i».ii:^L'iU/\i^ LEC'i'URiiS AND CLiNlCAL APHORISMS SAMUEL JONES GEE OXFORD MEDlCAl PUBLICATION aiatmU Mttioeraitg ffitbtarg Stiiaca, Jfem ^orb BOUGHT WITH THE INCOME OF THE SAGE ENDOWMENT FUND THE G[FT OF HENRY W. SAGE 1891 ^'imuiSLmmZtl '"<• aphorisms- olin,anx 3 1924 031 268 075 Cornell University Library The original of tliis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924031268075 ii>miK See note p. 352. 184 THE SIGNS OF the peritoneum alone whicli brings forth the pain? The skin also is tender, and is sometimes tender to the gentlest touch. In bygone days I have attempted to shave the head of a patient suffering from acute meningitis and have been compelled to desist on account of exquisite tenderness of the scalp. No question of pressure upon the membranes of the brain can arise under such conditions. Indeed, tenderness of the skin is apt to follow great pain of any under- lying part. I have already remarked that simple colic may be accompanied by great tenderness on pressure. And I commend the consideration of these facts to those who find a difficulty in believing that leeches or blisters applied to the skin can possibly affect a deeply seated part with which the skin has no obvious connexion. ii. Meteorism. — Leaving the topic of pain, I now pass on to the other local signs of peritonitis, namely meteorism and ileus. The pain is in great part intestinal, meteorism and ileus are wholly such. The pain is in great part due to intestinal spasm, meteorism and ileus are due to intestinal paralysis. The hollow viscera with muscular coats are the only viscera ACUTE PERITONEAL DISEASES 185 which are directly affected by the peritoneal inflam- mation, and this affection takes the form of spasm or paralysis. Patients with peritonitis are often unable to pass their water; whether from paralysis of the bladder, or from inability to start the reflex act, may be open to question ; the latter is probably the more usual cause. But about the intestinal paralysis there can be no doubt. It manifests itself in its earlier and slighter degree by meteorism or acute flatulent disten- sion of the bowels. I do not speak of that peritoneal meteorism which is due to the escape of air into the peritoneal cavity in consequence of rupture of some part of the alimentary canal, but of that intestinal meteorism only which is secondary to peritonitis. In- testinal paralysis is no longer a matter of inference : abdominal section nowadays often gives surgeons the opportunity of seeing how intestines which, when first exposed, were in active movement, afterwards become exhausted, and lie limp and motionless. This intestinal paralysis is not continual or not universal, for in patients whose abdominal walls are thin, vermicular movements of the intestines, either spontaneous or pro- duced by handling the belly, can be seen sometimes in 186 THE SIGNS OF spite of very great meteorism. But this is an exception to the rule : usually no intestinal movements can be. seen, and probably none occur, or else they are too weak to show themselves. So we may suppose that the flatulent distension is due partly to relaxation of the intestinal walls and partly to weak peristaltic movement insufficient to pass the wind onwards, a condition closely resembling constipation. This torpid meteorism, I just remark in passing, may be attended by great and constant pain ; a fact which seems to show that the pain of peritonitis is duo not altogether to colic, or painful intestinal contractions, but partly to the inflamed peritoneum itself. Another proof that the intestines are not so utterly paralysed as might at first seem likely, or that the large intestine at any rate escapes, is afforded by the fact that natural defaecation, or even diarrhoea, will accompany acute peritonitis. This was so in the epidemic disease which caused the death of Dr. Francis Anstie. Fifty-two girls in the Royal Patriotic School at Wandsworth were attacked, within one week, by a disease characterized by two main symptoms, namely, by lipothymia with coldness and lividity of ACUTE PERITONEAL DISEASES 187 the face and limbs, and by great pain in the belly, which was tender also to the lightest touch. Four children died, and dissection of the bodies revealed peritonitis. One fatal case suffered from diarrhoea with rice-water stools, and was examined by Dr. Anstie. He pricked his finger, and died six days afterwards. A remarkably similar epidemic which occurred in a charity school for girls at Edinburgh, called the Merchants' Hospital, is described by Aber- crombie. Peritonitis, by itself, would probably always be attended by the constipation of paralysed intestine : and surgeons note great constipation in cases of peritonitis following abdominal section. When diar- rhoea concurs, modern doctrine would lead us to infer the coexistence of an infection of the intestinal mucous membrane, especially that of the colon. iii. Ileus. — A higher degree of intestinal paralysis is marked by the state called ileus : a word which has been sufficiently constant in its meaning from the earliest times. It denotes disorder of an intestinal function, namely of the peristaltic function, and implies inability on the part of the intestine to propel its contents. The kind of ileus which concerns 188 THE SIGNS OF us here is that which is due to inflammation of the intestines, or enteritis. I have akeady remarked that the term enteritis originally meant an inflammation of the peritoneal coat of the bowels. It was Broussais who most unwarrantably perverted the meaning of the word, and who used it to signify an inflammation of the mucous membrane of the intestines : one out of many instances showing the degree to which cor- ruption of our technical terms has been earned. They who continue to use the word enteritis in its original sense do no worse than follow the example of Pember- ton, Abercrombie, Graves, and Watson. For those who desire a name to express inflammation of the intestinal mucous membrane, the terms eso-enteritis, muco-enteritis, enteritis mucosa have been invented. The sign of ileus is vomiting becoming faecal. The Father of physic has well described the course of events ; the matters vomited being first mucous, after- wards bilious, and lastly faecal. Until the vomit become faecal, or at least porraceous (meaning thereby an appearance like chopped grass or spinach), it is impossible to afiirm the existence of ileus. The con- currence of constipation is no help : and indeed,, on ACUTE PERITONEAL DISEASES 189 the other hand, faecal vomiting may be attended by the evacuation of small loose stools, resembling in colour and other respects the pale, uniform, pasty intestinal contents found in cases of mechanical obstruction. iv. Incision. — So that pain and the signs of intes- tinal pajralysis are the only evidences of acute peri- tonitis. It were much to be wished that the disease afforded physical signs such as are usually present in chronic peritonitis. There is, however, a surgical sign of the disease, a sign truly pathognomonic, which we must not hesitate to elicit when a patient's life is in jeopardy, and when accurate diagnosis is essential to rational treatment : I refer to direct observation of the state of the peritoneum as rendered possible by incision through the abdominal walls (p. 313). U, Universal Symptoms. — Let us now pass on to consider the remote or universal effects of peritonitis. i. And ffi'st of Fever. No symptom more uncertain than this : the temperature being sometimes high and reaching 105° or more ; usually but moderately raised ; whilst in other cases there may be no fever at all, so far at least as can be judged by a thermometer in the mouth or axilla. This apyrexia is a remark- 190 THE SIGNS OF able symptom when present, as it sometimes is, from first to last in peritonitis the most intense and fatal. We are tempted to speculate upon the cause of so strange a phenomenon ; whether an ordinary febrific poison be not produced by the inflammation, or whether an extraordinary febrifuge poison be pro- duced : at present we cannot do more than note the fact. Apyrexia sometimes becomes algidity ; an im- portant sign of the lipothymial state, to which I shall soon refer. ii. Putridity. — More certainly due to an infection of the blood are the putrid or septic symptoms which sometimes happen. When we bear in mind what Bichat pointed out, that the peritoneal cavity is a lymphatic sac with a most extensive absorbing surface and an extraordinary power of absorption, the wonder is that these symptoms do not occur often er. I will illustrate this form of disease by the case of a young man who was running along the street and got a heavy fall, which was the only dis- coverable cause for the acute peritonitis that occurred within forty-eight hours. Delirium and diarrhoea were associated with the abdominal pain and vomiting ACUTE PEEITONEAL DISEASES 191 of the first few days. On the sixth day he complained chiefly of pain in his joints : his feet and one shoulder were swollen and excessively tender. The skin over the feet, wrists, and ankles was red in patches. His urine was highly albuminousj but no blood corpuscles or casts were found in the sediment. The diarrhoea continued : he lay in a state of typho-mania, that is, of delirium with consciousness much impaired: he had a greater tendency to chills and occasional shiver- ing than is usually met with in cases of peritonitis ; the temperature varied between 102° and 105° until a few hours before death, which occun-ed on the eighth day. At the post-mortem examination nothing was found but peritonitis and its results; its cause was not found. iii. Idpothymia. I will next speak of that marked failure of the vital functions (that is to say, of the circulation, respiration, and body-heat) which very often accompanies peritonitis. It is a matter for surprise and regret that we have no term in common use to express this set of symptoms. No English word being precise enough, I suggest that we resusci- tate the Greek word, ' lipothymia,' to denote defectio 192 THE SIGNS OF animae, this failure of the vital constitution ; -whether it be attended or not by lipopsychia, defectio animi, or failure of the animal functions, marked by coma, delirium, or both. Sudden lipothymia is syncope or swooning; syncope due to injury is shock. Lipo- thymia is manifested by a small, weak, and sometimes irregular pulse, by weakness of the heart-sounds, by shallow breathing, by lividity with pallor (deathly paleness), and by algidity or failure of the body- heat, at least so far as the skin is concerned; the inner heat, as measured in the rectum, may or may not fail to a proportionate degree. In peritonitis (apart from perforation) lipothymia sometimes marks the whole course of the disease (witness the Wands- worth epidemic to which I referred a short time since) : and when to lividity, coldness of skin, and a weak small pulse, are added diarrhoea with watery stools and suppression of urine, the resemblance to cholera is great indeed. But more frequently lipo- thymia occurs only towards the end of life ; and then it may assume, as far as the body-heat is concerned, the form of lipyria (another ancient word which might be revived with advantage), that is to say, while the ACUTE PERITONEAL DISEASES 193 skin, especially of the limbs, is quite cold, the tempera- ture of the inward parts, as measured by a thermo- meter in the rectum, is much above the normal, it may be 105°, a very bad prognostic sign in all acute diseases, and a plain proof of extreme weakness of the circulation. Another sign which sometimes attends this final lipothymia, this mortal agony or struggle with death, a sign which has attracted the notice of physicians from the earliest times, is the disappearance of pain and suffering whilst the patient remains perfectly conscious: yet all the symptoms of vital failure persist; and he only, whose attention is fixed upon the local signs to the neglect of the prognostic con- dition of the whole patient, can be surprised by what will seem to him to be a sudden and unexpected death. It were curious to inquire into the causes of this cessation of pain, whether it be due to cessation of cramp, whether an anodyne poison be produced in the course of the disease, whether the lipothymia arrest the nutrition of the nerve-endings, or whether the sensorium for pain be similarly affected. Still more remarkable, although much Jess common, 194 THE SIGNS OF is the case of peritonitis attacking a healthy person, lipothymia supervening in the course of a few hours from the beginning, and any local signs of abdominal disease disappearing at the same time. The patient, when first seen, makes little or no complaint of the abdomen, it is not swollen and can be pressed deeply without causing pain. But the skin is cold, the heart beats very frequently, no pulse can be felt at the wrist, the respirations are very frequent, the secretion of urine is suppressed. The mind is aflPected little or much. The patient dies on the first or second day of illness : at the post-mortem examina- tion, acute peritonitis is found, but not necessarily perforation of the peritoneum, or disease of any other abdominal structure. Fades. — The last sign of acute peritonitis which I shall notice is that aflforded by the look and expres- sion of the face. These signs and such as these, which constitute the prognostics so much trusted by the earlier physicians, can be learnt in no other way than by a long familiarity with disease. If I allude to the countenance which still goes by the name of facies Hippocratica, it is only to remark that Laennec ACUTE PERITONEAL DISEASES 195 has endeavoured to walk in the footsteps of his great predecessor, and to depict an expression of face often seen in peritonitis and other severe abdominal diseases. This peculiar look, which he calls 'face grippde', is due chiefly, if not wholly, to the features being drawn upwards, so that the forehead is more or less wrinkled, and the naso-labial furrows are drawn inwards and upwards towards the root of the nose and inner canthi of the eyes. I have compared Laennec's verbal picture with the living patient, and have found it to be true to nature : but not universally true, not present in every case of acute peritonitis. Indeed I think that the face grippde denotes abdominal pain, and that it usually disappears with the pain, although the disease continue. But we must admit that the local suflEering and local signs of disease may be very small, and yet the onset of peritonitis be denoted by a profound change in the expression of the patient's features. Surgeons remark this change when an operation is followed by peritonitis : physicians also when a perforation occurs in the course of typhoid fever. Latent Peritonitis. — Now a few words concerning 02 196 THE SIGNS OF latent peritonitis. I have already spoken of peri- tonitis which is latent in respect of its local signs only ; peritonitis in which universal signs of disease, those namely, of alarming lipothymia, predominate to the exclusion of abdominal symptoms : the patient being killed in a day or two as if by the operation of a powerful venom. But peritonitis may be altogether latent, and manifested neither by local nor by universal symptoms : a form which is deuteropathic, intercurrent in the course of other serious disease such as ascites, renal dropsy, empyema, pyaemia, or typhoid fever; the peritoneal inflammation being revealed by the post- mortem examination only. What surprise we may feel at this latency diminishes when we reflect that the signs of peritonitis have little or no relation to the peritoneum, but depend upon disorder of other viscera, adjacent or remote. Suppose the onset to be marked by vomiting : what is there distinctive in this : in what disease does vomiting not occur : is not the stomach the great sympathizer with distress in any part of the body ? Add some pain in the belly and how does this help us ? Possessing no direct physical signs of peritonitis, and being compelled to rely upon ACUTE PERITONEAL DISEASES 197 indirect disturbance of the functions of other viscera (for the peritoneum itself has no manifest functions), we carmot expect to discover the presence of peritonitis in cases such as these. Types. — After analysing the symptoms of peritonitis I might endeavour to arrange them so as to form concrete pictures of patients suffering from that disease : but I will say no more than this, that according as one or other symptom prevails so does the appearance of cases of peritonitis differ ; and the differences are so great that we have to admit divers forms or types of the disease. We cannot manage with fewer types than three, namely, peritonitis characterized by paiu, or by ileus, or by lipothymia : for peritonitis discovered only after death cannot be admitted to be a form of disease as looked at from my present point of view. A given case of peritonitis is by no means necessarily constant to one type through- out : for instance, painful peritonitis may pass into ileus : and moreover the local and universal symptoms may be variously mixed. But the only reason I have for referring to facts so obvious is to be assisted by these types in comparing the signs of acute peri- 198 THE SIGNS OF tonitis with the signs of other peritoneal affections : which I wiU now proceed to do. i. Chronic Peritonitis. — Peritonitis which is essenti- ally chronic in its course, sometimes sets in suddenly, and thus resembles at first the acute disease. This is often observed in the commonest kind of chronic peritonitis, the tubercular: when, as I suppose, a sudden infection of the peritoneum takes place. The forms assumed by this acute onset of tubercular peri- tonitis are the same as those I have just discussed. That most often met with begins with pain, vomiting, and sometimes diarrhoea, and is followed in a few days by meteorism which may become very great. Lipothymia in a high degree may attend the choleric symptoms. The least common type, which assumes the form of ileus, deserves especial notice on account of its close resemblance to mechanical obstruction of the bowels : a resemblance so close that abdominal section has been performed in such a case under the notion that the patient wa-s suffering from a strangu- lated hernia (see p. 168). il. Haemorrhage into the peritoneal sac is another form of peritoneal disease in which we meet with the ACUTE PERITONEAL DISEASES 199 same types. The painful form is well illustrated by the case of ' a woman, twenty-nine years old, who was brought to the hospital in a most alarming condition, although her iUness had not lasted longer than a few hours. She had been suddenly attacked by great pain in the lower belly, and the pain had steadily increased. She had the face grippde and was deadly wan : her breathing short and frequent, interrupted by hiccup, her pulse hurried and very weak, her belly distended and tender. She died within forty-eight hours from the beginning : at the post-mortem exami- nation, there were found in the peritoneal cavity nearly three pints of liquid blood which had come from one of the Fallopian tubes : no peritonitis.' How peritoneal haemorrhage may be attended by ileus is shown by the case of a man, twenty-two years old, who was admitted into St. Bartholomew's Hos- pital in an extreme state of shock, following a fall off the tail-board of a van in motion. He complained of great pain at the pit of the stomach, and soon after the injury he began to vomit incessantly. On the second day the vomiting continued to be very frequent: he had a great desiie to defaecate, but passed nothing: 200 THE SIGNS OF his belly was very hard and tender : the urine was suppressed : his temperature was 99-6°, On the third day he was worse : abdominal section was performed : the peritoneum was found to be full of dark liquid blood, and nothing more was discovered. On the fourth day he died : the blood came from a rent liver, iii. Perforation of the Peritoneum.— A much more common acute affection of the peritoneum is that which I mention in the last place, namely, perforation or rupture of the wall of a canal or cavity or hollow viscus, and escape of its irritant contents into the peritoneal sac. When we seek to classify cases of this kind, we come upon the three or four types of which I have already so often spoken : the type characterized by pain, or by ileus, or by shock, and the latent type. But before depicting them, let us ask whether peritoneal perforation yield any peculiar signs 1 None ; unless peritoneal tympanites ensue : and this depends, of course, upon the perforated cavity, whether it contain air or not. In the case of peritoneal tympanites, physical examination usually affords more or less probability of the presence of air in the peritoneal sac, but seldom an absolute certainty. ACUTE PERITONEAL DISEASES 201 The distension of the helly is often very great, and greater in perforation of the intestine than of the stomach : when the distension is very great, the skin is tense and shining to a degree seldom seen in in- testinal tympanites. Visible coils of intestine or vermicular movements are decisive evidence of in- testinal tympanites. Absence of the liver dullness to percussion is a useful, but not altogether a trust- worthy, sign of peritoneal tympanites : for, when the intestines are extremely distended with air, they may come to lie between the liver and abdominal wall in front, and I have known this to happen even when the liver was enlarged to twice its natural size. On the other hand, adhesion of the liver's convex surface will obviously prevent the disappearance of its per- cussion dullness, even though the peritoneal cavity be full of air. The signs afforded by auscultation are less important, because they are common to all great accumulations of air within the abdomen, whether contained in stomach or intestines, or free in the peritoneal cavity. The chief sign is the bell-sound discovered by Laennec. In his Auscultation MSdiate he says that by percussing lightly and at the same 203 THE SIGNS OF time applying the stethoscope near by, we shall hear a silvery resonance : clearer, he thinks, in peritoneal than in intestinal tympanites. I cannot do more than just mention the other auscultatory signs of a large air-containing cavity, and which are sometimes present in peritoneal tympanites, namely, an amphoric quality in the respiratory sounds heard over the abdomen, metallic tinklej and succession splash. A valuable sign is yielded sometimes by an escape of air into the cellular membrane of the abdominal walls: this fact also is alluded to by Laennec (' a sort of dry crackling is felt upon pressure ' he says), and is, taken together with the signs aforesaid, peculiar to peritoneal tympanites as contrasted with the intestinal. Or the subcutaneous emphysema may be still more extensive. To conclude this topic of physical signs I will remark that, although their presence is a great help to diagnosis, their absence proves nothing. Perforation of a part of the alimentary canal (for instance the appendix vermiformis) may occur, may be followed by acutest peritonitis, and yet may be unaccompanied by peritoneal tympanites: nothing escapes from the rupture but offensive and poisonous pus. ACUTE PERITONEAL DISEASES 203 With respect to the symptoms of peritoneal per- foration, aU cases may be referred to the four types so often spoken of, those characterized by pain, or by ileus, or by shock, and those not characterized at all, the disease being latent ; latent, that is to say, so far as concerns the diagnosis. o. First, of perforation characterized chiefly by Pain. A lady had ailed for some time from pain in the stomach and the side, but she seemed to be other- wise in good health. One day after dinner, she complained several times of pain : she drank some succory water as a stomachic, and putting the cup down with one hand, with the other pressed her side, and said in a voice which betokened much suffering : ' Ha ! what a stitch in the side ; what pain ; I cannot bear it.' Speaking these words she flushed, and, a moment afterwards, turned pale with a wan lividity which alarmed everybody. She kept crying out, and begged to be carried away, for she could no longer hold up. Supported by the arms of others, she managed to walk, but with difficulty and bent double. Put to bed, she cried out more than ever that the pain in the pit of her stomach was past belief : she tossed 204 THE SIGNS OF from side to side. A physician was fetched who pro- nounced her complaint to be colic, and who prescribed suitable remedies. But the pain continued ; she said that her suffering was greater than could be conceived, and that she would die. All this occurred in less than half an hour. Whatever she swallowed made her retch : she brought up only a little mucus mixed with food. The efforts to vomit and the excessive pain threw her into a state of exhaustion which resembled repose : but she told the bystanders not to deceive themselves, that the pain was as great as ever, and that she had no strength left to cry out. She heard some one remark that she was easier, and she said: ' That is so far from being true that were I not a Christian I would kill myself, so great are my sufferings : it is wrong to wish evil to any,' she added, ' yet I would that somebody could feel for a moment what I feel, so as to know what my pain is like.' Her pulse became imperceptible, her, limbs cold : her friends anxiously asked if nothing more could be done ; they suggested a score of remedies, and at last, her physicians, in sheer desperation, made an attempt to bleed her, but the blood would not flow. They ACUTE PERITONEAL DISEASES 205 gave her some broth, for she had taken no food since dinner : she no sooner swallowed it than her sufferings (if not her pain) increased : she complained that her stomach was filling up : death was depicted on her face : the last struggle was short, and after two or three convulsive movements about her mouth, she died nine hours from the beginning of her illness. Would you not suppose that I have set before you a living picture in words, taken from the pages of a modern Aretaeus or of Sir Thomas Watson; or have you already recognized that I have been reading an account of the last hours of King Charles the First's daughter, Henrietta, Duchess of Orleans ? An account written by one of her ladies in waiting, Madame de la Fayette, a hundred and fifty years before ulcer of the stomach was discovered, so we may say, by Cruveilhier. That the patient died from perforation of such an ulcer was proved by examina- tion post mortem, although her physicians did not understand what they saw, and it was left for Littr^ to explain the real nature of her illness. I have always thought that reports of the kind just read, drawn up at the bedside by persons of keen intelli- 206 THE SIGNS OF gence but with no medical knowledge, are of great value. Such reports are true to nature, for the reporters have no preconceived notions which dis- colour and distort the appearances of things. More- over these observers see the sufferer and nothing else : but we physicians, on the other hand, in our eagerness to discover abstract signs of disease, and to arrange them into that wholly artificial notion which we call the diagnosis, are apt to overlook the patient. The physicians of Madame said that she was suffer- ing from colic, and that a wretched pulse and cold limbs, such as hers, were common in that disease. I likewise have stood by a patient writhing under the throes consequent upon perforation of stomach or duodenum, and have asked myself whether there was anything either in the pain or its concomitants which might not occur in intestinal colic, and have been compelled to admit that there was nothing. This difficulty in diagnosis is not to be wondered at if the pain be, as is very likely, in some part due to cramp or painful spasm of the intestines and stomach, and perhaps of the abdominal walls also. Yet our diagnosis may reach a high degree of ACUTE PERITONEAL DISEASES 207 probability under such conditions as these : — the ruptured organ being more often either stomach or duodenum than any other, there may have been some forewarning symptoms of ulcer of one of those parts : the perforation occurring suddenly, so does the pain, and especially after a full meal or an effort or both. The very acid contents of the stomach or upper half of the duodenum poured into the peritoneal cavity are excessively irritant, and the pain is violent in propor- tion, being far beyond the pain whereof the sufferer has had any experience or conception. The abdominal walls are contracted, tight, and hard, and often very tender. The pain will continue without remission to the end, or will cease altogether, or will only diminish ; as I said when speaking of acute peritonitis. The associated symptoms may or may not assist the diagnosis. Vomiting, often