Qfatttcll Mttiuersttg ffiihratg Dtljata, New ^atk BOUGHT WITH THE INCOME OF THE SAGE ENDOWMENT FUND THE GIFT OF HENRY W. SAGE 1891 Cornell University Library arV19409 Minor maladies.,and,,their;;eMm^^^^^^^ 3 1924 031 267 838 olin.anx 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/cu31924031267838 MINOE MALADIES AND THEIR TREATMENT, MINOR MALADIES AND THEIR TREATMENT BV LEONARD WILLIAMS, M.D. PHYSICIAN TO THE FRENCH HOSPITAL FOURTH EDITION LONDON BAILLIERE, TINDALL AND COX 8, HENRIETTA STREET, COVENT GARDEN 1918 All rights reserved Feinted is Gbeat Britain. PKEFACE TO FOURTH EDITION. Axil medical works are egotistical; either furtively or frankly. If the matter is not coloured by the author's experience, if it be not presented in the form in which it emerges from the mUl of his own brain, the result is a compilation which, though it may have some value in classifying facts, must nevertheless always fail in the more important direction of suggesting ideas. Orthodoxy is an easy comforting thing, but it is very confining. Heterodoxy, which in medicine is synonymous with progress, is a difficult and dangerous thing, but it is very interesting; often, it is even amusing. This book is entirely egotistical, and it is in many respects heterodox. It was first published in 1906; in each succeeding editiot^ very considerable altera- tions have been introduced; the present one em- bodies changes greater in number and more con- siderable in importance than any of the others. The section on Constipation has been entirely rewritten; the chapter on Change of Air has dis- appeared, to be replaced by one on Minor Glandular Insufficiencies ; and a small chapter on Old Age has been added. vi PREFACE TO FOURTH EDITION When I was first qualified, 1 went into general practice. I soon found that though moderately well equipped in the diagnosis and treatment of diseases which I seldom encountered, I was dis- concertingly ignorant in those matters about which I was most frequently consulted. Pneumonia I knew, and Rheumatic Fever, and Tj^phoid; I was so weU acquainted with Phthisis that I confidently recognized it in every trivial cough; and, so well versed was I in heart-murmurs that I was prepared to discover them and treat them — with a combina- tion of digitahs and words of serious warning — ^even v.'hen they had no real significance. With know- ledge concerning Tabes, Tumours, and Trematodes I was full to overflowing ; but I soon reahzed that I laiew very little about a common Cold, less about ordinary Indigestion, and nothing at all about the rheumatic conditions. My knowledge of the subject of Personal. Hygiene consisted in attributing to flannel all kinds of virtues, and to fresh air all mamier of vices. In tliis dilemma I searched for a book which would Hghten my darkness; but I found it not. I then determined that if time and circumstance should ever give me the opportunity of writing such a book, those of my juniors who found themselves in the same predicament should not want for such help as I might be able to afford them. The opportunity came about twelve years later, when I forsook the drive of a busy general practice for the comparative calm of consulting work. PREFACE TO FOURTH EDITION. vii Such of my experiences as I deemed of value in tliis connection (many of them were gained by sitting at the feet of elderly practitioners) first materialized in the form of some lectures. and demon- strations which I gave at the Medical Graduates' College and Polyclinic in 1904. These were after- wards published, chiefly in the Clinical Journal and the iledical Press and Circular. When they were being put into book form they were supplemented by matter which had been incor- porated in articles which had appeared in The Lancet, The Practitioner^ and other periodicals. In each fresh edition this process of laying under contribution portions of my writings which had appeared elsewhere has been steadily persevered with. I am pleased here to record my apprecia- tion of the facilities afforded me by the editors of these periodicals for this form of plagiarism, and to express my thanks to the proprietors of works of less evanescent character, the Oxford Medical Publications in particular, for allowing me to repro- duce here portions of what was written primarily for them. In rereading the proofs of the matter which has been left practically untouched since it first appeared in print, I have been forced to recognize that much of it is in reality once more in the crucible, not so much in detail as in principle. In therapeutics we often adopt measures merely because we know by experience that they succeed. An explanation viii PREFACE TO FOURTH EDITION. of the modus operandi conies later, and the correct explanation often much later still. Many of the subjects which I treated with dogmatism ten years ago have, in the interval, been subjected to fresher and fiercer Ughts which, in the future, may modify our present estimates, and may even change tliem beyond recognition. To write a medical book, however modest its aims, and to keep your hand conscientiously upon it, is to realize fully the first essential to the dignity and progress of medicine — namely, the ruthless cultivation of the open mind. To the contracting cerebral arteries of the seniors must be attributed the inadequate prestige of the profession in the body politic ; it is with the juniors to redi'ess the balance, by persisting in a divine discontent with present imperfections, and by pursuing with diligence the kind of heterodoxy which consists in a reasoned receptivity to new ideas. This is not to extol the excited welcome which I have too often seen extended to new thera peutic fashions. Those which are in my mind had no change in outlook to warrant them. It is exr perience alone which brings discrimination, buc it is a safe rule which bids us receive with cauf.ion new methods which are not based upon fresh ideas. The substitution of a synthetic drug for a vegetable, in the treatment of a disease whose pathology is obscure, may succeed in the whoUy laudable object of giving greater relief from symptoms, but we must not delude ourselves into beUeving that science PREFACE TO FOURTH EDITION. ix is thereby advanced. And it is, as a rule, precisely those who are most eager to follow new fashions who are ^ost impervious to fresh ideas. It is an easy thing to prescribe a drug, but it is not an easy thing to readjust your outlook. The man who discovers a new drug — hke Maclagan and his sahcylates — ia acclaimed as a deliverer; the man who preaches a new gospel, as Lister, Arbuthnot Lane, or George Gould, is despised by his contemporaries and stoned by his elders. In so far as this book can pretend to be anything nigher than an ephemeral practical aid to every- day practice, the larger claim would rest on the fact that in successive editions it has endeavoured to reflect the current of thought which is moving opinion among those who are really progressive. The ultimate object of medical science is prevention, not cure. The ultimate aim of any curative system is to influence a morbid process while it is still in a stage where skilful interference wiU do permanent good. Six James Mackenzie is fond of insisting that our present methods of investigation are not suffi- ciently directed towards the discovery of disease in its earlier stages, that we are content impotently to contemplate the full-blown, whereas we ought to search for buds and tendencies. In this criticism I see much justice, and I believe that the serious study of what are caUed minor maladies will in this way lead to the prevention or forestaUing of many serious diseases. Still more earnestly do I beUeve X PREFACE TO FOURTH EDITION. chat the study of the whole field of the Internal Secretions wiU enable us to detect and eoiTect j'norbid tendencies with a degree of success which has been denied to the older methods. The microbe — ^the seed — has ruled the immediate past ; the future is with the soil, the endocrine glands. LEONARD WILLIAMS. 123, Harlby Street, W. 1. January 1, 1918. CONTENTS. CHAPTER I. COLDS, COUGHS, AND SORE THROATS - PAGE 1 U. INDIGESTION - - 53 m. CONSTIPATION, DIARBHCEA, VOMITING, AND OIDDINJSSS 95 IV. RHEUMATISM, NEURALGIA, HEADACHE V. GOUTINESS VI. MINOR GLANDULAR INSUFFICIENCIES - Vn. GENERAL HEALTH Vm. OLD AGE IX. SOME DRUGS, AND THEIR USDS X. INSANITY . . . - INDEX .... 144 187 243 277 310 322 366 387 MINOE MALADIES AND THEIE TEBATMENT. CHAPTER I. COLDS, COUGHS, AND SOKE THROATS. The inflammatory conditions which are liable to affect the upper air-passages are usually attributed to inclement weather, and the elements, such as damp, cold, and chO, of which such weather is composed. This is a view which is no longer tenable. These inflammatory conditions we now know to be due to the same causes as those which produce inflammation in other mucous membranes — namely, irritation and microbic invasion. There is no doubt that these affections are more prevalent during inclement weather, and although we may admit that the in- clemency, by lowering the resisting powers, may, in some cases and in some degree, contribute towards the microbic invasion, it is evident that other and more important factors must also be in operation. These other factors are provided by the deficient 1 2 iVIINOR MALADIES. ventilation of houses, public buildings and con- veyances, whicb immediately ensues when the weather becomes cold or otherwise disagreeable. Windows and doors, which in summer-time are always kept open, are closed in winter, with the result that patho- genic germs are in the latter season allowed oppor- tunities for exercising their effects which are denied to them in the warmer weather. Moreovei', in the summer, people spend much more time out of doors, and are consequently less exposed to the activities of the germs, which, as we know, are more readily killed by sunshine and fresh air than by any other means. Colds, coughs, and associated conditions are due, therefore, not to damp and chill, but to microbic invasion. The surest method of avoiding them is to cultivate efficient ventilation, and the most certain method of encouraging them is to tolerate impurity of atmosphere. The association of ' chills ' with these conditions is very old, and until comparatively recently these ' chills ' were regarded as the cause of the malady. Most people now realize that this is not the case. The feelings of chilliness which so often occur at the outset of these complaints are not, as is so often erroneously believed, the cause of the symptoms — they are the primary manifestations of the malady, the sign which proclaims the success of the microbic invasion. The person who ' caught a chill ' and sub- sequently developed a sore throat was, although he failed to realize the fact, already infected when he COLDS, COUGHS, AND SORE THROATS. 3 experienced his chilly sensations. It is necessary to insist upon this view, because the laity cling with great pertinacity to the chill theory, with the result that fresh air, instead of being esteemed as a curative and prophylactic agent, is regarded as the deadliest enemy of the human race, and great vigilance is consequently exercised in excluding it by every possible means from houses, public rooms, and public conveyances, l/ntil people become more enlightened, ' colds ' and their congeners will continue to afflict them with quite unnecessary frequency. The commonest of all disorders is the catarrh affecting the naso-pharynx, the larynx, or the lai-ger bronchial tubes, which is known as a COMMOU COLD. For reasons which have just been considered, the term ' cold,' as applied to this condition, is pecuharly unfortunate ; for not only does it lend support to a mistaken view of the cause of the malady, but it tends to obscure what should always be realized in connection with it — namely, that it is iufectious. It is a well-recognised fact that colds are very liable to pass from one member of a household to another, which means that they are epidemic in character, and, being epidemic, they must necessarily be caused by bacterial infection. This fact supplies us not only with an obvious means of avoiding them, but it points unmistakably to the proper way of treating them. The infection induces inflammatory action, and in ordinary people the inflammation begins in the nose. In those who, from adenoids or nasal 4 MINOR MALADIES. obstruction, habitually breathe through their mouths, it may begin lower down in the air-passages ; but whenever it begins at a site which can be reached by nasal douching or gargling, it is, if taken in time, a very easy matter to abort a cold. This is done by the simple expedient of washing the microbes out of the part with an antiseptic solution, used both as a gargle and a nasal douche. It is curious to observe how few people know how to use a nasal douche. There are several patterns on the market, all of which have merits ; but the one which I prefer, because I am better acquainted with it than with any other, is called the Bermingham Nasal Douche.^ It is employed as follows : Having filled the douche with the necessary fluid, the index-finger is kept on the air inlet, and the nozzle placed well inside the nostril With the head thrown well back and to one side, the operator then raises the finger, and if the point of the nozzle is not too tightly pressed against the mucous membrane, the fluid will flow into the nostril. What becomes of it then depends upon one thing, and one thing only. If the mouth is kept widely open, and the patient goes on breathing, the fluid will flow out of the other nostril ; if the mouth is kept closed, the fluid will find its way into the oesophagus, the ear, or the larynx, giving rise to effects which are always disagreeable, sometimes alarming, and, in the case of the ear, occasionally very serious. The instruction to keep the mouth open ^ That sold as Dr. Woakes' Irrigator is also very good COLDS, COUGHS, AND SORE THROATS. 5 should, therefore, always be dwelt upon. If the fluid does not flow out of the douche at all, the nozzle must be withdrawn slightly. With regard to the fluid to be used, St. Clair Thomson insists upon the importance of the following three points : The solution should be warm — that is, not below 100° Fahr. ; it should be alkaline by reaction, and should be isotonic with the blood plasma. If it is of lower specific gravity than the plasma, there will be painful exosmosis from the pituitary surface; if of higher specific gravity, there will be equally painful endosanosis. In either case the patient will complain of disagreeable and occasionally even of agonizing drawing sensations in the nose. Of prepara- tions which fulfil these conditions, the most elegant and agreeable is that which is sold under the name of Glyco-Thymoline, whose active principle is a salicylate. It has, however, the demerit of being rather ex- pensive. A good substitute is the following : R. Sodii bicarb. I SoQU biborat. j Sodii benzoat. gr. J Euoalyptol ^^ Menthol gr. ^ Aquam ad gi- Solve et misce. Sig. : To be used frequently. The following is also agreeable and efficacious i Eazeline msx. Borax gr. v. Glycerine "Iv. Water ... «. to gi. 6 MINOR MALADIES. These solutions should also be used as gargles, so that the infective material may be flushed as rapidly as possible from all accessible parts of the upper air- By no means the least of the merits of this method of dealing with a nasal catarrh is, that should the catarrh be the first stage of an attack of whooping- cough, we are adopting the measures best calculated to cut short the attack, to provide against the spread of infection, and to prevent the occurrence of the sequela to which this disease owes its gravity. So effectual, indeed, is nasal douching in the treatment of this malady, even when delayed until the whoop is established, that to neglect to advise, and even to insist upon it, is in the judgment of many to under- take a very grave and a wholly unjustifiable responsi- bility. An excellent formula^ for this purpose, which is substantially the same as that which used to be known as Dobell's Solution, is : a. Sodii bicarb. \ Sodii biborat.J aa gr. rxi. Listerini 3ii. Glycerini 3vi. Aqnam ad Oi. M. Big. : To be used frequently. When the catarrh commences lower down in the air-passages — e.g., in the larynx — the local abortive treatment is not so easy of application, and is ' Amiala ef Ophthalmology and Otology, vol. v., No. 4. COLDS, COUGHS, AND SORE THROATS. 7 consequently not always so successful. Nevertheless, it should always be tried and persevered with, because its effects cannot be other tharn beneficial. Tb»> means to this end which I have found most successful consist in the use of oils, such as eucalyptus, well vaporized or atomized in a suitable apparatus, and inhaled vigorously and frequently both through mouth and nose. The atomizers on the market are numerous; that sold by Messrs. Oppenheimer under the name of the Universal Vaporizer is convenient, efficient, and comparatively inexpensive. The compound sold by the same firm under the name of Neboline No. 1, consisting of eucalyptus, menthol, and Scotch pine, is very agreeable; it is, however, expensive. A useful substitute is as follows : Oil of eucalyptaa ,.. lUXX.-xl. Menthol ... gr. x.-3i. Liquid paxaffin ... to §11. Dissolve and mix. Either ingredient may be used alone. Oil of eucalyptus is stimulating, though less so than thymol (of which 5 grains may be used in place of either of the above, and dissolved by heat). Menthol is sedative generally, but it is liable to excite lachryma- tion in some people. Aqueous solutions in the form of sprays may also be used, but they are less efficacious than the oleaginous. The following are useful formulse ; MINOR MALADIES Sodii bicarb. ■J - aa gr. v. Sodii biborat.J Acid, carbol. lev Hi Glycerini inxi. Aquam ad §i. Misoe. Mitte giv. Sig. : Spray freely through the nostrils into the throat every four hours, or oftener, using Eogers' No. 1 spray. R. Pot. permang. gr. i. Sodii chlorid. gr. v. Aquam ad 5i. Solve et misce. Whether the solution employed be aqueous or oily, the patient must be instructed to draw a sharp, deep breath each time the air-bulb of the atomizer is com- pressed. In this way the medicament will reach the larynx and the larger tubes. In addition to these local measures it is desirable to increase the powers of resistance to microbic activity — first, by sending the patient to bed, and secondly, by freeing the primse vise. This is best done by a mild purgative and a hot bath, or, better still, a hot wet pack. If, in addition to the local symptoms, there should be evidence of constitutional disturbance, such as headache and a slight elevation in temperature, then a single nocturnal dose of opium is invaluable. The form which I prefer is liq. opii sedativus, and of this at least 20 drops should be given. In influenza, taken early enough, I regard opium as ahnost specific, but even in common colds its effect in soothing the inflamed mucous membrane COLDS, COUGHS, AND SORE THROATS. 9 and in calming the irritated nervous system is most helpful. As a general tonic after a cold, nothing in my experience has proved so useful as quinine ; and when giving quinine, it is always better to prescribe it in fluid form, and preferably as an effervescing mixture. R. Quin. sulph gr. iiss. Acid, citric gr. x. Aquam ad gss. M. Sig. : The A mixture. R. Potass, bicarb gr. x. Ammon. carb. ... ... ... ... gr. iiss. Syr. simpl 5L Aquam ad §L M. Sig. : A tablespoonfnl of the A mixture to be added to two tablespoonfuls of this mixture and taken during effervescence. Quinine in powder is not only capricious in its behaviour, but, as compared to a solution, it is much more liable to upset the stomach. When dissolved in hydrobromic acid, the drug is comparatively tasteless. When once the inflammatory process is in full swing, the microbic activity is at an end. We can no longer expect any benefit by killing the organisms ; it is only their irritative effect upon the air-passages that we can hope to influence. And if we wish our interference, in a process which is by nature self- terminating, to be really beneficial, we must not lose sight of the time-honoured division of expectorants into soothing and stimulating. If we stimulate the 10 MINOR MALADIES. mucosa in the congestive period, the only effect which we can logically expect to produce is that of increasing the patient's sufferings ; and, similarly, if during the stage of free secretion we soothe the mucosa, the only reward for our activities will be a tardy and prolonged convalescence. When, therefore, the complaint is of rawness and a sensation of con- striction either in the throat or behind the sternum, when the cough is hard, and accompanied at most by some slight mucus, when the skin is harsh and dry and the tongue coated, the only proper treatment consists in soothing, or, as they are very properly called, depressing expectorants. A very old com- bination and a very excellent one is as follows • Vin. antimon." Vin. ipecac. / aa "13 Spts. sether. nitrosi ... nixxi. Liq. ammon. acetat 3". Syr. limonis . ... 3i. Mist, amygdal ... ad Si. M. Sig. : Every four hours, or, if the distress is great, half the quantity every two hours. This is a time-honoured prescription, to whose efficacy in relieving congestion and promoting secretion several generations of practical therapists have borne grateful and willing testimony. There is one counter- indication to the use of such a mixture to which it would seem necessary to direct special attention, and that is the existence of any valvular disease of the heart in the patient for whom it is proposed to prescribe it. I have known at least one fatal COLDS, COUGHS, AND SORE THROATS. 11 result to ensue from neglect of this very obvious precaution. Ipecacuanlia and antimony, be it remembered, are both very powerful cardiac depres- sants, and if we are careless enough to give them to a patient with an organ which is already labour- ing under mechanical disadvantages, we must not be surprised if by so doing we provide the proverbial last straw in the heart's burden. When a com- plication of this nature confronts the practitioner, he must content himself wifh relieving the congestion by such means as poultices, hot packs, and purga- tives, reserving his drug remedies for the relief of any symptoms which may be caused by the state of the heart. I must not be understood to imply, however, that such means as those just indicated should be ex- clusively reserved for cases in which valvular disease is present. On the contrary, a purgative and a hot wet pack are to be regarded as the very best sub- sidiary means of combating the condition, whether the intention be to abort an attack or to guide the inflammation to a rapid conclusion. When the congestion is relieved and freedom of the secretion is established, then, and not until then, is the time for those stimulating measures which many people erroneously prescribe at the outset. As a good example of an expectorant mixture of this class, let me recall one which is as time-honoured as that which I have just quoted ; it is as follows ; 12 MINOR MALADIES. Ammon. carb. Tr. oamph. co. Syr. scillse Syr. tolu. Inf. senegm gr. V. IUXXX. Si- ad Si. M. Sig. : Every four hours. It is well to remember that squill upsets the stomach in many cases, so that where this organ is weak this ingredient is better omitted. When the muco-purulent exudation is mainly tracheal, such a mixture may fail to give the neces- sary relief. In such cases cubebs usually acts very promptly. It is the main ingredient in a much- advertised remedy. Twenty grains of the powder in a cachet three times a day is a very convenient form for its administration. In connection with these catarrhal conditions, of which cough is such a prominent symptom, it wiU be convenient to glance briefly at some of the other CAUSES OF COUGH. We will leave out of consideration those coughs for which a cause is found as soon as the chest is examined — such, for example, as those which arise in the lungs and pleura from phthisis, pneumonia, pleurisy — and those which accompany tumours, aneurisms, and other gross cardio-vascular changes. Nor need such obvious causes as whooping-cough and measles detain us, for it is essentially the coughs which seem to own no relationship which give rise to difficulty. In the presence of such a cough in a child, it is well to remember two very potent but frequently COLDS, COUGHS, AND SORE THROATS. 13 overlooked causes : the one is a collection of cerumen in the ear, and the other is nasal or postnasal obstruction. Cerumen, of course, is very liable to collect in the ears of adults, but in them it more often gives rise to giddiness than to cough, whereas in childhood giddiness is seldom complained of, and cough is common. The removal, by the simple expedient of syringing the ears, of a troublesome cough which has caused anxiety and annoyance to a household for some time, is a proceeding which is highly calculated to increase the reputation of the man who does it and to injure the reputation of him who neglects it. So far as concerns nasal and postnasal obstruction, there can be no doubt that, though the former is often overlooked, the degree and importance of the latter are very generally exaggerated. Where there is any ob- struction in the nose itself to the free passage of air, that obstruction should be removed as soon as possible by operative measures. This is also true of gross obstruction caused by adenoids, but it is to be remembered that mild degrees of these vegetations are very rapidly and very efifectually removed by pulmonary exercises, and that with the removal of the adenoids the cough vanishes. It is well for a young practitioner to remember that suggestions of the tonsillotome and its congeners do not awaken in private patients the same acquiescent indifference which may be relied upon in those of the hospital class, and that a reputation for a too-ready appeal to 14 MINOR MALADIES. operative measures is one which it is prudent to avoid. The very simple details of chest exercises or pulmonary gymnastics should, therefore, be mastered in order that they may be explained to parents and intelligent nurses.^ A cough is sometimes excited by a relaxed ana elongated uvula, and such a cause should be suspected if the fits of coughing seem to be provoked by the recumbent posture. A relaxed uvula seldom arises independently ; it is usually a part of a general relaxation of the neighbouring structures, secondary to nasal or postnasal obstruction or other cause, and may be treated symptomatically by an astringent gargle such as the following : R. Aluminis Glyoerini Tnf rosEe acid. ... grx. 3i- adgl M. Ft. garg. Sig. ; ; To be tised frequently. Or, the parts may be painted at suitable intervals with glycerine of tannin, or with a mixture of equal parts of liq. ferri perchlor. and glycerine. This local treat- ment should be supplemented by measures directed to the removal of the cause, which is very often gouty or rheumatic. A brisk mercurial cathartic is always helpful. When the uvula, in addition to being relaxed, is also (Edematous, it should be seized at the point by a pair of forceps, drawn into the mouth and freely 1 Harry Campbell : ' E^spiratory Exercises in the Treatment of Disease ' (H. K, Lewis). COLDS, COUGHS, AND SORE THROATS. 15 scarified with a sharp knife. Such a proceeding is very simple, is almost painless, and the relief which it gives is instant and complete. The occurrence of such an csdema, however, even when it has been successfully dealt with by the above means, should never be hghtly regarded ; for although the majority of cases termiuate favourably in a short time, especially when the underlying cause is discovered and treated, in a certain proportion of them the oedema progresses downwards until the glottis is involved. Such a complication, according to Sir FeHx Semon, may be suspected if the ordinary redness of a relaxed throat presents a bluish tinge, or if the element of dysphagia is out of proportion to the amount of inflammation present. The patient in such circumstances should be carefully watched, and the friends warned of the possible danger. A mixture containing TTl_xx. of Hq. ferri perchlor. and m X. of liq. hydrarg. perchlor. to 3 ounces of water should be given, preceded by a brisk cathartic, and preparations be made either for intubation of the larynx or for the performance of tracheotomy on the occurrence of urgent symptoms. A cough which presents very distinctive features is that which is associated with chronic irritation either in the larynx or trachea. The irritation often amounts to nothing more serious than a relaxed and slightly catarrhal mucosa, the aftermath of a bronchitis or an attack of influenza. The latter is especially liable to give rise to it, but it may occur 16 MINOR MALADIES. independently of any obvious cause, and is then usually the result of anxiety, worry, and overwork. It is more common in relaxing climates, and is aggravated by dull, damp weather. Such a cough may be more or less present throughout the day, but it is, especially in the morning and at night, liable to energetic exacerbations. The amount of matter voided is very small in proportion to the violent efforts which its expulsion seems to entail, and consists mainly of colourless glairy mucus. During the paroxysms the patient's face becomes congested, and so rapid are the expulsive efforts that he is unable to inspire. A climax is often reached by a spasm of the diaphragm, which causes retching or even vomiting. Having regard to these facts, it is not surprising that such a cough is frequently mistaken for whooping- cough, its resemblance to which is further borne out by its obstinacy to ordinary cough- mixtures. If it is remembered that a cough of this kind is essentially a manifestation of debility, there should be no difficulty in affording speedy relief. Perhaps the best remedy of all is a complete holiday in some really bracing climate, such as that of Margate and the other stations on the east coast. This, however, may be out of the question, so that it is weU. to consider other means. As a measure for allaying the cough, an acid in combination with glycerine is very useful, and one of the best acids for the purpose is the acid phosphor, dil., of which 25 to 30 minims should be given to the drachm of glycerine in an ounce COLDS, COUGHS, AND SOHE THROATS. 17 of water three times a day. To such a mixture the addition of about 2 grains of quinine and 4 minims of tr. nux vom. will be found helpful in relieving the relaxed state of the mucosa, which is the real cause of the trouble. Gargles are of very little service in this condition — they are, indeed, quite useless — but lozenges are most valuable. That which I have found most effective is the Krameria lozenge. It is not very unpleasant, and it certainly helps to restore tone to the affected parts. Patients should be warned in connection with this lozenge that it is not meant to be sucked. It should be allowed to remain between the teeth and the cheek, and to dissolve slowly of its own accord, otherwise its activities will be expended upon the oesophagus, and the larynx remain altogether uninfluenced. There is another warning in connection with lozenges of all sorts of which it is well to remind patients, namely, that they should be taken out of the mouth if there is any immediate prospect of sleep; for during sleep, not alone a solution of its ingredients, but the whole lozenge, might easily find its way into the larynx, with disastrous consequences. If such measures fail to relieve the cough, there need be no hesitation in adding as a temporary expedient, say 10 minims of nepenthe to each dose of the above mixture. Heroin (^ to ^ grain) is most valuable. The coughs which arise in association with gastric, hepatic, and intestinal derangements are to some extent characteristic. They are generally loud, short, 2 18 MINOR MALADIES. and frequent, and do not result even in the discharge of mucus ; that is to say, they express a reflex and not a direct irritation. Their treatment is necessarily bound up with the discovery and efficient manage- ment of the original cause. Morte often than not this will be found to be chronic constipation ; it may turn out to be intestinal worms, inactivity of the liver, gastric dilatation, or some lesion even more serious ; the important point to remember being that, apart from aneurism, a cough which is persistent, obtrusive, and futile, generally has its cause not above, but below the diaphragm. Another kind of cough which is associated with gastric derangements is that which is typically seen in alcoholics. In its main features this cough may resemble closely that just described as laryngeal and due to debility; indeed, alcoholics very frequently have a huskiness due to relaxed vocal cords, but the existence of the chronic poisoning is generally easy to detect, and its detection not only prevents any misapprehension as to cause, but points unmistakably the right line of treatment. Having mentioned Influenza, it seems fitting that I should say a word or two in connection with it. It may begin as a minor malady, but it is very apt to become the reverse. If the illness be taken in time, and the patient sent to bed until the tempera- ture and other obtrusive symptoms have subsided, the disease is easily kept within the category of minor conditions ; but if it is allowed to obtain a COLDS, COUGHS, AND SORE THROATS. 19 ' hold ' of the patient, so as to give dangerous sequelae an opportunity of developing, then influenza is liable to be one of the deadliest of diseases. I know of no condition in the presence of which I feel less hopeful than a pneumonia which is secondary to influenza — a complication which supervenes most frequently, one might almost say exclusively, in cases where the primary condition has been regarded as a passing matter which should not interfere with the ordinary affairs of life. The necessity for early recognition and prompt treatment of these cases, even when slight, is further emphasized by the fact that when they are allowed to be ' ambulatory ' the subsequent depression is always much more pronounced and of infinitely longer duration than when they are taken in time and suitably treated. It is not that there is, nowadays, any tendency either to overlook influenza or to belittle it when present. The difficulty is, indeed, in exactly the opposite direc- tion, for it is quite certain that many conditions are constantly labelled ' Influenza ' which are no more due to the PfeiSer bacillus than they are due to the BacLUus typhosus. Since about 1890, ' influenza ' has become a sort of diagnostic rubbish-heap on to which is cast every febrile state which cannot with certainty be referred elsewhere. There is really no reason for this, because the Pfeiffer bacillus is as characteristic as the Klebs-Loeffler or any other whose presence is regarded as distinctive of a certain disease, so that a positive diagnosis of so highly infectious a condition 20 MINOR MALADIES, should not be made without the confirmatory evidence which the presence of the bacillus affords. It is, of course, often exceedingly difficult to be certain as to the exact nature of a febrile condition at first, or even subsequent, visits, but there is no excuse for seeking to overcome the difficulty by idly attaching a label, which, though it may be satisfying, is wrong. It is much better to be frank in such matters ; the practitioner who is straightforward always commands more confidence and greater respect than the one who poses as omniscient. The presence of real influenza may always be suspected from the sudden onset of symptoms with a high temperature. The symptoms may vary in degree and in kind (they are divided into nervous, respiratory, and gastro-intestinal), and their severity is not often great, but when they appear suddenly — so suddenly as to suggest a blow from an unseen hand — then the probability is that they are influenzal in origin. Occasionally, of course, the symptoms themselves are overwhelming in their severity — so overwhelming, in fact, as to convert a strong, healthy man into a prostrate mass of aches and pains in less than five minutes. The temperature at the onset is often high, reaching 106° F. or over, but it may be quite low, and even, according to some, subnormal from the first. Typical cases in an epidemic are by no means difficult of diagnosis, but atypical cases, especi- ally where they are sporadic, should always be referred to the bacteriologist before a positive opinion is given. COLDS, COUGHS, AND SORE THROATS. 21 If the disease is seen at its onset, the patient ought to be sent to bed at once, and kept there until the temperature has fallen to normal and the attendant discomforts have ceased. There is nothing which hastens this end so much as an initial dose of opium. I was first made acquainted with its merits about the time of the 1890 epidemic by a note in one of the journals by Sir Samuel Wilks, who told how, accord- ing to his diary. Prince Napoleon had been cured by such a dose, which had been prescribed by Corvisart. Since that time I have appealed to it on many occasions, and, if in a sufficiently early stage, never in vain. It is, however, necessary to give a full dose, say 20 to 30 minims, of liq. opii sed., if the beneficial effect is to result. This effect shows itself, as a rule, in a remarkably short space of time, and consists in the disappearance of the pains and the production of deep and refreshing sleep. So much impressed have I been with this line of treatment that I have learned to regard opium almost in the light of a specific against the Pfeiffer bacillus. That it should relieve the pains and soothe the irritated nervous system is not on general principles surprising, but that it should effect its purpose so rapidly, so completely, and so permanently, points to some action other than the ordinary effect of the drug, and is highly suggestive of some specific influence (see p. 52). When the acute stage is past, quinine seems to be the most useful drug. It appears to render the subsequent depression less profound and of shorter 22 MINOR MALADIES. duration. In connection with this depression, it is well to remember that it is often intensified by excessive and injudicious feeding. The ' keeping-up ' regime, which is so commonly prescribed during this stage, is regarded by the anxious friends as the height of therapeutic wisdom, but in reality it is liable to be quite the reverse. The system is very apt to become overloaded with effete matters, and the poisons have in consequence fewer opportunities for escape. The best thing to do with such a patient is to see that the food is simple and nutritious, contain- ing a little meat and some alcohol in the form of a well-matured wine, and to arrange for a complete holiday at the seaside as soon as possible. The locality chosen must depend, among other things, upon the time of year and the type of the attack, but bracing climates are as a rule strongly indicated. The next subject to be considered is that of SORE THROAT. There are, of course, several kinds of sore throat, and I wish it could be said that the degree to which specialism in this department has attained had been productive of any corresponding degree of precise knowledge as to their varieties and causation. To the plain man, where it does not mean scarlet fever or some similar condition, in which accompanying symptoms are present to clear the issue, sore throat spells tonsillitis ; and with regard to a tonsilUtis, the first point to decide is whether or not it is diphtherial. In these days of bacteriological investigation and antitoxin treatment, COLDS, COUGliS, AND SORE THROAtS. 2!^ the question may not seem to present the same im- portance as it did in the days when we were still without such assistance. But bacteriological investi- gation takes time, and reliable antitoxin is not always easy to procure, so that it is well to be prepared with a plan of campaign which leaves such luxuries out of account. Speaking as one who has had more than his fair share of experience in diphtheria, I may say that I know of no condition which, in its slighter forms, at any rate, is more difficult of diagnosis. It is, even now, no uncommon thing for a sore throat which has been dismissed as a passing matter tardily to vindicate its true character by a legacy of alarming and even fatal paralysis. Apart altogether, there- fore, from the question of preventing the spread of infection — a question whose importance and urgency cannot be too strongly insisted upon — it is essential that we should not, if we can help it, fail to recognise a case of diphtheria when we see it. ^ Now, there are two aids to diagnosis which, partly, perhaps, on account of the luxury of the bacteriological short- cut, seem to be falling into increasing disuse, of which, for this reason, and as being easy of per- formance and capable of yielding information of the utmost value, it is well that we should remind our- selves. The one is the state of the knee-jerks, the other the state of the urine. It is generally known, perhaps, that in diphtheria the knee-jerks are liable to disappear, and that albumin is often present in S4 AllNOR MALADIES. the urine. But it does not seem to be sufSciently realized that these phenomena, when they do occur, occur early, sometimes very early, in the disease, and that it is therefore our bounden duty to look for them in every case of sore throat, however slight, which presents itself to our notice. Now, let us suppose that we have detected such a case, and that a considerable amount of precious time must necessarily elapse before any reliable antitoxin can be obtained. What are we to do ? Taking the ordinary precautions as to isolation, etc., for granted, the first thing to do is to give the patient a mixture containing biniodide of mercury. Before the days of antitoxin I had learned to have so much confidence in this drug that I came to regard the occurrence of a case ot diphtheria with something very nearly approaching to equanimity. The biniodide is in- soluble in water, though freely soluble in the presence of an excess of iodide of potassium. The following is a convenient way of prescribing it: B. Hydrarg. perchlor gr.i Potass, iodid. gr. XXI. Glycerini 3ii- Aquam adgviU. In such a mixture a double decomposition takes place between the two salts, and the amount of result- ing biniodide is rather less than the original amount of perchloride, so that each ounce contains rather grain. The ordinary tablespoonful is, COLDS, COUGHS, AND SORE THROATS. 25 therefore, a perfectly safe dose for an adult ; and if its effects are carefully watched, it may be frequently repeated. The glycerine is added with the view of causing the mixture to adhere to some extent to the fauces, and of thus securing a local as well as a constitutional effect. The biniodide of mercury as a bactericide is four times as powerful as the per- chloride, and it has no tendency, as the perchloride has, to throw dowii an inert albuminate when brought into contact with the tissues. Whether for these reasons, or because it is especially inimical to the Klebs-Loeffler baciUus, in the same way that nitrate of silver is especially inimical to the gonococcus, there can be no doubt that, antitoxin apart, Hgl^ is a far more effective weapon in combating diphtheria than any drug, inhalation, or pigment which has ever been introduced. In severe cases of diphtheria, whether or not antitoxin be available, an early appeal should be made to strychnine, preferably by subcutaneous injection. This drug is believed to present a direct physiological antidote to the action of the toxins, by stimulating the very centres which the toxins tend to depress. Now, in a bad case, the toxins are being manufactured in large quantities, so that to be efficacious the drug must be vigorously pushed. The ordinary dose of ^ to ^ grain is quite useless even in the case of children. If the effects are watched, it will be found perfectly safe to give ^ or ^ grain four times a day for three or four days, and those who have not 26 MINOR MALADIES. tried it will be surprised to find how well it is tolerated. Strychnine is also infinitely the best drug for the treatment of diphtheritic paralysis. It is then best given by the mouth in combination with liq. ferri perchlor. (vide formula on p. 29). When we come to consider the forms of tonsillitis other than diphtheritic, I have to confess to an absence of settled convictions. That tonsillitis ' may be, and often is, a manifestation of true articular rheumatism, giving rise to endocarditis and causing valvular disease of the heart ; that it may, on the other hand, own no such relationship, and, even after repeated attacks, be followed by no such consequences ; that under the name of ' septic throat ' it is very properly recognised as due to bad drainage ; that not infrequently, especially in autumn, it seems to become epidemic ; and that, finally, it often arises under circumstances so ill defined that it is forced to herd with a motley company of congeners and aliens in that enormous pigeon-hole labelled ' Chills ' — these and perhaps some other facts are familiar to us, but connection and co-relation between them there is none. Fortunately, however, the aspect of the matter which we are considering — namely, the mere utili- tarian one of treatment — is but little affected by our ignorance, but before we discuss that question it is desirable to emphasize one point in the diagnosis. 1 'Tonsillitis' and 'quinsy' are terms which are frequently confused. TonsiUitia means an inflammation of the tonsil itself, whereas quinsy signifies a peritonsillar inflammation which frequently leads to abscess formation. COLDS, COUGHS, AND SORE THROATS. 27 There is, as I have said, nothing in the state of the throat itself to help us to determine whether a tonsil- litis is, or is not, of rheumatic origin, and as the settle- ment of this question is of paramount importance to the patient, it cannot be too strongly insisted that a careful examination of the state of the heart should be as much a matter of routine in a case of tonsillitis as it is in chorea or articular rheumatism. And in examining the heart, the feature to which particular attention should be directed is its size. The detection of any signs of dilatation, especially of the right heart, is of the utmost importance, for it enables us to deal with the condition while it is still amenable to treatment. If we wait until a murmur has declared itself, the time for effective interference may be already gone. With some people the examination of the heart is comprised in the use of the stetho- scope ; but auscultation is in reality far less important than percussion, and he who wishes to detect the earliest signs of impending mischief will do well to bear in mind that most excellent clinical rule, ' Eyes first, fingers next, ears last.' In the matter of the treatment of a tonsillitis, the first point of importance to be observed is the degree of the accompanying fever. If this is slight, the fact should give rise to a strong suspicion of the case being diphtheritic, and steps should immediately be taken to settle the diagnosis by bacteriological examination. In most illnesses a moderate elevation of temperature means a moderate degree of anxiety. 28 MINOR MALADIES. but sore throat provides a notable exception to this very obvious rule, which ought always to be borne in mind, not only because of diphtheria, but also because some, at any rate, of the worst septic throats are often attended by a quite insignificant amount of fever. If the temperature is high, which in most cases of tonsilKtis, other than diphtheritic, it usually is, the tincture of aconite has an excellent effect. When the thermometer registers 105° F. in a patient in whom we need not fear a certain amount of cardiac depression, tincture of aconite, in doses of 5 minims every four hours, or, better still (where its effects can be watched), in drop doses hourly for a few hours, will bring down the temperature rapidly, and wiU confer a degree of comfort on the patient which is really remarkable. And the higher the temperature, the greater is the confidence with which the drug may be prescribed. If a tonsillitis is taken early enough, it is quite possible to abort it by means of aconite alone. I have learned, however, not to depend on aconite alone. I find that it acts better, or, at any rate, that its action is not impaired by the presence in the mixture of other drugs directed against the local and constitutional aspects of the case. For instance, where the case is unquestionably rheumatic in origin, apart from the salicylates, upon whose importance I need not dwell, I have found guaiacum to be a most trustworthy remedy, and, in spite of the inelegance of the resulting mixture, I can fully recommend this formula : COLDS, COUGHS, AND SORE THROATS. Potass, chlorat. ... Tr. aooniti Tr. guaiao. ammon. Mucilag. acaciee... Aquam M. Sig. : Every four hours. gr. X. mv. 31. mxx. adgi. As soon as the temperature has fallen the aconite should be discontinued; but the other ingredients, the chlorate of potassium and the guaiacum, may be persevered with for some time. When a sore throat is neither diphtheritic nor rheumatic, it is always safe to treat it as due to some septic influence, and the treatment of such conditions is one of the most satisfactory things in all thera- peutics. The following mixture, with such slight Tariations as special circumstances may suggest, con- stitutes what the advertisements of quack medicines describe as a sovereign remedy, one of the very few with which I am acquainted : M E. Tr. aconiti , „ ... mii.-v. Potass, chlorat. .. gr. V. Liq. ferri perohlor .. mix. Liq. hydrarg. perchlor. .. mx. Liq. BtryohniaBB .. mv. Glycerini .. 3ii Aq. chlorof .. ad 5sB. . Sig. : Every four hours, or, better still, h alf the quantity every two hours, at any rate until the temp erature falls. As in the case of the previous mixture, the aconite should be stopped as soon as the temperature sub- sides, and the other ingredients continued until the local conditions in the throat are satisfactory. 30 MINOR MALADIES. This prescription owes its efficacy to its antiseptic powers. Few people seem to realize that liq. ferri perchlor. is, when taken internally, a bactericide of the utmost value. It was no doubt originally suggested in sore throat because of its astringency, but this attribute would not even partially explain its almost magical effects in a tonsillitis of septic origin. The liq. hydrarg. perchlor. is added with the view of account- ing for any cocci which may escape the attention of the iron salt, and the glycerine to enable the mixture to remain longer in contact with the fauces than it would otherwise do. Strychnine, in addition to being a general tonic, appears to have an antiseptic effect in most cases of septic sore throat, and it is, therefore, always well to include it. Chlorate of potassium is given more as a matter of routine than anything else. It has a reputation in inflammatory states of the pharynx, and if it does no good, it certainly does no harm. Treated with an initial purgative of a few grains of calomel, and by perseverance with this mixture, a tonsillitis which is neither diphtheritic nor rheumatic will yield completely in an astonishingly short space of time. In the matter of the taking of temperatures, not only in cases of sore throat, but in all cases, there is a word of warning to which I should like to direct attention. It has been proved that the temperature in the mouth is very materially influenced by many comparatively insignificant conditions which are purely local to the mouth itself. Thus hot fluids COLDS, COUGHS, AND SORE THROATS. 31 such as tea will raise the temperature two or even three degrees, and maintain this elevation for two hours or more. Food of any sort will also raise the temperature, though to a slighter degree, and cold fluids will depress it. The moral of this is that we should never be satisfied with a temperature which has been taken in the mouth. This is, of course, infinitely the most convenient place in which to take it, especially in a person fully dressed, but we do well to remember that a record so obtained is very un- reliable under all circumstances, and that it is con- spicuously BO when any portion of the buccal or pharyngeal mucous membrane is inflamed. There is a condition which, as it is often described as a FEVERISH COLD, it is as well to notice here. It is, indeed, known to fame by various names. The scientifically -minded call it 'febricula,' those who seek to be impressive describe it as a • chill on the liver,' while everyone is very liable to mistake it for influenza. It consists of a general feeling of malaise, with pains in the back and limbs, accompanied by a temperature which may ascend in forty-eight hours to 102° F. or over; It may be distinguished from influenza by its comparatively gradual onset, by the fact that the pains, though severe, are aggravated by movement and are always worse at night, by the comparative absence of other symptoms, and by its very rapid defervescence under suitable treatment. The condition has nothing to do with cold ; it is as a rule connected with the gouty diathesis even in young 32 MINOR MALADIES. people, and is essentially a myalgia or 'muscular rheumatism ' distributed over a wide area.* If it is seen early enough — that is, before the temperature has risen above 100° F. — a hot wet pack {vide p. 204) will probably cut it short. The primae vise should be cleared, and aspirin given in doses of 10 to 15 grains every three hours until the symptoms subside. In people who are otherwise healthy I have often known a single dose of 20 grains of aspirin to remove all symptoms in a few hours. It is important to recognise this condition, because the mistake of con- fusing it, as is now so often done, with influenza creates very unnecessary alarm in the patient's household and amongst his friends. Moreover, the condition being allied to goutiness, a wrong diagnosis of influenza will almost certainly lead to a disastrous line of after-treatment. The prostration which follows even mild attacks of real influenza suggests a tonic and stimulating regime, whereas the after-manage- ment of febricula should be directed to prevent a recurrence by combating the gouty tendency which predisposes to the condition. The person who has had influenza 'fourteen times in the last three months' has probably never had influenza at all. The attacks have been due to febricula, and their constant recurrence has been the result of a wrong diagnosis, and its logical outcome, mistaken treatment. In a great many of these so-called influenzal attacks the real cause is toxaemia of gastro-intestinal origin arising from abuse of meat foods, alcohol and tobacco, > See Chapter IV. COLDS, COUGHS, AND SORE THROATS. S& leading to high arterial tension, a question which is discussed in the chapter on Goutiness. Sore tliroats of septic origin are occasionally over- looked. Where the invasion is severe and the con- stitutional symptoms are consequently pronounced, the local discomfort is apt to be lost sight of; the patient does not mention the throat, and its condition is therefore not investigated. The high temperature being thus the only objective sign, the case is liable to be regarded as one of typhoid, a watching policy is pursued, and no improvement results. It is there- fore a good rule to examine the throat carefully in every case where a high temperature is not due to some obvious cause. In cases where there is reason to suspect typhoid, there is one simple diagnostic point which, when present, is very helpful. It is that in this disease, though the temperature is usually very high, the pulse may be low, the one registering, say, 104° F. and the other from 70 to 80. In cases of undoubted typhoid a rapid pulse is of evil prognostic omen. A CONSTANT SUCCESSION OF COLDS occurring in the same person should never be lightly regarded. The recent impetus which has been given to the study of tuberculosis has resulted in the bringing to light of various signs and symptoms which indicate a condi- tion of what is called pretuberculosis — a condition, that is, in which, although there may be nothing which permits of a positive diagnosis, there are never- 3 34 MINOR MALADIES. theless indications of sufficient importance to warrant grave suspicion. The time has now gone by when, before commencing treatment, we used to wait m prayerful patience until there was an involvement of the pulmonary area so definite as to be accessible to ordinary percussion and auscultation. We now realize that to wait for the classical signs of phthisis is to allow the period to slip by in which treatment is most likely to be effective. Phthisis is, no doubt, under favourable circumstances, a very curable disease; but the condition precedent to its ready curabihty is its detection in its earUest — that is, its pretuberculous — stage. The stigmata which may be said to reveal the exist- ence of this stage are, like a constant succession of colds, for the most part, individually so unimportant that they are properly regarded as minor conditions ; it is only the association of several or many of them which confers upon them their gravity. They would seem, therefore, to deserve more than a passing notice. In common with all other toxic agents, the poison of tubercle has certain physiological effects. Of these, one of the most important and far-reaching is its relaxing effect upon the peripheral vessels. When it is borne in mind that the tuberculous toxin is initially above all things a powerful vaso-dilator, it becomes comparatively easy to understand and recall many of the phenomena of pretuberculosis which otherwise seem disjointed and obscure. COLDS, COUGHS, AND SORE THROATS. 