought for. So also it may be very desirable that the dyspeptic should dine at regular and reasonable hours, and from a simple and discreet table ; but if this rule brings him to a solitary meal, set apart for his express condition, more of ill than of good is usually the result. It is rarely expedient that he should feed alone. His mind needs to be solicited away from attention to the functions and feelings of the stomach ; and this can only effectively be done by society at the time of eating. The apprehension of indigestion creates it; — sometimes almost as an instant effect. When the stomach is full, the less the mind has to do with it the better. In this fact, as well as in the hurried dealing with food while alone, we find explan- ation of what is often cause of surprise to the dyspeptic, that he feels better after the indulgences of a large dinner party, than in the seeming discretion of his solitary table. We are often then obliged to strike a balance between these evils, and to sacrifice something of principle for a practical expe- diency of greater importance. Upon the same principle it is obvious that rules of diet lose much of their value in practice, if too various and minute. This applies alike to the treatment of actual dyspepsia, and to general methods for preserving a healthy digestion. Multiplicity of rules may become as ineffectual 208 ON DIET, AND as no rules at all. We are bound to take human nature and society as we find them ; amending if we can, but not, tlirough aiming at too much, forfeiting that which may be gained by more simple and compendious means. The dyspeptic patient feeds his disordered fancy on minute maxims, adopting and dismissing them with equal facility and forgetfulness. The patient who seeks only a rule by which to preserve health, disregards a series of small observances, which he feels as burdensome ; and which in truth, if strictly observed, often become an unwholesome restraint. While diflScult then to say how far rules should go, so as to attain the greatest amount of practical good, the physician must be furnished with full knowledge of all that are sanc- tioned by reason or experience, in order to give them direction to particular cases. For the guidance of patients themselves, those of course are best which are most promptly and safely applied ; neither harassing the mind by anxieties of choice, nor the body by encouraging wayward fancies as to methods of prevention or cure. If, for example, I were to specify any general maxims as to food, preferable to others from distinctness and easy application, and serving as a foundation for lesser injunctions, they would be the following : — First, that the stomach should never be filled to a sense of uneasy repletion. Secondly y that the rate of eating should always be slow enough to allow thorough mastication, and to obviate that uneasiness which follows food hastily swallowed. Thirdly, that there should be no urgent exercise, either of body or mind, immediately after a full meal. The simplicity and familiarity of these rules may lessen their seeming value ; but in practice they will be found to include, directly or indirectly, a great proportion of the cases and questions which come before us. And many such DISORDERS OF DIGESTION. 209 questions, as for example those which relate to different qualities of food, would lose great part of their difficulty, were these maxims successfully enforced. When the quan- tity taken does not exceed the just limit ; — when it comes to the stomach rightly prej)ared by mastication, and by ad- mixture with the secretions of the glands which aid the first stage of digestion ; — and when no extraneous interruption exists to the proper functions of the stomach in this stao-e, the capacity of digestion is really extended as respects varieties of food, and tables of relative digestibility lose much of their value. It is certain that different temperaments require, what- ever be the causes of this diversity, different proportions of aliment; and the same constitution alters its demand at different times, both in health and sickness. No rules of diet, therefore, can be made positive as to quantity ; and the attempt at such is now generally abandoned. The criteria to be taken for particular cases are those furnished by the state of the several organs concerned in digestion, both imme- diately and at various intervals after food ; and also by the effect of digestion, while in progress, upon other functions of the body. This is for the most part too intricate an observa- tion for the patient himself. It is enough for him (and much indeed of positive good) if his adherence on conviction can be obtained to the simple rule stated above ; viz., habitually to stop eating at a point short of uneasy repletion. In effect, this maxim is nearly identical with the more familiar one of not eating beyond the appetite. But it is to be preferred for practical purposes, as being less liable to ambiguity and self- deception. Though with apparent relation only to the first stage of digestion, it is in truth more or less a provision for every succeeding part of the process, and for the well-being of all the organs concerned in it. A meal, which sits lightly p 210 ON DIET, AND on the stomach In the outset — producing during the first hour no oppression, drowsiness, heat, thirst, acidity, or other un- comfortable feeling — will probably pass healthily through all succeeding stages of digestion. If otherwise, the evil arises from some accidental or especial cause, against which no ordinary rule can provide. The symptoms just recited, though perchance slight and transient in each particular instance, yet are readily recog- nized both in health and sickness, and may fitly be taken as suggestions for the future.* Such effects may be owing either to excess in quantity, or to error in quality of food. When there is doubt as to this point, it is for the most part simpler and shorter in practice to act upon the former view, and to lessen experimentally the quantity of food taken. If the object be not thus wholly attained, the evil is at all events diminished in amount, and better indication given as to the real cause of mischief. That there is a general excess in quantity of solid food among the higher classes in this country, perhaps in all highly civilized countries, may be admitted as certain. In its effects, direct or indirect, it is one of the circumstances which most tend to equalise the actual condition of different classes. No reasoning or quotation of cases is needful for the proof of the mischiefs hence derived. Daily experience is the argument here ; both as to the efiects of single ex- cesses, and of that smaller habitual excess, which, little felt at the time, does, nevertheless accumulate a store of ills for the whole of life, affecting in various degrees all the functions both of body and mind. The observations of Dr. Beaumont, under the singular facilities afforded in the * Better and more succinct description of them cannot be given than that of Hippocrates. Ol /lev yap i]u apianicrhiai fir) ^vfitpepovroc avroimv, ivOvQ (iupttQ Kca vojOpoi TO aiofxa Kai TijV yvun)]!', X"'''A"?C '"' ''^"' vvarayfiov DISORDEKS OF DIGESTION. 211 case of St. Martin, add more direct proof to this ordinary experience. In showing to the eye the immediate effect of excess of food, as well as wine, in producing an erythematous state of the mucous coat of the stomach, they render more explicit the influence of such excesses long continued ; and the passage from slight and transient disorder to permanent disease of texture. These living observations have a value tenfold that of any attainable in other ways ; and especially as applied to an organ of such complex condition as the stomach, so variously acted upon by mental as well as phy- sical causes. The vague or mistaken use of the word debility is the source of much mischievous error in the management of diet ; both in acute disease, and in the ordinary treatment of dys- peptic cases. It behoves the physician to keep this con- stantly in mind, lest his own judgment be misled by the wrong interpretation of others. The term in question is often applied in cases where the sensations, so described, are in reality owing to oppression ; and oppression from that very food which is unceasingly sought for as a remedy. The organs of digestion are overloaded ; and not only their powers, but those of the whole body, thereby weakened and impaired. And to the condition, thus produced, we give the same name by which we describe the effects of excessive htemorrhage, of typhus fever, of pulmonary disease, or other protracted dis- ease, exhausting all the powers of life ! The whole subject of debility, in its more general sense, physiologically as Avell as practically considered, is of great interest, and merits the most careful examination, freed from those ambiguities of lan- guage which old medical controversies and the popular pre- judices of every age have alike contributed to engender.* * Those who are familiar with medical literature will remember the long and angry controversies which have existed, almost in our own age, p 2 212 ON DIET, AND The proper regulation of diet under actual disease is not, if rightly viewed, so difficult a matter as it might seem from the infinite variety of conditions with which we have to deal. The great law of the living economy comes in here for our guidance ; — that the appetite for food is lost or diminished, in exact relation to the impairment of the powers by which it is digested and converted to the uses of the system. The exceptions to this law (many of them such only in appearance) are too inconsiderable to require enumeration. Its truth is singularly denoted in all cases where there is on the questions of direct and indirect debility — disputes in wliich words, without due definition of meaning, have " mightily entangled and per- verted the judgment," and led to frequent and serious errors in practice. The best excuse for these controversies is to be found in the intrinsic diffi- culties of the subject. Debility scarcely admits of a single definition. It can only be defined by a description, including several different states of body, partial or general, in which a certain common condition is found, though the cause producing such states are of very various nature. This common condition may best, perhaps, be described by the simple phrase of loss of power, — a phrase involving no hypothesis, and ex- pressing well the main fact that pervades all the forms, and illustrates the causes, of real debility, as a state of the living body. There would be great value in a good treatise on this subject. But, to be complete, it must go deeply into these causes and forms ; designating not only what is partial or local, what general debility ; but further also, distinguishing clearly the causes concerned in both. Such are the debility of natural temperament, or a want of power proportioned to the bodily frame, existing from birth and pervading life ; — that, transient in kind, arising from an excess of use of the bodily powers ; — that consequent upon fever and other bodily diseases, including those of the brain and nervous system ; — that induced by physical agents, comprising even states of the atmosphere around us ; — and that proceeding from various emotions and moral causes affecting the nervous power. The mere statement of these several conditions (and others might be cited) show their singular complexity considered physiologically; while the experience of every medical man will testify to the supreme importance of a right discrimi- nation of them, for the safe guidance of his practice. DISORDERS OF DIGESTION. 213 febrile action present In the body ; and its generality gives it great value as an index of disorder, as well as of the right methods of dietetic treatment. I have mentioned elsewhere the aids we are entitled to draw from the patient himself, in this point of practice, where disease has restored nature for a while to its dominion over the appetites. It is rare that any mischief can arise from following this guidance, if care be taken to ascertain its reality. Nevertheless, the physician is liable here to various diffi- culties, created chiefly by the mistaken importunity of those around the patient. No conviction is harder to be removed than that which regards loss of appetite as itself the disorder — food as the proper and certain remedy. Even the con- currence of the patient's feelings with the judgment of the physician is scarcely of avail against this persuasion- And when these are altered in part by returning health, and old appetites and habits begin to recur, the risk of excess becomes greater, by the enfeeblement of that natural control which is the best security against it. The adult patient, however, is better able than the child or infant to protect himself against such hurtful importunities. In the case of the infant, more especially, a facility is often afforded to the commission of this mischief by the thirst of fever, which allows liquid food to be largely given, and under the deception of appearing to be taking eagerly, when most unfit for the disorder that exists. These evils are familiar in practice, and not easily obviated altogether. They may best be diminished by consistency and firmness in the medical man, whose unwilling concessions in a few instances weaken his influence in all. As to what regards our second point, the manner of taking food, little can be added to the maxims which are familiar on this subject. The recent experiments of some German r 3 214 ON DIET, AND physiologists on the properties of acidified mucus and other products from mucous membrane, as agents in digestion, give new proof of the necessity that the food should be well mixed with the saliva and secretions of the mucous glands, in the early stages of this process.* And the observations of Dr. Beaumont (aided by the facilities just mentioned) on the secretion of the gastric juice as an effect of the stimulus of food received into the stomach, and on the peculiar manner in which its inner coats contract on each fresh morsel, show the necessity of allowing due time to these operations, and not disturbing them by matters hastily swallowed and im- perfectly prepared. In youth, the activity of the system, seeking fresh materials for growth, and for other remarkable changes then in progress, readily overcomes all difficulties. But at more advanced age, and when these demands are diminished or have ceased, the stomach needs to be dealt with more leisurely and gently. And at all times of life, common experience tells us of the sort of convulsive reaction, weight, and other uneasiness, produced by hasty swallowing and hurried meals. This, in fact, is one of the many causes of dyspepsia to those of sedentary habits who feed alone ; and not less to those who eat, as they live, in a tumult of business, measuring their meals by minutes stolen from the labours of the day.f The dyspeptic often pleads to the phy- * I allude to the researches of Eberle, Schwann, and Mliller, which have been repeated and extended by Dr. Todd in this country. f In Thomas Paynell's Regiment of Health, 1557 (a translation of the Regimen Sanitatis Salernitanum), this matter is quaintly but well ex- pressed : — " Prolongynge of tyme in eatynge moderately (as an hour's space), to chawe and swalowe our meate well, is aloweable, and helpeth moche to the conservation of health. For good chawinge and swalowynge downe is as halfe a digestion. And ill chawinge doth eyther let dygestion, or else doth gretly hyndre it. But prolonginge of tyme in rallying and tellyng of tales two or three houros is ryght hurtful." And the reason DIS0KDER8 OF DIGESTION. 215 sician his solitary dinner, and plain joint of meat, as things that ought to protect him from his disorder; — ignorant, and hardly to be persuaded, that these are the very conditions which augment and protract it. It is another suggestion of prudent experience, that meals of animal food should not be admitted to crowd too closely together. The function of digestion as respects each organ is one of stages, and does not allow this forced interference of one stage with another. Animal food, of ordinary cookery, especially requires this caution ; and the meat luncheon and dinner, too closely brought together, are causes of mutual disorder to the digestion of each.* With these considerations is connected our thh^d rule, that there should be no sudden or urgent exertion soon after a full meal; nor indeed immediately before it; for the same general reason applies to both cases. The stomach requires (as does every organ for its appropriate function) a sufficient supply of nervous power, whencesoever derived ; and a pro- portionate increase of blood in its circulation, to minister to the actions of which digestion is the result. It may be a physiological fact that these two conditions are identical ; or that one needfully involves the other. But whether so or not, it is equally certain that both the nervous power, and the blood needful to digestion, are diminished and disturbed by strong exercise immediately before or after a meal. And to this cause of disorder must be added, in the latter case, the effects of mechanical agitation, which is no doubt often for the latter clause is just, though that of probable excess of quantity in such cases might also be added. " For when the last meate is received, the first is well neare dygested. Therefore the said meates in divers of their parties, as touching djgestion, be not like." * Regarding the relative digestibility of different kinds of food, the best information is that of the tables given by Dr. Beaumont ; though some ambiguity must still be admitted to exist on the subject. F 4 216 ON DIET, AND concerned in disturbing the process, either by interference with the chemical changes essential to it, or by preventing that remarkable distribution of aliments within the stomach, the result of powers we cannot yet pretend to define. The proofs of these facts are furnished by constant ex- perience, and are familiar to us amongst other animals ; yet is attention not sufficiently given to them, either in the habitual directions of physicians, or in the rules which men themselves apply to the management of their diet. Hard exercise and fatigue are often understood as a sanction for immediate and ample food, without regard to the expenditure of power that has taken plac«, or to the direction which the circulation has got towards the muscles and capillaries of the skin. Those who are exposed to the necessity of long and fatiguing journeys speedily learn the error of this. But experience of such kind is generally needed to teach it ; nor is this always sufficient against the force of early impres- sions, and the faulty habits of society.* What is true as to bodily exercise after food is almost equally so as to mental emotion, or intellectual labour. Neither with sound nor unsound digestion ought there to be any intent exertion of mind at this time. Strong or sudden emotion, from whatever cause, will instantly disturb or even stop the whole function ; and short of this there is every degree in which the mental feelings habitually derange it. To this cause we may in some part attribute the frequent occurrence of dyspepsia in middle life ; when the excitements are more active and various, and the passions inflict greater * I know from my own observation how well Government messengers, and the Tatar couriers of Turkey, have generally learnt this lesson ; derived from the necessities of their manner of life, which are far more effectual for teaching than any other maxims. We apply the rule care- ftilly and extensively in the management of our hoi'ses and dogs, without rightly heeding it for ourselves. DISORDERS OF DIGESTION. 217 disturbance on the body. Their influence is familiar to ob- servation in the sensations of the moment ; and not less in the symptoms which arise from repetition of the disturbance. Two or three days of continued anxiety will bring disorder and debility into all the actions of the digestive organs, how- ever healthy their previous state. But even urgent intellectual exertion, unattended by any emotion (unless a laborious effort of the attention be so termed) interferes for the most part with easy and perfect digestion. The precept of Celsus, " sin lucuhrandum est, non post c'tbum id faciendum, sed post concoctionem^^ will ever remain good. We have in this a particular example of that remarkable laAv, which stands at the threshold of every theory of life, viz., that one function in vigorous or excessive exercise diminishes more or less the power of simultaneous exertion of any other. One must give way, or both will be imperfectly performed. The experience of every man, and of every day, gives proof of the universality of the fact. We may, as before, seek explanation of this, by estimating the common nervous power as a given quantity at each moment of life ; capable therefore only of a certain amount of effect, however directed, and requiring replenishment when exhausted. Or we may look otherwise to the quantity of blood required by every organ for the complete per- formance of its functions; the due distribution of which, according to this demand, is expressly interfered with in the case before us. But whatever the manner of viewino- the subject, it is certain that this is a point of importance to good digestion, and that it ought to enter into every rule of treatment for disorders of the stomach. And the rather so, as the dyspeptic is often by temperament prone to what may be termed intellectual excesses, as well as to earnest and easily excited moral feelings. 218 ON DIET, AND The relation of digestion to sleep is one of the most im- portant in the economy of life. These two functions severally aid or disturb each other, in proportion as they are perfect or imperfect in their course ; and no rules are more important than such as apply to this relation. It must be admitted, however, that all such rules are exceedingly scanty and in- complete, notwithstanding the perpetual experiment which life affords on the subject. It is difficult to extricate clear results from so great a variety of conditions ; and unhappily the current fashions and phrases tend rather to perplex than inform our judgments on the subject. Setting aside the effects of particular articles of diet, which it is needless here to specify, the practical questions chiefly regard the relation of time and quantity of food to sleep ; and these are the fitter objects of study, as some averages are attainable and convertible to use. It is clear, for example, from observation both of man and other animals, that a certain quantity of food in the stomach, concurring especially Avith the habitual time of rest, tends to produce sound and healthy sleep ; — that an excess in quantity brings on such as is broken, uneasy, and oppressed ; — while sleeplessness is usually the effect of the stomach being empty and needing support. To these general facts, without inquiring into their physiological cause, may be referred most of the par- ticular relations between sleep and food, and the precepts founded upon them. The fashions of society infringe largely upon the principles thus established ; and though the powers of habit and accommodation in the system do much to lessen the evils that result, yet it is certain that some methods are greatly preferable to others, and that observation cannot better be employed than in ascertaining these. An important circumstance, in reference to sleep, is the relation between the principal meal of the day and the time DISORDERS OF DIGESTION. 219 of going to rest. This is a question of constant occurrence in practice ; and, without passing into details, it is enough to say that much may be done for the restoration of sleep, where this is at fault, by altering the time of dinner to an earlier hour ; so as not only to admit some bodily exercise in the interval, but also a light supper before going to bed.* The benefit of such change from the ordinary usage is often immediate ; depending partly on the avoidance of the re- cumbent posture, and of efforts to sleep at a period of diges- tion unfit for this state ; and further, and not less, on the direct effect of moderate repletion in disposing to rest. The latter circumstance, again, may depend in part on the me- chanical influence of such repletion ; principally, perhaps, on its furnishing material for the secretions of the stomach to act upon, which otherwise fret with uneasy sensations the nerves of the organ itself. A small quantity of acid formed in digestion, and remaining on the stomach, will often suffice to prevent or disorder sleep, and to disturb the sen- sations of the whole body ; — the proof of this being the degree of relief from a slight dose of some alkali taken at the time. Various other suggestions will occur in practice, founded on the facts just stated ; some of them, though simple, of greater value in the maintenance of health, and treatment of disease, than might be judged likely from their scanty em- ployment. I would mention, as an instance, the aid that may often be got to the relief of restless nights — to the general restoration of the body when weakened by illness, and to the removal of the depression and distress from which many suffer early in the morning, — by a small quantity of light * It is a somewlaat cui-ious contrast to modern habits, that the early dinner, in the time of Augustus, apjiears to have been a mark of Roman luxury and fashion. 220 ON DIET, AND food taken during the night; the time, kind, and quantity of* such food being; varied accordino; to the circumstances of the case. The benefits of this simple practice are too little un- derstood by physicians themselves ; and accordingly it is little in use in this country, though well fitted to supersede many more ambiguous means directed to the same objects.* The reciprocal importance of sound and sufficient sleep to a healthy state of the digestive organs, is familiar to all. This influence is probably in great degree of indirect kind ; in some respects certainly so. There is a circle of relations here, which, even if it were expedient, could scarcely be viewed separately. The connexions are those upon which all right practice is founded, and the knowledge of their causes is that which gives medicine its character as a science. Treating the subject thus cursorily, I may omit all those details as to particular articles of food which are to be found in most works on diet and digestion. The number of such facts has been materially increased of late ; and more cer- tainty and value given to them, both by direct experiment and by their association with organic chemistry. Notwith- standing this, fashion still too largely tampers with the whole subject of dietetics ; and injuriously, as regards the stability of its principles, and their application to practice. Of late years, for example, this fashion has directed itself against vegetable food ; — an erroneous prejudice in many, perhaps in the majority of cases. Allowing, what is partly proved, that vegetable matters are carried indigested to a lower part of the alimentary canal than animal food, and admitting that * This remark will apply to other cases more serious than dyspepsia- The morning perspirations of hectic fever, for example, may often best be relieved by a little wine and water, with a few mouthfuls of light food, taken about the time of their comin^i; on. DISORDERS OF DIGESTION. 221 more flatulence is usually produced from them, it still is the fact that a feeble digestion suffers no less, though it may be in different ways, from an exclusively animal diet. Morbid products are alike evolved ; and some of these affecting not only the alimentary canal, but disturbing other organs and functions through changes produced in the blood. I know the case of a gentleman, having the calculous dia- thesis strongly marked, in whom animal food, taken for three or four days, even in moderate quantity, invariably brino-s on discharge of lithic acid, as sand or gravel ; suspended upon return to vegetable diet. This is a particular instance ; but experience in gouty cases furnishes frequent and striking notices of the same general fact; thus indicating a large class of disorders, having much kindred with dyspepsia, in which excess in animal food rapidly becomes a source of mischief, not merely by overloading the alimentary canal, but by introducing morbid matters into the system at large. A steady abstinence from such excess may be counted amono- the most effectual preventives of gout in all its forms. A common, and, in its effects, often a serious error, is that of regarding animal food as the main source of bodily strength and support, and especially such as is taken in a solid form. Without dwelling on the important and some- what unexpected facts recently disclosed by chemistry, that vegetable matters used for food, do actually contain in dif- ferent forms and proportions, the tliree great constituents of animal food, — albumen, fibrine, and caseine, — it is enough to say that the distinction just noted is not founded on fact.* * It is worthy of note that in wheat flour all these three nitrogenised products of vegetation exist. Their combination with sulphur in definite proportions, in the vegetable as well as animal form, is another of those wonderful relations which organic chemistry has disclosed; promisino- access to still deeper mysteries in the history of organic life. 222 ON DIET, AND The flesh meat upon our tables is itself created out of vege- table substances ; and though we may admit that it contains a larger proportion of nutritive matter to its weight than any other kind of food, yet is this very quality often a hin- drance to easy and perfect digestion. Exuberance of nutri- ment, as of many of the other goods of life, is frequently rather a curse than a boon to the body. The rule of health being obviously that of blending the two kinds of food, I believe the exception more frequently required to be tliat of limiting the animal part in proportion to the other. The fashion of the day sets it down otherwise ; and this is one of the subjects where loose or partial opinions easily get the force of precepts with the world at large. Though it is generally difiicult to persuade a dyspeptic patient to such change, yet have I often attained much good by accomplishing the object, and this even in cases where flatulence, acidity, or diarrhoea were among the symptoms of disorder habitually present and requiring relief. The singular and seemingly wayward appetites which are frequent in illness or during convalescence, and the grati- fication of which is sometimes even a remedy in our hands, give proof how much we have yet to learn as to the various states of the stomach, and their relation to different kijids of food. However difficult to apprehend, it is clear that this organ, together with the parts associated in the function, is often an exponent for the rest of the system of other wants beyond those of mere quantity of aliment. And upon this remarkable instinct in the animal economy (for it is difficult otherwise to express it) depends, doubtless, the preservation of that balance amons; the constituents of the blood which is essential to the healthy state. In all diseases it is probable that this balance is in certain degree altered or impaired ; in some certainly much more than in others. The anomalous DISORDERS OF DIGESTION. 223 appetites of illness or convalesence are often, it may be presumed, natural efforts to restore it. There is enough of authority for this view from observed facts, to justify the physician in keeping constant watch upon such suggestions, however fanciful in kind. Separated by due caution from certain obvious sources of error, they become frequent and valuable aids in the treatment of disease. Another fashion, as it may be termed, among rules for diet, has been that of limiting the more solid part of the food to one or two articles, under the idea that digestion is better performed upon simples than on food variously compounded. In dyspeptic complaints, or with any active disorder present, there is general truth in the maxim. But even here limit- ation of quantity is more important than that of quality; and care is ever needful not to oppose our partial knowledge to the natural appetites just mentioned, when well attested to be really such. In ordinary health the habits of life rarely allow the rule to be persisted in, and the conditional objec- tions to it are on this account of little moment : otherwise it might be urged that extreme simplicity in the kind of food is not required by any proof we have of its effects on health; and is even contradicted to a certain extent by the best ex- periments we possess on the subject. The researches of Dr. Prout, founded on a simple and just principle, have rendered more exact than heretofore our knowledge of the elements of nutritious matter; and in referring them to three separate classes, with different chemical properties of each, have enabled us to understand the fitness of combinations of food, and even of some of the more artificial refinements which luxury has devised. It is obvious that there may be excess from a misproportion of these several elements; but it is equally true in principle, that there may be fault on the side of limitation and simplicity ; and this inference is justified 224 ON DIET, AND by various experiments on animals, attended with very remarkable results.* The various questions regarding wine as a part of diet have always had much interest; and reasonably so, from their importance to the welfare both of individuals and com- munities. Here also much has been written, and many maxims and fashions are current; but without inferences precise enough to afford a rule for those who seriously seek it. It is difficult indeed to obtain this rule, where the results are so far complicated by individual temperament, by the kinds and qualities of wine, and by the various manner of its use. That it is powerful as a medicinal agent is certain : that its habitual use, within fixed limits, is beneficial to some constitutions is equally so. But we have not less assurance that in numerous other cases it is habitually injurious, in re- lation both to the digestive organs and to the functions of the brain. And it may be affirmed generally (as a matter wholly apart from the enormous abuse of spirits among the lower orders) that the use of wine is far too large for any real necessity or utility in the classes which consume it in this country. Modern custom has abridged the excess; but much remains to be done before the habit is brought down to a salutary level ; and medical practice is in general greatly too indulgent on this point to the weakness of those with whom it deals. It has been a maxim anciently, as now, that habitual excess in liquors is less injurious than that of food.f And, with * The most striking of these experiments are derived from M.Magendie, to whom we owe much in this part of physiology. t " Saepe, si qua intemperantia subest, tutior est in potione quam in esca." — Celsus. Many other remarks on this subject might be quoted from the ancient physicians, remarkable for the truth of their application, DISORDERS OF DIGESTION. 225 regard to wine, this may perchance be true. But we are hardly entitled thus to let off one evil by comparison with another, where each is in itself so great; and where they so often concur in fostering one common usage of excess, in- jurious to all the functions of life. As respects quantity, kind, and admixture of wine or other liquors, general rules of ready practical application are the best which can be given. Those which aim at being more precise involve such various conditions, that evasion on the part of the patient is easy, and sure to follow. Here, indeed, it is essential to eno-asre his o;ood faith and understandino- in concurrence with the precept imposed, as the only protection against the facility of indulgence every where at hand. Even under the eye of the physician, appeal must be made more or less to his own observation of effects ; and this observation, therefore, it should be an object of all rules to cultivate and direct with as little ambiguity as possible. Much may be done in this way. As regards quantity of wine, for instance, the tests of what is to be deemed excess lie within the scope of ready remark, provided attention be fairly directed to the repetition of similar effects under cir- cumstances reasonably alike. If the excitement of the spirits exceeds that of simple comfort (a condition not difficult to note), then is it certain that there is a state of brain, the frequent recurrence of which becomes a source of serious mischief both to body and mind. Or if, as happens in other constitutions, heaviness and drowsiness ensue speedily on the wine taken, equally is it certain that the quantity is in excess, and will be injurious in proportion to the frequency of repetition.* Or If a hot dry skin, and increasing thirst, notwithstanding the great diversity both as to the materials and pre- paration of food, and the habits of life most pertaining to digestion. * As regards the two opposite effects here noted, I believe it will be Q 226 ON DIET, AXD the inference is the same, and the result no less assured. Or, again, if the early hours of the morning are languid and oppressed, with headach of one kind or another, foul mouth, and weak or disordered stomach, the, "hesterna vitia" may fairly be called to accovmt, and wine probably as principal among these. The familiarity of such tests makes them more valuable for practical enforcement ; and there are few cases where the patient may not obtain from them, if fairly dealt with, a suf- ficient rule for his guidance. The same tests will apply to kind of wine as to quantity ; but more ambiguously, from the many new conditions brought in, Avhich neither chemical examination, nor common experience, have yet been able to explain. The importance of the question is fortunately much less than in the other case. It is time here, as with regard to solid food, that, if the quantity be duly limited, the kind, though by no means to be disregarded, becomes of much less significance. It may even be doubted whether any practical good has hitherto been gained by our researches into and classification of wines. The comparison of qualities, of the influence of which upon the body we are very slightly in- formed, gives a specious license to the indulgence in certain kinds, often quite as hurtful as the more careless use of which the preference of the moment forms the only rule. We may admit, then, the simple tests just stated as the best that can be had, either for medical precept, or the self- direction of the patient. And, if strictly attended to, they would probably suffice for every purjwse in practice. It may be added further that it is the part of every wise man, once at least in life, to make trial of the effects of leaving off found that the latter is more common where the kidneys act but little under the influence of wine : a result, if correctly stated, which it may not be difhcult to explain. DISORDERS OF DIGESTION. 22^ wine altogether; and this even without the suggestion of actual malady. The point is one of interest enough in the economy of health to call for such experiment; and the results can seldom be so wholly negative as to render it a fruitless one. To obtain them fairly, however, the abandon- ment must be complete for a time : a measure of no risk even where the change is greatest ; and illustrating, moreover, other points of temperament and particular function, which it is important to every man to know, for the right guidance of his habits of life. In the common treatment of dyspeptic disorders in this country, it cannot be denied that injury is inflicted by the use of purgatives to excess. I shall speak of this elsewhere ; but the frequency and ill effects of the abuse warrant every caution on the subject. It may in truth be affirmed that the complaint is often brought on by the prevalence of such treatment in modern practice. The imagination of the dys- peptic solicits the momentary relief thus obtained, at the expense of his future health and comfort. Scarcely a symp- tom of the disorder which is not aggravated by the habit of frequent purging ; either directly from irritation of the ali- mentary canal, and disturbance of the natural course of its functions ; or indirectly, by morbid influence on the mind of the patient, an effect not less noxious than the former. The general course of English practice is doubtless still open to much reform on this point. A point of consequence, also, is the manner of using bitters in the treatment of stomach disorders. Experience leads me to think that this is generally too large and indiscriminate. Even were our knowledge of their relative qualities more exact than it is, and our adaptation of them more just in consequence, we still might often render this action more Q 2 228 ON DIET, AND beneficial in these complaints by lighter preparations than are usually employed. Bark, as having other and specific ob- jects, may be excepted in part from the question. But there are various states of stomach in which the ordinary doses and strength of bitter infusions are injurious ; while obvious good is got from a more moderate employment of the same means. Frequently the best mode of using bitters in these cases is in direct combination with the aperient which may be necessary. Thereby a smaller quantity of the latter is usually rendered effectual ; and the noxious effects of repetition materially abated. The addition of creosote to laxative me- dicines is beneficial in similar way ; and for this, as well as other reasons, it deserves more trial in dyspeptic cases than it has yet obtained. The theory and uses of tonic medicines — exceedingly vague, it must be owned, in every part of practice — are not least so in their relation to disorders of digestion. Of those fitly thus termed, iron, in one or other of its prepara- tions, is, according to my experience, the most generally beneficial. Comparing it with the whole class of bitters, I doubt whether there is any one among the latter capable of being made so variously useful. Regard of course must be had, in employing it, to the cause and particular character of the dyspeptic symptoms. But the circumstances which create apprehension (often most needlessly) as to its use, may be readily obviated by its conjunction with whatever lax- atives are required ; and this, as in the instance of bitters, is often better done by direct combination than by separate em- ployment. The ammoniated iron with an aloetic medicine, — or the sulphate of iron in solution with the sulphate of mag- nesia or soda — will be found among the most beneficial of these forms ; and applicable in numerous cases, without other difficulty than what may arise from the patient himself. For DISORDERS OF DIGESTION. 229 the Imagination of the dyspeptic, as before mentionedj is ever awake to discover sensations and draw inferences ; the latter often as much disordered as the feelings which prompt them. His prejudices, easily excited against any remedies, obtain a sort of countenance, in the case of steel medicines, from the phrases vaguely applied to them by the ignorant; and it often needs discretion and firmness in the practitioner to ensure that persistence in their use which alone can render them of avail. Though not seeing cause for the apprehension as to alkaline medicines which some have entertained, I believe that they are often employed in needless, perhaps injurious, quantity, and indiscreetly as to the time of taking them. As they cannot fitly be termed a remedy for dyspepsia, but a relief merely to one symptom of the disorder, there is reason for closely conjoining their use with that part of digestion which it is the object to alter. Taken together with the food requiring this correction, the effect is generally more bene- ficial than when used after acid has been actually formed. It is a manner of prevention better according with the whole function of digestion, and avoiding that sudden extrication of fixed air, which, if the alkaline carbonates are employed, is sometimes injurious to it. The larger dilution, too, thus given to the remedy, probably aids and equalizes its effect.* * The suspicion that the alkalies, taken medicinally, may produce a morbid state of the blood, and thereby disease in different organs, though it cannot be affirmed impossible, under excess of use, yet is not warranted by any ordinary experience on the subject. The effects of sudden injection of carbonate of soda into the circulation cannot be received as sufficient evidence. At the same time, the singul :r import- ance of this great relation of acid and alkali in every part of the chemistry of animal life, and the unquestionable agencies of alkalies on certain secre- tions, presumably through the blood, fully prove that the habitual use of this remedy is not negative in effect ; and we have probably yet to learn Q 3 230 ox DIET, AND Celsus mentions the " clai-a lectio'" among remedies for dyspeptic complaints ; and this merits more attention than it receives.* As the condition of the abdominal viscera affects the organs of respiration and the voice, so reciprocally does the free exercise of the lungs and diaphragm influence bene- ficially the organs of digestion ; and this effect may even perhaps be stated as one of the causes which make it more salutary to eat with others than alone. The effect is doubtless in part one of mechanical kind. But, since in dyspepsia the arterialisation of the blood by the lungs is generally deficient, it may readily be conceived that certain sustained and equable efforts of the voice are further beneficial in exercising the respiration, and thereby remedying the default. The influence of free air and sufficient respiration is, in fact, a point of singular importance in the treatment of this disorder, even independently of those exercises of the body which arc usually and fitly recommended to dyspeptic pa- tients. Good air is essential to perfect digestion : close and crowded rooms evidently disturb and impair it. The ex- perience of every one may afford proof of this ; yet is it certainly not enough regarded in common practice. f The dyspeptic, distempered in his feelings, languid in muscular power, and with feeble circulation, willingly indulges his some of its effects, only partially sliown when taken to neutralise acid in the upper parts of the alimentary canal. The Litjuor Potasssc, suf- ficiently diluted (a point of some consequence to its successful employ- ment), is perhaps the most beneficial form when a constitutional effect is desired. * Si quis stomaclio laborat, legere clare debet — post lectioneni am- bulare, &c. j A familiar illustration may be drawn from the singular difference of effect in travelling on the outside or inside of a carriage, immediately after a meal. Though the food Ije alike in bolli cases, digestion in tlie first 'M»es on easily and healthily ; — in the second, often with much disturbance and diliicully, increased in proportion as the air is more confined. DISORDERS OP DIGESTION. 231 indolence by making drugs the sole remedy for his ills ; and this preference is too much sanctioned by the ordinary course of medical treatment in such cases. The habits thus generated are the reverse of those which lead to cure. Neglecting or avoiding fresh air, the patient forfeits the safest and most effectual of all remedies; one which goes furthest towards the root of his disorder. For, in dyspepsia, no symptom is better marked than the languid circulation of the blood throuQ-h the extreme vessels. This is especially obvious in the state of the skin and extremities of the body ; and, looked to as a habit, forms one of the most essential characters of the disorder. If we might suppose, what is probable from the corresponding feebleness of the heart's action, that the same condition of faulty circulation extends to the capillaries of internal surfaces and secreting organs, we obtain a general expression of altered state and balance of blood throughout the system, which might well admit of being received as a proximate cause, and as render- ing explanation of many of the multiform symptoms of the complaint. The absence or diminished quantity of blood in the capillary system, tlu-ough which all the more important functions are performed, and its stagnation in the great vessels, and particularly within the venous system throughout the body, illustrate in especial manner some of the more singular anomalies of the disorder. Here the better arterialisation of the blood is a main remedy; and without which none other can be of thorouoh avail. Open air and free respiration are to be sought for ; under some condition of bodily exertion, if possible; but without it, if this be prevented. In another place I have men- tioned the benefits to be obtained from the direct exercise of respiration ; and these are scarcely less obvious and assured in dyspeptic complaints than in others which seem more ex- Q 4 232 ON DIET, AND pressly adapted to them. All that can give air free ingress to the lungs and to the blood, if not a primary remedy, is, at all events, so powerful an accessory to cure, that it behoves the physician to keep it ever before him in his treatment of the disorder. These considerations involve in some part the theory of dyspepsia ; a topic, however, which I refrain from here, as implying a more exact definition and history of the com- plaint than is intended in these general remarks. The or- dinary states, bearing this name, are produced chiefly by circumstances in diet and mode of life acting especially upon the organs of digestion. But that one remarkable form of it, connected with hypochondriasis, and often inducing atrophy, depends on a state of the nervous power, is likely, or per- haps even certain.* What this state actually is, whether of deficiency or depravation, or what part of the nervous system is chiefly concerned in it, our present knowledge does not enable us to afliirm. These are points involving many curious relations in pathology, and upon which we have much still to learn. An example illustrating the connexion between the states of dyspepsia and hypochondriasis, and not less remarkable in itself, is the effect of nursing in certain female habits, or of any great excess of nursing in all. The experience of most practitioners will furnish them with instances where this cause has brought on extreme disorder of the nervous system ; sometimes verging on maniacal state ; more frequently shown in general debility and hypochondriacal depression ; and in the latter case generally connected with obstinate dyspeptic * 111 Uio writings of Ur. Whytt, so fertile tliroiigliout in souiul and ori'^iiial views, will be found some cxccllont rouiarks on atropliy from morbid slate of the nerves of the stomach and alimentary canal. DISOIIDEIIS OF DIGESTION. 233 symptoms. I have known cases where eiFects, manifestly having this origin, have continued in certain degree even for years. The more rapid mischief occurring in some consti- tutions is familiar to all. Nor can we even assert the affection of the nerves to be itself a primary cause in these and other instances. It may be that the first condition is that of an altered state of blood, or in some cases a morbid matter, like that of gout, present in the circulation ; and thence producing its effects, more or less directly, on other parts of the system. And there is some argument for the latter view in the undoubted con- nexion between dyspeptic disorders and the irregular forms of the gouty constitution ; a connexion sufficiently close and familiar to observation to justify the belief of relation to some common cause ; acting under different modifications from age, sex, and other temperament of body; as well as from variations, it may be, in the quality or proportion of the morbid matter itself. Though much here is still specu- , lative, yet we know enough to see that future discovery lies before us in this direction. Recurring to the feeble state of the capillary circulation in dyspepsia, whether this depend on altered state of the nervous power or not, equally is it important to obviate what inflicts evil on every function of life. For this object, exercises on foot and horseback, friction, and bathing in different forms, together with change of air or scene, may rightly find place before most of the internal remedies which are usual in such cases. And our treatment of the disorder would be one of greater success, were these points more steadily insisted upon, and less concession made to the morbid preference for medi- cines ; arising partly from the natural indolence of the com- plaint, partly from the fashions ever prevailing in respect to it. Tills is one of the instances where the general course of 234 ON DIET, AND practice might be greatly altered and amended. Much is got, if the dyspeptic can be rescued from means, for the most part of doubtful or injurious effect ; — still more is gained if he can be led into habits Avhich invigorate the circulation with safety to every part, and may be modified under more certain rule than any remedies of internal use.* Here, un- happily, as in so many other cases, the simplicity of the means forms a hinderance to their sufficient application. What is obvious to the understanding or senses can rarely be brought into successful competition with what is vague or secret in the treatment of disease. The recommendation of travel to dyspeptic patients is familiar and reasonable. Some caution, however, is needed as to details; nor ought these to be considered below the * The ancients, as is well known, employed friction under a more general conception of its use than we do ; not merely as a remedy for feebleness or swelling of limbs, but as altering the condition of the whole body. And, without adopting all they have affirmed on this subject, it is certain that its employment, even in our climate, might be beneficially extended in a variety of cases ; in none more than those of enfeebled or disordered digestion. So applied, it affords another example of the many important relations subsisting between the external and internal surfaces of the body. Of the use of anointing, as practised by the ancients, we know from experience much less. Some explanation of its employment in hot cli- mates may be found in the protection it gives against the direct effects of solar heat on the skin. There is reason, as well as scope, for making larger trial of it as a curative means, even in disoi-dei's of the alimentary canal. The harsh dry skin of the dyspeptic patient might be improved in its texture and functions by rubbing with warm oils, &c., where wholly unaffected by internal rcme^'" '"" KaOapwg cnrav Spfv, kui rotcri f!Ti0vfii7j(n tTrstrOai tov larpov fir] fiiyaXa (SXavTOVTa ' apiarov yap rode, i}v firi Kaprn loipiXovvTwv opi^ig yictj. And we have an earlier and still more special maxim to the same effect in one of the aphorisms of Hippocrates, fo GjiiKpii) x^^pov Kai TTofia Kai (JiTioV y)diov Se, tmv fitXriovwv jUf j', arjSiffTipojv Of, jxaWov ulptreov. MAY JUDGE FOR HIMSELF. 381 The most important exception to this rule is in certain nervous and dyspeptic disorders of chronic kind, where it is needful to urge bodily exertion upon the patient; in con- tradiction to his own sensations, and sometimes even where the first trials are seemingly unsuccessful. With moderate care in observation, the tests of fitness here are so simple, that there can be little chance of any error leading to in- jurious consequences. As respects mental exertion during illness or convalescence, much more caution is needful. Here the patient is usually less able to estimate his own power, and is more entirely at the discretion of those around him. The present condition of life among the higher classes produces as much of evil from excesses of moral and intellectual excitement, as from those of the stomach : and it is equally difficult to place watch and reasonable restraint upon them. In these instances, and they are of constant occurrence, the judgment of the physician, as well as firmness in his manner of interference, are urgently required. But in ordinary cases, and under more tranquil methods of life, he may leave much to the discretion and feeling of power in the patient himself; with simple injunction that this feeling should be duly consulted before any change is made. Fourtldy. — The prudent physician, without sacrificing his science or authority, may often draw knowledge from his patient as to the fitness of particular medicines, or the fitness of employing medicines at all. Frequently it happens that the latter, at some period or other of his disorder (usually when convalescence has begun), expresses strongly his feelino- that medicine will do no further good, and that his future progress is best left to nature alone. Provided it be clearly seen that this does not arise from any whim or perverseness of mind (and the feeling may exist wholly without such), tlie 382 ON POINTS WHERE A PATIENT, ETC. medical man is bound to give attention to it, as suggestive at least of his further treatment. And if continued and re- peated, at a time when the urgent symptoms of disorder are past, it may for the most part be rightly acquiesced in ; — certainly so far as to make trial of the effects of the change ; which, being of negative kind, can rarely produce much evil, even if it tail of good. Convalescence is a wholesome process of nature, not wantonly to be interfered with by any less certain resources of art. Looking fairly, indeed, at the common course of practice in this country, I believe much more mischief to be done by needless protraction of the use of medicines, than by the pre- mature abandonment of them ; — a point if true, requiring at- tention to all such means as may best contribute to its reform, seeing the various injury thus inflicted upon all the objects and higher interests of medicine. The case just stated is one of those where the practitioner may often effect this, in the way most conducive to the welfare of his patient ; and it is his duty not to disregard the suggestions so obtained. There are other instances, as mentioned above, where the persevering distaste to a particular medicine, or method of treatment, will not only sanction, but call for its disuse ; though the authority of all ordinary experience be in its favour. On points of this kind a discreet forbearance is as needful to the physician as firmness. And the best ride is, not to be implicitly subservient to rule : — a maxim essential in all cases to the right practice of medicine, seeing the many contingencies which are ever arising in contradiction to its soundest methods and precepts. 383 CHAP. XVI. ON METHODS OF rRESCRIPTION. The simplification of medicine, and of methods as well as principles in the treatment of disease, ought ever to be pre- sent to the mind of the physician. The more complex the objects before him, the stronger the motive for adopting and maintaining this rule. Even with all the curtailments and sounder views of modern practice, it must be admitted that more might yet be done in furtherance of the object. We have long abandoned those preposterous compounds, of which the number of ingredients, or the secret methods of admix- ture, formed the sole science : but the error is still frequent of aiming at a greater number of objects than can be reached at once, or by any single combination of remedies ; thereby forfeiting the good to be derived from simpler and more ex- plicit means. Secondary and subordinate symptoms are apt to usurp a place in prescriptions, due to such only as are essential to the character and course of the malady. And it is not too much to affirm that the judgment of the medical man upon a disorder is often warped by the reflection of his own practice. He is apt to look at the symptoms through his own previous treatment of them, as well as through the false opinions of those around ; and the trifling or casual symptom of one day gains undue weight the next, from its needless admission among the objects for which he has prescribed. All this is natural in itself; but undoubtedly a serious error in practice. In no way can it better be obviated than by carefully simplifying the character of prescriptions; and 384 ON METHODS OF PRESCRIPTION. avoiding ambiguity, as far as possible, in tlie intention we assign to their several parts. It is an opinion, not infrequent among medical men, that the multiplication of medicines in our hands adds in the same ratio to the power and facilities of practice. This view is admissible only in a very qualified sense. It is, in truth, as cor- rect to say, that the addition of new medicines or preparations, which do not expressly accomplish new purposes, or fulfil more advantageously those already attained, becomes an incumbrance to the practitioner, and an impediment to the progress of the science. It may be alleged, and must be fully admitted, that combi- nations have often effects not resulting equally from any of their ingredients. This is true as respects many vegetable medicines of powerful action, whether narcotic, purgative, diuretic, or alterative. It is especially true as regards chemical medicines, where changes of combination may occasionally be calculated upon, favouring the effects desired ; though much more frequently the facts by which their use is determined are merely empirical in kind. The obser- vation of these facts is obviously one of the most important objects to the practitioner. But it must be added, one of the most difficult also ; for even in the simpler com- binations we can rarely obtain that precise estimate of effects, which is so essential to the success and certainty of practice ; — still less can we do so in those of complicated kind. Each new ingredient added to a medicine raises to a higher ratio the chances of error, and obscures the evidence by which such error may be detected and removed. And the application of other science to this subject (though never to be lost sight of) is here made so uncertain by being subjected to vital actions, that it must ever be admitted with great caution, and wholly in subordination to experience. Several ON METHODS OF PRESCEIPTIOX. 