present, is sometimes absent : some have thought that it is absent in perforation of the stomach especially, but the excep- tions to this rule, if it be a rule, are many and of both kinds, namely, rupture of stomach attended by vomiting, and rupture of a part not stomach yet unattended by vomiting. Peritoneal tympanites will 208 THE SIGNS OF ensue if gas escape into the abdominal cavity ; but gas does not always escape even when some part of the alimentary canal is ruptured. Shock attends the rupture, and usually the lipothymia persists to the end. When perforation occurs in the course of a febrile disease, defervescence is often a marked sign of shock. Suppression of the secretion of urine is common and seems to be sufficiently explained by the vomiting and the lipothymia, and their necessary consequences, defective absorption and secretion. /3. The second kind of perforation, that characterized by Ileus, is less common, and occurs especially in disease of the appendix vermiformis. The discharge of virulent offensive matter into the peritoneal sac seems to stun the intestines, they neither feel nor move. A woman, aged twenty-two years, was ad- mitted into St. Bartholomew's Hospital on March 8. She had taken, on the 5th, jalap and castor oil to relieve her habitual constipation : the bowels acted soon afterwards three times. Otherwise she was, so she and her friends averred, in perfect health, and quite free from pain or indications of disease in the abdomen or elsewhere. Her menses, due on the 5th, ACUTE PERITONEAL DISEASES 209 did not appear. On the 6th vomiting began, and it continued at intervals up to the time of admission. The bowels had not acted. She was admitted on the evening of the 8th, and one of my surgical colleagues, who happened to be at the hospital at the time, came straight to my house and told me that a woman with obstruction of the bowels had just been sent in to be under my care, and he thought that the question of operation arose. We went to see her, and we found a woman with no look of suffering, with a warm skin, a temperature of 99-2° in the armpit, and with no symptoms of failure of the vital functions, unless indicated by a pulse of 144, which was however by no means weak or small. The abdomen was fat and moderately distended, the muscles were tight, but there was no tenderness excepting about the right loin : the right iliac fossa was carefully examined, but nothing could be felt. Examinations per vaginam, per anum, and for hernia detected nothing wrong. An enema had brought away faeces. She vomited dark green liquid without smell. The urine was scanty, it contained a trace of albumen, was turbid with scaly epithelium and highly granular cylinders 210 THE SIGNS OF like renal tube casts, but there were no exudation corpuscles. The abdomen was opened : thin purulent liquid escaped, the small intestines were distended and purplish brown in colour. Examining the appendix vermiformis, we found a sloughy hole at its insertion into the caecum : the rest of the appendix much dilated, its lining membrane ulcerated and granular throughout, the outer surface covered with lymph. She died two or three hours after the operation. Nowhere any anatomical obstruction of the bowels. Between this form of disease and painful febrile peritonitis there are all possible varieties in respect of association of symptoms : the ileus being attended by more or less pain, tenderness and fever. Peritoneal tympanites is often absent : any distension of the abdomen being due to acutest peritonitis, to intestinal tympanites and inflammatory liquid effusion. y. The third kind of perforation is characterized by Shock. In some cases, particularly in rupture of the stomach or duodenum, the shock kills within a few hours ; and may be justly compared to the effect of a blow upon the pit of the stomach : though why the ACUTE PEEITONEAL DISEASES 211 shock of abdominal injury should be so especially profound, I will not undertake to explain. In other cases the patient lives a day or two, yet never rallies. A man, forty years of age, who was under treatment for a chronic ulcer of the stomach, became suddenly, at eight o'clock one morning, pale, pulseless and delirious (see page 192) ; he had evidently undergone a great shock. Throughout the day he continued to be delirious, consciousness never fully returned. Con- siderable reaction took place, his skin became hot, his pulse full and frequent ; he retched a little but did not vomit. The same night he became comatose, and so died at eight o'clock next morning. I regret being unable to say whether the urine was suppressed or not. On examining the body, the ulcer was found to involve the pylorus, and to have perforated on the duodenal side thereof. The contents of the stomach were in the peritoneal cavity : but there were no signs of peritonitis, neither excessive vascularity nor exudation of lymph. S. Lastly, the perforation may be Latent: that is to say, unattended by any symptoms adequate to the diagnosis. Not that symptoms are utterly wanting; p 2 212 THE SIGNS OF this is seldom the case ; there are more or fewer of those so often mentioned, pain, vomiting, lipothymia, and the rest, but they are rendered obscure by occur- ring in the course of a disease marked by no less serious disorders. The contrast between a person when in good health and when sufltering from per- foration of the peritoneum is great indeed : but when a patient has been exhausted by four or five weeks of severe typhoid fever, the occurrence of perforation may be a comparative trifle, so far as symptoms are concerned : a little pain in the belly, a little vomiting attracts no attention. Or there may be no pain, no tenderness, no vomiting, nothing but a sudden defer- vescence. Or again, a change in the patient's look is sometimes the chief sign. During a state of typho- mania, in particular, the gravest intercurrent lesions often happen unsuspected. But perforation, latent so far as symptoms are con- cerned, will sometimes yield one or more of the physical signs of peritoneal tympanites. For instance, in the later stage of typhoid fever, a rapid and great distension of the belly, such as to stretch the skin and make it shine, and attended by disappearance of the ACUTE PERITONEAL DISEASES 213 liver dullness to percussion, is a tolerably trustworthy token of intestinal perforation, and is sometimes the only token. The liver dullness may disappear before the abdomen becomes distended. Incision for the purpose of diagnosis. To conclude by referring once more to puncture of the peritoneum as a means for ascertaining the presence of inflam- matory effusion, of gas, or of chyme. An incision is justified whenever the patient affords more or less trustworthy indications of acute peritonitis, and es- pecially when there are reasons for believing that perforation of the peritoneum has occurred. Unless we can bring relief, the patient will probably die. An incision will not make him worse ; the only objection lies in the natural dislike to an operation, however small. I wish I could believe that chloro- form-sleep did no harm, but I fear that this drug has a depressing effect upon persons suffering from acute peritonitis. However, suppose a small incision made, and we find that the peritoneum contains pus^ or air, or chyme, or blood, further operation now becomes a means of treatment which affords the patient the only chance of life. 214 XIV SECTS IN MEDICINE ^ The subject of my address is ' Sects in Medicine '. I shall endeavour to make the following propositions clear unto you : That inasmuch as medicine is a part of philosophy, the sects in both are essentially the same. That these sects depend upon the original constitution of the human understanding, upon its native powers and weaknesses. And that inasmuch as the powers of the human understanding seem to be precisely the same now as they were when philosophy began, we may expect and we shall find that the sects are essentially the same in our time as they were in the early days of medicine. The existence of sects implies difierences of opinion, and differences of opinion imply imperfection of know- ledge. There are no differences of opinion concerning '■ Bead before the Aberuethian Sooiety on Juue 20, 1889. SECTS IN PHILOSOPHY 215 Euclid's propositions, the truth of his definitions and axioms being granted. Where knowledge is most imperfect, there are sects most numerous. I said just now that medicine is a part of philo- sophy, and philosophy is full of sects, which are not even agreed upon the meaning of the word philosophy. The Stoics meant thereby the whole of knowledge ; they divided it into six partitions : physics and theology, logic and rhetoric, ethics and politics. This is the sense in which Francis Bacon uses the word. But the great English school which is represented by Lord Herbert, Hobbes, Locke, Berkeley, and Hume, defines philosophy to be the theory of knowledge ; in other words, philosophy explains wherein knowledge consists, explores the conditions of knowledge, and thus refers chiefly to man himself. A third school, which is represented by the Eleatics among the ancients, and by Spinoza among the moderns, deems philosophy to be ' the search for reality and unity, the efibrt of thought to gain a point of view from which the contrasts expressed by the teiins One and Many, Universal and Particular, Infinite and Finite, God and Nature, shall be reconciled and harmonized'; 216 SECTS IN MEDICINE that is to say, philosophy is the theory of the cosmos, the universe. Man is a part of nature, therefore the knowledge of man is a part of the knowledge which the Greeks called physical (or natural) philosophy. I stop for a moment to point out that this is the reason why we are called physicians, for the knowledge of the human body is the most useful part of physics. Again, man is the most complex, most abstruse, and least under- stood part of nature. No wonder then that the science of man is overrun by opinions, by sects, by heresies, far more than infest any other part of natural philo- sophy. The same remark holds true of medicine, as being part of the science of man. To speak now of medicine in particular, I say that it necessarily partakes of the diverse opinions which inhere in philosophy. Now, the primary and funda- mental philosophic sects are two, the Dogmatic and the Sceptic. Dogmatists affirm that we can and do know ; sceptics neither affirm nor deny. Observe, sceptics do not deny, else they would be dogmatists ; a strict sceptic cannot even affirm that he neither affirms nor denies ; he cannot go beyond the question, PRIMARY SECTS 217 ' What know I ? ' But practically sceptics are deniers, and systematic scepticism (such as that of Sextus Empiricus) is full of dogmatism. In short, there are no absolute dogmatists or sceptics, and the truest way of putting the matter is to say that dogmatists tend towards affirmation, and sceptics towards doubt. These two sects exist and always have existed in medicine. Every man is born with a natural bend towards one or the other. A very little thinking will convince you that dogmatism may assume an infinite number of forms, whereas strict scepticism can assume only one form, so that all that I have to say will relate to different kinds and degrees of dogmatism. Moreover, I have already hinted that I shall base my remarks upon the medical sects which existed in the ancient world. For the powers and limits of human thought remain exactly what they were in the time of Thales, and nature mocks, nay she punishes, any effort to transcend them. The ancient sects exhaust all possible fundamental differences of opinion, and inasmuch as the story of the ancient world is completed and we can survey it from afar, we can comprehend it better than the world in which 218 SECTS IN MEDICINE we live. These ancient sects are reproduced in modern times. My object is to illustrate the sects of our own day, and I shall refer to ancient sects for this purpose only. I say that all sects are dogmatical, generally speak- ing, but one sect was called especially Dogmatic ; the other sects had other names. I will speak of the species Dogmatism in the first place. The Dogmatist seeks to understand what disease is ; he compiles systems of medicine, in which he sets forth the aetio- logy, anatomy, and physiology of diseases, in order that from these pathological data he may deduce indi- cations for treatment. In other words, his practice of medicine is reasoned from his theory of disease; he aims at a rational thei'apeutics. To translate the words of Celsus, ' They who profess rational medicine hold it to be necessary that we should know, first, the hidden yet essential causes of disease ; next, the causes which are manifest; after these the natural actions (of the body, to wit, human physiology) ; and lastly, the internal parts (or anatomy).' Did you ask me to give an instance of this form of dogmatism, I could call to mind no more recent name than that of Boer- DOGMATISM 219 haave, one of the most successful teachers that ever lived. From him proceeded not only Gaubius and the succeeding lights of the Leyden school, but also van Swieten, De Haen and the great Vienna school, and above all, HaUer. No doubt his personal appear- ance, his jovial temper, and his eloquence did much, but the main element of his success lay in the fact that he had a system. Students were not repelled by a sceptic standing at the very door, but all things seemed clear and easy. His pupils' interest and attention were roused, and what more was needed ? Even if the system were wrong, what matter? It served as an excellent cement of facts for the common class of men, whilst the Hallers were able, if they cared, to invent systems of their own. So far as I know, nobody has propounded a comprehensive dogmatic system for many years past. The reason seems to be that such a system requii-es the science systematized to be at a standstill, not to say dead. Knowledge in a ferment, expanding on all sides so much and so rapidly as during the past hundred years, must speedily burst the old bottle of any dogmatic system, 220 SECTS IN MEDICINE But another species of dogmatism, a form which is called Methodism, is far from being extinct. This sect is a revolt against the infinite multiplicity of the dogmatism which I have already discussed, and seeks for some simple principle which underlies all these innumerable particulars, and from which they may be deduced. Methodists are those dogmatists who strive to make the data of pathology and therapeutics as few as possible in number, and as universal as possible in extent. The dogmatist builds his system upon the greatest possible number of particulars ; the methodist erects his inverted pyramid upon a single proposition. The reason of methodism lies in the weakness of the human mind, impatient of slow pro- gress towards a goal which recedes as we go on, and wishing to find a royal road by which the end may be attained without passing through the necessary intermediate stages. There have been methodists in medicine from the earliest times. One of the most ancient medical books which we possess is directed against a methodical sect. I refer to the Hippocratic treatise On Ancient Medicine, written about 400 years before Christ. METHODISM 221 ' They who, having undertaken to speak or write upon medicine, have first laid down a hypothesis for themselves, are clearly mistaken in much that they say ' : bo opens this venerable document. The author then goes on to affirm that in medicine there is no need for any hypothesis, inasmuch as medical knowledge is gained by observation of particular matters of fact. He proceeds to illustrate this doc- trine, and then attacks the hypothesis from which some methodists of his day sought to deduce the science of medicine. This hypothesis is no other than the ancient dogma — That hot, cold, moist and dry, four Champions fierce. Strive here for Maistrie, and to Battel bring Thir embryon Atoms, 'For hot or cold, or moist or dry is that which becomes injurious to man, and he who would treat a sick person properly must apply cold to the hot, hot to the cold, moist to the dry, and dry to the moist.' Well may the Hippocratic writer say that ' he cannot think in what manner those who advance this doc- trine, and transfer the art from experience to hypothesis, will cure men according to the principle which they 222 SECTS IN MEDICINE have laid down '. But alas ! my friends, this severe critic of hypotheses has a hypothesis of his own, else he would he hardly human. He rejects the dogma of the four primary qualities, and sets up in its place the dogma of humours. The famous humoral pathology appears here in its earliest form. ' All the complaints to which man is subject arise from the powers,' which he explains to be ' intense and strong juices '. He does not enumerate these juices, but his hypothesis soon assumed the form under which the humoral pathology governed the world for so many years, and indeed we may say still governs it. When a man is called san- guine, melancholy, or phlegmatic ; when a patient complains of a bilious headache ; when we speak of being in a good humour or a bad humour, we use terms which are a survival of the undying humoral pathology. Celsus tells us that the name of Methodist was first given to a sect which was founded by Themison about a hundred years before Christ. But I have no intention of recalling the doctrines of that sect, nor those of the many methodic sects which have arisen in more modem times, have shone brightly for a time, HOMOEOPATHY 223 and have set for ever. I will illustrate methodism by tlie greatest living instance thereof, Homoeopathy. But I think that it has not yet lived long enough to enable us to discuss its doctrines in a spirit of impartial historical criticism. Time is the final critic in such matters. The violent opposition which homoeopathy aroused when first promulgated can be easily understood. In the first place it broke utterly with medical tradition, and attempted a revolution in our department of knowledge like that which the French had just attempted in politics. Homoeopathy thus became what is worse than a sect, a schism ; we may difier from our fellow men, we need not quarrel with them. Again, homoeopathy was burdened with an article of faith which seemed to be contradicted by the common sense, or common prejudice, of mankind. I allude to the doctrine of infinitesimal doses. To believe that a millionth part of a grain of charcoal or flint could possibly have any effect for good or for evil upon the human body, would seem to require a con- stitution of mind like his who exclaimed ' I know a thing to be sure and certain because it is impossible '. 224 SECTS IN MEDICINE Yet the human mind is naturally pleased by the won- derfulj and especially by the wonderful in medicine. I often meet with these expressions in books which appear to be written seriously, that a certain drug acts like a charm, or like magic. I suppose we must give to persons who write thus the credit of not meaning what they say. But that which makes homoeopathy to be a methodism is the dogma or war-cry contained in the proposition that like things are cured by like things. Proceeding to discuss this assertion, let me point out in the first place that the method peculiar to homoeo- pathy relates to pharmaceutics only. Homoeopathy has nothing to say to pathology, accepts it as it stands or ignores it; nor can I remember any addition made to pathological science by a homoeopathist : a fact remarkable when we bear in mind the gi-eat progress which pathology has made during the past century. Moreover, homoeopathy does not touch the most important parts of therapeutics. And here allow me to make a digression which will, I hope, be of use in clearing the ideas of some of my hearers. Our art relates to persons in health, to persons in THERAPEUTICS 235 disease, and to persons who are in a neutral position, as it were, between health and disease, that is to say, to healthy persons exposed to disease. With regard to healthy people, our art teaches how to preserve them so, and this is Hygienics, With regard to sick people, our art teaches how they may recover their health, and this is Therapeutics. Lastly, our art teaches healthy people, who are exposed to disease, how they may escape it, and this is Prophylactics. Now, with reference to therapeutics in particulai", I hope that nobody here thinks that it means the administration of drugs only. Therapeutics is a Greek word which answers to the Latin medicina or curatio, the treatment or cure of disease. And therapeutics consists of three parts; first. Dietetics or the management of the ordinary conditions of life for the patient, his food and drink, his clothing, his exercise and rest, his sleeping and waking, the air he breathes, his evacuations, and so forth. Next, Pharmaceutics or the use of drugs. And lastly. Surgery, Chirurgery, which includes whatever you do for the patient with your hands. Beginners sometimes ask wherein consists the distinction 226 SECTS IN MEDICINE between medicine and surgery ; they might as well ask wherein consists the distinction between Wales and Great Britain : surgery is a part of medicine. To return to homoeopathy : I say that its method does not touch the most important parts of thera- peutics, namely, dietetics and surgery ; and that homoeopathy is a doctrine of pharmaceutics only. Its formula, that like things are to be cured by like things, requires expansion before it can be discussed. What are the things compared and said to resemble each other 1 Doubtless the disturbance produced by a disease, and the disturbance produced by a drug administered to a healthy man. And the universal homoeopathic method of pharmaceutics is to give to a patient suflfering from a certain disease that drug whose operation upon the healthy body most closely resembles the disease. This dogma is intelligible enough ; the only question is whether it be true. No reasoning for or against the proposition is of any avail; no dialectics after the Socratic fashion as to the meaning of the words disease and similarity will help us ; experience alone must decide. Appealing to experience, we must admit that some drugs do HOMOEOPATHY 227 good homoeopathically. I find, for instance, that small doses of arsenic will often check vomiting, and that small doses of castor- oil are a good remedy for diarrhoea. Homoeopathy does not profess to explain how these results are brought about; it applies its criterion, an inexplicable criterion if you please, and such experiences as I have mentioned tally with the rule. But now I have to go further, and to point out that, from a few particular instances in which drugs may be fairly said to act according to the homoeopathic canon, the universal proposition is deduced that homoeopathy is the only rule of pharma- ceutic practice. Let us see what experience has to say to this exclusive and intolerant dogma. And I will begin by the remark that in all matters of natural philosophy I distrust universal propositions. I agree with Baglivi that nature is more subtle than the most subtle philosophy. I approve of the saying of Celsus, that the medical art knows of hardly any precepts capable of universal application. And coming to particular instances, my experience tells me that very few indeed of the most useful drugs act homoeopathically. I believe that our patients Q 2 228 SECTS IN MEDICINE derive much good from salicylate of soda and iodide of potassium and iron and quinine and bromide of potassium and mercury and digitalis, and aperients and astringents and alkalies and anodynes, and very many drugs which do not act homoeopathically. Indeed, for my own part I would repeat my convic- tion that very few of the most useful drugs can be deemed homoeopathic in any sense of the word. The English mind is averse from methodism, both in philosophy and in medicine. None of the famous methodic systems have sprung up in England. Van Helmont and Stahl, Brown and Broussais, were not English. It probably was not an accident that homoeopathy arose in Germany in the high and palmy days of the transcendental philosophy, spin- ning the web of its sophistry from some such universal terms as substance or being ; mere words : for 'words are the only universals, and there is nothing universal but words ' (Hobbes). I now pass on to consider another, yet similar, form of dogmatism which is characterized by the tendency to overrate the extent and import of a favourite dogma. The cause of this form of dogma- PNEUMATISM 229 tism lies in the small capacity of the human mind, unable to accommodate more than one thought at a time, and apt to see all things through the medium of this thought. Which thought becomes a dogma, very likely to be true so far as it goes : the fault lies in making it exclusive ; for other dogmas, indeed an infinitude of other dogmas, are no less true. This fault is the source of innumerable sects and heresies. In ancient times the Pneumatic sect stands forth as an instance of the form of dogmatism now under notice. The pneumatista were so called because of the great (unduly great) stress which they laid upon the doctrine of the pneuma or animal spirits. Let me remind you that when any one speaks of being in good or bad spirits, in high or low spirits, he uses terms which imply the dogma of the pneu- matists. It would be easy, and wearisome, to accumulate instances of this logical fault of overrating a favourite notion : idols of the cave, to use Bacon's figurative language. Such an idol has syphilis been to many pathologists, who have seen all diseases through a syphilitic fog. A few years ago an able French 230 SECTS IN MEDICINE physician propounded the doctrine that rickets was a form of inherited syphilis ; bat observe, a foundling hospital in Paris was the field of his labours. His generalization was probably correct so far as his data went; but his experience related to a very narrow field ; had he looked farther abroad, had he examined puppies as well as babies, he would have found that his opinion was exclusive, intolerant, and therefore wrong — a heresy, in short. Gout is another idol with strange power to make the mental vision dim. Leaving pathology, I will draw an instance of this fallacy from therapeutics, and will speak of the sect of physiological pharmaceutists, or, as we will call them for shortness, Pharmacologists. This sect is at least as old as the days of Thomas Willis, who wrote in the reign of Charles II a remarkable treatise entitled ' Pharmaceutice Rationalis, or an Exercitation of the operations of medicaments upon human bodies'. The doctrine of the pharmacological sect is as follows : Pathology is a part of physiology ; the laws of the internal actions, or functions, of the human body are PHARMACOLOGY 231 the same both in health and in disease, although the conditions under which these actions proceed are different in the two cases. Ascertain the manner in which the healthy body is affected by a di'ug, or, in other words, discover its physiological action, and you have a principle to guide you to the use of the drug in disease. Given a disorder of a certain function of the body, called a disease; this disorder can be combated by the appropriate drug. Up to this point the pharmacologists walk hand in hand with homoeo- pathists ; but at the next step they part company. They disagree upon two topics. In the first place, the homoeopathists content themselves with giving a drug to a healthy man and watching the result; they pay gi-eat attention to the effects of a drug given in poisonous doses. The pharmacologists aim at pro- founder knowledge than this, and rely chiefly upon vivisection as a means of attaining this knowledge. But supposing that a knowledge of the physiological working of a drug is attained one way or the other, the pharmacologists and homoeopathists differ utterly upon the principle which should guide us in the use of that drug in disease. The pharmacologists are 233 SECTS IN MEDICINE antipathists ; they argue in this manner : given, for instance, a disease in which the contractions of the heart are too frequent, and given a drug which can lessen the frequency of these contractions, administer the given drug in a case of the given disease, and the contractions of the heart will be reduced to or towards the normal. I need hardly say that the homoeo- pathists argue in quite another manner ; they apply their maxim of like curing like, concerning which I have already spoken. Nor have I time to discuss the doctrine by means of which some have sought to compose the strife between these contradictory sects : I refer to the theorem that the action of a drug given in small doses is the exact opposite of its action when given in large doses. If a homoeopathist employ small doses upon this principle he is obviously an antipathist in disguise. To return to the pharmacologists : I say, in the first place, that physiology owes much more to medicine than medicine does to physiology. Nature and surgeons perform vivisections for us. The greater and better part of what we know concerning the functions of many organs of the body, is derived from PHAEMACOLOGY 233 pathological observation and not from physiological experiment. Large tracts of physiology are regions unexplored. What more important operation can there be than the conversion of food into blood? And yet how little can physiology say for certain about the process! Some years ago a gentleman brought his daughter to see me on account of en- larged glands in the neck. Whilst I was prescribing the treatment, he suddenly asked me what was the use of the said glands. I at once called to mind the story they tell of Razes, who became blind in his old age. At first he thought of having his eyes operated upon, and he consulted a surgeon for that purpose. But when he found that the sui'geon could not tell him how many tunicles the eye possesses, Razes re- considered his intention and threw it up. Yet I believe that I gave my patient good and useful advice concerning the treatment of her disease, although I must confess that I felt painfully ignorant of the functions of lymphatic glands. When the greatest of discoveries in physiology had been made, namely, the circulation of the blood, thoughtful men were surprised to find that no corresponding improvement 234 SECTS IN MEDICINE in medical treatment followed.