35 Directly consequent upon this vaso-dilation is the important symptom of tachycardia. What is true of most of the other symptoms to which, in this connec- tion, reference will he made is very conspicuously true of tachycardia — namely, that it is by no means always present. In cases of demonstrable tuberculous lesions it is, of course, a prominent and constant symptom, but in the very earUest stages there are frequently no signs of heart-hurry. Nevertheless, an unduly rapid pulse in an otherwise seemingly healthy person should always suggest tuberculous infection as its cause. A grave error is often committed in attributing such a tachy- cardia in young men to excessive tobacco-smoking. Another symptom which is directly due to the vaso- dilation caused by the poison is alhwminuria. A good deal of very unnecessary, and, I may add, scarcely justifiable, alarm is occasioned to patients and their friends by the unduly narrow view which is commonly taken of the significance of this symptom ; for albuminuria, it seems necessary to insist, is a symptom, and nothing more than a symptom ; and it is as absurd to regard it as synonymous with kidney disease as it would be ridiculous to consider epistaxis as synonymous with typhoid fever. Albumin will appear in the urine if the kidneys are in any degree passively congested. A widespread vaso-dilation will readily cause this passive congestion, especially if the patient be going about in the ordinary way — if, that is, he is for the most part in the erect posture. This 36 MINOR MALADIES. is a phenomenon with which we are all familiar in the cyclical or postural albuminuria of adolescents, a condition which has been attributed to many causes, and has in numberless instances been made the occa- sion of solemn head-shakings, but which is in reality due simply to a want of tone in the muscular coats of the peripheral vessels, giving rise to passive conges- tion in the renal area. Owing to the vaso-dilative effect of the poison, this passive congestion is very liable to occur in early tuberculosis. It is not, of course, suggested that all those who present the phenomenon of cyclical or postural albuminuria are necessarily pretuberculous, but I am distinctly of opinion that the discovery of albumin in the urine of an adolescent, which has not been voided immediately after exercise, is a sign which should lead to a very minute examination for other evidences of tuberculous invasion. Collier of Oxford and others have con- clusively shown that albumin in the urine of young men soon after exercise is not only without morbid significance, but that it may even be regarded as a normal sequence of severe muscular exertion. Another symptom of early tuberculosis in the causa- tion of which vaso-dilation may reasonably be con- sidered to bear some part is dyspepsia. Dyspepsia, especially of the asthenic type, is due to a faulty adjustment between the blood-pressures in the local areas. A widespread vaso-dilation disturbs the normal balance, and tends to deprive the gastric COLDS, COUGHS, AND SORE THROATS. 37 area of that increment of blood which for the pur- poses of the digestive process is essential to it. The dyspeptic symptoms which so commonly forerun the ebullition of definite tuberculosis, more especially of the lung, are thus easy to understand. The difficulty consists in the fact that we are so liable to forget their true significance. Such a dyspepsia may be accompanied either by diarrhoea or constipation, but in the earliest stages constipation is much the more common of the two. Two other signs, which may be included under the head of results of vaso-dilation — namely, mental hebetude and muscular debility — are, of course, by no means peculiar to tuberculosis ; but, like others, their presence — especially their continued presence — in young people, without obvious cause, goes to swell the number of points upon which a superstructure of reasonable suspicion may be erected. The majority of lethargic children who are punished for indolence at school, when they are not the subjects of eyestrain or nasal obstruction, owe their lack of energy and want of comprehension to the relaxing effects of the tuber- culous toxin; and a large number of adults who are idly labelled ' neurasthenic ' undoubtedly owe their nervous exhaustion to the early inroads of the bacillus. Among the many causes which give rise to euppres- eion of the m,enses the action of the poison of tubercle should not be forgotten. This is another symptom 38 MINOR MALADIES. which is due directly to its vaso-dilative power. Menstruation is effected by the dilation of the pelvic vessels coincidently with a contraction of thei other systemic arteries. If the contraction of these arteries is prevented, as by nitrite of amyl or trinitrine, the menstrual flow does not appear. The poison of tubercle acts in the same way, though less power- fully, and hence it is that amenorrhcea is so common a precursor of obvious tuberculous mischief. The second physiological effect of the tuberculous toxin under which, in our efforts to generalize, we may group some of the phenomena of the very early stages, is irritation of the nervous system. The most important member of this group is certainly pyrexia. The fever of tuberculosis is one of the most interesting features of this complex disease. It is, as a rule, slight, sometimes so slight as to escape the notice of all but the most meticulous observer, and, although it is almost invariably present, it is usually only at night that it is to be detected. By no means infre- quently it follows in the wake of a pyrexia due to some obvious and well-recognized cause, and seeks, as it were, to conceal its real significance by masquerad- ing as a continuance of this initial complaint. But perhaps the most characteristic feature about the fever of tubercle is its persistence. We have all been taught to suspect the operations of the bacillus typhosus in a case where malaise and a temperature represent the only departures from the normal. It COLDS, COUGHS, AND SORE THROATS. 39 does not reduce the value of such advice to recall the saying of the late Dr. Moxon, of Guy's Hospital, to the effect that if a candidate at an examination failed to include tubercle among the causes of continued fever, he avways referred him to his studies. Among the many negations and ambiguities of this evasive and protean disease we have, then, this positive and unequivocal sign to aid us : that fever, whether it be of the intermittent, remittent, or hectic type, especi- ally if the rise be slight and present only in the after- noon between the hours of 2 p.m. and 6 p.m., which persists beyond the allotted span of recognisable fevers, is in all human probability tuberculous in origin. It is, however, necessary to remember that a tem- perature oi 99° F. to 99'6° F. is not uncommon from 2 to 8 p.m. for three or four days before a perfectly normal menstrual period. Moreover, Kingston Fpwler says that the only form of pyrexia which can be regarded as pathognomonic of tubercle is that in which the morning temperature is higher than the evening reading. A subnormal temperature when persistent and most pronoimced in the evening is generally due to thyroid insufficiency. To an undue irritability of the nervous system we may, I presume, attribute the psychical charac- teristics of most pretuberculous persons. The sufferers from gross lesions are notoriously, unduly, and even pathetically optimistic in their mental out^ 40 MINOR MALADIES. look, but such is seldom the attitude of the pre- tuberculous. The atmosphere surrounding the latter can only be described by the French word difficile. It is not that they are necessarily aggressive, though they sometimes are, but they present a conspicuous absence of what Matthew Arnold used to describe as ' sweet reasonableness.' They are passive resisters to any suggestions for their welfare, and they are apt to try the tact and patience of the physician more severely and more obstinately even than people who are definitely insane. A change of manner and dis- position in this rather indefinite direction, more especially when associated with other signs, consti- tutes confirmatory evidence of very anxious omen. Very considerable importance is attached in France to a sign of pretuberculosis, which is presumably the direct outcome of irritation of the nervous system, of which in this country we hear very little — namely, an exalted sexual appetite. The toxin of tubercle would seem, especially in young men, to exercise a very decided aphrodisiac influence, and our French friends contend that in the many cases in which the disease appears to supervene as a fitting nemesis upon a licentious adolescence, the real truth lies in the fact that when the unfortunate patient embarked upon his immoral career he was already the subject of tuberculous invasion — that it was, in fact, the action of the toxin which impelled him to the unbridled gratification of his passions. This view of the matter COLDS, COUGHS, AND SORE THROATS. 41 is well worthy of serious consideration among people like ourselves, in whom an unduly literal interpreta- tion of the Old Testament teaching has begotten a belief in the direct intervention of Providence for the immediate physical punishment of moral transgres- sion. Trousseau was the originator of the saying, which has been attributed to many physicians since his time, that an ancemia which does not yield to iron is probably due to tubercle. It would be difficult to overestimate the value of the practical lesson which this saying is intended to convey. The form of anaemia to which it refers is, of course, a general ansemia : in young girls we should call it chlorosis- An examination of the blood reveals nothing which serves to distinguish it from chlorosis, but it is of paramount importance that it should be so dis- tinguished, and that as soon as possible. There is also a local ansemia, which, as being more common, is of even greater importance than this general ansemia, and of which, in our search for the stigmata of pre- tuberculosis, we do well to remind ourselves. This is the ansemia of the soft palate with which throat specialists are familiar in all cases of laryngeal tuber- culosis. Now, this is a symptom which frequently occurs quite independently of a general ansemia, and independently also of definite laryngeal tuberculosis ; it is, in fact, a valuable sign of pretuberculosis, and one which from its ease of recognition should always 42 MINOR MALADIES. be looked for. It seems hardly necessary to point out that in the other two classical chronic diseases — namely, gout and syphilis — the soft palate, instead of being ischsemic and insensitive, is almost invariably injected and irritable. The pretubercuious throat supports a laryngeal mirror with equanimity ; the gouty or syphilitic throat will often refuse to tolerate it until cocaine has been liberally applied. In connection with the throat there is another matter to which it seems pertinent here to refer, and that is the significance of functional aphonia. This is commonly and very authoritatively described as one of the stigmata of hysteria, but it is now being invested with a fresh importance, inasmuch as it is confidently regarded as one of the very earliest manifestations of pretuberculosis. I have no experi- ence which enables me to confirm this view, but the quarter from which it emanates entitles it to every respect and consideration.^ Among the symptoms of pretuberculosis the exact meaning of which still await explanation the occur- rence of dyspnoea is probably the most important. The dyspnoea of the fuUy-developed or active pul- monary lesion requires, of course, no explanation ; ' Soon after the above was first published (Polyclinic, October, 1907), Dr. Fleming Browne wrote to tell me of a patient, now definitely phthisical, whom he had first seen six months previously with complete aphonia. The throat specialist who was consulted assured him that it was purely functional. The voice soon returned, and this was followed at a short interval bv the development of demonstrable phthisis, COLDS, COUGHS, AND SORE THROATS. 48 but it should be remembered that breathlessness due to a tuberculous cause is by no means confined to the later stages of the disease, nor is it even a special attribute of pulmonary invasion. There is a dyspncea which is apt to appear in the very earliest stages of tubercle, and it is just as likely to herald abdominal or intracranial mischief as the more classical phthisis. There is nothing characteristic about it except that the most careful examination of the heart and lungs fails to afford any explanation of its meaning. It is to be distinguished from the dyspnoea of slight effort, which is so suggestive of functional high arterial tension,^ only by the observation of concomitant signs. In tuberculosis there will probably be present some of the other stigmata with which this section deals, and the patient will generally be young. In the arterial condition there wUl be the accentuated second sound at the aortic base, and the patient will generally be at least middle-aged. There is also the sphygmomanometer to aid us; for whereas high blood-pressure from vaso-constriction is the essence of the one condition, low blood-pressure from vaso- dilation is characteristic of tubercle, even in its earliest stages. It has been well said that a per- sistent dyspncea which cannot positively be assigned to a definite cause is almost certainly tubercu- lous, * See p. 220, 44 MINOR MALADIES. In weighing the evidence for and against the presence of tuberculosis in any particular case, the importance of the condition of the bronchial glands cannot be overestimated. They constitute the first line of defence where the primary infection comes by way of the air-passages, so that they tend to show a very early reaction to any disturbing influence. It is unfortunately impossible to examine these glands during life, and they may therefore attain to a considerable size before they hoist signals of distress. There are, nevertheless, two signs for which it is our duty to search whenever there is any suggestion of tuberculous involvement. One of these is slight paresis of a vocal cord. Generally, but not in- variably, it is the left cord which is thus affected, for the same reason that it is affected in aneurism — namely, on account of the anatomical disposition of the left recurrent laryngeal nerve. In a few cases, however, it is, for some unexplained reason, the right cord alone which is affected. The other symptom is also associated in our minds with aneurism, and is doubtless due to pressure upon the sympathetic — namely, inequality of the pupils. This sign, like many of the others which we have been considering, can only be regarded as tending to confirm a suspicion otherwise aroused, more especially as it is undoubtedly present in many people who are perfectly healthy. A history of a constant succession of colds, to which reference has already been made, is very suggestive of COLDS, COUGHS, AND SORE THROATS. 45 early tuberculosis. This fact is now very generally accepted, but it is unfortunately as generally mis- interpreted. It does not mean, as is commonly sup- posed, that the person is originally or hereditarily unusually susceptible to the influence of the bacillus, but it indicates that the patient is living in unwhole- some surroundings, which depress his vitality and render him a ready prey to microbic invasion. Such are the people who wear flannel next their skins ; who in fine weather make a virtue of sleeping with the window ' a little bit open at the top '; who know that they are in a ' draught ' because it makes them sneeze — who, in short, live thoroughly unwholesome, coddling lives, and thus cultivate within themselves an atmosphere, both physical and moral, in which the bacillus flourishes and multiplies exceedingly. A constant succession of colds, therefore, has this degree of pretuberculous importance — that it implies a mode of life in which all aerial microbes are aff'orded abun- dant opportunities, with the result that the soil is suitably prepared for the reception of the bacillus of tubercle whenever the latter should think fit to advance. To ' live cleanly,' so far as the air-passages are concerned, is not only to avoid tubercle, but to avoid also the constant catarrhal attacks which are ignorantly attributed to draughts and chills. It has now been taught for some years that pleurisy is a tuberculous manifestation. I should be very sorry indeed to think that all pleurisies were of that 46 MINOR MALADIES. nature, and I am quite convinced that it is not so. It is nevertheless right that we should regard a person who has had a definite pleural effusion with a certain amount of anxiety. There is, however, one form of pleural effusion which is to be regarded with very special anxiety, and that is the form which comes on without pain, fever, cough, or any of the other signs which usually proclaim the onset. The patient feels unwell rather than positively ill ; his only complaint is dyspncsa ; but when his chest is examined, one pleura is found to be fuU of fluid. This stealthy form of pleural effusion may follow some definite pulmonary disease, or it may occur independently of any previous illness. It is perhaps rare, but when it does occur, it almost invariably connotes tuberculosis. When we do meet with it, therefore, we do well to treat it with all the circum- spection which its true inwardness demands. When suspicions have once been aroused, it is, of course, our duty to institute a minute search for any- thing by which they may be confirmed. The lungs should be examined for weak breathing, especially at the bases ; for harsh or cog-wheel breathing, especially at the apices ; and the possible presence of enlargcl Ij'mphatic glands, more especially in the neck ana axillffi, should engage our attention. The details of these matters are carefuUj^ reviewed in most of the text- books, so that they need not be considered here. COLDS, COUGHS, AND SORE THROATS. 47 An accessory diagnostic aid which has the double merit of helpfuhiess and ease of application is the ulrtar reflex} The patient's forearm is bared and the arm placed in the flexed position, with all the muscles, especially those of the fingers, fully relaxed. If a pin be now sharply drawn along the whole length of the ulnar side of the forearm from elbow to wrist, in most tuberculous cases the abductor minimi digiti will contract, and cause a distinct reflex wrinkling of the hypothenar eminence. This response of the abductor minimi digiti, while it cannot be called pathogno- monic of tuberculosis, may nevertheless be regarded as confirmatory evidence of the strongest description. It is very seldom present in conditions other than tuberculosis, but is by no means always present in cases which are undoubtedly tuberculous. The re- sponse has seemed to me to be more readily elicited in those accustomed to use the small muscles of the hand, and very difficult to obtain in those who are engaged chiefly in coarse employment. Like many other valuable signs, there is doubtless a certain degree of ambiguity in connection with it. When it speaks, within certain limits it speaks true ; but when it does not speak, we must not allow ourselves to be lulled by its silence into any false sense of security. When all the clinical methods have been exhausted we can, when still in doubt, carry our appeal into other, though not necessarily higher, courts. It is ' Phipps Institute, second Annual Beport. Dr. J. J. Gal- braith (Practitioner, June, 1907). 48 MINOR MALADIES. scarcely necessary to mention an examination of the sputum for the presence of bacilli, because the importance of such a procedure, if overlooked by the medical man, is sure to be remembered by the patient or one of his friends. At the stage which we are now considering, however, it is only right to say that such an examination would almost certainly prove negative. A laboratory method which is more likely to give positive information is that of estimating the opsonic index. It is, of course, by no means always possible to avail ourselves of the great advantage of this means of diagnosis, but where it is possible it should always be resorted to. There remain two methods to be considered, the one of which comes to us from Germany and the other from France. The first is von Pirquet's * cuti- reaction,' which is obtained by vaccinating the skin with a 1 per cent, solution of tuberculin. In a healthy person this produces no effect, but in the tuberculous, the vaccinated area becomes red, swollen, and occa- sionally pustulous, within twenty-four hours, return- ing to normal again in from five to ten days. This method is very valuable in children under ten years of age. In adults it is apt to be misleading, for the reason that in the majority of persons over ten years of age a more or less positive reaction is said to ensue. The second is the plan advocated by Pro- fessor Calmette, of Lille. A drop of a 1 per cent, solution of dried tuberculin is placed in the patient's COLDS, COUGHS, AND SORE THROATS. 49 eye. In a healthy person no reaction ensues, but in the tuberculous there follows the 'ophthalmo-reaction' — that is, an acute catarrhal conjunctivitis. The objection to this method is that the conjunctivitis is apt to be so acute as to endanger the eye itself. Very serious results have been reported in several cases. ADDITIONAL FOBMULiB. Nasal Washes. Lotions intended for cleansing the nose may be used as simple hand-washes, or placed in a nasal douche, irrigator, or spray. The nasal douche of any apparatus on the siphon principle is to be avoided, the great and continuous pressure exerted rendering its use dangerous. A very simple method is to sm£f the lotion from the palm of the hand or from a shallow cup or bowl up through the nose, letting it pass well into the throat and returning it through the mouth. This should be practised before rather than after meals, as it may excite retching or even vomiting. About an ounce and a half of solution should be used at each time, and it should be employed comfortably warm (about 100° F.). The use of a nasal irrigator should, however, where possible, always be substituted for the above. A spray may also be used, but it is not nearly so effective as a douche. An instrument giving aa coarse a spray as possible should be chosen. 4 50 MINOR MALADIES. The following formulae have stood the test of time :^ ?!. Sodii bicarb gr. iii. Sodii biborat gr. iii Acid, carbol gr. 1. SaccL alb gr. v. Aquam ad gi. M. et solve. Detergent. ^. Tr. benzoin, co. "Iv. Sodii biborat gr. v. Sacch. alb gr. v. Aquam ... ... ad 5i. M. Sedative. Seigle's steam spray producer is a very useful apparatus when a warm spray is preferred. Used in this apparatus, the following was a favourite combination of the late Mr. Arthur Durham's in the treatment of ' hospital throats ' : Boraeis ... 3iss. Acid, boric ... gr. xl. Tr. iodi ... 3ss. Liq. morph. hydrochl. ... 5i. Glycerine ... 5i. Aquam ... ad gviii. M. This may be used for ten minutes every hour, and will be found very soothing. Gargles. About half a fluid ounce should be taken in the mouth for each act of gargling, and this should be ' See Pharmacopoeia of the Hospital for Diseases of the Throat. COLDS, COUGHS, AND SORE THROATS. 51 repeated four times on each occasion. Gargles should be used about every four hours. ]^. Fotas. chlorat gr. xii. Sodii bioarb. ... ... ... ... gr. vi. Potas. bioarb gr. vi. Aquam ad 5i. M. Ft. garg. Detergent and sedative. IJ. Eesoroin gr. x. Aquam ad gi. M. Ft. garg. Antiseptic. The following is a useful snuff : a. Menthol gr. viiL lodol gr. lixx. Acid, boric gr. co. Sacch. alb. Si. M. Sig. : To be used as a snuff. Cough Mixtures. To allay Tickling Cough, Br. Tr. camph. co. 3ii. Ozymel acillse 5ii- Syr. tolu. 3ii. Glycerin. 3U. M. Dose : 1 drachm. B<. Heroin gr. i. Acid, hydrocyanic, dil. mnx. Oxymel acilliB 5ii. Syr. limonis 3ii. Aquam ... ... ... ... ... ad Si. Dose : 1 teaspoonful. An exceptionally agreeable mixture is that sold by Ferris and Company of Bristol under the name of syr. pectoralis rub. 52 MINOR MALADIES. A useful lozenge is : Menthol ... gr.J Pulv. glyoyrrhizae ... gr. ii, M, Ft. ' nigroid.' Influenza. Dr. J. 0. Boss, of Manchester, writing in the Lcmcet (NoTember 3, 1906), speaks in the highest terms of the effect of the oil of Ceylon citmamon bark in the treatment of this con- dition. The earlier the treatment is commenced, the more satisfactory axe the results ; but, however late in the disease the oil is administered, it never fails to do good. It allays the sub- jective sensations, rapidly reduces the fever, and prevents sequelsB. Twelve drops of the oU in a wineglassfnl of water are given immediately, and the dose is repeated in an hour. Two hours after the second dose 10 drops are administered, and then 10 drops every two hours until the temperature falls to normal. After this 10 drops are given three times a day for three days. Other writers appear to have had equally favourable results from this line of treatment, which seems well worth a trial. Chronic Bronchitis. In the treatment of the chronic winter cough of the aged, attended by copious expectoration. Sir Hichard Douglas FoweU ^ recommends the following : 9. Liq. picis aromat. (Bell) ... 3ii Glycerini ... ... ... 3iv. Ext. liq. glyoyrrhizas... ... 3iss. Spts. ammon. aromat. ... 5iv. to 3vi. Tr. oardam. co. ... ... 5iv. to 3vi. Aq. chloroform. ... ... ad 5'^i- M. Sig. : A sixth part thrice daily. 1 ' Senile Respiratory Disorders,' The Hospital, December 7, 1907. CHAPTER II. INDIGESTION. I INTEND in this chapter to confine myself to the consideration of those forms of dyspepsia which are not of organic origin. The dyspepsias which arise in association with cancer, with ulcer, with hepatic and renal cirrhosis, with pulmonary tuberculosis, and other forms of structural disease, are exhaustively considered in the text-books, whereas the purely functional dyspepsias — the dyspepsias, that is, whose symptoms are due to such faults as those of secretion and motihty — though far more frequently encountered in daily practice, are not so considered. These cases occur in people who are for the most part otherwise healthy, who are impatient of the disabilities and dis- comforts which the malady imposes upon them, and who are impatient also of anything short of prompt and complete relief. Their successful treatment is, therefore, a matter of considerable importance. To this end our first care must be to learn to classify them properly. In view of the multiplicity of qualifying and would-be distinctive adjectives which are generally found in connection with the 68 54 MINOR MALADIES. term ' dyspepsia,' this would not at first seem to be a simple matter. In quite a recent text-book the varieties of gastric indigestion are given as follows : atonic, gouty, renal, irritative, flatulent, and acid ; and reference to other text-books would in all probability reveal several more. But, in that they suggest essential distinctions, these terms are in reality misleading. It is better, therefore, to discard them altogether and to classify functional dyspepsias under two heads only — the sthenic and the asthenic. These two present distinct and definite clinical types, with different pathology, different symptomatology, and very different treatment. All else is chaff and dust, which let the wind blow whither it listeth. But before we proceed to the details of this classification, it is necessary to consider briefly the main facts of gastric digestion, in the light of the researches of Pawlow and others, which have recently been admirably crystallized in a short paper by Dr. Langdon Brown.^ We know that the masticated and insalivated food passes from the mouth along the oesophagus into the stomach, where it is acted upon by pepsin and HCl, and the arresting feature in connection with the above-mentioned researches is the prominent part which, in their light, must henceforth be assigned to the action of HCl. It used formerly to be believed that pepsin was the predominant partner ^ ' On the Eational Treatment of Gastric Disorders,' Practi- tioner, October, 1904 INDIGESTION, 66 in this association ; it is now recognised that HCl is of infinitely more importance. The presence of the acid is essential to the activity of the ferment, and if HCl is not present in sufficient degree, no conversion of the food can possibly take place. The mass becomes a mere mechanical irritant to the mucosa, and excites only the outpouring of alkaline mucus. This in its turn surrounds the mass and renders its permeation by the digestive fluids still more difficult. But this is not alL HCl, which is thus seen to be necessary to gastric digestion, is by the above-mentioned researches shown to be necessary also to pancreatic digestion. ' Bayliss and Starling have shown that the hydrochloric acid of gastric juice acts on the prosecretin stored in the intestinal mucosa to form secretin, a specific stimulant to the flow of pancreatic juice. . . . Therefore, if there is not a due secretion of acid, pancreatic digestion is impossible.' Now, we know that the functions of the pancreas include the digestion of fats and the elaboration of such of the carbohydrates as have escaped digestion by the saliva, so that it is evident that the absence of a proper quantity of HCl in the gastric process entails serious effects not only upon the digestion of proteids, but upon the digestion of all the proximate principles of food, proteids, carbohydrates, and fats. It is therefore impossible to overestimate the importance of the presence in full force of this constituent of the gastric juice. 56 MINOR MALADlteS. Let us now look at the other side of the picture, and consider for a moment what happens when the hydrochloric acid, instead of being deficient, is ex- cessive in quantity — a state of matters which, as we shall see presently, may be the result of various causes. In the normal person no more gastric juice is secreted at any individual meal than is necessary to the digestion of that meal, so that in a certain time after the meal is finished the secretion slows off and eventually ceases.^ If the stomach supplies too much juice, or if the supply is continued beyond the limits of the digestive requirement, the food-mass becomes too acid to be allowed into the duodenum. The pyloric sphincter therefore contracts and pre- vents the passage of the food out of the stomach until the bile and pancreatic juices are present in quantities sufficient to neutralize its acidity. This may take some hours, and the gastric mucosa and nerve-endings are, during the interval, subjected to continual irritation, which varies, of course, in degree, according to the amount of acid present in excess. Now, it is possible to bring all cases of functional dyspepsia under these two heads — those in which hydrochloric acid is deficient and those in which it is excessive. And, first, it is necessary to remember that the causa causans of the dyspepsia is the same in both — ^that is, the retention of food in the stomach long after that viscus ought to have finished with it. In both cases the mass becomes a species of foreign * Vide Starling, Oroonian Lectures, IQOCi. INDIGESTION. 57 body, giving rise directly to pain, the outpouring of mucus, and the development of flatulence ; and indi- rectly to languor, sleeplessness, and irritability of temper. These symptoms, then, are common to both classes, and indicate merely that we have a dyspepsia to deal with. They are Hable to be present in any and every case of indigestion, and consequently they afford no assistance in classification. As bearing on this fact, it is well to remember that there is a hne of treatment which, in so far as it is successful at all, is equally successful in both. This is the practice of giving alkahes before meals. Alka- lies were originally given before meals on the sup- position that they excited the flow of hydrochloric acid and pepsin in the stomach. As the practice gave relief to a very large number of dyspeptics, the supposition was held to be correct until the researches already referred to conclusively proved that, so far from promoting the flow of gastric juice, the alkalies very materially retard it. How, then, are we to explain the benefits which have admittedly followed the practice of prescribing alkalies in all forms of dyspepsia? In the light of what we have already seen as to the mechanism of dyspepsia, the explanation is not very far to seek. The mass which tarries in the stomach (whether the tarrying be the result of too little hydro- chloric acid or of too much) sets up an irritation, which in its turn provokes the outpouring of mucus and the development of flatulence, the evil eSeots of 68 MINOR MALADIES. which are still present when the time for the next meal has arrived. If, however, just before that meal is taken — say half an hour before — we put into the stomach a draught of water containing an alkali, we are applying lavage to that stomach — we are washing it out with a solution which is of all others the best calculated to remove the sticky mucus which is adhering to its walls and occluding the mouths of the secreting glands. Herein, then, resides the efficacy of the practice of giving alkalies before meals — the organ is relieved not only of the mucus, but also of the undigested residue of the last meal, and is thereby cleansed and prepared for the reception of the next. And, as 1 have said, it matters nothing in this connection which form of dyspepsia we are dealing with, for in both there are undesirable matters to be removed, and in the treatment of both, a clean stomach for each meal is a great desideratum. One practical point emerges from these considera- tions, namely, that if our desire is to wash out the stomach, we should see to it that the fluid is not stinted. The alkali — say 10 grains of sodium bicarbonate — should therefore be dissolved in, or immediately followed by, a full half-pint of water, preferably hot. In one other respect, and in one other only, is it unnecessary, from the point of view of treatment, to distinguish between the two forms of dyspepsia — I mean the freeing of the primse vise. Above all INDIGESTION. 69 things, let the state of the bowels engage the most serious attention. The presence of constipation will obscure every issue and nullify every therapeutic effort. The best initial measure is undoubtedly a dose of calomel. This drug is not only a purgative, but it is also the very best of all intestinal antiseptics. Further, the excretory function of the skin should not be despised. It is too large a question to be discussed here, but there are many facts which point to the conclusion that some of the more obscure phenomena of indigestion are to be explained by assuming that defective cutaneous activity reacts in a special manner upon the gastric secretions. Be this as it may, a hot bath or a hot wet pack at the onset of treatment will often make all the difference between prompt and tardy relief. Now how are we to distinguish between these two forms of dyspepsia, the sthenic and the asthenic ? There are certain marked differences both in the type of patient and in the nature of the symptoms which cannot fail to strike the careful observer. The sthenic form occurs in people who seem other- wise to be in robust health — people who are for the most part strong, active, and energetic, and who are seldom teetotallers. The asthenic form appears in weakly, nervous, convalescent, or overworked persons who may be teetotallers, but who are generally tea-drinkers. The one is essen- tially an active, positive, the other a passive negative, type; and the distinctions between the 60 MINOR MALADIES. symptoms are in consonance with these characteristics. The sthenic tongue is firm and generally furred ; the asthenic is flabby, frequently indented at the edges, and generally clean and glazed. The sthenic pulse is slow and full, the asthenic quick and feeble. The sthenic appetite is voracious and ever present; the asthenic is weak, capricious, and often absent. In the sthenic, the discomfort consists of a sense of epigastric fulness ; in the asthenic, it consists of actual pain in the epigastrium striking through between the scapulas. In the sthenic, a full meal relieves the symptoms ; in the asthenic, it aggravates them. In the sthenic, the mental state is one of irritability ; in the asthenic, it is one of depression. But perhaps the most striking, as it is certainly the most diagnostic, distinction is presented by the period of onset of the symptoms. This in the sthenic is delayed until towards the end of the digestive process — that is, from four to five hours after a full meal ; whereas in the asthenic the discomfort, always more or less present, becomes acute within half an hour of the ingestion of food. There is one symptom which is often mentioned in connection with dyspepsias of all sorts which, nevertheless, occurs only in the sthenic form — namely, heartburn. It is by no means always present, but when it is there can be no shadow of doubt as to the class to which the case belongs. The same may be said of pyrosis or the gushing of alkaline fluid from the mouth. This fluid is in reaUty saliva INDIGESTION. 61 of a rather higher alkalinity than normal, and its secretion represents an effort on the part of Nature to relieve the symptoms by introducing an alkali into the stomach. It only occurs in very severe cases, but when it does occur the diagnosis is no longer in doubt. The matter of differentiation is not, however, always so easy as the above distinctions would seem to indicate. It must be remembered that we are dealing almost exclusively with subjective phenomena; that not all patients are intelligent, and that most dyspeptics tend to exaggerate their symptoms. But, fortunately, where, after due consideration, a doubt does remain in our minds as to whether we are dealing with a sthenic or an asthenic case, it is speedily set at rest by the results of treatment. For, as will be readily understood from the essential features of the two conditions, what will relieve the one will tend to aggravate the other. If, for example, we give a dose of HCl to a patient suffering from sthenic dyspepsia, we thereby increase the amount of the offending material, and add conspicuously to his miseries; and, similarly, if to a stomach which is crying aloud for HCl we respond by administering an alkali, our interference can have but one effect — that, namely, of aggravating the existing mischief. This refers, of course, to medicines given after meals. As I have already pointed out, medicines given before meals have the effect of washing out the stomach, but they exercise no influence whatever 62 MINOR MALADIES. either upon the secretion of gastric juice or upon the digestion of the food itself. Effectually to treat either form of dyspepsia, then, it is necessary to rely absolutely upon the hction of the drugs which are introduced into the stomach after the meal is taken. Let us now take a case of STHENIC DYSPEPSIA, and see how it should be treated. We will assume the patient to be a man of middle age who has at one time been fond of athletics, but who has been obliged by business exigencies to give them up, who is capable, hard-working, and energetic. He complains of epigastric discomfort after food, flatulent eructa- tions, and mental irritability. The symptoms are not pronounced until some time has elapsed after a meal ; indeed, he not infrequently associates them with the period before a meal, and may attribute them to hunger, a theory which obtains support from the fact that a feeling of ' sinking ' in the epigastrium is often present, and that he is always better immediately after he has fully satisfied his rather vigorous appetite. He dines at 7.30 p.m., and is very often awakened between four and five in the morning with heartburn, pyrosis, sneezing, hiccoughing, asthmatic attacks or other troubles, which, however, rapidly subside as soon as he is able to ' disperse the wind ' of which his stomach appears to be full. In the daytime he is liable to suifer so much from palpitation that he feels sure there must be something wrong with his heart. The first thing to be done with such a man is to INDIGESTION. 63 clear his primse viae. He should be given a dose of calomel (remembering that those of dark complexion bear this drug better than those who are fair) ; he should be ordered a turkish bath, an electric light bath, or an ordinary hot bath, and induced, if possible, to take some daily exercise in the open air, or at least at the open window. The unwisdom of wearing wool or flannel 1 next his skin should be explained to him, and he should be enjoined to masticate his food adequately. These and other warnings suggested by the special circumstances of the case must be emphasized, but the great, the paramount, the urgent need in such a patient is for an antacid to be taken either as soon as his symptoms commence, or, if possible, immediately before their onset. The antacid which is most popular is the bicarbonate of sodium, but this salt is an antacid pure and simple, and is possessed of no sedative properties. It also has the disadvantage, especially where flatulence is troublesome, of increasing the amount of gas in the stomach. What is required is an antacid agent which is free from this objection, which at the same time is possessed of sedative properties. Such an agent is bismuth. There have been many differences of opinion regarding the merits of this drug, even so great an authority as Sir William Roberts going so far as to deny that it was an antacid at all. Sir Lauder Brunton, Dr. Burney Yeo, and other authorities, however, appear to esteem it very highly, » See Chapter VII. 64 MINOR MALADIES. and this view is supported by most of those who have made a systematic trial of its action. The disappoint- ments attending its use in suitable cases have been almost certainly due to its employment in insufficient quantities. The ordinary B.P. doses are utterly useless ; the minimum which I employ is : of the subnitrate 25 grains (B.P. 5-20), and of the liq. bismuth, ammon. cit. (B.P. 30-60) 2 drachms. It is these two preparations which I have learned to appreciate most highly. The subnitrate may be given either in cachet form, or suspended in a mixture. When prescribing it as a cachet I generally combine it with that excellent sedative, oxalate of cerium (whose B.P. dose of 2 grains is also ridiculously inadequate), thus : R. Bismuth snbnit. ••• ■•• •>• gr. XXV, Cerii oxalat. ... ■•• gr- X. M. Sig.: Ter die post cib. If, as is not infrequently the case, the patient has a gouty tendency, it is well to add 5 grains, or a little more, of pulv. guaiaci to each cachet, but it not infrequently happens that the ' little more ' is found to produce griping, purging, or both. Another drug which might be added to such a cachet is bicarbonate of sodium. It increases the alkalinity, but it increases also the bulk of the cachet and the quantity of gas in the stomach. Although the subnitrate is frequently prescribed in a mixture (20 grains of the salt to 20 f^ains of pulv. INDIGESTION. 65 tragacanth. co.), it is not wise to do so. The carbonate acts nearly as well, and does not tend to decompose as the subnitrate does. On no account should the subnitrate be placed in a mixture with bicarbonate of sodium. The decomposition of the former leads to CO2 being evolved from the latter, and explosions are apt to occur. If it is desired to give bismuth in a fluid form, the liq. bismuth, ammon. cit. should be used. I am in the habit of combining it (as in the cachet) with a sedative — i.e., hydrocyanic acid — thus : R. Liq. bismuth, ammon. cit.1 Syr. prmii virg. J Aquam ». ad gi. Misce. This makes an agreeable and palatable mixture ; but if, with a view of correcting any gouty tendency, we add, say, 3ss. tr. guaiaci ammon., we must remember to suspend the latter in 40 grains of mucilage of acacia, and even then the mixture will be deprived of its elegance. There is no objection to adding bicarbonate of sodium to this combination, but there is really no necessity to do so, for it is already sufficiently alkaline. Now, whichever form is decided upon, the cachet or the mixture, the important point to remember is that the proper time for its administration is some time after food. The length of time which should be allowed to elapse between the meal and the taking of the remedy depends, of course, upon the size of the meal. A full 5 61j minor maladies. meal will take five hours to digest, and will use up a great deal of HCl. A light meal, especially if it be poor in proteids, will use up very little acid — that is why sthenic dyspepsia is so much more common after light meals — and the surplus will want neutralizing relatively soon. It will want neutralizing sooner after breakfast than after luncheon, and sooner after tea than either. After a full dinner the symptoms frequently do not show themselves until about 4 or 5 a.m., and may then, in addition to pyrosis and heartburn, take the far more obscure forms of hiccoughing, sneezing, asthmatic, and even anginal attacks. The tendency of any symptoms, however little connected with the stomach they may at first sight appear, to recur regularly at 4 or 5 a.m. should give rise to a suspicion that dyspepsia is at the root of the mischief. It is probable that much of the success which has attended the practice of giving alkalies before meals has been due to the fact that the period immediately preceding one meal is the period which witnesses the close of the digestion of the last — the period, that is, in which there is surplus acid waiting to be neutralized. However that may be, there can be no doubt that the administration of alkalies, and especially of bismuth, at a suitable interval after food, offers a means of relief in sthenic cases which is practically unfailing, and I would go so far as to say that if relief is not obtained by such means, then the case is certainly not a dyspepsia of the class under consideration. INDIGESTION, 67 A line of treatment suggested, or at any rate recommended, by Sir William Roberts is that of prescribing lozenges to be sucked by the patient as soon as the symptoms have developed. Lozenges have the advantage of portability, and the sucking of them insures that the superfluous acid in the stomach shall be neutralized by its physiological antidote, namely, saliva. It is curious to note that the saliva secreted during a sthenic dyspeptic attack is hyper- alkaline. It is as if Nature herself were suggesting the best means of curing the condition, for not only is the reaction enhanced, but the amount of the fluid is markedly increased in those attacks which the presence of pyrosis and coryza proclaim to be of more than usual severity. The lozenge which Sir W. Roberts prefers is the trochis. bismuth, of the B.P., which contains B^ grains of chalk and 2| grains of carbonate of magnesia ; but, true to his disbelief in bismuth, he suggests that this ingredient should be omitted. However, so long as the lozenge is not acid, it probably matters little of what it is composed. The efficacy of this line of treatment resides in the use which is very properly made of the alkaline saliva in neutralizing the offending acid. Even the mechanical irritation of a clean pebble carried in the mouth is useful in this direction, and patients should be told to remember it in the presence of an attack where no alkalies are at hand. There is a point in prophylaxis which ought always to be brought to the notice of a sthenic dyspeptic. 68 MINOR MALADIES. The source of the muriatic acid present in the gastric juice is believed to be common salt; patients should, therefore, be told to eschew salted meats, and be warned to relinquish the habit of adding chloride of sodium to their food. It is merely a habit, and few have any difficulty in relinquishing it. If the supply of the raw material is checked, the over- production of the manufactured article will cease. And this consideration carries another lesson, which is this : The natural mineral waters which are so largely imported into this country have justly earned for themselves a great reputation in the treatment of chronic and occasional constipation. As nearly all these waters contain chloride of sodium, and some of them in very large quantities, it is inadvisable to recommend them to patients whose constipation is associated with sthenic dyspepsia. To relieve the difficulty in such cases recourse must be had to other means. Cascara is very serviceable, but I prefer either of the following, given three times daily before meals, followed by a glass of hot water ; R. Sodii sulphat. Sodii bicarb. ... Tr. nuois vom. Ess. menth. pip. Inf. gent, oo M. gr. XXX. gr. I. mv. mii. ad gi. R, Magnes. sulphat. ... ... ... gr. xxx. Magnes. carb. gr. x. Tr. nueis vom. niv. Ess. menth. pip utii. Inf. cascariUse ad ^. INDIGESTION. 6.') Either of these mixtures takes the place of that containing sodium bicarbonate suggested above for ' lavage ' of the stomach, and if persevered with, may be relied upon to dispose of the constipation. Among those who suffer from sthenic dyspepsia, there are a very large number of people (mostly maiden ladies and widows) who are persuaded that they want ' supporting,' that their condition is due to debihty, and that large and frequent meals are essential to their continued existence. Their miseries towards the end of digestion, and the prompt relief which is afforded by another meal, lend an amount of support to this view which no skill in the art of persuasion is in some cases sufficient to combat. If the real state of affairs is pointed out to them, they write the doctor down as an unsympathetic person, who is devoid both of perception and therapeutic instinct. Nevertheless, the attempt should always be made, for it is better to lose a patient than to share in the responsibility for the arterio-sclerosis and other serious manifestations which sooner or later provide a fitting Nemesis for these misguided people. And this leads me to say that mistakes in differ- entiating between the two kinds of dyspepsia generally take the form of diagnosing as an asthenic case one which is in reality a sthenic case. Patients who pity themselves readily dwell upon the weakness which they feel, and, believing their symptoms to be due to debility, seek, by graphic and heartrending descriptions, to persuade the doctor to the same view. 70 MINOR MALADIES. This is a pitfall against which it is very necessary that we should be on our guard. When there is any doubt about the nature of the case, it should be treated as if it was sthenic, by the exhibition of alkalies and sedatives. The reason for this is that alkalies and sedatives, though they may do an asthenic case no good, will certainly not aggravate the symptoms; whereas acids given to a sthenic dyspeptic immediately give rise to an acute exacerba- tion of all the troubles from which he was previously suffering. There is one other point to remember in this con- nection, and that is the futility of treating sthenic dyspepsia by any remedies directed to the stomach alone until we are quite certain that the cause of all the trouble does not lie in the transverse colon. When we recall the anatomical relations of this portion of the large intestine to the great curvature of the stomach, it is not difficult to believe that an irritation which has its source in the one will be readily communicated to the other; and I have repeatedly found, clinically, that a dyspepsia of the sthenic type, which had resisted every combination of alkali and sedative, responded promptly to calomel and an enema properly administered. Sir William Roberts divided the dyspepsia of substantially healthy people into the atonic form and the irritative or acid form, which is practically the same classification as that which is here advocated. Of the latter form he writes fully and instructively ; INDIGESTION. 71 but with the bias natural, perhaps, to one who has suffered much from one form, he dismisses the other, the atonic, in a few words as scarcely meriting the name of dyspepsia. From this view, and from the theory which would confine the term ' irritative ' to either form, I must express my dissent. Atonic or asthenic dyspepsia — the dyspepsia, that is, whose essential condition is a deficiency of HCl in the gastric juice — is an exceedingly common condition, more especially among the working classes and among neurotic people of all classes ; and the symptoms which such cases have in common with sthenic dyspepsia, the discomfort and the flatulence — albeit brought about in the one case by excess of acid and in the other by the presence of undigested food — are due to precisely the same condition, namely, an irritable state of the gastric mucosa.^ This element of irritation which the two forms have in common is important because failure t( appreciate it seems to lie at the root of much of the confusion which prevails on the subject. Where the symptoms of the two forms seem to overlap, they do so on account of this factor and its results, and when this is clearly understood the difficulties disappear. Let us now look at a tj^pical case of ASTHENIC DYSPEPSIA, and consider how it should be treated. The causes which may produce the condition are 1 I purposely refrain from any discussion of the fermentation theory, for even if there be any truth in this theory, which I doubt, it cannot affect the above considerations. 72 MINOR MALADIES. numerous, and some of them are remote. Setting aside those which are obvious, such as convalescence from acute disease, it is well to remember that any- thing which gives rise to a constant leakage of nervous force is peculiarly liable to set up an asthenic dyspepsia. Such conditions as worry, uncongenial surroundings, nasal obstruction, and errors of refrac- tion are among the most frequent, and it is safe to say that they are precisely those which are most commonly overlooked. Let us, then, take as our type a married but child- less woman of thirty, who is not exactly unhappy, but who has no definite object in life. She is lacka- daisical rather than melancholy, with a dull com- plexion and spare frame. Her tongue is clean, but pale and flabby, and some of her teeth are defective She complains of a duU pain in the chest, which passes through to the back. The pain is always more or less present, but every meal, no matter whether it be large or small, intensifies it. She has very little appetite as a rule ; though occasionally, when she forces herself to eat, it seems to improve after she has taken a few mouthfuls. She suffers from flatulence and palpitation, and is generally very constipated. Medicines may relieve the constipation, but they generally leave the discomfort and the flatulence unaffected. On examining her abdomen, we may find a movable kidney on the right side, and the muscles in the anterior abdominal wall will be found to be badly developed. She takes very INDIGESTION. 73 little exercise, and protests that she never feels up to it. The treatment of such a case is not difficult. Having freed the primse vise and attended to the other details already mentioned as suitable to both forms of the malady, we turn to the measures of active treatment. Having regard to what we know to be the essential condition in this case — namely, deficiency of HCl in the gastric juice — the first indication is, clearly, to supply the deficiency. And in doing so we must be careful to give doses large enough to effect our purpose. The ordinary B.P. dose of Tr\jK. is altogether inadequate ; the minimum dose which I employ is TTj^xxv. This it is well to combine with strychnia and pepsin, as in the following : St. Acid. mur. dil. ... Liq. strychnin. Glyc. pepsin. ... Aq. menth. pip. fllV. ad gss. M. Sig. : Thrice daily immediately after food. To such a mixture may be added other drugs which the nature of the case may seem to demand. Quinine hydrochlorate, liq. ferri mur., liq. morph. mur., and liq. arsen. hydrochlor., are all of them preparations which are frequently of great assistance in such cases, and aJl of them are quite compatible, not only with each other, but also with the other ingredients in the mixture. The most useful of them is perhaps the morphia salt. In cases of long 74 MINOR MALADIES. standing, where the element of irritation is conse- quently very pronounced, the addition of ni_x. of the liq. morph. hydrochlor. is invaluable. It soothes the mucosa and enables it to tolerate the stimulating effects of the HOI and strychnine, which in its absence are liable to cause so much local disturbance as to bring the patient back with the complaint that each dose of the medicine aggravates her sufferings. It is scarcely necessary to dwell upon the great importance of deleting this ingredient from the prescription as soon as there is any prospect of doing so with impunity. For the constipation, which is generally so pro- minent a feature in asthenic dyspepsia, the use of the natural mineral waters is not only unobjectionable — it is strongly indicated. The presence in them of common salt, which we have seen to be a contra- indication in sthenic dyspepsia, is here an advan- tage. Most of these waters are best taken in the morning (fasting), and their effect is enhanced by the association with each dose of a tumblerful of hot water. Such are the broad lines on which most cases of functional dyspepsia should be approached. But even in uncomplicated cases it is more easy to make mistakes than the facts as above stated would lead one to expect. It not infrequently happens that where there is a serious difficulty in coming to a conclusion as to whether the case is one of sthenic dyspepsia or its INDIGESTION. 