385 compound medicines, of undoubted efficacy, contradict che- mical laws even in the points where it might seem of greatest moment to maintain them. The best general rule seems to be, to define to ourselves in every case, as distinctly as possible, the main object of present treatment — to make this the basis of prescription — and to admit, subordinately and under limitation only, all such means as apply to collateral symptoms. This rule ought especially to be kept in mind, when a new medicine, or new applications of an old one, are on trial in our hands. Complexity here, especially that which arises from the ad- mixture of new agents in the same prescription, disguises those results which it imports us most to know, and which are always learnt with difficulty amid the many conditions tending to obscure the effect. I have often seen prescrip- tions in which three or four powerful agents, still new to our experience, were put down for simultaneous use, in such manner that no interpretation could possibly be obtained of their respective influence on the disease. In adding to other difficulties the uncertainty of combination, which is itself in most cases an experiment, we wrap one doubt within another, and play false with every just principle of medical research. Though it may seem inconsistent with the timidity of early practice, yet do we find error as to these several points most frequent among those still young in their profession. Some run after new medicines from the genuine desire of discovering new facts ; — others from the more meao-re motive of not appearing behind the knowledge or fashion of the day. The young physician, moreover, is often led to a needless or injurious complexity of prescription, in his eagerness to meet each single symptom by some specific antidote ; without due regard to those general characters of disease upon which all c c 386 ON METHODS OF PRESCRIPTIOIsr. particular symptoms depend. The nimia diligentia is some- times in this case more hurtful than positive neglect. Some of these recommendations may seem trite or trivial ; yet are they justified by the rarity of a principle of prescrip- tion, consistent with itself, and giving due proportion to the objects in view. The fitness of a man's understanding for medical practice can in no way be better estimated than by looking to these points. The physician who allows his attention to be distracted by secondary symptoms, and hampers a powerful medicine with petty appendages, di- rected to subordinate objects, shows a quality of mind adverse to sound practice, and incapable of attaining any valuable truth. Not in the technical part of prescription alone, but also in the examination of symptoms on Avhich it is founded, much may be gained by a rule of inquiry. Vague and inconsecutive questions, whether from timidity in the young practitioner, in- difference in the older one, or irregular habits of thought in either, are very generally useless, and often positively hurtful. They defraud the physician of his own judgment, and put the mind of the patient into the state least apt to give right in- formation. In the adoption of particular methods to obviate this, every one having discretion should exercise his own choice. A man of sound understanding, and who holds good faith with himself, may discover (and it is fit ha should seek to do so) in what points his faculties are oftenest at fault ; and this ascertained, he is in case to determine how the cor- rection may best be made. Rightly used, and not allowed to become too technical, a certain rule pursued in questioning the sick will strengthen, by disciplining, the powers of observation. Nor is there much danger lest this should cramp that higher and rarer quality (derived either from long experience, or from quick ON METHODS OF PKESCRIPTION. 387 natural perception) which enables some men — the dbnormes sapientes — to comprehend at the first glance, to seize by a sort of intuition, aU that is most needful to be noted in the diseases before them. These instances are not so frequent as to form a rule ; nor can the faculty, though an eminent one in itself, ever entirely preclude the necessity of further re- search. The persons thus gifted, moreover, cannot really be fettered by methods ; and will use them only so far as they are actually conducive to good. It is a frequent error in young practitioners to allow them- seves to be betrayed into hasty diagnosis or prognosis of dis- ease, either by their own nervousness, or by the importunity of the patient and those around him. The fault is serious ; — not merely as a source of embarrassment, but often by impairing integrity in practice, from the desire to redeem a wrong opinion thus given. It concerns greatly the reputation and usefulness of the profession, that every caution should be ex- ercised on this point. Forbearance in words, till the judg- ment is weU decided, is therefore in some sort a duty, as well as an act of prudence. And it further behoves the physician to acquire as much mastery and readiness as possible in the observation of those symptoms which distinguish a disease or foretell its probable event ; — another phrase, it may be, for medical experience ; yet with the advantage of being more explicit as to a very important part of practice, of which I have had occasion to speak at greater length In a preceding chapter. If mistakes in judgment be still made (and this wlU occur to every one), though their avowal is not always needful or desirable, yet I believe the character of the pro- fession, as well as of the practitioner, to be best sustained by truth ; — spoken as a man of sense and integrity will speak it. This is a point of medical morality to be Im- c c 2 388 ON METHODS OF PRESCRIPTION. pressed upon all who are still young in their professional career. Not only In the examination of symptoms, but also in describing them, it were much to be wished that something like a determinate method could be devised, admitting of being carried into general use. Such method, if attained, would render practice itself more exact, and the record of cases more intelligible and useful to others ; besides facilitating greatly the study of those general relations of disease and remedial means, upon which the progress of medicine, as a science, mainly depends. In the treatment of disease, it is a convenient rule to look first to the external remedies befitting each case, before deter- mining those for internal use. This also may seem a trifling suggestion. Yet such technical arrangement, if involving no practical error, is generally useful, and especially to the young practitioner; who is often painfully harassed, not only by the responsibility of instant judgment, but by the number of objects and methods present to him for consideration. Nor is it the technical aid alone which is of value here. It is well that every practitioner should keep in mind the expediency of attaining all that is possible by external remedies ; — a discreet preference, strongly sanctioned by modern research, and in no wise incompatible with the bold and sufficient use of internal means when called for by the more urgent neces- sities of practice. Such suggestion is the more needful, as remedies directed to the skin are those most apt to be neglected altogether, or carelessly and inadequately em- ployed. The draught and pill are taken with strict regard to time and order. The outward application is forgotten, or hurried over as a troublesome appendage to other treatment. As in argument some men's minds are indisposed to be con- tent with common reasons, however cogent, so here the ON METHODS OF PKESCRIPTION. 389 obvious and simple nature of the remedy becomes a hin- drance to its fair and sufficient adoption. The physician who leaves the bed-room of his patient, especially in cases of fever or acute disorder, without attend- ing to more than the prescription of medicine and diet, has very imperfectly fulfilled his office. He is bound further to look to temperature and ventilation ; the fit state of the patient's bed; his posture; the needful changes of clothing; the proper use of water for cleanliness or coolness ; and the maintenance of quiet. These things, contributing alike to the comfort of the patient and to the chances of recovery from disease, are often, it must be admitted, passed over, or too hastily dealt with, in the hurry of practice; — an omis- sion the more important, as many of them are expressly the subjects of popular prejudice and mischievous error. The patient himself being often wholly unable to explain what is needful to his situation, the physician is bound to act for him in regulating the whole economy of the sick room. A simple change of position, of bed-clothes, of the air of the chamber, will often do more towards the relief of suffering, than a page covered with the best medical Latinity. The ability and good faith of the practitioner are, in fact, equally put to test in these less ostentatious parts of his science, as in those to which common opinion assigns a higher value. And it is a further reason for the use of certain regulated methods in these details, that nothing may be omitted, where so much is to be considered and done ; and this under circumstances the least favourable to col- lectedness of thought, or exactness and sufficiency of direction. There is yet another point connected with this subject which I cannot forbear noticing, however slightly. This is, the influence of the countenance, the manner, and language c c 3 390 ON METHODS OF PRESCKIPTION. of the physician on the feelings, and, through them, on the bodily welfare of the patient. It needs no learned reasoning on the mutual influence of mind and body, to enforce this precept. The experience of every man, and of every day of life, denotes its truth ; and medical experience more es- pecially has the fact ever before it. A few simple and soothing words of comfort and hope, when they can justifi- ably be spoken to the patient, not merely dispel the gloom of a sick bed, but in many cases effect a positive good which no medicine could equally procure. Here then is a practical duty of the physician ; — difficult of exercise, it may be, where dangerous disease is present ; yet ever to be kept in mind as one of those happier remedial means which are committed to him for the welfare of others ; and not without a reflected good upon his own character and feelings.* * With his wonted good sense and sound experience, Celsus inculcates these duties of the physician in a sick room ; " assidere hilari vultu :" . . " prohabili sermone lenire,'" &c. The medical scholar will not fail to re- collect the various precejits which have reached us under the name of Hippocrates, as to the methods fitting to be observed in communication with patients ; together with his admirable maxims touching the moral demeanour of the ijhysician in his professional life. If It should seem that the remarks in this chapter are either too fa- miliar, or made too much ex cathedra, I must plead my conviction from experience of their importance ; and my hope that they may be useful to some who need guidance as to such details, in the earlier and more dif- ficult stages of practice. 391 CHAP. XVII. ON INTEENAL H^MOKRHAGES AND MORBID SECRETIONS AS THE SUBJECTS OF MEDICAL TREATMENT. In several other places I have had occasion to allude, directly or indirectly, to this topic ; one of the most important in medical practice, and liable to much difference of opinion upon points where wrong views may do, and have done, very great mischief. If it seem objectionable to comprise so much under one title, the answer must be found in the expediency of reaching some common principle in this part of the treatment of disease ; — a principle necessarily, indeed, very vague in many of its applications ; yet less so than the practice usually pursued, and ever pointing towards a better rule in cases which are peculiarly the subject of rash and fluctuating judgment. The practical question which stands foremost in each one of these cases is, — whether any given secretion or excre- tion, morbid either from excess of quantity or alteration of quality, is to be suppressed or otherwise altered by medical means, if this be attainable? — or whether such morbid appear- ance is to be received as producing or expressing some change in progress, salutary to the body, and therefore not to be checked or interfered with ? There may be other modes of stating the inquiry ; but practically they all come to the same point. And every physician will recognise in his ex- perience the numerous cases in which this question supersedes all others, and cannot be evaded without endangering the results of his treatment. c c 4 392 ON INTERNAL HAEMORRHAGES It is In truth a branch of that more general question as to a vis medicatrix naturcB, which has exercised the thought and speculation of physicians from the earliest time, and yet remains to us a perpetual problem in practice.* The phrase may be too general for the foundation of a system ; yet is it justified as involving an important reality, which, if kept constantly present before us, will be found to illustrate pathology more extensively than any other; and to contribute more largely and effectually to the success of medical treat- ment. The distinction between diseased and curative actions is at the root of all rational practice ; and no medical man can expediently or even safely disregard it. In discussing that part of the subject which the title of this chapter includes, I shall notice those instances especially which are either of greatest practical moment, or best illus- trate the principle conveyed in the phrase just stated. The subject of Hasmorrhages, as viewed under this light, is that which has perhaps received least attention, in propor- tion to its practical importance, though from various causes most exposed to the chances of error. Hajmorrhages from vessels accidentally wounded, or intentionally opened, may be excluded from the inquiry. But all such as occur within the body from structural changes; from irregularities in the flow and distribution of blood ; or from alterations in its quantity or quality, come fairly within the scope of the question. No practice can be sound or salutary which does not keep this question in view. Is hiemorrhage from the vessels of the lungs, or from those of the stomach, intestines, or kidneys, to be directly repressed by any such means as we possess? Or are we to give a certain scope and licence * The expressions of Hippocrates (Epidem. VI. 5. 1.), Hovatjjv (i,vanQ larpoi' avivpioKti i) (j>vuiq avTi] iavry rag fjiodovc, have given text to argu- ment and diversity of opinion from his time downwards to our own. AND MORBID SECRETIONS. 393 to what is for the most part but an effect of some morbid cause in operation, and often capable in itself of obviating the evil which produces it ? Hemoptysis may furnish the first instance in illustration. We have here blood coming from some part of the lungs — an alarming evidence, in most cases, of a state of structure verging on disease, and that of dangerous kind. The symp- tom justifies the fear with which it is regarded ; but not the interpretation that the haemoptysis is an integral part of the disease ; or urgently to be restrained, because we desire to obviate the morbid condition producing it. It is seldom that such quantity of blood is lost in this way as to be in itself any just cause of alarm. As much is often taken away by bleeding, under the profession of checking this internal haemorrhage — a treatment very doubtful in principle, and, according to my experience, little to be relied on in effect. The action of the heart may be so far subdued that the in- ternal bleeding ceases ; but the blood is lost in another way ; the disease which produces the symptom remains unchanged ; and the power of resistance to its future progress is often in- juriously lessened by the supposed remedy. But, further, is it certain that, in hastily checking Hsemo- ptysis, we are not repressing what is really a remedial dis- charge ? Is not this internal bleeding, Avhen moderate in degree, often the best means of relieving that local inflam- matory state, which either results from disease already in progress, or is concerned in producing it ? The capillaries unduly loaded, in parts and textures to which we have no direct access, suffice thus for their own relief; the effect abating when this pressure upon them is lessened or removed. Or if the expression of remedial be too strong for this case, may we not still fairly ask from experience what are the evils arising from haemorrhage within the lungs, except 394 ON INTERNAL HEMORRHAGES where much disease with debility already exists, or the bleed- ing comes from a vessel of such size that no means can be found to control it? In other cases, even those of incipient tubercular disease, alarm is much less justified by the loss of blood, than by the prospect of the fatal disease of which it is the precursor and omen. Haemorrhage from the alimentary canal, — whether Hsema- temesis, or the discharge of blood from the bowels — affords instances upon which we may still more securely rely. Some of these cases are clearly vicarious, having relation to the menstrual discharge in women ; and thus far carry with them the proof that they are not insalutary in kind. But the same conclusion may be drawn as to many cases, not thus clearly designated, from the effects of the hosmorrhage, either immediate or indirect ; — these results being often so clear as to allow no other interpretation. Every practitioner must have been struck with the fact, in certain cases of blood vomited from the stomach without obvious cause ; — often exceedingly profuse in quantity, and in quality such as to show that the venous system of the abdominal viscera has largely emptied itself through this channel. It cannot be denied that there is mischief from haemorrhage in some of these cases ; as the exhaustion is occasionally great, and needs care and time to repair it. But if it occurs by simple exuda- tion, and without any diseased texture concerned as the cause, it is rarely, if ever, fatal in event ; — not^ often hurtful, except from debility ; — and generally, it may be added, suflficient for its own relief, in the very depletion of vessels thus pro- duced. And what is more to our purpose, it may be affirmed that such hemorrhage does in numerous cases relieve the system from causes of actual or contingent disorder, which no medical treatment is capable of removing with equal security, speed, and completeness. Where we cannot show the AND MORBID SECRETIONS. 395 discharge to be a vicarious one, we still obtain proof of the results just stated, from comparison of the state which follows the haemorrhage with that preceding it. It is highly probable, in some of these cases of relief to the system, that the qualify of the blood, thus drained from the vessels, is concerned, as well as its mere quantity, in producing the haemorrhage; and that the benefit depends chiefly on this circumstance. Without entering into the questions, still not settled, what different states the blood may assume in different parts of the venous system, and particularly in the great venous trunks associated with the portal circulation, we have proof enough to be assured that these conditions are very various ; — that the blood undergoes great changes in quality in these vessels, some of them noxious in kind, altering the glandular secretions, and sometimes forcing on haemorrhage as a result. It may not be easy, and is often impossible, to decide as to these points in particular cases ; but in every such case there is reason enough to enforce the question, whether we are to aim at checking the haemorrhage by direct and cogent means, or to seek only to moderate excess in its degree, by withdrawing all that may directly excite or protract it ? A sound practice will, I believe, sanction the latter treat- ment in the majority of instances. If care be given not to exasperate the haemorrhage by any excitement of the vascular system ; — if quiet, abstinence, cool drinks, and counter- irritation to the abdomen, be duly employed ; — the true indi- cations of treatment are generally better fulfilled than by venesection, metallic salts, mineral acids, astringent medi- cines, and the other means with which an officious practice hurries to the relief of these cases. I do not affirm that this negative treatment is to be applied in all instances, or in all stages of such haemorrhage ; but in principle it is assuredly 396 ON INTERNAL H^MOEEHAGES that which is safest and best ; and the exceptions may usually be suggested and provided for by the discretion of the physi- cian at the time. Haemorrhage from the bowels (excluding that incidental to Hsematemesis) may probably proceed from any part of the canal ; but occurs more especially in the colon and rectimi, in connexion with haemorrhoidal swellings, enlarged veins, or other causes of local irritation in the bowel. The bleeding, which forms so frequent a symptom of piles, is important to the general view before us, as singularly testifying in many cases its connexion with the state of other parts ; and through the portal circulation especially, with some of the greater organs and functions of the body. The very obvious relief, in effect of. natural bleeding from the hemorrhoidal vessels, to disordered states of the head, of the heart, of the liver, &c. ; and the occurrence or return of such disorders, when an habitual discharge of this kind is suddenly suppressed, are facts familiar in the practice of all. The tendency in many instances to a periodical return of these hasmorrhages is a point of equal importance ; giving further cause for referring them either to general conditions of the blood throughout the body, or to changes of its quantity or quality in this part especially of the circulation. Here, then (admitting the exception for cases of local vascular irritation), we have a natural haemorrhage remedial in its nature ; and often, by patients themselves, as well recognised in this light, as is the simple bleeding of the nose in relieving congestion or other uneasiness about the head. These instances may be taken as illustrating others less obvious in character; such as the hjemorrhages proceeding from higher parts of the intestines, either under the form of pure blood, or of those dark grumous secretions (meljena) which are to be regarded as exudations, through the lining AND MOEBID SECRETIONS. 397 membranes, of fluids more or less approaching to blood in their nature. These discharges, as is well known, are often to enormous extent ; producing anasmia, and followed some- times by dropsical effusions. They represent in some cases ulceration, or other grave organic disease of the viscera, and particularly of the liver and spleen. In many instances, however, they occur without any evidence of diseased structure ; cease without leaving behind any injurious con- sequence ; and even appear to relieve the system from some prior oppression or disturbance. Such is the case in certain continued fevers, where, at a particular stage, discharges of blood from the bowels form a crisis to the malady ; probably by relieving some vascular congestion incident to the fever, if not, indeed, concerned in producing it. Here, then, we approach to the conditions already stated regarding other forms of haemorrhage. But, even under the more serious contingency of organic disease the wisest course of practice is not always that of greatest activity. Suppres- sion of the discharge does not remove its cause ; and we possess, in truth, few means of certain avail even to control the effect. The treatment by astringents and sedatives, generally employed, is in great part theoretical; and though the employment of these means may be admissible in many cases, he must be bold who would assert their certain efficacy, or even affirm that they are never injurious under this manner of use. There is more difficulty in applying these considerations to Hematuria, from the various parts and textures, and the very different causes (mechanical irritation amongst others) concerned in this form of haemorrhage. I will only remark that here also there are cases where it seems to be a simjile extravasation of blood from the kidneys, without the irritation of renal calculi or other local affection ; — occasionally even of 398 ON INTEENAL HEMORRHAGES periodical kind, and unattended with any obvious injury to the system. "What is needful then in Htematuria, is a just discrimination as to the particular organs and causes con- cerned. If it be probable that the case is of the nature just adverted to, and the bleeding not excessive, it is better to make the treatment one of forbearance and watchfulness, than to press hastily upon the symptoms by medicines pre- sumed to act as astringents or internal styptics ; but which for the most part must be admitted as of very doubtful effect. Such caution in the outset may be maintained even when there is cause to suspect renal disease ; the extravasation of blood in this way, from within the organ itself, sometimes o-ivine; an amount of relief which can in no other mode be so effectually obtained. If these remarks upon the treatment of internal hsemor- rhages seem too much opposed to our accustomed notions and practice, I must repeat that their object is to inculcate a more earful discrimination as to the cases which come before us under this form. In what I believe to be a large majority of instances, we are bound to regard such haemorrhage not as a disease in itself, but as the exponent of morbid conditions either of the blood or of the vascular structure, which may in some cases be aggravated by the loss of blood, but in others may be, and often are, decidedly relieved by it. The nature and importance of this distinction will be at once obvious ; and to none more so than those who have had large practical experience, and based their conclusions upon it. Having laid down in the foregoing instances the principle I wish to enforce, it will not be necessary to dwell at length on those other examples where, though the morbid actions are of very different character, they may still be submitted to the same considerations in practice. Diarrhoea in its AND MORBID SECRETIONS. 399 various forms, — disordered states of the urinary secretions, — excessive or faulty discharges from the mucous membranes and glands, — all involve similar questions, which the physi- cian is bound to keep sedulously before him ; the more so because natural prejudices and feelings, and the phrases current in the world, tend greatly to embarrass his judg- ment in cases of this kind. To maintain firmness of thought and action in the face of popular opinion — " cogitationem a consuetudine abducere " — is difl&cult, more or less, to every man ; but especially to the young practitioner, who is either too timid to resist the importunities pressing upon him, or too impatient and anxious himself to exercise that forbear- ance, which is frequently more essential than vigour. Even in the common course of medical instruction, deviations from the natural or average state of any function are too gene- rally inscribed with the name of disease, and their treatment taught under this view. It may be true, in the greater number of instances, that no such deviation can occur with- out a morbid cause being somewhere present. But this cause is often remote from the obvious and apparent symptoms, as in the many instances where morbid states of the blood are represented by the altered functions of different organs, — such alterations being not unfrequently curative in kind, even though they may create disorder and distress in their progress. The case of diarrhoea need the less be dwelt upon, as the most ordinary experience of every medical man supplies proofs of the various causes producing it, and the very dif- ferent or opposite treatment required for its relief. Take simply the two cases of excess of bile, or of its deficiency from obstruction of the gall-ducts, — each testified by diarrhoea, but so different in character and cause, that no common treatment can be expedient or salutary for both. 400 ON INTERNAL HiEMORRHAGES The mercurial which ordinarily acts as a purgative, becomes, by restoring bile to the bowels, the true remedy for the large and frequent clayey motions which indicate its defi- ciency. Or, take again the frequent case of diarrhoea pro- duced by undigested or irritating matters lodged in the intestines, where the purgative which dislodges them is the sole or most speedy remedy for the complaint. Without enlarging, then, on this familiar topic, it is enough to note, in reference to our subject, that there are instances of con- stant occurrence in practice, where diarrhoea, if unattended with pain or other distress, may best be allowed to take its course, without the interference of remedies to restrain it ; and where, in fact, the use of astringents, or other such remedies, not merely prolongs the disorder of which it is the symptom, but often produces more specific and serious mischief. The interest of pathological inquiry into all that concerns the kidneys, has been much increased of late by what we have further learnt of the functions of this great excretory organ. One among many important lessons derived from these inquiries, respects the manner of viewing the dif- ferent matters extricated from the system in the urine ; and giving, by their presence in it, the extraordinary physical and chemical characters which belong to this fluid. Looking at these numerous urinary products in relation to the subject before us, they may be broadly classed into such as seldom, or never, occur in healthy urine ; and those which are natu- rally present in healthy urine, but sometimes show themselves in morbid excess. The latter case is that to which our argu- ment chiefly applies. The excess here denotes for the most part a like excess of the same matters, or others out of which they are formed, in the circulation ; and the kidneys, AND MORBID EXCRETIONS. 401 in every such case, are acting a salutary part iji eliminating these supei-fluous elements from the blood — noxious if re- tained in it. The practical question in each case is — are we, upon these indications in the urine, to seek correction through the system to the morbid products thus evolved there ? or may we better await the effect of those natural discharges, which are themselves, through the kidneys, emptying the system of what is superfluous or noxious? This practical question fairly placed before his mind, the good sense and experience of the physician may best guide him in each particular case. I must remark here, that this consideration applies not only to those more acute cases, such as gout and rheumatic fever, where large deposits of morbid matters, through the urine, often form what may be termed the crisis of the disorder, but also to the chronic or habitual state of certain constitutions, where these excretions occur to such amount as might well be deemed disease, were it not that we have In their habitual discharge, the evidence of nature relieving itself. If in these instances the general well-being of the body is maintained, medicine and medical means may safely be pvit aside; — reserving them for those other and more needful occasions where the constitution is obviously disturbed in some of its functions, either by a suppression of these evacuations, or by an excess which the natural action of the kidneys is unable to remove. I would again state, that this reasoning applies chiefly to cases of excess In the ordinary ingredients of urine; and does not extend to those more serious cases where large albuminous or saccharine excretions through this channel testify disease in the chylopoetic organs, or a depraved state of the blood. I will not add to the length of this chapter further than D D 402 ON INTERNAL HEMORRHAGES, ETC. by slightly noticing another illustration of its subject, in the case of those secretions and discharges from the mucous glands, which, under various names — bronchitis, catarrh, catarrhus senilis, &c., — do often assume a chronic form, and become habitual, more or less, to the constitution. The sreneral argument here is the same as that which I have applied in the preceding instances. Provided there be no painful symptom present, or any obvious injury of health, we are not called upon to suppress such secretions, large though they may be ; or to carry the objects of direct treat- ment further than to check occasional excess, to facilitate expectoration, and to obtain rest at night if this be infringed upon. To aim at more by internal remedies is often to forfeit a greater good than any that can be attained. The physician who brings experience as well as discrimi- nation to his practice, will, I think, recognise, and acquiesce in, the distinctions I have been seeking to maintain through- out this chapter. But they are less familiar to those young in the profession ; and require to be dwelt upon the rather, because opposed in many respects to the common opinions or prejudices which are encountered in practice. 403 CHAP. XVIII. ON SOME SUPPOSED DISEASES OF THE SPINE. It has happened to me in practice to see a great number of these singular affections ; in which certain morbid states of the nervous system, or occasionally visceral disorders, assume every character of spinal complaints, and are medically treated as such. A large proportion of these cases occur among females; and though the complaint is now better understood than formerly, yet I doubt not the instances are more frequent than is imagined. The simulation of serious disease of this nature, independently altogether of the will, is often so remarkable, that we may fairly presume many such fictitious disorders to remain imdiscovered to the last. A common foundation of error in these instances is the existence of pain, sometimes fixed, sometimes fluctuating, along the course of the spine — this pain, according to the assertions and actual feelings of the patient, very distinctly augmented by pressure ; and often relieved by local bleeding, blistering, moxa, and other similar applications. Tliere is frequently, moreover, weakness or numbness of the lower extremities, sometimes such in amount as to be construed into paralytic affection; — pain from exertion, relief from recumbency; — tendency to muscular spasms; — and often difficulty in emptying the bladder. Yet all these, and other symptoms, may arise from nervous or hysterical state of the constitution without any true local affection; and in many D D 2 '1 01 ON BOME HUPPOSED v.tiHC/.i i\K'.y ;uv; l)(;i-:l, r<;li(;v';d by remedies which have no rcla- (lon wliii-tever l,o flu; HpiiKJ. 1 1, in,, ill friilli, one of llie ill cih-cli- <>i' tlie miBunderstanding oC llic comphiinl, liiat its KyMiploins an; often greatly aggra- vaLefJ |>y llie ineaiiH d(!Higned Cor their relief"; and spinal diHOnhirw cv<;n |»rodue(!d, when not existing before, by the nmHeular (l«l)ili(y due to long eonfinernent, recumbent pos- ture, and local d(!pletionH. I liavc Been cases, well worthy of notice, where ]i!il,i(!iitH having no nervousness or infirmity of mind, but siiirciing from tojiical nervous pains in some part of llic Hpiiic (tii(! rcHiilt often of sympathy with internal orgaiiHj, Ikivc been reduced by vjirious treatment of this kind lo a Htalx! of almost total inability ol' the lower extremities. 'I'he proof of tlie real cause is that alTorded by their recovery, in very few weeks, from Hym|)toms which have had duration for uioiillis (»i- yciirs; iind ibis recovery derived, not from recuiiibeul posture, or iVom remedies ;i|)plied locally to the Hpin(**, but lidiii steel, bark, niumoniii, and valerian, cold salt- water biitliiiig or wasliing, nnd exercise of tlie limbs sedulously persevered in :iud exleiided. In those otiier instances, of very IVee adci plat civ I'ul tilled or not , sliould ne\ er be lost sight press that due notice ol them, which may exempt the vouni;' physician iVom the i-liauci' ol' error; and cipially pi'o- U'ct llu> patiiMil tVoiu the mistakes o[' iiicre igniu-anee, and iVom tlu> mallrealmcnt i>l' (piackery ami fraiul. It is unhappily true, and a fact tiimillar lo every }ihysiclan, DISEASES OF THE SPINE. 405 that this class of disorders has been peculiarly the suljject of such malpractices. The reason is obvious ; — the result one much to be deprecated as a matter of medical dishonour. "J'he fact, already stated, well merits attention in relation to their history, how very large a proportion of those so af- fected are females. As there are no causes which can ade- quately explain this degree of disparity between the two sexes as to actual spinal complaints ; and as there are many pe- culiarities in the female constitution and habits of life, tending to produce the deceptive appearance of such diseases, we have here a practical intimation of the frequency of the latter occurrence, and of the importance of being well pre- pared for its recognition. Both firmness and experience, indeed, are greatly required in treating these anomalous disorders. Our first steps are often embarrassed, not only by the fluctuating nature of the symptoms, but by the condition of the patient's mind and nervous temperament — a state of constitution generally con- cerned in some degree in producing the malady, and almost al ways aggravated in its progress. These are cases in which, if the foundation of our practice be well laid, we need in nowise be disconcerted by seeming failure in the outset. Some of the most remarkable instances I have seen of com- })letc eventual success, have been those in which the contra- rieties in the early part of treatment were most numerous and discouraging. Ambiguous cases there no doubt are, where the topical symptoms of pain, fulness, or irritation upon some part of the s])ine, are sufficiently distinct to call for local remedies, on trial at least of their effects. In such instances, and equally so where reason is found for the continuance of these means, I think leeches are generally to be preferred to blisters, caustic, or other irritating applications. The symptoms, as D D 3 406 ON SOME SUPPOSED already noticed, are most frequent in habits where there is a morbid sensibility of the whole system; and any active irritation, or even one so slight as hardly to affect other persons, will frequently be found to excite disordered actions, and disturb the whole progress of cure. I have often seen the most obvious and immediate good from removing an issue, or open blister ; which had effect only in aggravating the symptoms they were intended to relieve.* In cases of this nature. Opium might be used much more extensively as an external application than is usual in prac- tice ; and, according to my experience, with great benefit. That very condition of the nervous system, which renders a slight local irritation of the cutaneous nerves a source of disturbance to the whole body, gives power and value to this means as an antidote. Where true inflammation has not existed, or has been removed; and where irritation and nervous sympathies are the source of the distress thus at- tached to the spine and limbs, it is singular what good this application will produce : — not used, however, in the careless and inefficient way which is common with external remedies ; but sedulously, and with sufficient proportion of opium in the forms employed. In another chapter " On the Use of Opiates," some remarks will be found as to the latter point. These cases of supposed spinal disease are further interest- ing, as they belong to and illustrate an important class of diseases, which, though much more closely examined than heretofore, have scarcely yet been defined in their whole extent. I allude to the various forms of Hysteria ; and especially to that frequent and curious variety of the com- plaint, where there is a disordered state of the sensations — * It is a proof, however, of the strange and anomalous character of these cases, when sensorial disorder is blended with them, that external pain or irritation is sometimes even courted by the patient himself. DISEASES OF THE SPINE. 407 or perhaps it may more truly be said, of tlie sensorium itself. The pains upon or along the spine, in the cases already referred to, often belong to this condition ; as does also the inability to give the natural action to the limbs, which is so marked a symptom in these disorders. Sir B. Brodie (with whom I have seen many examples of them) has made the observation, that in hysterical paralysis the muscles are not incapable of obeying the acts of volition, but the function of volition is not exercised. In the truth of this observation, all that I have seen leads me fully to concur. In fact, the whole series of symptoms in these cases, whatever the remote causes, is dependent directly upon sensorial derangement; affecting irregularly certain classes of sensations, and impair- ing the state and action of the voluntary powers. Many of these singular anomalies are expressly due to a depraved state of the sense of touch or feeling ; testified not solely by the increased irritability already noticed, but in other instances by the sensibility being unnaturally blunted. All, indeed, that pertains to this sense (which ought scarcely perhaps to be named or described as a single one) is of the greatest interest in human physiology. The peculiarities of which I have just spoken are rendered more remarkable by what is often observed of their partial occurrence and fre- quent change of place; — phenomena which belong to the general theory of sensation, as well in healthy as in morbid states of the body. In some of these cases the patient may be said to live in a sort of cycle of disordered sensations, displacing, and re- placing each other in the most singular way ; but all removed for the most part when a real pain supervenes, the result of inflammation or other true diseased action. I have known a toothache, or a slight catarrh, or the irritation of a sprain, completely to banish, for a time, morbid impressions of the D D 4 408 ON SOME SUPPOSED most distressing kind and long duration in the habit ; all re- curring when this cause of interference had subsided. The intellectual and moral faculties frequently partake, in greater or less degree, of the same infirmity ; producing some of the most singular perversions of feeling and action which it falls to the lot of the medical man to encounter ; and these sus- tained occasionally during a long period of time. Such cases, of which I have seen examples quite as remarkable as any I find recorded, give aid in explaining some of those anomalous phenomena which have perplexed even thinking men, and furnished in all ages large material for wonder to the credu- lous or uninstructed. But, as I have remarked, there are many instances where the bodily symptoms alone exist, with- out any such conjunction ; and it is to these chiefly that I seek to direct attention in the present chapter.* We are further indebted to Sir B. Brodie for the first de- scription of that very remarkable hysterical affection of the joints, which has close kindred with the disorder now under consideration. There are, in fact, corresponding effects of a common cause, and require for the most part similar treat- men for their relief. I have often found cause to susjDect, as stated in a former chapter, that some of the various forms of hysteria belong more especially to the gouty temjDerament ; ranking among its many other anomalous manifestations in the female habit. Looking generally to the cases associated together by this * In the latter cases we may perhaps best seek for a cause in the reflex actions of the nervous system of the spine, which have recently been the subject of much able research by Dr. Marshall Hall in this country, and by Professors Miiller and Stromeyer in Germany. To the former physician we owe the earliest distinct exposition of this class of facts, and their ap- plication to the phenomena of spasmodic disorders ; a very important step in physiological science, and promising to have much future value in tlie treatment of disease. DISEASES OF THE SPINE. 409 common character, they may be considered as amongst the most curious and instructive in all pathology. Like insanity and intoxication, they illvistrate many points in the connexion of the mind and bodily organs, which are not equally obvious in the healthy state : and they instruct us, moreover, in the history of insanity itself, by displaying various partial hallu- cinations of mind, often traceable thoughout their whole progress ; and forming links, as it were, betwixt reason and madness. It is a sort of natural analysis afforded us of con- ditions too complex for examination, when they are fully formed and established. 410 CHAP. XIX. ON HYPOCHONDRIASIS. There is difficulty as to the place of Hypochondriasis in our nosologies ; partly from the mental affection which is so marked among its symptoms, partly from the absence of any distinct local affection, by which to describe its character. This very ambiguity adds to the interest of the pathological inquiry. The malady is a real one, however difficult its definition, or obscure its relation to other bodily states. It is marked as such by the frequent periodicity of its returns, and approach to equality in the duration of the attacks ; and by an identity of symptoms, designating the complaint to our medical experience, as distinctly as any other of which obvious lesions of structure do not form a part. The fre- quent aspect of hereditary tendency is another proof to the same effect, which cannot be passed over ; — especially seeing the clue it affords to certain probable relations of the dis- order, which, if established, are important alike to its theory and treatment in practice. The dyspeptic symptoms, associated more or less with this malady, have tended much to embarrass all views as to its nature and cause. Their general concurrence with the mental affection makes it impossible to neglect them as part of the complaint; while, on the other hand, the various forms and degree in which they are present, and the occur- rence of analogous dyspeptic symptoms without any similar conjunction, gives cause to suppose that they are rather effects, than conditions essential to the nature of the malady. ON HYPOCHONDRIASIS. 411 The imperfect circulation common in hypochondriasis, and the morbid direction of the mind to all bodily sensations, may well be understood as mainly concerned in producing the disordered state of the digestive organs, thus associated with it. As a mental affection. Hypochondriasis, like many other morbid states of mind, has its analogous condition in certain phenomena of the healthy state. It is an excess in degree, and in permanence, of those feelings which traverse at times the soundest and most equable minds ; often without obvious cause, but especially, I believe, depending on incidents of digestion, sleep, or atmospheric states — disturbing and dis- torting reason while they last, and colouring life with dark and distempered shades — disappearing, it may be, as sud- denly as they have come on, and with as little apparent reason. These moods of mind, familiar in some degree or other to the consciousness of every one, do in fact graduate into hypochondriasis in its most complete form. The essen- tial characters are the same ; and observation fills up every link in the chain between such transient conditions, and deeper and more enduring disorders. This view I have elsewhere applied to mental maladies in a more general form, believing it to afford many new and important illustrations of their origin and nature. In its relation to hypochondriasis, much striking illustration may be drawn from the fluctuations of this disorder. Even in extreme cases, it is curious to mark the sudden changes the feelings sometimes undergo, without the smallest seeming alteration in external circumstances. Not merely from day to day, or hour to hour, do such changes happen, but I have seen them almost momentary in occurrence ; — the mind light- ing up, or darkening again into gloom, at the instant of observation. These phenomena, thus noted, must be taken 412 ON IIYrOCnONDRIASIS. as expressing certain i)liysical changes within the body ; how- ever dlflicult it may be to explain their nature or operation. That they have some reUition to tlic graver forms of mental disease, cannot be denied ; similar fluctuations being more or less incldcuital to every derangement of mind, even such as arc most permanent and severe. But one marked distinction is, that in the malady of which we are treating, the aberrations jiiid false perceptions have more frequent reference to the bodily feelings, and arc in fact generally associated with more of l)odily disorder. This distinction has some practical value In cases where the mental symptoms are severe in degree, and ol' long duration. Another especial circumstance about hypochondriasis, is its frer, due to a common cause, but modified by age, sex, individual tomporamout, and manner of life, is an object In every way of deep interest ; — a field of observation, still only partially cultivated ; but capable of yielding much to those who zealously and patiently work In it. The evidences of the connexion just stated are various In kind. Keforring to my own experience, I have notes of many oases where in families strongly marked with the gouty temperament, certain individuals were exempt from the ordinary forms of the disease, but severely affected by hypochondriiisis. A few cases I have known where. In ON HYPOCHONDRIASIS. 413 gouty habits, prolonged attacks of hypochondriasis, and regular fits of gout, occurred iu distinct reciprocal relation to each other — in one instance so exactly, that each year for a considerable period of middle life, either one or other disorder appeared ; seeming to preclude, or make unnecessary, the occurrence of the other. The case is much more com- mon, and equally illustrative, of hypochondriacal symptoms being relieved and superseded by a fit of gout. This happens most frequently, I think, in habits, where from frequent repetition, or other causes, the gouty attacks have ceased to take an acute form; and the conditions therefore coincide in part with the instances just stated, of the gouty diathesis not directing itself outwardly to the limbs. These relations, thus explicit to observation, clearly denote some community of origin; and even allowing that no certain knowledge were gained beyond the mere fact of connexion, yet is this, in various ways, of much value in practice ; fur- nishing a more secure prognosis, and suggesting various points of treatment. In truth, these connexions of disease which I have more largely dwelt upon in another chapter, are links of nature, which it is our business sedulously to seek for and apply, both in pathology and practice ; — fash- ioning our nomenclature thereby as far as may be possible ; and our classification of diseases, whenever this can reason- ably be done. Another fact denoting hypochondriasis as a disorder of the system, or more especially of the circulating fluids, is the frequency of large and long continued discharges of dark grumous matters ; separated from the blood, either through the liver, or by the membranes and glandular structures of the intestinal canal ; and especially, as I believe, by the great intestines. These morbid secretions often occur more or less throughout the malady; — in greatest abundance perhaps 414 ON HYPOCHONDRIASIS. towards its termination. The etymology of the terms Me- lancholic and Atrabilious, expresses the connexion, ever noticed, between a gloomy state of mind, and the presence of such vitiated fluids in the body.* I cannot affirm that they are always present, or in amount proportional to the other symptoms; but the concurrence is frequent and distinct enough to warrant the belief that they have essential rela- tions to the malady. Examination of their character shows that they often contain actual constituents of the blood. They may be considered to express some altered and vitiated state of this fluid, to which state it is probable the separa- tion by these secretions is a natural remedy. It is true, indeed, that injuries or disturbances of the brain do some- times produce disordered secretions from these organs, not wholly dissimilar. But still there is a distinction of cha- racter in the two cases; and this distinction is further at- tested by the fact that the free separation of these matters in hypochondriasis, seems to give relief to the disorder, and frequently to form a true crisis to it. I have notes of several cases in which the relation of cause and effect was so marked, as scarcely to admit of other explanation. Admitting this, as founded on experience, it becomes a strong evidence as to the general conditions of the system upon which hypochondriasis depends. We cannot yet indeed carry our interpretation further ; nor, on our present know- ledge, recognise in the blood those particular elements which in their nature or altered proportion, become the source of tliis disorder. Still less can we explain the manner of action of the blood, so changed, upon the nervous system and mental * The well known couplet of Dryden expresses the same observation, current at every period, — " The yellow gall that in your stomach floats, Engenders all these visionary thoughts." ON HYPOCHONDRIASIS. 415 faculties and feelings — whether it be that of privation merely, or an influence positively noxious on the brain and nerves. But these difl&culties belong to many analogous cases, and in nowise preclude the general view just given. Pathology in its every part abounds in examples, as explicit as striking, of the influence of the circulation on the mental functions ; and even the ordinary conditions of health are sub- ject to unceasing variation from this cause, too familiar to need illustration. The effects of altered quality of the blood are much less understood than those of quantity and impulse. Nevertheless it is certain that they enter largely into the phenomena of mental disorder ; from the simplest action of blood Imperfectly arterialised, to those more obscure and complex states where morbid matters, either finding access from without, or formed and retained within, disturb the functions of the brain and nervous system, and through them every organ and function of the living frame. To this influence of changes in the state of the blood on the nervous and cerebral systems, we may perhaps refer certain particular facts respecting hypochondriasis ; such as its occasional occurrence as an effect of over-nursing in women ; and its frequency in certain localities — the Western Isles of Scotland, Iceland, &c. — where there is much priva- tion and peculiarity of food.* The torpor of circulation, so * The common occurrence of hypochondriasis among the people of the Western Islands of Scotland is a fact for which we have the authority of Dr. MaccuUoch. It is curiously corroborated by an observation I made in Iceland (confirmed to me by the information of the priests and other intelligent natives) of the great frequency of the disorder in that island ; where similar conditions of diet and manner of life are probably concerned. The relation to scurvy is of some interest here ; a disease in which there is the same depression of nervous power ; and depending chiefly, as far as we can see, on non-acescent or salted diet, confinement to one spot, &c. ; circumstances to which the almost entire deficiency of 416 ON HYPOCHONDKIASIS. notable in general in this disorder, may be referred eitlier to the direct influence of vitiated blood on the heart ; or to in- direct effect upon this organ through the nervous system, itself so instantly affected by the state of the blood minister- ing to its functions. These instances do not afford more than presumption ; but upon the concurrence of presumptions truth is often founded. In admitting the connexion of hypochondriasis with the gouty diathesis, we go far towards the fact of its being an hereditary disorder. I have notes of many cases before me in which the attestation of this is such as to admit of little doubt. Nor is there anything here more marvellous than the transmission of other mental maladies, depending on physical causes. The great mystery of generation ; and the transmission not merely of life, but of likeness, from parents to offspring, involves and includes every question on the subject. It would be futile to raise difficulty as to a part, where the whole is inaccessible to our inquiry. Though the remark is open to many exceptions, yet I think it will be found that in persons of the hypochondriac temperament, the actual attacks of the disorder are more frequent in the spring, or early summer. Under the view I have taken of its causes, there might be some reason to expect such periodical occurrence ; either from external causes or conditions originating within the body. But the fact is not explicit enough to warrant more than this notice. The common treatment of hypochondriasis can scarcely vegetable food, the long winters, and possibly tlie singular contrast between the physical condition and intellectual culture of the Icelanders, peculiarly expose this remarkable people. Accordingly, scorbutic com- plaints are common and severe in Iceland ; treated (when even these remedies can be had) by decoctions of trefoil, juniper, the sedum acre, and scurvy-grass. In a Thesis I printed in 1811, on the Diseases of Iceland, may be found further details on this subject. ON HYPOCHONDEIASIS. 417 be said to be founded on any principle, or to include any- specific remedy. Bodily symptoms, especially those belong- ing to the secretions, are met as they occur; and certain methods, sanctioned rather by custom than success, are em- ployed to assuage the mental part of the disorder. We must admit that what is termed cure, is often merely the natural periodical close of a malady, of which intermission is in most cases a character and symptom. In those instances, already alkided to, where the period of illness tends to become regular in occurrence and duration, it is singular how little this uniformity is affected by any mode of medical treatment — a fact not warranting the physician in dealing inertly or carelessly with such cases ; but rather giving him motive for seeking new means to control a complaint, which is proved by this intermission not to depend on any perma- nent cause. The method of treatment by purgatives Is that in most general use ; sanctioned in some part by the morbid character of the secretions, and in many cases producing material relief; but in other instances failing to fulfil this object, even where the circumstances are seemingly much alike. This incongruity is most easily explained by reference to the nature of the purgatives employed, and the manner and duration of their use. Such as are drastic and irritatinsr often provoke more disorder than they relieve ; and are ill fitted for frequent repetition in cases of this kind, where the attention of the patient is morbidly concentrated upon his bodily sensations. On the other hand, mercurial medicines, given alone, or with mild aids to their action, will often procure such altered state of secretion from the organs chiefly affected in hypochondriasis, as to afford speedy and obvious relief to the symptoms. This altered state may be of quan- tity alone ; but under the most beneficial action, probably of E E 418 ON HYPOCHONDRIASIS. quality also ; — the effect consisting in the removal from the blood of those elements, on the presence or excess of which there is cause for supposing the malady to depend. But whatever the theory of action, the fact of relief from mer- curial alteratives I believe to be well assured ; and especially where used steadily for a considerable time, without looking for instant or strongly marked effects, and without discourage- ment from occasional fluctuations or relapse. It is this dis- couragement, ever apt to occur in the hypochondriac, which so often disturbs our practice, and renders its results un- certain or fruitless. Colchicum is a medicine deserving more trial in this dis- order than it has yet obtained. I was first led to employ it in certain cases, already mentioned, where the connexion with gout was fairly marked ; and with every allowance for doubtful effects, the result appeared to be favourable, in reference to the duration and severity of the attacks. The use of the remedy is readily made to concur with that of mercurials, just noticed ; or with the employment of stimu- lants, tonics, or anodynes, where these are needed to fulfil the purposes of treatment. No such speedy effect is to be looked for as in regular gout ; but with moderate doses con- tinued for a certain time, I believe its trial to be waiTanted in a disorder where we possess no specific remedy. The use of Opium in hypochondriasis is admissible, chiefly as a means of subduing the restlessness which generally disturbs the nights in this complaint, and thereby inflicts ill on each ensuing day. Its advantages, or fitness as a remedy, are doubtful beyond this ; seeing that the secretions are usually much disordered, and that any undue restraint put upon them may add to the evil, by retaining in the system that which probably acts as a cause of disease. Nevertheless cases come before us, where the nervous agitation of the ON HYPOCHONDRIASIS. 