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THE NEW SYDENHAM 
 SOCIETY. 
 
 INSTITUTED MDCCCLVIII. 
 
 VOLUME LXXX. 
 
THE 
 
 COLLECTED WORKS 
 
 DR. P. M. LATHAM. 
 
 EDITED FOE THE SOCIETY 
 
 By ROBERT MARTIN, M.D., Cantab., 
 
 FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS ; CONSULTING PHYSICIAN TO 
 ST. BARTHOLOMEW'S HOSPITAL. 
 
 VOL. II. 
 (WITH INDEX.) 
 
 THE NEW SYDENHAM SOCIETY,. 
 LONDON. 
 
 MDCCCLXXVIII. 
 
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 M'.f! 01'... 
 
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 PBISTED BY "W. CLISKSEEL, AT EASTCHEAP lEINTIKG WOEES. 
 
EDITOR'S PREFACE. 
 
 Lsr arranging tlie order in which reprints of Dr. Latham's 
 published works should be given by the New Sydenham Society, 
 it was considered advisable to depart from the strict chronolo- 
 gical sequence in which they first appeared. The two octavo 
 volumes in which were contained his "Diseases of the' Heart," 
 written, as they were, when his always feeble physical powers 
 perhaps best served him, and when he was in the fullest enjoy- 
 ment of his always great mental vigour, have been held by 
 general consent to constitute his "opus magnum," the work by 
 which he has been most widely known, and from which, indeed, 
 he soon came to be especially known as "Heart Latham." 
 These lectures, therefore, seemed naturally to demand priority 
 of publication ; and the convenience they offered for making 
 in themselves a first volume, of manageable size, being not 
 lost sight of, they were allowed to take precedence of writings 
 which had been published some twenty years earlier. 
 
 Next in importance to the Lectures on " Diseases of the 
 Heart," and comparing favourably with them in all the vigour 
 of expression and grace of diction of which their author 1 was 
 so great a master, comes the series in which he treats, more 
 generally, a. variety of subjects connected with Clinical Medi- 
 cine ; and with it the volume now offered to the members of 
 the New Sydenham Society begins. 
 
 Written more than forty years ago; when the science of 
 auscultation was only in its infancy, and as yet had done little, 
 if anything, for the elucidation of heart disease, they were in- 
 tended especially to' simplify auscultation for practical purposes 
 in the diagnosis- of ' diseases of the lungs; But this formed a 
 part only of the material of the Lectures-; and, admirably as 
 the subject* which Dr. Latham had especially in view was 
 treated (thV leading- points of his doctrine' still stand' fast and 
 true), the student of the present day; be he " tender juvenal" 
 or "tough senior," will derive equal pleasure and profit from a, 
 perusal of that earlier portion, in which he* handles ; the subjects 
 
■vi EDITOR'S PREFACE. 
 
 of medical education, of case-taking, of pathology, and of the 
 •doctrine of symptoms. 
 
 Next in the order of our reprints, hut published originally 
 in 1825, comes an " Account of the Disease lately prevalent at 
 the General Penitentiary." Sir Thomas Watson, in his bio- 
 graphical memoir of Dr. Latham, has written of this work, that 
 it is "pregnant with evidence of acute and patient research, 
 and of clear and cogent reasoning ; " and to this may surely be 
 ■added the assertion that so graphic, and at the same time so 
 ^picturesque, is the narrative, as to give to the reading all the 
 -charm of a really good romance. The story of the sanitary 
 vicissitudes of the General Penitentiary since Dr. Latham's day 
 is so interesting, and so instructive, that it has been thought 
 well to bring it up to the present time ; and, accordingly, some 
 •extracts from the writings of Dr. Baly, of Dr. Guy, and of 
 their successor, Mr. Gover, the present Medical Officer of the 
 Institution, all of whom have contributed to making the prison 
 ■at this moment one of the healthiest temporary residences in 
 England, will be found at the end of this Preface. 
 
 A paper, which was read before the College of Physicians 
 in 1832, on " the use of Opium in Fevers," short, but perfect 
 • as a model of style in embodying the results of patient obser- 
 vation, follows next, and contains the germ, which has since 
 developed, under the fostering care of Graves and others, into 
 a recognised and lull-grown mode of treatment. 
 
 Last of all are given a series of articles, written, and pub- 
 lished in the British Medical Journal, dirring the years 1861, 
 1862, 1863, having for their common title, " General Eemarks 
 on the Practice of Medicine," together with one, consisting of 
 :a few pages only, and containing Dr. Latham's last wise words 
 •on the subject which, through all his long life, he had most at 
 heart— " Medical Education." 
 
 Born on the 1st day of July, 1789, Dr. Latham was 72 
 years of age in 1861, when the first paper of this last series ' 
 was printed ; and 76 in 1864, when the last of them appeared. 
 To how few men in their eighth decade has been given the 
 power of sustained mental effort, even when their physical force 
 has been but little abated ! How many men have there not 
 been, who, tempted, at that age, once more to return to literary 
 work, and failing to recognise the waning of their powers, have 
 
editor's preface. vii 
 
 gone far by their later labours to imperil tbeir early fame, and 
 have laid themselves open to the imputation of writing " Homi- 
 lies beginning to smell of apoplexy." Dr. Latham was one of 
 the favoured few. 
 
 Sir Thomas "Watson writes of him ; " That he lived so long 
 was a marvel to all who were aware of his bodily constitution. 
 I have said that in childhood his health was delicate. In ma- 
 ture life, when he was living in London, besides a slight twist 
 in his spine, which tilted one shoulder a little upwards, his 
 lungs were known to be extensively emphysematous, and his 
 paroxyms of asthma by night were so extremely violent and 
 exhausting, that many times he fully expected to die before the 
 morning. Had he remained in London it is almost certain 
 that some one of such paroxysms would have been fatal." 
 
 It was during the last four years of his residence in London, 
 and during the merely comparative ease afforded between the 
 paroxysms of, often well-nigh mortal, distress which are de- 
 scribed in the paragraph above quoted, that Dr. Latham pro- 
 duced the really philosophical essays with which this volume 
 concludes. 
 
 "Where all are so admirable, it were perhaps well to avoid the 
 singling out of any one as though pre-eminently good. Still, 
 it may be permitted here to direct especial attention to article 
 No. VI., page 390, on " Cure," and to beg of the reader, who 
 has gone thus far with us, to turn at once to it for enjoyment, 
 and for a foretaste of much like excellent fare which is in store 
 for him. 
 
 A careful perusal of Dr. Latham's " Account of the Disease 
 lately prevalent at the General Penitentiary," by the additional 
 light thrown upon its obscurities from the researches of Dr. 
 Jenner in the different forms of Continued Fever, and of 
 Drs. Baly and Gruy in the subject of Scurvy, will leave but 
 little doubt in the minds of any reader that the disease was 
 Dysentery, complicated, in most of the cases related, with Scurvy, 
 and in many, with Typhus (?), Typhoid, or Relapsing Fever. 
 
 Dr. Latham, writing for himself and the physicians asso- 
 ciated with him, summarizes his belief as to the causation of. the 
 disease in the following words, p. 314 : — " That it was derived 
 
vlii editor's preface. 
 
 originally, and essentially, from something' noxious in the 
 situation^ and was rendered epidemic by an impoverished diet 
 and a severe- winter." 
 
 Leaving, for awhile, the first factor here mentioned, the 
 " something noxious in the situation," let us see how far other 
 and' later observers agree with him as to the potency of the 
 second, " an impoverished diet." 
 
 Dr. Guy, who succeeded Dr. Baly as Physician to the Peni- 
 tentiary, read an elaborate paper before the Statistical, Society 
 (June 15, 1863), upon " Sufficient and insufficient dietaries, with 
 especial reference to the dietaries of prisoners." In this paper 
 he discussed the question of the causes which led to the Mill- 
 bank outbreak ; and inasmuch as he has given, in addition to 
 his own observations upon this head, a good digest of Dr. Baly's 
 earlier researches in the same direction, it will be well to quote 
 his remarks at length : — " I must now revert to the outbreak of 
 scurvy and dysentery which occurred at Millbank in 1823, and 
 endeavour to answer the important question whether that fatal 
 epidemic ought to be i&ttribu'ted to the reduction which took 
 place in the quantity of food, or to the omission from that 
 dietary of some important element. Now, the reduction effected 
 in the original dietary of the prison went to the extent not 
 merely of cutting down the quantity of bread, meat^ and pota- 
 toes from a total of 304 ounces to one of 168 ounces perweek, 
 but the meat and potatoes were struck off altogether., except 
 such small quantity of the juice and fibre of meat as was to be 
 found in a broth containing one ox head, and even less, to one 
 hundred rations. On a liberal estimate, the quantity of meat 
 in the weekly rations of soup did not exceed ten ounces for 
 each prisoner. In order to ascertain whether the mere reduc- 
 tion in the quantity of the food coull have been productive of 
 such disastrous effects, I must again refer to the diet scales 
 given in the earlier part of this paper. I find that the least 
 liberal of the six pauper dietaries of 1836 allowed only 145 
 ounces of solid food, and 18 pints of liquid food ; that the 
 average of these dietaries only exceeded the reduced Millbank 
 allowance in the solid elements by 5 ounces per week, while 
 the liquid elements amounted only to 10 ounces in lieu of 21 ; 
 that the minimum of the twelve pauper dietaries sanctioned 
 by the Pb'or Law Board (doubtless after experience of their 
 
editor's PREFACE. ix 
 
 sufficiency) gives only two additional .ounces of solid 'food per 
 week, the liquid food amounting to only 11 ounces as. against 
 21 of the Millhank dietary; that all the dietaries prescribed 
 for the Scotch paupers in 1847, by Dxs.. Alison and iChristison, 
 fall greatly short of the Millbank reduced standard in their 
 solid.constituents ; that the-diet for soldiers under solitary-con- 
 finement for less than 56 days also falls short of it both in the 
 solid and in the liquid constituents ; that the seventh of the 
 Glasgow dietaries has 21 ounces less of solid food and 10 J pints 
 of huttermilk for 21 pints of gruel and broth ; and lastly, 
 that the consumption of agricultural and Other ' labourers, 
 according to Mr. C. Mott's enquiries, falls short of the Mill- 
 bank redueed dietary by no less than 28 ounces. This last 
 comparison, if the consumption of the labourer is correctly 
 estimated, is the most important of all, inasmuch as of the 140 
 ounces said to be consumed hy him, .136 consist of bread, of 
 which the quantity given -at Millbank amounted to. 168 
 ounces. 
 
 "After-m akin g -due allowance for' the long terms of confine- 
 ment to which the prisoners at Millbank were subject in 1822, 
 I am still of opinion that the mere reduction in the quantity of 
 the food would not account for the outbreak of scurvy, even in 
 a site so notoriously unhealthy as Millbank then was. Nor, 
 with the experience of Devizes, Stafford, and Glasgow before 
 us, would it be safe, to attribute the outbreak to the omission of 
 meat from the dietary. There still remains a possible explana- 
 tion of the event to which the researches of the late Dr. Baly 
 lend an air of probability* In the ' London'Medical Gazette,' 
 February 10th, 1843, Dr. Baly published a short paper ' On 
 the Prevention of Scurvy in Prisons, Pauper Lunatic Asylums, 
 &c.,' in which, after citing Sir Gilbert Blane and Mons. Julia 
 Fontenelle in favour of the anti-scorbutic virtue of the potato, 
 whether raw or cooked, he proceeds to make the following im- 
 portant statement: — 'In the Spring of 1840, I found that 
 scurvy was a disease of rather frequent occurrence amongst one 
 class of prisoners in the Millbank Penitentiary— the military 
 offenders sentenced by court-martial ; whilst amongst the other 
 more numerous class of inmates, the convicts, it was never 
 
 * For " lend an air of probability," may not. here be read, ".give-well nigh 
 absolute certainly ?" — Editor. 
 
editor's preface. 
 
 seen.' This led Dr. Baly to a comparison of dietaries, of which 
 I append the particulars in a tabular form, the arrangement 
 only being altered from his own Tables. I omit the column 
 showing the dietary for women, as this paper must be under- 
 stood to deal throughout with the dietary of adult males only. 
 
 Bread 
 
 Meat 
 
 Potatoes 
 
 Cheese 
 
 Onion 
 
 Total solid food 
 
 Rice soup, without vegetables 
 Peasoup, with vegetables 
 Gruel ... 
 Broth 
 
 Total liquid food 
 
 Military Offenders. 
 
 Convicts 
 
 First 
 3 Months. 
 
 Second 
 3 Months. 
 
 Over 
 6 Months. 
 
 ozs. 
 
 168 
 12 
 
 Nil. 
 Nil. 
 Nil. 
 
 ozs. 
 
 168 
 18 
 Nil. 
 Nil. 
 Nil. 
 
 ozs. 
 168 
 24 
 8 
 Nil. 
 Nil. 
 
 OZS. 
 
 176 
 20 
 
 80 ■ 
 4 
 1 
 
 180 
 
 186 
 
 200 
 
 284 
 
 pints. 
 2 
 
 17 
 
 pints. 
 2 
 1 
 15 
 
 pints. 
 2 
 1 
 14 
 
 pints. 
 
 11 
 
 3 
 
 19 
 
 18 
 
 17 
 
 15| 
 
 The following is an abbreviation of Dr. Baly's valuable com- 
 mentary on these facts : — 
 
 " Nearly all the cases of scurvy, he says, occurred in soldiers 
 who were passing through the second three months of their 
 confinement in the Penitentiary, during which period not only 
 had they very nearly as ample a supply of animal food as the- 
 convicts, male and female, but they had as much soup seasoned 
 with vegetables as the female convicts, who, although undergoing 
 far longer terms of imprisonment, yet were free from scurvy. 
 This exemption of the convicts from the disease could, there- 
 fore, only be attributed to their weekly diet, containing 5 lbs. of 
 potatoes and an onion. ' In order to afford to the soldier a larger 
 supply of vegetable food, Dr. Baly suggested the substitution, 
 for the rice soup, which contained no fresh vegetables, of pea- 
 soup with vegetables. The quantity of soup containing succu- 
 lent vegetables was thus made to exceed the quantity given tc- 
 the convict, and yet scurvy continued to appear among the 
 soldiers. It prevailed to nearly, if not quite, the same extent 
 after the change of diet as before ; and it was evident that the- 
 quantity of vegetables usually contained in two or three pints 
 
editor's PEEFACE. xi 
 
 of peasoup given weekly was inadequate to prevent the occur- 
 rence of scurvy. Dr. Baly accordingly recommended that the 
 soldiers, as well as the convicts, should have 1 lb. of potatoes 
 with each dinner of meat. The soldiers thus came to have 
 2 lbs., or 32 ounces of potatoes every week during the first 
 three months of their imprisonment, 3 lbs. during the second 
 three months, and 4 lbs. after the expiration of six months. 
 This addition to the dietary of the military prisoners was made in 
 January, 1842, and not a single case of scurvy occurred up to 
 February 10th, 1843, the date of Dr. Baly's paper." Dr. Baly 
 then proceeds to give a short sketch of the outbreak of scurvy 
 and dysentery at Millbank in 1823 ; and, after stating that he 
 deems it " unnecessary to argue that the want of animal food 
 could not have produced the scurvy," and showing that the 
 reduced dietary " was not deficient in vegetable constituents, 
 except as regarded the potatoes," gives it as his opinion " that 
 the withdrawal of the supply of potatoes was, in all proba- 
 bility, the cause of that part of the epidemic which was con- 
 stituted by the scurvy ;" and this inference he'strengthens by 
 the remarkable statement, that since the date of the outbreak 
 of scurvy and dysentery, the diet of the convicts " has con- 
 tained an abundant supply of potatoes, and scurvy has never 
 again attacked them, although other forms of disease, which 
 were described as parts of the epidemic of 1823, namely, the 
 fever, dysentery, and nervous affections, have frequently re- 
 appeared. 
 
 ) " Dr. Baly then fortifies his opinion thus expressed, by citing 
 the case of the Oxford County Gaol, in which a diet, consisting 
 of bread 168 ounces, meat 4 to 12 ounces, and 14 pints of gruel 
 per week, but with no regular allowance of vegetables, ' potatoes 
 or green vegetables being given only occasionally on Sundays, 
 when the prison garden would furnish them,' issued in the 
 production of scurvy ; and the case of the Northampton 
 County Gfaol, in which scurvy, having arisen under a dietary of 
 bread, soup, and gruel, disappeared after the addition to it of 
 4 lbs. of potatoes weekly. Other analogous facts are cited, 
 and especially the striking case of the Stafford County Gaol, 
 which I have already noticed, where, under a liberal allowance 
 of bread, potatoes, and gruel, but no meat, no soup, and no 
 milk, scurvy did not show itself. 
 
xii editor's peeface. 
 
 "It is worthy of remark that the diet of military offenders 
 for the first three months approximates very closely to the 
 reduced dietary at Millbank. The quantity of bread is exactly 
 the same, the 12 ounces of meat is little more than the equi- 
 valent, in the solid form, of the 10 ounces of meat in the soup 
 at Millbank ; while the two pints of rice-soup, without vege- 
 tables, and the 17 pints of gruel, would probably contain less 
 than the 14 pints of gruel and the 7 pints of soup after the 
 supposed removal from it of the 10 ounces of meat. 
 
 " The scurvy, which was a new disease at Millbank, in 18^, 
 occurred, therefore, under the long-continued use of a diet 
 differing little from the military diet of the first three months, 
 and not falling greatly short of that of the second three months. 
 The condition of the prisoners in Millbank in 1822 resembled 
 that of the soldiers in 1840 in the total omission of the potato, 
 the site of the prison, the season of the year, and the scurvy. 
 
 " It is probable, therefore, that the epidemic scurvy, which 
 associated itself with the epidemic dysentery of Millbank as a 
 mixed epidemic, in 1823, was not due to the mere reduction in 
 the quantity of food, nor to the omission of solid meat from the 
 dietary, but to the total exclusion of the potato element. 
 
 " In this outbreak of disease, therefore, we have no clue to 
 the solution of the question of sufficient or insufficient dietaries. 
 It is obviously quite possible that the reduction of the quantity 
 of bread from 168 ounces a week, or a pound and a half per 
 diem, to 112 ounces a week, or a pound per diem, and the 
 substitution for the half-pound of bread of the same quantity of 
 potatoes, would have saved the prisoners from the scurvy, and 
 the Government from the anxiety, trouble, and cost which the 
 sad and perplexing epidemic of 1823 entailed upon it." 
 
 Now, to return to the other factor, " something noxious in 
 the situation," as a cause of the disease. Dr. Baly, after many 
 years of unremitting labour as physician to the Penitentiary, 
 during which time he had under observation several hundred 
 cases of dysentery, and after experiencing at least one very 
 severe and fatal epidemic of the disease in 1842, discussed the 
 question of a " local noxious influence " very fully on two 
 occasions : first, in a paper read before the Medico-Chirurgical 
 Society, in 1845, on " The Mortality in Prisons," and later, in 
 
EDITOR'S PREFACE. xiii 
 
 his Grulstonian lectures on dysentery, delivered at the Royal 
 College of Physicians, in 1847. 
 
 The latter of these two works embodies the conclusions 
 arrived at in the former upon the question now before us, and 
 inasmuch as the lectures are not readily accessible to the 
 majority of readers, and because they contain a masterly 
 summary of the reasons for and against their author's expansion 
 of Dr. Latham's expression, " something noxious in the situa- 
 tion," some pages of his text are here given as a valuable 
 contribution to state medicine : — 
 
 " The physicians who had the medical charge of the Peni- 
 tentiary during the epidemic of the year 1823, reported as their 
 final opinion that the disease had been produced by a local 
 noxious influence. They adduced good reasons for holding this 
 opinion, and subsequent occurrences have shown its correct- 
 ness. DiarrhcBa of a very mild character has seldom been 
 altogether absent from the Penitentiary : dysentery has been a 
 frequent disease there; and in one year this disease has prevailed 
 as a severe and fatal epidemic. 
 
 "It cannot be doubted, therefore, that the cause of the disease 
 is a noxious influence fixed on the spot, but capable of under- 
 going variations in its power of action. The term noxious 
 influence, however, is a very general one. Cannot the nature 
 of this influence be more closely defined ? I think it can. 
 Here, as in other instances where dysentery is endemic in 
 prisons, workhouses, or lunatic asylums, the cause really pro- 
 ducing it is, I believe, a malaria rising from the surface of the 
 ground around the building. There are other influences from, 
 which dysentery might be supposed to arise, namely, diet, the 
 water used as drink, defective ventilation, and defective sewerage. 
 None of these, however, can have been the efficient cause of the 
 disease in the Penitentiary. I think it unnecessary to detail on 
 the present occasion the facts by which this has been rendered 
 certain. I shall therefore at once proceed to adduce those 
 reasons which, to my mind, prove the dependence of the disease 
 on a gaseous poison or malaria derived from the soil of the 
 surrounding grounds. 
 
 " One of these reasons, and an important one, is the relative 
 frequency of the cases of dysentery and bowel complaints in 
 general at different seasons and in different states of the weather. 
 
xiv 
 
 editor's preface. 
 
 They prevail most in the autumn and in the spring, especially 
 in a wet autumn following a hot summer, or in a mild spring 
 when the preceding autumn was wet and the winter severe ; m 
 other words, at those times when, from the state of the soil and 
 atmosphere, the decomposition of the organic matters in the soil 
 is necessarily most active. It may he recollected that the 
 epidemic of the year 1823 commenced at the close of a very cold 
 winter, and that the bowel complaints especially became preva- 
 lent and severe when mild spring weather ensued. The rise 
 and progress of the epidemic of the year 1842 have a similar 
 history. The latter half of the preceding year was remarkable 
 for long-continued rains ; and in the month of October the low 
 garden grounds to the north of the prison were inundated, 
 owing to the river overflowing its banks. A cold winter 
 followed. In the latter part of February, 1842, the weather 
 was mild, while the atmosphere was humid ; and then it was 
 that cases of dysentery suddenly became very numerous 
 amongst the prisoners, and continued so throughout the month 
 of March. From the beginning of April to the middle of July 
 the weather was dry and cool, and the dysentery gradually 
 subsided ; but at the close of July very hot weather set in, and 
 then the disease became prevalent more or less throughout the 
 country, and again attacked a large number of the prisoners in 
 the Penitentiary. At the end of September the hot weather 
 was succeeded by a cold and dry state of the atmosphere, 
 and the prison once more became very healthy. Lastly, about 
 the middle of October, a moist and foggy state of the air ensued, 
 and then dysentery returned, together with fever. This coinci- 
 dence between the prevalence of dysentery and bowel complaints 
 on the one hand, and particular states of the weather on the 
 other hand, has been observed in years when those diseases 
 have been less prevalent than in the year 1842, and it seems to 
 me reconcilable with no other theory of the cause of the 
 diseases in question than that which ascribes them to the 
 influence of a malaria rising from the soil. 
 
 " Another class of facts, strongly supporting the same theory, 
 are those which show the close alliance between dysentery and 
 other diseases which are more indisputably of miasmatous origin, 
 namely, common cholera and fever. Not merely have epidemics 
 of dysentery in the Penitentiary been preceded or followed by 
 
editor's PREFACE. XT 
 
 the prevalence of one or other of those diseases, hut an attack 
 of dysentery has often been ushered in by cholera, or has been 
 combined with fever in the same patient. The direct transition 
 from the choleroid state, attended with rice-water evacuations, 
 to a condition characterised by all the symptoms of inflammatory 
 dysentery, has been often observed, especially in hot summers 
 and autumns. 
 
 " I have already mentioned the frequent co-existence of 
 typhoid fever and dysentery in the same patient, in speaking of 
 the morbid anatomy and of the symptoms of the latter disease. 
 Dr. Latham, too, noticed the association of a fever with the other 
 disorders which constituted the epidemic in the Penitentiary in 
 the year 1823, and he has given an account of its relation to 
 those other disorders according so closely with what I have 
 myself observed, that I shall quote the passage : — 
 
 " ' While the flux of the bowels and the disorders of the 
 brain and nervous system,' Dr. Latham says, ' prevailed to their 
 greatest extent, the cases of fever were rare. It was not until 
 these complaints began to subside, that the fever showed itself 
 in a sufficient number of cases at once to make us accurately 
 acquainted with its type. At no time did it pervade the prison 
 to an equal extent with the other two forms of disease, but it 
 had a just claim to be considered as a part of the disease of the 
 Penitentiary ; and the manner in which it was mixed up with 
 the disorders of the bowels and the brain and nervous system 
 led to the belief that they had all a natural relation to each 
 other, and that they all sprang from one and the same morbid 
 ■condition of the constitution at large.' 
 
 "The fever thus associated with dysentery at the Penitentiary 
 has, during the period in which I have observed it, been 
 generally characterised by the predominance of intestinal 
 symptoms ; sometimes, in fact, the affection of the larger bowels 
 formed so important a part of the disease that it was difficult to 
 say whether the patient was labouring under fever complicated 
 with dysentery, or under dysentery with unusually active 
 symptomatic feverishness. In other cases the principal disease 
 was evidently idiopathic fever, the symptoms of the bowel 
 affection being by comparison only faintly developed. 
 
 " I must here, however, remark that fever at the Peniten- 
 tiary has not always had these characters; sometimes other 
 
XVI 
 
 editor's preface. 
 
 organs than the intestines, namely, the brain or the lungs, 
 have chiefly suffered. In a few remarkable instances, too, the 
 sole characteristic feature has been profuse and constant 
 sweating; the other symptoms being headache, pain in the 
 loins, a thickly-coated tongue, a quick and feeble pulse, and 
 great general debility. In these cases life was sustained, and 
 health at length restored, only by the aid of wine and bark 
 very freely administered. Cases of a similar kind seem to have 
 been observed by Dr. Latham, though, in the instances he 
 notices, the sweating and debility did not come on till the second 
 week of the disease, while in those I have seen they existed 
 from the first. The fever, however, of most frequent occurrence 
 in the Penitentiary has been that in which abdominal symptoms 
 predominated, and in which, after death, not only the ileum, 
 but the colon also, was found affected in various degrees. 
 
 " The close alliance subsisting between dysentery and con- 
 tinued fever in London strongly impressed the mind of 
 Sydenham. This is shown not merely by his denominating a 
 certain fever that was associated with dysentery the ' dysenteric 
 fever,' but also by his oft- quoted remark that ' dysentery was 
 the very fever itself, with this sole difference — that it was 
 turned inwards, and discharged from the system through the 
 bowels.' 
 
 " A close connexion, then, subsists between dysentery and 
 fever; and the prevalence of dysentery, and of the bowel 
 complaints allied to it, is greatest at those seasons, and in those 
 states of the atmosphere, which most favour decomposition of 
 organic matter in the soil. Now these two facts, together with 
 the constant, or almost constant, presence of the disease in a 
 mild form, and the absence of other causes capable of account- 
 ing for it, satisfy my mind that the dysentery observed in the 
 Penitentiary at Millbank is really produced by malaria. 
 
 " But several objections may be opposed to this conclusion. 
 The first I shall notice is, that dysentery, or at all events, 
 diarrhoea, is a common disease in prisons and workhouses, and 
 in them appears to be produced by deficient nourishment; an 
 increase in the diet having, it is said, in many instances, caused 
 the disappearance of the disease. 
 
 "To this objection I would answer, that, the prevalence of 
 bowel complaints in the establishment here referred to has not 
 
editoe's PREFACE. xvii 
 
 been caused by the poorness of the diet. During the summer 
 of the year 1842, I visited many prisons, workhouses, barracks, 
 and lunatic asylums, in various parts of England, with the view 
 of gaining information which might throw light on the origin 
 of the disease prevailing at Millbank. And I found that the 
 degree of prevalence of bowel complaints in the different estab- 
 lishments bore no constant relation to the poorness of the diet, 
 any more than it did to defective ventilation, or impurity of the 
 water which the inmates drank. Dysentery and diarrhoea 
 prevailed in barracks and lunatic asylums where the dietary 
 was abundant, and were absent from prisons in which the 
 allowance of food was scanty. In many instances, too; where 
 a salutary effect had been produced by an increase of the dietary, 
 the bowel complaints, before rife, had only been rendered less 
 prevalent ; they had not disappeared. It seemed, therefore, 
 impossible to believe that poorness of the diet was the primary 
 and essential cause of the disease. On the other hand, I found 
 that the frequency of bowel complaints in the different establish- 
 ments I visited did bear a relation to the character of their sites. 
 Where those complaints were of frequent occurrence, there the 
 site of the building was low, the ground around it damp or 
 imperfectly drained, and the subsoil often formed of peat or 
 clay. "Where bowel complaints were infrequent, the site was 
 elevated, the soil dry, and the subsoil generally composed of 
 gravel. The conclusion, therefore, I arrived at respecting the 
 origin of bowel complaints in these different institutions was, 
 that they were really caused by malaria, and that their 
 frequency and severity had been affected by the diet only in so 
 far as poorness of the diet had in some cases produced a great 
 susceptibility of the influence of the malaria, and the subsequent 
 increase of the diet diminished this susceptibility. 
 
 "The second objection to the theory which ascribes the 
 bowel complaints prevalent in the, Penitentiary to the influence 
 of malaria, is that the inhabitants of the immediate neighbour- 
 hood do not suffer in a similar way. This is true. Even the 
 private families residing in the Penitentiary are seldom at all 
 affected with the prevalent bowel complaints, and very seldom 
 indeed affected in a severe degree. But surely this is no valid 
 objection. For it must be remembered that these free persons 
 are living under conditions very different from those which 
 
xv iii editor's peefacb. 
 
 surround the prisoners. They are not constantly confined to 
 the atmosphere of the locality ; they commonly drink in the 
 course of the day some fermented liquor, as well as other stimu- 
 lants of the nervous system, such as coffee and tea; their bodies 
 are kept in a healthy state by active and voluntary exercise, and 
 their minds by cheerful and varied trains of thought. The 
 prisoners have none of these advantages. It might be expected, 
 therefore, that the former class of persons would be insus- 
 ceptible of disease from causes which might affect the prisoners 
 very generally. There is, indeed, nothing wonderful or 
 remarkable in one class of persons enjoying a comparative 
 immunity from the effects of morbific agents which prove hurt- 
 ful, and even destructive, to those of another class. During 
 the prevalence of almost every epidemic malady, we see that 
 the poor are cut off, while the rich generally escape. And this 
 has been especially observed of dysentery, when it has been 
 most destructive to our troops, not only in military campaigns 
 during the war, but also in time of peace, when the barracks 
 have had unhealthy sites. The officers have been far less 
 affected than the private soldiers.* 
 
 " The consideration of these objections, then, tends by no 
 means to weaken my conviction that the bowel complaints 
 prevalent in the Penitentiary have been caused by malaria. On 
 the contrary, it seems to me to render this theory more pro- 
 bable, since it shows why the effects of malaria on the prisoners 
 have been so well jmarked, though the neighbourhood of the 
 Penitentiary has not manifestly the features of a malarious 
 locality. 
 
 " For it has been asked, whence comes the malaria? There 
 is, indeed, no marshy ground near the prison, no considerable 
 extent of stagnant water : there are none of the more obvious 
 sources of miasm. Still, if we examine closely the state of the 
 ground around the Penitentiary, we find in it many points of 
 resemblance to those tracts near the borders or mouths of rivers 
 where dysentery is so often an endemic disease. The tracts of 
 country to which I allude are low, and have a damp alluvial 
 soil, containing much organic matter. Now such, in a less 
 degree, is the character of nearly all the open ground around 
 
 * Pringle, Diseases of the Army ; Tulloch, Reports of the Health of the 
 Troops ; Annesley, Diseases of India. 
 
editor's PREFACE. xix 
 
 the Penitentiary. The building itself stands upon an artificial 
 hill, but the surface of the surrounding ground is below the 
 level of high water in the river. The soil is loose, and contains 
 much organic matter, and the subsoil is formed in most parts 
 of an imperfect clay, beneath which are alternate strata of peat- 
 earth, marl, and sand. The ground has hitherto been im- 
 perfectly drained. But the chief defect of the site seems to 
 consist in the beds of sand just mentioned being full of water, 
 derived, in all probability, from rain which had fallen on distant 
 and higher grounds. In rainy seasons this water rises through 
 the many breaks in the superficial clayey stratum, and keeps 
 the soil itself, at all events its deeper layers, in a very wet 
 state. These characters show that the exhalation of miasms 
 from the ground around the prison is by no means impossible. 
 And there will, I think, be no difficulty in admitting even the 
 probability that sufficient malaria is produced there to affect 
 persons in whom, from mental as well as physical causes, the 
 power of repelling the attacks of morbific agents is weakened. 
 Indeed, that spot must be a remarkably healthy one where no 
 disease attributable to malaria would show itself amongst 
 persons in the condition of prisoners. And in the Millbank 
 Penitentiary, at the periods when dysentery has chiefly prevailed 
 the prisoners' susceptibility of disease must have been unusually 
 great, owing to the long terms of confinement then enforced. I 
 believe, therefore, that the dysentery and other bowel complaints 
 which have been prevalent in the Millbank Penitentiary are 
 attributable to its site. But, at the same time, I must remark 
 that the site is not an eminently unhealthy one ; this, indeed, 
 is proved by the fact, that the inhabitants of the neighbourhood, 
 and the families residing in the prison itself, have seldom been 
 affected with any disease attributable to any endemic influence ; 
 and I may add, that the site would never have been discovered 
 to be other than perfectly healthy had not a prison been built 
 there. 
 
 " My remarks on the causes of dysentery in the Penitentiary 
 and similar institutions have been extended ; for my personal 
 knowledge of the facts seemed to justify my entering into 
 details on the subject. In speaking of the disease as it is seen 
 under other circumstances, I shall be more brief, as my conclu- 
 sions must here be drawn, for the most part, from the observa- 
 
xx editor's preface. 
 
 tions of others, and must consequently be less positive, and less 
 entitled to attention. I cannot, however, altogether refrain 
 from noticing the extremely unsatisfactory character of the 
 doctrines generally propounded respecting the cause of 
 dysentery.* It seems to be admitted by most writers on the 
 disease that almost any agent capable of making an injurious 
 impression on the body may produce dysentery. Some of these 
 reputed causes of the disease we may, I think, safely reject. 
 Such are, ' acrid ingestaand irritating secretions from the liver, 
 pancreas, and upper part of the alimentary canal,' all of which 
 have been supposed capable of producing the disease.f Such 
 causes as these might occasion irritation of the parts of the 
 canal through which they passed, and consequent purging, but 
 it seems highly improbable that they should produce a severe 
 and rapidly destructive inflammation, confined to the part of 
 the canal they would last reach, and commencing around par- 
 ticular elementary parts of the mucous membrane, namely, the 
 solitary glands. The idea that the autumnal dysentery, 
 diarrhoea, and cholera of this climate, are due to unripe fruit, 
 or other acrid ingesta, if entertained, would be negatived by the 
 fact, that the same complaints prevail during the autumn in 
 prisons, where those causes do not exist, and prevail there to 
 even a greater extent than among the free population. But 
 such an idea is, I believe, no longer entertained by any educated 
 member of our profession in this country. The medical officers 
 of the army in India, however, still reckon the influences I have 
 mentioned among the causes of dysentery ; and this seems the 
 more extraordinary when we consider the frequently extreme 
 severity of the inflammation of the large intestine in the- 
 dysentery of India, and the acknowledged existence there of a 
 general and more adequate cause for the disease, namely, a 
 noxious state of the atmosphere. 
 
 " Another class of the causes of dysentery admitted by most 
 
 * When this lecture was delivered, the author was not acquainted with 
 the excellent article on dysentery, in the " Elements of Medicine," of the 
 late Dr. Robert Williams. 
 
 t See Annesley, Researches on Diseases of India, vol. ii. p. 234, et seq. - T 
 Parkes, Remarks on Dysentery, &c, p. 131, et seq. ; Copland, Dictionary 
 of Practical Medicine, art. Dysentery, pars. 70, 71, and 72 ; O'Brien on the 
 Dysentery of Ireland, p. 24. 
 
editor's PREFACE. xxi 
 
 writers, comprehends mere high temperature of the atmosphere, 
 or cold and moisture combined, or sudden alternations of heat 
 and cold, and especially the suppression of perspiration by cold 
 dews during the nights succeeding to hot days.* But it is 
 difficult to conceive why these causes should produce dysentery 
 any more than any other internal inflammation, while it is 
 obvious that a high temperature favours the rise of malaria 
 from the soil, and that hot days and cold night-dews are charac- 
 teristic of those countries and seasons in which malaria is most 
 abundantly generated. 
 
 " In India, and in all climates where dysentery is a frequent 
 disease, the influence of the season and weather on its degree 
 of prevalence is the same as I have shown it to be at Millbank. 
 Its close alliance, too, with typhus fever, and with cholera, has 
 been generally observed. Even the fatal Asiatic cholera which 
 visited Europe fifteen or sixteen years ago, manifested a close 
 relationship to dysentery. The transition of cholera into 
 dysentery was often seen in particular cases, and the epidemic 
 of cholera in several places passed gradually into epidemic 
 dysentery. Moreover, although cholera was not essentially 
 characterised by disease of the large intestine, yet in many 
 instances it was attended by a lesion of that part of the canal 
 very similar to the lesion characteristic of dysentery. This 
 fact is illustrated by one of Cruveilhier's plates (Livraison 14, 
 PI. 5.) 
 
 " From these facts, then, as well as from the consideration 
 of the whole character of the disease, I infer that dysentery is 
 always produced by a poison introduced into the system from 
 without, and that in most instances this poison is generated by the 
 decomposition of matters contained in the soil. Many other of 
 the reputed exciting causes of dysentery, such as intemperance, 
 or exposure to cold, may have a share in the production of the 
 disease; not, however, by acting as the efficient cause, but 
 merely by disturbing the general health, and thus rendering 
 the body obnoxious to the influences of the atmospheric poison 
 which it previously resisted. 
 
 " The most general source of the poison producing dysentery 
 is certainly the surface of the ground, and the soils generating 
 
 * Twining on Diseases of India, pp. 2, 3, and 4 ; Annesley, op. cit. p. 244; 
 O'Brien, op. cit. pp. 24-28. 
 
XX11 
 
 editor's preface. 
 
 it in the greatest abundance are those which are rich in organic 
 matter, and are imperfectly drained. But still there are facts 
 which show that dysentery may be produced independently of 
 the source of malaria just mentioned. It has not unfrequently 
 broken out in ships at sea, especially in tropical latitudes. In 
 these instances the poison of dysentery may haye been produced 
 as an exhalation from bilge- water, or from decaying vegetable 
 or animal matters in the ship; or the water used for dri n k in g 
 may have become putrid, and the poison having been developed 
 in it, may have been carried into the system through the 
 stomach. For there is no difficulty in admitting that the same 
 noxious matters commonly disengaged from the surface of the 
 ground under the influence of heat and moisture may be pro- 
 duced by the decomposition of organic matter in water, and 
 that the water containing them being taken into (the stomach, 
 and thence absorbed into the blood-vessels, may produce the 
 same injurious effects on the body, as result from the admission 
 of those matters with the air into the lungs. 
 
 " I must here also remark that there appear to be other 
 conditions of the atmosphere besides heat and moisture which 
 favour the development of malaria from the soil. The degree 
 in which dysentery prevails in a particular locality is not 
 always obviously proportionate to the circumstances which are 
 known to promote the decomposition of organic matter and the 
 disengagement of the gaseous products of decomposition. Dysen- 
 tery is in some years unusually prevalent over considerable tracts 
 of country without any obvious cause. In these cases, however, the 
 disease is especially severe and general in the spots where it is 
 at other times endemic in a milder form, and where, from the 
 character of the soil and disposition of the surface of the ground, 
 the presence of malaria might be expected. In the same way, 
 Asiatic cholera, when it visited Europe, showed a preference 
 for the banks of rivers and low moist spots, although some 
 general state of the atmosphere was undoubtedly necessary to 
 its production. 
 
 " Some unknown state of the atmosphere, too, appears to 
 have a share in determining whether the malaria shall produce 
 a mild diarrhoea, a severe dysentery, cholera, or fevers of different 
 kinds. For many of these diseases appear in the same locality at 
 different times, without our being able to determine exactly why 
 
EDITOR'S PEEFACE. xxiii 
 
 at a particular time one disease and not the others should prevail. 
 Sometimes, indeed, two or more of these diseases co- exist on 
 the same spot, and it might hence be supposed that these 
 variations in the effects of malaria are due to the greater or 
 less intensity of action of the poison, and to varying states of 
 the system of the persons on whom it acts. But this supposition 
 would not accord with the fact that all forms of endemic 
 disease are not met with in every malarious locality ; that ague, 
 for example, is never seen in certain spots where other 
 endemic diseases are rife, and that in some localities where 
 ague is prevalent other endemic maladies are absent. This 
 fact, indeed, seems to show that there are as many distinct 
 varieties of atmospheric poison as there are forms of disease 
 belonging to the class of endemic and epidemic disorders. 
 
 " I must notice still another question connected with this 
 part of my subject; namely, how the poison, when it has 
 entered the body, produces the diseased changes. Does it itself 
 circulate with the blood, and on reaching the part of the body 
 with which it has some chemical affinity disturb its normal 
 composition, and thus excite diseased action? Or, does the 
 noxious agent act at first on the blood and produce with some 
 of the elements of that fluid a new compound which becomes 
 the immediate cause of the local disease? This question in the 
 present state of our knowledge it is impossible to answer ; but 
 it seems to me equally impossible to doubt that in dysentery as 
 well as in fever the intestinal lesion is the effect of a chemical 
 action taking place between the glands, or the tissue immediately 
 surrounding them, and a morbific matter circulating with the 
 blood. The time, perhaps, will come when chemistry shall be 
 able to detect the subtle agents which produce these and other 
 disorders in our bodies, and shall explain the play of affinities 
 which, disturbing the normal constitution of particular parts, 
 causes destructive inflammation to arise in them. 
 
 " The poison of dysentery and that of typhoid differ much 
 in their action on the human body. The poison of fever has 
 an especial affinity for the glands of the small intestines, and 
 also produces almost immediately an evident change in the 
 constitution of the blood. The poison of dysentery attacks the 
 glands of the large intestines, and in the more common sthenic 
 form of the disease produces no obvious change in the condition 
 
xxiv editor's preface. 
 
 of the circulating fluid. There is, however, as we have before 
 seen, an asthenic variety of dysentery in which the blood does 
 apparently undergo a change in its composition and vital pro- 
 perties ; and here we must suppose that the poison of dysentery 
 is modified in its properties, or that it is combined with some 
 other noxious matter capable of disturbing the normal consti- 
 tution of the blood. 
 
 "It remains to inquire what cause or causes produced 
 those nervous disorders which at different periods have appeared 
 amongst the prisoners in the Millbank Penitentiary. How has 
 it happened that disorders of this kind have shown themselves 
 prominently in connexion with dysentery only in that esta- 
 blishment ? 
 
 " The first important fact to be noticed in relation to this 
 inquiry is, that these nervous disorders have not been constantly 
 prevalent in the institution. They have appeared only at those 
 times when dysentery was epidemic in the prison, or was about 
 to become so. This fact suggests the inference that some 
 alliance exists between the cause of the dysentery and the 
 influence giving rise to these nervous disorders : an inference 
 which is strengthened by another important fact, viz. that 
 tetanus and neuralgia have been observed as endemic diseases 
 in malarious countries. 
 
 " With respect to tetanus, no doubt exists but that it is 
 far more common among adults in hot climates than in tempe- 
 rate ones, and in hot seasons than in those that are cool ; while 
 the tetanus or trismus of infants is seen chiefly in pestilential 
 countries, such as the West Indies, and in temperate climates 
 only under circumstances which favour the belief that it is 
 produced by a noxious state of the atmosphere. Now it has 
 been observed that the adults attacked by idiopathic tetanus in 
 hot climates are for the most part persons who have suffered 
 hardships, or have been more than usually exposed to the 
 deleterious influence of the climate. The infants we may 
 suppose to have been predisposed to suffer from the disease by 
 the delicacy of their whole constitution, and especially by the 
 excitability of their nervous system. 
 
 " Will not these facts help us to explain the occurrence of 
 peculiar nervous disorders in the prisoners at Millbank ? Besides 
 confirming the opinion that the efficient cause o± these disorders 
 
editor's PREFACE. xxv 
 
 is some kind of malaria, do not these facts also render it pro- 
 bable that a peculiar state of the system of the prisoners has 
 predisposed them to be thus peculiarly affected by a cause which 
 would have produced no such symptoms in other persons ? 
 
 " We have already seen that the effects of imprisonment on 
 the nutritive system are such that severe inflammation and 
 •change of structure is produced in the prisoners by a morbific 
 influence which does not affect free persons who are equally or 
 almost equally exposed to it. May not imprisonment so affect 
 the nervous system, likewise, as to give it an extreme excita- 
 bility comparable to that which predisposes infants to suffer 
 from trismus under the influence of malaria ? 
 
 " If we consider for a moment the effect which long-con- 
 tinued exclusion of light has on the eye, the great sensibility 
 of that organ which results, so that it cannot bear ordinary 
 daylight, suddenly restored, without pain, or sunlight without 
 danger, we shall, I think, find it reasonable to expect that the 
 whole nervous system of prisoners who have been very long 
 •confined in complete or almost complete seclusion from society 
 and from all the ordinary sources of mental excitement will 
 manifest an exaggerated sensibility to the influence of unusual 
 stimulants. At all events, facts have occurred during the last 
 few years which prove the existence of this sensitive state of 
 the nervous system in prisoners under such circumstances. 
 
 " Prisoners sentenced to transportation after being confined 
 for a longer or shorter time in Government prisons in a state 
 of the greatest order and silence, deprived of the society of their 
 fellows and of all the causes of excitement to which they had 
 been accustomed, have been suddenly transferred to convict 
 ships in the river, where they have been thrown together with- 
 out discipline or restraint of any kind, and exposed to the 
 additional excitement of the parting with friends, and to the 
 tumult which must exist in ships preparing for sea. The effect 
 of this sudden change has been that many of the prisoners have 
 been thrown into fits of epileptic convulsions : not merely men 
 and women previously subject to epilepsy, but those who had 
 never before suffered from the disease, have been so affected. 
 This has occurred, not once only, but several times, many 
 prisoners being attacked with epilepsy in each ship. 
 
 " It is only during the first few days after embarkation that 
 
XXVI 
 
 editor's preface. 
 
 these symptoms of disordered nervous system have been 
 observed ; and no serious consequences have been left. But 
 although, so temporary, these phenomena are important from 
 their proving that imprisonment in a state of seclusion induces, 
 for a time at least, an enfeebled, and in consequence highly 
 excitable state of the nervous system. 
 
 " Now both in the year 1823 and in the year 1842, when 
 the nervous disorders associated with dysentery occurred in the 
 Penitentiary, the terms of confinement to which the prisoners 
 were subjected were much longer than at present. "We may 
 therefore, I think, fairly infer that the excitability of the 
 nervous system of the prisoners was at those times propor- 
 tionably great. 
 
 " Can we not now explain the occurrence of the nervous 
 disorders in the Penitentiary ? We have seen that they were 
 associated there with other disorders due to the influence of 
 malaria ; and that in hot and unhealthy climates analogous 
 nervous affections are met with, in adults of enfeebled frame, 
 and in infants whose nervous system is naturally sensitive. We 
 have seen too that the nervous system in prisoners is brought 
 by confinement to a similar sensitive state ; and is it not the 
 natural conclusion from these facts that the peculiar nervous 
 disorders seen in the Penitentiary were due to the action of an 
 atmospheric poison, on persons in whom the nervous system 
 was rendered thus excitable ? " 
 
 Strong confirmation of the correctness of the theory here 
 propounded is to be found in the history of the prison and its 
 neighbourhood during the thirty years which have elapsed 
 since Dr. Baly wrote. 
 
 The whole of the extensive, low-lying area, on the borders 
 of which the prison was built, has been year by year reclaimed 
 and raised and drained (in many places piled), and Cubittopolis 
 has quickly grown upon it. Pari passu with the occupation of 
 the surrounding area, and in proportion to the improvement 
 necessarily consequent in the character of the surface, and of 
 the deeper soil, the health of the inmates of the prison has also 
 steadily improved ; so steadily that the one amelioration can 
 hardly but be looked upon as in part, at any rate, effect of the 
 other. 
 
EDITOR'S PEEFACE. xxvii 
 
 It remains to notice one otter more than probable source of 
 some, at least, of the Penitentiary diseases — the water supply. 
 Some very interesting facts and figures have lately been published 
 by the present Medical Officer, Mr. Grover, in connection with this 
 subject, and the author of a recent work, " Memorials of Mill- 
 bank " (Captain Arthur Griffiths), thinks it " more than 
 possible that the continual use of Thames water for drinking 
 purposes was really more to blame than the actual unhealthiness 
 of the site." " This is a point," Captain Grriffiths goes on to 
 say, " which Dr. Baly missed, but it came out afterwards." 
 
 Dr. Baly cannot be fairly said to have missed the point. 
 On the contrary, entertaining a suggestion made to one of the 
 inspectors of the prison about the year 1844, that the Thames 
 water, cleansed by subsidence only, and not by filtration, was 
 likely to exert a deleterious influence on the health of the 
 prisoners, " he caused a supply of the purest water, from a 
 neighbouring artesian well, to be obtained every second day for 
 two months, and one-third of the prisoners (about 350) were 
 supplied with this water only, whilst the other two-thirds 
 (about 700) were allowed to drink the Thames water as before. 
 The result was that no difference in the health of the two 
 bodies of prisoners was experienced. Proportionally as many 
 cases of diarrhoea, and also of other diseases, occurred amongst 
 the one as amongst the other."* 
 
 Whether there was any source of fallacy in this large 
 experiment, it is now impossible to determine ; but, supposing 
 the water to have been originally pure (as was asserted of it), 
 and supposing its method of storage and its receptacles to have 
 been without reproach (as Dr. Baly was likely to have insisted 
 upon), the failure to secure immunity from disease, in those 
 who drank of it, left the cause of that disease still undetermined, 
 and strengthened materially Dr. Baly's case for some " mala- 
 rious influence." 
 
 In the year 1854, however, the use of Thames water was 
 entirely abandoned, and a permanent supply was obtained from 
 the artesian well in Trafalgar Square. The good results of this 
 very desirable change were at once evident in a virtually entire 
 prevention of enteric fever ; and this cause, working together 
 (it can hardly be doubted) with the beneficial effects of a more 
 
 * Paper on " The Mortality in Prisons." Med. Chir. Trans., 1845. 
 
 C 
 
xxviii EDITOR'S PREFACE. 
 
 scientifically assorted dietary, shorter periods of imprisonment, 
 better local drainage, and the improvements in the surrounding 
 district, enabled Mr. Grover to make the following satisfactory 
 report in 1876 : — 
 
 " The Prison continues to be almost free from diseases of 
 the miasmatic order, and this is equivalent to stating that 
 diarrhoea and dysentery, small-pox and erysipelas, typhus and 
 typhoid fever, are all but extinct as causes of mortality. "With 
 regard to the mortality from typhoid or enteric fever, the con- 
 trast between the ten years, 1845-54, and the twenty-one years 
 following is very remarkable. During the first period there 
 were 57 deaths from that disease ; during the second only 3. 
 The improvement in the water supply, which was effected in 
 August, 1854, explains this great difference, and constitutes the 
 separating line between the two periods. Prior to that date, 
 the Prison had been supplied with Thames water, pumped in 
 from the river immediately opposite the gates, and afterwards 
 filtered. This supply was cut off, and water from the artesian 
 well in Trafalgar Square took its place, with immediate benefit 
 to the health of the inmates of the Prison, and a large reduction 
 in the rate of sickness and mortality. Fifteen years have now 
 elapsed since a case of typhoid fever originated here, and it 
 may therefore be fairly said that in this Prison that disease is 
 extinct. Millbank, however, by no means stands alone among 
 the Government prisons in this respect. An enviable security 
 is enjoyed, but it is not monopolised. On looking through the 
 annual medical statistics of these prisons for the twenty years, 
 1855-74, I find that only 8 deaths are ascribed to enteric fever] 
 or 40 per annum, in a population, male and female, averaging 
 7,913. During the five years, 1870-74, only two deaths were 
 caused by this disease, in an average population of 9,509. If 
 the sanitary securities enjoyed by the inmates of convict prisons 
 could be extended to the general population of the country, 
 many thousands of lives might every year be saved " 
 
 Queen Anne Street, 
 
 January, 1878. 
 
LECTUKES 
 
 ON SUBJECTS CONNECTED WITH 
 
 CLINICAL MEDICINE. 
 
 AN ACCOUNT OF THE DISEASE LATELY PREVALENT 
 AT THE GENERAL PENITENTIARY. 
 
 ON THE USE OF OPIUM IN FEYERS. 
 
 GENERAL REMARKS ON THE PRACTICE OF MEDICINE, 
 
 A WORD OR TWO ON MEDICAL EDUCATION. 
 
CONTENTS. 
 
 LECTUBE I. 
 
 On the Education of Medical Men. — Difficulty of laying down any fixed 
 Eule respecting it. — Number and Extent of preparatory Studies often 
 much exaggerated. — Some general Recommendations upon the Subject 
 
 Page 1 
 
 LECTURE II. 
 
 Ample Materials afforded by Hospitals for the Clinical Study of Medicine. 
 — Reasons of its comparative neglect. — Its Indispensableness to suc- 
 cessful Practice. — Its Moral Uses. — Reluctance of Students to engage 
 in it. — Surgery, why more popular than Medicine. — What Clinical 
 Instruction is in the strictest Sense. — Method of taking Cases. — Remarks 
 npon Auscultation as an Aid to Diagnosis - 19 
 
 LECTURE III. 
 
 Further Remarks upon taking Cases. — Suggestions and Cautions in the 
 reading of Books. — Systematic, nosological, practical Books. — The 
 Degree in which they are valuable to the Student. — Dr. Clutterbuck. 
 — M. Broussais.— Mr. Abernethy. — Division of practical Medical Lite- 
 rature into that which regards Works of Observation solely, and that 
 which regards works both of Observation and Research into Morbid 
 Processes. — The last properly called the Pathological, and especially 
 recommended to the Student - - - - - 37 
 
 LECTURE IV. 
 
 Pathology. — What are its elements. — How Anatomy contributes towards 
 it — How Chemistry — How Experiment — How Clinical Observation. — 
 Illustrative Instances in Acute Inflammation of the Larynx — In dis- 
 ordered Conditions of the Urine — Of the Blood. — Dr. Prout. — Dr. 
 
xxxii CONTENTS. 
 
 Stevens. — The Knowledge of local Morbid Processes, one Element of 
 Pathology. — Inflammation.— Its vast Extent as an Object of Inquiry. 
 — Its general Laws. — Its modifications in different Structures. — Specific 
 Diseases. — Scrofula. — Cancer, &c. — Dropsy. — Spontaneous Haemor- 
 rhage. — Surgery properly introductory to Medicine in the Order of 
 Pursuit. —A Recommendation to study Diseases of the Eye Page 54 
 
 LECTUEE V. 
 
 On the proper Objects of Medical Investigation. — What Medical Facts are, 
 and what they are not. — The Observation and Collection of Pacts. — 
 Their Arrangement, according to Analogy or Eesemblance — According 
 to the Relation of Cause and Effect. — What is meant by the Relation 
 of Cause and Effect between Medical Facts. — Peculiar Difficulties in 
 the way of ascertaining that Relation. — The Task of ascertaining it 
 necessary to our Knowledge of the Sources of Disease — Of the influence 
 of Remedies — And of the Connexion between the Disease and its 
 Symptoms. — The Sources of Disease, how easily and quickly ascer- 
 tained in some Instances — How tardily and difficultly in others. — 
 The Influence of Remedies, how liable to Deception, from a vicious 
 Credulity on the one hand, and a vicious Incredulity on the other. — 
 The Nature of general Principles in Medicine, and how they are 
 reached - - 69 
 
 LECTUEE VI. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 General Notion of Symptoms.— How they differ from mere Signs.— The 
 Relation of Symptoms to Diseases not the same in all Cases.— Symp- 
 toms are direct or indirect.— Character of each. 
 
 Direct Symptoms respect the Sensations, Functions, and Structure of the 
 Part affected : — 
 
 1. Symptoms which respect Sensation.— Pain— Its Degrees— Its 
 Qualities.— Amount of Information derived from Pain as a Symptom. 
 — Sources of Deception arising from it. 
 
 2. Symptoms which respect Function.— Amount of Information 
 derived from them, as compared with that derived from Sensation.— 
 Amount from both taken together. 
 
 3. Symptoms which respect Structure.— The Information derived 
 from them limited to Parts within Reach of the Sight and the Touch 
 until Auscultation brought the Diseases of certain Organs within the 
 Scrutiny of the Ear . . _ 86 
 
CONTENTS. xxxm 
 
 LECTURE VII. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 Direct Symptoms of Diseases affecting the Structure of the Thoracic Organs, 
 known by means of Auscultation. — Modes of Auscultation. — Prelimi- 
 nary Acquaintance with Morbid Processes essential to its successful 
 Use. — Precise Nature of its Objects in respect to Diseases of the Lungs. 
 — General Directions for its Use. — Auscultatory Signs of healthy 
 Lungs. — Auscultatory Signs of diseased Lungs. — Known in the acts of 
 Breathing, Speaking, and Coughing. — These Signs consist in Dry 
 Sounds and Moist Sounds - Page 101 
 
 LECTURE VIII. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 Ehonchus and Sibilus — Where and how produced. — How they interfere 
 with the Eespiratory Murmur. — In what Sense they are Dry Sounds. — 
 Their Pathological Import. — Conditions under which Rhonchus occurs. 
 — Conditions under which Sibilus occurs— Illustrated by common 
 Forms of Bronchial Disease ; by Asthma, and by a peculiar Form of 
 Acute Bronchial Inflammation - 108 
 
 LECTURE IX. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 Crepitations, or Moist Sounds, that attend the act of Breathing. — Large and 
 small Crepitations. — The Distinction obvious and useful in its main 
 Characteristics' — Uncertain and useless in its lesser Degrees. — Crepita- 
 tions the most frequent of all Auscultatory Signs. — What they can, and 
 what they cannot, teach. — How they need other and more general 
 Symptoms to interpret their meaning. — Illustrated by Acute Inflam- 
 mation of the larger Bronchi — Of the smaller — By that Inflammation 
 of the Bronchi which accompanies Diseases of the Heart — By that 
 which simulates Phthisis — By that which is called Peripneumonia 
 Notha. — How much in each can be inferred from the Kind and Extent 
 of the Crepitations. — The Crepitation characteristic of Pneumonia, 123 
 
 LECTURE X. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 Bronchial Bespiration and Bronchophony. — Dry Sounds — Where and how 
 they are produced — Incident to several Diseases — Peculiar to none. — 
 Their Analogy to certain Sounds of the Heart in the Mode of their 
 Production, — Estimate of their Value as direct Symptoms. — Their 
 Value relative, not absolute — And little or great, according to circum- 
 stances — As seen in Phthisis, in Pneumonia, in Pleurisy - 134 
 
xxxiv CONTENTS. 
 
 LECTURE XI. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 Cavernous Respiration and Pectoriloquy.— Dry Sounds— Where and how 
 produced. — Cavernous Eespiration has many Modifications. — Whence 
 these are derived. — They cannot and need not be characterised by 
 Names.— Conditions most favourable to Pectoriloquy. — Gurgling Ees- 
 piration and Gurgling Cough. — Moist Sounds — How and where pro- 
 duced. — These four Auscultatory Signs, Cavernous Respiration and 
 Pectoriloquy, Gurgling Respiration and Gurgling Cough, are chiefly 
 concerned in the Diagnosis of Phthisis. — Estimate of their Value as 
 direct Symptoms in each Stage and Form of this Disease Page 141 
 
 LECTURE XII. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 Forms of Phthisis compared with kindred Forms of Disease in external 
 Parts. — Unmixed Phthisis commonly of long Duration. — Sometimes 
 lingering in one Stage, and reluctant to pass beyond it. — Sometimes 
 passing quickly through all its Stages, but occupying small Portions of 
 the Lungs in Succession — Ceasing in one and beginning in another. — 
 General and Auscultatory Signs of unmixed Phthisis. — Is Phthisis 
 curable? - - 151 
 
 LECTURE XIII. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 Subject continued. — Mixed Phthisis.— The mixed character of its Auscul- 
 tatory Signs ... 161 
 
 LECTURE XIY. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 Possible Fallacies of Auscultation. — How it may lead to an erroneous 
 Diagnosis — In Pneumonia — In Dilatations of the Bronchi — In Emphy- 
 sema of the Lungs. — Pathology of Dilatations of the Bronchi. — 
 Pathology of Emphysema of the Lungs. — How the Intimations of 
 Auscultation and Percussion may apparently contradict, yet really 
 confirm, each other - . 172 
 
 LECTURE XV. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 Auscultatory Signs of less frequent Occurrence. — How far worthy of 
 regard. — Metallic Sounds. — Where and how produced 189 
 
CONTENTS. xxxv 
 
 ACCOUNT OF THE DISEASE LATELY PREVALENT 
 AT THE GENERAL PENITENTIARY. 
 
 CHAPTER I. 
 
 Introduction - - - Page 207 
 
 CHAPTER II. 
 The Scurvy 219 
 
 CHAPTER III. 
 The Bowel Complaints - - 222 
 
 CHAPTER IV. 
 The Disorders of the Brain and Nervous System 242 
 
 CHAPTER V. 
 The Fever - - 259 
 
 CHAPTER VI. 
 Intercurrent Diseases - - 270 
 
 CHAPTER VII. 
 
 Review of the Extent of the Disease at different Periods. — Uncertainty 
 respecting its Causes - - - 275 
 
 CHAPTER VIII. 
 
 Removal of the Prisoners from the Penitentiary, and its Influence upon 
 their Health - - 282 
 
 CHAPTER IX. 
 Origin of the Disease 297 
 
 Appendix - 337 
 
xxxvi CONTENTS. 
 
 ON THE USE OF OPIUM IN FEVERS - - Page 339 
 
 GENERAL REMARKS ON THE PRACTICE OF 
 MEDICINE. 
 
 I. 
 
 The Practice of Medicine prior to the knowledge of Disease.— What it was. 
 —Knowledge of Disease improved it, while it preserved its original 
 outline.— What Practice owes to Pathology not exactly calculable.— 
 Distinction between curing the Disease and Treating the Patient 
 
 Page 353 
 
 II. — Curb. 
 
 On Special Medicines, and especially Cinchona.— Specifics and Cure con- 
 trasted with Non-Specifics and Treatment.— The difference between 
 Curing and Treating a Pever - 358 
 
 III.— Cube. 
 
 Cinchona : the acceptance it first met with from Sydenham and his Con- 
 temporaries. — Cure of Ague by it abolished error, but taught no truth 
 respecting Processes of Eecovery. — Obligation to use Special Remedies 
 in our present state of imperfect knowledge - 365 
 
 IV.— Cuke. 
 
 The vast use of Cinchona both as a single Specific and as a Special 
 Auxiliary to other Remedies. — The use of other Substances as Specific 
 or as Special Remedies. — Their secret operation is their common 
 characteristic. — Of Poisons, and the conditions which hinder their 
 sufficient trial as Special Remedies. — Of Common Remedies, which 
 seem occasionally to have a special power ... 372 
 
 V.— Cure. 
 
 New Special Remedies : to be rigidly tested before their trustworthiness is 
 admitted. — Example of M. Louis. — Such Remedies, long used and 
 trusted, and at length proved worthless, are discreditable to the com- 
 mon sense of Physicians, and denote their faulty education - 381 
 
CONTENTS. xxxvii 
 
 VI.^CuRE. 
 
 One chief cause of damage and discredit to Medicine as a Profession is to 
 be found in the notions popularly held of Diseases and Remedies ; and 
 in the use to which those notions lead of pretended Specifics or things 
 claiming a special Curative virtue - Page 390 
 
 VII.— Cuke. 
 
 Remedies to be accepted for Specific or Special only on the concurrent 
 testimony of the best and the most experienced men. — Such Remedies 
 few. — Great value of those few: 1. From their positive Effects; 2. From 
 the Hints they furnish or confirm of the deeper and more occult Ele- 
 ments of Diseases. — Their mixed use. — Faith in them gained in Acute 
 rather than in Chronic Diseases - - 399 
 
 VIII. — Treatment. 
 
 Treatment distinct from Cure. — Conversant not immediately with the 
 Disease, but with Intermediate Purposes. — What is meant by Indica- 
 tions of Treatment. — Chosen from present Symptoms. — Not necessarily 
 the most prominent Symptoms. — Or nearest akin to the particular 
 Disease Pathologically. — Often common alike to many Diseases. — And 
 the largest and most comprehensive - - - 407 
 
 VIII. — Treatment. Part II. 
 
 Indicative symptoms often single and simple. — The Quality of a Secretion. 
 — The Beat of an Artery. — A Local Pain. — Contrast between these and 
 the more comprehensive. — Excellence of Simple Treatment, grounded 
 on as few indications as possible. — Attainable only by long Experience. 
 — Success of Simple Treatment not a sure exponent of the Disease 
 Pathologically - 413 
 
 IX. — Treatment. 
 
 Distinction between the Proper and Common Elements of Disease. — All 
 Treatment conformable to this distinction and Illustrative of it. — 
 Small-pox. — Scarlatina. — Measles - 422 
 
 IX. — Treatment. Part II. 
 Subject continued. — Typhus. — Typhoid ... 429 
 
Kxxvm 
 
 CONTENTS. 
 
 X. — Fever. 
 What is Fever Page 436 
 
 X. — Fever. Part II. 
 
 Inflammation and its Fever - - 442 
 
 Eheumatism and its Fever - - - 446 
 
 Erysipelas and its Fever. — Boils. — Carbuncles - - 44& 
 
 XI. — Treatment. 
 
 Treatment of almost all Diseases. — Helped and Explained by the Study of 
 Fever. — Speculatively and Rudimentally Fever pertains to the Vas- 
 cular and Nervous Systems. — Practically and Consequentially to all 
 Parts and almost all Diseases.— Limit of Speculative Thought in 
 Practical Medicine ... 450 
 
 XII. — Treatment. 
 
 Experience. — Much Insight into its Nature to be gained from a single- 
 Disease and its Treatment, on a retrospect of years. — Let the Disease 
 be Erysipelas - - .... 459' 
 
 XIII. — Treatment. 
 Difficulties and Anomalies of Practical Experience ... 465 
 
 XIV.— Pain. 
 
 What is Pain? — It may Kill. — Its Relations to Diseases various. — Pain 
 sometimes a direct Indication of Treatment. — Sometimes not - 474 
 
 XV.-Pain. 
 
 Remedies for Pain. — Anaesthetics. — Anodynes' ... 483. 
 
 XVI. 
 
 What is meant by a Man's Constitution?— Great breadth of the Subject- 
 Full of things indefinite and difficult to name, but real and intelligible, 
 and requisite to be studied for their bearing upon the course of Diseases 
 and their Treatment - . . 491 
 
CONTENTS. xxxlx 
 
 XVII. 
 
 Further Remarks on Practical Experience. — Experience comes from Expe- 
 riments. — Shown in the Treatment of Acute Disease — as Pneumonia. 
 — And of Chronic Disease — as Pulmonary Consumption. — How super- 
 vening Accidents make the Treatment of Diseases more Experimental. 
 — In (so-called) " Expectant Medicine," no sound Experience attain- 
 able but by Experiments with the simplest Remedies - Page 502 
 
 The Heart and its Affections, not Organic. 
 I. — General view of the Subject. — The Pulse - - - 516 
 
 II. — Number of the Pulse. — Is there any certain number, or any limit 
 between certain numbers, that can be assigned as the standard of 
 Health generally ? - - 524 
 
 Have Individuals a certain number of the Pulse as their own 
 standard of Health ? - ... 526 
 
 Increased number of the Pulse in Diseases - - 527 
 
 Difference between the number of the Pulse and the quality of the 
 Pulse, as signs of Disease, and what each respectively imports - 529 
 
 III. — The frequent Pulse at its Highest degree of significance. — Cases 534 
 
 Further Commentary on the foregoing Cases - - 537 
 
 Frequent Pulse still at a very high degree of significance. — To what 
 conditions of Disease it belongs - - 539 
 
 IV. — The frequent Pulse at its lowest degree of significance - 544 
 
 The frequent Pulse of Acute Inflammation in the Strong and pre- 
 viously Healthy ... 546 
 
 The frequent Pulse of Acute Inflammation in the "Weak and 
 Cachectic - - ... 549 
 
 A WORD OR TWO ON MEDICAL EDUCATION - 555 
 Index ..... . 565 
 
AUTHOR'S PREFACE. 
 
 The Lectures contained in this volume are the first of a series 
 which I am engaged in giving to the Students of St. Bartho- 
 lomew's Hospital. It is, however, no part of my duty, as one 
 of the physicians to St. Bartholomew's, to deliver lectures. 
 The obligations of my office are limited to the wards of the 
 Hospital ; where my business is to attend the sick, and to aid 
 the studies of those who seek the knowledge of disease at the 
 bedside of the patient. 
 
 But, since there are many things which must be first 
 understood, in order that our inquiries at the bedside may be 
 pursued more profitably, I have thought that the practical 
 student had a further claim upon me for any information I 
 could afford him which might be necessary or conducive to his 
 purpose. And thus I have been led to give occasional lectures 
 " On Subjects connected with Clinical Medicine." 
 
 Considering the time of life at which the majority of those 
 who are intended to practise physic begin their professional 
 education, few can be supposed at once to understand the objects 
 with which it is conversant. I have therefore endeavoured to 
 put in as clear a light as I could, what is the nature of Facts 
 and Opinions, and Theories and Principles, in medicine ; and 
 what concern the clinical student has with each ; and how im- 
 portant it is for him rightly to distinguish between one and the 
 other. 
 
 With respect to the mode of conducting his inquiries at the 
 bedside, I have suggested to him how to observe and what to 
 observe; what demands his present attention and what may 
 wait the season of his more mature experience ; what books to 
 read and what to abstain from reading ; and the sort of know- 
 ledge which is principally auxiliary to clinical medicine. 
 
 But the subject to which I have chiefly desired to direct the 
 student's attention is Semeiology, or the Doctrine of Symptoms ; 
 not for the sake of pointing out the symptoms of particular 
 
xlii AUTHOR'S PREFACE. 
 
 diseases, but of showing what symptoms are in their own 
 nature ; what sense, or rather what various senses, they bear ; 
 and what is their import and value in enabling us to judge of 
 all diseases which are capable of being known and treated in 
 the living man. For this purpose I have constructed no system, 
 and have adopted only so much of arrangement as was neces- 
 sary for the convenient discussion of the subject. 
 
 The Lectures, now published, embrace one part only of 
 Semeiology. The inquiry, as far as it has gone, has been occu- 
 pied with the evidence, which each organ is capable of fur- 
 Dishing, of its own diseases by symptoms directly referable to 
 itself, and involved in the actual state of its sensations and 
 functions and structure. This is the simplest and the easiest 
 part of Semeiology. 
 
 Among such direct- symptoms I have chiefly dwelt upon 
 those by which Auscultation has enabled us to make discovery 
 of diseases of the lungs. 
 
 Auscultation is capable, I have thought, of being greatly 
 simplified for practical purposes. At all events, unless it be so, 
 it can never be successfully taught; the knowledge derived 
 from it must be confined to a few physicians of hospitals, and 
 the profession at large can never expect much benefit from 
 its use. 
 
 Whether I have succeeded in accomplishing what I think 
 so desirable, and have cleared Auscultation of its mystery in 
 any degree, others must judge. But thus much I can safely 
 say, that the intelligent student, by attending to the few cha- 
 racteristic sounds which I have pointed out, and taking pains 
 to understand their import, and guarding himself against over- 
 refinement, is able in a few weeks to discern the leading truths 
 connected with Auscultation, and in a few months to use it 
 and trust it as his safest guide in the diagnosis of pulmonary 
 diseases. 
 
 Such are the objects which these Lectures have in view. 
 They do not pretend to teach the clinical student any single 
 thing peremptorily or dogmatically, but only to furnish him 
 with certain aids and assistances by which he may be better 
 able to teach himself. 
 
 London, 1836. 
 
LECTUEES 
 
 ON 
 
 SUBJECTS CONNECTED WITH 
 
 CLINICAL MEDICINE. 
 
 LECTURE I. 
 
 ON THE EDUCATION OF MEDICAL MEN. — DIFFICULTY OF LAYING 
 DOWN ANY FIXED RULE RESPECTING IT. — NUMBER AND EXTENT 
 OF PREPARATORY STUDIES OFTEN MUCH EXAGGERATED. — SOME 
 GENERAL RECOMMENDATIONS UPON THE SUBJECT. 
 
 I wish to address a few observations to those of you especially, 
 who, having passed through various preliminary studies in this 
 great school of medicine, have now reached that department of 
 instruction in which it is my lot to be engaged with you — viz. 
 the clinical observation of disease, and the effects of remedies. 
 
 Tour education is now at length concentrating itself to its 
 great object : the time is arrived when you are to direct your 
 minds expressly to the knowledge of diseases, and their treat- 
 ment. All that you have hitherto learned in all the schools of 
 instruction which you have ever frequented, you must bring 
 with you, and make it ministerial to this knowledge. I talk not 
 of science and philosophy only in those departments which bear 
 immediately upon medical instruction, nor of science and 
 philosophy only in any shape ; but of everything by which 
 your intellectual and moral nature has been cultivated and 
 improved at any period of your lives. Every good principle 
 received from the counsel or example of parents in your earliest 
 years — every laudable habit derived from fortunate association 
 
 B 
 
2 SUBJECTS CONNECTED WITH [LECT. I. 
 
 with good men— every maxim of prudence and virtue from 
 good books— and, if there be a higher source (as I trust there 
 is), to which some of you have looked for the proper motives, 
 and ends, and hopes and destinies of man, and really know 
 what they are— bring these, bring all that you possess, and 
 engage them in active exercise, and link them to the great 
 business of your lives ; for now that business may be properly 
 said to begin. It is that by which you are to live and take 
 your station in the world— to do good, or to do evil— to gain 
 friends or enemies, honour or dishonour; and in which the 
 great accountable talent committed to your use will be well or 
 ill employed. 
 
 There are certain stages in the progress of any great design, 
 at which men are apt to pause and look back upon what has 
 been accomplished hitherto, to see if there be any errors to 
 correct, any omissions to supply ; that thus everything may be 
 rightly ordered as they go along, and made fit and conducive 
 to the chief end they have in view. 
 
 You are now arrived at such a stage in your professional 
 education. Having gone through many preliminary studies, 
 you have reached the most important of all — that for the sake 
 of which all the rest were prescribed to you. And from this 
 point you cannot help looking back ; and you must look back 
 with much or little satisfaction, according as, with much or 
 little diligence, you have well or ill secured each preceding 
 stage. The knowledge which lies behind is our natural help to 
 that which lies before. Those, therefore, who have been 
 diligent and learned much, I do indeed congratulate ; for their 
 further advancement will be easier and safer, and with a greater 
 interest. But those who have been idle and learned little, I 
 can only exhort to spare no pains in endeavouring to supply 
 their deficiency ; for, until they do so, the objects I am con- 
 cerned to point out to them they must view with little interest, 
 and will very darkly apprehend. Yet these objects are, above 
 all others, important to them ; for they are calculated to teach 
 them practical knowledge and practical skill in the exercise of 
 their profession. 
 
 But what is it, and how much is it, that a student ought to 
 know, before he can betake himself with effect to the observation 
 of real disease, and hope to acquire a practical skill in treating 
 
LECT. I.J CLINICAL MEDICINE. 8 
 
 it ? This is a question which, I make no doubt, you have often 
 asked, for your own sakes ; since you are especially concerned 
 that it should be satisfactorily resolved. And I, for my own 
 sake, as well as. yours, have often thought upon the same 
 question ; for I would not willingly mislead, by any rash 
 answer or recommendation, those who, from the situation I hold 
 in this place, might venture to trust to my advice. 
 
 There is no subject which at this time more needs the con- 
 sideration of sober-thinking and reasonable men, than that of 
 professional education. 
 
 The subject of education generally is one of great difficulty; 
 yet, strange to say, it is one upon which anybody thinks him- 
 self qualified to construct a system, and establish rules, and 
 dictate to a whole community ; not aware, perhaps, that the 
 wisest men have exercised themselves upon the same, with very 
 doubtful success. 
 
 Milton wrote a treatise on education, and so did Locke. 
 And it was in reference to them that Dr. Johnson said, 
 " Education in England has been in danger of being hurt by 
 two of her greatest men." 
 
 Strange things have been said in jest, or in earnest, con- 
 cerning the studies necessary to form a physician. Sydenham 
 advised Sir Richard Blackmore to read Don Quixote. He 
 probably spoke in jest. But it is impossible to read Sydenham 
 and not perceive that his mind did in truth hardly admit any 
 auxiliary to the exercise of its own observation. What he says 
 of anatomy must startle the painstaking pathologist of modern 
 times, who bestows all his industry in tracing diseases home to 
 the primitive structure in which they are engendered. Anatomy, 
 he has told us, is only fit for a painter. Sydenham might have 
 been professionally learned; but there is no evidence in his 
 works that he was so. Perhaps he was offended with the kind 
 of learning then in repute, which tended to make the practice 
 of physic rest chiefly upon authority ; or, perhaps, the very 
 structure of his mind was such, that it was really incapable of 
 gaining anything second-hand which it could gather fresh 
 from the reality ; or perhaps he had a noble confidence in that 
 wonderful faculty of observation with which he was endowed, 
 and so resolved to use and to trust it to the uttermost, unaided 
 and unencumbered by any foreign helps. 
 
4 SUBJECTS CONNECTED WITH [LECT. I. 
 
 But Sydenham's education, in so far as it -was not pro- 
 fessional, was evidently of the best kind. His mind had been 
 early acquainted with a strict, indeed, with a scholastic 
 discipline. His book is that of a scholar ; I do not mean on 
 account of the language in which it is written, but in its form 
 and structure. Without any apparent artifice, the material 
 facts, and delineations, and histories, arrange themselves all in 
 the right places for being well understood ; and they are all so 
 skilfully reasoned upon as to lead you easily and naturally to 
 the conclusions he desired. 
 
 Are we then justified, not by the advice of Sydenham, which 
 was probably spoken in jest, but by his example, in concluding 
 that nothing more is required, to fit a man for the safe and 
 successful practice of physic, than a good general education, and ' 
 an industrious use of his own observation in his intercourse 
 with the sick ? I think not ; and, among many other reasons, 
 especially for the two following : — First, Because you cannot 
 tax the faculty of observation beyond its common powers and 
 capacities ; you cannot estimate it in the generality by what it 
 was in Sydenham, and look to it for the same results. This 
 would be the same thing as to take measure of all mankind by 
 the proportions of a giant, and make the single wonder of a 
 hundred years the common expectation of every day. 
 
 Secondly, Supposing the faculty of observation existed in 
 each of us at its utmost perfection, and enabled each to learn by 
 it all that it is in its own nature capable of teaching ; yet there 
 are objects beyond its reach, the knowledge of which has, in the 
 progress of our art, come to be considered as essential to the 
 safe and successful practice of physic as those which lie strictly 
 within its sphere ; I mean the knowledge of morbid processes 
 in all their variety, as they affect the structure and functions of 
 our bodies. This knowledge has been derived from other 
 methods of research, from anatomy, from chemistry, from 
 experiment ; and you can only gain it either by the use of Ruch 
 methods yourselves, or from the instruction of those who have 
 used them. Sydenham himself could gain it in no other way. 
 
 But, in our own day, there is little fear that students will 
 be spoiled by the recommendation of their instructors to be 
 content with a scanty knowledge, and trust to their own 
 6agacity for the rest. They are not likely to suffer harm by 
 
LECT. I.] CLINICAL MEDICINE. 5 
 
 having Sydenham held up as an example for imitation : the 
 fear is of another kind (and it is well grounded), namely, that 
 many men of the best abilities and good education will be de- 
 terred from prosecuting physic as a profession, in consequence 
 of the necessity indiscriminately laid upon all for impossible 
 attainments, of which no example either is or can be held forth 
 for their imitation. 
 
 The different professions have one way of glorifying them- 
 selves, which is common to all. It is by setting forth a vast 
 array of preparatory studies, and pretending they are indispen- 
 sable in order to fit a man for the simple exercise of the prac- 
 tical duties that belong to them. I have heard lawyers make 
 such a mighty parade of the things which a man must know 
 before he is called to the bar, that, according to the average of 
 human capacities, not one in fifty has the smallest chance of 
 mastering them ; and of those who do master them, not one in 
 fifty can employ them to the uses for which they are intended. 
 
 I once saw a list of books recommended by a professor of 
 divinity to the study of those going into holy orders. They 
 were more numerous than the majority of even studious men 
 ever read in their whole lives ; yet these were a few prolego- 
 mena introductory to the office of a parish priest. 
 
 We, too, conceive that it befits our dignity to magnify our- 
 selves at certain seasons. The commencement of a session is 
 usually the time chosen ; and then, what a crowd of wonderful 
 things are marshalled by authority around the entrance of our 
 profession ! And through this crowd, it is implied, every man 
 must press his way before he can gain admission. As if we 
 wished to guard and garrison ourselves against invaders, rather 
 than to gain good and useful confederates ! In the affair of 
 literature are reckoned Latin, and Greek, and French, and 
 Italian, and German. In the affair of science, mathematics, 
 and metaphysics, and mechanics, and optics, and hydraulics, 
 and pneumatics, mineralogy, botany, zoology, and geology. 
 
 Such are the portentous forms that guard the threshold. 
 But further onward are placed anatomy, human and compara- 
 tive, and morbid ; physiology and pathology ; chemistry, gene- 
 ral and pharmaceutical, and materia medica; surgery, theoreti- 
 cal, clinical, operative, and ophthalmical ; medicine, theoretical, 
 clinical, obstetrical, and forensical. 
 
6 SUBJECTS CONNECTED WITH [LECT. I. 
 
 The general display of objects so grand and multifarious is 
 formidable enough ; but not half so formidable as their repre- 
 sentation in detail. Of the great cosmogony of medicine there 
 are several departments, and each professor never fails to 
 magnify his own, by counting the cost of time and labour, 
 which you must be prepared to bestow if you wish to make any 
 reasonable progress in it. "Haller (perhaps such an one will 
 say) surely knew what anatomy is, and how much goes to make 
 an anatomist; and Haller has estimated the cost at twenty 
 years of time and labour." 
 
 Now I am persuaded that there does not exist at this day in 
 the profession an individual who comes up to the standard 
 which (it is implied) all ought to reach. It has been my hap- 
 piness to know many men in my time who have had enough of 
 attainment to command my highest respect ; some who have 
 reached great eminence during their lives, and some who have 
 been thought worthy of monuments since their deaths ; yet I 
 have known one, and one only, who came up to the require- 
 ments of an introductory lecture, which I have read ; and that 
 was Dr. Thomas Young. But Dr. Young stood alone among 
 mankind. The most learned and scientific men of his time 
 were struck with wonder at the extent and variety of his 
 knowledge ; yet Dr. Young was the only person whom any man 
 now alive ever saw learned and scientific enough for a physician, . 
 according to the Utopian measure of things. 
 
 If all medical students had fifteen or twenty years at their 
 disposal, and could dedicate them all to professional education, 
 we might pardon a little innocent declamation in displaying 
 the rich and varied field of knowledge about to be disclosed to 
 them ; but even then, sober truth would compel us to confess 
 that the field so pompously displayed far exceeded in extent 
 what the best minds could hope to compass, even in fifteen or 
 twenty years. "When, however, we recollect what space of 
 time the majority of men so addressed really can give to their 
 education, the whole affair becomes inexpressibly ludicrous. 
 
 Now I do protest, in the name of common sense, against all 
 such proceeding as this. It is all very fine to insist that the 
 eye cannot be understood without a knowledge of optics, nor 
 the circulation without hydraulics, nor the bones and the 
 muscles without mechanics : that metaphysics may have their 
 
LECT. I.] CLINICAL MEDICINE. 7 
 
 use in leading us through the intricate functions of the nervous 
 system, and the mysterious connection of mind and matter. It 
 is a truth ; and it is a truth also that the whole circle of the 
 sciences is required to comprehend a single particle of matter : 
 hut the most solemn truth of all is, that the life of man is three- 
 score years and ten. 
 
 How has it happened that while, in other countries, the 
 medical profession has heen exhibited under every imaginable 
 form of ridicule, here, in England, it has been so seldom chosen 
 as a fit thing to laugh at ? The truth is, that here no idea of 
 ridicule was ever popularly associated with it ; and to have ex- 
 hibited it as if there were, would have been out of nature and 
 unsuccessful. 
 
 A vain, pompous, counterfeit form of knowledge without, 
 and a downright solid ignorance and incapacity within, made 
 up a precious combination, which, not long ago, was found 
 everywhere abroad. The mockery and fun that it excited were 
 irresistible and inexhaustible; and Moliere and Le Sage made the 
 world ring with laughter at the expense of physic and physicians. 
 
 Depend upon it, what all men indiscriminately are told they 
 ought to know, all men indiscriminately will soon pretend to 
 know, be it never so extravagant ; and when every medical man 
 in every town and village throughout England, be he physician, 
 surgeon, or apothecary, shall, in right of his profession, claim 
 the homage due to vast learning and science, there will not be 
 wanting some Moliere or Le Sage to hold us all up to the just 
 ridicule of mankind. 
 
 Let us take care then what we are about, and beware how 
 we change the character of the English practitioner of physic. 
 He is sound and unpretending, and full of good sense ; what he 
 wants is a little more careful and a somewhat larger instruction 
 in what bears directly upon the practical part of his profession. 
 Give it him (indeed we are giving it him), and he will become 
 more trustworthy and more respected every day. But for all 
 that is beyond this, we may recommend it, but we must not 
 insist upon it ; we must leave it for each man to pursue accord- 
 ing to his leisure, his opportunities, and his capacity, and not 
 exaggerate it into a matter of necessity for all. Where too 
 much is exacted, too little will be learned ; excess on the one 
 hand naturally leads to defect on the other. 
 
8 SUBJECTS CONNECTED WITH [lECT. I. 
 
 I know that much disquietude, if not unhappiness, has been 
 felt by students, and especially by the best informed and best 
 disposed, when, at the entrance of their profession, they have 
 been met by obstacles which seem insurmountable. It is the 
 special infirmity of ingenuous minds to reflect with too much 
 anxiety upon their own progress in knowledge ; to sit in judg- 
 ment upon themselves, calculating whether they have made the 
 best of all their opportunities, and wishing, vainly wishing, 
 that their time might come over again, to enable them to sup- 
 ply this omission, or rectify that mistake. By many such, who 
 are at all times too ready to deal hardly with themselves, 
 every exaggerated statement of what they are required to learn 
 is severely felt. 
 
 A well-weighed scheme of professional education, sound and 
 practicable, comprehensive yet moderate in its requirements, 
 and adapted to all, besides the many good purposes it would 
 serve, would have the special benefit of satisfying the minds of 
 students themselves that at each step of their progress they are 
 in the right path. Such a scheme we are not likely to have 
 soon. I will not presume to suggest what it ought to be ; I 
 would rather endeavour to show you, that, in spite of what you 
 are perhaps at present inclined to fear, you may hope to earn a 
 good reputation, to deserve and gain the approbation of man- 
 kind as others have deserved and gained it, although you do 
 not possess a perfeot literary and philosophical education. 
 
 Turn away, then, from the contemplation of this ideal per- 
 fection, which can only make you despair, and look to some real 
 examples for your encouragement. But take care that they be 
 high examples, and such as no small or ignoble efforts can 
 imitate. I eould choose them from among living men. For 
 there are living men who would satisfy my own notion of what 
 a physician ought to be. But I prefer to 190k for them among 
 those that are gone, because there can then be neither offence 
 nor envy in the selection. They shall, however, be such as are 
 fresh in the memory of contemporaries, that I may have wit- 
 nesses to the truth of what I say. 
 
 I will take Dr. Baillie and Dr. Babington ; and I am content 
 that the general estimate of the physician's character should be 
 measured by what mankind at large thought of these two. 
 Their intercourse with the world was large ; and. it is more 
 
LECT. I.] CLINICAL MEDICINE. 9 
 
 than probable that a great portion of the best informed men 
 in their time did, in point of fact, form their notion of what a 
 physician ought to be, from what Dr. Baillie and Dr. Babing- 
 ton actually were. I am content, also, that the professional 
 estimate of the physician's character should be taken at the 
 worth in which medical men held them. 
 
 Perhaps no men that ever lived were better understood, not 
 merely in the general outline of their characters, but in all that 
 nature, or erudition, or experience, or habit, or fortune, had 
 made them, than were these two eminent physicians. They 
 had both been public instructors in the lecture-room, and in 
 large hospitals, and both had immense private practice. Of 
 those who are now exercising their profession in the maturity 
 of their age and experience, many were their pupils ; and 
 almost all the medical men of London have met them in con- 
 sultation. 
 
 Now the reputation of Dr. Baillie and Dr. Babington would 
 not be exalted by any lavish praise of them for qualities which 
 they did not possess. They do not need our commendation for 
 what they were not. Enough will still remain to make us 
 content to be what they were, although it should be denied 
 that either of them was remarkable for the extent or variety 
 of his acquirements. We may still take them as our examples, 
 although neither of them did, or ever pretended to, possess a 
 knowledge of one-half the things now recommended to the 
 medical student as indispensable. In truth, those who knew 
 them best, and admired them most, will not say that their 
 admiration of either was called forth by the many things they 
 understood beyond all other well-educated physicians. 
 
 Dr. Baillie was an anatomist, and Dr. Babington a chemist. 
 And thus each had chosen well a department of knowledge on 
 which their minds seemed most capable of being exercised with 
 a happy result. The minds of both had their natural bent to- 
 wards matter of fact ; and the favourite pursuit of each served, 
 by its very use and exercise, to perfect their understandings 
 according to the mould in which they were originally cast. 
 
 The one taught anatomy, the other chemistry, with great 
 reputation and success ; and both were deeply and experiment- 
 ally versed in what they taught. But neither was anatomy, 
 in the hands of Dr. Baillie, nor chemistry, in the hands of 
 
10 SUBJECTS CONNECTED WITH [LECT. I. 
 
 Dr. Babington, made subservient to any great purposes of phy- 
 siological or pathological discovery. Yet doubtless they are 
 capable of such purposes, and to such they have been made to 
 contribute by others. But education contemplates the ordinary 
 fruits of knowledge. What is new exceeds its calculation. 
 Men are not educated for discoverers ; these stand alone ; for 
 they become what they are, beyond, and often in spite of, their 
 education. They can never be quoted as examples. 
 
 But the fruit of their knowledge to the two eminent men in 
 question was nothing more than the ordinary fruit ; and, there- 
 fore, I choose them as examples. It was the ordinary fruit, 
 but its measure was large. Their knowledge of anatomy and 
 chemistry served them for all the purposes to which they are 
 immediately applicable in the daily exercise of their profession ; 
 and, being in harmony with the natural bent of their minds, it 
 still kept them striving after accuracy in all their investiga- 
 tions, and confirmed them in the habit and skill of appreciating 
 the truth. 
 
 I am far from saying that in anatomy and chemistry con- 
 sisted all the scientific knowledge they possessed, subservient 
 to the uses of their profession. Herein, however, consisted the 
 strength of their knowledge ; and, for the rest, they were well- 
 educated gentlemen. But I will venture to affirm, that had 
 Dr. Baillie and Dr. Eabington been constrained to accomplish 
 half the course of literature and science now recommended for 
 common professional education, they would, from the very 
 texture of their minds, have been utterly spoiled as physicians. 
 
 My experience of human life has long since convinced me, 
 that the number of truly learned and scientific men in the world 
 is small. Therefore, real learning, and real science, must be 
 things of difficult attainment, since so many are engaged in 
 their pursuit. But be their attainment ever so difficult, it is not 
 half so difficult as their use. 
 
 Knowledge may be an incumbrance as well as a help Many 
 men know more than they are able to wield. There is a point 
 (I believe) in the acquisition of knowledge (and this point 
 varies infinitely in different individuals), beyond which, if more 
 be acquired, the whole mass becomes useless to its possessor. I 
 am acquainted with men who never have done, and never can 
 do anything, because they know too much ; and I am acquainted 
 
LECT. I.] CLINICAL MEDICINE. 11 
 
 ■with men possessing comparatively small knowledge, so dextrous 
 in its use that they have ridden over the heads of others far, 
 very far, their superiors in acquirement. Nothing is more 
 common than to hear it said of some eminent and distinguished 
 person, " Eminent and distinguished as he is, what would he 
 not have been had he possessed the learning of such an one ?" 
 Whereas, if he had possessed one particle more of learning than 
 he has, he would have been nothing at all; it would have 
 weighed him down, and he would never have been heard of. 
 
 I am not speaking of pretenders, who succeed nobody can 
 tell how — these are jugglers and mountebanks — but of those 
 who succeed we do know how, and know it to be by dint of a 
 knowledge not necessarily large, but solid and well chosen, 
 which is (as it were) ingrained into their minds, and always at 
 hand, and always producible for its purpose. 
 
 Fortunate, indeed, is the man who takes exactly the right 
 measure of himself, and holds a just balance between what he 
 can acquire and what he can use, be it great or be it small ! 
 
 With all becoming deference to those who so loudly trumpet 
 forth the praises of knowledge, and fright the trembling student 
 with a portentous array of the wonderful things he has to learn, 
 I would venture to crave some little regard for what is not so 
 much as named by them, but what is pre-eminently more 
 important than knowledge itself. I mean wisdom, as a thing 
 distinct from knowledge, but not opposed to it ; requiring, in- 
 deed, knowledge to work upon, but taking care to proportion 
 that knowledge to the real end which itself (wisdom) has in 
 view. I marvel that this wisdom is not enumerated among the 
 ingredients of the physician's character, since it is conspicuously 
 the chief of all, and was unquestionably that which gained for 
 the two eminent men whom we have mentioned the praise which 
 they justly merited from mankind. 
 
 It is, however, in its very nature, a thing too lofty for me 
 to venture to describe. You shall learn what it is from one 
 who well understood how distinct it is from mere knowledge, 
 and who was himself endowed with it in a measure beyond 
 ordinary mortals. 
 
 " Wisdom," says Robert Hall, " is to be distinguished from 
 knowledge, to which it bears an affinity, but ought not to be 
 confounded with it. Though wisdom necessarily presupposes 
 
12 
 
 SUBJECTS CONNECTED WITH [LECT. I. 
 
 knowledge, and it is impossible to exercise it in things of which 
 we are ignorant, yet it ought to be something more practical, 
 and rather more comprehensive : it ever bears a relation to the 
 end; and, in proportion as it is more perfect, to the highest 
 and the last end the agent can be supposed to have in view. ^ It 
 first judges of the end fittest to be pursued, and next determines 
 what are the most fitting and suitable means of accomplishing 
 it. It bein g the province of wisdom to preside, it sits as umpire 
 in every difficulty, and so gives the final direction and control 
 to all the powers of our nature. Hence it is entitled to be con- 
 sidered as the top and summit of perfection. It belongs to 
 wisdom to determine when to act, and when to cease ; when to 
 reveal, and when to conceal a matter; when to speak, and when 
 to keep silence ; when to give, and when to receive ; in short, 
 to regulate the measure of all things, as well as to determine 
 the end, and provide the means of obtaining the end, pursued 
 in every deliberate course of action."* 
 
 More simply, but with equal majesty and truth, spoke 
 another of congenial mind upon the same high subject : — • 
 
 " Knowledge and wisdom, far from being one, 
 Have ofttimes no connection. Knowledge dwells 
 In heads replete with thoughts of other men ; 
 "Wisdom in minds attentive to their own. 
 Knowledge, a rude unprofitable mass, 
 The mere materials with which wisdom builds, 
 Till smooth'd, and squared, and fitted to its place, 
 Does but encumber whom it seems to enrich. 
 Knowledge is proud, that he has learnt so much ; 
 Wisdom is humble, that he knows no more."t 
 
 These words might have been spoken by an oracle, they are 
 so suitable both to learners and teachers of our profession at the 
 present day. "We, of all men, ought to seek knowledge, not for 
 the sake of being knowing, but for the sake of being wise ; and 
 those who are our masters, and are to tell us what we ought to 
 learn, should not make a pompous announcement of all the 
 wonderful things with which medicine may hold a possible 
 alliance, but should prudently select and measure the knowledge 
 required, with a view to the general capacity, and conformably 
 to its end. 
 
 * Vol. V., Sermon xxiv. t Cowper's Task, book vi. 
 
LECT. I.] CLINICAL MEDICINE. 13 
 
 In laying down any scheme of education, you must take 
 care to make it suitable to the majority of those who are to be 
 educated. There may be circumstances in their condition and 
 objects, rendering that education, which is the best in itself, 
 not the best for them. Such circumstances belong, in an 
 especial degree, to our profession. Very few enter it who are 
 not to live by it : very few who are not required to exercise its 
 practical duties early, from the necessity they are under of 
 beginning as soon as possible to support themselves. So that 
 the majority cannot wait to be made philosophers before they 
 become practitioners. 
 
 These are homely considerations ; but they are true, and 
 most important to be borne in mind; — so important, that they, 
 above all other considerations, ought to regulate the kind and 
 extent of knowledge which should generally constitute the 
 education of medical men in this country. Herein is involved 
 a very urgent necessity. It is inherent in the state of society. 
 You cannot alter it : you cannot evade it. Conform to it you 
 must, if you desire to provide for the well-bringing up of those 
 in whose assured competency to the fulfilment of their peculiar 
 duties mankind have the highest interest. 
 
 This necessity, under which the majority find themselves, 
 of exercising their profession early, requires that they should 
 be made practitioners in the easiest and the nearest way. Their 
 knowledge should be of things obviously and confessedly neces- 
 sary, and this knowledge ought to be rigidly exacted, and 
 nothing more ; for if you go beyond this, you ruin the purpose 
 you wish to serve. 
 
 There are, doubtless, many things out of the profession, by 
 the previous knowledge of which the things within the pro- 
 fession are better understood. Such previous knowledge you 
 may recommend, but you must not demand it. You may 
 recommend that every man, before he enters upon the study of 
 physic, should obtain the best general education within his 
 reach : but you must specify nothing as absolutely necessary 
 but what bears immediately upon professional use. 
 
 Now, that is absolutely necessary, and must be studied prior 
 to experience, without which experience itself will hardly 
 profit us when we have obtained it. And that is absolutely 
 necessary, and must not only be studied prior to, but must be 
 
14 SUBJECTS CONNECTED WITH [lECT. 
 
 still cultivated simultaneously with, experience, without whose 
 constant help and guidance experience itself will be cramped, 
 and hindered in its exercise, and cannot go on to perfection. 
 Of processes of disease, and processes of reparation ; of the 
 great remedial agents, and the powers which belong to them, 
 and their modes of acting, and modes of counteracting, and 
 the methods of their application; of these some knowledge 
 must be had prior to experience, and a greater knowledge must 
 continually go along with it. Anatomy, and chemistry, and 
 materia medica, are the keys to such knowledge. You have, 
 therefore, a right to specify these as objects of study, to affirm 
 that a competent knowledge of them is essential to the practice 
 of physic, and to exact it. 
 
 The same necessity which the majority are under of prac- 
 tising their profession early, and of circumscribing their educa- 
 tion within a short period, while it imposes some limit and 
 selection of the things to be learned, requires also a prudent 
 method of teaching them. 
 
 Upon subjects, the proofs of which are contained in speci- 
 mens and experiments presented to the eye, instruction can 
 only be had by resorting to the places where such specimens 
 or experiments are exhibited and explained. Most properly, 
 therefore, are chemistry, and materia medica, and anatomy, 
 taught in lecture-rooms, where the proofs are continually ready 
 at every stage of the instruction, and the instruction itself con- 
 sists in little else than exhibiting them in their proper place 
 and order. 
 
 But are not medicine and surgery conversant with objects 
 presented to the eye ? and ought not they, in like manner, to 
 be learned by the contemplation of those objects ? Yes. 
 
 But in the lecture-room these objects cannot be constantly 
 present, so as to keep pace with the instruction, and be appealed 
 to as proofs. Description, therefore, is made to supply their 
 place, and become their substitute. Description, however, is a 
 poor substitute; for it is absolutely unintelligible, except to 
 those who have some acquaintance with the reality. 
 
 How, then, is medical and surgical instruction to be con- 
 ducted, so as to make it answer its purpose more effectually ? 
 By keeping its real objects more, .and as much as possible, in 
 
LECT. I.] CLINICAL MEDICINE. 15 
 
 view: and as those objects cannot be brought to the student, the 
 student must be brought to them. As he cannot see them in 
 the lecture-room, he must seek them in the wards of the hos- 
 pital ; and there he must seek his instruction too, if he is to 
 obtain any. And even there he will find it difficult enough to 
 learn, with the objects before his eyes. 
 
 I have long doubted whether systematic courses of lectures 
 on medicine and surgery ought to be considered as essential a 
 part of professional education as they are, and whether the 
 rigid attendance upon them which is required does not stand 
 in the way of other more indispensable means of obtaining 
 knowledge ; and whether they are not thus in. danger of 
 becoming a serious hindrance to the very purposes they are 
 intended to promote. 
 
 You must go to the lecture-room, and see dissections, or 
 perform them for yourselves, in order to learn anatomy : you 
 must go to the lecture-room, and see experiments made, or 
 make them yourselves, in order to learn chemistry. 
 
 And you must go to the wards of a hospital in order to 
 learn disease and its treatment ; for there only you can see the 
 sick man, and inquire his symptoms, and give the remedy, and 
 note its effects, and witness its success or its failure. 
 
 In the wards of this vast hospital, there are five hundred 
 experiments continually going on, day and night ; even the 
 great experiments of appeasing pain, of repairing injuries, of 
 controlling disease, of averting death. They are under the 
 direction and superintendence of us, the physicians and surgeons. 
 But we cannot take you into a room apart, and tell you what 
 they are. They are open to your inspection. Go and see what 
 they import. Your time is short. You will soon be engaged 
 with the like experiments yourselves, and upon your own 
 responsibility ; and then, be assured, you will soon perceive 
 that an acquaintance with all their particularities and details is 
 essential to their success in your hands. 
 
 From what I have thought it my duty to address to you 
 upon the subject of education, let no man impute it to me that 
 I desire to degrade physic from the rank which has hitherto 
 been conceded to it among the learned professions. 
 
 I believe (what my own observation has convinced me of) 
 
16 SUBJECTS CONNECTED WITH [LECT. I. 
 
 that there is a mischief in putting forth a vast inventory of 
 miscellaneous things, to be learnt by those whose time is hardly 
 sufficient for mastering that knowledge which is obviously 
 necessary for practical use. I believe, also, that it would be 
 absurd to demand from students generally, whatever might be 
 the time and opportunities at their disposal, a perfect literary 
 and philosophical education, in order to the exercise of our own 
 or any other profession. 
 
 But although I do not enumerate Latin, and Greek, and 
 French, and Italian, and German, and insist that all these you 
 must know, yet I by all means recommend you to get as good 
 a literary education as you can. Let each man learn as many 
 languages, beside his own, as are within the easy reach of his 
 time, his opportunities, and his understanding. For every 
 language will furnish him with a key to new stores of profes- 
 sional information. But to know a language, implies its ready 
 use, not a dark apprehension of its words and phrases. Our 
 own unassisted mother-tongue is a better way to be wise than 
 this. 
 
 Again, although I do not enumerate every department of 
 science that has obtained a name, and tell you it is indispensable 
 that you should be conversant with all, yet I recommend vou 
 to get the best scientific education you can. Let each man 
 according to his time and opportunities, pursue that department, 
 or those several departments, to which his mind inclines : but 
 let him take care to feel his ground firmly established beneath 
 his feet as he goes along. For here all half knowledge is no 
 knowledge at all. Even homely common sense arrives at 
 much safer conclusions in the things which belong to medi- 
 cine, than any scientific principles half understood, and 
 misapplied. 
 
 The medical men of England do, and will continue to, keep 
 pace with the age in which they live, however rapidly it may 
 advance in the course of improvement. They need not be 
 trained and sophisticated according to any compulsory discipline 
 in order to do so. By such accomplishments as are congenial 
 
 with their professional studies, yet unforced and unpretended, 
 
 by such moral qualities as, however they are engendered, are 
 I am persuaded, refined and exalted by their daily habits and 
 
LECT. I.] CLINICAL MEDICINE. 17 
 
 avocations, — their character has been, and always will be, 
 esteemed honourable, and their influence great. 
 
 Yes ! their character is honourable, and their influence 
 great ; and yet they are little conversant with the vulgar means 
 of popular credit. They are singularly abstinent from all 
 passionate interference with subjects of mere temporary interest. 
 No sect, no party in politics, has reckoned many of our profes- 
 sion among its clamorous advocates : but wherever there has 
 been any association of good men for laudable ends — wherever 
 any institution has sprung up having science or literature for 
 its object — or any great scheme of benevolence been designed 
 or perfected — medical men have been always found among their 
 first, their most zealous, and useful promoters. 
 
 In England, too, there always have been among physicians 
 those who have been upon an equality of education with the 
 noblest and most learned of the land. They have been mixed 
 with them at our public schools and universities ; they have 
 contended with them in honourable rivalrv ; and their minds 
 have taken a congenial character from the similar studies of 
 their youth. At length they have all separated to their several 
 destinies for life. Some to the senate, some to the bar, some to 
 the church, some to physic. These men, so educated, have ever 
 afterwards looked with esteem upon each other, and each other's 
 pursuits. And thus have the most illustrious men of every 
 age, who could know nothing of physic as a profession, viewing 
 it through those whom they have known engaged in it, been 
 compelled to regard it with reverence and honour. In this 
 way a credit has been derived to our common profession, 
 in which every individual in every rank of it has partaken, 
 when those whose good opinion is most coveted have taken 
 their estimate of physic and physicians from contemplating 
 the characters of such men as Dr. Heberden and Sir George 
 Baker. 
 
 "What has been will, I trust, ever continue to be ; for I have 
 a conservative jealousy of the rank due to my profession. I 
 wish to see physicians still instituted in the same discipline, and 
 still reared in fellowship and communion with the wisest and 
 the best men ; and that not for the sake of what is ornamental 
 merely, and becoming to their character, but because I am 
 
 C 
 
18 SUBJECTS CONNECTED WITH [LECT. I. 
 
 persuaded that that discipline, which renders the mind most 
 capacious of wisdom and most capacious of virtue, can hold the 
 torch, and light the path, to the sublimest discoveries in 
 every science. 
 
 It was the same discipline which contributed to form the 
 mind of Newton and of Locke, of Harvey and of Sydenham. 
 
LECT. II.] CLINICAL MEDICINE. 19 
 
 LECTURE II. 
 
 AMPLE MATERIALS AFFORDED BY HOSPITALS FOR THE CLINICAL 
 STUDY OF MEDICINE. — REASONS OF ITS COMPARATIVE NEG- 
 LECT. — ITS INDISPENSABLENESS TO SUCCESSFUL PRACTICE. — ITS 
 
 MORAL USES. RELUCTANCE OF STUDENTS TO ENGAGE IN IT. — 
 
 SURGERY, WHY MORE POPULAR THAN MEDICINE. — WHAT 
 CLINICAL INSTRUCTION IS IN THE STRICTEST SENSE. — METHOD 
 OF TAKING CASES. — REMARKS UPON AUSCULTATION AS AN AID 
 TO DIAGNOSIS. 
 
 I have always thought that hospitals are not converted to half 
 the good they are calculated to serve as schools of medicine; 
 and I think so still. 
 
 I have always thought that, in hospitals, knowledge is 
 perpetually running to waste for want of labourers to gather 
 it ; and I think so still. 
 
 I have always thought that, in our schools, every mode of 
 lecturing has been unduly exalted above clinical lecturing ; 
 and every place where knowledge is to be had, or is supposed 
 to be had, has been unduly preferred to the bedside ; and I 
 continue to think thus. 
 
 With respect to clinical lecturing itself, custom has robbed 
 it of its peculiar character, and, withal, of half its advantages, 
 and half its popularity. It has been separated too much from 
 the wards and the bedside, and has deviated into a discussion 
 of abstract pathology and therapeutics. There may, indeed, be 
 things which can be discussed with convenience and propriety 
 only apart from the patient ; and so let them be : but these 
 bear a small proportion to the multitude of things which can 
 only be learnt at his bedside, and in his very presence. 
 
 Here is a hospital containing 500 patients — a wonderful 
 spectacle ! Hither resort hundreds of students from every part 
 of the empire. Here they see what the majority will never 
 see again, after the period of their pupilage is over. They see 
 
20 SUBJECTS CONNECTED WITH [lECT. II. 
 
 collected in one place every variety of disease, and every variety 
 of injury, and numerous specimens of each. "What an oppor- 
 tunity of instruction gained, if rightly used ; what an opportu- 
 nity lost, if neglected ! 
 
 And which is generally the case ? Is the opportunity, in 
 fact, generally used or neglected? I speak from my own 
 certain conviction, and I answer, that it is generally neglected. 
 I know that five out of six of those who profess to attend the 
 medical practice of this hospital (and it is the same at other 
 hospitals) never watch a single case of disease through its entire 
 course, during the whole period of their pupilage. I say this 
 with great sorrow, and as a warning to those whose pupilage 
 has yet to begin. This is what I mean by the materials of 
 knowledge running to waste. 
 
 Now, seeing among the students of our prof ession that desire 
 for knowledge which I do, I must be slow to charge upon them 
 a systematic disregard of things most essential. May I presume 
 rather to suspect that the discipline they are subjected to is a 
 little faulty ? I should be sorry to prejudice students against 
 the course of instruction laid down for them : I would rather 
 urge them to greater diligence, that so they might overcome any 
 little impediments which lie in their way. Nevertheless, my 
 situation of physician to this great hospital having given me 
 some insight into the system of instruction pursued, and con- 
 vinced me that it does not work so well as it ought, it becomes 
 my duty to point out where I think the machinery labours. 
 
 I think, then, considering the limited period which the 
 majority of students can devote to their education, a great deal 
 too much is required from them as preparatory to their becom- 
 ing practitioners. Among the multiplicity of things which 
 they must bring certificates of having learnt, there is a fear that 
 they learn some very imperfectly, and some they do not learn 
 at all ; and there is a chance that what they thus learn imper- 
 fectly, or not at all, may be the very things concerning which 
 it is most important that they should be competently informed. 
 And such is really the fact. So pressing upon the student's 
 mind and time is the necessity of attending a multiplicity of 
 lectures, that he has neither attention nor leisure left to bestow 
 upon the observation of diseases and the effects of remedies. 
 
 But how are you to abridge the catalogue ©f lectures, and 
 
LECT. II.] CLINICAL MEDICINE. 21 
 
 what is there now taught which you could fairly exclude, in 
 order to make way for a more ample observation of diseases in 
 the wards of hospitals ? 
 
 Anatomy must he learnt : the form, the situation, the 
 structure of parts, must be known ; even their intimate healthy 
 structure should be much and often examined, by the medical 
 student especially, that his eye may become skilled in detecting 
 deviations from that structure, and tracing the visible vestiges 
 of disease. Dissection, too, must be practised, by the surgical 
 student especially, that his band may be accustomed to the ready 
 use of the knife. All the time that is bestowed upon it is, 
 therefore, fairly due to anatomy. 
 
 Then come chemistry and the materia medica. And let no 
 man who is making his entrance into the medical profession 
 henceforth ever neglect chemistry. Chemistry was once thought 
 to be conversant only with the physiology of external nature ; 
 but every day is bringing us to look more and more to chemistry 
 to explain the physiology of our own bodies. It cannot, there- 
 fore, be suffered to become a less prominent part of medical 
 education than it is. The same may be said of the materia 
 medica. The articles of the materia medica are not likely, upon 
 the whole, to increase in number ; but those in use will require 
 a more accurate study ; more will be known concerning them, 
 and more will consequently be to be learnt. Besides the natural 
 history of many vegetables, there is also their chemical analysis. 
 Chemistry has already detected, in several, the simple principle 
 to -which the whole plant is indebted for its medicinal virtue ; 
 and these simple principles are beginning to be largely and 
 beneficially employed in practice. This, then, is not a time to 
 abridge the study of the materia medica, when science is making 
 in it new discoveries every day, and drawing from it more 
 powerful and more convenient agents. 
 
 Then there are lectures upon botany ; lectures upon mid- 
 wifery, and upon the diseases of women and children ; lectures 
 upon forensic medicine. Now, I dare not say that the subject- 
 matter of all these lectures is not of the highest order; and 
 therefore I must not tell the student that this knowledge is less 
 important than that, and that one lecture he may attend less 
 diligently than another ; I must only speak generally upon so 
 delicate a subject, and contrive to intimate my opinion without 
 
22 SUBJECTS CONNECTED WITH [LECT. II. 
 
 giving offence. The prudent householder, when he would 
 furnish himself a house, sees well enough that some things are 
 of mahogany, and some of rosewood, and others of ebony and 
 gold. He sees much for beauty and much for use, and longs, 
 perhaps, to possess all. But his question is, " Can I afford to 
 possess them?" and his answer, "No, not at present; and I 
 must wait until I can." So, when there is laid before the 
 student this magnificent furniture of the mind, and he asks 
 himself, " Can I possess it ? " I will answer the question for 
 him, " No, you cannot at present." — " But can I ever possess 
 it ?"—" Certainly you can."— "But how?" — "By diligence 
 and by time. Your studies will not be limited to the period of 
 your pupilage, and you will know all these things in time; 
 but certainly not in the brief space of two or three years." 
 
 Observe, I am not captiously finding fault with these formal 
 requisites of medical education. The thiDgs themselves are 
 excellent. But I cannot help wishing, either that fewer had 
 been demanded, or that more time had been allowed for mas- 
 tering them. 
 
 But when all the lectures in question have had their share of 
 attention, and you have brought away from each what informa- 
 tion you can, your most important business, to which air these 
 serve but as the humble instruments, is still to be performed : 
 you have to learn disease, and how to treat it ; and there are 
 lectures immediately subservient to this purpose, viz. lectures 
 on the principles and practice of medicine ; also clinical lec- 
 tures ; also attendance at the bedside of the sick ; also exami- 
 nation of the bodies of those who die. 
 
 Now, lectures on the theory and practice of medicine pro- 
 fess to teach physic systematically, and to give an entire view 
 of the subject down to the present day. They are a kind of 
 medical orrery, in which fevers and inflammations, exanthe- 
 mata and haemorrhages, profluvia and cachexies, are made to 
 perform their circumvolutions with wonderful order and pro- 
 priety. And, as the youthful astronomer needs to contemplate 
 some mimic show of the heavens, before he can profitably scan 
 the heavens themselves, so the youthful physician needs (it is 
 thought) some orderly representation of the whole, to make him 
 know and admire the extent and nobleness of his art, before he 
 begins to deal with its important realities. 
 
LECT. II.3 CLINICAL MEDICINE. 23 
 
 Beware, however, of mistaking the intention of these sys- 
 tematic lectures on medicine, or of allowing your minds to rest 
 in them for purposes which they are not intended to serve. 
 They are introductory, and only introductory, to knowledge 
 which is to be acquired by other means. These means are 
 necessary and indispensable — so absolutely indispensable, that, 
 without them, there can be no knowledge. The knowledge in 
 question is the acquaintance with diseases in all their forms, and 
 the acquaintance with remedies in all their kinds, and all their 
 modes of application; and the means in question are inter- 
 course, continual intercourse, with the human beings who are 
 the subject of diseases. Diseases are not abstractions ; they are 
 modes of acting, different from the natural and healthy modes 
 — modes of disorganizing, modes of suffering, and modes of 
 dying ; and there must be a living, moving, sentient body for 
 all this. 
 
 This body must be your study, and your continual care — 
 your active, willing, earnest care. Nothing must make you 
 shrink from it. In its weakness and infirmities, in the dis- 
 honours of its corruption, you must still value it — still stay by 
 it — to mark its hunger and thirst, its sleeping and waking, its 
 heat and its cold; to hear its complaints, to register its 
 groans. 
 
 And is it possible to feel an interest in all this ? Ay, in- 
 deed it is ; a greater, far greater, interest than ever painter or 
 sculptor took in the form and beauties of its health. 
 
 Whence comes this interest ? At first, perhaps, it seldom 
 comes naturally: a mere sense of duty must engender it; 
 and still, for awhile, a mere sense of duty must keep it alive. 
 Presently, the quick, curious, restless spirit of science enlivens 
 it; and then it becomes an excitement, and then a pleasure, 
 and then the deliberate choice of the mind. 
 
 When the interest of attending the sick has reached this 
 point, there arises from it, or has already arisen, a ready 
 discernment of diseases, and a skill in the use of remedies. 
 And the skill may exalt the interest, and the interest may im- 
 prove the skill, until, in process of time, experience forms the 
 consummate practitioner. 
 
 But does the interest of attending the sick necessarily stop 
 here ? The question may seem strange. If it has led to the 
 
24 SUBJECTS CONNECTED WITH [LECT. II. 
 
 readiest discernment and the highest skill, and formed the con- 
 summate practitioner, why need it go further ? 
 
 But what if humanity shall warm it ? Then this interest, 
 this excitement, this intellectual pleasure, is exalted into a 
 principle, and invested with a moral motive, and passes into the 
 heart. What if it be carried still further ? "What if religion 
 should animate it ? "Why, then happy indeed is that man whose 
 mind, whose moral nature, and whose spiritual being, are all 
 harmoniously engaged in the daily business of his life ; with 
 whom the same act has become his own happiness, a dispensa- 
 tion of mercy to his fellow- creatures, and a worship of God. 
 
 Such a man any of you may be ; but you must begin by 
 learning to stand by the sick bed, and make it your delight. 
 
 But the interest of attending the sick, I have said, seldom 
 comes naturally; it begins in a sense of duty. All men, espe- 
 cially young men, have a repugnance to scenes of misery. A 
 single object of wretchedness is enough to disturb one at first ; 
 but to find one's self at once transported into a throng of 
 objects, where all are wretched, is apt to give a wrench to the 
 spirits from which they do not always easily recover. It is here, 
 then, just at the threshold of his practical studies, that the 
 young man must rest upon his sense of duty. His sense of 
 duty must rally him, and support him, and bring him back to 
 the objects which he is so reluctant to face; and the interest 
 will follow, if he is but just to himself. 
 
 I have now been a hospital physician many years, and 
 many a succession of students has passed before me. I have 
 not been an inattentive observer of their habits, and have 
 remarked some things respecting the growth of this interest for 
 the practical objects of our profession, which are really very 
 curious. 
 
 At first all students are averse from visiting the sick ; they 
 have no fancy for the wards, either medical or surgical, and 
 they especially shrink from the surgical. But when the repug- 
 nance is got over, and an interest begins to be felt, that interest 
 is almost sure to be for surgery in preference to medicine ; and 
 yet, when they settle in life, their skill in surgery will be little 
 called for, but nine out of ten of the cases which they treat 
 will be medical. 
 
 Now, one reason why surgery is more popular than medicine 
 is, that it is easier. Do not, I beseech you, imagine that I wish 
 
LECT. II.] CLINICAL MEDICINE. 25 
 
 to disparage surgery. In a profession like ours, nothing can 
 show such bad feeling, or such bad taste, as purposely to let fall 
 expressions which cast an imputation of inferiority upon those 
 who happen to cultivate a different portion of the same field of 
 science and usefulness from our own. And even here I will 
 allow, if you please, that cases occur in the department of 
 surgery, beset with difficulties and perplexities, which we in 
 the department of medicine do not meet with, and which 
 require information, and judgment, and skill of the highest 
 order to surmount. 
 
 But I am now speaking of the ordinary routine of cases, 
 such as we find them in hospitals ; and, upon a comparison of 
 such cases, surgery is certainly much easier than medicine ; and 
 students take to it the more kindly because it is easier. 
 
 Surgery, for the most part, requires fewer circumstances to 
 bring you to a knowledge of its object than medicine does. In 
 surgery there are prominent points of interest, which arrest 
 and command the attention at once; in medicine the points of 
 interest are to be sought after, and, being found, are to be 
 retained and cherished by much labour of the understanding. 
 External sores, external inflammation, and broken bones, re- 
 quire only to be seen and handled in order to be known. But 
 the same knowledge which, in surgery, is obtained by the use 
 of the senses, in medicine, which is conversant with internal 
 disease, can only be acquired by a process of reasoning ; and 
 reasoning is more difficult than seeing and touching, and its 
 conclusions are more uncertain, and much more liable to error. 
 
 Moreover, the adaptation of curative means requires more 
 vigilance in medicine than in surgery. There is no end of the 
 circumstances to be taken into consideration day after day, in 
 order to practise medicine with tolerable success. A man has 
 an external inflammation : the surgeon sees it, and is at once 
 sure of its existence ; he prescribes for it, and sees its gradual 
 decline as plainly as he first saw its rise and progress. A man 
 has an internal inflammation; but the physician, not seeing it, 
 is obliged to come to the knowledge of its existence by a great 
 variety of considerations : he prescribes for it, and is again 
 obliged to enter into a variety of considerations before he can 
 know that it has begun to decline or has ceased. The uncer- 
 tainty of physic I readily admit ; but I do not admit the 
 vulgar reproach which has followed from it. There is nothing 
 
26 SUBJECTS CONNECTED WITH [LECT. II. 
 
 absolutely sure but wbat rests upon the basis of numbers, or 
 falls within the sphere of the senses. Where reasoning begins, 
 there begins uncertainty ; and on this account the highest and 
 the best things in the world are all uncertain, and so is our 
 profession. But from this very uncertainty those who practise 
 it successfully claim their greatest honour : for where there is 
 no possibility of error, no praise is due to the judgment of what 
 is right. 
 
 Another reason why surgery is more popular than medicine 
 is, that it is easier for pupils to make surgical cases a matter of 
 discussion and conversation among themselves, and thus to 
 convey an interest to each other respecting them. They can 
 agree about the extent of this burn and that fracture, and 
 understand each other when they talk about them ; but con- 
 cerning the progress, of a fever, and all its circumstances — how 
 they differ to-day from what they were yesterday, and what 
 influence the means employed have had in determining the 
 changes which have taken place — it is quite impossible that 
 they should have any very general conversation. It is neces- 
 sary to be in the presence of the patient to point them out. 
 Language often fails of terms to designate them ; and the most 
 experienced often find a difficulty in making themselves 
 intelligible to each other in speaking of them. There once 
 flourished within these walls " The medical and Philosophical 
 Society of St. Bartholomew's Hospital." I fear it exists no 
 longer. The time was that it was attended weekly by at least 
 an hundred students and others. There was often no lack of 
 discussion, and good discussion too, upon professional subjects : 
 but the subject was almost always a surgical subject. I have 
 already shown the reason why it was so. It could not be 
 otherwise. 
 
 Again : young men like to be doing something — something 
 that shall be real employment. Thus they are gratified while 
 they are plastering, and binding, and dressing, &c. They see 
 and they feel that they are promoting some object daily and 
 hourly, with their own hands, for the benefit of the sick. But 
 in medicine, the quiet and almost passive manner in which they 
 are engaged about the sick requires a state of mind which is 
 seldom possessed in early life. 
 
 Why do I mention all these things ? In order to show 
 
LECT. II.] CLINICAL MEDICINE. 27 
 
 you that I am well aware of all the circumstances which are 
 apt to abate your interest for that department in which it is my 
 duty and my desire to promote your instruction, and of all the 
 difficulties I have to encounter, when I attempt to win you to it. 
 
 May I here be permitted to say a few words concerning 
 myself ? My office, as one of the physicians • to this great 
 hospital, makes it my first professional duty to further the 
 studies of those who resort hither for instruction. A certain 
 department is allotted me, and within that department I have, 
 upon deliberation, chosen a certain course. If it be not 
 essentially the best, it is at least that in which I feel myself to 
 have the greatest capacity of usefulness. I desire that you 
 should know what that course has hitherto been, in order that 
 you may understand what it will be henceforward, and what 
 you are to expect from me. 
 
 I have been physician here eleven years. Having no formal 
 lectures to give, I have considered my business to be expressly 
 in the wards of the hospital; and I have thought myself 
 expressly placed there to be a demonstrator of medical facts. I 
 use the term demonstrator, because it will at once carry my 
 meaning to your minds ; which is, that I have looked upon 
 myself as engaged to direct the student where to look for, and 
 how to detect, the object which he ought to know ; and, the 
 object being known, to point out the value of it in itself and in 
 all its relations. 
 
 In prosecuting this my duty, I have betaken myself to the 
 hospital at an early hour ; and I have had a purpose in so 
 doing. I have desired to meet the students before their minds 
 were preoccupied with other things ; that, among the inter- 
 fering demands of other objects which arise in the course of 
 the day, they should not have to catch a moment for that 
 which, I consider, is the greatest of all — to steal a brief interval 
 between lecture and lecture, and give it to that to which all 
 lectures, and all the knowledge conveyed in all lectures, is but 
 subsidiary and subordinate. I would not thank them for such 
 an irksome wearied attention ; I want them when their minds 
 are fresh ; and therefore I have always given myself to them 
 when mine is fresh. 
 
 My visit to the hospital has occupied, generally, two hours ; 
 sometimes a little less, sometimes a great deal more. Half an 
 
28 
 
 SUBJECTS CONNECTED AYITH [LECT. II. 
 
 hour of that time would be sufficient for me to prescribe for my 
 patients, as well as I could, and satisfy my conscience that I 
 had done them justice. The remaining hour and half I have 
 given to the duties of my office as a teacher of clinical me- 
 dicine. 
 
 But in this business of clinical instruction, I have not been 
 the only instructor, nor have the means of information been 
 limited to what I say or I point out. Surely this would be a 
 poor kind of schooling — a giving and taking of scraps of know- 
 ledge, where one mind receives just so much as another mind 
 may have to bestow. No ; it has been my chief care to put 
 everything about the sick in the point of view most favourable 
 for being well observed; that circumstances might become 
 didactic ; that they might give their own intimations, and 
 speak to you themselves in their own tongues ; and that thus 
 you might accept knowledge neither from me nor from anyone, 
 but gather it fresh from the reality. Such, I consider, is the 
 true method of clinical instruction. In short, whenever I have 
 entered my wards, I have been accustomed to regard myself 
 in no other light than that of one who presides over a great 
 solemnity, and is engaged so to manage all its circumstances 
 that they shall produce their appropriate impression upon the 
 mind of the spectators. You are those spectators ; and the 
 solemnity you witness has many scenes and several actors, and 
 one main subject runs through the whole. The scenes are the 
 diversified incidents of many diseases ; the actors are the sick 
 themselves, and those who minister to them — the nurse, the 
 physician, and the physician's attendants ; and the great sub- 
 ject of the whole is the life of human beings consigned to our 
 hands for a time, and used and treated according to our pleasure, 
 and always for purposes of good. This life is by all means to 
 be saved ; its diseases by all means to be alleviated or cured ; 
 and the arts and methods of saving, and curing, and alleviating 
 are to be so displayed, that the benefit and blessings of indi- 
 viduals may be multiplied infinitely. 
 
 But how multiplied infinitely? Even through you. B.ecol- 
 lect you are the spectators ; I am but the actor. For this is a 
 case in which the spectator's place is a thousand times more 
 important than that of the prime agent, if the measure of things 
 be calculated by the result. My business is with the few indi- 
 
LECT. II.] CLINICAL MEDICINE. 29 
 
 vidual patients before me ; and whatever good or whatever evil 
 I do, would be strictly limited to them, but for your presence. 
 Yes, you are there to take note of the errors into which I may 
 fall, that you may avoid them, and so restrict the mischief 
 within its present sphere; and you are there to take note, also, 
 of the good which I may do, and learn the method of doing it, 
 and make it your own, and carry it abroad with you, that it 
 may bear fruit an hundred-fold, and be multiplied among all 
 mankind. 
 
 You will perceive, then, that with me clinical instruction is, 
 as little as possible, a matter of formal lecture. I will tell you 
 the manner of my proceeding. 
 
 Upon the admission of a patient, my first object is to learn 
 the exact nature of the disease I have to deal with ; and this is 
 done by my own observation, and by inquiries to which the 
 patient himself or his friends make answer. This is taking 
 the case. 
 
 Now, in taking the case, I desire always to proceed after a 
 certain method ; and, when I am able to pursue that method, 
 all the circumstances which I seek to know unfold themselves 
 naturally and easily, and then it is a simple, agreeable, and 
 interesting employment. 
 
 But often, very often, I am driven from all pretence of 
 method in taking the case. The poor patient is embarrassed 
 by the novelty of his situation, or he is deaf, or his disease 
 incapacitates him ; and he hardly understands your questions, 
 and gives you strange' answers. Thus things drop out con- 
 fusedly one after another, and you must be content to accept 
 them as they come, and join them together as you can. But, 
 upon these terms, taking a case becomes a very irksome, dis- 
 agreeable business. 
 
 In taking the case, however, if I am able, I always proceed 
 thus : — 
 
 The patient being placed before me, I ask him no question 
 until I have learned everything worthy of remark which my 
 own eyes can inform me of. His physiognomy ; his complexion, 
 whether florid, pale, or dusky ; the general bulk of his body, 
 whether large and full, or spare and wasted; the condition of 
 particular regions, whether swelled or attenuated ; and of the 
 surface, whether there be any eruptions or sores upon it, and 
 
30 SUBJECTS CONNECTED WITH [LECT. II. 
 
 what is their character ; and, lastly, the power of locomotion, 
 whether he have free use of his limbs or not. 
 
 All these are most important particulars, and we ought to 
 make much of them. There can be no doubt concerning them ; 
 they are objects of our own observation, and come to us authen- 
 ticated by the testimony of our own senses. One step securely 
 ascertained leads to another ; and from what we see upon the 
 exterior, we obtain a clue for directing our inquiry to the seat 
 and centre of the disease within. If locomotion be hindered, 
 we look well to the brain aud spinal marrow ; if there be the 
 livid lip and dusky skin, we scrutinize particularly the con- 
 dition of the heart and lungs ; if the whole body, or some of its 
 parts, be attenuated, we examine well the organs of nutrition. 
 
 Having thus learnt all I can with my own eyes, and felt 
 the pulse and seen the tongue, I next proceed, in taking the 
 case, to that further inquiry in which the patient takes a part : 
 and first, I ask him concerning his general sensations, especially 
 whether he be hot or cold ; and I endeavour to learn whether 
 his heat and cold occur under conditions which constitute fever. 
 
 Next, I inquire into the state of particular organs ; and, 
 beginning with the head, I ask after pain, vertigo, and sense 
 of weight, the sight and the hearing, and sleep and wakeful- 
 ness. Many of these things are only glanced at, or perhaps 
 passed over altogether, if there be no reason to suspect disease 
 of the brain. 
 
 Then, passing to the chest and respiratory organs, I ask 
 concerning pain and cough and expectoration, and the state of 
 the breathing under various conditions of exertion and in 
 different postures of the body ; and I learn the force and 
 extent of the heart's pulsation. 
 
 These things are hardly dwelt upon, or soon despatched, if 
 there be no suspicion of disease in the chest; but if there be, 
 not all we can learn by simple inquiry is enough to ascertain 
 its nature. The patient must, moreover, be submitted to the 
 process of auscultation. This process, however, in order to 
 avoid interruption, I postpone until other inquiries are finished. 
 
 Lastly, proceeding to the abdomen, I ask here also con- 
 cerning pain and uncomfortable sensations, the appetite, the 
 digestion, and the evacuations, their frequency, quantity, and 
 appearance ; and then I ascertain with my hand its form and 
 
LECT. II.] CLINICAL MEDICINE. 31 
 
 fulness, the possible enlargement of particular viscera, the 
 effusion of fluid, or the existence of pain upon pressure. 
 
 Here the examination of the patient ceases, as to his actual 
 condition ; but the history of his complaint remains to be 
 learnt, its origin and its progress hitherto, and its probable 
 exciting cause. 
 
 Perhaps it would seem more in the order of nature, and 
 therefore the best method, to take the history first of all. 
 Formerly I used to do so, but I found it practically incon- 
 venient. If you first learn the existing complaint, you know 
 how much of its previous history you will require to illustrate 
 it ; but if you first inquire the history, since you do not yet 
 know what it is to illustrate, you cannot tell how much of it 
 you shall want, and must allow the patient to tell what he 
 thinks fit ; and, since every person's complaint is interesting 
 to himself, he is apt to discourse about it rather too much at 
 large, and too little to edification. Therefore it is, that I now 
 always inquire the history last, inverting (if you please) the 
 order of nature ; and I take care to make the patient answer 
 express questions rather than leave him to expatiate at his own 
 discretion. 
 
 And now the case is taken and recorded in a book by the 
 clinical clerk : not that I deliver over to be recorded all the 
 circumstances that come out in the progress of the examina- 
 tion, but only such a selection of them as may serve to declare 
 the disease, and furnish guidance and direction in the treat- 
 ment of it. 
 
 The case, I say, is now taken, provided there be no suspicion 
 of disease in the chest. But if there be, the patient must be 
 submitted to the process of auscultation. 
 
 What auscultation is, and the philosophical principles which 
 recommend it as an instrument of diagnosis, it belongs to the 
 lecturer on the principles and practice of medicine to teach you. 
 But as, in the course of my clinical instruction, I shall lay 
 great stress upon it, and at every visit shall present you with 
 instances of the necessity of using it, and shall invite you to 
 give much time (for much will certainly be required) in order 
 to learn to exercise it skilfully, you have a right to expect from 
 me, who have employed auscultation in this large hospital eleven 
 years, some observations concerning it, and some estimate of its 
 value. 
 
32 SUBJECTS CONNECTED WITH [LECT. II. 
 
 The more accurate physicians of our own times have not 
 disdained the guidance of another sense in the investigation of 
 disease. They make use of the hearing as well as the touch 
 and the sight ; and in those things which are more fitly and 
 naturally subjected to it, they have found it not an unfaithful 
 interpreter of the truth. 
 
 Auscultation, as it is called, professes to furnish important 
 aid in the diagnosis of diseases appertaining to all the organs 
 within the chest. Its use, however, has not yet become popular 
 in this country, nor is its value ascertained. 
 
 There are those who condemn it as absolutely worthless, and 
 there are those who commend it as infallible. 
 
 Its vehement and unqualified condemners, judging from 
 what they write and say, are absolutely ignorant of, and un- 
 practised in its use ; and its unqualified commenders are probably 
 of that happy temperament which is naturally averse from 
 admitting the real difficulties of any subject, and therefore find 
 none in medical diagnosis, which is of all things the most 
 difficult, whatever be the means employed for its illustration. 
 
 But there are many sober, well-informed men, who, having 
 the opportunity, have thought it their duty not to spare the 
 necessary pains of practically acquainting themselves with a 
 method of inquiry which comes recommended to the world by 
 one of the soundest patholc gists that ever lived : and among 
 these there will not be found one who does not attach some (and 
 that a very considerable) value to its use. 
 
 A priori, it would not have been believed that the pulse 
 could ever teach us what it does. Sir John Hawkins, in speak- 
 ing of a visit he paid to Dr. Johnson one day during his last 
 illness, says, " Before my departure, Dr. Brocklesby came in ; 
 and taking him by the wrist, Johnson gave him a look of great 
 contempt, and ridiculed the judging of his disorder by the 
 pulse." 
 
 If we had heard, for the first time in our own day, of some 
 physician going about this town, and putting his fore-finger 
 upon the wrists of his patients, and professing to know, from 
 something he found there, that this man had an inflammation 
 of his lungs, and that man of his bowels, and presuming to 
 prescribe bleeding and other gigantic remedies, simply from 
 faith in his own infallible fore-finger, grave men would denounce 
 
LECT. II. J CLINICAL MEDICINE. 33 
 
 him as a dangerous quack, and pleasant men would hold him 
 up as a fair subject for ridicule. 
 
 Yet use has so educated the fore- finger of us all, that this is 
 the very thing we are now doing every day of our lives. 
 When, therefore, so much is confessedly learnt by one sense, it 
 is rather hasty to conclude that nothing whatever can be learnt 
 by another. When, by touching an artery, be the disease what 
 it may, and seated in whatever part, we seldom fail to gain 
 some knowledge concerning it, and some suggestion how to 
 treat it, why should it appear incredible that two particular 
 organs only, the lungs and the heart, should submit some of 
 their diseases to the cognizance of the ear ? 
 
 Concerning the sense of hearing, in relation to its proper 
 objects, and in relation especially to diseases of the heart and 
 lungs, no man can learn from another the kind of information 
 which it is able to convey ; everyone must teach himself. In 
 this respect it is with hearing as it is with touch. You may 
 talk of a hard and a soft pulse, of a full and a small, of a quick 
 and an irritable pulse ; but be assured you thus convey no in- 
 telligible idea, except to those who are by practice as conversant 
 with the pulse as yourself. So, too, with respect to the heart, 
 you may talk of its sound being clear or dull, near or distant, 
 limited or diffused ; and, with respect to the lungs, you may 
 talk of the bronchial and vesicular respiration, of the bronchial 
 voice, and pectoriloquy, of rhonchus and sibilus, and large and 
 small crepitation ; yet none can understand you but those who 
 have given much time and pains to the exercise of auscultation. 
 
 Let us recollect that the pulse submits none of its qualities, 
 but those which respect its number, to actual measurement ; all 
 the rest are determined according to the perceptions of the 
 person who feels it. Yet, concerning these, there is a tolerable 
 agreement among medical men. It is the same with the heart. 
 The number of its contractions may be counted, and therefore 
 never can be doubtful ; but the modes and qualities of its con- 
 tractions, which are many, are determined according to the 
 perceptions of the person who hears them. These, however, 
 like the kindred qualities of the pulse, are accustomed to strike 
 all who habitually attend to them in the same way. 
 
 Summarily, then, concerning auscultation, my experience (I 
 think) warrants me in saying thus much : — 1. That there are 
 
34 SUBJECTS CONNECTED WITH [LECT. II. 
 
 some diseases of the chest which in their kind entirely elude it ; 
 2. That there are some which elude it not in their kind, but in 
 their situation ; 3. That there are some in which auscultation is 
 only a help to diagnosis, but still a very great help ; 4. That 
 there are some (and perhaps the larger number) in which the con- 
 clusions of auscultation are as unerring as those of sight itself. 
 
 Certainty is a big and. portentous word, applied to any the 
 smallest portion of our art. Yet still there is a small district 
 of the whole field of diagnosis, but a large district as it respects 
 particular organs, which auscultation has rendered absolutely 
 certain. 
 
 "With auscultation I almost always use percussion ; and the 
 results of the one perpetually correct or confirm the results of 
 the other, and strengthen the diagnosis. 
 
 But does all clinical instruction consist in directing the 
 mind how to ascertain mere particulars, whether by ausculta- 
 tion or percussion, or by whatever other method is adopted for 
 their discovery in different organs ? JSTo. Clinical instruction 
 is not merely occupied in directing observation to facts, but it 
 assists the mind in estimating their value. Thus, when the 
 record of the case has been read aloud, I admit you to share in 
 my deliberation upon all its particulars, while I endeavour to 
 assort them and bring them together, and make them yield all 
 the light they are capable of throwing upon the nature and 
 seat of the disease. Sometimes I can at once come to a confi- 
 dent diagnosis ; and when I can, I at once announce what it is, 
 and give my reasons for it. 
 
 Sometimes, after great pains of inquiry, I am still in the 
 dark ; and when I am, I say so, and desire to reserve the case 
 for future examination. 
 
 Sometimes, perhaps most frequently, I feel that I have a 
 tolerably right notion of the complaint, but require some cir- 
 cumstances to be more clearly made out, before I can be abso- 
 lutely certain. And then I state what are the circumstances 
 which give me the notion that I have, and what I still deside- 
 rate to bring me to a more confident conclusion. 
 
 The case still remains to be prescribed for. In prescribing, 
 I endeavour to be as simple as possible, to make the indications 
 of treatment as intelligible as possible, and the object I have in 
 view clearly seen. 
 
LECT. II. J CLINICAL MEDICINE. 35 
 
 The case thus examined, and commented upon, and pre- 
 scribed for, I then commit to your future observation as a 
 medical study. 
 
 In the further progress of the case I am still present, not to 
 give formal lectures, but to take care that none of the circum- 
 stances which continue to develop themselves may fall to the 
 ground profitless ; and that you may be tutored by them, and 
 not by me. 
 
 Not one only, but many cases, I shall thus consign to your 
 study with the like care ; and in all I shall be continually at 
 hand to render you my assistance. That assistance, however, 
 I shall never interpose, so as to hinder the exercise of your own 
 independent observation, and mar the very purpose of clinical 
 instruction. 
 
 With respect, however, to formal lectures, as a part of 
 clinical instruction, I will say this : that the teacher would do 
 well occasionally to call his pupils together, and state to them 
 his own views (for every man has his own views) of certain 
 leading points of pathology ; for these views, he must be con- 
 scious, give a bent and direction to every remark he makes upon 
 the objects which he and his pupils are daily contemplating 
 together ; and it is desirable that they should have the best key 
 to interpret him by. This would require a formal lecture. 
 
 Again, for the same reasons he would do well to acquaint 
 his pupils with any general principles at which he mav have 
 arrived in the treatment of disease. This, too, would require a 
 formal lecture ; and such lectures I am almost tempted to 
 promise you, if I was sure they would be acceptable. But it 
 must not be yet ; for I am not certain that we should at present 
 quite understand each other upon these interesting subjects. 
 
 The progress of the human mind is evermore from par- 
 ticulars to generals ; and he that would inform others must be 
 careful, in the manner of his teaching, not to transgress the 
 order of nature. Full of this important truth, I must first seek 
 to rivet you to the contemplation of individuals, and onlv 
 venture to unfold to you any general principles, which I may 
 conceive myself to have reached, either of pathology or practice, 
 in proportion as I judge you able to authenticate them by your 
 own growing experience. 
 
 But it is your present duty to exercise your observation 
 
36 SUBJECTS CONNECTED WITH [LECT. II. 
 
 carefully and unremittingly ; and it is my present duty to point 
 out the fittest objects, and place them in the light in which they 
 can he most profitably seen. 
 
 If ever the desire to view the beauties and sublimities of 
 nature has led you to ascend some lofty eminence, you have 
 probably taken with you one more familiar with the scene than 
 yourselves, as a guide ; but you have still trusted to your own 
 eyes and your own feelings, to fill you with the delight of the 
 prospect, and tell you what to admire and wonder at ; and you 
 have required no more from the guide than to point with his 
 finger, and say, " See here, and see there." 
 
 So in entering this place, even this vast hospital, where 
 there is many a significant, many a wonderful thing, you shall 
 take me along with you, and I will be your guide. But it is 
 by your own eyes, and your own minds, and (may I add) by 
 your own hearts, that you must observe, and learn, and profit : 
 I can only point to the objects, and have little more to say 
 than " See here, and see there." 
 
LECT. III.] CLINICAL MEDICINE. 37 
 
 LECTURE III. 
 
 FURTHER REMARKS UPON TAKING CASES. — SUGGESTIONS AND 
 CAUTIONS IN THE READING OP BOOKS. SYSTEMATIC, NOSOLOGI- 
 CAL, PRACTICAL BOOKS. — THE DEGREE IN WHICH THEY ARE 
 
 VALUABLE TO THE STUDENT. DR. CLUTTERBUCK. — M. BROUSSAIS. 
 
 — MR. ABERNETHY. — DIVISION OF PRACTICAL MEDICAL LITE- 
 RATURE INTO THAT WHICH REGARDS WORKS OF OBSERVATION 
 SOLELY, AND THAT WHICH REGARDS WORKS BOTH OP OBSER- 
 VATION AND RESEARCH INTO MORBID PROCESSES. — THE LAST 
 PROPERLY CALLED THE PATHOLOGICAL, AND ESPECIALLY RECOM- 
 MENDED TO THE STODENT. 
 
 The student often asks me such questions as these, — " "Would 
 you recommend me to note cases down for myself in writing ? 
 "What hooks should I read, or what studies should I pursue, in 
 aid of my daily ohservation of disease ? " These are certainly 
 very important considerations, and I will now give you the 
 hest advice concerning them I am able. 
 
 I often see young men, at the very commencement of their 
 attendance upon medical practice, taking cases ; and when I 
 do, I always dissuade them from doing so. At present, it is 
 quite impossible that they can do what they desire : they literally 
 cannot take a case. Their present business is to observe. Thev 
 must learn to know the things themselves before they can put 
 them down and set them in order for use and reference. 
 
 I will venture to give this general advice. During the first 
 three or four months record nothing ; use your observation to 
 the utmost ; be continually in the wards, looking at the sick 
 and asking them questions ; be inquisitive about the effects of 
 medicines; be listening perpetually, with your bare ears or 
 with the help of the stethoscope, at the chest, that you may 
 become familiar with the sounds of healthy respiration and the 
 healthy contractions of the heart ; and then try to use the same 
 means for the detection of disease. Accustom yourselves to feel 
 
38 SUBJECTS CONNECTED WITH [LECT. III. 
 
 the pulse ; the numher of its beats is easily measured, but it 
 has qualities which are referable only to the sensations of him 
 who feels it, and you must educate your touch to the discrimina- 
 tion of them ; for these qualities, much more than its mere 
 number, serve to guide us in the detection of disease and the 
 method of treating it. The tongue, too, must be often looked 
 at, before you will be able to detect upon it the marks which 
 are morbid. There are certain secretions, also, the different 
 morbid qualities of which you must learn by frequent examina- 
 tion : the expectoration, the urine, both have qualities upon 
 which may depend the diagnosis of disease and the choice of 
 remedies. I am not now making any orderly enumeration of 
 symptoms, but merely instancing a few cardinal points with 
 which habit must render you a little familiar, and enable you 
 to appreciate the information they are calculated to convey, 
 before you can take cases for yourselves with any promise of 
 advantage. 
 
 Let me also mention the physiognomy of disease. This can 
 never be adequately described, and I urge you always to remark 
 it and to dwell much on it ; for some acute observers have 
 drawn such secrets from the expression of the countenance, that 
 it has been to them in the place of almost all other symptoms. 
 
 I would recommend, then, that for three or four months the 
 student should allow his curiosity to range discursively over 
 every variety of disease, familiarizing himself with the great 
 signs which belong to all, before he binds down his mind to the 
 rigid contemplation of particular cases. When I say dis- 
 cursively, I still mean diligently, and with an earnest purpose 
 of improvement ; and, in the course of three or four months 
 thus employed, you will pick up much real knowledge, you 
 hardly know how ; but you will find it such as will stay by you. 
 
 And now you may begin to take cases : but take only a few 
 at first, and be discriminate in your choice ; let them be 
 instances of well-marked acute disease ; and, when you enlarge 
 your number, I would advise you to employ yourselves upon 
 several of the same denomination at the same time. Take three 
 or four cases of dropsy, or of fever, or of rheumatism. Thus 
 you will learn, by the benefit of comparison, what can be learnt 
 in no other way. You will see shades of difference in the 
 diseases themselves, arising from external circumstances or from 
 
LECT. III.] CLINICAL MEDICINE. 39 
 
 the different constitutions of those who bear them, and a conse- 
 quent variety in the modes of treatment required. 
 
 Take your cases in one of two ways. Either take them 
 altogether independently for yourselves, or copy them out of 
 the book kept by the clinical clerk, adding any particulars of 
 observation or comment which iriay have occurred to your own 
 minds during their progress. The last is the least laborious 
 way, and for a beginner (I think) the best, provided you make 
 a point of never copying cases which you have not attentively 
 watched during their whole course. At all events you might 
 trust to the clinical book for furnishing you their framework or 
 leading facts, and their history ; and thus leave yourselves more 
 at leisure to note down your own remarks from day to day, as 
 the cases proceeded. If, in this employment, you make a good 
 selection, and do your work carefully, you will, at the end of 
 your hospital attendance, take away with you a little body of 
 practical medicine founded on your own experience, which will 
 be useful to you, very useful, as long as you live. 
 
 Do not let a suggestion which I am going to add seem 
 trifling or impertinent. I would wish to see the freest inter- 
 course between pupils, with a view to mutual instruction. I 
 would rather find two or three taking the same cases together, 
 than one so employed alone. Tou have it in your power thus 
 to give infinite help to each other. Of all modes of instruction 
 that is the most agreeable, and often the most valuable, where 
 one, a little senior, or a little more advanced in knowledge, 
 communicates information to another not quite so forward. 
 There are, besides, many little difficulties which no man can tell 
 you better how to surmount than he who has just succeeded in 
 surmounting them. At this day I continue to feel gratitude to 
 two or three individuals a year or two senior to myself, whom 
 I found at this hospital when I first became a student. 
 
 Then comes the important question, What books the student 
 should read, and what studies he should pursue, simultaneously 
 with his attendance in the wards of the hospital, in aid of the 
 objects he has now in view ? 
 
 Perhaps it may appear very strange to you, that, while you 
 are intent upon observing the symptoms of diseases and the 
 effects of remedies, I should advise you to be very sparing in 
 reference to books which treat expressly of such matters. Tou 
 
40 SUBJECTS CONNECTED WITH [LECT. III. 
 
 see the things themselves; then why learn them at second 
 hand ? I do not know that I have any objection to certain 
 elementary books — "Yade Mecums," "Practical Manuals," — 
 provided they are short. Such books are to the medical student 
 what maps are to the traveller. They give a succinct summary 
 account of the whole subject according to the last survey ; they 
 help him to explore the country ; but no man can be said to 
 know a country who has gone over it only on the map. The map 
 may have given him his first general notion of it ; but his more 
 intimate acquaintance with it, that sagacity which enables him (if 
 I may so say) to take the right turn in the dark, can only come 
 from the habit of perpetually traversing it. Such are elemen- 
 tary books of practice to the student of physic. He wants them 
 to tell him where he is, and just to give him. a start ; but he 
 must never trust to them for anything beyond this. The mis- 
 fortune is, that these books are too often read, not to assist, 
 but to excuse the labour of practical observation. Many a young 
 man has preferred to sit by his fireside and read " Thomas's 
 Practice of Physic," to a diligent attendance upon the sick in 
 the wards of a hospital ; and the consequence has been, that he 
 has started into practice with Thomas under his arm, and 
 nothing else, and Thomas and he have been companions through 
 life, and he has never been able to do without Thomas to his 
 dying day; seeing and reading all things through Thomas's 
 spectacles. 
 
 Then there are books which give definitions, or succinct 
 descriptions of diseases by name. Not long ago, Cullen's 
 " Nosology " was the most popular, indeed the only, book of 
 the kind in use. But of late there has been a larger demand 
 for such books, and the supply has equalled the demand. 
 Nosologies are resorted to by the student to enable him to learn 
 " Practice " (as it is called) in a much shorter time than his 
 observation of actual diseases and their treatment in the wards 
 of a hospital can possibly teach it him. It would take him two 
 or three weeks at least to watch any actual case of fever 
 through all its stages, while by his book he gains an acquaint- 
 ance (such as it is) with all the kinds of fever that were ever 
 heard of in half the time. 
 
 But Nosologies teach the student " Practice " in no other 
 sense than that of enabling him to seem to have a knowledge 
 
LECT. III.] CLINICAL MEDICINE. 41 
 
 which he has not in reality. They qualify him to pass his 
 examination, not to understand and to treat disease. 
 
 This examination is an important concern ; and the majority 
 of students have unfortunately found out that they can fit 
 themselves for it by other means than those which they are 
 enjoined and invited to pursue. But it is my duty to tell you, 
 that, while you are committing to memory these technical 
 arrangements of diseases, and absenting yourselves from the hos- 
 pital, and fancying that you thus gain time in respect of one 
 particular purpose, you lose time wofully, perhaps irretrievably, 
 in respect of the great business of your lives. Nor is the loss 
 of time the greatest evil : your minds are led astray from their 
 proper object ; for, while you are learning a Nosology by heart, 
 you are no more studying Physic than if you were digging and 
 delving in a field. 
 
 It has often grieved me to see young men saunter about the 
 hospital square, with a little book in their hands, grinding a 
 Nosology, which they are sure to forget in a few months, 
 instead of going from bed to bed, full of interest and alacrity, 
 and gathering knowledge which would become their own, and 
 remain with them as long as they live.* 
 
 * It would be happy for those who have hut a short time to bestow 
 upon the study of their profession, if that method which alone is calculated 
 to make them good practitioners was the only one they could pursue re- 
 spective to their examination. I believe that things might be so ordered 
 as to produce this result. I offer the following remarks upon the subject. 
 
 Every one should be examined upon what he has seen, and that only ; 
 and he should be expressly asked what that is before he is examined. He 
 should be asked what diseases he has actually observed during his hospital 
 attendance, and then made to give a strict account of them and their mode 
 of treatment. An attendance iipon medical practice during a whole twelve- 
 month, in a large hospital, would bring him acquainted with an immense 
 variety of diseases ; so that there would be no fear of the examiner's inter- 
 rogatories being cramped within too narrow a sphere. 
 
 What encouragement would it be to a zealous pursuit of practical 
 medicine, if the student knew that this would be the form of examination 
 to which he would be ultimately subjected ! 
 
 But even if this were the case, it would, in nry notion, still fall short 
 of what is both desirable and attainable. I believe we have been all 
 hitherto wrong ; or, to speak more boldly still, I believe the best schools 
 never yet were right, in the prescribed modes of imparting, and acquiring, 
 and ascertaining the knowledge of practical medicine. The very examina- 
 tions themselves should be conducted in the wards of the hospital. The 
 
42 SUBJECTS CONNECTED WITH [LECT. III. 
 
 There is another class of books, not systematic, yet purely 
 practical, which professedly discuss the treatment of diseases, 
 and their nature and essence, entirely with reference to their 
 cure. They are generally written upon some one particular 
 disease, or upon several diseases of a like character. Some of 
 them you will feel a great temptation to read. 
 
 Among this class are found the great treasures of medicine ; 
 and among the writers of them are found the great benefactors 
 of the human race. The writer of a good practical book on 
 medicine, who tells the world something which it did not know 
 before, something of large application in fortifying or restoring 
 the health, strength, and comfort of man's body and mind ; or 
 who, if he tell nothing new, yet wisely sets in order what is 
 already known, and gives it a better and more convenient 
 adaptation to the same high purposes; such a writer, in all 
 just estimate of things, is second, and second only, to the great 
 expounders of moral and religious truth. 
 
 But, unhappily, among this same class of books is also found 
 
 presence of the patient is necessary at every step, for teaching, for learning, 
 and, finally and most of all, for examining. Surely it is not possible to 
 tell whether a man knows disease unless you see him in the very act of 
 searching after it and finding it ; or whether he can treat disease, unless 
 you see him while he is applying his remedies to it. 
 
 But (it would be said) the arrangements of a hospital would not admit 
 of all this. Nothing would be easier. This great hospital can provide for 
 anything which is manifestly conducive to the public good. I would only 
 ask for a small ward containing half a dozen beds ; and these beds should 
 be occupied by half a dozen well-chosen cases, drafted from the rest of my 
 patients. 
 
 This ward should be my clinical school, and into it none should be 
 admitted but myself and half a dozen pupils. These I would have under 
 examination for a month, and then the same number should succeed them ; 
 and so on, month after month, all the year round. 
 
