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CONTRIBUTIONS 
 
 TO 
 
 PRACTICAL MEDICINE. 
 
 SIR JAMES SAWYER, KNT., 
 
 M.D. LOND.; F.R.C.P. LOND.; F.R.S. kdin.; 
 
 CONSULTING PHYSICIAN TO THE QUEEN's HOSPITAL 
 LATELY PKOFESSOR OF MEDICINE IN QUEEN'S COLLEGE, BIRMINGHAM. 
 
 SECOND EDITION: 
 REVISED AND MUCH ENLARGED. 
 
 :tSicmtngbam: 
 
 CORNISH BROTHERS; 
 
 1891. 
 
^Isxanifev M^tnin^ 
 
 ^n ^etnaviam. 
 
PREFACE TO THE SECOND EDITION. 
 
 In five years, since the middle of 1886, a large 
 edition of " Contributions to Practical Medicine" has 
 become exhausted. In the present second edition I 
 have revised and corrected every page of the first, by 
 whatever experience I have been able to gather during 
 twenty-five years of busy practice in treating the sick. 
 I have added two new essays. The first is upon the 
 treatment of gastralgia, and it was published originally 
 in The Lancet, in 1887; the second deals with my 
 researches concerning the use of ether as a menstruum 
 in medication by the skin, and includes the substance of 
 my communications upon this subject to The Lancet, last 
 year. Throughout this little book I have aimed at 
 utility in medical practice, and I have tried to observe 
 the brevity of detail and expression which seems fitting 
 in a time when there is no end of making books. If 
 there be in these pages many wide gaps and much 
 literary incompleteness, I can only plead the pressure of 
 daily clinical work, and rely upon the generous judg- 
 ment of my professional brethren. 
 
 31, Temple Row, 
 
 Birmingham, 1891. 
 
PREFACE TO THE FIRST EDITION. 
 
 From such of my medical writings as have been 
 published previously, as clinical lectures, essays, and 
 annotations, in various professional periodicals, during 
 the last eighteen years, I have been induced to select 
 some which I hope may not be thought unworthy of 
 reproduction. These I have rewritten, pruned, and 
 amplified, corrected by my later experience, and col- 
 lected in this volume. 
 
 31, Temple Row, 
 
 Birmingham, 1886. 
 
CONTENTS, 
 
 PAGE 
 
 The Causes and Cure of Insomnia. (A clinical 
 lecture, published in The Lancet, June iSth and 
 22nd, 1878.) 
 
 Psychic, toxic, and senile forms of insomnia. — 
 Condition of brain in sleep. — Emotional shock 
 and mental strain as causes of insomnia. — 
 Syniptoms of insomnia. — Causes of toxic 
 insomnia. — Treatment . . . . . . ■ • 13 
 
 II. Phthisical Laryngitis. (A clinical lecture, pub- 
 lished in The Lancet, January 30th, 1875.) 
 
 Definition of the disease. — Value of the laryngo- 
 scope. — Concurrence of phthisical laryngitis 
 and pulmonary consumption.— Stages of phthisical 
 laryngitis. — Vocal symptoms. — Respiratory symp- 
 toms. — Difficulty of deglutition. — Cough. — Pain. 
 — Expectoration .. .. .. .. ..45 
 
lo CONTENTS. 
 
 PAGE 
 
 in. Thb Treatment of Phthisical Laryngitis. (A 
 paper published in The Birmingham Medical 
 Review, February, 1883.) 
 
 General treatment. — Counter-irritation. — Laryn- 
 geal brushings. — Inhalations. — Lozenges. — Rest. 58 
 
 IV. Note upon the Medicinal Treatment of 
 
 Pulmonary Consumption, with especial 
 reference to the value of Chloride of 
 Calcium. (Abstract of a paper published in 
 The British Medical Journal, June 5th, 1880.) 
 
 Phthisis a generic name. — Various remedies 
 required. — Value of chloride of calcium as a 
 general remedy in phthisis. — Its old repute in 
 struma. — Value in night-sweats . . . . . . 68 
 
 V. Some Points in the Treatment of the Severer 
 
 Forms of Constipation and of Intestinal 
 Obstruction. (A paper published in The 
 British Medical Journal, November 17th, 1883.) 
 
 Difference between constipation and intestinal 
 obstruction. — Remedies in habitual constipation. 
 — Signs of feecal retention. — Enemata. — Varieties 
 of intestinal occlusion. — Symptoms of intestinal 
 occlusion. — Treatment of intestinal occlusion. — 
 Value of combinations of therapeutic resources. — 
 When surgical interference is indicated. — Choice 
 of surgical procedure . . . . . . • . 77 
 
CONTENTS. 1 1 
 
 PAGE 
 
 VI. Accentuation of the Pulmonary Second 
 Sound of the Heart. (A clinical lecture, 
 published in The British Medical Journal., March 
 31st, 1883.) 
 
 What accentuation indicates. — Clinical import. — 
 Prognostic value. — Therapeutic indications . . 12: 
 
 VII. Remarks on Floating Kidney. (A digest of two 
 papers : Floating Kidney, The Birmingham 
 Medical Review, July, 1872 ; Remarks on Float- 
 ing Kidney, Ibid., October, 1883.) 
 
 Cases of floating kidney established by post- 
 mortem examinations. — Physical signs. — Case. — 
 Causation of floating kidney. — Frequency in 
 women. — Comparison of anatomical relations of 
 kidneys. — Frequency of floating kidney in women. 
 — Symptoms. — Treatment .. .. .. .. 137 
 
 VIII. The Treatment of Gastralgia. (A clinical 
 lecture, published in The Lancet, August 13th, 
 1887.) 
 
 Pain of gastralgia. — Importance of negative 
 diagnosis. — Romberg's description of seizure. — 
 Temperamental and sexual associations. — Diag- 
 nosis. — Cautions. — Employment of arsenic. — 
 Counter-irritation. — Diet .. .. .. .. 154 
 
12 CONTENTS. 
 
 PAGE 
 
 IX. Ethereal Tincture of Capsicum. (A note 
 published in The Lancet, May 17th, 1890.) 
 
 External use of capsicum. — Adva,ntages of ethe- 
 real tincture. . . . . . . . . . . . . 169 
 
 X. Ether as a Menstruum in Medication by 
 THE Skin. (A paper published in The Lancet, 
 July I2th, 1890.) 
 
 Absorption of medicines by the skin. — Faultiness 
 of officinal plasters. — Obstacles to absorption by 
 the skin. — Advantages of ether as a menstruum. — 
 Ethereal tinctures. — Belladonna. — Iodine. — 
 Menthol 172 
 
 XI. Randia Dumetorum. (A paper published in The 
 Lancet, March 21st, 1891.) 
 
 Action of saponin. — Indian uses of randia. — 
 Employment as a nervine restorative and anti- 
 spasmodic .. .. .. .. .. .. 183 
 
THE CAUSES AND CURE OF INSOMNIA.* 
 
 Psychic, toxic, and senile forms of insomnia. — 
 Condition of brain in sleep. — Emotional 
 shock and mental strain as causes of 
 insomnia. — Symptoms of insomnia. — Causes 
 of toxic insomnia. — Treatment. 
 
 I DESIRE to submit to you some practical 
 observations, based upon my own experience 
 as a physician, concerning the etiology and 
 management of insomnia. Inability to sleep 
 at all, or at a suitable time, or long enough, 
 without the aid of drugs, is one of the com- 
 
 ■ A Clinical Lecture : published in The Lancet, June 15th 
 and 22nd, 1878 ; since revised and entirely rewritten. 
 B 
 
14 THE CAUSES AND CURE OF INSOMNIA 
 
 monest complications and consequences of a 
 vast variety of morbid states. Pyrexia ; phy- 
 sical pain, if sufficiently severe, and from- 
 whatever cause arising; frequent coughing, as 
 that which often occurs in chronic pulmonary 
 phthisis ; urgent dyspnoea, such as results 
 from extreme dilatation of the cardiac cavities, 
 and requires an extraordinary vigilance of the 
 nervous centres for the maintenance of the 
 processes of respiration and circulation — are 
 conditions which prevent, shorten, or interrupt 
 sleep. In such and similar instances the 
 cause of the sleeplessness is obvious. Such 
 insomnia may mostly be controlled by one of 
 two therapeutic methods, or by a combina- 
 tion of them, namely, either by the exhibi- 
 tion of remedies which directly promote sleep 
 (hypnotics), or by the adoption of measures 
 which combat the cause of the insomnia, 
 by reducing the fever, by removing the pain, 
 by soothing the cough, or by relieving the 
 cardiac disturbance. But of sleeplessness 
 
THE CAUSES AND CURE OF INSOMNIA I 5 
 
 arising as the direct effect of these and like 
 conditions it is not my purpose to speak. I 
 shall endeavour to unravel the complex causes, 
 and point out the successful treatment of that 
 kind of insomnia which may be called, for the 
 sake of simplicity, but scarcely with strict 
 truth, insomnia per se, or simple inability to 
 sleep — a kind of wakefulness for which we fail 
 to find an objective or obvious physical cause, 
 and which seems to depend upon an inability 
 on the part of the brain and nervous system 
 generally to adapt themselves to the condi- 
 tions which are necessary for sleep. We meet 
 with this disorder more in private than in hos- 
 pital practice — mostly in persons who belong 
 to what are called the upper and upper middle 
 classes, and mostly in individuals of high 
 mental endowment. The malady is of extreme 
 importance, and happily, if its causes be 
 rightly understood and judiciously controlled, 
 there are few affections which are more within 
 the sphere of curative therapeutics. 
 
l6 THE CAUSES AND CURE OF INSOMNIA 
 
 A close study of cases of the kind of 
 insomnia of which I am speaking reveals strik- 
 ing differences in individual instances of the 
 disorder, in respect both to the causes and the 
 course of the malady. These differences de- 
 mand careful consideration, because they have 
 important bearings upon both our therapeutics 
 and our prognosis. I have endeavoured to 
 arrange the different varieties of insomnia into 
 groups, in which the cause of the affection is 
 the "principle of division." To these groups 
 I give the names " psychic," " toxic, " and 
 " senile." 
 
 In natural sleep the brain is relatively 
 anaemic. When the organ is in full activity 
 its arteries are filled with blood ; its cells are 
 living rapidly, actively receiving nourishment 
 from the blood, and pouring into it in exchange 
 the waste products of their vitality. But in 
 sound sleep the brain is inactive ; at least all 
 but that part of it which is concerned in the 
 processes of organic life. The cells which 
 
THE CAUSES AND CURE OF INSOMNIA IJ 
 
 think are as still as those of the muscles of a 
 limb which is at rest. The blood flows in a 
 smaller and gentler stream than in the waking 
 state; the cells are not expending energy, but 
 they are leisurely renewing it and storing it 
 up : in a word, they are resting. Any cause 
 which prevents the due repose of a sufficient 
 number of those brain-cells which are con- 
 cerned in conscious thought will prevent sleep ; 
 relative cerebral hypersemia is a consequence 
 of such activity, and is also a concurrent, 
 though subordinate, cause of wakefulness. 
 Hence there are causes of insomnia which act 
 primarily in sustaining cerebral activity, and 
 with it, and in consequence of it, relative 
 cerebral hypersemia. Again, any cause which 
 prevents the brain from becoming sufficiently 
 relatively anaemic for sleep will produce in- 
 somnia. Any agent which sustains cerebral 
 hypersemia, or any morbid condition which im- 
 pairs the contractility of the cerebral arteries, 
 may prevent wholly, or in part, the occurrence 
 
1 8 THE CAUSES AND CURE OF INSOMNIA 
 
 of such a degree and extent of cerebral anaemia 
 as is required for the production of sleep. 
 Hence there are causes of insomnia which act 
 primarily in exciting and sustaining relative 
 cerebral hypersemia, and with it, and in con- 
 sequence of it, cerebral activity. But in such 
 a complex condition as conscious cerebral 
 activity, where thought implies increased blood- 
 flow, and increased blood-flow implies thought, 
 we cannot in any given case allow with strict 
 accuracy entire causal precedence to either of 
 the factors which are essential to the common 
 result. But these considerations are strictly 
 pertinent to a clear conception of the causes 
 of insomnia. In some cases of sleeplessness, 
 as in the psychic group, undue and protracted 
 cerebral activity is the primary vice ; in others, 
 as in the toxic and senile varieties, relative 
 cerebral hyperaemia is the initial error, and 
 cerebral action its direct consequence. 
 
 I shall now consider more in detail the 
 psychic form of insomnia. A severe and 
 
THE CAUSES AND CURE OF INSOMNIA 19 
 
 sudden emotional shock of a depressing kind, 
 as grief at the death of a beloved relative, 
 will sometimes produce at once persistent 
 insomnia, which will only yield to carefully 
 directed therapeutic procedures. Prolonged 
 mental strain, in all its varied phases, is a 
 common cause of sleeplessness. Our patient 
 may be a student preparing for an examina- 
 tion. For weeks, in spite of fatigue, he may 
 have shortened his hours for sleep that he 
 might lengthen his time for reading ; and he 
 may have been in the habit of keeping 
 himself awake, when he could readily have 
 fallen asleep, by drinking strong tea or 
 coffee or by smoking tobacco. But he 
 could always go to sleep at once when he 
 went to bed, and sleep soundly, until, after 
 some weeks of his abnormal work, with the 
 nearer approach of the examination bringing 
 increased anxiety as to the result of the 
 ordeal, he found he began to sleep badly or 
 could not sleep at all. He grew miserable ; 
 
20 THE CAUSES AND CURE OF INSOMNIA 
 
 he could not remember what he read ; he 
 felt unfit for any exertion ; and he could 
 not face his examination. Or, our patient 
 may be a young professional man. He has 
 commenced practice, or rather to wait for 
 practice, as a barrister, a solicitor, a physician, 
 or a surgeon. He begins to find that 
 causes or cases have not been waiting for 
 his advent ; clients or patients are " few and 
 far between." For a time he manfully 
 struggles on, his hope and his health 
 sustaining him ; but these at last yield 
 under the continued pressure of new disap- 
 pointments and accumulating anxieties. He 
 wants money ; his friends will give it to him 
 readily if he will ask for it, but his pride 
 prevents him. It is not a gift or loan he 
 needs ; he does not want to beg or borrow 
 money, he yearns to earn it. And while he 
 has been hoping and waiting, and growing 
 sick with the failure of his expectations, he 
 has been working early and late in his study 
 
THE CAUSES AND CURE OF INSOMNIA 21 
 
 perhaps reading for some higher examination, 
 denying himself due sleep and exercise, in 
 the trust that he might thus so skill himself 
 as to secure the longed-for practice. At last 
 he has fairly broken down. He has grown 
 thinner ; he looks haggard ; he is filled with 
 groundless fears ; he is weighed down with 
 the ineffable misery of insomnia ; he has con- 
 stant headache and noises in his ears ; he 
 thinks his memory is failing ; he is dull and 
 listless ; he has been lying awake for hours 
 after going to bed, or, waking in the "small 
 hours," he has been unable to sleep again, 
 and when he has slept he has had horrid 
 dreams ; and he comes to us for help because 
 he can scarcely sleep at all, and he is pos- 
 sessed by the fear that he is going mad. In 
 these cases acute or continued mental strain 
 is the primary cause of the sleeplessness. 
 Where the shock has been sudden and severe 
 it has been sufficient to rouse a given group 
 of cells into persistent activity. Where the 
 
22 THE CAUSES AND CURE OF INSOMNIA 
 
 Strain has been less intense, but kept up long, 
 it has been all the more hurtful because the 
 same set of ideas has been maintained in 
 exhausting recurrence ; and because, as a con- 
 sequence of this monotony, the same part of 
 the brain has been continuously upon the 
 rack. But in either case sleeplessness did not 
 occur until there arose from exhaustion par- 
 tial or complete vaso-motor paralysis of the 
 intra-cranial blood-vessels ; until the arteries 
 of the brain, worn out by a sustained ere- 
 thism, could no longer, even when the brain 
 most needed it, find the force for that con- 
 traction of their calibre without which sleep 
 is impossible. 
 
 The subjects of the psychic form of 
 insomnia are mostly men, and mostly men of 
 the nervous temperament. We have lately 
 been too ready to ignore temperaments ; our 
 fathers studied them better and regarded them 
 more than we do. But I shall not go to any 
 authority for a portrait of the nervous tern- 
 
THE CAUSES AND CURE OF INSOMNIA 23 
 
 perament ; I shall describe it as I think I 
 have found it. I use the phrase nervous tem- 
 perament to indicate a distinct type of 
 outward form, of manner, of habits, and 
 of tendencies. Temperaments present their 
 various types most frequently in men. Com- 
 paratively few women exhibit a well-marked 
 temperament ; but when a woman is of the 
 nervous temperament, in her the temperament 
 is mostly very distinct indeed. Two or more 
 of the different kinds of temperament may 
 appear to be blended ; we have a compound 
 of modified temperaments. A man of dis- 
 tinctly nervous temperament has a quick 
 manner ; he is nearly always in a hurry ; he 
 is - apt to talk volubly and eat quickly ; if he 
 does not know us well, he fidgets with his 
 hands or legs when he is speaking ; he talks 
 abruptly, earnestly, and fluently, often splitting 
 up his phrases, or recalling and correcting 
 them, and especially modifying qualifying 
 words, such as adverbs and adjectives, in his 
 
24 THE CAUSES AND CURE OF INSOMNIA 
 
 anxious desire to express what he conceives to 
 be the finest shades of truth. A man of this 
 temperament is apt to " overdo " everything 
 into which his feeHngs enter. He is apt 
 for hobbies ; and he is oft€n a diligent 
 collector of curiosities. When he becomes a 
 patient he is harassed about some trivial 
 symptom ; he has felt his heart beating, and 
 he thereupon fancies he has some deadly 
 cardiac disease ; he thinks his memory is 
 failing, and he forthwith imagines he is going 
 mad. 
 
 A man who has suffered much from in- 
 somnia becomes the subject of a well-marked 
 group of symptoms. Most of them are given 
 by certain writers amongst the signs of 
 cerebral hyperaemia. It is probable that they 
 mark a particular variety of exhaustion of 
 the brain, attended by more or less abnormal 
 increase of intra-cranial vascularity, and ac- 
 companied by some general prostration of 
 the bodily powers. Here are the concomi- 
 
THE CAUSES AND CURE OF INSOMNIA , 2$ 
 
 tants of insomnia as I have found them. The 
 patient has a dull and listless look ; his eyes 
 are wanting in vivacity ; the upper lids may 
 droop a little, and they may be slightly 
 swollen. The complexion is sallow. There is 
 headache ; of this there are two kinds, which 
 either co-exist or occur separately. The com- 
 moner variety of headache is a dull pain felt 
 over the whole of the vertex, together with a 
 vague and widespread feeling of oppression 
 in the head ; the other is a sharp, shooting 
 pain, which comes on suddenly, and usually 
 in single flashes, and which gives the idea of 
 a knife being driven through the head from 
 one temple to the other. Occasionally the 
 patient feels a momentary giddiness ; this 
 may cause a false step, but it never lasts long 
 enough to give rise to staggering. The skin 
 of the head, especially near the saggital suture, 
 may be tender. There are noises in the ears, 
 in one or in both, usually of a low-pitched 
 whistling character. They may- come on sud- 
 
26 THE CAUSES AND CURE OF INSOMNIA 
 
 denly, and without apparent cause, as when 
 the patient is talking quietly, or they may 
 only come on when the attention is more 
 closely occupied, as in writing a letter or 
 casting up figures. A striking sign is a slight 
 impairment of hearing. The patient may be 
 unaware of it, but those with whom he lives 
 have noticed that he often asks them to repeat 
 what they say to him because he could not 
 quite catch their words. He may complain 
 of seeing spots before his eyes — little cob- 
 webby black lines, which come and go and 
 float about, or bright, bluish, phosphorescent- 
 like specks which seem fixed for a moment, 
 one before each eye, and which only appear 
 when he first directs his eyes towards an 
 object. There are some abnormal sensations 
 in the skin ; not formication, such as is apt 
 to arise in organic nervous disease, but a 
 sharp, transitory, and isolated prickling, as of 
 the movement of a single pin, which lasts 
 only for an instant, and affects either the 
 
THE CAUSES AND CURE OF INSOMNIA 27 
 
 limbs or the trunk, mostly the former. There 
 may be a peculiar twitching of muscles. It 
 is not a vibratory tremor, like that of pro- 
 gressive muscular atrophy, nor is it a con- 
 traction of a whole muscle, or of a group of 
 muscles, such as arises in true convulsion. 
 But, while the patient is sitting still, a con- 
 siderable part of a muscle becomes the sub- 
 ject of rapid clonic movements, and these are 
 wholly independent of volition. These move- 
 ments mostly occur in the lower extremities, 
 but they are rarely sufficient to move the 
 limbs ; they usually affect the lower part of 
 one vastus internus, and last for about a 
 minute. The patient can feel the movements 
 by attending to the affected part, and he can 
 also feel that the muscle moves by applying 
 his hand to it. In such a case there is often 
 unnatural and painful sensitiveness to external 
 impressions. The patient craves for quiet. A 
 bright light troubles him. Noises, the sight 
 of moving objects, touches, as of the hand 
 
28 THE CAUSES AND CURE OF INSOMNIA 
 
 of a friend upon his shoulder, annoy him. 
 There is not an increased sensitiveness to 
 external impressions, but impressions which 
 are enjoyed or unnoticed in health become 
 irritants. 
 
 I have been considering a kind of 
 insomnia in which unnatural excitation of 
 the cerebral cells is probably the initial fault. 
 In a very few words I shall indicate the 
 other forms of the disorder — the toxic and 
 the senile. 
 
 In toxic insomnia, the cause of the 
 sleeplessness acts primarily upon the vessels 
 of the brain, giving rise to some degree of 
 arterial hyperaemia. Some poisonous agent 
 maintains cerebral vascularity at such a 
 height that conscious cerebral activity — that 
 is, wakefulness — is an inevitable consequence. 
 Such a poison may be introduced into the 
 body from without, or it may be a product of 
 diseased processes arising within the body 
 itself Of course, I use the word " poison " 
 
THE CAUSES AND CURE OF INSOMNIA 29 
 
 in a restricted sense ; I do not mean 
 something which kills, but only something 
 which produces abnormal manifestations in 
 the living body. The external poisons 
 which most frequently cause sleeplessness are 
 tobacco, alcohol, tea, and coffee; the internal, 
 certain waste products of tissue-metamorphosis 
 which accumulate in the bodies of gouty 
 pei-sons, or of those whose kidneys act defi- 
 ciently. Many a man does not and cannot 
 sleep sufficiently simply because he smokes 
 excessively. Cut off his " cavendish " or his 
 cigars, and he will sleep well. Many smokers 
 know that they sleep badly if they smoke 
 more than their usual quantity of tobacco, or 
 if they smoke tobacco stronger than that to 
 which they are accustomed. If a man who 
 smokes two cigars every evening be induced at 
 some time to smoke three, or if a smoker of 
 "bird's-eye" venture to replace it by "caven- 
 dish," he may, when he has gone to bed, find 
 he cannot sleep ; and the cause of his sleep- 
 
30 THE CAUSES AND CURE OF INSOMNIA 
 
 lessness is the smoking of more or of stronger 
 tobacco than that to which he has been ac- 
 customed. Men of distinctly nervous tem- 
 perament, or men in whose temperament 
 there is a distinct and considerable admix- 
 ture of the nervous element, are often great 
 smokers. Men who are slow and calculating 
 are rarely smokers ; men whose activity is 
 of an objective type are happy in rarely 
 feeling the nervous unrest which tobacco 
 calms. Tobacco smoking stimulates the cere- 
 bral circulation ; it disposes to a succession 
 of pleasing ideas by inducing an easy flow 
 of mental activity. But this stimulation 
 of the blood-flow in the brain is sure, 
 if pushed' to undue limits, to induce cerebral 
 vaso-motor debility or paralysis, and, as a con- 
 sequence, persistent conscious thought. Some- 
 times, then, a man consults us for the relief of 
 insomnia, and we find he is young, he has had 
 no trouble, he takes plenty of food and exercise, 
 and he does not overtax his brain. But he is 
 
THE CAUSES AND CURE OF INSOMNIA 3 1 
 
 an excessive smoker ; he smokes morning, noon, 
 and night, and he has gone on from mild tobacco 
 to the strongest. He need not give up, nor 
 shorten, nor change his w^ork, and he does not 
 need drugs ; cut off or cut down his smoking, 
 and he at once sleeps well. And so, mutatis 
 mutandis, does alcohol cause sleeplessness. The 
 man who drinks to commencing drunkenness 
 mostly sleeps soundly, if not well. But many 
 a so - called moderate drinker knows that he 
 sleeps badly if he take a little more than his 
 usual quantity of wine after dinner, or even his 
 usual quantity of some unusual wine. Alcohol 
 flushes and dilates the smaller blood-vessels, 
 especially those of the brain ; if such a condition 
 be maintained, sleep is disturbed or wanting. 
 We have all seen the insomnia of delirium 
 tremens : the patient cannot sleep because the 
 lesser arteries of his brain are paralysed by 
 alcohol, and sleepless cerebral activity is the 
 inevitable consequence. Far short of what is 
 usually called alcoholism, we often meet with 
 
32 THE CAUSES AND CURE OF INSOMNIA 
 
 cases of insomnia in which alcohol alone is the 
 cause of the wakefulness. The patient may- 
 pride himself upon his moderate use of fer- 
 mented stimulants, and he may be wholly 
 ignorant of the cause of the sleeplessness for 
 which he consults us. We fail to find any 
 sufficient psychic cause for his insomnia ; but 
 if we take away or diminish his wine or his 
 grog, or induce him to consume it before the 
 evening, we find he soon begins to sleep well. 
 