419 hypochondriac, closely verging on insanity of mind, does itself become a powerful morbid cause, affecting all the organs and functions of the body. And this state we are called upon to subdue — by opium, if milder sedatives are imavailing — as well for the removal of its more direct effects, as also to render more availing other means which are inert or injurious while this nervous condition exists. The questions of practice, here alluded to, must be solved by the judgment of the physician in each case ; looking to the symptoms present, and further to the idiosyncrasy or habits of the patient regarding opium ; — a point always to be kept in mind. Attention is not enough given to the state of the skin in the treatment of this disorder. Much may be thus done, if the methods employed be duly persevered in. But here we have to encounter the general indifference to simple and obvious remedies ; and the despondent temper and feeble will of the patient, little capable of pursuing that which does not promise and procure an instant good. When these diffi- culties are overcome, the warm bath, or tepid shower bath, used assiduously, with frictions over the whole body, will often produce a notable improvement in the symptoms. Where the skin is harsh and dry, the use of some simple oil, or of lard, may beneficially come in aid of the frictions — a renewal of an ancient practice, which, as I have remarked elsewhere, might well form a substitute for modern remedies of more doubtful value. Change of place and scene, so generally suggested for hypochondriasis, may reasonably be tried ; though the re- sults seldom correspond with the expectations held out, un- less the change of climate be such as to alter the whole physical condition, and particularly the state of the skin and of the various secretions. Mere locomotion and diversity E E 2 420 ON HYPOCHONDRIASIS. of external objects, do not suffice to rid the patient of his burden of troubled imaginations, except in the lighter forms of the disorder, and in conjunction with free air and bodily exercises. A more certain benefit is often obtained where we can succeed (a difficult task, it must be owned, in most cases) in altering the whole train of life ; creating new impulses or necessities ; and thereby urging the patient to new habits of activity. Even in this case we are still working chiefly through physical means ; and giving repair and energy to the mental powers through those bodily func- tions which closely minister to their healthy exercise. I must further remark here, that in the mental treatment of hypochondriasis a great deal of good reasoning is often expended in vain. A simple regard to the nature of the distempered fancies of the hypochondriac is proof enougli that his mind is not in a state to be reached by mere argu- ment ; and experience in all severe cases of the malady teaches the same fact. The intellect seems as if closed to every suggestion from without ; or if any impression be made, it is speedily obliterated by recurrence to the dis- ordered sensations within. In such instances it becomes almost as futile to reason with the patient, as it would be in the delirium of fever or the rambling of intoxication. My experience tells me that it is generally best to express to him, in simple but cogent manner, the conviction that he is labouring under transient delusion of feelings ; — to adhere steadily to the same expressions, inculcating their use upon others around him ; — and to refuse all arguments, on the ground that his state of mind would render them for the time wholly unavailing. These methods, in the severe cases to which I refer, involve no real harshness ; and by a little care can be so contrived as not to sanction any suspicion of approaching insanity. In slighter cases they may be ON HYPOCHONDRIASIS. 421 modified according to the judgment of the physician ; which judgment in all forms of this singular malady needs to be exercised with discretion and firmness. The disorder of hypochondriasis, as will be seen from the foregoing remarks, is in itself a little volume ; recording some of the most curious relations of our physical and mental nature ; and thus be- coming a sort of type of various morbid conditions, by which these relations are more or less aiFected under the in- numerable incidents of life. B E 3 422 CHAP. XX. ON THE EXERCISE OF EESPIRATION. Might not more be done in practice towards the prevention of pulmonary disease, as well as for the improvement of general health, by expressly exercising the organs of respira- tion? — that is, by practising according to some method those actions of the body, through which the chest is alternately in part filled and emptied of air? Though suggestions to this efiect occur in some of our best works on Consumption, as well as in the writings of certain Continental physicians, they have hitherto had less than their due influence ; and the principle, as such, is little recognised or brought into general application. In truth, common usage takes for the most part a directly opposite course ; and, under the notion or pretext of quiet, seeks to repress all direct exercise of this important function, in those who are presumed to have any tendency to pulmonary disorders. Yet, on sound principle, and with reasonable care, it is certain that much may be done in this way to maintain and invigorate health, even in constitutions thus disposed. Omit- ting some points of controversy, particularly as to what re- gards the mechanical influence of respiration on the circu- lation through the heart and lungs (points meriting, however, much attention from their importance), the free and equable expansion of the latter by full insiilration is beneficial ; — first, in maintaining their healthy structure, by keeping all the air- passages duly open and pervious; — secondly, in preventing ON THE EXERCISE OF RESPIRATION. 423 congestion in the pulmonary circulation; — thirdly, in pro- viding more completely for the necessary chemical action on the blood, by changing at each act of respiration a sufficient proportion of the whole air contained in the lungs, and giving it more complete access to the vascular tissues ; — all objects of great importance, and all capable of being pro- moted more or less by the means in question.* The phrase of exercise of respiratioii may indeed be used almost in the same sense, and with the same fitness, as that of muscular exercise. Each is capable, in its respective way, of increasing the power and facility of the function concerned. It is remarkable how speedily this is often attained in the instance of the former. A person in ordinary health may so exercise the lungs by repetition of a given exertion, that what produced breathlessness at first is soon performed with- out effort or fatigue ; — a fact familiar to common observation, and attested by particular examples in those professing athletic exercises, which show not only the speed, but the great extent, to which the effect may be produced. This of course is not equally true where the liability to disease exists. But even then, the express exertion of the organs, under observance and regulation, and with due regard to the collateral circumstances of each case, may often be made a means of augmenting their capacity and power. Though the experiments as to this point are the subject of controversy, yet, as they render it nearly certain that the 40 or 45 cubic inches of a single ordinary inspiration are less than a sixth part of the air constantly present within the lungs, it is * The ingenious suggestion of Dr. Carswell, as to the cause of more frequent tuberculous deposit in the superior lobes of the lungs, is well known, and applies to the subject of this chapter. In the volume of Sir James Clark on Consumption will be found some valuable remarks having more direct reference to it. Oi E 4 424 ON THE EXERCISE manifest that there is great scope for change in the amount of that respired, without interfering too much with the natural course of the function. We might take lesson on this subject from some of the provisions made by nature for relief to these organs, when oppressed in their functions. The acts of sighing and yawn- ing are notable instances to this effect. . Coughing, another mode of expiration (far less to be dreaded in itself than from the inference of danger it often conveys), is an instrument in keeping the air tubes free from obstruction ; and there are many cases where the mistaken efforts of the practitioner to suppress this symptom, do actually much augment the very mischief it is sought to obviate. Other instances, however, occur, where, without any evil, coughing might be partially superseded, or lessened in severity, by the gentler exercise of respiration — so performed under the direct influence of the will, as somewhat to exceed, without passing into labour and fatigue, the ordinary course of the function. Trial is necessary in each particular case to give assurance of the effect ; and often the irritability of parts of the membrane may be such, as at once to negative any rej)etition. But the test as to this is so easy and certain from the observation of the patient himself, that no undue risk can be incurred in making and repeating the experiment. With all allowance for this and other exceptions, we may still affirm the fact that good is occasionally to be gained from the regulated exercise of respiration, even when diseased actions are already going on within the lungs ; — much more, where there is yet only threatening of these, from hereditary or accidental causes in the constitution. Here such exercise is beneficial, as well through its influence on the general health, as more directly by its effect on the lungs themselves, in the several ways mentioned above. There is even reason to OF RESPIRATION. 425 affirm (however this opinion may contravene all common belief on the subject) that, under discreet use of the remedy, a larger proportion of good may be obtained from it in these cases, than in any other where it can be employed. It is a good we are in nowise entitled to neglect ; seeing the paucity of the means we possess for dealing eifectually with the most frequent and fatal form of pulmonary disease; — that which has been so often cited as a reproach upon medicine ; though perhaps unjustly, when the nature and difficulties of the subject are fully taken into account.* * In adverting to this disease of pulmonary consumption (tubercular phthisis), it must fairly be admitted that the progress of medical science has hitherto effected nothing towards a valid cure ; whatever may have been done by methods for protecting the constitution against its earlier inroads, or in certain degree abating the symptoms in their progress. This, however, as remarked above, is less an opprobrium upon medicine than on first view it might appear. The more distinct knowledge that has been acquired of the tubercular diathesis — of the tendency in certain habits and in particular textures to the growth or deposit of a peculiar morbid matter — and of that more especial direction to the lungs, war- ranting M. Louis's assertion, that after the age of fifteen tubercles are never found in any part without appearing also in this organ, — all this points directly to a specific constitutional disease, for which none other than a specific antidote is likely to be of complete or certain avail. Whether such will ever be found (either general for the tubercular disease in the habit, or more especially preventive of its deposits in the lungs), is still very doubtful ; though the research is amply justified, both by analogy, and by the urgency of the cause requiring it. This analogy, however, does not extend to the nature of the morbid matter itself, or its relation to other specific remedies. Nothing has yet been ascertained as to these points, which can be considered even a plausible clue ; r,n 1 the discovery, if made, is more likely perhaps to be the effect of some happy accident, than of any concerted plan of inquu'y. These difficulties, which can be rightly understood by medical men only, become a vindication for that which the science has not yet attained, though sedulously sought for. Meanwhile, and in conjunction with these efforts, attention has justly been directed towards the means best cal- culated to guard constitutions so disposed against the active ingress of 426 ON THE EXERCISE It Is scarcely needful to say that the same regard which is paid to the quality of air in ordinary respiration, and espe- cially under tendency to pulmonary disorder, must be ex- tended even more carefully to cases where the quantity inspired is thus by effort augmented. "Where experience has clearly shown that air below a certain temperature produces irritation in the air passages, it is certain that this cannot be fitted for the exercise of respiration as here recommended. And the same with respect to a humid atmosphere ; under which any given degree of cold produces much more effect on an irritable membrane, from the medium through which it is applied. These points, Indeed, though adverted to as maxims in the treatment of phthisis and other pulmonary diseases, are not sufficiently made the subjects of trial in particular cases. Two or three experiments, readily devised for each case and unattended with risk, might suffice to decide a question which applies alike to the preventive and curative practice in these disorders, and throughout every part of their progress. As respects the modes of exercising the respiration, they should be various, to suit the varying powers and exigencies of the patient. The " clara lectio " is one of very ancient recommendation, the good effects of which are not limited to this object alone. It might be well, indeed, were the practice of distinct recitation (such as Implies a certain effort of the organs beyond that of ordinary speech) more generally used in early life; and continued as a habit and exercise, by those the disease. Tliis Is obviously the only alternative as a principle of treat- ment ; and it has been successfully pursued in many ways, so as un- doubtedly to place the pi-eventive practice in phthisis on a better footing than at any former period. More, however, is doubtless still attainable ; and the subject of the present chapter is one which furnishes evidence to this effect. OF KESPIKATION. 427 especially wliose chests are weak, and who cannot sustain stronger exertions. Even singing may for the same reasons be allowed in many of these cases ; but within much narrower limits, and under more cautious notice of the effects. If such caution be duly used as to posture, articulation, and the avoidance of all excess, these exercises of the voice may be rendered as salutary to the organs of respiration, as they are agreeable in their influence on the ordinary voice. The common course of education is much at fault in this respect. If some small part of the time given to crowding facts upon the mind, not yet prepared to receive or retain them, were employed in fashioning and improving the organs of speech, — under good tuition and with suitable subjects of recitation, — both body and mind would often gain materially by the substitution.* One or two remarkable cases are known to me, where a constitutional tendency to asthma, showing itself early in life, has been subdued to a great extent, and without ambiguity as to the effect, by thus tasking the chest in certain regulated efforts, of which recitation formed a part. However obscure the causes of this disorder, I doubt not that more might be done in prevention of its attacks by methods thus applied, and sedulously continued. The great difficulty in making * Those who are familiar with the strong sense and sound maxims of Quintilian, will, on this point, recur with pleasure to his instructions re- garding the culture of the voice, pronunciation, and manner of speaking, in the latter chapters of his first book. This is not the sole subject on which the physician may find valuable suggestions in his writings. In some of the French military schools, the young oflScers are now taught to give the word of command in the open air, with such strong and clear articulation as is fitted to their future function in life. I learn on good authority, that this practice is found very beneficial to the freedom and power of all the functions of the lungs, as well as of the voice in particular. 428 ON THE EXEKCISE such means of avail, is that of obtaining due persistence in their use. Of actual muscular exercises directed to this function, that of full and repeated inspiration in the free air is perhaps one of the best. The exercises which open the chest, as it is termed, arc salutary, provided they are not such in amount as to hurry the circulation, oppress the bfeathing, or occasion too large and sudden expenditure of muscular power. These precautions do not always receive the notice thy deserve in relation to exercises of the chest ; and especially in the case of those of feeble habit and disposed to pulmonary disease. If the exertion be such in kind or degree as to quicken materially the action of the heart, and hurry the respiration, no good is obtained, and much evil may be incurred. These functions are the best, as well as most ready, tests we can apply, to regulate what may expediently be done. Altered they are in degree even on the slightest exertion ; but they ought not to be so to such extent as to prove distressing to the sensations of the patient at the time, or to leave the feel- ing of languor behind.* The breathing, therefore, may best be exercised in these cases by full inspiration when the body is otherwise at rest, or in slight and easy movement. The lungs will thus be more completely filled than by hurried respiration, and with- out any evil to countervail the good. It is from this cause, chiefly, that exercises on horseback are for the most part more * This is particularly to be guarded against in those gymnastic exer- cises, which have had thoir periods of fashion as well as other less com- niondable remedies ; and have often been carried to injm-ious excess, both in this point-, and in the over-strain given to the several parts concerned m motion. Rightly applied and limited, they have great value in various ways for the maintenance of health, and the restoration of parts en- feebled or altered by disease. OF RESPIEATION. 429 beneficial to persons having weak chests than those on foot ; in which greater muscular exertion is required, and where the diaphragm particularly is brought into more hurried action. But there are cases where neither mode of exercise is practicable ; yet where the gentle exercise of inspiration by voluntary effort, so as to bring more air into the lungs than is done by the common act of breathing, is advan- tageous even to those who are deeply under the influence of pulmonary disease.* It is worthy of remark that rapid motion through the air, on horseback or in an open carriage, is often felt as more beneficial to those in ordinary health than a slower rate of movement. It may be that the air thereby gets more thoroughly into all the bronchial cells, removes what has been stagnant there, and produces more rapid and com- plete arterialization of the blood. This is obviously the same case as that of moving against a wind ; which is gene- rally found to be invigorating in its efiects, where the wind is not so strong as to produce much muscular toil in facing it. Other animals evidently share with man in the bodily feeling thus produced. t There is a distinct diflference of sensation in the opposite case of moving together with the wind, and * A caution regarding exercise In such habits may be given here, which I do not recollect to have seen mentioned, though founded on a remark- able fact. This is, the Increased difficulty of breathing for a time, on stopping suddenly from any exercise by which the respiration has been much hurried. Without entering into the causes, It is enough to mention this circumstance as suggesting the precaution of making the change more gradual, when a state of breathing occurs which in these cases ought especially to be avoided. f A coachman will say that his horses do not breathe so well, that they sooner become faint, with the wind blowing behind them, though the positive draught be less. Something is due here to the heat from exercise not being so freely carried away ; but this will not explain the whole of the effect observed. 430 ON THE EXERCISE at the same, or quicker, rate than Its motion; and I have even known instances where a certain degree of faintness appeared to be thvis produced, obviated speedily by changing the di- rection of progress. It is not improbable that these effects depend in great part on the different amount of change effected by the air upon the blood. Attention has scarcely enough been given to the rapidity with which such changes often take place; though both experiment and observation show how sudden, as well as singular, is their influence upon all parts of the frame. Everything which tends to give full ingress of air into the lungs contributes to this effect ; which may best be described by saying that all the functions are brought into greater ac- tivity, and the power of vitality augmented throughout the whole being. The remark just made as to the effect of rate of movement through the air without muscular exertion, might be usefully applied to many cases in practice, beyond those in which the chest solely is concerned. In dyspepsia, for instance, where the circulation is for the most part feeble, and both body and mind inapt to exercise, much good is attainable in this way ; and those fitting changes in the blood, which are interfered with by the whole manner of life of the dyspeptic, may be procured without efforts to which it is difficult habitually or sufficiently to rouse him. The frequent conjunction of dyspepsia with the earlier stage of pulmonary disease, affords suggestions here which merit much attention in practice. Adequate change of air by respiration, though it may not reach cure, yet as far as it goes is remedial for both. In cases of this kind, and still more in Chlorosis, it is worthy of note how veiy inertly the acts of respiration are often performed, and how little alteration is made in the air OF RESPIRATION. 431 within the lungs by each repetition of the act. The chest is hardly seen to rise during common inspiration; the patient seems scarcely capable of aiding it by voluntary effort ; and short spasmodic breathing comes on upon the slightest bodily exertion. I have seen many cases of this kind, where I could affirm, upon simple outward inspection, that not one half the number of cubic inches of air, which belong to na- tural inspiration, entered into the lungs. Here it is manifest that the proper changes in the blood, by oxygenation and the removal of carbonic acid, do not take place, and that all the organs and functions of life suffer in effect of this privation. Many of the symptoms in the singular class of disorders to which we refer — even some of those affecting the mind — are certainly derived from this source, whatever be the original causes in the state of the uterus, of the brain, or other parts of the nervous system. And it must be kept in view, that the deficient change of the blood (testified in chlorosis by a want of the right proportion of fibrine and red particles, and by lessened power of coagulation) has effect not only upon the secretions to which this fluid directly subserves, but also, as we have every reason to suppose, upon the vigour and equality of the circulation itself. The action of the heart, the state of the capillaries, and the altered production of animal heat, may be received as the more obvious proofs of a fact, than which there are few of greater importance in the animal economy.* * Some interesting experiments by Dr. Alison (Jieports of the Fifth Meeting of the British Association, 1835) lead to the presumption that the oxygen of the air has effect in exciting the flow of blood through the capillaries, independently of any action on the vessels themselves ; con- firming in this the curious notices of Haller as to the drawing of blood towards any part where an opening is made in a vessel, so as to admit the contact of air with the fluid within. Though we have no proof that the physical peculiarities of chlorotic 432 ON THE EXEKCISE I doubt indeed whether this point of the due arterial- ization of the blood, familiar as a physiological doctrine, has been enough considered by physicians in relation to the pre- vention or treatment of disease. Venous blood circulating in the arteries is a cause of speedy death to the functions of the brain ; and thence indirectly (to say nothing of its simul- taneous effect on other organs) to the whole body. Between this state of venous blood, and that perfectly arterial, there may be every possible grade of change. Such intermediate variations we know to exist in many cases, and most dis- tinctly in some forms of disease. It is certain that each proportion between the two extremes must have its definite effect, for good or ill, upon every part of the system; — partly by altering the power and rate of the circulation itself; — partly by ministering a fluid of different chemical composition for the nutriment, secretions, and other functions of the several organs ; — principally, perhaps, by the more direct influence on the nervous system just referred to. The great agent in determining these changes in the blood is undoubtedly the respiration. And commanding this function as we thus do to a great extent, both in the quantity and quality of the air inspired, we are bound to take more advantage than has yet been done of all which this important power can afford us for the prevention or relief of disease. The disappointment of earlier and more sanguine expecta- tion as to the medicinal value of the protoxide of nitrogen (nitrous oxide gas) has had the effect of withdrawing attention too much from this remarkable agent. That which can work such extraordinary effects upon the nervous system, affecting even the mind with a new sort of inebriety of thought and blood are owing to deficient respiration alone, yet there is reason to sup- pose this cause materially concerned ; more so, pex'haps, than is usually adverted to in histories of the disorder. OF EESPIEATION. 433 feeling, must, on the most assured grounds of analogy, be deemed capable of some remedial action, whatever its nature or degree. The inequality of influence upon different persons, and the disagreeable influence upon some, are cir- cumstances common to all powerful remedies we possess, and not fairly to be admitted in argument against its eventual use. Looking at the function of respiration under any view, it can scarcely be doubted that cases must occur where it may be important to add to the proportion of oxygen inspired ; and the evidence of effects from this particular compound is suf- ficient to suggest it, under modification, as the most expedient method of attaining the object. Whether oxygen under its allotropic condition of Ozone may ever become admissible and useful as a medicinal agent, is a question still untried to our experience. It is scarcely conceivable that a modification thus remarkable, of an element so important as oxygen to every function of animal life, should not have some distinct influence, even when partially blended with atmospheric air by the natural changes around us — still more influence, it may be supposed, were the proportion of Ozone artificially increased, as might readily be done by the means we possess. This is one of the many things open to future inquiry. F r 434 CHAP. XXI. ON SOME POINTS IN THE PATHOLOGY OF THE COLON. I DOUBT whether all the functions and disorders of this bowel have obtained proper attention in practice, or their influence in producing disorder of other parts of the body been sufficiently regarded. The Colon is often viewed merely as a part of the alimentary canal, with the oflSce of simple transference through it, after the more important stages of digestion have been completed. It is certain, how- ever, that there is much beyond this, in its actions both of healthy and morbid kind. Its peculiar situation, connexions, and flexures ; — its great extent of internal surface, mul- tiplied by the bands, folds, and other inequalities of the lining membrane ; — its liability to unequal distension, contraction, or stricture ; — and the variety of secretions from the glands and vessels of its inner surface ; — all concur in giving great importance to this intestine in the animal economy. From its continuity with the rectum, many circumstances are common to the two portions of the canal, and to these the following remarks equally apply. But each part has its peculiarities ; and those of the Colon, for obvious reasons, have hitherto engao-ed less than their relative share of notice. The nature and amount of change in the alimentary matters, as they pass through this part of the canal, are yet not wholly known ; nor are we assured as to the opinion lately propounded, on the authority of Dupuytren and other accu- rate observers, that the large intestines are peculiarly con- THE PATHOLOGY OF THE COLON. 435 cerned in the digestion of the vegetable part of food. That there is power of absorption into the system through some part of their structure seems certain ; and, equally so, that this power may be much augmented by especial circum- stances. But as a general fact it is probable that this portion of the intestine is much more an organ of secretion than of absorption ; and further, that these secretions are not merely subservient to changes in the matters passing through, but useful or necessary in removing other excrementitious or hurtful parts from the system. It cannot be doubted that much of what is healthily voided by the bowels is, in fact, a secretion from the follicles of the lower intestines, and not simply a residuum of food. Under this view, the Colon becomes one of the excretory organs in a more direct sense; and, admitting such double natural function, the study of its morbid conditions is one of much interest to the medical practitioner. I shall not here speak of the disorders or diseased states of the Colon, more familiarly known ; — spasms;' acute or chronic inflammation of its mucous membrane ; dysentery ; the various forms of ulcerated or gangrenous intestine ; induration or thickening of its coats, &c. ; but confine myself chiefly to a few points less recognised in general practice.* * It is difficult, however, to mention ulceration of the Colon (connected as so often happens, with similar state of the adjoining membrane of the ileum), without adverting to the singular and sudden influence which this state of bowel seems occasionally to have on the system at large — the condition of typhoid fever and sensorial disorder speedily brought on, and often with fatal issue. I have known this termination so rapid in some cases, even within a few days of the first seizure, and with so little severity of local symptoms, that it was difficult to consider the ulcerated state of the intestine as other than a partial effect of the constitutional disorder. This view, however, is not equally warranted by other cases ; and we have still much to learn on every part of the subject. The value of research F V 2 436 ON SOME POINTS IN Many morbid states attributed, with the too frequent vagueness of medical language, to the stomach and liver, are chiefly, as I believe, connected with the Colon as their seat and source. This remark applies alike to disorders of secre- tion, and to those in which the symptoms depend either on nervous sympathy, or simply on the mechanical effects of juxta- position and attachment of parts. As respects the first of these cases, it cannot be doubted that many of the various directed to it, is well indicated by the statement of Andral, that, out of ten cases of acute malady occurring in other parts of the body, there is an average of eight, in which derangement is found either in the texture or functions of the alimentary canal. This statement may be too precise for the many ambiguities depending on our ignorance of the primary seats of disease, but it is nevertheless true to a remarkable extent. The whole subject of gastro-intestinal disease has additional interest in its connexion with the modern doctrine of some pathologists (of whom Broussais is the most conspicuous), who regard all the varieties of con- tinued fever as merely symptomatic of certain morbid states of inflam- mation of these membranes, or their follicles and glands. This opinion, were it true, would go far to decide that still unsettled question which lies at the root of all pathology, whether there be any true idiopathic fever wholly separate from local irritation or lesion of texture? But, besides that the arguments for this doctrine are manifestly too exclusive in their direction to the intestinal canal, they do not furnish any adequate proof that the affections of its membranes are really prior in date to the febrile symptoms, even in some of the fevers to which the term of gastric seems especially applicable. The uncertainty arising from this source is best denoted by the fact, that almost every argument employed to prove the derivation of fevers (and especially those of typhoid type) from disorders of the intestinal membranes, may be equally directed to show their immediate origin in affections of the brain. The parity of weight? in reasoning thus differently applied, gives strong presumption that neither opinion can be really just. And adverting to all the circumstances in the history of fevers — their varieties, origin, course, and termina- tion — it is impossible not to find in the changes of the blood itself a source equally probable as those just mentioned, though perhaps as little to be determined by any precise evidence. No author has better treated this subject than Dr. Alison, in his Outlines of Physiology and Pathology. THE PATHOLOGY OF THE COLON. 437 egesta from the bowels, usually termed bilious, and treated as sucb, have no other relation to bile than that of mere admixture. They are separated from the vessels or glands of the larger intestine by exudation or secretion ; — act upon the contents of the bowel, as well as upon the living parts of the system, according as they deviate in quantity or quality from the healthy state ; — and, in the excess of such deviation, indicate a state of the glands and secreting membranes, or it may be of the system at large, connected with some of the most important diseases of which we have knowledge. The peculiar matter, resembling coffee-grounds, which some- times comes away in such large quantity from the bowels, is often described as disordered bile, though I believe it to be separated in great part in the lower intestines. Those secre- tions also which resemble chopped grass or spinach have pro- bably the same origin ; and even of the liquid which is called green bile it is doubtful what proportion may come from the liver. The colour of what passes from the bowels is often the effect of changes taking place within the intestine itself. This may readily be conceived, looking to the many materials present for chemical combination, both in the egesta and secreted fluids; and to the facility with which colour is changed from very slight causes, such as a small excess of acid, in matters thus composed. We know from experiment that such changes are readily effected by artificial means, as well in the urine, as in the matters passing from the bowels ; and, though not having certain knowledge of the same che- mical agencies going on in the body, many that are analogous may fairly be presumed to exist.* The liver in fact, important though its functions and dis- * The researches of Tiedemann and Gmelin in Germany, and those of Dr. Prout in our own country, afford many valuable results on this subject. F F 3 438 ON SOME POINTS IN eases are, is often charged with more than belongs to it; and the provocation of mercurials applied and continued under this view, in cases where the coats of the bowels are chiefly, or exclusively, the seat of the action which it is sought to re- medy. In some instances benefit may arise from the practice, though founded in error as to the direction of treatment. But if the appearance of the matters separated from the bowels be made, as it often is, the exclusive argument for persistence in these medicines, they may be carried to an in- jurious extent, and interfere with the natural course of actions really salutary to the system. In like manner, those other secretions which have the character of minute specks of blood disseminated through a fluid, or sometimes of a black matter almost as deep as ink in colour, may be considered chiefly owing to exudation from the mucous membrane of the bowels. These secretions or exudations, which are found by the microscope to contain ele- ments of the blood, may be extravasated, it would seem, from the membrane of any part of the intestines. But I have seen instances where products of this description, coming away in large quantity before death, have been found on examination everywhere lining the coats of the Colon, without any appear- ance of similar kind in the smaller bowels. Secretions, of the general character just described, do in fact show themselves in every grade of change from pure blood to appearances widely different ; with certain evidence that they are separated from the intestine itself, whatever name be given to the process by which this takes place.* It is important to distinguish these from mere bile, and to note * Andral describes the separation of this black matter (nielanose) from the coats of the intestines by the phrase " la membrane muqueuselalaisse suinter." — Anatomie Pathologique, vol. ii. No better description than this can probably be given. THE PATHOLOGY OF THE COLON. 439 their various appearances; partly as concerns questions of treatment directed to the membranes ; equally so, because these secretions are often the index to changes taking place in the system. In some cases they precede and indicate a fatal event ; depending here, it may be, on a particular state of the exhalants, akin to that which produces cold sweats upon the skin ; or possibly in still greater part on changes in the state of the blood itself. In other instances it would seem that these large discharges of dark grumous fluid (of different quality doubtless from the preceding) actually relieve the blood from some morbid matter, loading and disordering the whole system, and particularly perhaps the chylopoietic organs and venous circulation. This subject, in fact, must be viewed in especial connexion with the distribution, functions, and dis- orders of the portal system ; a due regard to which will aid us much in interpreting many obscure points in pathology. The apparent relation of certain of the matters, so removed, to the morbid products which have been classed under the name of melanosis, is one of the results derived from recent examin- ation into diseases of the blood. The alteration in general health, which often folloAvs these discharges, undoubtedly justifies our placing them among the various actions (whether assuming the aspect of disease or not) by which important changes are made in the mass of the circulating fluids, and through these on the various functions of the body. I have seen many cases of hypochondriasis of long duration, many also of protracted disturbance in the action of the heart, speedily and wholly relieved in this manner. We have other authority for this view in the peculiar quality of some of these excretions ; rendering them, if long retained, exceedingly noxious to the body in which they are generated ; producing sometimes great irritation, in other cases extreme depression of the vital powers. And there F F 4 440 ON SOME POINTS IN is further evidence here in the analogy to those curious fascal excretions from the roots of various plants, poisonous more or less to the vegetable life by which they are produced.* The treatment of the cases mentioned above is not without many difficulties, and we have reason to believe that mischief is often done by a mistaken practice. To deal with these instances as with common diarrhoea, by opiates and astrin- gents, is an injurious interference with actions beneficial or needful in their result. On the other hand, irritation, by medicine or otherwise, to the vascular surface which is the source of these peculiar excretions, may inflict mischief of another kind, and equally prevent a salutary issue. The rule of practice here can only be furnished by the observation and experience of the practitioner. These difficulties, in truth, are common to cases of diarrhoea of more ordinary kind, arising out of the complication of the causes concerned ; — the various ingesta received into the stomach — the different secretions poured into the alimentary canal, as well from the large glandular apparatus of the liver and pancreas, as from the innumerable mucous follicles in every part of the canal — and further, the great extent of vascular surface from which fluids may be separated by exudation or otherwise. In efiect of this, a great variety of division and nomenclature has arisen as to these disorders ; * The observations of Macaire on these remarkable excretions from the roots of plants are valuable to agriculture, as well as interesting in the analogies they afford to animal life. On the latter point I have notes of several instances, showing the noxiously sedative influence of some of these matters generated within the body, and thus separated from it. One case is now before me, where, in a vigorous young man of two and twenty, the pulse, habitually about seventy, was brought down below forty, and rendered very irregular, by the passage through the intestine of a large quantity of that peculiar secretion resembling black oil ; the pulse rising again immediately after it was removed from the body. THE PATHOLOGY OF THE COLON. 441 adding much to the embarrassment of the student, and in- creasing the chances of error in practice. It will probably be admitted by all who give honest expression to their ex- perience, that even in these very familiar complaints the rule of treatment is less certain and consistent than in most other disorders ; fluctuating perpetually between the doubt whether the diarrhoea present is to be checked by direct means, or allowed to proceed on its course ; — whether medicines should be given with intent gradually to alter the secretions ; or, with a bolder hand, to remove at once such as may be disordered or hurtful. This uncertainty of practice, of which I have spoken in a former chapter, can only be ob\dated by experience, and by a careful observation of what is mere mechanical irritation — what, vitiated secretion from other topical causes — what, the separation of noxious matters from the blood through the liver or intestinal membranes. Technical rules here may be too minute, as well as too general and vague, to be useful in practice. At all events, they can never supersede individual discrimination.* * In all general reasoning on the disorders of the abdominal viscera, it is needful to estimate fairly what is still wanting to an adequate know- ledge of the healthj functions of these organs. The stomach is now perhaps best known ; but chiefly through researches of recent date. The progress in the minute anatomy of the liver, for which we are chiefly indebted to Mr. Kiernan; and the many valuable experiments, and bold speculations, applied to its physiology, have left us yet in doubt as to the specific uses of this great organ in the animal economy. The functions of the spleen are still matter of vague conjecture. Numerous questions remain to be solved as to the especial functions of the several parts of the alimentary canal. And though much more has been done towards the history of the kidneys both in sound and diseased state, yet the rela- tions of the urine, in its quantity and properties, to the various changes occurring in other parts of the body, still offer singular difficulties to the physiologist. I have elsewhere referred to these and other deficiencies, for the illustration they afford of tlie difliculties attending all medical evidence. 442 ON SOME POINTS IN Some of the remarks, just made, relate to disorders of the small intestines as well as to those of the Colon ; but the cases are so numerous in which this bowel is esiDecially affected, and to which these questions of treatment directly apply, that it is impossible not to notice them as an essential part of the subject before us. The disturbances produced in the body by what may be called the mechanical conditions of the Colon, deserve some notice ; particularly as they are sometimes mistaken for more serious disorders of other organs. The whole subject, indeed, of sympathetic and reflex actions, produced by unequal dis- tension, or change of place, of portions of the intestinal canal, is curious and instructive in numerous points of pathology. Their influence upon the nervous system, even as connected with the common processes of digestion, is familiar to us in every moment of life. It is more strikingly shown in differ- ent states of disease, especially in the female habit ; as well as during the period of infancy, when the nerves are more sen- sitive to all automatic impressions, and less under the control of those functions of the brain which afterwards govern so large a part of the muscular system. As respects the Colon, these effects manifestly depend in part on the contiguity or attachments of this intestine to other organs ; making the latter liable to be affected by the distension which often occurs in the whole, or parts, of this bowel from temporary causes. Its peculiar course through the body renders some of these connexions very important in pathology ; since not only the stomach and other parts of the alimentary canal, but also the action of the heart and the respiration, are liable to great disturbance from this cause. The latter effects are more especially produced when the transverse arch, as so often happens, is distended throughout THE PATHOLOGY OF THE COLON. 443 its length ; forming a tight girth across the fcody, and pressing directly or indirectly upon the diaphragm, stomach, duo- denum, and even the large vessels underneath. Though there is often ambiguity from the distension of the stomach itself, yet in many cases it is obvious that the Colon is solely concerned ; either through air confined in the bowel, or from more solid matters compacted in some part of it ; thus be- coming one of the various circumstances in digestion by which the heart's action is disturbed, frequently so much as to alarm the most experienced practitioner. Looking to the irritation of the stomach thus produced by distension of the Colon, we shall find many states of dis- order, supposed to belong to the former organ, to be really due to this cause. The distress so common to dyspeptic patients in the course of the night, and obviously connected with the state of the bowels, seems to belong to this part of them more especially ; the recumbent posture, for obvious reasons, increasing all disturbances which depend on its distension, and pressure upon adjoining parts. The close attachment of this portion of the Colon to the stomach and duodenum, affords reasonable explanation of many other symptoms of disordered digestion ; and of the morbid sensations or actions rapidly diffused through distant parts of the alimentary canal. A distended state of the Colon may disturb an earlier stage of digestion ; either mechanically by pressure on parts nearer the stomach ; or indirectly through the system of nerves, by which these various organs are asso- ciated in one common function. Both these causes must be kept in view in treating the disorders to which they are severally subject. The actual complexity of such complaints may well embarrass the young practitioner ; seeking to un- ravel, by technical names and descriptions, symptoms which no nomenclature can reach. 444 ON SOME POINTS IN Disordered states of the Colon are not unfrequently mis- taken for complaints of the kidneys ; and there is the greater liability to this mistake from the influence they really have (either mechanically, or by some cause of sympathetic irrita- tion, or by changes in the circulation), in disturbing the state and secretion of the urinary organs. Whencesoever it arise, so close and frequent is this connexion, that we may always expediently begin the treatment of apparent disorder of the kidneys by full evacuation of the larger intestines ; secure that we shall obtain alleviation in this way, if not entire relief. Few of the means, especially directed to the urinary organs, are so effectual as those which operate upon them through this part of the intestinal canal. Many pains in the back and loins, which pass vaguely imder the names of lumbago and rheumatism, are distinctly to be referred to the same cause. The effect of treatment here is usually the most certain proof; purgatives and injec- tions relieving these symptoms speedily and effectually in many cases, while failing in others. ' The very peculiar pains in the same parts, which attend the whole course of acute dysentery (and which are by no means sufficiently indicated in the common descriptions of this disorder), give further evidence how remarkably the morbid state of these bowels affects the adjoining textures.* Cramps, and other spasmodic and painful affections of the lower limbs, are a frequent effect of the mechanical distension of different portions of this bowel ; perhaps also, of disordered and acrid secretions lodged within, or passing through it. Of * Those physicians who consider that dysentery expresses not so much a state of the intestinal membranes, as a more general disorder of the chylopoietic viscera and of the portal and mesenteric circulation, may find somewhat different explanation of these pains. It is probable, indeed, that they are derived from different sources. THE PATHOLOGY OF THE COLON. 445 the latter we obtain proof In the very common concurrence of these symptoms with dysentery or ordinary diarrhoea. The acid also, — which, according to recent observation, is for the most part predominant in the larger bowels, — may be in such excess as to produce various disturbance by sympathetic irri- tation. The Coecum, for obvious reasons, is the part most liable to distension ; often from solid matters accumulated there in extraordinary quantity. Its effects when thus loaded, even upon distant organs, are so various and considerable as to require discrimination in practice. I have seen more than one case, where pains were produced in the right leg, severe and constant enough to suggest the idea of more permanent disease in the joint or limb. There is some difficulty in understanding the cause of those circumscribed swellings, to which all parts of the in- testines seem liable ; and which are sometimes so contracted in extent as to convey to examination the idea of hard, well- defined tumours, occasionally deceiving for a time by the resemblance. These swellings, as well as all other distensions and inequalities of the bowels, are more frequent in the female habit, and seem in certain cases connected with the peculiarities of the hysterical temperament. As the passage along the intestine, though impeded, is not generally closed in these cases, Ave must suppose that its coats are distended into a sac out of the direct course of the canal ; — originally, perhaps, from air generated suddenly or detained in this part of the intestine ; — or from the irritation of other more solid matters producing partial contractions, with relaxation of the intervening membrane and loss of power in the mus- cular coat. The sudden and unequal distension of the bowels from certain articles of food, or during the action of irritating medicines, illustrates the nature of these more cir- cumscribed swellings. They are often relieved by a single 446 ON SOME POINTS IN active purgative (with which creosote or cajeput oil may beneficially be combined) : but the habit of using frequent laxatives, by weakening the canal and rendering its motions irregular, increases the tendency to such disorders. The whole subject of Tympanitis, to which these circum- scribed tumours have relation, is under some obscurity. It is certain that there occurs occasionally a powerless or palsied state of the intestine, over more or less of its extent, concur- rently with which tympanitic swellings come on; — whether as cause, or eifect, is not well ascertained. I think it probable that each supposition may be correct in part. The dis- tension of any portion of the canal beyond a certain degree clearly impairs or destroys its power of action; and still further distension may thereby be produced. But we have reason to suppose that this state of intestine (especially when general throughout the canal), arises from other causes; such as belong either to the nervous system of these organs, or to the effects of inflammation on the surface of the lining mem- branes. It is not easy to discriminate among these cases of mutual action; nor is it often attempted, though some points of practice might be founded on the distinction.* The various distressing sensations and disturbance to other parts, which thus arise from undue distensions of the canal of the Colon, almost defy enumeration. They form part of the sufferings of the dyspeptic, affecting all parts of the nervous system; and are unhappily aggravated in general by the means which such patients are prone to employ. I have elsewhere spoken of the importance to the healthy state of this bowel and of the rectum, that there should be a proper and equable distension by the contents passing through them ; * Dr. Abercrombie, in Lis work on the Diseases of the Abdominal Viscera, relates one or two cases in which large tympanitic swellings were speedily removed by the use of electricity. THE PATHOLOGY OF THE COLON. 447 and of the evils arising from habitual or frequent purging, in reference to this point, as well as to the state of the secretions from the coats and glands of the canal. I again allude to the subject from persuasion of its importance in practice. I may add further that the habit in question seems occasionally to be chargeable with that opposite state of the Colon, equally or even more distressing in its results, — viz., the permanent contraction of the canal for more or less of its extent, par- ticularly along the transverse arch of this intestine.* I have often sought to ascertain what are the appearances of the tongue, especially indicating disordered states of the Colon. Such have been described, though vaguely ; but it i^t certain that they exist, seeing how variously and delicately this organ gives testimony to changes in the long tract of internal membrane, of which it is one of the terminations. On its general value as an index in disease, some remarks will be found in the subjoined note.f So many, however, are * In two of the most remarkable instances I have seen of this organic disease, there had been a long habit of using large and very frequent doses of salts ; — in one of these cases to a greater extent than I have ever before known it. This may have been casualty, but it is worth noticing. f Among the external indices of change within the body, the tongue is perhaps the most valuable. Constantly as it is referred to in practice, we are still only partially informed of all the diagnostic marks it affords. Scarcely can the pulse compare with it in the extent, variety, and accu- racy of these indications ; which are not limited to disorders of the mem- branes and secretions of the alimentary canal, or to the presence of fever in its several forms; but extend also to the nervous power, of various states of which it affords very correct evidence. The sensibility, the voluntary powers, and even the more intellectual functions are often exactly thus interpreted. (Ai Tpo/no^itg yXttxraca aijfutov ovk 'iSpvuivijg yvuifiTjQ. — Hippocrates.) No one can doubt this who is famUiar with the appearance of the tongue under great debility ; slowly and with dlfSculty put out of the mouth ; withdrawn with equal effort ; tremulous the whole time ; its surface parched from stoppage of all secretions ; its sensations blunted or depraved. — There are various parts of morbid anatomy which 448 THE PATHOLOGY OF THE COLON. the complications in the present case, chiefly from the state of the intervening parts, that I have never been able to satisfy myself with having obtained any well-defined knowledge from this source alone. less merit the care bestowed on their representation or description than do the disordered states of this organ. The fugitive nature of the appearances, and their less fixed relation to disease from the variety of parts they repre- sent, are obstacles to the easy interpretation of them. But the opinion may be repeated, that the physician cannot better study any set of signs than those afforded by the tongue, the palate, and fauces ; the terminating portions of that inner surface along which so many actions are carried on, both of health and disease. The observations of Dr. Beaumont on the precise and uniform relation between the tongue and stomach, in the curious case of St. Martin, might well justify this remark, were it needful to seek other authority than the daily experience of every medical prac- titioner. 449 CHAP. XXII. ON THE ABUSE OP PURGATIVE MEDICINES. In several former chapters I have had occasion to allude In- cidentally to this subject. But such allusions are insufficient in commenting on a part of practice, where the use of a most important class of remedies is often converted into an abuse, by wrong and indiscriminate employment; — without due regard 'to the natural powers of the body in health, or to the peculiar course of morbid actions in disease. If asked whether the use of purgative medicines, beneficial beyond all others under certain conditions, is not carried too far in modern English practice, I must affirm my belief that it is so; and each successive year of experience strengthens this conviction. It may be noticed as one of those instances of fashion in medi- cine, so largely sanctioned by reason and experience as to last beyond the ordinary term of mere novelties ; yet so far carried into excess, that the same reason and experience re- quire much abatement of the abuse. Two or three works of merited reputation on this subject; — the success of anti- phlogistic treatment in many diseases which had formerly been dealt with otherwise; — and especially the great benefit derived from purgatives, in certain cases where such treatment had before been deemed injurious, — all these circumstances concurred, about the same time, to give new reputation to this mode of practice. It may be added, that the simplicity of the treatment favoured its adoption by medical prac- titioners; while it had further countenance from the pre- G G 450 ON THE ABUSE OF judlces of the world, always prone to accredit a method from which there are obvious and sj^eedy results, however doubtful the benefit thence derived. We cannot wonder that fraudulent advantage should be taken by empirics of a feeling thus general, and so far sanctioned by the habits of more regular practice. The mis- chiefs which have thence arisen are, in fact, notoriously great. One form of purgative drugs succeeds another in noxious fashion; a fictitious need is created; and the functions of nature are injuriously supplanted, even under reputed health, by the compounds of quackery and fraud. This evil can only be lessened by a more reasonable employment of these medi- cines among the profession at large: and hence a further motive for weighing well what is really their use, and what their abuse, in our present practice. One of the greatest abuses undoubtedly is, the system of giving daily purgatives, and insisting upon daily evacuation; making this the habitual management in health, and the in- variable treatment in disease. Under both conditions, it is a notion fertile in mischief. Looking first to that of health; — It is certain that the natural constitution of different per- sons varies greatly as to the action of the bowels, and not less so the constitution of the same persons at different periods of life. To seek therefore by medical means for any thing like a common rule, is in most cases an absurd and injurious interference with the natural functions. The instances are frequent of individuals in perfect health who have action of the bowels only every second or third day. I have known cases much more remarkable from the length of interval; yet without the impairment of a single function of life; and where mischief even was produced by any frequent or forced interference with this habitual state. The practice of habitual purgatives unhappily prevails most in the cases. PURGATIVE MEDICINES. 451 where default of natural action arises from simple torpor of the intestinal canal. Yet these cases (so common among the higher classes of society, from sedentary life, deficient exercise, and other habits of society) ought especially to be exempt from the irritation of strong or frequent medicine. Dyspeptic symptoms, with increased torpor, are usually the immediate effect ; while more serious disease frequently occurs as the sequel and consequence of a long continued habit. The Colon, perchance, cannot readily or quickly propel its contents, though the earlier staa;es of dig-estion are well and easily performed. To remedy this defect, it is goaded by the constant use of cathartics, which injuriously excite and fret the stomach and long tract of bowels, through which they have to pass before reaching this part. Such habitual irritation of the mucous membrane, and of the intestinal glands, alters and depraves their secretions throughout the whole course of the alimentary canal, becoming thereby a further source of mischief and suffering to the patient. These disordered se- cretions are too often urged in proof of the need of further evacuation (an error sometimes arising from inexperience in the practitioner, sometimes from a much graver source); and thus the practice proceeds in a vicious circle of habit, from which the patient is rarely extricated without more or less of injury to his future health.* It is not enough considered, either by physicians or patients, that a certain degree of distension of the alimentary canal by solid contents is even necessary to its healthy state. It is probable that this is more especially true as respects the * It is especially in this part of the treatment of dyspepsia, that Homoeopathy gains advantage — not by its infinitesimal doses, but by forbearing from frequent and strong purgatives ; and thus giving scope to that resumption of the natural actions of the body, which our common practice does not sufficiently confide in. G G 2 452 ON THE ABUSE OF colon and rectum. I cannot doubt, from observation, that these bowels, even if not actually assuming diseased state from constant irritation of the mucous membrane, are often much injured in their functions by the want of equable and sufficient distension, which the habit of purging implies. Distension by air, which is the alternative, produces various irritation and distress, and impedes in every way the proper peristaltic motions of the intestine.