75 opposite, it eventually turns out to be one whicli cannot, properly speaking, be placed in either category, but is due to some underlying cause which must be discovered and removed before either acid or alkali will have the desired effect. A large percentage of these aberrant cases are the result of causes which, for the want of a better term, we must call nervous or neurotic. Common instances are afforded by men on the Stock Exchange who lead strenuous and even exhausting lives, who are exposed to periods of de- pression, varied by sudden volcanic explosions of excitement and panic, in whom the philosophic calm so necessary to good digestion is hardly ever obtain- able except at a foreign health-resort, where tele- phones cease from troubling and ' markets ' are at rest. An instance drawn from another, though scarcely less famUiar, sphere is presented by a young lady who once consulted me, with all the signs of asthenic dyspepsia, with this' notable point of dis- similarity from the typical picture, that her acid symptoms began to trouble her as soon as the food obtained access to her stomach. The ordinary pre- scriptions of bismuth, soda, and hydrocyanic acid, in combination with laxatives, produced no result, and so at her third visit I got her mother out of the room and demanded to know the nature of the silent sorrow which I felt certain she was nourishing. It soon emerged in the shape of a secret engagement, which, should it leak out, would set the whole family by the ears, The combination of 15 grains of bromide of 76 MINOR MALADIES. potassium and 2 minims of Fowler's solution in water three times a day after food, coupled with a little worldly-wise advice, cured that dyspepsia in a few days. One of the most common causes of aberrant dyspepsias is that which, for some extraordinary reason, is the one most commonly overlooked. So common is it, indeed, that one feels almost ashamed to mention it. I mean dental caries. The teaching of the schools — and I say this without any implied reflection — tends to the too exclusive cultivation of the obscure in diagnosis and the heroic in treatment, with the sad result that the obvious and common sensical become overlooked. Thus it happens that patients are suspected to be suffering from cancer, gastric ulcer, oesophageal stricture, hepatic, pancreatic, and even splenic, disease, when a few visits to a competent dentist will cause the disappearance of all their symptoms. We talk glibly of the gastro-intestinal toxins and their nefarious consequences, but we appear to think of them as lurking, brigand-like, in the inaccessible ruga of the small intestine, when their real habitat is the commonplace cave of a decay- ing molar. That ' washing in Jordan ' should never be a popular proceeding with patients is comprehen- sible, because patients are generally in an epic mood ; but why doctors should avoid it as a prescription is less obvious. That the avoidance frequently impairs professional credit is a matter of common experience. Another condition which is very closely associated INDIGESTION. 77 with intractable dyspepsias is nasal obstruction. No one can pretend that a nasal obstruction due to ade- noids is now in danger of being overlooked. The very reverse is indeed the case, for adenoids are diagnosed, and even operated upon, in cases when they do not and never have existed. But that is by the way. Nasal obstruction may be due to causes other than adenoids, and such obstruction is a very common provoker or maintainor of a dyspepsia which fails to conform to either of the two regular types, and remains obstinate to treatment by their appro- priate remedies. Such was the case with a man whom I have known for many years, energetic, hard- working, capable, who at unequal intervals suffered from attacks of what both he and I agreed to call 'gouty dyspepsia.' It was distinctly of the sthenic type, and the worst discomforts connected with it scarcely ever failed to yield to bismuth and soda. Nevertheless, even when taking the medicine he was seldom entirely free from flatulence, eructations, heartburn, and constipation. The enemy was always on his flank, to fall upon him unmercifully should he commit any dietetic indiscretion, or in the event of any extra pressure of work, and on the occasion of any mental anxiety. Matters continued thus for several years until he was married. Not long after that event he came to see me with one of the usual attacks, and told me incidentally that his wife com- plained that he not infrequently snored, and that, in connection with this complaint on her part, he had 78 MINOR MALADIES. himself noticed that he always awoke with his mouth open. I then, for the first time, tested his nasal air- way, and found that it was practically blocked on the right side by a combination of spurs and a deviated septum. Since this condition was relieved, now over two years ago, he has never had any return of his trouble, or, if he has, it has been so slight in degree as to be readily amenable to ordinary treatment. This may seem an inconclusive story, but both he and I are quite convinced that the cause of his former troubles was the obstruction in his nose, an opinion which on my part is very strongly supported by other cases of a similar kind. But if nasal obstruction is a common cause of obstinate digestive troubles, an even commoner cause is to be found in uncorrected errors of refraction. These errors give rise to eye-strain, and eye-strain in its turn provokes disturbances which are by no means limited to the eyes or their neighbourhood. The teaching of too many of the schools is to the effect that unless a person with a slight error of refraction complains of definite symptoms, then it is a work of supererogation to correct it. Such advice might be sound if all the symptoms of eye-strain were easily recognisable as such; but they are not. A person who is the sub- ject of eye-strain may suffer from symptoms which neither he himself nor the vast majority of doctors would dream of referring to his vision.^ It is begin- 1 See Ernest Clarke, 'The Medical Aspect of Eye-Strain,' Clinical Journal, October 4, 1905. INDIGESTION. 79 ning to be recognised, perhaps, that headaches, supra- orbital and other local neuralgias, may be caused by visual defects, but it is seldom even admitted that dyspeptic troubles and many obscure and indefinable, but very persistent, miseries, which are either care- lessly or ignorantly labelled neurotic, neurasthenic, or hysterical, may be due to the same cause. This attitude is not altogether surprising when we remember that, in order to produce these results, it is essential that the defect should be slight in degree ; should be one, that is, which the patient himself, by contracting his ciliary muscle, can adequately correct. The grosser errors do not cause these symptoms, for the reason that no amount of ciliary contraction being sufficient to correct them, no effort is ever made. In the lesser degrees the effort, being successful, is not only made, but is maintained during the whole of the waking hours. It is this maintenance of muscular effort which is the crux of the whole situation, for the ceaseless and illegitimate contraction of the ciliary muscle means an equally ceaseless and illegitimate expenditure of nervous energy. The ' electric power ' intended for the motors in the various organs is all monopolized by the visual. There seems nothing to determine which of these organs will be the first to cry out that it is being starved of its due amount of nervous energy, and much of the trouble arises from the fact that its cry is almost invariably misunder- stood and misinterpreted. In the case of the stomach the responsibility is generally placed upon the diet, 80 MINOR MALADIES. which is pared and whittled both in quantity and quality until the fare of King Nebuchadnezzar may seem generous in comparison ; while the organ itself is now soothed with papaveric caresses, and anon chastised with Chilian scorpions, in the vain hope that it may thus be induced to make bricks without straw ; for unless the nervous energy or the motive power, or whatever else it may be termed, is prevented from leaking out through the crevice of that minor refrac- tive error, the stomach will be deprived of its due share of this energy, with the result that symptoms in very sooth, though symptoms of an aberrant and baffling type, will continue to afflict the unfortunate possessor of the organ, in spite of acid and alkali, and in spite, too, of their all too common and ridiculous association in the same mixture. So impressed have I been during the last ten years with this aspect of obstinate dyspepsias, that I now never fail to satisfy myself, at any rate in the case of a town-dweller, and more especially in the case of a town-dweller of over forty years of age, that an error of refraction is not at least a contributory cause in the case of troublesome indigestion which resists the ordinary remedies. If it is true, as I believe it to be, that the dentist cures more cases of indigestion than the physician, it is equally true that in the same direction the refractionist is more potent than the therapist. A great many dyspepsias which are confidently assigned to the rubbish heap labelled ' neurotic ' are INDIGESTION, 81 due to vaso-motor disturbances, and may thus be held to justify the label. The disturbance may take the form of an undue vaso-dilatation leading to a sub- normal blood-pressure, or to the opposite condition of undue vaso-constriction, causing a supernormal blood-pressure. It may, of course, be the result of faulty distributions of pressure, for which errors of vascular tone are not primarily or even mainly responsible, as in the case of mitral disease. It is scarcely necessary to refer to such cases, because the person who faUs to examine the heart in a case of dyspepsia will fail to examine it in a case of chorea, and is diagnostically past praying for. It is the vascular disturbances which own no such obvious cause which give rise to difiBculties. In the case of undue general vaso-dilatation the modus operandi is not difficult to follow. The patient is, so to speak, living under the constant influence of nitrite of amyl ; his. peripheral arteries are relaxed, and there is thus less blood available for the work of the internal organs. Consequently the appeal for more blood for digestive work on the part of the stomach is very inadequately responded to, and symptoms arise whose severity is in direct ratio with the degree of general vaso-dilatation. A dyspepsia which is due to this state of matters may always be relieved by causing the patient to assume the recumbent posture im- mediately after a meal, but it can only be cured by removing the cause of the general vaso-dilatation. The opposite condition of unduly high blood- 6 82 MINOR MALADIES. pressure frequently, if not invariably, carries a gastric disturbance of some kind in its train. The causation of high blood-pressure in some, at any rate, of its aspects, is still a matter of speculation, but there seems no escape from the conclusion that it may be, and frequently is, due to endogenous toxins. These toxins would seem in the majority of cases to act slowly — so slowly, that the existence of the high pressure is not even suspected until it has left its inexorable mark upon the arteries in some important organ, whose resulting degeneration has produced the symptoms from which the patient seeks relief. Here, then, is another, and by no means the least weighty, of the possibilities which should engage our attention where we have an aberrant dyspepsia to deal with. The use of the manometer is becoming more general every day, and such cases wiU therefore be overlooked with decreasing frequency, to the credit of the profession and to the satisfaction of the patients. Of the dyspepsias which result from high blood- pressure, the best instance is probably that which may be drawn from a consideration of what occurs at the menopause. The process of menstruation must be regarded as an excretory process, so that the com- mencement of the climacteric marks as a rule the commencement of a period of insufScient excretion. Add to this the consideration that the internal secre- tion of the ovary is believed, on sufficient grounds, to be both vaso-dilator and a toxin destroyer, and it is not surprising to find that at the ' gloaming of life,' as INDIGESTION. 83 the French poetically call it (I'dge cr^pusculaire), the blood distribution becomes deranged. The derange- ment shows itself as an elevation, which is always definite, and is not infrequently sufficiently alarming to warrant very active interference. For reasons into which it is impossible to enter here, this rise of pressure exercises a particularly unfavourable effect upon the vessels in the splanchnic area, and of these vessels it is, as one would expect, the gastric which show the greatest disturbance, with the result that dyspepsia, almost invariably of the sthenic type, is one of the commonest of the manifestations of the menopause. Any attempt to treat such a dyspepsia without very special attention to the state of the blood-pressure is to court certain failure, and in order to reduce that pressure we must bear in mind the above-mentioned factors in its causation. The fact that an excretory organ has been lost, and that its absence is not yet compensated for, will suggest gentle stimulation of the other emunctories, of which the skin is in this connection by no means the least important. The absence of the internal secretion may be met by giving ovarian extract by the mouth, a procedure which I believe to be of the greatest benefit. Ichthyol in 5-grain pills is also useful, and is perhaps the best of all drugs for com- bating the vague subjective discomforts which are apt to appear at this time. When the blood-pressure is really high — i.e., over 200 mm. Hg — and the above means fail to reduce it, I never hesitate to recommend 84 MINOR MALADIES. venesection. This little operation has in several oases within my knowledge been the means of a 'miraculous' cure of very troublesome climacteric dyspepsias. I feel that I must not leave this question without a reference to a form of dyspepsia which is associated with the menopause, but which has none of the characters of that just noticed. The processes peculiar to the climacteric affect different women differently, but they seldom fail to produce an instability of the nervous system, which in extreme cases proceeds to definite insanity. Short of this, one of the forms which it assumes is an abnormal craving for sedatives, and if the craving is satisfied there is very apt to ensue an irritable condition of the stomach, which gives rise to symptoms of indigestion. The sedative usually employed is, of course, alcohol, with regard to which it is necessary to remember that its excessive devotees fly to it, not as a stimulant, but as a narcotic, and that it is narcotic only when taken in doses large enough to act as an irritant on the gastric mucosa. There is a great deal of secret drinking at the time of the menopause, even among those who up to that period have been strictly temperate, so that the possibility of such a factor being at work in produc- ing or maintaining a dyspepsia should not be for- gotten. There is a condition which some, at any rate, of the manifestations of sthenic dyspepsia are liable very closely to simulate, and to which it therefore INDIGESTION. 85 seems desirable briefly to refer — namely, angina pectoris. Where sthenic dyspepsia is associated, as it not infrequently is, with some degree of gastric dilatation, symptoms resembling true angina are by no means uncommon. I have already referred to the fact that attacks of sneezing, dyspnoea, and the Uke, are in these cases very hable to occur in the early hours of the morning, and I have pointed out that these attacks are due to the irritation produced primarily by the excess of acid present at the end of digestion. Now, it is not difficult to understand how the consequent flatulent distension of a somewhat dilated stomach will cause serious mechanical embarrassment to the heart, nor that, as a result, symptoms should ensue which are very suggestive of true angina. Add to this the fact that the patient frequently brings a history of pain in the chest, evoked by exertion, which radiates down the arms, and the suspicion of angina is necessarily deepened. It is important to remember, therefore, that all these symptoms are entirely compatible with functional gastric disturb- ance ; and to prevent unnecessary alarm to the patient and his friends, it is well to avoid all mention of the more serious condition until the less serious can be excluded. There are some facts which may aid us in arriving at a conclusion upon this point, which is liable to present difficulties not only because of the general resemblance between the symptoms, but also 86 MINOR MALADIES. because an attack of flatulence may be the starting- point of the first of a series of true anginal seizures. In the first place, then, it may be said that the con- stant presence of palpitation in association with the attacks is against the suspicion of angina and in favour of simple dyspepsia. In favour of dyspepsia, also, is the regular occurrence of the attacks in the early hours of the morning. When inquiry elicits that the pain on exertion occurs always after a meal and never when the stomach is empty, the fear of angina may be allowed to recede, and it may be dismissed altogether if an antacid taken at a suitable interval after meals is successful in preventing the attacks. The occurrence of such symptoms, however, even when they are quite definitely dyspeptic in origin, should not be too lightly regarded. They are often associated with giddiness and other phenomena which occasion alarm to patients, and if the car dio- vascular condition be carefully examined, as it should always be, it is very seldom found to be in an entirely satisfactory condition. Setting aside the heart itself, whose state, when it is affected at all, is variable, and is always secondary to the changes which are present in the arterioles and capillaries, it is necessary to examine carefully into the state of the arteries. These will generally — one may say always — be found in a state of high tension, and the treatment of the dyspepsia by means of antacids will be only temporarily successful unless means be adopted INDIGESTION, 87 to insure that the intravascular pressure be perman- ently reduced. In order to reduce this pressure it is necessary to realize the nature of its cause. In nine cases out of ten this is the presence of toxins circulating in the blood. The toxins, by irritating the vessel walls, cause constriction of the muscular coats, and blood-pressure is at once increased. The real nature of the toxins which may give rise to this state of matters is not yet understood ; but in the cases under consideration — those, namely, of sthenic dyspepsia — they are generally, if not invariably, the result of excessive meat-eating. The first thing to do, then, is to impress upon the patient the necessity for abstention from meat foods ; and the older the patient, and the more sedentary his mode of life, the more urgent does this necessity become. A general reduction of intake, in quantity as well as quality, ia usually very desirable, and, in my experience, the meal which may be attacked with the best prospect of success is that which is taken at or about midday. This should consist of milk, eggs, cheese, fruit, and vegetables — of anything, in fact, which has not been killed — and it should be free from alcohol. So far as the meat at the evening meal is concerned, it is well to insist that it should be boiled, because it has been shown that boiled meats are much less liable to increase arterial tension than those which are otherwise treated. To insure the adequate excretion of such toxins as may already be present, the bowels, skin, and kidneys 88 MINOR MALAOmS. must be stimulated. Mercury is the best agent to employ for the first of these purposes. About a graie of calomel should be given every night for a week, followed each morning by a saline, and the saline should be continued for at least a week longer. Turkish and hot-air baths are useful for cutaneous stimulation, especially where they are combined with or followed by efficient massage. Even the ordinary hot bath, properly administered, is by no means without its value in this connection. For the stimulation of the kidneys the salts of potassium are to be preferred, and of these the iodide and the citrate are the best. Ten grains of the citrate with 5 grains of the iodide should be added to the mixture of bismuth above prescribed, and the patient should be directed to drink freely of Evian water between meals. Another excellent renal evacuant is theo- bromine. The importance of these measures resides in the fact that a sthenic dyspepsia which is accompanied by high arterial tension is but a symptom of an under- lying condition whose continuance is fraught with the utmost gravity to the patient. There is, as a rule, no difficulty in curing the dyspepsia ; but if we allow our- selves to rest satisfied with such an achievement, and shut our eyes to the possibilities of dangers ahead — dangers such as granular kidney and general arterio- sclerosis, which are two among many of the logical issues of sustained high arterial tension — the patient will have good cause to regret the promptitude INDIGESTION. 89 and completeness of the relief from bis dyspepsia which he has obtained at our hands. This is the condition to which the term • gouty dyspepsia ' has been applied, and if we use the term to denote a dyspepsia of the sthenic type, which is merely a manifestation of a general condition of goutiness, which general con- dition demands our attention even more urgently than the dyspepsia, then the term is altogether unobjection- able. There is, however, very little advantage to be gained from the multiplication of adjectives. Symptoms are often confidently attributed to dyspepsia which are in reality due to ovarian irritation. The dyspepsia is generally of the asthenic type, and is usually accompanied by nausea, frequently by vomiting, which may be very persistent, and occasionally by hsematemesis. When a dyspepsia in a young woman proves intractable to the ordinary remedies, the probability is great that the cause will be found in the ovarian region. To the seeing eye there is something very characteristic in the appearance of one who is suffering in this way. The appearance does not lend itself to verbal descrip- tion, but, when once observed, it is not easily for- gotten. Undue brightness of the conjunctivae in a person whose temperature is normal is very suggestive of pelvic disturbance, but this by no means exhausts the elements of which the ' ovarian ' look is composed. If the existence of this possible cause of an indigestion be borne in mind, it is easy to verify our suspicions. Palpation over the ovarian regions will elicit tender- 90 MINOR MALADIES. ness, sometimes very extreme, on one or both sides. The best treatment consists in the repeated applica- tion of small blisters over the congested viscus, com- bined with free purgation and the exhibition of bromide of potassium. This kind of dyspepsia is frequently referred to as ' nervous ' or * neurotic' It is not, of course, a dyspepsia at all. It is due to causes local to the pelvic organs, and unless these causes, which not infrequently comprise leucorrhoea and menstrual disturbances, are suitably treated, the remedies offered to the stomach will be wholly ineffectual. There are two symptoms commonly associated with dyspepsia which, from the discomfort to which they may give rise, it is often necessary to treat during the interval which may have to elapse before their cause can be removed : the one is flatulence, the other is hiccough. FLATTJLENCE may be either gastric or intestinal. The former is said to be due to fermentation in the stomach itself. Although there is good reason to beUeve that this is not the case, there is no doubt that the symptom is one which is nearly always present in every case of gastric derangement, from whatever cause arising. It may, on the other hand, be a pure neurosis, and is frequently provoked by worry and anxiety. In neurotic subjects and in mouth-breathers (as in the subjects of adenoids and deviations of the nasal septum) it is due to the swallowing of air. When this symptom is so INDIGESTION. 91 obtrusive as to demand treatment apart from its underlying cause, there are three remedies which can usually be trusted. To those who believe in the fermentation theory, carbolic acid, 2 grains, made into a pill with 1 grain each of liquorice powder and powdered althea, and given three times daily, will probably appeal, and it certainly is often very helpful. In the form of sulphocarbolate of sodium (10 to 15 grains) the same remedy may be added to mixtures prescribed for the relief of the complaint which causes the flatulence. The sodium salt sometimes acts better than the pure acid. An old and very reliable remedy is charcoal. This should be given in doses of at least a drachm three times daily. The drug which has seemed to me to be most trustworthy, however, is torebene: 10 or 15 drops may be put upon a lump of sugar for the patient to suck, or the same quantity may be given in a capsule three or four times a day. Whether by checking fermentation or by some other action, it is certain that few remedies possess so much power in relieving the distressing eructations to which some dyspeptics are liable. Where the flatulence is intestinal, the treatment should be directed towards increasing peristalsis by means of nux vomica and belladonna. The condition is generally associated with atony, and care should be taken not to administer drugs, such as magnesium sulphate, which increase the fluid contents of the bowel without increasing peristalsis, unless the muscular 92 MINOR MALADIES. action is simultaneously reinforced either by drugs or massage. Of all the remedies directed to the relief of this condition, nothing has seemed to me to compare with oil of cajuput. It should be given in doses of 2 minims, and may be combined in a pill with extract of gentian, or, when dissolved in a few drops of spirit, it can be added to any mixture. In the flatulence which is so Uable to develop after operations in the neighbourhood of the rectum this remedy is in- valuable. HICCOUGH is due to a sudden more or less violent contraction of the diaphragm, and may be produced by irritation, either in the immediate vicinity of the muscle or reflexly from a distance. An attack may last for a few minutes only or it may be protracted over several hours, and it may recur at intervals for weeks, or even months. It is a common symptom of dyspepsia, more especially of sthenic dyspepsia ; but it may also be due to organic affections of the stomach and intestines, such as carcinoma, and to hepatic disease, or appendicitis. It is a frequent accompani- ment of the tympanites of typhoid fever. It may be excited reflexly by organic disease of the nervous system, such as meningitis, hydrocephalus, and intra- cranial tumours. In functional diseases it is common ; hysteria, sudden shocks, and acute emotions providing a great many instances. It is not altogether un- known in epilepsy, and may occur in chorea. Certain constitutional conditions, especially gout, diabetes, gouty nephritis, and alcoholism seem to INDIGESTION. 93 create a strong predisposition to its development. So much is this the case that the absence of other obvious cause should lead one to suspect the operation of such an agent. Hiccough is very often associated with pregnancy, and it may complicate Graves' disease or Addison's disease. When it appears in a person who is seriously ill, especially if it becomes persistent, it is a sign of evil omen, and should lead us to be very guarded in prognosis. Its most obvious mechanical cause is pressure on the phrenic nerve within the thorax, a condition which is most likely to be produced by dilatation of the aorta, pericarditis, or new growths. Persistent hiccough, from whatever cause arising, is very distressing, not only to the patient, but to those around him, and it is necessary to allay it as soon as possible. Various means to this end have been suggested from time to time, including medicines to be taken by the mouth and applications of a stimulating nature to the epigastrium. Of the latter, warmth and small mustard-plasters are occasionally useful, and skilfully applied massage is frequently so. Of internal remedies, the best seems to be nitro- glycerine in doses of tJ^ of a grain upwards. It seems to act better when given in tablets than in the form of liq. trinitrini (2-5 minims), though I have used the latter with success. In either case the dose should be small and frequently repeated. Oil of turpentine is highly recommended by some. It should be given in doses of 10 minims mixed vrith mist, amygdal. 94 MINOR MALADIES. Ext. ergot, liquid in drachm doses, frequently repeated, has been very successful in some cases, and is always worth a trial where other things fail. It is generally conceded that morphia, chloral, bromide of potassium, and even the inhalation of chloroform, are useless. Ether by the mouth, however, sometimes proves effectual. Traction on the tongue will some- times produce the desired effect. Forcible holding of the breath in deep expiration is useful in slight cases, as is drinking a glass of water with both ears and nostrils closed. Of all these means, however, nitro-glycerine is the most likely to bo successful. Musk (5 to 10 grains) in a pill with liquorice may also be tried. It is well spoken of by many, the only objection to its use being its great expense. ADDITIONAL FOEMUL.ffi. Alkaline Mixture (Byrom BramweU). J^. Potass, bicarb. 1 -- ^••• Sodii bicarb, i Spts. ammon. co. 5iv. Tr. rhei ... ... ... ... 5ii. Inf. calumbsB ... ad §vi. M. Sig. : gss. in v.ater, thrice daily, a quarter of an hour before food. Mixture for Flatulence. IJ. Menthol gr. ^ Spts. ammon. co. Spts. ohlorot f ^^^• M. Sig. : One teaspoonful in water when required CHAPTER III. COISTSTIPATION, DIARRHCEA. VOMITING, AND GIDDINESS. COH'STIPATIOS' may be described as inadequate dis- charge of the contents of the lower bowel ; a definition which assumes, of course, that there is material in the lower bowel which is improperly retained. This is a fact which seems to require emphasizing, for the reason that the term constipation is often made to include infrequent defaecation in people with whom such, infrequency is habitual and normal. It is well to remember that the amount of faeces represents the excess of material consumed over what it is possible for the economy to utihze, and that consequently, if people took no more food than was necessary to their continued existence, the amount of faeces would be practically nil. There are persons — not very forceful persons perhaps, but still perfectly healthy persons — who are very spare eaters, and who are, in addition, very careful eaters, in the sense that their food is thoroughly masticated, whose bowels do not act more than once a week If we were to gauge the matter only by the standard of the practice of the 95 96 MINOR MALADIES. vast majority, this would seem absurdly and even dangerously inadequate, and yet the infrequenoy of the discharge in such cases, as being in consonance with the small amount of intake, must be regarded as natural to the physiological working of the individual, and, as such, not lightly to be interfered with. These people are, however, not ordinary people, and th ough it is wise to remember not only their existence, but also the physiological lesson of which they present living examples, it would be fooHsh to accept them as a standard by which to measure the practice of the majority. The ordinary individual does not regard his diet from the standpoint of mere existence; he likes a balance on the right side, and is consequently in the habit of eating more, both in quality and quantity, than his system can possibly make use o£ The excess in quality supplies him with a stimulant which he enjoys, which, indeed, he may even find necessary to the accomplishment of his daily work ; the excess in quantity is a mere accident, as it were, a con- comitant of the excess in quality, which he takes because it is part and parcel of the things he likes. This excess in quantity consists of what has been called ballast — material, that is, which he cannot digest, because it is indigestible by nature, material such as vegetable fibre and other constituents of food over which the digestive ferments exercise no dis- solving influence. It is of the excess in quantity thus constituted that the faeces are for the most par* CONSTIPATION, DIARRH(Ea, ETC. 97 composed. Some of the excess in quality — a portion that is, of the material which is by nature digestible — also enters into their composition, especially when that excess is very conspicuous ; but the discharged matter, as a rule, consists of material which has escaped digestion, not because the digestive organs are at fault, but because the material itself is insusceptible of solution and conversion into chyle. It is the inadequate discharge of this material which consti- tutes the condition which we are now considering. It will be convenient to spend a moment in tracing the course of the excess in quality, and to inquire what becomes of the soluble material which is con- sumed, even though it is not wanted and cannot be utilized. Some of it doubtless becomes entangled in the indigestible residue, and under favourable conditions is harmlessly discharged. The greater portion, however, is metabolized and ultimately finds its way into the blood. Nature's processes being essentially thrifty, the excess is not immediately thrown away; it is stored for use on a rainy day, as it were, and is deposited as adipose tissue in various parts of the body. There is reason to believe that the process of this manufacture of fat, at any rate after a certain quantity has been deposited, is attended by by-products which exercise a very deleterious influence on the economy, and give rise to gouty, rheumatic, and kindred manifestations. The bearing of this upon the subject of constipation is this : that not only the original excess itself, but 7 98 MINOR MALADIES. also the by-products, have infinitely less chance of escape if the faeces are unduly retained. Constipation may be either occasional or habitual. The former is seldom important, except in so far as it tends to lead to the latter, and this it does more often on account of its injudicious treatment than for any reason inherent in the condition itself. From the fact that there are so many remedies for it on the market, which are always given an extended trial before recourse is had to medical advice, occasional constipation is a matter about which a doctor is not often consulted. He may, however, be consulted about conditions which are directly due to a loaded rectum, though the cause is unsuspected by the patient. Diarrhoea is one of these, haemorrhoids is another ; but perhaps the most common are un- defined digestive disturbances. It is also well to remember that a loaded rectum may be the deter- mining cause of an asthmatic attack, a hysterical fit, an epileptic seizure, or of some even more obscure reflex manifestation, and that the nervous instability which these things denote will remain obdurate to treatment unless the simple, but easily overlooked, cause be removed. Three remedies stand pre-eminent in the treatment of occasional constipation of this sort, and with regard to them, it is well to state at once, that their use in habitual constipation is as futUe and injurious as their employment in occasional constipa- tion is desirable and successful. The &sst is castor CONSTIPATION, DIARRHCEA, ETC. 99 oil, the second calomel, and the third a soap- and-water enema. Castor oil is a siiiiple aperient, which generally acts without griping and may safely be given to people of all ages. The great drawback to its use is its nauseous taste, to overcome which various so-called tasteless oils have been placed on the market. With regard to these, it must be remembered that, to be efficacious, very much larger doses are necessary than in the case of the ordinary oil, and that none of them is quite tasteless. In order to avoid the taste, in so far as it is possible to do so, the dose of the ordinary oil should be given in milk, with which the rim of the glass has previously been wetted. If in the drinking care is exercised not to allow the oil to come into contact with the teeth — if, that is to say, the dose is 'tossed off' — the unpleasant taste is slight and transitory. Ringer says that a mixture con- sisting of castor oil, J ounce; fresh mucilage of acacia, 3 drachms ; distilled water, 5 drachms ; with, say, 3 drops of oil of peppermint, has very little taste. Calomel is rightly considered the best purgative we possess, mainly because, in addition to being a purga- tive, it is an intestinal antiseptic of the highest value. The mistake which is commonly made in connection with it is that of giving it in large doses — i.e., 2-5 grains. It effects its purpose much more satis- factorily if given in quite small doses, say ^ or J grain, repeated every four hours until the bowels act. In this way it remains much longer in the 100 MINOR MALADIES. intestinal canal, and its antiseptic properties have therefore an opportunity of exercising their beneficent effects. The importance of these properties in the treatment of occasional constipation does not seem to be realized ; people appear to imagine, that purgation is of itself an antiseptic measure. Such it may be, but very often it is the reverse. Faeces which remain a long time in contact with the colon become quies- cent, but as soon as they are disturbed by a purgative their toxins are set free, and unless the purgative con- tains the means of counteracting the effect of these toxins, it may do a great deal of harm. Calomel being the most reliable of all intestinal antiseptics, and a hepatic stimulant to boot, it is infinitely the best agent for occasional purgation. As a rule, it is advisable to foUow an evening dose of calomel with a morning dose of aperient water. Where it is desired to wash out the lower bowel without unduly stimulating the small intestine, or where the object is to hasten the action of a purgative given by the mouth, a soap-and-water enema is an excellent measure. For reasons just referred to, however, it is always well to add an antiseptic to the enema, and one of the best for this purpose is oil of eucalyptus, 4 or 5 drops of which should be well agitated with the soap and water before administra- tion. There is one practical point in the giving of an enema to which I should like to direct attention. Everyone knows that the fluid should be about CONSTIPATION, DIARRHOiA, El'C. 101 100° F., and everyone is aware that the success of the operation depends upon its being performed very slowly; but very few seem to realize either that the nozzle of the ordinary syringe is about the worst that could have been devised for its purpose, or that a very efficient substitute is very readily obtainable. The ordinary nozzle is too short, so that, in order to prevent the regurgitation of fluid, the disc which separates the nc zzle from the tube has to be firmly pressed against the anus, a process which may give rise to considerable pain. This nozzle should, therefore, be removed, and an ordinary No. 12 gum-elastic male catheter be put in its place. The bone rim at the end of the catheter is almost an exact fit for the rubber of the syringe, and wUl retain its place without wire or cord. The catheter thus attached, when warmed and oiled, makes an admirable nozzle. It is introduced without pain, it reaches well up to the sigmoid flexure, and, if the patient's pelvis is elevated, as it should be, the fluid shows no tendency to regurgitate. So much, then, for occasional constipation. We now pass to the consideration of the far more im- portant subject of habitual constipation. Of this condition I would like to affirm at the outset that it is in the vast majority of people a malady which is eminently and easily curable, provided that it has not been long enough in existence to cause gross alteration in the anatomical relations of the parts, and the persistence of this alteration by the forma- 102 MINOR MALADIES. tion of adhesions, kinks, and bands. It is not, as a rule, until middle age is reached that chronic con- stipation becomes incurable by medicinal means. And, although it is one of the commonest and most curable of maladies, it is, unfortunately, true that it is the one that is least often cured; that it is allowed to remain one of the chief scourges of our present civihzation, vying even with alcohol and syphilis in the multiplicity of its consequences and their magnitude. That it can be made to rank with the two latter is due to the fact that, like them, it supplies a toxin to the blood, which so befouls all the tissues as to render them suitable breeding- grounds for aU kinds of microbes. The poison wears down the normal defences and allows the enemies to enter, to flourish, and abundantly to multiply. Why it is that civihzed man should be a consti- pated animal is a question that requires answering. And the answer is not, in truth, very far to seek. It is this: Civihzed man eats too much, thinks too much, and sits too much. Also, he uses a water- closet. UncivUized man hunted his food, and thus justified its consumption. He frequently fasted, either actually or relatively. The hunting kept his abdominal muscles in good order ; and he slept, as a child sleeps, prone and fatigued. Civihzation, not altogether devoid of advantages, is, physiologically, full of drawbacks. The control of the lower centres by the higher is essential to social life ; it is the pivot round which the community revolves, and the dis- CONSTIPATION, DIAKRHCEA, KTC. 102 gusting act of defsecation is very properly the first to be brought under the iron heel of propriety. Very early in the life of the child the control centres are invoked, and defsecation, which, in strictest physiology, should occur after each meal — that is, at least thrice daily — is severely battened down until it reaches the level of a grudging diurnal concession to lower things. Then come social, scholastic, and other exigencies; the control is still further developed, until at length the control attains such complete mastery that the tail restrains the whole dog. That is the foundation; the super- structure erects itself. This hypertrophic development of the control mechanism is the cause of all the trouble. In very early days, when the child is still on the level of the pot de chambre, he is discouraged from using it too frequently. Then he is promoted to the water- closet, to poise himself on the seat of which is all the more an acrobatic feat to him because his instinct tells him that to fall backwards into that seemingly bottomless pit would be the end of aU things. Then come the school-days, and the neces- sity for regulating and stiU further controlling the excretory act. Boys are not encouraged to void their excreta, and girls are often positively dis- couraged. ' You must not give way to those feel- ings; you must learn to control them.' Alas ! she proves all too apt a pupil. The control attains not only to mastery, but to despotism ; and the healthy, 104 MINOR MALAijii:^. clean-skinned adolescent rapidly becomes the sour- smelling and sour-tempered adult. If peradventure such a victim ot custom and les covenarwes should at this point come in contact with a medical man who has not been impervious to the gospel according to Arbuthnot Lane, he may still find salvation. But even so, with reason and good advice to guide him, in comparison with the savage he finds himself handicapped. Many a time and oft he would like to, but cannot ; letting ' I dare not ' wait upon ' I would ' ; and even when he can, he is still surrounded by enemies. The chief of these is the modern water-closet. Savage man per- force adopts the crouching attitude, normal and necessary to complete emptying of the lower bowel, and he has only to turn round to assure himself that the bowel is indeed empty, that the tribute of the descending colon is really sufficient to lighten the burden of the day's work, and that he is, so to speak, a free man. The beneficent psychic effect produced by the sight of a generous stool cannot be overestimated. It turns a melancholy man into a joyous one; it makes the timid courageous and the lazy energetic. Now, the modern water-closet, for all its sanitary perfection vis-a-vis the community, is grossly defective vis-a-vis the individual, because it deprives him of the mental stimulus of the up- lifting vision afforded by the result of his peristaltic labours. Nor is this its only crime. That its fathomless depth should deprive man of the satis- CONSTIPATION, DIARRHOEA, ETC. 106 faction of ocular appreciation is bad, but it is almost worse that its height from the ground should para- lyze his abdominal muscles. These muscles are httle enough exercised by sedentary man, but when seated on the ordinary everyday water-closet, he could not exercise them even if he would. A chair or a tail footstool may find him salvation by raising his knees, but if the basin itself were properly con- structed, these adventitious and easily neglected aids would not be necessary. The Jennings, the Doultons, and the other practical sanitarians who have placed this generation under real obligations, shoTild extend their energies to the standardization of a rational and physiological closet. And what, in this connection, is meant by the term ' a sufficient evacuation ' 1 The reply to this question given by a sergeant to a medical officer is worthy of record. ' What do you mean by a good rear ? ' The answer was prompt. ' Twice round the pan and pointed at both ends.' Such, no doubt, represents an occasionally attainable ideal to the man who pays his homage to Cloacina but once a day. But the man who knows, has an ideal at once more attainable and more workable : he soUcits the goddess at least twice daily, and, careful though he be of the nature of his matutinal offering, it is to the vesper- tinal that he attaches the major importance. Then, freed from the press and distress which pursue him by day, he learns to lay his willing latria leisuxely, leniently, and lavishly at her gracious feet. 106 MINOR MALADIES. On the question of the mechanism of normal de- fsBcation, Professor Arthur Keith shed a flood of much - needed light in his Cavendish Lecture.^ Therein he showed that the intestinal tract has several ' bundles ' in many ways comparable to the bundles in the waU of the heart which originate the rhythmical contractions of that organ. The matter is best stated in Professor Keith's own words : ' In passing along the alimentary tract food is propelled through a series of zones or segments, each furnished with its own pacemaker and its own rhythmical con- tractions. In the heart we find two such zones, an auricular and a ventricular ; in the normal heart the sino-auricular node is the master pacemaker. But a block or imperfection in conduction may occur between the two zones of the heart, with the result that "back-pressure" — a venous stasis — is produced. Now, seeing the similarity between the cardiac and alimentary motor mechanisms, we do not seem overpresumptuous if we suppose that irregu- larities may occur in the nodal and conducting system of the alimentary canal — irregularities of the same kind as are known to occur in the heart. When such irregularities or blocks do occur, we should expect to find them at the points where one rhythmical zone or area passes into the succeeding zone. That is exactly what we do find. We find a block where the oesophagus joins the stomach; we find another where the gastric zone ends and the 1 Medical Press and Circular, July 28, 1915. CONSTIPATIOi\, DIARRHCEA, ETC. 107 duodenal begins ; we find it where the duodenal zone passes into the jejunal, and where the jejuno-iliac passes into the ileo-colic. We find a block may occur at any point of passage from a lower to a higher ■ rhythm. At several of these junctional points sphincters are situated, and I do not deny that the mechanism of such sphincters may become disordered and cause ahmentary stasis, but it will probably be found that a disturbance in the action of a sphincter is secondary to a disturbance in the excitability and action of the whole rhythmical zone or segment to which it belongs. ' Further, it is clear that to obtain an orderly propulsion of the food along the whole length of the alimentary canal those various rhythmical zones must be closely co-ordinated in their action, and there is a growing body of evidence, both experi- mental and cUnical, that points to a very close co- ordination by means of a complicated system of reflexes. Disturbance in any one segment upsets the rhythm in aU the segments. Bayliss and Star- ling observed that distension of the duodenum in- hibited the action of the ileum; surgeons are fami- liar with the fact that a duodenal disturbance upsets the rhythm of the stomach. From the facts already mentioned it is easy to see that disturbance in the excitability and rhythm of the pacemaker of the csecum will be reflected to the lower ileum. One can understand, on the hypothesis I place before you, how stasis in the great bowel may be followed 108 MINOR MALADIES. by ileal stasis, duodenal or gastric stasis, or how a disturbance of the conductivity or excitability of any of the rhythmical zone may ultimately give rise to stasis in all.' The pathology of the physiological position thus expounded is supphed by Sir Wilham Arbuthnot Lane in his book on ' Chronic Intestinal Stasis,'^ a work which should be carefully studied by anyone who desires to have clear ideas on this all-important question. Briefly stated, the sequence of events is as follows: The erect posture of man, which tends to displace the abdominal viscera downwards and backwards into the true pelvis, in perfectly normal conditions is counterbalanced or compensated by the prone position during sleep, which tends to return these same viscera upwards and forwards, away from the true pelvis. Thus, the drainage, which is impeded during the day, becomes free and active during the night. If the counterb. 'ance or compensation should fail from any cause, s/ch as a faulty position during repose, changes occur. These changes, originally designed for the purpose of maintaining the viscera in their places, ultimately reach such a point of development as to defeat their own ends. By the kinking of the tube and the con- sequent narrowing of its lumen, what was intended as a support becomes an obstruction, much as a lead pipe may be seen to kink over its narrow bracket when exposed to heat. The accompanying diagram, 1 Adlard and Sons, 1915. CONSTIPATION, DIARRHCEA, ETC. 109 reproduced from Sir William Arbuthnot Lane's book, shows very clearly tbe end-results of the pro- BTP. cess which he describes in detail. I say end-results advisedly, for it must be borne in mind that the complete monstrosity which the diagram represents 110 MINOR MALADIES. usually takes about forty years to develop. The physician is concerned with the matter at a very much earlier stage, and it is entirely due to the bril- liant pioneer work of Sir William Arbuthnot Lane — ^work for which his own and future generations cannot sufficiently honour him — that we are in a position to forestall and prevent the banding and kinking which impose such untold and such protean miseries upon their victims. Inasmuch as our ideas of the normal are neces- sarily based upon the majority, and inasmuch as intestinal stasis, in some degree, is a condition which afflicts the vast majority, it is no wonder that its symptoms and physical signs escaped recognition until Sir William Arbuthnot Lane came with clear vision to rescue humanity from its own cesspool. There are people, and they are many, and most of them are unconscious delinquents, who hoard their faeces as a miser hoards his gold. A certain amount is daUy and laboriously given to the world, but, in comparison to what remains behind, the amount is mean, physiologically insufficient, and therapeuti- cally ineffectual. When young, these people carry their avarice upon their earthy, oily, and pimply faces. In middle age they become ansemic, scant of breath, exiguous of shin, and abdominally opu- lent. Old age they never reach; or, reaching it, they afford examples of the slippered, petulant pantaloon whom Shakespeare has rendered classical. Methodical but persistent intestinal drainage has CONSTIPATION, DIARRHOEA, ETC. Ill now become a rule for him who has eyes to see, ears to hear, and a nose to smell withal. Intestinal stasis was not, it is true, invented by Arbuthnot Lane, for it was known to Galen and Celsus, but he rediscovered it, and his originahty and fearlessness have imposed its cure as a necessary condition pre- cedent to all other cures. The therapist who now neglects it, thus proclaims his own sad stasis in matters scientific. It is but a slight exaggeration to declare that every chronic disease is a symptom of chronic constipa- tion. It is no exaggeration whatever to say that chronic constipation is at least a contributory cause in all chronic disease. At the back of the microbe there is to be sought the cause of the microbe, and this cause in every case is the state of the soil which permits him to flourish. Such a state of soil is described as a chronic auto-intoxication, which is only another way of saying that the drainage system is defective. And when the drainage system is de- fective to the point of there being a cesspool under the floor of the gastric dining-room, the powers of resistance are so reduced that the microbe comes and takes possession with easy and stupefying as- surance. There are many diseases about which long articles and even large volumes have been written — pyorrhoea alveolaris and rheumatoid arthritis, for example — and many dyscrasias — the gouty, the glandular, the acid, and the migrainous, to wit — which are no more than symptoms of chronic intes- 112 MINOR MALADIES. tinal stasis. The percolations from the cesspool have permeated the soil, and the whole carcase becomes inhabited by the fauna and flora of de- composition and disease. The particular members of these hostile groups which are destined to lead the invasion, and the particular points selected for their ultimate development, are decided by considera- tions which are at present beyond ua. This general result, the toxsemic, of chronic con- stipation is not sufficiently insisted upon. The symptoms usually cited are correct enough in their way, but they are too local and too topical, and therefore too singular. The earthy complexion, the cold extremities, the subfaecal odour of the axiUae, the emaciation, the general malaise. Lane's cystic breast, and the like, are very real manifestations of the poisoning, but it is to be remembered that the same poisoning forms the foundation upon which actual diseases are built. Such are rheumatoid and other forma of arthritis; exophthalmic and other forms of goitre ; ' borderland ' and other functional nervous manifestations ; menstrual disturbances and various gynaecological conditions; and others too numerous to mention. The existence of a chronic disease should thus create a suspicion in our minds that its existence and continuance are rendered possible by insufficient intestinal drainage. The individual symptoms just referred to will always help in this direction; but even in connection with these it must be remembered that they must be CONSTIPATION, DIARRHOEA, ETC. 113 looked for; none are so salient but that they easily escape the superficial observer. From the foregoing it foUows that in treating chronic constipation we are treating not only a toxic blood state, but we are also treating many so- caUed diseases, and that many so-called diseases cannot be satisfactorily treated unless and until the constipation and the consequent blood state have been successfully dealt with. This does not mean that the said diseases do not require any additional form of treatment for the alleviation of the symptoms which form the complex of each. They do. But it does mean that unless the constipation and the toxaemia are removed, treatment directed to the more obvious manifestations will be attended by a very fleeting improvement. The textbook thera- peutics of such diseases generally includes the phrase ' attend to the general health.' This should be ex- tended so as to read ' attend to the general health and especially to the intestinal drainage.' Thus, in the treatment of intestinal stasis there are two main indications. The first is to discover and remove the cause of the stasis; the second, to nullify the toxaemia. The first is a problem which in the present state of our knowledge is surrounded by very considerable difficulties. We do not know enough to enable us to act with certainty and pre- cision. We know very little about Professor Keith's intestinal ' motors.' We know that they exist, but we do not know what actuates them ; still less do we 8 114 MINOR MALADIES. know what throws them out of gear. We know how Lane's ' kinks ' and the ' controlling appendix ' act in producing intestinal stasis, but we do not know why they themselves are produced. The method of their mechanical production has been shown us, and shown us in a manner so lucid and convincing that the dullest may see and believe; but the predispositions which lead to this mechanism still lie hidden in a closely sealed book. Nevertheless, we have some empiiical knowledge of the action of drugs in the treatment of constipa- tion, which, when applied with judgment, insight, and some accessories, enables us to do a great deal to fulfil the two main indications. The question of the second indication, the nullification of the toxae- mia, is one to which but very scant courtesy was paid until it engaged the attention of the vaccinat- ing bacteriologist. If this eager truth-seeker has done little else of value, he has at any rate taught us not only the real importance of, but the possi- bility of attaining to, something in the nature of relative intestinal cleanliness. That this may be assured by means less complicated than the prepar- ing and inserting of vaccines, does not detract from the merit of the vaccinator. Of these means one of the best is the regular exhibition of paraffin oil. The oil is said to be a laxative, which no doubt it sometimes is, but its beneficial effects upon the whole organism can scarcely be due to its very moderate power in this direction. Exactly how it behaves is CONSTIPATION, DIARRHCEA, ETC. 115 not easy to say, but it probably prevents the large intestine from absorbing undesirable matters by blocking the mouths of the glands ; and, by dissolv- ing and carrying ofE toxins, both liquid and gaseous, it reinforces the natural defences against toxic in- vasion. Paraffin oil should be as viscid as is consistent with the fluid form — that is to say, it should have a specific gravity as near 0-890 as possible. The pure oil is quite tasteless. There are, however, some people who object to its consistency; in these cases there is no objection to combining it with other substances, such as malt, so as to form a powder, or emulsifying it with acacia, which is done in some deservedly popular preparations. To combine it with active drugs such as iron or the iodides is a mistake. No good is gained, and the issue is ob- scured. In connection with paraffin there are two warnings which should be laid to heart. The first is that if it passes through the intestines so as to reach the outer world in a form still recognizable as paraffin oil, the fact must be taken as an indication either that the dose is excessive, or, what is more frequent, that the oil is insinuating its way past an obstruction which it is unable to move onwards. In the one case the dose must be decreased ; in the other a purgative, such as calomel, is necessary. The second warning refers to the power as a solvent which the oil possesses, a power which necessitates caution in prescribing it together with other drugs. 