 The effects of tea and coffee in causing 
 wakefulness are well known. Some individuals 
 are extremely susceptible to the action of these 
 stimulants. We sometimes meet with persons, 
 mostly women, who habitually drink enormous 
 quantities of strong tea ; such people are usually 
 troubled with flatulent dyspepsia, and sleep 
 badly, but they rarely suffer from serious 
 insomnia. 
 
 On this occasion I can only mention those 
 varieties of toxic insomnia which are apt to 
 occur in gouty persons, or in those whose 
 
THE CAUSES AND CURE OF INSOMNIA 33 
 
 kidneys are failing, and which arise from the 
 accumulation in the blood, in consequence of 
 deficient excretion, of the products of tissue- 
 metamorphosis. Insomnia of this kind is rarely 
 complete. But the patient may complain that 
 he sleeps very badly, that he lies awake for 
 some hours and has great difficulty in getting 
 off to sleep, that he is easily awakened and 
 wakes frequently, and that he always dreams 
 when he sleeps. In such a case we may find a 
 pulse of high tension ; the aortic second sound 
 may be accentuated, and the first sound of the 
 heart may be reduplicated at the apex. Where 
 there is chronic renal disease there may be the 
 physical signs of the characteristic cardiac 
 hypertrophy which accompanies chronic con- 
 tracting nephritis. Insomnia in such cases is due, 
 probably, to the maintenance of a state of high 
 tension in the cerebral arteries. I wish to impress 
 upon you that we find a clue to the cause of many 
 cases of sleeplessness in the signs of the gouty 
 diathesis or in the discovery of albuminuria. 
 
34 THE CAUSES AND CURE OF INSOMNIA 
 
 Again, there is a senile form of insomnia. 
 You may perhaps have observed amongst your 
 friends that an exaggerated appreciation of the 
 merits and value of early rising mostly increases 
 as age advances. The sleeplessness from which 
 many old persons suffer is mainly, if not entirely, 
 the result of senile degeneration of the smaller 
 cerebral arteries. Those vessels are less elastic 
 and less contractile than in health, and their 
 weakened, walls often lead to their permanent 
 dilatation ; they are physically unable to adapt 
 themselves fully to the condition of relative 
 arterial anaemia which is requisite for healthy 
 sleep. The tendency of this condition of the 
 blood-vessels of the brain to prevent or lessen 
 sleep is probably to a great extent counteracted 
 by the cardiac feebleness which so frequently 
 and so fortunately coexists with the vascular 
 changes. 
 
 In the treatment of insomnia we must 
 often use soporifics. Of these the chief 
 are chloral, opium, morphia, sulphonal, the 
 
THE CAUSES AND CURE OF INSOMNIA 35 
 
 bromides, Indian hemp, alcohol, and affusion 
 with cold water. The successful treatment 
 of a case of sleeplessness follows from the 
 discovery of its cause. In the severer forms 
 of psychic insomnia we must often at once 
 secure sleep by some efficient hypnotic. I 
 prefer opium or chloral. By the use alone 
 of one of these drugs we can often quickly 
 cure acute insomnia depending upon some 
 sudden mental shock or strain. A few nights 
 of sound and sufficient sleep, artificially in- 
 duced, will do more than anything else to 
 restore to the brain the power of sleeping 
 without aid from drugs. In the more chronic 
 forms of psychic insomnia, where the sleep- 
 lessness or wakefulness usually depends upon 
 prolonged worry or overwork, I employ 
 chloral sparingly. It should only be used as 
 a temporary remedy, when it is necessary 
 that we should at once secure a fair amount 
 of sleep. The patient ought never to be 
 allowed to swallow this dangerous but valu- 
 
36 THE CAUSES AND CURE OF INSOMNIA 
 
 able drug whenever he feels so disposed, or to 
 apportion its dose for himself; he ought only 
 to take it under medical direction and observa- 
 tion. Another important point must always 
 be kept in view. It is this : an overworked 
 man must never be permitted to go on with 
 his overwork, and habitually secure sleep by 
 chloral or any other hypnotic. In such a 
 case we must always aim at preventing the 
 sleeplessness by removing its cause, instead 
 of pursuing the easier but illogical and 
 precarious course of permitting that cause to 
 continue, and of trusting to counteract or sup- 
 press one of its effects by medicine. When 
 a man cannot sleep because he works his 
 brain too much, we must insist that he stop 
 or greatly lessen his labour. But I must 
 warn you that real work is not often the 
 cause of insomnia. Work fits for rest. It is 
 mostly worry, not work, that brings unrest. 
 It is not work that wears, but worry. What- 
 ever the cause of the insomnia, a holiday. 
 
THE CAUSES AND CURE OF INSOMNIA 37 
 
 with complete change of scene, will often do 
 much to effect a cure. The old maxim, 
 " Ccelum. non animum mutant qui trans mare 
 currunt," like most other maxims, old and 
 new, is not always wholly true. Send an 
 overworked and worried merchant or barrister 
 from his counting-house or from his chambers, 
 in a busy town, to a quiet village by the 
 sea, or across the Channel, to a French 
 watering-place, and let him substitute walk- 
 ing and bathing, rowing and fishing, for his 
 books or his briefs, and he will often need 
 no physic to make him sleep soundly and 
 sufficiently. But, however great the influence 
 of new surroundings and of new outlets 
 for energy, for the cure of many cases 
 of psychic insomnia we cannot dispense 
 with drugs. In well-nourished patients, 
 and in the slighter cases, bromide of 
 potassium is by far the best hypnotic. It 
 soothes the irritated and irritable cerebral 
 cells ; it is a~ direct and absolutely safe brain 
 
38 THE CAUSES AND CURE OF INSOMNIA 
 
 sedative. It is marvellously powerful in 
 producing nervous calm ; but it must be 
 given in full doses, thirty to sixty grains at 
 bedtime. "It is well to conjoin with it some 
 drug which will favour the contraction of the 
 weakened cerebral vessels. For this purpose 
 we may give tincture of ergot or tincture of 
 digitalis, one or both. In many cases of 
 chronic wakefulness, arising .from mental 
 strain, the patient is distinctly anaemic. 
 Unless the anaemia be remedied, the insomnia 
 cannot be cured. The patient's pale face 
 and soft, small pulse declare the condition 
 of his blood. Such a person mostly feels 
 drowsy when he is up, and wakeful when he 
 lies down. Of course he needs iron. We 
 may give him a grain or two of reduced 
 iron, sprinkled on a small piece of bread, or 
 a wineglassful of Orezza water, after each 
 meal. His diet must be liberal, containing 
 plenty of fish, meat, and eggs. For such a 
 patient alcohol is often the best hypnotic. 
 
THE CAUSES AND CURE OF INSOMNIA 39 
 
 To many people a " nightcap " of toddy is a 
 superfluous, perhaps hurtful, luxury. But it 
 gives, perhaps better than anything else, rest 
 and sleep to the exsanguine and worried 
 brain. We must never be blind to the 
 responsibility we incur when we prescribe 
 alcohol, neither need we exaggerate that 
 responsibility. When we use alcohol, in the 
 form of any of the fluids which contain it, 
 as a remedy in the treatment of disease, we 
 must clearly state the reasons for its adoption ; 
 and we must discontinue it, as we discontinue 
 the use of other drugs, when the conditions 
 which called for its exhibition have dis- 
 appeared. If I am sure of anything in thera- 
 peutics, I am sure that alcohol is the best 
 hypnotic in many, cases of chronic psychic 
 insomnia, when the patient is worried, 
 sorrowful, weakly, and anaemic. 
 
 Many comparatively minor points are 
 especially worthy of attention in the treat- 
 ment of chronic psychic insomnia. In most 
 
40 THE CAUSES AND CURE OF INSOMNIA 
 
 cases, whether he sleep well or ill, the patient 
 ought, from day to day, to go to bed and 
 get up at fixed and regular times. Healthy 
 sleep is a rhythmic act ; it tends to occur 
 periodically. Daily bodily exercise, in the 
 open air, if possible, but always short of 
 great fatigue, must be enjoined. Driving in a 
 carriage is good, walking better, riding on 
 horseback best. A worn and self-worrying 
 man, wrapt up in the absorbing torture of 
 self-consciousness, may take exercise in a car- 
 riage or upon his legs and still keep up his 
 fretting, but he must come out of himself 
 when he gets into a saddle. Gardening 
 affords good exercise, and it is very efficient 
 in keeping up objective attention. Those who 
 live in towns may find good objective employ- 
 ment in chopping wood ; if they have not 
 trees to fell, they can at least copy Arch- 
 bishop Whately, and give their minds a 
 refreshing objective bent and their muscles 
 healthy work by cutting up firewood. People 
 
THE CAUSES AND CURE OF INSOMNIA 41 
 
 who find it difficult to get off to sleep have 
 been advised to count monotonously one, two, 
 three, up to a thousand or more, until they 
 fall asleep ; to watch in imagination each 
 sheep of a large flock squeezing through a 
 narrow opening ; to picture some familiar 
 landscape and keep the mind fixed upon it ; 
 to repeat the letters of the alphabet, Sz;c. 
 These are expedients for changing the current 
 of cerebration. For a night or two one or 
 another may succeed, but they cannot be 
 relied upon. These practices often even keep 
 up wakefulness ; when the mind attends to 
 them too closely, they sustain the subjectivity 
 which keeps the brain from resting. Often the 
 surest way of keeping awake is to try hard 
 to go to sleep. We do most things best 
 when we forget ourselves: going to sleep is 
 no exception to the rule. Sleep may often 
 be induced by the temporary application of 
 cold to the head or to the general surface 
 of the body. A person who has been lying 
 
42 THE CAUSES AND CURE OF INSOMNIA 
 
 awake will often fall asleep at once after 
 getting out of bed and sousing his head, 
 neck, and hands in cold water, or after 
 following Charles Dickens' plan of standing 
 at his bed side until he feels chilly, and 
 thereupon turning over, shaking up, and 
 cooling his pillows and the bed-clothes, and 
 then getting into bed. 
 
 Especially must we endeavour, in the 
 toxic kinds of insomnia, to act upon the 
 maxim, " cessante causd, cessat et effectus." 
 We must stop or lessen the' consumption of 
 tobacco, alcohol, tea, &c., as the case may be. 
 A discussion of the treatment of gouty 
 insomnia, and of the sleeplessness arising in 
 some chronic kidney diseases, would involve 
 a consideration of the whole question of 
 therapeutics of the maladies upon which these 
 forms of wakefulness depend. I shall only 
 now say that in gouty lithiasis, with a pulse 
 of high tension, I have confidence in the 
 curative powers of colchicum, supplemented 
 
THE CAUSES AND CURE OF INSOMNIA 43 
 
 by the exhibition of dilute saline purgatives, 
 such as Pullna, Friedrichshall, Hunyadi Janos, 
 ^sculap, and Rakoczy waters. Senile 
 insomnia is very obstinate ; perhaps in the 
 bromides, with full doses of hop or henbane, 
 we have the most efficient and least harmful 
 means for its relief 
 
 To treat insomnia with precision, we 
 must in each case find its cause, and remove 
 such cause when we can, or subject it to 
 favourable modification. Each case needs close 
 individual study. We may find a man lies 
 awake in the earlier part of the night 
 because he works with his head too late ; 
 or we may find insomnia after a brief " first 
 sleep," the patient being unable to sleep 
 during the remainder of the night because 
 his brain is kept on the alert by worry in 
 his affairs, and especially by financial anxiety. 
 We must always remember that sleeping is 
 a rhythmical function, and we must not allow 
 our patients to sleep on too late in the 
 
44 THE CAUSES AND CURE OF INSOMNIA 
 
 mornings because they have been unable to 
 sleep at the proper time. In some cases 
 the good effects of a Httle food, a cup of 
 cocoa, or a small piece of dry bread, upon 
 getting into bed, or upon awakening after a 
 slumber which is too short for a night's rest, 
 are most happy. 
 
II. 
 
 PHTHISICAL LARYNGITIS.* 
 
 Definition of the disease. — Value of tJie 
 laryngoscope. — Concurrence of phthisical 
 laryngitis and pulmonary consumption. — 
 Stages of phthisical laryngitis.— Vocal 
 symptoms. — Respiratory symptoms. — Difficulty 
 of deglutition. — Cough. — Pain. — Expectora- 
 tion. 
 
 I PURPOSE to offer you a brief description of 
 phthisical laryngitis. I shall endeavour to 
 lay before you in outline, in as few words as 
 possible, an account of the clinical history 
 and progress of this common, painful, fatal, 
 
 * A Clinical Lecture : published in The Lancet, 
 January 30th, 1875 ; since revised and entirely rewritten. 
 D 
 
46 PHTHISICAL LARYNGITIS 
 
 and important malady. By phthisical 
 laryngitis,' I mean that peculiar form of 
 chronic inflammation of the structures of the 
 larynx which is met with in a very large 
 proportion of cases of ordinary chronic pul- 
 monary consumption. From the earliest 
 times this disorder has been recognised. 
 Celsus indicated it, probably, when he 
 described, as a result of exposure to bad 
 weather, " Tussis, destillatio, raucitas, in 
 quibusdam etiam tabes oritur." The general 
 symptoms of serious laryngeal disease are 
 always strikingly evident, even without the 
 aid of the laryngoscope ; and when these 
 were present in cases of consumption of the 
 lungs, it was usual to infer that laryngeal 
 phthisis existed as a complication. After 
 death, decided evidences of grave laryngeal 
 lesions were often found, more especially 
 ulcerations of the mucous membrane and 
 changes in the cartilages — conditions which 
 have been carefully described by Rokitansky 
 
PHTHISICAL LARYNGITIS 47 
 
 and other writers. But the laryngoscope, as 
 has often been said, literally threw light upon 
 these and many other pathological processes 
 in the throat. We have now become able 
 exactly to observe, and carefully to watch, 
 and so intelligently to treat, these local 
 maladies ; and it has become possible to mark 
 the earliest visible alterations of the larynx 
 in laryngeal phthisis, to recognise the disease 
 in its first beginnings, to divide its progress 
 into stages, and to apply remedies directly 
 to the morbid tissues. Mackenzie, Niemeyer, 
 Marcet, Cohen, Gibb, Aitken, Lennox Browne, 
 and many others have written excellent 
 descriptions of laryngeal phthisis — descriptions 
 which agree in the main, while they conflict 
 in not a few important particulars. But I 
 shall follow the writings of none of these 
 authors ; J prefer to base my brief account 
 of the course of the disease upon my own 
 clinical experience in private and hospital 
 practice. 
 
48 PHTHISICAL LARYNGITIS 
 
 Concerning the pathology of phthisical 
 laryngitis I shall say little. Our ideas of the 
 pathology of phthisis have recently undergone 
 some important changes. Amid much contra- 
 diction, but as the fruit of much patient 
 labour, very great advances — advances to my 
 mind unsurpassed in importance by any which 
 have been made in this generation in any 
 department of the science of medicine — have 
 been gained in our knowledge of phthisis and 
 tuberculosis. JPathologists and physicians who 
 have written about laryngeal phthisis have 
 differed much in their views concerning the 
 nature of the affection. For example, 
 " Virchow recommends the larynx as the very 
 place to study true tuberculosis ; " * while 
 Louis did not consider that tubercle was ever 
 deposited in the tissues of the larynx ; -f and 
 Mackenzie, describing the pathology of 
 
 * Niemeyer : Pract. Med., translated by Hupiphreys and 
 
 Hackley. 
 + Louis on Phthisis, quoted in Reynolds' System of Medicine. 
 
PHTHISICAL LARYNGITIS 49 
 
 laryngeal phthisis, says, "Tubercle appears 
 to play a very secondary part, if any part at 
 all." * My own observations lead me to 
 conclude that the local lesions in the larynx 
 in phthisis are inflammatory, and unconnected 
 with truly tubercular processes. But we must 
 recognise that the local changes in phthisical 
 laryngitis have a characteristic course of their 
 own ; the local inflammation, in its progress 
 and results, is distinctly of a specific type. 
 Phthisical laryngitis is a peculiar form of 
 chronic inflammation of the larynx. 
 
 I do not think 1 have ever met with a 
 case of laryngeal phthisis which was not 
 complicated, sooner or later, with pulmonary 
 consumption. The pulmonary changes usually 
 appear before those in the throat. But not 
 unfrequently laryngeal phthisis becomes fully 
 established before any lesions in the lungs 
 can be appreciated, and in these cases the 
 
 * Mackenzie : Reynolds' System of Medicine. 
 
50 PHTHISICAL LARYNGITIS 
 
 laryngoscope is of the greatest service in 
 helping us to decide whether a given case 
 of laryngitis, unattended by thoracic disease, 
 is phthisical or not. Adults are much more 
 liable to this disease than children, and men 
 than women. 
 
 For some time past I have found it 
 convenient to divide the laryngeal changes 
 in this affection into four stages, viz., i, the 
 stage of anaemia ; 2, that of tumefaction ; 
 3, that of ulceration ; and, 4, that in which 
 necrosis or caries of the cartilages may arise. 
 The first three of these stages are almost 
 always, met with ; the last is not nearly so 
 constant in its occurrence. The earliest 
 visible local change is anaemia — a very decided 
 and general pallor of the mucous membrane 
 of the larynx. Any one accustomed to use 
 the laryngoscope cannot fail at once to 
 recognise this condition. Sometimes the 
 anaemia extends to the whole of the upper 
 part of the throat, to the fauces, the soft 
 
PHTHISICAL LARYNGITIS 5 I 
 
 palate, and the roof of the mouth ; but it 
 never goes beyond these limits ; it is always 
 local ; in its localisation is its phthisical 
 significance. When the signs of anaemia are 
 general, this local bloodlessness loses its 
 phthisical import ; but when we find vocal 
 feebleness and laryngeal anaemia in a person 
 who is not anaemic, in the ordinary sense 
 of that term, we must search for other 
 evidences of phthisis, and closely watch and 
 strive to improve the nutrition of the larynx. 
 As the local disease progresses, the laryngeal 
 mucous membrane becomes hyperaemic ; the 
 cords lose the clear, white lustre of health. 
 For a time it may be very difficult or quite 
 impossible to distinguish the case from one 
 of simple chronic laryngitis. But sooner or 
 later the characteristic turnefaction of laryngeal 
 phthisis appears, and there remains no further 
 room for doubting the serious nature of the, 
 local malady. The swelling is usually most 
 marked in the ary-epiglottic folds. In extreme 
 
S2 PHTHISICAL LARYNGITIS 
 
 cases these folds are often expanded into 
 two large, tense, brawny-looking, pear-shaped 
 tumours, with their larger ends meeting 
 together in the middle line behind, while 
 their smaller extremities are directed upwards 
 and outwards towards the epiglottis. The 
 epiglottis is similarly changed ; it loses its 
 leaf-like form, its edges become thick and 
 rounded, and the whole organ presents the 
 appearance of an irregularly globular tumour. 
 Sometimes the epiglottis is more or less 
 twisted and drawn to one side, and the 
 swelling of the ary-epiglottic folds may 
 be unilateral at first. These tumefied tissues 
 seriously encroach upon the opening of the 
 glottis, and they often completely hide the 
 vocal cords from view. Even now the laryn- 
 geal mucous membrane looks paler than in 
 health, although irregular patches of con- 
 gestion and enlarged and tortuous vessels 
 may frequently be observed. When the 
 appearances of this stage of laryngeal phthisis 
 
PHTHISICAL LARYNGITIS 53 
 
 have become established, the case is sure to 
 terminate fatally. Sooner or later, if the 
 patient do not die from disease in other 
 organs, the swollen laryngeal tissues become 
 ulcerated. The ulcers are irregular in shape 
 and distribution ; there are usually more than 
 one of them, they may occur in any part 
 of the larynx, they tend to spread and run 
 together, and their surfaces are always 
 covered with a mixture of pus and mucus. 
 The ulceration frequently implicates the vocal 
 cords, usually at the junction of their middle 
 and posterior two-thirds. Caries or necrosis 
 of some of the cartilages, proceeding pro- 
 bably from perichondritis, is the last local 
 lesion in laryngeal phthisis, but this stage 
 is rarely reached. 
 
 Let us regard the effects of these changes 
 upon the voice, upon breathing, and upon 
 swallowing. In all cases the voice is affected 
 early ; in nearly all it is sooner or later wholly 
 extinguished. At first the vocal impairment 
 
S4 PHTHISICAL LARYNGITIS 
 
 may be slight ; the voice appears weak and 
 tends to become whispering. Failure of the 
 voice in reading aloud may first be noticed ; 
 those who sing find it difficult or impossible 
 to produce their higher notes. When con- 
 gestion appears, the voice becomes husky, 
 harsh, and hoarse. When there is much 
 submucous tumefaction, the movements of the 
 cords, and especially their approximation, are 
 mechanically interfered with, and the voice is 
 consequently still further impaired ; when the 
 tumefaction is considerable, and when it 
 passes into widespread ulceration, all truly 
 laryngeal voice is usually lost. 
 
 There is, as a rule, no embarrassment of 
 respiration at first. But when the second 
 stage of the malady is decidedly established, 
 the passage of air through the narrowed 
 glottis becomes more and more difficult ; 
 there is often loud stridor, which in some 
 cases is subject to alarming paroxysmal 
 exacerbations, and in a few instances the 
 
PHTHISICAL LARYNGITIS 55 
 
 laryngeal dyspnoea is so great that trache- 
 otomy may fee necessary to avert impending 
 sufifocation. 
 
 In most cases of laryngeal phthisis 
 deglutition is at some time interfered with ; 
 in many instances dysphagia becomes the 
 most prominent and most dangerous of all 
 symptoms. In many cases of laryngeal 
 phthisis the symptoms of organic stricture 
 of the oesophagus may be closely simulated. 
 There is never any difficulty in deglutition 
 until the disease has at least reached its 
 second stage. When the ary-epiglottic folds 
 are largely swollen, they project backwards 
 over the upper opening of the oesophagus, and 
 offer a mechanical obstruction to the passage 
 of food. In this stage, too, the swollen parts 
 cannot be perfectly approximated so as to 
 occlude the glottis and prevent the entrance 
 of portions of food into the larynx during 
 swallowing ; almost whenever swallowing is 
 attempted a violent fit of coughing is induced. 
 