 But how should I thus have them under examination for a month?' 
 By making them act before me, for a month together, the very part they 
 will have to act, for good or for evil, as long as they live. They should 
 have the cases under their own care and treatment, but strictly under my 
 superintendence ; for this superintendence would constitute the examina- 
 tion. They should question the patient before me, and apply whatever 
 means they thought fit for the detection of his disease, and give their 
 reasons for whatever notion they might form of it. Then they should pre- 
 scribe before me,- and make choice of their remedies, and give their reasons 
 
LECT. III.] CLINICAL MEDICINE. 43 
 
 everything that is wretched in the literature of our profession ; 
 and the had practical works have a mighty predominance of 
 quantity over the good. 
 
 In the shape of practical treatises our own age and country- 
 has bred, and is breeding, and the press is assisting at the birth 
 of, the oddest and most worthless trash ; and this often obtains 
 a wide circulation, and a strange popularity. 
 
 While you are watching various diseases, you cannot help 
 feeling a desire to know what they have said concerning them, 
 who have expressly written about them ; and in your wish to 
 read something, you are, without direction or warning, as likely 
 to lay your hand upon a bad book as a good one ; nay, more 
 likely, for a bad book is generally a very easy book, having 
 been composed by its author with no labour of mind whatever ; 
 whereas a good book, though it be not necessarily a hard one, 
 yet, since it contains important facts, duly arranged, and reasoned 
 upon with care, must require from the reader some portion of 
 the same attention and study to comprehend and profit by it, 
 
 for -whatever indications they thought fit to follow in the treatment. In 
 short, every day they should give the same sort of little lectures as I am 
 accustomed to give upon each patient as I go round the wards. 
 
 At the end of the month, I would give a certificate of competence to 
 those whom I thought deserving of it. 
 
 This method, besides being the best possible test of the knowledge 
 which a man had already acquired, would also be a lesson of instruction in 
 the use of it. Such an examination, or Tather such a practical exhibition 
 of knowledge, in its use and exercise for a month together, would have 
 none of the annoyance, either actual or prospective, which belongs to exa- 
 minations as they now are. As this would be the most profitable, so it 
 would be the most pleasant part of the student's professional education. 
 There would be none of the posing and puzzle of formal interrogatories, 
 but, instead of them, there would be the ease and comfort of the most un- 
 reserved communion between pupil and teacher, upon the subjects most 
 interesting to both. 
 
 After a student has gone through his prescribed course of education, 
 and been examined, he is ready to practise as soon as anybody will employ 
 him; and I would ask any person of common sense to which of the two 
 he would submit his body with the greater confidence — to him who had 
 Vogel, Sauvages, Cullen, or any other nosologist, by heart, or to him who, 
 having spent a twelvemonth in the diligent observation of a great variety 
 of diseases in a large hospital, had brought his knowledge to the test of 
 practice during a whole month under the eye of the physician 1 
 
44 SUBJECTS CONNECTED WITH [LECT. III. 
 
 as it required from the writer to compose it. A good book, 
 at all events, is never a very easy book, and never suddenly 
 popular. 
 
 What books of the practical kind you should read, I will 
 tell you presently; what you should not read, I will tell you 
 now. 
 
 Never read any book that bears internal marks of being 
 addressed more to the public than to the profession. They are 
 all bad, and many dishonest. 
 
 Mind that you are not betrayed to commit yourselves un- 
 warily to books (especially of modern date) upon diet and 
 digestion, upon the liver, and the stomach. Unfortunately, the 
 public is well understood to have such a relish for reading upon 
 these subjects, that new motives have been thus let in for 
 medical authorship, which are not very creditable. There is a 
 demand for books of the kind ; and if they are executed with 
 some plausibility, they have a certain sale, and a certain kind of 
 reputation is gained by them. Any of you, who may feel him- 
 self a little sharp and clever, might write such a book to- 
 morrow, with a tolerable chance of all its attendant advantages. 
 There is not a medical publisher in this town who would not 
 give you something handsome for a book " upon the stomach." 
 
 But there are books upon practical medicine, written in our 
 own times, much talked of, and containing much that is good ; 
 which, nevertheless, a student just beginning to observe for 
 himself would do well to avoid, for they are sure to give an 
 undue bias to his mind. Books, I mean, in which you find 
 some strong predominant theory ; as where numerous diseases, 
 apparently different, are uniformly ascribed to some single 
 cause, and an uniform practice recommended in conformity to 
 the theory: where, for example, every sort of pain, in what- 
 ever part, or every species of nervous complaint, is attributed 
 to plenitude or emptiness of the blood-vessels, or to errors in 
 the functions of the liver, or the stomach, or the duodenum, or 
 the bowels generally; and bleeding or leeches, or mercury or 
 purgative medicines recommended accordingly. 
 
 I do not mean to say that such books may not be read with 
 profit ; but they can only be so read when the reader is able to 
 guard himself with the checks and reserves of his own experience. 
 They have, for the most part, been written by men of talent ; 
 
LECT. III.] CLINICAL MEDICINE. 45 
 
 and, in attempting to show that all, or nearly all, diseases are 
 cured by the pursuit of one indication of treatment, while they 
 fail of establishing the point they intend, they succeed in 
 establishing something short of it. They often show that the 
 indication in question is just in many cases, and that it is one 
 which deserves to be borne in mind in all. 
 
 The seat of fever is placed by one modern author, whom I 
 greatly respect, in the head ; and by another, in the abdomen. 
 According to the one, all febrile movements radiate from in- 
 flammation of the brain as their centre ; according to the other, 
 from inflammation of the mucous membrane of the bowels. 
 The doctrine of both, as a piece of philosophy, is untrue ; but 
 still both Dr. Clutterbuck and M. Broussais have deserved well 
 of the profession, in so far as they have contributed to establish 
 two paramount indications in the treatment of fevers — by 
 showing, that in numerous cases our success will entirely depend 
 upon the undeviating steadiness with which we address our 
 remedies to the head or' the abdomen. Hereafter you may read 
 these books, but not at present. 
 
 I think I can illustrate all I have to say by one great ex- 
 ample. Recollect, I am cautioning the student, the medical 
 student especially, against trusting his mind to the fascination 
 of any tempting theory, before he has put it fairly upon its 
 guard by much independent observation of his own. 
 
 The work of Mr. Abernethy, upon " The Constitutional 
 Origin of Local Diseases," has extraordinary merit and ori- 
 ginality. The substance of the whole is this, — that local dis- 
 eases are rather symptoms of a disordered constitution than 
 primary and independent in themselves ; and that they are to 
 be cured by remedies calculated to make a salutary impression 
 on the general frame, not by topical dressings or any mere 
 manipulations of surgery. All this is good, and entirely 
 justified by experience. 
 
 Next, that this disordered state of the constitution either 
 originates from, or is rigorously allied with, derangements of 
 the stomach and bowels ; and that it can only be reached by 
 remedies which first exercise a curative influence upon these 
 organs. Even thus far it is a beautiful theory, and I am not 
 disposed to deny it a large share of truth. 
 
 Then come to be considered the real nature of these visceral 
 
46 SUBJECTS CONNECTED WITH [LECT. III. 
 
 derangements, of which little distinction is made, and the 
 remedies proper for their cure, which lie in the small compass 
 of a blue pill, or a compound calomel pill, at night, and a mix- 
 ture of gentian and senna in the morning. 
 
 Practically the sum of all is this : that be the local disease 
 what it may, the constitutional ailment what it may, and the 
 derangement of the stomach and bowels what it may, this one 
 method of treatment is at all times applicable. 
 
 What a tempting theory! and what a still more tempting 
 practice ! As soberly set down in print, the student can hardly 
 help receiving them ; for, being once faithfully received, what 
 a world of tedious study and observation must they save him ! 
 
 You, who never knew Mr. Abernethy, and have only read 
 the doctrine which I have endeavoured to sketch, as it is care- 
 fully and beautifully developed in his book, have no notion 
 what he made of it before his pupils in this room. A vein of it 
 ran through every lecture that he gave. In his book it stands 
 as a suggestion to surgeons, concerning the constitutional origin 
 and treatment of local diseases ; in his lectures it acquired an 
 amplitude and extent which embraced every kind of disease 
 incident to man. 
 
 You, who never knew Mr. Abernethy, have no conception 
 of his powers as a lecturer. He so eloquently expounded some 
 of the highest truths ; he so nicely disentangled the perplexities 
 of many abstruse subjects ; he made that so easy which was 
 before so difficult, that every man who heard him feels perhaps 
 to this day, that, for some important portion of his knowledge, 
 he is indebted to Mr. Abernethy. But he reserved all his en- 
 thusiasm for his peculiar doctrine ; he so reasoned it, so acted it, 
 and so dramatized it (those who have heard him will know 
 what I mean) ; and then in his own droll way he so disparaged 
 the more laborious searchers after truth, calling them con- 
 temptuously "the Doctors," and so disported himself with 
 ridicule of every system but his own, that we accepted the 
 doctrine in all its fulness. "We should have been ashamed to 
 do otherwise. We accepted it with acclamation, and voted our- 
 selves by acclamation the profoundest of medical philosophers, 
 at the easy rate of one half hour's instruction. 
 
 The great Lord Chatham, it is said, had such power of 
 inspiring self-complacency into the minds of other men, that 
 
LECT. III.] CLINICAL MEDICINE. 47 
 
 no one was ever a quarter of an hour in his company without 
 believing that Lord Chatham was the first man, in the world, 
 and himself the second ; and so it was with us poor pupils and 
 Mr. Abernethy. We never left his lecture-room without think- 
 ing him the prince of pathologists, and ourselves only just 
 one degree below him. 
 
 Now that an important practical doctrine had been unfolded, 
 is most true ; and that it had been carried to an unwarrantable 
 extent, is most true also : but how far to accept, it, and how far 
 to reject it, were questions for the sober judgment of a matured 
 experience. 
 
 Therefore I do say, that this great teacher, in so far as he 
 taught an exclusive doctrine, and claimed for it an almost 
 universal application, and won an acceptance "for it by the 
 fascinations which genius, and fancy, and eloquence can com- 
 mand, — gave a hurtful bias to the mind of the student, and in- 
 disposed him to the indispensable task of observing for himself. 
 For how is it possible that the mind, the youthful mind 
 especially, can bind and buckle itself to the labour of getting 
 possession of knowledge in the hardest possible way, by sifting 
 every particular, and by patiently observing at the bedside, 
 when it believes itself already furnished with all the wisdom 
 which such laborious and jealous processes can ever teach ? 
 Yes, observation of disease is not only a laborious but a jealous 
 process : it allows nothing to pass but under the warrant of the 
 most cautious reasoning, or of the senses themselves ; for these 
 are the natural sentinels of the truth. 
 
 Summarily, then, I will venture to say, of all books which 
 enter minutely into the practical examination of particular 
 subjects, and those especially which open peculiar views, that 
 it requires much personal experience to formjja correct judg- 
 ment of them, and to profit by them. "While you are yet inex- 
 perienced in the subject-matter, you may be pleased with them 
 as an argument, or a process of reasoning, and thus they are 
 likely to make an undue impression upon your mind. But you 
 will be at a loss about the simple conceptions, which are the 
 pith and marrow of the whole. Under such and such conditions, 
 and on such and such emergencies, says the writer, I reason 
 thus ; and this is my view of the case ; and this is my practice. 
 But to estimate the justness of his views, and the propriety of 
 
48 
 
 SUBJECTS CONNECTED WITH [LECT. III. 
 
 his practice, you must first be familiar with the conditions and 
 emergencies he speaks of. 
 
 I fear that by this time you are beginning to fancy me 
 possessed of some strange prejudice against books; for that, 
 whether they be good or bad, I still find some reason for 
 advising you not to read them. 
 
 Indeed, it is not so. In what I am now saying, I am only 
 endeavouring to explain myself a little more at large concerning 
 a subject upon which I have occasionally conversed with you 
 in the wards, when (as often happens) some one has asked me 
 what books he should read upon this or that disease, which has 
 at the time been the subject of observation. In truth, I want 
 to excuse you to yourselves from any misgivings you may have, 
 that you are not doing all you might for your own information, 
 when you are not reading about every disease you see ; for I am 
 persuaded of nothing more certainly than this, that there is a 
 previous necessity of disciplining our own mind by an inde- 
 pendent course of observation, in order to fit it for anything 
 like profitable instruction by the teaching of other minds, or, 
 indeed, to furnish us with any tolerable security against being 
 deceived instead of being taught. 
 
 They only who are practically informed can read good books 
 with profit, or bad books without injury. 
 
 But still the literature of our profession, in its direct bearing 
 upon practice, is a matter of the highest concern to you all. 
 It is true that you cannot make any great acquisitions in it at 
 present, but you ought to begin even now; not by running 
 from this writer to that for a seantling of knowledge concerning 
 each particular disease as it presents itself, but by seeking an 
 acquaintance with those, great writers who hold the keys to the 
 just knowledge of all diseases, and the just administration of 
 all remedies. Simultaneously with the observation of cases in 
 the wards of the hospital, you must begin to learn the nature 
 of morbid processes ; and the study of these, and the observa- 
 tion of symptoms, begun together in this place, must never be 
 separated in your minds as long as you live. 
 
 Hitherto I have spoken of books generally only, and as 
 they may chance to fall in the way of the student ; but now I 
 would lead you to view a little more closely the character of 
 medical literature in its bearing upon practice, in order that 
 
LECT. III.] CLINICAL MEDICINE. 49 
 
 you may judge whether mine is reasonable and sound advice, 
 ■when I desire you to direct your studies to that part of it 
 especially which is pathological. 
 
 Practical medical literature may be divided into that which 
 is purely the result and product of observation of the living 
 body, and that which is the joint work of such observation and 
 of research into the nature of morbid processes. 
 
 I speak of that only as literature, whether ancient or modern, 
 which is generally known and used and referred to, and has 
 thus become classical by common consent. The part of medical 
 literature bearing this character, which is purely the growth of 
 observation, has many times struck me with wonder. For when 
 I see that observation, exercised upon mere signs and external 
 things, has so assorted and arranged them, so ascertained their 
 import and described their succession, as if it possessed an 
 insight into the inward processes out of which they arise, yet 
 really possessing none; and when I see that, still guided by 
 mere signs and external things, it has often given to powerful 
 remedies the safest and the best direction ; and that, concerning 
 the event of diseases and the issues of life and death, it has been 
 able to see clearly, and discriminate nicely, and prognosticate 
 truly, — I feel assured, that from the records of practical medi- 
 cine may be adduced the highest instances of human sagacity 
 and prudence. I have lately been turning over the Prsenotions 
 of Hippocrates, and the Epidemics of Sydenham, and this is 
 the impression they have left upon my mind, concerning a class 
 of writers of which they are pre-eminently the chief. 
 
 This part of medical literature, with which pure observation 
 is conversant, receives few accessions from time to time ; and 
 this will hardly seem strange, when it is recollected that the 
 same, or nearly the same, things which we now observe, have 
 been observed by others, with the purpose of turning them to 
 the same account, for more than two thousand years. The field 
 of observation was well cultivated at an early period, and few 
 names stand forth in any particular age, at subsequent periods, 
 who have been really eminent in this department ; and these 
 have become fewer and fewer as the world has grown older. 
 
 Now, when I desire you to reserve the study and perusal of 
 these writers for some future period, even until the time arrive 
 when you have taken the treatment of diseases upon yourselves, 
 
 E 
 
50 SUBJECTS CONNECTED WITH [LECT. III. 
 
 do not conceive me to intimate that they are above the reach 
 of your abilities. The truth is, that at present you have to learn 
 their language. I do not mean the language of their words and 
 phrases ; these, indeed, are common words and phrases, but they 
 intend something beyond the common meaning. 
 
 This meaning you can only gradually pick up, by living in 
 the same region where they lived — by seeing the same things, 
 and conversing with the same objects, that they were conver- 
 sant with. This region is the region of observation ; and they 
 who live in it, and they who live out of it, cannot understand 
 each other. They can construe each other's phrases, but they 
 have a very dark apprehension of each other's meaning. 
 
 Do not imagine that I am forming an exaggerated estimate 
 of this class of writers, because you do not now hear of their 
 being much read by medical men at any period of life. I know 
 they are not much read, and I will tell you why : it is because 
 the majority of medical men have no real love for the practical 
 part of their profession. It is a labour to them to observe ; 
 therefore they are no observers. They cannot see clearly what 
 they must strain their eyes to see at all ; and I will tell you the 
 reason of this also : it is because when they were students (pray 
 take warning from what I say) medical practice was unpopular, 
 and they never attended to it ; and they never were able in 
 after-life to learn what they ought to have learnt in their 
 youth. Their very faculty of observing was sound asleep when 
 it should have been wide awake, and it could never afterwards 
 be roused to discern more than the most obvious forms of 
 things. No wonder, then, that the highest excellence in this 
 same department of observation should have found few to 
 appreciate it, and few to admire it. 
 
 But I hope better things from you. Only be diligent, and, 
 at your time of life, and in so vast a field as this hospital, the 
 very use and exercise of observation will naturally produce a 
 taste and tact for observing ; and then whatever you see in 
 after-life you will see with profit, and draw sound experience 
 from it; and not only so, but you will find yourselves of 
 kindred minds with the great masters of our art, — reading them, 
 relishing them, and improving by them. 
 
 But there is another part of practical medical literature, 
 viz. that which is the joint work of observation and of research 
 
LECT. III. J CLINICAL MEDICINE. 51 
 
 into the nature of morbid processes — in a word, the patho* 
 logical. 
 
 Observation, and mere observation, had been at work for 
 ages, and the extent to which it had penetrated into the nature 
 of diseases does, I confess, appear to me quite wonderful. But 
 it could go no further alone ; and it was obvious that, if diseases 
 were ever to be better understood and better treated, observa- 
 tion must be aided by some new method of inquiry. That new 
 method, in the course of time, was introduced, and is now 
 popularly employed ; it consists of research into morbid function 
 and morbid structure, and is based upon the knowledge of 
 healthy function and healthy structure. It is pathology founded 
 upon physiology. 
 
 By the combination of these two methods, observation of 
 symptoms, and a rigid research into the nature of morbid 
 processes, the face of practical medicine has been completely 
 changed, even in our day. 
 
 The advantage which the physician now has over the phy- 
 sician of old is this : he has the same observation to guide him, 
 and he has, moreover, a previous knowledge of the real condition 
 of things, from which the immediate objects of observation 
 derive themselves ; and, coming to his work of observation with 
 that previous knowledge, he is able to make observation itself 
 go as far again as it would go alone. 
 
 The fever, the cough, the sputa, the laborious breathing, the 
 wasting of the flesh — these are the immediate objects of clinical 
 observation, and they at all times intimated fearful things to 
 the physician of old, concerning diseases of the lungs. But 
 effusions and congestions, and softening and hardening, and 
 tubercles and vomicae — these are the real things from which the 
 fever, the cough, the sputa, the laborious breathing, and the 
 wasting of the flesh, all derive themselves ; and the physician 
 now knows them all, and what they are in their origin, in their 
 progress, in their termination, and which are capable of repa- 
 ration and which are not ; and, knowing what they are, he has 
 taxed his observation for the detection of them in the living 
 man ; and, having detected them, he has further taxed his skill 
 for a more exact application of remedies for their cure. And 
 unquestionably he has often succeeded, both in detecting and 
 curing, by the aids of this knowledge, what would have gone 
 
52 SUBJECTS CONNECTED WITH [LECT. III. 
 
 undetected and uncured if he had still worked by clinical obser- 
 vation alone. 
 
 Every day I go round the wards with you, I talk of things 
 which must be quite unintelligible, if you are ignorant of 
 morbid processes. There are forms of symptoms I am per- 
 petually pointing out, which cannot be estimated except in their 
 exact connexion with certain forms of disease previously under- 
 stood. All the principal changes of structure which the lungs 
 or the heart are capable of undergoing, must be well understood 
 before you can appreciate any of the signs derived from 
 auscultation or percussion. You may listen to the chest for 
 ever and be no wiser, if you do not previously know what it is 
 you are to hear. You may beat the chest for ever, and all in 
 vain, unless you know what it is that is capable of rendering it 
 now dull and now resonant. 
 
 The aid derived to practice from a knowledge of the means 
 and agencies by which the disease is carried on is not always 
 the same ; but still there are few cases in which it does not 
 contribute either to enlarge, or refine, or verify our observa- 
 tion, and to direct our treatment with a surer aim. 
 
 But this knowledge is not to be learned only in the wards 
 of a hospital, or in any one particular way. The sources of 
 it are various, and so too are the methods of obtaining it: 
 lectures, books, museums, dissecting rooms, and experiments 
 upon the living or the dead body. It is conversant for the 
 most part with demonstrable objects, which are capable of 
 being measured, and weighed, and delineated. It is beginning 
 to take the form of a science, and to be governed by certain 
 rules. 
 
 In as many places, then, and in as many ways as it is 
 capable of being learned, you are at liberty to learn it. 
 
 And, howsoever and wheresoever you learn it, you must 
 bring it with you into the wards of the hospital ; and your 
 observation will there breathe a spirit into it and apply it to 
 its proper use. 
 
 Thus an acquaintance with the means and agencies by 
 which disease is carried on will give greater effect and 
 certainty to clinical observation, each testing and confirming 
 the truths of the other, and both working together to the same 
 end, and producing a purer diagnosis and a safer treatment. 
 
LECT. III.] CLINICAL MEDICINE. 53 
 
 Such are the things which I have now called 'you together 
 to communicate ; and, simple as they really are, they have cost 
 me some thought ; and it is with some feeling of responsibility 
 that I offer them, when I reflect that the advice which I am 
 giving you now, at the entrance of your practical studies, 
 according as it is good or bad, may lead or mislead you for 
 life. 
 
 It is a matter of no trifling concern to the well-disposed 
 student, that he should be put in the right way of using his 
 own observation, and that he should be well aware of all the 
 means which are calculated to aid or hinder him in his task. 
 
 With respect to the taking of cases, which is one chief 
 mode in which the observation is exercised, I have advised 
 that the student should not begin to take them too early, and 
 before he has got a clear notion of the great cardinal symptoms 
 which are the guides to diagnosis and treatment : yet that he 
 should not begin to take them too late ; that, after he under- 
 stands the import of symptoms, he should not allow his mind 
 to rest too long in the abstract contemplation of them, but 
 apply his knowledge to its use and exercise upon particular 
 instances. 
 
 With respect to books, which are the chief aids or the chief 
 hindrances to clinical observation, I have told him what he 
 must read with caution, and what he must not read at all; 
 what he cannot read now without an injurious bias, but may 
 read hereafter with profit ; and what he may read now without 
 harm, but hereafter with more certain advantage. But, of all 
 books and all studies, those, I have told him, are best calcu- 
 lated to promote the business of clinical observation which are 
 especially conversant with the nature of morbid processes. 
 
 Medicine thus pursued begins to assume the form of a 
 science. We call it pathology. 
 
 Now pathology is a study for your whole life. But it must 
 be begun here, and it is important that it should be begun in 
 the right way ; arid I am interested in seeing that it is so, 
 because every right notion of pathology will be a great assist- 
 ance to you in the acquisition of that knowledge which is to be 
 gained in the wards of the hospital, and every wrong notion 
 a serious hindrance. 
 
54 
 
 SUBJECTS CONNECTED WITH [LECT. IV. 
 
 LECTURE IV. 
 
 PATHOLOGY. WHAT ARE ITS ELEMENTS. HOW ANATOMY CON- 
 TRIBUTES TOWARDS IT HOW CHEMISTRY HOW EXPERIMENT 
 
 HOW CLINICAL OBSERVATION. ILLUSTRATIVE INSTANCES 
 
 IN ACUTE INFLAMMATION OF THE LARYNX IN DISORDERED 
 
 CONDITIONS OF THE URINE OF THE BLOOD. — DR. PROUT 
 
 DR. STEVENS. THE KNOWLEDGE OF LOCAL MORBID PROCESSES 
 
 ONE ELEMENT OF PATHOLOGY. INFLAMMATION. ITS VAST 
 
 EXTENT AS AN OBJECT OF INQUIRY. ITS GENERAL LAWS. — 
 
 ITS MODIFICATIONS IN DIFFERENT STRUCTURES. — SPECIFIC 
 DISEASES. SCROFULA. CANCER, ETC. DROPSY. SPONTA- 
 NEOUS HAEMORRHAGE. SURGERY PROPERLY INTRODUCTORY 
 
 TO MEDICINE IN THE ORDER OF PURSUIT. A RECOMMENDA- 
 TION TO STUDY DISEASES OF THE EYE. 
 
 What is pathology? It would seem to imply whatever, either 
 of discourse or reasoning, has any reference to diseases. But 
 this is much too large and loose an acceptation ; yet I cannot 
 determine the exact compass of its meaning, so as to bring it 
 within the limits of a definition. 
 
 For popular uses it is often well to lean to the popular 
 sense ; and the popular sense regards pathology as conversant 
 with explaining the phenomena of diseases, not merely with 
 observing them. This is just an intimation of the truth. But 
 we must take a nearer view of the matter, and guard against 
 any mode of expression which may betray us into error at our 
 setting out. 
 
 True it is that pathology is " conversant with explaining the 
 phenomena of diseases, not merely with observing them." But 
 it is also true that, without observation of the living body, 
 there can be no pathology. Observation needs certain helps to 
 give it a pathological aim ; but these are only subordinate ; 
 and it still belongs to observation to concentre all that they are 
 capable of teaching in the real knowledge of disease. 
 
LECT. IV.] CLINICAL MEDICINE. 55 
 
 This should be clearly understood. Observation, working 
 by itself, was able to win from the waste a large field, and to 
 bring it into cultivation, and to reap from it a wonderful har- 
 vest. But the cultivation was expended upon the surface, and 
 did not go deep enough into the soil. 
 
 When anatomy betook itself to investigate morbid struc- 
 tures, and chemistry to analyse morbid fluids, and experiments 
 of various kinds upon the animal body pushed their researches 
 in their several ways, a number of new facts were brought to 
 light ; and diligent men made an inventory of them, and 
 clear-sighted men gave them an order and arrangement. But 
 neither was this pathology. 
 
 The truth is, that not one of these, taken separately, can 
 arrogate to itself the name and character of pathological ; but 
 all taken together, and brought within the sphere of mutual 
 illustration, furnish the full amount of our knowledge concern- 
 ing the nature of diseases. Therefore, whatever is learned by 
 dissection, concerning forms and structures ; whatever by 
 chemistry, concerning elementary constituents ; whatever by 
 experiment, concerning the appearance and behaviour of parts 
 and organs, under any new conditions in which they are arti- 
 ficially placed ; and, finally, whatever is learned concerning the 
 actings and sufferings of disease in the living man ; all these, 
 in their sum and aggregate, must be deemed to constitute one 
 pathology. 
 
 Sow, believe me, you are never more engaged in studies 
 strictly pathological than when you are busied about the sick 
 in the wards of the hospital ; when you are observing external 
 signs, indeed, but seeking to penetrate beyond them, and 
 endeavouring, through them, to come at the actual procedure 
 of the disease itself. And believe me, also, that you are never 
 less employed in pathological studies than when you are dissect- 
 ing, or analysing, or experimenting, if the facts thereby 
 adduced are suffered by you to remain inert and useless, and 
 dead, and are not delivered over to the observation, that it may 
 turn them to good account. 
 
 Anatomy, and chemistry, and experiment, by their own 
 authentic facts, are most necessary guides and safeguards to 
 the knowledge of disease by observation of the living body. 
 But these have not so much enabled observation to enlarge 
 
56 SUBJECTS CONNECTED WITH [LECT. IV. 
 
 its proper territory, as to penetrate deeper into the same 
 soil. 
 
 I have seen a man, young, and full of flesh, and with the 
 form and plumpness of health, laid out dead. And I have 
 scrutinized all his organs thoroughly and carefully ; and all 
 were healthy and perfect, save the margin of that little chink 
 which conducts to the larynx. And here there was a slight 
 swelling, partly of the membrane which invests it, and partly 
 of the cellular substance beneath ; but there was no ulceration, 
 no breach of surface. 
 
 And could this occasion death ? Why, there was hardly a 
 perceptible narrowing of the passage. And could this, I say, 
 produce death? Yes! indeed could it. Truly this little 
 swelling is a mighty disease. In two short days it had subdued 
 and annihilated this very man. Not all the force of remedies, 
 or all the vigour of his own frame, could save him. I had seen 
 him with all his might fighting for breath, but in vain, for he 
 died strangled. 
 
 But whence do we chiefly learn the pathology of this 
 disease ? In the corpse, or in the living man ? Why did the 
 little lymph and serum here effused become a fatal mischief? 
 The corpse did not, and could not, tell us. For anything it dis- 
 closed, he might still have lived; for after death the glottis 
 was open, and air was made to pass freely through it to the 
 lungs. 
 
 But what the corpse could not teach, the acting and suffer- 
 ing of .the living man declared intelligibly enough. He spoke, 
 and coughed, and breathed hardly and convulsively, and in an 
 agony, and with a loud scream, or croupy noise ; and he could 
 not swallow. At length, voice, and cough, and breath, were 
 all suppressed, and he died. 
 
 After death the glottis was open ; but what was its state 
 during life ? Unquestionably it was greatly narrowed, or 
 nearly closed ; all that the patient did or suffered gave proof of 
 the fact. 
 
 But what can narrow the glottis, if it be not narrowed 
 mechanically ? Surely nothing but the vital action of its own 
 muscles. 
 
 Behold, then, the whole pathology of the disease ! Those 
 tiny muscles, which move the arytenoid cartilages and the vocal 
 
LECT. IV.] CLINICAL MEDICINE. 57 
 
 cords, could not bear the contiguity of the disease of the mucous 
 membrane. It irritated them into a mighty spasm, which no 
 effort of the will, no struggle of the whole body, could arrest or 
 control ; and, acting beyond their natural sphere, they dragged 
 into a forced approximation every part which they could move, 
 and nearly closed the glottis. 
 
 Here is a disease of which the pathology is complete, and so 
 clearly and intelligibly made out by dissection of the dead and 
 observation of the living body, that it would not be difficult to 
 assign exactly how much is due to one and how much to the 
 other. The material change of structure, in its kind, its seat, 
 and extent, is disclosed by dissection after death. This is the 
 point of departure for the whole disease, and small enough it 
 seems. But the disease, in all its magnitude and terror, and 
 the very means and agents of its peril and fatality, become 
 known by observation of the living body. 
 
 It is useful sometimes thus to analyse the sources of our 
 knowledge, that we may apply to the same in fuller confidence 
 when we desire its increase. 
 
 But I have not done with this beautiful instance, which has 
 exhibited a perfect piece of pathology, as the conjoint work of 
 clinical observation and of dissection. I will still make use of 
 the same instance — this acute inflammation of the larynx, — in 
 order further to exhibit to you how pathology can add new 
 and wonderful resources to practical medicine. 
 
 As I was going round the hospital one morning, a dying 
 woman was carried in and laid upon a bed. What a frightful 
 picture she was ! Cold, and livid, and pulseless ; her eyes 
 starting from their sockets ; her mouth wide open, and lips, 
 and tongue, and teeth, black with sordes ; and breathing con- 
 vulsively, and with a kind of scream. With what agony she 
 struggled for life ! and what force she used to preserve it ! 
 Tossing about her arms, striking aside all who came near, 
 for they kept the air from her ; and dashing away a cup of 
 water that was offered, for she knew a single drop would 
 suffocate her. 
 
 What was to be done ? All I could learn was that a few 
 days ago the woman was well. She got wet ; and in conse- 
 quence she had sore throat and hoarseness. She had been 
 bled, without relief. Symptom after symptom arose rapidly 
 
58 SUBJECTS CONNECTED WITH [LECT. IV. 
 
 and uncontrollably, until they reached their present awful 
 consummation. 
 
 This was quite enough to know. I ordered her trachea to 
 be opened. Mr. Earle was at hand, and did the operation at 
 once. The relief was complete, and she sank into a calm 
 slumber. 
 
 For two weeks she breathed through the wound entirely ; 
 then partly through the wound, as it began to heal, and 
 partly through the glottis, her voice beginning gradually to 
 return. At the end of three weeks she breathed entirely 
 through the glottis, and in six weeks she was discharged well. 
 I have twice since, at distant intervals, met her in the street, 
 and she has recognised me with a smile. 
 
 Now, do you ask what it was that called for the use o£ 
 this extraordinary measure, and what was the manner of its 
 success? Revert to the pathology of the disease, and you 
 will see. 
 
 The disease was acute inflammation of the glottis. But 
 dissection finds nothing in inflammation of the glottis which is 
 peculiar. Dissection does not discover why it is not just as 
 curable as inflammation of any other organ. But recollect, 
 not more than half its pathology can be learned by dissection. 
 For the rest, we look to clinical observation ; and clinical 
 observation teaches, that all that is peculiar and intractable 
 in inflammation of the glottis is derived, not from its own 
 nature, but from the part it occupies. In its own nature it is 
 as curable as inflammation of any other part ; but the glottis, 
 from its essential irritability, will not suffer inflammation to 
 abide upon it long enough to go through the process of a cure. 
 The muscles of the larynx, if they .must act, will now act 
 convulsively ; and act they must ; for the larynx is an organ 
 of perpetual and vital use, and in that use the muscles are 
 engaged. 
 
 Hence the necessity of placing this organ under some 
 artificial condition, which would enable the constitution to 
 dispense with its use for a time. This is effected by opening 
 a new passage for air through the trachea into the lungs, 
 whereby the larynx is left at rest, and its inflammation 
 brought within the same possibility of cure as that of other 
 parts. 
 
LECT. IV.] CLINICAL MEDICINE. 59 
 
 Thus we have seen how clinical observation, guided by a 
 well ascertained anatomical fact, was able to concentre a com- 
 plicated series of morbid actions and sufferings in one point, 
 and arrive at a consistent pathological result. And we have 
 seen, also, how that result, leading to a new and successful 
 method of treatment, obtained thereby the best confirmation of 
 its truth. 
 
 In like manner, chemistry, by giving the aid of its au- 
 thentic facts to clinical observation, has led the way to large 
 and consistent views of pathology, which alone it could not 
 have enabled us to reach. In the hands of Dr. Prout, chemistry 
 has become a key to pathology. As a chemist, he has pushed 
 the analysis of the constituents of unhealthy urine much 
 further than his predecessors. As a physician, he has turned 
 both their discoveries and his own more largely and success- 
 fully to the uses of pathology. While he has given his own 
 peculiar skill and genius to the work of chemical analysis, he 
 has still adhered closely to clinical observation ; and thus he 
 has detected, in the disordered actions of different parts, and of 
 the constitution at large, a manifest pathological alliance with 
 the morbid products of the kidneys. 
 
 Head his chapters, especially upon " The Lithic Acid 
 Diathesis," and upon " The Phosphatic or Earthy Diathesis," 
 and you will see, not only how the characteristic constituents 
 of the urine in the one are opposed to those in the other, but 
 that the lithates have a peculiar kind of constitution to which 
 they are allied, and peculiar forms of disease with which they 
 are apt to be accompanied ; and so have the earthy phosphates ; 
 and that these are as much contrasted with each other as the 
 characteristic constituents of the urine itself. 
 
 I recommend Dr. Prcut's book upon Diseases of the Urinary. 
 Organs to you, for the sake of the important information which 
 it contains ; and, moreover, as the best specimen of that method 
 of philosophizing which medicine requires and admits. For if 
 we consider the peculiar place which medicine holds as a de- 
 partment of knowledge, and how many things may be made to 
 bear upon it which seem hardly to belong to it, no work can be 
 too much prized which will teach us how to reason upon me- 
 dical subjects, and especially how to unite the conclusions of 
 any demonstrative experiment with the results of clinical 
 
60 SUBJECTS CONNECTED WITH [LECT. IV. 
 
 observation, so as to render them both subservient to an ex- 
 planation of diseases. 
 
 When we speak most modestly of medicine, we call it nothing 
 more than a conjectural art. But this conjectural art so closely 
 borders upon the neighbourhood of the sciences, and draws so 
 much from their principles and discoveries, that we may be 
 pardoned for sometimes calling it, and even believing it to be, 
 itself a science. 
 
 Dr. Stevens, by experiment as a chemist, found that there 
 was a condition of the blood in which it lost its due proportion 
 of water, and its due proportion of neutral salts, especially 
 common salt. And Dr. Stevens, by observation as a physician, 
 learned that this condition of the blood was associated with the 
 malignant symptoms of yellow fever. The contemplation of 
 these facts led his mind to the employment of a new practice, 
 the object of which was to give back its defective ingredients 
 to the blood by the administration of salt and water ; and thus 
 he succeeded in curing an enormous proportion of those who, 
 by any other method of treatment previously known, would 
 have been thought incurable. 
 
 Here chemical experiment and clinical observation, leading 
 (as it were) each other by the hand, proceed together, and 
 arrive at the seminal principle of the disease. Passing by this 
 organ and that, and this function and that secretion, they pene- 
 trate to the spring and source of all, even to the blood itself, 
 and there they find it, and apply a remedy which is able to 
 reach it there. 
 
 Truly these things are calculated forcibly to arrest the 
 attention of every philosophical physician. Are we upon the 
 verge of a great pathological discovery? "We know how much 
 belongs in common to all diseases called febrile. Dare we pre- 
 sage that the worst, and hitherto most fatal symptoms of all 
 fevers, will soon be shown to have one origin ? that a pravity, 
 or deficiency in the constituents of the blood, is the cause? 
 that this is demonstrable? and that it is remediable by the 
 simplest means, which are always at hand ? 
 
 Thus far I have endeavoured, by suitable instances, to show 
 you the elements of pathological knowledge in actual operation, 
 and how they work their way to the rational explication of the 
 disease, and to the successful remedy. 
 
LECT. IV. J CLINICAL MEDICINE. 61 
 
 But these elements must be possessed before they can be 
 used. And, besides -what results from clinical observation, 
 which is one element, there are others which, you have seen, 
 are supplied by anatomy, and chemistry, and experiment ; and 
 by these means you must acquire them, or by the instruction of 
 those who already understand them. 
 
 I must presume that you are already tolerably acquainted 
 with the structure and functions of the body in its healthy 
 state; for otherwise you have a slender chance of compre- 
 hending its diseased conditions. The same blood-vessels, the 
 same absorbents, and the same nerves, which are the agents of 
 health, are also the agents of disease. The blood-vessels supply 
 the pabulum by which the whole body and all its parts live and 
 grow and perform their natural functions, and the blood-vessels 
 also supply the pabulum from which every morbid structure 
 and every morbid secretion is furnished and maintained. The 
 absorbents bring in from without whatever is capable of assi- 
 milation and conversion into blood; and thus furnishing the 
 materials by which the blood itself lives, they become, in the 
 first and highest sense, the very springs and fountains of the 
 body's nourishment. But the absorbents, which have assigned 
 to them the process of ulceration in all its degrees and extent, 
 become also, in an especial manner, the instruments of the 
 body's destruction. The nerves impart pleasure, and the nerves 
 impart pain. They regulate motion according to the will, and 
 they withdraw, it from the dominion of the will, rendering it 
 convulsive and disorderly. Thus are the conditions of health 
 made to give place to the conditions of disease by the instru- 
 mentality of the same agents, but by other modes of action. 
 
 You must seek to understand these things. As soon as you 
 enter upon the business of clinical observation, you must have 
 some right conception of them, if you would observe usefully; 
 and ever afterwards, while your practical experience increases, 
 you must take care that your knowledge of morbid actions 
 keeps pace with it ; that as your views become enlarged, they 
 may be still precise, still pathological. 
 
 A discouragement often attends the first inquiry into morbid 
 actions, from a belief that they are, in their very nature, so 
 irregular that no clear notion can be obtained concerning them. 
 But, although morbid actions, in comparison with healthy 
 
62 SUBJECTS CONNECTED WITH [LECT. IV. 
 
 ones, may be called irregular, they are not irregular in them- 
 selves, but capable of being reduced to laws, and conversant 
 with principles. 
 
 For this reason, your inquiry into the nature of morbid 
 processes should be careful and wary at every step. For here, 
 if anywhere in the whole range of your professional studies, you 
 must clearly understand each particular as you proceed, until 
 you reach the point at which you discern the proof of a general 
 law, and from that point you will advance rapidly and agree- 
 ably into a larger field. 
 
 Now the study of morbid processes begins with inflammation. 
 And even popular opinion has learned to associate many por- 
 tentous things with the notion of inflammation. And justly, 
 because the world finds us perpetually talking about it, and 
 perpetually dreading it. Practically, inflammation is never 
 absent from the minds of medical men. Wherever an organ 
 labours, wherever there is pain, the first practical question 
 which we seek to determine is, whether there be inflammation 
 present. 
 
 Inflammation is unquestionably the most capacious of all 
 medical subjects; and fortunately it is that to which the best 
 minds of our profession have been especially directed; and, 
 more fortunately still, which they have best succeeded in illus- 
 trating. We are, therefore, sure of the best guides to assist us 
 in the knowledge of it. 
 
 And since the knowledge of inflammation consists in great 
 part of demonstrable facts, it is the more valuable on account of 
 its certainty. And, moreover, since it is in a peculiar manner 
 fundamental of almost all other knowledge in pathology, it is 
 manifestly indispensable. 
 
 You must study inflammation as if it were a subject of rigid 
 philosophy, carefully and patiently, and with the purpose of 
 understanding every stage and step of it as you go along. 
 
 In inflammation there are numerous processes included; 
 these may either be considered as parts and parcels of one in- 
 flammation, or some only as properly constituting the inflam- 
 mation, and the rest as its products or consequences. 
 
 There is the vascularity, in which the blood-vessels act an 
 important part within themselves prior to any change in the 
 condition of parts without. 
 
LECT. IV.] CLINICAL MEDICINE. 63 
 
 There is the effusion, in which the contents of the blood- 
 vessels escape into the surrounding textures ; these are serum, 
 or lymph, or hlood. 
 
 There is the suppuration, in which a new and peculiar fluid 
 is formed. 
 
 And, coincident with these processes, there are adhesion, 
 ulceration, granulation, gangrene. Of which some are destruc- 
 tive and some reparatory. 
 
 Now the several processes have their own physical con- 
 ditions, which separate them from each other. And thus they 
 require a separate study ; by which you may know the very 
 channels and agents of each according to its kind, and what the 
 arteries, what the veins, what the absorbents do, and what the 
 nerves. , 
 
 But there is nevertheless a strict physical alliance between 
 them ; and, therefore, they must also be studied collectively. 
 One does not merely precede the other, but naturally conduces 
 to it ; another does not merely follow, but naturally germinates 
 from, its antecedent. 
 
 But there is no such thing as inflammation in the abstract. 
 It must belong to some part or structure. Yet, as soon as you 
 begin to contemplate it in one structure, you must not imagine 
 that you are to find it in all other structures strictly the same. 
 It is the same in kind ; but it has different forms and modifi- 
 cations, according to the part it occupies. You may first studv 
 inflammation in the subcutaneous cellular membrane. I would 
 advise you to do so, because here it exhibits the plainest example 
 of itself, and all the processes which it includes here display 
 themselves prominently and in a regular succession. But beware 
 of calculating the progress of inflammation in the brain, the 
 lungs, or the spleen, by what you have seen of it in the subcu- 
 taneous cellular membrane. What in this case is the com- 
 monest process of inflammation, viz. suppuration and abscess, 
 those organs very seldom admit. 
 
 Some or other of the processes enumerated occur in all 
 organized tissues, whenever they are inflamed. But different 
 organs are more ready (if I may so say) to accept this and to 
 refuse that, as they are induced by peculiarities of their own 
 structure. Perhaps there are no two organs of the body which 
 exhibit inflammation under exactly the same aspect, and the 
 
64 SUBJECTS CONNECTED WITH [LECT. IV. 
 
 variety is owing (as far as we know) either to the different 
 tissues of which they are composed, or to a different arrange- 
 ment of the same tissues. 
 
 Consider, then, that concerning inflammation you have two 
 great objects of inquiry. The first embraces what it is in itself, 
 the rationale of its several processes, and the general laws which 
 govern it, wheresoever it is found. The next embraces what it 
 is under all the modifications with which it is capable of being 
 impressed by the various structures and organs which it 
 occupies, its general laws still remaining inviolate — what it is 
 in the brain and spinal marrow, in the lungs and in the heart, 
 in the liver and spleen, in the complex structure of the joints, 
 in every coat of an artery, in every vestment and membrane of 
 the eye, and in the walls and marrow of the bones. 
 
 But this immense subject of inflammation, in all its details, 
 surely cannot be mastered by the student during the brief period 
 of his pupilage. Nevertheless he may make his entrance upon 
 it, and may proceed so far in it as to reach some just conception 
 of its general laws. Besides, now is the time when he has 
 peculiar helps at hand which will enable him to prosecute the 
 inquiry in the right way. What these helps are, I will tell you 
 presently. 
 
 Thus the knowledge of inflammation may be regarded as the 
 groundwork of all pathology. It is the commonest as well as 
 the most comprehensive of morbid actions. I call it common, 
 because it seems to arise inevitably in every man and in any 
 part of the body under certain circumstances ; you may even 
 produce it at will. 
 
 Besides inflammation, there are other morbid actions, the 
 processes and products of which require your study. These are 
 not common, in the sense which has been just explained. 
 Scrofula, or cancer, or fungus, or hydatid cysts, cannot be pro- 
 duced at will ; neither are they incident to all bodies ; neither 
 do they inevitably result from any known conditions. These 
 diseases are called specific, as contradistinguished from inflam- 
 mation, which is common. 
 
 Concerning specific diseases, we have not the same amount 
 or the same certainty of knowledge that we have concerning 
 inflammation. "We have a large inventory of facts, but not a 
 clear insight into the general laws which influence their pro- 
 
LECT. IV.] CLINICAL MEDICINE. 65 
 
 duction ; and knowledge, as long as it falls short of this, is still 
 uncertain and precarious. 
 
 Besides these, there are certain other diseases which require 
 to be studied in the very processes out of which they arise. 
 They are not so mysterious as specific diseases, and yet not so 
 common, or so well understood, as inflammation. Many 
 conditions of their production we profess to be acquainted with ; 
 but still we cannot produce them at will. Dropsies and 
 haemorrhages are of the class I mean. Each of them is a very 
 large subject. 
 
 I have been speaking of all these diseases — of inflammation, 
 and dropsies, and haemorrhages, of scrofula, cancer, &c. — as 
 local; that is, as having a place and locality in which the 
 special morbid processes of each are carried on; for it is to such 
 processes that I desire now to direct your attention, the know- 
 ledge of them being one of the elements of pathological medicine. 
 
 Not that each has not more belonging to it than its local 
 process which deserves inquiry — some disorder of parts remote, 
 or of the general system, out of which it may primarily arise. 
 But, however this may be, they none of them, whether inflam- 
 mation, or dropsy, or haemorrhage, or scrofula, or cancer, have 
 any demonstrable existence, until they declare themselves by 
 modes of action and modes of suffering, in the part, which are 
 beside the uses and conditions of health ; by something added 
 to, or something deducted from, or some change wrought upon, 
 its constituent structures. 
 
 Now I have told you, that, during your pupilage, and at 
 this hospital, you have peculiar helps, enabling you to make 
 a successful beginning in this element of pathology, the know- 
 ledge of local morbid processes. You have lectures both medical 
 and surgical. Of surgical lectures, a large portion is always 
 occupied in describing and explaining the processes of inflam- 
 mation, and in illustrating them as the results of injury, or 
 accident, or disease, in parts and organs which fall within the 
 special province of the surgeon. The medical lectures, also, are 
 largely explanatory of inflammation, what course it takes, and 
 what termination it has in different internal organs ; how this 
 course and termination vary in serous, in mucous, and in fibrous 
 membranes; how in the pleura, the pericardium, and the 
 peritoneum, they are of one sort ; in the lining of the trachea 
 
66 SUBJECTS CONNECTED WITH [LECT. IV. 
 
 and bronchi, stomach and bowels, bladder and urethra, of 
 another ; and still of another in the dura mater and pericranium ; 
 and how each circumscribed viscus of the body shapes and 
 qualifies its inflammation in its own manner, and to a par- 
 ticular end. 
 
 Concerning dropsies, besides their remote cause, medical 
 lectures dwell upon their cause in the part, or the very process 
 of the effusion ; and show why one organ or structure should 
 more readily accept it than another. 
 
 The subject of haemorrhage — I mean that haemorrhage 
 which is independent of injury or accident from without — is 
 laid before you in the same lectures ; and the process of its 
 production shown, as it occurs in the brain, in the bronchi and 
 lungs, in the stomach and bowels, in the kidneys, bladder, 
 and uterus. 
 
 Of specific diseases, take cancer and scrofula as examples 
 from among many which bear different names, and are formed 
 (perhaps) by different processes. These are diseases with which 
 •both medicine and surgery are equally concerned ; and the 
 teachers of each have most curious and interesting information 
 to give respecting their growth, by a well-defined succession of 
 morbid processes. Of cancer, the female breast and uterus, and 
 the stomach, are the most frequent seats, while hardly any part 
 is exempt from a liability to it. Of scrofula all parts are the 
 seat. It is enough to say, that it is the essence of that all- 
 pervading disease, pulmonary consumption, in order to engage 
 every one who intends to practise physic in the endeavour to 
 learn all that is known about it. 
 
 Concerning these several orders of disease, inflammation, 
 dropsy, and hsemorrhage, and specific complaints such as cancer 
 and scrofula, let me further add, that, besides the study of each 
 as it is in itself, in its own morbid process, there is a study of 
 them also in combination, which belongs to the knowledge of 
 pathology ; for they occur as frequently in combination as alone, 
 one process running into another, or one process exciting other 
 processes all around it. Thus inflammation will run into dropsy 
 or haemorrhage ; and it will be so blended with scrofula, as to 
 be called scrofulous inflammation. Cancer can hardly reach its 
 fatal consummation without inflammation and haemorrhage ; 
 and scrofulous tubercles of the lungs often excite at the same 
 
LECT. IV.] CLINICAL MEDICINE. 67 
 
 time inflammation of the surrounding pulmonary structure, 
 haemorrhage from the bronchi, and dropsy into the cavity of 
 the pleura. 
 
 You really must have some correct notion concerning all 
 these things before you can derive the profit which you ought 
 from clinical observation; and, as I know you cannot go through 
 a laborious investigation of them at present in all their accurate 
 detail, I must refer you to the sources of information nearest at 
 hand. I must advise you, for you have all attended medical, 
 and most of you surgical, lectures, and have taken and preserved 
 your own notes of them, — I must advise you, to review all those 
 parts of such lectures which expressly treat of morbid processes. 
 Those of you who are already conversant with surgical practice 
 will do well constantly to bear in mind what you have seen 
 upon the exterior of the body. You will find it of daily use in 
 every medical case you observe. Processes of disease within 
 and without the body are of the same essence. Their forms 
 only are influenced by structure, and are different in diffe- 
 rent parts. 
 
 Unquestionably, there is no better introduction to the 
 practice of physic than the practice of surgery. It is a course 
 which I strenuously recommend to all those who have time to 
 carry it into effect. The best and most highly instructed men 
 feel the necessity of it, and do not shrink from it. I believe I 
 am correct in saying, that of men educated at the universities, 
 and then resorting to St. Bartholomew's Hospital with the view 
 of becoming physicians, during the last sixteen years, there has 
 hardly been an individual who has not gone through the entire 
 business of a surgeon ; not as a mere looker-on, but as a dresser, 
 for as long a period as if he was to practise surgery all his life. 
 I mention it to their honour ; for an admirable race of physicians 
 has been produced by this system. Thus it has become the 
 established practice here for all who intend to be physicians to 
 begin with surgery. Professor Haviland of Cambridge first 
 brought the practice into fashion by his judicious advice to all 
 within the sphere of his influence ; and I have done all in my 
 power to second the recommendation of my excellent friend. 
 The benefit consists mainly in this, that it makes you familiar 
 with the visible processes of disease and reparation while they 
 are actually going on. 
 
68 SUBJECTS CONNECTED WITH [LECT. IV. 
 
 There is yet another recommendation which I would offer 
 to you ; and let it not seem a strange one, whether you are to 
 be physicians or surgeons. If you desire to make pathological 
 knowledge the groundwork of your credit and usefulness 
 through life, let me advise you not to allow the period of your 
 pupilage to pass by without making a special study of the 
 diseases of the eye. Here you see almost all diseases in minia- 
 ture ; and, from the peculiar structure of the eye, you see them 
 as through a glass ; and you learn many of the little wonderful 
 details in the nature of morbid processes, which, but for the 
 observation of them in the eye, would not have been known at 
 all. Let every one of you who has a few months to spare give 
 them to the Eye Infirmary. 
 
 Wow, after what has been stated, you will perhaps be ready 
 to ask me, Whether it be indeed true, that all this sort of 
 knowledge is required to fit a man to practise physic ? and I 
 will answer you honestly, That it is not required. Many a 
 clever man practises physic with tolerable success, who has 
 never troubled his head about morbid processes, and who has 
 not the remotest notion how those things come to pass which he 
 has been witnessing, in their effects or their symptoms, all the 
 days of his life. A man may practise physic without it, but 
 he cannot be a first-rate practitioner without it. In the treat- 
 ment of diseases we often minister to the symptoms, and the 
 symptoms only ; but, in the treatment of diseases, we often 
 minister partly to the symptoms, and partly to the very pro- 
 cesses of the diseases themselves. This he only can do who 
 knows what they are. Believe me, he who would be a first- 
 rate practitioner must lay his foundations broad and deep in the 
 knowledge of morbid processes ; otherwise, although he may 
 sometimes prognosticate truly concerning life and death, he can 
 never give an accurate diagnosis concerning the nature of 
 diseases of which he can understand nothing. Above all, he 
 must never hope to benefit mankind by advancing the know- 
 ledge of his profession a single step. 
 
LECT. V.] CLINICAL MEDICINE. 69 
 
 LECTUEE V. 
 
 ON THE PROPER OBJECTS OF MEDICAL INVESTIGATION. — WHAT 
 MEDICAL FACTS ARE, AND WHAT THEY ARE NOT. — THE OBSERVA- 
 TION AND COLLECTION OF FACTS. — THEIR ARRANGEMENT, AC- 
 CORDING TO ANALOGY OR RESEMBLANCE — ACCORDING TO THE 
 RELATION OF CAUSE AND EFFECT. — WHAT IS MEANT BY THE 
 RELATION OF CAUSE AND EFFECT BETWEEN MEDICAL FACTS. — 
 PECULIAR DIFFICULTIES IN THE WAY OF ASCERTAINING THAT 
 RELATION. — THE TASK OF ASCERTAINING IT NECESSARY TO OUR 
 KNOWLEDGE OF THE SOURCES OF DISEASE — OF THE INFLUENCE 
 OF REMEDIES — AND OF THE CONNEXION BETWEEN THE DISEASE 
 AND ITS SYMPTOMS. — THE SOURCES OF DISEASE, HOW EASILY 
 AND QUICKLY ASCERTAINED IN SOME INSTANCES— HOW TAR- 
 DILY AND DIFFICULTLY IN OTHERS. — THE INFLUENCE OF 
 REMEDIES, HOW LIABLE TO DECEPTION, FROM A VICIOUS CREDU- 
 LITY ON THE ONE HAND, AND A VICIOUS INCREDULITY ON THE 
 OTHER. — THE NATURE OF GENERAL PRINCIPLES IN MEDICINE, 
 AND HOW THEY ARE REACHED. 
 
 Certain observations which I formerly made* must be con- 
 sidered to comprise the method only in which the particulars of 
 a case may be most conveniently surveyed : but more remains 
 to be considered than the mere form of case-taking. 
 
 You may adopt this mode of case-taking, or any other 
 which your own experience may make most convenient to you : 
 but no method of recording the particular facts will be of any 
 use to you, unless you have right notions concerning the facts 
 themselves. The facts, in truth, are the case ; and it is only 
 for the sake of getting sure possession of them that we adopt 
 any form of (what is technically called) case-taking. 
 
 Now the whole business of your lives will be the business 
 of taking cases ; not necessarily with pen, ink, and paper, or 
 after any technical form. But still it will be the business of 
 
 * Vide page 29. 
 
70 SUBJECTS CONNECTED WITH [LECT. V. 
 
 your lives really and essentially, and in the justest sense ; for 
 each case is made up of its own facts, and the facts alone must 
 teach you the nature of the disease, and suggest the remedy m 
 every patient you see. Therefore, as long as you live, you will 
 be evermore conversant with facts ; learning and collecting 
 them, arranging and combining and separating them, tracing 
 their relations, and through them arriving at general principles. 
 
 There are peculiar causes which will ever prevent medicine 
 from arriving at the certainty of purely physical science. But 
 in so far as it is certain, in so far as it has taken the form of a 
 science at all, it is built upon the same foundation with all other 
 sciences ; namely, upon facts : and in so far as it is uncertain, 
 beyond what, in its own nature, it ever need to have been ; in 
 so far as it has not deserved the name of a science, it is raised 
 upon a foundation which never would have been deemed suffi- 
 cient for any other department of human knowledge. 
 
 It is important, then, to the right judgment and the right 
 treatment of every individual case that we see — it is important 
 for the sake of preserving to medicine whatever claim it may 
 have to the name of a science, and (I will add) for the sake of 
 our own credit and satisfaction, that we should utterly reject all 
 other foundation of professional knowledge except matters of 
 fact. 
 
 I desire to convince you of this, by showing you, first of 
 all, what matters of fact in medicine really are, and what they 
 are not. 
 
 Every man's notion concerning any department of know- 
 ledge is the popular notion, until it is rectified by further in- 
 quiry. The popular notion concerning medicine is, that diseases 
 are separate essences, and that an idea can be formed of them 
 apart from the living being in whom they occur ; that a fever, 
 or a pleurisy, would still be something real, although there 
 were no living beings in whom they could manifest themselves. 
 
 But diseases are not abstractions; they are (I have said) 
 "modes of acting different from the ordinary and healthy 
 modes — modes of disorganizing, modes of suffering, and modes 
 of dying; and there must be a living, moving, sentient body 
 for all this." 
 
 Endeavour to understand this truth; and at the very 
 entrance of your professional studies get rid of all abstractions* 
 
LECT. V.] CLINICAL MEDICINE. 71 
 
 that you may never record them and use them (as they are and 
 have been recorded and used) as matters of fact. 
 
 You may record that this man has a hot skin, a dry tongue, 
 and a frequent pulse, and call his disease a fever ; that this man 
 has a pain in his side, difficult breathing, and a hard pulse, and 
 call his disease a pleurisy; but beware of taking this fever or 
 this pleurisy for more than they really are. The fever is 
 nothing, and the pleurisy is nothing, but the complex of the 
 several facts which you have recorded under the head of each : 
 separate from them, they are mere names. The fever has "no 
 treatment, and the pleurisy has no treatment, but what is sug- 
 gested by the facts included under each. You prescribe for the 
 hot skin, the dry tongue, and the frequent pulse, and you bring 
 back their condition to what is natural, and so cure the fever ; 
 and you prescribe for the pain in the side, the difficult breathing, 
 and the hard pulse, and so cure the pleurisy. But if, without 
 regard to the facts apparent in the individual patients, you pre- 
 tend to address your remedies to the fever itself, or the pleurisy 
 itself, you take aim at an absolute phantom. 
 
 Bear in mind, then, that abstractions are not facts; and next 
 bear in mind that opinions are not facts. To record that a 
 patient is better to-day and worse to-morrow ; that he is at one 
 time doing well and at another doing ill ; is to give a summary 
 opinion upon the facts, not the facts themselves. 
 
 I do not mean to say that such summary opinions should not 
 be formed, or that they should not be announced. We always 
 do form them, and the patient, or the patient's friends, always 
 require us to communicate them; and most justly. But to 
 ourselves, and in communication with other medical men, either 
 for the sake of marking the exact state of the disease or sug- 
 gesting the remedy, they are utterly useless. 
 
 If, in going round the wards of the hospital, I had it punc- 
 tually recorded that this, that, and the other patient had a peri- 
 tonitis, a nephritis, or a hepatitis ; and that day after day this, 
 that, and the other patient were better, worse, or just the same; 
 and if, day after day, I were to order bleeding, blistering, or 
 purging, as the case might require, and thus you were to wit- 
 ness numerous instances of recovery, you would not reap the 
 slightest benefit from me and my pretended instruction, although 
 you went round with me for a twelvemonth. For this would 
 
72 SUBJECTS CONNECTED WITH [LEGT. V. 
 
 be to keep industriously from your notice everything in tie 
 shape of a fact by which you could estimate the nature and 
 progress of the disease, or the operation and effect of the 
 remedy. 
 
 In medical science, the only materials of our knowledge are 
 those things which are referable to our sensations and percep- 
 tions : matters of fact. Such are the temperature of the skin ; 
 the number and qualities of the pulse; the quantity and 
 qualities of secretion ; functions and modes of action in the 
 several parts and organs of the body ; and all their cognizable 
 deviations from what is natural : also pain ; for although pain, 
 as to its actual occurrence in a particular case, must be taken 
 upon the testimony of the sufferer, each man's own experience 
 must some time or other have convinced him that pain is a fact. 
 
 Such, too, are the conditions of parts discoverable after 
 death; their increased or diminished bulk; the changes of 
 structure and injuries they have undergone, and the morbid 
 products to which they have given origin. These are the sort 
 of facts with which we have to do, if we would know diseases 
 and how to treat them. 
 
 Such being the materials of our knowledge, it becomes 
 important to consider how we can use them best, and abuse 
 them least ; for the materials of our knowledge require to be 
 hewn and squared, and fitted to their place, with much care, 
 and skill, and diligence; otherwise, what might have been a 
 seemly edifice may chance to be no better than a heap of 
 rubbish. 
 
 First, then, as to the simple reception of medical facts, there 
 is a good deal to be learned. 
 
 All facts are not of equal value : some are trivial and acci- 
 dental, some important and essential to the subject. In your 
 inquiries at the bedside, you will have to select and to reject 
 cautiously and discriminately. Patients themselves are apt to 
 press upon their medical attendants symptoms (generally con- 
 sisting of strange sensations) which are irrelevant to their 
 present disease. Again: in your examinations by dissection, 
 you will have to use much care, lest you should admit appear- 
 ances as indicative of disease which are accidental, or may have 
 arisen during the process of dissolution, or from the position of 
 the body after death. 
 
LECT. V.] CLINICAL MEDICINE. 73 
 
 But in this sifting and separating of facts, be cautious of 
 throwing away anything that is really valuable. Beware of 
 rejecting facts of which you do not, perhaps, comprehend the 
 import, and because you do not comprehend it; but rather 
 reject those which you do comprehend, and know them to be 
 trivial. Be careful especially of not allowing their due weight 
 to facts which appear contradictory to each other ; rather ex- 
 amine them more scrupulously because they are so. For instance, 
 a patient may have a severe pain in the side and a frightful 
 dyspnoea, and the pain and the dyspncea may have arisen sud- 
 denly. Such symptoms at once carry -with them the suspicion 
 of active inflammation, and our thoughts may immediately run 
 upon copious bleeding. But the same patient may, in the 
 meantime, have his skin cool, and his pulse soft and tranquil, 
 and jiot more frequent than the pulse of health. Cases of this 
 and of the like kind are not uncommon, in which symptoms of 
 a contrary character neutralize the import of each other, dis- 
 prove the suspected existence of a dangerous disease, and forbid 
 the needless adoption of a severe remedy 
 
 The more you exercise yourselves in the observation of medi- 
 cal facts, the more you will understand the sources of error to 
 be avoided in the reception of them. Time and diligence, and 
 constant intercourse with the sick, if you have but an impartial 
 and honest mind, will enable you to lay up a large and useful 
 store of genuine facts, and to draw from it as the treasury of 
 your future knowledge. 
 
 I say an impartial and an honest mind, because it is remark- 
 able how apt some little favourite theory is to get early posses- 
 sion of the student's imagination, rendering him dishonest 
 (perhaps unconsciously) in the simple reception of facts. It is 
 like some little favourite sin in our moral nature, which taints 
 the character of the whole man. 
 
 A premature desire to generalize, an eagerness to arrive at 
 conclusions, and a readiness to rest in them, are very common 
 infirmities, and they offer very serious hindrances to the right 
 acquisition of facts. For, if the early habit of theorizing do 
 not estrange the mind of the student from the wish to observe 
 altogether, it may so pervert the faculty itself in its very use 
 and exercise, that, be his wish what it may, he cannot observe 
 honestly. He gives an undue weight to the facts which accord 
 
74 SUBJECTS CONNECTED WITH [LECT. V. 
 
 with his assumed principle, and no weight at all to those that 
 conflict with it: habit forces him to do so, and he cannot 
 help it. 
 
 A very good and wise man has explained this matter by an 
 illustration, which is so beautiful and so true, that I must 
 recite it to you : — "A watchmaker told me that a gentleman 
 put an exquisite watch into his hands that went irregularly. 
 It was as perfect a piece of work as was ever made. He took 
 it to pieces and put it together again twenty times. No manner 
 of defect was to be discovered, and yet the watch went intoler- 
 ably. At last it struck him that the balance wheel might have 
 been near a magnet. On applying a needle to it, he found his 
 suspicions true : here was all the mischief. The steel work in 
 the other parts of the watch had a perpetual influence on its 
 motions ; and the watch went as well as possible with a new 
 wheel. If the soundest mind be magnetized by any predilection, 
 it must act irregularly."* 
 
 In the reception of facts, then, it is essential, first, that they 
 be fully ascertained — i.e. upon sufficient observation ; 2ndly, 
 that they be fairly and honestly represented, without disguise, 
 modification, or omission, to make them suit particular theories ; 
 3rdly, that they be important and essential to the subject — not 
 trivial and merely incidental to it. 
 
 Next comes the arrangement of facts. Now, facts may be 
 arranged according to certain characters of agreement observ- 
 able between them. There is an agreement of analogy, and an 
 agreement of resemblance. Analogy is a loose sort of resem- 
 blance, in which points of agreement and points of difference are 
 mixed up together. By separating twenty points in 'which 
 they differ, and retaining the two or three in which they agree, 
 multitudes of things may be brought into this loose kind of 
 resemblance and classed together. Thus, analogy is enough to 
 bring diseases together in the same nosological order, as Fevers. 
 Then, again, by calculating what individuals of the general 
 order have most points of agreement, and distinguishing them 
 accordingly, we come to divide orders into genera ; and by still 
 further selecting the individuals of the genus which have most 
 points of agreement, we find the species ; and by dealing with 
 the species in like manner, we may divide it again and again, 
 * Cecil's Remains — on judging justly. 
 
LECT. V.] CLINICAL MEDICINE. 75 
 
 until thus, from the relation of mere analogy, we reach that of 
 a tolerably strict resemblance. This is the scheme upon which 
 nosologies are constructed ; and nosologies have their use, until 
 we can arrive at something better. It is better to arrange facts 
 according to the relation of analogies and resemblances than 
 not at all. 
 
 But it is far better still, if it be possible, to arrange them 
 according to their natural sequences, i.e. according to the .rela- 
 tion of cause and effect. Now, " our knowledge of cause and 
 effect, in reference to any two particular events, is founded 
 entirely upon the observation of a uniform sequence of the 
 events ; or of the one following the other in a uniform manner 
 in a great number of instances. The greater the number of 
 instances is in which the sequence has taken place, with the 
 greater confidence do we expect it to take place again under 
 similar circumstances ; and every single instance in which it 
 does not occur weakens our confidence, unless we can discover 
 some adequate cause by which the sequence was interrupted. 
 The result of this confidence is, that when we observe the first 
 of two such events, we expect the second to follow it ; and that 
 when we observe the second, we conclude the first has preceded 
 it. The first we call cause, the second effect."* 
 
 The philosophical physician is evermore studying how, upon 
 adequate grounds, he can assign to medical facts this relation. 
 But he knows in how delicate and difficult a task he is engaged. 
 He is obliged to wait upon experience, and to attend to 
 phenomena as they happen to occur. He cannot bring them 
 together at will, and vary and transpose them as he likes, so as 
 to learn their connexion. He envies the ease with which the 
 chemist can bring any substance within the sphere and influence 
 of as many others as he pleases ; and the accuracy with which 
 he can then ascertain the degrees of affinity it bears severally to 
 each, — an accuracy so precise, that he can express them by 
 numbers. 
 
 Further : when the physician has ventured to draw such 
 
 * Abercrombie ; Intellectual Powers, 390. 
 
 Whoever is interested in following the right path of medical investiga- 
 tion, would do well to acquaint himself with that pointed out by Dr. 
 Abercrombie. I recommend his book to the careful perusal of every 
 student. 
 
76 SUBJECTS CONNECTED WITH [LECT. . 
 
 conclusions as his long observation seems to warrant, he cannot 
 test their truth by any simple experiment. He has no litmus 
 or turmeric paper to tell him whether the blood-vessels or the 
 nerves are the prime agents in producing a certain form of 
 fever ; but what his long observation seems to have taught him, 
 he must still wait for the same long observation to confirm or 
 to confute. 
 
 Unfortunately for us, the nature of medical causation is such, 
 that it takes as much time and trouble to rectify an error as to 
 establish a truth. Thus it may require the experience of one 
 man's life to arrive at some plausible theory, and the counter- 
 experience of another man's life to show that it is false. 
 
 The vast experience required to establish a uniform sequence 
 of events, and the impossibility of applying any summary test 
 to the truth of our conclusions, are difficulties inseparable from 
 the nature of medical causation. They lie at the very root of 
 the matter. 
 
 And beside these, there are others, from sources impossible 
 to enumerate, which perpetually beset and waylay our path of 
 inquiry, breaking in upon the uniform sequence of events, and 
 disappointing the best conclusions of experience. Such are the 
 influences of places, and seasons, and climates, and the wills, 
 feelings, and propensities, and all that is understood by the 
 constitution, corporeal and mental, of human beings. 
 
 But however hard the task may be, we must still try to 
 know the true relation of the things which concern the ordinary 
 practice of our profession ; we must trace the influence of external 
 agents as causes of disease ; otherwise we can do nothing for its 
 prevention. We must trace the influence of external agents as 
 remedies ; otherwise we can do nothing for its cure. We must 
 trace, too, the connexion between certain symptoms and certain 
 morbid processes going on within ; otherwise we can adopt no 
 rational treatment of individual cases. 
 
 Respecting the external causes of disease, you must make 
 them your study as opportunities may present themselves to 
 you. But there are some so important, that their investigation 
 has become of itself a department of medical education ; I mean 
 what is called " forensic medicine." And, indeed, I know no 
 department of public teaching which, if it be entrusted to good 
 hands (and I am sure it is so in this hospital), promises more 
 
LECT. V.] CLINICAL MEDICINE. 77 
 
 benefit to medical science and medical practice than this. It 
 undertakes to illustrate the modes in which injury, disease, or 
 death, arrive from those external agents or accidents that are 
 most signally hurtful to animal life; from poisons of every 
 kind ; from lightning ; from hanging and drowning ; from cor- 
 ruption of the air ; and from every method of simple violence. 
 Thus forensic medicine is conversant with all the highest points 
 of physiology and pathology ; and its very purpose requires the 
 greatest exactness in the nature and display of its proofs. It 
 requires, in truth, that they should be so made out as to be 
 obvious to such understandings as ordinary men are accustomed 
 to bring with them into a jury-box. 
 
 Here, then, is provision made, within a large and interesting 
 field, for demonstrating to you the effects of external agents as 
 the causes of disease ; aud all matters of fact. 
 
 The display of the fatal effects resulting from the causes 
 enumerated to several vital parts and organs, furnishes so many 
 demonstrations of the possible ways in which the same parts 
 and organs are capable of suffering from causes less hurtful. 
 Not long ago, poisoning was an affair of the utmost darkness 
 and mystery ; but now, the rationale of poisoning in its several 
 kinds is so well made out, that I am able to refer to it for the 
 best instances which pathology affords of cause and effect in the 
 manifest influence of external agents and accidents for the 
 production of disease. 
 
 Poisoning, and the severer injuries, are a sort of pathological 
 experiments. They produce upon this or that organ all the 
 phenomena which any conceivable disease can exhibit ; and 
 they produce them in the greatest simplicity, because the subject 
 is often previously in a state of health. Thus it is that they 
 furnish an admirable introduction to the study of what is called 
 spontaneous disease in the same organs. 
 
 Very acute inflammations arising suddenly in a healthy body 
 afford the next best instances of the effects of external agents as 
 causes of disease. I am accustomed to regard them in the light 
 of medical accidents ; for although the inflammation come from 
 no injury in the ordinary sense, yet it will generally be found 
 to have followed the exposure of the body to influences which 
 act with a kind of violence, — such as sudden changes of tempe- 
 rature, or the use of meats and drinks which, from their 
 
78 SUBJECTS CONNECTED WITH [LECT. V. 
 
 preposterous kind or quality, have become in a manner poisonous. 
 Thus, the external cause productive. of inflammation, and the 
 time of its application, are sometimes as accurately determined 
 as a fall or a blow. 
 
 In proportion as diseases are more chronic, they are, upon 
 the whole, less easily assigned to their external exciting causes. 
 With respect to them, a longer experience and inquiry are 
 needed to establish a uniform sequence of the events. If you 
 are attentive observers in the wards of this hospital, it will 
 require a brief period only to convince you that the sudden 
 impression of cold is among the undoubted causes of acute 
 inflammation in various vital organs. But you cannot know 
 that the habitual indulgence in spirituous liquors is undoubtedly 
 productive of congestion of the liver until after years of 
 experience. For the present, you must be content to take this 
 fact upon trust from the testimony of others. 
 
 The question of malaria, of contagion, and of animal poisons, 
 the certainty of their influence as causes of disease, and the mode, 
 the sphere, and condition of their operation, are all questions of 
 the highest importance, and involving facts of great interest. 
 But I would advise you not to meddle with these questions at 
 present ; for at present you can only do it speculatively : there- 
 fore it is better that you should wait until a sufficient number 
 of facts have fallen under your notice, either to enable you to' 
 form some conclusions of your own upon these subjects, or to 
 have a sound judgment of the conclusions which have been 
 formed by others. 
 
 With respect to the influence of external agents as remedies, 
 I would recommend you to be most jealously observant of every 
 circumstance connected with the treatment of individual cases. 
 A mere sequence of events is not a necessary sequence. The 
 remedy may be administered, and the disease may cease ; and 
 yet the treatment and the cure may not be cause and 
 effect. 
 
 The remedy may have been really inert, and the spontaneous 
 powers of reparation in the constitution or in the part may have 
 been enough to surmount the disease ; or the remedy may have 
 been active in the wrong direction, and the powers of reparation 
 more than enough to surmount the disease,— enough both to 
 surmount the disease and to render the remedy harmless. 
 
LECT. V.J CLINICAL MEDICINE. 79 
 
 Tour only safeguard against such deception lies in the most 
 jealous and scrupulous observation at the bedside. Turn your 
 attention, first of all, to well-marked instances of disease which 
 is acute and rapidly progressive, where the remedies must be of 
 equal force with the disease, and must operate with equal 
 rapidity, and from which, if a curative impression follows, it 
 must be a sensible impression. Watch the treatment of inflam- 
 mation in various vital organs by the different modes of 
 bleeding, by calomel, by tartar emetic, by colchicum ; and the 
 treatment of certain convulsive and painful disorders, and 
 certain forms of delirium, by opium. 
 
 Beware of mistaking the nature of the disease, and then 
 believing that the remedy has cured what in fact never existed. 
 I lately read a book in which a certain remedy was recommended 
 as infallible for diseases by dozens ; tic douloureux, ovarian 
 dropsy, disorganization of the heart, paralysis, and I don't 
 know what besides, were all cured by it. Of these diseases no 
 description was given, but only the name ; so that there was 
 not the slightest evidence that any such diseases existed as those 
 that were said to be cured. 
 
 In like manner there have been remedies for cancer, reme- 
 dies for consumption, remedies for stone, all owing their 
 reputation to the nature of the disease being mistaken. 
 
 This is "the field in which ignorance and imposture reap 
 their golden harvests. Not that it is impossible for those of 
 good intention and good information to mistake the character 
 of a disease, and so ascribe an efficacy to a remedy which is not 
 its own ; but those have the best security against this error 
 who have taken the most pains to acquire a habit of faithful 
 and jealous observation. 
 
 But there is an opposite infirmity not uncommon among 
 medical men, which is just as much to be deprecated as the easy 
 credulity of which we have been speaking, — a scepticism in 
 regard to the influence of medicine — a stubborn reluctance to 
 admit the relation of cause and effect between remedy and cure. 
 Surely it is not at all less hurtful to take up a notion that a 
 number of diseases, from their nature or seat, are beyond the 
 reach of all remedies, than to believe that any or every disease 
 that gets well after the use of any remedy is necessarily cured 
 by it. In the one case things are linked together as cause and 
 
80 SUBJECTS CONNECTED WITH [LECT. V. 
 
 effect, which bear no such relation ; and in the other, things 
 which really bear that relation are perversely dissevered. 
 
 Many men pride themselves upon this vicious scepticism, and 
 wish to be thought to exercise a philosophical caution. Yoltaire, 
 who was upon the watch for every ludicrous infirmity of human 
 character, was sharp enough to discern this in physicians, and 
 has made excellent sport of it. 
 
 He makes a physician of renown come from Memphis to 
 cure Zadig of a wound in his left eye. The physician, however, 
 affirms it to be incurable, and predicts the very day on which 
 Zadig is to lose his sight, regretting at the same time that the 
 accident had not befallen the right instead of the left eye, for 
 then he would have promised his cure ; wounds of the left eye 
 being in their very nature irremediable. But Zadig gets well ; 
 and the physician writes a book to prove that he ought never- 
 theless to have lost his sight. 
 
 But much better than the fiction of Voltaire, and very much 
 more to the purpose, is what really happened, and stands 
 authenticated in a Scotch law book. Three physicians and two 
 surgeons made oath in a court of justice, that, " by the rules 
 of their prognostics," the wounds received by one James 
 Houston were mortal wounds. But James Houston was still 
 alive ; and, to the honour of the three physicians, the two sur- 
 geons, and " the rules of their prognostics," was plaintiff in the 
 very process wherein they had so memorably deponed.* 
 
 With respect to symptoms and their connexion with morbid 
 processes going on within, the subject is too extensive to allow 
 me to enter upon it at present. Indeed, it is so extensive and 
 so important, and so full of its own difficulties, and yet a subject 
 wherein right views are so expedient, and wrong views so 
 perilous, that I have thought it would not be altogether a pro- 
 fitless task either to you or to me, if we were to undertake 
 together a patient and comprehensive examination of this very 
 subject. Therefore, in connexion with the proper business of 
 the wards, and the observation of cases, and (as I trust) for 
 your help and my own, and for our mutual guidance at every 
 step of our practical studies, I will endeavour, in a series of 
 lectures, to give what illustration I am able to the doctrine of 
 symptoms. 
 
 * Edin. Med. and Surg. Journal, vol. i. p. 339. 
 
LECT. V.] CLINICAL MEDICINE. 81 
 
 It remains that we notice another, and (philosophically con- 
 sidered) a higher purpose, which concerns us in the contempla- 
 tion of medical facts — viz. the discovery of general principles 
 from them. 
 
 A principle (as the name imports) is a beginning. A 
 principle is some matter of fact to which numerous other matters 
 of fact are traced as to a common source ; and when we speak 
 of discovering a principle, we mean the business of analyzing 
 or decomposing compound matters of fact, into those which are 
 simpler, until we come to one which is simpler still, and more 
 general and elementary ; and, being unable to go beyond it, we 
 regard this as an ultimate fact, or a principle. A principle is 
 an ultimate fact, and a universal fact, and true, without a 
 single contradictory instance. 
 
 Now it must be confessed that there is no fact in medicine 
 (i.e. no fact respecting the animal body, its actions upon itself, 
 or its obedience to other influences) which has the same character 
 of universality with certain facts respecting the external world. 
 In medicine we have no fact so universal as that all bodies un- 
 supported fall to the ground, no principle so sure or irrefragable 
 as gravitation. 
 
 Nevertheless, in medicine we talk of principles, and we are 
 continually striving after them ; but in the strict philosophical 
 sense, have we ever really compassed them ? 
 
 We have reached forms of principles (if I may so say) rather 
 than principles themselves. By forms of principles I do not 
 mean things fictitious, or things purely imaginary, but facts 
 tested by observation, and carefully analyzed, and very com- 
 prehensive, but not universal : facts true in a vast number of 
 instances, but not true in all. 
 
 In medicine there have, indeed, been facts, which for a time 
 have passed for universal, and for a time have held the place of 
 principles ; but larger experience has shown that their title to 
 it was not a just one. 
 
 There is a certain order of symptoms constituting what is 
 called " angina pectoris ;" and angina pectoris was for years, by 
 the common consent of medical men, drawn from extensive 
 observation and dissection, universally ascribed to ossification of 
 the coronary arteries of the heart. But more enlarged experi- 
 ence has found angina pectoris to exist where there has been no 
 
82 SUBJECTS CONNECTED WITH [LECT. V. 
 
 such change of structure, but another form of disease, viz. dila- 
 tation of the origin of the aorta; and still more enlarged 
 experience has found it where there has been neither one nor 
 the other. 
 
 The disease produced by the vaccine virus gave proof, by- 
 instances almost innumerable, of imparting to the constitution a 
 protective power against small-pox. Accordingly, this power 
 was believed to be absolute and universal. At length contra- 
 dictory instances arose and multiplied ; and the protective 
 power of vaccination was now no longer a law or a principle. 
 In the present state of our experience we still ascribe to vacci- 
 nation a protective power against small-pox, but one which is 
 only highly probable, not certain. "We ascribe to it, moreover, 
 when its protective power fails, a mitigating power ; but this, 
 too, is only highly probable, not certain ; for assuredly both its 
 protective and its mitigating influence sometimes fails, and 
 small-pox after vaccination sometimes goes through all its stages 
 unaltered, and is in all respects the same small-pox, as when no 
 vaccination has taken place. 
 
 After the history of vaccination we know not what number 
 of concurrent instances is enough in medicine to prove a fact 
 universal, or when we can ever be safe against the intervention 
 of contradictory instances, and venture to rely upon any fact as 
 a doctrine or a principle. 
 
 But we are not, therefore, to abandon our search after 
 principles; and the same method which in other departments of 
 natural knowledge has alone led to their discovery, we must 
 still employ in ours ; for although in our hands a less eminent 
 success has hitherto attended this method, no success whatever 
 has attended any other. This method imperatively requires 
 that the principle sought be a matter of fact. 
 
 If, while we properly restrict ourselves to matters of fact in 
 every other stage of our investigations we yet take a fiction for 
 our principle, medicine will never improve as a science in our 
 hands, and ancient errors and follies will only give way to new 
 ones. 
 
 The fault of physicians has not so much been, that they 
 have shown a general disregard of matters of fact, as that they 
 have lost sight of them just when they ought especially to have 
 kept them in view — when they were concerned with principles. 
 
LECT. V.] CLINICAL MEDICINE. 83 
 
 Hence the mischiefs that have arisen to physic in the shape of 
 so many renowned theories, either shown to be false, or not 
 ■shown to he true. Take any of these false or unverified theories 
 you please, and you will always find it derived from some 
 principle gratuitously assumed, a principle which is either no 
 matter of fact at all, or incapable of being shown to be a matter 
 of fact. 
 
 The principle assumed may be some physical process or 
 property, such as a spasm of the extreme vessels, or a peccant 
 matter in the blood ; things which possibly may be, but which 
 are entirely without proof, and even too subtle to admit of any; 
 possible facts, but facts quite unascertained and gratuitous. 
 
 Or the principle may be neither process nor property, nor 
 anything that has a physical existence, real or possible, but a 
 mere figment of the mind. The Zoonomia of Dr. Darwin 
 abounds in principles of this kind. Even Mr. Hunter, with all 
 his wariness and penetration in search of truth, admits what he 
 calls " the stimulus of necessity," as a principle or element en- 
 gaged in the production of diseases before they are yet apparent 
 in their phenomena. This is to escape from physical inquiry 
 into the region of pure fancy. 
 
 What has been said of principles in medicine, whether 
 erroneously or legitimately pursued, may seem to offer small 
 encouragement to physicians to engage further in the search 
 after them. Many of the most celebrated that have given re- 
 nown to schools and universities have been abandoned altogether 
 — abandoned because they have been erroneously pursued, and 
 have not possessed the essential character of matters of fact. 
 Many, again, being real matters of fact, and legitimately sought 
 and accepted as principles for a time, have at length been 
 abandoned, because they have been found not to possess the 
 essential character of universality. 
 
 But we must still concern ourselves with principles; we 
 cannot help it ; all men do it in some sort or other ; for the 
 mind is not able constantly to. keep in view all the particulars 
 of its own experience. It must needs reduce them within a 
 narrower compass, and contemplate them (so to speak) in some 
 representative. Thus a law or a principle must be set up, right 
 or wrong. Some forge a maxim, and some forge a fact, and 
 soon find it conspicuously illustrated in every instance of disease 
 
84 SUBJECTS CONNECTED WITH [LECT. V. 
 
 they meet with. They find irritation in everything, or spasm 
 in everything, or bile in everything. While others, after 
 having gone on observing and collecting facts, and cautiously 
 arranging them according to their natural relations, venture at 
 length to rest in one which seems to have every characteristic 
 of a principle, and yet in process of time may turn out to be 
 no principle at all : witness the protective power of vaccination. 
 The truth is, something must be conceded to physicians in 
 respect of the very nature of the subject on which they are 
 engaged. Let the principle be ever so legitimately reached, we 
 are only answerable for it as a law explanatory of the facts 
 already known. But in medicine new facts are continually pre- 
 senting themselves. These may be still comprehended within 
 the same principle, or they may not. If they are, they furnish 
 a stronger attestation to its truth. If they are not, they weaken 
 or destroy the principle altogether. But it is no disparagement 
 to us that our principle has failed. We are only concerned that 
 the method by which we reached it is the right one ; and then, 
 though it fail, we are at liberty to arrive at a new principle, if 
 we are able, by the same method ; that is, to find some other 
 matter of fact comprehensive of the newly discovered particu- 
 lars, and to concede to it the character of a principle. 
 
 Such is the nature of medicine, that things which we have 
 laid up in our minds as settled truths often require to be modi- 
 fied by our future experience, and come at last to be rated many 
 degrees below the value at which we originally prized them. 
 
 Nevertheless, we do not claim for medicine a liberty to 
 transgress any of those landmarks which philosophy has set up 
 to indicate the path of truth. Let it have no other principles, 
 and no other method of arriving at them, but such as philosophy 
 approves ; only let no disparagement fall upon it (considering 
 the nature of the things with which it is conversant), if, for 
 just reasons, it be sometimes dissatisfied with principles which 
 it once embraced, and seek to discover new ones. 
 
 Finally, then, as to general principles in medicine, let it be 
 remembered that the mind must always seek to arrive at a matter 
 of fact, and there only be content to take its rest. But it need 
 not settle there longer than until the clear discernment of some 
 other fact, more general and elementary, opens the way to a safe 
 progression beyond it. Then the fact last discovered becomes 
 
LECT. VI.J CLINICAL MEDICINE. 85 
 
 the principle, and the other is only one of the several stages 
 conducting to it. 
 
 In this mode of proceeding our knowledge may be incomplete, 
 but it is never erroneous. The mind advances from fact to fact, 
 resting on one as the stepping-stone to another, and feeling safe 
 in the possession of the truth, although it may not be all the truth 
 that is capable of being ascertained. 
 
 Every fact from which another fact is derived is in some 
 sort a principle. To us it is a first principle as long as we 
 are obliged to rest in it ; but as soon as another fact is dis- 
 covered which is prior to it, it loses its character of & first prin- 
 ciple ; and, if it be a principle at all, it is only an intermediate 
 one, the first being always that to which we know nothing 
 prior. 
 
86 SUBJECTS CONNECTED WITH [LECT. VI. 
 
 LECTURE VI. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 GENERAL NOTION OF SYMPTOMS. HOW THEY DIFFER FROM MERE 
 
 SIGNS. THE RELATION OF SYMPTOMS TO DISEASES NOT THE 
 
 SAME IN ALL CASES. SYMPTOMS ARE DIRECT OR INDIRECT. — 
 
 CHARACTER OF EACH. 
 
 DIRECT SYMPTOMS RESPECT THE SENSATIONS, FUNCTIONS, AND 
 STRUCTURE OF THE PART AFFECTED: — 
 
 1. SYMPTOMS WHICH RESPECT SENSATION. — PAIN— ITS 
 DEGREES — ITS QUALITIES. — AMOUNT OF INFORMATION DERIVED 
 
 FROM PAIN AS A SYMPTOM. SOURCES OF DECEPTION ARISING 
 
 FROM IT. 
 
 2. SYMPTOMS WHICH RESPECT FUNCTION. AMOUNT OF IN- 
 FORMATION DERIYED FROM THEM, AS COMPARED WITH THAT 
 
 DERIVED FROM SENSATION. AMOUNT FROM BOTH TAKEN 
 
 TOGETHER. 
 
 3. SYMPTOMS WHICH RESPECT STRUCTURE. — THE INFORMA- 
 TION DERIVED FROM THEM LIMITED TO PARTS WITHIN REACH 
 OF THE SIGHT AND THE TOUCH, UNTIL AUSCULTATION* 
 BROUGHT THE DISEASES OF CERTAIN ORGANS WITHIN THE 
 SCRUTINY OF THE EAR. 
 
 In going round the hospital my mind often reverts to the 
 time when I was a mere beginner like yourselves ; and I re- 
 member how strange and puzzling to me was everything that I 
 saw; how I thought I never should be able to distinguish 
 diseases, one from another, as long as I lived ; and, as to treat- 
 ing them, I could not look forward with the hope that my con- 
 science would ever allow me to attempt any such thing. 
 
 Above all, I was perplexed with the number and variety, 
 and (as I humbly thought) contradictory nature of symptoms. 
 It seemed to me, that if I could ever succeed in learning them 
 
LECT. VI.] CLINICAL MEDICINE. 87 
 
 all, it would be to no profit ; for the same symptoms appeared 
 sometimes to import one thing, and sometimes another. 
 
 There was a patient, perhaps, suffering convulsions ; and 
 the physician evidently thought the case most grave and perilous, 
 for he employed several remedies of the most gigantic power, 
 and succeeded in saving him. But there was another patient 
 suffering convulsions no less severe, and to my apprehension 
 just of the same kind, yet so far was the physician from thinking 
 seriously of this case, or treating it severely, that he just looked 
 at the patient and smiled, ordered some cold water to be thrown 
 in her face whenever the convulsions returned, and said that 
 would cure her ; and, sure enough, he was right. Moreover, 
 many died who seemed to me to have little or nothing the 
 matter with them, and many recovered whom I did not hesitate 
 to condemn to death at first sight. 
 
 Thus health and sickness, and life and death, seemed the 
 most mysterious things in the world ; and the symptoms which 
 were said to indicate them were to me a long while unintelligible. 
 
 These recollections, at this day so often present to my mind, 
 enable me to place myself in your situation. They serve the 
 good purpose of making me feel, that just the same difficulties 
 which are yours now were once my own, and of making me 
 wish to aid you by my little experience in removing them. 
 
 Yet the very objects whichhave puzzled me, and are, perhaps, 
 now puzzling you, do in fact contain infinite instruction. It is 
 by symptoms, and by symptoms only, that we can learn the 
 existence, and seat, and nature, of diseases in the living body, 
 or can direct and methodize their treatment. But, first of all, 
 symptoms themselves must be understood, before we can make 
 the proper use of them for gaining the instruction which they 
 are calculated to convey. 
 
 It is important for us to understand that the symptoms or 
 signs of diseases are never to be taken in the like sense with that 
 in which the signs of external things are often regarded. The 
 buoy which, floating in the river, marks its navigable tract ; 
 the bell which, by striking, denotes the lapse of time ; the stone 
 by the wayside, which tells us how far we have come, and how 
 far we have yet to go ; these are most important signs, and of 
 indispensable service to us all, but they have no natural con- 
 nexion with the things they are made to indicate. They are 
 
88 SUBJECTS CONNECTED WITH [LECT. VI. 
 
 mere expedients, of conventional meaning and use. Navigable 
 rivers, and time and space, would still exist, though, there were 
 neither buoy, nor bell, nor milestone, in the universe. 
 
 There is nothing that we call the symptom of a disease, 
 which does not contain within itself much more than a mere 
 sign. Heat, pain, redness, swelling, are called the signs of 
 inflammation ; but nature does not intend by them barely to 
 intimate that inflammation exists ; they are essentially connected 
 with the processes she is carrying on. 
 
 Thus at early dawn we point to the first glimmering in the 
 east, and call it a sign of the rising sun ; but it is more, — it is 
 an emanation from his beams. We look at the cloud above our 
 heads, and say it is a sign of rain ; but it is the gathering of 
 the waters themselves. 
 
 Concerning symptoms I would nevertheless remark (what 
 is very important to be borne in mind), that they stand in 
 different relations to the diseases to which they belong. They 
 may flow out of the disease, so as, in idea at least, to be sepa- 
 rable from it ; or they may be involved in the disease, so as to 
 be identical with it. The difficult respiration, the cough, the 
 sputa, the emaciation, the hectic, are the symptoms of phthisis, 
 and are distinguishable from the disease itself. They are the 
 signs of something beyond themselves, which we do not see — 
 viz. tubercles of the lungs. But the symptoms which denote 
 an intermittent fever are the same which constitute the disease. 
 We have no idea of an intermittent apart from the rigor, the 
 heat, and the perspiration. The same may be said of other 
 fevers, and of almost all diseases not organic, in which, if you 
 seek to separate the symptoms from the disease, you must resort 
 to theory for the purpose, and conceive an action of a certain 
 kind prior to the actions which constitute the symptoms, and 
 productive of them. 
 
 There are then symptoms which, in the plain and intelligible 
 sense, are signs and tokens of the disease that exists separately 
 and distinctly from them ; and there are symptoms which, 
 however they may be spoken of as signs merely, are, never- 
 theless, all that we know of the disease itself. The disease is the 
 symptoms ; and the symptoms are the disease. 
 
 True : but it can hardly be conceived that they are in reality 
 the same. Yet it is better that they should be so regarded, 
 
LECT. VI.] CLINICAL MEDICINE. 89 
 
 than that we should go beyond our knowledge in attempting to 
 distinguish them. Better to see in fevers only a certain com- 
 bination of symptoms, than to run wild about a debility of the 
 nerves, a spasm of the extreme vessels, or a peccant matter in 
 the blood. 
 
 Again ; I would remark that it is often most difficult to 
 draw the line between what is disease, and what is symptom ; 
 and that the same conditions may, in different cases, become 
 now one and now the other. A dropsy, or an haemorrhage, are 
 sometimes primarily and essentially the disease. Sometimes 
 they are secondary, and incidental to the real disease, and are 
 themselves only symptoms. 
 
 How impossible, then, must it be to give any definition of a 
 symptom which shall be philosophically true, and at the same 
 time satisfy every sense in which it is practically regarded ! 
 
 From the imperfection of our knowledge the whole subject 
 of semeiology is beset with philosophical difficulties ; and no 
 advantage will be gained from conducting our inquiry con- 
 cerning it in a stricter method than its own nature will bear. 
 
 Whatever it is that bespeaks the presence of diseases, or 
 denotes their nature or their seat, or, moreover, whatever 
 indicates the proper method of treating them, may be equally 
 regarded in the character of a symptom. At present I shall 
 restrict myself to the symptoms which denote the disease, 
 reserving those which indicate the remedy for future con- 
 sideration. 
 
 There are certain popular tokens of disease which all the 
 world is acquainted with. A man is generally known by his 
 friends to be ill before he submits his case to a physician. They 
 judge, and judge rightly, from his complexion, his aspect, his 
 voice, his gait, or something unusual and unsatisfactory in his 
 whole form and behaviour. And these circumstances, which 
 strike everybody, are not unobserved by us. All can gather 
 from them that disease is present somewhere ; but we can often 
 draw from them intimations of its very nature and seat. 
 
 But how much soever physicians may learn from what con- 
 stitutes the physiognomy of diseases in its largest sense (and, 
 indeed, they may learn a great deal), their more accurate 
 knowledge is derived from symptoms which admit of a more 
 exact analysis. Upon such I propose principally to dwell. 
 
90 SUBJECTS CONNECTED WITH [LECT. VI. 
 
 Of symptoms some belong immediately to the part affected. 
 They proceed immediately from it, and are referred immediately 
 to it. "We will call these direct symptoms. Others, belonging 
 originally to the part affected, declare themselves through the 
 medium of other parts, or through the medium of the constitution 
 at large. We will call these indirect symptoms. 
 
 To begin with direct symptoms, there are those which 
 respect the sensations of the part, in whatever way they may 
 differ from what is natural. 
 
 Now, concerning unnatural sensations as evidences of disease, 
 to what extent they exist, or whether they exist at all, we are 
 not competent absolutely to determine. In matters of feeling 
 we must depend entirely upon what our patient tells us. Every 
 man smarts with his own pain ; himself, and nobody else, can 
 say how much. We must presume, therefore, that our patient 
 has no disposition to deceive us ; and, giving him credit for the 
 correct expression of his own feelings, we must act upon his 
 information concerning them. 
 
 Pain and uneasiness ! These are general terms. But there 
 is more to be learnt upon the subject of morbid sensations than 
 what these terms are calculated to convey. 
 
 There are qualities and peculiarities of pain arising from 
 parts which are disordered, diseased, or injured, as there are 
 qualities and peculiarities of sensations arising from parts which 
 are healthy. 
 
 Ask the man whose leg has just been amputated, and he will 
 tell, you that he suffered one kind of pain when the knife divided 
 the skin, and another when it cut through the muscles ; and 
 that sawing through the bone gave him still a different pain. 
 Ask the man who has just suffered the operation of a violent 
 purgative, and he will tell you, that after taking it he first felt 
 oppression and nausea ; that presently the nausea became fainter 
 and fainter, until it was exchanged for real pain ; twinges and 
 griping arose, and became more and more acute, until they were 
 relieved by an evacuation from the bowels. 
 
 Here we see various peculiarities of uneasiness arising from 
 the same mode of irritation applied in succession to the different 
 parts of the intestinal canal, and the different structures which 
 go to the formation of the leg. 
 
 Pain in vital parts is different from common pain ; and the 
 
LECT. VI.] CLINICAL MEDICINE. 91 
 
 pain in one vital part is different from the pain in another. In 
 the brain it' is heavy and stupefying ; in the heart and lungs, 
 and contiguous structures, it is apt to be acute, and generally 
 much circumscribed, or confined to a spot; in the liver, the 
 uterus, and testicles, it is oppressive and sickening. 
 
 Pain varies also in parts not vital. In skin, cellular struc- 
 ture, and muscle, it rouses and excites ; in tendon, ligament, 
 and bone, it rather oppresses ; in nerve, it is numbing, prick- 
 ling, or intolerably acute, and often runs along a string (as it 
 were) to a considerable distance. Witness tic douloureux; 
 witness the sciatic affection. 
 
 But, besides the qualities and peculiarities of pain belonging 
 to several parts, and denoting generally their unhealthy con- 
 dition, there are those which belong to the same parts under 
 different states of disease, and are thus expressive of the kind 
 of morbid action which produces them. There is what is called 
 throbbing pain, in which the patient, simply by attending to the 
 part affected, may count his own pulse. This throbbing pain is 
 characteristic of inflammation just at the point when it is 
 passing from the adhesive to the suppurative stage. There is a 
 pain which is called lancinating, almost the constant concomi- 
 tant of cancer, and very different from the pain which would 
 attend common inflammation in the same parts of the body. 
 
 The sense of pain is in proportion to the magnitude of the 
 disease, only within certain limits. The extremity of the disease 
 may abate or even abolish the sense of pain altogether. Thus, 
 there are circumstances in which it is in vain to seek to learn 
 the existence of pain by interrogation merely : the sense of it 
 must be awakened by hard pressure or rough handling of the 
 part in which the disease is thought to reside ; and sometimes 
 even these are insufficient for the purpose. The sense of pain 
 is irrecoverably gone. Surely there is a benevolent intention 
 conspicuous in all this. The way of death is often smoother 
 than the path of life ; and great bodily anguish (there is reason 
 to believe) does not often enter largely into the process of dis- 
 solution. 
 
 But I do not wish to insist upon pain, its quantity, and 
 peculiarities, as infallible criteria by which to detect what is 
 the seat of the disease, and what its kind. It is possible to 
 speculate too curiously upon morbid sensations ; to speculate 
 
92 SUBJECTS CONNECTED WITH [lEC'T. VI. 
 
 even so far as to deceive ourselves respecting them. Besides, 
 the patient himself, by 'an over anxious and over constant 
 attention to what he feels, is liable to miscalculate the kind and 
 quantity of his own sufferings, and thus to mislead you by 
 exaggerating every little ache into an intolerable grievance. 
 Again ; the patient himself, by habitual disregard of what he 
 feels, is liable to miscalculate in the opposite way. He either 
 has no pain, or he owns to none, where another would complain 
 of a great deal ; and thus he misleads you by extenuating a real 
 grievance, or entirely passing it by. Neither of these can be 
 safely trusted for a correct interpretation of their own sensa- 
 tions. 
 
 It is an important practical truth, well worthy of being 
 remembered, that diagnosis is capable of being greatly aided or 
 greatly obstructed by the personal character of the patient. 
 Education, and the better habits of civilized life, render men 
 more rationally attentive to their internal sensations and better 
 able to describe them ; whereas over refinement engenders such 
 excessive care and regard of the feelings, that it contrives to 
 sophisticate and spoil them ; and barbarity acts so much in 
 spite of them, that it blunts or nearly abolishes them alto- 
 gether. 
 
 Plain sensible men, who feel just what they ought to do, 
 and tell just what they feel, are the most agreeable patients to 
 attend. You make out their complaints easily and satisfactorily ; 
 they have noticed the first real deviations from healthy sensa- 
 tion, and can describe them intelligibly ; and they obtain from 
 you an earlier and more certain relief. But soft, delicate, 
 nervous persons, who feel extravagantly, and still exaggerate 
 what they feel, are very troublesome to deal with. You are 
 not certain that they do not deceive both you and themselves ; 
 and such a perplexity is cast over their complaints that you can 
 neither understand them nor treat them properly. Again ; the 
 stupid and half civilized, who are often literally insensible to 
 their disease until it has endured a long time, and made a con- 
 siderable progress, and done formidable injury to the parts 
 concerned, can hardly give you any help to the knowledge 
 of their complaints by their own description of their feelings. 
 
 I have often remarked, in the victims of extreme intem- 
 perance, that they have little or no consciousness of the pains 
 
LECT. VI.] CLINICAL MEDICINE. 93 
 
 and disordered sensations proper to the diseases which they 
 suffer. This strange want of correspondence between the 
 symptoms of disease derived from other sources, and those 
 derived from the sensations, is a subject of very curious specula- 
 tion medically, and of very melancholy interest morally. For 
 the chief cause of the anomaly I believe to be really that to 
 which I have alluded. There are whole classes of society in. 
 London who are never really sober for years together. The 
 sensations proper to health and to disease are alike unknown to 
 them. In health, the stimulus of spirits renewed day by day 
 and hour by hour, gives them feelings and excitement which 
 are unnatural ; and however they may be mistaken for those of 
 health, do in truth not at all belong to it. They are better, 
 perhaps, and more pleasurable, than any that health has to 
 give ; and they have superseded them. In disease (disease 
 which it has itself produced), the stimulus of spirits gives them 
 feelings and excitement which are still unnatural, and disguise 
 or supersede the sensations which they then ought to have. 
 
 People are frequently brought into the hospital just ready 
 to perish of complicated visceral disease, yet declaring that 
 they never suffered ache or pain in their lives until a few weeks 
 ago. Their liver, spleen, kidney, and heart, and blood-vessels 
 are all disorganized. They are breathing, perhaps, with one 
 lung ; and the cellular structure and some cavities of the body 
 are distended with fluid. Here is a disease which must have 
 been the growth of years ; yet true it is, as they say, that they 
 have felt neither ache nor pain until within a few weeks. 
 Spirits — spirits more and more recklessly taken — have sus- 
 tained and excited, and cheated them, with false strength and 
 false feelings, till fluid has gushed out everywhere, and vital 
 organs have been suddenly oppressed, and down they have sunk 
 at once, and irretrievably. 
 
 Nevertheless, the inquiry into morbid sensations is most 
 interesting in itself, and most proper and necessary to be pur- 
 sued for pathological and practical purposes. 
 
 There are complaints of sensation, and sensation merely. 
 People feel burning heat and pinching cold, in opposition to 
 the indications of the thermometer, and in opposition to the 
 perceptions of the physician, who applies his hand to the person 
 of his patient without being able to confirm the fact by his own 
 
94 SUBJECTS CONNECTED WITH [LECT. VI. 
 
 feeling. People will complain of severe pain upon some 
 external surface, which exhibits no visible marks of disease. 
 
 These complaints of sensation, and sensation merely, often 
 occur in those whom you cannot suspect of any intention to de- 
 ceive you. They are often real diseases, and being such, are 
 generally most difficult to cure. But these complaints of sensa- 
 tion, and sensation merely, are those which people most 
 frequently counterfeit when they have an interest in being 
 believed to be ill ; and they often counterfeit them successfully, 
 owing to the extreme difficulty of detecting the deceit. Yet 
 even here the physician would make the probability of deception 
 less, if he were acquainted with the kind of pain which is usually 
 felt in that part to which the patient refers it. 
 
 But, although we may learn from this order of symptoms all 
 that they are in their own nature capable of teaching us, yet, in 
 almost every case we meet with, we shall find a necessity of 
 inquiring into other symptoms, if we would know the real con- 
 dition of the part which falls under suspicion of disease. The 
 majority of complaints are not such as declare themselves by 
 this or by any one order of symptoms only. Diseases of mere 
 sensation are very few. 
 
 Now there are other direct symptoms (symptoms immediately 
 referable to the part affected) besides those which respect its 
 sensations ; and these are in truth more important, on account 
 of the more certain information which they are calculated to 
 convey. These other direct symptoms respect the functions of 
 the part. 
 
 If the patient own to pain in a part, we suspect that part to 
 be the seat of some morbid affection ; but we are not satisfied 
 that it is so, nor can we tell what the morbid affection is, until 
 we have made further inquiry. 
 
 Suppose a man complains of pain in the head. It may be a 
 mere nervous pain ; it may be a sick headache ; or it may be a 
 symptom of inflammation of the brain. But we cannot tell 
 what it is, and (what is worse) we cannot prescribe with any 
 reasonable chance of procuring relief, until we have ascertained 
 many more particulars concerning it. 
 
 Or if the patient own to no pain, yet, if a part has fallen 
 under a suspicion of disease, we cannot be satisfied that it is 
 healthy until we have made other inquiries. I have known 
 
LECT. VI.] CLINICAL MEDICINE. 95 
 
 people die of diseases of the brain, of the lungs, of the heart, 
 
 who have suffered no pain whatever. 
 
 It appears, then, that whether we learn much or little, or 
 
 nothing, respecting the sensations of a part, there is always a 
 
 necessity for further inquiry, if we would know the nature of 
 
 its complaint. 
 
 Our further inquiry is still into direct symptoms, viz. those 
 
 which respect the functions of the part. 
 
 The symptoms which respect function are of much more 
 practical value than those which respect sensation ; and for this 
 consideration especially, that the knowledge which they convey 
 is less fallible in itself, being the result, not of what we ask and 
 another tells us, but of what we see and note for ourselves. In 
 obtaining it, we depend not at all upon the representations of 
 the patient, but entirely upon our own observation and reasoning. 
 But, concerning the direct symptoms which respect the 
 functions of parts, and which consist in the various deviations 
 of those functions from their healthy state, let this especially be 
 borne in mind, that valuable as they are themselves, to us they 
 will be of much, or little, or no use, according as we take much, 
 or little, or no care, to prepare and capacitate ourselves for un- 
 derstanding them. Everybody cannot tell when and how the 
 functions deviate from what is natural. A competent acquaint- 
 ance with physiology must precede and prepare us for such 
 knowledge. We must begin with what is natural and healthy, 
 and afterwards inquire into what is unhealthy and disordered ; 
 and thus learn the latter by comparing and contrasting it with 
 the former. 
 
 As the anatomy of healthy structure must always be the 
 beginning and foundation of morbid anatomy, so must the phy- 
 siology of healthy function be always the beginning and foun- 
 dation of morbid physiology; for by this name of morbid 
 physiology I will venture to call the knowledge of all the various 
 ways in which the functions of the living body and its several 
 parts are capable of being perverted and deranged. 
 
 Some interruption or derangement of their ordinary func- 
 tions probably always attends disease or injury in every part 
 and structure of the body ; such interruptious or derangements, 
 being discovered, are the symptoms which bring us home to the 
 seat of complaint more surely than any other. 
 
96 SUBJECTS CONNECTED WITH [LECT. VI. 
 
 But there are parts in which they are not discoverable; 
 namely, those of which the ordinary functions are unknown, as 
 the spleen. And there are parts in which I will not say that 
 they are not discoverable, but only that they are never dis- 
 covered — namely, those whose functions are so mixed and 
 blended with the functions of other parts, that it is impossible 
 to determine how much belongs to them and how much not, 
 either in health or in disease. Who shall say when the pan- 
 creatic secretion is redundant or defective, or of an unhealthy 
 quality? 
 
 But the brain and the nerves ; the heart and the blood- 
 vessels ; the lungs, the liver, the stomach, and the kidneys ; all 
 give direct intimations of their diseases, by the interruptions 
 and derangements of their ordinary functions. 
 
 The brain and nerves exhibit direct symptoms of their dis- 
 eases in every manner and every degree in which sensation or 
 voluntary motion, the senses or the intellect, are capable of 
 being impaired or perverted. The heart and blood-vessels ex- 
 hibit direct symptoms of theirs, in the strength or weakness, the 
 unusual extent, and the irregular succession of their pulsations, 
 and the sounds accompanying these ; also in many qualities and 
 varieties of the pulse, and in the unequal course and distribution 
 of the blood itself. 
 
 All are acquainted with the direct symptoms which impute 
 diseases to the lungs, when, instead of a respiration which should 
 be easy and uninterrupted, there is panting and wheezing, and 
 stertor, and cough ; and when, instead of the humid vapour 
 which in health is separated by the bronchi, and mingles and 
 glides forth with the breath, there is a hard and difficult expec- 
 toration of phlegm, of mucous or purulent secretion, or of blood. 
 
 But the direct symptoms which impute diseases to the lungs 
 most unequivocally, and which make the most precise discovery 
 of their nature and seat, are not of common or popular appre- 
 hension. There is a method by which the entire lungs, and each 
 separate portion of them, can be scrutinized, and by which we 
 can learn where respiration is perfect, and where it labours. It 
 is the method of auscultation. And this method of auscultation 
 does not merely discover a defect or failure of function in the 
 lungs at this part or that, and so leave us to infer, from reason- 
 ing or from other circumstances, the exact nature of the disease 
 
LECT, VI.] CLINICAL MEDICINE. 97 
 
 (this indeed, would be a great deal, and as much as the direct 
 symptoms which respect the functions of parts are generally 
 able to do) ; but it often leads to more — discovering not merely 
 the symptom, but the disease itself. 
 
 The excess and defect of bile, and various qualities of that 
 secretion different from those of health, are the direct symptoms 
 by which the liver shows itself morbidly affected. And the 
 common consequences that immediately flow from impediments 
 to the digestive function are the direct symptoms by which the 
 stomach declares its complaint. Such are distensions, eructations, 
 and rejected food, which has undergone the process of fermenta- 
 tion, and become acid and putrid : for these plainly show that 
 the substances submitted to the stomach have been left to suffer 
 the chemical changes to which they are naturally obnoxious, 
 the organ having lost its controlling power over them. 
 
 So, too, in the various changes which the urine is apt to 
 suffer, in its excess and its defect, in the predominance of an 
 acid or an alkaline quality, in its amorphous sediments and its 
 crystalline deposits, we have the direct symptoms, which lead us 
 to search for disease in the kidneys. 
 
 But each of these systems and organs requires from the 
 student an express acquaintance with its natural functions, 
 before he can be prepared to examine and appreciate their errors 
 and defects ; and then these errors and defects themselves he 
 must expressly study, before they can yield him all the informa- 
 tion which, as direct symptoms of disease, they are calculated to 
 convey. 
 
 Now, whatever part be affected, when we bring our own 
 knowledge of its disordered functions, and add it to what the 
 patient tells us of its disordered sensations, we shall generally 
 come somewhat nearer to a right notion of the seat and nature 
 of the complaint ; sometimes, indeed, to a perfect comprehension 
 of it, so far as it is capable of being ascertained at all; inasmuch 
 as there are conditions of disease into which no further inqui- 
 sition can be made when we have learned the feelings and the 
 functions of the part to which they belong. 
 
 Many of the local complaints which we are called upon to 
 witness and to treat, are not of a nature to affect the structure of 
 the part. In them it is not clear that there is anything to be 
 ascertained beyond the symptoms which respect its sensations 
 
 H 
 
98 SUBJECTS CONNECTED WITH [LECT. VI. 
 
 and functions ; whether, if the part were laid bare to us, and 
 we could see and handle it, we should have any better notion of 
 its complaint, or how to treat it. A man has a pain in his 
 stomach, and he cannot digest, and yet he has no organic disease ; 
 and this being the case, I really do not comprehend how we are 
 more likely to learn the cause of the pain and the indigestion, 
 or the proper method of its relief, seeing the stomach, than 
 seeing it not. 
 
 But with all the knowledge of disordered functions which 
 our best observation can furnish us, and all the knowledge of 
 disordered sensations which the patient's faithful interpretation 
 of his own feelings can supply ; with all the light which sensa- 
 tion and function can, as direct symptoms, throw upon the 
 disease of the part affected ; still we often need other symptoms 
 and more light to inform us what the disease really is, and what 
 its treatment should be. 
 
 There is yet another order of direct symptoms besides those 
 which immediately respect the sensations and functions of the 
 part — viz. those which immediately respect its structure. 
 
 When parts are within reach of the sight or the touch, we 
 can often judge whether their forms and structure be different 
 from what they ought to be, and thus obtain direct evidence of 
 their disease : and this evidence may be all that we require. 
 What we see, or what we feel, may convey to us a complete 
 knowledge of the disease, and render all consideration of other 
 symptoms unnecessary. Sometimes these visible or tangible 
 deviations from healthy structure are not only the direct 
 symptoms expressive of the disease, but the disease itself. 
 
 In the morbid affections of external parts we can examine 
 at once their state and structure, and learn in what respect they 
 differ from what is natural ; and the observation of this direct 
 symptom almost supersedes the necessity of inquiry for any 
 other ; for herein we witness the very manner and process of 
 the disease itself. We see the increased vascularity and tumes- 
 cence which constitute inflammation, the lymph which is the 
 material of adhesion, and the fluid which is the essential product 
 of suppuration. We see all those sensible changes in the con- 
 dition of the skin and cuticle which constitute the many orders 
 and varieties of cutaneous diseases — rashes and vesicles, and 
 pustules and scales; in which it is obviously impossible to 
 
LECT. VI.] CLINICAL MEDICINE. 99 
 
 distinguish the symptom from the disease, or the disease from 
 the symptom. 
 
 Again : we learn by the touch that the os uteri is changed 
 in structure — that it is scirrhous, or that it is ulcerated, or that 
 a polypus passes through it or grows from it ; and here we have 
 not only the palpable evidence of the diseases, but the diseases 
 themselves. 
 
 But our business, as physicians, is chiefly with internal parts 
 and organs ; all of which are beyond the reach of our sight, and 
 but a few perceptible to the touch ; and these few only under 
 certain conditions of disease. 
 
 Some organs of the abdomen, when disease has produced an 
 increase of their natural bulk, become palpable through the 
 integuments, and allow an examination of their shape and 
 dimensions. But, after we have in this manner obtained such 
 information as is possible respecting the structural condition of 
 an internal organ, let us be careful to estimate it properly, and 
 not to value it for either more or less than it is worth. 
 
 To ascertain by the touch that certain organs within the 
 cavity of the abdomen have undergone an augmentation of their 
 natural bulk — that the liver, or the spleen, occupy a space far 
 exceeding that which nature has allotted them, beneath the 
 cartilages of the ribs on either side — is, without doubt, to fix 
 disease upon them. But it is not to determine the nature of the 
 morbid processes which either are or have been in action within 
 them. Finding the spleen enlarged, or the liver enlarged, we 
 have the palpable result of some morbid action ; but what that 
 morbid action has been, and whether it is still in progress (the 
 only questions which are pathologically or practically important), 
 we must seek to discover by other symptoms. The increased 
 bulk, then, of an organ, is a symptom, a direct symptom, of 
 great value and certainty in fixing the seat of disease, but 
 nothing more. 
 
 But it is by another sense that we are admitted to a much 
 more intimate scrutiny of an internal part than any which the 
 mere touch can afford ; and thus obtain direct symptoms of its 
 disease which are often as infallible as those derived from sight 
 itself. 
 
 By auscultation we not only become acquainted with the 
 remote effects or ultimate results of morbid action, but often, 
 
100 SUBJECTS CONNECTED WITH [LECT. VI. 
 
 when the disease is just doing its first rudiment of injury, the 
 secret of its proceeding is betrayed to the ear. 
 
 The ear not only discovers the vomica or cavity, which is 
 the last of many changes wrought by tubercular disease upon 
 the structure of the lungs ; not only finds their permeable 
 texture converted into a solid mass by the gradual deposition 
 (it may be) of tubercular matter, or (it may be) of inflammatory 
 lymph; but it can detect the first effusion produced by inflam- 
 mation into the vesicles of a single lobule : it can detect 
 pneumonia almost, perhaps altogether, simultaneously with its 
 beginning to exist. 
 
LECT. VII.] CLINICAL MEDICINE, 101 
 
 LECTUEE VII. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 DIRECT SYMPTOMS OF DISEASES AFFECTING THE STRUCTURE OF 
 
 THE THORACIC ORGANS, KNOWN BY MEANS OF AUSCULTATION. 
 
 MODES OF AUSCULTATION. — PRELIMINARY ACQUAINTANCE WITH 
 MORBID PROCESSES ESSENTIAL TO ITS SUCCESSFUL USE. PRE- 
 CISE NATURE OF ITS OBJECTS IN RESPECT TO DISEASES OF THE 
 
 LUNGS. — GENERAL DIRECTIONS FOR ITS USE. AUSCULTATORY 
 
 SIGNS OF HEALTHY LUNGS. — AUSCULTATORY SIGNS OF DISEASED 
 LUNGS — KNOWN IN THE ACTS OF BREATHING, SPEAKING, AND 
 COUGHING. — THESE SIGNS CONSIST IN DRY SOUNDS AND MOIST 
 SOUNDS. 
 
 Recollect for a moment the inquiry in which we were 
 engaged, and how far it has proceeded. It is an inquiry into 
 the nature of symptoms ; and hitherto we have spoken of symp- 
 toms directly referable to the part affected ; those which regard 
 its sensations, and those which regard its functions ; and we 
 have endeavoured to estimate the information which these are 
 respectively calculated to convey. We have spoken also of 
 those which directly regard its structure ; and are now con- 
 sidering the information to be gathered from them. 
 
 This information, it should seem, is necessarily very limited 
 in regard to internal organs in general ; but the thoracic 
 organs are excepted from the rest, because, being within the 
 cognizance of another sense, and thus subjected to a method of 
 investigation peculiarly applicable to themselves, all their 
 actions and conditions are more clearly perceived and known. 
 This is the method of auscultation. 
 
 There are different modes of performing auscultation. In 
 one mode we apply the ear itself to the surface of the chest : 
 this is (what is called) immediate auscultation. In another, we 
 apply the tube to the chest, and the ear to the tube : this is 
 mediate auscultation. In another, without applying the ear to 
 
102 SUBJECTS CONNECTED WITH [LECT. VII. 
 
 the chest either immediately or mediately, we strike its walls 
 with our fingers, and listen to the sounds which result : this 
 might be properly called auscultation by percussion. But per- 
 cussion and auscultation are often spoken of, as if they were 
 different things, whereas they are only different modes of 
 appealing to the same sense; for we gather our information 
 equally from what we hear, whether we strike the chest or 
 apply our ear to it, or use the instrument. 
 
 I have often taken occasion to point out to you the importance 
 of pathological knowledge to the just diagnosis and the successful 
 treatment of disease ; and, as a part of pathology, I have laid 
 especial stress upon the knowledge of morbid processes. Now 
 the use which you will or will not be able to make of ausculta- 
 tion, will depend upon your knowledge of the pathology of 
 those organs to which it is applied. 
 
 The sounds which reach the ear through the walls of the 
 chest during breathing, or speaking, or coughing, varied and 
 modified by divers diseases of the organs within, are easily dis- 
 criminated. Any person not deaf will soon learn that there is 
 some distinction of these sounds. But we may distinguish them 
 correctly, and call them by right names, and make a musical 
 scale of them, if we please, and still know nothing of the 
 morbid conditions which they indicate, and out of which they 
 arise. These cannot be discovered by a discriminating ear 
 only ; they must first be known what they are in themselves* 
 By means of auscultation, various diseases of the heart and 
 lungs are capable of being detected with wonderful certainty ; 
 but the power of so detecting them belongs to those only who 
 have studied these diseases in all the processes of their forma- 
 tion, and progress, and results. 
 
 It is with hearing as it is with the other senses. When 
 they are taxed to give intimations to the mind concerning the 
 objects by which they are impressed, it is necessary that the 
 mind should have a previous knowledge what those objects are. 
 Place a man within sight of London, and give him a telescope, 
 and tell him to look for St. Paul's. St. Paul's he will un- 
 doubtedly see, and many a striking object besides ; but he wi 1 
 not be able to distinguish it from Westminster Abbey or the 
 Monument, unless he is previously instructed what sort of 
 building St. Paul's is. 
 
LECT. VII.] CLINICAL MEDICINE. 103 
 
 A child will at once perceive a difference between the 
 fragrance of the violet and of the rose ; but it must know the 
 violet, and know the rose, and smell them both singly, and by 
 turns, before it can assign to each its peculiar sweetness. 
 
 Any man can discern a difference between the sound of a 
 trumpet and of a drum; but he must have been where 
 trumpets have been blown, and drums been beat, ere he can 
 tell which sound belongs to each. My voice is different from 
 yours ; but a man must be familiar with you and with me, and 
 have heard us speak a hundred times, before he can distinguish 
 us by our voices. 
 
 So diseases of the chest have, as it were, different voices ; 
 but we must first be familiar with the diseases themselves, and 
 then be accustomed to hear them speak, ere we can tell one 
 disease from another by its voice. 
 
 What are diseases of the chest ? Pneumonia, pleurisy, 
 phthisis. And do we mean that auscultation can distinguish 
 each of these from the other ? Yes, truly ; and we mean more 
 than this — much more. 
 
 Pneumonia, pleurisy, and phthisis are only the complex of 
 several morbid processes and results. There is no such thing 
 as a pneumonic, a pleuritic, or a phthisical sound. Pneumonia, 
 pleurisy, and phthisis have no sounds that are peculiar to 
 themselves as such : but the sounds that we hear in these 
 diseases result from certain morbid processes going on, and 
 certain changes wrought upon the structure of parts ; which 
 processes and changes make up the complex to which we give 
 a name. We hear the sounds denoting that this part of the 
 lung is loaded with fluid, that part condensed with solid 
 matter, and another hollowed with cavities. Thus we get at 
 inflammation ; thus we get at phthisis. We anatomize by 
 auscultation, if I may say so, while the patient is yet alive, the 
 very processes and changes of structure of which inflammation 
 or phthisis consist : and so of other diseases. 
 
 Auscultation professes to make us acquainted with the 
 actual condition of the lungs in many of the most important 
 diseases incident to them ; their actual condition at any 
 particular time; and their changes from one condition to 
 another from time to time. 
 
 I am not aware that, before auscultation lent its aid to 
 
104 SUBJECTS CONNECTED WITH [LECT. VII. 
 
 diagnosis, we could do more than speak generally concerning 
 the diseases of the lungs during the life of the patient. We 
 could affirm generally that the lungs were inflamed; and, 
 knowing, from our acquaintance with morbid processes, that 
 it was the tendency of inflammation to produce such and such 
 changes of their structure, we were aware what perils it 
 involved, and could anticipate with tolerable accuracy what 
 we should meet with when the patient died. So, too, we could 
 affirm generally that there were tubercles or vomicae in the 
 lungs ; and, understanding the forms and processes of phthisical 
 disease, we could foretel in the main what we should find after 
 death. 
 
 But auscultation anticipates the disclosures of morbid 
 anatomy. Nearly all that dissection can unfold, it tells while 
 the patient is yet alive. It does more : it brings us acquainted 
 with diseases long before they have reached their fatal stage. 
 By dissection we come in with our knowledge at last, and gain 
 assurance of the disease from its ultimate results. By auscul- 
 tation we are often — very often — enabled to make our know- 
 ledge keep pace with the disease from its least and earliest 
 beginnings, through all the stages of its progress to the end. 
 By auscultation we contemplate a living action going on, and 
 have cognizance of it while it is yet at work. By dissection 
 we contemplate the ruin as it is left, when all action has 
 ceased. 
 
 I am not going to give you a regular didactic discourse 
 upon auscultation : you can only learn it for yourselves, by the 
 use of your own ears, in the wards of the hospital. And even 
 by your own ears it is hardly possible to learn it anywhere 
 except in the wards of a hospital; for you must have many 
 patients to practise upon at the same time ; and, moreover, you 
 must have many fellow-students engaged at the same time in 
 making the same observations with yourselves, that you may 
 compare notes together, and agree about what you hear. I am 
 quite sure that no man can arrive at any useful or safe conclu- 
 sions from auscultation, if he studies it alone. I speak from 
 experience when I say this. When I first turned my attention 
 to auscultation, I found so many sources of deception connected 
 with it, that I determined to admit no fact which was not 
 attested by others besides myself ; and I would advise you to 
 
LECT. VII.] CLINICAL MEDICINE. 105 
 
 proceed at first with the same scrupulous care. " That every- 
 thing is easy when you know it," sounds like the simplest of 
 truisms ; but, indeed, it is a very wise apophthegm. It imports 
 that, be a thing ever so difficult, you may, by taking the 
 necessary pains, obtain such a mastery over it, as to be 
 surprised that you ever thought it difficult at all. Auscultation 
 surely is not the most difficult thing in the world ; neither is 
 it the easiest. It is beset with many perplexities, and requires 
 much time, and labour, and patience, and caution, to master it 
 perfectly ; but, being mastered, it becomes the safest, simplest 
 guide, within its proper sphere, to a just diagnosis. 
 
 But auscultation, I have said, can only be learned within 
 the walls of a hospital. Yet, perhaps, I may be able to give 
 you some general directions how to proceed, which may be of 
 use to you ; and I wish to speak of auscultation at present as it 
 respects the lungs only. 
 
 Now before you seek to acquaint yourselves with the sounds 
 which indicate diseases of the lungs, you must learn those which 
 are expressive of their healthy state : for the healthy sounds must 
 be your standard of comparison in judging of the unhealthy. 
 
 It is useless for me to attempt to describe (what is called) 
 " the healthy respiratory murmur ;" I could only tell you that 
 this sound is like some other sound with which you might be 
 more familiar. But in a few weeks you will know the respira- 
 tory murmur so well by experience, that it will itself become 
 the most familiar of all sounds. The pure perceptions of sense 
 cannot be made clearer by descriptions and similitudes. 
 
 I would recommend students to practise auscultation upon 
 each other, for the sake of learning what the healthy respira- 
 tory murmur is ; and to do it often, and upon many individuals. 
 The respiratory murmur is, I believe, the same in kind in all 
 men who have healthy lungs ; but it has differences of degree 
 belonging to it in different men, which are somewhat puzzling 
 at first. It does not reach the ear with the same clearness and 
 loudness in the fat and the lean man. Fat and muscle damp 
 the sound, where they abound above measure, as effectually as 
 coats and waistcoats. Ausculting a man who is very fat and 
 muscular, is like ausculting a man with his clothes on: you 
 must make the same allowance in both cases. 
 
 But still the reason why the healthy respiration is more or 
 
106 SUBJECTS CONNECTED WITH [LECT. VII. 
 
 less audible cannot always be found in the integuments of the 
 chest. It often happens, that in a thin spare man, whose lungs 
 are perfectly sound, you can scarcely hear it at all, while in a 
 fat man you hear it most distinctly ; and, what is more remark- 
 able, in a fat woman, even through the mamma. 
 
 People seem to me to differ very much in the mode and 
 intensity of their breathing : some fill their lungs at every in- 
 spiration : the air appears to go further, and to dwell longer, 
 within them. They breathe as if they had a luxury in breathing ; 
 and your ear seems to follow the air through every cell and 
 vesicle as it goes in and out. Some, on the contrary, let the air 
 just enter into their lungs, and come back again. They breathe 
 as if they were afraid of breathing ; and your ear can hardly 
 detect any respiratory murmur except when they breathe with 
 a forced effort. 
 
 It is probable that these diverse modes of breathing, in 
 people perfectly healthy, are required by peculiar states of the 
 circulation ; and that they are natural and necessary provisions, 
 not only consistent with health, but essential to it. 
 
 In children the respiratory murmur is far more audible 
 than in adults ; and on this account it would be well for those 
 to whom auscultation is new to make their first trials upon 
 children, that they may know what the healthy respiratory 
 murmur is in its full and complete development. 
 
 That the parietes of a child's chest are thinner, there can be 
 no doubt : and this may be one cause why its breathing is more 
 audible. But the mode and intensity of the breathing itself is 
 the chief cause ; and this peculiar breathing of a child is in 
 obedience to some natural necessity, and that necessity is pro- 
 bably respective to its circulation. 
 
 In adults (even in fat and muscular men and women) the 
 respiratory murmur is sometimes as loud as in a child. But then 
 it is generally in some part only of the lungs that it is so ; and 
 when this is the case, it is the result of disease, and the disease 
 is demonstrably of a nature to require that a larger quantity of 
 air should be received into that portion of the lungs whence the 
 louder respiratory murmur issues, and that there should be a 
 more energetic act of respiration. 
 
 All this you will soon be able to verify for yourselves, by 
 numerous cases in the wards of the hospital. 
 
LECT. VII.] CLINICAL MEDICINE. 107 
 
 Having learned the natural respiratory murmur, the sound 
 which indicates that the lungs are healthy, you have got your 
 standard of comparison, and are now prepared to judge of the 
 sounds which denote their disease, as far as they are connected 
 with the respiration. But you have got more than a mere 
 standard of comparison by which to try the quality of other 
 sounds. Youjare enabled to appreciate simple defects and 
 failures of the respiratory murmur itself; and, indeed, it is as 
 important a part of the business of auscultation to learn the 
 extent to which the respiratory murmur is absent, as to dis- 
 criminate the kind and character of the new sounds which are 
 present and have superseded it. Besides, the diseases of the 
 lungs are neither few nor inconsiderable in which auscultation 
 finds no new or unnatural sounds whatever, but only the natural 
 respiratory murmur abated, or abolished ; and these privative 
 signs are as valuable helps to the diagnosis of pulmonary 
 disease, as'any that are most positive and real. 
 
 But, after all, let it be borne in mind that the auscultatory 
 signs of pulmonary disease are not all developed in the act of 
 breathing : many occur in speaking or coughing ; as will here- 
 after be shown. 
 
 It seems to me that it would be enough for all practical 
 purposes if the unnatural sounds referable to the lungs, whether 
 in breathing, speaking, or coughing, were divided generkally 
 into two ; into Dry sounds and Moist sounds. 
 
 By dry sounds I mean those which result when bronchi, 
 vesicles, or pulmonary cavities, present impediments, or re- 
 bounding surfaces, to the passage of air, and thus become 
 sonorous or vocal from reverberation. By moist sounds I mean 
 those which result, when bronchi, vesicles, or pulmonary cavities, 
 present fluid to the passage of air, and thus yield a crackling 
 or bubbling noise from the mingling of air and fluid together. 
 
 Of these sounds, the dry and the moist, I will point out such 
 well marked varieties as (I conceive) need to be understood, 
 and will endeavour to give to each an appropriate name ; taking 
 care in the meantime to treat the subject as little artificially as 
 possible, while I state fairly and faithfully, from my own ex- 
 perience, how I have used, and what benefit I have derived from 
 using, this newly invented key to the diagnosis of thoracic 
 diseases. 
 
108 SUBJECTS CONNECTED WITH [LECT. VIII. 
 
 LECTURE VIII. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 RHONCHUS AND SIBILUS — "WHERE AND HOW PRODUCED. HOW 
 
 THEY INTERFERE WITH THE RESPIRATORY MURMUR. IN WHAT 
 
 SENSE THEY ARE DRY SOUNDS. — THEIR PATHOLOGICAL IMPORT. 
 
 CONDITIONS UNDER WHICH RHONCHUS OCCURS — CONDITIONS 
 
 UNDER WHICH SIBILUS OCCURS ILLUSTRATED BY COMMON 
 
 FORMS OF BRONCHIAL DISEASE ; BY ASTHMA, AND BY A PECULIAR 
 FORM OF ACUTE BRONCHIAL INFLAMMATION. 
 
 Before I employ any terms to designate particular sounds, I 
 would remark that the language of auscultation is not yet 
 uniform. All writers do not use the same terms to designate 
 the same things ; and, until they do, some inconvenience must 
 continue to he felt. Under these circumstances, I shall take 
 the liberty of using those which hare become current in St. 
 Bartholomew's Hospital, and have had here a certain meaning 
 attached to them. 
 
 In considering the direct symptoms of diseases of the lungs 
 derived from auscultation, I will begin with that part of their 
 structure which is most obnoxious to disease ; for there is a part 
 in which disease is found most frequently to begin, and to which, 
 wherever else it may begin, it is almost always found ultimately 
 to reach. This is the mucous membrane of the bronchi and 
 their ramifications. 
 
 It is essential to the healthy respiratory murmur, not that 
 the bronchi and their ramifications be merely free and pervious 
 in every part, but that their surface be equal and smooth, and 
 lubricated with moisture, and that the moisture be not in 
 excess. If the surface be unequal, rough, or unlubricated, dry 
 sounds reach the ear in the act of respiration ; if there be excess 
 of moisture, the sounds that reach the ear are those of air 
 mingling with fluid. The dry sounds thus proceeding from the 
 
LECT. VIII.] CLINICAL MEDICINE. 109 
 
 air passages I will call Rhonchus and SiUlus, and the moist 
 sounds Crepitations. 
 
 This Rhonchus and Sibilus, and these Crepitations, are 
 always produced in breathing, not in talking or coughing. And 
 first I wish to speak of what they are in themselves, and of 
 how they interfere with the healthy respiratory murmur ; and 
 then I will endeavour to estimate their pathological import. 
 
 The terms Rhonchus and Sibilus are perhaps as intelligible 
 in themselves as they can be made by further description. 
 Rhonchus is the larger and hoarser sound ; Sibilus the smaller 
 and shriller. And, from what you must familiarly know of the 
 sounds produced by blowing into a pipe of larger or smaller 
 size, you will readily conceive that Rhonchus proceeds from 
 the bronchi in their first divisions, and Sibilus from them in 
 their minute ramifications, or from the vesicular structure of 
 the lungs. 
 
 Rhonchus often occurs alone. It is often the only unnatural 
 sound that is heard ; and then the affection is of the bronchi in 
 their first or larger divisions exclusively. In this case, to what- 
 ever degree the rhonchus supersedes the healthy respiratory 
 murmur, it does so, not in the sense of preventing it from taking 
 place, but in the sense of preventing it from being heard. The 
 Rhonchus overpowers the respiratory murmur. The greater 
 sound overpowers the less ; but the less is extant notwith- 
 standing. 
 
 The reason is, that the bronchi in their first divisions have 
 nothing to do with producing the respiratory murmur ; it does 
 not arise in them, but in the lesser ramifications and vesicular 
 structure beyond them ; therefore they have no power to hinder 
 the respiratory murmur, except when they suffer such impedi- 
 ments as absolutely preclude the access of air even to themselves, 
 and consequently must prevent its further progress. 
 
 But, in point of fact, it seldom happens that the Rhonchus 
 is loud enough to overcome the murmur altogether ; and while 
 they exist concurrently the ear has often a distinct perception 
 of both. There is a loud hoarse sound in several parts, and 
 there is also, perhaps even in the same situations, a clear 
 respiratory murmur. The murmur is, as it were, heard through 
 the rhonchus. In such cases some of the larger bronchi contain 
 the cause productive of the dry sound, but offer, nevertheless, 
 
110 SUBJECTS CONNECTED WITH [LECT. VIII. 
 
 hardly any impediment to the free passage of air; which, 
 reaching the lesser bronchi and vesicles of the lungs, and finding 
 them healthy, glides through them, and produces as it goes the 
 murmur which is the best evidence of health. 
 
 So, too, Sibilus often occurs alone, and is often the only 
 unnatural sound that is heard during respiration ; and then the 
 affection is of the bronchi in their lesser ramifications, or of the 
 vesioles of the lungs. But in this case, to whatever degree the 
 Sibilus supersedes the healthy respiratory murmur, it does so 
 not in the sense of preventing it from being heard, but of 
 preventing it from taking place. And the reason is, that the 
 parts which produce the Sibilus and the respiratory murmur 
 are the same ; but the conditions under which they produce them 
 are different. Consequently the sounds themselves are incom- 
 patible with each other, and cannot co-exist. 
 
 But Bhonchus and Sibilus, though each often occurs alone, 
 do just as often occur both together. And nothing more is 
 wanted to this event than that a bronchus, through its several 
 divisions and ramifications, large and small simultaneously, 
 should contain the cause capable of modifying the vibrations of 
 the air in its passage. 
 
 The moist sounds occasioned by the mingling of air and fluid 
 in the bronchi and their ramifications during the act of breath- 
 ing, which have been variously denominated, I call by one 
 name, Crepitations; and of Crepitations I only make the 
 distinction of Large and Small. 
 
 Sounds so produced are ever without variety, and can only 
 differ in being greater or less. And according to their largeness 
 or smallness, and the space to which they are extended or con- 
 fined, they become important signs in all those diseases where 
 a separation of fluid from the mucous membrane of the air 
 passages is a pathological ingredient. 
 
 The Large Crepitation is occasioned by the mingling of air 
 with fluid in the first divisions of the bronchi. It arises from 
 the same parts as the Rhonchus, but results from a different 
 condition. 
 
 The Small Crepitation is occasioned by the mingling of air 
 with fluid in the lesser ramifications of the bronchi, or in the 
 vesicles of the lungs. It arises from the same parts as the 
 Sibilus, but is owing to a different state of those parts. 
 
LECT. VIII.] CLINICAL MEDICINE. Ill 
 
 The large and small Crepitation have the same effect of 
 suppressing or superseding the respiratory murmur that the 
 Rhonchus and Sibilus have; and each after its own manner 
 respectively. The Large Crepitation, proceeding from the same 
 parts as the Rhonchus, may overpower the murmur, but cannot 
 prevent it from taking place ; whereas the Small Crepitation, 
 proceeding from the same parts as the Sibilus, is instead of the 
 murmur, which it abolishes altogether. 
 
 All the bronchi in their primary divisions may contain an 
 excess of fluid, and Large Crepitation may be heard over every 
 part of the chest ; and yet, through that Large Crepitation, a 
 practised ear will be able to detect the respiratory murmur ; 
 obscured, indeed, by the louder sound, but itself genuine and 
 healthy. 
 
 So, too, all the bronchi in their lesser ramifications, and the 
 whole vesicular structure of the lungs, may contain an excess 
 of fluid, and Small Crepitation may be heard in every part of 
 the chest ; but, in the meantime, no ear is subtle enough to 
 catch the natural respiratory murmur, for no such murmur exists. 
 
 The Large and Small Crepitations may co-exist together in 
 every variety of combination. You may have both Large and 
 Small in every part of both lungs ; or Large in one lung, and 
 Small in the other ; or Large and Small in different parts of 
 the same lung. And with Large and Small Crepitation thus 
 differently combined, Rhonchus and Sibilus may be still inter- 
 mingled, and some natural respiratory murmur be here and 
 there distinguishable among all the rest. 
 
 I wish now to consider the pathological import of the 
 several auscultatory signs which have been specified, before I 
 proceed to others ; for they are practically the most momentous 
 of all. They are few ; but they convey vast information ac- 
 cording to the manner and combinations in which they occur. 
 Do not be surprised at this. There are but twenty-six letters 
 in the alphabet ; yet these compose all language ; and language 
 conveys all knowledge. Think of knowledge, its vastness, its 
 variety, its multitudinous particulars ! Yet language has com- 
 passed it all ; language has delineated it all ; and language is 
 daily furnishing to you and to me little pictures of such por- 
 tions of it as we desire to survey. Still the wonders of 
 language are comprised in twenty-six letters. 
 
112 SUBJECTS CONNECTED WITH [LECT. VIII, 
 
 Let it not, therefore, seem strange that many conditions of 
 disease are signified by a few simple sounds. 
 
 I hare called Rhonchus and Sibilus dry sounds, because I 
 thought it particularly important to distinguish them from 
 others which, arising from air and fluid in the act of mingling 
 together, are properly denominated moist sounds. But I must 
 warn you against inferring, from my designation of them as 
 dry sounds, that a preternatural dryness of the air passages is 
 essential to their production ; for such is not the case. Indeed, 
 respective to the conditions out of which they arise, I would 
 rather say, of Rhonchus and Sibilus, that they were not moist 
 than that they were dry. And if you like it better, there is no 
 objection to your speaking of sounds that are moist and sounds 
 that are not moist, instead of sounds that are moist and sounds 
 that are dry. 
 
 Rhonchus is the most fluctuating and inconstant of all 
 sounds that belong to the lungs. It arises out of various 
 pathological conditions, and out of some that do not deserve to 
 be called pathological at all. It would be affectation to pre- 
 tend to speak of them all with precision. 
 
 People in perfect health are apt to have Rhonchus mixed 
 with the ordinary respiratory murmur : they strive to clear 
 their throat by a forced effort of expectoration, and sometimes 
 bring up a little phlegm and sometimes not ; they only displace 
 it. Hereupon the Rhonchus ceases, and the respiratory 
 murmur remains alone. Again, people suffering disease of the 
 lungs are apt to have Rhonchus mixed with all sorts of un- 
 natural sounds. They make an effort to dislodge or reject a 
 little phlegm and the Rhonchus disappears, but all the other 
 unnatural sounds remain. 
 
 In these cases the cause of the Rhonchus is evidently 
 secreted matter from the surface of the bronchi ; but why does 
 it not produce crepitation and not rhonchus ? Simply because 
 it is not fluid enough to allow the air to penetrate it, mingle 
 with it, and pass through it. The air, in going in and coming 
 out, passes by it and impinges against it, and suffers a vibra- 
 tion from it ; and this yields the sound. 
 
 This Rhonchus, which is owing to tough and viscid phlegm 
 clinging to the part upon which it is deposited, is sometimes 
 propagated over the whole, or a considerable part of the chest ; 
 
LECT. VIII.] CLINICAL MEDICINE. 113 
 
 but then the extent of the Rhonchus is no just measure of the 
 quantity of the phlegm. The phlegm may still be very small 
 in quantity ; but being lodged in the trachea, or the first divi- 
 sions of the bronchi, where they are very large and free, it 
 vibrates, like a harp-string, to the impulse of air, and diffuses 
 the Rhonchus far and wide through the chest. 
 
 But, whether this explanation be satisfactory or not, it is 
 perpetually happening that a Rhonchus, heard in every part 
 of the chest, is made to cease at once by a stout voluntary 
 effort of expectoration. Indeed I may venture to say, from 
 my own observation, that a Rhonchus may almost always be 
 thus got rid of, whether it occur alone or be one amongst 
 other unnatural sounds. And hence I infer that the cause 
 of Rhonchus is almost always a small tough moveable piece of 
 phlegm, adhering to the trachea or first divisions of the bronchi. 
 
 The cause is, however, sometimes immoveable and perma- 
 nent, and quite of another kind. Anything, from within or 
 from without, that has the effect of narrowing or obstructing a 
 bronchial tube, in ever so small a space, may occasion the 
 same sort of sound. Changes of structure within the parts 
 themselves, such as a thickening of the mucous membrane, 
 or the ossification of a cartilaginous ring ; or morbid growths 
 from without, such as a bronchocele, an aneurismal sac, or a 
 tubercular mass in the bronchial glands, or in the lungs them- 
 selves, — have so compressed or distorted the trachea, or certain 
 bronchi, that the air could not force its way through them 
 without continual vibrations, and without the respiration being 
 constantly accompanied by a hoarse unnatural sound — by 
 Rhonchus. 
 
 It is not easy to determine the conditions which are essential 
 to the production of Sibilus. In seeking to assign them, I am 
 left to my own reasonable calculation of what they possibly may 
 be, having no direct means of proving what they actually are. 
 I never knew any person die whose only auscultatory symptom 
 was a Sibilus. Yet I believe people may and do die, and I have 
 myself seen several in imminent peril of death, from disease of 
 the lungs, whose only auscultatory symptom referable to the 
 lungs, has been a widely diffused Sibilus. Of such cases I will 
 speak presently: they are of great importance, and well' deserve 
 to be pointed out. 
 
114 SUBJECTS CONNECTED WITH [LECT. VIII. 
 
 Sibilus, like Rhonchus, may occur alone, or in combination 
 ■with other auscultatory signs. But whether alone or mixed 
 with others, it cannot, like Rhonchus, be got rid of by an effort 
 of expectoration. Yet the cause of both may be the same in 
 kind, and different only in situation. A secreted matter, not 
 fluid enough to admit air to mingle with its particles and thus 
 produce a moist sound, but so consistent as to present a reverber- 
 ating surface, and thus produce a dry sound, may be equally the 
 occasion of Rhonchus and Sibilus. But in Rhonchus this 
 matter is within reach of a voluntary succussion of the trachea 
 and bronchi to expel it ; in Sibilus it is beyond it. In Rhon- 
 chus it is contained within the first divisions of the bronchi; in 
 Sibilus, within their lesser ramifications. 
 
 Sibilus, whether alone or in its combinations, cannot, like 
 Rhonchus, ever be regarded as an innocent symptom. It is a 
 more unquestionable evidence of disease than Rhonchus, in 
 whatever that disease may consist. 
 
 Sibilus is almost always mixed with Small Crepitation. 
 They are united together' in the same individual, and often 
 succeed and supersede each other, as if they were contending 
 together for the mastery ; now one and now the other being 
 predominant. 
 
 This mixture of Sibilus and Crepitation, and the predomin- 
 ance first of one and then of the other, are chiefly seen where 
 both are largely diffused throughout the lungs ; and in such 
 cases one may often remark a fluctuation of the general 
 symptoms answerable to this fluctuation of the auscultatory 
 signs ; that these symptoms, in their aggregate, become more 
 inflammatory when the Sibilus increases, and less inflammatory 
 when the Sibilus declines ; also that the remedy which abates 
 their general inflammatory character commonly abates the 
 Sibilus ; also when the expectoration is freer the Sibilus is less, 
 and when the expectoration is scanty the Sibilus is more. 
 
 Now these are, indeed, great practical points, if they be 
 true ; and there are always examples enough to be found in this 
 hospital by which you may test their truth. There are plenty 
 of patients who have been suffering cough, expectoration, and 
 dyspnoea, long and habitually, — some from disease which belongs 
 primarily to the lungs — some from disease which is derived to 
 the lungs from the heart. "Watch these patients well for a few 
 
LECT. VIII.] CLINICAL MEDICINE. 115 
 
 weeks together; mark the auscultatory signs and their fluctua- 
 tions ; mark the general symptoms and their fluctuations also ; 
 mark the treatment, and its adaptation to, and influence upon 
 both; and then judge whether the practical points, which respect 
 the particular auscultatory sign now in question, are really such 
 as I have represented them. 
 
 These cases of chronic bronchial affection are the most 
 favourable for teaching the character of Sibilus, and how it 
 stands related to other auscultatory signs, and to more general 
 symptoms, and how it is amenable to methods of treatment. 
 Such cases tell their story (if I may say so) more leisurely: 
 they tell it over and over again, and with many interesting 
 variations and thus give you time to dwell upon it and under- 
 stand it. 
 
 But still of Sibilus, that is thus mixed with Crepitation, now 
 superseding it, and now superseded by it — becoming less as the 
 expectoration is more, and more as the expectoration is less — 
 increasing as the general symptoms are more inflammatory, and 
 yielding to the same remedies that they yield to; — of this 
 Sibilus I do not pretend punctually to know the local efficient 
 cause, or the exact pathological condition of the parts out of 
 which it immediately arises. I am content to believe (without 
 any curious speculation upon things which I cannot prove) that, 
 upon the access of a more inflammatory action, the secreted 
 matter in many bronchial ramifications becomes more scanty and 
 less fluid, so that the air that is breathed cannot freely mingle, 
 with it, and thus Crepitation yields to Sibilus ; and that, upon 
 the subsidence of the inflammatory action, the secreted matter 
 becomes more copious and more fluid, so that again the air 
 freely mingles with it, and thus Sibilus in its turn yields to 
 Crepitation. 
 
 But Sibilus does not occur under these circumstances only. 
 It does not merely go and come, or occasionally intervene in 
 chronic bronchial disease, of which the auscultatory symptom 
 that is most characteristic and abiding is of another kind. 
 There are cases in which Sibilus is itself the most characteristic 
 auscultatory symptom, — cases in which for a long period, and 
 cases in which even from first to last, there is no other auscul- 
 tatory symptom whatever but Sibilus. 
 
 There are cases of (what I suppose would be called) genuine 
 
116 SUBJECTS CONNECTED WITH [LECT. VIII. 
 
 asthma, that present some such symptoms as these : dyspnoea, 
 or rather an agony and fighting for breath; livid lips; cold 
 and livid extremities ; and a dry ineffectual cough, terminated 
 and relieved, after an uncertain interval, by a copious puriform 
 expectoration. Here, during the agony or paroxysm (and un- 
 fortunately it often continues long enough to allow a very 
 leisurely examination of the chest by the ear — sometimes many 
 days, sometimes a week or two), the sole auscultatory sign is a 
 Sibilus pervading a larger or smaller portion of the lungs, 
 according to the severity of the case. And, as the agony 
 lessens, and the expectoration begins to appear, Crepitation is 
 found mingling itself with Sibilus ; and, when the agony has 
 entirely ceased, and the expectoration become more copious and 
 free, Crepitation, and Crepitation alone, is then heard in the 
 same situations, and to the same extent, that Sibilus, and 
 Sibilus alone, was heard before. 
 
 I have witnessed instances of asthma in several individuals, 
 and several attacks of asthma in the same individual, where 
 the auscultatory signs have had as strict and definite a corres- 
 pondence with the stages, progress, and prominent symptoms 
 of the disease, as that which I have here described. 
 
 Now, if absolute Dryness can be ever safely predicated of 
 the respiratory passages, and can be ever safely reckoned 
 among the pathological ingredients of their diseases, and ever 
 clearly notified by one express symptom, it is in spasmodic 
 asthma, of which it seems the chief pathological ingredient 
 during its first and often most protracted stage, and is clearly 
 notified by a widely diffused Sibilus. 
 
 I am persuaded that the natural moisture of the respiratory 
 passages is then really in defect, and that Sibilus is really an 
 index ©f the fact. Sibilus may then, if ever, be truly called a 
 Dry sound. But I am not sure that the Sibilus directly results 
 from the mere condition of Dryness ; I doubt whether simple 
 Dryness alone would naturally produce it. In consequence of 
 its Dryness the mucous membrane may lose its elasticity, and 
 become to a certain degree unyielding; or it may undergo 
 wrinklings or puckerings at various spaces, or its general tume- 
 faction may produce a narrowing of the smaller tubes, and thus 
 present obstacles to the passage of air, and impart to it new 
 vibrations ; and hence the Sibilus. 
 
LECT. VIII.] CLINICAL MEDICINE. 117 
 
 Nevertheless, whether Dryness of the respiratory passages, 
 or other conditions necessarily resulting from it, give imme- 
 diate occasion to the Sibilus, the Sihilus may be properly re- 
 garded as the auscultatory symptom of the former. Dryness of 
 the mucous membrane bespeaks a well-known pathological 
 change; the other conditions are mere matters of conjecture. 
 
 Thus far I have spoken of Sibilus occurring in two forms of 
 bronchial disease. 1st, As it intervenes among the ausculta- 
 tory symptoms of certain chronic affections, characterized by 
 dyspnoea, expectoration, and cough, instances of which are per- 
 petually at hand to enable you to verify the fact. 2ndly, As it 
 presents itself as the sole auscultatory symptom that attends 
 the paroxysm or agony of an asthmatic attack, when it is so 
 marked that its presence can never be doubted. In both these 
 forms of disease Sibilus conveys pathological and practical 
 information of great importance. 
 
 But does Sibilus ever occur in acute bronchial or vesicular 
 inflammation ? And does it ever so occur as to throw essential 
 light upon morbid processes going on, and essential light upon 
 modes of treatment ? 
 
 Inflammation of the bronchial ramifications perhaps never 
 exists without the natural secretion of their mucous surface 
 being either diminished or increased, and, consequently, with- 
 out the accompaniment of those sounds which indicate its 
 defect or excess ; i.e. without Sibilus or Crepitation. 
 
 Sibilus is apt to occur at the beginning of such inflamma- 
 tion ; and thus it corresponds with the pathological condition 
 out of which it arises, the mucous membrane, when it is in- 
 flamed, becoming drier than ordinary before it yields a more 
 abundant secretion. 
 
 Sibilus, too, after it has arisen, is apt to be of short dura- 
 tion, seldom abiding long as the sole auscultatory symptom of 
 such inflammation. And herein also *it corresponds with the 
 pathological condition from which it proceeds ; for the dryness 
 of the mucous surface generally soon gives place to moisture. 
 
 Hence it happens that Sibilus is so seldom met with in 
 practice, except with some mixture of Crepitation. The inflam- 
 mation is, in truth, not submitted to our observation until the 
 .stage of dry sounds is passing, or has already passed, into the 
 stage of moist sounds. 
 
118 SUBJECTS CONNECTED WITH [LECT. VIII. 
 
 Nevertheless, there are cases in which Sibilus is the sole and 
 abiding symptom derived from Auscultation, and a dryness of 
 the air passages the sole and abiding morbid condition. They 
 are cases distinct from asthma — cases of genuine inflammation, 
 and so remarkable as to require an especial notice. 
 
 I have met with a frightful affection in children ; but what 
 its nature was I could never tell, until auscultation enabled me 
 to unravel it. It commonly passes for inflammation of the 
 lungs. But, when children have got well, they have got well 
 so soon and so entirely, that I could never believe the disease to 
 be pneumonia, although the symptoms seemed to indicate that 
 it could be nothing else. 
 
 Last summer I went out of town to see a little boy, seven or 
 eight years of age, whose life was very precious to his family. 
 He was thought to be dying of inflammation of the lungs. I 
 found him raised up in bed, supported by his nurse, and breathing 
 with all his might. His skin was hot ; his face flushed ; and 
 his chest heaved, and his nostrils quivered frightfully. There 
 was no croupy sound. "Whatever the disease was, it was all 
 within the chest. I percussed the chest : it sounded well in 
 every part: I listened: the air entered freely, and reached 
 every cell and vesicle of the lungs ; but there was not the least 
 perception of the natural respiratory murmur : a shrill Sibilus 
 had taken place of it altogether. Wherever you applied your 
 ear to the chest, you might fancy you heard the piping and 
 screaming of a nestful of unfledged birds. 
 