116 MINOR MALADIES. One of these is thymol, which, from the fact that it is a very good intestinal antiseptic, might easily be prescribed to be taken in conjunction with the oil if this warning were not heeded. - The symptoms of thymol-poisoning, thus induced by a very moderate dose, are very unpleasant and alarming. A warn- ing of another kind in connection with paraffin is one which should always be given to a patient who is about to take it for the first time. It is that paraffin oil leaks through the anal aperture often in such quantities as to soil the linen and even the outer garments, without the victim being cognizant of its passage. Omission to issue this warning has been known to bring the patient back to the pre- scriber with a burning fire on her lips and a dress- maker's bill in her hand. There are several drugs whose claim to act as intestinal disinfectants is generally admitted, and there are many more whose obscure but beneficial effect upon the organism generally is probably due to an underlying disinfectant power either in the intestines themselves or in the blood-stream. Of the latter, quinine may be taken as example. Of the former, thymol has already been mentioned. Thymol is an intestinal antiseptic of undoubted potency, which, if certain precautions are observed, may be given in much larger doses than those sug- gested by the Pharmacopceia (| to 4 grains). Inas- much as it is very soluble, not only in paraffin oil, but in castor oil, oHve oil, and oil of turpentine, these oils CONSTIPATION, DIARRHOEA, ETC. 117 should not be given at the same time as the thymol. It is also very soluble in alcohol, ether, and chloro- form, so that mixtures which contain these should be avoided. If these facts are borne in mind, thy- mol in powder, enclosed in a capsule, which may advantageously be keratinized, can safely be given in 10-grain doses, twice or even three times daily. Thus given, it acts not only as a disinfectant of the intestinal canal, but as a very powerful deodorant of the faeces. To do any real good it must be given over long periods of time, say a month or six weeks. The salicylates, especially in the form of salol (salicyUc ester of phenyl), quinine salicylate, and bismuth saUcylate, have a considerable reputation with some physicians as efficient intestinal antisep- tics. I cannot, however, share in the enthusiasm which is sometimes expressed for them. In my hands their results have been disappointing. The same may be said of beta-naphthol, of which many speak in high praise; it has never succeeded in con- vincing me of its efficacy. With its cousin-germane, benzo-naphthol, prepared by the action of benzoyl chloride on beta-naphthol, it is far otherwise. I regard this drug as second to none in its power of disinfecting the intestinal tract and the blood- stream. It may be given in doses of 10 to 15 grains three times daily as a tabloid (grs. v.), or in a cachet. Unlike thymol, no special caution is necessary in prescribing it; and unlike beta-naphthol itself, it 118 MINOR MALADIES. does not seem to have any tendency, when given over long periods, to derange the kidneys. One of the best of the intestinal disinfectants is mercury, but as mercury in aU its forms is something more than a disinfectant, its use is necessarily hmited by its chief physiological effects; it is con- sequently outside the present category. In the objection which is sometimes urged against chemical intestinal disinfectants it must be admitted that there is much force. The objection points out that an efficient bactericide will kill not only the enemy microbes, but those friendly ones upon whose beneficent activities Metchnikoff insisted with such curious results. This is a very pertinent criticism, which it would be more easy than it is to dismiss as mere theory, if the results of our present antiseptic therapy were always cHnicaUy satisfactory. In certain cases these chemical disinfectants succeed admirably, but in others they fail, and their failure reminds us that the real intestinal antiseptic is to be found in the intestine itself. If we could but evoke an increased activity of the natural defences, the necessity for such aids as thymol and benzo- naphthol would disappear. Attempts are already being made in this direction by administering ' secretin ' and other hormones. It is still too early to write with confidence on the measure of success which is to be expected from such endeavours, but the principle is undoubtedly sound. I have had some experience with a preparation known as CONSTIPATION, DIARRHCEA, ETC. 119 Secretogen (G. W. Carnriek), and the results have so far seemed to justify the hopes which led to its introduction. It appears to stimulate the gastro- intestinal tract to more vigorous function, and thus to lessen the toxsemia. It. seems well worth a trial in cases where the poisoning has led to loss of appetite and digestive disturbance. We pass now to the consideration of the measures at our disposal for overcoming the stasis itseK. Amongst the most important of these is the ensuring of proper support for the abdominal viscera, by toning and if necessary re-educating the muscles which form the anterior abdominal wall. It is not necessary here to consider the matter further than by saying that massage and properly directed exer- cises are capable of doing a great deal of good in this direction. Mechanical supports are very useful adjuncts even to well-developed abdominal muscles, especially after middle age, but the supports should be conceived on sound anatomical principles and carefully executed so as really to fit the individual patient. A great many of the abdominal belts upon the market are worse than useless, inasmuch as, by constricting the area above the umbilicus, they en- courage the viscera in that fatal descent into the pelvis which is so surely productive of kinks and bands. Many a good corse tiere is capable of making a well - fitting abdominal support, the so-called straight-fronted stays being very serviceable to this end. Messrs. Walton and Curtis, of 8, Old Caveri- 120 MINOR MALADIES. dish Street, make an excellent contrivance for this purpose, the original lines of which were, I believe, suggested by Sir Arbuthnot Lane himself. In so far as our knowledge permits, we should base our application of purgatives upon ascertainable facts. It is, for example, desirable to find out which of Keith's intestinal motors is at fault, and if possible to stimulate that particular one without overstimu- lating and thus fatiguing the others. In all pro- bability it is this fatigue of overstimulated motors to which we refer when we speak of a purgative — ■ e.g., castor oil — which leaves ' after-constipation.' It is too often assumed that the evil effects of stasis are due solely to absorption from the large intestine, an erroneous assumption which dictated the heroic lavage of the colon which is known as the Plom- bieres treatment. I am very far from saying that such treatment is undesirable. I believe, on the contrary, that in cases where the stasis is really in the colon, it is capable of doing a great deal of good, especially as a measure preparatory to treatment at once more sustained and more gentle. That the stasis is often, perhaps most often, in the small in- testine is obvious both from a study of Lane's kinks and the consideration of Keith's motors. In the bismuth meal and the radiograph we are now fortunately possessed of a certain means of diag- nosis on this very important point, and where such means are available they should always be appealed to. The two things which have most retarded the CONSTIPATION, DIARRHCEA, ETC. 121 scientific study of chronic constipation are the uni- versaUty of the ailment and the superficial ease with which it may temporarily be overcome. We do not yet know enough about Keith's motors and the causes which disorder them to enable us to deal effectively with their derangement, but we do know that certain drugs affect certain areas by pre- ference. Mercury, podophyllin, and euonymin, for example, exercise their influence mainly in the duodenum ; the sulphates of sodium and magnesium are active primarily in the ileum; colocynth chiefly in the large intestine; and aloes almost exclusively in the rectum. Most of the other purgatives which we employ — for example, cascara, rhubarb, and jalap — affect more than one area, and a great many produce their results as stimulants of the whole gastro-intestinal tract, bringing all or most of the motors within their influence. It is a curious and senseless and wholly unscientific parrot-cry which invests nux vomica with any power as a purgative. The search for a drug which will at once relieve constipation and abolish a tendency thereto is like the search for the elixir of life or the philosopher's stone. A little consideration wiU show that such a drug does not and cannot exist. For under what euphemism soever their real effect may be concealed, whether they be called aperients, laxatives, hydro- gogues, purgatives, cathartics, cholagogues, or what not, every one of them is essentially an irritant poison with a selective action on the alimentary ia2 MINOR MALADIES. tract or some part thereof, which, when taken habitually, provokes the production of antibodies which will ultimately more or less completely nullify its action. The discovery of cascara gave some encouragement to the futile search for an ideal drug, but anyone with any real experience of its properties must reaUze that its merit resides solely in the fact that it produces antibodies more slowly and less vigorously than most others. In the long-run the antibodies are duly evoked, and the dose of cascara must be increased. Until further investigation succeeds in throwing more light upon the whole question, we are thus reduced to handling such aperients as we possess, so that no one of them is employed to the point of producing its antibodies. This means that in the treatment of chronic con- stipation, in addition to para£Bn oil and benzo- naphthol, we must ring the changes on various laxative drugs. It is my own practice to give a list of seven, one for each day in the week, with strict injunctions to the patient that, vary them as he will, he is not to take any one for more than two days in succession. In otherwise healthy adults . my list always includes cascara, one mercurial and one saUne; in children, aloin; in old people, belladonna. A very good piU which figures in most of my lists is one of whose composition I am ignorant — Pil. Savonneuse (Boissy). In the matter of salines, it is to be remembered that these are less irritant than most other laxatives, CONSTIPATION, DIARRHOEA, ETC. 123 and are much less likely to evoke the neutralizing anti-bodies. They act by attracting fluid into the intestine, and thus aid in flushing out the back- waters. SaUnes have thus many advantages over most other laxatives. The disappearance from the market of the Austrian and German natural aperient waters at first caused some difficulty. British firms have now, however, filled the gap by the introduction of suitable substitutes. I can speak well of Tonalka and of Apwa. |In combating, the deeply rooted prejudice against the habitual taking of laxatives, begotten of the excesses of our forefathers, the profession of to-day has a long and stubborn furrow to plough. Nothing is more common than for patients to object to any treatment suggested for chronic constipation on the grounds that they do not want to get into the habit of taking drugs. That is academically a praise- worthy attitude, the reply to which is that it is much better to take drugs than to be a walking cess- pool. The most difficult people to persuade are those who are satisfied with a small but perfectly regular daily motion. They wiU not believe that there is a residue, the absorption of whose toxins is the cause of the symptoms arising in diverse places, most of them remote from the abdomen. Until the profession succeeds in overcoming these prejudices and obstinacies, the most potent cause of what may be called out-patient maladies will continue to flourish with destructive security. 124 MINOR MALADIES. DIARRHOEA. — The first thing we have to re- member about this condition is that, except in children, it cannot be regarded as a disease fer se. In the latter it must always be regarded as much more than merely symptomatic, and as in them the condition is hable to assume an aspect of the highest importance and the utmost gravity, which is ade- quately dealt with ra most textbooks, I do not pro- pose to refer to it, beyond caUing attention to a very masterly presentation of the subject to be found in Dr. Edmund Cautley's work on the "Diseases of Infants and Children. "^ The same author contributed a paper entitled " Summer Diarrhoea " to the Medical Press and Circular, which appeared on July 14, 1915, and is one of the most practical and helpful papers I remember to have read upon a very common and Uttle understood malady. In view of the latter-day campaign for the preservation of infant and child life, it behoves the medical man to be thoroughly well equipped in the treatment of such diseases as show a high infant mortality. Summer diarrhoea is one of these. It requires very prompt and thoroughly instructed treat- ment, with the details of which the young practitioner should make himself quite f amUiar. This is the more necessary because he will frequently encounter very decided opposition from ignorant mothers and mu-ses who are quite unable to appreciate the necessity for the measures which must be insisted on. • London, Shaw and Sons, Fetter Lane. CONSTIPATION, DIARRHCEA, ETC. 125 Diarrhoea in the adult, except where it means typhoid, dysentery, or some equally obvious condition, spells intestinal irritation. And in connection with this irritation we have to remember that what will irritate one person will fail to produce any effect upon another — or, for that matter, upon the same person under different conditions. The diarrhoea of the neurotic or neurasthenic person, for example, is an instance of the result of very minute stimuli upon a sensitive organism, and the proper way of treating it is not by attempts to remove the irritation, but by lessening the reactive power of the individual. There are a good many people who go about in mortal dread of being 'taken short' at inconvenient times and places — e.g., in church, or on a long railway journey ; and, their nervousness under such conditions supplies the stimulus necessary for the production of the very condition which they dread. In such cases the exhibition of the bromides and other measures, physical and moral, calculated to strengthen the nervous equilibrium, constitutes the proper line of treatment. Astringents, especially opiates, should be avoided. Diarrhoea may be salutary. This is worth remem- bering, especially in view of the fact that the condition is, to say the least of it, very inconvenient, and that the subjects of it are consequently very insistent in demanding relief. It is salutary when, as in alcoholism and kidney disease, the bowels are called upon to do more of the excretory work of the body than legiti- 125 MINOR MALADIES. mately falls to their share. When such a state of matters is to be suspected the right treatment consists in calling upon the other emunctories, especially the skin, to undertake their share of the burden, and by suitable diet to lessen as much as possible the manufacture of the offending material. A hot bath — hot enough, that is, to produce free dia- phoresis — is an expedient which is too much neglected in the treatment of this condition. The warmth is very grateful to the patient, and the diaphoresis helps to relieve the work of the intestines. In this way the diarrhoea is checked, while the discharge of the offending material is not interfered with. The commonest cause of diarrhoea, however, is the presence of irritating matter in the intestinal canal itself. Here the condition is not salutary, because it is as a rule futile. The irritant, whatever may be its nature, produces increased peristalsis below the point at which it is situated, so that the resulting diarrhoea tends to exhaust the patient, without in any wa}- contributing to the removal of the cause. In sucli cases, which constitute the vast majority of those with which we have to, deal, an efficient evacuant (say J ounce to 1 ounce of castor oil) which will act on the intestine from above the site of the irritant should be given at once. It seems needful to dwell upon the necessity for this, because I find that diarrhosa is so often treated by astringents without any preliminary evacuant — a procedure which is as unscientific as it is useless. Slight looseness of the CONSTIPATION, DIAllRHCEA, ETC. 121 bowels may, of course, occasionally be successfully so treated ; but we must remember that household remedies have invariably been tried before a case of diarrhoea reaches a doctor, and that household remedies consist of astringents. To neglect the evacuant, therefore, is to do wrong both scientifically and tactically; the only effects of so doing are to prolong the sufferings of the patient and to bring discredit upon the practitioner. When the bowels have been cleared of the offending matter, astringents may be given with every con- fidence. In these it is generally wise to include opium, always supposing, of course, that the kidneys are in a healthy condition. Opium not only assists the action of the astringents, but it affords rest to the bowel and soothes the irritated nervous system. The combina- tion which I have found most efiicacious for this purpose is as follows : Tr. opu ... mi. Sp. ammon. co ... mxxx Ess. menth. pip ... nixx. Tr. catechu ,.; ... 5i. At^uam ... ... ... ... ... ad gi M. Sig. : Every four hours. Preceded by a dose of castor oil and a hot bath, I have never known this mixture to fail in affording relief in diarrhoea when the condition was caused by a simple as opposed to a specific irritant. Diet is, of course, an important matter in guiding the malady to a satisfactory conclusion, but the dietetic 128 MINOR MALADIES. mauagement consists more in the application of rational general principles than in the prescription of any particular regime. It is advisable to remind the patient that food, when well masticated and insalivated, leaves very little for the irritated intestines to do, and that the more thorough these processes are the more quickly will the irritation subside. Milk is probably the best food for those with whom it agrees. For those who cannot take milk, fish, poultry, and meat, as less liable to give rise to fermentation, are better than farinaceous foods. Diarrhoea is apt to appear as an early event in two complaints, of whose existence it is occasionally neces- sary to remind ourselves — namely, Graves' disease and Addison's disease. The latter is not very com- mon, perhaps, but when it does occur it is well for all parties that it should be recognised early. To this end it should always present itself as a possible explanation of what may appear to be an ordinary attack of diarrhoea. The same is true of Graves' disease. This is far more common than Addison's disease, and as its only other symptom may be tachycardia, we should be on our guard against dismissing as a little ' intestinal irritation ' a case which may ultimately progress to thyroid enlarge- ment and exophthalmos. Tannigen (di-acetyl-tannin) is a good symptomatic astringent. It should be given in a cachet (10 grains) three times a day. Fissure of the anus and stricture of the rectum often lead to diarrhoea by causing accumulation of CONSTIPATION, DIARRHCEA, ETC. 129 feces. Persistent diarrhoea in a person over forty should always lead to a careful examination of the rectum, as malignant disease is, under such circum- stances, probably the commonest of all causes. A group of symptoms variously designated, but now usually recognised under the title of mucous colitis, may be associated either with constipation or diar- rhoea. As a rule, the one alternates with the other, but it is generally the diarrhoea which brings the patient under observation. There is always mucus in the stools, sometimes in very large quantities, and it is occasionally sufficiently organized to resemble shreds of membrane (muco-membranous colitis). Not infre- quently blood is also present. The diarrhoea, which is accompanied by a considerable degree of pain, is unafiFected by the ordinary remedies, and leads rapidly to emaciation and the development of symp- toms of * nervousness.' So much is this the case that mucous colitis has been considered a morbid entity, and has been described as a neurosis. Against this facile view of the matter and the mistaken therapy which is its logical outcome, it seems necessary to enter a warning. Lockhart Mummery has shown ^ that mucous colitis is merely a symptom ; that it may be due to a great variety of causes, amongst which may be mentioned malignant disease, ulcers, adhesions, retroflexed uterus, and the apparently ubiquitous and inevitable appendicitis. The symp- tom may, however, be due to a simple catarrhal 1 • The Causes of Colitis ' (Lancet, June 16, 1907). 9 130 MINOR MALADIES. inflammation of the large intestine, more especially of the region of the sigmoid flexure (resembling the catarrhal inflammation so commonly observed in the upper air-passages), which has been induced by the chronic irritation of masses of undischarged faecal matter. When due to such a condition, the treat- ment is both simple and efficacious, and, like that of bronchial catarrhs, it consists in the application first of sedatives and subsequently of astringents. The best way of applying sedation is to irrigate the bowel with the best lucca oil. Inferior oils are useless, because they act as irritants instead of sedatives. The oil, previously warmed, should be introduced very slowly by a douche (not by a syringe) with a catheter nozzle (see p. 101). The patient lies on his right side, with the hips well raised and all his muscles relaxed ; the douche-can is placed at a moderate elevation (not more than 2 feet above the level of the anus), and the oil is allowed to flow gently in. The degree of inflammatory catarrh can to some extent be gauged by the length of time during which the patient is able to retain the pint of fluid thus intro- duced. At first he may wish to return it at once, but he must be encouraged to bear with it. As improve- ment sets in, the irritability of the mucosa lessens, and the oil is easily retained for several hours at a time. When tolerance is established to the point of permitting the retention of the oil for ten hours, which generally occurs in the course of a week, an astringent fluid, such as argyrol (1 per cent.) or CONSTIPATION, DIARRHCEA, ETC. 131 potassium permanganate (1 in 2,000) may be substi- tuted, after which complete subsidence of the symp- toms quickly follows. It is needless to say that during this treatment the patient should be confined to bed ; nor should it be necessary to emphasize the necessity for the utmost patience and skill in securing that the injected fluid shall irrigate the whole length of the large intestine. If this line of treatment does not succeed in affording prompt and pennanent relief, it is practically certain that the colitis is due to some cause more serious than a simple inflammatory catarrh of the mucosa. An examination by means of the sigmoidoscope should therefore be advised. VOMITING, like diarrhoja, usually appears as a symptom of some definite underlying morbid con- dition; but, like diarrhoea, it also occurs as an apparently separate clinical entity, for which no cause can be discovered beyond an undue irritability either of the stomach itself or of the vomiting centre in the brain. It is a common symptom of gastric disorders, and in searching for a cause, one's thoughts naturally turn primarily towards the stomach. It should always be remembered, however, that there are two serious conditions with which it is often asso- ciated, and whose existence is liable to be overlooked if we make the mistake of considering too exclusively the gastric origin of the symptom : one is intracranial disease, the other is renal disease. In both these conditions the sickness may easily be the only obvious symptom, and, unless we make it a rule always to 1S2 MINOR MALADIES. examine the urine and the fundus oculi in every case of vomiting for which no obvious explanation is forth- coming, we lay ourselves open to the risk of very grave errors of diagnosis. Cerebral vomiting is generally accompanied by headache and optic neuritis, and careful search for physical signs in the nervous system will nearly always bring to light some other facts which point to its true origin. It is a common and very dis- astrous mistake to label as hysterical, sickness which is due to some serious intracranial lesion. Vomiting does, of course, occur in hysteria, but, then, hysterical or 'functional' manifestations are of very frequent occurrence in almost all intracranial conditions, so that it is never safe to make a diagnosis of hysteria until structural disease can be positively excluded. In children vomiting is commonly an early event in meningitis. Vomiting may be the first event to call attention to the existence of kidney disease, and negligence to examine the urine may thus be fraught with very serious consequences ; for if we do not realize that the sickness is of renal origin, not only shall we fail to treat the disease by appropriate means, but in our endeavours to stop the vomiting we may have re- course to measures, such as the giving of morphia which may actually militate against recovery. More- over, it is well to remember that absence of albumin does not necessarily exclude the possibility of disease of the kidneys. In nephritis, of the chronic inter- CONSTIPATION, DIARRH(EA, ETC. 133 stitial type especially, albumin may be absent, so that evidences of renal trouble must be sought for by examination of the heart and arterial system — the former for hypertrophy of the left ventricle, the latter for arterio-sclerosis. Other common causes of vomiting are hernia, pregnancy, whooping-cough, and phthisis. It is, of course, of the utmost importance to bear the existence of these factors in mind, so that they may be examined for. Our mistakes are less often due to ignorance than to the forgetfulness or negligence begotten of hurry. A form of vomiting which is characteristic enough to lead one immediately to suspect its true cause is that which heralds the invasion of an acute specific disease. Here the sickness is not accompanied either by nausea or retching, but the contents of the stomach are sud- denly, completely, and unexpectedly expelled without pain or discomfort. Except where an emetic has been given, this kind of sickness is very suggestive of the onset of an acute fever of some sort. The vomiting which occurs in association with the condition variously called sick headache and bilious headache is liable to be very troublesome, more especially if the true nature of the underlying con- dition is not recognised and treated. This matter is fully discussed in the next chapter, but I may say here that the name bilious, as applied to these attacks, is particularly unfortunate, for the reason that it suggests treatment by mercurial and other 134 MINOR MALADIES. cholagogue cathartics, than which, as a rule, nothing can be more harmful. These attacks are in a very large number of cases due to ocular refractive errors and other peripheral irritants ; and unless the patient is properly fitted with correcting glasses, or the irrita- tion otherwise subdued, drugs such as phenacetin, though they may give relief at the time, contribute nothing whatever to the prevention and ultimate cessation of the attacks. The influence of refractive errors in the causation of vomiting, apart altogether from headache, does not seem to be suflBciently appreciated. It is by no means uncommon for a person whose error — say a low degree of astigmatism — has been corrected, and, before he has accustomed himself to the use of the glasses, to complain that the glasses cause nausea, and even attacks of vomiting. These attacks will often lead to the discontinuance of the glasses. This is a very foolish procedure, into the result of which it is impos- sible here to enter. What it seems necessary to insist upon is that nausea, vomiting, and a host of other symptoms, often rightly attributed to neurasthenia, but more often wrongly relegated to hysteria, are very frequently due to uncorrected errors of refraction, and that, unless these errors are corrected, the symptoms will persist, Eyestraini is responsible for an enormous amount of ill-defined nervous troubles of modern life, and the practice of some ophthalmologists of dismiss- ing low degrees of error as unimportant is responsible 1 See next chapter. CONSTIPATION, DIAHRHffiA, ETC. 135 for much of the futility in the treatment of these troubles. Sea-sickness is in many cases, at any rate, traceable to the ocular apparatus. The landsman is unable, because he is unaccustomed, to accommodate his visual machinery to the rapid and sudden changes of movement caused by a rough or choppy sea, and his efforts to bring about this accommodation give rise to nausea and vomiting. That, in many cases, this is the sole factor at work is evident from the fact that the simple expedient of wearing a patch over one eye when on board has been sufficient in so many cases to prevent sea-sickness. No efforts are made to reconcile the workings of the two eyes ; strain is prevented, and sickness remains absent. It is not, of course, suggested that sea-sickness is always due to this cause, but it very often is, and the above-mentioned expedient is consequently always worth a trial. In the majority of cases, no doubt, other factors are also at work, and in most of them we must suppose that there is an undue irritability of the nervous system, which causes a too ready response to slight stimuli. In patients of this type it is generally quite easy to prevent sea-sickness if we can commence treatment a week or so before the voyage begins. The excitability of the general nervous system is reduced to normal by giving bromide of ammonium in lO-grain doses three times a day for at least three days. The primse vise are suitably cleared, and, with a view of exercising a special effect upon the stomach, some liq. bismuth, 13(5 MINOR MALADIES. ammon. cit. (2 drachms) with tr. nucis vom. (3 minims) is added to each dose of the bromide mixture. The medicine should not be taken on board — not only because it is then too late, but also because there is another drug which has proved in my experience unfailing, even when given without any preliminary preparation by bromides — namely, chloretone. A good way of giving chloretone is to prescribe it in 5 to 10 grain cachets — one cachet to be taken during the train journey down to the boat, another as soon as the patient is settled on board, and a third, if necessary, at any time during the voyage. If the patient is directed to preserve the dorsal posture when on board, the third cachet is very seldom necessary. I have now prescribed chloretone in a great number of cases, and where the way has been prepared for it by the bromide mixture, I have not known it fail, and even in the absence of any such preparation, I have learned to have the utmost confidence in it. It may be given in 10-grain doses if sickness threatens. It will often stop an attack which is actually in progress. It is not infrequently necessary to treat sympto- matic vomiting, either pending the removal of the cause or when the cause is unfortunately not re- movable. A great many expedients have been suggested for this purpose, some of which are often useful, but which seem as often to be without effect. The application of a blister or a mustard-plaster to the epigastrium is often very successful, but no less often CONSTIPATION, DIARRHCEA, ETC. 137 useless. Occasionally successful, also, is the application of an ice-bag to the same region, or a poultice, or gentle massage. These are all well worth trying, for they are simple enough, and if they do not succeed, they cannot do any harm. Of drugs, the simplest is undoubtedly lime-water, and Burney Yeo urges strongly that it should be given a trial more frequently than is now the case. A table- spoonful, he says, should be administered hourly for several hours before recourse is had to other means. He recommends, further, the addition of one drop of creosote well shaken up with each dose, in case the lime-water alone is unsuccessful. Champagne is per- haps one of the most popular of all remedies for this condition, and it has the merit of being one of the most efficacious. It should be given, preferably iced, in quite small doses, say 1 to 2 drachms, repeated at intervals of ten minutes or a quarter of an hour, until vomiting ceases, I have known many cases in which this succeeded when all other measures had failed. Vin. ipecac, liq. arsenicalis and hydrocyanic acid have all enjoyed some reputation in the treatment of vomiting, and for this purpose they are aU employed in minute doses — i.e., not more than 2 minims. Ringer speaks highly of vin, ipecac, but not everyone is able to share his enthusiasm. Fowler's solution is admittedly useful in the morning vomiting of drunkards, but I have found it beneficial in sympto- matic vomiting arising from other causes. Hydro- cyanic acid is usually very reliable, but it is not wise 188 MINOR MALADIES. to restrict its use to the small doses above suggested. It may be necessary to prescribe it in 3 or even 5 minim doses to produce the required effect, but these must obviously not be frequently repeated. A combination of all three drugs in 1 - drop doses, repeated at intervals of ten minutes or a quarter of an hour, is an expedient to which I have occasionally resorted with success. Bismuth is a useful drug in vomiting, and, in combination with oxalate of cerium, it is, when the stomach will retain anything, probably the most reliable of all. It is best given in cachets : Bismtith subnit. ,. gr. XX. Cerii oxalat , .. gr. V. M. Ft. pulv. in cachet L But the cachet must be well moistened before any attempt is made to swallow it. Finally, morphia by hypodermic injection, though it often causes vomiting, will not infrequently stop it. When given for this purpose the dose should be relatively large — that is, about ^ grain. Small single doses are much more liable to cause gastric disturbance than large ones. In association with vomiting it seems appropriate to consider briefly the allied condition of GIDDINESS.* Although this condition is common in cerebellar disease, especially cerebellar tumours, in disseminate sclerosis, and is not altogether uncommon in tabes, it 1 See ' The Border-Land of Epilepsy,' by Sir William Gowera (J. and A. Churchill, 1907). CONSTIPATION, DIARRHCEA, ETC. 189 should not be regarded as necessarily indicating the presence of some grave cerebro-spinal mischie£ It is frequently due to ocular troubles ; paralysis of an ocular muscle will give rise to it, and errors of refrac- tion are among the commonest causes. Abnormali- ties in or about the ears very readily occasion the symptom, hardened cerumen being among the most frequent. M^ni^re's disease, or aural vertigo, which is due to an affection of the semicircular canals, may cause paroxysmal attacks of giddiness, accompanied by vomiting, and is thus liable to be mistaken for migraine (q.v., p. 172). M^nifere's disease is, however, almost always associated with some degree of deaf- ness, which is seldom the case in migraine ; moreover, in aural vertigo the giddiness is very pronounced ; so much so that the patient not infrequently falls. For the treatment of aural vertigo, bromide of potassium and belladonna, persevered with over long periods, often do a great deal of good. During the attacks both quinine and the salicylates are highly spoken of. The former should be given in large doses (10 to 15 grains or more) ; the latter, in the form of aspirin (10 to 15 grains), is probably equally efScacious and less liable to produce unpleasant by-effects. Some- times hydrobromic acid acts better than any of the bromide salts. This drug is much the most reliable remedy we have in those persistent noises in the head which occasion annoyance and alarm to those who suffer from them. 140 MINOR MALADIES. Giddiness is said tx) be sometimes due to causes arising in the digestive apparatus. There is very con- siderable doubt as to the stomach ever being directly- responsible for the symptom. The real cause of giddiness in most cases, apart from those which have just been noticed, is some disturbance in the vaso- motor mechanism. We know that toxins originating in the digestive tract are very powerful disturbers of this mechanism, and it is exceedingly likely that digestive disturbances may cause giddiness in this way. The disturbance as a rule takes the form of vaso-constriction, but there seems no reason why the opposite condition of vaso-dilatation should not also bring about the same result. The circulatory apparatus in the brain is of so delicate a nature that any alteration of the calibre of the conducting vessels is liable to cause symptoms. The giddiness of elderly people usually means atheroma; that of the gouty, either high arterial tension or its next stage, arterio- sclerosis ; even the giddiness of epileptics is probably circulatory in origin, and that which is so common at the climacteric is certainly so. Attacks of giddiness, therefore, should never be lightly regarded. They may be due to transitory causes, but they may, on the other hand, indicate some very serious condition. They should always lead to a careful examination of the nervous system, including the special senses, and, failing the discovery of a cause therein, the question of the state of the heart and bloodvessels should engage the most CONSTIPATION, DIARRHCEA, ETC. 141 anxious attention. It is not too much to say that the vast majority of cases of ' simple ' giddiness are due to vascular changes, and that among these high blood-pressure occupies the first place. For a consideration of this question and its treatment, the reader is referred to the chapter on Goutiness. ADDITIONAL FORMULAS. For Colic (Ludlow). CUorof. 3ii. Morph. acetat gr. iii. Olei anisi nixvi. 01. menth. pip inxvi. Syr. acacia ... ... ... ... 5^9. Aq. camph. ad §iv. M. Sii.-gss. for a dose. For Colic with Constipation (Paris). 9. 01. cajuput ... miv. Saccb. alb. ... ... ... gr. X. Bub together, and add : Tr. jalap ... 3i- Decoc. aloes co ... ad gis8. M. Ft. haust. For Colic of Infants (Widerhofer). Tr. caBcarillEe ... nix. Tr. kramerise .r. mx. 01. aBthemidis ... mi-ii. Syr. simpliois ... 3iiss. Aquam ... ... ... ••• ... adSii. M. big. : One teospoonful every two hooia. 142 MINOR MALADIES. Constipation in very Young Infants (Monti). Mannite gr. ol. Hot water Bias. M. A dessertspoonful every hour until it aots. Sir James Paget's Cure for Constipation. 1 lb. French plums, in enough water to cover them. Stew for three hours, simmering gently, and then remove stones. 1 oz. of ground ginger (good weight). 1^ oz. powdered senna. 1 lb. Demerara sugar. Mis the whole together well in a pudding basin. Dose : A fceaspoonful at bedtime. Pills for Gouty Constipation. ^. Iridin ... Aloes pulv. Ext. hyoscyam. M. et divide in pil. xii. gr. xxir. gr. xviii. gr. vi. Sig. : One at bedtime, followr by a saline in the morning. For Diarrhosa in Infants, after an Aperient (Eustace Smith). Saponis duri Hispanioli ^. CretsE prep. ... Syr. flor. aurant. Aq. menth. sativ. Aquam foeniculi gr. XVI. gr. XX. 3ii. 3iii. ad^i. M. Sig. : A teaspoonful every eight hours for a child between six and twelve months of age. Older children may take the same quantity every six hours. (6) B<. Spts. ammon. aromat. Tr. rhei Tr. opii Spts. chlorof. Aquam oarui "ixx. M. "Ixxiv. miv. ... tlxxiv. ... ad gi. Sig. : One teaspoonful every eight hours for a child of six months old CONSTIPATION, DIARRH(EA, ETC. 143 Diarrhoea of Adults, after an Aperient (Hare). (a) (6)^. M. Sig. : 3i. in water every two or three bouxa. Tr. kino •-. ... 5L Tr. catechu >•■ ... Si. Mist, crets ... ... Siii. Aquam cinnaznonii ... ... ad3vl. M. Sig. : §as. every three hours. Acid, sulph. aromat. •■• •*. §88. OL cajuput ... mxL Ext. hsemafcoxyli ... 3ii. Spts. chlorot ... •.. 5i. Syr. zingiber ... ad5iiL CHAPTER IV. RHEUMATISM, NEURALGIA, HEADACHE. RHEUMATISM is a term which, if it ever had a precise meaning, has now, unfortunately, lost it. ' As appUed to acute rheumatism or rheumatic fever, it bears, no doubt, a definite significance, but it is now generally admitted that the disease which is so described has no real relationship with the numerous other morbid conditions to which the terms ' rheumatism ' or ' rheu- matic ' are commonly applied. These terms are made to comprise most of the arthropathies, both acute and chronic. The arthropathies have been very con- veniently divided into the essential and the accidental ; the former being those in which the joint affection is the predominant feature in the disease, such as gout, acute and subacute, rheumatic fever, morbus coxae senilis and rheumatoid arthritis ; the latter being those in which the joints are involved secondarily to some other affection, such as pulmonary osteo-arthritis, and the arthritis of gonorrhoeal, scarlatinal, septic, syphilitic or neuropathic origin. These conditions are, of course, quite distinct from each ojther, and, as they all belong to the sphere which is properly RHEUMATISM, NEURALGIA, HEADACHE. 145 covered by the text-books, they need not concern as here. There remain for our consideration, then, chronic gout and chronic rheumatism. The former is dealt with in the next chapter ; into the problems presented by the latter I now propose to enter. In the existence of chronic rheumatism, properly so called, I may say at once that I do not believe. I do not beZieve, that is, that there is any chronic form of the condition which we call acute rheumatism, or rheumatic fever. Fagge says : ' Chronic rheumatism ought to mean a chronic arthritis of the same pathology as the acute outbreaks of rheumatic fever. Such a disease, we may affirm, does not exist.' With this opmion, though it is not shared by all, even by so great an authority as Osier, I am in entire accord. Certain chronic joint troubles, it is true, are hable to appear as sequelae of rheumatic fever; but these same joint troubles appear equally often after true influenza, after sore-throats, and, in the predisposed, after local injury to- joints, such as sprains. Moreover, these joint troubles, inasmuch as they affect, not the cartilage, synovia or bone, but merely the fibrous tissues surrounding the joint, have no real relationship to those which occur in acute rheumatism. The conditions which are admittedly closely related to true rheumatism, such as chorea, tonsillitis, and subcutaneous nodules, have, of course, no arthritic element, and are not in any sense of the term chronic; so that although their power of causing rheumatic endocarditis should never be lost 10 146 MINOR MALADIES. sight of, it is impossible to include them in such a term as * chronic rheumatism.' The fact is, chronic rheumatism has nothing what- ever to do with true rheumatism, and it would be well if some authoritative name could be applied to the condition which is variously described as rheu- matics, chronic rheumatism, muscular rheumatism, tendinous rheumatism, rheumatic myositis, myalgia, and neuralgic rheumatism; for the morbid state which is thus buried beneath misleading and con- fusing names has a very distinct and very definite existence, with its own pathology, symptomology, and therapeutics, so that the retention of the term • rheumatism ' in connection with it is not to be de- fended even on the ground of convenience. In the meantime, being to some extent bound by custom, I propose to use the expressive, illiterate, but highly convenient term ' rheumatics,' invented by and be- loved of the laity, to designate the condition. Rheumatics, then, may be described in the terms of Stockman,^ who has done so much to introduce order into the chaos which previously existed on this subject, as a condition in which the essential pathological changes are confined to white fibrous tissue ; in which, therefore, the manifestations appear chiefly in aponeurosis, fibrous septa, the sheaths of muscles and nerves, periosteum, and the fibrous structures surrounding the joints. 'The lesion,' he • Brituh Medical Journal, February 27, 1904, RHEUMATISM, NEURALGIA, HEADACHE. 147 says, ' consists in inflammation and hyperplasia of the connective tissue in patches, and the condition may be widely spread over the body or be confined to a certain area of it." When once the conception presented by this description is realized, the isolated and disconnected facts which have hitherto been associated with the condition at once fall, as it were, into their appro- priate places. White fibrous tissue is found prac- tically in all parts of the body, so that the rheumatics may appear anywhere; but inasmuch as there is a special distribution of this tissue in connection with joints, voluntary muscles, and nerves, it is not sur- prising to find that it is in these structures that the disease most often shows itself. It is thus evident that so-called chronic articular rheumatism, muscular rheumatism, or myalgia, especially in the form of lumbago, neuralgia, especially in the form of sciatica and brachialgia, are all one and the same disease, the only real difference between them being the anato- mical situation of the fibrous tissue which is attacked by the inflammation and hyperplasia described by Stockman. Where the fibrous tissues all over the body are more or less impartially attacked, the result is what is known as febricula, or feverish cold — a condition to which reference has already been made (Chapter I.) as a fruitful source of error in diagnosis ; those who do not remember its existence almost invariably labelling it ' influenza.' 148 MINOR MALADIES. ' Rheumatics,' then, includes arthritis, lumbago, torticollis, and other aponeurotic and muscular inflam- mations, wherever situated; sciatica, intercostal and other neuralgias ; and, inasmuch as the pericardium, pleura, and dura mater are all richly supplied with white fibrous tissue, it will be proper to comprise in this category certain forms, at any rate, of cardialgia, pleurodynia, and rheumatic headache. This inflammation of white fibrous tissue or ' fibrositis,' as Sir William Gowers has named it,^ is said to be due to a variety of causes. It certainly seems to be determined by many conditions and influenced by many others, but the cause is probably always the same. This cause is connected with the gastro-intestinal tract, and is almost certainly pro- duced by the absorption of toxins therefrom. The toxins are the result of defective metabolism, from the too free ingestion of meat foods and alcoholic drinks, or their inadequate elimination. Such a state of matters does not constitute gout, but it constitutes a condition very nearly allied thereto, and we are generally quite safe in treating a person who is subject to fibrositis as if he were goutily inclined. And this we may do in spite of the fact that the manifestations are by no means confined to the old or middle-aged. The old are, perhaps, more prone to be attacked by chronic arthritic fibrositis, but myalgia is more common in ' 'Lumbago,' by Sir William Gowers {Britiah Medical Jowrnal, January 16, 1904). RHEUMATISM, NEURALGIA, HEADACHE. 149 young adults, and even children are occasionally affected. Of determining causes, damp, cold, and atmospheric changes appear to be the most potent. It is difficult to trace the connection between the states of the weather and the incidence of fibrositis, but that there is a very intimate connection everyone who has ever suffered from the disorder will readily agree. Many a patient complains that he is a regular baro- meter, that he can be sure that a change is imminent, but none can foretell with any approach to accu- racy what the nature of the change will be. Some will have an attack when the wind is going to the east, others when it is going to the west, and most will predict an increase in atmospheric humidity. The question is an interesting one, about which, however, very little is at present known. These atmospheric influences, whatever they may be, are particularly liable to affect joints or muscles which have been the seat of injury or overwork. Thus, the rheumatics will always select by preference the fibrous tissue surrounding a joint which has been sprained, and the ' golf shoulder ' or ' tennis elbow ' will be found afflicting the particular joint which has borne the brunt of the season's work. The prevalence of lumbago is almost certainly susceptible of a similar explanation, in that the muscles and aponeuroses therein concerned are those which maintain the erect posture. The application of sudden cold is a very powerful 10 150 MINOR MALADIES. determining cause. Sitting in a draught will un- questionably bring on an attack in a predisposed person. A common history is that of a sudden onset during the cold morning tub, and some bathing fatalities are probably due to this cause. But what- ever may be the exciting or determining cause of a particular attack, the point to remember is that the essential condition precedent is the existence of a toxin in the blood, and that that toxin in the large majority of cases, if not in all, is of gastro-intestinal origin. This fact at once points to the two most important indications in the treatment of a fibrositis wherever it may appear, and these are the cleansing of the gastro-intestinal tract by a mercurial purge, and the careful regulation of the diet by the diminution of meat foods and alcoholic drinks. An additional measure of the utmost utility at the outset is an ordinary hot bath of 100' F. or over, or, better still, the hot wet pack. A radiant heat bath is probably better than either where this can be procured without exposing the patient to the risk of subsequent cold. Warmth and equability of temperature are very important during the first forty-eight hours of an attack. So much, then, for the etiology, pathology, and general indications for treatment of fibrositis. Let us now proceed to consider the condition as it appears in the various parts of the body ; and first, as to its manifestations in the neighbourhood of the joints. One of the characteristics of the condition is that one RHEUMATISM, NEURALGIA, HEADACHE. 161 joint only is usually affected. This is the rule, to which there are, of course, exceptions, but it is seldom indeed that more than three are affected. In recurring attacks it is nearly always the same joint which is involved, and, if any joint in the body has ever been the seat of injury, it is tolerably certain that the fibrositis will select that one. When once the process has established itself in a joint there is not, as in true rheumatism, any tendency to leave that joint and go to another. The complaint in connection with the affected joint is one of pain and impaired mobility, the latter usually depending very much upon the former. The pain is not often to be described as merely chronic ; it is much more often subacute, and occasionally it is even acute. It is aggravated by sudden and violent movement, and varies greatly with changes of temperature and atmospheric humidity. The arthritis is never accompanied by fever, and it has no tendency to produce endocarditis or other complications. The medicinal treatment of this manifestation of • rheumatics ' is not very successful. The salicylates, especially in the form of aspirin (10 to 15 grains three times daily), are occasionally beneficial, though I have had better and more uniform results from iodide of potassium and guaiacum (10 grains of each three times daily). Anti pyrin, together with salicy- late of sodium, is a useful combination, especially where pain is a prominent symptom ; but this combination is less useful here than in the neuralgic type of the 162 MINOR MALADIES. affection. Locally, the application of warmth is invaluable. A hot douche, which, in the case of such joints as the wrist, knee, or ankle, can be improvised at home by holding the part under a hot tap, is an excellent expedient, to which recourse may be had two or three times a day with great advantage. Hot fomentations, especially when frequently re- peated, are also very useful, and compresses of potassium iodide and citrate of lithia often seem to hasten resolution. Local exposure to radiant heat is in my experience one of the very best means of bringing about resorption and disappearance of the fibrous thickening which is the essence of this condition. Although it is, on account of the pain, necessary to keep the joint for the most part at rest, this must not lead to forgetfulness of the fact that movement is absolutely essential to anything approaching a satisfactory issue. This movement must at first be slight and passive, but as the pain subsides it should become free and active. An enormous amount of avoidable crippling is brought about by allowing patients to ' coddle ' joints thus affected. Movement is the essence of the cure, and if it is neglected the joint very readily becomes stiff and disabled. Of course, the movement must be applied with sympathy and discrimination. It is better that the doctor himself should do it during the acutely painful period, if there be one, and as soon as circumstances permit he may delegate the duty to a competent masseur, or, RHEUMATISM, NEURALGIA, HEADACHE. 163 where such is not available, it is usually not difficult to instruct a member of the household in this means of restoring function. These and similar measures are in very chronic or recurrent cases much better carried out at a spa than in the patient's own home. It is, indeed, in the treat- ment of such cases that the baths, douches, and massage for which such places are famous, justify most completely the confidence which is now so generally accorded them. Of Continental summer resorts Aix-les-Bains justly enjoys the highest reputation, but Vichy, Luchon, Baden-Baden, and many others, are fully equipped for the treatment. In winter Salsomaggiore, in Italy, is a place to which such patients may very suitably be recommended. In this country at Buxton, Woodhall Spa, Llandrindod and Harrogate in summer-time, and at Bath and Sidmouth in winter, the necessary treatment is admirably carried out; and by no means the least advantage of the home stations is that the practising physicians have, owing to the English climate, opportunities for gaining an amount of experience in the various phases of the condition which is denied to their continental brethren. MYALGIA. — If, of the pains of arthritic fibrositis, it may be said that they are subacute more often than chronic, of those of myalgia, or muscular fibrositis, it may be affirmed that they are acute more frequently than subacute. They vary, of course, as do the others. They ai'c generally confined to one set of muscles, as 154 MINOR MALADIES. those of one shoulder-joint or one side of the neck (torticollis) ; they are usually relieved by firm pres- sure, and are invariably worse at night This aggravation at night, or rather in the early morning, is very characteristic. The patient wakes in great pain, so great that he doubts the possibility of being able to dress himself ; nevertheless, when he begins to move, even in his bed, he finds that matters are not so bad as they at first seemed, and by the time he gets downstairs his troubles may have resolved them- selves into stififness and fear of sudden movement. The onset of myalgia is generally sudden, occasionally so sudden as to give the impression of a blow, and when it starts in this way it is apt to be very acute. Lumbago is often quoted as the typical form of myalgia. This in my opinion it certainly is not, for the reason that in most cases, if not in all, the fibrous tissue in connection with structures other than muscle are always involved. Luff^ is certainly right when he says : ' In the majority of cases of lumbago the affection is not in the quadratus lumborum, nor even in the deeper muscles of the back, but is in the fibrous tissues directly over the sacro-iliac joint and in the joint itself It is from the spreading of the inflamma- tion along the sheath of the sciatic nerve that we find lumbago and sciatica so frequently associated, A much better instance of myalgia, though even here tissues other than the muscular are often included, is supplied by deltoid and brachial myalgia. ' CUnical Journal, October 11, 1905. RHEUMATISM, NEURALGIA, HEADACHE. 