S6 PHTHISICAL LARYNGITIS 
 
 during which fluid food may be ejected 
 through the nostrils. Apart from these serious 
 difficulties, deglutition always, sooner or later, 
 becomes acutely painful. Pain arises in part 
 from the mere pressure of passing food upon 
 the tumid and tender laryngeal structures, but 
 it is also due to the movements of the 
 diseased tissues which the act of swallowing 
 requires. 
 
 When the morbid parts are at rest, in 
 many cases there is little local pain. There 
 is nearly always a little unpleasant tickling 
 in the throat as an early symptom. Patients 
 feel as if there were something sticking in the 
 windpipe — as a fly — and causing irritation, 
 which they are prompted to try to remove by 
 violent hawking and coughing. When the 
 stage of ulceration is reached, severe burning 
 pain in the throat is sometimes felt, which is 
 propagated in various directions, but especially 
 towards the ears. 
 
 A considerable quantity of phlegm may 
 
PHTHISICAL LARYNGITIS 57 
 
 be derived from the larynx in phthisical 
 laryngitis. In the earlier stages of the disease, 
 nothing but a little glairy mucus may be 
 coughed up ; when there is much congestion, 
 a few streaks of blood occasionally appear ; 
 when there is ulceration, the sputa gradually 
 become chiefly purulent, and the admixture of 
 blood is more copious and more frequent. 
 
III. 
 
 THE TREATMENT OF PHTHISICAL LARYNGITIS.* 
 
 General treatment.^ Counter-irritation. — Laryn- 
 geal brushings. — Inhalations. — Lozenges. — 
 Rest. 
 
 Although we cannot hope to cure laryngeal 
 phthisis when it has become fairly established, 
 that is when it has reached its second stage, 
 we are able, nevertheless, to do a great deal 
 of good in retarding the progress of the 
 disease and in relieving its pains. By the 
 second stage I mean the stage of laryngeal 
 tumefaction, when the characteristic local 
 swelling appears, replacing the previous 
 
 * A paper published in The Birmingham Medical 
 Review, 1883, Vol. I. ; since revised and entirely rewritten. 
 
TREATMENT OF PHTHISICAL LARYNGITIS 59 
 
 anaemia, and leaving no further room for 
 doubting the serious and fatal nature of the 
 laryngeal affection. In all cases of phthisical 
 laryngitis, and in all cases of chronic laryn- 
 gitis in which suspicious phthisical symptoms 
 are presented, we ought to carry out, 
 systematically and perseveringly, all the 
 general medicinal and hygienic measures 
 which are beneficial in the therapeusis of 
 consumption. I do not regard laryngeal 
 phthisis as a local disease, any more fhan 
 I look upon cancer as a local disease ; it is 
 a local expression of a general constitutional 
 condition, albeit often determined by local 
 causes. To this pathological doctrine I can 
 add, from a fairly extensive experience, that 
 I have never seen a well-marked case of 
 laryngeal phthisis which was not complicated 
 by distinct physical evidences of chronic 
 consumption of the lungs. It is my present 
 purpose only to direct attention to the special 
 local treatment with which more general 
 
6o TREATMENT OF PHTHISICAL LARYNGITIS 
 
 measures may be supplemented in the 
 management of a case of phthisical laryn- 
 gitis. 
 
 Counter -irritation, in various forms and 
 of various intensity ; the application of re- 
 medies to the diseased parts by means 
 of a laryngeal brush ; inhalations, whether 
 atomised, steam, or fuming ; insufflations ; 
 and the local administration of medicines in 
 the form of lozenge, are therapeutic methods 
 which may be used in turn or in several 
 combinations, to suit different practical 
 indications. Counter-irritation over the front 
 of the neck is likely to be of service at 
 any time ; it is especially useful when the 
 larynx is congested or painful. We may 
 use iodine or croton liniments, antimonial 
 ointment, or mustard poultices or "leaves." 
 If the colour of iodine be objectionable, a 
 useful liniment may be made by adding to 
 a strong alcoholic solution of iodine enough 
 liquor potassse to discharge its colour. A 
 
TREATMENT OF PHTHISICAL LARYNGITIS 6 1 
 
 small fly-blister, placed just above the sternal 
 
 notch, is sometimes of marked service. 
 
 Stimulating and oleaginous liniments, well 
 
 rubbed over the front of the neck, are useful ; 
 
 their employment seems to favour the 
 
 expulsion of mucous accumulations from the 
 
 diseased surfaces. The following are good 
 
 liniments, which I prescribe frequently as 
 
 rubefacients : — 
 
 I. 
 
 R. Olei Pini Sylvestris, 
 
 Liquoris Ammonise, 
 
 .^theris, 
 
 Olei Eucalypti, singulorum gss. 
 Misce, fiat linimentum. 
 
 2. 
 
 R. Olei Terebinthina;, 
 Olei Gynocardiffi, 
 Tincturae Capsici .^therea;,* 
 Liquoris Ammonise, singulorum Jss. 
 
 Misce, fiat linimentum. 
 
 * See paper on ethereal tinctures, in tliis book. 
 E 
 
62 TREATMENT OF PHTHISICAL LARYNGITIS 
 
 3- 
 R. Acidi Acetici, 
 
 Olei Terebinthinae, 
 
 ^theris, 
 
 Olei Succini, singulorum |ss. 
 Misce, fiat linimentum. 
 
 Warm linseed or bread poultices, or pads 
 of absorbent cotton wool, which wool is now 
 sold variously medicated, wrung out of hot 
 water, and covered with oiled silk, are sooth- 
 ing and grateful when laid over the front 
 of the throat. My experience has led me to 
 place considerable reliance on the efficacy of 
 the application, by means of a suitable brush, 
 of various solutions to the laryngeal mucous 
 membrane. The brush must not be. blindly 
 plunged over the base of the tongue ; it 
 must be gently and accurately guided to the 
 tumid and tender parts by the aid of a good 
 light and a laryngeal mirror. Solutions of 
 chloride of zinc, of sulphate of copper, or 
 of nitrate of silver, of the strength of ten 
 
TREATMENT OF PHTHISICAL LARYNGITIS 63 
 
 to twenty grains to an ounce of water, may 
 be used. The solution of chloride of zinc 
 has a stimulant, and that of sulphate of 
 copper an astringent local action, while 
 nitrate of silver combines these two effects. 
 Local stimulants are especially indicated in 
 the first stage of laryngeal phthisis, when we 
 have to remedy the characteristic phthisical 
 anaemia of the laryngeal mucous membrane. 
 Astringents may be employed in the later 
 stages, when there is swelling or ulceration. 
 When deglutition is difficult, as it always is, 
 sooner or later, in the progress of the affec- 
 tion, when the movement of the swollen 
 parts is obstructed and painful, when the 
 tense ary - epiglottic folds project backwards 
 over the upper opening of the oesophagus, 
 and when the aperture of the glottis cannot 
 be properly protected during swallowing, 
 prompt, though temporary, relief may be 
 obtained by freely brushing the larynx with 
 a strong solution of nitrate of silver, of the 
 
64 TREATMENT OF PHTHISICAL LARYNGITIS 
 
 strength of one drachm to an ounce of 
 distilled water. The application must be 
 repeated every second or third day. We may 
 also use many medicines as inhalations. 
 These may be exhibited in various ways ; 
 for instance, as simple steam inhalations or 
 as atomised inhalations, and in this latter 
 class the spray may be produced either by 
 steam, as in Siegle's apparatus, or by air 
 driven by bellows, as in the well - known 
 hand -ball spray - producers. As a general 
 rule, moist and warm inhalations are best 
 when we seek to soothe irritation, cold spray 
 inhalations when we desire an astringent or 
 a stimulating effect, or both, while fuming 
 inhalations are more suitable when we desire 
 a stimulating and expulsive result, as in the 
 removal of local collections of phlegm. The 
 vapor coniae of the British Pharmacopoeia is 
 a good sedative. In the slighter cases, I 
 often use with advantage the following spray 
 inhalation : — 
 
TREATMENT OF PHTHISICAL LARYNGITIS 65 
 
 R. Aluminis, gr. 30. 
 
 Sodii Biboratis, gr. 30. 
 
 Tr. Catechu, 5iv. 
 
 Aq. Rosae ad §iv. 
 Misce, fiat solutio. 
 
 I can recommend the use of medicated 
 lozenges in laryngeal phthisis, especially of 
 some of those of the London Throat 
 Hospital. Theoretically, or rather a priori, 
 the local action of lozenges on the larynx 
 may be doubted, but, if we would do our 
 best as practitioners in our day and genera- 
 tion, we must accept empirical facts in thera- 
 peutics, and acquire the habit of not valuing 
 remedies the less because we can neither 
 explain nor understand their effects. I am 
 sure good can be done by lozenges in laryn- 
 geal affections. In the earliest stages of 
 laryngeal phthisis the trochiscus acidi ben- 
 zoici, an excellent " voice lozenge," is useful. 
 Later, more emollient and sedative prepara- 
 
66 TREATMENT OF PHTHISICAL LARYNGITIS 
 
 tions must be employed, such as the lozenges 
 of marsh-mallow, opium, morphia, or codeia. 
 
 Whether we use paints, sprays, powders, 
 or lozenges, there comes a time in the 
 progress of laryngeal phthisis when coughing 
 is not only an urgent symptom to be treated, 
 but also a condition to be arrested as 
 destructive in its local tendencies, and as the 
 prelude of vomiting, which may become so 
 frequent as to break down rapidly the 
 patient's remaining strength. Any measure 
 or remedy, pharmacopoeial or domestic, which 
 can keep down coughing affords much relief 
 and often substantial benefit in laryngeal 
 consumption. Prompted by the feeling of 
 local irritation, patients are prone to make 
 energetic efforts at clearing the throat. Such 
 efforts ought to be avoided as much as 
 possible. It is astonishing how much the 
 act of coughing can be brought under the 
 control of the will by an intelligent and 
 resolute person. We ought to impress upon 
 
TREATMENT OF PHTHISICAL LARYNGITIS 6j 
 
 our patients the importance of restraining and 
 refraining from coughing so far as they are 
 able to do so. While hawking and coughing 
 may give a brief relief by removing accumu- 
 lating secretions, such actions tend to 
 perpetuate and increase laryngeal inflamma- 
 tory changes. Here, as everywhere, rest is 
 a prime factor in the control of inflammation. 
 We ought to rest the larynx as much as 
 possible. In the management of laryngeal 
 phthisis keep steadily in view the fact that 
 the malady is a chronic local and specific 
 inflammation. With this idea as the basis 
 of therapeutic indications, you will have two 
 associated lines of treatment, directing your 
 remedies to the relief of local irritation, and 
 to the reform of the constitutional vice of 
 which the laryngeal lesion is a specific 
 expression. 
 
IV. 
 
 NOTE UPON THE MEDICINAL TREATMENT OF 
 PULMONARY CONSUMPTION, WITH ESPECIAL 
 REFERENCE TO THE VALUE OF CHLORIDE 
 OF CALCIUM * 
 
 Phthisis a generic name. — Various remedies 
 required. — Value of chloride of calcium as 
 a general remedy in phthisis. — Its old 
 ,repute in struma. — Value in night-sweats. 
 
 Have we a remedy for pulmonary consump- 
 tion ? I use the term pulmonary consumption 
 in a generic sense, as including a variety of 
 cognate pathological conditions, marked by 
 
 * Abstract of a paper read before the Birmingham and 
 Midland Counties Branch of the British Medical Association : 
 published in The British Medical Journal, June 5th, l88o ; 
 since revised and entirely rewritten. 
 
TREATMENT OF PULMONARY CONSUMPTION 69 
 
 certain common consequences and signs. We 
 know that the term chronic pulmonary- 
 phthisis includes a variety of pathological 
 conditions and a variety of textural lesions 
 in the lungs, which have long been recognised 
 as distinct, which recent research has done 
 much to unravel, and about which we may 
 confidently expect to learn more. The 
 differing, if cognate, clinical and pathological 
 courses of tubercular phthisis, of unresolved 
 lobar pneumonia, of chronic and catarrhal 
 lobular pneumonia, and of pulmonary cirrhosis, 
 have long been distinguished. All these^ at 
 least, are included in the generic name 
 phthisis. When I say, " Have we a remedy 
 for phthisis ? " I mean, have we a remedy 
 for this allied group of conditions, — conditions 
 with which we have so often to deal as 
 practitioners of the remedial art of medicine, 
 which are due, it is true, to varying patho- 
 logical changes, but which are marked in 
 common by progressive wasting of the body. 
 
70 TREATMENT OF PULMONARY CONSUMPTION 
 
 by progressing asthenia, by progressing dimi- 
 nution of respiratory capacity, and by fever of 
 a hectic type. Every case of phthisis requires 
 special study, and ought to be treated by no 
 rule-of-thumb practice because it is phthisis. 
 In one case anaemia is prominent and calls 
 for iron or for arsenic ; in another, continued 
 but scanty haemoptysis calls for ergot or for 
 hamamelis ; in another, a racking and fre- 
 quent cough calls for opium or some of its 
 derivatives ; in another, dyspepsia calls for 
 alkalies or for acids, for bitters, or for pro- 
 teolytic or amylolytic digestives ; in another 
 we have to aim at controlling profuse 
 perspiration or at checking an exhausting 
 diarrhoea. Apart from these and other parti- 
 culars, I suppose practitioners are agreed that 
 cod liver oil, given either alone, or variously 
 combined with other agents which tend to 
 promote its assimilation or supplement it as 
 a restorative, stands at the head of remedies 
 designed to advance the general nutrition of 
 
TREATMENT OF PULMONARY CONSUMPTION 7 1 
 
 the phthisical. Have we any other general 
 remedy? For a long time I trusted to syrup 
 of the iodide of iron. This I gave up for a 
 mixture of hypophosphites and iron — five grains 
 of hypophosphite of lime, ten grains of hypo- 
 phosphite of soda, and fifteen minims of syrup 
 of the phosphate of iron, for a dose. This is 
 a good combination, and I still use it. But 
 chloride of calcium is my favourite, general 
 drug in pulmonary consumption. I have used 
 it very extensively for many years, in hospital 
 and in private practice, and I believe with 
 great advantage. Perhaps you will say, in a 
 commendable spirit of logical scrutiny, do you 
 give chloride of calcium alone? I do not. I 
 give it with cod liver oil, or with some 
 emulsion of cod liver oil, in a separate 
 watery solution ; or I combine it, according to 
 circumstances, with a vegetable bitter, or with 
 morphia, or with ergot, and I believe I get 
 better results with chloride of calcium in these 
 combinations than I do with anything else 
 
72 TREATMENT OF PULMONARY CONSUMPTION 
 
 in the same combinations. By the logical 
 method of " concomitant variations," in the 
 limited and qualified sense in which it is 
 applicable to ordinary therapeutic experience, 
 I have worked out to my own satisfaction the 
 practical induction that chloride of calcium is, 
 next to cod liver oil, our best general remedy 
 in phthisis. Those of us who are in earnest, and 
 who believe that therapeutic art— an art which 
 includes, but which is much more than, the 
 administration of combinations of the materia 
 medica — can powerfully modify morbid pro- 
 cesses, and can powerfully aid the vis me'di- 
 catrix natur(Z, and who think well of what we 
 do, have done, have not done, and shall do 
 for our patients, must be constantly arriving 
 at conclusions, as the result of observation in 
 our own practices, which modify, confirm, 
 correct, or extend our therapeutic conduct. 
 These conclusions may not always be framed 
 by formal canons or able to bear the test of 
 an exhaustive logical scrutiny, but, if such 
 
TREATMENT OF PULMONARY CONSUMPTION 73 
 
 conclusions, which we are constantly forming 
 for ourselves, are accepted by each of us, as 
 reasonable and responsible men, as guides for 
 our own therapeutic action, they are eminently 
 worthy of communication to our brethren. 
 On this conclusion I have long acted with 
 confidence. My attention was first called to 
 the value of chloride of calcium in phthisis 
 by a paper in one of our medical journals, 
 wherein it was stated that the drug was 
 much used by the late Dr. Warburton 
 Begbie.* Scarcely mentioned, if noticed at all, 
 in the therapeutic text books of our day, 
 chloride of calcium has an old and well- 
 
 * Dr. Warburton Begbie read an instructive paper on " The 
 Therapeutic Actions of Muriate of Lime " before the Medico- 
 Chirurgical Society of Edinburgh, on May 15th, 1872. This 
 paper was afterwards published in the Edinburgh Medical 
 Journal, and is contained in Sir Dyce Duckworth's volume 
 of "Selections from the Works of the late J. Warburton 
 Begbie, M.D. , etc," issued by the New Sydenham Society, in 
 1882. Dr. Begbie wrote : — " The cases in which I have had 
 occasion most frequently to employ the muriate of lime have 
 been instances of struma, the most notable feature of which 
 was the enlargement of the lymphatic glands in the neck." 
 
74 TREATMENT OF PULMONARY CONSUMPTION 
 
 established repute as a remedy for strumous 
 glandular swellings. In 1808, Dr. James 
 Sanders, of Edinburgh, in an important work 
 on pulmonary phthisis, wrote : — " I think that 
 I have ascertained that the muriate of lime has 
 a more powerful effect in removing indolent 
 scrofulous tumours than any other, substance 
 used as a remedy." t In subacute and chronic 
 cases of pulmonary consumption I usually 
 give ten grains of chloride of calcium, dis- 
 solved in three drachms of water and mixed 
 with a drachm of glycerine, in a wineglassful 
 of water or milk, twice daily, immediately 
 after meals. I think the drug especially tends 
 to check phthisical night-sweats, and that it 
 favours increase of weight, and the drying 
 up of pulmonary lesions. Of course I do not 
 maintain it does these things in all cases. 
 What I have stated are general conclusions. 
 
 t" Treatise on Pulmonary Consumption.'' By James 
 Sanders, M.D., Edinburgh, 1808. 
 
TREATMENT OF PULMONARY CONSUMPTION 75 
 
 open, I am aware, to objection on the ground 
 of their insufficient logical basis, but they are 
 conclusions which have been and are for me 
 amongst my most trusted indications for 
 therapeutic action. In prescribing chloride of 
 calcium, we must be careful to write the 
 name of the remedy distinctly and in full, in 
 order to avoid an error from which one of 
 my patients suffered, namely, the substitution 
 of "chloride of lime " for the drug I had 
 intended to use. In the therapeutics of 
 phthisical and tubercular disorders the natural 
 saline mineral water of Leamington Spa may 
 be useful in some cases. This water is peculiar 
 in the large proportion of chloride of calcium 
 it contains. So far as I know, this proportion 
 is greater than in any other natural medicinal 
 water. Leamington water, at the temperature 
 of 40° Fahr., has a specific gravity of i-oi27, 
 and contains : — 
 
•j6 TREATMENT OF PULMONARY CONSUMPTION 
 
 Grains per 
 gallon. 
 
 Sulphate of Sodium 287 76 
 
 Chloride „ 688-i6 
 
 „ „ Calcium i66'32 
 
 „ „ Magnesium 94-88 
 
 Silica 096 
 
 Iron 0-88 
 
 1238-96. 
 
V. 
 
 SOME POINTS IN THE TREATMENT OF THE 
 SEVERER FORMS OF CONSTIPATION AND 
 OF INTESTINAL OBSTRUCTION.* 
 
 Difference between constipation and intestinal 
 obstruction. — Remedies in habitual consti- 
 pation. — Signs offmcal retention. — Enemata. 
 — Varieties of intestinal occlusion. — Symp- 
 toms of intestinal occlusion. — Treatment of 
 intestinal occlusion. — Value of combinations 
 of therapeutic resources. — When surgical 
 interference is indicated. — Choice of surgical 
 procedure. 
 
 I PURPOSE to make some remarks upon 
 
 * A paper read before the Birmingham and Midland 
 Counties Branch of the British Medical Association ; published 
 in the British Medical Journal, November 17th, 1883; since 
 revised and revi^ritten. 
 
 F 
 
78 TREATMENT OF CONSTIPATION 
 
 several points in the treatment of the severer 
 forms of constipation and of intestinal obstruc- 
 tion. I venture to do so because the subject 
 of faecal retention and of occlusions of the 
 bowel is a practical topic of the greatest 
 importance to us as medical and surgical 
 practitioners, because the details upon which 
 I shall touch have especially and long engaged 
 my attention as a physician, and because I 
 hope I may be fortunate enough to lead the 
 way to a discussion from which we may all 
 reap substantial profit. It is not my inten- 
 tion to attempt anything like a complete 
 examination of the whole question of consti- 
 pation and intestinal obstruction. The sub- 
 ject, if treated systematically, could not be 
 dealt with, even in a cursory manner, within 
 the limits of the time at my disposal. You 
 know that the literature of the subject is very 
 extensive, that it reaches back to the earliest 
 records of medicine, and that I could not give 
 a summary of it within the compass of a 
 
TREATMENT OF CONSTIPATION 79 
 
 readable paper ; you know that intestinal 
 lesions, and especially those pathological 
 changes which tend to faecal obstruction and 
 intestinal closure, have shared in being sub- 
 jects of the analytical precision which is the 
 leading note of the medicine of our century, 
 and that I could not recount their details 
 within a single sitting of our society. Keeping 
 to what is practical in the pathology and 
 practicable in the treatment of some of the 
 commoner forms of constipation and intestinal 
 obstruction, as I have met with them in my 
 own reading and clinical experience, I purpose 
 to ask you to consider with me the progress 
 of our art in one of the most important and 
 most striking departments of its usefulness. 
 
 We must avoid a common confusion of 
 terms in the use of the familiar words con- 
 stipation and intestinal obstruction. It is not 
 strictly accurate to speak of intestinal obstruc- 
 tion, as some writers have done, as an 
 exaggerated, an ultimate, form of constipation. 
 
80 TREATMENT OF CONSTIPATION 
 
 It is quite true that some of the worst and 
 most fatal forms of intestinal obstruction are 
 usually long marked by a prodromal consti- 
 pation, as, for example, cancerous constrictions 
 of the larger intestine. But the phrases con- 
 stipation and intestinal obstruction, when 
 properly understood, do not merely mark 
 different degrees of a similar result. They 
 apply to different extents of the intestinal 
 tube. Constipation concerns the large intes- 
 tine only ; intestinal obstruction the whole of 
 the intestines, small as well as large. Consti- 
 pation is slow faecal progress in the large 
 intestine, where alone true faeces are to be 
 found. Intestinal obstruction is a grave dis- 
 turbance of intestinal permeability in any 
 part of the intestinal canal ; it is practical 
 impermeability of the intestines to the passage 
 of their contents, either in the large or in the 
 small intestine, in any part of the bowel, from 
 pylorus to anus. "Constipation is essentially 
 slow progress of the faeculent mass from the 
 
TREATMENT OF CONSTIPATION 8 1 
 
 cfficum to the anus."* It is this, and nothing 
 more than this, so far as the mere position of 
 the difficulty concerns us, albeit the patholo- 
 gical causes of constipation, when organic, and 
 when such as narrow the lumen of the bowel, 
 are apt, in their extremer developments, to 
 determine intestinal occlusion. 
 
 The manifold errors of habits, of effort, 
 and of diet which tend to constipation are 
 well recognised by our profession. In the 
 discovery of some of these, and in their 
 timely and persistent rectification, we can 
 cure, without drugs, many of the slighter 
 forms of fsecal retention. We should make 
 quite sure we exhaust these measures in the 
 treatment of every case of habitual constipation. 
 In the slighter cases, such non-medicinal 
 treatment is usually sufficient for a good 
 result ; in severer cases, when drugs and 
 
 * This sentence is quoted from a clinical lecture on 
 "Retention of Fseces," by Dr. Matthews Duncan, published 
 in The Medical Times and Gazette, Nov. 8th, 1879. 
 