 But what was this disease ? Surely it was inflammation 
 largely diffused over the mucous surface throughout the 
 bronchial ramifications, but inflammation, as yet only in its first 
 stage ; for the air, as it passed through them, did not mingle 
 with a particle of fluid anywhere, and the sound it produced 
 was a dry Sibilus only. 
 
 But how inflammation yet only in its first stage ? The boy 
 had been already ill four days. Still it might be inflammation 
 in its first stage. The boy continued ill two days longer, with 
 the same kind and the same degree of suffering ; and then, 
 under the influence of tartar emetic, the fever began gradually 
 to subside, and the dyspnoea to abate. The Sibilus gradually 
 gave way to the healthy respiratory murmur, and he was well 
 
LECT. VIII.] CLINICAL MEDICINE. 119 
 
 again without expectoration of any hind. The inflammation 
 began and ended with the first stage ; and, although it continued 
 with great severity for a week, it never got beyond the 
 first stage. 
 
 This is an instance, which strikingly shows the value of 
 Auscultation in detecting at once the state of things, about 
 which you might go on conjecturing and conjecturing for ever 
 what it possibly might be, and not gain the least assurance what 
 it actually was. 
 
 In adults sometimes, but not so frequently as in children, I 
 have met with the same evidences of acute inflammation widely 
 diffused through the bronchial ramifications, and remaining in 
 this its first stage for days and days together. In the mean- 
 time their mucous surface has still been dry throughout a great 
 part of both lungs, and the ear has continued for days and days 
 together to hear no other unnatural sound but a Sibilus. Con- 
 valescence has taken place without expectoration, and the Sibilus 
 has given way, without the intervention of any moist sound, at 
 once to the murmur of health. 
 
 But such inflammation, after lingering long in the first 
 stage, will sometimes pass beyond it ; and the whole mucous 
 surface that was previously dry will pour forth an enormous 
 secretion, and the widely diffused Sibilus will be changed into 
 a widely diffused Crepitation. Still the lungs are unhurt 
 beyond the lining membrane of the air passages, and the 
 patient will get well, if he be not suffocated by the enormous 
 expectoration. 
 
 I am speaking of a disease which must be distinguished 
 from asthma, according to the usual acceptation — a disease not 
 habitual to the individual, and of which, perhaps, he has never 
 suffered a previous attack. I am speaking of acute inflammation 
 extending throughout the bronchial ramifications, and reaching, 
 perhaps, the vesicular structure of the lungs, puttin» on a 
 peculiar form, and affecting a peculiar course ; but still of acute 
 inflammation, as further evidenced by the remedies necessary 
 for its relief. 
 
 During the last summer I saw a gentleman, who had been, 
 two days previously, seized rather suddenly with feverish 
 symptoms, and with the most dreadful dyspnoea. His lips were 
 
120 SUBJECTS CONNECTED WITH [LECT. VIII. 
 
 blue ; he was labouring for breath, and coughing with hard and 
 ineffectual efforts to rid himself of something which seemed to 
 tease the larynx, but no expectoration followed. 
 
 Cupping on various parts of the chest (the state of vascular 
 action required that blood should be drawn), and tartar emetic 
 in frequent doses, were the remedies employed ; but in the same 
 state of agony he remained for a week, propped up in bed, 
 striving with all his might to free himself from his oppres- 
 sion, coughing and endeavouring to expectorate, but inef- 
 fectually. 
 
 "What was going on all this time ? There was anguish 
 enough for any disease of the most formidable name ; for fluid 
 in the pericardium ; for extensive hydrothorax ; for induration 
 of a whole lung ; for stricture at some orifice of the heart. A 
 few years ago the most sagacious physician could only have 
 guessed at the real state of disease, and probably would have 
 guessed wrong. Such severe dyspnoea, so long continued, with- 
 out expectoration, would probably have determined his diagnosis 
 to hydrothorax. 
 
 But what was the disease ? Every part of the chest sounded 
 well to percussion. The heart beat regularly, and with a 
 natural sound, only with too great frequency. 
 
 What could it be ? There reached the ear from every part 
 of the chest to which it was applied a loud Sibilus. The disease 
 was an inflammation largely diffused through all, perhaps, of 
 the bronchial passages, great and small ; inflammation abiding 
 long in its first stage, and limiting itself to one structure. 
 
 But in this case the inflammation ultimately passed 
 beyond its first stage ; for ultimately there arose an immense 
 expectoration, and so the disease reached a favourable termi- 
 nation. 
 
 I have said that it is the peculiar praise of auscultation, not 
 merely to discover disease in its ultimate results, but to analyse 
 it in its several processes as it goes on ; to mark its stay and 
 continuance in one process, and its passage and transitus from 
 one to another. Here we have a conspicuous instance of both 
 these circumstances discovered to us by Auscultation. 
 
 It is, I suspect, among the characteristics of inflammation, 
 that, in proportion as it is more widely diffused, it should be 
 
LECT. VIII.] CLINICAL MEDICINE. 121 
 
 less rapid in its progress ; not necessarily less severe, as far as 
 severity is measured by force of vascular action and by fever, 
 but less rapid in accomplishing its whole course; dwelling 
 longer in each particular stage before it passes to another, than 
 the inflammation which begins at a point. 
 
 Of this we have an example in acute rheumatism, which is 
 diffused over similar structures in many joints simultaneously. 
 In acute rheumatism, action and suffering are carried to the 
 utmost degree of severity. There are extreme heat, and 
 extreme pain, and extreme vascular action, in the parts, and in 
 the constitution at large ; yet all are expended upon one stage 
 of inflammation. 
 
 Rheumatism may exist for weeks and months together, 
 with all its pain, and heat, and vascular action, unabated. 
 Chronic in duration, but most acute in what respects action 
 and suffering, it should seem that any length of time was 
 permitted to it to do all that inflammation can effect within a 
 certain limit, but that it was restrained by a strong, though not 
 an invincible, law, from transgressing that limit, or doing 
 harm beyond it. 
 
 After many weeks or months the inflammation will cease, 
 and every joint be restored to the form, and feelings, and 
 functions, of health. 
 
 Such inflammation may exist in internal parts. (I do not 
 mean rheumatic inflammation. Do not let- me perplex you 
 with a name. I only refer to rheumatism as to something well 
 known, for comparison's sake, or analogy.) Inflammation, I 
 say, may exist in internal parts, which (like rheumatic inflam- 
 mation of the joints) is of a diffusive character, and occupies a 
 large extent of surface at once, travelling tardily from struc- 
 ture to structure, slow to disorganize, abiding long in each of 
 its stagfs, and giving leisure for the application of remedies in 
 all of them. Such an inflammation is especially incident to 
 the lungs ; and, of the pulmonary structures, especially to the 
 mucous membrane which lines the air passages. 
 
 I have given instances of such inflammation of the bronchi 
 lingering in its first stage, its stage of mere vascularity and 
 defective secretion ; and I have dwelt upon these instances for 
 the sake of showing you the real value of Sibilus as a patho- 
 
122 SUBJECTS CONNECTED WITH [LECT. VIII. 
 
 gnomonic sign. But for it, in the instances specified, I could 
 not have made out the nature of the disease. 
 
 Of Sibilus I will venture to observe, that sufficient regard 
 has not yet been bestowed upon what it is in itself. It is 
 usually spoken of as conducting to Crepitations, and mixed 
 with Crepitations, or moist sounds. But there wants some 
 illustration of it in its separate import, as standing alone. To 
 that illustration what I have said may, perhaps, contribute a 
 little. 
 
LECT. IX.] CLINICAL MEDICINE. 123 
 
 LECTUEE IX. 
 
 ON THE DOCTRINE OP SYMPTOMS. 
 
 CREPITATIONS, OR MOIST SOUNDS, THAT ATTEND THE ACT OF 
 BREATHING. — LARGE AND SMALL CREPITATIONS. — THE DIS- 
 TINCTION OBVIOUS AND USEFUL IN ITS MAIN CHARACTERIS- 
 TICS — UNCERTAIN AND USELESS IN ITS LESSER DEGREES. — 
 CREPITATIONS THE MOST FREQUENT OP ALL AUSCULTATORY 
 
 SIGNS. — WHAT THEY CAN, AND WHAT THEY CANNOT, TEACH. 
 
 HOW THEY NEED OTHER AND MORE GENERAL SYMPTOMS TO 
 INTERPRET THEIR MEANING. — ILLUSTRATED BY ACUTE IN- 
 FLAMMATION OP THE LARGER BRONCHI — OF THE SMALLER — ■ 
 BY THAT INFLAMMATION OF THE BRONCHI WHICH ACCOM- 
 PANIES DISEASES OF THE HEART — BY THAT WHICH SIMULATES 
 PHTHISIS — BY THAT WHICH IS CALLED PERIPNEUMONIA 
 
 NOTHA. HOW MUCH IN EACH CAN BE INFERRED FROM THE 
 
 KIND AND EXTENT OF THE CREPITATIONS. — THE CREPITATION 
 CHARACTERISTIC OF PNEUMONIA. 
 
 The sounds produced by the meeting and mingling of air with 
 fluid in the bronchial tubes during the act of respiration, I haye 
 called Crepitations ; and of Crepitations I have made one dis- 
 tinction only, large and small. 
 
 Between the largest of the large and the smallest of the 
 small there are many intermediate degrees ; and some of these 
 may perhaps seem to deserve a name. But, for my own part, 
 I always have had a great unwillingness to multiply names, 
 especially where things are essentially the same, and differ only 
 in being greater or less ; therefore I cannot bring myself to 
 invent several names to designate different degrees in the 
 present instance. 
 
 But though the extremes are far apart, yet in the midway 
 large and small Crepitation will so nearly meet, that there must 
 often be a doubt which is which ; and what one man calls large, 
 
124 SUBJECTS CONNECTED WITH [LECT. IX. 
 
 another will call small. Language, however, will afford no 
 remedy where the 'difficulty is in the thing itself. You can 
 only accurately distinguish things when they are some way 
 apart, and not when they lie close upon the confines of each 
 other. You can distinguish hetween light and darkness, hut 
 you cannot put a mark upon the boundary between day and 
 night. 
 
 Large Crepitation arises from air meeting and mingling 
 with fluid in the larger bronchi ; small Crepitation from the 
 same conditions in the smaller bronchi and the vesicles of the 
 lungs. This is an important distinction, and I desire to make 
 much of it : important, however, in its main and prominent 
 characteristics, but useless if it be refined into many degrees. 
 
 Without wishing to enter upon a criticism of nomenclature, 
 I would further remark that, in giving names to auscultatory 
 signs, we should take especial care that the names themselves do 
 not imply anything that is erroneous ; and that they do not go 
 beyond the truth, in pretending to designate that whi6h they 
 certainly cannot designate. 
 
 What I call " large Crepitation " is called by most French 
 writers " rale muqueux," and by most English writers "mucous 
 rattle." Call it rale, or rattle, or Crepitation, or what you will ; 
 but pray do not add " mucous " to it by way of specific diffe- 
 rence ; for this term must always seem to imply that the sound 
 is produced by air passing through mucus ; whereas it is pro- 
 duced equally by air passing through mucus, or pus, or blood, 
 or any fluid whatever. Besides, it is beyond the truth to say 
 that the quality of the fluid through which the air passes can be 
 distinguished by the quality of the sound that results. The 
 sound will indicate the situation and quantity of the fluid, and 
 no more. 
 
 Therefore, by whatever name you choose to designate the 
 moist sounds arising from the bronchial passages during respi- 
 ration, be it Crepitation, rale, or rattle, you cannot distinguish 
 it by any other epithets of more precise meaning than " large or 
 small," without implying more than you intend, and that, too, 
 something erroneous, or something beyond the truth. 
 
 Crepitation, or the sound which shows that the moisture of 
 the bronchial passages is in excess, is the commonest of all 
 auscultatory signs. Go round this hospital, and, out of the five 
 
LECT. IX.] CLINICAL MEDICINE. 125 
 
 hundred and more patients which it contains, you will probably 
 find Crepitation in forty or fifty. And in all these it arises 
 immediately from one and the same condition ; viz. from excess 
 of fluid in the bronchial tubes or in the vesicles of the lungs. 
 
 But all these patients cannot, in any just sense, be said to 
 have the same disease, because a single pathological condition 
 is the same in all. Neither, on that account, will all be found 
 to demand the same treatment. 
 
 I speak of disease and treatment in the largest and most 
 comprehensive sense. 
 
 Now the forty or fifty patients who have all Crepitation of 
 their lungs, are not suffering alike in other respects. And these 
 other respects in which they differ include the great charac- 
 teristics of their diseases, and the special indications of their 
 treatment. 
 
 At present I am speaking only of direct symptoms, imme- 
 diately referable to the part affected. "When I come hereafter 
 to speak of indirect symptoms, or those which, originating in 
 one part, declare themselves through the medium of another ; 
 and of general or constitutional symptoms, the signs of the 
 pulse, and of febrile and nervous affections in their various 
 kinds and degrees ; then I will endeavour to show that many 
 diseases, apparently local, have a much larger range through- 
 out the body, and that the treatment which is to compass their 
 cure must be alike comprehensive in its influence. 
 
 Learn, however, all that is capable of being known concern- 
 ing the mere part. Let the patient tell you how it feels amiss, 
 and ascertain for yourselves how it acts amiss ; and if it be a 
 part within reach of the sight, the hearing, or the touch, 
 make out what changes of structure it has undergone. Still 
 its sensations, its functions, and its structure, will only half 
 inform you what are the essentials of the disease it suffers. 
 
 Remember, there is a pathology of diseases beyond the part, 
 as well as a pathology of diseases within the part ; and that 
 the things beyond it are really and practically the great inter- 
 preters of the things within it. 
 
 Remember, there is a great vascular system, and a great 
 nervous system, and that these, according to the manner in 
 which they are actuated, assign a character to the local disease, 
 and determine its treatment accordingly. Concerning the 
 
126 SUBJECTS CONNECTED WITH [LECT. IX. 
 
 disease, they tell us what is its force of action, and what its 
 rate of progress ; and, concerning its treatment, they teach us 
 to choose the remedies, and so to regulate their impression as 
 to counteract this force of action, and to keep pace with this 
 rate of progress. 
 
 Bearing these considerations in mind, you will he ahle to 
 comprehend what I mean by saying, that the many patients in 
 this hospital who have Crepitation as a common auscultatory 
 sign, and redundant fluid in the bronchi or pulmonary vesicles 
 as a common pathological condition, may nevertheless have 
 different diseases. And, still bearing them in mind, you 
 will now be able to follow me as I run over a few prominent 
 distinctions. 
 
 Among the many who have this auscultatory sign, in some 
 it has endured for weeks or for months, and in some it has 
 sprung up since yesterday. In some it is accompanied bymuch 
 fever and great vascular action, and life itself seems already in 
 peril, although it has existed but for a few days. 
 
 In some it is accompanied by less fever and less vascular 
 action, and there is yet no peril of life, although it has existed 
 for many weeks. 
 
 This Crepitation is present in rheums and catarrhs, and 
 chronic coughs, which cleave to old people, from the end of 
 autumn to the beginning of spring, with little or no fever. 
 
 And it is seldom absent in chronic diseases of the heart ; 
 and here it is found sometimes with and sometimes without 
 fever, or any signs of inflammation ; as if the bronchial surface 
 had the power of simply increasing its secretions for the relief 
 of a burdened and baffled circulation through the lungs. 
 
 Crepitation also is a frequent accompaniment of pulmonary 
 haemoptysis, with or without fever. 
 
 Now, while the great constitutional symptoms are our para- 
 mount guides to the knowledge and treatment of the disease as 
 a whole, it is to this Crepitation that we are to look, in each 
 particular case, for the knowledge of what the disease is in 
 the lungs ; its exact seat, its extent, and the stage of its 
 progress. 
 
 The case is one, perhaps, in which there is much fever and 
 great vascular action ; while cough and dyspnoea, and some 
 
LECT. IX.] CLINICAL MEDICINE. 127 
 
 expectoration, denote tie lungs to be the part upon which the 
 inflammation has specially fallen. 
 
 We auscult, and discover Crepitation : and the Crepitation 
 has one main and prominent characteristic ; that it is large. It 
 is large, and large exclusively ; while through it, wherever it is 
 heard, the respiratory murmur is also heard in every part of 
 the lungs. 
 
 Such auscultatory Signs denote the mingling of air with 
 the matter of morbid secretion in the larger bronchial tubes, 
 and in them exclusively; the lesser tubes and the vesicular 
 structure of the lungs, the seat of the respiratory murmur, 
 being entirely free. 
 
 But the much fever, and the great vascular action, declare 
 this condition of the bronchi to be the work of severe inflamma- 
 tion, and of inflammation that is still going on. Yet, while 
 Auscultation continues to show that such is exclusively the 
 seat and limit of the inflammation, severe as it is, we are 
 warranted in expecting a favourable result; provided always 
 that we pursue a just treatment. For even the acutest inflam- 
 mation of the larger bronchi is unapt to extend itself to other 
 textures, or to involve the structure of the lungs beyond those 
 bronchi themselves. 
 
 But the case is one, perhaps, in which there are the same 
 constitutional symptoms bespeaking the disease to be inflam- 
 mation, and the same local symptoms, fixing that inflammation 
 upon the lungs. But withal, the Crepitation heard during 
 breathing is small, and small exclusively; and this small 
 Crepitation, wherever it is found, has entirely obliterated the 
 respiratory murmur. 
 
 Such auscultatory Signs denote the mingling of air with the 
 matter of morbid secretion in the lesser bronchial tubes, or in 
 the vesicles of the lungs. 
 
 In the former case, the disease was acute inflammation, and 
 it is no more than acute inflammation in this. We have the 
 same means of subduing inflammation in this which we had in 
 that, and the same plain indications to direct our treatment • 
 and the disease, in its own nature, is as amenable to remedies 
 here as it was there. Yet are we net warranted in forming the 
 same expectation of a favourable result. Because inflammation 
 of the lesser bronchi, unlike that of the larger, is ever ready to 
 
128 SUBJECTS CONNECTED WITH [LECT. IX. 
 
 pass beyond them to other textures, and to involve the whole 
 structure of the lungs. 
 
 Where you have small Crepitation one day, you may find 
 that it has entirely ceased the next ; and ceased, not to be 
 replaced by the respiratory murmur, but by absolute dulness 
 and total obliteration of sound. 
 
 And what is implied by this rapid change from small 
 Crepitation to total obliteration of sound ? Even this ; that 
 the bronchial ramifications and vesicular structure are so 
 pressed upon, from within and from without, by the effused 
 products of inflammation, by serum, or lymph, or pus, or blood, 
 or a mixture of all, that air cannot enter, and the lung has 
 become solid at that part, and may possibly have undergone 
 irreparable disorganization. 
 
 Let it not, then, be esteemed a small thing, that, upon 
 rational grounds, and by tokens which we can justify and 
 explain, we are able to arrive at this diagnosis ; that, in the 
 severest inflammation of such an organ as the lungs, we can 
 mark the cases which are within the probability of a perfect 
 cure, and those which are beset with the most perilous hazards. 
 
 To distinguish between inflammation of the larger bronchi 
 and inflammation of the smaller, or of the vesicular structure, 
 is still important in all its degrees, and whether it be chronic 
 or acute ; and auscultation will alway enable us to do so. 
 
 Chronic inflammation of the larger bronchi, after months 
 and years, is still reluctant to extend itself to other structures ; 
 whereas chronic inflammation of the lesser bronchi is always 
 ready to spread beyond its original seat. 
 
 The most frequent instances that I meet with, of inflamma- 
 tion, slight in degree and chronic in duration, affecting the 
 lesser bronchial tubes, and producing effusion into them, are 
 those in which it accompanies chronic disease or disorganization 
 of the heart. It is evidenced by small Crepitation proceeding 
 from a considerable space at the lower part of one or both lungs, 
 and often continuing to be heard for months and months 
 together. Thus, even for months and months, the lung may 
 remain quite pervious, but crepitating. Yet there is no 
 security, in the meantime, that what is pervious and crepitating 
 to-day, may not be absolutely impervious and dull to-morrow. 
 In point of fact, I have known, by the test of auscultation, 
 
LECT. IX.] CLINICAL MEDICINE. 129 
 
 nearly a whole lung become condensed and solid in the course 
 of a single night, when there has been nothing to give warning 
 of such a catastrophe. 
 
 Indeed, in the dissection of those who die of diseased hearts, 
 we are accustomed to find the lungs generally loaded with 
 serous and sanguineous effusions, while some portions of them 
 are solid and impervious, and sink in water. 
 
 But chronic inflammation of the larger bronchi, after 
 months or years, is still, I have said, reluctant to extend itself to 
 other structures. After months, or years, Auscultation still 
 finds it in its original seat; the air bubbling through a thickish, 
 copious, puriform fluid, and producing the truest form of large 
 Crepitation. 
 
 There is a form of Chronic Bronchitis, in which all the 
 conceivable signs of Phthisis are present except the auscultatory ; 
 emaciation, hectic fever, cough, and a copious thick yellow 
 globular expectoration. Yet the chest sounds well everywhere 
 upon percussion, and the auscultatory sounds are purely bronchial, 
 and nothing more, and proceeding from the bronchi in their 
 first divisions, and not beyond them ; large, not small Crepita- 
 tion ; but large Crepitation widely diffused, and permitting the 
 respiratory murmur to be heard everywhere through it. 
 
 Here the larger bronchi alone are inflamed, and filled with 
 the matter of morbid secretion, while the lesser bronchi and the 
 vesicular structure of the lungs are free. There is, moreover, 
 no cavity. 
 
 It would be beyond the power of the most sagacious 
 physician upon earth, without the help of Auscultation, to dis- 
 tinguish this case from a case of phthisis ; but by such help we 
 not only determine this disease, which is so like phthisis, to be 
 no phthisis at all, but we pronounce it curable ; that is, curable 
 in its own nature, although from circumstances not always 
 cured. 
 
 Cases of this kind — cases of chronic bronchitis, in which all 
 the conceivable signs of phthisis are present except those which 
 indicate vomica? — are not common : I see a few of them in the 
 course of the year. 
 
 They are more frequent, to my experience, in the hospital, 
 than in private practice. The disease usually begins in a 
 catarrh, which, from neglect or unavoidable exposure, is 
 
 K 
 
130 SUBJECTS CONNECTED WITH [LECT. IX. 
 
 aggravated into a similitude of phthisis. Under this similitude 
 it may endure even for a year or two ; and it becomes difficult 
 of cure in proportion to its continuance. 
 
 But, where there is Crepitation, it need not necessarily be 
 of one kind only. In the same patient you may hear at one 
 part of the lungs a Crepitation like the tracheal rattle of the 
 dying ; at another, like the bursting of large bubbles on the 
 surface of water ; at another, like the crackling of salt thrown 
 upon hot embers. 
 
 There is a disease which was first called by Sydenham 
 Peripneumonia Notha, and which is still known by that name. 
 It is, in fact, a diffused inflammation of the bronchial tubes, 
 chiefly incident to old people. One of its peculiarities consists 
 in the enormous secretion that is poured forth from the mucous 
 surface ; and another which I have remarked is, that the inflam- 
 matory symptoms often still remain, nay, often continue to 
 increase, after the secretion is freely established. This latter 
 peculiarity (if auscultation informs me aright) is derived from 
 the fact, that inflammation does not arise at once and simulta- 
 neously upon the whole surface which it is destined to pervade, 
 but travels over it progressively ; so that various portions of 
 the same continuous surface are in different stages of inflam- 
 mation at the same time. How possible this is, everyone knows, 
 who has watched erysipelas travelling over the whole body. 
 
 Cases of Peripneumonia Notha I recommend to you as 
 special studies for Auscultation : here you will often find, in 
 the same patient, every modification of those sounds which are 
 produced by the matter of morbid secretion mingling with air 
 in the bronchial ramifications of every size, from the largest 
 to the least. 
 
 The common opinion is, that old people die of Perineumonia 
 Notha simply because they have not power to bring up the 
 large accumulation of phlegm ; implying, that the whole disease 
 is limited to the first divisions of the bronchi, and that if they 
 were freed from obstruction, there is nothing beyond them, 
 nothing in the condition of the lungs elsewhere, capable of 
 producing death. Doubtless,- it is quite possible that accumu- 
 lated secretion of any kind in this situation may be the whole 
 and sole cause of death : it may suffocate by its very quantity. 
 But this I know, that since I have had Auscultation to help my 
 
LECT. IX.] CLINICAL MEDICINE. 131 
 
 inquiries, I have never seen anyone perish of Peripneumonia 
 Notha, in whom there was not elsewhere within the lungs 
 enough to claim a large share in producing his death. 
 
 But I find myself speaking of Auscultation too much in 
 detail for the purpose I have in view. In these lectures I 
 would rather wish to give you such a notion of the general 
 bearings of this and that subject, as will help you to follow it 
 up for yourselves in the wards of the hospital. Mere I am not 
 so much striving to teach, as I am encouraging you to learn. 
 
 There is a Crepitation which consists of the smallest con- 
 ceivable crackling — a noise like the crackling of salt thrown 
 upon burning coals. This is regarded as the characteristic 
 Crepitation of Pneumonia, because, wherever it exists, it is 
 always for a short period only ; and it is quickly followed either 
 by the return of the natural respiratory murmur, or by the 
 absence of all sound whatever. In the one case the passage of 
 air through the vesicular structure of the lung has again become 
 free, and a resolution of the disease has taken place ; in the 
 other case the passage of air is altogether precluded, and the 
 disease has passed into its next stage, and has condensed 
 the lung. 
 
 There is a doubt in what manner this particular sound is 
 produced, and where. Some conceive it to proceed from the 
 structure of the lung exterior to the bronchi and vesicles, and 
 to result from the tearing of parts asunder that have been united 
 by effused lymph. It may be so ; but the fact would be 
 extremely difficult to prove. To my ear the sound is the same 
 in kind with those which I have described by the generic term 
 Crepitation. Of these it is the smallest in degree, and probably 
 proceeds from the same continuous surface, from the extreme 
 yesicles and air-cells of the lungs ; and is probably formed in 
 the same manner, by the mingling of air with the morbid 
 secretion which it finds there. This little crackling sound, so 
 well known to those whose experience has taught them to 
 appreciate Auscultation in its practical use, — this little crackling 
 sound, reaching the ear from a limited and circumscribed space 
 within the chest, marks the commencement of Pneumonia. It 
 is a direct symptom, having immediate reference to the structure 
 of the part. And if we consider what the part is, and what the 
 disease, — the part the lungs, and the disease inflammation, — 
 
132 SUBJECTS CONNECTED WITH [LECT. IX. 
 
 we cannot too highly value this single symptom (simple and 
 mean as it may seem), which gives the earliest and surest 
 intimation that such a disease has hegun as tends to disorgani- 
 zation and the inevitable loss of life, unless quickly arrested by 
 its counteracting remedy. 
 
 But Auscultation, having detected inflammation of the lungs 
 at the point where it begins, still follows it as it spreads ; and 
 it follows not merely its progress, but its processes. 
 
 The Crepitus commencing at a small space, and gradually 
 reaching further and further, gives notice of inflammation 
 gradually passing from lobule to lobule, and effusing fluid into 
 their vesicles as it spreads. Then the Crepitus becoming 
 fainter and fainter, but not replaced by the respiratory mur- 
 mur ; and the spaces in which it was first heard becoming dull, 
 and larger and larger spaces becoming dull in succession, until 
 not a sound of respiration, either healthy or unhealthy, proceeds 
 from, perhaps half the chest ; these striking phenomena give 
 notice how the vesicular structure of a whole lung is progres- 
 sively obliterated by the effused lymph and morbid products 
 of the still unarrested inflammation. 
 
 Thus far the intimations of the ear keep pace with the 
 progress and processes of an acute attack of Pneumonia. 
 Auscultation pronounces the permeable lung converted into a 
 solid mass, and admitting no air, save what may just enter, 
 and immediately return from, a bronchus or two which still 
 remain pervious. Beyond this point Auscultation cannot go ; 
 but the disease may go further. 
 
 This is a painful period of suspense in every case of Pneu- 
 monia, when a whole lung, or a large part of it, has ceased to 
 admit air, and the patient still survives. 
 
 The disease (I say) may go further than Auscultation can 
 follow it. Auscultation only discovers that the lung does not 
 admit air ; that it has become solid from having been per- 
 meable. But its texture may be softened ; its cohesion 
 destroyed ; and it may be reduced to a state of pulp and 
 rottenness, which is irreparable. 
 
 But if its texture be not thus disorganized, it is yet capable 
 of reparation ; and then, the inflammation having ceased, 
 Auscultation beautifully takes up its part again, and gives the 
 first notice of reparation, as it gave the first notice of disease. 
 
LECT. IX.] CLINICAL MEDICINE. 133 
 
 Crepitation again begins to be heard where there was no 
 sound ; at first in a small space, and then more extensively ; 
 and then some vesicular breathing is mixed with it ; and the 
 respiratory murmur and the Crepitation seem as if contending 
 with each other for the mastery, until the respiratory murmur 
 is predominant ; and then all is well. 
 
 And what is going on all the while within the structure of 
 the lungs ? Even this. The lymph within and around the 
 pulmonary vesicles is gradually absorbed, and the air gradually 
 finds admission within them. At first, it is impeded by the 
 extravasated fluid it meets with in its passage ; but as the 
 permeable texture of the lungs gets disentangled and set free, 
 it glides through them unobstructed and alone, and with the 
 genuine murmur of health. 
 
134 SUBJECTS CONNECTED WITH [LECT. X. 
 
 LECTURE X. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 BRONCHIAL RESPIRATION AND BRONCHOPHONY. DRY SOUNDS — 
 
 WHERE AND HOW THEY ARE PRODUCED — INCIDENT TO 
 
 SEVERAL DISEASES PECULIAR TO NONE. — THEIR ANALOGY TO 
 
 CERTAIN SOUNDS OF THE HEART IN THE MODE OF THEIR 
 PRODUCTION. ESTIMATE OF THEIR VALUE AS DIRECT SYMP- 
 TOMS. THEIR VALUE RELATIVE, NOT ABSOLUTE — AND LITTLE 
 
 OR GREAT, ACCORDING TO CIRCUMSTANCES AS SEEN IN 
 
 PHTHISIS, IN PNEUMONIA, IN PLEURISY. 
 
 Upon the subject of Auscultation, hitherto we have only con- 
 sidered certain sounds occurring during the act of respiration, 
 and have endeavoured to estimate the amount of the informa- 
 tion they furnish concerning diseases of the lungs, both by 
 themselves and by their interference with the respiratory 
 murmur. And we have found that arising, as they do, from 
 certain pathological conditions of the mucous membrane which 
 lines the air passages, they become direct symptoms of all those 
 pulmonary diseases into which such conditions enter as 
 ingredients. 
 
 The sounds which I have called Rhonchus and Sibilus, 
 and large and small Crepitation, in the sense the terms bear 
 at this hospital, and which others have called by other names 
 bearing an equivalent sense, these sounds cannot carry us 
 further in the diagnosis of pulmonary diseases than I have pointed 
 out. Other sounds are required to detect pulmonary diseases 
 consisting of other pathological conditions, or occupying other 
 structures. 
 
 Of the other sounds, some still respect the respiration, some 
 the voice, and some the act of coughing. There are what are 
 called the Bronchial Respiration and the Bronchial Voice, or 
 Bronchophony ; and as Bronchial Respiration and Bron- 
 chophony will always be found to denote the same thing, I will 
 consider them together. 
 
LECT. X.J CLINICAL MEDICINE. 135 
 
 When there is Bronchial Respiration you hear the breath- 
 ing, and when there is Bronchophony you hear the voice, as 
 you never hear them when all is healthy. In health, the 
 respiration reaches the ear through the chest, in a clear, 
 smooth, uniform murmur. In health, the voice does not reach 
 the ear at all through the chest, except when it is applied just 
 opposite the first divisions of the trachea — viz. on either side 
 the second and the third dorsal vertebrse. But in certain con- 
 ditions of disease you perceive at particular situations of the 
 chest, while the patient breathes, audible gusts of air puffed in 
 and puffed out of the lungs, instead of the smooth respiratory 
 murmur ; and at the same situations, while the patient speaks, 
 a sort of humming or muttering, but no articulate word. Such 
 is Bronchial Respiration, and such Bronchophony. 
 
 Now these sounds, accompanying the respiration and accom- 
 panying the voice, are called Bronchial, because they are formed 
 in those first divisions of the air-tubes which are technically 
 called Bronchi. But the Bronchi themselves are not in fault ; 
 they need not themselves have undergone any disease or change 
 of structure whatever, in order to the production of these 
 sounds. 
 
 Bronchial Respiration, or Bronchophony, arises when the 
 lungs have undergone such changes of condition as are calcu- 
 lated to render them better conductors of sound than they are 
 in their natural and healthy state. 
 
 Now there are so many diseases and so many morbid pro- 
 cesses involved in, or contingent upon, those diseases, which 
 have the common effect of rendering the lungs more solid, and 
 thus augmenting their capacity of conducting sound, that 
 Bronchial Respiration and Bronchophony cannot be diagnostic 
 of any one in particular. The lungs are consolidated in phthisis 
 by tubercles ; in pneumonia, by effused lymph ; in pulmonary 
 apoplexy by effused blood ; in hydrothorax and empyema, by 
 compression, from without, of accumulated serum and of pus ; 
 — and in each of these affections, Bronchial Respiration and 
 Bronchophony are apt to occur. But they are not properly 
 diagnostic either of phthisis or pneumonia, of pulmonary 
 apoplexy or pleurisy. 
 
 In going round the hospital, I have often taken occasion to 
 point out to you cases of phthisis, in which the sounds of the 
 
136 SUBJECTS CONNECTED WITH [LECT. X. 
 
 heart were audible over the entire chest, or a considerable part 
 of it. "With the sounds themselves, their kind, their rhythm, 
 their succession, no fault was to be found ; only they were heard 
 beyond their natural limit, and were perhaps a little louder 
 than natural. The impulse of the heart, in the meantime, has 
 not been remarkably strong ; perhaps it has been remarkably 
 feeble, and the general state of the circulation has not indicated 
 disease. 
 
 In such cases, where, during life, the sounds of the heart 
 have been heard thus constantly and habitually beyond the 
 prsecordial region, I have found, upon examination after death, 
 that the organ itself has not exceeded, and often that it has 
 fallen short of, the natural and average dimension. - 
 
 When the heart is perfectly healthy, it must depend upon 
 conditions exterior to itself, if the sounds which accompany its 
 contraction be heard not only in the prsecordial region, but both 
 there and beyond it. In the cases I have mentioned, it depended 
 upon the condition of the lungs ; which, being rendered more 
 solid by the tubercular matter within them, and becoming 
 better conductors of sound, conveyed the sounds of the heart 
 extensively through the chest. 
 
 In particular instances of phthisis, where the patient has 
 been long under my observation, I have sometimes remarked 
 that the audible limit of the heart's sounds has varied from time 
 to time, according to circumstances, which seemed to me not 
 difficult to explain. During the first stages of the disease, and 
 in proportion as the lungs have been more and more beset with 
 crude tubercles, they have reached further and further beyond 
 the prsecordial region; during the later stages, and in proportion 
 as the tubercles have been more and more changed into vomicse, 
 they have receded more and more within their proper bounds. 
 
 And not in Phthisis only, but in other and curable diseases 
 within the chest, are examples found of the sounds, which 
 accompany the heart's contractions, being conveyed beyond the 
 prsecordial region, while the lungs are rendered more solid by 
 the various products of morbid action ; and again receding 
 within that region when reparation has taken place, and the 
 lungs have again become pervious and free. Pneumonia, 
 pulmonary hsemorrhage, and pleurisy, will often, during their 
 progress, conduct the sounds of the heart over half the chest ; 
 
LECT. X.] CLINICAL MEDICINE. 137 
 
 and the cure of pneumonia, pulmonary haemorrhage, and 
 pleurisy, will often bring them back again within their just 
 limits. 
 
 In like manner, and for the same reasons, and under the 
 same conditions of disease, do the bronchi acquire a resonance, 
 or a voice, which in nowise belongs to them when the surround- 
 ing structures are perfectly healthy. 
 
 Such I believe to be the true account of Bronchial Respira- 
 tion and Bronchophony. They are dry sounds, according to the 
 explanation already given, being not produced by the mingling 
 of air with fluid. 
 
 It now remains to determine the value that belongs to 
 Bronchial Respiration and Bronchophony, as auscultatory Signs. 
 If they be taken absolutely and alone, their value cannot be rated 
 very high ; for, inasmuch as they do not attach themselves to 
 any single morbid process, but result from conditions that are 
 common to many, they can never be exclusively trusted for the 
 diagnosis of disease ; yet they may be trusted very often for 
 lending important aid towards it. In truth, their value con- 
 sists rather in what they contribute as auxiliaries to other signs 
 than as standing alone. 
 
 As auxiliaries, their value varies very much, according to the 
 circumstances of the particular case, and as other auscultatory 
 signs present are more or less precise, and stand less or more in 
 need of that confirmation which these are capable of contri- 
 buting. 
 
 Bronchial Respiration and Bronchophony are worth very 
 little in Phthisis, when Gurgling Respiration, and Gurgling 
 Cough, and Pectoriloquy, have already put their authentic 
 stamp upon the disease. 
 
 They are worth very little in Pneumonia, when the respira- 
 tory murmur has been gradually overcome by small Crepitation, 
 and small Crepitation been succeeded by dulness, and no sound 
 is now elicited by percussion, or yielded to the listening of 
 the ear. 
 
 They are worth very little in Pleurisy, when already, over 
 one half the chest, the ear detects no respiratory murmur, and 
 percussion can produce no Resonance ; when the heart is pushed 
 from its proper seat, and the patient is fixed on this side or that 
 by a dread of suffocation if he move to the other. 
 
138 SUBJECTS CONNECTED WITH [LECT. X. 
 
 Yet it may happen in these several diseases, that the Bron- 
 chial Respiration and the Bronchial Voice may throw just that 
 light which is needed upon a number of doubtful symptoms, 
 and give just that guidance which is required to a right 
 diagnosis. 
 
 Phthisis may exist; but you cannot certainly pronounce 
 that it exists, though the flesh may waste and the strength 
 decline, and the pulse be habitually more frequent than natural, 
 and the breathing be habitually a little hurried, and some cough 
 be habitually present without expectoration; from all these 
 circumstances you cannot pronounce the disease to be certainly 
 phthisis ; you still need the help of some auscultatory Sign to 
 decide your diagnosis. But a little help is now enough. If the 
 Bronchial Respiration or the Bronchial Voice be now added, 
 and be always present, and always found in the same place, you 
 may securely trust either one or the other as the sure index of 
 phthisis. 
 
 Yet bronchial respiration and bronchophony are not abso- 
 lutely diagnostic of tubercles or vomicae, or of any morbid pro- 
 cess essentially phthisical. But it is enough that in this case 
 they are circumstantially diagnostic; for as such they are in- 
 fallible. 
 
 Pneumonia may exist ; but you can have no sure evidence of 
 its existence, though fever be present, and Small Crepitation be 
 more or less diffused through the lung. But if to this Crepi- 
 tation Bronchial Respiration or Bronchophony be added, these, 
 which are but indirect symptoms of condensation of the lung, 
 are, under the circumstances, as certain tokens of such condensa- 
 tion having already begun, as if the chest at some part already 
 yielded no sound to percussion ; and none, either healthy or 
 morbid, to the application of the ear. Small Crepitation is, 
 indeed, the auscultatory sign of inflammation in the smaller 
 bronchial ramifications ; yet as long as this is the only auscul- 
 tatory Sign, there is a hope that the inflammation may pass 
 away without involving structures beyond them. But Bronchial 
 Respiration and Bronchophony are enough to show that it has 
 involved other structures, and that air is admitted less freely 
 into the pulmonary vesicles. 
 
 In cases of Pneumonia, Bronchial Respiration and Bron- 
 chophony will sometimes precede, by no inconsiderable period, 
 
LECT. X.] CLINICAL MEDICINE. 139 
 
 those auscultatory Signs which more directly declare an 
 impervious state of some portion of the lungs. And in cases 
 of Pneumonia, Bronchial Respiration and Bronchophony will 
 often exist at one part of the lungs, while Crepitation still 
 exists at another : whereas dulness to percussion and to auscul- 
 tation do not arise until the Crepitation has ceased, and then 
 are found exactly in those situations where the Crepitation was 
 before. Bronchial Respiration and Bronchophony seem to 
 denote the growing incapacity of the general pulmonary 
 vesicles to admit as much air as they ought : dulness to 
 percussion and auscultation show the exact portions of the 
 lungs that are absolutely impervious. 
 
 Pleurisy may exist. Fever, dyspnoea, and pain in the side, 
 are enough to create a strong suspicion of it ; a suspicion, how- 
 ever, and no more. But only let the least auscultatory sign be 
 added, and the suspicion becomes a certainty. Bronchial 
 Respiration or Bronchophony, is as much as you want. One 
 or the other, found in any part of the affected side, and known 
 not to have been there before, will at once fix the character of 
 the disease. They show absolutely that the lung is beginning 
 to suffer compression ; and they show circumstantially, i.e. by 
 their union with fever, dyspnoea, and pain in the side, that the 
 compression in the present case is from fluid effused into the 
 cavity of the pleura, which is the first effect of its inflam- 
 mation. 
 
 But wait a little in this case ; and if the inflammation be 
 not arrested, and if the effusion within the pleura increase, 
 the Bronchophony will be attended by a peculiar echo. And 
 this echo (if echo it be) is the very pathognomonic sign of 
 Hydrothorax. It has been well likened to the bleating of a 
 goat, and therefore called (Egophony. But it is a sound that 
 admits of varieties, and has been denoted with equal propriety 
 by several similitudes. 
 
 Wait yet a little longer ; and if the fluid still increase, the 
 Bronchial Respiration, the Bronchophony, and the echo, and 
 every the least perceptible sound, will cease. 
 
 Finally, concerning Bronchial Bespiration and Broncho- 
 phony, if it be thought that they are things far too trivial to 
 bear out such vast conclusions as, in one case, that the lungs 
 are beset with tubercular matter, and the disease is Con- 
 
140 
 
 SUBJECTS CONNECTED WITH [LECT. X. 
 
 sumption ; in another, that inflammation, either in itself or in 
 its products, has travelled beyond the bronchial ramifications, 
 and the disease is Pneumonia ; and in another, that inflammation 
 has fallen upon the pleura, and Hydrothorax is already begun, 
 I repeat, that this mere Resonance of the Breathing and the 
 Voice within the larger bronchi, is diagnostic of these diseases, 
 not in itself, but circumstantially, and in the relation it bears to 
 other symptoms. 
 
 And thus we see, in the daily practice of medicine, that 
 things in themselves mean and of no account, do often, by 
 their place and by their relations, gain a just preponderance 
 over things more prominent and striking, and have the largest 
 share in guiding our decision upon the most important 
 questions. 
 
LECT. XI.] CLINICAL MEDICINE. 141 
 
 LECTURE XI. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 CAVERNOUS RESPIRATION AND PECTORILOQUY. — DRY SOUNDS — 
 WHERE AND HOW PRODUCED. — CAVERNOUS RESPIRATION HAS 
 MANY MODIFICATIONS. — WHENCE THESE ARE DERIVED. — THEY 
 CANNOT AND NEED NOT BE CHARACTERIZED BY NAMES. — CON- 
 DITIONS MOST FAVOURABLE TO PECTORILOQUY. — GURGLING 
 
 RESPIRATION AND GURGLING COUGH. MOIST SOUNDS — HOW 
 
 AND WHERE PRODUCED. — THESE FOUR AUSCULTATORY SIGNS, 
 CAVERNOUS RESPIRATION AND PECTORILOQUY, GURGLING RE- 
 SPIRATION AND GURGLING COUGH, ARE CHIEFLY CONCERNED IN 
 
 THE DIAGNOSIS OF PHTHISIS. ESTIMATE OF THEIR VALUE AS 
 
 DIRECT SYMPTOMS IN EACH STAGE AND FORM OF THIS DISEASE. 
 
 But there are other auscultatory Signs which respect the 
 respiration and the voice ; those, namely, which are called 
 Cavernous Respiration and Pectoriloquy. I will consider them 
 together, as I did Bronchial Respiration and Bronchophony, 
 because they too will he found to signify the same thing. 
 
 We call it Cavernous Respiration when, during the act of 
 breathing, a hollow sound reaches the ear through the walls 
 of the chest from some circumscribed space within. And we 
 call it Pectoriloquy, when, during the act of speaking, the 
 articulate words that are uttered reach the ear through the 
 walls of the chest from a circumscribed space within. 
 
 Cavernous Respiration and Pectoriloquy both result from a 
 cavity formed in the lungs, and communicating with the 
 bronchi. They are, in the sense already explained, Dry 
 Sounds — i.e. not requiring the presence of fluid for their 
 production. 
 
 In Cavernous Respiration the hollow sound probably does 
 not begin to be formed until the air enters the cavity, and results 
 altogether from reverberation against its sides ; whereas in 
 
142 SUBJECTS CONNECTED WITH [LECT. XI. 
 
 Pectoriloquy the articulate sound is first formed in the larynx, 
 and then conducted down the trachea, and, entering the cavity, 
 is merely augmented by reverberation against its sides. 
 
 I am convinced that the whole subject of Auscultation 
 would have been better understood if a little less artifice had 
 been used in the methods of teaching it — a little less industry 
 to find a name for every sound that is heard. This very sound 
 of Cavernous Respiration has been puzzled and perplexed to 
 the student by the fancy of giving an express name to each of 
 its modifications. 
 
 There may be, perhaps, now in the hospital, a dozen 
 patients who have Cavernous Respiration ; and in each one of 
 them the sound, besides being cavernous, has some distinct 
 peculiarity ; it is large or it is small ; it is a click, or a hum, 
 or a squeak. It is like blowing into a bottle with a narrow 
 neck, or into one with no neck at all ; it is like the flapping of 
 a valve ; it is metallic ; it is as if air was puffed into your ear, 
 or as if air was drawn from it. 
 
 It would be easy enough to agree upon a dozen terms to 
 designate the dozen different sorts of Cavernous Breathing in 
 the patients now in the hospital; but then the next dozen 
 patients would require as many new terms for as many new 
 sorts of Cavernous Breathing, which would still be different. 
 
 The varieties of Cavernous Breathing are doubtless owing 
 to different sizes and forms and situations of cavities, and to 
 different conditions of the surrounding lung. 
 
 A cavity may be very large or very small. Several 
 bronchi may open into it, or only one. It may be a simple 
 cavity, or it may have many chambers. Its sides may be con- 
 densed and equal, or rough and ragged. The lung around it 
 may be solid and indurated, or pervious and vesicular. It may 
 be near the ribs, or far from them ; adherent to, or separate 
 from, the pleura. 
 
 It is quite obvious that these different circumstances are 
 calculated to modify the sound, which will, nevertheless, be 
 always such as indicates a cavity. 
 
 Would you know what Pectoriloquy is? Put the tube 
 upon the larynx or trachea of a healthy man, and, when he 
 speaks, his voice will seem to come through his throat, and 
 pass directly up the instrument into your ear. Just in this 
 
LECT. XI.J CLINICAL MEDICINE. 143 
 
 manner does the voice reach the ear through the chest, when 
 the conditions within are favourable to Pectoriloquy. 
 
 The conditions most favourable to Pectoriloquy are, that the 
 cavity should have dense walls, that it should be near the 
 surface of the lung, and that, by mutual adhesion of the two 
 pleurae, the walls of the chest should themselves contribute to 
 form it, and that the cavity itself should be empty. Thus a 
 cavity that produces Cavernous Breathing may still not produce 
 Pectoriloquy. It must not be too small, or it will not allow 
 sufficient reverberation to the voice ; it must not be too large, 
 or the voice will be lost in an indefinite hum.. Thus there may 
 be a cavity without Pectoriloquy, but a cavity can scarcely 
 exist without Cavernous Respiration. 
 
 There is yet another auscultatory Sign, which belongs to 
 the respiration. It results from the mingling of air with fluid 
 in the act of breathing ; but it is heard in a circumscribed 
 space, and evidently proceeds from a much larger quantity of 
 fluid than is capable of being accumulated in the mere bronchi 
 within that space. 
 
 The French call it Gargouillement ; we call it Gurgling. 
 It is essential to this sound that there be a cavity, and that the 
 cavity contain fluid. 
 
 The Gurgling sound of the Respiration is exactly like that 
 which a boy makes when he blows up soap suds with a tobacco- 
 
 Pip e - 
 
 Allied with the Gurgling Respiration, and requiring the 
 same conditions to produce it, is the Gurgling Cough. I wish, 
 however, I had another term for the sound which attends the 
 act of coughing : for it is certainly different from the gar- 
 gouillement which attends the act of breathing. If you place 
 your ear upon the chest, immediately over a considerable cavity 
 containing pus, or any fluid that admits air to pass through it, 
 and tell the patient to breathe rather deeply and rapidly, you 
 will hear the sound of a hundred great bubbles agitating the 
 fluid and bursting in continual succession. But if you place 
 your ear upon the chest, and tell him to cough, the sound is as 
 if the whole contents of the cavity struck against your ear at 
 once. The one sound is a gurgling, the other a plash. I wish 
 Plash was not such an awkward word ; for it expresses the 
 very thing. 
 
144 SUBJECTS CONNECTED WITH [LECT. XI. 
 
 In the effort of coughing, more air penetrates the cavity. 
 It goes in and out of it with a rush. Moreover, it dwells longer 
 in it, and while it is there the whole chest suffers a succussion. 
 Thus, by the act of coughing, not only are the air and the fluid 
 mingled and agitated together within the cavity, hut the cavity 
 itself is shaken, like a bottle, against the ear. 
 
 This audible Plash of fluid is certainly produced during 
 coughing, as well by the general succussion of the chest which 
 then takes place, as by the forced impulse and agitation of air 
 within the cavity itself. Indeed, succussion alone will produce 
 it; and succussion .occasioned by other means than by coughing. 
 Very often, when the cavity has been close to the walls of the 
 chest, and the patient has been much emaciated, after I have 
 heard its contents Bubbling as he breathed, and Plashing as he 
 coughed, I have desired him to hold his breath for a few seconds, 
 and abstain from coughing if he could ; and still I have heard 
 distinctly a smaller sound of the same kind, a Plash synchronous 
 with the pulse. The sound is doubtless owing to the motion 
 derived to the same cavity from the impulse of the heart, or 
 large blood-vessels. 
 
 And now for the practical application of the several aus- 
 cultatory Signs; Cavernous Respiration and Pectoriloquy, 
 Gurgling Respiration, and Gurgling Cough. To illustrate 
 their diagnostic use I will take only one disease, but one which 
 includes many and various morbid changes in the structure of 
 the lungs, and see how far these signs, either by themselves or 
 as auxiliaries to others, enable our knowledge to keep pace with 
 such changes, as they arise. That disease shall be Pulmonary 
 Consumption. 
 
 Let us consider Pulmonary Consumption in the stage of its 
 first development, its most uncertain, but its most fearfully 
 interesting stage. An individual is suspected to be phthisical : 
 he has some fever, some acceleration of pulse, some emaciation, 
 and some cough ; all inconsiderable in degree, yet all abiding ; 
 but no expectoration. 
 
 In a patient thus suspected to be phthisical, Auscultation 
 may discover no more than this ; that beneath the clavicle and 
 about the scapula the respiratory murmur is less clear on one 
 side than on the other, and that, where the murmur is defective, 
 there, too, the chest is less resonant to percussion. 
 
LECT. XI.] CLINICAL MEDICINE. 145 
 
 Now if, after repeated examinations, Auscultation comes 
 always to this result, no doubt can remain that Tubercles are 
 already formed in the upper lobe of one lung. 
 
 But here is no unnatural sound, only the natural sound is in 
 part defective ; and this must arise from some impediment to 
 the passage of air through that portion of the lungs. Now 
 impediment may arise from the deposition of lymph, or any of 
 the common products of inflammation, as well as from tuber- 
 cular Matter. But inflammation is very unapt to take place, 
 and its products to be effused into the apex of an upper lobe, 
 while every other part of the lungs remains unaffected by 
 it. It may ultimately reach this situation, but seldom, 
 very seldom, begins in it. On the other hand, it belongs to 
 ' phthisical disease to deposit Tubercles in the upper lobes first, 
 and thence gradually to scatter them over the rest of the 
 lungs. 
 
 Thus, by help of Auscultation, but still rather by what we 
 do not hear, than by what we do, we arrive as surely at the per- 
 suasion that there are Tubercles in a certain case, as if there 
 were sounds properly denoting their existence. 
 
 Always bear in mind that there are no auscultatory Signs 
 which expressly bespeak Tubercles. You are left to get at the 
 knowledge of their existence by that sort of evidence which 
 has been called circumstantial ; Auscultation, however, having 
 an important share in the result. As thus, Auscultation finds 
 the respiratory murmur defective at a certain part of the 
 lungs ; and hence we infer its obstruction by the deposition of 
 some kind of matter or other. But the part is that which 
 nature chooses, above all others, for the deposition of tubercular 
 Matter ; and hence we further infer that the Matter is tubercular 
 in this particular instance. But, moreover, the constitutional 
 symptoms are such as are wont to accompany phthisical disease ; 
 and hence we finally infer almost a certainty that Tubercles 
 are deposited at the upper part of one lung. We conclude 
 that the thing must be, because it can be nothing else. 
 Circumstantial evidence, it is acknowledged, may be as in- 
 fallible as the evidence which bears direct attestation to the 
 simple fact. 
 
 I have been speaking of the auscultatory Signs that we 
 possess of consumptive disease, when it has proceeded no further 
 
 L 
 
146 SUBJECTS CONNECTED WITH [LECT. XI. 
 
 than the deposition of Tubercles (crude Tubercles) at the apex 
 of one lung. 
 
 In proportion as Tubercles are more largely deposited in one 
 lung, or extend to both, the auscultatory signs are the same in 
 kind, but more definite ; and the portions of lung that are 
 healthy are more strikingly contrasted with those that are 
 diseased. The healthy part, being called upon to compensate 
 by a more energetic respiration for the absence of respiration 
 in the diseased, gives out a louder and more puerile murmur, 
 while the diseased gives out no murmur, or almost none 
 at all. 
 
 Recollect, I introduced the subject of Auscultation for the 
 sake of illustrating to you the best means we have of knowing 
 organic disease by direct symptoms. But, if there be any 
 Signs, not auscultatory, which either give direct intimations of 
 disease in the same organ, or tend to give more force and pre- 
 cision to the auscultatory, it is fit that I should introduce them 
 as I go along. 
 
 At no period of Consumptive disease is haemoptysis more 
 apt to take place than at this which we are now considering, 
 when the lungs are beset by crude Tubercles. And the haemo- 
 ptysis illustrates the auscultatory Signs, and the auscultatory 
 Signs illustrate the haemoptysis. 
 
 The cases are numerous in the course of a twelvemonth 
 which I see in this hospital and elsewhere, of haemoptysis 
 occurring in every quantity, from a tea- spoonful to a pint, in 
 individuals whose general health has been previously declining, 
 but who have had no particular complaint except (what they 
 have called) a little hacking cough. 
 
 The great majority of such cases, as far as the mere haemo- 
 ptysis is concerned, do well. In a few days the haemoptysis 
 entirely ceases, and very often the patients tell you that they 
 are better since they spat blood than they were before. It is 
 my habit, however, to keep such patients still in the hospital 
 for a week or a fortnight, to satisfy myself respecting the actual 
 condition of their lungs, as far as I can learn it by Auscul- 
 tation. 
 
 And Auscultation gives the same results which have been 
 described. Respiration is unequally performed in different 
 portions of the lungs. There is less respiratory Murmur per- 
 
LECT. XI.] CLINICAL MEDICINE. 147 
 
 ceptible about the scapula, or beneath the clavicle, on one or 
 both sides, and less resonance upon Percussion, than else- 
 where. 
 
 I would invite your attention to all such cases as these, 
 whenever you meet with them in the hospital. I recommend 
 you particularly to exercise yourselves, whether by Auscultation 
 or otherwise, in detecting the signs of Tubercles deposited in 
 the lungs at the earliest possible period: because it is then 
 especially that a sound knowledge of the real state of things 
 may enable you to do infinite good ; by seasonable, and (I will 
 add) practicable advice to postpone the progress of disease, and 
 protract many a valuable life. 
 
 I do not wish you to fasten on small points, and swell them 
 into importance, and by refining and sophisticating to make 
 something out of nothing at all, and frighten families, and 
 deceive yourselves intoa belief that you have cured Consumption. 
 
 The cases I am pointing out are those in which there are 
 well-defined constitutional symptoms — fever, wasting of the 
 flesh, acceleration of pulse. These denote something going on 
 wrong somewhere. The cough fixes suspicion upon the chest ; 
 and the chest being examined gives such results as I have 
 mentioned. 
 
 Let us now consider Pulmonary Consumption in other stages. 
 In all stages, subsequent to the tubercular, the auscultatory 
 Signs are paramount and unerring, and you may implicitly 
 trust to them for your entire knowledge of each and every other 
 morbid change and process incident to the structure of the lungs 
 from Pulmonary Consumption. 
 
 The earliest and the least, but still a very authentic sign of 
 Vomica, derived from Auscultation, is a mere Click, or slight 
 ringing sound, heard in breathing, at some point beneath the 
 clavicle or about the scapula, in a patient in whom all the 
 surrounding parts have been for some time dull. This Click, 
 to remove all suspicion of its being owing to the accidental 
 lodgement of a piece of tough phlegm in one of the bronchi, 
 must always be found at the same point at several examinations 
 of the chest. It is one modification of Cavernous Respiration. 
 It results from a cavity or Yomica in its first formation, when 
 the tubercular Matter is softening, and it is just beginning to 
 admit air. 
 
148 SUBJECTS CONNECTED WITH [LECT. XI. 
 
 Those who have been accustomed to attend me for any 
 length of time in my visits round the hospital, must know how 
 often I have pointed out this particular sign, this little Click 
 in the breathing, and desired them to listen to it day after day, 
 until they gradually found it change into a sound of a more 
 certain character. 
 
 Where there is a Cavity, in the progress of its enlargement 
 and of the changes it undergoes, its auscultatory Signs are to 
 be sought in Breathing and Coughing and Talking. Breathing 
 will give them in one case, Coughing in a second, Talking in a 
 third. Or often in the same case, whether the patient breathe, 
 or cough, or talk, the evidence of a Cavity within the lungs is 
 equally authentic. 
 
 Thus the Bespiration, the Cough, and the Voice, may all 
 give equal_ assurance that Vomicae exist ; one confirming the 
 other, and all agreeing in the same result. 
 
 But in particular cases, from the situation of the Vomica, 
 from its size, from the kind and quantity of its contents, or 
 from the state of the surrounding lung, Auscultation gives 
 sometimes less and sometimes more notice of the disease by the 
 sound conveyed in one of these actions than another. One 
 is needed to supply the symptom which another does not 
 give. 
 
 Some time ago I was desired to pronounce upon the nature 
 of the disease, in a gentleman who was affected in this manner. 
 He had suffered a long and abiding hectic, and had reached a 
 state of extreme emaciation, but had a very slight cough, and 
 expectorated only one large globule of yellow heavy matter 
 once a day, immediately after he woke in the morning. His 
 little cough, his little expectoration, and his ability to inflate 
 his lungs freely and deeply, encouraged a hope that he still 
 might not have Consumption, his abiding hectic and his 
 extreme emaciation notwithstanding. 
 
 I examined the chest, and found the respiratory Murmur 
 clear and loud, and vesicular. In the act of breathing there 
 was no unnatural sound, either Cavernous or Gurgling, any- 
 where. 
 
 Having learnt thus much, or, rather, having puzzled myself 
 thus far, I was interrupted in my further examination by some 
 accident, and I postponed it until the next day. 
 
LECT. XI.J CLINICAL MEDICINE. 149 
 
 The next day I could get no more information from the 
 mere Breathing, except that, upon the whole, the air entered 
 more freely into one lung than the other ; the other, however, 
 not wanting the Vesicular Murmur in any part. Neither from 
 the Yoice could I get more information; it was neither 
 Cavernous nor Pectoriloquous. Percussion elicited a somewhat 
 different sound from the space between the clavicle and mamma 
 on one side and the other. But the sound was dull on neither 
 side. 
 
 "What, however, neither the Respiration nor the Voice 
 could declare by any authentic sign, was made clear and 
 manifest by the act of Coughing ; viz. that there was a large 
 Cavity, full of fluid, occupying a space in one lung between 
 the clavicle and the mamma. For when I desired the patient 
 to make as deep an inspiration as he could, and then to cough 
 with all the force he was able, instantly there came Plash 
 after Plash against my ear from the whole of this space ; a 
 sound, which could only result from the agitation of fluid in a 
 large Cavity. 
 
 But why was there ' a Vesicular Murmur at this space ? 
 Probably because the Cavity, large as it was, had a considerable 
 stratum of healthy lung interposed between it and the walls of 
 the chest. Why was there no . Pectoriloquy ? These same 
 ■conditions, the size of the Cavity, and the intervention of 
 healthy lung between it and the walls of the chest, were 
 enough to prevent it. Besides, the Cavity was full, and thus 
 was unfavourable to Pectoriloquy. 
 
 And why, above all, was there no Grargouillement, no 
 Gurgling sound in the respiration, and little or no expectora- 
 tion? The air during ordinary respiration might not have 
 free access to the Cavity. The Cavity was there, but there 
 might be no considerable bronchus entering it. Or, what is 
 most probable, a considerable bronchus or bronchi entered it, 
 but were obstructed by some obstacle, from within or from 
 without, before they reached it. Either hypothesis will furnish 
 the explanation, how a large Cavity full of pus can exist in the 
 lungs, and yet not enough of air find its way into it, in 
 ordinary breathing, to produce an audible agitation of its 
 ■contents, and not enough of matter find its way out of it to 
 furnish more than a scanty expectoration. In this case it 
 
150 SUBJECTS CONNECTED "WITH [LECT. XI. 
 
 took the whole night, and the continual oozing of pus by some 
 narrow passage from the cavity into the bronchi, to accumulate 
 half an ounce ready to be expectorated in the morning. 
 
 So much for the present. But you must inquire further 
 into the forms and stages of Phthisical Disease, if you would 
 know the real value that belongs to the auscultatory Signs in 
 question.' 
 
LECT. XII.] CLINICAL MEDICINE. 151 
 
 LECTUKE XII. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 FORMS OF PHTHISIS COMPARED WITH KINDRED FORMS OF DISEASE 
 
 IN EXTERNAL PARTS. UNMIXED PHTHISIS. — MIXED PHTHISIS. 
 
 UNMIXED PHTHISIS COMMONLY OF LONG DURATION. SOME- 
 TIMES LINGERING IN ONE STAGE, AND RELUCTANT TO PASS 
 
 BEYOND IT. SOMETIMES PASSING QUICKLY THROUGH ALL ITS 
 
 STAGES, BUT OCCUPYING SMALL PORTIONS OF THE LUNGS IN 
 
 SUCCESSION — CEASING IN ONE AND BEGINNING IN ANOTHER. 
 
 GENERAL AND AUSCULTATORY SIGNS OF UNMIXED PHTHISIS. 
 
 IS PHTHISIS CURABLE ? 
 
 I wish to consider some important distinctions of Pulmonary 
 Consumption, grounded on pathology, and brought to our 
 knowledge by Auscultation during the life of the patient. 
 
 You have all seen an absorbent gland of the neck beoome as 
 hard and as large as a marble, but without pain, or heat, or 
 discoloration of the integuments ; and hard, and indolent, and 
 marble-like, it has remained for weeks, or months, or years. 
 
 This is a mere deposition of tubercular Matter in the sub- 
 stance of the gland. 
 
 And you have all seen an absorbent gland of the neck hard 
 and large, and without pain, or heat, or discoloration of the 
 integuments, for a while ; but presently pain, and heat, and 
 redness, have arisen, and what was hard has become soft, and 
 the integuments have become thin, and have ulcerated or burst ; 
 and pus has been discharged, and with it a hard nucleus of 
 tubercular Matter ; whereupon the swelling, heat, and pain, 
 have subsided, and the parts have been restored without any 
 remaining mark of injury, save a slight scar. 
 
 This is a deposition of tubercular Matter followed by 
 inflammation in the substance of the gland. But the inflam- 
 mation is restricted almost, if not altogether, to the gland 
 
152 SUBJECTS CONNECTED WITH [LECT. XII. 
 
 itself; and it has no sooner done its work of eliminating the 
 tubercular Matter, than it ceases entirely. 
 
 In like manner you have seen many glands of the neck 
 remain hard and indolent, or all or several of them go on to in- 
 flame and suppurate simultaneously, or in succession. But the 
 inflammation and suppuration have not continued longer, nor 
 extended further, than was needful for the purpose of elimi- 
 nating the tubercular Matter. 
 
 There is (what is called) the specific limit of a disease. By 
 this is meant the limit proper to its local morbid action, which, 
 for any purpose it has to accomplish, it never need to transgress. 
 
 Thus, in the instances alluded to, the specific limit of the 
 disease was strictly preserved ; for if the tubercular Matter was 
 to be evacuated, no less degree of inflammation could have 
 succeeded in bringing it to the surface. 
 
 But in such tubercular Affection of the cervical glands, the 
 disease may spread beyond its specific limit. It may give 
 occasion to inflammation both more severe and more extensive 
 than is needed for the mere elimination of the tubercular Matter ; 
 to inflammation pervading the whole neck widely and deeply, 
 and accompanied by diffused redness, and swelling, and pain ; 
 the whole subcutaneous cellular structure, between the angle of 
 the jaw and the clavicle, being loaded with effused serum and 
 blood, and numerous apertures dripping with pus. 
 
 And all this inflammation, with its destructive processes, is 
 engendered and spread abroad from a mere nucleus of tuber- 
 cular Matter in a few absorbent glands. Yet in another case 
 this same tubercular Matter lay indolent and harmless, neither 
 the constitution nor the part feeling any apparent incon- 
 venience from it. And in another case it created just inflam- 
 mation enough (and no more) to produce a process of ulceration 
 which might bring it to the surface. 
 
 Behold here, upon the surface of the body, that very 
 Disease which in the Lungs constitutes Consumption ! Behold 
 here transacted before your eyes the same morbid changes and 
 processes which (allowance being made for difference of struc- 
 ture) are there transacted within reach of the ear ! 
 
 There are cases in which Pulmonary Tubercles abide long, 
 and, perhaps, never suppurate, or at a very late period ; and 
 there are cases in which Pulmonary Tubercles excite around 
 
•LECT. XII.] CLINICAL MEDICINE. 153 
 
 themselves just enough of inflammation and suppuration to 
 procure their own solution or evacuation, and no more ; and 
 again, there are cases in which Pulmonary Tubercles produce 
 and spread abroad inflammation of every degree and every 
 -extent throughout the lungs, beyond what is necessary to pro- 
 duce their own solution or evacuation. And these cases are to 
 be distinguished from one another by Auscultation. And 
 their distinction is of vast practical importance. 
 
 Tubercles and Vomicse are the specific part of Pulmonary 
 Consumption. If you do not detect one or other of these, you 
 cannot pronounce the patient to be consumptive. The auscul- 
 tatory Signs which denote their existence have been already 
 enumerated. 
 
 I shall take no notice of those cases in which a few Tubercles 
 are deposited here and there in the lungs, without any auscul- 
 tatory Sign of their existence. We find them after death, 
 where they were never suspected during life, and where the 
 entire lungs besides are perfectly healthy. 
 
 There are no auscultatory Signs which expressly denote 
 Tubercles. Keverthele'ss, I have shown that Tubercles may be 
 detected almost infallibly by circumstantial evidence, to which 
 Auscultation essentially contributes. But, before they can be 
 thus detected, Tubercles must be so largely deposited in some 
 part of the lungs, as to impede perceptibly the passage of air 
 through it. 
 
 Consumption is perpetually presenting itself to me in this 
 form. An individual loses the complexion of health, and be- 
 comes thin ; he coughs a little ; but perhaps he has no notable 
 fever, and no constant acceleration of pulse. I auscult his chest, 
 and find a Dulness beneath one or both clavicles, or about one 
 or both scapulae, and a free respiratory Murmur through every 
 other part of the lungs. Here there is no disease beyond 
 Tubercles ; and while they occupy the upper lobe, the whole 
 lungs besides are without a vestige of disease. , 
 
 This form of Consumption may endure for years and years, 
 the auscultatory Signs continually denoting the same thing, 
 and the patient getting neither a bit better nor a bit worse in 
 the meantime. But he is a wretched invalid, and finds that 
 there is something continually incapacitating him for the severer 
 business of life. 
 
15 SUBJECTS CONNECTED WITH [LECT. XII. 
 
 To such a person it is a continual puzzle why he does not 
 get well. He consults an infinite number of medical men ; and 
 it is remarkable that he gets no comfort or satisfaction from 
 those who understand his disease the best, and the greatest 
 comfort and satisfaction from those who understand nothing 
 about it. Those, who know what it is, out of kindness do not 
 tell him the truth, and they cannot asseverate a falsehood 
 stoutly enough to carry any weight with it ; whereas those 
 who know nothing about it affirm boldly and unhesitatingly 
 that it is all stomach, really believing that the whole and sole 
 disorder is in the stomach, and that it is within the reach of an 
 easy cure. 
 
 Surely Auscultation is so essential a help for arriving at the 
 truth in such a case, that they who are skilled in the use of it 
 always agree as to what the truth is : and, indeed, there is no 
 wonder in their agreement : the wonder is, that they who do 
 not arrive at the truth should so constantly agree in adopting 
 the same fallacy. I have been somewhat curious in my inquiries 
 concerning this matter, and the constancy with which I have 
 found the whole malady imputed to the stomach has appeared 
 to me very strange. There is, however, a circumstance in the 
 history of these cases which gives a colour of truth to this 
 opinion. The state of the bowels is very frequently such as 
 to demand the continual use of purgative medicine ; and the 
 cough often comes on, and with it a kind of asthmatic breathing, 
 soon after dinner; and both continue as long as the stomach is 
 distended with food. 
 
 In this form of Chronic Consumption spittings of Blood 
 are apt to take place occasionally; and, when they do, they 
 must give fearful intimations of disease of the lungs to those 
 who are not yet assured of it by Auscultation. But I have 
 known them also imputed to the stomach. 
 
 In this form of Chronic Consumption abscesses are apt to occur 
 by the side of the rectum, and to degenerate into fistulous sinuses. 
 
 But in this form of Consumption Yomicse are not postponed 
 indefinitely : they at length are formed, and from that time the 
 patient sinks rapidly. Often, when a fistulous sinus has been 
 cured by an operation, and the long abiding discharge from it 
 abolished, an expectoration of pus will occur for the first time, 
 and never afterwards cease. 
 
LECT. XII. J CLINICAL MEDICINE. 155 
 
 From the first formation of Vomicae the patient sinks rapidly. 
 In Pulmonary Consumption, characterized by the length of its 
 Tubercular stage (if I may so call it), and by a seeming reluct- 
 ance to pass on to the formation of Vomicae, when, after several 
 years, Vomicae do ultimately take place, it is often in great 
 numbers simultaneously, or in very quick succession ; so much 
 so, that a lung which two or three weeks ago was, in a great 
 part, dull to Percussion, and yielded no sound to the ear but 
 Bronchial Breathing or Bronchophony, will now give the 
 clearest auscultatory Signs that it is literally riddled with 
 Cavities ; and not only so, but, if the patient survive a little 
 longer, that many Cavities have run together, and a multitude 
 become one. The same simultaneous Gurgling when the patient 
 breathes, and the same simultaneous Plash when he coughs, 
 will reach the ear from half one side of the chest. 
 
 It is remarkable how to the very last the sounds are often 
 properly and exclusively those of Phthisical Disease, or rather 
 those which it belongs to the essential conditions of Phthisical 
 Disease in the lungs alone to produce, and those sounds only. 
 There are Cavernous Breathing, or Gurgling Breathing and 
 Gurgling Cough, or Pectoriloquy ; and in whatever parts of 
 the lungs you have not these, if you have any sound at all, it is 
 the vesicular Murmur of Health. 
 
 Nothing is more common, upon dissection, than to find the 
 lungs most largely beset with Tubercles and Vomicae ; and at 
 the same time every part of them, which a Tubercle or a Vomica 
 does not absolutely occupy, altogether healthy. 
 
 Such is one form of Pulmonary Consumption ; and it would 
 seem to be, in many striking circumstances, distinguishable 
 from others. I may fairly wish that I had a less accurate 
 knowledge of it ; for that knowledge first came to me from 
 observing its symptoms in two of my most valued friends, and 
 from watching in them, year after year, the sure but hesitating 
 approaches of death. 
 
 But Consumption is perpetually presenting itself to me 
 under a different character. The patient will live as long as he 
 whose disease is slow to advance beyond the stage of mere 
 Tubercles. His condition, however, is different ; and that 
 condition varies more from time to time : he will spit for a 
 while considerable quantities of pus, and then cease from expec- 
 
156 SUBJECTS CONNECTED WITH [lECT. XII. 
 
 torating altogether. He will suffer hectic fever, and then throw 
 it off, and then suffer it again ; lose his flesh, and recover it, 
 and then lose it again. Here, if you auscult the chest, you will 
 find Cavernous Respiration or Pectoriloquy, a Gurgling Respi- 
 ration or a Gurgling Cough at the apex of one or both lungs, 
 and at every other part a clear vesicular Murmur. 
 
 These are the cases in which Pulmonary Tubercles excite 
 around themselves just enough of inflammation and suppura- 
 tion to procure their own solution or evacuation, and no more. 
 The Phthisical Disease is carrying on its own specific processes 
 within its own specific limits. It is depositing tubercular 
 Matter, and then maturating, and softening, and evacuating 
 it ; and the result is the formation of a Vomica. But, except 
 in the seat of the Vomica, the whole lung still remains 
 healthy. 
 
 A very dear friend of my own was twelve years dying of 
 Consumption ; and another individual was twenty. They had 
 expectoration, and hectic fever, coming and going during 
 twelve and twenty years ; but they died before the days of 
 Auscultation, and, therefore, the exact condition of the 
 lungs at different periods during the progress of their disease 
 was not known. I know a man now living, who occasionally 
 spits blood and pus, and who has occasionally spit blood and 
 pus during the last twenty years. At various times during the 
 last four years Auscultation has discovered a Vomica or 
 Vomicas at the apex of one lung, but, withal, a satisfactory 
 Vesicular Murmur in other parts. This individual, in what 
 regards eating and drinking, has lived a life of abstinence, 
 but a life of great toil in what regards exertion of body and 
 mind. Sometimes his friends are full of apprehension about 
 him ; his hectic fever, his emaciation, his cough and expectora- 
 tion, seem preludes to the worst event ; but again he rallies, 
 and his mind and his body recover, or seem to recover, their 
 wonted powers. 
 
 But in this form of Pulmonary Consumption, a time 
 arrives at which there is no more resumption of the appearance 
 or reality of health, no more pausing between (as it would 
 seem) the formation of one Vomica and another. The hectic, 
 the cough, the expectoration, continue ; the emaciation in- 
 creases ; the strength declines ; and Auscultation has no longer 
 
LECT. XII.J CLINICAL MEDICINE. 157 
 
 to seek the Grargouillement, the Cavernous Breathing, or 
 the Pectoriloquy, in one spot, but finds them at all times any- 
 where between the clavicle and the mamma, or anywhere about 
 the scapula on one or both sides. 
 
 Here, too, however, it is remarkable, as in the other form of 
 Consumption, that the Vesicular Murmur of health is often 
 heard to the last in all parts of the lungs besides ; and upon 
 dissection, that all parts are often found healthy which a 
 Tubercle or Yomica does not actually occupy. 
 
 The difference between the present form of Pulmonary 
 Consumption and the former is this — that the former lingered 
 long in the tubercular stage, tubercular Matter continuing to 
 be deposited year after year, but no Vomica occurring, until, 
 at a very advanced period, many were formed simultaneously, 
 or in quick succession, and hurried on the patient to dissolution 
 with great rapidity ; whereas in the present, the Vomica, and 
 Vomica only, is the object recognised by Auscultation. Tubercle 
 must precede it. But the Tubercle is hardly deposited before 
 the process of softening and evacuating it arises, and a Vomica 
 is the result. Thus Tubercle is formed after Tubercle (as it should 
 seem), with some interval of time between, and Vomica after 
 Vomica ; but the Vomica is the more abiding morbid condition. 
 
 These are genuine and unmixed forms of Pulmonary Con- 
 sumption ; and I have dwelt upon them because they are so, 
 and because I am indebted for my knowledge of them, as dis- 
 tinguished from others, to Auscultation. 
 
 Of these two genuine and unmixed forms of Phthisis, the 
 first is unquestionably the most hopeless. Where Tubercles 
 are largely deposited, and continue still to increase, and do not 
 pass on to Vomicae, there is never the smallest attempt towards 
 a restoration to health — not even of a temporary or apparent 
 restoration. 
 
 But where Tubercles arise one by one, or a few together, 
 and this one or these few pass rapidly into the state of Vomicse 
 — and where a pause ensues between each successive formation 
 of Tubercles and Vomicae, — then, during that pause, there is 
 an opportunity for the powers of reparation to come into 
 action ; and, in truth, there often does arise a manifest endeavour 
 after health, — an endeavour which succeeds so far as to recover 
 some of its conditions, and to suspend the disease : and then 
 
158 SUBJECTS CONNECTED WITH [LECT. XII. 
 
 during that pause, there is always the hope (for where disease 
 is suspended and health is partly recovered, we cannot help 
 hoping) that, reparation may he complete, and the disease 
 abolished altogether. 
 
 But can this be ? Does Consumption ever admit of cure ? 
 If ever, it must surely be when it occurs in that form which we 
 are now considering. Let us, therefore, now give a few moments 
 to this interesting question. 
 
 A vomica certainly admits of reparation so far as not to be 
 a vomica any longer, but not so far as to leave behind it no 
 trace within the lungs. It leaves behind it a scar — that is, the 
 disease ceases in the part, but the part is not restored to the 
 exact condition in which it was before the disease began. 
 
 In examining by dissection the bodies of those who die of 
 Pulmonary Consumption, among many existing Vomicae we 
 occasionally find the traces of a Vomica healed. At the 
 apex of the lung we find an indentation, and descending from 
 it, for half an inch or an inch, a thick perpendicular line of 
 tough ligamentous substance. Sometimes this substance, by 
 being pulled asunder, is discovered to contain the remains of a 
 cavity, and sometimes not. 
 
 But what imports this reparation of a single Vomica, if so 
 many besides still exist ? A reparation of a twentieth part of 
 the existing disease cannot be called a cure. 
 
 But in those who have not died of any pulmonary symptoms, 
 and who were never known during their lives to have had any 
 symptoms apparently phthisical, the same evidences have been 
 found after death of what once was a Vomica, but no existing 
 Vomicae together with it. 
 
 This is a cure, or tantamount to a cure. It is as much a 
 cure as when a single scrofulous cervical gland goes on to 
 suppuration and heals with a scar. A single Vomica, you may 
 say, is as much of the essence of Consumption, as a hundred ; 
 and if the morbid structure (no matter how small) in which 
 the disease essentially consists be repaired, the disease is cured — 
 that is, the Consumption is cured. But it was a Consumption 
 which nobody knew to exist. 
 
 Now all this may be very fine reasoning ; but it does not 
 meet the plain meaning of the inquiry whether Consumption 
 be curable. It is not proof enough to common sense of its 
 
LECT. XII.] CLINICAL MEDICINE. 159 
 
 being so, that a few isolated Vomicae, which gave no sign of 
 their existence, should have undergone reparation. 
 
 All the world is asking us whether Consumption be curable ? 
 Indeed all the world is interested in the question : for there is 
 hardly a family into which Consumption, sooner or later, does 
 not enter ; and when a man makes the inquiry (as it were) 
 speculatively or indifferently, he has most likely a real practical 
 interest in it at home. He says, " Is Consumption a curable 
 disease ? " But he icould say, " I have a wife or a child, a 
 brother or a sister, who is decidedly consumptive ; is there the 
 least possible hope left me that they can recover ? " 
 
 To the question proposed with such intent, it is a mockery 
 to answer, " Consumption is a curable disease ; " because, 
 forsooth, its entire process from beginning to end — its formation, 
 progress, cure — may be secretly transacted within the body 
 without our knowing or suspecting anything about it. 
 
 If you ask me, as a Physician, whether I have ever had 
 experience of a perfect and satisfactory recovery taking place, 
 where there have been all the best known popular symptoms of 
 Phthisis decidedly marked, symptoms which {as far as they go) 
 no P hysician could possibly say were not those of Phthisis ? I 
 answer, " Often." 
 
 But if you ask me whether I have ever had experience of 
 the like perfect and satisfactory recovery where there were all 
 these popular symptoms, and, withal, the conditions proper to 
 Phthisis, ascertained by auscultatory Signs to exist beyond a 
 doubt within the lungs ? I answer, " Hitherto never." 
 
 What shall we say then ? How shall we answer the 
 popular question in the popular sense, and still answer it truly ? 
 We cannot say that Consumption is curable ; but we can say 
 (and truly) that there are cases of imputed consumption which 
 put on such an aspect of the real disease that they are with 
 difficulty distinguished from it, yet have not its essence. These 
 are all within the possibility of cure. 
 
 We can say that there are cases essentially phthisical, in 
 which the disease is so lingering in a particular stage, that 
 many years are often required to bring it to its fatal termina- 
 tion. The decline is gradual, almost imperceptible, but sure. 
 These fall within my first description. 
 
 And we can say that there are cases essentially phthisical 
 
160 SUBJECTS CONNECTED WITH [LECT. XII. 
 
 (and these fall under my second description) in which the 
 disease accomplishes its course, as it were, by parts and parcels; 
 many times apparently beginning, and many times apparently 
 ending, but always (as far as I see) beginning again : a year or 
 two of health, then a year or two of disease again. Tet, upon 
 these terms, I have known those who have passed neither a 
 short, nor a useless, nor an unhappy life. I hare known those 
 who have so gathered up the fragments of their broken health 
 as to make them serve for high and useful purposes, and put to- 
 shame the fewer and smaller performances of stronger men. 
 
LECT. XIII.] CLINICAL MEDICINE. 16l 
 
 LECTURE XIII. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 SUBJECT CONTINUED. MIXED PHTHISIS. — THE MIXED CHARACTER 
 
 OF ITS AUSCULTATORY SIGNS. 
 
 I have described two forms of Pulmonary Consumption, distinct 
 from each other in certain pathological particulars, and distinct 
 also in their auscultatory Signs. Both were specimens of 
 genuine and unmixed Phthisis ; — genuine, because they con- 
 sisted of Tubercles and Vomicae, which are the essence of the 
 disease; unmixed, because they consisted of Tubercles and 
 Vomicae only from first to last ; these fulfilling their specific 
 morbid processes within their specific limits, and leaving all 
 other parts of the lungs which they do not actually occupy free 
 from disease. 
 
 These two forms of Phthisis were represented as chronic ; 
 and chronic they are generally found to be : for disease which 
 does not easily impart irritation to surrounding structures, is 
 usually slow in its own actions. 
 
 Observe, I am not making distinctions of Phthisical disease 
 for purposes of mere arrangement and nosology ; but I am 
 selecting such forms of it as I find suitable to the purpose I 
 have in hand ; that purpose being to show that there is such a 
 disease as genuine and unmixed Phthisis, discoverable by 
 Auscultation, and distinguishable by Auscultation from mixed 
 Phthisis, which is presently to be considered. 
 
 There are forms, then, of Pulmonary Consumption, which 
 Auscultation is able to distinguish from those already described 
 mainly in this particular circumstance, viz. that the Tubercles 
 and Vomicae produce and spread abroad other disease within 
 the lungs beyond the parts which they themselves occupy, 
 and beyond the sphere of their own specific actions ; and 
 that other disease is Inflammation. These forms are charac- 
 terized during life by a mixture of the auscultatory Sounds 
 
 M 
 
162 SUBJECTS CONNECTED WITH [LECT. XIII. 
 
 belonging to Phthisis, and the auscultatory Sounds belonging 
 to that other disease; by those which denote Tubercles and 
 Vomicae, and those which denote effusion, of whatever kind, 
 into the bronchial and vesicular structure of the lungs ; by 
 Dulness beneath the clavicles or about the scapulae, or by 
 Cavernous Breathing or Bronchophony, Gurgling Breathing, 
 Gurgling Cough, or Pectoriloquy ; and, at any or every part, 
 where these are not found, by Sibilus or large or small Crepi- 
 tation. 
 
 The phthisical disease, however, must have reached a certain 
 point of its development, before each order of auscultatory 
 Sounds is clearly discernible. 
 
 Hence there are cases in which the disease indeed is mixed, 
 or of two kinds concurrently, while the auscultatory Sounds are 
 of one kind only. The specific Phthisical disease and the 
 common Inflammatory disease exist together ; but at the same 
 time the auscultatory Sounds present only indicate the one and 
 not the other : and, strange to say, the sounds that are present 
 often belong, not to the primary Phthisical disease, but to the 
 Inflammation which is secondary and incidental to it. 
 
 Mere Tubercles, at their first formation, are capable of 
 imparting such irritation to the whole lung, as to produce 
 inflammation of its entire bronchial and vesicular structure, and 
 an early abiding effusion within it; and this effusion gives 
 occasion to its own auscultatory Signs. But the Tubercles may 
 be so scattered through the lungs, and so little accumulated in 
 any one situation, as of themselves to cause no perceptible 
 obstruction to the passage of air, and consequently to give no 
 auscultatory Signs by which they can be suspected to exist. 
 
 In the autumn of the year 1833, a young man (Thomas 
 King) was admitted into this hospital, and remained here three 
 months, until he died. His case is so important pathologically, 
 and so aptly illustrative of those practical points I am now 
 considering, that I must be allowed to dwell upon it a little at 
 large. 
 
 He had already been ill three months before his admission. 
 His complaint began with Haemoptysis, which occurred to the 
 amount of four or five ounces when he was making some unusual 
 exertion, and continued in smaller quantities for a few days, 
 and then ceased altogether. 
 
LECT. XIII.] CLINICAL MEDICINE. 163 
 
 At his admission he was pale and emaciated ; his pulse was 
 140 in a minute, and of extreme feebleness. He had profuse 
 perspirations at night ; he suffered an agonizing dyspnoea, and 
 brought up a scanty glutinous expectoration, with great effort 
 of coughing. 
 
 Auscultation discovered at this time a clear respiratory 
 murmur in every part of the left lung, and in the right a clear 
 respiratory murmur, confined to its very upper part, and then a 
 widely-diffused small Crepitation, which gradually faded away 
 into absolute dulness as you approached nearer the bottom. 
 It was not long, however, before the condition of the left lung 
 was the same to Auscultation as the right. 
 
 I know no distress greater than that which attends the 
 collection of viscid mucus in the lesser bronchi and vesicular 
 structure of the lungs. There is a constant dyspnoea and 
 ceaseless provocation to cough, and an agony, and striving to 
 tear up from the respiratory passages something that will not 
 come. Such distress was unmitigated in this poor fellow for 
 three months together. 
 
 This same condition of the ' lesser bronchi and vesicular 
 structure, when it results from acute inflammation, seldom lasts 
 long ; yet even for a few days the agony of the dyspnosa and 
 fatigue of the cough are hardly tolerable. But here they were 
 abiding and unaltered for three months, kept up by inflamma- 
 tion (if you please), but inflammation of no action and no power, 
 where the pulse was always of extreme frequency and extreme 
 feebleness. 
 
 No remedies that were employed at all assuaged the distress 
 or altered the conditions of the disease within the chest ; and 
 the auscultatory Sign to the last, the only Sign, was small 
 Crepitation largely diffused through both lungs, which, at their 
 lower part, were almost dull. He died exhausted. 
 
 Now, long before his death, I certainly did suspect that 
 this effusion throughout all the bronchial passages was not 
 kept up solely by the idiopathic disorder of their lining 
 membrane, but that something would be found elsewhere 
 within the lungs capable of producing and maintaining it; 
 and I certainly did conjecture that we should find Tubercles, 
 partly from the whole malady having commenced with Haemo- 
 ptysis, and partly from not knowing what else there could be. 
 
164 SUBJECTS CONNECTED WITH [LECT. XIII. 
 
 Dissection discovered the pleura adherent on both sides, — 
 on the left partially, on the right , universally ; and the whole 
 membrane apparently converted into a thick cartilaginous 
 substance; the entire lungs loaded with bloody serum, and 
 their whole texture so softened as to break down easily under 
 pressure of the fingers. These were all the results of common 
 inflammation, which had reached to every tissue which com- 
 poses the structure of the lungs. 
 
 But dissection discovered, moreover, myriads of Tubercles, 
 distinct, and sprinkled universally throughout the lungs ; grey, 
 and as minute as millet-seeds, in the lower lobes ; yellow and 
 of a larger size in the upper. 
 
 This is not a common specimen of disease, but it is a very 
 instructive one, and therefore I have quoted it. It is remark-, 
 able, in contrast with the forms of Pulmonary Consumption 
 which I have before described, that here the minutest Tubercles, 
 not one of which had passed on to the state of Vomica, should 
 be capable of producing inflammation, and diffusing it so 
 generally, and maintaining it so constantly ; and that these 
 mere Tubercles should continually supply such an amount of 
 irritation that no remedy could in the least degree abate the 
 inflammation (otherwise perhaps curable in itself) which they 
 were always present and ready to renew. In this case the 
 secondary and incidental morbid processes entirely outran 
 those which were primary and specific ; and the patient perished 
 of inflammation of the entire lungs, the Phthisical disease 
 having not passed beyond its earliest and tubercular stage. 
 
 But, trusting to my own experience, I should say, that it 
 was a rare thing for Pulmonary Consumption thus to kill, by 
 producing chronic inflammation and chronic effusion into the 
 entire bronchial and vesicular structure of the lungs, itself 
 still remaining in the tubercular Stage, and the Tubercles not 
 yet occasioning any auscultatory impediment to the passage of 
 air. It is more according to my observation that, in this stage, 
 or under these conditions, it should produce acute inflammation, 
 either proving fatal in a few days, or requiring active treat- 
 ment to prevent it from becoming so. And it is still more 
 according to my observation, that in this stage, or under these 
 conditions, it should produce Haemoptysis ; which also may be 
 called acute, being accompanied by fever and much vascular 
 
LECT. XIII.] CLINICAL MEDICINE. 165 
 
 action, and liable, too, to prove fatal in a few days, or re- 
 quiring active treatment to prevent it from becoming so. In 
 the fatal cases the unsuspected Tubercles are only discovered 
 after death. 
 
 Yet attacks of acute Inflammation or acute Haemoptysis 
 from such a cause are not usually fatal: but, the cause still 
 remaining, they are apt to recur again and again ; and at 
 length, when the Tubercles increase sufficiently to obstruct the 
 passage of air through certain parts, and to occasion dulness 
 here and there, and a more energetic and compensating respira- 
 tion elsewhere, then the secret of the former inflammations 
 or haemorrhages are revealed. At this point the mixed 
 character of the disease begins to declare itself by the mixed 
 character of the auscultatory Signs. 
 
 Now, although Pulmonary Consumption (as we have seen) 
 unquestionably can, and sometimes does, produce Inflammation 
 or Hsemorrhage of the respiratory passages, long before it is 
 so far developed as to give any direct tokens of its own 
 existence, yet this is not the usual course : it most frequently 
 happens, that neither Inflammation nor Haemorrhage are added 
 to it, until Tubercles have at least reached that degree of 
 accumulation when they begin to give occasion to certain 
 auscultatory Signs. 
 
 I think I have observed that, as long as the Pulmonary 
 Consumption remains in its tubercular Stage, if an Inflamma- 
 tion or a Haemorrhage be added to it, they are apt to occur in 
 distinct attacks, occasionally and casually. 
 
 I formerly mentioned the frequent cases of Haemoptysis 
 admitted into this hospital, which were connected with 
 Tubercles of the lungs. The attack is usually sudden ; the 
 quantity of blood lost in a short time considerable; the treat- 
 ment required usually active; and the result, as far as the 
 mere Hsemorrhage is concerned, usually successful. Moreover, 
 the auscultatory Signs denote the mixed nature of the disease. 
 "While the spitting of blood continues, and perhaps for a short 
 time after it has ceased, there is a large or sjnall Crepitation 
 commonly arising from a considerable space at the lower part 
 of one or both lungs. This denotes the bronchial or vesicular 
 effusion, as distinguished from the deposition of Tubercles. 
 Then there is a diffused dulness both to Percussion and 
 
166 SUBJECTS CONNECTED WITH [LECT. XIII. 
 
 Auscultation somewhere; perhaps between the clavicle and 
 mamma on one side ; and an exaggerated respiratory murmur 
 somewhere else ; perhaps between the clavicle and mamma on 
 the other side. These denote the deposition of Tubercles, as 
 distinguished from the bronchial or vesicular effusion. 
 
 To my experience bronchial or vesicular Haemorrhage is 
 more familiar as an accompaniment of Phthisis, than bronchial 
 or vesicular Inflammation ; the effusion of blood than the effu- 
 sion of serum or mucus, while the disease is yet abiding in 
 its tubercular Stage. But when Inflammation does occur, I 
 have generally remarked in it the same circumstances and 
 attendant conditions which belong to the Haemorrhage; the 
 same sudden and distinct mode of attack ; and that degree of 
 excitement of the blood-vessels which requires the same 
 treatment ; and the same successful result. Moreover, there 
 have been the same auscultatory Signs ; namely, crepitation at 
 the lower part of the lungs, produced by the effusion of serum 
 or mucus ; and dulness at the upper part, produced by the 
 deposition of tubercles. The only difference is, that in one case 
 serum or mucus is expectorated, and in the other blood. 
 
 I here speak of Haemorrhage and of Inflammation as of two 
 things, not wishing to swerve from the customary language of 
 medical men ; but, if I might use my own language, I should 
 speak of vascular action terminating sometimes in effusion of blood, 
 and sometimes of serum or mucus ; as of one thing tending to- 
 two results ; for whether the result be the effusion of blood, 
 or the effusion of serum or mucus, the vascular action requires 
 the same treatment according to its degree, and is as much 
 inflammatory in one case as the other. Moreover, it is this 
 vascular action which is our only practical concern ; we treat 
 it, and it only, and have no special care of either blood, serum, 
 or mucus, for which in themselves we can do nothing 
 remedial. 
 
 But it is when Pulmonary Consumption has advanced 
 beyond the tubercular Stage that we find the most frequent 
 examples of its. mixed character. Bronchial or vesicular 
 effusion is almost the constant accompaniment of Vomicae ; and 
 the expectoration is now often as much supplied by the mucus 
 lining of the air passages as by the Cavities themselves. 
 
 You have only to go into the wards of the hospital, and 
 
LECT. XIII.] CLINICAL MEDICINE. 167 
 
 you may at once acquaint yourselves in a dozen instances with 
 the mixed character of the auscultatory Sounds. Gurgling 
 Cough, Gurgling and Cavernous Respiration, Pectoriloquy, 
 one, or several, or all together, will show that this, that, and 
 the other patient, have Vomicae in their lungs ; and Large and 
 Small Crepitation, one or both concurrently, will show also 
 that this, that, and the other patient, have fluid effused here, 
 there, or everywhere, within the respiratory passages. 
 
 Now when Vomicae have been-long formed, and the expec- 
 toration long established, Haemorrhage and Inflammation are 
 less liable to occur in sudden and distinct attacks. The blood, 
 or mucus, or serum, which are now separated from the surface 
 of the air passages, result from a vascular action of less 
 force, but of more permanency, and are themselves more 
 abiding. 
 
 It should be remarked, however, that blood, which is more 
 common in another stage of Pulmonary Consumption, is more 
 rare in this ; not that blood does not now sometimes appear, 
 but it appears rather as a part of the expectorated matter, 
 streaking or staining it, than as pure and sincere blood. 
 
 Assuredly, after the expectoration is established, sudden 
 and profuse gushes of blood seldom occur. Probably the 
 expectoration itself is the security against them, the circulation 
 thus obtaining all the relief it stands in need of. Probably, 
 too, the security becomes greater in proportion as the expec- 
 toration is more copious and more free, and proceeds from a 
 larger extent of mucous surface. 
 
 All this is, in the nature of things, very probable, and it is 
 confirmed to me by the striking fact which, in a few instances, 
 I have known, of a copious muco-purulent expectoration sud- 
 denly ceasing, and a frightful Haemoptysis at once bursting 
 forth ; as if the circulation, being suddenly baffled, had sought 
 and found the nearest way to free itself. In these instances, 
 when the Haemorrhage ceased, the expectoration was re-esta- 
 blished. 
 
 It should be mentioned, that in the destructive processes 
 connected with the formation of many and large Vomicae, the 
 blood-vessels of the lungs do not always escape ulceration, or 
 rupture, while they are yet pervious ; and then a mortal 
 Haemorrhage is the consequence. But such Haemorrhage is 
 
168; SUBJECTS CONNECTED WITH [LECT. XIII. 
 
 purely accidental, and independent of any proper hemorrhagic 
 action (if I may so call it) in the vessels themselves. 
 
 Let me guard you against a vulgar error. Haemoptysis 
 and rupture of a blood-vessel are, in the popular sense, con- 
 vertible terms ; so much is one conceived to be the natural 
 and necessary consequence of the other. But rupture of a 
 blood-vessel, which has been esteemed the only cause of 
 Haemoptysis, is unquestionably the rarest cause of all; and 
 this accident, which one might expect to find frequent in 
 Pulmonary Consumption, nature has taken great pains to 
 guard against ; for no sooner does the destructive process of 
 forming Vomicae within the lungs begin, than she sedulously 
 betakes herself to closing up the arteries which lead to them 
 by clots of blood : and as to the veins, partly (I believe) by 
 the same process, and by otherwise arresting the circulation 
 through them, she reduces them to impervious shreds. 
 
 Now, in all cases of Pulmonary Consumption arrived at the 
 stage of Vomicae, I would recommend a constant regard to the 
 extent of the disease beyond its specific limits. I would recom- 
 mend that, besides attending to the sounds indicative of cavities, 
 you should take especial note of Crepitations, and how they 
 vary in the distance to which they spread themselves from time 
 to time. The Gargouillement, and the Pectoriloquy, and the 
 Vomicae, from which they arise, are beyond our reach remedially; 
 not so the Crepitations, and the vascular action which produces 
 them. In my treatment of Pulmonary Consumption, I am 
 accustomed to make these Crepitations serve me for practical 
 indications, endeavouring by all means to lessen and circum- 
 scribe them, and thus seeking, under the guidance of Auscul- 
 tation, to bring back the disease as much as possible within its 
 specific limits. 
 
 The bronchial and vesicular effusion, which is the concomi- 
 tant of Vomicae, submits itself to the influence of medicine in 
 various degrees. Very often, when there are Gurgling Cough 
 and Gurgling and Cavernous Respiration and Pectoriloquy, at 
 certain points, and, withal, Large and Small Crepitations diffused 
 widely through the lungs, a seasonable remedy will entirely 
 sweep away the latter sounds, and leave the former alone. A 
 small cupping, a few leeches, a blister, a liniment, a mustard 
 cataplasm — one or other of these, according to the degree of 
 
LECT. XIII.J CLINICAL MEDICINE. 169 
 
 vascular action, applied at the right time and in the right place, 
 will produce immense relief, by bringing the disease back for a 
 while within its specific limits. 
 
 It is thus, as perhaps you may have remarked, that almost 
 every phthisical patient brought into the hospital experiences 
 great relief for a short time after his admission. The poor, 
 alas ! are not only the chief victims of Phthisis, but they suffer 
 the disease with all its occasional superadded evils, which their 
 exposure, their hardships, and their needful toils, will not allow 
 them to escape. With them, the superadded evils are often 
 beyond all proportion to the disease itself. The Tubercles and 
 Vomicae may be few, and the bronchial and vesicular effusion 
 immense; and this superadded effusion may be for the first 
 time submitted to a remedy when they reach the hospital, and 
 then it is often in a great part or altogether swept away. No 
 wonder that, from the relief which follows, the patients should 
 sometimes believe themselves cured at once and entirely ! 
 
 But the effusion again and again returns, and requires again 
 and again to be abated. 
 
 Thus I have given a sketch only of a vast subject, which is 
 interesting, fearfully interesting, to all mankind. I have not 
 crowded it with a multitude of instances, for I had not room 
 for them ; and I was afraid they might obscure the outline, 
 which was all I designed to give. 
 
 In tracing this outline my own experience has guided me ; 
 and yours will soon enable you to fill it up, and to determine 
 how far it is true and how much it is worth. 
 
 There are many strange things respecting Pulmonary Con- 
 sumption — many striking discrepancies between case and case, 
 and many contrarieties of opinion among the well-informed as 
 to its proper mode of treatment, — which, heretofore, the best of 
 us have been unable to reconcile or explain. In one case it is 
 a slow decline; in another a galloping consumption. It is 
 spoken of as incurable ; and yet now and then an individual 
 recovers, or seems to recover. Some are for treating it by 
 bleeding. Some by bark and steel, and ammonia. Some restrict 
 their patients to vegetables and asses' milk, and some give them 
 animal food and wine ; and all can boast of their success. 
 
 But these things have now ceased to be mysterious any 
 longer ; thanks to a more enlightened pathology and to that 
 
170 SUBJECTS CONNECTED WITH [LECT. XIII. 
 
 method of diagnosis which not only marks the due course and 
 progress of the specific disease, but does not allow even emergent 
 and contingent events to escape its scrutiny. 
 
 This same method, still aided and guided by a just pathology, 
 has enabled us to discern more clearly the avenues through 
 which nature admits relief, and to direct our remedies with a 
 steadier aim ; albeit such remedies are of various and even 
 opposite kinds. 
 
 Unquestionably, within the limits of possible success, Auscul- 
 tation has contributed to render our treatment of Phthisis more 
 successful. 
 
 It has been the means of discovering no new remedy. How 
 should it ? It has made nothing curable now, which was incur- 
 able before. But, while it has taught us to distinguish the 
 unmixed from the mixed Phthisis, the disease from its accidents, 
 what is reparable from what is not, in the patient while yet aim, 
 it has enlarged the resources of practical medicine, by more 
 clearly presenting to it the objects within its reach. 
 
 By keeping those objects, thus offered to you, steadily in 
 view, you will be able to fulfil more satisfactorily every purpose 
 that rational treatment can contemplate in a disease which, if 
 it be not incurable, is rarely cured. You will know better how 
 to remove its many superadded evils, to postpone or mitigate 
 its many pains, perhaps to lengthen life, and to procure for it, 
 while it lasts, some share of happiness. 
 
 I cannot finish this little sketch of Pulmonary Consumption, 
 and of the uses which Auscultation serves in distinguishing its- 
 kinds, and in furnishing guidance for its treatment, without 
 adding one further remark ; it is this : — In Pulmonary Con- 
 sumption death not unfrequently arrives at a much earlier 
 period than seems consistent with the morbid processes going 
 on within the chest. Patients die sometimes long before the 
 disease of the lungs has reached the point at which it is neces- 
 sarily fatal. I do not mean that phthisical patients may chance 
 to suffer fever or cholera, or may chance to break a limb, and 
 so die of other diseases or accidents. These cannot be anticipated 
 or guarded against. But I mean something more worthy of 
 your consideration. 
 
 In proportion as we are more intent upon investigating the 
 local processes of diseases in a particular organ, scrutinizing 
 
LECT. XIII.] CLINICAL MEDICINE. 171 
 
 them pathologically, and nicely weighing their diagnostic signs, 
 there is a danger that our minds may be withdrawn from those 
 larger views which regard their constitutional origin, and their 
 consequent liability to fall upon any or all organs of the body. 
 Thus, while we are expecting a man to die of Pulmonary Con- 
 sumption a twelvemonth hence, he may die in the meantime of 
 (if I may so speak) Intestinal Consumption, Peritoneal Con- 
 sumption, Mesenteric Consumption, or Vertebral Consumption. 
 For, from the same strumous constitution, which engendered 
 Tubercles and "Vomicae in the lungs, Tubercles and Ulcers are 
 formed in the mucous lining of the bowels ; hence comes an 
 incontrollable diarrhoea or dysentery. From the same cause 
 Tubercles are formed upon the peritoneum, and Tubercles in 
 the mesenteric glands; hence come slow peritonitis, and ascites, 
 and marasmus. From the same cause caries affects the bodies 
 of the vertebrae ; and hence comes lumbar abscess. 
 
 All these are liable to arise in the course of Pulmonary Con- 
 sumption ; and the fatal event may be greatly accelerated in 
 consequence. Not that, from arising in the course of it, they 
 are to be regarded as merely incidental to it ; for both it and 
 they are all of the same essence, the several products of the 
 same morbid constitution ; sometimes one and sometimes another 
 taking the lead; Pulmonary Consumption as often following 
 these, as these following it. 
 
 Finally, then, Pulmonary Consumption is no more than a 
 fragment of a great constitutional malady, which it would be in 
 vain to think of measuring by the stethoscope, and which it 
 belongs to a higher discipline than any mere skill in Ausculta- 
 tion rightly to comprehend. 
 
172 SUBJECTS CONNECTED WITH [LECT. XIV. 
 
 LECTUKE XIV. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 POSSIBLE FALLACIES OF AUSCULTATION. — HOW IT MAY LEAD TO AN 
 ERRONEOUS DIAGNOSIS — IN PNEUMONIA — IN DILATATIONS OF 
 THE BRONCHI — IN EMPHYSEMA OF THE LUNGS. — PATHOLOGY OF 
 DILATATIONS OF THE BRONCHI. — PATHOLOGY OF EMPHYSEMA OF 
 
 THE LUNGS. HOW THE INTIMATIONS OF AUSCULTATION AND 
 
 PERCUSSION MAY APPARENTLY CONTRADICT, YET REALLY CON- 
 FIRM, EACH OTHER. 
 
 I have endeavoured to speak of the auscultatory Signs that 
 belong to the lungs as plainly as I could. First I took them 
 singly, and tried to fix their separate value by a reference to 
 the simpler forms of disease ; and then I took them together, 
 seeking their relative and combined value in forms of disease 
 that are more complex. And thus I found that a single patho- 
 logical condition might be denoted by a single auscultatory 
 Sign ; that in Bronchitis, when it had not passed the stage of 
 mere vascularity, there was nothing but a dry Sibilus, and when 
 it had reached the stage of effusion, nothing but a moist Crepi- 
 tation. Moreover, I found that, as diseases were cumulative, so 
 might tbeir auscultatory Signs be cumulative also ; and that a 
 mixed case of Pulmonary Consumption often contained every 
 one of the auscultatory Signs that have been mentioned. 
 
 These Signs, both singly and cumulatively, I have followed 
 as far, perhaps, as they can be altogether trusted in the dia- 
 gnosis of pulmonary diseases. Not that, beyond this point, they 
 have no further aid to contribute ; only they need more con- 
 firmation from concurrent circumstances, and require more care 
 on our part, to avoid certain errors, to which, if too implicitly 
 relied upon, they are apt to conduct. 
 
 Auscultation is not infallible. I have known it betray the 
 most wary and experienced into downright error ; as when a 
 
LECT. XIV.] CLINICAL MEDICINE. 173 
 
 certain sound, which in forty-nine cases indicates one thing, 
 has in the fiftieth case indicated another. You ought to be 
 aware how this may happen. As also, when the several aus- 
 cultatory Signs of one and the same case seem to set themselves 
 in opposition to each other, one indicating this thing, and another 
 that ; one confuting what another affirms. This apparent con- 
 tradiction is at first very perplexing ; but, being understood, 
 turns, out to be no contradiction at all ; and the apparent con- 
 tradiction and the real consistency furnish together a sure dia- 
 gnosis of a particular form of pulmonary disease. You ought 
 to be aware how this, too, may happen. 
 
 In what manner, then, an auscultatory Sign may give false 
 intimations, and how several Signs may seem to contradict, and 
 yet be perfectly consistent with, each other, I will now en- 
 deavour to explain. For this purpose I must touch a little 
 upon some points of Pathology. 
 
 It has been by the light of certain facts in Pathology, con- 
 sidered as general truths, that Auscultation has reached some 
 of its most important conclusions. 
 
 Of such facts these two deserve to be especially noticed ; 
 viz. that Tubercles and Tubercular Cavities have their origin 
 in the upper lobes, and Inflammation its local origin in the 
 lower lobes, of the lungs. 
 
 These two facts are so generally true, that they have been set 
 up as signals (if I may say so) to steer our diagnosis by ; and 
 Auscultation has reached some of its safest conclusions entirely 
 from faith in them. 
 
 But ordinary diseases will sometimes occur under extraor- 
 dinary circumstances, or in unusual situations ; and then we 
 are as apt to be thrown out in our diagnosis, as the pilot is in 
 his course upon any unexpected alteration of lights or signals on 
 the coast. He makes false points, and so do we. 
 
 Thus in every instance of exception to the two general 
 truths which have been specified, there is a perilous chance that 
 Auscultation will lead us wrong. 
 
 In forty-nine cases out of fifty, Pectoriloquy is a direct 
 symptom of a cavity formed in the lungs, the result of 
 tubercular Disease, or the result of Inflammation. Then 
 comes the fiftieth case, in which there is Pectoriloquy, arising 
 not from a cavity either tubercular or inflammatory, but from 
 
174 SUBJECTS CONNECTED WITH [LECT. XIV. 
 
 some other condition ; and in this fiftieth case the Pectoriloquy, 
 I suspect, almost always deceives us. 
 
 A young woman (Mary Taylor) was admitted into the 
 hospital in September, 1833. For two or three years she had 
 been liable to slight coughs, and in the last spring had suffered 
 Influenza. The Influenza passed away, but a slight cough was 
 still left behind. 
 
 Three days before her admission she had a rigor, inability 
 to lie on the right side, and pain shooting from beneath the 
 right clavicle through the chest to the scapula. 
 
 At her admission she was flushed and hot, her respiration 
 hurried, her pulse 112 in a minute, and full and soft ; and she 
 complained of pain in the situation just mentioned. 
 
 Auscultation found a healthy respiratory murmur, unmixed 
 with any unnatural sound, throughout the entire left lung, but 
 in the right lung Cavernous Breathing, and a loud Pectoriloquy 
 above the spine of the scapula, and small Crepitation all around 
 it ; also a space beneath the clavicle dull to the ear, and dull 
 to Percussion, while the rest of the lung was healthy. Six 
 leeches were the most active remedy which her strength would 
 admit, and they were applied beneath the clavicle. 
 
 She was delirious through the night, and perspired greatly. 
 The next day she was more flushed : her dyspnoea was 
 aggravated ; her pulse had gained in frequency, and had lost 
 in power ; she was altogether very much sunk. The Pec- 
 toriloquy was still clear and evident, and the small Crepitation 
 still heard everywhere about the scapula, and moreover in front, 
 about the mamma. 
 
 Our diagnosis in this case was, that one considerable 
 Vomica at least existed in the apex of the right lung, and that 
 acute Inflammation of the vesicular structure had arisen all 
 around it. 
 
 She was treated by remedies as active as her feeble circula- 
 tion would admit, chiefly by leeches to the surface opposite the 
 parts where the Crepitation was heard. In four days the 
 Crepitation began to abate, and in six it was gone ; and, as 
 it gradually went away, the respiratory murmur gradually 
 returned, until it entirely took its place. 
 
 But what became of the Cavernous Respiration and Pec- 
 toriloquy ? These surely remained unaltered ; for the Vomica 
 
LECT. XIV.] CLINICAL MEDICINE. 175 
 
 could not be so soon cured, although the surrounding Inflam- 
 mation might ? 
 
 Not so. But the Cavernous Breathing and Pectoriloquy 
 were first changed into Bronchial Respiration and Broncho- 
 phony : and these last soon ceased ; when nothing was any- 
 where heard but the healthy respiratory murmur. The patient 
 was well, and the whole work of reparation was accomplished 
 in a week. 
 
 The diagnosis, I have said, was that she had one large 
 Vomica at least at the apex of the right lung, and that acute 
 Inflammation had arisen around it. I apprehended that she 
 would die quickly, so fearfully rapid was her sinking in the 
 first two days after she reached the hospital. But a week from 
 that time she was well, and a fortnight from that time she was 
 discharged from the hospital. 
 
 In this case I was entirely deceived in regard to one sup- 
 posed ingredient of the disease, the Cavity. And I was 
 deceived by Auscultation. Cavity there was none, which is the 
 very thing we expect to find at the apex of the lung. But 
 Inflammation there was, and of the acutest kind, and nothing 
 hut Inflammation, which is the very thing we do not expect to 
 find there. i 
 
 It is quite certain that the Cavernous Breathing and Pec- 
 toriloquy were formed in a bronchial tube passing through a 
 portion of lung which had become partially condensed by 
 Inflammation. As the lung began to admit more air, the 
 Cavernous Breathing and Pectoriloquy lost their distinctness, 
 and were changed into Bronchial Respiration and Broncho- 
 phony ; and when the lung became entirely free, the healthy 
 murmur was re-established alone and unmixed with any un- 
 natural sound whatever.* 
 
 * Inflammation, independent of tubercular disease, is so rare an event 
 in the upper lobe of the lungs, that my own experience does not enable me 
 to speak confidently of its auscultatory Signs. What I have noted as a 
 peculiarity, may be the natural and necessary result of Inflammation in a 
 part where the Bronchi are large and near the surface, and the lung par- 
 tially or altogether condensed around them. I am not prepared to say that 
 the same pathological conditions, which in other parts of the lungs would 
 produce Bronchial Bespiration and Bronchophony, may not always produce 
 Cavernous Respiration and Pectoriloquy in the upper lobes. The following 
 case lately fell under my observation : — A girl twelve years of age had a 
 
176 SUBJECTS CONNECTED WITH [l,ECT. XIV; 
 
 Let it, however, in justice be remarked, that although 
 Auscultation misled me both in my diagnosis and prognosis, yet 
 it betrayed me into no error of treatment. Nay, but for 
 Auscultation, I might have treated the case less precisely and 
 less effectively. It pointed out to me the very part where the 
 disease was, and told me that Inflammation was at least an 
 ingredient of it; things which could only have been conjectured 
 without the aid of Auscultation. 
 
 There are certain conditions of the lungs now familiarly 
 understood (or at least familiarly spoken of, as if they were 
 understood) by medical men, which had been little investigated, 
 and were little known, before Auscultation directed attention to 
 them ; and yet, both pathologically and practically, they are of 
 the highest import. Laennec seems to have been first led to 
 make accurate inquiry into the nature of Dilatations of the 
 Bronchi, and Dilatations of the Vesicular Structure of the 
 Lungs, for the sake of verifying certain auscultatory Signs. 
 And all who concern themselves with Auscultation, and seek in 
 like manner to verify its Signs by dissection, will soon feel 
 their obligation to him for his elucidation of these subjects. 
 
 Dilatation of the Bronchi may take place in one or in several, 
 in any or in almost all their branches, throughout the lung ; it 
 is, however, most frequently met with in the upper lobe, and 
 nearer its anterior surface. 
 
 A Bronchus may dilate, and still preserve its natural 
 cylindrical form. That, which would not naturally receive 
 more than a knitting-needle, becomes large enough to admit a 
 
 hot skin, a flushed countenance, a rapid pulse, difficult breathing, and small 
 Crepitation widely diffused throughout the left lung. Every part of the 
 lung was still pervious, but less air was manifestly admitted into the upper 
 lobe than elsewhere. Moreover, at two or three spots about the scapula, 
 Cavernous Respiration and Pectoriloquy were distinctly heard. No clear 
 account could be obtained of the girl's illness before her admission into the 
 hospital. But from present symptoms I had no doubt that the left lung was 
 extensively inflamed, and that it contained several Vomicae. 
 
 Nothing remained but to subdue the inflammation; and, indeed, the 
 remedies succeeded beyond our hopes ; for in curing the inflammation they 
 (apparently) cured the VomicEe also. In the course of ten days the 
 healthy respiratory murmur had taken place of the Crepitation, and the 
 Cavernous Breathing and Pectoriloquy were no longer to be heard. — 
 February, 1836. 
 
LECT. XIV.] CLINICAL MEDICINE. 177 
 
 crow-quill, or a goose-quill, or even a little finger. It seldom 
 happens that the common bronchial trunk is sensibly dilated, 
 but the branches become larger than the trunk from which they 
 are given off. 
 
 But a Bronchus may dilate and not preserve its natural 
 form. It may dilate so as to take the form of a Cavity, 
 having the same size and shape as a Vomica; it is distin- 
 guished, however, from a Vomica, by the structure of the 
 Bronchus being traceable into it; its mucous membrane, its 
 fibrous membrane, and sometimes vestiges of its cartilaginous 
 rings. 
 
 Again, a Bronchus may so dilate as to form several Cavities ; 
 that is, it may dilate and then contract itself again to its ordi- 
 nary calibre, and dilate and contract again and again at several 
 spaces in its course. Thus, upon dissection, the lungs have 
 sometimes appeared to be beset with Vomicae or abscesses full 
 of matter, which, upon examination, have turned out to be so 
 many Cavities formed from the dilatation of several bronchial 
 ramifications. 
 
 When the Bronchi are numerously and extensively dilated, 
 they so compress the intermediate pulmonary structure as to 
 preclude the admission of air into its vesicles ; and thus it be- 
 comes squeezed together and flaccid, exactly resembling lung 
 which has suffered from pleuritic effusions. 
 
 There seems good reason to believe that the Bronchi become 
 dilated by the long-continued residence and accumulation of 
 morbid secretion within them ; and that the bronchial trunks 
 are less frequently dilated than their branches, because this 
 morbid secretion is accustomed to linger within them for a 
 shorter time, being more easily dislodged by forced expiration, 
 i.e. by Cough. 
 
 I know no instance of dilatation of the Bronchi where it 
 has not followed or accompanied some disease especially charac- 
 terized by abundant secretion; such as protracted Hooping- 
 cough, chronic Bronchitis, or Catarrh. 
 
 Surely this little pathological sketch will at once show what 
 the auscultatory Sounds must necessarily be which accompany 
 dilated Bronchi. If they be enlarged uniformly through their 
 whole course, they must gire rise to Bronchial Respiration and 
 Bronchophony, and much more so, if they pass through com- 
 
W8 SUBJECTS CONNECTED WITH [LECT. XIV. 
 
 pressed lung. If they be formed into Cavities,, they must occar 
 sibn Cavernous Breathing and Pectoriloquy ; and when those 
 Cavities contain fluid (as they generally do) they must produce 
 Gurgling Respiration and Gurgling Cough. 
 
 But Bronchial Respiration and Bronchophony,. Cavernous 
 Respiration and Pectoriloquy, Gurgling Respiration and Gur- 
 gling Cough, have been dwelt upon and explained as the almost 
 certain signs of condensed lung and pulmonary abscesses ; of 
 lung, condensed by the products of common inflammation, or 
 of 7 specific disease; of abscesses formed by inflammation, or 
 left after the evacuation of tubercular matter. And of such 
 conditions they must still continue to be the almost certain 
 signs. It is only when they are interpreted by the special 
 circumstances of some particular case, that they can be construed 
 into a different meaning, or serve to indicate Dilatation of the 
 Bronchi. 
 
 But the circumstances are seldom special enough to turn aside 
 the auscultatory Signs from their most common object, and to 
 make them point to another which is of very rare occurrence. 
 Hence I am persuaded: that the most experienced and most 
 skilful physicians generally fail to form a just diagnosis in cases 
 of Dilatation of the Bronchi, and seldom fail to form a wrong 
 one ; the auscultatory Signs and every attendant circumstance 
 conspiring to lead them into error. 
 
 Chronic Bronchitis is the most frequent cause and concomi- 
 tant of Bronchial Dilatation. 
 
 Now chronic Bronchitis itself is often with great difficulty 
 distinguished from Pulmonary Consumption. Its attendant 
 emaciation, its copious puriform sputa, its abiding hectic,, are. 
 all phthisical symptoms. And it is only after repeated examina- 
 tions that we are able to exclude the idea of Phthisis when we 
 find no auscultatory Signs of a cavity. There is large 
 Crepitation extensively diffused through the whole lungs> 
 and that only; showing that the copious puriform sputa, 
 come from the mucous lining of the Bronchi, and from it 
 only. 
 
 But, suppose that in such a case there was Pectoriloquy 
 withal and Pectoriloquy in several placesj.or Gurgling Respira- 
 tion and Gurgling Cough in several places, no human penetra- 
 tion could distinguish the disease from Pulmonary Consumption ; 
 
ILECT. XIV.] CLIMCAX, MEDICINE. 179 
 
 and yet there might be neither Tubercle nor Vomica in any. 
 •part of the lungs, but a dilatation of the Bronchi into the form 
 of Cavities. 
 
 A man, 46 years of age, had been liable to Catarrhs for 
 several years, and for one year had suffered a slight habitual' 
 oppression of the chest. Be had once spit blood in December 
 of the preceding year. In the following February^ upon the 
 oecasion of his contracting- a fresh cold, an expectoration came 
 on, which was copious and puriform, and very fetid. Finally, 
 a week before his admission into the hospital, he suffered a 
 severe pain in the left side of the chest, which came on for the 
 first time after his being wet through, and_ever afterwards he 
 was constrained to keep his bed. 
 
 He entered the hospital at the end of March. He was ia a, 
 state of orthopnea, and his countenance expressed the greatest 
 anxiety. He rejected, by an easy cough, a foetid expectoration^ 
 •consisting of yellow thiek globules, mixed with a large quantity 
 of serum, upon which they floated. The pain was so great 0¥er 
 •the whole of the left side of ifae- chest, as not to allow the use of 
 Percussion. 
 
 Auscultation found the respiratory murmur' everywhere 
 strong and clear on the right side, and much more feeble every- 
 where on the left ; and on the left side, in the region of the 
 mammae and a little above the inferior angle of the scapula, 
 there was manifest Pectoriloquy. 
 
 Nobody entertained the slightest doubt in this case that the 
 disease was Pulmonary Consumption, and that "a Vomica was 
 formed. The patient remained in the hospital until his death, 
 —■nearly three months: In the meantime the pain of the 
 left side, the fetid expectoration, and the Pectoriloquy, all 
 remained, to which, at length, Diarrhoea was. added. It was 
 remarkable that every evening he suffered a chilliness, followed 
 by burning heat, but without perspiration. 
 
 Upon dissection, the left lung hardly crepitated at. all, 
 although it floated in water. In its upper lobe was a cavity 
 large enough to admit a. middle-sized nut, which] contained a 
 fluid of the same kind with that which had been expectorated. 
 A bronchial tube, a» large as a goose-quill, entered into it ; 
 and dissection traced a continuation between the walls of the 
 bronchus and the walla of the cavity : in both the same mucous 
 
180 SUBJECTS CONNECTED WITH [LECT. XIV. 
 
 membrane, red and thickened, the same fibrous membrane, and 
 some traces of cartilaginous rings. 
 
 Here was no Vomica, but a partial dilatation of a bronchial 
 tube. In the same lung several other bronchial ramifications 
 were dilated in the same way ; suddenly they acquired three or 
 four times their natural size, then contracted themselves again, 
 and then enlarged again ; thus in effect forming cavities. The 
 pulmonary tissue between the dilated bronchi was compressed 
 as by pleuritic effusion.* 
 
 This case did not occur at St. Bartholomew's, but at La 
 Charite\ I was not the person deceived, but Andral : the 
 possibility of deception, therefore, you will the more easily 
 conceive. I have abridged the case from the " Clinique MeMi- 
 cale." 
 
 I am very far from saying that a just diagnosis of bronchial 
 Dilatation "cannot be made during the life of the patient, or 
 that Auscultation cannot contribute essential aid towards it; 
 only I am persuaded that the physician must have very 
 favourable opportunities of watching his patient, and that the 
 case must be less complicated than such cases usually are, 
 before he can arrive at it. The case, too, must be one in 
 which the bronchi are enlarged, still preserving their natural 
 form, and not dilated into cavities. 
 
 But Laennec was led also by Auscultation to make inquiry 
 into the nature of Dilatation of the pulmonary vesicles ; and 
 this subject, as well as that of bronchial Dilatation, he has 
 made his own by the accuracy of his research. 
 
 The surface of the lung will sometimes present to the 
 naked eye the same appearance which is given to it by an 
 ordinary magnifying glass. The pulmonary vesicles will 
 appear of the size of millet-seeds, or hemp-seeds, or raisin- 
 stones; and thus dilated, they sometimes preserve the level of 
 the lungs, and sometimes transgress it a little. 
 
 This appearance results in part from the Dilatation of single 
 vesicles, and in part from the union of several produced by the 
 rupture of their intermediate partitions. 
 
 Sometimes a transparent vesicle, as large as a nut-kemel, 
 will rise very much above the surface of the lung, and seem to 
 spring from a pedicle or stalk. But this appearance is merely 
 
 * Andral, Clinique JKdicale ; Mai. de Poitrine, vol. i. p. 24. 
 
UECT. XIV.] CLINICAL MEDICINE. 181 
 
 owing to its simple constriction just at the point of its 
 emerging above the level of the surface. 
 
 Where the air-cells appear thus dilated at the surface of 
 the lungs, the same condition is found to exist within. In 
 order to see this condition in the lungs to the best advantage, 
 you should inflate them, and then let them dry. Afterwards, 
 when you have divided them with a sharp knife, you will find, 
 Joy examining the cut surface, that the air-cells are almost 
 always more dilated within than they appear to be on the sur- 
 face; and you will see, moreover, that of the air-cells some are 
 simply dilated, and some are ruptured and united together. 
 The smaller bronchi sometimes partake of the Dilatation of the 
 air-cells to which they lead : but this event, which one would 
 think likely to happen constantly, does in fact happen very 
 seldom. 
 
 In a lung, of which the air-cells are dilated, there" is some- 
 thing very peculiar to the touch. It has the feel of a downy 
 cushion, not the crepitant feel of healthy lung. It is softer 
 than healthy lung, and the same degree of pressure evidently 
 displaces in it a larger quantity of air at once. 
 
 Now all this description belongs to conditions in which 
 the air still remains within its proper vessels, those vessels 
 being permanently and unnaturally distended; or distended 
 and, moreover, ruptured into each other. 
 
 Hitherto I have abstained from using any name but what 
 was necessary to the description. I have used none but Dila- 
 tation of the air-cells or vesicles. But this same Dilatation of the 
 air-cells, in which the air is still contained within its proper vessels, 
 is called by everybody Emphysema. And Emphysema let it 
 be called ; only take care that the misnomer does not convey 
 an erroneous idea. I have no fancy for disputing about names ; 
 but this I would remark, that you might just as well call an 
 Aneurism a Haemorrhage, as a simple Dilatation of the air- 
 cells, or the Rupture of the air-cells into each other, an 
 Emphysema. 
 
 If an Aneurism bursts, then follows a Haemorrhage ; and if 
 air-cells burst, otherwise than into each other, then follows an 
 Emphysema. And, in fact, distended air-cells often do burst, 
 not into each other, but so as to allow the air to escape into 
 surrounding texture. 
 
J82 SUBJECTS CONNECTED WITH [lECT. XW- 
 
 One iform of this Emphysema proper (as it may be called) 
 is, when an air-cell bursts near the surface of the lungs, mA 
 air is effused beneath the pleura pulmonalis. Thus a vesicle 
 may be formed of any size, from the egg of a sparrow to the 
 egg of an ostrich, or even larger still. The air, now extra- 
 vasated beneath the pleura, is capable of being displaced by- 
 pressure. 
 
 Another form of Emphysema proper is described by Laemtec, 
 -which I never saw. It is occasioned by rupture of distended 
 air-cells; not on the surface, whence air escapes beneath 
 the pleura, but in the interior of the lung, whence ;air escape* 
 into the pulmonary tissue and lacerates it, and forms a cavity 
 in it. The cavity thus formed is capable of receiving a moderate- 
 sized nut. It is generally found about an inch deep beneath the 
 surface of the lung. It is permanently blown up with air, and 
 sometimes contains blood. The air-cells, which immediately 
 form the walls of the cavity, are effaced, and do not retain their 
 .natural rounded form, either to the eye or the magnifier. But 
 the air-cells at a little distance all around are still distended 
 with air. The air, under these circumstances, is not necessarily 
 effused into the interlobular structure; although it has escaped 
 from its own vessels, it is still limited to this cavity. 
 
 There is one very curious circumstance attending this form 
 of Emphysema. It is this : the pulmonary cavity, which is 
 about an inch from the surface, being permanently blown 
 up with air,",exercises a great stress upon surrounding parts. 
 Under this stress they yield the most readily in that direction 
 where there is the least resistance — viz. in the direction of the 
 surface-; and there a bump is forced .up, -correspondent in size 
 to the interior cavity, and just over the part where it issituated. 
 The Dilatation of the air-cells has been explained to depend 
 upon the forcible incarceration of air within them ; and a cause 
 capable of producing that incarceration has been found in in- 
 flamma'tiom.of the smaller bronchial ramifications which conduct 
 to them. 
 
 -There is an affection called by the French "eatarrhe sec." 
 It is characterized by habitual cough, or cough going and 
 coming for^years, and accompanied by little or no expectora- 
 tion. iBut^what expectoration there, is consists of small -pieces 
 of hard, tough, pearly phlegm. 
 
LECT. XIV. j] CLINICAL MEDICINE. KJ3 
 
 ¥pon this chronic affection attacks of a more acute kind.aie 
 liable to be engrafted from time to time, accompanied by fe\eer, 
 and producing an increase of the expectoration; and, when 
 they subside, often leaving the habitual disorder worse. 
 
 In short, it is one form of (what is called) Asthma ; and .the 
 essential morbid conditions in which it consists are a congestion, 
 and thickening of the mucous lining in the small ramifications 
 of the bronchi, and a secretion by it of this little glutinous 
 pearly phlegm. 
 
 Now the congestion and thickening of the mucous mem- 
 brane in that situation, and the residence of tough phlegm 
 upon it, may ibe obstacles sufficient to prevent the easy return 
 of air from the vesicles, while they may not be sufficient to 
 -prevent the access of air to them. The force of inspiration lis 
 evidently far greater than the force of expiration; and the 
 former is capable, moreover, of being augmented by an effort 
 of the will, in a much greater degree than the latter. 
 
 It is not difficult to conceive how, more air being thus 
 forced into the air-cells by each inspiration than each expira- 
 tion can expel from them, there would result a constant im- 
 prisonment of air within them, and their consequent dilatation 
 and their possible rupture. 
 
 I am, however, surprised that.such congestion and thickening, 
 and morbid secretion of the mucous membrane in this particular 
 situation, should be insisted upon by Laennec as almost the sole 
 cause of dilatation of the air-cells; for I suspect that all the 
 ordinary mechanical impediments to breathing, whether within 
 or without the lungs, have the common effect of raising hin- 
 drances and obstacles, especially to the act of expir.dtio% and 
 thus become capable of dilating the vesicles. It has occurred 
 to me to witness their dilatation to the greatest extent, and 
 their rupture and the extravasation of air beneath the pleura ?to 
 the greatest degree, in cases of -excessive deformity of -the .chest, 
 arising from curved spine. I have found the same, of less 
 degree and extent, in combination with Tubercles and Vomicae ; 
 and J have found dilated vesicles, or ruptured vesicle^, in 
 clusters, at the edges of the lungs, where there has been .no 
 concomitant disease of the lungs to account for them. 
 
 .And.nowfor;the ascultatory symptoms of Dilatation .of the 
 air-cells, or of their Dilatation and Rupture together, as far: fas 
 
184 SUBJECTS CONNECTED WITH [LECT. XIV. 
 
 they have hitherto been described. These symptoms are of a 
 very remarkable kind : they are derived both from Percussion 
 and from Ascultation, but from neither singly. The positive 
 intimations of the one are now in direct opposition to those of 
 the other ; yet do they point to the same thing, and illustrate 
 it especially by their contrast. Percussion gives a sound which 
 is loud and clear ; while, to the ear, or the stethoscope applied 
 to the same parts, either all is dull, and there is no respiratory 
 murmur at all, or there is one rather suspected than distinctly 
 audible. The chest does not give the same answer when you 
 knock as when you listen. 
 
 Now it is not the clear sound upon Percussion that indicates 
 Dilatation of the air-cells, or Emphysema; neither is it the 
 little sound, or the no sound, to the ear and the stethoscope, 
 that indicates it. Either of them taken alone would denote 
 something else ; but taken simultaneously, they denote Dilatation 
 of the air-cells, or Emphysema. 
 
 There is nothing more interesting in the whole subject of 
 Ascultation, than the various ways in which Percussion and 
 Ascultation aid each other. They aid each other by their cor- 
 respondent results, and they aid each other by their contrasted 
 results ; and each is thus made to go as far again by the help 
 of the other, as it could possibly go alone. 
 
 Hitherto, in the course of our inquiry, I have spoken of 
 Percussion occasionally only, introducing it to confirm the 
 signs derived from Auscultation by its correspondent intima- 
 tions. In inflammatory and tubercular diseases of the lungs, 
 what Auscultation found pervious, Percussion found resonant ; 
 what Auscultation found condensed, Percussion found dull. 
 But now I introduce Percussion, not to confirm by its cor- 
 respondent intimations, the signs derived from Auscultation, 
 but to rectify, by its contradictory evidences, what, if taken 
 upon the sole attestation of Auscultation, would be false. 
 
 It is necessary for the sake of obtaining the full use of 
 both these methods of appealing to the same sense in dis- 
 eases of the chest, to understand them in their disagreements : 
 
 to know why what one finds resonant, the other should find 
 dull. 
 
 Percussion, by the resonance or non-resonance that attends 
 it, simply intimates that air is or is not contained within the 
 
LECT. XIV.] CLINICAL MEDICINE. 185 
 
 chest beneath the part struck. It intimates so much, and no 
 more, with certainty. It gives no notice respecting the con- 
 dition in which the air exists, or respecting the exact situations 
 which it does or does not occupy. Whether it be moving 
 about or at rest, there is the same resonance upon Percussion ; 
 whether it be contained in the bronchi, or in the air-cells, or 
 in the cavity of the pleura, there is still the same resonance ; 
 or so nearly the same, that no one would venture upon a 
 diagnosis of its situation merely from a difference of sound 
 elicited by striking the chest. 
 
 But Auscultation gives no intimations absolutely concerning 
 the existence or non-existence of air within the chest. The 
 air must be there under certain conditions for Auscultation to 
 be able to detect it at all. For Auscultation to detect it, the 
 air must be in motion. If it be at rest, Percussion can detect 
 it, but Auscultation cannot. It must also be within the 
 respiratory passages, or in situations with which they freely 
 communicate ; if it be beyond them, Percussion can detect it, 
 but Auscultation cannot. 
 
 It is from air in these situations and under these conditions ; 
 from air in the respiratory passages, and from air put in motion 
 by the act of breathing, that Auscultation conveys to us 
 all the sounds diagnostic of so many varieties of pulmonary 
 disease. For, though air be still in the respiratory passages, if 
 it be imprisoned there, and no motion reach it from the act of 
 breathing, as in the case of dilated air-cells, — or if it escape 
 from the respiratory passages, as in the case of ruptured air- 
 cells and emphysema, beneath the pleura, — then Auscultation 
 can convey to the ear no sound, and is useless for the purposes 
 of diagnosis. 
 
 But in this case Percussion still produces a resonance, and 
 tells us (what is the fact) that there is air ; yet Percussion does 
 not tell under what circumstances or in what exact situation 
 it is. 
 
 By comparison, however, and contrast of the results drawn 
 from both methods, we arrive at conclusions in this case, to 
 which neither could carry us separately. The chest is resonant 
 to Percussion in every part, a sure evidence that in every part 
 there is air ; — but at the same time the chest is in several parts 
 dull to Auscultation. Yet here is no contradiction to the fact 
 
186 SUBJECTS CONNECTED WITH [LECT. XIV. 
 
 that air is still in these parts : but, upon comparison, it is a 
 sure diagnostic sign that, being there, it is beyond the reachof 
 the respiration to give it motion ; in short, that it is either 
 imprisoned within the air-cells, or extravasated beyond .them ; 
 and that we have to deal with a case of Dilatation of the air- 
 cells, or a case of Emphysema, or a case of Pneumothorax, of 
 which last I shall speak hereafter. 
 
 These, then, being the auscultatory Signs of dilated air- 
 cells and ruptured air-cells, and of air extravasated out of its 
 proper vessels, or (in one word) these being the signs of 
 Emphysema, it would seem to be of easy detection. And, 
 existing alone, and unmixed with other morbid conditions, it 
 unquestionably is so ; but, in point of fact, it seldom does 
 exist alone. 
 
 There are certain conditions of parts frequently met with, 
 which can hardly with propriety be called morbid. Although 
 they are departures from what is natural and healthy, they 
 exhibit no progressive morbid action. The blood-vessels are 
 laying nothing down, and the absorbents are taking nothing 
 up. There is only a yielding of parts to accommodate them- 
 selves to some pressing necessity, and a consequent change of 
 natural capacity and size. The common biliary duct, fromTbhe 
 passage of a gall-stone, the ureter from the passage of a renal 
 calculus, dilates, at the time, and remains dilated ever after- 
 wards. So too the bowel, above the seat of a stricture, by 
 gradually giving way to the pressure of its contents, will 
 become permanently enlarged, and take the form of a pouch. 
 These several states are all incidental to diseases, but, are not 
 diseases themselves. 
 
 The like conditions are exemplified, in the lungs, by dilata- 
 tion of the bronchi, and dilatation and rupture of the air-cells, 
 which grow out of preceding diseases, but hardly bear the 
 character of diseases themselves. 
 
 But, although Emphysema may not itself come up to one's 
 notion of what is understood by real disease, yet do real 
 diseases constantly compass it round on every side. Diseases 
 conduct to it, and diseases arise from it; and those that go 
 before, and those that follow after, all remain and exist con- 
 currently with it : so that I do not know any instances of more 
 complicated thoracic .affections than those of which, Emphysema 
 
LECT. XIV.] CLINICAL MEDICINE. 1ST 
 
 may, and generally does, form a part. There may be distortion 
 or disease of the dorsal vertebra ; chronic bronchial inflamma- 
 tion; tubercular depositions,, or vomicae: any or all of these 
 ^together, may have been concerned in imprisoning air *within 
 the vesicles, and so causing their dilatation or rupture ; and 
 having 'caused it, they still remain to augment it. Then there 
 is the Emphysema itself ; and, superadded to these, and arising 
 out of one or all of Ihem, may be dilatation of the right 
 cavities of the heart. 
 
 Imagine what must be the complexity of symptoms from 
 such complexity of disease ! To omit others, think what the 
 auscultatory Signs must be ! For the tubercular cavities, the 
 bronchial inflammation, the dilated heart, and the Emphysema 
 itself, each have their own. And I do not say that you cannot, 
 from among all the rest, pick out the auscultatory Signs which 
 denote the existence of Emphysema : but when you can, it is a 
 great triumph of diagnosis. 
 
 There is (what is called) Interlobular Emphysema, in con- 
 tradistinction to Pulmonary Emphysema, whose forms we have 
 been considering. 
 
 Interlobular Emphysema is an extravasation of air into the 
 eellular substance which intersects and separates the pulmonary 
 lobules. This substance in its natural state is of so close a tex- 
 ture, that the infiltration of air into it could not have been 
 thought possible. Yet the fact is certain. And then its real 
 cellular texture becomes expanded and displayed. Thus lobule 
 becomes separate from lobule, a space of half an inch or an 
 iinch being sometimes left between them, which is occupied by 
 •air that fills the intervening cellular tissue. 
 
 This tissue is more abundant and more cellular, and contains 
 more air, as it is nearer the surface of the lung, and goes on 
 diminishing and containing less air as it penetrates deeper. 
 Thus it is a good deal like the natural segment of an orange, 
 which contains more juice just beneath the rind, and less as it 
 approaches the centre. 
 
 From the manner in which the interlobular partitions run 
 parallel to each other, it must be obvious that, when several are 
 infiltrated with air at once, there will result a separation of 
 various pulmonary lobules entirely from each other, like little 
 islets. 
 
188 SUBJECTS CONNECTED WITH [lECT. XIV. 
 
 When this Interlobular Emphysema is near the root of the 
 lungs, it soon reaches the mediastinum, whence air escapes into 
 the cellular texture of the whole body. 
 
 Interlobular Emphysema, unlike the other forms described, 
 has nothing to do with dilated air-cells : no dilated air-cells are 
 found accompanying it, and where their rupture has taken 
 place cannot be traced. The pulmonary lobules, which are (as 
 it were) blown apart from each other, and have air infiltrated 
 all around them, are themselves in a healthy state. 
 
 The Emphysema from Dilatation or Bupture of the air-cells 
 is a chronic affection resulting from causes which are tardy m 
 their operation ; but the Interlobular Emphysema takes place 
 in a moment, and is the result of accident. Any violent effort 
 which holds or intercepts the breath may cause it ; the striving 
 of parturition, the straining to unload the bowels, or to lift a 
 heavy weight. I have myself seen it produced by the convulsive 
 struggle of hooping cough ; at least I presume so : for I have 
 seen the subcutaneous cellular tissue about the neck of a child 
 become blown up with air after a fit of coughing; but this 
 happened before I had Auscultation to help me in inquiring into 
 the conditions of the lungs. 
 
 The auscultatory Signs of this Interlobular Emphysema are 
 said to be such as cannot be mistaken, and strictly pathogno- 
 monic. They may be so, but I never had an opportunity of 
 verifying them. 
 
 All this air effused must insure a clear resonance upon 
 Percussion. Then there are, besides, the " Frottement Ascen- 
 dant " on inspiration, and the " Frottement Descendant " on 
 expiration ; and the " Large dry Crepitation." I wish I could 
 determine the degree of certainty which belongs to these 
 auscultatory Signs: but I cannot, having had no opportunity of 
 investigating the circumstances of such rare cases. 
 
LECT. XV.] CLINICAL MEDICINE. 
 
 189 
 
 LECTURE XV. 
 
 ON THE DOCTRINE OF SYMPTOMS. 
 
 AUSCULTATORY SIGNS OF LESS FREQUENT OCCURRENCE. — HOW 
 
 FAR WORTHY OF REGARD. — METALLIC SOUNDS. WHERE AND 
 
 HOW PRODUCED. 
 
 After you have been so long familiar with. Auscultation, and 
 have learned to appropriate its most important signs to the 
 pathological conditions out of which they arise, it will still from 
 time to time be presenting you with things that . are new. 
 Various sounds will reach your ear through the walls of the 
 chest in breathing, talking, or coughing, which perhaps you 
 never heard before. 
 
 Those unusual sounds, you will find, seldom occur alone, but 
 are commonly superadded to others better understood, by which 
 the essential character of the disease has been already ascer- 
 tained. 
 
 How often, in the wards of the hospital, may you examine 
 the chests of several patients, and find the same auscultatory 
 Signs telling you that they have one and all the same disease ; 
 and not only so, but the same disease in the very same stage 
 of its progress ! The auscultatory Signs may be Cavernous 
 Breathing, Gurgling Cough, and Pectoriloquy; the disease 
 Consumption, and the stage that it has reached the stage of 
 Vomicae. 
 
 But these auscultatory Signs, which as to their leading charac- 
 teristics, are the same in the several individuals, and bespeak 
 the same disease, may include little minor differences. And, 
 doubtless, these too are not without their causes. The various 
 forms and sizes of pulmonary cavities, the firmness or flaccidity 
 of their walls, the smoothness or roughness of their surface, the 
 many or few, the large or the small bronchi that enter them, 
 while they leave the auscultatory signs unaltered in their essen- 
 
igO SUBJECTS CONNECTED WITH [LECT. XV. 
 
 iial characteristics, serve to peculiarise them (if I may so speak) 
 in individual cases. 
 
 I have not names for all the strange sounds which I hear 
 every day proceeding from pulmonary cavities. And perhaps, 
 it is well that I have not. Auscultation is a new thing ; and 
 "therefore we are rather disposed to make too much of trifles 
 connected with it; a fault which it is worth your while to 
 guard against. If, by Auscultation, you already know the pre- 
 cise nature of the disease and its exact seat, the stage which it 
 has reached, and the very processes which are now going on 
 within the living, body, — if you know the essentials of the case 
 pathologically and practically, — it is a poor and profitless task 
 to be guessing and speculating about mere matters of accident 
 and uncertainty. It is the same thing as if a man, after he had 
 read a book fairly through and mastered it, should think him- 
 self bound to count how many lines there were in each page, 
 and how many words in each line. 
 
 Nevertheless, you are not at liberty to pass by all ausculta- 
 tory Signs, except those which are the most constant, and 
 which denote the most frequent forms of pulmonary disease. 
 These, indeed, must always be practically the most important. 
 Yet there are others less common but sufliciently definite, not 
 belonging to the essential character of the disease, but to its 
 -accidental varieties, or to ulterior morbid changes derived from 
 it, which require to be well understood. Some of these varieties 
 and changes are of great account in our calculation of the result, 
 and the signs which indicate them acquire a proportionate 
 importance. 
 
 It is so especially with those auscultatory Signs which are 
 called metallic sounds. These sounds accompany the acts of 
 breathing, of speaking, and of coughing ; of one or the other 
 severally in different cases ; or sometimes of one and sometimes 
 -the other, or sometimes of all equally in the same case. 
 
 These sounds have some variety, but they are all well ex- 
 pressed in general by the term "metallic;" for they are all 
 either ringing or iinlding sounds, and like such as metal is eonr 
 cerned in producing. Often, too, they have in them something 
 ef the nature of an echo, and last for an instant, after the voicej, 
 the congh, or the breath that caused them has ceased., 
 
 Perhaps the best way of conveying the notion of wha4 they 
 
LECT. XV.] CLINICAL MEDICINE. 191 
 
 are, would, be by stating wbat they have been thought to 
 resemble. The voice of a person speaking into a well isj in 
 kind, sometimes exactly like the metallic ringing that accom- 
 panies the voice and issues from the chest ; and the sound 
 produced by blowing sideways into the mouth of an empty 
 bottle, is sometimes like that which is heard in breathing. 
 Take an empty vessel of thin metal, or glass, or earthenware, , 
 and strike it lightly with your finger nail, or let a little dry 
 sand fall into it, and you will produce the fainter sort of 
 metallic tinkling. But the metallic tinkling is sometimes 
 louder than the sounds thus produced. The small bells, which 
 are borne by mules and pack-horses abroad, give a sound from 
 a. distance exactly resembling the metallic tinkling as I have 
 heard iti. 
 
 Now the metallic sounds may proceed either from a mere 
 cavity within the lungs, or from some complex disease formed 
 between the lungs and the pleura. 
 
 When the metallic sounds proceed from a mere pulmonary 
 cavity, one condition always found to belong to that cavity is, 
 that it is unusually large ; and another, that it contains a small 
 quantity of fluid in proportion to its size. And these two 
 conditions are as clearly ascertainable by Auscultation during 
 the life of the patient, as by dissection after his death. 
 
 Further, dissection discovers this large cavity always near 
 the surface of the lungs, and adherent to the ribs so closely and 
 with so little intervening substance, that they have seemed to 
 form its external boundary. 
 
 I have myself had only one opportunity of examining 
 after death a cavity of the lungs from which this metallic 
 sound has proceeded during life ; and this I owe to the kind- 
 ness of a friend. At the Middlesex Hospital Dr. "Watson met 
 with a consumptive patient, in whom the metallic sound 
 which amounted to a ringing, was strongly marked, and was 
 manifestly formed within a pulmonary cavity. Upon the 
 patient's death he had a preparation made of the parts involved 
 in the disease, and has deposited it in the Museum of King's 
 College. This preparation h& has permitted me to examine. 
 It. displays a cavity in the upper part of the left lung, large 
 enough (I conceive) to hold more than a pint of fluid. It is 
 of. an irregular shape. Internally it exhibits elevations and 
 
192 SUBJECTS CONNECTED WITH [LECT. XV. 
 
 depressions, and pits and sinuses. Yet the surface, as it at 
 present appears, is so smooth that it might be lined by a 
 continuous membrane. At one part a firm rounded cord, 
 which has the appearance of a blood-vessel, runs across it ; and 
 low down a single bronchial branch, of about the third division, 
 is seen entering it. Externally it adheres by at least two- 
 thirds of its circumference to the ribs ; and in all this space not 
 the least remnant of pulmonary structure intervenes. The 
 medium of adhesion interposed between the cavity and the 
 ribs is mere membrane, which the cut edges show to consist 
 of several layers, each about as thick as ordinary writing 
 paper. 
 
 Two cases have occurred within my own knowledge, in 
 which the metallic sound proceeded from a mere pulmonary 
 cavity. In them it was present both in breathing, talking, 
 and coughing. It did not accompany the ordinary respiration, 
 but a little more energetic breathing would always produce it. 
 
 With the metallic sound, and in the same situation there were 
 always present some, but not all, of the common auscultatory 
 Signs which denote a pulmonary cavity. Those, however, 
 which were present were so strikingly exaggerated, that any 
 one listening at the chest for the first time could not help being 
 convinced that there was a large hollow space beneath his ear. 
 
 In whatever way air was impelled into the cavity a dry 
 hollow sound resulted. The breathing was cavernous ; the 
 voice cavernous ; and the cough cavernous. But there was no 
 Pectoriloquy ; and no Gurgling in ordinary breathing, and 
 none in ordinary coughing. But Gurgling was still capable 
 of being produced by a hard and forcible cough. 
 
 In these two cases the metallic sound was heard over one 
 large space on the right side the chest, circumscribed by the 
 sternum and axilla laterally, and by the clavicle and the 
 mamma above and below, while from every part of the same 
 lung, except this space, the clearest respiratory murmur pro- 
 cseded. In one of the cases there was a cavity in the cor- 
 responding part of the left lung, but occupying a more limited 
 space. This gave out no metallic sound ; but it furnished all 
 those auscultatory Signs, which were defective in the other 
 cavity from whence the metallic sound proceeded. 
 
 Here, upon a comparison of the auscultatory Signs derived 
 
LECT. XV.] CLINICAL MEDICINE. 193 
 
 from both lungs, thus much at least may be learnt, that there 
 are conditions belonging to pulmonary cavities which naturally 
 produce one sound and naturally prohibit another; or, con- 
 versely, which prohibit one and produce another. The large- 
 ness of the cavity in the right lung, and the scanty fluid within 
 it, gave occasion to the metallic sound, and at the same time 
 prevented the Pectoriloquy and the Gurgling respiration from 
 taking place; while the smallness of the cavity in the left lung, 
 and the abundant fluid that it contained, forbade the metallic 
 sound, and caused at one time Pectoriloquy, and at another 
 Gurgling Respiration. 
 
 The metallic sound, arising from a mere pulmonary cavity, 
 is a curious phenomenon. It would be interesting to know a 
 little more than we do of its clinical history ; especially, whether 
 it belongs to any particular form of Phthisis to produce that 
 sort of cavity which gives occasion to it. 
 
 If I could trust my own observation and that of others for 
 proof of a general fact, of which the particular instances are few 
 in my own and not many in any man's experience, I should say, 
 that the pulmonary cavities, from which the metallic sound 
 arises, chiefly belong to unmixed Phthisis. 
 
 It is where the disease has been of long duration, and 
 where it has gone on enlarging itself within its own specific 
 limits, and has imparted little or no irritation to the surrounding 
 lung, that tubercle runs into tubercle, and vomica into vomica, 
 and one large cavity is ultimately formed out of many.* This 
 is the sort of cavity which gives occasion to the metallic sound. 
 But Phthisis must meet with all the circumstances most favour- 
 able to its progress as a purely specific disease, in order that it 
 may be able to form such a one. Above all, it must occur in 
 lungs not over disposed to inflammation. Lungs naturally apt 
 to inflame are impatient of the specific disease that is carrying 
 on its own processes within them. They interfere with its pro- 
 gress from first to last, and do not allow it to reach the greatest 
 increase of which it is capable in any stage, and least of all, in 
 that which is the fullest of irritation to surrounding structures 
 — the stage of vomica. 
 
 In the two cases to which I have alluded, within my own 
 experience, the Phthisis had been suspected for years, and had. 
 
 * Vide p. 155. 
 
 o 
 
194 SUBJECTS CONNECTED WITH [LECT. XV. 
 
 existed unequivocally for many months. In both I noted the 
 gradual progress and enlargement of the vomica, before the 
 metallic sound arose, and afterwards. And both before and 
 afterwards there was a clear respiratory murmur in every other 
 part of the same lung. 
 
 But it has been said that the metallic sound may result from 
 a complex disease formed between the lungs and the pleura. 
 Here also a cavity is equally concerned in producing it. But 
 the cavity is not in the lungs, but in the pleura ; or rather the 
 pleura itself constitutes the cavity. Here, too, the cavity con- 
 tains fluid, and it contains air. The fluid is supplied by the 
 surface of the pleura itself, but the air is supplied by the lungs. 
 
 Now these pathological conditions arise after the following 
 manner. Disease, first existing in the lungs, causes an ulcera- 
 tion or rupture of the pleura, and thus makes an aperture of 
 communication between the bronchi and the pleural cavity. And 
 this aperture once made continues ever afterwards, being kept 
 open by the air that passes through it in the act of respiration. 
 The fluid in the pleuritic cavity is either the mere serous effusion 
 of hydrothorax, or the pus or puriform secretion of inflam- 
 mation. 
 
 Such are the conditions of this complex disease, and such the 
 manner in which they come to pass. But how is the metallic 
 sound produced by them ? In every act of breathing, talking, 
 and coughing, the air which is forced through the aperture into 
 the cavity of the pleura, puts in motion the air and the fluid 
 already found there. Hence, a vibration results which is 
 followed by the metallic sound. 
 
 But what is the element of the whole disease? Of what 
 nature is the primary morbid process within the lungs which 
 serves as the point of departure (so to speak) for the series of 
 morbid processes that follow ? Surely it may be any disease or 
 morbid process that is capable of effecting a solution of con- 
 tinuity in the pleura investing the lungs ; whether by ulcera- 
 tion, slough, or rupture. But, in point of fact, Phthisis 
 Pulmonalis is found to do this more frequently than any other. 
 A Vomica, being formed and already communicating with the 
 bronchi on the one hand, reaches, penetrates, and communicates 
 with the cavity of, the pleura on the other. In all cases within 
 my own experience Phthisis has thus become the element of the 
 
LECT. XV.] CLINICAL MEDICINE. 195 
 
 whole disease, except one. And there a gangrenous portion of 
 lung opened the way of communication hetween the bronchi 
 and the cavity of the pleura, and produced all the conditions 
 necessary to the auscultatory Sign in question. 
 
 This, I believe, is a just explanation of the metallic sound 
 when it is produced by (what is called) Pneumothorax ; or that 
 complex disease between the lungs and the pleura, of which the 
 most striking result is a collection of air within the thoracic 
 cavity. 
 
 For the sake of this explanation I have thus far represented 
 the metallic sound as if it were a single auscultatory Sign 
 standing alone, that so you might understand it the better. But 
 you can only recognise it and see its importance and feel an in- 
 terest about it, by having it represented to you with all its 
 attendant circumstances, and especially with the other auscul- 
 tatory Signs concurrent with it ; these contributing to determine 
 its value and it to determine theirs. 
 