155 This is liable to be very acute, and is generally of long duration ; it is of all others perhaps that which is most conspicuously influenced by meteorological variations, and subject to nocturnal exacerbations. Stiff neck, or torticollis, is another good instance. This is especially common among young adults, and is fortunately very amenable to treatment. Myalgia will often pass off in a few days without anything more heroic in the way of treatment than a hot application and some rubbing. More often, how- ever, it becomes obstinate to household remedies and demands careful management. Internally nothing can compare with iodide of potassium, and externally nothing is so efficacious as massage. The latter, to be effectual, should be applied twice a day by some- one who is conscious of the needs of the situation. Mere superficial effleurage is useless. The muscles must be handled gently but firmly, so as to promote the lymph-flow within their substance. This will cause a certain amount of pain at first, especially if the operator be unskilful ; but, in spite of this fact, the treatment must not only be continued, but it must be reinforced by the application of warmth in the form of poultices and fomentations and by the addition of stimulating liniments. A good plan is to rub the part with liniment of iodine and then apply a poultice. Camphor liniment and chloroform liniment are also useful for this purpose. Luff^ prefers anodyne appli- cations, and recommends a mixture of equal parts of ' Loo, cit. 156 MINOR MALADIES. chloral hydrate, camphor, and menthol, which he says, when well rubbed together, form a liquid. Methyl salicylate and mesotan are in his experience also very valuable. But, whatever the medicament employed, a large part of its power for good resides in the method of its application, and unless this in- cludes vigorous massage — as vigorous, that is, as pain will permit — the virtues of the drug will remain largely inoperative. For chronic cases, the massage should be accompanied by douching, as at Aix-les- Bains, by light baths, or by electricity. Lumbago, as we have just seen, is a mixed fibro- sitis, partly muscular, partly aponeurotic, and largely arthritic, and inasmuch as it is so frequently accom- panied by sciatica, it may be considered as in a sense neuralgic. Acute lumbago is startling and disabling. It is startling from the extreme suddenness of its onset, and disabling from the fact that the trunk cannot be moved except with great pain, so that the patient is obliged to remain in bed. It is most common in men, at or about middle age, who usually present themselves with a diagnosis ready made ; for ' lumbago ' with the laity means any pain in the smaU of the back. Such a diagnosis should, of course, never be accepted, and we ought to be careful always to examine the back, the knee and plantar reflexes, and the urine, before confirming it. I have known very grave mistakes to be made through initial negligence of these very simple precautions. A line of treatment which was much in vogue RHEUMATISM, NEURALGIA, HEADACHE. 157 twenty years ago for a sudden attack of lumbago consisted in a hot bath (100° to 103° F,), a dose of Dover's powder (12 grains), and a drachm of sweet spirits of nitre, supplemented by a linseed-and-mustard poultice to the loins. This I still believe to be an admirable course of procedure in a large number of cases ; but I have learnt to distrust the action of the opium, especially in the very patients — namely, those about middle life — who are most prone to suffer from the complaint, so that I came to use James's powder, (pulv. antimonialis) 5 grains, in its stead, and to give therewith a mercurial cathartic. This method I have found to be not only more efficacious, but entirely free from the disadvantages attaching to the exhibi- tion of opium in such cases. For the rest, it is only necessary to reiterate what I have said above as to the value — I would almost say the paramount importance — of massage and stimulating applications in the further treatment of the condition, and the necessity for regulating the diet of the patient so as to eliminate as far as possible meat foods and alcoholic drinks. As long as pain is present the patient must keep his bed, not only on account of the pain itself, but because of the fact that equability of temperature is an important feature of the cure. Cold influences are not only in the highest degree unpleasant, but they tend above everything else to prolong convalescence and retard recovery. The NETJEAIGIC FIBEOSITIS which so often accom- 158 MINOR MALADIES. panies lumbago may occur independently thereof, and, when so occurring, it may be regarded as the type of an affection which is liable to attack almost any nerve in the body, some common examples of which are supplied by cervico-brachial neuralgia (often called neuritis), intercostal neuralgia, coccydynia, and plantar neuralgia. In sciatica, as in lumbago, we should be especially cautious in accepting a ready-made diag- nosis, for pain along the sciatic nerve may be due to causes other than fibrositis ; and if the pain is markedly worse at night, or, if both sciatic nerves are involved, it is tolerably certain that some much more serious factor is in operation.^ A ' sciatica ' may be caused by a loaded rectum, by uterine and ovarian displace- ments, by tumours and disease of the spinal cord itself, and such possible factors should always be carefully and exhaustively investigated before the pain is pronounced to be due to a neuralgia, and treated as such. For this purpose it is important to determine whether the pain is due to pressure, or to some factor in the nerve itself or in its sheath. In the former case the pain will not be sensibly aggravated when the nerve is put on the stretch ; it may, indeed, be to some extent relieved by the process, whereas, when the mischief is in the nerve or its sheath, the stretching will obviously increase the pain. In order to set this point at rest, ' F. J. Smith, ' Mistakes ' (Clmieal Journal, December 27, 1905). RHEUMATISM, NEURALGIA, HEADACHE. 159 the patient is placed upon his back and the pelvis firmly fixed against the bed by an attendant The limb on the affected side, which must be kept fully extended at the knee, is then gently and gradually raised by the examiner until it is at right angles to the couch. This will put the nerve on the stretch, and if no aggravation of pain results, then the cause is to be sought outside the sheath of the nerve ; it is not due to a fibrositis, and the condition is not, properly speaking, a sciatica. So far as the treatment of sciatica is concerned, there is not much to add to what has already been said in connection with other forms of fibrositis. Massage, which is of the utmost importance in all these forms, is in sciatica the one local remedy upon which any great reliance can be placed. Dr. Lee^ says : ' It is in sciatica, of all the neuralgias, that massage has won its greatest reputation. Truly astonishing results have been obtained, even when the affection has been of many years' standing, and after every other conceivable means of relief has proved un- successful.' This coincides completely with my own experience, and since I have used massage perseveringly, assisted in suitable cases by douching and the application of stimulating liniments, I have had no occasion to resort to acupuncture, surgical stretching of the nerve and other heroic remedies which are often recom- mended, and which the tedious nature of these cases ' Hare's ' Practical Therapeutics.' 160 MIxNOR MALADIES. so often suggests to the despairing physician. If massage were employed early in all cases, few would become chronic ; and if it is persevered with in cases which have become chronic, even to the causing of marked wasting of the muscles, it will in time al^rays bring about a cure. Some of the antineuralgic drugs, which will be noticed presently, may also be used concurrently. Some of them, especially phenozone and butyl-chloral, have often seemed to me to do good in the way of rendering the massage more tolerable. Without massage these drugs may be palliative, but they are never curative, as they are in neuralgia due to causes other than fibrositis. It would be easy to multiply instances of the manifestations of the ' rheumatics ' as they occur in various parts and structures, but no good purpose would be served by so doing. The essential points to remember are that these manifestations are due to inflammation of white fibrous tissue ; that they may be acute, subacute or chronic ; that they are seldom or never accompanied by constitutional disturbance ; and that they are very amenable to treatment, more especially by iodide of potassium internally ; and externally, by massage, passive movements and stimu- lating applications. NEITEALGIA. — Pain which follows the distribution of certain nerves is a very common disorder. It may, as we have just seen, be due to fibrositis ; but, so far at any rate as the smaller nerves are concerned, it is much more often due to other causes. Chief among RHEUMATISM, NEURALGIA, HEADACHE, igl these are unsatisfactory blood states. That neuralgia is the cry of a nerve for healthy blood is an oft-quoted saying, and certain it is that undue toxicity of the blood, from whatever cause arising, is an important, as it is certainly the most common, agent in the causa- tion of pain. For toxins in the blood act not only by direct irritation of a nerve, but they also act, as in gout, by causing vaso-constriction, thus depriving the nerve of its due quantity of nutritive material. Burney Yeo suggests that a factor of an opposite kind is not infrequently in operation — namely, that the blood state may give rise to vaso-dilatation, and that it is a kmd of blushing in the neighbourhood of the nerve which determines the pain.* How- ever that may be, all that it is necessary to realize is that impure blood is the most important cause of neuralgia, and that it may produce this effect not only directly, but also by interference with the normal vasomotor mechanism. Another cause, scarcely less in importance, is the existence of an irritant causing fatigue of the involved nerve. The presence of a neuralgia, then, should suggest — (1) a fibrositis, (2) an unsatisfactory blood state, and (3) the existence of an irritant. With the first I have already dealt ; there remain, therefore, the other two to consider. Of unsatisfactory blood states the commonest is surely ansemia. Whether this be due > See also ' The Vasomotor Factor in the Fain of Migraine,' by Dr. Franais Hare, OUmoal Jowmai, January 34, 1906. 11 162 MINOK. MALADIES. to convalescence from acute disease, to mere chlo- rosis, to deficient coagulability of the blood,* or other cause, it is very frequently attended by neuralgia, more especially about the head and lower part of the trunk on one side. The treatment of such cases resolves itself into the treatment of the ansemia by suitable hygienic, dietetic, and medicinal means. So far as hygiene is concerned, an out-of-door life in a bracing climate is strongly to be advised. The diet should be gene- rous, including meat foods and wines — preferably a good Bordeaux or Burgundy — and plenty of fats. Fats seem to be concerned in some very special manner with the nourishment of the nervous system, and in the form of butter and cream they may be freely given to such patients as we are now considering. The best medicine is undoubtedly iron, but the stronger salts, the sulphate and perchloride, are much less eifficacious than the citrates and tartrates. The two latter are readily assimilated, whereas the former are very apt to upset the stomach. A useful formula is as follows : ^. Ferri ammon. oitrat gr. s. Liq. arsenioalis iTiii. lui. qnasBicB ad ^se. M. Sig. : Ter die post cib. As the patient's strength improves it may be desirable to substitute the following : *■ B>uas, Lfmo«t, January 20, ICCC- RHEUMATISM, NEURALGIA, HEADACHE. 163 B.. Ferri quin. oitrat. gr. xx. Liq. arsenioalis iHv. Tr. nuois vom uiiv. Aquam aurant. flor adSsa. M. Sig. : Ter die post oifa. The presence of quinine, even in suchi doses, may help to suhdue the neuralgia. When giving iron in any form and for any purpose, it is of the utmost importance to keep the bowels open. This is best done by means of aloes at first, because this drug enhances the effect of the iron, and later by cas- cara. A daily morning dose of a natural mineral water is also very useful. But where the neuralgia is an obtrusive feature of the condition, it is generally necessary to prescribe something which has a direct influence upon the pain when this occurs. In anaemic cases and in aU those in which defective nutrition is pronounced I have had better results from quinine and gelsemium than from any other combination. R. Qtiin. mur. gr.v. Acid, hydrobrom. dil ... ilxx. Tr. gelsemini lUx. Aquam ohloroformi Ssi M. Sig. : Every twenty minutes till pain ceases. Not more than four doses to be talcen. This mixture, like most others where the relief of pain is concerned, acts better in small doses repeated at short intervals than in single large doses. The state of the blood in goutiness is such as to 164 MINOR MALADIES. be highly provocative of neuralgic pains. Inasmuch as this condition and its treatment are fully considered in another chapter, it is here only necessary to em- phasize the advisability of examining for high arterial tension in all cases of neuralgia, and where this is present, to point out the value of iodide of potassium in the treatment of the accompanying neuralgia. As this is the most potent of all drugs in counter- acting the gouty state generally, a gouty neuralgia ought very readily to yield to the measures proper to the treatment of the blood state itself. Occasion- ally, however, it does not, and then it is well to have recourse to the following combination : 5i. Sodii salicylat. 1 Phenazon J aa gr. v. Syr. zingiber 3i. Aq. ohloroformi ad gi. M. Sig. : Every quarter of an hour until pain ceases. Not more than four doses to be taken. This is a most admirable combination in the migrainoid neuralgic attacks to which the gouty are peculiarly prone. I have appealed to it in a very large number of cases, and so far never in vain. For a reason which it does not seem possible to explain, the combination of these two drugs is in- finitely more effectual than either given alone. When directed to be taken as above, the mixture acts better than in single large doses. A fruitful and easily overlooked cause of neuralgia, especially in women, is the toxic blood state induced RHEUMATISM, NEURALGIA, HEADACHE. 165 by chronic constipation. This must be treated by the curing of the vicious habit on the lines laid down in Chapter III. ; but here again we may have to treat the neuralgia concurrently with the treat- ment of the constipation, in which case the pheno- zone and salicylate mixture just described will usually be found the most useful, though quinine and gelse- mium are to be preferred where, in consequence of the long duration of the constipation, the patient is ansemic and emaciated. Neuralgia is considered by some as a hysterical manifestation. This, of course, it may be, though hypersesthesia is less characteristic of hysteria than ansesthesia. Neuralgia certainly occurs frequently in neurotic women, but I have generally found that there is some discoverable and removable cause for the neurosis of which the neuralgia is an occasional manifestation, and this cause is more often than not a peripheral irritation, of which the origin is to be found in the teeth, the ears, or the eyes. Such irritation, when acute, is a recognised cause of neuralgia in those who are not neurotic, and there is no difficulty in supposing that, when chronic, it may give rise to that nervous instability to which the term neurotic is applied. A common site for such irritation is the ovarian region. Examination of this region in neurotic women will often reveal pain on pressure over one or both ovaries, in which case infinitely the best drug to use is belladonna. It is usefully combined with phenozone, and its adminis- 16Q MINOR ?TALADIE3. tration should always be accompanied by the applica- tion of blisters, small in size, but frequently repeated, in the region where the pain has been elicited. A practical point of considerable importance in con- nection with the management of these cases is charac- teristically expressed by Goodhart, in that altogether admirable little work ' Common Neuroses ' (which should be carefully read by every young practitioner) in the following passage : ' I have said it is a bad day for a man when be first knows he has a heart ; it is a ten times worse day for a woman when the pelvic pains to which so many are subject are focussed for her by medical opinion upon uterus or ovary. If there is anything which curdles my blood, it is to hear a woman talk of her ovaries as she might of some intimate acquaintance.' In the manufacture of incorrigible neurotics the word ' ovarian,' blurted inadvertently from incautious iips, is a common and potent ingredient. Irritation within the buccal cavity is a frequent cause of facial neuralgia ; and it should be remem- bered that it is not only teeth which are obviously carious which may produce this result, but, as Savill* points out, careful examination, by tapping the teeth, or by the application of hot and cold liquids alternately, will often reveal the existence of an irritated pulp in an apparently sound tooth, the proper treatment of which is necessary to a cure. For the relief of neuralgia of facial or cranial distribu- * 'A System of Clinical Medicine,' vol. ii, RHEUMATISM, NEURALGIA, HEADACHE. 10[ tion arising from such a cause butyl-chloral is probably the best of all internal remedies. It should be given in pill form, 5 grains every half-houi until pain ceases ; not more than six pills to be thus taken. It is usefully combined with gelsemine, which is another drug with a selective influence over cranial neuralgias. E'or this purpose the pil. butyl- chloral c. gelsemina (Martiiidale) is very useful. Local applications are not usually accounted of much value in facial neuralgia, but I have found that the lin. aconiti carefully painted with a camel-hair brush over the area occupied by the pain is not only helpful in assisting the action of drugs taken internally, but that it is in some cases sufficient of itself to cut short an attack. For the vague, ill-defined neuralgic and ' rheumaticky ' pains of which people not infrequently complain, I have found chloride of ammonium, 20 grains, combined with tr. cimeifug., 20 minims, more effectual than any of the above-mentioned remedies. One of the most valuable drugs for the relief of neuralgic and neuritic pains, wherever situated, is acetanilid (antifebrin). In spite of its undoubted powers in this direction, even where such pains as those of tabes are concerned, it has of late fallen into disuse. This has been due in a large measure to the fact that it is credited with the production of un- toward effects. This is in reality only partly true. When properly employed, it is no more dangerous than any of the numerous drugs which daily flow, freely and callously, so to speak, from the point of 168 MINOR MALADIES. the prescriber's pen. First, then, as to dose. The old official dose of 10 grains is too high, at any rate, to start with. It is better to begin with 2 grains, which will in many cases be found sufficient. If not, the dose may be gradually increased to 10 or even 15 grains. It should not be increased above the latter if, the physiological effect having been produced, the pain fails to yield. This physiological effect is slight cyanosis. The lips and nails become a dusky red. This effect has in a great measure been responsible for the disuse into which the drug has fallen. There is nothing alarming about it, and it is necessary to remember that, as in the case of so many other drugs, the curative virtues of acetanilid very often decline to show themselves until this physiological effect has been evoked. These facts seem worth insisting upon, because, apart from morphia, acetanilid is in my judgment by far the most powerful anti-neuralgic at our disposal. It will relieve the pains of locomotor ataxy and of other organic diseases of the nervous system when nothing else will, and he who allows himself to be frightened by the occasional cyanosis which it causes, deprives himself of a most valuable therapeutic agent. That its use requires a certain amount of caution is not a sufficient reason for abandoning it. Acetanilid being practically insoluble in water, is best given in cachet, combined either with salicylate of sodium (10 grains) or camphor mono- bromat (6 grains). It is scarcely necessary to mention morphia as an RHEUMATISM, NEURALGIA, HEADACHE. 169 anti-neuralgic, except to say that it is not employed as often for this purpose as it might be. It is, of course, most undesirable that its use should be pro- longed, but there is no objection to exhibiting it for the relief of pain, pending the action of other remedies. For the intense neuralgia which some- times accompanies true influenza and other acute toxibmias it has no equal. Its use in recurrent neuralgias is undesirable, not only on account of the patient, but also for the sake of the practitioner, who, unless he is careful, will find himself urgently summoned at all hours of the day and night to administer the necessary dose. This, which is unsatisfactory enough, is on the whole preferable to entrusting, as is too often done, a needle and a bottle of tabloids to the all too willing patient. Another unduly neglected means of relieving neuralgic pains, in suitable cases, is leeching. One would not, of course, recommend it in weakly, ansemic subjects, but in full-blooded individuals the relief it gives often approaches the miraculous. This is especially true where the pain seems to be in, or to radiate from, the ear. A leech placed behind the ear and allowed to take its full quantity of blood will often give complete relief where other means have failed. HEADACHE. — There remains to be considered a highly important peripheral irritant, perhaps the most important of all in the causation of neuralgia, which I have left to this stage that I might discuss it inassocia- r,'. MINOR MALADIES. tion with headache, to which it also gives rise with great frequency — namely, eye-strain. Where eye-strain is concerned neuralgia and headache may be regarded as synonymous terms, for it is impossible to be certain where the one ends and the other begins. And I may say at once that these two conditions by no means exhaust the troubles to which eye-strain may give rise. It is, as we shall see presently, a frequent, though too often unsuspected, cause of neurasthenia, melancholia, intemperance, and drug habits, to say nothing of such minor matters as irritability of temper, dyspepsia, constipation, and ' sluggish liver.' The first point to remember in connection with eye- strain — and it is one upon which it seems very necessary to insist — is that the condition is produced, not by gross defects, but by slight ones ; not by high degrees of errors of refraction, bat by minor ones.i So much is this the case that patients are often indignant that any aspersions should be cast upon their eyesight, which, they will protest, has always been exceptionally good. And the truth is that such patients are able to see as well as anyone, for the reason that, the defect being slight, it has always been well within their power, by contracting the ciliary muscle, to overcome the defect. In the case of those with gross defects no amount of ciliary contraction enables them to see clearly, and so the effort, even if it is ever made, is very early abandoned. ' See ' Eefraetion of the Eye,' by Ernest Clarke (BaiUi6re, Tindall and Cox). RHEUMATISM, NEURALGIA, HEADACHE. 171 In the case of those with minor defects the difficulty arises from the fact that it is no more possible to keep the ciliary muscle contracted for hours on end than it is to keep any other muscle in the body so contracted without giving rise to fatigue. Especially does this apply when astigmatism is present, as the ciliary muscle is then contracted not only continuously, but also irregularly. The difference between the ciliary and other muscles is that in the latter the symptoms of fatigue are easily recognised as due to fatigue, but in the case of the eye, so long as the vision remains unimpaired, the seat of origin is almost certain to go undetected. The patient sees well, but in the majority of eases, he does so at a cost which, physiologically speaking, he cannot afford to pay. He lives well up to the limit of his nervous income, and any slight unexpected attack will very readily project him into bankruptcy. It is when he has reached this state that he appeals to his doctor to be relieved of a headache or an attack of neuralgia. For, be it remembered, the pains which are caused by eye-strain are by no means always present ; frequently — indeed, generally — they require some extraneous cause to provoke them. As long as the patient is permitted to pursue the even tenor of his way, he is able to live within his income and keep his enemy at bay ; but no sooner is that even tenor disturbed, as by worry or an over-generous dinner, than he finds himself at the end of his resources, with his enemy at his throat. The factor 172 MINOR MALADIES. which in a very large number of cases supplies the disturbing element is the advance of time. As long as a man is young and vigorous his nervous income is equal to almost any strain, but as years wear on this income gradually diminishes, and as he approaches the presbyopic age, when another disturbing element awaits him, he is always more or less on the margin of symptoms. When the presbyopic age is actually reached, and the lens has lost a great deal of its original elasticity, the ciliary muscle has still more work thrown upon it, and consequently such symptoms are liable to be of very frequent occurrence. The nature of these symptoms varies within very wide limits. Neuralgia and headache, with which we are for the moment especially concerned, take the first place. Neither the distribution of the neuralgia (except that it is generally cranial) nor the type of the headache, affords any indication that it is the eyes which are at fault, so that it is all the more important to keep constantly reminding ourselves of the now well-established fact that where either of these symptoms cannot be traced to any obvious cause, eye- strain is, in all probability, the main factor in their production. Another common effect of refractive errors is giddiness. This is hable to occasion very considerable alarm to patients, who are generally afraid that it indicates intracranial mischief. To medical men it generally suggests gastric disorders, auraj troubles, or circulatory disturbances. These are RHEUMATISM, NEURALGIA, HEADACHE. 173 all common causes, but probably the most common, especially in people about middle life, is that which is least frequently remembered — namely, ocular defects, which are slight, and therefore unsuspected by the patient. Nausea and vomiting, as we have already seen {vide Chapter III.), are often due to eye-strain. In these cases, as in most others, it is to be remembered that something more than eye-strain itself is generally required to precipitate an attack. That something is often so slight a matter that it altogether escapes notice unless the presence of eye-strain, acting as a chronic underlying irritant, is realized. In all these cases it is the summation of slight stimuli which produces the effect, and of these slight stimuli that which is constant and ever present is the one whose removal is important. With that gone the others cease to be operative. But the manifestations of eye-strain are not all so definite as the foregoing.^ The condition, indeed, expresses itself even more frequently in forms, which, untU we are familiar with its almost unlimited capacity for producing indefinite symptoms, are very difficult of recognition. 'The Autocrat of the Breakfast Table ' says that it is better to lose a pint of blood from your veins than to have a nerve tapped. Now, that is precisely what eye-strain does : it taps > Bee ' The Medical Aspect of Eye- Strain,' by Ernest Clarke, CUmical Jowmal, October, 1905. 'Eye-Strain as a Cause of Headache,' by L. H. Jessopp, Practmoner, July, 1906. 174 MINOR MALADIES. a nerve. The energy runs to waste, and the whole cerebro-spinal system becomes exhausted. When once the outKne of this picture is clearly discerned, it is by no means difficult to fill in the detail. For cerebro-spinal exhaustion, though it has no symptoms by which it may with certainty be recognised by the doctor, has a very real existence for the patient. In its slighter degrees it may mean no more than the deprivation from a particular viscus, say the stomach, of its fair share of nervous energy, leading to dyspepsia ; or it may spell an evident want of control in the higher cerebral centres, causing irritability of temper, undue emotionalism, or a craving, for stimulants. In more pronounced degrees it will cause the grouping of symptoms to which the term neurasthenia is applied. It may cause hysterical ebullitions, and may even be responsible for epileptic attacks. In degrees still more pronounced it may lead to melancholia, and even to suicide. There is, in short, no functional disturbance of any portion of the central nervous system which may not own eye- strain as its essential cause, so that it is impossible to insist too strongly upon the importance to every practitioner of being able to detect slight errors of refraction. Into the details connected with the necessary examination it is impossible to enter here, but the following hints may serve as a useful guide. 1. Objective Examination. — (a) Defects of vision may be suspected if the patient screws up his eyes or places his head on one side in order to kHEUMATioM, i>iiiUilAl.cilA, HEADACHE. 175 read or to see some object at a distance. If there is a hypersemia of the margin of the lids, generally the upper lid, an error of some kind is usually the cause ; and if a patient under forty years of age presents an arcus senilis, especially if one eye only be thus affected, it is almost certain that the premature degeneration has been brought about by eye-strain of some kind. (b) When the eye is examined by the indirect method with a concave mirror and focussing-glass, Hyperopia is present if the disc is larger than usual, and appears to diminish on withdrawing the glass from the eye ; Myopia is present if the disc is smaller than usual, and seems to enlarge on withdrawing the glass ; and Astigmatism is present if the disc is oblong and appears to alter in shape on withdrawing the focussing-glass. (c) By direct ophthalmoscopy. Hyperopia is present if convex glasses improve the view of the fundus; myopia, if concave glasses do so; and astigmatism shows itself by parts of the fundus being out of focus, while other portions at right angles are in focus. 2. Subjective Examination. — Hyperopia is probably present if the patient's vision is not made worse by convex glasses ; myopia is suspected if the patient's reading distance is nearer than normal ; and astig- matism, if the patient can read some of the letters in the lowest line of the distant type, but makes mistakes even when reading a line half-way down; or if, when looking at radiating lines, put at a distance 176 MINOR MALADIES. of 4 to 6 metres, some of the lines look blacker than others. It must, however, be distinctly borne in mind that if the patient is not under the influence of a cycloplegic, these tests, if negative, prove nothing, as he may be, and probably is, involuntarily correcting his error. Eye-strain is, however, by no means the only kind of chronic peripheral irritation which may give rise to headache. Dental troubles which fall short of gross caries, frequently produce it, overcrowding of the mouth, owing to eruption of the wisdom teeth, being a common and often unsuspected cause. Im- pairment of respiratory power, brought about by obstructions in the nose and throat, are other easily overlooked causes, chief among them being deviations of the septum and other factors acting upon one nostril only. Aural troubles of every sort should always be carefully examined for. A form of headache which presents special features, and concerning whose aetiology there has been a great deal of speculation, is mAgraine, or hemicrania. The latter name is applied to it because the pain generally begins on one side of the head, and is sometimes confined to that side throughout the attack. The characteristic of migraine is its periodicity. The attacks recur at intervals, though not necessarily at regular intervals, and their origin is exceedingly difficult to trace. Migrainous people, like epileptics, are always more or less liable to an attack, and, like epileptics, they have premonitions ; RHEUMATiciM, iNEURALGiA, HEAI>ACHE. Ill they know the sort of influence which may affect them, and immediately after an attack they know that they will enjoy immunity for a variable time. The attacks usually begin, significantly enough, with some ocular phenomenon, such as flickering lights of various forms and zigzag lines of colours in different parts of the field of vision; then follows an intense headache, accompanied generally by nausea, vomiting, and extreme prostration, which may last for varying periods. At the end of forty-eight hours the patient is generally well again. To understand the phenomena presented by migraine we have, as in epilepsy, to assume some imderlying instability of the nerve-centres, which are provoked into a stormy condition by stimuli which leave ordinary individuals unaffected. The attacks are common in the studious, in the sedentary, in the highly cultured, and are rare in the bucolic. In the light of what has been said above on the question of eye-strain, and the capacity of this condition to produce a disturbance of nervous equilibrium, coupled with the fact that migrainous attacks are almost invariably accompanied by ocular phenomena, very special care should be taken to eliminate this element in every case. A very large number of people have slight defects of vision, and such slight defects, while harmless to the peasant of robust organization, may very readily provide a con- stant irritant to the studious of delicate organization, and thus contribute a powerful underlying cause for 12 178 MINOR MALADIES. the attacks. A migrainous person should be examined very minutely by physician, oculist, aurist, and gynaecologist, and any defect in any department, however slight, which could possibly act as a cause of irritation, should be removed. The physician should pay particular attention to the cardio-vascular system, the oculist to the state of the refraction, and the aurist to any remediable errors in the ear, throat, or nose. If nothing abnormal can be discovered, then we are reduced to attempting to lessen the general nervous reactive sensibiUty by hygiene, diet, and the exhibition of bromides. A country, open-air life, a diet free from stimulating foods and alcoholic drinks, and the bromide of ammonium in lO-grain doses, three times daily, for a week every now and again, will very often keep the enemy at bay. During the attacks rest and a darkened room are essential. When taken in time — that is, before the attack has had time to develop — the phenozone and salicylate mixture above prescribed (see p. 160) wUl often — indeed, generally — act admirably. I have found it superior to phenacetin (10 grains), in which some people, however, express great confidence. Upon headache as a symptom of intracranial mischief it is unnecessary to dwell. When the pain, as in migraine, is accompanied by vomiting, the fundus oculi should always be examined for anything suggestive of optic neuritis, and careful search should be made for other physical signs of organic disease iu the nervous system. Intracranial tumours and RHEUMATISM, NEURALGIA, HEADACHE. 179 meningitis are causes which should always be borne in mind. There is a certain class of headache which is occasionally described as congestive. The term is misleading, because headaches due to a diversity of causes might legitimately be so called. If, however, we qualify the term by the adjective ' mechanical,' it is possible to recognise a separate and distinct group. Headaches due to mechanical congestion are produced by factors which are easily overlooked. Anything which interferes with the proper circulation of the blood may occasion them, and in ordinary life tight corsets in women and tight collars in men will be found to be common causes. This type of head- ache, which is described as a general fulness, aggravated on stooping, may be the first indication of the existence of a lesion at the mitral valve, so that a complaint of such a nature, more especially when it is accompanied by a history of epistaxis, should always lead to a careful examination of the cardiac area. Nasal obstruction, whether from enlarged tonsils, adenoids, or deviations of the septum, is exceed- ingly likely to cause headaches of the congestive type. The two former are nowadays very readily recognised, and very promptly — perhaps too promptly — removed, but the latter is often allowed to con- tinue unremedied. Nasal deformities constitute an exceedingly common cause of headache in adults, and as they are nowadays easily remedied, there need be no hesitation in advising their radical cure, even 180 MINOR MALADLiLS, in people who have passed middle life. The correction of these deformities must be left to the expert, but I would suggest that the most speedy, complete, and lasting benefit is to be obtained from the recently introduced method of submucous resection, by which the cartilaginous and bony obstruction is entirely removed, leaving a fleshy septum, an intact mucosa, and a clear air-way.* Headache is very often caused by change of climate. The removal of a person from sedative to bracing conditions, and, even more frequently, vice versd, commonly brings about changes in the vascular pressure, which, in the absence of adequate reactive power in the individual (in the convalescent, for example), very frequently cause headache and de- pression of spirits. If these symptoms do not pass off in a few days, it may be necessary to resort to treatment. Where the headache has been induced by relaxing climatic conditions, a mixture contain- ing 2 grains of quinine and 5 minims of liq. strychnin, will generally do all that is necessary. Where, on the other hand, the climate is 'too strong,' as the expression is, 10 grains each of the iodide and bromide of potassium three times a day will be found useful. In each case the mixture should be preceded by a dose of calomel. ' St. Clair Thomson : Proceedings of the Laryngologieal Society, London, May and June, 1904 ; Transactions of the Clinical Society, London, October 25, 1905 ; Lancet, June 80, 1908. RHEUMATISM, NEURALGIA, HEADACHE. 181 Pain in the head of a superficial character, such as seems confined to the scalp, is a frequent accompani- ment of ' colds ' in the head. In such cases the pain is usually due to a fibrositis of the tissues overlying the skull, and is to be treated on lines already suggested.^ Headache is a common symptom of nen/rasthenia. Most headaches are due to what are comprehen- sively described as blood-states. A good instance is supplied by chlorosis, in which the headache is due to the abnormal condition of the corpuscular elements ; and the same is presumably true where the symptom appears in leukaemia and other associated conditions. The offending blood-state in the majority of cases is, however, a toxaemia. There are numerous familiar instances of this. All the specific fevers are liable to be ushered in with a headache more or less severe, and the poisons of alcohol and lead almost invariably cause the symptom. Among the toxaemias due to defective excretion, kidney disease and diabetes are classical instances of causative factors while chronic constipation is probably both the commonest and the most generally overlooked. In all these cases the discovery of the cause immediately points the way to the proper treatment, and some people have en- deavoured to aid in the discovery of the cause by mapping out certain cranial areas in which pain occurs, and attaching to each area a particular group ^ See Chapter I. 182 MINOR MALADIES. of causes. Thus, pain which is mainly vertical is said to be due to the following : anaemia, hj'steria, neurasthenia, epilepsy, and disease of the uterus or appendages. A headache which is chiefly frontal is deemed gastro-intestinal, renal, ocular, syphilitic, or myalgic. An occipital headache is considered sug- gestive of intracranial mischief and spinal irritation. While believing a great many of these to be fanciful, I think there is no doubt that headaches due to de- fective elimination, such as those caused by uraemia, diabetes, constipation, and impure atmospheres, are generally frontal, and that those which appear in functional nervous troubles seem to have a preference for the vertex ; but even in such cases it is not wise to attach much importance to so variable an element as the site. In everyday life it is certainly the toxins of gastro- intestinal origin which are most frequently respon- sible for the occurrence of headache. These toxins generally act by interfering with the intracranial vaso-motor mechanism, causing now undue contrac- tion, and anon, undue dilatation, of the cerebral vessels. The indications in either case are the same — namely, to cut off the supply of the toxins, and to promote the excretion of those already absorbed. The means of doing this are fully discussed in the chapter on Goutiness, so that here it is only necessary to emphasize the importance of dietetic simplicity, such as absence of meat foods and alcoholic drinks, and of excretory vigour by means of purgatives RHEUMATISM, NEURALGIA, HEADACHE. l8iJ and diuretics. Stress may, perhaps, be laid on the importance of the latter, which seem very generally to be neglected. The salts of potassium, especially the iodide and citrate, are most useful, but the best of all renal stimulants is undoubtedly theobromine. Some physicians, who are possessed by the uric acid bogey, object to this drug on accoimt of its close relationship with xanthine and the other purin bodies. An over-curious regard for these would, however, lead also to the condemnation of caffeine, whose efficacy as a heart tonic in suitable cases is second only to that of digitalis. Whatever its connection with other bodies with the radical C^N^, and however dangerous such a connection may seem theoretically to be, there can be no doubt that theobromine is the most active renal evacuant we possess, and it may be prescribed with every confidence in all cases where we are desirous of ridding the system of a toxin, such as a nitrogenous toxin, which is normally disposed of through the kidneys. It is best given in cachets of 15 to 20 grains three times daily. It occasionally operates as a drastic purgative, in which case the dose must be lessened. Some people prefer to give it in the form of 'diuretin,' in which it is combined with a salicylate. In addition to general evacuants, it is generally desirable to prescribe measures directed to the relief of symptoms. Where there is reason to suppose that the headache is due to vaso-constriction, liq, trinitrini 184 MINOR MALADIES. is very useful. Its effect, however, is transitory, and it should not, for obvious reasons, be frequently re- peated. It is best given in conjunction with hydro- bromic acid — thus : ^. Liq. trinitrmi oiiv. Acid, hydrobrom. dil nixx. Aqnam ... ... ... ... ... ad Bss. M. Sig. : Ter die. Another useful drug for the symptomatic treatment of headache is cannabis indica. If given as the tincture, in combination with other drugs, it must be suspended in mucilage ; it is, therefore, better to give it separately in the form of extract, of which from | to 1 grain may be made into a pill with lycopodium and given three times daily. G. W. Ross, in a valuable paper contributed to the LaTicet,^ describes a chronic headache which shows itself as a dull, heavy ache, worse in the morning and tending to wear off as the day advances, and accompanied by mental and physical lassitude. This, he says, is associated with deficient coagulability of the blood, and yields readily to the exhibition of chloride of calcium (see Chapter VIII.), In very persistent headaches which resist all treatment, it is well to try the effect of a blister on the nape of the neck, to be kept open with savin ointment for a week or ten days on end. I have known this expedient succeed where other measures had failed. » January 20, 1906. •RHEUMATISM, NEURALGIA, HEADACHE. 185 ADDITIONAL FORMULAS. For JsTeuralgia, especially when Intercostal or due to Eye-strain. 9. Phenacetin ' ... gr. x. Caffeine citiate gr. v. M. Ft. pulv. in oaoliet i. Sig. : Every two or three hours tm pain ceases. For Neuralgia, Migraine, and the Pains of Organic Nervous Disease and Menstrual Troubles. ^. Pyramidon, gr. v. to viii., dissolved in water, three times iaUy. Hypnotics (Whitla). (a) ^. Paraldehyde Si. MucU. acao 5ii- Syr. simpl. 3ii- Aquam cinnamom. ... ... ... adgii. M. Sig. : To be taken at bedtime. (6)^. Lupulini gr. iii. Camphor gr. iii. Ext. hyoscyam. gr. iii. M. Ft. pil. ii. To be taken at bedtime. (c) Snlphonal (gr. xx.), Trional (gr. x. to xxx.), and Veronal (gr. V. to X.) are all valuable hypnotics. They should, however, be accompanied by appropriate remedies when the sleeplessness is due to pain. (d) Bromidia (Battle) is a useful hypnotic. It contains chloral, potassium bromide, and cannabis indica. Local Applications. (a) ^ Lin. aconite l Lin. chloroform, j ^5". Big. : To be gently rubbed into the painful part in myalgia or other flbrositis. I8t) MINOR MALADIES. (5) Dr. Q. H. Kenyon strongly advocates the local application of tartarated antimony in lumbago. The ung. antimon. tartarat. is thoroughly rubbed into the part twice daily, if necessary, until the characteristic pustules make their appearance (British Medical Journal, January 13, 1906). (c) Antiphlogistine (Denver Chemical Manufacturing Company) U ft convenient and, in some cases at least, a very efficacious form of stimulating local application. Over poultices it has the great merit of cleanliness and aseptioity ; to fomentations it is to be preferred in that it need only be applied once in twenty-four hours. It contains inter alia glycerine, boracio and salicylic acids, eucalyptus and iodine. CHAPTER V. GOUTINESS. Goutiness is a sufiSciently common and sufficiently well-understood term, but inasmuch as it is also a very elastic one, I must begin by explaining the limitations which are here applied to it. First of all, then, we must exclude acute articular gout a,nd those forms of subacute gout, such as tophaceous, as are usually described. Neither need we consider such conditions as renal and hepatic calculus. These are, in many cases at any rate, truly gouty in origin, but they are also in the nature of classical complaints, whose symptoms, diagnosis, and treat- ment are fully set forth in standard works. With these exceptions the whole field of troubles caused by the gouty diathesis is open to us, but I may as well say at once that I do not propose to try and exhaust it ; I shall, however, endeavour to include the most important points, and shall seek to lay stress upon those which seem to me to require emphasizing. In considering any question connected with gout, one is immediately brought face to face with 187 188 MINOR MALADIES. the numerous and very divergent theories which have heen expressed on the subject of its causation by very competent observers, and one finds one's self forced to confess that very little is really known concerning it. Fortunately, however, that does not prevent us from obtaining a very fair workable estimate of it from a clinical standpoint, nor from being able to treat it with a measure of success. Gout, it is generally agreed, is due to insufficient or perverted metabolism, leading either to the formation of material which is ioreign to the healthy economy, or to the inadequate discharge of normal excreta. Whichever of these views is correct matters nothing for our purpose. What we have to realize is that there is a something circulating in the blood which, in its endeavours to escape, may project itself, so to speak, upon any organ or tissue, and that the form which the gouty manifestation will assume will depend upon the organ or tissue selected. What determines that selection in any particular case it is quite impossible to say. Thus the ' something ' may project itself into the neighbourhood of joints, causing a chronic gouty arthritis ; it may project itself into the sheaths of nerves, causing a gouty neuritis ; it may project itself on to the integument, to cause a gouty eczema, a gouty psoriasis, and, what is contrary to general belief, a furunculosis. It may attack the air- passages to cause pharyngitis, laryngitis, bronchitis, or asthma ; it may find its way to the stomach and cause dyspepsia ; it may select the brain and give GOUTINESS. 189 rise to irritability, somnolence, and disinclination for work; it may provoke a cystitis, and, according to some, even a urethritis. There is, in fact, no part of the body which can be said to be free from the liability to invasion by the gouty poison, and fortunate indeed is he who, being obliged to suffer manifestations of the diathesis in any situation, suffers them in some painful and easily recognisable shape rather than in the painless, insidious, but far more inexorable, forms of arterio-sclerosis and kidney disease. The main thing, then, to remember about gout is not to forget it. In the presence of a disturbance of any sort, in any part of the body, it is wise to ask our- selves the question ' Is this due to gout ?' Many of us who do not forget the question are, perhaps, too liable on insufficient grounds to answer it in the affirmative, but such an attitude is less liable to lead to disaster than omission to remember it. The points upon which a correct answer to such a question depends are too numerous to enter into here. They involve such matters as heredity, habits, aspect, slight manifestations in other organs, and the like, which can in reality be acquired only by clinical observation and experience. There are, nevertheless, some points in connection with the condition of which the most experienced may profitably remind himself, some of which we will now briefly consider. Gouty symptoms are rare before middle life, and when that. period is reached they are conmioner in 190 MINOR MALADIES. those whose youth has been athletic. Our national pride in outdoor sports might well be tempered by the consideration that the habit of body which these sports engender is very apt to lead to gout in those who, having once indulged in them, are ultimately condemned to a sedentary existence. The boy is father of the man, and the man is apt to suffer if he is unable to continue the catabolic activity to which the boy has accustomed the organism. It is said that women do not suffer from gout. This is true only in so far as acute ' big-toe ' gout is concerned ; for women certainly suffer very frequently from irregular gout, especially in the form of headache, neuralgia, and bronchitis, and after the menopause they exhibit a very decided tendency to conform to the types, such as chronic arthritis, skin affections, and dyspeptic troubles, which are so common in men. The chief cause of gout, in whatever form it may appear, is want of balance between intake and output. Either the intake is too great or the output is too small. Not infrequently both factors are in operation. So far as the intake is concerned, the excess is not necessarily one of quantity. Meat foods and alcohol, even when taken in what is usually considered modera- tion, by a predisposed person leading an inactive life, axe very powerful producers of gout ; and, in the same way, a man who takes a great deal of exercise may be very gouty if he indulges too freely in the pleasures of the table. The discovery of a gouty manifestation, then, immediately provides two cardinal indications : GOUTINESS. 191 the one is to check the source of the poison, the other is to aid and hasten its elimination. The first of these is met by prescribing and insisting upon a suitable dietary ; the second, by increasing metabolism and invoking the active aid of all the emunctories. In the matter of diet the most important point is the reduction of the alcoholic drinks. Beers and ■wines in contradistinction to spirits are often spoken of as peculiarly productive of gout. It is no doubt true that the beer-drinker is more liable to gross and obvious forms of the malady than the spirit-drinker, but to argue from this that spirits are harmless to a goutily-disposed person is to play the part of the ostrich. Spirit-drinking, though it may not provoke arthritis or eczema, is in the highest degree calculated to cause arterial degeneration and granular kidneys, and these, though less strikingly, are no less truly gouty in origin than the others. That spirits, not being productive of gout, are therefore harmless and even ' wholesome ' to gouty people is a heresy which would be ridiculous were it not so pernicious, and no words of condemnation are too strong for him who aids in its dissemination. Alcoholic drinks of all sorts are in the highest degree harmful to the goutily inclined, and the larger the percentage of the contained alcohol, the greater is the harmfulness of the beverage. The first thing to do, then, with a gouty person is to make him, if possible, into a teetotaller. The • ostrich ' view of the question should be impressed 192 MINOR MALADIES. upon him, and it should be brought home to him that it is practically impossible to check the manufac- ture of an article except by stopping the supply of the raw material. If we have happily succeeded in this endeavour, our next care should be to convert him into some- thing approaching a vegetarian; for after alcoholic drinks, the ingestion of meat foods takes the highest place in the production of the malady. In the time of our forefathers there was a saying that the gouty patient should have three meals a day — ' one of fish, one of flesh, and one of neither.' This may be a use- fill formula for a recalcitrant patient, whom we are trying to persuade into the paths of physiological righteousness, but it is far indeed from being a counsel of perfection. The three meals of a person with definite manifestations of goutiness in any form (I am not now referring to such as are merely goutily disposed) should consist of one of fish or flesh and two of neither. Even the one of fish or flesh represents in the judgment of many a concession which it is sometimes necessary to make to the weaker brethren, for the less nitrogenous food of animal origin which a patient can be induced to take, the more rapidly and the more completely will he get rid of his troubles. There are, of course, nitro- genous foods and nitrogenous foods, and there seems no doubt whatever that those which, roughly speaking, are obtained without the sacrifice of animal life are less deleterious to gouty people than those which entail GOUTINESS. 19B such sacrifice. For instance, milk, cheese, eggs, and the pulses (peas, beans, and lentils), though rich in nitrogen, are, compared to flesh, poultry, fish, and game, very poor in the constituents which help in the elaboration of the gouty poison. It is from tba former, then, that the gouty patient should be encouraged to draw his nitrogenous supplies, and it should be made clear to him that, in the presence of a manifestation however slight, the latter will pro- long the attack and militate against the action of remedial measures. It used formerly to be believed that sugar was productive of gout. Although this is now very generally recognised as fallacious, there seems to be some measure of truth in it, inasmuch as sweets are very liable to upset the stomachs of gouty people. This they do more especially when introduced into that organ without having been thoroughly insaUvated. Gouty people who are afflicted with a sweet tooth, as the saying is, should therefore be warned against indulging it unduly; and it should be explained to them how they may indulge it with the best prospect of doing so with impunity — namely, by efficient mastication. Another question closely connected with diet, which has been engaging a considerable degree of attention during the last few years or so, is the part played by common salt in what we may call the indirect causa- tion of many morbid conditions which are asgociated with faulty metabolism and insufficient excretion. It i^i MINOR MALADIES. has been recognised since 1850 that the chlorides are retained in the body during acute illnesses, to be discharged en masse as soon as convalescence sets in. It has also been known for a long time that oedematous fluid contains a very large percentage of common salt, which is excreted by the kidneys as soon as the oedema disappears. Another fact which has been recognised for some time is that the amount of NaCl contained in the blood itself, is always the same under all normal circumstances, quite irrespective of the amount ingested — that is to say, if more is ingested the surplus is immediately excreted. Now, WidaP has shown that in many conditions which are associated with renal inadequacy, of which goutiness may be taken as a type, the inadequacy first shows itself by an undue retention of chlorides. The common salt passes out of the bloodvessels into the tissues. Here it attracts to itself fluids, and oedema is the result. This oedema is at first visceral and deep-seated, so that clinically it is not easy to detect, except by careful comparative observations of the patient's weight. And, as one would suppose, among the first of the viscera to be attacked are the kidneys. They become (edematous, and, consequently, to their inadequacy in the matter of chlorides there is superadded a general inadequacy. Thus it is that chlorides, though not poisonous in ' La Presse M^dicale, June 29, 1908, and Convpt. Bend. 8oc. Biol., 1904. See also Treatment, August, 1903, and an article in The Practitioner, August. 