* In effect of the causes of disorder cited above, the nutrition of the body generally suffers; the processes of digestion are imperfectly performed; the ingesta are hurried forward with- out the due amount of change and separation taking place; and there is usually decay of flesh and strength. The ex- pressions of Celsus, quoted below, are common to all the ancient medical authorities, and founded on the unequivocal observation of facts. f The effect of sudden and violent diarrhoea in depressing the vital powers is well known. Syncope is a frequent con- sequence; — death, when there is already great exhaustion, an occasional one. I have seen instances where a strong purgative, given directly after a severe and protracted oper- ation, or after a shock to the nervous system from accident, has produced very urgent danger by aggravating the ten- dency to collapse. These are extreme instances, but they form the index to others of more common occurrence. In cases where there is the habit of slighter, but constant, irritation by purgative medicines, the tendency of result is the same, though the immediate effects are less rapid and obvious. * To vTTOxwpiov tffTio OKXtjpop' Tr\r]£oQ Se Kara ra ticriovra. — Jiippocrat. Prcedic. f Purgationes, ut interdum necessariae sunt, sic, ubi frequentes sunt, periculum afferunt. Assuescit enim non ali corpus ; et ob hoc infirmum erit; cum omnibus morbis obnoxia raaximc infirmitas erit. PURGATIVE MEDICINES. 453 The extent of highly sensitive surface, forming the canal of the bowels, gives great scope to this influence; and few con- sequences can be stated more certain than the gradual un- dermining of the vital powers by the abuse in question. Disordered action of the heart, whether depending on disease, or on mere irritability of the organ, is often much aggravated by the habitual use of purgatives. Very fre- quently I have known it produced by this cause in nervous or dyspeptic constitutions, where the relinquishment of the habit has been found the only effectual cure. Such effects are readily explained, not only from the flatulence and acrid secretions thereby produced in the stomach and bowels; but also from the unequal balance and sudden changes in the venous circulation of these viscera, which always attend purging, and which affect directly the regular transmission of blood to the right side of the heart; — and further, it may be, by an impression upon the nervous centres, producing that sudden collapse, which I have already noticed as common under any inordinate action of the bowels. A discreet judg- ment is the more needful here, because there are other cases where disturbance of the heart is the effect of congestion about the liver and other chylopoietic viscera; requiring large evacuation for its relief. Firmness of practice, also, is essential in these instances; the persons who thus suffer being such as are least capable of interj)reting their own cases, or persisting in any principle of treatment. Every physician must be familiar with the frequent con- fession of patients, even of those most wedded to the habit, that they feel better on those days when there is no action of the bowels. Of such avowal we are bound to take advantage, unless there are circumstances especially to prevent us. It is difficult, in truth, to find a footing for relief in cases of this kind. The notion of instant remedy clings pertinaciously to G G 3 454 ON THE ABUSE OF such patients, and the mind becomes morbidly engaged to the habit. I have sometimes been successful in checking it, by expressly enjoining an action only on alternate days, as needful to health; thereby giving a new course to the sensations, and to the imaginations which attend them. In regarding the extent to Avhich this abuse exists, I am well persuaded that the judicious physician may do almost as much good by withdrawing medicines of this nature, as by their employment in cases of real need. And this, if it be a just opinion, is saying a great deal. For while thus speaking as to the excessive use of pur- gatives in ordinary health, — or in dyspeptic cases, where their abuse is the greatest, ^ I would in no wise seek to depreciate their value, as the most powerful means Ave possess in the treatment of disease ; — nor deny that modern practice has carried them into successful use (both by themselves, and in aid of the action of other remedies) where opposite prin- ciples of treatment had long unavailingly been employed. In truth, there are cases where the bold and steady per- sistence in this method produces effects attainable in no other way. Such is especially the fact where the head is the j^art affected; — or the liver and other organs connected with the system of the vena porta; — or in certain cases of dropsical effusion, depending on disease of these organs, and where the kidneys refuse their office; — or again, where the body is disordered by certain morbid matters collected and cir- culating in the blood, the removal of which can thus only be speedily and sufficiently obtained. The latter case, of which I have spoken more at large elsewhere, is one of much im- portance in pathology.* I may describe it briefly here as that attested in practice by the very large and long continued discharge of dark grumous matters, usually termed bile, and * See Chapters XVII. and XXI. PURGATIVE MEDICINES. 455 understood to come from accumulation in the liver; but which I doubt not to be secreted in great part from the membrane or glands of the intestines; and to be a gradual separa- tion from the blood of matters noxious to the system; such as produce, by retention, various forms of active disease. Here, if natural evacuations do not occur, the free and ade- quate use of purgatives gives proof not less of the judgment than of the boldness of the practitioner. In the foregoing cases (and others might be added to them) this vigour is sanctioned to an extent even beyond that to which it is carried in ordinary practice. For it is not para- doxical to affirm, that the practitioner who deals too familiarly with these medicines in all cases, is less likely to use them boldly and sufficiently where the need is greatest. The accustomed habit of practice is carried on to the particular emergency, and due discrimination is wanting in both. And again, with respect to the amount of dose, in those cases where there is express demand for purgatives for the relief of disease, it is a frequent error, and often arising from the very cause just cited, to reduce this too much; and to substitute small repeated quantities for those capable of more instant and powerful eifect. With the exception of cases of very feeble vital power, where sudden changes of any kind involve risk, there is commonly less disturbance to the constitution from this decided practice, with fitting pauses between, than from the seemingly milder plan of small doses and daily repetition. And further it is to be noticed, that the large dose often produces action different in kind, as well as degree, from that of smaller amount ; and is in this respect more beneficial in those instances where free evacuation is wanted from the system at large. Yet, even in many forms of actual and dangerous disease, it must be admitted that there is excess in our employment G G 4 456 ON THE ABUSE OF of these medicines, and some justification of the reproach which English practice has incurred on this score. In cases of obstruction of the bowels, where the name seems to lend complete sanction to the treatment, we may affirm that it is often carried on too grossly and indiscriminately. If vomiting does not actually prevent it (and frequently indeed at the risk of bringing this on) purgative is hurried after purgative, with increase of dose, or adoption of more drastic medicines, at each successive step; — often with little thought as to the causes of obstruction, — with much danger of producing in- flammation in the obstructed part or elsewhere, — and with no due allowance for the tendency which all parts have to resume a healthy action, if left in quiet. I do not mean that purgatives shoidd not be given in cases of obstructed bowels. But I am anxious to convey a caution, required, as I think, by the too uniform direction of practice in these instances; viz., that if there be distinct local pain, threatening inflammation in any part of the canal ; — or much active irritation, with nausea and vomiting; — and if the first cathartic medicines, freely given, fail of success, — it behoves the physician well to consider whether he shall urge this treatment farther. There are doubtless cases where it is expedient to do so; but many others where the irritation of drastic purgatives hurries on the patient to danger of fatal result: — and this not unfrequently, where thorough quiet; abstinence equally from food and medicine; leeches and fomentations over tender parts of the abdomen; or still better, in many cases, leeches to the hasmorrholdal vessels; Avould have removed obstruction, and the danger consequent upon it.* * The latter point of practice has not been sufficiently attended to ; though more on the Continent than in England. I doubt not that in various cases of visceral inflammation, obstruction, or disease, much more PURGATIVE MEDICINES. 457 In these important cases of apprehended obstruction of the bowels, it is obvious, on the grounds just stated, that the first use of cathartic means should be the most vigorous, instead of the reverse. If the effect be obtained, it signifies little that the dose has somewhat exceeded the necessity. If otherwise, the chances of mischief by repeated and augmented irritation are spared, and we obtain the indications most to be desired for further treatment. There can be no doubt of the fitness of using purgatives in the early stage of most fevers; though I believe it might be well in almost every case to let emetics have the precedence. But even in fevers there ought not to be daily purging, as is often practised; nor ought the use of such medicines to be continued needlessly or harshly, during the early periods of convalescence, when nature is seeking to right itself in all its . functions, and can ill bear such interference. The same re- marks apply still more explicitly to many diseases of local inflammation, where this treatment persevered in becomes a certain source of mischief to the patient.* In inflammations of the chest, for example, as well as in other disorders of this part, cathartic medicines are often employed to a very in- might be attained by drawing away blood from the bsBmorrhoidal vessels, than by the methods of treatment generally in use. Looking to the connexion of these vessels with the circulation through the liver and intestines, it is a strong presumption (and my experience justifies me in so stating it) that no given quantity of blood can be abstracted elsewhere, in cases of this nature, with equally good effect. The remedy particularly de- serves trial In inflammation of the bowels, with obstruction. The influence of the state of the liver upon htemorrhoids affords presumption of what may be obtained, in disorders of this organ, by bleeding from the vessels of the rectum. In the following chapter (on Bleeding in Affections of the Brain) I have spoken of this remedy, as applied especially to cases of cerebral or spinal disease. * Ev Toimv o^fcri iraQtaiv oXiyaKtc, Kai iv apxn'^t rijm ^apfiaKirjcn xpttcdut, is the expression of Hippocrates, in his aphorism on this subject. 458 ON THE ABUSE OF jurious extent. They have no specific effect in such cases ; and thoufrh the removal of vitiated secretions from the stomach and bowels is needful in aid of other treatment, and as preventing the access of fresh disorder, yet their retention for a while is generally much less hurtful, than the irritation created in thus incessantly forcing them away. It may further be affirmed (without recurring to any ancient theories of fever) that there is frequent injury arising from interference with the ordinary course of a disease, when this is so far definite as to mark a series of changes, con- nectedly taking place in the system. In the exanthematous fevers more particularly, the use of strong and repeated pur- gatives, prior to, or during, the eruptive part of the disease, is often a well-marked cause of evil; — retarding or repelling the eruption, and transferring morbid actions to parts out of the ordinary course of the disorder. The experience of every observant physician will remind him of cases illustrating this fact. The vigour of practice, which is mischievous and out of place here, more fitly belongs to the time when an eruption is receding ; and when morbid matters, the cause or product of the disease, are seeking egress from the system. These considerations include some of the most important questions in pathology and practice; nor have they, as I think, been duly recognised in the treatment of diseases at the present time.* The knowledge where to abstain is at least as valuable as that where to act. To preserve the character * Even as respects the practice of bleeding in acute inflammations, there is something yet to be learnt as to the relative fitness of the remedy at different periods of the disorder. We may wholly put aside the limit- ation of Hippocrates to bleeding on the fourth day in Inflammation of the lungs ; and yet acknowledge that one time for such remedy is fitter and more effective, as regards the given quantity of blood removed, than another : and further, that there may be specific inflammations of different organs, in which the rule matei'ially varies. PURGATIVE MEDICINES. 459 of medicine as a science, each path must be kept open; and the practice be decided by a regard both to what is the natural or necessary course of symptoms, and to those new actions which it is in the power of medicine to produce and maintain. Without embarrassing the question by the endless nomen- clature of fevers, I would remark that the disorder, often epidemic, to which the term of gastric fever is fairly applied (where there is manifestly great disturbance, congestion, and depraved secretion of the chylopoietic organs, without any symptoms of true inflammatory kind, but with tendency rather to a typhoid character), is, on my experience, the form of fever most benefited by the full use of purgatives; not merely in clearing away disordered secretions already in the bowels ; but further, perhaps, by aiding their more speedy and effectual separation from the blood. It will, I think, be found, that most physicians who have begun their practice with a large employment of active pur- gatives, abridge this more or less as their experience is matured by time. No physician, indeed, as I have before said, can rightly relinquish the benefits of this treatment, boldly and vigorously employed, in certain cases of disease ; but the limitation of such vigour to actual disease is that which a wise experience will teach, as the general rule of practice. It is a rule, however, like all others in medicine, with many needful exceptions. One of the most frequent and reasonable of these regards the use of laxatives with direct reference to the ■prevention of illness ; as in those cases where, from con- stitution or habits of life, there is a strong tendency to accu- mulations, morbid or otherwise, in the vascular system, or to various forms of deposit in the body. Here full purging, at certain intervals (and these may often most usefully be made periodical) is the best safeguard we have against con- 460 ON THE ABUSE OP tlngent evil. The gouty temperament, when strongly marked, will occur as an instance in point. The acute attacks of this disorder, if not obviated, may at least be mitigated and ren- dered less frequent by such periodical evacuations, giving egress to some part of the material of the disease. But here, too, the same principle must be kept in mind, and forbearance be blended with our vigour ; otherwise the prevention of one mischief becomes the source of many. Nor can the need be doubted of aiding the natural action of the bowels in many cases where there is habitual costive- ness, either from particular temperament or the casual con- dition of life. But I have already pointed out the great abuse by excess in this part of practice ; and the importance of giving more scope than is usually done, to the natural powers of the organs in retrieving any such casualties. I advert to the sub- ject again ; as well to enforce this, as also to suggest the value in these cases of the direct combination of tonics with aperi- ents ; a form of prescription which might well be brought into more general use. In the greater number of instances of this kind, weakness in the proper propelling action of the bowels is the cause of costiveness ; and in seeking to remove the effect by means Avhich act through irritation only, we do but add to the mischief, from the invariable effect of irrita- tion in lessening power. Here, then, the tonic, conjoined with the aperient, generally enforces its action, without weakening the organs. These in fact are the cases in which, if there be no ii'ritation of the mucous membrane, bark will itself often act as a laxative. I have known many instances where calomel, colocynth, and gamboge, in large doses, have had little other effect than that of injurious irritation ; but where a few drachms of infusion of senna, with decoction of bark, have been amply sufficient in habitually producing the desired action. The benefit ob- PURGATIVE MEDICINES. 461 tained in certain disorders from the combination of laxatives with the preparations of iron, though depending probably on other conditions, is well known to every physician. Such methods of practice are of more especial value in those languid and strumous habits in which good digestion is so essential to the maintenance of health, but where the digestive organs themselves partake in the general debility of the system. If these organs be further weakened by an irritation habitually repeated, without any countervailing aid to their functions, not only is nutrition impeded in such cases, but the foundation often laid for more active and lasting disease. 462 CHAP. XXIII. ON BLEEDING IN AFFECTIONS OF THE BRAIN. Though the form and argument of this Chapter are retained as they stood in the former editions, the errors in practice to which it relates are certainly of late years lessened in amount, and I have reason to indulge the belief of having in some part contributed to this effect.* The question, however, * The change, alluded to above, must in part be associated with the present more limited employment of bleeding as a general remedy. This very important modification (for I would not willingly call it a fasMoii) has chiefly occurred within the last twenty-five years. It is equally difficult to prove, or to disprove, the opinion entertained by some phy- sicians, that it depends upon, and is justified by, an alteration in the general type and character of disease during this period. It may well indeed be, that the frequent injurious, or even fatal, effect of bleeding in the earlier epidemic influenzas of our own time, before the adynamic character of the disorder was sufficiently known, has had influence in limiting the use of this powerful antiphlogistic remedy, even in cases where it was before deemed of the first necessity. Nor can it be reasonably doubted, that the continued fevers occurring during the last twenty years, have had more of typhoid character, and borne less depletion than heretofore. But the ulterior question still remains, whether we may suppose an epidemic constitution to extend over this later period of time, disj^osing all diseases to assume this low type ; and hence prohibiting or abridging the use of all such means as tend to abate the vital power, and of bleeding as the most powerful of them ? This is a question which descends to us even from the days of Hippocrates ; though generally applied rather to the constitution of a particular year or season, than to a series of years, as in the case before us. I cannot pursue the subject here ; but it well merits attention as a part of medical philosophy. It is curiously instructive in medical history, to contrast the large and BLEEDING IN AFFECTIONS OF THE BRAIN. 463 may yet be urged, whether the practice of depletion by bleeding is not still too general and indiscriminate in affec- tions of the brain, and especially in the different forms of paralysis ? I believe that the soundest medical experience will warrant the opinion that it is so. The vague conception that all these disorders depend upon some inflammation or pressure, which it is needful to remove, too much pervades and directs the practice in them : and if the seizure be one of sudden kind, this method of treatment is often pursued with an urgent and dangerous activity. Little heed is taken of the many cases where the symptoms depend upon irritation alone — or on loss of nervous power — or on defi- cient circulation of the blood within the brain — or on altered qualities of this blood — or, it may be, on morbid changes in the nervous substance itself. Theory might suggest that in some of these various cases, the loss of blood would lead to mischief. Experience undoubtedly proves it ; and there is cause to believe that this mischief, even in its abated form, is still neither infrequent nor small in amount. It is certain indeed that there is a state of brain, best perhaps represented to us in its general effect of diminished nervous power, which tends to produce sometimes spasmodic seizures ; sometimes delirious or maniacal affections ; sometimes palsy of different parts of the body ; — these effects being in no way ob\dated by depletion, but rather increased by all such means ; while they are relieved by remedies which tend to various use of bleeding at other periods with that customary at the present day. We must feel that Le Sage has in no way coloured his Dr. Sangrado too highly, when reading the Lettres de feu M. Guy Patin,, £)octeur de Medicine de la Faculte de Paris ; — one of the most curious, as well as voluminous, collections of letters that exist ; and prolific of ma- terials for the political, as well as social and medical history of the time. The record they give of the struggle between the disciples of the Lancet and those of the Antimonial school is eminently amusing. 464 BLEEDING IN AFFECTIONS OF THE BKAIN. excite the energy of the sensorium, and to augment the gene- ral power. I have known cases of this kind where bleeding has immediately been followed by convulsions of epileptic character ; occasionally by amaurosis or deafness ; more fre- quently still by rambling delirium ; and where wine or other cordials have as speedily abated these tendencies. The fevers of typhoid type, or those which are called nervous (in default of a better name) aiFord constant examples of delirium de- pending on this peculiar state of the sensorium. In cases of large and sudden haemorrhage (as in that of the uterus after childbirth) the whole system is often put into a state of seem- ing excitement ; and the head in particular affected with acute pain, throbbing, and vertigo ; which symptoms sometimes con- tinue for a considerable time, and are best removed by such means as gradually and equably restore the circulation and nervous power. Delirium, preceded generally by vertigo, is known to be an effect of extreme starvation, without other obvious disease ; as frequently recorded in the narrative of shipwrecks, &c. The condition of the patient in Delirium tremens, on whatever proximate cause this may depend, is one of the most marked instances of that state of brain which any large depletion might hurry on to fatal result. Here in- deed the treatment is not often mistaken ; but in many cases essentially the same, though less distinct in symptoms, and less obvious in their origin, the mischief done by large bleed- ing is long continued, and sometimes of irreparable kind. In the valuable experiments of Sir Astley Cooper (Guy's Hospital Reports, No. III.), the tying of the two vertebral arteries, which have seemingly a more important relation than the carotids to the cerebral circulation, brought on various forms of paralytic as well as spasmodic affection. Here we have direct proof that the brain, suddenly and largely deprived of blood, becomes liable to conditions apparently the same as BLEEDING IN AFFECTIONS OF THE BRAIN. 465 those which we so often employ bleeding to obviate or relieve. They may be really diiFerent in many cases, and the facts show them to be so. But where we have this source of ambi- guity, it behoves that our practice be carefully guided by a reference to the constitution, habits, and age of the patient, as well as to the first obvious effects of the treatment pursued. — I have known many instances where bleeding has been re- peated, to remove the very symptoms which it was next to certain it had been the means of bringing on. In the experiments just referred to, sudden privation of blood produced a state of the brain which doubtless exists in effect of other causes of slower operation ; manifesting itself in every grade of deviation from the healthy state. It would be difficult to define it by name ; but presumably it has close relation to that already mentioned, where there is a deficient or altered nervous energy ; — testified in slighter cases chiefly by its influence on the mind and animal spirits; in those more severe, by the tendency produced to convulsive and paralytic affections. This temperament, doubtless depending on a physical cause in the organ, will be familiar to all who have attended to this class of diseases. It appears to have much connexion in its nature with some of the changes which occur in the brain in old age ; and possibly from similar causes as respects the supply of blood to this organ. Anxiety and distress of mind long continued, or even the habit of over- strained intellectual labour, produce a similar state ; and fur- nish much reason to the physician why he should exercise singular caution in all such cases. Certain it is that bleeding unduly practised in habits of this kind — and especially when the time of youth is past — dej)resses the nervous system, and through it, more or less, all the functions of the body ; pro- ducing for a time a sort of premature approach to old age H H 466 BLEEDING IN AFFECTIONS OF THE BRAIN. throughout the whole being. I have notes of some remark- able cases to this effect, in which the influence of the cause was unequivocally continued for a long period, passing even into years, after the original occurrence. In infancy, also, when the brain and nervous system are more easily and critically affected by causes of excessive or deficient excitement, effects of the same kind folloAV great depletion, however produced. These, by a fatal error, are often mistaken for proofs of inordinate action, or of pres- sure; and a practice adopted of which it is difficult to recall the consequences, when once incurred.* Even in those cases of cerebral disorder where the tendency to coma might give stronger presumption of pressure, I have sometimes had the most direct cause to believe that large bleeding induced paralytic attacks, which might otherwise have been spared. f These are instances in which absolute proof can scarcely be attained; but where the presumptive evidence may be such as nearly to approach to it. Two or three examples have occurred to me, in which — looking at the circumstances before and after, as well as at the immediate concurrence in time of the bleeding and paralytic seizure — it could hardly be doubted that they stood to each other in the relation of cause and effect. The existence of such instances, * This important point in practice bas been explicitly noted by some of our best medical writers ; but experience shows that it is still not suffi- ciently enforced. f In using the term Cerebral here, as throughout this chapter, I have not thought it needful to advert to the distinction now established between the brain proper, and the system of the medulla-oblongata. The relation of these respective parts in their morbid states is so complex and close, ; s for as our present means of diagnosis go, that, even in reasoning upon points of medical practice, it is necessary, if not expedient, to consider them together. Even if we had more certain methods of distinguishing them, we have yet no well-determined rule of practice to adapt to this distinction. BLEEDING IN AFFECTIONS OF THE BRAIN. 467 or even the suspicion of them, may well warrant a singular caution in this part of practice. The state of Coma is indeed a very ambiguous one, as re- spects our knowledge of its proximate cause. In the ordinary use of the term, the notion of pressure is associated with it by most practitioners ; and this even in the cases where it seems but as an excess of the condition of sleep. But it is familiar to us also as a concomitant and token of the last stage of debility; and is often expressly induced by depletion and other depressing causes, as well as by those which are known to produce direct pressure on the brain. Even in children we have express instances of a state having all the characters of coma; but which is proved by the precursory causes, as well as by the effects of medical treatment, to depend on general feebleness of circulation and deficiency of nervous power. There is reason, indeed, to presume that the two states just alluded to are really distinct; and that the former is much more nearly akin to the condition of syncope than that of pressure : or however related, as respects the nervous sub- stance itself, so different in the operation of the causes pro- ducing it, as to require a method of treatment altogether opposite. Here, then, the governance of names must be put aside ; and the more sedulously, from that close resemblance of symptoms which makes the utmost discretion of the physician necessary, rightly to direct his practice for their relief. Nor can any rules be given, at once general and exact enough, to supersede the particular judgment in each case. Vertigo, in all its degrees, is another symptom which often conveys alarm, from the idea of pressure on the brain, and leads to immediate depletion under this view. In some cases the inference and practice are just and beneficial. But there are others (and these of very frequent occurrence) where vertigo is the effect of causes wholly remote from fulness or H H 2 468 BLEEDING IN AFFECTIONS OF THE BRAIN. over-action ; being in fact the approach towards syncope, and a proof of exhaustion of the nervous power. Here we re- quire, not bleeding, but cordials, to restore the due action of the heart and brain; and a wrong practice may lead into serious danger. As in the instance of coma, just mentioned, we must presume a wide distinction between states requiring a treatment so different, though the seeming resemblance of symptoms has led to the same name for both. The giddiness and confusion of senses, which precede a fainting-fit, must clearly be separated from symptoms which depend on vascular excitement of the brain. The frequent occurrence of vertigo, in apparent good health, as well as under actual or threatened disease, is a reason for sedulously noting this distinction; which may generally be done by observation of other symptoms, or of the causes especially acting on the body at the time. The difficulty of getting a correct nomenclature for morbid sensations applies peculiarly indeed to the head; of which the ambiguous use of the terms light and heavy head may be taken as a familiar example. It must be owned, however, that the names here are not much more vague than the know- ledge they represent. That state in which the head feels as if without weight or substance, common though it be, has not yet received any physical explanation. Many of the varieties of headache are as little defined by our knowledge of their cause, as by the terms used in describing them ; thovigh pro- bably the greater number depend on different conditions of the circulation through the brain. Of these conditions that of con- gestion or retarded circulation, varying in the degree of vas- cular pressure it produces, and in the vessels in which it occurs, is presumedly the most frequent.* * In regard to tlie cerebral circulation, and tbe effects of changes of vascular pressure within the cranium on the functions of the brain, the BLEEDING IN AFFECTIONS OF THE BRAIN. 469 Among other symptoms which are still to be considered doubtful, as representing states of the brain, I may mention the dilatation of the pupil, and susceptibility of the retina. Direct observations shoAV that these conditions depend for their degree upon different causes; and accordingly we find, as a pathological fact, that, in cases of compression, concus- sion, or other disorder of the brain, we may have either contraction of the pupil, and a very sensitive state of the retina, or the reverse of this, without our being able se- curely to predict either of these states. Sometimes, too, they pass into each other; and each may occur in high degree, yet disappear without fatal or even mischievous consequence. Inequality in the pupils of the two eyes is perhaps to be taken as a more certain proof of some organic injury. But here also we can rarely afSrm whether the dilated pupil con- curs with the side affected or not; and other evidence is re- quired to determine our practice as regards this distinction. I mention these various sources of ambiguity, not to incul- cate distrust of all practice in such cases ; but merely to hold out caution against that indiscriminate principle of treatment which finds pressure in every altered condition of the brain; and motive for bleeding in every transient irritation of parts, still but imperfectly known to us in their functions and various diseases. Even were the tendency to paralytic seizures as generally lessened by bleeding as common practice would imply, it does not thence follow that abstraction of blood from the brain should be needful or desii-able, in immediate sequel to such attack. In many cases it is undoubtedly otherwise. The paralysis, when depending on apoplexy, with extravasation reader cannot do better than consult the valuable treatise by Dr. Burrows, " On Disorders of the Cerebral Circulation," published a few years ago. H U 3 470 BLEEDING IN AFFECTIONS OF THE BRAIN. of blood or serum, or on other cause of continued pressure, may come on by degrees, and admit of relief in its progress by emptying the vessels of the head. But often it occurs as an instant shock to a portion of the brain or spinal marrow, without any proof of extravasation or obvious cause of pres- sure; — the shock itself being of momentary duration, though leaving lasting effects on the parts of the nervous system thus affected. In these cases, and they are frequent, the phy- sical causes of the change are little known to us. There are reasons for supposing that the nervous substance itself is often primarily affected. We have certainly no sufficient proof of mere pressure from fulness of vessels being concerned, to warrant large bleeding, especially after the stroke of palsy has actually occurred. The degree of coma, attending and following these seizures, is not alone sufficient cause for the practice; and will usually subside without it, where the ori- ginal attack is not such as to endanger life.* Looking indeed to the magnitude of the event which has occurred between, common reason Avould suggest a doubt whether the same treatment can be desirable immediately before y and after a stroke of palsy. I do not mean to give this the weight of an argument. From the nature of the circumstances, it is extremely difficult to bring unequivocal * The question as to what constitutes the cure of paralysis is not less difficult than that as to the causes of original seizure ; our Ignorance of the structure Involved forming the difficulty In each case. The medullary fibres are presumably the parts immediately affiacted ; — but whether by effu- sion between them, which is removed by absorption ; or by any breach of continuity which is repaired; or by conditions yet more remote and subtle, we are unable to affirm. From the operation of causes affecting the brain alone. It may be Inferred that In hemiplegia the morbid change takes place at or near the origin of the motor fibres ; but the evidence as to other kinds of paralysis would seem to show that this Is not a necessary part of the phenomenon. BLEEDING IN AFFECTIONS OF THE BRAIN. 471 proof on the subject; but thei'e is much cause to believe that the practice of bleeding in the latter case is often injuriously- pursued. The risk, I believe, will generally be less from waiting a certain time — to observe the effect of what has occurred, upon the circulation, the breathing, and the sen- sibility — than from hastily taking away blood, at the mo- ment of a great shock to the brain, and before we can rightly appreciate its consequences. This effect upon the principal functions of life, gives us in fact the best information we can have in guidance of further practice. But we forfeit all such evidence under the disturbance any large depletion makes in the system, and particularly in the organs upon which these functions depend. The importance of this consideration may readily be understood. It is a point constantly brought before us in practice. Even where evidence is obtained of the fitness of bleeding soon after one paralytic attack, for the prevention of another, the question still remains as to the manner of this ; — whether by copious depletion at once, or by smaller bleedings, repeated as observation may suggest. And this question the practitioner, while prepared for boldness in all fit and urgent cases, is bovmd always to keep before him ; seeing especially that any great excess in the remedy may hurry on the very mischief it is sought to prevent. I believe that in most cases the latter method is to be preferred. It accords better with the state of our knowledge of these disorders ; involves no irretrievable step ; and in its progress affords the information most requisite to decide how far it should be carried into effect. Paralytic cases there doubtless are, of such nature, that a few ounces of blood taken away at regular intervals will ward off a recurrence of the attack, which any large and sudden depletion would probably hurry H H 4 472 BLEEDING IX AFFECTIONS OF THE BRAIN. on. The proof here can seldom be explicit; but the pre- sumption is one I have often been led to entertain. These remarks, and the cautions they suggest, are familiar to many, and to such needless. But I feel assured, from what I have seen, that they ought to be carried further into general practice. The use of the lancet is easy, and gives a show of activity in the practitioner at moments when there appears peculiar need of this promptitude. Current opinions and prejudices are wholly on the side of bleeding ; and the complexity and danger of the cases tend to obscure the results of the treatment pursued. The physician needs all his firmness to decline a practice thus called for; where the event is so doubtful ; and where death may be charged upon his presumed feebleness or neglect. While making these remarks, however, I must be under- stood, as recognising, in the fullest sense, the value and need of this remedy, promptly and vigorously used, in various cerebral diseases ; or in prevention of such, where well-marked symptoms lead to their anticipation. And I dwell upon this the more earnestly, lest, while merely inculcating a cautious discrimination as to the cases for its use, I may seem to be seeking reasons against the practice altogether. In active inflammation of the brain or its membranes — in many states of pressure from congestion in the head, topical or general, without inflammation — in cases where extravasation may be presumed to be going on, which it is the object speedily to suspend — and even in other conditions of cerebral irritation less definite than these, we have no method of treatment equally eflfectual; and safety often depends solely on the speed and suflSciency'of its employment. But almost in the same ratio with the necessity of the remedy in these cases, is the importance of refraining from depletion in other in- stances, which can only be distinguished fi'om the former by BLEEDING IN AFFECTIONS OF THE BRAIN. 473 a careful observation of all the symptoms, and of the probable causes in which they have their origin. And, in the right direction of diagnosis and treatment here, we have the best proof that the mind of a practitioner is equal to the most difficult exigencies of his profession. There are one or two lesser points in the treatment of affections of the bi'ain, and connected with the circulation through this organ, which deserve more discrimination than they usually obtain. One of these is the general use of ice, or other cold applications, to the head. Any influence of cold, through its effect on the capillary vessels of the scalp, is at least ambiguous in such cases; and though its direct sedative effects on the nervous system may afford more cer- tain warranty for the practice, yet these require to be dis- tinguished and watched over in their progress. For even where relief is distinctly obtained from cold suddenly applied to the head (as after intoxication), it by no means follows that this application, long continued, will produce or maintain a like benefit. It is well known in various parts of practice that the fact is otherwise ; and that the effect of cold upon the circulation and nervous system is sometimes even reversed, according to the manner and degree of its application. Or allowing, as I readily do, tliat there may be a distinct sedative effect from cold, beneficial in cases of inflammation of the brain or its membranes, will this equally apply to apoplectic cases, where pressure occurs from fulness of vessels or extravasation ? If the relief to some kinds of headache be alleged, it must be remembered that other headaches are increased by this means. The same disparity doubtless exists as to the more serious affections of this oro-an, re- quiring discrimination wherever we can exercise it. Unfor- tunately these are cases in which patients themselves can gene- rally render least aid. Sometimes they are manifestly uneasy 474 BLEEDING IN AFFECTIONS OF THE BRAIN. under the application of cold ; and this feeling, whenever it can be ascertained, is far better than any other test. It is one of the cases where a patient may reasonably be admitted to judge for himself. I believe that patients labouring under affections of the brain are too indiscriminately forced to a raised position of the head, with the vieAV of lessening the flow of blood or congestion there. Such effect it undoubtedly has: and in many, perhaps most, of these cases it is a prudent precaution. Sometimes, hoAvever, it is employed without any good to compensate for the discomfort thereby produced. And fur- ther, there are many cases, like those already alluded to, where the diminished energy of the brain seems to require a full and equable circulation through it; and where the symptoms are aggravated by the compulsion of a raised pos- ture. The effect of sudden recumbency in relieving faintness is a familiar illustration of this ; and conversely, the vertigo which frequently occurs, especially in a weakened state of body, upon suddenly rising from a couch. Headache more- over in some instances is brought on, or much augmented, by the upright posture ; and subsides when this is changed. In general we may gather from the patient which position of the head is best : — or the colour of the face, the state of breathing, and the action of the heart will suffice to tell it, if he be unable to express his own sensations. Perhaps altogether the respiration is the most certain test we can employ in the absence of this expression. Bleeding by leeches from the haemorrhoidal vessels might be much more frequently employed than it is, in affections of the brain, as well as in those of the spinal cord. I know no mode in which a given quantity of blood can be removed with equal effect in such cases, when depletion is required. It may be difficult to give strict anatomical reasons why this BLEEDING IN AFFECTIONS OF THE BRAIN. 475 should be so : but what we know on the curious subject of the changes of balance in circulation, will at least furnish illustration of it. Nor can I doubt that something here is due to that peculiar relation between the blood in the portal circu- lation, and the functions and diseases of the brain, of which experience affords so many remarkable proofs. For the practice itself we have especial argument, in the frequent alternation of bleeding hasmorrhoids with headaches and other graver affections of the head; and also in the serious effects which sometimes ensue upon the suspension of such discharge, after it has become habitual to the system. In the foregoing remarks, particularly those which relate to bleeding in affections of the brain, I have spoken of these disorders in a way which may seem too general and vague for practical purposes. In explanation of this, I would make one or two remarks. In the first place, I think the object likely to be best fulfilled, of deterring from indiscriminate bleeding, by broadly pointing out the great practical dis- parity of certain conditions of the brain, which have some appearances in common ; and which even produce (though doubtless in different way) certain similar effects upon other parts of the body. The attention of the practitioner, if well awake to this distinction, will rescue him from a blind adhe- rence to the one method of instant treatment, so generally in use. It will further direct him to those special indica- tions — whether derived from the age and general habit of the patient ; from the action of the heart and arteries ; from the respiration ; or from change in the functions of the brain itself — Avhich may give better and safer guidance to his practice. Secondly, while fully admitting the value of what has been written on diseases of the brain, and the great advances re- cently made to their better classification, I can scarcely think 476 BLEEDING IN AFFECTIONS OF THE BRAIN. the latter object to be yet duly attained.* This remark applies alike to the diseases depending on inflammation of the brain and its membranes ; on altered circulation in the organ from other causes ; or on extravasation or effusion within the cavity of the cranium. Still more expressly does it apply to lesions, general or partial, of the nervous substance itself. Here the difficulties of exact observation, and ignorance of the func- tions of particular parts, have hitherto precluded any such intimate knowledo-e as might furnish a basis for classification and treatment ; and we are compelled rather to look to changes in vital condition, than to actual pathological states, in reasoning on the subject. f That there are diseased con- ditions of the nervous substance, more numerous and varied than those hitherto described, may well be admitted both from analogy, and from notice of effects not easily referrible. to any other cause. Nor can it be doubted that many of these will hereafter become known to us ; the path for such researches being widely open, and the methods and instru- * It is impossible not to advert here to the work of Dr. Abercrombie, which has done so much towards a right arrangement of these difficult and important diseases. Also to Dr. Bright's Treatise on Diseases of the Brain and Nervous System (vol. ii. of his Medical Reports), in which a very good basis of classification is proposed and followed. And, further, to the Memoir on Injuries of the Brain and its Membranes, by Sir B. Brodie, in vol. xiv. of the Med. Chirurg. Transactions. I have already alluded to Dr. Burrows's work on the Cerebral Circulation. t I may instance the question, still undecided, whether the state of ramollissement of the brain can ever occur without preceding inflammation. Dr. Abercrombie's opinion, that there are two distinct causes of this state, is probably that nearest the truth ; and the recent microscopical researches of Professor Gluge (Archives de la IMcdecine Beige, No. I.) woidd seem to confirm this opinion. The difficulty of obtaining unequivocal proof in these cases is hardly to be understood by those who do not know them on experience. The diagnosis in lesions of the brain Is not aided by those external physical signs which have lately obtained such invaluable application to diseases of the che?t. BLEEDING IN AFFECTIONS OF THE BRAIN. 477 ments of inquiry much better fitted for success than at any- former time. Meanwhile, in this yet imperfect arrangement of cere- bral disorders, there is cause for treating of bleeding as a general question of practice, even without express reference to the particular forms of cerebral disease. And from the difficulty as Avell as importance of this question, it is better perhaps that the medical man should have it constantly before him in this light, than that his judgment should be submitted to rules and nosological distinctions, the application of which to actual disease involves almost as great risk of error, as he can incur in proceeding without these technical aids. 47 CHAP. XXIV. ON THE USE OF EMETICS. Among the changes which time and fashion impose upon the treatment of disease, Emetics as a remedy have fallen into comparative disuse in English practice. It is no longer now, as heretoforcj one of the first questions before the mind of the practitioner, when called to prescribe for a disorder, whether the stomach should not be immediately thus re- lieved. The suggestion of the patient himself is for the most part needed, or some other equally express indication, to lead to their use. I am speaking here only of a general alteration that has occurred. The exceptions to it are of course numerous ; but the truth of the fact so stated will probably not be denied. The cause of this change may chiefly be found in that laro-er and more various employment of purgatives, which forms the character of our modern practice. To what extent is the alteration of method a beneficial one ? I believe a fair consideration will justify the opinion that in several respects the change has been carried much too far. Vomiting, es- pecially when brought on at the outset of fevers and many other diseases, produces effects of a kind, and with a speed, which no purgatives alone can equally obtain. The action of Emetics is not merely valuable in unloading the stomach and upper part of the alimentary canal ; but it is certain that their influence goes far beyond this point ; and that other parts of the body, even the most remote and different in ON THE USE or EMETICS. 479 structure, are powerfully acted upon. The emetic, more- over, if rightly used, is beneficial not merely in its effect of removing morbid matters from the body ; but often even by the nausea attending its operation, and by the muscular effort and struggle it induces, in the act of vomiting; a com- bination of advantages belonging to few other remedies. The experiments of Magendie seem to have proved that the stomach itself is passive in vomiting ; and that the action is due to convulsive movements of the diaphragm or abdominal muscles ; brought on, not solely by emetic or other irritatino- substances in the stomach, but by similar agents introduced directly into the blood ; as well as by certain states of the brain and nervous system. As I have in view only the practical application of the remedy, I need not advert to these points in physiology, further than to remark, that they illustrate much more satisfactorily the various causes of sickness, and the effects of Emetics, than the old notion that the stomach alone was concerned in this action. There are still points of ques- tion as to the proximate causes of vomiting ; even such as relate to the state of the diaphragm in the act, and in Avhat particular way it is connected with the function of respiration. Something also may be learned of the manner in which par- ticular irritations produce sickness, by reference to reflex nervous actions through the spinal cord. But, for the reason just given, I merely allude to these topics of inquiry. It is unnecessary to say much of the effects of vomiting as a remedy upon the stomach itself. The relief got by re- jecting undigested food, or morbid ingesta of other kinds, is not, however, to be regarded as the only benefit thus ob- tained. The secretions from the mucous membrane lining this organ are frequently such in kind and quantity, that their removal becomes necessary to all further treatment ; and ac- cordingly we find that instant good is often derived from 480 ON THE USE OF EMETICS. Emetics, where these matters alone are discharged. While still left on the stomach, all other treatment by internal remedies is injurious or unavailing ; — a point not sufficiently regarded in ordinary practice, where the failure of one medi- cine is too often made the prelude to another trial of similar kind. It may be that Emetics have influence also in changing the nature of the secretions from this organ, either by in- ducing the state of nausea, or by the act of vomiting ; each, as it would seem, capable of this effect, though perhaps in different manner. IMuch caution, however, is necessary as to the use of Emetics in another state of the stomach and alimentary canal where the secretions from the lining membranes are almost wholly suspended ; and where there is general gastric irri- tation, tending to inflammatory action, indicated by redness and dryness of the tongue, fauces, and throat ; and often by tenderness over the region of the stomach itself. These, indeed, are cases where the effort to vomit is often a symp- tom, and a very distressing one, of the disorder ; and where, of course. Emetics are interdicted by the most obvious cir- cumstances present. The value of Emetics in the treatment of Cynanche ton- sillaris, though understood as matter of medical precept, is not equally regarded in practice. Nor, indeed, as a general fact, do Ave sufficiently keep in view the close relation between the several parts of the internal fauces and the membranes of the oesophagus and stomach ; and the frequent and singular translations of morbid action which take place along this continuity of surface. Many more exact interpretations of disease, as I have elsewhere remarked, might be derived from looking to this connexion through contiguous structure and function, than from the minute division and nomencla- ture which are formed upon the mere locality of symptoms : ON THE USE or EMETICS. 481 and all the indications of treatment would in the same pro- portion become more exact, as instanced in the particular case to which I am now referring. The liver, and the whole system of the portal circulation, are singularly under the beneficial influence of Emetics as a remedy. Congestion, so prone to occur in this part of the body at the commencement of most fevers, as well as in other diseases, is with greatest ease lessened or removed by vomit- ing ; — the passage of bile into the bowels rendered more free ; — other secretions promoted or restored ; — purging often obtained without further aid ; — and a general state of all these viscera induced, peculiarly tending to diminish febrile action, and especially in those cases where it arises directly from gastric disorder. In most of the slighter cases of jaundice with which we have to deal. Emetics will be found much more capable of speedily restoring the passage of bile into the bowels than any other means. The instances, again, are numerous (including particularly those fevers of warm climates, which, however variously designated, have all such close relation to the func- tions of the liver and the circulation through the chylopoietic viscera) where the direct combination of an active emetic and purgative medicine in the outset of disease, with repe- tition of the same means when needful, has effect in subduing the violence of disorder beyond any other remedy. This combination is not sufficiently employed in ordinary practice, in the many cases where speedy disgorgement is required of the part of the system just referred to. The effect of Emetics upon the circulation is a complicated one, including, as it does, both nausea and the mechanical effect of vomiting ; each capable of influencing greatly the heart's action, and the general movements of the blood. From both may much benefit be obtained; though under I I 482 ON THE USE OF EMETICS. different mode of use according to the nature of the case. When the circulation is morbidly excited, nausea may be longer sustained ; — where there is congestion about the heart and great vessels, vomiting ought more speedily to be brought on. Nor is there cause for the degree of apprehension which exists as to the rupture of blood-vessels, or pressure upon the head, from this effort. Though cases of such kind have doubtless occurred, they are comparatively very rare, and generally depend upon causes peculiar to the individual. It is singular indeed to what extent, and with what violence, vomiting may take place, without producing any injury of this nature. Sea-sickness, and that attending every stage of pregnancy, are evidence of the fact ; and it is important this inference should be kept in mind, that there may not be undue discouragement to the use of the remedy in many cases where it is of singular value.* The influence of Emetics upon the nervous system is also complicated ; and one in which it is not easy to separate the direct from the indirect effects. It is unquestionably powerful, and capable of being very beneficially applied. The circum- stances, not yet wholly understood, which give such peculiar sensibility to the region of the stomach ; and so closely asso- ciate it, not only wnth all others of the vital organs, but also Avith the functions of animal life, render the several conditions of this part most important to the well-being of the Avhole * I may mention in further proof the common use of Emetics among the workmen in coal-mines, for the relief of the state brought on by breathing fixed air in excess, as well as after being subjected to fire-damp. I have had recent occasion of learning this fact in visiting the mines at "Whitehaven. It might be supposed in these cases, if in any, that conges- tion in the vessels of the brain was to be avoided. Yet if injury be thus produced, it is seemingly of much less import than the good gained by re- newing the action of the diaphragm and restoring respiration. ON THE USE OF EMETICS. 483 system. No illustration of this is needful to those who have felt the influence, both upon mind and body, of the sensations arising from disorders having this seat, even such as are casual and temporary in kind.* Here the action of Emetics is well marked, and often of singular avail ; and from hence their effects are largely diffused over other parts of the nervous system. Some part of the good they produce, when given at the outset of fevers, may depend on this circum- stance, in concurrence with the others already mentioned. In illustration of the benefit to be obtained from Emetics in this stage of disease, I would refer again to the epidemic influenzas, which have so repeatedly prevailed of late years. I have already stated my conviction that no remedy is equally sure and expedient, at the commencement of the disorder, in diminishing the severity of the attack; or apparently, when slight, in suspending it altogether. In the progress of the malady, too, there is often benefit from the repetition of the same means ; and especially in the case of children, where the want of due relief by expectoration is best thus svipplled. Here, as in other fevers tending to an intermittent or typhoid type, it forms the best and most speedy preparation for the use of bark — a fact well worthy of being kept in mind by those who travel through districts subject to malaria, and the febrile disorders consequent upon it. I name this instance of the epidemic influenzas, as one where the comparative disuse of Emetics has certainly been injurious to the general success of our practice. * The fitness of the term o? foyer epigastrigtie, in expression of a fact respecting this particular part of the body, has been made the subject of some controversy. Bichat denies its propriety as applied to any one spot; but, in connexion with his hypothesis that the vital organs are the proper and sole seat of the passions (an hypothesis which has foundation in language alone), he makes a sort of admission of the phrase in question as expressing a central influence of these organs. II 2 484 ON THE USE OF EMETICS. The mention of Emetics as aiding expectoration, brings us to one of the most important uses of this remedy. Though yet insufficiently employed for the express object, their effect in relievino; the chest, when the bronchial cells and tubes are gorged with mucus, is scarcely less beneficial than their action in unloading the biliary system. They may justly be reckoned the most powerful expectorants we possess ; speedy in effect, and often complete in relief. In bronchitis and other cases, where, from accumulation of mucus in the air passages, the breathing and pulmonary circulation are greatly oppressed, and the patient under much suffering, the change thus produced is sometimes surprising in degree, and such as we can obtain in no other way. Their value in croup is well attested, by the concurrence of all modern experience with that of the excellent physician who first enforced this treatment. I have already commented on the apprehension of haemor- rhage, or pressure on the head, which checks one important application of Emetics. In the case now before us, their use is often abandoned from the like fear of making undue pres- sure on the vessels, or producing suffocation ; an apprehension unwarranted by fact, and which the most common experience might correct. The converse of this is nearer the truth ; and forms, indeed, the especial value of the remedy in the in- stances alluded to. Even in cases of actual inflammation of the lungs I believe the risk of their use to be exaggerated, though undoubtedly more watchfulness is here required. There is the greater cause for referring to this application of Emetics, from our vague and imperfect views as to the whole class of expectorant remedies. Scarcely, indeed, is the term defined in its ordinary use in i^ractice. It is left doubt- ful whether the expectorant is a medicine which promotes the secretion of mucus from the bronchial surfaces — or ON THE USE OF EMETICS. 