 A patient may have all the general symptoms of Pulmonary 
 Consumption, such as emaciation, hectic fever, and cough. A 
 few days ago you may have examined his chest carefully, and 
 found on one side (the right perhaps) gurgling respiration and 
 gurgling cough, and cavernous breathing, and at times pecto- 
 riloquy, all in one circumscribed space beneath the clavicle ; and, 
 around this space and over the upper half of the right side, con- 
 siderable dulness both when you knock and when you listen ; 
 but over the lower half a satisfactory resonance to percussion 
 and a clear respiratory murmur. On the left side you may 
 have found no unnatural sound whatever, but the respiratory 
 murmur everywhere exaggerated, and the resonance to percus- 
 sion everywhere louder even than at the lower part of the right 
 side, where it was quite loud enough for health. 
 
 Here the diagnosis is plain enough. The upper part of the 
 right lung is full of tubercles ; and in the midst of them is one 
 Vomica at least : while the lower part is either free from tubercles 
 altogether, or contains so few that they furnish little or no 
 impediment to the passage of air. The left lung, which is 
 striving by a more energetic respiration to compensate for the 
 obstruction of the right, may contain a few scattered tubercles 
 or none at all. 
 
 Such is the diagnosis at which you arrived a few days ago ; 
 
196 SUBJECTS CONNECTED WITH [LECT. XV. 
 
 and such the obvious auscultatory Signs that led you to it. But 
 now the gurglings, the cavernous sounds, and the pectoriloquy 
 have ceased ; the upper half of the right side, before, behind, 
 and in the axilla, which was so dull, has become clear to percus- 
 sion, and hollow and resonant as a drum ; and the lower half, 
 which was so clear, has become so dull, that neither ear, nor 
 stethoscope, nor percussion, can ascertain or elicit from it any 
 sound whatever. On the left side the auscultatory Signs remain 
 just what they were. 
 
 But, on the right side, what sudden and extraordinary change 
 has taken place in the parts within, correspondent with the 
 sudden and extraordinary change in the auscultatory Signs? 
 You will see, if you wait and look a little more inquisitively into 
 all the circumstances. And I invite your most curious attention 
 to this instance ; for it assigns a sort of triumph to Auscultation, 
 showing, I conceive, the utmost perfection of which the diagnosis 
 of internal disease is capable. 
 
 Where it was dull, the chest is resonant ; where it was 
 resonant, it is dull. 
 
 It is resonant, loudly resonant to percussion at the upper 
 part* Then surely there is air within. — But the ear detects 
 no respiratory murmur. The air, therefore, must be under 
 some peculiar conditions. Is it imprisoned within the lung in 
 dilated vesicles, or effused from ruptured vesicles beneath the 
 pleura? There is, indeed, the same contrast between what 
 percussion intimates and what Auscultation, as in the case of 
 Emphysema. But there is no Emphysema, notwithstanding. 
 The resonance is too loud, and too uniformly clear all round the 
 chest ; and the air, wherever it is, is in too free a space for 
 Emphysema. For the same reasons the air cannot be contained 
 in any mere pulmonary cavity, however large. Besides, the 
 ear not only detects no respiratory murmur, but it has lost 
 the gurglings, the cavernous sounds, the pectoriloquy which 
 it once heard. 
 
 * I speak of " the upper part " of the chest generally ; for it is probable 
 that at its very summit the contrast -will not be so marked. By the time 
 the disease has reached the stage of vomicae, the apex of the lung has often 
 contracted firm adhesion to the ribs ; and the air, finding its way into the 
 pleura from an opening below this adhesion, cannot have the effect of 
 rendering tympanitic that part of the chest which is above it. 
 
LECT. XV.] CLINICAL MEDICINE. 197 
 
 But does the ear, by mere listening, catch no sound whatever, 
 where the resonance to percussion is so loud? Yes! at each 
 breath, each voice, or each cough, it catches a metallic sound, 
 which lasts for an instant, like an echo, after the breath, the 
 voice, or the cough has ended ; and this sound is a ring or a 
 tinkle. 
 
 But the chest is dull, absolutely dull, at the lower part. 
 And the cause of this dulness is the effusion of fluid into the 
 cavity. Do you doubt the fact ? Then move the trunk of the 
 body quickly to and fro ; and listen the while with your ear to 
 the thorax ; and you will at each succussion hear the plashing 
 of fluid within. Or make your patient alter his posture from 
 the vertical to the horizontal, or vice versa, and the resonance 
 and the dulness will sometimes shift their situations. 
 
 Thus air and fluid share the cavity of the pleura between 
 them. The air found its way thither from the Vomica, either 
 by a direct perforation of its walls, or by a fistulous channel 
 proceeding from it. The fluid is a secretion from the surface of 
 the pleura itself. And the air and the fluid, thus sharing the 
 cavity of the pleura between them, do, by the manner in which 
 they are made to act upon each other, produce the ringing or 
 the tinkling which accompanies the breathing, the voice, or the 
 cough, and the plashing, which attends succussion. 
 
 Observe, I have here spoken of a single instance, but 'I 
 have represented a class. And if you will view it as such, and 
 will consider, in this instance, how wonderfully Auscultation 
 enables your knowledge to keep pace with the actual procedure 
 of the disease, revealing its exact conditions at each particular 
 time, and its changes from one condition to another from time 
 to time, you must allow that the ear may sometimes be trusted 
 not less confidently than the eye itself for a sure diagnosis. 
 But each sense has its proper sphere. Yet, in this instance, if 
 you could look into the chest of the living man, what more 
 could you know than you do know by listening at it ? 
 
 Such is the metallic sound proceeding from Pneumothorax, 
 with all its attendant circumstances, and concurrent auscultatory 
 Signs. It has always been, when I have met with it, a tinkling 
 sound ; louder or fainter, more or less prolonged into an echo, 
 like this thing or that, but always a tinkling sound. 
 
 This metallic tinkling does not occur at any one certain 
 
198 SUBJECTS CONNECTED WITH [LECT. XV. 
 
 period of phthisical disease. I have known it discovered for the 
 first time a few days previous to the patient's death; and I have 
 known it and the other accompaniments of Pneumothorax exist 
 for six months ; and in the meantime the patient's general 
 health has improved, and he has even gained flesh. These varieties 
 in the clinical history of different cases are just what might be 
 expected. The conditions out of which the metallic tinkling 
 springs, are, in a certain sense, accidental. A vomica may happen 
 to be near the surface of the lung, and may ulcerate its way 
 through the pleura, as well at one period in the progress of the 
 disease as at another. 
 
 But I do not mean to limit the possibility of surviving, 
 after Pneumothorax has taken place, to six months, or to any 
 certain period. I recollect a patient or two, who, after they 
 had been for some time objects of great interest, on account of 
 the metallic tinkling and the audible plashing of fluid within 
 the chest, suddenly left the hospital, and took care to leave us 
 no means of tracing them. How long these men survived I 
 cannot tell. 
 
 It is worthy of remark that Pneumothorax thus superadded 
 to phthisis does not necessarily produce a great aggravation of 
 the patient's distress. For he is often still able to move his 
 body easily in bed, and even to walk about the room. In some 
 so affected I have remarked the interest, and even the amuse- 
 ment, they have taken in the circumstances of their own com- 
 plaint. The business of Auscultation, which to most patients, I 
 fear, is a trouble and a distress, they submit to with alacrity 
 twenty times a day. They hear, themselves, the plashing of 
 fluid within the thorax. And this, which they think so strange, 
 they are always ready to exhibit, and to shake their chests as 
 often as they are desired, until they have satisfied the curiosity 
 of every inquirer. 
 
 Probably the period to which the patient survives after the 
 metallic tinkling and its concomitant symptoms have arisen, 
 and the much or little augmentation of distress attending 
 them, may depend upon the kind of fluid effused within the 
 chest, and the kind of morbid process engaged in producing it. 
 
 In all the instances of Pneumothorax with the metallic 
 tinkling, except two, with which I have been acquainted, the 
 patient has lived several months, and the fluid found upon 
 
LECT. XV.] CLINICAL MEDICINE. 199 
 
 dissection has been the mere serum of hydrothorax. In one of 
 the accepted instances, the metallic tinkling was not present, or 
 at least not discovered, until within three days of the patient's 
 death ; and from that time the agony was frightful. Moreover 
 there was this peculiarity in the auscultatory Signs, that every 
 part of the chest, in all positions of the body, returned the 
 loudest resonance to percussion, and gave out the clearest 
 metallic tinkling in breathing, in speaking, and in coughing. 
 The patient was too ill to permit succussion. The absence of 
 its direct auscultatory Signs made us doubt whether there was 
 any fluid in the chest. Fluid, however, was found in very 
 small quantity ; but that fluid was pus. 
 
 In the other excepted instance, the metallic tinkling was 
 heard for eighteen days before the patient's death. It was a 
 case of pneumonia, in which, after the severity of the inflam- 
 mation was subdued, Pneumothorax arose, with metallic 
 tinkling and, during the last few days of existence, with fetid 
 expectoration. 
 
 If, on the left side, a line had been drawn round the chest 
 from the sternum to the spine, on a level with the mamma, you 
 might have heard the metallic tinkling and the loudest re- 
 sonance upon percussion, everywhere below it, and a clear re- 
 spiratory murmur everywhere above it. 
 
 Upon examination after death, the left lung was found 
 adherent to the ribs in a space corresponding with the imaginary 
 line just indicated. By this adhesion the pleura was divided 
 into two unequal cavities. In the upper and smaller cavity no 
 fluid was effused, and the lung was healthy. In the lower and 
 larger there were both air and fluid, and the lung was diseased. 
 The fluid was dark and fetid, and the lung was partly in the 
 state of grey and red hepatization and partly gangrenous. In 
 the midst of a gangrenous portion was an orifice through which 
 air found its way from the trachea into the pleural cavity. 
 
JlN 
 
 ACCOUNT 
 
 DISEASE LATELY PREVALENT 
 
 GENERAL PENITENTIARY. 
 
 P. MERE LATHAM, M.D. 
 
 FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, AND PHYSICIAN TO 
 ST. BARTHOLOMEW'S HOSPITAL. 
 
 LONDON. 
 
 MDCCCXXV. 
 
TO 
 
 JOHN LATHAM, M.D., 
 
 PHYSICIAN EXTRAORDINARY TO THE KING, 
 &C, &C. t 
 
 THE FOLLOWING PAGES ARE DEDICATED 
 
 WITH EYEBY FEELING OF 
 
 DUTY, GRATITUDE, AND AFFECTION, 
 
 HIS SON. 
 
PREFACE. 
 
 I feel it to be a duty which I owe to the Medical Profession 
 to give them some account of the Disease lately prevalent at 
 the General Penitentiary. I have abstained from doing so 
 until the present time, in order that I might secure for it that 
 attention which medical men never fail to bestow upon subjects 
 essentially their own, when they are left entirely to themselves. 
 
 So long as such questions happen, from circumstances, to 
 engage the interest of the public, or to admit the least mixture 
 of party spirit, medical men can hardly feel confident of their 
 own impartiality ; and they would do well, perhaps, to suspend 
 their inquiry, and, certainly, to withhold their decision, until 
 that interest and that spirit have had time to subside. 
 
 While the Disease of the Penitentiary engrossed a large 
 share of public attention ; while the newspapers were discussing 
 its nature and treatment; and a coroner's jury was giving 
 judgment concerning its causes ; while it furnished matter for 
 debate in Parliament, and Committees of the House of Com- 
 mons were examining evidence and reporting upon it, such a 
 time would not have been well chosen for inviting formally 
 the attention of medical men to the same subject ; and had I 
 then been prepared with this account, which I now submit to 
 them, I should still have suppressed it, until the fairness and 
 impartiality of their decision could be better ensured. 
 
 Dr. Eoget and myself were employed in the service of the 
 Penitentiary for fifteen months, from March, 1823, to May, 
 1824. During our attendance, we were accustomed to make 
 
204 PEEPACE. 
 
 memoranda of all circumstances which appeared important at 
 the time, respecting the prevalent disease ; and we both of us 
 find in our possession some short note of almost every case 
 which occurred. 
 
 Besides the detail of symptoms, and of the effects of 
 remedies in particular cases, I was in the habit of writing, 
 from time to time, general descriptions of the Disease under 
 its most striking forms, and of the modes in which, under each 
 form, medical treatment seemed to operate its relief. All these 
 details and descriptions, which I made in the course of my 
 attendance, I preserved, and, when the period of my employ- 
 ment at the Penitentiary expired, I revised and put them in 
 order, and found them capable of furnishing the materials for 
 the following history of the Disease. 
 
 During the first five months of our attendance, Dr. Roget 
 and myself felt our office one of great labour, and of peculiar 
 difficulty. The medical management of the Prison alone, from 
 the number of the sick, from the nature of the Disease, and 
 the character of the patients, was by no means an inconsider- 
 able charge. But in addition to this, we had - formal Reports 
 to make, questions to answer, and explanations to give, verbally 
 and in writing, to the Managing Committee of the Prison, and 
 to Government ; occasionally coroners' juries to attend, and to 
 undergo frequent examinations before a Select Committee of 
 the House of Commons. 
 
 These duties, however, which were simply laborious in 
 themselves, were only rendered painful by the extreme vigi- 
 lance and circumspection which peculiar circumstances, unne- 
 cessary to mention in this place, obliged us to exercise in all 
 our conduct. Nevertheless, our cordial co-operation, and our 
 mutual friendship and confidence, enabled us to sustain the care 
 
PREFACE. 205 
 
 and responsibility inseparable from our office ; and I only 
 now allude to them for tbe sake of stowing, that our daily 
 labours were too pressing and anxious to allow us to expend 
 much time in arranging the notes we had taken, or constantly 
 to bear in mind the purpose of publication. 
 
 These notes, however, were faithfully taken at the time, and 
 sufficiently copious ; and the history which I have drawn from 
 them, will be found (I trust) to represent the real character of 
 the Disease, clearly and intelligibly, to the minds of medical 
 men. 
 
 As the labour and responsibility of our charge were equally 
 divided between Dr. Roget and myself, so the practical measures 
 adopted were the result of our consultations. I am not aware 
 that there ever arose between us the smallest disagreement 
 either in opinion or practice ; and I reckon it among the best 
 fruits of my labours on this occasion, that they have procured 
 for me in my colleague a faithful friend. 
 
 To Dr. Roget I am also indebted for suggestions, most 
 useful to me in drawing up this account of the Disease, and I 
 am allowed to appeal to him in confirmation of its truth. 
 
 Four months of the fifteen, during which we were employed 
 at the General Penitentiary, that is, from the end of July until 
 November, 1823, we had the able assistance of Drs. Hue, Mac- 
 michael, and Southey. Under what circumstances, in conse- 
 quence of our own earnest solicitation, that assistance was 
 granted to us, will appear in the course of my Narrative. 
 
 It is my duty, however, in this place, to state, that to these 
 gentlemen, and to Dr. Macmichael especially, is to be attributed 
 whatever success may be thought thenceforward to have attended 
 our investigations into the origin of the Disease. Dr. Roget 
 and myself had already notified to the Committee our belief 
 
206 PREFACE. 
 
 that there was some cause in operation over and above those 
 to which we had originally attributed it ; and that there was a 
 suspicion of contagion, and a suspicion, moreover, of an injurious 
 influence peculiar to the place, but nothing ascertained con- 
 cerning either. 
 
 'Now, Dr. Macmichael, in perusing the evidence given by- 
 Mr. Pratt, the apothecary, before a committee of the House of 
 Commons, found a statement, from which he took occasion to 
 suggest to us a new train of inquiry. This inquiry ended in 
 the production of certain documents, which established (we con- 
 ceive) the prevalence of a disorder of the bowels, having the 
 same general character with that which constituted a principal 
 part of the late epidemic, within the Penitentiary, since its first 
 foundation. 
 
AN ACCOUNT 
 
 DISEASE LATELY PREVALENT 
 
 GENERAL PENITENTIARY. 
 
 CHAPTER I. 
 
 INTRODUCTION. 
 
 In giving a medical history of the disease lately prevalent at 
 the General Penitentiary, I shall best succeed in rendering it 
 intelligible to the reader, if I describe all the circumstances 
 connected with it in the same order in which they originally 
 presented themselves to my own observation. 
 
 The disease did not immediately discover its complete 
 character. It put on a great variety of forms, while all its 
 symptoms did not appear at one time and in each individual ; 
 and it is only, after continual observation of it during the 
 space of more than twelve months, in which it has existed and 
 ceased, and again and again recurred in many hundred indivi- 
 duals, that I can state, what I now venture to do, concerning 
 its symptoms and its essential nature, its treatment and its 
 probable causes. 
 
 There remain many circumstances respecting this disease, 
 of which I profess myself still ignorant, and which the oppor- 
 tunity of watching those who have been the subjects of it for 
 many years, could alone satisfactorily explain. 
 
 The character of the disease, as it first came under our 
 observation, will be best collected from the Report, which Dr. 
 Roget and myself delivered to the Committee on the 5th of 
 April, 1828. 
 
2 08 INTRODUCTION. 
 
 In consequence of the unusual degree of sickness which had. 
 recently been discovered in the Penitentiary, we were desired 
 to visit it, and to take the sick under our care, to inquire into- 
 the origin of the prevalent disease, and to turn our attention 
 particularly to the dietary. 
 
 This Report contains the sum of our observation and 
 inquiries during a month, and the conclusions which seemed- 
 fairly to result from them. 
 
 REPORT OF THE PHYSICIANS ON THE STATE OP THE. 
 GENERAL PENITENTIARY AT MILBANK . 
 
 5th April, 1823.. 
 
 to the committee of the general penitentiary at milbank. 
 
 Gentlemen, 
 
 In conformity with the instructions conveyed to us in your resolu- 
 tion of the 28th February last, we have visited the Penitentiary daily, 
 since the 1st of March ; we have carefully and repeatedly examined, at 
 different times, the state of health of each individual prisoner ; we have 
 taken constant charge of the sick in the infirmaries ; we have communi- 
 cated continually with your medical officers, Mr. Hutchinson and Mr. 
 Pratt, and frequently with the other officers of the establishment ; we have 
 made whatever inquiries seemed requisite to obtain correct information 
 concerning the nature and extent, and the origin and progress of the- 
 disease lately prevalent in the Penitentiary, the causes which probably 
 contributed to its production, and the means most expedient for its cure,- 
 and most likely to prevent its recurrence ; and we have agreed upon the 
 following Report : — 
 
 Prom the testimony of the officers of the establishment, and particularly 
 of the matron, it appears, that during the last autumn the general health of 
 the prisoners began visibly to decline. They became pale and languid,, 
 and thin and feeble. Those employed in tasks requiring much bodily 
 exertion, were unequal to the same quantity of work as formerly. Those 
 at the mill could grind less corn ; those at the pump could raise less water. . 
 Prom time to time several of the laundry-women fainted under their work ; 
 and the business of the laundry could only be carried on by continually 
 changing the hands engaged in it. Such was the general state of the 
 prisoners throughout the winter. 
 
 Still, notwithstanding this remarkable depression of the general health, . 
 there appeared among them no manifest signs of any peculiar disease. The 
 number of sick received into the infirmaries did not much exceed the pro- 
 portion which, in the winters of former years, it had borne to the total 
 
INTRODUCTION. 209 
 
 number of prisoners ; and their disorders were those commonly incident to 
 cold weather. It was not until the beginning of February, that any marks 
 of scurvy were reported by Mr. Hutchinson, as having been noticed by him 
 on a few individuals in the infirmaries. And here it may be observed, that 
 these marks are, at their first appearance, peculiarly apt to escape discovery 
 unless the attention be particularly directed towards them ; and that they 
 often exist for a long time, entirely unnoticed by the patient himself. 
 Between the 14th of February and the 1st of March, no less than forty- 
 eight prisoners came into the infirmaries, affected chiefly with diarrhoea 
 and dysentery. The diarrhoea and dysentery were of a peculiar kind, and 
 were suspected to have a connexion with the scorbutic disease. At this 
 time, also, all these various affections were found spreading extensively, 
 but in different degrees of severity, throughout the prison. 
 
 On the 28th of February, our assistance was called for ; and having 
 learned the facts already detailed, we began our examination of the prison 
 and the infirmaries on the 1st of March. We found the prevailing disease 
 to be the same with that which is known by the name of Sea Scurvy, and 
 which is characterized by livid spots, or blotches of the skin, especially on 
 the lower extremities. Conjoined with the scurvy, in almost every case, 
 there was diarrhoea or dysentery. There were indeed, a few instances of 
 scurvy without disorder of the bowels ; and moreover, numerous instances 
 occurred of diarrhoea and dysentery, where no marks of scurvy had 
 appeared. But still, whether the scurvy subsisted alone, or the diarrhoea 
 or dysentery subsisted alone, or whether they were conjoined in the same 
 individuals, there was found in all those who suffered from either, or irum 
 both, the same constitutional derangement, denoted by a sallow counten- 
 ance, an impaired digestion, diminished muscular strength, a feeble^ circu- 
 lation, various degrees of nervous affection, as tremors, cramps, or spasms, 
 and various degrees of mental despondency. 
 
 These facts seemed to lead directly to the belief, that the diarrhoea and 
 dysentery, and scurvy, had their origin in the same morbid state of the 
 constitution. In this belief we were more and more confirmed by further 
 observation ; and we soon had the means of determining with certainty, 
 that they, in reality, constituted one and the same disease. We examined 
 by dissection the bodies of two prisoners who died dysenteric, and found 
 in various parts of the intestines, the morbid appearances called, in 
 medical language, Ecchymoses; that is,. spots of the same kind as those 
 which on the skin constitute scurvy. We found, in fact, an absolute 
 scurvy of the bowels, of which the diarrhoea or dysentery was only a 
 symptom and consequence. 
 
 With regard to the extent of this disease, we found more than one-half 
 of the whole number of prisoners affected by it, in one or other, or in all 
 its forms ; but the proportion was not the same among the prisoners of 
 different sexes, or belonging to different classes. The women were 
 affected much more extensively than the men ; and of both men and 
 women, the second class, which is composed of those who have been 
 longest in confinement, was affected in a much larger proportion than the 
 
 P 
 
210 INTRODUCTION. 
 
 first class, which comprises those who have been more recently imprisoned. 
 Of the women, about two-thirds were ill of the disease ; of the men, rather 
 less than one-half. Of the women in the first class, one-half were ill ; of 
 those in the second class, five-sevenths. Of the men in the first class, 
 above one-third were ill ; of those in the second class, rather more than 
 one-half. The exact numbers are stated in the Table subjoined to this 
 Report. 
 
 Some striking exemptions require to be noticed. Of the 24 prisoners 
 employed in the kitchens (13 men and 11 women) belonging to the class 
 which had suffered most extensively, all were free from the disease, 
 excepting three, one woman and two men. These three had been pro- 
 moted to the kitchen within four days. It is proper to add, that the 
 officers and servants of the establishment, together with their families, 
 residing within the walls of the prison, and amounting to 106 individuals, 
 were universally exempt from the disease. 
 
 We took some pains to ascertain the period at which the disease in 
 question might be considered as having commenced, and the gradations by 
 which it had reached its present extent and aggravation. It appeared 
 reasonable to assume, that whenever upon the feeble and drooping 
 condition observed among the prisoners throughout the winter, diarrhoea 
 or dysentery, or scurvy supervened, then the disease was fully constituted. 
 With respect to the scurvy, it was scarcely possible to assign the exact time 
 at which it commenced, on account of the insidious mode of its attack, 
 and the facility with which it may elude observation on its first appearance. 
 But we have fully satisfied ourselves, that there existed among the female 
 prisoners, a few cases of decided scurvy, as early as the month of 
 November. Among the men we cannot trace any instance of scurvy, back 
 to a remoter period than two months. It is certain, however, that it was 
 not until after Christmas that the scurvy had spread very extensively 
 among either sex. About the middle of January, the instances had 
 become numerous among the women ; and among the men, about the 
 middle of February ; and it continued to increase progressively in both 
 sexes, until the first week in March. 
 
 The diarrhoea and dysentery appear, in their origin and progress, to 
 have kept pace with the scorbutic symptoms. Upon inquiry among the 
 prisoners, we found that some of them had been occasionally suffering 
 from diarrhoea before Christmas ; but the instances being few, and the 
 cases yielding readily to common remedies, they did not excite any alarm, 
 and were naturally imputed to accidental causes. Under ordinary circum- 
 stances, such a conclusion might have been fairly admitted ; but 
 considering what the general health of the prisoners then was, and with 
 our knowledge of what has since occurred, we cannot but suspect that in 
 some of these instances, the diarrhoea belonged to the same disease, of 
 which it has since been found to constitute the principal and most 
 formidable symptom. 
 
 In the course of January, the instances of diarrhoea were too numerous 
 to be attributable to common or accidental causes. But, even then, it had 
 
INTRODUCTION. 211 
 
 not become matter of general complaint, for it was not attended/with much 
 pain, and in most of the sufferers it continued for a short period only, and 
 then ceased ; but it renewed its attacks from time to time on the same 
 individual, gradually, though insensibly, impairing his strength. In this 
 manner, through the month of January, many of the prisoners were 
 sustaining a severe injury to their constitution, without being conscious of 
 more than an accidental ailment, and without applying for relief. 
 
 Increasing daily in extent and severity, it at length became matter of 
 complaint ; and at the latter end of February, diarrhoea and dysentery 
 constituted a large proportion of the cases in the infirmaries. Three 
 deaths from this disease, occurred between the 14th of February and the 
 1st of March, the day on which we made our first examination of the 
 prison and the infirmaries. In the prison, the disease had reached the 
 extent already mentioned ; and in the infirmaries there were 64 patients 
 labouring under the disease in one or other of its forms. 
 
 In inquiring into the causes of the disease in question, we think it 
 right to state our persuasion, that the situation of the prison has not 
 contributed to its production. First, because, if this had been the case, it 
 is reasonable to suppose that the same disease would have occurred in 
 former years ; whereas it has never appeared until the present winter. 
 Secondly, had this been the case, the officers of the prison, being equally 
 obnoxious with the prisoners to any injurious influence of situation, could 
 not have been universally exempt, as it appears they have been, from 
 the same disease. Thirdly, because, if the situation of the prison be 
 injurious, it must be presumed to be so in consequence of marsh miasmata 
 arising in its neighbourhood ; yet, since its establishment, the prison has 
 been altogether free from those diseases which marsh miasmata confessedly 
 engender. Fourthly, because marsh miasmata always arise during the hot, 
 and never during the cold seasons of the year ; and the diseases which 
 they engender belong to the same seasons. Lastly, because although scurvy 
 and dysentery have undoubtedly been found prevalent in marshy districts, 
 yet when marsh miasmata have produced them, they have been associated 
 with intermittent fevers, and have occurred only at the hot seasons of the 
 year. It may possibly be suspected that the simple dampness of the 
 situation may have contributed something to the disease. But we can 
 state with confidence, that every part of the prison is singularly dry ; 
 and that in no cell or passage, on no floor or ceiling, or wall of the 
 prison, have we found the smallest stain or appearance of moisture. 
 
 Several circumstances respecting the disease in question, which have 
 been already mentioned, seemed to limit the causes of its production to 
 such as could have had their operation exclusively upon the prisoners, and 
 especially at the present season, and now for the first time. One such 
 cause is found, we conceive, in the diet of the prison. During the last 
 eight months the diet was different from what it had been ever since its 
 establishment. The change which took place in July last, reduced the 
 animal part of the diet to almost nothing. In a soup made of pease or 
 barley, ox heads were boiled, in the proportion of one ox head to 100 
 
212 INTRODUCTION. 
 
 male, and one to 120 female, prisoners : and we found upon inquiry, that 
 the meat of one ox head weighed, upon an average, eight pounds, which, 
 being divided among a hundred, allows only an ounce and a quarter for 
 each prisoner. This new diet had been continued until the present time ; 
 and to it we mainly ascribe the production of the disease in question. 
 
 It does, nevertheless, appear to us, that the diet of the prison has not 
 itself alone been productive of the disease, but that it required the con- 
 currence of other causes, of which the severity of the winter was probably 
 the chief. The origin of the disease has been traced to the commencement 
 of the cold weather, and its progress and increase have kept pace with it. 
 There are, moreover, two circumstances which confirm us in the belief, 
 that diet and cold have been concurrent causes. The sufferers were most 
 numerous in that class of prisoners which were most exposed to the influence 
 of cold, from the lower temperature of the cells in which they pass the 
 night : showing, that where both causes most conspicuously concurred, the 
 disease was most extensively produced. Yet those individuals of that class, 
 who, sleeping in the same cells and exposed to the same low temperature 
 by night, were employed in the kitchen by day, and had access to richer 
 diet, were universally exempt ; showing, that where one cause was with- 
 drawn, the other was of itself inadequate to produce the disease. 
 
 Such being the character and extent of the disease in the Penitentiary, 
 and such its most probable causes, we proceeded to adopt those measures 
 for counteracting it, which its own nature, and the opinion we entertained 
 of its origin seemed to suggest. We ordered an immediate change in the 
 diet of the prison. In place of pease and barley soup for dinner, we sub- 
 stituted a daily allowance of four ounces of flesh meat, and eight ounces of 
 rice daily for each prisoner, and white bread instead of brown : and, as the 
 cheapest and best antiscorbutic article of diet which could be procured at 
 this season of the year, we ordered three oranges for every prisoner daily, 
 one at each meal. 
 
 It is unnecessary to detail the methods of medical treatment employed 
 in the infirmaries. 
 
 On our examinations of the prison between the 12th and the 19th of 
 March, we found the general aspect of the prisoners visibly improved. 
 The taskmasters jpforined us that they were more cheerful, and did more 
 work ; and particularly that those employed at the mill could grind one- 
 third more flour. The scorbutic marks had, in almost every case, 
 begun to decline, and in many of the slighter cases had absolutely dis- 
 appeared. 
 
 On our general surveys of the prison between the 31st of March and 
 the 4th of April, we could not find more than fifty individuals of both 
 sexes, on whom any marks of scurvy remained ; and on the greater number 
 of these, they were so slight as hardly to be detected. 
 
 The diarrhoea and dysentery have, upon the whole, kept pace in their 
 decline with the gradual disappearance of the scorbutic spots. On each of 
 our examinations of the prison, we found them relieved or cured nearly in 
 the same proportion ; and, on our last examination, there were not 
 
INTRODUCTION. 213 
 
 remaining so many as twenty oases of bowel complaints in the whole 
 prison. 
 
 It is proper to remark that the diarrhoea and dysentery, being the most 
 formidable part of the disease, was that for which medical treatment was 
 especially required. Therefore, of the prisoners thus affected, we have 
 constantly received as many into the infirmaries as there was room to 
 accommodate, whether their cases were severe or slight. At the period 
 when, as we have stated, the disease was upon the decline, that is, during 
 the last weeks of March, it will be observed that there was a greater 
 number of prisoners in the infirmaries than at the period when the disease 
 in all its forms was at its greatest aggravation and extent, that is, during 
 the first week in March. The truth is, that when we began our attendance, 
 we found only the severer cases of bowel complaints in the infirmaries ; 
 but as soon as we had learned, by the dissection of two patients who died 
 dysenteric, that the disease tended to produce irreparable organic mischief 
 of the intestines, we thought it right to bring as many cases as possible 
 under strict medical treatment : and moreover, as soon as we had learned 
 in the course of our observations, the great liability of the diarrhoea and 
 dysentery to return, we thought it right to use the greatest possible vigilance 
 over particular cases, during the period of their convalescence. Hence, 
 many in whom we most strongly suspected this proneness to relapse, were 
 still kept in the infirmaries, after the actual symptoms of their disease had 
 disappeared ; and a convalescent ward, in addition to the ordinary accom- 
 modation of the infirmaries, was opened for their benefit. These are the 
 circumstances that are to be borne in mind, in order to reconcile the 
 apparent inconsistency of the number in the infirmaries being greater, at 
 the very time when the disease in the prison was daily and rapidly 
 declining. 
 
 From the 1st of March to the present day, 222 patients have been 
 admitted into the infirmaries, making, with the 110 already there, a 
 total of 332 patients. Of these, eleven have died, six of dysentery, and 
 the remaining five of diseases unconnected with the present disease. At 
 present, the total number of patients in the infirmaries is 101, namely, 64 
 women and 37 men. Of this number we consider that 36 are convalescent, 
 and exhibit no symptom of disease ; and they are retained in the infirmaries 
 only by way of precaution against relapse : 19 only are still suffering the 
 symptoms of the disease ; and 46 are affected with other complaints. 
 
 It remains for us to fulfil the wishes of the Committee, by suggesting 
 to them some considerations respecting diet. With regard to the diet of 
 prisoners undergoing punishment for crimes, we presume the object to be, 
 that they should have enough for nourishment and health, and nothing 
 more. How much, and what quality of food will actually suffice for this 
 purpose, can be deduced only from numerous and careful experiments.. 
 But no such experiments, as far as we know, have ever been made. There 
 are certainly none upon record, to which we can refer for information. 
 We beg, therefore, that the observations we venture to make, and the 
 recommendations we offer, respecting diet, may be accepted as the result 
 
214 INTRODUCTION. 
 
 of the best consideration we can give to the subject, in the absence of 
 positive experiments. 
 
 Practically, the main question seems to be, Can animal food be safely 
 excluded from prisons, and particularly from the Penitentiary ? We are 
 aware that a large portion of the labouring agricultural population of this 
 country subsists altogether npon vegetable food, and is generally reputed 
 vigorous and healthy ; and we admit the justice of the inference, that an 
 exclusively vegetable diet is generally wholesome ; and we allow, moreover, 
 that to submit those confined in prisons to such a diet, is a justifiable 
 experiment. But still it is merely an experiment ; and considering that 
 every circumstance of the present condition and previous habits of those 
 imprisoned for felonious crimes, is as different as possible from the simple 
 condition and simple habits of an agricultural population, we should not 
 be surprised to find that the experiment generally failed. At the Peniten- 
 tiary there are, we conceive, peculiar obstacles to its success. These 
 consist chiefly in the long periods of confinement, and the great number of 
 prisoners. 
 
 To prisoners in a house of correction, whose period of confinement is 
 limited to a few months, little hazard would result from an habitually 
 scanty diet. People may be under-nourished for a short time, with 
 impunity ; but prisoners who are in the course of a confinement for five, or 
 seven, or ten years (and none are condemned to less in the Penitentiary), 
 cannot safely be subjected to the same system. Many injurious influences 
 will arise in the course of years, which a few months would not produce. 
 There will be changes and inclemencies of seasons to be provided against, 
 and the heavy pressure of moral circumstances, for which, although they 
 cannot be strictly appreciated, large allowances must be made. The great 
 number of prisoners at the Penitentiary, independently of the contingencies 
 to which they are exposed in the course of a long confinement, renders 
 such an experiment peculiarly hazardous. Eestriction to a vegetable diet, 
 or to a diet that is considered just sufficient for nourishment and health, 
 requires a constant vigilance over the health of each individual prisoner. 
 Such a vigilance is the only security against the possible evils that may 
 arise. In a prison containing 50 prisoners, a diet even of bread and water 
 may be adopted without hazard ; because there the requisite degree of 
 vigilance can be obtained ; and the medical superintendent of such a prison 
 would become so familiar with the aspect of individuals, as to see at once 
 the earliest indications of disease in any one of them. But in a prison con- 
 taining 900 or 1000 prisoners, the requisite degree of vigilance -would be 
 impossible ; and for the want of it, a great hazard would be incurred by 
 adopting the same system of diet. 
 
 For these reasons, and especially because the diet of the last eight 
 months, in which the animal matter was reduced almost to nothing, has 
 mainly contributed, as we conceive, to produce the present extensive 
 disease, we recommend that, in future, animal food should make a larger 
 part of the diet at the Penitentiary. 
 
 Upon the subject of diet, we recommend : — 
 
INTRODUCTION. 215 
 
 1st. That half a pound of flesh meat, without bone, be allowed to every 
 prisoner, once a week, ore Sunday. 
 
 2nd. That, in addition, half a pound of flesh meat be allowed to every 
 prisoner once a fortnight, on any day that the Committee may think proper. 
 
 3rd. That white bread should always be given to the prisoners, that is, 
 bread made of the best wheat flour, and free from all impurities. 
 
 4th. That the prisoners should have one meal each day entirely of solid 
 food ; that is, if they have gruel for breakfast, and gruel for supper, that 
 their dinner should not be of soups or broth; but that, of whatever 
 vegetable or animal substances it consist, they should be given in a solid 
 form. 
 
 As to the kind of vegetables suitable for the principal meal of the 
 prisoners, a certain latitude must be allowed in regard to those which are 
 most easily procured. All the vegetables in common use are wholesome. 
 Potatoes and rice can be procured at all times ; and fortunately they .are the 
 most nutritions. 
 
 We recommend, that the present allowance of four ounces of flesh meat, 
 with one orange, daily, be continued to every prisoner for a month : that 
 afterwards four ounces of flesh meat be given on alternate days for a 
 fortnight, and that then, if the general state of the prison be healthy, it be 
 put upon the ordinary diet, that shall be determined by the Committee. 
 
 In closing our Report, we beg to express our firm conviction that there 
 is now no obstacle to the entire re-establishment to the healthy state of the 
 Penitentiary. "We must, nevertheless, add, that for several weeks to come, 
 occasional cases of bowel complaint will probably still be found to arise in 
 the prison; we suggest, therefore, the necessity of great vigilance and 
 frequent inspection, that none of such cases may pass undiscovered ; and we 
 recommend, that every case, as soon as it is noticed, be removed to the 
 infirmary, and subjected to the strictest medical treatment. Security 
 against relapse will best be obtained by whatever is calculated to strengthen 
 the constitutions of those who have already suffered, and especially by still 
 employing the means which have hitherto mainly contributed to their 
 recovery. It is with this view that we have recommended the continuance 
 of the present allowance of animal food for another month. 
 
 We have examined the accounts, which have been transmitted to us 
 from the Secretary of State's office, of the diet used in different prisons in 
 England, contained in the answers to questions which were sent to the 
 visiting magistrates, on this and other subjects connected with the health of 
 prisoners. But on comparing the different plans of diet detailed in those 
 answers, which have as yet reached us, with the objects and system of the 
 General Penitentiary, we do not conceive that any of them will be at- all 
 suitable to that establishment. We have to observe, however, that answers 
 to the above-mentioned questions, have been received only from seven of 
 the prisons that have been written to for information on these subjects. 
 
 (Signed) P. M. Latham, M.D. 
 
 P. M. Eoget, M.D. 
 
 5th April, 1823. 
 
216 
 
 INTRODUCTION. 
 
 NUMBERS AFFECTED WITH THE DISEASE. 
 
 Table of the number of Prisoners of different denominations, who were 
 labouring under one or other of the forms of the Scorbutic Disease, in 
 the General Penitentiary, in the beginning of March, 1823. 
 
 Makoh, 1823. 
 
 Total 
 Number of 
 Prisoners. 
 
 Number ill 
 
 of the 
 
 Disease. 
 
 Equivalent 
 Number 
 per cent. 
 
 MALES. 
 
 First Class 
 
 Second Class 
 
 309 
 
 222 
 
 110 
 121 
 
 35 
 54 
 
 Confined ... under 1 year 
 
 .„ between 1 & 2 years ... 
 „ between 2 & 3 years ■ ... 
 „ between 3 & 4 years ... 
 „ above 4 j'ears 
 
 173* 
 
 156 
 
 165 
 
 28 
 9 
 
 40 
 74 
 91 
 19 
 
 7 
 
 23 
 
 47 
 55 
 68 
 78 
 
 Total Males 
 
 531 
 
 231 
 
 44 
 
 FEMALES. 
 
 First Class 
 
 Second Class 
 
 94 
 233 
 
 52 
 165 
 
 55 
 
 71 
 
 Confined ... under 1 yeaT 
 
 „ between 1 & 2 years . . . 
 „ between 2 & 3 years ... 
 „ between 3 & 4 years ... 
 „ above 4 years 
 
 37 
 93 
 
 106 
 68 
 23 
 
 12 
 65 
 74 
 56 
 10 
 
 32 
 
 70 
 70 
 82 
 43 
 
 Total Females 
 
 327 
 
 217 
 
 66 
 
 OF BOTH SEXES. 
 
 First Class 
 
 Second Class 
 
 403 
 455 
 
 162 
 
 286 
 
 40 
 63 
 
 Total Prisoners . . . 
 
 858 
 
 448 
 
 52 
 
 From this Report it is obvious, that we had no other opinion 
 concerning the disorder, than that it consisted of a diarrhoea or 
 dysentery, and a slight scurvy combined ; that it had been pro- 
 duced by impoverished diet and a severe winter ; that it was 
 already nearly cured, and that, although occasional instances of 
 
 * Of these 85 had been received into the prison since the 1st of January, 
 and therefore had been subject for a much shorter time to the influence of 
 the presumed causes of the disease. 
 
INTRODUCTION. 217 
 
 relapse might be expected, the health of the prisoners would 
 probably be re-established at no distant period. 
 
 With respect to the origin of the disease, all the facts, 
 which had come to our knowledge, seemed to conduct so 
 obviously to one conclusion, that we could not hesitate to adopt 
 it ; and the facts themselves, being entirely of a nature to be 
 comprehended by persons not medical, we thought ourselves 
 called upon to state them fully in the Eeport, in order that the 
 Committee might possess the means of judging how far the 
 conclusion to which they had brought us, was correct. 
 
 There were certain other circumstances which further con- 
 firmed us in our opinion respecting the origin of the disease 
 and the probability of its early disappearance. These, how- 
 ever, being more strictly medical, we did not think it necessary 
 (considering to whom the Eeport was addressed) formally to 
 specify. The rapid recovery of the sick, when the causes were 
 removed from which their disease was suspected to spring, was 
 a strong presumption, at least, that those causes were rightly 
 ascertained. 
 
 In regard to such diseases, especially, as are engendered by 
 defective nutrition, we knew it to be a matter of experience, 
 that they are generally capable of being speedily and effectually 
 cured by an improved diet ; and this had been strikingly the 
 case in the present instance. 
 
 Further, the medical expedients hitherto employed had 
 been very simple and very successful ; and we could not im- 
 pute a very formidable character to a disease which chalk 
 mixture and tincture of opium could eure. 
 
 These were the remedies which we found the medical 
 officers prescribing, when we were first called to the Peniten- 
 tiary ; and seeing that they answered so well, the purpose for 
 which they were intended, we abstained from instituting any 
 new method of treatment. 
 
 Such were the views we had taken of this disease after a 
 month's observation and inquiry ; and unfortunately it was 
 necessary that all we knew or believed should be published. 
 As soon as our investigations had enabled us to form (what we 
 thought) a satisfactory opinion, we offered our Report to the 
 Committee. By the Committee it was presented to the House 
 of Commons, and immediately ordered to be print el. 
 
218 INTRODUCTION. 
 
 This Report, as a medical document, was unquestionably- 
 premature, yet I candidly confess we had no such belief at 
 the time. 
 
 The conviction it expresses, that there is "now no obstacle 
 to the entire re- establishment of the healthy state of the Peni- 
 tentiary " was proved, by what speedily occurred, not to have 
 been well-founded ; and although our opinion respecting the 
 sources from which the disease was originally derived, was con- 
 firmed by numerous medical men who were examined upon the 
 subject, and was at the time entirely satisfactory to ourselves, 
 arid equally so to the Committee, facts, subsequently brought 
 to light, have led us to doubt whether this latter opinion was 
 entirely correct. 
 
 The Report had hardly been made public when the disease, 
 so far as it was referable to the bowels, began to re-appear : by 
 the middle of the month of May it had again pervaded the 
 prison; and by the middle of the month of June, all the 
 prisoners, without exception, who had formerly suffered ; and 
 all, with very few exceptions, who had been exposed to its 
 presumed causes, yet had never suffered before ; and all, with 
 very few exceptions, who had been admitted into the Peniten- 
 tiary since its presumed causes had been removed, were involved 
 in the same calamity ; and the remedies, which were formerly 
 successful in controlling it, had not now the smallest beneficial 
 influence. 
 
 It should be remarked, that that part of the disease, which 
 consisted in scorbutic spots and blotches, never returned. The 
 few fading vestiges of scurvy, which were still discernible in 
 some, entirely disappeared even while the patients were suffering 
 a relapse of the bowel complaint. 
 
THE SCUEVT. 21& 
 
 CHAPTER II. 
 
 THE SCURVY. 
 
 In the Report of the 5th of April, drawn up solely for the 
 information of the Committee of the Penitentiary, all minute 
 and formal descriptions of disease were purposely avoided. 
 Scurvy, and dysentery, and diarrhoea have been hitherto- 
 mentioned only by name ; but for the information of medical 
 men it becomes necessary to show what it was, that under the 
 name of scurvy, was once co-extensive throughout the prison, 
 with the complaints of the bowels. And we must here make 
 room for the description of it, before we enter upon the considera-- 
 tion of the bowel complaints themselves, which returned after the 
 final disappearance of the scurvy, and of other forms of disease 
 which were superadded. 
 
 There is a peculiar condition of the skin, which is vulgarly 
 called goose-skin. It is formed by numerous little elevated 
 points, which give a roughness to the surface. It occurs 
 chiefly upon the extremities ; and where it exists to a consider- 
 able degree, the surface is dry and unperspirable, and the cuticle 
 falls off in minute scales, or in the form of a white powder. 
 The act of stripping up the shirt sleeves, or pulling down the 
 stockings, often shakes off a quantity of this white powder from 
 the arms or legs. This state of the skin is produced by the 
 common causes of constitutional weakness, and there can be no 
 surer sign of the body being (if I may so say) out of condition. 
 It is met with chiefly among the poor, who are ill-nourished 
 and ill-clothed. Upon our first visit to the Penitentiary this 
 peculiar condition of the skin at once attracted our notice, for 
 it was found almost in every prisoner, and to a very remarkable 
 degree. 
 
 In whatever part of the extremities this condition of the 
 skin was most conspicuous, there were always found certain 
 specks or spots of a blue or livid colour, formed by blood extra- 
 vasated beneath the cuticle. 
 
220 THE SCURVY. 
 
 In some, these spots were no larger than a pin's head, and 
 quite circular ; when they showed themselves hardly anywhere, 
 except just at the outside of the knee near the bend of the 
 hams. 
 
 In some, intermixed with these spots of the smaller size, 
 were others of the diameter of a pea, and quite circular; when 
 they showed themselves over various parts of the extremities, 
 but still especially about the hams. 
 
 In some, there were blue and livid spots of a much larger 
 size, still preserving a sort of circular figure, and evidently 
 formed by two or three of the smaller spots, with which they 
 were intermixed, coalescing into one. These specks and spots 
 of all sizes, intermingled and coalescing with each other, were 
 distributed over every part of the extremities. 
 
 In others, together with these specks and spots which have 
 been described, or without them, there were large blotches of 
 an irregular shape, and of such an extent as to leave the legs, 
 or arms, or thighs, or buttocks, almost uniformly livid, with 
 hardly an appearance of their natural complexion. 
 
 In a few there was ecchymosis of the conjunctiva ; and in 
 a few, ecchymosis and swelling of the upper eyelid. 
 
 These appearances, occasioned by blood extravasated beneath 
 the cuticle, from the clusters of little livid points about the 
 hams to the large livid patches occupying thp whole limb, must 
 be regarded as indicating different degrees of the same disease, 
 by whatever name it is called. Some concomitant conditions, 
 which remain to be noticed, will enable us perhaps satisfactorily 
 to determine what that name»ought to be. 
 
 The gums were spongy, and soft, and livid, and disposed to 
 bleed, in all those who had extensive discolorations of the skin; 
 and in those who had mere specks and spots of ecchymosis, their 
 condition, although it might not have been noticed under ordi- 
 nary circumstances, was far from being healthy ; they had a 
 purplish hue, and were tender and sore, and often ragged, just 
 where they come in application with the teeth. In a few, and 
 especially in one man (Henry Peers) the mouth seemed in a 
 state of absolute rottenness, the gums bleeding and broken 
 down, the teeth loose, and their fangs half exposed, and the 
 whole mucous membrane of lips and cheeks black and ragged, 
 while a foul cadaverous smell was emitted with the breath. 
 
THE SCURVY. 221 
 
 In many who exhibited specks and spots only of ecchymosis, 
 and in all whose limhs were covered with large blotches, the 
 muscles of the legs were perfectly hard and rigid. In a few, 
 the legs were cedematous, and one man (Henry Peers, already 
 mentioned) was universally dropsical. 
 
 These forms of disease, which have been described, were 
 justly denominated scurvy. The scorbutic character was equally 
 unequivocal in all the degrees, from the least to the greatest, 
 in which the disease was seen at the Penitentiary, and fortu- 
 nately, in the great majority of cases, it was seen in its mildest 
 form. 
 
 It has been already stated in the Report, what means of 
 treatment were employed, and how far the scurvy had disap- 
 peared when those means had been in use a little more than a 
 month. After the lapse of another month there might still 
 remain several, in whom a very experienced eye could recognize 
 certain little brown spots, as the last and almost worn out 
 vestiges of scurvy ; but not more than half a dozen individuals 
 could have been shown, whom a common observer would have 
 regarded as authentic examples of what the disease had been. 
 These were the few who still exhibited the remnants of large 
 blotches upon their limbs. 
 
•222 THE BOWEL COMPLAINTS. 
 
 CHAPTER III. 
 
 THE BOWEL COMPLAINTS. 
 
 I will now proceed to describe the Disease under the various 
 forms in which, after the decline and disappearance of the 
 scurvy, it presented itself to our observation ; and the methods 
 of treatment, which, from experience, have been found most 
 serviceable. It is necessary, however, in the first place, to 
 premise, that although the flux of the bowels has throughout 
 been its leading and most prominent symptom, the symptom, 
 moreover, which has been most constantly present, and that 
 from which it has derived its character and its name, yet has it 
 ■constituted one part only of the Disease. The Disease was 
 neither a diarrhoea nor a dysentery simply, nor did it belong 
 exclusively to the bowels ; but it belonged to the whole system, 
 and was very extraordinary, and (as I believe) peculiar in its 
 nature. 
 
 There was every degree and species of flux, that was ever 
 seen or described. There were cases, which corresponded with 
 the descriptions of the Indian cholera. The patients were 
 seized with intolerable cramps at the pit of the stomach. They 
 retched and vomited, and a thin turbid serum ran from their 
 bowels, followed by severe tenesmus. The pulse became feeble 
 and frequent ; they were pale and chilly ; and a sudden anguish 
 pervaded the whole frame. Again, there were cases, which 
 corresponded with the common autumnal cholera of this country. 
 The patients had severe griping of the intestines generally, and 
 cramps of the extremities, while pure and unmixed bile ran 
 from the bowels, scalding them (as they expressed it) like 
 melted lead in its passage. 
 
 Moreover, there was every kind and degree of dysentery ; 
 eome purged pure blood in large quantities ; others a fluid like 
 the water in which raw flesh had been washed. In some, the 
 evacuations, otherwise healthy, were just streaked with blood ; 
 
THE BOWEL COMPLAINTS. 223 
 
 in some they contained (what seemed to be) lumps of flesh. 
 In others they were mixed with mucus and slime, or they con- 
 sisted of mucus and slime altogether. 
 
 Again, there were cases which differed very little from the 
 diarrhoea of common casual occurrence, except that they were 
 quite intractable by common remedies. The evacuations were 
 loose and attended with griping, but feculent and without any 
 morbid quality. 
 
 Lastly, there were cases which had no resemblance what- 
 ever, either to cholera, or dysentery, or diarrhoea, or to any 
 disorder that has obtained a name. In the evacuations, there 
 appeared nothing that had any sensible quality of fzeces, of bile, 
 or blood, or (of what is understood by) mucus and slime. But 
 they consisted sometimes of a mass, like green or black grapes 
 in a state of fermentation ; sometimes of a matter like yeast ; 
 sometimes they were in colour and consistence like half-slaked 
 lime, when it is beginning to crumble ; and sometimes like a 
 thin mixture of chalk and water, and always intolerably sour 
 and offensive, and in enormous quantity. 
 
 Now the probable issue of particular cases, and their degree 
 of danger could not be estimated by the kind of flux simply. 
 Experience taught us that those who had the extreme symptoms 
 of cholera or dysentery were as likely to recover as those who 
 had simple diarrhoea : and those who had simple diarrhoea were 
 as likely to die as those who had the extreme symptoms of 
 cholera or dysentery. Therefore it became the more necessary 
 to seek for indications among concomitant symptoms, which 
 might conduct us to a better judgment of the disease. Accord- 
 ingly we looked to the general condition of the abdomen, and 
 the presence or absence of pain within it ; to the condition of 
 the tongue ; to the pulse, and to the presence or absence of fever. 
 For hence it is always thought, in cases of intestinal flux, that 
 the actual state of disease is capable of being most safely 
 inferred. 
 
 When the abdomen was examined, it was found in some 
 partially distended, and chiefly about the epigastric region ; 
 in some universally distended and tympanitic. In others it 
 was found collapsed and retracted towards the spine. The 
 tympanitic state of the bowels was much more remarkable in 
 the women than the men. After every symptom of their 
 
224 THE BOWEL COMPLAINTS. 
 
 disease had ceased, and they had gained flesh, and recovered 
 the complexion of health, many of the women still continued, 
 for months together, with the abdomen enormously prominent. 
 In many, however, both women and men, during their disease 
 and afterwards, the belly was soft and natural in every respect. 
 In one instance, and in one only, was there any circumscribed 
 tumour to be felt by pressure, within the abdomen, and there 
 it arose from an enlarged liver. 
 
 Of pains referable to the bowels, there was great variety in 
 the kind and degree which different patients experienced. Some 
 experienced no pain at all, except just before each evacuation, 
 when the common urgency to stool seemed aggravated into real 
 suffering. Some experienced none at all, except just after each 
 evacuation, when it consisted of a scalding of the passage or 
 tenesmus. 
 
 The great majority, however, had some kind of perpetual 
 uneasiness within the abdomen. There was a very general com- 
 plaint of (what was called) sinking at the pit of the stomach. 
 What this sinking is those only know who have suffered it. All 
 patients speak of it by the same name, but do not describe it 
 further. From observing and interrogating those who now 
 complained of it, I suspected it to consist of a certain degree of 
 actual pain, combined with a feeling which is akin to approaching 
 syncope, and spreads from the stomach, as from a centre, over 
 the whole frame. It is a painful and overpowering sensation, as 
 if animal life itself was hurt and lessened. 
 
 Now this sinking was not only present with the bowel com- 
 plaint, but many suffered it alone, long before their bowel com- 
 plaint arose ; and many still suffered it long after their bowel 
 complaint was gone. In the one case, it gave notice that the 
 disease was approaching, before its more characteristic symptoms 
 arrived; in the other, it was an evidence that, although its 
 more characteristic symptoms had subsided, the disease had not 
 actually ceased. That this painful and depressing sensation, 
 among many other severe sufferings, was often still the greatest 
 of all, I infer from this consideration. Patients would con- 
 tinually endeavour to withdraw our attention from the more 
 tangible symptoms of their disorder, for the sake of fixing it 
 upon this. When we were interrogating them upon circum- 
 stances apparently more urgent, they would interrupt us, and 
 
THE BOWEL COMPLAINTS. 225 
 
 exclaim, " but this sinking, this sinking ; pray do something for 
 this sinking!" 
 
 Many suffered severe pains, which came and subsided, and 
 came again, and were often aggravated into paroxysms of ex- 
 treme torture. They occupied indifferently various parts of 
 the abdomen, and parts contiguous to it ; they were felt in the 
 seat of the stomach, or of the bladder, or about the navel ; they 
 bordered upon the loins, or shot round to the back. In the 
 same individuals, however, whatever part they once occupied, 
 to that part they almost constantly returned after their remis- 
 sions. These pains partook principally of the character of colic 
 pains; while, in some respects, they were not strictly such. 
 After having endured for a time, in great severity, they became 
 tranquillized, but did not absolutely cease ; and, although pres- 
 sure, very carefully and equally applied over a large surface, 
 would give relief when the paroxysm was present, it served to 
 exasperate the pain which still remained after the paroxysm 
 was gone. It seemed reasonable to infer that so much of the 
 pain, as was constant, and abiding, and less severe, but capable 
 of being exasperated by pressure, arose immediately from the 
 diseased condition of the bowels, and that so much as was occa- 
 sionally superadded and more severe, but capable of being 
 relieved by pressure, arose from their temporary spasm. 
 
 Many suffered the less severe, and constant, and abiding 
 pain, without any occasional aggravation of it into paroxysms 
 of colic. 
 
 In the great majority of cases, whatever was the kind of 
 flux, whether cholera, or dysentery, or diarrhoea, or any other 
 of the disorders described, whether it was severe or mild, the 
 tongue, during the whole course of the complaint, was quite 
 clean and moist, and of its natural colour. All the physicians 
 who visited the Penitentiary were struck with this anomaly. 
 In a few cases, it might be a little more red than natural ; in a 
 few loaded with mucus ; and in a few, even brown and dry ; 
 conditions which seemed determined by the presence of fever ; 
 but in no single case was there the red and glossy and smooth 
 tongue peculiar to dysentery, and in no single case was there 
 the slightest appearance of aphthae. 
 
 With respect to the pulse, in a few cases it had frequency 
 and strength enough to require bleeding, and in a few it had 
 
 Q 
 
226 THE BOWEL COMPLAINTS. 
 
 frequency and strength enough to require some means of de- 
 pletion short of Heeding. But in the great majority of cases 
 it had no morbid character, which called for the employment 
 of blood-letting or any other kind of depletion, and in many it 
 had no morbid character whatever. 
 
 Of fever, as a part of the disease, I propose to speak more 
 particularly hereafter, observing, in the meantime, that it was 
 present in some cases, but that the majority were entirely 
 exempt from it, and that, where it did occur, its symptoms 
 only reached a very moderate degree of excitement. 
 
 Such was the remarkable diversity of symptoms which 
 accompanied this strange and multiform disorder of the bowels. 
 
 From the species of flux (it has been already said) we could 
 derive no criterion of the actual state of the disease, or its 
 probable issue. Concomitant symptoms, which ordinarily 
 afford an essential illustration of the nature of similar diseases, 
 now rather contributed to perplex us. From the tongue 
 nothing could be learnt ; from the state of the abdomen very 
 little; and, although pain, and fever, and an excited pulse, 
 necessarily implied a more active disease, they did not bespeak 
 one more hazardous in the event. The danger was not to be 
 estimated, either by the degree of pain, or the degree of fever, 
 or by the blood that was purged, or by the violence of the 
 retching and vomiting, or by the frequency of the pulse. If 
 any form of the disorder was more formidable than another, it 
 was that which seemed to consist in mere diarrhoea. 
 
 Two cases especially, which occurred soon after our first 
 employment at the Penitentiary, made (as they were well cal- 
 culated to do) a striking impression upon our minds. They 
 had arrived, by a slow, and certain, and uninterrupted progress, 
 at their fatal termination. The patients had no other symptoms 
 of disease but a simple diarrhoea. 
 
 They had no pain, no fever ; their pulse was sixty, and no 
 more. Never did I witness the process of dissolution so 
 lingering. In the very act of dying, when the pulse could only 
 just be felt, it had not exceeded sixty. Their purging was 
 incessant and incontrollable ; but there was no morbid quality 
 in their evacuations, except that they were watery. One of 
 these patients (a female) was examined after death, and the 
 only traces of disease discovered, were three or four small spots 
 
THE BOWEL COMPLAINTS. 227 
 
 of ecchymosis at the upper portion of the large intestines, with- 
 out any appearance of vascularity or inflammation in their 
 neighbourhood. 
 
 In process of time cases of this kind became more and more 
 numerous. They consisted of simple diarrhoea alone : such a 
 diarrhoea as all physicians would have thought capable of being 
 instantly arrested by the simplest remedies ; yet this mere pas- 
 sive diarrhoea was the form of the disease which our own expe- 
 rience eventually taught us most to fear and deprecate. 
 
 Many poor wretches thus affected were given up by us as 
 lost, and were just ready to perish at the time when we first 
 resorted to the use of mercury. They lay in bed without fever; 
 without pain; without excitement of the pulse; but with a 
 turbid water continually running from their bowels. This was 
 their only symptom ; and this nothing could restrain. Their 
 complaint (as long as they did complain) was of " that dreadful 
 sinking." But now their complaining had ceased. Being 
 roused, they looked up for a moment, but made no lamentation, 
 and then laid their heads down again in despair. It was a 
 dismal office to watch over their tardy dissolution, and witness 
 the frustration of every expedient for their relief. These were the 
 cases in which we first put the efficacy of mercury to successful 
 proof; and I cannot help mentioning the relief my mind expe- 
 rienced from a sense of responsibility which had now become 
 truly awful, as soon as the salutary influence of this remedy 
 was apparent. 
 
 In those who died, dissection discovered various morbid con- 
 ditions in the course of the intestinal canal. They were such 
 as every one, at all conversant with morbid dissections, is well 
 acquainted with ; for there was nothing essentially new in their 
 kind. But at the same time many of the forms under which 
 they presented themselves were new, or at least not familiar to 
 my observation. 
 
 They were principally of three kinds, ecchymosis, conges- 
 tion of the small blood-vessels, and ulceration: the two first 
 belonging exclusively to the mucous membrane ; the last begin- 
 ning in the mucous membrane, but subsequently extending to 
 contiguous structures. 
 
 The ecchymoses were always of small extent, and few in 
 number. I do not recollect an instance in which they occupied 
 
228 THE BOWEL COMPLAINTS. 
 
 a space much larger than the diameter of a pea, or exceeded the 
 number of five or six throughout the whole tract of the intes- 
 tines. They were found indifferently in all parts of the stomach 
 and bowels. 
 
 Some died of long-continued and incontrollable diarrhoea, in 
 whom no other morbid appearance was found after death, but a 
 few of these small spots of ecchymosis. 
 
 With respect to congestion of the small blood-vessels, those 
 who are accustomed to the examination of dead bodies well 
 know, that nothing is more common than to find parts of the 
 intestines changed from their natural colour, without any 
 sensible alteration of their natural texture. These parts of the 
 intestines assume every shade, from an indistinct blush to the 
 most vivid scarlet and the deepest black. In its more intense 
 degrees, the discoloration is seen as soon as you open the cavity 
 of the abdomen, and appears at first to pervade the whole mass 
 of the bowel in the situations which it occupies. Upon further 
 examination, however, it is found to appertain especially to the 
 mucous membrane, and that the essential condition out of 
 which it arises, consists of an inordinate repletion of the minute 
 blood-vessels. 
 
 These discolorations of the mucous membrane were fre- 
 quently remarked in the intestines of those who died at the 
 Penitentiary. They occupied indifferently all situations in the 
 course of the intestinal canal, and often various situations 
 remote from each other in the same individuals. 
 
 They were peculiar, in assuming the form of small patches, 
 which were more distinctly circumscribed, and less shaded off 
 into the surrounding parts than I had been accustomed to see 
 them. There were perhaps, in the course of the intestines, 
 half a dozen of these patches, each an inch or two in diameter, 
 and no more, and of a deep and uniform red, while the mem- 
 brane in its neighbourhood preserved its natural pale colour. 
 Their deep and uniform red gave them the appearance of 
 spots of extravasated blood. When, however, the portions of 
 the intestine to which they belonged were held up to the light, 
 it was manifest that the blood was still contained within the 
 blood-vessels. 
 
 Some died of long-continued and incontrollable diarrhoea, 
 in whom no morbid appearance whatever was found, but a few 
 
THE BOWEL COMPLAINTS. 229 
 
 of these small patches of vascular repletion. In some, these 
 patches occurred together with spots of ecchymosis. 
 
 The ulcers, which were found in the bowels of several who 
 died of this disease, did not occupy especially those situations 
 in which ulcers are most commonly met with, namely, the 
 termination of the small and the commencement of the large 
 bowels, but all situations indifferently. They were generally 
 few in number, and occurred at distant intervals throughout 
 the whole tract of the intestines. Sometimes (most frequently) 
 they did not exceed in diameter the size of a pea, and were of 
 a circular shape. Sometimes they were large and irregular, 
 occupying in diameter a space of one or two inches. They did 
 not appear in the midst of an inflamed surface, but were cir- 
 cumscribed and distinct, while the mucous membrane in their 
 neighbourhood was of a perfectly natural colour. 
 
 These ulcers had a certain correspondence with the ecchy- 
 mosed spots and vascular patches already described. They 
 were of the same size and shape, and, like them, they were 
 found at intervals remote from each other, and without any 
 marks of inflammatory action around them. These considera- 
 tions led to the belief that, what was now an ulcer, had before 
 been a spot of extravasated blood, or a patch of small blood- 
 vessels in a state of congestion, and that one had terminated in 
 the other. The ecchymosed spot, the vascular patch, and the 
 ulcer, were found all three together in the same bodies ; and 
 the two first were sometimes found alone, and sometimes 
 together. But the ulcer was in no instance observed without 
 one or both of the other two. Indeed, the vascular patch was 
 sometimes met with in (what appeared to be) its state of transi- 
 tion into an ulcer. In the space which it occupied, the mucous 
 membrane was rough and unequal to the touch, and, upon close 
 examination, appeared visibly corroded. 
 
 The ulcers were discovered at various stages of their pro- 
 gress in different bodies, and in the same body. Sometimes 
 they had reached as far as the muscular coat of the intestines, 
 and sometimes as far as the peritoneum, which alone remained 
 to preserve the continuity of the bowel in these situations. In 
 a few instances the perforation was complete ; for they had 
 penetrated the peritoneum, and reached the cavity of the 
 abdomen. 
 
230 THE BOWEL COMPLAINTS. 
 
 Generally there was a mere absorption of parts in the space 
 which the ulcer occupied, constituting the simplest kind of 
 ulceration. But occasionally there was something more than 
 this. A foul yellow matter appeared in the centre of the ulcer. 
 This matter was either the sphacelated structure of the howeL 
 itself in the process of separation, or it was a morbid secretion 
 proceeding from the ulcerated surface. 
 
 Those who are conversant with morbid dissections, will 
 certainly not discover anything new in these states of ulcera- 
 tion. ' There was, however, one appearance not unfrequently 
 met with in our examinations, with which I was then unac- 
 quainted, and which (as far as I know) has never been par- 
 ticularly described. This was the appearance of ulcers in the ■ 
 course of their progress towards reparation. It is a question 
 (I believe), whether ulcers of the bowels be capable of repara- 
 tion at all. Here, however, there seemed to be sufficient 
 evidence that they were so. 
 
 In several bodies, which we examined, one, or two, or three 
 little spots were found, corresponding in shape and size with 
 the smaller ulcers, which have been noticed, where there was 
 no remaining character of ulceration, but the mucous membrane 
 apparently drawn and puckered, and its continuous smoothness 
 interrupted. At these spots, closer examination, by help of a 
 lens, discovered a circular margin, which was slightly elevated, 
 enclosing a space which was slightly depressed. This space had 
 a reticulated appearance, formed by minute white filaments of 
 lymph, crossing each other in various directions, among which 
 small red blood-vessels were visible. There was no unusual 
 vascularity of the mucous membrane in the neighbourhood, 
 nor any alteration of its natural colour ; so that these little 
 spots would probably have escaped our notice, had we not been 
 habitually minute in our examinations. In a few instances,, 
 however, we were led to them by observing a peculiar condition 
 of the peritoneal coat, which seemed here and there gathered, 
 up and drawn to a point, appearing externally as if a small 
 portion of the intestine had been taken up by the forceps and 
 tied with a ligature on the inside. Wherever such was the 
 condition of the peritoneum, upon examining the bowel within 
 we found an ulcer in (what I presume to be) the course of 
 reparation exactly opposite to it. It is probable that, where 
 
THE BOWEL COMPLAINTS. 231 
 
 such was the appearance of the bowel externally, the ulcer had 
 originally extended to a considerable depth ; that it had reached 
 perhaps beyond the muscular coat, and that its reparation was 
 in some sort necessarily effected at the expense of the peritoneum. 
 Granulations springing from the bottom of the ulcer, as they 
 contracted and coalesced, would pucker and draw together that 
 part of the peritoneum from which they grew. 
 
 Now it can hardly be doubted, that the conditions which 
 have just been described really arose from ulcers in the course 
 of reparation. They were found in the same bodies with ulcers 
 in a progressive state, and with spots of ecchymosis, and 
 patches of vascular repletion. 
 
 Upon a review of these several morbid appearances within 
 the intestines, it struck me, that not the spots of ecchymosis 
 only, but every morbid appearance which presented itself, had 
 the character of certain partial and chronic eruptions upon the 
 skin, when the whole surface is tolerably healthy, except the 
 space which the eruption occupies. 
 
 Such eruptions upon the skin no remedy can immediately 
 cure. They are curable only through the medium of the con- 
 stitution, out of whose morbid state they arise, and after a long 
 time, and with a choice of all the most favourable circum- 
 stances, it will hereafter appear that, in this respect also, a 
 parallel subsists between them and the morbid conditions of the 
 intestines, which we have been discussing. 
 
 In comparing the symptoms during life with the actual 
 state of disease found upon dissection, there did not appear any 
 very strict correspondence between them. The flux, accord- 
 ing as it partook of the nature of cholera, or dysentery, or 
 diarrhoea, or was of any other kind which has been described, 
 could not be made out to arise from ecchymosis in one case, 
 from congested blood-vessels in a second, or in a third from 
 ulceration. 
 
 There was, however, a certain correspondence between them 
 of a more general character. 
 
 Among the symptoms there was seldom found any vigorous 
 excitement of the constitution at large, any strong pulsation of 
 the arteries, or high inflammatory fever ; and, in the actual 
 state of disease, there was seldom anything calculated to pro- 
 duce them. 
 
232 THE BOWEL COMPLAINTS. 
 
 Among the symptoms, there were those well-marked 
 varieties which are conceived to denote that the disease, whatever 
 its kind be, occupies especially certain portions of the intestinal 
 canal. There was pain combined with great sinking and 
 depression, which bespeaks the disease to be not far from the 
 stomach. Pain combined with less and less of sinking and 
 depression, which bespeaks it to be more and more distant from 
 the stomach ; and pain, which rather rouses and excites, and is 
 augmented in severity until the bowels are relieved, showing 
 the disease to be probably in the large bowels. Hence, before 
 any bodies had yet been examined after death, it was anticipated, 
 that disease would be found in various parts of the intestines, 
 although its precise nature could not be foretold ; and, as soon 
 as dissections were made, such (we have seen) was found to be 
 the fact. 
 
 Still, upon the whole, the disease, as traced out by dissection, 
 was far from affording an entire explanation of the disease, as 
 manifested by symptoms during life. In a few instances, indeed, 
 there was enough to account for protracted illness of the kind 
 we witnessed, and for death ; as when ulcers were found 
 which had destroyed, in various degrees, the texture of the 
 intestines, or some one ulcer which had entirely penetrated 
 them. But, in many instances, certainly in the majority, there 
 was an apparent inadequacy of the cause to the production of 
 such results ; and we were surprised to find a few minute spots 
 where blood was extravasated beneath the mucous membrane, 
 or a few circumscribed patches where blood was detained in 
 the minute blood-vessels, the only visible traces of disease in 
 those who died, after long-continued and incontrollable diarrhoea 
 or dysentery. 
 
 But the entire disease does not always consist in its visible 
 marks upon particular organs. If injury be done to a healthy 
 body, there, indeed, it may ; and its anatomical character simply 
 may become the best criterion, whether it be of easy or difficult 
 reparation. But, where a visible change of structure arises, 
 independent of injury from without, there must be something 
 within the body that preceded, and conduced to it. This some- 
 thing, this inceptive movement, whether it be of the part or of 
 the constitution, which foreruns the actual manifestation of 
 visible disease, will not bear to be spoken of with precision. 
 
THE BOWEL COMPLAINTS. 233 
 
 We talk of cachexies, of constitutional taints, and morbid dis- 
 positions, not knowing how to define what we mean. This, 
 however, we know, that the local diseases which follow the con- 
 ditions we thus designate, upon whatever part of the body they 
 fall, are much more difficult of cure than their mere anatomical 
 character would imply. 
 
 Blood, extravasated in any moderate quantity from local 
 injury, is easily absorbed ; and small blood-vessels, which have 
 become overloaded from the same cause, easily empty themselves. 
 But blood extravasated, and vessels overloaded, when the cause 
 is in the constitution, may long remain so, and reparation be 
 tardy and difficult ; while, in the meantime, there may arise 
 various symptoms of disease, and various hazards of life, accord- 
 ing to the organs which are engaged. 
 
 Now it is certain that, at the Penitentiary, long before the 
 manifest signs of any particular disease had yet appeared, the 
 general health of the prisoners had begun to decline. It was 
 not until February, 1823, that scurvy, and diarrhoea, and 
 dysentery, were found spreading extensively throughout the 
 prison ; but it was in the autumn of 1 822 (as we collected from 
 the officers of the establishment), that the prisoners "became 
 pale, and languid, and thin, and feeble." This universal 
 cachexy (for so it may be called) endured for many months ; 
 yet no man can tell what it was in its essential nature. But, 
 indefinite as it was, it nevertheless was something real ; and, in 
 viewing the disease of the Penitentiary as a whole, this surely 
 claims to be considered as a part of it, and perhaps its most 
 important part ; for, subsisting at first alone, before the more 
 definite forms and symptoms appeared, it was probably this 
 from which they derived their origin; and afterwards still 
 subsisting, in many instances, it was probably this that mainly 
 contributed to retard their cure. 
 
 These symptoms, as they declared themselves through the 
 medium of the bowels, and the actual state of disease found 
 within the bowels, upon dissection, I have already described. 
 I shall now proceed to show how their cure was attempted. 
 
 At the beginning of the month of April, the flux, which 
 had affected between four and five hundred individuals, had 
 almost disappeared, no other remedy having been used but the 
 chalk mixture and tincture of opium ; and, under the influence 
 
234 THE BOWEL COMPLAINTS. 
 
 of an improved diet, the general health of the prisoners had 
 visibly improved. 
 
 But, when the flux of the bowels returned, at the end of the 
 month of April, it was no longer amenable to the same remedies. 
 Not even in those cases, which bore the character of simple 
 diarrhoea, did chalk mixture and tincture of opium procure the 
 smallest relief. No effectual good was derived from practice 
 directed to the simple purpose of restraining the flux, even 
 where this was tbe only indication to follow. 
 
 Still we endeavoured to reach the disease, by addressing 
 our remedies to the more conspicuous symptoms. Where there 
 was pain, aggravated by pressure, and attended with fever, 
 bleeding, or blistering, or fomentations were used, according to 
 the urgency of particular cases. But little abatement, even of 
 the pain, ensued, and none whatever of other symptoms, or of 
 the flux. Where there was simple colic pain, all the methods of 
 soothing were employed, by opium, fomentation, &c, &c. But 
 the consequence was only a brief respite from suffering, while 
 the flux continued. 
 
 When common remedies, directed to the fulfilment of plain 
 and intelligible purposes, did not succeed, we were, in a man- 
 ner, compelled to pursue other less certain indications, and to 
 employ other expedients of less acknowledged efficacy ; such as 
 astringent bitters, aromatics, mucilaginous drinks, antimonials, 
 and ipecacuan. Ipecacuan was given in small doses of a grain 
 or two grains, three or four times a day ; or it was given once 
 or twice only in large doses, of fifteen or twenty grains, com- 
 bined with a couple of grains of opium. Moreover, the root 
 was infused in water, and thus it was employed as a lavement. 
 But, in all modes of its administration, and in every quantity, 
 the result was equally unfavourable to the efficacy of the 
 remedy. 
 
 Grlysters, composed of starch and opium, and of liq. plumbi 
 acetatis dilut. and opium, were administered, with temporary 
 benefit, in a few instances, but they did no permanent good. 
 
 Warm baths were used ; the belly was swathed in flannel 
 rollers ; and stimulant liniments were rubbed upon the abdo- 
 men ; but they did no apparent good. 
 
 It is proper to mention, that the most efficacious remedy 
 (efficacious, I mean, as a palliative, and no more) was an 
 
THE BOWEL COMPLAINTS. 235 
 
 opiate plaster, or rather cataplasm, of which these were the 
 
 ingredients : 
 
 Empl. picis comp. |ijss. 
 
 Empl. plumhi Jss. 
 
 Opii duri contriti 
 
 Olei menthse 
 
 Camphorse ad^j. 
 
 M. 
 
 These ingredients constituted a kind of poultice, which was 
 spread upon folds of linen, and laid upon the abdomen. The 
 effect was to procure sleep, or to maintain a state of drowsiness, 
 or to excite and keep up delirium during forty or fifty hours . 
 The delirium was manifested by continual talking and laughter. 
 
 As long as the nervous system was kept under this influence, 
 the bowels seemed free from pain, and the frequency of the 
 evacuations was greatly diminished ; but, as soon as it threw 
 off its torpor, or lost its unnatural excitement, the pain returned, 
 and the evacuations became as numerous as before. Thus it 
 was evident, that no progress whatever had been made towards 
 the essential cure of the disease. 
 
 Still there was a remedy upon which all our reliance was 
 eventually placed, and that remedy was mercury. 
 
 Owing to considerations which had an unavoidable influence 
 upon our minds, some time elapsed before we resorted to its 
 employment. 
 
 Upon the first appearance of the flux, mercury (as we un- 
 derstood) had been fairly tried in a few cases, and had failed. 
 Upon its first appearance, too, the flux had been combined with 
 scurvy, in a large proportion of all the cases which occurred, 
 and spots of ecchymosis had been found in the bowels of several 
 who died ; and although there were now no longer any scor- 
 butic marks upon the skin, the disorder of the bowels, upon its 
 return, could not be certainly pronounced to have changed its 
 original nature. 
 
 "We abstained, therefore, from the use of mercury, because 
 we suspected at least that we had still to deal with the same 
 disease in which it had been already found prejudicial, and that 
 it might possibly still partake of the nature of scurvy. 
 
 But, after the failure of every other medicine in the treat- 
 ment of this disease, were we justified in abstaining even from 
 
236 THE BOWEL COMPLAINTS. 
 
 the cautious use of a remedy, ■which, its present circumstances 
 especially called for, merely from the recollection of. certain 
 symptoms which had been its concomitants a month ago. 
 
 With regard to mercury, as a remedy in scurvy, writers of 
 authority had denounced it as injurious, and we could not help 
 placing a certain reliance on what seemed to be the result of 
 their observation. But still their theory about putridity and 
 the crasis of the blood had evidently determined their notion of 
 the essential nature of scurvy ; and their theory about septic 
 and antiseptic remedies, had evidently led them to assign to 
 mercury a place among the former. Hence there was room to 
 suspect, that these speculations might possibly have had a share 
 in producing their unqualified condemnation of mercury in 
 scorbutic complaints. So that, even if the scurvy had still been 
 present, in the very slight degree (the slightest possible) in 
 which it formerly existed, I cannot think, when every other 
 remedy failed, that it ought to have been an absolute prohibi- 
 tion of the trial of mercury, after the cautious manner in which 
 we proceeded to employ it. But, in fact, the scurvy had almost 
 entirely disappeared. 
 
 While two hundred individuals were suffering a flux of the 
 bowels at the same time, and many seemed gradually approaching 
 to their dissolution ; and while the numbers of the sick were 
 every day increasing, and the forms of the disease were be- 
 coming more and more various and complex, and all the methods 
 of treatment hitherto employed had served to palliate only, and 
 not to cure, Dr. Roget and myself determined, after mature 
 deliberation, to get rid of all restriction upon our practice, 
 which had arisen from the consideration that the flux was 
 originally combined with scurvy ; and we agreed to employ 
 mercury, in such forms and combinations as the exigencies of 
 particular cases might seem to require. 
 
 We first made trial of this remedy in those cases which our 
 experience had brought us to regard with the greatest appre- 
 hension, cases (if I may so say) of mere passive diarrhoea, 
 where there was no excitement of the circulation, where there 
 was little pain, and little of morbid quality in the evacuations, 
 but where the evacuations were enormously frequent, and 
 hitherto absolutely incontrollable. In these cases all medical 
 expedients had failed, and we were now compelled to content 
 
THE BOWEL COMPLAINTS. 237 
 
 ourselves with such, temporary relief, and such short intervals 
 of ease, as opium, administered in draughts or clysters, or in 
 cataplasms, was able to procure. In our trial of mercury for 
 these cases, we proceeded thus :— Equal quantities of hydrargyr. 
 c. creta and pulv. ipec. comp. were made into pills ; each pill 
 consisted of five grains, two grains and a half of each ingre- 
 dient, and one of them was administered three times a day, to 
 about twenty patients. Still there was no abatement of the 
 diarrhoea. They were administered four times a day, and still 
 the diarrhoea continued. They were given five times a day ; 
 when, upon our next visit to the Penitentiary, we found, among 
 those who had taken mercury, one female in a profuse saliva- 
 tion, and the diarrhoea completely arrested in her, and in her 
 alone. This poor creature had formerly had scorbutic spots 
 upon the skin, at the same time that she suffered a flux of the 
 bowels. The scorbutic spots had disappeared altogether ; the 
 flux had subsided, but returned ; and that form of it, which 
 has been described, had now brought her life into imminent 
 hazard. 
 
 In this instance, the salutary effect of mercury was un- 
 questionable ; and the condition of its success seemed to be, 
 that it had procured salivation. We proceeded, therefore, more 
 boldly in the use of it, still giving it in the same form, and in 
 combination with Dover's powder. We increased the dose to 
 those who already took it ; and, as they became salivated in 
 succession, they were all freed from the symptoms of their 
 disorder. We subjected more and more of the prisoners to the 
 same treatment, watching them carefully in the meantime, for 
 the sake of still more confidently ascertaining the precise con- 
 dition, which was essential to the success of the remedy. This 
 we uniformly found to be the production of salivation. 
 
 Be it remembered that these cases, upon which the salutary 
 effect of mercury was first proved, were those which occasioned 
 us the greatest apprehension. Several of the patients were so 
 feeble and emaciated, so pale and faded in their aspects, that 
 while, on the one hand, we were feeling our way with the 
 mildest preparation of mercury for the purpose of curing their 
 disease, we were, on the other hand, administering wine and 
 cordials for the purpose of upholding their existence. 
 
 The success of mercury, under these unpromising circum- 
 
238 THE BOWEL COMPLAINTS. 
 
 stances, led first to the more general, and, finally, to the universal, 
 employment of it. "We resorted to it in every case of flux, where 
 ■ the remedies hitherto used had not satisfied our expectation. 
 In short, we resorted to it in every case without exception. 
 
 But, as it became more and more obvious, that salivation 
 was the condition of its success, there was no reason for 
 restricting its use to one preparation only. Yet, at the same 
 time, it was not enough that salivation should be procured in 
 any way, gradually or at once, quickly or slowly. 
 
 Experience taught us, that its curative effect depended, in 
 some degree, upon the manner in which salivation was brought 
 about. Hence a choice and a discretion were to be exercised 
 upon the kind of preparation, the quantity and frequency of 
 the dose, and its combination with other remedies. 
 
 "Where the flux was attended with severe tormina, or colic, 
 or cramps at the stomach ; or where the attack was sudden and 
 recent, and accompanied with fever, it was doing nothing to 
 prescribe small doses of hydrarg. c. creta. and Dover's powder, 
 which would produce their effect some days hence. It was 
 expedient that the impression of the remedy should be in pro- 
 portion to the force of the disease, and the rate of its progress. 
 Accordingly, large doses of calomel and opium were given, to 
 make the mouth sore immediately, or as soon as it could be 
 done with safety. 
 
 In several cases, in which the agony from tormina and 
 tenesmus was extreme, and the evacuations were enormously 
 frequent, and consisted altogether of morbid secretions, or blood, 
 fifteen grains of calomel and two grains of opium were given 
 at a dose. 
 
 The patients, to whom so large a dose of calomel was given, 
 were most attentively watched. Especial care was taken, that 
 nothing should divert it from its influence upon the constitu- 
 tion, and that every accidental inconvenience that might 
 accompany its operation should be rendered as tolerable as 
 possible. If the griping increased, they had peppermint 
 water to have recourse to ; if it still increased, they were to be 
 largely and frequently fomented with flannels wrung out of 
 warm water ; and if it still increased, they were to be supplied 
 with small doses of laudanum at short intervals. 
 
 It will hardly be expected, that this single dose of calomel 
 
THE BOWEL COMPLAINTS. 289 
 
 and opium could be effectual to the complete cure of the disease. 
 The degree of relief, which the patient experienced the next 
 day, and the changes which his condition had undergone, in the 
 meantime, determined the manner of proceeding in the further 
 treatment of the case. 
 
 The dose of fifteen grains of calomel and two grains of 
 opium administered under such emergencies as have been 
 described, had almost always the effect of calming the symp- 
 toms ; but the degree of relief it procured was various. 
 
 On the next day, we sometimes found, that the patient had 
 passed an easier night, that the evacuations had been somewhat 
 less frequent, and the tormina and tenesmus had been some- 
 what moderated, but that since the morning, the symptoms had 
 become worse again, the pains were as severe as ever, and the 
 evacuations as frequent, and quite unaltered in their appearance. 
 Under these circumstances, fifteen grains of calomel and two 
 of opium were given a second time. 
 
 Sometimes, the day after the first large dose of calomel and 
 opium, we found the relief, which had been procured through 
 the night, still maintained, and the appearance of the evacua- 
 tions changed in some obvious respect for the better. Perhaps 
 they were now free from all admixture of blood, which they 
 contained the day before. Under these circumstances, half the 
 former dose of calomel and opium was given. 
 
 Sometimes, the day after the first large dose of calomel and 
 opium, we found the patient exulting that he had been cured 
 as by a charm ; that he had slept all night, and his pains were 
 gone ; and that he had had several evacuations, of which the 
 two or three last were almost natural. With this sudden 
 improvement, salivation had either already arisen, or it was at 
 hand. Under these circumstances, the use of mercury was 
 either suspended altogether, or small doses of calomel and 
 opium were given until ptyalism appeared, which was generally 
 obvious at our next visit. 
 
 Our ultimate object, in all cases, was to produce salivation. 
 But, in these cases of severer suffering, we found a salutary 
 impression capable of being immediately produced by a few 
 large doses, or even by one large dose of calomel and opium. 
 This it was expedient to make the most of. Nevertheless, this 
 immediate salutary impression was soon lost, unless the same 
 
240 THE BOWEL COMPLAINTS. 
 
 practice was followed up to salivation; for which purpose 
 mercury was afterwards sparingly or largely exhibited, accord- 
 ing to the circumstances, which have been set forth. 
 
 It was remarkable, that the constitutions of many were 
 most slow and reluctant in admitting the peculiar influence of 
 mercury, and that the disease, in the meantime, was still un- 
 yielding. In such constitutions, after calomel and opium, 
 given internally, had failed of their accustomed effect, arid now 
 served to irritate rather than to soothe the bowels, we resorted 
 to inunction ; and salivation, thus procured, was productive of 
 the same benefits. 
 
 As an object of pathological interest, it was instructive to 
 observe the different modes of curative action, by which, under 
 the influence of mercury, different constitutions set themselves 
 free from their disease. In many the process of cure was so 
 gradual that there was hardly any perceptible action engaged 
 in it. The constitution seemed rather to lose the disease, one 
 symptom after another, than to surmount it by an effort of its 
 own. The pains became gradually less and less, until no pains 
 whatever remained ; and the healthy secretions gradually pre- 
 dominated over the morbid, until all were healthy. 
 
 In many the process of cure was by a sudden, vigorous, and 
 painful effort, when the constitution threw off its disease by a 
 sort of critical paroxysm. Sometimes the critical effort com- 
 menced as soon as the mercurial foetor was perceptible in the 
 mouth. Sometimes salivation would exist twenty-four hours 
 before the crisis began ; and sometimes the crisis preceded the 
 salivation twenty-four hours. But it never took place but 
 where there was salivation at the time, or immediately before, 
 or immediately after. 
 
 The critical effort was of this kind. After a calm, pro- 
 cured by one or two large doses of calomel and opium, or after 
 the employment of inunction for two or three days, the consti- 
 tution would become suddenly roused, and a very severe griping 
 would arise, and then a sensation would follow, as if the bowels 
 were filling and distending themselves with something, and, 
 afterwards, an incontrollable urgency to stool. With the eva- 
 cuation came the relief of all the preceding misery. The stools 
 were entirely changed. A few hours before, they consisted, 
 perhaps, of slime or blood, or some colourless turbid fluid. 
 
THE BOWEL COMPLAINTS. 241 
 
 Now they were a colluvies of the foulest, blackest matter, and 
 of every kind ; heavy ropy mucus and bile formed a consider- 
 able part of them. After one or two such evacuations the 
 patient felt himself entirely restored and well. It generally 
 happened, however, that the same sort of paroxysm returned, 
 and was terminated by the same kind of relief. Thus, after a 
 whole night spent in a succession of these critical paroxysms, 
 the patients were found, the next day, bathed in a warm per- 
 spiration, and fast asleep ; and, from this time, the evacuations 
 from the bowels became natural and healthy. 
 
 Such is the history of our employment of mercury ; and 
 such was its success in the various forms of bowel complaint 
 which have been described. Beset with all those doubts con- 
 cerning the propriety of using it, which the previous history of 
 the disease of the Penitentiary was calculated to suggest, we 
 were, at first, driven to make trial of it by the failure of every 
 other remedy. We began, therefore, and proceeded with the 
 greatest caution, venturing no further than observation did (as 
 it were) lead us by the hand. Thus, gradually making good 
 our ground, we succeeded, at last, in exploring experimentally 
 a very large field ; and learnt how, by varying its preparations 
 and its dose, and varying also its combinations, to adapt this 
 same medicine safely and successfully to the exigencies of the 
 disease under many different forms. 
 
242 THE DISORDERS OP THE BRAIN 
 
 CHAPTER IV. 
 
 THE DISORDERS OF THE BRAIN AND NERVOUS SYSTEM. 
 
 Much still remains to be added to the description already given 
 of the disease prevalent at the Penitentiary, in order to fill up 
 its entire character. Hitherto the description has been chiefly 
 conversant with certain symptoms apparently contingent upon 
 it as a disease of the bowels, and with the treatment which had 
 respect to it as such ; and thus the history of the disease has 
 (as I proposed) strictly kept pace with my own observation and 
 knowledge. For as it was gradually only that it discovered its 
 entire character, so it was gradually only that we learnt to 
 regard it, neither as a dysentery, nor a diarrhoea simply, nor 
 belonging exclusively to the bowels, but pervading other organs 
 and systems of organs, and, in fact, belonging to the whole 
 constitution. 
 
 No part of the disease was more striking and characteristic, 
 none more formidable and difficult to treat, than that which 
 declared itself through the medium of the brain and nervous 
 system. 
 
 In our Report of the 5th of April, 1823, we remarked that, 
 in all who had suffered either scurvy or dysentery, " there was 
 found the same constitutional derangement, denoted by a sallow 
 countenance, an impaired digestion, diminished muscular 
 strength, a feeble circulation, various degrees of nervous affection, 
 as tremors, cramps, or spasms, and various degrees of mental 
 despondency." Now these various nervous affections are here 
 mentioned, only as symptoms of constitutional weakness ; for 
 in that light they were certainly regarded by us at the time. 
 It is true, two prisoners had already died suddenly, after symp- 
 toms immediately referable to the head, and some instances had 
 already occurred of very frightful convulsions. But hitherto 
 we saw no reason to conclude that these cases had any essential 
 connexion with the predominant disease. In process of time, 
 
AND NERVOUS SYSTEM. 243 
 
 however, disorders of the brain and nervous system became 
 more and more frequent, and of various kinds, head-aoh, ver- 
 tigo, cramps, and twitching of the limbs, delirium, convulsions, 
 and apoplexy, But since these disorders did not immediately 
 discover themselves in all their variety and magnitude, it was 
 not until after much" observation, that we were enabled to tell 
 their genius and character, and to know that they constituted 
 one form of the predominant disease ; that they were not con- 
 tingent upon the flux, nor the flux contingent upon them ; that 
 either might exist separately, although they were generally 
 found in combination ; and that both arose from a morbid condi- 
 tion, essentially the same, but falling upon different parts. 
 
 I shall best convey a notion of what these nervous affections 
 were, by following the order of my own experience concerning 
 them, and describing them as they fell under my own obser- 
 vation. 
 
 Upon our visiting the Penitentiary, out of seventy men, 
 whom we found in the infirmary, there were five who had no 
 other complaint but severe head-ach, three who had no other 
 complaint but cramp in the limbs, and one who had cramp in 
 combination with diarrhoea ; and, out of ninety-three women, 
 whom we found in the infirmary, thirteen had simple head- 
 ach, three had no other complaint but cramp, and five had 
 head-ach combined with diarrhoea. We did not, however, from 
 these cases, at all suspect that the predominant disease involved 
 the brain and nervous system. 
 
 "We had not, however, been in attendance more than a week, 
 when a man (Robert Dyer), thirty-one years of age, in the 
 infirmary, and suffering cramp and diarrhoea, died suddenly, 
 apoplectic. Upon dissection, we found the vessels of the brain 
 slightly turgid with blood, and a few spots of ecchymosis in 
 the intestines, although there had been no scorbutic appearance 
 upon the skin. 
 
 About ten days afterwards, a woman (Harriet Church), 
 twenty- six years of age, whom we had found in the infirmary, 
 suffering head-ach, began to exhibit a strange per ver sen ess, 
 which was rapidly aggravated to mania, and she died. Upon 
 dissection, no morbid appearance was found beyond a very 
 slight congestion of the blood-vessels of the brain ; so slight, 
 that its existence might be doubted. 
 
244 THE DISORDERS OP THE BRAIN 
 
 Soon afterwards, as we were one day going round the infir- 
 maries, our attention was called to a young woman (Louisa 
 Cornforth) who was suffering the most agonizing spasms. Her 
 legs and arms were as rigidly tense as in tetanus. Suddenly 
 she gave a loud shriek, and her eyes were fixed, and she became 
 as pale as death. No pulse could he felt, and her breathing 
 was only just perceptible. By aether and ammonia, and all the 
 means of stimulating within our reach, we succeeded in rescuing 
 her. In two or three minutes perhaps (but it is not easy to 
 reckon time on such occasions), we could feel the pulse beginning 
 to undulate, and see the countenance beginning to redden, so 
 that it was evident that the blood was in motion again. Then 
 her eyes began to pass from object to object, and it was plain 
 her consciousness had returned. She could not yet speak ; but, 
 by inarticulate sounds, and by the motion of her hands around 
 the heart and stomach, she made us understand, that it was 
 there the sudden agony had seized upon her. This young 
 woman survived six weeks ; and, in the meantime, all her 
 dreadful symptoms frequently recurred, and her existence was 
 upheld, from hour to hour, by the most potent stimulants. If 
 she was left more than a certain period, without a small quan- 
 tity of brandy, her pulse became imperceptible ; but it was felt 
 again, as soon as the stimulus was again applied. And, in this 
 manner, even for as long a time as six weeks, existence was 
 still maintained, while it was continually tottering upon the 
 verge of dissolution. Before her death, diarrhoea was added 
 to her other complaints. Upon dissection, nothing was found 
 at the origin of the nerves, to account for the dreadful symptoms 
 referable to them. At intervals, throughout the intestines, 
 there were small circumscribed patches of, red, occasioned by 
 blood accumulated in the small blood-vessels ; but there was no 
 ecchymosis. 
 
 These three cases occurred in the month of March ; and, 
 occurring (as they did) among various other nervous affections, 
 they may be thought to have excited in us a suspicion, at least, 
 that the disease of the Penitentiary did not belong exclusively 
 to the bowels. Still we wanted further experience, to assure 
 us of the fact. 
 
 Early in the month of April, the bowel complaints and the 
 scurvy, in which the peculiar disease of the Penitentiary (as 
 
AND NEEVOUS SYSTEM. 245 
 
 we then thought) exclusively consisted, almost entirely disap- 
 peared. The scurvy, indeed, never returned ; but the bowel 
 complaints returned before the end of April, and spread 
 throughout the prison more extensively than before. With 
 them there appeared nervous affections of every kind, and of 
 that kind especially, which betrayed itself in cramps of the 
 muscles. The character and the frequency of these cases were 
 very remarkable. They occurred both to those who had, and 
 those who had not, bowel complaints, to men as well as women ; 
 but it was in the women that, from their severity and the 
 frightful circumstances accompanying them, they occasioned us 
 the greatest alarm. 
 
 Many women were affected nearly in the same manner as 
 Cornforth had been, and our apprehension was that they would 
 all come to the same miserable end. They had cramps in the 
 limbs and in the trunk. A few had that indescribable agony 
 at the heart, and the pit of the stomach, bringing with it those 
 frightful circumstances which seemed to threaten instant disso- 
 lution. Their life was again and again brought into jeopardy ; 
 but one only (Sarah Farley) eventually died. 
 
 Upon our first visiting the Penitentiary, we found this young 
 woman (her age was only twenty-three) slightly affected with 
 scurvy, and complaining of diarrhoea, which she had suffered 
 •occasionally for many weeks. As she became convalescent 
 from these disorders, there arose a succession of complaints in 
 every part of her body, and with them that frightful agony at 
 the pit of the stomach, which occurred in the case of Cornforth. 
 It was not a sinking merely, but an evident spasm, attended 
 with severe pain. She lingered, too, in the same manner as 
 Cornforth, and her existence was upheld by brandy and 
 laudanum, but not for so long a time. For several days previous 
 to her death, a remarkable lividity appeared upon the extreme 
 parts of her body. Upon dissection, small vascular patches 
 were found in the mucous membrane of the intestines and 
 nothing more. 
 
 Now, in all such cases, where there had already been 
 cramps of the voluntary muscles, and sudden pains within the 
 •chest, or at the pit of the stomach, followed by a failure or 
 suspension of the circulation, it must necessarily be believed, 
 
246 THE DISOEDEES OF THE BEAIN 
 
 that an impression was communicated through the nerves 
 expressly to the heart. 
 
 One instance occurred where, without previous spasms of 
 the extremities, or pains within the chest, and without any- 
 forewarning symptoms, the functions of the heart were suddenly 
 suspended, and the patient died. 
 
 Charles Thomson (aged twenty -nine) had suffered a degree 
 of scurvy, which was comparatively severe. He was one of 
 the few in whom the extravasated blood had formed large 
 blotches upon the legs ; whereas, in the generality, it had 
 appeared only in spots or specks. Of the scurvy, however, no 
 traces now remained. He had also suffered diarrhoea, from a 
 period long before we first visited the prison in the month of 
 March, with short respites, down to the month of June. His 
 bowel complaint still continued in a mitigated degree. He was 
 much emaciated, and his feebleness confined him almost con- 
 stantly to bed. He was in a very preoarious state, but he did 
 not yet bear the marks which denote the near approach of death. 
 
 On the 24th of June, I had been speaking with this poor 
 fellow about his complaints, and he had distinctly told me he 
 was better ; when, feeling his pulse, I remarked extraordinary 
 intervals between the beats. I called to Dr. Roget, who was at 
 the bedside of another patient, to come and feel it ; and while 
 I was in the act of passing his hand from my own to Dr. Eoget's, 
 his head fell back, and, to all appearance, he was dead. 
 
 We believed he was actually so. We applied warm fomen- 
 tations over the whole surface of the body. Still there were no 
 signs of life. Several persons were employed together in 
 rubbing and irritating the extremities. It seemed as if several 
 minutes had ^passed, and still he was dead ; but a tinge of red 
 was now seen running along his lips, which was the first sign 
 of life ; and then he breathed, and then his pulse became per- 
 ceptible. With life, sense and consciousness were not imme- 
 diately restored; and, as soon as the circulation was re-established, 
 there arose a violent convulsion of the whole body. When we 
 left him, on this day, he was yet insensible. The next day we 
 found him sensible, but learnt that he had had several convul- 
 sions. On the next day he died. Upon dissection, little patches 
 of vascular congestion were found in various parts of the 
 mucous membrane of the intestines, mixed with small circum_ 
 
AND NERVOUS SYSTEM. 247 
 
 scribed ulcers; also, increased vascularity of the brain, and 
 fluid effused between its membranes, and into the ventricles. 
 The heart was free from disease. 
 
 Among other cases of nervous affection, there were several 
 of phrenitis. To a sudden and acute pain in the head was 
 added, first, vertigo, then bewilderment of the intellect, then 
 twitching of the tendons, then strabismus, and dilated pupils, 
 and lastly, distortion of the mouth and hemiplegia. These 
 symptoms sufficiently indicated what the disease was. But, 
 unfortunately, we looked in vain for other symptoms which, in 
 ordinary cases ■of phrenitis, are accustomed to indicate what 
 the remedy should be. In almost every case the pulse was most 
 feeble. There was the disease, without the force of the circula- 
 tion, which is deemed essential to maintain it. There was the 
 disease, and, at the same time, a prohibition of the remedy, 
 which is deemed essential to its cure. Happily, as these cases 
 . became more frequent, we learnt an effectual method of treating 
 them. In the meantime, we proceeded, in great perplexity, 
 adapting (as we could) common methods of treatment to the 
 exigencies of these extraordinary cases. In a few, we ventured 
 to try the effect of bleeding from the arm, sitting by the patient 
 while the operation was performed; and thus, perhaps, when 
 four or five ounces of blood had flowed, the pulse would falter, 
 and we were compelled to stop ; or we were compelled to stop 
 when hardly a single ounce had been lost. I am sure there 
 was. no good derived from this practice, but, with all our 
 cautions, I am not sure there was no evil. We put leeches 
 upon the forehead, and found them of very uncertain effect. It 
 was to extensive blisterings upon the head, and in its neigh- 
 bourhood, that, for the present, we were obliged mainly to 
 trust ; and these remedies would check the symptoms, and post- 
 pone the progress of the disease, if they were fortunately em- 
 ployed so as to take effect at the time of its earliest formation. 
 From this insidious inflammation of the brain, we lost two 
 females, both of whom would, in all human probability, have 
 been saved, if they had been submitted to the treatment which 
 we eventually found successful. Upon their examination after 
 death, we found an universal vascularity of the encephalon, 
 and fluid effused between the membranes of the brain, and into 
 the ventricles. 
 
248 THE DISORDERS OF THE BRAIN 
 
 In process of time, disorders referable to the brain and 
 nervous system prevailed, almost as extensively throughout the 
 prison, as bowel complaints. In the majority of cases, indeed, 
 they did not reach the formidable character which has been 
 just described. They consisted, for the most part, of pain, and 
 strange sensations in the head, and cramps of the limbs. But 
 to this mere head-ach was superadded, so often and so suddenly, 
 vertigo, or delirium ; and to these mere cramps of the limbs, 
 was superadded, so often and so suddenly, a more terrible spasm 
 of some internal organ, that we could not help seeing, in the 
 minor affections, a tendency to some fatal result*. 
 
 Sometimes, in going round a division of the prison, where 
 the patients had all been in a state of improvement the day 
 before, we found a dozen in bed, and were told, that they had 
 severe pain in their heads, and that some were so giddy as to 
 be unable to stand. The next day, perhaps, three or four of 
 them had become delirious, and had twitching of the muscles, 
 and were rapidly passing into that formidable state which has 
 been described. 
 
 There were instances of individuals falling down suddenly, 
 as if they were shot (thus the seizure was described by the by- 
 standers), who, being brought into the infirmary, gradually 
 rallied, and referred to the head as the seat of severe uneasiness. 
 In these cases, no symptoms of a more formidable kind ensued, 
 in respect of the brain or nervous system. A permanent head- 
 ach, or vertigo, was the common consequence. 
 
 The description and the instances, which have been given, 
 plainly imply disease of the brain and nervous system, dis- 
 turbing the functions of the different organs to which their 
 influence extends. 
 
 If that part of the disease which belonged to the bowels, 
 from its great extent, from the strangeness and diversity of its 
 forms, and its intractability, under every form, by common 
 remedies, was formidable, this part, which belonged to the 
 brain and .the nervous system, was surely not less so ; for it, 
 too, had put on many unusual shapes. It was daily increasing 
 in extent, and was already found unmanageable by ordinary 
 methods of treatment. 
 
 Moreover, the frequent suddenness of the attack threw a 
 peculiar terror around many such cases, which was communi- 
 
AND NERVOUS SYSTEM. 249 
 
 cated to their fellow-prisoners, who were looking on, and ex- 
 pecting themselves to be the next victims. The frightful 
 sufferings of Louisa Cornforth and Sarah Farley, and the 
 sudden death of Charles Thomson, struck such dismay into the 
 sick prisoners, occupying the same wards, as was not easily 
 appeased. It was expressed in their looks, and by their con- 
 duct, and especially by an aggravation of the form of disorder 
 (whatever it was) that each was suffering at the time. This cir- 
 cumstance is peculiarly worthy of remark, since it raised new and 
 unexpected obstacles to the medical management of the sick. 
 
 Thus far the flux of the bowels, and the disorders of the 
 brain and nervous system have been spoken of separately, as if 
 they were essentially distinct, and their occasional occurrence 
 in the same individuals was merely accidental. In process 
 of time, however, a belief arose of some natural alliance sub- 
 sisting between them. As soon as the disorder of the brain 
 and nervous system became co-extensive with that of the bowels, 
 it had an equal claim to be regarded as the disorder of the Peni- 
 tentiary; and, as soon as both were not only co-extensive 
 throughout the prison, but co- existent in the same individuals, 
 almost constantly and inseparably, insomuch, that hardly an 
 instance occurred of one being present without the other ; and, 
 moreover, as soon as the sole remedy of the one was found to 
 be the sole remedy of the -other, there seemed to be enough to 
 constitute the requisite proof, that they were, in a certain sense 
 (and that the most important sense) one and the same disorder. 
 
 Disorders may be different in the manner of declaring 
 themselves, and may go by different names, according to the 
 organs which they involve ; and yet they may have in common 
 one morbid condition of the system at large, from which they 
 are derived, rendering them the same in their origin, and re- 
 quiring them to be treated by the same remedy. 
 
 Thus does Nature often bring together what nosologies and 
 artificial arrangements have put farthest asunder ; and thus 
 does it become possible, that convulsions and dysentery, although 
 in their symptoms they are absolutely unlike, may be essentially 
 the same, and curable by one and the same remedy. 
 
 It remains to speak of the various disorders of the brain 
 and nervous system, and of the various kinds of flux, as they 
 were found in combination. For the manner of their alliance 
 
250 THE DISORDERS OP THE BRAIN 
 
 in the same individuals, and certain conditions which they pos- 
 sessed in common, seemed especially to lead to the belief that 
 they were, in the sense which has been intimated, the same 
 disease. 
 
 One condition, common to both, was the frequent sudden- 
 ness of their accession ; and there was an alarm connected with 
 it which rendered it the more observable. Those who, to-day, 
 were quite free from pain and disorder of the bowels, and 
 appeared with the aspect, and with the perfect consciousness of 
 health, to-morrow we found purging blood, or pure bile, or a 
 turbid, watery fluid, and completely beat down and mastered 
 by their disease ; and, in like manner, those who, to-day, had the 
 same appearance and consciousness of health, and were alert 
 and cheerful, and working at their trades, to-morrow we found 
 so giddy, that they could hardly stand, or confined to bed with 
 racking pains in the head, with twitching of the tendons, or 
 cramps of the muscles, or even with delirium . 
 
 Here was an instant transition from the midst of health to 
 the midst of disease in both. 
 
 But where the accession of the disease, either as it belonged 
 to the brain and nervous system, or to the bowels, was not thus 
 instantaneous, still there was often a condition common to both 
 in the character of their premonitory symptoms. 
 
 There was a pale, and faded, and ^melancholy aspect, which, 
 in process of time, had become so familiar to us, as the har- 
 binger or attendant of the disease in all its forms, that we were 
 accustomed to select from among the prisoners those in whom 
 it was most conspicuous, and send them into the infirmaries, for 
 the sake of having them more constantly under our observation. 
 Wherever this well-known aspect appeared, it was certain that 
 the symptoms of real disease would soon arise ; it might be 
 from the bowels, or it might be from the brain and nervous 
 system ; and, in fact, it was as often from one as the other. 
 
 As to the alliance of these diseases in the same individuals, 
 no form of nervous complaint was more common than head-ach 
 and vertigo, and they were often combined with the bowel 
 complaint in the following manner : 
 
 The attack was introduced by simple head-ach or vertigo, 
 the bowels yet remaining in a perfectly natural state. Some 
 of the patients thus affected, when the head-ach and vertigo 
 
AND NERVOUS SYSTEM. 251 
 
 were not urgent, were simply brought into the infirmary and 
 watched ; all medical treatment being postponed for the pre- 
 sent. Others, in whom they were more severe, were bled with 
 leeches, or blistered, or had such common remedies administered 
 to them as they seemed to require. But every patient, almost 
 to a man, some the next day, some (the greater number) in 
 two or three days, and some at a more distant period, were 
 overtaken by some species of flux. The flux followed, whether 
 the head was relieved or not, and when the flux was established, 
 the head-ach or vertigo continued or ceas.ed indifferently. 
 
 Another, and a frequent combination of nervous disorder 
 with bowel complaint, was the following : 
 
 Certain sudden seizures have been mentioned, arising from 
 the brain, in which the patients were laid prostrate, at once, 
 with some circumstances of alarm. These seizures were by no 
 means of rare occurrence ; and all who were thus attacked, if 
 they were not suffering a bowel complaint at the time, were, to 
 a man, inevitably overtaken by it in a day or two. 
 
 But this head-ach, or vertigo, or this sudden seizure, did 
 not, in all cases, necessarily lead the way ; often they came on 
 in the midst of the bowel complaint, and at any stage or period 
 of it. 
 
 The disorders referable to the head were not combined espe- 
 cially with any particular kind of flux. They were not more 
 frequently found in cases which partook of the nature of cholera 
 and dysentery, or in cases where there was fever and excite- 
 ment of the circulation, than in those of slow passive diarrhoea, 
 where the pulse was in its natural state, and the tongue per- 
 fectly clean. 
 
 Further, they did not seem to have their duration or their 
 degree of severity at all determined by the character of the 
 flux. Where the bowel complaint was of the mildest kind, and 
 the shortest duration, the disorder of the head was often the 
 most severe and the most abiding, and vice versa. 
 
 What has been said of the head-ach, and vertigo, and the 
 sudden seizures referable to the brain, and the manner of their 
 alliance with the flux of the bowels, may be said, with equal 
 truth, of every other nervous affection which has been described. 
 
 The cramps of the extremities, and the internal spasms, 
 and the order of symptoms constituting a low phrenitis, were 
 
252 THE DISORDERS OF THE BRAIN 
 
 found to proceed, or to attend upon, any period or stage of the 
 flux indifferently, and to belong indifferently to any kind of it. 
 
 The cramps of the extremities were not exclusively, and 
 scarcely in a more remarkable degree, attendant upon the cases 
 of cholera, than upon other cases of bowel complaint. 
 
 "With respect to the morbid appearances found in the bodies 
 of those who died of such forms of nervous disease as have 
 been described, I regret not to be able to speak with the pre- 
 cision I could wish. 
 
 They who are accustomed to dissections, will agree with 
 me, where the question is concerning slight watery effusions in 
 any part of the body, that it is difficult to form an accurate 
 judgment of their nature, if a considerable period has elapsed 
 since the death of the patient. At the General Penitentiary, 
 as in all prisons, a coroner's inquest was held upon the bodies 
 of those who died, and no dissection was permitted until their 
 verdict was returned. Hence three or four days elapsed before 
 we could make our examinations. 
 
 The appearances upon dissection have been already antici- 
 pated. "What we found, when we found anything, was some 
 degree of vascular fulness of the brain and its membranes, 
 and some watery effusion between the membranes, and into 
 the ventricles. Both were generally inconsiderable. 
 
 There were instances in which, during life, the symptoms 
 were expressly referable to the brain, and in which death had 
 taken place, by an immediate interruption of its functions, 
 where, nevertheless, upon dissection, we found nothing in the 
 brain or its membranes apparently different from natural and 
 healthy structure. 
 
 No examination was made of the spinal canal. The requi- 
 site means of doing it successfully were not at hand as in an 
 hospital. I regret the omission ; but tbe circumstances already 
 mentioned, as calculated to perplex our judgment concerning 
 what was found in the brain, would also have stood in the way 
 of any satisfactory inference drawn from appearances of the 
 same kind in the spinal marrow. 
 
 As, during life, the symptoms referable to the brain, and to 
 the intestinal canal, were found to co-exist, for the most part, 
 in the same individuals ; so, after death, changes of structure 
 were found, for the most part, in both organs. Hence another 
 
AND NEKVOUS SYSTEM. 253 
 
 confirmation is added to the belief, that the diseases of both 
 had a natural alliance, and in their origin were essentially the 
 same. 
 
 Experience convinced us that common methods of treatment 
 were not to be trusted, for any effectual good they could do to 
 these various nervous disorders. They either failed entirely, or 
 they fell short of the salutary impression they are accustomed 
 to produce upon the same symptoms, occurring under ordinary 
 circumstances. 
 
 It has been already intimated, both what the means were 
 that proved unsuccessful, and what the principal remedy was 
 upon which our reliance eventually rested. There is no need, 
 therefore, to dwell long upon the details of treatment. It will 
 be enough to state the general results of the practice adopted, 
 and to make some few reflections upon the character of the 
 disorders in question, to which the extraordinary failure of all 
 the most probable means of cure, and the success of this par- 
 ticular remedy, seem naturally to conduct. 
 
 There are ailments concerning which physicians hardly 
 allow themselves to feel the smallest anxiety, holding (as they 
 conceive) in their own hands the almost certain means of their 
 relief. When, however, such ailments unexpectedly resist the 
 remedies which are accustomed to cure them, they cannot help 
 suspecting that there is more to contend with than the mere 
 symptoms seem to imply. Thus simple pain in the head they 
 are apt to think lightly of, until it is found incapable of relief 
 by common remedies. Of such intractable cases the number 
 (it has been seen) was very large at the Penitentiary. 
 
 Of pain in the head, accompanied by vertigo, they are apt to 
 think a little more seriously, but still not very seriously, until 
 simple remedies bring no relief ; and intractable cases of this 
 kind, also (it has been seen) were very frequent at the Peni- 
 tentiary. 
 
 Again, there are many, even acute diseases of vital organs, 
 which physicians always regard with great apprehension, but 
 which, with the advantage of seeing and treating them early, 
 they nevertheless have a good expectation of bringing to a 
 favourable termination. When, however, even with this 
 advantage, they absolutely fail in every case that presents itself, 
 they cannot help experiencing some perplexity, and suspecting 
 
254 THE DISORDERS OP THE BRAIN 
 
 that there may he more in these diseases than they have heen 
 able to discover. Thus, when to pain in the head or vertigo, 
 there are superadded cramps of the muscles, or twitching of the 
 tendons, or delirium, or strabismus, they look upon the cases 
 constituted of these symptoms with the greatest apprehension 
 of the result ; and there were (it has been seen) a few such 
 cases at the Penitentiary. But even in the cases constituted of 
 these symptoms, they do not look upon death as inevitable, 
 until the remedies, upon which they are accustomed to rely, 
 fail to make their ordinary impression. And thus it happened 
 with the few cases of this kind at the Penitentiary ; they passed, 
 uninterruptedly, to their fatal termination, their symptoms 
 hardly receiving the smallest check or abatement from the 
 remedies employed. 
 
 Now, before we resorted to the use of mercury for the various 
 forms of the disease prevalent at the Penitentiary, the state of 
 the prison, in regard to that form of it which involved the 
 brain and nervous system, was this : — Seven had already- 
 perished under our own observation ; of whom one died apo- 
 plectic, one maniacal, two with the symptoms of phrenitis, two 
 from cramps referable to the region of the stomach and the 
 heart, and one from symptoms belonging in part to the heart 
 and in part to the brain ; and there were not less than two 
 hundred now labouring under various degrees of disorder 
 belonging to the same organs. Of them a few only were 
 dangerously ill in respect of the magnitude of their symptoms. 
 These few were suffering that insidious form of phrenitis 
 already described, while we were checking the symptoms and 
 postponing the progress of their disease, with little hope of 
 eventually saving their lives ; and unquestionably, they were 
 in great present peril. But all the rest, though not in immi- 
 nent danger from the magnitude of their symptoms, gave just 
 cause for anxiety, from the consideration that they had not 
 been cured by any means hitherto employed, and moreover that 
 they were under the same conditions of disease through which 
 the seven had passed, before they reached their fatal consum- 
 mation. 
 
 Such was the state of the prison in respect to the disorders 
 in question ; and it may well be conceived that, under great 
 apprehension for the event of all these cases, and under great 
 
AND NERVOUS SYSTEM. 255 
 
 present alarm for a few, we sought most anxiously for the 
 means of their more successful treatment. 
 
 At this time many patients, in whom mercury was first 
 successfully employed for the cure of diarrhoea, were likewise 
 freed from certain obscure nervous complaints ; some from 
 head-achs, and some from vertiginous sensations. This occur- 
 rence, while it served to strengthen the belief that the flux 
 of the bowels, and the nervous affections, had a natural alliance, 
 and were, in some sort, the same disease, determined us to give 
 the same remedy a fair trial in its application to both. 
 
 And first, we most eagerly resorted to its use in those cases 
 which occasioned us the greatest present alarm, viz. in three 
 cases of insidious phrenitis. The patients already suffered 
 subsultus of the tendons, and delirium, and one had strabismus. 
 If life was to be rescued, it could only be by giving the 
 remedy in such a manner as to bring the constitution as 
 speedily as possible under its influence. Accordingly, as much 
 calomel was prescribed, in repeated doses, and in combination 
 with opium, as procured salivation in thirty hours ; whereupon 
 the most formidable symptoms were at once dissipated, and the 
 patients were left in a condition favourable to recovery ; and 
 they eventually did recover. 
 
 Next we resorted to its use in certain cases which occasioned 
 us peculiar perplexity, and some apprehension of distant con- 
 sequences, but no present alarm. There were many individuals 
 in whom an affection of the head had been originally combined 
 with bowel complaint. The bowel complaint had been very 
 slight, and of short duration, and had ceased altogether during 
 many weeks. But the affection of the head had been very 
 severe ; and although it had obtained a few respites from 
 common remedies, it still remained unmitigated ; and at length 
 all our medical expedients had lost the little temporary influence 
 which they once possessed. There was every motive for trying 
 the effect of mercury in these cases, and it was tried, and suc- 
 ceeded. 
 
 One of these cases was peculiarly striking, and is well worth 
 relating as an example. Upon our first visit to the Peniten- 
 tiary, on the 1st of March, we found, among the patients in the 
 infirmaries, a young man of the name of Eobson. He was 
 twenty-one years of age ; and told us that he had suffered a 
 
256 THE DISORDEES OF THE BRAIN 
 
 head-ach of the most excruciating kind during several months. 
 His sight was dim, and he had a constant twinkling of the eye- 
 lids, and great agony was depicted in his countenance. He 
 had moreover that faded, pale, and melancholy aspect already 
 alluded to. Yet the functions of his bowels were performed 
 naturally. His tongue was clean, and his pulse was of the 
 natural frequency and strength. At this time the alliance 
 between the disorders of the nervous system and the bowels was 
 hardly ascertained ; therefore no inquiry was made whether he 
 had suffered diarrhoea. Subsequently, however, we learnt 
 that, during the preceding winter, his bowels had been twice 
 slightly disordered for a few days. This poor fellow was under 
 our constant observation and treatment, from the beginning of 
 March to the end of June. He gained no respite from his 
 agony, but by means of leeches applied to the forehead, day 
 after day, for a week together, or by blisters kept open, or 
 applied in quick succession behind the ears, or on the nape of 
 the neck ; and the respite thus obtained was of short duration : 
 it might be for ten days ; it was never longer than a fortnight ; 
 and then the same agony returned, and the same cruel treatment 
 was to be resumed. In this case we eagerly resorted to the 
 use of mercury ; salivation was procured and maintained, to a 
 certain degree, during several weeks. "Whereupon the patient 
 was released from his misery, and ever afterwards, during 
 eleven months that I had the opportunity of watching him, he 
 continued free from complaint of every kind. 
 
 The beneficial influence of mercury upon that part of the 
 disorder of the Penitentiary, which belonged to the brain and 
 nervous system, soon became as unquestionable as upon that 
 which belonged to the bowels. It was proved upon the various 
 forms, both of one and the other, and most conspicuously upon 
 that form of each which occasioned us the greatest present 
 alarm. 
 
 Before the use of mercury, it was impossible to contemplate 
 the state of the prison, and not consider an extensive mortality 
 as inevitable. Experience of its effects during a fortnight 
 entirely changed our anticipations of the result, and encouraged 
 a hope that, with great care and vigilance in its administration, 
 the mortality would still be kept within narrow bounds. Thus, 
 for every species of nervous complaint, as well as for every 
 
AND NERVOUS SYSTEM. 257 
 
 species of flux, whether they were combined or separate (for 
 either might occur alone, although they were generally found 
 together), we were led by our own experience to the employ- 
 ment of mercury. 
 
 Seeing that the head-ach and vertigo were often the first 
 symptoms, and that they often subsisted a considerable time 
 alone before the accession of others, we thought it expedient to 
 begin the treatment of the disease, as soon as it showed itself 
 under this form, by our most efficient remedy. Our experience 
 hitherto had been, that these affections of the head, when they 
 were the first to declare themselves, were very seldom controlled, 
 or in any way relieved by common remedies, and that, whether 
 they were relieved or no, the flux almost inevitably followed. 
 Treated with mercury, however, in the great majority of 
 instances, they ceased ; and, where they did cease under such 
 treatment, in the great majority of cases, no flux followed. 
 
 Thus did this remedy effect the relief of both disorders, 
 when they appeared in combination, and of each, when either 
 occurred alone ; and, in the latter case, under such circum- 
 stances occasionally, that it seemed to prevent the accession of 
 the other. 
 
 In our administration of mercury for the relief of these 
 complaints, we observed that, in the great majority of cases, no 
 striking abatement of symptoms took place, until salivation 
 was procured. Whether the very salivation itself was essential 
 to the cure, cannot be determined ; but being the only sensible 
 effect of the remedy, with which the cure could be connected, 
 it served us for guidance in the administration of it. Hence it 
 always was our purpose to obtain salivation. 
 
 But we did not observe, upon the whole, that the abatement 
 of symptoms was connected with any certain degree of salivation. 
 Therefore we were, in every case, content with any, the least 
 degree of salivation, under which they would disappear. 
 
 As in regard to the various bowel complaints, so in regard 
 to the various nervous disorders, the condition most essential to 
 the success of the remedy was unquestionably this, that the 
 force and rate of its impression should be in proportion to the 
 force and rate of the disease. And the chief object of our 
 care was to preserve that proportion. 
 
 Thus, where the disease was less severe, and was slow in its 
 
258 DISOEDEES OP THE BEAIN AND NEBVOTJS SYSTEM. 
 
 progress, salivation (without reference to its degree) was to be 
 procured gradually ; where the disease was more severe and 
 rapid in its progress, salivation (without reference to its 
 degree) was to be procured at once. Head-ach and vertigo 
 which had come on tardily, and had abided many weeks, 
 without any perceptible excitement of the circulation, were 
 to be made to yield under the slow and alterative influence 
 of mercury, which the constitution could bear without in- 
 jury. Head-ach and vertigo which had been sudden in their 
 accession, were accompanied with excitement of the circulation, 
 and already seemed to threaten something beyond themselves, 
 as convulsion, or delirium, or phrensy, were to be at once 
 mastered by such a sudden and powerful impression of the 
 remedy as the constitution would severely feel. Hence the 
 quantity of the remedy was continually varied, according to the 
 exigencies of particular cases. For some we prescribed one 
 grain or two grains of calomel, with a small quantity of opium, 
 once or twice in twenty-four hours, and thus succeeded in pro- 
 curing relief after the lapse of a week or ten days ; doing no 
 harm, in the meantime, to the general health and sensations of 
 the patient. For others, we prescribed five, or ten, or even 
 twenty, grains of calomel, with proportionate quantities of 
 opium, once, or even twice in twenty-four hours ; and thus 
 succeeded in dissipating the symptoms at once, and in rescuing 
 life at the expense of some present injury to the constitution. 
 
THE FEVEK. 259 
 
 CHAPTER V. 
 
 THE FEVEE. 
 
 When I was describing that part of the disease of the prison, 
 which consisted of intestinal flux, I inquired how far it was 
 attended by the symptoms which usually accompany such com- 
 plaints, and serve to illustrate their nature. And with respect 
 to fever I stated, " that it was present in a few cases, but that 
 the majority were entirely free from it, and that, where it did 
 occur, its symptoms only reached a very moderate degree of 
 excitement." Now wherever, in cases of flux, and (I mayadd) 
 in cases of disorders of the brain or nervous system, fever was 
 present, the manner of their alliance was such as to raise a 
 doubt, whether the fever was derived from the local disease, or 
 the local disease from the fever. 
 
 For my own part, I believe that a fever arose at this time in 
 the prison, which was sui generis and idiopathic, however its 
 character might be obscured by an association with those forms 
 of disease which have been mentioned. When this fever 
 occurred alone (as it sometimes did, even at the time when the 
 bowel complaint, and the disorders of the brain and nervous 
 system were most prevalent), its type was manifestly peculiar. 
 It was a fever of very moderate excitement, and generally went 
 off in three or four days by perspiration. Or, if it failed of 
 such relief, either spontaneously or by the help of medicine, it 
 was apt to be protracted in the form of hectic during several 
 weeks. When this fever occurred (as it generally did) in 
 combination with some form of bowel complaint, or some affec- 
 tion of the brain or nervous system, its own peculiar type was 
 still visible, notwithstanding certain differences which it exhi- 
 bited correspondent with the disorder of a particular organ. 
 
 Further, since the fever and the local affection did not bear 
 the same relation to each other in the different cases where they 
 were found combined, it might hence be suspected that they 
 
260 THE FEVEE. 
 
 had no necessary alliance. Thus, in some the fever would first 
 arise, and the flux would follow, perhaps immediately, perhaps 
 not for several days, or perhaps not until the fever had been 
 protracted in the form of hectic for several weeks. In some the 
 flux would arise first, and then the fever would follow, perhaps 
 immediately, or perhaps not until the flux had become a chronic 
 disease. 
 
 But still, while the flux of the bowels and the disorders of 
 the brain and nervous system prevailed to their largest extent, 
 the cases of fever were rare. It was not until these complaints 
 began to subside, that the fever showed itself, in a sufficient 
 number of cases at once, to make us accurately acquainted with 
 its type. At no time did it pervade the prison to an equal ex- 
 tent with the other two forms of disease. But its extent, 
 nevertheless, was such, that it had a just claim to be considered 
 as a part of the disease of the Penitentiary ; and the manner in 
 which it was mixed up with the disorders of the bowels, and 
 the brain and nervous system, led to the belief that they had 
 all a natural relation to each other, and that they all sprang 
 from one and the same morbid condition of the constitution at 
 large, and were all, in some sort, the same disease. It remains 
 for me to give a more precise description of this fever, both 
 alone, and in its combinations. 
 
 In many cases, a slight shivering, followed by heat and 
 langour, and want of appetite, and a pulse ranging between 
 ninety and a hundred, constituted the whole disease, and the 
 use of common salines constituted its whole treatment. The 
 patients being put to bed, began to perspire, and in three or 
 four days they were well, with little loss of strength. Thus far 
 it was the mildest and the most manageable fever I had ever seen. 
 
 In many cases, to the common symptoms of fever, were 
 added pain at the pit of the stomach and head-ach ; which 
 together constituted the whole disease. In these cases, an 
 emetic, or a brisk purgative, followed by saline medicines, 
 operated a speedy and effectual relief. Thus, when the stomach 
 and bowels were cleared, and perspiration promoted, the 
 patients were well in three or four days, with little loss of 
 strength. 
 
 Now, with two or three exceptions, in which the lungs were 
 affected, and haemoptysis took place, the stress of the disease fell 
 
THE FEVEE. 261 
 
 (if upon any particular organ) always either upon the stomach 
 or bowels, or upon the brain, or upon both together ; and in 
 those who died, the brain, or the stomach and bowels, presented 
 traces of recent disease. For the symptoms referable to these 
 parts, mild as they generally were, yet were aggravated to an 
 alarming degree in several instances, and were rapidly fatal in 
 a few. A relation of some cases, in which these symptoms 
 reached their greatest pitch of severity, will best serve to show 
 the formidable character under which the disease occasionally 
 presented itself. 
 
 A young woman (Mary Chapman), aged twenty-six, was 
 attacked, like the rest, with the common symptoms of fever, 
 except that she had a shivering fit, which was remarkably 
 severe. After which, there arose a sudden and excruciating 
 pain in every part of the abdomen, a vomiting of bilious matter, 
 and a profuse purging of matter like tar. The patient sank at 
 once into a state, from which it was evident that she could 
 never rally. Her countenance was pale and full of terror ; and, 
 if she was moved, she was ready to faint away. After the 
 lapse of twelve hours her pulse was imperceptible, and she was 
 thought to be dying. Nevertheless, she survived four days ; 
 and, in the meantime, nothing could be attempted but to uphold 
 life by such small quantities of wine or brandy as she could 
 take. On the third day, her constitution in a manner re-acted, 
 and her countenance was a little flushed. Soon afterwards her 
 respiration became stertorous, and her mouth was a little dis- 
 torted, and then she died. 
 
 After the first gush of matter from the bowels, no further 
 evacuations took place spontaneously, or could be procured by 
 medicine. There was no tension of the abdomen, but, on the 
 contrary, it was flat and soft to the last. Upon opening the 
 cavity of the abdomen we found, here and there, throughout 
 the whole course of the intestines, from the stomach to the 
 rectum, large and extensive vascular patches, all of a very dark 
 colour, and some absolutely black. The great end of the 
 stomach, and the whole of the duodenum, were intensely black. 
 The small intestines were, in several places, puckered up and 
 contracted, for the space of an inch ; and wherever these con- 
 tractions were found, the bowel was of a deep black colour. 
 "Within the cavity of the abdomen, a small quantity of fluid 
 
262 THE FEVEK. 
 
 blood (about two ounces) was found. It seemed to have exuded 
 from the surface of the duodenum, just where its last turn 
 commences, and especially from that part of it which is un- 
 covered by peritoneum. It was just in this situation that the 
 blood was found, and this part of the intestine was soaked in it. 
 There was no effusion of lymph, or of any other fluid within 
 the peritoneum, but the blood above-mentioned. 
 
 The stomach, being opened, was found empty ; and, at its 
 great end, the mucous membrane seemed in one uniform state 
 of ecchymosis. But this was not really the case ; for when the 
 stomach was held up to the light for inspection, it was evident 
 that no extravasation had taken place, and that the apparent 
 ecchymosis was occasioned by every vessel, great and small, in 
 this part of the organ, being filled and gorged with blood. 
 There was also this same appearance of ecchymosis in the 
 mucous membrane of the duodenum, occasioned by a condition 
 of the blood-vessels essentially the same. Upon the valve of 
 the pylorus, however, there were three small spots, where blood 
 was actually extra vasated. At the various spaces of the small 
 intestines, which were black from without and contracted, there 
 was the same apparent ecchymosis of the mucous membrane, 
 which was, in fact, a remora and accumulation of blood within 
 the blood-vessels. The whole tract of the intestines was filled 
 with a matter resembling tar. 
 
 In the whole course of the bowels there was only one small 
 ulcer. This was in a part of the small intestines, most free 
 from vascularity, and seemed to be undergoing a process of 
 reparation. 
 
 The vessels of the brain and its membranes were loaded 
 with blood. But there was no effusion of fluid anywhere 
 within the cranium. 
 
 This case occurred among many other cases of fever, in 
 which symptoms were present expressly referable either to the . 
 stomach and bowels, or to the head, or to both. It could not 
 but be regarded, therefore, as essentially the same, although it 
 was distinguished from the rest by the extraordinary severity of 
 those symptoms, and the L rapidity with which it passed to its 
 fatal termination. 
 
 In the following case the fatal symptoms were more ex- 
 clusively referable to the brain : — J 
 
THE FEVEK. 263 
 
 It was our custom to visit occasionally the various apart- 
 ments of the Penitentiary, to examine the prisoners who were 
 professedly well, and to select from among them, for the purpose 
 of placing under medical observation, any whose looks seemed 
 to threaten the approach of illness. In one of our visits to 
 the laundry, we found a young woman huddled up among some 
 dirty linen, and lying upon the boiler, fast asleep. The fire of 
 the boiler was put out, but some warm water still remained in 
 it. Being roused, she looked strange and bewildered, but made 
 no specific complaint. She said, " I only feel cold at times, and 
 this is a good way of warming myself." The other women in 
 the laundry considered that not much was the matter with her. 
 As to lying upon the boiler, they told us, it was a fancy of 
 her's, and she often did it. 
 
 Nevertheless, from this very feeling of cold which she 
 described, and from her general appearance, we thought fit to 
 remove her into the infirmary. Here we soon found that this 
 sense of cold was the beginning of a fever. The next day her 
 skin was hot and her tongue dry. The following day the stress 
 of the disease had fallen upon the brain, and her head was in 
 continual agony. As long as she retained her senses, she 
 described the head-ach as most distracting. Then delirium 
 arose, and the pulse lost all its power. And before a week had 
 elapsed, she died with stertorous breathing, and with symptoms 
 much akin to apoplexy. 
 
 The name of this woman was Mary Yenables ; she was in 
 her twentieth year.* 
 
 But there were a few cases of fever nearly resembling those 
 two fatal ones just described, and even approaching to them in 
 the severity of the symptoms referable to the head and the 
 abdomen, which nevertheless did well. 
 
 In many cases, after the common harbingers of fever, and 
 at the time when the symptoms of re-action were expected, 
 there arose a pain, like a fixed and unshif ting cramp, at the pit 
 
 * I am not able to find the note taken of the morbid appearances, upon 
 examination, of this patient. As far as I can trust myself to speak from 
 recollection, the brain and its membranes were loaded with blood ; fluid 
 was effused into the ventricles, and between the membranes ; and there 
 were vascular streaks and patches in the mucous membrane of various 
 parts of the bowels, but no ulceration. 
 
264 THE FEVER. 
 
 of the stomach, and with it a most distracting head-ach ; while 
 the region of the scrobiculus cordis was most impatient of 
 pressure. Whereupon the pulse became very frequent and 
 feeble, and the countenance pale and full of terror. Clammy 
 perspirations broke out, and brought no relief; and extreme 
 sense of anguish seized upon the patient, and if he was moved 
 he was ready to faint away. In this condition there was some- 
 times a spontaneous discharge of dark-coloured morbid colluvies, 
 upwards and downwards, which put an end to the extremity of 
 distress. Sometimes there was a discharge of turbid water 
 only, by vomiting and stool, which was ineffectual for any 
 purpose of relief. Sometimes there was a most painful retching, 
 a striving in vain (as it should seem) without vomiting, and con- 
 sequently no relief. 
 
 The further description of these cases shall be accompanied 
 by a description of their medical treatment, since it will serve 
 to illustrate their nature. 
 
 It has been said, that there was sometimes a spontaneous 
 discharge of dark-coloured morbid colluvies, upwards and 
 downwards, which put an end to the extremity of distress. 
 Hence it seems probable that, in the case of Sarah Chapman 
 (described above) "the vomiting of bilious matter, and the 
 profuse purging of matter like tar," constituted in themselves 
 a curative effort. But the magnitude of the disease (as it 
 appeared upon dissection) was insurmountable ; and Nature, in 
 the struggle for relief, went beyond the purpose which she 
 intended, and thus occasioned a complete exhaustion of her 
 own powers, from which she could never afterwards rally. An 
 effect of the same kind, and produced in the same manner, is 
 occasionally seen in certain critical haemorrhages. 
 
 But as to the cases now in question, as soon as there was a 
 spontaneous gush of morbid secretion, upwards and downwards, 
 then the cramp at the pit of the stomach, and the distracting 
 head-ach ceased, and the pulse rose, and an universal warm 
 perspiration followed. 
 
 Seeing then through what channels Nature succeeded in 
 operating her own relief, we endeavoured, where there was 
 need for the interposition of medicine, always to direct the 
 remedies towards the same channels. Thus, when there was a 
 discharge of turbid water only, by vomiting and stool, or an 
 
THE FEVER. 265 
 
 ineffectual retching, and nothing rejected, and the distressing 
 head-ach still remained, and the cramp was still fixed at the 
 pit of the stomach, we sought by medicine, to procure the eva- 
 cuation, from the stomach and bowels, of matter of a different 
 kind, without which (as we conceived) there would be no 
 relief ; and this was effected by purgatives, but not by purga- 
 tives simply. If purgative medicine alone was given, the 
 evacuations were increased in quantity, but their quality 
 was still the same. But if the means, calculated to soothe 
 and to abate pain, were first successfully employed, together 
 with the remedies calculated to dispose the bowels to remit 
 their morbid action, then the administration of purgatives 
 compassed the end we desired. Thus, first by leeches applied 
 to the pit of the stomach, and by fomentations of the whole 
 abdomen, with flannel wrung out of warm water, and by 
 two or three grains of calomel, given every hour, or every 
 other hour, for three or four successive times, and lastly 
 (after all these several remedies had been daily administered), 
 by a drachm of sulphate of magnesia, given hour after hour, 
 until the bowels were moved, we seldom failed to bring away 
 copious evacuations of a foul and dark-coloured colluvies, and 
 thus to dissipate the severe epigastric pain, and the distracting 
 head-ach, and with them all the danger of the disease.* 
 
 * These cases were so peculiar in themselves, and the mode of relief, 
 whether spontaneous or by the help of medicine, was so striking, that I 
 may be permitted (in a note, at least) to make a few observations upon 
 their probable pathology. 
 
 Formerly much stress was laid upon "turgid matter" and "morbid 
 colluvies " in the first passages, as a cause of fevers ; and certain distinc- 
 tions of symptoms were thought to indicate that this colluvies was 
 " pituitous " in one case, and " bilious " in another. At present, medical 
 men are content to speak in more general terms of an accumulation of 
 '■ morbid secretions," still regarding them as the cause of disease, and 
 directing remedies for their removal. Emetics are given, and foul matter 
 is rejected by vomiting. Purgatives are given, and the same is passed by 
 stool. In consequence of which, the previous symptoms cease, or are 
 greatly mitigated ; and thus the theory is confirmed. 
 
 Nevertheless it may still be doubted whether the popular notion be 
 correct respecting the actual condition of the stomach, at the time the 
 symptoms referred to it are most intense ; and still more, whether the 
 matter rejected be really the " materies morbi," the accumulation of which 
 produced the symptoms, which cease upon its evacuation. 
 
 It consists better with sound pathology to believe that, at the period of 
 
266 THE FEVER. 
 
 Now, upon these cases I have been induced to dwell more 
 at large, on account of the express and paramount indications 
 of treatment contained in certain peculiar symptoms which 
 belonged to them. These cases, however, were not essentially 
 of a different type from the fever that prevailed in the prison 
 at the same time. In them, indeed, its type was obscured or 
 obliterated by the accession of the symptoms in question, 
 
 the severest local pain and severest constitutional disturbance, there is 
 hitherto no accumulation of morbid matter within the stomach, but that its 
 blood-vessels are engaged in a morbid process, which, if its termination is 
 favourable, will be finally resolved by a gush of foul secretion from their 
 extremities. 
 
 That it is not anything extraneous to the blood-vessels which produces 
 the symptoms, but the blood-vessels themselves by their own morbid 
 action, is rendered probable by the relief which leeches often procure, when 
 they are applied to the skin immediately over the seat of the pain ; also by 
 the relief more effectually obtained by remedies which have an express 
 influence upon the blood-vessels, being employed together with purgatives, 
 than by purgatives alone ; for instance, by several doses of calomel, given 
 in succession, at short intervals, and followed by senna or jalap, than by 
 senna or jalap alone. 
 
 Further, a spontaneous vomiting will sometimes bring away from the 
 stomach nothing but a turbid water, and a spontaneous purging will some- 
 times bring from the bowels nothing but a fluid which is thin, pale, and 
 inodorous. Hence no relief follows. This striving of Nature is premature 
 and ineffectual. 
 
 Moreover, emetics and purgatives will procure sometimes mere watery 
 evacuations, upwards and downwards, and . thus fail altogether of their 
 curative effect. 
 
 The fact seems to be, that the vessels must first pour out the morbid 
 colluvies into the stomach, before it can be rejected out of the body. This 
 its separation from the blood-vessels is the first and principal curative 
 effort; its expulsion by vomiting or purging is secondary and consequential, 
 and curative only in a less degree ; but still necessary. Emetics and 
 purgatives, so administered, as simply to procure its rejection out of the 
 body, do good, in assisting the last process of the cure ; but emetics and 
 purgatives, so administered, as first to aid its separation from the blood- 
 vessels, and then its rejection from the body, conspire with Nature in every 
 purpose she endeavours to effect, from the first to the last. 
 
 It appears, therefore, most probable, both from the course of the 
 symptoms themselves, and from the efforts of Nature for her own relief, 
 from the remedies, and from the conditions of their successful operation, 
 that the disorder of the stomach, described as incident to the early stage of 
 fever, is caused and maintained by a morbid action of a peculiar kind, in 
 which its blood-vessels are engaged at the time. 
 
THE FEVEK. 26.7 
 
 derived from the stomach and the brain. The sudden ex- 
 haustion, the clammy sweats, the rapid, feeble pulse, and pale 
 countenance, were derived from both; while the stomach 
 betrayed jts disorder more immediately by severe pain and 
 vomiting, or fruitless efforts to vomit ; and the brain, by pain 
 and delirium, or hurried and oppressed breathing, or diminished 
 sensibility. But when the severe distress, belonging imme- 
 diately to the stomach and the brain, and the overwhelming 
 symptoms derived to the constitution at large, through the 
 medium of these organs were dissipated ; if the fever still 
 remained, it put on the same character, and pursued the same 
 course with the fever of other cases, in which such symptoms 
 had never appeared. 
 
 Now, the fever of the Penitentiary, both when it was a 
 simple fever from the beginning, and when it was attended, 
 from the beginning, by symptoms of the milder sort referable 
 to the epigastrium and the brain, did generally disappear alto- 
 gether within a week. But in some cases it was protracted 
 beyond that period. Moreover, this fever, when it was attended, 
 from the beginning, by the severer symptoms referable to the 
 epigastrium and the brain, unless it proved fatal (as it did in a 
 few cases) within a week, was generally brought to a favour- 
 able termination within the same, period. But, in some cases, 
 it still continued its course. 
 
 Here, then, it must be observed, as a thing most remarkable, 
 respecting this fever, that whatever had been its character and 
 progress hitherto, if it was continued into a second week, the 
 type which now belonged to it was the same in all cases, viz. 
 the type of hectic. It was constituted of heat and perspiration, 
 going and coming with little intermission, and a frequent pulse. 
 
 "When the fever arrived at this stage, we were at first dis- 
 posed to leave it henceforward entirely to itself, administering 
 no medicine, either with a view of abating the symptoms, or of 
 pushing the patient into health ; for the symptoms seemed such 
 as would spontaneously wear themselves out. Experience, 
 however, soon taught us the necessity of a more active inter- 
 ference ; for the fever, being left to itself, contrary to our ex- 
 pectation, showed no disposition to cease spontaneously. "We 
 were compelled, therefore, to resort to tonic remedies, and found 
 them more beneficial the earlier the period at which they were 
 
268 THE FEVEE. 
 
 administered. The salutary effect of such remedies was most 
 strikingly manifest in those cases, where the accession was 
 marked by symptoms of peculiar severity referable to the head, 
 or the epigastric region. After these symptoms were dissi- 
 pated, by the means already pointed out, and simple fever re- 
 mained, bark and acid were required to prevent that fever from 
 becoming a slow hectic of many weeks' duration. And, if the 
 hectic had already begun, and continued for a time, bark and 
 acid were the medicines which sustained the patient under it, 
 and brought him safely through it. 
 
 I mention bark and acid more expressly, because from posi- 
 tive experiment it is certain that these remedies did good, while 
 wine and (what are called) diffusible stimulants did harm. The 
 employment of bark, to a good purpose, on the fourth or fifth 
 day of fever, may, perhaps, startle modern apprehension ; but 
 the necessity of it, and its success in these cases, were unques- 
 tionably proved. 
 
 In the cases in question, the whole secret of conducting the 
 fever to a successful termination consisted — first, in not being 
 deterred from using plentiful evacuations in the earliest stages, 
 on account of the sudden pallor, and f aintness, and feeble pulse, 
 and apparent exhaustion (symptoms derived from the present 
 oppression of particular organs) ; and next, in not withholding 
 bark and acid (remedies which sustained without heating) as 
 soon as the evacuations had relieved the internal oppression, 
 and nothing but the fever and its symptomatic sweats re- 
 mained. 
 
 Thus I have described the complaints prevalent at the 
 General Penitentiary, as they fell under my own observation. 
 These were a scurvy, a flux of the bowels, a disorder of the 
 brain and nervous system, and a fever. All four, from their 
 extent and frequency, had a claim to be considered the disorders 
 of the prison ; and the manner in which they were often com- 
 bined in the same individuals, and the way in which they were 
 taken up and succeeded by each other, induced the strongest 
 belief that they all sprang from the same cause, and were, in a 
 certain sense, the same disease. This belief was further con- 
 firmed, in respect to two of them, the flux of the bowels, and 
 the disorder of the brain and the nervous system, by the con- 
 sideration that they were both amenable to one and the same 
 
THE FEVER. 269 
 
 remedy, and (as far as our experience Vent) intractable by 
 any other. 
 
 "What then (it may be asked) was the essence of the disease, 
 considered as a whole? Of the inceptive error, or primary 
 morbid action, from which it arose, I am entirely ignorant ; 
 whether it belonged to the blood-vessels, or the nerves, or to 
 what particular organ, or system of organs. I only know that 
 its first cognizable effects were seated in the blood-vessels, and 
 that they consisted both in the admission of blood into their 
 capillaries, beyond the natural sphere of the circulation, and in 
 its transmission through their capillaries out of the sphere of 
 the circulation altogether ; that the consequences were ecchy- 
 mosis of the skin, and ecchymosis and vascular patches of the 
 mucous membrane of the stomach and intestines, and deter- 
 minations of blood to the brain and its membranes, and (pro- 
 bably) to the spinal marrow; and that, out of these, arose 
 diseases which obtained different names, according to the man- 
 ner of their occurrence and the parts upon which they fell, 
 such as the scurvy, and the various species of flux, and the 
 various species of nervous disorder, and some forms of fever, 
 all of which were nevertheless still the same disease in the 
 conditions of. their production. 
 
 I am well aware, that the essence of the disease must have 
 consisted in something prior to these effects, and productive of 
 them. But the present state of our knowledge does not enable 
 us to ascertain what it was ; and, indeed, the search after the 
 essence of any disease, beyond the point at which it begins to 
 fall within the reach of the senses, has seldom brought the 
 pathologist to any more certain conclusion than this, viz. that 
 it consists in "a morbid disposition or action, which is sui 
 generis." 
 
270 INTEECUEBENT DISEASES. 
 
 CHAPTER VI. 
 
 INTEECUEEENT DISEASES. 
 
 Theee were certain other complaints in the prison at the same 
 time, which were remarkable for their frequency, and some 
 which were peculiar in their character. But whether they had 
 any natural alliance with the reigning disorders, or were merely 
 accidental, I cannot tell. Cases of erysipelas were constantly 
 arising, and upon the whole were numerous. They were all 
 slight cases, yet they lingered in their cure, although- they all 
 did well. An affection, not unfrequent among the females, was 
 an inflammation and swelling of the labia pudendi. It was 
 accompanied by a smart febrile attack, which lasted two or three 
 days, and uniformly terminated in the formation of abscess, 
 without further inconvenience. Accidental sores and bruises 
 were, with difficulty, brought to heal ; and one young woman, 
 whose hand had been injured by pearl-ash, suffered a sloughing 
 of the integuments of the fore-arm, by the spreading of the 
 sore. In several individuals, the application of leeches to the 
 surface produced extensive extravasations of blood beneath the 
 surrounding cuticle. This effect was most remarkable in a boy 
 (John Shaw, aged seventeen), who, during a painful and pro- 
 tracted illness, required their application to different parts of 
 the body, at various times ; and in all these parts a blotch of 
 ecchymosis spread from the leech-bite, as a centre, to a con- 
 siderable distance. Nearly the whole thigh became black, in 
 consequence of half-a-dozen leech-bites. The ailment, for 
 which the poor boy required this treatment, was itself peculiar, 
 and deserves a brief notice. 
 
 Early in May, he suffered an inflammation of the con- 
 junctiva, which was cured by leeches. In the middle of the 
 month, he had severe pain in the head, which was relieved by 
 leeches. Next he had inflammation near the knee-joint and 
 shoulder- joint, and an inflammation and swelling opposite to 
 the sacrum, which required the same treatment, and eventually 
 
INTERCURRENT DISEASES. 271 
 
 matter formed in all these situations ; lastly, the whole thigh 
 became swelled, and painful, and hot, requiring the same treat- 
 ment, until a large quantity of pus, mixed with blood, was dis- 
 charged. These abscesses continued to form, in succession, 
 during six weeks, accompanied by fever, of great intensity and 
 excitement, and wherever a discharge took place, it continued 
 ever afterwards. The poor boy died exhausted, on the 7th 
 of July. 
 
 Another prisoner (George Prior, aged nineteen) suffered the 
 same kind of disease with Shaw, but in a more chronic form. 
 In the middle of the month of March, he had a soft tumour 
 beneath the scalp, opposite to the left parietal bone. Soon 
 afterwards, he had another soft tumour opposite one of the ribs. 
 They were both about the size of a hen's egg. He became 
 feverish, and his strength declined. The tumours were punc- 
 tured, and pus was discharged; and for several months the 
 punctured orifices still continued open, and matter still came 
 away. Afterwards, another soft tumour was formed opposite 
 the sacrum, and became an abscess. He eventually died con- 
 sumptive, on board one of the hulks, at "Woolwich. 
 
 At the Penitentiary, there were some cases of diseased 
 joints, where the complaint appeared a mere rheumatism in its 
 commencement, but soon put on a more formidable character. 
 In one instance especially, under the most careful treatment, 
 with the advantage of rest and change of air, the knee-joint 
 was rendered useless, and active disease, which would probably 
 render the boy a. cripple for life, was still going on, after the 
 lapse of several months. 
 
 Now, I do not wish to lay an undue stress upon these cases. 
 Unquestionably, occasional cases such as these are met with 
 elsewhere; and under ordinary circumstances, when it is quite 
 in vain to inquire their cause. But when, in the midst of an 
 epidemic, certain other diseases, occurring at the same time and 
 under the same circumstances, yet not obviously connected with 
 it, have an unusual course and termination, we cannot help 
 suspecting that the same cause which engendered the epidemic, 
 may have impressed upon them their peculiar character ; 
 especially if that character is such as to bring them into a 
 similitude with the epidemic, as far as in their own nature they 
 are capable of being thus approximated. 
 
272 INTERCURRENT DISEASES. 
 
 It was the custom of Sydenham (whom it is safe to regard 
 both as an authority and an example), after he had described 
 the epidemics of particular seasons, to dwell shortly upon 
 certain other complaints, which had happened at the same 
 time, and which he called intercurrents. In so doing, he would 
 show how, by the force of the predominant influence, their 
 character was sometimes altered into a kind of conformity with 
 the reigning disease ; and thus he considered them as furnishing 
 as strong a proof of the existence of such an influence as the 
 epidemic itself. 
 
 These observations contain all tbe commentary I wish to 
 make upon the preceding cases, and, at the same time, explain the 
 reasons why I thought it necessary to take some notice of them. 
 
 To them, however, I must add one case more. It created 
 great interest at tbe time, and some alarm lest this kind of 
 disease should not be limited to a single case. 
 
 S. "W. (middle aged), a nurse in one of the infirmaries, a 
 large, corpulent woman, with a most florid countenance, and an 
 habitual drinker of spirits, became suddenly ill. She had 
 buboes in the left groin, and, at the same time, a bunion on 
 the great toe, from the irritation of which' the buboes were 
 thought to proceed ; and so, indeed, tbey might, for there was 
 a streak of red running up the leg and thigh. The skin about 
 the glands in the groin began rapidly to inflame. Fever arose, 
 and with the fever spots of ecchymosis were scattered over the 
 inside of the left thigh. The spots became more and more 
 numerous, spread round the limb, and coalesced into one large 
 patch, which became completely black. In the meantime spots 
 of the same kind appeared on other parts of the body, on the 
 other leg and thigh, on the hands and arms, and loins and back. 
 They coalesced here and' there into large patches, and were 
 universally black. Then there was purging of blood; not a 
 copious discharge of unmixed blood, but of blood tinging other 
 matter evacuated from the bowels. The pulse sank so as to be 
 scarcely perceptible. The buboes in the groin inflamed and 
 suppurated and sloughed, and emitted a horrible foetor. The 
 cuticle over the ecchymosed patches was, in several parts of 
 the body, raised into vesicles. The hands and feet became cold. 
 Still the intellect was perfect; the stomach hitherto had not 
 failed, and she was continually upheld with wine and brandy. 
 
INTERCURRENT DISEASES. 273 
 
 Five or six days were occupied by the disease passing 
 through these stages, and arriving at this condition, which 
 seemed hopeless. From this condition, however, the constitu- 
 tion made a vigorous effort to rally. The pulse first became 
 perceptible, and then a little warmth returned to the skin. The 
 discharge from the buboes changed its quality, the foetor abated, 
 the slough was thrown off, and the edges of the wound became 
 firm and healthy. The spots and patches of extra vasated blood 
 changed from black to brown, and their margins were florid. 
 The vesicated cuticle peeled off, leaving no sore, and a new 
 cuticle was formed beneath it. 
 
 Under these favourable changes, it was still necessary to 
 uphold the circulation by brandy. It was thought one day 
 that the brandy might be dispensed with. It was so. But 
 the next morning her pulse had become so much more feeble, 
 and the circulation was so obviously leaving the extremities, 
 and the patient was altogether so sunk, that the brandy was 
 again eagerly resorted to, and with effect ; for in a few hours 
 the extremities became warm again, and the pulse rose. 
 
 There were still various changes favourable and unfavourable 
 for a week. The favourable, were the improved complexion 
 of the wound, and the partial fading of the ecchymosed spots. 
 The unfavourable, were an occasional coldness of the extremities, 
 and the impossibility of sustaining the circulation but by the 
 continual administration of brandy. This was a state of things 
 that could not last long. By continual watching, however, 
 she was still kept alive, until, on the 20th day from the com- 
 mencement of her disorder, she died. 
 
 Upon examination, after death, the intestines were of a 
 dusky brown colour externally, while they exhibited, at irre- 
 gular distances, spots and patches which were absolutely black. 
 This appearance was derived from the condition of the mucous 
 membrane, which was generally loaded with blood, but in a 
 very few places only in a state of ecchymosis. Some portions 
 of the bowel, that were of the deepest black, being held up to 
 the light for examination, showed distinctly that the blood was 
 contained within its vessels. The number of ecchymosed spots, 
 throughout the whole tract of the intestines, did not exceed six, 
 and the size was not greater than the diameter of a pea. They 
 all appertained to the mucous membrane. In the ilium, just at 
 
 T 
 
274 INTERCURRENT DISEASES. 
 
 its termination with the caecum, there was a very superficial 
 ulceration of the mucous membrane, about two inches in cir- 
 cumference. The valve of the caecum was especially loaded 
 with blood. 
 