1905, by J. H. Bryant. GOUTINESS. 195 themselves, very easily lead to the retention of other matters, and of these other matters, many are highly toxic. Widal has, in fact, shown that, in kidney affections, ursemic symptoms may be provoked or suppressed at will, by largely increasing or greatly diminishing the amount of common salt ingested. In view of these facts, it is obvious that chloride of sodium constitutes a very grave potential danger to the goutily disposed, and we should be particularly careful to warn such against the habit of adding large quantities of salt to their food. For the same reason, highly salted foods, such as bacon and salt- fish, are better avoided, and those natural mineral waters which contain large quantities of NaCl — and a great many of them do — should not be recom- mended as habitual laxatives. Widal's work teaches us a further lesson of some importance — namely, that the amount of chlorides in the urine offers a very fair gauge of the functional renal capacity of the patient, thus helping us to a very early diagnosis of renal inadequacy. Having by these dietetic regulations so arranged matters that the supply of the poison shall so far as possible be checked, our next care is to help in the disposal of that which has been already formed. To this end a vigorous appeal must be made to all the excretory organs for aid in ejecting the invader. Now, it is to be remembered that no appeal to the excretory organs is ever successful which is not accompanied by a liberal supply of fluids. An abundance of water 196 MINOR MALADIES. is necessary to the action of each and all of them, and to ask them to excrete poisons without fluid is to ask them to make bricks without straw. It is said by those who wish to belittle the spa treatment of gouty conditions that this treatment is successful only because of the large quantities of fluid which ^he patients are made to consume. It is not necessary to give adherence to this suggestion in order to learn a lesson from it. If the ingestion of large quantities of water, as water, is beneficial at health resorts, it must be equally beneficial at home ; and certain it is that if a gouty patient can be induced to take, say, from 2| to 3 pints of water in the twenty-four hours, he is materially aiding his recovery in a most essential particular. So much being established, let us see when and how the water is to be taken. First and foremost, it should be taken before meals, and not with or after meals. Half a pint may be taken half an hour before breakfast ; about half a pint at 11 a.m. ; the same quantity half an hour before luncheon, and again at 4.30 p.m.; before dinner a similar amount, and before bedtime a full pint. This is a large quantity, but if all the excretory organs are to be kept working vigorously, it is not too much. The question of how the water is to be taken, whether hot or cold, whether plain or with additions, must be left to individual tastes and peculiarities to decide. Some people will take water hot when they wiU not take it cold ; some will take water in which tea has GOUTINESS. 197 been infused, or to which some fresh lemon-juice has been added, when they will not take it plain ; others, again, will attach virtues to a water poured from a bottle which they will deny to that which is drawn from a tap. These are largely matters of fancy on the part of the patient and of diplomacy on the part of the doctor; the only suggestions on the subject which I have to make are that still waters are preferable to sparkling waters, and that lightly miner- alized waters are preferable to those which are strongly charged. Inasmuch as fresh lemon-juice is believed, by many observers whose opinion is entitled to respect, to have a beneficial influence upon some, at any rate, of the gouty manifestations, it is well to encourage its use ; for even if it has no other merit — and, as will appear presently, I am one of those who believe that it has — it can certainly claim to render the dose more palatable. Among drugs which possess a general influence in aiding the elimination of the gouty poison, iodide of potassium stands pre-eminent. There is no gouty manifestation which does not yield in a large measure to its intelligent employment — and by intelligent employment I mean its association with other drugs or measures specially directed against the particular manifestation present. The mistake which is usually made in connection with it is fear of large doses. The ordinary dose of 2 grains is much too small. If the drug is given at all, it should be given in doses which commence at 10 grains, and, 198 MINOR MALADIES. curious though it may seem, the larger quantity is infinitely less liable to produce coryza and the other symptoms of iodism than the smaller.^ If there is any suggestion of a rash appearing in consequence of its administration, a few drops of Fowler's solution added to the mixture readily prevents further trouble. Another drug which is very valuable in counteract- ing the gouty poison, and one which resembles iodide of potassium in the fact that the exact nature of its working is stiU hidden from us, is guaiacum. The two may very suitably be given together in cachet form : ^. Pulv. guaiaoi l Potass, iodid. ) M. Ft. cachet. Sig. : One three times daily. If the guaiacum causes purging, the dose must be reduced, or 5 or 10 grains of creta praep. added to each cachet. In any case the cachet should be followed by a draught of water. It is not desirable to give guaiacum in a mixture. Patients readily rebel against it on account of its unpleasant taste and ob- jectionable consistence. The salicylates, while regarded by some writers as excellent remedies in gouty conditions, are loudly condemned by others, notably in France. The objection urged against the salicylates, especially that of sodium, is that they are depressing and have an irritating efEect upon the kidneys. There may be some truth in this, but my personal experience with aspirin (10 to 20 grains) has so far been quite » See Chapter VIII., p. 3]0. GOUTINESS. 199 favourable. It is, however, well to remember the renal charge which is, on the Continent, very actively brought against it. Many people complain that the salicylates are inert. When this is true, it wUl usually be found that they have been combined with alkalies, and I find, in point of fact, that the combina- tion of salicylate of sodium and bicarbonate of sodium is a very favourite one. When salicylates are given they should be prescribed either alone or in conjunc- tion with such a drug as nux vomica, which does not influence their chemical medium ; for in the body they play the part of acids, and it is in virtue of this action that they do good. Another acid whose virtues in the gouty state have recently been attracting considerable attention on the Continent is phosphoric acid. According to the experiments of Joulie' it would seem that gouty manifestations are due to the retention in the blood of matters whose escape is favoured not by alkalies but by acids, and the acid which he has fixed upon as most potent in this connection is phosphoric acid. I believe there is a large measure of truth in his contentions; at any rate, I have been successful in giving reUef with dilute phosphoric acid where iodide of potassium and guaiacum had failed me. Citric acid, in the form of lemon-juice, has often been lauded in the management of the gouty 1 ' L' Acidity Urinaire,' par M. H. Joulie {Bevue OeWrale de Clinic, Paris, 1901). See also ' La Medication Phosphorique,' Dr. Jean Nioolaidi (Paris, Octave Etoin, 1904). 200 TvIINOR MALADIKS. diathesis. This drug, when taken in large doses — say J ounce in the course of the day — undoubtedly renders the blood more fluid by precipitating the calcium salts. What it does with these salts is a matter which still seems to await investigation ; at any rate, they disappear from the blood, thu«i rendering the fluid more mobile and better fitted for its purpose of bathing and flushing the various tissues, and so promoting efficient excretion. I believe citric acid to be a most useful general cor- rective to the gouty tendency. Having now paved the way for the efficient action of the excretory organs by ensuring for them an adequate supply of water, and having, by the action of the above-mentioned drugs, rendered the process of elimination more easy, let us inquire into the best means of setting these organs to work. So far as the bowels are concerned, if guaiacum is given, then the quantity in the above cachet may do all that is necessary. Where it does not, some purgative salts, preferably sulphate of magnesium, in doses of 30 grains, with nux vomica (vide p. 112), should be added to the morning dose of water^ and also perhaps to the evening dose ; or some of the natural aperient waters which are not overburdened with NaCl may be substituted.^ Either course is much to be preferred ' Arabella water, which contains chiefly the sulphate and bicarbonate of sodium, may be said, for practical purposes, to be free from the chloride. It has therefore a special value in gouty cases, GOUTINESS. 201 to the exhibition of cholagogue cathartics, which are so often recommended. There is no objection to an initial dose of calomel (say 2 to 3 grains) : it is an excellent measure, especially in sthenic cases ; but the practice of a sustained exhibition of hepatic stimu- lants is much to be deprecated. It was introduced in conformity with the theory that gout in all its forms was due to some dereliction of duty on the part of the liver, which could be counteracted by stimulation of that organ. As this theory is very far from being established, and as the continuous administration of cholagogues has well recognised drawbacks, the practice is not to be recommended. In gouty conditions the liver, together with aU the portal radicles, require unloading, but this may be done quite efficiently with the mixture above pre- scribed, especially when this is occasionally reinforced by smaU doses of calomel (1 grain), podophyUin (^ grain), iridin (2 grains), or euonymin (1 grain). The excretory organs to whose action the greatest importance is, in this connection, universally attached are the kidneys. It is my purpose to avoid as far a^ possible expressing an opinion about any of the theories concerning the causation of gout, but it is safe to admit that uric acid and the biurate of sodium are both in a measure actively engaged in producing the symptoms of the complaint ; and as these substances are normally excreted by way of the kidneys, it is obvious that anything which tends to increase renal activity will materially aid the dia- ^02 MINOR MALADIES. charge of these matters, and thus lessen the incidence of the m anifestations. The importance of fluid, which, as already stated, is considerable in the case of all the excretory organs, is here paramount, and water must therefore be exhibited in full quantities. As aids to its discharge by the kidneys rather than by any other route, it is well to have recourse to diuretics. There are diuretics, such as digitalis and sco- parium, which act by increasing the general blood- pressure, including that in the kidneys. As will appear later on, the blood - pressure in the gouty already rules over-high, so that such drugs are care- fully to be avoided. The routine prescription of digitalis, bad as it is in cardiac disorders, becomes, in conditions accompanied by high arterial tension, something in the nature of a therapeutic crime. It increases the arterial tension and acts as a diuretic only when oedema is present. For diuretics in the gouty state, then, we must look to those which increase the renal activity without raising the blood- pressure — such, for example, as the salts of potassium, the infusion of buchu, and theobromine. Fothergill says that buchu has upon the urinary passages the same inexplicable soothing influence which bismuth has upon the digestive apparatus. This I beheve to be true, and it has often seemed strange to me that so valuable a drug should recently have fallen into disuse. It is by no means un- palatable, and it increases very conspicuously the functional activity of the kidneys. Of the salts of GOUTINESS. 203 potassium, those which are most used are the citrate and bicarbonate. No one, I imagine, now gives these salts in the vain hope of increasing the alkalinity of the blood, so as to obtain the solution of uratic deposits ; but whatever the motive with which they are given, there can be no doubt either that they exercise a beneficent action over the symptoms, or that they increase very materially the renal activity. It is probable that such merits as these and all other alkaline salts may possess are due mainly, if not entirely, to their action as diuretics; and that the salts of sodium, even though they be, as some are stiU found to maintain, wrong in theory, are useful in practice, owing to their possessing a similar eliminative action. To insure the adequate discharge of the excreta from the kidneys, we have, then, to see, first, that enough fluids are being taken. The importance of this is so obvious that it seems absurd to dwell upon it, and in reality my only reason for so doing is to point out that the rule is liable to an exception. If there is too much fluid in the vessels, the urine is scanty because there is undue pressure in the kidneys. In such circumstances, to increase the amount of fluid ingested is to decrease the amount of urine excreted. If, therefore, after a few days the urine fails to increase in quantity, the fluids should be decreased until the urine flows freely. The next thing to do is to construct a prescription which wiU include such diuretic drugs as wiU assist 204 MINOR MALADIES. in the discharge of this fluid by the renal route. If the cachet^ be discontinued, we can include its most important ingredient, the iodide of potassium, in this prescription, which would then be as follows : '^. Potass, iodid ... ... gr. x. Potass, citrat 5ss. Inf. buchu ad gi. M. Sig. : Ter die. If, as is not altogether infrequent, the patient be ansemic, 6 to 10 grains of the potassio-tartarate of iron may suitably be added to this mixture, which should be taken immediately after the three principal meals of the day. There is another time-honoured drug which is not used as frequently in these conditions as it might be —this is spts. seth. nitrosi. When combined with citrate of potassium and acetate of ammonium, as in the following formula, it makes a very useful and agreeable mixture, increasing notably the flow of urine and acting, to some extent, as a diaphoretic. Potass, citrat , ... ... 3S8. Spts. seth. nitros. ... ... 3i- Liq. ammon. acetat. • ... ... gss. Aquam ... adgii. M. Sig. : In a tumblerful of water three times a day. In connection with spts. aeth. nitros. it is important to remember that it must not be combined with iodide of potassium, as the result is an explosive mixture. A diuretic of which Professor Huchard speaks in > Page 194. GOUTINESS, 205 the highest terms is theobromine. He prefers it to diuretin, in which it is combined with saUcylate of soda, because he believes that the latter is very liable to irritate the kidneys. Of theobromine (which he prescribes in 10 to 15 grain cachets, three times daily) he says : ' It is one of the most powerful and reliable diuretics with which I am acquainted. It is by far the best medicament in all cases where we desire to increase the secretory activity of the kidneys, and I prescribe it all the more confidently because it does not increase arterial tension, nor has it any effect upon the strength or frequency of the cardiac contractions. It acts solely upon the renal secretory elements.' The natural mineral waters of Contrex^ville, Vittel, and Evian have very powerful diuretic properties, and may be prescribed with great confidence for all gouty patients. These waters can be obtained in bottles in this country, but it is infinitely preferable to send the patient to the spring itself, as there is reason to beheve that a measure of their eflacacy is lost either in the bottling process or in transit. Of these three places, Evian, situated on the Lake of Geneva, is much the most agreeable. It has a very fine bathing establishment, and its waters act very markedly in increasing the renal output.^ The next most important excretory organ is the ' See A. E. Wright, Lcmcet, April 2, 1904, 'On a New Method of Testing the Blood and the Urine, with Special Eeference to the Excretory Efficiency of the Kidney.' 206' MINOR MALADIES. skin. There aie several drugs which increase cutaneous activity, chief among which is pilocarpine. This is a useful drug in many contingencies, and may occasionally be helpful in the gouty state, but the condition in which it is most generally recommended is precisely that in which it ought never to be employed — I mean ursemic poisoning. Pilocarpine induces not only a free flow of perspiration, but it induces also a great increase of bronchial, laryngeal, and tracheal secretion, and if the patient is partly insensible, these secretions may very easily choke him. Those who have a fancy for pilocarpine should reserve its use for patients who are conscious, and avoid it carefully in urjemia and other semi-conscious states. On the question of pilocarpine, I may mention parenthetically that it is one of the most useful of aU drugs in the treatment of pruritus, whether local to the anus or vulva, or associated with a skin disease such as eczema, or even when general, such as sometimes causes so much distress in old age. It should be given in doses varying from ^ to J grain, and when combined with atropine, say j-|^ grain, it does not cause inconvenient perspiration. In ordinary goutiness, however, the skin is best stimulated by means other than drugs. Pre-eminent among these stands muscular exercise in the open air. This should be sufficient, but not excessive; sufficient, that is, to induce free perspiration without, at the same time, giving rise to more waste products than the organs can conveniently deal with. When GOUTINESS. 207 we are trying to dispose of an excess of a material we must be careful not to pursue a policy which may have for one of its results the production of that material, or a similar one, in increased measure. The nitrogenous waste which is produced by muscular exercise has to be excreted for the most part by the kidneys, and it is well that these organs, which already stand in need of stimulation, should have no more work cast upon them than is absolutely necessary. A good substitute for muscular exercise is to be found in baths of various kinds combined with massage. These are undoubtedly best administered at a health resort, under the guidance of an ex- perienced physician who is accustomed so to graduate them as to obtain the maximum benefit with the minimum of fatigue. Hot baths followed by massage may be administered at the patient's own house, but when this is done, careful instructions should be given as to temperature and duration. The temperature of the first few baths should not exceed 100° F., and their duration should be limited to ten minutes. Both may be cautiously increased until the one reaches 105° F. and the other twenty minutes. Each bath should be followed by massage or shampooing, and thereafter the patient should be swathed in flannels and encouraged to perspire by the adrninis- tration of hot water. Such baths are, however, in- ferior to the hot wet pack which I shall presently describe. 208 MINOR MALADIES. Turkish baths, though excellent in many respects, have this against them : that very few, if any, of the estabhshments in which they are administered are adequately ventilated, so that the bather, especially when he is in the hot rooms, is breathing an atmo- sphere which is loaded with the cutaneous and pulmonary excreta of others. The home Turkish bath, of which there are now many patterns on the market, is not open to this objection ; but, then, it is lacking in those agreeable elements of shampooing, douching, coffee, cigarettes, and gossip, which recon- cile people to the discipline when administered in well-conducted establishments. Of all the forms of bath obtainable under ordinary circumstances in large towns, that which I have learned to value most highly is the radiant-heat bath. The addition of light to the hot air certainly seems to confer upon the latter properties which in the absence of light it does not possess. At the Dowsing Institutes, of which there are now a great number all over the country, these baths are well and carefully administered. They may be followed by massage if so desired, but even without this addition, I know of nothing so well calculated to stimulate cutaneous activity and to bring about resorption of gouty deposits in properly selected cases. Of routine household procedures nothing can com- pare with the hot wet pack. This is an old method, which has become unduly neglected. It is useful in a great variety of conditions, and as it is practically GOUTINESS. 209 always available, I shall describe it in detail. AU that is required is a mackintosh sheet, two ordinary blankets, a cotton sheet, a hot- water bottle, a pail of boiling water, and a wringer ; all of which, except the last-named, can be obtained in an ordinary house- hold. The wringer can be manufactured at short notice by hemming in enough of the two ends of a towel to allow a walking-stick to be passed through each ead easily. The mackintosh is placed on the bed, and on top of it, the two blankets fully spread out. The sheet, having been wrung out of the boiling water, is then laid on the upper blanket. The patient is then placed on the sheet, so that his occipital prominence is on its upper margin. With the patient's arms raised, the upper corner of the sheet on his right side is carried across and tucked under his left scapula. With his arms by his sides, the opposite corner is brought across and tucked under his right scapula. Each blanket is then carried across in a similar manner, the hot- water bottle is placed near the feet, and the free ends of all the coverings are tucked under the heels. In a period varying from twenty to forty minutes per- spiration will be found on the forehead, and that is the signal of sufficiency. The temperature taken in the mouth generally shows a rise of 1 or 2 degrees. After a tepid or cold sponging the patient is removed to bed, on which the coverings should not be too heavy. Two or even three of these packs may be given in a week. Patients, especially children, for 14 210 MINOR MALADIES. whom they are very useful in many conditions, always enjoy them, and an intelligent nursery nurse can be taught to administer them quite satisfactorily. The use of such means as are above indicated for stimulating the skin, derives its importance, not only from the point of view of excretion, but also from the point of view of vascular dilatation. One of the effects of the gouty poison (whatever it may be) is to irritate the bloodvessels, especially the arterioles and capillaries, causing their contraction, and thus giving rise to heightened arterial tension. Now, high arterial tension, if long continued, leaves its mark upon the vessel walls in the form of arterio-sclerosis, and ultimately, in the form of dilatation and relative insufficiency, upon the heart itself. The involvement of the coronary arteries in the sclerotic process may give rise to anginal attacks, and the inclusion of the renal arteries to cirrhosis. But we need not multiply examples in order to realize the necessity for taking early steps to over- come the chronic contraction of the bloodvessels, which is the direct cause of the increased blood- pressure. The general measures, dietetic and medi- cinal, already indicated, especially the avoidance of meat foods and alcohohc drinks, together with the exhibition of mercury and potassium iodide, will in the long-run do much in this direction ; but cutaneous stimulation by means of baths and massage causes prompt dilatation of the vessels over an enormous area, which lasts a considerable time, and may be GOUTINESS. 211 repeated frequently. The assistance in combating the condition to be obtained by such dilatation is the secret of a large portion of the success which attends the balneological treatment of these cases. So much, then, for the management of the gouty state in general Let us now consider how we are to treat the various symptoms of this state as they arise in different parts of the body. The most important are those which affect the joints, causing a subacute or chronic arthritis. When this arthritis is a legacy from an acute attack, its treatment, in so far as it differs from what has above been indicated, resolves itself into that which is laid down in all the text-books as proper to the attack itself.* Into the details of this it is not necessary to enter here, but I should like to say that where pain is at all obtrusive colchicum is the best palliative, and that it is desirable to withdraw the remedy as soon as the pain has subsided. There are, however, a great many varieties of gouty arthritis which are truly chronic from the beginning, attacking various joints, notably the small joints of the hands and the meta- tarso-phalangeal joints in the feet, giving rise to enlargement and deformity rather than to pain. This is the so-called chronic deforming gout, so frequently labelled chronic rheumatism, which is by no means easily distinguished from rheumatoid arthritis, especially if we make the mistake of concen- trating our attention upon the local manifestations of 2ia MINOR MALADIES. the disease to the exclusion of the general state of the patient. For in the gouty condition there is, as a rule, no difficulty in discovering the existence of sthenic manifestations in other organs or tissues, whereas in rheumatoid arthritis not only are such manifestations absent, but the clinical picture is essentially one of asthenia, demanding not an elimina- tive but a generous regime. The arthritis of chronic gout is probably more amenable to electric light baths than to any other therapeutic measure. The baths, especially when combined with massage, bring about the absorption of the deposits with a rapidity and completeness which is astonishing to those who have never tried them. Hot-air baths, douches, and the various measures of a similar kind which are employed at health resorts, stand next in order of efficacy, and where the patient's means permit, it is always well to advise a visit to a suitable spa.^ For the rest it is important to insist that chronic gouty joints should not be allowed to become fixed and deformed for want of exercise and move- ment. Massage is an excellent measure, so is elec- tricity ; so, in fact, is anything which will insure ^ Vichy and Eoyat are two places which may be recommended with confidence. Aix-les-Bains has deservedly a world-wide reputation. Buxton, Bath, Harrogate, Woodhall Spa, and Llandrindod offer exceptional advantages to people who prefer to stay at home. It should be remembered that the ingestion of sulphur waters seldom suits the gouty ; their external application does. GOUTINESS. 9A3 regular stimulation. In this direction much can be done by the patient himself, and there is generally no difficulty in inducing him to do it, if it is brought home to him that ultimate recovery of a crippled joint depends more upon his willing and intelligent co-operation than upon the assistance of others. Stimulating liniments are very useful adjuncts, especially when applied after the part has been steeped in hot water. Poultices and compresses con- taining bicarbonate of sodium or citrate of lithium are also very helpful in reducing swelling and restoring movement. A method of treating stiff and painful joints which is very highly spoken of by some, is cataphoresis, by which medicinal substances are transferred to the joint through the unbroken skin by means of the constant electric current. Theoretically the positive pole should be that to be placed in contact with the drug, but clinically it is found that some drugs penetrate better with the negative pole, and amongst these are iodide of potassium and salicylate of sodium. A procedure which has seemed to me to give good results is to paint the part with iodine, and then place upon it a pad of lint which has been steeped in a solution of lithium citrate. The positive pole is then placed on the pad, and a current of about 10 cells is allowed to flow. When the pad is removed the colour of the iodine will be found to have disappeared. Whether this fact has any ' suggestive ' effect in bringing about the result I am unable to say. S14 MINOR MALADIES. I feel I ought not to leave this question of gouty or lueumatic arthritis without saying a word in connec- tion with the reprehensible practice of lightly dismissing joint troubles in children as due to this cause. Such troubles, it is true, are seldom labelled gout, but they are labelled rheumatism -with a frequency which is far from creditable. The truly rheumatic state in children so rarely takes the form of an arthritis that, apart from the disease closely resembling rheumatoid arthritis and associated with the name of Dr. Still, such a condition may almost be said not to exist. Rheumatism in children shows itself as chorea, tonsillitis, subcutaneous nodules, erythema, purpura, and the like, but seldom or never as an arthritis. An enlarged or stifif and painful juint in a child, therefore, especially if only one joint be involved, is exceedingly unlikely to be rheumatic or gouty in origin, and great care should be taken in 80 describing it. Such conditions are more often due to tubercle than to anything else. Their progress is fraught with considerable anxiety, and their treat- ment demands the utmost care and watchfulness. Numberless limbs have been sacrificed and lives lost owing to the loss of precious time, due to the otiose diagnosis of ' a little rheumatism ' where arthritis in a child has been present. Of abarticular gout there are a great many forms. Chronic pharyngitis is by no means uncommon, chronic laryngitis is common, and chronic bronchitis is not rare. The gouty poisons as they affect the GOUTLNESS. 215 lower air-passages seem, however, to void themselves in acute explosions rather than in chronic irritation. Thus, an acute bronchitis of gouty origin is an exceedingly common event. It is important to remember this, because bronchitis is invariably attributed to chill, and if we allow ourselves to be beguiled by such etiological suggestions we shall fail to treat the case as it should be treated — namely, by mercurial purges and the addition of iodide of potassium, and perhaps some colchicum, to the drugs intended to combat the bronchial irritation. Asthma is another very common form of gouty ebullition. Inasmuch as iodide of potassium is one of the most useful remedies in ordinary spasmodic asthma, failure to recognise its gouty origin is, so far as the attack itself is concerned, not of much consequence ; the recognition becomes of importance only when we are considering the best means of providing against further attacks, and if we do not realize their true origin, our precautionary measures are likely to prove singularly inefi'ectual. One of the commonest associ- ations of asthma, which is a symptom and not a disease, is with high arterial tension. As this impor- tant question is considered in some detail later, it is here only necessary to call attention to the fact, and to insist that the high tension should be treated by appropriate means, rather than the asthma relieved by habit-provoking sedatives. The gouty affections of the nervous ?,;, stem consist in myalgia, neuralgia, neuritis, insomnia, mental 216 MINOR MALADIES. irritabUity, mental depression, migraine, and epilepti- form attacks. In the skin the diathesis may show itself as an eczema, a psoriasis, an erythema, and, contrary to what is generally believed, as furunculosis. Boils are commonly regarded as a symptom of asthenia ; they are, especially when occurring in successive crops, in my experience much more often due to the gouty poison. Why this poison should favour the activity of staphylococci in the hair follicles it is difficult to say, but that it does so is, to my mind, abundantly clear. An excellent treatment for boils consists in the administration by the mouth of pills of calcium sulphide (1 grain) three or four times daily (smaller doses are useless), and the local application of ichthyol ointment (about 15 per cent.). This does a great deal of good where the boil is a ' singleton,' relieving very considerably the local pain and hastening resolution. Where, however, the boils, as is often the case, tend to appear in successive crops, the patient should be injected with antistaphylococcic serum. This treatment, introduced by A. E. Wright, is practically painless; there is no constitutional dis- turbance, and the result is uniformly satisfactory. It does not, of course, in any degree influence the under- lying gouty condition, which should be treated on the lines already suggested. In treating of boils and carbuncles, when once established, a mistake which is often made is that of allowing them to heal prematurely by scabbing, with GOUTINESS. 217 the result that the retained poison shortly seeks exit by a neighbouring hair follicle, and another boil is the result. An old woman's remedy, consisting of a mixture of sugar and soap, is very effectual in preventing this. A. E. "Wright explains this efScacy by showing that this curious comhination prevents the lymph from clotting, and as a scab consists of clotted lymph, the effect of the soap and sugar is to keep the door open for the exit of the poison. It is often said that boils should not be poulticed or fomented, because such applications are apt to pro- duce a crop of smaller ones in the neighbourhood. Poultices are not easily rendered aseptic, but they can be applied with safety if the skin be first smeared with thymol vaseline. Fomentations wrung out of boracic solution are usually quite safe, but even here the use of the thymol ointment is an advantage, because the vaseline lessens the chance of irritation from slight scalding. Gouty men tend to become bald early, probably owing to vaso-constriction of the arteries in the scalp, and their nails assume a reedy appearance from longitudinal striation. So far as the other skin manifestations are con- cerned, such as gouty eczema, in the existence of which some dermatologists affect to disbelieve, they are to be treated locally according to dermatological rule ; but if their recurrence is to be prevented, their underlying gouty cause must receive adequate atten- tion on the lines already laid down. 218 MINOR MALADIES. In tho eye, gouty iritis and gouty conjunctivitis are common. These conditions, when of gouty origin, are less liable to be acute than when they own some other cause, and consequently the local treatment need not be so vigorous. A blister and a few hot fomentations, and perhaps a little atropine, are all that is required. If the blood state is properly treated the condition will quickly yield. In the alimentary tract dyspepsia is very common. The indigestion of gouty people is usually, but not invariably, of the sthenic variety, demanding alkalies and bismuth ; but it may, on the other hand, be asthenic, and require hydrochloric acid and pepsin for its relief.^ Another form of indigestion — namely intestinal indigestion — is much more common in gouty people than is generally supposed, more especially in such as take large quantities of alcohol. It takes the form of diarrhoea^ often accompanied by flatulence. It is generally painless, and is usually confined to the morning. If possible, it is well to refrain from interfering with this discharge ; the flux should, indeed, be encouraged by mercurial cathartics, for the process is entirely beneficial, in that it rids the system of efiete matters without irritating the kidneys. Tannigen (10 grains in cachet) is an excellent simple astringent. Tincture of catechu (1 drachm) is another. Whatever is used, it is ' Vide chapter on Indigestion. ' Vide Constipation and Diarrhoea, p. 117. GOUTINESS. 219 important to remember that neither lead nor opium should ever be prescribed. The connection between gout and kidney disease is one which has long been recognised. There exist, however, very decided differences of opinion as to the exact nature of this connection ; and yet the matter does not seem to present any very great difficulties. Luff expresses the balance of modern opinion on the subject of gout generally when he says that the disease is due to faulty metabolism giving rise to an auto-intoxication. He goes on to say : ' This auto- intoxication coincides with, or is followed by, in the majority of cases, a deposition of sodium biurate in certain of the joints or tissues, which constitutes the climax of the gouty attack. I cannot but think that with our increasing knowledge and experience of the disease, uric acid and its salts will, in all probability, have to be relegated to a position of subsidiary importance in the pathogenesis of gout. The joint manifestations are probably dependent upon much more general and much larger conditions than a mere excess of uric acid in the blood. The deposition of sodium biurate is possibly merely the sign of the disease, not the essence of it' Now, if we admit the auto-intoxication — and there is no escaping it — the connection between gout and kidney disease seems simple enough. And not only the connection between gout and kidney disease, but the connection between gout, kidney disease, and arterio-sclerosis. And this is how the matter would 220 MINOR MALADIES. seem to stand : the toxin circulating in the blood has, as one of its results, the irritation possibly of the vaso- motor centres, but almost certainly of the bloodvessels along which it passes. The effect upon these blood- vessels is to cause their contraction, and when the contraction is continued for a long period of time, the vessels become sclerosed. Now, this poison is normally excreted by the kidneys, so that it is projected on to these organs not only in a concentrated form, but with ' nozzle velocity.' If the initial power of resistance in these organs is weak, the renal vessels quickly sclerose, and the sclerotic process spreads, as it were, all over the viscus. Then arise the phenomena with which all are familiar — the increased blood-pressure, the enlarged left ventricle, and the consequent progressive arterio- sclerosis over the whole body. This is easy to understand, and is very generally realized. What seems to me to require insisting upon is that this process is frequently reversed, in the sense that the arterio-sclerosis, instead of beginning in the kidneys, may originate elsewhere and spread to these organs, so that the granular nephritis, instead of being the first stage, figures either as an accident or as the final event in the morbid process. For the process, like all other morbid processes, will begin at the site of least resistance, and this site will vary with the individual, so that if the renal vessels are not primarily below par there is no special reason why they should be first affected. And, as a matter of fact, they very GOUTINESS. 221 seldom are, and I am convinced that a great number of the cases of granular kidney and general arterio- sclerosis might be checked if sufficient regard were paid to the detection of the earlier manifestations of arterio-sclerosis in other parts. Now, although we are for the moment dealing with the gouty poison, I must not be understood to suggest that this is the only form of toxin which may give rise to the phenomena we are about to consider. It is, on the contrary, well recognised that the poisons of lead, tobacco, syphilis, typhoid, acute rheumatism, scarlatina, and other acute specifics, frequently carry arterio-sclerosis in their train ; and that worry, anxiety, and concentrated brain-work are very liable to produce it. But this I am prepared to affirm — that by far the commonest cause is to be found in those dietetic and other errors, such as excess of flesh foods, alcoholic drinks, and insufficient exercise, which all agree in associating with the pro- duction of the gouty state. The French have an aphorism to the effect that 'gout is to the arteries what rheumatism is to the heart,' which means, of course, that arterio-sclerosis is as common an accompaniment of gout as endocar- ditis is of true rheumatism. The idea would, however, be better expressed in English by saying that ' gouti- ness' is to the arteries what rheumatism is to the heart ; for in acute gout the poison usually exhausts its virulence during the attacks, which consequently protect the sufferer from the symptoms of goutiness. 222 MINOR MALADIES. Now, if we bear this aphorism in mind it helps us in a great measure to unders.tand that otherwise baffling element of ubiquity which characterizes the symptoms of goutiness, by teaching us to regard these symptoms as due primarily to some dereliction of duty on the part of the arteries in the immediate neighbourhood. Such an explanation does not, perhaps, cover all the facts ; it serves, at any rate, to remind us of what in our search after the exact nature of the gouty poison we are sometimes in danger of forgetting — namely, that this poison has a particular affection for the arterial vascular system. Let us now consider its modtts operandi. We have already seen that the gouty poison causes contraction of the arteries. It is important to re- member that this contraction is at first functional, and therefore curable, but that if it goes undetected and unremedied, it becomes organic, and therefore incurable. It becomes incurable in the ordinary acceptation of the term, but its effects may neverthe- less be mitigated, and in the earlier stages even nullified, by suitable treatment. The functional, the curable, stage is called by the French the stage of pre- sclerosis, and it is, of course, in this stage that it is desirable to recognise the condition, and to set about its treatment. For when once the stage of pre- sclerosis is past and the stage of organic sclerosis is entered upon, the disease, though much easier to detect, is much more difficult to treat. Now, how are we to recognise this first stage — the stage GOUTINESS. 223 of pre-sclerosis ? Well, it is by no means easy, and, as I have already said, in connection with goutiness generally, the first thing to remember is not to forget it. Because it must always be sought for; it never calls attention to itself by any very obtrusive symptoms, and the indications of its presence are very variable. The first effect of a general contraction of the branches of the arterial tree wiU be increased vigour of the heart's action. The cardiac muscle is stimulated by the resist- ance, which it seeks to overcome by slower and more forcible contractions. Now, if we keep these two iacts in mind, the contraction of the vessels and the increased vigour of the heart's action, the phenomena to which they give rise, individually and collectively, are not difficult to follow. First of all, then, with the contracted arterioles we find pallor of the surface, more especially of the face, cramps and numbness, together with coldness of the legs and feet, and fingers that ' go dead,' slight giddiness, and momentary mental confusion, which are very liable to be mistaken for attacks of petit-mal, which may, indeed, degenerate into such attacks unless their true origin is recognised and treated. Further, there may be mental lethargy, and, although the patient sleeps badly, he is always drowsy. Epis- taxis, conjunctival and other haemorrhages are common. There is also disinclination for work, especially pronounced in the morning. Another effect, referable to the nervous system, is the pro- iiU* MINOR MALADIES. duction of neuralgias of various sorts ; persistent or recurrent neuralgia, or headache, is very suggestive of high arterial tension. Someone has said that neuralgia is the cry of a nerve for healthy blood, so that if the arterioles which supply a particular nerve contain impure blood, and by reason of their contrac- tion are able to deliver such blood in reduced quantities only, it is not surprising that the nerve should become painful. The facial and sciatic are those most frequently involved. The effect of the vascular contraction in the bowels is, as one would suppose, the production of constipation, and in the kidneys, polyuria. These symptoms are fairly constant, more especially the polyuria. The contraction in the systemic periphery naturally causes plethora in the pulmonary periphery, and thus we find dyspnoea to be prominent, an important and a highly characteristic symptom. This dyspnoea, the dyspnoea of slight effort, must not be confused with the asthma which is so liable to supervene in the later stages of the affection. This dyspnoea, even when extreme, never has the characteristic laborious expiration of asthma, but resembles far more closely the panting of renal air- hunger, which one so often sees in the last stages of a chronic nephritis. It is provoked by very slight exertion, it is often accompanied by a vague feeling of uneasiness in the chest, or by palpitation, and is liable to occur at night, without obvious cause. This symptom derives its importance partly from the fact GOUTINESS. 225 that it is the one which usually brings the patient under observation, and largely from its liability to be confused with the dyspnoea and palpitation of ordinary dyspepsia. The complaint of dyspnoea would naturally lead every conscientious practitioner to an examination of the cardio-vascular system, and no examination of the cardio-vascular system is even partially satisfac- tory which fails to include a careful instrumental estimate of the blood-pressure. In previous editions of this book it seemed necessary to insist that digital estimation of the ' arterial tension,' as it used to be called, was altogether fallacious. The opinion of the profession has fortunately moved rapidly in this direction, and they are few indeed who do not now realize the importance of the use of a reliable instru- ment. It is long since Clifford Allbutt pronounced the final word on the subject by saying that to appreciate variations from the normal blood-pressure it is just as necessary to use a mechanical appliance as it is necessary to use a thermometer for the accurate appreciation of temperatures. There are a great number of very reliable instruments on the market. The best for the consulting - room is probably one of the many modifications of Riva Rocci's mercurial instrument. Dr. George Oliver's alcoholic instrument is also convenient and reliable. For family practice the best, because it is the most portable, is undoubtedly Dr. Rogers' Tycos mano- meter. It has, however, the disadvantage of being more than double the price of the others. 15 226 MINOR MALADIES. The normal systolic blood-pressure in a young and healthy male adult may be taken as 120 mm. Hg. In women it is rather lower, say 110 mm. Hg; in children lower still, say 90 to 100 mm. Hg. This pressure tends to rise with advancing years. At fifty years of age it may be 150 mm. Hg without exciting alarm ; at sixty a pressure of 160 mm. Hg is not abnormal ; and from seventy years onward it may be 200 mm. Hg with apparent impunity. Nevertheless, a pressure of 200 mm. Hg, even in the aged, must always be regarded with a measure of anxiety, and in those under seventy years it presents a danger-signal which ought not to be dis- regarded. And here let me once more emphasize the fact that high blood-pressure does not necessarily indicate renal disease. In many cases, if not in most, the first event is the high pressure, which, if undetected and unchecked, leads to arterial disease. The particular region in which the arterial disease may reveal itself it is ' impossible to predict, but the end is just as liable to come with a cerebral haemorrhage as with a contracting granular kidney. Now, how is this high blood - pressure to be lessened ? Obviously, by removing the poison which provokes it, and by taking such steps as will insure the permanent reduction of its manufacture in the system. Into the gei^eral principles which should guide us in these matters I have already entered in some detail, but I may briefly recapitulate those which GOUTINESS. n1 have a special bearing upon the question under con- sideration. First, then, as to diet, without careful attention to which it is quite hopeless to attempt the treatment of high arterial tension of gouty origin. The embargo upon meat foods must be absolute ; and imder meat foods, let it be clearly understood, are included fish, poultry, and game. Alcoholic drinks, tea, and coffee must also be absolutely forbidden. The patient must be encouraged to drink plenty of milk, and to take fruits and vegetables freely. What I have said about the great importance of taking plenty of fluid in the gouty state generally must be accepted with consider- able reservation in the case of high arterial tension. If the excretion of the extra fluid can be insured, then the extra fluid can do nothing but good. If, on the other hand, an appreciable portion of it remains, then, by increasing the actual quantity of blood in the vessels, and by thus adding to the state of tension, it is liable to do harm. For this reason, a flushing policy, though excellent when it succeeds, should in the first instance, at any rate, be undertaken with caution. The emunctories must, nevertheless, aU be urged to do their part in ridding the system of the gouty poison, and the purgatives, diuretics, and sudorifics already referred to must be pressed into the service. So far as purgatives are concerned, nothing can compare with mercury, and for a diuretic it is as well to use that which has been so highly spoken of by ^28 MINOR MALADIES. Professor Huchard, to whose teaching we owe almost all our knowledge of the pre-sclerotic state — namely, theobromine (see p. 205). The waters of Evian, Con- trex6ville, and Vittel are admirable aids to all diuretic drugs, and would seem, especially the first named, to possess a special value in the condition we are discussing. The best means of stimulating the skin — that is, by warm baths and electric light baths — have already been referred to. Another excellent general measure — namely, massage — is capable of rendering yeoman service in states of high arterial tension, especially when applied to the abdomen ; for it helps to dispel ' abdominal venosity,' and to pass the blood rapidly through the organs which are credited with being actively concerned in the manufacture of the gouty poison. This, which is mere recapitulation, refers to general measures, the importance of which should never be lost sight of. We now come to the question of our ability to act directly upon the high blood-pressure and to reduce it by means medicinal or otherwise. Do such means exist ? Well, they do, but none of them are satisfac- tory ; for the reason that their action is very transient, and their continued employment is by no means unattended with danger. First among them stands blood-letting. Where we find ourselves in an emergency, face to face with a threatening of cerebral haemorrhage or an anginal attack, no one would, I presume, hesitate to abstract blood from the arm to the extent of half a pint or more. But it is obvious GOUTINESS. 229 that this is a process which cannot be often repeated, and, as the high arterial tension depends less upon the quantity of the blood than upon the state of the vessel wall, it is useless to reduce the one (especially as the reduction cannot be maintained) without influencing the other. And a similar objection applies to the drugs hitherto introduced for this purpose. Nitrite of amyl, though entirely trustworthy in emergencies, is incapable of prolonged action. Trinitrin is in reality only a degree better. It takes longer to act than nitrite of amyl, and its eifect is maintained for a longer period ; but the relief it gives is ill-sustained, and it cannot be frequently repeated. The same objection applies to erythrol tetranitrate (1 grain in tablets three times daily), though to a much less extent. Thyroid extract seems to act beneficially in a good many cases, and where tachycardia is not yet present it may be tried with considerable confidence. In the high arterial tension which is so common with women at the menopause some observers claim to have had good results with ovarian extract. The physiological basis for its employment is certainly sound, and if it does no good, it can do no harm. Aconite has been recommended by some people, and chloral extolled by others. The employment of both these drugs is, how- ever, fraught with such obvious drawbacks that it is scarcely necessary to consider them. In the way of drugs, then, there is nothing upon which we can, in the present state pf onr knowledge, 230 MINOR MALADTF.S. depend for a definite and sustained action of a specific nature, without incurring rists which it does not seem to me that we are justified in taking. And this is perhaps all to the good ; for if we had such a drug we might be tempted to use it to the exclusion of those general principles of diet and hygiene on which the successful management of the gouty diathesis is known to depend, and on which, especially when combined with the judicious employ- ment of mercury and iodide of potassium, full reliance may always be placed. It must not be concluded from the foregoing that an abnormally high blood-pressure is of necessity so evil a thing that, when discovered, all our efforts must be directed to its immediate reduction. So far is this from being the case that a rapid reduction of arterial pressure, as by means of nitrite of amyl, may very easily be attended by fatal results. We have to remember that the arterial pressure must always be higher than the venous pressure. If it is not, the medulla is starved, and the patient dies. If, therefore, the venous pressure is unduly high (as, for example, in mitral stenosis), there must be a coincident and corresponding rise in the arterial pressure, and the manometer will register a very high figure. The indication here is to reduce, not the pressure in the arteries, but that in the veins. To attempt the former is to interfere with Nature's dispositions for the con- tinuance of life. The same considerations (i.pply when the arterial GOUTINESS. 231 -pressure rises iu response to an augmented intra. cranial pressure. In order to secure that the blood shall reach the medulla in spite of the obstacle thus provided, the blood-pressure in the arteries is in- creased commensurately with the increase of pres- sure inside the cranium. Here again the manometer win show a very high reading ; but if we allow our- selves to be beguiled into reducing the arterial pres- sure by venesection or other means, we shall surely place the patient in imminent danger of his life. It is essential to remember that high blood-pressure is not a disease per se, and although in many cases — the majority, perhaps — it is very desirable that it should be reduced, there are nevertheless others in which its thoughtless reduction would certainly be attended by very serious consequences.^ But if it be true that high blood-pressure is in the minds of many ineradicably associated with renal disease, it is even more strikingly the fact that albuminuria is still regarded by many more as a condition so desperate as to require an undertaker rather than a physician. Inasmuch as this attitude creates a great deal of unnecessary alarEa and inflicts great injustices, it seems profitable to consider the question here. The most convenient method of dealing with the ' See 'The Vagaries of Blood-Pressure' (The Hospital, June 22, 1907) ; and ' Blood-Pressure and the Nervous System ' (Clinical Jou/rnal, October 2, 1907). Also article ' Blood Pressure ' in Murphy's ' Practitioner's Encyclopaedia of Medicine,' .