82 TREATMENT OF CONSTIPATION 
 
 instrumental aid cannot be avoided, all that 
 well-ordered habits, well-directed efforts, and 
 well-chosen diet can do should be regarded as 
 the indispensable adjuvants of a more direct 
 therapeusis. 
 
 Our pharmacopoeias, officinal, non-ofificinal, 
 and popular, are richer in purgatives than in 
 remedies of any other class. I must not 
 digress into a comparison of the relative 
 values of our cathartic drugs, although the 
 subject is a very tempting one. The prac- 
 titioners of rational medicine have accumulated 
 a vast store of precise and valuable informa- 
 tion concerning the actions of purgative , 
 medicines, and this important branch of thera- 
 peutics is still growing. Each of us has his 
 favourite cathartics ; if we have tried their 
 adoption well, we should not lightly change 
 them. For cases of habitual constipation 
 which do not yield without drugs, my favourite 
 remedy is Socotrine aloes. I have little faith 
 in belladonna and none in nux vomica. Aloes 
 
TREATMENT OF CONSTIPATION 83 
 
 is especially useful in the faecal sluggishness 
 of sedentary persons. Properly given, the 
 drug niay be taken daily for years, without 
 either losing its aperient efficiency or pro- 
 ducing any but the best results. I give one, 
 two, or three grains of Socotrine aloes in a 
 pill, combined with a quarter of a grain of 
 sulphate of iron and one grain of extract 
 of hyoscyamus, at bedtime, every night.* I 
 find out in each case the exact quantity of 
 aloes required to produce one full alvine 
 evacuation after the first morning meal. In 
 this combination the quantity of aloes will 
 need readjustment from time to time, usually 
 
 * We are indebted to that veteran therapeutist, the late Sir 
 Robert Christison, for the valuable suggestion of combining 
 iron with aloes when we use aloes as a laxative. Neligan, in 
 reference to the use of aloes in habitual constipation, wrote : — 
 "Christison states that the cathartic property of aloes is much 
 increased by its combination with sulphate of iron, and that its 
 irritating action on the rectum is counteracted by combining 
 it with the extract of hyoscyamus ; both of which statements 
 my experience fully confirms. " — Neligan's Medicines, edited by 
 Macnamara, 6th edition, p. 130. 
 
84 TREATMENT OF CONSTIPATION 
 
 in the direction of reduction.* I shall mention 
 only one other drug for the class of cases I 
 am now considering, namely, the American 
 cascara sagrada. From my former experience 
 of so-called new drugs, I have learned to 
 employ such preparations with much caution 
 and to recommend them with more. But I 
 now venture to state that I have used cascara 
 sagrada in many cases of severe habitual 
 constipation, with marked success. I have 
 given from fifteen to thirty minims of the 
 officinal extract, thrice daily, adapting the 
 dose by the result, and endeavouring to secure 
 one, or at most two, dejections in each 
 twenty-four hours. 
 
 The ordinary symptoms of extreme faecal 
 retention are well known. Our experience, in 
 the main, justifies us in expecting that such 
 symptoms shall be acute, or at least subacute, 
 
 * I was led to adopt this combination of aloes and iron in 
 the treatment of habitual constipation by reading a paper by the 
 Rev. David Bell, M.D., which was published in The British 
 
TREATMENT OF CONSTIPATION 85 
 
 in their urgency and duration ; and that they 
 shall be associated with complete temporary 
 absence of alvine dejections, or at least with 
 very obvious insufficiency of such evacuations 
 both in quantity and frequency. But we 
 shall fall into error sometimes if we expect 
 considerable fsecal retention always to be 
 marked in this way. Of exceptional forms 
 of extreme faecal retention, I have met with 
 two distinct varieties. In both the process 
 
 Medical Journal, Nov. 5th, 1870, entitled "Remarks on the 
 Beneficial Effects of Combining Tonics with Aperients in 
 Chronic Constipation.'' Dr. Bell stated in this paper that he 
 had tried various combinations of drugs in the treatment of 
 constipation, and had come to the conclusion that the best 
 formula was the following: — R. Aloes Socotrinas, extracti 
 hyoscyami, aa gr. xij. ; quinse disulphatis, gr. vj. ; ferri 
 sulphatis, gr. iv. To be well mixed and divided into twelve 
 pills. Dr. Bell has found these pills to produce uniformly good 
 results, without inconvenience. Dr. Kent Spender, of Bath, 
 has kindly drawn my attention to his admirable paper on " The 
 Therapeutics of Chronic Constipation," published in The 
 Medical Times and Gazelle, Feb. 19th, 1870. Dr. Spender 
 recommends minute and frequent doses of watery extract of 
 aloes, given in combination with sulphate of iron. He informs 
 me he has treated cases of habitual constipation with pills of 
 aloes and iron for the last twenty-five years, with excellent 
 results. 
 
86 TREATMENT. OF CONSTIPATION 
 
 of accumulation has been but slow : in one 
 the graver signs of intestinal obstruction have 
 at last become urgently and rapidly developed, 
 as it were as a climax ; while in the other 
 and rarer form of slowly developed faecal 
 retention the condition has been chronic 
 throughout, and the disorder has not perhaps 
 been recognised until after a belly only dis- 
 tended by a dilated colon filled with faeces 
 has been regarded as the seat of a huge 
 tumour, the nature of which has been 
 variously interpreted. I have known the 
 extremest faecal retention, filling the belly, 
 encroaching on the thorax, and displacing 
 the liver, lungs, and heart, presenting itself 
 as a chronic condition lasting for many years. 
 Let me quote very briefly an extreme and very 
 instructive instance of this kind from my note- 
 book. In the year 1871, a medical friend sent 
 a case to me at the Queen's Hospital, as one 
 of obscure abdominal tumour, which had long 
 resisted treatment at two neighbouring medical 
 
TREATMENT OF CONSTIPATION 8/ 
 
 charities, and about the nature of which he 
 was in doubt, and desired my opinion. I 
 found the patient a pale, ill-developed girl of 
 fourteen. Her mother stated that when the 
 child was only two years of age, it was noticed 
 there was some enlargement of her belly. 
 The child's bowels had habitually been con- 
 fined, a week or more often elapsing without 
 the passage of a motion. The evacuations 
 generally consisted of small portions of hard- 
 ened faeces ; but, from time to time, frequent 
 and scanty liquid stools were passed. The 
 quantity of urine appeared to have been 
 normal ; the appetite poor and capricious. 
 The abdominal enlargement had gradually 
 increased up to the time of the patient's 
 application to me. I at once admitted the 
 girl as an in-patient. I found she complained 
 of occasional griping pains in the belly. She 
 had never had any vomiting. Her motions 
 were small in quantity and watery. The 
 tongue was clean. There was no pyrexia. 
 
88 TREATMENT OF CONSTIPATION 
 
 The body was fairly nourished. The abdomen 
 was generally enlarged, and the lower part of 
 the thorax expanded. The superficial veins of 
 the abdomen were slightly enlarged. A solid 
 tumour could be felt to occupy the whole of 
 the right side of the abdomen. It had no 
 distinct margin above, and reached, laterally, 
 about two inches to the left of the middle line; 
 below, the edge of the hand could be readily 
 passed between the tumour and the pelvis. 
 The tumour was uniformly dull on percussion ; 
 palpation gave the impression of a doughy 
 consistence, and firm and sustained pressure 
 with the tip of a finger upon the mass pro- 
 duced a depression which lasted for some 
 minutes after the finger was withdrawn. The 
 heart was displaced upwards considerably ; its 
 apex was found to strike the chest-wall at a 
 point one inch and a half above, and one inch 
 to the inner side of the left nipple. The 
 circumference of the abdomen at the umbilicus 
 was thirty-one inches. The rectum was found 
 
TREATMENT OF CONSTIPATION 89 
 
 to be largely distended, and filled with 
 hardened faeces. The patient was ordered a 
 pill, consisting of a grain and a half of 
 Socotrine aloes, half a grain of extract of 
 hyoscyamus, and a third of a grain of extract 
 of nux vortiica, to be taken with a drachm of 
 sulphate of magnesia in one ounce of infusion 
 of roses, thrice daily. An enema of cold 
 water and table salt was given night and 
 morning. Before the administration of the 
 first enema, I freely broke up the contents of 
 the rectum with my forefinger and the handle 
 of a large tablespoon, and I removed a very 
 large quantity of hardened faeces, together with 
 three plum-stones. On the following day, two 
 chamber-pots were literally filled to the brim 
 with pultaceous faeces, and the abdomen was 
 found markedly diminished in size. On the 
 next day, two chamber-potfuls of faeces followed 
 the morning injection. On the following day, 
 three copious motions were passed. On the 
 next day there were two free actions of the 
 
90 TREATMENT OF CONSTIPATION 
 
 bowels, and it was noted that the abdomen 
 was smaller and softer, and that the heart's 
 impulse had fallen to the level of the left 
 nipple. In three days more, the enemata were 
 finally discontinued. Careful physical explo- 
 ration failed to find any abnormal signs in the 
 abdomen. Faradisation was ordered to be 
 gently applied to the abdominal muscles 
 daily. From this time the patient did well, 
 without interruption, and was discharged four- 
 teen days after her admission. She attended 
 a short time as an out-patient, taking steel 
 and an aloetic purgative, and remained well, 
 without any faecal reaccumulation. In this 
 case you will notice that extreme faecal reten- 
 tion, sufficient to displace the heart into the 
 infraclavicular region, to distend the superficial 
 veins, and to form a very large abdominal 
 tumour, was unattended by vomiting, scanty 
 urine, abdominal tenderness, or other local 
 disturbance than " occasional griping pains in 
 the belly." You will notice, too, the record of 
 
TREATMENT OF CONSTIPATION 91 
 
 an important point in diagnosis. A large 
 portion of the patient's abdominal cavity was 
 obviously occupied by some solid mass. I had 
 to decide upon the nature of the abnormality. 
 I found that firm and sustained pressure with 
 the fingers over the tumour produced a 
 depression in its mass, which lasted for some 
 minutes after pressure was withdrawn. This 
 very exceptional physical sign is almost ab- 
 solutely diagnostic of considerable fsecal accu- 
 mulation. The successful progress of the case 
 illustrates, also, the value of using together a 
 variety of therapeutic measures. In the treat- 
 ment of faecal retention, the best results are 
 only obtainable by the adoption of a well- 
 considered combination of remedial resources. 
 I did not rely on only one method of emptying 
 the distended intestine. I broke up and dug 
 out all the excrement I could reach through 
 the anus ; and I kept up the concurrent and 
 continued use of aloetic purgatives, enemata, 
 and faradisation. 
 
92 TREATMENT OF CONSTIPATION 
 
 I am afraid our profession does not 
 adequately appreciate the immense advantages 
 to be derived in the treatment of many of 
 the severer forms of constipation and intestinal 
 obstruction by the efficient use of the enema. 
 In France, I understand, the enema is the 
 routine domestic aperient We do these things 
 better in England. The custom of relieving 
 slight constipation by an immediate resort to 
 an enema has never become popular on this 
 side of the Channel, and it is well it is so. 
 My experience has led me to discountenance 
 decidedly the systematic use of rectal injec- 
 tions in the ordinary domestic treatment of 
 the slighter forms of faecal sluggishness. Such 
 cases may be treated better, and especially 
 with less tendency to chronicity, by other 
 means. On the other hand, however, in the 
 severer forms of fsecal retention, we ought 
 always to use aperient enemata, and we must 
 take care we use them efficiently. In persons 
 past the meridian of life, and especially in 
 
TREATMENT OF CONSTIPATION 93 
 
 persons of sedentary habits, what may be 
 called simple faecal retention is a very frequent 
 form of constipation. In such persons this form 
 of constipation is relatively very frequent, both 
 as compared with other varieties of constipation, 
 and also as compared with the same form of 
 constipation at other times of life, and in 
 individuals of other habits. In such persons 
 coprostasis (a good old name for faecal stagna- 
 tion) is especially apt to produce complete 
 intestinal obstruction. It is in these cases, 
 especially, that life may be saved by enemata. 
 I do not know any form of intestinal obstruction 
 in which enemata can do harm. In most cases 
 they take a chief place amongst our most potent 
 means of doing good. In many cases which 
 at first are unpromising, and even when the 
 predisposing cause of the obstruction is some 
 organic and incurable disease, we may repeat- 
 edly relieve a threatening faecal accumulation, 
 and long keep off a fatal faecal stagnation, by 
 the due use of enemata. It is, perhaps, not 
 
94 TREATMENT OF CONSTIPATION 
 
 too much to say that enemata far surpass any 
 other remedies in curative value in the simple 
 coprostasis of advanced life. Within the limits 
 of this paper I cannot particularise all the 
 practical details of apparatus, of quantity, 
 quality, and frequency of intestinal injection, 
 and the various manipulative niceties of admini- 
 stration, concerned in the question of the 
 therapeutic use of aperient enemata. But I 
 would take this opportunity of affirming that 
 in all severe cases of constipation, and in all 
 cases of intestinal obstruction in which we use 
 enemata, we can only administer our injections 
 efficiently by means of the long tube of 
 O'Beirne. Let me recommend O'Beirne's 
 classical treatise on defaecation to those who 
 are unacquainted with it.* Than from a study 
 of its pages I do not think I have ever reaped 
 more practical profit from any of my medical 
 reading. The gist of O'Beirne's book is the 
 
 * New Views on the Process of Defaecation, &c. By James 
 O'Beirne, M.D., Dublin. 1833. 
 
TREATMENT OF CONSTIPATION 95 
 
 recommendation of the long enema tube, which 
 for fifty years has been known by his name. 
 Never entrust the use of O'Beirne's tube to a 
 nurse. The efficient passage of the instrument 
 into and through the sigmoid flexure of the 
 colon is a delicate and difficult operation, which 
 the medical attendant ought always himself to 
 perform for his patient. Much unnecessary 
 detail has been taught about the composition 
 of enemata. When we use an enema for the 
 purpose of clearing the bowel of fsces and 
 flatus the quantity of the injection is its chief 
 quality. I am accustomed to tell my pupils 
 that when they give an enema they should 
 always ask themselves whether it is to be 
 retained or returned ; if it be designed that 
 the injection shall be retained, as in the case 
 of a nutrient or sedative enema, its quantity 
 can scarcely be too small. If, on the other 
 hand, it is intended to move the bowels to 
 the expulsion of their contents, the quantity 
 of an enema can scarcely be too large. The 
 
96 INTESTINAL OBSTRUCTION 
 
 quantity of an aperient injection is precisely 
 so much of it as can be passed into the bowel, 
 without undue force. For such an enema to be 
 so large as possible is only to be large enough. 
 
 I now ask you to favour me with your 
 further indulgence while I consider very 
 briefly the celebrated question of the treat- 
 ment, and especially the operative treatment, 
 of intestinal occlusion. I feel I need not 
 apologise because, as a physician, I ask you 
 to consider with me the operative treatment 
 of intestinal impermeability. In the treatment 
 of this most grave and anxious condition, it 
 usually happens that it is not only the office 
 of the physician to determine whether and 
 when the aid of the operating surgeon is to 
 be sought, but also to join with him in 
 deciding upon the special operative measures 
 to be adopted in each particular case. This 
 question is no new one ; it is celebrated in 
 the records of controversies which reach back 
 to the earliest portions of our literature. 
 
INTESTINAL OBSTRUCTION 97 
 
 Whatever our conclusions on this question, 
 they can only be accepted as provisional. 
 From time to time its issues must be examined 
 anew, so that they may be brought to the 
 level of our latest curative advances. It is 
 especially necessary that we should often 
 recur to this important question now, when 
 we are witnessing such rapid advances in the 
 safety, precision, and scope of abdominal 
 surgery. 
 
 I shall not pause to enumerate the long 
 list of lesions which may determine the 
 clinical urgencies of intestinal impermeability, 
 and which, by causing that most grave con- 
 dition, may demand from us relief if life is 
 to be preserved. As intestinal compressions, 
 constrictions, degenerations, displacements, dis- 
 tortions, impactions, obturations, and stenoses, 
 these manifold pathological conditions have 
 been fully described. If, with practical pur- 
 pose, we translate the anatomical causes of 
 intestinal occlusion into their clinical manifesta- 
 
98 INTESTINAL OBSTRUCTION 
 
 tions and history, we shall find that they fall 
 into three fairly defined groups. A : Causes 
 which come into operation quite suddenly, and 
 which lead at once to complete intestinal 
 occlusion. Here we have sudden compressions, 
 displacements, and distortions, as all kinds of 
 strangulations and torsions or kinks, some 
 cases of intussusception, especially in children, 
 and some cases of plugging by gall-stones. 
 B: Causes which manifest themselves acutely, 
 but which do not give rise to immediate and 
 complete occlusion, although they produce very 
 grave disturbances of intestinal permeability. 
 Here we have partial strangulations of all 
 kinds, many cases of intussusception, many 
 cases of peritonitis, and cases of partial 
 obturation by gall-stones and foreign' bodies. 
 C : Causes which are developed slowly, and 
 which give rise often for weeks, months, or 
 years, to marked signs of impaired intestinal 
 permeability, and which either lead to a series 
 of subacute seizures of intestinal occlusion. 
 
INTESTINAL OBSTRUCTION 99 
 
 yielding for a time to treatment, but successively 
 increasing in severity and danger, or culminate 
 in a single sudden and final attack of complete 
 and unyielding obstruction, or lead to death in 
 some indirect way, as by perforation, peritonitis, 
 or asthenia. Here we have intestinal cancers 
 and neoplasms generally, strictures and stenoses 
 of all kinds, chronic local or general peritonitis, 
 compressions from the pressure of slowly 
 growing tumours, and faecal impactions 
 and chronic fsecal retention from degen- 
 erative changes in the muscular coats of 
 the larger intestine.* These various condi- 
 tions teem with practical interest, both in the 
 niceties of their differential diagnosis, and in 
 the details of their varying therapeutic require- 
 ments. Into these points I cannot now enter, 
 but I would state generally that by a considera- 
 
 * This classification is a modification and amplification of 
 one to be found in Dr. Leichtenstern's valuable essay on " Con- 
 strictions, Occlusions, and Displacements of the Intestines," 
 contained in Dr. Von Ziemssen's Cyclopaedia of the Practice of 
 Medicine. See English translation, Vol. VII., page 487, et seq. 
 
lOO INTESTINAL OBSTRUCTION 
 
 tion of the age of the patient, of the history 
 of his illness, of his special symptoms and 
 physical signs and of the results of our treat- 
 ment, checked by a recollection of the patho- 
 logical possibilities of intestinal occlusion and 
 some accurate knowledge of their relative 
 frequencies, we can usually make a practically 
 correct diagnosis, both of the particular portion 
 of the intestine which is affected and of the 
 pathological nature of its lesion. I cannot, 
 however, leave this part of my subject without 
 reference to certain well-ascertained statistics 
 and approximate generalisations which are of 
 great practical importance, and which have 
 often stood me in good stead at the bedside 
 in the diagnosis of the kind and place of an 
 intestinal occlusion. Firstly, it is generally 
 true that sudden and very marked obstruc- 
 tions, such as strangulations, torsions, intussus- 
 ceptions, and pluggings, affect the smaller intes- 
 tine, while more chronic but less accentuated 
 difificulties of permeability, such as strictures. 
 
INTESTINAL OBSTRUCTION lOI 
 
 cancers, and intestinal degenerations, affect the 
 larger intestine. Again, an intestinal stricture 
 is a circumscribed diminution of the lumen of 
 the bowel. It arises either from contraction 
 of the mucous and submucous tissues, or 
 from the encroachment upon the intestinal 
 canal of some new growth from the intestinal 
 walls. The latter process is usually cancerous, 
 the former is usually a consequence of ulcera- 
 tion. "Stricture may be met with in any 
 part of the intestine, yet it occurs in different 
 parts with very different degrees of frequency. 
 The published statistics of fatal cases show 
 that its occurrence as a fatal disease in the 
 small intestine is comparatively rare (according 
 to Dr. Brinton* in 8 out of every loo cases) ; 
 and that, as regards the large intestine (to 
 quote again Dr. Brinton's figures, with which 
 those of other writers agree pretty closely), 
 out of lOO fatal cases, 4 are in the caecum, 
 
 * Intestinal Obstruction. By W. Brinton, M.D., F.R.S. 
 1867. 
 
I02 INTESTINAL OBSTRUCTION 
 
 lo in the ascending colon, ii in the transverse 
 colon, 14 in the descending colon, 30 in the 
 sigmoid flexure, and 30 in the rectum. Dr. 
 Brinton calculates that stricture occurs three 
 times in men to twice in women ; and that 
 the average age at death is 44f years."* 
 
 From these figures we may gather the 
 important practical generalisation that at least 
 four-fifths of the strictures of the larger intes- 
 tine are situated to the left of the middle line 
 of the body. Again, excluding the grosser 
 forms of hernia, of all the different forms of 
 obstruction of the bowel, intussusception is 
 the one which is " most commonly attended 
 with the presence of manifest tumour ;"t and 
 further, excluding cancerous disease of the 
 larger intestine, the discharge of blood per 
 anmn is characteristic of intussusception, and 
 
 •Obstruction of the Bowels. By J. S. Bristowe, M.D., 
 F.R.C.P. Reynolds' System of Medicine, Vol. III., pa^e 74, 
 et seq. 1 871. 
 
 f Dr. Bristowe. Op. cit., page 100. 
 
INTESTINAL OBSTRUCTION IO3 
 
 is generally present from the onset of the 
 affection. Again, we have Mr. Jonathan 
 Hutchinson's valuable generalisations, from 
 which I select the following as being the most 
 reliable, and therefore the most important. 
 "When a child becomes suddenly the subject 
 of bowel obstruction, the malady is probably 
 either intussusception or peritonitis. When an 
 elderly person is the patient, the diagnosis will 
 generally rest between impaction of intestinal 
 contents and malignant disease. In middle 
 age, the causes of obstruction may be various, 
 but intussusception and malignant disease are 
 now very unusual. If repeated attacks of 
 dangerous obstruction have occurred, with 
 long intervals of perfect health, it may be 
 suspected that the patient is the subject of a 
 chronic diverticulum, or has bands of adhesion, 
 or that some part of the intestine is pouched 
 and liable to twist. If, in the early part of a 
 case, the abdomen become distended and hard, 
 it is almost certain that there is peritonitis. 
 
I04 INTESTINAL OBSTRUCTION 
 
 If the intestines continue to roll about visibly, 
 it is almost certain that there is no peritonitis. 
 This symptom occurs chiefly in emaciated 
 subjects, with obstruction in the colon, of 
 long duration. The tendency to vomit will 
 usually be relative to three conditions, and 
 proportionate to them. These are, (i) the 
 nearness of the impediment to the stomach ; 
 (2) the tightness of the constriction ; and (3) 
 the persistence or otherwise with which food 
 and medicine have been given by the mouth."* 
 No clinical spectacle is more terrible than 
 that afforded by a case of acute and complete 
 intestinal obstruction. All of us, probably, have 
 seen some examples of it. In the midst of 
 perfect health, without obvious cause or warning, 
 or after some unusual and sudden muscular 
 effort, or after a blow on the belly, or after a 
 trifling diarrhoea or some slight constipation, or 
 following some ordinarily insignificant error of 
 
 * Notes on Intestinal Obstruction. By Jonathan Hutchin- 
 son, F.R.C.S. British Medical /ournal, August 31, 1878. 
 