 The liver was pale ; the spleen was exceedingly soft. In 
 the chest, numerous spots of ecchymosis were found upon the 
 pleura covering the ribs of both sides. Their size varied from 
 a mere speck to a patch two inches in diameter. On the peri- 
 cardium, both on its loose and reflected portions, the same 
 appearances of ecchymosis were very strikingly exhibited. 
 
 This case appeared to me of sufficient importance to require 
 that all its particulars should be recorded as they were noted 
 down at the time. I know not with what form of the pre- 
 dominant disease it ought to be classed, and therefore I have 
 placed it alone. There, is, indeed, an extreme possibility that 
 it was merely an accidental case, and that the patient might 
 have suffered in the same manner wherever she had been. But 
 taking the most prominent symptoms, and the morbid appear- 
 ances found upon dissection together, we must consider them 
 as furnishing an almost certain proof that the disease was 
 essentially the same with the reigning disease of the prison, 
 and had derived itself from the same source. 
 
EXTENT OP THE DISEASE, ETC. 
 
 275 
 
 CHAPTER VII. 
 
 REVIEW OF THE EXTENT OF THE DISEASE AT DIFFERENT 
 PERIODS — UNCERTAINTY RESPECTING ITS CAUSES. 
 
 The following Tables will serve to show the extent of the 
 disease, from the numbers under medical treatment, at dif- 
 ferent periods during the month of May, June, and July : — 
 
 Prisoners under Medical Treatment, on the 15th of May, 1823: 
 
 (111 
 
 Diarrhoea < Better 
 
 (Well .. 
 Other complaints .. 
 
 Total . 
 
 46 
 48 
 49 
 21 
 
 164 
 
 44 
 87 
 20 
 30 
 
 181 
 
 90 
 135 
 
 69 
 51 
 
 345 
 
 On the 23rd of May: 
 
 (111 
 
 Diarrhoea < Better 
 
 (Well .. 
 Other complaints . . 
 
 Total . 
 
 MEN. 
 
 WOMEN. 
 
 TOTAL. 
 
 63 
 
 46 
 
 ... 109 
 
 51 
 
 56 
 
 ... 107 
 
 64 
 
 47 
 
 .... Ill 
 
 24 
 
 36 
 
 59 
 
 202 
 
 185 
 
 386 
 
 On the 11th of June : 
 
 
 MEN. 
 
 (111 
 
 73 
 
 Diarrhoea < Better .. 
 
 86 
 
 (Well 
 
 82 
 
 
 24 
 
 Total . 
 
 265 
 
 WOMEN. 
 
 35 
 
 38 
 
 189 
 
 TOTAL. 
 108 
 
 124 
 
 170 
 
 52 
 
 454 
 
 (111 
 
 Diarrhoea < Better 
 
 (Well .. 
 Other complaints .. 
 
 On the 3rd of July: 
 
 MEN. 
 
 17 
 
 70 
 179 
 
 8 
 
 WOMEN. 
 
 22 
 37 
 83 
 
 22 
 
 TOTAL. 
 
 39 
 
 107 
 
 262 
 
 30 
 
 Total . 
 
 274 
 
 164 
 
 438 
 
276 REVIEW OF THE EXTENT OF THE 
 
 In these Tables we designated as " 111," those whose disease 
 was either progressive or sta tionary ; as "Better," those who 
 had already lost some symptoms of their disease, and made 
 some advance towards health ; and as " Well," those who 
 were well, so far as they were free from the symptoms of 
 disease, yet not strictly well, inasmuch as they were judged still 
 prone to relapse, and were still the subjects of medical obser- 
 vation and care.- 
 
 It is necessary to observe, respecting these Tables, that they 
 are the same which were presented to the committee. In them 
 diarrhoea alone is mentioned, being put for every species of 
 flux which bas been described, and no separate enumeration is 
 made of nervous complaints and of fevers, which have been 
 considered as the disease of the prison, equally with the flux of 
 the bowels. The fact is, it was late before we ourselves arrived 
 at the conclusion that they were really so. Hence, when they 
 occurred alone (and this was rarely the case), they were placed 
 among the " Other Complaints," or accidental disorders of the 
 prison, until they were certainly known to be peculiar to it ; 
 and when, as it happened in the great majority of cases, they 
 were combined with bowel complaints, it was thought enough 
 to specify that which was the more notorious disease. 
 
 Thirty prisoners died at the Penitentiary while Dr. Roget 
 and myself were in attendance ; of whom thirteen were men, 
 and seventeen women. Twenty-two fell victims to the disease 
 in some of its forms, and the remaining eight to complaints 
 which had only a suspected connexion with it, or none 
 at all. 
 
 Of the thirteen men — 
 
 7 died of the various species of bowel complaints. 
 
 2 „ of disorders of the brain and nervous system. 
 
 2 „ of fever. 
 
 1 „ of abscesses, which had a suspected connexion with the 
 reigning disease. 
 
 1 „ of struma, which had no connexion with it. This man died 
 by accidental suffocation. A mass of diseased absorbent 
 glands occupied the whole space between the ears and the 
 clavicles on both sides, and met in front of the trachsea. 
 His respiration was habitually oppressed ; he was under 
 medical treatment in the infirmary, and one morning he 
 was found dead, with hia countenance swollen and livid. 
 
DISEASE AT DIFFERENT PERIODS, ETC. 277 
 
 Of the seventeen women — 
 
 4 died of the various species of bowel complaints. 
 
 5 „ of disorders of the brain and nervous system. 
 2 „ of fever. 
 
 1 „ of hepatitis, which had a suspected connexion with the 
 
 reigning disease. 
 1 „ of diseased spine, which had no connexion with it. 
 4 „ of phthisis, which had no connexion with it. 
 
 When the last of the Tables, given above, was presented to 
 the committee, it was accompanied by the following observations. 
 
 Gentlemen, 
 
 In presenting our Report of the present state of the Penitentiary, 
 we must be permitted to accompany it with a few observations. 
 
 When we were first engaged at the Penitentiary, it appeared to us 
 important to determine the period at which the diseases we had to treat 
 began to prevail; and for this information we resorted to the testimony of 
 the prisoners themselves. Owing, however, to certain suggestions made to 
 us by others, we were led to distrust the statement of prisoners respecting 
 their own complaints, unless it was .confirmed by other circumstances ; and 
 thus we were able to trace only a few cases of either diarrhoea or scurvy 
 back to a remoter period than Christmas. 
 
 But our greater experience of their conduct and character has led us to 
 give further credit to the prisoner's own statements ; and from the uni- 
 formity and consistency of their testimony, we have no doubt that both 
 diarrhoea and scurvy prevailed most extensively throughout the prison at 
 an early period of the autumn. Not longer than a fortnight after the diet 
 was changed, in July, the disorder of the stomach and bowels began first to 
 show itself. Even in the very month of July a few of the prisoners 
 suffered vomiting and diarrhoea. These (as we judge from the manner in 
 which they occurred) were unquestionably owing to the disagreement of 
 food. They ceased and recurred at intervals. The prisoners themselves 
 thought lightly of them, and did not make them a, subject of complaint 
 either then or at a much later period. Hence (as we have observed in a 
 former Report) no blame is imputable to the medical oificers, that they went 
 for a long time undiscovered. 
 
 Nevertheless the fact is certain ; and it is no wonder, therefore, that the 
 tliarrhoea especially, which had been so long unrestrained by any effectual 
 treatment, should at length have proved an intractable disease, and been 
 protracted by a succession of relapses nearly to the present time. For this 
 complaint (independently of other circumstances connected with it) is, 
 according to the length of its duration, always suspected of being main- 
 tained by a disorganization of (what is called) the mucous structure of the 
 bowels. 
 
278 REVIEW OF THE EXTENT OF THE 
 
 Such disorganization, in its least and lowest degree, is reparable tardily- 
 only, and -with difficulty ; and in its greater degree, it is altogether 
 irreparable. 
 
 In our Report to the Committee of the 5th of April, we ascribed the 
 forms of disease then prevalent in the Penitentiary mainly to the influence 
 of diet and cold, and our opinion has been confirmed by that of other 
 physicians who have been consulted upon this point. But many prisoners 
 admitted since the diet thought to be injurious, has been changed, and 
 since the weather has become milder, have become the subjects of dysentery ; 
 and several of the officers of the establishment most employed about the 
 sick have suffered the same disease. 
 
 Unquestionably, then, we do believe, that some injurious influence has 
 been in operation, over and above the causes to which the epidemic was 
 originally imputed. This injurious influence may have been present from 
 the first, or it may have been subsequently superadded. Whatever it be, 
 it has hitherto eluded our detection ; and, whether it is, or is not in 
 operation at present we cannot- tell. 
 
 If it consist of contagion (and such possibly may be the case) dysentery 
 will still probably linger in the prison, as long as any remain there who 
 have not suffered it ; and then it will entirely disappear. If it consist of 
 something peculiar to the place, or to the season, or to the moral and 
 physical condition of people so confined, it may be still capable of renewing 
 the same disease, or of creating another form of epidemic. 
 
 We are aware that the public mind is impatient to be satisfied as to the 
 causes which, from first to last, have produced and maintained the various 
 forms of complaint in the Penitentiary. Upon this subject we wish to 
 dwell for a moment, in order to show that the satisfaction which is sought 
 cannot be obtained. 
 
 The causes (the exciting causes, as they are called) of diseases are 
 involved in much uncertainty ; and when the question is concerning an 
 extensive epidemic, this uncertainty is felt, and confessed to be most 
 painful : still the inquiry into these causes can never be hastily dismissed ; 
 for to discover what they are, and to remove them, if they are within our 
 reach, may be essential to the effectual cure of the disease. 
 
 With respect to the Penitentiary, then, while we confess that there has 
 been, and still may be, a cause of disease in operation, which we are 
 ignorant of, we are most anxious for the committee to feel convinced, that 
 the fault does not entirely rest with us that it remains undiscovered, but 
 that the difficulty of detecting it is inherent in the subject itself. 
 
 We beg to state, that opinions respecting the causes of diseases are 
 formed, not from the mere observation of one or two things immediately 
 obvious to the senses, but from a cautious investigation of a great variety 
 of circumstances, and from a series of reasoning upon them. 
 
 It is obvious that opinions necessarily so formed, are very liable to 
 error ; and hence it happens, that no prudent physician ever arrived at 
 conclusions about the causes of a disease, with so certain a conviction that, 
 he was right, as not to confess that he might possibly be wrong. 
 
DISEASE AT DIFFERENT PERIODS, ETC. 279 
 
 Numerous cases in the Penitentiary, to -which, we have already alluded, 
 have seemed to us quite inexplicable, except upon the presumption of con- 
 tagion. The fact may be otherwise ; and authorities (we are aware) pre- 
 ponderate against the contagious nature of dysentery ; nevertheless, we 
 nave not thought ourselves justified in neglecting the practical measures 
 which the facts before us appeared to suggest, until medical opinion is 
 settled upon this point. 
 
 We beg to add a few remarks upon the Table just delivered in, which 
 represents the number of prisoners at present under medical treatment. 
 
 In this Table the committee will see with satisfaction, how small a pro- . 
 portion those who are now suffering the severer symptoms of the disease, 
 bear to those who are convalescent, and to those who are well. 
 
 Nevertheless, it may appear strange to the committee, that so many 
 should be still kept under medical observation and treatment, who as far 
 as health is attested by the absence of all symptoms of disease, are perfectly 
 well : in them, indeed, the disease may be effectually cured, and we trust 
 it is ; but the instances of relapse, after many weeks of apparent health, 
 have been too numerous to allow us to dismiss all apprehension concerning 
 them. 
 
 How to obtain for those who have already suffered the disease, and are 
 now apparently well, an effectual security against relapse, has become our 
 chief care and anxiety. This security (as it seems to us) can be procured 
 only by guarding them from the influence of all things that are obviously 
 injurious, and by still keeping them, in a moderate degree, under the 
 influence of the same remedies which have thus succeeded in restoring 
 them to health. 
 
 For ourselves we must be allowed to observe, that we have never felt 
 the responsibility of our charge so sensibly as at the present moment. 
 While we were engaged in actively ministering to above 400 sick, we were 
 not at leisure for useless anxieties ; but now that we have time to reflect 
 upon our situation, and consider that the public still holds us responsible 
 for the employment of all possible means for protecting this vast establish- 
 ment against the recurrence of the same terrible visitation, and the invasion 
 of any new epidemic, we cannot refrain from begging of the committee, that 
 they would be pleased to grant us the benefit of consulting with some 
 physicians of eminence and authority, who may either confirm us in the 
 means we are using, or suggest others more effectual. 
 
 We are not disposed to look with despondency upon the state of the 
 Penitentiary. There is one event, however, which, under the most fortunate 
 circumstances, will unquestionably come to pass, and it is proper that the 
 committee should be informed of it. 
 
 If we were sure that, from the present time, all causes would cease to 
 operate for the renewal of the same disease, and for creating any new form 
 of epidemic, and if we were sure, that all who have suffered the disease 
 were henceforward secure against relapse, still we must entertain the con- 
 fident belief, that among nearly 500 persons who have suffered so long and 
 so severely complaints peculiarly apt to debilitate the general frame, many 
 
280 REVIEW OF THE EXTENT OE THE 
 
 ■will be found, whose restoration to complete health, will he tardy, difficult, 
 and precarious, and who, in the meantime, will be ready to fall into any 
 diseases to which the constitutions of each may have an original proclivity. 
 Hence, we foresee, that independently of any general or epidemic complaint, 
 there will arise from time to time in the Penitentiary, occasional cases of 
 complicated and anomalous disease : of these cases some may be trivial, but 
 others will be formidable, and a few fatal ; and they will be as various in 
 their characters as the constitutions of individuals are various. 
 
 We cannot close this Report without thanking the committee for the 
 uniform kindness and confidence with which they have regarded our labours. 
 We have (we can assure them) most anxiously and scrupulously reviewed 
 all the practical measures we have employed during the prevalence of this 
 most formidable and extensive epidemic. These measures were adapted to 
 emergencies as they arose, with as much care and deliberation as circum- 
 stances would allow ; yet, upon reflection, we conscientiously affirm, that 
 we discover no error which we desire to palliate or amend, and see no suit- 
 able remedy or medical expedient which we have omitted to use ; and that, 
 should we again be called upon to treat the same malady, we should only 
 study to retrace our own footsteps, and should employ the same remedies 
 and medical expedients with an increased confidence in their success. 
 
 (Signed) P. M. Latham, M.D. 
 July 4th, 1823. P. M. Roget, M.D. 
 
 Our purpose in this Report was to intimate to the com- 
 mittee, that the disorder as a flux, had been of longer standing 
 in the prison, than we had at first been led to believe ; that its 
 origin could not be exclusively owing to those causes to which 
 it had been imputed ; that there had been, and perhaps still 
 was, some cause in operation, the nature of which had not been 
 discovered, and might not be discoverable ; that there was a 
 suspicion of contagion, and a suspicion of local injurious in- 
 fluence, but nothing ascertained about either ; that the extent 
 of the disease was at present greatly diminished, but that all 
 the prisoners were in a state of health, which (to say the least) 
 was dangerously valetudinary ; that disease was still to be ex- 
 pected in some form, either in the shape of relapse, or of some 
 new epidemic, or of those various, complaints which are the 
 consequence of debility. 
 
 The date of this Report marks the time at which the disease 
 of the Penitentiary had come to a kind of pause. Nevertheless, 
 the many apprehensions and doubts which we felt, as to what 
 might happen, and a very painful sense of responsibility, led 
 us, for our own satisfaction, and the satisfaction of the public, 
 
ETC. 281 
 
 to ask for further medical assistance. Our request was made 
 known to the Secretary of State, who directed the College of 
 Physicians to appoint whom they thought fit. The College 
 appointed four physicians of hospitals — Br. Hue, Dr. Mac- 
 michael, Dr. Chambers, and Dr. Southey. Three only of the 
 four undertook the charge. Dr. Chambers's professional en- 
 gagements obliged him to decline it. 
 
282 REMOVAL OF THE PRISONEBS 
 
 CHAPTER VIII. 
 
 REMOVAL OF THE PRISONERS FROM THE PENITENTIARY, AND ITS 
 INFLUENCE UPON THEIR HEALTH. 
 
 "Without calling in question, for the present, the salubrity of 
 the situation of the Penitentiary, it seemed to Dr- Roget and 
 myself, that the best security against the return of the old, and 
 the appearance of any new, forms of disease, would be obtained 
 by change of air and change of place. To individuals in private 
 life, after long illness and frequent relapses, physicians are 
 accustomed to recommend change of situation as indispensable 
 to their recovery. But such a recommendation, when the 
 question was concerning several hundred convicts, would (we 
 thought) be nugatory, from the impossibility of carrying it 
 into effect. Nevertheless, by the zeal of the committee, and 
 the special activity of the visitor, Mr. Holford, and the aid 
 furnished by Government, through the earnest interference of 
 Mr. Secretary Peel, it was entirely accomplished ; and all the 
 prisoners, both male and female, were eventually removed from 
 Millbank to situations deemed more eligible for the recovery 
 of their health. 
 
 The Ophthalmic Hospital, in the Regent's Park, being vacant, 
 was made fit for the reception of female prisoners, and 120 were 
 removed thither from Millbank, between the end of July and 
 the beginning of August. The Ethalion hulk, at "Woolwich, 
 was prepared for male convicts, and 200 were sent on board it, 
 between the middle and the end of August. 
 
 The prisoners, both male and female, selected for removal, 
 were those who had suffered the most seve.re and the most fre- 
 quent attacks of the disease in all its forms ; and the effect which 
 change of air might have upon them was to determine how 
 those were to be disposed of who still remained at Millbank. 
 
 The care of the prisoners at Millbank, and at the Regent's 
 
FROM THE PENITENTIARY, ETC. 283 
 
 Park, was now divided between Drs. Roget, Hue, Macmichael, 
 Southey, and myself; while we all paid frequent visits to those 
 on board the hulks, who were under the immediate care of 
 Mr. Bayles. 
 
 The benefit of change of air and situation was immediately 
 apparent, both upon the women at the Regent's Park, and the 
 men at Woolwich. In a fortnight after their removal, there 
 was much less complaint of illness among them, and their 
 general aspect bore the appearance of returning health. 
 
 In the meantime, the prisoners who remained at Millbank, 
 amounting to about 100 women, and nearly 300 men,* were 
 stationary as to their general health, while they were still 
 harassed by visitations of their former disease. It exhibited 
 itself, however, under none of those frightful forms which have 
 been before described. With the exception of two or three 
 cases of fever, which were formidable, rather on account of 
 their protracted duration than their severity, there were none 
 which occasioned us any apprehension. The present form of 
 disease was diarrhoea almost universally ; and it nearly re- 
 sembled that which we had witnessed upon our first visiting 
 the Penitentiary, in the month of March. It was then con- 
 trolled by chalk mixture and opium, and the same remedies, or 
 remedies of which opium was the main ingredient, had now a 
 beneficial influence. But if the disease, even now, went beyond 
 a certain degree, it was in vain to attempt its abatement by 
 any medicine but mercury; a fact, to which the physicians 
 lately called in, bore equal testimony with Dr. Roget and 
 myself. 
 
 Upon a comparison, during the month of September, of the 
 prisoners, male and female, still remaining at Millbank, with 
 those at Woolwich, and at the Regent's Park, the balance of 
 health was greatly in favour of the latter ; yet their condition, 
 five or six weeks ago, was so much the worse, as to obtain for 
 them the preference of being the first selected for removal. The 
 benefit, therefore, of change of air, and change of place, was 
 unquestionable. 
 
 On the i?0th of September, we were able to report formally 
 to the committee, that " the habit of all the prisoners, both at 
 
 * I cannot state the exact number, since it varied from time to time, on 
 account of the pardons that were obtained. 
 
284 REMOVAL OF THE PRISONERS 
 
 "Woolwich and the Regent's Park, is strikingly improved, and 
 the majority have recovered the appearance of robust health. 
 In this number many are included, whose lives had been brought 
 into hazard by successive attacks of the disease in its several 
 forms, and who, at the time of their removal, were in a state of 
 great debility. The disease itself, we have the satisfaction to 
 state, has assumed a much milder character, but even yet it is 
 extensively prevalent ; and it is remarkable, that many whose 
 general health seems entirely re-established, still experience, 
 from time to time, the recurrence of their former disorder in a 
 mitigated form." 
 
 Another month elapsed, and the prisoners at Millbank, 
 although they were suffering no formidable disease, still expe- 
 rienced some insurmountable impediment to the recovery of 
 their health. Their condition at this time, and the condition of 
 the men on board the Ethalion, and of the women at the 
 Ophthalmic hospital, respectively, may be learnt from the 
 following questions and answers : — 
 
 LETTER from Q. R. Dawson, Esq., containing certain questions to be 
 answered by the Physicians, by direction of the Secretary of State. 
 
 Whitehall, 21st October, 1823. 
 Sir, 
 
 In reference to your letter of the 18th October, I am directed by 
 Mr. Secretary Peel to request, that you will call upon the physicians in 
 attendance upon the sick belonging to the Penitentiary, for a detailed report 
 upon the several points following: — 
 
 1st. The state of the disease at present existing in the Penitentiary, as 
 compared, in point of malignity and extent, with its state at former periods. 
 
 2nd. What has been the general result of the experiment made in August, 
 and at subsequent periods, of transferring a portion of the male prisoners 
 from the Penitentiary to the Ethalion hulk. 
 
 3rd. The same question, with respect to the transfer of females to the 
 Ophthalmic hospital in the Regent's Park. 
 
 4th. Is there reason to believe that the transfer of the male prisoners 
 now in the Penitentiary to another hulk to be prepared for their reception, 
 would be an advantageous measure to the prisoners themselves, as con- 
 ducive to the recovery of the sick, and preventing the risk of disease in 
 the case of those who have hitherto suffered. 
 
 5th. The same question as to the removal of female prisoners now in 
 the Penitentiary, to some place of reception like that in the Regent's Park. 
 
 6th. Could the whole of the female prisoners, now in the Penitentiary, 
 
FROM THE PENITENTIARY, ETC. 285 
 
 be safely removed to a hulk at this period of the year ; or could any 
 portion of them, those for instance who have not suffered, or very slightly 
 suffered from the disorder. 
 
 I am, Sir, your most obedient servant, 
 
 (Signed) Geo. R. Dawson. 
 
 The Chairman of the Superintending Committee 
 of the General Penitentiary. 
 
 ANSWERS by the Physicians to the questions contained in Mr. Dawson's 
 Letter of the 21st October, 1823. 
 
 October 23rd, 1823. 
 1st. At former periods there was in the Penitentiary every gradation 
 of complaint from the severest dysentery to the mildest diarrhoea; and the 
 most formidable, or the dysenteric cases, were greatly predominant. At 
 present, with a few exceptions, there is no disease beyond a diarrhoea, and 
 the milder cases predominate. The malignity of the disease is therefore 
 greatly abated. With respect to the extent of the complaint, if it be esti- 
 mated from the number ill at the present moment, it is greatly diminished; 
 but all in the Penitentiary, who have once had the complaint, are continually 
 suffering short relapses. 
 
 2nd. The result of this experiment has been highly satisfactory. The 
 prisoners transferred to the Ethalion hulk have gained a greater degree of 
 health, and have suffered fewer relapses than those in any other situation. 
 
 3rd. The female prisoners now in the hospital in the Regent's Park, 
 and who had been originally selected as being those who were suffering the 
 most from the prevailing disease and its effects, have since their removal, 
 notwithstanding they have experienced frequent relapses, on the whole, 
 gained ground considerably. Comparing the general improvement that has 
 taken place in their health, with the progress made by the females who have 
 remained in the Penitentiary, we think ourselves warranted in concluding 
 that they have derived considerable benefit from their having been trans- 
 ferred to the Ophthalmic hospital. It is certain, however, that they have 
 benefited much less than the men on board the hulk. 
 
 4th. We think such a transfer of the male prisoners now in the Peni- 
 tentiary to another hulk, would be a measure advantageous for the purposes 
 contemplated. 
 
 5th. We think that such a removal would unquestionably be desirable. 
 6th. Although the period of the year be . unfavourable, still we should 
 consider that the removal of all the female prisoners to a hulk, if it could 
 be soon effected, would, upon the whole, be an advisable measure. 
 
 (Signed) P. M. Latham. 
 
 P. M'. Roget. 
 Clem. Hue. 
 H. H. Southey.* 
 
 * Dr. Macmichael's absence from London at this period prevented him 
 from joining in these answers. 
 
86 REMOVAL OF THE PRISONERS 
 
 Upon this representation, it was determined to transfer all 
 the prisoners, male and female, remaining at Millbank, to hulks 
 fitted for their reception at "Woolwich. Accordingly, on the 
 14th of November, the women, whose number was now reduced 
 by pardons to eighty, were removed on board the Narcissus, 
 and between the 8th and 10th of December, the men, reduced 
 to 281, were put on board the Dromedary. 
 
 At length the Penitentiary at Millbank was empty, and all 
 the prisoners were divided between the hulks at "Woolwich, and 
 the Ophthalmic hospital in the Regent's Park. 
 
 Now, considering what had been the condition of the 
 prisoners at Woolwich, and of those at the Regent's Park, since 
 their removal from Millbank, and comparing the present state 
 of both, we had much more reason to be satisfied with the result 
 of the experiment in regard to the former than the latter. 
 Immediately after their removal, both alike seemed to throw off 
 the remaining symptoms of their disease, and to put on the 
 appearance of returning health ; yet both afterwards continued 
 alike to suffer an occasional recurrence of their disease, chiefly 
 in the form of diarrhoea. There was, however, this manifest 
 difference between the two, that while those on board the hulks 
 at Woolwich, continued to recover their general health, in spite 
 of frequent occasional attacks of diarrhoea, the females at the 
 Regent's Park did not, in respect of their general health, go on 
 to improve during more than the few first weeks after their 
 removal. Moreover, among the prisoners on board the hulks, 
 during a period of between four and five months, there had not 
 occurred a single case of formidable disease ; whereas, among 
 those at the Regent's Park, during the same period, there had 
 been several. At the end of November, several women at the 
 Regent's Park, were seized nearly at the same time with that 
 insidious form of phrenitis which, five months before, had 
 been a great cause of alarm at the Penitentiary, and had, in 
 some instances, proved fatal. Dr. Roget, to whose care the 
 hospital in the Regent's Park was especially assigned, found 
 himself compelled to resort to the same remedy by which 
 these symptoms were formerly brought under control, and with 
 the same success. 
 
 Under these circumstances, and moreover because the females 
 recently removed to Woolwich from the Penitentiary, had 
 
PEOM THE PENITENTIARY, ETC. 287 
 
 experienced a striking improvement, it was thought desirahle 
 that all who now remained at the Eegent's Park, and were 
 reduced from 120 to 91, should (if possible) he transferred to 
 "Woolwich ; and accordingly, on the 21st and 23rd of January, 
 1824, they were put on hoard the Heroine, which had been 
 prepared for them. 
 
 All the prisoners belonging to the Greneral Penitentiary 
 were now on board hulks at Woolwich. They were 635 in 
 number, namely, 468 males, on board the Ethalion and Drome- 
 dary, and 167 females, on board the Narcissus and the Heroine. 
 
 When we first visited the Penitentiary, in the month of 
 March, the total number of prisoners was 858, of whom 531 
 were males, and 327 were females. Of the 531 males 50 had 
 been set at liberty, by the expiration of their terms of confine- 
 ment, and by pardons, and 13 had died ; and of the 327 females, 
 143 had been set at liberty, and 17 had died. 
 
 The immediate superintendence and treatment of the pri- 
 soners, after their removal to Woolwich, were consigned to 
 medical men resident on the spot. Mr. Bayles had the care of 
 the men, and Mr. Pratt, the apothecary of the Penitentiary, 
 had apartments on board the Narcissus, and took charge of the 
 women. The physicians, however, continued still to visit all 
 the Penitentiary hulks at intervals; and some circumstances, 
 which thus fell under my observation, require to be mentioned. 
 
 One remarkable circumstance was, that the prisoners in the 
 several hulks, although transferred at various times, and at 
 different seasons of the year, all experienced a striking change 
 for the better, almost immediately upon their arrival at Wool- 
 wich, and that their disorder ceased for a time. This happened 
 equally to the men put on board the Ethalion in August, and 
 the Dromedary in December, and to the women put on board 
 the Narcissus in November. When they had been on board 
 ten days, we found scarcely any complaint among them. 
 
 This speedy amendment, which uniformly followed change 
 • of air and change of place, held out at first a most encouraging 
 prospect. But in every instance it was fallacious ; for, after a 
 temporary pause, the disorder returned in the form of diarrhoea. 
 It was mild in its symptoms, but still it was evidently the same 
 which had prevailed at Millbank. 
 
 Another remarkable circumstance was, that neither the 
 
288 REMOVAL OP THE PRISONERS 
 
 total absence of the disorder, during a considerable period, nor 
 the complete re- establishment, in the meantime, of the general 
 health, furnished any security against its recurrence. The men 
 on board the Ethalion were under our observation during three 
 quarters of a year, after their removal, and among them there 
 were many, who, having been free from all symptoms of com- 
 plaint during two, three, four, and even five months, and 
 having in the meantime recovered robust health, again suffered 
 diarrhoea. 
 
 This liability of all the prisoners to suffer the recurrence of 
 their disorder, in spite of the re-establishment of their general 
 health, and of their complete immunity from it for a season, 
 rendered their condition very fluctuating. It was impossible 
 to anticipate what would be their condition from one week to 
 another. At our visits to Woolwich, we were accustomed to 
 see each individual prisoner, and to question him respecting his 
 health ; and thus, when at one visit we had found, among 200 
 men, not more than five and twenty with complaints of the 
 bowels, at the next visit we found half of the whole number 
 affected with diarrhoea. 
 
 These sudden transitions we were at first ready to impute 
 to sensible changes in the state of the atmosphere, but soon we 
 could discover nothing to which they could be reasonably 
 ascribed. It seemed as if, in all who had once suffered, there 
 still remained some morbid condition of the bowels, the relics 
 of former disease, which required time, and the choice of all the 
 most favourable circumstances, to effect its reparation. This 
 condition, however, appeared compatible with the re-establish- 
 ment of the general health, and compatible even with the 
 natural functions of the bowels themselves, holding them 
 nevertheless in a perpetual proneness to disorder, from occa- 
 sional causes, until reparation was complete. 
 
 In the description of the disease, as it prevailed when all 
 the prisoners were at Millbank, some account was given of the 
 morbid appearances found in the bodies of those who died. 
 From this it may be collected, what was the actual condition 
 of the parts upon which the stress of the disease fell, when it 
 declared itself in symptoms referable especially to the bowels, 
 or to the brain and nervous system, or when it appeared under 
 the more general character of fever. 
 
FKOM THE PENITENTIAET, ETC. 289 
 
 And now, haying described the same disease recurring in 
 one of its forms, that of diarrhoea, among the prisoners after 
 their removal, and still continuing to recur during many 
 months, and under every variety of circumstances, and even 
 after the complete re- establishment of their general health, I 
 shall be expected, perhaps, to state what was the actual condi- 
 tion of the intestines in those who were the subjects of such 
 attacks. I possess, however, no certain information upon this 
 point ; for the only means of obtaining it would have been by 
 dissection at the time ; but these, fortunately, were wanting, 
 since the attacks did not prove fatal in a single instance. 
 'Several dissections, however, performed at other times, and 
 with different views, seemed to me to throw some light col- 
 laterally upon the question. 
 
 In those who died at Millbank, after symptoms immediately 
 referable to the head, having formerly suffered disorder of the 
 bowels, but having been a long time free from it, we found 
 ulcers of the intestines. The intestines were otherwise exempt 
 from disease. The ulcers were few in number, not more than 
 three or four throughout the whole tract of the bowels. They 
 were of very small extent, and in progress towards reparation. 
 
 A young man who had originally suffered the bowel com- 
 plaint very severely, at Millbank, and whose life had been 
 rescued by the treatment adopted there, and who subsequently 
 at Woolwich, in spite of the re-establishment of his general 
 health, had frequent returns of diarrhoea, was ultimately 
 pardoned and set at liberty. A short time afterwards he pre- 
 sented himself to me among the patients applying for admis- 
 sion into the Middlesex Hospital. He was a miserable object, 
 worn down and emaciated by impoverished diet, and the hard- 
 ships he bad suffered since his liberation. His present com- 
 plaint was diarrhoea, with severe pain in the head. The diar- 
 rhoea was soon arrested ; but the disorder of the head assumed 
 the form of that insidious phrenitis already described, and he 
 died. Upon dissection, there was found inflammation of the 
 membranes of the brain, and fluid effused between them and 
 into the ventricles. In the intestines, after careful examina- 
 tion, nothing was found but three minute spots, exhibiting the 
 appearance already described, of ulcers in the process of re- 
 paration. 
 
 v 
 
290 EEMOVAL OF THE PRISONERS 
 
 A young woman who had suffered the bowel complaint, at 
 Millbank, with several slight relapses, died in the course of the 
 last summer, at the "Westminster Hospital, of pulmonary con- 
 sumption. Upon dissection, besides the disease of the lungs, 
 healing ulcers were found in the intestines. They were very 
 circumscribed in their situation, and entirely free from sur- 
 rounding inflammation. 
 
 It is not unreasonable to conjecture, that the same condition 
 of the bowels, which was found in these cases, existed also in 
 those who suffered the frequent recurrence of diarrhoea at the 
 hulks. A few minute ulcers, somewhere in the tract of the 
 intestines, tardily undergoing the process of reparation, and 
 without any surrounding inflammation, constitute just that sort 
 of morbid condition which is calculated to produce such a dis- 
 order. Being very circumscribed in extent, and free from in- 
 flammation, they would be capable of existing without constant 
 injury to the general health, and even without constant impe- 
 diment to the functions of the parts to which they belonged ; 
 yet, from the natural irritability of those parts, they would 
 still be liable to produce temporary disorders, under the in- 
 fluence of occasional causes ; and such disorders would con- 
 tinue apt to recur, until the process of their tardy reparation 
 was complete. 
 
 But however reasonable, and however true this conjecture 
 might be, we were not yet acquainted with all the facts just 
 mentioned, upon which it is grounded. So that, during the 
 actual prevalence of the disorder at the hulks, our method of 
 treating it was determined by the best view we were enabled 
 to take of its general character, in the absence of information 
 derived from dissections. And that view, which has been 
 already stated, led us to suggest the propriety of employing 
 such remedies only as were found to have the effect of checking 
 the symptoms as they arose, and the propriety of abstaining 
 from the use of mercury, and of being content to leave that to 
 time which time alone could repair. Opiates and aromatics 
 had the palliative effect which was desired, and they were 
 accordingly employed. 
 
 "Where, however, more disorder of the bowels arose (as it 
 did in a few instances) than could be supposed to proceed 
 merely from the relics of former disease, and these remedies 
 
FROM THE PENITENTIARY, ETC. 291 
 
 had no influence in checking it, then others were resorted 
 to from necessity, and all others were still in vain except 
 mercury. 
 
 Such a disorder arose on hoard the Narcissus; and the 
 symptoms seemed to bespeak a morbid action of an acute kind, 
 set up afresh, or ingrafted upon the old. The women on board 
 the Narcissus had, since their arrival at Woolwich, in November, 
 rapidly recovered their general health, and had been strikingly 
 exempt from their former complaints, when, in the month of 
 March, there were found among them numerous instances of 
 disorder, expressly referable to the stomach. It was of a severe 
 and formidable kind, and did not strictly resemble any of those 
 forms of disorder which have been described. There was a 
 sense of sinking, with extreme pain over the whole epigastric 
 region, great impatience of pressure, and enormous distention of 
 the abdomen, violent retching, with the rejection, in several 
 cases, of pure florid blood. The blood was generally small in 
 quantity, but, in a few instances, it amounted to more than a 
 pint. The pulse was feeble. Neither food nor medicine would 
 remain upon the stomach ; both were rejected, with extreme 
 aggravation of all the symptoms. 
 
 The disorder had already existed during several days, and 
 various methods of treatment had been employed, when Dr. 
 Eoget and myself were sent for to Woolwich. We found ten 
 womea at leait in a state of peril. The remedies used had 
 produced no abatement of the symptoms, which were daily 
 becoming worse in every case. Mercury had not been of the 
 number, the apothecary conceiving that he acted in conformity 
 with our wishes, when he scrupulously withheld it. 
 
 Now, although the order of symptoms which we now 
 witnessed, was not precisely identical with any we had formerly 
 seen at the Penitentiary, yet it was impossible not to regard 
 them as partaking of the same nature ; and surely, upon the 
 failure of every other remedy, we were not justified in with- 
 holding that, which had already rescued life under various cir- 
 cumstances of peril belonging to kindred diseases. Accordingly, 
 we resorted to calomel and opium. Five grains of calomelfind 
 one grain of opium were first administered to several patients ; 
 but there followed, to our disappointment, an aggravation of all 
 the symptoms. The retching, and vomiting, and spasmodic 
 
292 REMOVAL OF THE PRISONERS 
 
 pain were prolonged through the night. Yet it was not the* 
 remedy itself, but the largeness of the dose, that produced the- 
 disagreement ; for when one grain, or two grains of calomel,, 
 and a fourth, or half of a grain of opium, were given every 
 second, or every third hour, they were retained, and the stomach 
 was tranquillized, and there followed a gradual abatement of the 
 symptoms. Still all the symptoms, and especially the pain, 
 were not finally removed, until the gums were perceptibly sore. 
 
 This affection of the stomach was different from that already 
 described as the concomitant of fever. It did not tend to a 
 critical termination, and its relief, although it was procured by 
 the same remedy, was brought about in a different way ; not by 
 its producing a discharge of morbid secretions, but (as far as 
 we could judge) by its specific influence upon the constitution. 
 
 But what was the precise condition of the parts to which the 
 symptoms were expressly referred in these cases? Fortunately, 
 we had not the opportunity afforded us of determining, by dis- 
 section, what it was. But whatever it might be, undoubtedly it 
 was such as constituted an acute disease, tending to the destruc- 
 tion of the individual, if its course had not been arrested. From 
 the symptoms, and from the method of treatment which 
 procured their relief, and from our general experience of what 
 morbid anatomy has disclosed, under circumstances nearly the 
 same, perhaps we should not be far wrong in concluding, that 
 the seat of the disease was the blood-vessels of tl&e stomach, or 
 of the upper part of the intestinal canal, and that their sudden 
 and undue repletion was the condition which constituted the 
 disease itself. 
 
 In the course of ten days, this form of disease, which has 
 been described, attacked nearly half the women on board the 
 Narcissus in succession, and there was a continual apprehension 
 that it would prove fatal to some. In the meantime, almost all 
 on board the same vessel, who were not afflicted after this 
 manner, suffered either some form of bowel complaint, or some 
 affection of the brain or nervous system, such as formerly 
 prevailed at Millbank. Thus there was hardly an individual 
 who escaped an attack of severe illness, but none died. 
 
 It was melancholy to remark, when their severer sufferings 
 had terminated, the sad contrast which the condition of these 
 poor women now bore to what it had been a month ago. It 
 
FROM THE PENITENTIARY, ETC. 293 
 
 was not a long time since the Narcissus was so conspicuously 
 healthy, that it furnished an argument for the removal of the 
 women from the Regent's Park to Woolwich. But now, from 
 the relapse of former symptoms, and the accession of new ones; 
 from the relics of old disease, and from disease, either set up 
 afresh or ingrafted upon the old, a state of apparent health had, 
 in the space of a month, given place to emaciation and weak- 
 ness, and to that peculiar look of distress and exhaustion which 
 belongs to those who have just, with difficulty, surmounted an 
 acute disease. There was no one peculiar cause to which these 
 late attacks could be confidently ascribed. Yet there were 
 many causes inseparable from their condition as prisoners, from 
 which they might possibly come. Therefore, as long as they 
 remained in that condition, there was no security against the 
 return of the same or similar forms of disease. And in such an 
 event, if it soon occurred, there was every probability that many 
 would perish; for the same individuals had not strength enough 
 remaining to support it. 
 
 At the same time, the women brought from the Regent's 
 Park, and put on board the Heroine, at the end of January, 
 had not found that immediate benefit which all the other 
 prisoners experienced upon their removal. Moreover, many 
 severe cases of relapsed bowel complaints had occurred among 
 them since their arrival at Woolwich. 
 
 Deplorable, indeed, was the condition of all these wretched 
 women, both on board the Narcissus and the Heroine in respect 
 of their bodily sufferings, but more deplorable still (if possible) 
 in respect of their mental misery. It was painful to witness 
 the manner in which they all abandoned themselves to despair, 
 and those especially who had still before them the prospect of a 
 long captivity. Every day brought some fresh proof how great 
 was the influence of mental distress in augmenting bodily pain 
 and sickness. Whatever circumstances were calculated to make 
 a strong impression upon the spirits, threw them back at once 
 from a state of convalescence, into absolute disease. I will 
 mention one such circumstance, as an example. 
 
 Upon the recommendation of the committee, individuals 
 were pardoned, from time to time, for good conduct. Recently, 
 claims for such recommendation had been more easily admitted, 
 and consequently pardons had become very numerous. Hence 
 
294 REMOVAL OF THE PRISONERS 
 
 the prisoners themselves naturally began to think that the 
 claims of all were nearly equal, and everyone pleased herself 
 with believing that she should be the next who would be set at 
 liberty. Whenever, therefore, an individual was pardoned, all 
 the rest were thrown into an agony of the bitterest disappoint- 
 ment, and were, at the same time, overtaken by disease. It 
 was not a mere nervous or hysterical ailment, but some actual 
 form of real disease, such as they had before suffered, and 
 requiring the strictest medical treatment for its relief. 
 
 Now it was evident that every measure had been resorted to 
 for their benefit which was compatible with the condition of 
 prisoners. But there was reason to believe that causes insepa- 
 rable from that condition still prevented their recovery. As to 
 those who had been set at liberty, it can hardly be expected 
 that much accurate information could be obtained concerning 
 them after they left the prison. Several, however, had pre- 
 sented themselves at the Penitentiary since their enlargement, 
 and it appeared certain that they had enjoyed more uninter- 
 rupted health and a longer exemption from disease than those 
 who had remained in confinement. Several, also, who had been 
 pardoned upon the representation of the physicians, that their 
 enlargement afforded the only probable means of saving their 
 lives, had, after the lapse of a few weeks, appeared in perfect 
 health. 
 
 With such facts before us, it became a question whether the 
 same representation which had at different times been made in 
 favour of a few ought not now to be extended to all. After 
 witnessing the nature of the late severe attacks, the numbers 
 they involved, and the consequences they left behind, it did 
 appear to us that the only measure which remained was to set 
 at liberty all the female prisoners without exception, for the 
 sake of preserving their lives. The course of their sufferings 
 during more Jban twelve months might be thought justly 
 equivalent to many years' imprisonment ; at least, the humanity 
 of Mr. Secretary Peel led him to adopt this opinion, and to 
 admit the one in compensation for the other, when he recom- 
 mended them all to the mercy of the Crown for pardon. 
 
 Some delay, however, was requisite before this act of grace 
 could be carried into execution. It was easy to set these poor 
 women at liberty, but care was to be taken that, being set at 
 
FROM THE PENITENTIARY, ETC. 295 
 
 liberty, they were not left destitute. As soon, therefore, as 
 Mr. Peel made known his intention, the committee undertook 
 the laborious duty of corresponding with the friends of the 
 prisoners in every part of the kingdom. Thus each was par- 
 doned, as it was ascertained that they had friends willing to 
 receive them, until, finally, they were all pardoned. The lasl 
 left the Penitentiary hulks on the 18th of June, 1824 ; and the 
 committee had the satisfaction of knowing that there was not 
 one who had not a place of protection to go to immediately 
 upon her dismissal. 
 
 Of the men, two died consumptive, one in October, the other 
 in January ; otherwise, no formidable disease arose among them 
 after their removal to Woolwich. 
 
 They were still liable to occasional attacks of diarrhoea, but 
 it was probable that every individual who thus continued to 
 suffer only required to be put under circumstances a little more 
 favourable to health to secure his complete recovery. Although 
 they were on board hulks, they were still Penitentiary prisoners, 
 and, unfortunately, not amenable to hulk discipline. They could 
 not, therefore, be taken on shore to work, but were necessarily 
 allowed to remain in perfect idleness on ship-board — a state 
 which had already led to alarming acts of tumult and violence. 
 What, then, was to be done ? There were serious objections to 
 letting 400 men, who had been guilty of felonious acts, at once 
 loose upon the public. Yet it was impossible they should 
 continue where they were. It was determined, therefore, to 
 transfer all the male prisoners to the hulk establishment ; and, 
 accordingly, an Act of Parliament was obtained on the 12th of 
 April, 1824, to give Government the power of doing so. We 
 hoped that, by being distributed among the various hulks, and 
 subjected to active occupations, under their new discipline they 
 would be placed in a condition more favourable to the recovery 
 of their health. Some were sent to Sheerness, and some to 
 Chatham, and some remained at Woolwich, being transferred to 
 the hulk establishment there. 
 
 The gentlemen who have the medical superintendence of the 
 hulks, in these several situations, have favoured me with 
 answers to inquiries, which I lately took the liberty of address- 
 ing to them; respecting the health of the Penitentiary prisoners 
 under their charge. These are all of the most satisfactory 
 
296 REMOVAL OF THE PRISONERS, ETC. 
 
 kind. Mr. Bayles, of "Woolwich, writes, on the 1st of Novem- 
 ber last, " that from the time the Penitentiary prisoners were 
 incorporated with the other convicts, they have worked on shore 
 at whatever kind of labour they were ordered to, and have 
 continued in good health." Mr. Hope, of Chatham, on the 
 19th November, writes, " that the convicts from the Peni- 
 tentiary were mingled and employed with the other labourers, 
 and that he has not had complaints made to him by them more 
 frequently than by those received from other places." Mr. 
 Robertson, of Sheerness, on the 19th of November, informs me, 
 that only three or four boys came from the Penitentiary to the 
 hulk under his superintendence, none of whom had ever been 
 under his care for illness." And Mr. Cullen, of Sheerness, on 
 the 30th of November, says, " that the general state of health 
 of the prisoners, lately received from the Penitentiary, did not 
 appear to be different from that of the others, who all enjoy a 
 tolerable share of good health, considering all circumstances." 
 
 In this manner were the prisoners of the Penitentiary all 
 finally disposed of. It would be interesting to know the 
 present state of many, and especially of the women, who were 
 set at liberty from a conviction on our part, that their con- 
 dition as prisoners presented some insurmountable obstacle to 
 their perfect recovery. But such information could not now 
 be easily obtained. A few, whom Dr. Roget and myself have 
 casually met, had the appearance of health, but were not 
 exempt from occasional attacks of diarrhoea. 
 
OEIGIN OF THE DISEASE. 297 
 
 CHAPTER IX. 
 
 OEIGIN OF THE DISEASE. 
 
 The same course which I followed in my description of the 
 disease prevalent at the General Penitentiary, I shall still 
 pursue in my inquiry concerning its probable origin, stating the 
 circumstances connected with the question, according to the order 
 in which they presented themselves to my own observation. 
 
 Dr. Roget and myself, having observed the disease of the 
 Penitentiary during a month, and having witnessed its apparent 
 cure by the simplest remedies, and being tben unable to trace 
 it back to a period more remote than the preceding autumn, 
 did, in our Report of the 5th of April, 1823, ascribe its origin 
 to the conjoint influence of an impoverished diet and a severe 
 and protracted winter. We considered, moreover, that there 
 was sufficient evidence of these being its exclusive causes ; and 
 we had the satisfaction to find, that the opinion of many 
 eminent medical men coincided with our own. 
 
 The reasons assigned by us, and adopted by others, as con- 
 clusive at the time, are stated at length in the Report. 
 
 But the disease returned ; and our further observation of 
 its nature, and our subsequent acquaintance with new facts 
 connected with it, convinced us that our first opinion respecting 
 its origin was not tenable in its fullest extent. As to the 
 nature of the disease itself, when we looked back upon its pro- 
 gress during many months, and considered its various forms, 
 its duration, and its intractability by ordinary remedies, we 
 could not help acknowledging it to be contrary to experience, 
 that such a disease should derive itself exclusively from the 
 causes to which it had been imputed. 
 
 Cold, and scanty nourishment, are among the causes of 
 disease with which medical men are best acquainted. Among 
 the poor of large towns, they are known to be productive of 
 complaints at all times, and in seasons of scarcity, and during 
 winters of long and severe frost, being then applied in their 
 
298 OKIGIN OF THE DISEASE. 
 
 most intense degree, they are even capable of engendering 
 epidemic diseases. But at the Penitentiary, they were certainly 
 not applied in their most intense degree. The winter, indeed, 
 was cold, but the prison afforded a protection against its incle- 
 mency. The diet was defective in animal matter, but it was 
 wholesome in its kind. Still the winter being such as it was, 
 and the diet not a nutritious diet, might well be supposed 
 capable of producing some disease, but not a disease which 
 should reign like a pestilence within the prison, and require all 
 the prisoners to be removed for the sake of preserving their 
 lives. They might, in short, be thought capable of producing 
 such a disease as that of the Penitentiary seemed to be in the 
 month of March, but not such as our subsequent experience 
 found it to be. 
 
 In the month of March, not only was the disease such as 
 the alleged causes seemed capable of producing, but its history 
 and all the circumstances connected with it (all, at least, which 
 had then come to our knowledge), apparently excluded every 
 other cause, and pointed directly to these, and to these alone. 
 In its subsequent progress, however, the nature of the disease 
 itself made us first dissatisfied with our original opinion respect- 
 ing its exclusive causes, and the gradual disclosure of new facts 
 afterwards convinced us that others were actually engaged, both 
 in its production and continuance. 
 
 In our Report of the 3rd of July, 1823, we intimated to the 
 committee, that there was some cause in operation, over and 
 above those to which we had originally imputed the disease ; 
 and that there was a suspicion of contagion, and a suspicion, 
 moreover, of an injurious influence peculiar to the place. 
 
 I will state all the facts and circumstances within my 
 knowledge, which seem to bear upon the two questions, in order 
 that medical men may be able to form their own opinion con- 
 cerning them, keeping one question distinct from the other. 
 
 I will speak first respecting contagion. At the date of our 
 first Report, April 5, .1823, the disease had been found ex- 
 clusively among the prisoners. Subsequently, however, several 
 officers of the establishment were affected with it, and those 
 especially who were in frequent intercourse with the sick. 
 Twelve male and six female officers suffered the same forms of 
 disease with the prisoners themselves. The chaplain, also, and 
 
ORIGIN OF THE DISEASE. 299 
 
 various individuals of his 'family, residing within the walls of 
 the Penitentiary, had the disease in the form of bowel com- 
 plaint, himself (as he believed) in consequence of his attendance 
 upon the sick prisoners, and his family (as he believed) in con- 
 sequence of a female, selected from among the prisoners to 
 become his servant, being received into his house, before she 
 had entirely recovered from the disease, which she had suffered 
 in the form of bowel complaint, and a slight scurvy. 
 
 Further, prisoners recently admitted into the Penitentiary, 
 and not obnoxious to the influence of the causes to which the 
 disease was originally imputed, were nevertheless not exempt 
 from its attacks. , The diet was changed on the 1st of March, 
 and fresh convicts had been received into the Penitentiary 
 during the latter part of February. These certainly were not 
 subjected to the diet then in use for a period sufficiently long 
 to have derived any possible injury from it. The winter, too, 
 was now past, and fresh convicts were still sent to the Peni- 
 tentiary until the month of June. From the 16th of February 
 to June, 132 prisoners were admitted, namely, 127 males, and 
 five females. Of these 103 suffered the disease, namely, ninety- 
 eight males and five females. There was no difference in the 
 symptoms of their disease to distinguish it from that of those 
 who had been longer in confinement ; and, as far as the testi- 
 mony of one dissection goes, there was no difference in the 
 internal morbid conditions. 
 
 John Lampard, aged 29, was admitted into the Penitentiary 
 on the 25th of March. He had not been there more than three 
 weeks when he was seized with violent pains in the head. To 
 these fever succeeded. The fever declined into a slow hectic, 
 in the course of which dysentery arose, with evacuations of 
 slime and blood. The dysentery was mitigated, but the fever 
 continued, with delirium. Lastly, abscesses began to form in 
 the neck about the angles of the jaws, and a purulent discharge 
 took place from the ears. Thus he lingered until the 15th of 
 June, when he died. 
 
 Upon dissection, there were found vascular patches in 
 various parts of the intestines, ulcers of the large bowel, and 
 here and there spots of ecchymosis. The brain and its mem- 
 branes appeared free from disease. 
 
 These are the facts which led Dr. Roget and myself, in the 
 
300 ORIGIN OP THE DISEASE. 
 
 month of July, to express our suspicion to the committee, that 
 the disease had become contagious, and to recommend the 
 practical measures which such a suspicion would naturally sug- 
 gest. These facts were regarded in the same light by the other 
 physicians who were afterwards associated with us ; for when, 
 on the 27th of September, this question was formally proposed 
 to us by the committee, " Are the physicians of opinion that 
 the disease is contagious ? " we returned the following answer 
 conjointly : — " There are grounds for believing that the disease 
 has become contagious ; the evidence may not be of a nature 
 positively to establish the fact; but, practically, we feel it 
 imperative upon us to act upon the presumption that it is 
 contagious." 
 
 After the removal of the prisoners to "Woolwich and the 
 Regent's Park, certain circumstances occurred which seemed 
 still further to establish the prevalence of contagion ; and the 
 physicians (I fear) were thought rather perverse in not con- 
 sidering them quite so conclusive of the question as they were 
 regarded by others. 
 
 First. Three persons employed at the Ophthalmic Hospital, 
 who had not been at Millbank, suffered disorder of the bowels, 
 under one of the forms in which it had prevailed among the 
 prisoners, that of cholera morbus. But it was at a time of the 
 year when cholera morbus was everywhere a frequent complaint. 
 These three cases, therefore, could not be allowed to contribute 
 much weight towards the proof of contagion. 
 
 Secondly. The female prisoners on board the Narcissus had 
 been convalescent during several weeks ; when the females from 
 the Regent's Park, of whom several had recently suffered 
 renewed attacks of their disorder, were removed to "Woolwich, 
 and put on board the Heroine. Both vessels were moored close 
 to each other, and some women from the Heroine, for the sake 
 of better accommodation, were transferred to the Narcissus. 
 Not many days afterwards, there was a general complaint of 
 illness on board the latter vessel, which terminated in that form 
 of disease which has been described, occurring in the month of 
 March ; and thence it was concluded that the disease was com- 
 municated by the prisoners of the Heroine to the prisoners of 
 the Narcissus, and that another proof was obtained of its con- 
 tagious nature. 
 
OKIGIN OF THE DISEASE. 301 
 
 Now, if this were the fact, the disease was not only con- 
 tagious, but contagious in a manner peculiar to itself. For it 
 has never been shown (as far as I am informed) that the con- 
 valescents from any disease are capable of re-infection by those 
 who are the more recent subjects of it. 
 
 I am not disposed, therefore, to believe that the prisoners of 
 the Narcissus, in this instance of their sudden disorder, were 
 re-infected by those of the Heroine, because the fact itself 
 •would be contrary to general experience. And, further, I am 
 not disposed to believe it, because transitions from a state of 
 convalescence to a state of disorder had been just as sudden 
 among the men on board the Dromedary and the Ethalion, 
 when there was no possibility that it could have been derived 
 from contagion, unless you suppose the same people capable of 
 receiving and communicating the same complaint, from and to 
 each other, indefinitely. 
 
 Thirdly. "When the women were put on board the Narcissus, 
 a waterman was kept in constant employment communicating 
 between the vessel and the shore. This man had a severe attack 
 of dysentery. 
 
 If there had been many instances of this kind ; if it had 
 been notorious that, of the many individuals who in fact went 
 on board the Penitentiary hulks, such as friends, workmen, &c, 
 several had suffered the same symptoms with the prisoners 
 themselves, then there would have been evidence enough that 
 the disease was contagious after the removal from Millbank. 
 But this was not the case, and the single instance of the water- 
 man surely cannot justify this conclusion. Upon the whole 
 then, no other circumstances can be fairly admitted in proof of 
 the contagious nature of the disease but those which occurred 
 within the Penitentiary itself. Why the evidence which they 
 furnish " was not of a nature positively to establish the fact " 
 will plainly appear, when we have considered the question of an 
 injurious influence peculiar to the place. 
 
 I proceed next to state the facts and circumstances within 
 my own knowledge which bear upon the question of a noxious 
 influence peculiar to the place. The following Eeport, pre- 
 sented to the committee of the General Penitentiary on the 
 11th of October, 1823, contains some of the most important. 
 But before it is given, I think it necessary to state, concerning 
 
302 OEIGIN OP THE DISEASE. 
 
 the day-books which are there mentioned, and to which frequent 
 allusion will be made in the discussion of the present question, 
 that we had no knowledge whatever of their existence until 
 they were voluntarily produced by the apothecary himself a 
 few weeks before the date of the Report. The apothecary 
 either forgot that he had them in his possession, or he did not 
 think them capable of furnishing so much important informa- 
 tion, and therefore did not mention their existence. 
 
 TO THE COMMITTEE OP THE GENERAL PENITENTIARY. 
 
 llth October, 1823. 
 
 Gentlemen, 
 The severity of the disease prevalent at the Penitentiary having greatly 
 abated within the last few weeks, we have had more time to turn our atten- 
 tion from the immediate care of the sick, and to make further inquiry into 
 the origin and progress of the epidemic. We beg to lay before the com- 
 mittee all the details of our investigations. 
 
 We have perused all the written communications of the medical officers 
 to the committee, from June, 1820, when such communications were first 
 regularly made, down to the present time. 
 
 These communications consist of Reports made quarterly by the medical 
 superintendent and the apothecary; of Reports made monthly by the 
 apothecary ; and of numerous special Reports made by one or other, or by 
 both of them, at various times and at uncertain intervals. 
 
 The quarterly and monthly Reports contain observations upon the state 
 of health of all the prisoners in the Penitentiary ; the condition of those in 
 the prison at large, ascertained at their general inspection, as well as the 
 condition of the sick in the infirmaries, who were under constant observa- 
 tion and care. 
 
 The special Reports consist of returns made by the medical officers, of 
 all deaths that occurred, of notices of the diseases that proved fatal, also of 
 answers to inquiries respecting the health of individual prisoners ; and they 
 contain, moreover, various requests, suggestions, and observations, relating 
 to circumstances connected with their department. 
 
 In these communications we find the healthy state of the Penitentiary 
 announced after a general inspection in June, 1820, and constantly and 
 uniformly confirmed after every quarterly and monthly general inspection, 
 down to the commencement of the present year ; we find its exemption 
 from disease again and again insisted upon, as something striking and 
 peculiar ; and we also find comparisons drawn between the health of those 
 in common life and the health of the prisoners in the Penitentiary, and 
 conclusions deduced to the advantage of the latter. 
 
 Nevertheless, diseases did occur from time to time in the Penitentiary; 
 but we discover in these communications no opinion expressed by the medical 
 officera, that any one disease was predominant, or any one disease of a 
 peculiar character. 
 
OEIGIN OF THE DISEASE. 303 
 
 Throughout these communications, the only notices of disease resembling 
 that which has lately prevailed in the Penitentiary, are the following: — 
 
 In a Report after a general inspection, dated October 2nd, 1820, among 
 forty-seven cases of various diseases then in the infirmary, five cases of 
 diarrhoea are mentioned without further comment. No trace of this disease 
 is afterwards found, until a Report, after a general inspection, dated 
 November 2nd, 1821, a, single case of diarrhoea is mentioned, which proved 
 fatal, but without comment. Again, no trace of this disease is met with, 
 until in a Report, after a general inspection, dated January 6th, 1822, one 
 dangerous case of dysentery is mentioned ; and again, in a Report, after a 
 general inspection, dated February 2nd, 1822, one fatal case of diarrhoea. 
 Here the dangerous case of dysentery in one month, and the fatal case of 
 diarrhoea succeeding, refer to the same individual. 
 
 No allusion to the disease is afterwards made, until in a Report, after a 
 general inspection, dated June 4th, 1822, two fatal cases of diarrhoea are 
 mentioned ; and among the dangerous cases then in the infirmary, one of 
 diarrhoea is noticed, which, in a special Report made the next day, is said 
 to have proved fatal. 
 
 Afterwards, in a Report after a general inspection, dated July 1st, 1822, 
 one dangerous case of diarrhoea is mentioned, which terminated fatally, as 
 we learn from a special Report on the following day. From July, 1822, to 
 January, 1823, there is no allusion made to a single case of diarrhoea, when 
 in a Report, dated the 10th of the latter month, "a few more cases of 
 diarrhoea" are spoken of ; in the following month, viz. February, scurvy and 
 flux are said to be gaining ground, and in the beginning of March, these 
 two diseases pervaded the whole prison. 
 
 Thus, in these authentic records of the health of the Penitentiary, 
 regularly drawn up by the medical officers, and regularly presented to the 
 ■committee for their information, we can only find, daring the period of two 
 years and eight months which immediately preceded the declared existence 
 ■of the epidemic, eleven cases of any diseases at all similar to that epidemic 
 in its character and symptoms. Of these eleven cases, six proved fatal. 
 
 From these fatal cases, however, occurring as they did at periods remote 
 from each other, or indeed from all of them, mentioned as they were at the 
 time of their occurrence, without any special comment by the medical men 
 who observed and treated them, we should not now be justified in drawing 
 any inference. As far, then, as any information can be obtained from these 
 ■documents, we should still attribute this disease which has prevailed in the 
 Penitentiary, entirely and exclusively to the influence of diet, and to a 
 severe and protracted winter. 
 
 But we have thought it our duty to have recourse to other documents 
 And we have extracted from them facts of unquestionable importance 
 which were hitherto unsuspected by the medical men who have watched 
 the course of all the diseases that have occurred in the Penitentiary since its 
 first establishment. 
 
 We have examined the apothecary's day-book, and every paper upon 
 which any record has been preserved, of medicines ordered for the sick 
 
304 
 
 ORIGIN OF THE DISEASE. 
 
 from the year 1816 to the present time, including every prescription for the 
 severer ailments of those in the infirmary, and for the complaints of those 
 who were still well enough to pursue their ordinary occupations in the 
 prison! We have also examined the bills of charges for different kinds 
 of medicines that have bten furnished to the Penitentiary within the same 
 period. 
 
 By the help of these documents, and inferringi, as far as we could with 
 safety, the nature of disease from the medicines that have been procured, 
 and the kind of remedies prescribed for individual cases, we have en- 
 deavoured to form the most reasonable conjecture, whether any, and what 
 disease has been predominant in the Penitentiary before the last twelve- 
 month ; and if any, whether it has been at all similar to the epidemic that 
 has recently prevailed there. 
 
 The following Table gives the number of prisoners in the Penitentiary 
 every year since the year 1816, with the number of cases treated as 
 diarrhoea in every year : — 
 
 
 *1816. 
 
 1817. 
 
 1818. 
 
 1819. 
 
 1820. 
 
 1821. 
 
 1822. 
 
 Prisoners 
 
 72 
 23 
 
 212 
 104 
 
 246 
 106 
 
 351 
 
 82 
 
 609 
 85 
 
 798 
 87 
 
 866 
 
 
 88 
 
 "We are aware that inferences concerning the nature of a disease deduced 
 from the remedies employed for its cure would, in general, be hasty and 
 inconclusive. But as in the present case, the nature of the disease is 
 unequivocally indicated by the particular remedies used, we may, with 
 certainty, conclude that diarrhoea has existed in the Penitentiary from its 
 first establishment, and that it has prevailed in various degrees of extent 
 at different periods ; that, proportionably to the number of prisoners, it 
 prevailed to the greatest degree during the year immediately after its 
 establishment, and that it has prevailed in a less and less degree each 
 succeeding year, down to the period when the present epidemic was 
 discovered. 
 
 From the same documents we discover certain peculiarities belonging 
 to this disorder, peculiarities which become more and more remarkable in 
 each succeeding year (even although the numbers decrease), evidently dis- 
 tinguishing it from the disorder of the same name, which proceeds from 
 common and accidental causes. 
 
 Common diarrhoea is easily curable, and by the simplest means ; and in 
 constitutions otherwise healthy, we are not aware that it is at all liable to 
 recur habitually. 
 
 But this disorder (we find) did not readily yield to the methods of 
 
 * The numbers in this year refer to a period of six months only. 
 
ORIGIN OP THE DISEASE. 
 
 305 
 
 treatment employed. These records show how pertinacious and intract- 
 able it was in many whom it attacked* The same prisoners were again 
 and again brought under medical treatment for it in the same year. 
 Many of the patients of one year are found to have been the patients 
 of the preceding year, and as the period becomes more and more 
 remote from the first establishment of the Penitentiary, we find prisoners 
 still suffering diarrhoea, who had already endured it one, two, three, or 
 four years. 
 
 The following Table gives the gross number of cases treated as diarrhoea 
 in every year, and also the number of cases continued from preceding 
 years to the succeeding, the latter being included in the gross amount. 
 It furnishes also the number of new cases in every year, by subtracting 
 from the gross amount of each year the cases continued from preceding 
 years: — 
 
 
 1817. 
 
 1818. 
 
 1819. 
 
 1820. 
 
 1821. 
 
 1822. 
 
 Gross number of cases of ) 
 diarrhoea in each year ... f 
 
 Number continued from ) 
 
 104 
 11 
 
 106 
 32 
 
 82 
 31 
 
 85 
 23 
 
 87 
 20 
 
 88 
 17 
 
 Number of new cases in ) 
 
 93 
 
 74 
 
 51 
 
 62 
 
 67 
 
 71 
 
 The following Tables show how far back each case of diarrhoea that was 
 continued from one year to another can be traced : — 
 
 In 1817 : of 104 cases, 11 are traced back to — to 1816 
 In 1818 : of 106 
 
 In 1819 : of 82 
 
 In 1820 : of 85 
 
 In 1821 : of 87 
 
 32 
 
 31 
 
 23 
 
 20 
 
 26 to 1817 
 6 to 1817 & 1816 
 
 18 to 1818 
 
 13 to 1818 & 1817 
 
 12 to 1819 
 
 6 to 1819 & 1818 
 
 4 to 1819 & 1818 & 1817 
 1 to 1817 & 1816 
 
 7 to 1820 
 
 4 to 1820 & 1819 
 
 5 to 1820 & 1819 & 1818 
 1 to 1819 & 1818 
 
 1 to 1818 
 
 1 to 1818 & 1817 
 
 1 to 1817 & 1816 
 
 X 
 
306 ORIGIN OF THE DISEASE. 
 
 In 1822 : of 88 cases, 17 are traced back to 8 to 1821 
 
 4 to 1821 & 1820 
 2 to 1821 & 1820 & 1819 
 2 to 1820 
 
 1 to 1821 & 1820 & 1819 & 
 1818. 
 
 Upon the whole, we think that the facts adduced, warrant us in 
 concluding: — 
 
 That a disorder of the bowels, of a peculiar nature, at all times difficult 
 of cure, and of the same general character with that which has constituted 
 the late epidemic, has prevailed in the Penitentiary ever since its establish- 
 ment ; but that until the commencement of the present year it became 
 gradually more and more limited in its extent, and thfet although it has 
 been always difficult of cure, it has not upon the whole been attended with 
 much hazard to life, until the breaking out of the late epidemic. 
 
 Such are the details of our investigations, the facts they have disclosed, 
 and such the conclusions to which they have conducted us ; but as the 
 existence of any local influence productive of disease can only be presumed 
 from certain effects, it is also only from these same effects that the degree 
 and sphere of its activity can be estimated. Whatever noxious influence 
 peculiar to the Penitentiary may be suspected to exist, this influence must 
 have abated of its activity in proportion as the disease became more limited ; 
 that is, as the period was more remote from the first establishment of the 
 prison. It was, therefore (as everything seems to testify), when this dis- 
 order was reduced within narrower limits than at any former period, that 
 suddenly the same disorder became much more extensively prevalent than 
 it had ever been, that it assumed the form of an epidemic, and went far 
 beyond its former character, in the severity of its symptoms, and in its 
 fatal consequences. 
 
 Our belief is, that but for the change of diet and the severe and pro- 
 tracted winter, the disease never would have assumed the form of an 
 epidemic. The universal debility produced by these causes, rendered the 
 prisoners more obnoxious to an influence which, as far as we can judge, 
 had become less powerful in itself for the production of disease. 
 
 (Signed) P. M. Latham, M.D. 
 
 P. M. Eoget, M.D. 
 Clem. Hue, M.D. 
 Wm. Macmichael, M.D. 
 H. H. Southet, M.D. 
 
 This Report, being intended solely for the information of 
 the committee, was restricted to a plain statement of such facts 
 as were deemed capable of being understood, without explana- 
 tion, by unprofessional persons, and a plain statement of the 
 inference to which they seemed unavoidably to lead. It re- 
 
ORIGIN OP THE DISEASE. 307 
 
 presents that, from the first establishment of the Penitentiary 
 to the present time, there had been a very large prescription of 
 such remedies as could only have been given for a disorder of 
 the same general character with that which had lately prevailed 
 there; that a disorder of this character must always have 
 existed there to require that remedy, and that some^cause must 
 always have existed there to produce this disorder. 
 
 The remedies were designated "mist, cretse," and "pulv. 
 cretse." This " mist, cretse," we understood to be a compound 
 medicine, consisting of chalk mixture, aromatic confection, 
 tincture of calumba, and laudanum. The "pulv. cretae," we 
 understood was the pulv. cretse comp. c. opio. 
 
 Now medical men will acknowledge, that there is no species 
 of medicine from which the character of any disease can be so 
 certainly inferred, as a flux of the bowels from chalk mixture 
 or chalk powder with opium. From a large prescription of 
 bark, we could not have presumed the existence of ague, nor 
 from the extensive employment of sulphur or of mercury, could 
 we have safely inferred the prevalence of itch, or of syphilis. 
 Bark, and sulphur, and mercury, are continually administered 
 for other complaints besides those, for which they are the 
 reputed specifics. But chalk mixture, with the other ingre- 
 dients which have been mentioned, could only have been 
 employed for a bowel complaint which had flux for its pro- 
 minent symptom. If there could be any doubt of the fact in 
 the present instance, it was removed by the testimony of Mr. 
 Pratt himself, who prescribed the remedy, in whose examina- 
 tions before a committee of the House of Commons, on the 
 4th of March last, are found this question and answer : — 
 
 Question — Do you give the chalk mixture for any disorder hut diarrhoea ? 
 Answer — No ! ! 
 
 "We were in possession of other circumstances tending to 
 establish the same conclusions, which might have been in- 
 troduced into the Report, but which were purposely withheld, 
 because they were of a nature which medical men alone could 
 justly appreciate. At least they could not have been made 
 intelligible to others without certain explanations, which would 
 have been inconsistent with a simple statement. 
 
 These circumstaaces, however, must now be added, that 
 
808 ORIGIN OF THE DISEASE. 
 
 medical men (whom I consider myself now addressing) may 
 give them the weight to which they are entitled. 
 
 Long before the books were brought to light, which fur- 
 nished the facts upon which the Report is grounded, we were 
 morally convinced (as all physicians must have been) that 
 complaints, which had flux of the bowels for their prominent 
 symptom, had been frequent in the Penitentiary during former 
 years ; and this conviction was founded upon certain recorded 
 statements of the apothecary. In the minutes of evidence 
 before a committee of the House of Commons in the session of 
 1823, we found that Mr. Pratt, in his examination, had re- 
 ferred to a particular letter of his written in March, 1822, 
 when a change of diet was contemplated at the Penitentiary. 
 The letter contained a prediction that, in the event of the 
 change contemplated being carried into effect, those disorders, 
 which actually did take place, would be the consequence. 
 This warning was not forgotten when the evil became mani- 
 fest. Mr. Pratt was acknowledged by all to have predicted 
 truly, and allowed considerable credit. He was himself accus- 
 tomed to refer us to this prophecy and its verification, not 
 without some exultation; and indeed, well he might; for if, 
 without any help or suggestion from what had already occurred, 
 he really foresaw, not that some disease or other, but expressly 
 the very disease would follow the change of diet, which actually 
 did follow, it is one of the most splendid instances of medical 
 anticipation upon record. Nevertheless we were slow to allow 
 him more than the credit due to a sensible man, rightly con- 
 jecturing what would take place hereafter, from what had 
 heretofore fallen under his own observation. In short, we 
 were quite certain, that the prophecy could have had no other 
 foundation than in the bona fide experience of the prophet. 
 
 But convinced (as we were) of the fact, from the course in 
 which things are accustomed to happen in our own profession, 
 we could not insist upon it until some proof could be obtained, 
 which would be convincing also to others. "We continued, 
 therefore, in search of this proof, suppressing still our own 
 persuasion, until we had discovered it. 
 
 At length the books in question came to light ; and in them 
 it appeared, by the testimony of Mr. Pratt's own handwriting, 
 that at the very time he was prophesying to the committee, 
 
ORIGIN OF THE DISEASE. 309 
 
 that certain diseases would take place upon their projected 
 change of diet, he had already been prescribing most largely 
 for those very diseases ever since the foundation of the prison, 
 for six years in succession. 
 
 Knowing that bowel complaints always had been prevalent 
 in the Penitentiary, he came to the obvious and just conclusion, 
 that they would become still more so, if the diet was rendered 
 less nutritive than it was. "Whatever would debilitate must 
 render the prisoners more obnoxious to disease generally, and 
 especially to those complaints to which they had hitherto 
 always been liable. 
 
 With us, then, the facts stated in the Report only came in 
 confirmation of a belief which circumstances had already led 
 us to entertain, and which, as physicians, we must still have 
 entertained, whether those facts had been brought to light or 
 not. These circumstances, taken alone, were not calculated 
 (we knew) to conduct others to the same belief. But being 
 added, as they now are, to the facts of the Report, it will be at 
 once seen how much they strengthen its conclusion. 
 
 Another circumstance deserves to be mentioned, which gave 
 additional weight to the same conclusion. Before the books in 
 question were produced, we had no difficulty in seeing how the 
 apothecary came to foretell the disease of the Penitentiary just 
 as it came to pass. But we had the greatest difficulty in con- 
 ceiving how he alone should happen to foretell it, and the 
 medical superintendent have no such anticipation. His books, 
 however, soon cleared up this perplexity. For in perusing 
 them we found, that the apothecary alone was fully acquainted 
 with the facts upon which the anticipation was grounded, and 
 therefore that he alone could confidently entertain it. The 
 prisoners for whom chalk mixture, &c, was so largely em- 
 ployed were, for the most part, under Mr. Pratt's exclusive 
 care. More than half the number had medicine given to them 
 while they were following their ordinary occupations in the 
 prison. The functions of the medical superintendent and the 
 apothecary were so far divided, that while the daily business of 
 the former was only with the prisoners in the infirmaries, in 
 prescribing for their severer maladies, that of the latter was 
 moreover with the prisoners in the Penitentiary at large, in 
 prescribing for various ailments which did not require their 
 
310 ORIGJIN OP THE DISEASE. 
 
 removal into the infirmaries. Further, the medical superin- 
 tendent had nothing to do with the prison, except to make a 
 general inspection of it, accompanied by the apothecary, once 
 a month, when it is probable that the numbers taking chalk 
 mixture were not so regularly reported to him, as to make him 
 sensible how constant and extensive the prevalence of diarrhoea 
 had been within its walls. 
 
 There remains yet another circumstance to be insisted upon, 
 which bears upon the question of a noxious influence peculiar 
 to the place, and strongly confirms the conclusion of the 
 Report. 
 
 From the description of the disease lately prevalent at the 
 Penitentiary, it has been already seen that an affection of the 
 brain and nervous system formed as much a part of that disease 
 as did the bowel complaints themselves ; that it was co-extensive 
 with the bowel complaints, and consisted, for the most part, of 
 head-ach and vertiginous sensations, which, in many instances, 
 were aggravated into tremors, convulsions, and phrenzy. 
 
 By help of the apothecary's day-books, we were enabled to 
 show that one part of the disease (the bowel complaints) had 
 prevailed extensively in the Penitentiary since its first estab- 
 lishment. We could, moreover, have shown from the same 
 books that another part of the disease (the affection of the 
 brain and nervous system) had prevailed there almost co- 
 extensively, and during the same period. This latter fact (I 
 say) was also derived from the day-books; not, however, from 
 the books alone, but from them coupled with the explanatory 
 testimony of the apothecary himself. 
 
 We needed nothing but the record before us of the medi- 
 cines prescribed to ascertain the prevalence of bowel complaints 
 in the Penitentiary since its foundation ; but we were indebted 
 to the voluntary suggestion of Mr. Pratt for enabling us to 
 trace out retrospectively head-ach and vertigo through every 
 page of his own books. So confident was he, from a knowledge 
 of his own methods of prescribing, that certain remedies there 
 recorded were given by him for head-ach and vertigo, that he 
 undertook to draw up, and actually did draw up, a list of the 
 numbers afflicted with these disorders from the establishment of 
 the Penitentiary to the present time. These numbers were 
 almost as great as of those who suffered the bowel complaints- 
 
ORIGIN OP THE DISEASE. 311 
 
 in every year. They were arranged in a tabular form, and 
 were to have made part of the Report presented to the com- 
 mittee. But, upon deliberation, it was thought better not to 
 offer anything to the committee which was not self-evident, or 
 which stood in need of explanation beyond the mere statement 
 of the fact. 
 
 Chalk mixture and tincture of opium could only have been 
 prescribed for a flux of the bowels, and therefore unequivocally 
 denoted the disease. But emetics might have been prescribed 
 for various other complaints besides head-ach and vertigo, and 
 therefore could not be shown to denote their existence in the 
 present instance without further explanation, and without the 
 express testimony of the prescriber himself. 
 
 Now, concerning the circumstance last stated, it is too little 
 to say, that it merely confirms the inference of the Report — it 
 does more. If you admit as evidence that only which the 
 books, upon the very face of them, unquestionably prove, you 
 must conclude that a disorder of the same general character with 
 the late epidemic has prevailed in the prison since its establish- 
 ment ; and we went no further in our Report. But if, more- 
 over, you admit the explanatory testimony of the apothecary, 
 you must go near to allow, that the disorder which so prevailed 
 there was identical with the late epidemic. 
 
 I wish to add a few remarks concerning the books in 
 question, as bearing testimony to the existence of flux alone 
 within the Penitentiary, and concerning the use we have made 
 of them for that purpose. It was at first our intention to have 
 taken the books themselves to the committee, and to have 
 turned over the leaves in their presence, pointing out, in one 
 page after another, and frequently in the same page, the 
 abbreviated marks which signified the compound chalk mixture 
 and the compound chalk powder; to have stated tljat such 
 medicine could only have been given for disorders whose pro- 
 minent symptom was flux of the bowels, and then to have left 
 the committee to draw their own inference. But it was thought 
 more respectful to present a formal Report, and it was foreseen 
 that such a Report would be required for the information of 
 Government. Accordingly, in endeavouring so to frame it, as 
 to convey the most accurate notion of the extent to which flux 
 of the bowels had prevailed in the Penitentiary, we could 
 
312 ORIGIN OF THE DISEASE. 
 
 conceive no better method than that of the numerical Tables 
 "which have been given. Nevertheless, these mere figures do 
 not convey so much as the books themselves. The form of 
 certain entries which appeared there gave perhaps a more certain 
 assurance that diarrhoea was the predominant complaint of the 
 prison than any that could have been derived merely from their 
 numbers. 
 
 Among frequent entries of medicine delivered to individuals 
 by name, there were occasional entries of chalk mixture, sent 
 by quarts and half gallons, to companies of prisoners working 
 together at their various employments. Thus we find, without 
 any specification of the individuals who were to take the 
 medicine — 
 
 In 1816, an entry of 1 quart bottle of mixture for the kitchen women. 
 
 „ „ 1 „ Mrs. Clarke's women. 
 
 In 1817, „ 2 „ Mrs. Clarke's women. 
 
 „ „ 1 „ Mrs. Evan's women. 
 
 „ „ 2 „ the laundry. 
 
 „ „ 1 „ the carpenter's cell. 
 
 In 1818, „ 1 „ Mrs. Croome's women. 
 
 „ „ 1 „ Mrs. Gould's women. 
 
 „ „ 1 „ Laban's men. 
 
 „ „ 3 „ Brett's men. 
 
 In 1819, „ 1 „ Mrs. Clarke's women. 
 
 Here it is quite evident, that among these several companies 
 there was a predominant disorder requiring to be treated by 
 one and the same remedy, and that, from the nature of the 
 remedy, the disorder was diarrhoea. It is evident, also, that, in 
 each company, the cases of diarrhoea were so numerous that it 
 became needless or impossible to specify the individuals who 
 should take the medicine. The medicine, therefore, was delivered 
 out in large quantities, with general directions (we may pre- 
 sume), that it should be taken by all, or by as many as re- 
 quired it. 
 
 These are all the facts and circumstances within my know- 
 ledge which bear upon the two questions of contagion and of a 
 noxious influence peculiar to the place, as causes engaged in the 
 production and continuance of the disease prevalent at the 
 Penitentiary. 
 
 Now, to revert to the question of contagion, if its existence 
 
ORIGIN OF THE DISEASE. 313 
 
 and influence be allowed upon the proof of those facts and cir- 
 cumstances which have been mentioned as occurring within the 
 Penitentiary at the time specified, our first opinion concerning 
 the original and exclusive causes of the disease suffers, solely on 
 this account, no necessary contradiction. Those facts and cir- 
 cumstances were of too late a date to allow a belief that 
 contagion had any share in its original production. Im- 
 poverished diet with cold, might still be the causes which first 
 engendered the disease, while contagion might be a property 
 superadded to it in the eourse of its progress, and serve to 
 explain whatever has subsequently appeared in its nature and 
 extent, which these causes alone seem inadequate to account for. 
 
 This might be deemed a complete theory of the origin and 
 progress of the disease. But the disclosure of new facts 
 demands the admission of another cause, by which the theory is 
 destroyed. 
 
 To revert, then, to the question of a noxious influence 
 peculiar to the place, which is the cause I mean, if it be granted 
 upon the proofs adduced, its existence renders a contagious 
 property in the disease extremely doubtful, and, at the same 
 time, manifestly contradicts our opinion concerning its original 
 and exclusive causes. For all the imputed effects of contagion 
 admit equally of explanation, upon the presumption of a local 
 injurious influence. And whatever share an impoverished diet 
 and cold might ultimately have in promoting the disease, they 
 could have nothing to do with its origin, since it is traced back 
 to the first establishment of the prison, and found to have 
 prevailed during more than six years prior to that severe 
 winter and that reduction of animal food to which it has been 
 ascribed. 
 
 Finally, then, it may be asked, did an impoverished diet 
 with cold, did contagion, and did a noxious influence peculiar 
 to the place, all bear the relation of causes to the disease of the 
 Penitentiary ? And, if so, what was the share which belonged 
 to each in its production and continuance ? 
 
 That an impoverished diet with cold, and that a local noxi- 
 ous influence really bore this relation to the disease, is estab- 
 lished (I conceive) by a train of facts and circumstances, 
 which constitute a moral proof as strong as the nature of the 
 subject will admit. And as to the share which each had in its 
 
314 ORIGIN OF THE DISEASE. 
 
 production and continuance, it is pointed out (I conceive), with, 
 great probability of truth, by the physicians, in their Report 
 of the 11th of October. But with respect to contagion, nothing 
 can be stated with confidence. For we cannot pretend to 
 assign to it its proper share in the production and continuance 
 of the disease, while it yet remains very uncertain whether it 
 had any share at all. 
 
 In what has been stated concerning the origin of the Peni- 
 tentiary disease, my purpose has been rather to furnish medical 
 men with the materials of forming an opinion for themselves, 
 than to assert my own. My own opinion, indeed, I might have 
 entirely suppressed, had it not been the same to which four 
 other physicians were led by a contemplation of the same facts. 
 On this account, certainly, I have myself adopted it with more 
 confidence of its truth. 
 
 At the same time I am fully aware of all the difficulties 
 which naturally oppose themselves to the satisfactory solution 
 of such questions as the present ; and these difficulties are of a 
 kind which it may not be uninstructive briefly to point out. 
 
 Where it is admitted that a disease can be derived from one 
 cause only, its origin is easily assigned whenever it occurs. 
 Where there is small-pox, it must come from contagion. But 
 there is the greatest difficulty, where a disease is capable of 
 being produced by several causes, to point out any single cause, 
 or any two or three causes in combination, which have actually 
 produced it at a particular time. 
 
 The disease of the Penitentiary is of this latter kind. It 
 has no one proper and specific cause, but may arise from various 
 causes; from heat or cold, from moist or dry, from almost 
 any kind of injurious influence operating immediately upon 
 the body, or upon the body through the mind ; from bad diet, 
 from the influence of situation, and perhaps from contagion ; 
 and the difficulty of assigning such a disease expressly to any 
 one or two causes consists in this, that you cannot feel confident 
 in their particular operation until you have the best possible 
 reason for the exclusion of all others which are capable of pro- 
 ducing it. 
 
 Amidst all these difficulties, then, I may well be asked, 
 whether I really feel assured that the disease of the Peni- 
 tentiary was (as the Report suggests) derived originally and 
 
ORIGIN OF THE DISEASE. 315 
 
 essentially from something noxious in the situation, and was 
 rendered epidemic by an impoverished diet and a severe winter ? 
 and I answer, that I do not pretend to impute it to these causes 
 as punctually and confidently as medical men ascribe small- 
 pox to contagion ; for the nature of the thing forbids such 
 absolute certainty ; but that, from all the circumstances within 
 my knowledge, I cannot help coming to this as the most pro- 
 bable belief. 
 
 I wish to add a few words upon the question of contagion. 
 Whatever may have been the original source of this disease, 
 may not one part of it at least be entirely ascribed to contagion ? 
 
 The prisoners admitted into the Penitentiary, after the im- 
 proved diet was adopted and mild weather had returned, were 
 affected with the disease. Of 132 so admitted there were 103 
 who suffered. In them was it not entirely derived from con- 
 tagion ? 
 
 Assuredly it was in contemplation of these cases that, when 
 the question concerning its contagious nature was put to us 
 by the committee, we answered, that it was practically impera- 
 tive upon us to act as if it were contagious. By which we 
 meant to say, that the facts already known went to such a 
 suspicion of contagion, as to require us in prudence to act 
 upon it, as if it were an ascertained truth ; but that, neverthe- 
 less, the facts known did not come up to the best proof that 
 could be had of contagion, and, therefore, we, as physicians, 
 could not be so satisfied of this truth as absolutely to pronounce 
 it contagious. 
 
 Contagion is a very obscure thing ; and so, too, is the 
 noxious influence of situation. They are not only obscure in 
 themselves, but perpetually obscure the operation of each other 
 in the production of disease. We can never be sure of the 
 operation of contagion, except under circumstances which 
 exclude the operation of local influence. Thus it may take 
 ages to settle the question of contagion respecting a particular 
 disease, because it may not be found under circumstances in 
 which local injurious influence is unquestionably excluded. It 
 is a subject of much controversy, at the present day, whether 
 the yellow fever be contagious or not — and for the reasons to 
 which I allude. 
 
 Thus with regard to the disease of the Penitentiary, my 
 
316 OEIGIN OP THE DISEASE. 
 
 colleagues and myself have held the belief of contagion less 
 confidently in proportion as facts have arisen which go nearer 
 to impute an injurious influence to situation. 
 
 If I am asked, what would go to the full proof of contagion 
 in the disease of the Penitentiary ? I should say nothing less 
 than this ; namely, that various prisoners, under the actual 
 symptoms of the disorder, having been set at liberty, various 
 people, with whom they had intercourse in the several situations 
 to which they resorted, had been seized with symptoms precisely 
 the same. 
 
 On the 7th of February, 1824, a paper was laid by Mr. 
 Holford before the managing committee of the Penitentiary, 
 entitled "Observations on the Medical Report made by the 
 Physicians, dated 11th October, 1823." 
 
 It is, in fact, a formal answer to our Report; is written 
 with great deliberation, and contains (I presume) every objec- 
 tion which can be brought against our conclusions. 
 
 Now, I feel myself under great difficulty how to deal with 
 this document. If I make no allusion to it, I may be justly 
 blamed for suppressing whatever tends to recommend an opinion 
 different from my own ; while, in noticing it (as I am bound to 
 do), I unavoidably incur the hazard of diminishing the value 
 that might otherwise belong to a simple statement, by the 
 introduction of controversial matter. 
 
 The document in question was communicated to the phy- 
 sicians at the time it was laid before the managing committee 
 of the Penitentiary, and we ought (it may be thought) imme- 
 diately to have presented an answer to it, if any was capable of 
 beiDg given. But we knew (as all medical men must know) 
 how difficult it is to argue upon the subjects of our own pro- 
 fession with unprofessional persons. This was one reason of our 
 silence. Another, and a stronger reason, was our determination 
 never to become a party in any of the controversies around us, 
 and even to avoid, as much as possible, being drawn into dis- 
 putes with others about our own opinions and practice ; and al- 
 though the respectable quarter from which the " Observations " 
 proceeded might seem to demand some notice, yet we did not 
 think that either our credit, or our usefulness, would be in- 
 creased by entering into a contest with a member of the 
 
ORIGIN OP THE DISEASE. 317 
 
 managing committee. Besides, we were aware, that a com- 
 mittee of the House of Commons was about to sit upon the 
 affairs of the Penitentiary, and that we should 'be individually 
 subjected to examination upon all the points to which the 
 " Observations " relate.* 
 
 After recapitulating the conclusion of our Eeport, the 
 " Observations " continue thus : — 
 
 " Before I proceed to inquire how far these Tables prove the prevalence 
 of diarrhoea of any kind, I beg to ask, how they can show that the diarrhoea, 
 for which the medicine alluded to is supposed to have been given, was of a 
 peculiar nature, or had any resemblance to the present disease ? Can the 
 exhibition of the chalk mixture or powder prove that this disease was pre- 
 ceded or accompanied by petechial spots or blotches ] that it had a dysen- 
 teric character ? that it was attended with tenesmus 1 or with the inflation 
 of the lower regions of the abdomen, or the very sudden and violent pains, 
 which were observable in the present disorder i All these symptoms will 
 be negatived by the medical man who gave the medicine ; nor was the 
 treatment of the two disorders the same ; but we are called upon to infer 
 the existence of a diarrhoea similar to the present one, merely from the 
 supposed use of a medicine, by which the present disorder has not been 
 cured, the physicians having, on the contrary, found themselves obliged to 
 have recourse, for its cure, to the use of mercury, pushed in general to such 
 an extent as to produce salivation." 
 
 I presume that the several interrogations which here follow 
 each other in succession are intended to have the force of so 
 many distinct objections, imputing to us that we really did 
 insist, in our Eeport, that the diarrhoea of former years was of 
 a peculiar nature, and had a resemblance to the present disease; 
 and that, extending our notion of such resemblance to the 
 
 * I have been under some embarrassment what method to adopt in 
 replying to this document of Mr. Holford's. One method would have been 
 without printing the document at length, to state the objections which it 
 contains, and then to give answers to them. But this I could not follow in 
 consequence of the objections not being put in distinct propositions. 
 Another method would have been, still without printing the document 
 itself, to extract what seemed to me to bear the force of objections, and to 
 put them into distinct propositions in my own language. But this would 
 have had too much the appearance of making out a case for myself to reply 
 to, and might have exposed me to a suspicion of misrepresentation. It only 
 remained, therefore, for me to take the " Observations," paragraph by para- 
 graph, that the original might be at hand to determine whether I have 
 interpreted each objection in its true sense, and have fairly answered them. 
 
318 OKIGIN OF THE DISEASE. 
 
 minutest particulars, we really did insist, in our Report, that 
 the exhibition of chalk mixture or powder proved the diarrhoea 
 of former years to have been preceded, or accompanied, by 
 petechial spots or blotches ; to have had a dysenteric character, 
 and been attended with tenesmus, and inflation and violent pain, 
 like the present disorder. 
 
 Whoever will take the trouble of referring to the Report 
 itself, will find that the disorder formerly prevalent in the 
 Penitentiary is there spoken of in the most general terms, and 
 that the name diarrhoea is used in the largest sense, and as 
 synonymous with flux. He will find, moreover, that we strictly 
 abstain from ascribing to it any particular symptoms or ac- 
 companiments, and that, in mentioning its peculiarities, we 
 expressly state them to consist, not in its symptoms or accom- 
 paniments, but in its difficulty of cure, and liability to recur in 
 the same individuals. Lastly, he will find that all the corres- 
 pondence we pretend to have discovered between the disorder 
 of the bowels which has recently, and that which has always, 
 prevailed in the Penitentiary, is that they were both " of the 
 same general character." This was a flux, and that was a flux; 
 and as such they were as like each other as one fever is like 
 another, or as diseases commonly are which come under the 
 same generic denomination. In fact, the symptoms brought 
 forward to mark the essential difference of the two diseases 
 might or might not exist without changing their nature, or 
 altering any opinion which might otherwise be formed con- 
 cerning their origin. They apply to degrees of severity and 
 malignancy, not to the essence of the disease. 
 
 It is implied by the argument (otherwise the argument fails 
 altogether) that the signs enumerated were attendant upon the 
 whole course of the late flux, and the petechiae, the dysenteric 
 character, tenesmus, inflation, and violent and sudden pains 
 were present in every case. Now, the petechiae, if by them are 
 meant scorbutic spots upon the skin, were, indeed, very general, 
 as long as they lasted, but they lasted only six weeks ; and if 
 by them are meant ecchymosed spots in the intestines, they 
 could only be known to exist where they were found, namely, 
 in several who died and were examined after death, although 
 they might, and probably did, exist in many others. With 
 respect to the tenesmus, and the blood (or whatever is meant 
 
ORIGIN OF THE DISEASE. 319 
 
 by the dysenteric character), and violent pains, they did not 
 occur in more than half the cases. So that, should these 
 symptoms be held to constitute essential distinctions of disease 
 (which is impossible), the late flux was not only different from 
 the former diarrhoea, but was itself a different disease in one- 
 half of the prisoners from what it was in the other half. 
 
 The argument from the treatment of the two disorders not 
 being the same, proceeds upon the supposition that diseases of 
 the same general character and denomination are always treated 
 by one and the same remedy ; and, further, that their being 
 amenable or not to one and the same remedy, is the test 
 whether they are or are not entitled to such or such a character, 
 and to such or such a name. The supposition is not unreason- 
 able in itself, and very likely to occur to any unprofessional 
 person. But physicians (I fear) must admit that the present 
 state of their knowledge will hardly enable them to arrive at an 
 axiom which presumes so precise an insight into the essence of 
 diseases, and the operation of medicines. Although fevers, and 
 influenzas, and erysipelas require to be treated at different 
 times by different, or even opposite, methods, in the same place 
 and in the same individuals, yet physicians still talk of fevers, 
 and influenzas, and erysipelas, and still discern a certain con- 
 formity of character in each, whenever it occurs, by which they 
 are entitled to the same names under all circumstances. 
 Granting, therefore, that the bowel complaints of the Peni- 
 tentiary were, during six years and a-half, treated with chalk 
 mixture, and subsequently were treated with mercury, we did 
 not (I presume to think) greatly err, either in conceiving them 
 always to have borne the same general character, or in calling 
 them by the same generic name, the chalk mixture and the 
 mercury notwithstanding. 
 
 Medical men will hardly pardon me for dwelling so long 
 upon these observations ; but I have been led to do so from 
 recollecting the impression they made upon those to whom they 
 were originally addressed. 
 
 Mr. Holford next proceeds thus. " I deny, however, that the liability of 
 the prisoners to diarrhoea of any kind can be estimated by the quantity of 
 medicine administered for that disorder in the prison. 
 
 " The first thing which it occurs to a prisoner in any prison to say, when 
 he wishes to feign illness, is, that he has a pain in his bowels ; and when- 
 
320 ORIGIN OF THE DISEASE. 
 
 ever such, a complaint has been mentioned in the Penitentiary, the party- 
 has had the chalk mixture or powder, of course, without any previous in- 
 vestigation into the reality of the disease, as the surgeon will testify. Every 
 prisoner, therefore, who has pretended to have a pain in his bowels as an 
 excuse for not doing work enough, or from a wish to have a few days' 
 enjoyment of better food, or of ease and idleness in the infirmary, or from a 
 desire to miss chapel, or plague his turnkey to let him out of his cell to the 
 privy in his ward oftener than was convenient, or from any other cause, 
 even though he may have been discovered afterwards to have been shamming, 
 is included in these Tables as a case of diarrhoea, his name appearing on the 
 surgeon's books among those who had taken chalk ; and I believe the 
 medical gentlemen who drew the Keport may safely be appealed to as 
 witnesses for this fact, viz. that the class of cases of feigned illness is not a 
 small one in the Penitentiary ; and can speak from their own experience of 
 the curious tricks and devices practised in support of imposture, and of the 
 difficulty of detecting it ; they can also probably remember instances, in 
 which prisoners have purposely brought back their illness by drinking cold 
 water and other expedients ; and I can tell them, that when the prisoners 
 were employed in flax-beating some time ago, several of them were detected 
 in chewing the flax to produce a temporary derangement in their bowels, 
 all of whom now stand, of course, in these Tables as cases of genuine 
 diarrhoea." 
 
 The sum of the objection contained in this paragraph is, 
 that diarrhoea was the disorder which the prisoners were 
 accustomed to feign, for the sake of procuring indulgences 
 and avoiding labour ; yet that all cases, real and feigned, are 
 included in our Tables. 
 
 We unquestionably did not pretend to distinguish between 
 real and feigned cases, where all were treated alike. The fact 
 of feigned disease could only have been ascertained at the 
 time. If it was not ascertained at the time, it cannot now be 
 assumed ; and, if it was ascertained, it is rather extraordinary 
 that the counterfeits should still have been treated as actual 
 diseases, and indulgences still granted as to real invalids, and 
 fresh motives held out to counterfeits. 
 
 If there is anybody who, from memory, can speak to the 
 fact of a considerable number of these cases being counterfeits, 
 it must be the apothecary. Now, the apothecary was employed 
 by us, day after day, in our investigation, and when it was 
 completed, he was perfectly aware of the conclusion to which 
 it led. He was ready and unreserved in his communications ; 
 yet I do not recollect, neither do any of my colleagues recollect, 
 that he mentioned a single word about counterfeit cases, or 
 
ORIGIN OF THE DISEASE. 321 
 
 made any objection whatever to our mode of proceeding, or 
 stated any circumstance within his knowledge which could 
 invalidate our conclusion. Our impression was, that Mr. Pratt 
 regarded his own books as authentic records of medicines pre-* 
 scribed for real diseases. He brought these books to us unso- 
 licited, and he produced them with this memorable observation, 
 " How lucky it is I have kept them."* 
 
 But, when Mr. Holford concludes, that cases feigned, for a 
 great variety of motives, which he specifies, and cases pur- 
 posely produced in a great variety of ways, all " stand in our 
 Tables as cases of genuine diarrhoea," he, to our surprise, quotes 
 this very Mr. Pratt as the source of the information from 
 which he proceeds to his conclusion ; for he means no other 
 person, when he says, " as the surgeon will testify." Yet, 
 after all, what does he quote him as testifying? That 
 prisoners, making certain complaints of illness, " had chalk 
 mixture or chalk powder, of course, without any previous investi- 
 gation into the reality of their disease." Surely this is not an 
 announcement on the part of Mr. Pratt of the truth, as it 
 was actually ascertained by himself, that all the prisoners 
 who so complained were "shamming," but an acknowledg- 
 ment of his own omission to ascertain whether they were so 
 or not. 
 
 I will venture to make this general observation, for the 
 truth of which I appeal to all physicians of public institutions, 
 namely, that when people have an interest in seeming to be ill, 
 they always counterfeit disorders of sensation, and sensation 
 merely, and thus they often succeed, owing to the extreme 
 difficulty of detecting the deceit. If a person affirms that he 
 has pain, how can you be sure he has not ? But never was an 
 instance known of feigned diarrhoea, because no one was ever 
 silly enough to believe that the pretence could go undiscovered 
 for a moment. Surely the prisoners of the Penitentiary are 
 
 * These words are in the recollection of all the physicians ; for they 
 were the subject of frequent, very frequent remark at the time, seeming 
 (as we thought) to intimate the apothecary's own opinion, that his day- 
 books contained something useful towards the object of our inquiry. Now 
 the object of our inquiry at the time, was some definite proof of the exist- 
 ence of diarrhoea in the prison prior to the autumn of 1822, a fact which 
 we already more than suspected. (See page 308.) 
 
322 ORIGIN OF THE DISEASE. 
 
 the last one should be inclined to suspect as the authors of a 
 stratagem which would necessarily detect itself. 
 
 But let it be admitted, for an instant, that the prisoners of 
 •the Penitentiary did pretend a flux of the bowels for six years 
 and a half in succession, yet is it not incredible, that any 
 medical man could be so deceived as to go on prescribing, 
 during six years and a half in succession, for any disease what- 
 ever, as if it had affected from one-half to one-tenth of a certain 
 community ; while, in point of fact, the disease had not existed 
 at all during the whole of that period ? And is it not still 
 more incredible, that any medical man should so prescribe for 
 a disease, the characteristic symptom of which, if it had been 
 real, must have continually forced itself upon his senses ? 
 
 But let it be admitted, not only that flux of the bowels was 
 the feigned disease of the Penitentiary, during six years and 
 a half, but also, that feigned as it was, Mr. Pratt went on pre- 
 scribing chalk mixture and chalk powder for it, as if it had 
 been real during the whole of this period : what follows ? A 
 coincidence of the most extraordinary kind, namely, that this 
 same disease which had been the unreal and fictitious disease of 
 the Penitentiary during so many years, became all at once so 
 unquestionably real, that the lives of half the prisoners were in 
 jeopardy from it, and many actually died ; and, moreover, that 
 the very remedy which had been prescribed during so many 
 years, for no purpose whatever, was the same which, at length, 
 was found most necessary and indispensable* 
 
 Of the motives assigned by Mr. Holford for counterfeiting 
 a disease, which never can be counterfeited with success, I have 
 little to say. Of the minor motives, such as missing chapel, 
 and plaguing the turnkey, I know nothing, and can say nothing. 
 But concerning the principal motive, which includes every 
 other that can be imagined, that of obtaining admission into 
 the infirmary, where the prisoners enjoyed a better diet, idle- 
 ness, ease, society, &c, I wish to make a few observations. 
 
 It appeared to me, when this subject was investigated last 
 year, that those gentlemen (not professional) who dissented 
 from the conclusion of the physicians, respecting the existence 
 
 * Vide page 217, where it will be seen what remedies we found the 
 medical officers prescribing, with apparent success, when we were first 
 called to the Penitentiary. 
 
ORIGIN OP THE DISEASE. 
 
 323 
 
 of flux within the Penitentiary since its foundation, did so 
 upon the presumption, that all persons for whom the medicine, 
 considered by us unequivocally to denote the disease, was pre- 
 scribed, were, during the time of taking it, treated in every 
 other respect as invalids ; that they were released from their 
 usual labours, and brought into the infirmary, and allowed all its 
 indulgences and comforts. Consequently, as there seemed to 
 exist such strong motives for prisoners to pretend a trivial 
 disease, they could not help believing that they did so. The 
 fact, however, was not as it was presumed. Of those who took 
 the chalk mixture and powder, some were received into the in- 
 firmary, and some were not ; and the latter, upon the whole, 
 were the majority. These had the medicine sent to them in 
 their cells ; they were allowed no indulgence, and no exemption 
 from their ordinary labours, and could have no imaginable 
 motive for pretending disease. 
 
 My friend Dr. Macmichael, who took a peculiar interest in 
 this question, and to whose acuteness the discovery of a pre- 
 dominant disease always existing in the Penitentiary is prin- 
 cipally to be ascribed, has furnished me with an important 
 document, showing how many of those who were treated for a 
 flux of the bowels, were received into the infirmary in each 
 year, and how many were not : — 
 
 
 1816. 
 
 1817. 
 
 1818. 
 
 1819. 
 
 1820. 
 
 1821. 
 
 1822. 
 
 Number of Prisoners . . . 
 
 72 
 
 212 
 
 246 
 
 351 
 
 609 
 
 798 
 
 866 
 
 Number of those who ~) 
 were treated for ii > 
 Mux of the Bowels ) 
 
 23 
 
 104 
 
 106 
 
 82 
 
 85 
 
 87 
 
 88 
 
 Number of those so ~) 
 treated who were ( 
 admitted into the t 
 
 14 
 
 4 
 
 36 
 
 37 
 
 60 
 
 73 
 
 54 
 
 Number of those so } 
 treated who were ( 
 not admitted into [ 
 the Infirmary ) 
 
 9 
 
 100 
 
 70 
 
 45 
 
 25 
 
 14 
 
 34 
 
 It is remarkable that, as the disease became more limited in 
 extent, the numbers admitted into the infirmary were propor- 
 
324 OKIGIN OF THE DISEASE. 
 
 tionably greater ; and that, in the three last years, the cases 
 treated as flux in the infirmary, far exceeded those so treated in 
 the prison. My belief is, that as the extent of the disease be- 
 came less, its severity was greater, and that, from a smaller 
 number of cases, there were more that required to be carefully 
 treated. For, in the year 1822,* between January and the 2nd 
 of July, and before the less nutritive diet was adopted, five 
 deaths are reported from diarrhoea, or dysentery ; while, during 
 the whole year, not more than eighty-eight suffered those 
 diseases, as far as we can judge from the remedies employed ; a 
 mortality proportionably greater than that which subsequently 
 occurred from diseases of the same character, when they con- 
 stituted a part of the epidemic. 
 
 I had almost forgot to advert to the means which prisoners 
 are said to have used for purposely procuring bowel complaints. 
 Drinking cold water, and masticating flax, might, and pro- 
 bably did, reproduce diarrhoea in a few, who were hardly con- 
 valescent from recent attacks. But the question is not concerning 
 what has happened lately. It is allowed by all, that a disorder 
 of the bowels has lately prevailed, which was capable of being 
 reproduced by anything that had the least power of irritating. 
 We are inquiring what could have produced a flux of the 
 bowels de novo in a community otherwise healthy several years 
 ago, and continued to produce it for several years in succession. 
 The means specified certainly could not. He who, being in 
 perfect health, takes pure water for his purgative, or sucks out 
 the little juice that lingers in a bit of dried flax, will surely not 
 suffer such a commotion of the bowels, as will be mistaken for 
 disease. 
 
 " I come now to cases of sickness, neither feigned nor purposely pro- 
 duced. I believe that a great majority of the cases, for ■which medicine 
 may have been properly given in the Penitentiary, would never have been 
 brought under the observation of a physician or apothecary, if they had 
 occurred out of the prison, or have been known to any but the parties 
 affected, who would (to use a common phrase) have allowed the disorder to 
 carry itself off, or perhaps have varied their food. If a medical man were 
 to go round certain streets inhabited by poor families in a, part of the town 
 esteemed the most healthy, prepared to dole out his medicine to any 
 individual who chose to apply for it, and this for nothing ; and if he were 
 
 * Vide page 304. 
 
ORIGIN OF THE DISEASE. 325 
 
 besides to enter upon a regular examination of every inhabitant in those 
 streets once a month as to the state of his health, I suspect he would find at 
 the end of the year, that he had expended more medicine than had been 
 sold in any other district of the same size from the apothecaries' shops in 
 the neighbourhood ; but he certainly would not be warranted in drawing 
 any unfavourable comparison between the streets under his care and the 
 neighbouring districts. Now the wards of the Penitentiary are just like 
 these streets." 
 
 Here the matter of fact, as it regards the Penitentiary, that 
 the cases of real disease within it were such, for the most part, 
 as required no medical treatment, and the matter of fact, as 
 it regards certain districts of the town, that the inhabitants 
 have a natural love of physic, are both mere assumptions. 
 
 It will not, therefore, be thought disrespectful if I decline 
 answering them, since they can have naturally no weight in 
 determining the matter in question. I will only take the 
 liberty of observing, concerning the latter assumption in this 
 paragraph, that the parallel which is imagined should have 
 been carried further; for, as it stands, it would not, if true, 
 lead to the inference which is intended. It is not enough for 
 the argument, that people in certain districts should have an 
 inherent longing for physic generally, and pretend any disease, 
 for the sake of obtaining it, they must have an express longing 
 for chalk mixture, and the disease which they pretend must be 
 diarrhoea. 
 
 " Disorders of the bowels are, I am told, not uncommonly found in 
 prisons, or among any large bodies of men who are all fed alike, and have 
 not the opportunity of varying their food, until there shall be an actual 
 appearance of some derangement of the system ; and it is not improbable 
 that diarrhoea may have been prevalent in a prison where very coarse 
 brown bread has been the basis of the dietary ; but I deny that this fact 
 can be inferred in opposition to other evidence, from the mere examination 
 of the quantity of medicine sent into the prison, even if the surgeon had 
 stood by to see it taken, which he undoubtedly was not in the habit of 
 ■doing." 
 
 "When Dr. Roget and myself were first employed at the 
 General Penitentiary, questions were drawn up by us, and 
 addressed by the Secretary of State to various gaols in England, 
 respecting their schemes of diet, and their ordinary diseases ; 
 and, from the answers returned, it did not appear, that bowel 
 complaints, of the same general character with that of the 
 
326 ORIGIN OF THE DISEASE. 
 
 Penitentiary, had been prevalent in any of them. Thus much 
 I think it proper to state, as a matter of fact. Further I am 
 not concerned to reply to what is admitted to be hearsay. 
 
 " If it be true, that the number of eases in which the chalk mixture has 
 been given, has been gradually diminishing during the period of six years 
 and a half, alluded to in the physician's Report, so that comprehending 
 one-thirdf of the whole number of the prisoners in the first half year ending 
 on the 31st of December, 1816, they amounted only to one-ninth or one- 
 tenth of the number in the prison during the whole of the year 1822 (as is 
 stated in the Tables in the Report), I certainly cannot infer from that fact, 
 any change in the climate of the Penitentiary, or any gradual improvement 
 in the local circumstances connected with the prison, but should rather 
 look for the causes of the decrease in the number of patients or quantity of 
 medicine, to the surgeon's having discovered that he had been too lavish of 
 his physic, or to his having become more skilful in detecting the attempts 
 of prisoners to impose upon him, or to the greater care taken by himself or 
 the officers to see the medicines taken, or to such changes in the diet or 
 discipline of the infirmary, as may have diminished the desire of the 
 prisoners to be removed thither," &c. &c. &c. 
 
 This mode of arguing, that the diminution in the cases of 
 diarrhoea, year after year, was not real, but in consequence of 
 the apothecary and officers having become more skilful in de- 
 tecting the tricks of the prisoners, proceeds upon an implied 
 assumption of the whole question at issue. It is first taken for 
 granted, that a flux never existed in the prison, and then a 
 theory is set up to explain some deceptive circumstances which 
 have led " credulous" people into erroneous notions upon this 
 subject. 
 
 "There] are, moreover, other classes of persons residing within the 
 prison, who seem to have been strangely overlooked upon this occasion.. 
 We have a considerable number of inferior officers, male and female, 
 within the walls of the Penitentiary, and it is well known, that bowel com- 
 plaints have not been prevalent among them before the month of April 
 last, when the disorder, was evidently infectious, and several of the officers 
 employed among the prisoners were attacked by it. We have also had, 
 from the first establishment of the prison, families of superior officers 
 residing in the very centre of the building, which have been so healthy, 
 that no individual belonging to any of them has died since the prison was 
 opened." 
 
 Here is the induction of a particular fact with nothing- 
 raised upon it; and it would be hardly fair for me to pre- 
 
ORIGIN OF THE DISEASE. 327 
 
 sume what was the inference intended, and thus to make an 
 argument for myself to reply to. Surely the health of the 
 resident officers cannot be intended either to negative the fact 
 that the prisoners were ill, or to intimate that, of two classes 
 of people, differing from each other in all the circumstances of 
 their lives, although living in the same place, one could not 
 possibly derive disease from a source to which the other might 
 be exposed with impunity. 
 
 " To come now to the Tables exhibiting the number of patients affected 
 ' by diarrhoea in each year, and of thoae in whom that disease is traced to 
 successive years. Assuming, for the sake of argument, that every dose of 
 medicine was given for a real disorder, I must still doubt, how far the 
 principles upon which these Tables, though drawn up with great labour, 
 have been constructed, are correct, for the purpose of showing the preva- 
 lence of diarrhoea. The first defect in them appears to me to be, that they 
 make no distinction between cases, in which the bowels of the patient have 
 been relaxed for a single day, and cases which have been obstinate and 
 protracted." 
 
 "We did not make the distinction here required, because it 
 was not warrantable from the data before us. 
 
 " If the greater number of convicts within the prison should appear to 
 have had a looseness for one day in the course of the year, I think it can 
 hardly be stated, from any number of such cases, that diarrhoea has been 
 a prevalent disorder in the Penitentiary ; nor if many prisoners have had 
 relaxed bowels once in the course of each year, for several successive years, 
 can such persons be considered as having had a disorder "difficult of cure," 
 such repeated instances of relaxed bowels in a succession of years being 
 nothing more than is experienced by a large proportion of the inhabitants 
 of this country. Now there is in these Tables no distinction between the 
 cases of patients, to whom one single delivery of medicine has taken place, 
 and of those who may have been under a long continuance of medicine 
 either in the same year, or in successive years. I have been furnished by 
 Mr. Pratt, from whose papers these Tables have been formed, with a list of 
 the prisoners who have taken the medicine alluded to, from the first opening 
 of the prison, and with the daily quantity of medicine delivered out to 
 each. I cannot make the numbers amount to those mentioned in the 
 Report ; but there are a great many cases, in which one single delivery of 
 " a mixture," or of " chalk powder," appears to have taken place during the 
 whole period of the prisoners' confinement. There are also a great many 
 cases of prisoners who appear to have had medicine delivered to them on 
 two days only in the course of two or more successive years ; and there is 
 one case of a woman who had medicine only on the 31st of December in one 
 year, and on the 1st of January only in the next, who, I . learn from 
 
328 OKIGIN OF THE DISEASE. 
 
 Mr. Pratt, stands in these Tables as a patient for diarrhoea in the two 
 successire years." 
 
 From " a looseness for one day in the course of the year," 
 appertaining to any number of prisoners, unquestionably it 
 could not be inferred that diarrhoea had been the prevalent 
 disorder of the Penitentiary ; and from many instances of 
 " relaxed bowels once in the course of each year for several 
 successive years," unquestionably it could not be inferred that 
 the disorder had been difficult of cure. But how were these 
 facts concerning " looseness for one day in the course of the 
 year," and " relaxed bowels once in the course of each year, 
 for several successive years," to be ascertained ? 
 
 Mr. Holford, relying on certain lists which were furnished 
 him, seems to intimate (if I rightly understand him), that 
 these facts might have been ascertained from ihe quantities of 
 medicine therein stated to have been supplied to different 
 prisoners ; and that a single delivery of medicine might be 
 considered to indicate a diarrhoea of a single day, and the gross 
 number of single deliveries to stand for the gross number of 
 diarrhoeas of one day in each year, for several successive years. 
 
 But this calculation and its results are contrary to my 
 constant observation, which assures me that nine people out of 
 ten, in every condition of life, and especially among the poor, 
 would rather run their chance with a common diarrhoea, than 
 take medicine for its relief ; and that nine people out of ten 
 never do apply for medicine until it is gone beyond (what they 
 conceive to be) a common diarrhoea. By no other rule can I 
 pretend to judge concerning the disorder of the Penitentiary, 
 and the medicines prescribed for it, than that of my own ex- 
 perience ; and thus so far am I from believing a single delivery 
 of chalk mixture or chalk powder to have been always given 
 for a single day's diarrhoea, that I conceive nine prisoners out 
 of ten never took even a single dose, until the disorder had 
 already been troublesome to them during several days. 
 
 But the question is not concerning a dose of the medicine, 
 but concerning a delivery. I do not know what quantity of the 
 chalk powder went to one delivery ; but one delivery of chalk 
 mixture amounted to eight ounces, or five full doses. To half 
 an ounce of tincture of calumba, and twenty -five drops of lauda- 
 
ORIGIN OF THE DISEASE. 329 
 
 num, and two drachms of aromatic confection, was added as 
 much chalk mixture as would complete the eight ounces. 
 
 Now, from what obtains, in ordinary practice, and especially 
 in the practice of public institutions, I should infer that the 
 prisoners for whom this mixture of eight ounces was prescribed, 
 had, in the opinion of the prescriber, something more than a 
 common diarrhoea, or a diarrhoea of a single day. Since for 
 such a disorder, in a person otherwise healthy, one dose, and 
 one dose only, would be thought enough, and repeated doses, 
 to the number of five, would be deemed inexpedient, and not 
 without the hazard of some inconvenience. 
 
 Upon the whole, then, I must continue to believe, that the 
 physicians acted a prudent part in not admitting any dis- 
 tinctions of the kind intimated into their Report ; and that, 
 although they were quite aware of numerous cases, for which 
 the medicines were prescribed more and less frequently, and 
 might suspect that such cases were more and less severe, they 
 were still right in inferring no more than the general prevalence 
 of a certain disorder from the general use of certain remedies. 
 Thus much they thought they could do with safety. But, it is 
 said, that they cannot do even this ; while, at the same time, it 
 is complained, that they have not done more, namely, that they 
 have not made a distinction of cases, grounded upon the greater 
 and less frequency with which the medicines were prescribed. 
 
 There is one circumstance especially pointed out by Mr. 
 Holford in disparagement of the method of proceeding adopted 
 by the physicians, Upon which I must make a short remark. 
 It is, that " a woman, who had medicine only on the 31st of 
 December in one year, and on the 1st of January only in the 
 next, stands in these Tables as a patient for diarrhoea in two 
 successive years." 
 
 Now, it was the purpose of the physicians to show, by their 
 Tables, the extent of the disease at different periods of time 
 since the foundation of the Penitentiary ; and it was natural, 
 with this view, to fix upon the division of years. Thus they 
 reckoned all who were treated for a flux of the bowels in each 
 year, taking care not to count the same individuals more than 
 once, how frequently soever any might have been under treat- 
 ment between January and December ; for they considered 
 that the disease had not extended its sphere within a certain 
 
330 OEIGIN OF THE DISEASE. 
 
 period, so long as the same individuals were attacked by it. 
 Moreover, it was the purpose of the physicians to show, by 
 their Tables, how far the disease was maintained in the Peni- 
 tentiary by new cases, arising at different periods, and how far 
 by the same cases continued from one period to another ; and 
 with this view, also, it was natural to fix upon the division of 
 years. Thus, beginning each year as a fresh period, they 
 reckoned in the same manner as before, all who took chalk 
 mixture or powder in the course of it, including, however, both 
 those who had, and those who had not, been enumerated in any 
 former year ; yet finally distinguishing them, and specifying 
 the numbers capable of being traced back from one year to 
 another. Hence an individual case, being upon the confines of 
 two periods would be reckoned twice ; while occurring at both 
 extremes of the same period, and many times in the course of 
 it, it would be reckoned only once ; and thus it happened, that 
 the case of the female who was treated for flux on the 31st of 
 December in one year, and on the 1st of January in the next, 
 was included in two periods. 
 
 I have entered upon this explanation, because the instance, 
 so expressly pointed out, seemed to impute a sort of stratagem 
 to the physicians in their mode of reckoning ; nevertheless, I 
 am much surprised that it was not at once seen how this single 
 fault (if it be a fault), unavoidably arose from the structure of 
 the Tables. And indeed, all such tables must, from their very 
 nature, be obnoxious to faults of the same kind in single 
 instances. For no form of generalizing was ever known, which 
 could give a satisfactory view of a subject upon the whole, and 
 at the same time do exact justice to every particular included 
 in it. 
 
 The words " difficult of cure," are quoted from the Report 
 of the physicians, as falsely characterizing a disease, which in 
 many instances seemed to require little medical treatment. 
 Nevertheless, however mild it might have been in particular 
 instances, yet, since it was the predominant disease of the place 
 during many years, and since the patients of one year were 
 traced back, in the proportion of a third, a fourth, or a fifth, as 
 the patients of preceding years, and since it, or a disease of the 
 same general character, finally involved all at once, both those 
 who had, and those who had not suffered it before, namely, 
 
ORIGIN OF THE DISEASE. 331 
 
 almost the whole population of the prison, I do not think the 
 physicians were far wrong in stating summarily that it was 
 " difficult of cure." 
 
 " From these Tables, moreover, if framed with a view to the discovery 
 of the extent in which diarrhoea can have been produced by any local 
 influence in the prison, should be excluded all cases in which the looseness 
 of the bowels has arisen in the latter stage of other disorders, from the 
 debility occasioned by consumption, &c. &c, and cases, where the patients 
 are known to have had the digestive organs materially injured by drinking, 
 or other vicious courses, before they came into confinement, &c. When all 
 these shall be withdrawn, the numbers will, I suspect, be very materially 
 diminished ; at all events, so long as they stand on the file undistinguished, 
 the Tables cannot be considered as containing the result of an investigation 
 into the effects of local influence, even admitting, what I believe no person 
 will be credulous enough to believe, that all the cases, for which medicine 
 has been given, have been cases of real sickness for which physic would be 
 taken in ordinary life." 
 
 When the Tables were drawn up by the physicians, they 
 had the constant assistance of the apothecary, and some cases 
 were excluded for reasons which he suggested, and which were 
 deemed satisfactory at the time. I can therefore hardly 
 conceive it possible that many cases are still to be found in 
 them, which ought not to have been admitted. 
 
 Mr. Holf ord has added a postscript to the " Observations," 
 which I proceed to notice with great reluctance. Most will- 
 ingly should it pass without a single remark from me, but 
 that my total silence might seem to admit the censure as just, 
 which it is its express object to cast upon my colleagues and 
 myself. I say its express object, because the writer in the 
 meantime loses sight of every other, and even so entirely 
 forgets the conclusion, which he has hitherto been labouring to 
 establish, as to bring forward facts in support of his censure, 
 which furnish stronger grounds for the opinion of the physi- 
 cians than those which were adduced by the physicians them- 
 selves. 
 
 The Postscript is as follows — 
 
 " Since the foregoing Observations were written, I have looked more 
 narrowly than I had done before into part of the papers given to me by 
 Mr. Pratt, which he assures me are faithful extracts from, his books of all 
 the entries respecting the delivery of chalk mixture, or chalk powder, since 
 the opening of the Penitentiary (these entries being the ground of the 
 
332 ORIGIN OF THE DISEASE. 
 
 Physicians' Keport) ; and if these extracts have any pretensions to correct- 
 ness, the Tables of the physicians must be abandoned as entirely useless 
 with reference to the matter in question, or indeed as to any matter. I have 
 taken up that portion of the Tables which professes to give the whole 
 number of the patients who took chalk in 1822, and the numbers traced 
 back as having taken it in former years, and have examined these numbers 
 with the entries in Mr. Pratt's books as vouched and explained by the 
 extracts given to me. I chose the last year in the Tables (1822), because I 
 thought the year in which the prison began to be affected with the pre- 
 vailing epidemic, was that from which, if any similar disorder could be 
 traced back to former years, it was most important to trace it, and I have no 
 reason to suppose, that the Tables are more or less accurate in respect to the 
 patients of that year than they are concerning those of any other year. 
 
 The Tables make the whole number of patients for diarrhoea in that 
 year 88 ; I make them 90 ; but I find that more than the half of that 
 number, are cases in which medicine has been delivered out only once. 
 The physicians make the number traced back 17 ; I make them 24 ; but'in 
 a very large proportion of these, the patient has only had the medicine 
 once given to him in most of the years into which he is traced. If the 
 physicians mean, that the number given comprises all who had taken chalk 
 in the preceding years, they have omitted several ; but if they mean, that 
 there are 17 cases in which persons who were afflicted with diarrhoea in 
 1822, had been under the influence of chalk medicine in preceding years 
 for any considerable length of time, that is certainly not the case according 
 to these papers." 
 
 First, for the justice of the censure. The apothecary fur- 
 nishes Mr. Holford with certain papers, assuring him that they 
 are faithful extracts from the day-books of all entries respecting 
 chalk mixture and chalk powder ; and Mr. Holford, comparing 
 the numbers given in our Tables for one year, 1822, with the 
 entries of the day-books as vouched and explained by these 
 extracts made by the apothecary, finds they do not entirely 
 accord; hereupon he lays the foundation of his somewhat 
 sweeping censure, and adds, " if these extracts have any pre- 
 tensions to correctness," (putting the case hypothetically, but 
 arguing upon it as a fact,) "the Tables of the physicians must 
 be abandoned as entirely useless with reference to the matter 
 in question, or indeed as to any matter." 
 
 The few last words contain something more of contempt 
 than the physicians (I am persuaded) will be thought to de- 
 serve, certainly something more, than any reasons which are 
 apparent will be thought to justify. 
 
 Several times in the course of the "Observations" has 
 
ORIGIN OF THE DISEASE. 333 
 
 Mr. Holford raised his argument upon the sole authority of 
 statements furnished him by Mr. Pratt ; and in so doing, when 
 those statements related to professional points, upon which 
 Mr Pratt had peculiar means of information, he did what was 
 right ; hut in so doing, when those statements related to points 
 which were capable of being ascertained, and verified by him- 
 self, he did, what perhaps is hardly allowable in any inquiry 
 like the present. But, however this may be, when he finally 
 takes upon himself to dismiss the physicians with a sentence of 
 very strong censure and contempt, I may be pardoned for 
 thinking, that then especially he ought to have verified for 
 himself the facts which are the grounds of his harsh opinion, 
 or that at least he should not have allowed it to appear, that 
 he had taken them altogether upon the credit of another. The 
 facts were entirely within his own reach, and Mr. Holford 
 could, and (I presume to repeat) ought to have examined for 
 himself the original entries in the day-books, and compared 
 them with the Tables of the physicians, before he ventured to 
 hold up their labours to the contempt of the managing com- 
 mittee, and characterized them " as entirely useless with re- 
 ference to the matter in question, or indeed as to any matter." 
 
 Nevertheless the physicians are, upon the whole, under 
 some obligation to Mr. Holford for adding strength to their 
 conclusion by the very facts, which he has chosen to accept 
 from Mr. Pratt in support of his censure. For grant that, in 
 respect to the gross number of cases in the year 1822, and the 
 number of cases traced back from that year to preceding 
 years, we are wrong, and that he is right. We are wrong in 
 understating that which he is right in putting at a higher 
 amount. We make the number of cases in the year, 88 ; he 
 makes them 90. We make the cases traced back 17; he 
 makes them 24. Whence it will follow arithmetically, that he 
 goes so much further than ourselves in imputing disease to the 
 Penitentiary, as 90 are more than 88, and 24 are more than 17. 
 But after all it must be admitted that extracts of entries 
 from journals of the kind in question are very liable to error. 
 The question is to which side in the present instance the error 
 most probably belongs, whether to that of the physicians or of 
 the apothecary. If several persons should be employed sepa- 
 rately upon a journal, containing entries of various kinds ex- 
 
33rt 
 
 ORIGIN OF THE DISEASE. 
 
 tended over many years, in extracting from, it those which 
 related to a particular subject, it is probable that the numbers 
 as calculated by each would be different, and that in every in- 
 stance the numbers would be incorrect. But, if several persons 
 should be employed together upon such a journal, for the same 
 purpose, and so distribute their labours, that each should be a 
 check upon the other, it is probable that the numbers, thus 
 calculated by all, would be correct. In a long catalogue a 
 single entry is very apt to escape the eye, and to go unreckoned. 
 
 Feeling this liability to error, the physicians and Mr. Pratt 
 were conjointly occupied upon the day-books in question, which 
 contained prescriptions of various kinds, for various complaints, 
 during a period of six years and a half, for the purpose of 
 extracting from them the entries of chalk mixture and chalk 
 powder. And it is no disparagement of the accuracy of any of 
 us, to believe that the numbers thus calculated by us altogether 
 bear a greater probability of truth, than any numbers which 
 each might have calculated singly. Is it too much to suppose 
 that they are really more accurate than those so calculated by 
 Mr. Pratt ? 
 
 Subjoined to the Postscript are two Tables, upon which I 
 desire to make a few observations. The first is entitled 
 
 ABSTRACT OF THE NUMBER OF PRISONERS 
 
 To whom any delivery of Chalk Mixture, or Chalk Powders, has taken 
 place in the Penitentiary, during the latter part of the year 1816, and 
 during the years 1817, 1818, 1819, 1820, 1821, and 1822; distinguishing 
 the Number of deliveries to any one Prisoner during each year. 
 
 Number of deliveries. 
 
 1816. 
 
 1817. 
 
 1818. 
 
 1819. 
 
 1820. 
 
 1821. 
 
 1822. 
 
 One 
 
 9 
 
 40 
 
 49 
 
 53 
 
 62 
 
 71 
 
 72 
 
 Two 
 
 7 
 
 16 
 
 13 
 
 19 
 
 18 
 
 28 
 
 21 
 
 Three 
 
 
 7 
 
 4 
 
 7 
 
 4 
 
 7 
 
 6 
 
 Pour 
 
 3 
 
 2 
 
 3 
 
 4 
 
 2 
 
 8 
 
 3 
 
 Five 
 
 
 
 2 
 
 4 
 
 3 
 
 1 
 
 1 
 
 Six 
 
 
 
 1 
 
 1 
 
 
 2 
 
 
 More than six ... 
 
 2 
 
 3 
 
 5 
 
 4 
 
 
 5 
 
 10 
 
 Total 
 
 21 
 
 68 
 
 77 
 
 92 
 
 89 
 
 122 
 
 113 
 
 Average number of") 
 prisoners in the > 
 Penitentiary ) 
 
 
 
 
 
 
 
 
 64 
 
 151 
 
 224 
 
 273 
 
 427 
 
 631 
 
 745 
 
 
 
 
 
 
 
 
ORIGIN OF THE DISEASE. 335 
 
 The purpose of this Table is to show that of those, for 
 •whom chalk mixture or chalk powder was prescribed in each 
 year, the majority took so much only as was contained in one 
 delivery. But it has been already proved, that this fact, being 
 admitted, does not go to negative the existence of diarrhosa as 
 the predominant disorder of the prison.* 
 
 The following Table, which is the second subjoined to the 
 postscript of the " Observations," I have already taken the 
 liberty of using in another place,f because it seemed to me to 
 contain, in the most succinct shape, as strong an argument as 
 could be imagined of a predominant disease existing in the 
 Penitentiary, and of that disease being diarrhoea. In speaking 
 of the day-books, I observed that the form of certain entries in 
 them went especially to prove the fact, those, namely, of chalk 
 mixture, sent wholesale to prisoners working in companies, 
 without any specification of the individuals who were to take 
 it. But I had mislaid my note of the number of such entries, 
 and had I not accidentally turned to Mr. Holford's " Observa- 
 tions," and found this Table subjoined to them, I should have 
 been at a loss how to put the argument in its most convincing 
 form. I have yet another use to make of the same Table, and 
 therefore I now give it again in its proper place. 
 
 In 1816, an entry of 1 qrt. bottle of mixture for the kitchen -women. ~) 
 
 » » 1 „ Mrs. Clarke's women. 
 
 In 1817, „ 2 „ Mrs. Clarke's women. 
 
 1 „ Mrs. Evan's women. 
 
 2 „ the laundry. 
 
 In 1818, 
 
 In 1819, 
 
 the carpenter's cell. 
 
 1 
 
 1 „ Mrs. Croome's women. 
 
 1 „ Mrs. Gould's women. 
 
 1 „ Laban's men. 
 
 3 „ Brett's men. 
 
 1 „ Mrs. Clarke's women. 
 
 It is here well worthy of remark, that Mr. Holford himself, 
 who, in one part of his " Observations," insists' so strongly 
 upon the motives for " shamming " being a sufficient proof of 
 the fact, does in this very Table give the most glaring promi- 
 nence to a circumstance which destroys the supposition alto- 
 gether. For, by it we find the complaint, for which chalk 
 * Vide page 328. t Vide page 312. 
 
336 ORIGIN OF THE DISEASE. 
 
 mixture was prescribed, was so far from furnishing a claim of 
 indulgence, that not merely those who were employed at their 
 trades, but those who sustained the hard labour and household 
 drudgery of the prison, were not exempt from that labour and 
 drudgery in consequence of taking medicine. 
 
 Thus much I have thought it my duty to say in reply to 
 the "Observations" of Mr. Holford. They were considered 
 (I know) by those to whom they were addressed, to be a com- 
 plete refutation of all which the physicians had advanced con- 
 cerning flux, as the predominant disorder of the Penitentiary 
 since its foundation. The physicians themselves, however, 
 presumed to think otherwise, and even to believe that much 
 was contained in the " Observations," which tended rather to 
 confirm their own opinions. The question is an important one, 
 and it is now left for the decision of medical men. 
 
 In closing my review of the " Observations," I shall refrain 
 from passing, in my turn, any summary opinion upon them. 
 For I feel much too strongly what is due to a man, who, during 
 many years, and under circumstances of peculiar difficulty, has 
 bestowed his best exertions, zealously and profitably, upon the 
 great objects of the Penitentiary, to characterize any part of 
 his labours as " entirely useless with reference to the matter in 
 question, or indeed as to any matter." 
 
APPENDIX. 337 
 
 APPENDIX. 
 
 Respecting diarrhoea as the prevalent disorder of the prison 
 since its foundation, I have one more remark to make, which, 
 having omitted in its proper place, I think of sufficient import- 
 ance to subjoin in an Appendix. 
 
 The Tables of the Physicians are (I must own) imperfect 
 in one respect, and the day-books are not now within my reach 
 to enable me to supply the defect. They give the proportion 
 which those ill of diarrhoea in every year bore to the whole 
 convict population of the Prison, both sick and well ; whereas 
 they ought to have given the proportion of those ill of diarrhoea 
 to those ill of other complaints, or rather, to have given this 
 last proportion in addition to the former. 
 
 The Tables, indeed, as they stand, show enough : neverthe- 
 less, parallel statements are of great use in such cases ; and, if 
 the Physicians had admitted into their Tables, first the total 
 number of prisoners, then the number of all who were ill, 
 whatever was their complaint, and lastly the number of those 
 ill of diarrhoea, they might have obtained, with respect to the 
 two last, a parallel statement from any Hospital or Dispensary, 
 which would have shown at once, whether the proportion of 
 diarrhoea to other disorders in the Penitentiary, was greater or 
 less than elsewhere. 
 
 The following Tables are formed from Dr. Bateman's Book 
 " on the Diseases of London," in which an account is given of 
 the kind of Diseases and the number of Cases treated at the 
 Public Dispensary, Carey Street, during twelve years. They 
 show the proportion which the disorders, whose prominent 
 symptom is flux of the bowels, including dysentery, diarrhoea, 
 and cholera, bore to all others whatever in each year, during the 
 whole of that period, and enable us to form a comparison be- 
 tween the Penitentiary, and one particular District of London, 
 in respect to the prevalence of those disorders. 
 
338 
 
 APPENDIX. 
 
 Year. 
 
 1805. 
 
 1806. 
 
 1807. 
 
 1808. 
 
 1809. 
 
 1810. 
 
 Gross Number ) 
 of Cases ) 
 
 1821 
 91 
 
 2049 
 87 
 
 2063 
 134 
 
 1998 
 112 
 
 1957 
 95 
 
 2118 
 119 
 
 Year. 
 
 1811. 
 
 1812. 
 
 1813. 
 
 1814. 
 
 1815. 
 
 1816. 
 
 Gross Number ) 
 
 2224 
 140 
 
 2305 
 123 
 
 2504 
 144 
 
 2656 
 109 
 
 2610 
 121 
 
 2462 
 130 
 
 It appears that, during the twelve years, the cases of flux, 
 in the proportion they bore to the gross number of cases treated 
 at the Public Dispensary, varied between a fifteenth and a 
 twenty-fourth. 
 
 Now, if at the Penitentiary the proportion of those ill of 
 diarrhoea to the whole of the prisoners both sick and well, was 
 so considerable as one-tenth in the last and most favourable year 
 which our Tables embrace, and so enormous as one-half in the 
 first year, what must it have been to those only who were sick ? 
 
 But, if all the prisoners in the Penitentiary had been sick 
 the proportion of those suffering diarrhoea in the most favour- 
 able year, far exceeds that which is found in any Hospital or 
 Dispensary, where I have made inquiry. 
 
ON THE 
 
 USE OF OPIUM U FEYEES. 
 
 By P. M. LATHAM, M.D., 
 
 Physician to St. Bartholomew's Hospital. 
 [Read before the College of Physicians, March 17, 1832.] 
 
 There are forms of fever which are very simple and very easy 
 to treat ; and the simplest form is that in which all the symp- 
 toms observe a certain proportion to the state of the vascular 
 system, so that, however various they may be, and how many 
 soever the organs they involve, they become greater or less, 
 and rise or fall, according to the degree of excitement manifest 
 in the heart and arteries. Here the treatment is easy, because 
 it hangs upon a single indication. Reduce vascular action, and 
 the fever begins to decline ; and with it also begin to decline 
 whatever symptoms appertain to particular organs — to the sen- 
 sorium, to the organs of the chest, or the organs of the abdo- 
 men, or to any other part. 
 
 But there are forms of fever which are very complex and 
 very difficult to manage ; where the symptoms, taken altogether, 
 do not conform themselves to the existing state of the vascular 
 system, and where a single indication thence derived does not 
 guide us in the treatment of the entire disease. Here, what- 
 ever the condition of the blood-vessels may require to be done, 
 some special treatment is moreover demanded for the relief of 
 particular organs ; so that how far depletion should be carried, 
 is often in practice a very subordinate question ; while the life 
 of the patient may depend upon a just determination in giving 
 or withholding purgative medicine, or in making use of calomel 
 
340 ON THE USE OF OPIUM IN FEVERS. 
 
 largely or sparingly, according to present conditions of disorder 
 in the abdominal viscera. 
 
 But my present purpose is with, certain disorders of the 
 brain which arise in the course of fevers, and with opium as 
 their appropriate remedy. 
 
 It hardly ever happens that a fever passes through its 
 entire course without some symptoms declaring themselves which 
 are especially referable to the sensorium ; and in the majority 
 of cases where such symptoms appear, the morbid affection of 
 the sensorium is unquestionably derived from the blood-vessels. 
 Still the cases are not few in which it is derived from some 
 other source. 
 
 Now, how important the brain is as an object of the physi- 
 cian's attention in fevers, must appear, not only from its ex- 
 treme proneness to participate in the disease, but chiefly from 
 the consideration that it is through the medium of this organ 
 that death very frequently takes place. 
 
 The morbid affections of the brain in fevers are never with- 
 out an evil tendency, come from what source they may. If 
 from the blood-vessels, the danger is upon the whole less, 
 because the method of cure is more evident ; if from other 
 sources, the danger is augmented by the difficulty of obtaining 
 clear indications of treatment. 
 
 My observation has taught me that, connected with fever, 
 there are affections of the brain which are essentially inherent 
 in the organ itself; and capable of relief only by remedies 
 which exercise an immediate impression upon that organ. But 
 of such remedies, it is opium only which I have learnt to 
 employ to any salutary purpose. 
 
 "With respect to the diagnosis of these affections, they are 
 rather denoted by concomitant circumstances than by any 
 stamp of peculiarity they bear on themselves. So much so, 
 that I could not mention any series of symptoms flowing from 
 the brain, and cured by opium, which I have not also seen 
 cured by bleeding. Indeed, I only know a single symptom 
 referable to the brain which would suggest the use of opium as 
 the suitable remedy ; and that symptom is a state of wake- 
 fulness. 
 
 There may be much, or little, or no delirium — much, or 
 little, or no tremor, or subsultus ; in short, cases successfully 
 
ON THE USE OF OPIUM IN FEVERS. 341 
 
 treated by opium have, in respect of other symptoms belonging 
 to the sensorium, differed as much as possible from each other, 
 while they have agreed in this one of perpetual wakefulness. 
 
 Yet the state of wakefulness does not alone justify the 
 remedy ; if it did, nothing more would remain to be said in 
 defining its use. But the state of wakefulness may be present, 
 and- still opium not be the appropriate remedy. That it is or 
 is not, must be determined by circumstances to be sought for, 
 not in the sensorium itself, but elsewhere. To these concomi- 
 tant circumstances, therefore, both as best discriminating the 
 disease and best indicating the remedy, our attention must be 
 mainly directed. 
 
 These circumstances are often such as to exhibit a sort of 
 contrast with the existing affection of the brain. The proper 
 febrile symptoms are just enough to characterise the disease 
 and to constitute it a fever : some chilliness and some heat, 
 alternating with each other ; the countenance now a little pale, 
 and now a little flushed ; and the pulse more frequent, but not 
 more forcible than natural ; and the tongue merely clammy, 
 and the stomach and bowels not notably deranged. Yet, with 
 these moderate symptoms, there will arise at an early period, 
 or at the very commencement of the fever, a disorder of the 
 sensorium which is strangely disproportionate. Day after day 
 the disproportion will be more striking, until at no distant 
 period (for such cases pass on with great rapidity to their fatal 
 termination) with a pulse almost too feeble to be felt and too 
 frequent to be counted, will be combined the wildest delirium 
 and the most violent exertion of muscular force. If, under 
 these circumstances, a state of continual wakefulness form (as 
 it generally does) a part of the sensorial affection, opium is the 
 appropriate remedy ; and there is no other remedy (as far as I 
 know) that offers the slightest chance of saving life. 
 
 In the cases described, the symptoms referable to the sen- 
 sorium outrun, from first to last, every other symptom, whether 
 belonging to particular organs or to the constitution at large. 
 The symptoms, in their aggregate, constitute a fever ; but the 
 sensorium has its own special disorder, requiring a special 
 remedy, and which is independent of the blood-vessels. When 
 the patient dies, it is this disorder which kills him ; for he dies 
 of exhausted nervous energy, and upon dissection, you find no 
 
342 ON THE USE OF OPIUM IN FEVERS. 
 
 visible vestige of disease either in the brain or in any other 
 part. 
 
 But there are other cases of fever in which there is no 
 evident contrast between other symptoms and those belonging 
 to the brain, at first. The disorder of the sensorium keeps pace 
 with that of other parts, and with the state of the circulation ; 
 and thus the disease proceeds until it is somewhat advanced, 
 when the harmony between its symptoms is disturbed. Those 
 of the brain outrun the rest. New indications of treatment 
 arise, and if the patient can be saved at all, it must be by 
 opium. 
 
 Thus the heart and arteries may be full of activity, and 
 every symptom in proportion to it. Remedies are accordingly 
 addressed to the vascular system, and succeed for every 
 purpose they are intended to fulfil except one. The general 
 febrile symptoms are abated by venesection. By venesection, 
 or by topical bleeding, each organ loses its peculiar distress. 
 The respiration is easier ; the abdomen bears pressure, and 
 even the head ceases to ache and throb. But, withal, the deli- 
 rium continues. As other symptoms are relieved, the delirium 
 is even aggravated. The patient mutters, or sings, or talks, 
 nonsense ; he is absolutely sleepless day and night, and is 
 jumping up and endeavouring to get out of bed. Such is the 
 condition of the sensorium with an improved state of the circu- 
 lation and of other organs — and even of the tongue. 
 
 To this delirium, low, muttering, or wild, as it may happen 
 (for it may be all of these in the same individual in the course 
 of a few hours), subsultus is liable to be added, and the unre- 
 strained passage of the different evacuations. 
 
 In such a case as this, I have seen a single dose of opium, 
 dextrously administered, change the whole complexion of the 
 disorder in a single night, and place the patient at once in a 
 state of safety. 
 
 Again, I have seen the sensorial affections incident to fever, 
 which require opium for their cure, manifest themselves in 
 another form. There has been high vascular action from the 
 first ; and large depletion has been required to subdue it and to 
 guard particular organs, and especially the brain, from injury. 
 Under such treatment, all has gone on successfully, and the 
 patient has reached a point of convalescence ; with a soft pulse, 
 
ON THE USE OF OPIUM IN FEVERS. 343 
 
 a cleaning tongue, no pain, and refreshing sleep for two or 
 three days; when suddenly (the tongue, the pulse, and all 
 other circumstances continuing the same) some strangeness of 
 manner has arisen, and then the wildest delirium, and then the 
 unrestrained passage of the evacuations. I have known the 
 transition from such a state of convalescence to such a state of 
 peril, take place in a few hours ; and I have known the patient 
 again brought back to a state of convalescence in twenty-four 
 hours by a moderate dose of opium. This is a rare form of 
 disease, but one in which, when it does occur, opium is emi- 
 nentty indicated. 
 
 Now, when the affections of the brain put on a character of 
 great energy and violence, they are apt to suggest the notion 
 of inflammatory action. Indeed the mere sensorial symptoms 
 alone cannot be always distinguished from those of phrenitis ; 
 but there may be no phrenitis nevertheless. Those who are 
 experienced in the medical treatment of the insane, have ably 
 discriminated a class of cases characterized by great excitement, 
 which they know to be curable by no remedies which deplete, 
 but specially and exclusively by such as have a direct influence 
 upon the nervous system: and although, in fevers, the very 
 nature of the disease would always lead us to watch narrowly 
 the state of the circulation, and suspect its possible agency in 
 the production of any sensprial affections that occur, yet it need 
 not surprise us to find that even in fevers there should be some 
 such affections which are independent of the blood-vessels, both 
 in their production and their cure. 
 
 Still there are cases of fever in which the symptoms be- 
 longing to the brain have no such energy or violence, and the 
 symptoms belonging to the vascular system present no such 
 contrast with them as we have described, and yet opium is 
 essential to the cure. 
 
 There may be simple wakefulness, and literally no other 
 symptom whatever referable to the brain ; and, as to symptoms 
 belonging to other parts, they may be just enough to con- 
 stitute a fever, and no more. 
 
 This is a form of fever which often ends ill, to the utter 
 amazement of those who witness it, and who cannot tell how it 
 has happened thus. The patient has hardly any fever ; there- 
 fore there is no thought of danger. There is no change in his 
 
344 ON THE USE OP OPIUM IN FEVERS. 
 
 symptoms during several days ; until suddenly all his strength 
 is gone, and he cannot raise himself in bed. His tongue is 
 hecome dry, and it trembles ; some muttering delirium is added 
 to his wakefulness ; he passes his evacuations involuntarily, and 
 soon dies. 
 
 In this manner does death sometimes take place, hecause 
 one symptom, small and unohtrusive indeed, but of inestimable 
 importance as a guide to practice, has been unfortunately over- 
 looked from the beginning. The patient, perhaps, never 
 mentioned it, and the physician did not inquire after it. Yet 
 such a case as this, if this single symptom of wakefulness be 
 duly estimated, and opium administered in season, will gene- 
 rally terminate well, and at an early period. 
 
 These affections of the brain, incident to fever so peculiar 
 and so perilous, and requiring opium for their cure, deserve to 
 he illustrated by any circumstances that can be brought to bear 
 upon them beyond the mere symptoms of the particular case ; 
 and, indeed, they are capable of much illustration by the habits 
 and state of health of individuals before they became the sub- 
 jects of fever. 
 
 And here I would make one general remark— that, by 
 knowing what a man is, and how he lives habitually, the phy- 
 sician often arrives at a much better judgment and a better 
 treatment of his diseases. It is trying a man's diseases by his 
 health ; and a most valuable test it is, and of great practical 
 utility. 
 
 In healthy and vigorous bodies there is a certain balance 
 and regularity of function which, even when disease befalls 
 them, is seldom lost, but their morbid action is still harmonious 
 and proportional. In them diseases are often severe, but they 
 are generally simple : they often require the most active re- 
 medies, but they are generally easy of cure. On the other 
 hand, the weak and valetudinary, who at the best are full of 
 jars and incongruities, are obnoxious to the strangest forms of 
 disease, hard to understand and hard to treat. 
 
 Now fever, when it happens to a perfectly vigorous and 
 healthy man, is never characterized by any such peculiar affec- 
 tions of the sensorium as have been mentioned. These are 
 incident, according to my observation, to those only whose 
 habits and mode of living have been calculated to do an abiding 
 
ON THE USE OP OPIUM IN FEVERS. 345 
 
 injury to the nervous system, and who have heen long actually 
 suffering from such injury. 
 
 Every class of society has furnished me with instances of 
 this form of fever, and every instance has confirmed the truth 
 of the remark. 
 
 Among the higher and educated classes there is, in this age 
 and country, a wonderful striving for all the objects of wealth, 
 and honour, and power. We need only think upon the strife 
 of politics, the hazards of mercantile gambling, and the wear 
 and tear of hard professional toil, to see how many there must 
 be who, from the common business of life, have derived both to 
 their minds and bodies new feelings and impulses, and new 
 susceptibilities of disease. These susceptibilities belong chiefly 
 to the brain and nervous system, and they are apt to come forth 
 into frightful activity when such men become the subjects of 
 fever. The trouble of the brain gets the mastery (as it were) 
 of the disorder of every other part. 
 
 The poor and mean among mankind have the mind over- 
 wrought, and the nervous system exhausted, by real calamity, 
 just as the high and the educated by their more refined cares ; 
 and thus they often claim an unenviable approximation to them 
 in the character of their diseases. 
 
 Into the hospitals of London a miserable class of patients is 
 often admitted — the wretched outcasts of the streets. They 
 have crawled about asking alms all day, and at night have lain 
 down in the open air and slept. They are sometimes picked up 
 in a state of half-consciousness, and brought to a hospital. Of 
 these some only require to be washed and fed, kept warm, and 
 allowed to sleep, and then they recover without manifesting 
 any real disease. Others (and the greater number) after they have 
 lain awhile, and their blood-vessels begin to react, put forth the 
 symptoms of some serious malady ; it may be an inflammation 
 of some particular organ, or it may be a fever ; and if a fever, 
 it is almost always of that kind in which the derangement of 
 the brain outruns that of the vascular system, and of every 
 other part. 
 
 It appears probable, then, that the sensorial affections 
 alluded to are ultimately determined by something peculiar to 
 the constitutions of individuals before they become the subjects 
 of fever. One may call it an unhealthy susceptibility at least, 
 
346 ON THE USE OF OPIUM IN FEVERS. 
 
 if not an actually morbid condition, belonging at all times to 
 the sensorium and its functions. It is one of those things 
 which cannot be spoken of with precision, and of which more 
 may be learnt by attending to the moral causes (for such they 
 are) out of which it seems to arise than to the thing itself. To 
 these moral causes, in further illustration of it, I will add one 
 physical cause, which is of most extensive influence — the habitual 
 indulgence in spirituous liquors. Individuals, who have done 
 a permanent harm to the functions of the nervous system by 
 the abuse of spirits, do never, when they become the subjects 
 of fever, suffer a delirium of the ordinary kind, in which the 
 brain is excited nearly in the same proportion with the blood- 
 vessels, and which, by remedies addressed to the blood-vessels, 
 is uniformly controlled ; but they suffer a delirium in which 
 the brain is actuated disproportionately to and (perhaps) inde- 
 pendently of, the blood-vessels, and, if curable, to be cured by 
 opium. This I venture to state almost absolutely, and without 
 exception. 
 
 Now, when we contemplate these sensorial affections, said 
 to be incident to fever, in their kind, in their causes, and in 
 their cure, we cannot help seeing how much they possess in 
 common with what is called "delirium tremens." In fact, 
 they are the same thing. Yet I will not call them the " deli- 
 rium tremens of fever," for fear of misleading by a name. 
 Besides, the name itself is ill-chosen, inasmuch as there are 
 affections of the brain, which, from their causes, their method 
 of cure, and their own essential nature, must be supposed to 
 belong to the same category, and yet have no tremor whatever 
 among their symptoms. 
 
 There is a wide range of sensorial affections all pathologically 
 the same. But the extreme instances, being the most striking, 
 they have been picked out, and called by a particular name — 
 "delirium tremens," as if they constituted a class by them- 
 selves, whereas they are only individuals of a much larger 
 class. To this class also belong the sensorial affections in 
 question, which are incident to fever. 
 
 Having then settled the nature of the disease, and its 
 remedy, we must now determine the mode in which that 
 remedy is to be applied, and its quantity. 
 
 When we desire to abate pain by opium, the degree of pain 
 
ON THE USE OF OPIUM IN FEVEKS. 347 
 
 is the measure of the dose required. So, too, if we would 
 suhdue nervous irritation by opium, the degree of excitement 
 informs us how much we ought to give. Simple wakefulness 
 may be gently lulled to sleep by a few drops of laudanum, 
 but wild delirium requires to be mastered, and (as it were) 
 forced into repose by a much larger dose. 
 
 Thus the sensorial affections incident to fever, which are 
 curable by opium, require various quantities of the remedy 
 according to their degree. But in no case, even if the excite- 
 ment reaches to convulsive action of the muscles, and the 
 wildest delirium, is the quantity required absolutely very large. 
 And here my experience has led me to a conclusion which no 
 reasoning a priori could have reached, viz. that a much larger 
 quantity of opium is necessary to remedy certain sensorial dis- 
 orders when they exist alone, than when they are combined 
 with fever. 
 
 In extreme cases of delirium tremens you fling away the 
 resources of your art unless you venture to administer opium in 
 doses which would run the hazard of poisoning a healthy man. 
 The very same symptoms, carried to the greatest extremity, 
 and combined with fever, are still to be subdued by opium ; but 
 twenty minims of the tincture are now quite sufficient for the 
 purpose. I never gave a larger dose at once, and I have seldom 
 found it necessary to repeat it. If the dose be too little it is 
 easily increased, but there is great peril if it be too much — the 
 peril of coma. 
 
 The success of the remedy turns entirely upon the condition 
 of its procuring sleep ; and it is more or less complete in pro- 
 portion as the sleep procured is, within certain limits, of longer 
 duration. 
 
 When, therefore, in a case of fever, after long wakefulness, 
 accompanied by wild delirium and' a violent exertion of mus- 
 cular force, with such a state of pulse as absolutely forbids the 
 use of further depletion ; when, in this extreme case, we ad- 
 minister the extreme dose (for such it is) of twenty minims of 
 tincture of opium, we must be content to wait patiently the 
 result ; for the use of every other remedy is now sacrificed to 
 this single one ; indeed, while it is in the course of operation, 
 the effective employment of any other is necessarily precluded. 
 
 We should wait patiently four hours at least ; and in the 
 
348 ON THE USE OF OPIUM IN FEVERS. 
 
 meantime let everything be made to favour the success of the 
 remedy : let the room be kept silent and dark, and one indi- 
 vidual only remain with the patient, charged not to utter a 
 single word. 
 
 The four hours having elapsed, we are to determine from 
 the state of the patient whether still more opium be needed or 
 no, for the accomplishment of our purpose. We may find, 
 that soon after taking the laudanum, the patient fell fast asleep, 
 and has continued sleeping ever since. Thus the remedy has 
 done all that we desire. Or we may find that he fell asleep, 
 and soon woke again, and so has slept and woke, and slept and 
 woke again ten times in the course of an hour, and in the 
 intervals of waking his delirium has returned. Under these 
 circumstances, should more laudanum be given ? I think not. 
 After a considerable dose has been administered, if any real 
 sleep, however short, has succeeded, I would not give more 
 until after a long interval, because I would not hazard the 
 peril of an overdose. Besides, though the remedy has not 
 entirely fulfilled my wishes, it has not entirely disappointed 
 them. These little snatches of sleep, after long-protracted wake- 
 fulness, are often productive of great benefit. The sleep, 
 thus fitfully obtained in the course of one night, has entirely 
 changed the complexion of a doubtful case, and placed the 
 patient in security. 
 