^ So little do thera- peutics depend upon physiology. Again, physiological pharmaceutics deal with nothing but the manifestations of disease, its signs and symptoms ; which yield important indications for treatment no doubt, but which constitute by no means the only or the most important guides to therapeutics. Many of our most valuable drugs are specific, that is to say, they seem to act directly upon the more original and occult effects of the disease, which escape our anatomy and physiology ; unless it be that these specific remedies act directly upon the specific cause of the disease, which seems not always to be the case, at least in the sense of destroying or nullifying the cause : they modify or alter its action in some way unknown, and therefore are sometimes called altera- tives. Again it is not possible to predict from the opera- tion of a drug upon a healthy body what the efiect ' 'Doctor Harvey gave the first credit, if not rise, to the opinion about the circulation of the blood, which was expected to bring in great and general innovations into the whole practice of physic, but it has had no such effect.' Sir William Temple : Of Health and Long Life ; written about 1680. PHARMACOLOGY 235 will be upon a diseased body, simply because the conditions are not the same in both cases. Obviously no experiments upon the healthy could discover that iodide of potassium is a remedy for some forms of syphilis. Lastly, physiological experiment has hitherto con- tributed little to practical therapeutics. Indeed, its indications have been more often erroneous than not. The conditions- of disease are very complex, and require much more than such physiology as ours to make them understood. Bordeu tells an amusing tale which will serve to wind up what I have said about the dogmatists who aim at a rational system of medicine. Chirac saw a patient with three of his medical brethren, whose master he deemed himself to be; for Chirac, liks Thessalus, the Roman physician, loved to be called the conqueror of physicians. The patient, for eight- and-twenty days and more bad subsisted upon chicken tea and barley water only. He was hungry, but waited a long time before he durst say so ; at last, compelled by necessity, he imparted the fact to one of his physicians who seemed the least to agree with 236 SECTS IN MEDICINE the severe and terrible method of Chirac. Chirac, hearing of his patient's wishes, and seeing that the other physicians were disposed to relax the treat- ment so far that one of them would allow a little mashed sweetbread, anotherj two spoonfuls of soup, and the third, the yolk of an egg, — Chirac, after mature deliberation, declared that the patient might take some broth, seasoned with two pinches of parsley. To such lengths will dogmatism and rationalism and credulity go. I come now to the Empiric sect, much less dog- matic than any of the sects I have mentioned hitherto. This is the sect towards which I myself have the most kindly feeling, being led thereto, no doubt, by the hand of nature. In Celsus you will find a critical account of ancient empiric doctrines ; indeed the treatise of Celsus himself is an admirable instance of empiric medicine. If you ask me for a modern author thoroughly empirical, I give you the honoured name of Heberden. But what characterizes empiricism? It relates to therapeutics only ; and an empirical physician argues thus : My patient is suffering from such and such a disease ; I treat him in such and such EMPIEICISM. 237 a manner, because my past experience of patients atfected with this disease has convinced me that the mode of treatment which I adopt is the best I know of. I have no oUier reason for treating him in this way. What better reason than experience would you have ? No one feels more deeply than I the truth of the aphorism of the Father of Medicine that ex- perience is fallacious and judgement difficult; but this is a part of human frailty, and we have no better guide. In particular you must not ask me much concerning the manner in which drugs act ; I do not know how iodide of potassium does good in syphilis, and if you were to undertake to tell me, I could not believe you in the present state of our knowledge. Is this to despise knowledge ? On the contrary my only wish is that, in so serious an affair as medicine, my knowledge should be true. It is my bounden duty, and I desire nothing more than to increase my knowledge on all hands, and thereby to attain the ancient aspiration of our hospital, ' to bring health or ease to my poor patients.' I like the tale which Plutarch tells of ' one that cavilled upon a time with Captaine Iphiorates, and by way of reproach and 238 SECTS IN MEDICINE minding to prove that he was of no reckoning, de- manded what he was ? For (quoth he) you are not a man at armes, nor archer, nor targetter. I am not indeed, I confesse (quoth Iphicrates), but I am he who command aU these, and employ them as occasion serveth.' In like manner the empirical physician says, I am ready to accept help from any source, from physi- ology and pharmacology, but also from mechanics, optics and similar sciences, from bacteriology, electricity and chemistry, nay very gratefully from cookery, up- holstery, ironmongery, and indeed from any source. The method of empiricism begins by compiling a history of diseases, the result of the most assiduous, minute, and complete observation and examination possible of sick people. These particular facts are classified so as to constitute more universal types of disease, which serve as a standard of reference. Bear- ing these types in mind, the empiric proceeds to examine a patient, no less minutely and completely ; this is the autopsy. And this done, the patient's disorder is referred to that generic type of disease which it more or less closely resembles; this is the analogy or diagnosis : a most important affair for the EMPIRICISM 239 empiric, inasmuch as his line of treatment depends thereon. So that the empiric would almost agree ■with him who exclaimed that the fii-st part of treat- ment is diagnosis, and the second diagnosis, and the third diagnosis. After the diagnosis comes the fourth and therapeutic stage of the method, in which lies the essence of empiricism, namely this argument : Because my patient's disorder corresponds with such a type, therefore the treatment is such as experience has shown to be suitable in that form of disease. ' This was the method of Heraclides Tarentinus, the most famous of empirical physicians, who, according to Galen, never said anything that was not true, not even on behalf of his sect, and who recommended nothing which he himself had not tried ' (Bordeu), You will have discerned the faults of empiricism. In the first place, it is ' arena sine calce,' or, as we may say, bricks without mortar. It consists of in- dividual truths with nothing to make them adhere, no hypothesis to hold them together. The empiric is essentially asystematic, he writes aphoristically, he is the ant which gathers facts but does not transmute them. Another great fault of the empiric is this, that 240 SECTS IN MEDICINE in his eager search for knowledge which he sees to be immediately useful^ he overlooks much, the usefulness of which does not at once appear. Not loving know- ledge for its own sake, preferring fruit to light, he meets with an appropriate punishment, his harvests are scanty. Well for him that all physicians are not empirics. You will rejoice when I tell you, my friends, that I have now come to the last sect which I shall mention, the sect which most closely approaches scepticism ; I refer to the Expectants. The fundamental principle of this sect is a truth which is full of consolation for both patients and physicians, to wit, that many of our disorders spontaneously tend to recovery. Our body, which turns external things, food, drink, and air, into means of its own preservation, can likewise overcome the noxious influence of disease. The maxim of the expectants is that more diseases are cured by patience than by drugs, and that it is better to stand still than to go on groping in the dark. Contrast with this the dogmatic maxim that a doubtful remedy is better than none at all. The method of Hippocrates, which was largely expectant, was deemed by Asclepiades, a stout EXPECTANCY 241 methodist, to be little better than meditation upon death. But an expectant physician will reply, in the words of Bordeu : ' Methinks I hear nature cry aloud, Be not too officious with your help ; leave the business to me : 'tis I and not your drugs that work the cure. When to you I seem to be most stormy, I myself can best save myself, if you have not robbed me of my powers. Far better to cast all your care upon me than to try doubtful remedies. Behold the true catholicum, the panacea sought for by all the sects.' Bordeu tells us that Stahl, in his old age, was so deeply convinced of nature's power to control disease and of the uselessness of drugs, that he came to order nothing, for all sorts of disorders and diseases, more than a few grains of sea salt. And now that we have reached what would seem to be the extreme limits of scepticism, let me point out to you that the greatest sceptics do much for their patients, and that all these doubts and all these sects relate to drugs and to hardly anything but drugs. They are the cause of our disputes and our differences. We agree, for the most part, upon the principles of hygienics and prophylactics and speaking of therapeutics proper, there are no sceptics 243 SECTS IN MEDICINE in dietetics and surgery. It is pharmaceutics which is the weak point of medicine, and which will pro- bably always be its weak point. And yet it is that, unfortunately, upon which the mind of the laity is most strongly set. The fault of the expectants is the old fault of mankind : they carry things too far ; their principle is true, but not the whole truth. Drugs are often of little use ; drugs may be given so as to be baneful ; this we may confess, and yet refuse to go to the length of affirming that drugs are never of any use. Small as our knowledge of pharmaceutics is compared to what we would wish it to be, yet men have taken more than two thousand years to accumulate that knowledge, and whoever would cast it away as worthless, because it is so imperfect, could not be deemed wise. Drugs are of use, sometimes they are of great use ; and all honour to those who seek for more knowledge in this part also of medicine, its most difficult, most backward, and most disputed part. 243 XV CLINICAL APHORISMS COLLECTED BT DH. THOMAS J. HORDEB ' II faut voir, toujours voir, des malades. Ces matSriaux confua, que I'on amasse sans ordre et sans m^thode, sent pourtant d'excellents maWriaux; inutiles aujourd'hui, vous les retrouverez plus tard enfouis dans les tr^sors de vofcre mSmoire.' — Tkousseau. I. — 01" SOME PULMONABY PHYSICAL SIGNS 1. No other terms convey any information about the breathing sounds than those in the following table : — i. Ordinary. Vesicular. ■ ii. Weak. ,iii. Loud (= Puerile). i. Ordinary. ii. Bronchial. - ii. Cavernous. \ (iii. Amphoric. which correspond with no definite physical condition of lung, make a show of profound R 2 Breathing may be Distinctions, 244 CLINICAL APHORISMS and accurate knowledge, but really obscure it. They are idola theatri. 2. Intense bronchial breathing is rightly called cavernous because in most instances it indicates cavity. Hence the condition is present in (i) tuber- culous disease, (ii) dilatation of the air-tubes in emphysema, or (iii) cirrhosis of the lung, with dilated air-tubes. The co-existence of dullness would exclude (ii), much sputum would suggest (i), and discovery of tubercle bacilli would confirm it. 3. The screaming of young children rather helps than hinders auscultation of their lungs, for we thus obtain the signs afforded by deep inspiration and vocal resonance, and especially bronchophony which is often the most important sign of pneumonia. 4. In pleural effusion there is sometimes hardly any breathing sound to be heard, and sometimes there is loud bronchial breathing. If we accept the view that the breath-sounds are all produced at the glottis, then, bearing in mind that both solid lung and fluid are good conductors of sound, we shall rather wonder that the sign of bronchial breathing is not always met with in these cases. CLINICAL APHORISMS 245 5. ' Consonating rale,' termed ' cavernous rale ' by Laennec — a bad namej because it implied that the sound was always produced in a cavity — indicates that the rale is produced either near consolidated lung-tissue or in a cavity. 6. Children are sometimes thought to be the subjects of pulmonary phthisis when post-mortem examination shows no tubercles, but only cirrhosed lung and dilated air-tubes. 7. There is no disease of the chest in which the signs are more distinctive than in pneumo-thorax, and yet there is no disease which is more often overlooked. The observer, finding the percussion- tone natural, assumes that the respiratory organs are natui-al. II.— OF PHTHISIS 8. Phthisis at the bases of the lungs is not un- common, but its existence is sometimes overlooked because the apices alone have been examined. 9. In any case of phthisis the disease is more extensive than the physical signs would seem to indicate. 246 CLINICAL APHORISMS 10. Most cases of confirmed phthisis progress more rapidly, and terminate sooner, than is expected. If physical signs are present, the probabilities are against complete recovery ; but if the disease is detected before this, there is hope that it may be cured. 11. Before the appearance of physical signs it is the presence of some or all of the following facts which leads to a diagnosis — haemoptysis, cough, loss of flesh and colour, slight rise of temperature, and hereditary liability to the disease ; but above all, detection of tubercle bacilli in the sputa. 12. Therapeutics must begin before physical signs have developed ; for if you wait for physical signs, you wait too long. 13. Always say three things to a patient whom you suspect to be phthisical — (i) Get yourself weighed — by the same machine each time — to see if you are losing weight. (ii) Use a thermometer two or three times each evening to see if there is any fever. (iii) Save your sputa to be tested (for bacilli). If, besides auscultation and percussion, these three CLINICAL APHORISMS 247 points give negative results, you may infer there is no phthisis. 14. Never give a definite opinion as to how long a patient suffering from phthisis will live ; for the only certainty is, that if you do, you will be wrong. 15. Almost every chronic affection of the apex of the lung is tubercular in origin. 16. Phthisis may begin as bronchitis, as pneumonia, as pleurisy with or without effusion, as pneumo- thorax ; and in either case the beginning may be sudden. If. Tubercular phthisis, going on to the formation of cavities, is not extremely uncommon even in infants under a year old. 18. The diagnosis of phthisis is peculiarly difficult in young children, because their expectoration can seldom be obtained. 19. The absence of physical signs of disease, in some cases of slowly progressive pulmonary consumption, ending in death, is most remarkable. III. — OF HAEMOPTYSIS 20. The commonest cause of haemoptysis is phthisis ; 248 CLINICAL APHORISMS the next commonest cause is disease of the heart, which leads to congestion or to embolic infarction of the lungs. 21. When blood is brought up, if the sputa are themselves bloody, the blood has come from the lungs. 23. Fatal haemorrhage from the lungs is fluor sanguinis : a large quantity of unmixed blood gushes up, and the patient dies from loss of blood or from suffocation, before any remedies can be used. In the usual case of spviwrn sanguinis, in which blood mixed with mucus is coughed up sputum by sputum, the patient seldom dies, however abundant the bleeding. 23. Haemoptysis sometimes occurs, on and off, for many years — all through life, it might almost be said. In these cases, it probably is due to the presence of a small cavity, often not larger than a cherry, and giving no physical signs on examination of the chest. 24. Haemoptysis during an attack of asthma with bronchitis may be very great, and yet not dangerous. 25. Haemoptysis is not uncommon at the beginning of an attack of pleurisy with effusion; it is then probably due to collapse and congestion of the lung. CLINICAL APHORISMS 249 26. In a young man an attack of haemoptysis is quite sufficient indication for treating him for phthisis. It is not so in the case of a young woman. Women bleed much more easily than men, so that considerable importance should be attached to the question of sex. Again, in the case of a young man, it is not necessary that the sputa should be wholly coloured by blood ; a few streaks of blood, like threads of scarlet silk, are sufficiently characteristic. 27. The treatment of haemoptysis by drugs is not very satisfactory. The best drug is ipecacuanha in emetic doses ; but it should be reserved for the more serious cases. Gallic acid, though given in sufficiently large doses to produce a green colouration of the sputa, thus proving it to have reached the affected region, does not stay the haemoptysis. Ergotin seems sometimes to be of use, but at other times con- spicuously fails. Opium is of value here as it is in all cases of haemorrhage. But the patient who was wont to treat his own attacks of haemoptysis by ' going to bed, sucking ice, and feeding on milk', summed up the main points of treatment. 250 CLINICAL APHORISMS IV. — OF BRONCHITIS AND EMPHYSEMA 28. An ordinary case of bronchitis is not febrile for more than a week or so. Later than this the tem- perature becomes a valuable sign in diagnosing the disease from phthisis or scattered tubercle. 29. Collapse of a large part of lung occurs in children from very slight causes ; especially pul- monary catarxh. Hence when signs of consolidation are found in a young child we must always remember that they are possibly due to collapse. 30. I have satisfied myself that bronchi tic signs may be wholly restricted to one lung, and the con- dition still be mere bronchitis. But when this is the case, there is always the suspicion that something worse is at the bottom of the condition — i. e. tubercle. 31. There are no more potent causes of chronic bronchitis than alcohol and tobacco. 32. Diarrhoea setting in spontaneously in a case of bronchitis relieves the pulmonary complaint ; but do not attempt to imitate nature by inducing diarrhoea in treating a case of bronchitis, for purgation does no good. 33. Chronic bronchitis and emphysema may simi- labe asthma in the character of the dyspnoea, the CLINICAL APHORISMS 251 attitude of the patient, &c. When this is so, it may- be of use to try anti-asthmatic remedies. 34. Progressive bronchitis, or emphysema, or asthma, whichsoever opens the scene, the final result is much the same. 35. Contrary to what might be expected, operations upon small gangrenous cavities of the lung arc some- times attended by good results. v.— OF STINKING EXPEOTOEA.TION 36. The causes of stinking expectoration are five — (i) empyema ; (ii) gangrene of the lung ; (iii) phthisis ; (iv) diseased bronchial tubes ; (v) abscess of the bronchial glands, opening into the air-tubes. (i) The physical signs in a case of expectoration of an empyema are often very slight, because (a) the cavity is small and deep-seated, or (6) the cavity contains air, (ii) Usually only a small piece of lung is afiected. It is not necessarily fatal. One may often get good specimens of lung tissue from the sputa in these cases. (iii) In those cases where the cavity contains a small slough, or where the wall of the cavity itself 252 CLINICAL APHOKISMS sloughs, both the cavity and the slough may be very small. (iv) Here we have two varieties : — {a) Where the tubes are dilated, and the secretions putrefy in them : a condition which may be present in cirrhosis of the lung. (6) Where the secretions of bronchitis putrefy in undilated tubes. (v) A rare condition, and difficult of diagnosis. VI. — OF PLEUEISY AND EMPYEMA 37. It is safe to say that pleurisy is always due to infection by microbes. Nevertheless, it would be wrong to deny the influence of injury, exposure, or local cold as determining causes of an attack. 38. Tubercle is the commonest cause of a clear serous effusion. Cases occur where, on drawing off the fluid, advanced phthisis is discovered, with the existence of cavities in the lung, the detection of which was quite impossible before the tapping. More- over, many cases of serous pleural effusion end fatally within ten years from tuberculosis. Again, tuber- culous peritonitis is so often recovered from, that probably tuberculous pleuritis is also recovered from, CLINICAL APHORISMS 253 cases never proved to be tuberculous having really been so. 39. Vomiting is an almost invariable symptom at the onset of pleurisy in children. Haemoptysis is not uncommon in both children and adults. 40. Temperature is no guide to the nature of a pleural effusion, whether serous or purulent. Neither is the duration of the eflfusion. But rigor and a discharge from the ear, if associated, probably point to an effusion being purulent. 41. A large heart may so press upon the root of the left lung as to produce coUapse of its lower lobe. Such a condition can be distinguished from pleural effusion only by the needle. The symptoms which attend an effusion occurring in such circumstances are more often than not left unrelieved by tapping. 42. Solid tumours of the chest and pleurisy with effusion give much the same physical signs ; but the former do not displace viscera (e. g. the heart), whereas the latter does. 43. In the presence of a pleural effusion the co- existence of a pericardial effusion cannot be made out by physical examination of the chest. Post- 254 CLINICAL APHORISMS mortem, many unsuspected pericardial effusions are continually being discovered. 44. Blood-stained pleural effusion, though at one time supposed to be diagnostic of malignant disease of the lung, is not really so ; for it occurs in some cases which rapidly recover, and, on the other band, it is absent in some well-marked cases of cancer, the effusion being quite free from blood. 45. Serous pleural effusion so often clears up, that it is a good rule to wait a week or ten days before proceeding to paracentesis, unless the quantity of the effusion is large, such as nearly to fill the pleura. 46. Evacuate a very abundant pleural effusion as soon as you find it out, for it sometimes leads to sudden heart failure (lipothymia) and death within an hour or two. 47. Serous effusions do not tend to become puru- lent. In the great majority of instances purulent effusions are purulent from the beginning, and serous effusions remain serous throughout. In rare cases, an effusion which is purulent at first may be found to be serous at a later paracentesis. CLINICAL APHOEISMS 255 48. Those cases of pleurisy where one suspects tubercle as the cause clear up quite as quickly as others, if not more so. 49. You never know what may be at the bottom of a pleural effusion, especially when chronic. Often the treatment adopted is based upon the assumption that the condition is one of simple pleurisy, whereas one of several complications may be present (e. g. an aneurysm of the aorta), which render evacuation of the fluid dangerous. 50. In passive pleural effusions, such as the hydro- thorax of Bright's disease or heart disease, evacuation of the fluid does not give much relief. If the distress is gi"eat, however, it should be. done for what little relief does follow. (See Aph. 41.) 51. The chronicity of a pleural effusion affects the prognosis in a similar way, because the tendency is great for the chest to refill almost as soon as it is emptied in cases of long-standing effusion. 52. Paracentesis of the chest has been known to cause fatal haemoptysis on the spot, as in a case where it was due to the rupture of a minute aneurysm situated in a small phthisical cavity of the lung. 256 CLINICAL APHOEISMS 53. There are three signs for desisting from the aspiration of a pleural effusion : cough, pain in the chest, and staining of the fluid by blood. The cough- ing which is induced during a paracentesis is probably due to oedema of the lung, set up by the returning blood-stream ; this pi'oduces exudation, and, when the coughing is considerable, serous sputa containing much albumen are the result, involving a risk of death from suffocation, 54. I was wont to think that empyema confined to an apex of the lung did not occur, and that I could therefore exclude empyema as a cause of dullness in this region ; but I have since seen a case. 55. The microbe in the empyema of children is usually the pneumococcus ; in that of adults it is usually streptococcus. Hence, perhaps, the better prognosis in the former class of patients. 56. Empyema is seldom allowed to rupture spon- taneously nowadays ; but if this does occur, the commonest situation on the left side is at the point where the normal apex-beat of the heart is felt. 57. A small amount of most offensive-smelling pus may be drawn off by aspiration from the pleura, and CLINICAL APHORISMS 357 no further operation be required for the condition to clear up. If the amount present, however, is con- siderable, the chance of recovery without drainage is small. The foetor may be accounted for by the proximity of the oesophagus. 58. There is risk in puncturing a hydatid of the lung, even with a fine needle, and for the purpose of diagnosis only. Aspiration is full of risk. VII. — OF PNEUMONIA 59. Pneumonia is not a local, but a universal disease; and the brunt of it may fall upon any part — lungs, endocardium, membranes of the brain, intestines, kidneys. 60. Acute pneumonia in children often runs a short course, the crisis appearing sometimes on the fourth or fifth day, or even earlier, 61. Pneumonia may be a cause of otorrhoea ; in such cases the pneumococcus is abundantly found in the pus from the ear. 62. The way in which pneumonia clears up depends much upon the state of health the patient was in when attacked. In men who drink hard, the period 258 CLINICAL APHORISMS of resolution may be long. If evidence of consolida- tion of the lung be found after six weeks, the char- acter of the consolidation is the same as it would be at the end of one week — i.e. hepatisation. At the end of several months, however, it would be of the nature of fibrous induration. 63. The mortality from pneumonia in patients who drink hard is high, and one reason is to be found in the fact that alcoholism predisposes to delirium. 64. So many and so great are the uncertainties in the course of a case of pneumonia that a prudent man will not attempt to predict the end, as to recovery or death. Many patients, who for days show no un- favourable symptoms, die: some patients, who look as if they could not survive, recover, 65. Pneumonia is sometimes a cause of sudden and unexpected death in people going about their busi- ness, as if there were nothing the matter with them. VIII. — OF DISEASES OF THE HEAKT AND PERICARDIUM 66. In hospital practice, disease of the valves of the heart: in private practice, disease of its nerves and muscular tissues. In the end, both forms of disease CLINICAL APHORISMS 259 approximate each other: valvular disease leads to affections of the muscular walls, nervo-muscular disease leads to dilatation of the cavities and val- vular orifices. In the senile heart, both conditions are often associated from the first, although the valvular degeneration may afford no physical signs even throughout the whole course of the disease. 