INTESTINAL OBSTRUCTION I05 
 
 diet, a vigorous adult is seized with severe pains 
 in the abdorrjen. The pains are mostly griping 
 and colicky in character, they usually come 
 and go at short intervals, and they are usually 
 referred to the neighbourhood of the navel. 
 Sometimes the pains are excruciatingly violent, 
 or they are persistent, or they spread over the 
 whole of the belly, or they are of a " bearing- 
 down'' character, and are attended by painful 
 but fruitless efforts at stool. Acting on the 
 familiar hypothesis that something has " dis- 
 agreed " and requires clearing off, the patient 
 usually forthwith takes a domestic purge. The 
 pains continue and grow more frequent and 
 severe, and the bowels remain unrelieved. At 
 this stage vomiting generally appears, and a 
 doctor is summoned. The gravity of the 
 patient's condition is usually recognised, and 
 pains are quelled and peritonitis staved off by 
 opium, while efforts are made to open the 
 bowels by enemata ; sometimes, unhappily, the 
 pathological possibilities are not adequately 
 
I06 INTESTINAL OBSTRUCTION 
 
 appreciated, and the stronger cathartics are 
 injudiciously administered. Save for the pas- 
 sage of a little delusive flatus, or of the contents 
 of the bowel below the difficulty, the belly 
 remains ominously closed. Vomiting continues, 
 and, in a variable time, the vomited matter 
 becomes faecal in appearance and odour, while 
 at first it consisted only of ordinary stomach- 
 contents, or of a bilious watery fluid. The 
 case grows more desperate ; marked collapse 
 soon declares the patient's increasing danger. 
 The extremities chill, the respirations become 
 shallow and frequent, and the voice fails and 
 thickens, while the pulse is small and rapid, 
 the abdomen distended and drummy, and the 
 face pinched, with pointed nose, sunken eyes, 
 and thin, retracted lips. Hour by hour, and 
 day by day, the sufferer grows worse, until, 
 bathed in cold sweats, with parching thirst, 
 frequent faecal eructations, hiccup, shortening 
 and shallower breathing, voice all but extin- 
 guished, dry brown tongue, Hippocratic face. 
 
INTESTINAL OBSTRUCTION 107 
 
 failing and uncountable pulse, and mind 
 unclouded to the end or gently wandering in 
 the last few hours, death closes one of the 
 saddest and sharpest scenes which human 
 misery can show. 
 
 But the terrible and lethal condition* I 
 have endeavoured to describe is not wholly 
 hopeless. It is true it is very generally fatal, 
 within six days at the most, yet patients 
 have got well without surgical operation, 
 even when internal strangulation has brought 
 them to the very verge of death. Surgical 
 art, I freely and thankfully acknowledge, has 
 rescued not a few whom the skill of the 
 physician has proved powerless to save, and 
 this art promises, I believe, to include in a 
 not distant progress a material reduction in 
 the present high mortality of intestinal closure. 
 " There is no cause of acute occlusion of the 
 intestine," writes Leichtenstern, "which cannot 
 spontaneously disappear as well as originate. 
 
 * " Morbus terribilis, creberrime letalis." — De Haen. 
 
I08 INTESTINAL OBSTRUCTION 
 
 An intestinal knot can loose itself, an incar- 
 cerated or strangulated loop can become free, 
 an invagination can become disengaged, com- 
 pression cease, twisting or dislocation of the 
 intestine with angular bend can straighten 
 itself, a lodged gall or intestinal stone or 
 foreign body may be dislodged and evacuated, 
 and severe faecal obturation may be over- 
 come."* But we must never forget, I would 
 strongly insist, that the relative proportion of 
 cases of spontaneous recovery from acute 
 intestinal occlusion is very small indeed — so 
 small as to support only a very uncertain 
 hope of life in any particular case. I fear 
 such a hope is often a harmful one, for I 
 am afraid that its sympathetic exaggeration 
 has sometimes inspired a disastrous inactivity, 
 which has frittered away in fruitless endeavours 
 and vain expectations the hour for a fair cast 
 for life by surgical interference. 
 
 * Leichtenstern. Op. cit., page 508. 
 
INTESTINAL OBSTRUCTION I09 
 
 For want of time, I am compelled to 
 pass over many important points in the 
 treatment of intestinal occlusions, such as, 
 for example, how far purgatives are to be 
 given, if at all, the use of opium, of ice, of 
 the best methods of feeding, of copious 
 enemata, given while the patient is inverted 
 or otherwise, of abdominal kneadings and 
 manipulations, of warm baths, of rectal insuffla- 
 tion of air, of intestinal puncture with an 
 aspirating canula. We do well to combine 
 these measures variously, according to the 
 special indications of each particular case, 
 for clinical experience has abundantly shown 
 that cases of obstruction of the bowel, even 
 when they appear most unpromising, not 
 seldom exhibit the best results of a wise 
 combination of therapeutic resources. But 
 I must now pass by these important topics, 
 because I want to raise again the question, 
 whether, when, and how the abdomen is to 
 be opened for the relief of unyielding intes- 
 1 H 
 
I lO INTESTINAL OBSTRUCTION 
 
 tinal closure. If it be clear we have to deal 
 with a case of acute intestinal occlusion, if a 
 reasonable delay have been afforded for the 
 operation of suitable therapeutic procedures and 
 for a chance of spontaneous relief, if a due exam- 
 ination of all the hernial openings, including the 
 obturator foramina, the sciatic notches, and the 
 vagina, in the female, has excluded the evi- 
 dence of external strangulation, if the rectum 
 be found free, if full enemata, the passage of 
 O'Beirne's tube, and exploration of the abdo- 
 men arid loins by percussion and palpation 
 have demonstrated that the difficulty is not in 
 the colon, then the question must be decided 
 whether laparotomy or laparo-ileotomy should 
 be undertaken or not. 
 
 Laparotomy is abdominal section. Lapa- 
 rotomy may be performed in a case of 
 intestinal obstruction with the view of finding 
 and effectually relieving intestinal occlusion. 
 Laparo-ileotomy is abdominal section, plus the 
 formation of an artificial anus in the ileum. 
 
INTESTINAL OBSTRUCTION 1 1 1 
 
 Against the performance of laparotomy the 
 following considerations may be urged, with 
 various degrees of cogency, namely : — There 
 are some cases of acute internal strangulation 
 which cannot be relieved by laparotomy ; 
 consent is not usually given to the operation 
 until the patient is so far in extremis that 
 recovery is impossible ; the intestine may be 
 found so brittle that it is impossible to avoid 
 faecal extravasation into the peritoneal cavity ; 
 the surgeon may not find any obstruction to 
 relieve ; the diagnosis may be incorrect ; there 
 is always a chance of spontaneous recovery ; 
 the operation in itself adds very seriously to 
 the risk of death ; the results of laparotomy 
 are not such as to justify the performance of 
 the operation. But, to these considerations it 
 may be answered, the cases of acute intestinal 
 strangulation which cannot be relieved by 
 laparotomy, such as very complicated and 
 extensive volvulus, are so rare, as to be prac- 
 tically unworthy of consideration in determin- 
 
112 INTESTINAL OBSTRUCTION 
 
 ing our action in any particular case ; again, 
 that laparotomy has hitherto been performed 
 only when the patient has been in a hopeless 
 condition is not an argument against the per- 
 formance of the operation, but only a reason 
 why the procedure should be adopted earlier ; 
 and again, the difficulty of diagnosis in cases 
 of acute intestinal closure is daily diminishing, 
 and is already sufficiently certain for all prac- 
 tical purposes, and if the diagnosis of the 
 nature of the exact lesion in any particular 
 case be obscure, there is usually no difficulty 
 in the prognosis that the patient will die 
 unless relieved, and laparotomy gives him, at 
 least, a chance of life. I have already said 
 that the chance of spontaneous recovery is so 
 small as not to be a just ground for putting 
 off an operation when other means have had 
 a fair trial, and have' failed. With regard to 
 the pouring out of fseces into the abdominal 
 cavity, from the breaking of the intestine from 
 extreme brittleness during a surgeon's search 
 
INTESTINAL OBSTRUCTION II 3 
 
 for an occlusion, I may say that I have seen 
 such a case myself, and that I find instances 
 of this fatal condition are recorded as having 
 occurred in the experience of Billroth, Fergus- 
 son, and other eminent surgeons. In my case 
 the patient was a young lady, in perfect and 
 vigorous health up to her seizure with Symp- 
 toms of acute intestinal closure ; we did not 
 put off the operation too long, and the case 
 seemed quite favourable for the performance 
 of laparotomy with a fair chance of success. 
 As to the operation of laparotomy being a 
 serious risk in itself, I suppose I shall be told 
 that in these days it is not. But when we 
 have duly weighed all these considerations for 
 and against laparotomy, it seems to me that 
 the strongest point in favour of the operation 
 lies in the practical hopelessness of acute 
 intestinal occlusion if left to itself; while the 
 strongest point against the operation is to be 
 found in the records of its results. No very 
 large statistics of the results of laparotomy 
 
114 INTESTINAL OBSTRUCTION 
 
 have been collected ; and those which have 
 been published probably show a better result 
 than the truth, because of the unfortunate 
 tendency amongst us to think our unsuccessful 
 cases unworthy of publication. I find, how- 
 ever, that Leichtenstern has collected seventy- 
 nine cases, giving fifty-five deaths, or a 
 mortality of seventy per cent. So far as cases 
 within my own knowledge have enabled me 
 to judge, I have been inclined to conclude 
 that it is usual, in laparotomy, for a surgeon 
 to find " something," and to relieve it, and that 
 it has nevertheless been very usual for the 
 patient to die shortly afterwards. 
 
 I have good authority for stating that 
 laparo-ileotomy is an operation " far less dan- 
 gerous than laparotomy, and more easy of 
 execution."* Upon this point, which I regard 
 of great practical importance, I hope I may 
 be so fortunate as to elicit the opinion of my 
 
 * Leichtenstern. Op. cit., page 663. 
 
INTESTINAL OBSTRUCTION 1 1 5 
 
 surgical brethren. I have a strong impres- 
 sion, based on some experience of the results 
 of abdominal sections performed in cases of 
 acute intestinal closure, that it is usually safest 
 for the patient for the surgeon to follow the 
 great example of Nelaton, and not to attempt 
 a search for the occlusion, with a view to its 
 direct relief, but to be satisfied with the estab- 
 lishment of an artificial anus in the ileum, 
 above the seat of intestinal stoppage. As com- 
 pared with laparotomy, laparo-ileotomy is a 
 much safer operation, and a much easier one. 
 Even the relative disadvantage of a permanent 
 artificial anus is not always entailed ; for many 
 cases of successful laparo-ileotomy have been 
 recorded in which the artificial anus healed 
 upon the spontaneous establishment of intes- 
 tinal evacuations per vias naturales. I once 
 met with a case of this kind in an elderly 
 gentleman, whom I saw in consultation with 
 my friend and colleague, Mr. Oliver Pember- 
 ton. Excluding cases of insuperable intes- 
 
Il6 INTESTINAL OBSTRUCTION 
 
 tinal obstruction in the colon and rectum, for 
 which well established and special surgical 
 procedures are required, there is, I think, only 
 one class of cases of closure of the intestine 
 for which laparo-ileotomy is unsuited, namely, 
 for cases in which the occlusion is situated 
 very high up in the bowel. These cases, which 
 are very exceptional, are indicated, amongst 
 other signs, by the absence of marked or of 
 general tympanites. 
 
 My experience and my reading have led 
 me to the following conclusions :— 
 
 If I had to deal with a case of acute in- 
 testinal closure affecting the smaller bowel, 
 other than a case of external hernia, I should 
 allow a fair opportunity for relief by such 
 remedies as opium, enemata, time, and bella- 
 donna ; but I should by no means wait until 
 the patient was in extremis before I urged sur- 
 gical interference. If I obtained the patient's 
 consent to such interference, I should hope my 
 surgical colleague would perform laparotomy 
 
INTESTINAL OBSTRUCTION II 7 
 
 and relieve the occlusion, but only if its seat 
 were so near at hand and its nature so clear 
 that the operation could be thoroughly accom- 
 plished without much search amongst intes- 
 tinal coils ; but I should hope that he would 
 rather perform laparo-ileotomy than subject 
 the patient to the direct and collateral risks 
 of a prolonged effort at • disentangling his 
 abdominal viscera. 
 
 But, as I have already said, our decisions 
 on these topics can only be provisional, as, 
 indeed, all our therapeutic decisions must be, 
 if we be worthy the name of scientific practi- 
 tioners. The scientific spirit accepts no result 
 as final, but, with stern impartiality, presses 
 steadily onwards to fuller truth, by ever assimi- 
 lating the fruits of an ever Widening knowledge. 
 In such a spirit, if we are faithful to it, we shall 
 still expect and still secure further vantage in 
 our conflict with disease, and in this spirit our 
 practice shall ever promise progress, and our 
 art attempt and accomplish achievement. 
 
Il8 INTESTINAL OBSTRUCTION 
 
 Since this essay was first written the pro- 
 gress of medical and surgical opinion and 
 practice has moved in the direction of earlier 
 operative interference by laparotomy in cases of 
 intestinal occlusion other than those of simple 
 fsecal impaction. This progress is founded 
 upon two solid grounds, namely, upon the 
 increased precision we have acquired in the 
 differential diagnosis of the various forms of 
 intestinal closure, and upon certain improve- 
 ments in the surgical details and curative 
 results of the treatment of such closure by 
 abdominal section.* 
 
 My friend and colleague, Mr. Jordan 
 Lloyd, in a valuable paper, " On Acute Intes- 
 tinal Obstruction and its Treatment by Abdo- 
 minal Section, with illustrative cases," published 
 
 * For example, Dr. R. H. Fitz (in a. paper upon the 
 Diagnosis and Treatment of Acute Intestinal Obstruction, 
 published in the Boston Medical and Surgical Journal, 
 November, 1888), after analysing the symptoms of strangu- 
 lation, intussusception, twist, gall-stone, strictures, tumour, 
 &c., concluded that the symptoms, apart from stoppage of 
 the bowels, the presence of which establishes a diagnosis of 
 
INTESTINAL OBSTRUCTION II 9 
 
 in The Lancet, April 19th, 1890, gives the 
 following conclusions : — " i. In acute intestinal 
 obstruction our attention should be primarily 
 directed to the strangulation of the walls of 
 the bowel rather than to the stoppage of the 
 fsecal current. When strangulation exists im- 
 mediate operation is demanded. 2. The 
 ordinary text-book distinctions between ob- 
 struction in the large and small bowel are 
 not always to be depended on. 3. In all 
 obstructions above the rectum calling for 
 operation, median abdominal incision is the 
 proper primary procedure. 4. When the 
 abdomen is opened the examination of its 
 contents should be systematic and expeditious, 
 * * * and if the obstruction is not quickly 
 
 acute intestinal obstruction, are abdominal pain, nausea, or 
 vomiting, abdominal tympany, and abdominal tumour ; and 
 he goes on to say : — Acute intestinal obstruction is diagnos- 
 ticated by exclusion. Its seat is fixed by injection. Its variety 
 is determined by its seat, the age, antecedents, and symptoms 
 of the patient. Its treatment is surgical, on or after the third 
 day, if the symptoms are urgent and forced injections fail 
 to relieve. 
 
I20 INTESTINAL OBSTRUCTION 
 
 discovered the most distended coil should be 
 fixed to the skin and opened at once. If the 
 large intestine is the part involved, the 
 caecum or sigmoid flexure should be brought 
 through a special opening made in either groin." 
 After stating some further conclusions as to 
 operative details, Mr. Jordan Lloyd affirms 
 that the proportion of lives saved by abdo- 
 minal section in acute intestinal obstruction 
 will increase as earlier and more accurate 
 diagnosis comes to be made. 
 
VI. 
 
 ACCENTUATION OF THE PULMONARY SECOND 
 SOUND OF THE HEART.* 
 
 What accentuation indicates. — Clinical import. 
 — Prognostic value. — Therapeutic indications. 
 
 Accentuation of the pulmonary second 
 sound, or, to speak more precisely, accentuation 
 of that portion of the second sound of the 
 heart which is produced at the orifice of the 
 pulmonary artery, and is especially heard in 
 the " pulmonary," as distinguished from the 
 "aortic" area, although discovered and taught 
 by the great Skoda in the earlier days of 
 
 * A Clinical Lecture : published in The British Medical 
 Journal, March 31st, 1883 ; since revised and rewritten. 
 
122 PULMONARY ACCENTUATION 
 
 cardiac auscultation, is not generally recognised, 
 if I may judge from the scanty references 
 to it in text books, and from my observations 
 of its frequent neglect in the practice of 
 stethoscopists, as one of the most striking 
 and one of the most significant of the 
 physical signs of disturbance in the mechan- 
 ism and dynamics of the heart. It is a sign 
 which is to be found in association, in causal 
 relations which are tolerably clear and ap- 
 proximately constant, with the commonest 
 of the organic defects of the cardiac orifices 
 and valves, and with the commonest conse-, 
 quences and complications of embarrassed 
 cardiac action. Rightly interpreted, it is a 
 sign which traverses the whole domain of 
 practice, for it conveys reliable indications 
 in the three chief divisions of our relations 
 with a patient, inasmuch as it is significant 
 alike in diagnosis, in prognosis, and in thera- 
 peusis. Skoda, with his usual tendency to 
 over-refinement — that frequent fault of physi- 
 
PULMONARY ACCENTUATION 1 23 
 
 cians — did not grasp the simplicity and 
 singleness of the significance of accentuation 
 of the pulmonary second sound. He observed 
 the physical fact, but he went too far, and 
 in one line in a wrong direction, in his 
 speculation upon its import. He was wrong 
 in his teaching, for example, as Dr. Walshe 
 has pointed out,* that the presence of rein- 
 forcement of the second sound in the pul- 
 monary artery will distinguish a systolic 
 murmur at the left apex, caused by mitral 
 regurgitation, from a murmur of like time 
 and site, caused by friction of the blood 
 against roughnesses on the inner surface of 
 the ventricle. The essence of the matter is 
 this : Accentuation of the cardiac second 
 sound, as heard over the origin of the pul- 
 monary artery, is an unfailing indication of 
 increased tension in the blood current in 
 that vessel. In that it is this, it is a trust- 
 
 * Diseases of the Heart and Great Vessels. By W. H. 
 Walshe, M.D., &c. Fourth edition, 1873, P- 93- 
 
124 PULMONARY ACCENTUATION 
 
 worthy sign, which a little consideration will 
 enable you to understand, of a grave patho- 
 logical condition ; it is an unmistakable 
 physical accompaniment of a portentous 
 change in an area of the blood-circulation 
 which is vital, and which is removed beyond 
 the reach of those tactile and metric methods 
 of exploration which are applicable in varia- 
 tions of tension in the systemic arteries. 
 
 In health, the aortic portion of the second 
 sound of the heart predominates over that 
 produced at the valves of the pulmonary 
 artery. That is, the second sound is louder 
 in the ''aortic" than it is in the "pulmonary" 
 area. By this statement I mean that the 
 second sound is louder close to the right edge 
 of the sternum, over the lower portion of the 
 second right costal interspace, than it is close 
 to the left edge of the sternum over the upper 
 portion of the second left interspace. The 
 blood tension may be raised in pathological 
 states ; either in the systemic circulation, of 
 
. PULMONARY ACCENTUATION 125 
 
 which the aorta is at the commencement, or 
 in the lesser circulation, which passes from 
 the right to the left sides of the heart, through 
 the lungs, and at the commencement of which 
 is the pulmonary artery. 
 
 Whatever raises the blood-tension in the 
 aorta intensifies the aortic second sound ; what- 
 ever raises the blood-tension in the pulmonary 
 artery intensifies the pulmonary second sound. 
 What, then, is the clinical import of the 
 variety of abnormal loudness of the second 
 sound of the heart, to which I am directing 
 your attention ? Answering the question 
 broadly, I say it is beyond dispute that an 
 increased intensity of the pulmonary second 
 sound is due to an increase in the blood- 
 tension in the pulmonary artery, and that this 
 heightened tension is due to some obstruction 
 in the pulmonary or lesser circulation. The 
 sign is clinically associated with organic and 
 permanent lesions of the mitral valves and of 
 the mitral orifice. Either insufficiency of the 
 
126 PULMONARY ACCENTUATION 
 
 mitral valves, or narrowing of the mitral 
 orifice, adds a distinct and new physical 
 obstacle to the flow of blood through the 
 lesser circulation. In so far as such an obstacle 
 elicits increased force in the contraction of the 
 right ventricle, by so much does it raise blood 
 tension in the pulmonary artery, and conse- 
 quently accentuate the pulmonary second 
 sound. But, while this statement is strictly 
 true as a generalisation, you must remember 
 certain qualifying • circumstances which may 
 hold good in particular instances. Advanced 
 mitral regurgitation, or advanced mitral 
 stenosis, or both, may be present, and the 
 pulmonary second sound may not be accen- 
 tuated, but may even be less loud and clear 
 than in health. This may arise from one of 
 two causes, or from a frequent combination of 
 them, namely, from failure in the power of 
 the right ventricle, or from the appearance of 
 tricuspid regurgitation. In the course of mitral 
 disease, when the force of the right ventricle 
 
PULMONARY ACCENTUATION 1 27 
 
 at last fails to compensate for the obstacle on 
 the left side of the heart, the blood-tension 
 in the pulmonary artery inevitably fails and 
 falls, and with it the loudness of the pulmonary 
 sound inevitably declines and disappears. 
 When also, in the course of mitral disease, 
 the tricuspid valves, as so often happens near 
 the end, give way, the pulmonary tension is 
 at once lowered, and its physical sign disap- 
 pears. Let me emphasise these important 
 points by quoting some words of Rosenstein. 
 He writes : — " When the tension decreases in 
 the pulmonary artery, the intensity of the 
 second sound ceases; this takes place either 
 when the right ventricle's force has been im- 
 paired by disease in the performance of its 
 increased work, or when the right side of the 
 heart is so filled by the increased stagnation 
 that the ring of insertion of the tricuspid valve 
 is widened, and the valve is no longer able 
 to close the orifice."* I must also point out 
 
 * Rosenstein. Ziemssen's "Cyclopaedia of Medicine." 
 English translation, Vol. VI., p. 129. 
 
128 PULMONARY ACCENTUATION 
 
 to you that, in comparing the pulmonary 
 second sound with the aortic sound in cases 
 of mitral disease, you must remember that 
 the aortic second sound is likely to be rela- 
 tively weakened by reason of the reduced 
 systemic tension which mitral defects entail. 
 As Dr. Walshe points out, there is a " pseudo- 
 accentuation of the pulmonary second sound, 
 from real weakening of the aortic second 
 sound, through the lessened current and 
 diminished calibre of that vessel, that follows 
 on long-continued mitral regurgitation."* You 
 must not fall into the error of mistaking a 
 pulmonary second sound of normal loudness 
 for an accentuated sound, because it co-exists 
 with a feeble aortic sound. On this point, 
 which undoubtedly is sometimes a difficult 
 one in practice, you must look to an extended 
 experience of cardiac auscultation to aid you. 
 The recognition of variations in the tone and 
 loudness of the heart's sounds is a refinement 
 * Op. cit., page lOO. 
 
PULMONARY ACCENTUATION 1 29 
 
 of stethoscopy which only long practice can 
 develop. It is only when, by patient clinical 
 work, you have acquired in your minds a 
 sure standard of the characters of cardiac 
 sounds that you can readily detect deviations 
 from their normal intensity. 
 