 But we may find that the patient has not slept at all, or 
 that it is doubtful whether he has or has not ; yet, though the 
 wakefulness remain, there may be an evident abatement of 
 other symptoms which flow directly from the sensorium, of the 
 delirium, of the muscular twitching ; that the pulse is a little 
 diminished in frequency and increased in power ; in short, that 
 the patient is altogether more composed, although he has not 
 slept. Under these circumstances, it is safe and expedient to 
 give more opium to the amount of half the original dose. 
 
 In cases where the delirium and excitement, accompanied 
 by wakefulness, are less in degree, a smaller dose of opium may 
 be relied upon for effects equally beneficial. In such cases I 
 have been accustomed to give five minims of the tincture every 
 hour, or every other hour, until the patient begin to dose. 
 
 There are cases where the indications for the employment 
 of opium are doubtful. "Wild delirium, and long wakefulness, 
 
ON THE USE OP OPIUM IN FEVERS. 349 
 
 and a circulation weak and fluttering, seem to call for a con- 
 siderable dose of opium. Yet, withal, there is a certain jerk in 
 the pulse, so that we cannot help suspecting that the blood- 
 vessels have something to do with the sensorial excitement. 
 "Under such circumstances, I have certainly seen twenty minims 
 of laudanum produce tranquil sleep, from which the patient 
 has awoke quite a new man. But I have also seen the same 
 quantity produce a fatal coma, from which he has never been 
 roused. 
 
 Now, since it is a fearful thing to strike a heavy blow in 
 the dark, where the alternative is of such magnitude, it is the 
 safest and the best method to administer a small dose at 
 intervals of an hour or two, so as to stop short of actual mischief 
 at the first glimpse of its approach, or be led by a plain earnest 
 of benefit to push the remedy to its full and consummate effect. 
 Many doses may be required for this purpose, but we shall 
 see, after the first or second, whether to go on or to desist. 
 
 There are cases where all the curative effects of opium are 
 obtained by very small doses given at very distant intervals. 
 
 I have mentioned a form of fever in which simple wakeful- 
 ness exists from the beginning, while the proper febrile symp- 
 toms are very moderate, and delirium is only at length added 
 from the very exhaustion of the nervous system. Here the 
 whole treatment consists in the dextrous use of opium, and it 
 may be given at any, even the earliest period of the disorder. 
 Sleep, sleep is the want of nature. Five minims of laudanum 
 given every night will be enough to procure it while there is 
 mere wakefulness, but when a little delirium is added, five 
 minims more should be given twice in the twenty-four hours. 
 
 Do not let this be thought an insignificant practice. It is 
 enough to save life, which will inevitably be lost without it. 
 
GENERAL EEMAEIS 
 
 PEACTICE OF MEDICINE. 
 
 A SERIES OF AETICLES 
 
 WRITTEN AND PUBLISHED IN THE "BRITISH MEDICAL JOURNAL' 
 
 DURING THE 
 
 YEAES 1861, 1862, and 1863. 
 
 PETER MERE LATHAM, M.D., F.R.C.P. 
 
 PHYSICIAN EXTRAORDINARY TO THE QTTEEN. 
 
GENERAL KEMAEKS ON THE 
 
 PEACTICE OF MEDICINE. 
 
 i. 
 
 THE PRACTICE OF MEDICINE PRIOR TO THE KNOWLEDGE OF 
 
 DISEASE. WHAT IT WAS. — KNOWLEDGE OF DISEASE IMPROVED 
 
 IT, WHILE IT PRESERVED ITS ORIGINAL OUTLINE. WHAT 
 
 PRACTICE OWES TO PATHOLOGY NOT EXACTLY CALCULABLE. 
 
 DISTINCTION BETWEEN CURING THE DISEASE AND TREATING 
 THE PATIENT. 
 
 There was a practice of medicine long before there was any 
 knowledge of disease. The griefs, pains, and necessities of 
 man's body and mind did not call the less loudly for relief 
 because they were not understood. The practice of medicine 
 was always a daily need, and always brought with it a certain 
 measure of benefit. It seems providentially ordered, that what 
 is for our good should not altogether wait attendance upon our 
 knowledge. 
 
 But this practice of medicine, which was prior to the know- 
 ledge of disease, and so far uninstructed, was not always without 
 reason and method. It had two ways of proceeding. 1. It 
 dealt largely in specifics (special remedies). It did cures by 
 remedies, which had (as was thought) the direct power of 
 curing, and which seemed to reach the disease in its essence, 
 and abolish it without any intermediate or cognisable operation 
 whatever. Thus it had a reputed remedy for almost every 
 disease which had a name. 2. This uninstructed practice, 
 when it had no name to give the disease, and had no remedy 
 for curing it, was not without resource, if, notwithstanding, a 
 great illness were obviously suffered. It took note of heat and 
 cold, and hunger and thirst and pain, and of conscious weakness 
 and incapacity, and of some more obvious varieties of the pulse. 
 And to these, and to whatever else went plainly and discernibly 
 
 A A 
 
854 GENERAL REMARKS ON THE 
 
 wrong in those feelings and functions and movements, by 
 which the body makes chief display of its vitality, it tried to 
 minister as it could ; and it often ministered well and suc- 
 cessfully. For thus it often hit unconsciously upon right 
 indications of treatment, and thus procured recovery from 
 a disease, of which it knew neither the nature, the seat, nor the 
 existence. 
 
 Here we have a sort of primitive plan of medical practice ; 
 and the same remains to this day. Knowledge of disease and 
 a more cultivated experience have added much and corrected 
 much. But it has preserved its original outline. 
 
 If any man, a little accustomed to self-questioning, will call 
 to mind what he was at first as a physician, and what by 
 increase of knowledge and experience he afterwards became, he 
 will find not unfaithfully reflected in his own example the 
 beginning and progress of the art itself. 
 
 As the knowledge of disease increased, the practice of 
 medicine improved ; but neither propo'rtionably nor with equal 
 steps. Many diseases which we knew the best, we did not 
 therefore manage the better ; often, indeed, not better than in 
 the time of our ignorance ; because a fatal part of our know- 
 ledge was simply this, that the diseases, in their own nature, 
 were beyond the possible reach of any remedy. 
 
 Nevertheless, to affirm that the more we have known of 
 diseases, the better we have been able to manage them, would 
 be quite true in the general sense ; but to give, an exact account 
 of the debt due from practice to pathology would be hardly 
 possible. We could not take our knowledge of diseases as it is 
 at this day, and assort it, and weigh it, and put a value upon 
 it according to the help it affords us in practice. In some 
 diseases, its help is very great ; in some, it is very little ; and 
 in some, it absolutely amounts to nothing at all. In some, it is 
 plain, appreciable, and at hand ; in some, uncertain, equivocal, 
 and remote. Here we want more knowledge ; there we have 
 already more knowledge than we can use. Here we are in the 
 dark ; there we have plenty of light, but we cannot contrive to 
 throw the light we have upon the objects which require it. 
 The misfortune is, that practical medicine has from time to time 
 been darkened, as it were, by cross lights, let in from strange 
 quarters. They have set off the subject; they have made a 
 
PRACTICE OF MEDICINE. 355 
 
 show of it ; but they have given it lustre, rather than illus- 
 tration. 
 
 If any one, who had a turn for the thing, would spend half 
 his life in carefully surveying the various sorts of knowledge 
 deemed needful to make a good physician, and take, as it were, 
 their natural bearings, and at last reckon how far, in fact, they 
 had or had not fulfilled their aim, he would produce (supposing 
 him to have acquitted himself of his task tolerably well) an 
 interesting, a very curious, and an utterly useless exercitation. 
 To speak of practical medicine and the things concerning it 
 profitably, a man must draw either from what is his own entirely, 
 or from what he has made his own by experiment and trial. 
 Whether he handle particulars merely, or embrace general facts 
 and principles, he must make himself the representative of the 
 art he practises. 
 
 When first I found myself in the midst of between four 
 and five hundred patients ' in St. Bartholomew's Hospital, the 
 scene bewildered me, and I learnt nothing for months. It was 
 something, however, to become reconciled to the objects around 
 me, and to look with complacency on what was going on. All 
 I saw was " a great multitude of impotent folk," and the phy- 
 sicians busy among them with the expedients of their art. And 
 some were recovering, and some dying ; some getting better, 
 and some worse, and some remaining unalterably the same. 
 The physicians and their art confronted the patients and their 
 diseases, and exercised, I plainly perceived, a great power upon 
 the whole. But I could not yet discern their points of contact. 
 It was as if some mysterious scroll were being daily unrolled 
 before my eyes ; and all its inscriptions were unintelligible, for 
 want of the key for deciphering them. 
 
 At length this small ray of truth found me out in the dark • 
 viz. that some medicines were remedial simply by bringing 
 diseases to an end without any intermediate operation being 
 apparent, or intended, or thought of; and that some were 
 remedial by bringing diseases indeed to an end, but not without 
 intermediate operations, both apparent and designed, and 
 looked for as conditional to the result. This little light gave 
 me heart and encouragement, and a new interest. Not that by 
 help of it I was able to penetrate the modus operandi of medi- 
 cines in the least degree, but I could just read by it that they 
 
356 GENEKAL KEMAKKS ON THE 
 
 had, or seemed to have, at least two several ways of working 
 out their ends, and that physicians had two distinct purposes 
 in prescribing them. To me, as yet an uninformed looker-on, 
 the practice of medicine first presented itself taking this 
 outline ; it was its natural outline ; and it has remained distinct 
 and permanent and the same in my mind ever since. What- 
 ever I have since learnt has taken its shape from it, and its 
 place within it ; and so will what I have now to say. 
 
 It would save some trouble, and not, I trust, show me bent 
 upon handling the subject too artificially, and so spoiling it, if 
 of these two modes of dealing with disease remedially, I called 
 the one their cure, and the other their treatment. According to 
 popular notion, cure is the aim and end of all treatment, and 
 the result and complement of successful treatment. But let 
 cure and treatment now be taken to denote different things, so 
 far as the aims and objects of the physician are concerned in 
 his management of disease. Let cure be looked upon as con- 
 cerned with the disease as such, and having little or no regard 
 to the individual patient whom it befalls. Treatment is con- 
 cerned with the individual patient, and leaves his disease to 
 take care of itself. 
 
 There are eminent and familiar instances of cure in this sense : 
 the cure of ague by bark and arsenic ; of scabies by sulphur ; 
 of syphilis by mercury ; of scurvy by lemon-juice ; and of 
 certain periosteal diseases by iodide of potassium. And small- 
 pox, measles, scarlatina, the typhus and typhoid maladies, are 
 eminent instances of diseases which have no cure, and yet issue 
 in recovery and health by means of treatment. 
 
 It is an instructive fact that, as the knowledge of disease 
 has increased, the practice of medicine has been less and less 
 conversant with cures and more and more conversant with 
 treatment. The knowledge of disease is not naturally sugges- 
 tive of special remedies, which are always hit upon by chance ; 
 it rather goes to reducing the number of the old ones. From its 
 habit of inquiry, it is ever trying the claims of certain remedies 
 to the credit of curing certain diseases ; and it is ever finding 
 good reason to disallow such claims and reject such remedies 
 largely. Hence, practice has betaken itself of necessity to 
 manage many diseases by treatment, which were once deemed 
 within easy reach of cure. And thus the present state of our 
 
PRACTICE OF MEDICINE. 357 
 
 knowledge has come to warrant the conclusion that the number 
 of diseases is very small which are capable of cure by a proper 
 remedy of their own, and which exclude the need of other 
 remedies addressed to conditions belonging to the individual 
 patients ; whereas the number in which the converse obtains 
 would embrace the vast majority of human maladies. 
 
 But this cure of diseases by single special remedies is a 
 thing so complete and off-hand, so saving of thought and 
 trouble, and so accordant with the popular notion how diseases 
 are, or ought to be, dealt with, that one cannot help some regret 
 for the number in this happy predicament being small. Did 
 it include all or almost all diseases, it would go near to produce 
 unanimity among physicians, for there would be nothing for 
 them to disagree about ; and at the same time to banish all 
 thought from their practice, for there would be nothing for 
 them to think about. Nevertheless, we should greatly rise in 
 the opinion of the world, which, even with things as they are, 
 is ready to magnify none so highly as those who, whether 
 deceiving or self-deceived, have a cure for any or for all 
 diseases. 
 
 Cure by special remedies addressed to the disease, and treat- 
 ment by common remedies addressed to present indications in 
 the man, divide the domain of practical medicine between them; 
 unequally indeed, but still they divide it. Moreover, they mix 
 themselves a good deal together ; cure and treatment running 
 into each other, and special and common remedies co-operating 
 for good. 
 
 Let it, however, be remarked, that practical medicine takes 
 this shape from its own necessity, as things are. Our know- 
 ledge is incomplete. But such as it is, we must use it ; and the 
 first condition of using it safely or profitably is to know that it 
 is incomplete. An imperfect instrument is in our hands, and 
 we cannot trust it simply and entirely. It needs some art and 
 management in the handling ; but these must not be too much, 
 lest they hurt the fair play of our instrument, imperfect 
 as it is. 
 
358 GENERAL REMARKS ON THE 
 
 II. — Cure. 
 
 ON SPECIAL MEDICINES, AND ESPECIALLY CINCHONA. SPECIFICS 
 
 AND CUKE CONTRASTED "WITH NON-SPECIFICS AND TREATMENT. 
 THE DIFFERENCE BETWEEN CURING AND TREATING A FEVER. 
 
 Remedies given to cure diseases in some occult way of their 
 own we have called " special" remedies. "Would not " specifics" 
 nave been a better name, as being of more popular use ? Why, 
 no. Medical men, indeed, have never been remarkably exact 
 about the meaning of the terms they employ. Nevertheless, as 
 long as terms convey no error, it is well to abide by them and 
 let them pass. They cannot, however, be always made to suit 
 our purpose without some little explanation. Thus the common 
 notion of a "specific " is, that it deals with the disease after its 
 own way ; and, moreover, that it deals with it successfully. The 
 term " specific " always includes the idea of success ; and for 
 this reason it would be too restrictive for our purpose. " Spe- 
 cifics," in the popular sense, would still remain the choicest and 
 best, but would comprise a few only, of the remedies which 
 have place in the department of medicine which we call "cure" ; 
 whereas "special" remedies would comprise them all, whether they 
 cure single-handed and by themselves, or conjointly with others 
 and as auxiliaries ; with constant or occasional, with complete 
 or partial, or with whatever degrees of real or imputed success. 
 
 " Specifics," then, represent the perfection of special reme- 
 dies. But perhaps they may not be always found the most 
 interesting of the class to which they belong. Special remedies, 
 in proportion as they approach nearer to specifics, work with a 
 concealment which is impenetrable, and invite inquiry with 
 little hope of reward. But, in proportion as they fall short of 
 specifics, they are less absolutely covert in their operation, and 
 leave, as it were, chinks and crevices through which, as they 
 work, we may catch sometimes a glimpse of practical and 
 pathological truths. 
 
 The most universally allowed specific is cinchona ; and its 
 specific virtue is most eminently declared when it cures an 
 
PRACTICE OF MEDICINE. 359 
 
 ague. It may then be taken as a standard by which to try the 
 claim of any other remedy pretended to he a specific ; and a 
 standard, moreover, by which to try itself when it is used as a 
 specific for other diseases. In the cure of ague by cinchona, the 
 peculiarity of the whole affair is this, that the cure follows the 
 use of the remedy, without the apparent intervention of any 
 prior operation whatever. 
 
 Now cinchona has been found to do the work of cure in 
 certain other diseases as summarily, and as exclusively of any 
 intermediate operation, as it does in ague ; and so far it equally 
 deserves the character of a specific. But it does not do this 
 work of cure so constantly in them as in ague ; and therefore in 
 them it is not at all times to be fully trusted as a specific. 
 
 Cinchona often cures the severest headache ; the more 
 surely if it take the form of hemicrania, and have an intermit- 
 tent character ; and the more surely still if the patient be, or 
 have been, where agues prevail. And so cinchona often cures 
 severe neuralgia in all parts of the body, the intermittent 
 character and the probable malarious origin still giving a better 
 promise of its suocess. 
 
 It is remarkable the number of diseases (if diseases they 
 can be called of which nosology takes no notice) — the number, 
 I mean, of undescribed and indescribable ailments having their 
 origin, growth, and increase among agues and in agueish 
 districts — which are cured by quinine. 
 
 But a disease need not always claim known kindred with 
 ague, either in its intermittent character or in the place where 
 it is found, to be sometimes curable by quinine. Erysipelas 
 has often found in it a summary remedy. By its use, foul and 
 ill-conditioned sores have changed their complexion completely 
 and at once, and become healthy ; and thus the expectation of 
 gradual sinking and death has in twenty-four hours given 
 place to a confident hope of recovery and life. Such effects, so 
 rapid and so springing up under our very eye, can hardly be 
 brought about by any mere tonic power belonging to cinchona 
 in common with many other substances. Surely none of the 
 class of bitters could be trusted for the same result. If either 
 can they be well conceived to come from cinchona operating as 
 a mere stimulant. It does not merely do the work which wine 
 or brandy could do just as well. One cannot help believing it 
 
360 GENERAL EEMAEKS ON THE 
 
 does the work which only itself can do, and nothing else ; and 
 it does it acting by a specific power of its own, as much as 
 when it cures an ague. 
 
 The specific effects- of cinchona which are hest known are 
 really so full of wonder, that new and less familiar displays of 
 its curative power occurring from time to time do not surprise 
 us. Indeed, we can hardly make up our minds to be incredu- 
 lous when report is made of the marvels wrought by it, which 
 go far beyond our own experience. What, however, has been 
 of late promulged is startling. It should almost seem that, 
 as long as there is quinine in the world, no fever need go 
 uncured. Intermittent, remittent, and continuous fevers, 
 typhus and typhoid fevers, simple and complex, and in all 
 climates and in all stages of their progress, are to be cured by 
 quinine. So it is positively stated. The fault of physicians, 
 it should seem, has been that they have never given it often 
 enough or in quantity enough, otherwise they would have 
 acknowledged it for an universal antifebrile specific long ago. 
 
 Now, for the present, I would hint no suspicion that the 
 accidents of time, place, or circumstance might have largely 
 influenced the results, giving a new element to the disease, and 
 allowing an extraordinary virtue to the remedy. I will take it 
 for granted that the fevers mentioned by name, each and several, 
 and the classes of fevers indicated, are in their own nature 
 curable, and were actually cured by quinine ; f or« I wish to 
 make the important difference between cure and treatment as 
 intelligible as possible. And this I can best do by displaying 
 them in contrast ; and the contrast can never be more striking 
 than when each is seen in its separate dealing with the same 
 disease. 
 
 Let us then consider fever in its largest sense, and see first 
 what it is to mire it, and then what it is to treat it. This diffe- 
 rence will display the difference between cure and treatment, as 
 applied to the management of all other diseases whatever. 
 
 Take cold and heat, and perspiration, occurring inter- 
 changeably, whether regularly or irregularly, and in any 
 manner dr degree ; and a frequent pulse, whether strong or 
 weak, and pain in the head with wakefulness and delirium, or 
 drowsiness and torpor ; and the tongue dry and red and clean, 
 or sordid and black ; the breathing hurried, and perhaps the 
 
PRACTICE OF MEDICINE. 361 
 
 bronchi wheezing, the abdomen tympanitic and painful on 
 pressure, and perhaps a sanious discharge running from the 
 bowels ; take these symptoms on any day early or late in the 
 course of the disease ; take them all in a heap, and regard them 
 as one, and make them serve collectively for the single aim of 
 the single remedy, and that remedy quinine. This is pre- 
 eminently the cure of fever ; and its success, which comes 
 suddenly when it comes at all, must be a sort of triumph. 
 
 Again, take all these same phenomena which tell of disorder 
 and disease in the vascular system and the nervous system, and 
 in any or every organ of the body ; take them, not as they 
 appear on any one day, but as they ebb and flow and. fluctuate 
 every day and night for more than twenty days or nights in 
 succession ; and watch each, and try to interpret the meaning 
 of each, and judge which is most perilous in itself, and which 
 bears most perilously upon the whole disease ; and which is 
 most within reach of a remedy, and which is most urgent for 
 relief; then choose and apply, not the one remedy, but remedies 
 many and various, or few and simple, according to the aims 
 proposed ; and take care the right remedy of to-day be not the 
 wrong remedy of to-morrow : pure air to breathe, and pure 
 water to drink ; affusions or ablutions of the whole body, cold, 
 warm or tepid ; lotions or fomentations of this part or that ; 
 remedies for pain according to its nature and. seat ; expedients 
 for preventing sores, and expedients for healing them; aperients, 
 and astringents, and mercurial alteratives, according to their 
 several needs ; also opium, that great saver or destroyer of life 
 as it is rightly or wrongly given in fever,' in its various uses. 
 These are the sort of implements which the physician has to 
 work with when he has to treat a fever. And being thus 
 vigilant and analytical about the bedside emergencies of fever, 
 and dextrous in ministering to them, he saves many lives. 
 
 And this is pre-eminently the treatment of fever ; but it may 
 be, and often is, one part of it only. For, after all has been 
 done that need, or can, be done, in the way of thus noting 
 particulars and ministering to them, lives cannot be saved 
 without engaging observation and treatment in larger aims. 
 More in one case and less in another, more in one stage of the 
 same case and less in another ; but in some stage of almost 
 every case, we have to take the sum of the symptoms, and 
 
362 GENEEAL EEMAEKS ON THE 
 
 calculate whether, upon the whole, they mean strength or 
 weakness, vital reaction or vital yielding ; and to make choice 
 accordingly, whether it be right to restrain, to lower, to deplete, 
 or to support, to raise, to stimulate ; whether to give calomel and 
 antimonials, or to use some kind of bleeding, or to give wine, 
 or brandy, or ethers. 
 
 This is the treatment of fever in another of its parts. Both 
 together, that which is analytical and that which is summary, 
 comprise the ivhole treatment. If it succeed, its success is after 
 the lapse of many days, and the trial of many hopes and fears. 
 And when success comes at last, it produces nothing like exul- 
 tation and triumph, but rather quiet satisfaction and thank- 
 fulness. 
 
 Such is the difference between cure and treatment, when we 
 come to follow them out in their operations, and to think what 
 the one is and what the other, practically and in truth. The 
 difference is so great, that if this vast class of diseases, called 
 fevers, belonging to the whole world, and always existing and 
 raging somewhere, could be taken at once out of the domain of 
 treatment and transferred to the domain of cure now and for 
 ever ; and if, instead of needing remedies, as many and various 
 as are the times and places, and men and circumstances wherein 
 they arise, they were found capable of being safely and success- 
 fully consigned to one and the same remedy always, and 
 everywhere, and in all persons, the practice of medicine would 
 suffer the nature of a revolution. The thoughts, studies, habits, 
 and feelings of medical men would be utterly changed. 
 
 So great a revolution is not likely to happen. But a man 
 need not have grown old in the practice of medicine to bear 
 witness to its having undergone considerable changes ; and the 
 diseases which have been the objects of them are especially 
 those we have been speaking of ; and the changes themselves 
 have still respected treatment and cure. They have not, how- 
 ever, amounted to anything like a substitution of one for the 
 other ; but have only involved measures of more or less, in 
 which treatment and cure have been mixed together, and that 
 not always and everywhere, but partially and from time to time, 
 yet for long times together, and in this place or that ; yet it 
 may be over many countries. Thus, febrile diseases which 
 have a contagious or malarious origin, or which arise from 
 
PRACTICE OF MEDICINE. 363 
 
 causes so occult that they seem spontaneously engendered ; also, 
 typhus and typhoid fevers, scarlatina, erysipelas, spontaneous 
 febrile hsemorrhage, and purpura, will for a time, even for a 
 series of years, and over a great portion of the world, he capable 
 of successful management by remedies addressed to the circum- 
 stances and conditions of individual cases — that is, simply by 
 treatment. Again, some or all of these diseases in the same 
 place, during another series of years, will yield less satisfac- 
 torily to the same remedial method. The indications will be as 
 well chosen as before, and the medicines used will fulfil their 
 immediate purpose, but the whole disease will not decline as 
 easily or come to an end as soon or as completely as before. 
 And then physicians will not be able to make up for the failure 
 of their tried resources by seeking and finding new indications 
 and new remedies rationally suited to them, but by using a 
 special remedy which acts and cures nobody knows how or why, 
 even the great specific cinchona. Then cure has become the 
 needful auxiliary of treatment ; and a special remedy given on 
 the faith of a large experience has completed the imperfect 
 work of remedies addressed to rational indications. 
 
 Now there are subjects upon which the most sober and 
 practical minds cannot help speculating a little beyond what 
 they know. Sure and great results — yet familiar and common, 
 and procured at will and by certain means, but in an unaccount- 
 able manner — naturally set us thinking and forming notions 
 how they come to pass ; and then it is safest and best to fill up 
 the gaps of our knowledge from analogy. When we are 
 treating a disease, our aim may be to raise the pulse or to lower 
 it, to cool the skin or to warm it, to purge the bowels or restrain 
 them, to augment the secretion of this or that gland, or to 
 diminish it or alter its quality ; and as our remedies do their 
 appointed work, we witness the whole disease brought to an 
 end. But, when we give cinchona for an ague, we have no 
 single aims ; we give it for the whole disease, and the cure 
 follows. Nevertheless, it is according to analogy to believe 
 that it hits a mark of its own, which is more particular than 
 any within the scope of our discernment. Thus cinchona, and 
 all so-called specifics, may work after the same manner with 
 other remedies, which are better understood. They may all 
 equally produce their great results by intermediate operations ; 
 
364 GENERAL REMARKS . ON THE 
 
 only in the one case the intermediate operation is seen, and 
 unseen in the other ; aimed at in the one, and unaimed at in 
 the other. 
 
 From this view of the matter, it would turn out that our 
 distinction between cure and treatment is not in the nature of 
 things, but in the imperfection of our knowledge. 
 
 Further, from the same analogy, we may fairly believe that 
 there is a certain morbid element, of which cinchona is the 
 specific antidote ; that it exists most pure and unmixed in ague, 
 but that it may add itself as an accident to other elements 
 whose property is to produce other forms of disease ; and that 
 wherever it exists, and in whatever combinations, its power is 
 still predominant, and cinchona is still needed to bring the 
 disease to an end. 
 
 These things may be as analogy would suggest. But in 
 practice there is a mischief in conceiting ourselves wiser than 
 we are. Granted, that of the many morbid actions and sufferings 
 which make up the disease, one only may be reached and 
 swayed, or annulled, or curatively modified, by the one special 
 remedy ; granted, that thus the complex disease may cease by 
 removal of some one main element, and by some intermediate 
 operation of the remedy ; but inasmuch as we know no such 
 element of the disease, and see no such intermediate operation 
 of the remedy, they must be to us as if they did not exist. 
 We cannot construct aims and indications of practice out of 
 hidden things, but must be content for the present to regard 
 the whole disease as a single comprehensive indication, and so 
 prescribe for it the single remedy and expect the cure. We 
 shall perhaps know better some time ; but no good will come 
 from our pretending to know better now. Patience under 
 imperfect knowledge is no proof of an unwise mind. 
 
PBACTICE OF MEDICINE. 365 
 
 III.— Cuke. 
 
 CINCHONA : THE ACCEPTANCE IT FIRST MET WITH FROM 
 SYDENHAM AND HIS CONTEMPORARIES. — CURE OF AGUE BY IT 
 ABOLISHED ERROR, BUT TAUGHT NO TRUTH RESPECTING PRO- 
 CESSES OF RECOVERY. — OBLIGATION TO USE SPECIAL REMEDIES 
 IN OUR PRESENT STATE OF IMPERFECT KNOWLEDGE. 
 
 I have somewhere heard or read of the doctrine that every 
 disease has its antidote ; and that the proper specific remedy 
 capable of curing it exists somewhere in the world, if we could 
 but find it out ; and that the Divine wisdom and mercy are 
 pledged for such being the nature of things. This being 
 admitted would at once render the search after new specifics 
 our supreme duty. But I cannot follow the doctrine either 
 with my head or with my heart. On the contrary, I conceive 
 it hardly possible for a physician to employ his time worse 
 than in quest of new specifics. His common sense would be 
 about equal to that of the man who should trust his hopes of 
 growing rich to the chance of finding a bag of money. But a 
 specific medicine is an excellent thing, and so is a bag of 
 money ; and, being found, it is worth the study of a life to turn 
 them both to all the good purposes of which they are capable. 
 Now it strikes one that we should be able to make a better 
 use of specifics or special remedies if we knew more about 
 them ; if we could raise the curtain a little, and catch a glimpse 
 of them at work in some positive manner ; if we could discern 
 them doing something conducive to the ultimate end for which 
 we give them. I do not mean their modus operandi, but quite 
 a different thing, and more important and more practical. I 
 prescribe all my best non-specific remedies for the sake of 
 certain immediate effects, promising myself through these 
 effects to bring the disease to a favourable termination; But 
 in the meantime, I know nothing of their modus operandi in 
 producing even the immediate effects for which I give them • 
 and yet I continue to give them with as much confidence as if 
 
366 GENERAL REMARKS ON THE 
 
 I knew all about it. How mercury makes the bile to flow, or 
 how opium brings quiet and sleep, I do not know ; but my 
 experience trusts them for these effects ; and these effects are 
 in my hands preparatory to the successful management of many 
 forms of disease. 
 
 To ask, then, about specifics, What is their modus operandi ? 
 is to put a question which has not yet been answered about the 
 commonest and most useful remedies which we employ, being 
 non-specifics.* 
 
 Cinchona cures one disease at all times, in all places, and in 
 all men ; and that disease is ague. As a specific for ague, it 
 seems tied to no conditions. But, ever since cinchona has been 
 the known specific for ague, all diseases that have borne the 
 name of fever, all that have had fever in any way annexed to 
 them, have at some times, in some places, and in some men, been 
 deemed curable and cured by it. And in these diseases it often 
 does its work as cleanly and summarily as when it cures an 
 ague. It seems now the same noble specific as then ; but now 
 it must surely be tied to conditions, if we could but make out 
 what those conditions are. 
 
 There is a good deal about Peruvian bark in Sydenham, and 
 the acceptance it met with at the hands of physicians a quarter 
 of a century after its virtues were first heard of in English ; 
 and it is curious to note what manner of men Sydenham and 
 his contemporary physicians were, as he represents them and 
 himself sitting, as it were, in judgment upon the new remedy. 
 And some of them were wise, and some were foolish, as phy- 
 sicians are now ; and the most foolish were those who were the 
 wisest in their own conceit, as they are now. And then, as 
 now, a really wise man would occasionally make shipwreck of 
 part of his wisdom by venturing out of his depth and pre- 
 tending to know more than possibly could be known. 
 
 Men died largely of agues before bark was given to cure 
 them. For want of it, they displayed symptoms many and 
 shocking enough the longer they lasted and went uncured. 
 For these, Sydenham intimates, some physicians were on the 
 watch ; and no sooner was the bark given than they were ready 
 
 * Quid scammonese radix ad purgandum quid aristolochia ad morsus 
 serpentum, possit, video, quod satis est ; cur possit, nescio. (Cicero, De 
 Dwinat, Lib. I.) 
 
PRACTICE OP MEDICINE. 367 
 
 to ascribe them to it forthwith, though the patient might have 
 taken but a single dose of it.* Here was downright prejudice 
 or wilful dishonesty. Others, and the most part of physicians, 
 seeing the bark got rid of the disease by a secret virtue, and not 
 by any sensible evacuation, would have it that the materies morbi 
 was not got rid of at all, but that it was pent up and confined 
 by the astringent power of the remedy, and thus only lay covert, 
 like an enemy within walls, ready to begin new commotions.f 
 This was to take measure of the truth by the standard of their 
 own preconceptions, and believe Nature more likely to err doing 
 her own work in her own fashion than doing it in theirs. 
 
 Elsewhere Sydenham alludes to the extravagance of theory 
 and practice which had long prevailed touching intermittent 
 fevers, and which in his time seems to have gone so far that it 
 ■could not well go farther. " For how many ages," he remarks, 
 " had the observant men been exercising their wits in search of 
 the causes of these fevers ; and so each adopted the practice best 
 suited to the theory of his own excogitating. But how little 
 these exploits of medicine served to prove the truth of their 
 speculations was pretty evident from what was of recent memory, 
 when they placed the various species of intermittents in various 
 kinds of redundant humours, and then aimed at curing them by 
 -alteration and evacuation of the same. How unfortunate was 
 the whole business, both theory and practice, their own failure 
 showed ; but above all the more successful use of the Peruvian 
 bark, by means of which, he adds, we now-a-days, turning 
 topsy-turvy all notion of humours and regimen and diet, and 
 everything of the kind, and, only looking to the right way of 
 exhibiting the powder, aim directly at the mark, and hit it."f 
 
 But let not this brief allusion to the prejudices of past times 
 touching the Peruvian bark be deemed altogether useless. 
 
 * His autem potissimum de causia (nisi fallor) cortex male audit: primo 
 quia plurima ilia horrendaquae symptomata quae febres iutermittentes jam 
 •diutius BBgrum cruciantes cornitantur, etiam ubi ne minimum quidem 
 corticis deguataverit, cortici vel semel assumpto imputantur. (Epist. i. 
 Eesponsoria, § 15.) 
 
 t Secundo, quia cum occulta vi et non per sensibilem aliquam evacua- 
 tionem morbum averruncet, statuunt plerique materiam morbum commit- 
 tentem quae propelli debuerat, tanquam bostem intra moenia vi corticis 
 -astringenti inclusam latere, novos daturam tumultus. (Ibid.) 
 
 X Per quot jam ssecula homines quique solertissimi ingenia exercuerant 
 
368 GENERAL REMARKS ON THE 
 
 Bark may be taken as the type of all specific remedies ; and 
 what though it and they are only to be simply given, and the 
 disease simply ceases ? What though it and they threw no 
 direct light upon the nature of the diseases they cure, or upon 
 their own way of curing them ? Yet the indirect light which 
 they contribute to all rational study of pathology and practice 
 is considerable ; and of this Sydenham was well aware, and 
 ascribed to them a peculiar value on this account. 
 
 Sydenham believed (a curious fact) that there would some 
 day be found out a specific for gout. Long thought upon 
 the subject had, he tells us, brought him to that belief; 
 and he adds, " should it ever be realised, it will rebuke the 
 dogmatists for their ignorance, and show their extraordinary 
 hallucinations in pretending to discriminate the essences of 
 diseases, and in choosing remedies to compass their cure. Of 
 this we have an instance clear enough in the discovery of that 
 supreme specific for intermittent fever, the Peruvian bark." * 
 
 The next best thing to seeing, knowing, and getting well 
 hold of the truth, is to clear away impediments that block up 
 the road which leads to it. This the Peruvian bark did for 
 us two centuries ago, when first it was found a specific for 
 intermittent fevers. In curing them, it disclosed nothing of 
 their essence, and nothing of its own way of dealing with 
 
 in investigandis harum febrium causis, quibus praxin quilibet aptavit 
 theorise a se excogitatse optinie respondentem ! Quomodo vero hse medica- 
 tiones theoremata valebant defendere, ex iis constat quorum adhuc recens 
 est memoria, in quibus varias intermittentium species in variia humoribus 
 in corpore redundantibus collocantes, curationem ad humorum istorum 
 alterationem atq.ue avacuationem dirigere solebant. At quam inauspicato 
 id egerunt, eorum in his conaminum fruBtratio, praecipue vero lmjus corticis 
 usus felicior, palam faciunt : cujus ope nos nunc temporis turn humores 
 hnjusmodi omnes, turn etiam diaetam et regimen quodcunque, susque 
 deque habentes, ac nihil nisi methodum pulveri exhibendo debitam obser- 
 vantes, scopum recta attingimus. (Tractatus de Podagrd, 71.) 
 
 * Non his majora promitto ; quamvis a longst cogitationum serie, quas 
 huic rei impendere tantum non sum coactus, inducar credere ejusmodi 
 remedium quandoque inventum iri. Quod si unquam accident, inscitiam 
 suam dogmaticis exprobabit, atque exinde liquebit quam insigniter, tarn in 
 dignoscendis morborum essentiis, quam in medicamentis quibus eos 
 aggrediuntur, hallucinentur. Cujus rei exemplum satis luculentum habe- 
 mus in repertione summi illius ad febres intermittentes specifiei, Corticis 
 Peruviani. (Tractatus de Podagrd, VI.) 
 
PEACTICE OF MEDICINE. 369 
 
 them. It simply swept them away ; but, in so doing it swept 
 clean out of mind and remembrance many far-fetched notions 
 of them, their nature, and their cure, which by possibility could 
 not be true. It removed notions which had usurped the place 
 of efficient causes, but it did not substitute truths in their stead. 
 
 And now, after the lapse of two hundred years, what do we 
 in our day think of this same Peruvian bark ? Next to opium, 
 we value it above all remedies in the world. But, after two 
 hundred years, what more do we know of it ? Of the thing 
 itself we, indeed, know more, much more — even all, perhaps, 
 that can be known. Peruvian bark was the first or nearly the 
 first of vegetable substances used in medicine upon which 
 chemistry essayed its power of analysis, and seized and sepa- 
 rated the simple element containing all its curative power. 
 And not of the thing itself only, but also of its curative power, 
 do we know more, infinitely more. And the one knowledge 
 has led the way to the other ; for mere grains of this simple 
 element, quinine, were found curatively equivalent to scruples 
 and drachms of the bark. And hence came the readier use of 
 the remedy, and then its larger use ; and its larger use has 
 rapidly multiplied our experience of its curative power. But 
 neither scientific experiment upon the thing itself, nor trial of 
 its remedial effects during two hundred years, has enabled us 
 to catch a glimpse of it actually at work. It increases nothing, 
 and diminishes nothing. It neither evacuates nor restrains. 
 It has to do neither with bile, or with urine or saliva ; nor with 
 any special secretion. It neither directly soothes nor directly 
 stimulates. It neither puts to sleep nor keeps awake. It works 
 the cure ; but it does nothing, as far as we see, prior, prepara- 
 tory, and intermediate to the cure it works. 
 
 There are things in our living bodies which have never yet 
 been reached or touched by human knowledge. Much of health 
 and disease, and life and death resides in these things ; and the 
 means and instruments of health and disease, and of life and 
 death, are largely concerned with them. What strengthens 
 and weakens, what heals and injures, what preserves and 
 destroys, even all food and all medicine, whether for good or 
 harm, have their operation more or less in this region of things 
 inscrutable. Our present business is with medicine ; and even 
 of the remedies which we understand the best, and choose 
 
 B B 
 
370 GENERAL REMARKS ON THE 
 
 according to rational indications, and are able to guide, stage 
 by stage in the work we wish, them to do, there is not one 
 which in the way to its accomplished purpose does not do some- 
 thing beyond or beside what we comprehend. We lose sight 
 for awhile of it and its operations in this region of things 
 inscrutable ; we cannot follow it with a complete intelligence 
 of what it does from first to last. But the remedies which 
 fulfil their one and complete work of cure without show of 
 doing anything whatever prior or conducive to it, even specifics 
 or special remedies, afford the surest conviction of a region of 
 vital operations beyond the range and reach of our knowledge. 
 
 Yet we must not make our ignorance of how the special 
 remedy cures a bar to our use of it. Our knowledge of all 
 remedies, in the gradations and progress of their working* is 
 incomplete ; so that, after all, perhaps the most just distinction 
 between specifics and cure on the one hand, and non-specifics 
 and treatment on the other, would be, that of the former we 
 know absolutely nothing but the bare result, and of the latter 
 we know both the result and something of the way they travel 
 to it. But this something may be very much or very little ; 
 yet, be it much or be it little, we are naturally proud of it. 
 We prefer the implements which we in any measure guide by 
 our eye and impel by the force of our right hand, to those 
 which we must leave from first to last to their own self- working, 
 and trust to bare experience for the result. But be it always 
 remembered what is our calling. Human lives are given us 
 in charge ; and so the amount and certainty of benefit within 
 reach of the remedy may become grounds for its preference 
 before any knowledge we have of the way in which that benefit 
 comes to pass. It will not do to set up the conceit of a little 
 philosophy against the moral obligation of doing good. 
 
 In medicine, this inscrutable region is not only a pretty 
 large one, but there is often as good reason for trust of 
 things transacted therein as of things done in more open day. 
 And no disparagement of our profession is contained in this 
 truth. A vast experience of results is needed as the ground- 
 work of a sound faith in cure by specifics and special remedies ; 
 and surely such experience is a thing at least not opposed to 
 knowledge. 
 
 Specifics or special remedies always seem to me to contain 
 
PRACTICE OP MEDICINE. 371 
 
 within them a promise or prophecy of future knowledge, waiting 
 for time and opportunity and suitable minds to work it out. 
 But, in the meanwhile, the results are so full of benefit to 
 mankind, that they are allowed to have a premature accom- 
 plishment ; and so we are put in trust of them and their great 
 power and mystery of doing good, and find ourselves able to 
 use them aright upon the simple condition of a large general 
 experience. But the work is greater than the workman. It 
 must be so at present ; and there is good reason to be content. 
 It may take ages to bring out the explanation how bark cures 
 an ague ; and the explanation, when it comes, may carry with 
 it the discovery of new physiological truths. But these truths, 
 known at last, may leave the practical uses of the remedy where 
 they were. Thus, for wise ends, things seem to work in an 
 inverted order ; and the uses of knowledge take precedence of 
 knowledge itself. 
 
372 GENERAL REMARKS ON THE 
 
 IV.— Cure. 
 
 THE VAST USE OF CINCHONA BOTH AS A SINGLE SPECIFIC AND 
 
 AS A SPECIAL AUXILIARY TO OTHER REMEDIES. THE USE OF 
 
 OTHER SUBSTANCES AS SPECIFIC OR AS SPECIAL REMEDIES. — 
 THEIR SECRET OPERATION IS THEIR COMMON CHARACTERISTIC. 
 — OF POISONS, AND THE CONDITIONS WHICH HINDER THEIR 
 SUFFICIENT TRIAL AS SPECIAL REMEDIES. OF COMMON REME- 
 DIES, WHICH SEEM OCCASIONALLY TO HAVE A SPECIAL POWER. 
 
 It is wonderful how multitudinous are tlie uses of cinchona ; 
 and in all its uses it is still a specific or special remedy. It is 
 the type of remedies that cure, in all their powers, degrees, 
 and ways of curing, from the greatest to the least. It cures 
 single-handed and alone far beyond what can be ascribed to 
 any other remedy. Thus it is the greatest of specifics. And 
 it supplies, by a virtue of its own, the shortcoming of other 
 medicines to remove the disease and restore to health, oftener 
 and more effectually than any other special remedy. Thus it is 
 the greatest of special auxiliaries. 
 
 Here and elsewhere, and in all the known world, experience 
 has the same report to make of cinchona and its specific power 
 to cure alone and absolutely, and also of the special help it has 
 to give other remedies in curing diseases which would go 
 uncured without it. The renown of cinchona is ubiquitous, 
 because the diseases which it cures are found everywhere — 
 diseases bred of noxious things, which come from earth and 
 sky and changeful seasons. 
 
 If a man visit the fairest regions of the earth, he takes, with 
 him plenty of quinine as the safeguard of his existence ; for it 
 is in those regions that he is sure to encounter, in greater 
 frequency and force than at home, all the diseases over which 
 it exercises a specific or special power. The fruits of the 
 ground, springing up without the helping hand of man's 
 labour, seem to witness against the truth of the primeval 
 
PRACTICE OF MEDICINE. 373 
 
 sentence. Their gift is eminently gratuitous; it is neither 
 worked for, nor paid for, nor asked for. There is no sweat of 
 the brow in procuring it. But " the sweat of the brow " spoke 
 and prophesied of other and higher industries than the labour 
 of our hands, to become ministers of our well-being. The good 
 gifts are fatally tainted. To free them from their evil, or to 
 find the antidotes ; to take them and use them without hurt ; 
 to live by them and not die by them, — this has been the labour 
 of man's mind — the sweat of his better brow — for centuries. 
 And thus the primeval sentence stands firm as ever. 
 
 Now bear in mind what ague is, and what are its kindred 
 diseases ; and what the remedial power of quinine over it and 
 them ; and then think of other diseases common to the whole 
 earth — more frequent, indeed, and oftener epidemic, and oftener 
 fatal, in some than in other climates, but met with, and epidemic, 
 and fatal, in all by turns. Think of dysentery and cholera and 
 influenza, as they are called, and all their formidable kindred ; 
 and, finally, conceive that for dysentery, cholera, influenza, all 
 the world over, we had as sure a single-handed specific as 
 quinine for ague, and as hopeful a special remedy for their 
 kindred diseases as quinine for the kindred of ague ; verily, 
 three such remedies added to our stock, each in its own large 
 sphere of operation the rival of quinine, would immensely 
 diminish the amount of premature death and early incapacity 
 in the whole human race. But quinine stands alone ; there is 
 nothing like it or second to it. 
 
 Now my experience of what quinine will do as an absolute 
 specific goes for nothing, compared with that possessed by 
 surgeons of almost every British settlement abroad. Therefore 
 I shall say nothing more about it as such. 
 
 But here in England there is immense use made of quinine 
 by physicians. As an absolute specific, indeed, for a particular 
 disease, we have employed it less and less as aguish districts 
 have been more and more drained of their endemics. As an 
 occasional specific or special remedy for diseases which at 
 certain times and seasons are unaccountably found curable by 
 it, we still employ it largely ; and yet more largely we find 
 ourselves resorting to it as the special auxiliary of other 
 remedies in our management of various diseases. 
 
 But there are other substances used from time to time by 
 
374 GENERAL REMARKS ON THE 
 
 all of us, for the sake of the special power they have of dealing 
 with diseases curatively, either single-handed or as auxiliaries 
 to other remedies. All physicians have given mercury for 
 syphilis, and cured it ; arsenic for leprosy, and cured it ; col- 
 chicum for gout, and cured it ; iodide of potassium for bron- 
 chocele and periosteal nodes, and cured them. Here is a 
 formidable array of diseases, and a goodly array of special 
 remedies and cures ; and if these several remedies were absolute 
 specifics for the several diseases, there would be, as far as they 
 are concerned, an end of the matter, and a happy end too, as 
 between physicians and mankind. The world would have 
 nothing more to ask of us. Our duty would be complete, and 
 we might hand over these same diseases to the pure pathologist, 
 hoping at the same time that the remarkable fact of each 
 having in Nature one sure antidote would be for him a great ' 
 point to start from in search of their essence, and thus science 
 and humanity be both gainers alike in the end. 
 
 But of remedies such as these, even if they were absolute 
 specifics, and we had nothing to do but prescribe them and 
 register their curative effects, it would look strangely incurious 
 to have nothing more either to think or to say. 
 
 Now the first thing to be remarked is this, that of such 
 remedies — remedies specifically or specially curative in the 
 sense understood — physicians have greatly increased the 
 number and the use of late years, upon grounds, I presume, 
 sufficiently safe and trustworthy. And if the fact of one and 
 the same disease cured uniformly or almost uniformly by one 
 and the same remedy, as in the single instance of ague and 
 quinine, be taken to point to some great pathological truth 
 hitherto undiscovered, the like fact, when it comes to be predi- 
 cated of many several diseases and many several remedies, 
 denotes a whole region of still occult pathological truths. But 
 wherever it be within our bodies that these truths have their 
 place, wherever they live and exercise a living force and 
 agency, common observation has not reached ; yet it has searched 
 hard, and done its best within its own possible sphere. But 
 there is a sphere beyond ; and this science has found the means 
 and implements to penetrate, and there it has traced and 
 grasped a few elements of disease and a few substances, whether 
 remedial or poisonous. The means used are chemistry and the 
 
PRACTICE OF MEDICINE. 375 
 
 microscope; the sphere reached and unlocked is that of the 
 hlood and the tissues. 
 
 Doubtless, great things, ministering both to health and to 
 disease, are being constantly transacted within this sphere, 
 while they give no notice of themselves during their progress, 
 but only by their accomplishment. And it may be well believed 
 that remedies also which sim-ply cure, have this for their secret 
 laboratory. Specific and special remedies seem to have it almost 
 as a condition of success that their operation should be secret. 
 
 "We see how great a subject is this cure of diseases by special 
 remedies, and how it becomes fuller and fuller of interest the 
 more we think of it. But the interest is of different kinds. 
 We feel sure that it contains a mine of physiological and 
 pathological truths, if we could but reach it ; while it displays 
 upon the surface abundant proofs of the weakness and credulity 
 of medical men, from which we would willingly turn away if 
 we could. 
 
 But the subject cannot be systematised as a whole. Some 
 of its most important facts can only be fairly stated, without 
 any attempt to force them into compliance with prevailing 
 theories. 
 
 In our times poisons have been largely pressed into the 
 service of medicine ; but upon what terms ? Are they to be 
 considered as special remedies for curing certain diseases secretly 
 and mysteriously, it matters not how, if experience only give 
 sufficient warrant that they can cure them ? Or as remedies 
 for treating diseases, remedies rationally chosen for the sake of 
 operations, which we form some notion of from our knowledge 
 of their common, i.e. their poisonous effects ? These may seem 
 idle questions ; for practically it all comes to the same thing. 
 And physicians, however it may please them to account for the 
 results, have all one care in using these substances ; namely, 
 that in their way to become remedies they do not fatally show 
 themselves to be poisons. By some mode or measure of pre- 
 scribing them, we seek to cheat them of their poisonous and 
 insure their remedial effects. 
 
 It is a hard sentence to utter, but nevertheless true, that 
 there is nothing of which the physician need be so jealous as 
 his knowledge. Let the knowledge be ever so sound, and 
 consequently the desire and temptation to turn it to use ever so 
 
376 GENERAL REMARKS ON THE 
 
 great, the conditions of medical practice are often such as to 
 make its use dangerous or impossible. We have illustration at 
 hand in our present subject of what is meant, which it is worth 
 while to pursue. 
 
 The doctrine of poisons, or toxicology (as it is called) has 
 greatly helped pathology. But how far has it helped the 
 practice of medicine? Toxicology, making search for the 
 substances in which it deals, after their application to the body, 
 has traced and found some of them deposited and at rest within 
 the tissues, and some moving and circulating with the blood. 
 Thus it has disclosed a new sphere of their operations. And 
 as of many poisons, so of many medicines ; for poisons and 
 medicines are oftentimes the same substances given with diffe- 
 rent intents ; and, being the same, their operations, whether 
 for evil or for good, must, one would think, be always in the 
 same sphere. Thus, beyond these particular substances, a clear 
 intimation arises concerning some others, even our most power- 
 ful and summary, and hitherto mysterious agents of cure, that 
 they possibly may have their operations in this sphere also, and 
 that here they meet the first and finer and governing elements 
 of the disease, and here they counteract them. 
 
 Now, one would think that medicine and its effects would 
 derive abundant illustration from poisoning and its effects ; 
 that medicine, even practical medicine, would learn skill and 
 exact aims from toxicology. Both bring their means to bear 
 upon the same living body, and those means are often the same 
 and often much alike. They dwell (so to speak) in close neigh- 
 bourhood. They urge their labours, and ply their experiments, 
 within sight, and hearing, and knowledge of each other. It 
 cannot be, one would think, but that instructive hints must be 
 continually passing between them, and toxicology be most 
 helpful to medical practice. But the fact is otherwise. The 
 purposes and ends of each are so totally different that you 
 cannot reason or practise from one to the other. What does all 
 we know of poisoning by opium teach us of the uses of opium 
 as a remedy ? How to kill by it is quickly learnt. The few 
 cases of poisoning by it, accidentally or designedly, which occur 
 at any large hospital in the course of a year, are enough to 
 ' teach the student how to kill by it without fail. But a long 
 life, spent amid the emergencies of disease and the constant 
 
PRACTICE OP MEDICINE* 377 
 
 obligation of ministering to them, is required to teach physicians 
 the infinite remedial uses of opium and the skill to make those 
 uses good. 
 
 Take arsenic, strychnine, corrosive sublimate, and think 
 what the genius and experimental industry of toxicologists have 
 taught us, within these few years, of the sphere and mode of 
 their operation as poisons. Then, take arsenic, strychnine, 
 corrosive sublimate, and think of them as medicines, and how 
 physicians, whenever they use them, are obliged to handle 
 them as if they had still no knowledge of them whatever, and 
 still took them for dark mysterious specifics. For, understand- 
 ing all the characteristic effects of each as poisons upon the 
 living body, they are daily and hourly on the alert to bar and 
 exclude them. They so measure their dose as to keep it down 
 below the possibility of producing the least sensible effect* 
 They exclude all that is known of them as calculable, for fear 
 of poisoning, and they rest in what is unknown and inap- 
 preciable for the sake of curing. Poisoning and healing work 
 by the same means to different ends ; but the end of each so 
 imposes its own conditions upon the mode and measure of 
 dealing with the means, that the use of them lays open know- 
 ledge to us in the one case, and closes it against us in the other. 
 
 Poisons, be it always remembered, are esteemed poisons, not 
 because they are found in the blood and in the tissues after the 
 man is dead, but because, while he yet lives, they damage or 
 spoil the working of organs by which pre-eminently he holds 
 his life ; because they kill the brain, they kill the spinal marrow, 
 they kill the heart, or because they go near to killing them. 
 Poisons are poisons in their living signification ; and, however 
 much more may be known about them, this living signification 
 must always be the exact rule and measure of their use as 
 remedies. 
 
 All medicine is practised upon this condition, " Harm not 
 man's life ;" or if present harm must needs be, let it be such 
 as will be made up for by good to come, and so man's life suffer 
 no detriment in the end. But toxicology has life abandoned to 
 its experiments — brute life absolutely ; and as for human life, 
 toxicology is at hand to witness all forms of violence which 
 crime or accident can inflict upon it, and to study the ruins 
 they have left when life is gone. 
 
378 GENERAL REMARKS ON THE 
 
 My own experience in this class of remedies amounts almost 
 to nothing; for I confess myself altogether a coward in the 
 use of them. But as what a man does only once in his life is 
 memorable to himself, and he is naturally apt to make much of 
 it ; so to me is the single occasion in which I ever employed 
 strychnine as a remedy. Let this be my excuse for mentioning 
 it ; for the result only shows how magnanimous the patient 
 may be, and how pusillanimous the physician. 
 
 About a quarter of a century ago, there came into St. Bar- 
 tholomew's Hospital a fine, tall, intelligent fellow, at the prime 
 of life, with both his wrists paralytic and useless. He was a 
 painter. He suggested his own remedy; the same remedy 
 which, eighteen months before, when he was just as bad as he 
 now was, had, by his own account, perfectly cured him. This^ 
 remedy was strychnine. He had been in the Manchester 
 Infirmary, under the excellent care of Dr. Bardsley, who had 
 prescribed it and superintended its use. The result was the 
 happiest possible. He returned to his trade, and handled his 
 brush as well as ever. 
 
 Upon such showing, it was impossible to deny the man his 
 request : so, committing him to the charge and frequent visits 
 of a trusty student, I prescribed him strychnine. Well ! 
 things went on bravely with the patient, but nervously with 
 me. Never was man so happy as he. He had perfect faith in 
 the remedy, and was constantly interested in speculating upon 
 the progress of his recovery. At my visits, he was always 
 urgent with me to increase the dose of strychnine, and get on 
 quicker with his cure. And now he began to have involuntary 
 twitchings of the extremities, especially by night, which he 
 thought denoted the favourable operation of the remedy, and 
 entitled him to have more of it. One day, I found him happy 
 above measure ; for, in the course of the preceding night, a 
 convulsion had lifted him clean out of bed, and flung him 
 bodily on the floor of the ward. This was to him a sure 
 presage of recovery ; and must be to me, he thought, an irre- 
 sistible argument for a bolder use of the special remedy. Great, 
 therefore was his disappointment, when he found me pusil- 
 lanimous enough to order that for the present it should be 
 suspended altogether. The next day my patient was gone ; he 
 had positively run away. He left me his good wishes at his 
 
PRACTICE OF MEDICINE. 379 
 
 departure, expressing at the same time the small opinion he 
 had of a physician " who," he said, " could cure his disease if 
 he would, hut he would not." 
 
 "What a subject of contrasts and opposites is this of special 
 and specific remedies ! We find ourselves dealing rarely and 
 reluctantly with deadly poisons. "We wait and look on with 
 fear and trembling, while they are at work, upon their doubtful 
 and dangerous trials. And then we learn, on credible report, 
 that certain harmless familiar things, which we have used all 
 the days of our lives, doing no wonders with them, but yet a 
 great deal of good in a common way, turn out to have special 
 or specific virtues which nobody ever dreamt of. Remedies of 
 common use have gained from time to time the credit of a 
 specific or special use; valued and familiarly employed for 
 their known power over certain indications, and frequent sharers 
 in the treatment of whatever diseases, be they many or few, 
 are wont to present these indications; they are all at once 
 reputed to possess, moreover, a curative power over some one 
 disease in particular. The authorities or sponsors for these 
 facts are beyond all question; and thus old remedies gain 
 renown for their new virtues, and come largely into use for 
 new purposes. 
 
 Some years ago, my friends at Guy's announced to me that 
 lemon-juice was a cure for acute rheumatism ; and my friends 
 at St. Bartholomew's, that tinctura ferri muriatis was a cure 
 for erysipelas. I make no doubt that the present evidence was 
 sufficient for the fact thus far. There was the disease, and there 
 was the remedy. The remedy was given, and the disease 
 ceased sooner than according to common expectation. 
 
 I earnestly hope that the experience of these two great 
 hospitals has continued to run in the same groove ever since ; 
 that lemon-juice still cures acute rheumatism at Guy's, and 
 tinctura ferri muriatis still cures erysipelas at St. Bartholomew's. 
 If the case be really so, then can these two remedies justly 
 claim the rank of specifics, each for its disease respectively. If 
 it be not so, then they are no specifics for the particular 
 diseases, but remedies only upon conditions, though the con- 
 ditions were past finding out. Here we have great mysteries. 
 "We have remedies analysing diseases into something more than 
 we know, or diseases analysing the operations of remedies into 
 
380 GENERAL REMARKS ON THE 
 
 something beyond the uses of experience. At all events, the 
 things we witness are realities ; not visible and tangible, indeed, 
 hut still realities to be traced and acknowledged in their 
 practical bearings, and to be dealt with and used from time to 
 time, but very cautiously reasoned upon. 
 
 They suggest that the diseases spoken of, as well as other 
 and even all diseases, are often more than their symptoms 
 declare them to be, and that they contain some element beyond 
 our knowledge. This element may be occasional only ; and yet, 
 when it occurs, the part which it plays may, for the time, be so 
 essential to the entire disease, that the remedy which can reach 
 the single element deals curatively with the whole. 
 
 And further, they suggest concerning remedies, even the 
 commonest and those of which, as we fancy, we know the 
 most, that we do not know all ; that each may have powers in 
 reserve beyond the reckonings of our maturest experience, and 
 a possible sphere of operation beyond our deepest research. 
 
 But suddenly let the element which we have supposed be 
 withdrawn, and at once the medicine which did wonders is inert, 
 the disease becomes again its common self, and the specific is 
 reduced to a common remedy. 
 
PRACTICE OF MEDICINE. 381 
 
 V.— Cube. 
 
 NEW SPECIAL REMEDIES : TO BE RIGIDLY TESTED BEFORE THEIR 
 
 TRUSTWORTHINESS IS ADMITTED. — EXAMPLE OF M. LOUIS. 
 
 SUCH REMEDIES, LONG USED AND TRUSTED, AND AT LENGTH 
 PROVED WORTHLESS, ARE DISCREDITABLE TO THE COMMON 
 SENSE OF PHYSICIANS, AND DENOTE THEIR FAULTY EDUCA- 
 TION. 
 
 How far we are called upon to employ remedies which come to 
 us from time to time with the repute of a special power to cure 
 certain diseases, is an important and difficult question. I say- 
 emphatically, remedies to cure. New remedies to act upon this 
 or that particular organ and its functions — new anodynes and 
 sedatives, new diuretics, diaphoretics, or purgatives — are put to 
 quick and easy proof, and the commonest observation cannot 
 well err therein. They need only be given to a few different 
 patients, and the question is soon settled whether they have or 
 have not the virtues, ascribed to them. Besides, we can easily 
 understand how there may be substances unknown, or little 
 known, or unaccountably neglected by the profession at large, 
 which, being put to the proof, may turn out to have a power 
 over certain organs of our body and their functions. These 
 may be at length taken up by particular physicians, who, from 
 practice, learn to use them skilfully ; and in their hands they 
 are made to serve the purposes of procuring sleep, or assuaging 
 pain, or raising or depressing the pulse, better than the remedies 
 ordinarily in use for such purposes. 
 
 Indeed, any new remedy of this sort is well worth knowing 
 and trying ; for it may help us in the successful treatment of 
 twenty different diseases. But the remedy which can achieve 
 the summary cure of the single disease is the thing with which 
 we are now concerned. 
 
 Now, an uncomfortable sort of suspicion possesses me that 
 physicians from time immemorial have prescribed, and still go 
 on prescribing remedies, upon the credit they have got of 
 
& 
 
 382 GENERAL EEMARKS ON THE 
 
 curing particular diseases, without the least reasonable evidence 
 that the remedies ever did anything of the sort. The improved 
 education of which we boast in our day ought to have made us 
 less easy recipients of traditional errors, and more cautious in 
 fabricating new ones of our own, and handing them on as evil 
 gifts to our posterity. But it is not so. 
 
 When I was physician to a large hospital, having then the 
 opportunity, it seemed almost a duty incumbent on me to gain 
 an independent experience of sundry remedies which were much 
 employed, with various degrees of credulity or faith in their 
 curative powers. Indeed, I tried to do so ; but (doubtless, from 
 some fault of my own) I did not get on well with my task. 
 Perhaps I was unduly sceptical, or not patient enough ; or 
 perhaps I was both. For men do not go to work with the same 
 good will to detect what they suspect will turn out an error, as 
 to confirm what they hope to find a truth. Moreover, in medi- 
 cine (what men are scarcely aware of until they become some- 
 what severely practical), it requires as much labour and time 
 fairly to lay hold of an error, and uproot it, and have done with 
 it, as to learn and settle a truth, and abide by it. It is 
 commonly to (what are called) chronic diseases that remedies 
 said to cure have their application ; each case spreading itself 
 over a long time, is a case of mixed evidence ; and, though a 
 simple matter of fact is at issue, that evidence must be equally 
 gone into, on whichever side the verdict may be in the end. 
 Hence nothing is more certain than that numerous articles still 
 encumber our materia medica, and still pass for being able to 
 do something or other extraordinary, simply on account of the 
 infinite time and trouble that would be needed to prove them 
 utterly worthless. 
 
 "When remedies claiming, however falsely, a special curative 
 power, have been long in use, it is almost impossible ever to 
 get rid of them. Their use then becomes a good deal like 
 what the game of shuttlecock would be played by a crowd. The 
 shuttlecock need never fall to the ground ; there are so many to 
 knock it about and keep it up. But, on such terms, it is a 
 stupid game, or rather no game at all, and any left-handed 
 clown can play at it. 
 
 Now it is only upon their first introduction into practice 
 that special remedies are to be impartially examined and dealt 
 
PRACTICE OF MEDICINE. 383 
 
 with. In their trial, physicians of hospitals collectively have 
 it in their power to become to some extent the safeguards of 
 the profession ; and even individual physicians might do some- 
 thing to help us. Those especially who have bestowed much 
 time and thought upon, the investigation of particular diseases, 
 whatever positive truths they may fortunately discover or 
 explain, should consider their task still unfinished until they 
 have pointed out the stumbling-blocks of false facts, false 
 opinions, and false remedies ; and made a clean sweep of them 
 all. Strong in our esteem for the truths they have taught us, 
 they would have equal authority in exposing error. But then 
 they must not do it magisterially. They must admit us into 
 their confidence, and make us sharers in their modes of pro- 
 ceeding. 
 
 There is a living physician who has made his profession 
 doubly his debtors ; for not only upon whatever subject he has 
 written has he imparted to us new knowledge, but, what is 
 better even than new knowledge, he has by his manner of 
 dealing with it given us, moreover, a constant pattern to follow, 
 whereby each of us may pursue his own subject safely and suc- 
 cessfully. This physician is M. Louis. Now that disease which 
 is pre-eminently the scourge and terror of mankind has been to 
 M. Louis the chosen subject of thought and of research during 
 half his life, even pulmonary consumption. And when, for 
 this pulmonary consumption, he comes to take account of all 
 that in his experience art can do, he is constrained to admit 
 that its resources are limited to the one sphere of treatment. 
 The sum of his own experience is in treating, not in curing it. 
 Nevertheless, he deems his work incomplete until he has 
 reviewed the professed experience and success of others in the 
 way of cure. Thus, with a patience and impartiality worthy of 
 all praise, he passes in review ten different substances which, 
 under the shelter of good names and of seeming matters of 
 fact, had gained the credit of a special power for the cure of 
 phthisis. 
 
 The ten substances are — 1, protioduret of iron ; 2, chloride 
 of sodium ; 3, carbonate of potash ; 4, sal ammoniac ; 5, chlo- 
 ride of lime ; 6, chlorine gas ; 7, digitalis ; 8, hydrocyanic 
 acid ; 9, creasote ; 10, iodine. Of hydrocyanic acid, creasote, 
 and iodine, he considers it only necessary to remark the utter 
 
384 GENERAL REMARKS ON THE 
 
 insufficiency of the evidence by which they come recommended 
 to us as having power to cure consumption, and then leaves 
 them without a trial. Of chloride of sodium, induced by his 
 respect for M. Latour, who had introduced it and emphatically 
 recommended it, he made large trial. He gave it to every 
 phthisical patient admitted under his care into the Hotel Dieu 
 for five months successively ; and in all that time he did not 
 observe any change or amelioration in their condition which 
 could be fairly accredited to the remedy. He saw nothing, in 
 short, which is not constantly seen in phthisical patients placed 
 under the same circumstances, and submitted to different treat- 
 ment. He complains of the scanty and insufficient details in 
 M. Latour's cases brought forward to recommend the remedy. 
 Of carbonate of potash, recommended by M. Pascal of Stras- 
 , burg with such poverty of detail as to leave it uncertain for 
 what disease it was really given, though professed to be given 
 for phthisis, he fairly excuses himself from making any trial. 
 Of sal ammoniac or hydrochlorate of ammonia, recommended by 
 M. Cless of Stuttgard, and of chloride of lime by Dr. Hirzoy 
 of Posen, as curative agents in phthisis, he points to the brevity 
 with which their cases are related to be such that they could 
 hardly expect either to be believed or followed. Three sub- 
 stances remain, upon which he dwells at considerable length. 
 These are protioduret of iron, digitalis, and chlorine gas. The 
 care and patience and earnestness with which M. Louis betakes 
 himself to treat of the first of these, the protioduret of iron, 
 are remarkable. He starts with an evident desire and expecta- 
 tion of a favourable result ; for he knew and highly regarded 
 M. Dupasquier of Lyons, who introduced it into practice, and 
 had employed it with much reputed success for several years. 
 Having first taken care to make sure of the purity of the 
 remedy, M. Louis administered it to upwards of sixty patients 
 labouring under phthisis in all its stages, and in no single case 
 did he observe any improvement which could be ascribed to the 
 new agent. He cannot refrain from confessing his honest 
 surprise and disappointment that, after the fairest trial, it 
 should have utterly failed in his hands. Of digitalis, it 
 appears that M. Bayle had reasoned himself into the belief in 
 it as a cure for phthisis — not that he had reached it by experi- 
 ment. He had collected the evidence of twelve eminent phy- 
 
PRACTICE OF MEDICINE. 385 
 
 sicians, resulting in the conclusion that, of a hundred and fifty- 
 one cases treated by digitalis, eighty-three recovered, thirty-five 
 experienced benefit permanent or temporary, and thirty-three 
 no benefit at all. And this conclusion (or something near it) 
 M. Bayle thought himself in all reason bound to accept, upon 
 a choice of alternatives ; namely, to believe that eighty-three 
 cases (or thereabout) of phthisis out of a hundred and fifty-one 
 were cured by digitalis, rather than believe that twelve men of 
 reputation and honour were mistaken in their diagnosis of the 
 disease. But all these eminent authorities seem to have lived 
 prior to the use of auscultation ; and it is no disparagement 
 either of their honesty or their skill to believe them quite mis- 
 taken, since they did not possess the means of a sure diagnosis. 
 This is M. Louis' view of the question, and he does not think 
 it necessary to make experiments purposely to settle it. During 
 a dozen years he had prescribed digitalis to a few patients from 
 time to time, without any positive result ; and the occasional 
 trials of others had been alike unsatisfactory. To make the 
 heart beat slower by digitalis, and so believe oneself remedy- 
 ing consumption, is about as wise as it would be to think 
 of improving the weather by playing tricks with the baro- 
 meter, or altering the real time of day by tampering with the 
 clock. 
 
 Chlorine gas, administered by inhalation, once gained much 
 repute for the cure of consumption ; and M. Louis takes certain 
 cases, twelve in number, brought forward by M. Cottereau, as 
 the most interesting within his reach, and makes careful examina- 
 tion of them one by one. To these examinations I would in- 
 vite attention, as specimens of what is rarely met with in 
 medical literature, and of what in the present state of our 
 knowledge could be brought to bear on no organ of our body 
 except the lungs. Each of them is a study in itself. It makes 
 exact and discriminative analysis, by auscultatory signs and 
 general symptoms, of consumption and of other diseases, as 
 pneumonia and pleurisy, actually co-existing together during 
 life; of their unequal rates of progress, and of the different 
 effects wrought upon each by the impression of medicines, and 
 the cessation and disappearance of the one while the other 
 remains in its chronic state. Thus the conclusion results, that 
 many of the cases in question were a complex of pneumonia or 
 
 cc 
 
386 GENERAL KEMARKS ON THE 
 
 pleurisy and a certain amount of tubercles : the acute and 
 remediable part, pneumonia or pleurisy, being remedied, left 
 the patients in a satisfactory state for the present ; while the 
 few tubercles or incurable part still remained : further, that a 
 few of the cases were simple unmixed pneumonia. 
 
 The analysis of each of these cases, so clear, so discriminate 
 and exact, I have recommended as -a study. But it will be a 
 study not alike profitable to all, but to those only who are 
 already accurately instructed and well exercised in diseases of 
 the lungs, and, moreover, who have love and jealousy enough 
 of the truths of practical medicine to think great pains well 
 bestowed in disentangling them from constantly besetting 
 errors. Verily, there is nothing so self-deceiving and evasive, 
 and upon the whole so mischievous, as this love of specific 
 remedies. It is akin to the love of the marvellous. If it get 
 strong hold of a man, it incapacitates him from becoming a good 
 physician. And why this continual search after a specific 
 remedy for consumption ? 
 
 If I were to name any single disease in which medicine has 
 pre-eminent claims upon the gratitude of mankind for the 
 largeness and certainty of the benefits received at its hands, I 
 should name pulmonary consumption. True, I may believe 
 pulmonary consumption to be incurable in the sense of having 
 no remedy which can be brought to bear with counteractive 
 effect upon its own nature ; and I may greatly fear it to be 
 incurable, in the more popular sense, that once begun it can 
 never be brought to cease, and so entirely to disappear as if it 
 had never been. But still, by patient study of its pathology 
 and of what it is in its own nature, by patient scrutiny of what 
 it shows itself to be in individual living men ; of its seat and 
 its extent, whether small or large, and its several stages ; now, 
 of its oneness and simplicity, and now, of its mixtures and 
 complications ; of its rates of progress, whether rapid or slow ; 
 and what it gives to the vital being of those whom it befals, 
 and what it takes from it ; upon these several foundations we 
 raise our great landmarks of the treatment of this disease. And 
 thus, it has come to pass, that of the things in nature capable 
 of acting upon man's body for good, every one, in its turn, has 
 its just claim to be reckoned among the remedies of consump- 
 tion in the way of treatment, but not one to be reckoned a 
 
PRACTICE OF MEDICIHE. 387 
 
 remedy of consumption in the way of cure. There are a 
 hundred remedies for consumption, but no single remedy. 
 
 The result of these investigations of M. Louis is to raise the 
 curtain and to make us see an unwelcome truth where we would 
 much rather not have found it. It puts in a very strong light 
 the fact that the origin and spread of these lying wonders, and 
 the mischiefs they carry with them, must be largely ascribed 
 to physicians themselves. 
 
 This is a serious matter. Yet it would be well to look it in 
 the face, could we only make sure of doing so honestly and 
 without offence. 
 
 To insure success to those who practise it, medicine does not 
 require that their understanding should be of the highest order, 
 but it does require that it should be sound. Of all human 
 pursuits, medicine suffers the greatest detriment from a small 
 intellectual flaw. ISTot that practical medicine does not present 
 work fit to engage the highest understanding ; not that it does 
 not even require the highest to carry it to its greatest perfection. 
 But, then, the higher the understanding so engaged, the more 
 need there is that it is quite sound ; otherwise, it will do the 
 more mischief. 
 
 Whether we suppose a sort of flaw, or a certain vicious 
 element in the original mould of a man's mind, something there 
 is which all the world knows and speaks of as a reality. And 
 what the world makes sure of, and is familiar with, it is apt to 
 call by some homely vigorous name ; and this it calls wrong- 
 headedness. The name is almost descriptive of the thing itself ; 
 for, wherever it is found, it is always ready to hinder whatever 
 is best within the man from doing its perfect work, and to lead 
 to perverseness of opinion and conduct. 
 
 Now, this (so-called) wrong-headedness is found in various 
 measures, from small to great ; but, unfortunately, in practical 
 medicine, a little of it goes a long way ; it leavens a large 
 lump. In every profession, business, and calling, with all the 
 advantages of education and special training, men continually 
 fail, from some touch of wrong-headedness in their composition, 
 some trace of defective common sense ; and truly that a number 
 of clever, industrious, learned men should meet with nothing 
 but bad luck in life is lamentable enough. Still, it would be 
 well for the world if the worst misfortune that could be 
 
388 GENERAL REMARKS ON THE 
 
 reckoned were the misfortune of individuals; but the pro- 
 fessions, businesses, callings, themselves suffer detriment and 
 discredit and hindrance of advancement at the hands of those 
 who are daily practising them and spoiling them. And, above 
 all, the medical profession ; not because there are more wrong- 
 headed men in it than in other professions, but because a less 
 amount of the fatal ingredient goes to vitiate its conclusions. 
 Medicine has very few scientific tests at its command, and 
 almost all its great questions are left to the sole judgment of 
 well-instructed common sense. 
 
 Therefore, we need not be surprised that, taken upon a com- 
 parison with other professions, and having no more than its 
 average proportion with the rest, of that which is naturally 
 antagonistic to common sense in them all, medicine should suffer 
 a far greater practical evil from it. 
 
 I have spoken of well-instructed common sense ; for common 
 sense has somehow (perhaps from its name) come to be taken 
 for something coarse in itself and its operations, and only fit to 
 be coarsely used. But there is not a thing in the world more 
 delicate, or more easily spoiled, or requiring to be more deli- 
 cately handled. Left to itself, it is not good for much. It 
 must have culture and education ; but very different are its 
 issues, according as it is wrongly or rightly educated. It may 
 be sophisticated into folly, or it may be cultivated into sagacity, 
 which is its highest perfection. 
 
 Sad tricks have been played with our professional education 
 of late years. Medicine justly claims kindred with all things 
 that are best in human knowledge. But this is not a reason 
 why every man who is to practise medicine should be set to 
 learn them all. Let a man learn them all, if he can wield them 
 all ; or as many of them as he can lightly bear and freely use. 
 But a small overweight of knowledge is often a sore impediment 
 to the movements of common sense. 
 
 If half the scientific things now insisted upon as essentials 
 of medical education were dispensed with to-morrow, the know- 
 ledge of them would not perish from among us. They are much % 
 too attractive objects of study not to find many of the best 
 minds always ready to take them up and pursue them zealously 
 and profitably for themselves and their profession ; but by those 
 who must learn them they are only half learnt, and serve them 
 for no use whatever, but for a great hindrance. 
 
PRACTICE OP MEDICINE. 389 
 
 Should ever a few of the most right-minded and experienced 
 among us set themselves to settle, what is much wanted, a scheme 
 of medical education the fittest and best of all, or for the great 
 majority, and be quite agreed about it, and commend it to the 
 world, it would offend by the fewness of its requirements, and 
 so be unacceptable, and be rejected, and come to nothing ; where 
 the hitch and hindrance really lie is plain enough, and ought to 
 be plainly told. Men are vain only about themselves; but 
 about their clan, their calling, their profession, they are more — 
 they are vain- glorious. Hence the extravagant expenditure of 
 all the world upon mere show, socially, morally, mentally. The 
 evil is absolutely incurable ; and, alas ! it bears most heavily 
 upon the medical profession, whose basis is common sense. 
 
 Common sense is in medicine the master workman. With 
 it a few good solid materials become the ways and means to 
 practical results infinitely various and important ; without it, 
 materials ever so many and ever so good come to nothing or 
 come to mischief. 
 
 Moreover, medicine has (so to speak) no one grammar, or 
 orthography, or formal logic of its own. Men may spell it, and 
 write it, and reason it, how they will, and have none to take 
 them to task. It is the result only that is seen or appreciated. 
 But, then, the more each man is left to himself, the more strict 
 should he be in his self-questionings ; for every man then, being 
 (but in no evil sense) a law to himself, becomes responsible to 
 himself for exact compliance with its requirements, according 
 -to his own consciousness of what is right for him. And, might 
 we not add, according to his own conscience, too ? For, often 
 times, a man's intellectual self and his moral self must be 
 mutual safeguards and fellow-labourers, if he is to work his way 
 without mischance to the best conclusions. This is pre-eminently 
 the case in practical medicine. 
 
390 GENERAL REMARKS ON THE 
 
 VI.— Cuke. 
 
 ONE CHIEF CAUSE OF DAMAGE AND DISCREDIT TO MEDICINE AS 
 A PEOEESSION IS TO BE FOUND IN THE NOTIONS POPULARLY 
 HELD OF DISEASES AND REMEDIES; AND IN THE USE TO 
 WHICH THOSE NOTIONS LEAD OF PRETENDED SPECIFICS OR 
 THINGS CLAIMING A SPECIAL CURATIVE VIRTUE. 
 
 The abuse of specifics or special remedies has been spoken of 
 as it rests with physicians, when they choose them, and apply 
 them, and misjudge their effects from evidence which, upon 
 sober examination, turns out good for nothing. Now, should 
 anyone be inclined to cultivate a little plausible ill-will towards 
 physic and physicians, let him dwell for awhile in this unfor- 
 tunate region of our practice, and he will easily pick up enough 
 to confirm his own prejudices, and to convict us of weakness 
 and credulity. There is nothing edible or potable in the world, 
 which has not found somebody or other to eat it or drink it as a 
 sovereign remedy for some disease, and upon the recommenda- 
 tion of some physician. The records of Medicine show all this ; 
 and ludicrous enough they are. 
 
 But there is an expenditure of worthless things for special 
 remedies constantly going on, and never more than now, far 
 beyond what can be accounted for from any mere fault of 
 physicians. The world is much more in fault than we are. 
 Indeed, all the world practises medicine beside physicians. 
 And it holds pretty strong opinions on its own line of practice; 
 and its opinion and practice influence our's more than may at first 
 appear, and more than we may think or care to allow. Now its 
 line of practice is chiefly in curing, and it deals largely in specific 
 or special remedies. 
 
 Supposing, from the aggregate experience of ages, medicine, 
 as an art, to have now gained a certain level of perfection, and 
 supposing it to be always in good and skilful hands, there is that 
 constantly at work in the world which is calculated to keep its 
 practice below what it ought to be and what it might be, and. 
 
PRACTICE OP MEDICINE. 391 
 
 prevent the best physicians from doing their best, and lead the 
 wisest among us to do all sorts of foolish things, or allow them 
 to be done. 
 
 There are always two parties to the management of the 
 disease — the physician and the patient. But the share of each 
 would seem to be denned plainly enough ; and that it was the 
 physician's business to direct and the patient's business to 
 submit. This, however, rarely happens in fact. Unless when he 
 is so ill as to have no will of his own, the patient always inter- 
 feres with the physician in some measure, great or small ; and 
 it is hardly possible that he should not do so. And truly his 
 interference is sometimes for good, and the physician finds help 
 in it. Too often, however, it is for evil, and to the hindrance 
 of the physician ; and its mode and measure may make the evil 
 and the hindrance great and serious. Between patient and 
 physician there arises a perilous chance that some such practice 
 will result as is found to come from consultations between phy- 
 sicians themselves, bred in totally different schools, and of very 
 unequal experience. Unluckily, the physician of perverse views 
 and of little or no experience, is apt to be practically perti- 
 nacious and dogmatical. He sees no difficulties, and will have 
 his own way. On the other hand, the physician of sound views 
 and well tried experience, while he is ever ready to give you 
 the full benefit of them, if you choose to trust him, is not the 
 man to be for ever doing battle in their behalf, and forcing 
 a way for them against strong prepossessions. Hence, in the 
 management of any disease shared between such two physicians, 
 it is odds but the handiwork of the former will be visibly pre- 
 dominant throughout. 
 
 The world, or, as we should say, " all those that are without," 
 and that have not the estimable privilege of being physicians 
 and yet keep their common liability to become patients; all 
 mankind, in short, except physicians, even this entire world 
 conceives all diseases that have a name as distinct essences, and 
 of all remedies as distinct antidotes. Hence it has no sympathy 
 and common understanding with us and our proceedings. The 
 world, the educated world, has no other notion than that each 
 disease has its own remedy ; and that thus the whole practice of 
 medicine really consists in knowing the disease and its antidote, 
 and matching them fairly against each other. " You physicians 
 
392 GENERAL EEMAEKS ON THE 
 
 have not yet found out the remedy for hydrophobia." "Here is 
 cholera come again, and you physicians know nothing more 
 about the remedy for it than the first time it appeared among 
 us/' "Here is this diphtheria making cruel havoc, and you 
 seem to understand a good deal about it as a disease, but none 
 of you has any conception what is the cure for it." All such 
 common impeachments of our shortcomings plainly imply the 
 prevalent notion, that physicians have but two things to learn, 
 and have learnt only one of them, and not always that. 
 
 It has been a matter of painful concern to me half my life, 
 to see my profession lightly esteemed by many wise and good 
 men ; owing, I believe, to the utter impossibility of anybody 
 being brought to understand what that profession really is in 
 any other way than by partaking of its peculiar experience — 
 i.e. by practising it. The distinction, plain, simple, and needful 
 as it is, between curing the disease and treating the patient, is one 
 of those things which cannot be comprehended otherwise than 
 by being daily conversant with diseases and remedies. It 
 requires to be wrought into us by force of the facts, the peculiar 
 facts, of practical medical experience. 
 
 I had a friend, who was a lawyer, and had held a judicial 
 office many years ; and he had a son, also a lawyer, about 30 
 years of age. The son was taken ill of a fever, and was put 
 under my care a few days after its commencement. The fever 
 was what we now call typhoid. I took some pains to make the 
 father understand all that he was most interested to know about 
 it ; how that it had a certain course to run ; that it was the 
 business of medicine to avert or to mitigate its contingent evils, 
 and so carry it safely to its end ; but that there was not the 
 thing in the world which could cut it short, and at once and 
 directly cure it. He seemed to comprehend all I meant per- 
 fectly, and to assent to it ; and, upon the terms of this pre- 
 liminary explanation, I proceeded to do my best for his son. 
 
 The case went on hopefully in the main, but not without 
 circumstances of anxiety enough to make me glad of having 
 another physician called in consultation. Yet, notwithstanding 
 the two physicians, such circumstances did not become fewer or 
 less pressing as time advanced. And then the father announced 
 to me his resolve that he would have physician after physician, 
 until he hit upon one who knew the remedy that could cure his 
 
PRACTICE OP MEDICINE. 393 
 
 son's fever. Luckily, on that very day the symptoms began to 
 -clear up, and hope was more legible in them all ; and so the son 
 was spared the peril of the paternal experiment. In due time 
 the young lawyer got well, leaving the old lawyer to meditate 
 the mystery, how in the world it is possible for mortal man to 
 get rid of a disease for which there is no cure. 
 
 This instance strikingly shows the fact, and might have 
 shown the mischief, of the common belief, that the practice of 
 medicine consists altogether in the giving of antidotes. " Try 
 this. This not succeeding, try that. That and this both failing, 
 are there not yet things which are reputed sovereign for the 
 malady? Try them all one after another. None of them 
 succeeding separately, still do not despair; try them all at 
 once." The matter, thus plainly put, looks ridiculous in the 
 eyes of every experienced and thoughtful physician. But the 
 world — the greater part even of the well educated and intelli- 
 gent world — would see nothing at all ridiculous in it; it is 
 simply their notion of the practice of medicine. The popular 
 notion has, and it cannot help but have, a momentous bearing 
 upon medicine and its fortunes, as a profession. The world has 
 great faith in physic upon the whole ; but its faith is of a wrong 
 sort. It is not a belief, but a superstition. 
 
 To find the particular antidote for the particular disease 
 being the popular notion of the practice of medicine, it un- 
 happily comes to pass that no small portion of mankind have 
 actual motive enough for demanding these antidotes at our 
 hands, in cases where they can never be forthcoming — cases of 
 irremediable disease. And it is these, even these, that furnish the 
 principal field of trial for all worthless things, and the principal 
 source from which they issue and pass current for specifics or 
 special remedies. In truth, the amount of irremediable disease in 
 the world is enormous. There are small tuberculous deposits 
 at the apex of a single lung or elsewhere, which may be slow 
 to advance, or remain stationary for years and years. And 
 there is acute fungoid cancer sweeping and destroying all 
 organic structures before it, and killing in a few months. And 
 between these two there are diseases of various kinds — some 
 limited in their seat, some wide- spreading and diffusive, some 
 slow, some rapid — all admitting of various degrees of palliation 
 and postponement, but not to be got rid of, and all in the true 
 
394 GENERAL REMAKES ON THE 
 
 sense irremediable. Now no diseases have been so well studied 
 as these ; none have had, none still have, so much thought and 
 experimental industry bestowed upon them by the best minds. 
 And all for what ? 
 
 In this working-day world of ours, we must take things 
 according to their kind. If the greatest good be not attainable, 
 we must not count all that is short of it for nothing worth. If 
 the highest mark be beyond our reach, we must content our- 
 selves with a lower aim. By all his knowledge and experience, 
 the physician is convinced that, in certain diseases, he can 
 prosecute neither cure nor treatment to the restoration of perfect 
 health. But his office does not therefore cease. Still he can 
 palliate; still he can postpone; still he can procure years 
 and years of life and usefulness for the subjects of irremediable 
 disease. And I will be bold to say, that the prime condition of 
 his ability to do all this, is his knowledge that the disease is 
 irremediable. 
 
 Further ; it is no paradox, but an experimental truth, that 
 the physician holds his power of doing good in incurable diseases 
 so long only as he does not lattempt to cure them. And his 
 power of doing good is very great. 
 
 The world may think, naturally enough, that the knowledge 
 (howbeit only to be procured by hard study) of what is incur- 
 able and intractable in the nature of diseases, must indispose 
 physicians for putting forth the full power of their art, and lead 
 them to make too easy and premature surrender of its possible 
 masteries. But let mankind have no misgiving on this point : 
 our fault is the common fault of all. Oftentimes, in particular 
 cases, we catch ourselves at work fabricating a sort of fictitious 
 faith, and setting it up against all the experience of our lives, 
 sooner than give the disease up for incurable. We believe, or 
 try to believe, against knowledge ; and so we run a perilous 
 chance of acting against knowledge, and doing mischief. 
 
 There is hardly a man living, be his disease what it may, 
 who will bear to believe himself beyond the possibility of 
 restoration to health. He will allow the physician to profess 
 palliation, and postponement, and relief; and, when the phy- 
 sician does all which he professed to do, he will be thankful to 
 him, but he will think it strange that he can do no more. And 
 so he lets go his faith and his allegiance, and goes in search of 
 some one to cure him by a lucky remedy. 
 
PKACTICE OF MEDICINE. 395 
 
 Thus the comparison of what we can do with what we are 
 expected to do, is often mortifying enough. But it cannot be 
 helped. People are free to expect what they like ; while we 
 cannot do more than can be done. Our ability is bounded by 
 the nature of things, at all events. 
 
 The physician gains strange insights into the weaknesses of 
 poor human nature. Men are found to cultivate credulity, and 
 take refuge in it against the convictions of common sense, until 
 they bring themselves to believe impossibilities. An eye, or an 
 ear, or a large joint irreparably damaged by some bygone disease 
 or injury, is doubtless an evil hard to bear ; but, the fact being 
 demonstrably certain, nothing remains but to acquiesce in it. 
 Therein, however, consists the moral trial, of which we phy- 
 sicians are the privileged spectators and judges ; and, summarily, 
 this is the result of observation. The poor, and those who live 
 by their labour, and to whom the loss of an eye, an ear, or a 
 joint, is a serious hindrance in their daily work, do acquiesce in 
 it well upon the whole. They do the best they can without 
 them. They learn new shifts to supply their defects, and so 
 contrive to forget them, and get on pretty comfortably alto- 
 gether. Not so those who are delicately brought up and are 
 well off in the world ; not so those especially who have no 
 indispensable duties waiting upon their each day's thought and 
 each day's labour ; yet they have their own (perhaps many) 
 resources always at hand, and always ready to serve them if 
 they choose. But when the mind needs physic, the dose must 
 be compulsory to do any good. So many come to cultivate 
 credulity as a better expedient, and some with such success as 
 to cast anchor upon downright undeniable delusions, and rest 
 there with much content. 
 
 I knew a man who was totally blind of one eye. The eye 
 was gone. Disease had abolished it years ago ; and, in its stead, 
 all that now remained was a little round button of gristle or 
 cartilage, to which the muscles still had an attachment, and 
 moved it about. He was a man of fortune, and had had the 
 best professional advice, and must have been made acquainted 
 with the true state of his case. He was also a man of accom- 
 plishments, and his society was much sought and cultivated. Yet 
 he was going twice a week to a notorious quack, and having 
 something dropped upon what was once his eye. Thus he had 
 
396 GENERAL REMARKS ON THE 
 
 brought himself to believe that lucid glimmers followed each 
 application of the nostrum ; and this happy delusion kept alive 
 in him the hope of returning sight. 
 
 One would willingly believe this to be a very rare specimen 
 of self-deception ; but really it is not so. The experience, I 
 find, of many physicians has furnished them specimens to match 
 it. But surely it cannot be that any man, educated for our 
 profession, should have the requisite ignorance and the requisite 
 dishonesty to share and to promote so vast a delusion. The 
 transaction must always lie between the patient and his favourite 
 quack. 
 
 But let us concern ourselves only with actual diseases, 
 diseases existing and in progress. And of these let us ask 
 whether the fact that they are, or are deemed to be, incurable 
 or intractable — the fact that there is no medicine or method of 
 treatment known by which they have ever been successfully 
 managed — whether this fact be enough to warrant physicians in 
 doing and trying anything or everything indiscriminately upon 
 them? — enough to justify or excuse us in falling in altogether 
 with the world's notions, and adopting the world's practice of 
 medicine, as far as they are concerned ? I think not ; for this 
 would be mere gambling with drugs, and not the practice of 
 medicine. Gambling, too, it would be of the silliest kind ; the 
 chances being incalculably against you. For thus to try this, 
 that, and the other thing, implies an expectation of finding in 
 some one of them a specific or special remedy for the particular 
 disease, well knowing how very few such remedies exist in the 
 whole world. The absurdity is neither more nor less than that 
 of a man, who should trust the payment of his bills to the 
 chance of finding a bag of money. 
 
 But there is, it must be confessed, a good deal done every 
 day by eminent physicians which we cannot honestly compli- 
 ment and call it the practice of medicine. Bankruptcy of 
 means puts good men often upon strange shifts to stave off 
 pressing obligations ; and so they must be excused. 
 
 The conditions under which we are called to act are not 
 seldom such as to disturb all sober reckonings of the means and 
 methods which we employ, confounding even their choice, their 
 uses, and their effects. Irreparable disease, with its pains and 
 its perplexities, its fears and its despair, is apt to raise a very 
 
PRACTICE OP MEDICINE. 397 
 
 importunate cry. Ask what it will, in very pity it must be 
 granted. But it asks impossibilities ; and when it does, the 
 physician in very pity must attempt them for it. 
 
 But where nothing is expected, the least thing is exaggerated 
 by surprise, and comes to pass for something great. Morally, 
 no extremes so nearly meet as credulity and despair. Thus 
 cures are reputed for incurable diseases, which confessedly 
 remain as incurable as ever; and wonders are accredited to 
 particular remedies, which can never be got to do the like 
 wonders again. Physicians, who have worthily achieved great 
 reputation, become the refuge of the hopeless, and earn for 
 themselves the misfortune of being expected to cure incurable 
 disease. They find a necessity laid upon them of attempting 
 something when they have faith in nothing. Thus, for all who 
 resort to them, they must needs prescribe a remedy. But 
 acquiescence for long in any labour felt to be quite useless is 
 intolerable. And so physicians themselves are driven to get up 
 a sort of fictitious faith in certain remedies which hard necessity 
 forces them often to use ; even if it be but a faith to this small 
 amount, and thus faintly expressed, " that they do not know 
 but they may have seen them do good in a few cases." 
 
 What a penetrating insight had they of old into occult 
 moral truths ; and how they sketched them to the life in their 
 beautiful mythologies ! Thus they fabled some curious " penal 
 servitudes" in their world below, typifying the torment of 
 labour with utter uselessness. But, could the unhappy ladies 
 have stopped only one of the hundred holes in the leaky cask, 
 they might perhaps have deceived themselves into a little heart 
 and hope under the circumstances. And surely many a sensible 
 physician must half-willingly deceive himself, or he never could 
 go on prescribing the things he does under any necessity. 
 
 Now even we physicians have a motive for being careful of 
 acting foolishly, lest possibly we may find followers. Eemedies 
 known to be prescribed habitually by the best of us, but not 
 known with what little or no faith, are apt to make sad havoc 
 with the faith and practice of the profession at large. A 
 physician plausible, clever, and very active, a favourite and an 
 authority, perhaps, with people of the world, may, if he be but 
 right-minded, be a credit and a gain to us all in the position 
 which he holds ; but a little wrong-headedness, or a little 
 
398 GENERAL REMARKS ON THE 
 
 credulity, or his own opinions half worked out, and consequently 
 a facile compliance with the opinions of others and even with 
 the will and pleasure of good people who can know nothing 
 about the matter, must in the main greatly damage his own use- 
 fulness, and make him, all unconsciously perhaps, a worker of 
 mischief to his profession ; as, in other respects, so espe- 
 cially in this, that he keeps alive within it a talk and a fuss and 
 a barren interest about a pack of foolish things, which are utterly 
 worthless. 
 
 Thus it is beyond question that the adoption of special 
 remedies for diseases upon insufficient grounds is a main 
 hindrance to practical medicine, constantly withholding it in its 
 progress to that degree of perfection which it is capable of. A 
 motive for their adoption, and a strong one, has been seen in 
 the sway which the world is ever exercising upon us in the 
 manner explained. Another motive, also a strong one, has not 
 been concealed — the acquiescence and credulity of ourselves. 
 There is no doubt of the fact that what may be taken up to-day 
 without reason or proof by a plausible enthusiast or two will 
 have the multitude] of the profession using, and believing in, 
 and swearing by, a few months hence ; and thus it will gain a 
 credit from which the contrary experience and sober dissent of 
 well-judging minds will never be able to set us free. Unfor- 
 tunately, where there is no experiment of exact science to settle 
 the matter, it takes as much time and trouble to pull down a 
 falsehood as to build up a truth. Only let the most worthless 
 nostrum get backed by the credit of some good name, and it 
 will never cease to pass current for something in the world, and 
 will never be altogether got rid of from our materia medica. 
 Thus, upon the whole, it is sad to think how much of the 
 practice of medicine is blindly engaged in a busy, noisy work- 
 shop of impossibilities. 
 
PRACTICE OF MEDICINE. 399 
 
 VII.— Cure. 
 
 REMEDIES TO BE ACCEPTED FOR SPECIFIC OR SPECIAL ONLY ON 
 THE CONCURRENT TESTIMONY OF THE BEST AND THE MOST 
 EXPERIENCED MEN. — SUCH REMEDIES FEW. — GREAT VALUE OF 
 THOSE FEW: 1. FROM THEIR POSITIVE EFFECTS ; 2. FROM THE 
 HINTS THEY FURNISH OR CONFIRM OF THE DEEPER AND 
 
 MORE OCCULT ELEMENTS OF DISEASES. THEIR MIXED USE. 
 
 FAITH IN THEM GAINED IN ACUTE RATHER THAN IN CHRONIC 
 DISEASES. 
 
 The abuse of specific or special remedies, whether by physicians 
 or by the world, is a heavy clog and drag upon the credit and 
 fortunes of our profession. How it came to pass, and how it 
 always has prevailed largely, and always will and must pre- 
 vail, may be gathered from the explanation which has been 
 given. Should this be deemed too much of an explanation, let its 
 motive be its excuse ; namely, that thoughtful physicians may 
 be made more fully aware how great the evil is, and may guard 
 against it in their own practice and discountenance it by their 
 example, and thus hope to abate it a little. But they must 
 never hope to put it down until they can persuade all their 
 brethren to practise medicine wisely, and all the rest of the 
 world not to practise it at all. 
 
 Now let us resume the subject of cure and special remedies 
 where it was left off, and let us speak no more of their abuse. 
 For have we not seen an obligation to use them in their own 
 unaccountable success ; and have we not seen within them- 
 selves promises and prophecies of future knowledge ? ( Vide 
 article in.) 
 
 The specific remedy and its certain cure, and the special 
 remedy and its probable cure, will bear to be called "great 
 facts "; and, indeed, they are much to be admired. But, to be 
 so called and so thought of, they should bear the royal stamp 
 — the stamp of experience. They should be current at sight 
 among the wise and prudent, and pass with them for as good 
 
400 SENEGAL KEMAEKS ON THE 
 
 as gold. And, verily, such, specifics and special remedies there 
 are. But they are few ; few and precious — precious in them- 
 selves and beyond themselves. For it cannot be that they 
 should stand alone ; they must have kindreds enough of worth 
 and value, if we could but find them out. 
 
 True it is, that these same remedies officiate something 
 which we do not understand, and in parts of the body where 
 we cannot follow them. We know neither what they do, nor 
 where they do it ; yet the effects of their operation are positive 
 and unequivocal. They have been fairly surmised to have to 
 do with those first elements of disease, which are peculiar ob- 
 jects of interest and research in our own times, and which have 
 their seat within the blood. Perhaps there would be no harm 
 in following this surmise a little way in the direction to which 
 it points. 
 
 For, to be long busy about some spot where truth has 
 seemed to dwell, and to take up often and examine often the 
 curious things that are to be found there, and join them and 
 separate them, and separate and join them again and again, 
 skilfully or unskilfully, is not this the common lot and proba- 
 tion of those who have happily made them fit at last ? And 
 this fitness have they not welcomed for a notice of some truth, 
 which they sought, being not far off, and have gone on their 
 way rejoicing. 
 
 In like manner we would deal with these great remedies, 
 even the special instruments of cure ; and, before we take leave 
 of them as a formal part of our subject, we would take some of 
 them up and handle them a little, and try what fitness they 
 have, or seem to have, with the things they approach, or touch, 
 or mix with, and so gain what better insight we may into the 
 manner and place of their surprising operations. 
 
 Let us begin with the most familiar instance. No remedy 
 does its work so summarily and well as Peruvian bark when it 
 cures an ague. And when it cures other diseases, as some- 
 times it does, it still does its work summarily and well. But 
 how and where does it do it ? The man who finds out that, 
 will make a great discovery. But already one cannot help but 
 see much plausible fitness of things that cluster about the 
 matter, which tells of truth being somewhere near at hand. 
 
 All know it for a fact that, by accident or design, noxious 
 
PRACTICE OF MEDICINE. 401 
 
 elements are constantly gaining entrance within us, from which 
 it is the perpetual business of the body to set itself free. If 
 the element be such as specific or special remedy can reach 
 curatively, the body is spared a world of trouble, pains, and 
 perils in regard of it. 
 
 There is a certain noxious element of great activity and 
 power, and wide-sweeping operation, which seems to be sui 
 generis, and Peruvian bark is its antidote. 
 
 It belongs to intermittent fevers essentially and inseparably, 
 making Peruvian bark their remedy always and everywhere, 
 and in every body. And it seems to mix itself with other fevers 
 and other forms of disease accidentally and occasionally, calling 
 for Peruvian bark to aid their cure at certain places and 
 seasons, and in certain men. 
 
 But this same material morbid element, which has Peruvian 
 bark for its antidote, goes, after its entrance within the body, 
 nobody exactly knows whither ; yet we guess it goes into the 
 blood, and that there the special remedy reaches it and deals 
 with it, and somehow renders it harmless. And whoever 
 chooses to adopt this theory of its curative operation, may have 
 the satisfaction of knowing it to be in respectable conformity 
 with pathological views now commonly entertained. 
 
 Let us briefly run over these views, and so judge of their 
 fitness to furnish us convictions or surmises of the place and 
 manner where and how our specifics and special remedies have 
 their operation. 
 
 Pathologists are coming more and more to the belief that 
 diseases are developed from elements which have their first 
 existence in the blood. And, indeed, there is sure proof of the 
 fact in a few instances, as where sugar, or urea, or pus, are 
 found therein ; and there is next to sure proof of the fact in 
 contagious eruptive diseases. We know that they have a 
 material element. Entering the body, whither can it go but 
 into the blood ? "Where can it germinate and increase but in 
 the blood ? Whence can it be diffused throughout the body, 
 and be finally separated by the skin, but from the blood? 
 Further, by a very strong analogy, it commends itself to our 
 reason to believe that malarious diseases, from the least to the 
 greatest, from the headache a man has suffered for a few days 
 while a drain has been offensive in his house, to the fevers con- 
 
 DD 
 
402 GENERAL REMARKS ON THE 
 
 tracted in the Pontine marshes, have all their origin from a 
 foreign and noxious element gaining access to the blood. 
 
 All this, and more than this, the popular language of 
 medical men has already sealed and certified as true. We talk 
 of almost all diseases as blood diseases, and of their elements as 
 poisons ; of the scarlatina poison ; the typhus and typhoid 
 poison ; the cholera poison ; the poison of gout, of rheumatism, 
 of erysipelas ; the poison of boils and carbuncles. We speak 
 even of chronic constitutional diseases as live-long poisons, as 
 the poison of struma and cancer. 
 
 Without doubt this language may be taken in some extent 
 to express plain and almost demonstrable truth ; and, again, in 
 some extent to express truth of very high probability. But 
 then, in a much larger extent, it means nothing beyond surmise. 
 
 Now surely there is an evil in using language more precise 
 than our knowledge. If this were the place, it would be easy 
 to show that medicine has partaken especially of it. Its lan- 
 guage has almost always outrun its knowledge. And the evil 
 has been nothing less than this : our language, by ever persuad- 
 ing us that we are wiser than we are, has wedded us to many a 
 capital error for half a century. 
 
 The theory which we have been propounding is sober and 
 plausible enough ; but it has its weak points. Yet some 
 would think it complete throughout. Let us, however, beware : 
 for, accept it in its totality and without reserve, and give 
 it free play, and see what a wide extravagant sweep it will 
 presently take. The theory is this ; that the bark and all 
 other remedies whatever, which cure without any intermediate 
 operation being apparent, do in fact work their cure by finding 
 each that element of disease in the blood for which it is the 
 natural antidote, and there dealing with it and casting it out. 
 But let us beware: for the theory would go to creating as 
 many elements or quasi-elements of disease in the blood, 
 as there are specific or quasi-specific remedies in the world ; 
 and a precious nosology we should have of it ! It is all very 
 well to hold the belief that diseases and cures are largely trans- 
 acted within the blood ; there are facts enough pointing to it 
 and confirming it. But there are not facts either enough or of a 
 fit kind to furnish out anything like the perfect theory contem- 
 plated. The thing must wait. 
 
PEACTICE OF MEDICINE. 403 
 
 The number of facts within the knowledge of every ex- 
 perienced physician is enormous ; and every thoughtful phy- 
 sician has it perpetually in mind to put them in their natural 
 order, and to learn their true meaning. But then comes the 
 temptation common to all minds that are speculative (and what 
 mind that can think at all is not speculative in some degree ?) 
 — the temptation, namely, to press known facts a little further 
 than they will bear, when that little is all that is wanted to 
 establish a theory. Even sober minds are too apt to yield com- 
 pliance to this temptation. But we tread upon tender ground. 
 Let it be enough to notice the extremes which are, and always 
 will be, found among the best of those who study and practice 
 medicine. 
 
 There are those who are ready to work every bit of new 
 knowledge they pick up into the common fabric of what they 
 have in daily use and exercise ; this is a great temptation and a 
 great fault. And there are those who, always busy in acquir- 
 ing knowledge, are yet so religiously on their guard against 
 erroneous theory, that they are afraid even of generalising. Is 
 not this sometimes the case with Heberden? Doubtless this 
 too is a fault ; but then it is so rare, and where it exists, it so 
 often springs from that charming union of a modest with a 
 powerful mind, that it easily claims for itself a merit, and even 
 passes for virtue, in our esteem. The great and frequent fault 
 of our profession is of the other kind — to be premature and 
 precipitate in systematising new knowledge ; for thus some of 
 the best minds have been lost to the advancement of practical 
 medicine. 
 
 Something remains to be added respecting Special Remedies ; 
 but it would be altogether a mistake to attempt any orderly 
 account of them. A pretty sure insight into things, be they 
 what they may, is required to systematise them profitably. To 
 be exact beyond our knowledge is the worst of pretences. All 
 arrangements of facts aim at being didactic ; but then they must 
 be arrangements into which they naturally fall, not into which 
 they are forced. The facts which concern Special Remedies are 
 far too interesting and important not to be spoken of; but they 
 must be spoken of somewhat discursively. 
 
 Now, have these remedies anything like a domain to them- 
 selves, be it large or small, in the cure of disease. It is difficult 
 
404 GENERAL REMARKS ON THE 
 
 to say whether they have or not. The disease pre-eminently 
 deemed curable by its own specific will, in a few instances, 
 refuse to be cured by it without the help of some remedy suited 
 to emergencies of the individual patient. Ague commonly 
 yields to quinine ; but occasionally it does not until some 
 mercurial be given to redress a present wrong-doing of the 
 liver. Grout is often cured by colchicum single-handed ; and 
 erysipelas single-handed by bark. But gout from colchicum, 
 and erysipelas from bark, often obtain something short of cure, 
 which remains to be completed by common or non-specific 
 remedies. Or take the converse, which perhaps shows the fact 
 as it more frequently appears. Grout is treated by remedies 
 suited to the requirements of the particular case ; and they ful- 
 fil this, their immediate intention, and bring the whole disease 
 nearly into subjection. The patient is almost, but not entirely 
 well ; a trifle of gout still lingers, and vexes him pertinaciously ; 
 you give him colchicum and at once he is well altogether. In 
 like manner, erysipelas is treated by remedies suited to the 
 particular case, and they answer their immediate purpose. 
 Moreover, the whole disease is manifestly kept in check ; it is 
 reluctant to spread ; it fades ; but it does not disappear until 
 the patient takes quinine, and then it at once disappears alto- 
 gether. 
 
 Thus, brought to the test of how they demean themselves 
 under the trial of certain special remedies, diseases have much 
 that is mysterious to tell us concerning their nature. Truly, in 
 this regard, they would seem to change their natures from time 
 to time ; or the same disease to partake of a double nature, as 
 when it is curable in part by a special remedy, and treatable in 
 part by common ones ; or to share that double nature in variable 
 proportions, being now almost curable by a special remedy with 
 very little help from any common one, and now almost treat- 
 able by common remedies with very little help from a special 
 one. 
 
 How the two orders of remedies seem conjointly to analyse 
 the nature of the diseases with which they have to do ! 
 
 There is a good deal of difference how we regard the effects 
 of the same special remedy, according as it is brought to bear 
 upon an acute or a chronic disease, and as its own operation is 
 rapid or slow. The nearness or remoteness of the result 
 
PRACTICE OF MEDICINE. 405 
 
 strengthens or weakens our faith in the power of the remedy. 
 If some sure earnest of the coming result follow the first use of 
 the remedy, and the result, even the cure, be complete within a 
 few days, then we have all that reason can ask for faith in the 
 special remedy from first to last. But if the result be post- 
 poned for weeks, and still postponed for months, and the 
 earnests in the meanwhile, upon which hope likes to lean and to 
 refresh itself, be few and long between — then, though the result 
 arrive at last, even the perfect cure, the reason gives but a 
 hesitating faith to the special remedy for its share in pro- 
 curing it. 
 
 So when quinine is prescribed for an ague, or for any 
 rapidly progressive disease to which fever belongs, such as 
 erysipelas or acute rheumatism, and it ceases abruptly or soon, 
 or in a few days, our faith in the remedy as of special efficacy 
 is complete. But when quinine is given for strumous oph- 
 thalmia, or for swelled absorbent glands of the neck, or for 
 any complaint of whatever name which has the accompaniment 
 of a weak and cachectic constitution, and the ophthalmia or 
 the swelled glands disappear and health follows after the lapse 
 of months, then our faith in the special remedy, as such, gets 
 a good deal frittered away or is exchanged for the more 
 moderate expectation of good which waits upon the use of 
 tonic medicines. It sinks from a specific to a tonic, which is a 
 great fall. In like manner colchicum, given for the paroxysm 
 of gout, and at once abating its severity and finally abolishing 
 it in a few days, is justly regarded and trusted as a special 
 remedy; but given and continued week after week for chronic 
 pains of doubtful pathology, and those pains in the meantime 
 slowly and reluctantly yielding, and at length giving in alto- 
 gether, we thus lose faith in colchicum as a specific for gout. 
 If we allow it any credit in the result, it is of another kind. It 
 sinks from a specific to an alterative, which is a great fall. 
 
 But let us beware of all debate about "tonic" and "altera- 
 tive" ; which, whether applied to remedies or to their operation, 
 are most without meaning of all the terms in use among phy- 
 sicians. Tonics and alteratives include a countless heap of 
 things, and get much of the credit they have as a class from a 
 few remedies, passing by their names, which better deserve to 
 be called special or specific ; as cinchona when it cures other 
 
406 GENERAL REMARKS ON THE 
 
 diseases besides ague, and sarsaparilla when it cures chronic 
 syphilis. As to quassia, and gentian, and cascarilla, and cus- 
 paria, and orange-peel, they should rather he reckoned as con- 
 diments for food than as medicines. 
 
 This may seem a hard sentence to pass upon time-honoured 
 remedies, and so to dissever them from the art altogether. 
 Within the memory of man, bitters were in high esteem, and 
 their virtues were nicely studied. There were those who could 
 tell you which was to be preferred to which, and were not to be 
 caught confounding their effects, and giving one when they 
 ought to give another. The abundance of drugs to be taken 
 was a chief characteristic of medicine as it was practised forty 
 years ago, and not unnaturally it did its best to believe or 
 make-believe in their efficacy. 
 
 Here we take leave of Cures and Special Remedies as a 
 formal part of our subject ; but they will still be meeting us at 
 every turn. In truth, what we have called special and common 
 remedies never so well display their powers as when they are 
 seen at work concurrently or in conflict with each other. 
 Remedies, indeed, are our great analysers of disease ; common 
 remedies more plainly and sensibly, special remedies more inti- 
 mately and profoundly, but both alike in fact. Of living 
 disease hardly any analysis is possible but by help of both. 
 
PRACTICE OF MEDICINE. 407 
 
 VIII. — Treatment. 
 
 TREATMENT DISTINCT FROM CURE. — CONVERSANT NOT IMME- 
 DIATELY WITH THE DISEASE, BUT WITH INTERMEDIATE 
 PURPOSES. — WHAT IS MEANT BY INDICATIONS OF TREATMENT. 
 — CHOSEN FROM PRESENT SYMPTOMS. — NOT NECESSARILY THE 
 MOST PROMINENT SYMPTOMS. — OR NEAREST AKIN TO THE PAR- 
 TICULAR DISEASE PATHOLOGICALLY. — OFTEN COMMON ALIKE 
 TO MANY DISEASES. — AND THE LARGEST AND MOST COMPRE- 
 HENSIVE. 
 
 We come now to consider Treatment as distinct from Cure. 
 Treatment seeks to abolish the disease after fulfilling one or 
 several primary and intermediate purposes aimed at and in- 
 tended by the physician. These intermediate purposes are 
 called Indications of Treatment. They are, upon the whole, of 
 much variety, and in each particular case may be a single one, 
 or few, or many ; and, accordingly, the means or remedies by 
 which indications are sought to be fulfilled are various upon the 
 whole, and in each particular case may be a single one, or few, 
 or many. 
 
 Now, it is in the Treatment of diseases as distinguished 
 from their Cure, that our knowledge comes chiefly into play. 
 Here it is that by our knowledge we discern and choose the 
 aims or indications, be they many or few, which are interme- 
 diate and conducive to the ultimate scope of all, the restoration 
 to health. And here, again, it is by our knowledge that we 
 select, and apportion, and apply the means and remedies, be 
 they many or few, which are fitted for each particular aim or 
 indication we desire to compass. Often, indeed, we thus feel 
 ourselves (as it were) working with our knowledge experi- 
 mentally and in detail, leaning on it, trusting it, step by step. 
 Further, we are thus often able to survey retrospectively (and 
 it is a most profitable exercise) the course and management of 
 particular cases, and their results ; and see where we have done 
 well, and where we have done ill; where, from treatment 
 
408 GENERAL REMARKS ON THE 
 
 perfectly carried out in all its details, restoration has followed 
 as the natural and necessary consequence ; or where, from mis- 
 chance or mismanagement, from defect or misuse of knowledge 
 in this or that practical detail, restoration has been postponed, 
 or left imperfect, or has failed altogether. 
 
 The practice of medicine, when it is thus concerned with 
 Treatment, and proceeds upon the choice of aims or indications, 
 and of means and remedies fit to compass them, has pre- 
 eminently been called " Rational." It is a boastful appellative ; 
 well enough for those who are full of bope and expectation, at 
 the onset, of what knowledge is calculated to do and should do, 
 but too high-pitched for those who have made honest trial of 
 what it can do and has done. Men feel and speak differently 
 in putting on their armour and in taking it off. Truly, the 
 practice of medicine best deserves to be called "Rational," 
 when it is concerned with Treatment. But then, as such, it has 
 had its limits of success, which leave room enough still for 
 plenty of hard, well-directed research, but none at all for vain 
 boasting. 
 
 On the other hand, the practice of medicine, when it is 
 concerned with Cure has been pre-eminently called Empirical. 
 And it has often made its boast of the name, and been pleased 
 with its significance as contrasted with that of Rational. It has 
 rejoiced to acknowledge elements of disease deeper and simpler 
 and more powerful than any which it can sensibly apprehend. 
 It has used remedies given it by chance; and, knowing no 
 natural aptitude they have for their purposes, it has trusted 
 bare experience for their effects, and has not been disappointed ; 
 remedies surer and further reaching, and of more special virtue, 
 than any which industry, and science, and skill, and use, have 
 enabled " Rational " medicine to know, to choose, and to apply. 
 
 Thus, from time to time, the extreme " Rationalists " 
 among us have professed to know more than can be known ; and 
 the extreme " Empirics " to believe more than is credible. Each, 
 in their turn, have done signal detriment to practical medicine. 
 The physicians who have most benefited mankind have been 
 neither rationalistic nor empirical by pre-eminence, but a fair 
 mixture of both ; for faith and knowledge lean largely upon 
 each other in the practice of medicine. The mainstays of our 
 faith would be often giving way but for the contrivances of our 
 
PRACTICE OF MEDICINE. 409 
 
 knowledge ; and the insufficiency of our knowledge would often 
 leave us helpless but for the resources of our faith. 
 
 It lies at the foundation of all successful Treatment to 
 understand the intermediate purposes which medicine has to 
 fulfil, in order to reach the disease remedially. And these are 
 to be sought for in some present conditions of the individual 
 patient. To determine which they are, and determine how 
 far they can be trusted for guidance in the Treatment of the 
 disease, this it is which constitutes the doctrine of practical 
 indications. 
 
 Now, all conditions of the patient, which belong to him as 
 such, fall within the category of symptoms. And by his 
 symptoms it is that we get what knowledge we have of his 
 diseases, and what guidance we need for their Treatment. 
 
 But what is it that makes the practical indication ? "What 
 are the properties which, belonging to certain symptoms, mark 
 them out as guides for treatment. 
 
 Are the symptoms which suggest the remedy more pro- 
 minent and more striking than others from their mere magni- 
 tude ? Sometimes they are, and sometimes they are not. Often, 
 indeed, they are so faintly marked, that they might easily 
 escape the notice of those unaccustomed to search after them. 
 The patient wonders at the indifference with which the phy- 
 sician regards his greatest grievance or pain, and at the 
 attention he gives to some paltry circumstance (as it appears), 
 or to some minor uneasiness which he is himself hardly conscious 
 of, and makes it the scope of the remedy. Yet, although 
 symptoms are not made guides to practice by their mere magni- 
 tude, do they not become such by virtue of the real patho- 
 logical import belonging to them ? Now, their pathological 
 import must come from some essential connexion between them 
 and the disease ; and this connexion, by how much the stricter 
 and closer it is, must make them pathological in a higher 
 degree. Names have been given to symptoms for the purpose 
 of marking the nature of this connexion. Some are called 
 pathognomic and some diagnostic ; names which almost carry 
 their own meaning, and scarcely need explanation. The symp- 
 toms which characterise diseases in their essence (as far as we 
 have an insight into what that essence is) are called patho- 
 gnomic ; and the symptoms which distinguish diseases from 
 
410 GENERAL REMARKS ON THE 
 
 one another in their nature, or which distinguish them in their 
 seat, are called diagnostic. These have all been analysed and 
 arranged, and classified, with some show of philosophy and 
 some success, and hence our knowledge of diseases, within a 
 certain range, has been made easier and more precise. But' 
 then comes the question, do these symptoms which claim for 
 themselves the highest pathological import, even these, the 
 proper pathognomic and diagnostic symptoms of the disease, 
 claim, therefore, to stand pre-eminently for guides and indica- 
 tions of its treatment ? 
 
 As to pathognomic symptoms sometimes they do and some- 
 times they do not. The heat, the redness, the swelling, which 
 are pathognomic of external inflammation, largely suggest and 
 regulate the methods of managing it. But the pustules of 
 small-pox and the rash of measles, which are pathognomic of each 
 and due to the proper essence of each respectively, have little — 
 I will not say nothing — to do with the right management of 
 either. 
 
 As to symptoms called diagnostic (as we have only to do 
 with the practical uses of things, and have no further regard 
 to names than as they can help us in that behalf) it is fit to 
 remark that they and the pathognomic are commonly the same. 
 The symptoms which, under the name of pathognomic, have 
 already served to denote what the disease is in itself, are the 
 same which now, under the name diagnostic, serve to dis- 
 tinguish it from other diseases. The pustules of small-pox and 
 the rash of measles having bespoken the essential nature of each, 
 were rightly deemed pathognomic. But, pathognomic as they 
 were, they did not suggest the methods of treating either. And 
 now, the pustules of small-pox taken to distinguish it from 
 measles, and the rash of measles to distinguish it from small- 
 pox, are rightly called diagnostic. But, diagnostic as they 
 are, they do not suggest different methods of managing the 
 two. The same symptoms do not alter their practical value by 
 changing their names. Neither do the symptoms, which are 
 diagnostic in the sense of discriminating the seat of diseases, 
 demand for them, except subordinately, a treatment respective 
 to the parts they occupy, or require that the same disease — 
 inflammation for instance — should be dealt with differently in 
 each of the many organs it may chance to befall. 
 
PRACTICE OF MEDICINE. 411 
 
 Yet all these symptoms (I would repeat) are eminently 
 pathological ; all of nearest akin to their diseases, specialising, 
 severalising, localising them ; the symptoms by which we gain 
 all the knowledge we have of what diseases are in their own 
 nature, all our discernment of one disease from another, and 
 of the part which any disease occupies during the life of the 
 patient. 
 
 Small-pox and measles have been mentioned for the sake of 
 their contrast. But what has been said of them may be equally 
 said of almost all other diseases, especially febrile, which have 
 a distinct essence, and symptoms flowing from that essence 
 which are properly and exclusively their own. It is emphati- 
 cally true of them, when you come to treat them, that the 
 symptoms proper to each and distinctive of each, nearest akin 
 to its essence, and giving to each its stamp of individuality, 
 recede and give place to others which they have in common ; 
 and that these latter become the just indications of practice, and 
 serve for guidance and discretion in the use of remedies. 
 
 Well ! but touching the symptoms which, as indications 
 of treatment, practically supersede those of the highest patho- 
 logical import : what are they, and where are we to look for 
 them ? 
 
 Typhus fever, typhoid fever, scarlet fever, variolous, rube- 
 olous fever — all these diseases have severally an element of their 
 own ; and the element of each one is different from the element 
 of every other. But why do we call them all fevers ? Fever 
 is the proper element of none of these. Yet fever is, so to 
 speak, the motive power of them all, and common to all. 
 Assuredly, their outward presentment has always the accompa- 
 niment of fever. Fever is conditional to their known existence 
 as diseases. They cannot come into known activity without 
 fever. Yet each has a pathology of its own prior to the fever. 
 "We are quite sure of the fact, although we can make no use of 
 it, or extract anything from it which may serve as a guide to 
 practice. Our treatment must needs wait for the fever. It 
 can only begin with what it sees. It cannot take aim until it 
 catches sight of a mark. 
 
 Of these several diseases, the proper pathology and its 
 ingredients (whatever they may be) are unapproachable by 
 medicine. It is through their common pathology, through 
 
412 GENERAL REMARKS ON THE 
 
 their fever and its ingredients, that they are brought within 
 our sight and our knowledge, and the reach of our remedies. 
 At present, let it be enough to declare of fever, that it is con- 
 stituted of cold, heat, and perspiration, in various measures and 
 in various forms of combination ; and to point to the entire 
 vascular system and nervous system, now acting and suffering 
 beyond and beside the uses of health, as engaged in carrying it 
 on. Fever thus regarded is full of indications for the treat- 
 ment of all such diseases as have been mentioned. And it is 
 with the two great systems, the vascular and the nervous, in 
 their largest extent and reach, that we have to do, whenever we 
 deal with these indications. 
 
 Fever, or its ingredients of cold, heat, and perspiration, 
 take the first place for comprehensiveness and exigency among 
 symptoms which are guides to treatment. 
 
 It is through the vascular system as a whole, and the nervous 
 system as a whole, that the body makes chief display of its 
 vitality. 
 
PRACTICE OP MEDICINE. 418 
 
 VIII. — Treatment. Part 2. 
 
 INDICATIVE SYMPTOMS OFTEN SINGLE AND SIMPLE. — THE QUALITY 
 OF A SECRETION. — THE BEAT OF AN ARTERY. — A LOCAL PAIN. 
 
 CONTRAST BETWEEN THESE AND THE MORE COMPREHENSIVE. 
 
 — EXCELLENCE OF SIMPLE TREATMENT, GROUNDED ON AS FEW 
 INDICATIONS AS POSSIBLE. — ATTAINABLE ONLY BY LONG EX- 
 PERIENCE.— SFCCESS OF SIMPLE TREATMENT NOT A SURE EXPO- 
 NENT OF THE DISEASE PATHOLOGICALLY. 
 
 It happened, at first, in the mechanical arts, that every 
 operation had its own proper instrument, until, in process of 
 time, some simple power was successfully applied to many 
 different purposes. Something of the same kind may be 
 remarked in the progress of practical medicine. (The things 
 themselves have no natural alliance, but still enough of analogy 
 to assist in explaining what I mean.) There was formerly an 
 evident industry for combining in the remedy whatever was 
 thought to be of virtue for each of the symptoms which con- 
 stituted the disease. Hence, various nostrums were in daily 
 use containing twenty or thirty ingredients. But, in our days, 
 a remedy of two or three ingredients — often, indeed, of a single 
 article — is safely trusted for treating diseases of complex and 
 multifarious symptoms. 
 
 Such simplicity of Treatment has taken much time, and 
 some of the wisest minds, to bring it to the perfection which it 
 has reached. Physicians, however, have, for the most part, 
 been content to record their practice and its results ; and, 
 without analysing its principles, have left it to recommend 
 itself by its own success. But it is worth while to ascertain, if 
 we can, the sources of any power we possess which results from 
 our knowledge, and thus to obtain the surest means of still 
 keeping it and still enlarging it. And such a power as that 
 of bringing diseases under easier and better management, 
 ought especially to be had in possession and with the hope of 
 increase. 
 
414 GENERAL REMARKS ON THE 
 
 Indicative symptoms, or those which guide the Treatment, 
 may have to be sought for in a very narrow as well as in a very 
 wide sphere. Thus the unhealthy quality of the fluid secreted 
 by some one organ, as the liver or the kidney, will present 
 itself as the single indication for treating a complex disease, 
 made up of various and multitudinous symptoms. Thus, some 
 preparation of mercury adapted to the kind and amount of 
 bilious derangement; thus, some alkali or acid, suited to the 
 quality of unhealthy urine, has been the sole remedy which has 
 brought a crowd of concomitant disorders into subjection, and 
 led the way back to recovery. In this way, does a single 
 symptom become, for remedial purposes, the practical represen- 
 tative of the whole disease. 
 
 A strange quality of the pulse (it may be a hardness, or it 
 may be a softness ; but whichever it be, a thing very distinct 
 and palpable), has served for the single scope of the remedy. 
 The disease has involved half the organs and structures of the 
 body, and accordingly its symptoms have been of great com- 
 plexity and variety, and the peril of death has been urgent and 
 instant, from opposite conditions in some certain cases. But 
 all other indications have, in each case respectively, been passed 
 by, but one. The soft pulse has been, practically, the whole 
 disease in this case, and the hard pulse the whole disease in 
 that. In this, all Treatment has been bent to the one purpose 
 of raising the soft pulse into firmness and consistence, and in 
 that to the one purpose of bringing down the hard pulse to 
 softness. 
 
 A pain, or a disordered sensation of some certain part, has 
 been singled out from a multitude of such in various parts, 
 which, together, make up the whole complex disease, and it has 
 become the one scope of successful Treatment. Shall I cause 
 surprise by proclaiming my often proved experience of opium 
 being found at last the sole and simple remedy of disorders 
 which have been long abiding and long intractable ? 
 
 Among a multitude of symptoms which have practically 
 served only to lead astray, pain, referable to the stomach and 
 bowels, has proved the one just index of Treatment. Sydenham, 
 perhaps, might not be displeased to find that his experience still 
 stands good, and that he has a disciple among physicians in 
 these later days. 
 
PEACTICE OF MEDICINE. 415 
 
 But it has been said that Treatment may seek its indications 
 from symptoms made up of actions and suffering, which are 
 spread widely and diffusively throughout the whole body, and 
 consist of cold, and heat, and perspiration ; of excitement and 
 depression; of conscious strength and conscious weakness; and 
 all varieties of evil sensation and pain. These are found among 
 the ingredients of very many diseases, and call for remedies of 
 wide and diffusive operation. 
 
 Now there is a g< iod deal worthy of thought in the contrasts 
 here presented. That the practice of medicine, when it is 
 guided by rational indications, should be so different at different 
 times in what it intends and what it does ; that at one time it 
 should be so exact and eclectic and so restricted in its aims, and 
 have to do (apparently) so altogether with small things, aud at 
 another take such large and general views, and have operations 
 alike large and general. These are remarkable facts ; and it is 
 well to notice them. 
 
 But then, does it in truth often happen that the Treatment 
 of diseases is brought within the compass of one well chosen 
 indication and one well directed remedy? Is such simplicity of 
 practice often attained? I believe often. Happily for mankind, 
 there are, and always have been, physicians who have sought to 
 practise their profession with as much exactness as its nature 
 will allow. And to this end, among the many uncertainties of 
 medicine, they have been always in quest of those few things 
 belonging to it which are more sure and stable, and how and 
 where in every case to lay hold of them, and to use them, and 
 to make the most and the best of them. But it is no easy task 
 to pick one's way from truth to truth through besetting errors. 
 The man who to cross a dangerous stream must trust to 
 stepping stones, had need have a sharp eye to which is the 
 broadest and firmest before he rests his whole weight upon 
 it, and takes his spring from it to another. Indeed, this is a 
 tottering exploit until every day's crossing makes it easy, safe, 
 and bold. 
 
 To physicians, exact indications are the stepping-stones of 
 practice. At first, perhaps for years, they go softly and dis- 
 trustfully, waiting to examine each, and trying what each will 
 bear. It is only from time and experience that they tread 
 firmly and fearlessly. And this is the result : that the older 
 
416 GENERAL REMARKS ON THE 
 
 they grow, their practice becomes simpler and simpler, and at 
 the same time surer and bolder. Indeed, theirs is the only- 
 practice which is at the same time bold and safe ; and all 
 because it is simple. Moreover, time and experience convince 
 them of this particular truth, that, taking all diseases and their 
 Treatment, the cases are numerous beyond all belief, in which 
 safety and success are concentred in one chief indication and 
 one chief remedy. 
 
 But where is the constant proof one would desire of simpli- 
 city being the condition of its success ? The best physician is 
 found, oftentimes, busy about a dozen things. Yes ! but, even 
 then, is he not really intending and doing only one thing ? The 
 sagacious looker-on sees that he is, and the physician himself 
 would acknowledge it. He is intent upon making sure of his 
 one indication, and of the effect of his one medicine addressed 
 to it. In the meantime, perhaps, he willingly admits the use 
 of other medicines for good but subordinate purposes ; it may 
 be as helps and auxiliaries, it may be for comfort's sake, or it 
 may be for the prejudice's sake of patients or friends, which it 
 is innocent, or wise and needful, to satisfy. 
 
 Or a physician may fancy he has twenty remedies for every 
 disease, and as many cunningly devised notions of purposes 
 (that is, of indications) which his remedies are fulfilling. And 
 thus, lavish of aims and lavish of means, he may go on prac- 
 tising half his life, and ascribing what success he has to the 
 nice adaptation to their end, and the equal co-operation of all 
 his twenty remedies at once, in almost every case he meets with, 
 while, in fact, he has been doing the whole business with one or 
 two. For Nature has been practising upon him a happy deceit 
 all the while. She has been choosing her own single and suf- 
 ficient remedy out of his multitude of useless ones, and keeping 
 it true to its mark, and insuring its sovereign purpose, and 
 ridding herself from the incumbrance of all the rest. How wise 
 and indulgent is Nature, who thus contrives to vindicate herself 
 and her powers of reparation against the art of the physician 
 without hurting his vanity ! 
 
 Practice among the poor is a good school for teaching 
 simplicity of Treatment, and testing its worth. There is a 
 necessity in the case. Means are few, and they must not be 
 thrown away. What is absolutely needed must be done, and 
 
PRACTICE OF MEDICINE. 417 
 
 that only ; for nothing more can be afforded. Hence arises a 
 constant industry, to make sure what it is, and what will tell 
 upon it. Hence, though the poor man's disease is the most 
 severe, and calls the loudest for relief (for he does not succumb 
 to trifles), its Treatment lies often within a narrow compass, 
 and even the single aim and the single remedy are often sought 
 after and found. The best physicians have begun by being the 
 physicians of the poor. 
 
 So, too, the soldier's physician, when his patients are an 
 army in the field or on actual service, must work as best he can 
 with the means at his disposal ; and these are often few enough. 
 And so he betakes himself to reduce all that concerns their 
 diseases and their Treatment to the utmost practical simplicity, 
 and learns from hard necessity how much successful treatment 
 is concentred in one chief indication and one chief remedy. The 
 practice of medicine is, upon the whole, largely indebted to 
 army physicians. 
 
 On the other hand, among the rich and well-off classes of 
 the community, the Treatment of diseases is seldom as simple as 
 it might be. Superfluity of means leads to their useless 
 expenditure. Besides, the will and pleasure of others are ever 
 tempting and influencing the physician to do many things 
 where few are needed, and to divide and scatter abroad, and, 
 upon the whole, so to weaken the power of his art, rather than 
 to strengthen it by concentration. It is a fine thing pretty soon 
 in life to be employed and patronised by rich and great people ; 
 but it is not the surest way of making a good physician. 
 
 But simplicity of treatment may be pushed to a faulty 
 extreme. A conceit may lurk where it is least expected. 
 When, in the confusion and tumult of disease, life has been 
 poised, as it were, on a pin's point, and a single effort of skill 
 has saved it, the exploit speaks great things for the glory of our 
 art and its simple methods. But let not our over-zeal for 
 simplicity fetter our freedom of thinking and acting in the 
 management of disease. Oftentimes not one, two, or three, but 
 many well-considered indications, must • be fulfilled ; not one, 
 two, or three, but many well-directed remedies, must be brought 
 to bear upon them, before the disease can be successfully treated. 
 Still, to know the import of single indications and the power of 
 single remedies lies at the root of all sound practice ; and I am 
 
 E E 
 
418 GENERAL REMARKS ON THE 
 
 persuaded that no man can clearly see and prosecute many 
 indications together, or can safely and successfully use many 
 remedies together, who has not begun by studying both indica- 
 tions and remedies one by one. 
 
 Something more needs to be said of certain single indications 
 ■which experience commends to our notice as guide's to practice 
 in complex diseases, for the sake of the attestation they furnish 
 to the general fact or principle already noticed. For these 
 single indications of Treatment have often their value as such 
 rather because they point to organs and functions which 
 medicine can easily reach and deal with remedially, than because 
 they are known to hold any proper pathological kindred with 
 the diseases themselves. 
 
 Now, of all organs of the body, those are most within the 
 reach of medicine whose function is to secrete, and the products 
 of whose secretion consist largely of refuse matter to be cast 
 out of the system. And what has experience not learnt to 
 make of these organs, and their excesses and defects and errors 
 of function, as indications of Treatment ? — of the liver, and of 
 the stomach and bowels; and of the skin and of the kidneys; 
 and of bile, and excrements, and perspiration, and urine, 
 redundant, or scanty, or vitiated ? There are forms of disease 
 {i.e. groups of symptoms) which directly flow from the wrong- 
 doings of these several organs, and pathologically belong to 
 them. And then, when the physician addresses his remedies 
 to the liver singly, or to the stomach and bowels or skin or 
 kidneys singly, he does not only what is safest and best and 
 easiest to do, but he does it like a pure pathologist. He pursues 
 the disease through its own channels. He tracks it to its spring- 
 head, and takes hold of it there, and putR an end to it. But 
 there are diseases which certainly have not their origins in any 
 of these secreting organs, and which, nevertheless, are success- 
 fully treated by remedies addressed to them in part or altogether. 
 They spring from none of them ; but they involve injuriously 
 the functions of one or more of them, sooner or later, in the 
 course of their progress. Hence, in fevers of every name and 
 every climate, and from every source, malarious, contagious, 
 and accidental, whatever other and larger and more comprehen- 
 sive indications of Treatment need to be pursued, particular 
 indications present themselves, arising out of what is amiss in 
 
PRACTICE OF MEDICINE. 419 
 
 the functions of secreting organs ; and these must be pursued 
 also. Indeed, the disease can hardly be named, whether acute 
 or chronic, in which the liver, or stomach and bowels, or skin, 
 or kidneys, do not present something to be redressed, and 
 constituting an indication of Treatment. And this may be a 
 small, or it may be a large part of the whole Treatment. It 
 may be by much the largest part. Indeed, it may itself be the 
 whole Treatment, rationally and of necessity. 
 
 The gravest diseases, which are of a specific nature, and are 
 accompanied by fever, and have a definite course to run, can 
 none of them be cured. They must all of them be treated ; and, 
 according as they are well or ill treated, their termination is in 
 recovery or in death. And their Treatment turns altogether 
 upon the choice of the right indications, and of the right 
 remedies to reach them withal. But in how many cases of such 
 diseases are the more general indications so doubtful that, in 
 all prudent calculation, they go for nothing ! "We have no 
 sufficient guides to tell us whether to sustain or to deplete. To 
 do one or the other would be to strike a fearful blow in the 
 dark, and so we wisely do neither. And thus it comes to pass that, 
 among many things obviously going wrong, we are left to choose 
 what are most within our reach to set right. Accordingly 
 we make the liver and stomach and bowels the scope of our 
 remedies ; and, as they reach and take effect upon them day by 
 day, we see the formidable conditions of the whole disease con- 
 stantly kept in check, and are sure that thus many a life is 
 saved. 
 
 "What a temptation to easy and often erroneous theorising 
 upon the nature of diseases has come from the success of these 
 simple methods of Treatment ! There is no denying the facts 
 or their value — their plain, solid, appreciable value, practically ; 
 and, at the same time, there is no denying that they have set 
 speculation upon a wrong scent, and led it far astray in its 
 search of causes pathologically. 
 
 Thus fevers of various types and various names have from 
 time to time, and by well- esteemed physicians, had their cause 
 and point of departure assigned to them in the liver and its 
 vitiated and redundant bile, and congestions of blood, and I 
 know not what besides, therein ; also in the stomach and bowels, 
 and their foul and corrupt secretions. Physicians, taking these 
 
420 GENERAL REMARKS ON THE 
 
 for certain truths, and entirely believing in them, and conforming 
 their practice to them, have saved innumerable lives. They 
 have given mercury in every dose, from the largest to the 
 smallest, from ten grains of calomel to two or three grains of 
 hydrargyrum cum creta; and seldom or often, and with or 
 without aperients ; and this has been all their treatment. Or 
 they have applied leeches seldom or often to the abdomen ; and 
 this has been all their treatment. 
 
 Men who have had great duties in hand, and who know how 
 they have done them, and feel that they have done them well, 
 naturally hold strong practical beliefs ; and these beliefs soon 
 take the place of absolute truths in their minds. The pro- 
 cess is this. Being daily called to act, they read and study 
 the facts before their eyes, and trust to them for guidance; 
 and so acting frequently and successfully, and under the same 
 guidance, they confide more and more in the facts by which 
 they have been taught, until they hold them to contain the 
 whole truth, and deem it needless to look or reason further 
 about the matter. And these earnest assertors and followers 
 of what they believe to be the truth, seen and verified in the 
 great facts of daily experience, are the men by whom the world 
 has been especially benefited in the practice of medicine. Give 
 me one of these men for my physician, and I will take care 
 not to discuss with him the abstract truth of his beliefs until he 
 has set me upon my legs again; and then (most ungratefully on 
 my part), when I have had the full benefit of his practical 
 wisdom, I may venture to call in question his theory. 
 
 We are concerned to clear the subject from misapprehension, 
 seeing that it presents such notable instances of the all- sufficiency 
 of single indications and single remedies in the management of 
 complex diseases. 
 
 Modern research has brought us back to the blood as the 
 source and the distributor of disease throughout the body, and 
 thus taught us respect for the surmises of our forefathers by 
 furnishing us with reasons for them which they had not. "What 
 were surmises to them have become truths to us. Nevertheless, 
 what science has brought within our knowledge, science has 
 not placed within our power. By the tests of organic chemistry 
 and the microscope, we have proofs of elements of disease in the 
 blood; but we cannot reach them there. In this sense, there is 
 
PRACTICE OP MEDICINE. 421 
 
 no such thing as taking disease at the fountain-head. Elements 
 of disease, pure and simple, within the blood, present no 
 possible aim for medical treatment. Accordingly, we have to 
 wait and look for things which are beyond, and choose from 
 among them, as they arise, possible objects of interference and 
 fit indications of practice. We hare to wait and see how the 
 blood itself behaves within its own vessels ; whether it moves 
 with unwonted forces or unwonted rapidity ; how it makes dis- 
 tribution of itself throughout the body, whether equally or un- 
 equally ; and all that the pulse and local congestions may have 
 to notify as indications of Treatment ; then to see how the blood 
 maintains its great diffusive functions of animal temperature, 
 whether regularly or irregularly, and what of cold or heat or 
 perspiration ensue declaring the common phenomena of fever; 
 and then to see how the blood supplying the pabulum of 
 its functions to every organ and system of organs throughout 
 the body now hurts or hinders or variously disturbs those 
 functions ; and so from the nervous centres and from the 
 nervous system diffusively there arise pains and painful sen- 
 sations, and torpor or excitement, and sleep or wakefulness or 
 delirium. Thus we find and follow up indications. 
 
422 GENERAL REMARKS ON THE 
 
 IX. — Treatment. 
 
 DISTINCTION BETWEEN THE PROPER AND COMMON ELEMENTS OF 
 DISEASE. ALL TREATMENT CONFORMABLE TO THIS DISTINC- 
 TION AND ILLUSTRATIVE OF IT. — SMALL-POX. — SCARLATINA. 
 
 MEASLES. 
 
 A general outline has been given of what Treatment is ; 
 showing it at work within its own sphere, which is a pretty- 
 large one, and upon its own objects, which are numerous enough; 
 and how from among all the things within its reach and power 
 to deal with, it seeks and finds the fittest to become practical 
 indications, and then actually dealing with them produces great 
 results. 
 
 But some of these objects are worth a nearer inspection, if 
 we would understand how all good Treatment falls in with the 
 nature of disease pathologically. Besides, remedies have been 
 spoken of as the " great analysers of disease " (Art. 7). But 
 how so ? Verily in the sense of testing and discerning the 
 elements of which disease consists, even its vital elements, or the 
 things comprised in the doings and sufferings of those who are 
 the subjects of disease, while they are yet alive. All this, for 
 the sake of its importance, let us now consider a little carefully, 
 and try to explain it, relying upon the plainest and commonest 
 matters of fact as we go along. 
 
 It may be doubted whether the theories of clever men have 
 not done more harm to the practice of medicine than all the 
 mere blunders of the ignorant put together. At all events, 
 purely speculative conclusions about the nature of diseases have 
 heretofore done quite enough in confusing and misleading prac- 
 tice to make us cautious by this time, how we receive and trust 
 what comes to us in the same questionable shape. 
 
 But pathology has its general facts nevertheless ; that living 
 pathology, I mean, which is the physician's concern arid study, 
 as he sees and watches and ministers to disease, and all that 
 
PRACTICE OF MEDICINE. 423 
 
 belongs to it, in living men. This pathology contains facts of 
 high generalisation. And if among them there be any which 
 point to practice, it were a pity to pass them by and not follow 
 them in the direction to which they point. For ultimately 
 they may stand for practical principles. 
 
 The distinction between the proper and the common elements 
 of disease is a fact of this kind. It is plain and unmistakeable 
 enough in certain conspicuous instances. And these may be 
 taken advantage of to introduce and explain the general truth, 
 which pathological research seems in the way of verifying by 
 new instances continually. 
 
 And, first, for the proper elements of disease. Proper to 
 what. Proper to the disease itself in its own nature, and dis- 
 tinguishable from whatever else may attach to it in this, that, 
 and the other living body wherein the disease is found. 
 
 We take something on a pin's point, and with that pin's point 
 we just prick the skin hardly enough to be felt or seen. But 
 by this little prick the something has gained its entrance, and is 
 gone its way whither within the living body we do not exactly 
 know. They say it has gone at once into the blood, has 
 mingled with it, and is already distributed with it everywhere. 
 Indeed one can hardly believe otherwise. But wherever the 
 thing be gone, and whether moving or stationary, we can find 
 it no more. Still wait for a certain time, a time forereckoned 
 from the known quality of the thing upon the pin's point ; wait, 
 and a disease will come forth forereckoned also from the very same 
 thing, a disease having its own proper characteristics and dif- 
 ferent from all other diseases in the world. And that disease 
 is small-pox. 
 
 Here the element of the disease is the smallest that can be 
 sensibly made sure of, the least that can be palpably taken and 
 kept apart ; taken, that is, from one living body and kept apart 
 for some while (I know not how long), and then conveyed to 
 a second, in which it becomes the beginning of a disease after 
 its own kind, where there was no such disease before. Here, I 
 say, is the least element of disease which is obnoxious to the 
 senses. And from this example reason cannot refuse to admit 
 the possibility of elements too minute for the senses to reach. 
 Indeed, the possibility is made a certainty by the proved fact, 
 that the same disease which is propagated by inoculation is 
 
424 GENERAL REMARKS ON THE 
 
 propagated also by the contact or near approach of one living 
 body having the disease to another living body having it not. 
 
 Through what channels and by what processes we do not 
 punctually know, but instances innumerable of the like experi- 
 ments and results attest it for a truth, that the thing almost or 
 altogether too minute for the senses is the primary material 
 element of the whole disease which follows. Further, this 
 primary element in producing its disease multiplies itself into 
 new material elements which are divisible to infinity and sepa- 
 rable from their own living body, their native body (so to 
 speak), and ready to be transferred to other living bodies 
 innumerable, and so to bring vast communities into the same 
 conditions of disease. 
 
 It is a great subject this of the proper elements of disease, 
 seen or unseen, apart from the body. Their reality, the condi- 
 tions of their existence, their spread, their limit, also the sub- 
 stances to which they adhere, and much more besides ; all these 
 things require a pretty comprehensive mind to deal with them 
 to much purpose. Then the mixture in this subject of equivocal 
 facts and testimonies with the true, needs, moreover, a pretty 
 shrewd as well as a candid and wary mind to pick its way safely, 
 a mind not over-credulous and seeing contagion in everything, 
 yet not over sceptical and seeing it in nothing. 
 
 But our concern at present is with the proper elements of 
 disease within the body. 
 
 Their entrance within the body is one thing and the visible 
 outbreak of the disease is another. And between the two the 
 patient's consciousness and the physician's observation testify 
 either absolutely to nothing, or else to nothing distinctive, 
 Until diseases make outward presentment of themselves we know 
 not what they are or whether they are at all. And yet it is 
 certain that many diseases have a long period of latent being 
 within the body. This is the case with small-pox, scarlatina, 
 measles, and all that spring from a proper contagious element 
 of their own. Well, but is there nothing being transacted all 
 the while ? Is it a passive incubation altogether ? Nature 
 contradicts the belief by all its analogies. And all observation 
 of these same diseases goes to testify that the process, though 
 unfelt and unseen, must be an active process ; and not only 
 active, but that (be it what it may) it works and moves by a 
 
PRACTICE OF MEDICINE. 425 
 
 living law, and has stages and degrees and regular progressions 
 filling up the definite interval, until the time is full and ripe 
 for the disease to declare itself by its outward presentments. 
 What else can mean the average periods of latency in small- 
 pox, scarlatina, and measles, hut that things are to be done 
 therein, which require just those periods for the doing of them ? 
 The things themselves, be they what they may, unseen, unknown, 
 and out of reach, but timed, and ordered and forwarded by 
 nature with exact care, must be taken, upon the faith of nature, 
 to carry some weighty meaning and to contain more than a 
 formal preamble to the coming disease. The disease stands at 
 bay (so it should seem) within the blood, and there it defies our 
 scrutiny of what it is and our attempts to meddle with it re- 
 medially. 
 
 But in due season, when the foreknown period, according to 
 the nature of the disease, is complete, the proper elements come 
 forth into broad daylight, and make of themselves their clearest, 
 fullest display. They may be pictured to the eye and defined 
 in their forms, succession, duration, growth, completion. They 
 claim now pre-eminently to be called the disease, and group 
 themselves into small-pox, or scarlatina, or measles. 
 
 Nothing in the world can produce small-pox, or scarlatina, 
 or measles, but the proper element of each. And the disease 
 being produced is simply a multiplication of the element from 
 which each sprang, the same in kind and unaltered, be its 
 quantity much or little. 
 
 And now as soon as seen, surely now if ever, the disease 
 may be reached and laid hold of remedially in its proper ele- 
 ments ; the small-pox in its crops of pustules, the scarlatina 
 and measles in their diffused and figured rash. No ! it cannot, 
 «ven now. As when their proper elements, visible or invisible, 
 were in the smallest germ ; as when they were diffused, we 
 believe, through the blood during the period of their latent 
 progress and incubation ; so now do these same elements, made 
 visible and displaying this, that, or the other phenomenon 
 in succession until they have completed their course, equally 
 refuse to become the direct aim of any medical treatment. 
 
 Still medicine is constantly busying itself about small-pox, 
 .scarlatina, measles, and oftentimes, it believes, for good. But 
 
426 GENERAL EEMAEKS ON THE 
 
 in what way does it busy itself with them ? That is the question ; 
 and a question it is of great concern, and not to be answered 
 off-hand. 
 
 The disease, be it what it may, if it have a distinct nature of 
 its own, is never found pure and unmixed and its bare self and 
 nothing more in any living body. There is, moreover, always 
 something, which is not the disease and yet exists because of 
 the disease. It may be much or it may be little, but there is 
 always something. What the disease is and how it is identified 
 with its "proper elements " restrictively and exclusively, and 
 what they are, we have just seen. All the ijest have been left 
 and let pass for its " common elements." These we would now 
 take up in their turn and try to make them out. 
 
 But how common ? Because found in all diseases and thus 
 common to all, but identifiable with none. And common in a 
 wider sense still — common to all diseases, and common alike to 
 whatever the living body does or feels painfully or hurtfully, 
 though it may not bear to be called disease. But all this needs 
 to be made plain by familiar instances. 
 
 Suppose a man sound of body and sound of mind and at the 
 prime of life, and ready to do battle with the world for what 
 it deems its best things, for its wealth, its fame, its power. 
 Such a man must not spare himself, or he will have a poor 
 chance of success in this restless competitive age of ours. 
 
 Now, in some of his seasons of full activity, and enterprise, 
 let him give a little attention to himself, body and mind, and 
 note what they are doing and what they are feeling in com- 
 pliance with the uses and necessities, the hard uses and neces- 
 sities, of health to which he puts them. He will remark colds 
 and heats and perspirations coming and going strangely, his 
 pulse varying in force and frequency, perhaps his stomach, 
 bowels, liver, kidneys at fault in the quantity and quality of 
 their secretions ; more of thirst and less of hunger than he 
 likes ; less of sleep and less refreshment from the sleep he has, — 
 all this, and, besides, many an unusual pain in his head or heart 
 or limbs, which he would be glad to get rid of and seek a 
 remedy for. 
 
 Here are transacted, in brief and in little and many times 
 over, much of what the body does and suffers in real diseases. 
 
PRACTICE OF MEDICINE. 427 
 
 The common elements of disease, and nothing less, are sensibly- 
 present and at work, while in truth the body is only engaged in 
 some of the harder uses and necessities of health. 
 
 Let a man meet with some injury from without, small or 
 great, simple or complex ; presently all that is vital within him 
 will show its resentment of it, and continue to show it little or 
 much for a short or a long while, proportionably to the amount 
 of the hurt and the time needed for its reparation. But how ? 
 Truly in some, many, or all of those identical ways in which the 
 body is wont to be affected under the harder uses and neces- 
 sities of health. 
 
 And here, be it remarked, that all the several ways in which 
 the body is wont to show itself aggrieved from the harder 
 usages of health or from mere mechanical outward injuries, are 
 found among the constituents of fever. And being not soon 
 got rid of and being also severe, these come to shape and group 
 themselves into what none would hesitate to call by the name of 
 fever, and they may carry with them its consequences and its 
 perils. Hence of those who have had (so-called) fever thus 
 derived, some occasionally have been very ill, some have re- 
 covered by a narrow chance, and some have died. 
 
 But there is no such familiar image of disease (if, indeed, 
 it be the image and not the reality) as intoxication. The body 
 is abused into all the conditions of disease for a season. First 
 you have, as of disease, the proper elements foreign to the body 
 and without it ; and then the same introduced within it, and 
 left to it to deal with and bear with as it may ; but totally 
 beyond the reach and touch of remedies. Next you have, as of 
 disease, the common elements shown in what the vascular system 
 and the nervous system, and their two great central organs, the 
 heart and the brain, do and suffer according to the modes and 
 measures of which they are capable under any present stress 
 that is laid upon them. And oftentimes in intoxication these 
 actings and sufferings, identical as they are with the common 
 elements of disease, come with such rapidity and are carried to 
 such excess that, but for experience to the contrary, we should 
 constantly see in them great peril of life. 
 
 Again, let a man suffer real disease ; such as has demon- 
 strably an essence of its own and its own proper elements. Let 
 it be small-pox, scarlatina, or measles. This disease having 
 
428 GENERAL EEMAKKS ON THE 
 
 gained entrance within the body is left to its vital powers to 
 deal with as they may. By them it is to germinate and increase, 
 be matured, and be finally cast out. But it is a hard necessity 
 they have to strive with, a hard work they have to do, these 
 vital powers. Yet not so hard but that they often accomplish 
 it perfectly. Sometimes, however, it is so hard that they can- 
 not get through it without hindrances and drawbacks and dis- 
 asters, and, in the end, restoration is incomplete and not without 
 remnants of damage to the body for a time or permanently. 
 And sometimes so hard, that early or late or midway the vital 
 powers utterly fail and the patient dies. 
 
 Meanwhile the ways in which these vital powers sometimes 
 feel and act we summarily call fever. And fever is greatly in- 
 dicative of Treatment. Not that we can treat fever as sum- 
 marily as we talk of it. We cannot name it in one single word 
 and name its remedy in another. We cannot ever treat it 
 simply as fever, and have done with it. 
 
 If we would find the indications wrapt up in fever, we must 
 resolve it into its constituents. And in doing so we come 
 upon groups and forms and qualities of very common things. 
 And these common things are the same which, one by one or a 
 few combined, we constantly depend upon to tell us what to do, 
 and what means to use when we know of no specific or special 
 remedy and cannot pretend to cure ; even in all cases calling 
 for our interference from the ailments of abused health to the 
 terrible emergencies of the Plague. 
 
PRACTICE OF MEDICINE. 429 
 
 IX. — Treatment. Part 2. 
 
 SUBJECT CONTINUED. — TYPHUS. TYPHOID. 
 
 Or diseases, as separate things, things which have proper and 
 essential elements of their own, we are never more sure than 
 when they are introduced into the body from without. Those 
 which have been mentioned are among the most familiar 
 examples ; and they and all other diseases which fall within 
 the same category have more of wonder belonging to them, 
 the more comprehensively they are regarded. They preserve 
 their distinct essences for ever. They pass through millions of 
 living bodies, and come out pure and the same after a hundred 
 generations. 
 
 Eeally, " the blade, the ear, and the full corn in the ear," 
 are not more distinct from the earth in which they vegetate, 
 than are these diseases from the bodies in which they are found. 
 The proper germs of vegetation get all that they want for 
 reproducing and multiplying themselves from the earth, and 
 the proper germs of disease get all that they want from the 
 body. Our concern is altogether with the earth and the body, 
 and with their common powers and faculties, in whatever way 
 they may need, or will bear our interference, and not at all 
 with the seeds proper and the diseases proper which are inacces- 
 sible to us. How this teeming earth and this living body take, 
 and keep, and guard, the germs committed to them, and yield 
 them their materials of increase ; and how working (as it were) 
 by a model, they bestow upon the growths and products of each 
 that form which is its own and is always the same, and distinct 
 from all others ; these are things past finding out. 
 