67. Affections of the muscular tissue of the heart are usually more serious than those of its fibrous tissue (e.g. the valves), but afford much less definite physical signs, and therefore are less easily discovered. A beginner can hear murmurs and detect valvular diseases ; but it requires long experience to appreciate nervous and muscular affections of the heart. 68. If more than one valvular lesion be present in a heart, it often happens that not more than one is diagnosed. One of the commonest combina- tions is that of mitral stenosis with aortic insuffi- ciency, and then the development of the typical aortic diastolic murmur may be considerably interfered with. 69. Those valvular diseases of the heart which yield the most peculiar and characteristic symptoms S 2 260 CLINICAL APHOKISMS are, aortic regurgitation, mitral constriction, and tricuspid regurgitation. The other forms of valvular disease are less significant or less common. 70. Dilatation of the left ventricle may occur in a heart having mitral obstruction. This seems con- trary to theory, but cardiac dilatation cannot be wholly explained by a consideration of pressure- effects. The amount of dilatation in the case above- mentioned is sometimes astonishing. 71. There is no kind of valvular disease of the heart which may not produce a thrill. 72. Mitral disease causes lividity by interfering with the circulation of the blood, bronchitis by inter- fering with its aeration, and emphysema in both ways. 73. Jerking pulse, capillary pulsation, visible pul- sation and twisting of the arteries, though all useful signs of aortic regurgitation, are none of them patho- gnomonic. Each may occur without the presence of any valvular lesion, and in old people they are often due to arterial degeneration. Jerking pulse is common in atheroma of the aortic arch. 74. Venous pulse in the superficial veins of the arms or hands, however, must be regarded as a more CLINICAL APHORISMS 261 conclusive sign of aortic regurgitation, for it only occurs in the course of that disease, and perhaps in a few cases of extreme debility. 75. A rarer sign but one which is pathognomonic of aortic regurgitation, is conduction of the diastolic murmur into the large arteries, such as the femorals, over which vessels it is heard on auscultation, without using pressure by the stethoscope. In these cases the murmur is shrill. 7Q. Ulcerative endocarditis may produce quotidian fever some weeks before the appearance of physical signs on auscultation of the heart. 77. Very great dilatation of the heai't is commoner in children than in adults, and may be produced more rapidly ; in a few weeks even. 78. Signs afforded by the jugular veins are as useful indications in disease of the right heart as are signs afforded by the arteries in diseases of the left. 79. In the discovery of adherent pericardium we seldom get farther than a guess. 80. Pericardial effusion, even when not abundant, is sometimes a cause of sudden unexpected death. 81. Pericarditis is not so common now as formerly; 262 CLINICAL APHORISMS a fact which must be attributed to the use of sodium salicylate in the treatment of rheumatic fever. Endo- carditis, however, seems as common as ever: for it occurs before the patients come under treatment. 82. In cases of erythema you should always examine the heart, for pericarditis is sometimes found without any other rheumatic symptoms. 83. Pericarditis is common in Bright's disease, but is not often detected ante-mortem. 84. In pericarditis the friction sound may remain, in spite of a considerable liquid effusion. 85. Dropsy, lividity, scanty urine, and weak ir- regular pulse — these are the four symptoms which, taken together, indicate the use of digitalis, without regard to the nature of the heart-lesion producing them. On the other hand, the use of digitalis is not indicated by finding on examination that the heart is dilated, the above symptoms being absent. 86. Orthopnoea is usually a sign of heart disease ; even if the lungs be afifected in the first place. 87. Leaning forward in bed : a sign of disease of the pericardium, aorta, or mediastinum, or of a very large heart. CLINICAL APHORISMS 263 88. In cases of heart disease we should investigate first the symptoms afforded by the attitude of the patient in bed, by the colour of the lips and cheeks, by the pulse, by the jugular veins, or by dropsy, before proceeding to physical examination. For this reason books written before the discovery of auscul- tation (such as the treatise of Corvisart) are worth reading, if only to show how much the physicians of that day could find out apart from the help of physical signs. Symptoms and not physical signs guide our prognosis and treatment. IX. — OF DISEASES OF THE BLOOD AND BLOOD-VESSELS 89. It does not seem proven that what is called 'pernicious anaemia' is a definite disease. Cases so diagnosed often turn out on post-mortem examination to be cancer undiscoverable during life. 90. True leucaemia is rare in children. I have seen two cases, and hardly expect to see another. The term 'leucaemia' is ill defined; its use should be restricted to those cases in which the number of white blood-cells almost equals the number of red 264 CLINICAL APHORISMS and used in tlus way it may be said that cases of leucaemia never recover, though they may rally for a time. 91. In contradistinction from true leucaemia is that disease of young children in whom the spleen is enlarged — sometimes reaching the right iliac fossa — and in whom there are anaemia, bleeding from the gums, and a liability to bruising. Here, however, the prognosis is not necessarily bad, for the cases often recover. (See page 162.) 93. You should never see anaemia in a young woman without thinking of phthisis as a possible cause. 93. It is often a question, when called to treat a young woman suffering from dyspepsia and anaemia, whether the dyspepsia be due to the anaemia, or vice versa. To cure the indigestion will sometimes cure the anaemia: to cure chlorosis will cure attendent gastralgia. 94. There are cases of permanent anaemia in which the blood-forming faculty, wherever that resides, is feeble, and we cannot stimulate it. A single haemor- rhage may result in anaemia which lasts throughout CLINICAL APHORISMS 265 the i-est of life, as in the case of Paulina, the wife of Seneca, recorded by Tacitus. 95. Iron is not of much use in the anaemia of nephritis, or indeed in any form of anaemia but chlorosis, for which it is specific. 96. It is not uncommon for a patient to live after rupture externally of a thoracic aneurysm. Fainting after the first gush of blood tends to stay the flow, and the deposit of laminated fibrin protects from severe loss of blood afterwards. The presence of this fibrinous layer and its thickness or thinness are important points in determining the length of life in these cases. More common than actual rupture, however, is a process of gradual ulceration and leakage or oozing from the vessel. 97. Very copious epistaxis may be followed by dementia lasting for many months. X. — OF NEPHRITIS, ALBUMINDEIA, AND DROPSY 98. You win seldom be wrong if you consider all cases of nephritis not associated with some obvious specific disease, such as scarlet fever, diphtheria, pneumonia, &c., to be chronic. 266 CLINICAL APHORISMS 99. Quite apart from either diphtheria or scarlet fever, patients suffering from attacks of sore throat are liable to nephritis, which is of temporary duration, lasting as long as the quinsy. The urine is usually bloody in such cases. 100. It is not easy to distinguish with certainty between the varieties of nephritis during life ; much albumen and little urine may be found in a case of chronic interstitial nephritis. 101. Nothing cuts off the flow of urine bo much as persistent vomiting. This failure of urinary secretion may be so marked, that unless the cause be remembered, you may suspect suppression of urine. 103. Having excluded calculus and uric acid gravel, haematuria in people who are past middle life is most commonly due to granular kidneys. 103. Haematuria repeated at long intervals may be the only evidence of the existence of granular kidneys. (See page 3.) 104, Granular kidney may exist to a high degree without constant albuminuria. Moreover, in some cases no signs of cardiac hypertrophy can be made out. These cases usually terminate either by the CLINICAL APHOKISMS 267 development of the ordinary symptoms of Bright's disease, or by uraemia, or by the occurrence of cerebral haemorrhage. 105. Black hellebore and cantharides are the two most efficient drugs for arresting haematuria due to granular kidney. The latter drug, however, is a dangerous remedy, sometimes producing suppuration in the kidney, if carelessly used. 106. It is a mistake to suppose that early morning urine is best for testing for albumen; often it con- tains none, when that passed later in day contains a good deal. The same statement is true of sac- charine urine. 107. With valvular disease of the heart you can never tell at fii'st the significance of albuminuria: it may be transient and due to mere congestion of the kidneys. But if casts are found in the urine as well as albumen, this is an observation of more value, for it indicates the existence of disease of the kidneys. 108. An epileptic attack, like an apoplectic tit, may cause temporary albuminuria, 109. Travelling, and especially railway-travelling, produces temporary albuminuria in some people. 268 CLINICAL APHORISMS 110. Bad cases of chronic nephritis sometimes preserve a luddy complexion to the very end. 111. Sudden anasarca sometimes occurs in persons who have been the subjects of albuminuria without dropsy for a long time before. 112. Do not reduce the allowance of fluid food in dropsy ; it is bad practice, for anything is bad practice which reduces the amount of urine. For this reason, one of the best remedies for nephritis with scanty urine or with a tendency to uraemia, is whey. 113. Purgatives in dropsy are not of much use; the practice is a survival. If we cannot act upon the kidneys, we should do nothing to add to the patient's discomfort. XI. — OF GASTRIC ULCEE AND OAEDIALGIA 114. In chronic ulceration of the stomach, when the patient is young, it is generally a succession of ulcers you have to deal with; when the patient is old, it is generally one ulcer, which will not heal : a Chironian ulcer. 115. In young women a gastric ulcer which has been diagnosed seldom perforates. Perforation when CLINICAL APHORISMS 269 it takes place, is often the first definite symptom. Under treatment the risk of perforation is small. 116. Chronic gastric and duodenal ulcers are seldom to be distinguished clinically. ^ Duodenal ulcers only occur in the 'gastric' part of the duodenum, i.e. above the opening of the bile and pancreatic ducts, where the contents of the gut are still acid. 117. In chronic gastritis and gastric ulcer the pain is commensurate with the acidity of the stomach contents. It is owing to this fact that relief follows the act of vomiting. It is owing to the same fact that the pain usually comes on half an hour or so after food is taken. 118. The 'Carlsbad treatment' in cases of chronic gastritis is useful, though it has become of less im- portance since the introduction of the stomach-tube. It consists in the free use of alkalies and aperients. Carbonate of magnesium is a particularly useful drug, for it is a powei'ful antacid, and the soluble salts of magnesium are aperient, ensuring emptying of the stomach. No fermentible foods should be given in ' Since this opinion was expressed the diagnosis of duodenal ulcer has been improved. By consideration of the characters of the pain, its situation and its relation to taking food, we are often able to arrive at a correct opinion. 270 CLINICAL APHORISMS these cases ; but milk is an exception to this rule, for though it is fermentlble, experience shows it to be devoid of ill effects. 119. Washing out the stomach in cases of ulcer is not free from risk: I have known it cause fatal haematemesis. 120. Sub-diaphragmatic abscess occurring as a metastatic abscess (i.e. the result of pyaemia) must be very rare. Hence pyaemia (with a sub-diaphragm- atic abscess) is to be regarded as secondary to the abscess. 121. Cardialgia has been divided into two kinds, as it occurs in a full or in an empty stomach. The former depends upon excessive acidity (acrimony) of the contents of the stomach : the latter is neuralgia. The former kind requires careful feeding, so as to exclude articles of food prone to undergo acid fermen- tation : in the latter kind no special dieting is neces- sary. In the acid form alkalies (especially magnesia) are of great use : in the neuralgic form arsenic, can- nabis indica and nitro-glycerine. 122. Change of air and scene sometimes brings immediate relief in nervous cardialgia, when diet and drugs have failed. CLINICAL APHORISMS 271 123. Neuralgia and atonic dyspepsia (which is part of general weakness) are the only two common affections of the stomach in a young man who ia temperate in food and drink, XII.^OI" DIARRHOEA AND CONSTIPATION 124. In infantile cholera the temperature of the surface of the body may be as low as 97°, when that of the rectum is as high as 102°. 125. Many of those who are continually complain- ing of constipation, are suffering more from fear and hypochondria than from anything else. It is no law of nature that the bowels should be relieved punc- tually once in twenty-four hours. Some persons feel in better health when the bowels act only once in two or thi-ee days : free evacuations are followed by a sense of weakness. Patience and contentment with nature's operations are not the worst remedies for constipation. XIII. — OF ABDOMINAL TUMOURS 126. In physical examination by palpation, organs and tumours feel more superficial than they really are. 272 CLINICAL APHOKISMS 127. A renal tumour on the left side very often pushes the colon in front of it; but this condition is not found on the right side. 128. On palpation of the abdomen, in thin patients, the normal urachus can often be felt as a cord, stretching up from the bladder to the navel. In cases of malignant disease of the abdomen, the urachus often becomes infiltrated by the growth, and this band may then be felt thickened, and measuring as much as half an inch across. 129. In cases of malignant disease within the abdomen, it is not uncommon to find post-mortem a chain of enlarged lymphatic glands, stretching up the thorax on one or both sides, and appearing behind the clavicles. We may even be led to a correct diagnosis of malignant disease of the abdominal viscera by finding these glands. Thus, deep jaundice, obscure abdominal pain, but nothing abnormal felt in the abdomen itself, with hard glands behind the clavicle, would point to malignant disease of the head of the pancreas. Be this as it may, the dis- covery of these hard and enlarged glands is always most important. CLINICAL APHORISMS 273 130. The commonest seat of large faecal tumours is the caecum. Smaller tumours are common in the sigmoid flexure. Elsewhere faecal tumours are un- common. XIV. — OP DISEASES OP THE LIVER 131. Enlarged spleen may be the only evidence of cirrhosis of the liver. 132. Haematemesis in cirrhosis of the liver may be severe enough to cause very marked and prolonged anaemia, and may even be fatal. 133. There is a condition known as 'tympanitic ascites ', where the abdomen contains liquid but is everywhere resonant to percussion. Intestines will give resonance through a layer of liquid an inch thick. 134. Malignant disease of the liver may occur, and the patient gain weight for a time, under the benig- nant influence of hope : ' the only cheap and universal cure.' Indeed, a patient's gaining weight whilst under treatment does not exclude malignant disease of any organ. 274 CLINICAL APHORISMS XV.— OF JAUNDrCE 135. Fatal (or malignant) jaundice (icterus gravis) ia indistinguishable at first from ordinary simple jaundice. Let your prognosis be guarded in every case of recent jaundice until you have some little experience of the course that the disease is taking. 136. In jaundice the urine contains bilirubin before the skin or conjunctivae become tinged by it. More- over, urinary jaundice may be of very brief duration, and jaundice of the tissues never appear at aU. Iodine is a better test for the presence of bilirubin in the urine than is nitric acid. 137. A jaundiced skin may never wholly recover its natural colour in chronic cases, even when the cause of the jaundice is removed. 138. It is sometimes a good thing to let patients suffering from chronic jaundice due to a gall-stone take exercise. In this way the stone may be dis- lodged, a bad attack of colic ensue, and a spon- taneous cure be effected. 139. In women past middle age, gall-stones are so common, that one is not wrong to be always, suspect- ing them. CLINICAL APHORISMS 275 140. A distended gall-bladder is more often de- pendent upon cancer than upon stones. 141. Recurrent jaundice is probably due to gall- stones. XTI. — OF CEEEBRA.L HAFMORBHAGE AND HEMIPLEGIA 142. Contrary to current opinions of apoplexy, cases in which the patient is, as it were, struck down by a pole-axe — ' stunned,* as the word really means — are not common ; and when they occur, they are usually due to haemorrhage into the pons, though the haemorrhage may be quite small. The coma of fatal cerebral haemorrhage is usually ' ingravescent '. (See p. 15.) 143. In cases of hemiplexy (sudden hemiplegia) with coma, rigidity generally indicates haemorrhage into the ventricles, convulsions generally indicate haemorrhage into the pia mater. 144. Right hemiplexy, accompanied by aphasia, may be safely said to be due to softening from arterial obstruction, and not to haemorrhage. 145. Conversely embolism is not likely to be T 2 276 CLINICAL APHORISMS the cause of right hemiplegia if there is no associated aphasia. 146. In any case of hemiplexy, loss of conscious- ness, especially if complete, is in favour of haemor- rhage as its cause, rather than softening. 147. A hemiplegia, therefore, which comes on suddenly (hemiplexy) and is unaccompanied by loss of consciousness, is probably due to softening from arterial obstruction. Hysterical hemiplegia also some- times comes on suddenly, but is much less common. It is generally believed that the face is never para- lysed in the latter case, though this is incorrect. 148. Hysterical hemiplegia does not come on during an emotion. Unless there be some positive evidence for hemiplegia being hysterical, it should not be confidently diagnosed as such. Hemiplegia appearing during an emotion is more likely to be due to a small haemorrhage. 149. Uraemic hemiplegia is well known, but rare. Still, the possibility should always be borne in mind when there are evidences of gi-anular kidney in a hemiplegic patient. 150. When hemiplegia has come on suddenly, its CLINICAL APHORISMS 277 continuance for more than three or four days excludes both epilepsy and uraemia as possible causes. One has then to discuss actual lesions : (i) haemorrhage, and (ii) softening from arterial obstruction, as likely causes. In favour of (i) is any evidence of granular kidneys and a hypertrophied left ventricle ; conditions so often associated with cerebral haemorrhage. In favour of (ii) is the coexistence of aphasia with the hemiplegia. 151. A haemorrhage into the internal capsule produces rigidity sooner or later. It may appear as early as the fourth day or as late as the sixth week. Sometimes both legs become rigid even in hemiplegia ; a fact explained by the incomplete decussation of the pyramidal fibres. 152. In cases of hemiplegia it is difficult to say if there is, or is not, any paralysis of the face when the patient is lying upon the side. The examination should therefore be made with the patient lying upon his back or sitting up. 153. Congenital hemiplegia or • birth-palsy ' ex- cepted, the cerebral hemiplegia of children difiers in no respect from that of adults. 278 CLINICAL APHORISMS 154. The pain in the limbs which sometimes follows hemiplegia is often of the nature of arthritis, the shoulder-joint being most commonly afifected. At other times tender points appear along the course of the nerve-trunks. 155. The after-condition of old hemiplegics is often very sad, when they suffer from aphasia and verbal deafness also. They are little different, to all outward appearance, from idiots ; but what the state of their mental powers may be we can no more tell, than we can tell what passes through the mind of a dog. 156. The only form of spinal hemiplegia you are likely to meet with is that due to anterior polio- myelitis. XVII.— OF MENINGITIS 157. We rarely see a case of meningitis without being told of a blow upon the head some time before ; but the blow seldom or never has had anything to do with the disease. 158. No disease is more frequently followed by tubercular meningitis than is hooping-cough. 159. A direct diagnosis of tubercular meningitis is CLINICAL APHORISMS 279 rarely possible, for the only direct evidence is the discovery of tubercles in the choroid — too often only possible when the patient is moribund. But generally a diagnosis may be based upon the fact that the disease is — as shown by the symptoms — cerebral, is in a child, and had a sudden onset. 160. Aphasia is occasionally the first symptom in tuberculaj meningitis, and may be the only one present for some days. 161. By far the commonest manifestation of general acute tuberculosis in children is tubercular menin- gitis. 162. Uraemia in children may closely simulate tubercular meningitis, but albuminuria does not occur in the latter disease. 163. Recovery from non-tubercular meningitis sometimes occurs but is never to be desii'ed. For the recovery is apt to be incomplete, and the patient is left paralysed, blind, deaf, or an idiot. XVIII. — OP EPILEPSY 164. Epilepsy does not admit of definition, because we do not know what the essence of epilepsy is ; nor 280 CLINICAL APHORISMS has it any criterion ; certainly loss of consciousness is no criterion. 165. Fracture of the base of the skull may be produced by a violent fall during an epileptic attack ; and the special signs of fracture may be absent. The coma of the epileptic seizure becomes prolonged into the coma due to haemorrhage caused by the fracture. 166. Epileptic attacks are common in the course of any chronic disease of the brain or its membranes — sclerosis, general paralysis, chronic meningitis, old hemiplegia, &c. XIX. — OP HTSTEBIA 167. Hysteria is a distinct malady. It is a mistake to employ the term to cover all the cases of obscure nervous derangement in women which we do not understand. 168. Hysteria is generally diagnosed by the method of exclusion, and mistakes are sometimes made in consequence. Yet very often no other method of diagnosis is possible. The most characteristic symp- toms are defects in sensation (especially anaesthesia), and attacks of suffocation (passio hysterica). CLINICAL APHORISMS 281 169. Pain, muscular atrophy, loss of faradic excita- bility by the muscles, and loss of knee-jerk — either of these tells against hysteria being the cause of a paralysis. 170. Anaesthesia, and especially hemi-anaesthesia, is more often due to hysteria than to any other disease. XX. — OF MYELITIS 171. In medicine you can seldom say that anything is always the case ; but one of the instances most nearly justifying such an affirmation is the production of bladder symptoms in myelitis. 172. You will not be far wrong if you say that only one disease of the spinal cord begins by affecting the bladder, and that is myelitis. 173. The two most useful drugs in the treatment of myelitis are belladonna and strychnine ; and there seems a good deal of reason for adhering to the rule in vogue since Brown-Sdquard's time : to give the former in acute, and the latter in chronic cases. XXI. — OF NEURITIS 174. Sciatica is most commonly a neuritis, and traumatic, i, e. due to much driving on a hard seat 282 CLINICAL APHORISMS In this connexion note the frequent occurrence of some degree of wasting of the muscles, loss of sensa- tion, &c., after the attack. 175. Loss of knee-jerks may be the sole sign of post-diphtheritic neuritis. In one case the reflex was lost by a patient in whom it was known to have been previously well marked ; there had been abundant discharge of membrane from the trachea, the fauces and larynx being unaifected ; and there was no paralysis. 176. The patellar reflex is the last function to be regained in recovery from neuritis. 177. In cases of paralysis, pain must, as a rule, be regarded as contra-indicating the use of massage. 178. In cases of muscular wasting of parts, where the muscles are nicely antagonized, as they are at the ankle-joint, galvanism must be used with great caution, if at alL For by it you may do more harm than good, improving the nutrition of the antagonistic (unaflected) muscles out of proportion to any improve- ment resulting to those that are wasted. In this way deformity may be produced, or increased. So far as I know, massage does not entail a similar risk. CLINICAL APHORISMS 283 XXII. — OF SOME OTHER NERVOUS DISEASES 179. Double internal strabismus is often the earliest sign of tumour of the pons, because the sixth cranial nerves are so easily compressed. Disease of the pons is not uncommon in childreii, and is either tuTsercular or a diflFase glioma. 180. It is erroneous to regard pin-point pupils and a high temperature as diagnostic of a lesion of the pons ; any cerebral lesion may cause the latter symp- tom and the former is present in the case of haemor- rhage into the ventricles. 181. Cervical opisthotonus of children ^ is not a tuberculous affection ; it is due to chronic meningitis around the medulla oblongata. It may, however, occur as a temporary symptom in tubercular menin- gitis. 182. There seems no reason for thinking that any other difference than one of degree exists between paralysis agitans and so-called senile tremor. 183. It is improbable that haemorrhage into the spinal cord ever takes place apart from softening. ' See St. Bartholomew's Hospital Reports, vol. xiv. p. 23. 284 CLINICAL APHORISMS The fact that myelitis often sets in suddenly leads to the mistaken supposition of haemorrhage. XXIII. — OF DELIRIUM 184. Delirium, apart from insanity (which may be regarded as a chronic or oft-repeated delirium), is mostly due to alterations in the blood, i. e. to blood- poisoning. This is an old notion ; thus Shakespeare, speaking of a delirious man, has — ' All his blood is touched corruptibly.' 185. No conditions are more difHcult of diagnosis than those which are chiefly characterized by delirium or coma. 186. If called to a case of delirium with fever (phrenitis) it is useful to consider three conditions of which it may be a symptom : — (i) Brain disease — such as purulent meningitis ; these cases the old physicians called 'idiopathic phrenitis '. (ii) Blood-poisoning — including poisoning from drugs (alcohol, belladonna, &c.) ; from specific diseases (enteric fever, pneumonia, hydrophobia, &c.) ; and from local diseases (pericarditis, &c.}. CLINICAL APHORISMS 285 (iii) Insanity — remembering that insanity is really a chronic delirium ; that you may be dealing with the first attack ; and that fever is not an uncommon accompaniment of an acute attack of insanity, or mania. 187. Delirium does not occur until the intellectual faculties are more developed than they are in very young children. XXIV. — OF HEADACHE 188. Some people seem to be incapable of headache, even when they suffer from disease which is usually accompanied by this symptom, i. e. typhoid fever. 189. Indian hemp is a drug of great value in the treatment of chronic dull headache. Especially is it of value in overworked men and in Bright's disease. Its use should be cautiously commenced, especially in women. Persons accustomed to take much alcohol are usually very tolerant of the drug. 190. Iodide of potassium is very useful in head- aches of a different character — acute and violent headaches, often accompanied by a raised tempera- ture, the cause of which is obscure. Such cases are 286 CLINICAL APHORISMS not very uncommon — headache and fever are the two cardinal symptoms. Full doses of the drug should be given, and are often followed by speedy cure, though at first the pain may be aggravated by the iodide. In these cases, though a tempting hypothesis, syphilis can often be wholly excluded. XXT. — OF APHASIA 191. Aphasia is not a defect in the unuttered word, nor in the uttered word ; it is a form of paralysis — of the special movements of speech (see p. 27). 