 So far as I have been able to judge from 
 my own observations at the bedside, the 
 presence or the absence of accentuation of the 
 pulmonary second sound, or the presence of 
 a high or of a low degree of such accentuation, 
 is valueless as a differential sign in itself in 
 the diagnosis of mitral stenosis from mitral 
 insufficiency. I know this statement is opposed 
 to the teaching of some physicians and of some 
 writers of acknowledged authority in cardiac 
 diagnosis. Both varieties of mitral disease, 
 whether they exist singly and pure or howso- 
 ever they may be combined, impose a morbid 
 obstacle to the passage of blood from the 
 right to the left side of the heart, and tend, 
 pro tanto, to increase the blood-tension in the 
 
1 30 PULMONARY ACCENTUATION 
 
 pulmonary artery. So long as this obstacle is 
 met by a compensating increase of force in the 
 contraction of the right ventricle, so long is the 
 pulmonary second sound of more intensity 
 than in health. The presence of such accentua- 
 tion is not a sign which distinguishes one form 
 of mitral disease from another, but it is a sign 
 common to mitral lesions in general, which rises 
 and falls in direct proportion to the vigour of 
 the right ventricular systole. When, in the 
 backward march of the results of a mitral 
 lesion, the saving force of the right ventricle 
 becomes impaired by dilatation of that ventri- 
 cular cavity or by degeneration of its muscular 
 walls, the pulmonary second sound loses its 
 accentuation, and the sound may become 
 almost or quite inaudible. 
 
 You will now be able to appreciate the 
 help which may be gained in the diagnosis, 
 prognosis, and treatment of a given case of 
 organic disease of the mitral orifice or valves, 
 from observation of the condition of the second 
 
PULMONARY ACCENTUATION I3I 
 
 sound in the pulmonary artery. Stating the 
 case broadly, it may be said with approxi- 
 mate truth that mitral valvular defects are 
 generally results of acute endocarditis. Of 
 such results, they are usually both immediate in 
 time and permanent in duration. Once estab- 
 lished, the affection of the valves or orifice 
 becomes a permanent defect, which never grows 
 less, but which rather tends, by the organ- 
 isation and contraction of inflammatory exuda- 
 tions, and by other well-known consecutive 
 changes, to become more and more pronounced 
 as time goes on. From the date of the endo- 
 carditis which first damaged the heart, there 
 occurs a variable period of practically good 
 health, or of quasi-health, but slightly impaired 
 by certain of the less pressing signs of cardiac 
 embarrassment. This period may vary in length 
 from a few weeks or months to a few or many 
 years, being determined by a variety of variously 
 combined circumstances, such as the extent of 
 original mitral damage and the degree of subse- 
 
132 PULMONARY ACCENTUATION 
 
 quent compensation, and the age, mode of life, 
 social position, and habits of the patient. But, 
 whether this period be short or long, there 
 surely comes, sooner or later, an ultimate or 
 penultimate stage, marked by failure of com- 
 pensation and by dropsical complications, 
 leading on to death. 
 
 Accepting this brief outline as a rapid 
 sketch of the usual progress of mitral affec- 
 tions, let us answer this question : — What is 
 the usual state of the pulmonary second 
 sound in the progress of such a case ? When 
 the mitral disease arises, that is, from the 
 time acute endocarditis so affects the mitral 
 orifice or valves as to set up a physical 
 obstacle there to the normal progress of blood 
 through the heart, the pulmonary second 
 sound becomes accentuated, but only slightly 
 so, for the most part at this early stage. 
 During the second period of quasi-health, 
 that is to say, from the time of convalescence 
 from the acute endocarditis until the onset 
 
PULMONARY ACCENTUATION 1 33 
 
 of the later secondary complications con- 
 secutive to the mitral defect, the pulmonary 
 second sound remains only slightly reinforced. 
 You will generally find it as loud as the 
 aortic sound, or a little louder, but not very 
 markedly intensified. But towards the end 
 of this second period, when the pulmonary 
 tension is nearing the point when it will 
 overcome the compensating force of the right 
 ventricle, the pulmonary second sound becomes 
 very distinctly accentuated, and attains its 
 maximum development. The sign is at this 
 time of grave portent, for it is the sure index 
 of an extremely heightened tension in the 
 pulmonary circulation, which is not likely to 
 be borne long ; it is an unfailing sign that 
 the pulmonary circulation is only maintained 
 by an increased expenditure of force by the 
 right ventricle, which cannot long be kept 
 up. At this point a straw breaks the back 
 of the labouring camel. A little added 
 difficulty to the circulation through the lungs. 
 
134 PULMONARY ACCENTUATION 
 
 which usually comes as a bronchial catarrh, 
 which would be trivial under some other 
 circumstances, and the next, the ultimate or 
 penultimate, stage of mitral troubles is ushered 
 in. Compensation fails, and with it falls, 
 pari passu, the accentuation of the pulmonary 
 arterial sound. With failing compensation, 
 viscera and surface become engorged with 
 blood, anasarca gradually develops, and drop- 
 sical exudations begin to gather in the serous 
 cavities. 
 
 This is the stage at which you often see 
 patients admitted to my wards. With rest, 
 good and carefully adjusted evacuants, and, 
 above all, with digitalis, our great heart- 
 restorer, many improve, lose the later compli- 
 cations of their mitral disease, revert to the 
 second stage of quasi-health, which I have 
 been describing, and return to their occupa- 
 tions. As they improve, as rest, suitable food, 
 evacuants, and digitalis do good, you may 
 notice the pulmonary second sound, which- 
 
PULMONARY ACCENTUATION 135 
 
 had waned before, wax strong again, surely- 
 marking the recovery of compensation in the 
 propulsive power of the right ventricle, which 
 is the essential factor in the patient's relief. 
 Here observation of the pulmonary second 
 sound is of inestimable service. With a rising 
 sound, our treatment is doing good, and our 
 patient is making progress towards recovery. 
 
 But the complications of this later stage 
 of mitral disease, unhappily, cannot always be 
 removed even once ,- and if removed once, or 
 twice, or thrice, or oftener, there surely comes 
 a time when all our remedies are at last of 
 little or no avail. Be our treatment never so 
 patient and skilful, the patient's condition 
 remains stationary, or goes on from bad to 
 worse. Here the compensating power of the 
 right ventricle is finally and irretrievably 
 exhausted ; it is past all repair. Here the 
 pulmonary second sound never rises under 
 our treatment, but remains feeble to the end. 
 Its continued feebleness, in the presence of 
 
136 PULMONARY ACCENTUATION 
 
 dropsical complications, and in spite of our 
 best therapeutic efforts, is a sure sign that 
 the end is not far off, and that the patient is 
 suffering his last illness. 
 
 In the congestive and dropsical compli- 
 cations of advanced mitral disease, I have 
 often proved the therapeutic efficacy of a 
 well-known combination of digitalis, squill, and 
 blue pill. 
 
 Here is the formula for this excellent 
 prescription : — 
 
 R. Pulv. Digitalis, gr. j. 
 Pulv. Scillse, gr. j. 
 Pil. Hydrarg. , gr. j. 
 Ft. pil. One to be taken thrice daily, between meals. 
 
VII. 
 
 REMARKS ON FLOATING KIDNEY.* 
 
 Cases of floating kidney established by post- 
 mortem examinations. — Physical signs. — Case. 
 — Causation of floating kidney. — Frequency 
 in women. — Comparison of anatomical rela- 
 tions of kidneys. — Symptoms.— Treatment. 
 
 Floating kidney is a substantial reality, 
 which must always be remembered in abdo- 
 minal explorations. Its existence has been 
 abundantly established by post-mortem exami- 
 nations. 
 
 Some years ago a committee of the 
 Pathological Society of London, consisting of 
 
 * A digest of two papers : Floating Kidney, Birmingham 
 Medical Review., July, 1872 ; Remarks on Floating Kidney, 
 Ibid., October, 1883. 
 
138 FLOATING KIDNEY 
 
 Dr. Hare, Dr. Bristowe, Dr. Wilks, Dr. John 
 Williams, and Dr. Wickham Leggi was 
 appointed "to inquire into the matter of dis- 
 placed, movable, and floating kidneys.'' From 
 the report of this committee, which was pub- 
 lished in 1876,* I quote the following para- 
 graph : " Cases of undue mobility of the kidney 
 verified by examination after death have been 
 several times recorded. One specimen was 
 brought before our society sixteen years ago 
 by Mr. Durham. + Dr. Priestley has described 
 a case, under the care of Sir James Simpson, in 
 which after death the peritoneum was found 
 reflected over the posterior surface of the right 
 kidney, thus allowing great motion on the right 
 side.J Other instances have been recorded by 
 Mr. Adams,§ Dr. Iago,|| in which the state of 
 
 * Transactions of the Pathological Society, Vol. XXVII., 
 1875-6. 
 
 t Durham, Transactions of the Pathological Society, i860, 
 Vol. XI., p. 142. 
 
 } Priestley, Medical Times and Gazette, March 14, 1857. 
 
 § Adams, Ibid., p. 651. 
 
 II lago. Ibid., 1872, Vol. II., pp. 328 and 409. 
 
FLOATING KIDNEY 139 
 
 the kidney was diagnosticated during life and 
 verified by examination after death, Dr. Sawyer,* 
 Girard,t Urag,| and others." 
 
 A floating kidney is a movable kidney, 
 and something more. For a clear definition of 
 this distinction we are indebted to Sir William 
 Jenner. " A movable kidney is one thing ; a 
 
 floating kidney is another A floating 
 
 kidney is a kidney that has a mesentery — a fold 
 of peritoneum attaching it very loosely to the 
 spine. A floating kidney, therefore, can be 
 moved about to a considerable extent — to the 
 extent of the length of its mesentery. A mov- 
 able kidney can only be passed up and down 
 a little ; it slips a little under your fingers."§ 
 
 The largest statistics concerning movable 
 and floating kidneys with which I am 
 acquainted are to be found in the well-known 
 
 * Sawyer, Birmingham Medical Review, 1S72, p. 120. 
 
 t Grcati, Journal Hebd., 1836, p. 445. 
 
 J Urag, quoted by Fritz. Arch. Gen. de Med. , 1859, p. 167. 
 
 § Clinical lectures on the ' ' Diagnosis of Extra - pelvic 
 Tumours of the Abdomen." By Sir William Jenner, Bart., 
 M.D., &c., British Medical Journal, January, 1869. 
 
HO FLOATING KIDNEY 
 
 treatise of Sir William Roberts on renal 
 diseases. From these figures, from six cases 
 of floating kidney which I published in the 
 first volume of the Birmingham Medical 
 Review, from several cases which I have met 
 with since in my practice, and from other 
 instances which I have found recorded, it 
 appears that preternatural renal mobility may 
 be either unilateral or bilateral, that it is more 
 frequently unilateral than bilateral, that the 
 right kidney has been affected about four times 
 as often as the left, that floating kidney is much 
 more common in women than in men, and 
 that, amongst women, by far the larger 
 number of the subjects of floating kidney 
 have been women who have borne children. 
 These points are well established, and their 
 clinical bearings are very important. 
 
 When we palpate the abdomen of a 
 person presenting a floating kidney, the 
 patient lying in a recumbent position, with 
 the abdominal walls relaxed, we can feel a 
 
FLOATING KIDNEY I4I 
 
 swelling, which is rounded, smooth, of the 
 size and shape of a kidney, and which we 
 can move in various directions, the movement 
 being free and peculiarly slippery in its 
 character. All the borders of the tumour 
 can usually be easily defined by the fingers : 
 the inner concave edge of the swelling, how- 
 ever, is often somewhat obscured. The 
 displaced organ usually occupies a diagonal 
 position, from above downwards, lying just 
 below the free costal border, midway between 
 the umbilicus and the last rib. The swelling 
 can be readily moved in various directions ; 
 but it is most movable in a direction forwards, 
 downwards, and towards the middle line ; 
 ' ' and next most movable in an opposite direc- 
 tion, namely, upwards, outwards, and backwards. 
 The position of the tumour is affected by the 
 position of the patient, the swelling descending 
 when the upright posture is assumed, and 
 falling towards the right or the left, accord- 
 ing to the inclination of the body. 
 K 
 
142 FLOATING KIDNEY 
 
 The respiratory movements, too, influence 
 the position of a floating kidney. When the 
 patient is lying down a deep inspiration may 
 be necessary to bring the tumour forwards, so 
 that we can feel it. Sometimes pressure on 
 the renal region behind will suffice to bring a 
 floating kidney forwards ; sometimes pressure 
 alone, and a deep inspiration alone, alike fail 
 to do this, and both together are needed to 
 bring the organ into prominence in front. 
 The displaced kidney can generally be restored 
 with the fingers to its normal position, but it 
 usually falls forward again when pressure is 
 removed. Cases in which both kidneys " float " 
 are comparatively infrequent. In hospital and 
 private practice during twenty - five years, I 
 have met with only two patients who had both 
 their kidneys floating freely. In one of these 
 cases I could easily bring the two organs 
 forward at the same time, and maintain their 
 concave margins in contact in the middle line 
 of the abdomen. 
 
FLOATING KIDNEY 143 
 
 An opportunity of verifying or of correct- 
 ing, post-mortem, a diagnosis of floating kidney 
 occurs very rarely. The following is the only 
 instance in which such an occasion has 
 happened in my own experience : — 
 
 Early in the year 1870 I examined Mrs. 
 Mary Ann H., aged 35 years ; I saw her in 
 consultation with my friend the late Dr. 
 Hickinbotham, of Nechells. The patient was 
 a spare woman, rather anaemic, and of nervous 
 temperament. She had had seven children ; 
 her labours had been tedious, but natural. For 
 six years she had suffered pain in passing 
 her urine, with a constant desire to micturate. 
 The urine was turbid, containing pus and 
 phosphates ; it sometimes contained a little 
 blood. Sometimes the pain was very severe, 
 and then she frequently passed some shreds 
 of membrane in her urine, and occasionally, 
 this appeared in rolls as thick as a straw. 
 After the passage of these substances she was 
 usually better for several weeks. A sound 
 
144 FLOATING KIDNEY 
 
 introduced into the bladder indicated excessive 
 tenderness at one spot. A tumour, having all 
 the characters of a floating kidney, was found 
 in the abdomen, midway between the umbili- 
 cus and the anterior superior spine of the 
 right ilium ; this could be freely moved 
 upwards, it could be easily grasped, and 
 handling produced neither sickness nor pain. 
 I regarded the pus as renal in its origin, and 
 I suggested the existence of a calculus, with 
 consequent pyelitis, in the floating kidney.* 
 This woman died a few weeks afterwards, and 
 Dr. Hickinbotham exhibited the right kidney 
 at a meeting of the Pathological and Clinical 
 Section of the Birmingham Branch of the 
 British Medical Association, held November 
 25th, 1870. The following account of the case 
 is taken from the British Medical Journal, 
 December 24th, 1870: — 
 
 " Dr. Hickinbotham showed a specimen of 
 
 * I was indebted to Dr. Hickinbotham for the history of 
 the case. 
 
FLOATING KIDNEY I45 
 
 abscess occurring in a movable kidney. The 
 woman from whose body the specimen was 
 taken had repeatedly suffered from great pain 
 in the region of the bladder, with difficult 
 and painful micturition ; the urine being loaded 
 with pus. She had never had any pain in 
 the kidney itself until about fourteen days 
 before death, when acute inflammatory symp- 
 toms came on, and, in spite of treatment, she 
 sank and died on the 17th of September. The 
 post-mortem examination showed general in- 
 flammation of the whole peritoneum ; and. 
 the right kidney, which lay midway between 
 the umbilicus and the anterior superior spine 
 of the ilium was completely riddled by abscesses. 
 The ureter was dilated and thickened. The 
 bladder, except near the opening of the right 
 ureter, was healthy." 
 
 The production of a floating condition of 
 the kidney is an effect which is the result, 
 doubtless, of the concurrence of several causes. 
 Oppolzer thought that the affection is usually 
 
146 FLOATING ICIDNEY 
 
 congenital, and this view seems to have been 
 suggested by the lengthened condition of the 
 renal vessels which has been usually found in 
 these cases after death ; this opinion, so far as 
 my own reading extends, does not appear to 
 have been fully shared by other writers on 
 the subject. If the abnormality were con- 
 genital, it would be difficult to account for 
 the disproportionate frequency of its occurrence 
 in females. Cruveilhier thought the practice of 
 tight-lacing mainly contributes to the produc- 
 tion of this affection. 
 
 In the paper by Sir William Roberts 
 which I have before alluded to, child-bearing 
 and tight-lacing are given as the most pro- 
 bable predisposing causes of the affection. 
 " Becquet has proposed a somewhat novel 
 theory for the production of movable kidneys 
 in women. In the cases encountered by him, 
 there was a striking coincidence of time 
 between the displacement of the kidney and 
 the menstrual period ; and he was led to believe 
 
FLOATING KIDNEY 147 
 
 that the kidney became congested and tume- 
 fied at these periods, and that displacement 
 was the consequence of its increased volume 
 and weight."* More or less rapid emaciation, 
 occurring in persons who have previously been 
 corpulent, has been considered, and with reason, 
 to favour or of itself produce displacement 
 of the kidney, by removing the fatty cushion 
 which normally invests and supports the organ, 
 and helps to retain it in position. Such a 
 mode of causation probably existed in the 
 case published by Mr. Adams. 
 
 There is abundant evidence to show that 
 a blow or a violent concussion of the body 
 may be the determining causes in some cases. 
 Dr. Fleming attributed the mobility of the 
 kidney in one of his cases to injury. Dr. 
 Roberts quotes two cases, related by Henoch : 
 in one the right kidney became movable after 
 a blow on the right loin ; in another, in 
 
 • Urinary and Renal Diseases, by Sir W. Roberts. 
 
148 FLOATING KIDNEY 
 
 the case of a military officer, both kidneys 
 became movable after a fall from a horse. 
 
 Many, perhaps by far the larger number, 
 of the subjects of floating kidney are women 
 who have borne children. All the examples 
 which have fallen under my own notice have 
 been observed at some period after child-bear- 
 ing. To what extent a difficult and protracted 
 labour may be concerned as a cause, I am 
 unable to say. The powerful and prolonged 
 contractions of the diaphragm which are inci- 
 dental to such a condition would, doubtless, 
 favour displacement of the kidney. I think, 
 however, the circumstan,ces which determine 
 a liability to this affection arise rather as a 
 result of the sudden removal of the pressure 
 whiph the distended uterus exercises on the 
 kidneys, in common with other organs within 
 the abdomen. The tendency to falling forwards 
 of the viscera, as a result of the impaired 
 support afforded to them by the abdominal walls, 
 in a woman who has borne children, appears 
 
FLOATING KIDNEY I49 
 
 likely to contribute also to the production 
 of floating kidney. Feeble women, with lax 
 and atonic tissues, are probably more subject 
 to this abnormality than those who are more 
 robust. 
 
 The cause of the disproportionate fre- 
 quency of a floating condition of the right 
 kidney, as compared with the left, is to be 
 found, doubtless, in the difference between 
 the anatomical relations of the organs on the 
 two sides of the body. Cruveilhier, as quoted 
 by Roberts, observed : — " If the left kidney 
 is not so frequently displaced as the right, that 
 is owing to the fact that the left hypochon- 
 drium, occupied by the spleen and the great 
 end of the stomach, bears the pressure of the 
 stays with much more impunity than the right." 
 We must remember, also, that the kidneys are 
 moved a little by the respiratory movements. 
 " The right kidney," writes Sir William Jenner, 
 in the admirable lectures which I have 
 already quoted, " is more depressed during deep 
 
150 FLOATING KIDNEY 
 
 inspiration than the left, probably from its 
 relation to the liver." 
 
 The pressure of the liver — the pressure 
 of its weight and the pressure of its dia- 
 phragmatic movement — contributes, unquestion- 
 ably, to render the right kidney more liable 
 to displacement than its fellow. The renal 
 vessels, too, are usually a little longer on 
 the right side — the artery especially — than 
 those on the left ; and we may observe that 
 the ascending colon is not so closely applied 
 to the right kidney, as the descending portion 
 of the large intestine is to the left. The 
 chief support of the spleen, the costo-colic 
 ligament (the band of folded peritoneum which 
 passes from the left angle of the transverse 
 colon to the abdominal wall, opposite the last 
 rib), helps in some small degree, perhaps, to 
 increase the fixity of the left kidney. 
 
 Healthy floating kidneys bear manipulation 
 exceedingly well. Some authors allude to the 
 production of a sickening sensation when the 
 
FLOATING KIDNEY I 51 
 
 tumour is squeezed. I cannot say that I 
 have observed this ; but firm pressure, un- 
 doubtedly, causes pain. 
 
 The patients usually experience a feeling 
 of dragging, uneasiness, and of weight in the 
 abdomen, which they refer to the tumour, 
 and which may be increased by standing for 
 some time, or by exercise, or which may 
 never be felt except under such circumstances. 
 Sometimes movements of the displaced organ 
 are perceived by the patient, and then they 
 may give rise to delusions, which we find 
 great difficulty in dispelling. In one of the 
 cases I have given, the patient persisted, 
 in spite of all we could say to the contrary, 
 in believing the movements to be those of a 
 "child." Sir W. Roberts quotes a similar case. 
 
 Unless a displaced kidney be the seat of 
 structural disease, preternatural mobility of the 
 organ is not attended by urinary abnormalities. 
 In uncomplicated cases the secretion of urine 
 is always healthy, neither is there any inter- 
 
152 FLOATING KIDNEY 
 
 ference with micturition. The irritating con- 
 dition of the urine was quite a sufificient 
 cause for the frequent desire to empty the 
 bladder noticed in Dr. Hickinbotham's case. 
 
 The dragging and uneasy sensations 1 
 have described may be removed or relieved. 
 Sometimes they are completely removed by 
 wearing a tolerably tight, elastic, abdominal 
 bandage. Anaemia, or dyspepsia, or disorders 
 of the uterus, must not be overlooked, and 
 suitable means must be adopted for their 
 removal. Treatment of a tonic nature may 
 be pursued with great advantage. When the 
 abdominal walls are weak and relaxed, shower 
 or douche baths, rest, and chalybeates are 
 indicated. All constriction of the lower part 
 of the thorax, by stays or waistbands, or the 
 like, must be avoided, and petticoats should 
 be suspended from the shoulders rather than 
 from the waist. The action of the bowels 
 must be carefully regulated ; constipation, and 
 the consequent straining, invariably aggravate 
 
FLOATING KIDNEY 153 
 
 renal displacements. Violent exercise, such as 
 riding on horseback or dancing, should be 
 prohibited. Rest and good food do much for 
 our poorer patients. 
 
 Floating kidney, of itself, can never shorten 
 life ; it usually persists for an indefinite period. 
 It is necessary that we should clearly under- 
 stand this curious abnormality, and be able to 
 form a correct diagnosis of it, that we may 
 remove all alarm from the mind of the patient, 
 and prevent the adoption of injurious measures 
 of treatment. 
 
VIII. 
 
 THE TREATMENT OF GASTRALGIA * 
 
 Pain of gastralgia. — Importance of negative 
 diagnosis. — Romberg's description of seizure. 
 Temperamental and sexual associations. — 
 Diagnosis. — Cautions. — Employment of 
 arsenic. — Counter-irritation.— Diet. 
 
 I DO not propose to-day to attempt a com- 
 plete exposition of the nature and cure of 
 gastralgia. I desire to draw your attention to 
 some salient features of practical import in 
 the definition, etiology, symptomatology, and 
 diagnosis of the disorder, and especially to point 
 out to you a means of treatment in which I 
 have found confidence, based upon a long 
 
 • A clinical lecture : published in The Lancet, August 13th, 1887. 
 
THE TREATMENT OF GASTRALGIA 155 
 
 and frequent experience of satisfactory results. 
 Gastralgia is a very painful affection. The 
 pain has marked characteristics as to position, 
 duration, and onset, and as to its sexual, 
 constitutional, and temperamental associations. 
 The disorder has been variously called gas- 
 tralgia, cardialgia, and gastrodynia. The 
 nomenclature of the Royal College of Physicians 
 authorises the last name, and it gives "stomach- 
 ache" as a popular synonym. The malady is 
 usually held to be a neurosis, affecting the 
 gastric nerves. According to Dr. Leube, 
 gastralgia is limited essentially to the sensitive 
 sphere of the gastric nerves.* That the dis- 
 order is a neurosis is not quite proven — indeed, 
 it is scarcely demonstrable. But the idea is 
 a good " working hypothesis," which I commend 
 to you. Romberg distinguished two forms of 
 gastralgia : one, which he called gastrodynia 
 neuralgica, he held to be a hyperaesthesia of 
 
 * Von Ziemssen's Cyclopaedia. 
 