 But analogy must not be pressed too far into the service of 
 practical medicine. To provide that the things belonging to it 
 lose none of their natural simplicity in our hands, should be our 
 constant care. To make them simpler than they are, is an idle 
 conceit and a great mischief. 
 
 Now, proper and essential elements are terms which present 
 
430 GENERAL REMARKS ON THE 
 
 to the mind the idea of something speculative. But in certain 
 diseases (as we have seen) they are tangible matters of fact. 
 From these the diseases had their beginning, and without them 
 they could not have existed at all. Still, they are not alike 
 plain and distinguishable in all diseases. They are not found 
 out every day. Men can not betake themselves to their dis- 
 covery of set purpose and make sure of success. It is well, if 
 chance or industry discover one or two in the course of a 
 century. 
 
 Not that medicine has no place, power, or opportunity for 
 doing good in diseases as long as their proper elements are 
 undiscovered. From what has been seen, it is probable that 
 medicine has them all, and is now using them in as large and 
 complete a measure for good, not knowing the proper elements 
 of many diseases, as it ever will when it knows them. 
 
 It is a great field of pathological research this, which 
 respects the proper elements of diseases. The plainest examples 
 (we have seen) are at hand, and ready to point it out. But the 
 same examples also show how practical medicine may be well 
 aware of this field, and yet not able to enter it ; and how, with 
 a pretty good insight into it, it must be content to take up 
 with things without it, i.e. things short of the diseases them- 
 selves, and how it has done its office well notwithstanding. 
 
 Now, if practice, having full knowledge of certain diseases 
 and their proper elements, has been able to turn it to no direct 
 account, and yet has continued to do its work well, one need 
 not be surprised that, being wholly in the dark about other 
 diseases and their proper elements, it should still often have 
 done its work well ; or, at least, should not always have failed 
 for lack of knowledge. 
 
 This nineteenth century in which we live had finished half 
 its course, before Dr. William Jenner saw and fixed the proper 
 elements of the two diseases called " Typhus " and " Typhoid." 
 
 But the two diseases, yet unknown in themselves, had a 
 treatment not ill-understood or unsuccessfully prosecuted long 
 before. For their common elements had been always present, 
 and ready to suggest what that Treatment ought to be. For 
 years and years, Typhus and Typhoid were terms which had 
 borne intelligible meanings, and been familiarly spoken in our 
 schools and in the wards of our hospitals. Hitherto, indeed, 
 
PRACTICE OF MEDICINE. 431 
 
 experience had noted in them nothing more than the common 
 elements of diseases. But, then, they were grouped so con- 
 stantly into certain forms, and were of such definite duration ; 
 they presented such sure reckonings of life and death, and were 
 such intelligible guides to Treatment, that practice, finding in 
 them all that it wanted, was content to take them for the entire 
 diseases, and note them for Idiopathic Fevers, and call them 
 Typhus or Typhoid. 
 
 And now let us see how all prior observation was corrected 
 by the readings and decipherings of Dr. Jenner. 
 
 Fever having endured for about a week (between the fifth 
 and eighth day they tell us) a rash appears. It consists of 
 distinct spots, of a dusky pink or mulberry colour, slightly 
 elevated. The like spots still come out for three days, and then 
 no more are added to them. But those which have appeared, 
 be they many or few, remain and undergo certain changes. At 
 first, press them with the fingers and they fade ; but take off 
 the finger, and they return in an instant. In two or three 
 days, pressure alters them little, or not at all. In some cases, 
 they gradually grow paler of themselves, and so finally dis- 
 appear. In some, they become true petechise. They are generally 
 pretty numerous, and chiefly on the trunk ; but they may be 
 also on the extremities, on the face, and every part. In size, 
 they are anything between a mere speck and a large split pea. 
 Those of the larger size having become true petechise, I 
 have seen upon the face of a patient, almost as black as ink, 
 at the further end of the ward as I entered. 
 
 This spotted petechial rash, though not unknown to us before 
 in alliance with fever, took the physicians of hospitals by 
 surprise in 1837 and 1838, from its unwonted frequency. It 
 has, since that time, undergone patient investigation, and is 
 now believed to be as much " the proper element " of a distinct 
 disease as the pustules are the " proper element " of small-pox. 
 And the name Typhus is given to this disease by pre-eminence 
 and is restricted to it. 
 
 Again, Fever having reached its second week, a rash 
 appears of another kind from that just described. It, too, con- 
 sists of spots, or rather specks, a little elevated. But they are 
 bright or rose coloured, and often so like flea-bites as to be 
 easily mistaken for them. Yet the absence of the little black 
 
432 GENERAL REMARKS ON THE 
 
 point in the centre shows that no flea had the making of them. 
 They go and come again, as you put your finger upon them and 
 take it off. They never go on to any other form. They never 
 become petechial ; each particular spot does not last more than 
 three days, and then it vanishes away. But spot after spot 
 may continue to come out until the end of the third week. 
 In several cases, their number varies from one or two only to a 
 hundred from first to last. And, seeing they last so short a 
 time, and yet may be so few in number, the physician had need 
 be sharp-sighted and of pretty fair experience always to make 
 sure of them. 
 
 This non-petechial rash, whenever post-mortem examination 
 has gone in search of the fact, has been found in alliance with 
 the swelling, ulceration, and sloughing of Peyer's intestinal 
 glands, well known to the physicians of hospitals for half a 
 century. This rash and this intestinal disease are thus justly 
 held to have an essential connexion pathologically, and both to 
 be equally " the proper elements " of a distinct disease. And 
 to it the name " Typhoid " is given by pre-eminence, and is 
 restricted to it. 
 
 Behold, then, in these dusky petechial spots, the proper 
 elements of one disease, Typhus ; and behold, in these bright 
 non-petechial spots, and in this peculiar affection of Peyer's 
 glands the proper elements of another, Typhoid. And the one 
 is as distinct from the other as small-pox is from measles, and 
 as measles from scarlatina. 
 
 Further, in respect to treatment, these (so-called) Typhus 
 and Typhoid maladies are just on the same footing with small- 
 pox, measles, and scarlatina. Their proper elements afford no 
 direct indications for the management of any one of them. 
 That wherein their own essence consists can be at once touched 
 or handled remedially in none of them. 
 
 It is a great subject this, of the proper and common elements 
 of disease. To illustrate it, I have chosen examples where the 
 distinction is plainest and nearest at hand. In some of these 
 the proper elements are familiar and unmistakeable. Small- 
 pox, measles, and scarlatina, display themselves what they are to 
 all the world. But in the Typhus and Typhoid diseases the pro- 
 per elements are sure only to the practised eyes of physicians. 
 And even physicians have but lately been taught when and 
 
PRACTICE OP MEDICINE. 433 
 
 where and how to look for them. Yet these must always have 
 existed, and must essentially have played the same part in all 
 past times which they do now. But heretofore they lay 
 covert. 
 
 Now, I do not pretend to announce new things in pathology. 
 I only wish to put in a little better order things that are known ; 
 and, perhaps, I may make them easier to handle for practical 
 purposes. To tell the truth, most medical books have been a 
 puzzle to me all my life long. Their descriptions of disease 
 have been (to my thinking) needlessly complex and multifarious, 
 mixing what is proper, and constant, and first in order, with 
 what is common, and variable, and consequential ; both being 
 real enough in themselves, but meaning different things. Again, 
 their lessons of practice were conversant with too many aims 
 and too many implements for me ever to make myself master 
 of them. Hence, for itself and its own needs and uses, my 
 mind has always been in search of something simpler and easier. 
 Dr. Jenner has given me the key to unlock many a speculative 
 puzzle ; and I thank him for it. 
 
 In this place, I would make a remark which is of some 
 practical concern. It is this. Here are two diseases, each con- 
 stituted of its own proper elements, and both distinct from every 
 other disease in the world. One is called Typhus, and the other 
 Typhoid. Now, it is a misfortune that they, being new to our 
 knowledge, were not designated from the first by new names. 
 Each having a nature of its own should have had its own name 
 restrictively. But Typhus and Typhoid were names already 
 bespoken for other and commoner uses. They had been current 
 time out of mind, and were prefixes of fever, denoting it, not 
 with much strictness perhaps, to be of an evil character. For 
 in truth, they had no more definite meaning than what was 
 implied by their etymology. Typhus was the fever that smoul- 
 dered, but did not burn. Typhoid was the fever that neither 
 smouldered nor burned, but of the two it was rather given to 
 smouldering. Take small-pox, scarlatina, measles, erysipelas 
 dysentery, boils, carbuncles ; take these, or any other diseases 
 you please which have fever belonging to them, and you will 
 find that fever becoming Typhus or Typhoid in the old sense 
 -according to times, and places, and circumstances. Whatever 
 diseases get an entrance into camps, and into crowded squalid 
 
 FF 
 
434 GENERAL REMARKS ON THE 
 
 quarters of the- poor in large towns, are sure soon to be Typhus- 
 or Typhoid. Their fever smoulders, and is of an evil character.. 
 And thus it was by an unlucky chance that the names, which 
 had been taken to signify accustomed groups of the common 
 elements of I know not how many diseases, came all at once 
 to be restricted to the proper elements of two diseases in 
 particular. 
 
 The terms pervade all the best records of practical medicine 
 for the last century. But the radical difference between their 
 present and past meaning will be too likely to perplex future- 
 readers of those records, without help of a glossary. 
 
 Now, all the five diseases which have been mentioned,, 
 small-pox, scarlatina, measles, the typhus and the typhoid 
 maladies, commend themselves to the study of the physician for 
 their own sakes, and for much more besides. Having their 
 proper and common elements distinctly legible, they exhibit 
 specimens how diseases of several names and natures come by 
 a single characteristic in which they agree, to find their place 
 within the same category, and to fall within the easier reach of 
 the physician. The category to which these belong includes,, 
 together with them, many of the most formidable diseases 
 throughout the world. And so^ they become our examples near 
 at hand of what all the rest need practically, and, in a vital 
 sense, of what they are pathologically. Thus, knowing these 
 five, go where we will, we find ourselves not altogether stranger* 
 to the nature of diseases which we may never have seen before;, 
 and not quite unapt for their management, though we may 
 never before have been called to treat them. Of these five, and 
 the rest that fall within the same category all the world over, 
 none admit of cure ; none other require or tolerate a special 
 remedy. With them it is all an affair of Treatment, and of 
 choosing the right indications in particular cases, and dealing 
 fitly with them by whatever means they require. 
 
 These are a few simple things rescued (so to> speak), from a 
 great throng. They claim, however, the nature of principles,, 
 being verified by the numerous instances which they cover and 
 explain. And, indeed, the times we live in call upon physi- 
 cians for new and more strenuous endeavours after principles 
 in the exercise of their art. For it is being undone for want 
 of them.: 
 
PRACTICE OF MEDICINE. 435 
 
 Further, these five diseases have been all recognised as 
 fevers, and all so denominated ; variolous fever, scarlet fever, 
 rubeolous fever, typhus fever, typhoid fever. And it is likely 
 enough that many physicians, whatever speculations they may 
 have in reserve, take their familiar notion of fever from what 
 it has appeared to them to he in these examples. And no bad 
 notion either. But, however this may be, now is a fair occa- 
 sion for what remarks I presume to make on the same subject, 
 even Fever; 
 
436 GENERAL REMARKS ON THE 
 
 X. FeVEK. WHAT IS FEVER. 
 
 Stahl's Phlogiston looked very like the truth for its time. 
 Chemistry wanted a something in aid of its facts, to complete a 
 theory of combustion ; and it had recourse to this figment. And 
 figment as it was, the facts and it fitted into one another so 
 well, that it soon passed for a reality ; and Phlogiston kept its 
 ground for half a century. 
 
 Now the world in general invests fever with a quasi 
 materialism and personality, and regards it as offspring and 
 parent by turns of almost all diseases. And a great many facts 
 fit in curiously with this conceit, and make it a plausible piece 
 of pathology. Thus Fever has been our Phlogiston. 
 
 But one would not like to let drop a hint that Fever is 
 nothing better than a figment ! Far be it from me. Only take 
 me round a hospital, and you will have me acknowledging 
 Fever in half the poor fellows I see. Just so. But what is 
 Fever, and what the thing or things contained in it? If a 
 single thing, it must be very large ; if several things, they must 
 be very numerous. But, without saying which it really is, let 
 us, for the present, be allowed to take it as a single thing ; for 
 there are facts of practical moment belonging to it, which can 
 be most conveniently regarded from this point of view. 
 
 It would have a formidable look, if we began by requiring 
 a definition of Fever. There are things which will not be 
 defined, and Fever is one of them. Besides, when a word has 
 passed into everyday use, it is too late to lay a logical trap for 
 its meaning, and think to apprehend it by a definition. Vain, 
 too, is it to hunt after it in dictionaries, or consult antiquaries 
 and etymologists about it. After lapse of time, even common 
 language comes to vary its signification from mere custom. It 
 is not likely, therefore, that in a profession like ours, which, 
 itself and all belonging to it, suffers perpetual change, language 
 should be constant to its meaning, and the same word continue 
 for ever to express the same thing. Practical medicine must 
 
PRACTICE OF MEDICINE. 437 
 
 not ba overnice about the language it uses, or it will be brought 
 to a standstill altogether. 
 
 The term Fever is as old as the hills, and it must remain. 
 What it meant formerly, it may not mean now. But our 
 business is with the sense it bears at the present day, and to 
 give it and take it according to common acceptation. We must 
 use it. So let us make the best of it, and ask no curious ques- 
 tions about it. Listen to the fellows in the street, how they 
 bandy about some vulgar word from morning to night, giving 
 and taking it in its now unmistakeable sense, and little thinking 
 of all the trouble some antiquarian philologer has had with it. 
 It, a mere monosyllable perhaps, has cost him a chase of centu- 
 ries over half the world to find out whence first it came, whither 
 next it went, and where it has been, and what it has been doing 
 and meaning ever since, down to the present time. 
 
 Without retrospect or regard then of other times, if there be 
 any sense in which Fever is now popularly understood by phy- 
 sicians and the world, the same may be safely adopted. And 
 such a sense there is. 
 
 In casting our eye over the subject of fever historically, we 
 find this remarkable circumstance, that it fills a much larger 
 space in medical books, both ancient and modern, prior to the 
 century in which we live, than it has ever done since, and than 
 it does at present. In these days, physicians talk about Fever 
 as much as ever. They have it perpetually on their lips, and 
 keep up still a pretty vociferous report of it throughout the 
 world. But they do not now write much about it under that 
 name. 
 
 A fact like this must have its reasons. Verily, writing and 
 talking are different things. Is it that they of old studied the 
 subject more, and we less ? No ! But each of us has studied 
 it in our own way ; and our way is different from theirs. 
 
 They dealt with the subject more bravely and adventurously 
 than we, and more comprehensively too ; also, more with the 
 aim of coming to conclusions and constructing systems ; and, so 
 far, more successfully than we. For this bold and intrepid 
 thought of theirs upon the large subject of Fever took with it 
 such a sweep of things innumerable, and things of every sort 
 near and remote, as contrived to drag in almost all diseases. 
 And so it was that, readily and almost naturally, their theories, 
 
438 GENERAL REMARKS ON THE 
 
 and cure, and treatment of Fever, became their theories, cure, 
 and treatment of all the rest. It is, indeed, plain that most 
 of the doctrines, which aforetime have borne grandiloquent 
 names, and made professors and universities famous in their 
 day, have been expansions and reflections of what had been 
 thought and taught, and practised, concerning Fever. 
 
 But our studies are, and have been for some time past, more 
 about it and about it than of Fever itself. And no disparage- 
 ment to us on that account ! Search has been made by us 
 after places that engender Fever, or rather the noxious things 
 which are the proper elements of diseases that involve Fever; and 
 this search has engaged some of the best minds. And it had 
 need of them ; for it is difficult beyond measure. And it has 
 had great success. Nevertheless, it is not exactly the study of 
 Fever ; perhaps, it is something better. For better, indeed, it 
 may well be to prevent the whole pernicious work from being 
 set agoing, which carries Fever along with it, than to under- 
 stand what this Fever is when it arrives. Think what it is to 
 know the elements of certain diseases before they have entrance 
 within the body, and then to be able to lessen them and 
 reduce them to nothing ; or, failing the ability to do either, 
 to give warning where they are, and save communities their 
 perilous or fatal exposure to them. 
 
 Our studies have also been of contagion and its doctrines ; 
 and thus we have become conversant with the proper elements 
 of certain other diseases which, however originally engendered, 
 are now kept existent in the world by having human living 
 bodies to accept, and nurse, and multiply them, and impart 
 them to others. Many of these have Fever involved in them 
 from first to last. But the study of them, and the conditions 
 of their spread, is, strictly speaking, something beyond and 
 beside .the study of Fever. 
 
 Further, our studies have been of diseases which begin and 
 end with the individual man. With naked eye and scalpel, 
 and microscopic and chemical tests, we have been hard at work 
 of late years, and have searched out many wonderful things 
 within the body, claiming to be the proper elements of diseases, 
 which in their vital progress involve Fever ; but they are not 
 Fever themselves. 
 
 Behold us, then, circumventing and closing in upon our 
 
PRACTICE OF MEDICINE. #39 
 
 subject on every side. And are we none the wiser, after all, 
 what Fever is ? Yes ! far the wiser. For thus we have come 
 to know all that can be known of it ; and that it is neither 
 malarious, nor contagious, nor scissile, nor microscopic, nor 
 •chemical ; but that it is vital. Fever is not the man's disease, 
 but his life assailed by his disease ; even his life on a large 
 scale. 
 
 Let me, however, be careful what I say. Pure life is a 
 thing inapprehensible and unimaginable by human thought. 
 But the actings and feelings of the parts and structures which 
 •compose our body are, many of them, apprehensible enough. 
 .And, as it is by them that the man shows that he lives, we 
 must be content to deem them identical with his very life. Far 
 we cannot penetrate further. 
 
 With this explanation, let us come close to the bedside, and 
 there see and judge for ourselves what ails the patients who are 
 said to have Fever. 
 
 Well, then, some are said to have Fever, while, to outward 
 view, nothing ails them more than that they are hot above 
 measure. Others, that they are hot and cold by turns, after 
 some strange fashion. And others, that they are perspiring 
 too ; hot and perspiring or cold and perspiring at the same 
 time ; or none of the three together, but each by turns. 
 
 All this is apparent enough; and in outward show there is 
 inothing more than this. But there is something more, and no 
 trifle either. Question the patients about their feelings. And, 
 if it be really fever that they have, whether their heat, cold, or 
 perspiration, be much or little, or in whatever manner occurring, 
 they will all testify to a consciousness of something wrong 
 within them. What it is they feel they cannot exactly tell. 
 Perhaps they can say no more than that " they are ill," or ".that 
 they are downright ill." 
 
 But people in perfect health are hot and cold and perspiring 
 by turns ; and all because they are in perfect health. Take 
 them whose lot is labour. Whatever they have to do is by 
 voluntary muscle and limb ; and they-do it with all their might. 
 This is their outward life put forth day by day and every day 
 in all its power and energy. And their inward life shares the 
 vigour of their outward life, and co-operates with it. They put 
 -forth glowing heat and fresh perspiration.; and as for cold,, if it 
 
440 GENEBAL EEMARKS ON THE 
 
 be felt at all, it is but for a short season, and as a stimulus for 
 more beat and more perspiration. They testify to nothing 
 wrong within. All their consciousness is of health and power. 
 
 Here, then, we have our specimens of life healthily actuated, 
 and of life injuriously assailed. In each case, it is through its 
 same embodiments that we are enabled to judge now of its 
 health and now of its illness ; viz. through the entire vascular 
 and [nervous systems, and the great central organs of both. 
 For these, as far as mortal insight goes, are the prime movers 
 and ministers of all function, and feeling, and consciousness, 
 within us, ready to answer whatever calls or emergencies await 
 them, as they are able. If, from things not out of harmony 
 with themselves, and not of more force than they can bear, they 
 answer (as we have seen) boldly, according to the nature of 
 their office, by putting forth the simplest and surest manifesta- 
 tions of health ; if, from things essentially baneful or simply 
 overstrong, then they answer (as we have also seen) still accord- 
 ing to'the nature of their office, but strangely and confusedly. 
 
 It is upon life that we are looking ; upon life embodied in 
 the entire vascular and nervous systems, and on this large scale 
 injuriously assailed, whenever we contemplate Fever. 
 
 Is Fever, then, one thing or many ? The question has been 
 answering itself as we have gone along. Show me Life as a 
 single thing, and I will show you Fever as a single thing 
 taking forcible hold of it. But to contemplate either this or 
 that as a^single thing is utterly impossible. Fever must be 
 taken to stand for the sum and aggregate of many particulars. 
 
 But all general terms in use among physicians had need to 
 be jealously watched. Even strength and weakness, simple and 
 innocent as they look, have by turns been the marring of us. 
 The terms themselves cannot be dispensed with ; and as long 
 as they truly represent (as they always ought) an aggregate of 
 things real, and verifiable in their details, they serve an useful 
 purpose. But, failing this, they become pernicious abstractions. 
 In my time medicine has been going through a speculative crisis 
 of two opposite kinds by turns ; and strength (so-called) has 
 ruled the one, and weakness the other. Beyond all question, 
 during its critical ascendency, abstract strength cost the world 
 many lives by its practice of blood-letting ; and abstract weak- 
 ness, in its turn, has cost the world many also by its practice of 
 
PEACTICE OF MEDICINE. 441 
 
 brandy-giving. I have not statistics to show with exactness 
 which of the two has levied the larger mortal tax upon mankind. 
 My impression is that the bad pre-eminence belongs to the 
 latter. 
 
 Now Fever is a general term, and as such, carries with it 
 the danger, as far as its meaning is concerned, of degenerating 
 into a vague abstraction. And this danger is the greater, the 
 more it is thought of and talked of, apart from the patients who 
 suffer it. Therefore, in what remarks we have yet to make 
 about Fever, let us still keep close to the bedside. And not 
 only so ; but let us choose some large hospital, and conceive 
 ourselves to make daily visits to it for some three or four years 
 in succession, and there and then make acquaintance with the 
 real things, which Fever represents in its natural and necessary 
 alliance with bodily hurts and diseases. 
 
442 GENERAL REMARKS ON THE 
 
 X.— Fever. Part 2. 
 
 INFLAMMATION AND ITS FEVER. 
 
 Let it be constantly borne in mind that Fever is not the man's 
 disease, but the man's life assailed by his disease ; his life, not 
 as a single thing which is inapprehensible and unimaginable, 
 but as embodied in the functions and feelings of the entire 
 vascular system and nervous system, and seen and read of all 
 men. 
 
 Ifow our best insight into the nature of Fever is likely to 
 come from contemplating it in diseases with which it is most 
 conspicuously allied, beginning with any one that we know the 
 most of. And the most familiar thing bearing the name of a 
 disease with which we are acquainted is Inflammation. The 
 organic processes, which concern it, have been minutely scruti- 
 nised and had their meanings interpreted by pathologists. They 
 are all visible on the surface of the body, and many of them are 
 audible as they transact themselves in some important organs 
 within. Then of the antecedents of Inflammation, we have a 
 pretty good notion which they are that may be set down for its 
 exciting causes. Such are things that can hurt mechanically ; 
 such are unwonted transitions from heat to cold ; such are over- 
 taxing or too hard usage of the bodily powers in health, and of 
 the mental too sometimes. Of some of these we are so sure that 
 we could choose them, and apply them, and so procure Inflam- 
 mation at will. 
 
 At all times, and especially at sickly seasons, Inflammation 
 abounds in large hospitals. And cases of Inflammation are the 
 best studies we can have of Fever. Above all other cases they 
 represent : 1. The relation of Fever to the disease as a whole 
 from first to last. 2. The correspondence of Fever with the 
 disease in its intermediate changes, stage for stage. Further, 
 above all other cases they denote the bearing which it belongs 
 to Fever to exercise upon the management of the disease. Here, 
 
PRACTICE OF MEDICINE. 443 
 
 if ever, the vital movements of the vascular and nervous system, 
 now assailed and aggrieved, stand out as indications of treat- 
 ment. Here, if ever, they first suggest what that treatment 
 should be upon the whole ; and, then, from its effects upon 
 Fever and Disease correspondently, they suggest what it should 
 be from stage to stage until the end. And all with some evident 
 exactness. 
 
 Now, Inflammation is naturally the simplest of Diseases, 
 and Fever annexed to Inflammation is the simplest of Fevers. 
 But then they must meet with fortunate coincidences to make 
 them and keep them such. 
 
 The artist, whatever may be the material he uses for his 
 projected work, whether wood or stone, takes care to have the 
 most perfectly sound specimen of it he can get ; knowing that, 
 otherwise, the work itself is like enough to turn out a failure, 
 and be neither so good nor so durable as his ambition might 
 hope. And we physicians, when we want Inflammation for a 
 study of Fever, would like to choose the subjects whom it should 
 befall, and have them of the soundest material. But we must 
 take cases as they come. We are practitioners by necessity ; 
 we are pathologists by choice or by chance. It is well when we 
 can be both, but the first we must be. 
 
 In a large hospital, the cases of Inflammation are not all of 
 the right vital stuff for making the disease the thing which (so 
 to speak) it naturally ought to be. For entertaining Inflamma- 
 tion and its Fever, and insuring them their natural simplicity, 
 and carrying them to the perfection they are capable of, the 
 body must be previously healthy. There must be the antagon- 
 ism of health to show to the full what the disease naturally is. 
 
 This is no paradox ; but a truth put (I believe) into fitting 
 words, and worthy to be noted. 
 
 Now, it is where their natural simplicity is preserved, and 
 perhaps in consequence of it, that Inflammation and its Fever 
 do, if ever, display a superlative energy, and require and tolerate 
 the most powerful remedies. The cases typifying this course 
 of things make a great show in medical books. The disease is 
 then severe and unmistakeable ; and its Treatment heroic and 
 successful. But such cases are the few. Perfect health, like 
 perfect beauty, is a rare thing ; and so, it seems, is perfect 
 
444 GENERAL REMARKS ON THE 
 
 Still, not to speak of perfect health, good health is common 
 enough, and Inflammation does not befall those the oftenest 
 who have a fair share of it. Yet, when it does, then, if ever, 
 the case is demonstrative of the points most sought after, both 
 pathologically and practically, and is an easy and satisfactory 
 study. 
 
 But let us take the experience of a large hospital year 
 after year for a succession of years, and run over what records 
 we have of those who have suffered Inflammation there. Of 
 some patients, we shall find that they were old ; of some, that 
 they were half-starved ; of some, that they had chronic liver- 
 complaints ; of others, that they had habitual coughs ; of others, 
 that their constitution was bad at the best, and (what they 
 called) their health was no better than other men's disease. All 
 these many patients had Inflammation. The pneumonia, or 
 pleurisy, or peritonitis, was diagnostically the same disease in 
 them as it was in the few. But observe the difference. In the 
 few, Inflammation found Life unharmed and vigorous. In the 
 many, Inflammation found it hurt and deteriorated. In the 
 few, Life, embodied in the vascular and nervous systems, being 
 now assailed, was ready to resent and react according to its 
 strength ; in the many, according to its weakness. 
 
 By strength and weakness, is here meant nothing more than 
 the completeness or incompleteness of men's habitual health. 
 And these furnish us the measure or gauge of their vital suf- 
 ficiency or insufficiency to encounter whatever of an extraor- 
 dinary kind may befall them ; for instance, to bear inflamma- 
 tion when it comes, and bring' out its natural characteristics, 
 and help us to make good its treatment. 
 
 But, taking still the experience of a large hospital for a 
 few years, let us review as well what has been our treatment of 
 Inflammation as those who have been our patients, and note its 
 results. In so doing, we shall doubtless be able to give a goodly 
 account of some easy and successful experiments, in which all 
 went on well from first to last ; of Fever and Inflammation 
 proceeding in perfect harmony together, and preserving a con- 
 stant course, and presenting indications of treatment safe and 
 sure, because distinct and intelligible ; and of simple and 
 powerful remedies, all telling for good, and all producing the 
 effect for which they were given. But this goodly account, if 
 
PRACTICE OF MEDICINE. 445 
 
 it be honestly reckoned, will not be a numerous one. In fact, 
 the much more numerous account we shall have to give will be 
 of experiments in which our treatment has been successful in- 
 deed, but not easy. All came out well in the end. Meanwhile, 
 however, from intervening accidents, or some weakness of the 
 subject, Fever and Inflammation did not keep exact concord 
 together, and presented but obscure and half-legible indications 
 of treatment ; and these were adopted with much care and cir- 
 cumspection. And our treatment became all along a compro- 
 mise between what the disease required, and what the patient 
 could bear. Nevertheless, it was successful in the end, and 
 largely too. And then will come our inventory of unsuccessful 
 experiments, made up partly of cases in which our treatment 
 saved life indeed; but, being unequally matched with the 
 disease, could not bring it to an end on better terms than that 
 it should leave the part it occupied permanently damaged, and 
 the whole man permanently deteriorated ; and partly of cases 
 in which our treatment absolutely failed, and life was lost. 
 
 Thus, let Inflammation and Inflammatory Fever be naturally 
 ever so simple, they cannot exist without life and organisation. 
 And so variable a thing is Life, and such disguises does it 
 throw over them, and whatever else that can befall it from time 
 to time, that they are not always to be apprehended in their 
 entire natural simplicity. 
 
 Still we do but begin with the beginning, when, in seeking 
 to know what Fever is, we try first to trace it in its connexion 
 with Inflammation. For Inflammation is, pre-eminently, a 
 fundamental subject of practical medicine, and its great vital 
 ingredient is its Fever. It is to us a sort of grammar, which 
 helps us to construe half the things we see and deal with as 
 physicians. And therein our great grammarian is John Hunter. 
 For it is from him that at this day we have our most com- 
 prehensive teaching in all that Inflammation includes, and 
 especially its Fever. Observe how constantly sedulous he is to 
 keep apart what is local and simply organic from what is con- 
 stitutional and more eminently vital. As soon as the entire 
 vascular system and nervous system show themselves assailed 
 and aggrieved, i.e. as soon as Fever arises, he lays aside his 
 scalpel and every foreign implement, and abstains religiously 
 from all meddling and interference. He becomes, in the 
 
446 GENERAL REMARKS ON THE 
 
 strictest sense, a physician. He sits by the bedside, and takes 
 note of chilliness, and heat, and perspiration, and all the un- 
 wonted movements of the vascular system and nervous system, 
 as they follow the visible shiftings and changes of the Inflam- 
 mation ; and so he seeks to understand better the meaning of 
 both, and how they serve to interpret the Inflammation and it 
 them. 
 
 HHEUJIATISM AND ITS FEVER. 
 
 Within a large hospital, and side by side with cases of In- 
 flammation and Inflammatory Fever, are cases of Rheumatism 
 and Rheumatic Fever. The characteristics of these latter have 
 been well studied and are well marked and well known. The 
 thing which, seated in the joints, and in this part and that, is 
 called Rheumatism, if regard be had to the organic processes 
 which concern it, will just as well bear to be called Inflamma- 
 tion. And the manner in which, this Rheumatism being present, 
 the vascular and nervous systems show themselves assailed and 
 aggrieved, can be called nothing else but Fever. 
 
 But there is a great difference between them somewhere. 
 And it lies deeper than sight, or hearing, or microscope, or 
 stethoscope, or any instrument we have to help us, can reach. 
 Let us review our cases of Rheumatism. and Rheumatic Fever, 
 and collate our experience of their treatment for a few years-. 
 Such heat, perspiration, and pain ; such general vascular action 
 and nervous distress as we witness in Rheumatism, had they 
 occurred in Inflammation, would have been taken by us to hold 
 some correspondence with its amount, its extent, its stages, and 
 been used for plain indications of treatment, and the patient's 
 safety been thought to turn upon the just fulfilment of them. 
 But now, in their alliance with Rheumatism, we did not, and we 
 dared not, take them literally for what they were, and apportion 
 the force of our remedies accordingly. Further, with all our 
 observation, be it ever so correct, of times and places and 
 seasons and of antecedent and concurrent things, we cannot 
 pitch upon certain of them at our command, and take and apply 
 them, and so produce a Rheumatism in individual men and 
 women as we can produce an Inflammation. Where many or 
 most of them are present, there must still be something over and 
 above them, or there will be no Rheumatism. And oftentimes^ 
 
PEACTICE OF MEDICINE. 447 
 
 where none of them exist, there will still be Rheumatism. But 
 what this thing is, which, favoured by coincidents or by its own 
 sole agency, is the very cause of Rheumatism, no man knows. 
 All men, however, guess pretty unanimously whence it 
 comes. Sagacious observers and experimenters have, in these 
 later days, gone nigh to show that there is a chemistry within 
 us which is co-operative with life ; that making good its work, 
 it gives to our bodies the materials of their health ; and that 
 doing its work faultily, it suffers noxious things to form, which 
 become the elements of their diseases. 
 
 Already a miscellaneous throng of diseases is fairly conjec- 
 tured to issue from this vital laboratory ; many trivial enough, 
 and of smaller interest, and coming and going with little inter- 
 ference on our part; and many of deeper pathological and 
 practical concern, and more abiding. Among these, one of the 
 most momentous is Rheumatism with the Fever that accom- 
 panies it. 
 
 The disease cannot be named which makes a handsomer 
 figure nosologically than this Rheumatism. Yet there is none 
 about which we are more in the dark. For nosology, at the 
 best, is but a sort of provisional pathology, telling us something, 
 little, or nothing, as it may happen, about the nature of the 
 disease, and the management thereof. 
 
 This Rheumatism once begun, we can make no reasonable 
 calculation when it will end ; in a few days, or in a few weeks, 
 or in a few months; Begun in a single joint, we do not know how 
 many more joints it will visit, and what other and nobler parts 
 besides ; the heart, the lungs, the brain. Further, this Rheu- 
 matism calling for medical management, we are divided between 
 (what I have called) cure and treatment, between the use of 
 special remedies whose aim is nothing less than to be counter- 
 active of the entire disease as such, and the use qf any remedies 
 whatever best calculated to satisfy indications which present 
 themselves in individual patients. Hence upon a retrospect of 
 years, in the management of Rheumatic Fever, cinchona, col- 
 chicum, guaiacum, nitre, lemon juice, alkalis, and alkaline salts, 
 will claim the authority of our experience for their occasional 
 and inconstant success as special remedies for Cure. And so 
 will bleeding and purgatives and opium, as common remedies in 
 treatment. 
 
448 GENERAL REMARKS ON THE 
 
 ERYSIPELAS AND ITS FEVER. BOILS. — CARBUNCLES. 
 
 In a large hospital, and side by side with Inflammation and 
 Inflammatory Fever, are cases of Erysipelas and Erysipelatous 
 Fever ; also cases of Boils and Carbuncles. And these, together 
 with Rheumatism, regarded from the physician's point of view, 
 group themselves into a class, different as they are in outward 
 aspects ; for they are all alike favoured by external causes with 
 which we are not unacquainted, while they are essentially due 
 to something over and above— to something which we have no 
 exact knowledge of; and hence they are beyond Our power to 
 produce. Further, from time to time they all in their turn alike 
 surprise us by the success and the failure of the remedial 
 measures we adopt. Cure and treatment, special remedies and 
 common remedies, have gained for themselves the praise or the 
 blame of unaccountable results. But they all show their vital 
 import in one and the truest sense, by the power they have of 
 assailing life in the entire vascular and nervous systems, as seen 
 by the Fever of various degrees and durations that may or does 
 accompany them all. 
 
 The physician, finding these diseases — Rheumatism, Ery- 
 sipelas, Boils, Carbuncle — all beyond the power of known 
 external causes to set them a-going, has with good reason 
 transferred them pathologically to the sphere of those that are 
 engendered within. But in so doing he has pledged himself 
 to a task of great, perhaps insurmountable difficulty. 
 
 Touching external causes of diseases, there could have been 
 no certain proof given that any such exist, short of specialising 
 some of them, and showing that it was this, that, and the other 
 ■cause which set a-going this, that, and the other disease. And 
 this proof has been abundantly given in specialising many con- 
 tagious and malarious elements, and tracing their several diseases 
 infallibly home to them. 
 
 Now, even such philosophy as we physicians pretend to 
 cannot be satisfied with less, when the question is of causes 
 engendered within. Here there is even more and more need 
 of first specialising things into realities before fixing upon them 
 as germs of disease. 
 
 This is the work to be done. But the science which must 
 help us to do it is new to the age in which we live, and has 
 
PKACTICE OF MEDICINE. 449 
 
 almost taken us by surprise. One may be pardoned for being a 
 little jealous of it at starting, for already it has been made to 
 stand sponsor for some fantastic imaginings. 
 
 Diseases (so the history of medicine tells us) have many of 
 them been named and nosologised so luckily and so well from 
 their external characters, as to betray the physician into the 
 belief that he had a perfect understanding of them. But of 
 those among them whose proper elements are self-engendered 
 and within, he now sees that he knows little enough, and he 
 fears a natural interdict to his knowing more, until he has 
 specialised the cause or causes he is in search of ; and this may 
 be the work of ages yet to come. 
 
 But our subject is Fever. And it was for the sake of gain- 
 ing some better insight into its nature, that we came to meditate 
 upon the several diseases which have been named ; that in In- 
 flammation, seeing Fever allied with the disease of which .we 
 know the most, and then allied with others of which we know 
 the least, we might perhaps gain some surer reckoning of what 
 it is from contrast or comparison. "Whether we have really 
 done so, I cannot tell. But this is certain, where the question 
 is of Life (and, if the phenomena of Fever be rightly inter- 
 preted, it is now pre-eminently so), we must look for enlighten- 
 ment anywhere and everywhere. Even between Inflammation 
 and its Fever the proportions were not found exact. Large 
 allowances had to be made for age and for constitution, and for 
 hereditary and individual strength and weakness. And all this 
 implies nothing less than some power beyond the reach of 
 science, that can calculate what their life is worth in individual 
 men and women before it suffers the disease. And this power 
 belongs to practical experience — to busy, thoughtful, multi- 
 farious experience — the honest and just judge that ultimately 
 settles the worth of everything for physicians. 
 
 c a 
 
450 GENERAL REMARKS ON THE 
 
 XI. — Teeatment. 
 
 TREATMENT OF ALMOST ALL DISEASES — HELPED AND EXPLAINED 
 BY THE STUDY OF FEVER. — SPECULATIVELY AND RUDIMENT- 
 ALLY FEVER PERTAINS TO THE VASCULAR AND NERVOUS 
 SYSTEMS. — PRACTICALLY AND CONSEQUENTIALLY TO ALL PARTS 
 AND ALMOST ALL DISEASES. — LIMIT OF SPECULATIVE THOUGHT 
 IN PRACTICAL MEDICINE. 
 
 It was altogether accidentally and by the way, that we came to 
 discuss the great subject Fever. We were simply in search of 
 the symptoms which should serve us for indicators or guides of 
 Treatment; and we found them not among those which are 
 proper to the particular disease, as being nearest akin to it and 
 its real or supposed essence ; but among those which are common 
 to it, and to many another disease besides. 
 
 Take the five Diseases which served us for our first and 
 plainest illustrations. They were fitly called small-pox, scarla- 
 tina, and measles, and typhus and typhoid, from their proper 
 elements, which differenced them one from another, and from 
 every other disease in the world. And still were they fitly 
 called Fevers from their common elements, which kept them all 
 still related one with another, and with every disease in the 
 world of which Fever is predicated. 
 
 But I do not presume to tell medical men what they mean, 
 or ought to mean, when they talk of Fever. Some may mean 
 more, and some less, and many may not exaetly know what they 
 mean. Only we have strangely misnamed what we have all so 
 called, if this one and the same appellative denote now one thing 
 and now another in every different disease where Fever is found. 
 The name should stand for some pathological reality common to 
 them all. And so it does, and plainly too and unmistakeably, 
 in the many diseases of various types through which we have 
 just been tracing this (so-called) Fever. 
 
 Let it then be repeated, that Fever, wherever it is found, is 
 not the man's Disease but the man's Life assailed by his disease; 
 
PRACTICE OF MEDICINE. 451 
 
 Life as embodied in the functions and feelings of the entire 
 vascular and nervous systems. For my part I can go no deeper 
 than this, and can generalise no further. But if, as far as we 
 can see, the vascular system and the nervous system are first 
 and principal in acting or suffering wherever disease most tries 
 and imperils life, it would he well to consider what they are in 
 themselves prior to our more practical dealings with them. 
 
 In speaking of the vascular system and the nervous system, 
 I pretend to no greater accuracy than the nature of the subject 
 allows. Doubtless, to the eye of the anatomist, the vascular 
 system and the nervous system are things apart one from the 
 •other. But to the physiologist, the pathologist, and the prac- 
 tical physician, they are always mixed. One cannot fulfil its 
 natural and healthy functions without the other. One cannot 
 be drawn out of its natural and healthy habitudes, and display 
 the actings and sufferings of disease without the other. Nor 
 can one be subjected to the impressions' of medicine without the 
 other being subjected also. While each taken alone is vitally 
 inert, both taken together exercise the great vital forces which 
 move and actuate the whole body. 
 
 Nevertheless, the vascular system and the nervous system 
 have each its own proper instruments and power to aet with, 
 and each its own proper part to play. Though they cannot 
 work but by mutual help, their offices are not interchangeable. 
 •Some little may be learnt of these separate powers and offices 
 by observing their operations in health ; but much more by 
 attentively looking on when accident or disease forces them out 
 of their accustomed conditions into others which do not natu- 
 rally belong to them ; and much more still by noting accurately 
 the results of experiments of our own choosing in the treatment 
 of diseases. But for diseases, and the treatment of diseases, we 
 should know but little of the powers and offices of the vascular 
 -and nervous systems. 
 
 Now, all this is in analogy with the nature of things around 
 us, with the material elements of the world, and their separate 
 existence, and their co-operative agency in accomplishing their 
 great designs. 
 
 It is remarkable how few are the elements which nature 
 .makes use of in her grandest operations. Yet she never works 
 with them singly, but always in combination. By single ele- 
 
452 GENERAL EEMAEKS ON THE 
 
 ments she does nothing ; by two or three together she moves 
 the world. 
 
 These elements, inert in themselves and giving no self- 
 notice of a separate existence, have been hard to find out ; and 
 hence their discovery has been postponed to a late period in the 
 age of mankind. Yet have they always been chief objects of 
 human curiosity ; and it has ever been reckoned among the- 
 triumphs of science to win a new element from the jealousy and 
 concealment of nature. But such discoveries have not been, 
 made by simple observation of things as they are ; but men, by 
 contrivances of art, have forced them out of their natural 
 combinations, and transferred them into others of their own 
 choosing, and then noted their behaviour under new conditions 
 presented to them beyond the first intent and purposes of nature. 
 Thus, injury, or disease, or whatever, either by accident or 
 design, has been brought to bear upon the functions of our 
 bodies, so as to force them out of their natural course, has given 
 the first hint, and become the very test and experiment, and 
 ultimate proof of new and otherwise unattainable knowledge 
 concerning them. 
 
 Further, the vital functions of our bodies are in analogy 
 with the intellectual faculties of our minds. A mixed operation 
 and a separate essence belong to them both. The memory, the 
 imagination, and the reason do not, perhaps cannot, work but 
 in union one with another. Yet, it should seem, they are three 
 separate elements of intelligence. Lord Bacon, at least, re- 
 garded them as such ; he accepted this ancient truth, and gave 
 it pre-eminently his sanction by the use he made of it. For, 
 in accordance with it, he made a threefold division of his. 
 universe of knowledge, and found for its several parts a store- 
 house (as it were) and natural laboratory, either in the memory, 
 the imagination, or the reason. Thus, the three together go 
 essentially to make up the one mind ; and thus the one mind 
 becomes capacious of all knowledge. Where all three are 
 of equal power, and that power is great, and all are harmo- 
 niously blended, and all duly co-operative, there is the perfect 
 mind. But the difference between mind and mind is mainly 
 seen in the different measures in which they are conjoined. And 
 thus He who made us " has divided unto every man severally as 
 He willed." But a total defect of any one of the three elements. 
 
PEACTICE OP MEDICINE. 453 
 
 of intelligence can hardly consist with any mental operation at 
 all. The working of any one can scarcely be begun, certainly 
 it cannot be sustained, without some degree of impulse and sup- 
 port derived from the others. 
 
 But this utter spoiling of intelligence by one capital defect 
 is (I presume) very rare. And, on the other hand, the perfect 
 mind has been the lot of very few. To come near to possessing 
 it has not been the lot of many. And those who have the 
 greatest repute for intelligence, like those who seem to have the 
 best health, are often so self-conscious of some weak part, that 
 ihey are glad to resort to remedies from time to time to patch 
 themselves up mentally, as others take physic to patch them- 
 selves up bodily. 
 
 There are men whose business is thought. They come soon 
 to learn that it is above all things important for them to keep 
 in good working order the several implements which serve to 
 execute the operation of thinking. And these implements are 
 no other than the several faculties of the mind. Follow great 
 thinkers into their studies. In every age there are a few who 
 are inwardly prompted to give a life's labour, that they " may, 
 perhaps, leave something so written to aftertimes as they shall 
 not willingly let it die." All such abide under the burden of a 
 heavy task. But the labour of each is different according as 
 Nature has distributed the strength or the weakness of their 
 mental constitution. The labour of one is to keep his memory 
 in full grasp and possession of all the materials essential to his 
 great design ; the labour of a second, to draw upon his imagina- 
 tion for all that is suited for its illustration and adornment ; 
 and the labour of a third, while he has memory and imagination 
 ever ready and ancillary to his will, is to reason out his conclu- 
 sions, and raise it, and build it, and settle it, upon the sure 
 foundation and conviction of truth. , 
 
 It happens with our body and its life, and health and disease, 
 in like manner. Life is only known as the complex of many 
 functions, and health as the integrity of these functions, each 
 in itself, and their harmony among others. Every organ has its 
 proper function, which it only can fulfil, and no other organ. 
 Yet can no organ live and move, and be vitally at work upon its 
 own health in perfect singleness and independence. And what 
 knowledge we have of disease (of living disease) runs parallel 
 
454 GENERAL REMARKS ON THE 
 
 with our knowledge of life and of health. We see in disease 
 organs or systems of organs acting and suffering against their 
 healthy conditions and uses. But each organ or system of 
 organs then acts and suffers in its own way, and as no other can 
 act and suffer besides itself ; yet not one of them can be vitally 
 at work upon its own diseases in perfect singleness and inde- 
 pendence. 
 
 Now, medicine mediates between health and disease, and 
 must needs comply with the conditions of both. Hence it is 
 chiefly conversant with partial aims, and contrives single pur- 
 poses, well knowing that these only are fairly within its reach 
 and handling. Thus, it seeks to bring this, that, and the other 
 organ or system of organs in subjection to its remedies. It 
 deals with the vascular system, and reduces its plethora by 
 venesection ; and with the nervous system, and quiets its irrita- 
 tion by opium. It deals with the stomach and bowels, the liver 
 and the kidneys, and by acids, and alkalis, and aperients, and 
 astringents, and by whatever remedies have especial power to- 
 reach and modify the functions of each, it sets them right when 
 they are wrong. Such are its aims, and it sees them clearly, 
 and is pretty sure of hitting them. But they are partial aims, 
 after all. 
 
 Within the range, however, of such partial aims, medicine- 
 affects and prosecutes a sort of scientific exactness, and claims 
 and reckons some amount of certainty in the results. And if 
 all life were the life of distinct organs and nothing more, and 
 if health and disease were nothing more than what distinct 
 organs could work out for themselves through their own func- 
 tions singly and independently ; and if, moreover, nature had 
 supplied the means by which all organs and their functions 
 could be reached, and man had learnt the skill of using such 
 means with perfect safety and success ; then, indeed, would 
 medicine be a certain art. 
 
 But the domain of medicine is wider than its positive com- 
 mand. What it cannot reach it can reckon upon. True, its 
 aims are partial, and their range is narrow. Yet within that 
 range beginnings are made, and first impulses given, which 
 are felt and resented far beyond ; even further, and wider, and 
 more variously, than we can see, or trace, or follow them. Bust 
 
PRACTICE OF MEDICINE. 455 
 
 medicine looks to results, and calculates and often foretells 
 them, trusting to experience. 
 
 !Now, the Treatment of all diseases is helped and explained 
 by the study of Fever. And well it may ; if Fever be com- 
 prised in the actions and sufferings of the vascular and, nervous 
 systems, and they denote the measure and manner in which 
 life is assailed by the present disease. 
 
 The study of Fever ! "Why, speculatively, we have gone as 
 far as it is safe to go in search of a principle, and perhaps have 
 found it. But, practically, we must go much further, if we 
 would show that there is any truth and comprehensiveness in 
 the same principle ; and that, simple as it looks, it is anything 
 better than a pathological puzzle. 
 
 For all, then, that more concerns Fever we must go and 
 remain at the bedside and study it there. In so doing I wish 
 we could fix the limit of speculative thought in its bearing upon 
 practical medicine. 
 
 It is a delicate and difficult subject, and worth dwelling on 
 for a moment. The limit cannot be defined absolutely. If it 
 could, it would mark the boundaries of the Art itself. Never- 
 theless, all sagacious and experienced minds do, in fact, arbi- 
 trate and settle it for themselves. And in so doing they hold a 
 pretty near agreement with one another. This agreement is 
 not to be put in words ; but resting in their general conceptions, 
 it is brought out and tested by practice. 
 
 To understand, then, tolerably well what is this limit of 
 practical thought in medicine, and to walk circumspectly within 
 it, is the secret of all the power we have of doing good. And 
 really that power is very great. But not to understand what it 
 is, and wander heedlessly or rashly beyond it, is the secret of 
 all that, mistaken energy of ours, which makes the evil we do 
 weigh so heavily in the scales against the good. Within this 
 limit lie all the realities of medicine, both small and great, 
 which are at present available for its use. And outside it there 
 lie other realities, which are (as it were) upon trial, and waiting 
 for proof of their use and bearing on practice, that they may 
 thereupon claim entrance and a place within it. These outside 
 realities, too, are both small and great ; many as great as any 
 which are already found within, and comprising some of the 
 
456 GENERAL EEMAEKS ON THE 
 
 highest pathological truths. Physicians, therefore, must not be 
 forbidden all interest and inquiry about things (and such things !) 
 lying at present beyond this limit of practical thought. For 
 then it would never be enlarged. Only they must be admonished, 
 in their daily work of curing and treating diseases, to keep 
 jealously within it for the sake of present safety and success. 
 
 As to the realities themselves, some are solid, substantial 
 matters of fact, and some have rather the nature of feelings, 
 qualities, powers. These two have, by philosophers, been taken 
 and studied separately, and used in acknowledged contrast. Not 
 so by physicians. Medicine has not only to do with both ; but 
 the practice of medicine is a mixture of both, bringing them 
 together, and making them harmonious and co-operative to fulfil 
 its ends. Thus they both, in their kind, claim equally the name 
 and nature of realities; and, tested by use, both have their 
 place within the just limit of practical thought. 
 
 What is disease ? and what is it not ? These interroga- 
 tories have a formidable look. They seem to threaten deep 
 thoughts about the nature of diseases, or doubtful disputes 
 about their names. But I would keep clear of such hazards, and 
 leave the nature and names of diseases where I find them. Still 
 whatever may be the compass of our knowledge, or the limit of 
 our art upon the whole, we must hold with ourselves some sort 
 of questioning and answering in particular cases " what disease 
 is, and what it is not," if we would keep in view such aims as 
 are possible in the practice of medicine ; if we would have any 
 fair understanding what it is and what it is not, which day by 
 day we pretend to cure or to treat. 
 
 Think of three, four, or five hundred cases in the several 
 hospitals of London, and of the physicians that have them 
 in charge. Those living embodiments of disease teem with 
 realities which crowd and press upon their minds, and all with 
 some show of meaning and significance. Of these they try to 
 make sober reckoning. Yet not of them all ; but only of such 
 as each physician can fairly bring within his own limit of prac- 
 tical thought. And these and only these he takes and trusts 
 for guidance and direction in the use of remedies. 
 
 But what of all the rest ? 
 
 Now, all strenuous and earnest men, let their habitual work 
 be what it may, if it have but a serious purpose, carry home 
 
PRACTICE OF MEDICINE. 457 
 
 with them plenty of matter for thought springing out of that 
 work every day of their lives. It is eminently the case with 
 physicians. And the more truly practical they are, the more 
 things they find suggested Iby their practice but lying at pre- 
 sent beyond it. Let them be sure they have done their best, 
 and that the Art itself has done its best in their hands, yet their 
 success is ever suggestive of a greater possible success beyond 
 it. From things of easy and familiar use they gather intima- 
 tion of truths which lie too deep for common observation. 
 Thus, besides turning what can be turned to the best practical 
 account according to present duty and necessity, they put by 
 facts and (it may be) thoughts for further inquiry and experi- 
 ment, and hope thereby to gain new knowledge, or new 
 adaptations of knowledge, and so render that which they haye 
 in exercise more sure and trustworthy. 
 
 But every much employed physician passes his life in the 
 midst of speculative temptations. It is not, therefore, much to 
 be wondered at that sometimes a plausible faulty theory has 
 stolen into an otherwise sound and simple mind, and got mixed 
 with its practical reckonings, and corrupted them. Without 
 much care this may happen to any of us, and we may become 
 emblems of our profession in this respect. What is too often 
 seen and lamented in individuals is to be more seen and more 
 lamented in the profession at large. A theory of easy com- 
 prehension has obtained its ready acceptance, and so has become 
 the common tyrant and impostor of medical practice, dominating 
 over it and throwing it back for half a century. 
 
 It would be well for those of our profession who have a 
 touch of intellectual vanity in their composition, to make a 
 modest compromise between it and the satisfaction of doing 
 good. On the question what disease is and what it is not, if 
 they are to answer within the limit of practical thought, they 
 must commonly keep below the mark of their knowledge, and 
 be content to speak of it truly indeed, but simply and super- 
 ficially ; while they have much more to tell which is still true, 
 but recondite and beneath the surface. It must be confessed 
 that what is very showy and creditable to possess, and to talk 
 about, and good for many worthy purposes, may not yet be good 
 for the purpose of curing and treating diseases. 
 
 Physiology, pathology, and practice, often part company just 
 
458 GENEKAL REMAKES ON THE 
 
 where an intelligent looker-on would make sure of their becom- 
 ing sociable and co-operative. The practice of medicine is a 
 perpetual compromise between what we know and what we can 
 do, between our knowledge and ouifpower. There is a portion 
 of the nervous system, a little particle of matter at the top of 
 the spinal cord, which, in a plain, intelligible sense, is the most 
 vital of the whole body. In man, and in any animal like unto 
 man, hurt it substantially and life is gone at once. This part, 
 which is pre-eminently the cord of life, and which Nature has 
 well protected from mechanical or accidental harm, she would 
 take care (one might think) to put especially within the power 
 of man to influence for good, that remedies would go directly to 
 it, and might be aimed directly at it. Not so. Remedies can- 
 not otherwise reach it than through the whole nervous system 
 ahd the entire body. 
 
 The great discovery has been made within our own times, 
 that the nerves of sensation and motion are different nerves, 
 visibly different in having distinct origins within the spinal 
 marrow, and still visibly different as they emerge from it, until 
 both are included in a common sheath, and distributed together 
 throughout the body. But this great discovery has been no 
 help to us in the choice and application of remedies. True.! 
 there is a palsy of motion and a palsy of sensation, when they 
 are distinct diseases. And there is a palsy of motion and sensa- 
 tion combined, and the disease is mixed. But whether the 
 palsy be one or the other or a combination of both, it has not, 
 therefore, its own treatment ; and remedies cannot reach either 
 order of nerves except through the entire nervous system and 
 the body at large. 
 
PBACTICE OF MEDICINE. 459' 
 
 XII. — Treatment. 
 
 EXPERIENCE. MUCH INSIGHT INTO ITS NATURE TO BE GAINED 
 
 FROM A SINGLE DISEASE AND ITS TREATMENT, ON A RETRO- 
 SPECT OF YEARS. — LET THE DISEASE BE ERYSIPELAS. 
 
 Upon the whole, men agree hetter about what is subjected to 
 the senses than about anything else ; and they agree best of all 
 about what they see with their eyes. Certainly physicians do 
 so. Show us a redness of the skin, with some degree of swell- 
 ing, and a margin irregularly circumscribed and gradually 
 enlarging itself; and at once, without doubt or disagreement, 
 we call it Erysipelas. But there are plenty of things in the 
 world which, while they are seen by all in the same light, and 
 because they are so seen, are rightly enough called by the same 
 name, have moreover a great deal belonging to them beside 
 their visible or any other sensible properties, and consequently 
 si great deal not admitting of the best agreement among men. 
 Such are pre-eminently the subjects with which physicians have 
 -to do. Physicians know Erysipelas at the first glance, and 
 agree forthwith that such it is and so it shall be called. But 
 Erysipelas includes much that lies within reach neither of the 
 sight nor any other sense ; and upon all this physicians are 
 found in no constant accord. 
 
 Wrapt up in that visible thing which we call Erysipelas, 
 there is a living thing which does not tell itself to the eye ;. 
 and yet a real thing nevertheless, pre-eminently real. For,, 
 more than all that meets the eye, it denotes the character, 
 course, tendency, and probable end of every case of Erysipelas 
 that occurs, and suggests and regulates its treatment withal. 
 This living and invisible thing is a compound of action and 
 suffering ; and this action and suffering have qualities and de- 
 grees which vary in different cases, and vary in the same case 
 from time to time. 
 
 Now, to know Erysipelas as a living disease — i.e. as a com- 
 pound of action and suffering— and to test their qualities and 
 
460 GENERAL EEMARKS ON THE 
 
 degrees, and to eaten their variations as they occur in several 
 cases or in any single case, not all the observation, thought, 
 and experiment which can be brought to bear upon the mere 
 part will help us in the least. To know the living disease, we 
 must search the whole body. "We must look for signs in the 
 Vascular system, and take note of cold, and heat, and perspira- 
 tion; for signs in the Nervous system, and have regard to 
 excitement and depression, to conscious strength and conscious 
 weakness, and to pains ; for signs in the Pulse, and count its 
 number, and reckon from day to day its varying qualities. 
 
 These are the vital ingredients of the disease, its vital histo- 
 logy, so to speak — the living web upon which it is spun, woven, 
 and held together. 
 
 Taking these elements, and reckoning the sum of them, you 
 will find that in one case they amount to strength, and in 
 another to weakness ; and that strength or weakness is the cha- 
 racteristic of the disease from first to last. In one case you will 
 find the disease implicating the Vascular system principally, and 
 in another principally the Nervous, and in another equally im- 
 plicating both. And (what is remarkable of Erysipelas beyond 
 all other diseases that can be named) you will often find in one 
 and the same case the strength of yesterday become the weakness 
 of to-day — nay, the strength of midday become weakness at 
 midnight ; and also, more than in any other disease, rapidly 
 and in a few hours the stress of the symptoms transferred from 
 the Vascular system to the Nervous, and then as rapidly trans- 
 ferred back again from the Nervous to the Vascular. The 
 more predominantly the disease is of the Vascular system, the 
 more of strength does it contain ; and the more it is of the 
 Nervous, the more of weakness ; and the more equally it is 
 shared between the two, the more manifestly is it a disease of 
 moderate force, needing moderate treatment, and involving 
 small hazard. 
 
 As to Treatment, the bare announcement of the remedies 
 severally recommended by the experience of the best physicians 
 must astonish any thoughtful mind not yet let into the secret of 
 all that is involved in practical indications. The surprise will 
 be that remedies of such power and such opposite effects should 
 ever be brought to bear successfully upon a disease of one and 
 the same name. But, in the treatment of Erysipelas, it is the 
 
PRACTICE OF MEDICINE. 461 
 
 living disease with which we have to do ; not with the mere 
 mechanism of the thing in the part from which it takes its name, 
 hut with the actions and sufferings of the entire Vascular 
 system and Nervous system, and all their possible contrarieties 
 in different cases, and all their possible shiftings and incon- 
 stancies in the same case. 
 
 Now bleeding has a right to be put down as a remedy for 
 Erysipelas, even bleeding in all the ways in which it is prac- 
 tised — venesection, cupping, leeches. And so has wine, and so 
 has ammonia, and so has any diffusible stimulant nearest at 
 hand which you choose to name. And so has tartar emetic, 
 acting according to one or other of its several modes of opera- 
 tion, whether upon the skin as a diaphoretic, or upon tho 
 stomach as an emetic, or independent of any notable effect 
 upon the skin especially or the stomach especially, controlling 
 the force and modifying the character of the pulse by its gra- 
 dually augmented doses. Opium, too, claims justly to have a 
 place among the remedies of Erysipelas, both in large doses 
 and in small, and by the several ways it has of exercising its 
 impression for good through the Nervous system ; by abating 
 pain, or by procuring sleep, or by (what can hardly be described 
 in words, and is intelligible only to practical experience) doing 
 the double office of a sedative and a tonic, and at the same time 
 quieting irritation and sustaining strength. 
 
 Oftentimes nothing more surely tests the nature of the 
 disease than the remedy that restores the man to health. But 
 then your remedy must be one of plain and unmistakeable 
 effect, and of such power that it can never be nugatory, but is 
 always either for good or for evil. Of such a stamp are the 
 remedies just mentioned — remedies which, in reviewing the 
 records of past experience, I find myself to have employed for 
 the most part in the treatment of Erysipelas, adapting them 
 (as I thought) to the calls and emergencies of particular cases, 
 and nothing doubting, then or now, of their instrumentality in 
 the restoration to health. 
 
 "Well, then, my experience for the most part would go to 
 placing Erysipelas among diseases to be treated, not among dis- 
 eases to be cured; to be managed by remedies having regard to 
 things which may chance to be in the man, not by remedies 
 proper to the disease. I say " for the most part," not alto- 
 
462 GENERAL REMARKS ON THE 
 
 getber ; for I have met with cases of Erysipelas in which I 
 have been as sure as common sense could make me that, had 
 there been no Peruvian bark in the world, the patients must 
 have died. They have been cured by quinine — cured outright, 
 and in the strictest sense, without the fulfilment of any inter* 
 mediate purpose seen, known, or aimed at, whatever. The 
 specific has even seemed to work its cure unswayed by present 
 conditions, and indifferently, whether the sum of concomitant 
 symptoms has denoted strength or weakness, and whether their 
 stress has fallen upon the vascular or upon the nervous system 
 •especially, or equally upon both. 
 
 What shall we say, then ? That when our knowledge, as it 
 were, breaks down under us, it is well to have something to 
 supply its place ? or rather, that our experience of things in 
 their detail has sometimes to give way to our experience of their 
 gross results as more trustworthy, and that laws which we 
 understand the more intimately must sometimes bend to laws 
 which we understand the less ? All this may be justly said. 
 But it does not therefore follow that our ignorance is better 
 than our knowledge, or our lesser knowledge better than our 
 greater. The truth rather is, that our common sense — i.e. our 
 prudence — sitting in judgment upon our knowledge, discerns 
 its imperfections, and decides how far it can be trusted, and how 
 far it cannot, and so finally allows free play to some secret law 
 of life which is greater and stronger than any law within the 
 reaeh of our understanding. 
 
 It would not be incorrect to state that, when>I entered the 
 profession, bark was regarded by all physicians of mature age 
 and experience as aspecific for Erysipelas. The majoritv would 
 not have hesitated so to call it ; and the rest, without professing 
 .a faith thus absolute, would have been sorry to hold themselves 
 responsible for what might happen if in any case they omitted 
 its use. Surely my own experience has not run parallel with 
 theirs ; and what I have said of it may be taken fairly to repre- 
 sent the experience of physicians practising in London during 
 my time. 
 
 But how are we to be just to the experience of others ? 
 Even by making a fair reckoning of our own. Eemember there 
 is a secret inscrutable region wherein the things belonging to 
 health and to disease are largely transacted, and wherein causes 
 
PRACTICE OP MEDICINE. 463 
 
 are vitally at work into which we have no insight. Our ex- 
 perience, therefore, must be left very free ; for it cannot be 
 fettered by any known rule. It must needs be our guide and 
 master, but not in such sort that the greater experience should 
 always tyrannise over the less. The less contains its own truth, 
 as well as the greater. The greater need not convict the less of 
 falsehood. My own far greater experience represents Erysi- 
 pelas as a disease to be treated ; my far less experience, as a 
 disease to be cured. The first is conversant with very many 
 realities of things, and familiarises me with their use. The last 
 brings fewer realities within my view ; but, fewer as they are, 
 they are certain. Therefore it is not thrown away ; at least, it 
 is largely suggestive of what is possible. And no man can have 
 grown old in the practice of medicine, and not allow that things 
 which he once looked upon as barely possible have become with 
 him frequent realities at some after time. His rarer and his 
 more common experience have changed places altogether. 
 
 "Wherefore then serveth experience, and of what use is it ? 
 Its first and best use is for the guidance of him that has it. Its 
 next, and hardly less important use, is that it enables him to 
 judge rightly the experience of others. And this is the fair 
 reckoning by which to judge it. If, at the same place, our own 
 experience has differed from itself from time to time, surely it 
 is abundantly credible that another's may differ from ours often 
 or always, at other times, or at other places. 
 
 I am not of the number of those who rest in a self-satisfied 
 belief that diseases never were, never will, and never can be, 
 other than I have seen them ; and that they never were, will, or 
 can be, successfully treated or cured, otherwise than I have 
 treated or cured them. The physicians of one time have been 
 too prone to make a mock of what was deemed the sound prac- 
 tice of another. This is neither generous nor wise. 
 
 But I wish to make a still larger use of this instance of 
 Erysipelas in showing what the practice of medicine really is; 
 its differences and contrarieties in the same diseases ; its trust 
 in remedies of opposite effects ; now in treatment, now in cure, 
 now in non-specifics, now in specifics ; and in showing, never- 
 theless, that the practice of medicine is a rational practice. 
 
 The vital pathology of Erysipelas, regarded as a disease of 
 individual men, is full enough of conditions to account for the 
 
464 GENERAL REMARKS ON THE 
 
 success of many and various ways of dealing with it. Erysi- 
 pelas, however, has a vital pathology, I will not say of another 
 kind, but reflected from another aspect ; viz. from its natural 
 history. For every disease has its own place, kindred, and 
 relationships, near and remote, among the whole family of 
 diseases belonging to mankind. And so has Erysipelas. This 
 may be called their natural history. And the same is the natural 
 history of Erysipelas ; and wrapt up with it is a portion of its 
 vital pathology, as important and as suggestive, from time to time, 
 of its right treatment, as present conditions of individual men. 
 
 Now, the great physician found in Erysipelas the marks 
 characteristic of what he called an intercurrent disease. Its 
 cause might be purely accidental and from without, from ex- 
 posure to cold, or exposure to heat, or from mechanical injury. 
 Yet once formed, in its measure of fever, its strength or its 
 weakness, its excitement or depression, it ran parallel with the 
 stationary or dominant epidemic, and its successful management 
 was in nothing different from the management which the 
 epidemic demanded. Thus, in what it was pathologically, and 
 in what it needed, and what it could bear remedially, Ery- 
 sipelas was of close vital kindred with it. 
 
 Again, Sydenham put down Erysipelas as a disease which 
 was intercurrent, coming on in this way. And yet, there would 
 be no Erysipelas, but there would be fever, which was in 
 nothing different from the dominant epidemic. And when it 
 had continued for a few days, and been regarded as the epi- 
 demic itself, and nothing more, Erysipelas would be added to 
 it, and be, as it were, among its accidents ; and no other treat- 
 ment would be required of the whole disease than if Erysipelas 
 had formed no part of it, and no treatment of the Erysipelas, 
 but what was included in the treatment of the whole disease. 
 
 Perhaps Erysipelas may serve for the most signal example 
 of all that is most mutable in diseases, from whatever point of 
 view you regard them. If you want the best representative of 
 all that the different constitutions of men can do in diversifying 
 the aspect of diseases, you will find it in Erysipelas. If of 
 what times and places can do, you have it in Erysipelas. If 
 of how opposite remedies can save life and restore to health 
 from the same diseases, according to times, places, and men, 
 you have it in Erysipelas. 
 
PRACTICE OF MEDICINE. 465 
 
 XIII. — Treatment. 
 
 DIFFICULTIES AND ANOMALIES OF PRACTICAL EXPERIENCE. 
 
 EvpKJxov 6 larpos epaTr)9ev5 tov hihacricaXov, trap a> eiraiBevOrj, 
 irapa rq> "Xpova, e<fn}. (Stobei.) This being interpreted means, 
 " Euriphon the Physician, being asked what preceptor had the 
 teaching of him, made answer that his preceptor was Time." 
 These words are quoted by Dr. Heberden, and stand the last of 
 his Commentary on the History and Cure of Diseases. Dr. 
 Heberden's volume contains the condensed experience of his 
 life carried on to his seventy-second year, and left by him for 
 publication after his death. ' He lived until he was ninety. In 
 this remarkable work the preceptor Time is plainly seen ruling 
 and guiding throughout. 
 
 And time keeps school among physicians still. But he is 
 not, and never was, a popular lecturer. He is slow in coming 
 to the point. He has a cautious, hesitating, self-correcting 
 manner, which is not altogether pleasant, and makes him 
 difficult to follow. Hence a good deal more patience is required 
 to understand his teaching, and profit by it, than most men 
 care to give. That his disciples should value highly what 
 their venerable preceptor has hammered into them is natural 
 enough. But then they are themselves few and grey-headed, 
 and have often caught something of their master's manner, and 
 so do not obtain a ready ear from the world. And I can hardly 
 expect a better success than the rest while I rehearse some of 
 the leadings or misleadings, the teachings, and corrections of 
 my preceptor Time. 
 
 Nothing is so difficult to deal with as a man's own Ex- 
 perience, how to value it according to its amount, what to con- 
 clude from it, and how to use it and do good with it. 
 
 I had been physician to St. Bartholomew's Hospital eight 
 years, and eight years previously physician to the Middlesex, 
 ■when I ventured to write a book ; bestowing upon it as much 
 
 EH 
 
466 GENERAL REMARKS ON THE 
 
 care and thought as I was capable of. Indeed, it cost me a 
 world of labour, and, at least it was honestly done. This book 
 contained my own sixteen years' Experience of Fever, and 
 what conclusions as to its nature and treatment that Experience 
 would (I thought) fairly sustain ; and I was not without a 
 reasonable confidence in their truth. 
 
 Fever in those days, written or spoken of singly and without 
 adjunct of any sort before or after, stood for an idiopathic 
 disease. Gaining, however, an accession of many and evil things 
 in its progress, it became a fearful complexity ; and earned, 
 before it came to an end, the name of Synocha, Synochus, or 
 Typhus, as the case might be, but without prejudice to its ori- 
 ginal idiopathic rights. 
 
 It was Fever regarded from this point of view that I under- 
 took to write about. But my book never saw the light. For 
 abruptly, or within the short space of a year or two, all that 
 was called Fever suffered the nature of a revolution, and so did 
 its Treatment. What was life and safety to Fever, as it had 
 been, became death and destruction to Fever as it was. Pre- 
 sent Experience was in conflict with past. And my poor work, 
 with its truths, its beliefs, its opinions (call them what you will),- 
 all rudely shocked and scattered, was ashamed to show itself, 
 and so came to an end. It was a sort of violent end it came to. 
 It seemed as if some force (for such forces there are) indwelling- 
 in the nature of things, but latent, and so unseen and un- 
 reckoned upon, had suddenly come into action and demolished 
 it; just as one's foot demolishes an ant-hill, scattering the- 
 population within, and bringing ruin upon all its toil, and all 
 its instinctive wisdom, and the fruits thereof, in a moment. 
 
 We physicians had need be a self-confronting and a self- 
 reproving race ; for we must be ready, without fear or favour, 
 to call in question our own Experience and to judge it justly ; 
 to confirm it, to repeal it, to reverse it, to set up the new against 
 the old, and again to reinstate the old and give it preponder- 
 ance over the new. 
 
 Belief, opinion, truth ! When we cast up the sum of a long 
 Experience, by which of these names shall we call it ? Its 
 subject is one of the worthiest, even nothing less than the life 
 and well-being of man. Let it then be spoken of in the hand- 
 somest terms it deserves. And it is hard if there be not some- 
 
PRACTICE OF MEDICINE. 467 
 
 thing in the results of Experience that is worth the name of 
 Truth. But then it is an infirmity of men, finding a fragment 
 of Truth, to take it for the whole Truth ; or, intent upon what 
 may well pass for Truth now and for a few years to come, to 
 account it the Truth which stands fast for ever and ever. We 
 must be cautious, then, not to deceive ourselves, or take the 
 Truth there is in the practice of medicine for what it is not. If 
 what can he apprehended by fragments but not completely, if 
 what lasts safe and sure and trustworthy for times and seasons 
 but not for ever, can be called Truth, this is the Truth, which 
 is vouchsafed us to know and to use in the practice of medi- 
 cine, and this only. And we must make the best of it, and be 
 content. 
 
 Wow, my own sixteen years' Experience of Fever and febrile 
 diseases and of their treatment, may be taken as a fair sample 
 of what medical Experience really is. It was no fable, but 
 made up of undeniable matters of fact. Time went on, and 
 proved them more and more, and showed them still consistent 
 and trustworthy. And they were trusted accordingly, and the 
 practice grounded upon them had abundant success. But the 
 facts were constant and consistent only for their own season. 
 They did not hold together long enough (for what is sixteen years 
 after all ?) to become one solid Truth. They were but frag- 
 ments of Truth after all. Yet, fragments as they were, they 
 were not worthless. They go to make up my stock of good 
 working materials, and are still of use to me every day. They 
 do not serve me for building systems. But they help me to 
 treat diseases and to save lives. 
 
 How is it that in medicine Truth is thus measured out to us 
 in fragments, and we are never put in trust of it as a whole ? 
 How is it that Experience, upon which alone we can depend for 
 all the good we do, is continually breaking down under us as a 
 system ? 
 
 Well, one cannot indeed account for it; but one is not 
 surprised that so it should be. What with inscrutable things 
 within the body and inscrutable things without, and incalculable 
 and incontrollable withal, it is no wonder that Experience 
 should sometimes find itself at fault, and be not always able to 
 shape the future out of the past upon a large scale. 
 
 The one fact has been already noticed, of things within the 
 
468 GENERAL REMARKS ON THE 
 
 body belonging to life and health and disease, which are hither- 
 to untouched by human knowledge. All medicines give inti- 
 mation of it more or less in the course of their operation. 
 Specifics present summary proof of it from first to last. 
 
 The other fact, too, deserves to be well pondered, of forces 
 without the body exercising dominion over all that is vital , 
 within it — forces of some of which we know neither what they 
 are nor whence they come. But they are full of reality and 
 power. 
 
 On my first entrance into my profession, and for some time 
 afterwards, nothing was less intelligible to me than the writings 
 of our great Physician. All his discoursings about epidemic 
 constitutions, and stationary fevers, and intercurrent diseases, 
 and the same diseases needing different treatments from time 
 to time, were to me dark and mysterious. And just the same, 
 I am persuaded, is the case with every man who studies medicine ; 
 and the more so, the more he finds himself thus early in the 
 presence of real disease, and in the society of those who, like 
 himself, are daily watching it, and ministering to it, and com- 
 paring notes about it. For then the mind is at its freshest and 
 its best, and is most apt for observation. It holds strongly to 
 its own conclusions : and why should it not ? It takes for 
 absolute truth what has already come to it authenticated by a 
 hundred instances : and why should it not ? It is not yet upon 
 the look-out for what may gainsay or invalidate its own well- 
 observed facts concerning diseases and remedies : why should 
 it ? Tell, therefore, the student and the physician of a few 
 years' standing, that there is something more in diseases, and in 
 the effects of remedies upon them, than can be seen and known 
 from any number of individual patients during any given 
 period of time ; and he will neither understand you nor believe 
 you. Yet there is something more, nevertheless ; and phy- 
 sicians at length come to own it. 
 
 Choose almost any febrile disease you please, and question 
 the Experience of honest and well-informed physicians about it, 
 and what it was, and how it was best treated at their own time 
 and place of observation ; and you will find them tolerably well 
 agreed. But take this Experience and agreement of theirs to 
 determine its nature absolutely, and fix the canon of its treat- 
 ment for all places and all times ; and you will run into a great 
 
PRACTICE OF MEDICINE. 469 
 
 practical delusion. Still a man must have lived long enough 
 to see many phases of medical practice, and teen himself 
 engaged in it all the while, before he can be in a condition freely 
 to acknowledge what is here implied. 
 
 Take Pneumonia. It has been treated by bleeding, and got 
 well. It has been treated by brandy, and got well. It has 
 been left to itself, and got well. And the bleeders, the brandy- 
 givers, and the doers of nothing at all, respectively have had a 
 vast deal to say for themselves and against their rivals. And 
 which of them are to be our guides and masters in the Treat- 
 ment of Pneumonia ? None of them for a single day, much 
 less for always. Besides, the Treatment of Pneumonia happens 
 just now to be a matter of high controversy ; and from con- 
 troversy often comes exaggeration. And exaggeration often 
 does the work of falsehood unawares. Therefore I would will- 
 ingly have chosen some other instance, but that I wanted such 
 internal febrile disease for illustrating my purpose, as, whenever 
 it exists, declares itself infallibly. And, since Erysipelas well 
 served my purpose, because all about it was plain and unmis- 
 takeable to the eye ; so now Pneumonia will do the same, because, 
 of internal diseases, it and all about it are best ascertained by 
 the ear. 
 
 Now, we have the best testimony which the ear can afford 
 to the fact that Pneumonia has gone through all its processes 
 of disease and reparation, now advancing, now receding, until 
 the lungs have finally recovered the conditions of health, when 
 it had received no formal medical treatment whatever. Again, 
 we have the sure witness of the ear to the same fact, when the 
 Pneumonia had been treated by brandy ; and yet again to the 
 same fact when it had been treated by venesection. 
 
 Sere the means (for even the doing of nothing may now be 
 deemed to exercise a positive influence) — the means, I say, and 
 the end, are things so obvious, and are found so closely follow- 
 ing each other, that it is impossible not to put down their 
 sequence to the account of natural connexion. And this being 
 the case, and there being such vast odds between doing nothing, 
 giving brandy, and drawing blood, there is no wonder, if the 
 current of a man's Experience had run generally in favour of 
 any one of the three, that he should hold one to be absolutely 
 and always right, and the other two absolutely and always 
 wrong. 
 
470 GENERAL REMARKS ON THE 
 
 No wonder, indeed. But then practical medicine is unlike 
 all other things in the world. It has its own conditions ; and 
 they prohibit all such summary conclusions as these. Let a man 
 use his own Experience as best he can for the present ; but let 
 him not, upon the strength of it, rebuke the Experience of all 
 past times, and dictate to the Experience of all future ; for, if 
 he live long enough, nothing is more likely than that he may 
 find himself fallen under his own reproof, and inconveniently 
 confronted by his own maxims. From having been a bleeder, 
 he may become a stimulator or a passive looker-on in cases of 
 Pneumonia. He may find himself interchangeably all three 
 in the course of thirty years. 
 
 And what is the explanation of all this ? People not over 
 well disposed towards us and our profession (and there are many 
 such) find a sufficient key to the whole matter in the caprice of 
 medical men ; and they take this key of theirs, and turn the 
 lock, and bar the door against all further question ! " It is 
 neither more nor less," say they, " than the caprice of phy- 
 sicians ; so let us have done with it and them." 
 
 But let the world think of us as it pleases, there is a 
 rational practice of Medicine nevertheless. And let medical 
 men themselves still be right and wrong by turns, seeing 
 clearly and doing successfully what is at present to be seen and 
 done, yet mistaking the same for something more sure and 
 permanent than it really is ; finding (as it were) a fragment of 
 truth, and learning well what it will now bear, and now safely 
 trusting their own weight upon it, let them foolishly deem it a 
 rock and build a castle upon it. Whatever .physicians may be, 
 or the world may think of them, there is, I say, a rational 
 practice of Medicine nevertheless, and there are causes sufficient 
 to explain its greatest anomalies. A cursory glance can only 
 here be given at what these causes are. 
 
 The vital being of every individual man has its qualities. 
 What is summarily called his Constitution is full enough of its 
 own conditions to require in almost every case some deviation 
 from the standard treatment of the particular disease. Not 
 seldom are these conditions sufficient to justify great differences, 
 and even contrarieties, in practice. They are never to be lost 
 sight of at the bedside of the patient ; and we consider our- 
 selves as never practising more rationally than when we prac- 
 tise in obedience to them. 
 
PKACTICE OP MEDICINE. 471 
 
 Then there are the things which are the commonest and the 
 most inconstant in the world, yet which do and must surround 
 every man as long as he lives ; cold and heat, moist and dry, 
 dense and rare, foul and fair. All these reach and rule and 
 qualify the vital being of us all, and so vary the aspect of our 
 ■diseases and necessitate changes in their methods of Treatment. 
 Here is the very subject which in our own times has especially 
 attracted the interest of the world at large ; viz. the influence, 
 upon the well-being of mankind, of the air which they breathe 
 and the places where they dwell. Governments, military and 
 civil, national and municipal and domestic, have expended 
 abundance of study and labour and money upon it ; yet not 
 more than it deserves. Practically, what physicians have to do 
 with the subject may lie in a small compass and be reckoned by 
 -a few items, or it may expand itself infinitely, and run into 
 particulars innumerable. Our patient may be an individual, a 
 family, a community, or an army. Our concern may be with 
 the cleanliness and ventilation of a single room, the drainage 
 of a town, or the site of an encampment. 
 
 It is difficult to speak rightly of things which have no body 
 or form presentable to the senses. But we must speak of them, 
 and dwell upon them. Though we know hardly by what name 
 to call them, they cannot be ignored ; for they have oftentimes 
 a greater sway over the world without and the world within us, 
 than all things of substantial being put together. 
 
 Now, bearing upon diseases and upon their medical manage- 
 ment, there is a certain thing which I have thus far designedly 
 suppressed; for I was afraid of darkening the subject with a 
 mystery, and so I kept it out of sight. But this mystery is a 
 truth. Mystery indeed it is to us, for we know neither what it 
 is nor whence it is ; but it demands notice from its effects, 
 which are full of reality and power. It has been called the 
 " Epidemic Constitution " of certain years, or series of years. 
 And so let it still be called, rather than by any name of more 
 scientific pretensions. For it intimates nothing of the nature 
 of the thing itself. But it acknowledges a reality and a power- 
 This is enough. 
 
 The most eminent characteristic of this "Epidemic Con- 
 stitution " is its levelling influence. "Where it exists, and as 
 long as it lasts, it subdues into conformity with itself all that is 
 
472 GENERAL REMARKS ON THE 
 
 peculiar to the individual man's Constitution, as well as peculiar 
 to places and external things. These, which are wont to be so 
 potent in modifying the forms of diseases and ruling and quali- 
 fying their treatment, now disappoint our reckoning. Behold, 
 for a season mankind in various places and circumstances require 
 a Treatment for their diseases contradictory to the experience of 
 former times. Then wait for a season, and behold, mankind, in 
 the same places, and in the same external circumstances, will 
 require a Treatment for the same diseases contradictory to the 
 Experience of the present times. But neither now, nor for- 
 merly, nor hereafter, will there be found in the vital being of 
 men themselves, in their places or circumstances, anything to 
 reconcile the contradictions or at all explain them. 
 
 But it is not only that diseases, having this, that, or any 
 name, are rendered severally unlike themselves of other times 
 by the Treatment which they now need and bear. This, 
 indeed, would show an agency at work of great power — an 
 agency, however, only of special and partial bearing. But 
 these same diseases, which are thus made severally unlike 
 themselves as they were at other times, become all like one 
 another as they are at the present, by reason of the need they 
 have of now receiving, and their capacity of now bearing, the 
 same or similar modes of Treatment. 
 
 Thus febrile diseases — diseases, I mean, which require Fever 
 for their development, and which altogether make up a large 
 number of the sum total of all that flesh is heir to — become 
 types and tests and interpreters of one another at the times 
 wherein they are found, in what concerns their Treatment. 
 Thus all so-called inflammations, in every part of the body, also 
 diseases the products of different contagions and contrasted in 
 their outward forms of presentment, and so bearing different 
 names — Measles and Scarlatina, the Typhoid Typhus-Fevers — 
 all give and take, impart and accept illustration mutually and 
 interchangeably. You read them through one another. In 
 treating one you learn to treat another. What one needs and 
 bears, another needs and bears. These are facts of great 
 significance. They seem to point to some one wide- spreading 
 and pervasive influence ruling and dominating over them all 
 alike. 
 
 But do the diseases named denote the limit of the influence 
 
PRACTICE OP MEDICINE. 473 
 
 in question ? I believe that it may be traced much further. I 
 believe that even those diseases which more than others are 
 proper to the individual man, traceable to what he eats and 
 drinks, or does and endures, such as gout when it is a febrile 
 disease, the gout of distinct attacks and paroxysms, even they 
 often own subjection to times and seasons. Now for a series of 
 years the indications, which guide the treatment of particular 
 cases, will generally demand remedies of greater power and of 
 one kind ; and then for a series of years the indications will 
 generally be satisfied with remedies of less power, and of 
 another kind. But only let present indications be justly chosen, 
 and fulfilled according to a fit measure, and then the Treatment 
 which they suggest, while it is variable at different times, will 
 be at all times uniform in its success. 
 
474 GENERAL REMARKS ON THE 
 
 XIV.— Pain. 
 
 WHAT IS PAIN? IT MAY KILL. ITS RELATION TO DISEASES 
 
 VARIOUS. PAIN SOMETIMES A DIRECT INDICATION OF TREAT- 
 MENT. SOMETIMES NOT. 
 
 It would be a great thing to understand Pain in all its mean- 
 ings. To understand it, first of all, in its largest or universal 
 meaning; what it is in its own nature; how allied to the 
 various morbid states and conditions in which it is found, how 
 formed by them, how evolved from them. Then to understand 
 it in its diagnostic meaning, as a symptom for practical use ; 
 how it serves to interpret the seat and the kind of any present 
 disease. And then to understand it in its therapeutic meaning, 
 as a symptom for the most practical use of all ; how it may be 
 taken to indicate the choice of remedies, and to direct their 
 application and their aim. 
 
 An immense field of inquiry is thus opened to us. And, 
 indeed, it would be an affair of high philosophy to expatiate 
 worthily upon every part of it. But I come to the subject in 
 the temper of one who witnesses Pain under the constant 
 obligation of doing the best he can to mitigate or abolish it. 
 Therefore I must be pardoned for passing briefly and lightly 
 over much that presents itself of great speculative interest, if I 
 can but convey to practical minds some just notion of what 
 Pain is in relation to disease, and of its value and bearing as an 
 indication of treatment. There are, however, a few general 
 remarks which I first desire to make. 
 
 To anyone who should insist upon its being stated in terms 
 what Pain is, it would, I hold, be a sufficient answer to say, 
 that he knew himself perfectly well what it was already, and 
 that he could not know it the better for any words in which it 
 •could be defined. Things which all men know infallibly by 
 their own perceptive experience, cannot be made plainer by 
 words. Therefore, let Pain be spoken of simply as Pain. 
 
 Again, of the things which belong to simple perception, 
 
PRACTICE OF MEDICINE. 475 
 
 ihere is a wonderful agreement among mankind, as long as we 
 -are content not to talk too much or too curiously about them. 
 If we do, people get doubting and misunderstanding their own 
 feelings. And this is another reason for speaking of Pain 
 simply as Pain. It is safer to appeal to men's perceptions than 
 to their logic. 
 
 But, while upon these pleas, we are very fairly let off from 
 defining Pain ; we may perhaps he further admonished not to 
 make it appear other than it really is, by the mode we speak of 
 it. This, however, is a rather difficult business. Natural 
 sensation suffers offence from some cause or other ; and here- 
 upon it is altered, raised, exasperated, and so it becomes Pain ; 
 but it is sensation still, and nothing more. Nevertheless, it is 
 and always will be something more in common apprehension. 
 No man, wise or foolish, ever suffered Pain, who did not invest 
 it with a quasi materialism. I have known many a philosopher, 
 outreasoned by his feelings, take to rating and chiding his Pain, 
 as if it were an entity or quiddity of itself. Really, for prac- 
 tical purposes, we must often let people think and speak of 
 things as they seem to be, and not as they are, making a com- 
 promise between philosophy and common sense. We must let 
 them so speak of Pain. There is no help for it. 
 
 These are some of the considerations, interesting and 
 puzzling at the same time, which are apt to occur to us when 
 we think of Pain in the abstract. But let us now suppose 
 ourselves at the bedside and within hearing, when Pain raises 
 its cry of importunate reality. And the first thing to be 
 noticed is the difficulty we have in judging of Pain as a 
 symptom which we do not find in respect of other symptoms. 
 The fact of pain being suffered at all must always be taken on 
 the patient's own showing. For there is such a thing as 
 shamming Pain. Then, admitting our patient honest and his 
 Pain real, how are we to make sure of its degree ? Its degree 
 cannot safely be reckoned according to the patient's own esti- 
 mate of it. Some make much of a little, and some make nothing 
 -of a great deal. Pain, indeed, has or seems to have its many 
 •degrees, and its extremes of small and great. There is a Pain 
 which barely disturbs the complacency of a child, and a pain 
 which is too much for the strength of a giant. But are these 
 xeally the same in kind, and different only in degree ? Does 
 
476 GENERAL REMARKS ON THE 
 
 the smallest Pain contain all that essentially belongs to the 
 greatest, as the minutest atoms of matter have separately the 
 same properties as their largest aggregates ? Familiar language 
 would seem to attest the common belief that it does. But 
 small and great are spoken of Pain as in a figure. They belong 
 primarily to things of bulk and substance. But the things of 
 life and feeling are different from all things in the world beside. 
 They can neither be weighed in a balance nor made to give 
 answer of what they are to tests and reagents. Pain, itself a 
 thing of life, can only be tested by its effects upon life, and the 
 functions of life. And whether it be small or great (so to 
 speak), or of whatever degree, it is to its effect upon life and 
 the functions of life that we must look, if we would know the 
 part it acts pathologically, and what it requires remedially in 
 individual cases. 
 
 Playing upon the nerves as upon an instrument, the force 
 which Pain can exercise over the movements of disease is very 
 various. It can raise, and it can depress them. It can quicken 
 them into twofold activity and liveliness, and it can subdue and 
 bring them down as low as death. Moreover, still playing 
 upon the nerves, it can so jar and spoil the concord of symptoms 
 as to falsify the disease, and make it appear other than it 
 really is. 
 
 In such manner, rather than by complaint of the patient, 
 does Pain tell itself and its amount of great and small to the 
 reckoning of the physician. 
 
 Pain may kill. It may overwhelm the nervous system by 
 its mere magnitude and duration. 
 
 A poor fellow had suffered painter's colic for several days> 
 when, by the use of certain remedies which he took, his bowels- 
 were scantily opened, and the Pain subsided. In a few days, 
 however, the bowels became again constipated, and the Pain 
 returned with more severity than ever. Then it was that he 
 was admitted into the hospital under my care. I ordered him 
 warm bath and laudanum. The next day, at my visit, the 
 Pain was unabated, and the constipation remained. I did not 
 omit to examine the abdomen carefully. I made equable 
 pressure upon it with both my hands, and almost with the 
 whole weight of my body ; and, as long as that pressure was 
 continued, he experienced relief. In the course of this day, he 
 
PRACTICE OF MEDICINE. 477 
 
 went several times into the warm bath. "While he was in it, 
 his Pain ceased ; hut it returned as soon as he was removed to 
 his bed again. The constipation was not yet overcome. In 
 the course of the night, he became first cold, then delirious, 
 then pulseless, then insensible; then he vomited some dark 
 fluid, and then he died. 
 
 Upon examination of the body, neither within the abdomen 
 nor elsewhere did any visible appearance of disease present 
 itself to which his death could be attributed. There can be no 
 ■doubt, I presume, that the man was killed by Pain, and died 
 from exhaustion of his nervous system. 
 
 In vol. xiv. of the Medical Gazette, Dr. Borrett reports the 
 case of a lady who died from the Pain of gall-stones. Her 
 nervous system was overwhelmed by the agony arising from a 
 gall-stone impacted in the cystic duct. After continued suffer- 
 ing for sixty hours, she became cold and pulseless and delirious, 
 and so died. After death, nothing was found to account for it 
 but this gall-stone. 
 
 In Dr. Merriman's Synopsis of the Various Kinds of Difficult 
 ^Parturition is a case, furnished by Dr. Gooch, of a woman in 
 whom the severest Pain and the most violent expulsive efforts 
 still continued after the child was born, until she became cold 
 and delirious, and her pulse gradually went out, and she died. 
 After death, the Pain and the expulsive efforts were found to be 
 ■owing to a polypus, which had its attachment to the mouth and 
 some way up within the neck of the uterus. Dr. Gooch remarks 
 upon the case " as a striking proof that mere Pain can destroy 
 life." 
 
 There is an eminent instance of death from Pain — death by 
 •excitement and torture of the nervous system, followed by its 
 fatal exhaustion, to which I will just allude. Perhaps it has 
 •often occurred to many minds. 
 
 In all civilised nations calling themselves Christian, capital 
 •punishments are now so contrived that death should result from 
 a sudden arrest being put to the functions of an organ essential 
 to life, and thus the criminal be mercifully spared (as far as 
 possible) the pains of dying. But there was once a manner of 
 ■capital punishment, esteemed the most ignominious, and reserved 
 for the most criminal, which, when the Roman empire became 
 nominally Christian, Constantine thought fit to abolish ; I mean 
 
478 GENERAL REMARKS ON THE 
 
 crucifixion. It is obvious that crucifixion did not at once put & 
 stop to any vital function, but brought on death by pure, 
 unmixed, protracted torture. The victim died from slow ex- 
 haustion of the nervous system by Pain. 
 
 " It was the third hour, and they crucified Him. And when 
 the sixth hour was come, there was darkness over the whole- 
 land until the ninth hour. And at the ninth hour, Jesus cried 
 with a loud voice, and gave up the ghost." (Mark xv. 25, 33,. 
 34, 37.) 
 
 Six long hours of dying agony ! The thought is very 
 awful. 
 
 In that complex of action and suffering which belongs to- 
 injury and disease, small things and great, accidents and 
 essentials, are often so crowded together as to defy analysis, and 
 causes and effects get so mixed that one can hardly tell which 
 is which. Therefore it is an occurrence to be made much of, 
 when some great fact stands out and claims its sure and unmis- 
 takeable agency in the great result. Here we have Pain and 
 Death, and the sure connexion between them. And the rare 
 and extraordinary cases, displaying the connexion, have their 
 value mainly in this, that they show what, under given con- 
 ditions, is possible, though it seldom come to pass. The result,., 
 complete and accomplished in the few, denotes the tendency 
 which is wrapt up in the many ; even the tendency of Pain to 
 death, ever working towards it, and often making near ap- 
 proaches to it, but seldom arriving at it. 
 
 From the same or the like causes as the Pain that kills alstt 
 comes the Pain that brings to the verge of death, and yet 
 allows to live — from hepatic, renal, and vesical calculi — from 
 morbid growths involving nerves — from some forms of colic. 
 Pain from all these can produce the cold skin, the collapsed 
 features, and the failing pulse. And when it does, who can 
 mistake their meaning ? Who can doubt what should be the 
 treatment ? The parts are various ; the present actuating 
 causes are various. But Pain is the common adjunct of them 
 all ; and so crying and so urgent as now to become practically 
 in each case the representative of the whole malady — the sole 
 indication of treatment, superseding and excluding all other 
 indications for the time. 
 
 In this range of cases, the whole business of the physician 
 
PRACTICE OF MEDICINE. 479 
 
 is with the nervous system. All the power and all the ex- 
 pedients of his art are needed to lull it, and, if possible, to lay 
 it to sleep in its agony, and at the same time to hold it up m its 
 weakness, and prevent it from sinking into death. 
 
 But let us fully understand what it is that we do, and what 
 it is that we do not do, in such cases, by administering exclu- 
 sively to the pain. "We abate an accident, but we do not cure 
 a disease. The disease remains ; if curable, to be cured by other 
 treatment ; if incurable and uncured, to have the same Pain 
 engrafted upon it on a future day. The Pain is neither more 
 nor less than an accident resulting from the mere mechanism 
 of the parts, which renders them obnoxious to suffer offence 
 from foreign bodies within them or about them. The foreign 
 bodies happen to be the products of diseases within the body 
 itself; and the parts are affected by them not otherwise than 
 they would be by foreign bodies introduced from without. 
 
 But, in the vast majority of cases to which Pain belongs, it 
 is no superadded accident, but a true part of the disease. It is 
 involved in the morbid processes going on. It grows out of 
 them, and is sustained by them, and lasts as long as they last. 
 
 Now the Pain which waits upon the essential movements of 
 disease would be a pretty large theme to discourse about com- 
 prehensively, and too much for our present purpose. The view 
 we now take can only be partial, but it need not be erroneous. 
 
 Whatever sick-bed we stand by, and hear severe Pain com- 
 plained of, and find it the accompaniment of febrile or sudden 
 or rapidly progressive disease, we must not leave that bedside 
 until we have satisfied ourselves whether anything, or what, is 
 to be done expressly for the Pain. The result may be, either 
 that we altogether decline to meddle with it, or that we make 
 it our chief indication of treatment ; but not without due- 
 deliberation in either case. 
 
 What a crowd of symptoms go to make-up that best known 
 and most distressing of all remediable maladies, the sick head- 
 ache ! I mean the thing which is acute and occurs in paroxysms. 
 And the symptom which takes the lead of them all is the Pain- 
 Yet, when we come to treat the disease, we seek no direct 
 remedy for the Pain as such. Experience has warned us that 
 thus neither would the Pain itself receive any mitigation, nor 
 the whole malady be advanced towards its cure in the least 
 
480 GENERAL REMARKS ON THE 
 
 degree. Symptoms there are, besides, pointing to those organs 
 of the body which are above all others within the reach of 
 remedies — to the stomach, and bowels, and liver, and imputing 
 to them scanty, torpid, or disordered functions. Accordingly, 
 our trust is in medicines addressed to them, and not in opium. 
 And, the pain being thus got rid of, we do not merely abate an 
 accident, we remedy a disease. The entire complex disease is 
 swept away, and the Pain inclusively. True, the same patient 
 may have the same sort of Pain again ; but then he must first 
 have the same disease. 
 
 But have we here a constant rule of practice ? Whenever 
 (to re-state the premises) Pain is involved in the morbid pro- 
 cesses going on, growing out of them, sustained by them, and 
 lasting as long as they last, can it be laid down as a principle 
 that it does not need a remedy for itself ; but has its treatment 
 always included in the right treatment of the parent disease ? 
 Indeed, it cannot be absolutely so laid down. The duration of 
 the disease and of the Pain, as a part of it, according as it is 
 long or short, must guide the judgment what to do, or what to 
 abstain from doing, in respect of the particular symptom. In 
 the cases just referred to, the disease is short. The pain, severe 
 as it is, is endurable, while the disease runs its brief course and 
 hastens to its end. 
 
 But there is still a wide range of cases equally displaying 
 the subjection of the Pain, as in its nature so in its treatment, 
 to the nature and treatment of the disease ; equally showing the 
 final cessation of the one dependent upon the cessation of the 
 other, yet urgently calling in the meantime for something to be 
 done specially for the Pain, for the sake of present palliation 
 and relief. And it is still the duration of the disease which 
 compels this practice too. But now its duration is long (it may 
 be), very long, while the pain being severe (it may be), very 
 severe, cannot be borne, until the disease has accomplished its 
 entire course and brought itself to an end. 
 
 Take a severe attack of acute Rheumatism in a man pre- 
 viously healthy and at the prime of life. There are extreme 
 force of vascular action, extreme heat, profuse perspiration, 
 swelling of many joints simultaneously, and Pain, which is 
 agonising and unremitting. 
 
 Now, if this disease had a certain stated period to run, and 
 
PRACTICE OP MEDICINE. 481 
 
 that a short one ; if it could be trusted to come to an end, or to 
 conditions of sure mitigation in two or three days ; then we 
 might he content to treat it as a whole, and need not be fear- 
 fully calculating the tendency of its particular symptoms, or 
 seeking remedies for them ; we need not be making much of, 
 and be specially treating, its Pain. Pain, severe though it be, 
 so long as the nervous system bears it well and reacts upon it, 
 may add celerity and force to the existing disease ; it may 
 quicken and invigorate all its actions, without disturbing their 
 natural course and harmony. 
 
 But acute Rheumatism has no stated period to run. It is 
 oftener long than short ; oftener an affair of weeks than of days. 
 And Pain is its accompaniment from first to last ; Pain (it may 
 be) of the greatest severity, and such as the nervous system 
 cannot long continue to bear well and to react upon. Two or 
 three nights and days made sleepless by Paiu tell fearfully 
 through the nervous system upon the whole bearing of the dis- 
 ease. In proportion as the nervous system is brought under the 
 mastery of Pain, and is depressed, or subdued, or exhausted by 
 it, the entire disease suffers fluctuation and change. The pulse, 
 hitherto steady to a certain number, varies between great ex- 
 tremes ; and hitherto strong, it becomes weaker. The heat of 
 skin, which was uniformly high, becomes lower, and, at the 
 same time, unequally distributed. And now strength begins to 
 pass into weakness ; and now one vital organ anil now another 
 gives notice of something wrong. This may be the semblance 
 only of disease ; but it may be the reality. 
 
 Observation, I think, may be trusted for the fact that Pain 
 can do all this. Most rationally, therefore, does it become a 
 special indication of treatment in acute Rheumatism whenever 
 it seems likely to do it ; that is, whenever it is in excess. Thus, 
 in the conduct of a case of acute Rheumatism, the chief and 
 greatest remedy sometimes is opium. It is almost always a 
 necessary safeguard. 
 
 What has been said of the Pain of acute Rheumatism holds 
 good of the Pain which belongs to other diseases acute in their 
 kind, and of uncertain duration. It holds good of the Pain 
 which attends acute Gout and acute Erysipelas ; which attends 
 the Inflammation, acute, severe, and involving many and 
 various structures, produced by large burns, and lacerations, 
 
 1 1 
 
482 GENERAL REMARKS ON THE 
 
 and fractures, and sprains, and by the complex of several in tie 
 same man. We know, indeed, that Grouty and Erysipelas, and 
 Inflammation, are curable diseases, and tbat their Pain will 
 cease whenever they come to an end. Nevertheless, in the 
 meantime, their pain being more than the nervous system can 
 well bear, calls aloud for relief and remedy. For the exhaustion 
 conducing to death, and even actual death may come as much as 
 from the attendant Pain as from the diseases themselves. 
 
 More need not be said. For I am not specifying rules, but 
 declaring a principle — a principle that receives abundant illus- 
 tration from the fact to which all successful practice can testify; 
 namely, that oftentimes the medical treatment of these formid- 
 able affections has turned, from first to last, upon the right 
 administration of opium. 
 
 "What an easy and simple affair would be the practice of 
 medicine, if we could always find out what and where the dis- 
 ease was, and then had only to lay hold of it (so to speak) in 
 its seminal essence, and to treat it, and cure it ; and thus could 
 treat and cure exclusively all that belonged to it ; its fever and 
 all its disturbed functions of parts, and all its excitement or 
 depression of blood-vessels and nerves, and all its Pains ! 
 
 And, indeed, one has now and then seen all this accom- 
 plished. One has seen a hard and bounding pulse laid hold 
 of as the sole indication of treatment, and an heroic bleeding 
 brought to bear upon it as the sole remedy. And, forthwith, 
 an acute Inflammation, just emerged, with its many formidable 
 accompaniments, has been summarily swept away. Here surely 
 a great deed has been done ; enough to make a man proud of the 
 power of his Art, and a little vain, perhaps, of his own skill in 
 wielding it. 
 
 But disease in its progress, after it has some time emerged, is 
 apt to split itself into fragments, and each fragment to become 
 a several centre for new morbid actions and suffering, to radiate 
 from, and to present a several scope, at which new remedies 
 must take their aim. Pain is one of these fragments and one of 
 these centres. 
 
PRACTICE OF MEDICINE. 483 
 
 XV.— Pain. 
 
 REMEDIES FOE PAIN. — ANAESTHETICS. — ANODYNES. 
 
 Upon the all-important subject of Pain and its Remedies, there 
 is still something that I wish to say — a little in the way of 
 speculation, perhaps, but yet soberly. For I cannot help be- 
 lieving that physiological, pathological, and medical research is 
 now at work towards a better knowledge and a better treat- 
 ment of diseases of the Nervous system, and especially of 
 Pain. 
 
 Surprising facts have within these few years become familiar 
 to us respecting insensibility to Pain and the modes of pro- 
 curing it. Already they have carried with them to the mind 
 and hand of man a knowledge and a power so full of mercy in 
 their use, and so stamped with the character of a divine gift, 
 as to call for praise and thankfulness. Think of the world of 
 Pain that has been spared by the use of chloroform ! Think of 
 -the lives that have been saved by operations of surgery, which 
 never could have been accomplished without it ! 
 
 This would, indeed, seem enough, were nothing more to be 
 •expected. But there is .probably wrapped up in these facts 
 •something more yet to be learnt and used for beneficial ends, 
 though it may be of a less splendid sort and pretension. For 
 they must have their own place belonging to them in the sum 
 of our knowledge. And to ascertain what their just place is, 
 -and how they fall in with our prior experience of diseases and 
 of remedies would seem to be a first step to any reasonable 
 •calculation what more they are likely to teach us. 
 
 The observation is as old as Hippocrates (lib ii. aph. 6), 
 that in states of disease and injury which ought (so to speak) 
 naturally to produce Pain, even extreme Pain, it happens some- 
 times that none is complained of, and, there is reason to believe, 
 none is felt. But in all such cases, whatever be the present 
 •disease or injury sufficient to produce Pain, and yet not pro- 
 ducing it, there is, moreover, some present harm sustained by 
 
484 GENERAL REMARKS ON THE 
 
 the sensorium. Thus, in the insane, casual hurts and accident* 
 often lead to disease of great amount remaining unnoticed, 
 because uncomplained of. And thus, too, in those who suffer 
 fevers, when they continue long delirious, and so for the time 
 are on a level with the insane, deep ulcers often appear on the 
 back, or erysipelas r spreads over a limb, unaccompanied by the 
 least expression of Pain on the part of the patient. 
 
 Here nature offers us her own pattern of things ; a sample 
 (as it were) of her own handiwork for us to study. She blunts 
 or she abolishes the perception of Pain ; but, in the meanwhile, 
 she strikes the brain with confusion or incapacity. And it is 
 after this copy that we find ourselves working, whenever we 
 would bring Pain into subjection to the power of medicine. 
 There is nothing which we can administer with such intent but 
 will make itself felt by the sensorium, while it operates reme- 
 dially upon the suffering part. Be the effect proposed anaes- 
 thetic in the completest degree, or anodyne only in the ordinary 
 sense, the sensorium must still be interested. 
 
 Hence, when we use such remedies, two things come to be 
 considered and weighed against each other in almost every 
 case ; what does the pain need, and what will the brain bear ? 
 "When all that is needed by the one can be borne by the other, 
 then no restraint is put upon the just use of the remedy. But 
 oftentimes the susceptibility of the brain limits its use to some 
 inadequate measure, or entirely prohibits it. There are some 
 unfortunate cases in which you cannot use opium to abate Pain, 
 because the brain will not bear it. 
 
 But an anaesthetic remedy is a new thing under the sun. 
 Therefore let us be sure that we know what it means. And as 
 many things are better understood in contrast or comparison 
 with other things than by themselves alone, so is this. And, 
 therefore, we will still bring the anaesthetic remedy and the 
 anodyne together, and mark the distinction between them ; and 
 thus contrive to get a better notion of both. 
 
 To make myself better understood, I will define what I 
 mean by an anaesthetic, and what by an anodyne. 
 
 The Anaesthetic annuls the capacity of feeling Pain alto- 
 gether, without limit as to its degree. It defies all the powers 
 and methods of torture, all that fire or steel can inflict for the 
 production of Pain. 
 
PRACTICE OF MEDICINE. 485 
 
 But the Anodyne mitigates or abolishes Pain within limits. 
 Its remedial power is restricted chiefly to Pains which are the 
 adjuncts and consequences of disease. A sharp inflicted hurt 
 from without is enough to break down all the power of defence 
 or resistance it can offer against Pain. Your anodyne has no 
 chance with fire or steel. Chloroform may be taken as the 
 representative of one class of remedies, and opium of the 
 other. 
 
 Thus far, tested by their effects upon Pain, the anaesthetic 
 and the anodyne have the same operations in kind — only the 
 one can do more in that kind than the other. The anaes- 
 thetic has the greater, the anodyne the less force. Mind, 
 I say tested thus far, and as to the power which each has 
 over Pain. 
 
 Well, then, if thus far the anaesthetic can do all that the 
 anodyne can do, and much more, what need have we of both ? 
 Why, in our dealing with Pain, should not the remedy which 
 has the greater force be always chosen before that which has 
 the less ? And since, for such purpose, the greater force and 
 the greater certainty go together, why should not the anaes- 
 thetic entirely supersedere anodyne ? Why, as a remedy for 
 Pain, should not chloroform beat opium out of the field? 
 Because, in the very treating of Pain, more is to be taken into 
 account than the mere pain itself. Because, as aforesaid, the 
 two questions are always to be asked, both, What does the pain 
 need ? and, What will the Brain bear ? Truly, as regards this 
 intermediate operation upon the Brain, each remedy, anaesthetic 
 as well as anodyne, is tied to its own conditions of doing its 
 proper work. These are such, in the case of the anaesthetic, as 
 will not allow it to fulfil the manifold office of the anodyne ; 
 and such, in the case of the anodyne, as will forbid it, by any 
 augmentation of its dose, to reach safely the full power of the 
 anaesthetic. 
 
 This sensorial operation is now the thing to be considered. 
 
 Prior to 'experience, one would have thought that, when 
 absolute incapacity of feeling was produced summarily and 
 suddenly at our will, and by an agent at our command, and 
 by one and the same agent, as by chloroform, one would have 
 thought that its sensorial operation would be always the same 
 in every case. But the fact is not so. In one instance, as 
 
486 GENERAL REMARKS ON THE 
 
 soon as the insensibility to Pain is complete, and as long as it 
 lasts, there is a profound coma — no sense, no consciousness, no 
 voice, no motion. The lungs respire ; the heart contracts ; and 
 the blood circulates, telling us that the man is not really dead. 
 The anaesthetic dose is discontinued, and it is not renewed. 
 The sensorium throws off its coma. Sense, consciousness, voice, 
 motion, all return; and with them returns the capacity of 
 suffering Pain. But all has been a blank to the patient, from 
 the moment that the chloroform had its anajsthetic effect to the 
 moment that it lost it. 
 
 In another instance, as soon as the insensibility to Pain is 
 complete, and as long as it lasts, there is no coma. Sense, con- 
 sciousness, voice, motion, all remain ; but they exist divorced 
 from the present scene. The man is altogether in some vision- 
 ary world. He sees and hears and talks with phantoms. But 
 this world is always a happy world, and its phantoms are happy 
 phantoms. And, indeed, it is passing strange to witness the 
 dreadful business of a surgical operation going on, and see 
 something of anguish and doubt and fear in every other 
 countenance, and the patient himself the only person uncon- 
 cerned and apparently happy. But the anaesthetic dose is not 
 renewed ; and its effects are unsustained, and wear themselves 
 out. And then the sensorium wakes up from its dream, and 
 the man returns to the real world ; and he brings back with 
 him his senses and his consciousness, his will and his intelli- 
 gence, to live and dwell and converse again with things as 
 they are. And, moreover, he recovers his capacity of feeling 
 Pain. But he has to be told of all that has happened during 
 his dream. 
 
 Ecstasy, trance, somnambulism (for we want a collective 
 term for this class of affections), were things of rare occur- 
 rence, until we learnt that the means of producing them were 1 
 within our own power. Accordingly, beyond the few striking 
 phenomena, which bear the name, nothing was known about 
 them. The instances were too few to furnish an experience. 
 Nobody could tell what conduced to them, or what or how 
 much more than the mere ecstasy, the trance, or the som- ; 
 nambulism, was wrapped up in their essence — what, in 
 short, was the state of internal functions and feelings, what 
 
PKACTICE OF MEDICINE. 487 
 
 were the capacities and susceptibilities of pain in persons so 
 affected. 
 
 Whichever of these two remarkable states he induced, the 
 coma or the ecstasy, the anaesthetic effect, which was the thing 
 desired, is equally certain and complete : equally, whether the 
 brain has its actings and its consciousness extinct for the 
 time, or has them still alive and energetic, but under such 
 forms and guises as characterise ecstasy, trance, somnambulism. 
 
 The operation of chloroform is one of those things which 
 deserve to be dwelt upon and studied, for the sake of the light 
 it throws upon the effect of medicines which are our daily 
 resource and reliance in the treatment of diseases. Chloroform, 
 administered as an anaesthetic, while it displays much that is 
 properly and exclusively its own, exhibits something that it 
 has in common with other remedies — something, for instance, 
 in which it affords a magnified representation of what occurs 
 whenever we give opium as an anodyne internally. Besides its 
 local effect of abating or abolishing pain, which we desire and 
 aim at, opium has a sensorial effect annexed, which is no part of 
 our purpose, and which we had often rather be without. And 
 it is remarkable that^ incident to its operation as an anodyne, 
 the sensorial effect of opium is of two opposite kinds, just as the 
 sensorial effect of chloroform has been shown to be, which is 
 incident to its operation as an anaesthetic. 
 
 Opium, administered in sufficient dose to abolish the severer 
 degrees of Pain, such, for instance,' as attend the passage of 
 biliary or renal calculus, does not fully compass the purpose 
 until it has made itself powerfully felt by the sensorium in one 
 of two ways, either until it has subdued the sensorium into 
 sleep, or roused it into delirium. The Pain remains in subjec- 
 tion to either of these conditions as long as they last. But 
 when the sensorium awakes up from its sleep, or reposes from 
 its delirium, then the Pain is free to return ; and it will return, 
 the cause still existing which first produced it. 
 
 But chloroform and opium, both possessing this vast power 
 for the control of Pain, and both exercising it through the 
 sensorium, are nevertheless not convertible remedies. Each 
 can do what the other can not. Each can go beyond the other 
 within the range of its special power. And it is the mode 
 
488 GENERAL REMARKS ON THE 
 
 and conditions of their operation upon the sensorium which 
 prevent them from being employed convertible/ as remedies for 
 Pain. 
 
 That appalling impression upon the sensorium, which is 
 essential to its complete anaesthetic effect, chloroform can be 
 made to produce in a minute or two. But the impression does 
 not abide. As in a few minutes it reaches its full amount, so 
 in a few minutes it totally disappears. And if, for the sake 
 of a longer anaesthetic effect, a longer sensorial impression be 
 needed, the chloroform must be applied afresh ; and so on again 
 and again. Thus, when we use chloroform for its great purpose 
 of procuring insensibility to pain during a tedious operation, 
 we seem to be playing upon the sensorium, as it were upon an 
 instrument, sustaining its effect so long as we keep the pressure 
 upon the keys, and letting it subside when we take the pres- 
 sure off. 
 
 Arising spontaneously, or from causes independent of our 
 interference and intention, there are forms of disease, which, 
 in popular language, and, indeed, in medical language, are 
 called Fits. They are of great severity, of great present alarm, 
 and of short duration, and belong most frequently to the brain. 
 But Fits, severe as they are, and terrible as they look, and 
 having their root, as they often have, in incurable disease, are 
 themselves seldom fatal. Yet they are so sometimes. A man 
 may die in a Fit. But before this happens, his disease has 
 generally lost the character of a Fit. It has lost its shortness 
 of duration, and its distinctness of attack. Each attack abides 
 longer ; and when it is considered to have subsided, something 
 still remains as a memento of it, and occupies the interval until 
 another attack takes place. 
 
 Let us take Epilepsy, for instance. Epilepsy is made up of 
 elements which give it, apparently, a fatal stamp. Yet it is not 
 fatal while it retains the character of a Fit ; while it is an affair 
 of minutes, or not of more than a quarter of an hour. But 
 when it is lengthened out for half an hour, an hour, or more, 
 it thus loses its character of a Fit, and a fear begins to arise of 
 its proving fatal. Indeed, but for the shortness of its attack, 
 Epilepsy (one would think) must be always fatal. 
 
 And, thus, chloroform does not produce its vast impression 
 
PKACTICE OF MEDICINE. 489 
 
 otherwise than fitfully, and the impression itself may be said to 
 consist of Fits of coma or Fits of trance. From its own nature 
 the coma or the trance is ready to pass away every few minutes ; 
 but chloroform applied every few minutes succeeds again and 
 again in keeping and retaining it or bringing it back. And 
 numerous Fits procured in this manner serve to give an ap- 
 parent length and continuity to the impression. But let the 
 impression hold on spontaneously, let it sustain and prolong 
 itself independently, and so lose the fitful character, then peril 
 is nigh at hand. 
 
 This sensorial impression, then, produced by chloroform, 
 which looks so formidable, has in its fitful character the great 
 condition of its safety. And its subsidence, or inclination to 
 subside, again and again, after being again and again renewed 
 by fresh applications of chloroform for one, or even two hours, 
 is still a condition of its safety. 
 
 Doubtless, you can produce as great an impression upon the 
 sensorium by opium, if you only give enough of it, as you can 
 by chloroform ; but not an impression as great in degree, and, 
 at the same time, as short in duration. You cannot play upon 
 the sensorium with opium, as you can with chloroform. You 
 cannot urge and take off the pressure of your opium, and so 
 raise, or lower, or stop its effect once produced. Opium once 
 given is gone beyond your power to recal. It must be then left 
 to work according to its nature. And its nature is to exercise 
 its impression, not fitfully, but continuously. 
 
 Now, inflicted Pain is, beyond all experience and conception 
 of Pains, the most severe. No Pain can come near the Pain 
 of the knife. To counteract it, to stop its cry, requires an 
 insensibility which shall equal the insensibility of death. But 
 the world has grown old before the medicine has been found 
 which can procure the insensibility of death yet not procure 
 death itself. But it is found at last ; and that medicine is 
 chloroform ; and thus chloroform is peculiarly the remedy of 
 inflicted Pain. 
 
 Further, inflicted Pain is as short or as long as, guided by 
 the present necessity, we choose to make it. Generally it is 
 short ; or if it be long, it is rather several successive inflictions 
 than one continuous Pain. In the meantime, we want to have 
 
490 GENERAL REMARKS ON THE 
 
 that deadly insensibility, which, is counteractive of it, as much 
 at our command as the injury which we inflict is at our com- 
 mand. To make the insensibility short when we make the 
 injury short, and long when we make the injury long. Chlo- 
 roform is the medicine which can both procure the insensibility 
 and can put it thus wonderfully at our command. In this 
 respect, also, chloroform is peculiarly the remedy for inflicted 
 Pain. 
 
 But opium is no remedy for inflicted pain. The conditions 
 of its operation forbid it. Its operation, whether great or 
 small, is always continuous. It can produce the insensibility 
 of death, but not without producing death itself. 
 
PRACTICE OF MEDICINE. 491 
 
 XVI. 
 
 WHAT IS MEANT BY A MAN'S CONSTITUTION? — GREAT BREADTH 
 OF THE SUBJECT. — FULL OF THINGS INDEFINITE AND DIFFI- 
 CULT TO NAME, BUT REAL AND INTELLIGIBLE, AND REQUISITE 
 TO BE STUDIED FOR THEIR BEARING UPON THE COURSE Off 
 DISEASES AND THEIR TREATMENT. 
 
 What do we mean when we talk of a man's Constitution? 
 For, indeed, we are continually talking of it, both among our- 
 selves and to our patients ; and thinking of it, too, when we 
 come to treat their diseases. And, moreover, the older we get, 
 and the more conversant we have become with diseases, patients, 
 and remedies, the more stress do we find ourselves laying upon 
 a man's constitution. But this thing so talked of, and thought 
 of, and practically regarded, what is it ? Is it not a man's in- 
 dividuality, in a physical sense ? Thus much it is, at least ;. 
 and a great deal more than this expression would include. 
 
 Yet might not some lucky definition be hit upon, which 
 would carry the whole meaning of the thing, and give us a 
 rule. to work by, that might be invaluable ? But it is this very 
 thing, even a man's constitution, which fills the whole subject 
 of practical medicine with such endless circumstances and 
 conditions as to spoil it entirely for definition. And strange 
 indeed would it be, if what snatches everything else from the- 
 grasp of definition should itself submit to be defined. 
 
 True ! the practice of medicine is sometimes narrowed to a 
 point, and curiously eclective ; and sometimes it is broad and 
 free. But, whether narrow or broad, it cannot be fixed by 
 definition, or worked by rule. The physician's success in the 
 treatment of each particular case depends not upon the exact 
 definition under which he can bring it, or the exact rule he can 
 bring to bear upon it ; but it comes from his own free choice of 
 what is now best to be done, guided by the sum of all his 
 former experience. 
 
492 GENERAL REMARKS ON THE 
 
 But if this (so-called) constitution of the man meet us thus 
 at every turn in the practice of medicine, though it do not bear 
 definition, yet will it not bear, and does it not demand, some 
 careful thought ? Such let us try to give it. 
 
 A man's constitution, taken for his individuality in a phy- 
 sical sense, may be that with which the physician has most to 
 do upon the whole. But it is only part and parcel of his entire 
 individuality ; and the physician will find that he has to do 
 with every part in its turn, and even with all of them together. 
 The subject, therefore, needs to be considered a little compre- 
 hensively. 
 
 Now, all intercourse with the world as it is, and acquaint- 
 ance with contemporary men, all study of history and of the 
 characters of men still traceable upon its pages, would lead to 
 the conclusion that never, from the foundation of the world 
 until now, have there existed two individuals who, in outward 
 presentment and in intellectual and moral attributes, were the 
 exact counterparts of each other. Being first stated, this 
 sounds a monstrous paradox. Being pondered a little, it begins 
 to appear probably true. Something like the same bodies and 
 minds have been traced in different ages, furnishing historical 
 parallels. But no man of any age could be taken for either a 
 re-embodiment or a metempsychosis of any other man of an 
 age preceding. 
 
 There are certainly as many varieties of man as there are 
 individuals ; and these varieties reach to his entire nature. 
 Peruse men by items, and you will see that, however much they 
 resemble one another, no two were ever found each other's 
 counterparts. Take two brothers as near alike as any two 
 brothers were ever known to be. Being apart, they are con- 
 tinually mistaken for each other. In size, and form, and face, 
 and feature, they are the same ; but no man, the least observant, 
 can live with them for a day and not ever afterwards distinguish 
 between the two with as much ease as if one were white and the 
 other black. He will distinguish them, and perhaps not know 
 how it is that he does so distinguish them. But it is the expression 
 of countenance — that wonderful indefinable reality — which lets 
 out the secret, and tells which is which. From things of every 
 moment, things without and thoughts within, there peep out 
 or flash out gleams and changes which are the proper living 
 
PRACTICE OF MEDICINE. 493 
 
 light of every human countenance, and, going and coming, 
 photograph its individuality. 
 
 View men intellectually. Take two men educated together, 
 and in the same way, and in the same things. Let all tests of 
 competitive knowledge have found them equals. Let it he 
 fairly allowed that neither is hetter or worse than the other. 
 But there is a difference between them ; and, if we could come 
 at the secret of the manner in which the mind of each addresses 
 itself to its work, herein we should plainly discern them 
 different. One has had most trouble with his memory, the 
 other with his reasoning power, while they have worked up 
 their minds to the same mark, and have compassed equal 
 results. Truly one may be neither better nor worse than the 
 other, but they are intellectually different. Accordingly, put 
 them both into the same profession, and one will succeed and 
 the other fail. Put them into different professions, luckily 
 chosen and suited to their secret but real intellectual difference, 
 and they will both of them succeed. 
 
 View men morally, and still take them by pairs. Take two 
 as morally the same as men were ever seen. They have become 
 fast friends for life, from like dispositions and tastes. They 
 seem to joy and sorrow, hope and fear, like and dislike, in equal 
 measures and on equal occasions. The same accidents of life 
 make both happy or both miserable. But they differ ; and they 
 know it well, though nobody else may see it. And their very 
 friendship, however it began, is now maintained and strength- 
 ened by both of them well understanding wherein they differ, 
 and being naturally indulgent of what each may think the 
 other's weakness, perhaps by never touching it at all, perhaps 
 by gently handling it, perhaps by seasonably playing with it, 
 but never by assaulting it. True friendship has its own deli- 
 cate tests of the moral attractions and repulsions of man's 
 nature and its own intuitive skill in dealing with them. It is 
 the best touchstone of moral individualities. 
 
 But when physicians speak of the constitution of a man, 
 and make so much of it in reckoning the issue of diseases and 
 directing their treatment, they are understood to have in view 
 not what he is intellectually or morally, but physically. Yet 
 how physically? Surely our thought is not of a man's body, 
 and his body alone, when we speak of his constitution ; but 
 
494 GENERAL REMARKS ON THE 
 
 of his body with the life in it, at least. As to size and bulk, 
 shape and make of body 'and bodily organs, the differences 
 between men are pretty obvious, and need not be pointed out. 
 In the treatment of diseases, not much (I will not say nothing) 
 ■depends upon what these differences are either wholly or in 
 detail. But be the body or the body's organs of what size and 
 bulk and shape and make they may, it is how and what they 
 can do, and how and what they can endure under the ordinary 
 wear and tear of existence ; and again under the stress of un- 
 usual circumstances ; and still again under the harder stress 
 of diseases ; it is thus, and thus, and thus, that men make 
 show of their several constitutions and their physical or vital 
 individuality. x 
 
 It is a misfortune to have a great subject fall in one's way 
 to handle, and have the fear of not handling it worthily ; and, 
 moreover, to feel at every step how possible it is to fail in 
 explaining to others what has been impractical exercise by one's 
 self during half a life. And such is the subject of man's indi- 
 viduality, which, being restricted to his material vital nature 
 (o-w/taTt/tQ)?), is especially called his constitution. 
 
 There are more realities in medicine than we have language 
 to describe — realities known and acted upon and put to the 
 proof every day, yet not apprehensible as things which have 
 definite forms and substance ; and we have been obliged to find 
 terms suggestive of what they are in their own kind, not as 
 forms and substances, which they are not, but as living. energies, 
 which they are. Temperament, susceptibility, idiosyncrasy, 
 diathesis, are such terms. They are in very common use 
 among us ; and they bear a stricter or a laxer sense, according 
 to each man's habit of thought who uses them. But, stricter 
 or laxer, there is a practical need of them ; for they denote some- 
 thing real. Every living man has his health qualified by some- 
 thing which one or other of these terms may be allowed to 
 stand for ; and every living man has his diseases tinctured by 
 the qualities of his health. 
 
 Temperament, idiosyncrasy, susceptibility, diathesis, are 
 indeed terms of portentous sound ; and they all stand (it has 
 been said) for realities ; yet not for definite forms and sub- 
 stances, but for living energies. And their meanings, thus 
 denoted, seem transcendental and mysterious withal. But it is 
 
PEACTICE OF MEDICINE. 495 
 
 the great mystery of life itself which, is at the bottom of all the 
 mysterious language we are obliged to employ concerning it. 
 Yet it is far better for us to use these terms, even temperament, 
 idiosyncrasy, susceptibility, diathesis, wbich belong exclusively 
 and restrictively to vital things in their first and proper and 
 only sense, than any plainer and commoner terms, which could 
 only be made suitable to them in some secondary sense. For 
 the plainer and commoner terms, having (as needs must be) 
 their primary sense always adhering to them, would carry a 
 peculiar hazard of misteaching us in our conceptions of those 
 things to which, in their secondary senfce, they were trans- 
 ferred. 
 
 This matter concerns us more than is usually supposed ; 
 therefore it is worth while to pause, and try to clear it up a 
 little. Almost all language is figurative, and so far may 
 obscure as well as illustrate the subject which it is used to 
 denote. Inflammation and fever contain the figures of burning 
 and boiling ; and, in all our conceptions of their nature and 
 treatment, the ideas of burning and boiling have been continually 
 mixed up. But this is to make the name of a thing stand for 
 a very part of it ; and thus it is even possible that the name 
 may come to dominate in our minds over the thing itself. Is 
 it not true that the popularly prevalent notion of treating 
 inflammations and fevers turns to the purposes of extinguish- 
 ing and refrigerating ? Hence the popular term antiphlogistic, 
 which really takes one's understanding by storm ; also febrifuge, 
 which is startling enough. 
 
 Now, inasmuch as there is abundance of true inflammation 
 and true fever which does not bear the faintest analogy to 
 burning and boiling, and abundance of successful treatment of 
 the same which is as remote as possible from our conception of 
 antiphlogistic and febrifuge, it would have been well, perhaps, if 
 the terms both for the diseases and their remedies had never 
 been used. But the names are too ancient and venerable not 
 to remain for ever. Let it then be enough to beware of their 
 furtive figurative sense, as applied to diseases and remedies 
 which may belie the nature of the one, and confuse the appli- 
 cation of the other. 
 
 The realities, which these portentous terms, temperament 
 idiosyncrasy, susceptibility, diathesis represent, are nothing 
 
496 GENERAL EEMABKS ON THE 
 
 less than a man's constitution, or the individuality of his 
 physical and vital nature, and its distribution into certain 
 species which are to be understood but not defined. And truly, 
 in using the terms, we find ourselves in tolerable agreement 
 concerning what they represent, and probably shall continue in 
 this agreement as long as we are content to leave their mean- 
 ing to our general conceptions, and to measure it by no stricter 
 formula. 
 
 But in thus leaving the terms and their meaning free, we 
 should always remember that there is no greater fault than the 
 habit of employing them familiarly. It is an offence against 
 good taste, and has incurred and deserved some ridicule. More- 
 over, it is excused by no necessity. Nevertheless, if we were 
 denied their use entirely, the most sober-minded among us 
 would not be able to communicate together upon many of the 
 great practical realities of our profession. 
 
 Then there are other terms, in constant use among us, and 
 of sure meaning enough for men to be agreed about the realities 
 which they denote, yet not to be technically defined. Such are 
 sanguine, nervous, bilious, gouty, scrofulous. And when these 
 come to be added to temperament, susceptibility, idiosyncrasy, 
 diathesis, they must be taken to mark (as they really do) the 
 more special individualities of men. 
 
 All this, at least, "is meant when we speak of a man's con- 
 stitution" — at all events, it is as much as can be conveyed by 
 language. To venture upon describing more would be unsafe. 
 But there is more, and most physicians know more. By ob- 
 servation of individuals in sickness and in health, they come 
 to learn that this, that, or the other man, albeit in no outward 
 respects different from the majority of mankind, holds his 
 health upon conditions which none beside himself are tied to, 
 or gets rid of his diseases by methods of treatment which none 
 beside himself would require or bear. 
 
 Nothing so vitiates the practice of medicine as that over- 
 refinement, which either pretends to see more than can be seen, 
 or fritters away what it does see into endless idle particularities. 
 But it is not to over-refine, in either sense, when we patiently 
 study the constitution and individuality of men respective to 
 the treatment of their diseases. The practical end in view is 
 ever admonishing us to make sure of what we see, be it obvious 
 
PRACTICE OF MEDICINE. 497 
 
 or occult, near or remote ; and, instead of multiplying the par- 
 ticulars which we find, to reduce them to as few as possible, 
 that so they may be more easily grasped, and handled, and 
 turned to use. 
 
 A man's physical individuality, when it is written and dis- 
 played in any of its larger and broader characters, warns and 
 prophecies of things which threaten and beleaguer his mortal 
 state as long as he remains in the world. It tells of one man 
 that his health in its uses and duties and enjoyments, his real 
 health, will always be tied to conditions of place, of regimen, 
 and employment. It tells of another, that there are certain 
 forms of disease to which he will always be obnoxious. In 
 another, whatever be the disease he suffers, it points to the 
 likelihood of certain intercurrent accidents and events. And 
 thus does this individuality, which is written in larger characters, 
 and is seen and read of all men, call for and deserve the special 
 attention of the physician. 
 
 But a man's physical individuality may be written in a 
 much smaller character, or in a character legible only by the 
 physician, and not always by him, but only as circumstances 
 •chance to bring it out, and put it in points of view that make 
 it visible. Yet this smaller thing, seen but by the physician, 
 and by him occasionally and seldom, being, however, an un- 
 doubted reality, may become a vast event in its practical bearing 
 and use. As thus, let a man be overtaken in the midst of 
 health by some acute disease, by Typhoid Fever, or Pneumonia, 
 or Enteritis, or Erysipelas ; or let him suffer an extensive burn, 
 or meet with some grave accident, lacerating and contusing 
 soft parts deeply and widely; and after the lapse of weeks, 
 made up of days and nights full of emergencies, met and 
 managed according to their kind, and by remedies of definite 
 aim and purpose, let the man be restored to perfect health. 
 This single attack will serve the physician, who watched and 
 treated it, with information, which will ever afterwards be his 
 guide to the safe and successful treatment of every attack of 
 whatever disease the same individual may suffer as long as he 
 lives. 
 
 But how so ? Even thus. In the individual case, the phy- 
 sician has not been studying a typhoid fever, nor a pneumonia, 
 an enteritis, an erysipelas, a burn, a laceration, or a contusion. 
 
 KK 
 
498 GENERAL EEMARKS ON THE 
 
 He knew well enough before what they were in their own nature,, 
 and this case has not added one jot or tittle to his knowledge of 
 them. And he never expected that it would. Practically, h& 
 has been turning away from the disease, and fixing his atten- 
 tion almost or altogether upon the patient who suffers it. He 
 has been studying an individual constitution ; and studying it 
 under the surest test and trial that can be conceived of all its 
 living powers. And what has the physician found ? In one 
 case, he has found the disease lightly and patiently borne ; not 
 so much suffered as complied with ; and carried duly and 
 seasonably through all its stages to its termination in health.; 
 and, whatever remedies were needed in the meanwhile, he has 
 found them, too, as well borne as the disease, and answering 
 their intended purposes, and helping the progress, and insuring 
 the fortunate termination of the whole. In another case, he 
 has found the disease impatiently borne and violently resented ; 
 the vascular system and the nervous system reacting with 
 steady energy and power ; and strong counteractive remedies,, 
 such as blood-letting, needed and successful in rescuing from 
 death and procuring recovery — not without hazard. In another 
 case, he has found the disease impatiently borne ; and the vas- 
 cular system and the nervous system making a show of reaction 
 fitfully and capriciously, but mainly without power ; and reme- 
 dies as ill-borne as the disease ; and the treatment of each day 
 waiting upon each day's events; and depletion and support, 
 stimulant and sedative, given interchangeably, yet suitably to- 
 their indications," and manifestly instrumental to the saving 
 of life. 
 
 Thus, day and night, for two, or three, or four weeks to- 
 gether, have experiments, as if instituted for the very purpose,, 
 been going on to bring out of the several men what they are 
 vitally made of. And the sum of what is noted in them under 
 this sure test of acute diseases and their remedies, may be taken 
 as the sum of each man's constitution, of his physical and vital, 
 individuality. 
 
 Now, whoever may be the physician that has seen me safely 
 and well through an attack of Typhoid Fever, Pneumonia, 
 Enteritis, or Erysipelas, or an extensive burn, or some grave- 
 accident, let me have the same to attend me ever afterwards in 
 any severe disease which I may suffer. He may not absolutely 
 
PRACTICE OF MEDICINE. 499 
 
 be the best physician in the world ; but he is the best for me ; 
 for he knows my constitution. But the discerning public 
 delights in nothing more than a change of physicians for the 
 novelty of the thing. And for this, as for other novelties, it is 
 apt to pay dear. 
 
 Well ! but is it quite true, that either written in larger 
 characters, and under all conditions of health or disease, and 
 so seen and read of all men ; or written in smaller characters, 
 and brought out only by the emergencies of disease, and so 
 seen and read only by the physician ; is it quite true that this 
 physical individuality is always ready to show itself and to 
 play its part in modes of acting and suffering, and always to 
 distinguish man from man ? Not always ! There are diseases 
 which level all individualities. The plague, the cholera, yellow 
 fever, make all men alike. Temperament, idiosyncrasy, sus- 
 ceptibility, diathesis, sanguineous, lymphatic, bilious, nervous, 
 gouty, scrofulous, even strength and weakness, youth and age 
 and sex, go all for nothing. The disease is as a poison, making 
 no difference between life and life, but destroying all life, or 
 bringing all into equal jeopardy. 
 
 Again, there are diseases which have a way of levelling and 
 reducing to nothing the constitutional differences between man 
 and man, otherwise than after the exact similitude of poisons. 
 Poisons are poisons always and everywhere ; while diseases may 
 not have it for their constant power and property to level, and 
 destroy, and jeopardise, widely and promiscuously, but they 
 may have the power and property for times and places. It may 
 be for a short or for a long season, over small or wide extent, 
 perhaps for a year or part of a year, and over a certain district 
 only ; or, perhaps, for many years in succession, over a whole 
 country, or over a continent, or over half the entire world. [All 
 febrile diseases which are contagious or epidemic have exem- 
 plified these truths in their turn. A single one is enough for 
 our present purpose. 
 
 Of Scarlet Fever, consulting my experience of what it was 
 during the few first years of my professional practice, and 
 taking this for my guide, I must have pronounced that its 
 danger to life was as small as it is possible to conceive, and 
 that all the difference between case and case was manifestly 
 due to the difference of constitution in several men. But of 
 
500 GENERAL EEMARKS ON THE 
 
 Scarlet Fever, viewed by the light of a new experience, my 
 experience of what it was during a series of immediately sub- 
 sequent years, I must have pronounced it the most perilous of 
 diseases, and that, no matter whom it might befall, it levelled 
 all to a parity of suffering and an equal hazard of death. 
 
 The sum of our experience carefully reckoned is consistent 
 enough, upon the whole, to allow of our making fair anticipa- 
 tion of the course of diseases, and of the effects of remedies in 
 particular cases. "Without this there could hardly be a rational 
 practice of medicine at all. Certainly, there could be no agree- 
 ment among medical men as to what is expedient to be done in 
 any case. 
 
 Still of. the simplest diseases and their course, and of the 
 simplest remedies and their effects, our experience is not 
 uniform enough to make us always sure of events, and excuse 
 us from attentively watching all cases, if perhaps something 
 new or unusual may occur in some, requiring changes of 
 remedies and readjustments of treatment according to men's 
 constitutions. 
 
 And thus, to comply with men's constitutions gives exact- 
 ness and success to the treatment of their diseases, while it does 
 no prejudice to any sound practical principles, but rather 
 confirms them by showing their capability of yielding and 
 adaptation to present necessity. 
 
 Considering how much individual constitution has to do 
 with the treatment of diseases, a good deal more might, and 
 ought to, be said of it, if it could only be said intelligibly. But 
 it is difficult to deal with truths which are most important to 
 know, and yet cannot be submitted to scientific tests. The 
 truths of medical practice are many of them such, and in this 
 predicament. There are some of the most important realities 
 in the world, which, in all their fulness, can only be pictured 
 to the mind by the help of analogies and similitudes. Then, 
 "with what comparison shall we compare" men's constitu- 
 tions ? 
 
 As there is an atmosphere without the man by which and 
 in which who ever lives does live ; so there is, what may be 
 called, by a just analogy, an atmosphere within the man by 
 which and in which whoever lives does live. The external 
 atmosphere is the air we breathe ; and somewhere in the world, 
 
PRACTICE OF MEDICINE. 501 
 
 perhaps, it has and always preserves its purest possible con- 
 ditions, calculated to maintain existence at its best and its 
 healthiest. But, throughout the known world, heat and cold, 
 dry and moist, dense and rare, fair and foul, are variously 
 distributed, and calculated, according to their measures, to 
 subject life to degrees of deterioration, and to induce, and 
 prolong, and perpetuate forms of disease. The internal atmo- 
 sphere (so-called from analogy) exists diffusively within us, 
 and feeds our life. And as the external atmosphere may have 
 perfect purity in some places, but one cannot say where ; so 
 this internal atmosphere may have perfect purity in some men, 
 but one cannot tell whom. Being, however, at its purest and 
 its best, it maintains (we may suppose) in each and every part 
 the power and capacity of acting and feeling according to the 
 perfection of their nature. But it is variously qualified in 
 different men ; and his vitality so qualified is each man's con- 
 stitution. 
 
 Now, there are nicely constructed instruments, which pretty 
 faithfully denote to us the states of the atmosphere without 
 from time to time. Indeed, for any accurate information about 
 it, we depend entirely upon such instruments. So, diseases 
 and remedies, and all sorts of emergencies, physical and moral, 
 the wear and tear of life, are the instruments which test men's 
 constitution for us ; and we should know little about it but for 
 them. 
 
502 GENERAL REMARKS OS THE 
 
 XVII. 
 
 FURTHER REMARKS ON PRACTICAL EXPERIENCE. EXPERIENCE 
 
 COMES FROM EXPERIMENTS. — SHOWN IN THE TREATMENT OF 
 
 ACUTE DISEASE AS PNEUMONIA. AND OF CHRONIC DISEASE 
 
 AS PULMONARY CONSUMPTION. — HOW SUPERVENING ACCI- 
 DENTS MAKE THE TREATMENT OF DISEASES MORE EXPERI- 
 MENTAL. IN (SO-CALLED) " EXPECTANT MEDICINE," NO SOUND 
 
 EXPERIENCE ATTAINABLE BUT BY EXPERIMENTS WITH THE 
 SIMPLEST REMEDIES. 
 
 The highest praise which the world has to bestow upon the 
 physician is that he is experienced. There must, therefore, he 
 a good deal worth knowing about this experience, which is 
 deemed his characteristic excellence ; as, how he goes to work 
 in search of it, and how he gains it, experimenting after his 
 manner, and with whatever helps of science he can muster, or 
 with none at all ; but still experimenting. For in Medicine 
 nothing that deserves the name of experience can be otherwise 
 gained than by what deserves the name of experiment. 
 
 According to the common notion, experiment is usually 
 concerned with inert matter, or, at all events, with things which 
 have not life. But we need not hesitate to transfer it to vital 
 actions and processes. Medical practice satisfies the require- 
 ments of an experiment, when it puts the vital frame, with 
 which we have to do, under conditions of our own choosing, 
 and takes note of the results. The sum of these results becomes 
 our experience. And this is suggestive of future experiments 
 in eddem materia, how best to set about them, how best to con- 
 duct them, and the fittest means and instruments to employ 
 upon them. These experiments are, in fact, the practice of 
 physic, perfecting itself by use, and consummated in experience. 
 His experience is each physician's depository of whatever prin- 
 ciples, plans, and means he possesses for executing his future 
 experiments; his foundations to work upon, his diagrams to 
 work by, and his tools to work with. 
 
PRACTICE OP MEDICINE. 503 
 
 Now the practice of medicine, when it is engaged in treating 
 disease, acute disease especially, comes pretty near the current 
 idea of an experiment. There is, then, always something 
 within view and within reach, taken for the immediate object 
 of experiment, and so taken because it is within view and 
 within reach. Also there is test and trial made of things one 
 by one, and note taken of single consequences and effects as 
 they arise under our hands, promising, promoting, and ending 
 in the ultimate effect, which is the departure of disease and 
 restoration to health. 
 
 But, in curing disease, the current idea of an experiment is 
 upon the whole less apparent. The one ultimate effect is the 
 thing contemplated, and the thing aimed at by the remedy. 
 There are no tests or trials of things one by one preparatorily, 
 no note of single consequences and effects intermediately. Yet, 
 when the one ultimate effect is near at hand, and follows rapidly 
 upon the use of the remedy, as does, the cure of ague upon the 
 use of quinine, then there is nothing wanting to the idea of an 
 experiment in the completest practical sense. Thoughtful men 
 are at liberty to penetrate deeper into the secret, and find out 
 intermediate effects, if they can. The rest of us are content 
 with the simple result, and can repeat it any day by the same 
 instrumentality. "We can all cure an ague by quinine. The 
 arrow leaves the bow and hits the mark. "We see that, and we 
 see this. But between that and this the way of the arrow was 
 through the air, and for an instant we lost sight of it alto- 
 gether. 
 
 Now if it be true in any large sense that medicine, to have 
 sound experience for its conclusions, must have sound experi- 
 ment for its practice, there should be plenty of instances at 
 hand to prove it. And so there are. Since the least fallible of 
 our senses has been brought to bear upon the two most vital of 
 our organs, their diseases have come more and more within the 
 reach of our scrutiny, and more and more within the compass 
 of our knowledge. And so, too, has correlatively their treat- 
 ment. The treatment, especially, of diseases of the lungs, both 
 acute and chronic, can now hardly otherwise be prosecuted than 
 as it is made to take the form of an experiment, and to comply 
 with its conditions. 
 
 Take pneumonia, acute pneumonia. It tells itself articu- 
 
504 GENERAL REMARKS ON THE 
 
 lately to the ear. The ear follows it as it advances and as it 
 recedes, and the ear dwells upon it as it stands still. Not that 
 pneumonia can syllable its own name, and so tell us what it is. 
 But its living facts speak audibly for themselves ; and they are 
 the disease, be they few or many, very few or very many ; and 
 these same are the objects of remedial experiment. But mind r 
 there are other objects which are mixed with them and come 
 first in experimental order. 
 
 There are troubled states of the vascular system, and the 
 nervous system, which are, as it were, the body's signals of dis- 
 tress. Some intimate one thing, and some another. Certain of 
 them bid us specially beware that somewhere within the man 
 there may be inflammation going on. And, then, forthwith we 
 betake ourselves to search for it in any part which falls under 
 our suspicion, by whatever means we can. And thus finding, 
 wherever it be, any unwonted organic movements, such as have 
 part and place in inflammation, forming or formed or pro- 
 gressive, any that lie in the way by which it travels to its well- 
 known events, then we take the same, and, be they few or many, 
 we call them inflammation, and we treat them accordingly. 
 
 Thus a portion of the lung, crackling as it breathes, this is 
 pneumonia; a portion crackling as it breathes and another 
 portion giving no sound at all, these are pneumonia ; portions 
 crackling and portions silent, and, moreover, the bronchial 
 breathing and the bronchial voice, these are pneumonia. And 
 all these, as they shift and change, and precede and succeed, 
 and variously intermingle with one another, do much more than 
 by themselves singly or collectively, stamp and constitute the 
 disease pneumonia. 
 
 Now our treatment takes up pneumonia as it finds it, early 
 or late, and represented by few or by many of its living facts.. 
 But this treatment has two aspects. Indeed, I am not refining,, 
 being quite sure that, if it lose its simplicity, our treatment is 
 spoilt as an experiment altogether. It has, I say, two aspects,, 
 and complies with the conditions of an experiment in both. 
 One aspect is turned towards the lungs themselves ; the other 
 looks elsewhere, and almost everywhere, in the body beyond, 
 the lungs. 
 
 Not from the lungs themselves, nor from the living facts 
 now at work within them, or their number, or their combina- 
 
PRACTICE OF MEDICINE. 505 
 
 tions, or their changes, as noted and measured by the ear, does 
 the treatment of pneumonia take its beginning and make choice 
 of its remedies, and apply them with force, great or small ; but 
 from the vascular system and the nervous system, and from the 
 present condition of both, as they are taken to mean strength 
 or weakness, reaction or surrender, and all their degrees of 
 much or little, rapid or slow, as noted and interpreted by what 
 the pulse has to tell of them from day to day, or from hour to 
 hour. 
 
 This is one aspect of the treatment; and experimental 
 enough it is ! 
 
 But all the while, and from first to last, the treatment is 
 turned to the lungs, where it finds the aim of all, and the end of 
 all. Here it metes out what it has to do, and then what it has 
 done ; and here it again and again metes out what still remains 
 for it to do, and at length it makes its final reckoning of perfect 
 or imperfect reparation. This is the treatment's other aspect ! 
 And in this, too, it is experimental enough. And truly, when- 
 ever pneumonia is very acute, and the living facts within the 
 lungs are undergoing changes from day to day, and even from 
 hour to hour, and whenever the remedies employed are capable 
 of making a like rapid impression counteractively, then the 
 physician, if he is to proceed safely and successfully, must 
 work his treatment, as he would work an experiment, with his 
 finger upon the pulse and his ear upon the chest, from day to 
 day or even from hour to hour. 
 
 Strange enough, perhaps, it may seem to some, that I should 
 find an example of treatment shifting and variable, and curiously 
 experimental, according to the needs of particular cases in that 
 very disease, where braver spirits have made boast of a treat- 
 ment simple and uniform, and comprehensive of all cases, and to 
 be settled beforehand. Men have held that the proper treatment 
 of pneumonia is by depletion, always and absolutely, and so have 
 bled in every case ; and men have held that its treatment is by 
 stimulation, always and absolutely, and so have given wine or 
 brandy in every case. But if there be truth in the principles 
 which have been laid down, the unconditional advocates of 
 either extreme are hopelessly wrong-headed. Nay, should any 
 believe in a golden mean, equidistant from both extremes, and 
 pretend that they know it and can practise by it always and 
 
•500 GENERAL REMARKS ON THE 
 
 absolutely, tire experimental necessities' of every case they treat 
 should convict them of folly. 
 
 I have purposely dwelt upon this instance of pneumonia and 
 its treatment, believing it to contain a great practical lesson. 
 When disease is very acute, and its work of injury and dis- 
 organisation makes very brief stay in one stage and then 
 advances to another, and each stage is fairly denoted to the 
 watchfulness of the physician, and restoration to health and 
 soundness are yet within reach of treatment, that treatment 
 must be conducted strictly as an experiment from day to day or 
 from hour to hour. 
 
 But a large share of what is justly deemed the experience of 
 physicians, is conversant with results brought about by what, 
 in any popular sense, would hardly be called experiments. 
 Reparation of the disease, indeed, takes place, not without our 
 interposition, or without means of our choosing, or without the 
 witness of our senses. But then the amount, and the times, 
 and the occasions of interference on our part are less, and fewer 
 than seem naturally annexed to the business and working of 
 -experiments. 
 
 After a fair examination of their disease and its conditions, 
 and the choice made of some fit place to dwell in, and some 
 -cautions given against what is wrong, and recommendations of 
 what is right in diet and modes of living, how many patients 
 are left to nature to do all the rest, and never seen more by the 
 physician ! Or seen again after long times, once or twice or 
 thrice, and fairly examined again and again, and the same advice 
 reiterated, or new cautions and recommendations given, accord- 
 ing to altered conditions, the patients are remanded to nature 
 as before ! And thus, after the lapse of months or years, even 
 many months or many years, nature has done her work faith- 
 fully and well. She has restored to health from various forms 
 of chronic disease. Or, without perfect reparation, she has 
 brought even incurable disease to one of those pauses, now 
 understood by physicians, which are sure and lasting, and con- 
 sistent with a long and an useful, and, allowing for human 
 changes and chances, a happy life. 
 
 Physicians, the older they are, come to reckon a large amount 
 of this sort of experience ; and, in the meantime, they may 
 seem more like men waiting for results than procuring them, 
 
PRACTICE OF MEDICINE. 507 
 
 more as if passively looking on than busied with experi- 
 ments. 
 
 But, experiment or no experiment, call it what you will 
 (and one would not willingly press a word into our service to 
 distort the sense), yet if there be a choice and use of means with 
 a view to certain effects, and those effects be appreciable and 
 actually appreciated from, time to time, however slow may be 
 their progress and remote their accomplishment, something 
 tentative and in the way of trial has been going on all the 
 while. And who were its institutors and promoters ? Even 
 ourselves. We chose the means, and set them to work, and still 
 •continued them at work from observations, made at needful 
 intervals, that the work was proceeding slowly and surely 
 towards its accomplishment. And thus, and thus only, do 
 physicians gain whatever experience they have in the manage- 
 ment of many chronic diseases. And, though not exactly in 
 the popular sense, yet in a just and true sense, this experience 
 is the sum and complement of experiments ; equally so with 
 their experience in the management of acute diseases. 
 
 Take for illustration, the commonest of diseases with which 
 we have to do — a disease of the lungs too, and eminently 
 chronic, even consumption. What was the state of the lungs 
 when our patient went a certain winter to Madeira, and what 
 when he came back ? What was it during the next summer, 
 when he remained at home ? What when he again went to 
 Madeira, and what when he again returned home, and what 
 after he had remained at home a second summer ? Here the 
 treatment of the disease is brought plainly within the category 
 of experiment. It is ruled for years by the double experiment 
 of the good and evil of climate in individual cases. 
 
 There is no disease of which the treatment is so simply and 
 delicately experimental as pulmonary consumption. Its success 
 (within all possible limits of success) depends upon keeping it 
 experimental through its whole course ; and in particular cases 
 it is best secured when the treatment is allowed to rest from 
 first to last in the same hands. I am quite sure that its failure 
 in an infinite number of cases has been owing to their passing 
 from one physician to another. Let the general experience 
 and practical skill of the several physicians be equal, and equal 
 to the interest they take in the well-being of their patient ; 
 
508 GENERAL REMARKS ON THE 
 
 yet every time he passes from one physician's hands to another's, 
 the probability of his recovery is seriously diminished. The 
 reason is this : the treatment thus runs the chance of often 
 halting and often beginning afresh — of being taken up by one, 
 not at the same point where it was left by another, or not with 
 the same views ; in short, the chance of being utterly spoiled 
 as an experiment. 
 
 ^Nothing less than this could be fairly said of the treatment 
 of phthisis, if it were a disease always of a certain type, trans- 
 acting itself in its own way, and admitting no foreign admix- 
 tures. But there are in phthisis the accidents of the disease 
 (its separable accidents, you may please to call them. They 
 are scarcely separable, however, but in idea). There is hardly 
 a case in which]'some or other of them are not present ; and, 
 being present, they bear practically upon the treatment accord- 
 ing to their kind and degree, and never fail to bring it more 
 and more within the category of an experiment. Thus from 
 time to time, and under stress of its accidents, will phthisis 
 become practically an acute disease. 
 
 Inflammation is an accident of phthisis. More than an 
 accident, according to some, who would hold a measure of 
 inflammation needed to help and hand it on from stage to stage. 
 However this may be, enough of it is doubtless sometimes 
 present to require the treatment of inflammation for a little 
 season, in order to save the patient's life. 
 
 Haemoptysis is an accident of phthisis. No fact, which is 
 not of the essence of the disease, occurs more frequently. And 
 it is never a barren accident ; it always means something. 
 And, as its meanings are various, so is its treatment, which 
 takes the form of a carefully conducted experiment in every 
 case. 
 
 Much employed physicians are never without many cases of 
 phthisis under their care which are to them objects of interest 
 and experiment, at different stages, for years. And their 
 retrospect of twenty or thirty years, read by the needful 
 records they have kept of their experimental treatment, brings 
 forth an experience which is beyond all price. 
 
 Surely, for us physicians, it is not a vain exercise thus to 
 run over what knowledge we have of two diseases common 
 enough, yet very portentous, and try it and test it by its uses ; 
 
PRACTICE OF MEDICINE. 509 
 
 to take pneumonia and phthisis, and their living facts, ordinary 
 and extraordinary, and seek in them notices of times and oppor- 
 tunities and warrants of what to do and what to abstain from 
 doing ; and so to gain for the treatment of particular cases the 
 ■condition of exact experiments. Instances of other diseases 
 might be added, but let these be enough. 
 