485 facilitates, after being formed, its removal from the chest — or combines both these effects in its single power. The natural result is that of rendering practice almost equally vague on these points. And, though there is less liability to dangerous error here than in many other classes of remedies, yet it is obviously important to gain more distinct views than those currently received. The Emetic is probably the only agent which both pro- motes secretion, and directly discharges the matter secreted ; the latter action being chiefly a mechanical effect of the effort of vomitino; induced. There is reason to believe that no one of the medicines termed Expectorants can act in freeing the chest from mucus in the air passages, unless they be so given as to produce vomiting, or to bring on cough by irritating the membranes ; — or unless they increase or alter what is secreted, so as in this manner to excite cough, and render it more effectual for expectoration. Their influence iipon secretion is indeed the circumstance we must chiefly regard among medicines of this class ; and here, again, their effects and relative value are very ill defined. It is probable that the expectorants, so termed, which act as emetics in larger doses, are principally of avail in changing the secretions when used in such manner as to keep up a certain degree of nausea. This state has manifestly much influence in relaxing the exhalant and secreting vessels; and though I do not venture to affirm it, where proof is difficult, I believe it to be chiefly in this way that the medicines in question have gained their present reputation in practice.* * The whole class of Expectorants, however divided and defined, needs revision, as do so many other parts of the Materia Medica. The progress of medicine, as a science, requires that we should not bind ourselves toQ implicitly to old tables and formula ; which have their origin in doubtful sources, and gain authority chiefly by long transmission from one book or lecture to another. 113 486 ON THE USE OF EMETICS. The best aid to expectoration in ordinary cases, and where no inflammatory symptoms exist, is that of taking a moderate quantity of some warm food, either liquid or what is lightest of digestion, on the stomach. The effect of this is often felt immediately in augmenting and loosening the secretion of the mucous glands about the throat and fauces ; while at the same time more assistance is given to the effort of coughing, by which the mucus is extricated from the air passages. The question as to the proximate cause or seat of the sen- sation which we term nausea, and its relation to the act of vomiting, is in all respects a curious and difficult one. If any true explanation is found hereafter, it will probably be through the results obtained by Magendie and others, to which I have already alluded. Connected with this subject is the alleged effect of Emetics as a remedy in the early stages of pulmonary consumption ; an opinion held by many eminent physicians from an early period down to the present day ; and which has gained rather than lost weight by recent inquiries on the subject. The researches of Sir R. Carswell into the origin and seat of tu- berculous deposits afford a clearer notion how Emetics may act, by removing or preventing the growth of tubercle on the membrane of the bronchial cells. It is easy to understand that any means which can promote the natural secretion into these cells, render their contents more liquid and easy of removal, and aid in actually procuring it, may be of singular advantage ; — especially in that earlier part of the disease, where the presumption exists that tuberculous deposits are only beginning to take place. , The action of Emetics reaches further towards these several objects than that of any other remedy ; — it is compatible with every other part of treatment required; — and under regulation of their use, and with due regard to any acute inflammatory states which may occur in ON THE USE OF EMETICS. 487 the progress of the disease, I believe them to be among the safest and most probable means yet suggested for the relief of incipient phthisis. Unfortunately this must still be stated more on speculation than on certain experience. A few Continental physicians have made systematic use of the remedy ; but in England its employment with this object seems to have been very partial, though enforced by medical authorities which claim much respect. The difficulties, indeed, which oppose themselves to the treatment, especially among the higher classes, are not easily overcome. The remedy, from various associations, is regarded as more formidable than is really the case ; — the present habit of practice is adverse to it ; — and, further, the suggestion of the treatment comes at a time when fears may hardly yet be awakened, or when there is repugnance on the part of the patient, and those around him, to admit what argues a dangerous disease at hand. The influence of these causes is well known to every physician. The use of Emetics in producing absorption of effused fluids, or of parts morbidly enlarged, seems sufficiently attested. But we have no reason to suppose that they have any effect on tubercles actually formed; and their employment there- fore in phthisis, when we can obtain trial for them at all, is probably to be limited to the earliest stage of the disorder. I need advert but slightly to the benefit derived from Emetics in asthma; though here again it must be admitted that there is an insufficient use of the remedy, seeing the great good gained in many such cases by imloading the stomach and liver; and the equal advantage, though less obvious in explanation, from its influence on the actions of the circulation and nervous system. A single Emetic may cut short a paroxysm for which opiates and antispasmodics have long been employed in vain. I I 4 488 ON THE USE OF EMETICS. The use of this remedy In the disorders of children is at present much less general than it ought to be. In very many cases Emetics would beneficially supersede that employment of jmrgatives, which often adds to the irritation it professes to remove. In the infantile fever, for example, which is a type of various disorders, an occasional dose of ipecacuanha, so as to excite vomiting (especially where there is much of the cough Avhich attends this complaint, and large secretion fi'om the mucous membranes), will be found more effectual than any other means. It is to be noted, further, that the action of vomiting is for the most part singularly easy in children ; — more immediate, and generally less distressing, than that of purgative medicines. In these remarks I have attended rather to the general effects of Emetics, than to the several qualities and manner of action of the medicines so termed; it being my object only to draw attention to the fitness of their larger and more de- fined use in ordinary practice. The question of preference among different emetic substances is indeed of less moment, from their action in emptying the stomach of its contents. In the majority of cases, that may be deemed best which fulfils its purpose without actual pain, and with greatest cer- tainty and speed. If ipecacuanha were invariably of good qviallty, which unfortunately it is not, it might be sufficient in almost every instance. Antimonlals, from sustaining nausea longer, and producing more distinct sedative effect on the nervous and vascular systems, may be preferred where ex- citement of these exists. The emetic of simple mustard ought never to be lost sight of as an immediate resource, and as producing its effect with less previous nausea or distress than any other. In considering, however, the effects of Emetics, we must separate such as belong to the direct action of the medicine ON THE USE OF EMETICS. 489 on the coats of the stomach, from those produced by the act of vomiting. The former may be more or less hurtful, as depending upon a peculiar irritation of the part; and here the action of emetic medicines must be assimilated to that of acrid or poisonous matters received into the stomach or gene- rated there. But the mere effort of vomiting itself is much less injurious to this oi'gan than might on first view appear likely. Without referring in proof to the " vomitus luxuricB causa " of the Roman dinner tables*, I may again mention sea-sickness, the sickness of pregnancy, the frequent vomiting of infants, and the habit some individuals have of rejecting constantly in this way a portion of all food taken, as evidence that little mischief comparatively can be derived from this source. t And in the latter case of habitual or periodical vomiting, it may be remarked that the effort is usually at- tended with little nausea, though often with distension or other * Celsus, lib. i. cap. 3. Many of my readers will recollect that re- markable letter of Cicero to Atticus, describing the dinner he gave to Cfesar at Puteoli, a short time before the death of the great Dictator. The ambulatio in littore, the balneum, the tinctio, are all related in the order of their occurrence ; followed by the emetic, with which Csesar did honour to the banquet of his illustrious host, eating and drinking after- wards, as we are told, "dSaog et jucunde; opipai'e sane, et apparate." t I have known a patient, a young lady of delicate and irritable habit, who, during fourteen months, rejected invariably some portion of every meal ; — the quantity rejected, and the interval before vomiting occurred, depending much on the quality of the food. In this case (in which the malady depended not on organic disease of the stomach or pylorus, but seemingly on irritation translated from another part), the patient suffered chiefly from an uneasy distension preceding vomiting, little from nausea or the vomiting itself; and she even gained considerably in flesh while the disorder was going on. In another instance I have known the habit of vomiting continue for many years, after every meal of which animal food was the principal part; without any apparent injui-y to the constitution, or increase of mischief to the stomach itself. 490 ON THE USE OF EMETICS. uneasiness preceding the act. These points must always be kept in view in judging of the effect of Emetics in practice, and of the frequency and particular methods in which they may best be employed. I shall be gratified, because believing it to be a good result, if the preceding remarks should have any effect in restoring to its fit place in the treatment of disease, a remedy sanctioned to us by the oldest usages of medicine ; and yet more by the safety, speed, and completeness of all its effects. I know none equally capable in so many cases of arresting disorder in its earliest stage, without shock or injury to any organ or function of the body; — or of abating the severity and dura- tion of disease, w^here its sudden suspension is unattainable. 491 CHAP. XXV. ON THE USES OF DILUENTS. Though there may seem no sufficient reason for considering these as a separate class of remedies, yet I doubt whether the principle of treatment, implied in the name, is adequately re- garded in modern practice. On the Continent, indeed, the use of diluents is much more extensive than in England ; and, under the form of mineral waters especially, makes up in some countries a considerable part of the general treatment of disease, especially of all such as assumes the chronic form. The practice of resorting annually to some icatering place, though much governed by mere fashion, and not free from the worse influences of quackery and fraud, yet is undoubtedly beneficial in a vast number of cases ; — partly in eflfect of the mineral ingredients in these springs ; — partly (perhaps prin- cipally) from change of air, scene and society, and the more salutary manner of life associated with the remedy.* In very many cases, however, pai't of the good thus attained is certainly due to the water itself, irrespectively of the mineral matters it contains. And the consideration comes before us in an explicit form, to what extent, and with what effects, this great diluent, the only one which really concerns the animal economy, may be introduced into the system as a remedy ? Looking at the definite proportion which in healthy * We have proof of similar use and fashion as to mineral waters in the Roman practice. Pliny speaks of the " Medici qui deverticulis aquai-uvi fallunt cegrotos." 492 ON THE USES OF DILUENTS. state exists in all parts of the body between the aqueous, saline, and animal ingredients — at the various organs destined directly or indirectly to regulate this proportion — and at the morbid results occurring whenever it is materially altered, either by deficiency or excess — we must admit the question as one very important in the animal economy, and having various relation to the causes and treatment of disease. Keeping in mind then this reference to the use of water as an internal remedy, diluents may be viewed under three conditions of probable usefulness. Fust, tlie mere mecha- nical eifect of quantity of liquid in diluting and carrying off matters, excrementitious or noxious, from the alimentary canal ; — secondly/, their influence in modifying certain morbid conditions of the blood; — and thirdly, their effect upon various functions of secretion and excretion, and especially upon those of the kidneys and skin. Other more specific effects there may be; but these are presumably the most important; and each of them is capable of contributing to valuable ends in practice. The first is an obvious benefit in many cases, and not to be disdained from any notion of its vulgar simplicity. It is certain that there are many states of the alimentary canal, in which the free use of water, at stated times, produces good which cannot be attained by other or stronger remedies. I have often known the action of the bowels to be maintained with regularity for a long period, simply by one or two tumblers of water, Avarm or cold, on an empty stomach ; and this in cases where medicine had almost lost its effect, or become a source only of distressing irritation. The ad- vantage of such treatment is still more strongly attested, where the secretions taking place into the intestines, or the products formed there during digestion, become vitiated in kind. Here dilution lessens that irritation to the membranes ON THE USES OF DILUENTS. 493 wliicli we cannot so readily obviate by other means ; and aids in removing the cause from the body with less distress and disorder than any other remedy. In some instances, where often and largely used, its effect goes yet farther, in actually altering the state of the secreting surfaces, by direct application to them. But it is difficult in the greater number of cases to distinguish this result from the effect taking place through the circuit of the blood. I mention these circumstances upon experience, having often obtained much good from resorting to them in practice, when stronger medicines and ordinary methods had proved of little avail. Dilution thus used, for example, so as to act on the contents of the bowels, is beneficial in many dys- peptic cases, where it is especially an object to avoid needless irritation to the system. Half a pint or more of water taken when fasting, at the temperature most agreeable to the patient, will often be found to give singular relief to his morbid sensations ; and, where such is the effect, may even become a valuable aid to the other treatment pursued. Or, in cases where there is habitual excess of acid in the lower bowels, (a source of frequent distress, thovigh not so easily recognised as acid on the stomach), the solution of half a drachm of the Bicarbonate of soda in the quantity of water taken will add greatly to the good gained. It is often more beneficial in this way than given in smaller proportion of liquid ; — a point illustrating the action of mineral waters, which clearly influence by quantity and dilution the medicinal effect of their contents, while having at the same time the mechanical operation due to water alone. In reference to the foregoing uses of diluents, it is to be kept in mind that the lining of the alimentary canal is to all intents a surface, as well as the skin ; — pretty nearly equal in extent ; — exercising some similar functions, with others more 494 ON THE USES OF DILUENTS. appropriate to itself; — and capable in many respects of being acted uj)on in similar manner. Medical men themselves, and still more those with whom they have to deal, are prone to attach undue importance to the mere fact of a substance being taken into the stomach ; as if this were equivalent to its being received into the system. Though the apparatus for absorption and secretion is different for the two surfaces, yet may we regard substances in the alimentary canal, prior to absorption, as being exterior to the system, nearly in the same sense as if applied to the skin. As respects the subject before us, it is in many cases both expedient and correct to regard diluents as acting on this internal surface, ana- logously to liquids on the outer. And I Avould apply this remark, not only to the mechanical effects of the remedy, but also to their use as the medium for conveying cold to internal parts ; — a point of practice which either the sim- plicity of the means, or the false alarms besetting it, have hitherto prevented from being duly regarded. The abstraction of heat from an inflamed or irritable mem- brane within, is often indeed quite as salutary as the cold directly applied to a hot and dry skin without. The extent of use is from obvious causes much more limited ; but I have seen enough of the benefit from cold liquids freely given in the acute stage of gastric disorders, inflammatory and febrile, with express reference to this point of temperature, to justify the recommendation of more frequent recourse to it in practice. This is a point where the feelings and desire of the patient may fairly be taken in guidance ; and we can rarely go wrong in following them. The test, in fact, is simple and immediate ; depending on sensations which cannot readily be mistaken, and the changes in which not merely suggest the use of the remedy, but indicate the manner and fit extent of its employment. ON THE USES OF DILUENTS. 495 The second condition under which diluents may be viewed, as altering certain morbid states of the blood, is one of more difficulty ; and connected with questions in physiology and pathology still under active research. Independently of those recent observations of physiologists, which show the natural difference of proportion between the fibrin and serum of the blood in the two sexes, and under different ages and tempe- raments, we know as matter of fact that there are such mor- bid states, in Avhich the proportion of water to the solid animal contents of the blood is below the healthy standard. Slight variations of this nature, as well as those of opposite kind, may be presumed to be perpetually occurring ; delicate and beautiful though the adjustments of function are, through which the balance is maintained, and all inordinate deviations arrested in their progress. But passing over lesser instances, the singular facts ob- served as to the blood in the Asiatic Cholera, show the extent to which such change may take place under the influence of disease ; and give wide scope to the existence of gradations between this and the state of perfect health.* The import- ance of these changes of proportion, however produced, is best inferred from the experiments which prove how essential are the fibrin and colouring particles, not merely to the right constitution of the blood, but to all the phenomena of life ; — how many functions concur and are needful to their elaboration ; — and how speedily distress or death ensue in many cases, where they are exposed to the agency of foreign substances introduced into the circulation. The question with which we have now concern is, how far * Andral, ia bis "Anatomie Pathologique " (vol. i.), has given a siimmai'y of most of the facts in this interesting part of pathology ; and Lecanu, in his " Etudes Chemiques sur le Sang," makes this specification more distinct by the results of very exact analysis. It is part of our knowledge likely to be extended hereafter. 496 ON THE USES OP DILUENTS. the actual use of diluents may be capable of repairing such altered proportion of the serous part of the blood, whether the result of chronic causes, or of more acute malady. The tendency of modem inquiry regarding absorption has been to show that it takes place much more rapidly than was sup- posed ; and through textures, and by means, which were once believed to have no concern in this function. The concep- tion that the processes of absorption, as well as those of secre- tion, must be carried on through the open mouths of the vessels, and that communication of fluids can only take place by means of tubular structure, has given way to the distinct experimental proof of imbibition and exudation, through the coats of vessels or other parts of animal texture. In the phe- nomena of Endosmosis, more particularly, we find curious and satisfactory explanation of facts as to the transmission of substances by the animal fluids, which formerly per- plexed all our views of the economy of structure and function.* These points, hoAvever, are only important to us as proofs of the facility and speed with which liquids taken into the stomach, especially when fasting, may be absorbed into the circulation ; and it still remains a question, how far the blood can appropriate to itself, in alteration of its quality, fluids thus received. There can be little doubt that it does so, in those cases where the proportion of its watery parts is from any * These discoveries of Parrot and Dutrochet, continued and extended under different modifications by Graham and Matteucci, while remarkable as the exposition of a new physical law, have great interest in their application to physiology ; and show especially how much may be added to our knowledge of the vital functions by every such step in physical science. The views as to respiration, suggested by Dr. Steven's valuable observations on the affinity of carbonic acid and oxygen, afford another instance of similar kind, having various relations indeed to the former. ON THE USES OF DILUENTS. 497 cause materially lessened.* In that intense thirst, passing into febrile state, which follows the long privation of liquids, and appears to be the most vehement of all appetites, there is every reason to suppose that these feelings are the result of changes in the blood itself; depending on the altered propor- tion of its fluid and solid parts, and affecting the vascular sys- tem to its most minute extremities. Perhaps in all instances the tendency to absorption bears some ratio to the state of the blood in this respect; unless there be counteraction from causes of disease in active progress at the time. But it is equally probable, and for precisely the same reasons, that little alteration is made in its state by any excess of liquids beyond this natural demand. The processes for separating water become more active in the same ratio as the increased imbibition: and even admitting, what is now rendered very doubtful, that the whole or greater part passes through the blood, there is every reason to believe that the extrication thence, through diiferent channels, is so speedy as never to allow any material change in the proportion of its several parts. There is manifestly a constant and mutual relation between the blood and the kidneys, the organ most especially destined to this function of balance. Whether change of con- dition begins in the former or the latter, equally is it folloAved by reciprocal change in the other ; tending always, it may be presumed, to adjust or restore those proportions in the blood which belong to the natural state, f * The experiments of Orfila and other physiologists have shown tlie connexion between thirst and the proportion of water present in the blood, by the relief given to this sensation from the injection of different fluids into the veins. f Many extraordinary cases are recorded of the enormous quantity of water habitually taken, and urine voided, even without actual disease. In most of these instances it is difficult to determine where the excess of action begins, or by what causes it is produced. K K 498 ON THE USES OF DILUENTS. We cannot indeed prove, when there is habitual excess in the quantity of fluid taken, that there may be not some effect of this kind ; producing thereby a sort of chronic disorder of the blood, and affecting more or less every part of the system. A difference existing from natural temperament may be in- duced by habit also ; but probably to no greater extent, unless the change be aided by the operation of actual disease. And, in the latter case, the altered proportion presumably depends rather on the insufficient power of supplying the fibrin and albuminous part of the blood, than on any change tending directly to increase the ratio of water contained in the circulation. Applying these considerations to the medicinal use of dilu- ents, it may be inferred that we have little justification for giving them, with direct intent to alter the qualities or pro- l^ortions of the blood, independently of actual experience. Our knowledge on these points is still too limited to admit of any practice founded on theory alone. But, on the other hand, we have reason from the same considerations to believe that liquids may freely and without fear be given, wherever there is demand for them from the sensations of the patient. There is, in truth, no motive or rule of treatment upon which better to depend than these natural feelings; and, even when partially vitiated in their nature, we have the assurance that it is a case in which the system is well provided with means for remedying any excess. This conclusion, fairly attained, is one of great practical value. And it ought sedulously to be kept in view, in a part of practice, where prejudice or false maxims are ever at hand to check and contravene the sounder judgment of the physician. Viewing the subject, indeed, in relation to actual disease, when the appetites arc in part removed from the dominion of habit, there are few rules in practice which may be ad- ON THE USES OF DILUENTS. 499 mitted with such slight limitation as the one just given. Even in Diabetes, I have never found any continued good from op- posing the inordinate thirst of the patient ; nor aggravation of what are the essential symptoms of the disorder by assenting in full to this desire. The restraint as to liquids, sought for to slake the thirst in Cholera, is still less justified by any reason- able pi'inciple or experience in practice. Without admitting, what some have affirmed, that cold water is an actual remedy here, we may at least presume that it is beneficial, if finding access to the circulation, in modifying that state of blood which is so characteristic of the disease. The eager demand for liquid is in some sortan evidence of this; nor is it disproved by the occasional rejection from the stomach of what is so taken. The thirst occurring as an ordinary symptom of all fever, is for the most part to be viewed as authority for its gratification. In the greater number of cases, more harm will arise from opposing it, than from any excess in the use of liquids to which it can lead. The remaining point of view under which we have to con- sider simple diluents, as remedies, is in their effect upon various functions of secretion and excretion. This subject is closely connected with the preceding, inasmuch as the effects must take place chiefly, if not altogether, through the cir- culation ; and some change be produced in the blood itself by every alteration occurring in these functions. The kidneys and the skin are the organs most concerned here ; though it is probable that the lungs also have part in the effect, and that no secreting organ is wholly independent of it. Any large and rapid addition of water to the mass of blood brings into activity that jiart of the vascular system, whether glandular or otherwise, through which separation of the superfluous fluid may take place. The pressure of volume upon the ex- treme vessels, or upon the membranes through which cxu- K K 'J 500 ON THE USES OF DILUENTS. elation takes place, must have influence on the functions of these parts : — and the same might be inferred, if we regard as vital phenomena exclusively, the actions by which super- fluous fluid is thus sej^arated from the system. Under either supposition the secreting vessels or exuding membranes cer- tainly undergo alteration for a time; and this of nature to aflect the qualities of the blood, by altering the amount or kind of matter which such secretions carry away. In the kidneys, for instance, the proportion of the lithates or other saline ingredients, removed through these organs, may be augmented by a large and rapid passage of water through them; and the functions of the skin, as an excreting organ, may equally be rendered more active by the same means. It is probably in this indirect way that diluents have greatest influence upon the blood ; and here we find best explanation of their utility in certain cachectic cases, in which there is general disorder or deficiency of the secretions; and in rheu- matic fever, where the condition of the blood is evidently concerned as the main cause of disease.* It seems certain, further, in the medicinal use of diluents, that something is gained by mechanical eflect on the secreting tissues. These may become in any part less permeable than in the healthy state; a condition apparently capable of being removed by the more copious passage of fluid through them. The remark applies to many states of the skin, both in fevers and other disorders, where simple diluents, freely given, form the safest and most effectual sudorifics we can emj)loy. And * Those familiar with the writings of Sydenham, may recollect the report he makes of his large and beneficial emjiloyment of ivhey^ in certain severe cases of rheumatic fever, to the exclusion of all other nutriment. In one case he thus used the whey from eight pints of milk daily, for four successive days. Facts of this kind are not to be disregarded for their seeming simplicity; especially when coming to us with the name of Sydenham annexed to them. ON THE USES OF DILUENTS. 501 the same remark applies to various cutaneous disorders, where the use of this remedy, even in its simplest form of pure water, might be very beneficially extended, to the exclusion of many diaphoretics and alteratives of much more doubtful character and effect. This is, according to my experience, a point singularly meriting attention in practice ; and the simplicity and safety of the trial warrant every recommendation of it. In exan- thematous fevers, though the treatment by such means is more ambiguous, yet I believe that a much freer employ- ment of diluents than is commonly adopted might be bene- ficial ; certainly to the fullest extent in which they are called for by the feelings of the patient. I can affirm, after much observation, that I have never seen harm result from this treatment — in the great majority of instances, unequivocal good. On the same principle, there is much reason for their use even in certain cases of dropsical effusion, where the main object is to restore a due action of the kidneys. Popular feeling, and indeed medical opinion, inclines to the opposite treatment ; and with some reason, as respects any constant habit of drinking largely in such cases. But I have expe- rience of the good often obtained by the sudden and copious use of diluents in recovering these organs from a dormant state — an object which, I may remark, is generally best effected after the bowels have been fully relieved. The latter fact has some importance in regard to the action of almost all diuretics. They have little effect as such, while there is need of alvine evacuation ; and in ascites and anasarcous swellings, particularly, it is commonly desirable to preface all other treatment in this way. The io-norance or neglect of these precautions in practice often produces a K K 3 502 ON THE USES OF DILUENTS. hurtful activity where nothing can be gained, and a delay no less injurious in the actual relief of disease. As I have been treating of this remedy only in its simplest form, I do not advert to the use of the different mine- ral waters further than to state that they confirm these ge- neral views ; separating, as far as can be done, their eifect as diluents from that of the ingredients they contain. I have al- ready alluded to their more copious employment in Continental practice ; giving room for observation, which is wanting under our more limited use. I have often seen five or six pints taken daily for some weeks together, (a great part of it in the morning while fasting) with singular benefit in many cases to the general health, and most obviously to the state of the secretions. The functions of the kidneys and skin were maintained in great activity during the whole of this period ; but without assuming any disordered character ; and passing readily again into their natural state when the cause of in- creased action was removed. These courses, however, were always conjoined with ample exercise and regular habits of life; doubtless influencing much the action of the waters, and aiding their salutary effect. In cases where such aids are omitted, or only partially employed, a much smaller quantity generally disturbs the stomach, and the treatment altogether is of little avail for the amendment of health. Without reference, however, to these extreme cases, it must be repeated, that the use of water, simply as a diluent, scarcely receives attention and discrimination enough in our English practice. This is a point wholly distinct from the question regarding the fit proportion of liquids as a jmrt of diet. The process of digestion suffers more or less from any excess in quantity of these ; and though the natural appetite may be unduly controlled, yet a rule is generally required, in dyspeptic cases especially, to obviate such excess, even ON THE USES OF DILUENTS. 503 where the simplest and most innocuous liquids alone are con- cerned. For in these cases a morbid craving for them is often created ; partly by the vitiated sensations of the patient ; partly from the actual state of the membrane lining the palate, oesophagus, and stomach, and from the disordered se- cretions and products of digestion acting on this surface. It is obviously another question, how far and in what way diluents may be employed, expressly as such, for me- dicinal purposes ; — including under this question what relates to thirst as a symptom of disease ; to the use of liquids in dis- ordered states of the alimentary canal; and to their employ- ment in cases of general cachexia and vitiated secretion. These are the points to which the preceding remarks apply ; less, however, as furnishing explicit rules, than as suggesting the views upon which this part of treatment may best be founded, and rendered more generally useful. K K 4 504 CHAP. XXVI. ON SUDORIFIC MEDICINES. It must have occurred to the observation of most practi- tioners, that, of the direct evacuant remedies, Sudorifics are amongst those which can least be depended upon ; and this even in cases where natural perspiration is one of the symp- toms statedly present. It will, I think, be further admitted that joerspiration produced by artificial means rarely cor- responds, in the degree of benefit obtained, with that oc- curring from natural causes : — and, further, that it is a class of remedies where discrimination of effect is singularly vague as regards the several medicines so denominated. These indeed are points which different observers will differently estimate ; yet I believe the facts will be so far allowed, as to give some interest to a consideration of their cause. Docs not this uncertainty chiefly depend on mistaken views of perspiration, as a part and symptom of disease ? In general o[)inion, it seems to be regarded as an active cause of change, and usually of amendment, in the existing dis- order ; and practice is founded for the most part upon this impression. May it not more justly be considered as effect and proof of such change taking place ; frequently beneficial in kind, but by no means invariably so ? The distinction is obviously important ; inasmuch as it involves the question, how far, and by what means, this action is to be sought for as a direct object in the treatment of disease. In their employment of sudorific remedies, physicians at ON SUDORIFIC MEDICINES. 505 all times have manifestly dwelt much on the fact, that many- disordered actions, and especially those of the simple febrile paroxysm, and certain of the phlegmasige, are suspended in immediate sequel to natural sweating. Proofs as to this mode of inference might be largely drawn from medical writers, were it necessary ; nor is the reasoning devoid of plausibility. Setting aside all question of peccant humours, an obvious and general evacuation from the body, followed by mitigation of disorder, is a fact in pathology which could never escape notice, and might readily suggest the idea of like advantage from perspiration artificially obtained. Never- theless, there is great cause to doubt the justness of the in- ference, and the propriety of much of the practice which has been founded upon it. In this inquiry, it is needful first to consider, how far the natural action, which we seek in other ways to imitate, is truly remedial in kind. It would advance us very little here to enter into the various theories as to the functions of the capillaries and exhalant vessels. The probable statement seems to be, that what is termed perspiration in the widest sense involves two separate processes; — one a mere physical act of simple evaporation of moisture from the surface, — the other an act of specific secretion by vital power, and aflfected therefore expressly by the various states of the circulation and nervous system. The latter is that with which we are here concerned ; and, looking to the character of this function, it must be admitted as not impossible that what are called critical sweats may be really the cause of the relief which ensues upon them. But this admission by no means proves the fact to be so ; and there are various presumptions, more or less strong, which may be brought against it. First, the occurrence, often observed, of similar and equal relief under the same course of previous symptoms, without 50G ON SUDOKIFIC MEDICINES. intervening perspiration. This will be familiar to all who are accustomed to note the phenomena of fever. Here re- missions or intermissions take place ; always, no doubt, with an altered state of the vessels of the skin, but often with little or no actual perspiration succeeding to the hot stage. Even in the simple paroxysm of ague, which affords the best case for the inference now in question, this absence of a distinct sweating stage is occasionally observed : in other forms of fever, idiopathic or symptomatic, much more frequently. It may be difficult to say, why this resolution of fever or in- flammation should occur in some cases with copious perspira- tion, in others with little or none. But, the fact being so, it is safer and probably more correct to regard the sweating- stage or critical sweat, when it happens, as one in the series of changes constituting fever, rather than as the cause of the relief to symptoms that ensues. The second point I would advert to is, the frequent oc- currence of natural perspiration in morbid states of the body, without any such relief, and sometimes with aggravation of disorder. Proofs of this may be drawn from common ex- perience in continued fevers, pneumonia, acute rheumatism, and various other diseases attended with fever, where profuse ©r long continued sweating often occurs, Avitli doubtful benefit or even manifest disadvantage to the patient.* The perspi- rations in hectic fever, though marking the several periods of remission, yet augment the distress of the patient, and increase his weakness. In the fever attending the epidemic influenzas, * The remark of Hippocrates is warranted by fact, Icpiog TroXvg dfia TTvpiroimv oSffft yiyvo/ifvoij ^Xavpoi'. And elsewhere, K-fij' Trvptroicriv loowg tiriytvtjTai, /^ii] iKXiiTrovTog tov irvperov, KaKoi'. These are among the numerous prognostics which he derives from perspiration, as a symptom in the course of disease, and an exponent of changes taking place in the body. ON SUDORIFIC MEDICINES. 507 the more general state of the skin is that of a clammy perspiration, manifestly not producing any remission of the symptoms. Even in the exanthematous fevers, where it might be inferred from the eruptive symptoms that diaphoresis would be more uniformly beneficial, and a legitimate object of treatment, cases constantly happen where natural sweating is attended with no obvious good ; and where the attempt to force it out by medicines or other means is distinctly injurious to the patient. Many other instances will occur, more or less directly in illustration of the same point. In those complaints usually termed bilious, and where there is accumulation, or disordered change of secretion, in the digestive organs, pei'spirations break out often and copiously, Avithout any relief to the system. The same happens in vai'ious other disorders of the alimentary canal ; an effect of the intimate sympathy between this great internal membrane and the surface of the body. A tendency to perspiration is the consequence of purging in any excess ; as indeed of all causes which, even without fever, tend to de- bilitate the body. These instances, though less determinate than those of simple and symptomatic fever, yet illustrate the same general view. If perspiration be regarded as an index of the change of symptoms, rather than as the cause of this change, it may be expected to occur in many cases, where it does not indicate any favourable alteration, and where in fact none such takes place. Looking, indeed, to the various circumstances under which this symptom appears, we have reason to infer that the state of the exhalant vessels producing it is not a single and uniform one ; but that at least two, possibly more, conditions are ne- cessary to explain the different manner in which perspirable matter is thrown off. I doubt whether sufiicient inquiry has been directed to this point. It seems probable that one of 508 ON SUDORIFIC MEDICINES. these states may be simple relaxation of the vessels ; the re- verse of that which exists during the hot stage of fever, and indicating therefore a more entire removal of the febrile state : — another, a forced and active state of the same vessels, by which fluid is thrown out, but with little diminution of heat or febrile symptoms. Other causes of variation might be conjectured, to explain these differences of effect, as well as the phenomena of partial sweats, indicating some unequal pressure on the vessels in different parts of the body.* AVith- out attaching much weight to these explanations, it is certain that perspiration differs as respects the state of the vessels, and also as to the nature of the matter perspired, — the latter variation probably depending on the former in most cases ; though there may be others where the reverse is true, and where the condition of the blood in the extreme vessels may determine the state of the orifices through which exhalation takes place. On this subject 1 have made some observations ; but they need to be extended and confirmed before I can state them in distinct shape. Recurring, however, to the question of Sudorifics as a remedy, it may be alleged that something is due both to the quantity of perspirable matter thrown off by the skin, and to the quality of this, as ridding the blood of superfluous or noxious ingredients. It must be admitted as probable that both these causes have influence. But the little proportion in many cases between the amount of perspiration and the degree of relief attending the remission of fever, and the frequency of copious perspiration without any relief at all, * The ancient physicians attached more importance than we do to the " Sudores non per totum corpus ajqualcs," as a bad symptom in disease. They ai-e connected, doubtless, with the same general causes which pro- duce local determinations of blood, and variations of vascular action, in different parts of the body. ON SUDORIFIC MEDICINES. 509 proves tliat this at most is only partial and accessory. As respects the latter circumstance, viz. the nature of the matter thrown off^ it offers undoubtedly a question of greater difficulty. We have not yet sufficient knowledge of the varieties of this, especially under morbid conditions of the body, to be entitled to deny the influence of such changes ; and the researches which show that a function analogous to that of respiration is exercised by the skin, and vai'ied by disease, make it pro- bable that, in perspiration, the excretion of carbon through this channel may be considerably increased in amount.* Still it is very doubtful whether these presumed changes of quality in the matter perspired, can have much effect on the course and character of disease ; seeing that perspiration is one of the least constant symptoms, even where usually pre- sent ; and that the relation is very uncertain between its amount and the relief that ensues. The presumed influence of perspiration in reducing animal heat admits of the same general remarks. Even admitting: that there is no doubt as to priority in the order of occur- rence, the frequent continuance of morbid heat under ex- cessive perspiration shows that there is no certain ratio between the two symptoms, and lessens the value of this relation to the purposes of practice. Looking cursorily to medical history on the subject before us, it would appear that the use of internal sudorific medicines was comparatively infrequent among the Greek and Roman * The experiments of Dr. Edwards on the Batrachians with soft skins show to what extent this function, resembling respiration, may take place through the cutaneous vessels ; and confirm the observations which had before been made on the human body. From the researches of the same eminent physiologist, as well as the anatomical observations of Breschet on the skin, we are entitled to infer a distinction in quality of ingredients between perspiration by secretion, and the simple moisture which is eva- porated from the surface of the skin. 510 ON SUDORIFIC MEDICINES. physicians. Collecting the passages in Hippocrates which relate to this point, I doubt not that Dr. Friend Avas justified in believing, that by this great physician sweating was re- garded much more as a prognostic sign than an instrument of cure.* The practice, even if originating earlier, gained ground chiefly in the middle ages ; was extended by the larger introduction of chemical medicines into the Pharma- copocias; and naturally allied itself with the humoral pathology, and the notion of expelling peccant matters from the body. It is well known how far the custom was carried, at a period not distant from our own, of forcing perspiration by external heat, confined air, and stimulating sudorifics ; and this more especially in fevers and exanthematous disorders. No more beneficial change has occurred in modern practice than the abandonment of these methods ; nor any more conspicuous in its effects on the rate of mortality in disease. Yet we have cause to ask whether there is not yet too much influence from this source ; supported as it is by popular prejudices, and by maxims transmitted from one generation to another. The excitement of perspiration is still often made a direct object of treatment in cases where, even when not injvu'ious, it has little value except as an exponent of the state of other symptoms. Nor indeed can we draw this inference equally from per- spiration artificially obtained, as from that of natural occui- rence. In many diseases, perhaps more than our medical philosophy has hitherto dreamt of, there is much mischief done by forcibly disturbing and altering the train of symp- toms which forms the wonted course of the disease. No point is more difficult in the theory of medicine, none which * Etenim sudor pcrpctno apud Ilippooratein non ut curandi instru- mentiiin, scd tantiim iit prajsagii nota prjcpoiiitur. — Comment. Aovem de Fthril)u.t, Londin. 1717. ON SUDORIFIC MEDICINES. 511 puts to closer test the practical judgment of the physician, than the knowledge where boldly to break into, or cut short, the cause of a malady, — where to confine the treatment to such means as may simply mitigate the symptoms, obviate any irregularity in their course, or prevent injury to parti- cular organs. The question is one which, in connexion with the doctrine of a vis medicatrix naturce, has had influence, more or less direct, upon medicine and medical schools in every age. In some diseases there can be no reasonable doubt which of the respective plans should be pursued. But even in these more marked cases there is need of greater discrimination than is usually employed ; and to the young practitioner, more especially, it is often matter of much difficulty, not only to form his judgment, but to carry this judgment into action. A firmness of mind is requisite, which may show itself in boldness and vigour, when these are needed ; and no less in forbearance (Avhatever the solicit- ations to the contrary), when a disease is pursuing its course mildly, and without any unwonted symptoms. This forbearance, often the most difficult virtue, may fairly be inculcated as to the use of sudorific means, at those periods of diseases of definite course where sweating does not generally, or naturally, occur. The attempt to force it at such times, even if successful, is a very dubious benefit; and under many methods of treatment for this purpose becomes a positive evil. The effect in question, however, is by no means so easily obtained as we commonly suppose. The l)erspiration attributed to medicines is often, as already re- marked, a symptom in the natural progress of the malad}^, or depending on other causes in the animal economy. We have, for instance, every reason from direct observation to conclude that the state of sleep, as such, tends to increase perspiration, separately from all influence of other agents. I doubt not 512 ON SUDORIFIC MEDICINES. that the diaphoretic medicine often obtains for Itself the credit of an effect due chiefly to this cause. Even where more obviously the result of internal remedies, it would seem that these are effectual in the greater number of cases, rather by abating fever, and changing the course of actions in the system, than by direct influence on the exhalant vessels. The employment of Sudorifics may indeed be regarded, on the whole, as less determined by method or reasonable ex- perience, than that of other evacuant remedies; and every candid physician will admit his frequent disappointment in this part of the treatment of disease. The quantity of what Is perspired cannot be determined with any exactness: its quality is very seldom known sufficiently to become an index of practice; and there is ever much difficulty in deciding whether the effect taking place is due to means employed, or to the changes, natural or morbid, of the body itself. These doubtful views on which their general use is founded, will best explain the uncertain effects of the particular medi- cines brought under this class. The Antimonial preparations, though so largely employed from their presumed action on the skin, may nevertheless be noted in proof of this. There is reason to suppose that their beneficial effect in fevers and in- flammations is mainly owing to the influence they have in diminishing the force of circulation ; and thereby lessening that febrile action, which prevents secretion from the surfaces as well as from the glandular textures of the body. And their employment is generally more successful in proportion as this principle is kept in view, and the act of perspiration regarded as an effect of secondary kind. The reputation of James's Powder as a diaphoretic may have depended in })art on this sedative action upon the cir- culation; but still more, as I believe, upon the sweating regimen employed together with it. The comparative neglect ON SUDORIFIC MEDICINES. 513 of this regimen, as well as the smaller and less frequent doses of the medicine now used, will explain its lesser efficacy in modern practice, of which we often hear complaint. There is, besides, some reason to presume that its value was always rated too high. The latter remark will apply further to the use of anti- monials in cutaneous disorders, where a direct effect on the skin Is sought for. A fair estimate of the evidence here will lead to reasonable doubt whether this practice is ever of much avail. The proofs indeed are usually so far obscured by the conjunction of other means that little can be securely gathered from them. With respect to the stimulating sudorifics, as they have been termed, it may fairly be presumed that most of them act as such only by exciting a certain degree of febrile action, followed by relaxation of the exhalants ; — a doubtful benefit in any case, and often a certain source of mischief. Sydenham strongly reprehends this practice as it existed in his time; and other physicians have, at succeeding periods, repeated his censure. Yet even now it cannot be said to be wholly discarded. Of the various internal means for obtaining diaphoresis, I believe that Opium, in one or other of its forms, is the most vmiformly certain and beneficial. Its action, in conformity with the views just stated, may be considered to depend on the power of allaying inordinate circulation, or other excite- ment of the system. This opinion is justified, as well by the other effects of Opium, as by the similar influence of various narcotics on the state of the skin. I allude more especially to Opium as a diaphoretic, because I believe that in our modern practice we too much neglect the various and beneficial resources afforded by this medicine. Its influence upon the vascular system, in particular, is of singular L L 514 ON SUDORIFIC MEDICINES. importance in the treatment of disease. Whatever be thought of Lind's recommendation of Opium in the hot stage of ague, it is certain that in various stages of fever and inflammatory disorder, where preceded by sufficient evacuations, no medi- cine can be more safely used as a sudorific, or with greater collateral advantages. This is strongly urged by Dr. Friend, in the third of his Commentaries on Hippocrates; to which I would further refer, as containing some excellent observations on the sudorific plan of treatment in fevers ; — one of the earliest efforts to change the opinions before held on this part of practice. I have spoken elsewhere of the use of simple diluents as a means of exciting perspiration, too much neglected in modern English practice. It is connected with that close relation of the skin and internal surfaces which it is so im- portant to keep in mind in every part of pathology and practice. The influence of blood-letting in producing per- spiration doubtless arises from its diminishing what may be called, in default of a better term, the tension of the general circulation ; and thereby relaxing the vessels of the skin and other surfaces. Here then, also, while admitting that some benefit may be derived from the perspu'able matter thrown off, we must regard the act of perspiration principally as an index of the favourable change taking place in the vascular system at large. Limiting these remarks, however, chiefly to sudorifics of internal use, I say nothing of the various external means employed to the same end ; even though they might illustrate in many points the views already stated; and particularly as regards the relative effect of cold and hot applications to the skin, in pi'omoting a free action of the exhalants, under dif- ferent morbid conditions of the body.* Nor do I propose * TLe practice of IJydropatLy has affoi-ded some remarkable facts in ON SUDORIFIC MEDICINES. 515 here to apply these views to particular cases of disease. My object is merely to otFer suggestions which may tend to render our notions on the subject more simple and precise; and I venture to lay down the following positions as founded on sufficient evidence : — First, that it is more reasonable, as well as beneficial in practice, to have regard to the changes in the circulation producing diaphoresis, than to the action of sweating itself. And, secondly, that the amount of perspiration is rarely a just measure of the good obtained ; and that to make this a primary object is likely to give a wrong and injurious bias to the treatment of disease. It may be alleged that these are needless refinements of principle, not required by the present state of medicine among us: and I Avillingly admit that there has been in this instance a greater change in actual practice than in the general views upon which it is professedly founded. It Avas impossible, with increasing exactness of observation, to escape the conviction that in febrile and inflammatory dis- orders the direct cooling methods of treatment are the safest and most beneficial ; and these accordingly have been gaining ground to the exclusion of such as were previously in com- mon use. StUl there remains something to be done to render this change more general and complete. And yet further, it is of importance to give stability to all such practical results, by fixing them upon principles which cannot be changed with the fashions that affect particular medicines or methods of treatment. connexion with this part of physiology and therapeutics. As I have said elsewhere, it is impossible not to foresee in this practice, after its excesses have been curtailed, and its useful applications better determined, much that may furnish Important aid in the treatment of disease. L L 2 516 CHAP. XXVII. ON THE USE OF OPIATES. The manner of employing Opium in modern practice might, until very lately, have been cited among the many examples of perverse changes of fashion as to particular remedies and methods of treatment. All that tended to increase the credit and use of purgative medicines lessened -for a time, in the same ratio, the reputation and employment of this remedy. A contradiction was presumed, greater than actually exists, between the two modes of treatment. The fear of confining the bowels and checking the secretions, constantly present to the mind of the practitioner, readily imbued the patient with the same alarm. And thus was prevented the adequate use of a medicine, having the power of mitigating pain, of re- lieving spasm, of procuring sleep, of producing perspiration, and occasionally even of aiding the natural action of the bowels, by obviating the disordered actions which interfere with this function. I speak of this as having been, because it is certain that opiates are again more largely employed, since the intro- duction of Morphia, as a common preparation, has furnished new methods of administering the remedy, and revived atten- tion to the principles of its action. Yet even now it may be affirmed that there exists a distrust both as to the frequency and extent of its use, not warranted by facts, and injurious in various ways to our success in the treatment of disease. This is the more singular, seeing the boldness of our practice in ON THE USE OP OPIATES. 517 other points; that we have in the sleep produced a sort of Hmit and safeguard to its effects; and that we possess re- medies of easy application for all injurious symptoms that can arise. To the insufficiency indeed of the quantities given, may be attributed in some part the comparative disregard into which the remedy fell during a certain period. Half a dose might disturb and distress the night wliich a full dose would have made one of perfect rest ; or perplex the aspect of symptoms which a larger quantity would have alleviated or removed. Yet medical experience does but follow common observ- ation in recognising the inestimable value of sleep in sick- ness; of the suspension of pain, and the check to all disordered actions, thereby obtained. For pain and sleep- lessness, though strictly but symptoms of other ailment, may often in practice be viewed as disorders in themselves, the removal of which is essential to the success of our general treatment.* In a preceding chapter, I have treated especially of pain, as a symptom of disease ; and of the means by which it may best be obviated, including Opium as the most impor- tant and valuable of these. But apart from the more acute suffering of disease, how often do we see a nervous restless- ness come over the patient, the consequence of protracted illness or other causes — retarding cure, by preventing the due effect of remedies, and receiving no relief itself from the means employed for the original disorder. In such cases the physician must not submit himself to names or technica- lities. The regular course of treatment must be suspended till the hinderance is removed ; and even seeming contradictions * A physician of large practice, whom I knew only in the latter days of his life, acted not unwisely (perhaps warily) in carrying about with hini a box of small opium pills ; with which he often gave relief, or made preparation for it, while yet in the house of his patient. I- L 3 518 ON THE USE or OPIATES. to this course may safely be admitted for the attainment of the object. Here Opium is the most certain and powerful of the aids we possess ; and its use is not to be measured timidly by tables of doses, but by fulfilment of the purpose for which it is given. A repetition of small quantities will often fail, which concentrated into a single dose, would safely effect all we require. On this subject we must refer to a fact regarding Opium, singular in itself, and affording many curious inferences. I mean, the frequent absence of its ordinary effects in pro- ducing constipation, headache, and nervous symptoms, when given for the relief of acute pain or spasmodic actions in some part of the system. It would seem (however vague the expression) that the medicine, expending all its specific power in quieting these disorders of the nervous system, loses at the time every other influence on the body. Even the sleep peculiar to opium appears in such instances to be wanting, or produced chiefly in effect of the release from suffering. Though certain analogies may be quoted in illustration of these facts, nothing like explanation of them is furnished by our present knowledge. Their reality, however, cannot be doubted as matter of medical experience ; and the instances are further remarkable in the large doses which may fre- quently be given in such cases, with impunity as to all the ordinary effects of the medicine.* * An instance is just now before me of a young lady of fourteen, Avho had never before taken opium in any form ; but to whom from 140 to 160 drops of laudanum were given daily for many days in succession, to relieve the acute pain arising from inflammation of bone. Here, beyond the relief thus afforded, for which these large doses were essential, there occurred no obvious effect on any of the functions, bodily or mental, nor any need of counteracting remedies. Little assistance even was required for the bowels, though confinement of posture was added to the effect of the medicine. As the i)aln gradually abated, the peculiar influence of ON THE USE OF OPIATES. 