192. In many cases of aphasia attempts to protrude the tongue only succeed in getting it as far as the teeth; this illustrates the paralytic nature of this condition. 193. The cases of aphasia suddenly appearing during an emotion are not hj'stericaJ. The disorder may occur in adult men, and is better described under the term ' emotional aphasia '. The condition may last for several days (see p. 31). 194. There is no aphasia in disease of the pons. CLINICAL APHORISMS 287 XXVI. — OB" DISORDERS OP SLEEP 195. An apparition is sometimes nothing but a dream seen with open eyes by a person who is half asleep and half awake. When the awakening becomes complete, the apparition vanishes. The prophet Balaam ' saw the vision, falling into a trance, but having his eyes open '. 196. People are born good sleepers or bad. A tendency to sleep badly runs in families, and is some- times observed in the youngest infants. To make one who is naturally a bad sleeper into a good sleeper is an impossible task: all that can be done is to remove or remedy any accidental and temporary conditions which hinder sleep. The risk run by bad sleepers arises not so much from mere want of sleep as from the temptation to fly to narcotic drugs: hypnotic is nothing but a euphemism for narcotic: the mischief lies in remedies much worse than the disease. 197. Bad sleeping is largely aggravated by the fretfulness which it causes in those who sufler from it ; for they are often of a peevish disposition, given to 288 CLINICAL APHORISMS wony, and they will not or cannot let nature take her course. Anxious desire for sleep hinders sleeping according to the universal law that voluntary parti- cipation in an involuntary act inhibits accomplishment thereof. XXVII. — OF SOME INFECTIOUS DISEASES 198. The hoop is not an absolute criterion of hoop- ing-cough. A child may hoop for weeks with a cough which is not hooping-cough, and yet cannot be dis- tinguished from it, except by the fact that the said child does not convey the disease to other children who are susceptible. 199. In measles, although the fourth day is the commonest for the appearance of the rashj the eruption may be the first sign of the disease, or, again, may be delayed until the seventh or eighth day, the patient meanwhile being very ill. Indeed, there is no disease in which the duration of the invasion period is so variable. 200. Mumps may produce many curious nervous symptoms at times, e.g. intense giddiness. CLINICAL APHORISMS 289 XXVIII. — op ENTEKIO PBVEB 301. The febrile onset of secondary syphilis may be mistaken for typhoid fever : and an incipient syphilide may be indistinguishable for a few days from typhoid spots. 202. Enteric fever seldom begins with a rigor; pneumonia often. The reason probably lies in the fact that in the former disease the temperature rises slowly, in the latter it rises rapidly. 203. Scarlatiniform symptoms — a rash, sore throat, &c. — coming on early in enteric fever, are not un- common. In such cases diagnosis at first is often impossible. 204. Vomiting early in enteric fever, especially if frequent, indicates a severe case ; it ia accompanied by bad headache. 205. Muscular rigidity in enteric fever always marks a severe, and often a fatal case. 206. Deafness is common in enteric fever. StoU thought it indicated approaching convalescence, the other symptoms being favourable : but a statement so barely empirical ought to be well established before much importance is attached to it. 290 CLINICAL APHORISMS 207. Otitis interna is not uncommon in the course of typhoid fever ; both ears are usually affected. By means of this otitis, typhoid fever may be complicated with meningitis, at least if optic neuritis followed by atrophy can be accepted as evidence of meningitis. 208. That form of typhoid fever which is marked by incessant raving delirium is hard to be distinguished from meningitis or from phrenitis due to some other morbid poison. This is especially the case when the typhoid delirium sets in unusually early, during the first week of the disease, and before the eruption appears. Moreover, in some of these cases the eruption never appears. And suppose that this raving and roaring delirium (febris ululans) be attended by constipation, a retracted belly, temporary rigidity of the neck, and watery discharge from the ear ; suppose that spots be absent throughout the whole course of the disease, and that examination of the eyes be difficult through the restlessness of the patient, and the eyelids being kept tightly closed. Yet all this happened to a patient of mine who died in the fourth week of illness, and whose intestines showed typhoid lesions of that period, the brain being healthy. Test- CLINICAL APHORISMS 291 ing the blood by cultivations of typhoid bacilli (Widal's test) must be employed as an additional means of diagnosis, but a negative result may be expected early in the disease. 209. Haemorrhage from the bowels in enteric fever, if it occur not later than the second week, may be disregarded. After that time it is a serious symptom. The opinion of Graves and Trousseau that haemorrhage in enteric fever is not of much importance, is probably explained by assuming, with Collingridge, that they were referring to the class of early haemorrhages. Late and copious haemorrhage is a frequent precursor of perforation. 210. Nothing can be done to relieve the tympanites of enteric fever. Passing a rectal tube, puncturing the intestines with a trocar, administering small doses of turpentine or charcoal — all these have objections or produce no benefit. In patients fed on whey alone there is but little tympanites. XXIX. — OF SOME TUBEECULAR DISEASES 211. A period of improvement in general condition, even an increase in weight, does not exclude the u 2 292 CLINICAL APHORISMS possibility of a child's disease being tuberculous in nature, and fatal. 213. The existence of tubercles beneath the skin — a ' phlegmonous scrofulide ', but not lupus — is a very serious condition ; the patients die. The tubercles are apt to soften, disappear, and signs of general tuber- culosis follow speedily. 213. Tubercular peritonitis may come on quite suddenly ; but when it does so, the acute symptoms last for a short time only, and the disease then lapses into the usual chronic state. During the acute stage, however, the diagnosis from some form of intestinal obstruction may be difficult (see p. 168). 214. In chronic tubercular peritonitis indurations within the abdomen become manifest sooner or later in most cases. 215. Tubercle of the brain substance occurs as circumscribed tumours. There is, however, a very rare condition of miliary tubercular encephalitis, where the tubercles follow the ramifications of the blood-vessels, but this is only found in conjunction with tubercular meningitis.^ • See Reynolds' System of Medicine, 1st ed., vol. ii. p. 395. CLINICAL APHORISMS 293 XXX. — OF CHOREA AND RHEUMATISM 216. Choreic patients are nearly always weak- minded, so long, at least, as the chorea lasts. Insanity is an occasional accompaniment of the chorea of girls.^ 217. I have never seen a fatal case of chorea in which endocarditis was not found on post-mortem examination. 218. Salicylate of soda, guaiacum, and aconite — the three drugs having a reputation for curing sore throat — have all more or less specific action in rheumatism. Hence, if with a sore throat there is no other indication, you are justified in treating it as rheumatic. 219. The use of sodium salicylate was formerly often attended by attacks of vomiting, salivation, and deliiium, which are now seldom seen. These effects were probably due to impurities in the drug, such as carbolic acid. 220. Salicin is a feeble remedy in cases of acute rheumatism ; you may give a patient twenty-grain 1 See St. Bartholomew's Hospital Reports, vol. xxii. p. 89. 294 CLINICAL APHOKISMS doses every two or three hours without any effect, and then obtain almost immediate good from the use of sodium salicylate. As a fillip, used like quinine, and in mild cases, salicin is useful. 221. In rheumatic fever, delirium occurs under several distinct conditions : — I. Temporai-y slight delirium is not uncommon, even in persons who have not drunk hard; and especially at night-time. It may be that large doses of salicylic acid have something to do with it. II. But deliaium is sometimes the main symptom of the disease — delirium which is raving and apt to end in coma. The temperature in these cases may be high, but is not necessarily so : that is to say, the delirium cannot be attributed to the raised tempera- ture. (1) This delirium is sometimes of the same kind as that which occurs in typhoid fever, i. e. not connected with any local disease ; indeed, the arthritic symptoms are sometimes very slight. Cerebral rheu- matism this form of delirium has been called. Drunkards are prone to it. (2) Delirium is some- times associated with, and dependent upon, local CLINICAL APHORISMS 295 inflammation, namely, pericarditis, pneumonia, or meningitis. III. Delirium occurring after the cessation of rheu- matic fever ; a chronic lunacy, lasting for months, and of the same kind as sometimes follows typhoid and malai'ial fevers. 232. Rheumatoid arthritis, having an acute onset, cannot at first be diagnosed from rheumatic fever. XXXI.— OF SYPHILIS 223. I have never been able to satisfy myself that there is any such thing as syphilitic disease of the lung. Syphilitic disease of the mediastinum undoubt- edly occurs, but is very uncommon; it is certainly much rarer than aneurysm in this situation, which it may closely resemble in its symptoms. 224. There is too great a tendency to call all babies that are wasted and have sores on the body, syphilitic. These sores are often due to neglect, dirt, want of food. 225. Syphilis is almost the only cause of sudden blopharoptosis ; it is also the great cause of paralysis of the iris : indeed of all forms of ophthalmoplegia. 296 CLINICAL APHORISMS 226. Haemorrhage into the substance of the brain may occur as a sequel to gumma of this organ, especially when the patient is an infant. XXXII. — OF SOME SKIN DISEASES 227. Rheumatoid symptoms are very apt to occur in conjunction with three skin diseases, in this order of frequency : Erythema (especially E. papulatum), purpura, and urticaria; and these eruptions some- times interchange. 228. A person suffering from active psoriasis is likely to get it upon any irritated piece of skin, e. g. a scratch. 229. Ordinary facial psoriasis may simulate a syphi- lide if washed much with soap and water, the spots being no longer scaly, but becoming shiny, and of the colour that is common in syphilides. XXXIII. — OF DIABETES AND GLTOOSUBIA 230. Diabetes is a disease often overlooked, some- times because the urine is not tested for sugar on account of its having a fairly low specific gravity (say 1015°) ; which really is compatible with the CLINICAL APHORISMS 297 presence of a considerable amount of sugar: some- times because the patient is a child : and sometimes because there is no thirst or emaciation. 231. Diabetes sometimes becomes evident in two or three members of a family at the same time, so as to give an appearance of contagiousness. This notion is by no means new, but there is no proof that it is true. 232. Temporary and recurrent glycosuria, if not due to the ingestion of large quantities of carbo- hydrates, indicates a tendency to diabetes. 233. The great quantities of food which diabetics sometimes consume, to satisfy the excessive appetite which often occurs as a symptom of the disease, never seem to cause dyspepsia. 234. Diarrhoea is not uncommon in diabetes ; it may even be dysenteric. 235. Diabetes resembles motor ataxia in three points — loss of knee-jerk, perforating ulcer of the foot, and darting pains in the limbs. 236. Why is the diabetes of hospital patients so much more intractable than that of the well-to-do ? 237. It is dangerous to put diabetics upon a very 298 CLINICAL APHORISMS strict diet suddenly ; coma has come on when this has been done. 238. The beneficial effect of opium in the treatment of diabetes is pi'obably due to the power the drug has of allaying the feeling of weariness and discomfort, and of acting as a euphoric. XXXIV.— OF SOME SIGNS AND SYMPTOMS 239. Intermittent pulse in children after serious illness — or indeed after illness which was not serious — is so common as to be of little importance. The pulse of many old people intermits. 240. Difference in size of the pupils is often temporary, and is by itself no sign of disease. 241. Tache cMhrale is a sign of little or no value. £42. The most infallible early sign of death is that the muscles lose their faradic excitability. 243. During almost any acute illness the mind may become so clouded that afterwards the patient re- members scarcely anything that happened in the course of his disease. 244. In all nervous diseases sensory symptoms are apt to be fugitive. CLINICAL APHORISMS 299 245. Convulsions are often the sole symptom of any kind of brain disease in infants. 246. So little is known about the anatomy of anaesthesia, that, unless it be a herai-anaesthesia, a facial anaesthesia, or associated with some form of paralysis, perhaps the less said about it for purposes of diagnosis the better. 247. All sorts of anaesthesia are met with in disease of the pons ; difficult to explain because we know so little of the course of sensory fibres in this situation. 248. Examination of sputum for pus microscopically is of no use, for the naked eye appreciates the only important fact, that is to say, the amount of pus, whether great or small, and not its mere presence, which may always be presumed. 249. ' His cheek displays a second spring of roses taught by wine to bloom.' Beer also is a cause of this permanent dilatation of the capillary blood- vessels, associated sometimes with gutta rosea: but spirit-drinking, even for many years, often fails to produce any change in the face, except pallor. 250. The blue line of lead-poisoning may become apparent very early in the disease. When acetate of 300 CLINICAL APHORISMS lead was wont to be given freely for haemoptysis, a blue line sometimes developed in three weeks from the commencement of taking the drug. 251. There is no disease in which more or less permanent crippling may not result from the patient lying curled up in bed. In enteric fever and rheu- matism it is not uncommon, and bad contractures are occasionally seen in cases of neuritis. These deformi- ties should be studiously prevented, or, if this has not been done, they should be corrected early. There is a tendency for dislocation of the tibia backwards upon the femur to take place. 252. A muscle may be quite paralysed to faradism, and yet not be paralysed to volition. The opposite condition is, of course, much commoner, occurring as it does in all cases of upper-segment paralysis. 253. In acute diseases, more valuable prognostic signs are afforded by the breathing and aeration of the blood than by the pulse. 254. Delii'ium or frequent vomiting occurring sud- denly in a chronic disease is often prognostic of death within a day or two. 255. When severe abdominal pain is dependent CLINICAL APHORISMS 301 upon caries of the vertebrae, aneurysm of the aorta, aortic regurgitation, pneumonia, or pleurisy, the real disease is sometimes overlooked. XXXV. — OF FEVEE 256. Sudden pyi-exia, the temperature rapidly reaching a high degree, without any other signs of disease, seldom lasts. 257. Convulsions in children are often sufBcient to cause high temperature — a rise of 9°-10° even — and this hyperpyrexia will prove fatal unless counteracted by cold bathing. In such a condition it is obvious that no treatment can be much worse than the customary hot bath. 258. Haemorrhage may be attended by a rise of temperature quite apai't from the disease causing the loss of blood. This is well seen in some cases of haemoptysis. With Cullen, fever formed part of his definition of haemorrhage, ' Pyrexia cum profusione sanguinis absque vi externa.' 259. Frequently a convalescent patient, whose temperature will not settle down, acquires a steady normal temperature on being allowed to get up. In 302 CLINICAL APHORISMS patients convalescent from rheumatic fever this is especially noticed. XXXYI. — OF FOOD IN DISEASE 260. Pre- digestion of food given by the mouth ia of very little value in any disease. 261. You must not think that fever in itself contra- indicates the administration of solid food. 262. An apparently good condition of a patient fed only upon nutrient enemata is often deceptive, for dangerous symptoms of inanition may appear suddenly and without warning. A very little food in the stomach is much better than a large amount in the rectum, and on this account the former method of feeding should never be wholly abandoned without real necessity. 263. A strict milk diet is not to be recommended in cases of chronic nephritis. Some patients fare better upon a meat regimen, and few fare worse. Whey is always suitable. 264. In typhlitis avoid those kinds of food which leave much residue after digestion. For this reason whey is better than milk. CLINICAL APHORISMS 303 265. The best remedy for uric acid gi-avel is whey. XXXVII. — OF CHILDHOOD AND OLD AQE 266. Boys are sometimes very backward in learning to talk ; but if a boy cannot talk at four years of age, he is — with a single very rare exception — either deaf and dumb or an idiot. The former alternative can easily be excluded. The exception mentioned is the condition of congenital aphasia (see p. 32). 267. There is often a remai'kable latency about the diseases of old people. Phthisis particularly is often overlooked because of its supposed improbability. 268. People who are said to die of ' old age ' die nevertheless from failure of a particular organ, and not from universal senile decay. Still, it is sometimes difficult to say from what an old person is dying. XXXVIII. — MISCELLANIES 269. Prolonging life at the end of hopeless diseases: say rather, prolonging the act of dying. ' Mors minus poenae quam mora mortis habet.' 270. Gout and diabetes, two most mysterious diseases, both so easily known in their glaring mani- 304 CLINICAL APHORISMS festations, and both so utterly unknown in their essential nature. 271. A letter containing four pages or more, closely written and narrating the writer's own disorders, is a sure and certain sign of hypochondria. 272. When we have prescribed that continual temperance in all things which is necessary to the cure of most disorders, how often do we find that our patient reckons the loss of pain to be purchased too dear by the loss of pleasure. 305 APPENDIX I THE CONFLICT OF MEDICINE WITH THE SMALL-POX.' On May 14, 1796, Dr. Edward Jenner inoculated his first patient for the cow-pox. I shall not repeat, at any length, the oft-told tale of Jenner's life and his discovery, but I shall take leave to widen the boun- daries of my theme, and to occupy the time at my disposal this evening by a sketch of the history of the conflict of medicine with the small-pox. It is commonly assumed that the poison has but one source, namely, contagion from man. Jenner was of a different opinion, as I shall show hereafter. But assuming that contagion from man is now the only source of the disease, we may, with reason, ask whether history can tell us when the morbid poison first appeared in the world. All that we know is that ^ Bead before the Abernethian Society in 1896, to celebrate the hundredth anniversary of Jenner's first vaccination. 306 THE CONFLICT OF MEDICINE about a thousand years ago a Persian named Razes wrote a book upon small-pox and measles, the most important work which the Arabian school of medicine has left us. Razes' book is written in Arabic : some have supposed that the disease first arose in Arabia, and one reason for the supposition is that so many contagious diseases have travelled westward, with the sun ; as Bishop Berkeley said, ' Westward the course of empire takes its way.' Epidemic cholera certainly comes to us from the East ; so does influenza, and the plague. Diphtheria used to be called the Egyptian disease; possibly its original habitat was the valley of the Nile, as the valley of the Ganges seems to breed cholera, and as influenza was thought to have been caused by inundations of the Yellow River in China. Only one disease that I know of has been supposed to come to us from the West; but this cannot be proved ; and that true American disease, the yellow fever, has never been able to settle on this side of the Atlantic. Concerning the fountain- head of the small-pox poison we know nothing at all, nor do we know when it made its first appearance in England. WITH THE SMALL-POX 307 In an Anglo-Saxon book on medicine, called Lmce Boc (leech book), written about the year 950, refer- ence is made to a disease called p6c adl or pustular disease, which may or may not be a name for variola. But in the Compendium, Medicinae of Gilbertus Anglicus, written three hundred years later, or about 1250, there is a chapter upon variolae and morbilli, which were, no doubt, our small-pox and measles. About sixty years later, John of Gaddesden wrote his book called Bosa Medicinae, which I mention because the treatment he recommends for small-pox has become famous. A red scarlet should be taken — scarlet is a Persian word which originally signified not a colour, but some kind of costly thin cloth — I say, he recommends that a red scarlet be taken, or any other red cloth, and that the variolous patient be entirely wrapped up in it. He goes on to say that he thus treated a son of the most noble king of England, and that he made everything round the bed to be red, and that it is good treatment, and that he cured his patient without any traces of the variolae. The king was Edward I, and the son is supposed by Dr. Norman Moore to have been Thomas of X a 308 THE CONFLICT OF MEDICINE Brotherton. For this method of treatment, John of Gaddesden has been held up to ridicule or worse ; Sir Thomas Watson fears that he was a very sad knave : but there is no evidence that John of Gaddesden was a knave, or that he invented this special method of treatment, which turns out to be not at all ridiculous. Totally to exclude the rays at the violet end of the solar spectrum from acting upon the skin is said to have the remarkable effect of preventing pitting in small -pox, and this is just what Gaddesden tells us he succeeded in doing — ' I cured him without any vestiges of the pocks.' During the last few years many physicians (of whom Dr. Finsen of Copen- hagen is one) have treated variolous patients by red light, and have succeeded in curing confluent small- pox in unvaccinated patients, without suppuration, secondary fever, or pitting. Dr. Norman Moore tells me that in a manuscript copy of the Breviarium Bartholomaei, compiled by John Mirfield, a canon regular of St. Austin in the priory of St. Bartholomew in West Smithfield, and written about 1387 for the hospital of St. John the Baptist attached to the Abbey of Abingdon, a WITH THE SMALL-POX 309 manuscript which is now in Pembroke College, Oxford, on fol. 43a, after the heading ' De variolis et morbilis' are written the words 'i.e. smal pockes'. This is the earliest known use of the term small- pox. In what year soever the disease was brought among us, it became in course of time a dreadful scourge. I suspect that it reached its highest degree of virulence in the seventeenth century ; at least the literature of that period teems with allusions to small-pox. It decimated the population. No doubt many of you remember Macaulay's account of the death of the wife of William III, Queen Mary, who died on the eighth day of haemorrhagic small-pox. She ' had during two or three days been poorly ; and on the preceding evening grave symptoms had appeared. Sir Thomas Millington, who was Phy- sician-in-Ordinary to the King, thought she had the measles. But Eadcliffe, who, with coarse manners and little book learning, had raised himself to the first practice in London, chiefly by his rare skill in diagnostics, uttered the more alarming words, small- pox. That disease, over which science has since 310 THE CONFLICT OF MEDICINE achieved a succession of glorious and beneficent victories, was then the most terrible of all the ministers of death. The havoc of the plague had been far more rapid; but the plague had visited our shores only once or twice within living memory ; and the small-pox was always present, filling the churchyards with corpses, tormenting with constant fears all whom it had not yet stricken, leaving on those whose lives it spared the hideous traces of its power, turning the baby into a changeling at which the mother shuddered, and making the eyes and cheeks of the betrothed maiden objects of horror to the lover.' Such was the small-pox two hundred years ago. let us now inquire how our forefathers treated the disease. I turn to a translation of Eiverius's Practice of Physic, published in London in 1668, and I read as follows : ' The cure of the small-pox is performed in the satisfaction of four indications. Whereof the first consists in the evacuation of the peccant humours ; the second in assisting the motion of nature, or helping to expel the pox ; the third in the opposition of the malignant and venomous quality; WITH THE SMALL-POX 311 the fourth in correction of symptoms. First, that the patients be kept in a warm room, to the end their pores may be kept open, and the breaking out of the small-pox may there be furthered. Therefore they must be kept in a chamber well shut, which the cold air must in no wise enter into. And for the same cause they must be moderately covered with clothes. Many are also wont to keep an ewe or wether in the chamber or on the bed,' and so on, for time will not allow me to enumerate all the other details of treatment — the alexipharmacs, the cordials, the diascordium, Venice treacle, and applications to the skin. And when you bear in mind that these therapeutics were carried out, in most cases, not by physicians but by very ignorant women, you will readily agree that recovery of the patient was not much beholden to the treatment. Cooling Treatment. — But a man had arisen who was to change all this : Thomas Sydenham published his first medical work in 1666, and the treatment of small-pox constituted an important part of his subse- quent writings. What Sydenham said in eifect was this : You may talk as much as you please about 313 THE CONFLICT OF MEDICINE evacuating peccant humours, assisting the motion ot nature, and opposing malignant and venomous quali- ties, and I myself may sometimes use such expres- sions ; but, in the name of common sense, bring your treatment to the test of experience ; do most patients recover under this method of treatment or under that? And he came to the conclusion that most patients recovered under a treatment which was in many respects contrary to that in customary use; and he introduced what was called the cooling treat- ment. You will find it best set forth in his Episto- lary Dissertation. For example, the noble Lady Dacre sent for him to attend her grandson, Mr. Thomas Chute, in the flower of his age, and suffering from what turned out to be a very severe attack of confluent small-pox. Take this as a sample of Sydenham's treatment of the young man about the end of the first week, when things were at their worst. ' I gave him an ounce of syrup of poppies out of cowslip water at bedtime, and repeated it every night. I allowed him no more than his usual bedclothes. He might eat oatmeal porridge and barley broth, and occasionally a roasted apple. He WITH THE SMALL-POX 313 might drink a little small beer. On the eighth day I laid an onion wrapped in linen, on the soles of his feet, and renewed it every day until he was out of danger,' a harmless remedy, even if useless. Syden- ham might have complained with Virgil, Eos ego versiculos feci, tulit alter honores, for the physicians who came after him reaped the profit of his improve- ments in medical practice, and especially Radcliffe, whom Macaulay speaks of in the passage I quoted to you just now. The impression left upon my mind is that Sydenham was not a very successful man as the world commonly reckons success ; but I think he attained the most precious gift which man can attain, inward peace. He ends the Epistolary Dissertation, to which I just now referred, with this strain of reflections. 