I S6 THE TREATMENT OF GASTRALGIA 
 
 the gastric branches of the pneumogastric 
 nerves ; the other, which he called neuralgia 
 coeliaca, he regarded as a hypersesthesia of the 
 solar plexus. Although Romberg has indicated 
 what he thought to be the signs and conditions 
 upon which a clinical differentiation of these, 
 varieties of gastralgia might be established, 
 I agree with Niemeyer that in a given case it 
 cannot be determined by anyvmethods of clinical 
 investigation whether the patient's pains occur 
 in pneumogastric or in sympathetic distribution. 
 As Henoch has taught, although the distinction 
 may rest upon a correct theoretical and anatomi- 
 cal basis, it is one which is inapplicable and 
 worthless in practice.* It has been objected 
 that the term gastralgia is unscientific, because 
 it is only the name of a symptom. In practice, 
 however, and especially in private practice, 
 we meet with many cases for which I know 
 of no other name ; and I apply the name to a 
 
 * Niemeyer : Text-book of Practical Medicine. 
 
THE TREATMENT OF GASTRALGIA 1 57 
 
 clearly conceived and clearly defined condition. 
 I call a case one of gastralgia in which pain, 
 deep-seated and paroxysmal, in or about the 
 stomach, of a neuralgic or quasi -neuralgic 
 character, is the leading symptom. But this 
 statement is inseparable from the following 
 important qualification. Pain of the character 
 and position described can only be regarded 
 as that of gastralgia when it is unaccompanied 
 by marked evidences of gastric or gastro-hepatic 
 catarrh, and when, also, it is wholly unaccom- 
 panied by physical signs of structural disease 
 either in the stomach or in its neighbourhood. 
 The latter part of this definition involves an 
 essential and a negative conclusion. A negative 
 conclusion, of course, in any case is prover- 
 bially difficult. Such a conclusion should only 
 be formed in a supposed case of gastralgia 
 after a complete examination of all the cir- 
 cumstances. Further, a diagnosis of gastralgia 
 should only be held in the conduct of a case 
 of pain in the gastric region as a conclusion 
 
IS8 THE TREATMENT OF GASTRALGIA 
 
 which is subject to frequent diagnostic revision ; 
 that is, such a diagnosis can only be continued 
 when repeated physical exploration fails to 
 reveal any other " coarser " interpretation of 
 the patient's suffering. I desire to impress 
 this last statement upon you as an important 
 clinical caution, which you must especially 
 remember when your patient is a man at or 
 beyond middle life. In such a person the 
 danger of mistaking a graver and more material 
 condition for gastralgia is especially imminent. 
 The diagnosis of gastralgia is one which 
 should never be lightly made, nor negligently 
 maintained. Pain in the gastric region, you 
 should always remember, may long appear to 
 be simply gastralgic — that is, independent of 
 any local organic basis — when the appearance 
 of a tumour, or the discovery of an aneurismal 
 pulsation, or a sudden gastric or intestinal 
 haemorrhage may prove a diagnosis so com- 
 paratively favourable to be tenable no longer. 
 Romberg's short and vivid description of 
 
THE TREATMENT OF GASTRALGIA 1 59 
 
 an attack of the severest gastralgia has been 
 accepted as classical. Let me read it to you. 
 He wrote : — " A violent contracting pain at 
 the pit of the stomach supervenes suddenly, or 
 after being preceded by a sense of oppression ; 
 it generally extends to the back, there is a 
 sense of fainting, the face is fallen in, the 
 hands and feet cold, and the pulse small, 
 cramped, and intermittent. The pain attains 
 such a pitch as to cause the patient to scream 
 out. The region of the stomach is either 
 swelled and distended like a ball, or, as is 
 more frequently the case, it is drawn in, and 
 the abdominal parietes are tense. It is com- 
 mon to find pulsation at the epigastrium. 
 Pressure is not only well borne, but the patient 
 frequently forces the pit of the stomach against 
 some firm object, or compresses it with his 
 hands. Sympathetic sensations occur in many 
 instances in the thorax, under the sternum, or 
 in the pharyngeal branches of the vagus nerve, 
 while they are seldom met with in the super- 
 
l6o THE TREATMENT OF GASTRALGIA 
 
 ficial parts."* This is Romberg's account of 
 a typical and violent seizure of that form of 
 gastralgia which he called coeliac neuralgia or 
 paroxysmal hyperaesthesia of the solar plexus. 
 You may accept his clinical portrait as accurate, 
 although it is doubtful whether he was correct 
 in localising the pain solely in nerves of the 
 sympathetic system. Under the heading of 
 gastrodynia neuralgica you will find in Rom- 
 berg's excellent book a faithful clinical de- 
 scription of the milder cases of gastralgia, or 
 •' attacks of painful sensations in the stomach," 
 especially as they are manifested in associa- 
 tion with the nervous temperament, and with 
 the reflex expressions of sexual irregulari- 
 ties in women. I have ventured from my 
 reading and clinical experience to form the 
 opinion that Romberg did not describe two 
 distinct diseases under the several names of 
 coeliac neuralgia and neuralgic gastrodynia, 
 
 * Romberg's ' ' Nervous Diseases of Man." Translated 
 for the Sydenham Society by Sir Edward Sieveking, M.D., etc. 
 
THE TREATMENT OF GASTRALGIA l6l 
 
 but merely one and the same affection, which 
 I have been accustomed to call gastralgia, as 
 he met with it in different degrees of severity. 
 Of course a dual interpretation of painful 
 neuralgic affections in the gastric region 
 has an anatomical basis in the dual nerve 
 supply of the stomach — namely, in the inner- 
 vation of the organ by nerves of the sympa- 
 thetic system, and also by the vagus. But, 
 truly, in the words of Leube, " in the present 
 state of uncertainty with regard to the mode 
 of action of the gastric nerves, especially with 
 regard to the conditions of sensation, and in 
 view of the anastomotic connections between 
 the vagus and the sympathetic in the stomach, 
 such a division of cardialgia appears to be 
 both theoretically and practically untenable." 
 
 Gastralgia may occur at any age. It is 
 rare at the extremes of life. It is rarer in 
 children than in old people. It is most com- 
 monly met with in early middle life. Like 
 all neuralgias, it follows hereditary constitu- 
 
l62 THE TREATMENT OFGASTRALGIA 
 
 tion, and is especially associated with the 
 nervous temperament. I advise you to study 
 temperaments. In them you will find many 
 clues to morbid tendencies. Temperaments 
 denote distinct types of physical form, of 
 habits, and of capacities. A man of nervous 
 temperament is mostly slightly built, and he is 
 generally in a hurry. He is hypersensitive 
 to all influences, and to pain amongst them. 
 All his movements are quick, and he has a 
 strong tendency to " fidget " with his ideas 
 or with his extremities. His speech betrays 
 him : he talks volubly, abruptly, and earnestly, 
 often splitting up his phrases, or recalling and 
 correcting them, and especially modifying 
 qualifying words.* 
 
 As in all neuralgias, women are more 
 liable to gastralgia than men. As, also, in 
 all neuralgias, the manifestation of gastralgia 
 
 is favoured by every condition which reduces 
 
 4t 
 
 * I have given a fuller account of the nervous temperament 
 in the essay on " Insomnia," in this book. 
 
THE TREATMENT OF GASTRALGIA 1 63 
 
 the vigour of a patient's "general health." 
 Asthenia sharpens neuralgic pain, and favours 
 its development and persistence. Gastralgia 
 is a , frequent neuralgic development of 
 hysteria ; and, in women who are not hysterical, 
 its incidence is often determined by the pro- 
 stration of ansmia or by the exhaustion which 
 arises from prolonged uterine discharges. In 
 men gastralgia may be a consequence of sexual 
 excesses or of masturbation. All these cir- 
 cumstances must be remembered and dealt 
 with in the causal diagnosis and effective treat- 
 ment of the disorder. 
 
 The diagnosis of gastralgia is usually not 
 difficult. Pain is the leading symptom. When 
 we are satisfied as to the genuineness of pain 
 in the region of the stomach, its correct inter- 
 pretation largely depends upon an accurate 
 appreciation of various diagnostic data, per 
 viam exdusionis. I cannot deal exhaustively 
 with this part of the -subject to-day. I desire, 
 however, to give you these three cautions, which 
 
164 THE TREATMENT OF GASTRALGIA 
 
 I have learned in practice: — (i) Gastralgia is 
 not a wasting disease. (2) It is not safe to 
 diagnose cancer of the stomach until you can 
 feel the cancer. (3) Do not diagnose ulcer of 
 the stomach until you have seen blood from 
 the stomach, either in hsematemesis or melaena. 
 You may take it as a clinical truth, as the 
 late Dr. Wilson Fox clearly insisted, that pain 
 arising in the stomach when the organ is empty, 
 and relieved by the ingestion of food, is almost 
 diagnostic of its nervous origin and nature.* 
 Sometimes the pain of ulcer or cancer of the 
 stomach may for a time appear to be relieved 
 by taking food, but -such a condition is highly 
 exceptional. There is sometimes a kind of 
 gastric "sinking," even amounting to craving 
 for food, in gastric catarrh, and with greater 
 rarity probably in gastric ulcer ; the local dis- 
 comfort is not, however, relieved by feeding, 
 but, on the contrary, usually rnade worse. 
 There is another diagnostic sign of great im- 
 * Reynolds' System of Medicine. 
 
THE TREATMENT OF GASTRALGIA l6S 
 
 portance in the recognition of gastralgia. It 
 is this : firm pressure over the region of the 
 stomach relieves the local pain. Some patients 
 find this out for themselves, and press a 
 closed hand or the upper rail of a chair strongly 
 against the epigastrium, and so find relief 
 
 My chief object in drawing your attention 
 to the subject of gastralgia is to explain to you 
 a plan of treatment which I have found very 
 successful. I can tell you of a drug which 
 cures gastralgia. Before you prescribe it, how- 
 ever, you ought to find out if there be any 
 prominent pathological concomitants or causal 
 antecedents of the disorder, and to deal with 
 them. Anaemia, sexual excess, overwork, work 
 under wrong conditions, uterine discharges, mas- 
 turbation, — all must be appropriately met. But 
 for the cure of the gastralgia something more 
 is usually necessary. Of all the directly thera- 
 peutic results in medicine with which I am 
 acquainted, one of the most demonstrable is 
 that which can be produced by the suitable 
 
l66 THE TREATMENT OF GASTRALGIA 
 
 exhibition of arsenious acid in uncomplicated, 
 gastralgia. I give one-twenty-fourth of a grain 
 of arsenious acid, made into a pill with two 
 grains of extract of gentian, thrice daily, 
 between meals. The use of this remedy must 
 be continued for a few weeks. In a case of 
 moderate severity no other medicinal treat- 
 ment is necessary. The gastralgic pains become 
 less frequent and less severe, and recovery 
 is steadily and surely attained. In severer 
 cases I use some form of counter-irritation to 
 the epigastrium, and I usually employ a rube- 
 facient liniment of ammonia, or of ammonia 
 and capsicum. In the severest cases vesication 
 by a fly-blister is of service, and the blistered 
 surface should be kept raw for some days by 
 means of a daily dressing of savin ointment. 
 In severe cases a seton in the skin of the 
 epigastrium may be employed, and it is an 
 excellent chronic counter-irritant. But you must 
 not rely upon treatment by drugs alone. Every 
 hygienic adjuvant which tends to raise the 
 
THE TREATMENT OF GASTRALGIA 167 
 
 strength of the patient is of high value in 
 the cure of gastralgia, as of all neuralgias. 
 I especially advise you to make sure the 
 sufferer feeds well and fully. The diet should 
 be generous. A " dyspeptic " regimen makes 
 a case of gastralgia worse. When you are 
 satisfied there is no, or but slight, gastric 
 catarrh in the gastralgia of a fairly vigorous 
 adult, you should direct a dietary after this 
 plan: — Breakfast: bread-and-butter or dry 
 toast, with some fresh white fish, or some 
 cold chicken or game, or a mutton chop, with 
 a breakfastcupful of cocoa or weak tea or coffee. 
 Dinner (i P.M.) : fresh beef or mutton, with 
 bread, potatoes, cooked green vegetables, a 
 fruit tart or a farinaceous pudding, with a 
 glass of light bitter ale. Tea (at 5 P.M.) : 
 bread-and-butter or dry toast, with a small 
 cupful of cocoa, tea, or milk - and - water. 
 Supper (not later than 9 P.M.) : white fish, or 
 some cold chicken or game, or a little cold 
 meat, with bread, and a glass of ale. The 
 
l68 THE TREATMENT OF GASTRALGIA 
 
 dietetic restrictions which are proper in cases 
 of gastric catarrh, gastritis, atonic dyspepsia, 
 dilatation of the stomach, and gastric ulcer are 
 not suitable for cases of gastralgia. In gas- 
 tralgia, indeed, such restrictions are usually- 
 very harmful. Gastralgic patients have come 
 to me who have been getting worse and worse 
 upon a restricted " dyspeptic " dietary ; as they 
 have become worse such restrictions have been 
 increased improperly. In such cases I have 
 at once given a full diet, with the happiest 
 results. For a patient who has gastralgic pains 
 judicious boldness in feeding is often very 
 beneficial. Such patients are not slow to 
 learn this for themselves. Trousseau's caution 
 that we should never advise what a patient 
 should eat without knowing what he does 
 eat is shrewd and sound. Let me advise you 
 never to assume a patient is dyspeptic because 
 he has pains in his stomach. 
 
IX. 
 
 ETHEREAL TINCTURE OF CAPSICUM.* 
 
 External use of capsicum. — Advantages of 
 ethereal tincture. 
 
 I AM finding excellent results in practice by 
 the use of some preparations of capsicum as 
 rubefacient counter-irritants. In my hands this 
 old remedy, red pepper, has been successful 
 as a local application in cases of subacute 
 gout, in chronic gout, in chronic articular 
 rheumatism, in muscular rheumatism, and 
 also in some cases of bronchial catarrh and 
 chronic bronchitis. After some considera- 
 tion and observation upon the subject, I 
 
 * A note published in The Lancet, May 17th, 1890. 
 
170 ETHEREAL TINCTURE OF CAPSICUM 
 
 decided to employ an ethereal tincture of the 
 drug, and I asked Messrs. Southall to make 
 a new tincture of capsicum of the strength 
 of the alcoholic tincture of the PharmacopcEia, 
 but made with officinal pure ether instead of 
 with rectified spirit of wine. After some satis- 
 factory use of this ethereal tincture in my own 
 experience as a physician, I now venture to 
 recommend the remedy to my brethren. I 
 find an ethereal tincture of capsicum, by reason 
 of the comparatively rapid evaporation of its 
 ether, can be used more freely than an 
 alcoholic tincture as an application to the skin. 
 Furthermore, I think the solvent action of 
 ether upon the sebaceous secretion of the skin 
 makes ether a menstruum preferable to alcohol 
 for drugs designed to affect the cutaneous 
 surfaces, or to produce therapeutic effect 
 through the skin. If a little ethereal tincture 
 of capsicum be gently rubbed upon the back of 
 a hand it will produce a feeling of warmth, 
 with some sensation of burning and pricking. 
 
ETHEREAL TINCTURE OF CAPSICUM I/I 
 
 in about a minute's time, together with an 
 irregular and patchy hyperaemic redness, which 
 may last some hours. If the tincture of capsi- 
 cum be used as a rubefacient in the form of 
 a liniment, an oily admixture gives friction- 
 ability, and an equal part of some bland fixed 
 oil may be added. Solution of ammonia or 
 oil of turpentine, or both of them, in such a 
 liniment are good adjuvants, if a sharply 
 rubefacient effect be desired. An excellent 
 and powerful rubefacient liniment may be made 
 of equal parts of ethereal tincture of capsi- 
 cum, liquor ammonias, oleum terebinthinse, and 
 oleum lini. The ethereal tincture may also 
 be applied to the skin upon spongio-piline. 
 
X. 
 
 ETHER AS A MENSTRUUM IN MEDICATION BY 
 THE SKIN.* 
 
 Absorption of medicines by the skin. — Faultiness 
 of the officinal plasters. — Obstacles to absorp- 
 tion by the skin. — Advantages of ether as a 
 menstruum. — Ethereal tinctures. — Belladonna. 
 — Iodine. — Menthol. 
 
 In some researches in iamatology which I 
 have been making for some years, it has 
 occurred to me that the use of the skin in 
 therapeutics, as a channel for the exhibition 
 of remedies designed to effect either local or 
 remote curative results, or both of them, might 
 
 * A paper published in The Lancet, July, I2th, 1890. 
 
MEDICATION BY THE SKIN 1 73 
 
 be extended in range, cleared in precision, and 
 improved in efficacy. I know the question of 
 the absorption of medicines by the skin bears 
 many difficulties, and has excited some dis- 
 putes. Authorities have been divided as to 
 how far, if at all, the local and remote effects 
 of remedies applied to the human body in 
 morbid states can be produced through the 
 cutaneous surface. No practitioner of medicine 
 is likely to doubt, however, that the human 
 body, in many of its organs and tissues, can be 
 readily brought under the direct and distant 
 influences of hydrargyrum by the cutaneous 
 inunction of mercurial ointment. It is easy 
 to question the efficacy of remedies exhibited 
 by the skin when the effects which they pro- 
 duce are less objective in their demonstration 
 than those of mercury. We may recall that 
 the capacity of the skin to absorb medicinal 
 substances from their aqueous solution in 
 baths was accepted in the medicine of the 
 
 ancients, whose therapeutic uses of medicated 
 
 M 
 
174 MEDICATION BY THE SKIN 
 
 baths we are now learning, longo intervallo, 
 to imitate. The question has been discussed 
 frequently since the close of the last century.* 
 At that time Abernethy and Falkner con- 
 cluded, from a series of experiments, that the 
 absorption of some remedies through the skin 
 did take place under certain conditions ; and, 
 while some other observers were led to qualify 
 or to contradict these inductions, affirmative 
 conclusions upon the subject were fully sup- 
 ported by Braconnot, Chevallier and Petit, 
 and other investigators. Some striking in- 
 stances of efficient percutaneous medication 
 are well known to us. For example, ointment 
 of aconitia rubbed upon the skin of the face 
 produces anaesthesia of the subjacent sensory 
 nerves, " so that a razor passed over the part 
 in the act of shaving is not felt."-|- We are 
 accustomed in medical practice to present 
 
 ' See Dr. Scoresby-Jackson's Note Book of Materia Medica, 
 etc., fourth edition. 
 
 \ Farre's Pereira's Materia Medica and Therapeutics. 
 
MEDICATION BY THE SKIN 17$ 
 
 remedies to the skin with the view of pro- 
 ducing remote as well as local effects, in the 
 various forms of the officinal emplastra, of the 
 officinal liniments (alcoholic, oleaginous, and 
 saponaceous), and of fatty unguents. Of 
 these separate forms of medicaments in 
 enepidermic use, the ointments and the oily 
 liniments are probably the most active, because 
 of their easy admixture with the fatty seba- 
 ceous secretion of the skin. I do not think 
 the structure of any Pharmacopoeial plaster 
 is such as is likely to permit of the absorption 
 of its active ingredients. There are fourteen 
 plasters in the British Pharmacopoeia. A 
 *' true plaster " is held to have for its basis 
 litharge in union with oleic, margaric, and 
 stearic acids, and eleven officinal plasters are 
 so composed. The other plasters, which are 
 not strictly plasters, take their body from the 
 chemical action of their ingredients, as in 
 emplastrum ammoniaci cum hydrargyro, or 
 from wax, lard, pitch, frankincense, suet, 
 
176 MEDICATION BY THE SKIN 
 
 resin, soap, and some fixed oils, in various 
 combinations. Neither a plaster so formed 
 nor a solution in alcohol of the active principles 
 of drugs is a scientific medicament for enepi- 
 dermic employment and percutaneous action, 
 if we have regard to the structure and phys- 
 iology of the human skin. 
 
 I think it will be found there are in prac- 
 tice three separate obstacles to the absorption 
 of a medicine through the skin — namely, the 
 epidermis, the sebaceous secretion of the skin, 
 and the relative insolubility of the drug which 
 is employed in any particular case. After some 
 observation and consideration I thought ether 
 would be the best menstruum at our disposal 
 for the solution of many remedies designed for 
 enepidermic application; and I concluded that 
 ethereal liniments would be more active through 
 the skin, and certainly stand upon a better 
 scientific basis, than plasters, than any of the 
 officinal liniments, or even than fatty unguents. 
 Ether presents several advantages over other 
 
MEDICATION BY THE SKIN 177 
 
 bases and menstrua for remedies applied to 
 the skin. It has great endosmotic capacity ; 
 it probably possesses in a high degree what has 
 been called " diffusion power ; " it is a solvent 
 of high potency for many active drugs, or, more 
 precisely, for the active principles of many 
 such drugs ; and it also is a ready solvent of 
 the fatty constituents of the sebaceous secre- 
 tion of the skin. When we use ether as a dis- 
 solvent for an active drug which we apply to 
 the skin, we apply our remedy in solution in a 
 menstruum which is a perfect solvent for the 
 obstructing fatty sebaceous secretion of the 
 cutaneous surface ; we employ a menstruum 
 which, by its solution of the fatty secretion, per- 
 mits the most intimate application of the remedy 
 to the bare epidermal surface. In The Lancet 
 of May 17th of the present year I published a 
 brief account of an ethereal tincture of capsi- 
 cum, which I have been using largely in 
 practice, and which I have found to be a 
 very active rubefacient and an efficient remedy 
 
178 MEDICATION BY THE SKIN 
 
 in several painful maladies. I now venture 
 to recommend to my brethren the employ- 
 ment of ether as a solvent vehicle for some 
 other remedies which may be applied to the 
 skin. After examining a large number of 
 drugs I have selected belladonna, iodine, and 
 menthol, besides capsicum, as suitable for 
 external therapeutic employment in the form 
 of ethereal tinctures. Ethereal tinctures of 
 these well-known drugs have been made 
 according to my directions, and it has been 
 easy to find for these preparations some 
 considerable application in the exigencies of 
 daily practice. After using these ethereal 
 tinctures with satisfactory results, I have 
 searched my library for references to this 
 employment of ether, and I am glad to find 
 the following important passage bearing upon 
 the subject in Dr. Lauder Brunton's text-book 
 of therapeutics: "It would appear that the fat 
 in the skin as well as the epidermis presents 
 an obstacle to the absorption of substances in 
 
MEDICATION BY THE SKIN 1 79 
 
 solution, but when they are applied in such a 
 form that they can readily mix with the 
 sebaceous matter of the skin, they are toler- 
 ably readily absorbed, as, for example, when 
 they are used in the form of ointment. 
 They are also absorbed when dissolved in 
 ether, and especially in chloroform, even when 
 simply painted over the surface. Alcoholic 
 solutions are not absorbed when painted 
 in this way." This statement, by an authority 
 in therapeutics so high, that medicinal sub- 
 stances soluble in ether are absorbed through 
 the living human skin when the ethereal 
 solutions are " simply painted over " the dermal 
 surface, appears to be an observation very 
 pregnant with remedial possibilities. It is not 
 a little surprising that we should have over- 
 looked so promising a development of our 
 curative resources so completely and so long. 
 The disadvantages of chloroform as a 
 menstruum of this kind are numerous and 
 obvious ; but ether is an excellent medium, 
 
l8o MEDICATION BY THE SKIN 
 
 either as a simple solvent or as a menstruum, 
 for the preparation of a tincture from a crude 
 vegetable drug. Ethereal tincture of bella- 
 donna (tinctura belladonnse aetherea) I propose 
 should be made from belladonna root, with 
 camphor, of the same strength as the 
 belladonna liniment of the Pharmacopoeia, 
 using the officinal pure ether in its preparation 
 instead of rectified spirit of wine. The result 
 is a bright tincture of a brilliant "apple green" 
 colour. I think this tincture will be found 
 useful as a paint for the skin in cardiac and 
 other cases in which belladonna plasters or 
 liniments would otherwise be employed. The 
 external application of preparations of bella- 
 donna over the heart, to calm tumultuous, 
 irregular, and excessive beating of that organ, 
 has long been accepted in our practice. The 
 preparation usually employed is the officinal 
 plaster ; if its good effects depend upon the 
 absorption by the skin of the active principles 
 of the extract of belladonna contained in the 
 
MEDICATION BY THE SKIN l8l 
 
 plaster, such a result is likely to be attained 
 with more potency and precision by the local 
 use of an ethereal tincture. I have used 
 belladonna root instead of belladonna leaves, 
 because it gives a preparation which does 
 not colour the surface of the skin as one 
 made from the leaves does. In cardiac cases 
 emplastrum belladonnse is a clumsy and incon- 
 venient application. It is dirty, uncomfortable, 
 not seldom irritating, and it always offers some 
 obstacle to the examination of the heart by 
 physical methods. Ethereal tincture of iodine 
 I have had made of the same strength as the 
 officinal tincture of iodine. To form an ethereal 
 tincture of menthol I have, after many experi- 
 ments, fixed upon a solution of menthol in 
 pure ether, of the strength of one drachm of 
 menthol in a fluid ounce of the solution. This 
 preparation can be readily applied as a paint 
 to the skin, and it is an efficient means of using 
 menthol for its local therapeutic effects, espe- 
 cially for the removal of superficial neuralgic 
 
1 82 MEDICATION BY THE SKIN 
 
 pains. It -should be lightly painted over the 
 painful part. The quick evaporation of the 
 ether gives a grateful sense of coldness which 
 supplements the analgesic action of the menthol, 
 and allows the easy application of a succession 
 of coats, which leave pure menthol in a finely 
 divided condition upon the skin. For the 
 application of ethereal tincture of menthol I 
 have found it best to use a brush of glass. 
 When the meshes of the brush become clogged 
 with menthol by the evaporation of the ether 
 of the preparation, they can be freed in a 
 moment by dipping the brush into the tincture.* 
 
 * Messrs. Southall have given ine much assistance in the 
 experiments and enquiries upon which this paper is founded. 
 