519 These remarks apply further to certain cases, where, with- out any actual illness, there is a general irritability of con- stitution, carrying its morbid influence into all the functions of life. Here the use of Opium is for the most part admissible with less risk than in other temperaments ; its injurious eifects being in some degree merged in the relief given to this par- ticular state of the nervous system. The power of this remedy in checking various morbid actions in their earliest stage, even such as have no direct relation to the nervous system, is too much neglected in modern practice. In common catarrh, for instance, twenty or thirty drops of laudanum, or an equivalent dose of some other opiate, given with a warm diluent at bedtime, and followed in the morning by whatever laxative may be re- quired, will often arrest altogether a complaint, which the later use of purgatives, antimonials, and saline medicines only tardily removes. Nor is there, except in some cases to which I shall soon refer, any such risk as might seem likely from this sudden effect of opium in checking the train of morbid actions, even in cases of more Import than that just mentioned. The recommendation of its use, fairly attested by experience, in the treatment of the paroxysm of ague, may be cited as an instance in point. Where the check is given by the removal of irritation, — or of that which John Hunter has termed " alarm to the nervous system," — or by the procuring of sleep, the effect is almost always safe and beneficial to the patient.* opium came to be more felt ; and It was needful in the same ratio to lessen the amount employed. * It may seem strange, that while Lind strenuously recommends opium at the commencement of the hot stage of an intermittent, other authors have as strongly advised it at the beginning of the cold stage. We do not yet know enough of the mode of operation of the medicine through the L L 4 520 ON THE USE OF OPIATES. In truth, the injurious effects of this substance as a medi- cinal agent are altogether over-rated ; a natural consequence of the mental and bodily evils resulting from its abuse when taken otherwise. I have seen the distresses produced by this excess, too frequently and too impressively, to allow me to offer a word in palliation of it. But there is nevertheless reason to say, respecting the general action of opium on the animal economy, that no agent of equal and similar power produces its peculiar effects Avith less detriment to the consti- tution ; nor is there any which admits of such extension of use, if gradually made, without fatal result. The excess in it is a hurtful intoxication, enfeebling both mind and body ; but scarcely more so than the habitual excess in wine and other alcoholic compounds, with which we too largely and familiarly deal as a part of diet. Every sound and suffi- cient reason must lead us to limit its use strictly to medicinal purposes. But so limiting it, and in cases where it is rightly admissible as a mode of treatment, little apprehension need exist regarding the amount of dose ; and inconvenience is at least as likely to arise from deficiency as from any ordinary excess. In some cases there is doubtless an idiosyncrasy regarding Opium (as with respect to mercury, ipecacuanha, and other substances, whether in medicine or food), rendering it, even in minute quantity, a source of much injury to the nervous system. Instances of this kind occur, where the fact can no more be doubted than can the particular effect of tea and coffee upon some constitutions. Within the last three months nervous system, to be enabled to affirm that these opinions are incom- patible, though it is probable that both cainiot be just. It is a curious evidence how much is yet wanting to fixed principles of practice, even in the most familiar disorders, that the same contrariety exists as to the use of other powerful remedies iu the cold and hot stage of agues. ON THE USE or OPIATES. 521 I have seen two cases, in each of which there was distinct proof that oj)ium, in the ordinary dose, produced a great enfeeblement of voluntary power for some days ; — in one of these instances affecting the right side only, and so power- fully as to give alarm of hemiplegia. There seems also reason to believe, in conformity with the remark of some authors, that the effects of Opium are pro- portionally greater on young children, whether owing to the facility of absorption at this age, or to the greater suscep- tibility of the brain and nervous system ; — a point, if well established, of obvious importance in practice. But all cases of idiosyncrasy regarding Opium require scrutiny ; lest we bring under this head the mere errors of fancy or j)rejudice, or the effects of the medicine partially and injudiciously em- ployed. I recollect very many instances, where I have had occasion to correct at a later time an opinion thus conceived, or assented to on insufficient proof. It cannot be doubted that Opium is one of the most certain and beneficial means we possess of exciting general per- spiration. This is probably an effect of its power of allaying inordinate action in the vascular system throughout the body ; but there may be other causes also concerned, which are less obvious to us. I have spoken on this subject when treating especially of sudorific remedies ; but I revert to it here, as a point scarcely enough regarded in general prac- tice. In fevers, indeed, the use of opium for this purpose is often prohibited by the other conditions of the malady; but there are many cases of slighter kind, where the per- spiration and tranquillity, conjointly resulting from its use, suffice to arrest a disorder, which experience tells us might go much further were no such aid afforded.* * The usual doses of Dover's Powder, the form of opiate most fre- 522 ON THE USE OF OPIATES. The employment of opiates in inflammatory diseases, and especially in such as affect the chest and head, offer many diflScult points to the judgment of the practitioner. Here are morbid actions going on, of which we cannot safely for any length of time conceal from ourselves the amount. To stupefy the sensibility to pain, or to suspend any par- ticular disorder of function, unless we can simultaneously lessen or remove the causes which create it, is often but to interjDose a veil between our judgment and the impending danger. However beneficial are sleep and ease, they may be purchased at too dear a rate in such cases ; and we must seek them rather in sequel to the more active remedies by which the power of the disease is met and subdued. Fre- quently, indeed, no art can procure them before. Yet it is certain that there is a character of some inflam- matory diseases, and a time probably in all, where this remedy may safely and beneficially be admitted. In certain forms of peritoneal inflammation, whether puerperal or other- wise, attended with extreme pain and restlessness, and pass- ing very soon into the typhoid state, relief to the condition which thus rapidly exhausts the vital powers is at all events to be sought for ; and no appearance of distended bowels, or disordered secretions, can come in contradiction to this rule of greatest safety. Happily, the two modes of practice are not so incompatible as the more general use of the purga- tive treatment would seem to imply. The combination of calomel with full doses of opium is admissible and beneficial in most of these cases ; and, where more express laxatives are required, they are usually best employed when the urgent quently prescribed with this view, are too small for the object desired. Nor is there, according to my experience, sufficient reason for the pre- ference given to this medicine over other opiates as a sudorific. ON THE USE OP OPIATES. 523 irritation is removed. It is, for the most part, very difficult to render them effective before.* Again, in cases of inflammation less special than the preceding, there is a period in each, succeeding to the early and more active treatment, when opiates have their appro- priate value ; not merely in giving rest, but also, as is probable, in lessening what remains of excess in vascular action. A right judgment as to the symptoms which indi- cate their use at such times, or even at intervals between the active remedies, is one of the best proofs of the ability of the practitioner ; for no written rules, however plausible in show, can really minister certainty to this part of practice. The use of Opium needs discretion in another class of cases, which have not, I think, been sufficiently adverted to in this light. I mean those instances, where the heart and organs of respiration are in a state so critical, as to enfeebled power, that the condition induced by opiates may suffice to turn the balance against them. This may happen either directly, by its influence on the nerves of these organs ; or indirectly, by preventing the voluntary aids which a patient can render to himself, when the respiration is labouring and distressed. In an aged person, for example, suffering under chronic bronchitis or catarrhal influenza — and gasping, it maybe, under the difficulties of cough and expectoration — an opiate, by suspending these very struggles, often becomes the cause of danger or death. The effort here is needed for the recovery of free respiration ; and, if suppressed too long, mucus accu- mulates in the bronchial cells, its extrication thence becomes impossible, and breathing ceases altogether. * In the treatise on Puerperal Fever by Dr. Ferguson, published some years ago, I find a strong attestation of the success with which he has employed opiates in this dangei'oui disorder, and some valuable practicid comments on the subject. 524 ON THE USE OF OPIATES. This caution is not unnecessary. I have known more than one case, where there was cause to believe that the fatal event had been hastened, if not produced, by an opiate indis- creetly given at bedtime ; either from anxiety In tlie prac- titioner himself to relieve obvious distress, or from the solicitation of those around that something should be done. Instances of this extreme kind are happily not frequent. But the medical man is bound to be prepared for them ; and to have In readiness, not his judgment only, but his firmness and power of forbearance. For the feelings are often Invoked, as well as the reason ; and he has to balance a certain present distress against a doubtful and contingent danger. No tech- nical rule can be laid down for such cases. Experience and the discretion of the moment, must alone decide what should be done, and what refrained from. The employment of opiates In cerebral affections is another question of much Interest and various difficulty. It might be conjectured that there are some cases where the benefit Is great ; others, where injury alone can result : and experience fully confirms this presumption. Though It would be easy to detail particular cases in which one or other of these results is likely to ensue, I know no single principle, yet ascertained, by which they may be classed and distinguished. Perhaps one of the best practical tests might be found in the state of the pupil; known to be differently affected by opium, by belladonna, and certain other narcotics. Where con- traction of the pupil is one of the symptoms of the disease, it may with some reason be supposed that opium Is contra- dicted as a remedy ; and a like Inference might lead to the use of the opposite class of narcotics in Its stead ; transposing these methods, where the disease habitually produces a dilated state of the puplk As far as my experience goes, it [jartlally confirms the accuracy of the test, but is by no ON THE USE OF OPIATES. 525 means sufficient to allow me to speak of it with certainty. We are still obliged to act here upon the suggestions of the time and symptoms present, or upon the experience which partial trials may afford. There is great scope for further research on this subject, as on all that relates to disorders of the brain ; and a strono; presumption that opium is capable here of larger and more beneficial application than has yet been given to it. In cer- tain cases of insanity especially, where much active irritation is present without inflammation, its employment (not by partial and irregular doses, but by keeping the patient for some time steadily under its influence) is often attended with a good attainable in no other way. Here, as in so many cases of physical pain and irritation from other causes, the maintenance of repose is a summary advantage ; giving time and power to the functions of mind to resume their natural condition.* The latter remark applies strongly also to certain states of fever, where the typhoid character has come on ; and, with it, much disturbance in the functions of the brain, delirium, or intolerable restlessness. Here opiates may often be used with singular benefit, and without any of those ill effects which might be presumed from a hot skin, a dry tongue, suspended secretions, and disorder of the head. The re- moval of cerebral irritation, especially if sleep ensues, is a good which might weigh against many inconveniences, even if they occurred. But, in point of fact, they are much less likely to happen where the Opium directs itself specifically to the relief of irritation of this nature. It is needful to add, that there are other cases of fever of * Dr. Seymour has well distinguished these cases ; and made other valuable remarks in recommendation of opium, in his treatise on these disorders. 526 ON THE USE OF OPIATES. typhoid kind, and where seemingly the same cerebral irri- tation is present, yet where opiates appear to act injuriously, by producing a comatose state rather than sound sleep. Un- less distinction be found in the different state of the pupil, noticed above, — or in the hepatic symptoms which perhaps are more marked in these cases, and injuriously influence the state of the brain, — I have no practical test to recommend, beyond that careful observation of the first trial which may give guidance for the future. It is an important point in treatment, and deserves explicit attention. In many of these cases of disturbance of the brain, opiates may very advantageously be combined with the use of the tartarized antimony. And I would further observe, that morphia, in one or other of its preparations, may usually be preferred here to any other form of the remedy. Without entering into questions as to the separate action of narcotine and other principles contained in the common opium, I think it is proved that the effects of morphia are more explicit, more secure, and freer from injury or inconvenience, than those of any other opiate. It is in some sort the gain of a new agent in medicine; giving us not only less equivocal results, but also the power of a nicer adaptation of means to the peculiarities of each case. This is an acquisition of especial value, where the functions and disorders of the brain are concerned; and we have probably not yet ascertained all the sood to be derived from it.* The three topics I have thus slightly touched upon — the employment of opium in inflammatory diseases ; in dis- orders of the heart and respiratory organs ; and in affections * In like manner the discovery of aconltine and vcratria provides us •with other agents on the nervous system of great and singular power ; and capable, in their chemical form, of much more definite use than under the previous method of employing these narcotics. ON THE USE OF OPIATES. 527 of the brain — Involve some of the most difficult questions as to the use of this remedy. Many others would occur were the subject treated in detail; and particularly those which relate to its eifects in disorders of the liver and alimentary canal. Here again there is need of much discrimination; and it may be affirmed that these are especially the organs, the action of Opium upon which is liable to most suspicion of Injury or failure. Except in cases of simple morbid irrita- bility or spasm in some part of the canal, where it becomes a fit adjunct to other means, its general and certain tendency is to impede or disorder all the processes of digestion, and the secretions therewith connected. And in complaints of the liver and its appendages I scarcely know one, unless it be the painful passage of a gall-stone through the ducts, where Opium may not be said to be hurtful in its separate eifects, though occasionally and indirectly useful when com- bined with other means. I have alluded to affections of the brain in which the liver is concerned, in aggravating at least the symptoms ; and here too its influence is for the most part injurious, and always to be regarded with suspicion. In those cases, generally, where a course of purgative medi- cine is distinctly needed for the relief of the portal-circula- tion, or of congestions about these viscera. Opium can rarely be used without direct injury, or delay in the progress of cure. Where relief to irritation is required, it is better sought for in these cases by a temporary suspension of the active remedies in use ; and the physician shows his skill by steadily maintaining the principle of treatment which he has seen cause in the outset to adopt. To tamper with it by the inter- vention of opposite methods, is for the most part a feebleness hurtful both to the patient and practitioner. There is much greater difficulty in laying down rules for that large class of disorders to which the name of bowel com- 528 ON THE USE OF OPIATES. plaints is applied ; — some of them symptomatic of the more general states just mentioned ; others, the effect of irritation or disease of the mucous membrane in some part of the ali- mentary canal; others produced merely by improper or un- digested food. The second class of cases, including dysentery, is that in which opiates seem most frequently admissible; either conjoined with, or interposed between, the laxative medicines Avhich are more obviously essential. There are cases also of peculiar morbid irritability of the stomach, which are best relieved by a few drops of laudanum, sometimes combined with an alkali taken immediately before food. But it must be owned that the general course of treatment in all these disorders is vague and inconsistent; and that no divisions or descriptions have yet been adopted, determinate enough to define the proper direction of practice, or to super- sede the particular judgment in each case. While seeing, however, in this and other examples, how far medicine is from being an exact science, we may recognise the ample scope it affords for sagacity and watchful observation, and the eminent value of these qualities in every j^art of practice. The external application of Opium is not sufficiently brought into use ; nor is there a due appreciation of all that may be attained in this way. That certain of its specific effects are conveyed through the skin to other parts of the body is unquestionable from experiment ; though the action, so pro- duced, is less strongly marked than that of belladonna and some other narcotics. These effects are distinctly augmented by removing the skin ; so as to bring it into more direct action on the nerves of the part, if topical causes are con- cerned ; or within reach of readier absorption, if more diffused effect be sought for.* In many cases of painful affection of * The experiments of Sir B. Brodie {Phil. Trans, for 1811), and the more recent researches of Miiller, show that both these agencies of opium ON THE USE OF OPIATES. 529 particular nerves, I have found great benefit from a strong opiate ointment on a blistered surface ; or a little of the muriate of morphia sprinkled over it. In certain obstinate cases of gastrodynia, very trying to the skill of the practitioner, though the cause cannot thus be obviated, yet we can often obtain much relief to suffering by similar means applied to the epigastrium, or other more especial seat of pain. I have found no remedy more beneficial in those irritable forms of local psoriasis, which are so distressing from their obstinacy, than the application of poultices, prepared Avith a small pro- portion of a solution of opium, and continued until the state of the skin is thoroughly changed. In many nervous and spasmodic affections, as in some forms of asthma, when we have reason to suppose that the medulla spinalis is the chief source of disorder, the same remedies may be applied along the course of the spine ; and often with singular good, wheu all methods of depletion or counter- irritation have proved utterly unavailing. If Opium might be supposed capable of good in hydrophobia, after the many fruitless trials of it, this is the manner of use most likely to succeed ; diffusing its action over a large surfoce, and by the aid of rubefacients rendering the cutaneous nerves more sensitive to its influence. The general method of practice is one which I feel assured, on experience, may beneficially be carried much further than we have hitherto pursued it. must be admitted, but render it certain that the action of absorption into the blood is much the most important in kind and degree. All modern inquiry tends to show the facility and extraordinary speed with which substances may enter into the c'rculatlon by means of imbibition, not before known to exist. Even since the remarks in this chapter were written, the Endermic method of treatment, as it is called, has acquired a remarkable extension and increase of repute; justified on the whole by present experiment, and sanctioning the hope of much future benefit from this modification in the use of remedies. M M 530 ON THE USE OF OPIATES. The resources of external treatment ought ever Indeed to be present to the mind of the practitioner. If insufficient for cure, they yet are adjuncts of great value to other more active means of treatment. But often the relief they afford is more speedy than that from internal remedies ; and, what can never be too highly appreciated in medicine, Avith much less ambiguity of residt. Cases indeed arc related of serious mischief from opium applied externally to wounds, or exco- riated surfaces ; but such instances are rare, and probably to be qualified by facts regarding the peculiar temperament of those so affected.* The more common cause of failure in this remedy is its insufficient use ; either from the proportion of opium being too small, or from the careless manner of application common to this with other external remedies. It is more difficult to secure constancy in the patient and in those about him, when the means are simple and obvious, than when hidden under more obscure formulas for internal administration. * I Lave seen one or two remarkable instances of the noxious effect of belladonna, thus applied, upon the sensoriuni. In one of these, delirium, continued for more than thirty hours, was the consequence of dressing a blistered surface, by mistake, with belladonna ointment. 531 CHAP. XXVIII. ON MERCURIAL MEDICINES. It may seem that any remarks at the present day, on the principle or methods of using Calomel, must be trite and altogether needless. Yet is this only in part true. One comment I would make is, that, in the ordinary use of this medicine as a mercurial, its good effects are often much impaired by admixture Avith other aperients. Such com- bination is doubtless most beneficial, or even necessary, where the object is to obtain large and speedy evacuation of the liver and bowels. But in the numerous cases where the proper mercurial action is desired, either on the mucous mem- brane of the intestines, or on the different secreting organs, or in arresting certain states of inflammation. Calomel will generally be found to act most beneficially, and with greatest certainty, when given alone. Its combination with purgatives in these cases both obscures and impairs its effects ; intro- ducing at the same time causes of irritation, which disturb the body in other ways, and thereby check the influence of the medicine, and the general progress of recovery. The same remark holds good in many instances where the liver is the direct object of mercurial treatment, exception of course being made for the contingency mentioned above. Even in cases of obstruction of the bowels, when there is threatening of topical inflammation. Calomel adequately given, without the addition of other laxatives, will often be more effectual for relief than in any combination with them. M M 2 532 ON MERCUKIAL MEDICINES. Its separate action is mucli less irritating to parts in this condition ; while there is generally more distinct and speedy exercise of its specific effect upon membranes already in an inflamed state. To avoid irritation and pain, indeed, whenever this can be done without too palpable sacrifice of the objects in view, ought ever to be present as a principle in the treatment of disease. In all cases these are positive evils, counteracting or retarding more or less the good gained. In some habits their effects, long continued, are mischievous even to the extent of danger and death. I doubt whether this principle, which I have dwelt upon elsewhere, is sufficiently regarded in the ordinary course of practice. "We too often see methods of treatment, external as well as internal, usurping the names of remedies, and capable of acting as such in some constitu- tions; but Avhich in others, by repeated irritation, have fretted the body into new disease, more difficult and dis- tressing than that which was the original object of cure. The proof here is the relief gained by intermission of the means ; but it must be admitted that these are cases requiring judgment and discrimination. When thus given in a simple form, and where there is no strumous disposition or idiosyncrasy in the habit, it is re- markable how much Calomel may be borne without injury or inconvenience ; and even without any such urgent effect on the bowels, as might be supposed from its effects in ordinary use. That the medicine is often needlessly and injuriously employed, as are many others, cannot be denied. But there is an abuse also on the side of timid and deficient employ- ment, where its decided and speedy influence is required, This is often forfeited by using it in those small and scattered doses which harass the bo\Yels with fretful and irregular action, without being efficient for relief. If mercury be ON MERCURIAL MEDICINES. 533 needed for its specific effect on the system, or even on a part of the body, the sooner, generally speaking, that it is brought into action, the better.* Or if exception be taken against this as a rule, its agency is at least important enough to warrant its being used singly and steadily ; without the ambiguity of any combined means, other than such as may be wanted to support the system under its action, or to aid in directing it to any given part. This consideration, of supporting the action of Calomel by simultaneous assistance to the powers of the system, is often neglected; from some supposed incongruity, much greater than really exists, between its action and the functions which tend to repair or invigorate the body. In those cases where frequent repetition, or long use of the remedy is re- quired ; — or where the body, as often happens, is debili- tated by disease, which yet needs the activity of this medicine for a chance of favourable issue, — the direct conjunction of Calomel, or other mercurial, with tonics, is frequently not only the safest, but even the most effectual way of using the remedy. In such cases, of which some dropsical effusions may be taken as examples, the mercurial action in producing absorption seems to be quickened and sustained by the ad- dition of bark or steel ; and where no fever is present, or irritation in the primre vlte, these medicines may often be made beneficially to concur with every part of a mercurial * This is a question of some interest in pi'actice, and respecting wliich opinions will differ. Perhaps it may best be answered by reference to individual temperament, and the nature of the disease. My own impres- sion is, as stated above, that when we seek to obtain the specific efTects of mercury, it is for the most part expedient to get the medicine into the system as quickly as possible, with due regard to the other circumstances of the case ; regulating afterwards the degree and duration of its action according to the symptoms. M M 3 534 ON MEKCURIAL MEDICINES. course. I would willingly press this point as one of im- portance, and not duly admitted into practice. There is some cause to believe regarding mercury, as with respect to opium, that in certain conditions of active disease, where its agency is most beneficial and nearest to what may be termed specific, the medicine is capable of these effects, without any such action on other parts of the system as would have occurred under different circumstances. The truth of the observation is best attested in cases where it is given to subdue inflammatory actions in serous membranes ; such inflammation as tends to effusion, unless speedily over- come.* May it be supposed that this arises from a more express direction of the mercurial action to the kidneys in these and similar instances? It is known that there are certain states of organic disease of the kidneys, in which mercury produces its constitutional effects more rapidly than usual. The fact, which is an interesting one, would seem to illustrate the supposition just made; and by showing the intimate relation of mercurial action to this function, will explain other anomalies in its effects on the system. The remarkable influence of mercury in subduing certain inflammatory actions, both acute and chronic in kind, but particularly acute inflammations of serous membranes, is best explained by supposing its action to be on the capillary ves- sels, whether of membranous or glandular organs. Without assuming to define what is the particular state induced on these vessels as opposed to inflammation, I have always found this idea (long adopted by many eminent observers) to * I find it justly remarked by Dr. Seymour, in his Treatise on Dropsy, tliat the quantity of mercury which may be beneficially used in cases •where inflammation, ending in deposition of lymph, is going on in the pericardium, is almost inconceivable ; and this without aflfecting the gums or producing other inconvenience. ON MERCURIAL MEDICINES. 535 furnlsli the best clue to the various actions of mercury on the system. Its topical direction to particular organs (if indeed we rightly so interpret Avhat in many cases may be only the different tendency in these organs to show the influence upon them) is subordinate, as may fairly be pre- sumed, to this more general principle. And though it is difficult to understand how it should be a cause of specific inflammation in certain parts, compatibly with the other actions just stated, yet is this difficulty but part of our ignorance of the general theory of inflammation, attested still by so many differences both in opinion and the state- ment of facts. The whole subject is interesting, from the connexion it indicates between the action of a very powerful medicine, and the functions of that part of the vascular system which is noAV rightly looked to as the principal source and seat of disease. I believe that a mistake is frequently made as to the manner of operation of Calomel and other mercurials, in ascribing effects to their action on the liver, which are in fact chiefly due to their influence on the mucous membrane and glandular follicles of the intestines. The action, prompt and almost specific, of mercury upon the liver cannot be doubted; but scarcely less in amount or importance is its effect upon the parts last mentioned. The secretions and discharges thence arising, particularly from the mucous mem- brane and glands of the colon, are often mistaken for those from the liver ; and the treatment continued and pressed for- wards upon this supposition. In many cases there may be no practical evil in this ; in some it may even prove beneficial, mercury being the fit remedy, whatever the seat of the dis- order. But in other instances the error is certainly of mis- chievous tendency ; and at all events we are bound to seek for what is true in knowledge as the basis of our practice. M M 4 536 ON MERCURIAL MEDICINES. In the employment of blue pill, as well as of calomel, I believe that the benefit is often lessened by combination with more active aperients ; and this is especially the case, where it is used as an alterative for disordered secretions, or in certain cases of dyspepsia. In these instances it will gene- rally be found more advantageous to give it twice or thrice a day — in moderate doses and uncombined — than to limit it, as is usual, to one larger quantity at bed-time, with some purgative combination. I cannot affirm that I have seen any distinct effect from the very minute doses of the blue pill, recommended by some physicians ; but I do not doubt from observation the benefit of small quantities, frequently repeated in the chronic cases just mentioned. This mode of using mercurial medicines is common in the complaints of children, but by some incongruity less frequently applied in those of adults. There is certainly no practical reason for the distinction, unless it be the seemingly greater power of re- sisting the mercurial action in the former; a point itself liable to some doubt. I have no design here to enter into details as to the action or manner of use of Calomel in different diseases. This is too large a subject to be otherwise considered than in its relation to each. If I might venture a general comment upon the present employment of the medicine, it would be that it is too frequently used as a mere laxative remedy ; and too sparingly and inefficiently, where relief to certain varieties of inflammation is sought for — or the absorption of dropsical effusions — or the separation from the system, principally through the liver and the secreting surface of the intestines, of certain morbid matters which, under one denomination or other, are largely thus excreted from the body. And I would repeat that in pursuing some of these objects, particu- larly that of subduing inflammatory action, it is often much ON MERCURIAL MEDICINES. 537 more expedient to give it alone than in any form of com- bination. Tiie question of salivation is of less moment here than it might on first view appear. If the mercury, thus singly given, passes more readily into the body, it does for the most part accomplish more speedily the object sought for. And in the cases of exception to this, and of anomaly in the action of the medicine, the particular circumstances generally furnish best direction as to what should be done. Though most of the beneficial effects of mercury may be attained, short of that constitutional action which is testified by salivation, yet there are certain cases where it seems that the more complete ingress of the medicine into the system, thus testified, is followed by greater and more lasting benefit, than when the effect on the mouth has not been obtained. I think I have observed this most frequently in cases of hepatic disease ; but the fact is undoubtedly true in others also. Salivation occasionally, and in certain habits, becomes a serious evil ; but its earlier stage is generally so much under medical control, that no valid objection to the remedy can be thence derived. While commenting upon the ordinary manner of use of mercurial medicines, I may notice what I think to be a need- less degree of apprehension, not with patients only, but even among medical men, as to exposure at the time of taking them. In every case where purgative action is sought for, whatever the means employed for this purpose, it is right to guard against cold or other causes depressing the body, or creating sudden changes in the balance of circulation. The effect of this action in producing at the time a certain col- lapse of power, is a sufficient motive for the general caution. But there is nothing so especial in the case of mercury thus used, as to call for its relinquishment, when other means are fairly admissible for the object. Or if it be so in certain 538 ON MERCUEIAL MEDICINES. instances, I cannot doubt that the apprehension is carried much too far in others, thereby altering frequently the course of practice where no such change is required. I would not willingly withdraw any caution really salutary ; but medical practice ought not to be fettered by traditional oj)inions, or the current and careless phrases of society. The dread prevailing in France and Germany as to the use of Calomel, and the reprobation of English practice on this score, are well known. Unless partial cases of abuse be admitted as argument, such as may occur in the case of any other medicine, it cannot be allowed that there is much justi- fication for these harsh views. It may indeed be affirmed (and I state this on my own observation), that the judgment is formed mainly on hearsay, and has gained av eight by mere repetition. The actual knowledge from exjDerience of the medicinal qualities of calomel is, on the Continent, exceedingly limited ; yet this is the only evidence which can fairly be brought to the question. Who, for instance, that has not seen the effects of the medicine, duly given, in severe cases of croup — or in certain affections of the brain — or in cases of o;reat con2:estion about the liver and abdominal viscera — or in particular cases of membranous inflammation, — can rightly estimate the benefits procured from it, and procured, we are often able to say, without any injury to countervail the good? It is needless to multiply examples to this effect. The ex- perience of every medical man in this country will supply them ; but without such experience no censure like that alluded to can justly be applied. It is of course not to be inferred that these results are derived from the use of Calomel alone. Where the peculiar action of mercury is the main object, other preparations may be equally capable of fulfilling it ; and in some cases this object is perhaps even better attained by the form of mercu- ON MERCURIAL MEDICINES. 539 rial medicine of which I am about to speak. But the more explicit knowledge we possess of the effects of Calomel, and its undoubted sufficiency for all the most important purposes of practice, must ever sustain its repute ; whatever equivalents may hereafter be acquired for the results we now obtain through its agency. The error of many continental physicians on this subject arises, I believe, from their connecting the large use of pur- gatives in English practice with the idea that Calomel is the medicine chiefly employed for this object. I have spoken in another place of what I think to be the real excess in this part of our practice ; and, as respects Calomel, have allowed that it is often needlessly — sometimes, and in particular temperaments, injuriously — employed. But the admissions ought not to go further than this; and there remains to all who rightly estimate its use a large balance in favour of the medicine, fully sanctioning the place it holds among English physicians in the treatment of disease. Among the different mercurial preparations, the Oxy- muriate, or Bichloride of mercury, is not so generally used as it merits to be, though doubtless more extensively now than heretofore. Under discreet employment it is one of the most valuable remedies we possess. The power of givino- it in solution is a material advantage in various parts of j^rac- tice ; rendering its action more certain, more equable, and probably, by readier absorption, more effectual as an alter- ative upon the whole system. I have seen its influence in augmenting and improving the secretions — procuring the absorption of morbid growths — altering the state of the skin in many cutaneous disorders — and changing the character of morbid actions generally throughout the system — in cases where I believe no other medicine, or combination of medi- 540 ON MERCURIAL MEDICINES. cines, would have had equal effect. Its conjunction with bark, steel, sarsaparilla, &c., affords resources of the greatest value in the treatment of disease. And, though otherwise held by common opinion, I think it on the whole as safe a medicine as Calomel in the hands of the practitioner ; inas- much as its distribution can be made as equal and determinate; and its effects, from being given in a state of solution, are less likely to be interrupted by mechanical hindrances in the stomach and bowels. It is worthy of note, indeed, how long this medicine may be continued in uninterrupted use, without obvious injury or inconvenience. I have often given from four to six drachms daily of the Liquor hydrarg. bichlorid. {Pharm. Lond. 1836) for six or eight weeks ; without affection of the gums, irritation of the bowels, or any effect making it needful to intermit or modify its use. In other cases this is not equally possible : but the difficulties which occur from idiosyncrasy, or other causes, are quite as readily surmounted here as in the case of any other mercurial, and are rarely such as to prohibit the use of the medicine altogether. Perseverance in the use of this preparation is, according to my experience, of singular avail in certain cerebral or sj)inal disorders ; Avhcre there is presumption that some effu- sion may have taken place, or that the state of obscure inflammation exists, tending to this effect. I have seen o-reat benefit from it, thus steadily employed, in several cases of paraplegia ; the usual slow progress of the disorder giving ample scope for its effects, and the danger in prospect justifying the full trial of the remedy.* In other instances, where the * Adverting to tliis disease, I may remark that in those cases of it which appear (more perhaps in the results of practice than from any assured diagnosis) to be unconnected with atrophy or other change of the nervous substance itself, I know no remedy which can compare with ON MERCURIAL MEDICINES. 541 object has been to procure absorption of a deposit or thick- ened texture, or to change the condition of action leading to this, as in particular cases of hypertrophy, I have found equal facility in sustaining its action for a long period, and this without obvious injury to the system. I may repeat generally my persuasion that much advantage might be gained from the larger and more various employ- ment of this mercurial remedy. But to obtain the full benefit, we must be patient as Avell as decided in its use. In those cases where it is of greatest avail, the processes of change are often slowest ; and not testified by those instant and obvious results, which are sometimes needed to fortify the mind even of the physician in the perseverance proper to the mercury adequately used. One of the most remarkable cases I have seen, attesting this efficacy, was that of a patient about forty-three years of age ; where the symptoms, beginning with weakness of the lower limbs and loins, preternaturally slow pulse, and slight confusion of mind, pro- ceeded gradually in the course of a few months to total inability in these limbs, loss of power in the sphincters, extreme difficulty of articulation, failure of memory and intellect, and general want of nervous power throughout the whole system. Under a treatment of full doses of calomel twice a day for about five weeks, and then once a day for an equal time, without intermission, yet never proceeding to actual salivation, the symptoms were all progressively removed ; the restoration of the volun- tary powers and intellect being best proved by the patient regaining his power of walking and riding, and by being able to preside again as Chairman of the Quarter Sessions. The mercury was used in this case almost to the exclusion of other internal remedies. The only means, which could render the result ambiguous as to cause, were two issues kept open over the cervical and lumbar vertebra3. But, though these had doubtless some effect, the relation of date between the remedies and the relief obtained gave proof that the mercury was of greatest avail. I ought to mention, that life was terminated half a year after this re- covery by a sudden apoplectic seizure, the effect of some over-exertion in country sports ; an event not invalidating the inference as to treatment, though showing that the same tendency still existed In the habit. JSTo post mortem examination took place. 542 ON MERCURIAL MEDICINES. practice — still more to satisfy the patient and those around him; alarmed, it may be, bj' the name of the medicine, and by the precautions taken as to its dose and effects. As a result of these or other difficulties, I have repeatedly known a course to be abandoned in the middle (sometimes at the very moment when becoming most effective), which there was every reason to believe capable of relieving eventually a dis- tressing or dangerous malady. Such difficulties are best obviated by a just anticipation — and, it may be, declaration — of what is to be done, and Avhat expected ; and by a steady recurrence to the same principles throughout the whole pro- gress of treatment. In these few remarks on mercurial medicines, as on so many other subjects in this volume, I have referred to those points only which seem to deserve further consideration than they have hitherto received, or a more direct and certain ap- plication to practice. 543 CHAP. XXIX. ON THE USE OF DIGITALIS. After all that has been written upon this medicine, there is reason to doubt whether its capabilities have yet been brought into full use. An agent which can thus alter the heart's action, and, under management, safely sustain this alteration for a considerable time, is a very important one in the hands of the practitioner; affording means wherewith to control, more or less directly, all the actions of the system. It is, however, this singular sedative effect on the heart, and the occasional suddenness of the change so produced, which creates an apprehension as to its use, not warranted by what we learn from exact observation. Though employing the medi- cine somewhat largely in practice, I do not recollect a case in which I have distinctly seen injurious consequences from this cause ; — none such, certainly, as were not speedily relieved by its discontinuance, and other means of easy adoption. I am far from inculcating neglect of the symptom just mentioned. But while admitting that deviation below the average standard of the pulse is less frequent and consider- able than excess above it, and that certain morbid states of the brain are sometimes thus indicated, I feel assured that alarm is too readily taken in the early effects of Digitalis on the heart, even should intermittent action be one of these. Similar effects occur habitually from so many other causes affecting the body without injury which can be especially 544 ON THE USE OF DIGITALIS. referred to this symptom, that if there be justification on other grounds for sustaining the action, and care given in watching it, the practice may generally be pursued without any risk sufficient to countervail the good. More attention too is required, than is always bestowed, in estimating the actual changes in the pulse. It is not enough to feel it once, or in one posture only. The differ- ence between recumbency and the upright posture will often totally alter its character ; and it should be examined also after some cordial has been given, to ascertain the facility of bringing it back to its ordinary state. These and other precautions, by better determining the real amount of de- viation produced, afford securities for the continued use of the medicine which are of great practical value. Such suggestions regarding the pulse apply to many other cases, where we seek to know the effects of disease upon it ; and not, as here, the influence of the remedy. The value of its indications is often forfeited by the slight and careless manner in which they are sought for. An inference may be formed at one moment, or under one posture, which the lapse of five minutes, and change of position, will altogether belie. This is less the case in fevers and inflammatory diseases; but there are many others where the view of the disorder, and method of treatment, may be wholly perverted by trust- ing to a single observation. All recent inquiry into the pulse shows the need of attention to these points. The manner of employing Digitalis is undoubtedly of much consequence. I feel assured, on experience, that the com- bination with tonics and stimulants not only does not impair some of its specific effects, but even extends them by giving larger scope to its administration. This may be inadmissible when a direct sedative effect is required (though here, as in the case of Dr. Ferrier's original suggestion of Digitalis and ON THE USE OF DIGITALIS. 545 iron in phthisis, the line cannot always distinctly be drawn); but when the action of the kidneys is especially sought for, and in habits already debilitated by disease, such com- binations are often of the greatest value. That with iron seems to me more beneficial in many cases than with bark ; nor pi'oducing any mischief or ambiguous effect from the seeming incongruity of the two agents. I have frequently given Digitalis in the ordinary doses, for weeks together, in combination Avith various forms of steel, and especially the Tinctures, without finding cause to withdraw or in- termit the medicine; and this in cases where the patients were far advanced in years, and the circulation become feeble from disease. It would be difficult to find any single combination more effective than this in old cases of general dropsy; in edematous swellings from debility; or in the anasarca following scarlet fever, where, together with weak- ness, there is still left an excited and irritable state of the arterial system. The action of the foxglove, as a diuretic, seems even to be quickened and sustained by being conjoined with iron; while the latter acts apparently as a safeguard against some of its peculiar effects. It cannot be doubted that this medicine may often be given with safety and advantage, even where the action of the heart is already extremely irregular. The irregularity arises occasionally from causes which the Digitalis is capable of lessening or removing ; as from fluid actually effused. But, besides this less direct influence, it is probable that ita immediate action on the heart, tending under certain circum- stances to produce intermittent pulsation, may under other circumstances correct the irregularity already existing. And accordingly I have often found perfect equality of beat to ensue for a time upon its use, where the motions of the heart had been very unequal in their ordinary state. N N 546 ON THE USE OF DIGITALIS. The effect here is the same as that which frequently occurs from fever, or other cause of excitement to arterial action, in rendering regular a pulse habitually intermittent; but the fact is more remarkable in the instance of Digitalis, from its peculiar influence on the heart under ordinary circumstances. We have reason, indeed, to suppose at least tAvo different states of this organ, independently of structural disease, in which intermittent action may occur, from causes almost the converse of each other; and in this probably lies the ex- planation of the seeming anomaly in question. The point is a curious one in pathology, and meriting notice from the inferences it suggests. And here I am led incidentally to remark that a treatise on the various irregular actions of the heart, unconnected until organic causes, — and defined as such, — Would, if well executed, be of great practical value. The success recently attained in decyphering by external signs the various struc- tural changes of this organ, leaves too much in arrear the knowledge and classification of the many other causes which disturb its action, and often assume every aspect of real disease. To those especially who have not had time or op- portunity to reach the needful exactness in auscultation (and partial knowledge here is often more dangerous than ig- norance), it is of great moment to know the different causes which may render their first impressions ambiguous. It is no impeachment of the true value of such methods, to state that frequent mischief has been done by making them the sole interpreters of disease ; without due regard to those other numerous causes of disturbance — mechanical, chemical, and nervous — which are ever tending to affect and disorder this great centre of the circulation.* * I should depart too far from the subject of this chapter, were I to do more than simply enumerate in a note the chief irregularities in the ON THE USE OF DIGITALIS. 547 Recurring to the subject before us, I may add that I have often employed Digitalis beneficially, in cases even where there was proof from auscultation, or otherwise, of the heart being actually diseased in structure. There is need here, however, not only of much watchfulness, but of discrimination as to the kind of disease. The enlarged and flaccid heart, though on first view it might seem the least favourable for the use of the medicine, is perhaps not so. At least we have some reason to believe that in the dropsical affections which depend on with this organic change, the action of Digitalis, as a diuretic, is peculiarly of avail. Generally speaking, in all cases where there is obvious mechanical difficulty, valvular or otherwise, to the passage of the blood through the heart, so as from slight causes to give to the patient apprehension of fatal stoppage, we are bound to be cautious, lest, in seeking to relieve quick and irritable pulsation, we should bring on some worse alternative. heart's action which may, and do, occur transiently from various causes, independently of disease of structure in the organ itself. These are — alterations of rate of action, whether by acceleration or retardation ; alteration in the strength of beat, with or without change of rate ; deviations from the equality of rhythm, either by unequal intervals of time, or unequal strength of successive pulses ; complete intermissions, either at regular or irregular intervals ; the longer cessation of action in the fainting fit ; the jarring irritable action, without change either of rate or regularity ; and that condition best described by the term of laborious action, easify passing into inequality of rhythm and power. Other slighter irregularities might be named ; but rather with the effect of encumbering than aiding the young physician, amidst the difficulties which beset this part of practice. Of these now mentioned, many — perhaps nearly all — may occur in connexion with, or In effect of, organic disease of the heart. But it is important to know that they may all happen, in one degree or other, from temporary causes, and without any obvious or permanent change of structure. The practical value of dis- crimination here, for the welfare of the patient, and the credit of the physician, cannot be too forcibly dwelt upon. N N 2 548 ON THE USE OF DIGITALIS. The action of Digitalis seems, indeed, peculiarly the subject of anomaly throughout; and I am partly led to these re- marks, as pointing out the void there yet is in our knowledge of some of these very powerful physical agencies on the body. Scarcely even is the question wholly settled, whether it is directly, or only indirectly, sedative. The view^ of its action as one of accumulation in the body, and sudden effect, is still uncertain ; — or if thought to be determined in fact, liable at least to doubt in the practical inferences drawn from it. Another source of difficulty is the doubtful relation between the sedative and diuretic effects of the medicine; under- standing by the former term, its peculiar influence on the heart and circulation. This connexion, though doubtless ex- isting, and probably an integral part of its action, has not yet been rightly ascertained. In following the inquiry, there are certain points which occur in the outset, as essential to it ; such more especially as the question, whether the diuretic action of Digitalis is upon the kidneys immediately, or inter- mediately through changes it produces on the vital actions of the sanguiferous system ? In answering this question (which may probably be done by affirming the latter opinion), Ave are called upon to refer to the fact, that it is chiefly in dropsy of the cavities of the chest, and anasarca, that its action as a remedy is of any avail. Pursuing this observation, it be- comes likely that most of the doubtful or anomalous effects of the medicine will hereafter be found to resolve themselves into its influence, direct or indirect, on the heart and different parts of the circulation.* The recent experiments of Dr. Traube, of Berlin, by injection of the infusion of Digitalis * I have never seen an instance of ptyalism produced by Digitalis; but the case recorded by Dr. Henry, and some earlier evidence of the same kind, make it probable that this is an occasional consequence of excess in its use. ON THE USE OF DIGITALIS. 549 into the jugular vein, while confirming some of the results before obtained by Magendle, have illustrated other curious anomalies in its action on the heart, depending on the quantity- given, and the speed with which it is taken into the system* These experiments further show the remarkable effect of the division of the pneumogastric nerves, in obviating or annulling the influence of Digitalis on the pulse. Much, however, remains to be done before we can confide in our knowledge of this singular medicine. Organic che- mistry has of late been actively at work here, as elsewhere ; and MM. Homolle and Quevenne have obtained by analysis fourteen different substances from the leaves of foxglove ; to one of which, the Digitaline, the specific qualities of Digitalis appear to be chiefly due. In this respect, as in others, there is a close analogy to the chemical constitution of opium and other vegetable narcotics ; and there is reason to hope that by the same process of elimination as applied to them, we may bring the active principle of Digitalis into a form of use more simple and certain in all its effects. Until we thus, or through other means, acquire more exact knowledge of the mode of action of this medicine, we cannot look to obtain all those increased advantages in practice, which may be anticipated from its peculiar agency on the circu- lation. We must be content to proceed empirically, as we have hitherto done, in noting its effects in particular cases, and under given combinations. In proof of the present need of submitting all theory to practical observation, I may men- tion that though convinced of its value in combination with bark or preparations of iron, in dropsical cases, yet I am led by experience to acquiesce also in Dr. Withering's opinion, that its effects as a diuretic are often greater in states of feeble circulation and relaxed fibre, than where the habit is more vigorous and firm. Nor can I doubt, from observation, 550 ON THE USE OF DIGITALIS. the truth of Dr. John Davy's remark, that patients weakened by disease often bear much larger doses than those in sounder health. Admitting the facts to be severally so, we must refer for explanation of the seeming contradiction, to the manner of action of Digitalis on the vascular system, still so imperfectly known; and to analogy also in the case of mercury and some other medicines, where a certain state of the circulation is required to give specific direction to some of their eifects.* We know too little, moreover, of the manner of action of iron and bark, to be able to affirm that they would prevent this state being attained ; even though com- monly using these medicines for purposes apparently of opposite kind.f The uncertainty of diuretic medicines in general Is, in- deed, a point where medical practice is greatly at fault. Scarcely can one be named on which we may uniformly rely ; and the inequalities of action are rarely to be assigned to any known cause. As, however, they belong alike, or nearly so, to all these medicines, whether of mineral, vegetable, or animal kind, we must seek their origin not in the substances themselves, but in the functions of the kidneys ; — liable beyond all others to unceasing changes ; and from causes and combin- ations so various (Interpreting, as they do, the state of every other organ and function of the body), that we may readily understand how medicines directed to them should partake in the same uncertainty. * The experiments which prove that the facility with which poisong produce their effects by absorption, varies according to the quantity or dilution of the circulating blood, may be considered to bear directly upon this point. f In illustration of this remark upon our doubtful knowledge even of the medicines most familiar in use, I may refer to the recent experiments of Briquet (fully confirmed by Dr, Bence Jones) on the effect of large repeated doses of quinine in reducing greatly the frequency of the pulse, and depressing the vital powers. ON THE USE OF DIGITALIS. 551 It is among the remedies of this class, perhaps more than of any other, that combinations have their greatest value. Mercury, Digitalis, squill, cantharides, diuretic salts, and the different vegetable infusions having similar action, are seve- rally capable of being aided in this way, either by conjunc- tion mutually, or with other agents.