'And now, worthy sir, I desire you to accept this small treatise favourably, which was designedly written to return you thanks for your approbation of my other works. And, indeed, I have so seldom received anything like approbation, that either I have merited no such thing, or else the candid and generous men whom nature has framed with such excellency of mind as to know how to be 314 THE CONFLICT OF MEDICINE grateful, are very few, scarce so many as the gates of Thebes, or mouths of wealthy Nile. Yet, notwith- standing, I endeavour all I can, and will do so, to learn and promote the method of curing diseases, and to instruct those who are less conversant in practice than myself, if any such there be. Let other people think of me what they please. For having nicely weighed whether it is better to be beneficent to men or to be praised by them, I find the first preponderates and most conduces to peace of mind. As for fame and popular applause, they are lighter than a feather or a bubble, and more vain than the shadow of a dream. But if any think that riches got by such a reputation, has in it somewhat more of solidity, let them enjoy what they have scraped together with all my heart, but let them remember that many mechanics of the most sordid trades get and leave more to their children.' We know that Sydenham read Boethius'a Consolation of Philosophy. ' For he turned, and saw under the sun, that the race is not to the swift, nor the battle to the strong, nor bread to the wise, nor riches to men of understanding, nor favour to men of skill ; but time and chance overtake them all.' WITH THE SMALL-POX 315 Inoculation. After Sydenham's death his im- proved method of treatment was widely adopted, and we may believe that the ravages of small-pox were somewhat stayed thereby. Yet a few years more, and another means of dealing with the disease was introduced; I refer to inoculation, which was first performed in England at the desire of the famous Lady Mary Wortley Montague, in 1721. Her only brother. Lord Kingston, when under age, but already a husband and a father, had been carried off by small-pox, and she herself had suffered severely from it; which, though not leaving any marks upon her face, had destroyed her fine eyelashes, and had given to her eyes a fierce look which impaired their beauty. But the innovation was not well received, and she often declared that she would never have attempted to introduce the new treatment, if she had foreseen the vexation, persecution and obloquy that it would bring Vipon her. I shall say nothing more about inoculation, except- ing this, that it seems to have been a success or not a success according to the point of view from which we regard it. So far as the inoculated persons were 316 THE CONFLICT OF MEDICINE concerned, the mortality from small-pox was much diminished ; few inoculated patients died. But so far as the whole nation was concerned, the mortality from small-pox was much increased. ' The infection spread more widely ; many persons were obstinately prejudiced against inoculation ; many were altogether wanting in foresight, and neglected to avail them- selves of its advantages ; and many could not afford the time and expense incident to it. From these causes a large number of unprotected persons con- tinued to exist, and the smaU-pox spread more widely than before, inasmuch as inoculation estab- lished so many new centres of infection.' In short, there seems to be no doubt that the risk, to those unprotected, of infection by sroaU-pox was greater than before. Vaccination. I come now to vaccination. Jenner teLs us that he had heard that ' when the Duchess of Cleveland (he means King Charles the Second's Duchess) was taunted by her companions that she might soon have to deplore the loss of that beauty which was then her boast, the small-pox at that time raging in London, she made a reply to this efifeet, — WITH THE SMALL-POX 317 that she had no fear about the matter, for she had had a disorder which would prevent her from ever catching the small-pox '. This certainly seems to be an allusion to cow-pox. Early in the last century the milkmaids of some of the south-western counties knew that cow-pox prevented small-pox. About the year 1745 this fact became known to a boy named Benjamin Jesty. Thirty years later, in 1774, he inoculated his wife and two sons (aged three years and two years) with the cow-pox, or, in other words, he vaccinated them from the cow, in order to 'counteract the smaU-pox at that time prevalent where he resided '. But behold the fate of a reformer ! After Jesty's vaccinations, ' his friends and neighbours, who hitherto had looked up to him with respect on account of his superior intelligence and honourable character, began to regard him as an inhuman brute, who could dare to practise experi- ments upon his family, the sequel of which would be their metamorphosis into horned beasts. Conse- quently the worthy farmer was hooted at, reviled, and pelted whenever he attended the markets in his neighbourhood. He remained, however, undaunted. 318 THE CONFLICT OF MEDICINE and never failed from this cause to attend to his duties.' In 1805 he and his family came from Downshay, in the Isle of Purbeck, up to London on a visit. Jesty's portrait was painted, and one of his sons, whom he had vaccinated thirty years before, 'very willingly submitted publicly to inoculation for the sraall-pox in the most vigorous manner, and Mr. Jesty also was subjected to the trial of inoculation for the cow-pox after the most efficacious mode, without either of them being infected.' The portrait ^ shows ' a good specimen of the fine old English yeoman dressed in knee breeches, extensive double-breasted waistcoat, and no small amount of broadcloth. He is represented sitting in an easy chair, under the shelter of a widespreading ti'ee, with his stick and broad-brimmed hat in his left hand. His ample frame is surmounted by a remarkably good head, with a countenance which at once betokens firmness and superior intelligence'. Upon his tomb in the churchyard at Worth Maltravers in Purbeck, in 1 An engraving from the painting may be seen in tlie portfolio of the Koyal Society of Medicine. WITH THE SMALL-POX 319 Dorset, is this epitaph: — 'Sacred to the memory of Benjamin Jesty, who departed this life on the 16th April, 1816, aged seventy-nine years. He was born at Yetminster, in this county, and was an upright honest man, particularly noted for having been the first person known that introduced the cow-pox by inoculation, and who, from his great strength of mind, made the experiment from the cow on his wife and two sons in the year 1774.' It is a notable fact that a circle with a radius of five miles can be drawn upon the map of Dorset so as to include Winford Eagle — the birthplace of Thomas Sydenham ; Rampisham — the birthplace of Francis Glisson; and Yetminster — the birthplace of Benjamin Jesty. I come now to Edward Jenner. He was born at Berkeley, in Gloucestershire, in 1749. When he was twenty years old, in 1769, ' he was pursuing his pro- fessional education in the house of his master at Chipping Sodbury, in the same county, when a young woman came to seek advice ; the subject of small-pox being mentioned in her presence, she immediately observed, " I cannot take that disease, for I have had cow-pox." ' From this time forth his mind never 320 THE CONFLICT OF MEDICINE ceased to reflect upon the milkmaid's observation. ' To everything there is a season, and a time to every purpose under heaven.' It is clear that the fullness of time for the disclosure of vaccination had come, and the man for the purpose was ready. Men famous for one great discovery often have their attention drawn thereto in youth, and the rest of their life is wholly devoted to the development of their one idea. Jenner was essentially a man of one idea. For thirty years he was collecting facts and knowledge relative to cow-pox, and his book, which was published when he was nearly fifty years old, represents the final stage of his discovery, beyond which he never advanced: his book exhausted him. During those thirty years he studied the natural history of cow- pox, its relation to that disease which in horses is called the grease, the difierent eruptions on the teats of cows which are communicable to the hands of milkmaids, the distinction of that kind of eruption which is protective against small-pox (that which he called the true cow-pox), and lastly the possibility of intentional vaccination as a prophylactic. Jenner's procedure seems to have been very slow, and he did WITH THE SMALL-POX 321 not keep what was passing through his mind a secret. When he came up to London at the age of twenty- one, he tried to draw John Hunter's attention to the subject. After Jenner had settled in practice at Berkeley, he talked so much about cow-pox in the medical societies of the neighbourhood, and seemed so little able to talk about anything else, that he came to be looked upon as a well-meaning bore. Jenner's merit was that he believed in himself and in vaccination. The cow-herds and milkmaids of Wessex discovered that cow-pox prevented small- pox, Jesty practised vaccination, but Jenner was full of the enthusiasm of a man who believes that he has made a great discovery ; he saw the immense power latent in vaccination, and he did not rest until he had made other men see it too. What I have called Jenner's book was published in June, 1798 ; his subsequent writings did but re-affirm and illustrate the doctrines of his first book. To the chief doctrine, namely, that cow-pox is preventive of small-pox, he added two propositions (which he him- self calls conjectures), namely, that cow-pox is derived from a disease of horses named grease ; and that cow- 323 THE CONFLICT OF MEDICINE pox, grease, and small-pox are three different forms of what is essentially one and the same morbid poison. From the time when Jenner first propounded these theses up to the present day, they have not ceased to meet with strong opposition, It is no intention of mine to enter the fray, which has been carried on with more heat and less temper than might have been desired. Arguments have done their best, we have had enough of them, and the disputed questions are not yet settled. What we want are more facts, and, in particular, I think we want what Bacon calls instances of alliance. Judge of what would be the result, were such an instance to be discovered in the form of a microbe, an ens variolarum, which we could use as a touchstone of what is small-pox and what is not. Jenner's conjectures would disappear, they would be either truths or not. Meanwhile, we cannot get beyond opinions. Jenner possessed the first and most necessary of virtues, namely, courage. He never shrank from avowing his opinions. The name which appears on the title-page of the book, 'Variolae Vaccinae,' indicates as clearly as possible his belief that cow- WITH THE SMALL-POX 323 pox is simply small-pox occurring in the cow. And although he did not invent the term variolae equinae or horse small-pox, he could not have declared his opinions in this respect more strongly than he did when he went into some stables with his nephew, George Jenner, and, pointing to a horse with diseased heels, said, ' There is the source of small-pox.' Mark, not merely ' There is small-pox ', but ' There is the source of small-pox '. Indeed, he says much the same thing in the earliest pages of his book. Jenner's opinions concerning horse-pox are by no means to be lightly set aside; and they seem to have become stronger as he became older. In his book he doubts whether the virus of grease, directly inoculated into man, can be relied upon as a preventive of small-pox. But his friend Baron, who knew him in after life, tells us that ' Dr. Jenner was in the practice of using equine matter [for inoculation] with complete success ', and that grease ' when communicated to man is capable of affording protection against small- pox, even though it had never passed through the cow '. Here is a drawing ^ which shows the kind of ' Series Ivii, No. 902, St. Bai-tholomew's Hospital Museum. Y 2 324 THE CONFLICT OF MEDICINE eruption which grease produces in man, and you will observe its close resemblance to cow-pox. The drawing was taken from a patient of Mr. Langton's, from a groom, who, seven days before admission to the hospital, had charge of a horse suffering from inflammation of the legs and cracked heels, from which there was no discharge, but only a foul smell. I will conclude this topic by quoting a paragraph from the Traite de Midecine of Charcot and Bouchard, published in 1 892, and I choose a foreign book in order that you may know what they think about these matters abroad. ' Horse-pox (Jenner's grease) in spite of the descriptions of Loy and Sacco, was for a long time confounded with other diseases of horses' feet, but the researches of Lafosse and Bouley have determined exactly the symptoms of grease. It is characterized by an eruption which may appear on any part of the body, and is often confined to a limited space, such as the lower part of the legs, around the nostrils and lips, within the nasal fossae or the mouth. The eruption consists of vesicles which attain maturity on the eighth or ninth day. WITH THE SMALL-POX 325 Inoculation of cows with the exudation causes cow- pox. Inoculation of infants causes well-marked vaccinia, but with very violent inflammation. Con- versely, cow-pox or humanized vaccine, inoculated into the horse, produces horse-pox.' From the time of the first publication of Jenner's book, vaccination has been a field of strife. What was his attitude with respect to this wordy war? Baron tells us that ' although Dr. Jenner was the object of many harsh and unfounded assertions, he never thought it necessary to weaken that strong position which truth and knowledge had enabled him to take, by replying to them '. He agreed with Ben Sirach, that ' if thou blow a spark it will burn, and if thou spit upon it, it shall be quenched '. Segregation. For divers reasons vaccination did not succeed in exterminating small-pox. Of late years a powerful auxiliary has been found in stricter laws compelling segregation of variolous persons : and at the present time London may be said to be free from the disease. Thus has Apollo slain the small-pox python. 326 APPENDIX II ABBAHAM COWLEY, M.D., AND HIS PHILOSOPHICAL COLLEGE.^ Abeaham Cowley was born in the city of London in the year 1618. The precise place and date of his birth are unknown. His father, Thomas Cowley or Cooley, made his will ' on the four and twentieth day of July, Anno Domini one thousand six hundred and eighteen, and in the sixteenth year of the reign of our Sovereign Lord King James ' the First. In this will Thomas Cowley is described as being a ' citizen and stationer of London, and of the parish of St. Michael at Queme '. The will was proved only eighteen days after it was made, namely, on the eleventh day of August, in the same year, by Thomasine Cowley, widow of the deceased Thomas Cowley. The church of St. Michael at Quern, which was burnt in the Fire of London and was not rebuilt, can 1 Read before the Abernethian Society in 1903. ABRAHAM COWLEY 837 be easily identified on Ralph Aggus's map, by the help of Stow's survey. Stow says, ' But now to turn again to the Black Friars, through Bowyer Row, Ave Mary Lane, and Paternoster Row, to the church of St. Michael ad Bladum, or at the Corne (corruptly, at the Querne), so called because in place thereof was sometime a corn-market, stretching up west to the Shambles. At the east end of this church stood a cross, called the Old Cross in West Cheap, which was taken down in the year 1390. West from the said church, some distance, is another passage out of Paternoster Row, and is called (of such a sign) Panyer Alley, which cometh out into the north, over against Saint Martin's Lane.' So it would seem that the church of St. Michael at Quern stood at the west end of Cheapside, near to the spot where the Peel statue now stands. Abraham Cowley's birth happened after his father's death. There is no proof that he was bom in his father's parish (for the early registers are lost) ; but if he were we may perhaps go on to suppose that his father was a bookseller in Paternoster Row. Any- how, Abraham Cowley was born in the heroic age of 328 ABRAHAM COWLEY English history. Shakespeare had been dead two years; Francis Bacon had just been made Lord Chancellor and Baron Verulam ; Hobbes was thirty years old; Harvey was Physician to our Hospital, and had just been appointed Physician Extraordinary to the King; John Pym was thirty-four years old, and a Member of Parliament; Hampden was ten years younger ; Robert Blake was twenty years old ; Cromwell was nineteen; and Milton was a boy of ten, living in Bread Street, and studying at St. Paul's School. The first glimpse which we get of Cowley is given us by himself. ' I remember,' he says, ' when I began to read and to take some pleasure in it, there was wont to lie in my mother's parlour (I know not by what accident, for she herself never in her life read any book but of devotion), but there was wont to lie Spenser's works. This I happened to fall upon, and was infinitely delighted with the stories of the knights and giants and monsters and brave houses which I found everywhere there ; and by degrees, with the tinkling of the rhyme and dance of the numbers, so I think I had read him all over before ABRAHAM COWLEY 329 I was twelve years old, and was thus made a poet ' irremediably. Happy he, with such a mother and in such a home, with its peace and innocence, and ' pure religion breathing household laws'. Cowley's mother was left a widow with seven children, yet she managed to obtain a learned educa- tion for her youngest son. She procured his admission into Westminster School, where his character rapidly unfolded itself. He tells us, ' As far as my memory can return back into my past life, before I knew or was capable of guessing what the world or glories or business of it were, the natural affections of my soul gave me a secret bent of aversion from them, as some plants are said to turn away from others by an antipathy imperceptible to themselves and inscru- table to man's understanding. Even when I was a very yovmg boy at school, instead of running about on holidays and playing with my fellows, I was wont to steal from them and walk into the fields, either alone with a book, or with some one companion, if I could find any of the same temper. I was then, too, so much an enemy to all constraint, that my masters could never prevail on me, by any persuasions or 330 ABRAHAM COWLEY encouragements, to learn without book the common rules of grammar, in which they dispensed with me alone, because they found I made a shift to do the usual exercise out of my own reading and observa- tion.' In short, he was born to be a scholar. Men may be roughly divided into two classes, togati et militares, gownsmen and swordsmen, thinkers and fighters, scholars and men of business. A scholar loves knowledge for its own sake, he pursues truth and the fair form of intellectual beauty simply because he cannot help doing so ; this is his goal in life, he has no other. We will not stay to characterize the business man ; we will only observe that a man's worth is to be estimated by the value of the objects which he desires and seeks after. As he loves, so he lives. ' With these affections of mind,' Cowley goes on to say, • and my heart wholly set upon letters, I went to the University ' of Cambridge, and was made a scholar of Trinity College. He was elected a minor Fellow of the same college in the twenty-second year of his age, and a major Fellow in the twenty-fourth. But the Civil war broke out, and proved a turning- ABRAHAM COWLEY 331 point in his career. When a Parliamentary visitation of the University was made at the end of the year 1643, he refused to take the Covenant, and was ejected from Cambridge, ' torn from thence,' as he says, 'by that violent public storm which would suffer nothing to stand where it did, but rooted up every plant, even from the princely cedar to me the hyssop.' A great misfortune for Cowley ; he lost his Fellowship, and had little else to live upon. He withdrew to Oxford, the head quarters of the King's party, and there he ' grew familiar with the chief men of the court and the gown, whom the fortune of the war had drawn together. And, particularly, he came into the service of my Lord St. Albans ' (Sprat). Now this Lord St. Albans was not the great Viscount St. Alban (better known as Francis Bacon, who had been dead for some years), but a very different man, of bad character, Henry Jermyn, who gave his name to Jermyn Street, Piccadilly. In the suite of Jermyn Cowley attended Queen Henrietta when she retired into France. He little thought that twelve years of exile were before him ; we have it from his own mouth that when the refugees 332 ABRAHAM COWLEY first abode in France, they expected every post would bring them news of their being recalled. ' Upon this wandering condition of the most vigorous part of his life he was wont to reflect, as the cause of the long interruption of his studies. He was absent from his native country above twelve years, which were wholly spent either in bearing a share in the distresses of the Eoyal Family, or in labouring in their affairs. To this purpose he performed several dangerous journeys into Jersey, Scotland, Flanders, Holland, or wherever else the King's troubles required his attendance. But the chief testimony of his fidelity was the laborious service he underwent in maintaining the constant correspondence between King Charles the First and the Queen, his wife. In that weighty trust he behaved himself with indefatigable integrity and unsuspected secrecy. For he ciphered and deciphered with his own hand the greatest part of all the letters that passed between their Majesties, and managed a vast intelligence in many other parts, which for some years together took up all his days, and two or three nights every week ' (Sprat). This was harnessing a race-horse to a cart ; think of the nimble-minded ABRAHAM COWLEY 333 poet occupied in doleful drudgery of this kind, cipher- ing and deciphering ! But such is the irony of life. He was buying experience at a heavy price ; far better had he adopted the profession which he always affected. He would have been independent, even if poor; he might have pursued his studies in peace, heedless of the hurly-burly of politics and war; perhaps he might have lived the calm and quiet life which he loved so much. As Cowley's final judgement upon this period of his career, ' I saw plainly,' he says, ' all the paint of that kind of life the nearer I came to it ; and that beauty which I did not fall in love with, when, for aught I knew, it was real, was not likely to bewitch or entice me when I saw that it was adulterate. I met with several great persons whom I liked very well, but could not perceive that any part of their great- ness was to be liked or desired. Though I was in a crowd of as good company as could be found any- where, though I was in business of great and honour- able trust, though I ate at the best table, and enjoyed the best conveniences for present subsistence that ought to be desired by a man of my condition, in 334 ABRAHAM COWLEY banishment and public distresses,' yet he was un- happy ; in fact, he was a needy dependent. Cromwell's victories in Ireland and Scotland, the battle of Worcester, and Blake's victories at sea, put an end to Cowley's servitude, and to his expectations. His occupation was gone. He was nearly forty years old, and still a poor man. His noble patrons had fed him upon the chameleon's dish ; he had been promise- crammed. In order to find some way of earning his living, I suppose, he returned to London, but was soon arrested for a notorious royalist and a suspected spy; he was made a close prisoner, was repeatedly examined, committed to a severe restraint, and scarcely at last obtained his liberty upon the hard terms of a thousand pounds bail. He fortunately found a true friend in Dr. Charles Scarborough, who is best remembered as having been a disciple and friend of William Harvey. Scarborough took upon himself the surety of the thousand pounds bail. And thus probably were Cowley's thoughts turned towards the practice of physic. 'To this purpose, after many anatomical dissections, he proceeded to the consideration of ABRAHAM COWLEY 335 simples, and having furnished himself with books of that nature, he retired into a fruitful part of Kent, where every field and wood might show him the real figures of those plants of which he read. Thus he speedily mastered that part of the art of medicine' (Sprat), and poet-like, he wrote six books of Latin verses on plants. He was made Doctor of Physic at Oxford in December, 1657, and became acquainted with some of the learned men of the day, who were successfully promoting the natural sciences ; but con- cerning this aspect of Cowley's career I shall speak hereafter. The restoration of the monarchy now occurred to interrupt his schemes, whatever they were. At the same time one of his old delusions revived in full vigour. Both Charles the First and Charles the Second had promised him the Mastership of the Savoy, an ancient palace which stood on ground part of which is doubtless well known to you, for it is the site of the Examination Hall of the Eoyal Colleges, In Cowley's time the Savoy had fallen into decay, and seems to have been a sort of hospital, something like the Charterhouse at present. The post of Master 336 ABRAHAM COWLEY was much coveted, and Cowley had set his heart upon it. It was given to Henry Killigrew, a doctor of divinity, whose sister was one of the many mistresses of King Charles II. The sensitive and modest poet both mitigated and recorded his dis- appointment by writing some of his best verses in a poem called ' The Complaint.' ' In a deep vision's intellectual scene ' the Muse of lyric poetry appears to him, and reflecting his own feelings, speaks the true language of his heart, ^ although when the Muse has ended Cowley thinks it prudent to extenuate her sarcasms. This was hardly the way to regain lost favour ; afterwards, however, by the interest of Lord , St. Albans and the Duke of Buckingham, he obtained a lease of some of the Queen's lands at Chertsey. A lease implies a landlord ; I suppose that he had to pay rent, and that he sublet some of the land, and farmed the rest. About the same time his Fellowship at Trinity College was restored to him, and hence- forth he was at least free from the fear of want. 1 ' Go on, twice seven years more thy fortune try ; Twice seven years more, God in His bounty may Give thee, to fling away Into the court's deceitful lottery.' ABRAHAM COWLEY 337 Cowley's life at Chertsey is that which has endeared him to posterity. But at first he was still beset by delusions. ' I never,' he says, ' had any other desire so strong and so like to covetousness as that one which I have had always, that I might be master at last of a small house and large garden, with very moderate conveniences joined to them, and there dedicate the remainder of my life only to the culture of them and study of nature.' He looked forward to his future life at Chertsey with rapture. ' I thought,' says he, ' when I went first to dwell in the country, that without doubt I should have met there with the simplicity of the old poetical golden age. I thought to have found no inhabitants there but such as the shepherds of Sir Phil. Sidney in Arcadia or of Monsieur D'Urf^ upon the banks of Lignon, and began to consider with myself which way I might recommend no less to posterity the happiness and innocence of the men of Chertsey.' 'There were hills which garnished their proud heights with stately trees ; humble valleys whose base estate seemed com- forted with the refreshing of silver rivers; meadows enamelled with all sorts of eye-pleasing flowers; 338 ABRAHAM COWLEY thickets which, being lined with most pleasant shade, were witnessed so too by the cheerful disposition of many well-tuned birds; each pasture stored with sheep feeding with sober security, while the pretty lambs with bleating oratory craved the dam's com- fort ; here a shepherd's boy piping as though he should never be old; there a young shepherdess knitting and withal singing, and it seemed that her voice comforted her hands to work, and her hands kept time to her voice-music' (Sidney). This was the delightful vision which Cowley thought to find realized on the banks of Thames. But his notions of country life were no more than traditional fictions which experience was bound to dispel. 