^2 BtlNOR MALADIES. subject would seem to be briefly to review the physiological aspect of the matter, and see what light is to be obtained therefrom. We have it on the authority of Virchow, Martin, Hofmeister, and others that albuminuria is the rule with new-born babies. The amount of albumin is at first abundant, but diminishes gradually, until by the fourteenth day it has completely disappeared. Adolescents, who are apparently in good health, are subject to what is described as cyclical or postural albuminuria, a phenomenon which is now admitted on all hands to be devoid of pathological significance. Amongst adults of mature age, military men and doctors, Leube and Furbringer have described a con- siderable number of cases of this postural or cyclical albuminuria, unaccompanied and unf olio wed by any morbid tendency. Adolescents, who are undoubtedly in good health, very easily develop albuminuria as the result of fatigue. This has been conclusively shown by W. Collier, of Oxford,^ who examined young men in training for races, men who may therefore be assumed to have been in a high state of physical and physio- logical efficiency. In a very large percentage (from 67 to 100) of these young men albumin appeared in the urine a short time after hard exercise, to dis- appear again after a period of repose. According to Playfair,^ albuminuria occurs in 20 per * British Medical Journal, January 5, 1907, p. 4. ' ' Handbook of Midwifery,' 2nd edition, voL i., p. 222. GOUTINESS. 233 cent, of pregnant women after the third month, and in a much larger percentage of primiparse. Some of these cases, it is true, progress to definite renal disease, but the vast majority suffer no inconvenience from the occurrence of the symptom. Finally, there is Senator's statement to the effect that every urine will be found to contain albumin if suflBciently concentrated. The foregoing are, all of them, admittedly physio- logical conditions, the significance of which it is necessary to explain if we would realize the meaning of albuminuria as it occurs in conditions which are not physiological. Now, it is universally conceded that albuminuria may be caused by a congested state of the renal vessels, a fact with which we are all familiar in heart disease and similar conditions. Perhaps the most striking instance is afforded by the albuminuria due to injuries of the spinal cord, in which the vaso-motor nerves are paralyzed. But lesser degrees of congestion will produce the same results. Chills to the surface, for instance, as after cold bathing, especially in the sea, are known to provoke the appearance of albumin in the urine, presumably by increasing the amount of blood in the splanchnic area, and thus inducing a transient renal stasis. Let us see what bearing this has upon the physiological albuminurias just mentioned. The newly- bom infant is but partially adapted to the new conditions to which he is suddenly subjected. Most of the powers which he subsequently develops 234, MINOR MALADIES. are in a very embryonic state. More especially is this true of the co-ordinating or controlling power. He can, for instance, use muscles, but he has not learned to co-ordinate them. His sphincters act, but he is unable to control them. These powers are developed only by degrees and by training. We must, I think, assume the same to be the case in a much higher degree with the complicated mechanism of vaso-motor co-ordination and control. The blush- ing and pallor which occur involuntarily on any slight emotion, even at a very much later period, are suflScient to show that this mechanism is an exceed- ingly delicate one, which demands a considerable amount of training and adjustment before it can be considered to be in good working order. When a baby comes into the world he leaves a warm and equable climate for one which is cold and liable to considerable variations. However carefully he may be protected from such influences, they are bound to reach him, to the extent, at any rate, of causing very decided differences in the balance of blood distribution to which he has hitherto been accustomed. His skin is now, for the first time, called upon to contract, and this contraction causes the blood to seek refuge in the organs of the splanchnic area. The vessels in this area have not yet learned how to behave in the presence of such an influx, and the organs suffer a certain degree of congestion. The renal vessels are among those affected, and an albuminuria results. After a few days the splanchnic vessels leam their GOUTINESS. 235 lesson, the congestion is gradually reduced, and the albuminuria disappears. The case of the adolescent is not very different from that of the new-born baby. As the boy is being transformed into the man, and the girl into the woman, new activities are developed, which place an enormous strain upon the delicate vaso-motor mechanism, which tends, ia consequence, to fail. Failure of this mechanism is almost invariably in one direction — in that, namely, of undue vaso-dilation. The calls upon the nervous system are so consider- able and so pressing that the tone of the peripheral arteries is not adequately maintained, with the result which always ensues in such circumstances, namely, that during the erect posture the blood collects in the capacious vessels of the splanchnic area. Then ensues a congestion in the renal vessels, with consequent albuminuria. So long as the patient is recumbent the blood does not tarry unduly in the splanchnic area; there is no renal congestion and no albumin- uria. No sooner, however, is the erect posture assumed than the albumin reappears. The fact that in some of these cases the albumin diminishes or disappears towards the end of the day only signifies that by that time the vaso-motor mechanism has been provoked into a sense of its responsibilities, and has realized the necessity for contracting the splanchnic vessels in response to the change of posture. This postural or cyclical albuminuria is quite common in people who have been obliged to keep their beds for 236 MINOR MALADIES. a considerable time for some sucli cause as a fractured leg. In them the vaso-motor response atrophies from disuse, so to speak, and has to be re-educated as the erect posture is resumed. As an instance of what is liable to happen to an adolescent who exhibits the phenomenon of postural albuminuria, let me briefly relate the case of a young man, aged twenty-three years, whom I first saw some years ago. Eighteen months previously, after he had been working hard at the University for his degree, he tried to insure his life, but was refused. This naturally alarmed him, and he consulted his doctor. The latter found that his urine contained no less than 40 per cent, albumin, told him that he had Bright's disease, and ordered him to Cannes for the winter. I may say parenthetically that if the patient had really had nephritis, the Riviera, with its abrupt variations of temperature, was about as bad a place as could possibly have been selected for him. How- ever, to the Riviera he went, and returned home no better. His doctor then sent him to bed, and put him on a diet consisting only of milk. In about a week the albumin had completely disappeared, where- upon he was allowed up again. In two days the albumin had reappeared, but in reduced quantities, and he was sent back to bed. Again the albumin disappeared, to reappear as soon as he was allowed to get up. My notes do not say exactly how long this game of battledore and shuttlecock continued, but eventually the patient wearied of it. Having, in con^ GOUTINESS. yyr sultation with his friends, decided that appendicitis could be the only explanation of the mystery, he came up to town to consult a surgeon, through whose instru- mentality he eventually came to me, still, curious to relate, wearing his appendix intact. He was also wearing three or four layers of thick woollen under- garments, his skin was relaxed and sodden, his blood- pressure was 85 mm. Hg, his urine scanty and loaded with albumin. The most careful examination failed, however, to reveal any evidence of organic disease, so, when I had satisfied myself as to the absence of albumin after a few days in bed, and the absence of granular casts at all times, I instructed him how to clothe himself. I sent him to Margate with some strychnine and calcium chloride, and told him to pull himself together and live hard. Being anxious to get well, he did as he was told, and is now working hard, taking plenty of exercise and feeling perfectly well. He has learned how to test for albumin, and he tells me that, except after a dance or a hard set at tennis, his urine is now quite free from it. The albuminuria of young athletes described by Collier, and previously by Dunhill ^ of Melbourne, is not quite so easy of explanation as the foregoing. It is nevertheless safe to assert that it is purely vaso- motor in origin. The train of events is probably somewhat as follows : We know that during muscular exercise the general blood-pressure is raised. The heart increases the number of its systoles, the vessels ' Jniercolonial Medical Journal of Auitralasia, July 2Q- 1902. 238 MINOR MALADIES. in the splanchnic area are contracted, while those which supply the muscles actually in use are dilated. After the exercise is over there is a reaction, which varies in degree directly with the magnitude and duration of the effort. After severe and prolonged exertion, therefore, the splanchnics dilate, and the muscular vessels tend to contract. If this contraction is hastened, as it generally is in young men at Uni- versities and public schools, and as it was in all Dunhill's ^ cases, by a cold shower or plunge, the blood is driven inwards with such rapidity that a renal congestion is produced, and albuminuria results. It is probable, howeverj that, apart, altogether from the cold shower, the reaction from the conditions which necessarily obtain during active exercise are sufficient to induce a renal stasis, more especially in young men in whom we have seen the vaso-motor response to be but partially educated. It seems, however, that this may not be the whole explanation, for not only is the composition of the blood materially altered by vigorous exertion, in that the waste products are largely augmented, but the sudden and considerable elevation of blood-pressure entailed by such exertion is of itself sufficient to provoke a transient albuminuria. The presence of albumin in the urine of pregnant women after the third month is obviously mechanical. The enlarging uterus, even if it does not exercise direct pressure upon the renal veins, materially alters ' British Medical Journal, April 27, 1907, p. 1081. GOUTINESS. 23; ■ tlie distribution of pressure in the splanchnic area, and if the normal compensatory mechanism is not in good working order, a stasis with consequent albu- minuria is not difficult to imagine. It is a significant fact that such an albuminuria is more common in primiparse. We have, then, in albuminuria a symptom which may occur, and constantly does occur, in conditions which are purely physiological. We know, further, that it occurs in states which, though pathological in various degrees, are nevertheless not such as even to suggest that the kidneys are at fault. I have already mentioned cardiac disease and spinal injuries, but these by no means exhaust the conditions in which albumin is frequently, if not constantly, found in the urine. In pronounced myxoedema it is a classical and well-known finding, and it is also well known that the albumin rapidly disappears under thyroid treatment. It is by no means uncommon in minor degrees of thyroid insufficiency. In certain conditions, which are wrongly labelled obesity, which are nearly related to myxoedema, though quite distinct there- from, as shown by the fact that thyroid extract has no beneficial influence upon them, albumin is often present in the urine in very large quantities, and disappears rapidly under suitable treatment. Albu- minuria is very commonly present in chlorosis, in Graves' disease, in tonsillitis, even other than diph- theritic ; in some forms of dyspepsia, and in almost all cases of hepatic congestion; in migraine, in epilepsy, 240 MINOR MALADIES. during the gouty paroxysm and in most toxic pyrexias. Among pulmonary conditions it is found as an early sign of tubercle. It is common in asthma, and by no means uncommon in the bronchitis of emphysematous patients. Moreover, a very large number of drugs wiU give rise to it ; cubebs, copaiba, turpentine, mercury, morphia, quinine, arsenic, and phosphorus, are among the most important, but they by no means complete the list. Passing abnormalities anywhere in the urinary passages may provoke the symptom. An excess of oxalates in the urine will produce it ; so will the irritation of small calculi or sand. A slight cystitis is by no means an uncommon cause, and an exceedingly common one is the presence of spermatozoa in the urethra. Altered blood states, aa in the essential anaemias, almost always provoke albuminuria. Women, at or about the menopause, very frequently have an appreciable quantity of albumin in the urine, especially if this be examined at the time when an expected period has failed to appear. The combination of this with a certain rise of blood-pressure, which is very common at the climacteric, has frequently given rise to serious and alarming mistakes in diagnosis. It seems scarcely credible that a symptom which is common to so many diverse conditions, both physio- logical and pathological, should have succeeded for so long in masquerading as necessarily connoting renal disease. And yet it is within the experience of all of us that people have been, and, alas ! still are, refused t-^> GOUTlMiSS. i241 for life assurance and otherwise condemned as damaged individuals merely because, from some of the above-mentioned causes, a little albumin has been found in their urine. It would be just as logical — it would, indeed, be more reasonable — if dyspnoea were regarded as necessarily indicating pulmonary or cardiac disease. Dyspnoea is in many cases very significant of such disease, but inasmuch as we have all of us become very breathless hundreds of times in the course of our lives without any untoward effects, we have acquired some sense of perspective in the matter. It would be a good thing if the presence of albumin in the urine could be manifested by some sign equally gross and obtrusive. We should then come to realize how frequent an occurrence it is, and how seldom it indicates anything more serious than a passing change of pressure in the bloodvessels of the splanchnic area. Albuminuria, like dyspnoea, may be the expression of very grave and fatal diseases, but, like dyspnoea, it may also indicate nothing more serious than a considerable, though perfectly harmless, alteration in the distribu- tion of blood-pressure. We all make it a rule to gauge the significance of dyspnoea by the causes which provoke it. No one would dream of shaking his head and crying 'heart disease' because a man was breathless after a mile race; but it cannot be said that no one could be found to shake his head and cry ' renal disease ' because the same man pro- duced albuminous urine after the same ordeal. 16 242 MINOR MALADIES. Very often, of course, the meaning of an albumin- uria is suflBciently obvious. It is seldom, indeed, that we find ourselves in doubt about acute nephritis, or chronic tubal nephritis, or amyloid disease. In these cases and in gross tuberculous renal lesions, the coexisting symptoms are almost invariably such as to point unmistakably to the true source of the albumin. The cases which give rise to perplexity are those in which the albumin constitutes the only, or almost the only, symptom. In such cases one has no right to express anxiety, much less to pronounce a sentence of incurable disease, unless in addition to albumin the urine also contains definite evidence of structural disturbance in the kidneys. This ought to be an absolute rule which permits of no exceptions. Such evidence is afforded by the presence of epi- thelium, of blood, of tube casts, more especially of the granular or fatty variety. Hyaline casts, although they are suspicious, have not the same significance, for not only may they be found in small numbers in almost any urine if sought for with suiScient diligence, but they are often present in large numbers in nervous and febrile conditions which have no renal connection. It must be admitted, no doubt, that a specific gravity of less than 1015 is a suspicious factor, but inasmuch as nervous people very often have urine of low specific gravity, it affords no excuse for any relaxation of the above rule. CHAPTER VI. MINOR GLANDULAR INSUFFICIENCIES. Although it is my intention to devote this chapter mainly to the consideration of thjnroid insufficiency, it is well for the reader to understand that the interdependence of the endocrine glands renders it very difficult in the present state of our knowledge to be sure which particular gland is at fault. It is exceedingly likely that some of what we now take to be manifestations of th3T:oid insufficiency of slight degree, are in reality due to insufficiency of some other gland, partly opponent and partly comple- mental, such as the pituitary or the adrenal, which may be stimulated into increased activity by the exhibition of thyroid extract. If we consider the symptoms which in the various monographs are confidently attributed to the failure of the particular gland in question, say the thyroid, the pituitary, or the adrenal, we cannot fail to be struck not only by the resemblance between many of these symptoms, but with their practical identity. With substates of the thyroid, for example, we are accustomed to associate adiposity, infantilism, sub- 243 ^ii MINOR MALADIES. normal tsmperatures and subjective frilosity, a slow pulse, somnolence and mental hebetude, togethei with hairlessness and dermic pigmentation. In substates of the pituitary we find that aU these conditions are not only present, but are regarded as characteristic — if not pathognomonic. In the case of adrenal insufficiency, some of them, notably the infantilism, the low temperature, the hairlessness and pigmentation are prominent symptoms. It is therefore evident that when one member of the endocrine hierarchy is at fault, the mere disturbance of the glandular balance is sufficient to produce certain symptoms of which one can only affirm that they point to a disturbance somewhere in the endocrine system — the pluriglandular syndrome, as it is called. There are some indications, though, so far, they are not many, which enable us to say which gland is probably the primary offender. It is these w hich I now propose briefly to consider. Confusion is most likely to arise between insuffi- ciency of the thyroid and pituitary insufficiency. Adrenal inadequacy, though it may in its very early stages present some features which might lead to a mistaken diagnosis, is nevertheless as a rule suffi- ciently distinctive in its evolution. Here there is never adiposity ; the change in bulk, if any, is always in the direction of emaciation. Moreover, however much the general symptoms, such as asthenia, frilosity, and depression, may suggest thyroid or j^^^ifTiitary insufficiency, the urgency of the gastro- Minor glandular insufficiencies. 245 intestinal symptoms should prevent any mistake. These are anorexia, diarrhoea, and vomiting of a nature progressive and intractable, which are usually accompanied by pain and tachycardia. The diagnosis of adrenal insufficiency has been much assisted by Dr. Emile Sergent of Paris, who described the phenomenon of the ' white adrenal line.' This is his description: ' To bring about this phenomenon the skin of the abdomen is selected by preference and on it is traced a geometrical figure — a rectangle, triangle, or cross — thus obviating any possible confusion with lines possibly caused by scars, folds of the skin, etc. Ordinarily I outline a square around the umbilicus with a blunt object, as the rounded end of a fountain pen, or, simply, the finger tip, taking special care to avoid rubbing, particularly with the nail. The figure should be made by a simple superficial stroking — one must neither bear down nor scratch. The motion should be deliberate and never rapid. The early or premature appearance of an outline is always a sign of clumsiness, as such treatment strikes and surprises the vasomotors, thus inter- fering with the reaction instead of causing it. I am in the habit of telling my students that such a procedure is likely to be a source of error. When the tracing has been made properly, aU movement on the part of the patient is prohibited and one waits a short time. Immediately following the out- lining nothing is seen, provided the proper technique 246 MINOR MALADIES. has been followed; but after a few seconds, about half a minute, a pale line or band begins to be noticed foUoAving the course of the finger (or pen). Gradu- ally this becomes more and more distinct and white, at the same time becoming larger, so that eventually the line exceeds in size the actual area touched by the finger tip.' It is necessary to draw a distinction between adrenal insufficiency and Addison's disease. The tribute of the suprarenal glands to the blood-stream may become deficient from various causes. Addison's disease, which is due to tuberculosis of the glands — a tuberculosis which is always primary to those glands — is only one of the causes. Its original descrip- tion was so vivid and the complete clinical picture which it presents is so striking, that it has tended to obscure the minor manifestations of the glandular difficulties; much as myxoedema in its complete form so long obscured the lesser degrees of thyroid insufficiency. Perhaps the most striking objective signs of adi'enal insufficiency are to be found in the vascular system. The tone of the bloodvessels is below par, as evidenced not only by the manometer, but also by the instabihty of the pulse and the absence of reserve power in the heart itself. This, when accompanied by a subnormal temperature, as is usually the case, and somnolence with an over- readiness to fatigue, physical and mental, may easily give rise to a suspicion that the thjroid or pituitary is at fault, but, as I have already said, the MINOR GLANDULAR INSUFFICIENCIES. 247 emaciation which is characteristic of suprarenal insufficiencies ia not often seen in these others, and the gastro-intestinal troubles seldom or never. Diffi- culties may nevertheless arise when, as frequently happens, especially after acute specifics, two or more of the endocrine glands are simultaneously exhausted. The resemblance between the phenomena of thyroid insufficiency and those of pituitary insuffi- ciency is so close as often to require great care in arriving at a decision as to which of these two glands is really at fault. And here again it is necessary to remember that there is nothing to prevent a depres- sion of activity in both of them simultaneously. Both are charged with the neutralization of toxins, endogenous and exogenous; both are essential to bodily growth and mental development; both are intimately concerned with the function of reproduc- tion. The two are said by some to antagonize each other, and there is very definite evidence that in certain conditions the one wiU, so to speak, replace the other — or endeavour to do so. It is therefore not surprising that confusion should often arise as to which is the chief offender when symptoms point in the direction of either. It is of course true that no one with any experience is likely to mistake myx- oedema for Hutchinson's syndrome,^ but it is all too 1 I.e., dystrophia adiposo-genitalis, commonly called Froelich's syndrome. The condition was, however, first described by Jonathan Hutchinson in the Archives of Surgery, under the name of 'lipomatosis univMsalis asexualis,' and it ought in common justice to bear his name, if anyone's. ^iiS MINOR MALADIES. easy to be led into error in cases which fall short of their complete evolution towards these distinctive clinical pictures. I have already said that in both there is adiposity, subnormal temperature and subjective frilosity, a slow pulse, mental hebetude, together with hairless- ness and dermic pigmentation. Such is the rule. It is by no means the rule, but it may occur in either, that adenoids and nocturnal enuresis appear in children and that transient swellings, psychic dis- turbances, and menstrual vagaries appear in adults. But if you will look beyond these resemblances you wiU find differences which are illuminating. To begin with, the adiposity in the two cases is different in type and distribution. In pituitary insufficiency it is, to use Hutchinson's expression, universal; whereas in the case of the thyroid it favours certain well defined regions. Moreover, in certain cases even of complete thyroidlessness, the patient shows no appreciable adiposity, a state of matters which I have never seen associated with any pronounced degree of pituitary depression. The condition of the skin affords a striking contrast in the two cases. Where the thyroid is at fault, in degrees varying with the severity of the case, the skin is harsh, dry, and coarse, proceeding occasion- ally to the length of definite ichthyosis. Its minor manifestations favour certain regions, notably the the hands and the skin over the triceps. When the pituitary is the primary offender the skin is never MINOR GLANDULAR INSUFFICIENCIES. 249 coarse. It may be dry; it often is, but it is always fine, and in many cases it seems almost atrophic. The difference in the two cases extends to the nails, which in the case of the thyroid are coarse and brittle; in the case of the pituitary they are small and thin, and are often unprovided with crescents at the roots. It is much the same with the hair. On the head, subth3Toidic hair is ill-notu-ished and tends to faU; it may be dry or greasy, but the indivi- dual hairs are of good calibre. Subhypophyseal hair is always fine, almost baby-like in texture, and shows no great tendency to faU out. Investigation of the eyes may afford valuable information. In the lids themselves there is often a sufficient deposit of ' mucoid ' tissue to give a heavy- eyed appearance to the subthyroidic; and in extreme cases both upper and lower lids may be so suggestive of the cedema of renal disease, as to deceive aU but the most experienced. I have never met with anything of this kind in hjrpopituitarism. In this condition the ocular troubles, if any, are visual, and are due presumably to some circulatory disturbance in the neighbourhood of the pituitary itself. Hypopitui- tarism is often accompanied by an enlargement of the gland, just as hypothyroidism is frequently accom- panied by a goitre. Hertoghe has described one case, and I have seen another, in which amblyopia was present in fully developed myxcedema; in both mstances it cleared up under treatment by thyroid extract. Suoh a oompUoation is, however, so rare 250 MINOR MALADIES. that it is safe to regard visual disturbance as a sign rather of pituitary deficiency than of thyroidal. The enlargement of the gland which occurs in simple hypopituitarism is almost certainly the cause of the persistent headache, presenting exacerbations of extreme violence, which is a characteristic feature of the complaint . A very slight degree of enlargement is sufficient to cause pain within the closely packed cranium. The headache of hypothyroidism is a dull ache which is seldom insisted upon; but the headache of hypopituitarism is not infrequently the symptom whose urgency drives the patient to seek advice. In any case, it is one which is always put in the forefront of the indictment. Pituitary extract relieves it with astonishing rapidity. The effect of aspirin, pyxamidon, and their congeners is often good, but always transient. In thyroid deficiency the teeth usually show evidences of the disturbance of calcium metabolism. They decay rapidly in children, and in adults they tend to fall out. The calcium function of the pitui- tary is believed to be opposed to that of the thyroid. The latter is said to fix these salts in the body, the former to discharge them. We should therefore expect a deficiency of pituitary essence in the blood to lead to a retention of calcium salts. There are a great many facts which go to support this view, by no means the least striking among which is the excellent state of the teeth in most cases of hypo- pituitarism. This is a feature which has before now MINOR GLANDULAR INSUFFICIENCIES. 251 guided me to a correct diagnosis when the other signs were ambiguous. Although mental hebetude is a frequent accom- paniment of pituitary insufficiency, it is very far from being characteristic. I would indeed go so far as to say that a bright intelligence is a conspicuous feature of uncomplicated pituitary insufficiency. It is usually a concomitant thyi'oidal defect which causes the hebetude. Before leaving the subject of the pituitary, whicli I now propose to do, in order to concentrate attention upon the better understood thyroid, there is one matter upon which I desire to lay special stress. It is well recognised that the hypodermic administra- tion of pituitary extract raises the blood-pressure. Great care is therefore necessary in applying this form of medication to those in whom the arterial tension is already too high. That is a precaution upon which it is quite right to insist. It should, however, be distinctly understood that this pre- caution is quite unnecessary when the extract is given by the mouth. When introduced by the oral route the powerful pressor substance is not absorbed; it is presumably destroyed in the stomach. I have now on several occasions made very careful observa- tions on this point, as the result of which I can quite confidently affirm that pituitary extract administered by the mouth even in very large doses, has no appre- ciable effect upon the blood-pressure. This is an extremely important fact, which if it were genera ly 252 MINOR MALADIES. recognised would remove the timidity which now prevails about the exhibition of the drug to patients who are clearly in need of it. Pituitary feeding is said to produce no toxic effects. Although, in a general way, I am disposed to agree with this, it has more than once occurred to me, owing to the absence of any other explanation, to saddle the treatment with the responsibihty for occasional acute though transient rises of tempera- ture which have occurred during its course. The only harm which these febrile movements appeared to do, was to occasion very considerable alarm to those in charge of the case. Gushing points out that one of the characteristics of hypopituitarism being an abnormally high sugar tolerance, a fair gauge for the dose of pituitary extract required by a particular case is the degree to which this tolerance is reduced by the treatment. My experience has been that the necessary sugar tests are so much disliked by patients that I never now suggest them. Minor degrees of thjnroid insufficiency are at first very difficult of recognition. The observer's eye must be educated and his senses kept on the alert . In order to enable him to do this his attention must be called to the importance which may underlie the apparently trivial. It is this which I now propose to attempt. That the thyroid secretion is essential to the development of the foetus is shown by several facts. Myxcedematous women seldom become pregnant. MINOR GLANDULAR INSUFFICIENCIES. 253 and when they do, in the absence of thyroid medica- tion they invariably abort. It is normal for women during pregnancy to develop an enlargement of the thyroid gland, which subsides to some extent after the child is born, but is continued during lactation. By no means the least important function of the thyroid gland is that of fixing the calcium salts in the body. In order to permit of bone formation in the foetus the mother is obliged to provide more secretion than under normal circumstances she requires, and the gland consequently hypertrophies. After the birth of the child, the same degree of this increment being no longer necessary, the gland tends to resume its normal proportions. In some women this prolonged call of pregnancy has the effect of unduly exhausting the gland, and they are unable in consequence to suckle the child, for lactation is dependent upon a due supply of thyroid secretion.^ Such women generally become obese and lethargic, and remain so for varying periods until the thyroid has had time to recover itself. Judicious thyroid medication will frequently not only enable a mother to suckle her infant, but wiU materially shorten the period of her post-partum difficulties. But to retmrn to the child. Unsatisfactory babies are almost invariably the subjects of thyroid deficiency. Other dyscrasise may of course act as 1 Hertoghe, ' Nouvelles Reoherohes sur les insuflisances thyroidiennes,' BuUetin de rAoad^mie Royale de M^deoine de Belgique, vi. serie, tome xri. No. 4 25i MINOR MALADIES. contributory causes, more especially the syphilitic and the tuberculous; but even of these it may be said that some, at any rate, of their effects are due to their, depressing action on the thyroid. It has more than once occurred to me to succeed in trans- forming an unsatisfactory child into a satisfactory one by a combination of grey powder and thyroid extract, after having tried both separately with very partial success. When we pass from the region of general unsatis- factoriness to demonstrable clinical entities, we are, at this period of hfe, immediately brought face to face with rickets. Now, with regard to rickets, I feel in a position positively to affirm that if all the symptoms of the disease are not due to thyroid insufficiency, then certainly its most salient features are. Especially does this apply to the bony phenomena which are the most obvious signs of the disease. These phenomena are obviously due to inadequate osseous development, and, as in the foetus, so in the growing infant, thyroid secretion is essential to the full utihzation of the calcium salts. It is known that the bony phenomena are due to a relative absence of calcium salts, and it is also known that these salts, given in large excess though they be, have no influence in arresting the disease. This is because the all-essential link is missing, the thyroid secretion, by whose means alone the ingested calcium can be so assimilated as to be incorporated in the osseous tissues. No originality is claimed for this MINOR GLANDULAR INSUFFICIENCIES. 255 view as to the essential factor in rickets. It was first advanced by Professor Marfan in 1907,^ and upheld in an interesting paper which does not appear to have attracted the attention which it deserves. My own experiences have convinced me that the view is correct. If it be true anywhere, as the adage has it, that naturam morborum curationes ostendunt, it is pre-eminently true in the sphere of opotherapy ; and every case of rickets in which I have employed thyroid extract has shown such decided improve- ment as to leave no doubt in my mind that thyroid insufficiency is the main causative factor in the disease. As a child progresses in years, deficiency in thyroid secretion may reveal itself in various ways. One of the most dramatic and alarming is the production of night terrors. I do not pretend to be able to explain the association between these unpleasant ebullitions and a deficiency of thyroid essence in the circulation, but I can most positively affirm that they rapidly disappear under the influence of thjrroid extract. I have already shown that nocturnal enuresis,^ though it may own other causes, such as phimosis or intestinal worms, is in the vast majority of cases caused by thjnroid inadequacy and is readily curable by the administration of thjnroid extract. In the 1 ' Le Raohitisme dans ses rapports avec la deformation ogivale de la voute palatine,' etc., La Semaim Bledicale, September 18, 1907. 2 ' Adenoids, Nocturnal Enuresis, and the Thyroid Gland ' (Bale, Sons and Danielsson, Ltd., 1909). 866 MINOR MALADIES. same connection I discussed the question of adenoids, and made so bold as to suggest, concerning them, that they constituted one of the stigmata of thyroid insufficiency. The views expressed may be briefly summarized as follows: Adenoids and enlarged tonsils occur in children who have an inadequate supply of thyroid secretion. The hypertrophic condition in each case is apparently the result of an endeavour on the part of the organism to supply an internal secretion as nearly aUied as possible to the one which is lacking. If the hypertrophy is not very pronounced, and if it has been not very long in existence, great enough and protracted enough, that is, to produce complications, such as disease in the tonsils themselves or in the ears, then the exhibition of thjToid extract will cause their regression. It is only when medicinal means have failed that operative interference becomes justifiable. Enlarged lymphatic glands, so often observed in the necks of weakly children, are not infrequently due to thyroid inadequacy. Whatever their position and accompaniments, they are usually quite confi- dently attributed to tubercle, and are treated as such with more or less indifferent success. Arthur Latham has recently pointed out that even where their origin is undoubtedly tuberculous, there is no justification for removing them until other means have failed. But these glandular enlargements are less often due to tubercle than is commonly supposed. I have seen a good many children thus afflicted to whom I MINOR GLANDULAR INSUFFICIENCIES. 257 was emboldened to administer thjToid extract by the presence of some unmistakable coexisting sign of tli3rroid insufficiency. The enlarged glands in these cases have always been situated at the angle of the jaw; they have been hard and not tender, and have shown no tendency to suppurate. In this matter it is necessary to be quite sure of our ground before administering thyroid extract, because if the case be really tubercular the extract, instead of doing good, may very easily do harm. For some reason, which is so far unexplained, the majority of tuberculous people bear thyroid badly. In connec- tion with this matter of enlarged lymphatic glands, it is interesting to not© that Dr. John Orr, of Edin- burgh, has had good results with thyroid extract in Hodgkin's disease.-^ In tracing up to this point in its development the difficulties which may beset a child with an inade- quate thyroid gland, it has not been necessary to draw any distinction between the sexes. They appear to be equally affected. When we reach the age of puberty, however, we find that the boys have practically disappeared. There are, it is true, some few cases of delayed puberty — infantilism — most of which yield readUy to thyroid extract, and there are also the cases of adolescent albuminuria which also yield readily to the same treatment; they are clearly a matter of calcium metabolism; but in the vast majority of boys and young men the changes which 1 Folia Thtrapeutica, July, 1909. 17 858 MINOR MALADIES. ooour at this period appear to eroke such an activity of the thyroid gland as to protect them during the immediately ensuing decade from any eridences of thyroid inadequacy, always excepting those bony deformities which a previous insufficiency has stamped upon them. In the case of girls it is far otherwise. With them, it is precisely at the age of puberty that the worst of their troubles begin. But before separating the sexes I must make a generaliza- tion which refers equally to both. I stated at the outset that the prolonged call which pregnancy makes upon the thyroid gland frequently resulted in its exhaustion. The same thing must be said of the infectious diseases generally, more especially of those which are called the infantile diseases — mimips, measles, German measles, and scarlatina. It is evident that the internal secretion of the thyroid constitutes one of the defences of the organism against microbio invasion, for not only are sub- thyroidio children more liable to such invasion, but the occurrence of one of these diseases in a previously healthy child very often proves the starting-point of troubles due to thyroid inadequacy. The resistance to the effects of the poison makes a heavy demand upon the activity of the gland, and when the demand is over the gland becomes exhausted and its function depressed. A very large percentage of cases of rickets, adenoids, and nocturnal enuresis will be found on inquiry to date from one of the infantile fpbrUe diseases. In connection with this aspect of MINOR GLANDULAR INSUFFICIENCIES. 259 the matter it is convenient to call attention to the very depressing effect which real influenza at all ages is liable to exercise upon the functions of the thyroid. I say real influenza in contradistinction to the transitory febrile attacks which are diplomatically so labelled to satisfy importunate relatives who thirst after a label. Real influenza, as is weU known, produces a degree of subsequent mental and physical asthenia which defies the ordinary tonics and remains obdiu:ate to everything except time. Such, at any rate, was my experience until, on the theory of thyroid exhaustion, I began treating these cases with thjToid extract. The results of this treatment have always been gratifying, and I have no hesitation in affirming that if we were to realize more fully the exhausting effects upon the thyroid, and indeed of the endocrine system generally, of all acute specifics, we should be much more successful in dealing with the period of convalescence, which, to some natures, is even more trying than the disease itself. This defensive power of the thyroid secretion is one which deserves to be emphasized. When it has attracted the general attention which it certainly merits, we may look for good results from the exhibition of thyroid extract during the course of all acute specific diseases. It should be remembered that, if it be sought for, an enlargement with tender- ness of the thyroid wiU be found to be present in a large number of febrile diseases, notably in acute 260 MINOR MALADffiS. rheumatism. The headache which is so often present in such cases may reasonably be attributed to the pituitary, and the asthenia to the supra- renals. Let us now return to our chronological order, and proceed to consider the troubles imposed by thyroid inadequacy as the years advance. We had arrived at the age of puberty, at and after which boys may be dismissed as affording an interest which is but occasional and fortuitous. Of girls it is a truism to say that the establishment of the menstrual function constitutes a crisis no less critical than that which occurs at the menopause; but it is insufficiently realized that at both periods the pivot round which the critical phenomena revolve is the behaviour of the thyroid gland. That there is a certain physio- logical antagonism between the internal secretion of the ovary and that of the thyroid is well established,^ and the observed facts go far to prove that the activity of the ovary normally provokes a corre- sponding activity on the part of the thyroid. The clinical evidence of this is provided by the enlarge- ment of the thyroid, which is to be observed in the majority of women at each menstrual period. It is obAdous then that, given a girl with a congenitaUy inadequate thyroid, the advent of menstruation wiU serve to emphasize that inadequacy, and thus bring into view various symptoms which up to that time 1 ' Cardiopathies of the Menopause,' Clinical Journal, Maioh 3, 1909. MINOR GLANDULAR INSUFFICIENCIES. 261 had lain dormant. One of my cases of nocturnal enm-esis^ was certainly due to tliis cause. Without going much more fully into the matter than my present purpose permits, it would be impossible to offer an explanation of a clinical fact, of which any- one may easily convince himself — namely, that both dysmenorrhoea and menorrhagia are more frequently than not due to an insufficiency of thyroid secretion. Persistent amenorrhoea, whether it be congenital or acquired, is almost always due to hypopituitarism, and can generally be cured by pituitary feeding. ^ That simple enlargements of the thyroid are due to an insufficiency of the internal secretion of the gland is now generally admitted.^ That migrainous attacks, more especially such as affect by preference the menstrual period, are due to the same underlying cause, is a proposition which originated with Leopold Levi and H. de Rothschild,* and has been supported by numerous subsequent observations by these authors, and by others. Of dysmenorrhoea and menorrhagia enough has already been said. To this list of the disabilities which an inadequate thyroid may impose upon the female sex I would add one more — namely, sterility. Prom the fact that the thyroid enlarges during pregnancy, it may be taken 1 'Adenoids, Nocturnal Enuresis, and the Thyroid Gland,' p. 27. 2 ' The Bjrways of Thyroid Inadequacy,' American Medicine, April, 1914. 3 ' Organotherapy,' by H. Batty Shaw (Cassell and Co.), * Hertoghe, op. eti. 262 MINOR MALADIES. as certain that the maternal economy requires an additional amount of the internal secretion during that period, and it is evident that if this additional quantity be not forthcoming, the pregnancy will be brought to an abrupt termination. In the case of women whose thyroid activities are markedly in- adequate, this unhappy result wiU occur as soon as the first strain is put upon the gland — that is, when the next menstrual period is due. Many women who are labelled as hopelessly sterile are so only because of the general failure to recognise the para- mount importance of the thyroid gland in the func- tion of reproduction. I have known at least one case in which the repeated abortions were confidently attributed to syphilis, in which, nevertheless, the administration of thyroid extract brought a preg- nancy to a most satisfactory conclusion. Where thyroid feeding alone is ineffectual, it is well to associate it with pituitary feeding. The addition of suprarenal feeding may even be necessary. So fascinating and, in a sense, so facile is the diagnosis of thyroid insufficiency that it threatens soon to supplant gout in the position so long held by the latter as the last resort of the perplexed prac- titioner. When you have been fortunate enough to produce strikingly good results by prescribing thyroid extract, you are tempted to attribute a great many ills to thyroid insufficiency which have no necessary oormection therewith. To this mental attitude must be attributed the tendency of the moment, whioh is most appar«nt in France, towards blaming the inadequate thyroid for many mutually exclusive diseases. From the already formidable Mst of maladies for which the responsibility has been cast upon the thyroid, two seem to deserve more than a passing notice; one of these is rheumatoid arthritis, the other is chorea. Now, neither rheuma- toid arthritis nor chorea is, to coin an expression, a self-contained disease; each of them represents a group of symptoms which may be produced by several different causes. In both, thyroid inade- quacy may occasionally play a leading part, but either may occur in patients who do not show, nor ever have shown, the slightest sign of insufficient action of the gland. It has faUen to my lot to produce very brilliant results with thyroid medica- tion in both these conditions, but in the majority of the cases so treated the results have been negative. In these diseases and many others it is to be pre- sumed that an insufficiency of thyroid secretion provides a soil which is favourable to the unhindered action of the toxins, and that consequently the rectifying of the inadequacy wiU do much to protect the individual against invasion, though it can seldom ameliorate matters quickly enough and profoundly enough to influence the results of an invasion which has already succeeded. Chorea is often very favour- ably influenced by thyroid extract, but only in those who are definitely subthyroidic. In those who present none of the ordinary stigmata of thyroid 264 MINOR MALADliSS. inadequacy, the extract does not succeed. Rheu- matoid arthritis may be due to many causes, of which pyorrhoea, tubercle, and thyroid or other internal glandular inadequacy are only some. The commonest and the most potent is a toxaemia of intestinal origin. If the stigmata of thyroid insuffi- ency are apparent in any individual case, thyroid extract wiU probably give good results, but even then only when combined with other accredited measures, directed to the removal of the causative toxaemia. Women who have been perfectly healthy all their lives very often display a marked tendency to thyroid insufficiency about the time of the menopause. It is not only the reproductive organs proper which resign their functions at this period. A great many glands which are, in a manner which is still obscure, related to these organs, tend to become concomi- tantly deranged, and chief among them is the thyroid gland. The changes incidental to the menopause often begin much earlier than is commonly supposed to be the case. In this country we are taught to expect them about fifty years of age. In France the recognised age is forty. But the age varies not only with race and climate, but also with the individual, and it is far from unusual to find both spinsters and those married women who have begun chUdbearing at a comparatively early age, exhibiting very distinct evidences of the approaching climacteric as early as thirty-five years. Of such evidences a great many MINOR GLANDULAR INSUFFICIENCIES. 265 will be found to be very closely related to thyroid inadequacy, and a very considerable improvement, both subjective and objective, may usually be brought about by judicious thyroid medication. True myxoedema in my experience more often owns the climacteric as its cause than any other factor or combination of factors. For reasons less obvious and in a manner less dramatic than the menopause, the conditions sur- rounding the mere advance of years tend to produce inadequacy of the thyroid function. It is not that the thyroid gland declines more rapidly than the other internal secretory glands, for aU of them, even including the spleen, tend to diminish both in size and activity as the years advance. It is that the thyroid gland is so important to the economy that any diminution in its activities reflects itself un- mistakably in a great many directions. So much is this the case that one foreign writer contends that if the activities of the thyroid could be maintained unimpaired the condition of old age could never arise. It is not necessary to subscribe to such an extreme view in order to appreciate the value of suitable doses of thyroid extract in most of the troubles which are hable to beset the senile period. There are very few of these troubles whose treatment by the recognised means is not rendered more rapidly successftil by the addition of thyroid extract. I now pass to the consideration of some of the signs and symptoms from which we obtain confirma- 266 MINOR MALADIES. tory evidence when the existence of thyroid in- adequacy is in question. Some of these I hare already noticed in considerable detail,^ and I need not therefore do more than enumerate them. Among the most important is the subnormal temperature, which is usually a marked feature, and is not only revealed by the thermometer but is also complained of by the patient, who protests that she never feels warm. The eyebrow sign {signe de sourcil), &st described by Hertoghe, consists in a rarefaction, amounting sometimes to complete absence, of the hair on the outer two-thirds of the eyebrow. This sign, when present, is certainly very suggestive, but in my own experience very perfect eyebrows are compatible with a marked degree of thyroid inadequacy, more especially when this has been provoked, as by an acute specific, after the patient has attained to maturity. Carious and irregular teeth should always excite suspicion. So, likewise, should delay in the eruption of the permanent teeth. The most important among the signs which reveal a persistent deficiency of thyroid secretion are those which refer to the skin and its appendages. Amongst these, that which is most easily observed is the eye- brow sign just described. Premature greyness is generally, though not always, a sign of thyroid in- adequacy. The same may be said of premature baldness of a pronounced kind. Both these degenera- tions are so common in comparatively young people * ' Adenoids, Nocturnal Enuresis, and the Thyroid Gland.' MINOR GLANDULAR INSUFFICIENCIES. 9,91 In this country that little diagnostic value is attached to them. They are nevertheless, both of them, very suggestive, and should always excite a suspicion either that the thyroid is not acting properly or that its functions have been gravely depressed in the past. Abnormalities of cutaneous pigmentation are exceedingly common in all disturbances of the tky- roid, whether such disturbances take the form of excess or perversion, as In Graves' disease, or of inadequacy, as manifested by my^cedema, rheuma- toid arthritis, rickets, or climacteric disorders. The abnormalities in pigmentation which accompany such disturbances are not, as a rule, very obtrusive, nor, when present, must they be regarded as pathog- nomonic; but they afford valuable evidence in favour of suspicions otherwise aroused. Of these abnormalities, leucodermia is by far the most common. Amongst the grosser forms of skin lesion, that which is most frequently encountered in thyroid inadequacy affecting adults is certainly psoriasis, but eczema is almost equally common. Radeliffe Crocker^ found thyroid extract exceedingly useful both in lupus vulgaris and ichthyosis. Urticaria, and transitory cedemas affecting the deeper struc- tures, are concomitants of thyroid insufficiency to which Levi and de Rothschild attach very consider- able importance. In cases of what we may call submyxcedema in adults, there is usually a slight deposit of myxoedematous tissue under the skin, * ' Diseases of the Skin,' by Eadcliffe Crocker, 1903. 268 MINOR MALADIES. and this is more noticeable in certain parts of the body. In such cases it will be found that although the skin of the hand and forearm can be pinched up with ease, that which overlies the deltoid and the upper part of the trapezius cannot be so pinched up. In women, the area immediately below the breasts often presents the same phenomenon. This condi- tion has been called ' panniculitis,' an unfortunate name, though less unfortunate perhaps than the French ' celluhte.' The so-called obesity of the subthyroidio is not a true obesity. True obesity is a caricature of the normal outline; hypothjToidic obesity is a carica- ture of true obesity. The deposit of tissue favours certain regions. Not infrequently there is a decided hump over the seventh cervical vertebra, so pro- nounced as to give to a patient who is reaUy upright the appearance of stooping. This hump occasionally attains to the size of a closed fist. Its consistence is bard, giving a sensation to the fingers which is quite unlike that of ordinary fatty tissue. The region over the deltoids is often covered with the same material, and that over the triceps almost invariably. In some cases the breasts themselves remain relatively small, though even then they are apt to be hard; but the region immediately below them is generally covered by rolls of tissue which may easily be taken for true fat. In both men and women the walls of the abdomen are furnished with the same material, but in women the most noticeable deposit takes place in the gluteal region. MINOR GLANDULAR INSUFFICIENCIES. 269 Subthyroidio people, like the fuUy myxcedema^ tons, though voluble about irrelevant matters, often seem curiously reticent about themselves. Their brains move slowly and they are very forgetful. It is therefore necessary to interrogate them very closely on questions which are purely subjective. That they are unduly sensitive to cold, that they have considerable difficulty in concentrating the attention, that their memories are unreliable, especially in small matters, that they are very somnolent, especially at certain times of the day, are all facts which must be elicited by cross-examina- tion. Fatigue, muscular and mental, is very characteristic of the condition. Although this element is very rarely absent from a case, the fact of its presence is never volunteered. This is due as a rule to its having been quite confidently and often brutally attributed to ' nerves,' ' fancies,' ' vapours,' or whatever the epithet of the moment may happen to have been, and the patient has been urged to rouse herself and take plenty of exercise. Needless to say, this is very bad advice, which not only causes a great deal of unnecessary suffering, but militates very decidedly against any tendency to improvement. Such patients demand physical and mental repose, and it should on no account be denied them. THYROID MEDICATION.