 And these great experiments, and such as they, make up a 
 great experience. And the experience thus made is rich and 
 prompt and clear in devising and working out other future 
 experiments ; and both together stand for nothing less than the 
 active power and truth and faith of practical medicine. 
 
 The end of all the thought and labour of physicians is to 
 make experiments with men's lives. Then what mischances, 
 misjudgments, misinformation, what fallacies of all kinds, are 
 •apt to interfere with these experiments, and hinder or mar them ! 
 And then how difficult to assign them a place and a value 
 among the materials of a sound experience ! We study and 
 pore over the essential constituents of diseases, and learn where 
 to look for indications of their treatment. We wait and watch 
 for the customary accidents of diseases, and learn how to 
 encounter them. Precepts, books, authority, which is the 
 experience of other men, serve us for great helps. But, when 
 the cases come, their treatment must be specially and indi- 
 vidually our own experiment, and our own hands must have 
 the doing of it. 
 
 Excellent things have been spoken of Experience and of its 
 great value to the physician. And justly. But, then, men are 
 upt to talk largely and at random about what they are agreed 
 to praise. And they have so talked about the Experience of 
 physicians. Report would make it a very common thing 
 indeed ; as if all who had been in the way of it could not miss 
 of possessing it. But the having to do with diseases and 
 remedies for thirty or forty years does of necessity no more 
 make men experienced physicians, than looking upon the 
 heavens all their lives makes them astronomers, or digging and 
 ■delving the earth makes them geologists. 
 
 It is a divine aphorism (all know whence it comes) that 
 " Patience worketh experience." It is both divine and true ; 
 true of all good things, from the least and lowest to the greatest 
 and highest. And surely what belongs to man's mortal life, 
 
510 GENERAL REMARKS ON THE 
 
 and the physician's care concerning it, reaches no mean degree 
 in the general scale of all good things. 
 
 It is expedient that medical practice should in every case 
 be conformed to the current idea of an experiment as far as the 
 nature of that case 'will admit. No Experience worthy of the 
 name can be drawn from any number of cases less accurately 
 followed up than they might have been. In acute cases, 
 when the rate of progress in the disease is rapid yet distinct ; 
 so distinct that it can be measured by steps and stages from 
 day to day or from hour to hour, care must be taken that the 
 counteractive impression of the remedies be rapid, and distinct 
 withal ; to be seen from day to day or from hour to hour. 
 And to such cases, and to their remedies thus chosen and 
 applied, and to their effects thus noted and appreciated, 
 no one can deny the nature of experiments, and not allow 
 that the sum of such experiments may stand for a safe 
 Experience. 
 
 But when the rate of progress in the disease is by little and 
 little, and upon the whole so slow that it can only be seen after 
 the lapse of weeks or months, then the counteractive impression 
 of remedies must needs be also by little and little, and slow, and 
 incapable of being seen and measured except after the lapse of 
 weeks or months. The remoteness of the effect is the condition 
 which especially tends to perplex the procedure, and make void 
 the results of each case as it occurs, and take from it the cha- 
 racter of an experiment. 
 
 The power of medicine over chronic diseases is a thing hard 
 to get at and appreciate justly. Nevertheless, there is some 
 sound experience of it in the world. And this could only be. so 
 far as, in our dealings with particular cases, we have been able 
 to make them read to us the lessons of so many real experi- 
 ments. Experiments they must be in some sort, if they are to 
 furnish the materials of Experience. 
 
 But, in medical practice, as the one ultimate effect is more 
 and more distant in point of time, and little or nothing is to 
 be seen, or contrived, or done preparatorily and intermediately, 
 the current idea of an experiment becomes obscured or well- 
 nigh lost. 
 
 It is like a man travelling to some far off place, and finding 
 
PKA.CTICE OF MEDICINE. 511 
 
 no places by the way where he can sit down and rest himself, 
 and few or no guide posts to tell him whether he be in the 
 right direction for it or not. Still he holds on. Perhaps he 
 has been there before, and is pretty sure of this being the 
 direction in which he found it. Or, perhaps he has never been 
 there, but some of his friends have, and they told him of this 
 being the right road to it. And so it may be that, by his own 
 sagacity and the help of well-informed friends, he reaches it at 
 last. Or, after all his own pains, and all his friends can do for 
 him, it may be that he never reaches it at all. 
 
 This parable fairly sets forth the sort of Experience which 
 the physician is obliged to content himself with, in seeking 
 whatever good his art can reach within a large field of practice. 
 It is an Experience of summary and ultimate results, with 
 little or no insight of reckoning had of prior and conducive- 
 events. It is a general Experience made up of what a man 
 knows himself, and what he takes upon authority. In this 
 field of practice, it is hard to believe ourselves exercising the 
 same experimental art, as when every step we took was made 
 almost sure to us, and we could almost read and analyse the 
 disease by its remedies as we went along. 
 
 But there is what is called " expectant medicine." It points 
 to a more cultivated field of practice than that which we have 
 been just surveying. The term is significant, and implies the 
 attitude of expectation which the mind now maintains ; wait- 
 ing upon its own self-experience, and still waiting in faith of 
 (what it deems) trustworthy authority, for a more or less 
 distant event. Now, a rare enough thing to meet with among 
 physicians is this wisely expectant mind. It presumes a study 
 and sound judgment of the sort and measure of evidence which 
 the subject admits, and a decision habitually exercised upon it ; 
 not demanding more, but never content with less. 
 
 But there is a scepticism common among us, and much 
 fostered by the philosophical part of our training, which is 
 hostile to this state of mind. It requires evidence foreign to 
 the subject matter or more than it admits of ; and so not finding 
 it, it believes in nothing. 
 
 Again, there is a credulity common enough among us ; and 
 this is in sympathy with the larger credulity of the world on 
 
512 GENERAL REMARKS ON THE 
 
 medical subjects, and is strengthened by it. It incapacitates 
 for all patient inquiry ; and it may come to believe in every- 
 thing. Now, if there be no mean between the extremes of 
 scepticism on the one hand, and credulity on the other, there 
 can be no safe and successful practice in this region of " ex- 
 pectant medicine." But such a mean there is, in which all 
 good physicians meet, and communicate, and understand one 
 another, agreeing together in that prudent, patient, hopeful 
 faith which they all perceive, but none can define. 
 
 Yet, when we come to test the matter fairly, how can there 
 be any experience in this field of " expectant medicine ? " For 
 how can the management of individual cases of most chronic 
 diseases, whether by cure or treatment, be conformed to the 
 idea of an experiment ? Verily, to any great degree of per- 
 fection, neither one nor the other is possible. But even in 
 "expectant medicine" experiment would be practicable, and 
 experience attainable in much higher degrees than they are, if 
 physicians would only be content to work with fewer and 
 simpler remedies. 
 
 I have myself a reasonable amount of faith in the power of 
 medicine over chronic diseases. I have laid up a certain sum 
 of experience fairly collected (as I believe) from experiments 
 which I have been making all my life. But, then, all my life, 
 I have been careful about my experiments, in this respect 
 especially, I have sought to manage my cases of chronic diseases 
 — in other words, to work my experiments — as much as possible 
 by single remedies. On any other terms, I do not see how it 
 were possible that I should have any faith at all. It is a 
 mystery to me how such prescriptions as the following for 
 any known forms of disease can end in any trustworthy ex- 
 perience : — 
 
 Quinine 
 
 Ipecacuanha 
 
 Steel 
 
 Stramonium 
 
 Zinc 
 
 Colchicum 
 
 Valerian 
 
 Iodide of potassium 
 
 Nux vomica 
 
 
 Such complex prescriptions render the knowledge of the 
 jemedial effects of particular substances absolutely impossible. 
 
PRACTICE OF MEDICINE. 513 
 
 Do the prescribers impute a distinct effect of its own to each of 
 the ingredients, and so reckon the separate instalment brought 
 by each to the remedial mass ? Or are they content to take it 
 in the lump, and rejoice in the oneness of the effect. 
 
 My excellent friend Dr. Chambers, as soon as he had 
 chosen medicine for his profession, did not think it beneath 
 his dignity to work at a great pharmaceutical chemist's, com- 
 pounding medicines and making up prescriptions. Here he 
 saw what had been carefully preserved, the autograph prescrip- 
 tions of bygone physicians. And those which bore the initials 
 of the most eminent were remarkable for these two character- 
 istics, their plain and legible penmanship, and the very few 
 and simple articles which they directed. Surely, it is not 
 unsafe to read the men's minds in these documents, and 
 conceive the character of their thoughts and proceedings in the 
 great business of their lives. The men were evidently candid 
 and clear-sighted and of simple purpose ; and among them 
 were the best of their time — Dr. Heberden, Sir George Baker, 
 the elder Dr. Warren, Dr. David Pitcairn, and Dr. Baillie. In 
 our day, the profession of medicine needs a little gentle pres- 
 sure from some such hands as these, to steady it and keep it 
 within bounds. 
 
 A gentleman went from Scotland to consult a celebrated 
 watering-place physician. His complaint was asthma. A 
 •scheme of diet was laid down for him, scrupulously and minutely 
 strict ; and he followed it to the letter. A mixed multitude of 
 medicines was prescribed for him, which had an unpromising 
 look of strife and incongruity. But he took them all bravely 
 and obediently. And verily he> had his reward. He obtained 
 relief of his asthma. But the asthma would still return ; and, 
 as often' as it returned, he betook himself to his dietetic and 
 remedial discipline, and it went away again ; and so his faith 
 was confirmed. In process of time, however, whether the diet 
 was too austere or the medicine too nauseous, and so the flesh 
 began to rebel, or whether a laudable curiosity set him to find 
 out the secret of his treatment and relief, he certainly began to 
 question the necessity of all the means to the end. So, on his 
 next attack, adhering to his dietetic rules, he bravely took no 
 physic. But the asthma abided, and would not leave him until 
 
 n 
 
514 GENERAL EEMAKKS ON THE 
 
 lie had recourse to his accustomed medicines. On the following - 
 attack, he set at nought his dietetic rules, and scrupulously 
 took his physic ; and the asthma passed away as usual. 
 
 It was pretty plain that the physic-bottle contained the 
 cure. But to which of the many ingredients did it belong ? 
 To one or two or three, or to the whole hotch-potch working 
 mysteriously together for good? In a matter which so nearly 
 concerned him, the patient might be pardoned for laying his- 
 rash analytical hands upon the mysterious mixture. It con- 
 tained, among twenty other things, a few grains of iodide of 
 potassium. Ingredient after ingredient was deducted; and, 
 simpler and simpler as the mixture became, it still had equal 
 power to abate the asthma, until the iodide of potassium was 
 deducted in its turn, and then its sovereign power was gone. 
 Again, all the ingredients were tried, excepting only the iodide- 
 of potassium; but altogether they did not touch the asthma 
 remedially. Finally, every other ingredient was excluded, and 
 the iodide left alone ; and alone it displayed a sovereign reme- 
 dial power. 
 
 Fortunate the man who can get rid of an asthmatic attack 
 on any terms ; but unfortunate the art that is content with a 
 rare fortuitous and unaccountable success ; it must be either 
 retrograde or stationary. To scatter above twenty remedies, 
 and to let hit which may, is like pigeon-shooting in companies.. 
 The bird falls; but whose gun was it that brought it down? 
 Nobody is reputed the better marksman after a hundred 
 volleys. 
 
 With all the credit due to pharmaceutical chemistry, and 
 all our obligations to it, I doiibl^ whether, in one chief respect,, 
 it has not done some harm. To bring many important remedies 
 together, and unite them by a lucky combination, and compress 
 them within a small compass, and so place them within the 
 common reach, all this gives a facility of prescribing which is 
 hurtful to the advance of medical experience; The facility o£" 
 prescribing is a temptation to prescribe ; and, tinder this temp- 
 tation, there is a lavish expenditure continually going on of 
 important remedies in the mass, of which the prescribers have 
 made no sufficient experiment in detail. A simple implement 
 or two, which a man has well proved for himself, is worth en 
 
PRACTICE OF MEDICINE. 515 
 
 whole armoury of famous compounds taken upon the general 
 credit. A few thousand years ago, a whole people was in fear 
 and trembling. Their enemy was at the gate. Their hope 
 was turned to a single champion. All weapons of war were at 
 his service. The king's own armour was offered him — his 
 helmet, his. coat of mail, his sword. He did not (how could 
 he ?) resist the vanity of putting them on. But soon he put 
 them off again; for "he had not proved them." And "he 
 chose him five smooth stones out of the brook," and with one 
 of these he did the deed which saved his country. 
 
516 GENERAL REMARKS ON THE 
 
 The Heart and its Affections, not Organic. 
 
 i. — general view of the subject. — the pulse. 
 
 It is always desirable to trace out the just limit of a subject, 
 and to note the right places within it for all known facts ; and 
 also where kindred facts, hereafter to be known, may take up 
 their places beside them. This I some years ago sought to do, 
 as far as my observation then enabled me, for the subject of 
 diseases of the Heart (Lectures on Clinical Medicine, comprising 
 Diseases of the Heart). It was a sketch only that I attempted. 
 But the facts there considered, numerous as they are, and facts 
 of the like nature hereafter to be known, numerous as they may 
 be, would go to make up a part only of the entire subject. My 
 concern was with structural diseases and disorganisations of the 
 heart ; and the facts brought under consideration went to denote 
 them in their kind and in their seat, whether beginning or pro- 
 gressive, stationary or receding, curable or incurable ; also their 
 causes, consequences, and events. 
 
 But there are numerous facts, unquestionably belonging to 
 the pathology of the Heart, which are of another kind, and 
 which cannot be made to fall within the assigned limit. There- 
 fore we must enlarge its boundaries, that nothing may be 
 excluded which is found legitimately to belong to the subject. 
 
 In every organ of the body, and pre-eminently in the 
 Heart, the living actions and sufferings of disease have a compass 
 and a reach far beyond its material framework ; and not only 
 beyond it, but independent of it. Excess and defect in the 
 force of the Heart's impulse, excess and defect in the number 
 of its beats; also derangements of their natural order and 
 sequence, and the same made perceptible in the arteries ; also 
 varieties of morbid sensation immediately referrible to its seat, 
 from a mere sense of weight and oppression to acute and 
 agonising pain : any of these may exist alone, or a few or many 
 of them in combination, and yet the Heart be perfectly healthy 
 and sound of structure. 
 
PRACTICE OF MEDICINE. 517 
 
 But the Heart must act thus and suffer thus from some vital 
 necessity, although that necessity be not demonstrably inherent 
 in its own structure. And not being in the Heart, where is it 
 and what is it ? These truly are the very objects of inquiry. 
 Such affections have been denominated nervous and sympa- 
 thetic. But to call them nervous would seem to imply that 
 they all belonged to one pathological category : and this is 
 certainly not the case. To call them sympathetic, if the term 
 be not taken in any strict sense, would be less objectionable. 
 But if we so designate them, we must be allowed to embrace 
 more than is usually included under that title. 
 
 The Heart passes for the most sympathising organ in the 
 body. And it may be really so ; or it may be that it does not ' 
 in fact sympathise more than other organs, only more appa- 
 rently. For who shall say that every part of the body does not 
 sympathise with every other part, and that its functions are not 
 put out of sorts by every other's detriment or disease ? But the 
 functions of many parts are hidden functions, and we know not 
 how it may be with them. Yet the functions of others are 
 apparent enough ; of those, for instance, which secrete ; and we 
 know that their secretions are ever apt to be altered and vitiated, 
 not merely by diseases of their own, but by diseases, small and 
 great, beginning and ending in other parts, and altogether 
 restricted to them. And so, too, of the heart ; it cannot beat a 
 beat too many, or too few, or too strong, or too weak, without 
 its being straightway perceived ; and thus we become convinced 
 that it has as many modes of abnormal action derived from 
 diseases without as from diseases within itself. 
 
 But it is not enough that sympathies and sympathetic dis- 
 orders should be admitted as bare realities. They must become 
 objects of familiar knowledge, if the physician is to make any 
 safe use of them for practical purposes. 
 
 There are sympathetic affections of the Heart so constantly 
 found in company with certain conditions of disease in the con- 
 stitution at large and in particular organs, that they have seemed 
 to be naturally annexed to them, and have come to be ranked 
 among their symptoms, and taken for proofs of their existence, 
 and for guides of their treatment. Such are the greater force 
 and frequency of the Heart's action in fevers and inflammations. 
 A fever is hardly thought to be a fever, or an inflammation to 
 
518 GENERAL REMARKS. ON THE 
 
 be am inflammation, without them. Nor are these sympathetic 
 affections of the Heart barely annexed to such conditions of 
 disease. They are often found to keep exact measure with them. 
 Degrees of frequency and force in the action of the Heart and 
 arteries, and their variations from time to time, follow degrees 
 and variations of febrile and inflammatory movements, as they 
 increase and decrease and rise and fall, and so give notice of 
 their incidents and tendencies and events; moreover, of what 
 they need and what they will bear, for cure or palliation or safe 
 conduct. 
 
 Again, there are sympathetic affections of the Heart found 
 in company with certain conditions elsewhere, yet neither con- 
 ' stantly so nor in all persons, but occasionally and seldom, and 
 in a few. They look like mere casualties, if such things can be. 
 Or if they come from a real physical necessity (as indeed they 
 may), that necessity does not grow out of the nature of the 
 disease, but out of the constitution of the individual man who 
 suffers it. Such are the palpitations of the Heart and the 
 irregular and intermittent pulse, which sometimes go along with 
 disorders of the digestive and assimilative functions; which 
 attend states of plenitude and emptiness of the blood-vessels and 
 morbid qualities of the blood itself; also which are found in 
 nervous and mental maladies. Of all these I will not say that 
 no orderly account can be given, only that they can hardly be 
 made out to follow exact rules. Nevertheless, they demand 
 careful consideration ; fqr when they come to be viewed in their 
 instances and examples, then will appear their great importance 
 They will not, indeed, be found to claim the rank and value of 
 symptoms, because their alliance with the diseases which they 
 accompany is occasional only and extraordinary. Nevertheless, 
 what is occasional only and extraordinary is sometimes as a light 
 let in from a new quarter, and bringing into view what would 
 otherwise have lain hid. And thus these unwonted sympathies 
 of the Heart denote a possible reach of diseases beyond their 
 common range. Pointing to things which come to pass beyond 
 our thought and reckoning, they serve to abate our wonder at 
 the strange turns and issues of even common diseases, which 
 have taken the wisest and most experienced by surprise. 
 
 But sympathetic affections of the heart, in their wide range 
 and in their multitudinous forms and instances, have a very 
 
PEACTICE OF MEDICINE. 519 
 
 unequal interest. As there are some which cannot be made too 
 much of, so there are others which cannot be made too little. 
 What can be said of palpitations of the heart, and intermissions, 
 and irregularities of its beats, which come and go during a 
 man's whole existence, neither originating in any known disease, 
 nor terminating in any, nor abridging in any measure the 
 ■duration of life. They must come from something, but we 
 know not what. "We may call them sympathetic, but it must 
 foe in a very lax sense. 
 
 There are diurnal variations in the state of the circulation 
 which belong naturally to all men. In the great majority, they 
 ■concern only the force and frequency of the heart's action, 
 raising it a little and quickening it a little at different times 
 ■of the same day. They must be owing to something, yet they 
 are consistent with perfect health. But in some these diurnal 
 variations go beyond the mere force and frequency of the 
 heart's action. They go even so far as to disturb the rhythm 
 ;and succession of its beats, making them intermit and flatter at 
 •different times of the same day. And these two must be owing 
 ■to something, and yet they are consistent with perfect health. 
 
 The observations which have been made may at least serve 
 to notify the extent of the subject in hand. They do not pre- 
 tend to have done anything towards setting it in order. If 
 inquiry into the sympathetic affections of the heart is to be 
 fairly and fully carried out, it must begin with those which 
 -are the most common and the most constant,, and so pass from 
 4hem to those which are more rare. It must start from the 
 well observed varieties of modes and degrees of action in the 
 heart and arteries, which experience takes and uses as its 
 everyday index of diseases and its everyday guides to practice. 
 The elements of the whole subject are to be found in the Doc- 
 trine of the Pulse. 
 
 Before we proceed, let us just consider the standpoints from 
 which we must needs make our survey. There is no organ of 
 the body which during life submits its structural condition so 
 freely to our knowledge, as the Heart. Of the changes it is 
 •capable of undergoing, from age, from accident, or from 
 disease, it is remarkable how many may be fairly reckoned 
 within reach of our diagnosis; its bulk, whether great or 
 .small ; its consistence, whether hard or soft ; its cavities, 
 
520 GENERAL REMARKS ON THE 
 
 whether dilated or contracted, and even which is dilated and 
 which contracted ; its orifices, whether free or straitened, and 
 even which is free and which is straitened. All this know- 
 ledge is put within our reach by auscultation and the stetho- 
 scope. "Without them it would be unattainable, and with 
 them it is only attained after a world of patience and industry 
 and infinite trials and experiments. Difficult, however, as it is. 
 to get, it is pretty safe and sure when we once have got it. 
 Another circumstance, which greatly helps to make our know- 
 ledge of the heart's structural diseases among the surest know- 
 ledge we possess, is that their immediate effects upon the organ 
 itself, as well as their distant effects throughout the body, 
 result in a great measure from mechanical necessity. Hence 
 there is a good deal in every case which can be reckoned with 
 much exactness. But it is far otherwise when the Heart being 
 sound of structure is functionally deranged. All that then 
 arises must come from vital necessity. All our reckonings- 
 are then made from other points of view, and by other means- 
 and instruments, and with less certainty. 
 
 Well, but the elements of the subject are then, it has been 
 said, in the Doctrine of the Pulse. 
 
 There is not any disease, great or small, in any part of the- 
 body, vital or not vital, which the physician does not think to- 
 know better than he would otherwise know it, and treat it 
 better than he would otherwise treat it, by interrogating the 
 pulse. The information he thus gains is sometimes much and 
 is sometimes little ; but very seldom indeed is it none at all. 
 To be fully aware when it amounts to much, or little, or nothing 
 — that is, to appreciate the pulse at its true worth — is among 
 the chief concerns of medical practice. Very seldom, indeed, 
 I repeat, does the pulse convey no information at all. Even 
 when amid a complex of symptoms, it remains just as it is 
 in health ; yet, negative sign as it then is, does it often become, 
 under the circumstances, more pregnant of meaning, and give 
 surer notice of what is going on, and of what should and what 
 should not be done, than the most positive fact among them all. 
 The pulse remaining steady to the force and frequency of health 
 is often the very thing that is wanted to interpret a crowd of 
 urgent and doubtful symptoms ; to stamp them all with their 
 
PRACTICE OF MEDICINE. 521 
 
 true value, and make them pass just for what they are worth. 
 Thus, an appeal to the pulse is indispensable in every case. 
 There is no getting on safely without it. 
 
 But the Heart is the prime mover all the while ; and the 
 heart is so far the pulse. By its all-pervading sympathy, it 
 feels all that is hurtful throughout the body ; and by its own 
 peculiar mode of action it tells all that it feels, and telegraphs 
 intelligence of it through every artery that can be felt. 
 
 The Heart using its proper language of sounds and im- 
 pulses, how clearly and emphatically does it speak of its own 
 diseases to the ear and touch of experience. Then the complete 
 information which we desire comes almost always directly from 
 itself, and further appeal to the arteries is superfluous. On 
 some rare occasions, perhaps, the heart's direct language con- 
 cerning its own diseases may not be so absolutely indubitable, 
 but that it may gain clearness and explanation by what is 
 further spoken through the arteries. But the converse of thi3 
 comes to pass when the Heart is perfectly sound, and when it 
 has nothing to tell of itself, but a great deal to tell of every 
 organ and system of organs in the body beside itself, and of all 
 diseases everywhere beyond itself and out of itself. Then its 
 most frequent, precise, and trustworthy intimations are con- 
 veyed through the arteries, its own direct sounds and impulses 
 being but of rare and occasional use and significance. 
 
 It requires some courage to talk gravely and with a purpose 
 of instruction about common things. For either people do not 
 listen at all, expecting to hear nothing new ; or they listen 
 reluctantly, not liking to be schooled about what they under- 
 stand perfectly (they think) already. And if there be any one 
 thing which medical men may be thought to understand better 
 than another, and to have, literally and in every sense, at their 
 fingers' ends, it is the pulse. And yet I am about to take 
 upon myself to speak even to medical men about the pulse. It 
 lies, indeed, at tbe very root of my subject to do so. But apart 
 from this formal consideration, I am persuaded that I should 
 be rendering an useful service to my profession if I could speak 
 of it as I desire. I conceive that this same lamp, which we all 
 familiarly use and trust to guide our daily path, may still be 
 placed in a better position, and thence be made to throw a 
 
■S22 GENERAL REMARKS ON THE 
 
 more certain light upon the great objects of practical medi- 
 cine. 
 
 All that can be known concerning the pulse, we learn either 
 by attending to each separate beat, or to several beats in suc- 
 cession. By attending to a single beat we learn whether the 
 pulse be hard or soft, large or small, that is, its qualities. By 
 attending to many in succession we learn whether it be frequent 
 •or infrequent, regular or irregular, or intermitting, that is, its 
 number and its rhythm. And it must be obvious that its num- 
 ber and rhythm alone can be submitted to actual measurement, 
 and that all the rest, the qualities namely of each particular 
 beat, is to be determined by the perceptions of the person who 
 feels it. But men's watches agree better together than their 
 perceptions. Looking to our several watches, we have an 
 index as nearly uniform as possible, and sq we are always of 
 •one mind about the number of the pulse and its rhythm. Con- 
 sulting our several perceptions, we use a variable index ; and 
 no wonder that about the qualities of the pulse we are apt to 
 ■differ. Yet, after all, practical men are found to agree pretty 
 well about the quality of the pulse in particular instances. And 
 it is because they consult it with no purpose of refining, but 
 with the single aim of finding in it something to help them in 
 iiheir knowledge and treatment of disease. This single aim is 
 mine. Therefore, in every part of the subject, and above all in 
 this, which is naturally open to refinement, I shall avoid new 
 names and new distinctions ; for I know full well that if I 
 cannot handle the subject with simplicity I shall make a puzzle 
 of it. Let us, then, first consider the number of the pulse, 
 whether it be frequent or infrequent, and the succession of its 
 beats, whether it be regular or irregular, and afterwards the 
 ■qualities of the pulse, whether it be hard or soft, large or 
 small — in fact, these are all the distinctions which I wish to 
 insist upon. 
 
 Let me add a single remark, lest I should seem to affect an 
 over- simplicity. It is one thing for a man to understand a 
 matter for himself and for his own use, and another thing to 
 understand it and explain it for the use of others. Therefore, 
 I would not exclude a regard to other modifications of the pulse 
 (whatever they may be), which any man's own observation 
 
PRACTICE OF MEDICINE. 523 
 
 may have taught him, and which he may have used for guidance 
 and direction in the management of disease. There may be 
 many such with which I have no acquaintance. Still, since 
 there are things which practical men often know assuredly, and 
 employ successfully, yet of which they cannot convey to. others 
 either the knowledge or the use ; and since this is especially 
 true of our present subject, I would willingly avoid those parts 
 of it which, whatever I may fancy myself to know, I am still 
 incompetent to explain. 
 
524 GENEKAL KEMAHKS ON THE 
 
 The Heart and its Affections, not Organic — (continued). 
 
 II. — NUMBER OF THE PULSE. — IS THERE ANY CERTAIN NUM- 
 BER, OR ANY LIMIT BETWEEN CERTAIN NUMBERS, THAT CAN 
 BE ASSIGNED AS ' THE STANDARD OF HEALTH GENERALLY ? 
 
 There is a good deal in the nature of things without us which 
 might favour the expectation that the things within us would 
 be found to observe a more exact and undeviating order than in 
 fact they do. Thus, prior to experience, it might not be at all 
 unreasonable to expect that the pulse would be numerically the- 
 same in every healthy man; that the Heart would contract 
 within the minute a certain number of times, neither more nor 
 less ; that at each contraction it would deliver into the arteries 
 a certain quantity of blood, neither more nor less ; and that the 
 exigencies of health in all organs of the body would require 
 blood to be thus supplied to them according to one exact 
 measure of time and quantity. But a very little observation 
 directed to the point will be enough to show that the pulse of 
 health differs greatly as to number in several men. One man's 
 pulse will be found to beat twenty beats in a minute more than 
 another man's ; while there is no appreciable difference between 
 them of mind or body, and none of habit or pursuit, to account 
 for it. In some, the pulse habitually reaches 80 ; in some, it 
 falls short of 60 ; and in some, and those the majority, it is 
 found at various numbers intermediate between the two. But 
 which tells the best for health and long life — a pulse between 
 50 and 60, between 70 and 80, or between 60 and 70 — my own 
 experience has not yet informed me. 
 
 But while it is true that there is no general law of health 
 requiring the pulse to be of any certain number, and that the 
 same in all men ; and true also that the pulse may take a wide 
 numerical range in several men, and be consistent with health 
 in them all ; yet is there not some certain number which, being 
 found in the great majority, may be deemed healthy by pre- 
 eminence ? The world is very curious about this matter ; and 
 
PRACTICE OF MEDICINE. 525 
 
 physicians have made it so by their constant habit of counting 
 the pulse. Therefore they are bound to give the best answer 
 they can to its questioning. 
 
 People in general have no notion of the sort and amount of 
 evidence often needed to prove the simplest matter of fact. To 
 the question — "What is the numerical standard of the healthy 
 pulse ? — some might answer 68, some 70, and some 72. But I 
 am convinced that, as an ascertained fact, nobody knows any- 
 thing about it. The least sufficient proof .of it which can be 
 conceived would be so laborious, and so beset with possible 
 fallacies at every step, that the result would hardly be trust- 
 worthy. It would require tbat a hundred people at least should 
 be the subject of experiment ; and, considering that they would 
 stand as the representatives of all mankind, a hundred is few 
 enough. Then these hundred men should be all nearly of the 
 eame age, and all in perfect health constantly and every day as 
 long as the experiment lasted ; and they should be under ob- 
 servation for several weeks at least, and in the meantime have 
 the number of their pulse noted and recorded day by day and 
 several times a day. These are a few only of the conditions 
 which the experiment would demand. Lastly would come the 
 formidable calculations of arithmetic, and its severe result, 
 announcing, perhaps, that the number of the pulse in a healthy 
 man at the prime of life was If beats in a second. 
 
 Now, to those who walk about with their eyes open, objects 
 often present themselves with a fidelity and truth which are 
 too apt to suffer diminution and loss when the same objects are 
 submitted to more curious experiments. For Nature herself is 
 wise and discriminative in the conditions she imposes for 
 obtaining different sorts of knowledge ; and thus oftentimes 
 she is sternly practical, requiring that what is intended for use 
 should be learnt by use; bringing all that can or need be 
 known within the reach of daily observation, and presenting 
 it as her own free gift to common sense. 
 
 From use, and the daily habit of counting the pulse, all 
 that concerns its numerical healthy standard must have taken 
 some orderly shape in the minds of most physicians. The 
 following is the shape which it has taken in mine. Perhaps, 
 in such a matter, I may appeal to my own case, and not be 
 blamed for egotism. The oracle of old made it the top of 
 
526 GENERAL REMARKS ON THE 
 
 wisdom to know oneself, but did not fix the credit due to that 
 fragment of self-knowledge which enables a man to keep count 
 of his own pulse. My own pulse, when I am quite well and 
 quite free of excitement both from within and from without is 56. 
 And this number of 56 I meet with in others who are in good 
 health often enough to show that the thing, taken alone, means 
 nothing wrong ; but seldom enough to show that it is not com- 
 mon. The same I would remark of the pulse of 80. I find it 
 often enough in healthy people to make me sure that, taken alone,, 
 it denotes no evil ; but seldom enough to make it uncommon. 
 A pulse which is less in number than 56, or more than 80, is- 
 so rarely the habitual pulse of health, that I am obliged to 
 regard it as exceptional, and can make no comment upon it 
 from my own experience. Practically, then, and saving ex- 
 ceptions, I am wont to consider 56 and 80 as the two extremes- 
 consistent with health. But truly there are eminent odd& 
 between them. 
 
 Surely somewhere between these extremes, and distant from 
 both, are the numbers at which the pulse is most frequently 
 found in the healthy. !Nbw equidistant from both is 68 ; but 
 one would not venture to fix upon this as the number of health 
 by pre-eminence. Thus far, however, one might safely go. 
 The difference between 56 and 80 is 24, or three times eight. 
 Add eight to one extreme, 56, and deduct eight from the other 
 extreme, 80 ; and eight will remain intermediately, including 
 the numbers between 64 and 72. And between these numbers 
 (it would come as near the truth as experience can bring us to 
 say) the pulse is found in the great majority of healthy people. 
 But the centre equidistant between 64 and 72 is 68 ■: therefore it 
 may be added, "that the pulse of health hovers about 68, being 
 as often a trifle more as less, and less as more. 
 
 This, then, is the best answer I have to give to the general 
 question, What is the numerical standard of the pulse in 
 health? 
 
 HAVE INDIVIDUALS A CERTAIN NUMBER OF THE PULSE AS 
 THEIR OWN STANDARD OF HEALTH ? 
 
 But, while there is no general law of health requiring the 
 pulse to be of a certain number, and that the same in all men, 
 
PRACTICE OF MEDICINE. 527 
 
 yet may there not be a special law or (something like it) a 
 necessity of health in each individual fixing his pulse to some- 
 certain number, and keeping it constant to the same ? Obser- 
 vation must settle the question ; and mine leads me to settle it 
 in the affirmative. 
 
 It has been seen what a wide numerical range is consistent 
 with health. Now, whatever be the habitual number of the 
 pulse within that range in the healthy man, it is, as far as I 
 see, always the same so long as body and mind are at rest and 
 under no present excitement. If its number be 60, it is alwa3's- 
 60 ; if- 70, it is always 70 ; if 80, it is always 80. But a very 
 little stir of body, a very little emotion of mind, even the 
 stimulus of a temperate meal, is enough to add a few beats a 
 minute to the pulse of the healthiest man ; and as soon as body 
 or mind is at rest again, or digestion is over, his pulse settles 
 down to its habitual number. 
 
 The causes of excitement here contemplated are independent 
 of disease. They belong to the occurrences of every day, such 
 as even many times every day must and do accelerate the pulse- 
 inevitably and innocently, and then leave it to reach its stan- 
 dard number again. And it always does reach it, if the man be 
 in health. 
 
 Observe, by health I here mean not merely a state of exemp- 
 tion from positive disease, but of exemption too from those- 
 caprices of feeling and function which are called nervous, and 
 are ever making the pulse run wild, and hardly allowing it to- 
 remain at any given number for an hour together. Of health 
 thus understood, it is a chief characteristic that the pulse is- 
 habitually constant to a certain numerical standard, and that it 
 does not deviate from it but for adequate and appreciable 
 causes. These causes, considered comprehensively, involve 
 within them the whole pathological meaning and import of the - 
 number of the pulse both as a isymptom of disease and guide to- 
 practice. 
 
 INCREASED NUMBER OF THE PULSE IN DISEASES. 
 
 There is nothing that a man can feel or suffer — feel as a 
 passing incident of health, or suffer as a constant inseparable 
 element of disease, which may not be put down for a cause of 
 accelerated pulse. Of the incidents of health more need not 
 
528 GENERAL EEMAEKS ON THE 
 
 be said at present. But of diseases, whatever be their kind, if 
 by any avenue of sympathy they can reach the heart, they all 
 accelerate the pulse. All inflammations, all fevers, do so. The 
 inflammation which comes on abruptly from injury, accident, 
 or exposure, and overtakes men in the midst of good feeding 
 and rude health, and calls for blood-letting to arrest it, — this, 
 pre-eminently the inflammation of strength, accelerates the 
 pulse. Again : the inflammation which comes from nothing 
 seen or known, but arises and proceeds furtively in constitutions 
 bad by nature, and made worse by poverty and wretchedness, 
 and admits no blood-letting for its cure, — this, pre-eminently 
 the inflammation of weakness, accelerates the pulse. The fevers 
 {call them by what name you please) which dominated in the 
 hospitals of London thirty years ago, which bore and required 
 and were properly treated by such remedies as exercise restraint 
 upon the movements of the Heart and arteries — by calomel, 
 and antimony, and purgatives, and not unfrequently by blood- 
 letting in its several kinds ; also the fevers which now dominate 
 in the same places, and which will bear no such remedies and 
 no such handling, and are properly treated by whatever can 
 raise, sustain, and stimulate — by wine, brandy, ammonia, — 
 t>ese, pre-eminently the fevers of weakness, and those, pre- 
 « -.uinently the fevers of strength, both alike have among their 
 symptoms the frequent pulse. 
 
 In short, whatever be the nature of the disease, if the Heart 
 feel it at all, however diversely it may otherwise show what 
 it feels through the pulse, whether in rendering it stronger or 
 weaker, harder or softer, larger or smaller, than natural in 
 several cases, it will surely in all of them render it more fre- 
 quent. Often the Heart is a more delicate test of something 
 wrong within the man than his own consciousness. His Heart 
 is beforehand with him. It tells of disease covertly but surely 
 progressive by the unnaturally frequent pulse, while his own 
 feelings persuade him that he is well. At length, after the 
 lapse of weeks or even months, the constitution is awaked, as 
 it were, to a conscious alarm, and, by its fever and its nervous 
 irritation, confirms what the Heart has forefelt and foretold by 
 the frequent pulse. Tuberculous disease often forms and ger- 
 minates and maturates under these conditions. 
 
PRACTICE OF MEDICINE. 529 
 
 DIFFERENCE BETWEEN THE NUMBER OF THE PULSE AND THE 
 QUALITY OF THE PULSE, AS SIGNS OF DISEASE, AND WHAT 
 EACH RESPECTIVELY IMPORTS. 
 
 Such are the facts, stated generally. "We come now to con- 
 eider their pathological and practical import. This greater 
 number of the pulse in diseases, whence comes it, and what 
 does it mean ? What is the nature and amount of help which 
 it contributes towards our knowledge and treatment of the case 
 in hand ? For surely the number of the pulse ought to have 
 a vast deal to teach us, seeing what a point we make of ascer- 
 taining it in every instance. The pulling out of the watch, 
 and the deliberation which follows, must appear to the patient 
 at least the most solemn part of the interview with his phy- 
 sician. And, if this grave business has no great use in it, it 
 becomes a mighty foolish pretence. Far be it from me to 
 allow that it is so. But let us inquire and see. One thing is 
 plain to common sense ; namely, that the number of the pulse is 
 just the sort of symptom which ought to be pushed as far as it 
 will fairly go, and relied upon as far as it can be safely trusted ; 
 for the information it has to give, being in itself so easily ascer- 
 tained and so indubitable, that no two men can disagree about 
 it who are able to count. 
 
 Now the frequent pulse, being equally the accompaniment 
 of numerous diseases different in kind, cannot take its origin 
 from any of those proper elements which severalise them. It is 
 proper to no disease ; yet its constant presence in almost all 
 forbids it to be regarded as an accident in any. Moreover, the 
 frequent pulse is a passing event of health, as well as a necessity 
 of disease. Its origin, therefore, must be sought in something 
 common to both— something belonging to life and sympathy, 
 in their widest sense — something without which neither action 
 nor feeling nor suffering can exist — something without which 
 there could be neither health nor disease. 
 
 For the sake of illustration, let me here anticipate a part 
 of our subject which will be considered hereafter in its turn. 
 Let me take the qualities of the pulse and their meanings, and 
 put them in contrast or comparison with the number of the 
 pulse and its meanings, and illustrate one by the other. The 
 quality of hardness in the pulse has most important meanings 
 
 MM 
 
530 GENERAL REMARKS ON THE 
 
 as a symptom of disease ; but in health. I am not aware that the 
 palse ever assumes that quality, or suffers that quality to he 
 forced upon it. Heat, exercise, and stimulant drinks will for a 
 time augment the frequency and force of vascular action. But 
 mere force of vascular action is a different thing from the 
 quality of hardness in the pulse. This they cannot produce 
 unless they first (produce disease. I am not aware that by any 
 possible contrivance we can make a soft pulse a hard one at 
 will. In order to the change, there must first be disease. 
 Seeing, then, that this quality of hardness in the pulse has no 
 existence apart from disease, I infer it to be in its very nature 
 essentially morbid. 
 
 But in health the number of the pulse is continually found 
 to transgress its habitual standard from obvious causes. Every 
 sense and sensation, every moral feeling and faculty of the 
 mind, opens an avenue to impressions which travel to the heart, 
 and may so operate upon it as to raise the frequency of the 
 pulse without first producing disease. Thus it is that 'the ordi- 
 nary casualties of life accelerate the pulse by exciting thoughts, 
 feelings, and perceptions which are pleasurable or painful in an 
 unusual degree. And thus it is that we can accelerate the pulse 
 at will by subjecting the man to influences capable of being 
 felt above measure mentally, morally, or corporeally. Seeing, 
 then, that this numerical frequency of the pulse, unlike its 
 quality of hardness, may exist apart from disease, I conclude 
 that it is not in its own nature essentially morbid. 
 
 But though it is not in itself essentially morbid, yet is it 
 found in' constant connexion with diseases, and is reckoned 
 among their symptoms. The question then arises, how is the 
 number of the pulse connected with diseases ? 
 
 There is good reason, then, for believing that frequency of 
 pulse is produced in diseases after the same manner that it is 
 produced in health ; and that diseases operate upon the Heart 
 so as to accelerate the pulse, not as diseases, but as simple 
 irritants. They can and do operate upon it as diseases, when 
 they change the quality of the pulse ; and they can and do 
 operate upon it as simple irritants when they change the num- 
 ber. And they may do both the one and the other in the same 
 instance. 
 
 In almost all diseases (it has been already said) the pulse is 
 
PRACTICE OP MEDICINE. 531 
 
 raised above its habitual numerical standard. But no disease 
 can be mentioned in which ifc is always or so far of a certain 
 number, that the nature of the disease can be taken from the 
 number of the pulse. On the other hand, it is only in par- 
 ticular diseases that the pulse assumes certain qualities. But 
 then the quality may be so distinct and unequivocal, and so 
 ■commonly annexed to the disease, as to admit it to be reckoned 
 among its symptoms. This is the case with the quality of 
 hardness in the pulse of inflammation. 
 
 How and whence comes this difference ? It comes because 
 the number of the pulse has nothing to do with the disease as 
 such, but the quality of the pulse has everything. It comes 
 because the number of the pulse is annexed to the moral, 
 nervous, vital conditions of the man, which may be influenced 
 by several diseases in the same way, or by the same disease in 
 several ways, according to the varying susceptibility of in- 
 dividuals ; but the quality of the pulse is annexed to the nature 
 of the disease, which is the same in all men. 
 
 It is, then, the difference of the thing signified which 
 'Separates and contrasts the quality and the number of the pulse 
 as symptoms. The quality gives information concerning the 
 nature of the morbid processes going on. The number tells 
 nothing concerning these processes, but rather intimates how 
 the system at large is affected by them, be they what they may. 
 The quality notifies disease simply ; the number how the con- 
 stitution bears it, whether it feels it in that degree in which 
 {so to speak) it ought to feel it, or feels it less than it ought 
 and is passive under it, or more than it ought and is ex- 
 orbitantly affected by it. 
 
 With this clue we are prepared to deal with the subject 
 more closely. And, albeit the number of the pulse tells nothing 
 "Of the nature of any disease ; albeit it guides neither the choice 
 nor the aim of any remedy, so far as that remedy is counter- 
 active of morbid processes going on, yet it is not without reason 
 that physicians are ever counting it and making much of it. 
 For it denotes things more important than the diseases them- 
 selves, viz. how life and the springs of life are affected by them, 
 Whether they will hold out, or whether they will fail. And in 
 treatment it guides us to things just as important as the very 
 remedies, if there be any such, which are directly cnrative ; 
 
532 GENERAL REMARKS ON THE 
 
 viz. the force and extent to which they can be curatively era- 
 ployed. 
 
 But nothing can be taken for absolutely true in practical 
 medicine. Hence they who profess to teach others out of their 
 own experience, should be careful of using language which may 
 imply more than that experience will justify. At the same 
 time, they must not be continually dealing in doubts and 
 reservations, and so bring their experience below its value by 
 seeming to have small confidence in it themselves. The truth 
 which medicine is concerned with is a truth of degrees ; the 
 same, nevertheless, which the moral world is governed by. 
 Wise men seek it and cultivate it, and make the best of it. In 
 medicine there is small philosophy, and no use in making it 
 seem less than it is. 
 
 That the pulse is constant to a certain number in each 
 healthy man, is a fact already mentioned, and an important one 
 it is. And this fact, it might be thought, would become a 
 standard of reckoning in each man's disease. But in their 
 ordinary practice, physicians seldom come to the management 
 of diseases with the knowledge of this fact. Our patients are 
 too often strangers to us until we are called to treat them ; and 
 then we cannot take for our standard of reckoning the exact 
 number which belongs to health in the individual man, but can 
 only assume the healthy limit of the generality, and consider 
 that his pulse falls somewhere within it, viz. between 64 and 72. 
 It is worth a passing notice, how much safety and success- 
 in the treatment of present disease are promoted, when the- 
 physician has already known his patient in previous health or 
 in previous illness, or in both. Hereditary constitution, and 
 personal constitution and personal habits ; hereditary disease, 
 and personal disease once suffered but now past, may leave a 
 perpetual entail of something able to give a shape or colour to- 
 every future malady which may happen to a man, and suggest 
 one mode of treatment and prohibit another. I am even per- 
 suaded that any single severe attack of disease, and how the 
 patient bears it, and how he gets rid of it, will furnish an 
 exposition of what power there is in him for bearing and 
 recovering from all diseases as long as he lives. And a phy- 
 sician who has had the treatment of him in one such disease, 
 and brought him safely through it, has gained thereby a fore- 
 
PRACTICE OF MEDICINE. 533 
 
 cast of much that will surely be found in all future diseases 
 which he may suffer, as well as of the sort of remedies that they 
 will require. If this, indeed, be true, it were well for people 
 in general that they were aware of it. It might cure them of 
 their fickleness in running from one physician to another, and 
 teach them for their own sakes an honest allegiance to the one 
 who, whatever others may know better than he, knows them 
 best, at all events. 
 
 The health of individuals may differ from the health of the 
 many in some distinct peculiarity, and be sound authentic 
 health nevertheless. And this individual peculiarity of health 
 may impress an inevitable peculiarity upon every disease which 
 the man suffers, and yet leave it not less the same disease as 
 that which bears the same name in the many. The peculiarity 
 of the man's health may be an uncommon frequency or infre- 
 quency in the habitual number of his pulse, and this may be 
 carried forward into all his diseases. Thus, whenever he is ill, 
 his pulse will be much more or much less frequent than in just 
 proportion with other symptoms which constitute the disease 
 than experience says it ought to be. And thus I have known 
 some cases in which the unduly slow pulse of health was still 
 the unduly slow pulse in disease, even in severe disease, and 
 the patient has been thought much less ill than he really was. 
 And I have known many cases in which the unduly rapid pulse 
 of health was still the unduly rapid pulse in disease, even in 
 trivial disease, and thus the patient has been thought much 
 more seriously ill than in fact he was. 
 
 In the treatment of disease our business is with the in- 
 dividual, and our experience of the many goes to fit us for our 
 dealings with the one. Yet it may not exactly fit us. But if 
 to it be added a prior experience, had of the individual now the 
 subject of treatment, then it becomes a perfect experience, and 
 as nearly infallible as the nature of the things to which it is 
 applied will allow it to be. 
 
534 GENERAL KEMAEKS ON THE 
 
 The Heart and its Affections not O'&Gmic^continued). 
 
 III. THE FREQUENT PULSE AT ITS HIGHEST DEGREE OF 
 
 SIGNIFICANCE. — CASES. 
 
 There are things which, as they ordinarily present themselves 
 in nature, are so beset with collaterals that, but for their some- 
 times appearing in simple forms, they could never be fairly 
 understood. Such, among the symptoms of disease, is often the 
 frequent pulse. It is one of a crowd, and is lost in a crowd. 
 It is not duly attended to among many as urgent and as press- 
 ing for notice as itself. But then it sometimes stands almost or 
 altogether alone. There is the disease ; and all that can be 
 reckoned as belonging to it in the nature of a symptom, all that 
 can serve to direct its treatment and prognosticate its event, is 
 a very rapid pulse. 
 
 Such cases are rare ; but still they occur often enough to- 
 afford us opportunities of seeing and noting this symptom of 
 the frequent pulse in its simplest, its most elementary, and yet 
 most prominent form, and the fittest and best to develope its 
 true pathological meaning. 
 
 I was called one Friday, at midnight, to visit a young 
 married lady, aged 21, whose state had given just alarm to her 
 medical attendants. Her pulse was too rapid to be counted, and 
 so feeble that it could only just be felt. She made no com- 
 plaint of pain ; and no questioning, no examination by pressure 
 of the abdomen especially, could elicit the least expression of it. 
 The abdomen was soft, and very slightly distended. The 
 tongue was quite clear and moist ; the extremities quite warm. 
 Moreover, there was perfect consciousness ; and she expressed 
 surprise at the apparent anxiety of those around her. 
 
 Here the only present symptom was the pulse cauntless 
 from rapidity, and scarcely perceptible from feebleness. But 
 there had been another symptom. On the previous "Wednesday, 
 at 8 p.m., suddenly and without warning, there had been a long 
 and severe rigor. No reaction followed, when it passed away ;, 
 
PKACTICE OF MEDICINE. 53 J 
 
 the pulse became extraordinarily rapid and feeble, and it bad 
 so continued ever since. 
 
 A,t 10 a.m. tbe next day (Saturday), tbe state of things was 
 still the same, except that the abdomen had become flattened in 
 consequence of evacuations which had taken place in the course 
 of the night. There was still no positive symptom, but the 
 pulse most rapid and feeble. At 10 p.m. this symptom no 
 longer remained. The pulse was imperceptible at the wrist. 
 The hands were cold. Consciousness remained, and even intel- 
 ligence ; and there was evidently no feeling on the part of the 
 patient that she was going to die. She died in the night ; I 
 did not learn at what time. 
 
 Observe: of this rapidly fatal disease (if disease it was) 
 there were only two symptoms — the long and severe rigor, and 
 the rapid, feeble pulse. But they were not, either one or the 
 other, symptoms in the strict pathognomonic sense, being com- 
 mon to twenty diseases different in kind, and diagnostic of none. 
 But symptoms they were, and both alike, of things incident to 
 all diseases, and terrible when they occur. The inceptive rigor 
 denoted the shock suddenly given to the powers of life ; and 
 the countless feeble flutterings of the heart, which followed it, 
 denoted their surrender. 
 
 Now, as to the nature of the disease in this case, we must 
 seek it in things prior to the inceptive rigor, since it certainly 
 did not appear in what occurred afterwards. This lady had 
 been confined eight days. Tbe labour was favourable. But the 
 placenta was retained, and had to be torn away. Still she had 
 gone on favourably in every respect until the rigor. There 
 was nothing more to be told of previous history ; and this, and 
 experience of the like, were enough to show the nature of the 
 disease, and that it was puerperal fever. But shall I say "that 
 it was," or rather "that it would have been?" The morbid 
 element was taken up, and became a quick- working poison to 
 the powers of life. The disease had either only just emerged 
 and was cut short, or it never emerged at all. The disease^ so 
 to speak, killed itself; it killed itself in the birth. Its first 
 impression was a fatal shook ; and there followed, not the 
 symptoms proper to its own nature, but the one symptom of 
 coming death — this countless fluttering of the heart. 
 
 I was suddenly summoned to a lady, about 40 years of age, 
 
536 GENERAL REMARKS ON THE 
 
 who was to all appearance brought at once within the grasp of 
 death. She was pale and cold, and her lips were livid ; and 
 her pulse was of a countless frequency, and just perceptible, 
 and no more. Her mind was clear ; and she could just be 
 heard to whisper a few articulate words, telling me that she 
 saw all things in a mist, and did not well distinguish one 
 object from another ; and that she seemed as if she were going 
 to be suffocated. This looked awfully like dying. And into 
 this condition she had passed in the course of two hours. 
 
 I had no other expectation than that she would die imme- 
 diately. But hour after hour passed away, and she still lived. 
 Days and nights, even five days and five nights, between 
 Tuesday and Sunday, passed away, and she still lived. She 
 lived, but without the slightest appearance of rallying, and 
 without the least token of any positive disease. The countless, 
 scarcely perceptible pulse, comprised all the symptoms. Brandy, 
 ammonia, ether, anything and all things that could stimulate, 
 were given (for the power of swallowing remained), every ten, 
 or every five, or every three or two minutes, night and day. 
 But they produced no reaction. They kept the heart just 
 moving, and that was all. The pulse was sometimes perceptible, 
 and sometimes not ; and several times, when it was actually 
 gone, and all was over, as it seemed, life and a pulse were 
 brought back again by a larger supply of brandy. 
 
 After five days and five nights thus spent, a change took 
 place ; and it was all at once. It was within a certain half-hour. 
 As I sat by her bedside, I found her pulse had for the first time 
 become distinct enough to allow me to count it. Instead of a 
 confused flutter, it gave 120 distinguishable beats in a minute. 
 It continued perceptibly constant to this number for one half- 
 hour, without the help of brandy. Presently what was dusky 
 became red, what was cold became warm; and so much of 
 reaction brought so much of hope. 
 
 But how did this frightful mystery end ? How did it clear 
 itself up? The tongue became red, then intensely red, then 
 papillated ; and then a rash diffused itself over the neck and 
 chest, then over the whole body. And all was consummated in 
 a regular attack of scarlatina, which went through its course 
 without any unusual or unfavourable incident, and the patient 
 got well. 
 
PRACTICE OF MEDICINE. 537 
 
 In the first of these two cases, there was the highest pre- 
 sumption d priori (perhaps the proof), that the puerperal poison 
 had gained access to the Mood, and had entered into deadly 
 conflict with the powers of life. Had the conflict been less 
 than deadly, it would have had its natural issue in some 
 ^authentic form of puerperal fever, which would have had its 
 own perils. In the second case, there was the positive proof, 
 a posteriori, that the scarlatina poison, gaining access to the 
 blood, did for five days and five nights keep up an all but 
 deadly conflict with the powers of life. But life holding out, 
 the disease appeared as the natural consummation at last. 
 
 Now these two cases have the force of crucial instances. 
 They are experiments of Nature's own contriving, and exclude 
 all fallacy in the result. They prove the true significance of 
 the frequent pulse ; viz. that it is not a thing of disease as 
 belonging to its essence, but a thing of disease and of all that 
 •concerns disease only as being a sign and a measure of the 
 degree in which life and the powers of life are then brought to 
 feel and to suffer, and to languish and fail. And this is the 
 interpretation which the frequent pulse will be found to bear in 
 the whole range of diseases in which it occurs, and in all the 
 conditions, few or many, simple or complex, with which it is 
 combined. 
 
 FURTHER COMMENTARY ON THE FOREGOING CASES. 
 
 But, in these two remarkable. cases, everything was uncom- 
 mon and extreme. They furnished full-drawn representations 
 of the rapid pulse, and, as such, well suited for studying its 
 meaning ; not, however, exaggerated representations, but strictly 
 those which Nature offered. Yet it is startling to be told that 
 the meaning found to belong to the rapid pulse in these two 
 cases is the same in kind which it has in all diseases whatever. 
 The difference between great and small, or of mere magnitude 
 in things of the same kind, is often so considerable, that prac- 
 tically it is difficult to look upon them and believe them to be 
 of the same kind in fact. But, in the things pertaining to 
 diseases, identity of kind, when it is real, ought to be carefully 
 preserved, for the sake of doctrine and of truth. Mere mag- 
 nitude, however, forces itself into notice. And so it ought ; for 
 
538 GENERAL KEMAEKS ON THE . 
 
 life and death continually depend upon it, and it, cannot be 
 ignored with safety to practice. 
 
 In the two cases which have been cited, we have spoken of 
 life and the powers of life; and of the rapid fluttering- pulse 
 bearing sole and infallible witness to their utter prostration 
 and failure. But these expressions denote the truth popularly,, 
 rather than pathologically. Nevertheless, they do denote it. 
 Still they are expressions which, being employed about diseases, 
 are suited only to things of the greatest magnitude in their 
 kind. Accordingly, it would be too much to speak of life and 
 the powers of life being reached and implicated in every case of 
 disease wherein the pulse was frequent beyond the standard of 
 health. But it would be neither too much nor beyond the truth 
 to speak of something being reached and implicated which 
 holds peculiar relations with life — something, belonging to our 
 organisation, which communes with life more nearly and at, 
 once than through the circle of our grosser and more intelli- 
 gible functions. And this is the nervous system. 
 
 Now the nervous system has the heart for its gnomon or 
 finger of the clock. This notes, by the rate of its movement, 
 the various degrees in which the nervous system is affected, 
 from the least to the greatest. It is the greatest which must 
 still engage our attention, and the rapid pulse the index of 
 them. And the cases which have been just cited will help to 
 explain them. To press the language of our analogy a little 
 further, for the sake of illustration, we have already seen in 
 these two cases the index hurrying rapidly round the dial-plate, 
 and telling that, from some cause or other, the mechanism 
 within was running down, and, if it were not arrested, that it 
 would quickly stop. Even prior to any outward presentments- 
 to give assurance of disease, even earlier than its known begin- 
 ning, we have seen the countless fluttering of the heart and 
 arteries give token of the nervous system already under trial 
 of mortal suffering, and ready to let life go for ever. But 
 there is no reason in the nature of things (as far as I know) 
 why a morbid poison, or any other element of disease, should 
 not affect the nervous system soonest of all, and sooner than the 
 blood and blood-vessels, to which it properly belongs to work 
 out disease into its cognisable products and realities. Only 
 experience says that it is rare, very rare. 
 
PRACTICE OF MEDICINE. 539 
 
 FREQUENT PULSE STILL AT A VERY HIGH DEGREE OF SIGNIFI- 
 CANCE. TO WHAT CONDITIONS OF DISEASE IT BELONGS. 
 
 Not until disease is shaped and realised into something 
 •which can he seen or heard or touched, and can be called by a 
 name, is it wont to engage the nervous system perilously ; 
 and should the particular disease, according to its nature, have 
 to go through a stated course to a certain end, and so admit 
 a probable measure of its duration, it -will not commonly be 
 until towards its decline that extreme peril to life is indexed by 
 extreme frequency of the pulse. But the time is often antici- 
 pated. This sign of fearful significance — this countless flutter- 
 ing of the pulse — may break in upon the disease at any stage 
 of its progress, either early, even very early, or in its mid-course. 
 And when it does, some notable thing has often preceded it, 
 well capable of giving a shock to the nervous system. Some- 
 times a sudden profuse diarrhoea has been enough to account 
 for it ; sometimes a haemorrhage ; sometimes an unhappy error 
 of treatment by larger depletion than the patient could bear ; 
 sometimes pain — severe, long, uninterrupted pain ; sometimes 
 loss of sleep ; sometimes the solution of some organic texture 
 within, as the rupture and perforation of a bowel. Sometimes, 
 however, and oftenest, nothing incidental or casual can be found 
 to bear the blame, but only the malignant nature of the disease 
 itself. 
 
 Still there is a hope for these cases ; but it is small. Yet 
 small hope is made much of by the hopeful, and often serves 
 them for a great encouragement. And so it must and had need 
 do now, or there will be no saving of life. 
 
 And there is a treatment of these cases. Death is inevitable 
 if they are left to themselves. None ever recovered but by 
 known, palpable, and adequate means. The treatment is simple 
 enough. A single symptom has absorbed all other indications 
 of treatment into itself, and remains our sole infallible guide 
 what to do. The countless fluttering pulse now stands for 
 everything. Watch must be kept upon it and its meaning. And 
 its meaning is, that the nervous system is ready to sink into 
 death. Accordingly, stimulus is to be given so often and so 
 much as will keep it going and prevent it from coming to a stop. 
 All this is simple enough in the telling. I wish it were so in 
 
540 GENERAL REMARKS ON THE 
 
 the doing. As much, perhaps, has been told as can be told. 
 But the " how often" and the " how much" are the things upon 
 which life now hangs, and a judgment has to be exercised upon 
 them every hour or many times every hour. Therefore the 
 sick man has a poor chance, unless he can now have the services 
 of one intelligent nurse at least entirely to himself. To have 
 also one intelligent physician constantly within reach would 
 not be at all beyond his needs. But it is useless to insist upon 
 what is generally impracticable. Nevertheless, many cases 
 within my experience, in which life has been rescued contrary 
 to all probable calculation, have had this unspeakable advan- 
 tage ; and some of them have occurred in the family of phy- 
 sicians. 
 
 But be it borne in mind that we have now to do with a part 
 only of a very great subject. The nervous system, and its 
 actings and sufferings under disease, this is the great subject ; 
 and our small part of it is the frequent pulse. Nevertheless, 
 small though it be, it is the part which especially offers itself 
 as a handle to the whole. The part, by which we can best lay 
 hold of it, and apprehend it, and study it, and turn our little 
 knowledge of it to practical uses and benefit. 
 
 I wish still to keep hold of this handle that I may show the 
 share the nervous system has in the graver diseases, and how 
 it often determines their form, their course, and their event. 
 
 It is only in the most chronic diseases that the nervous 
 system does not sensibly participate. All which show an ap- 
 preciable progress from day to day ; all to which fever in any 
 measure belongs, either essentially or as an accident ; these 
 cannot exist without the nervous system feeling them and 
 showing that it feels them. Now, almost all such diseases have, 
 in respect of their essence, a due course to run and an end to 
 reach. Phlebitis has its mixture of pus with the blood, and its 
 deposit in abscesses within and without; erysipelas has its 
 diffused redness and swelling ; scarlatina one form of rash, and 
 measles another ; small-pox has its pustules ; typhus has its 
 petechial maculae of the skin, and the typhoid malady has its 
 tumescence and ulcers and sloughs of the intestinal glands. 
 And these several conditions represent the essence of the several 
 diseases, and show it to be different in each. But there are 
 other things belonging to them all in common, which have great 
 
PRACTICE OF MEDICINE. 541 
 
 force in guiding their treatment and ruling all concerning them. 
 It is, indeed, by the essential element of these diseases, and by 
 its mode of working, whether diffused through the veins, or 
 collected in abscesses, or sprinkled over the skin, or scattered 
 through the bowels, that each fulfils its course and accomplishes 
 its end. But it is the great vascular system and the great 
 nervous system that are most conspicuously engaged, and acting, 
 and suffering all the time and in all of them, and the sum of 
 their acting and suffering is called fever. The number of the- 
 pulse is our chief handle for apprehending the part specially 
 borne by the nervous system. 
 
 If the fever be small, with moderate sympathy of the nervous 
 system, there will be moderate frequency of the pulse, with 
 moderate increase of its power, and thus much is natural and 
 perhaps needful. If the fever be greater, with more sympathy 
 of the nervous system, the pulse will rise both in frequency and 
 force. And still all is natural and all is in harmony. 
 
 But, as the sympathy of the nervous system continues to 
 increase, and the frequency of the pulse to increase along with 
 it, anxiety begins to arise ; yet the strength of the pulse will 
 still be the vital safeguard. Let, however, the sympathy of the 
 nervous system increase more and more, and the number of the 
 pulse run on to greater and greater frequency, then assuredly 
 its strength will languish ; and if the balance be not soon 
 redressed, it will become a countless fluttering. And to such 
 extremity is the man now reduced, that this countless fluttering 
 of the pulse will represent all that is vital in him, and all that 
 can be treated in the disease. Gradually or abruptly, in any of 
 the diseases mentioned, this may become the condition of the 
 patient. It is often witnessed in the typhus and typhoid fevers 
 of late years. 
 
 This deadly sinking of the nervous system, represented by 
 the countless fluttering of the pulse, this most terrible incident 
 of febrile diseases ; coming on at their beginning, or middle, 
 or end, sometimes abruptly, sometimes gradually, not abso- 
 lutely hopeless, and not absolutely beyond reach of a remedy, 
 deserves to have all told of it that observation has learnt. "Well, 
 then, having once begun, it may continue many days or nights 
 (three or four) uninterruptedly. And during all that time, the 
 pulse will continue countless and almost imperceptible ; abating 
 
542 GENERAL KEMAEKS ON THE 
 
 nothing of its frequency and gaining nothing of power for all 
 the wine and spirits administered, but only just kept going and 
 prevented from coming to a standstill. And thus the quantity 
 even of spirits given in twenty-four hours has amounted to 
 pints. And after these three or four fearful days and nights, 
 the pulse may become of a calculable number again and of an 
 appreciable power, and maintain itself at the less number and 
 the greater power with a less amount of stimulus, and hence- 
 forth the disease will pursue its course exempt from the alarm 
 of this particular symptom, which is the sure expression of the 
 nervous system collapsing into death. But that the pulse 
 should go on fluttering, and the nervous system go on col- 
 lapsing into actual death, is the more common event. 
 
 Or this terrible incident of febrile diseases may occur after 
 a different manner. The pulse will be countless and fluttering 
 for a few hours, and then, under the use of stimulus, it will 
 recover power and a calculable number for a few hours ; and 
 then become countless and fluttering again. And after the 
 nervous system has thus gone on to sink and to rally alternately 
 for a few days, it will rally permanently, and the pulse become 
 slower and steadier, and the disease will proceed free from this 
 peculiar peril. But more often the nervous system will sink 
 irrecoverably, and the pulse flutter and flutter on, and the 
 patient die. 
 
 There is a very curious and interesting circumstance well 
 worth our notice, to which my observation, if it do not deceive 
 me, has often borne witness as a matter of fact. It is that the 
 nervous system having reached the degree of collapse, indexed 
 by the countless fluttering pulse, carries with it the pathological 
 consequence of suspending for the time the course of the 
 disease. Whatever be the disease which it attends, whether 
 scarlatina, or measles, or erysipelas, or small-pox, and whatever 
 be the stage it has reached, at that stage it will stop, and all 
 specific morbid actions come to a suspense and standstill; 
 perhaps to be resumed, perhaps not. To be resumed, when (if 
 ever) the pulse comes within some clearly calculable number, 
 and remains steadily within it, notifying the steady recovery of 
 the nervous system. Not to be resumed, if the pulse goes on 
 fluttering, although many days have yet to pass before the 
 nervous system has collapsed into death. It is curious how 
 
PRACTICE OP MEDICINE. 543 
 
 ■disease thus under the all-subduing constraint of the nervous 
 system, and halting for one, two, three, or four days, will, when 
 that constraint is taken off, take up its course again from the 
 stage at which it was arrested, and duly proceed to its end. 
 
 What took place in the remarkable case before cited is .a 
 specimen of the same thing in kind as that which now engages 
 •our attention ; only there the disease was latent in its state of 
 incubation ; here the disease is manifest and already formed. 
 There the disease had not yet begun, and the failing nervous 
 system still withheld it from beginning during several days ; 
 here the disease being already formed, the failing nervous 
 system withholds it from proceeding during several days. 
 
544 GENERAL REMARKS ON THE 
 
 The Heart and its Affections, not Organic — (continued). 
 
 IV. THE FREQUENT PULSE AT ITS LOWEST DEGREE OF 
 
 SIGNIFICANCE. 
 
 It is a fallacy to conceive that disease, as represented by its 
 symptoms, is difficult to know and to treat in proportion as it 
 is a thing of more danger and severity and altogether more 
 extreme. The contrary would be nearer the truth. In the 
 cases which have been considered, the symptom of the frequent 
 pulse, as the single representative of the disease and of the 
 vast peril involved in it, and as the single indication of what 
 is to be done to save life, if life can be saved, was compre- 
 hended in all its bearings at a glance. But, in the vast majority 
 of cases, this same symptom will be found less salient, and 
 therefore more to be searched after ; less standing alone, and 
 more one of a multitude, and therefore needing to be compared, 
 contrasted, and weighed with other symptoms, before its value 
 can be ascertained. For, indeed, it always has a value, small 
 or great, though it be a variable value in different cases of the 
 same disease, and variable, too, in the same case at different 
 times. These are things not to be seen through at a glance, 
 but contain matter for patient thought to work upon. 
 
 Now, as we have hitherto dwelt upon the class of cases in 
 which the frequent pulse is at the greatest and highest compu- 
 tation of danger, so we will next touch upon the class in which 
 it is at the least and the lowest, and reserve for our last con- 
 sideration the class which is intermediate between the two. 
 And this last we shall have a better chance of understanding 
 aright by previously knowing the two extremes. 
 
 Take twenty cases, and let the symptoms in each be charac- 
 teristically different enough to show that they represent twenty 
 several forms of ailment or disease ; but let all the twenty have 
 one symptom in common, and let that be the frequent pulse. 
 Such are realities which are presenting themselves day by day 
 
PRACTICE OF MEDICINE. 545 
 
 to the experience of physicians. Further, let the symptoms 
 differencing the nature of the ailment or disease in each 
 particular case he so little severe in any, and the one 
 symptom common to all— viz. the .frequent pulse — be in all 
 so little above the natural standard, that no apprehension is 
 felt about any single case from first to last ; and all the 
 twenty do, in fact, according to anticipation, come to a favour- 
 able result. And such, too, are happy realities familiar to our 
 experience. 
 
 Now what is it which makes the number of the pulse worth 
 the reckoning in such cases as these, that we should take so 
 formal an account of it as we probably should and ought to do 
 in our daily intercourse with the sick ? Perhaps some of ua 
 might not easily be got to trouble ourselves about the meaning 
 of a sympi om which occurred in twenty patients, all of whom 
 got well, as we expected they would, be its meaning what it 
 may. But the frequent pulse, as the accompaniment of disease, 
 is never without a meaning ; and, whether it be of great or 
 small degree, whether it denote a great present danger or no 
 danger at all, its meaning is always the same in kind. In all 
 these twenty supposed cases, the pulse, being a little above the 
 standard of health, denoted that the disease was making itself 
 felt by the nervous system. In none did it represent any pre- 
 sent peril ; but in all it contained the germ capable of possible 
 increase to the greatest magnitude and the greatest danger. 
 
 There are other things belonging to feeling and function, in 
 our vital economy, which follow the analogy of the frequent 
 pulse in this respect, that whether they be much or little, or 
 great or small, they preserve the same meaning in kind; yet, 
 according to their degree, they notify and prepare the way for 
 different results, even as different as life and death. 
 
 Hunger and thirst may amount to nothing more than a 
 little sense of physical impatience, natural, wholesome, and not 
 unpleasant to feel, about dinner-time ; or they may reach the 
 fierce craving which is ready "to demolish stone walls." But 
 they are the same hunger and thirst, after all. The first are 
 the hunger and thirst by which we live ; the last the hunger 
 and thirst by which we perish. And it is the chief business of 
 our lives to provide that the first become not the la^t; and 
 every day we are acknowledging practically the possibility, 
 
 M N 
 
546 GENERAL REMARKS ON THE 
 
 though we have neither thought nor fear ahout its being realised* 
 Nevertheless, we do sometimes find it realised in single instances 
 of shocking notoriety. And the fate of large armies in war, 
 and of some smaller " armies of martyrs," missionaries for 
 man's enlightenment or for God's truth, shows that hunger and 
 thirst should be the care of nations and governments, and that 
 they who put human life to its hardest uses should study to 
 preserve it. 
 
 The same may be said of pain. There is the pain which 
 scarcely disturbs the equanimity of a child, and there is the 
 pain which Mils ; and the first contains the germ of the last. 
 
 THE FREQUENT PULSE OF ACUTE INFLAMMATION IN THE STRONG 
 AND PREVIOUSLY HEALTHY. 
 
 There are diseases, then, almost too much for medicine to 
 combat with, and diseases almost too little for medicine to care 
 about ; and the frequent pulse is an ingredient of both. In the 
 former, it is the one ingredient which is the very gauge of their 
 formidable character ; in the latter, it is that which should at 
 least always prevent us from regarding them with indifference. 
 But there are many diseases far less appalling than the one 
 class, and less trivial than the other, which hold their place 
 between the two, and have a greater practical interest than 
 either. They are uncertain enough in their event to keep both 
 hopes and fears alive during their progress, and amenable 
 enough to remedies to encourage and reward the study of a 
 whole life how to use those remedies aright. These many 
 diseases have still the pulse, and its qualities and number, to 
 present as chief objects upon which such practical study can be 
 profitably bestowed. 
 
 Let the patient be in the prime of life and health, and let 
 his disease have nothing specific or malignant in it, but proceed 
 from some common accidental cause, such as exposure to cold, 
 or mechanical injury, or a blow ; also let the inceptive rigor or 
 chilliness be past, and the disease have now plainly declared 
 itSelf, both what it is and where it is — in fact, that it is acute 
 inflammation in some vital organ. And now, before the disease 
 has had any treatment to interfere with it for good or for evil, 
 or to alter it in any way, the pulse will denote the morbid action 
 in which the blood and blood-vessels are engaged by its new 
 
PEACTICE OP MEDICINE. 547 
 
 quality of hardness, and the sympathy of the nervous system 
 by the increased number of its beats. 
 
 Recollect, it is assumed that the patient was previously in 
 perfect health and the prime of life. At this stage, when the 
 •great trial of the constitution from the disease and its treat- 
 ment is yet to come, the pulse will be more or less frequent 
 from a given amount of inflammation, according as it occupy a 
 part more or less nearly allied with the nervous system by 
 sympathy. To speak generally, the pulse will from the first be 
 more frequent when the inflammation is of the organs within 
 the abdomen, than when it is of the organs within the thorax. 
 Moreover, the inflammation, though just emerged, will produce 
 a greater frequency of the pulse according to its extent ; and if 
 its extent be very great, and the part it seizes upon be in close 
 sympathy with the nervous system, the coincidence may even 
 be fatal. Strange events occur in the course of a long expe- 
 rience, taking one by surprise at the time, but, when duly 
 considered, finding their place in the order of things to which 
 they naturally belong. I have seen, in the young and robust, 
 inflammation (apparently common inflammation) seizing upon 
 the peritoneum, and the pulse at once becoming countless and 
 almost imperceptible, and rapidly sinking into death ; and exa- 
 mination has disclosed the disease pervading the entire surface 
 and every flexure and fold of the membrane. And still it has 
 been in its earliest stage. The membrane has been entirely 
 injected with red ; but scarcely a trace of fluid or of lymph — 
 the proper products of inflammation — has appeared upon any 
 part of its surface or in its cavity. 
 
 But to what order of things does such an event as this 
 naturally belong ? Truly it belongs to the same order with 
 those two remarkable cases already cited. There the disease 
 was in its germ or first development ; but already the nervous 
 system felt it, and was overwhelmed by it. Here the same 
 event is brought to pass in the same way. There the disease 
 partook of a specific poisonous quality, pus-poison in the one, 
 scarlatina-poison in the other mingling with the blood. Here 
 it is of the nature of common inflammation ; but its vast extent 
 and the part it occupies are equivalent for evil with a malig- 
 nant quality. It is no figure of speech, but a literal expression 
 of the fact, to say that the disease destroys itself and destroys 
 life at the same time. 
 
548 GENERAL REMARKS ON THE 
 
 This is a most rare event of inflammation, yet much too 
 interesting not to fix our attention for a moment. Well, but 
 suppose the inflammation acute, and the reaction complete and 
 vigorous, there will be found wrapt up together in the same 
 pulse these two cardinal symptoms — a quality of hardness 
 representing the disease ; and a more frequent beat, represent- 
 ing how the constitution bears it. Such an inflammation will 
 require remedies of much force ; and, at every stage and step of 
 the treatment, the pulse will still denote by its quality the need 
 of the remedy, and by its number the power of bearing it. Let 
 venesection be the remedy. Upon every use of it, a very strict 
 judgment must be held upon its immediate effects; and that 
 judgment is still to be concentred upon the pulse. What now 
 of its hardness, which called for the venesection ? What now 
 of its number, which said that the constitution would bear it ? 
 If, an hour or two afterwards, the pulse has lost much of its 
 hardness and many of its number, then assuredly the venesec- 
 tion has told remedially upon the disease, and not hurtfully 
 upon the constitution ; and, should it return to its former hard- 
 ness and its former number, venesection may be employed 
 again. After the second venesection, the like strict judgment 
 must be directed to the same points ; and, should the pulse 
 again show an abatement of its hardness and its number dimi- 
 nished, then has the venesection again fulfilled its immediate 
 purpose of good, with no contingent evil. 
 
 I cannot determine how often venesection may be safely 
 repeated as a remedy for acute inflammation, the hardness and 
 the number of the pulse thus rising and falling in constant 
 harmony witb each other. But as soon as that harmony ceases 
 to be maintained, or is much disturbed ; as soon as, whether it 
 be after a first or second or third venesection, the pulse, while 
 it has lost its unwonted hardness, is found to retain its un- 
 wonted number, or to have it increased, even greatly increased 
 — henceforth venesection will become a very doubtful or an 
 absolutely forbidden remedy. Thus far it has exercised a salu- 
 tary check upon the inflammation. And the hard pulse reduced 
 to softness testifies as much. But it is now beginning to have, 
 or it has had already, some hurtful influence upon the powers 
 of life, or upon the nervous system ; and the pulse, remaining 
 as frequent as it was, or becoming still more frequent, is- 
 sponsor for the fact. 
 
PRACTICE OF MEDICINE. 549 
 
 Now at this point the inflammation may cease altogether ; 
 and there may fee no further need of remedies properly anti- 
 phlogistic, either great or small. The last depletion brought 
 it to an end, and so did its work upon the disease well, very 
 well. But it would have done its work, upon the whole, better, 
 much better, if, in carrying off the disease, it had not left the 
 pulse as frequent or more frequent than when the inflammation 
 was present and progressive. The thing may be of no conse- 
 quence when we have' constitutions naturally vigorous and 
 healthy to deal with ; only, in now reviewing the treatment, 
 our just judgment of it must be, that we have pushed our great 
 remedy a little further than the necessity of the case required. 
 But the inflammation may not cease at this point ; it may still 
 call for treatment. And the treatment of the inflammation 
 now making progress, with a pulse of more frequency and less 
 power, is no easy task. Of this something may be said here- 
 after. At present, let it be further remarked, that not only 
 when we use venesection, but when we take blood in any way, 
 whether by venesection, or cupping, or leeches ; and, moreover, 
 not only when we bleed, but when we seek to arrest a rapidly 
 progressive inflammation by a rapidly impressive remedy, be 
 that remedy what it may, whether mercury, or tartar emetic, or 
 colchicum, — the number of the pulse still mediates between how 
 much is needed, and how much can be borne. It balances 
 between the force of treatment, as bearing salutarily upon the 
 disease on the one hand, and as bearing hurtfully upon the 
 nervous system and the powers of life on the other. And yet 
 it is not the number of the pulse taken absolutely. It is not 
 any certain number ; but its number as it is increased, or is 
 diminished, or remains the same, day by day, under the working 
 of means and agencies powerful alike for good and for evil. 
 
 THE FK.EQUENT PULSE OF ACUTE INFLAMMATION IN THE "WEAK 
 AND CACHECTIC. 
 
 But inflammation does not befall the young and strong ex- 
 clusively ; it is much oftener found in the weak and cachectic. 
 In them, too, it is more generally incident to all periods of life, 
 and comes from slighter provocations of injury and accident 
 from without. Indeed, its connexion with any external exciting 
 
550 GENERAL REMARKS ON THE 
 
 cause at all is, in the weak and cachectic, frequently so slight, 
 so uncertain and unapparent, that we are led sometimes to deem 
 it altogether spontaneous and engendered from within, and 
 coming direct from the pravity of the constitution itself. 
 
 Now it is a general truth that, in these weak, these cachectic 
 and often seemingly spontaneous inflammations, the frequency 
 of pulse begins earlier and abides longer, and runs up to 
 higher degrees, than in the strong and healthy ; or (to look 
 through the sign to the thing signified) the sympathy of 
 the nervous system and the trial to the powers of life are 
 now felt sooner and more constantly, and are carried to- 
 greater extremity. 
 
 Now, for brevity's sake, let us use the terms " inflammation 
 of strength" and " inflammation of weakness" ; for a little 
 more must yet be said of both in their contrast with each other, 
 if we are to get at the true meaning of the frequent pulse in 
 connexion with either, and gain from it all the help it can give 
 us in their treatment. 
 
 In all that anatomy discloses after death, and, if the part 
 affected be within reach of the ear, in all that auscultation 
 teaches during life, the inflammation of strength and the in- 
 flammation of weakness are the same thing ; no mere anatomist 
 or auscultator can tell which is which. But the same treatment 
 which saves in the one case will kill in the other ; for their 
 treatment is determined, not by the conditions in which they 
 agree, but by those in which they differ. Now they agree in 
 all that is organic ; they differ in all that is vital. What is 
 organic consists in what can be seen, heard, or dissected. "What 
 is vital consists in what is felt and acted, and in modes and 
 degrees of feeling and action — pre-eminently in pain; pre- 
 eminently in fever and its attributes of cold and heat and per- 
 spiration ; and pre-eminently, and above all, in the movements 
 of the heart and arteries, the qualities and number of the pulse. 
 
 It is remarkable how health and strength can entertain in- 
 flammation, and go through with it, and yet show few or no 
 signs of being vitally hurt by it. I have seen a few oases of 
 inflammation requiring blood-letting, and giving its character- 
 istic hardness in the pulse, where the number has not been in- 
 creased a single beat beyond the ordinary standard. Indeed, 
 where there are health and strength, while the inflammation 
 
PRACTICE OF MEDICINE. 551 
 
 denotes its severity by the force of the remedies needed, the 
 number commonly falls short of 100, and seldom exceeds it. 
 But where there are cachexy and weakness, though the inflam- 
 mation appertain to no part in strict alliance with the nervous 
 system, the number of the pulse is commonly very frequent 
 throughout. It often rises at once to 120, and in the end it 
 often exceeds it. 
 
 Thus strength seems to answer the stimulus of inflammation 
 vigorously, but temperately. It puts its characteristic hardness 
 into the pulse, without greatly multiplying the movements of 
 the heart and arteries. It feels the disease, and bears it well. 
 But weakness seems to answer it with (at most) only a show 
 of vigour, and impatiently. It may give something like its 
 characteristic hardness to the pulse, but not without multiplying 
 exorbitantly the movements of the heart and arteries. It feels 
 the disease, and bears it ill. 
 
 But the inflammation of strength and the inflammation of 
 weakness, albeit they are by nature the same things organically 
 and different things vitally, may, by force of accident and cir- 
 cumstances, become vitally equalised and the same. 
 
 The inflammation of strength is very liable to mischance in 
 respect of its treatment. Opportunity is lost ; and when a 
 (.severe and rapidly progressive disease needs a severe and rapidly 
 impressive remedy, opportunity is very precious, and the loss 
 of it may be the loss of everything. Many a fine robust fellow 
 have I seen who has suffered acute inflammation of an internal 
 organ two or three days without seeking or without being able 
 to procure medical aid ; and then, when he has procured it, his 
 disease and its treatment have become a puzzle, from the con- 
 flicting indications which have arisen in the meanwhile. Three 
 days ago, a venesection would probably have arrested the in- 
 flammation, and the patient have been safe by this time, and in 
 a fair way of recovery ; but now, if venesection be adopted, it 
 has been because present symptoms have made us rather afraid 
 to omit it than ready to use it. There has still been an inflam- 
 matory hardness in the pulse ; but, to set over against it, there 
 has been great frequency. There has been enough of heat and 
 enough of seemingly vigorous action still remaining ; but, to 
 set over against them,, there has been too much of nervous sym-. 
 pftthy, too manifest a trial of the powers of life already begun. 
 
552 GENERAL REMARKS ON THE 
 
 "Well, venesection has been adopted ; and, happily, it has 
 been just in time. It has abated the hardness and diminished, 
 the frequency of the pulse, and raised the nervous system and 
 the powers of life. And thus the inflammation has reclaimed 
 the characteristics of the constitution to which it belongs, and 
 been still the inflammation of strength. 
 
 Or venesection has been adopted; and, unhappily, it has 
 been just too late. It has taken the hardness out of the pulse, 
 but it has greatly augmented its number. Also it has sunk the 
 nervous system and the powers of life. The inflammation has 
 lost the characteristics of the constitution to which it belongs, 
 and become the inflammation of weakness. 
 
 But the inflammation of strength has been turned into the 
 inflammation of weakness in other ways than by unavoidable 
 mischance. Among the perils of disease we must not refuse to 
 reckon the errors of physicians. And this truth has had its 
 instances and its proofs when inflammation was to be treated 
 by venesection or some sort of blood-letting. The choice of the 
 remedy, and its time, and its measure, and its iteration, whether 
 often or seldom, or not at all, are confessedly among the diffi- 
 cult things of medical practice ; and he must be either very 
 self-complacent or very oblivious who cannot call to mind that 
 herein he has ever fallen into mistake. Amid many possibilities 
 of error, it would be strange indeed to be always in the right. 
 Nor among the perils of disease must we refuse to reckon the 
 interference of friends with its treatment ; and this, too, has 
 been seen when inflammation has had to be treated. And, in 
 charity to human feelings, it is hard to blame them. They see 
 a perilous disease and a perilous remedy. They cannot restrain 
 their anxiety. But it is unfortunate when they show it by dis- 
 trustful questionings at every turn of the disease and on the 
 use of every remedy ; thus always aggravating to the physician 
 his sense of responsibility, at the hazard of overruling his 
 judgment, and of withholding him from doing the full measure 
 of what is right. And too often this has been the sad result. 
 What might have been wholly remedied has been only half 
 remedied ; and what has remained has been far less tractable 
 now that it is allied with weakness instead of strength. In 
 truth, there is nothing in practical medicine harder to deal with 
 than this inflammation of weakness, whether it be natural 
 
PRACTICE OP MEDICINE. 553 
 
 weakness, or the weakness of circumstances and accident, or 
 strength abused into weakness by the fault or mischance of 
 medical treatment. It is all practically the same thing, how- 
 ever it come to pass. 
 
 Let it be remembered, however, that our subject is not in- 
 flammation and its treatment, but frequency of the pulse. Yet 
 this frequency of the pulse was not to be understood in its 
 pathological significance, otherwise than by our becoming 
 acquainted with it in those diseases which display it most con- 
 spicuously. Such are fevers and inflammations. For in them 
 the nervous system is most largely engaged. And the nervous 
 system, for the share that it has and the part that it plays, has 
 its surest index and measure in the number of the pulse. 
 
 Already, as to the inflammation of strength, we have gone 
 so far into its treatment as was needed to show the number of 
 the pulse guiding and regulating it. And just thus far, and 
 with the same intent, we will now touch upon the treatment of 
 the inflammation of weakness. 
 
 In the inflammation of strength and its treatment, we 
 showed the number of the pulse arbitrating between the cura- 
 tive and hurtful effects of great remedies, sanctioning their use 
 up to a certain point and no further, and thenceforth forbidding 
 them. We followed the treatment so far as, under this safe- 
 guard, the operation of these remedies was successful. But we 
 ceased to follow it, when the inflammation was found still to 
 continue, and the pulse becoming more frequent no longer 
 sanctioned the use of the same remedies for its cure ; when, in 
 truth, the inflammation has assumed the characteristics of 
 weakness, and required another treatment, but still under the 
 same safeguard. For in the inflammation of weakness, as in 
 the inflammation of strength, the number of the pulse does not 
 directly suggest the use of any remedy or any mode of treat- 
 ment ; but here as there it still serves for an arbiter. Here as 
 there, when other indications have pointed directly to the 
 remedy or mode of treatment, then it sanctions, or forbids, or 
 moderates their use. 
 
 Let it always be borne in mind that the progress of inflam- 
 mation within the part from one stage to another, until it 
 reaches irreparable disorganisation, need not be less rapid when 
 allied with weakness than when allied with strength. It does 
 
554 GENERAL REMARKS ON THE PRACTICE OP MEDICINE. 
 
 not move slower, because ifc moves with less force. And thus it 
 calls as much as ever for a remedy and requires as much as ever 
 that the remedy should be seasonably applied. Only the direct 
 and immediate aim of the remedy is now different. 
 
 The ultimate aim of all treatment is indeed the same. 
 "Whether the disease be one of weakness or of strength, be acute 
 or chronic, be common or specific, the end and aim is to cure it. 
 But intermediately treatment has to do with many an aim which 
 is not the end itself, but only conducive to the end. 
 
 When there is much and unremitting heat of skin, and the 
 pulse is hard and yet but moderately frequent, and the vascular 
 system and the nervous system are strongly and steadily 
 reacting, and all that moves and all that feels within the man 
 are (so to speak) doubly alive, then, the fact and the seat of the 
 internal inflammation being once ascertained, it is less abso- 
 lutely necessary for the success of our treatment to go into its 
 particulars. It is enough, for the present to take the inflam- 
 mation in its largest sense, without noting its stages and its 
 consecutive phenomena from day to day or from hour to hour. 
 For now the remedy has a less concentrated aim. The indica- 
 cations of treatment are more diffusive and general. 
 
 But in proportion as the heat of skin is less sustained and 
 less in degree ; and the vascular system, and the nervous sys- 
 tem, and all that moves, and all that feels, show less of reaction 
 and less of life, and the pulse is less hard and more frequent, 
 then we have the more need to be acquainted with the exact 
 seat and stage of the inflammation and all its organic condi- 
 tions ; and its shif tings and movements from day to day ; its 
 advancing, or receding, or standing still. For now the treat- 
 ment is more and more drawn towards the part, and more 
 concentrated in its aim. 
 
 Between no display of strength in the constitution at large 
 and extreme weakness ; between no notable sympathetic reac- 
 tion and vital surrender and collapse, there are many states and 
 degrees ; and the progress, the rapid progresSj of inflammation 
 in the part is compatible with them all. 
 
A WORD OR TWO 
 
 ON 
 
 MEDICAL EDUCATION: 
 
 AND 
 
 A HINT OE TWO FOR THOSE WHO THINK IT NEEDS 
 EEFOBMING. 
 
 By P. M. LATHAM, M. D. 
 
 [EXTBACTEIJ IEOM THB "BbITISH MeDICAI JOUBHAL," FEB., 1864.] 
 
 "Science is his forte, omniscience is his foible." This was 
 spoken by one well able to instruct mankind ; and with such a 
 lucky way of doing it, that he could wrap up wisdom in a 
 witticism. And this was one of the wisest and wittiest things 
 he ever said. He aimed it at some individual, and perhaps hit 
 him and made him smart. Had he aimed it at our profession, 
 would he have hit it ? Perhaps he would ; and if he had, we 
 Bhould only have laughed at it. For crowds keep one another 
 in countenance where individuals feel sharply. 
 
 The Profession of Medicine, in itself and in the things 
 pertaining to it, is running over with knowledge. The studies 
 proper, preparatory, and collateral to it, are enormous. There 
 are given us things to see which for their minuteness make our 
 eyes crack; and- things to understand which for their vastness 
 and infinitude, as they come pouring in upon our minds, make 
 us cry out, " Hold, enough !" Well may they, small and 
 great, all so generously forced upon us in the way of educa- 
 tional culture, turn us poor physicians to sadness, when we 
 think of the return the world may expect at our hands. 
 "Beneficia eousque lseta sunt dum videntur exsolvi posse; 
 ubi multum antevenere pro gratia odium redditur." (Tacit. 
 
556 A WORD OR TWO ON 
 
 Ann., iv. 18.) Benefits give pleasure as long as they seem 
 within the possibility of repayment; when they have gone 
 much beyond it, dislike takes the place of gratitude. Is not 
 the medical profession at this day accumulating scientific obli- 
 gations upon itself, which it can never pay in any tangible 
 current coin of usefulness either to itself or to the world. 
 
 Having been a good long time physician to a large hospital, 
 I was in the way to see how medical men might be made or 
 marred in the training. So noting or fancying some extrava- 
 gances in the course of their education laid down by authority, 
 and thinking they boded some harm to the profession, I 
 presumed to bear my moderate testimony against them. This 
 was more than a quarter of a century ago. But my voice was 
 a feeble one. It was no match at all for the edicts of halls, 
 colleges, and institutions, new and old, which were rivalling 
 one another in the ruinous amount of taxation they levied upon 
 the time and thought of medical students, with their hundreds 
 and hundreds of lectures sentenced and inflicted upon them 
 without mercy. At length, however, I am told that our rulers 
 are going to revise their taxation papers, and make their 
 educational imposts with some regard to what their subjects 
 can bear and can afford. Some public bodies, upon a retrospect 
 of this quarter of a century or more, have come to find out 
 and proclaim their error, and are honestly bent upon repairing 
 it. And they shall not want my voice, though now much 
 more feeble than ever, for their encouragement and congratu- 
 lation. 
 
 There is no doubt whatever that the grievance has been a 
 real and serious one, and that the more thoughtful students and 
 the best and more experienced teachers and practitioners of 
 medicine and surgery have been convinced in their own minds 
 that it was so, even for more than a quarter of a century. 
 
 It is now two and twenty years since I ceased to be physician 
 to St. Bartholomew's Hospital, and it was a few years before 
 that time, that I had a most interesting conversation with two 
 medical students. They possessed the better order of minds, 
 and had devoted to their professional education at St. Bartho- 
 lomew's three years with great applause. The day for the 
 annual award of prizes was just passed, and they had swept 
 away between them all of any account and credit. On the 
 
MEDICAL EDUCATION. 557 
 
 following day, they came to me both together, begging to be 
 told how they were to learn their profession. This was the 
 simple way in which they put the question to me. There was 
 no mock humility in it. Their look and manner were much 
 too serious for me to suspect anything of the kind. Thus the 
 matter stood with them upon their own showing. During 
 three whole years they had been hard at work upon all that 
 lectures and museums could teach them. And verily they had 
 thus far their reward. But they had utterly neglected the 
 wards of the hospital. This was their own honest confession 
 and regret. Their avowed temptation and excuse were the 
 eclat that awaited them when they returned into the country, 
 from the distinctions they had gained. 
 
 Here are two right-headed, accomplished students, in the 
 hour of their triumph, convinced that thus far they had not 
 gone the right way to work for making themselves good prac- 
 titioners. 
 
 Ten or a dozen years ago, I was present at the annual cele- 
 bration of one of our medical schools. The distribution of the 
 prizes had already begun, when an eminent member of our 
 profession came in, and, finding a place vacant near me, he 
 took it and sat down, and looked over the printed list of success- 
 ful candidates which I held in my hand. Whereupon he ex- 
 claimed, " Fifty distinguished students ! why, they will all be- 
 ruined!" He to whom I allude was then our best living 
 example of science and practical experience combined in their 
 just proportions. In him they had done all that they could do 
 for professional success, and he was looked upon by the world 
 as well deserving the high position which he held. He held it 
 without envy. Moreover, he had been a teacher. Now hi& 
 words need not be taken at the full of what their literal force 
 will bear. But at least they meant this : that the system under 
 which the fifty medical students had gained their present credit 
 was a wrong system in itself, and that so they would find it in 
 the long run. 
 
 Take, then, Sir Benjamin Brodie — for he was the man to 
 whom I allude — to represent the best and most experienced of 
 teachers and practitioners, and take the two students who have 
 been mentioned to represent the more thoughtful of their class, 
 and we have the sober judgment of learners, teachers, and 
 
558 A WORD OR TWO ON 
 
 practitioners, that there has been something radically unsound 
 in the medical education prescribed by authority for more than 
 a quarter of a century. 
 
 I often think of my profession and its fortunes as of a poor 
 man with a crowd of rich and noble relations. He thinks 
 surely they must help him in the world. And so he cultivates 
 them assiduously ; and perhaps they are well enough disposed 
 towards him. But then they are not constantly taking him by 
 the hand, and lifting him over the rough places of life ; and 
 simply because they cannot. The truth is, they do not under- 
 stand his daily objects ; and if they were to meddle with them, 
 they would only mar them. Perhaps, however, they may 
 render the poor fellow good service every now and then by 
 chance. Besides he has always the credit of belonging to 
 them ; and that is something as the world goes. But let him 
 beware of that very common evil among us, the vanity of large 
 acquaintance ; of having, or affecting to have, an intimacy with 
 everybody worth knowing. It is a vanity not fit for all men to 
 indulge in. All cannot afford the expense of time and trouble 
 required to keep it up. 
 
 Now here are real truths signified, whether my parabolical 
 mode of putting them be wise or foolish ; truths in which our 
 profession is concerned, and would do well to consider. There 
 is nothing honest or of good report in the whole world, nothing 
 of scientific truth or of high speculation, morally and mentally, 
 with which medicine does not claim legitimate kindred. But 
 then there are cunning genealogists among us who would make 
 out the links of kindred to be surer and closer than they are, 
 and the rest of us acquiesce for the glory of the thing. 
 
 There is not a more difficult problem in the world than the 
 education for a particular profession. In universities, so that 
 the things taught be good in themselves, education may be as 
 miscellaneous and omnifarious and even as redundant as you 
 please. The object is to rouse the mind and let it make 
 acquaintance with its powers and inclinations, so that it may 
 judge of its own natural fitness by what it is able to do the 
 best. In universities, education is for all professions and for 
 all callings. But when you come to the particular profession 
 or calling, whatever it may be, and seek to educate for it, you 
 must draw to a point, and become discriminate and eclectic, 
 
MEDICAL EDUCATION. 559 
 
 and above all, very fearful and suspicious of redundance and 
 excess, especially if it be the medical profession with which yon 
 have to do. 
 
 Now what is this medical profession ? It is the art how to 
 treat, cure, and minister all possible relief to men, women, and 
 children, when they have come to harm from disease, accident, 
 or any other adversity. This is the core and kernel of the 
 whole matter. And with this strictly and restrictively in view, 
 a sort of magistracy was given to certain bodies over medical 
 education for the public good. It was empowered to settle, 
 first, the course of training indispensable for all who would 
 practise medicine and surgery ; secondly, to test by sufficient 
 examination, one by one, the competency of all, before they 
 enter it : to tell them how they are to fit themselves, and then 
 tell the world who are fit. 
 
 Here are two about as delicate and ticklish problems as can 
 well be conceived ; and one can plainly see that in both of 
 them the temptation would be to err on the side of excess and 
 in things extrinsic ; an error which, of all professions in the 
 world, ours would least bear with impunity. 
 
 For the first are instituted lectures on Anatomy, not a few, 
 but by hundreds ; lectures on the Principles and Practice of 
 Medicine, lectures on the Principles and Practice of Surgery, on 
 both not a few, but by hundreds ; lectures on Forensic Medi- 
 cine, including Toxicology and Toxicological Analysis ; lectures 
 on Materia Medica. Every one of these things, by the very 
 names they bear, claim or seem to claim their right of place in 
 medical education. 
 
 Then there are lectures on Chemistry as a Science, lectures 
 on Botany as a science. 
 
 But Physiology remains to be mentioned, which, in the 
 hands of a powerful, accomplished, and popular teacher, may 
 be made everything of, and so win the student's mind away 
 from all other teaching. The subject itself is infinite. The 
 difficulty must always be to keep it within bounds, and make 
 it the subject of a separate course. There are physiologies 
 animal and vegetable, and physiologies de aere, aquis et locis — 
 physiologies that may be made to comprise the whole world 
 within us and the whole world without us. 
 
 On most of these subjects, it is not thought enough to 
 
560 A WOKD OR TWO ON 
 
 specify the number of lectures to be attended : prizes are 
 offered annually to stimulate competition, and are given to 
 the most proficient in all of them. The sum of the knowledge 
 which they contain implies a respectable start on the way to 
 omniscience ; and the student who, with thus much in his head, 
 can still find room for a trifle of medicine and surgery, may be 
 almost said to know a little of everything. Now I am con- 
 vinced that none are helped to become good practitioners by 
 this discipline ; that the majority are hindered by it ; and 
 those who, having gone through it, turn out good practitioners 
 nevertheless, become such in spite of it. 
 
 But where is the excess ? What are the things extrinsia 
 that can be pared off? Many a great chemist, a great 
 botanist, or a great master of analysis, may be found to con- 
 tend that what he has to teach is indispensable to the medical 
 student ; that the principles of his science are at the root of all 
 rational practice. But beware of great authorities. They have 
 a tyrannous way with them. They make common sense afraid 
 to stand up and say what it knows to be right. Believe them, 
 and they would commit the student to the whole circle of the 
 sciences, and make him unhappy because he finds himself unable 
 to follow his leaders. Surely there must be some shorter and 
 easier way than theirs of making physicians and surgeons, and 
 yet a safe way withal, or it will fare badly with mankind. 
 
 Now I have my own little suggestion to offer. It is a 
 humble one, but not unbecoming wise men to adopt: a 
 humble one, but bringing no loss of glory to the profession in 
 the end. Have a very great care, then, of your medical 
 student, and how you guide him at starting. Now especially 
 is the time for good advice, if you have any to give. Take 
 him now into the wards of the hospital at once ; fit or unfit, aa 
 people reckon fitness, thither take him. He may have learnt 
 all sorts of things already, or he may scarcely have learnt 
 anything at all. But as soon as you have become his masters, 
 thither take him, and there let him remain and make it for the 
 present his sole field of observation and thought, or curiosity, 
 and have a guard that the best things from without do not 
 reach him there, to his hindrance or destruction. 
 
 When you would teach a man to read, you do not begin 
 with the history of letters ; where and by whom letters were 
 
MEDICAL EDUCATION. • 561 
 
 first invented, and where and by whom the printing-press ; but 
 you leap over a century or two without remorse, and put a 
 dainty alphabet into his hand, and tell him something about 
 vowels and consonants. But about labials, dentals, and gut- 
 turals, the less said the better. Lips, teeth, and throat make 
 their own division of labour, and settle matters for themselves 
 wonderfully. People do not come to read by being taught the 
 philosophy of reading, but simply by doing the thing itself, 
 simply by reading. So, if you would teach a man medicine 
 and its practice, you must not begin with half a dozen philo- 
 sophies, or with any philosophy at all, but you must put, as it 
 were, his alphabet into his hand at once, and bid him learn its 
 simple characters one by one, and then help him to joiD them 
 together and make the best sense of them he can. 
 
 "Well ! but your student in the wards of the hospital is con- 
 sidered to be making acquaintance with diseases, specialising 
 them, learning their right names, discerning between this and 
 that, and getting up his diagnostics and nosologies. Yerily 
 this is a good deal more than learning his alphabet, and a good 
 deal beyond it. For technical names and diagnostics and noso- 
 logies import the finish and last polish of his perfect work ; yet 
 great stress is laid upon them, enough to imply that the common 
 run of individual cases can be finished and polished off in this 
 fashion. But go into hospitals, and see the facts how they 
 stand. There you find diseases mature and complete ; and 
 there diseases (and plenty of them) immature and incomplete, 
 and scarcely deserving the names they bear : diseases in their 
 embryo, their travail, their gestation, now coming to the birth, 
 now ending in abortions— their course broken in upon, and 
 their events determined by accident. Truly there are things in 
 these hospital wards better worth learning than the diseases 
 themselves — more simple, more primitive, more alphabetical 
 (if you please) and yet more profound— things which are a key 
 to the very diseases and their agreements and discordances ; a 
 kev to their remedies, too, their successes, and their failures, 
 ana to discrepancies of their effects inexplicable without them ; 
 which tell why pneumonia (so-called) is now cured by bleeding, 
 and now by brandy. These primitive, simpler, and more pro- 
 found truths are now what they have been always. They are 
 the common ground upon which the great physicians of distant 
 
 oo 
 
562 A WORD OK TWO ON 
 
 times, Sydenham, Heberdenj and the President of the College- 
 that now is, would be. found to think andi act alike, and upon 
 which (were it possible) they could meet and consult together 
 to-morrow, and treat, as well as they could be treated, most of 
 the; great emergencies of diseases. But what are the things? 
 They are pains ; they are heat and cold, and sleep and wakeful- 
 ness; and they are the pulse: all easily read, but all vital. in 
 their details, and vital comprehensively, including the sentient 
 energy of the nerves and vital motive energy of the blood- 
 vessels; throughout the body. In a word, they are the imma- 
 terialism of disease, with which a man can only gain acquaint- 
 ance by constant and familiar converse. 
 
 So unlike all other things in the world are medicine and 
 the practice of it, that indications of treatment (simple things, 
 but great mysteries) need to be pointed out to the most intelli- 
 gent student with the care and patience that you would teach 
 his letters to a child. But, in order to this, you must have the 
 right men for physicians to hospitals, and they must choose the- 
 right men for their clinical clerks. And thus there will be- 
 gradations of- clinical teaching and learning, free and .unf orcedj 
 which every man will look back upon in life as the best and 
 soundest part of his professional education. 
 
 Now your student, who. is to begin in the wards of the- 
 hospital, must continue to frequent them with the mind of a< 
 learner during all the years of his pupilage. 
 
 But lectures, • courses of lectures on. medicine or surgery 
 (for-of these only would I venture to speak), when are they to 
 come? Not too soon. Not until the student, from .such, ex- 
 perience as he has, can exercise some judgment upon thesubject 
 matter of what he hears. Unquestionably, there is> great profit 
 to be had from ■ lectures, if they come in at. their proper place, 
 and are properly used. Still, mixed with their: good, there is 
 some hazard of evil. They are a temptation to the, more con- 
 templative mind to learn • diseases by the study of models,, 
 rather- than ■ of the things themselves. They tend to divorce 
 him 1 from" the workshop and the chips and fragments and rude 
 designs that lie-about' within dt, and introduce him (into: a room 
 swept and garnished and hung round with .masterpieces for; his 
 contemplation. This maybe alii very well for gentlemen who- 
 patronise the arts ; but this is not the way to make, thei artiste 
 
MEDICAL EDUCATION. 563 
 
 Here I must stop. The whole subject of medical education 
 is far too large and difficult for me, and I confess myself not up 
 to it ; but it is exciting at the present moment a just and serious 
 and painful interest, and presses hard upon the wisdom of those 
 who, fully aware of its past mistakes, are expected to decide 
 what henceforth it shall be. There is one part, however, of 
 medical education in which I was once actively engaged, and 
 had come to hold strong beliefs. Upon it, at least, I thought I 
 might venture to touch. But what I had to say must be said 
 quickly, and now or never. I must strike while the iron is 
 hot, while the interest of the subject is at its glow. Let this 
 be my excuse for meddling with the subject at all, and plead 
 my pardon if the " word or two" and "hint or two" which I 
 have presumed to give my betters should be wide of the mark. 
 
ERRATA. 
 
 Page 95, line 3 from bottom, for "interruptions" read " interruptions." 
 130, „ 10 from bottom, for " perineumonia" read "peripneumonia." 
 166, „ 3 from bottom, for "mucus" read "mucous." 
 
 183, „ 1 from bottom, for " Ascultatory" read "Auscultatory." 
 
 184, lines 3, 19 and 20, for " Ascultation" read "Auscultation." 
 192, line 10 from bottom, for " right side the chest" read " right side of 
 
 the chest." 
 273, last line, /or "ilium" read " ileum." 
 434, line 11 from bottom, for " other" read " either." 
 482, „ V, for " as much as from'' read " as much from." 
 552, „ 4, for "reclaimed" read "retained" (?). 
 
INDEX 
 
 Abercrombie, Dr., quoted, ii, 75 
 Abernethy, Mr., work of, ii, 45 
 Abscesses, at Millbank, ii, 270 
 
 — from secondary pericarditis, i, 293 
 Abstractions are not facts, ii, 70 
 Acceleration of pulse, ii, 527 
 Accident, leading to disorganisation of 
 
 heart, eases of, i, 344, 346 
 Accidental symptoms, i, 304 
 Acute and chronic disease, differences, 
 
 i, 442 
 ■ — rheumatism, proportion of heart 
 
 disease in, i, 86 
 Adhesion of pericardium, i, 292 
 Advice as to medical studies, ii, 37 
 iGther in angina pectoris, i, 467 
 Age a cause of valvular heart disease, 
 
 i, 302 
 Ague, cure of, by cinchona, ii, 3S9, 366 
 Albuminuria, i, 364 
 Alcohol in secondary lung affections, i, 
 
 428 
 Alteratives, ii, 405 
 Amaurosis, mercury in, i, 171 
 Ammonia in angina pectoris, i, 467 
 Anaemia, i, 416 
 
 — following cardiac inflammations, i, 
 
 234 
 
 — in hypertrophy of heart, i, 382 
 
 — softening of heart from, i, 388 
 Anaesthetics, ii, 484 
 
 Analogy, ii, 74 
 Anatomy, ii, 55 
 
 — must be learnt, ii, 21 
 
 • — morbid, in bowel complaints, ii, 227 
 with nervous symptoms, ii, 
 
 252 
 Andral, cases by, i, 221 ; ii, 179 
 Aneurism of heart, i, 315 
 Aneurismal dilatation of left ventricle, 
 
 cases of, i, 317, 322 
 Anger in angina pectoris, i, 477 
 Angina pectoris, i, 446 ; ii, 81 
 
 cases of, i, 450, 452, 453, 475, 479 
 
 ■ condition of heart in, i, 446, 457, 
 
 470 
 
 Angina pectoris, paroxysm of, i, 465, 475 
 
 with pericarditis, case of, i, 222 
 
 treatment of, i, 467 
 
 Anodynes, ii, 485 
 Antimony in erysipelas, ii, 461 
 Antiphlogistics, ii, 495 
 Antiphlogistic power of mercury, i, 160 
 Aorta, dilatation of, i, 353, 446 
 
 — narrowness of, case of, i, 355, 356 
 Aortic valve, rupture of, case of, i, 341 
 Apices, pneumonia of, ii, 175 
 Apoplectic coma in heart disease, i, 431 
 Army, practice in, ii, 417 
 Aromatics in diarrhoea, ii, 290 
 Arterial circulation, effect of unsound- 
 ness of heart upon, i, 399 
 
 — disease, with softening of heart, 
 
 i, 390 
 
 — system, disease of, i, 384 
 
 . causing dilatation of heart, i, 362 
 
 Asthma, ii, 116, 183 
 • — case of, ii, 513 
 
 — ."jugular pulsation in, i, 397 
 Asthmatic diseases a cause of dilata- 
 tion of heart, i, 359 
 
 Atrophy of heart, i, 335 
 
 with angina pectoris, i, 446 
 
 effect of, upon circulation, i, 401 
 
 treatment of, i, 386 
 
 Auscultation, ii, 96, 99, 101 et seq. 
 
 — discovery of, » new starting-point, 
 
 i, 48 
 
 — fallacies of, ii, 173 
 
 — value of, i, 53 ; ii, 31 
 
 Babington, Dr., ii, 8 
 Bacon, Lord, ii, 452 
 Baillie, Dr., ii, 8, 513 
 Baker, Sir G-eorge, ii, 17, 513 
 Bark, in Millbank cases, ii, 268 
 Bateman, Dr., ii, 337 
 Bayle, M., ii, 385 
 Bleeding, in erysipelas, ii, 461 
 Blood-letting, ii, 440 
 
 — effect of, i, 153 
 
 — in acute rheumatism, i, 115 
 
566 
 
 INDEX. 
 
 Blood-letting, in angina pectoris, i, 473 
 
 — in apoplectic coma, i, 432 
 
 — in fever, ii, 340, 342 
 
 — in hypertrophy of heart, i, 380 
 
 — in inflammations, i, 162 
 
 — mode of, i, 175 
 
 — in iritis, i, 168 
 
 — in phrenitis, ii, 247 
 
 — in secondary cardiac inflammations, 
 
 i, 260 
 
 — See Venesection, Cupping, Leech- 
 
 ing 
 Blood murmurs, i, 41 
 follow loss of blood, i, 42 
 
 — poisonSjii, 401 
 
 — vessels,* extreme,, acted on by mer- 
 
 cury, i,' 164 
 Boils, ii, 448 
 Books, ii,.39 
 
 Borrett, Dr., caBe by, ii, 477 
 Bowel complaints at Millbank, ii, 222 
 connection with nervous symp- 
 toms, ii,.249 
 
 treatment of, ii,' 234 
 
 Brain, affections of, in fever, ii, 340 
 
 — disorders: of, from, heart disease, i, 
 
 430 
 
 at Millbank, ii, 242 
 
 Brandy giving, ii, 441 
 Breath sounds, ii, 105 
 Bright's, disease, i,364 
 Brodie, Sir Benjamin, ii, 557 
 Bronchi, dilatation of, ii, 176 et seq. 
 
 .case of, ii,179 
 
 Bronchial respiration, ii, 134 
 Bronchitis, chronic, ii,.129, 178 
 
 — severe,, in. children, ii, 118 
 Bronchophony, ii, 134 
 Broussais," M., on fever, ii,45 
 Burrows, Dr. Geo., on cerebral circu- 
 lation, i, 430 
 
 Cachexy" of prisoners at Millbank, ii, 
 
 233 
 Calomel in bowel complaints, ii,' 238 
 
 — and purgatives in acute rheumatism, 
 
 i, 122 
 Cancer, ii, 66 
 Carbuncles, ii, 448 
 Cardiac. See Heart 
 Cartilaginous formations in peri- and 
 
 endocardium, i," 299 
 Case taking, ii, 29,38 
 Catarrhe sec, ii,182 
 Causation, ii,''75 
 Cavernous respiration,, ii,, 141 
 Cavity, signs of, ii, 147 
 Cecil's remains quoted, ii, 74 
 Cerebral disorders from, heart disease, 
 
 i, 430 
 
 Chalk mixture, evidence from, ii, 307, 
 320 et seq. 
 
 Chambers, Dr., ii, 513 
 
 Character, personal, of patients, ii, 92 
 
 Chatham, Lord, ii, 46 
 
 Chemistry, value of, ii, 21 
 
 Chest, deformity of, a cause of dilata- 
 tion of heart, i, 359 
 
 Chloride of sodium in phthisis, ii, 384 
 
 Chlorine in phthisis, ii, 385 
 
 Chloroform, ii, 484 
 
 Chlorotic anaemia, softening of heart 
 from, 388 
 
 Choleraic symptoms at Millbank, ii, 
 222 
 
 Chronic and. acute disease, differences, 
 i, 442 
 
 — diseases always have a cause, i,'302 
 our knowledge of them piecemeal, 
 
 i, 94 
 Cinchona, ii,' 358, '365 et seq., 401 
 Circulation, diurnal variations in, ii, 
 
 519 
 
 — effect of unsoundness of- heart upon, 
 
 i,394 
 
 — mechanical obstructions to, i, 360 
 Classics, medical, iii.'49 
 
 Click, signiof vomica, ii, 147 
 Clinical instruction, method of, ii,"28 
 
 — lectures, ii,' 19 
 
 — observation, value, of, i, 207 
 ClutterbucK, Dr., on fever, ii, '.45 
 Colchicum . in acute -rheumatism, i, 
 
 131 
 
 — in gout, ii, 404 
 Cold, disease from, ii, 78 
 
 — effect of, ii, 297 
 
 — influence of, at Millbank, ii,' 212 
 Colic, fatal case of, ii,'476 
 Collapse, death by, ii,'542 
 
 — from pain, ii, 478 
 
 Cblluvies in cases at* Millbank, 2/264 
 
 Coma, apoplectic,, i, 431 
 
 Common sense, ii, 388 
 
 Concentric hypertrophy of heart, i, 337 
 
 Congenital imperfection'of heart, cases 
 
 of, i, 372 
 Congestions from .heart disease, i, 408 
 Congestion of intestines,, ii, '228 
 Constitution, ii, 491 et seq. 
 
 — epidemic, ii, 471 
 
 — strumous, ii, 171 
 Constitutions, .differences, of, with re- 
 spect to mercury, i, 159 
 
 Constitutional symptoms, i, 312 
 in bowel complaints, ii, 231 
 
 — treatment, Abernethy on, ii, 45 
 Consumption, pulmonary. . See Phthisis 
 Contagion at" Millbank, ii, 278 
 
 — evidence of, ii, 298,'312 
 
INDEX. 
 
 567 
 
 •Contraction of heart, i, 335 
 ■Convulsions from heart disease, i, 432 
 Cornea, secondary inflammation of, i, 
 
 261 
 •Coronary arteries; obstruction of, i, 446 
 
 ossification of, i, 446, 451, 463, 
 
 479 
 •Corvisart, cases of pericarditis, i, 218 
 
 — genius and work of, i, 41 
 Cottereau, M., ii, 385 
 Counter-irritants in secondary lung 
 
 . affections, i, 424, 427 
 Cowper on wisdom, ii, 12 
 Cramps, with bowel complaint, ii, 245 
 Creasote in phthisis, ii, 383 
 Credulity as to remediesj ii, 382, 390 
 Crepitations, ii, 109 et seq., 123 et seq. 
 Crucifixion, ii, 477 
 
 Cupping in cardiac inflammations, i, 
 152 
 
 — in secondary lung affections, i, 426, 
 
 427 
 Curability-of heart disease, principle of, 
 
 i,412 
 Cure and treatment, ii, 356, 361 
 Cyanosis, i, 399 
 
 Darwin,' Dr., his' Zoonomia, ii, 83 
 Death from pain, ii,~476 
 
 — mode of, in bowel complaints, ii, 
 
 226 
 in endocarditis, i, 69 
 
 — sudden, cases of, i, 462, 463 
 Deformity of chest a cause of dilata- 
 tion of heart, i, 359 
 
 Delirium, with > bowel complaints, ii, 
 248 etseq. 
 
 — in fever, ii, 342 
 
 — from heart disease, i, 432 
 Demonstrator, the physician a, ii, 27 
 Deposits, specific, in peri- and endo- 
 cardium, i, 299 
 
 Diagnosis, imperfection of, i, 212 
 
 — why often impossible, i, 173 
 Diagnostic symptoms, ii, 409 
 Diarrhoea following dysentery, ii, 283, 
 
 287 
 
 — at Mfflbank, ii, 209, 222 
 
 — prevalence of, ii, 303 
 
 Diastolic mitral murmur, why not pro- 
 duced, i, 23 
 
 Diathesis, ii, 494 
 
 Diet, influence of, at Millbank, ii, 211, 
 214 
 
 Digestion, faulty, in heart disease, i, 477 
 
 Digitalis in heart disease, ii 426 
 
 — in hypertrophy of heart, i,'379 
 
 — in phthisis, ii, 384 
 Dilatation of aorta, i, 353, 446 
 
 — of bronchi, ii,'l76 et seq. 
 
 Dilatation of bronchi, case of,,ii, 179 
 
 — of heart, i, 335,.390 
 active, i, 336 
 
 from deformity of chest, i, 359 
 
 from dilatation of aorta, i, 353 
 
 from diseased arteries, i, 362 
 
 from disease of lungs, i, 357 
 
 from fatty change, i, 328 
 
 from narrowness of aorta, i, 355 
 
 partial, i, 323 
 
 passive, i, 336 
 
 — oausing regurgitation, i, 395 
 
 — simple, i, 336 
 
 — of left ventricle, i, 405 
 
 — never the sole change, i, 391 
 
 — of pulmonary vesicles, ii, 180 et seq. 
 Dilatations- of . parts, i behind obstruc- 
 tions, ii, 186 
 
 Disease and disorganization, difference 
 
 between, i, 270 
 Disorganization, unsoundness of heart 
 
 from, i; 334 
 Dissolution, new disease in process of, 
 
 i, 215 
 
 — sense of, in angina pectoris, i, 467 
 Diurnal variations in circulation,,ii, 519 
 Drinking, habitual, a cause of structu- 
 ral disease, i ( 301 
 
 Dropsies, ii, 66 
 
 Dropsy, after cardiac inflammations, i, 
 235 
 
 — in heart disease, i, 435 
 
 cases of, i, 440, 441 
 
 Dulness, percussion, of heart, i, 13 
 
 — of pericarditis, i, 77 
 Dysentery, case of, ii, 299 
 
 — at Millbank, ii, 209, 222 
 Dyspepsia in angina pectoris, i, 478 
 Dyspnoea confounded with angina pec- 
 toris, i, 449 
 
 Early treatment in heart disease, i, 
 
 418, 437 
 Eccentric hypertrophy of heart, i, 337 
 Ecchymosis in bowel complaints, ii, 227 
 
 — from leech bites, at Millbank, ii, 270 
 
 — in scurvy, ii, 219 
 Education of medical men,,ii, 1 
 
 — medical, ii, 555 
 
 Effusions from.heart disease, i, 408 
 Effusion in pericarditis, i, 291 
 "Elements," common, of disease, ii, 423 
 
 — proper, of disease, ii, 423 
 Emetics in bowel complaints, at Mill- 
 bank, ii, 265 
 
 Emphysema, ii, 180 et seq. 
 
 — interlobular, ii, 187 
 
 — physical signs of, ii, 184 
 Empirical treatment, ii, 408 
 Endocardial disease, seat of, 118 
 
568 
 
 INDEX. 
 
 Endocardial murmurs, cases of, i, 283 
 
 causes of, i, 44 
 
 -with constant palpitation, i, 282 
 
 with occasional palpitation, i, 279 
 
 cases of, i, 280 
 
 — — progress of symptoms, i, 283 
 sometimes present without other 
 
 symptoms, i, 278 
 Endocarditis, i, 57 
 
 — with acute rheumatism, i, 138 
 
 — case of, i, 264 
 
 — changes in heart from, i, 269, 273 
 
 — from cold and fatigue, i, 197 
 
 — modes of commencement, i, 144 
 
 — diagnostic signs, i, 60 
 
 — murmur its chief symptom, i, 57 
 
 — frequency with acute rheumatism, 
 
 i, 87 
 
 — history of our knowledge of it, i, 61 
 
 — idiopathic, i, 200 
 
 — importance of its investigation, i, 204 
 
 — independent of rheumatism, i, 194 
 
 — cases of, i, 195, 197, 200, 202 
 
 — in last days of life, i, 197 
 
 • — effect of mercury in, i, 180 
 
 — prevention of, in acute rheumatism, 
 
 i, 141 
 
 — damage resulting from, i, 229 
 
 — permanent damage from, i, 239 
 
 — post-mortem appearances, i, 91 
 
 — results of, i, 88, 227, 276 
 
 — secondary, i, 242 
 
 cases of, i, 246, 253 
 
 diagnosis of, i, 243 
 
 — in acute rheumatism, treatment of, 
 
 i, 148 
 Endocardium, non-inflammatory disease 
 of, i, 298 
 
 — osseous and cartilaginous formations 
 
 in, i, 299 
 
 Enteritis, case of, ii, 261 
 
 Epidemic constitution, ii, 471 
 
 Epilepsy, ii, 488 
 
 Error, sources of, in drawing conclu- 
 sions, ii, 78 
 
 Erysipelas, ii, 459 
 
 — and its fever, ii, 448 
 
 — at Millbank, ii, 270 
 
 — quinine in, ii, 359 
 Essential symptoms, i, 304 
 Exactness in practice, ii, 415 
 Examinations, ii, 41 
 Exanthems, ii, 423 et seq. 
 Exertion in angina pectoris, i, 476 
 Exocardial murmurs, i, 44, 75 
 Expectant medicine, ii, 511 
 Expectoration, in heart disease, i, 423 
 Experience, ii, 466 
 
 — in medicine, ii, 502 
 "Experiment, in medicine, 502 
 
 Eye, diseases of, Bhould be studied, ii, 
 68 
 
 Facts, medical, ii, 69 
 Fallacies of auscultation, ii, 173 
 Fatal cases at Millbank, ii, 276 
 Fatty heart, i, 324, 326 
 
 with angina pectoris, i, 446 
 
 Febrifuge, ii, 495 
 
 Feigned disease at Millbank,' ii, 320 
 
 ■ motives for, ii, 322 
 
 Fever, ii, 411, 427, 436 et seq, 450, 466 
 
 — at Millbank, course of, ii, 267 
 
 — with bowel complaints, ii, 259 et 
 
 seq. 
 
 — cases, ii, 261, 263 
 
 — connection of, with other symptoms,, 
 
 ii, 268 
 
 — quinine in, ii, 360 
 
 — rashes of, ii, 431 
 
 — softening of heart in, i, 325, 387 
 
 — treatment of, ii, 339 
 
 — typhus and typhoid, ii, 430 et seq. 
 Fits, ii, 488 
 
 Fluttering pulse, ii, 542 
 Forensic medicine, ii, 76 
 Fragments of cases, value of, i, 345 
 Frequency of pulse, ii, 524, 529 et seq. 
 
 — extreme, cases of, ii, 524, 536 
 
 Frottement, ascendant, ii, 188 
 
 — descendant, ii, 188 
 Functional alterations, ii, 95 
 
 Gallstones, death from pain of, ii, 477 
 
 Gargouillement, ii, 143 
 
 Gastric symptoms, following dysentery, 
 
 ii, 291 
 General descriptions more pleasing 
 
 than profitable, i, 64 
 
 — Penitentiary, diseases at, ii, 207 
 
 — principles, ii, 81 
 Germs of disease, ii, 429 
 
 Glands, tubercular disease of, ii, 151 
 
 Glottis, spasm of, ii, 56 
 
 Gooch, Dr., case by, ii, 477 
 
 " Good " cases, fallacy of inferences 
 
 from, i, 133 
 Goose skin, ii, 219 
 Gout, a cause of unsoundness of heart, 
 
 i, 302 
 
 — connection with angina pectoris, i, 
 
 479 
 Granular kidney, with hypertrophy of 
 
 heart, i, 385 
 " Grinding," ii, 41 
 Gums, in scurvy, ii, 220 
 Gurgling, ii, 143 
 
 Habits, previous, effects of, on fever, 
 ii, 344 
 
INDEX. 
 
 569 
 
 Haemoptysis, ii, 146 
 
 — acute, ii, 165 
 
 — from heart disease, i, 423 
 
 — in phthisis, ii, 166, 167, 508 
 Haemorrhages, ii, 66 
 
 — from heart disease, i, 408 
 Hall, Kobert, on -wisdom, ii, 11 
 Haller, on anatomy, ii, 6 
 Hardness of pulse, ii, 530 
 Haviland, Professor, ii, 67 
 Headache, with bowel complaint, ii, 
 
 248 et seq. 
 Head symptoms, from heart disease, i, 
 
 432 
 Heart, affections of, not organic, ii, 516 
 
 et seq. 
 
 — aneurism of, i, 315 
 
 — atrophy of, i, 335 
 
 — treatment, i, 386 
 
 — changes in, in angina pectoris, i, 446, 
 
 457, 470 
 
 — contraction of, i, 335 
 
 — disease of muscular structure, i, 307, 
 
 315 
 
 — disease, cases of, i, 440, 441 
 in acute rheumatism, treatment 
 
 of, 148 
 
 cerebral disorders from, i, 430 
 
 dropsy in, i, 435 
 
 from inflammation and from 
 
 other causes, comparison between, 
 i, 305 
 
 lung symptoms in, i, 422 
 
 recognition of, in acute rheuma- 
 tism, i, 144 
 
 two classes of, i, 53 
 
 — dilatation of, i, 335, 390 
 
 from deformity of chest, i, 359 
 
 from dilatation of aorta, i, 353 
 
 from diseased arteries, i, 362 
 
 from disease of the lungs, i, 357 
 
 from fatty change, i, 328 
 
 from narrowness of aorta, i, 355 
 
 — disorganization of, from accident, 
 
 cases of, i, 344, 346 
 
 from shock, cases of, i, 348, 349, 
 
 351 
 
 — fatty disease of, i, 326 
 softening of, i, 324 
 
 — hypertrophy of, i, 335, 377 
 
 — inflammation of muscular structure, 
 
 cases of, i, 308, 309, 323 
 
 — difficulty of diagnosis of, i, 311 
 
 — injuries of, i, 348 
 
 — "mock" hypertrophy of, i, 378 
 
 — partial dilatation of. See Aneurism 
 
 — rupture of, i, 323 
 
 from fatty disease, i, 328 
 
 septum of, i, 331 
 
 — safety valve action of, i, 396 
 
 Heart, softening of, i, 387 
 in fevers, i, 325 
 
 — sounds, analogy to lung sounds, i, 
 
 45 
 their area increased in lung dis- 
 ease, ii, 136 
 
 — structural changes following influm- 
 
 mations, i, 269 
 
 — unsoundness of, from pericarditis, 
 
 i, 285 
 
 — effect of unsoundness, of, upon cir- 
 
 culation, i, 394, 399 
 
 — valvular disease of, i, 367 
 
 — weakness of, i, 430 
 Heberden, Dr., ii, 17, 403, 465, 513 
 
 on angina pectoris, i, 449, 459 
 
 Hemicrania, cure of, by cinchona, ii, 
 
 359 
 Hippocrates, id, 49, 483 
 Holford, Mr., on Millbank report, ii, 
 
 316 
 Hospital visit, ii, 27 
 Hospitals, ii, 15, 19 
 Hulks, removal of prisoners to, ii, 285 
 Hunter, Mr., ii, 83, 445 
 Hutchinson, Mr., ii, 208 
 Hydrocyanic acid in consumption, ii, 
 
 383 
 Hypertrophy of heart, i, 335,425 
 
 with angina pectoris, i, 446 
 
 beneficial effect of, i, 407 
 
 ■ death from, i, 384 
 
 — concentric, i, 337 
 
 ■ diagnosis of, i, 378 
 
 eccentric, i, 337 
 
 — — infrequency of cure, i, 377 
 effect of, upon circulation, i, 401 
 
 — of left ventricle, i, 405 
 
 — " mock," of heart, i, 378 
 
 Idiosyncrasy, ii, 494 
 Impulse of heart, i, 8 
 
 — — in endocarditis, i, 68 
 limits of, i, 8 
 
 modifications of, i, 12 
 
 modifying circumstances of, i, 9 
 
 Incubation of disease, ii, 424 
 Indications of treatment, ii, 407 
 Individual peculiarities, ii, 532 
 Individuality, ii, 492 
 Inflammation, ii, 62, 78, 120 
 
 — and its fever, ii, 442 
 
 — in phthisis, ii, 165, 508 
 
 — pulse, of, ii, 546 
 
 — secondary, effect of, i, 261 
 
 — tendencies of, i, 158 
 Inflammations, cachetic, ii, 510 
 
 — chronic, mercury in, i, 171 
 
 — from heart disease, i, 408 
 Injury of heart, i, 348 
 
570 
 
 INDEX. 
 
 Intemperance,, ii, 92 
 
 — effect of, in fever, ii, 346 
 
 — leading to softening of heart, i, 390 
 
 — results of, i, 366 
 Intercurrent; diseases at Millbank, ii, 
 
 270 
 Interest in medical etudy, ii,23 
 Interference of relatives, ii, 552 
 Interlobular emphysema, ii, 187 
 Intermittent heart, ii, 518 
 Intestines, condition of, in Millbank 
 
 epidemic, ii, 228,289 
 Intoxication, ii,;427 
 Iodide of potassium in asthma, case of, 
 
 ii, 513 
 Iodine in phthisis, ii, 383 
 Ipecacuan in bowel complaints, ii, 234 
 Iritis, blood-letting in, i, 168 
 
 — mercury in, vl69 
 
 Iron, in angina pectoris, i, 473 
 
 — proto-ioduret of, in phthisis, ii, 384 
 Irregular heart, ii, 518 
 
 from faulty digestion, i, 477 
 
 Jenner, Dr. W., ii, 430 
 Johnson, on education,, ii; 3 
 Joint diseases at Millbank, ii, 271 
 Jugular pulsation, i, 397 
 
 Kidney, disease of, with disease of 
 arteries, i, 363 
 
 — granular, with hypertrophy of heart, 
 
 i, 385 
 
 with softening of heart, i, 390 
 
 Knowledge maybe an incumbrance, ii,10 
 
 Labia pudendi, inflammation . of, at 
 
 Millbank, ii, 270 
 Lsennec, theory of, .as to -heart sounds, 
 
 i,19 
 
 as to murmurs, i,:19 r 20 
 
 Languages, value of knowledge of, ii, 16 
 Laryngitis, ii, 57 
 Latency of disease, ii, ,424 
 Lectures, ii, 563 
 
 — clinical, ii, 19 
 
 — formal, use of, ii, ,35 
 
 — whether essential, ii, 15 
 
 — systematic, ii, 15, 19, 22 
 Leeches in hypertrophy of heart, i, 382 
 
 — in cardiac inflammations, i, 152 
 
 — in Millbank cases, ii, 265, 270 
 
 — in phrenitis, ii, 247 
 
 — in secondary lung affections, i, 424, 
 
 427 
 Left side of heart, unsoundness, of, 
 
 effects, i, 400 
 Literature, medical, ii, 49 
 Liver, affections of, in [heart, rdisease, i, 
 
 434 
 
 Liver, acute rheumatism treated by 
 acting upon, i, 122 
 
 — disease of ? with disease of. arteries, 
 
 i, 363 
 
 — enlargement of j -with softening of 
 
 heart, i,. 390 
 
 Locke's treatise on education,. ii, 3 
 
 Loudness of murmur, its relation to 
 valvular, impediment, i, 275 
 
 Louis, M., n7383 
 
 Lungs; affections "of,, with acute rheu- 
 matism, i, 97 
 
 in; heart disease, i, 422 
 
 • — disease of, causing dilatation of 
 heart, i, 357 
 
 Luxury a cause of structural disease, i, 
 301 
 
 Macmichael, Dr., ii, 205 ( 323 
 Malformation,, congenital, of aorta, i, 
 ~ L 357 
 
 Materia medica,. ii, 21-, 382 
 Mechanical impediment to circulation, 
 
 i, 360 
 Meckel, ease reported by, i, 356 
 Medical education, ii, 1, 555 
 
 — literature, ii, 49 
 
 — men; status of, t ii, 16 
 Medicine, difficulty of, ji, 25 
 
 — lectures on,.ii, 22 
 
 — objects of, i, .392 
 
 — office of, i, 114 
 
 — practice of, .general remarks ' on, ii, 
 %^353 
 
 Mercury in amaurosis, i, 171 
 
 — in bowel complaints at Millbank, ii, 
 
 235, 265 
 
 — ini cardiac inflammations, i, 149, 151 
 
 — in chronic inflammations, i, 171 
 
 — conditions. favourable: to the action 
 
 of, i, 177 
 
 — in endocarditis, i, 180 
 
 — effect of, in eye diseases, i, 167 
 in inflammation, i, 157, 160, 165 
 
 — in iritis, i, 169 
 
 — mode of administration of, in inflam- 
 
 mation, i, 174 
 
 — in nervous symptoms (at Millbank) , 
 
 ii, 255 
 
 — in paraiplegiay l, 172 
 
 — in pericarditis, i, 179; 183 
 
 — in rheumatic, ophthalmia, i, 170 
 
 — in' secondary cardiac inflammations, 
 
 i, 260 
 Melaena, ii, 264 
 
 Mental distress,' influenoe of, iij 293 
 Metallic sounds, ii, 1Q0, 197 
 
 cases of, ii, 190, 191 
 
 Millbank Penitentiary, report on, ii, 
 
 208 
 
INDEX. 
 
 571 
 
 Millbank Penitentiary, cause of epi* 
 demio at, ii, 278 
 
 — origin of epidemic, ii, 297 et seq. 
 
 — extent of disease at, ii, 275 
 
 — fatal cases at, ii, 276 
 
 — epidemic foreseen by Mr. Pratt, ii, 
 
 308 
 
 — prisoners, effect of their removal, ii, 
 
 282 
 Milton's treatise on education, ii, 3 
 •" Mock " hypertrophy of heart, i, 378 
 Monographs,. ii,:42 
 Morbid anatomy as a method of 
 
 research, i, 49 
 
 — appearances in bowel complaints, ii, 
 .227 
 
 with nervous symptoms,. ii,. 252 
 
 — processes, ii, 51 
 
 — sensations, ii, 93 
 Mucoua rattles, ii,. 124 
 Murmurs, i, 16 
 
 — aortic, seat of, i, 27 
 
 — blood, i, 41 
 
 characters of, i, 17 
 
 frequently coincident with con- 
 sumption, i,40 
 
 — endocardial, i, 16, 57, 59 
 eases of, i, 283 
 
 circumstances modifying, ,i,.28 
 
 — «- — diagnostic value of, i, 72 
 
 from force of hearts contraction, 
 
 i,34 
 from impediment other than 
 
 valvular diseases, i,, 37 
 
 kind and quality of, i, 31 
 
 origin from valvular disease 
 
 sometimes doubtful, i, 33 
 
 with constant palpitation, i, 282 
 
 with occasional palpitation, i, 279 
 
 cases of, i, 281 
 
 progress of symptoms, i, 283 
 
 propagation of, i, 26 
 
 relation to-inflammation, i, 69 
 
 seat of, i, 65 
 
 sometimes come and.go, i, 34 
 
 — — sometimes present without other 
 
 symptoms, i, 278 
 
 a symptom of dissolution, i, 35 
 
 — : loudness of, i, 29 
 
 in relation to valvular •. impedi- 
 ment, i, 275 
 
 — exocardial, i, 16 
 characters of, i, 75 
 
 effect of effusion upon, i, 78 
 
 — from pressure with stethoscope, i, 
 
 38 
 — wmode of production, i, 17 
 
 — pulmonary, seat of, i, 27 
 
 — respiratory sounds, may be taken 
 , for, i, 39 
 
 Murmurs, a sign by itself of small 
 
 value, i, 32 
 Muscle of heart, disease of, i, 307, 315 
 
 — — inflammation of, i, 323 
 
 cases of, i,. 308, 309 
 
 Mutual help, ii, 39 
 
 Narrowing of aorta, i, 355 
 
 Nervous system in erysipelas, ii, 460 
 
 in fever, ii, 451 
 
 Nervous symptoms in heart disease, i, 
 
 236 
 
 cases of, i, 236, 237, 238 
 
 in inflammation of muscle of 
 
 heart, i, 313 
 
 — system, its . influence on the_heart, 
 
 ii, 538 et seq. 
 
 disorders of, at Millbank, ii, 242 
 
 cases of death with, ii, 243, 244, 
 
 245, 246, 263 
 
 connection with bowel complaint, 
 
 ii, 249 
 
 modes of death with, . at Mill- 
 bank, ii, 254 
 
 Neuralgia, cure of, by cinchona, ii, 359 
 
 Mosologies, ii, 40 
 
 Nutrition, defective, a cause of morbid 
 changes, i, 410 
 
 Observation the first thing, ii, 37 
 
 — faculty of, ii, 50 
 CEdema, in heart disease, i,436 
 CEgophony, ii, 139 
 
 Old age a cause of valvular heart 
 
 disease, i, 302 
 
 softening of heart in, i,.390 
 
 Ophthalmia, rheumatic, mercury in, i, 
 
 170 
 Opinions are not facts, ii, 71 
 Opium,, iij 487 
 
 — in acute rheumatism, i, 118 
 
 — in angina pectoris, i, 467, 473 
 
 — in bowel complaints, ii, 234,. 238 
 
 — in rcardiac inflammations, i,. 154 
 
 — in diarrhoea, ii, 290 
 
 — in erysipelaB, ii, 461 
 
 — in fevers, ii, 339 
 
 mode of administration, ii, 347 
 
 — as a preventive of heart disease, i, 
 
 142 
 Opportune treatment, importance of, 
 
 in heart disease, i, 418,. 437 
 Osseous formations in pericardium, i, 
 
 299 
 Over refinement in -medicine, ii, .496 
 
 Pain, ii, 90, • 41 4, 474 et<seq. 
 
 — of angina pectoris, i>:448 
 
 — with bowel complaints, ii,. 224,. 225 
 
 — in endo- and pericarditis, ii, 154 
 
572 
 
 INDEX. 
 
 Pain in head, from heart disease, i, 432 
 
 — in pericarditis, i, 85 
 
 — precordial, in acute rheumatism, i, 
 
 66 
 
 — remedies for, ii, 483 ■ 
 
 — of acute rheumatism, i, 118 ; ii, 481 
 Palpation, ii, 99 
 
 Palpitation of heart, ii, 518 
 
 — from ansemia with hypertrophy, i, 
 
 384 
 
 — with endocardial murmur, i, 279, 
 
 282 
 Paralysis, case of, treated with strychnia, 
 
 ii, 378 
 Paraplegia, mercury in, i, 172 
 Passive dilatation of heart, i, 337 
 Pathognomic symptoms, ii, 409 
 Pathology, ii, 51, 53, 54 et seq. 
 
 — influence of, ii, 354 
 Patients and physicians, ii, 391 
 Pectoriloquy, ii, 141 
 Penitentiary, General, diseases at, ii, 207 
 Pericarditis, i, 74 
 
 — in acute rheumatism, treatment of, 
 
 i, 148 
 
 — cumulative unsoundness from, i, 295 
 
 — damage resulting from, i, 230, 239, 
 
 269, 285 
 
 — dulness in, i, 77 
 
 — during dissolution, i, 215 
 • — in fevers, i, 210 
 
 — frecmencywith acute rheumatism, i, 
 
 87, 138 
 
 — independent of rheumatism, i, 208 
 
 — cases of, i, 213, 216, 217, 219, 220, 
 
 221, 222, 224 
 
 — mercury in, i, 179, 183 
 
 ' — cases of, treated by mercury, i, 184, 
 
 185, 186, 187 
 • — modes of commencement, i, 144 
 ■ — murmurs in, i, 75 
 
 — never seen idiopathic, i, 218 
 
 — often overlooked, i, 83, 213 
 
 — post-mortem appearances, i, 91 
 
 — prevention of, in acute rheumatism, 
 
 i, 141 
 
 — with complete recovery, case of, i, 
 
 287 
 
 — reparation after, i, 289 
 
 — repeated attacks, case of, i, 264 
 
 — results of, i, 89, 227 
 
 — secondary, i, 242 
 
 — — case of, i, 249, 253 
 
 with suppuration, i, 293 
 
 • — symptoms of, i, 83 
 
 — vibratory feeling in, i, 80 
 
 — visible undulation in, i, 80 
 Pericardium, adhesions of, i, 286, 292 
 
 — analogy to pleura, i, 45 
 
 — non-inflammatory disease of, i, 298 
 
 Pericardium, osseous and cartilaginous 
 formations in, i, 299 
 
 — thickening of, after inflammation, 
 
 i, 295 
 
 — tubercular disease of, i, 298 
 
 — white spots on, i, 208 
 Peripneumonia notha, ii, 130 
 Peritonitis, ii, 547 
 
 — during dissolution, i, 216 
 Personal character of patients, ii, 92 
 Phlogiston, ii, 436 
 
 Phrenitis at Millbank, ii, 247 
 Phthisis, ii, 507 
 
 — chronic, ii, 153 
 
 — forms of, ii, 161 
 
 — infrequency of dilatation of heart 
 
 in, i, 358 
 
 — Louis on treatment of, ii, 383 
 
 — mixed, case of, ii, 162 
 
 — physical signs in, ii, 137, 138 
 
 — reparation of, ii, 158 
 
 — signs of, ii, 153 et setf. 
 
 — treatment in, ii, 169 
 
 — unmixed, ii, 253 
 Physic, uncertainty of, ii, 25 
 Physicians and patients, ii, 391 
 
 — status of, ii, 17 
 Physiognomy of disease, ii, 38, 89 
 Pinchard, Dr. Richard, on angina pec- 
 toris, i, 479 
 
 Pitcairn, Dr. David, ii, 513 
 
 Plash, gurgling, ii, 144, 149, 197 
 
 Plethora, i, 44 
 
 Pleurisy, physical signs in, ii, 137, 
 
 139 
 Pneumonia, ii, 503 
 
 — of apices, ii, 175 
 
 — bronchial breathing in, ii, 137, 138 
 - — crepitation of, ii, 131 
 
 — with endo- and pericarditis, i, 99 
 
 — with fallacious signs of cavity, case 
 
 of, ii, 174 
 
 — pleuro-, with secondary peri- and 
 
 endocarditis, case of, i, 253 
 • — treatment of, ii, 469 
 Pneumothorax, ii, 194 et seq. 
 Poisoning, ii, 77 
 Poisons, ii, 375 
 Polypus uteri, death from pain caused 
 
 by, ii, 477 
 Poor, practice among the, ii, 417 
 Potassium, iodide of, in asthma, case 
 
 of, ii, 513 
 Practical books, ii, 42 
 
 — knowledge is commonly selected 
 
 knowledge, i, 56 
 Practice of medicine, general remarks 
 
 on, ii, 353 
 Pratt, Mr., ii, 208, 308 
 Precordial region, boundaries of, i, 1 
 
INDEX. 
 
 573 
 
 Premonitory symptoms of local com- 
 plaint, 250 
 Preparatory studies, ii, 5 
 Prescribing, simplicity in, ii, 512 
 Principle of curability of heart disease, 
 
 i, 411 
 Principles, general, ii, 81 
 
 — importance of, i, 225 
 Prisoners, pardons to, ii, 294 
 Privation, effect of, ii, 297 
 Professional education, ii, 3 
 Prognosis in heart disease, i, 419 
 Progressive diseases the most import- 
 ant to know, i, 53 
 
 Protective power of the growing heart, 
 
 i, 373 
 Prout, Dr., ii, 59 
 Public, books addressed to, ii, 44 
 Puerperal fever, case of, ii, 534 
 Pulsation, venous, i, 395 
 Pulse, ii, 414 
 
 — acceleration of, ii, 527 et seq., 539 
 
 et seq. 
 
 — in bowel complaints, ii, 225 
 
 — of cachectic inflammations, ii, 550 
 — • doctrine of, ii, 519 et seq. 
 
 — fluttering, ii, 542 
 
 — extremely frequent, cases of, ii, 534, 
 
 536 
 
 — frequency of, ii, 521 
 
 — hardness of, ii, 530 
 
 — individual standards of, ii, 520 
 
 — of inflammation, ii, 546 
 
 — qualities of, ii, 529 
 
 — significance of, i, 399 
 
 — value of, ii, 32 
 
 Purgatives in bowel complaints at 
 Millbank, ii, 264 
 
 — with calomel, in acute rheumatism, 
 
 i, 122 
 Purpura, case of, ii, 272 
 
 Quality of murmurs, causes of variety 
 
 in, i, 31 
 Quinine, ii, 359, 369, 405 
 - — ■ in erysipelas, ii, 462 
 
 Rales muqueux, ii, 124 
 Hash of fevers, ii, 431 
 Rational treatment, ii, 408 
 Rattles, mucous, ii, 124 
 Reception of facts, ii, 72 
 Reform of medical education, ii, 556 
 Regent's Park, health of prisoners at, 
 
 ii, 286 
 Regurgitation, doctrine of, i, 21 
 Remedies for pain, ii, 483 
 
 — special. See specifics. 
 Removal, effect of, upon Millbank 
 
 prisoners, ii, 282 
 
 Reparation, after cardiac inflammation, 
 
 ii, 228 
 hindrances to, i, 233 
 
 — after pericarditis, i, 289 
 Reparative effect of mercury, i, 165 
 Report on state of Millbank Peuiten- 
 
 tiary, i, 208 
 Resonance of precordial region, i, 10 
 Respiratory murmur, ii, 105 
 Rest in heart disease, i, 417 
 Rheumatism, acute, ii, 121, 446, 480 
 course of, when left to itself, i, 
 
 121 
 
 probable essential cause of, i, 138 
 
 with endo- and pericarditis and 
 
 pneumonia, cases of, i, 100, 104 
 
 exceptional cases of, i, 135 
 
 gravity of, i, 242 
 
 intractable cases of, i, 134 
 
 relation to unsoundness of heart, 
 
 i, 341 
 with repeated cardiac inflamma- 
 tion, case of, i, 264 
 with secondary endocarditis, case 
 
 of, i, 246 
 — ■ — with secondary pericarditis, case 
 
 of, i, 250 
 
 treatment of, i, 110 
 
 Rhonchus, ii, 109 et seq. 
 
 Rich, practice among the, ii, 417 
 
 Right side of heart, safety valve action 
 
 of, i, 396 
 Roget, Dr., ii, 203 
 Rupture of air-cells, ii, 182 et seq. 
 
 — of aortic valve, case of, i, 344 
 
 — of heart, i, 323 
 
 from fatty disease, case of, i, 
 
 328 
 
 — of septum of heart, i, 331 
 
 Safety valve action of right side of 
 
 heart, i, 396 
 Salivation in nervous symptoms afc 
 
 Millbank, ii, 257 
 Scarlatina, ea:,e of, ii, 536 
 Scepticism in medicine, ii, 79 
 Science, medicine as a, ii, 69 
 Scientific education needed, ii, 16 
 Scrofula, ii, 66 
 Scrofulous glands, ii, 151 
 Scurvy at Millbank, ii, 209, 219 
 
 — cure of, ii, 212 
 
 — mercury iu, ii, 236 
 
 — softening of heart from, i, 388 
 Secondary inflammations, effect of, 
 
 261 
 
 of heart sometimes slight, i, 259 
 
 treatment of, i, 260 
 
 liability to, i, 257, 263 
 
 obscurity of, i, 241 
 
574 
 
 INDEX. 
 
 Secretions, attention to, in treatment, 
 
 ii, 418 
 Self-teaching, all may practise and 
 
 profit by, i, 56 
 Sensations, morbid, ii, 93 
 Septum of heart, rupture of, i, 331 
 Serous membranes, disease of, with 
 
 diseased arteries, i, 363 
 
 during dissolution, i, 215 
 
 Shocks of heart/ cases of, i, 348, 349, 
 
 351 
 Sibilus, ii, 109 et seq. 
 Signs, ii, 87 
 
 Simple dilatation, i, 336 
 Simplicity in treatment, ii, 407, 415, 512 
 Sinking, Bensation of, ii, 224 
 Sleeplessness from heart disease, i, 432 
 Smallpox, ii, 423 
 
 Sodium, chloride of, in phthisis, ii, 384 
 Softening of heart, i, 325, 386 
 
 in angina pectoris, i, 457 
 
 ■ prognosis in, i, 389 
 
 • — of left ventricle, i, 405 
 
 Sounds of heart, analogy to lung 
 
 sounds, i, 45 
 
 — - — area of, increased in lung disease, 
 
 ii, 136 
 
 causes, i, 4 
 
 character and time, i, 3 
 
 — intonation of, i, 7 
 
 limits of audibility, i, 6 
 
 modifications of, i, 12 
 
 modifying circumstances, i, 4, 7 
 
 — respiratory, ii, 105 
 
 Spasm, angina pectoris due to, reasons, 
 i, 459 
 
 Special remedies, ii, 358, 403 
 
 Specific deposits in peri- and endo- 
 cardium, i, 299 
 
 — diseases, ii, 64 
 
 Specifics, ii, 353, 358/365, 373, 381, 
 399 
 
 — futility of search for, ii, 365 
 
 — popular belief in, ii, 391 
 Speculation in medicine, ii, 455, -457 
 Spirit drinking, a cause of structural 
 
 disease, i, 301 
 
 disease from, ii, 78 
 
 effects of, i, 366 
 
 in fever, ii, 346 
 
 Spleen, disease of, with disease of 
 
 arteries, i, 360 
 Stahl, ii, 436 
 
 Steel, in angina pectoris, i, 473 
 Stevens, Dr., ii, 60 
 Stimulants, ii, 441 
 
 — in angina pectoris, i, 467 
 
 — in erysipelas, ii, 461 
 
 — in fever, indications for, i, 337 
 - — indications for, ii, 539 
 
 Stokes, Dr., differentiated the signs of 
 pericarditis, i, 62, 75 
 
 — on softening of heart, i, 387 
 Stomach affections, following dysentery, 
 
 ii, 291 
 Strumous constitutions, ii, 171 
 Strychnia, ii, 378 
 Sudden death, cases of, i, 462, 463 
 Superstition in medicine, ii, 393 
 Suppurative inflammation of heart, case' 
 
 of, i, 308 
 Surgery easier than medicine, ii, 24 
 
 — introductory to physic, ii, 67 
 
 — more popular than medicine, ii, 
 
 34 
 Susceptibility, ii, 494 
 Sydenham, ii, 49 
 
 — on education, ii, 3 
 
 — on erysipelas, ii, 464 
 
 — on intercurrent diseases, ii, 279 
 
 — on Peruvian bark, ii, 366 
 Sympathetic disorders, ii, 517 
 Sympathies, i, 312 
 Symptoms, ii, 80, 86 et seq., 409 
 
 — essential and accidental, i, 304 
 
 — importance of, i, 447 
 
 Taking cases, ii, 29, 38 
 
 Tartar emetic, in erysipelas, ii, 461 
 
 Teaching, right methods of, ii, 14 
 
 Temperament, ii, 494 
 
 Theoretical books, ii, 44 
 
 Theories, mischief of, ii, 422 
 
 Theorizing, ii, 403 
 
 Thickening of pericardium, i, 295 
 
 Thinkers, ii, 453 
 
 Time, lessons of, ii, 465 
 
 Tinkling, metallic, ii, 197 
 
 Tongue, in bowel complaints, ii, 225 
 
 Tonics, ii, 405 
 
 — in Millbank cases, ii, 268 
 Toxicology, ii, 376 
 Tracheotomy, in laryngitis, ii, 58 
 "Treatment" and "Cure," ii, 356,361, 
 
 407 et seq. 
 
 — diversity of rational methods, i, 110 
 
 — simplicity of, ii, 512 
 Tropical fevers; i, 410 
 
 — inflammatory diseases, effectof mer- 
 
 cury in, i, 161 
 Tubercles, physical signs from, ii, 145, 
 
 153 et seq. 
 Tubercular disease of pericardium, i, 298- 
 Tympanites,followHig bowel complaints, 
 
 ii, 223 
 Typhoid fever, ii, 430 et seq. 
 Typhus, ii, 430 et seq.' 
 
 Ulceration of intestines, ii, 229,. 289 ■et 
 
INDEX. 
 
 575 
 
 Uterine polypus, death from pain caused 
 by, ii, 4,77 
 
 Vaccination, ii, 82 
 
 Valve, aortic, rupture of, case of, i, 344 
 
 Valves, position of, i, 25 
 
 Valvular disease, cases of, i, 372, 375 
 
 with angina pectoris, i, 446, 470 
 
 effect of, upon circulation, i, 401 
 
 prognosis in, i, 368 
 
 treatment of, i, 367 
 
 — impediment, in relation to loudness 
 
 of murmur, i, 275 
 
 — injury, with hypertrophy, i, 405 
 Vascular system, affections of, from 
 
 local disease, i, 312 
 
 in erysipelas, ii, 460 
 
 in fever, h, 451 
 
 Venesection, ii, 548 
 
 — in acute rheumatism, i, 115 
 
 — effect of, as to liability to heart 
 
 disease, i, 142 
 
 — in cardiac inflammations, i, 150 
 Venous hum, i, 42 
 
 Venous hum, circumstances of its pro- 
 duction, i, 43 
 symptoms associated with, i, 44 
 
 — pulsation, i, 395 
 
 — system, effects of unsoundness of 
 
 heart upon, i, 394 
 Vertigo, with bowel complaint, ii, 248 
 
 et seq. 
 Voltaire, ii, 80 
 Vomica, ii, 153 et seq. 
 
 — signs of, ii, 147 
 
 Vomiting with bowel complaints, ii, 264 
 
 Wakefulness in fever, ii, 340 
 Warren, Dr., the elder, ii, 513 
 Watson, Dr., differentiated the signs of 
 
 pericarditis, i, 62, 75 
 Weakness of heart, i, 430 
 White spots on pericardium, i, 208 
 Wisdom distinct from knowledge, ii, 11 
 Wrong-headedness in medicine, ii, 387 
 
 Yellow fever, Dr. Stevens on, ii, 60 
 Young, Dr. Thomas, ii, 6 
 
,1 
 
CONSERVATION 
 
 r , m 07 m , 
 
 ISERVATION 199S .c^ /