* It must be admitted that the results so derived are purely empirical in kind ; — not explicable when attained; and subject frequently to the same failure as when the same medicines are given uncombined. Nevertheless, these are the proper objects of diligent ob- servation ; and the ability of the practitioner is in no way better shown than in removing whatever may render his conclusions equivocal or obscure. Intending these only as general remarks on the action and application of Digitalis, I do not add to them by details of its employment in particular diseases. I would merely repeat my persuasion, that its use as a sedative to the circulation, in diseases of inflammation or excitement, might beneficially be much extended ; superseding depletion in some cases, the use of narcotics in others. Regarding its employment in pulmonary consumption, I am unable to add anything to the ambiguous recommendation it has heretofore received. It clearly has no power over tubercular deposits ; and the * In the instance of other diuretics, as well as Digitalis, it would seem that the direct conjunction with stimulants often adds to their efficacy. Ammonia, for example, independently of its own occasional action upon the kidneys, will often give to other medicines more certain and speedy direction to this organ. In another chapter (On the Uses of Diluents) I have mentioned the value of these in their action on the kidneys, even in some dropsical cases ; and it is well worth while to keep in mind such possible aid to diuretic medicines, when failing in their immediate and proper effect. It may be from disregard to this, that various popular remedies have less effect in regular practice than under older and more familiar methods of employment. N N 4 552 ON THE USE OF DIGITALIS. only influence to be understood in such cases is that of abating the rapidity of circulation, where greater than ia natural ; an effect of less real moment than is generally sup- posed. In this, as in many other instances, the importance of a particular symptom as a test, leads to a wrong estimate of its relations to the actual disease. We think ourselves on the way to cure, when merely lessening one effect of a specific disorder upon the n^itural functions of the body. Respecting the several forms under which Digitalis is used, there is some reason to believe the infusion, rightly prepared, to be the most certain and beneficial in its effects ; and admitting of every combination with other medicines which can in any case be required. This, indeed, is an instance where, from the nature of the agent, it is singularly needful that the quality of its preparations should be equal and uniform. It is certain that many of the inequalities and seeming anomalies in the effects of Digitalis are owing to neglect of this important precaution. 553 CHAP. XXX. ON ANTIMONIAL MEDICINES. I ANNEX this subject to the preceding, having chiefly in view what is still the insufficient use, in English practice, of those medicines expressly sedative to the actions of the circulation. I have noticed this in the instance of digitalis ; and it is equally true as regards some of the antimonial preparations; and the tartarised antimony especially. The opinions held in relation to the supposed sudorific effect of these medicines, has prevented due attention being given to their influence in allaying inordinate action ; either of the brain, as in mania and delirium of different forms ; or more generally in in- flammation, or febrile states of the whole system. In France, and still earlier and more extensively in some of the Italian schools, the use of emetic-tartar is well known to have been carried much further than in England, and under systematic views, as a contra-stimulant, which Ave scarcely yet fully re- cognise. The appreciation of its powers is now, indeed, be- coming more just and complete; but the progress is slow in relation to the assured benefits which may be derived from it in ordinary practice.* * The writings, as well as practice, of Professor Tomasslnl of Bologna, may be cited in proof of the extent to which the use of tartar-emetic may be carried ; and also for the best account of the doctrines of the new Italian school on this subject, to which the names of Rasori and Borda, as well as his own, have given reputation. The work more recently published by M. Lapelletier, "De TEmploi du Tartre Stibie a haute Dose 554 ON ANTIMONIAL MEDICINES. In another chapter I have noticed the uncertain yiews which determine our employment of antimonials as sudorifics ; and the probability that any such effect from them is due chiefly to their influence in abating the circulation and the febrile state. To this may be added a reasonable doubt regarding the efiicacy of some of the antimonial preparations most frequently in use. My own experience suggests the conclusion which has occurred to others, that the Antimonial powder of our Pharmacopoeia is perfectly inert in any ordi- nary dose ; and that the original James's powder has held a reputation barely justified by any method of its use ; certainly not by the trifling quantities in which it is now given. All the gain we derive from these medicines as sudorifics or otherwise, is obtained far more largely, and with much greater certainty, by use of the emetic-tartar in similar cases. This, in fact, is the preparation of Antimony which, under proper management, may be made to supersede any other ; and which, whether considering its power or variety of appli- cation, may fairly rank amongst the more valuable remedies we possess. Of these applications, that which depends on its sedative effect is perhaps the most important. Without referring to any theories of this particular influence, or the mode in which it is exercised in the living body, it is enough to know that there is the power, directly or indirectly, of diminishing excess of action ; and limiting thereby the degree, if not also the duration, of those conditions in which disorders of acute inflammation or inflammatory fever mainly consist. The dans le Traitement des Maladies," affords a complete history of all that Is known on the subject. I have elsewhere referred to the very curious account, in the letters of Guy Patin, of the violent struggle in France against the introduction of antimony into practice, during the early part of Louis XIV.'s reign. ON ANTIMONIAL MEDICINES. 555 reluctance shown by many to admit the phrase and idea of a direct sedative, may depend, in part, on too exclusive atten- tion to the fact. that augmented action is always followed by proportionate loss of power ; becoming in this way the most frequent and familiar cause of sedative effect which is known to us. But the full admission of this general law by no means precludes the allowance of other actions upon the body, or certain of its functions, producing, at once, the effect which indirectly results in the other case. Abstractedly considered, the notion of any part of vital action reduced below its average or natural state, is quite as intelligible as that of the same action raised above it. As a febrifuge, in the most distinct sense of the term, it maybe doubted whether Ave possess any more direct, or speedy in effect, than Antimony under this form. It is impossible to have witnessed its effects, when adequately given, in acute pneumonia, or bronchitis, or croup, without recognising the same fact ; and seeing, that where it does not wholly super- sede bleeding as a prior remedy, it at least abridges the demand for this; and comes in aid of it, by inducing the same state of the vascular system throughout the body. Its relation to mercury in these cases is that of most interest ; the effect apparently the same, so as in many instances to make it doubtful which of the two remedies may best be relied iipon for instant use ; yet the mode of operation pre- sumably very different.* The evidence of Laennec, Louis, and other eminent French * Dr. Stokes, in his work on Diseases of the Chest, remarks that the previous use of tartar-emetic in pneumonia seems to facilitate the further action of mercury in subduing the inflammation. He advises tliat in typhoid pneumonia the mercurial treatment should be pursued in pre- ference to that by antimonials. What I have seen would lead me to concur in both these points of practice. 556 ON ANTIMONIAL MEDICINES. physicians, on many of these points, is more explicit than ours ; as founded on larger use of the remedy, and more direct comparison of the cases of pneumonia, so treated, with those submitted to other means. I know not that its value has been equally attested in other forms of inflammation ; but suflficiently so, and especially in affections of the brain, to show that the sedative action is not limited to one organ, but extends generally to the whole system.* ThouQ-h the discussion as to the relative merits of the treatment by bleeding, and that by antimonials, in pneu- monia, is not without use, yet it has perhaps placed the remedies too much in seeming opposition to each other. They come, in fact, in common aid towards the same object, and are often needed in conjunction; — the bleeding first, in such cases, for more instant and powerful effect, and possibly also as giving more power to the action of the tartar-emetic; — the latter as sustaining the effect of the depletion, and often preventing the need there might otherwise be of its repe- tition. When the inflammation is slight, its relief may frequently be trusted to the antimonial alone. This appears to be the view by which the relative employment of the two remedies may best be guided in practice. I infer from my own observation, what is amply proved by that of others, that the sedative effects of antimony under this form are independent of all evacuation from the body. * The experiments of Sir B. Brodie, in tlie second of bis valuable papers on the Action of Poisons {Phil. Trans. 1812, p. 205.), render it probable that the brain chiefly is first acted upon by emetic-tartar so given ; but with some evidence of direct action on the heart also. The suggestion of Magendie, that its fiital effects are due to an inflammatory state of the whole system, supervening upon absorption, does not seem warranted by any express fact ; and is made less probable by the frequent absence of all inflammatory appearances on the coats of the stomach and intestines in such cases. ON ANTIMONIAL MEDICINES. 557 They may occur where there has been neither vomiting nor purgative action; and where perspiration, if happening at all, comes rather in sequel and effect, than as cause of the changes produced. We must consider the vascular system, either directly, or through the Influence of the nervous system, to be the part concerned in, and the subject of, these changes. Some ambiguity exists here, as to the nausea brought on by the use of the medicine ; and the relation of such effect to its sedative agency. It is not always easy to separate these effects ; which seem, indeed, to depend concur- rently upon the same cause acting on the nervous system. But there is enough to show the sedative action to exist independently of this, in the fact that it occurs where the nauseating effect has either not taken place at all, or been removed. It must be allowed that there are many singularities in the influence of this medicine as an emetic, and that we yet only partially understand the conditions which so variously modify this quality. The mode of administration is, doubt- less, in part concerned ; and particularly as regards the quantity of the fluid vehicle in which it is given. The state of the stomach itself is another of the conditions. But there is also an influence derived from the general state of the body at the time ; attested, as I think, in the case of fever ; where, according to my experience, there is less effect from given doses in producing sickness, that when this state is absent. The same conclusion seems to be justified regardino- its employment in inflammatory disorders. And further, it is manifest that a habit is acquired as to the medicine, lessen- ing or wholly removing effects that have occurred on its first use ; so that vomiting or nausea, very harassing in the outset, may cease to disturb the patient, even though the same doses are continued as before. 558 ON ANTIMONIAL MEDICINES. The influence, indeed, of dose and manner of employment, curious and important in all cases, well deserves notice here. Our practice in England (limited, as I have said, hj older views) seldom goes beyond such use of them in inflammatory disorders, as to sustain nausea for a time, and thereby repress the circulation; and even this intention is often subordi- nate to the view of forcing perspiration, as a means of relief. It is certain that the full value of the medicine is .not thus attained ; and though we yet want proof of the eflficacy or need of the large doses of emetic-tartar employed by some of the Continental physicians, it seems certain that those we use might beneficially be increased in relation to their sedative eff'ect.* The best test we have on this point is to be found in the objects for which we adopt the treatment; viz., the diminished action of the heart and arterial system, or the removal of some active irritation of the brain or other organ. In look- ing to this test, as well as on other accounts, it is very gene- rally expedient to give the medicine under its simplest form. With a powerful agent of definite purpose in our hands, combination ought rather to be regarded as an exception than a rule of employment; enfeebling, for the most part, the principle of treatment, and perplexing its results. I have elsewhere alluded to this maxim in practice, which, admitting all the needful qualifications, is still important enough to warrant a constant regard to it. In the instance of emetic-tartar, its combination with opium is undoubtedly that which most merits notice. This seems a * The doses of those French physicians, whose practice is best autho- rity (one or two grains, so repeated as tc extend from 5 to 20 grains in the twenty-four hours), may be assumed as affording every scope to the beneficial use of the medicine in different cases. The maximum quantity here little exceeds what llasori sometimes gave for a single dose. ON ANTIMONIAL MEDICINES. 559 fair example of a compound acquiring powers, which do not equally belong to either of its component parts. Its value is attested by the observation of many physicians, particularly in cases of mania and cerebral irritation; and my own ex- perience entirely concurs in this respect. In cases more strictly inflammatory in kind, whether pneumonia, bronchitis, rheumatism, or inflammation of the membranes of the brain, the same combination is often useful ; but under more re- serve, both as to the period of the disorder, and the propriety of bleeding as a previous remedy. The difference of opinion respecting the fitness of combining opium with the antimonial in such cases, arises probably from the different attention given to the latter points. Whether with or without emetic- tartar, it cannot safely be employed where bleeding is re- quired. But allowing for its unfitness in these instances, I still believe the harm done to be less, than were it given, under the like circumstances, not so combined. Revertino; to the use of this combination in affections of the brain, it is remarkable how speedy and assured the effect often is. In the wild restlessness of Delirium-tremens this is sometimes very strikingly seen. In fevers attended with much cerebral disturbance its employment has been attended with similar good.* And in various forms of spasmodic disease I have experience of the same kind; giving evidence of benefits which are not so readily, or completely, obtained by the use of opium alone. It is probable that other applications of the tartar- emetic in the cure of disease will hereafter be ascertained ; depend- * In a valuable paper by Dr. Graves (London Med. Gazette for July 8. 1837), this physician recommends the occasional use of emetic-tartar by enema : stating its effects to be the same as given by the mouth, and rightly commenting on the neglect of this means of administering various other remedies. 560 ON ANTIMONIAL MEDICINES. ing, it may be, uj)on other modes of agency than that to which I have chiefly aUuded.* For though employing the term sedative, thus far, in the most simple and practical sense in which we can understand it, it is obvious that much theory attaches at present to the subject. Sedative action, so understood as merely opposed to stimulant, may occur not only from different agents, but in different ways as regards the organs first affected ; and with varying influence on dif- ferent parts of the system. The agency of the hydrocyanic acid (an important addition to this class of medicines, and one of the most explicit examples of their action) is evidently not the same as that of digitalis or tartarised antimony ; and we have equal reason to suppose differences between the two latter medicines, seeing the diversity of their collateral effects. Though greatly instructed by modern inquiry in the action of poisons, yet is our knowledge likely to be much ausfmented hereafter in all that concerns their relation to the vital properties of the blood. And while thus approaching nearer to the solution of one of the most curious problems in physiology, we have the assurance of great aid in the treatment of disease ; by better determining the sj)ecific nature and application of those agents which are directly opposed to excess of action, either throughout the whole system, or in particular parts and functions of life. In alluding to the very powerful medicines of this class, and particularly to the prussic acid, it may be worth while to add one comment; needless, indeed, to all who are familiar with the principles of therapeutics ; but requisite to be kept in view while these agents are still waiting, as it were, for re- cognition, and deprecated by many who see in them only the * In a late paper by Dr. Gemelle (^Bulletin General de Therapeutique, Mars, 1838), cases are given of the successful treatment of synovial affections of the joints by the internal use of tartar-emetic. ON ANTIMONIAL MEDICINES. 561 virulence of their concentrated forms. What we have mainly to regard, in estimating the medicinal value of any sub- stance, or its just application to practice, is the well-defined nature of its action on some organ or function of the living economy. If this action be clearly ascertained, we have essentially a curative power in our hands. Every medicinal agent, even the most simple, is capable of being misused by excess ; and this excess, or the fitness of use, is determined, not by any comparison of the power of different agents, but simply by the nature and amount of the effects peculiar to each. The prussic acid, diluted as befits the particular ap- plication given to it, is not, in any practical sense, a stronger medicine than others most familiar to us, nor more dangerous in use. And we have even some additional security in the more definite nature of its effects, and in the greater care bestowed on its administration. o o 562 ON ANIMALCULE LIFE CHAP. XXXI. ON TnE HYPOTHESIS OF ANIMALCULE LIFE AS A CAUSE OF DISEASE? — ON CHOLERA. I PUT this title interrogatively, as expressing what is at present merely a speculation ; and, in so far, distinct from most of the other topics of this volume ; yet sufficiently within the scope of possible or even probable truth, to justify a few remarks upon it. In making these, the reasoning may most conveniently be applied as an argument for the hypo- thesis ; viewing it constantly, however, under the qualification just named. For reasons, which will be given hereafter, I have taken the Indian cholera as the example best fitted to illustrate the theory before us. Sixteen years have now elapsed since this chapter was first written, during which period the records of this disease have been greatly extended by its repeated re- currence in Europe and other parts of the globe ; and volume has rapidly followed volume in description of its progress and phenomena — in speculation as to its causes — or suggestion of methods of prevention and cure. Having admitted that I am defending an hypothesis, in which the proof is one of presumption only, I may perhaps be allowed to add that I find no cause, hitherto, to retract or alter any part of the original argument. On the contrary, I feel justified in con- sidering it as enforced by what has since been added to our knowledge of the phenomena of the disease, and by the failure of other hypotheses proposed. The changes I have AS A CAUSE or DISEASE ? 563 thought it well to make amount to little more than a slight extension of the reasoning, and a clearer specification of some points bearing upon the question. In all other re- spects the argument remains the same as at first proposed. The question under its most general form is — What weight may we attach to the opinion that certain diseases, and es- pecially some of epidemic and contagious kind, are derived from species of animalcule life ; existing in the atmosphere under particular circumstances ; and capable by application to the lining membranes, or other parts, of acting as a virus on the human body ? — This is by no means a new specula- tion ; and it would seem to have been much more frequently started during the last century, than at the present time.* The greater exactness of modern inquiry rightly represses all opinions which have not explicit facts for their support. Though the course of discovery has recently been approaching, in some points, nearer to the hypothesis in question, it still furnishes nothing beyond stronger presumptions and more numerous analogies ; nor has any endeavour been made to collect or class these, with a view to more general residts. Nevertheless the subject is one fairly open to inquiry ; and the more reasonably so, as we possess no information re- garding the causes of these maladies which can supersede research ; but rather have in our ignorance the motive for * Kircher is known as one of the earliest propounders of the opinion. Linnaeus gave his sanction to it, by inserting in the Amsenitates Academicaj several memoirs on the subject. The most detailed is that under the name of Nyander, entitled "Exanthemata Viva," in which small-pox, measles, the plague, dysentery, syphilis, and hooping-cough are all attri- buted to the agency of minute animals, chiefly Acari of different species. A second paper in the same work, on Lepra, applies the speculation also to this disease ; and other memoirs, severally entitled " Mundus Invisibilis," " Miracula Insectorum," and " Noxa Insectorum," produce the hypothesis in a more general form. o o 2 564 ON ANIMALCULE LIFE pursuing it through every new channel which science may disclose. That there are conditions of animal life in the atmosphere (however characterised), as minute, as numerovis, and as variously diffused, as those of which the microscope informs us in water and other media, may be considered from analogy next to certain. Our actual knowledge carries us so far into these minute forms of existence, and by such uniform grada- tions of change, that we cannot suppose the series to stop, because evidence is no longer drawn from our own senses or means of research. This would imply a sudden breach of continuity, such as we find in no other part of the scale of animal being. It is only of late that the wonderful eye of the microscope has clearly disclosed to us that vast domain of life to which the infusoria belong ; — a new world of or- ganised and active beings, which, but for the access thus af- forded by the happy invention of a single Instrument, might have remained for ever as much hidden from our sense and knowledge, as the Invisible forms of organic life, of which the hypothesis before us presumes the existence. The expression of Locke that ** in all the corporeal world we see no chasms or gaps," is a happy anticipation of what modern science is every day more largely disclosing to us.* * Even the unaided eye, indeed, gives us certain probable notices of these swarms of minute beings, which escape all individual examination. Reaumur and other naturalists have conjectured that the small floating clouds (imbeculcB cetherecB), like more opaque portions of the atmosphere, which, under summer temperature and in certain lights, are seen near the surface of the earth, are in fact insect swarms, depending for their fugi- tive existence on the conditions of the medium around them; but in this, as well as in their living habitudes, resembling the insect species more obvious to us. The phrase of Cuvier is in no wise exaggerated, when he speaks of the " richesse effrayautc " of the insect world. It is an abundance and diffusion of animal life, well fitted to inspire wonder and awe. AS A CAUSE OF DISEASE ? 565 Whether we may hereafter reach more dh-ect evidence on this subject is still uncertain. As a natural effect of the difficulties of the research in this medium, the atmosphere has not yet yielded to the microscope all that the earth and waters have afforded of these invisible forms of animal life. From direct observation they are removed, unless some such method as that suggested below should be found attainable.* Other means, however, may be conceived as possible, seeing the number and variety of resources furnished by modern science, and the unexpected quarters from which knowledge is often derived. I may name as an instance of this the paper of Dr. Wollaston {Phil Trans, for 1820), "On Sounds in- audible by certain Ears ; " showing the probable existence of whole domains of insect life, capable of exciting vibrations in the air, of which man's grosser hearing is wholly unconscious ; but which, received by their finer organs as audible sounds, minister to purposes of enjoyment and activity among beings unperceived by any of the human senses. Even admitting, however, that we may never reach actual proof of these more minute forms of life, be they insect or of other kind, the probability of their existence is little lessened * It has been supposed that the collection and condensation of dew, in situations where malaria or infectious miasmata abound, might afford a possible means of subjecting these material agents (for such they doubt- less are) to chemical or microscopical research. If it were true, as presumed in the hypothesis before us, that minute animalcules are con- cerned in giving pestiferous quality to a portion of air, might not colouring matter, suitable to animal organisation, be applied to the natural or artificial dew condensed from this air, so as to afford the chance of similar success to that which Ehrenberg has attained in his researches on the infusoria ? The absence of any such observation, when he was himself seeking to discover infusoria in dew, does not dis- prove the possibility of this ; as, fz'om the difference in the cases pre- sumed, the results, if ever thus obtained, would probably be only partial and occasional. 566 ON ANIMALCULE LIFE by the failure, seeing the obstacles which produce it. And if existing, the same analogy, carried further, will lead us to other not less probable inferences regarding the habits and instincts, in which they may be presumed to have affinity with the known insect genera. Such are, their frequent sudden generation, at irregular and often distant periods, under certain circumstances of season or locality, or under other conditions less obvious to apprehension : — and the dif- fusion of swarms, so generated, and with rapidly repeated propagation, over wide tracts of country, and often following particular Knes of movement. The further inference, which more especially concerns our subject, rests also on analogy, though of less explicit kind, viz. that certain of these animal- cule species may act as poisons, or causes of disease, upon particular parts of the body exposed to their influence. These presumptions, supported by various reasons, and contradicted by no ascertained facts, give foundation to the question before us. Whatever is true or peculiar as to the habits of insects, or the forms of animalcule life obvious to our senses, is likely to be equally applicable to those whose minuteness removes them further from our observation. Their generation may be presumed to be even more dependent on casualties of season and place ; — their movements determined by causes of which we have less cognizance;' — and their power of morbidly aifecting the body to be in some propor- tion to their multitude and minuteness. It cannot be deemed too mechanical an idea, that all conditions which give readier and more extensive access to the internal membranes, to any species capable of acting as a virus on these parts, must greatly increase their influence as causes of disease. It occurs then, as the first point of inquiry, whether we have grounds for believing that animal life under this form can act as a noxious or poisonous influence on the human body. And AS A CAUSE OF DISEASE ? 567 liere there are numerous facts wliich justify an affirmative answer; as showing that animal matter of certain kinds, applied to absorbing surfaces, may produce the most virulent symptoms of disorder, locally or generally ; according to the nature of the virus, its intensity, or the relations of the tex- ture first affected to other parts of the system. The evidence on tliis subject varies in kind and conclusive- ness. That which is most familiar and direct is our actual knowledge of numerous animal poisons ; the product, as well of living secretions, as of changes taking place in animal matter after death. Respecting the former class, the most important to our present purpose, it is enough to refer gene- rally to their many varieties in all parts of the animal king- dom, and particularly among the insects. From the danger- ously active venom of the Argas Persicus and the tarantula, to the more harmless poisons of the bee, the wasp, the ant, and other insects which surround us, we have every gradation and variety of these secretions, which thus act noxiously on certain textures of the human body ; and the instances would be much more numerous, if including those which affect other animals.* In the Cantharides we have a solitary example of * In the narrative of the travels of Humboldt, Ehrenberg, and Kose, In Siberia, the last of these eminent naturalists describes a pestilence prevailing on the great steppe between the Irtish and the Ob, affecting very fatally both men and horses; the most obvious symptom that of suppurating tumours, chiefly on the exposed parts of the body. The opinion on the spot is, that the disease proceeds from the stings of insects ; and there are various reasons for presuming it to be so. Many similar instances of greater or less authenticity, might be drawn from different sources, attaching disease to the casual or periodical occurrence of this cause. Speaking on this subject, I would hazard the question, whether the epidemic tendency to carbuncular boils during the last two years (1853 and 1854), so strikingly marked in England, as well as simultaneously in various parts of Europe, has not depended on causes from without ; and o o 4 568 ON ANIMALCULE LIFE their application to medicinal purposes, and at the same time a remarkable instance of the virulent action of an insect poison on the internal membranes. The class of reptiles affords many well-known instances of such animal poisons, under the form of natural secretions, fulfilling purposes in the economy of the several animals possessing them. The virus in hydrophobia is an example of the poisonous pro- duction of disease. Recent observations have shown that the glanderous matter of the horse is capable of producing the same disorder in man ; and it is probable that there are many more instances of this kind than we are yet acquainted with. Some of the secretions from diseased surfaces in the human body are known to acquire properties highly noxious, even to the frame within which they are generated ; and the singular effects upon others from inoculation, even with the smallest quantity of such morbid matter, are familiar to every medical man. We may perhaps attribute to the same cause the occasional poisonous quality of certain shell-fish, which com- monly are innocuous as articles of food. Or it may be that the latter are instances of a virus produced after death ; as we have many examples of animal matter undergoing change of this kind during the process of decomposition, after life is extinct. If it be urged that none of these, or similar instances apply expressly to the question, whether or not minute or invisible animal species may become causes of disease, the possibly on some virus, or form of organic life, thus acting on the parti- cular textures aifected. The singular uniformity of the appearances ; their definite course when not interrupted by internal treatment ; the manner of their succession ; and the seeming absence of connexion with any constitutional disorder : these circumstances concurrently would appear to warrant the question I have stated. That other varieties of boil are generated by other causes of local irritation, does not disprove the possibiliti/ of (his view. AS A CAUSE OF DISEASE ? 569 answer is, that the nature of the inquiry supposes evidence much less accessible in kind; and that we must seek for that of analogy and presumption where more direct proof cannot be had. Such evidence is found in the facts just stated, and in others still to be mentioned. One argument for the hypothesis before us, not complete indeed, but having much of reason and analogy to justify it, is founded on our increasing knowledge of the Entozoa; and of the various morbid products, as well as diseased actions, which are due to the presumed propagation of these animals within the body. Without assuming what some have supposed, that tubercles and carcinomatous formations are thence derived, we have sufficient proof through recent discoveries, that these morbid actions from parasitic animals are much more numerous and varied than has heretofore been believed. It seems certain that future research will still fur- ther increase the number within our knowledge ; and while indicating, by aid of the microscope, forms more minute and actions more definite than those yet discovered, will in these circumstances suggest their more extensive operation as causes of disease.* * Almost at the moment of transcribing this (1840) I see the notice of the discovery of minute worms {poly stoma sanguicola) in the expectorated blood of phthisical cases (Andral, Delle Chiaje, and others had before discovered cephalocysts in the venous blood of man, and even of some of the invertebrate animals) ; and also of animalcules (vibriones) in syphilitic pus. The latter fact, however, appears from one of the papers already cited, in the Amaenitates Academicte, to have been ascertained nearly a century ago. In other morbid secretions other animalcules have been seen ; and, according to M. Donne, the author of some of these researches, with constant relation to the acid or alkaline nature of the discharge. The occasional presence of a minute worm (trichinia spiralis) in the mus- cular substance, has been ascertained in this country; and still more recently another entozoon (the cysticercus cellulosd) has been found by Dr. Knox and others in the same texture. That excellent observer, 570 ON ANIMALCULE LIFE The same remark will apply to the ectozoa, and to the spurious worms infesting the human body as well as many other animals. They afford further proof of the extent and variety of those connexions which subsist between different forms of living organisation. It is a curious evidence of the progress of such research, that while only eleven species of intestinal worms are recorded in the 12th edition of the Sy stoma NaturjB of LInna;us, nearly 1000 species are de- scribed by Rudolfi in his Entozoorum Synopsis, and others have since been discovered. It is a remark of Ehrenberg, and seemingly founded in reason, that, looking to the extreme fecundity of some of the Entozoa, there is more cause for wonder at the limitation of their effects by the actions of the living bodies they inhabit, than at any morbid effects they appear actually to produce. Professor Owen, to whom we owe the best classification of the human entozoa, has been led by observation to suppose that the cataract of the eye is produced by a species of worm ; a supposition at variance, how- ever, with the results to which Sir D. Brewster has been led by his re- fined and beautiful researches on the crystalline lens in its healthy and diseased states. It is well known that minute animals (^filaria oculi) have been seen in movement in the aqueous humour of the eye of the horse. Still more recently they have been observed in milk. Different animals, according to Gruithausen, exist in pus and mucus. Some of these state- ments need confirmation, and, above all, the identity of the animal para- site in similar conditions of disease ; but, if obtaining such proof, they manifestly become very important to all future inquiries in pathology. I have already alluded to the efiect of animal poisons yrom without, upon the skin and cellular tissues. The question has further arisen whether any, and in what instances, the common cutaneous diseases may have their origin in parasitic life, animal or vegetable in kind. Omitting the more obvious examples of the Guinea worm, the acarus of Scabies, &c., the question chiefly applies to the different forms of porrigo, impe- tigo, and herpes. The recent discovery of fungous sporules in certain of these eruptions (as the tricophyton furfw-ans in the ringworm of the scalp,) gives a sanction to the inquiry, though not settling it at present by any sufficient proof. AS A CAUSE OF DISEASE ? 571 The speculations of this eminent naturalist derive a sanction for their boldness from his remarkable discovery of the fossil infusoria, as well as from his researches among the entozoa, in their various species, and in different parts of the globe. In ascertaining the highly organised structure, astonishing minuteness, and fecundity of these animals he has obtained argmnents for the belief that they form a direct cause of many of the diseases affecting man.* Reasoning upon the proba- bility that the minute ova of parasitic animals are taken up by the absorbents, and deposited in particidar textures of the body, he hazards the opinion that Scrofula, in its various forms, may be thus produced ; — a suj^position not wholly new, nor incompatible with the fact of its being an hereditary disorder ; but certainly requiring more evidence than has yet been given ; and perhaps incompatible with the relation of size between the ova of entozoa and the capillaries or lymphatics of the animal textures. However this may be, the whole subject of parasitic animals and plants, and of the mutual relation of each class. Is replete with curious matter of research ; and now first pursued with an earnestness proportionate to its importance. It provides us with argument and analogy from every part of organic existence, in attestation of the fact, that the life of one being is In innumerable cases supported by the life of another ; and that there are express relations of dependence of this kind established throughout creation, scarcely less definite and remarkable than those by which the functions of individual existence are carried on. These relations — the result of * It must be admitted, however, upon more recent evidence, that some of Ebreuberg's conclusions require material correction ; such, for instance, as the complex organisation he assigns to the Polygastrica ; and the attri- bution of animal life to many microscopic forms which later observations have shown to be of vegetable nature. 572 ON ANIMALCULE LIFE this inter-penetration of life in different forms — though often compatible with health, are in other instances the direct cause of the morbid actions and changes which constitute disease.* And the conjecture cannot be deemed a rash one that time and further research will both add to the number of these instances, and illustrate more clearly the various manner in which such morbid actions may commence, and be carried to maturity. If admitting, then, that certain diseases are thus produced by one species of animal life (whether truly parasitic or otherwise) acting on another, we must adopt the conclusion, as probable at least, that the symptoms of such disorders are derived, partly from the progressive changes incident to the affecting cause — partly from the vital or other actions of * It is a striking proof of the extent of the fact stated above, that ento- mologists have ascertained more than forty genera of insects to be infested by parasitic worms {Jilaince), and that it is often possible to determine the species of the insect by that of the parasite living upon it. Even yet more remarkable are the facts recently discovered as to the parasitic growth of minute fungi upon the bodies of different animals ; as the Muscardine upon the silk-worm ; the fungus which grows vigorously on the Polistes wasp of the West Indies ; another cryptogamic plant which has been found even on the body of the common fly, &c. ; thus affording the converse of the numerous cases in which animals live upon plants, and completing all the possible mutual relations of parasitic growth in animal and vegetable life. The discovery of living monades within the bodies of certain of the human entozoa, as in certain hydatids of the liver, is another circumstance not less worthy of notice. These facts are deeply interesting in themselves ; and further remarkable as showing the exact- ness of modern observation, and the advance it has made into the most secret and minute operations of nature. Ehrenberg has used a bold, but not unjustifiable figure, in speaking of the '■'■ milky way of the smallest or- ganisation " — accessible, we may add, to human research, like that of the heavens, only through artificial instruments; but yielding to these, in the one case as in the other, the most marvellous proofs of the infiniteness of creative power. A8 A CAUSE OF DISEASE ? 573 the recipient ; — and also that under both these conditions there will be a tendency to regular form, series, and duration of the morbid phenomena. And we are still further carried forward in this argument, to the notion of infection as apper- taining to such diseases ; — the element of life, thus in- troduced, affording a more intelligible idea of the generation of fresh virus, and its communication from one individual to another, than any other view with which science or common reasoning have hitherto furnished us. These considerations, it cannot be denied, are of much in- terest to the general theory of disease ; and the latter, more especially, affords large scope for inquiry. They have close reference to the contagious exanthemata in particular ; and though not sanctioned by any direct proofs in relation to these diseases, yet fully justify the prosecution of the research through every possible channel; and render plausible, at least, the arguments of those who have ventured to support the opinion that they depend upon the action and phenomena of parasitic life.* In the foregoing remarks, I have noticed only the more * I have alluded to this view in a former chapter — " On Diseases com- monly occurring once in Life." The most recent and powerful advo- cate of the doctrine is Dr. Henle of Berlin ; in whose Pathological Re- searches, published this year (1840) there is a very interesting memoir, entitled "Von den Miasmem und Contagien, und von den miasmatisch- contagiosen Krankheiten." In this he maintains the opinion that the material of all contagious disease is not merely organic, but matter pos- sessing all the conditions of parasitic life as regards the bodies affected by it. And in vindicating this doctrine, he applies with great ingenuity the facts recently ascertained, as to the connexion of fermentation with infu- sorial and vegetable life ; and the evidence also lately obtained, regard- ing infectious disease produced by parasitic influence in certain lower animals, of which that curious disorder, the muscardine of the silkworm, furnishes the most remarkable example. 574 ON ANIMALCULE LIFE general reasons for supposing it possible that certain diseases to which man is subject, maybe derived from animalcule life, existing in the atmosphere around us, and capable of acting noxiously on the human body. To carry the inquiry further, it is necessary to take some instance which may render its details more explicit, and connect together the analogies on which it is founded. Such instance is best sought for in the class of epidemic or contagious diseases ; where, if evidence exists at all of the influence of this cause upon the human frame, it is most likely to be found. And amongst the number, there is none to which the hypothesis so well ap- plies, as to the Asiatic or Epidemic Cholera ; that strange pestilence of our own time, which, while affrighting every part of the world by its ravages, has seemed to put at nought all speculation as to its causes, or the laws which govern its course ; — a disease, nevertheless, which by the mystery of its first appearance — its suddenness, inequality, and fatality — and the failure hitherto of every method of treatment — may well excite the inquiry of all who are zealous for the improvement of medical science. In taking this remarkable disorder for the instance re- quired, I would merely affirm that it furnishes the best evidence in a case where we can yet attain none other than presumptive proofs. Presenting close analogies to other diseases of this class, its essential characters are so strongly marked, both as to symptoms and manner of diffusion, as to fit it Avell for being taken as a type of the rest. It must further be admitted that the ground is one singularly free for speculation up to the present moment. I have met with no opinion as to the causes and mode of propagation of the epidemic cholera, which can be considered to afford even plausible explanation of the facts ; and in putting to trial the capability of another hypothesis to solve the phenomena of AS A CAUSE OF DISEASE ? 575 the disease, we are but seeking, by comparison of difRculties, to attain the conclusion which is least liable to them. In truth, the manner in which the assured circumstances in its history annul all theories, hitherto proposed, as to its origin, has almost the force of an argument for any new opinion or line of research. The outline of the problem to be solved may be stated thus. Here is a disease, which, appearing first in the Delta of the Ganges, and diifusing itself gradually over the pro- vinces of India, subsequently spread with more rapid course, so as to embrace within a period of seventeen years almost the whole habitable circumference of the o;lobe : — reachinsr China on the one side, the Mississippi and Mexico on the other ; — its general course traceable, step by step, over the whole of this vast distance, yet very irregular in details both as to time and space; — frequently appearing in remote parts long before it affected countries much nearer the general line of its direction ; yet never, even in these cases, without traces of its presence and progress throughout various parts of the intermediate distance.* During the whole period of its first diffusion, as well as during the twenty years which have since elapsed — under every climate, and in every place of its occurrence — the disease has been absolutely identical in kind ; the only variation that of the degree of intensity and virulence. In whatever countries it has existed, a tendency has been observed to its re-appearance as an epi- demic, in successive years ; though often with change in the * The Cholera had raged at New Orleans a year or two before it ap- peared in Sweden ; and four years before it devastated Naples and Sicily. But it existed in emigrant ships making the voyage from Liverpool and Greenock to Quebec and New York ; and might be traced along tlie great line of river communication in the United States, as well as by the coast line from the Northern States, to those of the Mexican Gulf, 576 ON ANIMALCULE LIFE particular localities affected, and under otlier conditions still very imperfectly known. These are the points which it is essential to keep in mind in all reasoning as to the causes of Cholera. Other pheno- mena of the disease are scarcely less remarkable ; but these stand so completely at the threshold of the question, that no opinion on the subject can be true or complete which does not include them, and furnish adequate explanation of their nature. In an argument embracing such a multitude of details, and so much that is still vague to our knowledge, it is important to define these essential points ; as well as to remove in the outset all cases and questions which can justly by reasoning be eliminated from the argument. Holding these things in view, any hypothesis regarding Cholera may best be prefaced by certain facts of negative kind; the admission of which gives clearer space to the remainder of the inquiry. Of these the first is, that no con- ditions of physical change in the atmosphere itself are known to us — statical, chemical, electrical or other — which afford even a plausible explanation of the phenomena of the disease. The earliest Indian official reports furnish nothing that can be admitted as proof to this eflPect ; nor have the later and more exact observations of Europe better warranted the opinion. Some arguments drawn from the prevalence of storms, and seasons of drought or excessive rain, during the years directly preceding its first appearance in Bengal, even if they gave any sort of explanation for India, would in no wise explain the successive spread of the disease over other parts of the globe.* Among those who have written on the subject, * Dr. Proiit noticed a very small but constant excess in the average weight of the air, during part of the time when the Cholera first pre- vailed in London ; but as there has been no repetition of this remark, either here or elsewhere, it was doubtless a casual coincidence. In rea- AS A CAUSE or DISEASE? 577 there are some who have dwelt much on a presumed electrical state of the air as the exciting cause; but without any just or sufficient grounds for the hypothesis.* Admitting that there is much still to be learnt regarding this great natural agent, and its relations to the body, nothing certainly has yet been discovered bespeaking its connexion with the disease in question; and the whole history of Cholera is utterly at variance with such opinion. Staking the question on a single argument, is it possible that a state of electricity (compatibly with what we know of its laws) can exist in any one spot, capable of destroying life in a few hours in one person, while others in the same place are scarcely affected in their ordinary sensations ? Or, again, that detached portions of air, thus strangely peculiar -in their electrical state, should move irre- gularly (yet ever tending to follow the tracks of man) over continents and across oceans, still retaining their virulent power of producing disease ? Such notions stand in contra- diction to all we know of the laws and conditions of electrical action on the globe. They are generally propounded by those who are content to wrap ignorance in the garb of scientific language ; without due knowledge of the particular soning upon questions of this nature, it is especially necessary to guard against conclusions from single and uncompared facts. The very obscu- rity of the subject tends to accredit hypotheses on evidence far slighter than would be required in other cases ; and it is incumbent upon men of science not to take advantage of this facility. * It has been a favourite idea that negative electricity of the atmo- sphere might favour the production of Cholera ; an opinion scarcely pro- fessing to have other basis than that the ordinary electricity of the air is positive. M. Peltier, from constant observations during 1835 and 1836, states that in 1835 the clouds were almost always in positive state; in 1836 generally neutral or negative. In neither of these years, except in a few insulated cases, did the disease appear either in France or England. P P 578 ON ANIMALCULE LIFE physical agency they invoke, or of the kind of evidence by which alone such questions can be rightly decided. All the arguments used in a former chapter, to prove that the Epidemic Influenzas are in no way directly produced by atmospheric states or changes, apply with equal or greater force to the disease before us. No notion of an epidemic constitution (to acquiesce for a moment in a phrase thus vague and doubtful in import) can be of avail against the facts belonging to the history of the disorder — its course, manner and time of progress, and various aspects — as it has spread over the world during the period, now nearly forty years, since the occurrence of the earliest known cases at Jessore. Had I been writing a treatise on Cholera, instead of a few remarks on a particular hypothesis, I might bring the most ample evidence for the truth of this negative asser- tion. The whole resolves itself into this : — that the disease in its most distinct and virulent form, has existed in different places under every possible variety of atmospheric state ; — and, conversely, that every such variation has existed in higher degree in the same places, and at all times, without producing the disease.* The admission of these facts makes * I have myself, at different periods, been in five several places where the Cholera was prevailing at the time; and have had sufficient proof of the different atmospheric circumstances under which It may subsist. Even with the disposition ever present to find especial causes for remarkable events, the records of former pestilences are equally wanting in admis- sible evidence as to any states of atmosphere or season likely to pi'oduce them. Professor Hecker, indeed, in his History of the Epidemics of the Middle Ages (the Black Death, the Sweating Sickness, &c.), has sought to connect them with contemporaneous records of earthquakes, eruptions, floods, droughts, &c. ; but a close examination of his argument will show how loosely his conclusions hang upon the premises. Searching through the world for them, similar and equally authentic catalogues of natural phenomena might be obtained for almost any period, without any cor- responding association of pestilential disease. AS A CAUSE OF DISEASE? 579 it almost needless to enforce further the conclusion from them. Nor have we the smallest reason, from knowledge or analogy, to assume that any gaseous, mineral, or vegetable matter, diffused in the atmosphere, or exhaling from the earth, could create a disorder thus peculiar, or spread it in a manner so remarkable over the face of the globe. The notion of terrestrial or mineral exhalations — a favourite one in all ages, and espoused by Sydenham — is defective in proof in every case, and singularly inapplicable to the cause and circumstances of Cholera. A natural morbid cause, or causes (for which, in default of a better, we must admit the name of malaricL) may originate locally, and produce various local endemic or epidemic diseases ; and of this we have suffi- cient evidence. But these very circumstances of limitation directly exclude any agent, so generated, as the source of a migrating disease, to which we are unable to assign boun- dary or limit. Equally inapplicable, for the same reasons, is every theory founded on the temperament, habits, food, or other con- ditions of particular communities. The history of Cholera, as followed through different countries, and climates, and races of mankind, negatives at once all suppositions of this nature ; nor need we follow them beyond the mere statement. Whatever be discovered hereafter as the cause of the disease, it must be one which has come into existence and active operation within the last thirty-eight years; and which, therefore, cannot possibly depend upon conditions long before existing without the production of any such effects. Dismissing, then, as improbable, or even as impossible, these different views as to the origin of Cholera, the inquiry forces itself upon us, whether any other hypothesis be more P P 2 580 ON ANIMALCULE LIFE compatible with the strange phenomena of this disease ? To any one approaching the inquiry, after having compassed the negative conclusions just stated, the words of Cicero may well occur : " Utinam tarn facile vera invenire possem, quam falsa convincere" It is, indeed, in this case far easier to convict of error, than to discover and to prove the truth. With this admission, which must needfully be made, let us come to the question proposed in this chapter, — whether the hyjDothesis be tenable, which looks to animalcule life, diffused by the atmosphere or by man, as the source of the disease ? — a form of life not cognizable by our senses, or other present means of research ; but nevertheless subject to the same general laws of j^ropagation and diffusion as species more obvious to us ; guided by special instincts like every other part of the animal creation; and producing a virus which acts noxiously or fatally on the body of man. In pursuing this subject, we must take account severally of the more essential facts regarding Cholera, to see how far they admit of such explanation ; premising what will noAV be gene- rally allowed, that the disease, though resembling the common Cholera Morbus in some of its symptoms, is actually distinct from it, as it is from every other disorder of which we have previous knowledge.* The first condition is the obvious and assured one, that the cause of the disease must be a material poison, definite in its nature, and specific in its effects. We cannot reason on * This is a point wliere we may recognise the influence of names in opposition to the most obvious facts. The Asiatic Cholera, certainly unknown to us before, reached Eurojie from the spot where its origin is dated, by steps, every one of which is known and recorded. The resem- blance in certain of its symptoms to another more familiar disorder is but •what occurs in many other relations of disease, and does by no means prove identity of nature or cause. AS A CAUSE OF DISEASE? 581 the subject without this admission; nor, under the shelter of vague terms, apply to the phenomena any hypothesis which excludes it. It is true that some of the suppositions already noticed admit a virus or specific cause ; and use may be made of the analogies furnished by other disorders, avowedly infec- tious through matters generated within the body. But this is at best analogy of difficulty rather than elucidation; and carries us little way towards solution of the circumstances which form the peculiar history of Cholera. It must be kept in mind that we have to deal here with a migrating malaria — ^ a wandering cause of disease ; — capable, not merely of being diffused through the atmosphere, and conveyed along vast tracts or lines over the globe, affecting different places with a varying intensity, which no known conditions of earth, atmo- sphere, or human habits, will explain ; but also possessing the power of reproducing itself, so as to spread the disorder by fresh creation of the virus which first evolved it. TYiis faculty of reproduction (admitting the term for what we cannot well otherwise express) stands foremost among the conditions essential to a right theory of Cholera. All our reasoning stops short, unless under recognition of the fact so stated. Without it, there would seem a physical Impossi- bility of explaining the phenomena of the disease ; and par- ticularly its distribution and succession in different places and seasons. A thorough study of these singular details of its history, keeping this principle constantly in view, will not only confirm and illustrate the latter; but lead us to organic life, as the only conceivable source and subject of such reproduction. It is against all the analogy of nature to suppose this power to belong to Inorganic matter. Either animal or vegetable life, in their simpler forms, must furnish the material cause we seek for ; since to them alone can belong the faculty of renewing unllmitedly the active cause p r 3 582 ON ANIMALCULE LIFE of the disease. Assuming the former, we must attribute the reproduction of the virus to some animal process ; occurring either within the bodies of those affected, and acting therefore by infection ; or produced by animal changes and propaga- tion taking place without. Through this liypothesls we obtain a conception of the reproduction and diffusion of the natural cause of the disease ; curiously conforming, as we shall see, with our observations of its phenomena, and also with what we know of the instincts and habits of insect life. 'Here, however, a question arises in limine, whether our argument may not be satisfied by the assumption of vegetable life, as the cause sought for ; without going to a higher grade of organisms, in quest of the virus of the disease? Such question is not only reasonable in itself, but justified by the parity of many of the arguments which apply to the two hypotheses. In all that concerns the great distinction just laid down, between organic and inorganic existences, they mainly coincide ; Avhile the difficulties incumbent upon both may be considered essentially the same. Such analogy might well be expected; seeing how closely, or almost inseparably, animal and vegetable life coalesce, under their simplest and most elementary forms. Modern science has been perplexed in its endeavour to find terms for a definition, which may clearly and naturally distinguish two modes of existence, thus nearly approaching in their lower organisms, while so widely diverging from each other in the higher parts of the scale. I must add, further, in relation to this question, that the hypothesis of the origin of Cholera from the diffusion of fungi, or kindred forms of cryptogamic life, capable of acting as a poison upon man, has been recently proposed, and ably argued, by more than one naturalist.* The argument, as far * I would mention especially a valuable memoir by Professor Daubeny, AS A CAUSE OF DISEASE ? 583 as it is special, is chiefly founded on the facts, that certain fungi have been discovered parasitic in the human body; that many species are noxious in their effects on animal life ; that almost all have enormous powers of rapid reproduction ; and that their presence in the atmosphere is attested, not only by the part they bear in many phenomena of ferment- ation and organic decay, but also by sudden and extraor- dinary deposits of mould, of various kind and colour, upon different bodies on the earth's surface. The records of every time and countiy tell of those showers of Mood, or hlood rain; once deemed the omen of impending evil, but now known to be fungous deposits of this vivid red colour ; — whence derived, or why thus suddenly appearing, nothing in our knowledge enables us yet to say. Two singular instances of this kind, mentioned in the note below, have occurred in places where Cholera prevailed at the time.