— Success in the treat- ment of disease by thyroid extract depends in the fii'st place upon the employment of a reliable 270 MINOR MALADIES. preparation, and in the second upon a very careful supervision of the dose. In the matter of the former, my own experience is not very extensive. I have tried but four preparations, with all of which I have been satisfied. One is Messrs. Burroughs Wellcome's tabloids, another is Messrs. Oppenheimer's Pala- tinoids, the third is the Elixir Colloid of Messrs, Squire and Sons, of Oxford Street, and the fourth is a French preparation, the Thyratoxin of Byla and Co., of Gentilly. The disadvantage of the tabloids used to be that the minimum dose is J grain,^ which, as wiQ appear later, I now regard as a large dose. This, however, is now remedied. The Palatinoids are made in doses of J grain* The advantage of these two preparations is that they are portable and reliable. The French preparation is a solid one, in the form of ' tablettes.' The makers claim that they have eliminated the lipoids and leucomaines which are present in all ordinary prepa- rations in such quantities as to give rise to symptoms which are regarded as those of physiological intoler- ance. It is certainly a fact that this preparation is very well borne by patients who seem unduly sensitive to those in more common use. One of the advantages of Messrs. Squire's Elixir is that the word ' thyroid ' does not appear on the prescription. A very large number of patients or their friends have made unpleasant and even tragic acquaintance with the drug, and are consequently apt to take fright at the mere name of it. It is therefore oou- MINOR GLANDULAR INSUFFICIENCffiS. ^71 venlent to be able to prescribe it under a difierent name. Another advantage is that one may vary the dose to any desired extent. The strength of the Elixir is 1| grains to the fluid drachm, so that 5 minims represent i grain, a dose with which I prefer to begin the treatment, even of severe cases. As it is very frequently desirable to associate other drugs with the thyroid, It is a convenience to include them in one mixture. The Elixir has no incompa- tibles. It is right to add that I have occasionally believed my results to be better with the solid preparations than with the liquid. The dose of thyroid extract is quoted in most text- books at 3 to 10 grains, three times daily: a dose so large that it would be ludicrous were it not so dangerous. The proper dose is from one-tenth grain to 1 grain, three times daily. With the exception of certain types of lunatics, it is .only the most robust among healthy people who can take larger doses with impunity, unless these larger doses have been arrived at progressively from very small beguinings. There is one important fact which the prescriber of thyroid extract should keep ever before him, which is, that the more a patient requires the drug, the smaller is the initial dose which he will tolerate. This is probably to be explained as follows : The want of thyroid essence has given rise to the deposit of mucin in various parts. Under the influence of thyroid medication this mucin is liberated into the circulation with a view of its excretion. If 272 MINOR MALADIES. it is liberated too rapidly, as by large doses it certainly is, there ensues such a surfeit in the blood that the excretory organs are unable to deal with it, and urgent symptoms of intolerance quickly arise. Professor Murray warns his readers against the exhibition of large doses in advanced cases of myxoe- dema, lest the degenerated myocardium fail under the strain and cause sudden death. The warning is much needed. And not only in advanced cases, for there are in reality very few cases of whatever degree of inadequacy which can tolerate without very grave disturbance an initial dose of more than i grain twice daily. It is commonly stated that the symptoms of excessive dosage are tachycardia, palpitation, diarrhoea, vomiting, excitement, and even maniacal symptoms. These certainly do occur, but only in the case of a dose so grossly excessive that its administration by accident would afford its only excuse. If the drug be given with circumspection, the fact that the limit has been reached will reveal itself quite unmistakably long before any of the above symptoms have time to develop. A Mttle looseness of the bowels there may be, but there ought to be nothing resembling real diarrhoea. A certain degree of quickening of the pulse-rate 3s to be expected, but if it amoxmt to anything approaching heart-hurry, the management of the case has been very unskilful. To quicken men- tality and promote alertness is one of the physio- MINOR GLANDULAR INSUFFICIENCIES. 278 logioal effects of the drug, but it argues ignorance or carelessness when these results are allowed to reach the etages of excitement and restlessness. If it is intended to give thjrroid extract over a period of several weeks, it is necessary to make observations upon the temperature and pulse-rate. If the drug is really required, the temperature is almost without exception subnormal, especially in the evening, and the pulse-rate is as a rule slow. When the tempera- ture rises to normal, the drug should be suspended, at any rate for a time, and the pulse-rate, whatever its initial figure, should never be allowed to go above 95 without calling a halt. In the case of children, other than cretins, the body - weight is a useful indication of the success of the treatment. So long as the weight increases the drug may be continued ; as soon as the weight becomes stationary the drug should be suspended, and if the weight decreases the drug must be discontinued. Having ascertained by cautious increase from small beginnings the dose which best suits the patient, my usual practice is to continue the dose for three weeks. I then suspend it for a week and then resume it for three weeks, and so on. If the pulse-rate is not slow at first, or if there is any other factor in the case which makes me fear intolerance, I give the drug for a fortnight, and suspend it for a fortnight. In the case of adult women, it is well to arrange so that the menstrual period should occur during an interval from the drug. Given in the doses above recommended, and 18 274 MINOR MALADIES. managed in this way, there is only one sign of commencing intolerance for which one need be on the lookout: this is coryza. A sudden and profuse nasal catarrh sometimes surprises people who are taking thyroid extract, and unless the physician realizes that such a thing is possible, he may attri- bute the catarrh to some ordinary cause and fail to discontinue the drug. Another signal which has occurred in some of my cases is a painless enlarge- ment of the glands at the angle of the jaw. It has always disappeared on suspension of the drug. A slight tenderness of the parotids, one or both, some- times occurs. In a few instances, at the commencement of thyroid medication, patients have exhibited all the symptoms of acute pancreatitis — i.e., a sudden attack of violent pain in the epigastrium, with vomiting, constipation, and local tenderness, which have in each case all passed off in a few hours. The close antagonistic relationship between the activities of the thyroid gland and the pancreas is my reason for regarding the latter as the seat of pain. The sudden active stimulus of the thyroid extract upon a pancreas which for a considerable period had been free from that stimulus would probably result in such a degree of pancreatic hjrperactivity as to cause the symptoms. The few patients in which these symptoms occurred were badly in need of the drug. Short of producing violent symptoms of this Jiind, it is by no means uncommon for patients taking MINOR GLANDULAR INSUFFICIENCIES. 276 thjToid extract in dosei which appear otherwise to suit them, to complain of feelings of discomfort after meals. The symptoms are usually those of the acid type, and they generally yield to alkalies and bis- muth. Not infrequently, however, the combination of HCl and pepsin seems to be more efficacious. Thyroid extract is said to be useful in the treatment of urticaria, its action presumably being that of utilizing fully the calcium salts in the diet. This may be so, but it is to my mind quite certain that thyroid medication tends to provoke urticaria even in those who are not subject to this irritating complaint. I have frequently been obliged to suspend the drug on this account, with the invariable result that the urticaria has subsided. Thyroid medication will occasionally, but by no means always, regulate the bowels. The stools of those taking the drug regularly generally become very light in colour. This may be due to an absence of bile pigment or to the presence of fats in excess. The latter cause is the usual one. When it is acting satisfactorily in an ordinary case of moderate degree, thyroid medication increases very largely the urinary output. The occasional presence of albumin in the urine need not excite alarm, but the appearance of sugar should lead at once to suspension of the drug. If the best results are to be obtained from thyroid medication, the ordinary mixed diet of the present day requires some slight modification. Carbohydrate 276 MINOR MALADIES. food* and alcoholic drinks are recognised as depres- sors of thyroid activity. I therefore direct those who suffer from thyroid insufficiency to be sparing in their use of them. Common salt I also endeavour to banish from the dietary. OHAPTEE VII. GENERAL HEALTH. ' 0, wist a man bow many maladies Folwen of excess and of glctonies He wolde be tbe more mesurable Of his diete, sitting at bis table.' — Ohaucbb. To obtain clear ideas on the subject of general health, it is necessary to realize two very obvious, but frequently overlooked, facts. The first is that, what- ever his intellectual and moral development may be, man is essentially an animal, primarily adapted to certain conditions and surroundings ; and the other is that the needs of civilization have imposed upon him the necessity for, or the temptation to, certain modifications of these conditions and surroundings. The problem which presents itself is this : How far and in what manner can the modifications be effected without impairing his animal powers — that is, his physiological or animal efficiency ? That man was originally a semi-nude animal, living in the open air, who obtained his food by tilling the ground and hunting his game, may be taken as beyond controversy. These were the conditions and surroundings to which he was originally adapted. He has, in course of evolution, become a very much beclothed animal, who lives in houses, and obtains his food less by the sweat of his brow than by the 277 278 MINOR MALADIES. work of his brain. This change of environment ought, logically, to entail corresponding changes in his habits. Certain changes have, doubtless, occurred, but they have for the most part been dictated, not by con- siderations of physiological suitability, but by those of pleasure or convenience. Departures from health are almost always due to o£fences against man's animal or physiological requirements ; and if we would fully realize what those requirements are, we must endeavour as far as possible to understand his primeval conditions and surroundings, untram- melled by the mists in which his pleasures or his convenience have enveloped him. This is the only scientific attitude from which to approach the subject of his general health ; for unless a scheme of living is in consonance with these general principles, it must necessarily rest upon a basis which is theoretical, and therefore insecure. The whole subject is too large to permit of its consideration in any real detail, but some aspects of the matter, approached from this point of view, may be useful in illustrating the ad- vantage of appealing to Nature for guidance rather than to fashion. There can be no doubt that man was intended to be a working animal; and by work is meant some- thing which must be done day in, day out, whether the doing accords with the inclination or not. Physio- logical eflBciency in every part of the body is de- pendent upon the regular exercise of function, and GENERAL HEALTH. a7i) what is true of each part is necessarily true of the whole. The man who does not work is never a reliable person, and he is seldom a healthy one— at any rate, for long. The normal individual demands legitimate outlets for his energy, and if he does not obtain them the energy becomes diverted into ille- gitimate channels. The majority of alcoholics, of hypochondriacs, and of neurotics, are people with nothing to do ; and one, at any rate, of the reasons why women are more prone than men to functional nervous ebullitions is that they are, compared to the men of the same class, the leisured portion of the community. To be healthy, then, a man should work. It is, of course, not an easy matter to compel a person to work who has no financial incentive thereto ; but there is plenty of voluntary work for those who have the leisure to devote to it, and it would be a good thing if all members of the profession were to im- press upon idlers the incontrovertible fact that idleness is by far the most potent enemy to healthy existence. Whether or not man was intended by Nature to be a naked animal is a subject which need scarcely detain us. The climate of the temperate zone and the exigencies of modern life have imposed a certain measure of covering upon all civilized races. The question for us to consider is whether the nature and the amount of the CLOTHINO which fashion now prescribes are such as to be conducive to man's 380 MINOR MALADIES. physiological efficiency. To elucidate this qnestion we must glance for a moment at two of the functions of that important organ the skin. The first of these to be considered is the power in virtue of which it contracts to a cold influence and relaxes to a warm influence. This power, in common with all the other vital powers, is dependent for its integrity upon its proper exercise. Here, as else- where, use gives rise to increase of function, disuse to abeyance, or loss of function. It is, therefore, obvious that the amount of clothing should be so regulated as not only not to interfere with this power, but, on the contrary, to afford every reasonable opportunity for its exercise. And we must not lose sight of the fact that the degree of efficiency of this function is a measure of the efficiency of the skin as a whole, because when one function of an organ suffers, the efficiency of the others becomes impaired. The right amount of clothing for a healthy person, therefore, is that which, while sufficient to protect the body from the harmful exposure to temperatures in which contraction cannot prevent undue loss of heat, is nevertheless not such as to protect the body from such a degree of cold as is necessary to the proper activity of the contractile power. In other words, the proper, the ideal, amount of clothing for a healthy person is the minimum which will protect that person &om undue depression of temperature whUe following his usual employment. If these conclusions, which are indeed sufficiently GENERAL HEALTH. 281 obvious, be correct, it is clear that the great majority of people are grossly overclothed. To judge by the general practice in this matter, one would be driven to suppose that the object to be attained was the avoidance, not of harmful degrees of cold, but of all degrees of cold. This practice, objectionable as it is in the case of adults, amounts to something in the nature of a hygienic crime where children are concerned ; for in addition to the interference with adeqi^ate metabolism which it causes in young and old alike, in children it militates against healthy development. The overclothed child has little incentive to run about and exercise his limbs and his lungs in the manner essential to normal animal evolution, and so it happens that rickets, adenoids, and iU-formed chests are, among the children of the well-to-do classes, the rule rather than the exception. Parents should be reminded at every possible opportunity that their children are primarily young animals, and that the practice of coddling inevitably means defective development, with its consequent physical and mental degeneracy. A full measure of cold should always be allowed to reach the skins of young people. It keeps the cutaneous contractile power in good working order, and incites the children themselves to the muscular exercise upon which their proper development depends. One of the best means of exercising this function of the skin is the cold morning tub. The exact temperature ^f the water to be used is a matter of S>« MINOR MALADIES. some importance, but it is one which can be decided only after a review of all the circumstances connected with each case. Speaking generally, it should be cold, but never so cold as to leave the bather chilled and miserable. The fashion of the moment prescribes the use of full-length baths. There is no objection 10 these in the case of healthy people, but for those who are weakly, the sitz bath is infinitely preferable. In the full-length bath all the blood is driven inwards to the internal organs, whereas in the sitz bath, the cold affusion being applied to various parts of the surface in turns, the determination of blood inwards is less sudden. One of the advantages of the cold bath is that the whole cutaneous surface is thereby exposed to the air at least once daily. To reap this advantage to the full, care should be taken that the atmosphere in the bath-room is as pure as possible, and this is best secured by the open window. The cold bath has other incidental advantages. One is that to obtain the desired reaction people usually apply friction to the skin with a rough towel. This entails a certain amount of exercise which is altogether to the good, and it results in a general stimulation of the whole cutaneous surface, which is highly conducive to its physiological efficiency. One of the cutaneous appendages — namely, the hair — often suffers from want of adequate stimu- lation. There has been a good deal of ingenious speculation as to the causes of baldness, especially GENERAL HEALTH. 28S as to why it should be comparatively common in men and relatively rare in women. The absence of physiological stimulation in the one case and its presence in the other supplies in reahty the solution of the riddle. Men cut their hair short, and BO deprive the follicles of the stimulus which the mere weight of long hair affords. In addition, hair which is long entails a'great deal more brushing and general attention than hair which is short, so that the hair follicles in man are deprived of a double measure of stimulus. If these facts were more generally recognised and acted upon, there would be less premature baldness than there now is. The drying process after the cold morning tub affords an excellent opportunity for thoroughly massaging the scalp by moving it freely on the underlying bone. If after this the brush is used forcibly enough to redden the skin, premature loss of hair is very unlikely to occur. The drying process should also be utilized for the purpose of applying friction to the ears. By this means the sclerotic process which so often gives rise to premature deafness may be indefinitely postponed. The other function of the skin which it is necessary to consider in this connection is the excretory func- tion. The cutaneous excretions are discharged either as fluid or watery vapour, and it is, therefore, very properly held that the clothing to be worn in contact with the cutaneous surface should be of an absorbent nature. The material should have the power, that is, of rapidly taking up the moisture. Curiously enough, 284. MINOR MALADIES. the material which is all but universally prescribed for underwear — namely, flannel or wool — is precisely the one which has the least capacity for absorption. Flannel is a warm material, as it is called. No material is, of course, warm per se. All warmth is derived from the body itself, and one material is warmer than another in virtue of the fact that one is a worse conductor of heat than another. Maimel is a non-conductor of heat, by reason of the air-spaces it contains, because air is a bad conductor ; but flannel is not absorbent. Silk, linen, and cotton are in a diflferent .category. These are all highly absorbent materials, but as their fibres contain no air-spaces they are not ' warm.' It is, however, possible to manu- facture them in such a way that they shall contain air-spaces, and thus become efficient non-conductors ; whereas it is quite impossible so to treat flannel as to render it absorbent. The obvious inference is that flannel is not a suitable material for underwear, and that silk, linen, and cotton can aU be rendered very suitable by causing their fibres to contain the air-spaces on which the reputation of flannel rests. These materials are all now manufactured on these principles, so that there is no longer any excuse for advising people to utilize wool or flannel for underwear. These two substances, which are in reality the same thing, as being practically unabsorbent, are inimical to healthy animal existence. When worn next the skin they imprison the moisture, and thus give rise to GENERAL HEALTH. 286 deficient evaporation, diminished metabolism, and great disinclination to mental and bodily exertion.^ And not only should clothing be of a suitable material, but it should be constructed so as to give the limbs free play and allow the circulation to proceed without let or hindrance. Tight vests and clinging drawers are much too common, especially with the young. It is not very long since the pro- fession had good reason to deplore the tight corsets affected by women. Fashion has fortunately decreed that these shall no longer be worn, but en revanche she has imposed upon the smart women of this generation a burden almost as deleterious. The tight, high collars stiffened with whalebone, which are de rigueur to-day, are scarcely less objectionable than the ' stocks ' worn by our ancestors, or the highly- starched, double dog-collar beloved of the con- temporary city clerk. It should be remembered that the neck is an isthmus containing very important organs. To say nothing of the larynx, the thyroid, and lymphatic glands, it contains large bloodvessels for the supply of the brain, and is traversed by many important nerve-trunks. Very Httle consideration will show that constriction of such a tract must seriously impede the free movement upon which so much depends. The 1 For a detailed diaeussion of this questioii, see 'Three Lectures on Personal Hygiene,' Clinical Journal, July 6, 13, and August 10, 1904 ; ' Some Aspects of Obesity,' PracUUoner, May, 1904 ; and ' Eheumatica in Belation to Climate,' Bir- imnghwm Medical Beview, May, 1905, 286 MINOR MALADIES. muscles waste, and the underlying organs become exposed to a pressure which Nature never intended them to encounter, with the result that headaches, giddiness, and the various symptoms of thyroid embarrassment quickly ensue. The neck should be as free as possible, and under no circumstances should tight or high collars be tolerated.^ General physiological efficiency is dependent more upon an ALEaUATE SUPPLY OF OXYGEN to the tissues than upon anything else. No one is capable of his best work unless he is able to obtain air of normal purity, and any habitual falling short of the normal lessens the general powers of resistance, and leads to disease. The normal standard of purity is given by authorities as 21 per cent, of oxygen and '04 percent. of COj, and they go on to say that a rise of COj to "08 per cent, is distinctly harmful. The normal standard is obtained from the examination of air in the country, on mountains, at sea, and in open spaces of towns, and it is found to be remarkably uniform in all portions of the globe, inhabited and uninhabited. The air in houses falls short of this standard, the proportion of OOj very commonly reaching '05 per cent., and where a large number of people are gathered together, as in churches, theatres, concert-rooms, and the like, it not infrequently reaches '08 per cent., or, indeed, *! per cent., either of which percentages represents gross impurity. The degree of impurity of ^ See a paper by Dr. Walter G. Walford, British Medial Journal, AprU 20, 1912, p. 886. GENERAL HEALTH. 287 an atmosphere is stated in terms of COj, because the amount of this gas is comparatively easy of estima- tion. The practice has one great disadvantage, how- ever, which is that it is apt to give rise to the supposition that the impurity consists solely in the presence of an excess of COj, and we are liable, in consequence, to forget the far more deleterious substances which an impure air contains. These substances comprise organic matters, watery vapour, bacteria, and decomposing organic matter given off by the skin and lungs. It seems necessary occasionally to remind ourselves that the skin and lungs are excretory organs, the degree and importance of whose activities it is, on account of their unobtrusive nature, very easy to underestimate. It is unnecessary to attempt any enumeration of the diseases and morbid states which are directly due to vitiation of the atmosphere.^ When it has been said that such an atmosphere lessens the vital resistance to the attacks of the bacteria, which at the same time it supplies in great abundance, all has been said that is requisite for the appreciation of the paramount necessity for the maintenance, in the highest possible state of purity, of the atmosphere in which each one finds himself. And this is a matter in which a very reasonable complaint may be lodged against the profession as a whole. In spite of the emphasis which has recently ^ See ' Maladies caused by the Air we Breathe,' by Dr. Thomas Oliver (Bailli^re, 1906). 288 MINOR MALADIES. been laid upon the importance of fresh air, in the brilliant results obtained thereby in the treatment oi phthisis, medical men, as a rule, are far too tolerant in their patients, and in the public generally, of impure and even grossly vitiated atmospheres. This tolerance is due in a large measure to the persistence of what may be called the chill theory — the theory, that is, by which any morbid condition whose etiology is obscure is attributed to the action of cold or chill. It is not very long since phthisis, pneumonia, and influenza were confidently stated to be due to chiU, and there are still some people who believe in pleurisy a frigore. In times stUl more remote, almost all diseases were deemed the result of chill. It is not surprising, therefore, that in the lay mind the word should suggest some obscure yet serious menace, nor that every precaution should be taken to guard against so deadly and ubiquitous an enemy. Among the causes of chUl, draughts are always given the first place. To sit in a draught is regarded by many people who are otherwise sane and reasonable as the most unwise and dangerous proceeding, not be- cause it is unpleasant, but because it is directly calculated to lead to serious disease. There is not only no justification for this view, but it is diametrically opposed to what we now know to be the truth. The majority of diseases are due to microbic invasion: microbes of all sorts abound in polluted atmosphere, and there is no means of pre- venting an atmosphere from becoming polluted GENERAL HEALTH. 289 except by the admission of fresh air. The admission of fresh air necessarily produces a draught, so that it is quite obvious that we have to choose between a draught, which is salutary, and stagnation of the atmosphere, which is deadly. If the open-air treatment of phthisis has estab- lished anything, it has proved beyond all cavil that currents of air are not injurious. The patients at sanatoria live, as I have heard it expressed, in a gale of wind, and it is a fact that when they return from these institutions people are particularly in- tolerant of anything in the nature of stuffiness. These patients, we must remember, are what the French call poitrinaires — lung sufferers — and are therefore drawn from amongst those to whom, accord- ing to the chill theory, draughts are most deadly. The success of the open-air system is in reality the reductio ad absurdum of the chill theory. Extreme cases are taken, not of the disease, of course, but of those who have delicate and debilitated air-passages, and who are therefore susceptible above all others to the supposed baneful effects of draughts. They are taken generally from the heart of a draught- eschewing household, and are suddenly, even in the depths of winter, deliberately and of malice afore- thought subjected to a system in which exposure to draughts is the leading and essential feature. And what is the result ? If there were the slightest basis of truth in the chill theory, they would die like flies ; but, instead of doing so, they not only 10 290 MINCA MALADIES. continue to live, but they increase in vigour and in weight, and their disease becomes arrested. No more convincing proof could possibly be afforded of the baselessness of this ignorant and pernicious fallacy which is gnawing at the vitals of the com- munity. The moral of this is simple enough. We cannot all live in open-air sanatoria, even if we would, but we can all put in practice the principles of which these places have established the correctness and the value. It is the duty of the profession to instruct the public in the prophylactic aspect of the matter, and to educate people into realizing that tuberculosis is only one, even though it be the most important one, of many evils which inevitably follow in the wake of polluted air, and that a pure, clean atmo- sphere is as essential to the maintenance of healthy lungs as pure, clean water is to the preservation of healthy intestines. It is unnecessary to enter into detail on this subject. People can only be weaned from the chill theory by having it pointed out to them that those who practise it are unhealthy, and by being made to experience the superiority of the effects of fresh air, however productive of draughts its ingress may be. Without adequate ventilation there can be no such thing as physiological eflSciency, and in the present method of house construction the only means to adequate ventilation is the open window. And the window should be kept open day and night, not GENERAL HEALTH. S91 occasionally only, nor ' a little bit at the top ' (the virtues of which little bit being sadly marred by drawn blinds, well-secured shutters, and heavily- draped curtains), but sufficiently open to provide for that really effective circulation of the air upon which healthy animal existence necessarily depends. The importance of DIET in the maintenance of health is now very generally admitted, the difficulty being to decide between the merits of the various rival systems which are advocated with considerable ability and much insistency by their respective authors. Dr. Alexander Haig' asks us to believe that any uric-acid-forming food is a slow poison, and invites us in consequence to delete from our dietary not only all fish, fowl, game, and meat, but also such vegetables as peas, beans, lentils, asparagus, onions, together with oatmeal, tea, and coffee. Dr. Hare,* on the other hand, brings a serious indictment against carbohydrates, and warns us to eschew them if we would avoid gout, asthma, migraine, and other evils. Dr. Chittenden' has made experiments to show that the main fault in our present system of dietetics is that we have hitherto overestimated by one-half the amount of proteid which is necessary to full mental and bodily activity, and that we can attain to real physiological economy only by reducing our intake under this head. Mr. Van Someren* insists that > ' Uric Acid in tbe Cansation of Disease.' » ' The Food Factor in Disease.' ' ' Physiological Koonomy,' etc. * Britith Medical Journal, October 12, 1901. 292 MINOR MALADIES. inadequate mastication is the root of all dietetic evil, and that every mouthful should be masticated not thirty-two times only, but until the mass ia both fluid and tasteless. All these writers — and each of them has many followers and co-workers — advance their various theories with great skill, and illustrate them by convincing cases. It is obvious, however, that they cannot all be right, and that to escape from bewilder- ment on the subject it is necessary to find a common denominator, a platform on which each can take his stand side by side with the other. Such a platform would seem to be provided by the proposition that the gravamen of the charge against the existing admittedly faulty system is that it leads in one form or another to surfeit. Dr. Haig, Dr. Chittenden, and Mr. Van Someren, either explicitly or by implication, condemn the use of food which has been obtained by the taking of life — food, that is, through which blood has circulated. They are, in fact, to a large extent, lacto- vegetarians. Dr. Haig's index expurgatori/us is exceedingly comprehensive, but, then, it is the outcome of a theory — that, namely, which attributes to the action of uric acid the responsibility for the majority of complaints with which the human body is afflicted. This theory has had a great vogue not only with the profession, but with the public, but it is, nevertheless, one which it is very difficult to sustain. It is admitted that unexcreted nitrogenous waste products are highly deleterious, and it is undeniable GENERAL HEALTii. !493 that uric acid is one of these. Bat, although it is the most easily identified and measured, it is by no means the only one, and to use its ease of identifica- tion as an argument in favour of its sole responsibility is as fallacious as it would be to suppose that carbonic acid gas constituted the sole cause of the pollution of an atmosphere in which it was present in excess. Dr. Haig's diet, then, if it succeeds, as in many cases it undoubtedly does, succeeds for reasons other than those which are advanced in its favour. It is a matter of importance to determine how far these systems can be reconciled with the incontro- vertible fact that primeval man was to a very large extent a carnivorous animal. The matter would seem to stand thus : Primeval man was nomadic, and depended for his sustenance largely upon hunting, and other forms of vigorous muscular exercise, which enabled him to digest and dispose of large quantities of animal food.^ In course of time he has become stationary and even sedentary, so that the muscular exercise which justified, and even perhaps necessi- tated, his carnivorous habits is no longer an essential portion of his existence. Thus it comes about that he is now physiologically unable to deal with foods of any sort, but especially with flesh foods, in anything like the same quantity as formerly. The muscles are the great furnaces in which foods are burned, and if the furnace bums low the foods are suboxidized. The • Dr. Harry Campbell : ' A Lecture on Diet,' OUnieai /oumal, March 14, 1906, 394 MINOR MALADIEi. fuel, instead of being burned to ash and dia«b«rged, is converted into cinder and retained. There are two ways of meeting such a diflSculty — the one by increasing the oxidation, the other by diminishing the fuel. In the case of the ordinary twentieth- century man the former is practically impossible, so that the physician and the hygienist must have re- course to the latter. Of course, there are enormous personal differences in the individual capacity for dealing with excessive food, differences as striking and as inexplicable as those which exist in the matter of stature ; but there seems to be no doubt that each succeeding generation becomes less able than its predecessor to cope with, and adequately to dispose of, a diet which in quantity as well as quality is an imitation of that to which primeval man accustomed the race. The exigencies of our present mode of life being what they are, it seems necessary that we should seek to adapt our dietetic habits thereto, and our guide in this matter, as in all others, should be the attainment of physiological efficiency. A truly scientific working standard could be arrived at only by gauging the irreducible minimum upon which full physiological efficiency could be maintained. For various reasons, which include personal, racial and climatic differences, such a standard is beyond our reach, but inasmuch as food is agreeable, it is safe to assume that such dietetic errors as are habitually committed arise from excess rather than deficiency of its consumption. GENERAL HEALTH. ^i'JS The systemB of diet above referred to have this in common, that they aim at a general reduction of intake. Most of them, it has been shown, provide for the abolition of flesh foods. Now, this last arises partly on account of the fact that some individuals, an increasing number perhaps, are unable to consume such foods without suffering from troublesome symptoms ; but it is also due to the stimulating properties of such foods, to the effect which they produce in augmenting the whole quan- tity of intake — the provocation, that is, of the insidious • appetite which comes with eating.' The foods of a lacto -vegetarian regime, if they possess this tendency at all, possess it in a very minor degree ; so that one, at any rate, of the advantages of such a regime is that there is, in those that follow it, much less likeli- hood of the evils of over- alimentation than there is in the case of the ordinary mixed feeder. The explanation of Dr. Hare's position, that it is the excess of carbohydrates rather than of proteids which is responsible for those faults of metabolism as to the existence of which all are agreed, would seem to indicate that some individuals tend to revert to the physiological type which prevailed in man's carnivor- ous period, and that these persons, therefore, display an inability to cope with carbohydrates which is as definite as the inability of others to cope with proteids. But even these cases can be reduced to the common denominator, which is represented by the necessity for a general reducticHi of intake. Thoug;!^ 29e MINOR MALADIES. meats are undoubtedly Btimulating and appetizing when consumed along with other kinds of food, a regime consisting solely of proteids very soon induces that form of disinclination and ready satiety which is expressively known as toujours perdrix. There would seem, then, to be no escape from the position that such evils as are associated with our present system of dietetics are evils which arise, not from any faults in the quality of the foods ingested, but rather from the quantity of these foods which, in spite of his sedentary occupations, man still insists on consuming. It is a commonplace that we all eat too much, but a recitation of the belief seems very seldom to lead to an improvement in the practice, and such improvement is not likely to occur until we can succeed in bringing home to our patients the physiological inefficiency and its consequences which habitual excess necessarily entails. The causes of this excess are numerous. The most prominent is perhaps mere selfish indulgence in the pleasures of the table, accompanied, as it often is, by a grim determination to suffer the consequences of surfeit rather than forego the pleasures. Another cause is mere careless habit. When people are young and vigorous they can consume large quantities of food, not only with impunity, but even with seeming benefit, and the habit thus begotten is apt to be con- tinued long after the age of impunity is passed. A third cause is the deficient mastication of foods. This is the keystone of the system which Mr. Van GENERAL HEALTH. 297 Someren has brought into prominence, and thero remains no doubt in the minds of those who have tried this system, that adequate mastication, according to the standard laid down, leads to a decrease in the whole quantity of intake, which is very surprising. The rationale of the system may be briefly stated as follows : We live by what we digest, and not by what we eat. That we eat more than we can digest is evidenced by the large amount of feeces which we daily evacuate, and whose regular discharge we have come to regard as so urgent a necessity. For fseces, we are reminded, are not the products of digestion; they are the materials which have escaped the digestive process, and represent, therefore, the excess of intake over the legitimate physiological needs, And we take this excess because we do not prepare our foods by adequate mastication and insalivation. If we did this, we should not feel the desire for the excess which many now feel. The desire is probably begotten by the demand from the economy for suitably prepared food. In response to this demand, a food is supplied which is not suitably prepared, and the needs of the economy are, therefore, im- perfectly satisfied, so that the demand is continued until the stomach is physically incapable of holding more, and a mechanical satiety is induced. The ultimate disposal of this excess places a great strain upon the digestive and excretory organs, more especially the kidneys, so that suboxidation and deficient excretion, leading to dyspepsia, gout, and 39S MINOR MALADIES. eonstipatioQ, are the oonditioo^ which dominate our •veryday lives. Among the remaining causes of excessive eating, the practice of drinking fluids with the meals must be given an important place. This prevalent practice is quite unphysiological. If we seek a lesson from the lower animals in the matter, we find that none of the mammals are in the habit of drinking with their meals. The taking even of pure water with a meal enables the person to eat more than he otherwise would. There are some differences of opinion as to why this should be, but the fact itself is not in dispute. The probability is that the extraneous fluid supplies the moisture which ought in reality to be supplied by the saliva. The saliva not only digests certain foods, but it also lubricates the whole mass, and if this lubrication is artificially provided, the person tends to take an excess of solids. Fluid is, of course, very necessary to the economy, but it should not be taken at meals. The best time to take it is about half an hour before a meal, but if this is inconvenient, as it often is, the drink should be delayed until all the solids have been eaten. There is one great advantage in taking fluid before a meal, which is that it exercises a flushing effect on the stomach, and tends to free that organ from any remains of a previous repast which it may happen to contain. And if the taking of fluids of all sorts can thus be held responsible for g, larger consumption of food than GENERAL HEALTH. «99 is ueoe&sary, it Is obvious that the ingestion of a local and general stimulant, such as alcohol, must be produc- tive of the same effect in a very much higher degree. It is impossible to enter here into the ethical side of the question of alcohol. The physiological side may be expressed by saying that whereas its occasional and infrequent consumption may justly be regarded as a legitimate indulgence, its habitual use, especially for those who have to work with brain or muscle, is undoubtedly fraught with evil ; and further, that, if taken at all, it should be taken, not with the meal, but after all the solids have been consumed. There is, however, one aspect of the matter which seems deserving of brief notice — namely, the form in which, when it is recommended, it is now the fashion to take alcohol. It has now been the custom for some years to recommend those who insist upon taking alcohol of some kind to take it in the form of spirits rather than in the form of wine or beer. This custom has very little to recommend it. In the first place, spirits are by far the cheapest, the easiest, and therefore the most insidious, form in which alcohol may be taken, and thus lead much more readily to habitual excess than either wines or beers. Moreover, of the diseases which are commonly attributed to alcohol, such as cirrhosis, hepatic and renal, and various diseases of the nervous system, the great majority appear in spirit-drinkers, and not in those who take merely wine or beer. Most spirits contain 50 to 60 pej aOO MINOR MALADIES. oent. of alcohol, and they all owe their stimulating properties almost exclusively to this element in their composition. Wines, on the other hand, contain on an average about 10 to 15 per cent, of alcohol, and owe their stimulating properties largely to the volatile ethers which give them their bouquet The alcohol, as we know, leaves its mark upon the liver, kidneys, and nervous system — that is to say, it circulates a long time in the blood before it is excreted. The ethers, on the contrary, pass rapidly out of the system through the lungs, and a few hours after their ingestion they have quite disappeared. And yet we hear it said that whisky is ' wholesome.' What exactly is meant by the adjective in this connection it is difficult to say, but this, at any rate, is certain — that of all the methods of taking alcohol, spirits, whether in the form of whisky, brandy, gin, or liqueurs, are the most insidious and dangerous beverages to recommend to patients. A practice which is commonly associated with that of whisky-drinking is the taking of aerated waters. This is another custom which, on physiological grounds, it is impossible to defend. Gaseous dis- tension of the stomach leading to dilatation is a very common complaint. It may be too much to say that it is often induced by the consumption of aerated waters, but there can be no doubt that it is frequently gravely aggravated thereby. These waters are in public favour apparently because they, too, are considered 'wholesome.' No good purpose GENERAL HEALTH. 301 can possibly be served by introducing carbonic acid gas, normally a waste product of metabolism, into the system at all, and to introduce it into an organ which is all too frequently the subject of gaseous distension is a dietetic error too obvious to dwell upon. The drinking of fluids with meals, then, as tending to over-alimentation, should be discouraged. If alcohol is taken at all it should be in the form of well- matured wine, and its consumption should be reserved for the end of the meal. Aerated waters are powerless for good, and very potent for evil. Their habitual ingestion should, therefore, be forbidden. Such are among the most important causes of overeating. The broad effects of this practice may now be briefly considered. Unnecessary food which is introduced into the system is not, as is commonly supposed, passed on and discharged as useless. All assimilable material is assimilated; it is only the unassimilable which is rejected. If too much assimilable material is taken, the organs concerned in the metabolic processes have too much work thrown upon them. If they are able to perform this work, the blood becomes surcharged with oxidizable matter, so that instead of being a nutrient, the plasma is in the nature of a depressant, producing the same results as an excess of fuel produces on a fire. Hence it is that overeaters are generally dyspeptics, and are usually either drowsy or irritable after a meal The organism, however, makes an effort to cope with this excess, and calls for a plentiful supply of oxygen S<^ MINOR MALADIES. to carry on its work. This explains the dyspnoea, the breathlessness of slight effort, of which such people generally complain. The overloaded condition of the plasma constitutes an irritant either to the walls of the bloodvessels or to the vasomotor centres in the brain, thus producing constriction of the smaller arteries, and a consequent general rise of blood- pressure. The task of excreting the excess is under- taken mainly by the kidneys, which important organs have therefore cast upon them an amount of work which is out of all proportion to the physio- logical necessities of the case. If the metabolic processes do not succeed in adequately coping with the surplus food, the surplus is suboxidized, and causes the symptoms in various parts which are spoken of as gouty or rheumatic. The evils of excessive eating, therefore, may show themselves in any system or organ, but, except perhaps in the case of the stomach itself, the disturbance is due to the overloaded state of the liquor sanguinis, and it is consequently in the circulatory system, by the occurrence of dyspnoea and increased blood-pressure, that the earliest symptoms are most likely to show themselves [vide Goutiness, p. 221). There are two ways of combating the evil effects of overeating in its early stages : the one is by the obvious course of reducing the amount of the intake ; the other, by increasing the oxidizing processes. It is unnecessary to dwell upon the former further than to empliasize the fact that the older a person grows the less GENERAL HEALTH. food does he require. The French say that man does not die — he kills himself; and the same idea is ex- pressed in our own saying that man digs his grave with his teeth. Certain it is that when middle age is reached, it is only those who live a vigorous life in the open air who can indulge in the pleasures of the table with any degree of impunity. For the sedentary liver who would retain a full measure of physiological efficiency a considerable, if gradual, reduction of intake becomes essential at this age, and the reduction should proceed pari passu with advancing years, until at three score and ten it has reached a minimum. A distinguished physician, who is still alive, has explained his vigorous old age by saying that he never rises from a meal without feeling that he could sit down and eat it all over again. The alternative of increasing the output by stimu- lating the oxygenating processes brings us to the question of EXERCISE. Here, again, having regard to the enormous personal differences which exist, it is quite impossible to lay down any hard-and-fast rule. This, however, may be said with confidence — that he who eats much, must exercise much, and the man for whom much exercise is impossible must meet the situation by consuming little. It is a common experience that brain work in the study is, with some people at any rate, an even greater provoker of appetite than muscular exertion in the fields. The explanation of this fact is too involved to enter upon here, but it may be asserted that the hunger begotten of study should not be appeased in the same manner 804 xMINOR MALADIES. as that which is begotten of muscular exertion. For the latter, a plentiful supply of nitrogenous foods, especially of meat foods, is sometimes considered appropriate. Although very decided doubts are now expressed upon this point, it seems generally to be agreed that such foods when taken in abundance by a sedentary worker lead inevitably to impaired health. The man, then, who has ample oppor- tunity for efficient oxidation may be left to work out his own dietetic salvation; but he who is deprived of such opportunity should have it explained to him that, be his study-begotten appetite never so vocal, he must satisfy it otherwise than by meat foods and alcoholic drinks. Of exercise in general, it may be said that the necessary amount depends upon individual require- ments, a powerful factor in determining which is the amount of food consumed. It also depends to a great extent upon individual opportunity, and the amount to be recommended in each case can be arrived at only after due consideration of these points. The best kind of exercise is also a matter which must vary considerably in each case, though riding and golf are, as a rule, appropriate to both sexes and all ages. The objection, however, which is to be urged against these and most other exercises, with the exception of rowing, is that they contribute nr thing to the development of the abdominal muscles. The importance of keeping these muscles in good condition must be evident to those who remember that, practically, they constitute the anterior abdominal GENERAL HEALTH. ;J05 wall, and that if they are allowed to become lax they &il to give adequate support to the internal organi. There was at one time a good deal of talk about th« responsibility of the ' abdominal pool,' or ' splanchnic lake,' for deficient metabolism, and practitioners at health resorts, especially in Germany, are still in the habit of attributing a good many of the morbid conditions which they are called upon to treat to ' abdominal venosity.' These are, in reality, all synonyms for the same thing — namely, the state of matters which is brought about by lax and un- developed abdominal muscles. To keep these muscles firm and in good order their regular use is essential, and, as the ordinary forms of exercise help but little in this direction, it is evident that we must resort to an exercise ad, hoc. Various forms of such an exercise have been recommended, but the one which seems to be the best, in that it is not difficult, violent, or time- consuming, is the following : Wearing as little clothing as the circumstances permit, and with the windows wide open, the patient lies on his back on the floor, with his feet under the opened lowest drawer of a chest of drawers, or anything else which will keep his feet from rising from the ground. With his arms fully extended above his head and touching the floor in their whole length, he proceeds to pull himself into the sitting posture by means of his abdominal muscles, keeping the knees unbent. Care must be taken not to advance the arms beyond the line of the trunk, and to perform the movement 20 806 MINOR MALADIES. deliberately. This will be found a very trying discipline to those who are unaccustomed to use their abdominal muscles ; indeed, it is to many quite impossible, so that it is wise to begin with a modification, which consists in allowing the arms to be crossed on the chest while the rectus muscles pull the trunk forward. This exercise should be done two or three times each morning to begin with ; and when it can be done seven times without undue efiFort, the arms should be placed above the head as first described. With the arms thus placed, the number of times must again be reduced and then gradually increased as before. Another exercise which may immediately follow on the foregoing is performed as follows: The feet are released from the chest of drawers, and, still lying flat on his back, the patient raises the fully extended legs until they are at a right angle to his trunk. While this is going on, the hands are engaged in pinching up the skin and otherwise massaging the abdomen. These procedures may sound very formidable, but they are in reality not so. If they are done regularly, without hurry or strain, they take very little time and can do no harm, while their effect in keeping the figure from becoming aldermanic is very marked. This consideration appeals to most people — more especially to women — and if a greater number of the fair sex undertook these exercises there would be fewer cases of floating kidney and other abdominal and pelvic troubles than now unfortunately exist. GENERAL HEALTH. S07 Of other exercises which are adapted to ordinarily healthy people who have insufficient opportunities for spending much time in the open air, skipping holds a high place. Although usually regarded as suitable only to children,, it is in reality a very excellent discipline for middle-aged and even elderly people, when undertaken with due regard to the necessities of each case. It exercises every part of the body, including the abdominal muscles, and subjects the internal organs to a species of massage which is very beneficial.* There are several systems of exercises, Swedish, Danish, and others, now in vogue, the majority of which, as entailing no violent exertion, and as tending to keep most of the muscles in good working order, may be confidently recom- mended to healthy persons. All these exercises should, if possible, be performed daily, as a matter of routine, in the morning before the bath, and preferably in a room the window of which is wide open. The question of the temperature of the daily bath is one which is often referred to the medical man. I have already said that as a general rule it should be cold — • that is, of a temperature between 40" and 60° F. This, however, refers only to healthy people under middle age, in whom a reactionary glow is easily obtained by the aid of a rough towel. To such people a cold bath is very invigorating ; it > The Girbola. a08 MINOR MALADIES. promotes metabolism and effectually exercises the contractile power of the skin. If, however, it should not be followed by a reactionary glow, or if it should cause headache or loss of appetite, it should be discontinued. People who from any cause have a blood-pressure which is definitely above the normal, always complain of discomfort after a cold bath. The contraction of the peripheral arterioles increases the arterial tension, and if the baths are persisted in, accidents are very liable to happen. I have more than once been led to the discovery of an otherwise unsuspected vascular disorder by complaints of head- ache, giddiness, and the like, which have been positively referred to the cold morning tub. Where for any sufficient reason it is decided that the daily bath should not be taken quite cold, it is necessary to decide at what temperature it should be taken. A tepid bath is one which, though definitely below the normal temperature, is, nevertheless, not so cold as to cause much contraction of the cutaneous vessels — that is, from 85° to 95° F. A warm bath is one which is about the same temperature as the surface of the body, and causes neither contraction nor dilatation of the cutaneous vessels — that is, from 90° to 98° F. A hot bath is one which is substantially higher than the normal body temperature, and tends to cause dilatation of the cutaneous vessels — that is, from 98° to 105° F. In connection with the hot bath, it is to be remembered that its effect varies not only with its temperature, but with its duration, and, GENERAL HEALTH. 309 further, that there are a great number of personal idiosyncrasies in the degrees of heat which can be tolerated. Women, as a rule, can take baths at much higher temperatures than men. Very hot water causes an initial contraction of the cutaneous vessels, but if the bath be prolonged, this effect gives way to one of dilatation, and the ultimate result is one of general relaxation. If, therefore, the hot bath is substituted for the cold morning tub, it should be made clear that the exposure to the hot water, though it should not be so prolonged as to produce a general relaxation, should nevertheless be prolonged enough to enable the cutaneous vessels to recover from their initial contraction. If a daily hot bath of long duration is desired, it should be taken, not in the morning, but at night, when the day's work is over and relaxation is normal and physio- logical. It is said by some physicians, chiefly on the Continent, that a daily bath is not only unnecessary, but actually injurious, on account of the fact that the natural oil of the skin is thereby removed. Such a view has nothing whatever to support it. The ' natural oil ' of the skin is an excretion, and it should be removed at least once daily with the aid of soap and a due amount of friction. For those who are unable to take a cold morning tub, the warm bath of not more than 100° F. is the most generally suitable for these necessary daily ablutions. The duration