'To confess the truth,' says he, ' I perceived quickly, by infallible demonstrations, that I was still in old England, and not in Arcadia or La Forrest ; and that if I could not content myself with anything less than exact fidelity in human conversation, I had almost as good go back and seek -for it in the Court, or the Exchange, or Westminster Hall.' A letter which he wrote soon after his arrival at Chertsey is more definite. ' The first night that I came hither I caught so great a ABRAHAM COWLEY 339 cold, with a defluxion of rheum, as made me keep my chamber ten days; and two after had such a bruise on my ribs with a fall that I am yet unable to move or turn myself in my bed. This is my personal fortune here to begin with. And besides, I can get no money from my tenants, and have my meadows eaten up every night by cattle put in by my neighbours.' Cowley now settled down at Chertsey for life. His experience of city, Court, and country had taught him that men everywhere are much the same. He had learned that the universe is a perpetual whirl, and that rest is not vouchsafed unto the eye from seeing, nor unto the ear from hearing. We may believe that he had gained as much enlightenment as he could gain. But I feel that when we come to a man's last, and largest, and loftiest experiences of life we are entering into a holy place, where it behoves us not to talk, but to meditate in silence.; and I wiU say no more than that Cowley would no doubt have joined in the confession of faith which Adam makes to the archangel in the last book of Paradise Lost, Gotama and Plato, Koheleth and z 3 340 ABRAHAM COWLEY Boethius, Montaigne and Shakespeare ; all wise men become quietists at last. Nothing can be had for nothing, and for wisdom, Cowley, like all men, had to pay the price of repeated disappointment and sorrow. Together with wisdom he attained freedom ; he had always been virtuous ; and possessing wisdom, freedom, and virtue, what more could he desire? He now wrote his essays, which alone of all his numerous writings can be said to live. As a poet he is almost forgotten, for he wrote to display his wit and fancy, to surprise, to gain notoriety and fame. But great thoughts come more from the heart than from the wit, and his essays speak the 'language of his heart,' they are full of the wisdom of his mature experience 'upon some of the gravest subjects that concern the content- ment of a virtuous mind ' (Sprat). Hence the essays come home to the business and bosoms of all men, and have gained for Cowley a place beside Addison and Charles Lamb. The beautiful little ode (Epitaphium vivi audoris) with which he closes his book, breathes the gentle, tender and pensive spirit of the man. At Chertsey he died, in the forty -ninth year of his ABRAHAM COWLEY 341 age. He was not old, but he died not prematurely, for this life had nothing more to teach him. Amid all the changes and distresses of his life Cowley never lost his love of learning; this is the aspect of his character which I shall now set before you. After he gave up his connexion with the Court ' he betook himself to the contemplation of nature, as well furnished with sound judgement, and diligent observation, and good method to discover its mysteries, as with abilities to set it forth in all its ornaments. This labour about natural science was the perpetual and uninterrupted task of that obscure part of his life ' (Sprat). And first of his friendship with Thomas Hobbes. Cowley no doubt came to know Hobbes when they were both refugees in Paris. Hobbes returned to London in 1651, and Cowley in 1656. Soon after his return Cowley published a book of poetry con- taining an ode in celebration of Hobbes, whose most important works had been published in 1650 and 1651, when he was more than sixty years old. Hobbes is a thoroughly English thinker; he sets 342 ABRAHAM COWLEY his feet firmly on the ground, and has no notion of trying to soar into the sublime ether of absolute being. His philosophy was the fruit of long and patient reflection; his thought fermented until it worked itself clear, which is more than can be said of many philosophers. His clear thinking leads to clear writing: his language is a perfect exponent of his thought. 'In the prime qualities of precision and perspicuity, and also in economy and succinct- ness, in force and terseness ' (Craik), Hobbes's is the perfection of a scientific style. His language is, in Macaulay's opinion, more precise and luminous than has ever been employed by any other metaphysical writer. Hobbes was a contemporary admirer of Harvey. In the dedicatory epistle to the book Be Gorpore, published in 1655, while Harvey was still living, Hobbes writes that 'the science of man's body, the most profitable part of natural science, was first discovered with admirable sagacity by our country- man Dr. Harvey '. And Hobbes goes on to say that 'the science of human bodies hath been extra- ordinarily advanced by the wit and industry of ABRAHAM COWLEY 343 physicians, the only true natural philosophers, especially of our most learned men of the College of Physicians in London '. I have spoken of a friend of Harvey, Dr. Charles Scarborough, the physician, who set Cowley free from prison. Perhaps it was in gratitude for this good service that a panegyric ode was addressed by Cowley io Scarborough; but there seems not to have been anything very definite to praise in him. Cowley's ode loses itself in vague extravagant eulogy, and is an unfavourable example of his Pindaric art. It was probably through Scarborough that Cowley came to know the great Harvey himself. Cowley composed an ode to Harvey, but it is hardly worthy of the praiser or the praised. By far the best evidence of the deep interest which Cowley took in natural science is found in a pamphlet which he published in 1661, containing 'A Proposition for the Advancement of Learning', by A. Cowley. Cowley's is a beautiful scheme, wise and practical; yet we cannot be surprised that it came to nothing when we remember the fate of the 344 ABRAHAM COWLEY college actually founded and endowed by Sir Thomas Gresham, many years before, in Bishopsgate Street. Gresham College, had it been fostered generously and in the spirit of its founder, or had it been only administered with simple honesty, might have grown into a flourishing university for the City of London. But in a hundred years this college had become ' an object of contempt to the citizens. Petitions were sent into Parliament for leave to destroy the building; and though the Government in the reigns of William III and George I evinced their respect for the will of Sir Thomas Gresham by rejecting these petitions, yet the Legislature of 1767 passed an Act authorizing the destruction of the building. For the poor sum of 5001. per annum the trustees agreed to demolish the college and to part with all the land: but this was not all. Not only were the citizens of London thus deprived of their college, with the spacious lecture hall in which they had been accustomed to assemble, but another part of the Act compelled the trustees and guardians of this property to pay 1,800^. for the expense of pulling the college down. That is, they were constrained, by an especial ABRAHAM COWLEY 345 law, to commit a gross and flagrant violation of their trust, and to employ those very funds which Gresham had vested for the maintenance of his college in demolishing it. Am I wrong in asserting that this transaction has had no parallel in any civilized country? Nor was any effort made by the citizens to oppose the disgraceful breach of trust. Thus was this venerable seat of learning and science, where Barrow, Briggs, Bull, and Wren had lectured, and where Newton, Locke, Petty, Boyle, Hooke, and Evelyn associated for the advancement of knowledge, razed to the ground ' (Weld). Offices for business were built upon the land. Our old English universities have proceeded upon a wrong principle, inherited from the age when they were founded. They have assumed that knowledge is a more or less complete dogmatic system, to be handed down from one generation to another. But knowledge, like all things else, is in perpetual change ; it never is, but always is becoming. No sooner is our science taught than it is already obsolete and ready to perish. True universities teach by learning — learning is the main thing; and they could not 346 ABRAHAM COWLEY adopt an apter motto than that of Solon, TiipdaKO) 6' aJei iroWa bibaiTKOixevos. London has had a university in name for sixty years and more — a mere examining board. Efforts are now being made to develop it into a 'teaching university ', but should these efforts be successful the result will fall short of Cowley's idea. Cowley's intention was the same as that of Salomon's House in Bacon's New Atlantis: 'The end of our founda- tion is the knowledge of causes and secret motions of things, and the enlarging of the bounds of human empire to the effecting of all things possible.' Cowley's main object was the advancement of learning by research. His professors were to be devoted to experiment, observation, discovery, and invention. Teaching or the education of youth would have been a secondary purpose. His students would have learned more from what they saw than from what they heard, more from example than from precept; they would have taught themselves. Cowley's college remained a poet's dream. Yet it had an unforeseen result, and promoted the founda- tion of the Royal Society. Sprat, the friend of ABRAHAM COWLEY 347 Cowley and historian of that society, tells us that it had its beginning in the year 1660, when a number of learned men, who had been in the habit of meet- ing in Gresham College, began to imagine some greater thing. ' While they were thus ordering their platform there came forth a treatise which very much hastened its contrivance, and that was a pro- posal by Master Cowley of erecting a philosophical college. Some of the particulars of his draft the Royal Society is now putting in practice' (Sprat). But the Royal Society is no more than a small part of what Cowley's college would have been, ' However,' says Sprat, ' it was not the excellent author's fault that he thought better of the age than it did deserve ; his purpose in it was like him- self, full of honour and goodness.' The first official record of the society, dated November 20, 1660, contained a list of persons who were judged to be willing and fit to join in the design. In this list appear the names of many eminent physicians. Dr. Cowley being one of the number. Cowley celebrated the society in a noble ode pre- fixed to Sprat's history. Much of the poem is a 348 ABRAHAM COWLEY celebration of Francis Bacon, who at that time and long afterwards was deemed to have done more than any other man to promote natural philosophy. In the last — the nineteenth — century some persons arose who, animated by the envy which is innate in vulgar souls, denied Bacon's worth, and strove to belittle his greatness. But to Cowley, Bacon is the Moses who set men free from Egyptian thraldom, and idolatrous worship of traditional authority, that 'scarecrow deity '. The first book of the Novum Organum, is a grand hymn prophetic of the time when men shall take possession of the golden lands of new philo- sophies, which, from the mountain top of his exalted wit. Bacon sees and points out to others, but which he himself is not allowed to enter and possess. Cowley's relation to learned men did not cease even with his death, for the Fellowship which he vacated thereby was bestowed upon Isaac Newton. Cowley's imaginary college has a useful lesson for us at this present time, when St. Bartholomew's seems to have arrived at what the old physicians would have called a ' climacteric period '. Greater ABRAHAM COWLEY 349 changes are impending over the Hospital than it has undergone since it was rebuilt in the middle of the eighteenth century. If I, like Cowley, might indulge my fancy a little, and draw a picture of what I should wish the Hospital to be, I should begin by saying that its relation to London has completely changed during the last two centuries. Our Hospital has lost — irrecoverably lost — the distinguished posi- tion which it held in Cowley's day, when St. Bartholomew's, St. Thomas's, and Bethlem were the only hospitals for the sick in London. Now ours is but one among a crowd of hospitals, infirmaries, dispensaries, asylums which have sprung up by scores, and the number of these more or less rival institutions will continue to increase. But we have also been eminent as the greatest medical school. Herein lies our hope; could we make our medical school more eflBcient and worthy of its name, in the sense of Bacon and Cowley. The sick poor of London are amply provided for, but London does hardly anything to promote medical knowledge. St. Bartholomew's ought to include a noble school of pathology and medicine, not as an 350 ABRAHAM COWLEY appendage to the hospital, but an equal to it. The hospital and school should go hand in hand, neither predominant, and each assisting the other. Preliminary sciences should be taught elsewhere. We should devote ourselves to the study of disease, its causes and cure. But the men who would give themselves up to these great and humane researches must possess the necessary means of living ; and here we are brought face to face with the sordid but inevitable question of money. Can nothing be done to arouse in the bosoms of those who are rich some little love for learning? The only return that the man of business and wealth can make for the in- estimable benefit which he derives from the labour of the scholar is to contribute towards the scholar's maintenance. Vast sums of money are given away, much of it is thrown away, wasted, in what is called charity; but charity, not guided by knowledge, profiteth nothing. Do our hospital benefactors ever remember that they contribute nothing towards the support of scholars who are perpetually seeking and finding new means of alleviating or preventing the miseries which ABRAHAM COWLEY 351 render hospitals necessary ? He who endows a hos- pital shallhave the praise he merits, but let us tell him that his bounty fades into insignificance when compared with the charity of men who enrich the whole world by their beneficent labours, men who have expelled fatal and loathsome diseases, men who do all this without fee or reward, save the gratitude of mankind and the testimony of a good conscience. NOTE TO PAGE 183. Since the above paragraph was written the activity of surgeons has thrown more light upon the seat of pain in peritonitis. Mr. C. B. Lockwood in his book on Appendicitis (2nd. edit. Lond. 1906) says, ' Inflamed parietal peritoneum is exquisitely sensitive when touched or stretched, and, without doubt, the inflamed visceral peritoneum has the same properties ' ; p. 155 ; cf. p. 234. In a letter he says, 'The parietal peritoneum is supplied with somatic sensory nerves. The sensibility of the visceral peritoneum is somewhat peculiar : it is perfectly true that it may be cut with scissors, as for instance, in opening the sigmoid flexure in the second stage in inguinal oolotomy ; but it is not to be assumed from this that it is insensitive, because the patients do experience some sort of sensation, although it is not always that of pain.' RECOLLECTIONS OF SAMUEL GEE PHYSICIAN TO SAINT BARTHOLOMEW'S HOSPITAL BEOUGHT TOOETHEK BY J. WICKHAM LEGG HON. D.Lrrr. in the university op oxford ; f.s a. lond. SOMETIME ASSISTANT PHYSICIAN TO ST. BARTHOLOMEW'S HOSPITAL LECTURER ON PATHOLOGICAL ANATOMY, AND DEMONSTRATOR OP MORBID ANATOMY IN THE MEDICAL SCHOOL A SI, PREFATORY NOTE The pages which follow are almost wholly what I can gather from ' the dark backward and abysm of time '. I took no notes of our conversations, and I must trust to the indulgence of the reader if any be pleased to suspect the accuracy of my recollections ; though I would say that I do not think my memory has in many cases played me false, even if human weakness be so great that absolute certainty be not possible in any appeal to remembrance. These are recollections beginning a little before 1870 and ending in 1908, the year in which our intercourse almost entirely ceased, owing to my withdrawal from London into the country. It is with much hesitation that I have undertaken the task of putting these recollections together. It is not of my own seeking that I attempt it ; but it has now happened to me again, as it has happened to me before in life, that I have had to do that which no man else would, however little fitted I might be for the work. Of the imperfect way in which this duty to so great a physician has been carried out, no one is more sensible than his humble friend J. W. L. OXFOKD, January, 1914. Aa 2 RECOLLECTIONS Samuel Gee was, I think, the ablest man that I have ever known at all well. He might have been a professor of English literature, or a professor of philosophy, and he was, as we all know, a professor of medicine. His ability in medicine was early recognized. Soon after his election at St. Bartholo- mew's Hospital, Sir James Paget said to Sir William Jenner : Can't you send us another Gee 1 In the other branches of knowledge his unusual attainments were only perceived by his friends. Of his surname there are two theories in vogue, if we follow the writers on the origin of names. One is that it is an English place-name : Gee, now Gee- Cross, is a prosperous village in the parish of Stock- port.i The other is that the name comes from Gde, in the Anjou, a few miles from Angers, which is reached from Beaufort-en- Vallee or Baug^. Thus both G^e and Beaufort would seem to have given names to English families. We may note that arms were granted in 1592 to Samuel Gee, but whether he were an ancestor of the subject of these recollections I do not know. It used to be said of the celebrated Master of BalKol, Benjamin Jowett, that he was like Melchisedec, ' without father, without mother, with- out descent, having neither beginning of days, nor * C. W. Bardsley, A Dictionary of English and Welsh Surnames, London, Frowde, 1901. 358 RECOLLECTIONS OF end of life.' An attempt has been made to fasten the same character, touching father and mother, upon the subject of this memoir. It is not worth while saying that it is wholly untrue ; I knew his parents. They could trace their stock back to the time of George I. The father had been in business ; but he had also marked literary tastes, and frequented the British Museum. He left behind him a large collection of notes upon Fulke Greville, Lord Brooke. He was also a Cromwellian, for I used to hear of pilgrimages to the Cromwellian holy places. He was very proud of his son, and he told me that ' Sam ' had done very well, notwithstanding that he had never studied abroad, at Berlin, or Vienna, or Paris. At first Gee lived with the old people, when he began practice in Harley Street, where I often saw them. They were Church of England people, but of rather strict Puritan opinions, as I gathered from their way of keeping Sunday, and their avoidance of certain amusements, such as card playing and theatre going. There were three children of the marriage, besides the subject of this memoir. They did not grow up. I think, but I may be mistaken, that he got his school learning at University College School. He told me that the Reports stated that he did not do as well as he might, and that he could do much better if he chose. Gee's academical career was distinguished enough, if success in examinations can confer distinction. He had gold medals in every subject, and he used to make a jest of them. He would say: Sir, I have forgotten more anatomy than you ever knew. SAMUEL GEE 359 Gee's character was exceedingly complex, and it is very difficult to unravel. He had no zeal. He followed Talleyrand's advice : Surtout, point de zhle. Incessantly, but quietly, occupied as he was, he never seemed to have the least temptation to overwork himself. Early in life he once gave me the gravest warning against following the example of a colleague of ours, which was making me, he said, into an Egyptian slave. The work at the Hospital was in fact for me very severe, and more than one man could do ; but it had to be done ; and I was trying to do as well original work of my own. Gee much preferred, in the long run, the plodding against the brilliant. Yet in his early days he was certainly infected with the worship of intellect. At a school board election in Marylebone he gave all his votes to Mr. Huxley because he was an able man. The other candidates he considered humdrum. His learning was prodigious : he seemed to have read everything from Hippocrates downward, and to have retained what he read. It always seemed to give him pleasure if he could find that any modern observation had been anticipated by the Greeks. Even the mediaeval writers, worthless as they usually are from the medical point of view, had not escaped his attention. And he made himself acquainted with all the new German and French works of importance as they came out. How it was done I cannot con- ceive. It used, I confess, to appal me when I went to the library of the Medical and Chirurgical Society, then at 53 Berners Street, and see the multitude of new books and periodicals laid out for our instruction. It seemed more than human powers could cope with : 360 RECOLLECTIONS OF and, I fear, had its share in driving me away from medicine, and making me take up a study_ where one was not flustered by such superabundant literature. I am indebted myself to Gee for advice which I fear I have but imperfectly carried out in life, and this was: Never to write upon a subject without having mastered its literature. His opinion evidently was that an attempt, at least, at an exhaustive know- ledge of the subject should precede any setting down of thoughts upon paper. If this effort seems too severe for some, no harm is done. The world is saved what cannot be of very great value. His dislike of any attempt to deal with a subject on which the speaker was not fully equipped came out in his opinion that field preaching by laymen meant mere self-conceit. Though he had read so much German, yet he thought but little of German work and was sorry that in early life he had followed the multitude. He had the notion that there was in their books a great display of extensive reading, while their accuracy in reproducing the results of that study was not so plain. He would say of their reading what Montaigne said of their drinking : their aim is not to taste but to swallow. What came from America was but little prized. His lectures and speeches were delivered in a most deliberate manner and were very impressive. The matter was excellent, clear, and well thought out. If somewhat archaic in way of expression, they were none the worse for that, seeing the journalese and slang which are now allowed in serious discourse. He abhorred the German-English in which the writers of so many books bearing a scientific air delight to hide their meaning. The thoughts might be in- SAMUEL GEE 361 telligible in German, but in this curious dialect they must be dark to every one. This sort of speech will always be repulsive to a man of education who thinks in English, and may account in part for Gee's cry in his later years : anatomy, not physiology. In anatomy you have facts; in physiology more or less theory. Gee would urge upon his hearers the use of English words ; not indeed such barbarisms as ' swart hound ' for a black dog, or ' foreword ' for preface. He would say ' We are all of one mind in this matter ' instead of unanimous. ' Hereafter ' instead of for the future. We were not to talk of ' lumen ' or ' calibre ' if ' bore ' would be enough ; nor take over any such borrowings from Germany or elsewhere. A man came into St. Bartholomew's Hospital with the dysentery, and when Gee asked what was the matter with him, the patient replied : Sir, the bloody flux. I think he took a special interest in the man thereafter. If he could use an English quotation he preferred it, even if the line quoted were quite classical and well known. At the Children's Hospital, he objected to putting up in Latin the verse from 2 Corinthians v. 1, beginning For we know : best, if in the mother tongue, he said ; if not that, let it be in the original Greek. When he was disturbed by some talkative disputatious fellows he said he would have set up in the lecture room in large letters : Timothy, avoid profane and vain babblings, and oppositions of science falsely so called. ' Thrift in words ' was one of his mottoes. And what he said was very concise but to the point. _ So were his letters. He once said to me : I hate writing letters; and so it came to pass that he wrote very few and these very short. Of this the following is 363 RECOLLECTIONS OF an instance. A contested election was going on at the Hospital, and his colleagues wanted to know which way he intended to vote. Accordingly a note was sent to him, and the reply came back : ' I sup- port ', the name of the candidate; and that was all. His knowledge of medicine was certainly ency- clopaedic. There was hardly a disease of which he did not know all that was known. And the by- paths of medicine were quite familiar to him. For a short time I had the care of the patients with diseases of the skin at St. Bartholomew's, and very rare diseases showed themselves. I found that often he knew more of these out-of-the-way cases than did the expert members of the Dermatological Society. He was very determined in his opposition to specialism in medicine. Nothing vexed him more than the obstinate resolve of the public to make him a specialist in children's diseases, whether he would or no, a subject for which he seemed inclined to entertain a certain amount of scorn. Indeed, he took pains to prevent children being brought to him. I believe that his reputation for skill with children was due merely to the fact that he knew as much about children as he did of everything else in medicine, while the average physician was somewhat at a loss with babies. It was only a part of his extraordinarily thorough acquaintance with disease of every kind. He did not profess to arrive at his diagnosis by intuition. He told me he based his method upon that in Bacon, Novum Organum, II. He would first lay aside the diseases of which, to begin with, the case could not be ; this first stage reached, the second would be begun ; and so on, until some definite opinion were reached, or the diagnosis left in doubt SAMUEL GEE 363 for a time. He held it a most useful practice to record in cases of doubt the various opinions that suggested themselves day by day. His diagnosis, when it was made, was very rarely wrong, and his practical knowledge of disease was enormous. Hypotheses non jingo was often in his mouth. Though he knew so much, yet his scepticism was very deep. He went so far as to doubt of the value of experiment in the natural sciences, a position which seems almost unthinkable to most of us ; and it led him to refuse to deliver the Harveian Oration at the College of Physicians. This he refused, I believe, more than once. Experiment seemed to Gee to be no safe way of enlarging the bounds of knowledge ; and that we should find out the secrets of nature by way of experiment, was one of the conditions of the Trust imposed on the Orator, and he could not under- take to defend such methods in the Oration. And yet it has been said that every time we take a dose of physic, it is an experiment, for we are not sure what the results will be, and are ready to learn by those results. What increased his scepticism in the natural sciences was the new geometry, and the now generally accepted proof that the three internal angles of a triangle are not always equal to two right angles. W. K. CliflFord had measured the angles of great triangles, and found that the sum might vary as much as 10°. So also the doctrine of gravitation, which, though declared by the professors to be in no manner of danger, will have, they admit, to be ' restated '. At last he declared that in natural know- ledge there was nothing left but complete Pyrrhonism : for if geometry and dynamics be upset, the very foundations of all natural knowledge are shaken. The thought of Sextus Empiricus, contra Mathematicos, 364 RECOLLECTIONS OF gave Gee a satisfaction; it would be a successful attack upon the basis of natural knowledge. Macaulay, the ' C. Cocksley Cocksure ' of the Edinburgh Revieiv, scoiFed at the notion that there could be a reaction against the ' assured results ' of the natural sciences. In the Essay on Ranke's History of the Popes he says : There is no chance that, either in the purely demon- strative, or in the purely experimental sciences, the world will ever go back or even remain stationary. Nobody ever heard of a reaction against [Brook] Taylor's theorem, or of a reaction against Harvey's doctrine of the circulation of the blood. And in spite of all this, we are living in an age when more fundamental positions than these are challenged. On the other hand, Gee retained a lively interest in the theory of aether and atoms ; so that he counted it one of the disadvantages of dying that we were cut off from learning the newest ideas that were broached on this earth. There is a beautiful thought in one of the old Spectators by Addison (No. 237) : It is very reasonable to believe, that Part of the Pleasure which happy Minds shall enjoy in a future State, will arise from an enlarged Contemplation of the Divine Wisdom in the Government of the World, and a Discovery of the secret and amazing Steps of Providence from the Beginning to the End of Time. This would indeed balance the disadvantage that Gee fancied might follow the great change. And when Dr. Johnson lay a-dying he uttered the strange thought that he should receive no letters in the grave. It would have been a compensation to Gee to reflect SAMUEL GEE 365 that there we shall not have to write any. Con- sidering the feebleness of the human senses, the limitations of the human intellect, and the shortness of human experience, it seemed to him rash to dogma- tize, either by way of assertion or denial. He would compare an asserter of negatives to an oyster, denying the existence of music, because it could not hear. I think his main feeling was that there was little progress, and that the course of human opinion was like the swinging to and fro of a pendulum. He has written in his commonplace book : The Systole and diastole of all things : ebb and flow : ' undulatory theory '. There is a passage in Goldwin Smith which I think represents Gee's position. He compares man to an animalcule : A creature whose sphere of vision is a speck, whose experience is a second, sees the pencil of Saphael moving over the canvas of the Transfiguration. It sees the pencil moving over its own speck, during its own second of existence, in one particular direction ; and it concludes that the formula expressing that direction is the secret of the whole.