* They might, "On the Influence of the Lower Vegetable Organisms In the Produc- tion of Epidemic Diseases," read to the Ashmolean Society of Oxford, November, 1854; and since reprinted in the Edinburgh Philosophical Journal. * These instances occurred in the two distant localities of Philadelphia and Berlin. During the presence of the Cholera in Philadelphia in 1832, there was seen on one occasion the strange phenomenon of a mould of bright vermilion colour, suddenly tainting the bread and other articles of farinaceous food, in various parts of the city. Precisely the same thing happened at Berlin on the 26th of October, 1848, the Cholera pre- vailing there at the time. I received from Professor Ehrenberg some specimens of the bread thus singularly tainted ; the microscopic exami- nation of which showed (as it had before done to him) the presence of two fungi, and one animal organism. In this film of bright red mould. There are several instances on record of similar sudden falls of these coloured moulds in places where epidemics existed at the time, as at Cremona in 1529 ; but, as I have stated above, this is a matter In which the negative evidence far outweighs the affirmative. We find it related by Q.uintus Curtius that at the commencement of the siege of Tyre by Alexander, a fall of blood occurred; terrifying those p p 4 584 ON ANIMALCULE LIFE upon that frequent mode of interpretation, whicli raises mere concurrence to the higher relation of cause and eifect, be deemed an evidence in the question before us. But any such inference is at once annulled by the innumerable local examples of Cholera without similar concurrence. And eren were it otherwise, the evidence would be rendered ambiguous by the detection of animal organisms, associated, as it would seem, with all such fungous deposits ; showing the wonderful interblending and coalition of these microscopic forms of life ; and leaving it doubtful (as in the instances of perio- dical blight, or mildew, on plants of hum.an culture,) to which we must assign the eai-lier place in the phenomenon. While giving all due weight to the facts just stated, and believing that were the animal hypothesis of Cholera dis- carded, none other than that of a vegetable virus could take its place, I still am of opinion that the former is more in ac- cordance with the j)henomena of the disease. We cannot deny the possibility that fungous sporules may be transported to great distances by the atmosphere; retaining any specific virulent properties they possess, and the power of reproduc- tion to unlimited extent. But the peculiar manner of progress and distribution of Cholera, and the course and character it assumes in any given locality, though not easily submitted to any certain law, are nevertheless, in many ways, too definite to admit of being explained by such vague diffusion of the elements of disease as would belong to vegetable life. We can hardly look elsewhere than to animal instincts (more various and wonderful in aspect, as we become more cognizant both within the city and without. This story, unsupported as it is by the authority of Plutarch or Arrian, would hardly deserve mention but for the curious coincidence which enters into the narrative, of the bread having been thus afiected. '•'■Apud Macedonas quoque, quum forte pane m qriidam militiim frangeront manantis sanguinis guttas notaverunt." AS A CAUSE OF DISEASE? 585 of them) for solution of these and other problems, so essential to any just theory of the disease. I do not further discuss here the question between the two hypotheses, because the examination of the several phenomena of Cholera, in argument for one of them, will best aid us in making the comparison. To this examination I proceed ; after having clearly, as I hope, shown the necessity of admitting a material virus of the disease, and its powers of reproduction, as the foundation of inquiry; thereby excluding all vague hypotheses as to atmospheric or telluric causes independent of organic life; and reducing the question to the simplest form of which it is capable. The manner of diffusion of Cholera (taking this phrase in its largest sense) will be easily apprehended as the impor- tant point of the argument; comprising, as it does, all the most essential questions; and defining the facts and analogies necessary to their solution. I have already alluded to the first great spread of the disease, from the place of its origin, across continents and oceans, in a continuity of course, so as well nigh to have compassed the whole northern hemisphere of the globe. Looking now to the more special measures of its diffusion, one of the most striking facts we find in the history of Cholera, is its frequent suddenness of appearance and disappearance in given localities; while, in other places of its occurrence, a regular period and series of events are observed, marking what may perhaps be called the normal course of the epidemic. The former case is exemplified to us in the sudden invasion of insulated tOAvns or villages, apart from all obvious communication ; — the disease disap2:)earing again, almost as suddenly, after having inflicted a certain number of deaths, generally beyond the average proportion of mortality in this disorder. In the second and more com- mon manifestation of Cholera, as it occurs in large and 586 ON ANIMALCULE LIFE crowded cities, a few detached cases are first observed, also for the most part fatal in event; — then, after a certain period not very distinctly marked, a wide and fearful prevalence of the disease usually for two or three weeks; — and, again, a period of gradual decline, during which the cases are less malignant ; and the recoveries become frequent in proportion. Taking the whole course of the disorder in any one place, the rate is singularly uniform between the number of those affected with the true Cholera collapse and the amount of mortality; thus further showing how definite and uniform is the action of the virus, amidst all the inequalities of its local distribution. The numerous volumes written upon Cholera, describing its progress through different countries, abound in curious examples of the facts just stated; as well as of others, more anomalous, which have endlessly perj)lexed the question as to the contagiousness of the disorder. Yet these conditions, seemingly so incongruous, accord well with what we know of the habitudes of animal life, under the forms here pre- sumed. The sudden appearance and wonderfully rapid mul- tiplication of insect swarms, at certain times, and in situations favourable to their propagation, are facts familiar to naturalists. The diffusion of such swarms — sometimes by continuous flight for great distances ; sometimes by tardy, broken, and divided progress — is equally familiar to observation; how- ever scanty our knowledge of the peculiar animal instincts by which these movements are governed.* The same analogy * The Hessian fly, on its first appearance in America, afforded a sin- gular example of this slow progressive movement. First observed in Long Island in 1776, it proceeded into the interior, at the rate of ten or fifteen miles in the year, destroying all the wheat in its progress. The appearance and spread of the Blatta orientalis in the northern parts of Europe is another fact of similar kind. We are more familiar with the history — wonderful and incomprehen- AS A CAUSE OF DISEASE? 587 extends to the disappearance of these swarms; — either sud- denly, by further flight, or atmospheric changes on the spot; — or more gradually, by completion of their term of existence ; want of food; or any physical causes tending to destroy their ova, or retard their development and the successive meta- morphoses they undergo. In various respects, indeed, the erratic and ambiguous course of Cholera is well represented by the flight, settlement, and propagation of the insect swarms which inflict blight upon vegetable life. Their appearance at different and often distant periods, without obvious cause for such irregu- larity; — their direction to certain plants only; — their set- tlement upon these in clusters and detached localities; — the frequent suddenness of their change of place and final dis- appearance; — are all circumstances of remarkable analogy; as also the curiously abrupt limitation of some of these swarms, showing itself in definite lines of direction, along which their work of destruction is carried on. These lines, as well as the other local configurations of vegetable blight, though to our observation seemingly arbitrary, are doubtless connected with the instincts of life under this form, and with the relation of such instincts to the surrounding media. The diseases, thus produced in certain trees at particular periods (the elm, the plane-tree, &c., are recent examples), furnish many curious proofs as to the erratic influences of parasitic life; and still more are obtained from plants of artificial culture. The blighted potato or turnip field, or the vineyard, are pages on sible though It be — of those vast swarms of insect life which suddenly appear at undefined periods of time, sweeping over wide tracts of country, and marking their course by the devastation they inflict. The locust swarms and migrations furnish the most remarkable example of this phenomenon. In a succeeding note I shall have occasion to mention curious analogous occurrence, of recent date, in our own vicinity. 588 ON ANIMALCULE LIFE ■whicli to read the history of many natural phenomena ; and the philosopher may often best go to the farmer or gar- dener for knowledge of those details, which no theory can disregard. Applying the facts thus obtained to the case of Cholera, we find striking analogies to multiply around us; offering pre- sumption at least, where no certain proof can be had. This disease has been often defined in its course by similar lines of direction ; sometimes stretching over considerable tracts of land or sea; but more frequently obvious in particular localities ; where the partial distribution of the virus, in lines, or ever limited patches of surface, is often attested in very curious ways. In neither case can explanation be obtained from any physical conditions of the globe; from currents of air; or local circumstances of soil and climate. Nor will human communication, though certainly concerned in part in the transmission of the disorder, resolve these phenomena; of which innumerable examples might be cited, from the first appearance of Cholera in India to its latest ravages in Europe. We have similar occurrences in the history of some other epidemics; but none perhaps so remarkable in kind and degree. Connected with these facts is the observation, seemingly well attested, that the Cholera sometimes spreads in face of a prevailing wind, and where no obvious human commu- nication is present; — a circumstance difficult, if indeed possible, to be explained, without recourse to animal life as the cause of the phenomenon. No mere inorganic matter could be so transferred ; nor is vegetable life better provided with means for overcoming this obstacle. Another analogy, as it may be considered, to the habits of insect life, is the apparent preference of direction along the course of waters, which has been noticed in the spread of AS A CAUSE OF DISEASE? 589 the disease. This is one of the few facts which seems to have acquired something like certainty. Nearly every other conclusion as to what may be termed the natural history of Cholera, has been curiously refuted by fresh observations, almost before usurping the name of discovery. And even here, though the evidence is stronger and more complete, yet is it still not free from the contradictions and anomalies which press on every part of the subject. No certainty is yet attained as to the manner in which water — running or stagnant, pure or impure — favours, or otherwise affects, the diffusion of the disease. "We cannot say more than that, under admission of the general fact, the animal hypothesis accords with it better than any other.* Again, the frequent occurrence of insulated cases of Cholera in any given locality, before the more violent out- break of the disorder there, though in some instances it might be referred to infection, cannot be so explained in others. The fact, however, has close analogy to what is observed as to the habits of swarms of apkides, and other insects, infesting plants; and it would be difficult to find any more plausible * If I were to specify any instance within my own knowledge, pecu- liarly illustrating our ignorance of the causes which give local direction' and malignity to Cholera, it would be that of its occurrence in 1835 at TroUhattan in Sweden; which place I visited immediately after the cessation of the disease. It Is a village of scattered, clean, and comfort- able dwellings; standing on primitive slate rock just above the highest of the great cataracts of the Gotha, the waters of which, emerging from Lake Wenern, are as clear as those of a mountain torrent ; — the only accumulation of refuse about the place the saw-dust from the saw-mills on the river. In this village, so circumstanced, the Cholera suddenly appearing. In a very short time carried off forty-eight people — about one tenth of the whole population of the place. The mortality at Gottenberg at the same period was nearly in the same ratio ; but here there are local conditions which (granting the Interpretation usually put upon them) might better explain the results. 590 ON ANIMALCULE LIFE solution than one whicli connects the phenomenon with animal life. The reappearance of the disease in the same countries or localities at uncertain intervals, but generally during the hotter part of the year, is another fact bearing on our hypo- thesis. The earlier evidence on the subject left much that was obscure as to the causes concerned in these recurrences of Cholera; and even now we can but vaguely conjecture what may be due to fresh virus, brought (as originally) from remote distances, — what, to the revival of the germs of former disease on the spot itself. Observations indeed have been now endlessly multiplied; but on this, as on all other points, with such strange diversity or contrariety of results, as rather to perplex than settle the question. The vast col- lection of facts obtained by the Cholera Committee of the College of Physicians, (admirably arranged, and commented upon by Dr. Baly and Gull in the published volume of Reports), goes chiefly to show the present impossibility of assigning laws, either to the original diffusion of the disease, or to its recurrence in particular localities. Difficult of certain solution on any hypothesis, these phe- nomena are less so, I think, on the supposition of an animal virus than on any other. This theory offers the contingencies of new swarms arriving; — or of the development of ova or other germs of existence, deposited during the preceding invasion of the disease, and called more or less numerously into life, by increased temperature or other physical causes; — or perhaps of the concurrence of these conditions in extending or other- wise modifying their effect.* Such views sufficiently accord * A valuable document on this subject is the paper by Dr. Budd and Mr. Busk, in the 21st vol. of the Med. Chirurg. Transactions, on twenty cases of Cholera, which occurred in October, 1837, in the Hospital Ship at Greenwich. The circumstances of limitation to this vessel, in which AS A CAUSE OF DISEASE? 591 with the facts ascertained regarding Cholera, and are recon- cileable with all we know of insect life and reproduction. The connexion of each great outbreak of the disease in Europe, witli the Avarmth of summer and autumn, and its general suppression in winter, may indeed furnish argument either to the animal or fungoid hypothesis; but more espe- cially, I think, to the former. Animal ova, or germs, do often remain dormant for long and indefinite periods of time ; yet, like the seeds of plants, retain the powers of life, and burst into active existence when circumstances occur to favour the change. One of the most singular facts in natural history is this sudden appearance of insect swarms, with all their instincts complete, in localities where they have not been seen for years before; either brought from unknown dis- tance, or the produce of the ova of foi-mer seasons deposited on the spot, in preparation for this later development.* the Cholera had twice occurred before, gave strong proof of a local reproduction of the virus of the disease. Such special instances often do more to elicit truth than a multitude of widely spread but detached observations. * Though such instances are familiar, even in our own country, I may briefly notice one, somewhat remarkable, and of recent occurrence. In October, 1836, a vast swarm of minute aphides (whether one of the numerous known species was not ascertained) passed over a wide dis- trict in Cheshire, Derbyshire, and the southern parts of Lancashire and Yorkshire. The air was so thickly filled with them, that the clothes and faces of persons walking out of doors were completely covered. When getting into the eyes they excited considerable inflammation. The height to which the column reached could not be known. From the best observations in one localit}', its superficial extent must have been at least twelve miles in one direction by five miles in another ; but the detached notices from other places make it certain that the continuous swarm Avas much more widely spread. No sufficient comparison appears to have been made of local observations to furnish proof as to the rate and direction of movement ; but it is worthy of notice, that the town of Manchester was infested by these insects for two or three successive days. Wherever 592 ON ANIMALCULE LIFE And here we again approach to speculations, which, though founded on the most minute forms of existence, have yet a vastness in their obscurity, and in the results to which their solution would lead. I allude to the hypothesis of equivocal generation ; — the question, whether animal or vegetable life (for the inquiry equally regards both) is in any case pro- duced without the egg^ or seed, of prior individuals of the species ? The result of modern research has been chiefly on the negative side of the question; and the old dogma of " Omne vivum ah ovo " remains sanctioned to an extent, which considering the exquisite minuteness of the objects, could scarcely have been supposed within the scope of human observation. Where, as in the genus Aphis, eight successive generations of females may be fertile Avithout fresh impreg- nation, or where such phenomena exist as have been described under the name of Parthenogenesis and Metagenesis — it seems needless to seek for other manner of production. Nevertheless, we are still very far from certainty. Instances may be indefinitely multiplied to the effect just stated, and yet it is possible that there are also simple germs of life around us, awaiting development ; or matter so constituted as to be capable of assuming new and various forms of livino* organisation, according to the circumstances present to favour such change. The generation of some of the Infusoria would scarcely seem explicable on any other view. The question, thus obscure to our present knowledge, is closely connected with that, equally obscure, as to the im- mutability of species. In both, the greater familiarity of the idea of successive propagation by ova, or by seed, disguises generated, or by whatsoever instinct carried on, there is cause to suppose that the swarm was in transit from one place to another, and possibly brought nearer to the earth by some peculiar state of atmosphere existing at the time. AS A CAUSE OF DISEASE? 593 the fact that such propagation is quite as incomprehensible in itself, as the conversion of the same organic elements, under altered circumstances, into new forms. In the second Chapter of this volume (on Hereditary Disease), I have stated my belief that all present evidence tends to establish the opinion of the permanence of species. And this belief may be held, even while fully recognising the tendency and result of recent inquiry to introduce life as an element and agent, both in past and existing phenomena, where the relations of inert matter only were before presumed to exist. We may never reach the entire solution of this question ; but time and research will undoubtedly bring us nearer to it hereafter.* Without entering further on these controversies, we find in facts, well ascertained, of the occasional length of time during which the ova of animal life retain their power of re- production, much that bears on the hypothesis before us. * Notwithstanding this imperfection of our knowledge, the whole subject of organization, whether of animal or vegetable life, affords a signal testimony to the progress of modern science; — realizing on the one hand some of the poetical imaginations of antiquity ; — on the other, by mathematical exactness of observation directed to the most minute forms of matter, laying a basis for discovery, of which the boldest specu- lator can scarcely yet see the full extent. We may agree with Male- branche, — "II est bon de comprendre qu'il y a des choses qui sont absolu- ment incomprehensibles" — and yet be sedulous in seeing that the line of demarcation is not drawn too closely around us. The Memoir of MM. Beauperthuy and Roseville, and the observations of Schwann, Liebig, Cagniard de la Tour, &c., are among the most valuable of the recent inquiries bearing on this subject ; indicating the development of animal and vegetable life in different media, as the pro- bable cause of the various processes of fermentation, putrefaction, &c. It is one of those curious questions where doubt exists as to the respective conditions, — which is cause, which effect, in their mutual relation ? Such doubt is generally solved in the event by some simple and single observa- tion, deciding not merely the particular problem, but opening a way to knowledge beyond. Q Q 594 ON ANIMALCULE LIFE There is reason to presume, upon various evidence, that the simpler and more minute the form of organization, the greater is the faculty of thus retaining life in a dormant state. And if comj)lete animal organization, such as that of the infusoria, or the vibriones of wheat, is capable of being restored to vital activity, after long apparent extinction, still more may animal ova be supposed retentive of the principle of life and repro- duction ; awaiting merely the conditions necessary to their evolution.* These considerations bring us to one of the most curious questions respecting Cholera; viz., how a poison should be thus locally generated, unknown before, but capable, by some means of reproduction, of being diffused over every part of the earth ? I have just alluded to certain obscure points of philosophy — equivocal generation, and the permanence or mutability of species — which bear closely on this problem. Its solution is difficult on any hypothesis ; but least so, I am led to believe, on that of animal origin. This furnishes a reason why the disease, existing perchance at some anterior time, may have disappeared for ages ; the seed of the pestilence, however, yet remaining, to be called into activity by future contingencies. Or, if we admit the doubtful assertion of some authors, that the same disorder has existed repeatedly in India, though never with equal virulence, no view will so well suggest an explanation, as that which admits on the one side all the instincts of animal- cule life ; on the other, the varying casualties of place, season, and human communities. Swarms may be evolved in * In .1 recent communication of Ehrenberg to the Academy of Sciences at Berlin (April 16, 1855,) he relates his observations on the revival, by immersion in water, of microscopic animals (the Callidina scarlatina, Milnesiu7n alpigenum, &c.) taken up originally from a dry earth, at the height of more than 10,000 feet on Monte Rosa ; and preserved for four years, in moss earth, in his writing-desk. AS A CAUSE OF DISEASE ? 595 a given locality, and perish, before migration or communica- tion to man have given cause to their wider diffusion. It is here that the argument comes in closest relation to those singular questions regarding certain other diseases, such as Sraall-pox and Syphilis ; which have perplexed all medical reasoning and research, and still remain unsettled and obscure. The presumption as to these diseases is, that they were un- known to the ancient physicians; — that they have appeared in Europe (if not in the world) at some later but uncertain date ; — and that they have since undergone modifications of character, either from human precautions, or under that mysterious law (if we are entitled to call it such) by which the physical constitution of races and communities of men seems in time to habituate itself to certain morbid agents and conditions of disease. This latter expression may seem vague ; but language is forced to become so, when touching upon subjects of this nature. Another, and perhaps closer, relation may also come into notice here ; associating Cholei'a with those other strange and fearful pestilences which are recorded in the history of every age and country — desolating great cities, or diffusing death more widely over whole nations. The plague of Athens has gained celebrity from the place and period of its occurrence, and from the genius which has been given to its description. The plague called the " Black Death," as it occurred in Florence, has received similar celebrity from the pen of Boccaccio; but these partial records give faint idea of such a pestilence as that last named, which, about the middle of the 14th century, spread into every corner of Europe; producing a mortality beside which the history of Cholera is a fair page to look upon.* The " Sweating Sickness," * In his treatise on this fatal epidemic (^Schwarze Tod) Hecker calcu- QQ 2 596 ON ANIMALCULE LIFE as manifested In its different irruptions upon England and all Europe, from 1485 to 1550, is another example of these extraordinary wandering pestilences ; affording in its history (as does also the Black Death) so many striking analogies to that of Cholera, as regards the manner of diffusion and other incidents of the disease, that it is impossible not to suppose some connexion of physical origin. The virus of the diseases is doubtless not identical ; but where the effects are thus far alike, the causes cannot be without some certain common relation. I am unable to pursue this topic here, but it well merits further inquiry. The whole subject of the migration, presumed in our hypo- thesis, will occur as one of its great difficulties ; seeing that we have no evidence of any of similar extent in the animal kingdom; and that the manner and duration of insect life are in many respects opposed to one, which involves such variety of country and climate ; most of the species known to us ap- pearing to be submitted to geographical distribution, like plants, and the other classes of the animal kingdom. What may be said in reply (even admitting the restriction to insect life, properly so termed) is, that we are singularly ignorant of all that relates to animal migrations in general; — that our knowledge becomes less as we descend to the more minute forms of life; — that the facts known respecting the occurrence of insect swarms meet some of these objections; — that different insect species vary infinitely in their habits and lates that twenty-five millions of people may have perished in Europe alone. But statistical reports were not then invented; and the sources of his calculation are so vague, and the original details so obviously exag- gerated, that it is impossible to assent to this belief. Numbers, ever the subject of popular error, are not likely to have "been very exactly dealt with at a time of so great calamity. AS A CAUSE OF DISEASE? 597 capacity for diffusion ; — that the ova themselves may be widely disseminated, independently of the living animal migrations ; — and that the rapidity of propagation and change, incident generally to this part of the animal creation, if introducing some difficulties, provides the means of obviating others which press upon the argument.* Pursuing the hypothesis (still tentatively upon all these points), we reach the question as to the infectious nature of Cholera; and may gain from hence some further argu- ment in removal of the objections just stated. If this point, so warmly contested, be answered in the affirmative, man becomes an agent in the diffusion ; and the transit over continents and oceans, otherwise impossible, is brought within comprehension and the analogies of other disease. Much of this controversy might, as I think, have been obviated by a regard to the principles mentioned in a former chapter. It seems certain that the virus of Cholera, whatso- ever its nature, may be sj)read in different ways. That the atmosphere, though not in any of its states the cause of the disease, forms one medium for diffusing it — and this over great distances — is clearly to be inferred from numerous facts in its history. From the same evidence, and particularly from the details of its introduction into new localities, and passage across seas, it is impossible not to admit that its transference is frequently effected by human means ; and it may perhaps be affirmed (without involving the question in more doubtful phrases) that man, the peculiar recipient of this cause of disease, is also the principal agent in its dif- * Professor Lacordaire of Liege, one of the most recent and able writers on the geographical distribution of insects, records numerous examples showing the influence of particular physical causes upon their distribution or casual diffusion ; while yet leaving many instances of diversity and anomaly to which no known explanation will apply. QQ 3 598 ON ANIMALCULE LIFE fusion. On a question of this nature, it is always well, if we can obtain them, to select a few proofs unequivocal and com- plete, wherewithal to meet the many ambiguous or anomalous cases which are certain to occur: and it would be easy to state several such circumstances in the history of Cholera, scarcely admitting of other interpretation than that just given.* Allowing this, some of the apparent contradictions which have embarrassed the question as to contagion may be solved, by referring to the habitudes of that class of animal life which the hypothesis assumes ; and particularly to the circumstances which favour the propagation, diffuse the ova, direct the flight, fix the resting-places, or modify the virus, of the swarms thus supposed. We can understand in this sense the respective relations of man and the atmosphere to the spread of the disease. The human body may be a means of concentrating the morbid cause ; and conveying it, possibly in a state more prone to inflict the disorder, to distant and * One, wlilch I think includes every condition of perfect evidence, is the transportation of Cholera from the infected towns of Liverpool, Dublin, and Greenock to Quebec ; in vessels having emigrants on board, among whom the disease existed during the whole passage across the Atlantic. The details of this occurrence, including the place, time, and manner in which the Cholera first showed itself in Quebec, are such as to leave no point of ambiguity. I have before stated the iiict that the disease ap- peared here, at New York, and other parts of the United States long before it occurred in many parts of Europe, out of the main line of its westward course. The circumstances which attend the transmission of the disorder over land are not often so explicit in their conclusions. The Treatise on Pestilential Cholera, by Dr. Copland, published in 1832, contains an excellent statement of the argument regarding contagion, as of all besides relating to the disease. In adopting the opinion of its infectious nature, he has ably and justly dwelt on the inadequacy of the experiments by inoculation, and certain other modes of exposure, to uega» tive this opinion. AS A CAUSE OF DISEASE? 599 cletaclictl localities. The atmosphere (the medium in every case of communication from one body to another) may itself, independently of man, carry the agent of disease over wide distances ; and by its changes in temperature, humidity, and electrical state, produce many of the modifications observed. And in the separate, or concurrent, agency of these causes of communication, a plausible solution is found of most of the singular anomalies presented to us.* Some allusion may be expected here to the question of Quarantine; — whether of avail, or otherwise, in preventing the ingress of Cholera into any particular country or locality? The views, and entire course of argument, pursued in this chapter, will show my opinion to be, that it is wholly in- effectual; and this judgment I consider to be amply con- firmed by the evidence of facts. The practical conclusion is one of great importance ; but it will be long, I fear, before we can expect it to be generally adopted and acted upon. That man should be so peculiarly the subject of Cholera is a difficulty which belongs to all hypotheses, but least perhaps to that of an animal origin. It is difficult to conceive any other physical cause thus far exclusive in its effects; while, in support of this view, we have various analogies in insect life ; and, generally, in the nature and habits of parasitic life, as already noticed. Though man, however, is chiefly ob- noxious to this virus, whatever it may be, we have some proof that he is not exclusively so ; and it is worthy of note, that the most distinct evidence relates to its effects on birds ; * Some physicians have urged the opinion that the virus of Cholera is conveyed through drinking water, or food, which has been contaminated by the evacuations, or other contact with patients under the disease. Were this proved to be so, the fact would readily connect itself with our hypothesis ; but it is too doubtful to be admitted as an argument. Q Q 4 600 ON ANIMALCULE LIFE and to the rare appearance of certain species of birds in tlie localities where Cholera is prevailing at the time.* The cause assigned in the hypothesis under review is at least as probable as any other in explanation of this curious fact. The question, connected with the preceding, why the miasma of the Cholera should destroy some persons, and leave others in the close vicinity little if at all affected, applies equally to other disorders of contagious and epidemic kind, and presents similar difficulties to every hypothesis. These difficulties, however, attach themselves much more forcibly to the notion of an inorganic agent, than to a supposition which includes all the conditions of animal life ; and particu- larly of that form of life which is so rapid and abundant in reproduction, undergoes such remarkable changes, and is submitted to instincts of which we have so little cognisance. No view, as far as can be seen, better illustrates the various degrees of the disorder ; — from the diarrhoea or ill-defined dis- turbance about the epigastrium and bowels, subsiding without further issue — to the powerful and virulent disease, j)ro- ducing instant collapse, and destroying life within a few hours of the earliest seizure. The fact that every gradation of disease exists between these extremes is scarcely compatible with the idea of any simple physical agent; but accords far better witli the notion of an animal virus, variously diffused in a given locality, and as variously acting upon those exposed to its influence. * This statement of the effect upon birds is fully confirmed in a late re- port of the Medical Faculty of Vienna, upon whom the inquiry as to the influence of Cholera upon other animals was expressly enjoined. A similar fact has been noticed in the history of other pestilences of older date, and attributed vaguely to atmospheric changes affecting this class of animals. The report just named is the most complete document we possess on the subject, and contains many very curious observations. AS A CAUSE OF DISEASE? 601 These considerations bring us more directly to the patho- logy of the disease, and the relation of the various alleged causes to its actual symptoms. The weak part of medical science lies here, where morbid agents from without come into contact with living actions in the body : and if we fairly examine into this part of pathology, we shall find how little certain knowledge has been gained from the earliest date of medical history to the present day. Singular though the symptoms of Cholera are, in their suddenness and fatality, they offer no difficulty which does not equally belong to other kindred diseases. We may even go a step further, and affirm that the notion of an animal virus, applied to absorb- ing surfaces, and engendering the disorder by entering into the circulation, is that which on the whole best accords with the character of the disease, and with the analogies most obvious to other morbid affections. We have many proofs of the power and virulence of different poisons of this class, and of the remarkable changes they produce on the nervous system and the blood; — often so speedily after their absorp- tion, that all observation is frustrated in seeking to follow the train of events ; and speculation equally at fault in attempting to find a theory for them. The action of the morbid cause in Cholera seems to have most kindred with these poisons ; the change which takes place with such rapidity in the properties of the blood being, as I think, the great feature in the disease ; the basis probably of all the other symptoms. The extreme depression of animal heat throughout the body ; — the peculiar secretions so largely poured out from the inner surface of the intestines ; — the suppression of the natural secretions ; — the severe spasmodic actions ; — the various effects on the nervous system ; — and the typhoid and other symptoms which occur in sequel to the acute stage of the disease ; — are all more readily and con- 602 ON ANIMALCULE LIFE sistently explained, by looking to this altered state of the blood, as the effect first resulting from the influence of the morbid cause.* Some of these symptoms, indeed, scarcely show themselves where the Cholera exists in so virulent a form as to terminate life in a few hours ; proving thereby that they are not essential to the character of the disorder, nor to its event. This fact (Avhich I believe to be a well attested one) helps us here, as in many other medical questions> towards a right theory, by distinguishing the secondary and subordinate symptoms from the primary and essential con- ditions of the disease. It is conceivable indeed, and we have no direct proof to the contrary, that the original impulse of the virus of Cholera may be upon some part of the nervous system. But I con- sider the supposition much more probable which makes the influence on the blood the first in the series of changes : and it is undoubtedly that which has most obvious and general relation to the other symptoms of the disease. If the mag- nitude of the effect here seems out of proportion to the cause, we have but to look to the certain influence of other morbid agents on the blood; — whether the imperceptible virus of many contagious diseases — the minute quantity of certain other animal poisons producing death — or the action of different salts in preventing the coagulation of this fluid. Inability to explain the rationale of such changes applies * I would apply the same remark to the diseased or disorganised state of tlie Inner coat of the blood-vessels, observed in many of the dissections after death from Cholera, and particularly described by Dr. Mackintosh. The experiments of Dr. Namias, of Venice, are alleged to show that inoculation with the blood from cholera patients, under collapse, will often destroy other animals, as rabbits, within a few days; and by changes which render their blood again destructive to others of the same species. I doubt, however, if these experiments have been authenticated by that repetition which is so essential in every inquiry of this nature. AS A CAUSE OF DISEASE? 603 alike to every view of the subject ; and cannot therefore be admitted as an exckisive objection to one alone. In the subject of this Chapter there is nothing which di- rectly involves the inquiry as to the prevention or treatment of Cholera. Nevertheless the interest of these questions is such, and their relation so intimate with every hypothesis as to the origin of the disease, that it is impossible to exclude them from consideration. Neither the hypothesis of which we are treating, nor any other alleged cause, can be con- sidered as hitherto affording even plausible suggestions to this effect. The requisitions in common to every view are, the discovery of means to prevent the access of the cause — or a specific capable of obviating the virus when received — or remedies adequate to sustaining the body under its in- fluence ; — objects, it must be confessed, hitherto wholly unattained. The singular uniformity in the proportion of deaths, in every place of the occurrence of Cholera over the globe, not only affords proof that no valid means of cure have been discovered for the disease, when fully developed in its more malignant form ; but shows, moreover, how inert even the most drastic remedies become, when directed asralnst this extraordinary poison. Methods of treatment the most oppo- site, yet equally insisted upon by their respective advocates, and many of them such that their use would be dangerous in other cases, lose here all their distinctive effects, and are found alike inefficient and harmless. I have seen from 100 to 150 grains of calomel given within twenty-four hours; not merely with no abatement of the disease, but with scarcely a single obvious effect on the character and course of the symptoms. Opium and brandy, and the many other powerful astringents and stimulants which have been brought into trial, fail of all their wonted effects; or act so am- 604 ON ANIMALCULE LIFE biguously, that the most sanguine practitioner can hardly record them as remedies for the disease. I doubt not that in some habits, and especially when the morbid cause is present in slight degree (a contingency ever to be kept in mind), good may be done by all means which tend to moderate the symptoms, restore right secretions, and sustain the powers of life. But until the proportion of mor- tality under collapse is distinctly abated by some given plan of treatment ; and this effect well attested by comparison with other places where different methods, or no methods at all, have been pursued; the inevitable conclusion will remain, that no real antidote has yet been discovered ; and that the cases of true malignant Cholera, which we interpret as cures, are rescued from fatal result by causes which we can neither recognise nor command. This may possibly appear to some too disparaging a view of what has been attained in the treatment of Cholera. It will not, I think, be felt as such, by those who duly examine their own experience, and all that has been derived from the most authentic records of the disease. These records, as already remarked, are now exceedingly numerous ; drawn from every country, climate, locality, and condition of social life ; and so tabulated in many instances as to convey very exact averages. The results thus obtained, if fairly weighed, admit but of one interpretation. They show us that zeal, ingenuity, and science have been taxed in vain, to discover a remedy, effectually and uniformly capable of lessening the proportion of deaths, among those attacked with the disease under its more severe forms. I say effectually/ and uniformli/, because some of these tables seem to yield results partially favourable to certain methods of treatment. But the difference of pro- portion obtained is so small, and the conclusions require to be qualified by so many doubtful circumstances, that it argues AS A CAUSE OF DISEASE ? 605 rather a sanguine spirit than a sound reason to be satisfied of their stability. Where Cholera reaches the state of collapse, our practice is still that of experiment only ; and of experiment little guided by any principle or uniformity.* If the disease should still continue in the world, and a remedy, justly so called, be happily discovered hereafter, it will probably be of the nature of a specific antidote to the action of the virus on the blood. I hazard this opinion, look- ing to the singular importance of this action in the pathology of Cholera ; to the promise which animal chemistry gives of new methods of altering the state of the blood ; and to the * I allude here chiefly to the report of the Cholera Treatment Com- mittee of the Board of Health. The Committee took cases, under col- lapse from the disease, as the foundation of their inquiry ; and reasonably so, since in no other way could they have obtained even an approach to parity of trials. Slight or incipient cases of the disorder are obviously incapable of furnishing any scale of symptoms explicit enough for com- parison. Allowing for difference of results from the treatment within hospitals or elsewhere (a manifest source of ambiguity in many ways) the inference from these tables would seem to be that the treatment by Calomel and opium, and by Salines, tends most to lessen the mortality under collapse. But we are bound to remark that this inference is drawn merely from the comparison with other modes of treatment (by stimulants, astringents, emetics, acids, castor oil, &c.), which, though pro- pounded by medical authority, would appear on the evidence of these tables to be positively injurious in effect. It is an ancient medical maxim, and of high authoi-ity, " w(pe\tiv ■>] fxri pXaTTTciv" A question may be started, with which this maxim has close concern, whether it is possible to reach any sound conclusion without in- cluding in the averages those cases where there has been no treatment at all. If the tables show a mortality of 75 per cent, under one method of treatment, and only 60 per cent, under another, this does not logically prove the latter to be beneficial, but merely gives evidence that the former is injurious. The only valid comparison is that to which I have just referred. And to this we must look for whatever certain conclu- sions regarding the treatment of Cholera we are likely hereafter to obtain. 606 ON ANIMALCULE LIFE actual results obtained by means expressly applied to the object in question. I allude here to the treatment by Saline injections into the veins ; which, though not yet sufficiently established by experience, and liable to various difficulties in its use, has nevertheless in many cases been found to possess singular power in checking the progress of collapse ; and ap- proaches nearer, perhaps, to a successful issue than any other method yet employed. Still it is only an approach; and the problem yet remains to be overcome ; either by accident, or the better fortune of future experiment. Casualty may perchance serve us here better than reason; but we are bound to follow the latter as far as it will lead us. The best contingency, next to that of a specific remedy, seems to be the discovery of means capable of sustaining or restoring tlie nervous power of the vital organs, so rapidly and deeply affected by the disease. Any agent equal to fulfil such purpose must presumably be both simple and powerful: — whether Electricity, in any form of Its action, may be capable of this, is a question not yet fully answered. Speaking generally of the treatment of Cholera, I certainly do not believe that an efficient method of cure will ever be attained by dealing with the symptoms in detail. The magnitude of the disease, and intensity of its cause, are beyond such means of reaching them ; and it is probably only in the milder cases — where the virus has been slightly received, and diarrhoea is the single or principal symptom — that any favourable result can thus be obtained. After all, is it just to speak of our ignorance of a remedy for Cholera as a peculiarity of this disorder ? Have we any more certain or specific cure for other contagious or epidemic diseases, unless dignifying with this name that mitigation of symptoms, and prevention of particular misclilefs, which alone come within the rule of safe practice in most of these cases ? AS A CAUSE OF DISEASE? 607 The Instance is one among many, where long familiarity with certain disorders, or their milder character, disguise the con- nexion they have with other diseases, less known and of greater virulence. The preventive remedy discovered for Small-pox is an eminent, though partial, exception to the remark ; and an indication, at the same time of what may yet be possible in other diseases where a specific virus is present — the cause of malady to the individual, and the means of its dissemination to others. Whatever the nature of the virus of Cholera, the contingency of discovery Is the same here as elsewhere : and if, like the small-pox. It is to be considered a new form of disease engendered in the world, and destined to remain as a wandering pestilence here, the attainment of this object is manifestly most important to human welfare. These remarks, however, have no peculiar application to the hypothesis before us. This has now been discussed In as much detail as a speculation merits to be In which direct proof Is wanting ; and for which a main argument Is the inadequacy of all other hypotheses to explain the facts. I have not noticed the further objection which may be urged against It, viz., that. If well-founded, its application would not be limited to Cholera ; but must of necessity extend to certain other contagious or epidemic diseases, (and especially to the epidemic influenzas,) of which the essential conditions are so far the same, as to warrant the belief of a similar, though not identical, cause. In the justness of tliis Inference, I must ac- quiesce ; and admit also the extent to which It carries specu- lation in advance of our actual knowledge. This in truth Is the wider question, serving as title to the present Chapter ; — how far, and in what manner, the animal life of one species may become a source of disease to another ? And I selected the instance of Cholera, simply as furnishing the most various and remarkable Illustration of the argument. 608 ON ANIMALCULE LIFE AS A CAUSE OP DISEASE ? The general question is one largely open to research; — sanc- tioned in its object by our ignorance of other causes for these genera of disease ; — affording some curious presumptions where certainty may be unattainable ; — and involving a topic than which none is more remarkable, viz., the origin and progress of those disorders, which, if not newly generated, have first appeared in our parts of the world within the period of modern record ; and in some cases become endemic, where there is no authentic trace left by history of their prior existence.* * While this sheet is passing through the press (August 1855), the Report of the Medical Council of the General Board of Health, on the Epidemic Cholera of 1853-4 in London, has been presented to Par- liament. Among other valuable averages and conclusions which it contains, may be mentioned those as to the proportion of mortality at different ages ; — those as to the probabilities of recovery at different stao-es of the disease ; — and those which attest a diminished rate of mortality in some proportion to the elevation above the Thames. It will be found, I think, that these conclusions (admitting, as is pro- bable, their confirmation by future experience) are in nowise incom- patible with the views proposed in the foregoing Chapter. 609 CONCLUDING REMARKS. In the preface to tliis volume I have briefly stated the motives which originally led me to this manner of publication, and the principles by which I have guided myself in it. But as prefaces are often not read, or scantily remembered, I am desirous to add a few concluding pages, which may form a sort of summary to the foregoing chapters, both as respects their general design and the method of its fulfilment. Such revision, while sought for partly on my own behalf, will not, I trust, be wholly indifferent or useless to the reader. An object which I have sedulously kept in view in the selection, as well as treatment, of the topics included in this volume, has been their relation to those more general prin- ciples of theory and practice, which alone can give sanction to the name of Medical Philosophy. Even in the few in- stances where treating of particular diseases or remedies, I have sought, as far as possible, to bring them into connexion with these general views ; believing that in this manner I might render more useful the notes and reflections, derived from a long practice, which I have ventured to make the foundation of my work. The reader will, I think, see that this object has been always before me ; and that it has led in several cases to the association of certain diseases, or morbid states, not usually classed together in our systems of nosology. The relations, thus indicated, must ever be im- portant ; even if in part superseded hereafter by the discovery of others, still closer and more determinate. In a field wide R R 610 CONCLUDING KEMARKS. as tliat of Medical Science, there are many paths, seemingly parallel in the outset, but ultimately converging toward those higher truths and more general laws, which, here as elsewhere, must be regarded as the just object and end of all research. I trust it will be further seen, that I have constantly en- deavoured to separate what is actual and assured knowledge from that which but usurps the name and show of it. The nature of the subject peculiarly demands this pi'ecaution. The inherent difficulties of Medicine, as a science, of which I have spoken elsewhere, are greatly augmented by its neces- sary connexion with those feelings, fashions, and prejudices of the world, which tend to impair even the soundest judg- ments, and to mislead them in the search after truth. In seeking to follow out the principles just stated, I have found it needful to deviate frequently from the usual mode of treating these topics ; and in several instances to modify, or impugn, opinions, which have become traditionally current in medical literature. I can affirm that I have never done this wantonly, or otherwise than from conviction. It may, and probably will, be thought by many, that I have taken too disparaging a view of the actual state of medical knowledge, and often inculcated doubts without providing a solution for them. Persuaded of the truth of the maxim, that " It is generally shorter and easier to proceed from ignorance to knowledge, than from error," I have never scrupled to note what I think doubtful or deficient in evidence ; suggesting other conclusions where I could venture to do so ; and where not, seeking to indicate the channels through which the inquiry might best be pursued in the future. In giving up all false or untenable pretensions, the best preparation is made for remedying what is vague or deficient in our present knowledge. CONCLUDING REMARKS. 611 In the treatment of these various topics, I have further kept constantly in view all that I felt as likely to serve the interests of those entering the profession, or still young in its practice. Some chapters will be noticed, as especially directed to this object. In all I have sought to avoid mere technicalities ; and to place in the clearest form those prin- ciples of thought, observation, and conduct, which may most conduce to the progress of medicine, and the honour and usefulness of those who profess it. The experience derived from nearly forty years of active practice may perhaps be admitted as giving some title to offer such advice. A pro- fessional life, thus prolonged, must have been unprofitably used, if not affording the suggestion of many things to be learnt or done — of many others to be put aside or avoided. Of these things, thus taught by experience, some will be seen to relate to the moral discipline of the profession (a matter to which it is impossible to attach too great Aveight) ; others again involve certain technical duties of the physician, not equally essential, yet nevertheless very important to the credit and integrity of practice. The inculcation of these things may lessen at least some of the difficulties inseparable from early medical life, and which now and then blight it in the very beginning. It will probably be remarked that I have in this volume referred, more frequently than Is usual, to the medical authors of antiquity, as well as to those of the age more immediately preceding our own. Had my limits allowed of it, I should gladly have carried these references yet further. The vast aids which Medicine, both in its theory and practice, has recently derived from its growing connexion with the other physical sciences, have naturally withdrawn attention from authors who were scantily, if at all, provided with these great resources. But, considering how much the practical 612 CONCLUDING REMARKS. part of medicine must ever depend on observation and ex- perience, it is injurious, as well as unjust, to neglect the records of what has been attained by the industry and acute- ness of older observers. Those who are familiar with the pages of Boerhave, Morgagni, Sydenham, and even of the physicians of antiquity, will find in them many of the very cases, methods, and opinions, which are unwittingly offered to us as novelties in the medical writings of our own day. I must not unduly prolong what may seem a superfluous recurrence to the objects and methods pursued in this volume. But where the topics are so various, and to all appearance desultory, I feel that it cannot be amiss thus shortly to have indicated the principles which have mainly guided me in their discussion. And I the rather venture on these con- cluding remarks, inasmuch as they will serve to my vindica- tion in certain points, where I may seem to deviate from common opinion, or to carry too much distrust into matters of common belief. I cannot, however, close what I am now writing, without some reference to another object, of which I have never lost sight in the consideration of these subjects. 1 mean, the relation of Medicine, both as a science and system of practice, to the other physical sciences — a connexion ever tending to closer approximation; and through which its progress to higher attainments and powers is mainly to be looked for in the future. This is a field for exertion so vast and various, that every physician may fulfil some part in the required labour, by observation, experiment, or reasoning. Chemistry in its every branch, (but especially the Chemistry of Organic Life, associated, as it now is, with the doctrine of definite atomic proportions) stands foremost in the connexion thus established. But Electricity, Optics, Meteorology, Natural History, and even the mechanical sciences, severally contri- CONCLUDING REMARKS. 613 bute towards this great circle of relations; which, while unceasingly enlarged by new discoveries, is at the same time ever concentrating itself around common laws and higher generalisations. To these I have often had occasion to refer in the preceding chapters; and have indicated, wherever able to do so, the means by which their association with medical knowledge may best be enlarged and defined. For from the growth of the other physical sciences. Medicine has not only enlarged its own sphere, and gained a sounder philosophy, but it has also acquired new methods and instruments with which to conduct future inquiry. Numerous and exact records now give effect to that haj)py method of averages, which we have noted as being an almost mathematical guide to truth. Every well-attested case thus acquires its appropriate place and value ; and facts, before lost or dispersed, are now virtually registered in the conclusions to which they have contributed. Of the direct instruments which science has furnished in aid of medicine and physiology, the Microscope is the most consummate and wonderful example. But other refined applications of phy- sical agents have become familiar to our use; giving the power of looking more deeply into the interior of the livino- frame ; of better determining its morbid conditions ; and of applying remedies more closely and effectually for their relief. I must yet advert to another branch of knowledge, now forming an integral part of Human Physiology ; the growth and better definition of which may be said to exercise a new influence on every department of medical science. In another volume I have treated of this subject, under the title of Mental Physiology ; using the term to express more especially the reciprocal action and relations of mental and 614 CONCLUDING REMARKS. l3odily phenomena, as they exist in, and make up the totality of, human life. The history of the mind, regarded simply as an inquiry into the faculties and feelings, intellectual and moral, is an inheritance to us from early antiquity ; and we may doubt whether later research, though using new nomen- clature and better definitions, has really added the knowledge of a single phenomenon to those already recorded ages ago. But between these purely mental inquiries, and those which reo-ard the physical nature of man, there lies an interspace; destined ever to continue such; yet greatly narrowed, we may affirm, by the remarkable discoveries regarding the functions of the nervous system, and their relation to mental as well as bodily phenomena, which of late years have given a new character to physiology. While recognising still a line and limit, impassable by human reason or research, we have approached nearer to it on this side ; and are justified in believing that the same investigation, further pursued, will bring us yet closer to the boundary. But all experience teaches that it is a ground to be trodden over with caution ; — that the evidence as to facts becomes more precarious at every step we advance ; — and that ambiguities of language and vague speculation are ever tending to mislead the judg- ment, and obscure the truth. A sound spirit of philo- sophical induction, so important in every part of science, is especially needed in this branch of human physiology. To remove error — to perfect what is incomplete in know- ledge (ra -^fjLLspya ss tsXos s^spya^scrOai,) — and to attain by discovery what is new — may fitly be placed before the young medical man, as objects not merely comjiatible with the practical duties of his profession, but as even aiding their more entire fulfilment. Few indeed possess the means requisite to command fame or success in such pursuits. But CONCLUDING REMARKS. 615 the objects tliemselves need not, and ought not, to be alien to any condition of medical life ; and the endeavour to attain them, to whatever extent it may in each case be possible, will ever form the best guarantee for the just and honourable discharge of professional duty. THE END. London t A. and G. A. Spottiswoooe, New-street- Square. UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. iKUidED LID. 3 1 58 00373 0693