XL 
 
 RANDIA DUMETORUM.^ 
 
 Action of saponin. — Indian uses of randia. — 
 Employinent as a nervine restorative and 
 antispasmodic. 
 
 In Messrs. Southall's exhibit at the meeting 
 of the British Medical Association in Birming- 
 ham last summer, there were some interesting 
 Indian drugs, comparatively or quite unused 
 or unknown in England, which had been 
 collected by Mr. David Hooper, the eminent 
 Oriental pharmacologist, who has been for some 
 time engaged in India in the office of quino- 
 logist to the Madras Government. I examined 
 
 * A paper published in Tht Lancet, Marcli 2ist, 1891. 
 
l84 RANDIA DUMETORUM 
 
 these drugs, and considered the information I 
 could gather about them ; and one of them — 
 namely, randia dumetorum^appeared to me 
 to be worthy of further investigation and trial. 
 Under my directions, Messrs. Southall prepared 
 a series of tinctures of the drug, and one of 
 these — a tincture made with the spirit of ether, 
 B.P. — I have been using in practice, as a nervine 
 calmative and antispasmodic, in cases in which 
 the vegetable antispasmodics, such as valerian 
 or assafoetida, appeared to be indicated. I now 
 desire to invite my brethren to examine this 
 drug for themselves, and to say my experience 
 of its employment points to its proving a useful 
 addition to our repertory of nervine anti- 
 spasmodics and cardiac excitants. The fruit 
 of randia dumetorum has an ancient repute as 
 a popular medicine in India — being given in 
 large doses as an emetic. The pericarp, 
 especially when fresh, has a powerful and 
 penetrating odour, due to valerianic acid. The 
 active principle of the drug is said to be allied 
 
RANDIA DUMETORUM 1 85 
 
 to saponin, which is a glucoside found in soap 
 bark, and also contained in senega and sarsa- 
 parilla. We may remember that saponin has 
 been shown to possess some very marked 
 physiological potencies, of a kind which point 
 to valuable and numerous therapeutic applica- 
 tions. For example, Dr. Lauder Brunton 
 describes saponin in various places in his well- 
 known text-book of therapeutics as a respiratory 
 excitant and depressant ; as a sternutator}' ; 
 as a stimulating expectorant ; as a depressant 
 of the cardiac inhibitory ganglia and of the 
 vagus ends in the heart ; and as a cardiac 
 antagonist of digitalin. In the official pharma- 
 copoeia of India, in the edition of 1868, 
 prepared under the direction of Dr. Waring, 
 of the India Office, I find randia dumetorum 
 described as a non-officinal drug. Randia 
 appears to be a shrub common in most parts 
 of India, growing, as its second name states, 
 in thickets. The fruit is held in high esteem 
 by the natives on account of its emetic 
 
l86 RANDIA DUMETORUM 
 
 properties. The following note upon its use 
 was comnnunicated to Dr. Waring's pharma- 
 copoeial committee by Dr. George Bidie : — 
 
 "The fruit is about the size of a crab- 
 apple, round, two - celled, many - seeded, and 
 crowned with the rim of the calyx. It has a 
 peculiar sweetish sickly smell, which increases 
 after the fruit has been kept for a few days. 
 It is very commonly used as an emetic by the 
 poorer classes in Mysore, and is said to be safe 
 and speedy in its action. I have myself seen 
 it used several times, when it produced emesis 
 in about fifteen minutes. The dose is one ripe 
 fruit, well bruised, which may be repeated if 
 necessary. It is apparently an irritant emetic." 
 
 Dr. Waring also adds — 
 
 " According to Ainslie, an infusion of the 
 bark of the root is used by the natives to 
 nauseate in bowel complaints. Roxburgh 
 mentions that the bruised fruit thrown into 
 the water intoxicates and even kills fish, which. 
 
RANDIA DUMETORUM 1 87 
 
 however, are not considered less wholesome 
 in consequence." 
 
 I have had four tinctures of randia made 
 — namely, with spirit of ether, rectified spirit 
 of wine, aromatic spirit of ammonia, and proof 
 spirit, respectively, and of the strength of one 
 part of the drug in five parts of the tincture. 
 . When any one of these tinctures is diluted 
 with water and acidulated with acetic acid, the 
 odour of valerian is very apparent ; and it is 
 most apparent in the tincture made with spirit 
 of ether, and this is the tincture I have selected 
 for therapeutic use. The dose of tinctura 
 randiae dumetorum setherealis is from fifteen to 
 sixty minims. It is given diluted with water, 
 and the two fluids make a milky-looking mix- 
 ture. The tincture has a strong and character- 
 istic odour and taste, and is of a bright maize 
 colour. It may be given with iron, if a 
 greenish colouration be permissible. 
 
INDEX, 
 
 Absorption by the skin 173 
 
 Accentuation of the pulmonary second sound 121 
 Accentuation of the pulmonary second sound, 
 
 clinical import of - 122 
 Accentuation of the pulmonary second sound, 
 
 Dr. Walshe on 123 
 Accentuation of the pulmonary second sound, 
 
 therapeutics in 134 
 
 Affusion of cold water in insomnia 41 
 
 Alcohol as a cause of insomnia 31 
 
 Alcohol as a hypnotic 38 
 
 Alcohol as a remedy in insomnia 39 
 
 Alcohol, cautions in use of 39 
 
 Aloes in the treatment of habitual constipation 82 
 
 Arsenic in the treatment of gastralgia 166 
 
 Begbie, Dr. Warburton, on the use of chloride of 
 
 calcium 73 
 
 Bell, Dr. David, on the treatment of habitual 
 
 constipation 84 
 
 Belladonna, ethereal tincture of 180 
 
 Belladonna plaster, disadvantages of 181 
 
igo INDEX. 
 
 PAGE 
 
 Brain, state of, in insomnia- 17 
 
 Brain, state of, in sleep 16 
 
 Brinton, Dr., on intestinal obstruction- loi 
 
 Bristowe, Dr., on intestinal strictures 102 
 
 Bromides, use of, in insomnia 37 
 
 Brunton, Dr. Lauder, on saponin 185 
 
 Capsicum, ethereal tincture of 169 
 
 Capsicum, external use of 170 
 
 Cascara sagrada, use of, in constipation 84 
 
 Causes of insomnia 16 
 
 Causes of intestinal occlusion 97 
 
 Chloral, use of, in insomnia 35 
 
 Chloride of calcium, administration of 74 
 
 Chloride of calcium. Dr. Sanders on the use of 74 
 Chloride of calcium. Dr. Warburton Begbie on 
 
 the use of 73 
 
 Chloride of calcium, therapeutics of, in phthisis 74 
 Christison, Sir Robert, on the treatment of 
 
 habitual constipation 83 
 
 Coffee as a cause of insomnia 32 
 
 Colchicum, use of, in insomnia 42 
 
 Constipation, aloes, use of, in 82 
 
 Constipation, definition of 80 
 
 Constipation, enemata in 92 
 
INDEX. 191 
 
 PAGE 
 
 Constipation, habitual, treatment of 81 
 
 Constipation, O'Beirne's tube in - 94 
 
 Consumption, chloride of calcium in - 71 
 
 Consumption, medicinal treatment of - 68 
 Consumption, pulmonary, relations of, to phthisical 
 
 laryngitis 49 
 
 Consumption, remedies in - 70 
 
 Coprostasis 93 
 
 Counter-irritation in gastralgia - 166 
 
 Counter-irritation in phthisical laryngitis 60 
 
 Cure of insomnia - 34 
 
 Deafness in insomnia - - 26 
 
 Defaecation, O'Beirne on 94 
 
 Deglutition, painful, in phthisical laryngitis - 55 
 
 Diagnosis of fsecal retention - 84 
 
 Diagnosis of floating kidney - 140 
 
 Diagnosis of gastralgia 163 
 
 Diagnosis of intestinal occlusion - 102 
 
 Diet in gastralgia - 167 
 
 Digitalis in insomnia - 38 
 
 Duncan, Dr. Matthews, on retention of faeces 80 
 
 Dyspnoea in phthisical laryngitis - - 54 
 
 Enemata, administration of- - 92 
 
192 INDEX. 
 
 PAGE 
 
 Enemata, quantity of 95 
 
 Enemata, use of, in constipation - 92 
 
 Enemata, use of, in intestinal obstruction 93 
 
 Ergot, use of, in insomnia 38 
 
 Ether, in medication by the skin - 176 
 
 Ethereal tinctures 178 
 
 Exercise, use of,' in insomnia 40 
 
 Fsecal retention, Dr. Matthews Duncan on 80 
 
 Faecal retention, extreme case of 86 
 
 Faecal retention, signs of 84 
 
 Floating kidney 137 
 
 Floating kidney, case of, verified after death 143 
 
 Floating kidney, causation of 145 
 
 Floating kidney, definition of 139 
 
 Floating kidney, diagnosis of 140 
 Floating kidney, established by post-mortem 
 
 examinations 138 
 
 Floating kidney, frequency of, in women 140 
 
 Floating kidney, prognosis in 153 
 
 Floating kidney, Sir William Jenner on 139 
 
 Floating kidney, Sir William Roberts on 139 
 
 Floating kidney, statistics of 140 
 
 Floating kidney, subjective symptoms of 151 
 
 Floating kidney, tight-lacing a cause of 146 
 
INDEX. 193 
 
 PAGE 
 
 Floating kidney, traumatic origin of 147 
 
 Floating kidney, treatment of 152 
 
 Gastralgia 154 
 
 Gastralgia, arsenic in 166 
 
 Gastralgia, counter-irritation in 166 
 
 Gastralgia, diagnosis of 163 
 
 Gastralgia, diet in 167 
 
 Gastralgia, Romberg on 158 
 
 Gastralgia, sex in 162 
 
 Gastralgia, temperament in - 162 
 
 Gastralgia, treatment of 165 
 
 Gouty insomnia 32 
 
 Gouty insomnia, colchicum in 42 
 
 Habitual constipation - 81 
 
 Habitual constipation, aloes in 82 
 
 Habitual constipation, cascara sagrada in 84 
 
 Habitual constipation, Dr. Bell on the treatment 
 
 of 84 
 Habitual constipation, Dr. Kent Spender on the 
 
 treatment of 85 
 Habitual constipation, Sir Robert Christison on 
 
 the treatment of 83 
 
 Habitual constipation, treatment of 81 
 
194 INDEX. 
 
 PAGE 
 
 Holiday, use of, in insomnia 36 
 Hutchinson, Mr. Jonathan, on intestinal obstruc- 
 tion 103 
 Hypnotic use of alcohol - 38 
 
 Inhalations in phthisical laryngitis 64 
 
 Insomnia, affusion of water in 41 
 
 Insomnia, alcohol as a cause of 31 
 
 Insomnia, alcohol as a remedy in 39 
 
 Insomnia, bromides in 37 
 
 Insomnia, causes and cure of 13 
 
 Insomnia, chloral in 35 
 
 Insomnia, coffee as a cause of 32 
 
 Insomnia, colchicum in 42 
 
 Insomnia, deafness in - 26 
 
 Insomnia, digitalis in ' 38 
 
 Insomnia, ergot in 38 
 
 Insomnia, exercise in - 40 
 
 Insomnia, gouty - 32 
 
 Insomnia, holiday in 36 
 
 Insomnia, iron in 38 
 
 Insomnia, mental shock as a cause of 19 
 
 Insomnia, mental strain as a cause of 19 
 
 Insomnia, mineral waters in 43 
 
 Insomnia, muscular twitching in - 27 
 
INDEX. 19s 
 
 PAGE 
 
 Insomnia, opium in 34 
 
 Insomnia, psychic 18 
 
 Insomnia, purgatives in 43 
 
 Insomnia, senile 34 
 
 Insomnia, shock as a cause of 19 
 
 Insomnia, soporifics in 34 
 
 Insomnia, state of brain in 17 
 
 Insomnia, subjective results of 24 
 
 Insomnia, symptoms of - 25 
 
 Insomnia, tea as a cause of- 32 
 
 Insomnia, treatment of 34 
 
 Insomnia, tobacco as a cause of 29 
 
 Insomnia, toxic 28 
 
 Insomnia, varieties of- 16 
 
 Insomnia, water, affusion of, in 41 
 
 Insomnia, waters, mineral, in 43 
 
 Intestinal obstruction - 96 
 
 Intestinal obstruction. Dr. Brinton on - - i o i 
 
 Intestinal obstruction, Dr. Leichtenstern on 99 
 
 Intestinal obstruction, O'Beirne's tube in 94 
 
 Intestinal obstruction, Mr. Jonathan Hutchinson 
 
 on 104 
 
 Intestinal obstruction, treatment of 109 
 
 Intestinal occlusion 97 
 
 Intestinal occlusion, causes of 97 
 
196 INDEX. 
 
 PAGE 
 
 Intestinal occlusion, laparotomy in 110 
 
 Intestinal occlusion, laparo-ileotomy in 114 
 
 Intestinal occlusion, operations in no 
 
 Intestinal occlusion, recovery in 107 
 
 Intestinal occlusion, signs of 104 
 
 Intestinal occlusion, spontaneous recovery in 107 
 
 Intestinal occlusion, surgical procedures in no 
 
 Intestinal occlusion, treatment of 109 
 
 Intestinal occlusion, varieties of 97 
 
 Intestinal stricture - 100 
 
 Intestinal stricture. Dr. Bristowe on 10 1 
 
 Iodine, ethereal tincture of - - 181 
 
 Iron, in habitual constipation 83 
 
 Iron, in insomnia 38 
 
 Jenner, Sir William, on floating kidney 139 
 
 Kidney, floating (see floating kidney) 137 
 
 Kidneys, relative anatomy of 149 
 
 Laparotomy no 
 Laparotomy, indications for, in intestinal occlusion in 
 
 Laparo-ileotomy, comparative safety of 1 14 
 
 Laparo-ileotomy, in intestinal occlusion 115 
 
 Laryngeal brushings ■ 62 
 
INDEX. 197 
 
 PAGE 
 
 Laryngitis, phthisical (see phthisical laryngitis) 45 
 
 Laryngoscope, use of, in phthisical laryngitis 47 
 
 Leichtenstern, Dr., on intestinal obstruction 99 
 
 Leube, Dr., on gastralgia 155 
 
 Lozenges, use of, in phthisical laryngitis 65 
 
 Mental shock as a cause of insomnia 1 9 
 
 Mental strain as a cause of insomnia 19 
 
 Menthol, ethereal tincture of 181 
 
 Menthol, external use of 181 
 
 Mineral waters in insomnia - 43 
 
 Muscular twitchings in insomnia- 27 
 
 Nervous temperament 22 
 
 O'Beirne, on defsecation 94 
 
 O'Beirne's tube 95 
 
 Opium, in insomnia 34 
 
 Pain in gastralgia - 159 
 
 Phthisical laryngitis 45 
 
 Phthisical laryngitis, codeia in 66 
 
 Phthisical laryngitis, cough in 56 
 
 Phthisical laryngitis, counter-irritation in 60 
 
 Phthisical laryngitis, definition of 46 
 
 Phthisical laryngitis, deglutition in 55 
 
igS INDEX. 
 
 PAGE 
 
 Phthisical laryngitis, diagnosis of- 50 
 
 Phthisical laryngitis, dyspnoea in - 54 
 
 Phthisical laryngitis, frequency of, in men 50 
 Phthisical laryngitis, general treatment in - 59 
 
 Phthisical laryngitis, hoarseness in 53 
 
 Phthisical laryngitis, inhalations in 64 
 
 Phthisical lar5mgitis, laryngeal brushings in 62 
 
 Phthisical laryngitis, laryngoscope in 47 
 
 Phthisical laryngitis, lozenges in 65 
 
 Phthisical laryngitis, morphia in 66 
 
 Phthisical laryngitis, opium in 66 
 
 Phthisical laryngitis, pain in 56 
 
 Phthisical laryngitis, pathology of 48 
 
 Phthisical laryngitis, prognosis in 53 
 Phthisical laryngitis, relation of, to pulmonary 
 
 consumption - 49 
 
 Phthisical laryngitis, respiratory difficulty in - 54 
 
 Phthisical laryngitis, rest in 67 
 
 Phthisical laryngitis, sputum in 56 
 
 Phthisical laryngitis, stages of 50 
 
 Phthisical laryngitis, treatment of 58 
 
 Phthisical laryngitis, voice in 53 
 
 Phthisis, chloride of calcium in 68 
 
 Phthisis, generic significance of term 69 
 
 Phthisis, medicinal treatment of 69 
 
INDEX. 199 
 
 PAGE 
 
 Phthisis, remedies in 70 
 
 Plasters, composition of 175 
 
 Psychic insomnia 18 
 
 Pulmonary second sound, accentuation of 121 
 
 Pulmonary second sound, accentuation of, clinical 
 
 import of 125 
 
 Pulmonary second sound, accentuation of, prog- 
 nosis in - 131 
 Pulmonary second sound, accentuation of, thera- 
 peutics of 136 
 Purgatives, in habitual constipation 82 
 Purgatives, in insomnia 43 
 
 Randia dumetorum 183 
 
 Randia, Indian uses of 186 
 
 Randia, therapeutic use of 184 
 
 Randia, tinctures of 187 
 
 Respiratory difficulty in phthisical laryngitis 54 
 
 Retention, f«cal. Dr. Matthews Duncan on - 80 
 
 Retention, fxcal, extreme case of 86 
 
 Retention, fsecal, signs of 84 
 
 Roberts, Sir William, on floating kidney 139 
 
 Romberg on gastralgia 159 
 
 Sanders, Dr. James, on chloride of calcium 74 
 
2CX3 INDEX. 
 
 PAGE 
 
 Saponin, action of 185 
 
 Second sound, pulmonary, accentuation of 121 
 Second sound, pulmonary, accentuation of, clinical 
 
 import of - 125 
 Second sound, pulmonary, accentuation of. Dr. 
 
 Walshe on 123 
 Second sound, pulmonary, accentuation of, prog- 
 nosis in 131 
 Second sound, pulmonary, accentuation of, thera- 
 peutics of - 136 
 Senile insomnia 34 
 Sex in gastralgia- - 162 
 Skin, medication by the 172 
 Sleep, state of brain in - - 16 
 Sleeplessness, state of brain in 17 
 Soporifics, use of, in insomnia 34 
 Spender, Dr. Kent, on the treatment of habitual 
 
 constipation 85 
 
 Spontaneous recovery in intestinal occlusion - 107 
 
 Sputum in phthisical laryngitis 56 
 
 Statistics of floating kidney- 140 
 
 Stricture of intestine 100 
 
 Stricture of intestine. Dr. Bristowe on - loi 
 
 Surgical procedures in intestinal occlusion no 
 
 Symptoms of insomnia 25 
 
INDEX. 20I 
 PAGE 
 
 Tea, as a cause of insomnia 32 
 
 Temperament, importance of 162 
 
 Temperament and gastralgia 162 
 
 Temperament, nervous 22 
 
 Tobacco as a cause of insomnia zg 
 
 Toxic insomnia 28 
 
 Treatment of constipation 8 1 
 
 Treatment of constipation by enemata- 92 
 
 Treatment of consumption 68 
 Treatment of gastralgia • 165 
 
 Treatment of habitual constipation 8 1 
 
 Treatment of insomnia 34, 
 
 Treatment of intestinal obstruction 109 
 
 Treatment of phthisical laryngitis 58 
 
 Tube, O'Beirne's 95 
 
 Voice in phthisical laryngitis S3 
 
 Walshe, Dr., on accentuation of the pulmonary 
 
 second sound 123 
 
 Water, affusion of, in insomnia 41 
 
 Waters, mineral, in insomnia 43 
 
BY THE SAME AUTHOR. 
 
 CRO-WN OCTAVO, CLOTH, WITH PLATES, pp. 251. 
 
 A GUIDE 
 
 TO THE 
 
 PHYSICAL DIAGNOSIS OF DISEASES 
 
 OF THE 
 
 LUNGS AND HEART; 
 
 Together with an Introduction to the 
 Examination of Diseases of the Kidneys. 
 
 LONDON : HARDWICKE, 1870. 
 
 Opinions of the Medical Press. 
 
 " A digest of the best known facts respecting its subject 
 matter. It conveys instruction in those facts in a- lucid manner, 
 and will no doubt be appreciated by many students." — British and 
 Foreign Medico-Chirurgical Review. 
 
 " Full of very good and very instructive material." — Lancet. 
 
 " An excellent and judicious collection of facts, done by a 
 man who knows his work." — Medical Times and Gazette. 
 
BY THE SAME AUTHOR. 
 
 Crown Octavo, Scarlet Cloth, pp. 129. 
 
 NOTES ON MEDICAL EDUCATION 
 
 (Three Essays, Founded upon Three Addresses 
 Delivered to Students). 
 
 London: SIMPKIN, MARSHALL & CO. 
 Birmingham : CORNISH BROTHERS. 
 
 OPINIONS OF THE PRESS. 
 
 "... Excellent for medical students, . . . displaying 
 much good feeling and considerable literary knowledge. . . ." 
 — The Saturday Revieiv. 
 
 "... An admirable little manual, cram full of good 
 advice. . . .'' — The Midland Counties Herald. 
 
 CONTRIBUTIONS TO CLINICAL 
 THERMOMETRY. 
 
 (Founded upon several thousands of comparative 
 
 observations made during residence in the Queen's 
 
 Hospital from 1867 to 1871.) — 1875. 
 
 BIRMINGHAM: WHITE AND PIKE.