^ To take one instance, I think he would have con- sidered that the man who denied the possibility of miracles had a much narrower outlook than the man who accepted such a possibility. I think he would have affirmed that the laws of nature with which we are now acquainted need not have existed from all eternity. Spontaneous generation does not now occur. Has that always been so ? And when have we know- ' Goldwin Smith, The Study of History, Oxford, Parker, 1861, p. 49. 366 RECOLLECTIONS OF ledge enough to affirm that there is a law ? In his quarto commonplace book, at No. 357, he has copied out St. Paul's question (Acts xxvi. 8) : Why should it be thought incredible with you that God should raise the dead ? Speaking of the relative frequency of genius, in letters and natural knowledge, he said that Cambridge would produce many Newtons before it produced another Milton. When first I knew him he was very busy with his work on Auscultation and Percussion. A good part was written as he was walking down to the hospital, when he would draw aside, up a blind alley, and write down the sentence he had thought of while it was still fresh in his mind.^ He was then also deep in Epictetus, and he would praise the piety of Arrian in preserving the Discourses. He gave me a copy of the Enchiridion. He was much drawn to the Stoics, and one may find quotations from Marcus Aurelius Antoninus in Auscultation and Percussion, where he says that the scanty records of the life of Auen- hic'^ger show that he went on from one social act to another social act. A little later he turned the Hymn of Cleanthes into English verse.^ There are quota- tions from Montaigne in his Gulstonian Lectures, if one looks for them. It was at this time that we would take long walks together in the neighbourhood of London, to Richmond, or Hampstead before it was built over, and the like ; 1 I don't know if Gee would be pleased to be compared with Sir Richard Blackmore. His Prince Arthur was written ' in passing up and down the streets'. (Johnson, Lives of the English Poets.) ^ It is printed below in the Appendix. It bears date : January 6, 1872. SAMUEL GEE 367 but, after my first attack of septic rheumatic fever, walking became troublesome, and the little expedi- tions had to be given up. It was interesting in these walks to hear him talk of the plants met with, especially if they were spoken of by the poets ; e. g. Milton's euphrasy and rue. And his cottage at Mid- hurst was a great delight to him from the birds and plants he found there of a rarer kind. This love of nature lasted to the end of his life. In a letter to his daughter written on October 1, 1908, he says : Hyde Park is becoming quite rural. Yesterday I saw a buttercup in flower, several white butterflies, a bright green beetle creeping across a path, and I picked up an acorn. ' Practical men ' he did not admire. I don't know, on the other hand, whether he shared Napoleon Bona- parte's scorn of ideologues. He had a deep contempt for the politicians of his time. The only politician that I have heard him speak well of was Gambetta, and that for his energy in providing defences for France during the Franco-Prussian War. He joined in drink- ing his health on New Year's Day, 1871, It was during this war that he said : There is nothing like being armed to the teeth ; for then if anybody says anything to you, you can tell him to go to the devil. Bismarck's honesty, he used to "say, had all the effect of a most profound dissimulation. He told me that he never read the political speeches in the newspapers ; and yet I fear it is true that the average Englishman now reads little else. He used to say that in politics he considered him- self an Old Whig : but he had long begun to think our position very insecure, especially in finance ; and of late I do not feel at all certain that he would not 368 RECOLLECTIONS OF have agreed with the lines which Addison puts into the mouth of Cato : When vice prevails, and impious men bear sway, The post of honour is a private station. As to femininism his first thought, when confronted with the idea, was to follow the advice of Gamaliel. But before very long he saw that this counsel and work was not of God, and he perceived the immense harm it would do to the sex ; and that soon there would be women who would do nought womanlike. This indeed has been fully verified. He made me come home from Orleans to vote against the proposal for giving to women a licence to practice from the College of Physicians ; now allowed by law, I fear, to the ruin of their character, which is the only thing in this world of any value. When I look back upon my own life and see that almost all the good in it is due to the influence of women, I can only speak with horror of the attempts, too often successful, made in our time to injure them, under pretence of liberating them. It is because I yield to no man in my sense of chivalrous duty to women that I abhor what their false friends have done during the last forty years. The movement has always seemed to me to be not merely anti-Christian, but anti-theistic. Bad as the nineteenth century was, the twentieth century was to be worse. I think Gee saw clearly enough that we were descending into a Merovingian darkness, and that democratic institutions would destroy civilization. I was once saying to him that the only thing for which I felt in any way indebted to the University of London was for its making me go through a short course of philosophy before giving the M.D. degree. SAMUEL GEE 369 Though I had to learn Barbara Cdarent, yet it was chiefly Mill and Bain that we were examined in. He said : ' Yes, Mill was an able fellow, but Bain was a dunderheaded Scotchman.' And even of Mill the undergraduate has been known to say that it took him half an hour to make out what Mill meant, and when he had done this he found he knew it before ; this is another instance in which the world mistakes obscurity for depth. I once ventured to say to my tutor in philosophy that I thought Mill hard to under- stand and a very obscure writer. He looked at me as if I had spoken blasphemy. This was in the sixties of the nineteenth century. Things have mended since. And what reward did the University of London reap by the severity of its medical examination? I heard the President of the College of Physicians, himself a doctor of that University, tell the College from the presidential chair that the examination for the degree of M.D. was a ridiculous examination by reason of its stringency. Those who had gone through the mill retained no gratitude for this elaborate forcing. Thus it happened that the tone of the University of London, so new-fangled, and pedantic, mid-Victorian, worshipping examinations, was not to Gee's taste, and wlien he was asked to propose the University of London as a toast at a public dinner, he did it in these terms : ' For fifty years it has been an examining university ; now for another fifty years it may be a teaching university : perhaps at the end of that time it will become a learning university.' We may here be reminded of the University of Naples founded by the Emperor Frederick II. The first pupil of any distinction that issued from that University was St. Thomas of Aquinum, and we may GEE B b 370 RECOLLECTIONS OF imagine how little sympathy there would be between St. Thomas and an University founded by Frederick. Like St. Thomas, Gee would be tanquam rosa de spinis ortus. He thought that as soon as it was found out that any one could go to the older Universities, their value as a place of education would fall. And this is a very just remark. For at Oxford and Cambridge it is not so much what the undergraduate learns from the dons, but what the undergraduate gains from his fellows, that is important. The training is all done by the life in college, and thus depends almost wholly upon the character of the undergraduates. The motto of the University of London, on the other hand, when first founded, was Cundi adsint; which meant that any young villain with sufficient money to pay his lecture fees, a Titus Oates, or a Francis Chartres, could demand admittance and no inquiry would be made as to his past history. It was not so until quite lately at the older Universities ; and even now there remain still some shreds and scraps of the ancient discipline of the days of Clarendon. The idea of the older University was to raise up able and honest men to serve God in Church and State. The idea of the modern Universities founded in the nine- teenth century is rather to teach a man how to make money and get on in the world ; and, if possible, die a millionaire. And the University of London has been the chief criminal in England in spreading this idea. Gee paid very little regard to what is called the higher criticism of any document. We had both been brought up in what may be called the school of Francis Adams; and been told to look upon Hippo- crates as a mere name for a collection of ancient SAMUEL GEE 371 books, some of which might, perhaps, be genuine Hippocrates. The real could be distinguished from the pseudo-Hippocrates by their greater insight into disease; while the residue were held to be mere superstitious jargon too often unworthy of the father of medicine. The Aphorisms were taken to be right Hippocrates, and without any documentary evidence the claims of the other writings in the Hippocratic collection were decided according as they approached to, or were distant from, the Aphorisms. Later on in life, one saw the folly of the process. I think it was with some satisfaction that one day Gee told me that a papyrus had been found, not of the same age as Hippocrates, it is true, but some two hundred years after his day, in which a list of his writings was given ; and in the list were the treatises considered the most foolish of all, and least like to the Aphorisms in knowledge of disease. In spite of his great scepticism he retained all his life a devotion to what he considered to be the truth. He would point out an expression used by the author of De iTnitatione Ghristi early in the work : Veritas Deus.^ If one looks for them, equivalent expressions may be found in other parts of the book as well. For example: Veritas mea et misericordia mea, Deus meus;^ and again: Christe Veritas aeterna.^ I must leave to divines the interpretation of these words. He would often remind us of the old Persian who counted speaking truth amongst the first elements of culture. It may be doubted if anybody ever succeeded in making Gee pass in speech beyond the bounds of what he considered the just facts. He exasperated ^ Lib. I. cap. iii. § 2, in the disposition of Sommalius. 2 Lib. III. cap. xl. § 6. ' Lib. IV. cap. i. § 1. Bb2 872 RECOLLECTIONS OF a coroner at an inquest at St. Bartholomew's by his refusal to say one word more than he thought true. There is the story that when quite a young man he was called to a boy in a state of coma, to whom the chief men in the profession had been summoned ; they had given varying diagnoses, but also opinions with more or less unanimity that the disease was mortal. Gee saw the mother and said : ' Mrs. , I have examined your little boy very carefully, and I do not know what is the matter with him.' He then prescribed some ordinary remedy, and the child woke up, and made a good recovery. A patient was brought to him that amongst other things had some trifling appearance on the tongue; and the mother was most anxious that he should expound the cause of this appearance ; but she could get nothing out of him but that he did not know. So, too, a patient, who asked him what was the use of the lymphatic glands in the animal oeconomy, was told that he could not tell. The public do not as a rule like a confession of ignorance on the part of a man they are consulting ; and a most arbitrary or unfounded opinion would have satisfied the patients, had Gee chosen to utter what he did not believe. Twice, he told me, he had succeeded in curing his patients by a look. A practitioner brought him a patient and said: You may not remember it, but years ago you did me the greatest service that one man may do to another. To an expression of sur- prise, he answered : When I saw you last, I was on the high road to becoming a confirmed drunkard ; and when you said I must give up stimulants, I replied : I can't do without my beer ; and you then cast me such a look of contempt that I went home and pulled myself together, and asked myself : am I then fallen SAMUEL GEE 373 so low that another man has the right to treat me thus 1 This began my reformation. The other case was of a fat old woman who came to him for obesity, and whom he told in the usual way to abstain from sugar, potatoes, bread, and the like. She came in another six weeks just as fat as ever. On being remonstrated with, she said she could not be so bothered as to give up the fattening foods. Whereupon he threw her such a look that her pride was touched and she went home and began the diet recommended. Of course, he said, you must be quite unconscious of the look. Gee was not an absolute unbeliever in the value of medicines : he would say ' medicines are of use '. Yet all treatment was not for him summed up in the administration of substances to be swallowed by the patient. When the late Dr. Ringer's book came out about 1870 he denounced it as 'a book of little dodges ', and he saw the great danger there was that the physician might degenerate into a mere drug- giver. He has copied out into his commonplace book that famous statement of Fielding's about the school of physicians, who with great gravity, deliver it as a maxim, that ' Nature should be left to do her own work, while the physician stands by as it were to clap her on the back, and encourage her when she doth well." Myths swarmed about him at St. Bartholomew's. Some had been told before of Eadcliffe. I will only make mention of one which seems to show the im- pression made by Gee on his fellows : That being set to soothe one of his children in the cradle, he was 1 Tom Jones, Book II. oh. ix. 374 RECOLLECTIONS OF discovered doing this by reading aloud Hippocrates in the original Greek. I told him this story, which amused him ; but he could not recall any circumstance that might possibly have given rise to the fable. _ It seems to me inspired by the story about the judicious Hooker and his rocking the cradle with one hand, while he held Horace in the other. In his hatred of a pretence at learning he would sometimes become savage. He said of a man who made a fine appearance in fluent speech though but ill equipped in knowledge : A showy humbug. And of another, anxious to appear separate from the some- what dubious company in which he had placed himself, and to look as if he encouraged a high professional tone, there was this biting judgement: He has bragged of his honesty. He liked as little clever g-uesses. When told that Swift had anticipated the discovery of two satellites to Mars he exclaimed at once : The old humbug. The only time to my recollection that I ever heard him laugh heartily was when I told him the old story of the Highland minister, forbidden by the Hano- verian Government to name the Pretender in the pulpit; but the next time he preached, he gave out his text as : ' James the Third and Eighth : The tongue can no man tame.' Saying one day to him that I thought the eighteenth century after all had been the time to live in ; London was not then too big, he replied : the present size of London is one of the greatest monuments of the folly of mankind. Telling me once of a peculiarly foolish new method of treatment for some disease, he added : Yes, it is an amusing world; and he might have strengthened his observation with a remark of Fielding in his preface to Joseph Andrews: 'Life SAMUEL GEE 375 everywhere furnishes an accurate observer with the ridiculous.' When Dr. Matthiessen was lecturer on Chemistry at St. Bartholomew's, we expected a new base to be discovered once a week. One of these new bases was Apomorphin, and it was given to Gee that he might investigate its physiological action. He was the first human being that took the new drug, and on the eve of its operation still continued to doubt its emetic properties, but his scepticism was not justified by results, which soon after declared themselves. One point may be forgotten, and so should be remembered here: his discovery of the cause of the death of Andrew Marvell. Marvell died somewhat suddenly, and of course in those days the death was attributed to poison; but, as Gee said, he was not poisoned, he was only murdered by his doctor, who refused to give him the bark for a tertian ague. Gee found the case set out in Morton's Pyretologia, and communicated his discovery to the AthencBum of March 7, 1874. He would complain that people thought him easy to oppress and put upon, until they came to close quarters with him, and then their surprise and anger were great if they found such a quiet-looking man hard, implacable, and unbending. This side of his character is well illustrated by a story current of him at University College. When on the resident staflf of the Hospital he discovered one Sunday night when it was not his turn to be in, that he was the only one of the house-staff" in the building. The others had gone out without giving him notice. He immediately put on his hat and went out, walking up and down the street outside the hospital. No appeal to good nature or to sympathy had the least effect. He would 376 RECOLLECTIONS OF often say, in the words of Antoninus : I do my duty, other things trouble me not. He once opened the session of the Abernethian Society at St. Bartholomew's with a lecture the text of which was: St. Bartholo- mew's expects every man to do his duty. Perhaps his inability to yield to the weaknesses and foibles of mankind may have had some influence upon the distribution of public honours and decorations. The Order of Merit would have been most appropriate for the first physician of his time ; but as Dr. Johnson says : Princes are commonly the last by whom merit is distinguished. Perhaps good nature is the quality which men value in others most of all. In Fielding, good nature seems to be the principal virtue. It does not so much matter if you break most of the ten commandments Cas in the case of his hero, Tom Jones) provided you have this one necessary quality. And in this opinion the generality of men would agree with Fielding. Tom Jones is their notion of a ' good fellow '. There is to be no austerity; you must follow the line of least resistance in dealing with your fellow men, if you wish to be prized by them. ' Qui vitia odit, homines odit.' Self-preservation, self-love, ' this reasonable Self- love ', Bishop Butler tells us, ' wants to be improved, as really as any principle in our Nature ', and, he says, ' so little Cause is there for Moralists to disclaim this principle '.^ This motive became in Gee a very pro- minent feature. The care of health, always a praise- worthy influence, rose to be to him something of a tyrant in later years, debarring him from pleasures, if not from duties. It also influenced him in other ways as well. 1 Joseph Butler, The Analogy of Religion, &c., part I. ch. v. § 4. note. SAMUEL GEE 377 He may have dwelt upon a couple of verses of his favourite author, Pope. Thus God and Nature link'd the gen'ral frame, And bade Self-love and Social be the same.' As he drew near to seventy years of age he was evidently looking back a good deal upon his life, and with but little satisfaction. He had the feeling that life was but a sorry thing after all. He writes some- thing in this tone in his essay on Nervous Atrophy. 'A young maiden . . . expects more from life than life can give.' This is enough to cause a melan- choly. Still, it is reported of Julius Caesar that in conversation he would say : That he was satisfied with his share of Life and Fame, satis diu vd naturae vixi vel gloriae.^ But then few attain to such a height of glory as Caesar. And yet I doubt not that there is many an average man, average in health and wealth, who would say much as Caesar said. Gee held that old men made a great mistake in handing over their estates to their heirs so as to avoid the extravagant death duties; for he would add : What else is an old man esteemed for, but for his money ? Seeing, too, how hard it is for some old men to grasp the fact that increasing age renders them unable to perform their duties, he pointed this out in the Winter's Tale (ii. i. 173) : Either thou art most ignorant by age, Or thou wert born a fool. And Robert Burton, he, might have noted, was of the same mind. Democritus to the Reader says : Old men account Juniors all fools, when they are meer 1 A. Pope, Essay on Man, III. 317. 2 See Cicero, pro M. Marcello, § 25. 378 RECOLLECTIONS OF dizards. So Goethe laughing declared that people fancy that we must become old to become wise ; but the trouble is in old age to keep ourselves as wise as we were.^ Gee recommended the exercise of memory, learning pieces by heart, as good in old age. I may say of myself that I have found this very uphill work, and have not perceptibly benefited thereby. He thought little of post mortem fame : all it meant, he would say, was the number of times after death the letters composing the man's name were put together in one order. He used to quote the line of Maecenas : Nee tumulum euro : sepelit natura relictos. I do not know if he had ever read the Confessions of St. Augustine, and come across a thought some- thing like this, to which St. Monnica gave utterance at Ostia : Ponite, inquit, hoc corpus ubicumque, nihil uos eius cura conturbet : tantum illud uos rogo, ut ad Domini altare memineritis mei. II Of letters, as apart from medicine, he has left us traces of some of his studies in a few commonplace books, loose sheets of papers, odds and ends of cards, reminding one of ' paper sparing Pope '. The only commonplace book that has a date is marked on the cover : ' January 1872, 54 Harley Street '. But a good many of the original sheets have been separated and ' See J. P. Eckermann, Gesprdche mil Goethe, Th. ii. p. 184. Don- nerstag, 17. Feb. 1831. SAMUEL GEE 379 the cover used for keeping loose leaves and some of the original sheets on which an analysis of Caelius Aurelianus has been written. The change in the handwriting may guide to an opinion upon the time when any of the notes were written. On the back of one of the cards is printed an advertisement with the date 1907. Another commonplace book, 9 by 7 inches, has not suffered such dilapidation. It is more interesting ; inasmuch as Gee has marked many of his extracts with references to other extracts on the same topic, and having numbered the extracts (they run up to 412) it is easy to find the one referred to by its number. Some dozen of the cards are an attempt at an index to this book ; the subject being written, followed by the numbers of the extracts to which subject the extracts refer. To show what these extracts are like, it may be well to give one of the shortest, from his once highly valued Wordsworth, with the references in numbers to preceding extracts under the main number. 400°. A soul by force of sorrows high Jf-^^^'aTT-e • 360 Uplifted to the purest sky g^tta Nipata^ 235 Of undisturbed humanity. 839. White JDoe ofBylstone, ii. ad finem. Judging from this commonplace book it may be thought that his meditations and reading took a strongly anti-materialistic shape ; but it is always hard to determine what his opinions on these matters really were. The books are large evidence of his wide reading in philosophy and literature. Gee's opinions on one subject, books or men, rarely lasted the same for any time. One would have talk with him, and a fortnight after resume the conversa- tion at the point where it was left off and then it 380 KECOLLECTIONS OF would be found that the whole tone of his thought had changed. For example : he once said to me that James Mill's History of British India was written in a cold unimpassioned style, giving the impression of the utmost impartiality, whereas as a matter of fact it was one of the most one-sided books ever written. Some time after this I happened to mention Mill's British India to him and he spoke warmly in its praise. He might have taken to himself one of his own extracts in his commonplace book, No. 336 (Plutarch, Flawdninus, at end) : We cease to change only when we cease to exist. He has made long notes on Mandeville's Fable of the Bees. He is inclined to compare Mandeville to Montaigne. Of the first volume he says : The Search into the nature of Society is very good. Two of the chief replies to Mandeville are : (besides Law) I. Adam Smith : Theory of Moral Sentiments : VII. 2. iv. (vol. ii. p. 258) But he forgets that Mandeville does not set forth a ' system ' : ' the whole is a rhapsody, void of order and method ' (p. 467) : and what he says is for the most part true : yet not the whole truth. II. Berkeley : Alciphron : Dialogue II. To this Mandeville himself has replied in his Letter to Dion. But it seems to me that Mandeville's critics have lost sight of the fact that his book is more a treatise upon Politics than upon Ethics. And his method is empirical. He does not enquire what the motives of States should be (as Plato, More and others have done), but what they are. And he finds that the strongest, richest, and famousest states have not become so by SAMUEL GEE 381 the practice of the rules of ethics, such as they are in the_ case of individuals. In other words, the rules of ethics and those of politics are not the same. Of the second volume he says : Dull as a whole : when he leaves description of matter of fact for speculation as to the origin of society, &c. he becomes very dull. He is a satirist, more than aught else, a Diogenes. In early life Wordsworth was something of a master to Gee. Dr. Horder tells me that Gee at one time knew the Prelude by heart, and his common- place books bear ample evidence of a wide study of Wordsworth's poems. Extracts from Wordsworth begin the quarto book; then they cease, but from No. 72 to No. 81 all are from Wordsworth. And yet later in life the great homage that he once paid to this poet had almost wholly gone. He said rather maliciously : that after a journey Wordsworth would come back to England with his portmanteau full of sonnets. Gee would say of Shelley that the Cenci was the finest play since Shakespeare and Prometheus Unbound the finest poem since Paradise Lost. I would retort with Jowett's opinion that 'it is impossible to con- vert Shelley into a decent and honourable man '. The Cenci is now put into the hands of girls of eighteen in certain women's hostels, and this worship of Shelley is only one degree less offensive than the worship of Oscar Wilde, a cultus which reminds one of the worst days of the Italian Renaissance. Gee had read W. Lucas Collins's little book on Butler, from whence he has copied out the gist of that celebrated dictum that whole nations may go mad as well as individuals. The first appearance of this 382 RECOLLECTIONS OF is most likely in a record of a conversation of the Bishop with his chaplain, Josiah Tucker, held as they were walking together one night in the garden. It was published in 1775. I don't think Gee had read the Analogy, though he told me he considered the scheme of the book very reasonable : he had certainly read the Sermons, for he has commented upon the earliest ones. There are notes on them following immediately those on Mandeville. The first three sermons and the preface are pure unmixed Stoicism : an admirable commentary upon TO Kara